Examination of the rectum under anaesthesia with a circular anal dilator is crucial before, during and after rectal prolapse correction surgery - 'Getting it right first time': a video vignette.

Internal rectal prolapse (IRP) is a bewildering condition that is met with a host of different reactions from colorectal surgeons. It lacks the consensus and attention that, for example rectal cancer might have, with many surgeons viewing it as a variant of normal and fearful of surgical correction. This is in part due to the difficult and often multifactorial nature of the problem, as well as concerns of using mesh in the pelvis. Due to an increase in scientific assessment and advances in cinedefecography a more objective classification has been possible along with treatment options. Herein we advocate a careful assessment of the condition, ideally within a pelvic floor clinic and an initial trial of conservative management along the "salt to cooking" mantra. In treatment resistant, and carefully selected, cases we advocate discussion in a pelvic floor MDT. In those small number of cases where surgery is recommended, we propose that there is no "one-size fits all" approach, and that a bespoke and precise approach tailored to the individual patient's symptom complex, history and anatomy are crucial to give the best chance of success. Where anatomical correction is indicated (rectopexy) we advocate the use of pre, peri- and post-operative assessment of the prolapse using a circular anal dilator. The authors believe that this is essential to ensure that the rectopexy has "worked". Whilst anatomical correction does not always correlate to an improvement of symptoms, we believe that "blind" correction of the prolapse without intra-operative "testing" is likely to fail. JB conceived the idea of using a CAD intra-operatively during the rectopexy. Both operations were done together. JB wrote the manuscript and EDC approved it. EDC wrote the ppt slides. JB narrated. Complete collaboration.