When both the tube and ovary are to be removed, incision is made as shown in Figure 6. The half-length clamps are applied to the infundibulopelvic ligament, which includes the ovarian vessels (Figure 6). Prior to ligating the ovarian vessels the pararectal space should be opened and the uterus identified. The vessels are divided and tied with a transfixing suture of 0 absorbable suture. The leaves of the broad ligament are either doubly clamped with curved, half-length clamps and divided with scissors or scalpel, or ligated with mattress sutures carefully placed so that the needle does not penetrate any of the thin-walled veins between its layers. Now the interstitial portion of the fallopian tube is removed as shown in Figure 4. The appearance of the raw surfaces of the broad ligaments after the tubes and one ovary have been resected is shown in Figure 7. Where the ovarian ligament is quite long, allowing the ovary to prolapse into the pelvis, it is shortened by means of a mattress suture through the posterior wall of the uterus and the ovarian ligament, thus suspending the ovary adjacent to the posterior wall of the uterus. The raw surfaces remaining after the excision of part or all of the uterine adnexa must be covered with peritoneum. Moreover, some type of suspension is usually advisable after removal of a part or all of the adnexa.
When the suspension of the uterus is to be carried out after removing the tube or tube and ovary, the shortening of the round ligament may be accomplished so as to cover a great part of the raw surface with peritoneum on either side. If the cut surface of the infundibulopelvic ligament is not covered, a suture, S, which includes a bite of the peritoneum on either side of the pedicle, is taken to enfold it with peritoneum (Figure 8). When another type of suspension is used, the raw surfaces remaining after removal of part or all of the adnexa may be buried by approximating the peritoneum over them, using either a continuous suture, A, of 00 absorbable suture, or interrupted mattress sutures, B (Figure 9). Several interrupted sutures are placed to approximate the posterior wall of the fundus of the uterus and the round ligaments (Figure 8). Three or four sutures are usually sufficient to ensure an adequate midline suspension of the uterus and at the same time to cover most of the raw surfaces.