INTRALIGAMENTOUS AND RETROPERITONEAL TUMORS 
OF THE UTERUS AND ITS ADNEXA. 
BY 
WILLIAM H. WAT HEN. A. M.. M. D. [Reprinted from the 1894 Transactions of the American Gynecological Society.] 
INTRALIGAMENTOUS AND RETROPERITONEAL TUMORS 
OF THE UTERUS AND ITS ADNEXA. 
BY 
WILLIAM H. WATHEN. A. M.. M. D„ 
Professor of Abdominal Surgery and Gynecology in the Kentucky School of Medicine; 
Fellow of the American Gynecological Society and of the Southern Surgical and 
Gynecological Society; Gynecologist to the Kentucky School of 
Medicine Hospital and the Louisville City Hospital, 
etc., Louisville, Kentucky. 
With two Illustrations. 
A few years ago paroophoritic cysts embedded between the 
layers of the broad ligament deep into the pelvic cellular tissue, 
and intraligamentous and retroperitoneal myomata of the uterus 
or its muscular processes, were not amenable to surgical treat- 
ment, and when such conditions were encountered in a celiotomy 
the abdomen was closed without attempting to remove the tumor. 
Fortunately we now know more about the pathology of these 
tumors, and have learned how they may be removed with less 
mortality than was usual twenty years ago in ovariotomy. 
Paroophoritic cysts and subperitoneal myomata have nothing in 
common in their etiology, but, as the technique of the operation 
for their successful removal is in many particulars identical, I will 
include both kinds of tumors in what 1 will say to-day. 
Alban Doran, J. Bland Sutton, and other authorities have 
recently written so much about the pathology of these tumors 
that it will not be necessary for me to consider that part of the 
subject further than to make intelligent what I will say about the 
operative treatment. 
With few exceptions, cysts that unfold the layers of the broad 4 
TUMORS OF THE UTERUS AND ITS ADNEXA. 
\igament and burrow deep into the pelvic and retroperitoneal con- 
nective tissue, often developing nearly continuity in relation to- 
other structures, probably arise from the remnants of the meso- 
nephros in the paroophoron. They are both unilocular and 
multilocular, and at some stage of their existence are papillomatous. 
In rare instances cysts that arise in the tubules of the parovarium, 
in the broad ligament between the parovarium and the uterus, in 
the mesosalpinx between the parovarium and the Fallopian tube, 
or in the oophoron, unfold the layers of the broad ligament and 
become embedded, but seldom firmly attached to adjacent tissues. 
These cysts, except the oophoritic cyst, arise from the Wolffian 
tubules or duct, and stray remnants of the mesonephros may 
extend into the ovarian parenchyma. Oophoritic cysts origi- 
nate from Graafian follicles undergoing retrograde processes of 
development, are nearly always multilocular, and have glandular 
intracystic growths, with which papillomata may sometimes be 
associated. Cysts that arise from the remnants of the meson- 
ephros do not have intracystic glandular growths, but at some 
stage of their existence warts develop, partially or completely 
lining the internal surface of the cyst; and sometimes, having 
filled the cyst cavity beyond its capacity, they penetrate its walls 
and present on the external surface, forming adhesions to adjacent 
parts. Cysts of any relic of the mesonephros, except in the fibrous 
tissue of the parodphoron, are nearly always unilocular, and 
when they develop to any considerable size generally become 
pedunculated; and if they do not, they are so feebly connected 
to the investing membrane that they may be easily enucleated 
without encountering dangerous complications. 
As paroophoritic cysts increase in size the peritoneum of the- 
broad ligament and the muscle fibres between its layers increase TUMORS OF THE UTERUS AND ITS ADNEXA. 
5 
in thickness, and often become very vascular. This vascularity 
is especially marked when the cyst has separated the peritoneum 
from its posterior attachment and opened the mesorectum, the 
mesocolon, or the mesentery of the small intestine. In these 
cases 1 have seen the greater part of the surface of the investing 
membrane covered with veins larger than a goose quill—a con- 
dition similar to that seen in intraligamentous and retroperitoneal 
myomata. These cysts are often bilateral, which greatly increases 
the difficulties and dangers in their removal; and in such cases 
there may exist an almost indissoluble connection with the uterus, 
which may necessitate its removal with the cysts, if the operation 
can be successfully completed at all. When the tumors are small 
they lie in the folds of the broad ligament, and as they increase in 
size they unfold its layers, finally passing beneath Douglas’ sac 
into the prevertebral space. The peritoneum may be separated 
anteriorly, so that the tumor may lie in front of it, attached to 
the bladder and to the fascia and muscles of the anterior abdomi- 
nal walls, the separation sometimes being so extensive that it 
may be possible to reach the cyst and enucleate it through a 
median incision between the pubes and umbilicus without wound- 
ing the peritoneum. But the peritoneal separation is usually from 
the posterior pelvic and abdominal walls; the tumor, having 
passed beneath Douglas’ sac, unfolds the mesorectum, mesocolon, 
or the mesentery of the small intestine; or, passing under the 
appendix, the cecum, or the ascending colon, lies between them 
and the abdominal walls. In these cases the muscularis and con- 
nective tissue of the bowel are in immediate relation with the cyst 
wall, and the union may be so intimate as to be nearly a continuity 
of tissue that can hardly be separated without destroying the 
integrity of the bowel. The same intimate and firm connection 6 
TUMORS OF THE UTERUS AND ITS ADNEXA. 
may exist between the cyst wall and the ureters, deep pelvic 
vessels, the uterus, and the bladder. 
As intraligamentous and subperitoneal myomata of the uterus 
and its muscular processes sustain relations to the peritoneum 
and the pelvic and abdominal viscera and structures nearly iden- 
tical with the relations sustained by paroophoritic cysts, a further 
description is not necessary. It must, however, be remembered 
that the union between a myoma and the capsule is less firm, and 
that enucleation is easier and less dangerous to the intestines, 
bladder, ureters, and deep-seated vessels. With either a cystic 
or solid tumor the organs may be so distorted and displaced as 
to make it difficult to correctly and practically appreciate their 
ralations to the tumor. Several times the ureter has been found 
under the capsule in front of the tumor, and has been cut or torn 
in efforts at enucleation. This abnormal position is more fre- 
quently observed in myomatus tumors. The venous sinuses 
coursing over the surface of the investing membrane of the retro- 
peritoneal myomata are larger and more abundant than in paro- 
ophoritic cysts. 
In one patient upon whom I operated the myoma had unfolded 
the layers of the broad ligament on the left side, the left lateral 
half of Douglas’ sac, and the mesorectum and mesocolon. In 
another case the myoma appeared to have enlarged the uterus 
nearly symmetrically, unfolding both ligaments, and was held 
firmly in the pelvic cavity. In another case the tumor had its 
origin posteriorly in the cervix and lower part of the body, had 
lifted the peritoneum from Douglas’ sac and separated the meso- 
rectum and mesocolon. Two of these tumors I will show you, 
together with a typical intraligamentous cyst, removed from the 
left side, that contained sixteen pints of liquid and had separated TUMORS OF THE UTERUS AND ITS ADNEXA. 
7 
the peritoneum from Douglas’ sac and unfolded the mesorectum 
and mesocolon. Five years ago I opened the abdomen, and, when 
extensive adhesions were separated, found an intraligamentous 
cyst on the right side the size of a large orange, which was so 
deeply seated and so intimately attached to the uterus and blad- 
der that 1 did not attempt its removal, feeling that the feeble con- 
dition of my patient did not justify it. The tumor has decreased 
one-half its size, but the uterus is still nearly immovably fixed 
She frequently has much pelvic pain, and menstruation is exces- 
sive. In another case, operated on two years ago, the tumor con- 
tained twelve pints of liquid, was on the left side, had lifted the 
peritoneum from Douglas’ sac, separated the folds of the mesorec- 
tum and mesocolon, and extended up under the peritoneum to the 
left kidney. Anteriorly the tumor had burst through its capsule 
and extended upward and to the right side two inches above the 
umbilicus. The sac was so fragile and tore so easily that enucle- 
ation was impossible; and, after removing the projecting part, 
the cyst wall and capsule were sutured to the abdominal incision. 
She recovered from the operation, but has a sinus that continues 
to discharge pus. 
Intraligamentous and retroperitoneal myomata are relatively as 
infrequent as are paroophoritic cysts. They arise in the cervix 
uteri and lower part of the body, or possibly from the muscular 
processes of the uterus—round ligament, ovarian ligament, ovary, 
or muscle fibres in the broad ligament. 
I can find recorded but one case of myoma of the Fallopian 
tube, but, as the tube is composed of unstriped muscle fibres, 
there is no reason why myomata should not develop in its walls. 
Myomata of the round ligament, ovarian ligament, and of the 
ovary rarely become embedded in the connective tissue under the 8 
TUMORS OF THE UTERUS AND ITS ADNEXA 
peritoneum; and while myomata that develop from the muscle 
cells of the broad ligament may do so, I suggest that probably 
most of these tumors primarily have their origin in the uterus, 
and finally become broad-ligament myomata by being extruded or 
forced from its walls. Uterine myomata are soft or hard, but, as 
there is a preponderance of fibrous and connective tissue in the 
cervix and lower part of the body, intraligamentous and retroper- 
itoneal soft myomata are infrequent. They may be cavernous 
or telangiectatic, and so vascular that the danger from hemorrhage 
in an operation for their removal is much greater than in operations 
for the removal of hard myomata which are practically non- 
vascular. The vascular currents, however, in a soft myoma are 
sluggish and hemorrhage is therefore more easily controlled. In 
soft myomata, and especially in hard myomata, the blood vessels 
from which we may expect the most dangerous hemorrhage are 
mainly confined to the capsule and the connective tissue uniting 
the capsule to the tumor. While developed myomata are usually 
encapsulated and practically live outside the uterus—parasitic, as 
it were—red, soft myomata, being seldom completely encapsul- 
ated, sustain more intimate relations with the uterine muscle 
fibres. We sometimes encounter so-called fibro-cystic subperito- 
neal uterine tumors the result of partial or complete mucoid degen- 
eration of myomata. 
No one should attempt the removal of intraligamentous or retro- 
peritoneal embedded cystic or solid tumors who is not practically 
familiar with the normal relations of every pelvic and abdominal 
viscus and structure and the relations that these tumors may 
sustain to surrounding tissues; otherwise he is at sea without a 
compass, and the immediate and subsequent results of his work 
will be bad. As hemorrhage is the most dangerous complication, TUMORS OF THE UTERUS AND ITS ADNEXA. 
9 
he must know that these tumors and the uterus are mainly sup- 
plied with blood by the two spermatic and the two uterine 
arteries, and that if these vessels are ligated this danger is greatly 
lessened, as is also the danger of injury to the intestines, bladder, 
ureter, or deep-seated vessels that might result in the hurry of 
excitement caused by inability to control bleeding. When these 
tumors have formed extensive adhesions to the omentum, etc., 
they may receive blood from that source also. The dangers of 
the operation which we may anticipate are: 
1. Hemorrhage from separated adhesions, from the capsule of 
the tumor, from the denuded surface of a myoma, from injury to 
the spermatic and uterine arteries, the iliac arteries and veins, 
and inferior vena cava. 
2. Wounding the ureters, the bladder, and the intestines. The 
causes of death are hemorrhage, shock and sepsis. 
While the general principles that govern us in controlling 
hemorrhage, avoiding injuries to adjacent structures, and prevent- 
ing sepsis, are common to all operations for the removal of these 
tumors, in a surgical sense they are, in a degree, atypical, and no 
single or special method of treatment will be applicable in every 
particular to all cases. The results of the operation depend 
mainly upon controlling hemorrhage and successful enucleation, 
and this applies equally to cystic and solid tumors, as the tech- 
nique is practically identical. To prevent injury to a ureter that 
may be in front of the tumor it is best to incise the capsule, and 
to introduce ligatures, parallel to the abdominal wound. In open- 
ing the capsule avoid large vessels, and, if possible, make the 
incision so as to give two flaps of nearly equal size that may be 
evenly approximated, and, if preferred, united with a continuous 
suture. A cyst should be tapped before enucleation is begun ; 10 
TUMORS OF THE UTERUS AND ITS ADNEXA. 
this causes the calibre of the vessels in the capsule to contract. 
Hemorrhage will be greatly lessened by careful enucleation close 
to the cyst wall or the substance of a myoma, thus pushing the 
vessels in the capsule and in the connective tissue away from 
the tumor without wounding them. If the spermatic arteries have 
previously been ligated near the uterus and near the pelvic walls, 
the enucleation may sometimes be completed without wounding 
a vessel large enough to cause troublesome hemorrhage. In fact, 
it may be possible in some cases, by enucleating close to the 
tumor and the uterus, to do total hysterectomy without ligating 
the uterine arteries, they being pushed aside and left in the pelvis 
uninjured. Enucleation is best done with the fingers or blunt 
instruments, and not with the knife or scissors. We should not 
lose our bearings, and should work as rapidly as possible consist- 
ent with conservative and successful surgery. If it can be 
avoided the capsule should not be torn. Apposition of the raw 
surfaces or drainage may be better accomplished by keeping the 
sac entire. If an assistant will, with vulsella or other forceps, 
lift the cyst sac or myoma firmly out of the pelvis or abdomen, 
enucleation will be facilitated and hemorrhage lessened. Great 
care must be observed in separating the tumor from the bladder 
and the intestines, and especially is this necessary in paroophoritic 
cysts, otherwise these organs may be wounded or the coats so 
injured that sloughing may result. When the enucleation has 
reached the prevertebral space in the pelvic connective tissue 
careful dissection must be made—always hugging the tumor to 
avoid the ureters or deep-seated vessels—and, if possible, bring 
the field of enucleation into view. 
Hemorrhage should be controlled by forceps, separate ligation, 
and ligation en masse, and a continuous suture may be used. TUMORS OF THE UTERUS AND ITS ADNEXA. 
11 
Where it can be used gum tubing may encircle the tumor and 
control hemorrhage, but it is not applicable in many cases. The 
rope ecraseur of Tait may also be applied, but it has no real ad- 
vantages over the gum tubing and may injure the capsule. Hem- 
orrhage from the substance of a soft, cavernous myoma may be 
controlled by firm gauze pressure or by ligation en masse, the 
ligature being introduced deep under the bleeding vessel with a 
long curved needle. Forceps should be so shaped as to be readily 
applied to any part of the separated capsule, and the surface of the 
blades should be comparatively smooth and the edges so rounded 
as not to cause hemorrhage by cutting through the thin fragile 
walls of the vessels. Here are forceps, two of which I have 
recently devised, which will serve this purpose. Adhesions to 
the omentum or other abdominal or pelvic structures should be 
separated, if possible, before the capsule is incised, and they 
should be divided between forceps or ligatures. When enuclea- 
tion is completed a paroophoritic cyst may have no pedicle, or a 
pedicle so small that it may be easily ligated ; the same may also 12 
TUMORS OF THE UTERUS AND ITS ADNEXA. 
be true of myomata of the broad ligament; but intraligamentous 
and retroperitoneal myomata can not usually be removed unless 
we do a hysterectomy. In these cases, and in paroophoritic cysts 
where hysterectomy is necessary, total extirpation is preferable, 
for we can not get sero-serous union over the uterine stump, and 
unless this can be done the cervix ought to be removed. If a 
myoma is small and confined mainly to one side of the pelvis, the 
uterine artery of the opposite side may be ligated, the vagina en- 
tered through Douglas’ sac, the other uterine artery ligated, and 
the vagina cut from the uterus, as practiced by Krug and Pryor, 
before enucleation is begun. This method is difficult, not applicable 
to many cases, and not often necessary, as hemorrhage can usually 
be controlled without it, and ligation is easier and more rapid after 
enucleation. In total extirpation hemorrhage is better controlled 
by dissecting out and separately ligating the uterine arteries out- 
side of the ureter before they give off branches that supply the 
upper part of the vagina and the cervix ; but this may not always 
be possible, and then the ligation should be close to the cervix, 
so as to protect the ureters ; if the vaginal branches bleed they 
may be separately ligated. If in every case of total extirpation 
strict prophylactic antiseptic measures are observed, the results, 
as shown in August Martin’s last series of twenty-six cases, will 
be much better. As suspicious germs, and sometimes streptococci, 
are found in myomatous uteri, thorough cleansing, curetting, and 
antiseptic irrigation should always be observed in preparing for 
total extirpation, and the uterine cavity should be tamponed 
tightly with iodoform or bichloride gauze, or the cervical canal 
closed by sutures, as practiced by Martin. 
In paroophoritic cysts it is not always possible to enucleate the 
entire sac, and in such cases the capsule and the cyst wall should TUMORS OF THE UTERUS AND ITS ADNEXA. 
be sutured to the abdominal wound and drained. Prolonged sup- 
puration, and finally death, may follow this treatment, but I know 
of nothing better, and it is preferable to suturing the capsule and 
draining through the vagina. In these operations the patient 
should be in the Trendelenburg position, so that the different 
structures and their relations may be seen as we proceed. There 
is no fixed opinion or uniform practice in the treatment of the sac 
cavity. It is drained through the vagina; through the abdominal 
walls, with and without suturing the capsule to the abdominal 
wound ; or it is not drained at all. Drainage in total extirpation 
should be through the vagina; but if hemostasis has been nearly 
perfect and the operation aseptic it is not necessary, and then the 
vaginal vault should be closed with interrupted catgut sutures. 
If, after enucleation of a tumor without performing hysterectomy, 
there are no indications of immediate or subsequent hemorrhage, 
drainage is not indicated. Martin, Hegar, and Sanger do not now 
use it unless they are positive of excessive secretions from the 
denuded surface of the sac cavity. If the capsule has been 
torn, all irregular or lacerated parts should be cut away. In 
drainage through the vagina a rubber tube or gauze may be 
used, and in suprapubic drainage a glass tube or Mikulicz gauze 
drain may be used. As it is a recognized principle in abdominal 
surgery that sutures or ligatures should not be left in the peri- 
toneal cavity unless they are positively necessary, I would advise 
against uniformly suturing the incision in the capsule. Drainage 
through the vagina is peculiar to August Martin, but probably the 
late Dr. Byford was the first to suture the capsule of a paro- 
ophoritic cyst to the abdominal v/ound. His report was made to 
the Chicago Gynecological Society in 1881. 
As George Granville Bantock is the recognized authority upon 14 
TUMORS OF THE UTERUS AND ITS ADNEXA. 
suprapubic drainage, this method of treating the sac cavity may be 
forcibly presented by the following extract from a letter recently 
received. He says: “* * * Finally, as regards the treatment 
of the cavity, you should stitch the sac to the parietes by inter- 
rupted sutures—the first, at the lower angle of the wound, should 
catch up the sac just free of its mouth ; then a double suture on 
each side passing from without inward, pursing the sac, and then 
going back from within outward, and tying over a roll of gauze or 
lint to prevent cutting into the skin ; then another suture above, 
the same as the first. You should not cut away any of the sac 
until you see how much you require and you have put in your 
sutures. Finally, put a glass drainage tube into the sac. This 
is, I am sure, much better than the iodoform gauze drain as pre- 
scribed by Mikulicz. Should there be much oozing you should 
not be in a hurry to remove the drainage tube, and, if obliged to 
retain it until suppuration threatens or has actually taken place, 
you have only to wash it out two or three times a day with sulphur- 
ous acid (1:10), then substitute india-rubber tubing for the glass, 
and gradually shorten it as the cavity contracts. For washing 
out the sinus the best plan is to have a tube made of celluloid 
with a hole at the end, six inches long and of the calibre of a No. 
2, 3, or 4 catheter, attached to a small syringe by means of a 
piece of india-rubber tubing. With this you can always insure 
clearing out the bottom of the sac. A sinus need never yield 
offensive discharge if you use the sulphurous acid sour enough.”