Use of posterior culdotomy in pelvic operation

Use of posterior culdotomy in pelvic operation RAYMOND JOHN ANTON Rochester,

ENTHUSIASM

A. S.

LEE,

WELCH, F.

M.D. M.D.

SPRAITZ,

JR.,

M.D.

Minnesota

FOR

INCISION

for routine laparotomy, 4.1 days in the present series. The ability to perform adequate culdotomy may be severely limited, if certain criteria are not met. Exceeding the limitations imposed by these criteria will offer considerable hazard to the novice. The vaginal canal must offer reasonabie dimensions for approach, and the uterus should be moveable enough that the tissues to be incised can be visualized and manipulated. The cul-de-sac itself must be free from endometriosal or adhesive obliteration-at least sufficiently so that the free peritoneal cavity closely approaches the vagina. Finally, it must be realized that successful culdotomy may fail to yield sufficient exposure to accomplish definitive therapy. Anatomically, one is usually limited to the uterus, to moderately diseased adnexa, and occasionally to portions of the abdominal viscera which lie in the pelvis (sigmoid colon, ileum, cecum, appendix, and omentum). During a 6 year period (1957 through 1962) at the Mayo Clinic, 273 patients were selected for definitive treatment or diagnosis through a posterior colpotomy. Their ages ranged from 12 to 82 years (average, 36.3 years). Forty-eight of the 273 patients were nulliparous, and 76 had had previous pelvic operations. These circumstances represented, in the preoperative evaluation, relative but not absolute contraindications to culdotomy. In 21 cases, the posterior colpotomy was thought at operation to be inadequate, and abdominal exploration was carried out. Eight of these failures were due to ectopic preg-

into

the posterior cul-de-sac has waxed and waned since the early reports of Howard Kelly. We think posterior culdotomy provides a safe, accurate, and relatively easy surgical approach to the pelvic viscera for the diagnosis and treatment of some of their disorders. Although the technique is simple, hazards and complications are rare only when patients have been selected intelligently. Reduction of postoperative discomfort and of the duration of hospitalization have enhanced the value of this approach. Posterior culdotomy is not meant to replace pelvic laparotomy and does not, in our practice, supplant culdoscopy. Culdotomy does offer the added advantages of immediate vision, of primary palpation, of controlled biopsy, and frequently of immediate surgical therapy. Its rewards are greater than those of simple puncture of the cul-desac. In this period of increased cost of hoscertain pelvic ailments lead pitalization, directly to thoughts of culdotomy. Thus, this “minor-major pelvic laparotomy” has found increased usefulness in the diagnosis and treatment of moderate-sized uterine and adnexal masses primarily, since the average period of hospitalization is less than

From the Mayo Clinic and Mayo Foundation, Section of Obstetrics and Gynecology and the Mayo Graduate School of Medicine (University of Minnesota). Read at the meeting of the Central Association of Obstetricians and Gynecologists, Milwaukee, Wisconsin, Sept. 24 to 26, 1964. 777

778

Lee, Welch,

and Spraitz

nanq with marked hernoperitonrurn : 7 to adhesions secondary to previous pelvic operations; 5 to extensive endometriosis of the cul-de-sac; and one, to a large ovarian cyst. If at any time we found that we had extended our indications, rather than performing manipulative tiqmnastics, we selected the abdominal route for definitive therapy. Procedure The patient is the evening before is given a vaginal and the perineum room, the patient thal sodium and,

Fig. 1. Cervix vaginal

wall

is elevated, below.

Fig. 2. Transverse demonstrating

admitted to the hospital the day of operation. She douche and an enema; is shaved. In the operating is anesthetized with Pentoafter preliminary vaginal

incision an ovarian

exposing

of posterior cyst.

loose

fold

cul-de-sac,

of

preparation with soal). ~.\at~~t. .~IKI XI .ippropriatr antiseptic, is dralxd in thr, lithotonly position. A pelvic c.salnination is tlonc. after which dilatation and curcttagr ih p~:rformed, if indicated. ;2 \~cightcd sp~culurr~ is inserted in the vagina. and the postGot lip of the cer\k is grasped \cit.h a tcnaculum and elevated toward the symphvsis I Fia. I I. The loose fold of the ~x$nal wall betwcktxn the ureterosacral ligaments is grasped. by mcans of toothed forceps. about 2 on. trh the ccrvis and incised transverxly with scissors I,Fig. 2). The p&toneal cayit). is entered through the same OI a scxparate ill&ion. Placing the patient in the l’rendclcnburg position will usually displace the abdominal

Fig. 3. Deawr tubal pregnancy

retractors is brought

provide cxposurr into virw.

Fig. 4. Cul-de-sac is closed with interrupted tures. Small Prnrose drain was uwd in this

as lclt

SW ,asr:

Posterior

viscera and allow the small intestines to mobe out of the pelvis. Then the application of Deaver retractors in the 3, 9, and 12 o’clock positions of the incision will provide adequate exposure (Fig. 3). Preliminary palpation of pelvic viscera may be carried out through the incision, after which direct visualization can be aided by gentle traction on the parts with ovum forceps or MayoRussian forceps. Resection of cysts with ova tian reconstruction, salpingectomy, oophorectomy, salpingoplasty, ovarian wedge resection, excision of small myomas, and tubal ligation can be performed without difficulty in most cases. In certain cases, appendectomy or Meckel’s diverticulectomy is quite feasible. ‘7’he incision is closed with a single layer of four or five simple interrupted sutures of No. 0 chromic catgut, each incorporating all incised layers (Fig. 4). No drain is used, except in the treatment of pelvic abscess or hematoma. A firm iodoform vaginal pack is placed behind the cervix and against the incision; it is left in place for 48 hours.

in

pelvic

(:omplications were minimal. Hemorrhage at the time of operation or during convalescence was never a problem. Two patients de\ eloped pelvic abscesses after operation. Thl:y responded rapidly to incision, drainage, and to treatment with antibiotics. One patient developed a pulmonary lesion, thought to be pulmonary embolism. A third patient developed small bowel obstruction secondary to an inflammatory adhesion arising from the operative site in the adnexa. The only death in this series occurred in a patient with chronic renal disease. When she was sent to us 10 days after accidental perforation of the uterus, she was anuric and had a pelvic abscess. Despite dialysis, she died of renal failure 2 days after successful incision and drainage of the pelvic abscess. Comment

simple diagnostic culdotomy is with great ease, the cul-de-sac

operation

779

approach for definitive operation requires considerable diagnostic acumen. No gynecologist should expect to predict the successful completion in all cases of operations via this route. The 274 culdotomies in this group of 273 patients were categorized preoperatively

Table I. Posterior culdotomy from through 1963: Preoperative diagnosis reason for undertaking procedure Diagnosis

OT reason

for

operation

Pelvic mass Ectopic pregnancy Pelvic pain of undetermined etiology Tubal ligation Stein-Leventhal disease Abscess Question of carcinomatosis Question of endometriosis Infertility Pelvic evaluation (obesity) Uterine fibroids Functioning ovarian tumor Hematoma Evaluation for vaginal hysterectomy Twisted ovary Juvenile bleeding Total

Complications

Although performed

culdotomy

1957 or

1 Cases 149 43 13 12 10 7 7 6 6 6 5 3 2 2 2 1 274

Table II.

Posterior culdotomy from 1957 through 1963: Primary operative diagnosis or accomplishment of purpose Diagnosis or purpose accomplished Simple ovarian cyst Endometriosis Ectopic pregnancy Uterine fibroid Tubal ligation Stein-Leventhal disease Dermoid cyst of ovary Pelvic inflammatory disease Carcinomatosis Fibroma of ovary Abscess Cystadenofibroma Hydrosalpinx Chronic diverticulosis Hematoma Adhesions Epiploic tags Twisted ovary Thecoma Examination onlv Total

Cases 93 27 24 13 12 10 10 9 9 7 7 6 4 3 2 2 3 2 1 31 274

780

tee,

Table

Welch,

III.

through route

and

Spraitz

Posterior culdotomy from 1957 Operations completed by this

1963:

Operations Resection of ovarian cyst Examination only (for infertility or pelvic pain) Excision of specimen for examination Salpingectomy Oophorectomy Salpingoplasty Drainage of abscess Wedge resection of ovary Salpingo-oophorectomy Myomectomy Tubal ligation Vaginal hysterectomy Lysis of adhesion Appendectomy Failed colpotomy Total

Cases 80 49 27 27 41 JO 9 8 6 5 4 4 2 1 21 274

quite broadly as noted in Table I. No mass was explored vaginally where localized malignancy was thought probable and no mass measuring more than 8 cm. was exposed in this manner unless it was freely moveable. Seven instances of probable malignancy were investigated for diagnosis and

o\xrian resection. \ik’tktrt: r:xtcnsi\ c entiometriosia, pel\Gc inflammatory diseastx, 01’ adhesions were known to be present, each was judged operable vaginally on the basis of pelvic esamination performed in ttic office. LTterine pregnancy was not fount1 to be a definite contraindication to the procedure: in fact, 7 patients of this group were’ pregnant. All of thesr, delivered I.aginall) at term without complictions attributed to the vaginal procedure. The principal operative diagnoscas or Wsuits are listed in Table II. There was a great preponderance of adnexal diseasc which could be directly attacked x,ia the vaginal route i Table III I. Conclusion Posterior culdotomy provides a simple and short route to the pelvis. Properly performed, it permits direct visualization and exploration of the pelvic viscera. Experience based on its use in 274 instances during a 5 year period seems to suggest its further use as a tool in primary diagnosis and treatment of gynecologic disease.