The prolapse tends to present without difficulty (Figure 1), and Babcock or Allis forceps are applied for traction purposes to determine the extent of the prolapse. The relationship of the prolapse to the pouch of Douglas and the sphincter muscles of the anus is shown in Figure 2. The protruding mass is palpated to make certain the small intestine is not entrapped in the hernia sac anteriorly. Absorbable 000 sutures are placed in midline (Figure 3, A) anteriorly, posteriorly, and at the halfway point on either side (Figure 3, B and B1) near the anal margin, not only to serve as a retractor but for subsequent landmarks at the completion of the procedure. The identification of the pectinate line is important, since the incision through the presenting rectal mucosa will be made 3 mm proximal to this anatomic landmark. This minimal amount of mucosa is adequate for the final anastomosis and is short enough to prevent postoperative protrusion. A sharp knife or electrocautery can be used (Figure 3). This area tends to be quite vascular, and meticulous hemostasis by electrocoagulation or individual ligation is essential (Figure 4). The incision through the outer sleeve should divide the full thickness of bowel wall, including mucosa as well as the muscularis. The pouch of Douglas is not entered. The dissection is facilitated if the surgeon inserts his index finger in a developed cleavage plane between the two layers of prolapsed bowel wall (Figure 5).