PERINEAL LITIIOTOMY (LATERAL). The instruments required for this opera tion are a grooved staff, lithotomy-knife, probe-pointed bistoury, lithotomy-for ceps, lithotomy-scoop, a large-sized pure rubber catheter, a catheter en chemise, haemostatic forceps, scissors, ligatures, and sutures.
The patient having been etherized, the vesical sound is introduced, and if the stone is detected the operation is proceeded with. The urine is with drawn, the bladder irrigated with warm boric-acid solution, after which 6 or S fluidounces are allowed to remain. The patient is then so arranged that the but tocks project slightly from the end of the table; the thighs are flexed upon the abdomen and the legs upon the thighs and retained in this position by assistants. The grooved staff is then in troduced and placed in proper position by the surgeon, after which it is held by an assistant whose duty it is to accurately retain it in this position. The handle should be held either perpendicularly or inclined slightly toward the patient's right groin, and should be drawn well upward so that the curve rests against the under surface of the symphysis pubis. The surgeon should then fix in his mind the central point of the perineum, which is midway between the anus and the perineo-scrotal junction, and in the adult is about an inch and a half in front of the farmer. Finally observing that the staff remains in proper position, a lithot omy-knife is introduced vertically in the direction of the staff at the central point of the perineum and just to the left of the raphe and carried downward and outward across the left ischio-rectal space, terminating on a line between the anus and the left ischial tuberosity and rather nearer to the latter than the former. This incision is deepest at the beginning and becomes shallower at the posterior extremity. It passes through the skin, superficial fascia, transverse perinea] muscle, nerve, and vessels, the lower edge of the anterior layer of the triangular ligament, and the inferior hemorrhoidal vessels and nerves.
The surgeon then introduces the left index finger into the wound, and locates the groove of the staff. The knife is now passed along the finger and made to en gage in the groove, after which it is pushed along toward the bladder, being careful not to allow it to escape from the guide until the gush of fluid indicates that the bladder has been reached, when it is made to cut downward and outward in the line of the first incision. This di
vides the membranous and prostatic por tions of the urethra, the compressor urethra; muscle, the posterior layer of the triangular ligament, a few fibres of the levator-ani muscle, and the left lobe of the prostate. The left forefinger should then be introduced into the blad der, using the staff as a guide, and when the stone is felt the staff should be with drawn, the lithotomy-forceps introduced along the finger and made to seize the calculus. which is then extracted.
In children in whom it is desirable to operate through as small an incision as possible, the lithotomy-forceps may be introduced along the groove of the staff and the stone extracted without intro ducing the finger at all. Little difficulty is experienced in finding the stone in children, inasmuch as there is no pouch ing of the bladder. Occasionally it will be found that the stone is too large to extract through the incision, in which case it may be broken into two or more fragments by means of a lithotrite intro duced through the wound. It is desir able, however, to extract a stone without fragmentation when possible; but this should not be done at the risk of injur ing important neighboring structures. Finally the bladder should be explored in order to make sure that other calculi do not exist, the wound is inspected for any bleeding vessels that should be tied, a large rubber catheter introduced, the bladder irrigated, and a little iodoform gauze laid in the superficial portion of the wound around the catheter,—which should be held in place by sewing to the edge of the incision,—and a dressing ap plied. Trsually the hmmorrhage which follows the incision subsides after the patient's legs are brought together. If any pronounced bleeding continues from the deep portion of the wound, it is best controlled by introducing a catheter en chemise, which is made by introducing the end of a large rubber catheter for about two inches through the centre of four layers of sterile gauze about eight inches square and fixing the gauze in this position by tying firmly with a silk thread. This is then introduced into the wound and gauze packing placed firmly and evenly around the catheter and inside of the gauze.