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 be left 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.