In a simple case the broad ligaments are seized with hæmostatic forceps;
if the ovaries and tubes are healthy and the surgeon wishes to preserve
them, the forceps are applied between the ovary and the uterus; but if
they are obviously diseased and must be sacrificed, the forceps are
applied to the broad ligaments near the brim of the pelvis beyond the
outer pole of the ovary. In some instances the round ligament of the
uterus can be seized with the same forceps, but in many cases it is
necessary to clip it separately. It is an advantage to secure the round
ligament at this stage, for the forceps controls its artery and prevents
the stump of the ligament unduly retracting the peritoneum. The broad
and round ligament on each side are divided, and the uterine artery is
exposed on each side of the uterus and caught with forceps: a peritoneal
flap is then fashioned on the anterior wall of the uterus at its
junction with the neck, taking care not to injure the bladder; and a
similar flap is cut on the posterior wall. The uterus is then detached
at a point well below the junction of the cervix with the body of the
uterus: if the forceps are correctly applied to the vessels the
detachment of the uterus is an almost bloodless proceeding: a small
vessel here and there will perhaps require the application of a pair of
forceps.
The principle involved in this part of the operation may be explained by
reference to the diagram (Fig. 9). The blood-supply of the uterus
follows four routes; two of these are the ovarian arteries which
traverse the broad ligaments to reach the cornua of the uterus, where
they anastomose with the terminations of the uterine arteries; the
latter come into relation with the uterus near the junction of the body
and cervix, and then ascend the sides of the uterus to the cornua. No
large vessels are found on the anterior or posterior surface of the
uterus. An arterial twig runs along the round ligament, bringing the
ovarian artery into relation with the deep epigastric artery. If the
surgeon thoroughly appreciates the distribution of the ovarian and
uterine vessels he will at once perceive that if the four forceps are
properly applied to the vessels the blood-supply is under absolute
control: indeed, in many cases a subtotal hysterectomy can be performed
without the loss of more than an ounce of blood. When the broad ligament
is clamped and detached there is a spurt of blood from the uterine cornu
which lasts until the corresponding uterine artery is caught with the
forceps, and the cessation of the bleeding at the uterine cornu is a
sign that the artery is securely clipped. It must be remembered that
with a small tumour in the uterus the vessels follow their normal
courses and can be easily found, but when the uterus is deformed by huge
tumours, the vessels are not so easily seen, and they are of large size
and give rise to furious bleeding when divided. In dealing with large
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