Fig. 43. Repair of a Vesico-vaginal Fistula by Dédoublement.
A. The flap-splitting stage.
B. The flaps separated and the suture passed.
C. Suture tied, approximating the flaps.
a. Bladder mucous membrane.
b. Vaginal wall.
c. Suture.
e, e'. Liberating incisions.
k, k'. Flap-splitting incisions.
In A the flap-splitting is seen in section (k, k'); in B the flaps have been everted towards the bladder and vagina respectively and the suture passed. In C this suture has been tied; liberating incisions, e, e', have been made on the vaginal surface to prevent tension in the wound.
The patient is placed, as before, in the lithotomy position, and the cervix is pulled down, while the edges of the fistula are kept steady by a volsella on either side. The margin of the orifice is then split all round to a depth of from a quarter to half an inch. Vesical and vaginal mucous membrane flaps are thus produced, giving a large raw surface without any loss of substance. The sutures are passed as shown in Fig. 43, C.
After-treatment. This is very simple: if the patient is able, she should pass water, either in the dorsal or genu-pectoral position, otherwise a catheter should be passed every six hours.
Modifications of this operation have been devised, more especially for the larger fistulæ: they will be briefly mentioned.
1. Repair by turning up vaginal flaps to form the base of the bladder is recommended by A. Martin of Berlin. He first frees the adherent edges of the fistula and then raises the flaps from the vaginal wall and brings them over the opening, suturing them carefully together. By this method the mucous membrane of the vagina forms the new lining to the bladder, and the exposed raw surface a new anterior vaginal wall. The edges of this latter denuded surface are united by sutures, as in the operation of colporrhaphy.
2. Closure of the fistula by detaching the bladder from the vagina and suturing it independently is described and practised by Mackenrodt.
The patient is placed in the lithotomy position, and the fistula is exposed: the cervix is drawn downwards and backwards by means of a wire loop or tenaculum, and the urethral prominence held with a pair of hooked forceps. An incision is then made in the median line extending across the fistula and through the vaginal walls down to the bladder, in this way exposing the entire base of the bladder. The edges of the fistula are then split so that the bladder and the vaginal walls are separated. The two vesical flaps are now carefully and separately sutured by catgut and the edges of the vaginal wound are brought together as much as possible: if necessary, the fundus of the uterus may be used to assist in closing the opening.