Plate 179

Removal of the fallopian tubes 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 so forth. 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 malignancies every effort should be made to conserve even remnants of functioning ovarian tissue in the younger patients.

(See Gynecologic System—Routine for Abdominal Procedures.) The skin is covered by a sterile transparent plastic drape.

The skin is prepared in the routine manner. The surgeon stands on the patient's left side.

See Gynecologic System—Routine for Abdominal Procedures. In the presence of extensive pelvic inflammation, the intestines are often attached to the adnexa by adhesions that must be separated either by blunt or sharp dissection. Haste and roughness must be avoided. 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. The intestines are pushed aside carefully and 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).

Details of Procedure

The uterus is held forward either by a tenaculum applied to the round ligament adjacent to the uterus (Figure 1) or by a fine absorbable suture through the fundus (Figure 7). The mesosalpinx is clamped with a sufficient number of half-length clamps, usually three pairs, to include its entire length (Figure 3). To avoid possible interference with the blood supply of the ovary, the line of incision is kept near the fallopian tube (Figure 1). As an alternative, the mesosalpinx may be saved by controlling the blood supply with three or four mattress sutures meticulously placed to avoid vessels when the needle is introduced (Figure 2). Regardless of the method used to divide the mesosalpinx, an elliptical incision is made through the thickness of the uterine wall to cone out the interstitial portion of the fallopian tube (Figure 4). Ligatures are applied to the mesosalpinx as the half-length clamps are removed (Figure 4). Brisk bleeding is usually encountered from the cornual artery, which may be controlled either by placing deep mattress sutures through this area before the interstitial portion of the tube is excised, or by manual compression while mattress sutures are placed (Figure 5). These mattress sutures, which are tied together gently to avoid tearing the friable uterine wall, effect an even approximation and give complete hemostasis.

Details of Procedure

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.

Closure

(See Gynecologic System—Routine for Abdominal Procedures.)

Postoperative Care

(See Gynecologic System—Routine for Abdominal Procedures.)