again. During this procedure, the cylinder-Hke shaft is held firmly and
steadily in its position with the left hand.
4. The instrument is at once opened again, and an attempt is made to
grasp one of the fragments and to crush it in the same manner ; this pro-
cedure is repeated until all of the larger fragments have been crushed ; it
can then be taken for granted that the stone has been entirely crushed into
small pieces. For grasping even the last portions, the beak is turned down-
ward toward the neck of the bladder, so that it can grasp any fragments
concealed behind the prostate.
5. If the stone is too hard to be broken by screw power, it may be
broken by striking the handle with a hammer.
If, in this manner, the stone has been broken into small fragments,
another lithotrite is introduced, the female arm of which is not perforated at
the end, but scooped out like a spoon {e.g. Fig. 1432). With this the
fragments are grasped again, one after another, and ground to a fine gravel.
After this has been accomplished,- a large evacnation catheter \Nith a large
opening at its beak-like end is introduced (Fig. 1434, 3). Through it, the
fluid present in the bladder generally flows out with a portion of the
fragments of stone.
784
SURGICAL TECHNIC
6. The cvaataiion of the fragments of stone is then made at once (litho-
lapaxy, Bigelow).
For this purpose is used the evaaiator {Bigelozv, Otis, Fig. 1434), a
suction pump, the end of which is screwed into the opening of the catheter.
The whole apparatus is filled with boric solution ; and by compressing the
elastic bulb a portion of the solution is forced into the bladder, from the
bottom of which it whirls up the debris. If the pressure is discontinued,
the bulb aspirates the fluid, bringing with it some of the fragments of stone ;
these fall at once into the glass receiver (2) filled with glycerine and screwed
Fig. 1434. Otis's Evacuator for Litholapaxy
to the apparatus. The compression and suction by the elastic bulb are now
slowly but rhythmically continued until no more fragments can be removed
from the bladder. The interruption of the current of fluid in the glass
receiver by means of a tube opening above and another opening below,
prevents the fragments of stone withdrawn from returning into the bladder.
If fragments of stone are no longer evacuated, the evacuator is removed,
and the lithotrite is introduced once more, to search for any fragments that
may have remained. If any are found, they are removed in the manner
described before.
OPERATIONS FOR CONGENITAL CLEFT FORMATION OF THE
ANTERIOR PELVIC REGION
(a) In ectopia vesicae, that is, exstrophy of the bladder.
The congenital defect of the abdominal wall and the bladder exists nearly
always in connection with a cleft of the pubis, with epispadias and inguinal
hernias.
For relieving to some extent the pitiable condition of the patient suffer-
ing from these defects, — the continuous trickling of urine from the vesical
OPERATIONS ON THE PELVIS
785
Fig. 1435. Receptacle for Urine
apertures of the ureters freely exposed in the protruding posterior wall of
the bladder, — the urine is collected in a suitable receptacle made of soft
rubber (Fig. 1435).
The operative closure, however, offers exceedingly great difficulties, and
the operator can feel satisfied when he has covered the vesical defect so far
that some urine may collect in the bladder,
which has been forced back. The urine is
retained by a trusslike appliance, and is evac-
uated at pleasure by removal of the truss.
Covering the protruding posterior wall of
the bladder (cystoplasty) has been attempted
by the formation of flaps ( Wood, Thiersch).
The flaps of skin must be taken from the
immediate neighborhood, that is, from the
abdominal wall. They can be stitched di-
rectly with their fresh wound surface to the
vivified margins of the vesical defect. For
this purpose, either one large flap {HirscJiberg)
can be employed, or several, simultaneously,
or one after another (^Thiersch). Underlining
by turning over a sufficiently large flap (attempted by Nelaton)vs, not practical,
because the epidermis side turned into the interior of the bladder furnishes
the cause for obstinate stone formations by deposition of phosphates on the
hair. It is sufficient to fasten over the cleft a large flap, with the wound
surface toward the bladder. If its heahng succeeds, it is true, the flap sub-
sequently contracts considerably ; but during cicatrization it partly draws
the mucous membrane of the bladder toward its inner surface. Wood and
Thiersch closed the cleft by Hning it zvith three flaps (Figs. 1436-1438).
First, from the skin of the abdomen over the bladder, a large flap {A ) was
excised, turned downward, its epidermis side toward the bladder, and sutured
to the vivified margins of the bladder ; this flap was then covered by sliding
and turning two pedunculated flaps {B and C\ obtained from the lateral
inguinal regions. The annoying condition mentioned above — the forma-
tion of concretions — might perhaps be removed by grafting (according to
Wolfler) the large flap with mucous membrane, as a preliminary step to its
transplantation (A), after a superficial removal of the epidermis, or by
destroying the several hair follicles by electrolysis or galvanocautery.
ThierscJi afterward proceeded as follows : He detached t^vo lateral
flaps, having an upper and a lower bridge, near the margin of the bladder,
3E
786
SURGICAL TECHNIC
and allowed them to granulate upon a plate of tinfoil, ivory, or glass, placed
under them. When the flaps began to contract and fold, he divided the
upper bridge, and sutured first one lap over the inferior portion of the
bladder; after it had healed, he closed the superior portion by means of
the flap of the other side, treated in the same manner ; by a final operation,
he closed the transverse cleft remaining between the two flaps.
The skin of the scrotum, often considerably enlarged by inguinal hernias,
may also be very well used for such flaps ; the healing hardly ever succeeds
completely. In most cases, small fistulas remain between the several
sutures ; these must be closed subsequently.
Fig. 1436
Fig. 1438
Fig. 1437
Wood's Cystoplasty. Fig. 1436, forming flaps; Fig. 1437, suturing lateral flaps over
inverted middle flap; Fig. 1438, healing of wound
Czeniy succeeded in directly suturing the margins of the defect by dissect-
ing off, all around, the prolapsed mucous membrane of the bladder with the
exception of a portion in the middle about as large as a ten-cent piece, and by
turning it over and suturing the margins of the wound in the median line.
Battle proceeded in a similar manner. Suturing of the margins of skin,
however, must be effected by a plastic operation.
Schlange and Rydygicr sutured the margins of the vesical cleft by
including the recti muscles and portions of the pubes ; Pozzi proceeds in a
similar manner.
Miculicz sutures two bridge flaps, containing the recti and their chiselled-
off pubic insertions, with silver wire over the bladder, previously detached
and sutured to form a hollow sphere ; he subsequently forms the urethra
and the penis by uniting the margins of the cleft vivified longitudinally, and
OPERATIONS ON THE PELVIS 787
finally occludes the neck of the bladder by circumscribing it with the knife
and inversion suture of the fistula.
Poppert, after the bladder had been sutured, effected a rather good
continence by allowing the posterior portion of the urethra (which contains
the sphincter) to extend for a short distance into the lower wall of the
bladder. Stretching of the ring of the sphincter muscle by intravesical
pressure cannot then take place.
Passavant advantageously employed Demme s suggestion, that is, to
remove first the cleft of the piibes ; having the patient wear a rubber belt
or a steel belt provided with screws, or having him lie upon a wooden log
with a cuneiform excision FXZI. ^^ tried very gradually to force together
the gaping margins of the pubes, so that they almost touched each other.
Meanwhile, by suitable apparatus, he forced back into the abdominal cavity
the wall of the bladder (elastic bulb with gutta-percha plate and rubber
bandage). When the margins of the cleft had been approximated by this
treatment (after several months), he sutured the cleft of the bladder after
vivifying broadly ; next, he approximated the pubes by sutures, and then
attempted the formation of a sphincter ring, which in its original position
forms only a straight muscular band. Finally the groove of the urethra,
open in an upward direction, was closed by suturing the corpora cavernosa
of the penis, which had been turned upward.
Trendelenburg effected reduction in the size of the cleft of the pubis in
a 7nuch shorter time by dividing the sacroiliac articulations. For this pur-
pose, the left forefinger is introduced into the rectum of the child lying on
the abdomen, and the sciatic notch is sought for. Then the skin over the
articulations is divided from without, and the operator penetrates in the
same line through the posterior masses of ligaments, until the connection
has been sufficiently loosened to enable a vigorous lateral pressure upon the
two pelvic halves to rupture it, so that the stumps of the symphyses touch
each other. The wounds are closed by skin sutures. The child is then
placed for four to six weeks into an apparatus which keeps the pelvis
laterally compressed. Then, after a broad vivifying, the approximated
margins of the cleft are sutured with silver wire in a vertical line. If too
great a tension is caused thereby, the skin can be made more movable by
lateral incisions parallel to the margins of the cleft (as in Fig. 1404).
Koch obtained good success with a similar procedure. He decreased
the cleft of the symphysis hy forcibly rupturing the articulations.
Konig approximates the divided symphysis after chiselHng through the
horizontal and the ascending ramus of the pubis on both sides.
788
SURGICAL TECHNIC
In exstrophy, with very marked protrusion, Sonnenbiirg removed the
whole bladder, after having detached it carefully from above from the
peritoneum (extirpation of the urinary bladder), and sutured the dissected-
off ureters into the groove of the penis at the lower sutured extremity of
the cavity of the wound covered by sliding lateral flaps. Langcnbnch pro-
ceeded in a similar manner.
After extirpation of the bladder, Maydl and others implanted the ureters,
together with a portion of the vesical mucous membrane, into the sigmoid
flexure.
Even in healthy kidneys, Harrison extirpated the left one, implanted the
ureter of the right kidney into a small skin-incision of the right lumbar
region, and closed the bladder by a plastic operation.
The success of all these operations consists in
reducing the defect and thus in obtaining a smaller
opening at the lower extremity of the covered defect,
after the mucous membrane of the bladder, which,
owing to its inflammation, is exceedingly painful,
has been covered or removed. The small opening
resulting from the operation can be closed by the
stump of the penis turned upward, and by a S2t,it-
able pad ; or, at least, it is better adapted for apply-
ing a portable urinal, which is fastened laterally to
the patient's leg (Fig. 1439). Finally, by removing
the epispadias, which nearly always exists, the urine
may also be evacuated through the thick stump of
the penis, whereby approximately normal conditions are produced ; or, at
least, the continuous irrigation of the scrotum and the perineum with decom-
posing urine is lessened.
(/;) EPISPADIAS
The operation for epispadias consists in transforming the gutter on the
upper surface of the penis into a closed urethral canal. This is done prefer-
ably by
THE METHOD OF THIERSCH,
who proceeded at various sittings as follows : —
I. Formation of the glans portion of the urethra: By two incisions,
extending along the margins of the canal of the glans, obliquely inclined
toward each other and penetrating deep into the substance of the glans, the
latter is divided into three flaps (Fig. 1440, a, b). After the hemorrhage has
Fig. 1439. Portable Uri
NAL AFTER CySTOPLASTY
OPERATIONS ON THE PELVIS
789
been arrested, the median flap, containing the mucous membrane of the
canal, is depressed with a grooved director ; and the two elastic lateral flaps
Fig. 1440. Forming Glaxs Portion of Urethra
are folded over it and united with deep interrupted or continuous sutures
(Fig. 1440, c). After the wound has healed successfully, the attempt is
made
2. To close the penile portion of the gutter. On both sides of the gutter
two oblong rectangular flaps (Fig. 1441) are excised from the skin of the
dorsum of the penis. One of these flaps, the broader, is turned with its free
Fig. 1441
Fig. 1442. Closure of Open Slit between
Glans and Penis
Closure of Penile Portion of Gutter
Fig. 1443
margin {b) toward the gutter. The smaller of these two flaps with its base
[a) (like the leaves of a door) is turned over the gutter in such a manner
that its outer (epidermis) surface is directed toward the canal; the other,
the broader flap, is turned over the smaller, flap, so that its wound surface
comes to lie upon the wound surface of the smaller flap, which has been
turned over. After the position of the two flaps has been secured by a fev\^
790
SURGICAL TECHNIC
quilt sutures, the margin of the larger flap, serving for a cover, is united by
superficial sutures with the opposite margin of the wound of the wall of the
penis (Fig. 1443). When, in this manner, after the healing of the flaps, the
groove of the penis has been changed into a closed canal, then follows : —
3. The closure of the open slit between glans and penis, for which the
prepuce, hanging down below the glans like an apron, may be used. The
same is slit below the corona glandis by a transverse incision (Fig. 1443, c),
and the glans is passed through it as through a buttonhole, so that the pre-
puce comes to lie on the slit in the form of a ridge. After the margins of
the prepuce have been vivified, they are stitched to the corresponding vivi-
fied margins of the glans and the penile tube (Fig. 1442). There remains
4. The closure of the funnel existing at the root of the penis. This
must be done by pedunculated flaps taken from the neighboring skin of the
abdomen (Fig. 1444).
ThicrscJi formed two lateral flaps, — a triangular and
a rhomboidal flap, — which he placed over each other
in a similar manner as in forming penile portion of the
urethra (Fig. 1442). It is better to form only one flap,
and before suturing it to graft its wound surface with
mucous membrane by transplantation according to
Thiersch, in case the existing mucous membrane of the
funnel should not be sufficient for grafting (see page
765). Kiistcr effected transformation of the groove of
the penis into a canal by dividing the inferior surface
of the penis by a deep, longitudinal incision extending
between the corpora cavernosa. He then turned the
two halves upward. He If eric h divided even down to
the mucous membrane. The deep incision wound is
left to granulation. If the penis is very small and in
very young subjects, Rosenbej-ger proceeded in such a manner as to turn
the penis (having been sutured to the scrotum) upward toward the abdo-
men, after having vivified the groove broadly ; here it healed into two vivi-
fied margins (Fig. 1445). The penis directed upward was subsequently
turned downward by excising a flap from the abdomen (Fig. 1446). The
wound on the dorsal surface was covered with this flap, and the thin defect
of the abdominal wall closed by suturing.
Fig. 1444. Closure uf
THE Funnel
OPERATIONS ON THE PELVIS
791
(r) HYPOSPADIAS
The operator proceeds according to the methods just described ; or he
covers the defect according to the methods given in the operations for
7t,rethral fistulas (see page 765).
By a simpler method and in considerably less time, Landerer's (Rosen-
berger's) Procedure seems to bring about the desired end.
Fig. 1445 Fig. 1446
Rosenberger's Operation for Epispadias
He restores the missing lower urethral wall from the skin of tJie scrotum.
First two strips about 3 to 4 milhmeters wide are vivified on both sides of
the groove of the penis as far as and into the scrotum ; the penis is turned
down upon the scrotum, its glans portion is sutured to the deepest point of
the scrotal wound, and the remaining portion of the penis is fastened on both
sides to the scrotum by three superficial sutures (similarly as in Fig. 1445).
After the penis has become completely embedded in this position (after
six to eight weeks), it is liberated from the scrotum and covered with skin
on its lower surface. For this purpose, from the external urinary meatus of
the penis drawn upward at the glans, two lateral incisions are made into
the scrotum, a little longer than the penis is intended to be, and the rhom-
boidal defect caused thereby is closed by suturing it longitudinally.
OPERATIONS ON THE PENIS AND THE SCROTUM
OPERATION FOR PHIMOSIS
1^^^
The abnormal stenosis of the preputial orifice can be removed : —
1. Bluntly, by repeatedly stretcJiing the contracted opening of the
prepuce crosswise with dressing forceps, or by pushing it back forcibly
several times, whereby any existing adhesions are separated at the same
time. This procedure suffices nearly always in little boys, and gives better
results than incision.
2. By incision, Roser's dorsal incision. Upon a grooved director, intro-
duced between the prepuce and the dorsum of the glans, with a pair of
scissors, the prepuce is divided longitudinally beyond the anterior half of
the glans (Fig. 1447). (The
division can also be made
wnth a curved tenotome from
within outward.) By draw-
ing back the external layer
of the prepuce, the internal
layer remains still lying on
the glans, its wound angle
lies in front of the angle of
the external layer. By two
lateral incisions with the scis-
sors from this angle of the
wound, a triangular flap is
formed (Fig. 1448, a\ whose
point turned over in an up-
ward direction is united by suture with the angle of the wound of the
external layer {b).
Finally, the two surfaces of the lateral margins can also be united by
suture. The two flaps formed by the incision then hang down like a small
apron.
A better form of prepuce is obtained if similar but smaller incisions are
made at both sides of the prepuce, and if the margins of the wound are
792
Fig. 1447
Fic. 1448
OPER-vnoN FOR Phimosis (Roser's dorsal incision)
OPERATIONS ON THE PENIS AND THE SCROTUM 793
united transversely by fine sutures (Fig. 1449); or, in less serious cases, the
prepuce is divided by a simple incision only to such an extent that it can be
retracted as far as the corona glandis. There it remains until the wound
has healed, which then extends in a transverse direction. In order not to
soil the dressings, the patient may urinate through a wide tube (broken-off
test-tube).
Likewise, by several very shallow nickings, the opening of the prepuce
may be enlarged until it can be retracted as far as the corona glandis.
3. By circumcision, especially if the length of the prepuce is excessive.
The prepuce is steadied by two forceps grasping its margin, and held tense.
Next, it is cut off with a pair of scissors parallel to its margin in front of the
glans without injuring the latter. Still simpler is the procedure if the por-
tion to be removed is grasped transversely with forceps, and cut off on the
outer side of the same as along a ruler ; the internal and external layers are
then united by a few sutures.
Fig. 1449. Operation for Phimosis by suturino, transversely Two
LATER.A.L Incisions (von Esmarch)
The removal of the whole prepuce is rarely required. It is made for
malignant disease or for elephantiasis. The dorsal incision is made as far
as the corona glandis, and from the angle of the wound the prepuce is
removed with the scissors by cutting on both sides close to the sulcus coro-
narius as far as the fraenulum ; the internal layer is united by suture with
the external layer.
In children, sometimes, the whole internal surface of the glans is adhe-
rent by epithelium to the prepuce. This can be removed easily soon after
birth by retracting the prepuce or by using blunt instruments. But if this
is not done, the internal lamella adheres so firmly to the glans that it can-
not be detached from the same in this simple manner. If the adhesion were
removed with the knife, the former condition would still recur from cicatri-
zation. In such cases Dicffenbach formed a new prepuce by a plastic opera-
tion (Posthioplasty).
794 SURGICAL TECHNIC
He removed the proboscis-like anterior margin of the prepuce and sepa-
rated the external layer, which had been forcibly retracted from the internal
layer by superficial incisions, as far as i centimeter behind the corona glan-
dis ; next, he carefully dissected off the whole internal lamella from the
glans, and cut it off all around along the corona glandis.
Then he inverted the free margin of the external layer as far as the sul-
cus coronarius, and fastened the thus doubled external layer in this position
by a few sutures. A reunion by adhesion could not occur after that, and
the surface of the glans became cicatrized after a short time.
Probably it is better not to remove the firmly adherent internal
layer, but to graft the wound surface of the internal lamella at once with
epidermis.
The cedcvm of the prepuce and skin of the penis frequently occurring
after all these operations should be prevented by immediately dressing the
whole penis with fine gauze or rubber bandages.
(Dressing the wound with carbolated vaseline, elastic compression from
the tip of the glans to the root of the penis, rest in bed, and elevation of the
penis are the most efficient means in preventing oedema and in expediting
the healing of the wound.)
OPERATION FOR PARAPHIMOSIS
If the glans is strangulated by a retraetcd tight pj'epnce, oedema and gan-
grene of the prepuce and glans soon occur, unless the strangulation is
removed. Since the chief obstacle to reduction consists in adevia, which
quickly develops, its removal must always be first attempted. This is accom-
plished in most cases by wrapping a small elastic rubber bandage around the
whole penis. Commencing at the tip of the glans, slowly envelop the whole
penis as far as its root under moderate traction of the bandage. The com-
pression should be strongest over the glans and diminish gradually in the
direction of the root of the penis. After a few minutes the bandage is
removed; then the reduction of the prepuce (taxis) can generally be made
without difficulty.
1. The penis is held with the left hand so as to be encircled by the fore-
finger and the thumb behind the incarcerated swelling, while with the first
three fingers of the right hand pressure is made against the glans in the
direction of the constricting ring {Desruelles, Fig. 1450), or
2. While the forefinger and the middle finger of each hand encircle the
penis behind the swelling, and push the prepuce over the glans anteriorly.
OPERATIONS ON THE PENIS AND THE SCROTUM
795
the two thumbs lying together upon the glans, press the same through the
incarcerating ring [Coster, Fig. 145 1).
Fig. 1450
Fig. 145 1
Reduction of Prepuce (Taxis) in Paraphimosis
If these attempts do not succeed, or if gangrene of the prepuce has already
set in, it is preferable to incise the strangulating ring (Fig. 1452;. Into
the middle of the dorsum of the penis a pointed grooved director is pressed
from behind beneath the strangulating ring (groove due to compression
between the two swelHngs corresponding to the anterior margin of the pre-
puce), and the same is divided with the knife. If the strangulating ring
can be exposed by drawing apart the two ridge-like swellings (oedematous
internal and external layer of the prepuce), it is completely divided in layers
from without inward.
Fig. 1452. Incising Strangulating Ring
After a subsequent reposition of the prepuce, it is sometimes desirable to
remove the existing phimosis a few days later.
796
SURGICAL TECHNIC
AMPUTATION OF THE PENIS
The penis must be aniputalid for malignant disease involving the glans,
prepuce, and the penis.
The operation is made by the "bloodless method " by elastic constriction,