460 



APPLIED ANATOMY. 



OPERATIONS ON THE FEMALE PELVIC ORGANS. 



The most usual operations are the removal of the uterus, hysterectomy, 

 removal of the ovary, oophorectomy, removal of the Fallopian tubes, sal- 

 pingectomy. The ovaries are often removed with the diseased tubes and also in 

 cases of hysterectomy. These operations are usually done through an abdominal 

 incision near the median line between the umbilicus and the symphysis pubis. Not 

 infrequently they are done through the vagina. After the abdomen is opened it is 

 important to be able to recognize and isolate the individual organs, this is much facil- 

 itated by elevating the pelvis so that the intestines gravitate toward the diaphragm 

 Trendelenburg' s position (Fig. 463). The incision having been made and the 

 abdomen opened the first structure seen is the great omentum. This often extends as 

 low as the symphysis. As it hangs from the transverse colon it is to be displaced 

 upward and not toward the sides. The next structures exposed are either the small 

 or large intestines. The transverse colon normally should not come below the umbil- 

 icus but it often does come lower and may even descend to the level of the symphysis. 

 When it is low it lies in front with the small intestines behind. It likewise should be 

 displaced upward. Sometimes the sigmoid colon may make its appearance from the 

 left and more rarely the caecum from the right. It should not be forgotten that both 



Round ligament 

 Fallopian tube 



Broad ligament 



Ovary 



Fimbriated extremity 

 of Fallopian tube 



-Bladder 



Uterus 



Douglas's ix>uch 



FIG. 463. View of the interior of the female pelvis in the Trendelenburg position. 



these structures are bound to the posterior abdominal walls and may often be covered 

 in front by coils of small intestine. Quite frequently however, the caecum on the 

 right and iliac colon on the left come in contact with the anterior abdominal walls in 

 the iliac fossa in the neighborhood of the anterior iliac spines and may extend part 

 way down Poupart's ligament. The sigmoid colon if distended may bulge anteriorly 

 but more usually it lies posteriorly covered by the small intestines. If it or the caecum 

 are encountered they are to be pushed upward and to the side. The small intestines 

 are to be displaced upwards. In the median line anteriorly is now seen the bladder 

 and directly behind it the uterus. If the uterus is drawn to one side the broad liga- 

 ment of the opposite side is made tense and the round ligament is seen running to the 

 internal ring anteriorly and, more posteriorly, the Fallopian tube. On the posterior 

 surface of the broad ligament below the outer end of the Fallopian tube is seen the 

 ovary. Farther posteriorly, in the hollow of the sacrum, is the rectum, with Doug- 

 las's pouch between it and the uterus in front. If it is desired to recognize the 

 structures by touch instead of sight then the anterior abdominal wall is followed 

 down over the bladder and the fundus of the uterus recognized as a hard rounded 

 mass. This can be grasped between the thumb and fingers and followed laterally 

 past the cornu to the broad ligaments. If the tubes and ovaries are enlarged they 

 may be found lying posterior to the uterus in Douglas's pouch instead of laterally. 



