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In some instances, especially when the prolapse is not particularly marked, the pouch of Douglas may be developed from the anterior rectal wall similar to a direct hernial sac (Figure 12). The peritoneum is then carefully incised and the margins held apart by traction with two or three forceps (Figure 13). The surgeon's index finger should be inserted to ascertain that the pouch of Douglas is free from attachments to either the small bowel or the adnexa in the female. It may be necessary to enlarge such an opening and insert a small retractor to accomplish this with good visualization. The pouch of Douglas should be closed as high as possible with a purse-string 00 absorbable suture (Figure 14). Considerable time may be required to make certain that the pouch of Douglas has been obliterated as high as possible. If the obliteration cannot be done satisfactorily, it may be judicious to obliterate the pouch of Douglas by a transabdominal approach as part of a plan for a second-stage or a two-stage procedure. After the peritoneum has been closed, the redundant peritoneum is amputated, and additional sutures are taken to control bleeding and reinforce the pouch of Douglas (Figure 15).

The next step involves identification of the levator muscles, since the reinforcement of the pelvic floor is essential to prevent recurrence. The procedure to be followed is not unlike the approximation of the levator muscles in the performance of a posterior perineorrhaphy. A small narrow retractor can be inserted anteriorly as the surgeon inserts the index and middle fingers of the left hand to better define the levator ani muscles on the left side. An Allis or Babcock clamp grasps the levator muscles to better define their margins, and a deep 00 absorbable suture is inserted (Figure 16). The first suture can be applied at either the top or the bottom of the proposed closure, depending on which is easier. In Figure 17, the first suture shown is placed in the bottom of the ...

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