Gynecology . sed of the rectocele, and restored the lateralvaginal attachments of the rectum, attention is now directed to bringing togetherthe separated levator ani and trans versus perinei muscles. In order to exposethe field of operation and to indicate the final position of the perineal body, thelast two internal sutures are not cut, but clamped together, and drawn stronglyupward by the assistant until the posterior wall of the introitus touches theanterior, and held in this position until the end of the operation (Fig. 236). 542 GYNECOLOGY The tissue of the external perineum is now dissec
Gynecology . sed of the rectocele, and restored the lateralvaginal attachments of the rectum, attention is now directed to bringing togetherthe separated levator ani and trans versus perinei muscles. In order to exposethe field of operation and to indicate the final position of the perineal body, thelast two internal sutures are not cut, but clamped together, and drawn stronglyupward by the assistant until the posterior wall of the introitus touches theanterior, and held in this position until the end of the operation (Fig. 236). 542 GYNECOLOGY The tissue of the external perineum is now dissected so as to give access tothe separated levator ani muscles. This is quite important, especially whenthere is a considerable amount of scar-tissue present. No attempt is made todevelop the muscular fibers of the levator muscles, for in this way fascial tissueis removed which is valuable for the purpose of union in healing. The fascialcovering of the muscles should, however, be cleared of intervening scar and. Fig. 235.—Opjekation for denudation is carried out as in the usual Emmets perineoplasty. The reduction of therectocele is accomplished entirely during the suturing of the lateral sulci. The stitches are carrieddeeply into the levator muscles on the sides. They are quilted into the rectal portion in the mannerhere shown, each one being carried further around toward the front until the last (fourth) stitchreaches the median line of the rectocele. When the stitches on both sides are drawn taut the rec-tocele is made to disappear. fatty tissue. In order to facilitate the isolation and clearing of the muscleslong-pointed tenacula are carried deep into the lower portion of the levators tothe sides of the sphincter ani, and the muscle bellies brought prominently intoview in the manner depicted in Figs. 236, 237. After removing all interveningtissue that may interfere with the union of the muscles, a figure-of-8 catgut stitchis introduced so as to create a broad s
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