A Text-book of Diseases of Women

by Charles B. Penrose

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.