Transperitoneal Hysteror- rhaphy : A New Method of Ventral Fixation of the Uterus without opening the Peritoneal Cavity. FLORIAN KRU^M. D., GYNECOLOGIST TO THE GERMAN HOSPJTAL, NEW YORK. REPRINTED PROM Neto ¥orfe f^eUical journal for January 3y 1891. Reprinted from the New York Medical Journal for January 3, 1891. TRANSPERITONEAL HYSTERORRHAPHY: A NEW METHOD OF VENTRAL FIXATION OF THE UTERUS WITHOUT OPENING THE PERITONEAL CAVITY * By FLORIAN KRUG, M. D., GYNAECOLOGIST TO THE GERMAN HOSPITAL, NEW YORK. Although we nowadays hear the statement frequently made by electricians that misplacements of the uterus will almost unexceptionally yield to the electric treatment, still there are a good many of us who have been considerably less fortunate when introducing the electrode, turning on the current, and watching the milliamperemeter. The millennium has evidently not come yet, and, while fully recognizing the galvanic and faradaic currents as valuable therapeutic agents and adjuvants in suitable cases, those who see a great many gynfecological patients will still find themselves confronted with a goodly number of retrodis- placements which will resist all so-called conservative methods of treatment, and which will ultimately call for surgical interference. I do not propose to enter upon the question whether deviation of the uterus is a symptom or a disease, prefer- ring to let this often-trodden topic alone for to-night. I will simply say that, while admitting that in some instances * Read before the Section in Obstetrics and Gynaecology of the New York Academy of Medicine, November 28, 1890. 2 TRANSPERITONEAL HYSTERORRHAPHY. a retroflexed uterus will not give rise to any symptoms and may only be discovered accidentally, I take the ground that not infrequently such a malposition is the only apparent pathological condition when very annoying symptoms com- pel the patient to seek medical advice and treatment; and whether we attribute these symptoms to the retroflexion it- self, or to the accompanying metritis and endometritis, or whether we consider the latter as causative of the develop- ment of the retroflexion, the indisputable fact remains that in a certain number of cases a cure will not be accomplished unless we cure our patient of the retroflexion. No doubt this cure can in the majority of cases be ef- fected by a well-selected pessary, by Thiire Brandt's method of massage, and by electricity. I take this for granted, and do not solicit any discussion on this subject. But, as I stated before, in some cases these methods, although faith- fully and skillfully tried, will fail, and our patient will con- tinue to complain of the same annoying symptoms. Other cases, again, are not amenable to the above - mentioned methods, owing to external circumstances. For instance, a servant girl or working woman who has to support her- self, and whom you can not relieve by means of a pessary in a short time, will often be compelled to refuse a pro- longed treatment by Thiire Brandt's method or by electric- ity, but will gladly subject herself to a surgical operation not accompanied by any danger in order that she may regain her health and the ability to make a living. It is for these reasons that various surgical operations for the cure of retrodisplacements have been devised, and the very number of them is ample proof that not one of them has given full satisfaction. I have therefore thought it pardonable to bring before the profession a procedure which I have adopted for some time in the above-mentioned cases and which has thus far given me excellent results. Of TRANSPERITONE AL HYSTERORRHAPHY. 3 course, it is too early yet to speak about ultimate results. The method will have to be tested as to its permanently curative effect before it can be generally adopted, still I feel justified in inviting its use by others in order that it may be tested on a wider basis and its results be compared with those of other surgical procedures devised for the same purpose. To avoid all possible misunderstanding, I would say just here that the method is only applicable to the freely mova- ble uterus, retroplaced or descended, without accompany- ing disease of the appendages. Retroflexions with fixation or diseased tubes and ovaries do not come within the scope of ray paper and are not taken into consideration. If I am allowed to give a brief review of the different surgical procedures for the cure of movable retrodisplace- ments and prolapsus, I shall have to mention Rabenau's method of excising a wedge-shaped piece from the anterior lip, which has been universally abandoned on account of its inefficiency. Then there is the Adams-Alexander operation of shortening the round ligaments and stitching them to the inguinal canal. The controversy over the propriety of this operation is still open, and, while a great many gynae- cologists have only met with disappointment from its use and have more or less given it up, others still adhere to it firmly and seem to have desirable results. While I have practically given up the operation, I must confess that Dr. Edebohls's modification-consisting in splitting open the entire length of the inguinal canal up to the internal ring, strikes me as a practical one. It certainly renders the act of searching for the ligaments much less tedious. Still I have some serious objections to it: 1. Even if the entire inguinal canal is laid open, the ligament can not be found sometimes because of its atrophied condition. 2. I should be afraid that in some cases in the course of time 4 TRANSPERITONEAL HYSTERORRHAPHY. an inguinal hernia might form in the cicatrix, a condition worse than the original one for which the operation was undertaken. 3. The operation requires in Dr. Edebohls's own hands at least forty-five minutes, and if, as is true in most cases, an additional plastic operation on the perinaeum is required, it involves a rather long ether narcosis. A third way of attempting a surgical cure for retrodis- placements is the one devised by Schuecking, of Pyrmont With regard to this, I think we can not be too loud in its condemnation. From all that I have read, heard, and seen of it, I must, for my part, denounce it most emphatically as an irrational and risky procedure. The sooner it falls into desuetude, the better for the patients. Should it be- come a common practice, T should expect to see many utero- vesico-vaginal fistulae in the future. If we contemplate but for a moment the anatomical relations of the uterus and bladder in the pelvis, it seems almost impossible to thrust a trocar needle through the fundus uteri without risk of in- jury to the bladder. Those who believe in the operation say that this can be avoided by crowding the bladder to one side and allowing the needle to come out more on the opposite side. But if that is the case, then we have at best a latero-position of the strongly antcflexed uterus in- stead of the previously existing retroflexion, but never a normal condition ; and I utterly fail to see what good the operation could do a patient who had a marked degree of prolapsus. With regard to this procedure I feel as Marion Sims did when, in 1859, he had a cannula made for carrying a silver wire to be used in stitching the uterus to the anterior wall. After he had passed the instrument to the fundus he could not muster courage to plunge the weapon on through the tissues, and he did not finish the operation. I therefore consider it a much safer undertaking to open the TRANSPERITONEAL HYSTERORRHAPHY. 5 abdominal cavity so that one can see what one is doing, and to stitch the uterus to the abdominal wall, either by passing a suture through the fundus, or by using the ova- rian ligaments for that purpose (Kelly), or by Gill Wylie's or Dudley's device of doubling up the broad or round liga- ments intraperitoneally. Although many operators feel nowadays justified in opening the peritonaeum for the mere purpose of correcting a malposition of the movable uterus, still I must say that the propriety of this undertaking is an open question. Realizing the serious objections to major operations for a comparatively slight disease, efforts have been made by several to accomplish the same result with- out doing a laparotomy, thus obviating opening the perito- neal cavity and its attending risks. As early as 1882 Caneva, of Italy, tried to fasten a pro- lapsed uterus to the anterior abdominal wall without open- ing the cavity after having cut down to the peritonaeum. If I am not mistaken, Dr. T. G. Thomas has worked in the same direction by passing a knitting needle through the parietes and the uterus, and leaving it until fixation had taken place. Howard Kelly described before the American Gynaecological Society in 1889 his method of fastening the freely movable uterus to the anterior wall without making an incision at all. He said: " After emptying the bladder, cleansing the vagina and abdomen, and shaving the pubes, the patient is brought on her buttocks to the edge of a low table, and her legs straddled over the knees of the operator, who is sitting. The uterus is then brought to anteflexion, and its posterior surface pushed up against the anterior abdominal wall just above the pubes by means of two fingers in the vagina pressing on the anterior face of the uterus. In this way the fingers, acting through the uterus, force the skin and subjacent tissues into a prominent hill- ock just above the symphysis pubis. The operator then 6 TRANSPERITONE AL HYSTERORRHAPHY. takes a stout, well-curved needle, threaded as a carrier, and, with a turn of the wrist, sweeps the needle through skin, subjacent tissues, and uterine body, and out on the other side. It should be directed with a view of passing deeply into the body of the uterus. The silkworm gut or silver wire is then drawn through by the carrier thus introduced and pulled up taut, and shotted close to the abdomen. One or two more sutures are passed in the same way above this, and under each of the shot a silver coin with a slot in it is slipped, which prevents ulceration of the skin from press- ure. The suture should be well watched, kept antiseptic, and the patient kept in bed two weeks, when the sutures are cut and pulled out." But, in the July number of the American Journal of Obstetrics, page 729, Dr. Williams has published the ulti- mate results of this operation, which, as he says, has failed to accomplish its purpose. Dr. Kelly himself states, in a note appended to the same article : " The above attempt to perform hysterorrhaphy without opening the abdomen prom- ised at first to yield very important results. I am there- fore very anxious, after having fully tested the method, to record the results and discourage any further attempts." Of late, Assaky, of Bucharest, has reported several cases before the Beilin Congress in which he employed Caneva's method for prolapse of the uterus with good results. He states, however, that this method is contra-indicated in all retrodisplacements, even if there are no adhesions or dis- eased ovaries. He makes an incision in the median line, of from five to eight centimetres, down to the peritonaeum, and sutures the uterus to the anterior wall with two or three silk ligatures. Before proceeding further and before passing any criti- cism upon the latter methods, let me describe the plan which I have adopted, and which seems to me and a number TRANSPERITONEAL HYSTERORRHAPHY. 7 of gynaecologists with whom I have communicated especially well adapted for the treatment of obstinate cases of mova- ble retrodisplacements which do not yield to the ordinary therapeutic measures. It is, furthermore, a valuable help toward curing prolapsus of the vaginal walls and uterus when accompanied by other surgical operations-viz., am- putation of the hypertrophied cervix and plastic operations upon the vagina and perinaeum. The patient is prepared for the operation with the same care as for laparotomy. The bowels are freely moved, a bath is given, the pubes is shaved, and the entire field of operation, abdominal walls as well as vagina, is rendered thoroughly aseptic. The patient is then placed in Trende- lenburg's posture-namely, with the pelvis elevated at an angle of at least forty-five degrees. A sound is then intro- duced into the uterine cavity, while a tenaculum holds the anterior lip of the cervix, and a catheter is placed in the bla'lder, which has been previously emptied. The assistant who is trusted with said instruments brings the uterus for- ward against the anterior wall, no force being necessary for that purpose, as there are no adhesions. The uterus can now be felt clearly by the operator. Should the ligaments be so long as to allow the uterus when anteverted to take a position too far above the symphysis pubis, it can readily be put in a position closer to the latter by a slight pull on the tenaculum. After having thus selected a suitable place where to ventro-fixate the uterus-say, a little above the symphysis-a very small incision is made in the linea alba, in lean persons not over three quarters of an inch long. In cases in which there is a good deal of adipose tissue an incision of from an inch to an inch and a half may be necessary. After dividing cutis, fascia, muscle, etc., the serosa is exposed, and the finger, then introduced into the wound, 8 TRANSPERITONEAL HYSTERORRHAPHY. will readily recognize the fundus uteri immediately under the serosa, Trendelenburg's posture preventing the intestines from slipping in between. I now tell my assistant to make slight movements with the catheter and the sound alternate- ly, and in this way I can easily make out the bladder and avoid it. I then pass a needle, which I had made especially for this purpose, entirely through the abdominal walls, about a quarter of an inch from the edge of the incision. The needle is Peaslee's, made on the Hagedorn principle, with the exception that the eye is placed somewhat farther back from the point, thus allowing a longer cutting edge on the back. After the needle has entered the abdominal cavity, it can be easily felt between the uterus and the peritonaeum. I then use the cutting edge on the back of the needle to denude about a square inch on the anterior surface of the uterus. The needle is then passed through the body of the uterus, taking up sufficient thickness of tis- sue, and allowed to come out at a place corresponding with the point of entrance. It is then threaded with a strand of silkworm gut and withdrawn, bringing the end of the sut- ure with it. In order to make sure that the ligature has taken hold of the body of the uterus, I give it a slight pull, and the assistant who is holding the sound can immediately tell that I am pulling on the uterus. A second suture is introduced in the same manner. The two strands are now tied, and generally prove sufficient to close up the entire wound. If not, one or two additional superficial sutures are introduced into the abdominal walls. An aseptic button, with two holes, may be suitably included in the ligatures holding the uterus, in order to prevent them from cutting- down too deep into the abdominal walls. The wound is dressed in the usual way. As a rule, the entire operation does not require more than from five to eight minutes. If there is to be a plastic TRANSPERITONEAL HYSTERORRHAPHY. 9 operation for repair of the perinaeum, the patient is placed in the lithotomy position and the further operation pro- ceeded with. The patient is kept in bed from ten to four- teen days. The ligatures are allowed to remain from four to six weeks, when, on removal, the uterus will be found firmly adherent to the anterior wall in a normally ante- flexed position. In the six cases so far operated upon by me I have never seen any rise in the temperature, or any complica- tion following the operation, and no bladder symptoms have ever been observed. Let me now give a very brief history of the cases: Case I.-Miss M., aged twenty-one, normal menstrual his- tory up to a year and a half ago, when, after a severe fall, she commeuced having pains in the back and abdomen previous to and during the menstrual period. Obstinate constipation. Has been under treatment for a year, pessaries and other means being used without any improvement. Condition before opera- tion : Freely movable retroflexed uterus; normal appendages. Operation June 21,1890 : Transperitoneal hysterorrhaphy. Dis- charged cured July 20th, the uterus then being adherent, in good position. The symptoms had disappeared. The patient was seen again November 18th; had been quite sick with ty- phoid fever since the operation. The uterus was not firmly adherent to the anterior abdominal wall, although there was no retroflexion. No constipation. Only slight pain during the last menstrual flow. Case II.-Mrs. F., aged twenty-three, mother of three chil- dren. Former history normal up to the last confinement, when she suffered a laceration of the perinseum. Since then there has been considerable backache and pain in the abdomen pre- ceding and during menstruation ; leucorrhoea, constipation, in- ability to do housework. Present condition, June 23d : Lacera- tion of the perinmum, laceration of the cervix with erosion, movable retroflexion. The patient had worn a pessary before. Was operated upon July 8th ; transperitoneal hysterorrhaphy. 10 TRANSPERITONEAL HYSTERORRHAPHY. Discharged cured July 23d; uterus in normal anteflexion, ad- herent to the abdominal wall. In order to test the procedure, the plastic operation was not done on the perinseum in this case. The patient has been seen several times since; has men- struated normally ; the erosion of the cervix has healed ; all for- mer symptoms have disappeared. In fact, she feels so well that she now refuses to have any operation done on the perinseum. Case III.-Miss W., aged twenty-nine. Menstruation began at the age of sixteen; was always preceded and accompanied by a good deal of pain in the back and abdomen. Her condi- tion has become worse during the last eighteen months, al- though under constant treatment with pessaries, massage, and electricity. Marked anaemia, headache, great nervousness. Present state (September): Movable uterus, retroflexed to such a degree that the fundus could be felt lower than the cervix. Appendages normal. Transperitoneal hysterorrhaphy per- formed September 25th. Mechanical result: The uterus nor- mally anteflexed, adherent to the abdominal walls. The local symptoms have disappeared ; the general condition of the pa- tient somewhat improved. Case IV.-Mrs. S. T., aged twenty-five, marrie'd four years, had one child three years ago. Menstruation normal after con- finement. Later she has had all the symptoms of laceration, with pain in the back and abdomen before and during menstru- ation, and difficult defecation. Present state (before opera- tion): Complete laceration of the perinaaum; retroflexed, movable uterus, pressing on the rectum. Appendages normal. Opera- tion October 18th: Transperitoneal hysterorrhaphy; Tait's peri- neorrhaphy. Uninterrupted recovery. The patient menstru- ated on November 5th without any pain or difficulty. Dis- charged November 9th. Perinaaum well healed; sutures holding the uterus well still in position. Case V.-Mrs. B., aged thirty-eight, married ten years, mother of four children; has had prolapsus for the last eight years, which has become worse since last childbirth. Back- ache, dragging-down pains in the abdomen, inability to do house- work. Present state (when operated upon): Large cystoceleand rectocele; cervix at the vaginal entrance. Operation, October TRANSPERITONEAL HYSTERORRHAPHY. 11 1st: Transperitoneal hysterorrhaphy. Uninterrupted recovery. October 14th, the uterus was found firmly adherent to the an- terior wall; the cystocele had disappeared, an anterior colpo- perineorrhaphy being, therefore, unnecessary. A plastic op- eration (Hegar's) was done on the posterior vaginal wall and perinseum. Patient discharged November 12th ; uterus firmly adherent to abdominal walls; perinaeum fully two inches and a half long ; all former symptoms had disappeared. Case VI.-Mrs. H., three children, laceration of perinaeum since last childbirth. Was operated upon in a hospital in Bos- ton ; not benefited. Still complains of backache, pelvic pain dur- ing and before the period; unable to do her work. Present state (before operation): Laceration of the perinaeum; cicatrix from the former operation; uterus prolapsed and retroverted, movable; appendages normal. Operation, Novemberl8th: Trans- peritoneal hysterorrhaphy and Hegar's colpo-perineorrhaphy. Uninterrupted recovery. Uterus adherent to abdominal wall. While the first case can not be taken as a fair test of the operation, owing to the intercurrent illness, the patient having acquired typhoid fever, yet the operation has ac- complished in the other cases all that could be expected of it. While I am fully aware that it is too early yet to pro- claim them as permanently cured, still I have great confi- dence that no recurrence will take place. I certainly have benefited my patients greatly while all other methods pre- viously employed had completely failed. It is clear to my mind why Howard Kelly has failed to effect a cure in his cases. Passing a suture through the ab- dominal wall without opening the cavity does not set up a sufficient amount of adhesive peritonitis to insure ventral fixation. The same objection applies to Caneva's and As- saky's method as well, although theirs is preferable to Kel- ly's, because it certainly offers less risk of injury to the in- testines. In order to insure ventral fixation I consider it indispensable to denude a portion of the anterior surface of 12 TRANSPERITONEAL HYSTERORRHAPHY. the uterus, which can be readily accomplished in the way already described. I might be asked why not, after cutting through the ab- dominal walls, open the peritonaeum ? My answer is that, even in the hands of the expert operator, there is still a mortality of from one to three per cent, in uncomplicated cases of laparotomy. I think I can avoid just that small percentage. As this operation can be done in a much shorter time than the Alexander-Adams operation, and certainly does not involve more risk to the patient, I should prefer it even if the results were only equally good. Certain objections might be offered which apply to all hysterorrhaphies, especially the one that, should the patient become pregnant, it might interfere with carrying the child to term. This objection, however, does not hold, as has been shown in cases of repeated Caesarean section in which there certainly must have been a large amount of anterior adhesion. It might also be supposed that, since the uterus is a pel- vic organ, it should not be fixed in the abdominal cavity. My answer is that, even granting this, yet the uterus cer- tainly has no business outside of the vagina, or away behind, pressing on the rectum. Moreover, it does not matter to the patient whether it is a pelvic or an abdominal organ so long as it does not trouble her. In closing, I should like to say that I do not want the operation to be considered a panacea which should be em- ployed in every case of movable retroflexion and prolapsus, but only in well-selected cases where the ordinary measures have been tried and failed, or where for extraneous reasons they are not applicable. 13 East Forty-first Street. REASONS WHY Physicians Should ; aBwft Subscribe *0R The New York Medical Journal, Edited by FRANK P. FOSTER, M. D.,i Published, by D. APPLETON & CO,, 1, 3, & 5 Bond St. I. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE: It is the exponent of the most advanced scientific medical thought. 3. 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