A Text-book of Diseases of Women

by Charles B. Penrose

The operator should bear these facts in mind when he considers the subject of drainage.

A certain amount of absorption of blood or other sterile fluid may be trusted to the peritoneum.

It is sometimes impossible to arrest all venous oozing from raw surfaces, and the blood must be left for absorption by the peritoneum, or must be carried off by drainage with the glass tube or with gauze. Drainage enables the operator to watch the amount of hemorrhage after operations, so that if excessive he may employ measures to check it. Drainage also acts as a hemostatic. The direct pressure of the gauze upon the bleeding area checks the hemorrhage, and the continual removal of blood, the promotion of dryness, and the contact of air through the glass tube have a decided hemostatic effect.

Drainage, therefore, is sometimes used not only to remove blood, but to aid in arresting hemorrhage. As the operator becomes more experienced he practises more perfect hemostasis, and learns to obliterate by buried suture, to fold in, or to cover with peritoneum raw bleeding surfaces, so that drainage as a means of hemostasis is less often required. If the operator fears that the peritoneum has become infected from imperfect asepsis at the operation, or from the escape into it of some septic material like pus, he should employ drainage, especially if he expects much subsequent serous or bloody discharge to take place.

If the intestinal wall has been extensively injured, as we sometimes find after an adherent intestine has been liberated, drainage should be employed; for septic organisms most readily pass through such an injured wall, and the damage may be so great that necrosis may take place, with the escape of intestinal contents. It must be remembered that all purulent accumulations in the abdomen and pelvis are not septic. Such accumulations were septic in the beginning, but in the majority of chronic cases the septic organisms have died and disappeared, and the pus is perfectly sterile and harmless to the peritoneum. Consequently, if an ovarian or a tubal abscess ruptures during removal, and the contents escape into the peritoneum, drainage is not necessarily required. For a period of three years the writer had in such cases immediate bacteriological examination of the pus made, and determined drainage from the result of such examination. In the majority of cases the pus was sterile and drainage was not employed. It has been found, as would be expected, that the pus is most often septic in the cases of recent suppuration and in the chronic cases during an acute attack. Experience also teaches that suppurating dermoids are very likely to be septic.

It will be seen from these considerations that in determining the question of drainage much must be left to the judgment and the experience of the operator.

If an aseptic operation has been performed, and there is no intestinal lesion and hemostasis is perfect, drainage is not required. This condition of things is, of course, most often attained by the experienced operator. If the operator fears septic infection for any reason, or fears that the hemostasis is not good, he should employ drainage. At the present day the decided majority of the best operators use abdominal drainage very little.

When general peritoneal sepsis exists before the abdomen is opened, drainage is always indicated.

Vaginal Drainage.—Drainage of the peritoneum through the vagina is usually accomplished by making an opening through Douglas’s pouch into the posterior vaginal fornix. A rubber drainage-tube or a gauze drain may then be inserted. The vagina and vulva should, of course, have been thoroughly sterilized. The vagina should be lightly packed with gauze, and the vulva should be protected by a gauze and cotton dressing. As has been said, the chief objection to vaginal drainage of the peritoneum is the difficulty of sterilizing and maintaining sterile the vagina and the vulva.

The Incision of the Abdominal Wall.—The various abdominal operations of gynecology are performed through an incision in the median line. The position of the incision depends upon the condition to be treated. The incision for performing ventro-suspension of the uterus is made near to the symphysis pubis. The incision for the removal of a large cyst is made at a higher point. As a rule, the incision, about 2 or 2½ inches in length, should be made about midway between the umbilicus and the pubis, and should be extended upward or downward as necessary. The incision should be as small as the operator can conveniently work through. He should not hesitate to enlarge the incision to facilitate any manipulations. The length will depend a good deal upon the thickness of the abdominal walls.