The posterior portion of the incision is extended backward over the coccyx, and the anus is tipped upward to enable its attachments to the coccyx to be severed more readily. After the anococcygeal raphe is severed and the presacral space is entered, the accumulated blood from above is suctioned out. The surgeon can then insert the index finger into the presacral space (Figure 6). The finger is swept laterally to identify the levator and muscles on either side. The levator muscle is exposed on one side and, with the finger held beneath it, is divided between paired clamps as far from the rectum as possible (Figure 7). Curved clamps should be applied to the levator ani muscles as they are divided to prevent the retraction of bleeding points. Following the ligation of all bleeding points on one side, a similar division of the levator ani muscles is carried out on the opposite side. Alternatively, the levator muscles may be transected with electrocautery, which can also control bleeding vessels. Vessels that are not easily coagulated with electrocautery should be individually secured with mattress or figure-of-eight absorbable sutures.