Part 21 (1/2)

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 was.h.i.+ng 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.