[Illustration: FIG. 50.--Introduction of the sutures. The point of the emerging needle is held by the tenaculum.]
[Illustration: FIG. 51.--Sutures introduced in both sulci.]
In the denudation no skin is sacrificed. The denudation is not carried below the line of junction of vaginal mucous membrane with skin.
Each sulcus is closed by sutures separately, as in the immediate operation. The first suture is passed across the upper angle _b_.
[Illustration: FIG. 52.--Method of securing sutures with perforated shot.]
[Illustration: FIG. 53.--Both sulci are closed. The support of the perineum is restored. The posterior wall of the vagina is brought forward. The rectocele is cured.]
The second suture is introduced about an eighth of an inch from the edge of the mucous membrane on the left vaginal wall, is passed backward, downward, and outward so as to grasp retracted muscular fibers, and is made to emerge at the bottom of the sulcus. It is then re-introduced and passed forward between the mucous membrane of the rectum and the denuded surface, and somewhat upward, to emerge on the edge of the mucous membrane of the rectocele. A third and, if necessary, a fourth suture are passed in a similar manner. Similar sutures are then passed to close the right-hand sulcus.
[Illustration: FIG. 54.--Sutures for closing the superficial perineum and fourchette. The anterior suture is called the “crown suture.”]
[Illustration: FIG. 55.--Emmet’s operation of perineorrhaphy completed. Compare this figure with that representing the condition of the parts before operation (Fig. 45).]
The sutures thus far introduced are sufficient to close the sulci, and therefore to restore the supporting structures of the perineum. The remaining sutures are merely to close the skin-perineum. The first of these sutures is called the crown suture. The needle is introduced on the cutaneous aspect of the perineum, at the anterior end of the lateral denudation. It passes outside of the denuded area, and emerges within the denuded area, at the edge of the mucous membrane of the vaginal wall, immediately below the last suture of the sulcus. It is then passed so as to transfix the rectocele beneath the mucous membrane, and across the lateral denudation on the other side. When this suture is shotted the fourchette is restored. A second suture behind the crown suture is usually necessary to complete the closure of the skin-perineum.