Reconstructive and reproductive surgery in gynecology, volume two: gynecological surgery malcolm g.
Reconstructive and Reproductive Surgery in Gynecology, Volume Two: Gynecological Surgery Malcolm G. Munro
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Reconstructive and Reproductive Surgery in Gynecology, Volume 1: Fundamentals and Conditions Malcolm G. Munro
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1
I. Brill, Robert M. Rogers, Jr., and Victor Gomel 2
3
4
Vadim V. Morozov, and Ceana Nezhat 6
Gomel and Malcolm G. Munro
7
8
9
50
Michel Canis, Nicolas Bourdel, Céline Houlle, Benoit Rabischong, Revaz Botchorishvili, and Jean L. Pouly
Denis Querleu, Sophie Deutsch-Bringer, and Alejandra Martínez
Contributors
Jason A. Abbott MD PhD
Professor, Gynaecological Surgery
University of New South Wales
Royal Hospital for Women Sydney, Australia
Sugandha Agarwal MBBS MS
Senior Research Officer, Department of Obstetrics and Gynecology
Vardhman Mahavir Medical College Safdarjung Hospital New Delhi, India
Mobolaji O. Ajao MD MPH
Instructor, Department of Obstetrics, Gynecology and Reproductive Biology
Division of Minimally Invasive Gynecologic Surgery
Harvard Medical School
Brigham and Women’s Hospital Boston, Massachusetts
Fabiola Balmir MD
Fellow, Department of Obstetrics and Gynecology
Division of Reproductive Endocrinology and Infertility
University of Pittsburgh Pittsburgh, Pennsylvania
Mohamed A. Bedaiwy MD PhD
Professor and head, Department of Obstetrics and Gynecology
Division of Reproductive Endocrinology and Infertility
University of British Columbia Vancouver, Canada
Nicola Berlanda MD
Adjunct Professor, Department of Gynecology and Obstetrics
Gynecologic Surgery Unit
University of Milan Milan, Italy
Revaz Botchorishvili MD
Department of Gynecologic Surgery
University of Clermont-Auvergne
CHU Estaing
Clermont-Ferrand, France
Nicolas Bourdel MD PhD
Department of Gynecologic Surgery
University of Clermont-Auvergne
CHU Estaing
Clermont-Ferrand, France
Mauro Busaca MD
Professor, Department of Gynecology and Obstetrics
University of Milan Milan, Italy
Michel Canis MD
Professor, Department of Gynecologic Surgery
University of Clermont-Auvergne
CHU Estaing Clermont-Ferrand, France
Perrine Capmas MD PhD Department of Gynecology and Obstetrics Service de Gynécologie-Obstétrique
University of Paris-Sud Hôpital Bicêtre Paris, France
Scott Chudnoff MD MSc
Clinical Professor, Department of Obstetrics and Gynecology
Columbia University Irving College of Physicians and Surgeons Stamford Health Stamford, Connecticut
Ana Cobo PhD
Director of Cryopreservation Unit IVI, Valencia Valencia, Spain
Geoffrey W. Cundiff MD
Professor and Head, Department of Obstetrics and Gynecology University of British Columbia Vancouver, Canada
Xavier Deffieux MD PhD
Department of Gynecology and Obstetrics Service de Gynécologie-Obstétrique University of Paris-Sud Antoine Béclère Hospital Paris, France
Sophie Deutsch-Bringer MD
Department of Obstetrics and Gynecology University Hospital Montpellier, France
Jon Ivar Einarsson MD MPH PhD
Professor, Department of Obstetrics, Gynecology and Reproductive Biology
Harvard Medical School
Division of Minimally Invasive Gynecologic Surgery
Brigham and Women’s Hospital Boston, Massachusetts
Mark Hans Emanuel MD PhD
Visiting Professor, Department of Gynaecology
University of Utrecht
Senior Consultant University Medical Center Utrecht, The Netherlands
Tommaso Falcone MD
Professor, Department of Surgery
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Medical Director
Cleveland Clinic London London, England
Hervé Fernandez MD PhD
Professor and Head, Department of Gynecology and Obstetrics
University of Paris-Sud Hôpital Bicêtre
Paris, France
Victor Gomel MD
Professor Emeritus, Former Head, Department of Obstetrics and Gynecology
Faculty of Medicine
University of British Columbia Vancouver, Canada
Miriam M.F. Hanstede MD
Consultant, Department of Obstetrics and Gynecology
Spaarne Gasthuis Hoofddorp/Haarlem Amsterdam, The Netherlands
Eleanor Hawkins MD
The Women’s Health Center Fountain Valley, California
Céline Houlle MD
Department of Gynecologic Surgery
University of Clermont-Auvergne
CHU Estaing
Clermont-Ferrand, France
Fred M. Howard MS MD
Former Professor Emeritus, Department of Obstetrics and Gynecology
University of Rochester School of Medicine and Dentistry Rochester, New York
Yaël Levy-Zauberman MD
Department of Gynecology and Obstetrics
University of Paris-Sud Hôpital Bicêtre Paris, France
Marit Lieng MD PhD
Associate Professor, Department of Obstetrics and Gynecology
University of Oslo Oslo University Hospital Oslo, Norway
Alejandra Martínez MD
Department of Surgery
Institut Claudius Regaud
Institut Universitaire du Cancer de Toulouse Toulouse, France
Sukrant Mehta MD
Assistant Clinical Professor, Department of Obstetrics and Gynecology
David Geffen School of Medicine at UCLA University of California, Los Angeles Los Angeles, California
Malcolm G. Munro MD
Clinical Professor, Department of Obstetrics and Gynecology
David Geffen School of Medicine at UCLA
University of California, Los Angeles
Kaiser Permanente Los Angeles Medical Center Los Angeles, California
David L. Olive MD
Wisconsin Fertility Institute Middleton, Wisconsin
William H. Parker MD
Clinical Professor, Department of Obstetrics, Gynecology and Reproductive Sciences
University of California, San Diego School of Medicine La Jolla, California
Kathryn D. Peticca MD
Graduate Medical Resident, Department of Obstetrics, Gynecology and Reproductive Sciences University of Pittsburgh Pittsburgh, Pennsylvania
Jean L. Pouly MD
Department of Gynecologic Surgery
University of Clermont-Auvergne
CHU Estaing Clermont-Ferrand, France
Denis Querleu MD
Honorary Professor of Oncology University of Toulouse Toulouse, France
Institut Bergonié Cancer Center Bordeaux, France
Benoit Rabischong MD
Department of Gynecologic Surgery University of Clermont-Auvergne CHU Estaing Clermont-Ferrand, France
José Remohí MD
Professor of Obstetrics and Gynaecology School of Medicine University of Valencia IVI Fertility Valencia, Spain
Barry H. Sanders MD
Clinical Professor, Department of Obstetrics and Gynecology Faculty of Medicine
University of British Columbia Vancouver, Canada
Joseph S. Sanfilippo MD MBA
Professor, Department of Obstetrics, Gynecology and Reproductive Sciences
Division of Reproductive Endocrinology and Infertility University of Pittsburgh Pittsburgh, Pennsylvania
Howard T. Sharp MD
Professor, Department of Obstetrics and Gynecology University of Utah University of Utah Health Sciences Center Salt Lake City, Utah
Sukhbir S. Singh MD
Associate Professor, Department of Obstetrics and Gynecology University of Ottawa The Ottawa Hospital Research Institute Ottawa, Canada
Paolo Vercellini MD
Professor of Gynecology and Obstetrics University of Milan
Department of Clinical Sciences and Community Health Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico Milan, Italy
http://taylorandfrancis.com
Surgery for congenital anomalies
Hysteroscopic, laparoscopic, laparotomic, and vaginal
JOSEPH S. SANFILIPPO, KATHRYN D. PETICCA, and FABIOLA BALMIR
Key points
• Surgical management of Müllerian anomalies has been revolutionized by imaging, and the development of hysteroscopic and laparoscopic surgical techniques that have rendered laparotomic management infrequent, and office hysteroscopic management of selected anomalies a reality.
• The CONUTA system of classification provides increased granularity allowing for more accurate descriptions of Müllerian anomalies affecting the uterine corpus, particularly when they affect the cervix and the vagina.
• For women with Mayer–Rokitansky–Kuster–Hauser syndrome (CONUTA U5-C4-V4) the success rate of the patient selfadministered “Frank technique” is about 85%–90%.
• For those with vaginal agenesis for whom the Frank technique isn’t feasible or successful, there exist other procedures, such as the Vecchietti and Davydov procedures that can be performed under laparoscopic guidance without the need for skin grafting.
• Isolated cervical agenesis (CONUTA U0-C4-V0 or V4) has been treated with procedures linking the corpus to the existing or artificially created vagina, but study sample sizes are small, and there is inadequate reporting of pregnancy outcomes to allow for meaningful counseling of patients.
• The unicornuate uterus and variants, CONUTA U4-C3 (rAFS Class IIb), are often associated with abnormalities of the urinary tract, such as unilateral renal agenesis, and can be treated with laparoscopically directed removal of the underdeveloped or obstructed uterine horn.
• Uterus didelphus, which is CONUTA U3b-C2 (rAFS Class III) and rAFS Class VI (there is no corresponding CONUTA designation) generally require no surgical or medical intervention to deal with symptoms or to improve pregnancy outcomes.
• The bicornuate uterus, CONUTA U3a-C0 (rAFS IV a/b), can be treated expectantly, or with Strassman metroplasty with hysterotomy and unification of the two endometrial cavities.
• The septate uterus, CONUTA U2-C0/1 (rAFS Va/b), can generally be treated with hysteroscopically directed transection of the septum.
INTRODUCTION
As described in Chapter 11, approximately 10% of females are born with a congenital anomaly of the reproductive tract, and while many do not benefit from interventions, a number will experience improved clinical outcomes with an appropriate surgical procedure.1,2 From a historical perspective, the surgical management of anomalies involving the reproductive tract has, in many instances, changed dramatically because of advances in surgical technique and technology. As detailed in Chapter 11, the advent of minimally invasive surgical technological innovation has provided clinicians with a plethora of options for management.
Hysteroscopy is not only a means for assessment of the uterine cavity; it is also the method of access for reconstructive surgical intervention. Resectoscopes, radiofrequency needles (RFNs), and electromechanical morcellators complement more traditional operative instruments that include scissors and biopsy forceps placed through the operative channel. Indications for concurrent laparoscopy
are variable and need to be considered on a case-by-case basis with knowledge that intraoperative sonographic monitoring is often at least as efficacious and, in most instances, readily available to the reproductive surgeon.
VAGINAL AND CERVICAL
Transverse vaginal septum (CONUTA V3)
The incidence of transverse vaginal septum is 1:80,000, with variable location and extent, occupying some portion of the lower, middle, and/or upper segments of the vagina. 3 The septa are more commonly perforate (61%), with resultant menses, but are frequently imperforate (39%), the latter being associated with amenorrhea and hematocolpos.4
As described in Chapter 11, evaluation of these patients requires a combination of physical examination, transperineal or transvaginal sonography, and, frequently, MRI. Examination of both the vagina and rectum allows for assessment of the caudal aspect of the
septum and for the presence of hematocolpos, should it exist, cephalad to the obstruction. However, MRI allows a more complete evaluation of the vaginal canal, including characterization of the position, length, and thickness of the septum, as these findings are important in designing the surgical approach. The septum may be present at a number of levels in the vagina; viz. low (14%), mid (40%), and high (46%). 5
Surgical correction of the transverse vaginal septum is the management of choice. Ideally, we recommend performing resection surgery at the time of puberty to allow for improved healing of the vaginal epithelium in the presence of physiological levels of systemic estrogen. Following menarche, complete transverse septa are typically associated with distension of the upper vagina in the form of a hematocolpos, a circumstance that facilitates the surgical resection. The overall strategy for thin septa is resection with vaginal epithelial reapproximation. Another approach when there exists a thickened transverse septum or partial atresia of the vault is the modified Z-plasty technique described by Grünberger. Here, eight vaginal epithelial flaps are created and add vaginal vault length of up to 1 cm (Figure 29.1). This procedure also minimizes the risk of vaginal stenosis by postoperatively employing the use of a rigid plastic vaginal mold with concurrent use of estrogen cream.6 Another consideration for patients with complete obstruction is the potential sequelae of retrograde menstruation that include endometriosis and associated adhesion formation secondary to inflammation. In such instances, simultaneous laparoscopy should be considered to manage the resulting adhesive disease. Relief of the outflow tract obstruction frequently results in complete reversal of even extensive endometriosis.7
The imperforate septum is generally approached vaginally. The procedure should be preceded by catheterization of the bladder with a Foley catheter. The surgeon must remain cognizant of both the bladder and the rectum during the resection. For thick transverse septa, the process is started by placing a large bore spinal needle through the septum to confirm and orient the presence and location of the hematocolpos with the aspiration of old, thickened blood. Resection of the septum is then undertaken, a process that can include use of a monopolar radiofrequency (RF) electrical needle or blade electrode used to incise through the center of the septum along the needle tract. This incision should be created with extreme care, avoiding posterior or anterior deviation toward the rectum or urethra. With such electrodes, a setting of 25–35 watts “cutting” current is generally effective for septum dissection. In cases of thin septa, resection should be done as widely as possible to reduce postoperative vaginal stenosis. Upon completion of the resection, it is important to perform a careful rectal examination to detect otherwise occult injury.
It is important to establish continuity of the vaginal epithelium across the area of resection. Consequently, once the septum is resected, the proximal and distal ends should be approximated with interrupted sutures with,
Figure 29.1 Grünberger Z-plasty technique for transverse vaginal septum (From Wierrani F, et al., Fertil Steril 2003;79(3):608-12. With permission.)
for example, 2-0 or 3-0 polyglactin 910 positioned with a tapered (non-cutting) needle such as a SH, V20, CT-1, or GS-21 design (depending on the manufacturer), the former especially if there is space limitation within the vagina.
With thicker vaginal septa, if there is a significant gap, the vaginal epithelium can be addressed with the Z-plasty technique, which is performed to add length to the vagina and minimize the risk of vaginal stenosis. Where Z-plasty is not feasible, a split-thickness skin graft may be required with postoperative placement of a vaginal stent. The role for a postoperative acrylic vaginal stent when a skin graft is not used is controversial; there is no available quality evidence to provide guidance. Consequently, the use of a stent should be determined by the surgeon on a case-bycase basis if there is concern for contraction of the newly created space. Postoperatively, the maintenance of vaginal depth is important. If the patient is not sexually active, a vaginal stent should be considered. The vaginal stent can be placed either routinely each evening at bedtime or, at least, several times per week.
The abdominal perineal approach is rarely used. This technique can be considered if the transverse vaginal
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septum is difficult to appreciate and there is no hematocolpos to allow for bulging of the septum. We recommend that during laparoscopy, a 5 mm colpotomy incision is created, followed by the placement of a suction irrigator tip through the incision allowing the compartment of the vagina to be distended. Concurrently, at the perineum, an incision is created vaginally over the bulge. Moreover, we find that the suction irrigator tip can also be used to apply pressure to the septum and locate the area of the septum for incision.
It would stand to reason that outcomes, in part, are predicated upon whether the septum is imperforate, i.e., associated with amenorrhea, or perforate and has an open area for egress of menstrual fluid. The imperforate septum can lead to a hematocolpos that, over time, can apply pressure on the septum, thereby causing thinning. The imperforate septum can also facilitate surgical interventions by allowing for bulging of the septum that facilitates dissection away from surrounding structures. The location and the thickness of the septum are also important prognostic variables. A high vaginal septum is technically more difficult to surgically correct. In general, complication rates are low.4 The main long-term complication is vaginal stenosis, which may generally be managed by vaginal dilation. As previously mentioned, the risk of this adverse event can be minimized with postoperative use of a vaginal stent placed by the patient until she becomes sexually active.8
Longitudinal vaginal septum (CONUTA V1 and V2)
Since a longitudinal vaginal septum, CONUTA V1 or V2 from the ESHRE system, is often associated with other Müllerian anomalies, most commonly the didelphic and septate uteri (ASRM Class 3 and 5, respectively), this finding must prompt further workup for other abnormalities (see Chapter 11). This type of septum, when not associated with outflow tract obstruction, typically doesn’t present until the patient attempts tampon insertion or becomes sexually active. The patient may bleed despite tampon insertion, and experience dyspareunia secondary to vaginal compromise. The septum can be complete, which is more often associated with uterus didelphys (AFS Class 3; CONUTA U3), or can be fenestrated.
Management is surgical transection, usually performed after menarche. Prior to surgery, it is important for the surgeon to perform a careful pelvic examination to evaluate the length of the septum and to confirm the presence and number of cervices. There are several techniques from which to select, with perhaps the most common and traditional being serial resection and suture ligation of segments using Haney- or Kelley-type clamps and a scalpel, scissors, or monopolar needle or blade electrode for transection.
Alternatively, and if possible, the entire length of the septum can be clamped with appropriate Peon or Kelly clamps and then transected with a monopolar blade or needle electrode; then the clamps can be sequentially removed and the incisions closed with a continuous, locking 2-0 polygalactin 210 suture.9
Additionally, Perez-Millcua et al. introduced the LigaSure™ (Medtronic/Covidien Minneapolis, MN) for vaginal septum transection starting at the most caudal portion of the septum and extending cephalad until the cervix or cervices are reached. As an RF bipolar vesselsealing system the Ligasure has an advantageous small jaw that can be used to maneuver tight vaginal spaces. The thermal energy spread is 1–4 mm and is, therefore, less likely to cause adjacent bladder or rectal injury. While it is probably unnecessary, the edges of the resected area can then be oversewn with interrupted polyglactin 910 (or equivalent), and a vaginal mold can be considered for use immediately postoperatively to minimize stricture and scarring of the vagina (Video 29.1).10
There have also been reports of hysteroscopic techniques such as RF resectoscopy being used for transection of a vaginal septum in virginal girls and women who prefer to maintain an intact hymen. In this case, the vagina is distended with fluid media, and RF electrical energy through a cutting loop or needle-cutting electrode is then applied to the magnified fibrous layer of the septum. Ultrasound guidance is used simultaneously.
With each method, periodic rectal examination should be undertaken to ensure that the zone of dissection is kept away from the bowel. The resections (or transections) are ideally brought to the level of the cervix or cervices; care must be taken not to traumatize the cervix (or cervices) at the upper limits of resection.8 In general, reapproximation of denuded vaginal epithelium is often necessary in the area of resection or transection. Absorbable sutures, e.g., 3-0 polyglactin 910, can be used to reapproximate the vaginal epithelium. Although post-operative stenosis or adhesion formation is a rare sequella of longitudinal septum resection, reassessment in two to four weeks is appropriate to evaluate the vagina and break down anteroposterior adhesions that may have formed.
MÜLLERIAN ANOMALIES AFFECTING THE UTERUS
rAFS Class I-hypoplasia/agenesis (CONUTA U5) Mayer–Rokitansky–Kuster–Hauser (MRKH) syndrome (CONUTA U5b-C4-V4)
Psychologically, it is important that procedures designed to create a vagina be initiated at an appropriate age, considering several factors, including the patient’s sexual orientation, her motivation for the surgery, and the availability of professional and family support. Consequently, psychosocial counseling before treatment intervention is appropriate.11
Non-operative techniques can be very successful and, consequently, should be considered the first line approach.9 The original technique (Frank technique) employs the patient’s use of graduated Lucite (vaginal) dilators of progressively increasing diameter to create a functional vagina (Figure 29.2).12 The process begins at the vaginal dimple with the patient instructed about the proper orientation and angle of dilator placement to minimize the risk of trauma to the urethra. Success rates are in the realm of 85%–90% regarding satisfactory coitus.9,13
Figure 29.2 Vaginal obturators or dilators. These devices, of progressively increasing length and diameter, may be used by patients with vaginal agenesis to progressively create a functional vagina, starting with the smallest and progressing as appropriate to the largest size. They also can be of use for women with “vaginismus” to desensitize the muscles of the perineum and pelvic floor, and postoperatively following surgical vaginal reconstruction. This brand, from Vaginismus.com, comprises six dilators and a universal handle. The smallest, attached to the handle, is 0.6 inches (15 mm) wide and 3.48 inches (88 mm) long. The largest (far right) is 1.5 inches (38 mm) in diameter and 5.96 inches (151 mm) long.
The Ingram passive dilation technique uses a bicycle seat to secure the dilator in place while providing increasing pressure to create a functional vagina.14 The goal of these techniques is the creation of a vagina more than 7 cm in length and the achievement of successful coitus. The available evidence suggests that this approach is associated with a success rate of 90%.9,13,15,16
One of the original surgical approaches to vaginal agenesis was the Wharton–Sheares–George technique, in which the surgeon identifies and then dilates the vestigial Müllerian ducts in the space between the two labia, just dorsal and lateral to the urethral meatus. Hegar or similar dilators are used, aligned with the axis of the urethra and then firmly pressed to form two parallel tunnels with a resulting intervening central septum. This surgically created septum is subsequently transected (as for a longitudinal vaginal septum) to form a blind pouch.17 With the George modification, only a vaginal mold is inserted into the cavity and left for a week, when it is exchanged for a larger obturator. This device is then used by the patient day and night for three months after which time epithelialization has occurred to the point that intercourse is possible.18
A procedure designed to create a blind pouch between the bladder/urethra and rectum that is then lined with a split thickness skin graft was originally described by Abbe in 1898,19 and then later revised by Macindoe and colleagues. 20,21 The Abbe–Macindoe procedure can be performed in a fashion like that of the Wharton procedure or by incising the perineum between urethra and rectum with subsequent development of the usually avascular rectovaginal space with a combination of blunt and sharp dissection (Figure 29.3). Then the vaginal stent or
mold is covered with an inverted split-thickness graft typically taken from the skin of the buttocks or thigh. Unfortunately, the graft site can be a source of morbidity and provides a less than ideal cosmetic result. A number of options to the split thickness grafts have evolved including the use of amnion, 22 artificial dermis, 23 and in vitro cell culture; each of these tissue types was designed to develop into vaginal squamous epithelium. Long-term outcome studies are not available regarding the effectivity these options. With use of any of these techniques, a vaginal mold is continuously left in place for at least a week, but then, to preserve the vaginal length and caliber, is used in daily by the patient, until she is engaged in regular sexual intercourse.
There exist several other methods for creating a vagina that combine a laparoscopic and vaginal approach. The laparoscopic Vecchietti procedure is a modification of the original laparotomic approach 24 and uses a segmented acrylic mold placed in the vaginal dimple with sutures brought out through the abdominal wall in a way that allows for continuous traction.25
There are several variations in technique (Figure 29.4) (Video 29.2). For one, after emptying the bladder and establishing a pneumoperitoneum, the laparoscope is placed transumbilically and two ancillary cannulas are positioned in the left and right lower quadrant.26 The peritoneum between the bladder and the uterine remnant is incised for about 5 mm with an appropriate instrument, most commonly laparoscopic scissors. One of the laparoscopic ports is replaced with a specially designed ligature carrier that is passed just subperitoneally and then caudally between the rectum and bladder, guided by a finger placed in the rectum. Cystoscopy and anoscopy/ sigmoidoscopy are performed to ensure that the needle has not captured the lumen of either viscus. The needle is then used to penetrate the skin of the “pesudohymen” or vaginal dimple between the anus and urethra. Threads attached to the acrylic “olive” are threaded through the fenestration in the ligature carrier that is withdrawn, thereby pulling the threads into the peritoneal cavity and then subperitoneally and out through the abdominal wall where they are affixed to a traction device. Alternatively, the ligature carrier can be used via the vaginal dimple, placed under firm stretch in a cephalic direction in a fashion that allows, with laparoscopic assistance, puncture into the peritoneal cavity. The threads are then drawn through the subperitoneal space and subsequently externalized with the ligature carrier.25 The suture threads are tightened 1–1.5 cm/d for seven to ten days. Subsequently, a vaginal dilator is used to complement coitus, all of which is focused on maintenance of adequate vaginal length and satisfactory intercourse. Success regarding coitus has been excellent and reported at over 90%.26–28
The Davydov procedure, originally performed laparotomically and described from Russia in 1969, creates the neovagina by lining the dissected vesicorectal space with peritoneum advanced from the adjacent peritoneal cavity.29 The laparoscopic Davydov procedure (Figure 29.5)
is simply a minimally invasive adaptation of the same procedure (Video 29.3). 30 With the bladder catheterized, the procedure is started laparoscopically by separating the urinary bladder from the rectum after forming a 4–5 cm transverse peritoneal incision between the two rudimentary uterine remnants, generally with laparoscopic scissors. With a finger in the rectum, the incision can be extended for about 1 cm between the bladder and rectum. From the perineum, the vesicorectal space is identified after making an “H”-shaped incision, and developed in a fashion similar to that used for the Wharton–Sheares–George technique with a large 27–28 Hegar dilator or with a combination of sharp and blunt dissection until the peritoneal edges are seen. The incised peritoneum is mobilized and drawn down caudally through this space and sutured to the edge of the “H” incision with interrupted 3-0 delayed absorbable monofilament sutures. After identifying the location of the ureters, a purse string or two “hemipursestring” sutures of a 2-0 delayed absorbable monofilament are positioned to include the lateral aspect of the mesorectum, the anterior rectal serosa, the peritoneum of
the bladder dome, the round ligaments, the uteroovarian ligament, and lateral peritoneal leaf. This step can be accomplished either before or after the anastomosis of the peritoneum and the vestibule. 31 A vaginal stent (mold) is left in place for ten days followed by fitting with a permanent mold to complement maintenance of vaginal depth with intercourse.
The potential complications associated with these procedures include injury to bowel, bladder, and urethra as well as surgical bleeding. In addition, reduced vaginal length is likely to occur if there is lack of compliance with use of molds and/or coitus. Stricture and contracture secondary to scarring can occur as well as formation of granulation tissue and, if a split skin graft is used, hair growth in the vagina. Vesicovaginal, urethrovaginal, or rectovaginal fistula formation is also possible if there is injury to these adjacent structures. Vaginal vault prolapse is a potential problem after any intervention. However, overall, the incidence of such complications is low and in general less than 10%.13,15,16
Other methods of vaginoplasty are less popular and include use of bowel, sigmoid, jejunum, and ileum to line
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STSG
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Absence of vagina
Figure 29.3 (a–k) Macindoe procedure. (Modified from www.atlasofpelvicsurgery.com. With permission.)
the newly created vagina; however, foul-smelling mucus discharge and requirement for laparotomy make these approaches less desirable.32
Success rates are at least 74% when vaginoplasty techniques are viewed as a whole.16 Functional success based on the validated Female Sexual Function Index reflects a range of 0 (poor) to 36 (extremely satisfied); this index provides scores of 25.2+/–3.7 for vaginal dilation and 27.9 +/–3.0 with vaginoplasty, compared to the general population of 30.2 +/–6.1.13,14,16,33
Instances of isolated agenesis of the lower vaginal tract may result from errors in the development of the sinovaginal bulbs and the vaginal plate. This can present as primary amenorrhea with findings of hematocolpos on imaging (Figure 29.6).34 There may be a dimple present at the location of the vaginal introitus. Treatment for this is surgical and typically timed with adequate hematocolpos to distend the upper vaginal canal.
A transverse incision should be made at the perineum at the location of the vaginal dimple approximately 2 cm in length. Using a scalpel, the incision is continued until the bulging hematocolpos is reached. Care should be taken to remain in the same plane while creating the incision at the perineum to avoid injury to the urethra, bladder, or rectum. We recommend placement of a Foley catheter prior to incision to adequately show and palpate the location of the urethra throughout the procedure. A rectal exam should also be performed initially to palpate the hematocolpos location and then again at the end of the procedure to ascertain that no injury was incurred to the rectum. Once the hematocolpos has been reached and evacuated, vaginal epithelium can be seen. The vaginal epithelium should then be grasped with atraumatic clamps, such as an Alis clamp, at four corners and then pulled out to the level of the perineum to begin to create an introitus. The four corners of the vaginal epithelium can then be secured to the perineum using interrupted delayed absorbable sutures such as 2-0 polygalactin 910. Additional sutures may be added along the perimeter of the neointroitus. 34
Figure 29.5 Surgical management of cervical agenesis. (From Fedele L, et al., Fertil Steril. 2008;89(1):212-16. With permission.)
This tract can allow for additional drainage of any remaining hematometria or hematosalpinx. Postoperatively, patients should be told to expect ongoing chocolatecolored discharge until adequate drainage of the tract has occurred; visualization of the next menses will confirm the patency of the tract. Cases of vaginal stricture have been noted postoperatively where the vaginal epithelium was pulled out more than 3 cm.35 There has been no good evidence to support the use of vaginal stents or molds following the pull out method.
Cervical agenesis (CONUTA C3 [unilateral aplasia] or C4 [cervical aplasia])
Isolated cervical hypoplasia or agenesis is extremely rare, with the actual incidence unknown.15,32,36 The coexistence with vaginal agenesis has been estimated to be about 25% based on cases reported in the literature.36 Much of the available evidence is derived from case reports and very small series, a circumstance that makes it difficult to generalize recommendations. Reconstruction based on the concept of uterovaginal anastomosis has been described and rarely reported to result in successful spontaneous pregnancy.37–42 In the past, the procedures typically included a uterovaginal graft as part of the accompanying vaginoplasty that was required for the commonly encountered patients with vaginal agenesis. This approach has also been associated with tragic outcomes, including infection and even death related to endomyometritis, reobstruction, and death secondary to sepsis.40,43
More recently a different laparoscopically directed technique has been described that does not require a graft, involving mobilization of the uterus with dissection of the vesicouterine and rectouterine spaces and by dividing the
round ligaments.42 Then, a probe is passed into the endometrial cavity through a small midline fundal hysterotomy. This probe is then applied to the cervical plate, displacing the uterus caudally. From below, an “H” incision is made in the retrohymenal dimple, and blunt and sharp dissection is carefully performed until the caudal end of the corpus is reached. After stabilizing the corpus, incisions are made over the probe entering the cavity, and the corpus is attached to the flaps of the “H” incision, thereby creating a neovaginal canal. A mold can be left in place and then inserted and reinserted. A series of 12 such patients has been reported, with long-term maintenance of vaginal caliber, and all who had attempted vaginal sexual function had done so successfully; no pregnancies had been attempted.42
For those with cervical hypoplasia, but with a patent canal without hematocolpos, ART.approaches include zygote intrafallopian transfer44,45 and image-guided transmyometrial transfer of embryos to the endometrial cavity to bypass cervical passage can be considered.46,47
Unicornuate uterus (rAFS Class II; CONUTA U4-C3)
As mentioned in Chapter 11, there is no evidence to support surgical treatment of a unicornuate uterus with contralateral agenesis. No surgical intervention is deemed necessary unless the Class II anomaly is associated with a contralateral uterine horn with functional endometrium and outflow tract obstruction (rAFS Class II b; CONUTA U4a-C3).
Class II b anomalies are associated with a higher incidence of endometriosis, in addition to premature labor and malpresentation. A spontaneous abortion rate of 37%, preterm delivery rate of 16%, term delivery of 45%, and live birth rate of 54% have been reported.48,49
Figure 29.6 Cervical agenesis. (From Kriplani A, et al., J Minim Invasive Gynecol. 2012;19(4):477-84. With permission.)
Surgical intervention of an obstructed uterine horn requires assessment of the renal system, as anomalies may include either agenesis or distortion of anatomy, such as the course of the ureter. If a decision is made to excise the involved uterine remnant, this can usually be accomplished laparoscopically (Video 29.4). Following positioning of the laparoscopic ports, and with confirmation of the anatomy including the location of the ureter or ureters, the dilated and obstructed horn is identified. Adhesions are lysed as appropriate with scissors or an appropriate energy source. The pedicle comprising the round ligament, the fallopian tube, and the ovarian artery (“triple pedicle”) is identified and transected after coagulating the tissue with RF or ultrasonic energy. The pedicle is transected and the leaves of the broad ligament opened and then divided, exposing the vascular supply to the horn, usually from the ipsilateral uterine artery. It is advisable to extend the peritoneal incision to the vesicovaginal fold isolating the bladder from the area of dissection. Then the blood supply can be sealed and transected. Attention can then be turned to separation of the horn from the “normal” corpus in a way that preserves optimal myometrial caliber. This is usually performed with an RF needle or blade electrode or an ultrasonic scalpel or shears. The dissection is continued until it meets that from the lateral side when the blind horn can be removed. Removal from the peritoneal cavity can be accomplished with an appropriate morcellation technique (Chapter 4). Suture reapproximation of the detached round, broad, and uteroovarian ligaments to the “normal” horn can be performed using running or interrupted delayed absorbable 2-0 sutures.
Didelfic uterus (rAFS Class III; CONUTA U3b-C2)
Generally, there is no indication for surgical intervention except for excision of an associated symptomatic vaginal septum, i.e., hemi-vagina with associated hematocolpos. Overall the spontaneous abortion rate is 32%, preterm birth rate is 28%, term delivery is 36%, and live birth rate is 56%.48,49 Controversy remains regarding the role of Strassman metroplasty in women with recurrent pregnancy loss, especially those that occur in the second trimester. Unification of the uterine cavities (described below with Class IV anomalies) can be accomplished via laparotomy or with minimally invasive techniques; following laparotomy, outcomes describing an 80% live birth rate have been reported.50 However, overall, the available evidence does not support this type of unification procedure.51
OHVIRA (obstructed hemivagina and ipsilateral renal agenesis) is one of the more common Müllerian anomalies associated with obstruction (CONUTA U2/U3b-C2-V2).
Resection of the wall between the patent and obstructed hemi-vagina on the involved side results in relief of pain in association with retained menstrual fluid. Ideally, management includes a single stage approach that entails vaginally directed resection of the hemi-vagina aided by intraoperative ultrasound and laparoscopy as appropriate. Upon resection, a hematocolpos is usually noted, and thus creation of an outflow tract relieves the unilateral
obstruction. Care must be taken to widely excise the septum, and in a manner similar to that for transverse vaginal septum resection, the vaginal epithelium is then well approximated (see Chapter 11).
Bicornuate uterus (rAFS Class IV; CONUTA U3a, b, and c-C0)
Surgical reconstruction can be considered in the patient with recurrent pregnancy loss and an rAFS Class IV anomaly. Outcome data are variable with pre-operative live birth rates ranging from 2%–21% to post-surgical success at 60%–86%.51–53 The spontaneous abortion rate has been reported to be 36%, the preterm rate 23%, term delivery rate 41%, and live birth rate 55%.16
One option, as noted for Class III/U3b anomalies, is the Strassman metroplasty, a procedure that results in unification of the two uterine horns after the creation of a transverse fundal incision. Following access to the peritoneal cavity, the procedure starts with use of dilute vasopressin (concentration varies, e.g., 1 unit diluted with 30 ml normal saline) injected into area of planned uterine incision. The myometrium is incised with a monopolar RF blade or needle electrode using a low voltage (“cutting”) waveform at about 30 watts (depending on the design of the electrode); the incision is made from the superomedial aspect of each uterine horn with care being taken not to disturb the cornual aspects on each side of the uterus. The incision is extended down to the endometrial cavity. This is followed by transposing the incision to a vertical orientation and then approximating the myometrial edges with interrupted 0-polygalactin 910 (Vicryl), or equivalent delayed absorbable sutures. The serosa is reapproximated with a 3-0, delayed absorbable suture. The result resembles the appearance of the repaired incision associated with a classical Cesarean section.32,54
Cervical cerclage has also been reported to reduce the risk of second trimester pregnancy loss and preterm birth; however, available comparative evidence suggests that expectant management appears to be of equal efficacy.48
Septate (rAFS Class V; CONUTA U2-C0/1)
As previously mentioned, there is a large body of evidence to support the surgical management of a septate uterus to improve pregnancy-related outcomes in patients with a history of recurrent pregnancy loss.55–57 Additionally, Chapter 11 addressed the argument for prophylactic transection of the septate uterus in patients with primary infertility.
The question of septum management prior to in vitro fertilization overall seems most supportive of septum transection.58 This question has been addressed in a series reflecting IVF outcomes before and after hysteroscopic septum transection. In patients with a large septum (rAFS Va; CONUTA U2b) that was left intact, the spontaneous abortion rate was 83.3% and with a small septum (rAFS Vb; CONUTA U2a), 28.9%. This was in comparison to patients for whom a larger septum was removed, where the miscarriage rate was found to be 30.6% while with small septum transection it was reported as 28.1%.58
The technique is NOT septum resection but hysteroscopic transection. This approach appears to result in an “almost normal prognosis for pregnancy outcomes and term delivery rates.”48 If the septum reaches the level of the exocervix (CONUTA U2b-C1), there has been some controversy regarding management—some suggesting that the cervical component be left intact, while others remove the cervical septum in its entirety.59 If there is uncertainty regarding the diagnosis—i.e., the distinction between a rAFS Class IV and Class V anomaly—it is most appropriate to perform the procedure in the operating room under laparoscopic guidance. However, when 3-D TVUS or MRI is available this should not be necessary.
There does not appear to be any uniform approach to pre-op endometrial suppression with progestins, danazol, or Gonadotrophin-releasing hormone agonists, but it is apparent that they avoid the specter of endometrial fragments obscuring visualization and potentially clogging the flow channels of the hysteroscope.
At least for rAFS Va (CONUTA U2b) anomalies, the technique can be performed under local anesthesia as an office procedure using no or, preferably, local anesthesia;60 it can also be performed under conscious sedation (see Chapter 7). All that is necessary is a hysteroscope placed within a 5 or 5.5 mm OD continuous flow operative sheath with a 5 Fr operating channel and either 5 Fr hysteroscopic scissors or an RF needle. Such an approach may be associated with reduced operating time and complications but equivalent outcomes.61 Usually, the selected hysteroscope has an oblique lens, either 12°–15° or 25°–30°. When mechanical or bipolar RF instruments are used, the distending media should contain electrolytes such as a normal saline solution. Nonelectrolytic media such as sorbitol, glycine, or mannitol are used for uterine distention when monopolar RF instrumentation is selected. The fluid deficit should be monitored throughout the procedure as described in Chapter 7 with maximum deficits of 1000 mL with non-electrolyic solutions and 2000–2500 mL with saline media, each signaling termination of the procedure. For more details regarding hysteroscopic distending media, see Chapters 7 and 10 and the AAGL Practice Report on management of hysteroscopic distending media.62
The specific approach utilizing hysteroscopic scissors, laser energy, or RF monopolar or bipolar devices is, in large part, operator choice. If the surgeon is confident of the diagnosis based on MR imaging or prior laparoscopic evaluation, and the septum is confined to the endometrial cavity, it is rather simple and safe to perform in an office setting. After obtaining appropriate local anesthesia (see Chapter 7) (Video 29.5) the cervix is dilated as necessary to accommodate the outer diameter of the hysteroscopic system to be used in the procedure. After accessing the cervical canal, the septum is identified with the two “tunnels” that represent the endometrial cavities on each side. In such instances, additional anesthesia may be provided with hysteroscopically directed injection of 0.5% lidocaine (or mepivacaine), with 1/200,000 adrenaline into the septum with a suitable needle passed through the operating
channel of the hysteroscope. Examples include an oocyte retrieval needle or a 5 Fr Williams needle. Then the scissors or, preferably, a bipolar needle is passed through the operating channel of the operative sheath. Transection of the septum can start with the most caudal portion dividing the tissue while continually ensuring that the plane of transection is midway between the anterior and posterior aspects of the endometrial cavity. In general, this plane will be relatively avascular—if bleeding is encountered, it is possible that the dissection has deviated off plane. The surgeon should also be aware of the cephalic extent of dissection with the end point being the observation of muscular tissue, bleeding, and/or the transection reaching a plane that is approximately level with the cornua.61 It is better to leave a small amount of the septum than to go too far.
If the procedure is performed under laparoscopic guidance, the laparoscopic light source can be turned off while viewing the uterus to visualize uniformity of hysteroscopic resection. In this case, the uterus seen through the laparoscope takes on the appearance of a “jack-o’-lantern” when uniform hysteroscopic transect is accomplished.
For Class Va anomalies that reach the level of the exocervix (CONUTA U2, C1), the approach changes somewhat, as there is controversy regarding the propriety of removing the cervical component of the septum.
Advocates for preservation of the cervical septum at the time of metroplasty propose a hypothetical risk of iatrogenic cervical incompetence in subsequent pregnancies. To transect the septum in the uterine corpus while preserving the cervical component of the septum, a pediatric #8 Foley catheter or metal probe is inserted into one hemicervix. A resectoscope or operative rigid hysteroscope is then placed in the contralateral hemicervix and the other hemicervix is distended with fluid media. The septum is then incised with hysteroscopic scissors or with a needle or blade electrode just above the internal cervical os until the Foley bulb or metal rod is visualized. Transection of the septum is continued in a cephalad direction until both tubal ostia are visualized and the hysteroscope can move free about the cavity.
Proponents of cervical septum transection have postulated that removal of the septum allows for an easier and safer hysteroscopic metroplasty. One randomized controlled trial comparing those women with cervical septum transection versus retention found that in the transection group, total operative time was reduced owing to improved visibility and ease of initial uterine septum incision during hysteroscopy.63 The use of distending media was reduced in the cervical transection group. No difference was found in subsequent pregnancy rates, first trimester abortions, the need for cerclage, or the proportion of preterm deliveries. The group with cervical septum retention had a significantly higher number of cesarean sections.
Transection of the septum can be performed by first placing two single tooth tenacula on the anterior aspect of the cervix. Then the two cervical canals can be dilated one at a time to 6 mm. Next, using Metzenbaum scissors, the cervical septum can be incised to the level of the cervical canal
Table 29.1 Complications of vaginoplasty.
Urinary Complaints and Bleeding 1%
Bladder Trauma 2%
Rectum or Bladder Perforation 1%–4%
Long-term UTI 4%–7%
Vaginal Stricture or Contracture 4%–9%
Vesicovaginal/Rectovaginal Fistula 1%–3%
Skin Graft Necrosis 1%–3.5%
Persistent Vaginal Discharge 3%
Vaginal Prolapse 3%
Source: Adapted from Callens N, et al., Hum Reprod Update 2014;20(5):775-801.
sufficient to allow adequate distension following placement of an operative hysteroscope or resectoscope. Then, with hysteroscopic scissors, or a suitable needle electrode, the surgeon can transect the remaining portion of the septum in the cervix and the uterine corpus (see Table 29.1).
Concurrent laparoscopy may be used to monitor for perforation of the corpus or cervix; however, with preprocedure imaging, good hysteroscopic visualization, and, if necessary, intraoperative transabdominal ultrasound, this step is usually unnecessary. The procedure should be performed either in the follicular phase of the menstrual cycle or following preoperative treatment with progestins to thin the endometrium and improve hysteroscopic visibility.
There is some controversy regarding the utility of postoperative intrauterine stents or barriers. Estrogens, progestins, and stents, including intrauterine devices and pediatric Foley catheters, are used by many without abundant evidence of value.64 A randomized clinical trial was conducted to address the utility of an intrauterine device (IUD) placed postoperatively vs. no placement of an IUD upon completion of hysteroscopic metroplasty. All patients received postoperative conjugated equine estrogens at 1.2 mg twice daily for 30 days with the addition of medroxyprogesterone acetate 10 mg daily on days 26–30. The researchers concluded the use of an IUD with hormonal therapy did not seem to be efficacious.65 Moreover, additional trials have shown that the use of neither postoperative estrogen, copper IUD, nor intrauterine balloon had any benefit in the prevention of postoperative adhesion formation following metroplasty.
Other approaches, not necessarily recommended in light of the advances in hysteroscopically directed surgery, include abdominal metroplasty, which requires
laparotomy, or laparoscopy for septum resection, examples of such include Jones metroplasty, where a cuneiform portion of fundal myometrium is resected, and the Bret–Tompkins metroplasty, in which an anteroposterior incision is made into the uterus, the septum is incorporated into the myometrium, and uterine muscle closure occurs without removal of any tissue.64 In addition, El Magoub reported approaching the fundus with a small transverse incision along the septum through which the septum is removed.66
Arcuate (rAFS Class VI; CONUTA-No categorization)
The arcuate uterus is “a variant of normal”; patients with Class VI lesions should not be advised to undergo surgery. As described in Chapter 11, and by definition, the arcuate uterus equates with a septum measurement of less than 1 cm in length. The reported reproductive outcomes reported are similar to those of “historical controls.”20–23,52,54,67,68
Diethylstilbestrol (DES)-related anomalies (rAFS Class VII)(CONUTA U1)
Until 1971, DES was given to help prevent miscarriage in women with a prior history of spontaneous abortions. The relationship of DES to uterovaginal anomalies is a subject discussed in Chapter 11. There has been no good evidence to suggest metroplasty or other corrective surgeries as being efficacious.10 If genetic progeny are desired, then the individual or couple can consider controlled ovarian hyperstimulation, IVF, and subsequent gestational carrier. Possible infertility with cervical hoods, collars, or vaginal adenosis may be overcome with intrauterine insemination. Again, there is no good evidence to suggest that surgical intervention is warranted here.
VIDEOS
Video 29.1 Transection of longitudinal vaginal septum. https://youtu.be/jXK_AvILhVQ
Video 29.2 Laparoscopic Vecchietti procedure. https:// youtu.be/0IGbkMYZwA8
Video 29.3 Laparoscopic Davydov procedure. https:// youtu.be/pJLCHZhl7lc
Video 29.4 Laparoscopic removal of uterine horn. https:// youtu.be/Mc_TVO14C4M
Video 29.5 Hysteroscopic metroplasty rAFS Va septum. https://youtu.be/uJ1RBeDdPBs
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55. Homer HA, Li TC, Cooke ID. The septate uterus: a review of management and reproductive outcome. Fertil Steril. 2000;73(1):1-14.
56. Pabuccu R, Gomel V. Reproductive outcome after hysteroscopic metroplasty in women with septate uterus and otherwise unexplained infertility. Fertil Steril. 2004;81(6):1675-8.
57. Mollo A, De Franciscis P, Colacurci N, Cobellis L, Perino A, Venezia R, et al. Hysteroscopic resection of the septum improves the pregnancy rate of women with unexplained infertility: a prospective controlled trial. Fertil Steril. 2009;91(6):2628-31.
58. Ban-Frangez H, Tomazevic T, Virant-Klun I, Verdenik I, Ribic-Pucelj M, Bokal EV. The outcome of singleton pregnancies after IVF/ICSI in women before and after hysteroscopic resection of a uterine septum compared to normal controls. Eur J Obstet Gynecol Reprod Biol. 2009;146(2):184-7.
59. Le Ray C, Donnadieu AC, Gervaise A, Frydman R, Fernandez H. [Management of ten patients with complete septate uterus: hystersocopic section of and obstetrical outcome]. J Gynecol Obstet Biol Reprod (Paris). 2006;35(8 Pt 1):797-803.
60. Bettocchi S, Ceci O, Nappi L, Pontrelli G, Pinto L, Vicino M. Office hysteroscopic metroplasty: three “diagnostic criteria” to differentiate between septate and bicornuate uteri. J Minim Invasive Gynecol. 2007;14(3):324-8.
61. Colacurci N, De Franciscis P, Mollo A, Litta P, Perino A, Cobellis L, et al. Small-diameter hysteroscopy with Versapoint versus resectoscopy with a unipolar knife for the treatment of septate uterus: a prospective randomized study. J Minim Invasive Gynecol. 2007;14(5):622-7.
62. Worldwide AAMIG, Munro MG, Storz K, Abbott JA, Falcone T, Jacobs VR, et al. AAGL practice report: practice guidelines for the management of hysteroscopic distending media: (Replaces hysteroscopic fluid monitoring guidelines. J Am Assoc Gynecol Laparosc. 2000;7:167-8.). J Minim Invasive Gynecol. 2013;20(2):137-48.
63. Parsanezhad MD, Alborzi D, Zarel A, Dehbashi S, Shirazi LG, Rajaeefard A, Schmidt EH. Hysteroscopic metroplasty of the complete uterine septum, duplicate cervix, and vaginal septum. Fertil Steril. 2006; 85(5):1473-7.
64. Valle RF, Ekpo GE. Hysteroscopic metroplasty for the septate uterus: review and meta-analysis. J Minim Invasive Gynecol. 2013;20(1):22-42.
65. Vercellini P, Fedele L, Arcaini L, Rognoni MT, Candiani GB. Value of intrauterine device insertion and estrogen administration after hysteroscopic metroplasty. J Reprod Med. 1989;34(7):447-50.
66. el-Mahgoub S. Unification of a septate uterus: Mahgoub’s operation. Int J Gynaecol Obstet. 1978;15(5):400-4.
67. Maneschi F, Marana R, Muzii L, Mancuso S. Reproductive performance in women with bicornuate uterus. Acta Eur Fertil. 1993;24(3):117-20.
68. Lin PC. Reproductive outcomes in women with uterine anomalies. J Womens Health (Larchmt). 2004;13(1):33-9.
Surgery for vulvar disorders
HOWARD T. SHARP
Key points
30
• Vestibulectomy is indicated for women with chronic localized provoked (NOT unprovoked) vulvodynia who do not respond to medical therapy.
• For vestibulectomy
– The excision should extend to Hart’s line and no further.
– The hymen is removed with the specimen.
– Vaginal tissue should be undermined to close tension-free.
– 3-0 chromic catgut is used for rapid release to minimize scarring.
• For reduction labioplasty
– Approximately 1.5 cm of labia should remain for functional purposes.
– Measuring and marking the lines of incision aid in symmetry.
• For Bartholin duct cyst and abscess management
– 1% lidocaine with added sodium bicarbonate can reduce infiltration pain.
– A small gauge needle (27- or 30-gauge preferably) and a small volume syringe are used.
– The skin stab wound should be only 5 to 6 mm wide to hold the Word catheter in place.
– The catheter should remain in place for four weeks.
• For Bartholin gland excision
– The dissection can be quite vascular due to branches from the pudendal artery.
– Vascular branches should be clamped and sutured or electrodesiccated.
– A drain may be left in place if there is significant oozing through the surgery.
• For laser ablation for VIN
– The surgeon should be familiar with the four surgical planes of the vulvar skin.
– Postoperative pain can be treated with oral analgesics as well as local measures: – Ice
– Topical lidocaine
– Topical 1% silver sulfadiazine cream
Sitz baths
• For wide local excision of the vulva
– The area of excision should be an ellipse that can be closed primarily.
– The margins should be undermined 1 to 2 cm to aid in closure.
There are several vulvar conditions that may be associated with pain and reduced vulvar and vaginal function. Many of these conditions can be treated successfully with conservative medical therapy. When contemplating vulvar surgery, it is important to establish a diagnosis and to try conservative management when indicated. Many surgeries performed on vulvar tissues include surgery for malignancy and surgery for aesthetic purposes. This chapter will focus primarily on benign and premalignant vulvar conditions for general gynecologic surgeons. Aesthetic surgery is not covered in this chapter.
VESTIBULECTOMY
Vestibulectomy may be performed for localized, provoked vulvodynia (LPV), previously referred to as vulvar vestibulitis (see Chapter 23). Before performing vestibulectomy, it is important to make an accurate diagnosis and to distinguish this from unprovoked vulvodynia, and other conditions that may mimic provoked vulvodynia (Table 30.1). Failure of conservative therapies should be confirmed. One of the key features associated with LPV is the characteristic of
vestibular pain when provoked, usually with tampon insertion, or vaginal intercourse. The presence of constant pain or burning should be a red flag for a different diagnosis, falling under the unprovoked vulvodynia category, which typically does not respond to surgery. There is no absolute consensus for making the diagnosis of LPV, though Friedrich suggested three criteria: (1) vestibular pain with direct contact (a cotton tipped applicator is often used), (2) erythema at the minor vestibular gland openings, and (3) pain with pressure at the vestibule, occurring for at least three to six months duration.1 Biopsy should be considered when in doubt, as other medically treatable conditions are often identified when a biopsy is evaluated by a dermatopathologist.2
Informed consent
The risks associated with vestibulectomy include bleeding/ hematoma, infection, skin breakdown, scarring, and formation of Bartholin cysts that may require additional therapy. There is also the possibility that the surgery will not render the patient pain-free. The patient should be aware that the recovery is usually acute for one to two weeks
where sitting will be painful, and movement will be somewhat limited due to pain. Most patients can return to work within two weeks, if their work does not require strenuous activity. Sexual intercourse is usually not advised for six to ten weeks. If there is a significant degree of levator ani tension myalgia present, the patient may need physical therapy of the pelvic floor postoperatively.
Performing a complete vestibulectomy
I prefer to use high lithotomy under general or regional anesthesia in the operating room for maximal exposure to the vestibule (Video 30.1). There are no high-quality studies supporting the use of prophylactic antibiotics. The vulvar vestibule is traced with a sterile pen to outline the margins of dissection. I mark the patient’s left anterior apex, just cephalad to the Skeen’s glands and trace along Hart’s line to the posterior fourchette (Figure 30.1a). The left medial border starts at the apex
above Skeen’s glands and usually borders the urethra (within 3 mm or so) and then connects with the vaginal skin just cephalad to the hymen, to include the entire hymen in the dissection.
The dissection area is infiltrated with 0.5% bupivicaine without epinephrine. I do not use epinephrine for two reasons. The first is out of concern for potential infection risk with vasoconstriction, and the second is to be sure all bleeding is adequately sutured at the end of the case, to avoid hematoma risk after the epinephrine has worn off. To make the dissection easier, I use an Allis clamp at the apex of the dissection (Skeen’s glands), at 1 and 11 o’clock. Allis–Adair clamps are placed at the 3, 6, and 9 o’clock positions. While an assistant holds the clamps at 1, 3, and 6 o’clock, the scalpel is used to trace the lateral dissection along Hart’s line to the posterior fourchette. The same is carried out on the contralateral side, holding the clamps at 6, 9, and 11 o’clock. The dissection is made much easier if the incision is made deep enough to remove the entire vestibule (3 to 4 mm deep). With the same clamps held, the medial incision is made hugging the hymen in a semi-circumferential manner, to be sure that the entire hymen will be removed. Once the medial and lateral borders of the dissection are incised, Metzenbaum scissors are used to remove the skin as both incisions are straddled. I often perform a small relaxing skin incision at the midline to overcome the potential tightening that may occur during healing.
The most challenging aspect of this surgery is the closure. It is important that the skin be closed without tension and with an optimal cosmetic result, while maintaining good hemostasis. I do not use any
Figure 30.1 Vestibulectomy. (a) The vulvar vestibule is marked to include Hart’s line, which can be seen as the transition of smooth to a rougher epithelium. Inside the hymen is not marked, but by placing an Allis–Adair clamp on the hymen, the area is more easily visualized. (b) The vaginal epithelium is undermined to avoid closure on tension. (c) The figure of X stitch. The stitch is placed high on the lateral skin (vulva) to low on the medial (vagina) and then low on the lateral skin to end up high on the vaginal skin, forming an X. (d) When closing the vestibule with interrupted stitches of 3-0 chromic catgut, the area near the urethra is closed first, then the rest of the vestibule is divided into quadrants.
electrosurgical hemostasis, to avoid poor healing and scarring. The vaginal skin should be undermined carefully such that the closure is tension free (Figure 30.1b). This is performed by grasping the vaginal epithelium with an Allis–Adair clamp and making a delicate releasing incision with a Metzenbaum scissor along the vaginal border.
The urethral portion of the incision is closed first. This usually requires two interrupted 3-0 chromic catgut sutures. I prefer chromic catgut suture as it dissolves quickly, around ten to 14 days, with a very low risk of the scarring than can sometimes occur with suture that remains for several weeks. It also precludes the need to remove sutures in the clinic, a process that can be painful in this delicate region. An interrupted stitch is placed at 6, 3, and 9 o’clock to best ensure a symmetrical closure, and to divide the closure into quadrants. Each quadrant is then closed with three to four interrupted sutures, approximately 3 to 4 mm apart. I try to avoid figure of eight stitches, which, though hemostatic, are not anatomic, and can cause narrowing of the introitus. I find that if the interrupted stitch is carefully placed by ensuring that the needle traverses the entire depth of the resection, the area is unlikely to bleed or develop a hematoma. The medial aspect is much more prone to bleed. On occasion when the area is bleeding to the point that an interrupted suture is ineffective, I will use the figure of X stitch, which is hemostatic, yet cosmetic. The stitch is placed high on the lateral skin (vulva) to low on the medial (vagina) and then low on the lateral skin to end up high on the vaginal skin (Figure 30.1c). At the end of the case, no dressing is placed, and hemostasis should be complete (Figure 30.1d). See Video 30.1.
Postoperative care
Patients are sent home after they can void, drink, and have adequate pain control with oral analgesics. To provide comfort I offer oral narcotics, and NSAIDs, as well as a donut type cushion and advise liberal baths/sitzbaths in warm water. I encourage them to lie down rather than sit, and see them back in clinic in two weeks and then four weeks after that to assess the need for dilator therapy. At six weeks, most patients can use a small dilator and progress to a medium and then a large within an additional two to four weeks. If the levator ani muscles are still painful, physical therapy of the pelvic floor is recommended.
HYMENECTOMY
The hymen is a membrane consisting of fibrous connective tissue attached to the vaginal wall. The hymen usually ruptures before birth due to degeneration of the central epithelial cells. Typically, a thin mucous fold persists around the vaginal introitus. Hymenal abnormalities occur when the central portion of the hymen is incompletely degenerated. If conservative therapies of manual dilatation or dilator therapy have failed, or if the patient is unable to tolerate conservative therapy, hymenectomy may be offered.
Informed consent
The risks associated with hymenectomy include bleeding/ hematoma, infection, skin breakdown, and scarring. The patient should be aware that the recovery is usually acute for one to two weeks where sitting will be painful, and movement will be somewhat limited due to pain. Most patients are able to return to work that does not require significant physical activity within two weeks. Sexual intercourse should be avoided for six to ten weeks depending upon their healing and degree of tenderness.
Performing hymenectomy
In cases where minimal tissue resection is needed, and if the patient is motivated, the procedure can be performed in the office under local anesthesia. I prefer to perform more involved hymen excisions in the operating room under conscious sedation with local anesthesia, or regional, or general anesthesia. I use a longer-acting local anesthesia for postoperative pain relief. I do not use prophylactic antibiotics.
The hymen is injected circumferentially with 0.5% bupivicaine, using approximately 5 to 10 mL in total. Bupivicaine lasts approximately four times longer than lidocaine; hence, it is preferred. I do not use epinephrine to avoid delayed postoperative bleeding and infection complications. Before making an incision, the urethra should be identified to be sure it is avoided. I do not use a urethral catheter, but have the patient void just prior to being taken to the operating room. This allows the patient to void earlier and be able to go home earlier, and lessens the risk for urinary tract infection.
The center of the hymen is grasped with an Allis clamp, and if there is a perforation, the perforation is opened laterally at the 3 or 9 o’clock position (Figure 30.2a) to avoid coming in contact with the urethra or rectal sphincter. Once the hymen is opened sufficiently (2 cm), the additional edges are grasped with Allis clamps and the border of the hymen can see both seen and felt. The hymen is cut to its base with a scalpel or Metzenbaum scissors and then trimmed circumferentially until it is removed. I do not use any electrosurgical hemostasis to avoid delay in healing or scarring. For hemostasis, I use interrupted sutures of 3-0 chromic catgut at approximately 4 mm intervals (Figure 30.2b), which will absorb or release by ten to 14 days.
After hymenectomy, and while in the operating room under anesthesia, it is good practice to view the cervix for associated anatomic anomalies which may be associated with Müllerian anomalies.
Postoperative care
Patients are sent home after they are able to void, drink, and have adequate pain control with oral analgesics. I offer oral narcotics, and NSAIDs, as well as a donut type cushion and advise liberal baths/sitz baths in warm water for comfort measures. I encourage them to lie down rather than sit, and see them back in clinic in two weeks and then four weeks after that to assess the need for dilator therapy. At six weeks, most patients are able to use a small dilator
30.2 Hymenectomy.
and to progress to a medium and then a large within an additional two to four weeks.
Reduction labiaplasty for labia minora hypertrophy
Enlargement of the labia minora can be painful and interfere significantly with sports, daily activities, and sexual intercourse. Hypertrophic labia minora are often associated with lymphedema.3 These symptoms may lead women to opt for surgical management. When counseling patients about reduction labiaplasty, it is important to remember that the labia minora function to protect the urethra and vaginal introitus; hence, complete removal is not advised. The goal is to restore normal anatomy and function. I tend to measure the labia from the medial aspect to assess the longest span of each labium from mid tip to the hymen base. Normal length is not clearly defined; however, in my experience, this is rarely an issue in patients with labia under 2 cm from the hymen to the distal central curvature. In women who opt for surgical correction, most labia minora are in the 2.5 to 5 cm range.
Informed consent
The risks associated with reduction labiaplasty include bleeding/hematoma, infection, skin breakdown, scarring, and asymmetrical labia. They may have decreased sensation over the sutured skin, and the labia may be asymmetrical after surgery (as they are often before surgery). Complications are rare. I have not found scarring to be an issue with this technique; however, other surgeons may prefer to use a W-shaped excision.4 There are no comparative trials to date. The patient should be aware that the recovery is usually acute for one to two weeks, where sitting will be painful, and movement will be somewhat limited due to pain. Most patients can return to work, provided it does not require significant physical activity within two weeks. Sexual intercourse is usually not advised for six to ten weeks.
Performing reduction labiaplasty of the labia minora—curvilinear technique
It is important to understand that the labia minora emanate from the clitoral hood and extend to the posterior fourchette. The mid portion of the distal labial curvature is between these two points, and is the area that I measure for reference length. It is important to mark the area for excision before making an incision, after performing the surgical prep. I prefer to leave 1.5 cm of tissue at the midpoint for adequate coverage of the vaginal introitus. The line is tapered toward the posterior fourchette and toward the clitoral hood (Figure 30.3a). I prefer to stay as far away from the base of the clitoral hood as is feasible (1 to 2 cm) to avoid any decrease in sensation to the clitoral region. I mark the medial side of the first labia minora with a sterile surgical marking pen, then find the contralateral point at the 1.5 cm midway point, and bring the labia to the middle such that they touch, causing the mark from the initial marking to transfer a faint line to the contralateral side. This will help for symmetry. Fine adjustment can be made afterward with a marking pen. I also measure the lateral labial curvature, based upon the area that will be removed on the original medial border measurements.
Once both labia minora have been measured and marked on the medial and lateral sides, 0.5% bupivicaine without epinephrine is injected with a 25-gauge needle, using 5 to 10 mL in total. The labium minora is grasped with three or four Allis–Adair clamps and held by an assistant, while a Metzenbaum scissor is used to carefully excise the distal curvature of the labium. The scissors
(a) (b)
Figure 30.3 Reduction labiaplasty of the labia minora. (a) The incision borders are drawn on the medial aspect of the labia minora. There should be adequate distance from the clitoral region, and approximately 1.5 cm from the hymen to allow for proper labia minora function. (b) The incision is closed with interrupted 3-0 chromic catgut sutures. A figure of X stitch can be used for hemostasis if needed.
(a)
(b)
Figure
(a) Incising the hymen with a scalpel while maintaining traction with an Allis clamp. (b) The hymen is closed with interrupted 3-0 chromic catgut sutures, which dissolve rapidly.
are held such that the curve faces the patient to allow for straddling of both marked lines (medial and lateral). Alternatively, a scalpel can be used along the lateral and medial lines separately, and then the Metzenbaum scissors can be used to make a final excision.
Interrupted sutures of 3-0 catgut are used to close the incision (Figure 30.3b). Because the labia are fairly well vascularized, a figure of X suture technique is sometimes needed (see vestibulectomy, Figure 30.1c), which brings tissue together in a symmetrical, hemostatic, and cosmetically appealing fashion compared to a figure of 8 stitch, which causes asymmetrical tension on the skin. If a subcuticular closure is used, it is important to be sure of good hemostasis to avoid hematoma formation. No dressing is used.
Patients are sent home after they are able to void, drink, and have adequate pain control with oral analgesics. For comfort, I offer oral narcotics, and NSAIDs, as well as a donut type cushion, and advise liberal baths/sitz bathes in warm water. I encourage them to lie down rather than sit, and see them in clinic in two and again at six weeks for assessment.
Bartholin duct cyst and Bartholin abcess management
Bartholin glands are mucus-secreting glands providing lubrication to the vagina. They are located within the vulvar vestibule, with ducts external to the hymen at the 4 and 8 o’clock positions. The ducts are approximately 2.5 cm in length and can become obstructed from perineal inflammation, trauma, or infection. Bartholin cysts do not necessarily need to be treated if not symptomatic with pain, infection, or perceived disfigurement. In general, for symptomatic Bartholin cysts or abscesses, a conservative approach with Word catheter placement in the clinic is ideal (Figure 30.4a). Marsupialization is generally reserved for Word catheter failures. Antibiotic use is not indicated with drainage in uncomplicated cases. 5
Word catheter placement
The Word catheter is used to facilitate cyst or abscess drainage, and to allow an epithelialized tract for fistula formation. The key feature is to make a stab wound into the cyst, large enough to place the catheter, but small enough to keep it from falling out. Making a stab wound too large is a major reason for Word catheter failure. The risks that may be discussed for informed consent include: bleeding, infection, cyst recurrence, scarring, dyspareunia, and distortion of anatomy.
The area of the cyst is prepped with a sterile solution, and 1 to 2 mL of 1% lidocaine is used to infiltrate the cyst near the hymen rather than on the vulvar surface (Table 30.2). Due to the very sensitive nature of the area, a 30-gauge needle is ideal for infiltration. Because these are performed in the clinic, I use 1 mEq/mL of sodium bicarbonate to nine parts of 1% lidocaine to decrease the pain of infiltration, and inject at a slow rate, with a small volume syringe (1 to 3 mL). A number 11 blade is used to make a stab wound between 5 and 6 mm wide and 1 to
Figure 30.4 Word catheter placement. (a) Word catheter kit. Top to bottom, 3 mL syringe (fill with normal saline), number 11 scalpel blade, inflated Word catheter, non-inflated Word catheter. (b) A relatively small incision is made with a number 11 blade to avoid a large incision that will cause the Word catheter to be expelled. (c) The end of the Word catheter is tucked into the vagina so it will not catch on clothes.
Table 30.2 Supplies for word catheter placement.
Antiseptic solution
Small gauge needle 30-gauge for local anesthesia infiltration
1% lidocaine—1 to 2 mL (may buffer with sodium bicarbonate)
Number 11 scalpel
Word catheter
3 mL syringe with sterile saline for Word catheter inflation
1.5 cm deep to enter the cyst (Figure 30.4b). A hemostat may be useful if there are loculations that need to be disrupted. The Word catheter is inserted into the cyst cavity and inflated with saline. Be sure to inject the needle into the center of the insufflation port, and insert it centrally without deviating, or the needle can puncture the catheter wall and render it useless. Two to 3 cc of normal saline are injected into the catheter to inflate the distally located balloon designed to maintain appropriate placement. The
(a)
proximal end of the catheter is then tucked into the vagina for comfort, and to reduce the chance that it becomes dislodged by catching on clothing (Figure 30.4c).
The patient should be counseled that the cyst or abscess will continue to drain, and that a peripad may be used. She should maintain pelvic rest by avoiding vaginal intercourse or tampon use. Baths/sitz baths and analgesics will help with symptomatic relief. The catheter should be maintained in place for four weeks, and then removed by deflating the balloon in clinic. If the cyst returns, marsupialization may be necessary.
Marsupialization
For recurrent, symptomatic Bartholin cysts or abscesses, marsupialization may be necessary. Marsupialization may often be performed in the clinic under local anesthesia, but may also be performed in the operating room with conscious sedation and local, regional, or general anesthesia depending upon the circumstances.
The area is prepped with a sterile solution and infiltrated with local anesthesia. I typically use 5 mL of a 0.5% bupivicaine solution for infiltration along the line of incision if performing this with conscious sedation, but use a sodium bicarbonate buffered 1% lidocaine solution if performed under local infiltration alone. The skin incision is typically made in a line parallel with the hymen in the vulvar vestibule (Figure 30.5a), long enough to place several sutures to keep it open. This is usually 3 cm in length. The cyst wall is also incised and irrigated with normal saline. A hemostat is used to break up any loculations if present. The cyst wall is then everted and sutured to the vestibular epithelium on either side of the incision with a 3-0 delayed absorbable suture (Figure 30.5b). I prefer a suture that will maintain tensile strength for three to four weeks, to ensure patency, rather than the rapidly absorbing chromic catgut sutures used in other vulvar surgeries. Follow-up is similar to that of Word catheter placement. Sutures are allowed to dissolve.
Figure 30.5 Bartholin cyst marsupialization. (a) The epithelium is incised, then the cyst wall is incised in the same direction. (b) The cyst wall is sutured to the vulvar and vaginal epithelium with a 3-0 delayed absorbable suture to allow it to remain patent for four weeks.
Bartholin gland excision
Bartholin gland excision is reserved for cases that are either refractory to conservative management, or when there is concern about malignancy. Because of its significant blood supply from branches of the pudendal artery, it can be associated with hemorrhage and hematoma. This surgery is performed in the operating room under appropriate anesthesia with the patient in lithotomy position. Examination under anesthesia including a rectovaginal exam is helpful in defining the depth of the cyst. Access and visualization are important to be maximized, as these cysts can be deep. It is often helpful to place Allis–Adair clamps for retraction on the labia minora and to have an assistant gently retract laterally.
An incision is made in a line parallel with the hymen in the vulvar vestibule, rather than the vulvar skin, long enough to dissect the entire cyst and gland, usually 3 to 4 cm in length, or larger depending on the domed surface exposed (Figure 30.6a). Allis–Adair clamps are used to retract the incised epithelium as well as the cyst wall to increase exposure to the dissection plane. Metzenbaum scissors are used to release filmy adhesions (Figure 30.6b). A “scissor spread” technique is helpful in removing filmy adhesions and to minimize bleeding, as this is where the branches from the inferior pudendal artery are usually encountered. Vessels
Figure 30.6 Bartholin gland excision. (a) A linear incision is made along the domed surface close to the hymen. (b) With retraction on the cyst wall and the vulvar and vaginal epithelium, Metzenbaum scissors are used to dissect the cyst wall. (c) The bed of the cyst is sutured deeply with interrupted or figure of X stitches to close the deep space and prevent hematoma formation. (d) The skin is closed with 3-0 delayed absorbable interrupted sutures. A drain may be placed.
(a)
(b)
(a)
(b)
(c)
(d)
to the gland are best rendered hemostatic by clamping the vessel with a hemostat and applying electrodessication with “cutting” (low voltage continuous output) current. Suture ligation may also be necessary. Once the gland is removed, the bed of the gland is closed with interrupted or figure of X sutures using 3-0 absorbable sutures for hemostasis (Figure 30.6c). The skin is closed with 3-0 absorbable sutures (Figure 30.6d). I prefer to use sutures that will hold tensile strength for approximately three to four weeks. Because of the vascular nature of this area, some surgeons prefer to leave a small drain in place for two or three days to avoid hematoma formation.
Patients are sent home after they are able to void, drink, and have adequate pain control with oral analgesics. For comfort, I offer oral narcotics, and NSAIDs, as well as a donut type cushion and advise liberal baths/sitz baths in warm water. I encourage them to lie down rather than sit, and see them in clinic in two and again in six weeks.
VULVAR INTRAEPITHELIAL NEOPLASIA
The tenants of treatment for vulvar intraepithelial neoplasia (VIN) are to prevent the development of vulvar cancer and relieve symptoms, while preserving normal function and anatomy of the vulva. Therefore, the treatment of VIN is usually individualized based upon the location and extent of the lesion. Superficial laser therapy tends to have a cosmetic advantage compared to skinning vulvectomy.6 Deep laser therapy often leads to scarring, with less clear advantage over excisional techniques.
Laser vaporization of the vulva
Laser therapy is often used in patients with multifocal lesions. The depth of treatment is directed by colposcopy. Tissue destruction of less than 1 mm will treat VIN and still allow rapid healing. In areas with hair distribution, a deeper destruction is necessary to 3 mm, as the root of the hair may contain VIN and extend to a depth of 2.5 mm. Laser vaporization to this depth is much more destructive and may lead to scar formation. Four surgical planes have been identified. The first surgical plane consists of the epidermis down to the basement membrane, which has a red appearance when treated with the laser. The second surgical plane transitions into a tan appearance as it extends into the papillary layer of the dermis. The third surgical plane extends into the reticular dermis that contains the root of a hair follicle and is identified as grayish white fibers of collagen bundles. It is not necessary to treat VIN beyond the third surgical plane. The fourth surgical plane is complete removal of the dermis down to fat.
Informed consent
The risks associated with laser ablation of the vulva include bleeding, infection, scarring, and decreased sensation over the ablated skin. They should be aware that the area will be irritated and painful for weeks postoperatively, and full healing will take six to eight weeks.
Laser ablation procedure
If laser ablation is performed, a power density of 750–1,250 W/cm 2 is used to avoid deep coagulation injury. A 3%–5% solution of acetic acid is applied to the area while colposcopy is used to delineate lesion margins. The area to be treated is marked with a sterile marking pen. A hand piece or micromanipulator with a depth gauge aids in application of high-power density without defocusing. The margin of normal skin should be treated. In hair-bearing regions, the hair follicle must be treated. The first step is to identify the tan appearance of the papillary dermis. Cold water on a sponge may be used to help dissipate heat and remove char to help identify the white appearance of the third surgical plane as laser therapy proceeds.
Postoperative care
An antibacterial cream such as 1% silver sulfadiazine cream is commonly applied once or twice daily to decrease wound bacteria colonization, and to provide some relief from pain. There is no evidence that there is a preferred agent, nor is there clear evidence that these reduce infection. A 5% lidocaine gel can also be applied to aid in pain relief. Bupivacaine 0.25% without epinephrine may be injected into the lasered area at the end of the treatment to deliver up to six hours of pain relief. An ice pack (or for practical purposes, a bag of frozen peas) can be placed against the vulva for the first 72 hours after surgery to decease inflammation and pain. Sitz baths may be used three times daily even on the first postoperative day, and continued for three weeks if needed. Patients are seen at two and six weeks postoperatively for routine follow up.
Wide local excision of the vulva
Wide local incision is appropriate when pathologic findings are suggestive of cancer despite a biopsy diagnosis of VIN for histologic confirmation. This is an option when there are one or two focal lesions that will allow a 1 cm margin.7 The depth should be the full thickness of the skin.
Informed consent
The risks associated with wide local excision of the vulva include bleeding/hematoma, infection, skin breakdown, and scarring. The patient should be aware that the recovery is usually acute for two weeks where sitting will be painful, and movement will be somewhat limited due to pain. Full return to work may take six to ten weeks.
Wide local excision procedure
The patient is placed in the dorsal lithotomy position, and the perineum is prepped and draped. An indwelling bladder catheter is placed. A marking pen is helpful to measure a margin and design an ellipse that can be closed. The lesion is excised with an elliptical incision with a scalpel down to the subcutaneous tissue (Figure 30.7a). Mobilizing the skin makes closure easier, and should be undermined fairly aggressively (1 to 2 cm). Electrosurgery is used to achieve hemostasis. Closure is performed with two to four
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“I leave to children, inclusively, but only for the term of their childhood, all and every, the flowers of the fields, and the blossoms of the woods, with the right to play among them freely, according to the customs of children, warning them at the same time against thistles and thorns. And I devise to children the banks of the brooks, and the golden sands beneath the waters thereof, and the odors of the willows that dip therein, and the white clouds that float high over the giant trees. And I leave the children the long, long days to be merry in, in a thousand ways, and the night and the moon and the train of the milky way to wonder at.”
What thinks the teacher of such riches, what the librarian with her catalogue number? A book is a fact, nay, a friend, a dream. Is there not a creed for us all in the wisdom of that crazy man? Here was one with clear vision, to whom fact was as nothing before the essential of one’s nature—a prophet, a seer, one to whom the tragedy of growing up had been no tragedy, but whose memory of childhood had produced a chastening effect upon his manhood. Are we surprised to find him adding:
“I give to good fathers and mothers, in trust for their children, all good little words of praise and encouragement, and all quaint pet names and endearments, and I charge said parents to use them justly and generously, as the needs of their children may require.”
And so, we ask, more especially the parent than the librarian, is there not excitement in the very drawing out from a child his heart’s desire? Imperative it is in all cases that book-buying should not be a lottery, but more persistently apparent does it become that a child’s one individual book upon the Christmas-tree or for a birthday should not represent a grown-up’s after-thought.
Bibliographical Note
The articles referred to in this chapter are: B , R —Literature for Children. No. Amer. 167:278 (Sept., 1898).
C ’ B —[From the Quarterly Review.] Liv. Age, 2:1–12 (Aug. 10, 1841).
T , C F.—Significant Ignorance About the Bible as Shown Among College Students of Both Sexes. Century, 60:123–128 (May, 1900).
FOOTNOTES
[1] Mr. Jenks, besides editing for St. Nicholas Magazine during many years a unique department known as “Books and Reading,” has written widely on the subject of juvenile literature See his “The Modern Child as a Reader ” The Book-buyer, August, 1901, p 17
[2] An interesting field for research is that of the illustration of children’s books Note Thomas Bewick, John Bewick, etc Of a later period, Tenniel, Cruikshank, Doré, Herr Richter Vide “The Child and His Book,” Mrs. E. M. Field, chap. xiv; “Some Illustrators of Children’s Books.” Also “Children’s Books and their Illustrators.” Gleeson White, The International Studio. Special Winter No., 1897–98.
THE GROWTH OF JUVENILE LITERATURE
Transcriber's Note: Text version of the above two diagrams
GROWTH OF JUVENILE LITERATURE A
PARTIAL
INDICATION, BY DIAGRAM
FRENCH IMPETUS
Jean de La Fontaine[6][7]
Charles Perrault[6][7] Comtesse D’Aulnoy[6][7] (1621–1695) | (1628–1703) (1650–1705)
Oliver Goldsmith[3]-------John Newbery[3]
(1728–1774) (1713–1767)
| Jean Jacques Rousseau[6][7] Isaiah Thomas[4] | (1712–1778) (1749–1831) | | | +----------------------------------+---------------------------------------------+
DIDACTIC SCHOOL | Sarah Kirby Trimmer[3]--------------------------------+ (1741–1810) | | +-------------------------+-----------------------+--------------------+ | | | | | | Joseph Jacotot[6][7][11] F. Froebel[8][12] F. A. W. Diesterweg[8][12] | C. G. Salzmann[12] (1770–1840) (1782–1852) (1790–1866) | (1744–1811)
| | | | | | | | | | | | | | | | | |
Madame de Arnaud Berquin[6][7] | R. L. Edgeworth[3] | John Aikin[3] | Thomas Day[3] Maria Genlis[7] (1749?-1791) | (1744–1817) | (1747–1821) | (1748–1789) Edgeworth[3] (1746–1830) | | | | (1767–1849) | | Anna L. Barbauld[3][11] | | | | (1743–1825) | |
| | | | | Mme. Le Prince de Hannah More[3] tr. Mary Wollstonecraft[3] | Beaumont[6][10] (1745–1833) [Godwin] | (1711–1780) | (1759–1797) | | Patty More | Dr. Isaac Watts[3] | | | | (1674–1748) | | BOOKS FOR THE
| William Godwin[3]------------+ | | | (1756–1836) | Aikin Mrs. Margaret Scott Gatty[3] | Mrs. Godwin[3] William Blake[3] (1809–1873) | | (1757–1827) | | |
| | | | Peter Parley Robert Raikes[3] Mary Lamb Charles Lamb[3] S. G. Goodrich[5] (1735–1811) (1765–1847) (1775–1834) (1793–1860) | | | | +----------------Jane Taylor[3] William Martin[3] | | (1783–1824) (1801–1867) | Mrs. Cecil Ann Taylor[3] | | Frances Alexander (1782–1866) SPURIOUS PARLEYS | (b. circa 1830) | | | | | Jacob Abbott[5] | +---------------R. L. Stevenson[3] (1803–1879) | (1850–1894) [13] SUNDAY SCHOOLS [14]
[3] Dictionary of National Biography Gives further bibliography
[4] Appleton’s Biographical Dictionary
[5] Lamb’s Biographical Dictionary
[6] Nouvelle Biographie Générale Gives further bibl
[7] La Grande Encyclopédie Gives further bibl
[8] Meyers Konversations-Lexikon Bibl
[9] Diccionario Enciclopedico Hispano-Americano
[10] Influence of Perrault
[11] Sister of John Aikin
[12] Influence of Rousseau
[13] American End of the Development
[14] English End of the Development
II. THE RISE OF CHILDREN’S BOOKS
I wish Mrs. Marcet, the Right Honourable T. B. Macaulay, or any other person possessing universal knowledge, would take a toy and child’s emporium in hand, and explain to us all the geographical and historical wonders it contains. That Noah’s ark, with its varied contents—its leopards and lions, with glued pump-handled tails; its light-blue elephants and ꓕ footed ducks—that ark containing the cylindrical family of the patriarch—was fashioned in Holland, most likely, by some kind pipe-smoking friends of youth by the side of a slimy canal. A peasant in a Danubian pine-wood carved that extraordinary nut-cracker, who was painted up at Nuremberg afterwards in the costume of a hideous hussar. That little fir lion, more like his roaring original than the lion at Barnet, or the lion of Northumberland House, was cut by a Swiss shepherd boy tending his goats on a mountain-side, where the chamois were jumping about in their untanned leather. I have seen a little Mahometan on the Etmeidan at Constantinople twiddling about just such a whirligig as you may behold any day in the hands of a small Parisian in the Tuileries Gardens. And as with the toys, so with the toy books. They exist everywhere: there is no calculating the distance through which the stories come to us, the number of languages through which they have been filtered, or the centuries during which they have been told. Many of them have been narrated, almost in their present shape, for thousands of years since, to little copper-coloured Sanscrit children, listening to their mother under the palm-trees by the banks of the yellow Jumna— their Brahmin mother, who softly narrated them through the ring in her nose. The very same tale has been heard by the Northmen Vikings as they lay on their shields on deck; and by Arabs couched under the stars on the Syrian plains when the flocks were gathered in and the mares were picketed by the tents. With regard to the story of Cinderella, I have heard the late Thomas Hill say that he
remembered to have heard, two years before Richard Cœur de Lion came back from Palestine, a Norman jongleur—but, in a word, there is no end to the antiquity of these tales....”—“Michael Angelo Titmarsh on Some Illustrated Children’s Books,” in Fraser’s Magazine for April, 1846.
I. H - ; C - ; T N E P .
Previous to the impetus given to child study by the educational theories of Rousseau, little was written intentionally for children that would not at the same time appeal to adults. Yet there are chapters still to be penned, stretching back into English history as far as 1430 and earlier, when words of instruction were framed for youth; when conduct, formality, austere manners, complete submission, were not only becoming to the child, but were forced upon him.[15]
There are several manuscripts extant of that year, 1430, one whose authorship is ascribed to John Lydgate and which bears the Latin title, “Puer ad Mensam.” There is also the “Babees Book” of 1475, intended for those boys of royal blood who served as pages in the palace. The American student has to reach an understanding of the purport of most of these treatises from secondary sources; the manuscripts are not easily accessible, and have so far been utilised only in a fragmentary character. For the present purpose, the mention of a few examples will suffice.
We note “A Booke in Englyssh metre, of the great marchaunt man called Dyves Pragmaticus, very pretye for chyldren to rede; wherby they may the better, and more readyer rede and wryte Wares and Implementes in this worlde contayned.... When thou sellest aught unto thy neighbour, or byest anything of him, deceave not, nor oppresse him, etc. Imprinted at London in Aldersgate strete by Alexander Lacy, dwellyng beside the Wall. The . of April 11, 1563.”[16]
Those boys bound out or apprenticed to members of the Middle Age crafts and guilds perhaps benefited by the moral of this; no doubt they bethought themselves of the friendly warning, whenever they cried their master’s wares outside the stalls; perhaps they were forearmed as well as forewarned by the friendly rules contained in the “Books of Good Manners”
(1560) which, though they could not own, were repeated to them by others more fortunate. These same boys, who played the angels in the miracle plays, and the Innocents in the “Rachel” dramas, who were held suspended by a rope high up in the nave of the church, to proclaim the birth of the Lord in the Christmas cycles, were actors also, around 1563, in “A New Enterlude for Chyldren to Play, named Jacke Jugeler, both wytte, and very playsent.”
Fundamentally, the boys of the early centuries must have been not unlike the boys of all ages, although the customs of an age usually stunt whatever is not in conformity with the times. He who, in 1572, was warned in “Youth’s Behaviour” (“or, Decency in Conversation Amongst Men, Composed in French by Grave Persons, for the use and benefit of their youth, now newly turned into English, by Francis Hawkins, nephew to Sir Thomas Hawkins. The tenth impression.”), was likewise warned in the New-England township, and needs to be warned to-day. No necessity to paint the picture in more definite colours than those emanating from the mandates direct. “Hearing thy Master, or likewise the Preacher, wriggle not thyself, as seeming unable to contain thyself within thy skin.” Uncomfortable in frills or stiff collars, and given no backs to benches, the child was doomed to a dreary sermon full of brimstone and fire; he was expected, “in yawning, [to] howl not.” The translation, it will be remarked, was made by Master Francis when he had scarce attained the age of eight; this may be considered precocious, but, when French was more the official language than English, it was necessary that all persons of any distinction should have a mastery of the polite tongue, even though they might remain not so well equipped in the language of learning.[17] Hawkins was therefore carefully exercised and the translation became a task in a twofold way. His uncle soon followed the first section of “Youth’s Behaviour” with a second part, intended for girls.
Poor starved souls of those young gentlewomen of the sixteenth century, who were recommended, for their entertainment in hours of recreation, to read “God’s Revenge against Murther; and the Arcadia of Sir Philip Sydney; Artemidorus, his Interpretation of Dreams. And for the business of their devotion, there is an excellent book entitled Taylor’s Holy Living and Dying; The Duty of Man in which the Duty to God and man are both comprehended.” Such guidance is not peculiar alone to this period. It was
followed, in slightly simplified form, throughout the didactic school of writing.
Fortunately we are able, by means of our historical imagination, to fill up the interstices of this grave assemblage with something of a more entertaining character; we have a right to include the folk tales, the local legends and hero deeds which have descended to us through countless telling. Romance and interest still lie buried in annals which might be gathered together, dealing with the lives of those nurses who reared ancient kings. As a factor in the early period of children’s literature, the grandam is of vast meaning.
About the time of which we have just been speaking, as early as 1570, little folks began learning their letters from horn-books and “battle-dores.”
Take an abacus frame and transfer the handle to one of its sides as a base. Within the frame insert a single leaf of thick cardboard, on one side of which place the alphabet, large and small, lettered heavily in black. Then, with the regularity of a regiment, string out three or four slender columns of monosyllables. Do we not here detect the faint glimmer of our college song, “b-a, ba; b-e, be; b-i, bi; babebi”? Should one side not hold all this, use both, although it is not preferable to do so. However, it is essential that ample room be left in any case for the inclusion of the Lord’s Prayer. When this is done, slip over the face of the cardboard a clear piece of diaphanous horn, in default of which isinglass will suffice. Through the handle bore a hole, into which run a string. Finally, attach your handiwork to a girdle or belt, and behold, you are transformed into a school child of the Middle Ages! Your abacus has become a horn-book, quite as much by reason of its horn surface, as because of its essential use. Should you be looking for historical accuracy, let the “Christ-cross” precede the alphabet, whence it will become apparent why our letters are often styled the Criss-cross row. Flourishing until some time during the reign of George II, these curiosities are now rare indeed. There is little of an attractive nature in such a “lessonbook,” but childhood had its compensations, for there is preserved the cheerful news that horn-books were often made of gingerbread. Were these the forebears of our animal crackers or our spiced alphabets?
A survey of chap-books[18] presents a picture of literature trying to be popular; we find all classes of people being catered to, young and old, rich and poor. The multitude of assorted pamphlets reflects the manners, the superstitions, the popular customs of rustics; the stories stretch from the
humourous to the strictly religious type. There are many examples preserved, for not until well on in the nineteenth century were chap-books supplanted in favour. To-day, the largest collection that the world possesses, garnered by Professor Child, is to be found in the Harvard University Library; but the Bodleian and the British Museum claim to be richer in early examples, extending back to 1598.
Charles Gerring, calling the chap-books “uninviting, poor, starved things,” yet lays before readers not an unwholesome array of goods. He writes:
“For the lads, there were tales of action, of adventure, sometimes truculently sensational; for the girls were stories of a more domestic character; for the tradesmen, there was the ‘King and the Cobbler,’ or ‘Long Tom the Carrier’; for the soldier and the sailor, ‘Admiral Blake,’ ‘Johnny Armstrong,’ and ‘Chevy Chase’; for the lovers, ‘Patient Grissil’ and ‘Delights for Young Men and Maids’; for the serving-lad, ‘Tom Hickathrift’[19] and ‘Sir Richard Whittington’; while the serving-maid then, as now, would prefer ‘The Egyptian Fortune Teller,’ or ‘The Interpretation of Dreams and Moles.’”
Every phase of human nature was thus served up for a penny. In those days, people were more apt to want tales with heroes and heroines of their own rank and station; a certain appropriateness in this way was satisfied. Such correspondence was common as early as 1415, when a mystery play was presented by the crafts, and the Plasterers were given the “Creation of the World” to depict, while the Chandlers were assigned the “Lighting of the Star” upon the birth of Christ.
There were to be had primers, song-books, and joke-books; histories, stories, and hero tales. Printed in type to ruin eyes, pictured in wood-cuts to startle fancy and to shock taste—for they were not always suited to childhood—these pamphlets, 2½″ × 3½″, sometimes 5½″ × 4¼″ in size, and composed of from four to twenty-four pages, served a useful purpose. They placed literature within reach of all who could read. Queer dreams, piety of a pronounced nature, jests with a ribald meaning, and riddles comprised the content of many of them. A child who could not buy a horn-book turned to the “battle-dore” with his penny—a crude sheet of cardboard, bicoloured and folded either once or twice, with printing on both sides; the reading matter was never-failingly the same in these horn-books and “battle-dores,”
although sometimes the wood-cuts varied. A horn-book is recorded with a picture of Charles I upon it.
The sixteenth or seventeenth-century boy could own his “Jack and the Giants” and “Guy of Warwick,” his “Hector of Troy” and “Hercules of Greece”; he could even have the latest imported novelty. Some believe that because Shakespeare based many of his plays upon Continental legends, a demand was started for such chap-books as “Fortunatus,” “Titus Andronicus,” or “Valentine and Orson.” The printers of these crude booklets were on the alert for every form of writing having a popular appeal; there was rivalry among them as there is rivalry among publishers to-day. Not long after the appearance of the English translation of Perrault’s “Tales of Mother Goose,” each one of them, given a separate and attractive form—“Blue-beard” in awful ferocity, “Cinderella” in gorgeous apparel, and the others—was made into a chap-book. In Ashton, we find mention of an early catalogue “of Maps, Prints, Copy-books, Drawing-books, Histories, Old Ballads, Patters, Collections, etc., printed and sold by Cluer Dicey and Richard Marshall at the Printing-Office in Aldermary (4) Church Yard, London. Printed in the year MDCCLXIV.” These men appear to have been important chap-book publishers.
The hawkers, who went through the streets and who travelled the country-side, much as our pioneer traders were accustomed to do, were termed chapmen. They were eloquent in the manner of describing their display; they were zealous as to their line of trade. Imagine, if you will, the scene in some isolated village—the wild excitement when the good man arrived. He was known to Piers Plowman in 1362, he perhaps wandered not far away from the Canterbury Pilgrims; each of Chaucer’s Tales might well be fashioned as a chap-book. Along the dusty highway this old-time peddler travelled, with packet on his back and a stout staff in hand—such a character maybe as Dougal Grahame, hunch-backed and cross-eyed—by professions, a town crier and bellman, as well as a trader in literature. On his tongue’s tip he carried the latest gossip; he served as an instrument of cross-fertilisation, bringing London-town in touch with Edinburgh or Glasgow, and with small hamlets on the way.
“Do you wish to know, my lady,” he would ask, “how fares the weather on the morrow?” From the depths of his packet he would draw “The Shepherd’s Prognostication” (1673), wherein is told that “the blust’ring and noise of leaves and trees and woods, or other places is a token of foul
weather.” “And prithee, mistress,” he would add, “I have a warning herein for you. A mole on the forehead denotes fair riches, but yonder brown spot on your eyebrow bids me tell you to refrain from marriage, for if he marry you, he shall have seven wives in his life-time!”
Many a modern reader would be interested in the detailed directions given for falling in love and for falling out again; for determining whom fate had decreed as the husband, or who was to be the wife. It is more wholesome in these days to name the four corners of a bedroom than to submit to the charm of a pared onion, wrapped in a kerchief and placed on the pillow; yet the two methods must be related.
For the little ones, there were picture-books in bright colours, smug in their anachronisms. The manufacturers of chap-books never hesitated to use the same wood-cuts over and over again; Queen Anne might figure in a history, but she served as well in the capacity of Sleeping Beauty; more appropriate in its historical application seems to have been the appearance of Henry VIII as Jack the Giant-Killer.
The subject of chap-books is alluring; the few elements here noted suggest how rich in local colour the material is. Undoubtedly the roots of juvenile literature are firmly twined about these penny sheets. Their circulation is a matter that brings the social student in touch with the middle-class life. Not only the chap-books and the horn-books, but the socalled Garlands, rudimentary anthologies of popular poems and spirited ballads, served to relieve the drudgery of commonplace lives, toned the sluggish mind by quickening the imagination. A curious part of the history of these Garlands is their sudden disappearance, brought about by two types of hawkers, known as the “Primers-up” and “Long-Song Sellers,” who peddled a new kind of ware.
The Primers-up are relatives of our city venders. They clung to corners, where dead walls gave them opportunity to pin their literature within sight of the public. Wherever there happened to be an unoccupied house, one of these fellows would be found with his songs, coarse, sentimental, and spirited, cut in slips a yard long—three yards for a penny. Thus displayed, he would next open a gaudy umbrella, upon the under side of which an art gallery of cheap prints was free to look upon. Conjure up for yourselves the apprentice peering beneath the large circumference of such a gingham tent.
Across the way, the Long-Song Sellers marched up and down, holding aloft stout poles, from which streamed varied ribbons of verse—rhythm
fluttering in the breeze—and yelling, “Three yards a penny, songs, beautiful songs, nooest songs.”
It is apparent that much of the horn-book is incorporated in the “New England Primer,” although the development of the latter may be considered independently. The Primer is an indispensable part of Puritan history in America, despite the fact that its source extends as far back as the time of Henry VIII, when it was probably regarded more in the light of a devotional than of an educational book. The earliest mention of it in New England was that published in the Boston Almanac of 1691, when Benjamin Harris, bookseller and printer, called attention to its second impression.[20] Before that, in 1685, Samuel Green, a Boston printer, issued a primer which he called “The Protestant Teacher for Children,” and a copy of which may be seen in the library of the American Antiquarian Society of Worcester, Massachusetts. The title would indicate also that in America the primer for children at first served the same purpose as the morality play for adults in England; it was a vehicle for religious instruction.
The oldest existent copy of the New England Primer bears the imprint of Thomas Fleet, son-in-law of the famous Mrs. Goose, of whom we shall speak later. This was in 1737. Before then, in 1708, Benjamin Eliot of Boston, probably encouraged by earlier editions of primers, advertised “The First Book for Children; or, The Compleat School-Mistress”; and Timothy Green in 1715 announced “A Primer for the Colony of Connecticut; or, an Introduction to the True Reading of English. To which is added Milk for Babes.” This latter title suggests the name of the Reverend John Cotton, and, furthermore, the name of Cotton Mather, one of the austere writers, as the titles of his books alone bear witness.
Six copies of the New England Primer lay before me, brown paper covers, dry with age; blue boards, worn with much handling; others in gray and green that have faded like the age which gave them birth. The boy who brought them to me wore a broad smile upon his face; perhaps he was wondering why I wished such toy books, no larger than 3¼″ × 2½″. He held them all in one hand so as to show his superior strength. Yet had he been taken into the dark corridor between the book stacks, and had he been shown the contents of those crinkly leaves, there might have crept over him some remnant of the feeling of awe which must have seized the Colonial boy and girl. What would he have thought of the dutiful child’s promises, or of the moral precepts, had they been read to him? Would he have shrunk
backward at the description of the bad boy? Would he have beamed with youthful hope of salvation upon the picture of the good boy? It is doubtful whether the naughty girls, called “hussies,” ever reformed; it is doubtful whether they ever wanted to be the good girl of the verses. That smiling boy of the present would have turned grave over the cut of Mr. John Rogers in the flames, despite the placid expression of wonderful patience over the martyr’s face; his knees would have trembled at the sombre meaning of the lines:
“I in the burial place may see Graves shorter far than I; From death’s arrest no age is free, Young children too may die.”
The New England Primers[21] were called pleasant guides; they taught that the longest life is a lingering death. There was the fear instead of the love of God in the text, and yet the type of manhood fostered by such teaching was no wavering type, no half-way spirit. The Puritan travelled the narrow road, but he faced it, however dark the consequences.
Sufficient has been said to give some idea of the part occupied by these early publications—whether horn-book, chap-book, or primer. They bore an intimate relation to the life of the child; they were, together with the Almanack, which is typified by that of “Poor Richard,” and with the Calendar, part of a development which may be traced, with equal profit, in England, Scotland, France, and Germany. Their full history is fraught with human significance.
II. L F P .
Folk-lore stretches into the Valhalla of the past; our heritage consists of an assemblage of the heroic through all ages. A history of distinctive books for children must enter into minute traceries of the golden thread of legend, fable, and belief, of romance and adventure; it must tell of the wanderings of rhyme and marvel, under varied disguises, from mouth to mouth, from country to country, naught of richness being taken away from them, much of new glory being added. But for our immediate purposes, we imagine all this to be so; we take it for granted that courtier and peasant have had their fancies. The tales told to warriors are told to children, and in turn by nurses
to these children’s children. The knight makes his story by his own action in the dark forest, or in the king’s palace; he appears before the hut of the serf, and his horse is encircled by a magic light. The immortal hero is kept immortal by what is heroic in ourselves.
Jean de La Fontaine (1621–1695) was a product of court life; and the fable was the literary form introduced to amuse the corsaged ladies of Versailles. La Fontaine was the cynic in an age of hypocrisy and favouritism, and one cannot estimate his work fully, apart from the social conditions fostering it. He was steeped in French lore, and in a knowledge of the popular tales of the Middle Ages. He was licentious in some of his writing, and wild in his living; he was a friend of Fouquet, and he knew Molière, Racine, and Boileau. He was a brilliant, unpractical satirist, who had to be supported by his friends, and who was elected to the Academy because his monarch announced publicly that he had promised to behave. Toward the end of his life he atoned for his misdemeanours by a formal confession.
There was much of the child heart in La Fontaine, and this characteristic, together with the spleen which develops in every courtier, aided him in his composition of the Fables. Unclean his tales may be, likened to Boccaccio, but the true poet in him produced incomparable verses which have been saved for the present and will live far into the future because of the universality of their moral. The wolf and dog, the grasshopper and ant, all moved in silks and satins at the court of Louis XIV, and bowed for social rank, some trailing their pride in the dust, others raised to high position through the fortune of unworthy favour. So successfully did La Fontaine paint his pictures that the veiled allusions became lost in time beneath the distinct individuality of the courtiers’ animal prototypes. The universal in La Fontaine is like the universal in Molière and Shakespeare, but it has a wider appeal, for children relish it as their own.
Another figure was dominant at the court of Louis XIV—one equally as immortal as La Fontaine, though not so generally known—Charles Perrault (1628–1703). He was a brilliant genius, versatile in talent and genial in temper. He dabbled in law, he dabbled in architecture, and through it won the favour of Colbert. With an abiding love for children, he suggested and successfully carried the idea of keeping open the royal gardens for young Parisians. Through Colbert he became an Academician in 1671, and, with the energy which usually marked his actions, he set about influencing the
rulings of that body. He was a man of progress, not an advocate of classical formalism. He battled long and hard with Boileau, who was foremost among the Classicists; his appeal was for the future rather than for the past. He was intellectually alert in all matters; probably, knowing that he possessed considerable hold upon the Academy, he purposely startled that august gathering by his statement that had Homer lived in the days of Louis XIV he would have made a better poet. But the declaration was like a burning torch set to dry wood; Boileau blazed forth, and the fight between himself and Perrault, lasting some time, became one of the most famous literary quarrels that mark the pages of history.
After Perrault retired to his home in the year 1686, and when he could have his children around him, he began the work which was destined to last. Lang calls him “a good man, a good father, a good Christian, and a good fellow.” It is in the capacity of father that we like to view him—taking an interest in the education of his children, listening to them tell their tales which they had first heard from their nurse; his heart became warmed by their frank, free camaraderie, and it is likely that these impromptu story hours awakened in him some dim memories of the same legends told him in his boyhood.
There is interesting speculation associated with his writing of the “Contes de ma Mère l’Oye.” They were published in 1697, although previously they had appeared singly in Moetjen’s Magazine at the Hague. An early letter from Madame de Sévigné mentions the wide-spread delight taken by the nobles of the court in all “contes”; this was some twenty years before Perrault penned his. But despite their popularity among the worldly wise, the Academician was too much of an Academician to confess openly that he was the author of the “contes.” Instead, he ascribed them to his son, Perrault Darmancour. This has raised considerable doubt among scholars as to whether the boy should really be held responsible for the authorship of the book. Mr. Lang wisely infers that there is much evidence throughout the tales of the mature feeling and art of Perrault; but he also is content to hold to the theory that will blend the effort of old age and youth, of father and son.
The fact remains that, were it not for Perrault, the world might have been less rich by such immortal pieces as “The Three Wishes,” “The Sleeping Beauty,” “Red Riding Hood,” “Blue Beard,” “Puss in Boots,” and “Cinderella,” as they are known to us to-day. They might have reached us
from other countries in modified form, but the inimitable pattern belongs to Perrault.
Another monument preserves his name, the discussion of which requires a section by itself. But consideration must be paid in passing to the “fées” of Marie Catherine Jumelle de Berneville, Comtesse D’Anois (Aulnoy) [1650 or 51–1705], who is responsible for such tales as “Finetta, the Cinder-Girl.”[22] Fortunately, to the charm of her fairy stories, which are written in no mean imitation of Perrault, there have clung none of the qualities which made her one of the most intriguing women of her period. She herself possessed a magnetic personality and a bright wit. Her married life began at the age of sixteen, and through her career lovers flocked to her standard; because of the ardour of one, she came near losing her head. But despite the fact that only two out of five of her children could claim legitimacy, they seem to have developed in the Comtesse d’Aulnoy an unmistakable maternal instinct, and an unerring judgment in the narration of stories. She is familiar to-day because of her tales, although recently an attractive edition of her “Spanish Impressions” was issued—a book which once received the warm commendation of Taine.
III. M G .
There has been a sentimental desire on the part of many students to trace the origin of Mother Goose to this country; but despite all effort to the contrary, and a false identification of Thomas Fleet’s mother-in-law, Mrs. Goose, or Vergoose, with the famous old woman, the origin is indubitably French. William H. Whitmore[23] sums up his evidence in the matter as follows:
“According to my present knowledge, I feel sure that the original name is merely a translation from the French; that the collection was first made for and by John Newbery of London, about . . 1760; and that the great popularity of the book is due to the Boston editions of Munroe and Francis, . . 1824–1860.”
It appears that, in 1870, William A. Wheeler edited an edition of “Mother Goose,” wherein he averred that Elizabeth, widow of one Isaac Vergoose, was the sole originator of the jingles. This statement was based upon the assurances of a descendant, John Fleet Eliot. But there is much stronger
evidence in Perrault’s favour than mere hearsay; even the statement that a 1719 volume of the melodies was printed by Fleet himself has so far failed of verification.
The name, Mother Goose, is first heard of in the seventeenth century. During 1697, Perrault published his “Histoires ou Contes du Tems Passé avec des Moralitez,” with a frontispiece of an old woman telling stories to an interested group. Upon a placard by her side was lettered the significant title already quoted:
CONTES DE MA MERE LOYE
There is no doubt, therefore, that the name was not of Boston origin; some would even go further back and mingle French legend with history; they would claim that the mother of Charlemagne, with the title of Queen Goose-foot (Reine Pédance), was the only true source.[24]
Mr. Austin Dobson has called Mr. Lang’s attention to the fact that in the Monthly Chronicle for March, 1729, an English version of Perrault’s “Tales” was mentioned, done by Mr. Robert Samber, and printed by J. Pote; another English edition appeared at The Hague in 1745. This seems to be the first introduction into England of the “Mother Goose Fairy Tales.” It was probably their popularity, due not only to their intrinsic interest, but partly to the speculation as to Mother Goose’s identification, that made John Newbery, the famous London publisher, conceive the brilliant plan of gathering together those little songs familiar to the nursery, and of laying them to the credit of Mother Goose herself. In so doing, he solicited the assistance of Oliver Goldsmith (1728–1774). Mr. Whitmore writes:
“If, as seems most probable, the first edition of ‘Mother Goose’s Melody’ was issued prior to John Newbery’s death in 1767, there is an interesting question as to who prepared the collection for the press. The rhymes are avowedly the favourites of the nursery, but the preface and the foot-notes are an evident burlesque upon more pretentious works.”
There are two small pieces of evidence indicating clearly Goldsmith’s editorship. On January 29, 1768, he produced his “Good Natur’d Man,” and with his friends dined beforehand in gala fashion at an inn. Subject to
extremes of humour, on this occasion he was most noisy, and he sang his favourite song, we are told, which was nothing more than “An old woman tossed in a blanket, seventeen times as high as the moon.” As it happens, this ditty is mentioned in the preface to Newbery’s collection of rhymes, without any more apparent reason than that it was a favourite with the editor, who wished to introduce it in some way, however irrelevant. Again, we are assured that Miss Hawkins once exclaimed, “I little thought what I should have to boast, when Goldsmith taught me to play Jack and Jill, by two bits of paper on his fingers.”
Thus, though the tasks performed by Goldsmith for Newbery are generally accounted specimens of hack work, which he had to do in order to eke out a livelihood, there is satisfaction in claiming for him two immortal strokes, his tale of “Goody Two Shoes,” and his share in the establishment of the Mother Goose Melodies.[25] Many a time he was dependent upon the beneficence of his publisher, many a time rescued by him from the hands of the bailiff. The Newbery accounts are dotted with entries of various loans; even the proceeds of the first performances of the “Good Natur’d Man” were handed over to Newbery to satisfy one of his claims.
The notes accompanying the melodies, and which have no bearing upon the child-interest in the collection, show a wit that might very well belong to Goldsmith. He was perhaps amusing himself at the expense of his lexicographer friend, Johnson. For instance, to the jingle, “See saw, Margery Daw,” is appended this, taken seemingly from “Grotius”: “It is a mean and scandalous Practice in Authors to put Notes to Things that deserve no Notice.” And to the edifying and logical song, “I wou’d, if I cou’d, If I cou’dn’t, how cou’d I? I cou’dn’t, without I cou’d, cou’d I?” is attached the evident explanation from “Sanderson”: “This is a new Way of handling an old Argument, said to be invented by a famous Senator; but it has something in it of Gothick Construction.” Assuredly the names of those learned authors, “Mope,” credited with the “Geography of the Mind,” and “Huggleford,” writing on “Hunger,” were intended for ridicule.
By 1777, “Mother Goose” had passed into its seventh edition, but, though its success was largely assured, there are still to be noted rival publications. For instance, John Marshall,[26] who later became the publisher of Mrs. Trimmer’s works, issued some rhymes, conflicting with the book of Melodies which Carnan, Newbery’s stepson, had copyrighted in 1780, and had graced with a subtitle, “Sonnets for the Cradle.” During
1842, J. O. Halliwell edited for the Percy Society, “The Nursery Rhymes of England, collected principally from Oral Tradition,” and he mentioned an octavo volume printed in London, 1797, and containing some of our wellknown verses. These it seems had been first collected by the scholar, Joseph Ritson,[27] and called “Gammer Gurton’s Garland.” The 1797 book was called “Infant Institutes,” semi-satirical in its general plan, and was ascribed to the Reverend Baptist Noel Turner, M.A.,[28] rector of Denton. If this was intended to supplant Newbery’s collection, it failed in its object. However, it is to be noted and emphasised that so varied did the editions become, that the fate of “Mother Goose” would not have been at all fortunate in the end, had not Monroe and Francis in Boston insisted upon the original collection as the authentic version, circa 1824. Its rights were thus established in America.
The melodies have a circuitous literary history. In roundabout fashion, the ditties have come out of the obscure past and have been fixed at various times by editors of zealous nature. For the folk-lore student, such investigation has its fascination; but the original rhymes are not all pure food for the nursery. In the course of time, the juvenile volumes have lost the jingles with a tang of common wit. They come to us now, gay with coloured print, rippling with merriment, with a rhythm that must be kept time to by a tap of the foot upon the floor or by some bodily motion. Claim for them, as you will, an educational value; they are the child’s first entrance into storyland; they train his ear, they awaken his mind, they develop his sense of play. It is a joyous garden of incongruity we are bequeathed in “Mother Goose.”
IV. J N , O G , I
T .
Wherever you wander in the land of children’s books, ramifications, with the vein of hidden gold, invite investigation,—rich gold for the student and for the critic, but less so for the general reader. Yet upon the general reader a book’s immortality depends. No librarian, no historian, need be crowded out; there are points still to be settled, not in the mere dry discussion of dates, but in the estimates of individual effect. The development of children’s books is consecutive, carried forward because of social reasons;
