Gynecology . e the first step in theordinary perineoplasty—i. e., the lateral sulci are denuded and sutures placed,uniting the anterior portion of the levator ani muscles (puborectales) to the sidesof the rectum. This in some cases is unnecessary, for it often happens that theperineal separation is entirely in the median line along the raphe uniting thelower bellies of the levators, and not at all along the sides of the rectum. This 548 GYNECOLOGY is usually the case when the rectovaginal septum is ruptured for any consider-able distance. When there is no separation in the lateral sulci and no
Gynecology . e the first step in theordinary perineoplasty—i. e., the lateral sulci are denuded and sutures placed,uniting the anterior portion of the levator ani muscles (puborectales) to the sidesof the rectum. This in some cases is unnecessary, for it often happens that theperineal separation is entirely in the median line along the raphe uniting thelower bellies of the levators, and not at all along the sides of the rectum. This 548 GYNECOLOGY is usually the case when the rectovaginal septum is ruptured for any consider-able distance. When there is no separation in the lateral sulci and no extensivetear of the septum a simple median denudation is used with catgut approxima-tion from side to side, care being taken not to make the introitus too there is extensive rupture of the rectovaginal septum a special technic isrequired (see below): The type of case most commonly seen is depicted in Fig. 243. When theinternal vaginal part of the operation is finished, the two last catgut sutures. y1.^-G>gs—? Fig. 243.—Operation for Complete Laceration of the internal part of the perineum operation has been completed. The red line indicates theoutline of the area to be denuded from the external perineum. It is carried below the dimples thatmark the position of the sphincter ends. This denuded area should not be made so wide that theskin edges cannot be approximated without too much tension. which close the lateral sulci are left long, clamped together, and held firmlyupward by an assistant for the remainder of the operation. The area of denuda-tion of the external perineum is now outlined. Beginning at the Bartholinduct of the left side, a light mark is made in the skin with the scalpel down tothe dimple which indicates the retracted end of the sphincter muscle. Thisline should be curved slightly inward. On reaching the dimple the line is OPERATIONS ON THE VAGINA 549 carried around it, and across to the dimple that represents the other end of th
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