FOTHERGIL'S OPERATION

This operative description is useful for students

1. Fothergill’s Operation DR SHIVAMURTHY H M PROF IN OBG . SNMC BAGALKOT , KARNATAKA . INDIA

2. Objectives To ampuatate the Portiovaginalis of the cervix only when there is elongated. Approximation of the cardinal ligaments in front of the cervical stump Fothergil stitch. Repair of enterocele. 4 Cystocele repair

3. Indication It is done in 2 nd and 3 rd degree uterine prolapse with cystocele , Supravaginal elongation of the cervix in a women desirous of retaining her mentrual function.

4. Contraindications Suspected pregnancy Pelvic Infection . Suspected malignancy of genital tract

5. Disadavantages Cervical incompetence and habitual abortion Preterm labor and precipitate labor Excessive fibrosis may lead to cervical stenosis and dystocia during labor. Dysparunia Increased incidence of caesarean section.

6. Prerequisites : Blood compatible with the patients blood should be ready Cervical exfoliative cytology. Urine routine and microscopy.

7. Steps of Operation The patient is put in dorsal position,legs supported, buttocks at the edge of the table . Perineum is painted and draped and bladder catheterised.

8. Steps of Operation Exposure of the operative field and do diagnostic currettage : A sims specullum is placed in the vagina,the anterior lip of the cervix is grasped with a tenaculum, uterocervical length is measured,cervix is dilated to a 10mm H egars dilator ,uterus curetted and then the cervix is pulled down. The vaginal wall covering the cervix is elevated in the midline between two allis clamps.

9. Initial incision on the anterior vaginal wall: Marking Silk sutures are placed in the vaginal wall on either side of the cervix at a point adjacent to the attachment of cardinal ligaments. a transverse incision is cut through the vaginal wall into the areolar tissue space between cervix and the vaginal wall.

10. Fothergills Points The vaginal mucosa is grasped with 4 Allis forceps at four fothergills points, Just below the urethral orifice Behind the cervix in the posterior fornix in the midline about the lower level of uterine isthmus. 3 Two lateral points which ( when approximated to each other in front of the cervix) would make the vaginal vault of the right size. An incision is made in the vaginal mucosa joining these four points .

11. 6.Separation of the bladder from the cervix: Cervix held in downward traction and lower margin of the bladder is elevated with allis clamp. Fascial attachments of bladder to the cervix is cut. Proper cleavage between bladder and cervix is identified, bladder is advanced above the cervix with gauze covered finger. .

12. FOTHERGILLS KEY SUTURE (for the anterior lip) The suture enters the vaginal skin at the level of Fothergill’s lateral point and transfixes the cut cardinal ligament pedicles. The needle next passes from without inwards through the full thickness of the ant cervical muscle near midline at 12 o’clock. The needle isnow repassed from within outwards and through cardinal ligament pedicle of the opposite side and finally out at opposite lateral fothergill point. These two are tied together in anterior midline.

13. Complete covering of the cervix . The lateral aspect of the raw cervical stump may be closed by interrupted sutures . Sounding of the cervix and packing of the vagina

14. Problems with Fothergills operation : Improper dilation of cervix makes fothergills stitch difficult. If pedicles of cardinal ligaments are short it is difficult to fix it anteriorly at internal os. The cardinal ligaments should be doubly ligated.

15. Complications Primary hemmorrhage . Secondary hemorrhage from cervical stump after ten to twelve days. Post surgery cervical stenosis Recurrence of prolapse Bladder injury Vesico vaginal fistula UTI Urinary stress incontinence from overcorrection of cystocele Perineal abscess Rectovaginal fistula

16. Shirodkars modification of Fothergills operation Indication-same as fothergills but without supravaginal elongation of cervix. Steps- A circular incision is made all around the cervix as for anterior colporrhaphy . Posterior peritoneum is opened . Anterior colporrhaphy is done. Uterosacrals and adjacent part of cardinal ligaments are cut ligated and crossed in front of the cervix and fixed by nonabsorbable sutures. Rest of the ant vaginal wall is closed.

17. The end