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Operation for Uterine Retrodisplacement and Prolapse by Reduction and Attachment of the Round Ligaments
OPERATION POR UTEIUNE I~ETRODISPLAC~JMENT AND PROLAPSE BY REDUCTION AND ATTACHMENT OP THE ROUND LIGAMENTS K.
P.
A.
TAYLOR,
B.S., }[D., F.A.C.B.,
PUER'l'O ARMUELLES, PAXAMA
NE must advance an adequate reason, if not an excuse, for intro-
ducing another operation for retrodisplacement of the uterus. O In the present instance, dissatisfaction with the admittedly infrequent shortcomings of the standard operations prompted the development of a modified technique which possesses definite advantages. I do not share with Dannreuther 1 his partiality for the Baldy-V{ ebster and Gilliam-type operations, but agree rather with Graves ' 2 statement that no operation which depends upon shortening of the round and uterosacral ligaments can be depended upon to withstand gestation and partlirition. In addition, the Baldy-Webster maneuver predisposes to the formation of adhesions in the cul-de-sac which may readily defeat the operation's purpose; furthermore, tlw reported incidence of herniation through the broad lig-ament openings is now so convincing that the technique should be employed only with the greatest rare and proper misgtvmg. Similarl;r, the Gilliam operation has the following defects: The creation of three poekC'ts between the round ligament emplacement.'! and at the sides whieh favor herniation and ileus; in the presence of inflammatory disease, a fixed harrier or shelf vertically dividing the pelvis, may result from adherence of the round and broad ligaments and the fundus to the abdomina] wall; in addition, many pntients complain of pain in the re~don of the intf'rnal ring which pf'rsists for several months after the nilliam t~'pe operation. W f', therefore, prefer the principlt>s set forth hy Olshausen, and ach'anced br Graves. In the Olshausen operation. the thiekt'st, most dependable part of the round ligaments, close to the corpus, is fixed to the anterior abdominal wall by a permanent suture through the peritoneum, muscle, and fascia. This operation is, in effect, a ventral fixation of the uterus, since the segment of round ligament employed must he ronsidered a projection of the corpus. Because, as Dannreuther has indieated, many suspensions became fixations, we prefr-r to discard both terms in favor of the more inclusive name, attachment. OLSHA USEK OPI'JRATION
The disadvantages of this procedure may be enumerated as follows: Two-point fixation, with the resulting three interspaces which invite intestinal incarceration; restriet(•d mobility of the uterns and reduction of bladder space, as mentioned by Damn·euther and others, which is common to all operations for retrodisplacement or prolapse; reduction of bladder space which cannot oeeur if the attachment is sufficiently high 102t1
TAYLOR:
OPERATION FOR RETRODISPI... ACEMEN'l'
1027
on the parietes-a point emphasized in the operation to be described. A fourth objection to this admirable operation is its failure to redu<•e or shorten the round ligaments. REDUCTION -ATTACHMENT OPERATION
Our objective has been a method which permits reduction or shortening of the round ligaments, utilizes the strong proximal portions of the round ligaments, and allows attachment of the uterus at a single point to the abdominal wall. This we have evolved by attachment of the corpus through the direct medium of the round ligaments. Secondary objectives were facility of operation and use of a single suture for the completed procedure.
Fig. 1.-Suture of four strands of No. 2 4 cotton thread passed through round liga ments
1. 5 em. from corpus and through a segment of eorpus. OPERATIVE TECHNIQUE
A 14-inch suture composed of four ~trands of No. 24 plain blaek spool cotton thread (3) (or an equivalently strong single silk or linen suture) is passed through a round ligament 2 em. from the corpus, through a 1 em. segment of the uterus 2 em. below its fundus, and through the other round ligament at the same level. The suture ends, of equal length, are tied in a single square knot which brings the ligaments together at a point of attachment. 'The needle is then introduced through the round ligaments at the midpoint from corpus to internal rings, and the ·suture again tied to th.e original end. Thus th e ligaments are reduced by half. Clamps are placed on the peritoneal edges 6 em. above the lower wound angle. The needle is passed from within-out through peritoneum, muscle, and fascia on the left side of the incision, and returned to the abd omen from without-in through fascia, muscle, and peritoneum of the right side. 'l'he suture is then tied to the original long end within the peritoneal cavity, thus eompleting the attachment. lt is seen that the directional streRs or ·support is through the strongest units of the round ligaments to the corpus itself. The 4-stra nd cotton suture can be depended upon for permanency. Adherent attachment will n.lso occur. In prolapse, the usual plastic vaginal repairR a re don e fir~t. W e hav e not found it necessary to plicate or sew together th e ut eroRacral ligaments. In se\'ere prolapse, the attachment is made as high as the fundu s can be extended, without tension . Removal of all or pa rt of th P "'ll"JlUS will frequently make
1028
AMERICAN JOURNAL OF OBSTETRICS AXD GYKECOLOGY
possible a still higher relative attachment in third and fourth degTee prolapHe with r.elaxed abdominal musculature. . It is indicated that thiR operation doeH not aim at anteflexion. The attachment is on the anterior Hurface of the uterus, so that growth during gestation will not be hampere\l. Rinee the attaehment-Huture doses and frequently invert~
Fig. 2.
Fig. 3.
Fig. 2.-Suture tied and passed again through round ligaments at midpoint to internal ring. Fig. 3.-Second tie. Point of uterine suspension is 2.5 em. below top of fundus.
Fig. 4.-Same suture passed through peritoneum and fascia on both sides of incisio·n 6 to 8 em. above lower angle of wound. Inset: Suture tied to original long end within the abdomen.
the peritoneum at the point of fixation, unusual care must he exercised in sewing the peritoneal edges to prevent the formation of a cleft or defect which would predispose to ventral hernia. Presence of the bulk of folded round ligaments at the attachment point emphasizes the need for meticulous closure.
FINCH:
ALJ,ERGIC REACTION IN NAUSEA OF PREGNANCY
102~!
RESULTS OF OPERATION
This technique has been developed ovrr a four-year period in 120 11atient'l. In its present form it has been used for two years, the quadruple cotton suture for one year. Our opportunity for re-examination is necessarily limited. No failures have been detected. The few patients ( 6) subsequently seen in parturition and puerperium have not had dystocia due to operation and have not had recurrence of retrodisplacement. No sinuses have resulted. The postoperative and ronvalescent courses in cases not .romplicated hy other pelvic pathology have been relatively comfortable. RESUI\[E
1. A simple, rapid technique is presented for reduction of round ligaments and single-point attachment of the uterus. Pocket formation of the Gi11iam and Olshau..'len operations is avoided. 2. This operation has the merits of the Olshausf'n procedure and apparently none of its disadvantages. 3. A single 4-strand cotton suture is utihzed. REFERENCES
(1) Dannreuther, W. T.: .T. A. M. A. 113: Hl09, 1939. (2) Graves, W. P.: Gynecology, ed. 4, Philadelphia, W. B. SaunderA ('o. ( il) Taylor, K. P. A.: Am. J. Surg. In pl'ess. ll>TlTED FRUIT COMPANY HOSPITAL
THE NAUSEA AND VOMITING OP PREGNANCY DUE TO ALLERGIC REACTION
A
J.
STUDY OF
WILLIAM FINCH,
192
M.D.,
CASES HOBART, OKLA.
(From the Department of Obstetrics of the University of Oklahom
T
HIS report is a summary of work done subsequent to a publication in 1938,1 theorizing that tht:' nausea and the vomiting accompanying pregnancy are due to an allergic reaction of the patient to the secretion of her own corpus luteum graviditatis. A report of 192 cases is presented to substantiate this theory further. J:<'rom one-half to two-thirds of all obstetric patients experience nausea and vomiting in some degree during the first trimester. The symptoms may vary in severity from the mild case, so frequently seen, in which there is morning sickness, with or without vomiting, to the moderate case, in which there are nausea all day long, frequent vomiting, and extreme discomfort for weeks. A few cases will advance to a true hyperemesis gravidarum with a definitely serious prognosis.
P.
A.
TAYLOR,
B.S., }[D., F.A.C.B.,
PUER'l'O ARMUELLES, PAXAMA
NE must advance an adequate reason, if not an excuse, for intro-
ducing another operation for retrodisplacement of the uterus. O In the present instance, dissatisfaction with the admittedly infrequent shortcomings of the standard operations prompted the development of a modified technique which possesses definite advantages. I do not share with Dannreuther 1 his partiality for the Baldy-V{ ebster and Gilliam-type operations, but agree rather with Graves ' 2 statement that no operation which depends upon shortening of the round and uterosacral ligaments can be depended upon to withstand gestation and partlirition. In addition, the Baldy-Webster maneuver predisposes to the formation of adhesions in the cul-de-sac which may readily defeat the operation's purpose; furthermore, tlw reported incidence of herniation through the broad lig-ament openings is now so convincing that the technique should be employed only with the greatest rare and proper misgtvmg. Similarl;r, the Gilliam operation has the following defects: The creation of three poekC'ts between the round ligament emplacement.'! and at the sides whieh favor herniation and ileus; in the presence of inflammatory disease, a fixed harrier or shelf vertically dividing the pelvis, may result from adherence of the round and broad ligaments and the fundus to the abdomina] wall; in addition, many pntients complain of pain in the re~don of the intf'rnal ring which pf'rsists for several months after the nilliam t~'pe operation. W f', therefore, prefer the principlt>s set forth hy Olshausen, and ach'anced br Graves. In the Olshausen operation. the thiekt'st, most dependable part of the round ligaments, close to the corpus, is fixed to the anterior abdominal wall by a permanent suture through the peritoneum, muscle, and fascia. This operation is, in effect, a ventral fixation of the uterus, since the segment of round ligament employed must he ronsidered a projection of the corpus. Because, as Dannreuther has indieated, many suspensions became fixations, we prefr-r to discard both terms in favor of the more inclusive name, attachment. OLSHA USEK OPI'JRATION
The disadvantages of this procedure may be enumerated as follows: Two-point fixation, with the resulting three interspaces which invite intestinal incarceration; restriet(•d mobility of the uterns and reduction of bladder space, as mentioned by Damn·euther and others, which is common to all operations for retrodisplacement or prolapse; reduction of bladder space which cannot oeeur if the attachment is sufficiently high 102t1
TAYLOR:
OPERATION FOR RETRODISPI... ACEMEN'l'
1027
on the parietes-a point emphasized in the operation to be described. A fourth objection to this admirable operation is its failure to redu<•e or shorten the round ligaments. REDUCTION -ATTACHMENT OPERATION
Our objective has been a method which permits reduction or shortening of the round ligaments, utilizes the strong proximal portions of the round ligaments, and allows attachment of the uterus at a single point to the abdominal wall. This we have evolved by attachment of the corpus through the direct medium of the round ligaments. Secondary objectives were facility of operation and use of a single suture for the completed procedure.
Fig. 1.-Suture of four strands of No. 2 4 cotton thread passed through round liga ments
1. 5 em. from corpus and through a segment of eorpus. OPERATIVE TECHNIQUE
A 14-inch suture composed of four ~trands of No. 24 plain blaek spool cotton thread (3) (or an equivalently strong single silk or linen suture) is passed through a round ligament 2 em. from the corpus, through a 1 em. segment of the uterus 2 em. below its fundus, and through the other round ligament at the same level. The suture ends, of equal length, are tied in a single square knot which brings the ligaments together at a point of attachment. 'The needle is then introduced through the round ligaments at the midpoint from corpus to internal rings, and the ·suture again tied to th.e original end. Thus th e ligaments are reduced by half. Clamps are placed on the peritoneal edges 6 em. above the lower wound angle. The needle is passed from within-out through peritoneum, muscle, and fascia on the left side of the incision, and returned to the abd omen from without-in through fascia, muscle, and peritoneum of the right side. 'l'he suture is then tied to the original long end within the peritoneal cavity, thus eompleting the attachment. lt is seen that the directional streRs or ·support is through the strongest units of the round ligaments to the corpus itself. The 4-stra nd cotton suture can be depended upon for permanency. Adherent attachment will n.lso occur. In prolapse, the usual plastic vaginal repairR a re don e fir~t. W e hav e not found it necessary to plicate or sew together th e ut eroRacral ligaments. In se\'ere prolapse, the attachment is made as high as the fundu s can be extended, without tension . Removal of all or pa rt of th P "'ll"JlUS will frequently make
1028
AMERICAN JOURNAL OF OBSTETRICS AXD GYKECOLOGY
possible a still higher relative attachment in third and fourth degTee prolapHe with r.elaxed abdominal musculature. . It is indicated that thiR operation doeH not aim at anteflexion. The attachment is on the anterior Hurface of the uterus, so that growth during gestation will not be hampere\l. Rinee the attaehment-Huture doses and frequently invert~
Fig. 2.
Fig. 3.
Fig. 2.-Suture tied and passed again through round ligaments at midpoint to internal ring. Fig. 3.-Second tie. Point of uterine suspension is 2.5 em. below top of fundus.
Fig. 4.-Same suture passed through peritoneum and fascia on both sides of incisio·n 6 to 8 em. above lower angle of wound. Inset: Suture tied to original long end within the abdomen.
the peritoneum at the point of fixation, unusual care must he exercised in sewing the peritoneal edges to prevent the formation of a cleft or defect which would predispose to ventral hernia. Presence of the bulk of folded round ligaments at the attachment point emphasizes the need for meticulous closure.
FINCH:
ALJ,ERGIC REACTION IN NAUSEA OF PREGNANCY
102~!
RESULTS OF OPERATION
This technique has been developed ovrr a four-year period in 120 11atient'l. In its present form it has been used for two years, the quadruple cotton suture for one year. Our opportunity for re-examination is necessarily limited. No failures have been detected. The few patients ( 6) subsequently seen in parturition and puerperium have not had dystocia due to operation and have not had recurrence of retrodisplacement. No sinuses have resulted. The postoperative and ronvalescent courses in cases not .romplicated hy other pelvic pathology have been relatively comfortable. RESUI\[E
1. A simple, rapid technique is presented for reduction of round ligaments and single-point attachment of the uterus. Pocket formation of the Gi11iam and Olshau..'len operations is avoided. 2. This operation has the merits of the Olshausf'n procedure and apparently none of its disadvantages. 3. A single 4-strand cotton suture is utihzed. REFERENCES
(1) Dannreuther, W. T.: .T. A. M. A. 113: Hl09, 1939. (2) Graves, W. P.: Gynecology, ed. 4, Philadelphia, W. B. SaunderA ('o. ( il) Taylor, K. P. A.: Am. J. Surg. In pl'ess. ll>TlTED FRUIT COMPANY HOSPITAL
THE NAUSEA AND VOMITING OP PREGNANCY DUE TO ALLERGIC REACTION
A
J.
STUDY OF
WILLIAM FINCH,
192
M.D.,
CASES HOBART, OKLA.
(From the Department of Obstetrics of the University of Oklahom
T
HIS report is a summary of work done subsequent to a publication in 1938,1 theorizing that tht:' nausea and the vomiting accompanying pregnancy are due to an allergic reaction of the patient to the secretion of her own corpus luteum graviditatis. A report of 192 cases is presented to substantiate this theory further. J:<'rom one-half to two-thirds of all obstetric patients experience nausea and vomiting in some degree during the first trimester. The symptoms may vary in severity from the mild case, so frequently seen, in which there is morning sickness, with or without vomiting, to the moderate case, in which there are nausea all day long, frequent vomiting, and extreme discomfort for weeks. A few cases will advance to a true hyperemesis gravidarum with a definitely serious prognosis.