If the operation is performed for cancer of the cervix, the incision is made more accurately beyond the limits of the disease if the vaginal vault is opened through the vagina than if it is opened from above.
Werder, of Pittsburg, has advised the following combined operation: The abdomen is opened, and the uterus, tubes, and ovaries are freed as in ordinary hysterectomy. The ureters are dissected out, and the uterine arteries are ligated near their origin. The bladder is entirely freed from the uterus, and also, for a considerable distance, from the vagina. The recto-vaginal space is then opened, and the posterior vaginal wall is stripped from the rectum as far down as necessary. The lateral vaginal attachments are loosened. The uterus and vagina are then pushed down into the pelvic outlet, and the peritoneum from the anterior pelvic wall is united with that covering the rectum, thus shutting off the pelvis from the general peritoneal cavity and covering all raw surfaces with peritoneum. The abdomen is then closed.
The patient is then placed in the lithotomy position. The uterus—which is found protruding at the vulva—is seized with volsella forceps and drawn completely out of the vulvar orifice with the inverted vagina. With the finger in the rectum and the sound in the bladder as safeguards against injuring these organs, the inverted vagina is amputated with the knife or the thermo-cautery. The chief advantage of this operation is that a large vaginal cuff may be removed.
Abdominal Myomectomy.—In some cases of uterine fibroid it is proper to remove the tumor without taking away the uterus. This operation—myomectomy—is performed as follows:
The abdomen is opened by a free incision, the pelvis is elevated, and the intestines are displaced from the pelvic cavity in the usual manner. The tumor and the uterus are surrounded by gauze sponges, and, where possible, should be brought outside the abdominal cavity. An incision is made around the pedicle or through the capsule of the tumor, and it is enucleated by dissection with the sharp or the blunt end of the scalpel. During the operation hemorrhage may be controlled by an assistant, who compresses with his fingers the vessels on each side of the uterus, or by placing a temporary rubber ligature about the cervix uteri.
Hemostasis is effected and the wound in the uterus is closed by layers of continuous or interrupted catgut sutures. Great care should be taken to prevent hemorrhage between the layers of suture, and to insure accurate closure of the incision in the uterus. The temporary ligature about the cervix, or the compression of the vessels of the broad ligaments, should be removed from time to time during the process of suturing and after closure of the uterine wound, in order to determine the position of bleeding points and the efficiency of the hemostasis; and before closing the abdominal incision the uterine wound should be inspected for several minutes while the woman is in the horizontal position.
The abdomen may usually be closed without drainage.