THREE is, probably, no branch of surgery that requires more thought, ingenuity, and operative dexterity, than do the plastic operations for the restoration of the pelvic structures in women. A study of the anatomy, physiology, natural and acquired relation of parts, immediate and remote effects of injury and their reflex influences, is essential to a correct understanding of the subject. When the pelvic floor is weakened by a repute of its supporting structures, the functions of all the pelvic organs are, more or less, disturbed, and, ultimately, the entire human organism may become affected.
The levator and muscles form the floor of the pelvis. They are two broad, thin muscles, which have their origin, principally from the posterior aspect of the and ramus of the pubes; posteriorly, from the inner surface of the spine of the ischium. They pass downward and unite in the middle line. The most posterior fibres are inserted into the sides of the coccygeal apex. The middle fibres, which form the bulk of the muscle, are inserted into the side of the rectum, blending with the sphincters.
The transverse perinaei arises from the inner side of the tuberosity of the ischium and is inserted into the sides of the sphincter vaginae and levator ani. These, in conjunction with other less important muscles, and the faciae, make up the perineal body. The levator ani, which constitutes the bulk of the perinaeum, supports the lower end of the rectum, the vagina, and the bladder. A rupture of these parts, such as often occurs during labor, disturbs the muscular equipoise of the region. The torn fibres separate, the transversus perinaei muscles, instead of holding the central raphe in a state of tension, pull open the vaginal orifice. The anus is drawn upwards and backwards, towards the coccyx. The fascia, having lost its attachments, allows the anterior rectal wall to pouch forward, forming a rectocele, which drags the vaginal wall downward.
The vaginal muscle which has its principal attachment to the rectovaginal fascia, loses its tonicity, permits the cervix to fall forward, changing the position of the uterus, which becomes more or less prolapsed, dragging down the bladder, preventing its entire evacuation, which causes increased relaxation and stretching of tissue, cystocele. The blood vessels having lost their support, a general venous stagnation, with its consequent engorgement of the pelvic viscera and discomfort, ensues.
The variety and complexity of vaginal and perineal tears is, indeed, surprising. It has always been my habit to make a careful inspection of the parts after every confinement, and, I believe that I have seen almost every form that could be produced. The orthodox central lesion is the most frequent, but not, by any means, the most injurious. Lateral internal vaginal ruptures, that are often made with the tip of the blade of the forcep when removing it, before the head is born, are among the most mischievous. I have seen these extend from near the cervix uteri to the vaginal orifice, the outside structures being intact, and so deep that the cellular fat protruded through the gap. A infrequent tear, of which I have seen three, is where the vaginal outlet is torn away from its attachments being pushed forward by the head; the mucous membrane gives way just within the orifice.
The most extensive one, extended upward on either side, almost to the urethra, and downward to the sphincter ani muscle, making a pocket-like chasm, in which the four fingers of the hand could be inserted. A small central laceration, though which the child’s shoulder emerged, existed, yet the sphincter was not torn. Another most significant lesion that is often overlooked, is where the muscular structures of the perinaeum are torn in two and the skin remains uninjured; these tears are often deep, from pockets for the retention of septic matter, do not unite but granulate, and form large cicatrices, and yield disastrous results to the pelvic viscera.
A rare condition that I once repaired, was an oblique laceration, one and one-half inches long, that existed well forward near the urethra. It bled furiously, and was difficult to close. I have repeatedly seen a submucous separation of the perineal structure where the mucous membrane of the vagina and the skin on the outside remained intact.
The power to prevent many of the severe disasters to the general health follow ruptures of the perinaeum and vagina, lies with the accoucheur. It is his imperative duty to make a critical examination of the genitalia after every labor, and if he finds any form of rupture, it matters not how insignificant it may seem to him, it may in some remote way produce trouble; therefore, it should be repaired before be leaves his patient. This should be done in the most systematic and painstaking way.
If necessary, an anaesthetic should be given. The genital tract and adjacent parts should be most carefully cleansed, and douched with an antiseptic lotion; the torn surfaces trimmed of all ragged and contused tissue, rendering the parts even and clean cut. The wound should then be closed with two sets of catgut sutures deep and superficial, coaptating like structure. Two much care cannot be exercised in doing the operation. It properly executed, the results are most satisfactory,and failure will rarely follow.
When a laceration has been sustained, and the evil consequences manifest themselves, the case then becomes one for the surgeon’s consideration, and the question that confronts him is, how can a restoration be accomplished; how can the over- distended and everted vaginal tissue be replaced, and the proper support given to the pelvic viscera and blood vessels? The relaxed tissue in front, that forms a cystocele, must be removed; the separated levator ani muscles must be brought together, the retracted pelvic fascia united so as to lift the posterior vaginal wall in contact with the anterior, obliterating the rectocele and closing the gaping vulva. When all this is successfully done, the normal support capillary circulation is relieved, the hyperplasiac deposits absorbed, the hypertrophied organs reduced and a healthy function restored.
The operator who does not fully appreciate the requirements of each case, and deal with it according to its individual demands, but simply endeavors to restore an imaginary perinaeum-a dam-like obstruction to the prolapsing structures-will meet with disappointment in almost every instance.
The time allotted to read a paper does not admit of my taking up the entire list of plastic operations upon the vulva and vagina; therefore I shall only attempt to deal with three, viz., Removal of scars, cystocele and perineal injuries.
It is an established truth with all close observers who treat diseases of women, that cicatrices of the vagina produce both local and reflex irritation, disorder the nervous system, and thereby, more or less, impair the entire bodily nutrition; and I will say here, for the benefit of those who oppose in immediate repair of vaginal and perineal lacerations, that it is bad surgery to leave any wound of those parts, whether it occurs during parturition or from other causes, to heal by granulation.
For aside from the ultimate injury that the pelvic viscera sustains, these reflex troubles may arise, and will yield to no treatment excepting the removal of the scar. Considering the above facts, amputation of the uterine cervix or operations about the vagina ought not to be performed with either the ecraseur or the galvano-cautery. The knife or the scissors should be used, and the demanded surfaces covered with mucous membrane.
These scars of the vagina demand serious attention at the hands of the surgeon; they should be managed with the same care accorded laceration of the cervix. All other or contracting cicatrices should or contracting cicatrices should be dissected away and the resulting wound closed with sutures. Remnants of a lacerated hymen and thickened and sensitive nymphae should be excised, excrescences about the meatus clipped away, adhesions of the clitoris broken up, and, if necessary, a V-shaped piece cut from its hood.
CYSTOCELE.-A cystocele is a pouching deformity of the anterior vaginal wall, caused by a laceration or an over- distension of the structures. It contains the base of the bladder, and is gradually increased by the frequent straining at micturition-an ineffectual effort to evacuate the urine that constantly remains therein. The constant irritation increases the vascularity and causes a thickening of the walls. The condition is one that entails great suffering and is often overlooked by operators. Like other conditions about the vagina that demand repair, many devices-some of them extremely complicated-have been instituted for its correction. Its successful management is simple enough if the requirements are fully understood. The object sought is to change the convex to a plain surface; take all the shack out of the anterior vaginal wall, but not shorten it to any great degree. No stereotyped or set rules can be laid down to govern beforehand the amount of tissue to be removed or to designate the shape of the denuded surface.
Before beginning any of the operations for the repair of the vaginal or perineal structures, it is proper to dilate and curette the uterus, if necessary, and repair any laceration of the cervix that any exist. If the cervix be badly diseased, as it often is in old subject, an amputation is demanded. All the required operations may be done at one sitting or divided into two, as the necessity of the case may demand. It has generally been my habit to do the operations upon the womb and anterior vaginal wall first, leaving the return and perinaeum for a subsequent time, before the patient leaves her bed.
With the patient anaesthetized and in the lithotomy position, with the parts in an aseptic condition, the surgeon takes a sharp tenaculum in either hand, hooks them in the mucous membrane on either side of the cystocele, and draws the tissues to the centre until all the slack has been taken up. It is often the case that a urethrocele coexists, when it will be necessary to carry the dissection well up to the meatus. At times the broadest area may be near the os uteri. After making out the area to be denuded, as before described, the vaginal wall is seized in its central line by one or two pairs of T-forceps which are held and drawn forward by an assistant. Then with a sharp scalpel, beginning down at the os uteri, an incision, that extends through the v muscle, is carried forward on one side, along the line of election, to near the meatus; another one, in like manner, is made on the opposite side.
Then with a few strokes of the knife, the loose cellular tissue which connects the vaginal muscle with the bladder is divided and the flap removed. Any irregularity or unevenness of surface may then be cut away with a pair of sharp scissors. The bladder is then evacuated with a catheter, the parts irrigated with hot water, to control the oozing, and the sutures introduced. This should be accomplished with medium- seized catgut, introduced in two rows, deep and superficial. Beginning at the cervical end of the wound, the needle is introduced just within the cut surface, so as not to include the mucous membrane, and made to pass straight through, across and emerging in the opposite side a like distance inside the cut surface.
A continuous, or running, stitch is carried in this way up to the meatus, and the end left long. Commencing at the same point, another row of sutures, that tame a strong hold in the mucous membrane, is introduced; the two ends that emerge at the meatus are tied. This closely unites the divided edges of the mucous membrane and makes a strong seam, and is a successful measures. The posterior vaginal wall is then treated according to the demands of the case.
Various changes follow lacerations in the pelvic, floor depending upon the amount of injury done; therefore, a satisfactory management of the condition depends upon a restoration of the natural anatomical relation of the parts. This cannot be done by a superficial denudation of the mucous membrane. The mucous membrane and submucous tissue down to the muscular structures muse be dissected up and all scar tissue removed (scar tissue is wanting in vascularity and does not unite well), like tissue brought together and the normal contour restored. To accomplish this established operations will not answer; every case must be a law into itself, and the individual requirements must guide the surgical procedure. I can probably give a clear idea of my views by dividing perineal operations into three classes. 1. Where the tear is of moderate extent and not extending far up into the vagina. 2. Where the tear is deep, extends well up into the vagina, and a resulting rectocele exists. 3. Where the sphincter-ani muscle is involved-a complete laceration.
The operation for the first condition is simple and easy of execution. The sphincter-ani muscle having been stretched and the lower bowel evacuated and thoroughly douched, the labia is seized at its mucocutaneous junction on either side, with a pair of T- forcep just anterior to the point to which we intend to carry the dissection. These are handed to an assistant, who puts the parts upon the stretch laterally. One or two fingers are then introduced into the rectum as a guide, while a sharp scalpel in the right hand is entered flatwise at the raphe and pushed inwards toward the os uteri, beneath the vaginal tissue to the point that it is desired to carry the dissection, the highest point of the tear.
With a sawing motion the flap is loosened up on either side; then, with the scissors, a pear-shaped piece is cut out of the flap. With a curved needle, threaded with medium- sized catgut, beginning above, two or three deep sutures are taken at right angles with the vaginal axis, the last one lying just inside of the vaginal outlet, drawn moderately tight, securely tied, and cut short. Then, beginning at the highest point in the vagina, a superficial row of sutures is applied, which coaptates the mucous membrane in the vagina and the skin on the outside; the parts dusted with iodoform and a strip of iodoform gauze, for protection and drainage, applied. This is removed at the expiration of the fifth or sixth day, and a vaginal douche used every twelve hours.
This gives a most satisfactory result. The process of healing is comparatively free from pain; there is no cutting of stitches, swelling and distortion of parts, and consequent cicatrices and unevenness of surface as in the older methods, and if the operation has been dexterously done, the parts present an appearance that is not distinguishable from the natural condition.
When a rectocele exists, the preceding operation is somewhat modified. The dissection is carried much higher, the recto- vaginal septum is divided well up toward the uterine cervix, but the flap is only cut away as high as the internal perineal border. Beginning at the highest point at which the recto-vaginal septum was separated, a needle, threaded with a medium-seized catgut, is entered on the left side and made to penetrate the flap, carried across the space, and brought out in the vagina at a like distance (one-third of an inch) from the first point of introduction.
One or two of these sutures (as may be necessary) are introduced, then tied in the vagina, bringing together laterally the cut surfaces, making a heavy ridge in the vaginal floor, taking up all the slack tissue. The outer part of the would, from which the flap has been cut away, is then closed as in the previous operation. This procedure not only eradicates the rectocele, but gives an additional posterior support.
When complete laceration of the perinaeum exists, greater complexities follow. The torn muscular fibres contract and atrophy from non-use; the severed ends of the sphincter muscle separate and retract; there is a thinning and stretching of the recto-vaginal wall, relaxation and sagging of the vagina, and, at times, prolapsus of the rectum. All these conditions must be considered and corrected. The operative measure adopted must be one that will establish the normal relation of the several parts, support the pelvic viscera, relieve the over-distended circulation, and restore the functional activity of the sphincter-ani muscle.
From the many different methods in vogue for the repair of a complete laceration, and from the fact that I have known patients who have been operated upon two or three, and even four, times without successful issue, leads me to think that perfection in method is yet to be desired. In fact, even in partial ruptures; I have on several occasions been called upon to do the work again where other reputable surgeons had failed in their efforts. Indeed, my successes in this line have been very flattering. I have the record of over one hundred consecutive cases without a single failure.
For the restoration of the perinaeum in complete laceration, I have devised the following method, which, in my experience, meets all the requirements better than any other. I have now performed it many times with complete success in every instance. The healthy bowel brought down, protects the wound from infection and obviates the necessity of rectal flaps and bringing stitches into the gut, with its attendant dangers of rectal fistula. .
First rendering tense the recto-vaginal septum with two pairs of T-forceps in the hands of assistants, an incision is carried along the line of junction of the rectal and vaginal structures, and then upwards on either side to the highest point of the tear, splitting the rectovaginal septum and dividing the skin from the vaginal mucous membrane, after which an anterior vaginal flap is dissected up to the desired extent. The first step of the American operation is then done, viz.: the mucous membrane of the gut is seized on a line with the upper border of the internal sphincter, drawn down and divided all round by a circular incision, dissected down and removed at the muco- cutaneous junction.
The ends of the torn sphincter are next loosened up and secured with medium-sized catgut, uniting them accurately. If there is much tension upon the parts, two or three heavy silk approximating ligatures should be introduced, taking a good hold on either side, as in an ordinary perineal operation. The deeper portions of the wound are then brought together with buried catgut, so as to leave no gaping spaces. The silk ligatures tightened and tied, the flap trimmed up and the necessary coaptating catgut sutures applied. The gut is then grasped with forceps, drawn down, and united all round to the skin, completing the American operation.
MOSES T. RUNNELS, M.D.: Believing that all gynaecologists agree about the anatomy of the vagina and floor of the pelvis, I need not discuss the part of Dr. Green’s excellent paper relating to that subject. Nor have I the time to review the different kinds of lesions of the vagina and perinaeum. The character and extent of these lesions are not overstated in the paper. I have seen the different kinds mentioned, and have had much to do with their repair. The discussion is limited to three plastic operations, viz.: removal of scars, cystocele and perineal injuries.
The statement is made that it is bad surgery to leave any wound of the vagina and perinaeum, whether it occurs during parturition or from other causes, to heal by granulation; that it is the imperative duty of the accoucheur to make a critical examination of the genitalia after every labor, and if he finds any form of rupture, it should be repaired before he leaves his patient.
I grant that a through examination of the patient’s genital organs should be made immediately after each labor, but I do not believe that a surgical operation must necessarily follow labor immediately in a case of laceration of the cervix, vagina or perinaeum, one or all. In the majority of cases I hold that it is bad surgery to operate on distended and ecchymosed tissues which must undergo physiological involution; that in a case of extensive laceration of the perinaeum, the soft parts have been traumatized and predisposed to infection which a surgical operation does not hinder but rather invites; that the superficial and not the deep structures of the perineal body are united by immediate perineorrhaphy, provided that union of the parts takes place at all; and that, as a rule, the delayed operation in a case of laceration of the cervix or perinaeum requiring surgical interference affords the best results.
I have examined a good many women, from one month to several years after they had undergone the immediate operation, by different obstetricians for lacerations of the perinaeum extending down to or through the sphincter ani muscle, and I must acknowledge that I have not met with a perfectly restored perinaeum in the entire number. I am convinced that the obstetrician who invariably resorts to immediate perineorrhaphy not only deceives himself but misleads his patient into the belief that she has a good perineal body.
Let nature and good treatment do what they may towards restoring tears of the vagina and perinaeum, and wait until after the eighth week from labor to make a thorough operation on the lacerated part under aseptic and favorable conditions. Removal of scars at that time will be a trivial matter in comparison to the long list of evils following the delusion of a restored perineal body by immediate perineorrhaphy.