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Minor Gynecologic Surgery
MINOR GYNECOLOGIC SURGERY
HERBERT E. SCHMITZ, M.D., F.A.C.S,'"
AND
GEORGE BABA, M.D.
BIOPSY AND CURETTAGE·
ALTHOUGH classed under minor surgical procedures, biopsy and . curettage are of decidedly major importance. Biopsy or curettage findings dictate the proper management. Failure to observe this important diagnostic step preliminary to the institution of surgical or medical treatment of a given patient has resulted in what amounts to a moral malpractice, to-wit, inadequate surgery or failure to intervene while the malignant process advances beyond the stage amenable to adequate surgery or curative radiation therapy. Furthermore, the two procedures are important from the point of view of prognosis. Comparative biopsy or curettage studies at properly spaced intervals will accurately reveal the tissue response to therapy and thus permit a more nearly accurate prognostic evaluation. This has been showri by Schmitz, Sheehan and Towne on corpus cancer and more recently by Spear and Glucksmann on cervical cancer. . That the biopsy must be made the essential part of any investigation of cervical lesion is shown by the great frequency of such mlllignancies. Pearl, from the postmortem statistical study at the Johns Hopkins Medical School, found that the primary location of malignant disease was most frequent in the alimentary tract in the male and in the reproductive tract in the female. Of the female reproductive tract, the distribution in the order of decreasing frequency was: according to Pearl, uterus (50 per cent), breast (30 per cent) and ovary ( 20 per cent); and according to the mortality statistics from England and Wales, uterus (46.12 per cent), breast (45.17 per cent), ovary (6.21 per cent) and vagina and vulva (2.40 per cent). The relative incidence of cervical to corpus cancers is generally placed around 10:1. The cervix, therefore, is the most frequent site of malignancy. Early detection of malignant changes requires judicious utilization of biopsy. It is essential that an adequate amount of tissue be obtained from the properly suspected areas. The point of bleeding may indicate the site or Schiller's tinctorial test may designate the proper place to be biopsied. TeLinde and Galvin stress the external os or the junction of the squamous and columnar epithelium as the most vulnerable spot for the beginning of cervical cancer. Enough tissue must be removed to permit careful study. Novak even suggests cervical ampuFrom the GynecolOgic Department, Mercy Hospital-Loyola University Clinics . ... Professor of Obstetrics and Gynecology, Loyola University School of Medicine; Senior Attending Gynecologist and Director of the Department, Mercy Hospital-Loyola University Clinics.
222
MINOR GYNECOLOGIC SURGERY
223
tation rather than biopsy particularly in a woman past the childbearing period and in whom malignancy is suspected. Findings of early cancer in the cervices removed at plastic operation or in the course of Manchester operation and in the cervix of a hysterectomized specimen emphasize the need for repeated biopsies and eternal vigilance. Cancer of the cervix can and does occur without any sign or symptoms and may not be recognizable except by histologic study. Since even a normal-appearing cervix may harbor carcinoma, it is much more likely that a pathologic cervix be the seat of cancer. Biopsies must be obtained from all cervical lesions subject to spontaneous or contact bleeding, all "precancerous" lesions such as leukoplakia, chronic inflammatory and chronic irritative lesions including erosions, ectropions, lacerations, etc., as well as from the more frankly appearing lesions. Follow-up biopsies must be made to check on the initial negative findings and to detect possible later development. 'The earliest malignant lesion is the so-called pre-invasive carcinoma (also referred to as intra-epithelial carcinoma, carcinoma-in-situ, carcinoid and Bowen's disease of the cervix) where the' epithelium shows anaplastic changes ordinarily associated with cancer but without the penetration through the basement membranes. Such a picture of noninvasive cancer, however, may also be seen if only the very margin of a frankly malignant lesion is studied. Furthermore, the follow-up studies by TeLinde and Galvin on a series of cervices diagnosed "preinvasive" carcinoma by biopsy, showed that invasive character may be present elsewhere in the lesion. They are of the opinion that abnormal cellular activity which eventually results in fully~ developed cancer begins in the basal cells of the surface epithelium arid that the surface lesions may exist for years before developing gross .carcinomatous lesions. The value of tissue study in prognosticating the clinical course of cervical cancer has been recently emphasized by Spear and Glucksmann. These investigators have found that, with the "Stockholm Technique" and its modifications, the most "radio-curable" are the well differentiated growths, and that the differentiated tumors predominate in the early, and the undifferent:ated, in the late stages of the disease. Furthermore, by comparative qualitative and quantitative histologic studies of preradiation and postradiation tissue sections, Glucksmann has worked out a method whereby it is possible to make a more nearly accurate prognosis of the final results of the treatment. Sections must always be taken from the growing edge of the tumor as the section frOm the center may show cells too necrotic to give results of any value. Biopsies are taken on at least two occasions after treatment is started. It is apparent from the preceding remarks that biopsies have both diagnostic and prognostic significance. It is also obvious that what has just been said is applicable to biopsy studies of sites other than
224
HERBERT E. SCHMITZ
the cervix. One additional point requires mentioning. Dr. James Henry, the pathologist, has frequently observed that, although the biopsied tissue showed no malignancy, the lymphatic and blood vessels may at times show congestion or stasis to suggest nearby obstruction possibly on the basis of adjacent new growth. Further biopsies taken at his recommendation have revealed the presence of malignancy at a higher location. The role of biopsy in such cases was to direct the investigation toward the possible site of the lesion. Judicious, full utilization of this most important procedure is absolutely essential for the proper management of a patient. The more frequently biopsies are taken, the greater will be the data available for true evaluation. ENDOMETRIAL BIOPSY AND CURETTAGE
Endometrial biopsy and diagnostic curettage must be employed similarly to biopsy procedures elsewhere. Endometrial studies are necessary for the intelligent management of problems in sterility and menstrual dysfunction particularly where hormonal therapy is used. Endometrial biopsy has the practical advantage of office applicability. With proper precaution, it has been used to diagnose or rule out hydatid mole and ectopic pregnancies. For this purpose the Novak or Randall endometrial biopsy curet is available. . Diagnostic curettage is really an extensive biopsy of the uterine lining. The information gained, in addition to the nature of the uterine lining, includes data regarding the contour of the uterine cavity diagnostic of the presence or absence of such tumors as myoma. Therapeutically, curettage may control bleeding in incomplete abortion, incomplete shedding of the endometrium and some bleeding due to unknown factors. Here again, a procedure may serve a dual purpose of diagnosis and therapy. CERVICAL DILATATION
Dilatation of the cervix is an essential preliminary to the curettage but, in the treatment of cervical stenosis or stricture, this procedure is the important part. Dilatation must be gradual to guard against trauma leading to secondary stenosis or stricture from scar tissues. In the treatment of dysmenorrhoea secondary to the cervical stricture, stem pessary may be inserted after the dilatation to maintain an adequately patent cervical canal. Secondary cervical stenosis or stricture may result in hematometra and pyometra. Particularly in the latter, drainage is important. A simple rubber T drain made from firm tubing may be inserted after the dilatation. The preparation of the T drain from a rubber tube is illustrated in Figure 70a. The importance of proper treatment of cervical stricture or stenosis becomes apparent when the high incidence of pelvic endometriosis is considered in the light of the generally accepted Sampson's theory of
225
MINOR GYNECOLOGIC SURGERY
retrograde drainage. It becomes still more important when authorities such as Curtis consider obstructed uterine 'drainage an important factor in the development of carcinoma in the body and cervix of the uterus. Furthermore, retrograde drainage of pus from a pyometra will cause peritonitis and may even result in the death of the patient. CAUTERIZATION, CONIZATION AND AMPUTATION OF THE CERVIX
As has been mentioned previously, the detection of early malignancies with increasing frequency even in normal-appearing cervices makes it imperative that all diseased cervices be treated and, if they show no response, be removed. Cauterization was popularized by Guy L. Hunner by his report in 1906. His method of making radial strokes for the destruction of the deep cervical gland without causing future
.
\
:
\
\.;
--
/
'--'
Fig. 70a.-Preparation of rubber T drain.
stenosis is still the procedure followed today. Excellent results have been obtained but postcauterization checks must be made to insure adequate patency of the cervical canal. Conization and amputation have been employed in cases of cervicitis resisting ordinary cauterization. Both procedures have given excellent results but both are not without some disadvantages. Miller and Todd in a series of 899 conizations reported strictures of the cervix requiring dilatation in 6.46 per cent and an increased tendency toward premature labors in those who became pregnant. Cervical amputation is not advocated in women in the child-bearing period as the incidence of abortion, premature labor and difficult labor was shown to be greatly increased following the amputation. Another disadvantage is the relative frequency of postoperative bleeding occurring in about seven to fourteen days. In properly selected cases, however, cervical amputations as a part of plastic operation or Manchester operation have given excellent results. COLPOCENTESIS, COLPOTOMY AND COLPOPERITONEOSCOPY
Colpocentesis, colpotomy and colpoperitoneoscopy are diagnostic procedures which will eliminate most unnecessary "exploratory" laparotomies and at the same time will not subject the patient to the
226
HERBERT E. SCll}<1ITZ
risk of "expectant treatment" resulting from uncertainty of diagnosis. Colpocentesis is of particular value where intra-abdominal bleeding of gynecologic origin is under consideration. Withdrawal of old blood signifies long-standing intra-abdominal bleeding and is very suggestive of ectopic pregnancy. Differentiation from bleeding of ovarian origin, puncture of hemorrhagic ovarian cyst or endometrial cysts and bleeding produced by neoplasm should not be difficult when the history and clinical findings are correlated with the colpocentesis finding. Aspiration of bright red or fresh blood does not indicate intra-abdominal bleeding but rather a puncture of blood vessels. Failure to withdraw any blood, of course, does not rule out ectopic pregnancy. In all questionable circumstances, colpotomy exploration will reveal the true pathologic condition. Through a colpotomy wound, the pelvic organs may be directly observed as well as palpated. Even major surgical procedures as salpingectomy and oophorectomy have been performed. If findings require abdominal approach, it is a simple procedure to close the colpotomy and little damage is done. In addition to direct inspection and palpation, colpotomy affords a means of obtaining intrapelvic biopsy. By this method, a positive diagnosis of pelvic endometriosis is possible without the "exploratory" or "diagnostic" laparotomy. Colpoperitoneoscopy studies are now being reported by TeLinde. Accurate study of the pelvis and its content is now possible. As the operator's familiarity with the intrapelvic appearance of the organs increases, earlier recognition of pathologic deviation will be possible. The tremendous import of this fact becomes apparent when we consider that the present poor salvage from ovarian malignancy is too often the result of our failure to detect the neoplasm until the changing contour and increasing size make the diagnosis obvious but also too late. As with the malignancies anywhere, early diagnosis means greater curability. The value of. colpoperitoneoscopy is not confined to diagnosis by observation. Biopsy and even some treatment should be possible. Therapeutic colpoperitoneoscopic instruments on the order of the urologist's resectoscope and coagulation-cauterization instruments are within the realm of practicability. From the therapeutic viewpoint, colpocentesis and colpotomy procedures are useful. Colpocentesis and colpotomy drainage of abscesses and fluid drainage from neoplasms such as pseudomyxoma peritonei are common practices. Any removal of organs or parts of organs such as tubes or ovaries belongs under major surgery and will not be discussed here, even though the procedure is carried out through the colpotomy incision. RADIUM INSERTION AND PLASTIC OPERATIONS
Radium insertions and plastic operations such as the repairs of urethrocele, cystocele, enterocele, rectocele and third degree l~cera-
MINOR GYNECOLOGIC SURGERY
227
tion are classed under minor surgery by many operators but are, in reality, major procedures. Proper use of radium requires intimate knowledge of radiology if effective end results are to be obtained without the unfortunate sequelae so often caused by mismanagement. Adequate knowledge of the physical properties of radium and the physiological responses evoked by it will limit its use to certain conditions and will avoid inadequate radiation or radiation burns. Radium in the hands of a competent operator is a valuable and effective therapeutic agent; but in the hands of a person not qualified, it becomes a dangerous and harmful instrument. Plastic operations belong among the major surgical procedures. Proper corrective operations imply detailed knowledge of anatomy. Studies by Curtis, Anson and others have revealed the anatomical complexity of the female perineum and pelvis. Failure to recognize the finer but more important anatomical points may result in annoying complications or rapid recurrence of the original condition. OTHER MINOR SURGERY
Bartholin's Gland.-Acute bartholinitis usually responds to adequate chemotherapy and operative procedures should be avoided. Where incision and drainage becomes necessary, the patient should be warned of the likelihood of recurrence and eventual need for excision. Chronic bartholinitis and Bartholin cyst may require removal. Complete surgical excision or destruction of the entire lining by heat or chemicals is necessary for cure. The usual surgical method is to dissect out the entire sac intact but Curtis advocates incision through the gland substance, grasping the posterior wall of the sac and peeling the entire sac by traction and dissection. Schauffier prefers to treat the abscess or cyst by cruciate incisions over the skin and tumor and destruction of the entire lining and diverticula by electrocoagulation, then permitting the wound to heal by secondary intention. Skene's Duct and Periurethral Gland.-Acute infection of the structures is treated chemotherapeutically. Curtis describes a procedure for removal of chronically infected Skene's glands but, in the light of recent anatomic studies showing the direct contiguity of Skene's duct with the periurethral glands with their extensive branchings, such a procedure would seem palliative rather than curative. Hymenectomy.-Enlargement of the hymenal orifice may be accomplished by multiple incisions of the hymenal membrane or may require a little more extensive corrective procedure. Incision of the perineum in the midline and closure of the incision in the opposite direction will provide a permanent enlargement of the introitus. In some cases of vaginal stenosis, the underlying muscle in the perineum may have to be incised and sutured in the opposite direction to enlarge the vaginal outlet.
HERBERT E. SCHMITZ, M.D., F.A.C.S,'"
AND
GEORGE BABA, M.D.
BIOPSY AND CURETTAGE·
ALTHOUGH classed under minor surgical procedures, biopsy and . curettage are of decidedly major importance. Biopsy or curettage findings dictate the proper management. Failure to observe this important diagnostic step preliminary to the institution of surgical or medical treatment of a given patient has resulted in what amounts to a moral malpractice, to-wit, inadequate surgery or failure to intervene while the malignant process advances beyond the stage amenable to adequate surgery or curative radiation therapy. Furthermore, the two procedures are important from the point of view of prognosis. Comparative biopsy or curettage studies at properly spaced intervals will accurately reveal the tissue response to therapy and thus permit a more nearly accurate prognostic evaluation. This has been showri by Schmitz, Sheehan and Towne on corpus cancer and more recently by Spear and Glucksmann on cervical cancer. . That the biopsy must be made the essential part of any investigation of cervical lesion is shown by the great frequency of such mlllignancies. Pearl, from the postmortem statistical study at the Johns Hopkins Medical School, found that the primary location of malignant disease was most frequent in the alimentary tract in the male and in the reproductive tract in the female. Of the female reproductive tract, the distribution in the order of decreasing frequency was: according to Pearl, uterus (50 per cent), breast (30 per cent) and ovary ( 20 per cent); and according to the mortality statistics from England and Wales, uterus (46.12 per cent), breast (45.17 per cent), ovary (6.21 per cent) and vagina and vulva (2.40 per cent). The relative incidence of cervical to corpus cancers is generally placed around 10:1. The cervix, therefore, is the most frequent site of malignancy. Early detection of malignant changes requires judicious utilization of biopsy. It is essential that an adequate amount of tissue be obtained from the properly suspected areas. The point of bleeding may indicate the site or Schiller's tinctorial test may designate the proper place to be biopsied. TeLinde and Galvin stress the external os or the junction of the squamous and columnar epithelium as the most vulnerable spot for the beginning of cervical cancer. Enough tissue must be removed to permit careful study. Novak even suggests cervical ampuFrom the GynecolOgic Department, Mercy Hospital-Loyola University Clinics . ... Professor of Obstetrics and Gynecology, Loyola University School of Medicine; Senior Attending Gynecologist and Director of the Department, Mercy Hospital-Loyola University Clinics.
222
MINOR GYNECOLOGIC SURGERY
223
tation rather than biopsy particularly in a woman past the childbearing period and in whom malignancy is suspected. Findings of early cancer in the cervices removed at plastic operation or in the course of Manchester operation and in the cervix of a hysterectomized specimen emphasize the need for repeated biopsies and eternal vigilance. Cancer of the cervix can and does occur without any sign or symptoms and may not be recognizable except by histologic study. Since even a normal-appearing cervix may harbor carcinoma, it is much more likely that a pathologic cervix be the seat of cancer. Biopsies must be obtained from all cervical lesions subject to spontaneous or contact bleeding, all "precancerous" lesions such as leukoplakia, chronic inflammatory and chronic irritative lesions including erosions, ectropions, lacerations, etc., as well as from the more frankly appearing lesions. Follow-up biopsies must be made to check on the initial negative findings and to detect possible later development. 'The earliest malignant lesion is the so-called pre-invasive carcinoma (also referred to as intra-epithelial carcinoma, carcinoma-in-situ, carcinoid and Bowen's disease of the cervix) where the' epithelium shows anaplastic changes ordinarily associated with cancer but without the penetration through the basement membranes. Such a picture of noninvasive cancer, however, may also be seen if only the very margin of a frankly malignant lesion is studied. Furthermore, the follow-up studies by TeLinde and Galvin on a series of cervices diagnosed "preinvasive" carcinoma by biopsy, showed that invasive character may be present elsewhere in the lesion. They are of the opinion that abnormal cellular activity which eventually results in fully~ developed cancer begins in the basal cells of the surface epithelium arid that the surface lesions may exist for years before developing gross .carcinomatous lesions. The value of tissue study in prognosticating the clinical course of cervical cancer has been recently emphasized by Spear and Glucksmann. These investigators have found that, with the "Stockholm Technique" and its modifications, the most "radio-curable" are the well differentiated growths, and that the differentiated tumors predominate in the early, and the undifferent:ated, in the late stages of the disease. Furthermore, by comparative qualitative and quantitative histologic studies of preradiation and postradiation tissue sections, Glucksmann has worked out a method whereby it is possible to make a more nearly accurate prognosis of the final results of the treatment. Sections must always be taken from the growing edge of the tumor as the section frOm the center may show cells too necrotic to give results of any value. Biopsies are taken on at least two occasions after treatment is started. It is apparent from the preceding remarks that biopsies have both diagnostic and prognostic significance. It is also obvious that what has just been said is applicable to biopsy studies of sites other than
224
HERBERT E. SCHMITZ
the cervix. One additional point requires mentioning. Dr. James Henry, the pathologist, has frequently observed that, although the biopsied tissue showed no malignancy, the lymphatic and blood vessels may at times show congestion or stasis to suggest nearby obstruction possibly on the basis of adjacent new growth. Further biopsies taken at his recommendation have revealed the presence of malignancy at a higher location. The role of biopsy in such cases was to direct the investigation toward the possible site of the lesion. Judicious, full utilization of this most important procedure is absolutely essential for the proper management of a patient. The more frequently biopsies are taken, the greater will be the data available for true evaluation. ENDOMETRIAL BIOPSY AND CURETTAGE
Endometrial biopsy and diagnostic curettage must be employed similarly to biopsy procedures elsewhere. Endometrial studies are necessary for the intelligent management of problems in sterility and menstrual dysfunction particularly where hormonal therapy is used. Endometrial biopsy has the practical advantage of office applicability. With proper precaution, it has been used to diagnose or rule out hydatid mole and ectopic pregnancies. For this purpose the Novak or Randall endometrial biopsy curet is available. . Diagnostic curettage is really an extensive biopsy of the uterine lining. The information gained, in addition to the nature of the uterine lining, includes data regarding the contour of the uterine cavity diagnostic of the presence or absence of such tumors as myoma. Therapeutically, curettage may control bleeding in incomplete abortion, incomplete shedding of the endometrium and some bleeding due to unknown factors. Here again, a procedure may serve a dual purpose of diagnosis and therapy. CERVICAL DILATATION
Dilatation of the cervix is an essential preliminary to the curettage but, in the treatment of cervical stenosis or stricture, this procedure is the important part. Dilatation must be gradual to guard against trauma leading to secondary stenosis or stricture from scar tissues. In the treatment of dysmenorrhoea secondary to the cervical stricture, stem pessary may be inserted after the dilatation to maintain an adequately patent cervical canal. Secondary cervical stenosis or stricture may result in hematometra and pyometra. Particularly in the latter, drainage is important. A simple rubber T drain made from firm tubing may be inserted after the dilatation. The preparation of the T drain from a rubber tube is illustrated in Figure 70a. The importance of proper treatment of cervical stricture or stenosis becomes apparent when the high incidence of pelvic endometriosis is considered in the light of the generally accepted Sampson's theory of
225
MINOR GYNECOLOGIC SURGERY
retrograde drainage. It becomes still more important when authorities such as Curtis consider obstructed uterine 'drainage an important factor in the development of carcinoma in the body and cervix of the uterus. Furthermore, retrograde drainage of pus from a pyometra will cause peritonitis and may even result in the death of the patient. CAUTERIZATION, CONIZATION AND AMPUTATION OF THE CERVIX
As has been mentioned previously, the detection of early malignancies with increasing frequency even in normal-appearing cervices makes it imperative that all diseased cervices be treated and, if they show no response, be removed. Cauterization was popularized by Guy L. Hunner by his report in 1906. His method of making radial strokes for the destruction of the deep cervical gland without causing future
.
\
:
\
\.;
--
/
'--'
Fig. 70a.-Preparation of rubber T drain.
stenosis is still the procedure followed today. Excellent results have been obtained but postcauterization checks must be made to insure adequate patency of the cervical canal. Conization and amputation have been employed in cases of cervicitis resisting ordinary cauterization. Both procedures have given excellent results but both are not without some disadvantages. Miller and Todd in a series of 899 conizations reported strictures of the cervix requiring dilatation in 6.46 per cent and an increased tendency toward premature labors in those who became pregnant. Cervical amputation is not advocated in women in the child-bearing period as the incidence of abortion, premature labor and difficult labor was shown to be greatly increased following the amputation. Another disadvantage is the relative frequency of postoperative bleeding occurring in about seven to fourteen days. In properly selected cases, however, cervical amputations as a part of plastic operation or Manchester operation have given excellent results. COLPOCENTESIS, COLPOTOMY AND COLPOPERITONEOSCOPY
Colpocentesis, colpotomy and colpoperitoneoscopy are diagnostic procedures which will eliminate most unnecessary "exploratory" laparotomies and at the same time will not subject the patient to the
226
HERBERT E. SCll}<1ITZ
risk of "expectant treatment" resulting from uncertainty of diagnosis. Colpocentesis is of particular value where intra-abdominal bleeding of gynecologic origin is under consideration. Withdrawal of old blood signifies long-standing intra-abdominal bleeding and is very suggestive of ectopic pregnancy. Differentiation from bleeding of ovarian origin, puncture of hemorrhagic ovarian cyst or endometrial cysts and bleeding produced by neoplasm should not be difficult when the history and clinical findings are correlated with the colpocentesis finding. Aspiration of bright red or fresh blood does not indicate intra-abdominal bleeding but rather a puncture of blood vessels. Failure to withdraw any blood, of course, does not rule out ectopic pregnancy. In all questionable circumstances, colpotomy exploration will reveal the true pathologic condition. Through a colpotomy wound, the pelvic organs may be directly observed as well as palpated. Even major surgical procedures as salpingectomy and oophorectomy have been performed. If findings require abdominal approach, it is a simple procedure to close the colpotomy and little damage is done. In addition to direct inspection and palpation, colpotomy affords a means of obtaining intrapelvic biopsy. By this method, a positive diagnosis of pelvic endometriosis is possible without the "exploratory" or "diagnostic" laparotomy. Colpoperitoneoscopy studies are now being reported by TeLinde. Accurate study of the pelvis and its content is now possible. As the operator's familiarity with the intrapelvic appearance of the organs increases, earlier recognition of pathologic deviation will be possible. The tremendous import of this fact becomes apparent when we consider that the present poor salvage from ovarian malignancy is too often the result of our failure to detect the neoplasm until the changing contour and increasing size make the diagnosis obvious but also too late. As with the malignancies anywhere, early diagnosis means greater curability. The value of. colpoperitoneoscopy is not confined to diagnosis by observation. Biopsy and even some treatment should be possible. Therapeutic colpoperitoneoscopic instruments on the order of the urologist's resectoscope and coagulation-cauterization instruments are within the realm of practicability. From the therapeutic viewpoint, colpocentesis and colpotomy procedures are useful. Colpocentesis and colpotomy drainage of abscesses and fluid drainage from neoplasms such as pseudomyxoma peritonei are common practices. Any removal of organs or parts of organs such as tubes or ovaries belongs under major surgery and will not be discussed here, even though the procedure is carried out through the colpotomy incision. RADIUM INSERTION AND PLASTIC OPERATIONS
Radium insertions and plastic operations such as the repairs of urethrocele, cystocele, enterocele, rectocele and third degree l~cera-
MINOR GYNECOLOGIC SURGERY
227
tion are classed under minor surgery by many operators but are, in reality, major procedures. Proper use of radium requires intimate knowledge of radiology if effective end results are to be obtained without the unfortunate sequelae so often caused by mismanagement. Adequate knowledge of the physical properties of radium and the physiological responses evoked by it will limit its use to certain conditions and will avoid inadequate radiation or radiation burns. Radium in the hands of a competent operator is a valuable and effective therapeutic agent; but in the hands of a person not qualified, it becomes a dangerous and harmful instrument. Plastic operations belong among the major surgical procedures. Proper corrective operations imply detailed knowledge of anatomy. Studies by Curtis, Anson and others have revealed the anatomical complexity of the female perineum and pelvis. Failure to recognize the finer but more important anatomical points may result in annoying complications or rapid recurrence of the original condition. OTHER MINOR SURGERY
Bartholin's Gland.-Acute bartholinitis usually responds to adequate chemotherapy and operative procedures should be avoided. Where incision and drainage becomes necessary, the patient should be warned of the likelihood of recurrence and eventual need for excision. Chronic bartholinitis and Bartholin cyst may require removal. Complete surgical excision or destruction of the entire lining by heat or chemicals is necessary for cure. The usual surgical method is to dissect out the entire sac intact but Curtis advocates incision through the gland substance, grasping the posterior wall of the sac and peeling the entire sac by traction and dissection. Schauffier prefers to treat the abscess or cyst by cruciate incisions over the skin and tumor and destruction of the entire lining and diverticula by electrocoagulation, then permitting the wound to heal by secondary intention. Skene's Duct and Periurethral Gland.-Acute infection of the structures is treated chemotherapeutically. Curtis describes a procedure for removal of chronically infected Skene's glands but, in the light of recent anatomic studies showing the direct contiguity of Skene's duct with the periurethral glands with their extensive branchings, such a procedure would seem palliative rather than curative. Hymenectomy.-Enlargement of the hymenal orifice may be accomplished by multiple incisions of the hymenal membrane or may require a little more extensive corrective procedure. Incision of the perineum in the midline and closure of the incision in the opposite direction will provide a permanent enlargement of the introitus. In some cases of vaginal stenosis, the underlying muscle in the perineum may have to be incised and sutured in the opposite direction to enlarge the vaginal outlet.