After thus completely closing the bladder, the opening into the vagina is denuded and the body of the uterus pulled clown (as in the operation for vaginal fixation) and attached to the anterior vaginal wall, the vaginal margins being brought together as completely as the defect will allow. Where approximation is impossible the uterus is united to the sides by a number of interrupted sutures.
Dittel has recommended (Wiener klinisehe Woehensehrift, 1893, No. 25), as a method of closure in difficult cases, an incision through the abdominal wall exposing the vesico-uterine pouch, a transverse incision freeing the bladder from the uterus and then from the vagina, until the fistula is exposed. The hole in the bladder is now sewed up, the peritoneal surfaces again united, and the abdomen closed. The opening in the vaginal wall is not closed but drained by means of a strip of iodoform gauze.
The closure of vesico-vaginal fistulm by buried sutures was recom mended by Yulliet, in Geneva (Xouvelles Archives d' Obstetrigue et de Gynecologie, 1887, Nov. 25th), and practised in a case where a patient had been already three times operated upon. The margins of the bladder wound were denuded and united with a continous suture, after which the vaginal surfaces of the wound were brought together in like manner. The sutures used were of silk.
Where the fistula lies close to the cervix, it may readily be closed by making the area of denudation include as much of the cervical tissue, as well as of the neighboring vaginal tissue, as may be neces sary to secure broad surfaces of approximation.
Where there is much scar tissue about the cervix, or where the fistula opens into the uterus above, the best plan is to dissect the vaginal vault free from the anterior part of the cervix and to carry the dissection up high enough to release the fistula entirely from its uterine connections, and leave a broad margin of freshened tissue surrounding it on all sides. The fistula may now be closed with buried sutures of fine silk, catgut, or silkworm-gut. The wound surface between the bladder and uterus may now either be closed by sutures or drained by iocloform gauze. In one case of my own, where there was a small vesico-vaginal fistula just in front of the cervix and a vesico-uterine fistula about LI cm. above the vault, I closed both by the following procedure : The cervix was caught by a pair of bullet forceps and drawn down, making the vaginal vault tense. The vagina was then dissected free from the cervix anteriorly, and the dissection was carried above the vault until the vesico-uterine fistula was ex posed and severed from its uterine connection for about 1 cm. on all sides. The margins of the vesico-vaginal fistula were then denuded. The sutures were now passed in such a manner as to oppose the fistulous orifices 'one to the other, so that with a single row of su tures from side to side both fistulae were closed.