A METHOD
OF COVERING BY
GEORGE
GELLHORX,
RAW
SCR,FXCE~
M.D.,
F.A.C.S.,
UPoN ST.
THE
LOUIS,
c’lJERe’S*
&IO.
T IS a surgical axiom that raw surfaces within the abdominal cavity should be covered with intact peritoneum. This, in many instances, is a comparatively easy procedure where only small parts of the intestine have become denuded. When more extensive portions of the intestinal tract are involved as in the removal of large and widely adherent ovarian tumors or fibroids, the prevailing custom is to leave these areas of denudation to themselves. It is not only impractical to stitch over the affected field in its entirety, but actual observation has proved abundantly that adhesions between intestinal loops do not oft.en affect the well being of the patient.s. as soon, however, as intestines or omentum become adherent to the uterus a train of unpleasant symptoms inevitably ensues. A pulling sensation in the upper part of the abdomen, gastrointestinal disturbances of various degrees, and more or less ill-defined pains occur, and even transitory ileus-like phenomena are not uncommon. On the part of the uterus, the abnormal attachment of loops of intestine with a varying amount’ of distention leads to decreased mobility of this organ and, in its further development, to menstrual disturbances. The continuous pull exerted by the structures above and behind may eventually force the uterus backward and may, in some cases, even undo the result of a previous antefixation operation. I
Here, then, is the problem that confronts us. We have, for example, decided on a Gilliam operation or one of its numerous modifications or substitutes in a case of fixed retroflexion. We have broken the adhesions that held the uterus to the depth of the culdesac or the rectum. We have shortened the round ligaments and now behold the uterus lying in normal position but with a more or less extensive area of denudation upon its fundus which invites the speedy formation of new adhesions. Or take, as a second possibility, the case of an inflammatory process in one of the tubes, which is rarely confined to the affected side but implicates the uterus as well. Shall we remove the diseased tube and ovary and close the abdomen without an attempt to peritonealize the raw fundus? Where a bilateral pyosalpinx of gonorrhea1 origin demands the extirpation of both tubes, my personal choice is a panhysterectomy, after which the covering of the entire field of operation with intact peritoneum is an easy matter. I am aware, however, that such radicalism, despite its well-established advantages, has not yet become a general practice and the question is still before us, how to protect the uterus from further harm, uselessthough it is as an organ after a double salpingectomy. It is evident that these two categories of fixed retroflexion and of adnexal disease constitute a not inconsiderable percentage of our gynecologic 36,
*Read 1920.
at the
Forty-fifth
Annual
Meeting
of
the 263
American
Gynecological
Society,
Chicago,
Xay
Z+
GELLHORX
:
COVERING
RAW
SURFACES
UPON
263
UTERUS
operations so that a method of covering the denuded uterus with intact peritoneum may lay claim to practical importance. The very sporadic efforts The Cargile that have been made in the past have been rather discouraging. membrane of R. T. Morris has never become popular, and the grafting of pieces of omentum first introduced into surgery by Senn, has been largely disappointing. Yet, the difficulty is easily solved by a procedure, the various steps of which are as follows: The fundus is grasped by a volsellum and pulled backward and upward The reflection of the bladder peritoneum in the direction of the promontory. upon the cervix, which now becomes plainly visible, is incised transversely as in a hysterectomy and pushed off from the uterus (Fig. 1). If this blunt dissection with the finger is gentle enough and does not extend into the
Fig.
l.-The
bladder
peritoneum has been the fundus. Note
pushed off the cervix and is held ready the bladder in the depth of the wound.
to be reflected
across
broad ligaments, the -bleeding is usually insignificant and is quickly checked by the pressure of a sponge. The uterus is then tilted forward, the bladder peritoneum is pulled over the uterus and stitched to the posterior aspect of the fundus where an intact peritoneal surface presents itself (Fig. 2). In small uteri, the bladder peritoneum may be fastened as far back as the insertion of the sacrouterine ligaments, if necessary. After the first few turns of this continuous catgut stitch, the volsellum is removed and the stitching is continued until the entire fundus with its denuded area has disappeared beneath its new peritoneal covering. By using an inverting stitch, even the catgut knots become invisible. The newly formed covering consists only of the bladder peritoneum which in many cases, is so thin and transparent that the raw uterine surface and even the volsellum holes may be distinguished.
264
THE
AXERICAN
JOURNAL
OF
OBSTETRICS
AND
GYKECOLOGY
The method just outlined not only supplies the raw fundus with a new serous coat, but it also safeguards a normal position and mobility of the uterus, and the late results have remained most satisfactory. It is, however, not to be relied upon in a case of fixed retroflexion. In such a case the order of the operative steps is this, viz., first, loosening of the bladder peri-
Fig.
2 -The
apron
of bladder
peritoneum
is being
stitched
to the
posterior
aspect
of
the
fundus.
toneum as described above; second, shortening of the round ligaments; third, fastening of the bladder peritoneum to the back of the uterus beyond the area *, of denudation. I anticipate two pertinent questions: “Is the function of the bladder disturbed after this procedure 7” and, “What happens to the bladder in a In the six or seven years that I have employed subsequent pregnancy?”
Fig.
3.--A
diagrammatic
view of unchanged.
the postopsrative conditions shows Hence no probability of vesical
the relation disturbances.
of
bladder
and
uterus
the method, I have feeder observed instances of vesical disturbance other than those that may follow any laparotomy. A moment’s visualizat.ion of the condition created will supply the theoretical explanation of the absence of postoperative complications. The relations of the bladder and uterus are
GELLHORN
:
COVERING
RAW
SURFACES
UPON
265
UTERUS
not essentially altered. The uterus still lies on top of the bladder. Only the peritoneum which at this point is loosely connected with the bladder, is stretched and pulled across the fundus (Fig. 3). The bladder, at the border of posterior and upper walls, may adhere to the uterus a little higher than normally, but still on its anterior aspect. Hence, the filling of the bladder with urine will cause neither subjective nor objective disturbances. The same freedom of the bladder obtains in pregnancy when the gravid uterus may rise into the abdominal cavity without dislocating the bladder much more than is the case normally. I have seen one case that terminated in a miscarriage after four months. This patient at no time complained of vesical sympt0ms.l None of my other private patients has conceived thus far. I have no knowledge whether any of my hospital patients had become pregnant because our follow-up system is as yet undeveloped. Theoretically, the probability of pregnancy in the class of cases concerned is not very promising. Pathologic changes within the uterus that may have become permanent, alterations in the functions or structure of tubes or ovaries, azoospermia in the husband-all these factors may militate against conception. The plan of preventing uterine adhesions is so simple and so self-evident that I doubt not but that others may have invented the method for themselves. In any event, I submit it to your consideration in t,he conviction that it will still further increase the efficacy of our gynecologic operations. METROPOLITAN
BWIDTNG. (For
INOTE. Since writing the foregoing, a second patient on whom enucleation of several fibroids. has conceived. She is now (November, and has had no bladder symptoms of any kind.
disc,kssioia,
this procedure 1920) about
see was
four
done months’
p.
310.)
after the pregnant