OVARIAN TUMOURS.
At the present day it is scarcely necessary to say that the treatment of ovarian tumours may be shortly stated in the words—complete removal as soon as practicable. No drugs, whether administered per os or applied locally, can have any beneficial effect on the tumour, and short of complete removal, surgical interference such as tapping does more harm than good by inducing inflammatory changes in the tumour or in its surroundings, with the certainty of forming adhesions and the possibility of setting up a fatal peritonitis or giving rise to a dangerous collapse.
Ovariotomy in an uncomplicated case of tumour, whether mulilocular proliferating or papillary cyst, dermoid cyst, unilocular cyst or fibroma of the ovary, is one of the simplest and safest of major operations. The results are almost uniformly satisfactory, recovery is usually speedy and uneventful, and unpleasant after-effects are almost unknown. The best time to choose for the operation is about a week or so days after a menstrual epoch. The patient should he prepared beforehand by a course of aperients administered for 3 or 4 nights in succession, so as to empty the bowels thoroughly. She should have a vaginal douche of r in 4,000 Perchloride of Mercury on the 3 nights preceding the operation, and if there is a purulent or muco-purulent discharge measures should be taken to get rid of it before she is operated on (see under Leucorrhcea and Endo metritis). The preparation of the patient and of her surroundings are detailed in the article on Operations, Treatment of, which should be consulted by the practitioner in default of special instructions from the operating surgeon.
The steps of the operation consist in an incision through the abdominal wall between the umbilicus and the pubes just to the left of the middle line. The earlier ovariotomists made a short incision of about 3 inches in length, tapped the cyst with a trochar, and after evacuating most of its fluid contents drew the collapsed tumour through the incision and pro ceeded to secure the pedicle. The trend of modern surgery is in the direc tion of dispensing with tapping altogether and enlarging the incision so as to permit of the cyst being delivered intact through the abdominal wall.
In this way there is no possibility of the abdomen being soiled with the cyst contents, and there is therefore no possibility of grafting on the peritoneum living cancer cells, should the growth turn out to contain malignant elements. With the modern technique of closure of the abdom inal wound the risk of subsequent ventral hernia is reduced to a minimum, and as it is possible to operate more rapidly and to deal more easily with adhesions by this method, it seems likely that it will continue to gain adherents. In several instances in which I have incised the abdominal wall from the pubes practically to the ensiform cartilage, convalescence has been as rapid and the after-results as good as with a 3-inch incision. When the tumour has been delivered it will be seen to be attached to the pelvis by a pedicle consisting of the suspensory ligament of the ovary with the ovarian artery, the Fallopian tube and the ovarian ligament with the anastomosis between the uterine and ovarian arteries, enclosed between the peritoneal layers of the broad ligament.
The classical method of dealing with the pedicle is to transfix it with a pedicle needle, avoiding the large venous trunks. The ligature with which the needle is armed is divided into two halves, which are interlocked, and each half is then tied separately. The pedicle is then cut across between the tumour and the ligatures, leaving an ample button of tissue on the stump above the ligature to prevent slipping. Many operators reinforce the ligature by picking up the vessels on the face of the stump and tying them separately. A few points of suture may be inserted so as to lessen the raw surface of the stump, and after the peritoneal cavity has been sponged clear of blood, the other ovary inspected to make sure of its healthiness, and the stump finally looked at to see that all bleeding is controlled, the suturing of the abdominal wall is begun.