ABDOMINAL VS. VAGINAL HYSTERECTOMY FOR UTERINE CARCINOMA
Journal of the American Medical Association (JAMA)
The choice of routes for hysterectomy must be selected for each case. It is my desire to present a concise r\l=e' \sum\l=e' \of the reasons for each route, and the advantages which it offers in the cases to which it is applicable. The views laid down are those of a general surgeon, and are based upon an experience in this work that justifies him, I think, in offering an opinion. It has been claimed that vaginal hysterectomy is an operation that requires special training, and such an attention
... such an attention to detail and technique as can be acquired by the specialist alone. I can not, however, allow this statement to go unchallenged, for I believe that the general surgeon, with his larger field and constant application to detailed technique is, at least, equally as well equipped to perform every operation of gynecology as is the specialist himself. What surgeon to-day, except in extraordinary instances, would dream of amputating a carcinomatous mammary gland leaving in situ the axillary chains of lymphatics whether they are macroscopically infected or not? Yet, how many of the leaders of gynecology recommend or themselves perform the complete operation for carcinoma of the uterus? Carcinoma of the uterus is a very common disease, not more so to-day than formerly, but with increased knowledge and diagnostic skill we are able to discover and remove in good time, uteri that otherwise would soon end in the destruction of the patient. The synopsis of this paper shows the position I take upon this most important subject. I favor and perform abdominal hysterectomy for the great majority of cases of uterine carcinoma, although I grant there are cases where the vaginal operation may be the better. That the vaginal operation offers any advantages over the abdominal route is with me a question. I know of no condition supposed to indicate vaginal hysterectomy which can not possibly be better dealt with by the abdominal route. For the sake of clearness and logical reasoning I propose to take up the different points for discussion in the order laid down in the synopsis. THE REMOVAL OF THE PELVIC GLANDS. For the purpose of refreshing our memory I give a brief account of the lymphatic glands and their connecting channels which are involved in the morbid processes of the uterus: The superficial lymphatics of the uterus, together with those of the ovaries and Fallopian tubes, empty into the lumbar glands. We therefore have two chains of lymphatics in each median half of the uterus to consider, and while the chains nearest the disease are probably engaged in draining the part, it is not unusual to have both the upper and lower chains on one or both sides involved necessitating their removal if we wish to give the patient the only possible hope of recovery. In late carcinoma, or even in the early stage of rapidly advancing disease, if there is, macroscopically, involvement of the broad ligament, any operation short of total extirpation of the lymphatics of the pelvic organ would better not be attempted. The abdominal operation offers the only way by which we can perform such a complete hysterectomy. The incision must be a long one; the intestines and omentum must be kept away from the field of operation by gauze packing; the wound must be widely retracted, and the light should be good, in order to perform so delicate and intricate an operation. The reasons given for the first heading hold good for the second. I can not conceive of skill so great as would make a dissection of a carcinomatous broad ligament as easy or as complete through the vagina as by the abdominal route. LESSENED DANGER TO URETERS. The weak spot of vaginal hysterectomy has always been the danger of injury to the ureters. As a matter of fact, the ureters are in danger of injury by either route; but it seems to me that the danger is less by the abdominal route, for the evident reason that one can see what he is doing, and is therefore enabled to protect these important structures. Granting that either ureter has been torn in removal of the carcinomatous uterus, the repairing must be done through an abdominal incision, and if it has happened in the course of a vaginal hysterectomy the abdomen must then be opened.