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J. CHRISTOPHER O'DAY
contractility of the bladder's muscular coat. If this is true, the fact that the
bladder has a muscular coat, moots the question. However, that cannot be
discussed here. But whatever the truth of it may be, compression, up to
some unknown degree, seems to be the determining factor in forcing the
mucous membrane to herniate into an extravesical sac. It must not, however,
be forgotten that unless ectopia of the muscular fasciculi be present, neither
the obstruction, distention nor compression can give rise to the deformity.
To elucidate the primary or congenital cause of these diverticula, it will
FIG. I.-(a) Small sacculations; the fasciculi are not displaced to a degree capable of pouting the
bladder's mucosa into a diverticulunm (b) Large sacculations. Here are the openings that lead
to a sac only. Diverticulitis is not to be expected where so many large sacculations are present. It
may occur, but the fasciculi are usually discouragingly arranged. (c) Typical opening into divert:culum. Note the fibrous ring. (d) Section of diverticulum.
be necessary to briefly review the embryologic development of the genitourinary tract. In doing this, we will find something to puzzle over when,
through speculative curiosity, we would like to find out the time that the
kidneys begin the first secretion of urine.
Of course, this question is irrelative. Perhaps it should have been omitted,
yet it is an emphasis on that which is of paramount interest, for it becomes
apparent that unless the allantois had opened into the ventral cloaca in time to
save itself from becoming distended by the urine from the newly functioning
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J. CHRISTOPHER O'DAY
ring. This ring must be removed else union will be thwarted. The incision
should be an elliptical one, its long axes directed to the securing of the best
working facilities. It includes the entire fibrous ring with the mouth and end
of the sac. With this accomplished, the freed portion is grasped with light
forceps and gentle traction is continued into the bladder while a gauzecapped finger gently pushes back whatever tissue may be adherent. If the
opening thus made in the wall of the bladder is large enough to admit a finger
without the likelihood of tearing, the fibrous ring may be severed by a snip
FIG. 2.-(a) Elliptical incision preliminary to dissection of the diverticulum. (b) Ellipse with
opening into sac being drawn into bladder while a gauze-capped finger pushes back all adhering tissue.
(c) Ring incised to admit finger. (d) Once the sac is made free a finger within facilitates the
dissecting.
of the scissors and the further dissecting of the sac facilitated by inserting
a finger within it. Throughout the time it may require to complete the removal of the sac and the subsequent closure of the opening, sopping with
sponges will take care of the urine that is coming in from the ureters.
The ease with which the water-shed closure of the opening may be effectedl
will, of course, depend very much upon what portion of the bladder wall is
involved. If high, and easily reached from the suprapubic incision, little dif-
has been in a posterior position, the closure should be effected from within
the bladder, for extensive separation from surrounding tissues is liable to
invite sloughing. The method we have followed is not difficult, yet, it may,
at the first try, seem so. Number 0 0 chromic gut is the ideal suture material, but it should be softened and rendered pliable in warm water, and by
gauze-friction before using. Otherwise it will be too harsh. For the suturing, a small, full-curved, non-cutting intestinal needle is ideal. The stitch
may be begun at either angle of the ellipse according to the convenience of
the operator. Inverting the edges of the wound, the needle is made to pick
up, right side first, two or more bites of the inverted edge, working the
needle away from the free edge while doing so. It is then passed across
to the left side of the incision and the maneuver repeated with the exception
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FIG. 3.-a, b, and c shows technic of a modification of Murphy's (the late John B.) water-shed
suture. This stitch closes the bladder wound without appearing within the viscus. This avoids leaving
any foreign substance to precipitate crystallization of the urinary salts.
that on this side the needle is made to work toward the free edge. The
suture from this point on is zigzagged toward the opposite angle which,
when reached, is given a horizontal direction as in the first application, then
zigzagging back, crossing the others to make a series of X's, similar to the
lacing of a shoe, until the place of beginning has been reached. The two
free ends of the suture are permitted to protrude from between the edges
of the wound while a pterygium hook draws the lacing taut. Finally, traction
on the ends will approximate the edges in to an appositional or water-shed
welt.
The suture may then be tied, the ends cut, and the knot induced between
the edges and forced into an extravesical position.
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