-I SHIRODKAR'S MODIFIED MANCHESTER OPERATION

by LALITA SITARAM, * M.B.,B.S., D.G.O. S. H. SHAH,** M.D., D.G.O., D.F.P. and E. J. SEQUEIRA,*** M.D., F.C.P.S.

Genital prolapse forms a major The choice of a particular surgical part of gynaecological practice. Al­ procedure depends on many fac­ though the principles of anatomy of tors:- prolapse have been agreed upon by (1) Nature and extent of struc­ many, no two gynaecologists would tural changes present. agree upon a particular operation as (2) Aetiology in each case. a remedial measure. (3) Nature and severity of symp­ At the present time, a diversity of toms. operative techniques is available for ( 4) Need for conservation of func- the treatment of prolapse. Although tions. 1 there is still a place for further re­ ( 5) Presence of associated disease. - 1 finement of their technical details, it (6) Tolerance of the patient. is true that in a sense these techni­ ques are already quite adequate to Despite the weight of tradition, the meet with the needs of the wide treatment of genital prolapse is es­ range of conditions-loosely denoted sentially a practical discipline; the by the term 'Prolapse'. practice must be based primarily on Every surgeon has his favourite experience. There are a variety of methods-methods which in his hand factors that need consideration prior give good results over a wide range to the selection of operation during of his cases-but the danger of re­ the reproductive period for a parti­ garding these methods as right and cular case as there are disadvan­ others wrong must be guarded tages like increased incidence of steri­ against. lity, abortions and premature labours, marked increase in the complications *Acting Registrar. attendent upon labour with the re­ **Asst. Professor. sultant increase in the operative deli­ ***Head of the Dept.," Han. Ohstetrician very rate associated with the Man­ & Gynaecologist and Han. Professor. chester operation. Depart. of Obst. & Gynec. B. Y. L. Nair Shirodkar logically feels that "in Charitable Hospital and T. N. Medical Fothergill's operation, the paracer­ College, Bombay vical tissues are brought forwards Received for publication on 6-3-67. forcibly and is a poor attempt to- SHIRODKAR'S MODIFIED MANCHESTER OPERATION 297

shorten the ligaments and does not uterus is thus maintained in the ante­ effect in pulling the cervix high up verted position. Anterior colporraphy in its natural position. To obtain the and posterior colpoperineorrhaphy anatomical result, amputation of the were always done in Shirodkar's ope­ cervix has to be done and the appar­ ration like in all other repair ope­ ent result is obtained at the expense rations done vaginally. of the anterior fornix, which is in­ variably obliterated as a result of ex­ Material:-This report is intended . cision of 'V' shaped· part of the ana- to be the statement of results follow­ terior vaginal wall. The amputated ing Shirodkar's advancement of cervix leads to the disadvantages utero-sacral operation carried out in mentioned above in women of child­ B. Y. L. Nair Charitable Hospital, bearing age." Bombay, between January 1961 and To overcome these disadvantages December 1965. Thirty-three patients he devised a new procedure. He were taken up for this operation. believes that the uterosacrals along This operation was performed on with their peritoneal covering act young women, where child-bearing as the main supports. The pouch or menstrual function had to be pre­ of Douglas is opened up. The served. The average age of the pati­ uterosacral ligament is dissected ents was 26 years (minimum 18 years along with its peritoneal cover­ and maximum 34 years). ing and depending upon the length of uterosacral ligament available, Clinical Features he fixes them in front of the cer­ The chief complaints were, some­ vix or crosses them in the midline, if thing coming out per vaginam, dy­ sufficiently long, thus effecting the suria, backache, dysmenorrhoea, leu­ shortening and the advancement as corrhoea and pain in lower abdomen. 'Nell. Four patients attended primarily for Another advantage of this proce­ secondary sterility. Two cases had dure is that the retroversion having supravaginal elongation varying been corrected by either the uterine from 1" to 2". There were 24 cases sound or Fenton's dilator, the utero­ with second degree and 9 cases with sacrals are fixed to the cervix. The 3rd degree prolapse.

I 1..- TABLE I Details of Clinical Findings in this Series

Prolapse Degree of Urethro- Cytocele of pouch of Rectocele Prolapse cele Douglas

1st Degree Nil 2nd Degree 24 19 2 3 16 3rd Degree 9 9 2 2 8

Total 33 28 4 5 24 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA

Investigations done Complioations Hemoglobin estimation (average Eight cases were found to have -• haemoglobin in this series was 60%), pyrexia in the immediate post-opera­ urine examination, blood V.D.R.L. tive period. Six of these cases show­ blood grouping and cross matching ed pus cells on microscopic examina­ and screening of chest were done as tion of urine and were treated with a routine. Urine culture and antibio­ Sulpha drugs and furadantin. Maud­ tic,sensitivity tests were done in cases sley gives incidence of urinary tract of dysuria and large cystoceles, and infection following vaginal surgery vaginal cytology was done only in as 47.5% and attributes the same to selected cases. indwelling catheter or repeated-­ catherisation. Our low incidence Post-operative management (18%) may be due to the fact that All the patients in this series re­ our diagnosis was clinical and routine ceived injection Crystalline Penicillin culture was not carried out in every 5 lac. 12 hourly, Inj. Streptomycin ·~ case post-operatively. One case deve­ grm. 12 hourly, daily, for an average loped a haematoma following ante­ period of 10 days. A tight acriflavine rior colporrhaphy and was treated by vaginal pack was kept in for 8 hours. drainage of the haematoma and A self-retaining catheter was intro­ higher antibiotics. One case had duced post-operatively and removed pyrexia. By exclusion of other causes, on the morning of the 3rd day. The the rise of temperature was found to patients were allowed to move be due to breast engorgement as the about in the wards after the catheter patient had weaned during her stay was removed. in the hospital. The average period of hospitalisa­ Haemorrhage: One patient collaps­ I tion was 12.2 days (minimum being ed on the evening of the day of ope­ 1 7 days and the maximum 30 days). ration. The catheter had come out, an As a part of out-door treatment, attempt to put in the catheter failed. vaginal antiseptic tablets were ad­ There was slight bleeding per vagi­ vised for a variable period-usually nam. In view of the patient's condi­ 10 days. tion one finger vaginal examination The patients were instructed to was done gently. The anterior vagi­ avoid intercourse for a period of 2 nal wall was bulging so much that the months and conception for at least 6 cervix could not be felt. The anterior"'" months. vaginal wall felt cystic. The patient Two patients from this series did did not allow proper examination due not menstruate after the operation as to tenderness. A swelling above the they conceived immediately. In these symphysis pubis was also felt. two cases, the perineorraphy gave The patient was taken to the thea­ way at the time of delivery but there tre, blood transfusion was started, was no uterine prolapse. It is advis­ catheterization was done but there able to make routine episiotomy fol­ was no urine. It was thought lowing repair of prolapse. that the haematoma could have oc--..

. . SHIRODKAR'S MODIFIED MANCHESTER OPERATION 299 curred between the bladder and the an indication for transfusion. Each vaginal mucosa and the mucosal one of the above cases was given 1 stitiches were cut. Haematoma could unit of blood. Robertson used blood not be visualized. A decision was transfusions as a routine in . vaginal made to open up the abdomen. There operation if the haemoglobin was less was bulging of anterior peritoneal than 10 gm. % . In this series blood pouch. There was a big haematoma transfusion was used only when indi­ but active bleeding point was not cated and not specifically for anae­ found and a decision was taken to pro­ mia. ceed with hysterectomy. The patient Some complications are reported was kept in hospital for 4 weeks and after this operation but they were not did well post-operatively. The patient observed in this series. required 3 blood transfusions of 350 ( 1) Sloughing of the cervix may c.c. each. Incidently it may be men­ occur if the cervical suture is tioned here that she had two taken very deep leading to children. necrosis. Extensive clamping Serosanguinous oozing from the of utero-sacrals might include wound the uterine artery and may be a factor responsible for These cases were treated with sloughing of the cervix. hydrogen peroxide and acriflavine vaginal instillations. In 12 cases this ( 2) Cervicovaginal fistula: may could have been attributed to wound follow sloughing of the cervix infection. -one patient operated at an­ Weakness of the rig'ht quadriceps other teaching institution was muscle occurred in one case which examined in the out-patient could be attributed to spinal anaes­ department of this hospital thesia. She was treated with physio­ and this entity was recognized. therapy with some improvement. This patient later conceived and delivered through the cer­ Indications for blood transfusion vicovaginal fistula. Delivery Seven cases in this series were was uneventful. given blood transfusion either during (3) Elongation of the anterior the operation or during the near post­ andj or posterior lip may occur. operative period. In one case 3 units of blood had to be given for internal Additional procedures haemorrhage. In two patients the (i) Rubin's test, and dilatation and blood pressure fell to 60 mm. mercury curettage were done in three cases as following spinal anaesthesia. It was the patients, although attending pri­ considered that blood transfusion marily for prolapse, were cases of would serve the purpose better as the secondary sterility. (ii) Trache­ patients were anaemic to begin with lorrhaphy was done in one case as (average 60 7c haemoglobin). In the the cervix was torn. In one patient remammg 4 patients extra oozing cervicopexy had been done at another during the operation was considered institution for sterility and prolapse. 300 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA

This case was taken up for Shirod­ responded by attending for follow up. kar's operation. (iii) The pouch of One patient had cervicopexy done at ...... Douglas was not opened in 2 ca~es. another hospital which failed and In the strict sense, this could not be Shirodkar's procedure was done; ute­ called Shirodkar's procedure, as he rosacrals were thin and prolapse re- counts on uterosacral ligaments curred. The other patient had second j along with the flap of peritoneum as degree of prolapse during subsequent a support. But this procedure being pregnancy but improved markedly 1 nearer to Shirodkar's these cases are during the puerperal period with included in this series. pessary and physiotherapy. Ventral suspension was done in one The results obtained in this series ~ ....J case as an additional support as the seem to be quite satisfactory. The re­ uterosacrals were found to be very currence of cystocele and rectocele weak and flimsy. Tubal ligation was seems to be higher compared to Hun- done in four cases as the patients were ter's series. This could be the indi­ young but multiparous and hysterec­ vidual factor as the major difference tomy was not advisable. between these two procedures lies with the repair of the ligamentary Results supports of the uterus. Table III. Out of 33 patients, 21 responded by attending the follow up; 6 pati­ TABLE III ents had 9 pregnancies and they were Comparison of Results of Manchester Fothergill Colporraphy (John uneventful. Hunters') with our Results The cases selected for this --- - series consisted of a group of Hunter's Series of Our series women of child-bearing age and cases of 33 cases hence the desire to preserve the 330 mentrual, reproductive and coital Recurrence of cystocele 6.9 % 19 % function. Table II shows only 2 Recurrence of rectocele 3% 33 o/a TABLE II Recurrence of prolapse 10%

Postope- Details of two cases explained in text. rative fol- No. of cases operated: 33 low up Summary and conclusions 21 cases (1) Thirty-three cases of Shirod­ Prolapse (uterine) 33 2 kar's modification of Manches- .,..,. Cystocele 24 4 ter operation are reviewed. Urethrocele 4 2 (2) The sound anatomical basis of Prolapse of pouch of Douglas Shirodkar's operation has been Rectocele 24 8 emphasised in the background Deficient perineum 5 2 of Manchester operation. Retroversion 30 4 (3) This operation seems to have a definite place in the treat­ cases of recurrence of uterine pro­ ment of genital prolapse espe­ lapse in the group of 21 cases who cially during the reproductive ...... _ SHIRODKAR'S MODIFIED MANCHESTER OPERATION 301

age, where child-bearing func­ delphia, London, 1950, Saunders tion has to be preserved. p. 491. ( 4) The results obtained, especi­ 9. Danrelson, C. 0.: Year Book of ally as far as uterine prolapse Obst. & Gynec. 1958-59, ,p. 398. is concerned, are very im­ 10. Donald, A. A.: J. Obst. & Gynec. pressive, the post-operative Brit. Emp. 28: 256, 1921. complications and morbidity 11. Fothergill, W. E.: Am. J. Surg. 29: being minimum. 151, 1915. 12. Gordon, C. A. and Gordon, R. E.: Acknowledgement Am. J. Obst. & Gynec. 74: 392, Our thanks are due to Dr. T. H. 1957 . ..~.-{indani, M.D., F.A.Sc., F.A.M.S., 13. Howkins Shaw's Text Book of D.Sc.; Dean, B.Y.L. Nair Charitable Gynec. ed. 8, J. & A. London 1, Hospital and T.N. Medical College; 1962, Churchill Ltd., p. 521. Bombay-8 for his kind permission to 14. Jeffcoate, T. N. A.: Principles of publish this paper. Gynec., ed 2, London 1962, Butter­ worths, p. 283 References 15. Joe, V., Meigs, M. D. and Somers 1. Bailey, K. V.: J. Obst. & Gynec. H. Sturgis M. D.: Progress in Brit. Emp. 61: 291, 1964. Gynec. Vol. III, New York London. 2. Bailey, K. V.: J. Obst. & Gynec. 16. Masani, K. M. A.: Text Book of Brit. Emp. 63: 663, 1956. Gynec., ed. 4, Bombay, 1963, 3. Bonney, V. A.: Text Book of Gyna­ Popular Press, 505. ecological Surgery, ed. 6, London, 17. Maudsley, R. F. and Robertson, 1952, Casell, p. 588. E. M.: Surg. Gynec. & Obst. 1965, 4. Brady, L: Am. J. Obst. & Gynec. Oct. p. 859. 65: 400, 1953. 18. McCall, M. C.: Obst. & Gynec. 10: 5. Colmer, W. M.: Am. J. Obst. & 595, 1957. Gynec. (i.5: 170, 1953. 6. Crossen, H. S. and Crossen, K. J.: 19. Rice, T. V.: The Geneology of Operative Gynaecology, ed. 6, St. Gynec. History of the Develop­ Luis, 1948, Mosb., p. 381. ment of Gynecology, 1943. 7. Currie, D. W.: J. Obst. & Gynec. 20. Shirodkar, V. N.: Contributions to Brit. Emp. 59: 96, 1952 a. Obstetric and Gynaecology, Edin­ 8. Curtis, A. H. and Huffman, T. W.: burgh and London 1960, E. & E. S. A Text Book of Gynec. ed. 6, Phila- Livingstone Ltd., p. 16.

10