New concept of total hysterectomy and anatomy of the cervix

New Concept of Total Hysterectomy and Anatomy of the Cervix MORRIS JOSEPH, M .D .,

Passaic, New Jersey

the past ten years total hysterectomy, either by the vaginal or abdominal route, has gradually increased in popularity . Primarily, the object of this operation to include the cervix was designed to eliminate existing disease of this organ . At the same time this procedure obviated the potential carcinoma that involves the cervix in about 2 per cent of all cases after simple subtotal hysterectomy has been performed . For many years Richardson' has strongly opposed any operative procedure on the female genitalia which would destroy the important fibrous cervical ring, acting as a fulcrum, that supports the cardinal ligaments . Crossen 2 and others have also stressed this danger and the incidence of complete prolapse following these procedures . In total hysterectomy, regardless of the abdominal or vaginal route, this cervical ring is removed . Simply bringing the cardinal ligaments and round ligaments together, in the closure of the pelvic floor, does not supply a satisfactory substitute . As women grow older the strong resilient elastic tissue of the pelvis and vagina often becomes parchment-like in character . This tissue has very poor supportive qualities and a very distressing prolapse ensues . Because of the nature of the tissue a satisfactory repair is often difficult, if not impossible . For this reason this type of hysterectomy with the use of a special knife has been designed . This procedure not only eliminates the defects already mentioned but also removes all the necessary cervical tissue as well as the mucosal channel and the body of the uterus . In this way all existing or potential cancer areas are completely eradicated .

D

URING

PROCEDURE

Most of our patients are prepared with spinal anesthesia, often supplemented with very light pentothal intravenously . The addition of this light pentothal produces a mild state of unAmerican Journal of Surgery, Volume 89, Mareb, r9gs

6o8

consciousness . The complete relaxation of the patient, however, is produced by the spinal . The patient is placed in position for abdominal hysterectomy . The routine supracervical hysterectomy is performed, except that the cervix is not completely amputated. The muscular portion at the uterocervical junction corresponding to the internal os is incised and circumscribed down to the fibro-elastic tube, which completely encloses the mucosa of the cervix . This structure was discovered in our early cases and presented an entirely new concept in the anatomy of the cervix . It was this fibro-elastic avascular tube that facilitated the complete enucleation of the mucosa of the cervical canal, without entering the canal and with little or no bleeding . This tubular structure is left intact and remains attached to the corpus uteri . The dissection is continued downward to and including the external os . A small or larger area of the squamous lining of the cervix, circumscribing the external os, may be included . If this is done, it is advisable to do it vaginally before the abdominal procedure is begun . The reason for this sequence is that at times after the squamous covering is removed, little or no bleeding is evident . However, after the abdominal portion of the operation is performed, the blood supply from the uterine artery is limited entirely to this small segment of cervix . With a sudden and abundant increase in the arterial pressure what appeared like little or no bleeding at the cervical tip suddenly may be converted into an alarming hemorrhage . There have been two such cases in our series . This complication can really be of major proportion . When it is deemed advisable to excise the squamous epithelium of the cervix because it is manifestly diseased, cystic or scarred from previous lacerations, it should be done . Then the cervical phase of the operation is carried out initially and the cervical branches of the uterine



Total Hysterectomy and Anatomy of Cervix

FIG .

2.

fibroid .

r . Specimen external os . Pro.

of

total hysterectomy including

artery must be adequately secured by a suture ligature . It is also preferable to cover the small remaining raw area by undermining the cervical reflection of the vaginal mucosa sufficiently and placing a few small sutures to cover this area . After the cervical stump is drawn high into the vaginal vault and anchored in the pelvis, following the abdominal excision, control of hemorrhage becomes extremely difficult . This point cannot be stressed too strongly . One of our cases presented such a problem recently . It is our belief that once the entire cervical mucosa is removed to include the external os, there is little to fear from future carcinoma of the cervix . Once the secretory element of the cervix is removed there should be no hazard from carcinoma . The resulting stump is simply a solid muscular column serving as a hitching post . A tA'I'OMV 01- ME CERVIX

It seems strange and surprising that after all these years a simple structure such as the cervix is found inadequately described in any of our anatomy texts . The libro-clastic tube encasing the cervical mucosa is what facilitates and makes possible this new concept of total hysterectomy . It dissects out like a miniature 609

Same case . Adenocarcinoma within the invasion below internal os or adnexae .

No

esophagus and because of its avascularity the procedure becomes very simple ; with a little practice it should consume less time than the standard total hysterectomy . The "cone excision" of the cervical canal without entering the canal was first suggested by Matthew .s, in his description of the Stunndorf operation . One of our very recent patients* showed evidence of earl- adenocarcinoma in a fibroid uterus . There was no invasion below the internal os of the cervix . '['he excision of the cervical canal in this case might have been very timely_ (Figs . I and 2 .) COMM EN I S

In performing this type of hysterectomy everything that the routine standard total hysterectomy accomplishes is made possible . The anatomy of the cervix likewise makes possible its preservation for its very important supporting purpose . This also allows the normal preservation of the pelvic floor and spares disabling the patient in later years . All potential cancer is eliminated and at the same time its splendid supporting qualities are preserved . The operating time clement, if anything, is reduced . With a little practice the technic is simpler than the standard total hysterectomy . The very distressing prolapse and other com*This patient was a t .birty-seven year old woman who had bled steadily for one month . Fibroid uterus was diagnosed . She had never been pregnant .



Total Hysterectomy and Anatomy of Cervix plications which follow in many cases of the standard operation are greatly reduced. f7 Of course it is clearly understood that before any vaginal or abdominal procedure has been undertaken every precaution to rule out malignancy is first performed . Both biopsy and TABLE I DIFFERENTIAL IN COMPLICATIONS BETWEEN TOTAL VS . SUBTOTAL HYSTERECTOMY (NEW TYPE Or TOTAL HYSTERECTOMY)

Total Subtotal Hysterectomy I lysterectomy Authors Number

Per cent

Number

Per cent

tomy is exemplified in the statistics shown in Table I . CONCLUSIONS I . This new concept of total hysterectomy was originally described as a vaginal-abdominal procedure.' The special knife' has greatly facilitated this operation . 2 . The present modification simplifies the technic and reduces the time element . 3. It has all the advantages of the presently accepted standard procedure, without its disadvantages . 4. A new concept of the structure of the cervix has facilitated the development of this operation . REFERENCES

H . D . Adams 8 30 cases of prolapse . . .

I . RICHARDSON, E . H .

2. T . W . Adams' 436 cases of unilateral ureteral injury 97 cases of bilateral ureteral injury J . C . Weed and C . Tyrone° 52 cases of enterocele . .

Composite operation . Aln . J .

Obst . e Gynec ., 34 : 815, 1937.

12

3T2

65 .4

57

12 .3

67

69 .7

7

7 .0

27

smears should be taken to rule out the slightest evidence of incipient malignancy . The difference in complications following the standard total versus this new type of hysterec-

and CROSSEN, R . J . Operative Gynecology, 6th ed . St. Louis, 1948 . C . V . Mosby Co . 3 . ADAMS, H . D . Total colpocleisis for pelvic eventration . Surg., Gvnec . er OhsL, 92 : 321-324, 1951 . 4 . ADAMS, T. W . Ureteral injury during gynecologic surgery . West . J. Sure ., 51: 305 - 3 24, 1943 . 5 . WEED, J . C . and TYRONE, C . Enteroccle (an analysis of 52 cases) . Am . J . Ohst . b' Gvnec., 6o : 324-332, 1950 . 6. JOSEPH, M . New vaginal-abdominal hysterectomy with special knife . West . J . Stag., 58 : 227-228, 1950 . 7 . JOSEPH, M . New knife for cervical cancer . J . M . Soc . Neu, Jersey, 46 : 345, 1949 . 8 . MATTHEWS, H . B . Electric cautery vs . Sturmdorf operation . J . A . A4. A ., 87 : 1695, 1926 .

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CROSSEN, IT . S .