The patient should be placed in the dorsal lithotomy position and prepped and draped in the usual manner for pelvic surgery. At this point, an accurate diagnosis should be made as to whether the patient has an enterocele alone or an enterocele associated with a rectocele. STP identifies the superficial transverse perineal muscle.

By excising an edge of perineal body skin at the fourchette, the surgeon carries the triangle up over the posterior fourchette into the posterior vaginal mucosa and converts the triangle to a diamond-shaped defect. The Allis clamps on the vaginal mucosa over the rectocele are elevated by an assistant.

The posterior vaginal mucosa is undermined by curved Mayo scissors and opened in the midline. The edges of the vaginal mucosa are grasped with T-clamps and held on traction. It is essential that the assistant create a triangle for the surgeon by elevating the Allis clamps on the posterior vaginal mucosa upward and the T-clamps on the edge of the vaginal mucosa downward. The incision in the posterior vaginal mucosa should be carried up to the vaginal apex and should expose the sac of the enterocele.

When the entire posterior vaginal mucosa has been opened, the sac of the enterocele is identified and grasped with an Allis clamp. Blunt dissection is carried out to remove the perirectal fascia from the posterior vaginal mucosa so that the sac of the enterocele can be clearly identified. A small incision is made into the sac.

A finger is immediately inserted into the opening of the sac, and the intestinal contents are identified and displaced back into the abdomen. A pursestring suture of 0 synthetic absorbable suture is placed around the neck of the enterocele sac.

A second pursestring suture of 0 synthetic absorbable suture is placed around the neck of the enterocele sac.

Before either of these sutures is tied, a finger should again be inserted into the sac to displace any intestinal contents back into the abdomen. The rear pursestring suture should be tied first; then the front pursestring suture should be tied.

High ligation of the sac has been completed, and the sac can now be removed.

The stump of the sac is seen. The uetrosacral ligaments and the anterior rectal wall are identified. Three sets of 0 synthetic absorbable sutures should be placed between the anterior rectal wall, the stump of the enterocele sac, and the uretrosacral ligaments. Each suture is placed progressively lower in the genital canal than the previous one. Each suture is held on hemostats until all are placed; then each is progressively tied.

Uterosacral ligaments, the stump of the amputated sac of the enterocele, and the anterior rectal wall have all been plicated. The development of any future enterocele is unlikely.

Attention can now be directed toward repair of the rectocele if present. A finger is inserted in the midline, depressing the rectum and exposing the levator muscles. Zero synthetic absorbable sutures should be placed in the levators and held prior to tying. After all sutures have been progressively placed in the levators, they should be tied from the lowest suture in the genital canal, placed first, to the uppermost suture, placed last.

Excessive vaginal mucosa is trimmed away.

A 0 synthetic absorbable suture is used in a running fashion to close the posterior vaginal mucosa. Note how the long end of the suture is left in place from the apex of the closure. Each suture is carefully placed above this suture; care is taken not to entrap the suture with another bite of the running stitch. STP identifies the superficial transverse perineal muscle.

The entire posterior vaginal vault wall down to the hymenal ring has been closed. At this point, the suture is tied. Note that the free end of the original suture placed at the apex remains. By tying the free end of the suture left after the vaginal mucosa has been closed down to the hymenal ring, the surgeon draws the apex of the posterior vaginal mucosa against the levator muscles and eliminates dead space.  After tying the running suture in the posterior vaginal mucosa at the hymenal ring, the surgeon inserts the needle behind the hymen into the vagina and brings it out through the insertion of the bulbocavernosus muscle.

At this point, plication of the superficial transverse perineal muscle (STP) is made by several interrupted 0 synthetic absorbable sutures. The insertion of the bulbocavernosus muscle is plicated in the midline, incorporating a suture into the superficial transverse perineal muscle to completely reconstruct the perineal body.

The bulbocavernosi muscles are approximated in the midline by the running suture. The skin of the perineal body is approximated by a subcuticular suture.

The reconstructed vaginal vault and perineal body are shown.

A sagittal view shows how the direction of intra-abdominal pressure is now applied to the anterior vaginal wall. Note how the cul-de-sac has been obliterated by the suturing together of the posterior vaginal wall, pelvic peritoneum (P), anterior rectal wall, and uterosacral ligaments. This line of pressure is directed away from the genital hiatus in the levator plate, reducing the possibility of recurrent prolapse. B, bladder; and R, rectum.