The operation that at present seems to possess most advantages for the cure of those cases of retroversion of the uterus that cannot be cured by the pessary is the operation of ventro-suspension of the uterus ([Fig. 96]). It is performed as follows:
An incision, one and a half to three inches in length, is made in the median line of the anterior abdominal wall, immediately above the pubis. Two fingers are introduced into the abdominal cavity, and the fundus uteri is lifted forward. The plane of the abdominal incision is exposed, and a curved needle carrying a medium-sized silk suture is passed through a few fibers of the rectus muscle and the peritoneum on one side, immediately above the lower angle of the incision. The needle is then passed through the tissue of the fundus uteri on the line joining the uterine cornua or a little posterior to this line. The amount of uterine tissue included in the suture is about one-quarter of an inch broad and one-eighth to one-quarter of an inch deep. The needle is then passed through the peritoneum and a few fibers of the rectus muscle on the side of the abdominal incision opposite the point of entrance. The fascia of the rectus should not be included. A similar suture is passed about one-third of an inch above this, traversing the uterine wall on a line about one-third of an inch posterior to the first suture. While the fundus is held forward by the finger of an assistant these sutures are tied, so that the fundus uteri is brought into contact with the anterior abdominal wall. The ends of the sutures are cut short. The abdominal incision is then closed by three layers of sutures—silk for the peritoneum, catgut for the muscle and fascia, and the intra-cutaneous suture for the skin. Accompanying disease of the tubes and ovaries may be treated directly by this operation, and any adhesions may readily be broken.
Fig. 96.—Position of the sutures in ventro-suspension of the uterus.
In performing this operation it should be remembered that we do not wish to make a fixation of the uterus to the anterior abdominal wall. The inclusion of a broad mass of uterine tissue in the suture, and scarification of the anterior face of the uterus, which is sometimes practised, may result in a broad, unyielding adhesion which will interfere with the normal mobility of the uterus and with the course of pregnancy and labor.
Fig. 97.—The suspensory ligament two years after the operation of ventro-suspension. The ligament measured three inches in length.
After this operation of ventro-suspension the fundus uteri does not remain permanently in contact with the anterior abdominal wall. In time it drops somewhat backward and downward. The silk sutures drag out a ribbon-shaped fold of tissue consisting of peritoneum and a little muscle-fiber from the anterior abdominal wall, and a similar fold of peritoneum and perhaps some muscular fibers from the uterus, so that in time the uterus becomes attached by a slight pliable ligament from one to three inches in length ([Fig. 97]). Bimanual examination of the uterus one year after this operation shows that the uterus has about the normal range of mobility. If this operation is properly performed, the course of subsequent pregnancies and labors seems to be in no way impeded.
The operation of ventro-suspension should always be accompanied by perineorrhaphy in case there has been laceration of the perineum. The two operations may be done at the same time.
The treatment of retrodisplacement of the uterus may be briefly summarized as follows: