The secondary operation is performed at any time after cicatrization has occurred--often many years after the receipt of the injury. This operation is at present one of the commonest in gynecology, because the injury is not detected, is neglected, or is improperly repaired after labor. In the secondary operation an anesthetic is necessary. The mucous membrane must be removed or denuded on the posterior wall and about the mouth of the vagina, in order that the lacerated structures may be brought again in apposition. The denudation is best made by means of scissors curved on the flat (Figs. 24 and 25). The strip of mucous membrane to be removed is picked up with a tenaculum (Fig. 26) or with tissue forceps (Fig. 27); the scissors are placed with the blades parallel to the surface to be denuded, and the strip is cut away evenly, in one piece if possible. A similar contiguous strip is removed, and so on until the necessary surface is bare. Sponges in holders (Fig. 28) or continuous irrigation may be used to remove blood. [Illustration: FIG. 27.--Tissue-forceps.] [Illustration: FIG. 28.--Sponge-holder.] For all operations on the perineum round-pointed needles curved at the tip should be used (Fig. 29). The tissues are always sufficiently soft for the passage of such a needle. A needle with a cutting edge is unnecessary and may increase the bleeding. The needle may be held in any kind of needle-holder preferred. The Emmet needle-holder (Fig. 30) is very convenient. [Illustration: FIG. 29.--Emmet’s perineal needle.] [Illustration: FIG. 30.--Emmet’s needle-holder.] The point of the needle should be guided and held by the tenaculum. The tenaculum must always be held in a plane parallel with the plane of the needle-holder; otherwise the needle-point may escape from the embrace of the tenaculum. Silver wire and silkworm gut are the best sutures in the operation of perineorrhaphy. The suture is conveniently attached to the needle by means of a silk carrier (Fig. 31). [Illustration: FIG. 31.--Perineal needle with silk carrier.] [Illustration: FIG. 32.--Shot-compressor.]