Tikhov-Grammatikati Operation

TIKHOV-GRAMMATIKATI OPERATION was proposed with the aim of expanding the limits of conventional surgical intervention for cervical cancer and reducing the number of inoperable cases to the possible minimum. Thus, the Tikhov-Grammatikati operation is intended for advanced cases of cervical cancer where conventional removal of the uterus is unfeasible or where, in the case of removing only the uterus, the patient is not completely rid of her disease due to the significant spread of the cancerous process. The Tikhov-Grammatikati operation begins with the ligation of both hypogastric arteries, by which maximum exsanguination of the operative field is achieved. After this, the uterus with appendages and as much of the parametrial tissue as possible is removed. In the case of significant spread of the cancerous process into the parametrial tissue or onto the urinary bladder, the ureters are resected, the urinary bladder is removed, and if necessary, the rectum is also resected. A voluminous gauze tampon, inserted through the vagina, fills the entire wound surface of the small pelvis; the peritoneum is sutured over the tampon. The ureters are transplanted into the rectum. In 61 cases of advanced cervical cancer, Tikhov and Grammatikati resected the ureters without removing the urinary bladder in 12 cases, performed removal of the urinary bladder with transplantation of the ureters into the rectum in 18 cases, and in 2 cases, in addition to removing the urinary bladder, they resected the rectum. With this method of operating, Tikhov and Grammatikati brought operability to 88% with a mortality rate of 31%. The Tikhov-Grammatikati operation did not meet with sympathy, because, despite the high percentage of primary mortality, in advanced cases of cervical cancer, despite the great radicalism of the surgical intervention, a significant part of the tissue in the posterior section of the pelvis remains unremoved, where, as is known, the spread of cancer is observed especially often. Thus, the Tikhov-Grammatikati operation cannot justify itself in the vast majority of cases of advanced cervical cancer; therefore, it is hardly possible to recommend the Tikhov-Grammatikati methodology in its entirety for broad, systematic application, especially since, at the present time, it has become possible with the help of radiation therapy to cure even advanced forms of cervical cancer or to significantly prolong the life of these patients. Nevertheless, in individual cases, the need may always arise for a surgeon, in addition to removing the uterus, to perform a resection of the ureters, remove the urinary bladder, and transplant the ureters into the rectum. A number of authors have cases where such an operation was performed with lasting recovery thereafter. Clinical observations related to the Tikhov-Grammatikati operation, as well as corresponding anatomical studies, have provided very valuable data concerning the ligation of both hypogastric arteries. Fears that the ligation of these vessels could cause a disruption in the nutrition of the urinary bladder and rectum, in the case of removing only the uterus, were not justified. Studies have shown that, thanks to anastomoses, the ligation of the hypogastric arteries cannot in any noticeable way affect the blood supply to the urinary bladder and the lower section of the rectum. At the present time, many gynecologists successfully use the ligation of both hypogastric arteries during the Wertheim operation. It should be kept in mind that the restoration of blood circulation in the branches of the hypogastric arteries is in some cases detected already during the operation and is expressed by bleeding from the severed uterine vessels. This bleeding is not, however, as profuse as it is in cases where the ligation of the hypogastric arteries was not done; however, this indicates the necessity, when ligating the hypogastric arteries, to also ligate the uterine artery.