CHAPTER XII

PREPARATION OF THE PATIENT FOR PERINEAL AND VAGINAL OPERATIONS: OPERATIONS FOR INJURIES TO THE PERINEUM AND PELVIC FLOOR

PREPARATION OF THE PATIENT

In operations upon the perineum and vagina, the same scrupulous precautions against sepsis should be taken as in abdominal section. Before proceeding to practical details, it will be useful to consider a few points regarding the distribution of bacteria in these parts. Not only the ordinary bacteria of the skin, but also those from the rectum, and, under certain conditions, from the urine and the vaginal secretion abound on the perineal and vulval surfaces. The healthy virgin vagina may be considered free from pathogenic organisms, harbouring only the harmless vaginal bacillus of Döderlein. After sexual congress the vagina contains pathogenic organisms, and in conditions such as carcinoma of the cervix and body of the uterus, and in all forms of vaginitis, many varieties of bacteria are present in great numbers.

The normal uterus is germ-free; in fact the external os uteri may be said to divide the bacteria-free from the bacteria-containing area of the genital canal. But in carcinoma and in the various forms of septic endometritis, the uterus not only contains many pathogenic bacteria, but acts also as a continual source of infection to the vagina and external genital organs. It follows, therefore, that this area may be exceedingly difficult to render sterile, and in certain conditions this is indeed impossible. None the less, every effort should be made to attain this object; for even if the organisms cannot be entirely removed, yet their numbers can be considerably reduced, and it must be remembered that the action of septic organisms is, to a great extent, directly proportionate to their numbers.

The same general principles apply to the preparation of patients for operations on the perineum and vagina 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 fæcal 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.

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 vulva. After the enema has acted, and after the final wash-out, the washing and douching should be repeated and a fresh compress applied.

If there is any vaginal discharge, the vagina 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 vaginal discharge.

When the patient is on the table and under the anæsthetic, the external parts should again receive a thorough final disinfection, and, in addition, the vagina 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 vaginal hysterectomy for carcinoma, particular attention must be paid to the preliminary disinfection of the vagina by means of douching for two or three days before the operation. The vagina 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 anæsthetized and placed on the table in the lithotomy position, the legs being kept well apart and fixed by means of a crutch. The buttocks 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 vagina) is included any operation in which denudation and subsequent suturing of one or both walls of the vagina 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 vagina.

The appearance of the parts in this condition is quite characteristic (Fig. 30); the laceration of the recto-vaginal septum appears as a triangular space 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-vaginal 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 vaginal douches of lysol (1 drachm to the quart).

=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-vaginal 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 vaginal flap are now raised by means of catch-forceps and the scissors passed carefully into the cellular tissue, and the recto-vaginal septum is split transversely, producing a raw surface somewhat the shape of a butterfly 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.

Closure of the recto-vaginal 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 passed 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 passed 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 rectum.

We have now a large butterfly raw surface to deal with. The extension corresponding to the head is first of all dealt with by four or more separate sutures (Fig. 33, _a_). The large raw surface is now reduced in size by the passage of a deeply buried suture (Fig. 33, _b_); those used in the preceding manœuvres are best of silk. The buried suture should be catgut, and is passed in a spiral direction, as is seen in the diagram; the area of the raw surface is very much reduced by it (Fig. 33, _b'_).

The parts to be brought together will now present the appearance shown in Fig. 33, B, and they are approximated by means of silk sutures, which are entered on the skin surface on one side, passed beneath the raw surface, and made to emerge on the skin surface on the opposite side. Four to six of these may be inserted.

Great care must be taken to see that no bleeding points are left unsecured, and a current of hot 1 in 4,000 perchloride solution should be allowed to play over the surface, after which the sutures are tied. Each suture should be left about an inch and a half long in order to facilitate removal later on. A gauze drain should be passed into the vagina and an antiseptic gauze pad placed over the perineum.

=After-treatment.= The patient’s knees should be tied together, the urine drawn off by a catheter every six hours for the first 48 hours, and the wound kept as dry as possible. Throbbing and pain in the perineum with slight rise of temperature are generally indicative of suppuration taking place either between the flaps or along the sutures. A smart purge should be given on the morning of the third day and daily afterwards. If there are any scybala left in the rectum it is better to inject a little warm olive oil into it through a catheter before the bowels are expected to act.

The patient should be allowed to get up on the twenty-first day. There should be proper control of flatus and motions from the date of operation.

OPERATION FOR LACERATION OF THE PELVIC FLOOR

The objects of this operation are twofold: first, to secure the torn ends of the levator ani to the lateral vaginal sulcus and perineum; and, secondly, to draw up or lift the pelvic floor, which is more or less depressed.

The patient is placed in the lithotomy position and a retractor is inserted in the anterior cul-de-sac in order to elevate the anterior vaginal wall: Fig. 34 shows the appearances then seen. The left forefinger or some gauze packing is placed in the rectum and a double triangular space is denuded by means of sharp-pointed scissors, the base line of the double triangle being formed by the hymen. Two tenacula are inserted as indicated in the drawing (Fig. 34, _t_, _t_). The mucous membrane is now removed from the M-shaped space, great care being taken to penetrate deeply into the lateral sulci. After all bleeding has been arrested in the usual manner, the sutures should be passed. On the left-hand side of the figure these are indicated as inserted, not tied, whereas on the right they are tied and cut. Subsequently the somewhat quadrilateral raw surface which is left is brought together by five deep sutures, and the operation is complete. A Y-shaped cicatrix will be the result.

=Cases in which the perineum is apparently intact, but in which the sphincter is not united= (Figs. 35, 36).

These are the cases in which a complete laceration of the perineum is apparently completely healed after operation, but the patient finds that she has incontinence both of flatus and fæces.

On inspection of Fig. 35 this will be well explained. The patient is lying on her back in the lithotomy position: _a_ represents the sphincter which has been torn through; the two cut ends, _b_ and _c_, are represented by two dark circular, somewhat depressed spots. The rectal orifice gapes; there is no sphincteric power present. The perineum anterior to the anus is firmly healed.

=Operation.= The most certain and effectual method in these cases is to split up the healed perineum antero-posteriorly and treat the case as one of complete laceration of the perineum (see p. 128). This has been carried out in the case represented in the illustration (Fig. 35), and Fig. 36 shows the result: the patient entirely recovered power over the sphincter ani and the sustaining power of the pelvic floor was much improved.