**6.2 Transanal approach**

Within the transanal approach, there are classic techniques performed by and sewing such as transanal rectoceleplasty, and others more innovative in which mechanical sutures are used.

#### *6.2.1 Hand sewing*

Transanal rectoceleplasty [19] is classically performed in the jackknife position and with prior retrograde preparation with a cleansing enema and an anal retractor. After infiltration of saline with epinephrine, a transverse incision is made in the dentate line, and a muco-muscular flap with a broad base is made about 7–10 cm proximally. After careful revision of hemostasis, successive plications are performed, first longitudinally and later transversely with absorbable material (plyglicolic acid) sutures. After resecting the excess part of the flap, it is completed with the closure of the flap with simple stitches also made of absorbable material.

Other transanal rectoceleplasties have specific variations in their technique, such as those described below: In the Sarles technique, an opening of the mucosa is performed over the rectocele and subsequently a transverse plication of the rectal muscle layer is performed.

In the Sullivan technique, a horizontal plication is performed with several sutures.

The Khubchandani technique is a mixed technique in which a stapler suture is performed on the posterior rectal wall and subsequently a U-shaped flap and after that transverse and vertical plicatures on the anterior wall [5].

Regarding results, transanal approach achieves an anatomical improvement of the defect and the symptoms of obstructive defecation. Infection is more common in this technique as a complication [15]. In addition, it can also compromise the function of the anal sphincter [19], which in this case may cause de novo incontinence.

## *6.2.2 Mechanical suture (stapled)*

Continuing on the topic of transanal approach, we will discuss the technique of transanal rectal resection with stapler (stapled transanal rectal resection STARR) [15].

The STARR technique involves double stapling with a circular stapler and an anal dilator and a purse-string suture. It is performed through a transanal approach in order to achieve a circumferential resection of the entire thickness of the anterior and posterior rectal wall. There are modifications in which the resection of the rectal wall is performed with an endostapler, or with the CONTOUR®TRANSTARTM semicircular stapler, a technique called TRANSTAR, which can facilitate the resection of the entire thickness of the rectal wall and is considered a safe and effective treatment for ODS (STARR TRANSTAR) associated with rectal wall intussusception and/or rectocele in the hands of experienced surgeons [20].

The STARR technique has positive impact in anatomical and obstructive defecation symptoms. The most frequent adverse effects and complications are urgency fecal incontinence, in up to 40%, that usually improves with time and resolves in about 3 months, minor bleeding, and postoperative pain [15]. Other important but infrequent complications are rectal diverticulum, rectovaginal fistula, rectal obliteration, rectal wall hematoma, or perforation. These complications appear to be reduced by using a parachute

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

suture instead of a purse-string suture [20]. The existence of various ways or tricks in this type of approach is a sign of the real need for standardization of the technique.

The TRREMS (transanal repair of rectocele and rectal mucosectomy with one circular stapler) [21] performs the section with a single circumferential stapler, and it is suggested as a safe, economic, and effective procedure for the treatment of rectocele associated with mucosal prolapse.

Within the techniques performed with a stapler, there is a transperineal variation that consists of the mechanical stapling of the rectocele with a GIA, after dissecting the rectovaginal septum, adding a reinforcing PLP mesh at this level. This technique is called SPERR (Stapled Perineal Rectocele Resection).
