1414 



THE URINOGENITAL ORGANS 



may be performed in any case iri which the uterus or the uterus and tumor are not too large to he 

 withdrawn through the vagina. It is difficult in this operation to deal with adhesions and other 

 complications in the upper part of the pelvis, and for this reason many surgeons prefer the abdom- 



Fimbriated extremity 

 of 



' 



Broad ligament, 

 upper part 



Artery and 

 vein. 



Vagina, anterior wail. 



FIG. 1170. The uterus and its appendages. Posterior view. The parts have been somewhat displaced from 

 their proper position in the preparation of the specimen; thus, the right ovary has been raised above the Fal- 

 lopian tube, and the fimbriated extremities of the tube have been turned upward and outward. (Prom a prepa- 

 ration in the Museum of the Royal College of Surgeons of England.) 



inal operation. Vaginal hysterectomy is performed by placing the patient in the lithotomy posi- 

 tion and introducing a large duckbill speculum into the vagina. The cervix is then seized with a 

 volsellum and pulled down as far as possible and the mucous membrane of the vagina incised 

 around the cervix as near to it as the disease will allow, especially in front, where the ureters are 

 in danger of being wounded. A pair of dressing forceps are then pushed through into Douglas' 



pouch and opened sufficiently to allow of the 

 introduction of the two forefingers, by means 

 of which the opening is dilated laterally as 

 far as the sacrouterine ligaments. A some- 

 what similar proceeding is adopted in front, 

 but here the bladder has to be separated 

 from the anterior wall of the uterus for about 

 an inch before the vesicouterine fold of 

 peritoneum can be reached. This is done 

 by carefully burrowing upward with a director 

 and stripping the tissues from the anterior 

 uterine wall. When the vesicouterine pouch 

 has been opened and the opening dilated 

 laterally, the uterus remains attached only 

 by the broad ligaments, in which are con- 

 tained the vessels that supply the uterus. 

 Before division of the ligaments these vessels 

 have to be dealt with. The forefinger of the 

 left hand is introduced into Douglas' pouch 

 and an aneurism needle, armed with a long 

 silk ligature, is inserted into the vesicouterine 

 pouch, and is pushed through the broad liga- 

 ment of one side about an inch above its lower 

 level and at some distance from the uterus. 

 One end of the ligature is now pulled through 

 the anterior opening, and in this way we 

 have the lowest inch of the broad ligament, 

 in which is contained the uterine artery, 

 enclosed in a ligature. This is tied tightly, and the operation is repeated on the other side. The 

 broad ligament is then divided on either side, between the ligature and the uterus, to the extent 

 to which it has been constricted. By traction on the volsellum which grasps the cervix, the uterus 



FIG. 1171. Relations between uterus, ureter, and 

 uterine artery. (Schematic.) 



