Rectocele has been treated by many surgical techniques (1,2,3,4,5,6) including, the recent, novel stapling techniques (7,8,9,10,11,12,13). The transanal repair of rectocele and full rectal mucosectomy with one circular stapler (TRREMS procedure) was initially reported in 2005 (14). This method demonstrated two main advantages: the ability to quantify the amount of mucosa to be resected and the requirement for only one circular stapler. It is indicated in all patients with grade III rectocele, whether or not the rectocele is associated with mucosal prolapse, rectoanal intussusceptions, or hemorrhoids. The technique is contraindicated in patients with enterocele and in all patients with anismus. The latter group of patients should be preferentially treated by biofeedback and/or botulinum toxin.

Broad-spectrum antibiotic prophylaxis is recommended before surgery. A circular anal dilator (Fig. 28.1) is inserted into the anal canal and secured to the perianal skin with two stay sutures (anterior and posterior). The rectocele is delivered through the anal canal with a finger inserted into the vagina to identify the apex. The posterior vaginal wall is delivered through the vaginal introitus with a Babcock forceps. The apex of the rectocele is pulled down through the anal dilator (Fig. 28.1) and a running horizontal suture (Greek suture technique) is placed through the base of the rectocele all the way through, including the mucosa, submucosa, and the muscle layers of the whole anorectal
junction wall (Fig. 28.1). This suture is appropriately 2 cm cephalad to the dentate line, depending on the size of the rectocele. The excess of prolapsed mucosa and the muscular layer is then excised with an electrocautery/diathermy, and the wound is left open with the edges joined by the previous manual horizontal suture (Fig. 28.2

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