A System of Operative Surgery, Volume IV (of 4)

ied to the surgical operation

for injury, and certain morbid states due to acute and chronic sepsis; and for a condition but little understood, termed generically fibrosis. Hysterectomy is also carried out for

n cause for which hysterectomy is required, and t

on in the belly-wall; this is termed abdominal hysterectomy. In the other, the whole uterus is extir

removing the uterus may

body of the uterus and the whole of its neck are excised: this is total hysterectomy (or panhysterectomy). The ovaries and Fallopian tubes may, or may not

of abdominal hysterectomy the Tre

L HYSTE

by a small incision. As soon as the peritoneal cavity is reached, the surgeon introduces his hand and carefully makes out the nature of the case, the presence or otherwise of adhesions, other tumours, and the relation of the fibroid to the uter

show the Arterial S

ith the same forceps, but in many cases it is necessary to clip it separately. It is an advantage to secure the round ligament at this stage, for the forceps controls its artery and prevents the stump of the ligament unduly retracting the peritoneum. The broad and round ligament on each side are divided, and the uterine artery is exposed on each side of the uterus and caught with forceps: a peritoneal flap is then fashioned on the anterior w

on with the deep epigastric artery. If the surgeon thoroughly appreciates the distribution of the ovarian and uterine vessels he will at once perceive that if the four forceps are properly applied to the vessels the blood-supply is under absolute control: indeed, in many cases a subtotal hysterectomy can be performed without the loss of more than an ounce of blood. When the broad ligament is clamped and detached there is a spurt of blood from the uterine cornu which lasts until the corresponding uterine artery is caught with the forceps, and the cessation of the bleeding at the uterine cornu is a sign that the artery is securely clipped.

It separates the ovarian ligament, Fallopian tube, and

nu will grow in such a manner that it widely separates the ovarian ligament, the Fallopian tube, and the round ligament from each other as shown in Fig. 10. In such a condition it is impossible to save the ovary without risk, and also inadvisable

septic or cancerous both ovaries and tubes should be removed. When the surgeon decides to leave an ovary and its corresponding Fallopian tube, he should take care in securing the ligatures to include the ligament o

of suture is so useful that the mode of inserting it may be given in more detail. In the diagram (Fig. 11) the silk is represented in position before it is tied, and in that particular instance it is represented as being passed through the peritoneal flaps from before backwards, and this is usually the most convenient route; occasion

ture. A diagram to show

Hysterectomy. To show the method

hen the flaps are brought together by one or two interrupted sutures, and the edges more carefully approximated by a continuous suture of thin silk. In suturing the flaps it is necessary to avoid puncturing the bladder, which is quite close to, and often f

cting stump on the floor of the pelvis; the sutured edges of the pe

ts are counted, and it is also useful to examine the condition of t

is then sutured in th

HYSTER

well out of the abdomen and the bladder peeled off its anterior aspect. The surgeon then feels for the extremity of the cervix and opens the vagina with the scalpel and carefully detaches it from the neck of the uterus, taking great care to keep close to the cervix in order to avoid wounding the bladder or the ureters. As soon as the uterus is detached, the

inal arteries is invaded, and these vessels are apt to bleed when the patient is returned to bed, unless care is taken to secure them in the course of the operation. The parts which require most attention are the lateral angles in the immediate neighbourhood of the uterine arteries; these angles may be secured by a mattress suture involving the anterior and posterior wall of the vagina; any oozing on the anter

are ligatured, the cut edges of the vagina are secured in the following way: the cut edge of the peritoneum covering the bladder is stitched to the cut edge of the anterior wall of the vagina, and in the same way the peritoneum in relation with the posterior vaginal wall is

d, and the wound sutured as recommended on p. 9. In septic conditions the abdominal incision should be closed with a single row of through and through sutures. Before the patient leaves the operating table it is usef

nditions it is easy to apply a pair of fenestrated forceps to the oozing area and leave them on for thirty-six hours. They will cause the patient t

sily and safely controlled by applying a pair of fenestrated forceps on each side of the cervix,

cornu contains a fibroid. Removed from a spinster aged 32 on account of acu

n connexion with uterine fibroids are occasionally very formidable, and tax the skill and resource of the boldest; e.g. fibroids which are inflamed and adherent to the colon, rectum, or small intestines; fibroids associated with unilateral or bilateral pyosalpinx, or a suppurati

riety needs separate consideration because these tu

ur is wide and so fixed in the pelvis that it will be necessary to split the uterus longitudinally and to enucleate the fibroid from its bed; then an ordinary subtotal or total hysterectomy can be carried out.

livery. The pregnancy occurred in the left h

hape (Fig. 13). When the body of the uterus is double (bicornate) and the surgeon stumbles upon it in the course of a pe

with the peritoneum covering the posterior surface of the bladder (Fig. 14). That portion of the vesico-rectal ligament which lies between the rectum and the neck of the uterus divides the recto-vaginal fossa into a right and a left half. This peritoneal ligam

some, and when the uterus was removed it seemed as if the floor of the pelvis had been stripped of its serous covering. The bifid nature of the uterus had be

ence of the vesico-rectal ligament would probably bar the removal of the uterus by the vaginal route. The ex

has taken place in the operation of abdominal hysterectomy for fibr

terectomy for fibroids in the hospitals of Lo

omew's 7 wi

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pital for W

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ew Hospital for Women the re

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tion. The cavity is dilated and occupied by a villous tumour growing from i

ex Hospital, as verified by the Registrars, were 101 abdominal hysterectomies for fibroids; all th

cial dangers, such as h?morrhage; injury to the vesical segments of the ureters, and especially the bladder; injury to the intestines, especially the rectum; acute intestinal obstruction

rhage, lobar pneumonia, thrombosis of the right auricle, embolism of the femoral artery ending in gangrene of the leg, suppression of urin

safe that even in advanced age it has been empl

rectomy was performed on Wome

ure of Operation.

r Fibroid 28 lb. R. Trans.

for Fibroid 19 lb. R. Aust

Villous disease. Fig. 15. R. Tra

broids. R. Brit. Med. J

NAL MY

, through an abdominal incision, not only of pedunculated subserous fibro

ly advocated by A. Martin (1880) and Schroeder (1893). The operation has been practised by many surgeons and gyn?cologists imbued with conservative ideals in regard to the uterus.

TOMY AND ENUCLEA

edunculated subserous fibroids through an incision in the abdomin

ssile fibroid is shelled out of its capsule:

oid is removed, through an incision in the wall

dures is the same as for ovariotomy, and the

es are carefully protected by a warm d

be shelled out of its capsule, and any obvious blood-vessel is easily secured with forceps and ligatured with silk. The opposite flaps of the capsule are brought int

it shells out quite easily. This is followed by free bleeding. The vessels are then seized with forceps and ligatured with thin silk. In order to comp

fibroids, and each must be enucleated and the ca

sutures the edges of the capsule to the lower angle of the i

, the surgeon necessarily opens the uterine cavity (hysterotomy). After controllin

ut myomectomy or enucleation, he has such difficulty in co

ideal operation of removing the tumours and leaving the uterus and ovaries intact can only be carried out in a small proportion of cases, probably in less than 10 per cent., and it is fair

myomectomy or enucleation in a woman in the reproductive period of life we cannot give her this assurance, for she may

which myomectomy and enucleati

ingle and admits of myomectomy or enucleation, may have her uterus spared. Although I have carried ou

ly in pregnan

s trouble by twisting its pedicle, or by shrinking to such a size that it falls into the true pelvis and becom

five consecutive cases of myomectomy and enucleation out of my practice, with the subs

in the fourth week after operation, and one a few days after operation: in this case there

days before I recognized that 'red degeneration' of fibroids complicating pregnancy caused them to be painful and tender (see p. 78). In one patient this complication was clearly recognized. In the sixth patient the tumour was regar

ds were subserous. I have not known a patient to become pregnant after abdominal myomectomy for a submucous fibroid, large or small.

-bearing period of life and marr

probably capable of bearing chil

were spinsters

hysterectomy became a necessity on account of menorrhagia in seven of them; of these, two died from the operation, which was difficult a

id had been enucleated from the cavity of the uterus (hysterotomy), died

indicates that the chief objection to the abdominal e

lity of 10.5 per cent. Olshausen, in the years 1900–5, performed enucleation on 124 patients with 14 deaths. Eight of the patients sub

licate pregnancy and labour, or give trouble a

ysterectomy performed for

n a Unicorn Uterus. Clin. J

ves of a Bicornate Uterus. Proc. R. Soc. of M

nicollis, &c. Centralbl. f.

om a Uterus Unicornis in a Parous Sub

yoma with Double Uterus. Trans. Obst

aren Uterus bicornis unicollis. Monatschr.

in the Left Horn; Subtotal Extirpation of the

he Dangers and Treatment of Myoma of

dbuch der Gyn?kologie, Wies

erus. Trans. Obstet. Soc., 1888, x