A Text-book of Diseases of Women

by Charles B. Penrose

The structures that are incised are the skin, the subcutaneous fat, the parietal fascia, the linea alba or the edge of the rectus muscle, the subperitoneal fat, and the peritoneum.

If the incision is made exactly in the median line, the linea alba will be divided and the sheath of the rectus will not be opened. This is most usual in multiparous women with lax abdominal walls and widely separated recti muscles, and in cases in which the abdomen is distended by a tumor. If the sheath of the rectus is opened, the muscle will be exposed, and the linea alba should be sought on the side upon which the fascia fails to retract.

If the linea alba cannot readily be found, the incision should be carried directly through the muscle. Some operators consider it an advantage, in obtaining subsequent firm union, to expose the muscle in this way. When the subperitoneal fat is reached, it should be torn and pushed aside with the blunt closed forceps or with the fingers.

The peritoneum should be caught with forceps and drawn forward. The assistant should catch the peritoneum with a second pair of forceps at a point about ⅓ or ½ inch to the side of the first pair, and the small fold of peritoneum thus produced should be incised with the knife. As soon as the smallest opening is made in the peritoneum the air rushes in and the intestines and omentum fall back. The opening is then enlarged with the knife or scissors.

The greatest care must be exercised in those cases in which the omentum or the intestines are adherent to the anterior abdominal wall. The experienced operator usually observes indications of such a condition as soon as he has passed through the linea alba. The tissues are more rigid and unyielding than normal, and the peritoneum cannot be readily picked up with the forceps. In such cases the operator should proceed very slowly, and if necessary should enlarge the outer incision and enter the peritoneum at a point above or below the area of adhesion.

Exploration of the Abdomen.—Having opened the peritoneum, the operator should insert two fingers (the middle and the index finger of the left hand) and should carefully examine the condition to be treated.

If necessary, he should retract the edges of the incision, and should place the patient in the Trendelenburg position, in order to make an ocular examination.

It is always advisable to make a preliminary investigation of this kind before proceeding with the operation. In this way the diagnosis will be corrected and complications which must be treated will be determined. It may be found that what was thought to be a cyst is in reality a uterine fibroid or perhaps a normal pregnancy; or the surgeon may discover a hopeless condition, such as extensive cancer or peritoneal papilloma, for which further operation will be useless.

Protection of the Intestines and Omentum.—During all manipulations within the abdomen the peritoneum, intestines, and omentum should be handled most gently. Injury of the peritoneum increases the danger of shock, sepsis, and intestinal adhesions. The intestines should never be allowed to protrude through the abdominal incision unless it is necessary for the performance of the operation. Such a necessity rarely, if ever, arises in gynecological operations. All the intestines may be removed from the field of operation—the pelvis—by placing the woman in the Trendelenburg position. Protrusion of intestines through the abdominal incision should be prevented by using large gauze pads or sponges. It is advisable always to surround the field of operation by a wall of gauze pads. They protect the intestines and prevent the escape of fluids into the upper peritoneum. This precaution is especially desirable when the Trendelenburg position is used, to prevent fluids from the pelvis escaping into the upper abdomen. The pads should be introduced after being wrung out of warm water, and should be replaced by fresh warm pads as soon as they become saturated with fluid. If they become soiled by pus or other septic fluid, it is safest to discard them for the remainder of the operation.

Toilet of the Peritoneum.—The field of operation, and, if necessary, the general peritoneum, should always be cleaned and dried before the abdominal incision is closed. This is done by sponging and by irrigation with warm sterile water or with normal salt-solution. The sponging should be performed with great gentleness, to avoid peritoneal irritation. There are several regions in which fluids and blood-clots are most likely to collect, and which therefore demand especial inspection.