different layers of tissue described with so much precision in the
textbooks. On the contrary, all that one needs is to know when the
knife is approaching the peritoneum. An excellent landmark is the thin
layer of fat overlying the peritoneum. So, after pinching up the
abdominal wall to estimate its thickness, the surgeon can boldly cut
down through the skin and its underlying fat, but somewhat cautiously
through the aponeurotic structures until the second layer of fat is
reached. Practically, therefore, he need regard but the following
layers: skin with its underlying fat, the intermediate tendinous or
muscular structures, the supra-peritoneal fat, and the peritoneum.
Before the abdominal cavity is opened all bleeding is stopped by the
use of pressure-forceps, of which one dozen will sometimes dangle from
the wound. When the hemorrhage has been wholly stayed, and not until
then, the peritoneum is hooked up by a delicate uterine tenaculum and
nicked open. On a broad grooved director or on the finger this opening
is slit up for a distance of about two inches, either by a {323}
right-angled pair of scissors or by a probe-pointed bistoury. A little
serum usually escapes and the nacreous wall of the cyst comes into
view. This is called an exploratory incision, for by it the diagnosis
is confirmed, the presence of adhesions ascertained, and the
possibility of completing the operation determined. When it has been
decided to go on with the operation, more working room will be needed,
and the wound is therefore enlarged by the scissors, the finger being
used as a guide to prevent injury to the omentum or to any chance
knuckle of bowel that may lie in the way. The size of the incision will
depend upon the character of the cyst and on the number of its
adhesions. Hence it may range from a length of three inches to the
distance from ensiform cartilage to symphysis pubis. An incision
contained between the umbilicus and symphysis pubis is technically
called a short incision, and one extended above the umbilicus a long
incision. Should it be found needful to prolong the wound to a point
above the umbilicus, the incision is usually carried to the left of the
navel and brought back in a curved line to the linea alba. This is done
to avoid the round ligament of the liver and its vessels, which come in
there from the right side. Keith, however, cuts directly through the
navel; and I find this straight incision to be superior in every
respect to the curved one. Other things being equal, the short incision
is safer than the long one; but it is a good rule to have an opening
large enough for easy manipulation and for the easy withdrawal of the
cyst. For instance, a large monocyst without adhesions after being
emptied can, like a wet rag, be pulled out, hand over hand, through a
very small opening, whereas a much smaller polycyst, which cannot be
wholly emptied, and which is more or less adherent, will need a long
incision. I once removed an oligo-cyst weighing one hundred and twelve
pounds through an incision barely admitting my hand; while I had to
open the abdominal cavity from ensiform cartilage to symphysis pubis in
order to remove a solid ovarian fibroid tumor weighing but eighteen
pounds. Both patients recovered, but the chances were, of course, more
against the woman with the long incision. To avoid the escape into the
abdominal cavity of any blood from the wound, and to prevent the
soiling of the operator's hands, a clean napkin wetted with the
carbolated water is doubled over each edge of the incision.
Whenever the cyst-wall in the line of the incision is glued by
adhesions to the parietal peritoneum, the latter is liable to be
mistaken for the former, and accordingly to be stripped off from the
abdominal wall. To avoid this very serious error, either proceed with
the cutting until the cyst-wall unmistakably comes into view or is
opened, or else extend the incision upward until a point is reached
where the cyst is free from adhesions. Adhesions binding the cyst to
the abdominal wall are of importance only from the troublesome oozing
their rupture often gives rise to. To lessen this risk, they are to be
sundered by the finger whenever possible. Should the scissors be used,
the adhesion bands must be snipped close to the surface of the cyst,
and not to that of the abdominal wall. Thus, a free end is gained,
which may, if needful, be subsequently tied or in which the dangling
blood-vessels may the more readily constringe. All thick and long bands
of adhesion should be tied in two places and be divided between the
ligatures. These ligatures should consist either of very fine silk or
of gut. For isolated vessels the latter {324} are the better ones, but
the silk is more suitable for tying en masse a group of bleeding
vessels or for pursing up an oozing surface by an in-and-out stitch. A
very important rule, on the observance of which one's success greatly
depends, is, never to let a bleeding point or an oozing surface get out
of sight. It must either be ligatured at once, or else caught by
pressure-forceps and tied later if needful. If the delicate omental
apron be found glued to the cyst, it should be carefully detached with
as little tearing and splitting as possible, for each shred will bleed,
and so will the fork of the split. It should then be turned out of the
abdominal cavity on a clean napkin wetted with the carbolated solution.
If its bleeding vessels be few, each one may be tied with gut; but if
they are many, the torn portion of the omentum should be tied en masse
or in sections, and the ligatures cut off close to the knot. All shreds
and ragged ends of omentum must be trimmed off, and it is then returned
to the peritoneal cavity.
When all the adhesions within reach, and those that do not demand great
force, have been severed, it will be time to tap the cyst. This should
be done with a large-sized trocar, such as Wells's, which is furnished
with spring teeth to prevent it from slipping out of the cyst. Any
trocar will do, provided it has a large bore, so that the vent may be
free and that none of the acrid fluid can escape along its side into
the abdominal cavity. In order to save time, neither Schroeder nor
Martin use a trocar. They incise the cyst, and try by pressure and the
lateral position to direct the contents externally. Frequently,
however, some of the fluid escapes into the abdominal cavity, but they
contend that if antiseptic precautions be taken no harm accrues.[51]
Although dissenting from this opinion, I must confess to having had the
contents of the cyst escape repeatedly into the abdominal cavity
without doing any harm whatever. Always tap at the upper angle of the
wound, because as the cyst collapses the trocar is drawn downward
toward the lower angle. Hence, were the trocar entered low down it
could not travel with the collapsing cyst, which would therefore slip
off. While the fluid is flowing flat sponges should be packed in
between the abdominal wall and the cyst, and the edges of the incision
should be pressed firmly against them, so that the peritoneal cavity
may not receive a single drop of that which frequently escapes along
the side of the trocar. To avoid this accident--which, without being a
very serious one, is yet not to be invited--some ovariotomists before
tapping turn the woman well over on her belly and over the edge of the
table; but this is liable to cause a protrusion of the bowels; which
is, in fact, a more dangerous accident than the entrance of some of the
fluid into the abdomen. Rosenbach, indeed, reports that during the
extraction of biliary calculi through an abdominal incision a cure
resulted, although several calculi were lost in the peritoneal
cavity.[52] Should the mother-cyst not collapse on account of its
containing a few other large cysts, the point of the trocar, without
being withdrawn, can be made to enter each one. But if the child-cysts
are many and small, the trocar is withdrawn, the opening enlarged, its
edge seized by several pressure-forceps, and the hand introduced to
break up these cysts.
[Footnote 51: _Berlin. klin. Wochenschrift_, 1883, No. 10.]
[Footnote 52: _Medical News_, Feb. 3, 1883, p. 130.]
Before this hand can again be used for separating adhesions it must be
{325} carefully cleansed with soap, and dipped into the carbolated
solution in the tray of instruments.
The empty cyst is next gently pulled out through the abdominal wound.
It is, however, so slippery that this cannot ordinarily be done with
the hands alone. A strong forceps with a firm grip is needed, and one
of the best is Nélaton's. While the cyst is being withdrawn the bowels
are sheltered from the air and the spray by one large flat sponge, and
the abdominal cavity must also be packed with smaller ones at every
exposed point; and one of them should always be placed between the womb
and the bladder.
In the majority of cases there is not much difficulty in freeing the
cyst from its ordinary attachments and in reaching its pedicle. But
should adhesions bind the cyst to the adjacent viscera, matters will
not go on so smoothly. Such adhesions to bladder, liver, bowels, or to
other important organs sometimes present difficulties which are
insurmountable. The problem here is to sever these bands of adhesion
without injuring the viscera to which they are attached. When these
adhesions are numerous or very firm, much advantage will be gained by
having the assistant put his hand within the cyst and stretch its wall
while the operator severs the adhesions over it. By this means the
adhesions can be better broken off close to the cyst, which is the
all-important course to pursue in visceral attachments. Sometimes it
will be needful to peel off the outer and non-secreting layers of the
cyst and leave them behind--sometimes to cut off the adherent portion
of the cyst and scrape off or strip off the secreting surface. Whenever
the stalk of the tumor can be reached before all the adhesions are
severed, it will be well to catch it with one or two pressure-forceps,
or even to tie it and cut it off between two ligatures, like the
umbilical cord. This will prevent bleeding from the torn surfaces of
the cyst. When the cyst is closely adherent to the edges of the
abdominal incision, either extend the wound upward until a free point
is reached, and work downward on the adhesions, or else cut into the
cyst, empty it, and seize with strong forceps its inner surface just
beyond where the adhesions begin. The sac is then inverted by traction,
which will break up its adhesions to the abdominal wall, the last
portions to be freed being those attached to the edges of the incision.
This prevents the stripping up of the peritoneum. Should the appendix
vermiformis be so adherent to the cyst as not to be detached, it must
be ligated in two places, between which it is to be cut, in order that
its contents may not escape into the abdominal cavity. The fecal plug
in each distal end should also be carefully squeezed out. Double
ovarian cysts sometimes fuse together, and, rupturing at the point of
fusion, form apparently one cyst. Such a cyst will have two pedicles,
and will be very puzzling to the inexperienced operator.
When the cyst has been freed from its attachments and turned out of the
wound, the very important question comes up of the treatment of the
stalk or pedicle. Shall it be secured by a clamp? shall it be burned
off by the actual cautery? or shall it be tied, cut off, and dropped
back? The first is called the extra-peritoneal method; the others, the
intra-peritoneal. For many years the clamp claimed the most advocates,
but it has lost ground on account of possessing the following
disadvantages: By keeping the wound open it prevents a strictly
antiseptic treatment; {326} the stalk sometimes sloughs below the line
of constriction and conveys putrilage into the abdominal cavity; the
stalk always becomes united to the abdominal wall, hence when it is
short the womb is dislocated or it is too much dragged upon. Then,
again, in one-third of the cases the oviduct has a trick of remaining
open, and the woman will menstruate indefinitely from the abdominal
cicatrix. This is owing to the fact that the clamped portion sloughs
off too early for a firm plug of cicatricial tissue to be formed, and
the oviduct is therefore liable to stay open. In my first case of
ovariotomy this happened, and one year later the cicatrix degenerated
into a malignant growth which destroyed the life of my patient. It is,
however, probable that in this instance the cystic disease of the ovary
was malignant, although the sac did not look so at the time of its
removal. Another disadvantage arising from the use of the clamp is the
subsequent weakness of the cicatrix at its site, and the liability of
ventral hernia to form there. These are the objections to the clamp,
and they are so valid that at the present time all distinguished
ovariotomists have abandoned its use.
The actual cautery, performed by Paquelin's instrument or by
platinum-tipped irons, which do not scale off or discolor the tissues,
is theoretically the very best way of dealing with the stalk. No
foreign body besides the charred portion of the stalk is left within
the abdominal cavity; but, on the other hand, it cannot always be
trusted to close the vessels. On this account it is looked upon with
disfavor by all ovariotomists with the exception of Keith. His method
is as follows: The pedicle is spread out evenly within Baker-Brown's
clamp, so as to get equable compression. The cyst is cut off, leaving a
stump about an inch in height above the clamp. To protect the parts
from heat a folded napkin wetted in the carbolated solution is tucked
under the clamp. The stump is next carefully dried, and then burned
slowly down to the level of the clamp by wedge-shaped cautery-irons at
a brown heat. They give off a whistling sound during the process. The
thick end of the stump can be more quickly burned down, but the thin
end should be burned very slowly, and the blades of the clamp by
prolonged contact with the cautery-iron must also be made hot enough to
dry up and shrivel that portion of tissue which they compress. In order
not to disturb the stump after it has been cauterized, it is best to
clean out the peritoneal cavity first, and to leave this treatment of
the pedicle for the last thing. Before removing the clamp, which is to
be unscrewed very slowly and carefully, one side of the pedicle is
seized by a pressure-forceps, by which it is kept in sight and out of
harm's way if the peritoneal cavity needs further cleansing.
The plan of treating the pedicle most in vogue, and the one which I
adopt, is that of the ligature--one of fine carbolated silk, the finest
compatible with safety. The ends are cut off close to the knot, and the
stump is dropped into the peritoneal cavity, where the silk, being
animal tissue, will in time become disintegrated and absorbed. Now,
when I say silk, I mean silk, and not silver or gut ligature. Silver,
being inelastic, cannot bind a shrinking stalk, while the gut is a
treacherous ligature, and will sooner or later bring one to grief. It
slips in the tying, it is liable to untie, it gives instead of
shrinking, and it is too short-lived for the obliteration of large
vessels.
{327} The reasonable objection has been urged that since the abdominal
cicatrix left by the use of the clamp is liable to reopen every month
to give vent to menstrual fluid, the same phenomenon will by this
intra-peritoneal method happen within the abdominal cavity and expose
the woman to all the risks of a hæmatocele. But fact is here opposed to
theory, for it has been found that either the oviduct in the stump
atrophies into an impervious cord of fibrous tissue, or that its raw
end, by contracting adhesions with the surrounding tissues, becomes
hermetically sealed. It might also be supposed that the distal end of
the ligatured stalk would slough and expose the woman to septic
peritonitis. But such sloughing rarely happens, and for the following
reasons: From shrinkage of the stump the constriction is lessened, and
the capillary circulation is re-established; or the peritoneal surfaces
on each side of the narrow and deep gutter made by the fine silk will
bulge over and touch one another. Adhesion then takes place between the
two, and the blood-vessels which shoot over from the proximal or
uterine side of the ligatured stump will carry life into the distal
end; or lymph exuded by the irritation of the ligature will throw a
living bridge across the gutter in the stalk; or, what is the least
desirable, the raw end of a long stalk glues itself to any peritoneal
surface with which it may come in contact. I say least desirable,
because sometimes such an adhesion makes a kink in the bowel, and may
so constrict it as to give rise to fatal obstruction. To prevent this
accident, Thornton stitches with gut the raw end of the stump to the
broad ligament, to which it adheres; while Bantock catches it up out of
harm's way by including it in the lowest abdominal suture, which, being
of silkworm gut, can be left in for a long time. If the stump be short,
it stands upright, and does not then need this treatment.
If the stalk be a thick one, it is transfixed by a blunt needle
threaded with a double ligature, and is tied on either side, each half
by itself, and then the whole is further tied by the free ends of one
of the ligatures, or the Staffordshire knot, recommended by Tait, may
be used. If it be a broad one, it is tied in three or more sections by
cobbler's stitches. In thick or in broad stalks it is a good plan to
catch the stalk in Dawson's clamp, which compresses it circularly, and
to transfix and tie it in the furrow made by the clamp. This lessens
the risk of secondary hemorrhage, which is usually caused either by the
slipping off of the ligature or by its loosening through
tissue-shrinkage. When this clamp is used the pedicle need not be tied
until the wound is ready to be closed. The stalk must be cut off at a
distance from the ligature of not less than three-fourths of an inch,
so as to leave a button of tissue sufficiently large to prevent the
loops from slipping off. In short and broad stalks the outer or broad
ligament portion, which is thin and membranous and sustains most of the
tension strain, is liable to slip out of its ligature and cause a fatal
hemorrhage. To avoid this accident the ends of the corresponding
ligature may, before being tied, be repassed in opposite directions
through the stalk very near its margin to form the cobbler's stitch.
Another way is to pass a fine silk thread through the thin portion of
the stalk about one-third of an inch from its edge, and tie it. In the
notch thus made, and below the knot, is laid and tied the outer
ligature.
In anæmic cases Thornton ties the arterial side of the pedicle first,
but in young and vigorous women he ties the venous side first, so as to
{328} deplete the woman by gorging the tumor with blood. While cutting
off the cysts the abdominal cavity must be so protected by sponges that
not a drop of blood shall fall into it. A dilated oviduct in the
pedicle tends to suppurate; hence in such a case the ligature should be
applied as close to the womb as possible, so as to get below the
expanded portion. Before the cyst is cut away the pedicle should be
seized on one side by a pressure-forceps, and kept more or less in
sight until the wound is ready to be closed up. This will also prevent
the ligatures from being rubbed off by the sponges while the abdominal
cavity is being cleansed.
Sometimes the cyst has no stalk, but lies between two folds of the
broad ligament, or else it is bound to the bladder, womb, and the
pelvic tissues by intimate adhesions which cannot be safely severed.
Formerly, under such circumstances the abdominal wound was hastily
closed up and the case abandoned. Now, thanks to Miner of Buffalo, New
York, we can fall back on enucleation, and need rarely be foiled.[53]
This operation is performed by slitting open the peritoneal capsule of
the sac at points close to its attachments, by introducing one finger
or more into the opening, and by stripping off this serous and vascular
envelope up to where the vessels enter the cyst-wall and become
capillary. The artificial stalk thus made is to be treated precisely
like a natural one--that is to say, by clamp, ligature, and cautery,
or, if it does not bleed, by nothing whatever. This operation I have
repeatedly performed, but it is seldom easy, and is always anxious
work. Should the cyst be so wholly adherent to the viscera as not to be
even enucleated, an incision is made into it. It is then emptied,
thoroughly cleansed, and the child-cysts are also crushed by the hand.
The edges of the opening thus made in the sac are now included in the
stitches of the abdominal wound, but the latter is kept open either by
a large cloth tent at the lower angle or by two glass drainage-tubes,
one at each angle running down into the sac. Sometimes it may be
needful to tie the adherent portion in sections and to cut the free
portion away. A drainage-tube must then be inserted at the lower angle
of the wound. This expedient has the sanction of Atlee and Olshausen,
who have reported successful cases thus treated.[54] My own practice in
such cases would be, after breaking up the child-cysts, to gather
together the free portion of the cyst and bring it out at the lower
angle of the wound. A short nickel-plated steel drainage-tube of large
bore is inserted, the sac firmly clamped to it by a small wire
écraseur, and the redundant portion cut away. Into this metal tube is
passed a glass drainage-tube long enough to touch the lowest portion of
the sac.
[Footnote 53: _Transactions International Med. Congress_, 1876, p.
801.]
[Footnote 54: _Monthly Abstract_, July, 1877, p. 334.]
In such cases, when feasible, I think it would also be well to adopt
Freund's plan of tying the pedicle and severing it, in order to lessen
the blood-supply to the cyst.[55]
[Footnote 55: _Boston Med. and Surg. Journal_, Aug. 24, 1876, p. 219.]
The sac having been removed, the other ovary should be examined, and,
if diseased, be tied and cut off. From the sundered bands of adhesion
more or less bleeding has been taking place, which must now be attended
to. It can usually be stopped by pressure with a sponge or with a
finger, or with sponges wrung out of very hot carbolated water. For
single vessels torsion will usually succeed, but if it does not, fine
{329} carbolated silk or gut ligatures must be used; and it is
wonderful how many can be applied without materially compromising the
safety of the woman. I once tied over thirty vessels in a lady
sixty-eight years of age, who recovered without any symptoms of
peritonitis. The free ends of the ligatures should always be cut off
close to the knot. Stubborn oozing surfaces can very generally be
stanched by searing them with Paquelin's thermo-cautery, or by passing
a needle armed with fine silk under and ligating any vessel that may be
detected leading up to the seat of the oozing. In some cases nothing
answers so well as the pressure of the finger moistened with alcohol or
with a drop or two of the ferric subsulphate or of the tincture of
iodine. In oozing from inaccessible points in the pelvis a sponge
dipped in the undiluted solution of iodine or in Monsel's solution of
iron, and afterward well squeezed out, may be pressed firmly down for a
few moments into Douglas's pouch. When the oozing comes from a large
surface of the abdominal wall, it may finally be arrested by the
doubling of the raw surface on itself. The fold thus made is then
secured either by a long acupressure needle or by cobbler's stitches
passed through from skin to skin. Forty-eight hours after, this needle
or these stitches should be removed. For this ingenious device we are
indebted to the late Kimball of Lowell, Mass. Should all these measures
fail, put in a drainage-tube, close up the abdomen in the manner about
to be described, and temporarily lay over the dressings some heavy
weights, such as bags of sand or of shot. This plan I have not been
obliged to resort to, but it has the sanction of Nussbaum, who uses two
large bricks, and it is worthy of being borne in mind.[56] In my hands
an elastic flannel binder pinned very tightly over a large roll of
cotton wool has made pressure enough to check the hemorrhage.
[Footnote 56: _British Med. Journal_, Oct. 26, 1878, p. 617.]