5. Strangulation in a sac formed by a yielding cicatrix.
The form of intestinal obstruction with which we are most concerned here arises shortly after the operation and in the course of convalescence; it may be caused by adhesions to the abdominal incision, the pedicles, raw surfaces in the pelvis left after the removal of adherent cysts and tumours, and the cervical stump of a subtotal hysterectomy.
The subject is one of importance, for the complication is fairly common in the practice of some surgeons, and is one which it is very necessary to recognize, for, unless measures of relief are undertaken promptly, the patient surely dies.
From a careful study of the matter I have come to the conclusion that acute intestinal obstruction is more frequent after ovariotomy than after hysterectomy, and this is due to the fact that the stump or pedicle left after the removal of an ovarian tumour lies higher in the pelvis, and in closer relation to ileum and jejunum, than the cervical stump left after the removal of the uterus. This view also receives support from the fact that acute intestinal obstruction following hysterectomy is more frequent in the practice of those surgeons who perform subtotal hysterectomy improperly, and leave a large piece of the neck of the uterus sticking up like a median post in the floor of the pelvis. As far as I can judge from the scanty records relating to this complication after hysterectomy, it is the sigmoid flexure of the colon which is most commonly adherent to the cervical stump. The best way of avoiding this accident is to remove the supravaginal cervix so freely that, when the peritoneum is closed over the incision in the floor of the pelvis, there is nothing visible except a narrow thin line of suture at the base of the bladder.
The only rational method of treating acute intestinal obstruction following operations in the pelvis, is to promptly reopen the abdomen and set free the adherent coil of gut. Operations of this kind after hysterectomy are more often successful than when they are a sequel to ovariotomy, and this is, I think, due to the fact already mentioned, that when intestinal obstruction follows ovariotomy or oöphorectomy, the obstruction arises in the small intestine and is usually very acute and more dangerous; whereas after hysterectomy the obstruction affects, as a rule, the sigmoid flexure of the colon, and though it may be fairly acute, is not nearly so dangerous, and gives far better results to operative treatment.
Perforating ulcer of the stomach and small intestine. A rare cause of death after ovariotomy or hysterectomy is a perforating ulcer of the stomach or jejunum. Since 1887 I have seen three cases. In each instance the patient died from septic peritonitis. Rosthorn lost a patient from perforating ulcer of the stomach after hysterectomy. Olshausen states that he has seen at least four examples of this accident.[2]
Injuries to the bladder. This viscus has been injured in a variety of ways during operations on the pelvic organs. An overfull bladder has been mistaken for an ovarian cyst and been punctured with a trocar before the mistake was discovered. When tumours are impacted in the pelvis the bladder is often pushed up into the hypogastrium; this happens with bilateral ovarian tumours, incarcerated fibroids, and especially with large cervix fibroids. When the bladder is pushed up, care should be exercised in making the abdominal incision, or it will be cut. Punctures and incisions in the bladder should be immediately closed with sutures of fine silk.
The bladder is liable to be injured in the performance of subtotal and total hysterectomy, especially in the latter operation when separating it from the neck of the uterus. In the subtotal operation the risk arises chiefly in suturing the peritoneal flaps over the cervical stump, for the bladder is liable to be punctured with the needle as it lies close to the anterior flap.
Injuries to the ureter. Since the vulgarization of hysterectomy, injuries of the ureters have become common; nearly all are inflicted in cases where the neck of the uterus is removed, as in total abdominal hysterectomy, and in vaginal hysterectomy, because the vesical segments of these ducts come into close relationship with it.