THE SPECIAL TECHNIQUE OF OPERATIONS UPON THE UTERUS AND THE UTERINE APPENDAGES.
A thorough knowledge of the anatomical relations of the various structures in the pelvis is essential for the performance of the various operations upon the uterus and its appendages.
A detailed description of such anatomical relations is out of place here. It is especially important to study the distribution of the arterial supply and the relations of the ureters. [Fig. 208] will refresh the memory upon these points.
Fig. 208.—Posterior view of the uterus, the tubes and ovaries, and the broad ligaments: I.P.L., infundibulo-pelvic ligament; O.A., ovarian artery; U.A., uterine artery; U., ureter. The utero-sacral ligaments are seen on each side of the posterior aspect of the cervix.
The ovarian artery, which corresponds to the spermatic in the male, is a branch of the abdominal aorta. It runs tortuously between the layers of the upper part of the broad ligament, from the pelvic wall to the upper angle of the uterus. Before reaching the uterus it divides into two branches. The upper branch supplies the fundus uteri; the lower branch anastomoses at the side of the uterus with the uterine artery.
During its course in the broad ligament the ovarian artery gives off branches to the ampulla and the isthmus of the Fallopian tube, to the ovary, and to the round ligament.
Fig. 209.—Anterior view of the uterus, the tubes and ovaries, and the broad ligaments. The upper part of the bladder, the anterior wall of the vagina, and the peritoneum on the anterior aspect of the broad ligaments have been removed. U., ureter; U.A., uterine artery; O.A. ovarian artery; R.L., round ligament.
The uterine artery arises from the anterior division of the internal iliac, and runs downward and inward toward the cervix uteri. The vessel is tortuous, and is loosely supported by the cellular tissue at the base of the broad ligament. The lowest point which it reaches is on a level with the external os uteri, and at this point it crosses the ureter.
At about this point it gives off the circular artery of the cervix, which anastomoses with its fellow of the opposite side. The uterine artery then passes upward, and reaches the uterus near the level of the internal os. It passes along the side of the uterus in a very tortuous manner, and anastomoses with the ovarian artery.
The vaginal arteries usually arise from the anterior division of the internal iliac artery. They sometimes arise from the uterine or middle hemorrhoidal artery.
The ureter passes behind and beneath the uterine artery. The uterine artery crosses the ureter at about the level of the external os uteri. At this point the ureter is ⅗ of an inch distant from the cervix. The distance between the ureter and the artery at the point of crossing is about ⅖ of an inch. It is important to remember these relations in applying a ligature to the uterine artery.
It must not be forgotten that the anatomical relations are altered by any displacement of the uterus from its normal position. Such displacement occurs in disease and when the uterus is dragged upward or downward during operation.
In conditions, such as cancer, which are accompanied by hypertrophy of the cervix, the distance between the ureter and the cervix is much diminished.
Removal of the Uterine Appendages (Salpingo-oöphorectomy).—This operation is performed by ligaturing the ovarian artery in its course through the infundibulo-pelvic ligament and at the uterine cornu, and then excising the Fallopian tube and the ovary.
The peritoneum is opened, and the index and middle fingers of the left hand are introduced into the abdomen. If necessary, the omentum is swept upward out of the pelvis. The fundus uteri is sought, and the fingers, with the palmar surface directed downward, are passed over the posterior face of the uterus, and then outward over the posterior aspect of the broad ligament. The ovary and tube are palpated, and are lifted forward upon the palmar aspect of the two fingers or between the fingers, perhaps with the subsequent assistance of the thumb, into the abdominal incision. The infundibulo-pelvic ligament is exposed, and is rendered tense by the pressure of the fingers behind it. It will be observed that the upper edge of the ligament is thick, while there is a thin, sometimes transparent, area below the free edge. The vessels run in the upper edge of the ligament, and a ligature passed through the thin area will secure them ([Fig. 210]).
Fig. 210.—Salpingo-oöphorectomy. On the right side ligatures have been placed about the ovarian artery, at the uterine horn, and at the pelvic wall. On the left side the tube and ovary have been excised between such ligatures. If bleeding takes place from the broad ligament, the anterior and posterior peritoneal aspects may be united by suture.
The heavy silk carried in the pedicle-needle should be used. The ligature should be placed sufficiently near the pelvic wall to permit complete excision of the tube and ovary without cutting too close to the ligature. The broad ligament should then be transfixed by a second ligature at a point somewhat to the inside of the first. The second ligature should embrace the ovarian ligament, the isthmus of the tube, and the uterine end of the ovarian artery. This ligature should be placed close to the uterine cornu, in order to permit complete excision of the ovary.
The Fallopian tube, the ovary, and the mesosalpinx are then cut away with the scissors. There is usually no bleeding whatever from the unligatured portion of the broad ligament between the two ligatures. The stumps should be carefully inspected, and any bleeding point in the intervening portion of the broad ligament should be picked up and secured by fine ligature; or the peritoneal edges may be united by suture.
This method of operating is in accord with the best surgical principles.
The vessels are secured in their course by ligatures which embrace a minimum amount of surrounding tissue. In the early days of modern abdominal surgery, the operation usually advised was performed with the Tait knot ([Fig. 211]) or the link-ligature ([Fig. 212]).
| Fig. 211.—The Tait knot. | Fig. 212.—The link-ligature. |
The ovary and the tube are drawn into the abdominal incision, and the pedicle formed by the broad ligament is transfixed with the pedicle-needle carrying a double ligature.
The loop of the ligature is passed over the tube and ovary and the Tait knot is tied, or the ligature is cut and each half of the pedicle is separately secured, the ligature being crossed or linked in the middle of the stump, to prevent separation.
The operators who apply the ligature in this way do so because they fear hemorrhage if every portion of the broad ligament is not secured.
This fear is unfounded. The objections to this form of ligature, the Tait or the link-ligature, may be given by the following quotation from a former paper by the writer.[4]
“The objections to these ligatures are: The liability to slip; the difficulty or impossibility in some cases of removing all the ovary and tube; the fact that the broad ligament is puckered up and made more tense than normal, and may for this reason cause subsequent pain and discomfort; an unnecessary amount of tissue is strangulated.
“Most operators have seen cases, either in their own experience or in the experience of others, in which the ligature has slipped from the pedicle, either during the operation or some days afterward. I think that this accident, usually unrecognized, is a very common cause of death after oöphorectomy. Tait speaks of a certain number of cases in his own experience in which a hematoma occurred in the broad ligament some hours or days after operation. He says, ‘I cannot form any exact estimate of how many cases of these operative hematoceles I have seen, but it certainly is not less than 50, and is more likely to be 70 or 80.’
“It seems probable that this accident is due to the retraction or slipping of the artery from the embrace of the ligature, while the remaining mass of tissue which forms the pedicle is still retained, and the hemorrhage, therefore, is confined to the broad ligament. I have seen this accident happen before the abdomen had been closed, and have sought for and ligated separately the retracted vessel.
“Slipping of the ligature is due to the form of the mass of tissue which is ligated. The broad ligament is drawn up into a more or less conical shape, all parts converging toward the ligature, and the ligature is really placed at the apex of a cone from which it may readily slip; and the elastic artery, tied when upon the stretch, tends to retract and escape from the embrace of the ligature.
“The second objection is the difficulty or impossibility of removing all the ovary and tube. If the broad ligament is tense, as it often is in single women, or if it is thickened from inflammatory deposit, it is sometimes impossible to bring the tube and ovary through the abdominal incision and to obtain a pedicle which may be ligated so that we may with safety remove all of the ovary. And it is in just such cases that it is usually most desirable that all ovarian tissue should be removed.
“The third objection—the puckering and tension of the broad ligament—may be of less importance than those just considered. However, it seems probable that some of the pain which women suffer after oöphorectomy is due to the traction and counter-traction exerted by different parts of the broad ligament upon a sensitive cicatrix. The broad ligament is pulled up from different directions and converges to the cicatrix, which becomes the point from which the lines of traction radiate.
“It was thought that in case of retroversion this tension of the broad ligament would maintain the uterus in place, the ligaments acting as guys. This, however, is not true. Repeated secondary operations have shown that the uterus has fallen back again to extreme retroversion, notwithstanding such methods of ligature of the broad ligaments.
“The fourth objection is one which appeals to our surgical sense. It is always better surgery to ligate the vessel alone than to include with it a mass of surrounding tissue.”
If the isthmus of the Fallopian tube is diseased, as in some cases of pyosalpinx, so that it is necessary to exsect the tube from the uterine cornu, the second ligature may be passed immediately beneath the tube, including the ovarian ligament and the ovarian artery, but not including the tube; the tube may then be cut out by a wedge-shaped incision in the horn of the uterus. The uterine wound should be closed by interrupted suture ([Fig. 212], A). In such cases, however, if the tubal disease is bilateral, it is best to remove the uterus as well as the appendages.
It is not necessary to place both ligatures before cutting away the ovary and tube. The first ligature may be placed about the proximal portion of the ovarian artery, and then the infundibulo-pelvic ligament may be cut, bleeding from the distal end being controlled with forceps. This will enable the operator readily to bring the ovary and tube through the incision and to ligate the ovarian artery at the uterine cornu.
Fig. 212, A.—Position of ligatures and sutures in exsection of the tube.
Fig. 212, B.—Pyosalpinx which has been exsected from the uterine cornu.
If adhesions exist, they should be broken with the fingers, or the patient should be placed in the Trendelenburg position and the adhesions should be divided with scissors. The tube and ovary are sometimes completely imbedded in adhesions, and it is necessary to shell them out by careful work with the fingers. The adhesions may be so dense and the anatomical relations so altered that it is difficult or impossible to determine what is ovary and what is tube until the mass is brought into the abdominal incision. In these cases the experienced operator may work by the sense of touch alone. The inexperienced operator had better expose the parts and obtain the assistance of visual examination.
The fundus uteri can usually be determined, and will form a valuable landmark. The enucleation is most easily performed with the fingers. The index and middle fingers, with the palmar surfaces turned downward, should be passed outward from the posterior aspect of the uterus, and should seek a plane along which the structures most readily separate. As a rule, adhesions give way more easily than the tissues of normal structures. Adhesions should not be roughly torn: they should be pushed away from the posterior aspect of the ovary and broad ligament.
The adhesions between the ovary and the broad ligament must be broken by pressure with the fingers before the ovary can readily be brought into the abdominal incision.
After all other adhesions have been relieved it is often found that the ovary still lies low in the pelvis, glued to the posterior aspect of the broad ligament. It should not be dragged, in this condition, into the incision, or the broad ligament may be badly lacerated. It should be peeled off from the broad ligament and rolled up to the incision.
After the structures have been carefully examined and the anatomical relations determined the ligatures should be placed and the tube and ovary cut away. The bleeding from the pelvic adhesions is usually arrested or much diminished as soon as the ovarian artery is ligated. It is best, therefore, to waste no time in attempts to arrest moderate hemorrhage until the appendages have been removed. The pelvis should then be inspected and any bleeding points secured. Omental adhesions should be ligated, if necessary, as they are divided.
If there is a general oozing from the bed of adhesions that cannot be controlled by ligature, one or two gauze pads should be pressed over the region and retained there until the abdominal sutures have been placed. If the bleeding continues notwithstanding such sponge-pressure, it may be necessary to employ drainage. The bleeding may always be controlled by the pressure of the end of the gauze drain placed directly over the raw surface.
If the operator is anxious to arrest menstruation, he must be certain to remove all ovarian tissue and the Fallopian tubes at the uterine cornua. Sometimes, after an adherent ovary has been enucleated, part of the ovarian stroma remains glued to the pelvic wall, the posterior face of the broad ligament, or some other structure. These portions of ovary should be carefully picked off with the forceps. If the operator doubts the complete removal of all ovarian tissue, he should make a note to this effect in the history of the case. Were this always done, the existence of a supernumerary ovary would not be so often assumed.
The directions that have been given here apply to the removal of tubal tumors and small cystic and solid tumors of the ovary. When the ovary is removed there is but little, if any, advantage in leaving the corresponding Fallopian tube in case the tube on the opposite side is healthy.
If the patient is anxious for children, the operator should remember that conception is possible with one tube and one ovary, though they be on opposite sides. If an ovarian tumor is removed independently of the corresponding Fallopian tube, the pedicle of the ovary should be transfixed and ligatured in two or more masses.
Removal of an Ovarian Cyst.—The removal of a large ovarian cyst may be facilitated by preliminary tapping as soon as the peritoneum is opened, and withdrawal of the fluid contents. As a general rule, this procedure is advisable if the cyst is too large to be removed through a 3- or 4-inch incision. If, however, the operator should suspect the contents of the cyst to be septic, it is safest to enlarge the incision and to remove the tumor intact, thus avoiding infection of the peritoneum. This advice is especially applicable to dermoid cysts. The contents of such cysts are very often septic. They are thick, and contain a large amount of solid material which passes with difficulty through the trocar. The walls of the cyst are friable and easily torn, so that the puncture-wound of the trocar becomes enlarged and the cyst-contents escape around it; and, finally, the contents of a dermoid are very difficult to remove from the peritoneum.
The dermoid character of a cyst may be suspected from the dull appearance of the walls and the putty-like feeling upon palpation. They are usually of small size, and may be removed bodily through an incision of moderate extent.
Every tumor should be carefully examined before the trocar is plunged into it. The operator should make certain by palpation that the tumor is cystic. The trocar has been thrust into the pregnant uterus, and frequently into a fibroid tumor. In the case of a fibroid profuse hemorrhage may occur from such an accident. The hemorrhage may usually be controlled by forcing a small sponge or gauze pack into the puncture wound. Before tapping the cyst the operator should pass his hand around it and determine the position and character of adhesions.
Small cysts about the size of a child’s head may be tapped with the small trocar. The larger instrument is used in cysts of greater size.
In a multilocular cyst the largest loculus should be tapped first. Sponges should be placed in the abdomen around the point selected for puncture. An incision about half an inch in length should be made through the outer coat of the cyst, and the trocar should then be introduced. As the fluid escapes through the trocar and the rubber tube into a vessel at the side of the table, and as the cyst becomes flaccid, the wall of the cyst near the trocar should be seized with large forceps. As the tumor diminishes in size it should be dragged through the abdominal incision. This procedure should not be done quickly or roughly, or adherent intestines may be torn, and bleeding from omental adhesions may escape detection.
As the cyst is drawn out the surface should be examined and adhesions should be separated, and ligatured, if necessary, as they appear. Omental adhesions usually require ligature. The bleeding from omental vessels is often profuse and is not arrested spontaneously. An adherent omentum should be ligatured with medium-sized silk in small sections, not in one mass, before it is cut away from the tumor.
The intestine is sometimes so adherent to the surface of the tumor that it cannot be separated without serious danger to the intestinal wall. In such a case it is best to cut out the adherent portion of the outer wall of the tumor and leave it glued to the intestine. If there is bleeding from the raw surface, it may be checked by folding in the bleeding area with silk suture.
While the operator is dealing with the adhesions the assistant should see that the opening in the cyst is kept in a dependent position and that cyst-contents do not escape into the abdomen. This precaution should always be taken, though it is especially important in the cases of septic and papillomatous cysts.
When the pedicle of the cyst is exposed, it should be ligatured as already advised. If the stump of the pedicle is very broad, it may be folded in or covered with peritoneum to prevent intestinal adhesions to it.
The other ovary should always be examined before closing the abdomen.
Operation for the Removal of Intra-ligamentous Cysts.—Intra-ligamentous cysts grow between the folds of the broad ligament. Any oöphoritic tumor may be intra-ligamentous, though the condition is most usually found in cysts of the paroöphoron and the parovarium.
The intra-ligamentous cyst may drag out the broad ligament so that a pedicle may be formed, and the tumor may be removed by the methods already described.
In other cases, however, the cyst is strictly sessile. It lies between the layers of the broad ligament, deep in the pelvis, or perhaps it may have migrated to some other part of the abdomen behind the peritoneum.
The removal of such tumors requires accurate anatomical knowledge of the region in which the growth is situated.
It is necessary to incise the peritoneal covering of the tumor and to enucleate it from its bed. The peritoneum should be incised in the position in which there are fewest blood-vessels. Thus, if the tumor has migrated between the layers of the mesocolon, the incision should be made through the outer peritoneal layer.
Intra-ligamentous cysts often have no pedicular attachments whatever, and may be enucleated without the application of ligature. In other cases a distinct vascular pedicle is found after the peritoneal investment has been opened and its adhesions to the cyst-wall have been separated.
The relations of an intra-ligamentous cyst should be carefully examined before the surgeon proceeds with the operation, and such a cyst should not be mistaken for an extra-ligamentous cyst that has become adherent.
If the tumor is situated between the layers of the broad ligament, it is advisable, as a preliminary step, to ligate the ovarian artery in the infundibulo-pelvic ligament and at the cornu of the uterus. This may usually be readily done; much subsequent bleeding will be prevented by it.
The peritoneum is then incised at the most convenient point over the surface of the tumor, and the surgeon, with the fingers, knife-handle, or closed blunt scissors, proceeds with the enucleation. If inflammatory adhesions have not taken place, enucleation is usually easy. Bleeding vessels should be secured by forceps as they appear, and should be ligated, if necessary, after the cyst is removed.
If a pedicle or fleshy adhesion is met, it should be ligated before division.
During the enucleation the surgeon should follow closely the surface of the tumor. When he has reached a point deep in the pelvis he should be especially careful to avoid injury of the large vessels and the ureter. If the cyst is difficult of removal in this region, it may be advisable to cut out a portion of the cyst-wall and leave it.
Preliminary tapping of intra-ligamentous cysts is not often necessary. They are usually of moderate size, and enucleation may be most readily performed if the cyst is tense.
Sometimes large cysts are but partly intra-ligamentous: the greater portion is free, while the base is included between the layers of the broad ligament. In such cases it is best to tap the cyst and then to enucleate the base as already described.
In other cases the process of enucleation may be facilitated and rendered safe by incising the cyst-wall and introducing two fingers into the cavity to act as guides in separating the cyst from structures deep in the pelvis.
After the cyst has been removed and bleeding points have been secured by ligature, the raw surface, or the bed of the tumor, may be obliterated by bringing the sides into apposition by layers of buried fine silk sutures and by closing with suture the incision in the peritoneum. These raw surfaces often contract very much by the falling together of the sides after the tumor has been removed.
If bleeding from the bed of the tumor cannot be thoroughly arrested, it is unsafe to close the incision in the peritoneum, for a hematoma will form and will cause subsequent trouble. In such a case the gauze drain should be introduced into the bed of the tumor, perhaps after partial closure of the peritoneal incision. Or if the bleeding be very profuse, the edges of the incision in the broad ligament should be sutured to the lower angle of the abdominal wound, and the cavity should be packed with gauze.
The sutures that attach the broad ligament to the abdominal incision may be passed through the whole thickness of the abdominal wall, or through only the fascia, muscle, and peritoneum. The ends of the sutures should be left long to facilitate removal.
In the removal of a cyst of the parovarium by enucleation, the tube and ovary should not be sacrificed unless they are diseased. Small cysts of the parovarium which develop between the layers of the mesosalpinx may very easily be removed by simple incision of the peritoneal capsule and enucleation of the cyst, without injury to the tube and ovary.
Marsupialization of the Cyst.—In rare cases a cyst is found to be so firmly and generally adherent to surrounding structures that its removal is impossible. It is then necessary to practise marsupialization.
The cyst should be evacuated with the trocar, which is introduced at a point which can be readily brought to the abdominal incision. Vegetations, etc. should be removed from the interior of the cyst with the fingers. The opening in the cyst should then be attached to the lower angle of the abdominal incision by interrupted sutures of strong silk that pass through the whole thickness of the abdominal wall and of the cyst-wall. The sutures should be placed close together, and the ends should be left long to facilitate removal. The upper portion of the abdominal incision should be closed with interrupted sutures.
A large double drainage-tube of rubber should be introduced into the cyst, and strips of gauze should be packed around the tube.
The subsequent treatment consists of frequent washing of the interior of the cyst. The sutures in the cyst-wall should be removed at the end of two weeks.
Though marsupialization frequently results in cure, yet it should never be practised unless it is absolutely necessary. It exposes the patient to the dangers of prolonged suppuration and persistent fistula. Malignant degeneration has occurred in the wound. Papilloma may extend to the peritoneum. The procedure is of but little use in the case of multilocular tumors, as all the loculi cannot be evacuated.
OPERATION FOR REMOVAL OF THE UTERUS.
The uterus may be removed through an abdominal incision (abdominal hysterectomy), or it may be removed through the vagina (vaginal hysterectomy). A combination of the two methods of operating is sometimes employed.
In many conditions it is not necessary to remove the cervix. Partial hysterectomy or supra-vaginal amputation of the uterus at some convenient point of the cervix may be performed.
Such supra-vaginal amputation of the uterus may be done in nearly all operations that are not performed for malignant disease. In sarcoma or cancer the whole uterus should be removed at the vaginal junction, and, if necessary, the upper portion of the vagina should be excised.
In the case of fibroid tumor and in non-malignant disease of the body of the uterus supra-vaginal amputation is sufficient. Supra-vaginal amputation is an easier and safer operation than complete hysterectomy. Abdominal hysterectomy is most easily performed with the patient in the Trendelenburg position.
Supra-vaginal Amputation of the Uterus.—After the abdomen has been opened, the ovarian artery should be ligated in the infundibulo-pelvic ligament, as in the operation of salpingo-oöphorectomy. A second ligature, or forceps, should then be placed upon the ovarian artery at the uterine cornu.
The round ligament should then be ligatured with medium-sized silk at a point situated about an inch from the uterus. Similar ligatures should then be placed about the ovarian artery and the round ligament on the opposite side.
Fig. 213.—Supra-vaginal amputation of the uterus, first step: ligatures have been placed on the ovarian arteries and the round ligament.
The infundibulo-pelvic ligament immediately outside of the abdominal ostium of the tube, the round ligament between the ligature and the cornu, and the broad ligament as far as the uterus should then be divided with scissors on each side.
The uterus is thus freed from all its attachments down to a point somewhat above the level of the internal os. The vessels that remain to be secured are the uterine arteries.
The peritoneum is next divided by a transverse incision across the anterior face of the uterus, immediately below the line of reflection of the peritoneum from the uterus to the bladder. This incision should join at each end the incisions that had been previously made in dividing the broad ligaments.
Fig. 214.—Supra-vaginal amputation of the uterus, second step: the broad ligaments have been divided down to the level of the internal os uteri.
The bladder should then be dissected from the anterior face of the uterus and cervix, down to the vaginal junction.
The bladder is but loosely attached to the uterus, and may be readily pushed off with the finger or with closed scissors. The finger pressed out to a short distance on each side of the cervix will push away the anterior layer of the broad ligament with the bladder, so that the uterus is perfectly free in front.
Fig. 215.—Supra-vaginal amputation of the uterus, third step: the peritoneum has been incised across the anterior face of the uterus; the bladder has been dissected from the cervix; the bases of the broad ligaments have been opened; the uterine arteries have been secured by ligatures placed between the ureters and the cervix.
The posterior layer of the broad ligament and the cellular tissue may then be divided, with scissors, along the side of the uterus down to a point somewhat below the level of the internal os. This incision should not be made too close to the uterus, or the uterine artery that runs up along side of the uterus and cervix may be divided. The operator should place one or two fingers upon the posterior aspect of the broad ligament, immediately beside the cervix, and while the uterus is drawn upward should pass a heavy ligature beneath the tissue that includes the uterine artery. The pulsation of the uterine artery may usually be felt by the finger placed behind the broad ligament. This ligature includes the cellular tissue at the base of the broad ligament, the uterine artery, and part of the posterior peritoneal layer of the broad ligament. It does not pass through the anterior peritoneal layer of the broad ligament, which had been previously dissected away. The ligature should be placed as closely as possible to the cervix without including cervical tissue. It should be remembered that the ureter lies about half an inch from the side of the normal cervix and at the level of the external os. The ureter is usually more remote than this when the ligature is passed, because the uterus is drawn upward and the ureter is pushed aside by the fingers at the side of the cervix.
The uterine artery should be secured in a similar way upon the opposite side.
The bases of the broad ligaments should then be divided with scissors between the cervix and the ligatures of the uterine arteries. To prevent slipping of the ligature, ample tissue should be left between the incision and the ligature. As the cervix is not malignant, the incision may be made as close to this structure as necessary.
Fig. 216.—Supra-vaginal amputation of the uterus, fourth step: the uterus has been amputated below the level of the internal os; sutures have been introduced to close the stump of the cervix.
The uterus should then be amputated by a wedge-shaped incision through the cervix, making an anterior and a posterior flap.
When the cervical canal is opened, it may be immediately sterilized with a solution of bichloride of mercury (1:500).
As the uterus is cut away the flaps of the cervix are secured with forceps. The cervical stump is usually white and dry.
The flaps of the cervix should next be united by interrupted silk suture. Care should be taken to avoid passing a suture through the cervical canal, as it might become infected.
Fig. 217.—Supra-vaginal amputation of the uterus, completed operation: the anterior and posterior peritoneal layers of the broad ligament have been united by sutures; the peritoneal covering of the bladder has been drawn over and sutured to the posterior aspect of the stump of the cervix.
The anterior peritoneal layer of the broad ligament and the peritoneal reflection from the bladder are then drawn over the field of operation and secured by fine silk sutures to the posterior peritoneal layer and the posterior aspect of the cervix. The stump of the cervix, the stump of the uterine arteries, and the cellular tissue of the broad ligaments are thus covered by peritoneum. The only raw surfaces exposed are the stumps of the ovarian arteries and of the round ligaments. These surfaces may also be covered if the operator so desires.
Preservation of the Ovaries in Hysterectomy.—Many surgeons consider it advisable to leave the ovaries in hysterectomy for fibroid tumor of the uterus in case these organs are not diseased. If the woman has not yet reached the menopause the disagreeable symptoms of the artificially induced menopause are thus avoided, and any metabolic function that the ovaries may possess is preserved. In hysterectomy for fibroid in women under forty years of age with healthy ovaries it is advisable to leave these organs if this can be done without seriously complicating the operation.
The ovarian artery should be ligated between the ovary and the uterus and the broad ligament should be divided inside of this ligature. The tubes may be left if they can not readily be removed.
Complete Abdominal Hysterectomy.—In this operation the uterus is removed at the vaginal junction. The operation is absolutely necessary in cases of malignant disease of the body and neck of the uterus. It is not often necessary in the treatment of the other conditions for which hysterectomy is performed. The operation requires a longer time than the operation of partial hysterectomy; it is often accompanied by profuse bleeding from the edge of the divided vagina; there is more danger of injury to the ureters, and there is more danger of septic infection, because the vagina is opened; and, finally, the operation very considerably shortens the vaginal canal.
The first steps in the operation of complete hysterectomy are the same as those in partial hysterectomy. In the case of malignant disease of the cervix the ligatures on the uterine arteries should be placed as far from the cervix as possible without including the ureters.
Some surgeons advise the preliminary introduction of bougies into the ureters in order to locate these structures and thus prevent injury to them. If the operator is sure of the position of the ureter he may ligate the uterine artery upon the outer side of the ureter, and carry the incision through structures well outside of the diseased cervix.
After the vessels have been secured and the bladder has been separated from the uterus and the upper part of the vagina, and the broad ligaments have been divided down to the vagina, a transverse incision is made with the knife or scissors into the anterior vaginal fornix. The position of the anterior vaginal fornix may be determined by palpation and percussion. A drum-like sound is obtained by snapping the finger upon the tense vaginal wall.
With the finger in the opening in the anterior vaginal fornix as a guide, the incision is continued around the sides and posterior wall of the vagina. The edge of the vagina is secured by forceps, and bleeding vessels in the walls are ligated. When hemostasis is complete the vagina is closed by sutures that pass through the outer portions of the walls, but do not enter the vaginal canal. The peritoneum is then drawn over the field of operation and the abdomen is closed. If hemostasis is not perfect, gauze drainage through the vagina or the abdominal incision must be employed.
Some operators do not ligate the uterine arteries until the vagina has been opened. The ovarian arteries are secured, the bladder is separated from the uterus and the upper part of the vagina, and the broad ligaments are divided down to a point somewhat below the level of the internal os.
The anterior vaginal fornix is then opened, and the incision is carried around toward the lateral fornices as far as may be done without injury to the uterine arteries. The uterus is then drawn forward and the posterior vaginal fornix is opened, the finger introduced through the opening into the anterior fornix acting as a guide.
The uterus is now attached to the body only by two lateral bands of tissue that include the cellular tissue at the base of the broad ligament, the uterine artery, and a strip of vaginal mucous membrane over the lateral vaginal fornix. This band of tissue, exclusive of the vaginal mucous membrane, is then secured by a ligature that does not enter the vagina, but passes immediately above the strip of vaginal mucous membrane. A finger introduced into the vagina serves to guide the ligature-needle. The uterus may then be cut away.
The ligatures of the uterine arteries are sometimes left long, the ends being carried down into the vagina and a gauze drain being introduced into the vagina, the upper portion of the drain reaching just above the level of the stump of the uterine arteries.
The peritoneum may be left open, or it may be drawn over the drain and the field of operation as already described.
Drainage through the vagina in this way is advisable if the hemostasis be not perfect and if the operator fears septic infection.
In hysterectomy for cancer of the cervix it is usually advisable to remove as much as possible of the cancerous mass by a preliminary operation two or three days beforehand. The diseased tissues should be cut away with the knife, scissors, and the sharp curette, the cavity seared with the thermo-cautery, and closed by approximation of the edges with a few silk sutures. The dangers of septic infection and of transplantation of cancer-cells during the hysterectomy are thus diminished.
The surgeon should always keep in mind the possibility of the transplantation of cancer-cells from diseased into healthy tissues. It seems very probable that some cases of recurrence have been due to this cause. During hysterectomy the operator should therefore avoid, as much as possible, cutting into or manipulating the cancer mass. Instruments, such as hemostatic forceps and volsella forceps, which have grasped diseased tissue, should not be used upon healthy tissue without previous sterilization; and sponges and pads which have been in contact with the cancerous tissue should be discarded.
The methods of operating just described, modified to meet special indications, are applicable to all cases in which hysterectomy is required.
Sometimes, in cases of fibroid tumor, the broad ligament is very much hypertrophied and contains enormous veins, and additional ligatures besides those on the ovarian and uterine arteries are required. It is often necessary to place a large number of forceps upon bleeding vessels on the surface of the tumor as it is cut away from the broad ligament.
The anatomical relations are often very much disturbed, and it may be impossible to determine the position of the cervix and the uterine arteries until the greater part of the tumor has been freed from its connections. Sometimes the tumor so fills the pelvis that it is impossible to ligate, at first, both ovarian arteries. The operator must first attack the more accessible side, ligate the ovarian artery, cut away the broad ligament, strip off the bladder, ligate the uterine artery, and perhaps divide the cervix, before he proceeds to the other side. Bleeding from the tumor must be controlled by the careful application of forceps or ligatures. An inaccessible uterine artery is sometimes most readily reached in this way from below, after the attachments upon the opposite side have been divided and the cervix has been amputated. Some operators perform hysterectomy in all cases by ligating and cutting away from above downward on one side—the more accessible—then cutting across the cervix, and ligating and cutting away on the opposite side from below upward.
The difficulties are greatest in the case of intra-ligamentous fibroids. Such operations are among the most difficult in surgery. The directions given for the treatment of intra-ligamentous cysts are applicable also to this condition. The surgeon should always at first secure the ovarian arteries if possible. He should then incise the peritoneal investment across the anterior or posterior face of the tumor.
Enormous veins often lie immediately beneath the peritoneum, and care must be taken to avoid injuring them.
The peritoneum should be stripped off with the fingers or with blunt scissors. Bleeding vessels are secured with forceps as they appear. No attaching structures should be divided until they have been carefully examined, for all anatomical relations are distorted by these growths. The ureter may pass over the top of the tumor, far removed from its normal position on the pelvic floor.
After the surgeon has started the enucleation of a tumor of this kind he must complete the operation. Bleeding cannot be arrested until the tumor has been enucleated, the cervix exposed, and the uterine arteries secured.
The operation is often accompanied by very profuse hemorrhage, but this hemorrhage is always arrested by the ligature of the ovarian and uterine arteries, which alone supply the growth. The surgeon should therefore not delay the operation by the ligature of separate bleeding points until the main vessels have been secured.
Vaginal Hysterectomy.—Vaginal hysterectomy may be performed for the relief of any condition in which the uterus or attached tumor is sufficiently small to pass through the vagina. The operation is very popular with some surgeons. It is but rarely used by the writer. The difficulty in dealing with adhesions and other complications in the upper part of the pelvis seems to be much less when the operation is performed through an abdominal incision.
Fig. 218.—Lateral vaginal retractor.]
The technique of vaginal hysterectomy varies considerably in the hands of different operators. The vaginal vault is opened with the knife, the scissors, or the cautery. The vessels of the broad ligament are secured with the ligature or with the clamp. The uterus is sometimes divided by longitudinal incision and the halves are separately removed.
Fig. 219.—Vaginal hysterectomy with clamps: first step (Baldy).
The following are the general directions for the performance of the operation:
The woman is placed in the lithotomy position. The vagina is opened with the Sims speculum and with lateral vaginal retractors ([Fig. 218]).
If the cervix is septic, it is thoroughly curetted, sterilized with the cautery or by other means, and the sides of the excavation are united by suture.
The cervix is seized by tenaculum forceps and dragged downward and forward.
A transverse incision with knife, scissors, or cautery is made in the posterior vaginal fornix, and Douglas’s pouch is opened.
Fig. 220.—Vaginal hysterectomy with clamps: second step (Baldy).
A sponge is introduced into the peritoneum behind the uterus.
Some operators suture the posterior peritoneal layer of Douglas’s pouch to the posterior vaginal wall, to control bleeding and to prevent stripping of the peritoneum.
The cervix is now dragged backward and a transverse incision is made across the anterior vaginal fornix.
The bladder is carefully dissected from the anterior face of the cervix with the knife, scissors, and finger, and the utero-vesical fold of peritoneum is opened. The peritoneum and the anterior vaginal wall may here also be united by suture.
Fig. 221.—Vaginal hysterectomy with clamps: third and final step (Baldy).
An incision may then be made through the vaginal mucous membrane of the lateral fornices, uniting the anterior and posterior incisions.
With a finger in Douglas’s pouch as a guide, the broad ligaments are then secured in successive portions by ligature or by strong clamp forceps, and the uterus is cut away with the scissors as the ligatures or clamps are placed.
As the upper portion of the broad ligaments is reached the procedure may be facilitated by retroverting or anteverting the uterus, the fundus being dragged through the posterior or the anterior incisions in the vaginal vault.
The tubes and ovaries should be removed when possible, especially in the case of malignant disease.
After the uterus has been removed the vagina may be packed with a gauze drain that reaches upward between the stumps of the uterine arteries; or, if ligatures have been used, the vaginal vault may be closed. The former procedure is the safer. When the gauze drain is used, it is advisable to leave the ends of the ligatures on the uterine arteries long and protruding into the vagina. The ligatures usually become infected, and their removal is facilitated by this procedure. If clamps are used, they should be removed in forty-eight hours.
The treatment after vaginal hysterectomy is the same as that already described after celiotomy.
Combined Vaginal and Abdominal Hysterectomy.—A combined vaginal and abdominal operation is sometimes performed in order to enable the surgeon to deal with adhesions and other complications in the upper part of the pelvis.
The operation is usually begun below. The vaginal connections and the bladder are separated from the uterus, and the bases of the broad ligaments are secured with the ligature or the clamp; the cervix is freed from its attachments to the broad ligament.
The abdomen is then opened and the operation is finished from above, the uterus being removed through the abdominal incision.
The writer performs the combined operation in the reverse order, as follows:
The abdomen is first opened. The ovarian arteries and the round ligaments are secured by ligature. The bladder is separated from the uterus and the upper part of the vagina. The broad ligaments are divided to a point somewhat below the level of the internal os.
A gauze pad is then introduced to the bottom of Douglas’s pouch, and another to the bottom of the space between the uterus and the bladder. The abdominal incision is then closed.
The rest of the operation is performed through the vagina. The posterior and anterior vaginal fornices are opened by incisions made directly upon the gauze pads. The vaginal mucous membrane is divided over the vaginal fornices by an incision that joins the anterior and posterior incisions in the vaginal vault. The bases of the broad ligaments are secured by strong clamp-forceps, and the uterus is cut away and removed through the vagina. The gauze pads are then removed, and the vagina is drained with gauze introduced as far as the upper end of the forceps.
The following are the advantages of the latter method of operating:
If sterilization of the vagina and the cervix is not perfect, the cleaner part of the operation is performed first. The bladder is more easily separated from the uterus by operating from above than by way of the vagina. The vaginal vault is quickly and safely opened by incisions made upon the gauze pads, which keep the intestines out of the way.
The uterus and the infected cervix are removed through the vagina, and not through the abdominal cavity.
If the operation is performed for cancer of the cervix, the incision is made more accurately beyond the limits of the disease if the vaginal vault is opened through the vagina than if it is opened from above.
Werder, of Pittsburg, has advised the following combined operation: The abdomen is opened, and the uterus, tubes, and ovaries are freed as in ordinary hysterectomy. The ureters are dissected out, and the uterine arteries are ligated near their origin. The bladder is entirely freed from the uterus, and also, for a considerable distance, from the vagina. The recto-vaginal space is then opened, and the posterior vaginal wall is stripped from the rectum as far down as necessary. The lateral vaginal attachments are loosened. The uterus and vagina are then pushed down into the pelvic outlet, and the peritoneum from the anterior pelvic wall is united with that covering the rectum, thus shutting off the pelvis from the general peritoneal cavity and covering all raw surfaces with peritoneum. The abdomen is then closed.
The patient is then placed in the lithotomy position. The uterus—which is found protruding at the vulva—is seized with volsella forceps and drawn completely out of the vulvar orifice with the inverted vagina. With the finger in the rectum and the sound in the bladder as safeguards against injuring these organs, the inverted vagina is amputated with the knife or the thermo-cautery. The chief advantage of this operation is that a large vaginal cuff may be removed.
Abdominal Myomectomy.—In some cases of uterine fibroid it is proper to remove the tumor without taking away the uterus. This operation—myomectomy—is performed as follows:
The abdomen is opened by a free incision, the pelvis is elevated, and the intestines are displaced from the pelvic cavity in the usual manner. The tumor and the uterus are surrounded by gauze sponges, and, where possible, should be brought outside the abdominal cavity. An incision is made around the pedicle or through the capsule of the tumor, and it is enucleated by dissection with the sharp or the blunt end of the scalpel. During the operation hemorrhage may be controlled by an assistant, who compresses with his fingers the vessels on each side of the uterus, or by placing a temporary rubber ligature about the cervix uteri.
Hemostasis is effected and the wound in the uterus is closed by layers of continuous or interrupted catgut sutures. Great care should be taken to prevent hemorrhage between the layers of suture, and to insure accurate closure of the incision in the uterus. The temporary ligature about the cervix, or the compression of the vessels of the broad ligaments, should be removed from time to time during the process of suturing and after closure of the uterine wound, in order to determine the position of bleeding points and the efficiency of the hemostasis; and before closing the abdominal incision the uterine wound should be inspected for several minutes while the woman is in the horizontal position.
The abdomen may usually be closed without drainage.