Type 1 rectoceles are treated by the endorectal approach, which was described by Sullivan et al. [16] and Sarles et al. [14, 31] and is usually carried out with the patient in the prone jackknife position. We prefer a classic gynaecologic position with the advantage of less anaesthetic risk and a shorter operating room time while the patient position does not need to be changed. The anterior rectal submucosa above the dentate line is infiltrated with a solution of local anaesthetic and a vasoconstrictor. A flap of mucosa is raised off the rectal circular muscle to expose the rectal wall as far as the apex of the rectocele. The rectal muscle is then plicated, using a series of five to eight vertically placed sutures to reinforce the rectal wall. Redundant mucosa is excised and the defect closed [14, 16]. Some surgeons prefer to plicate the muscle with horizontal mattress sutures [10, 32] (Fig. 9.3a–c).

In the presence of an intact but weak sphincter and a short anterior anal canal, the longitudinal plication can be completed by two or three double-V transverse sutures to lengthen the anal canal. This reinforces the occlusion mechanism and improves incontinence.

An anterior Delorme’s procedure has been described as another anal approach to rectoceles, especially with an associated mucosal prolapse [33] or rectal invagination [34].

Endorectal procedures done with mechanical sutures were already described in 1993 by different authors [21, 22].

This likely inspired Longo and partners in the description of the STARR procedure. The stapled transanal rectal resection (STARR) procedure has been proposed for large rectoceles with intrarectal intussusception and a history of obstructed defaecation syndrome. Intrarectal intussusception described on defaecating proctography may suggest a mechanical obstruction to defaecation. Unfortunately, this has never been clearly proven as a direct cause of obstructed defaecation because the proctograms used in demonstrating this theory have always shown an empty rectum; thus intussusception cannot be advocated as the cause of obstruction.

The objectives of the STARR procedure in these patients are:

The largest prospective multicentre trial containing 90 patients undergoing the STARR procedure for treatment of outlet obstruction caused by the combination of intussusception and rectocele has shown encouraging early results [35–37]. All patients had significant improvement in constipation symptoms without affecting continence, and postoperative defaecating proctography showed the disappearance of both the intussusception and rectocele [17].

Severe complications, however, have been reported, including bleeding, faecal urgency, incontinence, stenosis, dramatic chronic pain, constipation [38] and rectovaginal and enteral fistulas [39, 40].

In our experience these complications are very difficult to treat. They result in an important negative influence on patient quality of life following treatment of a benign disease. The presence of an entero- or sigmoidocele at rest is a contraindication to the use of this technique.

Type II rectoceles may be treated by transvaginal or transperineal approaches, with or without the use of prosthetic materials to support the repair.

If a transverse perineal incision is used, the whole of the rectovaginal septum is exposed, separating each structure to demonstrate the levator ani, which is plicated using a series of horizontal mattress sutures. The interposition of mesh at this site has been reported [41]. Major complications such as erosion and infections may occur between 5 and 25 % [42–46]. It has been proposed that this approach is limited as it does not allow enough access to the upper part of the rectovaginal septum and to the pouch of Douglas. However, this approach can be useful in cases with a concomitant sphincter repair.

The transvaginal approach with an extensive posterior colpomyorrhaphy is a technique that has traditionally been preferred by gynaecologists and performed in the lithotomy position. A Lone Star retractor is useful, and following local anaesthetic and vasoconstrictor infiltration, the vaginal mucosa is incised transversely at the posterior hymen level and mobilized as far as the cervix or vaginal vault. The peritoneum at this point is mobilized and pushed up, and a Douglasorrhaphy may be performed. The levator ani and puborectalis muscles are dissected out and approximated at the midline with sutures. The first three sutures include the rectal muscle superficially 1–1.5 cm below the level of the first stitch into the puborectalis muscle. The rectal wall is then lifted and an anterior rectal mucosal prolapse is prevented (Fig. 9.4a–e). When the vaginal vault is prolapsing, a sacrospinal fixation may also be added [3, 47, 48]. In these cases, a colpopexy to the sacrospinal ligament may also be carried out.

If there is sphincter rupture or stretching, a sphincteroplasty may also be performed. One should note that an endovaginal approach is necessary in order to repair cases involving a ruptured puborectalis muscle (Fig. 9.5).