This section is from the book "Applied Anatomy: The Construction Of The Human Body", by Gwilym G. Davis. Also available from Amazon: Applied anatomy: The construction of the human body.
Certain tumors originating either from the structures of the broad ligament or ovary, or side of the uterus, grow between the layers of the broad ligament. Parovarian cysts arising from the remains of the Wolffian body are of this character. These intraligamentary cysts are retroperitoneal. The Fallopian tube is spread over and adherent to their upper surface. As they grow down they come in contact with the ureter, which becomes adherent to the bottom and sides of the growth. The liability of injury to the ureter is the greatest danger in these cases, and can only be escaped by searching for, recognizing, and avoiding it. These growths are exposed by splitting the peritoneum covering them and then shelling them out. At times they are large and formidable and extremely difficult to remove.
The most dangerous factor in operating for extra-uterine pregnancy is hemorrhage. The tumor is usually tubal in position. The bleeding comes from the sac, therefore loosening and isolating it should be done with the greatest care to avoid rupturing it. If already ruptured the blood is to be rapidly sponged out, the uterus recognized and grasped with the hand, which is then slid outward until the ruptured tumor is felt and drawn up. The blood comes to the tumor from the ovarian artery and uterine artery. To control the former a clamp is placed on the broad ligament close to the pelvic wall. To control the latter a clamp is placed low down on the broad ligament close to the uterus. The active bleeding then ceases.
The uterus if not much enlarged can be removed through the vagina when, as is the case in multiparas, it is lax and capacious.
The cervix is grasped and drawn down to the vulva and the mucous membrane incised in the anterior fornix and posteriorly close to the uterine tissue. The bladder is pushed up and separated from the cervix by dry dissection with occasional snipping of fibrous bands by scissors until the peritoneum at the level of the internal os is reached. The peritoneum, which from this point up is adherent to the uterus, is opened and divided to the broad ligaments on each side. Douglas's sac is next opened posterior to the cervix and close to it, and the opening enlarged with the finger to the broad ligaments. A clamp is now placed on each broad ligament low down to control the uterine arteries. By hooking the finger above the fundus it can be brought back and down and out, the ovaries usually coming with it. The remaining portion of the broad ligaments is then either clamped or tied to control the ovarian arteries. Some operators use clamps alone, others use ligatures. Vaginal branches which bleed are grasped with haemostats and ligated. The ureters, which lie 1.5 to 2 cm. (1/2 to 3/4 in.) away from the cervix, are pushed outward when the opening in Douglas's sac is enlarged, and will be avoided by not placing the clamps too far away from the cervix.
The cervix is made accessible for operation by grasping it with tenaculum forceps and drawing it down to the vulva. It is there held to one side, which renders the laceration easily accessible for excision and the introduction of sutures. Bleeding is controlled by the sutures.