SUPRA-VAGINAL HYSTERECTOMY. Hysteromyomectomy with Suspension of the Stump in the Lower Angle of the Abdominal Incision. BY HOWARD A. KELLY, M.D., GYNECOLOGIST TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE. FROM THE MEDICAL NEWS, June 28, 1890. [Reprinted from The MEDICAL NEWS, June 28, 1890.] SUPRA VAGINAL HYSTERECTOMY. Hysteromyomecfomy with Suspension of the Stump in the Lower Angle of the Abdominal Incision. GYNECOLOGIST TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE. HOWARD A. KELLY, M.D., The method here proposed1 is limited to cases conceded to be most favorable for operation—those in which there naturally exists a pedicle, or in which it is possible to form a pedicle below the tumor masses. Ido not wish to consider atypical cases, in which total ablation of the uterus. (panhyster- ectomy) is called for, or those in which the uterus from fundus to cervix is a mass of fibroid tumors. I also purposely avoid the important question as to the best method of forming a pedicle when the broad ligament is choked with fibroid tumors. Fig. 1 is a generic representation of the class under dis- cussion. I have adopted in these cases an original method combining the advantages and eliminating many of the dangers of Hegar’s and Schroder’s methods— the ordinary extra- and intra-peritoneal methods. The operation consists of seven steps, as follows: First. A long incision in the linea alba (Fig. 2) for the delivery of the myomatous uterus. 1 See American Journal of Obstetrics, April, 1889. 2 KELLY, Fig. i. TT T, tumor. P, pedicle. V, vagina in section. FIG. 2. SUPRA-VAGINAL HYSTERECTOMY. 3 Second. The elevation of the tumor until the ped- icle is brought into view for treatment by tying the broad ligament structures, or for enucleation of tumors from the broad ligament until a pedicle is formed, when the rubber ligature is applied and tied tightly, controlling the circulation. (Fig. 3.) Third, The tumor is cut away from one to two inches above the rubber ligature (Fig. 4), by first Tumor delivered, rr, rubber ligature in place and ready to be drawn tight. • Dotted line shows the incision through the peri- toneum. splitting the peritoneum and then cupping out the upper face of the stump, cutting with each stroke down toward the vaginal canal. The cervical canal must next be carefully dis- sected out and its site well cauterized. Fourth. This consists in the closure of the raw face of the stump by uniting the opposite sides by means of a continuous buried suture of catgut as seen in Figs. 5 and 6. Fig. 5 represents the appearance seen upon looking down on the stump from above, 4 KELLY, Fig. 4. Tumor separated from pedicle. Method of closing upper raw surface of stump by means of a continuous buried suture. SUPRA-VAGINAL HYSTERECTOMY. 5 Fig. 6 being a vertical section through the cervix. The last row of sutures, which brings the peritoneal surfaces into apposition, is of interrupted silk sutures, with the long ends left uncut, for a purpose to be Fig. 6. Stump united up to last row of imerrupted surface-sutures, SS. bs, last rows of buried sutures. V, vagina, cv, vaginal cervix. described later. All of these sutures, buried and superficial, must be applied with the view of con- trolling the circulation as well as securing approxi- mation. They must, therefore, be drawn tight, and must encircle any vessels in view. 6 KELLY, Fifth. After the surface of the stump has thus been closed and there remains nothing of Fig. 7. Pedicle Ligation of left uterine artery. Pedicle is pulled toward the right by means of the long interrupted silk sutures S S, while the needle carrying ligature is passed under the uterine artery. wound but the linear union of the peritoneal sur- faces, the rubber ligature is cut away, and the lips SUPRA-VAGINAL HYSTERECTOMY. 7 of the wound are carefully observed. If there is any persistent oozing the nearest uterine artery must be ligated. This is accomplished by grasping the long ligatures and pulling the stump to the right or left, exposing the site of the left or right artery. A stout needle armed with a catgut ligature is then swept boldly through the side of the stump, well below the sutured area (Fig. 7) and tied, thus cut- ting off all communication between the artery and the stump. Fig. 8. Showing union of the peritoneal surface of the stump to the parietal peritoneum. Both arteries may be treated in this way without any danger of destroying the vitality of the stump. 8 KELLY, If, however, there should be no flow of blood from the closed lips of the stump, the fifth step may be omitted. Sixth. The abdominal incision is closed down to the stump, putting in a drainage-tube, if needed, well above the stump. Following this the parietal peritoneum of the abdominal incision is united to the peritoneal coat of the stump, below the lips of the stump, by means of a continuous catgut or silk ligature (Fig. 8) ; and in this way the stump is sepa- rated from the peritoneal cavity. Seventh. The wound is dressed with some dry antiseptic powder, or simply packed under the edges of the skin, around the suspended stump, with antiseptic gauze. Finally, a large square of gauze, six or eight folds in thickness, with a small Fig. 9. Dressing applied. Interrupted sutures of the surface of stump are brought through a hole in the gauze and grasped by forceps. slit in it, is prepared, and the long ligatures which unite the peritoneal lips of the stump are pulled SUPRA-VAGINAL HYSTERECTOMY. 9 through the slit. These are lifted well up, and grasped by a pair of long Keith’s forceps laid hori- zontally on the body (Fig. 9). This dressing serves effectually to keep the stump from pulling back into the abdomen, and the ope- rator has at all times full control of it at a moment’s notice in case of accident. This gauze can be changed as often as soiled. Once every two or three days is usually sufficient. The silk sutures uniting the peritoneal lips of the wound finally either come away or are cut loose and pulled out in about ten days. The small pit which is thus left in the lower angle of the abdominal wound over the stump rap- idly fills by granulation. This method has distinct advantages over internal or external methods commonly in use. It is better than dropping the stump back among the intestines (Fig. 10). By the new method hsemorrhage is not dangerous, being at all times under control. The danger of sepsis is also removed, a danger to which large numbers of cases have succumbed after the in- tra-peri ton eal treatment of the stump. It is better than the common external method (Fig. n), because, in the first place, it is there necessary to elevate even a short pedicle far enough to attach the parietal peritoneum below the rubber lig- ature. By my method the attachment is higher, and the method is, therefore, better for short pedicles, doing away with a traction which is often excessive. Again, when the rubber ligature is left on, it is impossible to limit the depth of the slough which KELLY, Fig. io. Intra-peritoneal treatment. Stump S dropped back into perito- neal cavity and abdominal walls closed above. Fig. ii. skin muscle periion • Extra-peritoneal treatment of stump S, which sloughs off at the rubber ligature rI. The union of the peritoneum of the stump to that of the abdominal walls is shown by the dotted circles. SUPRA-VAGINAL HYSTERECTOMY. takes place as the distal end drops off, and it will readily be granted on general principles that a method which constricts any part of the body, and waits for it to drop off by sloughing is a coarse and unscientific means of performing an amputation. A National Weekly Medical Periodical, containing 24-28 Double- Columned Quarto Pages of Reading Matter in Each Issue. $4.00 per annum, post-paid. THE MEDICAL NEWS. The year 1890 witnesses important changes in The Medical News resulting from a careful study of the needs of the profession. Its price has been reduced, and its bulk also, though in less proportion. The mass of information, on the other hand, has been increased by condensing to the limit of clearness everything admitted to its columns. Three new departments have been added to its contents—viz.: Clinical Memora7ida, being very short signed original articles, Therapeutical Notes, presenting suggestive practical information, and regular Correspondence from medical centres. Hospital Notes will detail the latest methods and results of leading hospital physicians and surgeons. Special articles will be obtained from those best' qualified to write on subjects of timely importance. Every avenue of information appropriate to a weekly medical newspaper will be made to contribute its due information to the readers of The News. The American Journal of the Medical Sciences. Published monthly. Each number contains 112 octavo pages, illustrated. $4.00 per annum, post-paid. In his contribution to A Century of American Medicine, published in 1876, Dr. John S. Billings, U. S. A„ Librarian of the National Medical Library, Washington, thus graphically outlines the character and services of The American JoURNAL ; “ The ninety-seven volumes of this Journal need no eulogy. They contain many original papers of the highest value; nearly all the real criticisms and reviews which we possess; and such care- fully prepared summaries of the progress of medical science, and abstracts and notices of foreign works, that from this file alone, were all other pro- ductions of the press for the last fifty years destroyed, it would be possible to reproduce the great majority of the real contributions of the world to medical science during that period.” The Medical News, published every Saturday, "1 The American Journal of the Medical ] Sciences, monthly, , COMMUTATION RATE.—Postage paid. in advance. $7.50. LEA BROTHERS & CO., 706 and 708 Sansom St., PhHa.