Iliococcal suspension is primarily an apical suspension procedure. It also provides support to the proximal part of the posterior vagina. This makes it a good procedure for patients with proximal posterior vaginal wall prolapse. The objective of this video is to demonstrate our technique of performing a rectocele repair with iliococcygeus fascial suspension. The goal of surgery is to achieve proximal posterior vaginal wall support using iliococcygeal suspension. Distal posterior vaginal wall support is obtained by suturing the dorsal perineal membrane or the rectovaginal septum to the distal levator fascia along the archostendinous rectovaginalis. This is a sagittal histologic section of the posterior vaginal wall. The area corresponding to the hymen is shown. The perineal body and the external anal sphincter are immediately posterior. The internal anal sphincter partly overlaps and extends cephalad to the external anal sphincter. The longitudinal muscles of the rectum are shown. The rectal lumen is immediately posterior. The dorsal perineal membrane extends from the proximal portion of the perineal body to 2-3 cm cephalad. Similar to this is the rectovaginal space. This is a 64-year-old gravidar 2 par 2 with a stage 2 posterior vaginal wall prolapse. The prolapse had both proximal and distal components. Alice clamps are placed on the posterior vagina at the area corresponding to the proximal iliococcygeus. The procedure begins by placing marking sutures at this level. Posterior vaginal dissection is carried out and the rectovaginal space is entered. The rectovaginal septum or the dorsal perineal membrane and the perineal body are demonstrated. The rectum is dissected away posteriorly. A combination of sharp and blunt dissection is carried out towards the ischial spines bilaterally. After the rectum is dissected away, the dorsal perineal membrane is dissected away from the posterior vagina and the pelvic sidewall. The anteroseal sac is identified and this is reduced by placing series of pursing sutures. The rectoseal is reduced by placating the rectal muscularis in midline. This is accomplished using a series of stitches with 2-O-Vicryl. Using a right angled retractor, the right iliococcygeus fascia is exposed. A 2-O-PDA stitch is placed on the right iliococcygeus fascia and tagged. This is going to be tied down at a later stage. For the purpose of demonstration, traction is placed on the stitch and the depth of the stitch is also demonstrated. The exact same procedure is now performed contralaterally. After the iliococcygeal stitch is placed, a long straight needle driver helps in retrieving the needle. The PDA stitches are now passed through the posterior vagina at the area of the marking stitches placed at the beginning of the procedure. The dorsal perineal membrane or the rectovaginal septum is now sutured to the distal levator fascia along the archostendinous rectovaginalis. This is performed with 2 stitches of 2-O-PDS on each side. Suturing the dorsal perineal membrane to the distal levator fascia provides support to the distal part of the posterior vagina. This image shows the anatomic relationship of the perineal body and the dorsal perineal membrane on a sagittal view and a patient in lithotomy position. The dorsal perineal membrane providing support to the distal 2.5 cm of the posterior vagina is shown. This is confirmed on rectal examination. The edges of the vaginal incision are trimmed. The vaginal incision is closed with 2-O-Vicryl in a running continuous fashion. After the vagina is closed halfway, the iliac occipital stitches are tied down. Evaluation reveals good posterior vaginal wall support. Vaginal closure is resumed. Note the incorporation of the dorsal perineal membrane into the posterior vaginal wall closure. A perineurophy is performed with 0-Vicryl and the perineal skin is closed with 3-O-Vicryl in a subcuticular fashion. Note the unique technique in performing perineurophy in order to avoid skin bridging. A perineurophy is performed with 0-Vicryl. A rectal examination at the end confirms excellent proximal and distal posterior vaginal wall support. In summary, incorporation of iliac occipitous fascial suspension into a rectocele repair provides excellent proximal posterior vaginal wall support. Moving the dorsal perineal membrane to the distal levator fascia along the archostendinous rectovaginalis provides excellent distal posterior vaginal wall support. This is a good surgical option for patients with proximal and distal posterior vaginal wall prolapse using patient's native tissue without any graft material.

rectocele repair

iliococcygeus fascial suspension

posterior vaginal wall support

native tissue technique

proximal and distal prolapse support