is no longer extended. To facilitate dissection and reduce bleeding, epinephrine mixed with normal saline can be injected; however, in our hospital, it is only used to distinguish the mucosa from the muscle layer at the rst incision, and it is no lon­ger used during dissection. The mucosal layer of the rectum is dissected until it is no longer pulled, and the muscles are folded vertically in four directions to form plication, and then additional 8 points in between. The plication suture is done by pushing the muscle layer into the anal canal. The mucosal layer can be sutured together with plica­tion, or plicate only the muscle layer, and suture can be done separately (Fig. 11.6). As this approach has almost no postoperative complica­tions, it is the preferred method for patients with poor condition, but it can result in postoperative tenesmus and cause heavy feeling. Also, patients with severe constipation should consider a differ­ent surgical method, as it can be the cause for early recurrence of straining in defecation after surgery. In the case of long-term prolapse, it can be possible that the damaged sphincter cannot recover even after the surgery, and incontinence is likely to persist with patulous anus, so in this case, Thiersch’s procedure is combined using lapa-tape. This procedure is mostly used in pro­lapse within 5cm, and as it is generally considered safe, it has been used for patients with poor gen­eral condition. Recurrence rate (10–15%) is known to be higher than the Trans-abdominal approach but this might be coming from the dif­ference in the selected patients [26–28]. Which means, as this is mostly used in the elderly patients and therefore the recurrence rate can be higher, but in the other patients the recurrence rate is known to be no different [29].