The Post-Sims Era

Abstract

The Professor of Midwifery at Heidelberg, Germany, Gustave Simon, had visited Paris, earlier in his career, as a pupil of Jobert de Lamballe and whilst appreciating fully the merits of Lamballe’s procedure, in 1854 made his own modifications to the technique of fistula closure by doing away with lateral relieving incisions except in special circumstances, substituting two rows of sutures—one to approximate the edges and the other to relieve tension of the primary closure. Using an exaggerated lithotomy position, the hips were raised high with the legs strongly flexed on the body, and the uterus drawn down and held by sutures passed through the cervix, so pulling the anterior vaginal wall out between the labia. The Simon speculum was a retracting speculum with long handles, and also he used lateral retractors. A steeply precipitous funnel-shaped denudation was prepared, and the first row of sutures united the wound edges accurately and without tension. Simon was not concerned whether or not the suture passed through the vesical mucosa. The second row of sutures entered and emerged at a greater distance from the wound edges than the first line, so removing all tension. He reported 35 cures in 40 cases (Kelly. 1912) Novel elements in this approach were relaxation sutures, and a more vertical incision which were important advances in the evolution of fistula surgery technique (Fig. 31 a, b). Between 1856 and 1868 he published several papers on the place of colpocleisis in the management of vesico-vaginal fistula, stressing the necessity for applying the transverse vaginal closure immediately beneath the defect. Circular denudation of the vagina was effected adjacent to the fistula, and the wound surfaces opposed with sagittally applied sutures, but inevitably a small diverticulum formed. In most cases, the normal lower vagina was adequate for cohabitation. Technically the method was simple and very successful since the anterior and posterior vaginal walls normally were in contact so tension was avoided (Fig. 31 c). In 42 vesico-vaginal fistulae he performed “occlusio vaginae” 12 times with 12 cures, nevertheless the excellent results reported by Sims and Bozeman made colpocleisis unnecessary and technically wrong, for even when the diverticulum was very small, still, menstrual discharge with cervical and uterine secretions, commonly caused severe cystitis and calculi. Emmet (1879) stated that, “There was no greater blunder in surgery than the Simon operation, and in recent years all modern authors have regarded the procedure as obsolete and removed it from the list of fistula operations”. More recently however, colpocleisis following total hysterectomy has been reevaluated as an entirely different situation from colpocleisis with the uterus present (Latzko 1942). In 1867, Simon recommended transposition of the ureteric openings from the edge of a vesico-vaginal fistula into the bladder interior by splitting the anterior wall of the ureter (Latzko 1942).