A System of Operative Surgery Part 9

RICHELOT. _La Gynecologie_, 1903, viii. 399.

TURNER, G. _Brit. Med. Journ._, 1905, ii. 953.

REFERENCES IN RELATION TO THE OCCURRENCE OF CANCER IN THE UTERUS AFTER BILATERAL OVARIOTOMY

BLACKER, G. F. Uterus with Fibroids and Carcinoma of the Cervix. _Trans.

Obstet. Soc._, 1896, x.x.xvii. 213.

BLAND-SUTTON, J. A Clinical Lecture on Adenomyoma of the Uterus. _Brit.

Med. Journal_, 1909, 1.

BUTLER-SMYTHE. Carcinomatous Uterus removed eighteen and a half years subsequent to Double Ovariotomy. _Trans. Obst. Soc._, 1901, xliii.

214.

PLAYFAIR. Carcinoma of Uterus. Ibid., 1897, x.x.xix. 288.

MARTIN, A. _Die Krankheiten der Eierstocke und Nebeneierstocke_, 1899, s. 907.

REFERENCES CONCERNING THE VALUE OF BELATED OVARIES

BLAND-SUTTON, J. Abdominal Hysterectomy for Myoma of the Uterus, with brief notes of twenty-eight cases. _Transactions of the Obstetrical Society_, 1897, x.x.xix. 292.

---- The Value and Fate of Belated Ovaries. _The Medical Press and Circular_, 1907, ii. 108.

BOND. An Inquiry into some Points in Uterine and Ovarian Physiology and Pathology in Rabbits. _British Medical Journal_, 1906, ii. 121.

DORAN, A. Subtotal Hysterectomy: after history of sixty cases.

_Transactions of the Obstetrical Society_, 1905, xlvii. 363.

THOMAS, G. C. The after histories of one hundred cases of Suprav.a.g.i.n.al Hysterectomy for Fibroids. _Lancet_, 1902, i. 294.

CHAPTER VII

HYSTERECTOMY FOR PRIMARY CARCINOMA OF THE UTERUS

The modern operation of hysterectomy as a radical measure for the relief of cancer of the uterus has a somewhat curious history. In 1878 Freund extirpated the uterus for carcinoma of the cervix through an abdominal incision; his method was quickly practised by other surgeons, but the great mortality of the operation soon caused it to be abandoned for the v.a.g.i.n.al route advocated by Czerny and supported by Schroeder, Olshausen, Martin, and Pean amongst other gynaecologists. This method, however, has been abandoned, for, although the operative mortality of v.a.g.i.n.al hysterectomy for cancer of the uterus has fallen to 5 per cent., the operation has disappointed expectation, as it can only be employed on early cases of the disease with anything like a hopeful prospect of curing the patient, and, even when performed on carefully selected cases, the risks of recurrence are so great and often follow so rapidly on the operation that surgeons have lost confidence in the method. This has induced gynaecologists to turn their attention again to the abdominal route. The cancerous uterus is now subjected to what is known as 'radical abdominal hysterectomy', a method with which the names of Ries, Mackenrodt, Duhrssen, and Wertheim are closely a.s.sociated.

=Hysterectomy for cancer of the cervix.= The greatest obstacle to the success of v.a.g.i.n.al hysterectomy in the radical treatment of cancer of the neck of the uterus is the limitations which the anatomical environment imposes on the surgeon, for as soon as the disease overruns the cervix it implicates the v.a.g.i.n.a, the bladder, the vesical portions of the ureters, and the r.e.c.t.u.m. The 'radical abdominal operation'

enables the operator not only to remove the uterus and its neck, but the broad ligament, the ovaries, Fallopian tubes, infected lymph glands, and the infected para-uterine connective tissue, and by affording the operator free access to the floor of the pelvis the proceedings may be carried out with a free exposure of the operating field, thus allowing important structures like the ureters to be dissected out of implicated tissue. Indeed it has even been recommended, in cases where the bladder has been extensively involved, to resect this viscus and engraft the ureters into the r.e.c.t.u.m.

The primary object of these extensive operations is not only to facilitate the wide removal of connective tissue around the cervix in early cases of carcinoma, but also to allow the advantages of operative treatment to be extended to patients to whom it would be otherwise absolutely barred.

One great danger which attends operations for the removal of cancerous organs is what may be called 'post-operative cancer-infection', that is, in the course of the operation tracts of connective tissue are opened up and become soiled with cells, which engraft themselves on this tissue and on the peritoneum, and give rise to extensive ma.s.ses of cancer which are often described as recurrent cancer. This accident often causes the patient to die quicker than if the primary cancer had been left untouched. In the radical operation it is one of the essentials to avoid soiling the wound with cancer cells. This rule, of course, applies to operations for cancer in any part of the body.

=Operation.= The steps of the radical abdominal operation advocated by Wertheim are as follows:--

As a preliminary, the cancerous cervix is treated by sc.r.a.ping, cauterizing, and disinfectants. It is an advantage to carry out these measures a few days before the main operation. The Trendelenburg position is indispensable and the abdomen is opened by a free median sub.u.mbilical incision. After isolating the intestines with dabs, the _ureters_ are exposed by incising the posterior layer of the broad ligament; they are then traced to the parametrium. It is necessary to avoid too free a disturbance of their vascular network or they will slough.

The _bladder_ is then separated from the uterus. The _infundibulo-pelvic_, the _broad_, and the _round ligaments_ are ligatured and divided. The particular order in which they are dealt with is not a matter of consequence. The uterine vessels are secured in the following manner:--The index finger is pushed along the ureter through the parametrium towards the bladder, until the tip of the finger appears there; the vessels are then raised on the finger, which covers the ureter so as to protect it whilst the vessels are ligatured and divided.

As soon as the uterine vessels are divided the vesical segments of the ureters are exposed, cleaned if necessary, and separated from the cancerous cervix.

The posterior layer of the peritoneum is divided and the r.e.c.t.u.m separated from the v.a.g.i.n.a: at this stage the uterus is sufficiently isolated from the surrounding structures to allow of removal. This is effected in the following way:--

The two layers of the parametrium are taken off as close as possible to the pelvic wall, and the v.a.g.i.n.a closed with bent clamps and divided below them: the clamps are used to prevent soiling the operation-area with cancerous cells.

In order to extirpate the _lymph glands_, the peritoneum is divided upwards and the iliac vessels laid bare, and every enlarged gland from the division of the aorta to the obturator foramen is removed and the oozing vessels carefully secured.

The wound is treated in the following way:--

The cavity created by the removal of the uterus is filled in loosely with iodoform gauze, which extends to the v.u.l.v.a. An exact closing of the peritoneal cavity over this gauze is effected by the sewing up of the anterior and posterior flaps of peritoneum. The final step is the closure of the abdominal incision.

=After-treatment.= This is relatively simple. The strips of iodoform gauze are removed through the v.a.g.i.n.a in from five to ten days successively. The patient gets up on the fifteenth day. The bladder requires very careful attention, as it is usually paralysed for some days.

=Mortality.= The immediate mortality of these extensive abdominal operations for cancer of the neck of the uterus is very high, more than 20%, but recent statistics (1909) show that this death-rate is being considerably improved with increased experience on the part of the operators.[1]

[1] Comyns Berkeley and Bonney have published the best immediate results of this operation which have been obtained in England. _British Medical Journal_, 1908, ii. 961, and _Lancet_, 1909, i. 320.

=Dangers.= The chief risks of the operation are sepsis, cancer-infection, and injury to the ureters.

The ureters have proved a fertile source of trouble because they are deliberately exposed in the course of the operation, and they are sometimes accidentally divided. It is not uncommon to find a ureter completely blocked by cancer, and occasionally the ureter, after being bared by the operator, undergoes necrosis a few days later.

Wertheim points out that in some instances ureteral fistulae due to necrosis may be induced to close by the application of iodine or sulphate of copper. It is, however, unfortunately true that many patients with ureteral fistulae after the radical operation have been obliged to undergo nephrectomy (see p. 112).

The 'radical operation' for cancer of the neck of the uterus is on its trial in Great Britain. The operative mortality is very high, and no reliable returns concerning the remote results are at present available.

=Hysterectomy for cancer of the body of the uterus.= The most satisfactory method of dealing with cancer arising in the corporeal endometrium consists in performing total abdominal hysterectomy (see p.

40), removing not only the uterus and its neck, but both ovaries, Fallopian tubes, mesometria, and any enlarged lymph glands that are detected. In the course of the operation the surgeon should avoid any undue handling of the uterus, and, in withdrawing it from the pelvis, care should be taken not to infect the operation area with any fluid or semi-fluid stuff which is liable to escape from the cervical ca.n.a.l.

[Ill.u.s.tration: FIG. 19. CANCER OF THE UTERUS. Coronal section through a uterus affected with primary cancer of the corporeal endometrium. The ma.s.s measured 10 centimetres transversely and 12 centimetres vertically.

Removed by abdominal hysterectomy. Two-thirds size.]

There is a rare variety of cancer of the corporeal endometrium, namely, that which attacks small atrophic uteri. These small uteri may sometimes be extirpated by the v.a.g.i.n.a, but often the narrowness of the v.a.g.i.n.a in aged spinsters compels the surgeon to resort to the abdominal route.

Cancer of the body of the uterus occasionally causes such enlargement of this organ as to render its removal by the v.a.g.i.n.al route difficult as well as undesirable. When this form of cancer is complicated with fibroids, as a rule, v.a.g.i.n.al hysterectomy is impracticable.

Cancer of the body of the uterus is more frequent in spinsters and barren wives than in multiparae; for this reason the cancer often a.s.sumes the ma.s.sive form, because the cervical ca.n.a.l being narrow, pathogenic micro-organisms do not obtain such free ingress as in the case of women with a patulous ca.n.a.l. In some instances the cancerous ma.s.s will expand the uterine cavity and lead to thinning of the walls as in Fig. 19.

Clinically, cancer of the corporeal endometrium is a more insidious disease than cancer of the neck of the uterus, but since its frequent a.s.sociation with fibroids has been recognized (see p. 52) mainly as a consequence of the vulgarization of hysterectomy, many cases are detected fairly early and with improved results for the patients.

=Mortality.= The risk to life in abdominal hysterectomy for cancer of the body of the uterus is somewhat greater than after removal of the uterus for fibroids. This is due to the fact that when the cancer ulcerates and sloughs, the risk of sepsis is therefore increased; this also makes convalescence slower.

The remote results vary greatly; these depend in a large measure on the extent of the disease at the time of the operation. When the cancerous ma.s.s is compact, as in Fig. 19, good results may be expected. When the growth has perforated the uterine wall and small bud-like processes project on the serous surface, the disease may be expected to recur rapidly in the abdomen. Cancer of the uterus remains an opprobrium to operative gynaecology.