Anterior colpotomy. A posterior Pozzi’s (Fig. 47) or Péan’s retractor is passed into the vagina, and the cervix is seized with a volsella and drawn downwards and backwards. A sound passed into the bladder defines its lower limit. A T-shaped incision is now made through the vaginal mucous membrane, the transverse portion just below the point to which the bladder has been found to extend (Fig. 48, b). This incision should pass completely through the vaginal mucous membrane, but no further, and should extend across the whole width of the anterior surface of the cervix. Some operators use a simple longitudinal or a transverse incision. The vaginal mucous membrane is now carefully pushed upwards with the pulp of the finger until the lower limit of the bladder is defined. Great help is gained at this stage by the use of the bladder sound. On pushing up the vaginal mucous membrane still further the peritoneum is reached, and is recognized by its white glistening appearance, and by the fact that its two opposed surfaces glide freely over one another under the finger. The next step is to open the peritoneum: it is picked up with catch-forceps, and a small transverse incision is made into it with a pair of scissors; the finger is passed through, and the incision is extended on either side, care being taken not to pass too far outwards for fear of injuring the ureters or uterine vessels.
After the peritoneum has been opened, the pelvic organs can be carefully examined with the fingers, and the purposes for which the operation has been undertaken can be proceeded with. The next step usually consists in drawing out the fundus of the uterus, by which much more room and much better access to the pelvic organs is gained. To accomplish this, the uterus is caught with a volsella in the middle line, as high up as possible, and drawn downwards and forwards. If necessary, a second volsella is applied above the first, and so on, until the uterus is delivered. A very complete examination of the appendages can now be made, for the tubes and ovaries can be drawn out of the wound and examined directly.
When the object of the operation has been attained, and all the blood has been carefully removed by swabs, the next and final step consists in closing the peritoneal and vaginal wounds. The uterus is replaced, and the peritoneal incision is closed by a single layer of catgut sutures; the vaginal incision is similarly dealt with. The vagina is cleared from blood-clot and gently irrigated with an antiseptic solution. A gauze plug is inserted lightly, and the patient is put back to bed. The catheter should be used every six or eight hours for the first twenty-four hours.
Posterior colpotomy. A posterior speculum is passed and the cervix drawn downwards and slightly forwards with a volsella. A transverse incision is then made through the vaginal mucous membrane at the junction of the posterior fornix with the cervix. This exposes the peritoneum more or less easily, and this structure is picked up with catch-forceps, and a transverse incision made into it with scissors; a finger is passed through this, and the incision is extended on either side. The pelvic organs can now be explored and the tubes and ovaries drawn down and examined. The peritoneal and vaginal incisions are then closed by separate layers of catgut sutures.
To open a collection of pus in Douglas’s pouch, the best method is to pass a pair of sinus-forceps, with the blades closed, into the most prominent part of the swelling. The blades are then opened and the forceps withdrawn. The finger passed into the abscess cavity gently breaks down any adhesions. The cavity is then irrigated with hot salt solution and a drainage tube inserted, which projects just outside the vulva: the lower end of the tube should be carefully packed around with cyanide gauze. The tube should be changed every day and the vagina douched with an antiseptic. Another method is to plunge a Martin’s trochar (Fig. 49) into any softened spot in the swelling and then withdraw the needle, leaving a blunt dilating forceps to extend the opening.
Fig. 49. Martin’s Trochar for Pelvic Abscess.
In opening an abscess, the most stringent precautions against sepsis should be observed. The vagina must be most carefully prepared beforehand, by rubbing over with swabs and ethereal soap, and by a subsequent copious douche of 1 in 1,000 perchloride of mercury: otherwise continual reinfection of the abscess cavity occurs, and healing is much delayed.
Lateral colpotomy—Paravaginal section.
Indications. The object of the operation is to increase the amount of room in the vagina in certain cases of vaginal hysterectomy in elderly virgins, or in women who have a small vagina.