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Tubal resection as treatment for recurrent salpingitis
TUBAL RESECTION AS TREATMENT FOR RECURRENT SALPINGITIS * PRELIMINARY REPORT HENRY
C.
PALK, M.D., F.A.C.S.
Clinical Professor of Gynecology, New York University Medical College; Director of Gynecology, Harlem Hospital; Gynecologist, French Hospital
NEW YORK
T
HE patient with salpingitis seeks ad- uterine cornu whereas in the pus tube on mission to the hospital only when the other side the connection with the there is incapacitating pain or fever. uterine cavity seemed to be maintained. The amount of pathology found in the 4. It has been shown by Simpson 2 and pelvis is not an index of the number nor Curtis 3 that gonorrhea of the tube is a self severity of the symptoms. Large masses limited disease and that the organisms in may be present with few or no symptoms. the tube die when the patients temperature yet frequently, little pelvic pathology is is normal for two weeks. As a result, one palpable in patients giving a history of might therefore assume that the tube can three or four recurrent attacks of incapaci- not reinfect itself. The infection must come tating pain. The economic independence of from without. most of the patients presenting themselves 5. It was found that those patients on at our large institutions depends upon their whom a bilateral cornual resection had ability to work and this is destroyed by an been performed for sterilization purposes, incapacitating salpingitis. In an attempt never developed pus tubes. to properly evaluate the methods of treatAs a result of this study five conclusions ing salpingitis the rule was adopted that were reached: surgery, in the treatment of tubal infections I. That the uterus is the necessary should be resorted to, only for the cure of avenue by which gonorrheal infection incapacitating symptomatology. rather than reaches the tubes from the cervix and the removal oj pathology. external genitalia; In studying a large series of cases 2. That even in the presence of the of tubal infection certain facts were uterus and a quiescent tubal infection, the discovered. absence of infection from the internal os I. That when a patient with quiescent outward prevents reinfection; pus tubes was adequately treated so as to 3. The tube does not spontaneously remove all infection from her genitalia reinfect itself, Simpson and Curtis have (cervix, urethra, etc.) and she was sepa- shown that pus tubes sterilize themselves; rated from her consort to prevent reinfec4. When a patient has a complete occlution, her tubal infection did not recur. sion at the uterine end of the tube, tubal 2. That reinfection of chronicly infected reinfection does not occur and pus tubes do tubes did not occur in patients who had not develop even though infection is preshad a hysterectomy. In the literature, it ent at the cervix and external genitalia; was found that Robinson l described hys5. In those cases where the connection terectomy as a treatment for pus tubes. between the uterine cavity and the tubes 3. That in spite of the known fact that a has been broken no cases of pus tubes gonorrheal infection of the tubes is always developed. . It was then argued that if theseconc1ubilateral, patients were seen repeatedly who had a pus tube on one side and grossly, sions were correct, in order to prevent a fairly normal tube on the other. reinfection of the tubes one of four proAs a result of this observation several of cedures might be followed. these tubes were removed and examined. I. Clear up all infection and do not allow It was found that the apparently normal sex trauma so as to prevent reinfection; tube was completely obstructed at the 2. Do a hysterectomy;
* From the Gynecological Service of Harlem Hospital. 50 9
510 American Journal of Surgery
F alk-Tubal Resection in Salpingitis
3. Remove the infected tubes with or without fundectomy; 4. Resect the tubes at the cornu of the
SEPTEMBER, 1936
Procedure NO.3, removal of the tubes with or without resection of the fundus, is an excellent procedure. However, in remov-
FIG. IA. Figure of eight stitch placed in cornu of uterus; V-shaped excision of uterine end of tube. B. Suture passed through mesosalpinx.
uterus breaking the connection between the infected cervix, uterus and tubes. Having adopted as our premise the rule that surgery, in the treatment of tubal infection should be resorted to for the cure of incapacitating symptomatology rather than the removal of pathology, which of these procedures should be followed? Procedure No. 1 could be followed if the patients would cooperate, but it is practically impossible to prevent sex trauma. Reinfections have occurred in some cases following sex trauma where one could absolutely exclude reinfection from the consort. This first procedure can be accomplished theoretically but as a result of the impossibility of control it is usually doomed to failure. Procedure NO.2, hysterectomy, is radical surgery for infected tubes; patients will not submit to it, the mortality and morbidity is too high and it breaks every principle of preserving as much of the pelvic organs as possible.
ing the tubes with or without a piece of the fundus one frequently interferes with the blood supply of the ovaries and on the check up of the patient ovarian cysts are found. Procedure NO.4, resection of the tubes, a minimum of surgery is performed. Interference with the ovarian supply is reduced to a minimum and reinfection of the tubes is prevented. Allowing infected tubes to remain in the abdomen is not a new procedure. Little, 4 of Montreal, showed that it was not necessary to remove the infected tubes to cure the patients' symptoms nor was it necessary to remove the mass. He punctured the pus tubes, drew off the fluid and injected 10 per cent turpentine in oil. The symptoms cleared up but the pathology still remained, the masses were still present. Holden 5 did salpingostomies in a dozen cases. He incised the pus tube along its anterior surface from the clubbed end to the uterine cornu, removed the pus and
NEW SERIES VOL.
XXXIII,
NO.3
F alk-Tubal Resection in Salpingitis
then suspended the incised tubes to the round ligament by three or four sutures turning the raw surface of the incised
American Journal of Surgery
5I
I
and ovary causing late pain. It was therefore decided to deliver these tubes and ovaries from the pelvis and suspend them
FIG. 2A. Figure of eight stitch tied and clamp applied to ligature. B. Suture through mesosalpinx tied around proximal end of tube and left long. Needle with suture passed through posterior wall of uterus below suspensory ligament of ovary.
tubes downward. These men proved that infected tubes could be left in the abdomen andJthe patients be symptomatically cured. TECHNIQUE OF TUBAL RESECTION
The abdomen is opened with the usual left paramedian incision. The pelvis is walled off with abdominal pads. Step 1. The pelvic pathology is thorously examined. This is absolutely essential because the operation of tubal resection should not be done in cases with injected or abscessed ovaries. To thoroughly examine the pelvic pathology it may be necessary to dig the tubes and ovaries from their adhesions. In pure gonorrheal tubes the adhesions will be at the fimbriated end only. In our first series of cases nothing was done t,o these tubes and ovaries except resect the cornu. In our discussions the question was raised as to the possibility of a low tuhe
to prevent late postoperative pain. Steps 2 and 3. The right tube and ovary are delivered into the wound. A hot laparotomy pad is placed in the pelvis to control any oozing. The tube close to its origin at the uterine end is grasped with a small artery clamp and a figure of eight stitch is inserted in the cornu of the uterus (Fig. IA). A "V" shaped excision of the uterine end of the tube is made and the figure of eight stitch is drawn taut and tied (Fig. 2A). This is left long and a clamp applied. Step 4. A plain catgut suture is passed through the mesosalpinx tying the cut end of the tube (Figs. I and 2B). This suture is not cut and the needle is not removed. The suspensory ligament of the ovary is grasped with an Allis clamp and lifted; the needle with the long end of the suture is then passed through the posterior wall of the uterus below the suspensory ligament of
512
American Journal of Surgery
F alk-Tubal Resection in Salpingitis
the ovary and tied. All clamps are removed. The suture is cut fairly short (Fig. 3). Step 5. The same procedure, Steps 1 to
SEPTEMBER,
1936
Clinical. Forty-three or 67 per cent of the cases were reported as clinically cured or asymptomatic, 16 cases or 24 per cent
FIG. 3. All sutures tied and cut short. Proximal end of tube is thus buried.
4, is followed on the left side. Step 6. The outer end of the ovary is sutured to the parietal peritoneum of the pelvis above the iliopectineal line with a non-absorbable suture material, generally silk. (Poole Suspension.) Step 7. The appendix is removed and some form of uterine suspension, preferably a one point fixation, is performed. RESULTS
Seventy-five patients have been operated; the first operation was performed May 17, 1934, the last one April 26, 1936. Seventy per cent of these cases were in the age group between twenty and twenty-nine years. Sixty-four cases or 85 per cent have been seen in the follow-up clinic. The average numbe~ of times see~ is two: This average may gIve a wrong ImpreSSIon as some patients have been seen four times while others, and they form the large majority, only once. Anatomic. Fifty of these 64 cases are reported as having no masses, 10 having a moderate size mass and 4 cases had definite masses present.
had slight symptoms and 5 cases or 7 per cent had definite complaints. Ten cases or 15 per cent have sufficient symptoms to interfere with work. No cases have had to be readmitted for severity of symptoms and there have been no reoperations. CONCLUSIONS
A procedure for the cure of recurrent salpingitis is described with a minimum of surgical trauma, giving a high percentage of clinical and economic cures. REFERENCES
I. ROBINSON, BYRON. The Utero-Ovarian Artery, E. H. Colegrove, 1903. 2. SIMPSON, F. F. Choice of time for operation for pelvic inflammation of tubal origin. Trans. Amer. Gyn. Soc., 34: 161, 1909; A precise method of choosing a safe time for operation in pelvic inflammation of tubal origin. Trans. Amer. Gyn. Soc., 40: 166, 19 15. 3. CURTIS, A. H. Bacteriology and pathology of Fallopian tubes removed at operation. Surg. Gynec. and Obst., 33: 621, 1921. 4. LITTLE, H. M. The treatment of salpingitis by local injection of turpentine. Trans. Amer. Gynec. Soc., 40: 134, 1930. 5. HOLDEN, F. C. Radical conservatism in the surgical treatment of chronic adnexal disease. Trans. Amer. Gyn. Soc., 46: 276, 1921.
C.
PALK, M.D., F.A.C.S.
Clinical Professor of Gynecology, New York University Medical College; Director of Gynecology, Harlem Hospital; Gynecologist, French Hospital
NEW YORK
T
HE patient with salpingitis seeks ad- uterine cornu whereas in the pus tube on mission to the hospital only when the other side the connection with the there is incapacitating pain or fever. uterine cavity seemed to be maintained. The amount of pathology found in the 4. It has been shown by Simpson 2 and pelvis is not an index of the number nor Curtis 3 that gonorrhea of the tube is a self severity of the symptoms. Large masses limited disease and that the organisms in may be present with few or no symptoms. the tube die when the patients temperature yet frequently, little pelvic pathology is is normal for two weeks. As a result, one palpable in patients giving a history of might therefore assume that the tube can three or four recurrent attacks of incapaci- not reinfect itself. The infection must come tating pain. The economic independence of from without. most of the patients presenting themselves 5. It was found that those patients on at our large institutions depends upon their whom a bilateral cornual resection had ability to work and this is destroyed by an been performed for sterilization purposes, incapacitating salpingitis. In an attempt never developed pus tubes. to properly evaluate the methods of treatAs a result of this study five conclusions ing salpingitis the rule was adopted that were reached: surgery, in the treatment of tubal infections I. That the uterus is the necessary should be resorted to, only for the cure of avenue by which gonorrheal infection incapacitating symptomatology. rather than reaches the tubes from the cervix and the removal oj pathology. external genitalia; In studying a large series of cases 2. That even in the presence of the of tubal infection certain facts were uterus and a quiescent tubal infection, the discovered. absence of infection from the internal os I. That when a patient with quiescent outward prevents reinfection; pus tubes was adequately treated so as to 3. The tube does not spontaneously remove all infection from her genitalia reinfect itself, Simpson and Curtis have (cervix, urethra, etc.) and she was sepa- shown that pus tubes sterilize themselves; rated from her consort to prevent reinfec4. When a patient has a complete occlution, her tubal infection did not recur. sion at the uterine end of the tube, tubal 2. That reinfection of chronicly infected reinfection does not occur and pus tubes do tubes did not occur in patients who had not develop even though infection is preshad a hysterectomy. In the literature, it ent at the cervix and external genitalia; was found that Robinson l described hys5. In those cases where the connection terectomy as a treatment for pus tubes. between the uterine cavity and the tubes 3. That in spite of the known fact that a has been broken no cases of pus tubes gonorrheal infection of the tubes is always developed. . It was then argued that if theseconc1ubilateral, patients were seen repeatedly who had a pus tube on one side and grossly, sions were correct, in order to prevent a fairly normal tube on the other. reinfection of the tubes one of four proAs a result of this observation several of cedures might be followed. these tubes were removed and examined. I. Clear up all infection and do not allow It was found that the apparently normal sex trauma so as to prevent reinfection; tube was completely obstructed at the 2. Do a hysterectomy;
* From the Gynecological Service of Harlem Hospital. 50 9
510 American Journal of Surgery
F alk-Tubal Resection in Salpingitis
3. Remove the infected tubes with or without fundectomy; 4. Resect the tubes at the cornu of the
SEPTEMBER, 1936
Procedure NO.3, removal of the tubes with or without resection of the fundus, is an excellent procedure. However, in remov-
FIG. IA. Figure of eight stitch placed in cornu of uterus; V-shaped excision of uterine end of tube. B. Suture passed through mesosalpinx.
uterus breaking the connection between the infected cervix, uterus and tubes. Having adopted as our premise the rule that surgery, in the treatment of tubal infection should be resorted to for the cure of incapacitating symptomatology rather than the removal of pathology, which of these procedures should be followed? Procedure No. 1 could be followed if the patients would cooperate, but it is practically impossible to prevent sex trauma. Reinfections have occurred in some cases following sex trauma where one could absolutely exclude reinfection from the consort. This first procedure can be accomplished theoretically but as a result of the impossibility of control it is usually doomed to failure. Procedure NO.2, hysterectomy, is radical surgery for infected tubes; patients will not submit to it, the mortality and morbidity is too high and it breaks every principle of preserving as much of the pelvic organs as possible.
ing the tubes with or without a piece of the fundus one frequently interferes with the blood supply of the ovaries and on the check up of the patient ovarian cysts are found. Procedure NO.4, resection of the tubes, a minimum of surgery is performed. Interference with the ovarian supply is reduced to a minimum and reinfection of the tubes is prevented. Allowing infected tubes to remain in the abdomen is not a new procedure. Little, 4 of Montreal, showed that it was not necessary to remove the infected tubes to cure the patients' symptoms nor was it necessary to remove the mass. He punctured the pus tubes, drew off the fluid and injected 10 per cent turpentine in oil. The symptoms cleared up but the pathology still remained, the masses were still present. Holden 5 did salpingostomies in a dozen cases. He incised the pus tube along its anterior surface from the clubbed end to the uterine cornu, removed the pus and
NEW SERIES VOL.
XXXIII,
NO.3
F alk-Tubal Resection in Salpingitis
then suspended the incised tubes to the round ligament by three or four sutures turning the raw surface of the incised
American Journal of Surgery
5I
I
and ovary causing late pain. It was therefore decided to deliver these tubes and ovaries from the pelvis and suspend them
FIG. 2A. Figure of eight stitch tied and clamp applied to ligature. B. Suture through mesosalpinx tied around proximal end of tube and left long. Needle with suture passed through posterior wall of uterus below suspensory ligament of ovary.
tubes downward. These men proved that infected tubes could be left in the abdomen andJthe patients be symptomatically cured. TECHNIQUE OF TUBAL RESECTION
The abdomen is opened with the usual left paramedian incision. The pelvis is walled off with abdominal pads. Step 1. The pelvic pathology is thorously examined. This is absolutely essential because the operation of tubal resection should not be done in cases with injected or abscessed ovaries. To thoroughly examine the pelvic pathology it may be necessary to dig the tubes and ovaries from their adhesions. In pure gonorrheal tubes the adhesions will be at the fimbriated end only. In our first series of cases nothing was done t,o these tubes and ovaries except resect the cornu. In our discussions the question was raised as to the possibility of a low tuhe
to prevent late postoperative pain. Steps 2 and 3. The right tube and ovary are delivered into the wound. A hot laparotomy pad is placed in the pelvis to control any oozing. The tube close to its origin at the uterine end is grasped with a small artery clamp and a figure of eight stitch is inserted in the cornu of the uterus (Fig. IA). A "V" shaped excision of the uterine end of the tube is made and the figure of eight stitch is drawn taut and tied (Fig. 2A). This is left long and a clamp applied. Step 4. A plain catgut suture is passed through the mesosalpinx tying the cut end of the tube (Figs. I and 2B). This suture is not cut and the needle is not removed. The suspensory ligament of the ovary is grasped with an Allis clamp and lifted; the needle with the long end of the suture is then passed through the posterior wall of the uterus below the suspensory ligament of
512
American Journal of Surgery
F alk-Tubal Resection in Salpingitis
the ovary and tied. All clamps are removed. The suture is cut fairly short (Fig. 3). Step 5. The same procedure, Steps 1 to
SEPTEMBER,
1936
Clinical. Forty-three or 67 per cent of the cases were reported as clinically cured or asymptomatic, 16 cases or 24 per cent
FIG. 3. All sutures tied and cut short. Proximal end of tube is thus buried.
4, is followed on the left side. Step 6. The outer end of the ovary is sutured to the parietal peritoneum of the pelvis above the iliopectineal line with a non-absorbable suture material, generally silk. (Poole Suspension.) Step 7. The appendix is removed and some form of uterine suspension, preferably a one point fixation, is performed. RESULTS
Seventy-five patients have been operated; the first operation was performed May 17, 1934, the last one April 26, 1936. Seventy per cent of these cases were in the age group between twenty and twenty-nine years. Sixty-four cases or 85 per cent have been seen in the follow-up clinic. The average numbe~ of times see~ is two: This average may gIve a wrong ImpreSSIon as some patients have been seen four times while others, and they form the large majority, only once. Anatomic. Fifty of these 64 cases are reported as having no masses, 10 having a moderate size mass and 4 cases had definite masses present.
had slight symptoms and 5 cases or 7 per cent had definite complaints. Ten cases or 15 per cent have sufficient symptoms to interfere with work. No cases have had to be readmitted for severity of symptoms and there have been no reoperations. CONCLUSIONS
A procedure for the cure of recurrent salpingitis is described with a minimum of surgical trauma, giving a high percentage of clinical and economic cures. REFERENCES
I. ROBINSON, BYRON. The Utero-Ovarian Artery, E. H. Colegrove, 1903. 2. SIMPSON, F. F. Choice of time for operation for pelvic inflammation of tubal origin. Trans. Amer. Gyn. Soc., 34: 161, 1909; A precise method of choosing a safe time for operation in pelvic inflammation of tubal origin. Trans. Amer. Gyn. Soc., 40: 166, 19 15. 3. CURTIS, A. H. Bacteriology and pathology of Fallopian tubes removed at operation. Surg. Gynec. and Obst., 33: 621, 1921. 4. LITTLE, H. M. The treatment of salpingitis by local injection of turpentine. Trans. Amer. Gynec. Soc., 40: 134, 1930. 5. HOLDEN, F. C. Radical conservatism in the surgical treatment of chronic adnexal disease. Trans. Amer. Gyn. Soc., 46: 276, 1921.