COLPOPERINEORRHAPHY AND THE fascial accompaniments complicate its origin and STRUCTURES INVOLVED. insertion, as well as the interpretation of its function. 2. The various as to the form of the levator DEDICATED TO DR. THOMAS ADDIS EMMET AND MR. LAWSON TAIT, opinions are as sex IN RECOGNITION OF THEIR LABORS IN THE SURGERY ani explained by differences regards idio- OF THE PERINEUM. syncrasies of individuals, disturbances from gestation and parturition, variation of the shape of the pelvis BY BYRON ROBINSON, B.S., M.D. and fascial insertions and attachments. Professor in the Chicago Post-Graduate School of Gynecology and Abdominal Surgery; Professor of Gynecology and Abdominal 3. The different views as to the function of the Surgery in Illinois Medical College; Professor of Gynecology levator ani lie in confusing its function with the le- and Abdominal Surgery in Harvey Medical College; vator ani fascia, superior and inferior, in exaggerating Gynecologist to St. Anthony's Hospital; Consulting its size and to it function and be- Surgeon to the Mary Thompson Hospital for attributing utility Women and Children. longing to other genital supports. It is especially CHICAGO, ILL. erroneously inferred that a muscle will act as a con- tinuous tensionized for viscus. The The structures involved in the of a defective support any repair of the levator ani muscle is are muscles and fasci\l=ae\.The operative pro- knowledge fragmentary perineum and difficult of access. Its dissection is far from cedure consists in denudation with coaptation or flap- easy splitting methods. Notwithstanding the successful and its adjacent relations are complicated. The mus- claims in the varied surgical methods of colpoper- cle does not resemble a funnel with the rectum or the anatomical basis is neither vagina at the bottom or apex, but is more similar to ineorrhaphy generally a a flat or a which does not nor understood. It is sling, loop horseshoe, pull perfectly probable, however, the rectum or but draws the that the essential success lies in the reunion of the vagina directly upward, two canals forward and toward the cord. levator ani muscle means of its fasci\l=ae\ upward pubic separated by The muscular of the levator ani muscle resem- and inferior with some other fasci\l=ae\,and also loop superior bles a horse's collar the rectum or the that this success has been due to sutur- encircling chiefly deep In the female it controls two ing. The object of this essay is to demonstrate that vagina. vigorously the chief factor in successful colpoperineorrhaphy is the restoration by the aid of deep sutures of the fasci\l=ae\, especially the levator ani fasci\l=ae\,superior and inferior. The muscles of the pelvic floor may be divided into two classes: a, the deep layer\p=m-\thelevator ani coccy- geus and pyriformis; b, the superficial layer\p=m-\the transverse perinei, bulbo-cavernosus and sphincter ani externus. A peculiar characteristic of the muscles of the pelvic floor, and one which demands respect in colpoperineorrhaphy, is the extensive fascial attach- ments of one or both ends of the muscles. The levator ani, the bulbo-cavernsous and the transversus perinei have a fascial attachment. We will consider in detail the muscles and fascia? involved in colpoperineor- rhaphy. The basis of this labor is a careful anatomic investigation with considerable clinic and surgical experience. THE LEVATOR ANI MUSCLE. Fig. 1.—(Robinson-Scholer.) This cut is drawn from a female pelvis The levator ani muscle is perhaps the most difficult dissected by the author and intended to show the muscular floor of the to understand as its insertion and func- pelvis with fascia dissected off. 1,1, the levator ani muscle; 2, 2. tho regards form, white line or origin of the levator ani ; 3,3, the obturator internos muscle : tion. The origin of the muscle is sufficiently plain, .4, 4, the coccygeus muscle : 5, 5, the pyriformis muscle ; 6,6, the inner wall of pelvis ; 7,7, sacrum ; H, H, the horse-shoe loop of the levator ani muscle, and is considered established by anatomists. Few drawn darker; 8, the Y-shaped urethra; 9. the vagina, cut close to the as to exact even at this late and pelvic floor, whose wall does not flare like the radial wall, 10; 11,11, the agree insertion, day, obturator nerves; 12, 12, inner wall of pelvis; 13, pubic crest; 14, 14, iliac opinions vary as to the exact function, form and in- fossa; 15, last (5th) lumbar vertebra. sertion of this muscle. My own investigations demon- canals—rectum and vagina—yet its control of the strate that there is a foundation for these varied vagina depends on that of the rectum. The rectum opinions. being forced forward against the middle of the pos- 1. The insertion and origin of the levator ani vary terior vaginal wall produces the H-shape to the vagina. as to the extent of distinct muscular loops which em- The excess of vaginal wall is compelled to fold at the brace the rectum and vagina, as to the tendinous sides producing the upright columns of the H. It is rapha? (between muscle loops and distal ends of the very thin. In an excellent specimen which I dissected coccyx), also regarding the precise relation to the from a good-sized woman the levator ani muscle is so vaginal wall, whether muscular or connective tissue, thin as to be really membranous, and the muscular band and also as regards the exact relations to the muscle between the vagina and rectum is but a few lines in of the lower end of the rectal wall. Moreover, its thicknes. It is really a pelvic diaphragm. The muscle partial fascial origin and insertion is sure to endow the should be considered as to its origin, course and extremities with varying appearances as to the length insertion. of the fascial or tendinous conditions; in other words Origin.—The levator ani muscle arises: from bone, the distance of the red muscular fibers from the from the posterior surface of the pubis and ischial extreme origin and insertion of the levator ani vary. spine; or from fascia, arcus tendineus and vesico- Perhaps this variation in insertion may be explained pubic ligament. The bony origin is the posterior by considering the levator ani as a rudimentary mus- surface of the pubic bone and ischial spine. The cle and to be disappearing with the tail. Its double larger portion of the levator ani of bony origin arises Downloaded From: http://jama.jamanetwork.com/ by a University of British Columbia Library User on 06/18/2015 from the posterior surface of the pubis. It begins at the white line or a short distance from it. The about half an inch from the symphysis and one and muscle may shade into a flat tendinous layer before it one-half to two inches below the pubic crest. This reaches the white line. The proximal tendon of the point of origin is about two fingers wide or one and levator ani muscle varies muchas to its relations with one-half inches, and does not meet its fellow of the the white line. It may arise below it as well as from opposite side, one-half to one inch existing between it. The white line may project into the pelvis as a them on the posterior surface of the pubis, which is tendinous fold, and be capable of being separated filled in by the obturator fascia. The bundle of mus- from the origin of the muscle. cles originating on the posterior surface of the pubis The course of the fibers of the horseshoe loop of passes downward and backward to embrace the vagina the levator ani muscle is backward and downward and rectum. This is the pubic sling or horseshoe loop, in two fleshy bundles, the smaller to the side and pos- which is quite thick and strong in some cases, and terior surface of the vagina, and the larger to the very thin and membranous in others. The margin of side and posterior wall of the rectum. The loops the loop, which is applied against the sides of the which pass along the sides of the vagina seem to be vagina and rectum, is often the thickest part of the attached to the vaginal walls by connective. tissue muscle. The muscular bundles of the horseshoe loop only, while the loops of muscular fibers which join those of the opposite side of the levator ani pos- embrace the rectum interweave with the muscular terior to the vagina and rectum without an interven- bundles of the rectal wall, forming a strong connec- ing perineal tendon or raphe. In some dissections it tion. The part interwoven in the rectal wall acts as is absolutely plain that no tendinous raphe exists, an elevator. It would appear that in some cases the while in others it can not be told. The smaller portion of the levator ani of bony origin is from the ischial spine immediately anterior to the origin of the coccygeus muscle. Quite a distinct strip one-fourth to one-half inch wide comes from the Pig. 2.—(Robinson-Scholer.) This is a cut drawn from a female pelvis dissected by the author. It illustrates the inferior surface of the pelvic floor. On the left side (in the fig.) the levator ani fascia inferior is not dissected off, while it is on the right side, showing the inferior surface of the levator ani muscle. 1,1, shows the levator ani muscle with its parallel bundles; 2, the levator ani fascia inferior; 3, 3, the obturator internus muscle; 4, 4, the coccygeus muscle; 5,5.