No. 3 is a photograph showing the ends of the sphincter muscle, dissected out and held in the grasp of forceps E and F. and to prevent subsequent thinning of the perineum, from stretching of the new tissue. In the operation for complete tears, the usual denudation is made on the rectal margins, which are brought together with interrupted sutures. After closing the rectum and lessening the chances of contamination from that source, the denudation is continued after the method of Emmet, except that the mucous membrane is pared off the rectum or rectocele, between the sulei on either side and terminating at a point on the upper margin of the rectocele, in the median line of the vagina. The tissues over the ends of the sphincter muscle are drawn up with forceps and split open, in a line parallel to its fibers, as illustrated in figure 2. Then the mucous and sub-mucous structures, including, when necessary, the anterior wall of the rectum, are brought together in the median line, by interrupted sutures of catgut, tacking the rectocele behind the line of union. When the fascia overlying the levator ani muscle is reached, it is included in the stitches up to the posterior commissure of the vaginal orifice. The levator ani muscle should be approximated by a catgut suture close to the rectum, to prevent the formation of a dead space. This suture should include a full quantity of the muscle to secure coaptation, without the necessity of tight-tying, as the latter may produce tenesmus. The deep pelvic fascia is next brought together with fine silk sutures, as illustrated in figure 7, 8 and 9. This fascia is easily located in central tears, but when the laceration is lateral, it often retracts to an extent that makes it difficult to find. In such circumstances, the tissues in the body of the perineum, at the margin of the sphincter ani muscle, should be grasped with double-hooked forceps, and drawn toward the median line, which will facilitate palpation of the lower border of the triangular fascia, figure 6. No. 4 is a drawing illustrating the method of tucking in the ends of the sphincter muscle with the mattress suture. This suture may be displaced by two or more small interrupted sutures, unless there is considerable tension upon the muscle; in that case it is safer to include the ends of the sheath in the stitches. Sphincter muscle. No. 5 is a drawing, showing the fascia of the pelvic floor, and the method of locating the edge of the triangular fascia (G) and under surface of the deep pelvic fascia (H) with blunt hook. I is the fascia overlying the levator ani muscle (J). No. 6 is a photograph showing the method of feeling for the lower edge of the triangular fascia, with index finger in the vagina and thumb on a line with the anus. By palpating in this way, the fascia may be easily located, except in lateral lacerations extending around the side of the anus and rectum. |