**5. Abdominal approach**

In the main abdominal approach (Colpoperineopexy), an opening of the pelvic peritoneum is performed, and a non-absorbable mesh is placed in the rectovaginal septum, attaching the top of the vagina on the sacral promontory. In the case of also performing the pexy of the rectum on its anterior or posterior face, it will be called colporectosacropexy (**Figure 4**). It can be performed using a minimally invasive approach such as laparoscopic or robotic, which is why this technique has been more popular in recent years.

This technique shows improvement in ODS (> 70%) with low morbidity and low recurrence rates (7.5 and 14.2% in 3 and 10 years, respectively) [3]. Although there is an anatomical improvement after surgery, there are studies that report that, however, this improvement is not reflected in defecation symptoms and may even worsen [15]. Thus, this technique is indicated mainly in patients with complex rectocele or invagination or associated rectal prolapse and symptoms of ODS.

In very few cases of ODS, no damage to the posterior wall is associated, which is corrected with vaginal apical pexy. In these cases, laparoscopic ventral rectopexy can be performed, indicated in patients with enterocele or ODS secondary to rectal intussusception [4].

When rectal prolapse is associated, techniques such as Frykman-Goldberg technique can be used. This technique, described in 1969, combines rectopexy and resection of the redundant sigma with anastomosis [16].

In this technique, a rectal dissection must be performed low on the posterior vaginal wall for a subsequent pexy "to the periosteum of the sacral promontory" once the rectum is freed and mobilized, as described in the reference [16]. After the pexy, the redundant sigmoid colon resection and the anastomosis are performed. It is therefore, a technique recommended in cases in which there is a constipation due to a redundant sigma existence or due to the rectum angulation. It is also used in cases in which the surgeon avoids placing meshes taking into account the associated risk as in pregnancies.

In the absence of an ideal mesh for intra-abdominal placement, we prefer the perineal approach in cases of celes in the posterior compartment and the abdominal approach with direct pexy to the sacrum in case of several compartments involvement, avoiding the use of mesh as much as possible.

*Perspective Chapter: Surgical Management of Symptomatic Rectocele DOI: http://dx.doi.org/10.5772/intechopen.105505*

#### **Figure 4.**

*Rectocolposacropexy: (A), (B). Laparoscopic mesh placement and fixation with PDO stitches and tackers to sacral promontory. (C) Peritoneum closure.*

Frykman-Goldberg surgery can be performed by open, laparoscopic, or robotic approach [17]. However, in this chapter we focus on extra-abdominal techniques.
