The abnormal communication between the bladder and the cervical canal is most often either the result of a trauma to the mild toil in prolonged labor, when the fetal head is permanently stuck in the pelvis when the uterine cervix has not yet smoothed, or the result of obstetric( vaginal cesarean section) or gynecological operationscolposhysterotomy).Symptomatology and diagnosis of cystic-cystic fistula is the same as vesicovaginal fistula. The principles of the operation are essentially the same, that is, they are based on the method of splitting and separating the wall of the bladder from the front wall of the cervix. Operation Technique
.Mirrors reveal the vaginal part of the uterus. If the fistula is located so that the anterior lip of the uterine throat is retained, it is seized with bullet forceps and reduced to the anteroom;if the front lip is so destroyed that it is impossible to grasp it, then grasp the posterior lip with forceps. In order to gain access to the fistulous opening in the b
ladder, a transverse incision is made in the anterior vaginal vault immediately above the cervix, which is bent at the ends to the top. Thus, we get a patchwork cut, which we use for many vaginal operations. Acute way to separate the wall of the bladder from the front wall of the neck and gradually reach the fistulous course. In a sharp way, the scars formed around the fistula between the walls of the bladder and the cervix are split. In order not to injure the wall of the bladder anywhere near the existing defect, it is necessary to keep as close as possible to the wall of the cervix. The detachment of the bladder is continued until the fistulous opening in it is completely naked, and its edges become so mobile that they can be seamed without any tension. The fistula in the bladder is sutured in one or two tiers, and the needle should not pierce the mucosa of the bladder. When sewing a hole in a bubble in one tier, most authors use nodal sutures from the finest silk, and with a two-tiered seam for the seams of the first tier take the finest silk, for the second - thin catgut. When the defect in the bladder is sewn, a sterile 2-4% boron solution is injected into the bladder through the urethra to check if fluid is seeping somewhere between the seams, and if necessary, additional seams are applied. The fistulous course, which is present in the uterine wall, after refreshing, is sewn with catgut, without piercing the mucous membrane of the cervical canal. Some surgeons do not at all sew up the fistulous opening in the cervix, relying on the fact that this hole will heal spontaneously, as soon as the urine ceases to be released from the fistula aperture in the bladder. IB Levit believes that it is sometimes more appropriate for freshening and suturing of the fistula in the cervix of the uterus to first dissect the entire anterior wall of the cervix in the longitudinal direction, starting from the fistula downwards.
When the bladder is removed, the vestibular fold of the peritoneum may be accidentally opened. If the operation is performed with pure urine and no infection in the field of the operative field, this is not a serious complication. After the fistula in the bladder is sewn into two tiers, the upper edge of the open peritoneum can be sewn to the peritoneum with two or three thin catgut threads. The edge of the open peritoneum can be sewn to the lower edge above the place of its normal location in the uterus;then the sewn hole in the bladder will have as its kind of lining an intact wall of the lower segment of the uterus;it is possible, on the contrary, the cicatricial edge of the opened fold of the peritoneum, if it is sufficiently mobilized, pulled down and sewed to the bladder below the defect, sewn into it, and so cover it with the peritoneum.
But if the vestibular fold of the peritoneum is not opened, it is advisable to reattach the fistulous hole in the bladder sewn into two tiers to the cervix of the uterus, but not at the same place as before the operation, but slightly higher or lower,so that the sewn hole of the bladder does not lie on the sewn hole in the cervix and does not coincide with it completely.
In conclusion, the patchwork incision in the vagina is sewn with a medium-sized catgut.
Maintenance of the postoperative period is the same as after the operation of the vesicovaginal fistula.
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