Operation. The steps of the radical abdominal operation advocated by Wertheim are as follows:—
As a preliminary, the cancerous cervix is treated by scraping, cauterizing, and disinfectants. It is an advantage to carry out these measures a few days before the main operation. The Trendelenburg position is indispensable and the abdomen is opened by a free median subumbilical incision. After isolating the intestines with dabs, the ureters are exposed by incising the posterior layer of the broad ligament; they are then traced to the parametrium. It is necessary to avoid too free a disturbance of their vascular network or they will slough.
The bladder is then separated from the uterus. The infundibulo-pelvic, the broad, and the round ligaments are ligatured and divided. The particular order in which they are dealt with is not a matter of consequence. The uterine vessels are secured in the following manner:—The index finger is pushed along the ureter through the parametrium towards the bladder, until the tip of the finger appears there; the vessels are then raised on the finger, which covers the ureter so as to protect it whilst the vessels are ligatured and divided. As soon as the uterine vessels are divided the vesical segments of the ureters are exposed, cleaned if necessary, and separated from the cancerous cervix.
The posterior layer of the peritoneum is divided and the rectum separated from the vagina: at this stage the uterus is sufficiently isolated from the surrounding structures to allow of removal. This is effected in the following way:—
The two layers of the parametrium are taken off as close as possible to the pelvic wall, and the vagina closed with bent clamps and divided below them: the clamps are used to prevent soiling the operation-area with cancerous cells.
In order to extirpate the lymph glands, the peritoneum is divided upwards and the iliac vessels laid bare, and every enlarged gland from the division of the aorta to the obturator foramen is removed and the oozing vessels carefully secured.
The wound is treated in the following way:—
The cavity created by the removal of the uterus is filled in loosely with iodoform gauze, which extends to the vulva. An exact closing of the peritoneal cavity over this gauze is effected by the sewing up of the anterior and posterior flaps of peritoneum. The final step is the closure of the abdominal incision.
After-treatment. This is relatively simple. The strips of iodoform gauze are removed through the vagina in from five to ten days successively. The patient gets up on the fifteenth day. The bladder requires very careful attention, as it is usually paralysed for some days.
Mortality. The immediate mortality of these extensive abdominal operations for cancer of the neck of the uterus is very high, more than 20%, but recent statistics (1909) show that this death-rate is being considerably improved with increased experience on the part of the operators.[1]