ANNALS OF SURGERY

VOL. 105 JUNE, 1937 No. 6

THE TECHNIC OF COLPOPERINEORRHAPHY

Lucius E. BURCH, M.D., AND JOHN C. BURCH, M.D.
NASHVILLE, TENN.
FROM THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, VANDERBILT UNIVERSITY SCHOOL OF MEDICINE
NASHVILLE, TENN.

THE surgical cure of rectocele requires an operation that affords an ample

dissection of the lesion, its correction by plication or rectopexy, the suturing
of the levators to the side of the rectum, the obliteration of dead space, the
exact approximation of the vaginal mucous membrane, and an adequate
repair of the perineum. These requirements have been repeatedly noted by
numerous authors and their achievement is the objective of all operators.
Annoying hemorrhage, however, is frequent and at times prevents the
surgeon from adequately carrying out his technic. It is the purpose of this
INF ILTRATED

FIG. I.-Diagram showing location of blood vessels in the wall

of the vagina and the effect of infiltration of the field with
adrenalin in novocain.
paper to present a method of dissection, based on anatomic considerations,
which will do much to control the hemorrhage and thereby facilitate the
operation.
Many of the blood vessels supplying the posterior wall of the vagina run
in a rather definite bundle in the fascia. Their course is obliquely downward
and inward, and they can be seen in the vaginal fascia, on the posterolateral
aspect, about three-fourths to one and one-fourth inches from the introitus.
881
 I

cain.
FIG. 2.-The rectocele is caught with clips
and the field infiltrated with adrenalin in novo-
FIG. 4.-The mucous membrane is removed
with scissors.
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:~ .
FIG 3.-The area to be denuded is outlined
with the scalpel.
FIG. 5.-The vessels are identified. The
pararectal space is opened and the levators are
exposed.
 FIG. 6.-The vessels on the right side are
ligated and the rectum is pushed back from
edge of the mucous membrane. A clamp is
shown on the vessels on-'the left side.
FIG. 8.-Stitch is continued, taking wide
bites at the side of the rectum and plicating
the rectum through the exposed portion. This
obliterates the rectocele.
883
FIG. 7.-Suture is passed, taking a small
bite of the rectum, going through the vaginal
mucous membrane, crossing the midline, pene-
trating the vaginal mucous membrane, and tak-
ing a bite of the rectum. It is tied in the
midline.
FIG. Q.-The levator sutures are passed.
 BURCH AND BURCH Annals of S;urgery
J u n e. 1 9 3 7

They run toward the midline, breaking up into many small branches before
they penetrate the fascia on their way to the mucosa (Fig. i ). It is obvious
that, if one can remove the mucous membrane without going deeply into the
fascia, the larger vessels will not be opened. A thorough preliminary injec-
tion of the field with adrenalin in novocain will separate the mucous mem-
brane from the fascia and check the blood flow from the smaller vessels.
The mucous membrane can be removed with scissors, after which the field
is so dry that the vessels can be identified and ligated before exposing the
sides of the rectum. The ligation of these vessels greatly decreases the
.........

t;res
are tied.:
FIG. IO.-The inner portion of levator sutures FIG. I I.-The first two on-edge mattress su-
are hooked upon the finger, withdrawn from the tures are tied. The deep portion of the third
wound, and held by engaging the handle of a suture penetrates the vaginal mucous membrane,
clamp in them. takes a bite of the levator fascia, is reefed
through the top of the rectum and the levator
fascia of the opposite side, and penetrates the
vaginal mucosa.
hemorrhage and allows the operation to proceed smoothly. The details of
the dissection will be found in the following description.
Operative Technic.-(i) The mucous membrane of the vagina is caught
with mucosa clips at the carunculae myrtiformes, at the top of the rectocele,
and in the midline at the mucocutaneous junction. The field, as well as the
area adjacent to it, is thoroughly infiltrated with adrenalin (I :I20,000) in '4
per cent novocain (Fig. 2).
(2) The area to be denuded is outlined with a scalpel (Fig. 3).
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Number 6
COLPOPERINEORRHAPHY
(3) The mucous membrane is removed with scissors (Fig. 4).
(4) The vessels are identified. A mucosa clip, placed on the mucous
membrane above the vessels, draws it toward the symphysis. A finger is
placed on the mucous membrane behind the clip and pushes its under sur-
face into view. The vaginal fascia at this point is incised with a scalpel
and, after very gentle dissection with the knife handle, a finger will open
the pararectal space. The levators are well exposed laterally and the vessels
stand out superiorly and medially. These are clamped and cut (Fig. 5).
(5) The vaginal fascia is now incised
superiorly to the vessels and the rectum-
is pushed back about one-half inch from .
the edge of the mucous membrane. The
entire field is now exposed, and the
rectocele can be reduced by plication or
rectopexy (Fig. 6). Plication will be
described.
(6) A needle, armed with No. i
chromic catgut, enters the fascia at the
lef tside of the rectum, penetrates the
vaginal mucous membrane in an upward
direction, crosses the midline, penetrates
the mucous membrane in a downward
direction, grasps the fascia at the right
side of the rectum, and is tied (Fig. 7).
(7) The suture is continued, plicat-
ing the rectum, and is tied at the lower
angle of the wound. This obliterates
the rectocele (Fig. 8).
(8) The levator sutures are passed,
and the ends clamped (Fig. 9).
(g) The inner portion of the levator
sutures are hooked upon the finger, with-
drawn f rom the wound, and held by en-
gaging the handle of a clamp in them FIG.sutures
12-The trigone is closedwith
and the skin isclosed withinterrupted
clips.
(Fig. io).
(io) The sides of the rectum and levator are reapposed by the use of
interrupted on-edge mattress sutures of No. i chromic catgut. This suture
obliterates the dead space and adequately approximates the vaginal mucous
membrane without inversion. In passing the suture, a needle is threaded at
both ends of the suture. One needle enters the mucous membrane three-
eighths of an inch from the edge, picks up the fascia at the left side of the
rectum, passes over the rectum (picking it up at one or more points), grasps
the fascia at the opposite side, and then passes out through the mucous mem-
brane. The other needle is passed through the edge of the mucous membrane,
on each side, and the suture is tied. Sutures are inserted in this manner until
the incision in the mucous membrane is closed (Fig. i i).
(ii) The levator sutures are tied, the trigone is closed with interrupted
sutures of plain No. I catgut, and the skin is closed with clips-(Fig. I2).
885