Cesarean hysterectomy

Cesarean hysterectomy JOHN H. MORTON, M.D. Los Angeles, California

C E S A R E A N H Y S T E R E C T 0 M Y since Bixby 1 and Porro10 has been a useful operation in the management of certain obstetric complications. The type of hysterectomy had usually been the subtotal operation until more widespread interest in the total was aroused by Davis3 in 1951 and emphasized recently 4 when he reported 395 total cesarean hysterectomies done between 1947 and 1961 without a maternal death. Gynecologists have been the leaders in rendering obsolete the subtotal hysterectomy in spite of the fact that total hysterectomy is a longer operation and usually causes more blood loss. The advantages gained by elimination of cervical infection and neoplasm outweigh the noted disadvantages. Prophylac~ tic removal of pathologically normal uteri is widely accepted in the treatment of pelvic relaxations and, assuming a constant incidence of uterine pathologic change, the increasing incidence of cesarean hysterectomy probably reflects more prophylactic indications and its substitution for tubal sterilizing operations.

Hospital from one to 303 in 1931-1941 to one to 104 in 1958-1961. 4 The figures from Belgrade7 compare United States figures with those of an Iron Curtain country. They did but two total hysterectomies in a series of 63 cases so that the subtotal operation remains most prevalent there. In spite of gradually increasing evidence, reviewed and added to by Montague8 in 1959 and others, a feeling persists among many gynecologists that a total cesarean hysterectomy is a dangerous operation and that the subtotal procedure is a safe one. The

present study was undertaken to determine further the utilization and results of this operation in this area and if there are unusual hazards with the total operation. Present report

We are reporting 250 cesarean hysterectomies (Table II) from two private Los Angeles hospitals (the Hospital of the Good Samaritan and the California Lutheran Hospital) and one public hospital (the Los Angeles County General Hospital). The cases represent consecutive ones between the indicated dates. The two private hospitals averaged 31.3 per cent for the total hysterectomy and the County 76 per cent, which reflects a high interest in the total operation among the residents and faculty there. Maternal age, parity, weight, type of anesthesia, fetal information, and fetal position are shown in Tables III to VIII. These are about what one would expect. The longer operating time caused the increased number of combined spinal and general anesthesias, and the 24.8 per cent of general anesthesias includes nearly all of the critically ill patients where spinal was considered to be too

Incidence

Table I shows that the cesarean hysterectomy incidence rose at three Los Angeles hospitals from one to 659 deliveries in 1956 to one to 352 in 1959; at Chicago's Cook County HospitaP 2 from one in 1,340 in 1956 to one in 453 in 1959; at Chicago Lying-in From the Department of Obstetrics and Gynecology, Loma Linda University. Presented by invitation at the Twentyeighth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Yosemite National Park, California, Sept. 20-23, 1961.

1422

Volume 83 Number 11

Cesarean hysterectomy

1423

Table I. Incidence of cesarean hysterectomy

24 38

1:659 1:352

2.6 1.95

8 40

1:1340 1:453

1,500 470

5.1 5.6

96 79

1:303 1: 104

1;207

4.2

63 (2 total)

1:425

T.ll(1 .Ano-PlP<~. -··o-.. . .

1956 1959

15,832 13,457

649 713

Cook County Hospital

1952 1959

10,724 18,133

242 353

Chicago Lying-in

1931-41 1958-61

29,290 8,335

Medical Faculty, Belgrade

1948-57

26,832

~~~

~

( three hospitals)

Ratio to deliveries

Cesarean hysterectomy

Hospital

dangerous. The "out of uterus" fetal position shows how many escaped the uterus in eleven ruptures. Operation time. The operation time (Fig. 1) is included so that we may see how long one may expect to take with the average cesarean hysterectomy. The total is close to 2 hours and significantly longer than with subtotaL Two total hysterectomies were done

in 70 minutes, but one surgeon later spent an additional 140 minutes tying off bleeders. Blood loss. In the attempt to assess blood loss we spent much time trying to correlate pre- and postoperative hemoglobin levels, but the records were simply inadequate. We feel that the transfusions given with or after an operation indicate quite well how things were going (Table IX). The mean number of transfusions was close to two with the total and one with the subtotaL The techniques of the operators doing the total hysterectomy with no or with one transfusion were reviewed and are noted later. Many times a single transfusion settled a problem satisfactorily, and it seemed perfectly justified in most instances. We tried to assess the importance of membrane rupture and cervical dilatation, but records were not satisfactory for conclusions. Indications. The indications for hysterectomy are divided into the pelvic (Table X) and extrapelvic or prophylactic (Table XIV). The largest pelvic group is uterine scar, 190 (188 previous sections and 2 myomectomies) . This group is followed by fibroids, uterine rupture, amnionitis, pla-

Table II. Incidence of cesarean hysterectomy at three Los Angeles Hospitals Type of

hysterec-

tomy

I California I

Good Samaritan

(1941-61)

(1955-61)

19 (17.7)

21 (44.9) 28

72 (76)

49

94

Total Subtotal

88 107

Los Angeles County I

(1956-61)

22

Table III. Maternal age at time of hysterectomy

Le~

than 20 (17) 20•24 25-29 30-34 35-39 40-45 Over 45*

0.4 7.2 28.8 31.6 21.6 10.4 00.0

*Two patients were 45 years old.

Table IV. Parity at time of hysterectomy Parity 0 1 2

3

4 5 6 7 8

9

10 11

12

No.

%

14 35 80 63 21

5.6 14.0 3Q.O 25.2 8.4 4.0 4.0 2.0 1.2 0.4 1.6 0.4 0.8 0.4

10 10 5

3 1

4 1 2 1

1424 Morton

June I, l'lli2 Am. J. Obst. & Gym-c.

TIME {MI~UTE5l

)80

!50

IZO

___ ... __ ................. . . ---

90

60 TOTAL SUBTOTAL

30

a

~

~

~

~

~

ro

~

~

~

CASES %

Fig. I. Comparison of operating time of patients treated by total and subtotal hysterectomy. as expressed in percentage of all cases of each typP requiring a given time for performance.

Table V. Preoperative maternal weight No. Over 200 176-200 150-175 Under 150

18 30

59 125

7.2 12.0 23.6

50.0

Table VI. Types of anesthesia Anesthesia

No.

ri~

Spinal Spinal and general General

91 97

::16.4 30.8 24.8

62

Table VII. Infants delivered by cesarean section No. Tl"rm Premature Male Died (uncorrected)

226

90A

19

9.6 45.6 7.6

24 114

Table VIII. Fetal position No.

Vertex

Breech Transverse Out of uterus

226 16 4

4

6.4 1.6 1.6

centa previa, and the small miscellaneous group. Details of the scar group are shown in Table XI. There were 54 hysterectomies following one previous section and 90 after the second. The greatest number of previous sections was 5. Uterine rupture. The uterine rupture group detail is shown in Table XII. One 280plus pound patient fell out of bed on her abdomen. The cervix was fully dilated and she was receiving intravenous stimulation with posterior pituitary extract. The operative notes said that the uterus appeared to havf' ruptured from external pressure but did no1 describe this appearance. Four of the .1 patients with rupture of cesarean scars had been delivered vaginally previous to the first section. The indications for the first section were: bleeding ( 2 cases) , prolapsed cord ( 1) , and fetal distress from a Bandl's rinli· ( 1) . It is of interest that at operation this latter patient had a thick contraction ring above the ruptured lower transverse scar. There were ::i ruptured classical scars, all associated with dead babies outside of the uterus and two low transverse scar ruptures with both infants being retained in the uterus and surviving. In several more cases there were notes suggesting extremely thin or possibly separated scars but these nondrarnatic cases are not included hen·. Other concurrent pathology. Placenta accreta was found six times, and in 3 cases this was associated with placenta previa. Placenta previa accreta is rare. Koren, Zuckerman, and Brzezinski" recently reyiewt>d 58 cases previously recorded and reported 3 cases of their own, and Quinlivan 9 reported one, a total of 62 previously reported. Five of the present 6 cases were treated by subtotal hysterectomy. The occurrence of this complication was always a very nnhappy surprise and was accompanied by serious hemorrhage. It was noted that much hemorrhage occurred from the stump after fundal amputation and attempts at cervical ligation. With placenta previa accreta or low-lying accreta it might be wise not even to attempt a subtotal hysterectomy with ligatures through the accreta area. The longest operation in the entire

Table IX. Paraoperative transfusions Subtotal

Total Units

No.

%

No.

5 or more

19 26 39 14 8 6

16.9 23.2 34.8 12.5 6.2 5.3

71 31 14 8 3 11

(}

I

2 ~)

4

1425

Cesarean hysterectomy

Volume 83 ~~umber 11

% 51.4 22.3 10.1 5.7 2.1 7.9

Table X. Pelvic indications for operation Uterine scars (Cesarean 188) (Myomectomy 2) Uterine rupture Pelvic neoplasms Fibroids Carcinoma ovary Dermoid Adenomyosis Placenta previa ( 3 accreta) Placenta accreta Amnionitis Couvelaire uterus Lacerated uterine artery Cancer of cervix (situ)

190 11 (5 previous)

23 1 1 1 6

6

7 2

1 1

group was on such a patient (6 hours). Two patients with diagnosed placenta previa had serious hemorrhage when low transverse incisions were used. The lacerated uterine artery occurred with manual extension of the transverse uterine incision. One of the Couvelaire uteri occurred in an unmarried 17-year-old primigravida. In an attempt to save the uterus both uterine arteries were ligated but hemorrhage was not controlled. The patients with amnionitis (with the exception of one who died) did very well postoperatively. Nonemergency indications. The extrapelvic indications for hysterectomy are shown in Table XIII. This group is selfexplanatory. In 24 cases no indication other than sterilization was given. It is our opinion that if one has only sterilization in mind, it can be accomplished in far more simple ways than by cesarean hysterectomy. Completion of a family can be one of the items

to take into account when making the decision about cesarean hysterectomy. Treating or preventing disesae must be our indication and, as we all know, the uterus is a potent source of trouble and, as previously noted, prophylactic removal of an organ after it has served its purpose or is functionless is gradually being more widely accepted. We have not followed Sandberg's11 classification of "indicated" and "elective" hysterectomies which may leave others with the thought that hysterectomy is "indicated" only for desperately ill patients as a lifesaving measure. Additional surgical procedures. Operations done in addition to cesarean hysterectomy are shown in Table XIV. Appendectomy was done electively in 23 cases, and in this series there was no complication directly traceable to this additional operation. The salpingooophorectomies were for disease or bleeding, and prophylactic removal was not noted except in the case of breast carcinoma with Table XI. Previous uterine operations Cesarean section

Myomectomy No previous operation

No.

t;t,

1

54

2 3

31

21.6 36.0

90

12

4 5

1

2 60

12.4

4.8 0.4 0.8 24.0

Table XII. Uterine ruptures Parity

Infant

3 6 5 3

4

Alive Dead Dead Dead Dead Dead

One previous section Low segment Low segment Classical Classical

8 7 3 3

Alive Alive Dead Dead

Two previous sections Classical

2

Dead

Etiology No previous section Failed forceps Failed forceps* Fall Spontaneous ( 34 weeks) ? Outside hospital ? Outside hospital

*Died,

1

1426 Morton

./•,..m.

Table XIII. Operative indications Abdon1inal adhesions Carcinoma of breast Coronary Cretin Dermatologic Diabetes Hepatitis Previous intestinal obstruction ( 3 times) One kidney and uterus didelphys Postpolio paralysis Psychiatric Rh incompatibility Scoliosis Thrombophlebitis Toxemia Varices StPrilization

2

1 1

5

2 1

2 3

3 24

Table XIV. Surgical procedures in addition to hysterectomy Sub-

ITotal I total Appendectomy Salpingo-oophorectomy (unilateral) Salpingo-oophorectomy (bilateral) Bladder closure Repair vaginal laceration Repair umbilical hernia

14

9

3 6 0 0

1 2 1 3

7

3

Table XV. Hemorrhagic complications Total Complication Intraperitoneal hemorrhage Vaginal hemorrhage Hematoma (pelvic) Hematoma ( subfascial)

Subtotal

(112)

(138)

No.I%

No.I%

1

0.89 1.7

3 1

2.6 0.89

2

2.1

3 6 3

4.2

0

0.0

2.1

Table XVI. Urinary complications

Complication Bladder opened Cystitis Pyelitis Vesicovaginal fistula Ureterovaginal fistula, failed repair, nephrectomy

I I

Total (112)

No. I% 6

5 2

I Subtotal I (138) No.I%

2 5.3 10 4.4 0 1.7 0.89 0

0.0 0.0

0

0.0

0.89

1.3

7.2

J.

June I, 1962 Obst. & Gynec.

metastases. The vaginal laceration occurred with uterine rupture. Prophylactic removal of the adnexa on one side would prevent future disease in that tube and ovary, and the remaining one would be more than adequate for hormone supply. Since we have never been able to decide how many ovaries 45 or more years old we would trade for even one woman dead of ovarian carcinoma we usually remove both ovaries at 45 or more and give oral hormones. The bladder closures will be discussed later. Complications. The postoperative hemorrhages that occurred in this series are shown in Table XV. One patient with total and 3 with subtotal hysterectomy had intraperitoneal hemorrhage. Two with total and 6 with subtotal procedures had vaginal hemorrhage. Pelvic hematomas probably occurred in greater numbers than indicated, but were not diagnosed because of the marked vaginophobia apparent in the progress notes. Hematomas usually were painful, often caused mild febrile reactions and often eventually drained spontaneously. All in this group were self-limited although some were large. The subfascial hematoma was asymptomatic, large, and easily palpable, which led to trouble we will review later. In this series it is obvious that there was less postoperative bleeding with the total than with the subtotal operation and that conservative treatment of hematomas is indicated. Urinary complications are shown in Table XVIII. During operation the bladder was opened six times with total hysterectomy and two times with subtotal. One of the six was opened voluntarily to check indigo carmine ureteral drainage. In all cases the bladder opening was recognized and closed and healing was normal and primary. The cystitis figures are probably inaccurate on the low side because of circumstantial evidence of cystitis without the diagnosis being made. The ureterovaginal fistula developed 14 clays postoperative, following a previously normal afebrile course and discharge from the hospital. Later repair by ureteral trans-

Volume 83

Cesarean hysterectomy

Number 11

plant (without ureteral catheter splint) was unsuccessful, and nephrectomy was done 14 days later. The vesicovaginal fistula measuring 4 by 1 em. was concurrent with a Streptococcus viridans pelvic abscess for which the patient was readmitted to the hospital 9 weeks postoperatively. Four months later this was repaired, and it healed satisfactorily after a stormy course of 35 hospital days. Bladder function following cesarean hysterectomy (Table X\1II) sho\ved that 82 per cent of the cases required catheterization 24 hours or less. In 12 per cent catheters were not used or needed. lnfections-nonurinary. Pelvic peritonitis was diagnosed by exclusion in a febrile case. Usually there was some accompanying distention (Table XVIII). Three of the patients with total and 11 with subtotal hysterectomy were considered to have had this complication, and none were of serious consequence. The patient with general peritonitis died. The other infections were rather evenly divided between the patients with total and those with subtotal hysterectomies. The percentage of "febrile" cases, based on the customary criteria, was 12.8 per cent ( 11.6 per cent of the total and 13.8 per cent of the subtotal) . Because of heavy antibiotic usage this figure probably is meaningless and too low, for such complications as proved pneumonia, thrombophlebitis, and pyelitis were present in patients who were "afebrile" according to the recorded temperatures. Reoperations. Reoperations precipitated by cesarean hysterectomy are shown in Table XIX. Four laparotomies were done on 3 patients: ( 1) intraperitoneal bleeding from the r.ervix; (2) intraperitoneal bleeding from the bladder flap after total hysterectomy; ( 3) a negative exploratory laparotomy after evacuation of an asymptomatic subfascial hematoma. This latter patient later developed an obstruction and was operated on the third time. Postoperative vaginal bleeding from the cervix in one case was successfully controlled through the vaginal approach. The fistulas have already been discussed.

1427

Table XVII. Postoperative bladder function ···-·····--~-··-·--~~- · · • " " " " " " " " " " " " -

1

No.

Catheterization 24 hours or less Catheter not used or needed

o/o

I

70 12

17 5 30

Table XVIII. Postoperative infections

Infection Pelvic peritonitis

General peritonitis Pulmonary infection Wound infection, abdominal Wound infection, vaginal Thrombophlebitis Phlebothrombosis

Total

Subtotal

(112)

(138)

No.I% 3 2.6

No.I%

0 5 3 1 1 1

7.9 1* 0.7 5 3.5 1 0.7 0 0.0

11

0.0 4.3 2.6 0.89 0.89 0.89

1 0

0.7

0.0

Table XIX. Reoperations Subtotal

Laparotomy cervical bleeder Vaginal closure cervical bleeder Laparotomy, exploratory after subfascial hematoma evacuation Laparotomy, No. 3 intestinal obstruction Laparotomy, multiple bladder flap bleeders Vesicovaginal fistula repair (vaginal and abdominal) Ureterovaginal fistula repair, left (ureteral transplant)

1 1

Surgeons' comments. It was thought that some of the comments made by the operators would be of interest, and these are listed in Table XX. The most common complaint was of a thin lower segment and many times it was described as transparent. By literal translation of descriptions one would have a high per cent of occult, nondramatic uterine dehisccnces. The next most frequent complaint was difficulty in dissecting the bladder flap; then "high" bladder flap. On five occasions intended total hysterectomies were abandoned because of shock, low-lying placenta, and bladder flap difficulties. Perhaps it is possible to lessen bladder flap problems. The cesarean section patient is the

1428 Morton

Am.

Table XX. Surgeons' comments Bladder flap difficult Bladder flap high Thin lower segment Scarred lower segment Abandoned attempt at total: Shock

25 17 32

2 1

1 3

Table XXI. Nonroutine surgical procedures Amputation of fundus Cervix incised Drains Finger through cervix Gelfoam to bladder "Intrafascial" incision Longitudinal incision Oxytocic Uterine

20

8 14

14 1

2 29

most likely candidate for cesarean hysterectomy at a later time. Displacement of the bladder to make a low incision is routine. After uterine contraction under it, the bladder remains high and the peritoneum is reattached higher than normal, sometimes very high. With the next section the same mechanism occurs and the problem is accentuated. With a slightly higher low segment incision and replacement of the bladder and flap to a normal position we might be able to leave a small undissected plane to work with later when performing a total hysterectomy. The thin low segment can be a problem but not usually. One must be careful not to include any endometrium when cutting pedicles. Operative technique. Recommendations regarding special techniques for total ce-

J.

June 1, 196'2 & Gyrwc.

Ob~t.

sarean hysterectomy have been outlined by Bradbury/ Davis/ Montague,S and others. However, many surgeons are still using the same technique used in the removal of the nonpregnant uterus. Table XXI shows some of the nonstandard techniques used that facilitated the hysterectomy. The fundus was amputated twenty times prior to cervical removal. Perhaps this was done because nearly 90 per cent of the uterine incisions were transverse. Very likely there was frequent anterior gaping of the incision and amputation was done to obtain equal traction on the cervix. We prefer a low longitudinal incision which is first closed. The fundus is then a very efficient tractor. We rechecked techniques of the total hysterectomies accomplished without transfusions or with very little blood loss, and in nearly all there was direct control of cervical removal either by posterior vaginal incision~ anterior longitudinal incision of the cervix, or by inserting a finger through the cervix. Many operators did not use an oxytocic; very few used uterine packing; none noted attaching the uteroovarian stump to the round ligament as recommended by Bradbury; a few were still attaching this ligament to the cervical or vaginal stump. Davis recommends using Gelfoam under the bladder flap laterally to minimize hematomas, but this technique was noted only once. We found no comments about problems with a dilated cervix except in a few of our personal cases. We have had difficulty with land marks when the cervix was over 4 em. dilated and have had some success injecting oxytocic directly into the cervical area and relaxing fundal traction for a period to allow

Table XXII. Maternal mortality

Shock (ruptured uterus) Amnionitis, pelvic thrombophlebitis Cancer of breast, metastasis ( 5 months postoperative) Cancer of ovary, metastasis

0 0 0 1 0

0.89

1

0.7

1 1

0.7

0 1 ( 3 months postoperative)

0.7

0.7

Volume 83

Cesarean hysterectomy

Number 11

the cervix to recontract enough for definite identification. We do not use uterine packs or allow the placenta to remain in the uterus because they may drop and stretch the lower segment. Maternal mortality. There were 5 deaths in the group caused by general peritonitis, shock, amnionitis with pelvic thrombophlebitis, metastatic ovarian carcinoma, and metastatic breast carcinoma, respectively (Table XXII) . The deaths from carcinoma occurred later and were not related to the hysterectomy. Mortality figures have been corrected to 1.2 per cent by elimination of these. The patient dying of peritonitis had had a cesarean hysterectomy, subtotal, for sterilization. She was a 40-year-old gravida viii, para v ( 1 abortion) who weighed 27 4 ponds. She had been discharged home on the fifth postoperative day feeling well but febrile and on antibiotics. She was readmitted 11 days later complaining of 3 days of diarrhea followed by vomiting. The hemoglobin level was 5.1 Gm. and the white blood count was 91,000. She was given 9 pints of blood and treated with heavy antibiotic therapy but died 7 days later. Autopsy showed multiple abdominal abscesses. She did not call her doctor when she became ill because she did not want further hospitalization. The patient who died in shock was a gravida vii, para vi, aged 34, in whom labor was induced with intravenous oxytocin because of ineffective intermittent uterine contractions. At complete dilatation, a forceps delivery was attempted and failed under pudendal block. The patient went into shock and a ruptured uterus was diagnosed. In spite of seven transfusions, a subtotal hysterectomy, and open heart massage she died on the table. The infant was stillborn. The death from amnionitis was that of a gravida v, para iv, aged 35, whose membranes ruptured at 36 weeks, 10 days before admission to the hospital. Eight days later she had chills and fever and consulted a chiropractor who gave her 400,000 units of penicillin orally. On admission she was nearly moribund and a subtotal hysterectomy was done under hypothermia in an attempt to

1429

eliminate the infected focus. Two transfusions were given and thoracotomy and tracheotomy were done unsuccessfully for cardiac arrest on the table. The blood culture was positive for Streptococcus viridans. The infant was described as macerated and premature. This death could probably have been prevented had the patient made use of medical facilities available to her. Summary

1. Two hundred and fifty cesarean hysterectomies done at three Los Angeles Hospitals have been studied and an effort made to compare the total and subtotal techniques. 2. It was found that hemorrhagic and inflammatory complications were less with the total than with the subtotal hysterectomy. Blood loss, operating time, and urinary complications were greater with the total techniques. 3. The five maternal deaths were due to infection ( 2) , carcinoma ( 2) , breast and ovary, and shock ( 1). One of these cases was in the nonemergency group. Conclusions 1. Cesarean total hysterectomy can be safely performed prophylactically and therapeutically in well-equipped hospitals by trained gynecologists, and in many instances should replace the subtotal and simple sterilizing operations. 2. Utilization of suggested technical modifications of usual hysterectomy technique will facilitate accomplishment of cesarean total hysterectomy. We wish to thank the many doctors who have allowed us to review their private records. Without exception or reservation, permission was granted. Also we wish to thank Dr. M. Edward

Davis of the Chicago Lying-in Hospital for al· lowing us his most recent data previous to publication elsewhere. REFERENCES

1. Bixby, G. H.: Extirpation of the Puerp<"ral Uterus by Abdominal Section, J. Gynec. Soc. Boston, 1869. 2. Bradbury, W. C.: West. J. Surg. 63: 232,

1955.

june 1, 1962 Am. J. Obst. & Gyncc.

1430 Morton

3. Davis, M. E.: AM. J. 0BsT. & GYNEC. 62: 838, 1951. 4. Davis, M. E.: Personal communication. (In press.) 5. Hallatt, J. H., and Hirsch, H.: AM. J. 0BsT. & GYNEC. 75: 396, 1958. 6. Koren. Z.. Zuckerman, H., and Brzezinski, A.: Obst. &Gynec. 18:. 138, 1961. 7. Kostic, P., Meadenovic, D., and Price, A.: Srpski Arch. celok. !ek. 87: 745, 1959.

Discussion RALPH C. BENSON, Portland, Oregon. Dr. John Morton's stated purpose was to determine whether total cesarean hysterectomy is a dangerous operation and, if so, how its hazards can be reduced-assuming that the subtotal is reasonably safe but not as desirable as the total procedure. As a reader already won to the proposition that cesarean hysterectomy is an important operation which should be employed more often, I was eager to identify with the author. We still arc "close" but not in apposition because the presentation is involved and some of the essential background material either is incomplete or is omitted altogether. The author divides his cases into the type of hysterectomy, either total or subtotal, but he does not consider the type relative to those medically indicated ( 76 per cent) and those done electively (34 per cent). Choice is important and the total operation is often better, but there may be no election: the patient in shock is usually a candidate for a subtotal and a patient with placenta previa accreta requires a total hysterectomy. Moreover, an investigator considering the subject of cesarean hysterectomy is obliged to compare the operation of cesarean section (perhaps low cervical) not accompanied by hysterectomy with cesarean section followed by one or another type of operation for removal of the uterus and/ or tubes. Nevertheless, certain facts allowing reasonable deductions are presented. Initially, let us consider the dangers and problems of cesarean hysterectomy as reflected by this material: The average time for the subtotal operation was 1V4 hours; the total took almost twice as long. I estimate that subtotal hysterectomy requires about 15 minutes more than the usual low flap cesarean section but nowhere could I find DR.

8. Montague, C. F.: Obst. & Gynec. 14: 28, 1959. 9. Quinlivan, W. L. G.:]. A. M. A. 176: 1035, 1961. iO. Porro, E.: Deila amputatazione utero-ovarian come complemento di taglio cesareo, Milan, Rechiedei, 18 76. 11. Sandberg, E. C.: Obst. & Gynec. II: 59, 1958. 12. Webster, A.: West. J. Surg. 69: 255, 1961.

the average time required for cesarean section

only. At least twice as much blood is required for replacement for total as compared with subtotal cesarean hysterectomy. Hemorrhagic complications occur with either type of cesarean hysterectomy. Although intraperitoneal bleeding requiring re-entry was stated to be more common with subtotal cesarean hysterectomy, if one combines the cases of pelvic hematoma with those having acute intra-abdominal bleeding, there is little difference in the rate of concealed postsurgical hemorrhage in the two procedures. Urinary tract injury is six times as likely during the total as compared with the subtotal cesarean hysterectomy and it may be more serious than mere recognized laceration of the bladder. Dissection of the bladder from the lower uterine segment and cervix is the most troublesome point in technique, especially with total hysterectomy. Posthysterectomy operations were required with equal frequency in patients who had a total or a subtotal cesarean hysterectomy. Regrettably, the author does not afford actual over-all morbidity figuregc-true, urinary and nonurinary infections are tabulated. These are not enough, of course. The rate of occurrence of urinary infection is similar, however, for both the complete and incomplete operation. Peritonitis was almost three times as common in patients having a subtotal procedure, however. Case selection is important here also. Three deaths in 250 cesarean hysterectomies ( 1.2 per cent) were related to the problems of pregnancy and delivery ( 2 to sepsis) and all were in the subtotal group. No maternal deaths were due to the hysterectomy as such, apparently, although one would like to be more certain of this. Using Dr. Morton's figures to determine whether total (or subtotal) cesarean hysterec-

Volume 83 Number 11

tomy is a dangerous operation, I should have to conclude that either operation is hazardous on occasion and that total cesarean hysterectomy is definitely more serious. Numerous helpful details in technique and prophylaxis are stressed by Dr. Morton to make cesarean hysterectomy less formidable: 1. Avoid high advancement of the bladder in routine cesarean section to prevent functional and surgical problems in the future. 2. Employ a longitudinal incision for better traction in cesarean hysterectomy. 3. Administer an oxytocic (ergot derivative) to reduce blood loss and to contract the cervix, making total hysterectomy easier. 4. Insert the finger through the cervix to aid in the dissection of the bladder from the cervix and vagina in the total operation. A number of interesting details discussed by the author should be mentioned because they reveal local trends or policy: The total operation was done almost twice as often at the Los Angeles County Hospital as in two private institutions. Again, perhaps a greater number of complicated cases requiring the complete operation overshadowed eagerness on the part of the residents to elect more extended surgical procedures. Seventy-eight per cent of patients subjected to cesarean hysterectomy were under 35 years of age and a parity of over 4 was admitted by only 15 per cent. Hence, this operation is being applied to the younger woman with a fair-sized family rather than to the elderly multipara in the three Los Angeles hospitals. Operations in addition to hysterectomy rarely included prophylactic oophorectomy, but appendectomy was elected in 10 per cent of the group. These are both creditable attitudes. From this experience and approximately 180 additional cesarean hysterectomies from Portland, partly reviewed by Montague ( Obst. & Gynec. 14: 28, 1959), it would appear that critical complications are not frequent with either the incomplete or the complete operation done electively. I believe that the experienced obstetrician should perform a total rather than a subtotal procedure whenever the uterus should be removed after cesarean section. Elective to· tal hysterectomy after uncomplicated cesarean section carries a slightly greater hazard than tubal sterilization, but in the majority of patients this risk is more than offset by the benefits derived.

Cesarean hysterectomy

1431

DR. RoBERT H. FAGAN, Beverly Hills, California. Once in discussing hysterectomies in general, Emil Novak, who subscribed, of course, to the policy of always doing a total cesarean section, mentioned that some operators said it was just as easy to do a total hysterectomy as a subtotal, and his remarks were, "Well, I just don't believe it," and I just don't believe that it is as easy to do a total hysterectomy following a cesarean as a subtotal. In a nonpregnant woman you are operating upon a uterus that exhibits some reason for its removal other than sterilization. When a woman is pregnant your primary function is to deliver a good baby, and I have never been in favor of surgical acrobats who try to do more than is needed. I ¥.till admit that "'.rhen one is doing a cesarean

hysterectomy it is advisable to do a total hysterectomy in certain uncomplicated cases. As a matter of fact, the slight edema that occurs at term often outlines the fascial plane so that it is quite easy for an experienced operator to do a total hysterectomy following a cesarean section. I would be very reluctant for this organization to go on record as recorrnnending this as routine procedure, because I believe that if it is generally accepted there will be a lot of men who will think, "Well, this is the thing that the Pacific Coast Society recommends; it is the thing to do," and I feel quite convinced that there will be a great deal more morbidity resulting from such procedure. DR. KARL L. ScHAUPP, JR., San Francisco, California. I feel, as does Dr. Fagan, that we should be careful in recommending this as a routine procedure. In the past year in San Francisco there were seen at least 2 cases of patients who required reoperation because of postpartum postoperative bleeding following a total hysterectomy. Both had to have a ligation of the hypogastric artery. There is a tendency to consider this a harmless procedure. There were obviously more complications in the total hysterectomy group reported by the essayist. I was surprised that there were not more infections or other morbidity. The operating time is longer and there were more transfusions. There is obviously more risk of homologous semm jaundice, for the more transfusions the more risk. If you are treating disease when you do a hysterectomy, as in the nonpregnant state, the

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June 1, 1962 Obst. & Gynec,

risk you take is justified or you would not be doing the operation. If you are doing a hysterectomy on a woman to sterilize her, you have got to babnce the extra risk you are taking against what you are accomplishing. You can accomplish the same thing by a tubal ligation, which does not add appreciably to your operating time or to your risk. Also many of the young women I see like to go on n1enstruating. This is something that was not shown in the paper. What is the psycholo,gical impact on these people in the next year? If you remove the uterus from a 25-year-old girl, how does she feel about it in 2 or 3 years? Certainly for me a subtotal hysterectomy is easier than a total. I would hate to have an organization such as this sponsor total hysterectomy over other alternatives.

reaction. Actually it was a mismatched transfusion. The reason it was mismatched is because the house staff short-circuited the usual safeguards because the woman needed a lot of !Jiood ill a hutry, and the reason she needed a lot of blood in a hurry was because she was losing excessive quantities of blood during the performance of an elective total hysterectomy, and I think we have to charge that death to the performance of the total hystcr~cton1y in this instance. I would like to reiterate that whereas subtotal hysterectomy appears to be a dirty word among our existing house staff mt:mhers, I think that we have to look at it from the standpoint of the ultimate safety to the mother and balanrl' the risk against the risk of carcinoma of thr: stump.

DR. ERNEST W. PAGE, San Francisco, California. I want to take slight issue with the first discussant, Dr. Benson, who presented some very beautiful arguments why routine total hysterectomy should not bc done after cesarean section and then for some reason made an about face and concluded that under ordinary circumstances it should always be a total hysterectomy because of the bPnefits derived. Now, these benefits that derive, I take it, Dr. Benson, and I presume Dr. Morton is also advocating this stand, arc primarily the prevention of carcinoma of the CPrvix. '1\'e would have to do SOO to 1,000 total hysterectomies in order to prevent one carcinoma of the cervix. If in doing a thousand total rather than subtotal procedures we should lose one patient, I doubt that it is worth this effort. Last year we lost a patient from a transfusion

DR. MoRTON (Closing). Tht:re is little followup except personal experience with some of thr~ patients I know personally. There is a rather large number of private patients where thP follow-up will probably be satisfactory, hut the county patients have almost all disappeared. There is a tendency to feel "safe" ahout doing a subtotal procedurP. The surgPon believes he can close it off well. Our data point out that you have just as much, or more, bleeding from the cf'rvix that is left as you do with a total opt'ration. \Vhether you are mor.' careful with it whr>n you arc doing a total I do not know. Then~ is also no greater infection, perhaps !t•ss. \1\'c have tried to make the point that in choosing between a subtotal and a total operation, if you are a surgeon of the quality that belongs to this group you can probably handle a total as well as you can a subtotal.