Part 28 (1/2)

[Ill.u.s.tration: FIG. 68. SUBMUCOUS FIBRO-MYOMATA, CAPABLE OF TREATMENT BY MORCELLEMENT. (_From drawings made at time of operation._)]

=v.a.g.i.n.al hysterectomy.= By v.a.g.i.n.al hysterectomy is meant removal of the whole uterus by the v.a.g.i.n.a, with or without the appendages. The advantages that the v.a.g.i.n.al operation possesses over abdominal hysterectomy are, there is less disturbance of peritoneum and intestines, less shock, and no abdominal scar or risk of subsequent hernia. The operation is limited to uteri not exceeding in size the head of a full-time ftus.

=Indications.= (i) Malignant disease of the uterus (fundus or cervix) in an early stage: chorio-epithelioma malignum.

(ii) Certain cases of fibro-myoma of the uterus.

(iii) Certain cases of inflammatory disease of the uterine appendages complicated by recurrent attacks of local perimetritis.

(iv) Other conditions, such as intractable uterine haemorrhage, usually due to uterine myo-fibrosis, and, as a last resort, severe dysmenorrha.

It has also been advised for irreducible chronic inversion of the uterus, and for severe procidentia uteri. No case of the former has occurred in the author's experience in which the operation was found necessary. In the latter condition the operation is not to be recommended, the almost certain result of the procedure being prolapse of the v.a.g.i.n.al walls and the intestines (enterocele).

=v.a.g.i.n.al hysterectomy for carcinoma.= The only cases suitable for operation are early ones, in which the disease is still confined to the uterus itself, which should be freely mobile in all directions. No signs of infection of the surrounding cellular tissue and v.a.g.i.n.al walls should be present. It cannot be too strongly insisted that all cases should be thoroughly examined under anaesthesia to settle this point before operation is decided upon. Rectal examination is most important to estimate the condition of the sacro-uterine ligaments, the cervix being pulled down so as to place them on the stretch.

Occasionally, cases of carcinoma of the cervix are seen, in which the cellular tissue immediately surrounding the cervix is apparently free from disease, but if search be made further outwards, a hard, fixed ma.s.s is found plastered, as it were, on to the side of the pelvis, indicating advanced disease of the lymphatic glands, or cellular tissue at the outer part of the broad ligaments. Such cases are hopeless for operation.

If the disease is in the sloughing stage, and there is foul discharge, Paquelin's cautery should be applied to the diseased surface, followed by v.a.g.i.n.al douches of formalin (?j to the pint), or some other efficient antiseptic, given three times a day for three days prior to operation.

The operation consists of three main stages:--

(_a_) Separation of the cervix from the v.a.g.i.n.a, pus.h.i.+ng up of the bladder and ureters, and opening the anterior and posterior peritoneal pouches.

(_b_) Removal of the uterus by ligaturing and dividing the broad ligaments.

(_c_) Treatment of the peritoneal and v.a.g.i.n.al flaps thus left.

First of all, the growth, if of the cervix, should receive careful preliminary attention, for it const.i.tutes a continuous source of infection, not only by means of septic organisms, but also of cancer cells, which may become implanted in the wound and cause early recurrence. The cervix is drawn down with a volsella and all visible growth is burnt away with the Paquelin cautery, until apparently healthy tissue only is left. The cervix is then completely closed by the application of a volsella or three or four stout silk sutures, pa.s.sing through both anterior and posterior lips. The ends of the sutures may be left long if preferred and serve as tractors.

After these preliminary measures against infection have been completed, the removal of the uterus is proceeded with. A posterior speculum, Auvard's or Pozzi's, is pa.s.sed, and the cervix is drawn downwards and somewhat backwards by traction on the volsellum or the long ends of the silk sutures. A sound is pa.s.sed into the bladder to define its lower limit. A transverse or T-shaped incision (Fig. 48) is now made through the v.a.g.i.n.a at the level of the cervico-v.a.g.i.n.al junction in front. This const.i.tutes the anterior incision, and the transverse portion should extend completely across the anterior aspect of the cervix, pa.s.sing through the whole thickness of the v.a.g.i.n.a, but no further.

[Ill.u.s.tration: FIG. 69. GALABIN'S BROAD-LIGAMENT NEEDLE (RIGHT).]

[Ill.u.s.tration: FIG. 70. JESSETT'S BROAD-LIGAMENT NEEDLE.]

The knife is now laid aside, and the operator proceeds to push up the v.a.g.i.n.a and bladder from the anterior aspect of the cervix with the index-finger or a winged director, until the anterior peritoneal pouch is reached. This is at once recognized by its glistening white appearance and by the manner in which its opposing surfaces glide over one another.

This part of the operation must be conducted very cautiously for fear of injury to the bladder: the pulp of the finger only must be used in the separation. The frequent use of the bladder sound is very useful at this stage, as it is quite easy to wound this viscus laterally. Bleeding from the divided twigs of the v.a.g.i.n.al vessels often obscures the field of operation and renders the separation of the bladder troublesome: it well repays the operator to stop all bleeding after making the v.a.g.i.n.al incision.

The peritoneum is next picked up and opened with scissors. The anterior fold of peritoneum may sometimes be more easily reached after the bases of the broad ligaments have been ligatured and divided, thus allowing the uterus to be drawn down more readily, and making the peritoneum more accessible. An anterior retractor is then pa.s.sed to keep the bladder out of the way.

[Ill.u.s.tration: FIG. 71. v.a.g.i.n.aL HYSTERECTOMY. The patient is in the lithotomy position, the v.a.g.i.n.al incisions have been made and the peritoneal cavity opened. The left broad ligament is exposed, and a Galabin's needle threaded with silk is being pa.s.sed from before backwards on to the index-finger of the operator's left hand inserted into the peritoneal cavity. (_Semi-diagrammatic, from a photograph._)

_a, a_{1}, a_{11}_. Retractors.

_c._ Cervix.

_p._ Suprav.a.g.i.n.al cervix denuded of its coverings.

_ut._ Uterine artery.

_b.lig._ Broad ligament.

_n._ Galabin's needle.