444 Lateral Lithotomy 



makes a little stab in the middle line of the perineum, just behind 

 the base of the scrotum and the bulb, and three-quarters of an 

 inch, more or less, according to the size of the patient, in front of the 

 anus. He cuts freely backwards and outwards, through the left 

 ischio-rectal fossa, to halfway between anus and tuberosity. Thus 

 far he has wounded skin, superficial layer of superficial fascia, and 

 deep layer, a few branches of the superficial perineal vessels and 

 nerves, and many twigs of the inferior haemorrhoidals, and also the 

 transverse vessels and nerve. After this he cuts towards the groove 

 of the staff through the anterior part of the wound, dividing a few of 

 the posterior fibres of the accelerator urina3, the base of the triangular 

 ligament, and within it the compressor urethras and the urethra itself. 

 The point of the knife being lodged in the groove, he slides the blade 

 into the bladder, slicing part of the left lobe of the prostate and its 

 investment of recto-vesical fascia, and dividing some of the prostatic 

 fibres of the levator ani, some of the prostatic plexus of veins, and the 

 neck of the bladder. Sometimes the common ejaculatory duct is also 

 wounded. 



The neck of the bladder being opened, urine escapes from the 

 wound ; so the surgeon lays down the knife, puts the index-finger on 

 the naked staff in the membranous urethra, and artfully works it into 

 the bladder, dilating the wound in the process. He touches the stone. 

 Then he has the staff withdrawn, and, taking out the finger, he intro- 

 duces the lithotomy forceps, and catches and withdraws the stone 

 through the axis of outlet of the pelvis. He then re-introduces his 

 finger to see that there is not a second stone, and, bleeding having 

 well-nigh ceased, the patient's legs are brought down and he is taken 

 back to bed. 



Cautions. First, the surgeon must not stab the perineum too far 

 forwards or he will wound the vascular erectile tissue of the bulb ; 

 in tailing off the first incision he must not cut against the wall of the 

 ischio-rectal fossa or he will wound the internal pudic vessels and 

 nerve ; and he must not bring the incision too far inwards or he will 

 cut a hole in the wall of the rectum, which here is bulging over the 

 fossa. His deep incision must not be too limited or the staff will not 

 be sufficiently laid bare, and, in trying to introduce his finger into the 

 bladder (itself unopened), he may tear the urethra across, and push 

 the prostate and bladder bodily up into the pelvis. This is a frightful 

 calamity, and a not infrequent cause of 'blank lithotomy.' On the 

 other hand, he must not use the knife too freely, lest he cut through 

 the whole length of the prostatic lobe, and, widely wounding its fascial 

 investment, lay the ischio-rectal fossa, the neck of the bladder, and 

 the interior of the pelvis into one large space. Thus urinary infiltra- 

 tion and a fatal cellulitis and peritonitis would probably be set up. 



On account of the high pelvic position of the bladder in boyhood, 

 lateral lithotomy is not an easy operation. To obtain confidence and 



