A Text-book of Diseases of Women

by Charles B. Penrose

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.