In all cases where thick cervical lips lie close together, as in most instances of antoversion, it is desirable instead of the sagittal discission to remove a wedge-shaped piece from the cervix. The same procedure is applicable to cases where there exists a crescentic os and a short vaginal portion of the cervix. The apex of the removed wedge points upward, and thus the patency of the os is secured.
Even the most careful after-treatment will not secure as wide an ex ternal os as it was immediately after discission, seeing that contraction to a degree infallibly occurs.
The description of the operation which we have given applies to sim ple discission as we were originally taught it by Sims. Attempts at the prevention of cicatricial contraction; at making union certain by cover ing over the surfaces with mucous membrane; the knowledge that together with the operation diseased portions of the cervix could be removed, all of these factors have led to a number of modifications in the operative technique. For the sake of completeness we will refer here to the most useful of these modifications, the majority of them being treated of at length under the description of disease varieties.
Gusserow first incised the os cross-wise, a procedure which Kehrer extended by making six to eight radiating incisions. There remains after these a widely open star-like os, which, after cicatrization, is still relatively large, with a number of depressions at its borders. The pro cedure is self-descriptive, only the hemorrhage must be even more care fully checked than in case of the bilateral discission. This method of discission cannot, however, be entirely endorsed, for with the number of incisions the size of the wound is increased, and therefore there is addi tional risk of hemorrhage and absorption. Furthermore, we often obtain very mishapen orifices, for it is not possible to guard against union of one or another of the incisions.
A more certain way of keeping the os open is by following Fritsch's Method, which consists in making the crucial incisions and then trimming off the edges of each little flap. It is not necessary to incise to the depth of the vaginal vault, but incisions to about .39 of an inch suffice, and then the removal of the inner half of each flap. This operation is ex ceedingly simple, and Fritsch performs it in his office. After the crucial incision with the knife the flaps are lifted up on a tenaculum, and with scissors or knife the edges are cut off to as to leave a funnel-shaped open ing The slight hemorrhage may be checked by an iodoform or a tannin iodoform plug. Formerly, before I began to use iodoform, I was in the habit of cutting through the cervix with an elastic ligature. With a sharply curved needle I passed the ligature through the cervix towards the vagina and then clamped the ligature with shot.
Far safer and surer in its results is the plastic covering of the wounded surfaces, and it guards most certainly against infection and later mal formation of the os, Following Roser in his phimosis operation, after discission of the cervix and the vaginal mucous membrane, I have turned in each flap, so that the apex lay inwards and the base upwards, and sewed it into the angle of the wound. The passage of the sutures is very
difficult, but the result has been very good. To cover the edges of the incision I have brought together the external mucous membrane and that of the cervix. Kiister performs a similar operation (stomatoplastice uterine interne) which has been followed by good results. Also in case of cicatricial contraction of the internal os, resisting all other methods of treatment, he has performed bilateral discission, excised the cicatricial tissue and turned in the vaginal mucous membrane, thus securing cure. For these difficult operations a special needle-holder is requisite, one having various curves, and Mister has specially devised one.
The patency of the os is best secured, however, by the conical (Kegelmantelformig) excision of M. Marckwald. The operation belongs properly under the consideration of infra-vaginal amputation of the cervix, but when so performed as not to lessen the length of the vaginal portion of the cervix it may be considered as a species of discission, and will here be briefly described.
The bilateral incision of the cervix is first performed with the patient in the dorsal or in the left lateral position. Then the anterior portion of the cervix is seized by a tenaculum forceps, and a slender sharp-pointed knife is inserted near the border of the cervical mucous membrane and about parallel with it to the depth of about .39 of an inch, and an in cision is made with it to the same depth from one side to the other. The knife is again inserted nearer the external border of the cervix, about .18 to .39 of an inch from the former incision, deep enough to reach its inter nal border, and by an oblique incision a piece is removed from the cervix which has the appearance of a segment of a cone. In addition then to the two large flaps resulting from the bilateral discission we have two smaller ones, an internal which is covered with cervical mucous mem brane, and an external, thicker, which is the outer wall of the cervix. Then, if the uterus is drawn down, with a straight needle-holder, and if in situ, with a curved, three to five sutures are passed through both flaps to the bottom of the incision and these are tied with accurate adaptation of the mucous membrane. Similar steps are then followed on the pos terior lip; there remain small openings at the lateral incisions which are closed by a few sutures. The sutures are cut short, the vagina is cleansed and packed with iodoform.