Gynecology . Fig. 248.—Vesicovaginal of mucous membrane around the fistulous opening. operation of Marion Sims is entirely satisfactory. It is performed in the follow-ing way: 554 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 thec
Gynecology . Fig. 248.—Vesicovaginal of mucous membrane around the fistulous opening. operation of Marion Sims is entirely satisfactory. It is performed in the follow-ing way: 554 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. Fig. 249.—Vesicovaginal being sutured longitudinally by the classical method of closure. are approximated, usually from \ to \ inch. The ends of the oval are carriedout still further from the opening. The direction of the denuded oval is deter-mined by the individual case, and is made longitudinal, transverse, or evenoblique in relation to the vaginal axis, according to which way the tissues canbe brought together with the least tension. As a rule, the transverse denuda-tion is the most favorable. When the denudation has been cleanly and sym-metrically made, interrupted sutures are introduced from side to side, beingcarried well into the vaginal tissues and down to the edge of the bladder mucosa, OPERATIONS ON THE VAGINA 555 but not including it (Fig. 249). The suture material is, preferably, fine silverwire, carried by silk guides, which are threaded on fine full-curved is advisable to begin at the center of the wound and work each way, so thatthere will be
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