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Extraperitoneal cesarean section
Extraperitoneal A simplified
GEORGE MICHAEL Washirzgton,
cesarean section
technique
J.
ELLIS, R.
M.D.
DEVITA,
M.D.
D. C.
A M A T E R N A L death recently occurred in our department from generalized peritonitis and septicemia. The patient was a 16-yearold primigravida with pre-eclampsia and cephalopelvic disproportion, whose pregnancy was terminated by transperitoneal cesarean section 38 hours after the membranes had ruptured. This case was presented at our staff conference. One conclusion of the discussion was that the patient might have been offered a better chance for survival had an extraperitoneal cesarean section been performed. Study of existing procedures for the extraperitoneal cesarean section and their related problems, resulted in the development of the technique described in this paper. The concept is erroneous that there is no longer an indication for extraperitoneal section because of earlier intervention in problem cases and the safety factor afforded by antibiotic therapy. Physicians must keep in mind that virulent bacteria may invade the uterus and that the introduction of these organisms into the tissues and the peritoneal cavity by transperitoneal section may spell disaster. Every obstetrician should be able to perform an extraperitoneal cesarean section to be considered a well-rounded practitioner of the specialty. The modern education program of the obstetrical resident, in addition l:o didactic
teaching, includes breech extractions, versions and extractions, all types of forceps operations, and cesarean sections, including classical and low cervical, and cesarean section combined with hysterectomy. It should also include a form of extraperitoneal cesarean section. Experiments at the extraperitoneal approach have been made as far back as 182 1 when Ritgenl tried it on a patient at the University of Giessen. Latzko2 devised a paravesical technique in 1908 with which he achieved moderate success. Other obstetricians of this era employing his method reported bladder and ureteral injuries, and it was gradually abandoned. It was not until 1940, when Water? developed the supravesical approach, that the operation attained a degree of popularity. His technique was found to be difficult for the average obstetrical surgeon, and repeated performances of this method in various clinics resulted in equivocal appraisal. At this time antibiotic medication came into general use. Many obstetricians abandoned the extraperitoneal operation, rationalizing that the transperitoneal approach for the patient safeguarded by antibiotic therapy was sufficient, even in the presence of infection. In 1946, Norton* devised the unilateral paravesical approach to the lower segment. Because this operation seemed easier and less time-consuming, interest in it was renewed. Bourgeois and Phaneuf5 in 1949 reported
From the Department of Obstetrics and Gynecology, Providence Hospital. 695
696
Ellis
and
September, 1961 & Cynec.
DeVita
Am. J. Obst.
Deep
epigastric
v
nsversalis
fascia
Fig. 1. The skin and superficial fascia are open. The anterior rectus sheath is partially open, and the rectus and pyramidalis muscles are seen. The close relation of the
epigastric
vessels
can be noted.
Inset,
the approximate
a bilateral parasupravesical approach whereby both paravesical spaces were opened; the dissection started down the posterior surface of the bladder and ended, upward, by removal of the peritoneal fold from the anterior surface. In 1942 at our hospital, the members of the department staff began doing the supravesical operation as described by Waters. Our results were anything but uniform. With optimum conditions, the operation was excellent and the approach to the lower segment provided all the room desired; but with adverse conditions, the operation was difficult and, on occasion, the bladder and peritoneum were incised.
elevated by blunt dissection. The method of anchoring the muscle to the fascia is seen. Again the relation of the epigastric vessels can be noted.
of the
incision.
After Norton reported his method, our department staffs adopted the paravesical technique. The results were uniformly better. Although the method was easier for the average operator, the exposure afforded was never satisfactory. The large infant and the one in abnormal presentation were hard to deliver through the available space. With use of the vertical S-shaped incision in the lower segment as advocated by Norton, extensions occasionally occurred which were difficult to repair. In institutions where staff members are adept at the extraperitoneal approach, there should be no reason for sacrificing a uterus following cesarean section because of infection. Waters7 states, “We have done no cesarean hysterectomies in the last twenty-five years as a treatment for uterine infection. It is our past and present opinion that none should be done.” The purpose of this paper is to present a preliminary report on a new technique for performing the extraperitoneal cesarean section. This operation combines the simplicity of the paravesical operation and the ample room of the supravesical, while eliminating the difficult dissection of the older supravesical
Fig. 2. The rectus muscles have been exposed and
level
technique.
Technique 1. The patient is hydrated with 2,000 to 3,000 ml. of 5 per cent dextrose in distilled
Volume Number
82 3
given over a 2 to 3 hour period. This aids to make the tissues “wet” and to facilitate the dissection. If the patient has edema, this step is not necessary. 2. A Foley catheter is inserted into the bladder and connected to a “Y” tube which is hooked up to a reservoir of sterile water. A tube from the remaining end of the 7”’ is placed in a drain basin. By means of this arrangement the bladder may be filled or emptied by clamping or unclamping the proper tubing. 3. The patient is given spinal or peridural anesthesia. The advantages in the use of block anesthesia are: ( 1) adequate time is allowed for performance of the dissection, and (2) injurious effects of anesthetic agents to the fetus are avoided. 4. A low transverse incision is made in the abdomen. The rectus sheath is transversely incised, and the resulting retraction exposes both rectus muscles (Fig. 1) . The index finger is inserted under one muscle from the medial to the lateral aspect, with care being exercised to avoid injury to the deep epigastric vessels. Two Allis clamps are placed on the upper margin of the retracted rectus sheath. While the assistant makes downward traction, 2 sutures are placed lateral to each other and tied so .as to anchor the muscle to the sheath (Fig. 2) . The clamps are then placed on the lower margin of the sheath and, while the fascia is pulled upward, 2 additional sutures are placed as before. The rectus muscle is transected while tension is applied from underneath by the operator’s index finger (Fig. 3). The 4 sutures function to control bleeding from vessels in the muscle and to facilitate muscle approximation when the fascia is being closed. The same maneuver is effected on the opposite rectus muscle. The :muscles will retract, enhanced by blunt dissection, providing considerable room. 5. The deep epigastric vessels at the lateral edge of each rectus muscle are isolated, clamped, cut, and ligated. This should be done as inferiorly as possible, allowing the vessels to retract laterally at a later stage without the danger of tearing them. Occa-
Extraperitoneal
cesarean
section
697
water, fluid
Fig. 3. Both rectus muscles have been anchored to the fascia superiorly and inferiorly, and the left rectus muscle has been transected. It is to be noted here that the muscles are transected in layers rather than from side to side. It is at this point that the relation of the epigastric vessels is of paramount importance.
._..”.-.- “.._fascia .“““._
Transversalis overlying
be
bladder ated
and
cut
Fig. 4. The muscles are transected and the underlying transversalis fascia exposed. The inferior epigastric vessels are being clamped.
Transversalis
fascia transected
Fig. 5. The transversalis fascia over the bladder is incised. This is done with the scissors beginning in the midline and extending laterally to both sides. The paravesical space on the right is visualized, and the bladder is seen to herniate up through the opening in the fascia. Bladder vessels are also seen, as are the ligated ends of the epigastric vessels. The Balfour retractor blade is in place.
698
Ellis
and
DeVita
Fig. 6. Blunt dissection with gauze over the fingers is being carried out on the left side. The right side has already been dissected and the lower segment can be visualized. The lateral umbilical ligaments can also be seen. The peritoneal-fascial fold is seen superior to and partially overlying the bladder.
Fig. 7. The two paravesical spaces have been dissected and connected behind the bladder by blunt finger dissection as described in the text. The lateral umbilical ligaments are seen on either side. With a finger behind the bladder, the tissue to be dissected off the b!adder now lies over the finger. Insets, the isolation, ligation, and section of the lateral umbilical ligaments.
sionally, the vessels are located under the muscle. If the muscle is slowly divided at the lateral aspect, the vessels can be identified and ligated (Fig. 4). At this stage of the dissection there is accessibility to the bladder superiorly and laterally, and the space may be enlarged by placing the lower blade of the Balfour retractor in the inferior border of the incision. 6. The bladder is easily identified after filling with about 150 to 200 ml. of fluid. The transversalis fascia over the bladder is
September, 1961 Am. J. Obst. & Gynec.
picked up with tissue forceps, and with the dissecting scissors an incision is made beginning at the midline and extending laterally to both sides (Fig. 5). The transversalis fascia may be variable in different patients, ranging from a structure well defined with a thin layer of fat between it and the bladder adventitia to a structure poorly defined and filmy. The partially infilated bladder will “balloon” upward into the line of incision and the proper plane is attained when the bladder vessels are exposed (Fig. 5). 7. The paravesical spaces are now identified on either side. These are the “yellow chicken fat” areas described by Norton.4 They are located lateral to the bladder, medial to the deep epigastric vessels, and inferior to the peritoneal-fascial fold, which is not identifiable at this time. With a moist 4 by 4 inch gauze sponge on each index finger, the operator incises one paravesical space by blunt dissection down to and exposing about 1 to 2 sq. cm. of the lower uterine segment. The level of dissection should be inferior enough so that the peritoneum is not entered (Fig. 6) . An identical procedure is carried out on the opposite side. 8. The index finger is now introduced into one paravesical fossa and tunneled across to the opposite side, with care being exercised not to enter the peritoneum. It is at this part of the procedure where most failures to stay extraperitoneally occur. This hazard can be avoided by directing the finger downward so that it comes across the posterior surface of the bladder and below the peritoneal fold. It is important not to use force, but only gentle blunt dissection. The finger will find the proper plane and can be brought through to the opposite fossa. Occasionally, in repeat sections a plane cannot be found. One should not persist beyond establishing a tunnel on either side which will allow the index finger to exert upward pressure from underneath the bladder. When the finger is in the proper plane, it will be against the lower uterine segment, the bladder will be anterior, and the peritoneal-fascial fold will be superior.
Volume Number
82 3
9. It will be noted that thick bands of tissue seem to be holding the peritoneal fold to the bladder on each side. These consist of fat, areolar tissue, and the obliterated hypogastric arteries or lateral cmbilical ligaments. The latter go from the hypogastric arteries to the umbilicus passing lateral to the bladder. These obliterated vessels are isolated by blunt dissection down near the bladder, ligated, and cut (Fig. 7). Initially, these ligaments may be mistaken for ureters, but further dissection will make it apparent that this is not the case. As the lateral ligaments are cut, there is a feeling as though “something gave” and the peritoneal fold seems to separate partially from the bladder. 10. The finger is reintroduced into the tunnel and upward traction is made under the bladder and peritoneal-fasci.al fold. Only areolar tissue holds the fold to the bladder. Starting well below the level of peritoneal reflection, sharp dissection is begun with a scalpel over the anterior surface of the bladder. The tissue to be cut will stand out as small fibrous bands. The finger exerting pressure from underneath the bladder will feel the fold being released (Fig. 8). If the bladder muscularis is exposed, one must seek a more superficial plane, superior to the previous dissection. Eventually, the white line of the peritoneal reflection is identified resembling a hernial sac. Dissection is then carried out about 1 to 2 mm. inferior to the white line. As one pulls upward, the fold will be felt to give and peel off the bladder. Bleeding vessels are clamped as they are encountered. The width of the fold decreases as the urachus is approached in the midline (Fig. 9). This structure is tied and cut and the dissection is continued down the posterior surface of the bladder until the entire fold is separated. The bleeders on the surface of the bladder are now tied. The bladder is emptied, a tape placed over it, and the lower blade of the Balfour retractor reinserted, displacing the bl.adder under the symphysis. Another wide retractor is placed at the upper end of the incision holding up the peritoneal-fascial fold. The whole
Extcaperitoneal
cesarean
section
659
lower segment is now in view. There is usually a thin film of fascia over the lower segment which is divided with a scalpel. 11. The uterus is incised transversely. At this stage, a suture is placed in the inferior edge of the incised lower segment and left long because the lower edge tends to fall well down behind the bladder (Fig. 10) . The transverse incision is extended by lateral pressure with the fingers. The infant is delivered. Indicated cultures, if desired, are taken at this point. The oxytocic is given
Fig. 8. Sharp dissection of the peritoneal-fascial fold is shown in progress. It should be noted that the width of the fold has decreased after section
of the lateral ligaments. Inset, a schematic diagram in sagittal section. It shows the peritoneal fold to be dissected off the bladder, and the direction of pull of the finger behind the bladder. The knife edge is shown cutting the fibrous connective tissue holding the fold to the bladder.
Fig. 9. The dissection is shown near completion as the urachus comes into view. By this time the white line of the peritoneal reflection can be seen. Inset, the dissection completed and the urachus being clamped. Note the ties on the bladder vessels.
700
Ellis
and
September, 1961 Am. J. Obst. &Gym.
DeVita
Midline approach. In the presence of a midline scar, the described method of entry. is not used, to avoid multiple abdominal scars. Instead, the midline approach is used, and the rectus muscles are retracted laterally rather than transected. The remainder of the operation follows the procedures as listed. The only real disadvantage in this modification is slight loss of exposure. Analysis
Fig. 10. The entire lower uterine segment is exposed and the line of incision into the uterus is shown. The lower segment is being tagged with a suture to prevent it from falling out of reach behind the bladder. Upper inset, the uterine incision after closure with a Lembert suture. Lower inset, the method of cutting the conventional Penrose drain so that it may be placed in both paravesical spaces.
by the anesthetist and the placenta and membranes are allowed to deliver spontaneously. The uterine edges are then clamped and the uterus is closed with a double layer of suture in the manner of a low cervical section. After all bleeding has been controlled, the bladder is filled and inspected for injury and additional bleeding vessels. 12. A Y-shaped Penrose drain is now placed with one side of the “Y” in either paravesical area. The peritoneal-fascial fold is allowed to fall back into place (Fig. 10). The fascia is now closed with interrupted chromic figure-of-eight sutures, which causes the edge of the cut muscles to be approximated because of the fixation to the fascia. The subcutaneous tissue and skin are then closed and a large dressing is applied to absorb drainage. The Foley catheter is left in place until the next day to help eliminate the excess fluid which was administered before the operation. After removal of the catheter, the bladder is tested for residual urine at the next voiding. The drain is removed after 24 hours and the wound redressed. Care is otherwise no different from that after other cesarean sections.
of cases
To date, 17 cases have been performed by this method. The series is too small to warrant a critical analysis. Thirteen primary and 4 repeat sections were performed. In one case, failure of the technique necessitated completing the operation as a lower segment transperitoneal section. In the early cases, when the technique was being perfected, the peritoneum was incised five times. When this complication occurred, the opening was repaired and the operation continued as described. The bladder was not entered in any of the cases, and in one case repeated catheterizations were needed for residual urine. In this case the abdomen had to be reopened the first postoperative day and a hematoma under the rectus muscles evacuated. One patient who was in labor more than 30 hours with ruptured membranes developed a wound infection. Another patient had a seropurulent discharge from the wound for 2 weeks postoperatively. Thirteen operations were done with use of spinal anesthesia; 2 with epidural; one with general anesthesia with thiopental, ethylene, and d-tubocurarine; and one with no anesthesia. In the latter case, the patient had a transection of the spinal cord at the level of T-9 as a result of a bullet iodged in the spinal cord. In the series there was one neonatal death which was not attributable to the type of section. Comment The type of extraperitoneal cesarean section presented in this report has several advantages. The simplified technique can be
Volume 82 Number 3
Extraperitoneal
performed by the average obstetrician and requires only one assistant. It provides the operator with sufficient space for delivering large babies or babies with abnormal presentations without the danger of injuring the urinary system, particularly the ureters. It eliminates the difficulties in the dissection around the bladder encountered in the supravesical section. Fifteen to 30 minutes is required to deliver the infant. While the time factor may be considered a disadvantage, there were no untoward effects in any of the infants. The employment of block anesthesia decreases the importance of the time factor with regard to fetal morbidity and mortality as compared to other anesthesia modality. The total time
cesarean
section
701
of the operation does not exceed the average low cervical section by more than 5 to 10 minutes. Summary
1. The use of extraperitoneal cesarean section in modern obstetrics is discussedand a brief history of the operation is given. 2. A modified technique is described in detail. 3. This technique lessensmany of the dangers and difficulties of the old supravesical and paravesical approaches. 4. Extraperitoneal cesarean sections can eliminate the necessity for doing cesarean sectionscombined with hysterectomies in infected cases.
REFERENCES
1. 2. 3. 4.
Ritgen, F. A. : Heidelberger 263, 1825. Latzko, W.: Munchen. med. 2207, 1908. Waters, E. G.: AM. J. OBST. 423, 1940. Norton, J. F.: AM. J. OBST. 519, 1946.
Klin.
Anal.
Wchnschr.
1: 55:
& GYNEC.
39:
& GYNEC.
51:
5. 6.
7.
Bourgeois, G. A., and Phaneuf, L. E.: AM. J. OBST. & GYNEC. 57: 237, 1949. Ellis, G. J., Sheffery, J. B., and Paquin, J.: M. Ann. District of Columbia If: 553, Oct. 1948. Waters, E. G.: Clin. Obst. & Gynec. 2: 989, 1959.
GEORGE MICHAEL Washirzgton,
cesarean section
technique
J.
ELLIS, R.
M.D.
DEVITA,
M.D.
D. C.
A M A T E R N A L death recently occurred in our department from generalized peritonitis and septicemia. The patient was a 16-yearold primigravida with pre-eclampsia and cephalopelvic disproportion, whose pregnancy was terminated by transperitoneal cesarean section 38 hours after the membranes had ruptured. This case was presented at our staff conference. One conclusion of the discussion was that the patient might have been offered a better chance for survival had an extraperitoneal cesarean section been performed. Study of existing procedures for the extraperitoneal cesarean section and their related problems, resulted in the development of the technique described in this paper. The concept is erroneous that there is no longer an indication for extraperitoneal section because of earlier intervention in problem cases and the safety factor afforded by antibiotic therapy. Physicians must keep in mind that virulent bacteria may invade the uterus and that the introduction of these organisms into the tissues and the peritoneal cavity by transperitoneal section may spell disaster. Every obstetrician should be able to perform an extraperitoneal cesarean section to be considered a well-rounded practitioner of the specialty. The modern education program of the obstetrical resident, in addition l:o didactic
teaching, includes breech extractions, versions and extractions, all types of forceps operations, and cesarean sections, including classical and low cervical, and cesarean section combined with hysterectomy. It should also include a form of extraperitoneal cesarean section. Experiments at the extraperitoneal approach have been made as far back as 182 1 when Ritgenl tried it on a patient at the University of Giessen. Latzko2 devised a paravesical technique in 1908 with which he achieved moderate success. Other obstetricians of this era employing his method reported bladder and ureteral injuries, and it was gradually abandoned. It was not until 1940, when Water? developed the supravesical approach, that the operation attained a degree of popularity. His technique was found to be difficult for the average obstetrical surgeon, and repeated performances of this method in various clinics resulted in equivocal appraisal. At this time antibiotic medication came into general use. Many obstetricians abandoned the extraperitoneal operation, rationalizing that the transperitoneal approach for the patient safeguarded by antibiotic therapy was sufficient, even in the presence of infection. In 1946, Norton* devised the unilateral paravesical approach to the lower segment. Because this operation seemed easier and less time-consuming, interest in it was renewed. Bourgeois and Phaneuf5 in 1949 reported
From the Department of Obstetrics and Gynecology, Providence Hospital. 695
696
Ellis
and
September, 1961 & Cynec.
DeVita
Am. J. Obst.
Deep
epigastric
v
nsversalis
fascia
Fig. 1. The skin and superficial fascia are open. The anterior rectus sheath is partially open, and the rectus and pyramidalis muscles are seen. The close relation of the
epigastric
vessels
can be noted.
Inset,
the approximate
a bilateral parasupravesical approach whereby both paravesical spaces were opened; the dissection started down the posterior surface of the bladder and ended, upward, by removal of the peritoneal fold from the anterior surface. In 1942 at our hospital, the members of the department staff began doing the supravesical operation as described by Waters. Our results were anything but uniform. With optimum conditions, the operation was excellent and the approach to the lower segment provided all the room desired; but with adverse conditions, the operation was difficult and, on occasion, the bladder and peritoneum were incised.
elevated by blunt dissection. The method of anchoring the muscle to the fascia is seen. Again the relation of the epigastric vessels can be noted.
of the
incision.
After Norton reported his method, our department staffs adopted the paravesical technique. The results were uniformly better. Although the method was easier for the average operator, the exposure afforded was never satisfactory. The large infant and the one in abnormal presentation were hard to deliver through the available space. With use of the vertical S-shaped incision in the lower segment as advocated by Norton, extensions occasionally occurred which were difficult to repair. In institutions where staff members are adept at the extraperitoneal approach, there should be no reason for sacrificing a uterus following cesarean section because of infection. Waters7 states, “We have done no cesarean hysterectomies in the last twenty-five years as a treatment for uterine infection. It is our past and present opinion that none should be done.” The purpose of this paper is to present a preliminary report on a new technique for performing the extraperitoneal cesarean section. This operation combines the simplicity of the paravesical operation and the ample room of the supravesical, while eliminating the difficult dissection of the older supravesical
Fig. 2. The rectus muscles have been exposed and
level
technique.
Technique 1. The patient is hydrated with 2,000 to 3,000 ml. of 5 per cent dextrose in distilled
Volume Number
82 3
given over a 2 to 3 hour period. This aids to make the tissues “wet” and to facilitate the dissection. If the patient has edema, this step is not necessary. 2. A Foley catheter is inserted into the bladder and connected to a “Y” tube which is hooked up to a reservoir of sterile water. A tube from the remaining end of the 7”’ is placed in a drain basin. By means of this arrangement the bladder may be filled or emptied by clamping or unclamping the proper tubing. 3. The patient is given spinal or peridural anesthesia. The advantages in the use of block anesthesia are: ( 1) adequate time is allowed for performance of the dissection, and (2) injurious effects of anesthetic agents to the fetus are avoided. 4. A low transverse incision is made in the abdomen. The rectus sheath is transversely incised, and the resulting retraction exposes both rectus muscles (Fig. 1) . The index finger is inserted under one muscle from the medial to the lateral aspect, with care being exercised to avoid injury to the deep epigastric vessels. Two Allis clamps are placed on the upper margin of the retracted rectus sheath. While the assistant makes downward traction, 2 sutures are placed lateral to each other and tied so .as to anchor the muscle to the sheath (Fig. 2) . The clamps are then placed on the lower margin of the sheath and, while the fascia is pulled upward, 2 additional sutures are placed as before. The rectus muscle is transected while tension is applied from underneath by the operator’s index finger (Fig. 3). The 4 sutures function to control bleeding from vessels in the muscle and to facilitate muscle approximation when the fascia is being closed. The same maneuver is effected on the opposite rectus muscle. The :muscles will retract, enhanced by blunt dissection, providing considerable room. 5. The deep epigastric vessels at the lateral edge of each rectus muscle are isolated, clamped, cut, and ligated. This should be done as inferiorly as possible, allowing the vessels to retract laterally at a later stage without the danger of tearing them. Occa-
Extraperitoneal
cesarean
section
697
water, fluid
Fig. 3. Both rectus muscles have been anchored to the fascia superiorly and inferiorly, and the left rectus muscle has been transected. It is to be noted here that the muscles are transected in layers rather than from side to side. It is at this point that the relation of the epigastric vessels is of paramount importance.
._..”.-.- “.._fascia .“““._
Transversalis overlying
be
bladder ated
and
cut
Fig. 4. The muscles are transected and the underlying transversalis fascia exposed. The inferior epigastric vessels are being clamped.
Transversalis
fascia transected
Fig. 5. The transversalis fascia over the bladder is incised. This is done with the scissors beginning in the midline and extending laterally to both sides. The paravesical space on the right is visualized, and the bladder is seen to herniate up through the opening in the fascia. Bladder vessels are also seen, as are the ligated ends of the epigastric vessels. The Balfour retractor blade is in place.
698
Ellis
and
DeVita
Fig. 6. Blunt dissection with gauze over the fingers is being carried out on the left side. The right side has already been dissected and the lower segment can be visualized. The lateral umbilical ligaments can also be seen. The peritoneal-fascial fold is seen superior to and partially overlying the bladder.
Fig. 7. The two paravesical spaces have been dissected and connected behind the bladder by blunt finger dissection as described in the text. The lateral umbilical ligaments are seen on either side. With a finger behind the bladder, the tissue to be dissected off the b!adder now lies over the finger. Insets, the isolation, ligation, and section of the lateral umbilical ligaments.
sionally, the vessels are located under the muscle. If the muscle is slowly divided at the lateral aspect, the vessels can be identified and ligated (Fig. 4). At this stage of the dissection there is accessibility to the bladder superiorly and laterally, and the space may be enlarged by placing the lower blade of the Balfour retractor in the inferior border of the incision. 6. The bladder is easily identified after filling with about 150 to 200 ml. of fluid. The transversalis fascia over the bladder is
September, 1961 Am. J. Obst. & Gynec.
picked up with tissue forceps, and with the dissecting scissors an incision is made beginning at the midline and extending laterally to both sides (Fig. 5). The transversalis fascia may be variable in different patients, ranging from a structure well defined with a thin layer of fat between it and the bladder adventitia to a structure poorly defined and filmy. The partially infilated bladder will “balloon” upward into the line of incision and the proper plane is attained when the bladder vessels are exposed (Fig. 5). 7. The paravesical spaces are now identified on either side. These are the “yellow chicken fat” areas described by Norton.4 They are located lateral to the bladder, medial to the deep epigastric vessels, and inferior to the peritoneal-fascial fold, which is not identifiable at this time. With a moist 4 by 4 inch gauze sponge on each index finger, the operator incises one paravesical space by blunt dissection down to and exposing about 1 to 2 sq. cm. of the lower uterine segment. The level of dissection should be inferior enough so that the peritoneum is not entered (Fig. 6) . An identical procedure is carried out on the opposite side. 8. The index finger is now introduced into one paravesical fossa and tunneled across to the opposite side, with care being exercised not to enter the peritoneum. It is at this part of the procedure where most failures to stay extraperitoneally occur. This hazard can be avoided by directing the finger downward so that it comes across the posterior surface of the bladder and below the peritoneal fold. It is important not to use force, but only gentle blunt dissection. The finger will find the proper plane and can be brought through to the opposite fossa. Occasionally, in repeat sections a plane cannot be found. One should not persist beyond establishing a tunnel on either side which will allow the index finger to exert upward pressure from underneath the bladder. When the finger is in the proper plane, it will be against the lower uterine segment, the bladder will be anterior, and the peritoneal-fascial fold will be superior.
Volume Number
82 3
9. It will be noted that thick bands of tissue seem to be holding the peritoneal fold to the bladder on each side. These consist of fat, areolar tissue, and the obliterated hypogastric arteries or lateral cmbilical ligaments. The latter go from the hypogastric arteries to the umbilicus passing lateral to the bladder. These obliterated vessels are isolated by blunt dissection down near the bladder, ligated, and cut (Fig. 7). Initially, these ligaments may be mistaken for ureters, but further dissection will make it apparent that this is not the case. As the lateral ligaments are cut, there is a feeling as though “something gave” and the peritoneal fold seems to separate partially from the bladder. 10. The finger is reintroduced into the tunnel and upward traction is made under the bladder and peritoneal-fasci.al fold. Only areolar tissue holds the fold to the bladder. Starting well below the level of peritoneal reflection, sharp dissection is begun with a scalpel over the anterior surface of the bladder. The tissue to be cut will stand out as small fibrous bands. The finger exerting pressure from underneath the bladder will feel the fold being released (Fig. 8). If the bladder muscularis is exposed, one must seek a more superficial plane, superior to the previous dissection. Eventually, the white line of the peritoneal reflection is identified resembling a hernial sac. Dissection is then carried out about 1 to 2 mm. inferior to the white line. As one pulls upward, the fold will be felt to give and peel off the bladder. Bleeding vessels are clamped as they are encountered. The width of the fold decreases as the urachus is approached in the midline (Fig. 9). This structure is tied and cut and the dissection is continued down the posterior surface of the bladder until the entire fold is separated. The bleeders on the surface of the bladder are now tied. The bladder is emptied, a tape placed over it, and the lower blade of the Balfour retractor reinserted, displacing the bl.adder under the symphysis. Another wide retractor is placed at the upper end of the incision holding up the peritoneal-fascial fold. The whole
Extcaperitoneal
cesarean
section
659
lower segment is now in view. There is usually a thin film of fascia over the lower segment which is divided with a scalpel. 11. The uterus is incised transversely. At this stage, a suture is placed in the inferior edge of the incised lower segment and left long because the lower edge tends to fall well down behind the bladder (Fig. 10) . The transverse incision is extended by lateral pressure with the fingers. The infant is delivered. Indicated cultures, if desired, are taken at this point. The oxytocic is given
Fig. 8. Sharp dissection of the peritoneal-fascial fold is shown in progress. It should be noted that the width of the fold has decreased after section
of the lateral ligaments. Inset, a schematic diagram in sagittal section. It shows the peritoneal fold to be dissected off the bladder, and the direction of pull of the finger behind the bladder. The knife edge is shown cutting the fibrous connective tissue holding the fold to the bladder.
Fig. 9. The dissection is shown near completion as the urachus comes into view. By this time the white line of the peritoneal reflection can be seen. Inset, the dissection completed and the urachus being clamped. Note the ties on the bladder vessels.
700
Ellis
and
September, 1961 Am. J. Obst. &Gym.
DeVita
Midline approach. In the presence of a midline scar, the described method of entry. is not used, to avoid multiple abdominal scars. Instead, the midline approach is used, and the rectus muscles are retracted laterally rather than transected. The remainder of the operation follows the procedures as listed. The only real disadvantage in this modification is slight loss of exposure. Analysis
Fig. 10. The entire lower uterine segment is exposed and the line of incision into the uterus is shown. The lower segment is being tagged with a suture to prevent it from falling out of reach behind the bladder. Upper inset, the uterine incision after closure with a Lembert suture. Lower inset, the method of cutting the conventional Penrose drain so that it may be placed in both paravesical spaces.
by the anesthetist and the placenta and membranes are allowed to deliver spontaneously. The uterine edges are then clamped and the uterus is closed with a double layer of suture in the manner of a low cervical section. After all bleeding has been controlled, the bladder is filled and inspected for injury and additional bleeding vessels. 12. A Y-shaped Penrose drain is now placed with one side of the “Y” in either paravesical area. The peritoneal-fascial fold is allowed to fall back into place (Fig. 10). The fascia is now closed with interrupted chromic figure-of-eight sutures, which causes the edge of the cut muscles to be approximated because of the fixation to the fascia. The subcutaneous tissue and skin are then closed and a large dressing is applied to absorb drainage. The Foley catheter is left in place until the next day to help eliminate the excess fluid which was administered before the operation. After removal of the catheter, the bladder is tested for residual urine at the next voiding. The drain is removed after 24 hours and the wound redressed. Care is otherwise no different from that after other cesarean sections.
of cases
To date, 17 cases have been performed by this method. The series is too small to warrant a critical analysis. Thirteen primary and 4 repeat sections were performed. In one case, failure of the technique necessitated completing the operation as a lower segment transperitoneal section. In the early cases, when the technique was being perfected, the peritoneum was incised five times. When this complication occurred, the opening was repaired and the operation continued as described. The bladder was not entered in any of the cases, and in one case repeated catheterizations were needed for residual urine. In this case the abdomen had to be reopened the first postoperative day and a hematoma under the rectus muscles evacuated. One patient who was in labor more than 30 hours with ruptured membranes developed a wound infection. Another patient had a seropurulent discharge from the wound for 2 weeks postoperatively. Thirteen operations were done with use of spinal anesthesia; 2 with epidural; one with general anesthesia with thiopental, ethylene, and d-tubocurarine; and one with no anesthesia. In the latter case, the patient had a transection of the spinal cord at the level of T-9 as a result of a bullet iodged in the spinal cord. In the series there was one neonatal death which was not attributable to the type of section. Comment The type of extraperitoneal cesarean section presented in this report has several advantages. The simplified technique can be
Volume 82 Number 3
Extraperitoneal
performed by the average obstetrician and requires only one assistant. It provides the operator with sufficient space for delivering large babies or babies with abnormal presentations without the danger of injuring the urinary system, particularly the ureters. It eliminates the difficulties in the dissection around the bladder encountered in the supravesical section. Fifteen to 30 minutes is required to deliver the infant. While the time factor may be considered a disadvantage, there were no untoward effects in any of the infants. The employment of block anesthesia decreases the importance of the time factor with regard to fetal morbidity and mortality as compared to other anesthesia modality. The total time
cesarean
section
701
of the operation does not exceed the average low cervical section by more than 5 to 10 minutes. Summary
1. The use of extraperitoneal cesarean section in modern obstetrics is discussedand a brief history of the operation is given. 2. A modified technique is described in detail. 3. This technique lessensmany of the dangers and difficulties of the old supravesical and paravesical approaches. 4. Extraperitoneal cesarean sections can eliminate the necessity for doing cesarean sectionscombined with hysterectomies in infected cases.
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Bourgeois, G. A., and Phaneuf, L. E.: AM. J. OBST. & GYNEC. 57: 237, 1949. Ellis, G. J., Sheffery, J. B., and Paquin, J.: M. Ann. District of Columbia If: 553, Oct. 1948. Waters, E. G.: Clin. Obst. & Gynec. 2: 989, 1959.