ABSTRACT
Step 9. The operating surgeon relocates to the perineum at this point and makes a circumanal incision. For malignant disease, the incision is deepened, extending into the ischiorectal fossae bilaterally. (For benign disease, this incision can be con tinued proximally in the intersphinceteric plane between the internal and external sphincter.) The anococcygeal raphe is divided in the posterior midline as the posterior three-quarters of the anus is mobilized in a cephalad direction using electrocautery. The inferior hemorrhoidal vessels are encountered in the anterolateral region of the ischiorectal fossae at the level o f the upper anal canal. These vessels usually require separate ligation.
