Mark out the mucocutaneous junction at the posterior vaginal fourchette for the initial transverse incision, particularly if there are plans to correct a perineal defect at the time of surgery. Dissection of the posterior vaginal wall flap is best performed using primarily sharp dissection, with Allis clamps on the epithelial edge to retract the flap superiorly. Alternatively, a midline incision can be useful if the defect extends more proximally along the posterior wall. Digital manipulation of the rectum using the O’Connor shield can help facilitate this step by allowing the defect to be palpated, guiding further dissection (Fig. 13.2). Be prepared to encounter scar tissue during the initial dissection of the epithelium off the perineal attachments from prior prolapse and/or episiotomy repairs. At this point, an avascular plane should be identifiable between the vaginal epithelium and rectocele sac. The proper plane allows the surgeon to free the rectocele completely using blunt dissection. As the sac is dissected, identify the rectovaginal fascia and follow it laterally until its attachment at the arcus tendineus levator ani. If an isolated defect is encountered, then a “site-specific” fascial repair is indicated. Otherwise, traditional plication of the rectovaginal fascia to reduce the rectocele is most commonly performed; in this situation, we prefer to use an absorbable suture, such as 0 or 2-0 polyglactin (Vicryl®) suture, but a slow-absorbing suture (such as polydiaxonone, PDS) is also an option.

The plication consists of a series of interrupted sutures from one sulcus to the other, incorporating the rectovaginal fascia. Each suture is left untied and clamped with a mosquito clamp or hemostat. Once all the sutures are placed, they are tied one at a time, starting from proximal (deep) to distal (superficial). We use a DeBakey forceps or a narrow malleable retractor to reduce the sac while tying the sutures. A critical maneuver at this point is to avoid overtightening the plicating sutures, which may potentially introduce de novo dyspareunia. Examination of the vaginal introitus and canal after the sutures are tied to allow two fingerbreadths width easily without any palpable “ridge” to avoid dyspareunia. Once the placating sutures are placed, any redundant or macerated epithelium can be trimmed to permit closure of fresh wound edges. The epithelium is then closed using a running 2-0 absorbable suture.

In cases with an extensive defect, prior failed native tissue repair, and/or a woman who is no longer sexually active, the high midline levator myorrhaphy (Chap. 11) is an intraperitoneal technique that can be useful not only to correct a rectocele, but also for vaginal vault fixation and to prevent enterocele recurrence [15].