A Text-book of Diseases of Women

by Charles B. Penrose

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 should be 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.