The parts to be brought together will now present the appearance shown in Fig. 33, B, and they are approximated by means of silk sutures, which are entered on the skin surface on one side, passed beneath the raw surface, and made to emerge on the skin surface on the opposite side. Four to six of these may be inserted.
Great care must be taken to see that no bleeding points are left unsecured, and a current of hot 1 in 4,000 perchloride solution should be allowed to play over the surface, after which the sutures are tied. Each suture should be left about an inch and a half long in order to facilitate removal later on. A gauze drain should be passed into the vagina and an antiseptic gauze pad placed over the perineum.
After-treatment. The patient’s knees should be tied together, the urine drawn off by a catheter every six hours for the first 48 hours, and the wound kept as dry as possible. Throbbing and pain in the perineum with slight rise of temperature are generally indicative of suppuration taking place either between the flaps or along the sutures. A smart purge should be given on the morning of the third day and daily afterwards. If there are any scybala left in the rectum it is better to inject a little warm olive oil into it through a catheter before the bowels are expected to act.
The patient should be allowed to get up on the twenty-first day. There should be proper control of flatus and motions from the date of operation.
OPERATION FOR LACERATION OF THE PELVIC FLOOR
The objects of this operation are twofold: first, to secure the torn ends of the levator ani to the lateral vaginal sulcus and perineum; and, secondly, to draw up or lift the pelvic floor, which is more or less depressed.
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Fig. 34. Laceration of the Pelvic Floor.
The double triangular surface has been denuded. (Semi-diagrammatic,
from a photograph.)
The sutures, 1–5, on the operator’s right side are passed and
tied; those on the left are passed but not tied.
a. Anus c. Cervix h. Site of hymen. p1–p3. Sutures passed through the quadrilateral denuded surface. r. recto-vaginal wall. s. Speculum (Pozzi’s anterior retractor). t, t. Tenacula. The arrow denotes the direction in which the sutures are passed. |
The patient is placed in the lithotomy position and a retractor is inserted in the anterior cul-de-sac in order to elevate the anterior vaginal wall: Fig. 34 shows the appearances then seen. The left forefinger or some gauze packing is placed in the rectum and a double triangular space is denuded by means of sharp-pointed scissors, the base line of the double triangle being formed by the hymen. Two tenacula are inserted as indicated in the drawing (Fig. 34, t, t). The mucous membrane is now removed from the M-shaped space, great care being taken to penetrate deeply into the lateral sulci. After all bleeding has been arrested in the usual manner, the sutures should be passed. On the left-hand side of the figure these are indicated as inserted, not tied, whereas on the right they are tied and cut. Subsequently the somewhat quadrilateral raw surface which is left is brought together by five deep sutures, and the operation is complete. A Y-shaped cicatrix will be the result.