Plastic surgery; its principles and practice . as to avoid thepossibility of damage either to the ureter itself, or to its vessels. As soon as the bladder is well isolated it is drawn upward out of theway by an assistant. In the bottom of the wound the rectum with itsperitoneal reflection is now seen. The peritoneum is then strippedupward from the front of the rectum until 10. or (4 or 5 inches)of the bowel are exposed. The finger of an assistant having been passedinto the rectum to make it prominent, traction sutures are placed and EXSTROPHY OF THE BLADDER 303 an incision cm. (3I
Plastic surgery; its principles and practice . as to avoid thepossibility of damage either to the ureter itself, or to its vessels. As soon as the bladder is well isolated it is drawn upward out of theway by an assistant. In the bottom of the wound the rectum with itsperitoneal reflection is now seen. The peritoneum is then strippedupward from the front of the rectum until 10. or (4 or 5 inches)of the bowel are exposed. The finger of an assistant having been passedinto the rectum to make it prominent, traction sutures are placed and EXSTROPHY OF THE BLADDER 303 an incision cm. (3I2 inches) in length is made along the anteriorsurface of the bowel. Into this opening the bladder is placed, beingturned upside down so that its former anterior surface becomes posterior,and its former lower end becomes the upper. The ureters instead ofpassing forward to the bladder pass backward, and the catheters passinto the rectum and out at the anus, the sphincter having previously Deep surface of the bladder The incision into the rectum. Fig. 268.—Moynihans operation for exstrophy of the bladder, continued (Jacobson).The ureters should not be stripped as freely as shown, as the blood supply must bepreserved. been dilated. The edge of the bladder and the cut edges of the rectumare sutured together with a continuous suture on each side for themucous membrane, and any appropriate infolding intestinal suturefor the outside. A few additional sutures may be inserted when neces-sary. In the Maydl operation the trigone is implanted into the rectumintraperitoneally (Figs. 267-269). The Bergenhem-Peters operation is done extraperitoneally, and theprocedure is practically identical with the Moynihan operation just 304 PLASTIC SURGERY described, except that each ureter with a rosette of bladder tissue sur-rounding the orifice is separately implanted on opposite sides of therectum. Both ureters may be implanted at the same operation, or oneat a time. The Implantation of the Free Ure
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