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The procedure in the male is illustrated because the dissection between the rectum, membranous urethra, and prostate poses more problems than dissection in the female. Palpation of the inlying urethral catheter will facilitate the procedure by localizing the urethra and preventing accidental injury to the above-mentioned structures (Figure 8). The skin and subcutaneous tissue of the perineum are retracted upward, while the anus is pulled downward and backward to assist in the exposure. The rectum is pulled down, the remaining attachments of the levator animuscles and transversus perinea are divided, and all bleeding points are ligated. In the female the dissection between the rectum and vagina is more easily accomplished if counterresistance is applied to the posterior vaginal wall by the surgeon's fingers. In the presence of extensive infiltrating growths it may be necessary to excise the perineal body as well as a portion of the posterior vaginal wall.

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The upper end of the bowel segment is grasped and delivered posteriorly over the coccyx (Figure 9). A retractor is introduced anteriorly to assist in exposure, while any remaining anterior attachments of the rectum are divided (Figure 10). The large pelvic space is thoroughly inspected under direct illumination in order to clamp and ligate any active bleeding point. The cavity is packed with dry sponges until the field is free of oozing (Figure 11). When a two-team approach is used, irrigation may now be carried out from above.

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It is usually possible to approximate the divided levator ani muscles in the midline (Figure 12). Two closed suction Silastic catheter drains are placed in the presacral space and brought out through the skin lateral in the incision and secured to the skin. The subcutaneous tissue and skin are closed with very large and widely spaced interrupted vertical mattress sutures of no. 1 nylon or silk. These are tied loosely (Figure 13).

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The blood loss must be replaced during the operation and postoperatively. Intravenous Ringer's lactate solution is given and the hourly urine output monitored. With accelerated postoperative care pathways, urinary catheters are now often removed on the first postoperative day. This does not obviate the need for careful attention to voiding as described in the more traditional approach below.

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