THE FEMALE PELVIC ORGANS. 461 



Hysterectomy (abdominal). The uterus is to be drawn to one side and the 

 posterior portion of the broad ligament is grasped out toward the pelvic wall. As 

 the ovarian artery and veins run along the top of the broad ligament, a ligature is 

 passed through it below them, but posterior or above the round ligament. A clamp 

 may be placed on the side toward the uterus to prevent bleeding from the other side. 

 The ligament is then divided between the ligature and clamp ; sometimes the ovaries 

 are allowed to remain, but usually they are removed with the uterus. A liga- 

 ture is then placed around the round ligament and it is divided ; often the round 

 ligament is included in the first ligature. The incisions in the broad ligament are 

 then carried through the peritoneum around the front of the uterus at the vesico- 

 uterine junction and also posteriorly. The bladder being loosely attached can be 

 separated by blunt dissection down to the level of the external os. A clamp close 

 to the side of the cervix controls bleeding from the sides of the uterus, and by push- 

 ing away the connective tissue outwardly the uterine artery can be recognized, 

 ligated, and divided. The ureter lies below and behind i to 2 cm. (^ to ^ in.) 

 distant from the cervix. The cervix is then detached from the vagina, and the bleed- 

 ing from the small vaginal vessels controlled first by clamps and then by sutures. 



-Ovarian artery 

 Body of uterus-T | ^^, ^^ -^ ~^ -f_ B road ligament 



-Round ligament 



^Uterine artery 



* Bladder 

 . 

 Denuded surface of bladder 



FIG. 464. Removal of the entire uterus. 



The same procedure can be repeated on the opposite side either by continuing from 

 below up, or, as before, from above down (Fig. 464). 



Oophorectomy. In removing ovarian tumors any adhesions present are first 

 loosened, and then the tumor raised up and its pedicle ligated. The Fallopian tube 

 is usually adherent to and removed along with the tumor. The pedicle is formed by 

 the utero-ovarian ligament on the inside and the infundibulopelvic on the outside ; 

 also the Fallopian tube and part of the broad ligament and branches or trunks of 

 the ovarian artery and veins. As the ovarian vessels run horizontally, if the ligature 

 is not placed low they may not be included, but only the branches which come off 

 from them and proceed to the tumor. 



Salpingectomy. In removal of the Fallopian tubes for purulent or other con- 

 ditions, adhesions are frequently encountered owing to previous inflammation. To 

 remove such a tumor it is better usually to do it by sight rather than by touch alone. 

 If the patient is placed in the Trendelenburg (elevated pelvis) posture the intestines 

 fall out of the pelvis and are kept back by gauze pads. Any coils which are stuck 

 fast to the adjacent organs can then be carefully dissected and peeled loose and 

 the tumor exposed. It will be found either posteriorly in Douglas's pouch, or 

 laterally between the uterus and side of the pelvis, pushing the former toward the 

 opposite side. The distended, enlarged tube with the ovary adherent to it can 

 then be isolated by inserting the finger between it and the pelvic wall, beginning at 

 the posterior edge of the broad ligament and following it around posteriorly, loos- 

 ening it from the rectum and Douglas's pouch until the uterus is reached. The 



