a double inverting of the tissue, a narrowing of the bladder neck, and a delineating of
the posterior ureterovesical angle (see figure 2-5 C).
(4) The connective tissue on the lateral aspects of the cervix is sutured into
the cervix with chromic gut number 2-0 sutures swaged on curved needles. This is
done to shorten the cardinal ligaments.
(5) Allis forceps are applied to the edges of the incision, and the left flap of
the vaginal wall is drawn across the midline. Edges are trimmed according to the size of
the cystocele (see figure 2-5 D). This process is repeated on the right flap of the
vaginal incision. Adair forceps, tissue forceps, and curved scissors are needed.
(6) The anterior vaginal wall is closed with interrupted chromic gut number
2-0 sutures in a manner resulting in reconstruction of an anterior vaginal fornix.
d. Posterior Wall Repair.
(1) Allis forceps are placed posteriorly at the mucocutaneous junction on
each side, at the hymenal ring, and just above the anus.
(2) Skin and mucosa are incised and dissected from the musculature
beneath, using a knife, tissue forceps, curved scissors, and sponges.
(3) Allis-Adair forceps are placed on the posterior vaginal wall, scar tissue is
removed, and dissection is continued to the posterior vaginal fornix and laterally,
depending on the size of the rectocele.
(4) The perineum is denuded by sharp dissection; the trimming of the
posterior vaginal wall is carried out, using Allis forceps, curved scissors, and sponges
(5) The free edges of the levator ani muscle on each side are brought
together in front of the rectum by insertion of interrupted chromic gut number 0 sutures.
(6) Bleeding is controlled, and the vaginal wall is closed from above
downward to the anterior edge of the puborectal muscle, using continuous chromic gut
number2-0 suture. The rectocele is repaired from the posterior fornix to the perineal
body. Remains of the transverse perineal and bulbocavernosus muscles are used to
build up the perineum. The anterior edge of the levator ani sling may be approximated.
(7) The mucosa and skin are trimmed, and the remaining closure is effected
by interrupted sutures. The skin is closed with subcuticular sutures, chromic gut
(8) The vagina is packed with 2-inch vaginal packing. An indwelling urinary
drainage system is established. A perineal pad may be applied to the wound and held
in place by means of a perineal binder.