. A manual of gynæcology and pelvic surgery, for students and practitioners. d if the 150 INJURIES TO THE PERINEUM AND PELVIC DIAPHRAGM dissection. is carried widely enough toward the lateral vaginalwalls it permits of the adjustment of the levator muscle andfascia behind the vagina. After placing forceps on either side of the vulva as in thepreceding operation, the posterior commissure is split trans- FiG. 65.—Secondary repair of incomplete perineal laceration by split-flapmethod. Sutures in levators not tied. Flap in process of removal. versely from one forceps to the other, and the vaginal
. A manual of gynæcology and pelvic surgery, for students and practitioners. d if the 150 INJURIES TO THE PERINEUM AND PELVIC DIAPHRAGM dissection. is carried widely enough toward the lateral vaginalwalls it permits of the adjustment of the levator muscle andfascia behind the vagina. After placing forceps on either side of the vulva as in thepreceding operation, the posterior commissure is split trans- FiG. 65.—Secondary repair of incomplete perineal laceration by split-flapmethod. Sutures in levators not tied. Flap in process of removal. versely from one forceps to the other, and the vaginal flap israised and dissected from the rectum by the finger coveredwith gauze. At both sides some cicatricial tissue may need tobe cut with scissors but the dissection as a whole is made bluntly. SPLIT-FLAP PERINEORRHAPHY 151 This separation may be continued as high as is deemed neces-sary, even to the peritoneum, and should extend sufficiently farlaterally to expose the levators to view. There is no danger ofperforating the rectum and no necessity for soiling the fingers. Fig. 66.—Secondary repair of incomplete perineal laceration by split-flapmethod. The edges of the flap have been approximated after tying deep skin sutures are also tied. Operation completed. by their introduction into the anus. An occasional large veinwhich is torn across needs tying. The sutures of small sized chromic catgut are started at theapex of the denudation and approximate the lateral vaginal walls 152 INJURIES TO THE PERINEUM AND PELVIC DIAPHRAGM posterior to the flap and superior to the levator muscles. Thesutures may be either continuous or interrupted, preferably acombination of both in order to avoid the annoyance of a brokenstrand when the suture is nearing completion, so necessitatingre-suture of the entire wound if the continuous stitch is usedwithout interruption. When the levators are reached, as they are after one or twostitches are in place, great care is used to approxima
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