Part 28 (2/2)

_v._ Volsella.

A second incision similar to the first is now made across the posterior aspect of the cervix at the level of the cervico-v.a.g.i.n.al junction, more or less cellular tissue is traversed, and the posterior peritoneal pouch is opened. By joining the ends of these two incisions the cervix is completely separated from the v.a.g.i.n.a.

The uterus is now suspended in the pelvis by the attachments of the broad ligaments only; the next step consists in ligaturing and dividing these. The cervix is drawn over towards the patient's right side by an a.s.sistant, so as to expose the base of the left broad ligament.

Additional s.p.a.ce is gained by drawing aside the left wall of the v.a.g.i.n.a by means of a retractor. By pa.s.sing the left index-finger behind the broad ligament the tube and ovary can be easily felt, and if necessary the bent finger can pull them down for inspection; the finger is then placed beside the cervix below and behind the base of the broad ligament. A Galabin's or Jessett's (Fig. 70) needle, carrying a stout silk suture, is pa.s.sed through the ligament from before backwards, on to the tip of the finger (Fig. 71).

[Ill.u.s.tration: FIG. 72. v.a.g.i.n.aL HYSTERECTOMY. _Final stage._ The uterus has been removed, and the peritoneal flaps are in process of suture.

_a, a_{1}, a_{11}, a_{111}._ Retractors.

_f, f'._ Spencer Wells forceps attached to the anterior and posterior v.a.g.i.n.al flaps.

_p._ Circular orifice left open in the peritoneal flaps for insertion of gauze drain.

_sp._ Stump of left broad ligament with bundle of ligatures (_l_).

_cl._ c.l.i.toris.

_l.m._ Labium majus.

_u._ Urethra.

The ligature should be pa.s.sed about one-third of an inch up the broad ligament. It is then tied tightly and the ends left long and drawn aside. The segment of broad ligament included in the ligature is divided as near the uterus as is justifiable; in carcinoma of the cervix at least half an inch from the disease should be allowed. Care must be taken at this stage to avoid injury to the ureters; these lie about one inch distant from the cervix; consequently all ligatures must be pa.s.sed as near the cervix as possible compatible with being clear of the disease.

A second ligature is now pa.s.sed through the broad ligament above the first and then a third, and more if necessary. The second generally includes the uterine artery, which can always be recognized by its strong pulsation under the finger; the third ligature will control the Fallopian and ovarian arteries. After the arteries on the left side have been secured and divided, attention is directed to the right broad ligament. The cervix is drawn over to the left side, the fundus delivered, and the upper portion of the right broad ligament is dealt with in a similar manner, but from above downwards. If the ovaries and tubes are diseased, they can now be removed by piercing the pedicle and tying the stump in the usual way.

[Ill.u.s.tration: FIG. 73. SCHAUTA'S NEEDLE-HOLDER.]

The uterus having been extirpated, the next step consists in dealing with the wound. First, all bleeding is stopped, and the wound is swabbed clean and dry. The ligatures on either side are tied in two bunches and the ends cut off just within the v.a.g.i.n.a (Fig. 72). The anterior and posterior flaps of peritoneum are united with a few catgut sutures pa.s.sed by means of Schauta's needle-holder (Fig. 73); the walls of the v.a.g.i.n.al vault are treated in a similar fas.h.i.+on, leaving a circular orifice in the median line into which gauze can be inserted for the purpose of drainage.

Some operators prefer to control the vessels in the broad ligaments by means of haemostatic forceps instead of ligatures. Each broad ligament is clamped in three or more portions and the tissue between them and the uterus cut through. They must be allowed to remain in position for at least forty-eight hours, as recurrent haemorrhage is possible if they are removed earlier. The only advantages of the forceps appear to be the rapidity with which the operation can be carried out, and the good drainage. The disadvantages are, that it is a somewhat unsurgical proceeding; there is often much pain from the nipping of the broad ligaments, and inconvenience from the presence of the handles between the l.a.b.i.a; the intestines may be damaged; sloughing and risk of sepsis must be reckoned with.

=After-treatment.= The catheter should be used at first four times daily; the author recommends that the gauze should be removed at the end of twenty-four hours, but some operators retain it longer. The ligatures should be pulled upon a little daily after the seventh day, and they gradually cut their way through the tissues in their grasp. No v.a.g.i.n.al douching should be administered until after the expiration of a week.

=v.a.g.i.n.al hysterectomy for fibroids.= This is not often called for. The operation is necessarily limited to fibroid uteri not exceeding in size a ftal head. Uterine fibroids of such a size can usually be treated in other ways, either temporarily by curetting, or, if submucous, permanently by enucleation through the v.a.g.i.n.a. The operation is most suitable for uteri containing many small fibroids causing severe haemorrhage which cannot be controlled by more palliative measures.

The v.a.g.i.n.a must be large enough to admit of delivery of the uterus through its lumen. Therefore, in virgins and nulliparae, the abdominal operation is always to be preferred. In any case, if the v.a.g.i.n.a be too narrow, additional room may be gained by lateral v.a.g.i.n.al section (see p.

148) or episiotomy.

The operation does not differ in technique from the removal of the uterus for carcinoma, already described. In some cases it may be preferable to bisect the uterus in the sagittal plane before removing it, after the cervico-v.a.g.i.n.al attachments have been separated and the peritoneal pouches opened.

SECTION II

OPHTHALMIC OPERATIONS

BY

M. S. MAYOU, F.R.C.S. (Eng.)

a.s.sistant Surgeon, Central London Ophthalmic Hospital; Surgeon, The Children's Hospital, Paddington Green

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