. Manual of operative surgery. ^ inches below the line of section (Fig. 714.) Make an incision throughthe skin alone, immediately below the biliary fistula. Introduce a forcepsinto this wound and burrow a canal between the skin and aponeurosis downto the laparotomy wound. With the forceps pull the end of the lower segmentof gut (temporarily closed by a ligature) through the subcutaneous tunneland unite it to the cutaneous opening of the biliary fistula. (It may be nec-essary to mobilize the end of the fistula slightly). Close the laparotomywound, being careful not to constrict the portion of g
. Manual of operative surgery. ^ inches below the line of section (Fig. 714.) Make an incision throughthe skin alone, immediately below the biliary fistula. Introduce a forcepsinto this wound and burrow a canal between the skin and aponeurosis downto the laparotomy wound. With the forceps pull the end of the lower segmentof gut (temporarily closed by a ligature) through the subcutaneous tunneland unite it to the cutaneous opening of the biliary fistula. (It may be nec-essary to mobilize the end of the fistula slightly). Close the laparotomywound, being careful not to constrict the portion of gut where it passes through. Fig. 714. i4. Anastomosis between end upper segment gut and side lower segment. F. Biliary fistula and in-cision through which forceps is passed subcutaneously to grasp and pull up to F the segregated portion oflower segment of gut L. the deep structures of the belly-wall. It might be wise to supplement the longi-tudinal laparotomy wound by a small transverse incision through the rectusand aponeurosis at the point where the segment of gut passes through thesestructures. The author used this method in one case (reported by Sutton, Annals ofSurg., Sept., 1910). The segment of intestine passing under the skin to thefistula retained its vitality but acted as a faecal fistula. These methods of v. Stubenrauch have been suggested for certain rare andvery difficult cases. Only one of the methods has been used with are described here as they are worthy of consideration and may be help-ful in an emergency. INDICATIONS FOR AND CHOICE OF OPERATION It is undoubtedly true that in at le
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