. Gynecology : . Fig. 302.—Vesicovaginal. of mucous membrane around the fistulous opening. operation of Marion Sims is entirely satisfactory. It is performed in the follow-ing way: 654 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
. Gynecology : . Fig. 302.—Vesicovaginal. of mucous membrane around the fistulous opening. operation of Marion Sims is entirely satisfactory. It is performed in the follow-ing way: 654 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. 303.—Vesicovaginal being sutured longitudinally by the classical method of closure. are approximated, usually from \ to \ inch inuii. The ends of the oval are carriedThe direction of the denuded oval is deter- out still further from the openingmined 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 655 but not including it (Fig. 303). 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 w
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