Three phases of gynecologic plastic surgery

THREE

PHASES T.

BY ROBERT

OF, QYNEC&JOGIC

PIJASTIC

SURGERY”

A.M., M.D., k’.R.C.S., NEW YORK

FRANK,

HAVE chosen an extremeIy practical topic, namely, that of gynecologic plastic operations, a topic which has always interested me greatly, and a phase of our specialty which I feel is still to be clarified and technically improved. As I propose to cover three main subjects, it will be necessary to be most summaristic and brief. The three headings of my paper arc: (I) principles underlying the repair of vesicovaginal tistula, (II) the treatment of prolapse of the uterus, rectocele and cystoqele, (III) the construction of an artificial vagina by means of tube flaps.

I

.~__ 1923 10

Plastic and ventrofixation Plastic and ventrosuspension Plastic, anterior and posteri Plastic, anterior colporrhaphy Plastic, posterior colporrhaphy Ventrofixation Le Fort operation Interposition operation Moscheowitz operation, rectal Vesicovaginal fistula Artificial vagina Total

1926 24

-~-.-I___-____

19”i4 16

1928 27 3 16

5 n 3 1 3

TOTAL

77 6

62 22 20 9 5 2 5 9

_~ 3 220

The table shows my material from the fall of 1925 to December, 1928. My remarks are, however, based upon an experience of twenty-five years and include a correspondingly larger number of cases. ( I)

REPAIK

OF

VESl(‘OVAOINAL

FISTULA

My ,personal experience is limited to 33 cases, due, in the main, to two causes, the one to obstetric, the other to operative injuries. The resulting defects varied from pinpoint in size to complete loss of the lower wall of the bladder, including the sphincter and urethra. It follows that no final conclusions can be drawn from statistics based on such a small number of cases, although at the present time, few individual operators have the opportunity of dealing with a large series. Old Technics.-Of the older, well-established and useful technics, the freshening of the edges and direct suture by the Marion Sims method is still applicable in a considerable number of cases. If approximation without tension can be obtained either by liberating incisions at. the

PRANK

:

THREE

PHASES

OF

GYNECOLOGIC

PILAYTIC

SURGERY

172

time of operation, or by preliminary dilatation treatments, the Sims technic is particularly useful in small or medium-sized defects in the region of the sphincter vesicae. The flap splitting operation is of great value in a number of cases where the septum separating the bladder and vagina is of sufficient thickness to permit of separation of the two mucosae, and of separate suture of the bladder and vaginal mucous membrane. Where the septum is too thin, flap splitting is impossible. Newer Technics.-Transposition of the uterus: In one instance I was able to close a large gap in the inferior surface of the bladder as well as to reestablish continence, by utilizing the superior surface of the transposed uterus to close the gap, as well as to supply pressure at the vesicourethral junction, and thus reinforce sphincter action. This method will be rarely utilizable. Mobilization with or without suture: In 1917 I called attention to t)he technic which before and since then has stood me in good stead in cases of great technical difficulty, especially where the large size, and the presence of dense scars made the ordinary technics inapplicable.* Sometimes by the vaginal approach, more often through the abdomen from above, and then preceded as a rule by a supravaginal hysterectomy for technical reasons, the bladder is widely mobilized. This mobilization must be done boldly and t,o such an extent that the entire defect is freed from the subadjacent tissues. If feasible, suture of the gap should be attempted. If not feasible, this has happened twice to me, the abdominal field is carefully extraperitonealized by union of the vesical and retrocervical peritoneum, and by securing a loop of the sigmoid over this first suture line. At the lower angle of the wound a rubber tissue drain may be placed down to the bottom of the space of Retzius. Under these conditions, the main and essential requisite for healing is a constantly funotioning indwelling catheter by means of which the bladder is kept in a complete state of contraction for fourteen days. It will then be found that, just as sometimes happens in a spontaneously formed fistula arising postpartum, when similarly treated, complete healing of the bladder has taken place. The reestablishment of continence: In mild cases, freshening and suture of the canal by the Sims technic closes the urethrovesical defect. It is then of the utmost importance to gather the fasciae, especially the triangular ligament, across the vesicourethral junction. This usually reestablishes complete control. Reconstruction

of a torn’

frequent number of cases be wasted in est,ablishing short urethral canals, if, perfectly. T have ha.d no gratifying

w&hi-a

is followed’

in a disappointingly

by dribbling of urine. No great effort need the full length of the urethral canal. Very the sphincter apparatus is intact, function ” results with elaborate neoformations of ure-

thrae. The canal has been satisfactory from a cosmetic point of view but functionally incompetent. Possibly subsequent use of the StoeckelGoebel technic might offer better functional effect. In one instance, I was able to construct and apply a pessary which exerted pressure against the new urethra, and thus gave a fair degree of continence. At present I am more concerned with constructing a good vesical opening of small size (just admitting a No. 7 to No. 8 French catheter), the resultant closurcl being effective except on severe pressure and coughing. (II)

TlIE

TREATJIRXT

OF

PROLAPSE

OF

‘CITE

IJTERUS,

RECTOCELE

AND

CYSTOCELE

I have no intention of attempting to cover the entire subject, nor do I propose to weary you with an accumulation of statistics. On the contrary, I shall attempt merely to give you my own preferences which I have arrived at after prolonged and soul-searching eflorts to find a generally applicable cure. I may say that every case is an individual problem and that depending upon the type of our material, the individual patient, and our own experiences and preferences, differentoperators have come to prefer different methods. I do not hesitate to assert that even in the best of hands, a minimum of 10 per cent of recurrences is bound to occur in a large material properly followed up. (1) The interposition operation, which was so largely worked out in Chicago, is but rarely used by me and is then employed in women past the menopause, with a small but not too small uterus, suffering from what I designate as a billiard ball cysfocele, complicated by not. more than a first degree of prolapse. (2) Vaginal hysterectomy : 1 have used this operation twice in cases of prolapsed uteri in which adenoearcinoma simultaneously necessitated removal of the uterus. Today, if such a case should again confront me, I would prefer the abdominal route with fixation of the vaginal stump in the abdominal fascia. I have seen no more desolate condition than recurrence of prolapse in cases in which the uterus was removed for its cure and in which a subsequent eventration of the pelvic floor resulted. IJnder these conditions nothing but complete excision and obliteration of the vagina is possible. The lie Fort operation of producing a median longitudinal septum has proved unsafisfact,ory in the few cases in which I employed this technic. (3) Anterio)*

and. Posterior

CoEpodaphy

With

Vedrofixatiorz.---In

all cases of complete prolapse, in all large rectoceles and cystoceles, if operation is undertaken (and this will exclude women in the childbearing period who still desire further progeny) I am in the habit of performing an anterior and posterior colporrhaphy according to the technic which T have described, in 191Y and 1922,” followed at once?

PRASK

:

THREE

PHASES

OF

GYNECOLOGIC

PLASTIC

SURGERY

175

or at a later date, as 1 shall explain, by extraperitoneal ventrofixation of the uterus. (4) This operation is unsuitable in women who still desire to have children. In selected cases, an anterior and posterior colporrhaphy, and a careful Alexander-Adams shortening of the round ligaments have been used in young women who have thereupon successfully borne children without recurrence of their prolapse, although a certain number may be expected to recur with or without subsequent childbirth. (5) In every case where abnormal bleeding has been noted, a curettage is performed at the time of the plastic operation. Curettings suspicious of malignancy, or t.he possibility of early pregnancy, as sometimes happens, demand postponement of the plastic operation until microscopic confirmation of the findings has been obtained. In the case of early pregnancy and abortion, the main operation should be postponed for at least four months. (6) Amputation of the cervix has been performed less and less often as a preliminary step. Ry confining the patient to bed for one or two weeks before operation, ulcerations are healed, and hyperplastic, edema.tous cervices show a gratifying involution. Alzesthesia.-Particularly in my ward hospital practice, many of the candidates for plastic operation are found to be short, overweight, afflicted with high blood pressure, with poor myocardiums, often impaired renal function, emphysema, and bronchitis, in other words, far from attractive or safe. operative risks. Such patients formerly were strong arguments in favor of selecting a short method, such as the interposition operation by means of which the cystocele as well as, in certain cases, prolapse of the uterus is overcome. Today, however, I use parasacral anesthesia in these patients, obtaining a surprisingly relaxed and painless field, postponing the ventrofixation until the vaginal plastic has entirely healed, usually a matter of from fifteen to eighteen days. The ventrofixation is then performed rapidly under gas ox.ygen anest.hesia with very little postoperative reaction. I need hardly say that to the ventrofixation performed during the childbearing period, ligation of the tubes is always added. Tech&C.-The actual technic requires little elaboration. The anterior colporrhaphy is performed by fully exposing the pubocervical fascia, which is not only brought together but is also transplanted to a. higher level on the cervix after the bladder has been thoroughly liberated, thus effectually holding back that viscus. The posterior colporrhaphg is performed by means of a simple Hegar triangle or a linear longitudinal incision. The rectum, in cases of high vaginal enterocele, is fully freed from the herniated Douglas sac. The peritoneum is resected, as in any hernia, and a suture brings together the anterior surface of the rectum. the two sacrouterine ligaments and

the posterior surface of the cervix, thus closing up the Douglas defect. Thereupon a perineorrhaphy is superadded by bringing together these fascial planes which cover the rectum (fascia recti), as well as those which cover the levator muscles. I have found exposure and suture of the levator ani muscle leading to thin, starry, painful perineums. Ventrofixation through a small incision is performed by means of a slightly modified Kocher technic in which the fundus of the uterus is extraperitonealized by means of a peritoneal suture, the uterine tissues being brought in direct contact with the fascia of the external oblique and sutured there with chromic catgut. Tying of the tubes, when necessary, is performed by passing a thin silk suture (the only occasion in which I use silk in surgery) through the mesosalpinx at the beginning of the ampullary end of the tube, forming a sharp angle loop of tube, and tying this same suture across each piece of the loop. Care should be taken not to tie the suture so tightly as to favor cutting through. The top of the tubal loop is then snifiped off, leaving a double barreled lumen which, in my experience, has shown no tendency to reformation of continuity. Special technics : In fivta instances in the presence of large fibroids, I have found it necessary to perform a. supravaginal hysterectomy for the tumor where large rectocele and cystocele as well as weak cardinal ligaments made the subsequent occurrence of inversion of the vagina certain. In these cases, I have performed a supravaginal hysterectomy leaving a long cervical stump. The cored out cervical stump was carefully sutured. Before further repair was then undertaken, the bladder was pushed away from the vagina, iti the median line, down to the urethrovesicle junction, and thereupon the typical Polk operation was performed. This, as you will see, consists in bringi,ng the pubocervica~ fascia together below the bladder, just as I do by the vaginal route, only using the abdominal approach. Great care must be exercised in keeping close to the median line, otherwise serious hemorrhage may result. After closure of the fascial planes, the vesicle peritoneum is sutured to the anterior surface of the stump which, however, as in the early operation for abdominal hysterectomy, is left extraperitoneal and is fastened to the fascia of the external oblique just as the fundus of the uterus is fastened in the ventrofixation technic previouslp described. 111 ?Y cases th(l operation has proved satisfactory. When necrssary, and this usually is so, a posterior colporrhaphy is performed at a Jater session. The reason for selecting the Polk operation in these cases is that if the anterior colporrhaphy is performed after ventrofixation of the stump, it is quite likely that the stump will be torn from its abdominal

FRAXK

:

THREE

PHASES

OF

GYNECOLOGIC

anchorage during the manipulations anterior -vaginal wall. .’

(III)

CONYTRUCiION

OF AN

necessary ARTIFICIAL

PLASTIC

SURGERY

in exposition

177 of the

VAGINA

The danger of the Baldwin operation in which only partial statistics show a mortality of 20 per cent, the sloughing and stenosis following the’schubert rectal technic, have prevented me from ever attempting these operations for the reconstruction of an artificial vagina. Dr. Samuel Geist and myself have devised a method based on the tube flap technic which we learned during our war experience, and which has served us in an encouraging fashion in the two cases completed and the one case in process of construction.’ 1 limit this operation to feminine individuals in whom I have been able to demonstrate a cyclical accumulation of female sex hormone in the blood, whose psychic inclination toward the male is well marked, and in whom weighty personal and social factors incline me to follow their wishes. The two first patients were married and threatened with divorce. Two young women at present under treatment are engaged to be married. Another one who will be started within the next few weeks is engaged and her fiance is fully aware of her disability. A fourth patient is obliged to submit to the operation because of the unhappiness resulting from family disagreement, as her parents insist t,hat she qualify for the marriage state. The opt%+ation, we have found, is free of risk, requires at the minimum eight weeks of more or less intern&tent hospitalization, but offers a very excellent chance of the permanent establishment of a satisfactory vagina. In one case in which I attempted to shorten the steps by using a direct flap instead of the tube technic, complete necrosis of these skin flaps resulted. We feel confident that the tubulization gives a tremendous additional vitality and independence to t,he flap and enables us to utilize it with a great degree of impunity. The steps consist in brief (1) in the formation of one or more bilateral tube flaps which are well described as “satchel handle flaps.” After full healing has taken place (2) an incision is made between rectum and urethra, closer to the rectum, in order to obtain as large and movable an anterior flap of vestibular mucosa as is possible, and by means of blunt, dissection, a false passage is established in the rectourethral septum until the peritoneum is reached. (3) The distal portion of the tube flap is severed, (4) the tube is reopened throughout its pedicle, fully mobilized, &lvd (5) the skin is spread over a vaginal plug with the skin surface”toward the plug. (6) By means of this ptiothesis, the flap is introduced and fixed in the false passage. (7) The free distal end of the flap is sutured to the raw skin edge of the vagiha. (8) A permanent catheter is introduced int,o the urethra. (9) After

178

THE

AMERICAN

JOURKAL;

OF

OBSTETRICS

AND

GYNECOLOGY

ten to twelve days, depending on the type of healing, the pedicle at the vulvar margin is severed, the stump of pedicle used to cover any defect on the thigh, the free end of the flap being sutured to the freshened vulvar margin. (10) A vaginal plug is worn constantly for the first two months and thereafter for another eight to ten months during the night. These are the technics which have stood me in good stead. They still can be improved upon in principle as well as in details of exeeution. The operations require minute care, some operative experience and manipulative skill. They possess the advantage of being anatomic and therefore can be readily taught. The results are permanent and satisfactory. REFERENCES

(1) Frank, 11. T.: Burg. Gynec. Obst. p. 538, November, 1917. (2) Franlc, R. T.: Surg. Gynec. Obst., p. 42, January, 1917. (3) Frank, 3. T.: AM. J. OBST. & GYNW. 5: 8, 1923. (4) Frank, II. T., awd G&t, 8. H.: AM. J. OBST. & GYNEC. 14:

712,

1927.

10 EAST

EI~IITY-FIFTH

STREET.

(For diuuuusioa, gee paye J87.)

RUhl, A.:

Noktol

as a Soporific

in Child-bed,

Miiuchen.

med.

Wchnschr.

73:

863,

1926. Noktol. whose chemical formulg is isopropyl-brompropheynl-barbiturie acid, was tried in 30 cases, twelve normal deliveries, eight cesarean sections, and ten forceps deliveries, the dosage being two tablets of 0.1 gm. each; one tablet of 0.1 gm. was insufficient. This drug was very effective following operations. normal physical sleep occurring in one-half hour. There was no bad effect on mother or child. Neither bromide ion nor barbituric acid radical passed into the milk. Noktol is very safe in doses of 0.2 gm. following operation and in fever. WILLIAM B. SERBIN.

HiIlfNlIllallIl:

Leucorrhea,

Ztschr.

f.

Geburtsh.

u.

Gynlk.

93:

349,

1928.

The author uses a telescope, magnifying up to 40 times with intense light, to examine the vaginal wall and finds that there are inflammatory changes visible in 60 to 70 per cent of all cases having leueorrhea. He believes that endocervicitis following gonorrhea is much less common than vaginitis. Leucorrhea coming from the endometrium is found only in from 10 to 20 per cent of cases. The discharge may be seen being expelled from the cervix if observation is continuous for up to twenty minutes. The differentiation of the source of a leueorrhea is made by this method of examination with the addi.tion of the microscopic examination of small pieces of tissue excised from different parts of the genital tract which appear to be inflamed when looked at with this telescope. HANK A. PEMBERTON.