AN UNUSUAL HAZARD ENCOUNTERED DURING A PRESACRAL SYMPATHECTOMY

Report of a Case

by M. K. BAsu MALLIK*, M.B.B.S. (Cal.), Ph.D. (Lond.), D.Obst.R.C.O.G.

Introduction literature of such instances, the fol­ In modern gynaecology, there is a lowing case has been considered worthy of reporting. definite place for the operation of presacral sympathectomy. Broadly Case R eport speaking, the common indications are Miss D. W., 22 yrs., was first seen in the out-patients department on the 27th severe and intractable dysmenor­ November, 1957. rhoea not amenable to any other Complaints: (i) Dysmenorrhoea, ever method of treatment, in connection since . m enarche, and gradually getting with conservative treatment of endo­ · wor se. (ii) Pain in the right iliac fossa­ metriosis and for the relief of visceral for past 12 months. Past history of illnesses-Nothing signi­ pain in inoperable cases of carcinoma ficant. of the cervix. Other conditions for Menstrual history-Menarche-13 years. which this operation has been used Menstrual cycle-6/ 14 to 28 days; al­ are, pruritus vulvae, dyspareunia and ways irregular. for the cure of mittelschmerz. (Te Loss-Average. Linde) Pain-Premenstrual and continuing throughout the period. The operation was first performed Felt mostly in the lower abdomen and by Jaboulay (1898), and was pop­ in sacral region. ularized by Cotte ( 1925), the latter Last menstrual period- 18th Novem ­ reporting a large series of cases with ber, 1957. favourable results. Since then a No subjective symptoms referable t o gastrointestinal and urinary system. spate of literature has appeared on On examination the subject. General health-good. Well-developed There are certain well known diffi­ adult female. culties and dangers that one may B.P.= ll0/ 65 mm. Hg. expect during the course of the opera­ Heart and lungs N.A.D. Pulse= 76/min tion. A case is reported herein in Breasts-Well-developed. Per abdomen-Some tenderness over the which an abnormal kidney caused McBurney's point. Otherwise normal. considerable difficulty in the per­ Pelvic examination (rectally) formance of the operation, and as I Uterus anteverted, normal in size and have not seen any reports in the mobile. Cervix healthy. •:•Registrar in Obstetrics & Gynaecology, Adnexa and pouch of Douglas-normal. Barrow and Furnacess Group of Hospi­ Treatment tals, Lancashire. The patient was advised to follow 124 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA regular healthy life, to avoid constipation promontary of the sacrum, which contains and to take things quietly during the the presacral or the hypogastric nerve periods. She was also given Placadol (Fig. 1). tablets to use during the painful episode of bleeding, and advised to report in two months. llicnt Ureter ----H After using the regime for two months Left IJ nt'r patient reported no relief. Subsequently i'he ~•• she was treated with various analgesics and R1cht. eo 01Jn11 ll1ae antispasmodics such as codeine, A.P.C. ;.rl.etjl tablets, Panadol, Buscopan and even atropin and pethidine. All these com­ pounds gave her relief temporarily but immediately on cessation of the treatment Fig. 1 Showing encroachment of the mass in the the dysmenorrhoea recurred with the ori­ triangle Cotte. ginal severity. Pethidine was quite effec­ tive but because of its habit forming The swelling was palpated and was fell effects it was not used for more than three continuous with the left kidney. The occasions. She was also treated with right kidney was then palpated and was oestrogens for 3 months, which failed to found to be slightly elongated in shape. give her relief permanently. There did not seem to be any connection It was then decided to examine the between the two kidneys along their upper patient under anaesthesia and to dilate the poles. The uterus, tubes and ovaries were cervix. This examination confirmed the next palpated and were found normal. presence of normal genital organs and then The peritoneum of the triangle was the cervix was dilated to size 12 Hegar's incised in its lower half and its under­ dilator. surface cleared of the areolar tissue which Following this procedure the patient re­ contains some nerve fibres. The ureters mained almost free from pain for about and the inferior mesenteric artery were four months but again the dysmenorrhoea drawn aside but even then the left com­ recurred. She complained of feeling com­ mon iliac vein was not exposed, as it was pletely miserable during each period and under the mass. The peritoneum over the that the dysmenorrhoea was definitely in­ mass was carefully incised for about an creasing. The question of marriage and inch and it was found to have the same pregnancy was discussed with her, to which. colour and texture of the kidney. The she did not show any inclination. lower pole of the mass was separated from the subjacent structures by blunt dissec­ Under these circumstances, in the bes ~ tion and all areolar tissue containing nerve interest of the patient, a presacral sympa­ bundles were removed. Thus all connec­ thectomy was decided and the procedure tive tissue was stripped and cleaned in front was explained to the patient, to which she of the fourth and the fifth Jumb::tr vertebra readil:y: agreed. and along the left and the right common iliac arteries down to their bifurcations. Operation (2-2-60) The lower pole of the mass was then re­ The abdomen was opened by a midlin ~ placed in its place and the peritoneum was subumbilical incision. The intestines were closed by continuous number 0 catgut packed off and the operating table was suture. The appendix was then removed made Trendeleberg. Three points of Cotte and finally the abdomen was closed in were then idenfied, namely, the bifurca­ layers. tion of the aorta, the promontory of the The post-operatve period was uneventful. sacrum and the inferior mesenteric artery. Intra-venous and retrograde pyelogramJ It was found that there was a swelling were done after a month and a picture of occupying the upper half of the triangle the latter (Fig. 2) is reproduced. A cystos­ formed by the aortic bifurcation and the copic examination revealed a normal blad- ) AN UNUSUAL HAZARD DURING PRESAC~AL SYMPATHECTOMY der and two normally functioning urete­ plications that may ensue after any ric orifices. abdominal operation in general. Ureters can be saved by bearing their position in this situation in mind, by exposing them in the early part of the operation and by gently retracting the structures out of the way. The left common iliac vein lies in the upper part of the triangle of Cotte and can be avoided by carrying out blunt dissection. In this case this structure was particularly vul­ neral::le to trauma because it was hidden almost entirely from view b-1 the lower pole of the abnormal kid­ ney (Fig. 1). Another hazard en­ countered was to avoid the mid-sacral artery which, again, was covered over by the mass. The artery lies in the fascia covering the fifth lumbar vertebra and the presacral nerve lies superficial to it, and extremely care­ ful blunt dissection . avoided :the Fig. 2 trauma. Retrograde pyelogram to shaw the left kidney, The question arises whether the which covered more than 2/3rd of the treanglE' of cotte. pressure of the abnormal kidney was responsible in any way for the occur­ Follow-U}l: The patient has remained rence of the intractable dysmenor­ well ever since although the first two rhoea. The patient was completely periods were heavy. She is now able to relieved when the nerve was remov­ do her duties during the period without any trouble whatsoever. ed. It is known that the presacral nerve carries constrictor and sensory Discussion fibres from the uterus. Cotte ( 1925) and Davis (1938) held that in majo­ In this paper I do not wish to dis­ rity of cases of dysmenorrhoea there cuss the results of this particular pro­ is subacute or chronic neuritis in the cedure but would concentrate on the · sympathetic nerves of the uterus and hazards of the operation. Among the in their ganglia. Cotte and Davis well recognised difficulties and dan­ found the degenerative changes in gers of the operation, injuries to the 75 per cent and 70 per cent respec­ ureters, inferior mesenteric blood tively. They believed that the pain vessels, left common iliac vein and was due to exaggeration of either the median sacral artery are import­ motor or sensory impulses rendered ant. In addition to these, one has to hypersensitive by the inflammatory take into consideration the dangers process. It is just possible that the of general anaesthesia and the com- abnormal kidney was pressing on the ) laG JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA nerves producing an effect akin to viewed at laparotomy. The presence that of compression of nerve bundle of a septum in the uterus was ex­ by inflammatory oedema. eluded by means of the uterine sound, It is urged here that an intraven- · which is sometimes more useful than ous pyelography should be done in a hysterogram when the septum is a all cases in whom the operation of small one and partial. presacral sympathectomy is contem­ plated. Besides showing the struc­ Acknowledgement ture and disposition of the kidneys, it would disclose other abnormalities I wish to thank Mr. G. R. Stone­ such as double ureter, megaloureter, ham, F.R.C.O.G., for his permission or postcaval uret2r and a fore­ to report this case. knowledge of their presence is a fore­ warning to the operator who would References be doubly careful. In addition to 1. Cotte G.: Lyon Med.; 135, 153, this, needless to say that cystoscopic 1925. examination is very h2lpful. Consi­ dering the fact that renal tract ab­ 2. Davis A. A.: Dysmenorrhoea, its normalities are often associated with Aetiology, Pathology and Treat­ genital tract abnormalities, both ment; 1938; London; Oxford Uni­ systems should be investigated, when versity Press. abnormality is found in either of 3. Jaboulay (1898): Referred in them. In this particular patient the Operative Gynaecology by R. W. genital tract was normal on gynaeco­ Te Linde. J. B. Lippincott Com­ logical examination and also when pany, Philadelphia, 1946.

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