THE FEMALE PELVIS 395 



forwards and medially on the pelvic floor till it reaches the 

 base of the broad ligament. It then runs medially between 

 the two peritoneal layers to the lateral border of the uterus. 

 At a distance of three-quarters of an inch, from the uterus the 

 uterine artery crosses above and anterior to the ureter, and, in 

 tying the vessel, great care must be exercised not to include 

 the ureter within the ligature. In order to avoid this danger, 

 the artery is usually tied close to the uterus, as it lies above 

 the lateral fornix of the vagina. 



The uterine artery, after giving off a branch which descends 

 to supply the cervix and vagina, ascends along the lateral border 

 of the uterus, supplying it with numerous branches. Finally it 

 ends by supplying the isthmus of the uterine tube and by 

 anastomosing with branches of the ovarian artery. 



Hysterectomy. The operation of removal of the uterus 

 has been much simplified by the adoption of the Trendelenberg 

 position and the abdominal route. Access is obtained by 

 means of a median infra-umbilical incision (Fig. 76) through 

 the abdominal wall. 



The suspensory ligaments of the ovary and the round 

 ligaments are seized in forceps, to secure the contained arteries, 

 and are then divided. The ovary and tube are lifted up on 

 each side, and, lateral to them, the broad ligaments are divided 

 medially and downwards towards the uterus. Before the 

 uterus is reached, artery forceps are passed downwards and 

 medially to secure the uterine artery in the interval between 

 the point where it crosses the ureter and the point where it gives 

 off its descending cervical branch. The peritoneal covering of 

 the uterus is then incised transversely in front and behind so 

 as to join the incisions already made in the broad ligaments. 

 The fingers are inserted into the cellular interval between the 

 bladder and the cervix, and the two viscera are carefully 

 separated from one another. The uterus is then dragged up- 

 wards and the supra- vaginal portion of the cervix is cut through. 

 All the cut vessels are tied, and, in order to prevent slipping, 

 the ligatures should be passed through the peritoneum. In 

 the case of the uterine artery, a secure hold may be obtained 

 by passing the ligature through the stump of the cervix. 

 Subsequently, the cut edges of the peritoneum are sutured 

 together across the floor of the pelvis, all the ligatures being 

 inverted beneath the peritoneum. The last step in the operation 

 consists in placing the pelvic colon in the empty pelvis. 



