Albert J. (Albert John) Ochsner.

A new manual of surgery, civil and military online

. (page 72 of 94)
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The cystic fluid. The fluid contained in these cysts may vary in color
from a perfectly clear, limpid, to a yellow or dark-colored kind. The latter
color is usually the result of a hemorrhage into the cavity of the cyst and
ordinarily occurs in those which have been subjected to some form of trau-


matism, such as a blow upon the abdomen. Cysts which have previously
been tapped frequently contain dark-colored lluid because of some hemorrhage
which has taken place into the cavity through the wound made ui tapping.
Many cysts contain a thick, gelatinous lluid, which, however, is present usually
only in case the lining of the cyst has undergone papillomatous degenera-
tion. The substance may be so thick that it cannot be forced through a
trocar, and then the abdominal wound will have to be enlarged so that tlie
tumor may be removed entire. This gelatinous fluid often contains cells
which may give rise to the formation of secondary growths upon the peritoneal
surfaces, consequently it is wise not to permit any of it to get into the free
peritoneal cavity.

The clear fluid contained in ovarian cysts is sterile and harmless, and
its introduction into the peritoneal cavity does not result in any harm to
the patient.

After the removal of the contents to a sufficient extent to cause the cyst
wall to become less tense the same may be grasped in forceps and drawn
partly out through the abdominal wound, thus protecting the free peritoneal
cavity against the introduction of any fluid. After the cyst has become
entirely empty it may be withdrawn through the abdominal wound and its
pedicle, consisting of the broad ligament and the Fallopian tube, may be
transfixed and ligated with catgut or fine silk, and then the tumor may be
cut away, care being taken to leave a sufficient amount of pedicle beyond
the ligature to prevent slipping.

Throughout the operation there should be as little unnecessary disturbance
of the tissues as possible.

The stump which is left after cutting away the tumor may be covered with
peritoneum by means of a few catgut stitches. It is supposed that this will
prevent the forming of adhesions with the intestines, but we believe that after
an aseptic operation, in which no traumatism is inflicted upon any of the
surrounding tissues, such adhesions practically never occur even if the stump
is not covered with peritoneum ; while they do occur, notwithstanding this
covering, provided the operation is septic or traumatism has been caused to
the tissues.

If the cyst is multiple, composed of many small cysts, the trocar may
be carried from one to the other of these without being withdrawn from
the original puncture, provided these separate cysts are large enough to
make such practice feasible. If the cysts are too small it is better to enlarge
the abdominal wound sufficientlj^ to permit the removal of the tumor in toto.
This should also be done in case of a papillomatous cyst, or one containing
fluid too thick to be forced out through the trocar. The pedicle of such
cysts should be tied and the tumor removed in the manner described for
the removal of simple cysts.

It is wise always to examine the opposite ovary at the time of operation,
because it frequently happens that the second ovary contains a small cyst
which, if left undisturbed, will enlarge and require a second abdominal sec-
tion. Should the fellow ovary contain cysts of any size in a patient over
forty years of age, it is wise to remove the entire organ, together with the
Fallopian tube, according to the method described. In a younger patient
it is usually better to leave at least one-fourth or one-half of the ovary, mak-
ing a concial excision of the diseased portion and closing the surface caused
by this excision by means of fine catgut stitches. This will insure the nor-
mal functions of the ovary, which is of great importance to a young patient.
It is well in these cases to examine the vermiform appendix, because
remnants of disease may exist in this organ indicating its removal, which


can be accomplished without danger to the patient, according to the methods
described in the section devoted to appendicitis.

The abdominal wound is closed in the usual manner, care being taken
to unite corresponding layers. ^ ^ . . ,

It is our practice to split the inner fascia of the rectus abdominis muscle
on each side and to unite the wound by inserting deep silk-worm gut sutures
grasping the layers down to the transversal is fascia, and then applying a
separate row of continuous catgut sutures to the peritoneum and trans-
versalis fascia, uniting the recti muscles with a few interrupted catgut sutures ;
then uniting the deep fascia, the aponeurosis of the external and internal
oblique muscles, by means of a continuous catgut suture; then tying the
silk-worm gut sutures and applying a row of coaptation stitches to the skm,
as illustrated in suture of the abdominal w^ound elsewhere herein.

Complications. The most common complication of ovarian cysts affecting
the method of operation is the presence of adhesions. These may exist between
the ovarian cyst and any one or more of the intra-abdominal organs. The
most common adhesions are to the omentum, the anterior abdominal wall,
and to the intestines. It does not matter to what portion an ovarian cyst
may be adherent, it is always wise to expose the adhesion before an attempt
is made to dispose of it, because although it may occasionally become neces-
sary to lengthen the abdominal incision for this purpose, still this is of slight
importance as compared to the benefit the patient derives from having this
portion of the operation performed in plain sight. These adhesions fre-
quently contain very large veins and their injury results m a great loss of
blood, which is in itself undesirable and complicates the operation by cover-
ing the tissues so that they can be recognized with less ease. It is usually
best to grasp long adhesions between two pairs of forceps, to cut between
these and to ligate the portion which is not connected with the ureters, and
then 'drop the adhesions into the abdominal cavity. If the adhesion is to
the intestine or other abdominal organ it is usually possible to select a point
at which these tissues can readily be separated from each other, because
there seems to be a union between the peritoneal surfaces which is not farm
and can easily be disturbed if one succeeds in finding the point of cleavage.
It is well to cover at once with peritoneum any abraded surface which is
caused by this separation, so as to prevent future adhesions. This is espe-
cially important if the abraded surface is on the intestine. If this precaution
is not observed a perforation may readily occur.


Principles. The removal of the uterus is in itself one of the simplest and
safest abdominal operations in cases in which the condition for which the
operation is performed is not connected with troublesome complications. The
success of the operation depends upon the appreciation of a few exceedingly

In this operation, as in every other abdominal one, the first principle is,
of course the prevention of infection. This may be accomplished very easily,
as the only source of infection connected with the operation itself is the
uterine canal, and infection from this may easily be avoided with care.

The next important point to be observed is the control of hemorrhage.
The uterus is supplied with blood by two small arteries on each side ; the
ovarian approaching it through the upper part of the broad ligament on
each side, and the uterine artery approaching it from each side lower down.
These vessels are ordinarily not larger than a good-sized knitting needle
and are consequently of no importance, provided they are recognized and



carefully ligated. The method to be employed for the control of hemorrhage
will depend upon the choice of plan for removal; with the uterus, the Fallo-
pian tubes and ovaries, which is always indicated in patients over forty
years of age ; or the removal of the uterus without the ovaries and tubes,


Abdominal Hysterectomy.

a uterus; 6 forceps on broad ligament; c Fallopian tube; d forceps on uterine side of
broad ligament; e forceps on ovarian side of broad ligament; / bladder; i round ligament;
o ovary.

indicated in younger patients in whom these organs in themselves are not

Technique. If the ovaries and tubes are to be removed with the uterus, two
pairs of long-jawed, strong hemostatic forceps should be applied to the broad
ligament, side by side, just externally to the ovary. They should extend par-
allel to each other with a space of one-half to three-fourths of an inch between



them. The points of these forceps should extend to the body of the uterus.
This should be done alike on both sides ; then the tissues between these for-
ceps is severed and the uterus, ovaries and tubes, grasped by the two pairs
of forceps which are nearest together, can be elevated. The broad ligament


Abdominal Hysterectomy.

b posterior flap of uterine stump; c anterior flap of uterine stump; d forceps on uterine
artery; e forceps on broad ligament; / bladder; i round ligament; j peritoneal flap for cover-
ing stump of uterus; g colon. The suture grasping tissues b and c should be peritoneal flap
/ instead.

is then severed farther down toward the cervix, until the uterine artery is
exposed. This is grasped by a separate pair of forceps on each side; then
the peritoneal flap is cut from the anterior surface of the uterus and dissected
downwards until a point opposite the internal os is approached. The uterus
is then cut away by means of a conical incision. This leaves the mucous



membrane lining the cervix at the bottom of a conical space. It is necessary
to exercise great care in cutting down upon the uterine arteries in order to
approach them on each side of the body of the uterus after they have escaped
from the broad ligaments. If this precaution is not taken there is danger

Abdominal Hysterectomy.

b suture closing in entire surface with peritoneum ; c Fallopian tube ; / bladder ; j flaps
of uteru!^; g colon; o ovary. To the right the plate shows the ovary and tube removed; to
the left they have been preserved.

of injuring the ureters, which pass through the broad ligament near this

If the operation is performed for the removal of a myomatous uterus
great care must be taken in making the anterior peritoneal flap, because it
frequently happens that the bladder is carried a considerable distance up
over the anterior surface of such a uterus, and if care is not exercised in
performing this part of the operation this organ is likely to be injured.


It is necessary to be careful in sponging the surface of the uterine stump
not to carry any infectious material in the mucous membrane lining this
stump to other portions of the abdominal cavity, thus causing infection.
For the same reason it is "well to eliminate this remnant of the canal from
the operation by applying catgut stitches to unite the sides of the conical
cavity which has been formed. It is this part of the operation which should
be done with especial care, because most deaths occurring after abdominal
hysterectomy are due to gangrene of the uterine stump, which results from
a faulty application of the sutures. During the early practice of this opera-
tion surgeons were taught to fear hemorrhage following hysterectomy, and
consequently most of the older surgeons acquired the habit of tying the
sutures applied to the stump so tightly as to make gangrene thereof a very
common occurrence. These sutures, and, in fact, all of the sutures uniting
the surface in hysterectomy, should be tied just sufficienth^ firm to bring
the surfaces together, but not so firm as to cause pressure-necrosis. (The ob-
servation of this precaution in our own practice has reduced the mortality in
abdominal hysterectomy to almost nothing.)

During the past few years we have abandoned the plan of suturing
the tissues of the uterine stump and have simply covered this stump by apply-
ing fine catgut sutures to the peritoneum, thus carefully covering the raw
surface of the stump. In this way the danger from pressure necrosis of
the part is entirely eliminated and the operation becomes as safe as a simple
ovariotomy or appendectomy.

The broad ligament is now transfixed with a catgut or fine silk stitch
and ligated on each side, care being taken to apply this ligature so that
there is no possibility of slipping. Then a stitch is placed around the uterine
artery on each side and tied only just firm enough to prevent hemorrhage.
Then it is our practice to apply a separate ligature to the end of the uterine
artery grasped by the forceps on each side. This does not seem necessary,
but we continue to do this as a result of the old superstition concerning the
likelihood of hemorrhage.

The entire wound should now be sutured from side to side, so that every
portion is covered with peritoneum. This completes the very simple opera-
tion ; the four points to be borne in mind being :

1. The avoidance of infection.

2. The protection of the ureters and bladder,

3. The careful control of hemorrhage.

4. And (most important of all) the prevention of gangrene of the stump
by avoiding too firm tying of sutures.

In order to prevent this most serious complication we now never pass
sutures through the muscle of the uterine stump but simply cover the stump
with peritoneum from the loose portion in front which is sutured to the peri-
toneum on the posterior surface. If the uterine arteries have been ligated
as indicated above there is never any danger from hemorrhage and these
patients make quite as smooth a recovery as after a simple ovariotomy.

In order to obtain a good floor of the pelvis which will prevent prolapse
of the stump we suture the ends of the broad ligaments and those of the
round ligament over the stump, thus making a perfect truss for the sup-
port of the pelvic floor.

The sutures used are ordinary catgut reinforced by a few of fine chromic
catgut for the broad and the round ligaments.

In case it is desirable to remove the ovaries and tubes the operation
is done in the same manner, with the exception that the control forceps
are applied to the broad ligament directly along the side of the uterus, leav-
ing the ovaries and tubes to the outer side of the other forceps.




If it is difficult or impossible to apply the forceps to the broad ligaments
because of the presence of tumors or adhesions, or both, conditions which
occur occasionally, the operation may be greatly facilitated by inserting a
strong pair of tenaculum forceps in each horn of the uterus, having an assist-

Eadiograph of Female Pelvis.

" A " and " B ", calcareous myomata of the uterus. " C '
careous iliac lymph gland.

calcareous ovary, " D " cal-

ant make firm traction upon these, and then splitting the uterus longi-
tudinally down to a point opposite the internal os. The tension upon the
forceps in the horns of the uterus prevents hemorrhage from the cut sur-

Of course, the same precaution must be used against injuring the blad-
der on the anterior surface of the uterus, if it extends above the normal posi-
tion, that was mentioned in the operation just described.

When the internal os has been reached a slight lateral incision is made on


one side to a point at which the uterine artery is exposed. The broad liga-
ment, together with the uterine artery, is then grasped from below by means
of strong forceps, and the uterus is cut away to the inner side of these
forceps. Another pair of tenaculum forceps is inserted in the lower end of
the half of the uterus under consideration, and tension made upon this, as
well as upon the tenaculum forceps in the horn of the uterus on this side.
Care must be taken not to relax upon the other pair of tenaculum forceps'
for fear of causing a hemorrhage upon the half of the uterus not immediately
under consideration.

After the lower end of the uterus has been loosened it is an easy matter
to grasp the remaining vessels in the broad ligament by means of clamps,
and remove the half of the uterus together with the tumor it may contain.
If the Fallopian tube or ovary are also in a pathological condition they can
readily be removed with this portion of the uterus. The same steps are taken
upon the opposite side.

After the uterus has been removed the vessels are ligated precisely as
in the operation which has just been described. The stump of the uterus
is disposed of in the same manner, and, in fact, the remainder of the opera-
tion is in no way different from that which has just been outlined.

Adhesions. If there are adhesions between the uterus, or the ovaries and
tubes, and some other abdominal organs, these must be loosened with great
care and all bleeding points properly ligated, and all abraded surfaces care-
fully covered with peritoneum by means of Lembert sutures. Especial pains
must be taken in covering large abrasions upon the small intestine, due to
the necessity of loosening extensive adhesions. Whenever possible it is wise
to make transverse closures of these abraded surfaces for fear of causing
a narrowing of the small intestine, Avhich, however, is not very likely to
occur because of the elasticity of the peritoneum. If any abraded surface
in the pelvis cannot be covered with peritoneum it is wise to place the sigmoid
flexure upon this surface, and, if necessary, to fasten it by a few fine catgut
stitches. The abdominal wound is closed in the usual manner.


Generally speaking it is proper to make a hysterectomy for any cases
of fibroid tumor of the uterus in patients of forty j^ears of age or over, in
whom this operation seems to require the least amount of traumatism. In
younger patients, whenever possible, the excision of fibroid tumors of the
uterus, without the removal of the uterus itself, should be practised, even
though the operation be connected with greater difficulty and with greater
traumatism. It is surprising how easily fibroid tumors may be enucleated
from the uterus even when deeply-seated, and if traction is made upon the
organ this operation is not connected with much hemorrhage.

If the tumor is in the superior portion of the uterus the transverse incision
should be made and the tumor enucleated. Here again the same principle
should be applied that has been mentioned in connection with the closure
of the stump in abdominal hysterectomy. The space from which the tumor
has been removed should be closed by means of fine catgut sutures which
are tied just firmly enough to bring the surfaces together, but not sufficiently
firm to cause pressure-necrosis. As many rows of these sutures as are required
to close the entire cavity should be employed; their number is of no special

AA^hen the outer wound in the surface of the uterus is reached it is impor-
tant to extend the suturing a little beyond each end of the wound, because


this will overcome the troublesome oozing which frequently occurs from the
very ends of the incision.

If the uterine cavity is opened during the operation, it should be care-
fully sponged or curetted and a folded piece of rubber protective tissue
passed through the uterine canal into the vagina for the purpose of drainage.
In this case the first row of sutures should pass down to, but not through, the
mucous membrane, for fear of infecting the deeper tissues in the uterus.
The danger of infection from the uterine canal in these cases has been
greath' over-estimated, and we believe that in eases in which there has
apparently been such an infection it has resulted from the fact that the
sutures which were applied for the purpose of protecting the wound in the
uterus were tied too firmly and gave rise to pressure-necrosis. In case a
large fibroid has developed in the broad ligament, so that after its removal
there remains a large raw surface, this should be covered with peritoneum,
but if the uterine cavity has been opened during the operation, or if the
rectum or the sigmoid fiexure have been disturbed, it is best to insert a small
glass drain or a cigarette drain into the angle of the broad ligament next
to the uterus and to permit this to pass out of the lower angle of the abdom-
inal wound. It may be removed in two to five days.


Clinical example. This is typical of the disease under consideration. The patient is
twenty-three years of age, married fourteen months, and gives the following history:

She suffered from mild attacks of all the contagious diseases of childhood, but experienced
no unfavorable after-effects. Menstruation began at the age of fourteen, was regular and
painless, and the patient 's health was excellent until a short time after her marriage, when
she suddenly experienced severe pain in the lower portion of her abdomen. She had previously
observed the presence of leucorrhea and a mihl attack of cystitis, to which she gave no atten-
tion. After remaining quiet for two days, taking hot douches and a cathartic and applying
heat to the abdomen, the pain subsided and she was able to be up and about, but since that
time she has never felt perfectly strong and well. Her next menstrual period was characterized
by severe pain, lasting for two days and leaving her slightly worse than before. She felt
feverisli during the entire period of menstruation. She has continually grown worse, sutt'ering
from severe pain every few days, and during each successive menstrual period having an
attack more severe than the preceding. During the past two months she has scarcely recovered
from the effects of one attack before experiencing the next. At the time of her marriage she
was strong and vigorous and in every way in excellent health.

Present condition. Anemic, somewhat emaciated, having lost twenty pounds during the
past yjar. Her appearance indicates that she has suffered severely. Skin is rough and her
color is bad.

Physical examination. All organs, with the exception of the pelvic, are normal. A pelvic
examination reveals the presence of severe induration throughout the pehic floor. In the
left broad ligament there is a mass as large as a man's fist. The right broad ligament contains
a mass about one-half as large. The cervix of the uterus is enlarged to twice the normal size;
it is hard and edematous. Bimanual examination seems to reveal a slight amount of fluctuation
in the left side.

Upon rectal examination there is found an indurated area opposite the cul-de-sac of
Douglas, which renders this portion of the bowel quite rigid. The patient complains severely
of pain during l)oth the rectal and vaginal examinations. Upon bimanual examination the
abdominal muscles contract to protect the inflamed tissues underneath.

Diagnosis. The history, as well as the physicial investigation, indicate
the presence of an infection involving the uterus. Fallopian tubes and pelvic
peritoneum. This is undoubtedly gonorrheal in origin, because of the time
of its occurrence, the presence of leucorrhea and cystitis, and the physicial

Upon inquiry we have determined that the husband suffered from an
acute specific urethritis two years ago, from which he recovered after four
months, but that he occasionaly noticed a sliorht amount of secretion after
some indiscretion in diet or over-exertion. About one week after his mar-


riage he noticed a slight recurrence of this condition, which, however, disap-
peared after a few days.

It is likely that the infection advanced slowly through the uterine canal
and through the Fallopian tubes and that the fimbriated extremities of the
latter organs have become adherent to the ovaries and thus become occluded,
and that pus has accumulated in the distended Fallopian tubes.

The patient has received local treatment almost constantly since the begin-
ning of her illness, by means of hot douches, the application of tincture of
iodine and nitrate of silver to the uterine canal and the cervix, and by the
application of vaginal pads saturated with glycerine and ichthyol; but none
of these remedies has been of any permanent benefit.

Medical treatment. During the early part of the disease it is best to make

Online LibraryAlbert J. (Albert John) OchsnerA new manual of surgery, civil and military → online text (page 72 of 94)