IThe Bristol
fll>ebico==Gbmu-otcal Journal. "
Scire est nescire, nisi id Scire alius sciret."
JUNE,
AN
1920.
THE
AND
CYSTOCELE.
Walter C.
PROLAPSE
OF
FOR
OPERATION
Professor 0/
me
CURE
Swayne, M.D., B.S.,
Obstetrics in the University to the Bristol Royal
Prolapse and cystocele may
of Bristol; Infirmary.
occur
either
as
Obstetric
Physician
separate entities,
both may be found in the same patient. The operative procedures described are applicable to either condition
or
separately,
to
principle, but The
both
when
they
occur
together,
with certain modifications in detail,
object
of the
procedure
is to reconstruct the
anatomical relations of the parts concerned, the anatomical relations existing as the result of the or
that the
or,
in
to rectocele.
so
original to alter
deformity
effect of the
original physical before is It necessary reproduced. a moment for to consider the describing operative procedures the normal anatomy of the parts concerned and the altera-
or
displacement
natural
relations
is
tions therein which lead to the mentioned. Vol. XXXVII.
No. 139.
production
of the deformities
82
WALTER C. SWAYNE
DR.
It is unnecessary to describe in anatomical detail the construction of the upper part of the pelvic diaphragm beyond making the following statements :?
(the sides of which are formed by the anal and pelvic fascial planes) is so attached and at such a level that in the erect posture it can have no possible function as a support of the uterus. 2. It does enter into the perineum, and at the point where its fibres divaricate to permit of the passage of the vagina, it can prevent the egress from the latter organ of any solid body which may be within it, e.g. a pessary. 3. The bases of the broad ligaments contain a comparatively large mass of connective tissue, the fibres of which follow the course of the uterine artery from the parietes The levator ani with its fascial sheath
1.
to the uterus.
4. The floor of the bladder is separated from the anterior wall of the vagina by an interval which contains a felt-work of connective tissue described a
by
one
of
the
(which, by the way, is exactly meanings of the word fascia,
mat). It should be stated with
regard to 3 and 4 that the tissue elements described connective do not form either definite dissectible bands, such the
joints,
or a
thigh, but a a soft woolly triangular bell-rope
lata of the likened to and
so
a
the
ordinary ligaments of plane, such as the fascia structure which may perhaps be as
definite dissectible
in the
one case
felted mat in the other.
The structures in 3 and 4 are more or less continuous, that the connective tissue of this part of the pelvic floor
would, if
separated left in
only being obscured by with
an
a
from the other soft
situ),
parts (the
resemble in outline the
circular disc of
more
than her
indentation in the centre of its
The connective tissue
(the
two
uterus
moon
own
half
diameter
intersecting arc. portions of which found
OPERATION
between
FOR
CURE
OF
PROLAPSE
AND
CYSTOCELE.
83
layers of the broad ligaments at their bases accompanying the uterine vessels from their origin to the uterus and described as the ligaments of Patterson) is the actual support both of the uterus and the base of the bladder. The uterus is retained at its proper level in the pelvis by the so-called ligaments of Patterson, and the the
prolapse of the uterus is, in the majority stretching of these structures by parturition, cystocele is due to a divarication, or one might say a
primary
of
cause
of cases, the while
hernial orifice in the felt-work of connective tissue between the bladder and the the
Basing my practice
prolapse
vaginal wall. operative procedure
on
these facts, it has been
for the last seventeen years to deal with and cystocele as follows :?
cases
of
The cervix uteri is first
grasped with vulsellum forceps and drawn outside the vaginal outlet. A median incision through the vaginal mucous membrane is carried from a point about three-quarters of an inch behind the urethral orifice to the mid-point of the reflection of the vaginal mucous membrane from the cervix. The vaginal mucous
to
a
membrane is then incised
on
each side of the cervix
point just behind the mesial plane completed forming a T "
incisions when
"
of the uterus, the with
a
curved top.
(Fig- i.) Two lateral in
shape
then dissected up roughly and attached by their longer sides.
flaps
are
triangular
The bladder is separated from the uterus as high as may be necessary to expose the bases of the broad ligaments, and the dissection carried onwards on each side until sufficient space is obtained. (Fig. 2.) At this stage, if there is
bladder will be
seen
a
well-marked
projecting through
in the felt-work connective tissue
(Fig- 3-)
as a
cystocele,
the
the hernial orifice
soft
puckered
mass.
DR.
84
WALTER C. SWAYNE
Fig. Pig. Volsellum on cervix. membrane. 3. Longitudinal incision round cervix. i. i.
Fig. i i
and 2.
Flaps
i.
Tenaculum grasping vaginal mucous incision in vaginal wall. 4. Transverse 2.
2. 2.
he]d raised and held
by
tenacula.
OPERATION
FOR
CURE
OF
PROLAPSE AND CYSTOCELE.
85
.bio. Fig. 1. 1, 1.
Flaps
as
before.
2. 2.
3. Base of bladder
protruding.
fully curved Hagedorn's needle, a thick catgut suture is passed through the base of the broad ligament on each side, usually from above downwards in each case. (Fig. 4.) With
a
Fig. 1 ,
*? J.
r. 1.
as Flaps as r?ad road ligaments.
before. 2, 3. Suture.
2.
4. Needles carry suture
through
bases of
86
DR.
WALTER C. SWAYNE
This suture is then cervix is
pushed
firmly tied,
with the result that the
upwards, and two folds running from just outside the symphysis forming a well-
backwards and
of connective tissue
can
be
seen
the tied suture to the back of
triangle with its base at the cervix. These folds sewn together by means of a continuous suture of medium catgut, the bladder being pressed upwards with a flat retractor. (Fig. 5.) This suture can be reinforced if necessary by a second over it. The vaginal flaps are now After the ends have been cut off brought together.
marked are
then
Fig. Fig. 5. 5. Suture in bases of broad ligaments tied. of broad tied. 2. 2. Running suture bringing Running suture bringing 4. 3. Base of of bladder folds of fibrous tissue together. bladder now now pushed 3. Base 4. pushed up. up. removed. to be of redundant redundant flaps Dotted lines marking edge of flaps to be removed. 1.
deep sutures and any redundant portions cut away with scissors, the flaps are sewn together with either interrupted or continuous catgut sutures. (Fig. 6.) The cervix may be amputated or the perineum repaired the
as
case may demand ; in the case of between the first and second steps of the procedure
the necessities of the
thejformer described, case
or
on
of the latter.
the
completion
of the
procedure
in the
OPERATION
This
likely
FOR
operation
to
CURE
OF
should not be
become
disability, late
only
and that
a
had
was
AND
performed
failure to
one
due to
a
parturition
a
woman
will
almost
on
as
suture round
87
CYSTOCELE.
parturition Care injury. original
pregnant,
certainly reproduce the be taken to^avoid passing So far I have
PROLAPSE
must
also
ureter. cure
the
at an
original unusually
age.
Fig. i. i.
Longitudinal Urethral orifice.
incision sutured.
Since I wrote the above
6. 2.
Transverse incision sutured.
opportunity has occurred examining after an abdominal section the conditions produced by this operation. It was found that there was a definite shelf right across the anterior half of the pelvis in front of the uterus. This shelf is produced by the tension put on an
of
the cellular connective tissue in the situations mentioned under
(3)
and
(4).
The illustrations
Sewell.
were
sketched
from life
by
Mr.
A.
fll>ebico==Gbmu-otcal Journal. "
Scire est nescire, nisi id Scire alius sciret."
JUNE,
AN
1920.
THE
AND
CYSTOCELE.
Walter C.
PROLAPSE
OF
FOR
OPERATION
Professor 0/
me
CURE
Swayne, M.D., B.S.,
Obstetrics in the University to the Bristol Royal
Prolapse and cystocele may
of Bristol; Infirmary.
occur
either
as
Obstetric
Physician
separate entities,
both may be found in the same patient. The operative procedures described are applicable to either condition
or
separately,
to
principle, but The
both
when
they
occur
together,
with certain modifications in detail,
object
of the
procedure
is to reconstruct the
anatomical relations of the parts concerned, the anatomical relations existing as the result of the or
that the
or,
in
to rectocele.
so
original to alter
deformity
effect of the
original physical before is It necessary reproduced. a moment for to consider the describing operative procedures the normal anatomy of the parts concerned and the altera-
or
displacement
natural
relations
is
tions therein which lead to the mentioned. Vol. XXXVII.
No. 139.
production
of the deformities
82
WALTER C. SWAYNE
DR.
It is unnecessary to describe in anatomical detail the construction of the upper part of the pelvic diaphragm beyond making the following statements :?
(the sides of which are formed by the anal and pelvic fascial planes) is so attached and at such a level that in the erect posture it can have no possible function as a support of the uterus. 2. It does enter into the perineum, and at the point where its fibres divaricate to permit of the passage of the vagina, it can prevent the egress from the latter organ of any solid body which may be within it, e.g. a pessary. 3. The bases of the broad ligaments contain a comparatively large mass of connective tissue, the fibres of which follow the course of the uterine artery from the parietes The levator ani with its fascial sheath
1.
to the uterus.
4. The floor of the bladder is separated from the anterior wall of the vagina by an interval which contains a felt-work of connective tissue described a
by
one
of
the
(which, by the way, is exactly meanings of the word fascia,
mat). It should be stated with
regard to 3 and 4 that the tissue elements described connective do not form either definite dissectible bands, such the
joints,
or a
thigh, but a a soft woolly triangular bell-rope
lata of the likened to and
so
a
the
ordinary ligaments of plane, such as the fascia structure which may perhaps be as
definite dissectible
in the
one case
felted mat in the other.
The structures in 3 and 4 are more or less continuous, that the connective tissue of this part of the pelvic floor
would, if
separated left in
only being obscured by with
an
a
from the other soft
situ),
parts (the
resemble in outline the
circular disc of
more
than her
indentation in the centre of its
The connective tissue
(the
two
uterus
moon
own
half
diameter
intersecting arc. portions of which found
OPERATION
between
FOR
CURE
OF
PROLAPSE
AND
CYSTOCELE.
83
layers of the broad ligaments at their bases accompanying the uterine vessels from their origin to the uterus and described as the ligaments of Patterson) is the actual support both of the uterus and the base of the bladder. The uterus is retained at its proper level in the pelvis by the so-called ligaments of Patterson, and the the
prolapse of the uterus is, in the majority stretching of these structures by parturition, cystocele is due to a divarication, or one might say a
primary
of
cause
of cases, the while
hernial orifice in the felt-work of connective tissue between the bladder and the the
Basing my practice
prolapse
vaginal wall. operative procedure
on
these facts, it has been
for the last seventeen years to deal with and cystocele as follows :?
cases
of
The cervix uteri is first
grasped with vulsellum forceps and drawn outside the vaginal outlet. A median incision through the vaginal mucous membrane is carried from a point about three-quarters of an inch behind the urethral orifice to the mid-point of the reflection of the vaginal mucous membrane from the cervix. The vaginal mucous
to
a
membrane is then incised
on
each side of the cervix
point just behind the mesial plane completed forming a T "
incisions when
"
of the uterus, the with
a
curved top.
(Fig- i.) Two lateral in
shape
then dissected up roughly and attached by their longer sides.
flaps
are
triangular
The bladder is separated from the uterus as high as may be necessary to expose the bases of the broad ligaments, and the dissection carried onwards on each side until sufficient space is obtained. (Fig. 2.) At this stage, if there is
bladder will be
seen
a
well-marked
projecting through
in the felt-work connective tissue
(Fig- 3-)
as a
cystocele,
the
the hernial orifice
soft
puckered
mass.
DR.
84
WALTER C. SWAYNE
Fig. Pig. Volsellum on cervix. membrane. 3. Longitudinal incision round cervix. i. i.
Fig. i i
and 2.
Flaps
i.
Tenaculum grasping vaginal mucous incision in vaginal wall. 4. Transverse 2.
2. 2.
he]d raised and held
by
tenacula.
OPERATION
FOR
CURE
OF
PROLAPSE AND CYSTOCELE.
85
.bio. Fig. 1. 1, 1.
Flaps
as
before.
2. 2.
3. Base of bladder
protruding.
fully curved Hagedorn's needle, a thick catgut suture is passed through the base of the broad ligament on each side, usually from above downwards in each case. (Fig. 4.) With
a
Fig. 1 ,
*? J.
r. 1.
as Flaps as r?ad road ligaments.
before. 2, 3. Suture.
2.
4. Needles carry suture
through
bases of
86
DR.
WALTER C. SWAYNE
This suture is then cervix is
pushed
firmly tied,
with the result that the
upwards, and two folds running from just outside the symphysis forming a well-
backwards and
of connective tissue
can
be
seen
the tied suture to the back of
triangle with its base at the cervix. These folds sewn together by means of a continuous suture of medium catgut, the bladder being pressed upwards with a flat retractor. (Fig. 5.) This suture can be reinforced if necessary by a second over it. The vaginal flaps are now After the ends have been cut off brought together.
marked are
then
Fig. Fig. 5. 5. Suture in bases of broad ligaments tied. of broad tied. 2. 2. Running suture bringing Running suture bringing 4. 3. Base of of bladder folds of fibrous tissue together. bladder now now pushed 3. Base 4. pushed up. up. removed. to be of redundant redundant flaps Dotted lines marking edge of flaps to be removed. 1.
deep sutures and any redundant portions cut away with scissors, the flaps are sewn together with either interrupted or continuous catgut sutures. (Fig. 6.) The cervix may be amputated or the perineum repaired the
as
case may demand ; in the case of between the first and second steps of the procedure
the necessities of the
thejformer described, case
or
on
of the latter.
the
completion
of the
procedure
in the
OPERATION
This
likely
FOR
operation
to
CURE
OF
should not be
become
disability, late
only
and that
a
had
was
AND
performed
failure to
one
due to
a
parturition
a
woman
will
almost
on
as
suture round
87
CYSTOCELE.
parturition Care injury. original
pregnant,
certainly reproduce the be taken to^avoid passing So far I have
PROLAPSE
must
also
ureter. cure
the
at an
original unusually
age.
Fig. i. i.
Longitudinal Urethral orifice.
incision sutured.
Since I wrote the above
6. 2.
Transverse incision sutured.
opportunity has occurred examining after an abdominal section the conditions produced by this operation. It was found that there was a definite shelf right across the anterior half of the pelvis in front of the uterus. This shelf is produced by the tension put on an
of
the cellular connective tissue in the situations mentioned under
(3)
and
(4).
The illustrations
Sewell.
were
sketched
from life
by
Mr.
A.
