A system of practical medicine. By American authors. Vol. 4

by Unknown

FIG. 10.

Folds on the Anterior Vaginal Wall formed after Twisting the First Suture (Emmet).

Inasmuch as the operation often fails at the point of the first suture, the author has usually introduced two or three of this kind instead of one. Two longitudinal folds are now formed on the anterior vaginal wall, which serve as guides for denuding and turning in the remaining redundant tissue by a line of sutures, which should extend forward along the centre of the vesico-vaginal wall until the folds are lost in the vaginal surface near the neck of the bladder. Sometimes the redundant tissue about the urethra cannot be disposed of by turning it in from side to side. Then it is desirable to make a crescentic denudation across the lower portion of the vagina, its concavity being on the uterine side, and to unite the margins below to those above by means of a curved line of sutures. The completed operation is shown in Fig. 11.

FIG. 11.

Emmet's Operation for Procidentia and Urethrocele completed. Sims's Speculum, Left Latero-prone Position (Emmet).

The after-treatment requires the self-retaining Sims's sigmoid catheter in the urethra for a week or frequent catheterization, absolute rest in bed, hot-water vaginal douches, regulation of the bowels, and the removal of the sutures on the twelfth day. After the completion of the operation the cervix is maintained near the hollow of the sacrum, and the organ remains normally anteverted and anteflexed, making an acute angle with the vesico-vaginal wall, which has now been restored to its normal direction and length. Unfortunately, it is not unusual to abandon the patient after this operation, in the vain hope that the uterus and anterior vaginal wall will maintain their normal relations without the support of the perineum and posterior vaginal wall. This is a great mistake, because the cystocele and procidentia almost always completely reappear within a few months. Anterior elytrorrhaphy, therefore, is simply one of the steps in the treatment.

PERINEORRHAPHY.—This is the name usually applied to the repair of the ruptured perineum, but the scope of the operation has been extended to include also the surgical treatment of rectocele and relaxation of the posterior vaginal wall. The most scientific operation yet devised is the one proposed by Emmet,⁸ which is performed as follows: The patient being etherized and in the lithotomy position, the operator seizes with a tenaculum the crest of the rectocele or posterior vaginal wall at a point which can be drawn forward without undue traction—point a. With another tenaculum the lowest caruncle or vestige of the hymen (point b), and with another the posterior commissure of the vulva (point c), are hooked up. The triangle included between these points defines one-half of the surface to be denuded. The three tenacula are now placed in the hands of assistants, the sides of the triangle are made tense by traction, and the included surface denuded. The tenaculum at c is then removed, and the middle point of the line a b is caught and drawn toward the interior of the vagina in the direction of the vaginal sulcus on that side, and the sutures are introduced, as in Fig. 13. The same thing is then repeated on the other side, and the sutures are all tightened, forming a line of union running back into each sulcus, as shown in Fig. 14.

⁸ Trans. Am. Gynæcological Society, 1883; Principles and Practice of Gynecology, 3d ed.

FIG. 12.

a is at the crest of the rectocele; b at the caruncle just within the labium; and c at the posterior commissure. The cut represents that half of the surface to be denuded which is on the operator's right. The dotted lines represent the other half, on the left.