SUPRAPUBIC LITHOTOMY. — The in struments required for this operation are scalpels, dissecting-forceps, haemostats, retractors, rectal bag, lithotomy-for ceps, lithotomy-scoop, catheters, syringe, stone-searcher, scissors, needles, sutures, etc.
The preparation of the patient has al ready been described. After anaesthesia the presence of the stone should be de termined before proceeding. The next step should be the introduction of the rectal bag, previously oiled, well above the internal sphincter. A catheter is then introduced, the urine withdrawn, and the bladder irrigated with warm boric-acid solution, after which from 6 to 10 ounces are allowed to remain. A catheter or rubber tube should be tied around the penis in order to avoid ex pulsion of the solution. From S to 10 ounces of boric solution should then be injected into the rectal bag and retained. In operating in children the quantities of fluid both in the bladder and in the rectal bag should be very much smaller, and, owing to the higher position of the bladder at this time of life, the rectal bag may be dispensed with altogether. The incision should begin in the middle line about half an inch below the sym physis pubis and in the adult may be carried upward about three inches. The incision is carefully deepened, either be tween the muscles or through them, until the transversalis fascia is reached. When this is divided the prevesical fat and connective tissue are exposed. It is desirable to reach the bladder by blunt dissection from this point, pushing upward the fat and connective tissue, which frequently contain a number of large veins, with the finger and handle of the scalpel; this procedure also raises the peritoneum out of danger. It should always be borne in mind that the peritoneal reflexion may be abnor mally low in any case, and that it may be opened if due caution is not observed.
After the bladder has been exposed all bleeding should be controlled by pressure-forceps, the bladder-wall trans fixed with a sharp hook, and a scalpel thrust vertically into the bladder, cut ting downward toward the symphysis. The edges of the bladder-opening may then be caught with tenacula or trans fixed with needles carrying strong silk threads. The forefinger may then be in troduced, and the stone located and re moved by the forceps. After being cer tain that the bladder is empty, if the walls are in a healthy condition, the in cision may be united by chromicized cat gut sutures. They should be passed close together and should include all of the coats except the mucous membrane.
The abdominal wound is to be united by suturing, a small drainage-tube being in troduced through the external wound and retained until it is certain that the incision in the bladder is going to heal kindly. A catheter should be introduced through the urethra and retained for a week or ten days.
If the bladder-walls are unhealthy, or if there is a pronounced cystitis so that immediate suture is unsafe, the margins of the bladder-wound may be united by a few stitches to the deeper portion of the abdominal incision and a large drainage-tube introduced. The use of siphon-drainage is very desirable in pre venting the urine from saturating the dressings and excoriating the patient's skin. The bladder should be frequently irrigated and the skin around the wound cleansed and protected by an antiseptic ointment. As soon as the condition will permit, the external drainage should be removed and the wound allowed to close.
Drainage of the bladder can be at tained in a simpler manner than Cath cart's. Besides the rubber tubing, only three straight pieces of glass tubing with slightly-dilated ends are required. The S-shaped piece of glass tubing below the junction of the tubes coming from the irrigator and the bladder, respectively, is replaced by looping up a simple rubber tube by a piece of bandage. Keen (Ann. of Surg., Feb., '96).
For bladder drainage after suprapubic cystotomy the tubing and clamp of what is known as a fountain-syringe may be used. This comprises a bag to contain water and two pieces of rubber tube joined at a right angle. The upper end of the longer limb of the T-shaped tube is held vertically, and fixed to the bag; the shorter placed horizontally, and con nected with a soft catheter in the blad der. The clamp is fixed so that it is all but occluded close below the irrigator bag. The S-shaped tube of the outlet of Cathcart's arrangement is replaced by a simple hitch-knot tied loosely in the rub ber-tube. One or two drops per second from the irrigator prevent the bladder from filling, so that it is not necessary to replenish the bag of the fountain-syringe oftener than once in several hours. It makes no difference in the working of the apparatus whether the bag is hung above the patient or lower. The catheter in the bladder should have a second opening made into it opposite the original one, to prevent blocking by a piece of mucous membrane being sucked in. Dawbarn (N. Y. Med. Rec., May 30, '96).