Part 24 (1/2)

Irrigation and packing with gauze may be resorted to as after-treatment, but are considered unnecessary by a large number of operators.

Atresia of the v.a.g.i.n.a may be congenital or acquired. In the latter case the condition results from contraction of adhesions developed from damage done during labour; or it may follow acute septic vaginitis, the introduction of acids or irritating materials to produce abortion, or as a sequel to typhoid fever.

Treatment is by slow dilatation with Hegar's bougies over an extended period of time; relapse is common.

DILATATION OF THE v.u.l.v.aL ORIFICE

=Indications.= This is done for vaginismus due to a pathological spasm of the levator ani and resulting in more or less complete obstruction to coitus.

=Operation.= Under an anaesthetic the v.u.l.v.al orifice should be thoroughly dilated by means of the thumbs, and for some days subsequently graduated Sims's 'v.a.g.i.n.al rests' (Fig. 46) should be inserted twice daily and worn for twenty minutes at a time. This treatment may be necessary for a fortnight or longer. In many cases of dyspareunia the cause will be found to be due to a thick, fleshy, and unruptured hymen or to tenderness about the remnants of that organ. Under these circ.u.mstances, exsection is the better plan to pursue. The hymen is seized with a pair of toothed forceps and removed with curved scissors along its entire base of attachment. Free bleeding often occurs from the raw surface, which must be controlled by ligatures. The two almost parallel cut edges must then be carefully brought together either by continuous or interrupted suture.

[Ill.u.s.tration: FIG. 46. SIMS'S v.a.g.i.n.aL REST.]

COLPOTOMY OR v.a.g.i.n.aL CLIOTOMY

By colpotomy is meant making an opening into the peritoneal cavity through the v.a.g.i.n.a; the operation is known as anterior or posterior colpotomy, according to whether the opening is made through the anterior or posterior fornix.

Colpotomy has certain _advantages_ over abdominal section. There is less interference with the peritoneum and intestines, and therefore less shock; if pus is present, there is less risk of infecting the general peritoneal cavity, and better drainage; there is no abdominal scar, and therefore no risk of hernia; lastly, there are certain pathological products which can be more easily reached by this route. The operation is difficult in a nullipara, where the v.a.g.i.n.a is narrow, and easier in a multipara, where the v.a.g.i.n.a is more capacious, and it is still easier if the cervix can be drawn down as far as the v.a.g.i.n.al orifice.

A serious _disadvantage_ is that, during the course of the operation, it may be found impossible to deal adequately with the conditions for which the operation is being performed; in the case of a tumour, for instance, its size, position, or the presence of adhesions may render it necessary to complete the operation by the abdominal route. Further, in more than one instance, the abdomen has had to be opened after the completion of the operation on account of bleeding, the source of which could not be dealt with by the v.a.g.i.n.a.

Therefore, before deciding upon the removal of a tumour by colpotomy, all the above points must be taken into consideration.

=Indications.= When the above conditions are fulfilled, colpotomy is suitable for:--

(i) The evacuation of collections of pus or blood in Douglas's pouch.

(ii) The removal of fibro-myomata, ovarian tumours of small size, and early tubal pregnancies.

(iii) The drainage of collections of pus or the removal of the appendages in cases of acute inflammation where immediate operation is necessary.

(iv) Conservative operations upon the Fallopian tubes or ovaries.

(v) A preliminary to the performance of v.a.g.i.n.al hysteropexy.

(vi) Those cases in which the patient's general condition is unfavourable to the performance of exploration by the abdominal route.

Anterior colpotomy is more suitable for removing small tumours growing from the anterior wall of the uterus, or for conservative operations on the ovaries. Posterior colpotomy is more suitable for removing inflamed appendages, and for evacuating collections of pus or blood from Douglas's pouch.

[Ill.u.s.tration: FIG. 47. POZZI'S RETRACTORS.]

Posterior colpotomy has been used for many years for the opening of abscesses and haematoceles in Douglas's pouch. The anterior operation is of more recent date, and its relative advantages and disadvantages and the indications for its use have not yet been definitely agreed upon by the majority of gynaecologists. Taking all things into consideration, the disadvantages of colpotomy seem to outweigh its advantages, and, except for the evacuation or drainage of collections of blood or pus behind the uterus, the operation may be said to have few indications.

=Anterior colpotomy.= A posterior Pozzi's (Fig. 47) or Pean's retractor is pa.s.sed into the v.a.g.i.n.a, and the cervix is seized with a volsella and drawn downwards and backwards. A sound pa.s.sed into the bladder defines its lower limit. A T-shaped incision is now made through the v.a.g.i.n.al mucous membrane, the transverse portion just below the point to which the bladder has been found to extend (Fig. 48, _b_). This incision should pa.s.s completely through the v.a.g.i.n.al 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 v.a.g.i.n.al 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 pus.h.i.+ng up the v.a.g.i.n.al 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 pa.s.sed through, and the incision is extended on either side, care being taken not to pa.s.s too far outwards for fear of injuring the ureters or uterine vessels.

[Ill.u.s.tration: FIG. 48. ANTERIOR COLPOTOMY.

The patient is in the lithotomy position, the speculum is pa.s.sed and the cervix pulled down by a tenaculum. The T-shaped incision has been made.

_b._ Outline of bladder.