A Manual of the Operations of Surgery / For the Use of Senior Students, House Surgeons, and Junior Practitioners

by Joseph Bell

b. In organisation.—Occasionally they are so soft and friable as to break down under the finger with ease, and so slightly organised as not to bleed at all in the process, while again they may be so firm and close as to require a careful and prolonged dissection, and so vascular as to require many points of ligature to be applied to large active vessels.

c. There are special dangers connected with the presence of these adhesions, and varying much in different cases. Thus adhesions to the intestines can generally be separated with comparative ease, and seem, as a rule, to require the application of fewer ligatures than those which unite the tumour to the abdominal wall. Adhesions to the wall are sometimes so firm as to be quite inseparable, and thus to necessitate some of the cyst-wall being left adherent. In Sir Spencer Wells's cases, adhesions to the liver and gall-bladder occasionally occurred, requiring careful dissection to separate them, and yet the patients all survived, while pelvic adhesions, especially to the bladder and uterus, on more than one occasion prevented the completion of the operation.

Vascular adhesions to the wall which require many ligatures certainly add to the dangers of the case, while adhesions to the anterior wall of the abdomen render the operation, especially its first stages, much more difficult, preventing the cyst from being recognised.

2. The condition of the pedicle is of great importance. If it is too short, it prevents the use of the clamp, as if applied it is apt either to pull the uterus up, or, pulling the clamp down, to make undue traction on the wound, and rupture any adhesions. This is especially the case where much flatus is generated, or where the patient is naturally stout.

Treatment.—Where the pedicle is just long enough to allow the clamp to be applied, and yet too short to leave room for any distension of the abdomen without undue tension, the best plan is to transfix it with a stout double thread just below the clamp, tie it in two halves, and bring the threads out past the clamp, so that, if tension does occur, the clamp may be removed, the part beyond it cut off, and the rest allowed to slip back into the pelvis, the ligatures being kept out at the mouth of the wound.

Or again, it is sometimes possible, after applying one clamp firmly as near the tumour as possible, to apply another above it when the greater part of the tumour has been cut away; when the second is firmly fixed it may then be safe to remove the first, and thus an artificially elongated pedicle is obtained.

When still shorter, two plans remain for selection—(1.) to transfix the pedicle in one or more points, then, securing it in two, three, or more portions, cut it off above the ligatures and return it, leaving the ligatures at the lower end of the wound. This gives a free drain for pus, but theoretically the sloughing pedicle might be expected to set up peritonitis; (2.) to transfix and tie the pedicle with one or more loops of stout string, cut the ends off short, and return the whole affair, closing the external wound at once. Theoretically there are grave objections to this plan, but it has proved very successful, especially in the hands of Dr. Tyler Smith.

Another ingenious modification, sometimes useful in a short narrow pedicle, is to tie it as close to the cyst as possible, bring the ligature out at the wound, and then with a strong harelip needle transfix the pedicle, along with both sides of the wound, just below the ligature.

When the pedicle is excessively broad and stout, it should be transfixed by strong needles and double threads in various places, and thus tied in several portions. Absence of the pedicle greatly adds to the danger in any given case. Various plans have been tried, as cutting the attachment through slowly by the écraseur, ligature of each vessel separately, so many as twelve being sometimes required, and cauterising the stump. The latter, as used by Mr. Baker Brown, has met with a large measure of success, and is much used now.[142]

Dr. Keith for a time operated with antiseptic precautions, but has now (1883) entirely given up the use of the spray, which he believes has especial dangers in abdominal surgery.