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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_630_Библиотеки_им_академика_М_И_Перельмана
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a
7
Uterine vessels
8
b
Clamps on
uterine vessels
9
Uterosacral ligament
Clamp on vault
7a
Cervix
Method of
applying clamps
10
Incising the
vaginal wall
Double ligature of
uterine pedicle
Cervix
11
Cervix
12
Closure
of vault
383
PLATE
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179
INDICATIONS Removal of the fallopian tubes or ovaries is indicated
for in ammatory involvement of the adnexa that cannot be relieved by
the use of conservative measures including antibiotics, for ovarian cysts,
neoplasms, ectopic pregnancies, and so forth. Bilateral oophorectomy is
advised by some as a desirable procedure in extensive carcinoma of the
rectum because of the susceptibility of the ovaries to tumor transplantation from lesions of the gastrointestinal tract. In the absence of malignancies every e ort should be made to conserve even remnants of functioning
ovarian tissue in the younger patients.
PREOPERATIVE PREPARATION (See Gynecologic System—Routine for
Abdominal Procedures, page .) e skin is covered by a sterile transparent plastic drape.
OPERATIVE PREPARATION e skin is prepared in the routine manner.
e surgeon stands on the patient’s le side.
INCISION AND EXPOSURE See Gynecologic System—Routine for Abdom-
inal Procedures. In the presence of extensive pelvic in ammation, the intestines are o en attached to the adnexa by adhesions that must be separated
either by blunt or sharp dissection. Haste and roughness must be avoided.
By placing the adhesions on tension as they are cut, the cautious surgeon
can almost always develop a cleavage plane between the diseased adnexa and
the other structures. e intestines are pushed aside carefully and packed
away with warm, moist gauze pads, or placed in a plastic bag and moistened
with warm saline. e free adnexa are then held upward with a half-length
clamp (figure 1).
S—O
A. SALPINGECTOMY
DETAILS OF PROCEDURE e uterus is held forward either by a tenacu-
lum applied to the round ligament adjacent to the uterus (figure 1) or
by a ne absorbable suture through the fundus (figure 7). e mesosalpinx is clamped with a su cient number of half-length clamps, usually three pairs, to include its entire length (figure 3). To avoid possible
interference with the blood supply of the ovary, the line of incision is kept
near the fallopian tube (figure 1). As an alternative, the mesosalpinx
may be saved by controlling the blood supply with three or four mattress
sutures meticulously placed to avoid vessels when the needle is introduced
(figure 2). Regardless of the method used to divide the mesosalpinx,
an elliptical incision is made through the thickness of the uterine wall to
cone out the interstitial portion of the fallopian tube (figure 4). Ligatures are applied to the mesosalpinx as the half-length clamps are removed
(figure 4). Brisk bleeding is usually encountered from the cornual artery,
which may be controlled either by placing deep mattress sutures through
this area before the interstitial portion of the tube is excised, or by manual
compression while mattress sutures are placed (figure 5). ese mattress
sutures, which are tied together gently to avoid tearing the friable uterine
wall, e ect an even approximation and give complete hemostasis.
B. SALPINGECTOMY AND OOPHORECTOMY
DETAILS OF PROCEDURE When both the tube and ovary are to be
removed, incision is made as shown in figure 6. e half-length clamps
are applied to the infundibulopelvic ligament, which includes the ovarian vessels (figure 6). Prior to ligating the ovarian vessels the pararectal space should be opened and the uterus identi ed. e vessels are
divided and tied with a trans xing suture of absorbable suture. e
leaves of the broad ligament are either doubly clamped with curved,
half-length clamps and divided with scissors or scalpel, or ligated with
mattress sutures carefully placed so that the needle does not penetrate
any of the thin-walled veins between its layers. Now the interstitial portion of the fallopian tube is removed as shown in figure 4. e appearance of the raw surfaces of the broad ligaments a er the tubes and one
ovary have been resected is shown in figure 7. Where the ovarian ligament is quite long, allowing the ovary to prolapse into the pelvis, it is
shortened by means of a mattress suture through the posterior wall of
the uterus and the ovarian ligament, thus suspending the ovary adjacent
to the posterior wall of the uterus. e raw surfaces remaining a er the
excision of part or all of the uterine adnexa must be covered with peritoneum. Moreover, some type of suspension is usually advisable a er
removal of a part or all of the adnexa.
When the suspension of the uterus is to be carried out a er removing
the tube or tube and ovary, the shortening of the round ligament may be
accomplished so as to cover a great part of the raw surface with peritoneum on either side. If the cut surface of the infundibulopelvic ligament is
not covered, a suture, S, which includes a bite of the peritoneum on either
side of the pedicle, is taken to enfold it with peritoneum (figure 8). When
another type of suspension is used, the raw surfaces remaining a er removal
of part or all of the adnexa may be buried by approximating the peritoneum
over them, using either a continuous suture, A, of absorbable suture, or
interrupted mattress sutures, B (figure 9). Several interrupted sutures are
placed to approximate the posterior wall of the fundus of the uterus and the
round ligaments (figure 8). ree or four sutures are usually su cient to
ensure an adequate midline suspension of the uterus and at the same time
to cover most of the raw surfaces.
CLOSURE (See Gynecologic Procedures—Routine for Abdominal Procedures.)
POSTOPERATIVE CARE (See Gynecologic Procedures—Routine for Abdom-
inal Procedures.) ■
384
1
Round ligament
Mesosalpinx
Fallopian tube
Ovary
Line of amputation
2
Alternate method
3
67
Mesosalpinx
Ovary and tube
4
Interstitial
portion of tube
5
Closure
of cornu
Infundibulopelvic
ligament
Line of amputation
8
S
S
Posterior plication of round ligaments
Infundibulopelvic
ligament
9
A
Continuous
suture
Ovary
B
Interrupted
sutures
385
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G S—R
V P
PREOPERATIVE PREPARATION In the majority of instances, no douches
are used over a prolonged period. e symphysis, perineum, and adjacent
surfaces are not shaved or clipped carefully before operation. A cleansing
enema is not necessary. Prophylactic antibiotics are administered.
ANESTHESIA Light general or intravenous anesthesia may be employed.
Saddle-block or low spinal anesthesia is very satisfactory.
POSITION Vaginal procedures are carried out in the lithotomy position.
A er the induction of anesthesia, the patient’s legs are raised simultaneously
to avoid straining the sacroiliac joints and are xed in stirrups. Whenever
possible, the legs are elevated upward and backward to permit the assistant
to be nearer the eld of operation. e patient’s hips are li ed well beyond
the margin of the table to provide better exposure, to avoid unnecessary
wetting of the patient, and to make possible the later introduction of the
weighted speculum. e operating table is turned so that the light falls on
the eld and is focused on the introitus.
OPERATIVE PREPARATION e surgeon or rst assistant, wearing sterile
gloves, places a folded sterile towel over the patient’s symphysis as a guide to the
upper margin of the eld to be cleaned and a similar towel under the buttocks.
e vulva and adjacent skin areas are scrubbed from above downward with
pairs of gauze sponges held in gloved hands. e gauze sponges are saturated
with a solution of water and a detergent with germicidal action, such as a povidone-iodine–containing scrub. In all, ve pairs of sponges are used, each being
discarded as it comes in contact with the anus. e vaginal vault is cleaned with
six saturated sponges held in long sponge forceps. Four dry sponges are used to
remove excess solution from the vaginal vault. e cleaned skin is blotted dry
with a sterile towel. e anus may be excluded from the operative area by the
use of a spray-on adhesive compound and the application of a piece of sterile,
transparent plastic lm. e footboard of the operating table is raised to a convenient level and serves as an instrument table for the surgeon. A sterile, fenestrated perineal drape is applied, and the bladder is emptied by catheterization.
EXPOSURE Adequate exposure is obtained by introducing into the vagina
either a weighted vaginal speculum or a self-retaining retractor, depend-
ing on the type and location of the operation to follow. A thorough pelvic
examination is made as a preliminary to the technical procedures.
POSTOPERATIVE CARE A er the completion of the operation, the vagina
and perineum are cleaned with sponges moistened with saline or a mild
antiseptic solution. A sterile perineal pad is then applied and held in position by a T binder. When constant bladder drainage is desired, a retention
catheter is inserted and held by adhesive tape anchored to the thigh. e
drapes are removed, and the legs are withdrawn slowly and simultaneously
from the stirrups to prevent disturbances in blood pressure and straining
of the sacroiliac joints.
e immediate postoperative care is similar to that following abdominal procedures, with certain added perineal precautions. Indwelling
catheters are not necessary. e patient may be catheterized every to
hours, depending on the uid intake, until she voids voluntarily. Postvoiding residuals should be checked. Values less than mL usually indicate satisfactory emptying. ese patients should take in extra oral liquids
to ensure a liberal urine output. Antibiotics may be given if a urinary
tract infection occurs. e daily intake and output are recorded for at least
hours.
Blood transfusion may be indicated, depending upon the blood loss at
the time of operation. If sepsis is suspected or any cystitis exists, antibiotics
are usually indicated.
A er every voiding or defecation, the perineum is cleaned with cotton
pledgets moistened with an antiseptic solution and a sterile pad is reapplied. e nurse must be careful to do all wiping away from the site of operation. is strict sterile perineal precaution is continued for approximately
a week. Warm, moist applications or dry heat to the perineum may be used
to relieve pain. Sitz baths promote comfort and stimulate voiding. A stoolso ening preparation is given starting either on the evening of surgery or
the rst postoperative morning. A er procedures requiring extensive tissue
dissection, bowel movements are delayed for to days. Douches of saline
or a mild antiseptic solution may be started a er to days unless vaginal
bleeding is initiated. e principle of early ambulation is followed. ■
387
PLATE
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180
D T C
L—D C
INDICATIONS Cervical conization is indicated for suspicious lesions of
the uterine cervix to con rm or exclude the diagnosis of cervical cancer.
Certain outpatient procedures usually precede conization and are useful
in the investigation of cervical lesions. e Papanicolaou smear taken with
an Ayerst applicator is an e cient method of establishing the diagnosis of
gross or microscopic lesions of the uterine cervix. In the event of a suspicious Papanicolaou smear or an obvious lesion of the cervix, the cervix
is sprayed with Graham’s iodine solution. A punch biopsy is taken in
the area, which does not stain in an otherwise deep-mahogany stained cervix (figure 1). A er exposure of the cervix, the punch biopsy forceps is
introduced, and a piece of unstained cervical tissue is removed with inclusion of a small bite of surrounding healthy tissue. Alternatively, many surgeons now stain the cervix with acetic acid and perform the biopsies with
a culposcope.
A suspicious or positive Papanicolaou smear and/or positive punch
biopsy necessitates operation with cold knife conization, the de nitive
diagnostic procedure for malignant lesions of the cervix.
PREOPERATIVE PREPARATION (See Gynecologic System—Routine for
Vaginal Procedures, on the preceding page.) Douches are omitted.
ANESTHESIA Either general or spinal anesthesia is given.
POSITION e patient is placed in a dorsal lithotomy position.
OPERATIVE PROCEDURE e usual preparation of the perineum is car-
ried out, but preparation of the vagina and cervix is avoided, lest loosely
attached epithelium essential for diagnosis be destroyed. Even during the
pelvic examination under anesthesia, the examiner’s gloved ngers avoid
the surface of the cervix. Following the pelvic examination, a speculum is
inserted into the vagina and the anterior lip of the cervix is grasped with
a single-toothed tenaculum. Dilatation and curettage is not performed
before conization because it interferes with the lining of the endocervical
canal and the squamocolumnar junction, making a pathologic diagnosis
more di cult.
DETAILS OF PROCEDURE e cervix may be sprayed with a iodine
solution for evidence of possible carcinoma. A Garret retractor can be
placed in the cervix for traction purposes. e surgeon maintains traction
on the tenaculum as an incision is made with a No. triangular-shaped
blade at a -degree angle toward the endocervical canal. e involved portion of the cervix is excised (figure 2). e proximal . cm of the endocervix is also removed (figure 3). e removed tissue, which appears as a
cone, is immediately placed in a xative to avoid loss of diagnostic epithelium through contact with gauze and so forth. It is important to remove
the endocervical canal, since carcinoma of the cervix is frequently of multicentric origin and over percent of invasive lesions occur in the endocervical canal. It is advisable not to do too deep a conization, which would
involve the internal os, because stenosis could result (figure 3a). A laser
may be used in place of the cold knife or electrocautery wire.
A er the cone is removed, some prefer to smooth surgical margins by
using the cutting current with the triangular wire loop completely encircling the coned area. is is o en satisfactory in establishing hemostasis. e
wire triangle is kept quite super cial. No e ort is made to cut deeply into
the body of the cervix. Individual points of hemorrhage are coagulated if
necessary. e complete cone can be excised with the triangular wire loop
(figures 4 and 4a). Persistent bleeding a er cold-knife conization is controlled by interrupted gure-of-eight ne sutures.
In the presence of extensive chronic cystic cervicitis, especially when
the cervix is hypertrophied, a more extensive conization or amputation of
the cervix should be considered. A rim of mucosa at least cm wide should
be mobilized from the entire margins of the amputated cervix. e mobilized mucosa will be necessary to reconstruct the new cervix. is can be
accomplished by the placement of anterior and posterior Sturmdorf sutures
(figures 5 and 6).
e proper placement of the rather complicated Sturmdorf stitch can
be enhanced if a moderate-size Hank’s dilator is inserted into the cervical canal. A cervical cutting needle is introduced approximately cm from
the cervical margin in the midline anteriorly and directed out over the
Hank’s dilator (figure 5). e mobilized mucosa in the midline anteriorly
is grasped with forceps and a transverse bite is taken with the same needle
(figure 5). e Hank’s dilator is reinserted in order to assist mechanically
in the proper placement of the needle within the cervical canal and back
out in the midline anteriorly.
e e ciency of this suture in inverting the anterior wall is tested by
traction on the suture. Accuracy is essential, and the surgeon should not
hesitate to replace the suture (figure 7).
e patency of the reconstructed cervical canal is tested by the insertion
of a Hank’s dilator (figure 7a). A similar Sturmdorf suture is placed in the
mid-line posteriorly. Again, with the Hank’s dilator in the cervical canal to
ensure its patency, the lateral margins of raw surface are closed with interrupted absorbable sutures. ese lateral sutures should include the margins
of the mucosa and a bite in the underlying cervix. One or two sutures on
either side are usually su cient (figure 8). It is preferred to leave no pack
in the vagina, as good hemostasis should be obtained at the completion of
the procedure.
e patency and direction of the cervical canal are determined by the
passage of a uterine sound. e cervix is dilated gently with a series of lubricated, graduated Hegar dilators, and a systematic curettage is carried out
(figures 9 and 10). For diagnostic curettage dilatation up to a No. or
Hegar is adequate. e largest sharp curette than can pass through the
dilated cervix is gently inserted and passed to the fundus. e anterior wall
is scraped until all endometrium is removed, then the posterior wall. Curettage is then repeated on the right and le walls, the fundus, and nally the
uterine cornua. Following curettage of the uterus, persistent bleeding from
the cold knife conization is controlled with gure-of-eight sutures. Diagnostic conizations are of such limited scope that plastic reconstruction of
the cervix is not required.
POSTOPERATIVE CARE Postoperative care in a cervical conization is most
important. Wide and deep conizations of the internal os may be the source
of cervical stenosis. Postconization stenosis may be associated with the
development of dysmenorrhea as well as sterility. Postconization patients
should be seen in the o ce in weeks for dilatation of the cervix. Under
no circumstances should a stem pessary be le in the cervix at the time of
conization, since infection may supervene in the presence of a foreign body.
On occasion, patients develop a perimetritis. is usually responds very well
to antibiotics. ■
388
1
Biopsy forceps
4
Cautery
4a
Speculum
2
5
3
Amount
3a
removed
6
7
Dilatation and curettage
9
7a
Dilator
Dilator
8
10
Curette
Weighted
retractor
389
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ADDITIONAL
PROCEDURES
PLATE
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181
INDICATIONS e indications for subtotal thyroidectomy are decreasing
because of the lower incidence of endemic goiters, both colloid and nodular,
and the increasing e ectiveness of medical therapy in patients who present
with thyrotoxicosis, whether this is due to Graves’ disease or to nodular
toxic goiter.
A de nite indication for subtotal thyroidectomy is the removal of a solitary nodule in a young person, especially female, when the mass does not
take up radioiodide on thyroid scan and hence is suspected of being malignant. A simple ne needle aspiration may yield a suspicious cytology. Total
lobectomy ensures a better margin and allows pathologic examination of
the excised thyroid lobe for multicentric foci should a malignant tumor be
found. Many surgeons combine a total lobectomy on the involved side with
a subtotal lobectomy on the alternate side.
e controversy as to whether surgical or medical treatment for thyrotoxicosis is desirable in patients younger than to years and in pregnant
patients has yet to be resolved, but it is generally agreed that the use of
radioactive iodine is contraindicated. Surgical removal should be considered if antithyroid drugs are tolerated poorly or required in large, prolonged
doses and if thyrotoxicosis recurs a er an apparently successful medication regimen. In the poor-risk patient or one who has had a recurrence
of toxicity following previous thyroid surgery, medical therapy is usually
the treatment of choice. Also, some pregnant patients may be best treated
with antithyroid drugs in order to defer surgery until a er the patient has
delivered. However, thyroid replacement is given daily once the patient is
euthyroid to prevent the development of a goiter in the fetus.
Subtotal thyroidectomy or total thyroidectomy is performed for an
enlarged thyroid gland that produced pressure symptoms or an undesirable cosmetic e ect (endemic goiter), for toxic goiters, and occasionally for
in ammatory conditions such as Riedel’s struma and Hashimoto’s disease.
PREOPERATIVE PREPARATION e only indication for emergency thy-
roidectomy is in that exceedingly rare situation where pressure symptoms
develop rapidly due to intrathyroid hemorrhage. In all other situations
thyroidectomy should be considered an elective procedure performed
when the patient is in optimal physical health. is is true particularly in
thyrotoxicosis.
Patients with thyrotoxicosis should be treated with antithyroid drugs
until an euthyroid state is reached. Because the (thiourea) compounds block
the synthesis of thyroxine but do not inhibit the release of the hormone
from existing colloid stores, the time required for symptomatic improvement may vary widely from weeks to as long as months. e variability
is in part related to the size of the gland, since large goiters usually contain
more colloid. When the patient has become euthyroid, iodine—given as
Lugol’s solution, potassium iodide solution, or tablets or syrup of hydriodic
acid—can be administered for days before surgery (optional). If this procedure is followed, almost any thyroidectomy can be performed under optimal conditions. If signi cant tachycardia due to an increased intraoperative
or postoperative release of thyroid hormone is encountered, propranolol
should be used to control it.
ANESTHESIA Endotracheal intubation is preferred, particularly if there
has been long-standing pressure against the trachea, substernal extension,
or severe thyrotoxicosis. For the severely toxic or apprehensive patient, a
short-acting intravenous barbiturate may be given in the patient’s room to
avoid undue excitement. General inhalation anesthetic agents are used.
POSITION e patient is placed in a semierect position with a folded sheet
underneath the shoulders so that the head is sharply angulated backward
(figure 1). e head rest of the table can be lowered to hyperextend the
neck further. e anesthetist should make certain that the head is perfectly
aligned with the body before the line of incision is marked. Any deviation
to the side may cause the surgeon to make an inaccurately placed incision.
OPERATIVE PREPARATION e patient’s hair may be covered with a
mesh cap to avoid contamination of the eld. e skin is prepared routinely.
T, S
Before the incision is made, it may be accurately outlined by compressing
a heavy silk thread against the skin. e incision should be made about
two ngers above the sternal notch and should be almost exactly transverse, extending well onto the borders of the sternocleidomastoid muscles
(figure 2). In the presence of a large goiter, it should be made a little higher
so that the nal scar will not lie in the suprasternal notch. A short midline
crosshatch may be made across the outlined incision to provide a guide to
accurate approximation of the skin at closure (figure 2). e site for the
incision is then draped with sterile towels secured with towel clips at the
four corners, similar to a routine abdominal draping. Trans xing sutures or
staples may be placed through the towel into the skin in the middle of the
incision on either side. is secures the towel at the center of the incision
and avoids contamination when the aps are re ected upward and downward. Skin towels sutured or clipped to the eld may be eliminated by the
use of a sterile transparent plastic drape that is made adherent to the skin
with an adhesive spray. A large sterile sheet with an oval opening completes
the draping.
INCISION AND EXPOSURE e surgeon stands at the patient’s right side,
since it is customary to commence the procedure at the right upper pole.
He or she should be thoroughly familiar with the anatomy of the neck,
especially with the blood supply and anatomic relationships of the thyroid
gland (figures 3, 4, and 5). A thorough understanding of the anatomy
of this region should lessen the complications of hemorrhage or injury to
the recurrent laryngeal nerve, which may course through the bifurcation
of the inferior thyroid artery, and injury to the parathyroids. A dry eld is
maintained if the various fascial planes are carefully considered during the
procedure (figure 3). e locations of the major blood vessels, the para-
thyroids, and recurrent laryngeal nerve are shown in figures 3 and 5.
e surgeon applies rm pressure over gauze sponges to one margin of
the wound, while the rst assistant applies similar pressure to the opposite margin. In this manner the active bleeding from subcutaneous tissue
is controlled and the margins of the wound are evenly separated. e skin
incision is made with a deliberate sweep of the scalpel, dividing the skin and
subcutaneous tissue simultaneously if the panniculus is not too thick. e
belly of the scalpel should be swept across the tissues but not pressed into
them. Bleeding vessels in the subcutaneous tissues are seized with hemostats; the large vessels are ligated, while small vessels are merely clamped
and released or cauterized. Hemostats with nely tapered jaws that can be
applied to the vessel alone are the best type to use, because they permit
ligation without strangulation of a tab of surrounding fat. One or two mass
ligatures may do no harm, but many strangulated bits of tissue cause induration and in ammation during healing since the avascular tabs must be
absorbed. Electrocautery is preferred to control bleeding.
e incision is deepened to the areolar tissue plane just below the platysma muscle where an avascular space is reached. All active bleeding points
are grasped with curved, pointed hemostats that are re ected upward or
downward depending upon to which side of the incision they have been
applied (figure 6). Active bleeding and danger of air embolus may occur
from accidental openings made into the anterior jugular vein if too deep
an incision is made. Sharp dissection may be used alternately with blunt
gauze dissection to facilitate the freeing of the upper ap (figures 7 and 8).
Usually, a small blood vessel will be encountered, high up beneath the ap
on either side, which will produce troublesome bleeding unless it is ligated
(figures 8 and 9). e dissection goes up to the thyroid notch, exposing all
of the thyroid cartilage, as well as down to the suprasternal notch. Outward
and downward traction is then applied to the lower skin ap as it is freed
from the adjacent tissue down to the suprasternal notch (figure 9). At the
very lowest part of the wound, care should be taken to avoid damage to the
communicating arch connecting the two anterior jugular veins. If the veins
or the arch is entered, the descending branches of the anterior jugular vein
should be ligated below the level of the communicating arch in order to
minimize the chance of air embolism (figure 9).
CONTINUES
392
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