The posterior vaginal apex (vaginal vault) is then identified and elevated by a vaginal trainer and sutured to same strip of mesh. Two lateral sutures incorporate the (remainder of the) uterosacral ligament. If an enterocele is present, more sutures must be made. Ideally, the sutures should not perforate the vaginal wall. This maneuver allows closure of the rectovaginal septum and suspension of the middle pelvic compartment. In this way, a vaginal vault prolapse or enterocele is corrected.

The lateral borders are closed over the mesh using the V-Loc 90 absorbable wound closure device (Covidien, Mansfield, Massachusetts, USA) elevating the pouch of Douglas over the colpopexy (and creating a neo-Douglas) (Fig. 21.4). This maneuver is important to avoid any later small-bowel entrapment and/or erosion.

No peritoneal drain is left in place. Ports are removed in a routine fashion, and only the fascia at the 12 mm port is closed.

It can be difficult to complete the rectovaginal septum dissection to the level of the pelvic floor. This maneuver is important in treating a complex, supra-anal rectocele. In this specific situation, the surgeon can decide to complete the laparoscopic dissection with a small perineotomy. The incision is made immediately dorsal to the vaginal orifice to open the perineal body. Dissection should be meticulous to avoid any perforation of the vagina or rectum. After perineotomy, this dissection joins the laparoscopic dissection plane, allowing mesh fixation in the deepest part of the rectovaginal septum and restoring the perineal body. However, a perineotomy can be avoided in most patients with a total rectal prolapse and should only be performed when laparoscopic dissection at the level of the perineal body fails.

The patient can resume oral intake the day of surgery. A fiber-enriched diet is prescribed. The urinary catheter is removed the following day, and mobilization is started. According to clinical progress, the patient can be discharged from day 1 onwards. Straining efforts and heavy lifting are discouraged for 4–6 weeks after surgery.

From January 1999 to December 2008, 405 patients underwent LVR for rectal prolapse syndromes. The mean age was 54.6 years [standard deviation (SD) 15.2] and median age was 55 years (range 16–88). Most patients were women (n = 376, 93%). Of the 405 patients, 168 (41.5%) had undergone previous pelvic surgery, the most common of which was hysterectomy in 154 patients (39%) (Table 21.1). In 27 patients (6.8%), LVR was performed for recurrent rectal prolapse.

Most of the patients had an internal rectal prolapse (45.9%, n = 186). Other indications were total rectal prolapse (43%, n = 174) and isolated rectocele and/or enterocele (11.1%, n = 45). In 95 of the patients (23.5%) the laparoscopic dissection of the rectovaginal septum was completed with a small perineotomy to treat a complex supra-anal rectocele, as previously described [13].

Data concerning operative difficulties and conversion, postoperative morbidity, and recurrence were gathered from a prospective database. Postoperative complications were graded according to Clavien-Dindo [14, 15]. The mean follow-up was 25.3 months (SD ±30, range 6–143). An extensive institutional questionnaire that assessed symptoms of anorectal and sexual dysfunction was used.

Data are presented as mean and SD, median and range. The Wilcoxon signed rank test was used for nonparametric paired data and a t test for paired and unpaired samples. p < 0.050 was considered statistically significant.