The Evolution of Uterine Surgery and Hysterectomy







“What cannot be cured with medicines is cured by the knife, what cannot be cured by the knife is cured by fire, and what fire cannot cure is incurable.”


Hippocrates



The evolution of uterine surgery is an intriguing story whereby original procedures and theories would fall from favor only to be successfully resurrected and popularized by subsequent generations. Prior to the nineteenth century an inadequate understanding of pelvic anatomy and physiology plagued practitioners. Moreover, despite a surgeon’s best efforts, early attempts at uterine surgery were often foiled by an ignorance of asepsis, the absence of anesthesia, faulty suture materials, inadequate instrumentation, and suboptimal exposure. As a result, any consistent success was delayed until the midnineteenth century. Particularly intriguing was the development of an amazing variety of innovative instruments of remarkable craftsmanship and materials that paralleled the many surgical advances.


This chapter is an attempt to touch upon the milestones leading to successful trachelectomy and hysterectomy and to acknowledge the many pioneers who paved the way. The author’s selection of important milestones is listed in Table 1-1 . Kindly note that this chapter emphasizes American and some European contributions and benchmarks that influenced contemporary thought, patient care and surgical practices. Throughout the chapter an effort is made to identify individuals who were first to perform a particular operation or technique. However, a number of variables confound the process including whether or not the procedure was purposefully planned or the result of intraoperative necessity or misadventure. Also important are whether or not the patient survived the actual operation and had a full recovery and whether there is documentation (clinical or pathologic) that verifies all the surgical details.



Table 1-1

Timeline of Milestones Related to Uterine Surgery










































































































































100 ce First good description of the human uterus: De Morbis Mulierum by Soranus.
1507 Earliest authentic account of vaginal excision of the uterus in a case of prolapse: Giacomo Berengario da Carpi.
1561 First accurate description of the human oviduct: Observationes Anatomicae by Gabriele Falloppio.
1663 First work on operative gynecology: Heel-konstige aanmerkkingen betreffende de gebreeken der vrouwen by Hendrick van Roonhuyze.
1672 First accurate account of the female reproductive organs and ovarian follicles—”graafian follicles:” De Mulierium Organis Generationi Inservientibus by Regnier de Graaf.
1737 Description of the peritoneum and the posterior cul-de-sac: A Description of the Peritoneum by James Douglas.
1774 The finest work on uterine anatomy to date: Anatomy of the Gravid Uterus by William Hunter.
1801 Friedrich Benjamin Osiander performed the first partial trachelectomy by means of a knife for the treatment of cervical cancer.
1812 Although planning to perform a trachelectomy for cancer, G.B. Paletta inadvertently performed the first vaginal hysterectomy; the patient died 3 days later.
1813 Conrad Langenbeck performed the first intentional complete vaginal extirpation of the uterus for prolapse with cervical ulceration, using an apparent extraperitoneal approach, after which the patient survived.
1822 J.M. Sauter of Baden, Germany, performed the first planned and successfully executed complete vaginal hysterectomy for cervical cancer.
1826 First American textbook on gynecology: A Treatise on the Diseases of Females by William Potts Dewees.
1829 Earliest report of a successful trachelectomy in America: Case of a successful excision of the cervix uteri in a scirrhous state by John B. Strachan.
1846 First deliberate abdominal supracervical hysterectomy in America for fibroids (with the correct preoperative diagnosis) was performed by John Bellinger of Charleston, South Carolina. The patient died on the fifth postoperative day.
1849 Anders Adolf Retzius described the prevesical space.
1850 First successful vaginal hysterectomy performed in America by Paul F. Eve of Augusta, Georgia.
1852 Hugh Lenox Hodge detailed the use of his pessary for the correction of uterine displacement.
1853 Walter Burnham of Massachusetts performed the world’s first successful (albeit unplanned) abdominal supracervical hysterectomy. Extirpation of the uterus and ovaries for sarcomatous disease (Nelsons Am Lancet 1853;7:147). It was done with the patient under chloroform anesthesia; the patient survived.
1853 Gilman Kimball performed the first deliberate and successful abdominal supracervical hysterectomy for a fibroid uterus. (Kimball G: Successful case of extirpation of the uterus. Boston Med Surg J 1855;52:249–255.)
1861 Samuel Chopin performed the first successful vaginal hysterectomy for prolapse in America.
1861 James Marion Sims described method for trachelectomy: Amputation of the cervix uteri .
1863 Earliest successful excision of the uterus and ovaries for tumor. Exstirpation de l’uterus et des ovaries by Eugene Koeberle.
1868 First attempt at cesarean hysterectomy in America by Horatio Robinson Storer of Boston.
1876 First successful cesarean hysterectomy by Edorado Porro of Pavia, Italy.
1878 First carefully planned and successful abdominal hysterectomy for cancer using Lister’s antiseptic method. Eine neue Methode der exstirpation des ganzen uterus by Wilhelm Alexander Freund. Freund also introduced “compression forceps” (clamps) to vaginal hysterectomy to secure vascular pedicles.
1890 Freidrich Trendelenburg described his manner for positioning patients to enhance exposure.
1893 Karl August Schuchardt described his mediolateral incision to enhance exposure for radical vaginal hysterectomy in cases of cervical cancer. He performed the first radical hysterectomies for cervical cancer. (Garrison FH, Morton LT: Morton’s Medical Bibliography , 5th ed. Aldershot, England, Scholar Press, 1991.)
1895 The first radical hysterectomy for invasive cervical cancer by John Goodrich Clark at Johns Hopkins Hospital.
1895 Alwin Mackenrodt provided a comprehensive and accurate description of the pelvic connective tissue and its relationship to pelvic prolapse.
1898 Howard Atwood Kelly’s text Operative Gynecology published. Provided the foundation for the specialty in America.
1900 Hermann Johannes Pfannensteil introduced a transverse incision for laparotomy.
1900 Ernst Wertheim described his radical operation for cervical and uterine cancer.
1901 Alfred Ernest Maylard advocated an oblique transection of the rectus muscles to improve exposure.
1906 Albert Doderlein and S. Kronig described their technique for vaginal hysterectomy beginning with an anterior colpotomy incision.
1908 Friedrich Schauta described his method for radical vaginal hysterectomy in cases of carcinoma of the cervix.
1911 Max Brödel chaired the world’s first Department of Medical Illustration at Johns Hopkins University.
1915 William Edward Fothergill modified Archibald Donald’s operation for complete uterine prolapse: Anterior colporrhaphy and its combination with amputation of the cervix , the so-called Manchester operation.
1915 Arnold Sturmdorf introduced his tracheloplasty technique.
1928 Edward H. Richardson reported his simplified technique for abdominal hysterectomy, using the uterosacral and cardinal ligaments in vaginal cuff closure.
1934 Nobel Sproat Heaney described his technique for vaginal hysterectomy using a clamp, needle holder, and retractor of his own design. His method for suturing the vaginal cuff in a manner that incorporates peritoneum, vessels, and ligaments is eponymously termed the “Heaney stitch.”
1941 A.F. Lash described the coring method for reducing the size of the uterus to facilitate vaginal hysterectomy.
1941 Leonid Sergius Cherney proposed a modified low transverse abdominal incision, whereby the rectus muscle is reflected off its insertion into the posterior pubis, to maximize access to the space of Retzius.
1946 Richard Wesley TeLinde published his Operative Gynecology , which remains the standard American work on the subject under successive authors.
1972 Allen and associates first reported that perioperative prophylactic antibiotics (cephalothin versus placebo) reduce major infection rate after abdominal hysterectomy.
1989 Reich described the first laparoscopic hysterectomy.


Clearly we owe a great debt of gratitude to these and many others who established the foundation for successful pelvic surgery and ultimately for our specialty. Perhaps Kelly, an avid historian and bibliophile, summarized it best by stating, “No group should ever neglect to honor the forebears upon whom their contributions are based. Great is the loss to anyone who neglects to study the lives of those he follows.” We are particularly grateful for the works of Dr. Thomas Baskett, Dr. James V. Ricci, and Dr. Harold Speert, whose extensive research on the subject made this chapter possible.


Antiquity





“Never as yet have I gone astray, whether in treatment or in prognosis, as have so many physicians of great reputation. If anyone wishes to gain fame … all that he needs is to accept what I have been able to establish.”


Claudius Galen



The foundation of all surgical specialties is predicated on an accurate and thorough understanding of the pertinent anatomy. Magnificent prehistoric drawings on the walls of caves and carvings of human figures have been dated as far back as 40,000 to 16,000 bce However, it was not until many millennia later that any real effort was devoted to the study and illustration of human anatomy. The earliest descriptions of the uterus are gleaned from the Ebers Papyrus (1500 bce ), which depicts the uterus as an independent animal, capable of movement within the abdomen and pelvis of its host. Similar accounts in other documents correspondingly describe the uterus as a salamander, crocodile, or tortoise ( Fig. 1-1 ).




Figure 1-1


An eighteenth century umbilical cord clamp mounted on a tortoise representing the uterus.


Accounts by Hippocrates (460–377 bce ) regarding the uterus portray the organ as going wild when not sufficiently nourished with male semen. During the second century ce the eminent Greek physician Aretaeus reinforced this animalistic concept stating in his Causes and Indications of Acute and Chronic Diseases :




In the middle of the flanks of women lies the womb, a female viscus closely resembling an animal, for it moves hither and thither in the flanks, also upwards in a direct line to below the cartilage of the thorax, and also obliquely to the right or the left, either to the liver or the spleen; and it is likewise subject to prolapse downwards; and in a word is all together erratic. It delights also in fragrant odors and advances towards them, and it has an aversion to fetid odors and flees from them; and on the whole the womb is like an animal within an animal.


Aretaeus



This animalistic concept of the uterus was subsequently replaced, during the Common Era, by the notion that the uterine cavity comprised seven separate compartments—three on either side and one elongated compartment in the center. The so-called “seven cell doctrine” proposed that male embryos developed in cells on the right, females developed on the left, and from the center cell hermaphrodites were produced. This and other similar theories remained popular throughout the Middle Ages until cadaver dissections would prove otherwise.


Perhaps the earliest acceptable description of the uterus came from Soranus of Ephesus (98–138 ce ), a learned and leading medical figure of the early second century ce . Soranus is best known for his text on the diseases of women, De Morbis Mulierum , which ultimately provided a basis for gynecologic texts up to the seventeenth century. He suggested that a prolapsed uterus that had become gangrenous could be safely excised without harm to the patient but otherwise a pessary should be employed to restore the prolapse. His description of the uterus is clearly based on cadaver dissections as evidenced in his elaborate description regarding adjacent organs in the pelvis. Soranus related his concept of the uterus and appreciation for its surrounding structures in his narrative, “What Is the Nature of the Uterus and of the Vagina?”




The uterus (metra) is also termed hystera and delphys. It is termed metra because it is the mother of all the embryos borne of it or because it makes mothers of those who possess it: or, according to some people, because it possesses a metre of time in regard to menstruation and childbirth. And it is termed hystera because afterwards it yields up its products, at least broadly speaking. And it is termed delphys because it is able to procreate brothers and sisters.


The uterus is situated in the large space between the hips, between the bladder and the rectum, lying above the rectum and sometimes completely, sometimes partly, beneath the bladder, because of the variability of the uterus. For in children the uterus is smaller than the bladder (and lies, therefore, wholly beneath it). But in virgins in their prime of puberty, it is equal to the size of the superimposed bladder, whereas in women who are older and have already been deflowered and even more in those who have already been pregnant, it is so much bigger that in most cases it rests upon the end of the colon.


By thin membranes the uterus is connected above with the bladder, below with the rectum, laterally and posteriorly with the excrescences of the hips and the os sacrum. When these membranes are contracted by an inflammation, the uterus is drawn up and bent to the side, but when they are weakened and relaxed, the uterus prolapses. Although the uterus is not an animal (as it appeared to some people), it is, nevertheless, similar in certain respects, having a sense of touch, so that it is contracted by cooling agents but relaxed by loosening ones.


The shape of the uterus is not curved as in dumb animals, but is similar in shape to a cupping vessel. For beginning with a rounded and broad end at the fundus, it is drawn together proportionally into the isthmus, neck and finally a narrow orifice. The orifice lies in the middle of the vagina, for the neck of the uterus is enclosed tightly by the vagina while the outer part ends in the labia. … In the natural state the orifice is in most cases as large as the external end of the auditory canal. Yet at certain times it is dilated, as in the desire of intercourse for the reception of semen. … and to an extreme degree till it even admits the hand of a grown-up person. In its natural state in virgins, the orifice is soft and fleshy, similar to the spongy texture of the lung or the softness of the tongue. But in women who have borne children it becomes more callous and, as Herophilus says, similar to the head of an octopus or to the larynx.


Soranus (from )



The ancients are credited with a great many basic instruments fashioned from tin, iron, steel, lead, copper, bronze, wood, and horn. Ferrous metals were likely the most popular, but few survived the oxidation of more than 2000 years. Nonetheless, a surprising number of instruments including scalpels, forceps, and catheters that date to the first century were recovered from archeological digs at Pompeii. Of the instruments recovered, the most impressive are the massive bivalve, trivalve, and quadrivalve vaginal specula which were fabricated from bronze and thus remain nicely preserved.


Arabian medicine texts, despite their large numbers, contained very little with respect to gynecology and are, for the most part, an accumulation of Greek contributions with numerous translations from the Indian, Persian, and Syrian. Perhaps their greatest value was the preservation of Greek medical literature and culture that likely would have all but vanished during the Dark Ages.




Medieval Medicine





Those unfortunate enough to contract The Black Death “ate lunch with their friends and dinner with their ancestors in paradise.”


Giovanni Boccaccio



The Medieval Period or Middle Ages marked the end of Arabic supremacy and is commonly referred to as the Age of Faith or Era of Monastatic Medicine, a period whereby confidence in any one individual was replaced by divine trust. As such, St. Benedict, founder of the Benedictine Order, encouraged his monks to tend to the sick but forbade any formal study of medicine. The struggle against leprosy, plagues, and prostitution were the main challenges of the day, and few meaningful contributions were made to the fund of medical knowledge. Moreover, medicine during the period was essentially nonsurgical and the majority of physicians were typically itinerant practitioners, many of whom were likely quacks and charlatans.




The Renaissance





Regarding Leonardo da Vinci “He was like a man who woke up too early, in the darkness, while everyone else was still sleeping.”


Dmitri S. Merezhkovsky, 1901



The Renaissance was marked by the rescission of medieval oppression of liberty of thought and inquiry, the rise of universities, the dawn of the printing press, and the subsequent emergence of self-education, which collectively led to the rebirth of medical thinking in general and investigation of human anatomy in particular. These essential elements served to elevate medicine to the next level and would provide for a more clear understanding of female anatomy.


Early on was the work of Leonardo da Vinci (1452–1519), founder of iconographic and physiologic anatomy that served as a foundation for modern anatomic illustration. Da Vinci, “the greatest artist and scientist of the Italian Renaissance produced over 750 sketches portraying all the principal organs of the body” ( ) and the earliest accurate depiction of the fetus in utero. Unfortunately, his work was appreciated by only a few of his contemporaries and was not published until the end of the nineteenth century. Da Vinci’s contemporary, Giacomo Berengario da Carpi (circa 1460–1530?), introduced iconography and independent observation into the teaching of anatomy. His Commentaria was the first work since Galen to present a substantial amount of anatomic illustrations based on his own investigations and observation. Da Carpi’s work included the most extensive account of the female reproductive organs up to that time ( ).


Most remarkable, however, was the contribution of Andreas Vesalius (1514–1564), who at the age of 29 published the Fabrica in 1543 containing “the most famous anatomical illustrations of all time. His work more than any other, with its extraordinary blend of scientific exposition, art and typography, revolutionized the science of anatomy and the manner in which it was taught” ( ). Vesalius was among the first to successfully challenge the anatomic teachings of Galen, but more important, he asserted that the physician must perform cadaver dissection firsthand to master the art. An apparently engaging young man, he made human dissection a respected and viable profession. His illustrations include an accurate description of the entire female urogenital tract and its vasculature depicting the left ovarian vein entering the left renal vein for the first time. Vesalius also produced a number of distinguished pupils including Matteo Realdo Colombo (circa 1510–1559), who is credited with earliest use of the term “labia,” which he thought were essential in protecting the uterus from the cold, dust, and air; Gabriele Falloppio (1523–1562), who became professor of anatomy at Ferrara, Pisa, and Padua and who is eponymously remembered for the fallopian tube among his many contributions; and Bartolomeo Eustachi (circa 1510/1520–1574) whose fine copper plates, produced in 1552, provided the first accurate delineation of the uterine cavity and cervical canal. Unfortunately they remained unprinted and forgotten in the Vatican Library until the early eighteenth century, when they were recovered and subsequently presented by Pope Clement XI to his physician, who published them in 1714.


Gynecologic surgeries during the Renaissance, although few and far between, were nonetheless a consideration. Jacopo Berengario da Carpi (1470–1550) a pre-Vesalian anatomist and surgeon provided the earliest account of a vaginal hysterectomy performed with a scalpel, by his father, on a prolapsed gangrenous uterus. Later, Berengario himself would perform a vaginal hysterectomy by circumferentially ligating the prolapsed uterus with some very strong twine and tightening the ligature until the organ was severed. The renowned French military surgeon Ambroise Paré (1510–1590) was the first to employ vascular ligatures in place of cautery or boiling oil for hemostasis. However, the use of ligatures quickly fell from favor due to faulty suture materials with insufficient strength and longevity and a likely increased rate of resulting infections and foreign body reactions. More than two centuries would pass before the suture ligature was resurrected, improved and popularized by Lister in the mid-nineteenth century. Although best known for contributions to military medicine, Paré was equally ingenious with respect to his gynecologic therapy. He was the first to employ a pessary fashioned of hammered brass and waxed cork for uterine prolapse, he suggested trachelectomy for cervical cancer, and he devised an imaginative and elaborate fumigation apparatus employing a special elongated pessary of gold or silver with perforations along its length and an open end to introduce medicated steam into the vagina and to ventilate the uterus ( Fig. 1-2 ). He is credited with the development of a great many instruments including vaginal specula of his own design and is said to have excised an inverted uterus and the patient survived ( ). Among the more comprehensive accounts of Renaissance gynecologic surgery is Caspar Stromayr’s Practica Copiosa (1559), which contains beautifully executed plates depicting diseases of women. Together with the many illustrations of instruments and surgical techniques are several that depict the replacement of a uterine prolapse by placement of a pessary comprising a sponge bound with twine, sealed with wax, and dipped in butter. He also created one of the earliest illustrations of a standing pelvic examination for a woman with prolapse ( Fig. 1-3 ).




Figure 1-2


Fumigation apparatus. A sixteenth century woodcut illustrating Ambroise Paré’s uterovaginal fumigation apparatus for the treatment of uterine prolapse.

(From Johnson TH (transl.): The Works of Ambroise Paré. London, 1678.)



Figure 1-3


Sixteenth century illustration showing examination of women with uterine prolapse.

(From Stromayr’s Practica Copiosa, 1559, Edited by W. von Brunn, Berlin, 1925.)


Ultimately, despite the many academic advances in areas outside medicine during the Renaissance, the approach to the majority of gynecologic problems changed very little from that which was popular since the classical period.




Seventeenth Century





“We are now at odds with our barber-surgeons who wish to unite with the surgeons of St. Cosmas, our ancient enemies. Those of St. Cosmas are miserable rascals, nearly all tooth-pullers and very ignorant who have attached the barber-surgeons to their string, by making them share their halls and their pretended privileges.”


Guy Patin (1601–1672), Dean of Medicine, Paris



Throughout the seventeenth century, many theories with respect to anatomy, physiology, chemistry, and generation received clarification and a more credible basis for medicine began to emerge. “In medicine, this was the century of ‘systems,’ speculations and explanations, and surgery consequently remained in the background” ( , p 99).


The anatomist, Regnier de Graaf (1641–1673), published his work De Mullierum Organis Generationi in 1672, which provided the first accurate account of the ovary’s gross morphology, anatomic relations, and function ( Fig. 1-4 ). He also provides clear descriptions and illustrations of the uterine vasculature, lymphatic drainage, uterine fibroids, and the ovarian follicle, which was named the “graafian follicle” in his honor.




Figure 1-4


De Graff’s illustration of the uterus, vagina, tubes, and ovaries arranged to show clearly the ovarian and hypogastric arteries with their ramifications.

(From de Graaf R: De Mulierum Organis Generationi Inservientibus. Leyden, Hackiana, 1672.)


The first illustrations of gynecologic procedures are nicely portrayed, in a stepwise fashion for the first time, in the engravings by Johannes Scultetus (1595–1645) in his Armamentarium Chirurgicum (1655). Included are examples of treatment of imperforate hymen, hematocolpos, and clitoral hypertrophy and the use of a T-binder to control hemorrhage following vaginal surgery. Scultetus advocated and described the use of a vaginal speculum so that afflictions of the rectum, vagina, and uterus could be seen and treated ( Fig. 1-5 ).




Figure 1-5


Early iron vaginal speculum from the mid-sixteenth century.


Successful surgery during the period was limited and hysterectomy was not a popular method of therapy during the seventeenth century unless the organ had prolapsed and became gangrenous. Instead, classical notions for treating prolapse persisted as evidenced in the writings of Francois Thevenin (?–1656) who favored replacement of the organ followed by placement of a foul-smelling vaginal pack (to drive the organ upward), and application of sweet scents to the mouth and nose to attract the uterus (capable of movement within its host) upward, and thus preventing it from prolapsing. Only if such measures failed or the organ became gangrenous would ligation or extirpation be seriously considered.




Eighteenth Century





“Two inconveniences generally attend the use of the Cautery … forcing us to neglect it. First, the patient is usually wonderfully terrified of it and second, Mankind in general looks upon it as barbaric to advise it.”


Lorenz Heister, 1718

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