The sutures must be passed in such a manner as to bring the mar gins of the fistula snugly together with the least possible resistance. In general, it is easier to pull the upper part of the vagina clown into apposition with the lower part than to attempt to make up a large defect by pulling together the wound surfaces from side to side.
Too great care cannot be observed throughout to avoid catching the ends of the ureters in the sutures. The consequence of such an accident is urfemia. If the symptoms of such a condition were dis covered in time the sutures would have to be cut immediately. Such an accident may be guarded against by carefully locating the position of the ureteral orifices, and also by not passing sutures too deeply so as to include too much tissue.
For the smaller fistul.ae either silk or silkworm-gut sutures may be used; for the larger the best sutures are deep silkworm-gut, with superficial silk sutures between them.
The easiest way to pass the sutures is by a needle threaded with a carrier. The needle is entered about 3 mm. from the margin of the wound on the vaginal surface, and brought out on the vesical margin without penetrating the mucosa; it is re-entered on the opposite side on the vesical margin, and brought out again on the vaginal surface. After several sutures have been introduced in this way, about 5 mm. apart, they may be tied, and others introduced in the same way and tied, and so ou until the whole fistula is closed. It is not necessary to tie them very tightly. Each suture should bring the margins of the wound neatly and snugly together. Between these deeper su tures superficial sutures of finer silk are passed for accurate approxi mation on the surface. Au iodoform gauze pack is now placed in the vagina and a soft catheter laid in the bladder through the urethra to drain the urine for the first five days. To avoid irritation from the catheter, it is better to leave it out for a while in the morning and again in the evening. After the fifth day, the patient may be cathe terized every three or four hours for three days longer, after which she may void urine. The stitches may be removed from the fifth to the tenth day.
Ability to retain a quantity of urine always increases as the blad der grows accustomed to resuming its functions.
I have ventured with success in some of the smallest fistulae to dis pense entirely with the use of the catheter, and to allow the patients from the first to empty the bladder when they felt the inclination.
Dr. A. Martin, of Berlin (Zeitschrift fiir Gyaikologie, 1891), de scribes a method of healing a large fistula after numerous other at tempts had failed, by dissecting a flap off from the vagina and filling out the defect with that.
Prof. H. Fritsch, of Breslau (Centralblatt fiir Gynaloologie, 1888, No. 49), recommends a flap method of closing fistulae by splitting the margins of the wound enlarged by an incision passing through the centre of the fistula and for some distance beyond on either side. When the fistula is small, the fistulous tract itself must be dissected out in such a way as not to make the wound margins uneven. He looks upon the method as especially serviceable where the fistula is attached to the bone.
One of the most remarkable operations for large vesico-vaginal fistula was that performed by Dr. E. C. Dudley, of Chicago, upon a woman who had lost so much of the base of the bladder with the an terior vaginal wall, that it was impossible to close the fistula in the ordinary way. Dr. Dudley completely relieved the woman by one operation, in which he freshened a strip on the mucosa encircling the inside of the bladder. He then folded this line of denudation on it self and sutured with silver wire, in such a way as to divide the bladder into two parts, an upper closed sac communicating with the urethra and receiving the urine from the ureters, and a lower open portion, replacing the anterior vaginal wall.
The following plan for the treatment of the larger vesico-vaginal fistuhe has been recommended by A. Mackenrodt of Berlin (Central Uatt fiir Gynakologie, No. 8, 1894). The cervix and the urethral prominence in the vagina, the upper and lower limits of the fistula when it extends so far, are caught by bullet forceps, and the anterior vaginal wall is put on the stretch by traction upward and downward by the forceps. If the uterus is prevented from coming down, the scar tissue holding it back is cut through. An incision is now made through the tense anterior vaginal wall from urethra to cervix, pass ing through the fistula. The edge of the fistula is now split on all sides and the anterior vaginal wall freed from the bladder. The blad der is also separated from the uterus high up, so as to release the wall of the bladder as far as possible in front and behind. The margin of the fistula opening in the bladder is now freshened on all sides and united with fine silkworm-gut sutures close together. Over this layer of sutures a second and even a third layer may be passed, turning the bladder wall in upon itself.