CHAPTER XLI.

Fig. 205.—The mass-suture for closing the abdominal incision:S, skin;F, fascia;M, muscle;P, peritoneum.

Closing the Abdominal Incision.—A variety of methods have been introduced for closing the abdominal incision. The simplest method, that is applicable to all cases, is the interrupted mass-suture, or the “through-and-through” suture. This suture passes through all the structures of the abdominal wall (Fig. 205). Some operators advise passing the suture to, but not through, the peritoneum. The writer includes the edge of the peritoneum in the suture. These sutures should be placedtwo or three to the inch, according to the thickness of the abdominal wall.

Care should be taken to include all the structures in the embrace of the suture. A carelessly applied suture sometimes fails to include the retracted fascia and muscle. The needle should first be directed outward and then inward as it passes through the abdominal wall. It should not pass directly through, parallel to the sagittal plane of the incision. Thus when the suture is tied it forms approximately a circle, and the structures included in it are brought into a plane of apposition.

Fig. 206.—The subcuticular or intra-cutaneous suture. The fascia has been united by an interrupted suture.

A long straight needle with a spear-point is convenient for introducing the mass-suture. A gauze sponge should be placed beneath the incision as the sutures are introduced, to prevent injury of the intestines and the escape of blood into the peritoneum. When the pad is removed, the omentum, if readily found, should be drawn down behind the incision. Before each suture is secured the sides of the incision should be drawn forward by traction on the ends of the suture, to ensure accurate apposition upon the posterior or peritoneal aspect. If this precaution is not taken, in a thick or rigid abdominal wall the cutaneous aspect of the incision may be brought into accurate apposition, while a gap will exist between the more posterior structures. Such imperfect apposition is a frequent cause of ventral hernia. The mass-sutures should not be removed for two weeks. The early removal of sterile sutures is of no advantage whatever, andmay cause ventral hernia. The writer often leaves them in for three weeks.

After the sutures are removed the incision should be strapped with adhesive plaster.

The application of a buried suture of catgut or of silver wire, passed through the muscle and fascia, is a useful addition to the mass-suture and an additional preventive of hernia.

Various methods of uniting the tissues by sutures in separate layers are used. A very good method is to close the peritoneum by a continuous suture of fine silk, then to unite the muscle and fascia by a continuous suture of catgut, and finally to close the cutaneous edge with an interrupted or a continuous suture of silkworm gut or silk. The subcuticular or the intra-cutaneous suture (Fig. 206) is very convenient for this purpose.

If the abdominal wall be fat, it is advisable to introduce a second catgut suture through the subcutaneous fat. When the structures are united in layers, a hematoma sometimes forms between two planes of suture, and, if not absorbed, the anterior portion of the wound may break down. This accident, which is caused by hemorrhage after the sutures are secured, may be prevented by employing, in addition to the usual dressing, a compress of gauze placed over the incision.

The after-treatment of celiotomy is usually very simple. A special nurse is required for the first three days. The patient should lie upon her back for the first two or three days; after this she may be moved partly upon either side, and a pillow may be placed behind her for support.

The head may be supported by one or two pillows. Much comfort is experienced by raising the knees over pillows. The patient often complains bitterly of backache, which may be relieved by slipping a folded sheet or towel under the small of the back.

Thirst is always present after celiotomy, and is usually the symptom of which the patient complains the most. There is much diversity of practice in regard to the administration of water after celiotomy. The writer allows no water during the first twenty-four hours. During this time the lips and mouth are frequently moistened with a cloth wet in cold water or wrapped about a piece of ice. At the end of twenty-four hours small quantities of hot water or cold soda-water (1 dram) are given every fifteen minutes or half hour, and gradually increased as it is found to be retained by the stomach. Hot water relieves thirst as well, and is not so likely to cause vomiting, as cold water.

The chief objection to the early administration of water after celiotomy is that it may cause vomiting. Some operators avoid this by administering the water by the rectum.

Another reason, more or less theoretical, for withholding water is that the absorbing power of the peritoneumis greatest when the tissues of the body contain a deficient amount of water.

Pain after celiotomy seems to bear no relation whatever to the amount of traumatism that has been inflicted. More discomfort may be experienced after ventro-suspension of the uterus than after a hysterectomy. In operations upon the generative organs the chief seat of pain is in the region of the sacrum. Pain is also felt in the ovarian region and in the abdominal incision. The pain begins to abate after the first fifteen or twenty hours. Opium should not be administered unless it is absolutely necessary to allay nervous excitement in a cowardly woman. In such a case a small dose (gr. ⅙) of morphine may be administered hypodermically.

The writer rarely finds it necessary to administer an anodyne. Most patients are able to endure the pain if they are properly encouraged by the physician and the nurse.

There are several objections to the administration of opium. It increases the thirst and it diminishes the functional activity of the gastro-intestinal tract. It retards the passage of flatus by the rectum and causes tympanites, and it increases the difficulty of moving the bowels. It obscures and delays the recognition of symptoms that may demand immediate treatment. The patient who has had no opium is more comfortable at the end of three or four days after celiotomy than one to whom it has been given.

The patient should be encouraged to pass water voluntarily. The application of hot moist cloths to the external genitals sometimes facilitates urination. In many cases the use of the catheter is never necessary. If the urine is not voided about every eight hours, it should be drawn with the catheter. Catheterization should be done with strict attention to asepsis. The former frequency of cystitis from the improper use of the catheter has already been referred to. Catheterization should never be performed under any circumstances by the aid of thetactile sense alone. The nurse should always see what she is doing. The catheter—metal, glass, or preferably soft rubber—should be sterilized by boiling, and should be preserved in a 1:20 solution of carbolic acid.

The catheter may be lubricated with sterilized oil or glycerin. The labia should be separated, and the vestibule and the external meatus should be wiped off with a solution of bichloride of mercury (1:2000).

After the catheter has been used once it should be thoroughly cleansed, inside and out, and sterilized by boiling before being replaced in the carbolic solution.

The secretion of urine is always diminished for a few days after celiotomy, probably on account of the restricted ingestion of fluids. The writer has found the average secretion in 111 cases of celiotomy on women to be, during the first twenty-four hours, 13.4 ounces; during the second twenty-four hours, 14.6 ounces; during the third twenty-four hours, 19.6 ounces. In considering these numbers it should be remembered that the gynecological patient passes, before operation, a daily amount of urine much less than that passed by the average healthy woman.

Food is usually first administered at the end of forty-eight hours. If the patient be feeble, nutriment may be given by the mouth or the rectum before this time. The patient may have any easily digested food that she wishes, such as buttermilk, soup, beef-tea, milk or milk and lime-water, soft-boiled egg, etc. The food should be given frequently in small quantities. Buttermilk is one of the best foods with which to begin. It gratifies thirst and is more readily digested than milk. Half an ounce to an ounce may be given every hour until the retentive power of the stomach is determined.

The bowels should be moved at the end of forty-eight or seventy-two hours. If the patient is uncomfortable and is unable to pass flatus freely, or if there is any abdominal distention, the purgative should be administered at the earlier time (forty-eight hours). If she is comfortableand passes flatus easily, she may wait for three days. Purgation is most readily produced with Rochelle salts, given, in doses of ½ dram in about 3 or 4 ounces of water or soda-water, every hour. After the patient has taken five or six doses she usually feels the inclination to have a movement. If she is unable to accomplish this, she may be assisted with a rectal injection of 1 pint of soap and water and 2 drams of turpentine. The bowels should be moved at least once in every forty-eight hours during the remainder of the convalescence.

Sometimes the bowels are more difficult to move, and it is necessary to repeat the rectal injection at intervals of two or three hours until a good movement is produced. A compound enema composed of Epsom salts ℥j, glycerin ℥j, turpentine ℥iss, water ℥viij, injected high in the bowel through a rectal tube, may be effective. If the Rochelle salts are not retained, or if they fail to act, 1 grain of calomel may be administered every hour for five or six hours.

If the patient does well, vomiting does not often occur after the first twenty-four hours, when the effects of the ether have passed off. When vomiting occurs later than this, it is usually accompanied by abdominal distention and general abdominal pain. It is then an alarming symptom, and may indicate the onset of intestinal paralysis and general peritonitis.

This group of symptoms (vomiting, general abdominal pain, and distention) demands immediate treatment. A hot mustard plaster or a turpentine stupe should be placed over the epigastrium, and an enema of 1 pint of water and ½ ounce of turpentine should be administered, and should be repeated every three or four hours until a fecal movement occurs and flatus is freely discharged. At the same time Rochelle salts should be administered, or, if there is persistent vomiting, 1-grain doses of calomel. The escape of flatus may be assisted by inserting a rectal tube. In case of moderate distention or of intestinal pain from inability to pass flatus, the insertion in theanus of the ordinary rectal nozzle of the syringe will usually give relief. If this is not sufficient, the long rectal tube or a large rubber catheter should be introduced. It should be well greased and passed slowly into the rectum for a distance of 10 or 12 inches.

The patient is sometimes able to pass flatus when upon her side, though she may not be able to do so upon her back. Inability to pass flatus is not necessarily a sign of peritonitis or intestinal paralysis. It may be caused by the unaccustomed position, or pain or nervousness may prevent the woman relaxing the sphincter ani.

If the vomiting persists and becomes bilious, relief is sometimes obtained by thoroughly washing out the stomach through the stomach-tube.

The internal administration of medicines—except the purgatives already mentioned—is of little use in vomiting of this character.

The pulse after celiotomy usually remains below 100. It often, however, reaches 115 or 120, and sometimes higher, in patients who have a favorable convalescence. A rapid pulse unaccompanied by unfavorable abdominal symptoms often indicates some heart-trouble.

A pulse of over 120 accompanied by abdominal distention and vomiting should always excite alarm.

Strychnine and digitalis, administered hypodermically, are the most useful medicines for strengthening the heart and diminishing the rapidity of the pulse. They should be given in large doses—1/20 of a grain of strychnine every three or four hours, and 10 minims of tincture of digitalis at similar intervals.

Hypodermic injections of strychnine are most useful for shock after celiotomy. This drug may be exhibited until the physiological action—twitching or jerking of the muscles—is observed. The writer has administered between 1 and 2 grains during the first twenty-four hours after celiotomy, with recovery.

The temperature after celiotomy runs no regular course. It usually remains below 102° F. A greater elevation oftemperature than this may occur during a favorable convalescence; and; on the other hand, a fatal termination may take place when the temperature remains lower. The maximum temperature is usually observed about the second or third day.

The temperature often rises on account of very trivial causes. It may go up one or two degrees if the patient should become constipated, and will drop as soon as a free fecal movement has taken place.

Fig. 207.—Composite temperature-chart of a series of 150 successful cases of celiotomy: average temperatures, pulses, and respirations for two weeks after operation.

The comfort of the patient is much increased by sponging the arms and legs with tepid water. The nurseshould be instructed to sponge the patient in this way whenever the temperature reaches 102° F.

The patient should maintain the recumbent posture for three weeks after celiotomy. She may then sit up in bed for two or three days, and if then sufficiently strong, she may leave the bed.

Too great haste in getting up may result in ventral hernia. The incision should be strapped with adhesive plaster for five or six weeks after operation, and the woman should wear some simple form of abdominal binder for the following six months, or for a year if the incision be large. She should be warned against resuming hard work, involving lifting or other abdominal strain, for several months after operation. She should be told of the possibility of ventral hernia, and advised to return immediately for treatment should this condition appear.

The usual causes of death after celiotomy are peritonitis and hemorrhage. The frequency of hemorrhage as a cause of death is often overlooked. The writer feels confident that many deaths which, without post-mortem examination, are attributed to peritonitis, are really caused by hemorrhage. Without doubt, peritonitis and hemorrhage often occur together; the blood that escapes into the peritoneal cavity may be too great in amount for absorption, and may become septic. The source of the hemorrhage is usually a vessel of the pedicle that escapes from the embrace of an imperfectly applied ligature. This accident should not happen if the operator is careful to see that hemostasis is perfect before the abdomen is closed. Bloody oozing from a surface of adhesion is not sufficient to cause death, and may be removed by drainage; the fatal hemorrhage comes from an arterial vessel that has slipped from its ligature. All ligatured vessels should be finally inspected immediately before the abdomen is closed. If a stump is not perfectly dry, a reinforcing ligature should be applied. Care in this particular will save much subsequent anxiety. If the operator knows that his ligatures have been securely applied, hecan exclude the possibility of hemorrhage in case alarming symptoms should arise.

If the symptoms of the patient after celiotomy indicate hemorrhage, the abdomen must be reopened and the bleeding vessels secured.

The causes of peritonitis after celiotomy have already been discussed.

The common symptoms are rapid pulse, abdominal distention and pain with inability to pass flatus or feces, and vomiting, which may finally become stercoraceous. The temperature is usually elevated, though it may remain normal or subnormal. Auscultation of the abdomen reveals total absence of all peristaltic sounds. If these symptoms are not arrested by the use of purgatives, turpentine enemata, and the rectal tube, it is probable that the result will be fatal. Death usually occurs on the third day.

The mortality after celiotomy depends upon the condition to be treated, the skill of the operator, and the environment of the operation. Some operations, like ventro-suspension of the uterus, are attended by no mortality. The average mortality after celiotomy for large numbers of gynecological cases of all kinds, in the hands of experienced operators with good operative surroundings, is about 5 per cent.

A thorough knowledge of the anatomical relations of the various structures in the pelvis is essential for the performance of the various operations upon the uterus and its appendages.

A detailed description of such anatomical relations is out of place here. It is especially important to study the distribution of the arterial supply and the relations of the ureters.Fig. 208will refresh the memory upon these points.

Fig. 208.—Posterior view of the uterus, the tubes and ovaries, and the broad ligaments:I.P.L., infundibulo-pelvic ligament;O.A., ovarian artery;U.A., uterine artery;U., ureter. The utero-sacral ligaments are seen on each side of the posterior aspect of the cervix.

The ovarian artery, which corresponds to the spermatic in the male, is a branch of the abdominal aorta. It runstortuously between the layers of the upper part of the broad ligament, from the pelvic wall to the upper angle of the uterus. Before reaching the uterus it divides into two branches. The upper branch supplies the fundus uteri; the lower branch anastomoses at the side of the uterus with the uterine artery.

During its course in the broad ligament the ovarian artery gives off branches to the ampulla and the isthmus of the Fallopian tube, to the ovary, and to the round ligament.

Fig. 209.—Anterior view of the uterus, the tubes and ovaries, and the broad ligaments. The upper part of the bladder, the anterior wall of the vagina, and the peritoneum on the anterior aspect of the broad ligaments have been removed.U., ureter;U.A., uterine artery;O.A.ovarian artery;R.L., round ligament.

The uterine artery arises from the anterior division of the internal iliac, and runs downward and inward toward the cervix uteri. The vessel is tortuous, and is loosely supported by the cellular tissue at the base of the broad ligament. The lowest point which it reaches is on a level with the external os uteri, and at this point it crosses the ureter.

At about this point it gives off the circular artery of the cervix, which anastomoses with its fellow of the opposite side. The uterine artery then passes upward, and reaches the uterus near the level of the internal os. It passes along the side of the uterus in a very tortuous manner, and anastomoses with the ovarian artery.

The vaginal arteries usually arise from the anterior division of the internal iliac artery. They sometimes arise from the uterine or middle hemorrhoidal artery.

The ureter passes behind and beneath the uterine artery. The uterine artery crosses the ureter at about the level of the external os uteri. At this point the ureter is ⅗ of an inch distant from the cervix. The distance between the ureter and the artery at the point of crossing is about ⅖ of an inch. It is important to remember these relations in applying a ligature to the uterine artery.

It must not be forgotten that the anatomical relations are altered by any displacement of the uterus from its normal position. Such displacement occurs in disease and when the uterus is dragged upward or downward during operation.

In conditions, such as cancer, which are accompanied by hypertrophy of the cervix, the distance between the ureter and the cervix is much diminished.

Removal of the Uterine Appendages (Salpingo-oöphorectomy).—This operation is performed by ligaturing the ovarian artery in its course through the infundibulo-pelvic ligament and at the uterine cornu, and then excising the Fallopian tube and the ovary.

The peritoneum is opened, and the index and middle fingers of the left hand are introduced into the abdomen. If necessary, the omentum is swept upward out of the pelvis. The fundus uteri is sought, and the fingers, with the palmar surface directed downward, are passed over the posterior face of the uterus, and then outward over the posterior aspect of the broad ligament. The ovary and tube are palpated, and are lifted forward upon the palmar aspect of the two fingers or between the fingers,perhaps with the subsequent assistance of the thumb, into the abdominal incision. The infundibulo-pelvic ligament is exposed, and is rendered tense by the pressure of the fingers behind it. It will be observed that the upper edge of the ligament is thick, while there is a thin, sometimes transparent, area below the free edge. The vessels run in the upper edge of the ligament, and a ligature passed through the thin area will secure them (Fig. 210).

Fig. 210.—Salpingo-oöphorectomy. On the right side ligatures have been placed about the ovarian artery, at the uterine horn, and at the pelvic wall. On the left side the tube and ovary have been excised between such ligatures. If bleeding takes place from the broad ligament, the anterior and posterior peritoneal aspects may be united by suture.

The heavy silk carried in the pedicle-needle should be used. The ligature should be placed sufficiently near the pelvic wall to permit complete excision of the tube and ovary without cutting too close to the ligature. The broad ligament should then be transfixed by a second ligature at a point somewhat to the inside of the first. The second ligature should embrace the ovarian ligament, the isthmus of the tube, and the uterine end of the ovarian artery. This ligature should be placed close to the uterine cornu, in order to permit complete excision of the ovary.

The Fallopian tube, the ovary, and the mesosalpinx are then cut away with the scissors. There is usually no bleeding whatever from the unligatured portion of the broad ligament between the two ligatures. The stumps should be carefully inspected, and any bleeding point in the intervening portion of the broad ligament should be picked up and secured by fine ligature; or the peritoneal edges may be united by suture.

This method of operating is in accord with the best surgical principles.

The vessels are secured in their course by ligatures which embrace a minimum amount of surrounding tissue. In the early days of modern abdominal surgery, the operation usually advised was performed with the Tait knot (Fig. 211) or the link-ligature (Fig. 212).

Fig. 211.—The Tait knot.

Fig. 212.—The link-ligature.

The ovary and the tube are drawn into the abdominal incision, and the pedicle formed by the broad ligament is transfixed with the pedicle-needle carrying a double ligature.

The loop of the ligature is passed over the tube and ovary and the Tait knot is tied, or the ligature is cut and each half of the pedicle is separately secured, the ligature being crossed or linked in the middle of the stump, to prevent separation.

The operators who apply the ligature in this way do so because they fear hemorrhage if every portion of the broad ligament is not secured.

This fear is unfounded. The objections to this form of ligature, the Tait or the link-ligature, may be given by the following quotation from a former paper by the writer.4

“The objections to these ligatures are: The liability to slip; the difficulty or impossibility in some cases of removing all the ovary and tube; the fact that the broad ligament is puckered up and made more tense than normal, and may for this reason cause subsequent pain and discomfort; an unnecessary amount of tissue is strangulated.

“Most operators have seen cases, either in their own experience or in the experience of others, in which the ligature has slipped from the pedicle, either during the operation or some days afterward. I think that this accident, usually unrecognized, is a very common cause of death after oöphorectomy. Tait speaks of a certain number of cases in his own experience in which a hematoma occurred in the broad ligament some hours or days after operation. He says, ‘I cannot form any exact estimate of how many cases of these operative hematoceles I have seen, but it certainly is not less than 50, and is more likely to be 70 or 80.’

“It seems probable that this accident is due to the retraction or slipping of the artery from the embrace of the ligature, while the remaining mass of tissue which forms the pedicle is still retained, and the hemorrhage, therefore, is confined to the broad ligament. I have seen this accident happen before the abdomen had been closed, and have sought for and ligated separately the retracted vessel.

“Slipping of the ligature is due to the form of the mass of tissue which is ligated. The broad ligament is drawn up into a more or less conical shape, all parts converging toward the ligature, and the ligature is really placed at the apex of a cone from which it may readily slip; and the elastic artery, tied when upon the stretch, tends to retract and escape from the embrace of the ligature.

“The second objection is the difficulty or impossibility of removing all the ovary and tube. If the broad ligament is tense, as it often is in single women, or if it isthickened from inflammatory deposit, it is sometimes impossible to bring the tube and ovary through the abdominal incision and to obtain a pedicle which may be ligated so that we may with safety remove all of the ovary. And it is in just such cases that it is usually most desirable that all ovarian tissue should be removed.

“The third objection—the puckering and tension of the broad ligament—may be of less importance than those just considered. However, it seems probable that some of the pain which women suffer after oöphorectomy is due to the traction and counter-traction exerted by different parts of the broad ligament upon a sensitive cicatrix. The broad ligament is pulled up from different directions and converges to the cicatrix, which becomes the point from which the lines of traction radiate.

“It was thought that in case of retroversion this tension of the broad ligament would maintain the uterus in place, the ligaments acting as guys. This, however, is not true. Repeated secondary operations have shown that the uterus has fallen back again to extreme retroversion, notwithstanding such methods of ligature of the broad ligaments.

“The fourth objection is one which appeals to our surgical sense. It is always better surgery to ligate the vessel alone than to include with it a mass of surrounding tissue.”

If the isthmus of the Fallopian tube is diseased, as in some cases of pyosalpinx, so that it is necessary to exsect the tube from the uterine cornu, the second ligature may be passed immediately beneath the tube, including the ovarian ligament and the ovarian artery, but not including the tube; the tube may then be cut out by a wedge-shaped incision in the horn of the uterus. The uterine wound should be closed by interrupted suture (Fig. 212,A). In such cases, however, if the tubal disease is bilateral, it is best to remove the uterus as well as the appendages.

It is not necessary to place both ligatures before cutting away the ovary and tube. The first ligature may be placed about the proximal portion of the ovarianartery, and then the infundibulo-pelvic ligament may be cut, bleeding from the distal end being controlled with forceps. This will enable the operator readily to bring the ovary and tube through the incision and to ligate the ovarian artery at the uterine cornu.

Fig. 212,A.—Position of ligatures and sutures in exsection of the tube.

Fig. 212,B.—Pyosalpinx which has been exsected from the uterine cornu.

If adhesions exist, they should be broken with the fingers, or the patient should be placed in the Trendelenburg position and the adhesions should be divided with scissors. The tube and ovary are sometimes completely imbedded in adhesions, and it is necessary to shell them out by careful work with the fingers. The adhesions may be so dense and the anatomical relations so altered that it is difficult or impossible to determine what is ovary and what is tube until the mass is brought into the abdominal incision. In these cases the experienced operator may work by the sense of touch alone. The inexperienced operator had better expose the parts and obtain the assistance of visual examination.

The fundus uteri can usually be determined, and will form a valuable landmark. The enucleation is most easily performed with the fingers. The index and middle fingers, with the palmar surfaces turned downward, should be passed outward from the posterior aspect of the uterus, and should seek a plane along which the structures most readily separate. As a rule, adhesions give way more easily than the tissues of normal structures. Adhesions should not be roughly torn: they should be pushed away from the posterior aspect of the ovary and broad ligament.

The adhesions between the ovary and the broad ligament must be broken by pressure with the fingers before the ovary can readily be brought into the abdominal incision.

After all other adhesions have been relieved it is often found that the ovary still lies low in the pelvis, glued to the posterior aspect of the broad ligament. It should not be dragged, in this condition, into the incision, or the broad ligament may be badly lacerated. It shouldbe peeled off from the broad ligament and rolled up to the incision.

After the structures have been carefully examined and the anatomical relations determined the ligatures should be placed and the tube and ovary cut away. The bleeding from the pelvic adhesions is usually arrested or much diminished as soon as the ovarian artery is ligated. It is best, therefore, to waste no time in attempts to arrest moderate hemorrhage until the appendages have been removed. The pelvis should then be inspected and any bleeding points secured. Omental adhesions should be ligated, if necessary, as they are divided.

If there is a general oozing from the bed of adhesions that cannot be controlled by ligature, one or two gauze pads should be pressed over the region and retained there until the abdominal sutures have been placed. If the bleeding continues notwithstanding such sponge-pressure, it may be necessary to employ drainage. The bleeding may always be controlled by the pressure of the end of the gauze drain placed directly over the raw surface.

If the operator is anxious to arrest menstruation, he must be certain to remove all ovarian tissue and the Fallopian tubes at the uterine cornua. Sometimes, after an adherent ovary has been enucleated, part of the ovarian stroma remains glued to the pelvic wall, the posterior face of the broad ligament, or some other structure. These portions of ovary should be carefully picked off with the forceps. If the operator doubts the complete removal of all ovarian tissue, he should make a note to this effect in the history of the case. Were this always done, the existence of a supernumerary ovary would not be so often assumed.

The directions that have been given here apply to the removal of tubal tumors and small cystic and solid tumors of the ovary. When the ovary is removed there is but little, if any, advantage in leaving the corresponding Fallopian tube in case the tube on the opposite side is healthy.

If the patient is anxious for children, the operator should remember that conception is possible with one tube and one ovary, though they be on opposite sides. If an ovarian tumor is removed independently of the corresponding Fallopian tube, the pedicle of the ovary should be transfixed and ligatured in two or more masses.

Removal of an Ovarian Cyst.—The removal of a large ovarian cyst may be facilitated by preliminary tapping as soon as the peritoneum is opened, and withdrawal of the fluid contents. As a general rule, this procedure is advisable if the cyst is too large to be removed through a 3- or 4-inch incision. If, however, the operator should suspect the contents of the cyst to be septic, it is safest to enlarge the incision and to remove the tumor intact, thus avoiding infection of the peritoneum. This advice is especially applicable to dermoid cysts. The contents of such cysts are very often septic. They are thick, and contain a large amount of solid material which passes with difficulty through the trocar. The walls of the cyst are friable and easily torn, so that the puncture-wound of the trocar becomes enlarged and the cyst-contents escape around it; and, finally, the contents of a dermoid are very difficult to remove from the peritoneum.

The dermoid character of a cyst may be suspected from the dull appearance of the walls and the putty-like feeling upon palpation. They are usually of small size, and may be removed bodily through an incision of moderate extent.

Every tumor should be carefully examined before the trocar is plunged into it. The operator should make certain by palpation that the tumor is cystic. The trocar has been thrust into the pregnant uterus, and frequently into a fibroid tumor. In the case of a fibroid profuse hemorrhage may occur from such an accident. The hemorrhage may usually be controlled by forcing a small sponge or gauze pack into the puncture wound. Before tapping the cyst the operator should pass his hand around it and determine the position and character of adhesions.

Small cysts about the size of a child’s head may be tapped with the small trocar. The larger instrument is used in cysts of greater size.

In a multilocular cyst the largest loculus should be tapped first. Sponges should be placed in the abdomen around the point selected for puncture. An incision about half an inch in length should be made through the outer coat of the cyst, and the trocar should then be introduced. As the fluid escapes through the trocar and the rubber tube into a vessel at the side of the table, and as the cyst becomes flaccid, the wall of the cyst near the trocar should be seized with large forceps. As the tumor diminishes in size it should be dragged through the abdominal incision. This procedure should not be done quickly or roughly, or adherent intestines may be torn, and bleeding from omental adhesions may escape detection.

As the cyst is drawn out the surface should be examined and adhesions should be separated, and ligatured, if necessary, as they appear. Omental adhesions usually require ligature. The bleeding from omental vessels is often profuse and is not arrested spontaneously. An adherent omentum should be ligatured with medium-sized silk in small sections, not in one mass, before it is cut away from the tumor.

The intestine is sometimes so adherent to the surface of the tumor that it cannot be separated without serious danger to the intestinal wall. In such a case it is best to cut out the adherent portion of the outer wall of the tumor and leave it glued to the intestine. If there is bleeding from the raw surface, it may be checked by folding in the bleeding area with silk suture.

While the operator is dealing with the adhesions the assistant should see that the opening in the cyst is kept in a dependent position and that cyst-contents do not escape into the abdomen. This precaution should always be taken, though it is especially important in the cases of septic and papillomatous cysts.

When the pedicle of the cyst is exposed, it should be ligatured as already advised. If the stump of the pedicle is very broad, it may be folded in or covered with peritoneum to prevent intestinal adhesions to it.

The other ovary should always be examined before closing the abdomen.

Operation for the Removal of Intra-ligamentous Cysts.—Intra-ligamentous cysts grow between the folds of the broad ligament. Any oöphoritic tumor may be intra-ligamentous, though the condition is most usually found in cysts of the paroöphoron and the parovarium.

The intra-ligamentous cyst may drag out the broad ligament so that a pedicle may be formed, and the tumor may be removed by the methods already described.

In other cases, however, the cyst is strictly sessile. It lies between the layers of the broad ligament, deep in the pelvis, or perhaps it may have migrated to some other part of the abdomen behind the peritoneum.

The removal of such tumors requires accurate anatomical knowledge of the region in which the growth is situated.

It is necessary to incise the peritoneal covering of the tumor and to enucleate it from its bed. The peritoneum should be incised in the position in which there are fewest blood-vessels. Thus, if the tumor has migrated between the layers of the mesocolon, the incision should be made through the outer peritoneal layer.

Intra-ligamentous cysts often have no pedicular attachments whatever, and may be enucleated without the application of ligature. In other cases a distinct vascular pedicle is found after the peritoneal investment has been opened and its adhesions to the cyst-wall have been separated.

The relations of an intra-ligamentous cyst should be carefully examined before the surgeon proceeds with the operation, and such a cyst should not be mistaken for an extra-ligamentous cyst that has become adherent.

If the tumor is situated between the layers of the broadligament, it is advisable, as a preliminary step, to ligate the ovarian artery in the infundibulo-pelvic ligament and at the cornu of the uterus. This may usually be readily done; much subsequent bleeding will be prevented by it.

The peritoneum is then incised at the most convenient point over the surface of the tumor, and the surgeon, with the fingers, knife-handle, or closed blunt scissors, proceeds with the enucleation. If inflammatory adhesions have not taken place, enucleation is usually easy. Bleeding vessels should be secured by forceps as they appear, and should be ligated, if necessary, after the cyst is removed.

If a pedicle or fleshy adhesion is met, it should be ligated before division.

During the enucleation the surgeon should follow closely the surface of the tumor. When he has reached a point deep in the pelvis he should be especially careful to avoid injury of the large vessels and the ureter. If the cyst is difficult of removal in this region, it may be advisable to cut out a portion of the cyst-wall and leave it.

Preliminary tapping of intra-ligamentous cysts is not often necessary. They are usually of moderate size, and enucleation may be most readily performed if the cyst is tense.

Sometimes large cysts are but partly intra-ligamentous: the greater portion is free, while the base is included between the layers of the broad ligament. In such cases it is best to tap the cyst and then to enucleate the base as already described.

In other cases the process of enucleation may be facilitated and rendered safe by incising the cyst-wall and introducing two fingers into the cavity to act as guides in separating the cyst from structures deep in the pelvis.

After the cyst has been removed and bleeding points have been secured by ligature, the raw surface, or the bed of the tumor, may be obliterated by bringing the sides into apposition by layers of buried fine silk sutures and by closing with suture the incision in the peritoneum.These raw surfaces often contract very much by the falling together of the sides after the tumor has been removed.

If bleeding from the bed of the tumor cannot be thoroughly arrested, it is unsafe to close the incision in the peritoneum, for a hematoma will form and will cause subsequent trouble. In such a case the gauze drain should be introduced into the bed of the tumor, perhaps after partial closure of the peritoneal incision. Or if the bleeding be very profuse, the edges of the incision in the broad ligament should be sutured to the lower angle of the abdominal wound, and the cavity should be packed with gauze.

The sutures that attach the broad ligament to the abdominal incision may be passed through the whole thickness of the abdominal wall, or through only the fascia, muscle, and peritoneum. The ends of the sutures should be left long to facilitate removal.

In the removal of a cyst of the parovarium by enucleation, the tube and ovary should not be sacrificed unless they are diseased. Small cysts of the parovarium which develop between the layers of the mesosalpinx may very easily be removed by simple incision of the peritoneal capsule and enucleation of the cyst, without injury to the tube and ovary.

Marsupialization of the Cyst.—In rare cases a cyst is found to be so firmly and generally adherent to surrounding structures that its removal is impossible. It is then necessary to practise marsupialization.

The cyst should be evacuated with the trocar, which is introduced at a point which can be readily brought to the abdominal incision. Vegetations, etc. should be removed from the interior of the cyst with the fingers. The opening in the cyst should then be attached to the lower angle of the abdominal incision by interrupted sutures of strong silk that pass through the whole thickness of the abdominal wall and of the cyst-wall. The sutures should be placed close together, and the ends should beleft long to facilitate removal. The upper portion of the abdominal incision should be closed with interrupted sutures.

A large double drainage-tube of rubber should be introduced into the cyst, and strips of gauze should be packed around the tube.

The subsequent treatment consists of frequent washing of the interior of the cyst. The sutures in the cyst-wall should be removed at the end of two weeks.

Though marsupialization frequently results in cure, yet it should never be practised unless it is absolutely necessary. It exposes the patient to the dangers of prolonged suppuration and persistent fistula. Malignant degeneration has occurred in the wound. Papilloma may extend to the peritoneum. The procedure is of but little use in the case of multilocular tumors, as all the loculi cannot be evacuated.

The uterus may be removed through an abdominal incision (abdominal hysterectomy), or it may be removed through the vagina (vaginal hysterectomy). A combination of the two methods of operating is sometimes employed.

In many conditions it is not necessary to remove the cervix. Partial hysterectomy or supra-vaginal amputation of the uterus at some convenient point of the cervix may be performed.

Such supra-vaginal amputation of the uterus may be done in nearly all operations that are not performed for malignant disease. In sarcoma or cancer the whole uterus should be removed at the vaginal junction, and, if necessary, the upper portion of the vagina should be excised.

In the case of fibroid tumor and in non-malignant disease of the body of the uterus supra-vaginal amputation is sufficient. Supra-vaginal amputation is an easier andsafer operation than complete hysterectomy. Abdominal hysterectomy is most easily performed with the patient in the Trendelenburg position.

Supra-vaginal Amputation of the Uterus.—After the abdomen has been opened, the ovarian artery should be ligated in the infundibulo-pelvic ligament, as in the operation of salpingo-oöphorectomy. A second ligature, or forceps, should then be placed upon the ovarian artery at the uterine cornu.

The round ligament should then be ligatured with medium-sized silk at a point situated about an inch from the uterus. Similar ligatures should then be placed about the ovarian artery and the round ligament on the opposite side.

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