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The Portes Cesarean Section with Report of a Case*
VOGT
AND
VOGT,
PORTES
JR.:
The authors wish to express their stetrics at Morrisania City Hospital, who helped in organizing the material
499
CESAREAN SECTION
thanks to Dr. Harry Aranow. and to Drs. M. J. Goodfriend for this paper.
Director of Oband A. 13. Tamis
REFERENCES
(1) Moench, G. L. : AM. J. OBST. & GYNGC. 38: 153, 1939. (2) Hilltin, J.: (4) Cody, Surg. 19: 76, 1933. (3) Baker, J. R.: J. Hyg. 31: 189, 1932. J. Urol. 13: 175, 1925. (5) Yzlschat, M.: Surg., Gynec. & Obst. 42: 7’78, 1926. (6) Cohn, E. J.: Biol. Bull. 34: 167, 1918. (7) Jahsel, F.: Klin. Wchnschr. 17: 1273, 1938. Am. J. B. A.:
STATION
HOSPITAL
Fort Bragg, N. C.
THE
PORTES
WILLIAM
H.
VOGT,
CESAREAN
SECTION CASE@
M.D., F.A.C.S., ST.
(From the Department
AND LOUIS,
of Obstetrics University School
WILLIAM
WITH
REPORT
OF
A
H. VOC~T, JR., A.B., M.D.
MO. and Gynecology of Medicine)
of the St. Louis
T
HE choice of treatment in definitely infected labor cases has been a moot question for many years. Classical cesarean section may be mentioned only to be condemned when performed upon a frankly infected case. The low cervical section with transverse cervical incision is perhaps somewhat more adaptable. Latzko introduced an extraperitoneal section, hoping it would prove to be the logical procedure in such cases. This operation, however, has great technical difficulties. Within the past year Waters’ and Smith2 each have suggested modifieations of the Latzko procedure. Such operations, if technically not too difficult, would probably offer the greatest degree of success in the treatment of neglected individuals. These authors admit that the procedures are time consuming. In the poor surgical risk a shorter operation is advisable. The Portes type of section answers this need. It has the disadvantage of including two separate stages and a prolonged hospitalization for the patient. It has the distinct advantage of precluding the spill of infectious material into the abdominal cavity since the peritoneum is closed before the uterus is entered. This, of course, does not hold true in the Porro section wherein the uterus is removed supravaginally after the infant is extracted. Because of the more or less general debate and argument as to the proper method of handling patients exhibiting evidence of infection, it seemed worthwhile to present a brief r&sum6 of appropriate literature on the subject together with a case report. The Portes section performed upon this woman was the first ever done in the St. Louis University Group of Hospitals. REVIEW
OF LITERATURE
In 1923 at the Maternite de Port Royal de Paris, Dr. Louis Portes first perSince formed a cesarean section followed by temporary exteriorization of the uterus. that time, a number of these operations have been done in France and other foreign *Presented Gynecological
before a combined meeting of the Kansas City, Societies, St. Louis, MO.. February 15, 1941.
Chicago
and
St. ~uis
500
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
CXNEC~LOOY
countries but only a very few in the United States. It is to be noted that the procedure is frequently referred to as the Portes-Gottschalk operation. Gottschalk of Germany described a similar technique to that of Portes as far back as 1909, but to the best of our knowledge never performed such au operation. PhaneufsB 4 believes that the Portes operation is reserved for the occasional hopelessly infected patient wherein the matter of the time element is a serious consideration. This author had performed two of these procedures up to 1937, resulting in two maternal recoveries and the survival of one infant. The uterus was exteriorized for forty-one days in the case of the first patient and for thirty days in the second. The operation itself, as described by Portes, is done in two stages. The initial portion of the procedure includes an abdominal incision, the delivery of the pregnant uterus, the closure of the abdominal wall behind the uterus down to the cervix, a high uterine incision, extraction of fetus, membranes and placenta, closure of the uterine defect allowing the uterus to remain on the s,bdomen, and wet packs to the wound. The second stage follows only after the complete healing of the uterine incision and consists of re-opening the abdominal incision, freeing whatever adhesions which may have formed, dropping the uterus and adnexa back into the pelvic cavity, draining the area posterior to the uterus and closing the abdomen. Several of the French authors, however, have deemed it necessary to remove the uterus following its exteriorization owing to excessive and prolonged infection. The mortality rate from this seemingly extensive procedure is not high considering that most cases so treated were definitely infected. Couvelaire,s in 1925, reported a mortality of 6.2 per cent in 32 cases. We know of Phaneuf’s good results in two cases. In 1938, Parsons6 reported three neglected cases seen in China and treated by this method. None of the babies was living on admission to the hospital. One mother recovered and 2 died of heart failure after operation. All 3 eases showed evidence of frank infection. DISCUSSION
Of the comparatively few authors who have written on this subject all seem to agree that the Portes operation is primarily of value in markedly infected cases wherein a Porro type of section would consume too much time. Therefore, the most important indications for the procedure seem to be neglected individuals in whom a frank infection is present and who manifestly are poor surgical risks. All authors claim a very short operative time for the Portes section, twenty-five to thirty minutes appearing to be about the average duration for completion of the first stage operation. It is, however, our impression that the procedure can be done little, if any, faster than the Porro section. We realize that practice aids in a swifter technique but the first stage operation in the case to follow required only thirty minutes. The Porro operation, in most competent hands, takes little longer and seems to us the safer procedure in the majority of cases although it must be admitted that the amputation of the uterus plus the uterine incision in this operation allows for the possible spill of infectious material into the peritoneal cavity. The case herein reported represents a 23-year-old primigravida who was just beginning her reproductive life. In this particular subject it would have been regrettable to have removed her uterus at the time of abdominal section. Therefore, since the time element is practically of no import in evaluating the Porro and Portes
VOGT
AND
VOGT,
techniques, we believe section should include early in her reproductive
JR. :
PORTES
CESAREAN
SECTION
the general indication for the Portes type frankly infected eases in which the mother life.
501
of is
In 1937, M. P. Hue0 pointed out, in referring to the original work of Louis Portes, that the first operation of this kind was done on an infected individual, aged 21 years. Porte9 conceived his idea of exteriorizing the uterus because he believed that section followed by hysterectomy would have been a regrettable choice in 50 young a woman. CASE The
May 29, 1940, was a 2%year-old presented nothing unusual. Her pelvic measurements The blood pressure had been moderately elevated had some treatment. When first seen her temperature The white blood cell count was 20,000 with a shift to the left in the differential. The membranes had ruptured forty-eight hours previously, and she had been in fairly strong labor for three days, The abdominal examination revealed a uterine pregnancy of approximately full term with a right position. The fetal heart tones were good in the right !ower quadrant. The rectal examination revealed the presenting part, the head, high in the pelvis. It was ascertained by questioning that both the patient and her husband were desirous of future pregnancies and beeause of this fact and the evidence of frank infection in so young a woman, a Porte8 type of eesarean section was decided upon. The patient was given several vaginal instillation5 of an antiseptic solution and taken to the operating room where the abdomen was opened under gas anesthesia. The uterus was delivered through the incision and the peritoneum was then closed about the uterus. An incision was then made into the uterus and a fullterm male infant, weighing 9 pound5 3 ounces was delivered from an R.O.P. position. The cry and respiration were spontaneous. The placenta was removed manually and a foul odor arising from the uterine cavity was noted. The uterine incision was then closed, leaving the uterus outside the abdominal cavity. The time consumed in this procedure was thirty minutes. Following this operation the patient ran a temperature of IO1 to 103” F. for several weeks. Neoprontosil was given in large amounts together with several blood transfusions. The area around the uterine wound sloughed extensively despite This condition finally was controlled the presence of constantly wet saline packs. sufficiently to permit the second stage operation fifty-five day5 after the original procedure.
rrimipara
patient,
seen in Firmin
RRPORT
Desloge
Hospital on of labor, were apparently normal. and for this condition she had was 102" F. and pulse 120.
whose pregnancy, until the time
On the twenty-fourth of July, 1940, the patient was again anesthetized, the uterus was freed from its attachments to the abdominal wall and the abdominal cavity was re-opened. The uterine fistula was closed with 2 rows of catgut sutures. The raw uterine surface was covered with bladder peritoneum and the uterus was dropped back into the pelvic cavity. The right tube was found to be patent but a probe The abdomen was closed in layers. This could not be passed into the left tube. procedure, which was made exceedingly difficult due t,o a retraction of the peritoneum, was completed in slightly less than two hours and was complicated only by the development of a small abdominal wall fistula which was treated by styptics and which gradually healed. The patient left the hospital on Sept. 4, 1940, exactly ninety-eight She ha5 menstruated regularly since then and to days after the initial operation. all external evidence is in good condition. REFERENCES (1) Waters, E. G.: AK J. OBST. & GYNEC. 39: 423, 1940. (2) Smith, E. F.: Lo&: Am. J. Surg. 36: 446, 1937. (4) Idem: Ibid. 39: 763, 1940. (3) Phanezcf, Surg., Gynec. & Obst. 44: 738, 1927. (5) Couueluire, a.: Bull. Sot. d’obst. et de (6) Parsons, E.: AM. J. OBST. & GYNEC. 35: 311, gynec. de Paris 14: 148, 1925. Mem. Acad. de Chir. 63: 40, 1937. 1938. (7) Huet, Y. P.:
AND
VOGT,
PORTES
JR.:
The authors wish to express their stetrics at Morrisania City Hospital, who helped in organizing the material
499
CESAREAN SECTION
thanks to Dr. Harry Aranow. and to Drs. M. J. Goodfriend for this paper.
Director of Oband A. 13. Tamis
REFERENCES
(1) Moench, G. L. : AM. J. OBST. & GYNGC. 38: 153, 1939. (2) Hilltin, J.: (4) Cody, Surg. 19: 76, 1933. (3) Baker, J. R.: J. Hyg. 31: 189, 1932. J. Urol. 13: 175, 1925. (5) Yzlschat, M.: Surg., Gynec. & Obst. 42: 7’78, 1926. (6) Cohn, E. J.: Biol. Bull. 34: 167, 1918. (7) Jahsel, F.: Klin. Wchnschr. 17: 1273, 1938. Am. J. B. A.:
STATION
HOSPITAL
Fort Bragg, N. C.
THE
PORTES
WILLIAM
H.
VOGT,
CESAREAN
SECTION CASE@
M.D., F.A.C.S., ST.
(From the Department
AND LOUIS,
of Obstetrics University School
WILLIAM
WITH
REPORT
OF
A
H. VOC~T, JR., A.B., M.D.
MO. and Gynecology of Medicine)
of the St. Louis
T
HE choice of treatment in definitely infected labor cases has been a moot question for many years. Classical cesarean section may be mentioned only to be condemned when performed upon a frankly infected case. The low cervical section with transverse cervical incision is perhaps somewhat more adaptable. Latzko introduced an extraperitoneal section, hoping it would prove to be the logical procedure in such cases. This operation, however, has great technical difficulties. Within the past year Waters’ and Smith2 each have suggested modifieations of the Latzko procedure. Such operations, if technically not too difficult, would probably offer the greatest degree of success in the treatment of neglected individuals. These authors admit that the procedures are time consuming. In the poor surgical risk a shorter operation is advisable. The Portes type of section answers this need. It has the disadvantage of including two separate stages and a prolonged hospitalization for the patient. It has the distinct advantage of precluding the spill of infectious material into the abdominal cavity since the peritoneum is closed before the uterus is entered. This, of course, does not hold true in the Porro section wherein the uterus is removed supravaginally after the infant is extracted. Because of the more or less general debate and argument as to the proper method of handling patients exhibiting evidence of infection, it seemed worthwhile to present a brief r&sum6 of appropriate literature on the subject together with a case report. The Portes section performed upon this woman was the first ever done in the St. Louis University Group of Hospitals. REVIEW
OF LITERATURE
In 1923 at the Maternite de Port Royal de Paris, Dr. Louis Portes first perSince formed a cesarean section followed by temporary exteriorization of the uterus. that time, a number of these operations have been done in France and other foreign *Presented Gynecological
before a combined meeting of the Kansas City, Societies, St. Louis, MO.. February 15, 1941.
Chicago
and
St. ~uis
500
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
CXNEC~LOOY
countries but only a very few in the United States. It is to be noted that the procedure is frequently referred to as the Portes-Gottschalk operation. Gottschalk of Germany described a similar technique to that of Portes as far back as 1909, but to the best of our knowledge never performed such au operation. PhaneufsB 4 believes that the Portes operation is reserved for the occasional hopelessly infected patient wherein the matter of the time element is a serious consideration. This author had performed two of these procedures up to 1937, resulting in two maternal recoveries and the survival of one infant. The uterus was exteriorized for forty-one days in the case of the first patient and for thirty days in the second. The operation itself, as described by Portes, is done in two stages. The initial portion of the procedure includes an abdominal incision, the delivery of the pregnant uterus, the closure of the abdominal wall behind the uterus down to the cervix, a high uterine incision, extraction of fetus, membranes and placenta, closure of the uterine defect allowing the uterus to remain on the s,bdomen, and wet packs to the wound. The second stage follows only after the complete healing of the uterine incision and consists of re-opening the abdominal incision, freeing whatever adhesions which may have formed, dropping the uterus and adnexa back into the pelvic cavity, draining the area posterior to the uterus and closing the abdomen. Several of the French authors, however, have deemed it necessary to remove the uterus following its exteriorization owing to excessive and prolonged infection. The mortality rate from this seemingly extensive procedure is not high considering that most cases so treated were definitely infected. Couvelaire,s in 1925, reported a mortality of 6.2 per cent in 32 cases. We know of Phaneuf’s good results in two cases. In 1938, Parsons6 reported three neglected cases seen in China and treated by this method. None of the babies was living on admission to the hospital. One mother recovered and 2 died of heart failure after operation. All 3 eases showed evidence of frank infection. DISCUSSION
Of the comparatively few authors who have written on this subject all seem to agree that the Portes operation is primarily of value in markedly infected cases wherein a Porro type of section would consume too much time. Therefore, the most important indications for the procedure seem to be neglected individuals in whom a frank infection is present and who manifestly are poor surgical risks. All authors claim a very short operative time for the Portes section, twenty-five to thirty minutes appearing to be about the average duration for completion of the first stage operation. It is, however, our impression that the procedure can be done little, if any, faster than the Porro section. We realize that practice aids in a swifter technique but the first stage operation in the case to follow required only thirty minutes. The Porro operation, in most competent hands, takes little longer and seems to us the safer procedure in the majority of cases although it must be admitted that the amputation of the uterus plus the uterine incision in this operation allows for the possible spill of infectious material into the peritoneal cavity. The case herein reported represents a 23-year-old primigravida who was just beginning her reproductive life. In this particular subject it would have been regrettable to have removed her uterus at the time of abdominal section. Therefore, since the time element is practically of no import in evaluating the Porro and Portes
VOGT
AND
VOGT,
techniques, we believe section should include early in her reproductive
JR. :
PORTES
CESAREAN
SECTION
the general indication for the Portes type frankly infected eases in which the mother life.
501
of is
In 1937, M. P. Hue0 pointed out, in referring to the original work of Louis Portes, that the first operation of this kind was done on an infected individual, aged 21 years. Porte9 conceived his idea of exteriorizing the uterus because he believed that section followed by hysterectomy would have been a regrettable choice in 50 young a woman. CASE The
May 29, 1940, was a 2%year-old presented nothing unusual. Her pelvic measurements The blood pressure had been moderately elevated had some treatment. When first seen her temperature The white blood cell count was 20,000 with a shift to the left in the differential. The membranes had ruptured forty-eight hours previously, and she had been in fairly strong labor for three days, The abdominal examination revealed a uterine pregnancy of approximately full term with a right position. The fetal heart tones were good in the right !ower quadrant. The rectal examination revealed the presenting part, the head, high in the pelvis. It was ascertained by questioning that both the patient and her husband were desirous of future pregnancies and beeause of this fact and the evidence of frank infection in so young a woman, a Porte8 type of eesarean section was decided upon. The patient was given several vaginal instillation5 of an antiseptic solution and taken to the operating room where the abdomen was opened under gas anesthesia. The uterus was delivered through the incision and the peritoneum was then closed about the uterus. An incision was then made into the uterus and a fullterm male infant, weighing 9 pound5 3 ounces was delivered from an R.O.P. position. The cry and respiration were spontaneous. The placenta was removed manually and a foul odor arising from the uterine cavity was noted. The uterine incision was then closed, leaving the uterus outside the abdominal cavity. The time consumed in this procedure was thirty minutes. Following this operation the patient ran a temperature of IO1 to 103” F. for several weeks. Neoprontosil was given in large amounts together with several blood transfusions. The area around the uterine wound sloughed extensively despite This condition finally was controlled the presence of constantly wet saline packs. sufficiently to permit the second stage operation fifty-five day5 after the original procedure.
rrimipara
patient,
seen in Firmin
RRPORT
Desloge
Hospital on of labor, were apparently normal. and for this condition she had was 102" F. and pulse 120.
whose pregnancy, until the time
On the twenty-fourth of July, 1940, the patient was again anesthetized, the uterus was freed from its attachments to the abdominal wall and the abdominal cavity was re-opened. The uterine fistula was closed with 2 rows of catgut sutures. The raw uterine surface was covered with bladder peritoneum and the uterus was dropped back into the pelvic cavity. The right tube was found to be patent but a probe The abdomen was closed in layers. This could not be passed into the left tube. procedure, which was made exceedingly difficult due t,o a retraction of the peritoneum, was completed in slightly less than two hours and was complicated only by the development of a small abdominal wall fistula which was treated by styptics and which gradually healed. The patient left the hospital on Sept. 4, 1940, exactly ninety-eight She ha5 menstruated regularly since then and to days after the initial operation. all external evidence is in good condition. REFERENCES (1) Waters, E. G.: AK J. OBST. & GYNEC. 39: 423, 1940. (2) Smith, E. F.: Lo&: Am. J. Surg. 36: 446, 1937. (4) Idem: Ibid. 39: 763, 1940. (3) Phanezcf, Surg., Gynec. & Obst. 44: 738, 1927. (5) Couueluire, a.: Bull. Sot. d’obst. et de (6) Parsons, E.: AM. J. OBST. & GYNEC. 35: 311, gynec. de Paris 14: 148, 1925. Mem. Acad. de Chir. 63: 40, 1937. 1938. (7) Huet, Y. P.: