Gynaecology

From Primary Surgery

20 Gynaecology 20.1 Some of the simpler operations As with the rest ofsurgery, the highest incidence ofgynaecological disease, and the worst cases are to be found where there are fewest gynaecologists. Inasurvey oftwoIndianvillages55%ofwomen had gynaecological complaints, 92% had one or more gynaecological or sexual diseases and the average number ofthese diseases per woman was 3.6. Only 8% of them had had any gynaecological treatment. This is some indication of how little attention is given to the reproductive health of non-pregnant women, most of whom only encounter the health care system when they are the target of family planning programs. So there is much gynaecology to do! You can evacuate an incomplete abortion (16.2), drain and marsupialize a Bartholin's abscess (20.4), drain a pelvic abscess (6.5), and tie a patient's tubes (15.3). You may have to do an emergency hysterectomy; but you should, if possible, try to refer a 'cold' one. The standard repertoire ofan expert gynaecologist includes an anterior and a posterior colporrhaphy, a Manchester repair, and a vaginal hysterectomy. These are difficult, particularly the latter two, so we have included Le Fort's operation and ventrisuspension. Bang RA et al., 'High prevalence of gynaecological disease in rural indian women'. Lancet 1989;1:85-87. 20.2 Abnormal and 'dysfunctional' uterine bleeding ('DUB') 'Abnormal uterine bleeding' includes any bleeding which is abnormal in its degree and timing. 'Dysfunctional uterine bleeding', or 'DUB', is abnormal bleeding which has no obvious pathology. In the developing world, abnormal uterine bleeding usually has some obvious pathology. The list of its possible causes is a long one and is given below. Only diagnose DUB after you have excluded obvious pathology. DUB occurs most commonly at the extremes of reproductive life: (1) In young girls for their' first few cycles, before these settle into a normal pattern. (2) In older women, nearing the menopause, before complete amenorrhoea sets in. DUB should be an uncommon diagnosis in the prime oflife; ifyou make it often, you are probably misdiagnosing abortions or chronic ectopics. In the developing world it seems to be rare, even in older women, perhaps because patients here are more tolerant of minor menstrual irregularities. This is in sharp contrast to the industrial world, where DUB is one of the commonest gynaecological diagnoses. The commonest cause ofDUB is the failure to ovulate. Because ovulation does not occur in the middle of a cycle as it should, the corpus luteum does not develop and produce progesterone normally. The endometrium grows abnormally thick under the influence ofunopposed oestrogen, and eventually begins to shed unevenly. Courses ofprogestogen stop bleeding temporarily, and when these are stopped normal periods usually follow. The important diseases not to miss are carcinoma of the cervix (very common), and, usually after the menopause, carcinoma of the endometrium (rare in the developing world). The investigation of abnormal bleeding often requires a 'D and C', but you may not have time to do very many of these, so you will probably have to limit yourself to priorities. These are intermenstrual bleeding, and especially postcoital bleeding, which does not have some more obvious cause. Heavy regular periods are a common complaint, and are usually benign. Ovular cycle ABNORMAL UTERINE BLEEDING HISTORY. A careful history and examination will nearly always reveal some obvious cause. "When did the bleeding start? Last year? At Easter? At the beginning of the cold season? For how many days do you bleed and when?" Ask about the last episode. "Are you bleeding now?" "Were you bleeding last week? Last month?" Describe the bleeding pattern by giving approximate dates and amounts. Make sure the patient distinguishes blood escaping vaginally, from blood in her urine. CAUTION ! (1) Avoid statements like 'Has periods x2 a month', 'polymenorrhoea', 'menorrhagia', etc. (2) Ask about postcoital bleeding. (3) Bleeding patterns are imperfectly matched to diagnoses, so don't always expect her history to give you the answer. EXAMINATION, Is she anaemic? Examine her abdomen. Examine her cervix with a speculum. Do a Pap smear (M 29.1). DIAGNOSIS AND TREATMENT. The treatment of most conditions is described elsewhere. Diagnose 'DUB' by exclusion, and remember that a '0 and C' is not automatic treatment for all forms of uterine bleeding. Pregnancy-related. Abortion in all its forms (16.2), ectopic pregnancy (16.7). Contraception-related. 'Depo provera' or a loop (M 3.10). Hormone treatment elsewhere at a health centre or by a private doctor. Pathology in the genital tract. Fibroids (20.6), cervical polyp (20-5), chronic pelvic infection (6.6), vaginitis (trichomonas, atrophic menopausal or foreign body), cervical erosion, cervicitis, ovarian cysts and tumours (20.7), carcinoma of the cervix (common, 32.35), endometrial carcinoma (rare, 32.25), choriocarcinoma (uncommon, 32.38). If she is less than 20, and you have excluded the above pathology, she probably has DUB. Avoid treating her if you can. If treatment seems to be necessary, try cyclical progestogens (see below) first. If they fail and bleeding is severe or persistent, curette her. If she is between 20 and 40, she can have most of the pathology listed above. Don't miss carcinoma of the cervix. If she has intermenstrnal orpostcoital bleeding, be sure to take a wedge or punch biopsy of any hard, friable, or ulcerated area on her cervix. A '0 and C' will not diagnose carcinoma of the cervix (32.35); you can almost always diagnose this by looking at her cervix with a speculum. See also Section 32.35. If she is over 40, and especially if she has postmenopausal bleeding (bleeding 1 year or more after the menopause), always do a '0 and C' to exclude carcinoma of the endometrium. Other causes include fibroids, especially prolapsed submucosal fibroids (20-4), and senile vaginitis. If she has a heavy loss and no obvious cause, and emergency treatment is necessary, see below. CYCLICAL PROGESTOGENS TO STOP ACUTE BLEEDING NOW, give her norethistrone 5 mg 3 times daily for 5-10 days. Or, give her one 'combined' contraceptive pill twice daily for 10 days. Bleeding will probably stop while she takes these pills. She will get a withdrawal bleed (normal, scanty, or heavy) 2-3 days after stopping them, but this should not last more than a week, after which normal periods should restart. Explain this to her. See her again in a month, to see if treatment has worked, and she has stopped bleeding. If she has not stopped bleeding: (1) your diagnosis was wrong. Or, (2) she did not take her tablets regularly. Or, (3) her DUB is unsuited to hormonal treatment. So do a '0 and Cl. FOR RECURRENT DUB treat her as for an acute episode, then put her on the 'combined pill', as for contraception without a '0 and C'. CAUTION! 'DUB' is only a diagnosis of exclusion, and in many settings an immediate '0 and C' is simpler. 20.3 'D and C'—dilatation and curettage There are two superficially similar operations: (1) The evacuation of an incomplete, or septic abortion, which does not usually require that the cervix be dilated, and which is descibed in Section 16.2. And, (2) dilatation and curettage of the uterus, which is described here. Although both operations have similar complications, they have different indications. A 'D and C' is a complement to a carefully taken history and examination, and is not a substitute for them. It is also one of the commonest operations in gynaecology, and one of the the most abused ones, so make sure that you only do it on the proper indications, which are: (1) To diagnose the cause of abnormal bleeding, unless you have already found the cause in a patient's lower genital tract. (2) To exclude carcinoma ofthe endometrium and tuberculous endometritis. (3) To make sure that a patient is ovulating, when you are investigating her for infertility. (4) To treat DUB (dysfunctional uterine bleeding), when A 'D and C' can occasionally be life-saving. ' Ideally, all curettings should be sent for histology. Unfortunately, this is unlikely to be possible, so you will probably have to send only the most urgent ones. If a patient is less than 40, sending her curettings for histology is less urgent, unless they look abnormal macroscopically (profuse, thick, 'cheesy', or infected), or you suspect choriocarcinoma. Although a 'D and C' is usually simple, the long list of difficulties described below show that it can be dangerous, and even fatal. The main risks are: (1) Perforating the uterus, perhaps followed by haemorrhage or sepsis. (2) Injuring a nulliparous cervix. Most of. the complications we list are very rare. . DILATATION AND CURETIAGE — 'D and C' INDICATIONS. Use dilatation followed by curettage: (1) To investigate abnormal bleeding. It may reveal: carcinoma of endometrium, endocervical adenocarcinoma (but not squamous 316 DILATATION A AND CURETTAGE If you are not careful you can perforate her uterus Passing the sound c keep your index finger along the stem of a sound, dilator, or cusette, and you will be less likely to perforate the uterus Fig. 20-1 DILATATION AND CURETIAGE. A, the main danger is perforating the uterus. B, passing a sound. C, inserting Hegar's dilator. Perforation of the uterus is less likely if you use your finger as a guide and steadier like this. After 'Bonney's Gynaecological Surgery: Bailliere Tindall, with kind permission. carcinoma of the cervix, see below), choriocarcinoma, 'chronic endometritis', tuberculous endometritis, chronic anovulation, or submucous fibroids. (2) To treat post-menopausal cervical occlusion causing pyometra, and to exclude carcinoma as its cause. Use dilatation only, without curettage: (1) To correct cervical stenosis after amputation, or conization (32.35). (2) To permit the insertion of an IUD. If you are doing and '0 and C' for infertility, its purpose is to decide whether there is histological evidence of ovulation, and to exclude tuberculous endometritis. So always do it in the premenstrual phase. Send the curettings for histology, and make sure you tell the pathologist that this is what you want to know, or he may merely report them as 'normal'. He will usually make the diagnosis of tuberculosis histologically, but consider sending a separate specimen in a sterile bottle, for culture for tuberculosis, if you think that this is the cause, and are working in an area of high incidence. If your pathological services are under pressure, you won't be able to do this very often. CAUTION! (1) Don't do a '0 and C' to treat primary dysmenorrhoea, even if other methods have failed. Persevere with analgesics. If necessary give her a 50µg oestrogen combined pill to suppress ovulation. (2) A '0 and C' will not diagnose squamous carcinoma of the cervix, for which she needs a cone or wedge biopsy (32.35). Don't do a '0 and C' if you suspect she has a tubo-ovarian abscess, which you should be able to diagnose clinically. Infection will have fixed her uterus; moving it with dilators may tear it, spread the pus, and cause a fatal peritonitis. USING A MENSTRUAL REGULATION SYRINGE If you only want to do a biopsy, consider using a menstrual regulation syringe (M 3.19), which is ideal for assessing whether she is ovulating or not, and for the diagnosis of tuberculous endometritis. You can do it as an outpatient using only a paracervical block (A 6.14). STANDARD METHOD FOR DOING A '0 AND C' You can do this as an outpatient. Ask her to empty her bladder. There is no need to catheterize her. ANAESTHESIA. (1) General anaesthesia. (2) An anaesthetic 'cocktail' (A 8.8). (3) A paracervical block (A 6.14). EQUIPMENT. A catheter, Sims' and Auvard's vaginal specula, a uterine sound, 2 vulsella, a pair of narrow ovum forceps, sharp curettes of different sizes, and a set of Hegar's uterine dilators. Arrange these in order of size on the trolley. EXAM INATION. If necessary, empty her bladder. Swab her vulva and vagina. When you dilate her cervix, you will need a mental picture of the shape, length and direction of her uterine cavity. Get this picture by: (1) Examining her bimanually, to feel the size, position, and mobility of her uterus (feel also for disease in her adnexae). Note particularly if her uterus is retroverted, because this increases the chance of perforating it with a misdirected dilator. (2) Measure the depth of her uterus with a sound, except when you suspect an abortion. 01 LATATION. Start by making sure that her buttocks are well over the edge of the table. Grasp the anterior lip of her cervix with one, or even two vulsella, and pull it well down. This will bring a sharply anteverted or retroverted uterus towards the axial position, and reduce the risk of perforation. If it is soft, as after labour or an abortion, use sponge forceps. With the picture of her uterine cavity in your mind, dilate her cervix, starting with the smallest dilator. As you do so, place a finger beside it to act as a 'brake', if you enter her cervix suddenly. Insert the dilator in the direction which minimizes the resistance to it as far as possible. When it has been in place for at least half a minute, insert the next size without delay, and without waiting for her cervix to contract again. Dilate a large uterus more than a small one. If your purpose is only to do a biopsy, use a fine curette, and don't dilate beyond Hegar size 8-larger sizes may tear her cervix. CAUTION! (1) Be gentle. (2) Dilate slowly, leave each dilator in place for at least half a minute. (3) Don't twist the dilators. (4) Be particularly careful not to perforate her uterus, if you suspect a missed or incomplete abortion, or carcinoma of her endometrium. All these make it soft, friable and easily perforated. (5) If you suspect a carcinoma, make sure you dilate her cervix enough to let you explore her uterus adequately. (6) Don't allow a dilator or a probe to become trapped in a false passage. (7) Never use a douche. CURETTAGE. Do a complete or a partial curettage on these indications. If all you want is some endometrium to find out if she is ovulating, do a partial curettage. Explore her uterus with long, careful strokes, so that you get long thin strips of endometrium for histology. If you are curetting for an incomplete abortion, or for the diagnosis of intermenstrual bleeding, or other forms of abnormal bleeding, and are anxious not to miss carcinoma of the corpus, do a full curettage. Start scraping at her fundus, and scrape towards you all round the anterior, posterior, and lateral surfaces of her uterine cavity. Continue until there is a scratching feeling. EARLY DIFFICULTIES DURING A '0 AND C' See also Sections 16.2 and 6.6a. If you CANNOT PASS A SOUND or small dilator, her uterus is probably acutely flexed, either forwards or backwards. Feel it carefulIy. If her uterus is anteverted (flexed forwards), pass the sound under direct vision though her external os, remove the speculum, and depress the handle of the sound posteriorly on to her perineum. When it is in the axis of her uterine canal it will probably pass. If her uterus is retoverted (flexed backwards), it may be held in place by adhesions. If a bim-anual examination shows that it is fixed, consider abandoning the operation. But, if she must have a '0 and C', put the volsellum on the posterior lip of her cervix and pull it well down; pass the dilators with their points backwards. If you tear the adhesions that are holding her uterus, she may bleed into her pouch of Douglas, or into her peritoneum. You may then have to open her abdomen (rare), and secure the bleeding vessels. If her CERVIX IS SO RIGI D that the larger dilators will not pass without the risk of tearing it, leave one dilator in place for several minutes, before introducing the next one. If a dilator is tightfy gripped as you remove it, reinsert it and leave it in a little longer before inserting the next largest size. Nulliparous and senile cervices are often stiff. Don't use excessive force. You can usually do an adequate curettage with a small, sharp curette, when her cervical canal is only dilated to Hegar 6 (20 Ch). If LARGER DILATORS DO NOT GO IN as faras smaller ones, you are inserting successive dilators a progressively shorter distance into her uterus. If you fail to realize what you are doing, you may only curette her cervical canal, and not the body of her uterus. Return to the smaller dilators, and start again. If you find that INSERTING LARGER DILATORS IS UNNATURALLY EASY, stop! You have probably lacerated her cervix, and increased the risk of bleeding and sepsis. The tear may run into her vaginal vault from her external os, or it may start near her internal os, so that the tips of succeeding dilators catch in it, and ultimately enter her broad ligament. If a DILATOR SUDDENLY SLIPS IN much further than the one before (not uncommon), you have probably perforated her uterus into her peritoneal cavity, or into her broad ligament on either side, or into her bladder. Even experts occasionally do this, especially if a patient is pregnant, postpartum, or postabortion, or if her uterus has been softened by an endometrial carcinoma: (1) Abandon the operation, and don't try to confirm the diagnosis by probing her uterus. (2) Don't irrigate her uterus. What you do now depends on whether she is a clean case, or a septic one. If she is a 'clean case', take her pulse, blood pressure, and temperature half-hourly. She will probably recover. If her pulse rises and her blood pressure falls, and there are signs of fresh blood in her peritoneal cavity (rare), restore her blood volume and do a laparotomy. If she is potentially 'septic' as after an abortion, give her antibiotics, and observe her as above. If you perforate her uterus and a LOOP OF GUT APPEARS AT HER VAGINA (rare), don't: (1) be tempted to resect it and anastomose it at her vagina, or (2) to push it back through the tear and plug her uterus with gauze. Instead, open her abdomen and draw the prolapsed gut back. Clean it, resect it, if it is damaged, and inspect the rest of her gut. Ifyou SPLIT THETIGHTVAGINA of a postmenopausal patient with a speculum, suture it if it bleeds. If the LACERATION which is causing the bleeding runs up from her external os (rare), you may be able to seize the bleeder with a haemostat and secure it with a mattress suture. LATER DIFFICULTIES WITH A '0 AND C' If, as she recovers from the anaesthetic, her PULSE RATE IS FASTER than it should be after a simple dilatation, she complains of pain (which she should never do), she is pale, cold, and restless, and has some lower abdominal rigidity: (1) She has probably bled into her peritoneal cavity after a perforation. (2) You may have missed an ectopic pregnancy and ruptured it with your 'D and C'. Immediately explore her pelvis through an abdominal incision. Find and suture the perforation. If it is extensive, and sutures will not control the bleeding (rare), tie her internal iliac arteries. If this fails, remove her uterus. Leave her vagina open to allow free drainage. If she develops symptoms of low abdominal PAIN AND FEVER, suspect salpingitis, and treat it as usual. This is an unusual complication of a 'D and C'. If, postoperatively, she has PAIN on one side, and a swelling develops in her broad ligament, a haematoma has formed. Occasionally, 'it may be so severe as to raise the peritoneum of the side wall of her pelvis, and extend even to her loin. If so, she will have the signs of a mass and of hypovolaemia. You may need to open her abdomen and secure the bleeding vessel. If she develops symptoms of PERITONITIS (lower abdominal tenderness, and rigidity), her prognosis is worse if they appear early, and you cannot feel a pelvic mass, which shows that the infection is localizing. The difficult decision to make is whether you should explore her abdomen or not. If her symptoms are not severe or worsening, give her antibiotics (2.7), wait and watch her closely. Her peritonitis or pelvic cellulitis may only be local, and symptoms may subside. If her symptoms are severe or worsening, or generalized, or you have inadvisedly given her an irritant douche, open her abdomen, repair the tear, and mop out her pelvis. If her peritonitis is generalized, wash out her peritoneal cavity and instil tetracycline (6.2). Don't remove her uterus. Make quite sure that her gut has not also been injured. 20.4 Bartholin's cyst and abscess If a cyst develops in one of Bartholin's glands, don't try to excise it completely; marsupialize it instead, which means bringing its wall to the surface as a pouch, which will slowly heal. This is easier than trying to excise it, which is more difficult for routine use under the conditions in which we work. Also marsupialize an abscess; this is less easy, because its wall is soft and poorly defined. If necessary, merely incise it and marsupialize it later when it is not infected. BARTHOLIN'S CYST AND ABSCESS Marsupialization can sometimes be an outpatient operation. ANAESTH ESIA. Give the patient a general anaesthetic, or use ketamine, or subarachnoid or epidural anaesthesia. MARSUPIALIZING A CYST. Ask your assistant to immobilize the cyst with sponges on forceps. Make a longitudinal incision, with extensions at either end, in the margin between her vulval mucosa and her skin, on the inside of her labium minus. Let the fluid escape. Apply Allis' forceps on the edges of her labium minus, and retract them laterally. If necessary, push the cyst forwards by putting a finger behind it. Use interrupted catgut sutures to tie the edges of the cyst wall to her skin, and to stop bleeding. MARSUPIALIZING A BARTHOLIN'S CYST c Fig. 20-2 MARSUPIALIZING A BARTHOLIN'S CYST. A, the cyst. B, the incision with its extensions. C, opening out the cyst. D, the first sutures. E, sutures almost complete. PROLAPSE OF THE URETHRA pulling the suture through prolapsed _urethra excised suturing the urethra c to the mucosa of the introitus Fig. 20-3 PROLAPSE OF THE URETHRA. A, passing a suture through the prolapsed urethra. B, cutting the suture so as to make two separate sutures at either side. C, inserting further sutures as needed. After 'Bonney's Gynaecological Surgery: Figs. 92 to 94, Bailliere Tindall, with kind permission. MARSUPIALIZING AN ABSCESS is a painful minor emergen cy, which is easier before the abscess ruptures, so operate soon. Excise an ellipse of skin over the abscess, to include the duct, and suture the cyst wall to her skin. Give her antibiotics (ampicillin or tetracycline), advise several salt baths daily, and give her an analgesic. CAUTION! Don't try to excise a cyst unless it has recurred after marsupialization. If so, admit her; excision is often com plicated by heavy bleeding and haematoma formation. 20.5 Prolapse of the urethra In some tropical communities prolapse of the mucosa of the urethra is common in young girls between the age 6 months and 8 years. It usually causes no symptoms, but a child may have slight dysuria, or her mother may notice blood on her clothes. While most of her urethra remains in its normal place, its mucosa is gradually extruded at the external orifice to form a deep red or bluish tubular mass, which swells and becomes oedematous, and occasionally even gangrenous. You cannot replace her prolapsed urethral mucosa, so you have to excise it. Be careful to distinguish it from a schistosomal granuloma, or a venereal wart. PROLAPSE OF THE URETHRA is not as easy to treat as it looks, so refer the patient if you can. Under ketamine, use a small sound to find her meatus in the prolapsed mass of tissue. Pass a catheter, withdraw it, and then replace this by fine artery forceps. Open the points slightly to distend her urethra. With the forceps as a guide, transfix it from side to side and then from front to back with strands of 3/0 catgut. Use a knife or scissors, or, better, diathermy, to cut off the mucosa distal to the point at which the sutures cross the lumen. Pull the strands of catgut down as two loops, cut them, and then tie each of the four pieces, so as to join the edge of her urethral muco,sa to her skin. What little bleeding there is is usually controlled by the sutures. Insert a Foley catheter for at least 24 hours. As soon as her bladder function is normal, she can go home. Warn her that her vulva will be sore for at least a week. 20.6 Fibroids Fibroids are uncommon in young women, but common in older ones. In the developing world a patient with fibroids usually presents with: (1) Infertility or subfertility. (2) Recurrent abortion. (3) Abnormal bleeding. (4) An abdominal swelling. (5) Lower abdominal pain. The severity of her symptoms depends less on the size of her fibroids, than where they are; a small submucous fibroid can cause severe bleeding, whereas a huge interstitial one may hardly be noticed. She commonly has PID also, and the pain it causes may be her presenting symptom. Several operations are possible: (1) Hysterectomy, which should ideally be total, so that her cervix is removed, and with it any risk of cervical carcinoma. (2) Myomectomy, which is usually abdominal, but which can be vaginal. Surgery can be difficult because of associated subacute or chronic PID, her wish not to have a hysterectomy and to continue menstruating, and the technical difficulties of doing a myomectomy. There is one particular presentation that you should be aware of: A pedunculated submucous fibroid may prolapse and present as a mass in her vagina, or less commonly at her vulva, as in Fig. 20-4. She may also complain of bleeding, and present as if she had an abortion, with a lump hanging in her vagina. Her cervix dilates to allow it to pass, and remains partly dilated around it. The mass may be large, necrotic, infected, and smelly. Bleeding may have made her very anaemic. The risk in merely tying the pedicle and cutting it off, is that her peritoneal cavity may have come down with it, so that you may open this by mistake. She is also at risk from from infection and bleeding. FIBROIDS TH E 01 FFERENTIAL DIAGNOSIS is that of a pelvic mass: (1) Pregnancy. (2) A full bladder. (3) An ovarian cyst (20.7). (4) A chronic ectopic pregnancy (16.7). (5) PlO with an inflammatory mass (6.6). CAUTION! (1) A centrally placed fundal fibroid may feel like a pregnant uterus, but is much harder. (2) Pregnancy can occur in a fibroid uterus. INDICATIONS FOR SURGERY. The rate at which a fibroid grows varies greatly. If it causes no symptoms, consider leaving it unless it is the size of a 12-week pregnancy or larger. At this size it will probably cause symptoms, so if she has completed her family, suggest hysterectomy. The indications for removing a fibroid depend more on symptoms (bleeding, anaemia, and premenstrual pain), than on its size. If it is causing symptoms, you may have to remove it when it is quite small. Other reasons for removal include torsion and prolapse. Many patients don't need surgery. If the patient's uterus and the mass seem fixed and tender, and especially if she has fever, she is more likely to have PlO, with or without fibroids. Treat her medically at first. Admit her, give her an antibiotic, and reassess her in 3 or 4 weeks. If her temperature does not settle after a reasonable time, and her uterus remains tender, examine her under anaesthesia. She may have: (1) A tubo-ovarian abscess which fluctuates and needs draining. If so, leave her fibroids until later. (2) Mobile degenerating fibroids that you can operate on. 'Red degeneration' can occur in a fibroid during pregnancy, and can cause pain and a tender mass, but not the degree of fever that is common with PlO or a tubo-ovarian abscess. If she is younger and wants children, consider doing a myomectomy or referring her for it.Make sure she understands that: (1) If it is found to be impracticable, she may have to have a hysterectomy, or to have her abdomen closed after nothing has been done. (2) She may grow more fibroids later, especially if she does not conceive. If she is older and does not want children, consider doing a total hysterectomy (20.12). MYOMECTOMY INDICATIONS. A patient with fibroids who wants children. Myomectomy is hazardous, and has more complications than hysterectomy. Most patients are better with a hysterectomy, or with no surgery at all. If you are inexperienced, don't attempt it unless she has: (1) A si.ngle fibroid <10 cm in diameter. Or, FIBROIDS A Fig. 20-4 FmROIDS. A, the surgical pathology offibroids. B, a submucous fibroid polyp has brought the fundus ofthe uterus down with it. C, the correct site for incision. First, incise the fibroid longitudinally ('Y') to find the level of its capsule. You can then cut and transfix or twist off the pedicle transverselyjust above this ('X'), with no danger ofentering her peritoneal cavity. Don't incise at level 'Z'! Fibroids can be: 1, intramural. 2, subserous, distorting the tube. 3, submucous. 4, subserous and pedunculated. They can also project into the uterine cavity (5), through the cervix (6), or into the parametrium (7). (2) a fibroid which is subserous (pedunculated into her peritoneal cavity), or submucous (pedunculated into her uterine cavity, and usually coming through her cervix into her vagina). CONTRAINDICATIONS. (1) Multiple fibroids (>3) (2) Active sepsis. (2) Dense adhesions of both tubes which make pregnancy impossible. (3) If she has a large posterior fibroid in her pouch of Douglas, leave it unless you are an expert. Removing this without damaging her bladder or ureters is difficult, and can be bloody. If you are inexperienced, refer her. If you cannot refer her proceed as follows. MYOMECTOMY FOR INTRAMURAL FIBROIDS. Bleeding is the great danger. Cross-match 2 units of blood, with due consideration for HIV. Use tourniquets to prevent bleeding. Make small openings at the base of her broad ligaments. Take three rubber catheters. Pass one round her cervix and the other two round each of her ovarian pedicles. Pull them tight and hold them with clamps to occlude the vessels temporarily. Alternatively, pass a catheter round her cervix and clamp her ovarian vessels with rubber covered bowel clamps. Special vascular clamps are better if you have them. If her anatomy makes applying catheters or clamps difficult, consider abandoning the operation. Make an incision over the fibroid which exceeds its diameter by 2 or 3 cm. The correct plane to remove it in may not be easy to find. Cut into the fibroid and you should see it. Shell it out. If necessary, remove some of the wall of her uterus to reduce the size of the dead space. Repair her uterus with at least 2 rows of mattress sutures of '1' or '2' chromic catgut. Fig. 20-5 THREE WAYS OF REMOVING MUCOSAL POLYPI. A, by twisting. B, by ligation. C, by section. These mucosal polypi are much more common and are more easily removed than fibroid polyps. Don't try to remove pedunculated fibroids this way. Kindly contributed byJack Lange. Remove the catheters. If her uterine incisions bleed, insert more mattress sutures. If bleeding continues, decide whether to do a hysterectomy, or to tie her internal iliac arteries. Close her abdomen in layers without drainage. Make sure she knows what you have removed, and understands that she must always be delivered in hospital in future. MYOMECTOMY FOR A SUBMUCOUS FIBROID POLYP She may have only a single vaginal fibroid. If she has others, they can be removed later by myomectomy or hysterectomy. Bleeding is usually mild, but however you remove a fibroid, it can occasionally bleed so severely that you have to tie her internal iliac arteries (3.5), or to do a hysterectomy (2.12). If necessary, give her an antibiotic and a blood transfusion. If the pedicle of the polyp is thick and is attached well within the cavity of her uterus, be careful. Incise it longitudinally to find the level of the capsule of the fibroid first, as in Fig. 20-4. You can then cut and tie the pedicle just above this, with no danger of entering her abdomen. Transfix the pedicle as far distally as you can, and divide it distal to the ligature, so that you minimize the risk of opening her peritoneal cavity. If you don't remove it completely, it will recur. If she has a large submucous polyp presenting at her cervix, but not protruding through it, treatment is difficult. It is sure to be partly necrotic, so that a hysterectomy carries the risk of sepsis. You can: (1) Define it as well as you can with your fingers first and then twist it off vaginally (risky). If she continues to bleed (unusual) see above. (2) Improve her general condition, transfuse her, give her antibiotics, and then do a hysterectomy. CAUTION! Don't try to twist off a fibroid polyp, it is usually impossible. The only kind of cervical polyp to twist off is a mucosal one, as in Fig. 20-5. DIFFICULTIES WITH FIBROIDS If her FIBROID IS PAINFUL, either spontaneously or on palpation, with perhaps a low fever, this is due to aseptic necrosis (red degeneration), or associated torsion of a pedunculated fibroid. If you discover a SMALL SUBMUCOUS FIBROID when you are doing a 'D and C' for abnormal vaginal bleeding, you may be able to remove it with the curette. If she has a MUCOSAL POLYP, it may come from her cervix or endometrium and cause menorrhagia, or intermenstrual bleeding, or both. If it comes through her cervix, you can see it with a speculum and twist it off, as in Fig. 20-5. You will only see an endometrial polyp when you do a '0 and C'. If she is PREGNANT, don't remove a fibroid, unless it it is pedunculated and very easy to remove. See Section 18.7. REMOVING CERVICAL B POLYPI 20.7 Ovarian cysts and tumours Many ovarian tumours are cystic, but some cysts are not tumours and some tumours are not cysts. Their classification is complex, so here is a simplified scheme. First the cysts you may meet. Benign:

(1) Functional cysts of the follicles and corpus luteum. (2) Benign serous or mucinous cystadenomas. (3) Dermoid cysts (teratomas or hamartomas). (4) Unclassified benign cysts (simple cysts). Malignant: (1) Malignant serous or mucinous cystadenocarcinomas.

(2) Metastatic carcinomas (from the gut, or breast) (3) Burkitt's lymphoma. (4) Other rarer tumours. 'Pseudocysts' are postinflammatory collections of fluid between adhesions in the pelvis (6.6), and are not true ovarian cysts; but the distinction is not always easy, even at operation.

An ovarian cyst can be of any size, from a pingpong ball to larger than a full-term pregnancy, and may: (1) Present as a mass, or as abdominal distension, which may be massive. If so, the patient may be in poor health, or she may be fairly well. (2) Be found accidentally during a pelvic examination done for some other purpose, such as family planning. (3) Cause abdominal pain due to torsion (see below). Ask your clinic staff to refer any patient with an ovarian cyst larger than a small orange. If it is not too large, removing it should not be too difficult, provided it has not stuck to surrounding structures. Don't try to biopsy it; instead, remove it entirely, and send a sample for section. Large cysts are more likely to be malignant than small ones. But huge cysts (larger than a full term pregnancy) are usually benign, or only of low-grade malignancy. They are more common in places where there are few doctors removing small ones, which is why they are relatively common in the developing world. Solid ovarian tumours are more likely to be malignant, and to have spread by the time you see them. Most large cysts are mucinous or serous cystadenomas; some are cystadenocarcinomas. Try to remove a cyst without spilling the fluid, because if you do, you may spread a malignant tumour and harm the patient greatly. If a tumour has not spread through the wall of a cyst, its removal intact without spilling will usually cure her. Aspirating a cyst before you try to remove it: (1) Makes it easier to remove. (2) Requires a smaller incision lower in the abdomen. (3) May make dissection of adhesions easier. (4) Is likely to cause some spillage. Not aspirating a cyst either causes no spillage, or, if it bursts or you cut into it, a much worse spillage than if you had aspirated it first. Should you aspirate or not? Opinions vary; much depends on how skilled you are. As you will see below, we advise you not to aspirate, if you can avoid it. Even large cysts are not too difficult to remove intact-if you make an incision which is large enough (see below). Most ovarian cysts have few adhesions. If adhesions are dense you may be dealing with: (1) Old PID. (2) A malignant cyst in which the growth is already spreading into the peritoneum. (3) Previous peritonitis that has left adhesions which have stuck the cyst to the peritoneum. (4) A cyst which has previously undergone torsion. Don't be put off by the difficulties we describe below: some are rare and others only occur with really huge cysts of 20 kg or more. Cysts of the size of a full-term pregnancy or a bit larger commonly cause no trouble. Don't operate unnecessarily, adhesions and infertility may follow. Try to avoid removing both ovaries for bilateral benign tumours (usually dermoids). Remember that operating on a pseudocyst, or a cyst in the broad ligament, is particularly dangerous. IF YOU ARE INEXPERIENCED, ONLY OPERATE FOR SUSPECTED ACUTE COMPLICATIONS (torsion) OVARIAN CYSTS EXAMINATION bimanually reveals a round solid or cystic mass, which is dull to percussion and separate from the uterus. OVARIAN TUMOURS Fig. 20-6 OVARIAN TUMOURS. A, a pseudomucinous cystadeoncarcinoma shown in cross-section on the right. B, a solid primary carcinoma. C, the same carcinoma in cross-section. Adaptedfrom a drawing by Frank Netter with the kind permission of CIBA-GEIGY Ltd, Basle (Switzerland). TH E 01 FFERENTIAL DIAGNOSIS varies according to the way in which a cyst presents, but there is considerable overlap. Torsion (see below), is more likely to be confused with an inflammatory lesion. Any presentation of an ovarian cyst may be confused with:

(1) Pregnancy. (2) A distended bladder, which may contain up to 5 litres of urine. (3) Pseudocysts. (4) Hydrosalpinx. (5) Fibroids.

(6) A chronic ectopic pregnancy (haematocele). (7) A broad ligament cyst arising from the Wolffian ducts. (8) An appendix mass, or a small-gut mass. (9) Mesenteric cysts. (10) An enlarged spleen with a long pedicle. (11) Hydronephros.

Presenting as an acute abdomen (torsion, see below). (1) Appendicitis or an appendix mass (12.1). (2) Acute ectopic pregnancy (16.6). (3) Degeneration, bleeding, or infection in a fibroid (20.6). (4) A mass due to PI D (6.6). See also 10.2. Presenting as an abdominal mass or distension. (1) Ascites (she is dull to percussion in her flanks, rather than in the centre of her abdomen). (2) Obesity (fat is usually generalized). (3) Distension with gas in a false pregnancy. CAUTION! (1) Be quite sure she is not pregnant. (2) Always catheterize her before you try to diagnose an intra-abdominal cyst-it may subside dramatically! THE MANAGEMENT OF AN OVARIAN CYST If you are inexperienced, refer her. If she is pregnant see below under 'Difficulties'. If you cannot refer her, proceed as follows. If a cyst is <5-10 cm in diameter, it is usually a functional (follicular or luteal) cyst, and may be associated with fibroids and dysfunctional uterine bleeding (DUB, 20.2). 5 cm is the size of a small orange. Don't include her normal ovary in the measurement. The simple rule is that a cyst like this need not come out. Review her in 6-8 weeks, and only operate if the cyst persists. Most functional cysts will have disappeared. If you find such a cyst at laparotomy for some other condition, leave it. If you must interfere, aspirate it. If she is <15 (before the menarche), many cysts are benign, but there is an increased risk of malignancy, which is sometimes low-grade. At operation the decision to remove her ovaries is particularly difficult. Only remove large (> 10 cm), solid ovarian tumours, and be sure to send them for histology. If she is 15 to 35 years old, and the cyst is >5 cm, it is probably a dermoid, especially if it is firm. An X-ray may show bone or a tooth. Remove it; to do so you may have to remove the whole ovary. If it is bilateral (15%), try to leave some ovarian tissue. If she is 30 to 55 and it is large, it is likely to be a cystadenoma, which may be bilateral (20%). The contents may be serous, and there may be papilliferous growths inside its wall (less likely to be malignant), or outside (more likely to be malignant). If it is very large, its contents are likely to be mucinous. Malignant change is unusual. If however the mucin spills into her peritoneum, dense adhesions (myxoma peritonei) may form. Remove these cysts: they may undergo torsion, or occasionally rupture spontaneously. If she is past her menopause, the risk of malignancy is increased. Be prepared to do a hysterectomy, when you remove the cyst. If you can remove a serous cystadenoma intact, before there has been any spread, as shown by peritoneal deposits and ascites, her prognosis is very good. If there is peritoneal spread, the cyst will probably be adherent to the surrounding structures, and her prognosis is poor. If you are not an expert, don't try to remove ovarian carcinomas which have spread to the peritoneal surface. If she presents with a palpable mass, ascites, or oedema of her legs (due to lymphatic obstruction from peritoneal deposits), consider the possibility of a solid adeno-or undifferentiated carcinoma of the ovary, which characteristically presents like this. It is often bilateral, and by the time she reaches laparotomy, it will probably have spread widely. Her prognosis is poor, but rare cases do occasionally regress spontaneously. If there is peritoneal spread, remove the primary if this is not too difficult; but it will not cure her. There is little to be gained by removi ng her uterus. If the tumour is solid, remember the unusual possibility that it may be a fibroma, which is benign, but can cause ascites (Meig's syndrome). Remove it. If you are in an endemic area and she is between 10 and 25, remember Burkitt's lymphoma (32.3), which is often bilateral. INDICATIONS FOR SU RGERY. The treatment or prevention of complications: torsion, bleeding, or infection. (2) Suspected malignancy. (3) Discomfort due to size. CAUTION! Infertility is not an indication. ANAESTHESIA. (1) General anaesthesia. (2) Subarachnoid anaesthesia. MORE OVARIAN TUMOURS Fig. Fig. 20-' MORE OVARIAN TUMOURS. A, a papillary serous cystadenoma. B, the same in cross-section. C, a very large ovarian cyst showing dilated veins on the abdominal wall. A, and B, adapted from drawings by Frank Netter with the kind permission ofClBA-GEIGY Ltd, Basle (Switzerland). C, after James Young. REMOVING AN OVARIAN CYST A exploring the surface of the cyst delivering the cyst through the wound clamping and dividing the pedicle F applying the encircling ligature Fig. 20-8 REMOVING AN OVARIAN CYST. A, exploring the surface ofthe cyst. B, delivering the cyst without rupturing it. C, clamping and dividing the pedicle. D, transfixing the pedicle. E, tying the pedicle in halves. F, applying the encircling ligature. After 'Bonney's Gynaecological Surgery: Figs 4.29 to 4.34, Bailliere Tindall, with kind permission. CYSTECTOMY FOR SMALLER OVARIAN CYSTS INCISION. Make a median or paramedian incision, big enough to allow you insert your hand, and to remove the cyst intact. Feel its whole surface for adhesions-if you find them see below. Search for secondaries in the rest of her peritoneal cavity, over the surface of her liver, and under her right diaphragm. You may need both hands. When the cyst is free of adhesions, deliver it through the abdominal wound, and hand it to your assistant, taking care not to pull on its pedicle, which may be so thin that it easily tears, causing the proximal end to slip into her pelvis and bleed. CAUTION! Before you remove the cyst, examine her other ovary. If her other ovary is also cystic, and she is relatively young, try to do an ovarian cystectomy (see below), unless there is a suspicion of malignancy. Suspect malignancy on the combination of these factors: (1) she is over 40 years, (2) the tumour is solid or lobulated, (3) there are papillary excrescences on its surface (especially) or inside it, (4) she has ascites, (5) there are secondaries on the surface of her peritoneum, (6) the cyst is fixed and immobile. If she has a bilaterar, papilliferous, or obviously malignant ovarian tumour, what you should do depends on your skills, and how far the tumour has spread: (1) If there is no peritoneal spread, and you can do a total hysterectomy with the removal of both ovaries, do so. Otherwise, do a bi lateral oophorectomy (removal of the cyst with the ovary). (2) If there is little or no spread, do a bilateral oophorectomy. It will remove the bulk of the tumour, but it will not cure her, so the benefit will be minimal. (3) If there is wide peritoneal spread, merely biopsy a deposit on her parietal peritoneum. The pedicle of an ovarian cyst consists of: (1) the infundibulopelvic ligament and ovarian vessels, (2) the ovarian ligament, (3) a portion of the broad ligament, and (4) frequently the Fallopian tube. If it is wide (often it is not), clamp it with several clamps, taking a bite of not more than 2.5 cm in each of them. Cut through the pedicle at some distance from each clamp; it will be less likely to slip off if you do this. Transfix the pedicle in each clamp with double '1' or '2' catgut sutures, or '0' or '1' multifilament, taking care to avoid the plexus of veins as you insert the needle. Some surgeons advise that, if a pedicle is very broad, you should apply a chain of 3 to 4 or more ligatures. Finally, ask your assistant to hold the clamps, and pass a further ligature round the entire pedicle. This will tie any veins which may have escaped the other ligatures. Swab the stump, and, if bleeding has been controlled, cut the ligatures short. Remove the cyst from the operation site, and ask an unscrubbed assistant to open it. If it looks malignant and she is >40, remove her other ovary also, and if you can, her uterus too. If she is younger, wait for histological confirmation of malignancy, and refer for more radical surgery later if necessary. CYSTECTOMY FOR A VERY LARGE CYST POSITION. She may develop the supine hypotensive syndrome (A 16.6), if she lies on her back, so lay her with a sandbag under one buttock. INCISION. Make a paramedian or median incision. If you hope to remove the cyst intact, make it at least 5 cm longer than the diameter of the cyst. If you are not sure if you can remove the cyst intact, make the incision at least 25 cm long and examine the cyst, separating such adhesions as you can see, without too forceful traction on the wound. If you cannot dissect further in safety, enlarge the incision to see the outline of the cyst and any adhesions. Aspirating fluid (see above) may help you do deliver it through the abdominal wall, but seldom helps in dissecting adhesions. A flabby cyst has an edge which is difficult to define, so that vital structures, such as the ureter, are more easily cut. If you do decide to aspirate flUid, use a syringe and needle, don't aspirate more than is necessary, and don't contaminate the operation site with the fluid you have aspirated! NOTE: (1) The size of an incision makes almost no difference to the probability of operative shock. (2) A large one will not affect her adversely, except to increase the incidence of postoperative pain, and slightly increase the risk of wound breakdown. (3) A wound which is too small is dangerous because you cannot dissect safely, and you are obliged to exert excessive traction. This will kill cells in the edges of the incision, and increase the risk of subsequent wound sepsis, and possible breakdown-see Section 9.2. Remove the cyst by clamping its pedicle as above. Be careful not to pull it so hard that you tear this. Insert tension sutures (9.8), and apply an abdominal binder. OVARIAN CYSTECTOMY This removes the cyst but leaves the tissue of her ovary. It is usually not difficult. INDICATIONS. (1) She is less than 40, especially if her other ovary is also damaged. (2) The cy.st is >5 cm. If it is <5cm, it is probably functional, so leave it. (3) The cyst must be benign, a reasonable amount of normal ovarian tissue should be present. If her cystic ovary is her only remaining one, it is not important if its tube is intact or not. She needs its endocrine function, regardless of possible fertility. You may be able to shell out even quite large cysts, and retain some ovarian tissue. METHOD. The cyst lies in the substance of her ovary and is covered by the ovarian capsule. Cut around the edge of the cyst, well away from the remaining mass of her normal ovary. Using scissors or fingers, dissect between the cyst and her ovarian tissue. Control bleeding with 2/0 chromic catgut, and close the outer layer of her ovary with continuous locking sutures. SALPINGO-OOPHORECTOMY INDICATIONS. Removing a tube and ovary is indicated when cystectomy, or ovarian cystectomy is not desirable, or not possible, because: (1) They have been damaged by torsion, bleeding, or infection. (2) There is a possibility of malignancy. (3) There are extensive adhesions between her tube and ovary. (5) If she is >45-50 a bilateral salpingo-oophorectomy with hysterectomy is likely to be preferable. METHOD. The tube and ovary receive their blood from two sources which anastomose with one another: (1) The ovarian vessels in the infundibulopelvic ligament (20-17), and (2) the ascending branches of the uterine vessels. Carefully divide any adhesions between her ovary and broad ligament, approaching them from below and behind. Raise her tube and ovary, find her infundibulopelvic ligament, and identify her ureter, so that you can avoid it. Clamp, divide, and tie her ovarian vessels in her infundibulopelvic ligament. Clamp, divide, and tie her ovarian ligament. Clamp, divide, and tie her tube. Suture her round ligament over the raw area (optional). CAUTION ! Be sure not to tie her ureter. This is not a problem if the structures are mobi le. But if there are adhesions, and especially if her ovary and tube have stuck to the back of her broad ligament, be sure to mobilize them before you resect. DIFFICULTIES WITH OVARIAN CYSTS If she has severe, COLICKY LOWER ABDOMINAL PAIN, sometimes with vomiting, suspect TORSION OF AN OVARIAN CYST. Her pain if may come and go, as it twists and untwists. She may not know she has a mass in her abdomen; it may enlarge acutely as the veins in its pedicle become obstructed. For the differential diagnosis see Section 10.2. Rule out retention of urine preoperatively. Do a laparotomy, tie and transfix the pedicle, and excise the cyst. If she is PREGNANT, you may meet any of these complications. If the cyst is < 5 cm in diameter, it is probably a luteal cyst (very common, and usually disappears after 16-18 weeks). Leave it and follow her up after delivery. If it is > 5 cm, it is probably a cystadenoma, a dermoid, or a cystadenocarcinoma, and delivery may be difficult. Ovarian cystectomy or salpingo-oophorectomy are possible after the first trimester, and before the last few weeks of pregnancy. Don't remove it in early pregnancy, because abortion is more likely. Instead, remove it between the 16th and 24th week, even if you diagnose it earlier. If it is large, operate up to the 30th week. If it causes pain, this may be due to torsion or haemorrhage. Remove it urgently at any stage of pregnancy. If you diagnose it after the 30th week, allow her to deliver vaginally, unless it is very large (>25-30 cm). The ideal time to remove it is 4 to 6 weeks later. If she goes into labour with an ovarian cyst and obstructs, see Section 18.4, and especially Fig. 18-5. If you find an ovarian cyst at Caesarean section, remove it if it is > 5 cm. See Section 18.10. If there are EXTENSIVE ADHESIONS, she may have a pseudocyst (postinflammatory cyst), and not a true ovarian one. Don't try to deliver the tumour until you have divided them, or you may lacerate her gut or tear large veins. Separate them using your hands, swabs, or scissors (not a scalpel!). Gently pass your hand between the cyst wall and the floor of her pelvis. Don't mistake her parietal peritoneum for the cyst wall. Don't tie off any colon when you tie off adhesions. CAUTION ! It is safer to leave a little cyst wall on her gut or the bladder, than to remove a little gut or bladder with the cyst wall. If you meet a collection of PSEUDOCYSTS, there may still be signs of inflammation. Aspirate as many collections of fluid as you can, close her abdomen, give her antibiotics, and hope they will not recur. If the cyst is NOT FREELY MOBILE, but seems to be embedded in her broad ligament, it may be arising from the remains of her Wolffian duct. Removing it may be difficult. It may be: (1) stuck to her broad ligament, or (2) inside it. The distinction is usually unimportant. If it is inside the ligament:

(1) be sure to avoid her ureter, which may run anywhere over the cyst.

(2) Don't damage the venous plexuses in this region. Study her anatomy carefuIly before you start.

If the cyst does not shell out easily, and extends down close to her ureter, you would be wise to remove as much as you can, and leave the remai ns open to her peritoneal cavity (marsupialization). If you can define the cyst clearly by finger dissection, and are able to push her ureter out of the way, you may be able to remove it completely. It is covered by peritoneum which you will have to dissect off. Divide her round ligament on the same side, to open up her broad ligament. Then dissect off her peritoneum posteriorly, until you reach her ovarian vessels in her infundibulopelvic ligament. Tie them. Then dissect anteriorly and medially, and divide her tube and ovarian ligament close to her uterus. Finally, slowly and carefully dissect the cyst from the posterior leaf of her broad ligament, so as to avoid her ureter. If you find BILATERAL BENIGN CYSTS (common with dermoids), try to spare at least some ovarian tissue on one side. If a cyst looks MALIGNANT, consider her age and her wish to have children. If she is young and has no childrern, remove the tube and ovary which are involved, and send tissue for histology. If it is found to be malignant, it may be necessary to remove her uterus and other ovary. If she is older and does have children, and particularly if you cannot follow her carefully, consider doing a bilateral salpingo-oophorectomy together with a hysterectomy. This is a difficult operation and a difficult decision, so refer her if you can. If her INFUNDIBULOPELVIC LIGAMENT IS GROSSLY THICKENED, so that her ovarian vessels are difficult to distinguish from her ureter, open up her peritoneal tissues lateral to them, and extend the incision towards her pelvic brim. Grasp her ovarian vessels and draw them medially. You will then see her ureter attached to her peritoneum, crossing her common iliac artery. DIFFICULTIES WITH GIANT OVARIAN CYSTS If she develops CARDIAC FAILURE, which may be delayed for a day or two postoperatively (rare), the reasons for it are not clear. Don't overload her with fluid; if necessary, give her a diuretic. If she develops RESPIRATORY FAILURE (rare), due to the paradoxical movement of her diaphragm, which is lax and overstretched, now that the the cyst has been removed, give her oxygen and sit her up. If necessary, do a tracheostomy and control her ventilation (A 16.1). If her ABDOMEN DISTENDS postoperatively (unusual), it is probably due to ileus. Insert a nasogastric tube and give her intravenous fluids (10.13). If her ABDOMEN IS ABNORMALLY LAX, apply an efficient binder postoperatively. CAUTION ! Don't be tempted to resect any redundant abdominal wall. This will make the operation much more extensive, and open up more tissue planes. This is a cosmetic procedure; refer her for it later if necessary. 20.9 Prolapse of the uterus Childbirth may so injure a patient's pelvic organs that her uterus, her bladder, or her rectum may prolapse, either singly, or in combination. If her bladder or urethra prolapse as a cystocele, the standard operation is an anterior colporrhaphy. If her rectum prolapses, it is a posterior colporrhaphy. If her uterus prolapses it is either a Manchester repair, if it is to be left in, or a vaginal hysterectomy if it is to be removed. Prolapse appears to be comparatively uncommon in much of the developing world, despite the much greater multiparity of its mothers, but it is uncertain if this is a real difference; they may merely complain less. A Manchester repair or a vaginal hysterectomy involve some fairly difficult vaginal surgery, with the risk that, if you are not expert, you may enter her rectum or her bladder and cause a fistula. If her uterus has prolapsed, they are certainly the best operations, so refer her for them if you can. If this is impossible, or she is unwilling to undergo them, Le Fort's operation, or ventrisuspension, are possible alternatives. They are old-fashioned and less effective than the modern operations, so that experts no longer PROLAPSE OF THE UTERUS cystocele Fig. 20-9 PROLAPSE OF THE UTERUS. A, a cystocele and a rectocele. H, a third degree prolapse. C, and D, the same patient with procidentia; her fundus is outside her introitus. Ideally, all these patients need a vaginal hysterectomy and an anterior and posterior colporrhaphy. If you are unable to do this, you could do an anterior and posterior colporrhaphy on A, and a Le Fort's operation on the other two patients. Patient CD is also suitable for ventrisuspension. After Young James, 'A Textbook of Gynaecology: (5th edn 1939). A and C Black, permission requested. do them. But if you are not an expert, you will find that they are your only way of helping an old woman whose genitalia are prolapsing. Contributors differ as to whether we should include ventrisuspension or not. Because it is disputed we have put it in small print; it may have a place. If she has a cystocele or rectocele which are large enough to cause symptoms, without much uterine prolapse, you can, if you are sufficiently skilled, do an anterior repair (colporrhaphy), or a posterior one, which is somewhat more difficult or both. MARY, an old lady of 80, complained that her husband was accusing her of having given him an STD, because he was having pain in pasing his urine. She wanted a letter she could take to the court saying that she was free of any STD. On examination her uterus was grossly prolapsed, ulcerated and stinking, but she had no evidence of any STD. A Manchester repair cured her completely. LESSON A patient's symptoms are not always what they seem. Pessaries for prolapse. Many old women prefer to avoid surgery, and can be treated with a pessary. Ring pessaries are suitable for most of them. If a patient is comfortable she can leave it in indefinitely, but you should see her from time to time. Menstruation (if she is still menstruating) and sex (if she still wants it) can take place as usual; she may not even be aware that she has one. • PESSARY, ring pattern, semi-rigid polythene, 40 to 120 mm, assorted sizes, predominantly the larger ones, 25 pessaries only. INSERTING A PESSARY A Fig. 20-9a A RING PESSARY IS OFTEN very acceptable to an older patient with moderate prolapse. Choose its size as you would a diaphragm, by measuring the depth ofher vagina with your fingers. After Garry MG, 'Gynaecology Illustrated; Churchill Livingstone, permission requested. RING PESSARIES FOR PROLAPSE INDICATIONS. If surgery is impracticable. Moderate prolapse especially in an older patient; if her perineal muscles are very deficient, they will not hold a pessary. If too big a ring is required, her vaginal wall or cervix may prolapse through it. METHOD, Choose the size of a ring pessary, as you would a diaphragm, by measuring the depth of her vagina with your fingers. It will usually be about 70 mm. Warm it in hot water to soften it, lubricate it, compress it, and insert it like a diaphragm, with the posterior part behind her cervix, and the anterior part behind her symphysis. It will resume its ring shape and take up a position in the coronal plane. If a 70 mm pessary falls out, try a larger size in 5-10 mm intervals. If it feels very tight and uncomfortable, so that she cannot pass urine, try a smaller size. See her in 3 months; if all is well then, see her annually and ask her if the pessary is comfortable. Ideally, she needs a new pessary each year. If it is not coated with solid material, you can wash and replace it. If her pessary keeps falling out, she needs surgery. If her vagina is ulcerated at her annual checkup, leave her pessary out for a 1-2 months and give her some oestrogen cream to insert nightly. When her ulcers have healed, insert a smaller pessary, and see her in 3 months. 20.10 Ventrisuspension In this operation a patient's prolapsed uterus is sutured to her anterior abdominal wall. This relieves both her prolapse, and the rectocele or cystocele, which she will probably have also. If it does not, you can do a simple diamond-shaped excision of her anterior or posterior vaginal wall. Ventrisuspension alone does not interfere with her bladder, her urethra, her rectum, or her vagina. It is not difficult, and is a convenient operation if you are inexperienced, because you can do it through a large lower median incision; it does however sometimes fail. The approach is the same as that for a Caesarean section, which you will have to master anyway. Aim to: (1) Make the anterior wall of her uterus, cervix, and bladder stick to her rectus muscles. (2) Make the peritoneum of her bladder, and the anterior wall of her cervix stick to the back of her pubis, so that there is no chance of an internal hernia occurring between them. Opinions vary as to whether this operation is advisable in a premenopausal patient who may become pregnant. Pregnancy is possible, but it would seem wise to tie her tubes, if she will let you. You will occasionally find that, when you cut down on an old Caesarean section scar that was infected at the time of the original operation, you will go straight into the amniotic space. Such a patient has, in effect, had an unintentional ventrisuspension. VENTRISUSPENSION INDICATIONS, (1) Any patient with a prolapse involving a considerable descent of her uterus. (2) Prolapse in old postmenopausal patients. METHOD, Open the patient's abdomen through a midline incision, extending well down towards her symphysis pubis. The VENTRISUSPENSION B abdominal wall G no gap between and abdominal wall H Fig. 20-10 VENTRISUSPENSION. A, the bare area you aim to create on the patient's uterus, with the sutures in place. D, her abdominal wall before starting the operation. e, her abdominal wall opened and her posterior rectus sheath reflected. D, the sutures in place, and the posterior sheath sewn to her uterus. E, and F, closing the sutures. G, a side view ofthe completed operation, showing her uterus close up against her abdominal wall. H, the space through which gut can herniate that you are trying to avoid. Kindly contributed by Andrew Boddham-Whetham. upper limit of the incision will depend on how far up you can pull up her uterus, when you have examined it. Separate her uterus and adnexa from any adhesions, bring them into the wound, and examine them. Identify the peritoneal reflexion of her bladder, so that you can avoid it. Separate her rectus abdominis muscles from their posterior sheath, along their whole length on each side of the wound. Use a scalpel to vigorously excoriate the anterior surface of the body of her uterus, to within a centimetre of its upper and lateral borders (A, in Fig. 20-10). Don't excoriate her cervix. Instead, elevate and remove a strip of peritoneum about 2 cm wide off her cervix, her bladder, and her anterior abdominal wall, to join up with the skin incision. Prepare three large curved cutting needles with strong monofilament. Decide how high up her uterus should come behind her abdominal wall. Pass each needle through the outer surface of her rectus sheath on one side, through her rectus muscle, and then out of its bare posterior surface. Then pass it deeply in and out of the bare area of the anterior wall of her uterus, across into the bare area of her other rectus muscle, and out through her rectus sheath and anterior rectus muscle. As you do this, avoid her posterior rectus sheath, which will fold inwards (B, e, and D). Apply clamps to each suture, and leave them until later (E). Now comes the tricky part. Using 2/0 monofilament on a round-bodied needle, and starting at the apex of her bladder (but without penetrating it), sew her peritoneum to itself along the line that you have previously excoriated. Leave no gap between her uterus and her anterior abdominal wall. When you have closed this gap, sew her peritoneum and her posterior rectus sheath (which are very thin) to the edges of the excoriated area on her uterus. Use a continuous suture, and make sure that it passes behind the three large sutures that emerge from the body of her uterus. In this way, close her peritoneal cavity, still leaving most of her uterus and all her adnexae intraperitoneally, but with most of the excoriated area of her anterior uterine wall exposed in the bottom of the wound. Now bring her rectus muscles lightly together with continuous monofilament sutures. Close her anterior rectus sheath with continuous monofilament, and tie the three large sutures which you previously passed through the anterior wall of her uterus. The main strength of the suspension is the adhesions that are formed, not these sutures. If a ventrisuspension is not enough, you can do a simple diamond-shaped excision of her anterior or posterior vaginal wall, to tighten up her vagina without doing a full Manchester repair. 20.11 Le Fort's operation In Le Fort's operation the anterior and posterior walls of a patient's vagina are bared, and sewn together, so that a central longitudinal partition runs down its centre. This gives her a bipartite vagina which cannot prolapse, and which will also prevent her uterus from prolapsing. Prolapse of her bladder and rectum are also almost impossible. She cannot have sex, but there is still sufficient vaginal drainage to allow her to menstruate. This operation is rarely done in premenopausal women, because they usually want to have sex. Unfortunately, prolapse may recur down one side. This operation may not be popular in your community: she must understand what is to be done. LE FORT'S OPERATION INDICATIONS. An old postmenopausal woman with procidentia, or advanced prolapse of the second degree, who no longer has sex. CONTRAINDICATIONS. (1) Premenopausal women. (2) Ulcerations of the vaginal mucosa. ANAESTH ESIA. (1) Saddle block. (2) Ketamine. (3) Local infiltration. (4) Subarachnoid anaesthesia. METHOD. Put the patient into the lithotomy postion and examine her uterus. If she has any cervical lesions, deal with them-it will be the last opportunity you will have to take a Pap smear. Using careful aseptic precautions, grasp her cervix and draw it out of her vulva with a vulsellum. Mark out an area on her anterior vaginal wall to be excised (A, in Fig. 20-11). Excise a rectangle of mucosa. Do the same on her posterior vaginal wall. Replace her cervix, and use catgut mattress sutures to unite the bare areas and cover her cervix, except for small channels on either side. If the local circulation is good, and there is no infection, the anterior and posterior walls of her vagina will unite. 20.11a Anterior and posterior colporrhaphy A patient's anterior vaginal wall, and with it her bladder, may bulge towards her introitus when she coughs or strains (cystocele). The same thing can happen to her rectum (rectocele). If her cervix descends more than a little at the same time, she needs a Manchester repair, or ifyou cannot do this or refer her for it, Le Fort's operation (20.11), or ventrisuspension (20.10). An anterior and particularly posterior repair are more difficult than these two procedures, but they are much more satisfactory, so learn to do them if you can. An anterior colporrhaphy mobilizes her bladder, returns Le FORT'S OPERATION CONTRAINDICATIONS. (1) Ascites. (2) A severe chronic cough. Fig. 20•11 LE FORT'S OPERATION. A, the cervix pulled downwards with vulsella, and the area ofvaginal skin mapped out. D, mucosa being dissected offits anterior surface. e, mucosa being dissected offits posterior surface. D, the cervix inverted, and the raw surfaces being united with mattress sutures. E, the raw surfaces beingjoined together over and around the cervix. F, the cervix has disapppeared. G, the repair, complete with small channels at either side. Roberts TWO, in Rob C, and Smith R, 'Operative Surgery: Gynaecology and Obstetrics; p. 89. Butterworth, with kind permission. it to its normal place, and fixes it there. Cut through the tissues joining her cervix and her bladder, so as to expose the peritoneum of her uterovesical pouch, and then suture the fascia on either side, so as to make a supporting buttress from her urethra to her cervix. A posterior colporrhaphy, reduces her gaping introitus, reconstitutes her perineal body, reinforces her pelvic diaphragm by approximating her levator ani muscles, corrects her rectocele and eliminates the hernia of her pouch of Douglas. You can feel the levator ani muscles ofa normal nullip 5 cm from her introitus. The key sutures in this operation bring her levator ani muscles together in this position. COLPORRHAPHY If possible, refer the patient for both these operations, otherwise proceed as follows. If she is postmenopausal, give her a course of oestradiol before starting. ANTERIOR COLPORRHAPHY (anterior repair) INDICATIONS. (1) Prolapse of her anterior vaginal wall which troubles her, especially if she has to push it back to micturate, provided there is little or no descent of her uterus. Preferably wait until childbearing is ended, because a prolapse may recur after pregnancy. She can be pre-or postmenopausal. EXAMINATION. Lay heron her side in the left lateral position. Insert a Sims' speculum posteriorly and ask her to cough and strain downwards. Her cystocele will then show its full size and the degree of uterine descent. If her cervix comes down to her vulva, she is not suitable for an anterior repair alone. Refer her for a Manchester repair, or if this is impossible, consider doing le Fort's operation, or ventrisuspension. These are mainly for third degree prolapse (when the cervix is at the introitus or lower). PREPARATION. Her tissues must be clean before you operate. Ask her to bath in a basin of salt solution (10 gll). If she is already sufficiently clean, do this for 2 days prior to surgery. ANAESTHESIA. (1) Subarachnoid anaesthesia (A 7.4). (2) Ketamine (A 8.1). (3) General anaesthesia (A 10.1). METHOD. Put her into the lithotomy position and clean her vulva and vagina. Towel her and suture her labia minora to her skin with catgut about 4 cm from her vulva (optional, shown in I). InfiItrate her tissues, from her anterior urethral orifice to the anterior lip of her cervix, with 1/200000 adrenalin in saline, or sterile water (A 5.4); you will probably need 20 or 30 ml. Insert a Jacques (simple rubber) catheter to help identify her urethra. Put vulsellum forceps on her cervix and draw it down. Incise her vaginal wall covering her cervix about 1.5 cm from her cervical os, and continue this laterally for about 2 cm on each side. Undermine the edge away from her cervix, and continue to within 1cm of her urethral orifice, using the 'push and spread technique' with scissors (4-8). CAUTION! Keep close to her vaginal wall to avoid injuring her bladder. Distending her tissues with adrenalin solution makes this easier. The key to success is to work in the right layer. Cut the wall of her vagina in the midline (A, Fig. 20-12). Dissect her vaginal wall away from the underlying tissues with a combination of blunt and sharp dissection, until you expose her bulging bladder fully on both sides. Where possible, use a gauze-wrapped finger (B). Take great care to separate her bladder from her vagina in the lateral part of the flap near her cervix. Dissection should be almost bloodless, until you reach the veins which lie well laterally. Dissect her bladder away from her cervix (C).lf necessary, draw up her bladder with dissecting forceps and cut it from her cervix with Mayo's scissors. Separate her bladder from her cervix with a retractor and expose the peritoneum of her uterovesical pouch, but don't open her peritoneal cavity. Using gauze dissection, separate the lateral extensions of her bladder from the lateral border of her uterus. Feel for a stout pillar of fascia on each side of her uterus. The secret of success is wide and courageous dissection, the fascia you want is always there if you go far enough laterally. Use a series of interrupted simple, or, better, mattress sutures of chromic catgut or polyglycolic acid ('Dexon'), to pick up this fascia as far laterally as you can, starting anteriorly (D). If this fascia is difficult to identify, insert the sutures into the fascial envelope of her bladder. When you reach her cervix, take a bite of that. When you have tied the sutures, her bladder wiII be suspended (E). Remove redundant vaginal wall (F); this usually needs to have a diamond-shape. If she has a large cystocele, you will have to remove much vaginal wall, but if you remove too much, her vagina will be too narrow. Close it with interrupted sutures. Insert a Foley catheter. If she has a rectocele, usually accompanied by a deficient perineum, repair this at the same time. POSTOPERATIVELY, drain her bladder into a bag or bottle. Spigot the catheter and remove it 2-hourly. Remove the catheter on the 5th day. About 6 hours later ask her to pass urine and then recatheterize her. If her residual urine is <100 ml, let her pass urine normally. Restart salt baths. If her residual urine is >100 ml, rei nsert the catheter for another 2 days and repeat the process. POSTERIOR COLPORRHAPHY (posterior repair) INDICATIONS. A significant rectocele (bulging of her posterior COLPORRHAPHY-ONE Anterior colporrhaphy A F H Fig. 20-12 COLPORRHAPHY-ONE. Anterior colporrhaphy: A, incise the patient's anterior vaginal wall. B, mobilize her cystocele. C, mobilize her cystocele from her cervix. D, insert the tightening suture as far laterally as you can. E, the obliteration of her cystocele is complete. F, remove her redundant vaginal wall. Posterior colporrhaphy: G, excise an ellipse ofskin at thejunction of her vagina and perineum. H, mobilize her posterior vaginal wall. I, separate her rectocele from her posterior vaginal wall. vaginal wall), with little or no descent of her cervix. Usually her perineum is deficient also. Do the operation at the same time as an anterior repair (see above). EXAMINATION. Lay her in the left lateral position, with the speculum placed anteriorly to push her anterior vaginal wall out of the way. Demonstrate her rectocele by asking her to cough and then strain. PREPARATION. As for an anterior repair. Give her an enema preoperatively. METHOD. Infiltrate her subepithelial tissues with adrenalin solution as above. On each side place Allis forceps about 2 cm apart over the posterior termination of her labium minus, just inside her fourchette at the level of her carunculae hymenales (the little skin tags remaining from the hymen), and retract them. If you place them lower than this, the repair produces a bridge of skin which, causes dyspareunia. Retract the forceps, and use scissors to remove a little ellipse of skin between them (G). Hold her posterior vaginal wall with forceps. Use blunt dissection, and the 'push and spread technique' with scissors (H), to dissect to a point where her posterior vaginal wall bulges less. When you have establ ished a plane of cleavage, you can use your index finger (I). CAUTION! Keep near her vaginal wall to avoid incising her rectum. At this point you usually need to excise some posterior vaginal wall (J, and K). How much you remove will decide how tight you leave her vagina. If she does not want sex, remove a generous amount, if she does remove only a little (L, assumes that you have not removed any). Use 1/0 chromic catgut or polyglycolic acid ('Oexon') sutures on a curved needle to pick up: (1) Her levator ani muscles high in the wound on each side. (2) The fasciallayer, which is rather thin, and tie it on each side. This will support her rectal wall (L). Pick up her transversus perinei muscles on each side to reconstitute her perineal body (M). Finally, close her posterior vaginal wall and skin longitudinally in the sagittal plane (N). If you have done an anterior and a posterior repair together and she wants to have sex, her vagina should admit 2 fingers easily. If you can only insert one finger, she will have some dyspareunia. Remove the 2 sutures closing her vagina and skin, and reconstitute the margin (fourchette) transversely. POSTOPERATIVELY, if you have done an anterior repair also, manage her for that. If you have done a posterior repair only, start salt baths on the second day, and give her a full diet on the th ird day. As soon as her bowels have opened and her COLPORRHAPHY-J TWO Posterior colporrhaphy-continued Fig. 20-13 COLPORRHAPHY-TWO. J, removing some skin from the posterior of the vagina. K, carrying the excision up to the apex of the freed vaginal skin. L, obliterate her rectocele by tightening the fascial layer. M, suture her perineal muscles together. N, both operations nearly complete. wound is satisfactory, allow her home to continue salt baths there. DIFFICULTIES WITH COLPORRHAPHY If THERE IS MUCH BLEEDING: (1) If it is venous, inject adrenalin solution and wait 3 minutes or better 5. If necessary, pack her vagina. Don't try to control venous bleeding with haemostats and ligatures. (2) Underpin a bleeding artery with a needle and catgut. If you OPEN HER BLADDER BY MISTAKE, which is unusual if you operate carefully, repair it with a purse string suture and reinforce it with a second layer of Lembert sutures (9-5). Drain her bladder for 10 days. If you OPENED HER RECTUM BY MISTAKE this is not a disaster. If it is a large wound, close it transversely; if it is a small one, longitudinal closure is adequate. 20.12 Hysterectomy You may occasionally have to do an emergency hysterectomy if a patient has: (1) A ruptured uterus, and repair is impossible (not uncommon). (2) Uncontrollable postpartum haemorrhage (PPH, uncommon). Hysterectomy for a ruptured uterus differs from the operation described below, and is described in Section 18.17. The only occasion on which you may have to use the method which follows urgently, is for an otherwise uncontrollable PPH; all other indications are nonurgent. The indications for nonurgent 'cold' hysterectomy include: (1) Severe anaemia, as the result of excessive bleeding, due to fibroids. (2) Carcinoma of the body of the uterus. (3) Severe DUB (dysfunctional uterine bleeding) which you cannot control by other means (rare, 20.2). (4) Removal of the Fallopian tubes with the uterus for chronic pelvic pain due to PID which fails to respond to medical treatment. If possible try to refer all these cases, especially the last. 'Cold hysterectomies' can have disastrous complications, even in the hands of experts, and their patients even die occasionally. So don't do them, unless you are experienced, and cannot refer a patient. Fibroids may cause disability, but they seldom threaten life. Ifyou are going to operate on them, start with nicely mobile uteri, without huge intraligamentary or cervical fibroids. You can do a total hysterectomy by removing a patient's entire uterus; the advantage of doing this is that you remove her cervix, which is a common site for carcinoma. Or, you can do a subtotal operation, and leave a stump of her cervix behind. Experts almost always remove the whole uterus, so that subtotal hysterectomy is almost obsolete. Subtotal hysterectomy is contraindicated, if there is any suspicion of carcinoma in either the cervix, or the body of her uterus. But it is an easier operation, because you can more easily avoid the ureters. If you are inexperienced, start by doing a subtotal operation, particularly ifyou are operating for fibroids. But even this can be difficult, if there are adhesions from chronic PID. Don't attempt a radical hysterectomy which also removes her pelvic lymph nodes. It is the only adequate surgical treatment for carcinoma of the cervix, but this really is a task for an expert. Ifyou start by making a bladder flap, you will see the relations of the patient's ureter, her uterine artery, and her cervix more easily. The great danger is that you may cut, tie or clamp her AVOIDING THE URETER A Fig. 20-16 AVOIDING THE URETER. A, notice how the ovarian vessels pass in front ofthe ureter. B, the ureter passes over the brim ofthe pelvis, just after the common iliac artery has divided into its internal and external iliac branches. C, the ureter passes close round the vault ofthe vagina under the uterine artery. D, the relation of the urethra, the trigone of the bladder, and the ureters when you retract the cervix. See also Fig. 3-7 which shows the relation ofthe ureter to the internal iliac artery when you come to tie it. Garry MG, IGynaecology Illustrated; pp. 308 and 309. Churchill Livingstone, with kind permission. THE LIGAMENTS OF B THE PELVIS Fig. 20-17 THE LIGAMENTS OF THE PELVIS. A, you are standing on the patient's right and looking down into her pelvis. B, a sagittal section ofpart ofher pelvis along line 'X-V' in Diagram A. e, a section through a her pelvis, parallel with her pelvic brim. D, the main supporting ligaments of her pelvis viewed from above. -1, her broad ligaments. 2, her infundibulopelvic ligaments. 3, her round ligaments. 4, her ovarian ligaments. 5, her cardinal (transverse cervical) ligaments. 6, her uterosacral ligaments. 7, her bladder. 8, her rectum. 9, the fundus ofher uterus. 10, her cervix. 11, her ovaries. 12, her Fallopian tubes. 13, her ureters. 14, her uterine arteries. 15, the veins of her pelvis. 16, fat filling the odd spaces in her pelvic connective tissue. 17, the arrow shows how an opening can be made from her posterior fornix into her pouch ofDouglas. A, afterJames Young. C, after Last. D, after Jeffcoate. ureters. They are at risk at several stages: (1) When you tie her is that the ovarian vessels run in them. (3) Her round ligaments are folds of tissue ovarian vessels. So, lift these clear of her ureters before you tie which run from her uterus close to its junction with her tubes, anterolaterally towards the brim of her pelvis. They are really anterior folds or leaves in her them. (2) In the base of her exposed broad ligament. So before broad ligaments. (4) Her ovarian ligaments support her ovaries, and hang off you do anything in this region which might injure her ureters, the back of her broad ligaments. (5) Her cardinal (transverse cervical) ligaments feel for them carefully. You can roll a ureter between your finger are thickenings of her pelvic connective tissue which run laterally from her cer and thumb, and when you pinch one, it slips through your fingers. vix to the sides of her pelvis. (6) Her uterosacral ligaments run from her lower segment to her sacrum on each side of her rectum. They are, in effect, the posterior Gentle continued traction is the secret of all pelvic surgery: edges of her cardinal ligaments. (1) It demonstrates the tissue planes. (2) You are less likely to pick up structures that you do not want to cut. (3) Vessels stand out more clearly. (4) You are less likely to injure her bladder, or HYSTEREClOMY her ureter. (5) You can find the relation of her bladder to her cervix and vagina more easily. INDICATIONS. See above. Bleeding can be severe, especially from the uterine vessels. CONTRAINDICATIONS TO TOTAL HYSTERECTOMY. (1)An in Divide these late in the operation, after most of the other struc experienced operator. (2) Active PI D. (3) A uterus, which on tures have been removed from around them. Even when you have clinical examination is 'fixed' in the pelvis. Dense adhesions, divided them, you are still in a bloody triangle at the sides of such as those due to PlO, may pull the ureters out of place and her vaginal vault. make the operation difficult. (4) Obesity does the same. Ifyou are not careful, you can also cause a vesicovaginal fistula. ANAESTH ESIA. You must be able to keep the gut out of the This will be much less likely if: (1) You develop a bladder flap. operative field, so you will need good muscular relaxation, and (2) You carefully separate her bladder from her cervix. (3) You a moderate head-down ti It. (1) General anaesthesia with a long separate it from her uterine vessels. acting relaxant (A 14.3). (2) Lumbar epidural anaesthesia (A 7.2). All these dangers will be much more likely ifyou clamp blind(3) Subarachnoid anaesthesia (A 7.6). (4) Ether alone (A 11.3). ly with a large clamp. So: (1) Don't clamp blindly. Only clamp Set up a drip, and have blood cross-matched. what you can see. (2) Don't include more tissue in a clamp than EOUIPMENT. A general set, a catheter, a uterine probe and it can safely hold. sounds, a suitable self-retaining retractor, preferably Finally, wound infection is likely to be disturbingly common. Kirschner's, Gosset's, or Balfour's; also a Deaver's retractor and a tenaculum. At least 4 and preferably 6 long curved uterine ANATOMY. The most critical items of a patient's pelvic anatomy are her ureters, clamps, either Hunter's or Maingot's. 1% iodine or Bonney's as shown in Fig. 20-16. 'Ligaments' mean quite different things to gynaecologists and to orthopaedic surgeons. To a gynaecologist a 'ligament' is a fold ofperitoneum, blue or gentian violet, a large damp pack with a tape. '0' or '1' or a local thickening of the pelvic connective tissue. Gynaecologists recognize: multifilament or '1' or '2' chromic catgut for all pedicles. '1' (1) A patient's broad ligaments which are folds of tissue running from her Fallocatgut for the vagina. 2/0 catgut for the peritoneum. pian tubes towards the floor of her pelvis. The ureter and the uterine artery lie in the base of the broad ligament; vessels run round its edge, and its middle is PREPARATION 0 Make sure that she has signed the consent avascular (see Fig. 18-20). (2) Her infundibulopelvic ligaments are folds of tissue form and understands that she will have no more children and which run from the lateral ends of her tubes to her pelvic wall. Their importance no periods. HYSTERECTOMY-ONE a median incision put your finger through the thin part of her broad ligament if you are going to remove an ovary clamp laterally 10 9 Fig. 20•18 HYSTEREClOMY-ONE. Make the incision (1), open the patient's broad ligament (4), reflect her bladder (6 and 7). Either remove her ovary (9) or retain it (10 and 11). After Parsons L, and Ulfelder H, 'An Atlas of Pelvic Operations: pp. 21ff WB Saunders, with kind permission. Four hours before the operation give her a gram of metronidazole rectally (tablets or a suppository, 2.9). Find yourself a competent assistant. If he is inexperienced, go through this account with him first. Catheterize her bladder. Compress it suprapubically to make sure it is empty, and leave the catheter in for continuous drainage. First put her into the lithotomy position, to paint and drape her perineum. Paint her vagina with 1% iodine, Bonney's blue, or gentian violet. This will make a big difference when you come to open it. Then lay her supine on the table and remove the lithotomy poles. Tip her slightly head-downwards to let her gut fall away from her pelvic cavity. Provided the ang le is not too steep, it will not make anaesthesia difficult. Ideally, adjust the break in the table so that her knees are slightly flexed. Abduct her arm on an arm board. You can choose whether you stand on her left or her right. The illustrations here assume you are standing on her left, which most right-handed surgeons find easier. INCISION. If you are inexperienced, make a median or a left paramedian incision (9.2), from her symphysis to her umbilicus (1, in Fig. 20-18). If you are skilled, and her uterus is not more than 15 cm high (equivalent to a 14-16 week pregnancy), a transverse (Pfannensteil) incision gives the best cosmetic result. Open her peritoneum in the middle of the incision, and make the first cut upwards, so as to more easily avoid her bladder. CAUTION! Make sure your incision is long enough, and that you have divided her rectus sheath and muscles as far as her symphysis pubis (an extra 1 cm at the bottom is worth 5 cm at the top). If necessary extend the incision generously above her umbilicus. Exploration is the first step. Inspect her pelvic cavity. If you find an inflammatory lesion, don't proceed to explore her upper abdomen, because you may spread the infection. Otherwise, put your left hand into the wound to feel the organs in her abdominal cavity quickly and thoroughly. Follow a set pattern, for example-right kidney, liver, gall-bladder, HYSTERECTOMY-TWO find her uterine define, tie, and divide the lateral end of 15 arteryher round ligament find her uterine artery dissect the peritoneum off the back of her cervix 20 clamp the pedicle containing her uterine artery Fig. 20•19 HYSTEREClOMY-TWO. Isolate and tie the patient's round ligaments (13 and 14), find her uterine arteries (15 and 16), tie her uterosacralligaments(18), reflect the peritoneumoffthebackofhercervix (21), and clamp her uterine arteries (22). After Parsons L, and Ulfelder H, 'An Atlas of Pelvic Operations; pages 21ff. WB Saunders Co, with kind permission. stomach, duodenum and pancreas, left kidney, spleen, and finally her colon from her caecum to her sigmoid. Look particularly for metastases in her liver. Clear the operative field. This is often the most difficult part ofthe operation. Don't start removing any organs until you have cleared the site of operation: (a) Clean away any adherent bowel or omentum from her pelvis. (b) Use blunt dissection to free any loose adhesions between her uterus and its surrounding structures-her sigmoid colon, her ovaries, or the walls of her pelvic cavity. Her tubes and ovaries may be stuck down behind her broad ligaments; get your fingers under them and free them from below upwards. Denser adhesions will have to be divided with scissors, or if you think they are likely to contain blood vessels, clamped, divided, and tied. Try stretching them before you divide them. Divide any adhesions between the fundus of her bladder and the fundus of her uterus. (c) Carefully pack her gut out of the way with a large damp pack, marked by a tape, to which a haemostat is attached. Protect the wound edges with moist gauze, and insert a self retaining retractor (2). You can put the crossbar towards her head or towards her feet, and use the third blade to retract her bladder. Make sure it does not compress her caecum, her sigmoid, her small gut, or her iliac vessels. When necessary, use Deaver's retractor. Put clamps on either side of her fundus, over her tubes and round ligaments (3). Use them to exert traction, and control back bleeding. Alternatively, if these structures are friable, use a myomectomy screw or traction sutures on the fundus. Ask your assistant to pull on the clamps, so as to demonstrate the thin part of her broad ligament more clearly. Push your finger through this thin part near her uterus, from behind forwards, to make a hole (4). Do the same on the other side. Reflect her bladder. Incise the peritoneum on the front of her cervix, near to its vesico-cervical reflexion (5). Dissect her bladder off the front of her cervix, and upper vagina (6 and 7), HYSTERECTOMY-THREE (SUBTOTAL) complete the task of pushing incise the anterior incise the posterior wall of her cervix wall of her cervix apply a clamp on the incised edge 25 of her cervix apply a suturing the right suturing the left clamp of her cervix of her cervix posteriorly Fig. 20-20 HYSTERECTOMY-THREE, SUBTOTAL HYSTEREC• lOMY. The part ofthe uterus to be retained (24). Making a cone-shaped cut to remove the uterus (25 to 28). Suturing the round ligaments to the cervix (32). Closing the peritoneum over the stump (33). After Parsons L, and U1felder H, 'An Atlas ofPelvic Operations; pp. 45 and 47. WB Saunders Co, with kind permission. until you can feel the tip of her cervix (8). Feel her cervix from in front and behind. Separate her bladder from the underlying tissues also. Find her ureters. They enter her pelvis at the bifurcation of her iliac vessels. Trace them distally to beyond the tip of her cervix; recognize them by their feel: they are rather hard, they do not pulsate, and you can roll them between your finger and thumb-see Fig. 20-16. CAUTION! Ureters are apt to be easy to find when they are in no danger, and almost impossible to find when you need to find them. If you cannot find them these steps will protect them: (a) Free her adnexa from adhesions before you remove them. (b) Lift her infundibulopelvic ligament and find her ovarian vessels before you clamp them. (c) Carefully dissect her bladder away from her cervix, and the adjoining part of her broad ligament. (d) Cut and mobilize downwards the posterior peritoneal leaf of her broad ligament, and the posterior surface of her cervix. 332 Deal with her ovaries. You must now decide if you want to retain them or not. If they have multiple cysts, they are better removed, but try to retain at least one if she is premenopausal, or less than 5 years postmenopausal. If you are going to remove an ovary, clamp its vessels, lateral to it, taking care not to clamp her ureter at the same time (9). Divide her ovarian pedicle medial to the clamp, and tie it with a double transfixion suture using No. 1 or No. 2 catgut. If you are going to retain an ovary, apply a clamp across the Fallopian tube and its pedicle, 1 cm lateral to the first clamp that you applied to these structures near her uterus (10). Divide her tube and broad ligament between these clamps (11 and 12). Remove the lateral clamp and tie its pedicle as above. Do the same thing on the other side, removing or retaining her ovary, as you decide. Tie her round ligaments. Define, tie, and divide the lateral end of her round ligament. Do this by pushing your finger under it and tying it (13 and 14). Find her uterine artery. Cut the posterior leaf of her broad ligament with the loose areolar tissue inside it, almost as far as the artery (15 and 16). If your assistant stretches her broad ligament well by pulling on the clamps, you may see the artery through the tissues you are going to cut. Repeat this on the other side. Ask your assistant to lift up her uterus again (17). This will demonstrate her uterosacral ligaments. Clamp, divide, and tie them (18 and 19). Dissect the peritoneum off the back of her cervix (20 and 21), if it is not too adherent, otherwise leave it. Her uterus will now be much more mobile. Divide her uterine arteries. Feel for her uterine arteries again. There is no need to dissect them out. Next feel for her ureters on each side of her distal cervix. Again, identify them by their feel-firm cords which you can roll between your finger and thumb. Clamp the pedicle containing her uterine artery almost horizontally, well away from her ureter, with the tip of the clamp biting the side of her cervix, and leaving 0.5 to 1 cm of tissue on the uterine side (22). Better, use two clamps and divide between them. Use scissors, not a knife, in this region (23). Complete the task of pushing her bladder down her cervix, if you have not already done so (24). Blunt dissection is usualIyenough. You can now decide if you want to do a subtotal or total hysterectomy. If you are inexperienced, do a subtotal one. But, before proceeding, here is an alternative to some of the above steps, as used by one contributor: An alternative to the above method, and some say a safer one: (a) Divide her round ligaments between clamps, 2-3 cm from her uterus; this opens the anterior peritoneal leaf of her broad ligament. (b) Enlarge the opening. (c) Find the avascular area of her broad ligament and push your finger through it. (d) Clamp and divide her infundibulopelvic ligament (or her tube and ovarian ligament). (e) Do the same on the other side. (f) Divide the peritoneum between her bladder and her cervix. (g) Feel for her cervix. (h) Lift the peritoneum over her bladder while an assistant pulls on her uterus. This will stretch the connective tissue between her bladder and cervix. Cut this with scissors and push her bladder downwards bluntly. Then proceed to deal with her uterine arteries and uterosacral ligaments as above. SUBTOTAL HYSTERECTOMY When you are sure you have reflected her bladder adequately (24), pull on the clamps attached to her uterus and incise the anterior wall of her cervix, above the reflexion of her bladder and the stump of her uterine vessels (25). Then draw her uterus sharply forwards towards her symphysis, and incise the posterior wall of her cervix (26). Place a clamp on its anterior incised edge (27). Make a cone-shaped cut, so that you remove the endocervical lining. Place clamps on the posterior and anterior cut edges of her cervix (28), so that you can maintain traction-making sure that you avoid clamping her bladder! Bring the two cut edges of her cervix together to control bleeding. Use a cutting Mayo half-circle needle, and place the first stitch in the edge of her cervix, close to the point where you tied her uterine arteries. Control bleeding by placing the sutures through the posterior peritoneal reflection, deep into the muscle of both lips, at the apex of the cone (29, 30 and 31). Suture her round ligaments to her cervix (32), and close her peritoneum, taking care to avoid her bladder (33). TOTAL HYSTERECTOMY Cut through her cardinal ligaments flush with her cervix, until you feel the end on each side (34). Meanwhile, ask your assistant to pull on her cervix to give you good exposure. You should be able to feel her cervix through the wall of her vagina from in front and behind with your finger and thumb (35). Opening her vagina. Before you do fhisinsert clamps on her vaginal angles immediately below hercervix -these are not shown in (35) and (36) or (37) but they are shown in (38). Ask your assistant to pull up her uterus. Use a broad-bladedor rightangle retractor to pull back her bladder. Plunge the scalpel into her vagina through its anterior wall, just distal to where you feel her cervix is. Hold it at an angle of 450 from the line of her cervix (36). Cut laterally to the left and right, keeping near to her cervix. If you can easily see to complete the cut, cut across her posterior vaginal wall with a scalpel. If not, use curved scissors (37). Complete the incision across her anterior and posterior vaginal walls to remove her uterus (38). CAUTION! To avoid damage to her ureters, make sure you find them. Clamp her uterine pedicles away from them, and cut her vaginal wall very close to her cervix. Use transfixion sutures to tie her uterine pedicles, making sure that you do not include her ureters (not illustrated). Use '1' or '2' catgut, or '0' or '1' multifilament, keeping the ends long as markers. Closing her vagina. Hold the cut ends of her anterior and posterior vaginal walls with clamps or vulsellum forceps. Close her vagina with '1' continuous chromic catgut (39 and 40). This should stop any bleeding. If it does not, control it with mattress figure of eight sutures-taking care to avoid her ureters! If you can easily do it, suture her round ligaments to the ends of her vaginal vault (41). This will help to prevent prolapse, but is not essential. Starting at one end, use '0' chromic catgut to close her peritoneum with one long continuous stitch (42 to 45). Leave her ovaries free in her peritoneal cavity. If you sew them into the extraperitoneal space, or fix them to the side wall of her pelvis, she may have dyspareunia. CAUTION ! When you close up her peritoneum make sure that you do not pick up her ureters by mistake. They may be very close. Remove the swab holding her gut, and close her abdomen in the usual way. There is no need for a drain. CLOSING HER ABDOMEN AFTER A HYSTERECTOMY Remove and count all packs and sponges. Grasp her sigmoid colon and carefully place it so that it fills the lower part of her pelvis. Place her omentum so that her small intestine is completely covered. Close her abdomen as usual. Postoperatively, check her vaginal pads to make sure she is not bleeding. Alternatively, suspend the vault of her vagina by sewing her cardinal ligaments separately from her cervix. Clamp them as far distally as you can from her uterine artery pedicles, before you cut them away from her cervix. Check the position of her ureters before you do this. When you have removed her uterus, use a mattress suture to join her cardinal ligaments to the ends of her vagina, before you close it. THESPECIMEN. Openheruterustosee ifthereisacarcinoma of its body. Do this after the operation, to avoid contaminating the wound with tumour cells if any are present. DIFFICULTIES WITH HYSTERECTOMY If ADHESIONS from old PlO or endometriosis prevent you starting, begin by dividing her round ligaments. Then put your hand behind her uterus and push a finger through her broad ligament under her tube and out through her divided round ligament. You now have her tube and ovarian vessels and can clamp and divide them safely. If her UTERUS is so LARGE that it obstructs your access to her pelvis, do a subtotal operation first, and, if necessary, cut across her cervix quite high up. When you have removed the body of her uterus you will have plenty of room to complete the operation. If you CANNOT FIND HER URETER, but must proceed with the operation, keep close to her uterus. You will nearly always be safe there. Do only a subtotal operation. If a FIBROID EXTENDS INTO HER BROAD LIGAMENT this may: (1) Be growing out from her uterus and displace her uterine vessels and ureter downwards and laterally, and her ovarian vessels upwards. (2) Be separate from her uterus and arise de novo from the connective tissue in her broad ligament. Both are difficult; if possible refer her. If you must attempt to deal with (1), divide both her ovarian vessels and dissect out the upper part of the fibroid. Then proceed with the operation as usual on the normal side of her uterus only. Clamp and tie her uterine artery and uterosacral ligament. Cut across hervagina. As you reach the affected side of her vagina you will see her uterine artery on that side. Clamp and divide it (it may be large) and shell out the remainder of the fibroid. HYSTERECTOMY-FOUR (TOTAL) cut through her cardinal you should be able 36 cut to rightligaments flush with her cervix to feel her cervix and left I -close the wound_ use transflexion sutures to37 cut across her vaginal wall tie her uterine vessel pedicles 38 I close her vagina Fig. 20-21 HYSTERECIDMY-FOUR, TOTAL HYSTEREClOMY. Reflect the patient's bladder (34), feel for her cervix (35), incise the fornices ofher vagina (36 and 37), and cut her uterus free (38). Close her vagina (39 and 40). Suture her round ligaments to her cervix (41). Close her peritoneum laterally (42). Close it over her vagina (43 to 45). After Parsons L, and Ulfelder H, 'An Atlas ofPe1vic Operations; pp. 33 and 34. WB Saunders, with kind permission. . If you must attempt to deal with (2), open her broad ligament by dividing her round ligament, as you would for a broad ligament cyst. Her ureter wi 11 be attached to the posterior edge of her broad ligament above; lower down it will be displaced downwards and medially by the fibroid. If there is a FIBROID IN HER CERVIX, removing it can be very difficult. Either do only a subtotal operation. Or, do a subtotal one and then cut down on to the fibroid as for a myomectomy and shell out the fibroid before you remove her cervix. If you DIVIDE HER URETER and recognize that you have done so, you can: (1) Repair her ureter over a T-tube (2) Refer her for reimplantation. This is better if the cut end will reach her bladder. If you OPEN HER BLADDDER, repair it in at least two layers. Leave a catheter in for 10 days. The tear is likely to heal uneventfully. If you HAVE INJURED HER COLON, repair the tear and do a proximal defunctioning colostomy. lif she BLEEDS or there is a PERSISTENT OOZE at the end of the operation, try a warm pack and tie any arterial bleeders. If this fails, don't close her vaginal vault. Instead, insert a purse string suture all round her vaginal vault and pull it tight. This will leave a central hole in her vagina through which any haematoma can escape. If she suffers from insidious RETENTION OF URINE postoperatively (uncommon), it is likely to be due to detrusor failure, and to be difficult to treat. Try 4 weeks of catheter drainage and urethral dilatation. If this fails, teach her intermittent self-catheterization (64.16), which is effective and safe. Use a clean but not sterile simple plastic catheter, which she can use for at least a week. In a woman a retentive bladder is much better than a leaky one. 20.13 The sequelae of female circumcision Female circumcision, which includes all deliberate mutilations of a girl's genitalia, is still done in many parts of the world, sometimes as early as 8 days after birth, but usually at puberty, when it is part of a coming of age ritual which is willingly entered into, and endured with stoicism. In some districts all your female patients will be circumcised. The commoner types are: Circumcision proper (Sunna circumcision) removes only the clitoral prepuce, and is analogous to male circumcision. Excision removes the prepuce, the glans, and sometimes the clitoris itself, together with part or all of the labia minora. Infibulation (Pharaonic circumcision) is still almost universal among Muslims of the Sudan. It excises a varying amount of vulval tissue, and partly closes the vaginal orifice. In its most drastic form all or part of the mons veneris, the labia majora and minora, and the clitoris are removed, and the raw areas are left to heal across the lower vagina. A piece of wood (commonly a matchstick) is then inserted, and the girl's legs are strapped together for 40 days while the lesion heals. The final result is a flattened vulva, without labia, made of a membrane of skin which hides her urinary meatus, and is marked by a midline scar extending backwards from her symphysis pubis to her narrowed and scarred vulval orifice, which may only admit one finger, and sometimes not even that. ZEINAB (6 years) was laid naked across a bed, securely tied by her arms and ankles. With a deep sweep of the razor, the midwife removed the anterior twothirds of one ofher labia, together with her clitoris. The unfortunate girl's shrieks were drowned by "That's nothing to fuss about!" — while the midwife removed her other labium in the same way. As usual, there was a sadistic smile on the face of the operator, and the whole business was thoroughly enjoyed by the priviledged spectators. Haemorrhage is always profuse, and was dealt with as usual. A clamp, made of a bent piece of split cane, was adjusted so as to grip the raw edges together, and its ends tied. For the next three weeks the girl's life was far from being a bed of roses, the clamp remained in place, and her urine had to find its way out as best it could... Derived from Alan Worsley's account of infibulation and female circumcision in the Sudan. Verzin JA, 'Sequelae of Female CircumcIsion', Tropical Doctor 1975;163-69, Worsley A, 'Circumcision in the Sudan', Journal of Obstetrics and Gynaecology of the BritIsh Empire, 1938;45:686, THE SEQUELAE OF CIRCUMCISION COMPLICATIONS. can occur at various times in the patient's life. Their true incidence is not known. Immediate complications: (1) Haemorrhage (common). (2) Infection. (3) Retention of urine. (4) Trauma to her rectum and anus. (5) Amputation of the urethra, resulting in a vesicovaginal fistula. Late complications: (1) Implantation dermoids (common) which may be as large as a football, and hang down over her introitus. (2) Coital difficulties due to excessive stenosis. In its extreme form the narrowed introitus will barely admit a fine probe, and may lead to anal intercourse. (3) Infertility; pregnancy can however occur when the introitus is too tight to admit the penis. (4) Keloid formation. (5) Urinary tract infection. (6) Difficulty of micturition may occur after many years. (7) Calculus formation in her vagina. (8) Haematocolpos. Obstetric complications: (1) The impossibility of making an adequate vaginal examination. (2) Difficulty passing a catheter. (4) Delay in labour due to a tight perineum. DECIRCUMCISION FOR DYSPAREUNIA. Under local anaesthesia, saddle block (A 7.7), subarachnoid anaesthesia (A 8.1), or ketamine, make a midline incision forwards from her stenosed vulval orifice. EXCISION OF A DERMOI D CYST. Make an elliptical incision round the base of the mass and excise it. DIFFICULTY IN LABOUR. If pharaonic circumcision is practised the introitus will not be big enough to allow the baby to pass, so it will be the local practice to make an anterior episiotomy ('the cut'). Failure to make one delays or obstructs labour, and may force the baby's head backwards and cause Fig. Fig. 20-22 FEMALE CIRCUMCISION. A, the usual appearance ofthe end result ofcircumcision. B, a midline circumcision scar healing in patches to give a perforated appearance. C, in its extreme form the narrowed introitus will only admit the point ofa fine probe. D, a large implantation dermoid following circumcision. AfterJA Verzin, with the kind permission of the editor of Tropical Doctor. severe perineal lacerations. The anterior episiotomy is usually adequate; but if it is not, make a posterolateral one also. CAUTION ! Bladder and urethral fistulae have followed carelessly done anterior episiotomies. REPAI R. After delivery you may be asked to repair her introitus, so that it is narrow once more. If this is a cultural requirement, it may be kind to grant her her wish. On the other hand, she may may be anxious not to be sewn up, and resist your attempts even to sew up her posterolateral episiotomy, which must be repaired. 20.14 Some other gynaecological problems Here are a few more problems; some, such as congenital abnormalities and injuries, occur anywhere. Others are specifically tropical. OTHER GYNAECOWGICAL PROBLEMS CONGENITAL ABNORMALITIES OF THE GENITAL TRACT If A GIRL FROM 14 TO 16 HAS LOW ABDOMINAL PAIN AND AN ABDOMINAL MASS (not uncommon), examine her vagina and vulva. If you find a bulging membrane, her vagina and HAEMATOCOLPOS Fig. 20-23 HAEMAlOCOLPOS. A, the bulging membrane retaining a girl's first menstrual discharges. B, a cross-section shows that there is also some degree ofhaematometra. After Young,James, 'A Textbook ofGynaecology; (5th edn. 1939). A and C Black, permission requested. perhaps her uterus are distended with her first menstrual discharges-haematocolpos, perhaps with haematometra, as in Fig. 20-23. Make the diagnosis by inspecting her introitus and by a finger in her rectum. If the membrane feels thin, incise it with a cross-shaped incision. If it is not thin, refer her. Don't do anything more than make a cruciate incision in a thin membrane. Don't insert a drain; you risk introducing infection. If the gap between her upper and lower vagina is more than a thin membrane, the operation to establish patency is not easy, and restenosis is common. The problem is not urgent. If a girl6 months to 2 years after puberty has a LOWER ABDOMINAL MASS, one of the possibilities is a haematometra in the horn of a uterus didelphus (double uterus with two cervices, rare) with one cervix stenosed so that a haematometra develops. You can usually manage her by repeatedly dilating her stenosed cervix. If she complains of a SWELLING IN HER ANTERIOR VAGINAL WALL behind her urethra, especially before the reproductive years, consider the possibility of a URETHRAL DIVERTICULUM (not uncommon in some tropical communities), and don't confuse it with a cystocele or a urethrocele. If you can squeeze its contents into her urethra, the diagnosis is confirmed. If necessary, do a urethrogram as in Section 34.5. If you cannot refer her, consider excising the diverticulum, which is usually not difficult. Operate with a urethral catheter in place. Repair the small defect in her urethra which was the neck of the diverticulum. INJURIES OF THE GENITAL TRACT If an irritant has been placed in her vagina so as to cause a CHEMICAL VAGINITIS, this may be so severe as to involve the whole thickness of her vaginal wall, and be followed by stenosis. Irritants include caustic soda and rock salt and are sometimes used to procure abortions. If you see her in the acute phase, admit her and remove all traces of the chemical, under anaesthesia if necessary. Douche the lesion with a mild antiseptic, and give her an antibiotic to limit the infection. Continue with salt baths until her wound is clean. If the whole thickness of her vaginal skin has sloughed, severe fibrosis and a VAGINAL STRICTURE are likely. If you cannot refer her, consider inserting a skin graft (57.2) on a large mould, as soon as her vaginal cavity is clean. A dentist may have suitable material for the mOUld. Make it round a Hegar dilator, and then withdraw this, so as to make a passage for her menstrual fluid to escape. Stick a split skin graft to the outside of the mould with Compound Paint of Mastic BPC, or Corn- pound Tincture of Benzoin BPC. Hold the mould in place with sutures. Remove these 21 days later, and immediately regraft any raw areas. If PART OF HER URETHRA HAS BEEN DESTROYED, she might have lost the proximal part during labour (18.18) ef the distal part from lymphogranuloma venereum (see below). Provided the proximal quarter is intact, the loss of the distal threequarters usually causes no symptoms. An operation for repair of the proximal quarter is difficult, so refer her for this. CHRONIC INFECTIONS AND PARASITOSES OF THE GENITAL TRACT If she presents with NODULES OR PAPILLOMAS of her lower genital tract, and you are in an endemic area for S. haematobium or S. mansoni, consider the possibility of SCHISTOSOMAL GRANULOMAS. These take various forms: (1) Frond-like (fern-like) lesions with a narrow base or plaques developing on the vulva, usually before puberty from the age of 6 to 15 years. These are often single, cause no problems, seldom bleed, and can be removed easily. (2) Multiple granulomata of the vagina and cervix in the reproductive years and after them. These also seldom bleed, but they may be so extensive that they distort the bladder/urethral angle and cause incontinence. (3) Ulceration or papillomas of the cervix, closely resembling carcinoma. Look for ova in her urine, stool, vaginal discharge, and tissue scrapings or biopsies. Venereal warts (condyloma acuminatum) are the major differential diagnosis. Give her the appropriate chemotherapy. CAUTION! (1) In a schistosomal area don't consider all suspicious vulval or cervical lesions as carcinoma. (2) She may have carcinoma and something else. (3) Don't excise large vulval lesions without doing a biopsy first. If she presents with CHRONIC ULCERATION OF HER VULVA, the differential diagnosis includes: (1) Small and usually ulcerated granulomata arising in a perineum that is permanently wet from a VVF (salt baths will improve her temporarily). (2) Furunculosis; she may be diabetic, test her urine for glucose.

(3) Secondary syphilis; painless, moist, flat-topped swellings.

(4) Chancroid; painful shallow ulcers. (5) Tuberculosis (29.1). (6) Amoebiasis (rare); painless ulcers which may mimic carcinoma and usually respond dramatically to metronidazole (31.2). (7) Schistosomiasis (see above). (8) Carcinoma (32.35a). (9) Donovanosis (granuloma inguinale); red, angry, destructive lesions with a raised edge. (10) Lymphogranuloma venereum (see below, 22.10). Distinguishing between these last two can be difficult, and she may have both. Donovanosis can cause a pseudoepitheliomatous hyperplasia, which may be mistaken histologically for carcinoma. Fortunately, they both respond to tetracycline given for 3 weeks. You can also give chloramphenicol.

If she has LYMPHOEDEMA OF HER VULVA, consider the possibility of tuberculous glands of her groin (29.1), bancroftian or Malayan filariasis, lymphogranuloma venereum, secondary or tertiary syphilis, and donovanosis, etc. Massive elephantiasis of the vulva is usually caused by donovanosis or filariasis (31.4). Vulval oedema can sometimes be so gross as to mimic elephantiasis of the scrotum. Suggesting lymphogranuloma: a fistulated inguinal adenitis with a sour smell, a concealed indolent sore of her vaginal vault, vesicovaginal or rectovaginal sinuses and rectal strictures; painlessness. Histology is often non-specific. Treat any local sepsis. tf elephantiasis has produced a large tumour of her vulva, you may have to excise it, but excision, particularly of enlarged labia majora, is likely to be disappointing. Excise a wide area of skin, so that the incision goes through healthy skin; this will assist healing, and make recurrence less likely. Insert an indwelling catheter to make nursing easier during the first week. Apply a well-padded dressing of vaseline gauze. CAUTION! (1) Operate under antibiotic cover. (2) Don't excise her lymph nodes, this will only make the condition worse, since all lymph from the involved areas has to drain through them. OTH ER GYNAECOLOGICAL PROBLEMS If she complains of a PROFUSE VAGINAL DISCHARGE OR POST-COITAL BLEEDING, one cause is CERVICAL EVERSION (also called a cervical erosion); other more common ones are described elsewhere (M 29.6). The normal columnar endothelium of her cervix bulges out, and you can see it when you do a speculum examination. Cervical eversion usually causes no symptoms. If necessary, cauterize her cervix with a hot cautery or a stick of silver nitrate. If you use a cautery, make 6-8 radial burns from her external os to the junction of the glandular eversion (the erosion) with her normal squamous epithelium. You will need a cervical block or general anaesthesia. If you use a stick of silver nitrate, just touch all the glandular epithelium. Warn her that her discharge will get worse for a week before it improves. No anaesthesia is necessary. If she complains of a small round red LUMP ON THE POSTERIOR MARGIN OF HER URETHRAL ORIFICE, it is probablya URETHRAL CARUNCLE. Usually, it needs no treatment; if it is pedunculated and bleeding, excise it. See also prolapse of the urethra 20.5. If an OLD WOMAN COMPLAINS OF SUDDEN SEVERE VAGINAL BLEEDING, suspect a vaginal tear (not uncommon), usually in her posterior fornix as the result of sex, especially after a period of abstinence. You will see the tear on speculum examination: (1) If she has stopped bleeding, do nothing. (2) Fig. 20-24 URETHRAL CARUNCLE. This usually needs no treatment (A); if it is pedunculated (B), excise it. After Young, James, 'A Textbook of Gynaecology: A and C Black, permission requested. If she continues to bleed, insert one or two mattress sutures. (3) If the tear has gone through her posterior fornix (rare), replace her gut and repair it.