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Laparoelytrotomy or abdominal delivery without uterine incision
990
Communications
in brief
were several other factors which could have led to heart failure. There could have been hypoxic episodes with the tachycardia or small infarcts of the heart during the episode of disseminated intravascular coagulation. However, these problems were monitored as closely as possible by arterial blood gases, cardiac enzymes, and electrocardiograms. The ltbe of Inderal could be implicated: however, it was not felt that Inderal was a casual factor in this severe degree of left ventricular dysfunction. Therefore, this case appears to be one of the rare cases of peripartum cardiomyopathy. REFERENCES
1. Demakis, J. G., Rahimtoola, S. H., Sutton, G. C., Meadows, W. R., STanto, P. B., Tobin, J. R., and Cunnar, R. M.: Satural course of peripartal cardiomyopathy. Circulation 44:1053. 1971. 2. Klepper. I.: Cardioversion in late pregnancy, Anesthesia 36:611, 19x1.
Laparoelytrotomy or abdominal without uterine incision ROBERT JOSEPH RPILPH JOSEPH D$nrtmmt.~ lJnirwr.tity
C.
diagram of late second stage of labor with ,d, Retracted and fully dilated cervix. R, in vagina after bladder has been retracted.
GOODLIN
C. E.
delivery
Fig. 1. Schematic intact membranes. Point of incision
SCOTT.
JR.
WOODS
C.
ANDERSON
01 Ob.&tno crud G~~n~colog and Radiology, of Nebraska ;M~rlicnl C&rr, Omaha, Ncbmsk
ACCORDING to Garrigues,’ Joerg, in 1806, was the first to propose a “cesarean section” in such a way as to a\,oid incision into the uterus. In 1871. Thomas,’ of New York, presented before a local medical association a successful case of laparoelytrotomy which he claimed to have performed three times. In 1878, Garrigues, in a 70-page review of “On gastro-elytrotomy,” was enthusiastic about the abdominal extraperitoneal approach to the vagina and delivery through the fully dilated cervix. The extraperitoneal approach was subsequently modified by LatLko of Vienna and Kustner in Breslau. This communication presents a modern-day transperitoneal laparoelytrotomy (elytrotomy is a r,aginotomy).
D. J.. a 19-year-old, para O-O- l-0, black woman, was at term and had been in the second stage of labor for approximately 2% hours with no analgesia. The vertex remained at a +2 station in the left occipitotransverse position for ll/? hours. The fetus was estimated to weigh 3,600 gm, and the mother was in good condition. After the options of a midforceps
Reprint requests: Robert C. Goodlin, Obstetrics and Gynecoloo, University Center, 42nd and Dewey Ave., Omaha, 0002.937H/82/240990+02$00.20/0
@ 1982
M.D., Department of of Nebraska Medical Nebraska 68105. The
C. \'. Mosby
Co
Fig. 2. Static ultrasound scan of patient in late second-stage labor at 30 weeks’ gestation with breech presentation. C = Retracted cervical lips: B = maternal bladder; I’ = vagina.
Point of vaginal entry would be between C and 1.. delivery under spinal anesthesia versus a cesarean section were explained, the patient elected to undergo a cesarean section. With the patient under genet-al anesthesia, the peritoneal cavity was entered. After the bladder flap was defiected downward, it was suspected that the cervix had risen relatively high into the false pelvis. The vagina oYer the fetal vel-tex appeared distensible and free of any major vessels and was entered through a transverse midline incision. The fetal head was easily disengaged from the bony pelvis, and a 3.810 gm male infant in good condition was delivered through the vaginal incision. The vaginal incision was closed in two layers of running lock after irrigation of the vagina with 1 gm of ampicillin solution. The bladder flap was approximated over the incision.
She was placed on a regimen of prophylactic antibiotics, 500 mg of ampicillin four times a day for six doses, and had a benign postoperative course. The infant did well, and both were discharged home on the fourth postoperative day. When the patient was seen at the time of her +week postpartum check. the vaginal incision .Ippeared well healed with only minimal induration. Four other laparoelytrt)tomy procedures have been performed at the Univc,rsity of Nebraska Hospital. These were similar in thai the second stage of labor had been prolonged and the cervix was completely retracted and dilated. In tttese four cases, it was not initially appreciated that tht, vagina rather than the lower uterine segment was being entered at the time of the incision. In these cases, Ii-hen the vaginal incision was about to be closed, it w.~s noted that the cervix was abole or included in the, vaginal incision. These patients all had benign postoperative courses. When laparotrachelotomy (low-segment uterine cesarean section) is attemlfted, “taparoelytrotomy” may he inadvertently perfornied. There is a lack of discussion in our literature of’tllis “complication,” but vaginal incision apparently has frw. if any, remote complications. It is suggested thal the technique of laparoelytrotomv be similar to thar of the tow cervical cesarean section: To utilize the abclominat-vaginal approach effectively, the cervix should be completely dilated, elevated, and retracted. The fetal vertex should be well into the vagina, and the vesicouterine fold should be freed downward further than in the conventional cesarean section. Exposure IIf the upper 3 cm of anterior vaginal wall is needed. .fhe bladder flap is retained behind a large retractor placed between the bladder and uterus to draw it for\\ ard (Figs. 1 and 2). The \fagi-
nal
wall
incision
is made
in
Communications
in brief
991
a transverse
direction
in
order to avoid the cervix. The advantages of taparoelytrotomy are that the uterus remains intact and that the thin vaginal tissue wilt have a reduced amount of bleeding. Possible disadvantages of the procedure include the following: (1) The patient must be in the late second stage of labor: (2) there is a risk of infection with the transperitoneal approach to the vagina; (3) it is unknown whether the scarred vagina might rupture or obstruct delivery in f’uture labor. i\lso, the nineteenth-century surgeons were concerned about damage to the ureters or bladder.’ At the time of laparotomy in pregnant women in the late second stage of labor, it is sometimes difficult to discern the location of the cervix prior to the opening of either the lower uterine segment or the upper vagina. After complete retraction of the bladder, thr vagina has a characteristic “ballooned out” and shiny appearance. However, if there is any doubt as to landmarks, it is probably better to err on the upper side and to approach the fetus through the lower uterine segment. Given the current tendency toward longer second stages of labor and avoidance of the use of midforceps for delivery, this operation may have more of. a place now than at any time since it was first proposed. As noted by Thomas,” in 1871, there are alternatives to cesarean section for abdominal deliverv.
REFERENCES
1. Garrigues, H. J.: On gastro-elytrotomy. N. Y. Med. J. 28:449 and 520, 1878. 2. Thomas, G. T.: Gastro-elytrotomy; a substitute for the caesarean section, Am. J. Obstet. 3: 125. 1871.
Communications
in brief
were several other factors which could have led to heart failure. There could have been hypoxic episodes with the tachycardia or small infarcts of the heart during the episode of disseminated intravascular coagulation. However, these problems were monitored as closely as possible by arterial blood gases, cardiac enzymes, and electrocardiograms. The ltbe of Inderal could be implicated: however, it was not felt that Inderal was a casual factor in this severe degree of left ventricular dysfunction. Therefore, this case appears to be one of the rare cases of peripartum cardiomyopathy. REFERENCES
1. Demakis, J. G., Rahimtoola, S. H., Sutton, G. C., Meadows, W. R., STanto, P. B., Tobin, J. R., and Cunnar, R. M.: Satural course of peripartal cardiomyopathy. Circulation 44:1053. 1971. 2. Klepper. I.: Cardioversion in late pregnancy, Anesthesia 36:611, 19x1.
Laparoelytrotomy or abdominal without uterine incision ROBERT JOSEPH RPILPH JOSEPH D$nrtmmt.~ lJnirwr.tity
C.
diagram of late second stage of labor with ,d, Retracted and fully dilated cervix. R, in vagina after bladder has been retracted.
GOODLIN
C. E.
delivery
Fig. 1. Schematic intact membranes. Point of incision
SCOTT.
JR.
WOODS
C.
ANDERSON
01 Ob.&tno crud G~~n~colog and Radiology, of Nebraska ;M~rlicnl C&rr, Omaha, Ncbmsk
ACCORDING to Garrigues,’ Joerg, in 1806, was the first to propose a “cesarean section” in such a way as to a\,oid incision into the uterus. In 1871. Thomas,’ of New York, presented before a local medical association a successful case of laparoelytrotomy which he claimed to have performed three times. In 1878, Garrigues, in a 70-page review of “On gastro-elytrotomy,” was enthusiastic about the abdominal extraperitoneal approach to the vagina and delivery through the fully dilated cervix. The extraperitoneal approach was subsequently modified by LatLko of Vienna and Kustner in Breslau. This communication presents a modern-day transperitoneal laparoelytrotomy (elytrotomy is a r,aginotomy).
D. J.. a 19-year-old, para O-O- l-0, black woman, was at term and had been in the second stage of labor for approximately 2% hours with no analgesia. The vertex remained at a +2 station in the left occipitotransverse position for ll/? hours. The fetus was estimated to weigh 3,600 gm, and the mother was in good condition. After the options of a midforceps
Reprint requests: Robert C. Goodlin, Obstetrics and Gynecoloo, University Center, 42nd and Dewey Ave., Omaha, 0002.937H/82/240990+02$00.20/0
@ 1982
M.D., Department of of Nebraska Medical Nebraska 68105. The
C. \'. Mosby
Co
Fig. 2. Static ultrasound scan of patient in late second-stage labor at 30 weeks’ gestation with breech presentation. C = Retracted cervical lips: B = maternal bladder; I’ = vagina.
Point of vaginal entry would be between C and 1.. delivery under spinal anesthesia versus a cesarean section were explained, the patient elected to undergo a cesarean section. With the patient under genet-al anesthesia, the peritoneal cavity was entered. After the bladder flap was defiected downward, it was suspected that the cervix had risen relatively high into the false pelvis. The vagina oYer the fetal vel-tex appeared distensible and free of any major vessels and was entered through a transverse midline incision. The fetal head was easily disengaged from the bony pelvis, and a 3.810 gm male infant in good condition was delivered through the vaginal incision. The vaginal incision was closed in two layers of running lock after irrigation of the vagina with 1 gm of ampicillin solution. The bladder flap was approximated over the incision.
She was placed on a regimen of prophylactic antibiotics, 500 mg of ampicillin four times a day for six doses, and had a benign postoperative course. The infant did well, and both were discharged home on the fourth postoperative day. When the patient was seen at the time of her +week postpartum check. the vaginal incision .Ippeared well healed with only minimal induration. Four other laparoelytrt)tomy procedures have been performed at the Univc,rsity of Nebraska Hospital. These were similar in thai the second stage of labor had been prolonged and the cervix was completely retracted and dilated. In tttese four cases, it was not initially appreciated that tht, vagina rather than the lower uterine segment was being entered at the time of the incision. In these cases, Ii-hen the vaginal incision was about to be closed, it w.~s noted that the cervix was abole or included in the, vaginal incision. These patients all had benign postoperative courses. When laparotrachelotomy (low-segment uterine cesarean section) is attemlfted, “taparoelytrotomy” may he inadvertently perfornied. There is a lack of discussion in our literature of’tllis “complication,” but vaginal incision apparently has frw. if any, remote complications. It is suggested thal the technique of laparoelytrotomv be similar to thar of the tow cervical cesarean section: To utilize the abclominat-vaginal approach effectively, the cervix should be completely dilated, elevated, and retracted. The fetal vertex should be well into the vagina, and the vesicouterine fold should be freed downward further than in the conventional cesarean section. Exposure IIf the upper 3 cm of anterior vaginal wall is needed. .fhe bladder flap is retained behind a large retractor placed between the bladder and uterus to draw it for\\ ard (Figs. 1 and 2). The \fagi-
nal
wall
incision
is made
in
Communications
in brief
991
a transverse
direction
in
order to avoid the cervix. The advantages of taparoelytrotomy are that the uterus remains intact and that the thin vaginal tissue wilt have a reduced amount of bleeding. Possible disadvantages of the procedure include the following: (1) The patient must be in the late second stage of labor: (2) there is a risk of infection with the transperitoneal approach to the vagina; (3) it is unknown whether the scarred vagina might rupture or obstruct delivery in f’uture labor. i\lso, the nineteenth-century surgeons were concerned about damage to the ureters or bladder.’ At the time of laparotomy in pregnant women in the late second stage of labor, it is sometimes difficult to discern the location of the cervix prior to the opening of either the lower uterine segment or the upper vagina. After complete retraction of the bladder, thr vagina has a characteristic “ballooned out” and shiny appearance. However, if there is any doubt as to landmarks, it is probably better to err on the upper side and to approach the fetus through the lower uterine segment. Given the current tendency toward longer second stages of labor and avoidance of the use of midforceps for delivery, this operation may have more of. a place now than at any time since it was first proposed. As noted by Thomas,” in 1871, there are alternatives to cesarean section for abdominal deliverv.
REFERENCES
1. Garrigues, H. J.: On gastro-elytrotomy. N. Y. Med. J. 28:449 and 520, 1878. 2. Thomas, G. T.: Gastro-elytrotomy; a substitute for the caesarean section, Am. J. Obstet. 3: 125. 1871.