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An operation for creating an abdominal “shelf” in certain cases of visceroptosis in women
738 Schubert,
THE
G. :
Monatsschrift
AMERICAN
JOURNAL
The Operation fur
OF
OBSTETRICS
for Prolapse
Geburtshilfe
und
AND
GYNECOLOGY
and Fixed Retroflexion
Gynakologie,
19‘76, lxxv,
of the Uterus.
69.
Twelve years ago, the author described an operation which fixed the uterus in an anterior position by means of a transplanted hand of fascia. He formerly used a piece of fascia from the fascia lata but now uses a preparation of the pericardium of an ox. The operation is carried out as follows: After perform ing the necessary cystocele and rectocele operation, the ahdomen is opened. The middle of the piece of fascia to be used is sewn to the uterus at the insertion of the utcros:~cral ligaments. The inguinal canals are then pierced with clamps and the free ends of the fascial strip are pulled through these canals. The uterus is drawn up into an anterior position and the fascial ends sewn to each other over the fascia. of the recti muscles. Of the 100 patients operated upon by this method, 93 were traced. Two of the patients died soon after the operation, one on the day after operation of hemorrhage and the other on the 19th day of embolism. Among the remaining PO there was not a single recurrence even though 15 of them had gone through :I pregnancy. In all the examined women, the uterus was anteflexed. The advantage of this operation is that in addition to its assurance against a recurrence, it can be performed at any age witlrout regard to the rcproductivc function of the patient. J. P. GREENMILL.
Benthin, W. : Prolapse Therapy. 1927, lxxv, 384.
Nonatsschrift
fiir
Geburshilfe
und GynLkologie,
In mild cases of prolapse of the uterus, Renthin advocates the Alexander-Adams operation regardless of age, but the uterus must he movable and not abnormally enlarged. If there is weakness of sphincter rontrol, and the patient is near or past tho menopause, a vaginal fixation operation should be performed. Where the uterus is very large, neither of those operations should be dono. In such cases the cervix should be fixed to the abdominal mall after amputating the body of the In cases of marked descensus with cystocele formation, and in cases of uterus. actual prolapse, the type of operation to be performed depends upon the age of the patient. In patients who are in the reproductive period, an abdominal cervical fixation should he done but in Iv-omen past the menopause, this operation or an interposition operation may he performed. The latter operation should be done only when there is advanced sphincter weakness. J. P. GREENIIILL.
An Operation for Creating an Abdominal “Shelf” Bonney: Visceroptosis in Women. Lancet > 1946, ccxi, 487.
in Certain
Cases of
The symptoms complained of by patients suffering from this form of visceroptosis are a sense of weakness preventing any prolonged exertion; backache, and pain referred to the lateral parts of the lower abdomen in the region of the appendix and cecum on the right side, and the point vvhere the colon crosses the pelvic brim on the left side. This pain which is evoked by standing and exertion, and which disappears with recumbency is probably due to a drag on the ovariopelvie ligaments. The writer feels that the downward extension of the peritoneal cavity plays an important part in the mechanism of defecation because it permits pressure to be brought to the upper part of the rectum by the intestinal coils forced into the pouch during straining. The operation is a combined operation for direct ventrofixation and round ligaA puckering suture is run along each round ligament starting ment shortening.
REVIEWS
AND
739
ABSTRACTS
about an inch from the point where the ligament leaves the abdominal cavity and ending at the attachment of the ligament to the uterus. The suture should be passed through the ligament itself. The ends are then tied and left long. These long suture ends are then carried out through the internal inguinal ring between the external rectus sheath and the rectus muscle toward the line of incision, much as is done in the suspension operation when the round ligament is brought through the internal inguinal ring and between the rectus sheath and muscle. Traction, of these sutures pulls the pleated part of the round ligament against the abdominal wall to which they are subsequently fixed by passing the two ends of each suture through the aponeurosis at either side and tying them there. The uterus itself is now attached by passing two silk sutures through the upper anterior wall and through the aponeurosis and peritoneum on either side of the wound. Before tying, a mattress suture is taken on either side between the peritoneum of the anterior abdominal wall and the region of the cornua of the uterus. This procedure results in the formation of a partition running transversely across the abdominal cavity entirely separating it from the uterovesical space. This partition in a standing posture forms a shelf on which the intestines rest. The intestinal pressure is directed downward and backward into an opened euldesac or Douglas’ pouch. NORMAN F. MILLER.
Beuttner, Oscar: The Examination of the Appendix and the Indications for Appendectomy in the Course of 1400 Gynecologic Laparotomies. Presse M&btale,
1924,
No.
97, p. 958.
In this series, the appendix was not inspected in 121 cases. In the others, it was macroscopically normal in 1063 instances and macroscopically abnormal in 216; all in the first group were left in situ, while some of the latter group were excised. One hundred of these excised appendices were studied histologically; of these, 63 were found to present lesions, while 37 were normal. In only four of these 100 cases did the author consider that appendectomy was absolutely indicated. He found very little correspondence between the macroscopic appearance and the microscopic picture, so that in difticult cases he does not hesitate to leave the appendix, even though it is macroscopically altered. He would consider the removal of an appendix presenting little or no macroscopic change only if the history pointed definitely to past appendiceal trouble, or if the patient insisted on its excision. The author, in eighteen years, has never encountered a case of appendicitis in a patient previously subjected to gynecologic intervention. He feels that routine appendectomy in the course of gynecologic laparotomies is not justified, on account of the additional risk (even though slight). Furthermore, he is not as yet convinced that the appendix has no function. E. L. KING. Faure,
J. L:
Appendicitis
Again!
Presse
MBdicale,
1924,
No.
101,
p. 1001.
Faure vigorously protests against Beuttner’s conclusions, in his’article in the same journal two weeks previously. Faure contends that the French gynecologists, being general surgeons as well, have occasion to examine many more appendices than gynecologists of the German school, to which Buettner belongs. Consequently, the opinions of the former, based on numberless observations, are of more value than those of the members of the latter school. The author also lays more stress on a careful macroscopic study of the whole organ, splitting it from end to end, than on a microscopic examination, in which one or two slides are examined. He feels that four-fifths, or even nine-tenths, of the appendices encountered in abdominal work are altered and diseased, and should be removed if this can be done without subjecting the patient to serious risk. E. L. KINQ.
THE
G. :
Monatsschrift
AMERICAN
JOURNAL
The Operation fur
OF
OBSTETRICS
for Prolapse
Geburtshilfe
und
AND
GYNECOLOGY
and Fixed Retroflexion
Gynakologie,
19‘76, lxxv,
of the Uterus.
69.
Twelve years ago, the author described an operation which fixed the uterus in an anterior position by means of a transplanted hand of fascia. He formerly used a piece of fascia from the fascia lata but now uses a preparation of the pericardium of an ox. The operation is carried out as follows: After perform ing the necessary cystocele and rectocele operation, the ahdomen is opened. The middle of the piece of fascia to be used is sewn to the uterus at the insertion of the utcros:~cral ligaments. The inguinal canals are then pierced with clamps and the free ends of the fascial strip are pulled through these canals. The uterus is drawn up into an anterior position and the fascial ends sewn to each other over the fascia. of the recti muscles. Of the 100 patients operated upon by this method, 93 were traced. Two of the patients died soon after the operation, one on the day after operation of hemorrhage and the other on the 19th day of embolism. Among the remaining PO there was not a single recurrence even though 15 of them had gone through :I pregnancy. In all the examined women, the uterus was anteflexed. The advantage of this operation is that in addition to its assurance against a recurrence, it can be performed at any age witlrout regard to the rcproductivc function of the patient. J. P. GREENMILL.
Benthin, W. : Prolapse Therapy. 1927, lxxv, 384.
Nonatsschrift
fiir
Geburshilfe
und GynLkologie,
In mild cases of prolapse of the uterus, Renthin advocates the Alexander-Adams operation regardless of age, but the uterus must he movable and not abnormally enlarged. If there is weakness of sphincter rontrol, and the patient is near or past tho menopause, a vaginal fixation operation should be performed. Where the uterus is very large, neither of those operations should be dono. In such cases the cervix should be fixed to the abdominal mall after amputating the body of the In cases of marked descensus with cystocele formation, and in cases of uterus. actual prolapse, the type of operation to be performed depends upon the age of the patient. In patients who are in the reproductive period, an abdominal cervical fixation should he done but in Iv-omen past the menopause, this operation or an interposition operation may he performed. The latter operation should be done only when there is advanced sphincter weakness. J. P. GREENIIILL.
An Operation for Creating an Abdominal “Shelf” Bonney: Visceroptosis in Women. Lancet > 1946, ccxi, 487.
in Certain
Cases of
The symptoms complained of by patients suffering from this form of visceroptosis are a sense of weakness preventing any prolonged exertion; backache, and pain referred to the lateral parts of the lower abdomen in the region of the appendix and cecum on the right side, and the point vvhere the colon crosses the pelvic brim on the left side. This pain which is evoked by standing and exertion, and which disappears with recumbency is probably due to a drag on the ovariopelvie ligaments. The writer feels that the downward extension of the peritoneal cavity plays an important part in the mechanism of defecation because it permits pressure to be brought to the upper part of the rectum by the intestinal coils forced into the pouch during straining. The operation is a combined operation for direct ventrofixation and round ligaA puckering suture is run along each round ligament starting ment shortening.
REVIEWS
AND
739
ABSTRACTS
about an inch from the point where the ligament leaves the abdominal cavity and ending at the attachment of the ligament to the uterus. The suture should be passed through the ligament itself. The ends are then tied and left long. These long suture ends are then carried out through the internal inguinal ring between the external rectus sheath and the rectus muscle toward the line of incision, much as is done in the suspension operation when the round ligament is brought through the internal inguinal ring and between the rectus sheath and muscle. Traction, of these sutures pulls the pleated part of the round ligament against the abdominal wall to which they are subsequently fixed by passing the two ends of each suture through the aponeurosis at either side and tying them there. The uterus itself is now attached by passing two silk sutures through the upper anterior wall and through the aponeurosis and peritoneum on either side of the wound. Before tying, a mattress suture is taken on either side between the peritoneum of the anterior abdominal wall and the region of the cornua of the uterus. This procedure results in the formation of a partition running transversely across the abdominal cavity entirely separating it from the uterovesical space. This partition in a standing posture forms a shelf on which the intestines rest. The intestinal pressure is directed downward and backward into an opened euldesac or Douglas’ pouch. NORMAN F. MILLER.
Beuttner, Oscar: The Examination of the Appendix and the Indications for Appendectomy in the Course of 1400 Gynecologic Laparotomies. Presse M&btale,
1924,
No.
97, p. 958.
In this series, the appendix was not inspected in 121 cases. In the others, it was macroscopically normal in 1063 instances and macroscopically abnormal in 216; all in the first group were left in situ, while some of the latter group were excised. One hundred of these excised appendices were studied histologically; of these, 63 were found to present lesions, while 37 were normal. In only four of these 100 cases did the author consider that appendectomy was absolutely indicated. He found very little correspondence between the macroscopic appearance and the microscopic picture, so that in difticult cases he does not hesitate to leave the appendix, even though it is macroscopically altered. He would consider the removal of an appendix presenting little or no macroscopic change only if the history pointed definitely to past appendiceal trouble, or if the patient insisted on its excision. The author, in eighteen years, has never encountered a case of appendicitis in a patient previously subjected to gynecologic intervention. He feels that routine appendectomy in the course of gynecologic laparotomies is not justified, on account of the additional risk (even though slight). Furthermore, he is not as yet convinced that the appendix has no function. E. L. KING. Faure,
J. L:
Appendicitis
Again!
Presse
MBdicale,
1924,
No.
101,
p. 1001.
Faure vigorously protests against Beuttner’s conclusions, in his’article in the same journal two weeks previously. Faure contends that the French gynecologists, being general surgeons as well, have occasion to examine many more appendices than gynecologists of the German school, to which Buettner belongs. Consequently, the opinions of the former, based on numberless observations, are of more value than those of the members of the latter school. The author also lays more stress on a careful macroscopic study of the whole organ, splitting it from end to end, than on a microscopic examination, in which one or two slides are examined. He feels that four-fifths, or even nine-tenths, of the appendices encountered in abdominal work are altered and diseased, and should be removed if this can be done without subjecting the patient to serious risk. E. L. KINQ.