Special Surgical Procedures II
LESSON 2: Procedures in Gynecological and Obstetrical Surgery
Section Ii:
2-32
2-32. FOTHERGILL-HUNTER OPERATION FOR PROLAPSE OF THE UTERUS
a. General. This procedure, following D and C, involves a complete repair of the vaginal walls. This is done from above downward, correcting faulty supportive structures of the pelvic floor. It is usually done on women of childbearing age who desire preservation of the childbearing function.
b. Operative Procedure.
(1) Dilatation of the cervix and curettage of the uterus is done, as previously described in paragraph 2-24.
(2) An inverted V incision is made through the full thickness of the vaginal wall. It extends from the bladder reflection to the urethral meatus.
(3) The cervix is circumscribed and bleeding vessels ligated. A knife, Allis-Adair forceps, hemostats, tissue forceps, moist sponges on holders, and chromic gut number 2-0 ligatures are used.
(4) The mucosal flaps are dissected free laterally and posteriorly to expose the cardinal and uterosacral ligaments, which are clamped, ligated, and cut close to the cervical sutures. The cardinal and uterosacral ligaments containing vesical arteries are secured with chromic gut number 0 or 2-0 sutures swaged to 112- circle, taper-point needles.
(5) The cervix is amputated at a site to permit shortening of the ligament. The remaining portion of the cervix is grasped with a Jacobs vulsellum forceps. The rectovaginal septum is exposed by blunt and sharp dissection.
(6) The upper portion of a rectocele is repaired, as described for posterior vaginal plastic repair. A wedge-shaped incision is made with a knife in the portion of vaginal wall to be removed. Repair is performed, using an inverting suture to bring the flaps of the vagina over the sutured fibromuscular tissue of the cervix. Interrupted sutures, chromic gut number 0 swaged to 1/2- circle, trocar-point or taper-point needles are placed to approximate the posterior wall.
(7) Cardinal ligaments are sutured in the midline with interrupted sutures of chromic gut number 0 to shorten the parietal connective tissue, thereby permitting them to provide more support for the pelvic floor.
(8) An anterior and posterior Sturmdorf-type suture is placed in the upper and lower vaginal wall. Flaps are grasped with Allis forceps, the excised vaginal wall is resected on each side using Metzenbaum scissors, and the anterior vaginal wall is closed and reconstructed.
(9) A plastic reconstruction of the genital aperture is done, using interrupted chromic gut number-O and 2-0 sutures. The musculature of the perineum is reconstructed by placement of sutures in such a way that the bulbocavernosus and the remaining transverse perineal muscles decrease the genital aperture and add support of the pelvic viscera.
(10) A urinary drainage system is established, packing is placed in the vagina, and vaginal dressings are applied.
