A Text-book of Diseases of Women

by Charles B. Penrose

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.