A Text-book of Diseases of Women

by Charles B. Penrose

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 broad ligament, 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.