Suture rectopexy is one of the most widely used abdominal approaches to the treatment of full-thickness rectal prolapse. Cutait is credited with the first description of suture rectopexy [1, 2]. It is a safe procedure with low morbidity and mortality [2, 3]. Other abdominal approaches have results that are comparable to suture rectopexy and are described elsewhere [3, 4]. Recurrence rates after suture rectopexy for prolapse have been consistently reported to be less than 10%, which are lower than reported for perineal approaches [5, 6]. Traditionally, suture rectopexy and other abdominal approaches such as mesh rectopexy have been used in relatively healthy patients. In older or frail individuals a perineal approach is more likely to be chosen, as the patient does not need to recover from an abdominal incision. This dogma has recently been challenged. In a review of the American College of Surgeons National Surgical Quality Improvement Participant data, suture rectopexy and other abdominal approaches were found to be safe and feasible in highrisk patients, including octogenarians and those with an American Society of Anesthesiologists score greater than 3 [2]. Technical factors may impact the success of suture rectopexy, such as the extent of rectal mobilization, choice of open or minimally invasive approach, and the decision to include colon resection as part of the surgical procedure.

Suture rectopexy may be approached by open or minimally invasive techniques. The patient is placed in a modified lithotomy position. The open technique incision may be lower midline or Phannensteil. Laparoscopically, bilateral ports are required. The sigmoid colon and rectum are first identified and assessed for redundancy. The ureters must be identified and avoided during dissection. The peritoneal reflection is incised and rectal dissection is performed. The rectum is mobilized posteriorly through the avascular plane, with care taken to avoid hypogastric nerve injury and bleeding. A deep posterior rectal dissection to the level of the pelvic floor is important. Once posteriorly mobilized, lateral dissection of the rectum is done to the level of the lateral stalks. The lateral ligaments may or may not be divided, and the choice to divide the lateral ligaments is discussed later in this chapter. The rectum is then sutured to the sacral promontory using nonabsorbable sutures. One to three sutures are placed on each side, tacking the lateral rectal ligaments to the presacral fascia bilaterally. Great care must be taken not to penetrate the rectum with the sutures. If a resection is included, the rectopexy sutures should be placed several centimeters distal to the anastomosis to help avoid angulation of the anastomosis. In addition, the splenic flexure, inferior mesenteric artery and vein, and superior rectal artery and vein are preserved. Flexible endoscopy is performed to assess the anastomosis and as part of an air leak test after creation of the anastomosis. After verification of anastomotic integrity, the rectopexy sutures are tied and then endoscopy and air testing are repeated to ensure that the rectal lumen has not been narrowed by the rectopexy sutures. Although some angulation is expected, if stenosis is noted one or more of the rectopexy sutures should be removed and the endoscopy repeated.