Two essentially different operative methods are the perineosynthems of Langen beck, and Bischoff's plastic operation. Both depend on the fact that a flap of mucous membrane is dissected off, and is utilized for covering over the new perineum which is to be formed.
These operations suffice as well in case of laceration of the perineum, as in case of prolapsus. This, however, is not the place for considering the connection between prolapse and laceration.
In Bischoff's operation the flap is obtained in particular from the col umna, and the first step is to mark out the surface which is to be de nuded. The flap is next undermined, brought forward, and the denuded surfaces brought together. In passing the sutures the border of the vagi nal flap is first united with the denuded edges next to the nymphs; on both sides, and six to eight sutures on each side will suffice. These sutures had better be of catgut or thin silk. The perineal sutures are next inserted from below upwards, and should be passed deeply. In order that the apex of the flap may fit well in the posterior commissure, it must often be trimmed off, and it may be held in place by inclusion in a perineal suture.
In case of incomplete laceration there is not much difference between Langenbeck's and Bischoff's method. The latter denudes a trifle more anteriorly. The results obtained by Bischoff by his method are very good. Egli-Sinclair reports that in twenty-four cases union by first in tention occurred in twenty-three, and that in three out of five cases there was no re-laceration at the next confinement.
• Freund's method differs from Hegur's triangular denudation in that by it a triangle is not removed from the posterior vaginal wall, but the columns rugarum are untouched, a tongue-shaped portion of mucous membrane being removed to the right or left, or to both sides of the col umna. The annexed figures describe the method sufficiently. The lateral denudation each side of the columna serves the purpose of lessen ing the strain caused by the sutures. In Fig. 83 at a is shown the peri nea] rent and the denuded surface, at b is represented the appearance when the rectal sutures have been tied, at c the result of the union of the lateral wings at and after tying of all the sutures.
Although we have already referred to a number of modifications of the perinea] operation, there are still others to be mentioned. Martin's method aims at restoring the lumen of the vagina to its original state. He does not think it necessary or advisable to denude the posterior col umna, but deems the lateral denudations sufficient. The shape of the denudation obtained by this method is shown in Fig. 84. The two lateral denuded surfaces are first united, and then the denudation on the labia and the perineum. As in case of all operations on the perineum, it is essential that the denudation be not carried too far anteriorly, else the introitus vagina will be too narrow. Martin has reported over twenty cases operated upon after this method with general success.
The latest plastic method on the perineum has been suggested by Lawson Tait. The principle of the method is the dissection of flaps
from above downwards to cover over the rectum, as it were. He removes no tissue and operates with sharp scissors. His sutures are inserted in the axis of the wound, and they surround and bring together large sur faces. The dissected flaps are large, so that there is no fear for their vitality. The upper suture is inserted first, and the points of entrance and of exit are near the line of union. The needle is inserted at the left border, and is passed around as is shown in the figure, issuing at the cor responding point on the opposite side. The suture should not appear in the rectum, and only the knot should be seen in the vagina. When necessary a second similar suture should be passed, but two are always sufficient. The remaining steps do not differ from what is customary. Tait uses silk, and removes the sutures on the twelfth to the fourteenth day. Staude has suggested a method on the same principle as Tait's, although his manner of passihg the sutures has not the same advantages.
In order, after operation on the perineum, to facilitate the exit of gases and ftecal matter, and to avoid the tension on the newly united surfaces, Dieffenbach favored making incisions into the subcutaneous cellular tissue, parallel to the wound of the perineum, and Langenbeck followed him. Simon rejects these incisions, and indeed they are not able to fulfill the desired aim, for they are not made at the right place. In order to avoid tension on the sutures, the cause of the retention of the faecal matter must be removed, that is to say, the sphincter ani must be incised. This was Baker-Brown's practice almost uniformly, and Hegar adopted the method. In his paper at Copenhagen, Koberle spoke in favor of it.
As yet we have not made special reference to the sutures of utility in operations on the perineum and the posterior vaginal wall. The choice lies between the ordinary surgeon's knot and the quill suture of silk, cat gut, or metal. The running suture has been recommended by some, and Brose has latterly favored it. In the only case in which I tried it the result was a failure, but this was in pre-antiseptic times. We have still to mention the Heppner's suture, which aims at bringing the surfaces to gether under equable pressure, and the manner of insertion is sufficiently clear from Fig. 86.
In case of incomplete lacerations I prefer Simon's method, as modified by Hegar and Kaltenbach. It is the simplest method of all. In case of complete lacerations, where a portion of the recto-vaginal septum is torn, I would place Lawson Tait's flap method above others. I formerly per formed the Simon modified operation, but not always with the desired result. I have tried Tait's method in three instances, and each time have obtained union by first intention. In the first case I tried it after the usual method had failed, and I was highly pleased with the excellent result and the simplicity of the method.