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.