CHAPTER XIV

OPERATIONS UPON THE VULVA AND VAGINA

OPERATIONS UPON BARTHOLIN’S GLANDS

The glands of Bartholin, or the vulvo-vaginal glands, are two racemose structures about the size of a pea, lodged between the layers of the triangular ligament, one on each side of the orifice of the vagina. Their ducts open a little in front of the fossa navicularis, on each side of the vaginal orifice, in the groove between the attached border of the hymen and the labium minus.

=Removal of a cyst of Bartholin’s gland.= These cysts really arise in the ducts rather than in the gland itself. The orifice of the main duct is very liable to become blocked from inflammation of the vulva, and leads to the formation of a single cyst varying in size from a cherry to an orange. Less common is the blocking of the secondary ducts, wherefrom a collection of small cysts results. The cyst forms a characteristic tense ovoid or pyriform swelling in the posterior third of the labium majus. The chief symptoms the patient complains of are discomfort in walking and pain on coitus.

=Operation.= The best procedure is complete excision of the cyst. A longitudinal incision is made over its cutaneous surface, and the cyst carefully dissected out, together with the gland itself: care must be taken not to perforate the vaginal mucous membrane stretched over the inner surface of the cyst. Brisk bleeding from vessels at the base of the cyst, usually follows from the cavity which contained the cyst and this must be carefully arrested, otherwise a large hæmatoma may result. The cavity is closed by five or six interrupted catgut sutures, passing deeply through its sides and floor, so as to ensure complete closure. A gauze drain may be inserted and retained for twenty-four hours.

The method of incising the cyst, swabbing its interior with undiluted carbolic acid, and packing it with gauze is not to be recommended, for cure is neither so rapid nor so certain as in excision.

=Incision of an abscess of Bartholin’s gland.= Abscesses arise by infection passing into the gland along the ducts, and are a very frequent accompaniment of gonorrhœa. The orifice of the duct can usually be seen red and prominent, and may exude pus if pressure be made over the abscess-sac. Sometimes the abscess bursts and spontaneous recovery may follow, but it is very liable to recur, for infection lurks among the smaller ducts and is carried to a fresh part of the gland, and the process may continue until the whole gland has been thus destroyed.

=Operation.= The abscess must be freely incised and all pockets and septa broken down. It is stuffed with iodoform gauze, which is changed daily, and the cavity is allowed to granulate up from the bottom. If the abscess recurs, or if it consists only of a small collection of pus surrounded by brawny œdema, the whole gland should be excised.

OPERATIONS FOR ATRESIA OF THE HYMEN AND THE VAGINA

Occlusion of the hymen is the commonest form observed. The vagina becomes slowly distended with blood, forming an elastic pelvic swelling (hæmato-colpos) upon which the uterus is, so to speak, perched. Later in the course of the disease, this organ itself (hæmato-metra) and the Fallopian tubes (hæmato-salpinx) may become affected similarly.

=Indications.= In atresia of the hymen symptoms only commence after puberty; there is then congenital amenorrhœa with periodic pelvic pain and gradual formation of a pelvic swelling. On inspection the hymen is distended and the blood-tumour above it gives a bluish tint to its surface.

=Operation.= After administration of an anæsthetic, careful palpation of the tubes should be made _per rectum_: if they are distended it is better to open the abdomen, ligature and remove them; if not, the hymen should be incised by means of a crucial opening and the characteristic tarry fluid allowed to escape: no hypogastric pressure should be used.

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 vagina 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 VULVAL 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 anæsthetic the vulval orifice should be thoroughly dilated by means of the thumbs, and for some days subsequently graduated Sims’s ‘vaginal 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 circumstances, 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.

COLPOTOMY OR VAGINAL CŒLIOTOMY

By colpotomy is meant making an opening into the peritoneal cavity through the vagina; 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 vagina is narrow, and easier in a multipara, where the vagina is more capacious, and it is still easier if the cervix can be drawn down as far as the vaginal 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 vagina.

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 vaginal 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.

Posterior colpotomy has been used for many years for the opening of abscesses and hæmatoceles 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 gynæcologists. 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 Péan’s retractor is passed into the vagina, and the cervix is seized with a volsella and drawn downwards and backwards. A sound passed into the bladder defines its lower limit. A T-shaped incision is now made through the vaginal mucous membrane, the transverse portion just below the point to which the bladder has been found to extend (Fig. 48, _b_). This incision should pass completely through the vaginal 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 vaginal 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 pushing up the vaginal 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 passed through, and the incision is extended on either side, care being taken not to pass too far outwards for fear of injuring the ureters or uterine vessels.

After the peritoneum has been opened, the pelvic organs can be carefully examined with the fingers, and the purposes for which the operation has been undertaken can be proceeded with. The next step usually consists in drawing out the fundus of the uterus, by which much more room and much better access to the pelvic organs is gained. To accomplish this, the uterus is caught with a volsella in the middle line, as high up as possible, and drawn downwards and forwards. If necessary, a second volsella is applied above the first, and so on, until the uterus is delivered. A very complete examination of the appendages can now be made, for the tubes and ovaries can be drawn out of the wound and examined directly.

When the object of the operation has been attained, and all the blood has been carefully removed by swabs, the next and final step consists in closing the peritoneal and vaginal wounds. The uterus is replaced, and the peritoneal incision is closed by a single layer of catgut sutures; the vaginal incision is similarly dealt with. The vagina is cleared from blood-clot and gently irrigated with an antiseptic solution. A gauze plug is inserted lightly, and the patient is put back to bed. The catheter should be used every six or eight hours for the first twenty-four hours.

=Posterior colpotomy.= A posterior speculum is passed and the cervix drawn downwards and slightly forwards with a volsella. A transverse incision is then made through the vaginal mucous membrane at the junction of the posterior fornix with the cervix. This exposes the peritoneum more or less easily, and this structure is picked up with catch-forceps, and a transverse incision made into it with scissors; a finger is passed through this, and the incision is extended on either side. The pelvic organs can now be explored and the tubes and ovaries drawn down and examined. The peritoneal and vaginal incisions are then closed by separate layers of catgut sutures.

_To open a collection of pus in Douglas’s pouch_, the best method is to pass a pair of sinus-forceps, with the blades closed, into the most prominent part of the swelling. The blades are then opened and the forceps withdrawn. The finger passed into the abscess cavity gently breaks down any adhesions. The cavity is then irrigated with hot salt solution and a drainage tube inserted, which projects just outside the vulva: the lower end of the tube should be carefully packed around with cyanide gauze. The tube should be changed every day and the vagina douched with an antiseptic. Another method is to plunge a Martin’s trochar (Fig. 49) into any softened spot in the swelling and then withdraw the needle, leaving a blunt dilating forceps to extend the opening.

In opening an abscess, the most stringent precautions against sepsis should be observed. The vagina must be most carefully prepared beforehand, by rubbing over with swabs and ethereal soap, and by a subsequent copious douche of 1 in 1,000 perchloride of mercury: otherwise continual reinfection of the abscess cavity occurs, and healing is much delayed.

=Lateral colpotomy--Paravaginal section.=

=Indications.= The object of the operation is to increase the amount of room in the vagina in certain cases of vaginal hysterectomy in elderly virgins, or in women who have a small vagina.

=Operation.= The same preliminaries are carried out as before. The incision is carried completely round the cervix at its junction with the vagina. The lateral margin of the vulva is then held tense, and an incision is made, beginning at the circumcervical incision running down the lateral vaginal wall, through the margin of the vulva and on to the skin externally, ending at a point midway between the perineum and the ischial tuberosity, _i.e._ about 1-1/2 inches to the side, and in front of the perineum; the incision may be lateral only or bilateral. In sewing up, it is important to reunite the cut edges of the levator ani, or pelvic weakness will result.