**6.1 Transperineal approach**

The transperineal extra-abdominal technique begins with the infiltration of saline serum and adrenaline at the level of the rectocele, to facilitate its dissection. After that, transverse perineal incision is performed, and the plane between the external anal sphincter and the posterior vaginal wall is dissected with either blunt or sharp dissection [13].

Once the apex of the vagina is reached and the exposure of the rectocele and the levator muscle is completed, the upper limit of the rectocele is identified as the point at which it differs from the longitudinal muscle of the lower rectus wall. A plication of the rectocele is performed in the midline from the most apical point downwards, successive plications can be performed. The plication can be vertical or horizontal, presenting better results the horizontal according to Waleed et al. [18]. Levatorplasty may or may not be associated. Finally, the cutaneous plane is closed after the reconstruction of the rectovaginal septum.
