. Gynecology : . ures, silver wire or silkworm-gut. AVe have found the latter method more successful. The opertion is practi-cally identical with that for vesicovaginal fistula. A wide denudation is madein an oval shape about the fistula, the direction of the oval being made longi-tudinal or transverse, so that the tissues may be brought together from side toside with as little tension as possible. If the wound is to be sewed in layersthe rectal mucous membrane is separated from the vaginal membrane for ashort distance about the fistulous opening. The membranes are then sewedseparately with ca
. Gynecology : . ures, silver wire or silkworm-gut. AVe have found the latter method more successful. The opertion is practi-cally identical with that for vesicovaginal fistula. A wide denudation is madein an oval shape about the fistula, the direction of the oval being made longi-tudinal or transverse, so that the tissues may be brought together from side toside with as little tension as possible. If the wound is to be sewed in layersthe rectal mucous membrane is separated from the vaginal membrane for ashort distance about the fistulous opening. The membranes are then sewedseparately with catgut. The other and better method is to close the entire wound with silver wire,the sutures being placed well out from the margin of the wound, so that theymay act as a sort of splint. (See Operations for Vesicovaginal Fistulae.) OPERATIONS FOR VESICAL FISTULA For vesicovaginal fistula several operations have been devised. For smallfistulae, where there is plenty of healthy tissue about the opening, the classical. Fig. 302.—Vesicovaginal. of mucous membrane around the fistulous opening. operation of Marion Sims is entirely satisfactory. It is performed in the follow-ing way: 654 GYNECOLOGY The patient is either in the lithotomy or in the Sims position. The latteris sometimes preferable where the fistula is high up toward the vault of the vagina,as is frequently the case when the injury has been done in the process of a hys-terectomy. An oval denudation is made with fine scissors about the openingdown to the vesical mucous membrane, special care being taken to trim off thecicatricial edge of the bladder opening. The denuded margin about the orificeshould be as wide as possible without causing too much tension when the edges
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