The patient is placed in the dorsal lithotomy position. The pelvis and large intestine are prepared for surgery.

A bimanual examination under general anesthesia is performed to differentiate between an enterocele and a rectocele. Observation of the perineal body is made to determine the extent of reconstruction needed.

The labia are retracted with interrupted sutures. The upper extent of the rectocele is identified. Allis clamps are applied to the posterior vaginal mucosa over this area. The clamps are elevated, creating a triangle.

Allis clamps are placed at the margins of the original hymen. An additional Allis clamp is placed in the midline at the top of the rectocele. A transverse incision is made at the posterior fourchette. A Kelly clamp is inserted under the posterior vaginal mucosa, dissecting the posterior mucosa off the perirectal fascia. An additional incision is made in the perineal body, removing a triangular piece of skin, outlined by the dotted line. This will expose the insertion of the bulbocavernosus muscle. Only the skin of the perineal body should be removed, and care should be taken not to remove the underlying superficial transverse perineal muscles.

The vertical incision in the posterior vaginal mucosa has been made, and the edges are held with Allis clamps. The perirectal fascia is dissected off the posterior vaginal mucosa. The apex of the rectocele is held in an Allis clamp. The dissection of perirectal fascia off the vaginal mucosa is started with a scalpel but is completed with the handle of the scalpel or with scissors.

A finger is placed over the rectocele, pushing it into the rectum, thus revealing the margins of the levator ani muscles. A heavy, number 1 synthetic absorbable suture is passed through the margin of the levator ani from the apex down to the posterior fourchette. Frequently, 5-6 sutures are required to completely approximate the levator ani. By depressing the anterior rectal wall downward with one finger and elevating the previously placed suture, the surgeon sees the margin of the levator ani more clearly, and placement of sutures becomes easier.

After all levator ani sutures have been placed, they are progressively tied.

The excessive posterior vaginal mucosa has been trimmed away; the triangular defect in the perineal body can be seen. The insertion of the bulbocavernosus muscle is adjacent to the triangular defect in the perineal body.

The perirectal fascia is closed with interrupted 0 synthetic absorbable suture in the midline

A 0 synthetic absorable suture is placed at the apex of the vaginal mucosa and tied (a). The tail of the suture is left for a length of 20 cm. The suture (b) is placed superficial to the tail of the suture (a).

The closure of the posterior vaginal wall is completed to the posterior fourchette. The former hymenal ring is reconstructed. The suture (b) is tied to the tail of the first suture (a) placed at the apex. The vaginal mucosa is approximated to the perirectal fascia to eliminate dead space.

The same suture completes the closure of the perineal body. Several interrupted 0 synthetic absorbable sutures are placed in the insertions of the bulbocavernosus muscles to reconstruct the perineal body.

The posterior vaginal mucosa suture (b) is placed in the subcutaneous tissue of the perineal body. Note that the suture marked a is still left long for eventual tying.

The same suture (b) that completed the closure of the posterior vaginal wall is used to close the subcutaneous tissue and the insertions of the bulbocavernosus muscles. The suture marked a is the long end of the tie at the apex of the posterior vaginal mucosa incision.

The subcuticular suture (b) is placed in the skin of the perineal body from the apex of the wound immediately above the anus to the posterior fourchette. At the posterior fourchette it is tied to suture a.

The completed operation is shown, with the rectocele reduced and the perineal body reconstructed. Vaginal packs are not required. Bladder catheterization is rarely indicated.