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COLPOPERINEOPLASTY (Greek kolpos female bosom, vagina + lat. perineum a crotch + plastike sculpture, plastics) — plastic surgery of sewing up of a back wall of a vagina and muscles of a crotch. Its essence consists in recovery and strengthening of muscles of a pelvic bottom at omission and loss of bodies of a small pelvis.

Studying of questions of operational treatment of omission and a falling of the vagina and a uterus began in the second half of 19 century. The big merit in development of the operational equipment belongs to D. O. Ott who considered necessary recovery and strengthening of muscles of a pelvic bottom at omissions and losses of bodies of a small pelvis.

Various modifications are offered To., differing from each other generally in a form of the rag found from a back wall of a vagina.

To. it is made as independent operation in combination with front or median colporrhaphy (see), and also vulval hysterectomy (see).

Indication for To. omission of walls of a vagina and uterus is (see. Prolapse of the uterus, vaginas ), followed by omission of a bladder and rectum (most often owing to a rupture of muscles of a crotch in labor).

Contraindications — inflammatory diseases of female generative organs, existence of fistulas (rectovaginal, rektopromezhnostny, etc.), III—IV degree of purity of a vagina.

Diagrammatic representation of operation of a colpoperineoplasty: 1 — clips took a rag on a back wall of a vagina (the dotted line outlined borders of the excised rag); 2 and 3 — options of suture on legs of the muscle lifting an anus after cutting out of a rag (2 — underrunning of a muscle with the fascia covering it, 3 — underrunning of the isolated muscle after a section of a fascia); 4 — the pulling together stitches on the muscles lifting an anus, and the second row of seams on a back wall of a vagina are put; 5 — operation is complete, stitches on a crotch are put.

The equipment

Training of the patient and situation — typical for vulval operations. Anesthesia according to indications — local anesthesia or an endotracheal anesthesia. After processing of a surgery field from skin of a crotch and a mucous membrane of a back wall of a vagina find a rhomboid rag (fig., 1). For this purpose a clip take the basis of small vulvar lips on both sides; pulling together the ends of clips, it is possible to determine height of a crotch, edges it will be created during operation (after operation the entrance to a vagina shall be passable for two fingers). The third clip is imposed on the centerline of a back wall of a vagina that corresponds to the top of the rag which is subject to excision. Side clips stretch in the parties assistants. Make a section of skin of a crotch between clips in the direction down. Edges of a section connect at an obtuse angle approximately on border of an average and back third of a crotch over an anus. The point of connection of edges of a section of skin of a crotch will correspond to the lower, more obtuse angle of a rhomboid rag of a back wall of a vagina. At cutting out of a rag of triangular shape its basis is located on border of a mucous membrane and skin of a crotch.

After a section of skin of a crotch the bottom corner of a rag is taken tweezers and otseparovyvat a scalpel from below up to an entrance to a vagina. Then the lower rag is taken clips and pulled. After that make a section of a wall of a vagina in a straight line from the clip imposed in the depth of a vagina to an entrance to a vagina. The mucous membrane is pulled clips and otseparovyvat in the acute way from the subject tissues and muscles of a crotch to both parties to the line of side cuts of the planned rhomboid rag. Separating can be made also from below without the preliminary cuts defining borders of a rag. And. JI. Braude at considerable omission of a back wall of a vagina recommended to otseparovyvat a rag of a yakoreobrazny form. Then the rag is cut on border of separating; the wound at the same time has an appearance of the wrong rhombus, at the bottom of it the front wall of an ampoule of a rectum is located. Edges of cuts of a wall of a vagina separate from the subject fabrics on width of 1 — 2 cm for the best rapprochement of edges of a wound during the mending.

A round thick needle take medial edges of legs of the muscles lifting an anus on both sides in an upper part of a wound (fig., 2); units take on a clip and delay up, edges of legs at the same time approach. Otstupya 1 — 1,5 cm from the first seam, impose the second and then the third seam, is closer to an anus; seams are not tied. After that threads lower from top to bottom on a gauze napkin, a cut cover the bottom of a wound. At considerable degrees of a falling of the vagina and a uterus it is recommended to make the isolated sewing together of the muscles lifting an anus. Make a cut of a fascia for allocation of legs, and then release a muscle from a fascial bed and sew (fig., 3).

For connection of edges of a mucous membrane of a vagina with capture of the subject fabrics put a stitch on Reverdena, since an upper corner of a wound to that place where back commissure of a crotch will be formed (fig., 4). Edges of levators connect, tying earlier imposed ligatures. Setting of ligatures is begun with an upper ligature. If necessary on a wound of a crotch put additional stitches. Edges of a skin wound of a crotch recover a continuous intradermal catgut suture or separate silk seams (fig., 5). The line of seams is processed iodine, enter a tampon with a liquid paraffin into a vagina.

For treatment of the old cicatrized ruptures of a crotch, preferential the II Art., Tate's operation can be used; excision of fabrics in this case is not made. After a section through the area corresponding to back commissure, a mucous membrane of a vagina otseparovyvat up, bare and sew deep muscles of a crotch. Put several submersible stitches, and then the purse-string seam on a free rag of an otseparovanny mucous membrane of a vagina which is bringing together her in folds; sew skin of a crotch.

Complications (discrepancy of seams of a crotch, injury of a rectum) are possible only at disturbance of the operational equipment.

In the first 4 — 5 days later To. the easy diet (table No. 2), a liquid paraffin inside, then a table d'hote is recommended. Within 7 — 8 days the patient shall remain in a bed. The area of seams is daily greased with iodine or solution of potassium permanganate. According to indications antibacterial therapy is carried out, apply anesthetics. The patient can be written out from a hospital for the 12th days.

The long-term results To. are satisfactory; a recurrence is rare, is observed, as a rule, at women, the engaged physical. work.

Bibliography: Braude I. L. Operational gynecology, M., 1959; Davydov. N, Hromovb.M.i Sheykov. 3. Atlas of gynecologic operations, L., 1973, bibliogr.; Persianinov L. S. Operational gynecology, M., 1976; Havash I. The atlas of the main gynecologic vulval operations, the lane with in., Bratislava, 1967; Reiffensthul G. u. P 1 a t z e of W. Die vaginalen Opera-tionen, Miinchen, 1974.

H. D. Seleznyova.