Part 23 (1/2)

_b._ v.a.g.i.n.al wall.

_c._ Suture.

_e, e_{1}._ Liberating incisions.

_k, k_{1}._ Flap-splitting incisions.

In A the flap-splitting is seen in section (_k, k_{1}_); in B the flaps have been everted towards the bladder and v.a.g.i.n.a respectively and the suture pa.s.sed. In C this suture has been tied; liberating incisions, _e, e_{1}_, have been made on the v.a.g.i.n.al surface to prevent tension in the wound.

The patient is placed in the lithotomy position, and the fistula is exposed: the cervix is drawn downwards and backwards by means of a wire loop or tenaculum, and the urethral prominence held with a pair of hooked forceps. An incision is then made in the median line extending across the fistula and through the v.a.g.i.n.al walls down to the bladder, in this way exposing the entire base of the bladder. The edges of the fistula are then split so that the bladder and the v.a.g.i.n.al walls are separated. The two vesical flaps are now carefully and separately sutured by catgut and the edges of the v.a.g.i.n.al wound are brought together as much as possible: if necessary, the fundus of the uterus may be used to a.s.sist in closing the opening.

=For vesico-utero-v.a.g.i.n.al or juxta-cervical fistula.= In this affection the cervix is involved, and it must therefore be carefully differentiated from the vesico-v.a.g.i.n.al variety, in which the cervix is intact.

[Ill.u.s.tration: FIG. 44. REPAIR OF A VESICO-v.a.g.i.n.aL FISTULA. _Sims's Operation._ The edge of the fistula has been denuded and the sutures have been pa.s.sed.

_a.v.w._ Anterior v.a.g.i.n.al wall.

_cl._ c.l.i.toris.

_s_{1}, s_{11}._ Retractors.

_sp._ Posterior speculum.

_t._ Tenaculum.

_u._ Orifice of urethra.

_v.v.f._ Vesico-v.a.g.i.n.al fistula.

In operating upon such cases the chief difficulty will be found in denuding the surfaces necessary for the introduction of the sutures, owing to the density of the cicatricial tissues, which are always present. This is best overcome by drawing the cervix forcibly downwards and backwards and incising the anterior cul-de-sac; the bladder wall with its fistulous opening is then dissected off the anterior surface of the cervix and carefully sutured independently of the cervical laceration; the latter is treated by suture in the usual way (see p.

128). In the deeper forms of juxta-cervical fistula, the above technique is impossible, and suprapubic incision and suture of the bladder must be subst.i.tuted.

RECTO-v.a.g.i.n.aL FISTULA

This condition may be defined as an opening between the r.e.c.t.u.m and v.a.g.i.n.a through which flatus, or faeces, or both, may pa.s.s from the former into the latter; it is chiefly the result of an imperfect union subsequent to an operation for complete perineum laceration. It may also be caused by the rupture of a pelvic abscess or by the spread of primary malignant disease of the rectal wall.

=Operation.= If the sphincter ani is incompletely united, it will be found much the most satisfactory proceeding to divide the healed portions of the perineum and make a complete perineal laceration; this may then be treated as described above (see p. 128).

If, however, the sphincter is intact and serviceable the fistula should be pared and the edges brought together by silk sutures. It is not infrequently necessary to perform a temporary colostomy (see Vol. II) in order to divert the faecal contents of the bowel during the process of healing.

OPERATIONS FOR CYSTOCELE

In cystocele there is prolapse of the anterior v.a.g.i.n.al wall and the corresponding area of the posterior bladder wall. Cystocele often complicates rectocele and prolapsus uteri, and operation upon it is often carried out in combination with colpo-perineorrhaphy.

=Operation.= The operation for the cure of this affection is very simple, and may be performed:--

(1) By denuding an oval s.p.a.ce over the swelling and bringing the raw edges together.

(2) By Stoltz's operation, which is really purse-string suture.

The instruments necessary are a bladder sound, two tenacula, sharp-pointed angular scissors, a needle-holder and fine silk.

(1) The parts are exposed with a Sims's or Auvard's speculum and a volsella, or silver wire is pa.s.sed through the cervix, by means of which traction downwards and backwards may be exerted. The cystocele itself is fixed by tenacula, and, with the sound in the bladder, an oval incision is carried completely round the base of the cystocele. The whole area contained in this incision is denuded by knife or scissors, care being taken to avoid wounding the bladder mucous membrane.