Cases have been reported in which, after traumatic rupture, or tapping, of a dermoid, the epithelial contents escaped into the belly. Subsequently the peritoneum was found dotted over with minute nodules furnished with tufts of hair growing among the visceral adhesions. When a woman with an ovarian cyst contracts typhoid fever, the cyst may become filled with pus which contains the bacillus typhosus. Such a case occurred in my practice in 1907.
For many years I have abandoned the use of clumsy trocars of all kinds and remove the tumour entire, although it may require an incision from the ensiform cartilage to the pubes. These large incisions heal quickly, and are no more prone to hernia than the short incisions. This is the only way of ensuring the safety of the peritoneum from being contaminated by the harmful, dirty, and often malignant contents of the cysts. In dealing with burst cysts a free incision enables the surgeon to thoroughly and gently clean the peritoneal cavity.
The abdominal cavity is opened by a median subumbilical incision (see [p. 7]). Occasionally a difficulty may be encountered on reaching the peritoneum, for, if the cyst has been infected, the peritoneum and cyst wall may be so intimately adherent that they cannot be separated. In these circumstances it is a wise plan to extend the incision upwards and enter the abdominal cavity above the tumour. It is also to be borne in mind that when the tumour adheres to the abdominal wall it is extremely probable that a coil of intestine may be adherent also. When a tumour is impacted in the pelvis it may push the bladder high in the abdomen; in such an event this viscus is apt to be opened in making the incision. If the surgeon has any doubt concerning the position of the bladder, he should instruct an assistant to introduce a sound into it through the urethra.
In a typical case, when the peritoneum is opened the surgeon at once recognizes the bluish-grey glistening surface of the ovarian cyst, and gently sweeps his hand over it in order to ascertain its relations and to learn whether the cyst wall be free from adhesions. It is of the utmost importance to be satisfied as to the nature of the tumour, especially when the operator follows the unsatisfactory practice of tapping, for if he plunge a trocar into a uterine tumour, or into a pregnant uterus, he will involve himself in anxious difficulty. Decomposing fluid, tenacious mucus, or blood-stained fluid may obscure the parts, and should be sponged away: they indicate a ruptured cyst, a malignant tumour, or a twisted pedicle. Much free blood may be due to the bursting, or abortion, of a gravid tube. When the surgeon has satisfied himself that the cyst or tumour is free to be removed he lifts it out of the abdominal cavity, and if in this process the wall be so thin that it is likely to burst, or actually leaks, the weak spot may be freely incised with a knife over a convenient receptacle.
Adhesions. Although the surgeon may have had reasons to suspect the presence of adhesions, frequently he finds none, and on other occasions when he least expects them there are many. The most frequent adhesions are omental, and fortunately they are the least important: they should be detached and tied with thin silk. Adherent epiploic appendages require the same treatment. Intestinal adhesions require care and patience. When the intestines are adherent by strands and bands, these may be cautiously snipped with scissors; when the adhesions are sessile and soft the gut may be gently detached by means of a moist dab; but if very firm it may be necessary to dissect off a piece of cyst wall and leave it on the gut. The vermiform appendix requires especial care, for it may be mistaken for an adhesion and divided. When intestines are accidentally opened in the course of an ovariotomy they require the most careful attention. Wounds in the colon may be safely sutured. Holes in adherent small intestine may sometimes be sutured, but if the gut has been extensively involved it may be necessary, and often judicious, to resect a few centimetres and join the cut ends by a circular enterorrhaphy.
Adhesions to the parietal peritoneum are as a rule easily detached with the finger. The most serious adhesions are those which occur in the depths of the pelvis, involving the uterus, bladder, or rectum, and the separation of these may involve such accidents as wounds opening the rectum or bladder, and injury to the ureters and iliac veins. The treatment of such misfortunes will be considered later.
The pedicle. When the tumour is withdrawn from the belly the pedicle is easily recognized: the Fallopian tube serves as an excellent guide to it. The pedicle consists of the Fallopian tube and adjacent parts of the mesometrium containing the ovarian artery, pampiniform plexus of veins, lymphatics, nerves, and the ovarian ligament. When the constituents of the pedicle are unobscured by adhesions, the round ligament of the uterus is easily seen and need not be included in the ligature.
In transfixing the pedicle the aim should be to pierce the mesometrium at a spot where there are no large veins, and tie the structures in two bundles, so that the inner contains the Fallopian tube, a fold of the mesometrium, and occasionally the round ligament of the uterus; whilst the outer consists of the ovarian ligament, veins, the ovarian artery, and a larger fold of peritoneum than the inner half.
Pedicles differ greatly; they may be long and thin, or short and broad. Long thin pedicles are easily managed. The assistant gently supports the tumour, whilst the operator spreads the tissues with his thumb and forefinger, and transfixes them with the pedicle needle armed with a long piece of silk doubled on itself. The loop of silk is seized on the opposite side and the needle withdrawn. During the transfixion care must be taken not to prick the bowel with the needle. The loop of silk is cut so that two pieces of silk thread lie in the pedicle. The proper ends of the thread are now secured, and each is firmly tied in a reef-knot; for greater security the whole pedicle may be encircled by an independent ligature, taking care that it embraces the pedicle below the point of transfixion. (I use No. 4 plaited silk for transfixing the pedicle, and a piece of No. 6 silk for surrounding it.)