THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS.
The technique of some of the special gynecological operations, such as
perineorrhaphy, and trachelorrhaphy, has already been considered in
discussing the treatment of the conditions in which such operations
are applicable. The general and local preparation of the patient, the
instruments, the dressings, etc., and the technique of the general
operations of gynecology that are applicable to a variety of different
pathological conditions, such as oöphorectomy and hysterectomy, now
demand consideration. The general rules of asepsis that are followed in
gynecological operations are the same as those that should be observed
in all surgical operations. And although every surgeon should strive
to attain perfect asepsis in all operations, yet it is of especial
importance for the gynecologist to do so, for he, more often than
all others, invades the peritoneal cavity. Of the various structures
of the body, the peritoneum is one of the most susceptible to septic
influences; and septic infection of the peritoneum, unlike infection of
other structures, implies not merely a local disturbance and delay of
healing, but general sepsis and death.
Moreover, the gynecologist, operating in the peritoneum, cannot correct
any imperfection in his aseptic technique by the use of antiseptic
solutions, as can be done in other operations of general surgery. Such
antiseptic solutions, if of sufficient strength to be of any value as
germicides, are very dangerous in the peritoneum. They may produce
fatal poisoning from absorption through the peritoneum; they destroy
the delicate peritoneal surface, and thus diminish the very useful
power of the peritoneum to absorb blood and serum after the operation;
they cause intestinal and other adhesions; and they so impair the
integrity of the intestinal walls that septic organisms may be enabled
to pass through and infect the general peritoneum.
The gynecologist, thus debarred from the use of antiseptics during a
peritoneal operation, must rely altogether upon the perfection of his
aseptic technique.
It must not be forgotten that the danger of peritoneal infection,
though very much less in the minor gynecological operations on the
perineum and the cervix, is yet never altogether absent. The whole
genital tract of women communicates directly with the peritoneum, and
infection at any point may extend and cause fatal peritoneal sepsis.
The danger increases with the proximity of the infected point to the
peritoneum. The danger of salpingitis and peritonitis from trivial
intra-uterine manipulations not performed aseptically, such as
the passage of a dirty sound, has already been referred to. Fatal
peritonitis has followed trachelorrhaphy.
In the various plastic operations of gynecology disastrous results
are, of course, not so likely to occur from imperfect asepsis as in
those operations that involve opening the peritoneum. In some of these
operations, such as closure of a vesico-vaginal or a recto-vaginal
fistula, it is impossible to obtain perfect asepsis.
In minor gynecological operations, however, we may use antiseptic
solutions which are inadmissible within the peritoneum; and the
vascularity of the genital tract is so great that healing is usually
rapid and perfect even with very imperfect asepsis. This fact, however,
should never justify carelessness on the part of the physician. In
every surgical procedure, however trivial, the strictest asepsis should
always be observed. The practice avoids, at any rate, a minimum danger;
it is a useful training for the physician; and it sets a valuable
example to the assistants and nurses. No part of the technique should
be “good enough.” It should be as good as it can be made.
The greatest factor in the success of modern gynecology has been
asepsis. The doctrine has become so widely spread that the technique,
and consequently the results, of careless operators of the present day
are much better than those of the best operators before the days of
Listerism.
This is not said to justify carelessness. No woman should at operation
be exposed to any dangers not inseparable from her condition. The
assistants and the nurses should be especially made to feel the
responsibility of their positions. A careless nurse or assistant may
introduce sepsis and cause death after the most skilfully performed
operation. Unfortunately, there is not a distinct realization of this
fact. An assistant, though conscious of some carelessness of his
own, usually beguiles himself with the belief that death was due to
some other cause. If there were a distinct realization of personal
responsibility among all concerned at an operation, death from
infection through carelessness would be avoided as are other kinds of
manslaughter. Unless a surgeon knows that he can furnish the proper
aseptic conditions, he has no right to advise a patient to submit to
operation unless the disease is such that operation is demanded under
any circumstances.
At the present day the gynecologist advises a woman to submit to a
serious--potentially fatal--operation, like celiotomy, for the relief
of many conditions which cause suffering, but which do not cause death.
He does this conscientiously, because he knows that if the operation
is properly performed the danger to life is very small. If he is not
certain that the proper operative conditions will be at hand, he
cannot conscientiously give this advice, and he had better follow some
palliative treatment.
Operations are always better done in a well-equipped operating-room
than in a private house. In the operating-room we have better asepsis,
better light and mechanical appliances, better discipline of
assistants and nurses, and greater opportunity of successfully dealing
with unexpected complications.
In an operation which is performed in a private house something is
always used which is more or less of a makeshift; and makeshifts should
not be used in surgery, especially in abdominal surgery. If we hope to
obtain perfect results, we must insist upon perfect surroundings and
appliances. Continuous success is the result of scientific accuracy and
attention to detail. I say continuous success, because this is the only
test of good surgery. We should not be misled by occasional brilliant
results obtained under imperfect conditions. In such circumstances the
operator admits to himself that his patient was lucky. The element of
luck should be entirely eliminated. Nothing should be trusted to luck.
Fortunately, most of the operations of gynecology are performed for
conditions of such a character that there is no demand for instant
operation. The woman can usually wait until suitable conditions are
furnished. In cases of emergency the surgeon can only do his best under
the existing circumstances, not his best under the best circumstances.
It cannot be denied that good results, as far as mortality is
concerned, are obtained in abdominal operations in private houses. The
mortality, however, for a long series of cases of all kinds is greater
than that obtained in well-equipped hospitals by operators of equal
ability. The number of incomplete and imperfectly performed operations
is much greater in private houses than in the hospital, for the
operator with imperfect surroundings fears to deal radically with some
unexpected conditions which he meets, and is satisfied if the woman’s
life is saved, though she be not perfectly cured.
It is not necessary to dwell upon the need of proper training of
the operator himself in abdominal surgery. The minor gynecological
operations may be performed by any one who is familiar with the
ordinary principles of surgery and who understands the special
technique of the operation. There is no fear of unexpected
complications in such operations. Rapidity of work is not essential, as
in abdominal surgery, and the operator may study the condition as he
proceeds; moreover, errors arising from inexperience or ignorance are
not attended by fatal results.
In abdominal surgery, however, the operator should be specially trained
for the work. Except in cases of emergency, he should not perform
these operations unless he expects to do so continuously. He should be
trained by work upon the cadaver and the lower animals and by watching
and assisting experienced operators. He should be prepared to deal,
without hesitation, with every pathological condition that may be met
with in the abdomen; a glance at works on abdominal surgery will show
how numerous such conditions are.
A few successes in simple cases in the hands of an incompetent operator
will lure him on with false confidence until he finally meets a
condition with which he is unable to cope. Either the patient dies as a
result, or, if the operator be conservative, the abdomen is closed over
an incomplete operation.
The directions which are about to be given apply especially to those
operations in which the peritoneal cavity is entered. They may be
modified in obvious particulars in case a minor operation is to
be performed upon the vagina or the uterus. In such cases special
abdominal cleansing is unnecessary and complete evacuation of the
intestinal tract is not so important.
The technique described is that which is followed by the writer.
Various equally good modifications are employed by other operators.
It seems best, however, to give but one rigid method which experience
has proved successful. The experienced operator is able to change it
according to his individual preferences.
=Operating-room.=--The operating-room should be well lighted from the
top and at least one side. If a good natural light cannot be secured,
an electric drop-light will be found very convenient. For work deep
in the pelvis or the abdomen a good light is essential. If necessary,
light may be directed to the desired point by means of the ordinary
head-mirror.
The floor, walls, and ceiling of the room should be of some
non-absorbing material. There should be in the room no appliances
whatever that are not essential for the performance of the operation.
The interior of the room should be wiped throughout with a mop or
with wet cloths, or, still better, flushed with the hose, in order
to remove and lay all dust. The room may be wiped throughout with a
solution of bichlorid of mercury (1:2000). At the Gynecean Hospital the
operating-rooms are disinfected once a week with formaldehyd gas.
The temperature of the room should be not less than 75° F. Shock from
bodily loss of heat and exposure of the peritoneum is diminished if the
atmosphere of the room is at an elevated temperature.
=Apparatus.=--All apparatus, such as basins, tables, etc., should
be of such a character that it may be sterilized by boiling or by
washing with a solution of bichloride of mercury (1:1000). Glass-top
tables with painted or nickel-plated frames are preferable. The
operating-table should be so arranged that the patient may be placed
in the Trendelenburg position (Fig. 193). This position permits the
intestines to gravitate out of the pelvis, and is very useful in many
operations. There are a great variety of tables in use. Before the
Trendelenburg posture was introduced the writer used for several years
a plain hard-wood plank supported by two wooden horses. The Boldt table
is very convenient. With it there is no necessity for a rubber pad for
catching fluids. It is applicable for all gynecological operations.
Some operators are in the habit of dressing the operating table by
placing on it a blanket and sheet. This is unnecessary, unless the
patient is in such a condition of collapse that it is essential to
preserve all bodily heat. The blanket usually becomes saturated with
fluids and serves no good purpose.
The number and arrangement of the basins, tables, stands, etc. used in
an abdominal operation are shown in Fig. 194.
The basins are best sterilized by boiling, or by washing with scalding
water (inside and outside) and a solution of bichloride of mercury
(1:1000).
The tables and stands are sterilized by washing with the bichloride
solution. If wooden-top tables are used, they should be covered with a
towel wrung out of a 1:1000 bichloride solution.
[Illustration: FIG. 193.--Trendelenburg position.]
=Operator, Assistants, Nurses.=--Usually one assistant, who stands
opposite the operator, and two nurses, are sufficient. A second
assistant, standing beside the operator, is useful to thread needles
and to hand instruments and ligatures. The operator, assistants, and
nurses should possess such general cleanliness as follows a morning
bath. They should not attend any patients suffering with a septic or
infectious condition upon the day of the operation. If they have done
so upon the previous day, they should subsequently take a general
bath and change all clothing. Care in this respect is especially
desirable on the part of the nurses, whose long hair prevents easy
cleansing of the head.
[Illustration: FIG. 194.--View of the sterilizing and operating rooms
of the Gynecean Hospital, Philadelphia. The apparatus is arranged
for operation. _A_, flasks of sterile water; _B_, jar containing
silk ligatures in glass tubes; _C_, instrument-sterilizer containing
boiling water; _D_, tray containing sterile water for instruments at
operation; _E_, basin for washing sponges; _F_, basin for washing hands
of operator during operation; _G_, tray for sutures, ligatures, and
needles; _H_, jar of cold sterile water; _J_, kettle of hot sterile
water; _K_, water-sterilizer; _L_, dressing-sterilizer.]
The operator and assistants should wear sterilized outer
clothes--cotton shirt and duck trousers. A large sterilized apron put
on immediately before the operation is an additional protection. The
nurses should wear large sterilized aprons over freshly washed, if not
sterilized, dresses.
The hands and forearms of the operator, assistants, and nurses should
be bare and especially sterilized. The finger-nails should be short,
rounded, and smooth. A long nail is difficult to clean, and in the case
of the operator is dangerous, as it may lacerate important structures
in the process of enucleation of a tumor. Enucleation of adherent
growths is best done with the blunt finger, which passes along the
planes of separation. The sharp nail may perforate an intestine or
lacerate a blood-vessel, instead of pushing it aside.
The nails, fingers, hands, forearms, and lower part of the upper arms
should be thoroughly scrubbed with frequently changed hot water and
soap (preferably soft soap) and a large stiff nail-brush. The process
should not be done hastily or but once. The soap should be repeatedly
washed off and renewed. Five minutes, at least, should be devoted to
the scrubbing. The hands and arms should then be similarly scrubbed
with alcohol, and finally scrubbed with a solution of bichloride of
mercury 1:1000. Immediately before proceeding with the operation the
hands and arms should be rinsed in sterile water.
There should be a nail-brush for each solution used. The brushes
should be clean and sterilized by boiling or by placing in the steam
sterilizer.
After sterilizing the hands, the operator, the assistants, and nurses
should touch nothing which is not sterile. If they are obliged to do
so, the hands should be again washed.
Rubber gloves, such as are used in general surgery, are very useful in
the operations of gynecology. They may be worn to protect the patient
in case the operator or the assistants are not certain of the sterility
of their hands, or to protect the operator when working upon a septic
patient. Rubber gloves should be sterilized in the steam sterilizer.
=Sterilization of Dressings, Towels, etc.=--The operating-cloths,
aprons, sheets, towels, dressings, gauze pads, etc. are most
conveniently sterilized by steam heat. The temperature should be at
least 100° C. (212° F.). The dressings and bandages should not be
too tightly packed, so that all parts may be exposed to the same
temperature.
Several kinds of steam sterilizers have been introduced. The most
easily obtained is the Arnold sterilizer. An apparatus like the Sprague
sterilizer, in which the steam is superheated, is preferable, but, as
it is not portable, it is adapted only for hospital use.
The dressings should be maintained at the elevated temperature for an
hour or more. Although this method secures very good sterilization,
yet there are certain spores which resist such elevated temperature
even after a two hours’ exposure. The method of _fractional_ or
_discontinuous sterilisation_ has therefore been introduced. Two
or three successive sterilizations are practised at intervals of
twenty-four hours. Spores which at first escape destruction will have
developed into vegetative forms in the intervals, and are destroyed by
the final sterilizations.
At the Gynecean Hospital all dressings are sterilized for three
consecutive days for two hours each day. The dressings, towels, etc.,
after sterilization, should be preserved in sterile glass jars or other
sterile receptacle.
=Sterilization of Instruments.=--Instruments, drainage-tubes,
catheters, and any rubber appliance may be sterilized by boiling in
water for fifteen to thirty minutes. A dilute solution (1 per cent.)
of carbonate of soda is preferable, as the instruments are not so
easily rusted, and this solution, when boiling, has greater germicidal
qualities than plain water.
Very convenient instrument-sterilizers are made, in which the
instruments are contained in a tray that may be lifted out and placed
in the receptacle for containing the instruments during the operation.
This receptacle or pan should itself be sterilized, and should contain
sterile water, or preferably the sterile solution of bicarbonate of
soda, in sufficient quantity to cover the instruments.
It is very convenient to keep on hand a saturated solution of carbonate
of soda, sterilized by boiling, a small quantity of which may be
added to the water in the instrument-tray. Rusting of instruments is
diminished by this means.
Appliances that are injured by moist heat or by steam may be sterilized
by thorough washing and soaking in a solution of bichloride of mercury
(1:1000). It is useful to keep a large vessel of such a solution on
hand, in which apparatus that is not injured by the bichloride may be
placed.
=The Water.=--The water used during the operation, for washing the
wound, the abdominal cavity, the sponges, and the hands of the operator
and assistants, should be sterilized by boiling or by distillation.
The water should be boiled for two hours a day on two consecutive
days, or it should be boiled under pressure as in some of the modern
water-sterilizers. If the water contain a perceptible sediment, it
should first be filtered.
Very convenient water-sterilizers are made, from which the water may be
drawn of any desired temperature, after having been both filtered and
sterilized by heat. There should always be a large quantity of sterile
hot water at hand. Water below the temperature of the body should not
be introduced in the peritoneal cavity, and pads brought in contact
with the intestines should be wrung out of hot water.
About fifteen gallons of sterile water are usually required in an
abdominal operation.
The water should be preserved in sterile pitchers, basins, or other
receptacles.
Glass flasks are very convenient for containing the water with which
the abdomen or pelvis may be washed out. The water may be poured
directly into the abdomen from the flask. The flask should be plugged
with non-absorbent cotton to prevent the entrance of dust.
Some operators prefer to use a normal salt solution (sodium chloride
gr. 90 to water ℥xxxiiiss) for washing out the peritoneum. Such a
solution is probably less irritating to the peritoneum than plain water.
If the flasks are used for containing the water, it may be boiled
in them, and then preserved by plugging with absorbent cotton until
required at the operation. The temperature of the water used for
abdominal irrigation should be 100° to 115° F.
=Sponges.=--In the minor operations about the vagina or uterus the
field of operation may be kept clean by irrigation with sterile water
or by the use of sponges. Small sponges in holders are commonly
used. These sponges, after being washed free of sand and bleached if
necessary, may be sterilized by soaking for twelve hours in a solution
of bichloride of mercury (1:500). They should then be rinsed in warm
water and preserved in a 3 per cent. watery solution of carbolic acid,
which should be changed every week.
Artificial sponges, or gauze sponges, are the most convenient in
abdominal surgery. They are cheap, and may be destroyed after each
operation, and they are very easily and certainly sterilized in the
steam sterilizer. Good marine sponges are so expensive that but few
operators destroy them after they have been once used. The cleansing
and sterilization of such sponges are tedious and uncertain. The gauze
sponges answer every purpose.
The gauze sponges may be made of various sizes by sewing together about
eighteen layers of plain absorbent gauze. The edges of the gauze should
be folded in and hemmed to prevent the escape of loose threads in the
peritoneum. Some operators use sponges made by wrapping absorbent
cotton somewhat loosely in gauze.
The number of sponges used should always be recorded before the
operation. It is advisable to preserve the sponges in sets always of
the same number, so that in every case the operator knows that this
number, or some multiple of this number, of sponges has been used. The
writer uses such sets of seven gauze sponges of the following sizes:
one sponge 3 by 3 inches; one sponge 10 by 7 inches; five sponges 5 by
5 inches. Usually one such set of sponges is enough for an abdominal
operation. In some cases, however, the first set of sponges may become
soiled by the discharge from an abscess or a suppurating tumor, and it
is advisable to discard these sponges and to complete the operation
with a second clean set.
The number of sponges should never be altered during an operation by
cutting one in two.
Sponges should never be removed from the operating-room until the
abdomen has been closed and the sponges have been counted. If a sponge
falls on the floor or in the vessel to receive slops, it should be put
aside until the final counting is completed.
When a set of sponges is used, they should always be carefully counted
as they are placed in the basin, for the nurse who prepared and put up
the set may have carelessly miscounted them.
Accuracy in regard to the sponges is of the greatest importance. There
are a number of recorded cases, and many unrecorded, in which sponges
have been left in the abdomen. This accident is usually fatal, though
there are several cases on record in which the sponge has made its way,
by ulceration, into the intestine, and has been discharged from the
anus, or has been removed by subsequent incision through the abdominal
wall.
=Discipline of the Operating-room.=--The discipline of the
operating-room should be most rigid. Perfect personal asepsis can be
obtained only by continuous watching and criticism. The work should be
systematically divided among the assistants and nurses, and each should
attend strictly to his or her own department, and to nothing else.
The first assistant should assist the operator with sponges, etc.
The second assistant should attend to the instruments, ligatures,
and sutures. The first nurse should wash the sponges and place them
in a basin of sterile water beside the first assistant. She should
also attend to the towels and dressings. The second nurse, under
direction of the first, should change soiled water in the sponge- and
hand-basins, etc.
No one should pick up anything that may have been dropped upon the
floor, and no one, unless it is absolutely necessary, should touch
anything that has not been sterilized.
=Anesthesia.=--With the exception of the operator, the anesthetizer
is the most important person at an abdominal operation. A careful,
experienced anesthetizer is desirable in all operations, but especially
so in an abdominal operation. Much more depends upon him than upon
the assistant. The custom of trusting the anesthesia to the least
experienced man is reprehensible. Many fatal cases after celiotomy may
be attributed directly to the anesthesia.
Every operator of experience has observed the difference in reaction
between those patients who have been carefully anesthetized and those
who have been improperly anesthetized. In a serious case attended by
unavoidable shock the superadded depression of ether-poisoning may be
enough to cause a fatal result.
The operator should have nothing to do with the anesthesia, and it
should not be necessary for him to watch it. The anesthetizer should
make a careful examination of the heart, and should be provided with a
hypodermic syringe and the necessary stimulants, which he should use at
his own discretion.
He should, of course, use the minimum amount of ether. He should be
familiar with the steps of the operation, and he should so regulate the
anesthesia that the operator will not be impeded by the straining or
struggles of the patient at critical moments.
=Preparation of the Patient.=--It is always desirable, when possible,
to have the patient under observation for several days before
operation. As I have already said, a more accurate diagnosis may be
made by repeated examinations, and opportunity is afforded for the
administration of medicines to improve the general condition. A weak
woman about to submit to a serious operation is benefited by the
administration of 1/20 grain of strychnine three times a day, for
several days before the operation.
During this period the patient should receive a daily bath, a laxative
when necessary to produce a daily movement, and a vaginal douche of one
gallon of hot water every morning and evening.
The special preparation of the patient is directed to sterilizing
the abdominal surface, the external genitals, and the vagina, and to
emptying the gastro-intestinal tract. This preparation should begin
twenty-four hours before the operation. During this time it is best to
confine the patient to bed.
Thorough evacuation of the intestinal tract is very desirable in
abdominal surgery. When the intestines are empty and collapsed, the
various intra-abdominal manipulations are most easily performed. If the
intestine is injured and it becomes necessary to repair it, or if any
other intestinal operation is required, it may be performed most easily
and with the greatest cleanliness if the gut is empty.
Though it is impossible to sterilize the intestinal tract, yet we most
nearly approach the condition of sterilization by thorough evacuation
of the bowels.
Twenty-four hours before the operation purgation should be begun by
the administration of 1 dram of Rochelle salts, dissolved in half a
tumblerful of water or soda-water, every hour until the bowels begin
to move freely. Five or six doses are usually sufficient. The lower
bowel should finally be emptied thoroughly by an enema of soap and
water administered three or four hours before operation. During the
twenty-four hours preceding operation the diet should consist of light,
easily digested, concentrated nourishment, such as milk, buttermilk,
soft-boiled eggs, rare beef, soups, beef-tea, coffee, tea, and whiskey
if necessary.
Unless the patient is very weak, no food should be given on the morning
of the operation. If her condition does not warrant such abstinence,
she may have a glass of milk, buttermilk, coffee, or milk-punch. Such
food is required if the operation is performed late in the day.
In very feeble patients a nutrient enema may be administered about two
hours before the operation.
A hypodermic injection of 1/20 grain of strychnine is often useful upon
the morning of the operation when the patient is in poor condition.
_Preparation of the External Genitals and Vagina._--The pubis and the
external genitals should be shaved. The woman should be drawn down
to the edge of the bed, and the anus, the external genitals, and the
vagina should be scrubbed with green soap. The vagina should be washed
throughout. The nurse may do this by inserting one or two fingers,
or she may retract the perineum with the Sims speculum, and scrub
the vagina, the fornices, and the vaginal cervix with cotton held in
forceps.
The scrubbing should be followed by a vaginal douche of a gallon of
hot water to wash out the soap, and then by a douche of two quarts of
bichloride solution (1:2000). One hour before operation the vaginal
douche of bichloride should be repeated, and the nurse should introduce
in the vagina as far as the cervix a light vaginal tampon of gauze wet
with the bichlorid solution. In every abdominal operation on women it
is desirable that the external genitals and the vagina should be clean.
It may be necessary to pass the catheter or to perform some vaginal
manipulation, or the vagina may be opened during the operation.
If the vagina is small or virginal, or if the woman is nervous, the
nurse may be unable to perform the method of cleansing just described;
and it is then necessary for the operator or the assistant to clean
the vagina after the woman is anesthetized. Such cleansing should
always be performed, in addition to the cleansing by the nurse,
whenever a vaginal operation is performed or it is expected that the
vagina will be opened from above. Thorough vaginal sterilization is
most easily accomplished when the patient is under the influence of
ether, as the perineum is easily retracted and the vagina becomes more
patulous. The woman should be placed in the lithotomy position, and
the washing should be performed with two fingers or with a soft brush
like a jeweller’s brush, or with cotton in forceps. If necessary, the
perineum should be retracted with the speculum. Green soap should be
used, and the vaginal walls, the fornices, and the cervix should be
thoroughly scrubbed. The soap should then be carefully washed out, and
the scrubbing should be repeated with bichloride-of-mercury solution
(1:2000).
The cleansing of the external genitals and the vagina is best done by
the nurse after the final movement of the bowels and immediately before
the woman has her general bath.
_Sterilization of the Abdomen._--The patient should have a warm bath
from head to feet upon the morning of the operation. The abdomen,
from the ensiform cartilage to the pubis, should be scrubbed with a
nail-brush. Special care should be devoted to cleansing the umbilicus.
After this bath the patient should be dressed in a clean flannel
undershirt and night-gown and should be placed in a clean bed.
The nurse should then wash the abdomen, from the ensiform cartilage to
the pubis and from flank to flank, and the upper third of the anterior
aspect of the thighs, first with turpentine, second with green soap,
and finally with ether, devoting special care to the umbilicus. The
abdomen should then be covered with a large wet bichloride dressing
(1:2000), which should not be removed until the patient is upon the
operating-table. A towel wrung out of the bichloride solution and held
in place by a bandage or binder will answer the purpose. A second
cleansing of the abdomen by the operator or the assistant should be
done after the patient is upon the table. The surface should be washed
with green soap and sterile water, then with ether, and finally with
the solution of bichloride of mercury. The washing should not be
restricted to the central abdomen, but should extend over the upper
parts of the thighs and the flanks, which may be exposed during the
operation.
[Illustration: FIG. 195.--Tait’s hemostatic forceps.]
[Illustration: FIG. 196.--Spencer Wells’ forceps.]
The bladder should be emptied by the catheter immediately before the
patient is placed upon the operating-table.
The patient should be placed upon the operating-table by clean nurses
or assistants.
The legs should be strapped to the table. The hands should be held
out of the way by the anesthetizer. They may be retained very well by
a safety-pin passed through the lower sleeve and the shoulder of the
night-gown or the pillow-case.
The undershirt and night-gown should be drawn well up behind, to
prevent wetting. If the clothes become wet, they should be changed
immediately after operation.
The legs and the chest should be covered with clean blankets. The field
of operation should be surrounded by sterilized towels. One large towel
with a hole of suitable size in the center is convenient. A pocket may
be made immediately below the hole, to retain the instruments when the
Trendelenburg position is employed.
[Illustration: FIG. 197.--Knife.]
=Instruments.=--The number and the variety of instruments used by the
gynecologist in abdominal operations depend a good deal upon the taste
of the individual operator. The list given here comprises all the
instruments that are found useful by the writer in abdominal work:
Small hemostatic forceps (Fig. 195) 12
Medium-sized forceps 2
Large forceps (Fig. 196) 4
Knife (Fig. 197) 1
Scissors--two pairs of long scissors, one straight and
one curved on the flat.
Pedicle-needles (Fig. 198) 2
Cyst-trocars (Figs. 199 and 200) 2
Straight, spear-pointed needles, 2½ inches in length,
for closing the abdominal incision by the mass-suture.
Curved needles for suturing within the abdomen.
Fine straight and curved needles for the repair of intestinal
injuries.
Large curved needles for catgut, etc.
Abdominal retractors (blunt) 2
Needle-holder (Fig. 201) 1
Long dressing-forceps 2
Three sizes of twisted silk are used for suture and ligature: heavy
silk for ligature of the large arteries; medium silk for ligature of
smaller vessels and for various suturing in the abdomen; fine silk for
peritoneal and intestinal suture.
[Illustration: FIG. 198.--Pedicle-needle.]
The silk should be as small as is consistent with secure ligature. The
heavy silk is necessary for the ligature of pedicles in which a large
amount of surrounding tissue is included with the artery.
[Illustration: FIG. 199.--Small curved trocar.]
The silk is rolled on glass spools or on cores of gauze, contained in
glass tubes plugged with cotton, and is then sterilized in the steam
sterilizer by fractional sterilization. It is advisable always to
use, for heavy ligature, silk of a uniform size, because the operator
becomes accustomed to the strength of the silk and knows just how much
strain it will bear. Silkworm-gut is the best material to use for
suture of the abdominal incision in case the “through-and-through” or
interrupted mass-suture is employed.
The silkworm-gut should be of the heaviest and the longest size. It may
be sterilized by boiling with the instruments before the operation.
[Illustration: FIG. 200.--Large cyst-trocar.]
_Catgut_ is sometimes employed for ligature and suture. The difficulty
of securing certain sterilization makes it advisable to avoid using
this material within the peritoneal cavity. Sterilized silk is so
certainly absorbed in all cases and is so easily employed that the
writer has altogether given up the use of catgut within the peritoneum.
It is useful as a buried suture for the muscle and fascia of the
abdominal wall. Silk is not so certainly absorbed in this position,
and if the catgut should happen to be imperfectly sterilized, no worse
result than suppuration of the incision will occur.
[Illustration: FIG. 201.--Reiner’s needle-holder.]
Various methods of sterilizing catgut have been introduced. The writer
uses the following method, which bacteriological experiments and
clinical experience have shown to be good: The catgut is soaked in
juniper oil for one week. The oil is then washed out with ether and
the catgut is soaked in ether for forty-eight hours. The gut is then
rolled on glass spools and is placed in a glass jar containing pure
alcohol. The alcohol is boiled in the jar for an hour at a time on
several successive days. The gut is used directly from this jar, and is
always boiled in the alcohol for an hour before each operation. In this
way, if a considerable amount of gut is prepared at one time, it is
subjected to many boilings before it is used up. The alcohol is boiled
by placing the glass jar in a vessel of hot water.
The following methods of sterilizing catgut are also good:
_The Claudius or Iodin Method for the Sterilization of Catgut._--Cut
the catgut into the desired lengths and wind on glass slides or spools.
Place in a wide-mouth jar with a glass stopper containing a solution
composed of iodin and potassium iodide, each one part, and distilled
water 100 parts. In making this solution the iodin and potassium iodide
should first be pulverized in a mortar, the distilled water should be
added, and stirred with the pestle until solution is complete.
At the end of eight days the catgut is sterile and ready for use. It
may be kept indefinitely in the solution without deterioration. Before
using take the catgut from the jar with sterile forceps and rinse in
sterile water.
_The Cumol Method for the Sterilization of Catgut, employed at the
Johns Hopkins Hospital._--1. Cut the catgut into the desired lengths,
and roll 12 strands in a figure-of-8 form, so that it may be slipped
into a large test-tube.
2. Bring the catgut gradually up to a temperature of 80° C., and hold
it at this point for one hour.
3. Place the catgut in cumol, which must not be above a temperature of
100° C., raise it to 165° C., and hold it at this point for one hour.
4. Pour off the cumol, and either allow the heat of the sand-bath to
dry the catgut, or transfer it to a hot-air oven, at a temperature of
100° C. for two hours.
5. Transfer the rings with sterile forceps to test-tubes previously
sterilized as in the laboratory.
The cleanest specimens of the crude catgut should be obtained for
surgical purposes. There is no doubt that some specimens of crude
catgut are more difficult to sterilize than others. A special apparatus
has been introduced for sterilizing catgut which renders the process
safe and certain.
The writer uses catgut only for suture of the abdominal fascia and
muscles. Large-sized gut is employed.
=The Dressing.=--The dressing of the abdominal wound consists of ten
or twelve layers of sterilized gauze, covered by a large sterilized
abdominal pad about 1 inch thick, 13 inches long, and 9 inches broad.
The pad is made of absorbent cotton enclosed in a layer of gauze. The
dressing is retained in place by a six-tailed sterilized abdominal
binder of flannel.
If no drainage through the abdominal incision is employed, the use
of celloidin with the gauze dressing is of advantage. It retains the
dressing securely in position for an indefinite period, and, if used
liberally, it acts as a splint for the abdominal wall. Either of the
two following formulæ given by Robb may be used:
℞. Ether (Squibb’s),
Absolute alcohol, _āā_. ℥viss;
Of a solution made of 15 grains of
bichloride crystals dissolved in 11
drams of absolute alcohol, ♏xvj.
Mix, and add of Anthony’s “snowy cotton” enough to give the solution
the consistence of simple syrup.
℞. Absolute alcohol, ℥viss;
Iodoform powder, ʒxiiss;
Mix, and add ether, ℥viss.
Mix, and add of Anthony’s “snowy cotton” enough to give the solution
the consistence of simple syrup.
The celloidin should be poured over the edges of the first layers of
gauze that are placed upon the wound.