. Gynecology : . al incision. Tenacula have been applied at the caruncles and drawn outward. The mucocuta-neous border has been incised. The tissues are being separated by blunt dissection with scissors. of the Emmet operation except that the two wings of the area are asymmetricon account of the difference that usually exists in the extent of the two lateralscars. The perineal muscles and trigone are next developed, obstructing scar tissuebeing dissected away. The muscles are not bared to their muscle-fibers, but arebrought to view in their fascial investments. The deep sutures are now placed.
. Gynecology : . al incision. Tenacula have been applied at the caruncles and drawn outward. The mucocuta-neous border has been incised. The tissues are being separated by blunt dissection with scissors. of the Emmet operation except that the two wings of the area are asymmetricon account of the difference that usually exists in the extent of the two lateralscars. The perineal muscles and trigone are next developed, obstructing scar tissuebeing dissected away. The muscles are not bared to their muscle-fibers, but arebrought to view in their fascial investments. The deep sutures are now placed. A suture with needle at each end is started at the rectal protrusion surmountedby the central vaginal tab. The needle is then passed very deeply into the pubo- 640 GYNECOLOGY coccygeus muscle of the one side behind and not including the trigone. The needleof the other end of the suture is then carried into the belly of the other pubo-coccygeus muscle. The final course of the suture is to include the anterior end. Fig. 288.—Studdifords of the lateral sulci. The vaginal mucous membrane is freed in the two sulci by for-cibly inserting the forefinger beneathfche scars. The scar tissue is cut away as in the drawing. Themucous membrane of the left sulcus has been removed. That on the right is about to be final appearance is similar to that of the denudation of Emmets perineoplasty. of the sphincter muscle, that end of the suture being applied which will best drawthe sphincter toward the side on which the laceration was deeper. A second deepsuture is applied in the same manner. The next step is to close the lateral sulci which have been thus exposed. OPERATIONS ON THE VAGINA 641 This is done with a running subcuticular Gushing stitch starting from the apexand extending to the base of each lateral triangle, care being taken to secure asfar as possible the investing fascia. (In the drawings this step precedes theplacing of the deep stitches.) When t
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