The same general principles apply to the preparation of patients for operations on the perineum and v.a.g.i.n.a as for operations on other parts of the body. Very particular attention, however, must be paid to the bowels; nothing is more prejudicial to the success of an operation, or more annoying to the operator, than to have the area of operation soiled by an escape of faecal matter from an imperfectly emptied lower bowel. The aperient should be given at least 24 hours before the time of operation. A copious soap-and-water enema should follow after the usual interval, and, an hour or two beforehand, the lower bowel should be thoroughly washed out with a gentle stream of warm water.

[Ill.u.s.tration: FIG. 29. PATIENT PREPARED FOR OPERATION. In lithotomy position with crutch applied, Auvard's speculum inserted, and volsella attached to the anterior lip of the cervix uteri. Kelly's pad is omitted for sake of clearness. (_From a photograph._)]

The external genitals should be shaved, and washed with ethereal soap solution and hot water the day before the operation, then douched with a 1-2,000 solution of perchloride of mercury, and a compress, soaked in the same solution, laid over the v.u.l.v.a. After the enema has acted, and after the final wash-out, the washing and douching should be repeated and a fresh compress applied.

If there is any v.a.g.i.n.al discharge, the v.a.g.i.n.a should be douched out three times a day for two or three days previous to the operation, with an antiseptic such as 1-4,000 perchloride of mercury, or 1% formalin.

The healing of a perineal wound is considerably impaired if it be continually bathed in an unhealthy v.a.g.i.n.al discharge.

When the patient is on the table and under the anaesthetic, the external parts should again receive a thorough final disinfection, and, in addition, the v.a.g.i.n.a should be thoroughly swabbed out with ethereal soap solution, by means of swabs on holders. A final douching with 1-2,000 perchloride of mercury completes the process.

In all cases of v.a.g.i.n.al hysterectomy for carcinoma, particular attention must be paid to the preliminary disinfection of the v.a.g.i.n.a by means of douching for two or three days before the operation. The v.a.g.i.n.a is swarming with various kinds of bacteria, and by careful attention to these principles the risk of sepsis will be materially diminished.

After the above preparations have been carried out, the patient is anaesthetized and placed on the table in the lithotomy position, the legs being kept well apart and fixed by means of a crutch. The b.u.t.tocks are brought well to the edge of the table, and a Kelly's pad may be placed beneath them. The legs should be encased in sterilized towels or linen stockings, and towels placed on the hypogastrium (Fig. 29).

OPERATIONS FOR THE REPAIR OF COMPLETE LACERATION OF THE PERINEUM

Under the term _colporrhaphy_ (suture of the v.a.g.i.n.a) is included any operation in which denudation and subsequent suturing of one or both walls of the v.a.g.i.n.a is carried out. Anterior colporrhaphy includes the various operations devised for cystocele; posterior colporrhaphy, the procedures carried out for incomplete rupture of the perineum (colpo-perineorrhaphy), prolapse of the pelvic floor, and to produce narrowing of the v.a.g.i.n.a.

The appearance of the parts in this condition is quite characteristic (Fig. 30); the laceration of the recto-v.a.g.i.n.al septum appears as a triangular s.p.a.ce with its apex upwards, its sides equal, and its base formed by the retracted sphincter ani (Fig. 32). The separated ends of the sphincter are seen as two slightly depressed circular spots at the base of each side of the isosceles triangle _a_, _a_{1}_. The object of the operation is to adapt these two ends, repair the recto-v.a.g.i.n.al rent, and re-form the perineal body. There is often much irregular scar tissue about the opening, which may cause additional difficulty at the operation.

The instruments necessary are six Spencer Wells artery forceps, long dissecting forceps with hooked points, a pair of sharp-pointed angular and a pair of sharp-pointed curved scissors (see Fig. 31), flat curved needles and Schauta's needle-holder (Fig. 73).

The preparatory treatment consists in regular gentle purgation daily for a week, dieting, rest in bed for three days, and antiseptic v.a.g.i.n.al douches of lysol (1 drachm to the quart).

[Ill.u.s.tration: FIG. 30. COMPLETE LACERATION OF THE PERINEUM. (_From a photograph._)

_a_, _a_{1}._ Ends of torn sphincter ani.

_cli._ c.l.i.toris.

_l.i._ Labium internum.

_m.v._ Mons Veneris.

_p.c._ Preputium c.l.i.toridis.

_sph._ Sphincter ani.

_ur._ Urethral orifice.

=Operation.= The patient is placed in the dorsal position on a Kelly's pad, and after the usual purification, _denudation_ is commenced. The skin over the circular depressions corresponding to the ends of the severed sphincter (Fig. 30, _a_, _a_{1}_) is seized with the dissecting forceps and slightly raised. This portion of skin on either side is removed by means of the scissors, thus baring the ends of the sphincter and opening up the cellular tissue.

The point of one blade of the scissors is now buried in the cellular tissue at this bared spot on the operator's right side, and is carried along the free torn edge of the recto-v.a.g.i.n.al septum between the deep and superficial tissues until the apex of the laceration is reached. A similar incision is made on the opposite side.

The triangles of the v.a.g.i.n.al flap are now raised by means of catch-forceps and the scissors pa.s.sed carefully into the cellular tissue, and the recto-v.a.g.i.n.al septum is split transversely, producing a raw surface somewhat the shape of a b.u.t.terfly in outline (Fig. 33). A median extension of the denudation is made in an upward direction for another inch in length to form a supporting column. This flap may, if the tissues are sufficiently redundant, be removed along the line running at its base. The raw surface should be swabbed over carefully, and any bleeding points secured by ligatures. Large venous sinuses are very often opened, and, should the bleeding recur after the adaptation of the flaps, the operation will inevitably fail.

[Ill.u.s.tration: FIG. 31. LONG-HANDLED SHARP-POINTED SCISSORS CURVED ON THE FLAT.]

Closure of the recto-v.a.g.i.n.al rent is first carried out by interrupted sutures, as is seen in the semi-diagrammatic drawing (Fig. 32). The threaded needle in a holder is pa.s.sed from the rectal side of the flap through the flap on to the raw surface, then over the rent on to the raw surface of the other side; it finally finds its exit again on the rectal side of the flap. Four or more sutures may be pa.s.sed in this way, a final one bringing the cut ends of the sphincter ani together. Each suture should be tied and the ends cut short before the next one is inserted, and the knots will lie just beneath the mucous membrane of the r.e.c.t.u.m.

[Ill.u.s.tration: FIG. 32. COMPLETE LACERATION OF THE PERINEUM.

Semi-diagrammatic drawing of a ruptured recto-v.a.g.i.n.al septum, indicating the method of pa.s.sing the sutures for its repair.

_r.m.m._ Rectal mucous surface.

_sph._ Torn end of sphincter ani.

_v.m.m._ v.a.g.i.n.al mucous surface.

The arrows indicate the direction of the sutures.

We have now a large b.u.t.terfly raw surface to deal with. The extension corresponding to the head is first of all dealt with by four or more separate sutures (Fig. 33, _a_). The large raw surface is now reduced in size by the pa.s.sage of a deeply buried suture (Fig. 33, _b_); those used in the preceding manuvres are best of silk. The buried suture should be catgut, and is pa.s.sed in a spiral direction, as is seen in the diagram; the area of the raw surface is very much reduced by it (Fig. 33, _b'_).

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, pa.s.sed beneath the raw surface, and made to emerge on the skin surface on the opposite side.

Four to six of these may be inserted.

[Ill.u.s.tration: FIG. 33. COMPLETE LACERATION OF THE PERINEUM. In A the 'b.u.t.terfly' surface has been denuded and the recto-v.a.g.i.n.al rent repaired (_c_).

_a._ Sutures pa.s.sed through the sustaining column, but not tied.

_b._ The 'buried' spiral suture pa.s.sed but not tied.

In B is shown the oval raw surface left to be brought together by sutures (_d_) after the buried suture (_b'_) has been tied.

(_Diagrammatic._) ]

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 pa.s.sed into the v.a.g.i.n.a and an antiseptic gauze pad placed over the perineum.

[Ill.u.s.tration: 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 pa.s.sed and tied; those on the left are pa.s.sed but not tied.

_a._ a.n.u.s _c._ Cervix _h._ Site of hymen.

_p_{1}-p_{3}._ Sutures pa.s.sed through the quadrilateral denuded surface.

_r._ recto-v.a.g.i.n.al wall.

_s._ Speculum (Pozzi's anterior retractor).

_t_, _t._ Tenacula.

The arrow denotes the direction in which the sutures are pa.s.sed.

=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 r.e.c.t.u.m 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 v.a.g.i.n.al sulcus and perineum; and, secondly, to draw up or lift the pelvic floor, which is more or less depressed.

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 v.a.g.i.n.al wall: Fig. 34 shows the appearances then seen. The left forefinger or some gauze packing is placed in the r.e.c.t.u.m and a double triangular s.p.a.ce 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 s.p.a.ce, 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 pa.s.sed. 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.

[Ill.u.s.tration: FIG. 35. REPAIR OF A LACERATED PERINEUM, WITH NON-UNION OF THE SPHINCTER ANI, BEFORE A PLASTIC OPERATION. (_From a photograph._)