A System of Operative Surgery Part 22

_a._ Ununited sphincter ani.

_b_, _c._ Buried ends of torn sphincter.

=Cases in which the perineum is apparently intact, but in which the sphincter is not united= (Figs. 35, 36).

These are the cases in which a complete laceration of the perineum is apparently completely healed after operation, but the patient finds that she has incontinence both of flatus and faeces.

On inspection of Fig. 35 this will be well explained. The patient is lying on her back in the lithotomy position: _a_ represents the sphincter which has been torn through; the two cut ends, _b_ and _c_, are represented by two dark circular, somewhat depressed spots. The rectal orifice gapes; there is no sphincteric power present. The perineum anterior to the a.n.u.s is firmly healed.

=Operation.= The most certain and effectual method in these cases is to split up the healed perineum antero-posteriorly and treat the case as one of complete laceration of the perineum (see p. 128). This has been carried out in the case represented in the ill.u.s.tration (Fig. 35), and Fig. 36 shows the result: the patient entirely recovered power over the sphincter ani and the sustaining power of the pelvic floor was much improved.

[Ill.u.s.tration: FIG. 36. REPAIR OF A LACERATION OF THE PERINEUM AFTER A PLASTIC OPERATION. (_From a photograph._)

_a._ Repaired sphincter ani.

_b._ a.n.u.s.

_s._ Resutured perineum.

CHAPTER XIII

OPERATIONS UPON THE URETHRA AND BLADDER

EXTIRPATION OF A URETHRAL CARUNCLE

=Indications.= A urethral caruncle is a bright red, tender tumour, usually on the posterior portion of the urethral orifice.

The symptoms requiring interference are pain on micturition, dyspareunia, bleeding and discomfort on movement, and, occasionally, retention of urine which is probably due to apprehension of pain rather than to any mechanical obstruction.

=Operation.= To be effectual this must be thorough, and may take the form of deep cauterization with a Paquelin's cautery, or excision. The latter operation consists in excising a wedge-shaped piece of the posterior wall of the urethra containing the caruncle. Free bleeding will usually take place, which must be controlled by means of haemostatic forceps. The edges of the wound are brought together by fine silk or catgut sutures, which must be pa.s.sed completely through the raw surfaces to prevent recurrent haemorrhage.

The _after-treatment_ consists in keeping the wound as clean and dry as possible.

OPERATIONS FOR INCONTINENCE FOLLOWING LABOUR

This is probably due to injury to the pelvic floor and the anterior fibres of the levator ani, producing a backward displacement of the urethra.

=Operation.= The operation recommended by Dudley consists of first denuding the v.a.g.i.n.al mucous membrane over a horseshoe-shaped s.p.a.ce between the c.l.i.toris and the urethral orifice and then drawing the urethra forward with sutures pa.s.sed through the anterior portion of the orifice and inserted near the c.l.i.toris. It will then be seen that the urethra is carried forward nearly an inch. The raw edges are brought together in the usual manner by catgut or silk sutures.

The author's experience of this operation has been unsatisfactory on the whole, and he has obtained better results by the wearing of a ring pessary.

OPERATIONS FOR VESICO-v.a.g.i.n.aL FISTULA

=For simple vesico-v.a.g.i.n.al fistula.= This condition is fortunately very rare at the present time. Many operations have been devised for this condition, but the original one recommended by Sims, with subsequent modifications, appears to the author to be most efficient and applicable to the large majority of varieties of this condition.

[Ill.u.s.tration: FIG. 37. AUVARD'S SELF-RETAINING SPECULUM.]

[Ill.u.s.tration: FIG. 38. KNIVES FOR FRESHENING THE EDGES OF A VESICO-v.a.g.i.n.aL FISTULA.]

[Ill.u.s.tration: FIG. 39. TOOTHED FORCEPS FOR USE IN VESICO-v.a.g.i.n.aL FISTULA.]

=Preparatory treatment.= The chief object is to obtain a healthy condition of the fistulous edges, which are nearly always inflamed, thickened, and covered by urinary deposits, usually of a phosphatic character. These are best removed by means of a soft sponge or cotton-wool, and the raw edges treated with a weak solution of nitrate of silver (gr. ij to the ounce). Hot v.a.g.i.n.al douches of lysol solution (?j to a quart) should be given night and morning, and the parts freely smeared with vaseline to protect them from the action of the irritating urine. Any cicatricial tissue which may be present around the fistula should be treated by submucous division.

[Ill.u.s.tration: FIG. 40. EMMETT'S HOOK.]

=Operation.= The instruments necessary are: a Sims's or Auvard's (Fig.

37) speculum; two flat spatulae; three long-handled knives (Fig. 38), one with a long haft and a short straight narrow blade, and the others with angular blades (right and left); two long-handled, sharp-pointed, curved scissors (right and left); an Emmett's hook for making counter-pressure (Fig. 40); toothed forceps (Fig. 39) and tenaculum; six Spencer Wells's forceps; Schauta's needle-holder (Fig. 73) with short curved needles.

[Ill.u.s.tration: FIG. 41. SIMS'S OPERATION FOR THE REPAIR OF A VESICO-v.a.g.i.n.aL FISTULA.

_a._ Bladder mucous membrane.

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

_c._ Suture pa.s.sed but not tied.

_d._ Section of denuded surface.

_e, e_{1}._ Liberating incisions.

_f._ The fistula.

The patient is placed in the lithotomy position. A strip of mucous membrane is then removed from the whole of the v.a.g.i.n.al edge of the fistula by means of an angular knife. In the original operation Sims (Fig. 41) made the surface oblique, but Simon (Fig. 42) considered the raw surface should be at right angles to the mucous membrane. The blade of the knife should not wound the vesical mucous membrane.

After the bleeding has ceased, the sutures, which may be of silk or catgut, are pa.s.sed by means of the needle through the pared edge of the fistula on one side, pa.s.sing across the fistula, and piercing the raw surface on the opposite side. The entry of the needle should be made about 1/4-1/3 of an inch from the raw edge (Fig. 44). Emmett's hook, shaped like a b.u.t.ton-hook, is useful to produce counter-pressure against the needle point. The sutures are tied, and milk is injected into the bladder to test the accuracy of the union.

As a rule, fistulae are bounded by rather scanty and inelastic walls, owing to the presence of cicatricial tissue; it is therefore more advantageous not to remove any tissue in order to produce a raw surface, or as little as possible. To fulfil this condition, the method of _dedoublement_ or flap-splitting, as practised by Walcher, may be carried out (Fig. 43, A, B, and C).

[Ill.u.s.tration: FIG. 42. SIMON'S OPERATION FOR THE REPAIR OF A VESICO-v.a.g.i.n.aL FISTULA. Letters as in the preceding figure.]

The patient is placed, as before, in the lithotomy position, and the cervix is pulled down, while the edges of the fistula are kept steady by a volsella on either side. The margin of the orifice is then split all round to a depth of from a quarter to half an inch. Vesical and v.a.g.i.n.al mucous membrane flaps are thus produced, giving a large raw surface without any loss of substance. The sutures are pa.s.sed as shown in Fig.

43, C.

=After-treatment.= This is very simple: if the patient is able, she should pa.s.s water, either in the dorsal or genu-pectoral position, otherwise a catheter should be pa.s.sed every six hours.

_Modifications of this operation_ have been devised, more especially for the larger fistulae: they will be briefly mentioned.

1. Repair by turning up v.a.g.i.n.al flaps to form the base of the bladder is recommended by A. Martin of Berlin. He first frees the adherent edges of the fistula and then raises the flaps from the v.a.g.i.n.al wall and brings them over the opening, suturing them carefully together. By this method the mucous membrane of the v.a.g.i.n.a forms the new lining to the bladder, and the exposed raw surface a new anterior v.a.g.i.n.al wall. The edges of this latter denuded surface are united by sutures, as in the operation of colporrhaphy.

2. Closure of the fistula by detaching the bladder from the v.a.g.i.n.a and suturing it independently is described and practised by Mackenrodt.

[Ill.u.s.tration: FIG. 43. REPAIR OF A VESICO-v.a.g.i.n.aL FISTULA BY DeDOUBLEMENT.

A. The flap-splitting stage.

B. The flaps separated and the suture pa.s.sed.

C. Suture tied, approximating the flaps.

_a._ Bladder mucous membrane.