A Text-book of Diseases of Women

by Charles B. Penrose

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.