A System of Operative Surgery Part 2

The operator then sponges up any blood or fluid which may have collected in the recesses of the pelvis. Whilst employed in this way he gives instructions to have the dabs and instruments counted.

When the operator limits the number of dabs to six he can easily have them displayed before him. The incision is sutured in the manner described on p. 9.

=Cysts of the broad ligaments.= Occasionally the surgeon on opening the abdomen finds that the cyst or tumour is situated between the layers of the broad ligament. Sessile cysts of this kind are removed by what is known as enucleation. The peritoneum overlying the cyst is cautiously torn through with forceps until the cyst wall is exposed; then by means of the forefinger the surgeon proceeds to sh.e.l.l the cyst out of its bed, taking care not to tear the capsule or any large vein in its wall; it is also necessary to exercise the greatest care to avoid injury to the ureter. It is not uncommon, after enucleating a cyst in this way, to find the ureter lying at the bottom of the recess. (For treatment of an injured ureter see p. 112.)

When the enucleation is completed the walls of the capsule are carefully examined for oozing vessels which require ligature. The capsule can often be closed in such a way as to bring its walls into apposition and thus obliterate its cavity; it then requires no further attention. When there is much oozing the capsule is treated on the plan known as marsupialization. The edges of the capsule are brought to the lower angle of the abdominal wound and secured with sutures, and a drain, either of gauze or a rubber tube, is introduced, and the remainder of the wound closed in the usual manner.

Enucleation is usually accompanied by more loss of blood than simple ovariotomy; this, and the prolonged manipulation, is often responsible for severe shock.

=Spurious capsules.= It is necessary for the surgeon to remember that an ovarian cyst, and especially an ovarian dermoid, is sometimes invested by a spurious capsule. It is now well known that slow effusions of blood, tuberculous exudations (Fig. 4), hydatid cysts, and ovarian cysts become enclosed by capsules of fibrous tissue formed by the organization of the peritoneal exudation which their presence excites. These capsules are often so firm, and so completely encyst the fluid exuded into the pelvis in cases of tubal tuberculosis, that such encapsuled collections of fluid resemble, and are often mistaken for, ovarian cysts. It is also necessary to mention that true ovarian cysts project from, but never invade the layers of the broad ligament. From time to time cases are reported in which ovarian cysts, especially dermoids, have been found between the layers of the broad ligament: such are in all probability instances in which a false capsule has formed around the cyst, and the surgeon committed an error of observation in regarding it as a layer of the broad ligament.

[Ill.u.s.tration: FIG. 1. SECONDARY CANCER OF THE OVARY. An ovary converted into a solid ma.s.s of cancer secondary to a focus in the sigmoid flexure of the colon: it weighed 5 lb. Two-fifths size.]

=Ovariotomy in carcinoma of the ovary.= When an operation is undertaken for the removal of solid or semi-solid tumours of the ovary, and especially when bilateral and accompanied by vomiting, it is inc.u.mbent on the surgeon to make a careful examination of the gastro-intestinal tract, for in many of these cases cancer will be found either at the pylorus, or in the caec.u.m, or the colon, and particularly in the sigmoid flexure. In such circ.u.mstances the ovarian ma.s.ses are secondary to the cancerous focus in the gastro-intestinal tract.

Bilateral malignant tumours of the ovaries are sometimes secondary to primary cancer of the gall-bladder and the breast. Some of these secondary cancerous tumours of the ovaries form ma.s.ses as big as the patient's head.

In such conditions the ovaries and sometimes the uterus should be removed even for the purpose of making the patient comfortable. When the primary disease is in the caec.u.m, colon, or sigmoid flexure, and is operable, the growth should be resected and the cut ends of the bowel united by circular enterorrhaphy. In one instance, where the cancer occupied the ileo-caecal valve, I succeeded in making a lateral anastomosis between the ileum and ascending colon, after performing bilateral ovariotomy. The woman survived the operation two years.

=Incomplete ovariotomy.= The surgeon may start on an operation and, after opening the abdomen, may find many adhesions, yet he feels that the removal of the tumour is possible. He sets to work and overcomes many of the difficulties, but finds at last such extensive pelvic adhesions that it is imprudent to proceed further. In such cases he evacuates the contents of the cyst and st.i.tches the edges of the opening in the cyst to the margins of the abdominal wound, and drains the cavity. This mode of dealing with a cyst is usually termed 'incomplete ovariotomy'.

[Ill.u.s.tration: FIG. 2. SECONDARY CANCER OF THE OVARY IN SECTION. This is a section of the ovary represented in the preceding figure. Half size.]

An incomplete ovariotomy is a very different condition to an enucleation. The cavity left after enucleation closes completely, but when the wall of an ovarian cyst or adenoma is left the tumour gradually grows again, or it may suppurate so profusely that the patient slowly dies exhausted. There are few things sadder in surgery than the slow, miserable ending of an individual who has been subjected to an incomplete ovariotomy.

=Anomalous ovariotomy.= In a few instances, generally under an erroneous diagnosis, surgeons have removed ovarian tumours through an opening other than the cla.s.sical one known as the median sub.u.mbilical incision.

Under the impression that the tumour was splenic, an ovarian tumour of the right side has been successfully removed through an incision in the left linea semilunaris (R. W. Parker). An ovarian tumour, supposed to be a renal cyst, has been successfully extracted through an incision in the ilio-costal s.p.a.ce (Le Bec). Strangest of all, a small ovarian dermoid has been removed through the r.e.c.t.u.m under the impression that it was a polypus of the bowel (Stock, Peters).

=Hysterectomy after bilateral ovariotomy.= After the removal of both ovaries for cysts or tumours, the uterus is a useless organ: it is fast becoming the practice under such conditions to remove it. There is much to be said in favour of this procedure, especially if the uterus be large and flabby, because it tends to fall backwards into the pelvis. In such circ.u.mstances it is better surgery to remove it than to perform hysteropexy. The risk of intestinal obstruction after bilateral ovariotomy is greater than after hysterectomy. Cases are known in which cancer has attacked the uterus years after bilateral ovariotomy and ooph.o.r.ectomy (see p. 55).

=Repeated ovariotomy.= Very many cases are known in which women have been twice submitted to ovariotomy. Thus it is the duty of the surgeon when removing an ovarian tumour to examine carefully the opposite ovary.

So many examples are known of women who have borne children after unilateral ovariotomy (twins and even triplets) that this alone is sufficient to prohibit the routine ablation of both glands.

A second ovariotomy is not attended with more risk than a first ovariotomy. The abdominal incision must be made with extra caution, because intestine may be adherent to it and runs a risk of being wounded. In some instances the cicatrix is very thin, and the surgeon cutting through it is liable to cut the intestine before being aware that the knife has entered the abdomen.

Some surgeons recommend that in a second ovariotomy the opening may with advantage be made a little to one side of the original incision.

Cases have been reported in which patients have been thrice submitted to ovariotomy: in such instances it is probable that one of the tumours was a sessile broad ligament cyst.

=Pregnancy after bilateral ovariotomy.= It is an interesting fact that several cases have been carefully reported in which women who have had bilateral ovariotomy have subsequently become pregnant. This event has been explained by a.s.suming that in some of the patients a portion of at least one ovary has been left. This meets with more favour than the idea of the existence of a supernumerary ovary. The cases have been collected by Doran.

In order to afford some notion of the relative frequency of the various cysts and tumours cla.s.sed as ovarian, a list of one hundred consecutive examples which I removed at the Chelsea Hospital for Women is appended:--

Fibromata 2 Sarcomata 2 Carcinomata 1 Simple cysts 45 Adenomata 25 Dermoids 15 Papillomata 2 Parovarian 5 Tubo-ovarian 3

The case cla.s.sed as a carcinoma was secondary to cancer of the pylorus; both ovaries were affected. The three cla.s.sed as tubo-ovarian were probably exceedingly large examples of hydrosalpinx; one was so big that it came in contact with the liver.

I have compared this table with the experience of other surgeons, and although there is much variation in them it represents a fair average of the proportions of the different ovarian operations usually cla.s.sified under the head of ovariotomy.

=Ovariotomy at the extremes of life.= Cysts and tumours arise in the ovary during intra-uterine, and at all periods during extra-uterine life, even in extreme old age: they also attain such dimensions in infants and old women as to demand the aid of the surgeon, and with excellent results. Many years ago I collected the recorded cases and tabulated one hundred instances in which ovariotomy had been performed in infants and girls under fifteen years of age. These tumours fall into three groups:

Simple cysts and adenomata 41 with 3 deaths.

Dermoids 38 " 5 "

Sarcomata 21 " 7 "

In the case of simple cysts, adenomata, and dermoids, the results are encouraging. It is possible that some of the cases described as sarcomata belonged to the deadly group now known as malignant teratomata.

Ovarian tumours sometimes attain large dimensions in children, and Keen reported a case in which he removed an ovarian tumour from a girl which weighed 44 kilogrammes: the girl weighed 27 kilogrammes after the operation. An ovarian cyst with a twisted pedicle has been found in a ftus at birth (Otto von Franque).

The subjoined table shows cases in which ovarian tumours have been removed from infants under three years of age. It is often stated that Professor Chiene performed ovariotomy on an infant of three months. This is an error; it was an ovary occupying the sac of an inguinal hernia.

OVARIOTOMY IN INFANTS

-+------------+-----------+--------+----------+---------------------- _Reporter_ _Age_ _Result_ _Nature of _Reference_ Tumour_ -+------------+-----------+--------+----------+---------------------- 1 D'Arcy Power 4 months R. Dermoid _Trans. Path.

Soc._, xlix. 186.

-+------------+-----------+--------+----------+---------------------- 2 MacGillivray 11 months R. Cyst _Lancet_, 1907, i. 1487.

-+------------+-----------+--------+----------+---------------------- 3 Roemer 1-3/4 years R. Dermoid _Deutsche Med. Woch._, 1883, ix. 762.

-+------------+-----------+--------+----------+---------------------- 4 Pean 2 years R. Dermoid _Clin. Chir._, 1887-8, 8th series.

-+------------+-----------+--------+----------+---------------------- 5 Hooks 2-1/2 years D. Dermoid _Am. J. of Obst._, 1886, xix. 1022.

=Ovariotomy in old age.= In 1891 I was able to find twenty-two records of successful ovariotomy in women over seventy years of age. Since that date Howard A. Kelly and Mary Sherwood made a collective investigation, and succeeded in obtaining notes of one hundred cases of ovariotomy performed on women over seventy years of age: the death-rate amounted to 12%.

The subjoined table concerns itself with ovariotomy performed on women after the age of eighty years, and the results are remarkable, notwithstanding the circ.u.mstance that these women of eighty years and upwards must have been blessed with a stronger const.i.tution than their contemporaries.

OVARIOTOMY IN WOMEN OF EIGHTY YEARS OF AGE

--+-------------+-----+--------+------------------------------------ _Reporter_ _Age_ _Result_ _Reference_ --+-------------+-----+--------+------------------------------------ 1 Owens 80 R. _Brit. Gyn. Soc. Journal_, iv. 88.

--+-------------+-----+--------+------------------------------------ 2 Richardson 80 R. _Brit. Med. Journ._, 1894, i. 523.

--+-------------+-----+--------+------------------------------------ 3 Heywood Smith 81 R. _Lancet_, 1894, i. 1618.

--+-------------+-----+--------+------------------------------------ 4 Spencer 82 R. _Brit. Med. Journ._, 1893, ii. 1271.

--+-------------+-----+--------+------------------------------------ 5 Homans 82 R. _Bost. Med. and Surg. Journ._, 1888, 454.

--+-------------+-----+--------+------------------------------------ 6 Edis 81 R. _Brit. Med. Journ._, 1892, i. 860.

--+-------------+-----+--------+------------------------------------ 7 Bush 84 R. _Ibid._, 1894, ii. 67.

--+-------------+-----+--------+------------------------------------ 8 Remfrey 83 R. _Trans. Obstet. Soc._, x.x.xvii. 152.

--+-------------+-----+--------+------------------------------------ 9 Kraft 84 R. _Hospitalstidende_, Copenhagen.

--+-------------+-----+--------+------------------------------------ 10 Owens[1] 87 R. _Lancet_, 1895, i. 542.

--+-------------+-----+--------+------------------------------------ 11 Thornton 94 R. _Trans. Obstet. Soc._, x.x.xvii, 158.

--+-------------+-----+--------+------------------------------------ 12 Bland-Sutton 85 R. Middles.e.x Hospital.

--+-------------+-----+--------+------------------------------------ [1] A second operation on patient No. 1 in the list.

=Mortality.= The death-rate after ovariotomy is hard to estimate, especially as surgeons differ widely in the cla.s.sification of the cases.

In the simple and uncomplicated forms of ovarian cysts and tumours the operation should be almost free from risk. Many surgeons, excluding malignant conditions, have had lists of a hundred operations with no deaths.

If all kinds of tumours are included as represented in the table on p.

17, a 5% mortality in experienced hands would be regarded as a good result. In general hospital work it is probably as high as 10%. With less experienced surgeons who do not perform many operations the death-rate will vary from 10 to 15%.

The risks and after-consequences of ovarian operations are set forth in Chapter XI.