2).Amid-sizedKellyclampisusedtocreateatracthigharoundthelower

sphinctercomplexintheischiorectalfossa(Fig.19-3).Theincisionsare connected,andtheclampisleftinplace(Fig.19-4).Thesilasticslingis constructedonthebacktable;a1.5cmwidepieceiscutalongthe stretchabledirectionofthesilastic(Fig.19-5).Thelengthshouldbelong enoughtopassthroughthetracts,completelyencircletheanus,andhave generousoverlaptosutureandsecureinplace.Thesilasticslingisthen graspedwiththeKellyclampanddrawnbackthroughthecreatedtractin theanteriortoposteriordirection,placingtheendsoftheslingtobe approximatedposteriorly(Fig.19-6).Whendissecting,theoperator shouldbecarefultoavoidenteringtherectalwallwhenpassingthesling, andacrosstherectovaginalseptumwhichisoftenmuchattenuated.The Kellyclampisthenpassedintheoppositedirectionthoughthe contralateralincision.Theotherendofthesilasticslingisgraspedwith theclampanddrawnbackthroughthetract.Thismaneuver circumferentiallyencirclestherectumandenoughtoavoidrecurrent prolapse(Fig.19-7AtoD).Afterthelimbsoftheslingareperfectly overlapped.Then,atotalofthreetofive2-0Prolenesuturesareplaced acrosstheslingintworows.Thesuturesareplacedinastaggered fashion,assuringnonearetooclosetotheslingedgestosecurethetwo limbstoeachother(Figure19-8).Theidealdiameterisbestdetermined aftertheinitialsuturesareplaced.Iftheslingisfelttobetooloose, anotherrowoftwoorthreesuturescanbeplacedtotightenthesling.The excessslingmaterialiscutabovethesuturesandpositionedwithinthe woundtobeclosed(Fig.19-9).Thetractsareirrigatedwithanantibiotic solution.Then,theincisionsareclosedwithabsorbable4-0monocryl subcuticularsutures(Fig.19-10).Antibioticointmentandasterile dressingareplaced.