External Pelvic Rectal Suspension (the Express Procedure) for Internal Rectal Prolapse, with or without Concomitant Rectocele Repair: A Video Demonstration

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Internal rectal prolapse has been proposed as a cause of symptomatic rectal evacuatory dysfunction. Abdominal rectopexy, the standard surgical approach, has significant attendant risk and does not address any concomitant rectocele. This video was designed to demonstrate a novel surgical method that uses porcine collagen implants (Permacol™), designed to correct internal rectal prolapse, with or without rectocele.


Inclusion criteria: severe rectal evacuatory dysfunction refractory to maximal conservative therapy and full-thickness internal rectal prolapse impeding rectal emptying on defecography with or without associated functional rectocoele; normal colonic transit. Patients undergo comprehensive preoperative and postoperative symptomatic assessment and anorectal physiologic testing, including defecography. A crescenteric perineal skin incision allows development of the rectovaginal/rectoprostatic plane to Denonvilliers fascia, with rectal mobilization. A curved tunneller inserted via the perineal wound is guided retropubically to emerge through suprapubic wounds created on each side. Permacol™ T-strips are sutured to the anterolateral rectal wall bilaterally, upward traction exerted, and the stem of each T-strip is sutured to the suprapubic periosteum, suspending the rectum. Concomitant rectocele is repaired using a Permacol™ patch in the rectovaginal plane.


Short-term results for the “Express” are encouraging with improvement in evacuatory and prolapse symptoms and concomitant anatomic improvement at defecography.


This procedure promises to be an effective technique for managing patients with refractory evacuatory dysfunction secondary to internal rectal prolapse, with or without rectocele.

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The authors thank David Futcher of Flowmotion for his expert technical skills, invaluable for the recording and editing of this video.

Author information

Correspondence to Norman S. Williams M.S., F.R.C.S., F.Med.Sci.

Additional information

Reprints are not available.

Professor N. S. Williams is a consultant to Tissue Science Laboratories plc, the company that manufactures Permacol™.

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Dench, J.E., Scott, S.M., Lunniss, P.J. et al. External Pelvic Rectal Suspension (the Express Procedure) for Internal Rectal Prolapse, with or without Concomitant Rectocele Repair: A Video Demonstration. Dis Colon Rectum 49, 1922–1926 (2006).

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Key words

  • Surgery
  • Perineal approach
  • Internal rectal prolapse
  • Rectal intussusception
  • Rectocele
  • Rectal evacuatory dysfunction
  • Permacol™