FLAP-S PLITTING OPERATION. - This operation was introduced by Lawson Tait and indorsed by Saenger, Martin, Munde, and others. In this operation no tissue is removed, the result being achieved by simply splitting transversely and perpendicularly the surfaces which are later united. This operation is useful alike in partial and in complete rupture.
The patient, after the usual prelimi nary preparation, being placed in the lithotomy position, the recto-vaginal sep tum is split from side to side, beginning in the middle line, by means of a pair of sharp-pointed scissors. If the laceration be an incomplete one, the incision is pro longed up on either side to the upper border of the perineal cicatrix, the depth of the wound upward being not more than from a quarter to a half inch. The upper, or vaginal, flap is then drawn up ward by means of a tenaculum or forceps; the lower, or rectal, flap downward in the same manner; and the sutures are then passed, being carefully concealed throughout, from the left side of the patient to the right, beginning at the point nearest to the anus, using a straight or very slightly curved needle. Thomas and Munde advise that the sutures be in troduced just outside the edge of the wound, emerging at the same spot on the opposite side. Tait recommends passing them just within the edge of the wound, which does not allow the edges of the skin to be brought into close apposition as by the method of Thomas and Muncie. After all the sutures have been intro duced, they are tied, and the puckering of the posterior vaginal commissure is corrected by short interrupted catgut su tures, so as to insure complete closure of the wound.
In complete laceration, on either side of the transverse incision which splits the recto-vaginal septum a downward and backward incision is carried, which goes just beyond the edges of the separated sphincter-ani muscles. A more marked
dimpling on each side of the anus shows plainly the location of the retracted ends of the sphincter ani when the laceration is complete. The points must be de nuded and the sutures so placed as to bring and hold them in apposition until union has occurred. The flaps are held apart, upward and downward as already described, and the first suture, beginning from behind, is inserted just outside and below the edges of the torn sphincter ani and brought out exactly at the same spot on the opposite side. The stitches are then introduced and tied as in the incom plete operation. Although the operation may be performed within ten minutes, it will be found necessary to introduce a certain number of superficial catgut su tures into the perineum or along the vagino-perineal commissure, if we wish to secure perfect cutaneous union. In complete lacerations there is more cer tainty of securing a perfect restoration of function of the sphincter-ani muscle, and in preventing the formation of a recto vaginal fistula than with other methods.
In the after-treatment especial care should be taken to protect the wound from contamination by the urine. The urine should be drawn by a catheter or the patient may be allowed to turn over upon her face and urinate in that posi tion, after which the parts should be thoroughly douched with a boro-salicylic solution. The sutures may be removed after ten days, but such removal should be delayed if they are not causing irrita tion or have not ceased to hold the parts. The recumbent posture should be main tained for three weeks, and four weeks should elapse before the patient is al lowed upon her feet.