Treatise on gynaecology : medical and surgical . Fig. 77.—Sdtdre of Vesico-vaginal Fistula ;Deep and Supekficial Sutures in Place. Fig. 78.—Suture of Vesico-vaginal Fistula;Sutures tied. it at once (Fig. 77), Then tie the deep sutures. If silver wire is used,it can be gently brought together and then tAvisted with a wire twister(Fig. 74). In piassing the sutures we may use mouse-toothed for-ceps, blunt and sharp hooks, and a little forked instrument; a cathe-ter is to be kept in the bladder. We prefer a transverse directionwhere it is possible to choose the line of the sutures. If the perfora-
Treatise on gynaecology : medical and surgical . Fig. 77.—Sdtdre of Vesico-vaginal Fistula ;Deep and Supekficial Sutures in Place. Fig. 78.—Suture of Vesico-vaginal Fistula;Sutures tied. it at once (Fig. 77), Then tie the deep sutures. If silver wire is used,it can be gently brought together and then tAvisted with a wire twister(Fig. 74). In piassing the sutures we may use mouse-toothed for-ceps, blunt and sharp hooks, and a little forked instrument; a cathe-ter is to be kept in the bladder. We prefer a transverse directionwhere it is possible to choose the line of the sutures. If the perfora-tion is extensive, it may be best to give it the direction of the letterYj or that of a double Y united by the stems (Fig. 80). Various Modifications of the OptratlGe Technique.—I have just. 314 CLINICAL AND OPEEATIVE GYNAECOLOGY. described tlie general process of denudation and sntnre wliicli is, inits essential features, wliat Yerueuil and Follin call the Americanmethod. Certain special conditions call for modifications of thistechnique. I shall describe them briefly, and shall indicate alsocertain peculiarities in the j)ractice of different operators whichshould not be |)assed over in silence, Flrst Stage. Exposure of the Fistula.—In order to limit the num-ber of assistants, several oi3erators have invented self-retaining spec-ula. Bozeman first constructed an instrument of this kind whichhas served as the pattern for a number of others. Neugebauers ap-paratus (Fig. 71) is fixed to the patients backby straps (Fig. 72), and the hooks, chains, andweights serve to put the parts upon stretchwithout the aid of assistants (Fig. 73). Simondepresses the cervix by passing loops of silkthrough the lij)s; these take up less space thanforceps. The larger number of surgeons whofi
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