VENTRO-SUSPENSION FOR RETROFLEXION OF THE UTERUS
The preliminary preparation and the instruments required as those used for a simple cœliotomy (see [p. 5]).
Operation. The patient is placed in the Trendelenburg position, and the abdomen is opened as for ovariotomy, except that the incision is shorter; the operator then determines with his fingers the position and condition of the body of the uterus. If it be free, it is then straightened, and the condition of the ovaries and the tubes ascertained.
In many patients, where retroflexion of the uterus is accompanied by pain, the distress is often due to a prolapsed ovary, incarcerated in the pelvis by the retroflexed fundus of the uterus; in another set of cases the retroflexion is produced by a tumour in the ovary, such as a small dermoid, but more often the body of the uterus is drawn backwards by a small fibroid in the fundus of the organ. In these conditions an operation embarked upon as a simple hysteropexy may become an oöphorectomy, an ovariotomy, or a myomectomy, according to the necessity of the case. When the enlargement of the ovaries is due to œdema from incarceration, they should be left, as the swelling will quickly subside when the misplacement of the uterus is corrected.
The uterus is fixed to the abdominal wall in the following way:—
A curved needle armed with a silk thread (No. 4) which has been carefully boiled is passed through the aponeurosis and adjacent peritoneum on one edge of the wound, then through the anterior surface of the uterus near the fundus, and finally through the peritoneum and aponeurosis on the opposite edge of the incision; when this suture is tightened, it will be found to draw the uterus to the anterior abdominal wall, and at the same time approximate the edges of the wound. Two sutures should be introduced. In patients who have had children care should be taken not to pass the needle so deeply into the uterus that the suture traverses the superficial parts of the endometrium and becomes infected: this will lead to a suture sinus. The rest of the wound is then closed according to the method described on [p. 9].
VENTRO-FIXATION FOR PROLAPSE OF THE UTERUS
Operation. When hysteropexy is needed for a large, bulky, and prolapsed uterus, the steps of the operation are the same as for retroflexion, but it is necessary to introduce a greater number of retaining sutures. Further, as the uterus tends to slip downward into the vagina, it is an advantage, as soon as the fundus of the uterus is drawn into the wound, to transfix it with a stout suture, in order that the assistant may use it as a tether to keep the uterus in position whilst the surgeon introduces the main sutures. In some cases, where the uterus is very large, it may be requisite to employ four, five, or even six sutures to secure it to the abdominal wall.
In all cases of hysteropexy the uterus is of necessity sutured to the lower angle of the wound, and is therefore in close relation to the bladder. It facilitates the operation to introduce the lowest sutures first and then gradually work up to the fundus. The wound is then closed and dressed as described for cœliotomy.
After-treatment. This is conducted on the same lines as after ovariotomy.