Fig. 31—Kelsey's Fistula-Knife.
After etherization the patient should be placed on the side on which the fistula exists, the buttock being brought to the edge of the operating-table. Occasionally the lithotomy posture is preferable, as in cases in which there is a complex fistula.
The first step in the operation is to dilate the sphincter muscles, which is to be done in a slow but steady manner by introducing the thumbs into the rectum, back to back, and making gradual pressure around the anal orifice until muscular contraction is overcome.
Fig. 32—Probe-pointed Director.
Fig. 33—Kelsey's Fistula-Director.
In dealing with COMPLETE FISTULÆ a flexible probe-pointed director (Figs. 32, 33) is passed through the sinus, and is then brought out of the anus by means of the forefinger of the left hand introduced into the bowel. The tissues lying upon the director are then to be divided with a sharp bistoury. A careful search is now to be made for any diverticula, which if found should be divided. If none exist, the granulations lining the track should be scraped away with a Volkmann's spoon (Fig. 34). The healing process will be facilitated by removing with scissors all overtopping edges of skin and mucous membrane.
Fig. 34—Volkmann's Spoon.