The difficulties are greatest in the case of intra-ligamentous fibroids. Such operations are among the most difficult in surgery. The directions given for the treatment of intra-ligamentous cysts are applicable also to this condition. The surgeon should always at first secure the ovarian arteries if possible. He should then incise the peritoneal investment across the anterior or posterior face of the tumor.
Enormous veins often lie immediately beneath the peritoneum, and care must be taken to avoid injuring them.
The peritoneum should be stripped off with the fingers or with blunt scissors. Bleeding vessels are secured with forceps as they appear. No attaching structures should be divided until they have been carefully examined, for all anatomical relations are distorted by these growths. The ureter may pass over the top of the tumor, far removed from its normal position on the pelvic floor.
After the surgeon has started the enucleation of a tumor of this kind he must complete the operation. Bleeding cannot be arrested until the tumor has been enucleated, the cervix exposed, and the uterine arteries secured.
The operation is often accompanied by very profuse hemorrhage, but this hemorrhage is always arrested by the ligature of the ovarian and uterine arteries, which alone supply the growth. The surgeon should therefore not delay the operation by the ligature of separate bleeding points until the main vessels have been secured.
Vaginal Hysterectomy.—Vaginal hysterectomy may be performed for the relief of any condition in which the uterus or attached tumor is sufficiently small to pass through the vagina. The operation is very popular with some surgeons. It is but rarely used by the writer. The difficulty in dealing with adhesions and other complications in the upper part of the pelvis seems to be much less when the operation is performed through an abdominal incision.
Fig. 218.—Lateral vaginal retractor.]
The technique of vaginal hysterectomy varies considerably in the hands of different operators. The vaginal vault is opened with the knife, the scissors, or the cautery. The vessels of the broad ligament are secured with the ligature or with the clamp. The uterus is sometimes divided by longitudinal incision and the halves are separately removed.
