A System of Operative Surgery Part 3

REFERENCES

DORAN, A. On complete Intraperitoneal Ligature of the Pedicle in Ovariotomy. _St. Bartholomew's Hospital Reports_, 1877, xiii. 195.

---- Pregnancy after the Removal of Both Ovaries for Cystic Tumour.

_Trans. Obstetrical Society_, 1902, xliv. 231.

BLAND-SUTTON, J. On Secondary (metastatic) Carcinoma of the Ovaries.

_Brit. Med. Journal_, 1906, i. 1216.

---- On Cancer of the Ovary. Ibid., 1908, i. 5.

LE BEC. Ovariotomie double; un des kystes enleve par la region lombaire, l'autre par le devant de l'abdomen; adherences totales; guerison.

_Gaz. des Hopitaux_, 1887, 290.

STOCKS. Prolapse of an Ovarian Cyst. _Brit. Med. Journal_, 1857, ii.

487.

PETERS, H. Ovariotomie per anum. _Wiener Klin. Wochensch._, 1900, xiii.

110.

CHAPTER III

OoPh.o.r.eCTOMY

_Ooph.o.r.ectomy signifies the removal through an abdominal incision of an ovary and Fallopian tube for affections mainly inflammatory._

The evolution of this operation is of great interest to surgeons. The removal of ovaries as a surgical operation was introduced independently by Hegar in Germany and Battey in Georgia, for the relief of pelvic pain and dysmenorrha, in 1872. In the same year Lawson Tait performed his pioneer operation and removed an ovary and tube for the relief of pain due to disease of the ovary. Subsequently he advocated bilateral ooph.o.r.ectomy for the purpose of inducing an artificial menopause in women with uterine fibroids. From these beginnings the operation began to be performed for the relief of a variety of conditions connected with the generative organs, such as--

Pyosalpinx and tubo-ovarian abscess, hydrosalpinx, tuberculous ovaries and tubes, sarcoma and carcinoma of the Fallopian tubes, gravid Fallopian tubes, ovarian abscess, ovarian pregnancy, prolapse of the ovary; finally bilateral removal of the ovaries has been practised for the relief of inoperable cancer of the breast.

Bilateral ooph.o.r.ectomy is occasionally performed for osteomalacia (a rare disease in Great Britain), as it arrests pain and the excessive output of phosphates in the urine, which is a marked feature of this affection. This extension of the operation we owe to Fehling of Bale (1887).

Time and experience have considerably modified surgical opinion in regard to ooph.o.r.ectomy. Removal of the ovaries is no longer practised for the relief of haemorrhage due to fibroids: it is easier, safer, and affords greater relief to the patient to remove the uterus (see p. 36).

When dysmenorrha is so severe as to need radical operation, hysterectomy is the only certain method, with conservation of at least one ovary. The removal of both ovaries in certain forms of insanity is now abandoned, and this is true of bilateral ooph.o.r.ectomy for the relief of mammary cancer.

In other directions the operation has undergone extension, for in some chronic diseases of the Fallopian tubes it is difficult to completely extirpate the affected tissues without removing the uterus. These will be considered in describing the actual operation.

Apart from the many modifications in the details of the operations some operators prefer to remove the ovaries and tubes through an incision in the v.a.g.i.n.al fornix. This is known as Colpotomy, or v.a.g.i.n.al Cliotomy.

Some writers attempt to subdivide the various modifications of ooph.o.r.ectomy and apply to them special terms: for example, the removal of the ovary and tube would be termed salpingo-ooph.o.r.ectomy. Removal of the tube would be called salpingectomy, and the excision of the ovary, ooph.o.r.ectomy. This terminology may be precise, but it is certainly clumsy. A few writers designate these operations as 'removal of the uterine appendages'; this phrase, though comprehensive, is neither precise nor elegant.

=Operation.= The patient is prepared in the same manner, and the same instruments are required, as for ovariotomy. In many of these operations the Trendelenburg position is of the greatest advantage.

[Ill.u.s.tration: FIG. 3. AN INFECTED FALLOPIAN TUBE. The clomic ostium of the tube is unoccluded and is in the process of slowly engulfing the fimbriae. Removed from a woman in the acute stage of salpingitis.

Three-quarter size.]

In a case of prolapse of the ovary, or a gravid tube or ovary in the earliest stages, the operation presents no difficulty and can be carried out with the ease and safety of the simplest ovariotomy; but there are many cases where the tubes and ovaries contain pus and are distended into cysts as big as a fist, or even as large as the patient's head, which are adherent to bowel, uterus, bladder, indeed everything with which they come in contact; this renders their removal tedious and exacting for the surgeon and dangerous to the patient. Although a suppurating ovarian cyst adheres to surrounding organs, its removal is simpler than in the case of a large pyosalpinx, because the Fallopian tube is intimately enclosed within the folds of the broad ligament, and these connexions serve to bind it firmly in the pelvis.

In undertaking the removal of such enlarged tubes the surgeon's first duty is to expose the parts by a free incision, and then carefully isolate the intestines and upper parts of the abdomen with dabs in order to prevent them from being contaminated with pus. He will quickly recognize in the majority of cases that he has to deal with tubal disease, because the distended uterine section of the tube will lie on the more globular outer portion of the tube and a.s.sume the familiar shape of a chemical retort. With the fingers the adherent omentum and bowels are carefully detached, and the adhesions between the distended tube or ovary and the r.e.c.t.u.m are carefully broken through with the finger, and the parts withdrawn from the pelvis. With great care it is usually possible to carry this out without bursting the tube. This is important as it prevents the universal spread of pus in the pelvis. When the tube bursts in the process of removal it is useful to swab it up with some strips of gauze and thus keep the 'Gamgee dabs' clean for the final stages.

[Ill.u.s.tration: FIG. 4. A TUBERCULOUS FALLOPIAN TUBE AND OVARY: ENTIRE AND IN SECTION. Caseous matter has exuded through the clomic ostium of the tube and become encapsuled. Natural size.]

As soon as the diseased parts are extracted, a dab is pressed into the hollow to check the oozing: the pedicle is clamped with forceps and the tube and ovary detached.

It is the common practice in dealing with inflamed and septic ovaries and tubes to transfix and ligature the pedicles as in a simple clean ovariotomy. The consequences of this practice are not satisfactory, for the pedicles being infected often give rise to trouble, because the silk acts as a seton, an abscess forms which may open up through the abdominal wound, the r.e.c.t.u.m, or perforate into the bladder, and leads to the establishment of a sinus which persists for many months until the ligature is extruded. There are several methods of avoiding this: for example, the arteries in these broad pedicles may be ligatured separately with thin silk, and the edges of the peritoneum drawn together by two or three mattress sutures (Fig. 11, p. 40).

In cases where the Fallopian tube is thickened quite up to the uterine angle, it may be exsected from the uterus: in such cases the uterine artery will be tied and the flaps at the uterine angle can be brought into apposition by a mattress suture.

In acute cases of salpingitis the clomic ostium is open and the infective material can be seen leaking from it (Fig. 3). In chronic cases this ostium is firmly occluded (Fig. 4). Acute cases are dangerous as they are apt to cause post-operative peritonitis. Chronic cases are difficult on account of visceral adhesions.

The most serious complication likely to arise in the enucleation of a pyosalpinx, especially on the left side, is a firm adhesion to the r.e.c.t.u.m; this may be occasionally antic.i.p.ated when the patient gives a clear history of one or more sudden discharges of pus from the a.n.u.s. An accidental tear of the r.e.c.t.u.m through comparatively healthy tissues may be repaired by interrupted sutures, but when the injury is in tissues altered by chronic suppuration, the only course open to the surgeon is to drain with a wide rubber tube, and it is surprising as well as gratifying to know that a fistula of this kind low in the r.e.c.t.u.m will often close in a week or ten days. It is important to bear in mind that an undetected tear into the r.e.c.t.u.m, if the abdomen be closed without drainage, will, in all probability, lead to fatal peritonitis.

It has happened that a surgeon in removing a pyosalpinx tore a hole in the r.e.c.t.u.m; he was unaware of the accident, and a few hours after the operation ordered 10 ounces of saline solution to be injected into the bowel. This fluid pa.s.sed through the rent in the gut direct into the pelvis with fatal consequences.

After removing the diseased parts and securing the large vessels directly concerned in the pedicles, attention is directed to the oozing from the torn tissues in the floor of the pelvis. Any vessel which is bleeding should be ligatured with thin silk, and then the recesses of the pelvis may be firmly plugged with a dab wrung out of hot water: this is a valuable measure of haemostasis. This dab is removed in two or three minutes, and any vessel which is bleeding is quickly seen and ligatured.

In cases where the enucleation of adherent and inflamed tubes leaves large raw and slightly oozing surfaces in the pelvis, drainage is a wise precaution. After a trial of a variety of measures for this purpose I find the simplest to be a narrow rubber drainage tube reaching to the bottom of the pelvis and emerging at the lower extremity of the abdominal incision. It is rarely required for more than forty-eight hours. Some surgeons are opposed to drainage, and one writer compares it to 'defending oneself against the sparks of Vulcan with an umbrella'; his mortality is high.

In simple cases the incision is closed according to the method described on p. 9; but after the removal of suppurating ovaries and tubes it is better to unite the wound by a single layer of sutures through all the tissues of the abdominal wall: buried sutures in such conditions nearly always give trouble.

=Abdominal hysterectomy after bilateral ooph.o.r.ectomy and ovariotomy.= After the complete removal of the ovaries and tubes the uterus is a useless organ, and when the 'appendages' have been removed for inflammatory lesions, acute or chronic, it may become a troublesome organ. In some instances a uterus devoid of its appendages has been attacked by cancer. In a few instances in which patients have undergone bilateral ooph.o.r.ectomy, or bilateral ovariotomy, successful conception has followed the operation (see p. 17).

The most annoying consequences which follow bilateral ooph.o.r.ectomy for salpingitis, acute or chronic, are haemorrhage, pain, or a purulent discharge. Every surgeon with an ordinary experience of this cla.s.s of surgery has probably had to remove the uterus on several occasions as a sequel to bilateral ooph.o.r.ectomy.

It is advised by many surgeons, when they find the appendages so hopelessly diseased that they must be removed, to perform subtotal hysterectomy at the same time. My own practice in this matter is to perform subtotal hysterectomy when it is necessary to remove the uterus as well as the appendages in chronic disease; and total hysterectomy when it is deemed advisable to remove the uterus with the appendages in acute infective conditions. The reasons for this modification are obvious, because in chronic conditions there is little liability for the stump to become infected, for experience teaches that though the distended tubes contain pus in chronic cases, yet on bacteriological examination this pus is sterile. In the acute cases the pus swarms with micro-organisms--bacillus colli, staphylococcus, and occasionally streptococcus; these infect the stump, set up suppuration, infect the ligatures, and establish a chronic sinus. To cure this condition it is necessary to remove the stump by the v.a.g.i.n.al route.

In cases of tuberculous infection of the Fallopian tubes it is not necessary to remove the uterus unless it is obviously implicated by the disease. In several patients I have left an ovary without any subsequent ill consequences.

=Mortality.= In order to estimate the risks of ooph.o.r.ectomy it is necessary to cla.s.sify the heterogenous conditions for which this operation is required. In the majority of cases the chief cause is inflammatory (septic) affections of the Fallopian tubes: other causes are tubal and ovarian pregnancy, and prolapse of the ovary. Tubal pregnancy is considered in a separate chapter, and as prolapse of the ovary is so often a.s.sociated with retroflexion of the uterus it is dealt with in the chapter on Hysteropexy.

In order to give some notion of the relative frequency of the infective conditions of the tubes and ovaries usually cla.s.sed in Hospital Reports as 'diseased uterine appendages', I chose one hundred consecutive operations from my case-reports at the Chelsea Hospital for Women. They are cla.s.sed thus:--

Salpingitis 49 Pyosalpinx 31 Hydrosalpinx 10 Tuberculous 8 Ovarian abscess 2

In order to give some idea of the risks of unilateral and bilateral ooph.o.r.ectomy, I gathered the following facts from the Hospital Reports, prepared by the Registrar. During the years 1903-7 (both years inclusive) the staff performed the operation of ooph.o.r.ectomy for diseased uterine appendages on 287 women. Of these four died. During the thirteen years I have filled the post of surgeon to this hospital I have performed on an average twenty ooph.o.r.ectomies yearly for the diseased conditions set forth in the above table. I lost one patient during the whole of this period, and that was in 1902. The chief risks of ooph.o.r.ectomy for inflammatory conditions are undetected injury to bowel, especially the r.e.c.t.u.m, and septic peritonitis when the streptococcus is present in the tubes in acute cases.

=Operation for primary cancer of the Fallopian tube.= This disease is rarely diagnosed before operation. The treatment adopted in the cases first reported was ooph.o.r.ectomy, but in the majority of patients the disease quickly returned and destroyed them in a few months.

It subsequently became the practice to remove the uterus as well as the tubes and ovaries, but a quick recurrence in these circ.u.mstances is the rule.

The really favouring factor in the case is the condition of the clomic ostium of the tube. When this remains open, the cancerous cells escape freely and implant themselves on the pelvic peritoneum and adjacent organs. In very rare instances the clomic ostium is occluded: in this happy circ.u.mstance a fairly long freedom from recurrence may be hoped for.

The relation between the condition of the clomic ostium of the Fallopian tube and the recurrence of cancer is ill.u.s.trated by the following cases:--