Gynaecology for students and practitioners . Fig. ASo. Kai>ical CtraE of Ctstocele. SUp II (coiHinMed) : Separatingthe bladder from the cervix. and a swab {-see Fig. 4S2). but here and there fibrous bands mustbe divided with scissors. In long-standing cases of prolapse, inflam-matory adhesion of the superficial and deep structures may haveoccurred, to an extent which necessitates a good deal of catting. Theseparation is carried out laterally on each side, until the finger definesthe edge of the bony pubic jirch : large veins may here be met with,which require careful ligature. Xext the blad
Gynaecology for students and practitioners . Fig. ASo. Kai>ical CtraE of Ctstocele. SUp II (coiHinMed) : Separatingthe bladder from the cervix. and a swab {-see Fig. 4S2). but here and there fibrous bands mustbe divided with scissors. In long-standing cases of prolapse, inflam-matory adhesion of the superficial and deep structures may haveoccurred, to an extent which necessitates a good deal of catting. Theseparation is carried out laterally on each side, until the finger definesthe edge of the bony pubic jirch : large veins may here be met with,which require careful ligature. Xext the bladder is dissected offthe anterior wall of the cervix in the same manner (5€t Fisr. 4rS3). the 810 GYNECOLOGY separation being carried up as far as the peritoneal reflection, butthe peritoneum should not be opened. The whole of the base of thebladder now lies fully exposed in the wound, and all bleeding-pointsupon it should be carefully controlled. It will be found that, with. Fig. 484. Radical Cure of Cystocele. Stej} III: Restoring the supportsof the bladder. Note that the bladder has been pushed upwards behind the pubes. the finger, the bladder can be pushed upwards behind the pubes untilit is out of sight [see Fig. 484). Step III. The supports of the bladder are next restored. Oninspecting the deep surfaces of the lateral flaps which have been raised,it will be seen that muscular and fascial structures are present, whichcan be defined with the finger, or at times muscular fibres can actuallybe seen in the position shown in Figure 484. These represent the anterior PLASTIC OPERATIONS 811 portions of the pubo-coccygeus (levator ani) muscles and the viscerallayer of the pelvic fascia. Without further dissection these structurescan be brought together in the middle line by interrupted suturespassed deeply through them. In introducing these stitches, thebladder is pushed up out of the way by an assistant, and should be heldthere until the stitches are tied. T
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Keywords: ., bookcentury1900, bookdecade1910, booksubjectgynecology, bookyear1
