The optimal operation for rectal prolapse is unclear. Various options exist. Broadly, one can carry out the operation via a perineal or abdominal approach. If perineal, should it be a Delormes or rectosigmoidectomy combined with a levatorplasty or not? If abdominal, should it be open or laparoscopic and should the rectum be simply mobilised or fixed? If fixed, what with and where from and to? Should the lateral ligaments be divided or preserved and should the redundant sigmoid be resected? With such a huge variation in techniques, what is the evidence that will tell us what the best approach for prolapse surgery is? Unfortunately, the literature is full of poor quality data mainly from case series and expert opinion. So the first step must be to concentrate on only the quality comparative data in the form of randomised controlled trials. Can this data tell us anything? The next step is to decide what outcome to assess. The obvious outcome is recurrence. When considering the two broad approaches, there is a perception that an abdominal procedure will result in a lower incidence of recurrence. Indeed, the recurrence rate for any perineal procedure may be greater than 40 % if the patient is followed up for long enough [1]. Is there good quality comparative data to back up this perception that the abdominal procedure is more robust? Two randomised trials have taken on this comparison [1, 2]. Both have inadequate numbers of patients to reach any meaningful conclusion, but for the numbers that have been examined no difference in recurrence was seen for either approach. The most recent trial failed to recruit adequate numbers despite the trial being multicentre, indeed multinational, and running for many years. Herein lies the problem with such trials. Surgeons are inclined to individualise when it comes to approach, with the perineal procedure, perhaps done under regional anaesthetic, reserved for elderly frail patients, and the abdominal approach indicated for younger patients who can tolerate a more invasive procedure and have potentially many more years of life. Equipoise does not therefore exist, and any trial becomes very difficult to recruit to. But perhaps it is time for a readjustment of this surgical dogma; the advent of laparoscopic techniques means that elderly patients can undergo abdominal procedures without an increase in complications [3]. If we assume the decision has been made to carry out an abdominal approach, is there any evidence to suggest how to carry out the operation? In terms of recurrence there probably is not. However, one large reasonably welldesigned trial has shown that the rectum cannot simply bemobilised; it has to be fixed to reduce recurrence [4]. However, recurrence is not the only important outcome. For instance, in terms of recovery, it is clear that a laparoscopic approach results in shorter postoperative stay and actually reduces overall costs [5]. Constipation is another important outcome, and the common perception is that abdominal rectopexy alone will increase the incidence of constipation in many patients, justifying the need for resection to be combined with the rectopexy [6]. Is this true? Is the added possibility of anastomotic breakdown, even if rare, really worth the risk? The study by El Muhtaseb et al. [7] would suggest it is not, with resection rectopexy failing to correct abnormal transit Comment on El Muhtaseb et al.: Colonic transit before and after resection rectopexy for full-thickness rectal prolapse (doi:10.1007/s10151-013-1053-4).