PLASTIC SURGERY OF THE VAGINA



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.

DISCUSSION.

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.

W E Green