BRIEF COMMUNICATIONS A SECURITY LIGATURE THERE is often a great deal of difficulty in securely tying certain, inacces- sible structures in surgery, such as in ligating of a cystic duct and artery after cholecystectomy. In order to assure ease in application, security in placing and tying such surgical points as above indicated, the knot to be described is proposed. Having selected the ligature material of choice, two strands of pr4er length are taken and tied, as shown in the diagram, leaving a square knot "A" and two ends, marked "I" "I" and 2 '2'. The part "A" fits over the clamp and the ends "I" "'I and '"2" "2 are so grasped that the thumbs of the right and left hands impinge on the sides of the knot and press in the ends "I" "I" and "2" "2" respectively. This allows placing the knot as deep down over the stump to be tied as desired. By pulling in the opposite directions the two ends, "2" "2" and "I" "it, the knot "A" is securely tied and does not slip. To further assure nonslipping, ends "2" "2" or "I" "I" can be held by clamp or assistant, while the other end is being tied. Either end can now be easily tied without fear of slipping, as the end being tied is firmly held in place by the opposite ligature. The square knot is further tied at ends "I""I", andl once this is accomplished, ends "2" "2" can be readily tied with ease an(d without fear of anything slipping. Thus, this gives a double ligature tie which is easily applied, which can be securely tied, and which leaves, as a final result, three square knots, one in the centre, and one on each side. If so desired, after tying ligatures "i" "i" and "2" "2", ends "I" "I" can be tied to ends "2" "2", thus leaving five square knots, one in the centre, and one in each quadrant. VICTOR CARABBA, M.D., New York, N. Y. From the Department of Experimental Surgery of New York University and Bellevue Hospital Medical College. 1267 BRIEF COMMUNICATIONS VIC .c ad Cd bo (Ut U:} *- ~4) hE~ bcU 3Uo C. 0 .CbC, r"lo ._ ._ 0 CU U bt rn, 1268 SYNCHRONOUS DERMOIDS OF OMENTUM AND OVARY SYNCHRONOUS DERMOID CYST OF THE GREAT OMENTUM AND OF THE OVARY DERMOID cysts may occur in any region of the body, but are nmost commonly found in the ovary. The object at the present communication is to report a case in which a dermoid cyst was present in the great omentum and was associated with a dermoid of the left ovary. CASE REPORT.-R. K., a woman, aged forty-eight was first seen November 3, 1930. She was then complaining of pain in the right side of the abdomen of three weeks' duration. The pain was dull, aching, intermittent in character, and became accentuated about one-half hour after the ingestion of food. A previous history of similar pain was not elicited. The pain did not radiate to the back or shoulder. There was no heartburn, fullness or belching after eating, and no history of jaundice. The appetite was always good and she never vomited, but had been constipated as far back as she could remember. Melena was not present. Save for diurnal frequency, voiding every hour or two, there were no other urinary symptoms. She had lost ten pounds in weight during the previous three months. There was no cough nor night sweats. Her past history was essentially negative save for metrorrhagia which had been present for the last year or two, evidently incidental to the climacteric. She did not appear ill. The heart action was good and the lungs were clear. The breasts were normal. The systolic blood-pressure was I62 and the diastolic 92. The abdomen was obese and lax. In the right umbilical region one could feel a freely movable, round mass of uniform hardness and about the size and consistency of an orange. It was not tender, did not move with respiration and was not fixed to the overlying abdominal wall. The rest of the abdominal examination was negative. Due to the depth of the vaginal vault, the adnexa could not be palpated. Cystoscopy revealed a slightly trabeculated bladder with normal ureteral orifices. Both kidneys were easily catheterized. Microscopic examination of the urine from both kidneys was negative. The 'phthalein concentration from both kidneys was fair. A right pyelogram (Fig. i) was normal. The right kidney appeared to be of normal size, shape and position. Situated about one and one-fourth inches below the lower pole of the right kidney, and overlapping the right ilium there was a circular shadow about four inches in diameter with a well-defined border and mottling within its confines. It seemed to have no connection with the right kidney or ureter. A barium meal (Fig. 2) showed the tumor to be outside the gastro-intestinal tract. On the sixth of November, under spinal anaesthesia, the abdomen was opened through a three-inch right mid-rectus muscle-splitting incision. The great omentum was found to be densely adherent to the anterior parietal peritoneum. Incorporated in the posterior leaf of the great omentum and adherent to the lateral abdominal parieties and to some loops of intestine, there was a hard, cystic tumor about the size of a grapefruit with a dense wall of yellowish-pink color. A cystic tumor about the size and shape of a large hydronephrotic kidney in the left ovary was also revealed. The appendix was very much elongated and densely adherent to the mesentery and the lateral pelvic wall. By careful dissection, it was possible to completely enucleate the tumor from the omentum. The portion of the omentum which harbored the tumor was resected and the appendix removed. A left salpingo-oophorectomy was then done. Convalescence was smooth and uneventful, the patient being discharged from the hospital on the eleventh day after operation. She has been seen on several occasions since then and on February 4, I93I, her condition was excellent. She had fully recovered and had resumed her domestic duties. The omental cyst (Figs. 3 and 5) measured 8X2 by 7X2 by 5X2 centimetres. The external surface was covered with thick, parchment-like tissue which contained haemor- rhagic areas and fibrinous strands. A cut section disclosed a hollow cavity which was 1269 BRIEF COMMUNICATIONS 0 co co '0o i0 C0 Ij '. 0 0424 1270 SYNCHRONOUS DERMOIDS OF OMENTUM AND OVARY FIG. 5.-Surface view of ovarian dermoid cyst. .: :: FIG. 6.-Sagittal view of ovarian dermoid cyst. 1271 BRIEF COMMUNICATIONS filled with yellowish, cheesy material in which manly hairs were imbedded. The walls were firm and conitained areas of calcareous deposits. The second specimen consisted of ani ovarian cyst (Figs. 5 anid 6) with the attached fimbriated portioni of the fallopiani tube and measured 14 by 9 by 6 centimetres. The external surface conisisted of parchmenit-like tissue which was covered with small blood- vessels and several yellowish-colored nodules measuring about I centimetre in diameter. The tube was firm and haemorrhagic and in the tubo-ovariani ligament was a small mucinous cyst one-half inch in diameter. Oni cut section the tumor was found to be divided inito four loculi. The initerior was filled with a pasty, lemon-colored material in which a few hairs were imbedded. The cyst-walls were smooth. At one pole of the tumor there was a small cyst one-half centimetre in diameter. Histologically, both the omental and ovarian cysts were typical dermoid tumors containing inspissated sebum and numerous areas of calcareous deposits. In a review of the literature, Mumey found only fourteen cases of dermoid cysts of the great omentum reported up to 1928. Abbe, in I895, reported a case of a dermoid cyst involving the great omentum which was associated witlh a dermoid of the left ovary which also contained a mucous cyst, simulat- ing the case here reported. As far as our review of the literature goes, the total number of dermoids of the great omentum, including the one here re- ported, is sixteen. The first case to be reported was by Lebert, in I734, and the next by Laflize, in 1792 (Quoted by Mumey.) Meckel reported another in 18I5. Since then isolated cases have been added to the literature. These tumors seem to predominate in the female in the ratio of 8 to I. It has been suggested by observers such as Sajous that they are detachments from the ovaries which become imbedded in the omentum during menstruation or pregnancy. Lexer and Bevan are of the opinion that they are formed in the pre-natal period by the incorporation of a fragment of ectoderm in the great omentum-i during the closure of the abdominal wall. Some have advanced the theory of trauma and heredity as etiologic factors, but it is hard to coIi- ceive how these factors can play a causative r6le in the production of these tumors. Dermoid cysts of the omentum produce no pathognomonic symptoms. The patient usually complains of a vague pain or heaviness in the abdomen and may feel a swelling over the involved area. Should the tumor impinge upon a loop of intenstine, pressure symptoms may result, giving rise to vomiting, constipation and meloena. Asthoenia and loss of weight may occur. A tumor lying low in the abdominal cavity may be detected by vaginal or rectal exam- ination. Rontgenograms are useful adjuncts in the establishment of a diag- nosis, particularly when the tumor cyst is calcified and contains opaque material such as teeth and hair.