Rectocele is a common condition in parous women that may lead to symptoms of obstructed defecation syndrome (ODS) [1]. To move toward surgical intervention, certain indications are required including rectocele >3 cm, significant barium entrapment on defecography, and frequent need for digital assistance of defecation [2]. Surgical treatment of a rectocele can be done by the posterior colporrhaphy or with a site-specific repair. The traditional repair may be done by transvaginal or transperineal approach, transanal approach. Stapled transanal rectal resection (STARR) and ventral mesh rectopexy are also alternatives. Traditionally, the open approach through transperineal or transvaginal has the same method to access the rectocele except for the incision, then the posterior colporrhaphy is done by midline side-to-side (vertical) plication of the rectovaginal septum with or without levatorplasty [3]. Also, some authors reported promising outcomes of horizontal (craniocaudal) plication of the rectovaginal septum through other approaches rather than transanal one .

The aim of this review is to assess the current literature regarding the outcomes of horizontal repair of rectocele through different perineal approaches (transvaginal and transperineal).

An organized literature search for studies that assessed the outcome of horizontal repair of rectocele was performed. PubMed/Medline, Embase, Google Scholar, and Cochrane Library were queried in the period January 1991 through December 2021. The main outcome measures, whenever possible, were improvement in ODS symptoms, improvement in sexual functions and continence, changes in manometric parameters, and impact on quality of life (QoL).

After the screening of 67 studies, and with the exclusion of similar transanal techniques (Sarles and Block techniques), 4 articles were found eligible for inclusion in the review. 
Through a prospective case series study ,after exposure of the rectovaginal septum through transvaginal incision , Schmidlin-Enderli and Schuessler sutured the rectovaginal fascia in a craniocaudal fashion with sagittally positioned running absorbable sutures with a careful reapproximation of the laterally separated perineal body in the midline with 3-4 sutures, thus covering the perineal part of the rectocele. All the 54 patients suffered from ODS and 70.4 % had protrusion symptoms preoperatively. ODS showed remission or improvement in 72.2 %. Also, the anatomical correction rate was 92.1 % and protrusion symptoms were resolved in 73.6 %. Among sexually-active patients, 5.2 % reported de novo dyspareunia postoperatively. There were no major intra- or postoperative complications. [2]. 
Similarly, a retrospective study was adopted by Henn and Cronje using  the same horizontal plication technique but with the sutures running in a zig-zag fashion. Among the 123 female patients, ODS was observed in 35.3% and fecal incontinence in 25.2%. The majority of women (51.8%) had stage 3-4 prolapse. All symptoms significantly improved except for fecal incontinence. There was a significant improvement in rectocele (p < 0.001) with the majority of women noted to have a stage 0 or 1 (88.6%) prolapse at follow-up. While a non-significant decline in overall dyspareunia from 18% to 12.2% was observed [3].
Recently, Omar , Elfallal and colleagues prospectively  compared horizontal and vertical plication in a randomized control trial . This trial included 40 (20 in each group) female patients with anterior rectocele. There was no significant difference between the two groups regarding the postoperative Wexner score. Complete cure and significant improvement in ODS symptoms were comparable after the two techniques. The reduction in rectocele size after horizontal plication was significantly greater than after the vertical one (1.7 vs. 2.6, P < 0.0001). Significant improvement in dyspareunia was recorded after horizontal plication (P = 0.001) but not after vertical plication (P = 0.1). There was no significant difference between the two groups concerning complications and recurrence [1].
Moreover, Leanza and colleagues adopted the classic plication technique but with the addition of perineorrhaphy (perineal body anchorage) using horizontal sutures (covering the lower part of the rectocele) in comparison to the classic and transanal techniques. All the used techniques were effective to repair posterior compartment defects and improving the QoL. The authors reported lower sexual and better anatomic and pain outcomes with vaginal techniques and better functional outcomes with transanal repair .

According to the law of Laplace, the anterior bulging of the rectal wall (tubal structure) to form a rectocele (spherical structure) is associated with a decline in both intraluminal pressure and wall tension. The attempt to repair the rectovaginal septum will return the rectum into a tube again. In horizontal repair, the direction of repair in a craniocaudal fashion creates a tension force perpendicular to that in the rectal wall. While, in vertical repair, the direction of repair in a side-to-side fashion creates a tension force that is parallel to and against that in the rectal wall (as shown in Figure 1) rendering them weaker and more liable for disruption.

Horizontal (craniocaudal) plication provides a valuable technique with promising outcomes. Unfortunately, only a few studies adopted this technique. So, we recommend performing further studies with larger sample sizes and in comparison to other standard techniques to get more accurate and precise results

Omar W, Elfallal AH, Emile SH, Elshobaky A, Fouda E, Fathy M, Youssef M, El-Said M. Horizontal versus vertical plication of the rectovaginal septum in transperineal repair of anterior rectocele: a pilot randomized clinical trial. Colorectal Dis. 2021 Apr;23(4):923-931. doi: 10.1111/codi.15483
Schmidlin-Enderli K, Schuessler B. A new rectovaginal fascial plication technique for treatment of rectocele with obstructed defecation: a proof of concept study. Int Urogynecol J. 2013 Apr;24(4):613-9. doi: 10.1007/s00192-012-1911-z.
Henn EW, Cronje HS. Rectocele plication: description of a novel surgical technique and review of clinical results. Int Urogynecol J. 2018 Nov;29(11):1655-1660. doi: 10.1007/s00192-018-3623-5. Epub 2018 Mar 12. PMID: 29532125.

Continence 2S2 (2022) 100373
DOI: 10.1016/j.cont.2022.100373