This part of the operation must be conducted very cautiously for fear of injury to the bladder: the pulp of the finger only must be used in the separation. The frequent use of the bladder sound is very useful at this stage, as it is quite easy to wound this viscus laterally. Bleeding from the divided twigs of the vaginal vessels often obscures the field of operation and renders the separation of the bladder troublesome: it well repays the operator to stop all bleeding after making the vaginal incision.
The peritoneum is next picked up and opened with scissors. The anterior fold of peritoneum may sometimes be more easily reached after the bases of the broad ligaments have been ligatured and divided, thus allowing the uterus to be drawn down more readily, and making the peritoneum more accessible. An anterior retractor is then passed to keep the bladder out of the way.
A second incision similar to the first is now made across the posterior aspect of the cervix at the level of the cervico-vaginal junction, more or less cellular tissue is traversed, and the posterior peritoneal pouch is opened. By joining the ends of these two incisions the cervix is completely separated from the vagina.
Fig. 69. Galabin’s Broad-ligament Needle (right).
Fig. 70. Jessett’s Broad-ligament Needle.
The uterus is now suspended in the pelvis by the attachments of the broad ligaments only; the next step consists in ligaturing and dividing these. The cervix is drawn over towards the patient’s right side by an assistant, so as to expose the base of the left broad ligament. Additional space is gained by drawing aside the left wall of the vagina by means of a retractor. By passing the left index-finger behind the broad ligament the tube and ovary can be easily felt, and if necessary the bent finger can pull them down for inspection; the finger is then placed beside the cervix below and behind the base of the broad ligament. A Galabin’s or Jessett’s (Fig. 70) needle, carrying a stout silk suture, is passed through the ligament from before backwards, on to the tip of the finger (Fig. 71).
| Fig. 71. Vaginal Hysterectomy. The patient is in the lithotomy position,
the vaginal incisions have been made and the peritoneal cavity opened. The left
broad ligament is exposed, and a Galabin’s needle threaded with silk is being passed
from before backwards on to the index-finger of the operator’s left hand inserted
into the peritoneal cavity. (Semi-diagrammatic, from a photograph.)
a, a', a''. Retractors. c. Cervix. p. Supravaginal cervix denuded of its coverings. ut. Uterine artery. b.lig. Broad ligament. n. Galabin’s needle. v. Volsella. |