Hysterectomy (Abdominal)

The uterus is to be drawn to one side and the posterior portion of the broad ligament is grasped out toward the pelvic wall. As the ovarian artery and veins run along the top of the broad ligament, a ligature is passed through it below them, but posterior or above the round ligament. A clamp may be placed on the side toward the uterus to prevent bleeding from the other side. The ligament is then divided between the ligature and clamp; sometimes the ovaries are allowed to remain, but usually they are removed with the uterus. A ligature is then placed around the round ligament and it is divided; often the round ligament is included in the first ligature. The incisions in the broad ligament are then carried through the peritoneum around the front of the uterus at the vesicouterine junction and also posteriorly. The bladder being loosely attached can be separated by blunt dissection down to the level of the external os. A clamp close to the side of the cervix controls bleeding from the sides of the uterus, and by pushing away the connective tissue outwardly the uterine artery can be recognized, ligated, and divided. The ureter lies below and behind 1 to 2 cm. (1/2 to 3/4 in.) distant from the cervix. The cervix is then detached from the vagina, and the bleeding from the small vaginal vessels controlled first by clamps and then by sutures.

Fig. 464.   Removal of the entire uterus.

Fig. 464. - Removal of the entire uterus.

The same procedure can be repeated on the opposite side either by continuing from below up, or, as before, from above down (Fig. 464).

Oophorectomy

In removing ovarian tumors any adhesions present are first loosened, and then the tumor raised up and its pedicle ligated. The Fallopian tube is usually adherent to and removed along with the tumor. The pedicle is formed by the utero-ovarian ligament on the inside and the infundibulopelvic on the outside; also the Fallopian tube and part of the broad ligament and branches or trunks of the ovarian artery and veins. As the ovarian vessels run horizontally, if the ligature is not placed low they may not be included, but only the branches which come off from them and proceed to the tumor.

Salpingectomy

In removal of the Fallopian tubes for purulent or other conditions, adhesions are frequently encountered owing to previous inflammation. To remove such a tumor it is better usually to do it by sight rather than by touch alone. If the patient is placed in the Trendelenburg (elevated pelvis) posture the intestines fall out of the pelvis and are kept back by gauze pads. Any coils which are stuck fast to the adjacent organs can then be carefully dissected and peeled loose and the tumor exposed. It will be found either posteriorly in Douglas's pouch, or laterally between the uterus and side of the pelvis, pushing the former toward the opposite side. The distended, enlarged tube with the ovary adherent to it can then be isolated by inserting the finger between it and the pelvic wall, beginning at the posterior edge of the broad ligament and following it around posteriorly, loosening it from the rectum and Douglas's pouch until the uterus is reached. The finger is then passed beneath the tumor and it is peeled off the pelvic floor, it can then be raised up and its base ligated much like the pedicle of an ovarian tumor. If this is carefully done the parietal peritoneum will not be broken through and there will be little or no bleeding.