Fig. 45.—An old laceration of the perineum in both sulci. Rectocele. The mouth of the vagina is held open to show the appearance of the parts before operation: a, apex of the rectocele.
A perineum in this condition is often said to be relaxed. It is relaxed because the muscular and fascial supports have been destroyed.
Treatment.—The treatment is directed to the restoration of these supports. Each vaginal sulcus must be denuded, so that the condition existing in the recent injury ([Fig. 43]) is reproduced, and the sutures must be passed so that the retracted muscles and the fascia are brought back to their normal attachments. The best method of operating for this condition has been devised by Emmet.
| Fig. 46.—The rectocele is seized with the tenaculum at a, and is drawn to the right, exposing the left vaginal sulcus, a, b, c, which must be denuded. The point b should be secured with a tenaculum before denuding. | Fig. 47.—Method of denuding the sulcus. |
Emmet’s Operation (Figs. 45-55).—When the labia have been separated, it will be observed that there is a bulging or prominence of the lower portion of the posterior vaginal wall, which is called a rectocele. The most prominent point or the apex of the rectocele should be held by a tenaculum or by a silk ligature passed immediately beneath the mucous membrane.
This point should be such that it may without undue traction be drawn to either orifice of the vulvo-vaginal glands.
| Fig. 48.—The left sulcus denuded. | Fig. 49.—Both sulci denuded. |
If the apex of the rectocele is drawn to one side, there is formed on the other side a triangular area ([Fig. 46], a, b, c). The base of this area (a, c) is at the ostium vaginæ. The inner side (a, b) runs along the side of the rectocele. The outer side (b, c) runs along the lateral vaginal wall. The apex b is approximately the highest point of the tear in the sulcus. The angle c is immediately below the orifice of the vulvo-vaginal gland. The angle b is fixed by a tenaculum held by an assistant, and the triangular area is denuded. The denuded area does not correspond exactly with the original tear in the sulcus, but the denudation exposes the sulcus, so that sutures may be passed in such a way as to include the muscles and fascia. The sulcus on the opposite side is then denuded in a similar manner, and the lower face of the rectocele is denuded. It is best to begin the denudation by seizing with tissue-forceps the mucous membrane of the posterior vaginal wall at the ostium vaginæ, at the junction of skin and mucous membrane, and to remove contiguous strips of tissue by cutting upward toward the apex of the vaginal sulcus ([Fig. 47]).
| Fig. 50.—Introduction of the sutures. The point of the emerging needle is held by the tenaculum. | Fig. 51.—Sutures introduced in both sulci. |