**6.3 Transvaginal approach**

For a century, posterior transvaginal **colporrhaphy** and its modifications have been the usual transvaginal approach with optimal anatomical results.

In lithotomy position, and after infiltration of the vaginal wall with saline and adrenaline to facilitate dissection and reduce bleeding, a transverse incision is made at the level of the mucocutaneous junction (vaginal introitus) in the posterior vaginal wall. Annex 1 shows the main steps of this technique shown in a real case.

Dissection of the rectovaginal septum is continued, combining blunt and sharp dissection, until reaching the proximal end of the rectocele and laterally until exposing the puborectal muscles [4, 13].

After completing the dissection, the rectovaginal septum and the rectal wall are plicated in a longitudinal direction with simple stitches, using a non-absorbable polypropylene suture (prolene®), long-term absorbable monofilament (PDO), or absorbable polyglycolic acid braided suture. 2/0.

In the case presented as an example in Annex 1, it was combined with the previous performance of purse-string plications with vicryl® suture at the point of maximum protrusion of the rectocele, given the large size of this specific case. In case of an associated enterocele, the sac is opened after dissection and subsequently closed, hence repositioning the Douglas sac.

Perineorrhaphy with horizontal sutures and levatorplasty may be associated or omitted. It is important to check both the consistency of the rectovaginal septum and the correct size of the vagina post plication by rectal and vaginal examination, some authors propose at least two fingers in diameter.

Finally, the excess tissue of the vaginal mucosa flap is excised, which is done in the exposed case after marking the section level using indocyanine green. However, the use of this technology is not imperative. Finally, the closure of the vaginal plasty is completed with simple absorbable sutures. It is not necessary to place drains in the closure.

Regarding the results [15] of posterior colporrhaphy with native tissue, the literature shows that an improvement in anatomical and obstructive defecation symptoms is achieved after this technique. Side effects or complications have a low incidence, being dyspareunia the most common.

After the exposition of the main techniques, the existence of **Site-Specific Repair** [15] should be explained. This technique also improves anatomical defects and most obstructive defecation symptoms, but its results in terms of constipation are unclear. The most common side effects are dyspareunia and also tenesmus.

Specifically in the transvaginal approach, with the use of non-absorbable synthetic meshes, post-surgical complications have been described. There is a wide variety in terms of the severity of these complications, from pain, infection, bleeding, granulomas, urinary tract infection, dyspareunia, and even extrusion of the mesh or formation of fistulas or visceral lesions such as rectal, bladder, or vaginal perforation (1–4%). In the long term, up to 30% of patients may present mesh contraction with pain and dyspareunia [22].

FDA (Food and Drug Administration) has made a safety communication concerning about this topic, making a recommendation for the use of mesh in the transvaginal approach only "after weighing the risks and benefits of surgery with mesh versus all surgical and non-surgical alternatives" [23]. So, it should be used only in complex cases after failures of other surgeries and providing information about the possibility of all possible complications.
