Defundation of the uterus as a conservative measure in myomas and hyperplasias of the endometrium

DEFCNDATION MEASURE EY

ARTIIUR

OF THE

UTERUS

AS A CONSERVATIVE

IN MYOMAS AND BPPERPLRSIAS OF THE ENDOi\!IETRIUJI E. HERTZLER,

JC.D., HALSTEAD?

T

KANSAS

HERE is a renewed interest in conservative operations on the uterus for nonmalignant conditions 1rit.h t.he object of conserving the menstrual function. In some quarters it seemsto have been recognized for the first time that the human female is something besides a The machine for replenishing an already too numerous population. surgeon must be obtuse indeed who docls not recognize in the castrate too often a worse than useless human salvage. The new awaliening must, thercforr, be hailed with enthusiasm. With a hope to encourage this, it is my purpose to review my own results along this line and to present in a general way t.he technic now employed. Whether the operation is clone for myomas or some disease of the mucosa, the final problem is the samp. After the diseased portion has been removed, the uterus must be restored as near the normal as possible! leaving so much of the mucosa as is needed to carry on the function of menstruatiotl and leaving the fundus of the uterus unattached and without clelluclrd surfaces which invite adhesions after the operation has been finished. As a general stat,ement one should plan to leave a mueosal area one-third that of the normal uterus and should spare the circulat,ion of the uterus as much as possible in order to prevent secondary changes due to deficient blood supply. The problem of conservative surgery has been confused in recent years by the use of x-rays and radium. These agents are as destructive as the knife, and it is impossible to limit their action to the site of disease. A resection under the e-c of t)he surgeon is a much more exact procedure. Radium all too often destroys the ovaries as well as the offending endometrium. It is even more likely to destroy permanently the normal endometrium, which is usually situated just above the internal OS, than the more diseased areas at the fundus. These objections have less force in women at the menopause than in younger women. A new objection arises at this time, however, because radium does not permit a diffrrentiation between hyperplasia and incipient carcinoma. Certainly in hemorrhage occurring after the menopause has been passed, radium cannot compete with the trained eye and touch of the surgeon as a safe and sure means of ridding the patient of her disease. In operat,ions for myomas, the sole question the surgeon needs to 180

HERTZLER

:

nEFUNnATION

OF

THE

181

TJTERUS

ask, in selecting his type of operation, is, what is the age of the patient? If at the menopause, but little criticism can be offered to a hysterect,omy. At any other age, myomectomy is imperative and is always possible if the surgeon is experienced and diligent, The younger the patient thta more imperative is conservatism. It is a curious thing that, there are still many operators who believe that if

Fig. l.-The 3 ctxtctriform

diseased defect, (c)

area and

of the (cl).

uterus

is

remove~l,

(a)

and

(b),

which

Fig. Z-The raw surfnces are eoapted, beginning at the lowest paCtIt placing successive layers (b anal c) until all hemorrhage is controlled. Anal sutures the ends of the tubes and round ligaments are pulled into c.f the wound (c), and the peritmcal sul’faces :II’O then coopted Cd).

leavrs

(a) and With the the angle

the ovaries are spared the constitutional disorders due to castration mill be obviated. Experience seems to have made no impression. The two general groups of diseases of the uterus requiring conservative operations are the myomas and the diseases of the endometrium, either a polypoid or diffuse proliferation of the mucosa. In the case of the myomas, the tumors must be removed, of course. It is al-

Fi.sx. S.--The

fundus

is excised

as broadly as m:,y btx necessary, the diseased area.

in order

to remove

dominal mall is to follow. The vaginal route is the method of election when some form of lower fixation, snch as the Watkins-FreundWertheim operation is to follow. Thc~ vaginal operation is convenient in fat women at 01’ beyond the menopauw, paAicnlarly if beginning malignancy of the fundus is likely, for if snch a condition is discovered, vaginal hysterectomp may be substitutecl for the conservative operation. l’he

ABdontinaZ

Operutiox.--The

discnvetl

portion

of

the

uterus

is

removed

(a, Fig. l), preferahly through a Pfannenstiel incision. Seen in profile (b, Fig. I), tile excised portion of tile uterus leares :I f~~~~wl-sl~npedcavity, estelldillg to within

HERTXZR:

DEFUNDATIOiK

OF

THE

-183

UTERUS

nn inch or so of the internnl OS. If possible the arterial arch is preserved. In myomas this may not be possible. In such cases the cornua must be removed (c, and d, Fig. 1). In either case a. funnel-like &feet remains. This funnel-shaped defect must be obliterated by suture which at once cow trols the hemorrhage and brings the denuded surface in coaptation. The first line of suture begins just above the mucosa which has been spared (n, Fig. 2). Several rams of sutures mflr lw rquirell. Aftcxr the hernorrh:~gc has been well cwntmlleil, the suture r.:ltehvs tllv stump of the tube :~nrl rnun~l ligament and pulls them into the, Ilefrct in thrx top of thfx utwus (71, and C, Fig. 3). The remaining edges of the l~uund arc the11 w:r]‘tc~l, cowring in ali rlcnutled surfaces, leaving a uterus which be:~rs a geurral rcsrn~blance to n;Ltuw ‘s llnudiwork and one tllat

Fig.

4.-The

is the the

capable

clcfect

in tllC! utrlw

is

accurately rhage.

coaptcd

in

order

to

control

the

henror-

of continuing the function of menstruation. If it is desired to attach uterus to the abdominal wall, tllis can be done by any method that suits fancy of t,he operator. In closing the defect, I use pyoctanin gut for the deeper sutures, since chromic gut may last too long. For the final lapel, chromic gut is used, as the shortel enduring gut may allow the wound to gnlw before the union is formed. T7Le Guginal Opr~u.lio7~.--The uterus is delivered either 1,~ traction downwv:~r~l or by inverting the fundus when the uterus l!:Lnllut be pullrd dowr1. The uterus is split after the vagina is lifted (Fig. 3). The diwased area is then located and excised. The parts of the uterus :ire then sutured (Fig. 4) so that the hemorrhage is nccnratel~ controllrd. The tubes and round ligaments are

184

Fig.

THE

S.-The

AMERICAN

emls

nf

JOURNAL

the

tubes

and the

OF

round uterine

OIJ,STETKICS

ligaments wound.

AKD

arc

GYNECOLOGf

drawn

into

the

anfiles

of

two complications may arise. Some t,wentg years ago, following one of my first operations of this type, l)regnancy followed. Since t,hen, I have been earcful to see that the tubes are not. allowed to extend deeply enough in the walls of the uterus to reach the mucosa which has been preserved. When the uterus is att~achecl to the abdominal walls, a sinus may form, extending through the abdominal wall. In such a case, the menstrual flow passes through t,he sinus and is discharged on the skin of the abdomen. This complication is obviated by careful coapkttion of the raw surfaces of the uterus and by t,he use of a chromic suture for

HERTZLER

:

DEFtlXDATION

OF

THE

185

t?I%RtJS

the final layer. If a sinus results, it may heal spontaneously or it may need to be reamed out and the mound unitecl. In one ease, an aclenomatous t,umor developed, and in another, a considerable t?lmor These were remeof keloid structure dpvelopecl about such a sinus. died by excision. It seems curious to one who does not understand the physiology of menstruation (incluclin g myself) that blood can be forced up through a small sinus whrri the ctarvix readily admits a sound 16 or 20 French. In t.he vaginal operations, the complications common to the interposition operation may follow. They are chiefly those clue to infection incident to the vaginal won~~il. Sometimes a slight, rise in tem-

Fig.

C.-The

flnal layer tucks in

of the

sutures ends

of

closes the

the tubes

peritoneal and round

surface of ligaments.

the

uterus

and

perature may exist for several ~~1~s. In such cases, there may not be complete healing for three or four weeks. It is rare, however, that the complications confine the patient to the hospital for more than three weeks. The after-results are all that can be desired. The patient retains her menstrual function and her normal balance. Even in the most complicated myomas, it has been possible to preserve a patch of mucosa somewhere. It has been possible to construct a wall about such areas to produce an organ closely resembling the normal uterus. Late complications have not arisen. Though I have repeatedly done

a conservative operation on hrmorrha.gic myomas, sa.rcoma has never followed. Eveu if such a complication should arise sometime, I shall not, be distressed front tloitlg the operation, for in several instances sa.rcoma has followed complete hystc~rwtouty ill hrmorrhapic myomas. Here, a.s iti “doubtful” tumors of the breast,, there is no excuse for mutilating the innocfnt riiultitutle to Kaitl the theoretical chance of presrrviug the occasional patient. \‘icTvinF tile vast 1I11niber of (‘as-

Fig.

$.--The

incisions

in

the

body

of

the

uterus

and

vagina

are

then

close~l.

that have passed t,lirough this clinic, 1 am disposed to feel a sympathy for those patients who t~sI~~w th(a feeling that after all death is not the snperlativ(J calamity in h~mlan experience. fi’ortuiiately, conservative surgery oil the uterus uecds 110 apologist, for in my experience no patient t,lius treated has dircl. All that is required is a fair knowledge of livin g anatomy and of surgical technic and the industry stimulated by a human uilderstauding to do the operation carefully and systematically. tratecl