A System of Operative Surgery Part 10

CHAPTER VIII

OPERATIONS FOR DISPLACEMENT OF THE UTERUS

HYSTEROPEXY (VENTRO-SUSPENSION AND VENTRO-FIXATION OF THE UTERUS)

_Hysteropexy is a term applied to an operation for fixing the uterus, by means of sutures, to the anterior abdominal wall._

This procedure was advocated as a definite surgical operation for displacements of the uterus independently by Olshausen and Kelly (1886).

The operation when employed for severe retroflexion of the uterus is now known as ventro-suspension of the uterus; when carried out for prolapse it is termed ventro-fixation of the uterus. When care is taken in the selection of patients, hysteropexy is an operation which is followed by satisfactory consequences.

VENTRO-SUSPENSION FOR RETROFLEXION OF THE UTERUS

The preliminary preparation and the instruments required as those used for a simple cliotomy (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 ooph.o.r.ectomy, an ovariotomy, or a myomectomy, according to the necessity of the case. When the enlargement of the ovaries is due to dema 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 pa.s.sed 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 pa.s.s 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 v.a.g.i.n.a, 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 a.s.sistant 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 cliotomy.

=After-treatment.= This is conducted on the same lines as after ovariotomy.

=Risks.= Hysteropexy, when performed by surgeons experienced in pelvic surgery, is such a simple operation that it should have no mortality. At the Chelsea Hospital for Women, from 1904 to 1906, both years inclusive, this operation was performed on 190 patients, all of whom recovered from the operation.

Many of these operations were complicated with ooph.o.r.ectomy, ovariotomy, or myomectomy. A wide study of operation returns show that hysteropexy is not absolutely free from risk, as deaths from sepsis, lung complication, and intestinal obstruction have been reported.

The remote consequences of hysteropexy are of interest. When the uterus has been enlarged by previous pregnancy its fundus can be brought without undue strain into contact with the anterior abdominal wall, so that when it is secured by sutures there is little or no strain on them.

When hysteropexy is performed on spinsters or barren married women in whom the uterus is small, there is, in many instances, a strain on the sutures. The effect of this strain is twofold. When the uterus is attached to the abdominal wall by an aseptic suture, lymph is exuded from the surfaces of the peritoneum in contact with the retaining sutures. This effused lymph organizes into a tenacious tissue, and the strain of the uterus, when the operation is performed on virgins, or the weight of the organ when it is done for prolapse, will cause the sutures to erode their way out of the uterine wall, but the plastic material effused around the silk threads slowly stretches as the uterus descends into the pelvis, producing a tendon-like structure which may be called the 'artificial fundal ligament' (Fig. 20).

[Ill.u.s.tration: FIG. 20. THE FUNDUS OF A UTERUS. A long fibrous cord arises from the fundus as a result of hysteropexy performed nearly five years previously for inveterate retroflexion. Full size.]

In patients in whom the length of the uterus allows its fundus to come in contact with the abdominal wall without strain, the union may be so secure that the woman may pa.s.s through one or more pregnancies successfully without disturbing the union, or even stretching it. This I have proved in twelve instances where some subsequent trouble such as appendicitis, gall-stones, ovariotomy, cancer of the colon, or the like has led to a repeated cliotomy, and has afforded me an opportunity of examining the condition of the uterus.

In one remarkable case where a small uterus had been securely fixed by its fundus to the abdominal wall by means of ten thick sutures (the operation had been performed in a cottage hospital in Yorks.h.i.+re), the patient complained of persistent pain, and was sent to me on this account. I found the sigmoid flexure of the colon caught in one of the sutures, which accounted for some of the woman's trouble, but the uterus was so firmly fixed to the abdominal wall and had been so dragged upon that it had become a rounded sausage-like organ. Its removal was followed by immediate relief. Among rare accidents which have followed this simple operation is teta.n.u.s when catgut and wallaby tendon has been used for the retaining sutures (see p. 107).

REFERENCES

KELLY, H. A. Hysterorrhaphy. _American Journal of Obstetrics_, 1887, xx.

33.

OLSHAUSEN. Ceber ventrale Operationen bei Prolapsus und Retroversio Uteri. _Centralblatt fur Gynakologie_, 1886, x. 698.

CHAPTER IX

OPERATIONS UPON THE UTERUS DURING PREGNANCY, PARTURIENCY, AND PUERPERY

Pregnancy is apt to be complicated with tumours growing in the walls of the uterus, _e.g._ fibroids, cancer of the neck of the uterus, or cysts and tumours of one or both ovaries; morbid conditions of the Fallopian tubes, _e.g._ pyosalpinx, tubal pregnancy; tumours and cysts in the broad ligament; displaced viscera occupying the pelvis, _e.g._ the spleen or the kidney; tumours arising in the pelvic bones, _e.g._ osteoma, enchondroma, or sarcoma; and echinococcus cysts and colonies growing in the omentum, but occupying the pelvis, or arising in the pelvic tissues.

This is a formidable list, and any one of them may so complicate the pregnancy that it may be necessary to remove the tumour, and in some instances to perform Caesarean section, or even hysterectomy.

CaeSAREAN SECTION

This signifies the removal of a ftus and placenta from the uterus through an incision involving the abdominal and uterine walls.

This operation is required when the outlet of the pelvis is too narrow to permit the transit of a viable child, as in rickets and osteomalacia; when the v.a.g.i.n.a is malformed; when the pelvic outlet is narrowed by tumours growing from the pelvic wall. Occasionally the pa.s.sage of a ftus is barred by tumours growing from the uterus, especially a large cervix fibroid, or a fibroid growing from the lower segment of the uterine wall. An ovarian cyst, especially a dermoid incarcerated by the uterus, may render this operation necessary. The rarest causes are cancer of the neck of the uterus and cancer of the r.e.c.t.u.m.

This operation is advocated by some obstetricians in certain cases of eclampsia and placenta praevia.

=Operation.= When it is known some days beforehand that the patient will be submitted to this operation, she should be prepared as for ovariotomy. Often it happens that the operation is undertaken after labour has commenced, and in circ.u.mstances which make time very precious. Even then the abdomen, p.u.b.es, and v.u.l.v.a can be shaved and thoroughly washed with warm soap and water, and lightly rubbed with ether and cotton wool.

The instruments required are those given on p. 5.

When the patient is under the influence of ether and the bladder emptied with the catheter, an incision is made in the linea alba from the umbilicus to the p.u.b.es. The belly-wall of a woman advanced in pregnancy is very thin, and, unless the surgeon be cautious, the knife will come in contact with the uterus before he is aware of it.

The uterus lies just under the incision, and the operator ascertains that it lies centrally (often the uterus is somewhat rotated to the right or left), and then makes a free incision through the uterine wall and extracts the ftus and placenta; as the uterus contracts, he slips his left hand behind the fundus, and grasps the uterus near the cervix, and effectually controls the bleeding. The a.s.sistant pa.s.ses a large warm flat dab into the belly to restrain the intestines and omentum. The uterine cavity is sponged out, and the finger pa.s.sed through the os uteri into the v.a.g.i.n.a in order to ensure a free pa.s.sage for blood and serum.

The incision in the uterine wall may be closed either by a double or a single set of silk sutures. When two layers of sutures are employed, the first set involve the mucous and adjacent half of the muscular layer[;]

these sutures should be fairly close together, for they not only bring the parts into apposition, but they restrain the bleeding. A second row of silk sutures is now inserted, including the serous coat and adjacent half of the muscular layer. These threads should not be tied too tightly, as the tissues of a gravid uterus are soft and easily tear. In closing the uterine incision the surgeon should not spend time vainly in endeavouring to stanch the bleeding from the edges of the incision; this is best effected by dexterously inserting and securing the sutures.

The recesses of the pelvis are carefully cleaned by gentle sponging, and the parietal incision is closed as after ovariotomy.

The dressing varies with the fancy of the operator; a piece of sterilized gauze and a square of Gamgee tissue held in position by a many-tail of flannel firmly applied is all that is necessary.

Although Caesarean section is one of the simplest operations that can be performed on the pelvic organs, it formerly had a very high mortality; but since the principles of asepsis have been thoroughly established the death-rate from this operation has been so reduced that it varies from 4 to 10% according to the skill of the operator; indeed the results are so good in the hands of careful and skilful men that on recovery from the operation the patient may reconceive, and there are conditions in which the patient is desirous to produce more children with the knowledge that they must be extricated by Caesarean section. There are many instances on record of women being submitted to this operation twice, and some thrice; and at least two patients have undergone this operation four times (Sinclair). In view of the fact that a woman after being submitted to Caesarean section may reconceive, it has been urged (especially by Sinclair) that the anterior surface of the uterus should be attached to the abdominal wall in such a manner as to promote the formation of adhesions, so that when the patient needs to be submitted to 'repeated Caesarean section', the adhesions resulting from the primary operation will so shut off the operation area from the general peritoneal cavity, that the uterus may be opened and the ftus and placenta extracted by a practically extraperitoneal operation. This question has been discussed in an able and comprehensive paper by Wallace, and also by Sinclair.

There is one great danger which women run by becoming pregnant after Caesarean section, namely, rupture of the uterus. Some cases ill.u.s.trating this accident have been reported. This accident has been discussed by Wallace.