A Text-book of Diseases of Women

by Charles B. Penrose

The lower end of the recto-vaginal septum that forms the anterior margin of the anal opening is usually thin and cicatricial where the mucous membranes of the vagina and rectum unite. All this cicatricial tissue should be cut away, and the mucous membrane of the vagina may be drawn forward and separated by dissection from the mucous membrane of the rectum, in order to make a somewhat broader surface through which to pass the sutures.

Special care should be directed to the denudation of the ends of the sphincter muscle. The tissue lying at the bottom of the depression that marks the end of the sphincter should be picked up with forceps or a tenaculum and carefully cut away. In removing tissue attached to the mucous membrane of the rectum the operator should avoid cutting the healthy portion of this mucous membrane, as bleeding from it is often annoying.

Fig. 37.—An old laceration through the sphincter ani. The sphincter muscle lies behind the anal opening. Its position is indicated by the wrinkled skin; its ends are marked by the depressions on each side of the anal opening.

The first suture should be introduced at the margin of the anal opening, within the area of corrugated skin that marks the position of the muscle, and behind the depression that marks the end of the muscle. The end of the muscle may be seized with a tenaculum or with tissue-forceps and drawn out to ensure that the suture includes muscular tissue. The needle is then passed near the edge of the rectal mucous membrane to the apex of the tear in the recto-vaginal septum. whence it emerges. It is re-introduced here, and passed in a similar manner to emerge upon the opposite side, behind the other end of the sphincter ani muscle ([Fig. 38]). This suture is introduced very near the edge of the wound, so that there may not be any inversion of skin to prevent perfect apposition of the ends of the muscle. In case there has been much retraction of the sphincter ani muscle, the ends of the suture may appear to lie behind the anal opening. The second suture is introduced somewhat outside of the first—still, however, within the area of the sphincter muscle—and is passed in a similar manner to emerge in the apex of the recto-vaginal tear anterior to the first suture. The remaining sutures to close the perineum are passed as already described in the operation for slight median tear of the perineum. When the sutures are shotted, great care must be exercised in making perfect apposition of the parts brought together by the first two sutures. Sometimes such apposition is more easily secured by shotting the anterior perineal sutures first. When the operation is completed the first suture through the sphincter is sometimes drawn upward, so that it disappears in the anal opening. If the muscle has been properly secured, it will be observed that the anal opening is surrounded by the ring of wrinkled or corrugated skin ([Fig. 39]).

Fig. 38.—Denudation and sutures for repair of laceration. The two posterior sutures pass through the sphincter muscle.	Fig. 39.—Completed operation. The anal opening is surrounded by the sphincter. One shot has disappeared in the anus. The anterior suture is omitted.

After this operation the bowels should not be moved for five or six days. The intestinal contents should then be rendered as soft as possible by the administration of small repeated doses of some saline purgative, as Rochelle salts ʒj, every hour for five or six hours. If the woman feels that she may have difficulty in having a passage, a rectal injection of a pint of soapsuds and warm water should be very carefully administered. The nozzle of the syringe should be well greased and passed along the posterior margin of the anal opening. After this the bowels should be moved every forty-eight hours. The sutures should be removed at the end of two weeks.

Fig. 40.—Laceration through the sphincter ani, extending up the recto-vaginal septum.

Laceration through the Sphincter Ani, involving the Recto-vaginal Septum.—In case the recto-vaginal septum has been torn, it may be necessary to repair the tear before operating on the perineum and the sphincter ani muscle. In some cases the laceration extends for three or more inches up the septum ([Fig. 40]).