Preparatory treatment. The chief object is to obtain a healthy condition of the fistulous edges, which are nearly always inflamed, thickened, and covered by urinary deposits, usually of a phosphatic character. These are best removed by means of a soft sponge or cotton-wool, and the raw edges treated with a weak solution of nitrate of silver (gr. ij to the ounce). Hot vaginal douches of lysol solution (ʒj to a quart) should be given night and morning, and the parts freely smeared with vaseline to protect them from the action of the irritating urine. Any cicatricial tissue which may be present around the fistula should be treated by submucous division.

Fig. 37. Auvard’s Self-retaining Speculum.

Fig. 38. Knives for freshening the Edges of a Vesico-vaginal Fistula.

Fig. 39. Toothed Forceps for use in Vesico-vaginal Fistula.

Fig. 40. Emmett’s Hook.

Operation. The instruments necessary are: a Sims’s or Auvard’s (Fig. 37) speculum; two flat spatulæ; three long-handled knives (Fig. 38), one with a long haft and a short straight narrow blade, and the others with angular blades (right and left); two long-handled, sharp-pointed, curved scissors (right and left); an Emmett’s hook for making counter-pressure (Fig. 40); toothed forceps (Fig. 39) and tenaculum; six Spencer Wells’s forceps; Schauta’s needle-holder ([Fig. 73]) with short curved needles.

The patient is placed in the lithotomy position. A strip of mucous membrane is then removed from the whole of the vaginal edge of the fistula by means of an angular knife. In the original operation Sims (Fig. 41) made the surface oblique, but Simon (Fig. 42) considered the raw surface should be at right angles to the mucous membrane. The blade of the knife should not wound the vesical mucous membrane.

Fig. 41. Sims’s Operation for the Repair of a Vesico-vaginal Fistula. a. Bladder mucous membrane.
b. Vaginal wall.
c. Suture passed but not tied.
d. Section of denuded surface.
e, e'. Liberating incisions.
f. The fistula.
    Fig. 42. Simon’s Operation for the Repair of a Vesico-vaginal Fistula. Letters as in the preceding figure.

After the bleeding has ceased, the sutures, which may be of silk or catgut, are passed by means of the needle through the pared edge of the fistula on one side, passing across the fistula, and piercing the raw surface on the opposite side. The entry of the needle should be made about 1/4 – 1/3 of an inch from the raw edge ([Fig. 44]). Emmett’s hook, shaped like a button-hook, is useful to produce counter-pressure against the needle point. The sutures are tied, and milk is injected into the bladder to test the accuracy of the union.

As a rule, fistulæ are bounded by rather scanty and inelastic walls, owing to the presence of cicatricial tissue; it is therefore more advantageous not to remove any tissue in order to produce a raw surface, or as little as possible. To fulfil this condition, the method of dédoublement or flap-splitting, as practised by Walcher, may be carried out (Fig. 43, A, B, and C).