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FIG. 87. Dissection of a body upon whom years before a vaginal hysterectomy had been performed. L, a calcified silk ligature upon the right uterine artery; U, the left uterine artery. No trace of ligature was found on this vessel and the artery still contained a small channel throughout its entire length; B, bladder; R, rectum. The manner in which the vault of the vagina becomes closed by a thin transverse line of union is well shown. Notice how the bases of the broad ligaments hold up the vagina. There is no tendency to hernia, and the posterior cul-de-sac is just as deep as ever it was. This specimen is of value to us as showing the manner in which the vaginal vault continues to be supported even after removal of the uterus.

MORCELLATION.

The uterus is removed in fragments by a process of decentralization.

There are certain cases of very large ovarian abscess which pin the uterus up against the symphysis and immovably fix it there. In such cases the anterior peritoneal space cannot be reached until the uterus is either split or partially cut away as the abscess is evacuated. All broad ligament accumulations demand either hemisection or morcellation. Such are broad ligament abscess, broad ligament hematoma produced by ruptured ectopic gestation, broad ligament cyst of large size, and fibroids with intraligamentous nodules. Morcellation is here necessary because the uterus is displaced so far upwards or to one side and the pelvis so blocked that to even feel the ovarian region the uterus must be removed. In such cases the morcellation is atypical. The peculiar relation of these broad ligament growths to the posterior cul-desac must be remembered (see Exploration).

The necessity for morcellation is not usually determined until the attempt at removal by hemisection has been found impracticable. Indeed, by whatever method the ablation is attempted, a resort can always be had to morcellation. A most accurate knowledge of the minute and regional anatomy of the parts is needed for this operation. Remembering that the blood supply of the uterus approaches the cervical and cornual points and has lateral anastomoses between the upper and lower vessels, and that the arteries which course across the anterior and posterior surfaces of the uterus are small, the operator feels secure in severing all tissue which lies between the lateral ovarian-uterine anastomoses. The object in doing this is to so weaken the tissue in view that more can be pulled down from above by the process of decentraliza

tion, or removing the center, and allow of diminution of the bilateral diameter of the organ. There are two chief ways of doing this. The one most successful in dealing with large uteri associated with pus (the condition we are discussing) is to weaken the anterior uterine wall by removing successive vertical strips of tissue. Mere fixation of the uterus is no indication for morcellation; the fixation must be accompanied by marked enlargement. Typical or symmetrical morcellation is rarely possible when dealing with pus cases, the operator often combining several methods in excavating the uterine wall.

Operation. It is a great aid if the posterior cul-de-sac can be opened. This is first done; next the bladder is dissected from the uterus until the anterior peritoneal pouch is opened up as far as is possible. While the bladder is held up by a Jackson speculum and the intestines protected by a gauze pad, the anterior wall of the uterus is split as high as possible. Holding the everted edges of the cut with bullet forceps, the operator trims a strip of tissue about a quarter of an inch wide, first from one side, and then from the other (Fig. 88, 1 and 2). A halfinch has now been taken out of the entire visible anterior uterine wall. The removal of this amount of tissue from the cervix will usually be all that can be taken away without reaching its sides. The other slices cut out will be above the cervix and limited to the body of the uterus. In most cases it will be found that the removal of the first two strips has so weakened the anterior uterine wall that the median splitting of the anterior wall can be continued, and the cornua uteri can be brought into view beneath the bladder (3 and 4 of Fig. 88). But in some cases the bladder is attached so high up upon the uterus that the dissecting finger can not effect the separation. Then it will be necessary to split the uterus up as high as possible and remove from each side one, and perhaps two wedge-shaped pieces with their bases upward (5 and 6 of Fig. 88). The stumps are firmly grasped and the anterior wall pulled further down, while the bladder is pushed up so as to expose more of the uterine tissue. What

appears is again split in the middle line, and from each side a wedge of tissue is removed (7 and 8 of Fig. 88). Progressively pulling down the uterus and cutting out pieces, the cornua appear. So far there has been free capillary bleeding, but none from vessels of large size. There has been no hemostasis. When the cornua come into Central incision

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FIG. 88.-A scheme of symmetrical morcellation. The segments are removed as numbered. Sometimes it will be necessary to remove segments 1, 2, 3, 4 only, and this is especially true in pus cases with hypertrophy of the uterus. But in fibroid cases the procedure will have to be pursued so as to embrace most of the tissue included within the dotted lines.

view, if necessary, a large wedge is cut from the fundus, the base of which is at the top of the uterus. This piece will encroach upon the posterior surface of the uterus, and at once upon its removal the cornua with their tubes

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