ON SOME MODIFICATIONS IN THE TECHNIQUE 
OF ABDOMINAL SURGERY, LIMITING THE 
USE OF THE LIGATURE EN MASSE. 
BY 
LEWIS A. M.D., 
OF NEW YORK. 
FROM 
THE MEDICAL NEWS, 
July 27, 1889. [Reprinted from The Medical News, July 27, 1889.] 
ON SOME MODIFICATIONS IN THE TECHNIQUE 
OF ABDOMIN AL SURGERY, LIMITING THE 
USE OF THE LIGATURE EN MASSE.1 
By LEWIS A. STIMSON, M.D., 
OF NEW YORK. 
The period during which the important and bril- 
liant operations, now so frequently and successfully 
performed within the abdominal cavity, have been 
practised is relatively very brief, and although the 
accumulated, and, in many instances, the individual 
experience is large, the work has, in the main, been 
done along lines and according to methods and 
principles which, it may be assumed, have yet to 
undergo modifications that will be slowly evolved 
from the thoughts and experience of successive gen- 
erations of surgeons. In this respect abdominal 
surgery differs widely from the other branches of 
the art: it can profit, not by the experience of cen- 
turies within its own field, but by that of only a few 
decades of years; and as, in addition, the material 
conditions of this field present wide variations from 
those of the regions upon which the skill and thought 
of surgeons have heretofore been concentrated, it is 
1 Read before the American Surgical Association, 1889. 2 
STIMSON, 
not singular that corresponding differences should 
appear in its operative principles and methods. Of 
these differences the most striking is in the measures 
taken to prevent or arrest hemorrhage, which con- 
sist, as a rule, of ligatures en masse, ligatures of 
heavy silk, each embracing a large mass of tissue, 
and thus creating one or more "stumps" from 
which the blood-supply has been cut off, and which, 
subsequently, are either fixed in the external wound 
to be slowly cast off, or are left in the abdominal 
cavity to undergo molecular disintegration and ab- 
sorption. 
The advantages which, in theory at least, belong 
to this method are celerity of performance and free- 
dom from hemorrhage, and it is not to be denied 
that in many cases, and especially in those which 
were the first undertaken in this branch, and success 
in which led to the great extension that has followed 
-the removal of narrow pedunculated cysts of the 
ovary-these advantages do exist. By no other 
method of treatment, probably, could the cyst be 
removed through so small an incision, so rapidly and 
so safely, and it is not strange that its admirable 
adaptability to these cases should have led to its 
habitual use in others, and that the attention and 
ingenuity of operators should have been directed by 
its defects to its improvement and modification 
rather to the substitution of a radically different 
method. 
The principal objections to the ligature en masse 
are two in number : (i) It is not always an efficient TECHNIQUE OF ABDOMINAL SURGERY. 
3 
protection against hemorrhage, and (2) the mass of 
tissue embraced by it and forming the stump is 
sometimes so large or so related that it cannot safely 
be returned within the cavity and treated intra-peri- 
toneally, but must be fixed in the parietal wound to 
be cast off as a slough, and thus to necessitate healing 
by granulation, with its delay and risks. The size 
of the stump is not the only reason for treating it 
extra-peritoneally; another and equally strong one 
arises from the fear of hemorrhage or from the nature 
of the means used to prevent it, such as the elastic 
ligature, the clamp, or the 6craseur, which cannot be 
left within the peritoneal cavity. The danger of 
hemorrhage from a stump that is long enough to be 
treated extra-peritoneally is not great, for the pro- 
tective means at our disposal are efficient, and, if 
bleeding should occur, it can be promptly detected 
and readily controlled. But it is vastly different 
with ligatures that are left within the cavity, ligatures 
of silk or catgut embracing, usually, a broad layer 
of parietal peritoneum that has been drawn in from 
all sides toward the ligature and is retained by it 
under considerable tension. Within this puckered 
fold of peritoneum lie the vessels and the tissue in 
which they are imbedded, all tense because they 
have been lifted up and drawn upon in the applica- 
tion of the ligature, and all constantly solicited by 
this tension to slip out of the loop. Each slight 
yielding to this traction makes the next one easier, 
for it diminishes the amount of tissue embraced 
within the loop, and thus diminishes also the friction 4 
STIMSON, 
by which the rest is retained. Hemorrhage from 
such a ligature is not uncommon, and has been fatal, 
and the post-mortem examination plainly shows the 
mechanism by which it has been made possible; 
there is the large circular gap in the peritoneum, the 
wide extravasation in the subperitoneal connective 
tissue, and far up within it the divided vessel, all 
indicating by their separation the traction necessary 
to bring them within the loop of a single ligature. 
The fault is not in the tying of the ligature ; it has 
not become untied, but it has failed to hold, just as 
it would have failed if it had been placed upon a 
smooth, hard cone. The ligature has not simply to 
compress the vessels contained within it, but it has 
also to oppose a constantly exerted everting strain, 
acting toward all sides, widening its loop, and favor- 
ing the escape of the central vessels by loosening the 
friction upon them, and in this contest it has too 
often proved the weaker. 
The consideration that appears to have had most 
to do with the general use of this dangerous form of 
ligature is the supposed necessity of tying all divided 
tissues in order that all hemorrhage may be pre- 
vented, not only that from the larger vessels, but 
also that from the minute vessels of the peritoneum 
and connective tissue. But this necessity, I think, 
does not exist, and this mode of ligature should be 
abandoned, except in certain special cases, for that 
which is the rule in operations upon other parts of 
the body, the ligature of the arteries alone with the 
smallest possible amount of additional tissue, and technique of abdominal surgery. 
5 
every effort should be made to exclude the perito- 
neum itself from the grasp of the ligature. Ordina- 
rily, this is not difficult to accomplish. Take, for 
example, the outer portion of the broad ligament, 
where its peritoneal layers are reflected forward, 
backward, and outward, over the pelvis, and where 
the bundle of ovarian vessels lies. Draw it well up 
by lifting the ovary, place a rather long-bladed pair 
of self-holding forceps transversely upon it close to 
its base, divide the ligament a half inch on the distal 
side of the forceps along the full length of its blades; 
the divided vessels will be plainly seen on the cut 
surface, where they can be readily grasped with an 
artery-clamp, the peritoneum stripped back, and a 
ligature applied. Then, on removal of the first pair 
of forceps, the peritoneum retracts to its original 
position, the vessels lie free in their bed of connec- 
tive tissue, and the ligature is subjected to no other 
strain than if it had been placed upon an artery in 
continuity; traction upon the parietal peritoneum 
by any shifting of the viscera or change in the atti- 
tude of the patient leaves it unaffected thereby. 
This can be done wherever a clamp can be placed 
between the abdominal wall and the part that is to 
be removed, and the cases in which ligature en masse 
will be preferable appear to me to be only those in 
which the abdominal incision is so small or the an- 
terior wall so thick and so slightly depressible that a 
clamp cannot be securely applied and the cut surface 
readily inspected and handled. The cut edges of 
the peritoneum can afterward be brought together 6 
STIMSON, 
with a continuous suture, if it is thought best to 
close this gap. The principle which, in my judg- 
ment, should govern the method of securing vessels 
divided in the removal of a viscus or a tumor from 
the abdominal parietes may be formulated as follows: 
The ligature should be applied to the vessels alone, 
underneath the peritoneum, and should under no 
circumstances include a circular layer or sleeve of 
parietal peritoneum that has been forcibly drawn up 
to form a pedicle, and will have to be held by the 
ligature against a diverging lateral strain. 
A special and very valuable application of the 
substitution of isolated ligature of the vessels for the 
ligature en masse is the preliminary ligature of the 
uterine arteries in continuity, in supra-cervical or 
total abdominal hysterectomy. I have employed it 
with complete success in five cases, the first two of 
which were reported to the New York Surgical 
Society, January 9, 1889, and published in the New 
York Medical Journal, March 9, 1889. Each artery 
is sought for at the side of the upper part of the 
cervix by palpation of the broad ligament between 
the finger and thumb; after its position has been 
thus ascertained, a small incision is made through 
the peritoneum along its course on the front or, 
preferably, the back of the broad ligament, the 
artery separated from the veins with a director, and 
a ligature passed by means of an aneurism needle. 
The ureter lies to the outer side and is easily avoided. 
When both uterine arteries have been thus tied, and 
the ovarian vessels secured, as above described, by Technique of abdominal surgery. 
7 
clamps, both ovaries and tubes and the body of the 
uterus can be removed by a transverse incision just 
above the clamps and ligatures, and the cut surface 
will be almost absolutely bloodless. The cervix can 
then be removed by cutting through between it and 
the bladder into the vagina and then cutting around 
it with scissors, or, of course, the cervix can be 
removed without previously cutting away the body 
of the uterus by cutting through each broad liga- 
ment to the side of the uterus, carrying the incisions 
through the peritoneum on the front and back of 
the uterus, and then working down through these 
latter incisions to the vagina as in the other' case. 
The hemorrhage from this part of the operation is 
trifling, and as the cut surface is freely exposed to 
view, any vessel that may require it can be readily 
caught and tied. The following record of a hitherto 
unpublished case (my fourth) may serve to show the 
details. 
F. W., forty-eight years old, colored, unmarried, 
had suffered for a number of years from abdominal 
pain and discomfort, and profuse hemorrhages from 
the womb attributed to a slowly increasing abdom- 
inal tumor situated in the hypogastrium. When I 
first saw her, in March, 1889, she was greatly 
reduced in strength and had been confined to bed 
for several weeks. Examination showed a solid, 
irregular, movable tumor filling the space between 
the umbilicus and pubes, and extending a hand's 
breadth to either side of the median line. The 
cervix could not be reached per vaginam, and the 
upper wall of the vagina was somewhat depressed by 8 
STIMSON, 
a firm, rounded mass, movable and apparently con- 
tinuous with that lying above the pubes. The diag- 
nosis of multiple uterine fibroids was made, and an 
operation for their removal was proposed and 
accepted. I sent the patient to the New York Hos- 
pital, and operated there March 26, 1889. 
The peritoneal cavity was opened by an incision 
extending from a little above the pubes to the um- 
bilicus, and through this the tumor and both ovaries 
were with some little difficulty turned out. By divis- 
ion of some broad adhesions between the rectum and 
the back of the uterus, Douglas's pouch and the 
posterior surface of the broad ligaments were freely 
exposed to sight and touch. The two layers of each 
broad ligament were found to be widely separated 
from each other near the uterus by the development 
of a fibroid low down upon the back of this organ, 
and each uterine artery could be felt lying much 
nearer the anterior than the posterior layer. The 
left one was first sought for through an incision in 
the posterior layer low down in the pelvis close 
beside the above-mentioned fibroid; it was found at 
the depth of about an inch, raised upon an aneurism 
needle for inspection and identification, and tied 
with catgut. The search for the right uterine artery 
was more difficult, because of its even greater dis- 
tance from the posterior layer, but it was ultimately 
secured and tied, although not so cleanly isolated as 
the other had been. Up to this time twenty-five 
minutes had been consumed in the operation, fully 
ten more than in any of the preceding operations, 
the delay being due partly to the difficulties created 
by the depth at which the arteries were placed, and 
partly to an intercurrent exploration made to ascer- 
tain if they could be exposed and recognized with Technique of abdominal surgery, 
9 
certainty close to their origin upon the anterior 
branch of the internal iliac artery. 
The outer portion of each broad ligament was 
then clamped with haemostatic forceps well below 
the ovary, each ligament completely divided with 
the knife above the clamp, the cuts united by 
incisions through the peritoneum covering the front 
and back of the uterus, and through these incisions 
the uterus was peeled away from the peritoneum 
well down to the cervix, and then its body cut away 
by a transverse cut. There was no bleeding from 
the cut surface. 
The stump of the uterus was seized with Volsella 
forceps and drawn upward and backward, the cut 
edge of the peritoneum adjoining the bladder drawn 
forward, and the anterior surface of the cervix 
rapidly dissected out until the vagina was opened 
into, the dissection being guided by the left fore- 
finger introduced through the vulva into the vagina. 
After the opening had been made the finger was 
withdrawn and reintroduced into the vagina through 
the opening to serve as a guide in the division of the 
remaining attachments of the cervix; this was 
quickly and easily made with scissors, taking care 
to cut on the sides between the ligated uterine arte- 
ries and the cervix. There was no hemorrhage 
requiring attention, except from two small vessels 
divided in the dissection of the anterior surface of 
the cervix. 
Turning then to the cut surfaces of each broad 
ligament at its outer part, where held by the clamp, 
the bunch of divided vessels was caught with another 
clamp, drawn out of its peritoneal sheath, and tied 
with catgut. The removal had thus been made and 
all bleeding arrested or prevented by six catgut liga- 10 
STIMSON, 
tures, two on the uterine arteries, two on the bunches 
of ovarian vessels, and two on small bleeding points 
between the bladder and vagina. 
The remaining details may be briefly given. The 
peritoneal flaps raised from the front and back of the 
uterus were turned down toward the vagina so that 
their serous surfaces were opposed to each other, 
and the sides of the peritoneal gap left by division 
of each broad ligament were brought together by a 
continuous catgut suture; a rubber drainage tube 
was placed in the vagina so that its inner end pro- 
jected about two inches into the peritoneal cavity, 
and the anterior incision was closed. The vagina 
was loosely packed with iodoform gauze. The 
drainage tube was removed after forty-eight hours; 
loose packing was kept in the vagina for a week, and 
this passage was occasionally cleaned with a douche. 
The patient made a good recovery. 
The capital point to be attended to is that the 
uterine arteries should be tied sufficiently low down 
in the pelvis, before branches of any considerable 
size are given off, for otherwise time will be lost in 
securing these branches when they are subsequently 
divided. In case of accident, such as the slipping 
of the knot of the ligature, or the wounding of the 
artery or of a branch by the aneurism needle, or of 
hemorrhage from an unsecured branch, the bleeding 
can be easily arrested by pressure with the finger 
upon the corresponding internal iliac artery or its 
anterior branch, and an opportunity thus afforded 
leisurely to repair the damage or secure the wounded 
vessel. TECHNIQUE OF ABDOMINAL SURGERY. 
11 
The advantages of the method are apparent: 
rapidity and ease of execution, absolute and perma- 
nent security against hemorrhage, relief from the 
necessity of creating strangulated stumps with the 
concomitant risks of setting up suppurative or septic 
processes, and immediate closure of the abdominal 
wound. In cases in which it maybe deemed desira- 
ble to retain the cervix, it can be entirely shut off 
from the peritoneal cavity by drawing the peritoneum 
together over it, and its raw surface and that of the 
subperitoneal space can be drained by a tube placed 
in the cervical canal and brought out through the 
vagina. If the operation is undertaken for proci- 
dentia, the cervix may be retained and fixed in the 
lower angle of the abdominal wound, as in one of 
my fibroid cases, or it may be removed and the 
upper cut edges of the vagina fixed in the same place, 
as was recently done with success by my friend and 
colleague Dr. William M. Polk. 
Whether or not the isolated ligature of vessels 
upon the cut surfaces of the base of implantation of 
broadly pedunculated tumors of the ovary and of 
those formed by distention of the tubes can be 
advantageously substituted for the ligature en masse 
I have not yet had an opportunity to determine by 
trial, but I believe that it can be. Certainly the 
ovarian artery can be thus secured, and it does not 
seem probable that the branches coming from the 
side of the uterus will prove too large or too numer- 
ous thus to be safely and promptly secured. It is 
within the experience of all that a heavy silk ligature 12 
TECHNIQUE OF ABDOMINAL SURGERY. 
drawn with all the force that it will bear about such 
a pedicle does not always prevent bleeding, but that 
separate ligatures need in addition to be placed 
upon one or two spirting vessels. The trial can be 
easily made, and, I believe, without serious risk. THE MEDICAL NEWS. 
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