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Culdotomy: A method of evaluating the pelvis
Culdotomy: A method of evaluating the pelvis F.
J.
Milwaukee,
HOFMEISTER,
M.D.,
F.A.C.O.G.
Wisconsin
This report is based on 502 culdotomies performed by the author and his associates. Culdotomy, historically, commonly, and erroneously designated colpotomy, relates to the technique of entering the cul-de-sac of Douglas for diagnosis as well as for definitive surgical procedures. Ovarian biopsy, ovarian wedge resection, ovarian removal, and tubal interruptions, as well as treatment of ectopic pregnancy and some infertility operations, can be accomplished. Of the 502 culdotomies, 293 were performed for tubal interruption. The last 25 were performed by the author under combined infiltration, amnesic, and analgesic medications. The remaining 209 were done for diagnosis and other surgical procedures. There were nine complications: three required abdominal intervention.
C u L n 0 r 0 MY, a means of investigating the pelvis for diagnosis and therapy, is better recognized by various names. The most common error of designation is that of “colpotomy.” This, by definition, means “incision of the vagina.” “Colpotomy,” curiously enough, is the most widely adopted. Other designations have been posterior colpoperitoneotomy, posterior colpoceliotomy, posterior vaginoperitoneotomy, and posterior vaginoceliotomy. The standard term defining precisely what is done is culdotomy. It is interesting to note that the technique of “colpotomy” was generally used to describe the insertion of a trocar to drain the pelvis when abscess formation or ovarian cysts were thought to exist. Historically, Joachim Fredrich Henckel, in 1760, is recorded as the first to “tap a cyst per vaginam.” A. Pelleton is credited with first draining a tubo-ovarian abscess “per vaginam” by a “colpotomy,” in 1835. Ricci also documents vaginal pro-
cedures to remove abdominal pregnancies and diagnose ectopic pregnancies. Of late, the use of the vagina as an approach to tubal ligation has gained popularity. Actually, the late Dr. N. S. Heaney,3 responsible for the “reincarnation” of vaginal surgery in America, and Dr. Edward Allen performed “colpotomy” as a routine procedure for diagnostic therapy at Presbyterian Hospital (now Presbyterian-St. Luke’s-Rush Medical Center) in Chicago. Dr. Allen2 reported the removal of a right ectopic pregnancy through “colpotomy” in 1936 and a left ectopic pregnancy by “colpotomy” in the same patient in 1938. This procedure was widely used as a diagnostic tool for investigating pelvic pathology and the author, as one of their former residents, has used this procedure in increasing numbers since 1947. Previously, as a preceptee in general surgery, he also performed posterior “colpotomy” for cul-de-sac drainage. article+ 4, 6, 7, ’ have Though multiple been written about results, complications, and analyses of series accomplishing vaginal tubal ligations, only McMaster and Ansari have illustrated their approach. Of interest, also, is the fact that all methods of tubal interruption, except “colpotomy,” are discussed in the Proceedings of the recent Fourth Annual Meeting of the International Family Planning Research Association, Inc.
From the Department of Obstetrics and Gynecology, Lutheran Hospital of Milwaukee, Department of Gynecology and Obstetrics, Medical College of Wiscomin, and Milwaukee County General Hospital. Presented at the Forty-first Annual Meeting of the Central Association Obstetricians and Gynecologists, Scottsdale, Arizona, October 18-20, Reprint requests: 10425 W. North Wisconsin 53226.
of 1973.
Dr. F. J. Hofmeister, Ave., Wauwatosa,
39
40
May 1, 1974 Am. J, Obstet. Gynecol.
Hofmeister
Is it by oversight or deliberate disregard that culdotomy, or “colpotomy,” is not mentioned? The author will refer to the approach for procedures done in the cul-de-sac as culdotomies. Culdotomy is an incision into the cul-de-sac. It is a practical means of investigating the pelvis to determine the status of the uterus, tubes, and ovaries, and it is an essential step in all vaginal hysterectomies. For the past 10 years, it has been the first and principal step in our vaginal hysterectomy technique. Though the incision for vaginal hysterectomy is made differently from the incision used in routine culdotomy, within 1 cm. to 1.5 cm. from the posterior lip of the cervix instead of in the redundant tissueof the region of the cul-desac, the goal is the same. It is made to visualize the open pelvis through the cul-desac. It permits evaluation of the character of the peritoneal fluid: clear, turbid, bloody, or purulent. It permits palpation of the structures. Are they unusually enlarged or adherent? Are all structures freely movable? With this knowledge, additional steps can be taken to successfullycomplete a vaginal hysterectomy or a decision can be made to take another route. When a culdotomy alone is planned as a diagnostic procedure for suspected ectopic pregnancy, diagnosis and resection of ovarian disease, or for tubal ligation, the transverse incision is made in the region of the redundant tissue of the cul-de-sac between the uterosacral ligaments and about 5 cm. from the posterior lip of the cervix. A total of 502 culdotomies, of which 293 were performed for tubal interruption and 209 for diagnosisand ovarian surgery by the author and his associates,* form the basis of this presentation. Nine complications occurred. Five were associatedwith tubal interruptions (1.7 per cent). Two of these were associated with undiagnosed preoperative salpingitis. Antibiotic therapy resolved the condition. Two complications were associated with postoperative cuff bleeding ‘Drs. Vondrak,
W. P. Wendt, R. P. Reik, and W. E. Martens.
W.
R. Schwartz,
B. F.
and one was associatedwith a postoperative hematoma and abscessformation. An abdominal hysterectomy, six weeks postoperatively, resulted in cure, Four complications were associated with culdotomies done for diagnosis or tuboovarian surgery. Of these, one was secondary to resection of an ectopic pregnancy with subsequent abscess formation. Antibiotics and spontaneous drainage resulted in cure. That patient was recently delivered of a normal infant. One was secondary to ovarian resection. Intra-abdominal bleeding required a laparotomy. One, secondary to ovarian resection, required incision and drainage of a pelvic abscess.One complication secondary to ovarian removal resulted from ovarian vesselsbleeding. A laparotomy was required to ligate the bleeding vessels. In the uncomplicated cases, patients for tubal interruption were discharged from the hospital 42 hours after admission.There have been no pregnancies in the 293 tubal interruptions. Complexities of hospital administration, insurance programs, and especially fear of malpractice suits prevent early morning admissionand afternoon discharge; these need to be eliminated if an hourly charge rather than an automatic 48 hour charge is to be accomplished. The stay for patients when operations for diagnosis or ovarian pathology were done averaged 72 to 96 hours. Procedure
Preliminary evaluation of the patient always includes a Papanicolaou smear, an attempt to detect pathogens in the vagina, and a culture for gonorrhea. Any vaginitis should be eliminated before surgery is undertaken. An attempt must be made to detect the potential of all episodes of chronic or recent pelvic inflammatory disease by accurate history and pelvic examination. In anticipation of any vaginal surgery, the vagina is adequately prepared. This routine preparation is in addition to adequate therapy for specific infections, Trichomonas, Monilia, or gonorrhea. For the past five years the author has routinely used, when specific infections do not exist, preoperative,
Volume 119 Number 1
Culdotomy
41
Fig. 1. A, Culdopack. Compare with scale (E). C, Emmett hooks, 9% in long; D, E, long Allis clamps, 7 5 in. ; and F, long Babcock clamps, 9 in. self-insertion of Gantrisin cream, v* applicator, three times weekly at night until the week before surgery and nightly the week before surgery. Betadine douche may be used occasionally to cleanse the vagina if the cream becomes bothersome. Anesthesia-analgesia If the patient could be admitted on the morning of surgery, she could be discharged the following morning by 10 A.M.-~ interval of about 27 hours. The actual procedure may be done with a general anesthetic or, preferably, with neurolept analgesia and local infiltration anesthesia. One hour before surgery, 75 mg. of Demerol or 8 to 10 mg. of morphine sulfate is given intramuscularly. When the patient is settled on the table and intravenous administration of lactated Ringer’s solution is started, neurolept analgesia is given.* This consists of the administration of 5 mg. of morphine *Dr. William Rouman, anesthesiologist at Lutheran Hospital of Milwaukee, has recommended neurolept analgesia using Valium and morphine sulfate in preference to the more potent Innovar, which is a commercial mixture of fentanyl and droperidol.
sulfate and 5 mg. of Valium (both given slowly intravenously). Depending on the reaction to the medication, this dose of Valium may be repeated in five minutes. When the actual surgery is started, a third dose of 5 mg. of Valium and, if necessary, 5 mg. of morphine is administered. The patient responds very little to the infiltration of NeoSynephrine and lidocaine. When the cul-desac is opened, 5 C.C. of one per cent lidocaine is deposited by hypodermic syringe into the cul-de-sac. This results in peritoneal anesthesia. No Neo-Synephrine is used. The patient may respond a bit when the Allis or Babcock clamp grasps the ovarian ligaments. No patient has complained. After the Culdopac has been removed and sutures to close the culdotomy have been placed, the patient is given 0.4 mg. of Narcan intravenously and, in addition, 10 mg. of Ritalin may also be given. Within a very few minutes the patient responds to questions. The big advantage is the great analgesic and amnesic quality. Respiration and pulse must be monitored. After complete relaxation, the patient is
42
May 1, 1974 Am. J. Obstet. Cynecol.
Hofmeister
Fig. 2. Neo-Synephrine posterior
and
lidocaine
infiltration,
uterosacral.
placed in the lithotomy position with the buttocks two inches beyond the table edge. Shaving of the perineum is confined to the immediate lateral and posterior areas of the vulva. Routine vaginal preparation is accomplished by the method of individual choice and experience, i.e., that which is considered the best in a particular institution. As a final preparation, the author suggests that the gynecologist should also cleanse the vagina with aqueous merthiolate and personally catheterize the bladder. Operative
technique
The labia are not sutured laterally when local anesthesia is used and need not be sutured under general anesthesia. A midline perineotomy may be done to facilitate the operation when culdotomy is done as a diagnostic procedure in nulliparous patients. Nulliparity is not a contraindication to the vaginal procedure. The perineotomy is made after local infiltration of the perineum. Tenaculi are placed on the anterior and posterior lips of the cervix. Figs. 1 through 11 demonstrate technique. Approximately
Fig. 3. Transverse
line indicates area for incision in vaginal hysterectomy. Redundant area indicates position of culdotomy incision.
20 cc. of the solution of one per cent NeoSynephrine in one per cent lidocaine is used for infiltration of the vaginal skin of the portio of the cervix and the paracervical tissue. Of importance is actual parametrial penetration for injection of the solution. The area of the anticipated incision is also infiltrated. This solution is made by combining 1 cc. of one per cent Neo-Synephrine and 100 C.C. of one per cent lidocaine. This is a 1: 10,000 solution and has been effective as an anesthetic as well as free of significant complications such as prolonged hypertension. A uterine probe is used to determine size and position. Some use the probe or a similar instrument to assist in retroverting and retroflexing the uterus when culdotomy is done.8 This can be hazardous. Perforations can occur. We have found this generally to be unnecessary. Endocervical and endometrial curettage is always done. The cervix is drawn downward and forward by the assistant. The redundant tissue tif the culde-sac is demonstrated with a tissue forceps. A deliberate transverse incision is made with a Mayo scissors. Often the cul-de-sac is
Volume Number
119 1
Fig.
Culdotomy
4. Actual
cul-de-sac
exposure.
entered immediately. At times, a second placement of the tissue forceps will be necessary and a second incision made through the peritoneum. Once opened, the cul-de-sac is inspected. Note is made of the type of fluid encountered. Beware of the turbid fluid. Unclotted blood may indicate the existence of an ectopic pregnancy. The cul-de-sac is inspected by palpation to determine areas of adhesions, mobility, and size of tubes and ovaries. A Culdopac is inserted. This is a convenient, miniature pack with a band for tagging. The author has used the Culdopac since the Presbyterian days and it is the most practical type of pack developed. If more room is necessary, a small vertical incision may be made in one or both of the upper and lower edges of the incision at the midline of the transverse culdotomy incision. One per cent lidocaine (5 c.c.) , without Neo-Synephrine, is injected into the cul-desac for local peritoneal anesthesia. An Emmett hook, not the right-angle hook, but the complete hook, nine inches long, is used to stabilize the uterus. The tenaculi as well
Fig. into
5. Insertion cul-de-sac.
Fig.
6. Hook
of 5 C.C. of 1 per
levers
uterine
corpus
cent
43
lidocaine
to patient’s
left.
as the uterine probe, if used, are removed and complete retroversion and retroflexion of the uterus become a reality. The corpus is levered to either the right or left side at the discretion of the gynecologist by “walking” the hooks toward the junction of the corpus and the ovarian ligament. No tearing or
44
May 1, 1974 Am. J. Obatet. Gynecol.
Hofmeister
Fig. 7. Actual photograph of ovary in view and adjacent fimbriated end of tube (both tubal and ovarian surgery possible). Long Babcock clamp holds ovary.
Fig. 8. Mixter clamp in place. Distal one third of tube and fimbria clamped in preparation for ligation and removal.
Fig. 9. Segment onstrated.
removed
and
ligated
stump
dem-
bleeding, such as frequently occurs with a tenaculum, is encountered. The delicate size of the hook eliminates the significant Meeding. The ovarian ligament is grasped with a Babcock or a long Allis clamp. The ovary is delivered and inspected. The fimbriated end of the tube falls into view. It is easily identified and the tube is inspected for pathology. The tube is grasped in midportion if a Pomeroy or modified Pomeroy is planned or at the fimbriated end with an Allis clamp if a resection of the distal one third, including the fimbria, is done. A right-angle, longhandled Mixter is placed to clamp the tube in either procedure; 00 chromic catgut is used for ligation ; a second 00 chromic suture is also placed in the same site. The sutures are always placed distal to the crushed area. The loop or the distaI segment of the tube is then removed. The ovary and the area from which the tubal segments have been removed are carefully inspected to be certain of no coincidental pathology and of hemostasis and then repositioned into the pelvis. The procedure
Volume Number
119 1
Fig. 10. Midportion of tube tion for Pomeroy or Madlener.
Culdotomy
clamped
in prepara-
is repeated on the opposite tube. Ovarian resection or removal can also be easily accomplished. If done, double-row suture, 00 chromic catgut is used. The first row is a double mattress stitch. The second is a lock stitch. Closure of the culdotomy is accomplished with Dexon 00. Special attention is directed to securing the perineum at the corners of the culdotomy incision. This aids in eliminating postoperative hemorrhage. Only four sutures are placed for closure. These are placed in figure-of-eight manner. The closed incision is inspected. The uterus is raised into the anterior position either by using a tenaculum or gently inserting t.he uterine sound. The neurolept analgesia can be reversed almost completely with the use of 0.4 mg. of Narcan intravenously. Ritalin (10 mg.) may be given in addition for more complete reversal. The patient is returned to the recovery room and could be discharged four to six hours later. It is advisable that she stay until the following morning. Approximately 25 to 30 minutes is the average time for the procedure from the first injection to reversal.
Fig. 11. Closure with four Dexon purse-string suture of corners.
00 sutures.
45
Note
During the past year, all patients were given 1,000 mg. of Keflex, orally, daily for five days, starting 24 hours preoperatively, as a prophylactic agent. Very occasionally, nausea and/or dizziness can occur for several hours after the reversal of the neurolept analgesia. Postoperatively, sexual contact is not advisable for four weeks. The patient is requested to use Gantrisin vaginal cream three times weekly. If closure has been accurate, there will be no granulation tissue. If her work is not strenuous, she may return to work as soon as she desires. Laparoscopy, culdoscopy, and even laparotomy may be the approaches of choice in some instances, but remember that the pelvis can be investigated by dilatation and curettage and by direct vision and palpation for ectopic pregnancy, ovarian tumors, definitive procedures, ovarian surgery, tubal ligation biopsies, and ovarian resections, and that these can efficiently be accomplished by culdotomy. This is an efficient and practical approach to the pelvis for diagnosis and therapy and it belongs in first place in the available aids of the gynecologist.
46
Hofmeister
REFERENCES
1. Akhter, M. S.: AM. J. OBSTET. GYNECOL. 115: 491, 1973. 2. Allen, E.: AM. J. OBSTET. GYNECOL. 38: 717, 1939. 3. Boysen, H., and McRae, L. A.: AM. J. OBSTET. GYNECOL. 58: 488, 1949. 4. John, A. H., and Dunster, G. 0.: J. Obstet. Gynecol. Br. Commonw. 79: 381, 1972. 5. McMaster, R. H., and Ansari, A. H.: Obstet. Gynecol. 38: 44, 1971.
Discussion H. BEATON, Grand Rapids, Michigan. The cul-de-sac is a thin partition which excludes the outside world from the secrets within the female pelvis. Any gynecologist who is willing to master the basic fundamentals can learn to open this door, take a good look, and do his thing. Dr. Hofmeister has demonstrated the usefulness of culdotomy, not only for evaluation but also for the treatment of pelvic problems. Curiously, his presentation comes at a time when our specialty is being showered with gleaming fiberoptic scopes for culdoscopy and laparoscopy. Whether this transvaginal operation should be termed culdotomy or colpotomy is merely an exercise in semantics. Whatever you call it, the name is not as important as how wet1 you do it! Dr. Hofmeister does it well, as many of you have observed in his movies and personal performances. Nine complications in 502 operations, with prompt response to treatment without death, is a good performance. Bleeding and infection are always a challenge in pelvic surgery. Six of the nine complications were due to bleeding or infected hematoma. Careful hemostasis can usually prevent this and early probing insures drainage of infected pockets of blood. In several hundred colpotomies done by our group, there were only a few postoperative infections. They responded readily to simple drainage and antibiotics. There was no death and no need for abdominal exploration. Dr. Hofmeister reported one complication of bleeding ovarian vessels which required laparotomy. Ligation of ovarian vessels in transvaginal surgery is challenging for two basic reasons: exposure is limited and the fragile pedicle is easily torn by an ambitious operator. This is what makes televised surgery so exciting for the audience and so humiliating for the operator. This complication can be avoided by putting DR.
JAMES
May 1, 1974 Am. J, Obstet. Gynecol.
6. Roe, R. E., Laros, R. K., and Work, B. A., Jr.: AM. J. OBSTET. GYNECOL. 122: 1031, 1972. 7. Sagolow, S. R.: Obstet. Gynecol. 38: 888, 1971. 8. Shute, W. B.: AM. J. OBSTET. GYNECOL. 115: 998, 1973. 9. Smith, R. A., and Symmonds, R. E.: Obstet. Gynecol. 38:400, 1971.
two clamps on the ovarian pedicle. First, replace the proximal clamp with a cautiously applied ligature. Then replace the distal clamp with a firm tie. Dr. Hofmeister uses the Emmet hook on the back of the uterus to pull the adnexa down into view. I wonder if this creates a site for postoperative oozing, which leads to an infected pool of blood? We use a smooth retractor to elevate the uterus, thus allowing the adnexa to drop into view. Visualization is further increased by tilting the head of the table downward about 30 degrees. It is then better for the operator to stand. Many scientists say that you cannot sterilize the vagina. However, most pathogens can be inactivated by a vigorous Betadine scrub follow by five minutes of “marinating” the vagina with full strength Betadine. Since Betadine was the first choice for the space capsules, we believe it should effectively cleanse the vagina. I agree with Dr. Hofmeister that infiltration of the vaginal wall with a vasoconstrictor provides excellent hemostasis. Thus, one is less apt to leave a pool of blood in the pelvis for bacterial incubation postoperatively. For years we used the 1 : 10,000 Neo-Synephrine solution and noted hypertensive reactions in several patients. Our anesthesiologists have now convinced us that a 1 :200,000 solution of epinephrine provides excellent hemostasis without the alarming hypertensive effects. My experience in tubal ligation is nil. As Department Chairman in a large Catholic hospital, my sterilizing procedures have been limited to scrubbing the vagina with Betadine. Since I routinely perform ovarian wedge resection on nulliparous women transvaginally, tubal ligation would be relatively easy to do in this manner, especially on multipara. I share the same enthusiasm for transvaginal surgery as Dr. Hofmeister. Our group uses colculdoscopy, and laparoscopy in the pow,
Volume Numb&
119 1
practice of gynecology. We urge our residents to learn all of these methods while in training. Later they can fit each to the needs of their practice. DR. HOFMEISTER (Closing). We use 15 degrees Trendelenburg routinely in all of our cases. The Emmett hook is an atraumatic type of instrument which aids in bringing the fundus of the uterus down easily. In not all cases that we have done would the fundus “fall down” as my eminent discussant indicates. There are some more difficult situations and the gynecologist
Culdotomy
47
needs the help of the hook or a probe at timesbut be cautious of the probe. Do not perforate the uterus. Why would you do culdotomy in a nulliparous individual? We have used the approach for ovarian wedge resection. It is easy to make a small perineotomy. Note, I say perineotomy, because Dr. Mengert indicated some years ago that an episiotomy is made when the patient is pregnant. Perineotomy is the correct terminology when the incision is made in the nonpregnant patient.
J.
Milwaukee,
HOFMEISTER,
M.D.,
F.A.C.O.G.
Wisconsin
This report is based on 502 culdotomies performed by the author and his associates. Culdotomy, historically, commonly, and erroneously designated colpotomy, relates to the technique of entering the cul-de-sac of Douglas for diagnosis as well as for definitive surgical procedures. Ovarian biopsy, ovarian wedge resection, ovarian removal, and tubal interruptions, as well as treatment of ectopic pregnancy and some infertility operations, can be accomplished. Of the 502 culdotomies, 293 were performed for tubal interruption. The last 25 were performed by the author under combined infiltration, amnesic, and analgesic medications. The remaining 209 were done for diagnosis and other surgical procedures. There were nine complications: three required abdominal intervention.
C u L n 0 r 0 MY, a means of investigating the pelvis for diagnosis and therapy, is better recognized by various names. The most common error of designation is that of “colpotomy.” This, by definition, means “incision of the vagina.” “Colpotomy,” curiously enough, is the most widely adopted. Other designations have been posterior colpoperitoneotomy, posterior colpoceliotomy, posterior vaginoperitoneotomy, and posterior vaginoceliotomy. The standard term defining precisely what is done is culdotomy. It is interesting to note that the technique of “colpotomy” was generally used to describe the insertion of a trocar to drain the pelvis when abscess formation or ovarian cysts were thought to exist. Historically, Joachim Fredrich Henckel, in 1760, is recorded as the first to “tap a cyst per vaginam.” A. Pelleton is credited with first draining a tubo-ovarian abscess “per vaginam” by a “colpotomy,” in 1835. Ricci also documents vaginal pro-
cedures to remove abdominal pregnancies and diagnose ectopic pregnancies. Of late, the use of the vagina as an approach to tubal ligation has gained popularity. Actually, the late Dr. N. S. Heaney,3 responsible for the “reincarnation” of vaginal surgery in America, and Dr. Edward Allen performed “colpotomy” as a routine procedure for diagnostic therapy at Presbyterian Hospital (now Presbyterian-St. Luke’s-Rush Medical Center) in Chicago. Dr. Allen2 reported the removal of a right ectopic pregnancy through “colpotomy” in 1936 and a left ectopic pregnancy by “colpotomy” in the same patient in 1938. This procedure was widely used as a diagnostic tool for investigating pelvic pathology and the author, as one of their former residents, has used this procedure in increasing numbers since 1947. Previously, as a preceptee in general surgery, he also performed posterior “colpotomy” for cul-de-sac drainage. article+ 4, 6, 7, ’ have Though multiple been written about results, complications, and analyses of series accomplishing vaginal tubal ligations, only McMaster and Ansari have illustrated their approach. Of interest, also, is the fact that all methods of tubal interruption, except “colpotomy,” are discussed in the Proceedings of the recent Fourth Annual Meeting of the International Family Planning Research Association, Inc.
From the Department of Obstetrics and Gynecology, Lutheran Hospital of Milwaukee, Department of Gynecology and Obstetrics, Medical College of Wiscomin, and Milwaukee County General Hospital. Presented at the Forty-first Annual Meeting of the Central Association Obstetricians and Gynecologists, Scottsdale, Arizona, October 18-20, Reprint requests: 10425 W. North Wisconsin 53226.
of 1973.
Dr. F. J. Hofmeister, Ave., Wauwatosa,
39
40
May 1, 1974 Am. J, Obstet. Gynecol.
Hofmeister
Is it by oversight or deliberate disregard that culdotomy, or “colpotomy,” is not mentioned? The author will refer to the approach for procedures done in the cul-de-sac as culdotomies. Culdotomy is an incision into the cul-de-sac. It is a practical means of investigating the pelvis to determine the status of the uterus, tubes, and ovaries, and it is an essential step in all vaginal hysterectomies. For the past 10 years, it has been the first and principal step in our vaginal hysterectomy technique. Though the incision for vaginal hysterectomy is made differently from the incision used in routine culdotomy, within 1 cm. to 1.5 cm. from the posterior lip of the cervix instead of in the redundant tissueof the region of the cul-desac, the goal is the same. It is made to visualize the open pelvis through the cul-desac. It permits evaluation of the character of the peritoneal fluid: clear, turbid, bloody, or purulent. It permits palpation of the structures. Are they unusually enlarged or adherent? Are all structures freely movable? With this knowledge, additional steps can be taken to successfullycomplete a vaginal hysterectomy or a decision can be made to take another route. When a culdotomy alone is planned as a diagnostic procedure for suspected ectopic pregnancy, diagnosis and resection of ovarian disease, or for tubal ligation, the transverse incision is made in the region of the redundant tissue of the cul-de-sac between the uterosacral ligaments and about 5 cm. from the posterior lip of the cervix. A total of 502 culdotomies, of which 293 were performed for tubal interruption and 209 for diagnosisand ovarian surgery by the author and his associates,* form the basis of this presentation. Nine complications occurred. Five were associatedwith tubal interruptions (1.7 per cent). Two of these were associated with undiagnosed preoperative salpingitis. Antibiotic therapy resolved the condition. Two complications were associated with postoperative cuff bleeding ‘Drs. Vondrak,
W. P. Wendt, R. P. Reik, and W. E. Martens.
W.
R. Schwartz,
B. F.
and one was associatedwith a postoperative hematoma and abscessformation. An abdominal hysterectomy, six weeks postoperatively, resulted in cure, Four complications were associated with culdotomies done for diagnosis or tuboovarian surgery. Of these, one was secondary to resection of an ectopic pregnancy with subsequent abscess formation. Antibiotics and spontaneous drainage resulted in cure. That patient was recently delivered of a normal infant. One was secondary to ovarian resection. Intra-abdominal bleeding required a laparotomy. One, secondary to ovarian resection, required incision and drainage of a pelvic abscess.One complication secondary to ovarian removal resulted from ovarian vesselsbleeding. A laparotomy was required to ligate the bleeding vessels. In the uncomplicated cases, patients for tubal interruption were discharged from the hospital 42 hours after admission.There have been no pregnancies in the 293 tubal interruptions. Complexities of hospital administration, insurance programs, and especially fear of malpractice suits prevent early morning admissionand afternoon discharge; these need to be eliminated if an hourly charge rather than an automatic 48 hour charge is to be accomplished. The stay for patients when operations for diagnosis or ovarian pathology were done averaged 72 to 96 hours. Procedure
Preliminary evaluation of the patient always includes a Papanicolaou smear, an attempt to detect pathogens in the vagina, and a culture for gonorrhea. Any vaginitis should be eliminated before surgery is undertaken. An attempt must be made to detect the potential of all episodes of chronic or recent pelvic inflammatory disease by accurate history and pelvic examination. In anticipation of any vaginal surgery, the vagina is adequately prepared. This routine preparation is in addition to adequate therapy for specific infections, Trichomonas, Monilia, or gonorrhea. For the past five years the author has routinely used, when specific infections do not exist, preoperative,
Volume 119 Number 1
Culdotomy
41
Fig. 1. A, Culdopack. Compare with scale (E). C, Emmett hooks, 9% in long; D, E, long Allis clamps, 7 5 in. ; and F, long Babcock clamps, 9 in. self-insertion of Gantrisin cream, v* applicator, three times weekly at night until the week before surgery and nightly the week before surgery. Betadine douche may be used occasionally to cleanse the vagina if the cream becomes bothersome. Anesthesia-analgesia If the patient could be admitted on the morning of surgery, she could be discharged the following morning by 10 A.M.-~ interval of about 27 hours. The actual procedure may be done with a general anesthetic or, preferably, with neurolept analgesia and local infiltration anesthesia. One hour before surgery, 75 mg. of Demerol or 8 to 10 mg. of morphine sulfate is given intramuscularly. When the patient is settled on the table and intravenous administration of lactated Ringer’s solution is started, neurolept analgesia is given.* This consists of the administration of 5 mg. of morphine *Dr. William Rouman, anesthesiologist at Lutheran Hospital of Milwaukee, has recommended neurolept analgesia using Valium and morphine sulfate in preference to the more potent Innovar, which is a commercial mixture of fentanyl and droperidol.
sulfate and 5 mg. of Valium (both given slowly intravenously). Depending on the reaction to the medication, this dose of Valium may be repeated in five minutes. When the actual surgery is started, a third dose of 5 mg. of Valium and, if necessary, 5 mg. of morphine is administered. The patient responds very little to the infiltration of NeoSynephrine and lidocaine. When the cul-desac is opened, 5 C.C. of one per cent lidocaine is deposited by hypodermic syringe into the cul-de-sac. This results in peritoneal anesthesia. No Neo-Synephrine is used. The patient may respond a bit when the Allis or Babcock clamp grasps the ovarian ligaments. No patient has complained. After the Culdopac has been removed and sutures to close the culdotomy have been placed, the patient is given 0.4 mg. of Narcan intravenously and, in addition, 10 mg. of Ritalin may also be given. Within a very few minutes the patient responds to questions. The big advantage is the great analgesic and amnesic quality. Respiration and pulse must be monitored. After complete relaxation, the patient is
42
May 1, 1974 Am. J. Obstet. Cynecol.
Hofmeister
Fig. 2. Neo-Synephrine posterior
and
lidocaine
infiltration,
uterosacral.
placed in the lithotomy position with the buttocks two inches beyond the table edge. Shaving of the perineum is confined to the immediate lateral and posterior areas of the vulva. Routine vaginal preparation is accomplished by the method of individual choice and experience, i.e., that which is considered the best in a particular institution. As a final preparation, the author suggests that the gynecologist should also cleanse the vagina with aqueous merthiolate and personally catheterize the bladder. Operative
technique
The labia are not sutured laterally when local anesthesia is used and need not be sutured under general anesthesia. A midline perineotomy may be done to facilitate the operation when culdotomy is done as a diagnostic procedure in nulliparous patients. Nulliparity is not a contraindication to the vaginal procedure. The perineotomy is made after local infiltration of the perineum. Tenaculi are placed on the anterior and posterior lips of the cervix. Figs. 1 through 11 demonstrate technique. Approximately
Fig. 3. Transverse
line indicates area for incision in vaginal hysterectomy. Redundant area indicates position of culdotomy incision.
20 cc. of the solution of one per cent NeoSynephrine in one per cent lidocaine is used for infiltration of the vaginal skin of the portio of the cervix and the paracervical tissue. Of importance is actual parametrial penetration for injection of the solution. The area of the anticipated incision is also infiltrated. This solution is made by combining 1 cc. of one per cent Neo-Synephrine and 100 C.C. of one per cent lidocaine. This is a 1: 10,000 solution and has been effective as an anesthetic as well as free of significant complications such as prolonged hypertension. A uterine probe is used to determine size and position. Some use the probe or a similar instrument to assist in retroverting and retroflexing the uterus when culdotomy is done.8 This can be hazardous. Perforations can occur. We have found this generally to be unnecessary. Endocervical and endometrial curettage is always done. The cervix is drawn downward and forward by the assistant. The redundant tissue tif the culde-sac is demonstrated with a tissue forceps. A deliberate transverse incision is made with a Mayo scissors. Often the cul-de-sac is
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Fig.
Culdotomy
4. Actual
cul-de-sac
exposure.
entered immediately. At times, a second placement of the tissue forceps will be necessary and a second incision made through the peritoneum. Once opened, the cul-de-sac is inspected. Note is made of the type of fluid encountered. Beware of the turbid fluid. Unclotted blood may indicate the existence of an ectopic pregnancy. The cul-de-sac is inspected by palpation to determine areas of adhesions, mobility, and size of tubes and ovaries. A Culdopac is inserted. This is a convenient, miniature pack with a band for tagging. The author has used the Culdopac since the Presbyterian days and it is the most practical type of pack developed. If more room is necessary, a small vertical incision may be made in one or both of the upper and lower edges of the incision at the midline of the transverse culdotomy incision. One per cent lidocaine (5 c.c.) , without Neo-Synephrine, is injected into the cul-desac for local peritoneal anesthesia. An Emmett hook, not the right-angle hook, but the complete hook, nine inches long, is used to stabilize the uterus. The tenaculi as well
Fig. into
5. Insertion cul-de-sac.
Fig.
6. Hook
of 5 C.C. of 1 per
levers
uterine
corpus
cent
43
lidocaine
to patient’s
left.
as the uterine probe, if used, are removed and complete retroversion and retroflexion of the uterus become a reality. The corpus is levered to either the right or left side at the discretion of the gynecologist by “walking” the hooks toward the junction of the corpus and the ovarian ligament. No tearing or
44
May 1, 1974 Am. J. Obatet. Gynecol.
Hofmeister
Fig. 7. Actual photograph of ovary in view and adjacent fimbriated end of tube (both tubal and ovarian surgery possible). Long Babcock clamp holds ovary.
Fig. 8. Mixter clamp in place. Distal one third of tube and fimbria clamped in preparation for ligation and removal.
Fig. 9. Segment onstrated.
removed
and
ligated
stump
dem-
bleeding, such as frequently occurs with a tenaculum, is encountered. The delicate size of the hook eliminates the significant Meeding. The ovarian ligament is grasped with a Babcock or a long Allis clamp. The ovary is delivered and inspected. The fimbriated end of the tube falls into view. It is easily identified and the tube is inspected for pathology. The tube is grasped in midportion if a Pomeroy or modified Pomeroy is planned or at the fimbriated end with an Allis clamp if a resection of the distal one third, including the fimbria, is done. A right-angle, longhandled Mixter is placed to clamp the tube in either procedure; 00 chromic catgut is used for ligation ; a second 00 chromic suture is also placed in the same site. The sutures are always placed distal to the crushed area. The loop or the distaI segment of the tube is then removed. The ovary and the area from which the tubal segments have been removed are carefully inspected to be certain of no coincidental pathology and of hemostasis and then repositioned into the pelvis. The procedure
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Fig. 10. Midportion of tube tion for Pomeroy or Madlener.
Culdotomy
clamped
in prepara-
is repeated on the opposite tube. Ovarian resection or removal can also be easily accomplished. If done, double-row suture, 00 chromic catgut is used. The first row is a double mattress stitch. The second is a lock stitch. Closure of the culdotomy is accomplished with Dexon 00. Special attention is directed to securing the perineum at the corners of the culdotomy incision. This aids in eliminating postoperative hemorrhage. Only four sutures are placed for closure. These are placed in figure-of-eight manner. The closed incision is inspected. The uterus is raised into the anterior position either by using a tenaculum or gently inserting t.he uterine sound. The neurolept analgesia can be reversed almost completely with the use of 0.4 mg. of Narcan intravenously. Ritalin (10 mg.) may be given in addition for more complete reversal. The patient is returned to the recovery room and could be discharged four to six hours later. It is advisable that she stay until the following morning. Approximately 25 to 30 minutes is the average time for the procedure from the first injection to reversal.
Fig. 11. Closure with four Dexon purse-string suture of corners.
00 sutures.
45
Note
During the past year, all patients were given 1,000 mg. of Keflex, orally, daily for five days, starting 24 hours preoperatively, as a prophylactic agent. Very occasionally, nausea and/or dizziness can occur for several hours after the reversal of the neurolept analgesia. Postoperatively, sexual contact is not advisable for four weeks. The patient is requested to use Gantrisin vaginal cream three times weekly. If closure has been accurate, there will be no granulation tissue. If her work is not strenuous, she may return to work as soon as she desires. Laparoscopy, culdoscopy, and even laparotomy may be the approaches of choice in some instances, but remember that the pelvis can be investigated by dilatation and curettage and by direct vision and palpation for ectopic pregnancy, ovarian tumors, definitive procedures, ovarian surgery, tubal ligation biopsies, and ovarian resections, and that these can efficiently be accomplished by culdotomy. This is an efficient and practical approach to the pelvis for diagnosis and therapy and it belongs in first place in the available aids of the gynecologist.
46
Hofmeister
REFERENCES
1. Akhter, M. S.: AM. J. OBSTET. GYNECOL. 115: 491, 1973. 2. Allen, E.: AM. J. OBSTET. GYNECOL. 38: 717, 1939. 3. Boysen, H., and McRae, L. A.: AM. J. OBSTET. GYNECOL. 58: 488, 1949. 4. John, A. H., and Dunster, G. 0.: J. Obstet. Gynecol. Br. Commonw. 79: 381, 1972. 5. McMaster, R. H., and Ansari, A. H.: Obstet. Gynecol. 38: 44, 1971.
Discussion H. BEATON, Grand Rapids, Michigan. The cul-de-sac is a thin partition which excludes the outside world from the secrets within the female pelvis. Any gynecologist who is willing to master the basic fundamentals can learn to open this door, take a good look, and do his thing. Dr. Hofmeister has demonstrated the usefulness of culdotomy, not only for evaluation but also for the treatment of pelvic problems. Curiously, his presentation comes at a time when our specialty is being showered with gleaming fiberoptic scopes for culdoscopy and laparoscopy. Whether this transvaginal operation should be termed culdotomy or colpotomy is merely an exercise in semantics. Whatever you call it, the name is not as important as how wet1 you do it! Dr. Hofmeister does it well, as many of you have observed in his movies and personal performances. Nine complications in 502 operations, with prompt response to treatment without death, is a good performance. Bleeding and infection are always a challenge in pelvic surgery. Six of the nine complications were due to bleeding or infected hematoma. Careful hemostasis can usually prevent this and early probing insures drainage of infected pockets of blood. In several hundred colpotomies done by our group, there were only a few postoperative infections. They responded readily to simple drainage and antibiotics. There was no death and no need for abdominal exploration. Dr. Hofmeister reported one complication of bleeding ovarian vessels which required laparotomy. Ligation of ovarian vessels in transvaginal surgery is challenging for two basic reasons: exposure is limited and the fragile pedicle is easily torn by an ambitious operator. This is what makes televised surgery so exciting for the audience and so humiliating for the operator. This complication can be avoided by putting DR.
JAMES
May 1, 1974 Am. J, Obstet. Gynecol.
6. Roe, R. E., Laros, R. K., and Work, B. A., Jr.: AM. J. OBSTET. GYNECOL. 122: 1031, 1972. 7. Sagolow, S. R.: Obstet. Gynecol. 38: 888, 1971. 8. Shute, W. B.: AM. J. OBSTET. GYNECOL. 115: 998, 1973. 9. Smith, R. A., and Symmonds, R. E.: Obstet. Gynecol. 38:400, 1971.
two clamps on the ovarian pedicle. First, replace the proximal clamp with a cautiously applied ligature. Then replace the distal clamp with a firm tie. Dr. Hofmeister uses the Emmet hook on the back of the uterus to pull the adnexa down into view. I wonder if this creates a site for postoperative oozing, which leads to an infected pool of blood? We use a smooth retractor to elevate the uterus, thus allowing the adnexa to drop into view. Visualization is further increased by tilting the head of the table downward about 30 degrees. It is then better for the operator to stand. Many scientists say that you cannot sterilize the vagina. However, most pathogens can be inactivated by a vigorous Betadine scrub follow by five minutes of “marinating” the vagina with full strength Betadine. Since Betadine was the first choice for the space capsules, we believe it should effectively cleanse the vagina. I agree with Dr. Hofmeister that infiltration of the vaginal wall with a vasoconstrictor provides excellent hemostasis. Thus, one is less apt to leave a pool of blood in the pelvis for bacterial incubation postoperatively. For years we used the 1 : 10,000 Neo-Synephrine solution and noted hypertensive reactions in several patients. Our anesthesiologists have now convinced us that a 1 :200,000 solution of epinephrine provides excellent hemostasis without the alarming hypertensive effects. My experience in tubal ligation is nil. As Department Chairman in a large Catholic hospital, my sterilizing procedures have been limited to scrubbing the vagina with Betadine. Since I routinely perform ovarian wedge resection on nulliparous women transvaginally, tubal ligation would be relatively easy to do in this manner, especially on multipara. I share the same enthusiasm for transvaginal surgery as Dr. Hofmeister. Our group uses colculdoscopy, and laparoscopy in the pow,
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practice of gynecology. We urge our residents to learn all of these methods while in training. Later they can fit each to the needs of their practice. DR. HOFMEISTER (Closing). We use 15 degrees Trendelenburg routinely in all of our cases. The Emmett hook is an atraumatic type of instrument which aids in bringing the fundus of the uterus down easily. In not all cases that we have done would the fundus “fall down” as my eminent discussant indicates. There are some more difficult situations and the gynecologist
Culdotomy
47
needs the help of the hook or a probe at timesbut be cautious of the probe. Do not perforate the uterus. Why would you do culdotomy in a nulliparous individual? We have used the approach for ovarian wedge resection. It is easy to make a small perineotomy. Note, I say perineotomy, because Dr. Mengert indicated some years ago that an episiotomy is made when the patient is pregnant. Perineotomy is the correct terminology when the incision is made in the nonpregnant patient.