A System of Operative Surgery, Volume IV (of 4)

n abdominal incision of cystic and solid t

all abdominal gyn?cological operations; they followed as a natural consequence on the establishment of ovari

fact a still-born operation. The pioneers of this operation were undoubtedly Baker Brown and Spencer Wells in London, Thomas Keith in Edinburgh, and Clay in Manchester. These surgeons brought the operation out of a 'slough of despond' and pl

ut left the ligature hanging out of the wound. Doran, who has written an excellent review of this matter, ascribes the intraperiton

adopted with great success by Thomas Keith. The method of ligature is so

are apt to be firmly adherent to the floor of the pelvis. In cases where the abdomen contains free fluid, ascitic or due to the bursting of a cyst, or pus, it is a wise precaution to conduct the early stages of the operation wi

ded because it was regarded as a method making for safety to extract the cyst through a small abdominal incision. Occasionally it is possible to extract the wall of a large single-chambered parovarian cyst, after tapping, through an incision 7 centimetre

e peritoneum was found dotted over with minute nodules furnished with tufts of hair growing among the visceral adhesions. When a woman with an ovaria

hese 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 b

ircumstances 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 impa

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. Mu

quire 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 a

n the depths of the pelvis, involving the uterus, bladder, or rectum, and the separation of these may involve such accidents as wounds

ists of the Fallopian tube and adjacent parts of the mesometrium containing the ovarian artery, pampiniform plexus of veins, lymphatics, nerves, and the ovarian l

in two bundles, so that the inner contains the Fallopian tube, a fold of the mesometrium, and occasionally the round ligament of the u

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

this simple mode of tying the pedicle, he may,

or the stump will slip through the ligature; on the other hand, too much tissue should not be left behind. The stump is seized on each side by pressure forceps, and examined to see that the

everal ligatures are required it is important to remember that the ovarian artery lies in the outer fold of the pedicle and the uterine artery at the inner end

tightly twisted its pedicle, the ligature should be applied

ommon sense must be exercised, and at the present day, when ovariotomy is practised so widely, no one would think

cure, the surgeon examines the opposite ovary,

llected in the recesses of the pelvis. Whilst employed in this wa

he can easily have them displayed before him. The i

eum overlying the cyst is cautiously torn through with forceps until the cyst wall is exposed; then by means of the forefinger the surgeon proceeds to shell the cyst out of its bed, taking care not to tear the capsule or any large vein in its wa

apposition and thus obliterate its cavity; it then requires no further attention. When there is much oozing the capsule is treated on the plan known as marsupialization. The edges of the capsule a

lood than simple ovariotomy; this, and the prolonged

peritoneal exudation which their presence excites. These capsules are often so firm, and so completely encyst the fluid exuded into the pelvis in cases of tubal tuberculosis, that such encapsuled collections of fluid resemble, and are often mistaken for, ovarian cysts. It is also necessary to mention that true ovarian cysts project from, but never invade the

y vomiting, it is incumbent on the surgeon to make a careful examination of the gastro-intestinal tract, for in many of these cases cancer will be found either at the pylorus, or

mary cancer of the gall-bladder and the breast. Some of these secondary c

nto a solid mass of cancer secondary to a focus in the sigm

ection. This is a section of the ovary rep

r sigmoid flexure, and is operable, the growth should be resected and the cut ends of the bowel united by circular enterorrhaphy. In one instance, where the cancer occupied the ile

ork and overcomes many of the difficulties, but finds at last such extensive pelvic adhesions that it is imprudent to proceed further. In such cases he evacuates the contents of the cyst

l of an ovarian cyst or adenoma is left the tumour gradually grows again, or it may suppurate so profusely that the patient slowly dies exhaust

ssion that the tumour was splenic, an ovarian tumour of the right side has been successfully removed through an incision in the left linea semilunaris (R. W. Parker). An ovarian tumour, supposed to be a renal cyst, has been su

said in favour of this procedure, especially if the uterus be large and flabby, because it tends to fall backwards into the pelvis. In such circumstances it is better surgery to remove it than to perform hysteropexy

eon when removing an ovarian tumour to examine carefully the opposite ovary. So many examples are known of women who have borne childr

ution, because intestine may be adherent to it and runs a risk of being wounded. In some instances the cicatrix is very thin,

iotomy the opening may with advantage be made

e submitted to ovariotomy: in such instances it is probabl

ral ovariotomy have subsequently become pregnant. This event has been explained by assuming that in some of the patients a portion of at least one

cysts and tumours classed as ovarian, a list of one hundred consecutive

ta 2 De

a 2 Papi

ata 1 Pa

ts 45 Tubo

omat

es were affected. The three classed as tubo-ovarian were probably exceedingly larg

ere is much variation in them it represents a fair average of the proportions of

they also attain such dimensions in infants and old women as to demand the aid of the surgeon, and with excellent results. Many years ago I collected the recorded c

nd adenomata 4

ids 3

ata 21

encouraging. It is possible that some of the cases described as sarc

ved an ovarian tumour from a girl which weighed 44 kilogrammes: the girl weighed 27 kilogrammes after th

three years of age. It is often stated that Professor Chiene performed ovariotomy on an infa

omy in

Age Resul

r Ref

hs R. Dermoid Trans.

months R. Cyst Lan

Dermoid Deutsche Med.

ermoid Clin. Chir.,

Dermoid Am. J. of Ob

rs of age. Since that date Howard A. Kelly and Mary Sherwood made a collective investigation, and succeeded in obtainin

ears, and the results are remarkable, notwithstanding the circumstance that these women of eight

Women of Eight

Age Resul

rit. Gyn. Soc.

. Brit. Med. Jour

h 81 R. Lancet

Brit. Med. Journ

t. Med. and Surg.

it. Med. Journ.

. Ibid., 18

Trans. Obstet. S

Hospitalstiden

7 R. Lancet,

Trans. Obstet. S

on 85 R. Midd

tion on patient

ation of the cases. In the simple and uncomplicated forms of ovarian cysts and tumours the operation should be almost

d hands would be regarded as a good result. In general hospital work it is probably as high as 10%. Wit

ences of ovarian operations

ere

ure of the Pedicle in Ovariotomy. St. Barth

th Ovaries for Cystic Tumour. Trans.

astatic) Carcinoma of the Ovaries.

the Ovary. Ibi

région lombaire, l'autre par le devant de l'abdomen; adh

Ovarian Cyst. Brit. Med

er anum. Wiener Klin. Wo