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Visual Field Examination

vision or palpated. Preferably no clamp should be used and a suture on a round-bodied Mayo type needle can be passed with a safe distance between the vascular structure in the ligament and the readily seen or palpated ureter. The structure is then divided in usual fashion. (b) Should there be anatomical distortion in this area, e.g. tubo-ovarian mass, previous pelvic inflammatory disease, endometriosis &c., and the ureter cannot be seen (it is surprising even in these circumstances how frequently it can be seen if sought) it can still usually be palpated. This is dependent on the degree of pathology present. The anatomy should be restored to as near normality as possible. If the surgeon is unhappy about this and he cannot see or feel the ureter, he should divide the round ligament between two clamps gaining access to the potential space between the anterior and posterior leaves of the broad ligament and developing this space by gentle sharp and blunt finger dissection. This is a relatively avascular process and the ureter can either be seen or easily palpated between finger and thumb on the posterior leaf of the broad ligament even if there is considerable thickening of the latter structure. Once this has been achieved, dissection and mobilization of diseased structures with application of clamps or sutures can confidently proceed.