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Technic of presacral neurectomy
TECHNIC OF PRESACRAL
NEURECTOMY
GASTONCOT-TE, M.D. Lyon, France
T
HE resection of the peIvic sympathetic pIexus, which I did for the first time in 1925 as a treatment of dysmenorrhea, is aheady accepted in a11 countries of the worId. Since 1925 I have extended the indications of this resection to the treatment of vaginismus, peIvic neuralgias, resistant vuIvar itch and some cases of genita1 superexcitement. However, if one judges the articles pubIished on that subject, the resuIts are not always as they are expected to be; some surgeons cIaim that onIy 50 of IOO patients have been cured. PersonaIIy, in over 1,500 patients seen in a period of twenty-two years ‘I count onIy 2 per cent who were not cured by the operation. These patients are cIassified as having dysmenorrhea caused by a psychic or a physica defect which this operation couId not improve. If we cIoseIy anaIyze the articIes pubIished by some surgeons with regard to their Iack of success in that operation, we can say without hesitation that their resuIts are the consequence of a defective technic. In our first operations, which gave us good resuIts, we Iooked on the presacra1 Iamina for some nervous strings the way anatomists taught us. In 1926 we reported that it was necessary to do a radica1 resection of a11 the fibro-ceIIs of the Iamina in which the eIements of the superior hypogastric pIexus Iay and which contained more or Iess important nerve ceIIs and numerous gangIionic tissues. SeveraI times we heard from foreign surgeons that they had never done such radica1 operations as the ones we did in their presence. Afterward, using our technic in this operation, those surgeons had good resuIts which were comparabIe to ours.
TECHNIC
Technic being the important question for good results, it is important for us to give a11 the detaiIs: I. Anesthesia. SpinaI anesthesia, 12 or 15 mg. of novocain, is our preference. It produces good abdomina1 reIaxation and, the patient being in TrendeIenburg position, it is easy to reach the promontory. Very 2. Incision of the Abdominal Wall. often we do a Iow PfannenstieI incision so that the cutaneous scar wiII be hidden by the pubic hair. This incision, however, needs carefu1 contro1 of bIeeding. The abdomina1 aponeurosis must be incised at least 3 or 4 cm. higher than the cutaneous incision. Otherwise it wouId be d&uIt to reach the body of the fifth Iumbar vertebra in front of which one must find the presacra1 nerve. 3. Intraperitoneal Maneuvers. At first one must cIoseIy examine the interna genitaIia in case any Iesion is present which couId be so smaI1 as to be overlooked by a cIinica1 examination before operation. One may discover sIightIy diseased ovaries or IittIe foci of endometriosis or adenomyomatosis of the cornua, etc. It is aImost aIways possibIe to treat such smaI1 Iesions by conservative operations if one does the resection of the presacra1 nerve afterward. Sometimes these Iesions are sufficient to expIain the dysmenorrhea and, even if their excision wouId cure those patients, I have aIways insisted that one do the resection of the presacra1 nerve in cases of dysmenorrhea because most often these Iesisns of the genitaIia are not incIuded in the pathoIogy of menstrua1 pains. 4. Resection of the Pelvic Sympathetic. It is on the body of the fifth Iumbar vertebra sIightIy above the promontory that the nerve is the most easiIy accessible.
50
American
Journal
of Surgery
Cotte-PresacraI It is important to see the promontory very we11 for it is the first anatomic point to remember. Above and sIightIy outside of the promontory the two primary iliac arteries, which are lying immediateIy under the peritoneum, form a triangle with an inferior base and the apex is formed by the division of the aorta. This forms the second anatomic point to remember. In this area, which wiI1 be more visibIe if one recIines the peIvic colon, one wiI1 see, a IittIe outside of the middIe Iine at the Ieft, the inferior mesenteric artery which runs in the mesocoIon near its insertion Iine. We aIways cut the peritoneum verticaIIy. This permits us to make a Ionger incision up and down if we decide to do a more or less important resection of the pelvic sympathetic. (Fig. I.) GeneraIIy we are satisfied with an incision 4 to 5 cm. Iong, the middIe of which shouId correspond to the promontory. Retracting the two Iips of the peritonea1 incision, one can see forward to the spine a ceIIuIofibrous mass which covers the body of the vertebra. In this ceIIuIofibrous mass the peIvic sympathetic Iies (superior hypogastric pIexus of HoveIacque). (Fig. 2.) To perform a good resection of that pIexus it is important before cutting it to dissect the presacra1 Iamina cIeanIy on its sides. To do this, either with the tip of Iong scissors or with a dissector of Leriche, one has to separate the edges of that fibrous lamina. (Fig. 3.) AnteriorIy the Iamina has been separated from the peritoneum aIready. On its edges this Iamina is mixed with subperitonea1 ceIIs but on the right side it is easy to recognize the edge of the fibrous Iamina in which the sympathetic nerve lies. The posterior part of the Iamina is aIso easy to separate. UsuaIIy the medium sacra1 vesseIs remain adherent to the skeIeton. On the Ieft side the mesenteric vesseIs may be troubIesome but one has to be carefu1 not to injure them. In certain cases the primary root of the mesocoIon has its insertion on the median Iine making it more diffIcuIt to reach the promontory. If this condition exists, we July,
‘949
Neurectomy
FIG. I. Incision of the posterior peritoneum in front of the fifth Iumbar vertebra.
5’
Iifted up
aIways make our incision of the posterior peritoneum I cm. outside the median line. Retracting the Ieft Iip of that peritonear incision, we push aside the mesenteric vessels and usuaIIy the anterior part of the presacra1 lamina is easy to dissect. To have a better dissection of the fibrous Iamina in which the nerves Iie, we use as a ruIe the Deschamps needIe which is introduced in the hoIe made on the right side. This needIe is used to dissect the Ieft side by pushing away the mesenteric vessels. (Fig. 4.) If we Iift up the presacra1 Iamina with a Deschamps needIe at the IeveI of the fifth Iumbar vertebra, we see that it becomes wider as it passes the promontory and then takes a trianguIar form with its apex up. (Fig. 5.) This is the cross section of the presacra1 nerve from which the two hypogastric nerves proceed to the two corresponding gangIions (inferior hypogastric plexus of HoveIacque). The nerve being Iifted up, it is easy to finish its dissection upward and downward. Before cutting it is very important to be sure that the whoIe nerve wiI1 be cut and not just one of its branches right or Ieft. For this reason it is very important to see the angIe of the cross section where the presacra1 nerve gives birth to the hypogastric nerves. If onIy one of the two nerve cords is seen, the reason is that onIy haIf
52
Cotte-Presacral
Neurectomy
FIG. 2 FIG. 3 FIG. 2. Retraction of the peritoneum to give a clear view of the presacral Iamina; on the Ieft are the mesenteric vesseIs in the base of the mesosaIpinx; on the right is the ureter after crossing the hypogastric vessels. FIG. 3. Separation of the presacra1 Iamina on its right side.
FIG. 4 FIG. 5 FIG. 4. Separation of the presacra1 Iamina is performed with a “Deschamps needIe” and a dissector. FIG. 5. The entire Iamina is Iifted up with a curved, smooth-edged needIe before being wideIy resected. trianguIar shape formed by the hypogastric nerves which proIong it.
of the presacra1 nerve Iies on the needIe. Then it is important to find and dissect the other haIf. It is very usefuI to have at your disposa1 two Deschamps needIes, one right-handed and one Ieft-handed. Before cutting the Iamina with a soft instrument such as the handIe of a Deschamps needIe, we break the few afferent branches which come from the two Iast Iumbar gangIions or the first sacra1 gangIion. UsuaIIy we cut a Iength of 2 to 4 cm. of the nerve. The Iamina in which the nerve Iies contains onIy smaI1 bIood vesseIs (vasa vasorum). Therefore, it is useIess to tie both ends. We even think that tying the Iamina is a cause of pain. If there is sIight
Note the
bIeeding, pressure for a whiIe on the Iamina aIong the spine wiII contro1 it. The use of eIectrocautery to cut the presacra1 Iamina wiI1 prevent this bleeding. The Ieft primary iliac vein is behind the sectioned Iamina. It is aImost aIways a IittIe higher than the point where the presacra1 Iamina is Iiberated practicaIIy where there is no danger of hurting it. The ureters are more outside. If the surgeon is on the Ieft side, it is very easy to IocaIize the right ureter. OnIy once did we accidentaIIy hurt the Ieft ureter which was very near the insertion of the peIvic mesocolon. This had not been dissected properIy. American
Journal
of Surgery
Cotte-PresacraI The nerve being cut, we suture the posterior parieta1 peritoneum. The Iatter is so loose that it may be cIosed with a purse string suture. If the uterus is movabIe and, even more if it is retroverted, we compIete the operation by fixing the Iigaments using the method of DoIeris-GiIIiam-PeIIanda. It is done to prevent scar retraction of the uterosacral ligaments and a secondary retractire parametritis in case there wouId be a shght serosanguineous exudate. 5. Closure of the Abdominal Wall. This in particular. procedure offers nothing However, it has to be done very carefuIIy so that the anatomic reconstruction wiI1 be as perfect as possibIe. 6. Postoperative Results. There is usually no incident. We have never noted any immediate disturbances which were due to the sympathectomy. There is no urine retention and micturition is often much easier after than before the operation. In over 1,500 operations we never saw any major accident. In onIy two cases was there slight bIeeding of the posterior peritoneum on the first postoperative day so we had to re-operate and repair the posterior peritoneum. In two other cases there was an infiItration of bIood in the sub-
July, ‘949
Neurectomy
53
peritonea1 tissues which inMtrated in the posterior region of the rectum but was spontaneously absorbed. Before cIosing the posterior peritoneum, one must be sure of perfect controI of bIeeding. It is to be noted that these patients need three or four injections of morphia on the first day on account of their postoperative pains. PhIebitis and puImonary infarcts are rare and do not exceed I per cent, due to the fact that the patients are young and free from any viscera1 diseases. We have never noted any Iater disturbances among our patients. There were numerous women who had one or moie absoIuteIy norma pregnancies afterward. Women suffering from dyspareunia now have norma coition. We never saw a case of frigidity foIIowing the operation. Symptoms may recur but that has been the exception; we count onIy 2 per cent of them. In a11 cases the symptoms existing with dysmenorrhea, nameIy, fever, vomitintestina1 cramps, etc., cIear up ing, simuItaneousIy. We did the iirst resection of the presacra1 nerve twenty-three years ago and we can definiteIy affirm that, unti1 now, no other method of treating dysmenorrhea has given such consistent good resuIts.
NEURECTOMY
GASTONCOT-TE, M.D. Lyon, France
T
HE resection of the peIvic sympathetic pIexus, which I did for the first time in 1925 as a treatment of dysmenorrhea, is aheady accepted in a11 countries of the worId. Since 1925 I have extended the indications of this resection to the treatment of vaginismus, peIvic neuralgias, resistant vuIvar itch and some cases of genita1 superexcitement. However, if one judges the articles pubIished on that subject, the resuIts are not always as they are expected to be; some surgeons cIaim that onIy 50 of IOO patients have been cured. PersonaIIy, in over 1,500 patients seen in a period of twenty-two years ‘I count onIy 2 per cent who were not cured by the operation. These patients are cIassified as having dysmenorrhea caused by a psychic or a physica defect which this operation couId not improve. If we cIoseIy anaIyze the articIes pubIished by some surgeons with regard to their Iack of success in that operation, we can say without hesitation that their resuIts are the consequence of a defective technic. In our first operations, which gave us good resuIts, we Iooked on the presacra1 Iamina for some nervous strings the way anatomists taught us. In 1926 we reported that it was necessary to do a radica1 resection of a11 the fibro-ceIIs of the Iamina in which the eIements of the superior hypogastric pIexus Iay and which contained more or Iess important nerve ceIIs and numerous gangIionic tissues. SeveraI times we heard from foreign surgeons that they had never done such radica1 operations as the ones we did in their presence. Afterward, using our technic in this operation, those surgeons had good resuIts which were comparabIe to ours.
TECHNIC
Technic being the important question for good results, it is important for us to give a11 the detaiIs: I. Anesthesia. SpinaI anesthesia, 12 or 15 mg. of novocain, is our preference. It produces good abdomina1 reIaxation and, the patient being in TrendeIenburg position, it is easy to reach the promontory. Very 2. Incision of the Abdominal Wall. often we do a Iow PfannenstieI incision so that the cutaneous scar wiII be hidden by the pubic hair. This incision, however, needs carefu1 contro1 of bIeeding. The abdomina1 aponeurosis must be incised at least 3 or 4 cm. higher than the cutaneous incision. Otherwise it wouId be d&uIt to reach the body of the fifth Iumbar vertebra in front of which one must find the presacra1 nerve. 3. Intraperitoneal Maneuvers. At first one must cIoseIy examine the interna genitaIia in case any Iesion is present which couId be so smaI1 as to be overlooked by a cIinica1 examination before operation. One may discover sIightIy diseased ovaries or IittIe foci of endometriosis or adenomyomatosis of the cornua, etc. It is aImost aIways possibIe to treat such smaI1 Iesions by conservative operations if one does the resection of the presacra1 nerve afterward. Sometimes these Iesions are sufficient to expIain the dysmenorrhea and, even if their excision wouId cure those patients, I have aIways insisted that one do the resection of the presacra1 nerve in cases of dysmenorrhea because most often these Iesisns of the genitaIia are not incIuded in the pathoIogy of menstrua1 pains. 4. Resection of the Pelvic Sympathetic. It is on the body of the fifth Iumbar vertebra sIightIy above the promontory that the nerve is the most easiIy accessible.
50
American
Journal
of Surgery
Cotte-PresacraI It is important to see the promontory very we11 for it is the first anatomic point to remember. Above and sIightIy outside of the promontory the two primary iliac arteries, which are lying immediateIy under the peritoneum, form a triangle with an inferior base and the apex is formed by the division of the aorta. This forms the second anatomic point to remember. In this area, which wiI1 be more visibIe if one recIines the peIvic colon, one wiI1 see, a IittIe outside of the middIe Iine at the Ieft, the inferior mesenteric artery which runs in the mesocoIon near its insertion Iine. We aIways cut the peritoneum verticaIIy. This permits us to make a Ionger incision up and down if we decide to do a more or less important resection of the pelvic sympathetic. (Fig. I.) GeneraIIy we are satisfied with an incision 4 to 5 cm. Iong, the middIe of which shouId correspond to the promontory. Retracting the two Iips of the peritonea1 incision, one can see forward to the spine a ceIIuIofibrous mass which covers the body of the vertebra. In this ceIIuIofibrous mass the peIvic sympathetic Iies (superior hypogastric pIexus of HoveIacque). (Fig. 2.) To perform a good resection of that pIexus it is important before cutting it to dissect the presacra1 Iamina cIeanIy on its sides. To do this, either with the tip of Iong scissors or with a dissector of Leriche, one has to separate the edges of that fibrous lamina. (Fig. 3.) AnteriorIy the Iamina has been separated from the peritoneum aIready. On its edges this Iamina is mixed with subperitonea1 ceIIs but on the right side it is easy to recognize the edge of the fibrous Iamina in which the sympathetic nerve lies. The posterior part of the Iamina is aIso easy to separate. UsuaIIy the medium sacra1 vesseIs remain adherent to the skeIeton. On the Ieft side the mesenteric vesseIs may be troubIesome but one has to be carefu1 not to injure them. In certain cases the primary root of the mesocoIon has its insertion on the median Iine making it more diffIcuIt to reach the promontory. If this condition exists, we July,
‘949
Neurectomy
FIG. I. Incision of the posterior peritoneum in front of the fifth Iumbar vertebra.
5’
Iifted up
aIways make our incision of the posterior peritoneum I cm. outside the median line. Retracting the Ieft Iip of that peritonear incision, we push aside the mesenteric vessels and usuaIIy the anterior part of the presacra1 lamina is easy to dissect. To have a better dissection of the fibrous Iamina in which the nerves Iie, we use as a ruIe the Deschamps needIe which is introduced in the hoIe made on the right side. This needIe is used to dissect the Ieft side by pushing away the mesenteric vessels. (Fig. 4.) If we Iift up the presacra1 Iamina with a Deschamps needIe at the IeveI of the fifth Iumbar vertebra, we see that it becomes wider as it passes the promontory and then takes a trianguIar form with its apex up. (Fig. 5.) This is the cross section of the presacra1 nerve from which the two hypogastric nerves proceed to the two corresponding gangIions (inferior hypogastric plexus of HoveIacque). The nerve being Iifted up, it is easy to finish its dissection upward and downward. Before cutting it is very important to be sure that the whoIe nerve wiI1 be cut and not just one of its branches right or Ieft. For this reason it is very important to see the angIe of the cross section where the presacra1 nerve gives birth to the hypogastric nerves. If onIy one of the two nerve cords is seen, the reason is that onIy haIf
52
Cotte-Presacral
Neurectomy
FIG. 2 FIG. 3 FIG. 2. Retraction of the peritoneum to give a clear view of the presacral Iamina; on the Ieft are the mesenteric vesseIs in the base of the mesosaIpinx; on the right is the ureter after crossing the hypogastric vessels. FIG. 3. Separation of the presacra1 Iamina on its right side.
FIG. 4 FIG. 5 FIG. 4. Separation of the presacra1 Iamina is performed with a “Deschamps needIe” and a dissector. FIG. 5. The entire Iamina is Iifted up with a curved, smooth-edged needIe before being wideIy resected. trianguIar shape formed by the hypogastric nerves which proIong it.
of the presacra1 nerve Iies on the needIe. Then it is important to find and dissect the other haIf. It is very usefuI to have at your disposa1 two Deschamps needIes, one right-handed and one Ieft-handed. Before cutting the Iamina with a soft instrument such as the handIe of a Deschamps needIe, we break the few afferent branches which come from the two Iast Iumbar gangIions or the first sacra1 gangIion. UsuaIIy we cut a Iength of 2 to 4 cm. of the nerve. The Iamina in which the nerve Iies contains onIy smaI1 bIood vesseIs (vasa vasorum). Therefore, it is useIess to tie both ends. We even think that tying the Iamina is a cause of pain. If there is sIight
Note the
bIeeding, pressure for a whiIe on the Iamina aIong the spine wiII contro1 it. The use of eIectrocautery to cut the presacra1 Iamina wiI1 prevent this bleeding. The Ieft primary iliac vein is behind the sectioned Iamina. It is aImost aIways a IittIe higher than the point where the presacra1 Iamina is Iiberated practicaIIy where there is no danger of hurting it. The ureters are more outside. If the surgeon is on the Ieft side, it is very easy to IocaIize the right ureter. OnIy once did we accidentaIIy hurt the Ieft ureter which was very near the insertion of the peIvic mesocolon. This had not been dissected properIy. American
Journal
of Surgery
Cotte-PresacraI The nerve being cut, we suture the posterior parieta1 peritoneum. The Iatter is so loose that it may be cIosed with a purse string suture. If the uterus is movabIe and, even more if it is retroverted, we compIete the operation by fixing the Iigaments using the method of DoIeris-GiIIiam-PeIIanda. It is done to prevent scar retraction of the uterosacral ligaments and a secondary retractire parametritis in case there wouId be a shght serosanguineous exudate. 5. Closure of the Abdominal Wall. This in particular. procedure offers nothing However, it has to be done very carefuIIy so that the anatomic reconstruction wiI1 be as perfect as possibIe. 6. Postoperative Results. There is usually no incident. We have never noted any immediate disturbances which were due to the sympathectomy. There is no urine retention and micturition is often much easier after than before the operation. In over 1,500 operations we never saw any major accident. In onIy two cases was there slight bIeeding of the posterior peritoneum on the first postoperative day so we had to re-operate and repair the posterior peritoneum. In two other cases there was an infiItration of bIood in the sub-
July, ‘949
Neurectomy
53
peritonea1 tissues which inMtrated in the posterior region of the rectum but was spontaneously absorbed. Before cIosing the posterior peritoneum, one must be sure of perfect controI of bIeeding. It is to be noted that these patients need three or four injections of morphia on the first day on account of their postoperative pains. PhIebitis and puImonary infarcts are rare and do not exceed I per cent, due to the fact that the patients are young and free from any viscera1 diseases. We have never noted any Iater disturbances among our patients. There were numerous women who had one or moie absoIuteIy norma pregnancies afterward. Women suffering from dyspareunia now have norma coition. We never saw a case of frigidity foIIowing the operation. Symptoms may recur but that has been the exception; we count onIy 2 per cent of them. In a11 cases the symptoms existing with dysmenorrhea, nameIy, fever, vomitintestina1 cramps, etc., cIear up ing, simuItaneousIy. We did the iirst resection of the presacra1 nerve twenty-three years ago and we can definiteIy affirm that, unti1 now, no other method of treating dysmenorrhea has given such consistent good resuIts.