Journal FACTORS OF SAFETY IN ABDOMINAL condition of the blood stream, the nervous system, HYSTERECTOMY.* DONALD GUTHRIE, M. D. Surgeon to Robert Packer Hospital. SAYRE, PA. The modern methods of preparing patients for operation, the improvement in the operative technic and anesthesia, and intelligent postoperative care, have made the operation of abdominal hysterectomy a safe procedure. In reviewing our 551 hys and kidney efficiency. Patients who have suffered severe loss of blood at the menstrual time we believe should be operated upon just before the onset of the next period, giving the body a chance to recover from the last severe hemorrhage. Women with severe metorrhagia, flowing at the time of examination, should be given salines, and tonics, and such measures should be carried out that will tend to stop the hemorrhage and give the body a chance to recuperate. If the hemoglobin is reduced below Fig. 1.-Trendelenburg Anesthesia. Showing the coils of small intestine gravitated out of the pelvis when the patient is anesthetized in the Trendelenburg position. terectomies of all types performed in the last seven and one-half years, we are impressed with the following factors of safety: PREPARATION OF THE PATIENT. First: The preparation of the patient. It is important for the surgeon to know the exact physical condition of every patient presenting herself for operation. This necessitates careful history taking, careful examination of the chest, the circulation, the *Read before the Joint Session of the Interstate Association of Anesthetists and the Indiana State Medical Association, Hotel Claypool, Indianapolis, Ind., Sept. 25-27, 1918. 40 per cent. and the bleeding cannot be controlled, direct transfusion of blood from some blood relation is a valuable aid in the preparation as was borne out in five of our cases. I am satisfied these patients could not have stood operation had not transfusion been performed. Two factors which promote postoperative shock are loss of sleep and dehydration. In our preparation of patients for any abdominal operation we consider these two factors carefully. In nervous excitable cases with insomnia we advise a few days* Anesthesia Supplement Fig. 2.-Lifting up abdominal wall to free pelvis of any coil of small intestine. but a harmful one. Large amounts of fluid are lost by the purge and a night which should be spent in comfort and rest is made a veritable nightmare. Alvarez and Taylor have shown experimentally that the purged gut is less able to empty itself and is prepared with their empty but distended coils, and yet, we all have been slow to realize that purgation is not only unnecessary but harmful. We rely upon a morning enema to empty the lower bowel, except in the patient who is obstinately constipated. She is given a small dose of cascara the night before operation and the morning enema. If the operation does not come until late in the morning we allow our patients hot coffee, tea, or broth when they are awakened. We plan to have the patients lose as little fluid as possible on the operating table; therefore, our operating rooms are at normal room temperature instead of excessively hot. The patients are not wrapped in blankets, and no measures are taken to on the table should the case be one for complete hysterectomy. SKILLED ANESTHETIST AND TRENDELENBURG ANESTHESIA. The value of good anesthesia by a trained anesthetist cannot be too strongly advised. The responsibility of the anesthetist in major operations is next to that of the surgeon. Most hospitals today have the services of skilled anesthetists. The personality of the anesthetist is most important, for he Fig. 3.-Compare the difference in the amount of small intestine in the pelvis when the patient is anesthetized in the dorsal position. keep the operating table warm. It is seldom necessary to change the patient's night garment on the table after the operation is over because of perspiration. In all cases of hysterectomy the patients are shaved in the afternoon and the abdomen treated with tincture of iodin. This is repeated just before operation. In addition the vagina is washed out well with soap and water, and a 1 to 5,000 bichlorid douche given. This is repeated or she can by skilled suggestion calm the most nervous patient. In all of our cases of pelvic surgery we employ the Trendelenburg anesthesia. The anesthetic is started with the patient in the Trendelenburg position on the operating table. It is not necessary to have all patients come to the operating room, but if the anesthetic is given in an anesthetizing room the patient is put to sleep in the Trendelenburg position on the table which is to be used during the opera Anesthesia Supplement Fig. 4. Forceps applied to broad ligaments, including ovarian arteries, and forceps placed on round ligaments. used it is usual to find but a coil or two of small intestine in the pelvis, and it is seldom ever necessary to use more than one small square of gauze to get excellent exposure (Fig. 1), When we open the peritoneum we insert two fingers into the abdomen and lift the abdominal walls well up (Fig. 2) the inrushing air will cause any coil of intestine that has not gravitated out of the pelvis to slide upward. When this method is compared with the one usually employed, of putting the patient to sleep in the dorsal position, or not they should be attended to depends upon the condition of the patient at the end of the pelvic operation. The appendix is always removed after hysterectomy unless some critical state of the patient contraindicates its removal. THE SURGICAL TECHNIC. In our operation for abdominal hysterectomy we use the clamp method, clamping and cutting first the broad ligaments containing the ovarian arteries on both sides, next the round ligaments separately (Fig. 4). After freeing the uterus Anesthesia Supplement Fig. 5.-Showing uterus freed on all sides. Clamps on uterine vessels. Bladder pushed forward. hesions. In two of our earlier cases the patients had to be operated on for this condition. The objection some few men have to the clamp operaion is the fear that it produces thrombosis in the veins. This I do not believe because the results in vaginal hysterectomies where clamps were used are good, and pulmonary embolism is not any more common in this class of work than any other. Our sutures are placed well behind the clamps and are placed in immediately so in then securing the vessels firmly by another tie of the same ligature (Fig. 6). If a panhysterectomy is to be performed we isolate the ureters by splitting the posterior peritoneum, following them throughout their course. In a few cases we have used the ureteral catheter passed in the ureter and left in place. This makes it easy to recognize these structures, as they pass close to the cervix. To my knowledge we have never cut or ligated a ureter in a pan |