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 vaginal hysterectomy (see p. 168), while the latter should be dealt with according to their relations and attachments to the uterine wall.

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 (interstitial).

=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 écraseur 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).

The cervix is steadied with a volsella and the loop of the écraseur is shaped and bent to the size and position of the fibroid. The instrument is then passed 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 passed 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 hæmorrhage 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 interstitial tumours.= Interstitial fibroid tumours, if not above the size of a small fœtal head, should be treated by vaginal hysterectomy (_vide infra_); if large, by hysterectomy by the abdominal route (see p. 36).

=Vaginal hysterectomy.= By vaginal hysterectomy is meant removal of the whole uterus by the vagina, with or without the appendages. The advantages that the vaginal 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 fœtus.

=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 hæmorrhage, usually due to uterine myo-fibrosis, and, as a last resort, severe dysmenorrhœa.

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 vaginal walls and the intestines (enterocele).

=Vaginal 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 vaginal walls should be present. It cannot be too strongly insisted that all cases should be thoroughly examined under anæsthesia 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 mass 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 vaginal douches of formalin (ʒj 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 vagina, pushing 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 vaginal flaps thus left.

First of all, the growth, if of the cervix, should receive careful preliminary attention, for it constitutes 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, passing 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 passed, 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 passed into the bladder to define its lower limit. A transverse or T-shaped incision (Fig. 48) is now made through the vagina at the level of the cervico-vaginal junction in front. This constitutes the anterior incision, and the transverse portion should extend completely across the anterior aspect of the cervix, passing through the whole thickness of the vagina, but no further.

The knife is now laid aside, and the operator proceeds to push up the vagina 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 vaginal 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 vaginal 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 passed to keep the bladder out of the way.

A second incision similar to the first is now made across the posterior aspect of the cervix at the level of the cervico-vaginal 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 vagina.

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 assistant, so as to expose the base of the left broad ligament. Additional space is gained by drawing aside the left wall of the vagina by means of a retractor. By passing 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 passed through the ligament from before backwards, on to the tip of the finger (Fig. 71).

The ligature should be passed 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 passed as near the cervix as possible compatible with being clear of the disease.

A second ligature is now passed 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.

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 vagina (Fig. 72). The anterior and posterior flaps of peritoneum are united with a few catgut sutures passed by means of Schauta’s needle-holder (Fig. 73); the walls of the vaginal vault are treated in a similar fashion, 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 hæmostatic 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 hæmorrhage 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 labia; 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 vaginal douching should be administered until after the expiration of a week.

=Vaginal hysterectomy for fibroids.= This is not often called for. The operation is necessarily limited to fibroid uteri not exceeding in size a fœtal 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 vagina. The operation is most suitable for uteri containing many small fibroids causing severe hæmorrhage which cannot be controlled by more palliative measures.

The vagina must be large enough to admit of delivery of the uterus through its lumen. Therefore, in virgins and nulliparæ, the abdominal operation is always to be preferred. In any case, if the vagina be too narrow, additional room may be gained by lateral vaginal 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-vaginal attachments have been separated and the peritoneal pouches opened.

SECTION II

OPHTHALMIC OPERATIONS

BY

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

Assistant Surgeon, Central London Ophthalmic Hospital; Surgeon, The Children’s Hospital, Paddington Green