CHAPTER XLIII.

Fig. 213.—Supra-vaginal amputation of the uterus, first step: ligatures have been placed on the ovarian arteries and the round ligament.

The infundibulo-pelvic ligament immediately outside of the abdominal ostium of the tube, the round ligament between the ligature and the cornu, and the broad ligament as far as the uterus should then be divided with scissors on each side.

The uterus is thus freed from all its attachments downto a point somewhat above the level of the internal os. The vessels that remain to be secured are the uterine arteries.

The peritoneum is next divided by a transverse incision across the anterior face of the uterus, immediately below the line of reflection of the peritoneum from the uterus to the bladder. This incision should join at each end the incisions that had been previously made in dividing the broad ligaments.

Fig. 214.—Supra-vaginal amputation of the uterus, second step: the broad ligaments have been divided down to the level of the internal os uteri.

The bladder should then be dissected from the anterior face of the uterus and cervix, down to the vaginal junction.

The bladder is but loosely attached to the uterus, and may be readily pushed off with the finger or with closed scissors. The finger pressed out to a short distance on each side of the cervix will push away the anterior layer of the broad ligament with the bladder, so that the uterus is perfectly free in front.

Fig. 215.—Supra-vaginal amputation of the uterus, third step: the peritoneum has been incised across the anterior face of the uterus; the bladder has been dissected from the cervix; the bases of the broad ligaments have been opened; the uterine arteries have been secured by ligatures placed between the ureters and the cervix.

The posterior layer of the broad ligament and the cellular tissue may then be divided, with scissors, along the side of the uterus down to a point somewhat below the level of the internal os. This incision should not be made too close to the uterus, or the uterine artery that runs up along side of the uterus and cervix may be divided. The operator should place one or two fingers upon the posterior aspect of the broad ligament, immediately beside the cervix, and while the uterus is drawn upward should pass a heavy ligature beneath the tissue that includes the uterine artery. The pulsation of the uterine artery may usually be felt by the finger placed behind the broad ligament. This ligature includes the cellular tissue at the base of the broad ligament, the uterine artery, and part of the posterior peritoneal layer of the broad ligament. It does not pass through the anteriorperitoneal layer of the broad ligament, which had been previously dissected away. The ligature should be placed as closely as possible to the cervix without including cervical tissue. It should be remembered that the ureter lies about half an inch from the side of the normal cervix and at the level of the external os. The ureter is usually more remote than this when the ligature is passed, because the uterus is drawn upward and the ureter is pushed aside by the fingers at the side of the cervix.

The uterine artery should be secured in a similar way upon the opposite side.

The bases of the broad ligaments should then be divided with scissors between the cervix and the ligatures of the uterine arteries. To prevent slipping of the ligature, ample tissue should be left between the incision and the ligature. As the cervix is not malignant, the incision may be made as close to this structure as necessary.

Fig. 216.—Supra-vaginal amputation of the uterus, fourth step: the uterus has been amputated below the level of the internal os; sutures have been introduced to close the stump of the cervix.

The uterus should then be amputated by a wedge-shaped incision through the cervix, making an anterior and a posterior flap.

When the cervical canal is opened, it may be immediately sterilized with a solution of bichloride of mercury (1:500).

As the uterus is cut away the flaps of the cervix are secured with forceps. The cervical stump is usually white and dry.

The flaps of the cervix should next be united by interrupted silk suture. Care should be taken to avoid passing a suture through the cervical canal, as it might become infected.

Fig. 217.—Supra-vaginal amputation of the uterus, completed operation: the anterior and posterior peritoneal layers of the broad ligament have been united by sutures; the peritoneal covering of the bladder has been drawn over and sutured to the posterior aspect of the stump of the cervix.

The anterior peritoneal layer of the broad ligament and the peritoneal reflection from the bladder are then drawn over the field of operation and secured by fine silk sutures to the posterior peritoneal layer and the posterior aspect of the cervix. The stump of the cervix, the stump of the uterine arteries, and the cellular tissue of the broad ligaments are thus covered by peritoneum. The only raw surfaces exposed are the stumps of the ovarian arteries and of the round ligaments. These surfaces may also be covered if the operator so desires.

Preservation of the Ovaries in Hysterectomy.—Many surgeons consider it advisable to leave the ovaries in hysterectomy for fibroid tumor of the uterus in case these organs are not diseased. If the woman has not yet reached the menopause the disagreeable symptoms of the artificially induced menopause are thus avoided, and any metabolic function that the ovaries may possess is preserved. In hysterectomy for fibroid in women under forty years of age with healthy ovaries it is advisable to leave these organs if this can be done without seriously complicating the operation.

The ovarian artery should be ligated between the ovary and the uterus and the broad ligament should be divided inside of this ligature. The tubes may be left if they can not readily be removed.

Complete Abdominal Hysterectomy.—In this operation the uterus is removed at the vaginal junction. The operation is absolutely necessary in cases of malignant disease of the body and neck of the uterus. It is not often necessary in the treatment of the other conditions for which hysterectomy is performed. The operation requires a longer time than the operation of partial hysterectomy; it is often accompanied by profuse bleeding from the edge of the divided vagina; there is more danger of injury to the ureters, and there is more danger of septic infection, because the vagina is opened; and, finally, the operation very considerably shortens the vaginal canal.

The first steps in the operation of complete hysterectomy are the same as those in partial hysterectomy. In the case of malignant disease of the cervix the ligatures on the uterine arteries should be placed as far from the cervix as possible without including the ureters.

Some surgeons advise the preliminary introduction of bougies into the ureters in order to locate these structures and thus prevent injury to them. If the operator is sure of the position of the ureter he may ligate the uterine artery upon the outer side of the ureter, and carry theincision through structures well outside of the diseased cervix.

After the vessels have been secured and the bladder has been separated from the uterus and the upper part of the vagina, and the broad ligaments have been divided down to the vagina, a transverse incision is made with the knife or scissors into the anterior vaginal fornix. The position of the anterior vaginal fornix may be determined by palpation and percussion. A drum-like sound is obtained by snapping the finger upon the tense vaginal wall.

With the finger in the opening in the anterior vaginal fornix as a guide, the incision is continued around the sides and posterior wall of the vagina. The edge of the vagina is secured by forceps, and bleeding vessels in the walls are ligated. When hemostasis is complete the vagina is closed by sutures that pass through the outer portions of the walls, but do not enter the vaginal canal. The peritoneum is then drawn over the field of operation and the abdomen is closed. If hemostasis is not perfect, gauze drainage through the vagina or the abdominal incision must be employed.

Some operators do not ligate the uterine arteries until the vagina has been opened. The ovarian arteries are secured, the bladder is separated from the uterus and the upper part of the vagina, and the broad ligaments are divided down to a point somewhat below the level of the internal os.

The anterior vaginal fornix is then opened, and the incision is carried around toward the lateral fornices as far as may be done without injury to the uterine arteries. The uterus is then drawn forward and the posterior vaginal fornix is opened, the finger introduced through the opening into the anterior fornix acting as a guide.

The uterus is now attached to the body only by two lateral bands of tissue that include the cellular tissue at the base of the broad ligament, the uterine artery, and a strip of vaginal mucous membrane over the lateral vaginalfornix. This band of tissue, exclusive of the vaginal mucous membrane, is then secured by a ligature that does not enter the vagina, but passes immediately above the strip of vaginal mucous membrane. A finger introduced into the vagina serves to guide the ligature-needle. The uterus may then be cut away.

The ligatures of the uterine arteries are sometimes left long, the ends being carried down into the vagina and a gauze drain being introduced into the vagina, the upper portion of the drain reaching just above the level of the stump of the uterine arteries.

The peritoneum may be left open, or it may be drawn over the drain and the field of operation as already described.

Drainage through the vagina in this way is advisable if the hemostasis be not perfect and if the operator fears septic infection.

In hysterectomy for cancer of the cervix it is usually advisable to remove as much as possible of the cancerous mass by a preliminary operation two or three days beforehand. The diseased tissues should be cut away with the knife, scissors, and the sharp curette, the cavity seared with the thermo-cautery, and closed by approximation of the edges with a few silk sutures. The dangers of septic infection and of transplantation of cancer-cells during the hysterectomy are thus diminished.

The surgeon should always keep in mind the possibility of the transplantation of cancer-cells from diseased into healthy tissues. It seems very probable that some cases of recurrence have been due to this cause. During hysterectomy the operator should therefore avoid, as much as possible, cutting into or manipulating the cancer mass. Instruments, such as hemostatic forceps and volsella forceps, which have grasped diseased tissue, should not be used upon healthy tissue without previous sterilization; and sponges and pads which have been in contact with the cancerous tissue should be discarded.

The methods of operating just described, modified tomeet special indications, are applicable to all cases in which hysterectomy is required.

Sometimes, in cases of fibroid tumor, the broad ligament is very much hypertrophied and contains enormous veins, and additional ligatures besides those on the ovarian and uterine arteries are required. It is often necessary to place a large number of forceps upon bleeding vessels on the surface of the tumor as it is cut away from the broad ligament.

The anatomical relations are often very much disturbed, and it may be impossible to determine the position of the cervix and the uterine arteries until the greater part of the tumor has been freed from its connections. Sometimes the tumor so fills the pelvis that it is impossible to ligate, at first, both ovarian arteries. The operator must first attack the more accessible side, ligate the ovarian artery, cut away the broad ligament, strip off the bladder, ligate the uterine artery, and perhaps divide the cervix, before he proceeds to the other side. Bleeding from the tumor must be controlled by the careful application of forceps or ligatures. An inaccessible uterine artery is sometimes most readily reached in this way from below, after the attachments upon the opposite side have been divided and the cervix has been amputated. Some operators perform hysterectomy in all cases by ligating and cutting away from above downward on one side—the more accessible—then cutting across the cervix, and ligating and cutting away on the opposite side from below upward.

The difficulties are greatest in the case of intra-ligamentous fibroids. Such operations are among the most difficult in surgery. The directions given for the treatment of intra-ligamentous cysts are applicable also to this condition. The surgeon should always at first secure the ovarian arteries if possible. He should then incise the peritoneal investment across the anterior or posterior face of the tumor.

Enormous veins often lie immediately beneath the peritoneum, and care must be taken to avoid injuring them.

The peritoneum should be stripped off with the fingers or with blunt scissors. Bleeding vessels are secured with forceps as they appear. No attaching structures should be divided until they have been carefully examined, for all anatomical relations are distorted by these growths. The ureter may pass over the top of the tumor, far removed from its normal position on the pelvic floor.

After the surgeon has started the enucleation of a tumor of this kind he must complete the operation. Bleeding cannot be arrested until the tumor has been enucleated, the cervix exposed, and the uterine arteries secured.

The operation is often accompanied by very profuse hemorrhage, but this hemorrhage is always arrested by the ligature of the ovarian and uterine arteries, which alone supply the growth. The surgeon should therefore not delay the operation by the ligature of separate bleeding points until the main vessels have been secured.

Vaginal Hysterectomy.—Vaginal hysterectomy may be performed for the relief of any condition in which the uterus or attached tumor is sufficiently small to pass through the vagina. The operation is very popular with some surgeons. It is but rarely used by the writer. The difficulty in dealing with adhesions and other complications in the upper part of the pelvis seems to be much less when the operation is performed through an abdominal incision.

Fig. 218.—Lateral vaginal retractor.]

The technique of vaginal hysterectomy varies considerably in the hands of different operators. The vaginal vault is opened with the knife, the scissors, or the cautery. The vessels of the broad ligament are secured with the ligature or with the clamp. The uterus is sometimes divided by longitudinal incision and the halves are separately removed.

Fig. 219.—Vaginal hysterectomy with clamps: first step (Baldy).

The following are the general directions for the performance of the operation:

The woman is placed in the lithotomy position. The vagina is opened with the Sims speculum and with lateral vaginal retractors (Fig. 218).

If the cervix is septic, it is thoroughly curetted, sterilizedwith the cautery or by other means, and the sides of the excavation are united by suture.

The cervix is seized by tenaculum forceps and dragged downward and forward.

A transverse incision with knife, scissors, or cautery is made in the posterior vaginal fornix, and Douglas’s pouch is opened.

Fig. 220.—Vaginal hysterectomy with clamps: second step (Baldy).

A sponge is introduced into the peritoneum behind the uterus.

Some operators suture the posterior peritoneal layer of Douglas’s pouch to the posterior vaginal wall, to control bleeding and to prevent stripping of the peritoneum.

The cervix is now dragged backward and a transverse incision is made across the anterior vaginal fornix.

The bladder is carefully dissected from the anterior face of the cervix with the knife, scissors, and finger, and the utero-vesical fold of peritoneum is opened. The peritoneum and the anterior vaginal wall may here also be united by suture.

Fig. 221.—Vaginal hysterectomy with clamps: third and final step (Baldy).

An incision may then be made through the vaginal mucous membrane of the lateral fornices, uniting the anterior and posterior incisions.

With a finger in Douglas’s pouch as a guide, the broad ligaments are then secured in successive portions by ligature or by strong clamp forceps, and the uterus is cut away with the scissors as the ligatures or clamps are placed.

As the upper portion of the broad ligaments is reached the procedure may be facilitated by retroverting or anteverting the uterus, the fundus being dragged through the posterior or the anterior incisions in the vaginal vault.

The tubes and ovaries should be removed when possible, especially in the case of malignant disease.

After the uterus has been removed the vagina may be packed with a gauze drain that reaches upward between the stumps of the uterine arteries; or, if ligatures have been used, the vaginal vault may be closed. The former procedure is the safer. When the gauze drain is used, it is advisable to leave the ends of the ligatures on the uterine arteries long and protruding into the vagina. The ligatures usually become infected, and their removal is facilitated by this procedure. If clamps are used, they should be removed in forty-eight hours.

The treatment after vaginal hysterectomy is the same as that already described after celiotomy.

Combined Vaginal and Abdominal Hysterectomy.—A combined vaginal and abdominal operation is sometimes performed in order to enable the surgeon to deal with adhesions and other complications in the upper part of the pelvis.

The operation is usually begun below. The vaginal connections and the bladder are separated from the uterus, and the bases of the broad ligaments are secured with the ligature or the clamp; the cervix is freed from its attachments to the broad ligament.

The abdomen is then opened and the operation is finished from above, the uterus being removed through the abdominal incision.

The writer performs the combined operation in the reverse order, as follows:

The abdomen is first opened. The ovarian arteries and the round ligaments are secured by ligature. The bladder is separated from the uterus and the upper part of the vagina. The broad ligaments are divided to a point somewhat below the level of the internal os.

A gauze pad is then introduced to the bottom of Douglas’s pouch, and another to the bottom of the space between the uterus and the bladder. The abdominal incision is then closed.

The rest of the operation is performed through the vagina. The posterior and anterior vaginal fornices are opened by incisions made directly upon the gauze pads. The vaginal mucous membrane is divided over the vaginal fornices by an incision that joins the anterior and posterior incisions in the vaginal vault. The bases of the broad ligaments are secured by strong clamp-forceps, and the uterus is cut away and removed through the vagina. The gauze pads are then removed, and the vagina is drained with gauze introduced as far as the upper end of the forceps.

The following are the advantages of the latter method of operating:

If sterilization of the vagina and the cervix is not perfect, the cleaner part of the operation is performed first. The bladder is more easily separated from the uterus by operating from above than by way of the vagina. The vaginal vault is quickly and safely opened by incisions made upon the gauze pads, which keep the intestines out of the way.

The uterus and the infected cervix are removed through the vagina, and not through the abdominal cavity.

If the operation is performed for cancer of the cervix, the incision is made more accurately beyond the limits of the disease if the vaginal vault is opened through the vagina than if it is opened from above.

Werder, of Pittsburg, has advised the following combined operation: The abdomen is opened, and the uterus, tubes, and ovaries are freed as in ordinary hysterectomy. The ureters are dissected out, and the uterine arteries are ligated near their origin. The bladder is entirely freed from the uterus, and also, for a considerable distance, from the vagina. The recto-vaginal space is then opened, and the posterior vaginal wall is strippedfrom the rectum as far down as necessary. The lateral vaginal attachments are loosened. The uterus and vagina are then pushed down into the pelvic outlet, and the peritoneum from the anterior pelvic wall is united with that covering the rectum, thus shutting off the pelvis from the general peritoneal cavity and covering all raw surfaces with peritoneum. The abdomen is then closed.

The patient is then placed in the lithotomy position. The uterus—which is found protruding at the vulva—is seized with volsella forceps and drawn completely out of the vulvar orifice with the inverted vagina. With the finger in the rectum and the sound in the bladder as safeguards against injuring these organs, the inverted vagina is amputated with the knife or the thermo-cautery. The chief advantage of this operation is that a large vaginal cuff may be removed.

Abdominal Myomectomy.—In some cases of uterine fibroid it is proper to remove the tumor without taking away the uterus. This operation—myomectomy—is performed as follows:

The abdomen is opened by a free incision, the pelvis is elevated, and the intestines are displaced from the pelvic cavity in the usual manner. The tumor and the uterus are surrounded by gauze sponges, and, where possible, should be brought outside the abdominal cavity. An incision is made around the pedicle or through the capsule of the tumor, and it is enucleated by dissection with the sharp or the blunt end of the scalpel. During the operation hemorrhage may be controlled by an assistant, who compresses with his fingers the vessels on each side of the uterus, or by placing a temporary rubber ligature about the cervix uteri.

Hemostasis is effected and the wound in the uterus is closed by layers of continuous or interrupted catgut sutures. Great care should be taken to prevent hemorrhage between the layers of suture, and to insure accurate closure of the incision in the uterus. The temporaryligature about the cervix, or the compression of the vessels of the broad ligaments, should be removed from time to time during the process of suturing and after closure of the uterine wound, in order to determine the position of bleeding points and the efficiency of the hemostasis; and before closing the abdominal incision the uterine wound should be inspected for several minutes while the woman is in the horizontal position.

The abdomen may usually be closed without drainage.

Removal of the tube and ovary upon one side has no effect upon menstruation or upon any of the other characteristics of the woman.

Removal of the tubes and ovaries upon both sides is followed within forty-eight hours by slight bleeding from the uterus, lasting for one or two days.

If the removal of the tubes and ovaries has been complete, menstruation, in the majority of cases, never reappears.

In a few cases menstruation appears for one, two, or three periods after the operation, usually in diminished amount, and then ceases for ever. In some other cases there is a period of a few months of amenorrhea, followed by two or three scanty menstrual flows, before the bleeding permanently ceases.

These phenomena, it will be observed, are similar to those of the normal menopause.

The woman after double salpingo-oöphorectomy experiences the nervous and gastro-intestinal disturbances that so usually accompany the menopause. She, in fact, passes through a premature menopause, the phenomena of which may persist for one or two years.

The secondary sexual characteristics of the woman—the voice, the figure, and the growth of hair—are not altered if the appendages are removed during adult life. The case may be different if the appendages are removed in the undeveloped girl, in whom the ovarian influence is essential for complete development.

The woman loses none of her feminine attractions.She may, indeed, become better-looking if the operation has relieved chronic suffering. It is said that Gyges, king of Lydia, caused the removal of ovaries from women with a view to prolonging their charms.

Double oöphorectomy may be followed by obesity if the woman have a tendency to form fat. The relief of suffering and the consequent improved nutrition favor the development of obesity. There seems to be nothing inherent in the operation to cause it. Many women remain thin after the operation.

The emotions of the woman are unaltered by double oöphorectomy, with the exception of some cases in which the sexual desire is destroyed. Sexual desire is dependent upon such a variety of conditions, both within and without the woman, that it is difficult to determine the amount of influence that removal of the ovaries exerts upon this feeling.

It is undoubtedly true that sexual desire is sometimes destroyed by the operation. On the other hand, the sexual desire is very often restored by the operation, which relieves the former dyspareunia, or painful coitus.

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