A rectovaginal fistula may be closed by formal operation, similar to that for closure of a vesicovaginal fistula, based upon the simple principle of freshening the edges of the opening and then holding them together with suitably placed sutures. A rectovesical fistula would, in most instances at least, require a laparotomy, with careful separation of the rectum from the bladder, and then a separate suture of each opening. Such an operation might be quite difficult, made so not by its plan of performance but by the conditions which necessitated it. Any bladder thus attacked should be kept perfectly empty for several days by the use of a self-retaining catheter. Every case of fecal communication with any large abscess cavity, or through the diaphragm, directly or indirectly, as with a bronchus, should be treated on its individual merits, it being a grave question whether operation would be indicated or not.
Certain fecal fistulas will justify more formidable operation, in which, after opening the abdomen and carefully protecting its contents against contamination, the adhesions should be separated entirely and that portion of the bowel which is involved removed, making either an end-to-end suture or a lateral approximation. If this be done it will be best also to completely excise the old fistulous tract through the abdominal wall, and to remove everything that was involved in the previous condition.
It is possible to atone for almost every opening of this character, save those produced by some seriously malignant disease. If such a condition be the result of cancerous extension then it is practically hopeless.
OPERATIONS UPON THE INTESTINE.
Intestinal Suture.
—Intestinal suture is by no means a new or modern operation. It was spoken of by the ancient writers and was evidently practised in the middle ages by the “Four Masters” of the School of Salernum and their followers. But until it was reduced to a science by the French surgeons, Jobert and Lembert, during the first quarter of the past century, it was always a hazardous measure. Success with intestinal suture depends upon exact hemostasis of the edges to be united and their accurate approximation in layers (i. e., mucosa to mucosa and serous and muscular coat to its like). Save when haste compels, this accurate application is effected by two distinct suture rows, the first or deeper (of hardened gut) made to include the mucosa alone, the suture being usually continuous, but knotted at intervals, with stitches close together and drawn tightly to amply secure against leakage from the relatively large vessels of this membrane. It is better to apply this row by itself, as any suture drawn through the mucosa and out again through the serous coat is liable to contaminate the latter, it being much better to keep the contaminated row of sutures distinct. The first row having been applied and the surface carefully cleansed the operator may then coapt the balance of the annular wound by a continuous row of fine silk sutures, made to include the serous and muscular coats and to avoid the mucosa. The stomach and the colon are sufficiently thick to take a row of rather coarse sutures for this purpose, but most of the small intestine is so thin-walled that these need to be applied with caution as well as with dexterity.
Every row of sutures should be so applied and directed that the lumen of the bowel be not reduced by its presence, it being a serious matter to greatly encroach upon the diameter of the bowel, since obstruction will thereby be favored and extra tension made upon the sutures ([Figs. 564] and [565]).
Fig. 564
Application of the interrupted Lembert suture. (Richardson.)