Part 27 (2/2)

=Results.= Primary union is the rule, and the wire sutures may be removed at the end of the tenth or twelfth day. The cervix has the appearance observed in the nullipara, and may lead to complications in any ensuing labour from difficulty of dilatation.

Duhrssen modifies Emmett's operation by a flap-splitting procedure which, however, does not appear to possess sufficient advantages to warrant its general introduction.

v.a.g.i.n.aL FIXATION (Hysteropexy)

This operation consists in the fixation of the retroverted fundus uteri in an anteverted position, by suturing it to the anterior v.a.g.i.n.al cul-de-sac.

=Indications.= These are somewhat uncertain, and the field of utility of the operation is rapidly becoming more limited. Advocates of this procedure recommend it for backward displacement of the uterus with or without adhesions. It is considered specially applicable to cases in which slight retroversion is complicated by moderate prolapsus. The results which have so far obtained do not appear to be so good as those resulting from the use of a well-fitting pessary.

=Operation.= The technique recommended by Duhrssen appears to be the most satisfactory, and is as follows: The patient is anaesthetized and placed in the dorsal position with the knees supported by a Clover's crutch. After purification of the parts (see p. 126) the cervix is pulled down as far as possible by means of a volsella: a curettage is then carried out as a preliminary measure (see p. 154). If cervical hypertrophy is present, amputation by Marckwald's method (see p. 160) should be performed, as an elongated cervix acts as a preventive to satisfactory anteversion of the uterus. A transverse or T-shaped incision is now made as in v.a.g.i.n.al hysterectomy (see p. 169), and the cellular tissue pushed up by the index-finger until the peritoneum is reached. The peritoneum is now seized with a volsella and cut through, and the edges sutured to the lips of the v.a.g.i.n.al wound. The uterine fundus is then anteverted by means of a sound: by pressing the handle of the instrument towards the perineum the fundus is brought into the wound. By means of a rectangular curved needle a stout silk suture is pa.s.sed through the anterior wall of the fundus as high up as possible: the v.a.g.i.n.al flaps are not included, as the suture is to be used for traction only. The uterus is now forcibly pulled down and two other sutures are introduced in the same manner higher up. Three sutures of catgut are pa.s.sed through the uterine wall, including the v.a.g.i.n.al and peritoneal flaps. The silk traction sutures are now withdrawn and the permanent ones tied. The v.a.g.i.n.al wound is carefully sutured by means of fine silk.

=Difficulties and dangers.= The risks of the operation are peritonitis and wounding of one or both ureters or the bladder wall. Absolute rest for fourteen days is necessary and no local after-treatment is called for.

CHAPTER XVI

OPERATIONS FOR NEW GROWTHS OF THE UTERUS

Uterine growths include primary malignant disease and fibro-myomata; the former should be treated by exploration and subsequent v.a.g.i.n.al hysterectomy (see p. 168), while the latter should be dealt with according to their relations and attachments to the uterine wall.

[Ill.u.s.tration: FIG. 66. PEDUNCULATED FIBROID POLYPI IN VARIOUS STAGES OF EXTRUSION. (_From drawings made at time of operation._)]

OPERATIONS FOR UTERINE FIBRO-MYOMATA

Fibro-myomata may present themselves to the operator in one of the following forms:--

1. As a fibroid polypus still intra-uterine or presenting through a naturally dilated and thinned-out cervix (submucous pedunculated).

2. As sessile growths presenting by their lower segments at the os uteri, which may be closed, or may be in varying degrees of dilatation (submucous sessile).

3. As tumours incorporated in the uterine wall (interst.i.tial).

=Operations for pedunculated tumours.= _If a fibroid polypus be still intra-uterine_ (Fig. 66) the proper treatment is to dilate the cervix (see p. 156), and, if the pedicle be sufficiently thin, to seize the growth with a pair of stout polypus forceps and twist it off by a slow rotary movement of the handles. Should the pedicle be thicker than the finger, the use of the wire ecraseur is advisable. This is a scientific snare, with a loop of pianoforte wire and a handle or wheel by which it can gradually be tightened, causing the wire to slowly cut through the stalk of the growth (Fig. 67).

[Ill.u.s.tration: FIG. 67. WIRE eCRASEUR.]

The cervix is steadied with a volsella and the loop of the ecraseur is shaped and bent to the size and position of the fibroid. The instrument is then pa.s.sed into the uterine cavity and the noose pushed over the tumour up along the pedicle. The wire loop is then tightened up by means of the handle or wheel, and the wire cuts its way through and separates the growth from the uterine wall. It is somewhat dangerous to put any traction on the tumour before its separation, as is recommended by some writers, as the uterine wall itself may become somewhat inverted and the wire loop may cut through into the peritoneal cavity.

_If the fibroid polypus has pa.s.sed through the external os uteri_, treatment is more simple. Slight traction may be made upon it by means of forceps, and the pedicle severed with scissors; no haemorrhage takes place, owing to the retraction of the stump.

=Operations for sessile tumours.= In submucous sessile fibroids (Fig.

68) in which the lower segment of the uterus is somewhat thinned out and dilated, operative interference may be as follows: Preliminary dilatation of the cervix by bougies may be necessary. The capsule of the tumour is then incised with a sickle-shaped knife and the growth is enucleated by means of the finger or a blunt spoon. In some cases mere incision of the capsule is sufficient, and the uterus expels the growth later on.

Another method of treating these cases is by the operation of _morcellement_, which consists in removing the tumour piecemeal by means of specially made forceps.

The instrument used by the author consists of a strong pair of forceps somewhat like those used in lithotomy, with the two distal ends notched with sharp teeth like a volsella. A portion of the tumour is seized between these two blades, and partly cut and partly twisted off. With patience and care the whole tumour may be thus removed. In one case the author was enabled to remove two large growths, each filling a pint measure. This operation is specially suitable in women in whom an abdominal operation is to be avoided.

=Operations for interst.i.tial tumours.= Interst.i.tial fibroid tumours, if not above the size of a small ftal head, should be treated by v.a.g.i.n.al hysterectomy (_vide infra_); if large, by hysterectomy by the abdominal route (see p. 36).

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