THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS (Continued).
ABDOMINAL DRAINAGE.--Drainage of the peritoneum is accomplished by
means of the glass drainage-tube (Fig. 202), or by capillary drainage
with gauze. The peritoneum may be drained through the abdominal
incision or through the vagina. On account of the difficulty of keeping
the vagina sterile, drainage through the abdominal incision is the
safer method. Vaginal drainage is preferred when the operation is
performed through the vagina and no abdominal incision is made, as in
the operation of vaginal hysterectomy.
[Illustration: FIG. 202.--Glass drainage-tube.]
The glass drainage-tubes should be of various lengths--5 to 7 inches.
The outer diameter should be about ⅜ or ½ inch. The lower portion of
the tube is perforated with small holes over a distance of about 1½
inches. Around the upper part or neck of the tube, which protrudes
from the abdomen, is placed a square of rubber dam, such as is used
by dentists, about 8 by 8 inches in size. The tube passes through a
hole in the center of the rubber. The tube and the rubber dam may be
sterilized by boiling. The tube is usually placed in the lower angle of
the abdominal incision, and the abdominal dressing is split so that it
may be placed around the tube. The bandage is applied so that the four
upper tails pass above the tube and the two lower tails pass below it.
The opening of the tube and the rubber dam are outside of the bandage.
When the dressing and bandage have been applied, the opening of the
tube is plugged with sterile absorbent cotton, and a handful of cotton
is placed in the dam, which is then folded over and pinned. A sterile
towel is placed over the dam. Some operators insert a cord of cotton
or a few narrow strips of gauze to the bottom of the tube, in order to
maintain a continuous capillary drain.
Cleansing or emptying the drainage-tube is a procedure which should be
very carefully attended to. Strict asepsis should be observed in all
the manipulations. For the first few hours the general peritoneum is
exposed to danger of infection every time the tube is opened. After
the first twenty-four hours, though the danger of general peritoneal
infection is remote or absent, yet there is always danger of local
infection of the tube-tract. Such local infection may result in a
persistent sinus or other complication. A ligature near to or in
contact with the tube may become infected, and the sinus will remain
open until the ligature is discharged.
The tube may be cleaned by any careful nurse. The bedclothes should
be drawn down to the pubis and the clothing should be drawn up, so
that the abdomen is exposed. Sterile towels should be placed about the
rubber dam. The hands of the nurse should be sterilized. The dam should
be opened, the cotton should be removed, and the orifice of the tube
exposed. The tube should be emptied with the long-nozzled syringe (Fig.
203), or with some other easily sterilized apparatus by which the fluid
may be withdrawn.
[Illustration: FIG. 203.--Syringe for cleaning drainage-tube.]
All fluid should be withdrawn from the drainage-tube. The dam should
be carefully cleansed by wiping with cotton wet with the solution
of bichlorid of mercury. A fresh cotton plug should be inserted in
the tube, and the dam should be folded and pinned over a handful of
cotton. The whole should then be covered with a sterile towel.
The tube should be emptied or cleaned as often as it becomes filled. It
is often necessary at first to clean it every fifteen, thirty, or sixty
minutes. If free bleeding is taking place, it is most quickly arrested
by frequent cleaning of the tube. Unless the nurse is experienced, the
operator or assistant should watch the drainage-tube for the first hour
after operation, in order to direct the nurse in regard to the required
frequency of cleansing. A record should be kept of the amount of fluid
withdrawn.
The intervals between cleansings are gradually increased until once
every six or twelve hours becomes sufficient. It is not often necessary
to keep the tube in the abdomen longer than two or three days.
The tube should be removed when the fluid discharged becomes serous in
character and small in amount--about one dram every four or five hours.
Before removing the tube the flannel binder should be opened and the
wound should be exposed. When the glass tube is withdrawn, it is best
to replace it by a small rubber tube. This may be done by inserting the
rubber tube to the bottom of the glass tube, which is then withdrawn.
If we were certain that the tube-tract were aseptic, the introduction
of the rubber tube would be unnecessary, and we might close the lower
angle of the incision immediately by suture. This procedure, however,
may be followed by fluid-accumulation and the formation of abscess in
the tube-tract. It is therefore safest always to use the rubber tube.
The rubber tube should be withdrawn gradually, an inch or two every
day, so that the tract will close from the bottom. In order to prevent
the rubber tube slipping altogether into the drainage-tract, it is
advisable to insert a small safety-pin through the extra-abdominal end.
The end of the rubber tube should be surrounded and covered by several
layers of gauze and the abdominal pad.
=Gauze-drainage.=--Capillary drainage with gauze is sometimes more
convenient than drainage with the tube. A strip, about 2 inches in
width, of several layers of gauze should be carried, from the part of
the pelvis to be drained, out through the lower angle of the abdominal
incision. When the sutures are introduced the lower angle of the
incision should not be too tightly closed, or drainage will be impeded.
The extra-abdominal end of the gauze drain should be surrounded and
covered by several layers of loosely-packed gauze and by the abdominal
pad and binder. Sterile cotton should be tucked under the binder
immediately above the pubis, and, if necessary, around the upper and
lateral margins of the pad. The dressing need not be disturbed for
one, two, or three days, unless the discharge has soaked through the
abdominal binder.
A convenient capillary drain is made of a gauze bag containing several
strips of gauze.
One objection to the gauze drain is the difficulty of removal.
Lymph-processes and granulations penetrate the interstices of the
gauze, and often render its removal very difficult. The surgeon fears
to use too much force in attempts at withdrawal, because an adherent
loop of intestine or the omentum may be pulled out of place or damaged,
or the lymph-wall of the drainage-tract may become opened and expose
the general peritoneum to infection. To avoid this difficulty the
writer has for some time employed a drain made by surrounding the gauze
bag with an ordinary rubber condom the end of which has been cut open
(Fig. 204). With this arrangement the surgeon may feel certain that
there are no adhesions except at the end of the drain. Such drains may
be removed as easily as the glass tube. The condom may be sterilized
by boiling. Gauze drains should be removed at the end of two or three
days. After withdrawing the gauze it is advisable to insert a small
rubber tube, for reasons that have been mentioned in considering the
use of the glass drainage-tube.
The gauze drain may be used in all cases except when it is necessary to
drain pus or some solid material like feces. In such cases the glass
tube should be employed, either alone or surrounded by a gauze pack to
protect the general peritoneum.
In pelvic surgery the drain, whether glass or gauze, should, as a
rule, be placed at the most dependent part of the pelvis, which is
the bottom of Douglas’s pouch. It may be placed to either side of the
median line in case the chief discharge is expected to take place from
this position. Hemorrhage from a bleeding surface deep in the pelvis
may often be controlled by the direct pressure of the end of the gauze
drain placed over it.
[Illustration: FIG. 204.--Gauze drain with rubber cover.]
The drain should be introduced immediately before the abdominal sutures
are tied.
=Indications for Drainage.=--Great diversity of practice exists among
operators as to the use of drainage after celiotomy, and a decided
change has taken place in regard to drainage during the past twenty
years. In the early days of modern abdominal surgery drainage was used
very much more than it is at present; some of the best operators used
it in the majority of their cases; now a number of operators never
use drainage after celiotomy, while others use it only when specially
indicated. Much depends upon the individual methods of the operator.
The operator who is careless in his asepsis and hemostasis should
use drainage oftener than he who is careful in these particulars. The
advice, “When in doubt drain,” is very good; but the surgeon should
strive to eliminate the element of doubt as much as possible, and to
have a definite reason for all his procedures. If drainage is not
necessary, it is harmful. It necessitates more frequent dressings and
disturbance of the patient, and it prevents perfect closure of the
abdominal incision.
The object of drainage is the removal from the peritoneum of discharges
which are, or which may become, septic or dangerous. Such discharges
are blood, pus, serum, cyst-contents, and ascitic fluid.
Even though the peritoneum be dry and all bleeding be arrested when the
operation is completed, yet it must be remembered that a subsequent
free serous exudation will take place if the peritoneum has been
exposed or subjected to chemical or mechanical irritation.
Infection may take place from imperfect asepsis at the time of
operation; or it may be caused by the escape into the peritoneum of
septic material which existed in the abdomen before the operation; or
it may occur subsequently, from the passage of septic organisms from
the interior of the intestine through the intestinal wall.
The absorbing power of the healthy peritoneum is so great that a large
amount of fluid (even though not absolutely sterile) may be taken up by
it. Injury of the peritoneum from exposure or other irritation not only
increases the amount of fluid to be absorbed, but it diminishes the
power of absorption; and injury of the intestinal peritoneum or of the
wall of the intestine favors the passage of septic organisms through it.
The operator should bear these facts in mind when he considers the
subject of drainage.
A certain amount of absorption of blood or other sterile fluid may be
trusted to the peritoneum.
It is sometimes impossible to arrest all venous oozing from raw
surfaces, and the blood must be left for absorption by the peritoneum,
or must be carried off by drainage with the glass tube or with gauze.
Drainage enables the operator to watch the amount of hemorrhage after
operations, so that if excessive he may employ measures to check it.
Drainage also acts as a hemostatic. The direct pressure of the gauze
upon the bleeding area checks the hemorrhage, and the continual removal
of blood, the promotion of dryness, and the contact of air through the
glass tube have a decided hemostatic effect.
Drainage, therefore, is sometimes used not only to remove blood, but to
aid in arresting hemorrhage. As the operator becomes more experienced
he practises more perfect hemostasis, and learns to obliterate by
buried suture, to fold in, or to cover with peritoneum raw bleeding
surfaces, so that drainage as a means of hemostasis is less often
required. If the operator fears that the peritoneum has become infected
from imperfect asepsis at the operation, or from the escape into it of
some septic material like pus, he should employ drainage, especially if
he expects much subsequent serous or bloody discharge to take place.
If the intestinal wall has been extensively injured, as we sometimes
find after an adherent intestine has been liberated, drainage should
be employed; for septic organisms most readily pass through such an
injured wall, and the damage may be so great that necrosis may take
place, with the escape of intestinal contents. It must be remembered
that all purulent accumulations in the abdomen and pelvis are not
septic. Such accumulations were septic in the beginning, but in
the majority of chronic cases the septic organisms have died and
disappeared, and the pus is perfectly sterile and harmless to the
peritoneum. Consequently, if an ovarian or a tubal abscess ruptures
during removal, and the contents escape into the peritoneum, drainage
is not necessarily required. For a period of three years the writer
had in such cases immediate bacteriological examination of the pus
made, and determined drainage from the result of such examination.
In the majority of cases the pus was sterile and drainage was not
employed. It has been found, as would be expected, that the pus is most
often septic in the cases of recent suppuration and in the chronic
cases during an acute attack. Experience also teaches that suppurating
dermoids are very likely to be septic.
It will be seen from these considerations that in determining the
question of drainage much must be left to the judgment and the
experience of the operator.
If an aseptic operation has been performed, and there is no intestinal
lesion and hemostasis is perfect, drainage is not required. This
condition of things is, of course, most often attained by the
experienced operator. If the operator fears septic infection for any
reason, or fears that the hemostasis is not good, he should employ
drainage. At the present day the decided majority of the best operators
use abdominal drainage very little.
When general peritoneal sepsis exists before the abdomen is opened,
drainage is always indicated.
=Vaginal Drainage.=--Drainage of the peritoneum through the vagina
is usually accomplished by making an opening through Douglas’s pouch
into the posterior vaginal fornix. A rubber drainage-tube or a gauze
drain may then be inserted. The vagina and vulva should, of course,
have been thoroughly sterilized. The vagina should be lightly packed
with gauze, and the vulva should be protected by a gauze and cotton
dressing. As has been said, the chief objection to vaginal drainage of
the peritoneum is the difficulty of sterilizing and maintaining sterile
the vagina and the vulva.
=The Incision of the Abdominal Wall.=--The various abdominal operations
of gynecology are performed through an incision in the median line.
The position of the incision depends upon the condition to be treated.
The incision for performing ventro-suspension of the uterus is made
near to the symphysis pubis. The incision for the removal of a large
cyst is made at a higher point. As a rule, the incision, about 2 or 2½
inches in length, should be made about midway between the umbilicus
and the pubis, and should be extended upward or downward as necessary.
The incision should be as small as the operator can conveniently work
through. He should not hesitate to enlarge the incision to facilitate
any manipulations. The length will depend a good deal upon the
thickness of the abdominal walls.
The structures that are incised are the skin, the subcutaneous fat, the
parietal fascia, the linea alba or the edge of the rectus muscle, the
subperitoneal fat, and the peritoneum.
If the incision is made exactly in the median line, the linea alba
will be divided and the sheath of the rectus will not be opened. This
is most usual in multiparous women with lax abdominal walls and widely
separated recti muscles, and in cases in which the abdomen is distended
by a tumor. If the sheath of the rectus is opened, the muscle will be
exposed, and the linea alba should be sought on the side upon which the
fascia fails to retract.
If the linea alba cannot readily be found, the incision should be
carried directly through the muscle. Some operators consider it an
advantage, in obtaining subsequent firm union, to expose the muscle in
this way. When the subperitoneal fat is reached, it should be torn and
pushed aside with the blunt closed forceps or with the fingers.
The peritoneum should be caught with forceps and drawn forward. The
assistant should catch the peritoneum with a second pair of forceps at
a point about ⅓ or ½ inch to the side of the first pair, and the small
fold of peritoneum thus produced should be incised with the knife. As
soon as the smallest opening is made in the peritoneum the air rushes
in and the intestines and omentum fall back. The opening is then
enlarged with the knife or scissors.
The greatest care must be exercised in those cases in which the omentum
or the intestines are adherent to the anterior abdominal wall. The
experienced operator usually observes indications of such a condition
as soon as he has passed through the linea alba. The tissues are more
rigid and unyielding than normal, and the peritoneum cannot be readily
picked up with the forceps. In such cases the operator should proceed
very slowly, and if necessary should enlarge the outer incision and
enter the peritoneum at a point above or below the area of adhesion.
=Exploration of the Abdomen.=--Having opened the peritoneum, the
operator should insert two fingers (the middle and the index finger of
the left hand) and should carefully examine the condition to be treated.
If necessary, he should retract the edges of the incision, and should
place the patient in the Trendelenburg position, in order to make an
ocular examination.
It is always advisable to make a preliminary investigation of this kind
before proceeding with the operation. In this way the diagnosis will be
corrected and complications which must be treated will be determined.
It may be found that what was thought to be a cyst is in reality a
uterine fibroid or perhaps a normal pregnancy; or the surgeon may
discover a hopeless condition, such as extensive cancer or peritoneal
papilloma, for which further operation will be useless.
=Protection of the Intestines and Omentum.=--During all manipulations
within the abdomen the peritoneum, intestines, and omentum should be
handled most gently. Injury of the peritoneum increases the danger
of shock, sepsis, and intestinal adhesions. The intestines should
never be allowed to protrude through the abdominal incision unless it
is necessary for the performance of the operation. Such a necessity
rarely, if ever, arises in gynecological operations. All the intestines
may be removed from the field of operation--the pelvis--by placing
the woman in the Trendelenburg position. Protrusion of intestines
through the abdominal incision should be prevented by using large
gauze pads or sponges. It is advisable always to surround the field
of operation by a wall of gauze pads. They protect the intestines and
prevent the escape of fluids into the upper peritoneum. This precaution
is especially desirable when the Trendelenburg position is used, to
prevent fluids from the pelvis escaping into the upper abdomen. The
pads should be introduced after being wrung out of warm water, and
should be replaced by fresh warm pads as soon as they become saturated
with fluid. If they become soiled by pus or other septic fluid, it is
safest to discard them for the remainder of the operation.
=Toilet of the Peritoneum.=--The field of operation, and, if necessary,
the general peritoneum, should always be cleaned and dried before
the abdominal incision is closed. This is done by sponging and by
irrigation with warm sterile water or with normal salt-solution. The
sponging should be performed with great gentleness, to avoid peritoneal
irritation. There are several regions in which fluids and blood-clots
are most likely to collect, and which therefore demand especial
inspection.
The chief of these regions is the hollow of the sacrum, or Douglas’s
pouch. Fluids also collect on the anterior surface of the broad
ligaments and in the renal hollows.
If but little fluid has escaped into the abdomen, and the field
of operation has been confined to the pelvis, we need look for
accumulations of fluid and blood only in Douglas’s pouch and in front
of the broad ligaments. If the upper portion of the abdomen has been
invaded, it is advisable to inspect the renal hollows. Blood-clot and
fluid may be readily removed by the sponge held in the fingers or in
forceps.
Irrigation of the peritoneum is not often required. It is not necessary
to flood the peritoneum with water in order to wash out blood-clot,
which may be removed with more accuracy by sponging. There is always
danger, in general irrigation of the peritoneum, of spreading infection.
Local washing of the pelvis is sometimes advisable if the operator
fears that the field of operation has been infected by the escape of
septic material. Such a condition may exist in operations for tubal or
ovarian abscess. The upper peritoneum should be first shut off from the
pelvic cavity with a wall of gauze sponges. This may be readily done
while the patient is in the Trendelenburg position. She should then be
placed in the horizontal position, while the operator, with the left
hand pressed against the wall of pads, prevents the intestines entering
the pelvis. The abdominal incision should be held open with retractors,
and the sterile irrigating fluid should be poured in from a flask or a
pitcher. The temperature of the fluid should be 100°-115° F. The fluid
may be removed by sponging, and washing may be repeated as often as
necessary.
In septic cases the writer has frequently performed such local washing
with a bichloride solution (1:2000 or 1:4000), followed by irrigation
with plain water.
If the patient is horizontal and the gauze pads be properly placed,
there is no danger of any of the fluid entering the upper peritoneal
cavity.
[Illustration: Fig. 205.--The mass-suture for closing the abdominal
incision: _S_, skin; _F_, fascia; _M_, muscle; _P_, peritoneum.]
=Closing the Abdominal Incision.=--A variety of methods have been
introduced for closing the abdominal incision. The simplest method,
that is applicable to all cases, is the interrupted mass-suture, or
the “through-and-through” suture. This suture passes through all the
structures of the abdominal wall (Fig. 205). Some operators advise
passing the suture to, but not through, the peritoneum. The writer
includes the edge of the peritoneum in the suture. These sutures should
be placed two or three to the inch, according to the thickness of the
abdominal wall.
Care should be taken to include all the structures in the embrace of
the suture. A carelessly applied suture sometimes fails to include
the retracted fascia and muscle. The needle should first be directed
outward and then inward as it passes through the abdominal wall. It
should not pass directly through, parallel to the sagittal plane of
the incision. Thus when the suture is tied it forms approximately a
circle, and the structures included in it are brought into a plane of
apposition.
[Illustration: FIG. 206.--The subcuticular or intra-cutaneous suture.
The fascia has been united by an interrupted suture.]
A long straight needle with a spear-point is convenient for introducing
the mass-suture. A gauze sponge should be placed beneath the incision
as the sutures are introduced, to prevent injury of the intestines and
the escape of blood into the peritoneum. When the pad is removed, the
omentum, if readily found, should be drawn down behind the incision.
Before each suture is secured the sides of the incision should be drawn
forward by traction on the ends of the suture, to ensure accurate
apposition upon the posterior or peritoneal aspect. If this precaution
is not taken, in a thick or rigid abdominal wall the cutaneous aspect
of the incision may be brought into accurate apposition, while a gap
will exist between the more posterior structures. Such imperfect
apposition is a frequent cause of ventral hernia. The mass-sutures
should not be removed for two weeks. The early removal of sterile
sutures is of no advantage whatever, and may cause ventral hernia. The
writer often leaves them in for three weeks.
After the sutures are removed the incision should be strapped with
adhesive plaster.
The application of a buried suture of catgut or of silver wire, passed
through the muscle and fascia, is a useful addition to the mass-suture
and an additional preventive of hernia.
Various methods of uniting the tissues by sutures in separate
layers are used. A very good method is to close the peritoneum by a
continuous suture of fine silk, then to unite the muscle and fascia
by a continuous suture of catgut, and finally to close the cutaneous
edge with an interrupted or a continuous suture of silkworm gut or
silk. The subcuticular or the intra-cutaneous suture (Fig. 206) is very
convenient for this purpose.
If the abdominal wall be fat, it is advisable to introduce a second
catgut suture through the subcutaneous fat. When the structures are
united in layers, a hematoma sometimes forms between two planes of
suture, and, if not absorbed, the anterior portion of the wound may
break down. This accident, which is caused by hemorrhage after the
sutures are secured, may be prevented by employing, in addition to the
usual dressing, a compress of gauze placed over the incision.