Her symptoms are purely due to Intussusception

Who was the first ,  the hen or the egg?.

Forty percent of women has rectocele which get worst with delivery. If you already has a MIR defecography with a sever rectocele plus recto rectal intussusception I would rather go first for a Lap "prolapse" correction,  with or without sigmoid resection depending on findings, wait and see if this problem was corrected, in 3 to 6 months if the patients still has symptoms of obstructed defecation,  then I go to add a STAR procedure, but not before the transabdominal one.

Recto rectal intussusception with obstructive symptoms requires a rectopexy. The rectocele can be repaire same sitting by perineal approach

Thank you for the case! We need actually a more detailed history of the patient emphasized on previous defecatory problems, since e.g. a long history of functional constipation may predispose to secondary intussusception and rectocele. Should the symptoms of patient launched in the postdelivery period, and the possibility of the co-existance of other primary causes of constipation has been excluded, thw choise of S.T.A.R.R. seems to be reasonable and effective according to my personal experience.

In my experience, proper rectocoel repair with meticulous reconstruction of recto-vaginal septum will relieve her defecation obstruction. This will prevent the progress of her intersuspetion into rectal prolapse.

It all depends on, like everything in Medicine, the history. If she is having to digitate vaginally then that goes more with a symptomatic rectocele - the treatment options of which include: transanal repair/transvaginal repair/STARR or best lap VMR.

If it's more anal digitation as a manifestation of ODS then lap VMR again is best.

If you have exhausted all conservative measures (biofeedback/laxatives/anal irrigation etc) then the best operative options, without a doubt, would be a lap VMR. She is quite young and VMR ought not affect the nerves of sexual function. I would exhaust all conservative options first however. If you go ahead to lvmr probably worth using a biological mesh.

Of note, anatomical correction as manifest by a "normal" post-op MR-DP or fluor DP do not always correlate to symptomatic resolution.

I'd probably try to avoid a STARR.

Hope that helps.

JB.

She had no symptoms of defecation problems before delivery.

She had 5 cm hematoma in the vagina after delivery which was left to resolve on its own by treating gynecologist as it was detected very late. She still has fibosis in that part of the vagina.

She doesnt have to digitate for defecation or I had suggested her splinting to help in defecation but it doesnt work for her.

I recommend a "internal Delorme". The STARR Is dangerous (and, in fact, now replaced by the TRANSTARR)

FB

In case of a big rectocele and difficult bowel emptying I would suggest the pelvic reconstructive surgery. The choice of surgery depends on the age, other co-morbidities, BMI, sexual activity, occupation (hard physical work), wish for another pregnancy, associated anterior or central POP, etc.

If she is young and is planning another pregnancy, the vaginal approach consisting of posterior colporrhaphy and levatororrhaphy maybe the treatment of choice. In my opinion, the transvaginal mesh placement may not be the primary approach, especially if the patient is young and sexually active. 

In case of big proximal rectocele, the above mentioned native tissue procedures will not address the problem correctly, therefore, the mesh repair is needed.

I would select either the laparoscopic approach (rectopexy, maybe in combination with hysteropexy in case of associated POP) or transvaginal mesh placement (Elevate posterior), which would be my second choice.

Well, there is no easy and simple answer to your question. I would taylor the surgery towards the wishes of the patient and do the least invasive surgery first....

Hope this helps.

IB

I agree with Igor. In this case, she have 3 options:

1.Wait and plan next pregnancies.

2.Colporrhaphy post. with levatoroplastic.

3.Prolift,or surgimesh,or Elevate posterios.

In my opinion this patient complaining about obstructive defecation and clinical and imaging diagnosis of recto-rectal intussusception and rectocele, should be studied first of all in her distal digestive function, so ano-rectal manometry can give us interesting information. If outlet obstruction is detected, a biofeedback re-education should be carried out prior to any surgical treatment.

My surgical choice in this case is a laparoscopic (or open) mesh ventral rectopexy.

I agree in terms of surgical approach that this woman will probably be best served with mesh ventral rectopexy. From the description of her anatomy, I suggest dissecting all the way down to the perineal body and including attachment of the mesh there.

I agree with Mitchel in a very distal mesh ventral rectopexy and attachment there

I think this lady should have her expectations managed first and be told that there are no cures. From my own experiences patients with mesh repairs remain dissatisfied and some report further deterioration in symptoms.

I would refer this lady to biofeedback after completing the standard investigations recommended by Anicet. I would also include a gastrografffn enema to exclude sigmoid redundancy. Within biofeedback I would advocate rectal irrigation (Qufora) and suppository use for at least six months. If this fails to improve symptoms then as long as the proctogram demonstrates 50% trapping and the patient digitates on more than 50% of bowel movements will she be considered for surgery. If the patient is young and wishes to have more children, I would perform a modified ventral suture rectopexy (no mesh). If there is redundancy then this will include a resection of this loop. I would not recommend a perineal approach in patients with a scarred perineum and who are sexually active.