The triangles of the vaginal flap are now raised by means of catch-forceps and the scissors passed carefully into the cellular tissue, and the recto-vaginal septum is split transversely, producing a raw surface somewhat the shape of a butterfly in outline (Fig. 33). A median extension of the denudation is made in an upward direction for another inch in length to form a supporting column. This flap may, if the tissues are sufficiently redundant, be removed along the line running at its base. The raw surface should be swabbed over carefully, and any bleeding points secured by ligatures. Large venous sinuses are very often opened, and, should the bleeding recur after the adaptation of the flaps, the operation will inevitably fail. [Illustration: FIG. 31. LONG-HANDLED SHARP-POINTED SCISSORS CURVED ON THE FLAT.] Closure of the recto-vaginal rent is first carried out by interrupted sutures, as is seen in the semi-diagrammatic drawing (Fig. 32). The threaded needle in a holder is passed from the rectal side of the flap through the flap on to the raw surface, then over the rent on to the raw surface of the other side; it finally finds its exit again on the rectal side of the flap. Four or more sutures may be passed in this way, a final one bringing the cut ends of the sphincter ani together. Each suture should be tied and the ends cut short before the next one is inserted, and the knots will lie just beneath the mucous membrane of the rectum. [Illustration: FIG. 32. COMPLETE LACERATION OF THE PERINEUM. Semi-diagrammatic drawing of a ruptured recto-vaginal septum, indicating the method of passing the sutures for its repair. _r.m.m._ Rectal mucous surface. _sph._ Torn end of sphincter ani. _v.m.m._ Vaginal mucous surface. The arrows indicate the direction of the sutures. ] We have now a large butterfly raw surface to deal with. The extension corresponding to the head is first of all dealt with by four or more separate sutures (Fig. 33, _a_). The large raw surface is now reduced in size by the passage of a deeply buried suture (Fig. 33, _b_); those used in the preceding manœuvres are best of silk. The buried suture should be catgut, and is passed in a spiral direction, as is seen in the diagram; the area of the raw surface is very much reduced by it (Fig. 33, _b'_). The parts to be brought together will now present the appearance shown in Fig. 33, B, and they are approximated by means of silk sutures, which are entered on the skin surface on one side, passed beneath the raw surface, and made to emerge on the skin surface on the opposite side. Four to six of these may be inserted. [Illustration: FIG. 33. COMPLETE LACERATION OF THE PERINEUM. In A the ‘butterfly’ surface has been denuded and the recto-vaginal rent repaired (_c_). _a._ Sutures passed through the sustaining column, but not tied. _b._ The ‘buried’ spiral suture passed but not tied.