Lithotomy, by either of the above methods, is performed by utilizing a grooved sound known as a staff, which is first inserted into the bladder, and serves not merely the purpose of a grooved director, but to indicate the course of the urethra.
For the suprapubic operation the staff is passed deeply, and its handle depressed between the thighs, so that the end of the instrument rises behind the pubis and carries the bladder up toward the surface. A median incision above the pubis permits access between the recti muscles to the prevesical space (space of Retzius), which is more or less filled with fatty and connective tissue. If the bladder has been previously distended with fluid and elevated on the point of the staff, there is but little danger of wounding the peritoneum, although its reflection may be sought and carried out of harm’s way. It is a convenience to pass a silk suture with a stout, full-curved needle through the bladder wall after it has been exposed, on either side of the point of the staff which elevates it, and to pass this through in such a way as to have thus a double loop, or two retractors, by which it may be more conveniently manipulated after it has been opened and would otherwise collapse. The bladder should be opened upon the point of the staff, whose groove may then serve as a guide in still further nicking or incising it, the silk sutures on each side preventing it from collapsing as it otherwise would after the gush of escaping fluid. The surgeon should now endeavor so far as possible to dilate rather than to merely cut this opening, and thus give it a size sufficient to permit the introduction of the finger, by which intravesical exploration and orientation are effected. Calculi having been identified and located, suitable forceps are then introduced, and with them the stone or stones seized and withdrawn through the opening, which may be stretched still farther for the purpose unless their size make it advisable to crush them and remove them in fragments.
Fig. 652
Method of seizing the stone behind the prostate.
Fig. 653
Ordinary position in seizing the stone.
Fig. 654
