Removal of the fallopian tubes and/or ovaries is indicated for inflammatory involvement of the adnexa that cannot be relieved by the use of conservative measures including antibiotics, for ovarian cysts, neoplasms, ectopic pregnancies, and endometriosis. Bilateral oophorectomy is advised by some as a desirable procedure in extensive carcinoma of the rectum because of the susceptibility of the ovaries to tumor transplantation from lesions of the gastrointestinal tract. In the absence of malignancy every effort should be made to conserve even remnants of functioning ovarian tissue especially in the younger patients, but recently conservation has also been recommended for menopausal patients without other indications for ovarian removal.
The skin is prepared in the routine manner.
See Chapter 93. In the presence of extensive pelvic inflammation, the intestines are often attached to the adnexa by adhesions that must be separated by sharp dissection. Meticulous dissection and careful handling of the tissue is important in order to avoid unintentional injury to the bowel. By placing the adhesions on tension as they are cut, the cautious surgeon can almost always develop a cleavage plane between the diseased adnexa and the other structures. In minimally invasive surgery, the bowel (except for the pelvic sigmoid colon) will usually fall out of the pelvis secondary to placing the patient in Trendelenburg position, but loops of small bowel may be needed to be carefully flipped into the upper abdomen with blunt atraumatic instruments. During a laparotomy, the intestines are carefully packed away with warm, moist gauze pads, or placed in a plastic bag and moistened with warm saline. The free adnexa are then held upward with a half-length clamp (figure 1).
The uterus is held forward by placing a Kelly clamp to the round ligament adjacent to the uterus (figure 1). The mesosalpinx is clamped with a sufficient number of half-length clamps, usually three pairs, to include its entire length (figures 1 and 2). To avoid possible interference with the blood supply of the ovary, the line of incision is kept near the fallopian tube (figure 1). The clamps are then ligated with transfixing sutures using 2-0 absorbable suture. Alternatively, a bipolar electrosurgical unit (ESU) can be applied in sequential bites along the mesosalpinx to the level of the cornu of the uterus (figure 3). The proximal aspect of the fallopian tube is then excised from the cornu (figure 4) and ligated at the level of the uterine fundus with a transfixing suture (figure 5) or with the bipolar ESU.
B. SALPINGECTOMY AND OOPHORECTOMY