Transrectal repair with Sehapayak method

Sehapayak method for rectal incision repair for the treatment of rectal bulging. The anterior rectal bulge, that is, the anterior rectal wall protrudes into the vagina, and is also referred to as the rectocele, which is more common in women. When defecation, the direction of the high pressure in the rectal cavity changes, the pressure is toward the vagina, not to the anus, some of the feces can not be discharged before swelling, and when the defecation is stopped, it can "bounce back" into the rectum, defecation Incompleteness can force the patient to exert more force, leading to a gradual deepening of the bulge and a vicious circle. The insertion of a finger into the vagina to counter the tendency of the bulge during defecation is beneficial to rectal emptying. Indexing: According to the bulging depth is divided into 3 degrees, the lightness is 0.6 ~ 1.5cm, the moderate is 1.6 ~ 3cm, the severity is > 3.1cm, according to the bulging part is divided into high, medium and low 3 types. The high rectal bulge is caused by excessive stretching or rupture of the middle and upper 1/3 vaginal wall or uterine ligament, often combined with small bowel bulging, bladder bulging and uterine prolapse. The median rectal bulge is the most common, due to the loss of support of the pelvic floor and the effects of childbirth. Low rectal anterior bulge is often caused by insufficient repair after birth injury or excessive expansion during labor. According to statistics, about 80% of women have asymptomatic rectal bulging. Where the rectal bulge diameter <2cm is asymptomatic, it is a normal finding, the diameter >2cm often have symptoms, and some need surgery. Patients with symptoms before anterior rectal bulging need treatment. Generally non-surgical treatment, including diet therapy, such as 30g bran daily, water 2000 ~ 3000ml, eat more fruits and vegetables, if necessary, take laxatives, increase activities. Surgical treatment may be considered for patients who are not responding to surgery. The principle of surgery is to repair the defect, eliminate the weak area to interrupt the vicious circle, but still need to pay attention to keep the stool smooth after the operation, in order to prevent the recurrence of the anterior bulge. The rectal bulging repair can be rectally or transvaginally, and the advantages of transrectal repair: 1 can simultaneously treat sputum and anal lesions and suture the lengthy rectal mucosa; 2 reveal clearly. However, the smaller rectal cavity should be repaired by the vagina. Patients with pre-rectal bulging often have symptoms of constipation. Constipation is also the cause of anterior rectal bulging, but constipation also has its own cause. Pre-rectal bulging repair surgery sometimes fails to completely cure constipation, and the surgical effect is sometimes unsatisfactory. Therefore, before the operation, defecation angiography, colon transport test, electromyography, and pelvic angiography were performed to exclude intestinal bulging to determine the cause of constipation. Treatment of diseases: rectal bulging Indication Beck and Wexner (1998) consider that 3 of the following are indications for Sehapayak's rectal incision: 1. The diameter of the rectal bulge after defecation is 4cm. 2. Pre-rectal bulging in the defecation angiography can not be reserved or only partially emptied. 3. Rectal and/or vaginal symptoms for up to 12 months. 4. Although dietary fiber (>35g / d) for up to 4 weeks can not relieve rectal or vaginal symptoms. 5. Need to use the fingers of the rectum and / or vagina and / or perineal support to assist rectal emptying. Contraindications 1. Asymptomatic rectal bulging. 2. The diameter of the rectal bulge is <1cm. 3. The rectal cavity is relatively narrow and should be repaired from the vagina. Preoperative preparation 1. Diet: 3 to 5 days before surgery into the semi-liquid diet, 1 to 2 days before surgery into the clear stream. 2. Oral laxative: 30 ml of 25% magnesium sulfate or 30 ml of castor oil per day for 3 days before surgery. 3. Mechanical intestinal lavage: 3 days before surgery, saline enema 1 time per night, clean enema before surgery. 4. Oral antibiotics: one of the following options can be selected: 1 neomycin 1 g, erythromycin 0.5 g, 1 d 8 o'clock, 14 o'clock, 18 o'clock, 22 o'clock before surgery; 2 kanamycin 1 g, metronidazole 0.4 g, 3 days before surgery, 3 times / d. 5. Other drugs: vitamin K4 ~ 8mg, 4 times / day. Note that water and electrolyte balance. If necessary, enter an appropriate amount of water and electrolyte solution intravenously 1 day before surgery. In order to avoid insufficient nutrient supply during colon preparation, the elemental diet can be used to replace semi-liquid and whole-flow foods. The elemental diet itself can cause mild diarrhea, so laxatives should be reduced or not given. If the factor diet is about 1 week, oral laxatives and intestinal lavage can be dispensed with, but antibiotics and vitamin K are still needed. 6. Total gastrointestinal lavage: Before the operation, the Chinese food was given to the food, and the whole gastrointestinal lavage was started 3 hours after the lunch. The lavage fluid is an isotonic electrolyte solution or a solution prepared by adding 1000 ml of warm water with 6 g of sodium chloride, 2.5 g of sodium hydrogencarbonate, and 0.75 g of potassium chloride, and injecting or orally through a gastric tube, and injecting 2000 to 3000 ml per hour. Until the liquid discharged from the anus is clean and free of dung. The advantage of this method is that it is fast, effective and free from hunger. The disadvantage is that it is easy to cause abdominal distension, which can cause sodium and water retention, so heart, liver and kidney dysfunction should not be applied. Surgical procedure 1. Anal to 4 fingers. A small amount of 1:1000 adrenaline was injected submucosally at the incision to help stop bleeding. 2. At the lower end of the rectum, a longitudinal incision is made with an electric knife above the tooth line, which is about 5 to 7 cm long and reaches the submucosal layer to reveal the muscular layer. 3. According to the width of the bulge, free the mucosal flaps on both sides, each about 1 ~ 2cm, carefully stop bleeding. 4. The left finger of the surgeon is inserted into the vagina for guidance. The intestine is made with 2-0 chrome, and the needle is inserted from the outside to the inside of the right levator ani muscle. Then, the needle is pulled from the inside to the outside from the left levator ani muscle. Stitch 4 to 6 needles, and repair the depression, leaving no dead space. 5. Cut off the excess mucosal flaps on both sides, and suture the mucosal incision with a chrome gut. 6. If there are internal hemorrhoids or mixed hemorrhoids, they can be removed at the same time. complication 1. Wound hemorrhage: often caused by insufficiency of hemostasis during surgery, usually oozing blood, hemostasis after compression and hemostasis. 2. Rectal vaginal fistula: rare, mostly caused by intraoperative injury, if you use your fingers to insert into the vagina, you can avoid this damage.