The sharp point of the tunneller is replaced by a plastic olive which has attached to it a T-shaped strip of Permacol™ (Fig. 17.1b). This strip is then drawn down to the perineal wound and its transverse part, measuring 2 cm in width, is sutured to the anterolateral rectal wall with two 0 PDS™ sutures with its lower edge at approximately 6–8 cm above the superior border of the sphincter complex (Fig. 17.1c). The vertical part of the strip is left emerging from the suprapubic wound with an artery forceps attached. This maneuver is repeated on the opposite side. Once in place, vertical traction is exerted on the strips via the suprapubic wounds. Once firm but not excessive traction of the rectal wall is achieved, the proximal parts of the T-shaped strips of Permacol™ are sutured to the periosteum of the pubic bone with the two interrupted 0 PDS™ sutures previously placed (Fig. 17.1d). If a rectocele is also present, it can be repaired at the same time using a patch of Permacol™. The patch is shaped 5 ± 5 cm in size with two extensions on the lateral sides. The patch is sutured over the anterior rectal wall with interrupted 2.0 PDS™ sutures (Fig. 17.2). The lateral wings are routed behind the puborectalis and sutured to the periosteum overlying the medial aspect of the ischium in line with the rectocele on either side with two sutures of 0 PDS™ on a J needle. This is performed from within the perineal wound, the rationale being to reinforce the rectovagianal septum and at the same time limit the anterior protrusion and ballooning effect of the anterior rectal wall causing the rectocele.