The use of implants in surgery has become increasingly frequent over the last century, particularly polypropylene-based meshes in the management of abdominal wall defects/hernias. The disadvantage, however, of synthetic meshes in particular reference to colorectal surgery has been the well-documented risks of infection, extrusion, and fistulation (1,2). With these concerns biological implants have been introduced. They are
predominantly derived from porcine dermis, due to its similarity in structure to human dermis.

One such commercially available porcine dermal implant is Permacol™ (Covidien, MA, USA), an acellular cross-linked porcine collagen. The cross linking prevents degradation by collagenases and it is therefore theoretically permanent once implanted. It also elicits a very mild inflammatory response, with minimal fibrosis, and can be successfully used to reconstruct defects within infected fields. In addition, histological studies have demonstrated the implant to be associated with ordered neocollagen deposition presumed to result in greater tissue strength than at the time of implantation (3). These characteristics make Permacol™ an ideal implant to utilize in surgery for pelvic disorders, particularly those of the posterior compartment, which require any implant to be placed in close proximity to the rectum.

Rectal evacuatory disorder/dysfunction (RED) is a complex problem where the primary abnormality is the preferential storage of residue in the rectum for prolonged periods, with the inability to evacuate this residue adequately. The pathophysiologies that underlie RED are not well understood as the etiology is varied: anatomical disorders of the rectum, for example, megarectum and prolapsing disorders of the rectal wall, for example, RI and rectocele. Rectal intussusception can be defined as a full thickness invagination of the rectal wall, which is thought to cause symptoms by impeding the evacuation of the rectum either by occlusion of the rectal lumen (recto-rectal) or the anal canal (recto-anal). Furthermore, the presence of the intussusception, particularly in the upper anal canal, may result in a sense of incomplete evacuation despite adequate clearance of rectal contents. However, the significance of RI is not fully understood due to its presence in studies of asymptomatic volunteers, albeit in a less severe form (4). Commonly associated with RI is a rectocele, a ballooning of the anterior rectum into the posterior vaginal wall resulting in trapping of rectal contents thus contributing to symptoms of evacuatory dysfunction.

There are few described procedures for a surgical repair of RI (5), and can be divided into resectional, intra-rectal Delorme’s, stapled transanal rectal resection (STARR) procedure, or suspensory techniques, such as the various forms of abdominal rectopexy. Most, however, are universally associated with poor functional outcomes (6), or serious complications (7,8).

With these limitations in mind we have developed an innovative minimally invasive technique that combines the advantages of abdominal rectopexy procedures, namely, lower recurrence rates, with the advantages of perineal approaches, lower morbidity, and ability to repair a coexistent rectocele. The EXternal Pelvic REctal SuSpension (EXPRESS) is essentially an anterior perineal rectopexy, which involves fixation of the rectum to the periosteum of the superior pubic ramus with or without simultaneous reinforcement of the rectovaginal septum with a Permacol™ patch, to correct any coexistent rectocele.