W. L. Burrage (Anuabi of Gyuree. and 1 .11 ay. 1t1001.
Ten cases of ovariotomy during preg nancy, followed in four instances by abortion: all the patients recovered. 8cries of 148 cases of pregnancy compli cated by ovarian tumors also collected. The mortality had been 2.7 per cent., in 22,5 per cent, the pregnancy had been interrupted. In such cases the writer concurs with other authorities that ovariotomy should be performed as early as possible. Orgler (Arehiv f.
Ild. lxv. S8. 126-100, 1902).
operation consists in: first, the incision of the abdominal wall; second, puncture of the cyst and separa tion of adhesions; third, ligation of the pedicle and removal of the cyst; fourth, exploration of the remaining ovary and toilet of the peritoneum; fifth, drainage; sixth, closure of the wound; seventh, dressing. The abdominal incision is made in the median line about three inches in length midway between the umbilicus and symphysis. Incision is made through skin, superficial fascia aponeurosis, and deep fascia to the peri toneum. It is generally aimed to make this incision through the lines alba, but in undiluted abdominal walls the separa tion may be so slight as to render it diffi cult. The sheath of the rectos muscle is opened from the side; the incision should extend through the muscle, as its injury is immaterial. Bleeding vessels are secured before the peritoneum is opened; it is then picked up and incised between forceps so as to avoid injuring the sac or a knuckle of intestine which may be situated in front of it. With the completion of the incision, the pearly white sac is exposed. It may be explored by introducing the hand, passing it around the tumor, thus recognizing the presence or absence of adhesions. With an assistant pressing the sac firmly against the wall, a trocar to which a long rubber tube is attached may be plunged into the tumor and the fluid carried into a vessel at the side of the table. In the absence of the trocar an ordinary glass syringe-nozzle can be util ized. Incision is made with the knife into the tumor-wall and then the syringe nozzle introduced. The assistant presses the tumor down against the abdominal wall, and keeps it tense. As the fluid is
discharged the sac becomes relaxed. It should he seized with haemostats or cyst forceps and drawn out so that the open ing is kept outside the peritoneal cavity, to prevent its being soiled with the tu mor-contents. As the sac is drawn out, the adhesions are separated; those which are recent and soft may be overcome by pressing against them with a sponge or gauze pad. In this way the adherent intestines are sponged away from the cyst. Where the adhesions are old and firm, they require scissors or knife to accom plish their separation. Bleeding vessels in these adhesions should be secured with hwinostat or immediately ligated. Where the adhesions are very firm and short, so that the intestine lies directly upon the tumor-wall, separation will fre quently be attended with marked injury to intestine. To prevent this, a portion of the sac-wall should be permitted to remain in contact with the intestine, taking the precaution to strip off from it the secreting surface. The adhesions should be as far as possible separated under the eye, keeping a watch for large vessels and avoiding injury to intestines, and particularly to the spleen and liver. Vascular adhesions in the omentum should be at once secured either by clamp-forceps or ligature.
Ligation of the Pedicle and Removal of the may be accomplished with silk or catgut, preferably the latter. In a long, slender pedicle it is transfixed in the centre, ligated in two portions. Thicker, shorter pellicles, may be ligated in several sections or it may cut through the pedicle, using clamp-forceps to se cure it and ligate the vessels separately. After ligation of the principal vessels clamp-forceps are removed and the sur faces carefully observed for further bleed ing. In these cases the peritoneum is sutured over the raw surface. Where the pedicle is ligated in sections the sutures should be interlocked to prevent their tearing below, which might cause serious bleeding. In large cysts, for the with drawal of the cyst the pedicle is seized with clamp-forceps and the cyst cut away as a preliminary to the ligation.