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(BQ) Part 2 book “Bonney’s gynaecological surgery” has contents: Cervical cancer, uterine cancer, ovarian cancer, exenterative surgery, vaginal cancer surgery, reconstructive procedures, operations for urogenital fistulae, operations for urinary incontinence,… and other contents.
C H APT ER 1 Operations for urinary incontinence Paul Hilton Differences in study populations, the definition and quantification of urinary incontinence and the sur vey method used result in a wide range of preva lence estimates Some women may not see their urinary incontinence as a major problem; for oth ers, who perceive a problem for which they would like help, there are often barriers to presen tation Where the most inclusive definitions have been used, prevalence estimates in the general pop ulation range from 5% to 69% in women 15 years and older, with most studies in the range 25–45%.1 The prevalence of any urinary incontinence tends to increase up to middle age, then plateaus or falls between 50 and 70 years, with a steady increase with more advanced age Slight to moder ate incontinence is more common in younger women, while moderate and severe incontinence affects the elderly more often.2 Stress urinary incontinence (SUI) or exertional incontinence is the most common type in sympto matic terms and, overall, 50% of women in one large epidemiological survey reported this as their only symptom; 11% described only urgency uri nary incontinence and 36% reported mixed incon tinence symptoms The trends in the prevalence of urinary incontinence at different ages reflect a reduction in complaints of SUI in those aged 50 years and over, with an increase in urgency and mixed urinary incontinence in women aged 60 years and above.2,3 There are relatively few epidemiological data on the prevalence of overactive bladder syndrome, although surveys from the United States, Europe and the UK all report the prevalence of urgency urinary incontinence of the same order, at around 10% overall in women, rising from around 5% in those aged less than 45 years to 20% in those over 65 years.4–6 It must be recognized that most urinary incontinence can be treated without surgery, by lifestyle adaptations, behavioural modification, pelvic floor muscle exercises or drug treatments Where these methods are not effective or are not acceptable to patients, surgery should be considered Classification of procedures There are said to have been over 200 operations, modifications and devices used in the treatment of SUI over the past century and a half, many with little or no evidence base to support their use In an effort to rationalize procedures for the treatment, a proposed classification system was published in 2005 (Table 17.1).7 This chapter reviews those pro cedures (highlighted in bold text in the table) that are currently in use and of proven value Alternative classifications include more compli cated forms of urethral disruption including post‐ surgical trauma, sling erosion, other trauma, ‘drainpipe’ urethra, radiotherapy damage and con genital abnormality, such as female epispadias.8 Many (but not all) of these pathologies can be managed by the procedures categorized in the table, so are not described separately here Bonney’s Gynaecological Surgery, Twelfth Edition Alberto (Tito) de Barros Lopes, Nick M Spirtos, Paul Hilton, and John M Monaghan © 2018 John Wiley & Sons Ltd Published 2018 by John Wiley & Sons Ltd 193 194 Chapter 17 Table 17.1 Classification of stress urinary incontinence procedures Procedure Approach Examples Vaginal Anterior colporrhaphy with Kelly, Kennedy and Green modifications Needle suspension Stamey, Peyrera, Raz, Gittes Suprapubic Burch colposuspension, Marshall‐Marchetti‐ Krantz, vagino‐obturator shelf Synthetic tapes Tension‐free vaginal tape ‐ TVT™ Urethral/bladder neck supporting: Vaginal wall suspension Suburethral retropubic space slings Biological: autologous, allograft, xenograft – ‘traditional’ slings Synthetic tapes Monarc®, Obtryx® Biological tapes Bioarc®, Pelvilace® Intramural urethral injection therapy Bulking agents Contigen®, Macroplastique® Extraurethral devices Non‐circumferential retropubic adjustable compression devices ProACT™ balloon Suburethral trans‐obturator foramen Urethral sphincter augmentation: Fixed‐resistance perineal devices (in men) Circumferential variable resistance devices; i.e artificial urinary sphincter The role of urodynamic assessment before surgery for stress urinary incontinence Urodynamic assessment has been a routine investi gation in patients with urinary incontinence over the past 40 years, the aim being to demonstrate urine leakage objectively and to differentiate between types of incontinence so that the most effective method of treatment for the individual patient can be determined However, there has been little evidence that this approach improves clinical outcomes for patients A Cochrane review on the subject found some evidence that urody namic assessment might change clinical decision making but no evidence that this resulted in improvements in continence rates after treat ment.9 Despite two major trials on the subject, a 2015 feasibility study concluded that there was still a place for a further definitive trial on the role of urodynamic assessment prior to surgery in women with stress or stress‐predominant mixed urinary incontinence10 and that such further research AMS 800™ would have added health economic value.11 Paraphrasing only slightly the current recommen dations from the National Institute for Health and Care Excellence (NICE) in the UK in this respect are that, in a woman with SUI, invasive urody namic assessment should be carried out: • when she feels that her symptoms are bad enough to justify treatment, and • where conservative management (by pelvic floor muscle exercises) has been ineffective, and • where she wishes to consider surgery, and • where, in addition to the above, one or more of the following situations pertain: in addition to SUI: ▪▪ there are symptoms of frequency, urgency or urgency urinary incontinence (raising the possibility of detrusor overactivity) ▪▪ there are symptoms of poor or intermittent urinary stream or a feeling of incomplete bladder emptying (which may indicate void ing dysfunction) ▪▪ there is evidence of anterior vaginal wall prolapse Operations for urinary incontinence there has/have been previous attempt/s to cor rect the incontinence surgically neurological disease that might contribute to the urinary symptoms is known or suspected.12 Urodynamic asssessment is not required in the absence of these additional complaints; that is, where the only symptom is of SUI in a woman who has not had previous surgery.12 The place of cystoscopy during surgery for stress urinary incontinence Although it has not been traditional for nonspecialist gynaecologists to undertake cystoscopy, the advent of retropubic mid‐urethral sling procedures has meant that cystoscopy has become an essential skill for those carrying out any surgery for SUI The subsequent development of tapes introduced through the obtura tor foramina was fostered in part by the wish to limit the rate of bladder injury, and several authors sug gested that cystoscopy was no longer routinely required Additionally, several commercial companies encouraged this view, to make their devices accessible to a wider range of surgeons Nevertheless, increasing reports of urethral injury have caused concern about this strategy While not evidence‐based, nor recom mended by other guidelines, the current advice from the American Urological Association (AUA) is that intraoperative cystourethroscopy should be per formed in all patients undergoing sling surgery.13 The use of bladder drainage following surgery for stress urinary incontinence Historically, Foley urethral catheterization was the standard for postoperative bladder drainage follow ing SUI surgery With the advent of suprapubic procedures to stabilize the hypermobile urethra, suprapubic catheterization gained popularity Over the past 20 years, as mid‐urethral slings have become the standard, the majority of patients not require postoperative bladder drainage, unless regional anaesthesia is used or concurrent prolapse surgery undertaken Those who experience postoperative difficulty in voiding are now most commonly man aged by clean intermittent self‐catheterization.14,15 195 It has been shown that the use of intermittent urethral catheterization following pelvic floor surgery is associated with shorter periods of cathe terization and hospital stay than routine suprapu bic catheterization; the latter, however, remains in common use following suprapubic operations for SUI, being more comfortable, less prone to urinary tract infection and less demanding on nursing time.16 Although many types are available, either the BonnanoTM (BD Worldwide), or Stamey (Cook Medical) catheters are the author’s prefer ences; alternatively, a Foley catheter can be inserted at open cystostomy or by using the Robertson cys totrocar, or pulled through into the bladder using a forcep passed through the urethra Although practices vary considerably, the man agement regimen for postoperative suprapubic catheterization might be as follows: • A fluid intake of 1.5–2 litres/day is encouraged and a strict fluid chart maintained • The catheter tubing (not the catheter itself) is clamped on the morning of the first postopera tive day (or when the patient is sufficiently mobile to be able to get to the toilet) • If the patient is unable to void or becomes d istressed by the sensation of fullness, the catheter should be released to avoid bladder overdistension • If the patient achieves normal voiding, the resid ual urine volume should be checked after eight hours (after the nearest void to this time) The residual urine volume is checked by emptying the catheter drainage bag, allowing the patient to void at her next desire, then unclamping the catheter for 5–15 minutes (depending on the calibre of the catheter) The habit of checking the residual urine v olume after each void is not recommended, as this may mask an accumulating residual volume Opinions vary as to what constitutes an accept able residual urine volume, although it is the author’s practice to use less than 100 ml or less than 50% of the voided volume, whichever is achieved first • Generally, the catheter is left on free drainage overnight until the residual urine volume is less than 100 ml with voided volumes greater than 200 ml At this stage, the catheter is clamped overnight and the residual urine volume checked in the morning When the patient voids normally 196 Chapter 17 over a 24‐hour period with a residual urine vol ume less than 100 ml the catheter is removed • Prophylactic antimicrobial therapy is not rou tinely used postoperatively.17 Urine samples should only be tested for culture and antibiotic sensitivities in symptomatic patients Urethral and bladder neck supporting procedures Anterior colporrhaphy The anterior colporrhaphy or anterior vaginal repair is well established as the standard procedure for the treatment of anterior vaginal wall prolapse (see Chapter 16) It has also been used historically for the treatment of SUI, where emphasis is placed on elevating and supporting the bladder neck by sutures inserted either into bladder muscle (Kelly sutures), or paraurethral fascia Although included in earlier editions of this book, there is now good evidence that anterior colporrhaphy is substan tially less effective than alternative approaches for SUI and it is not recommended by either NICE or the AUA.12,13,18 It is not therefore discussed further in this context Bladder neck needle suspension procedures As noted for anterior colporrhaphy above, out comes from needle suspension procedures have proved inadequate in the long term; these are no longer recommended and are not discussed further in this chapter.12 Suprapubic procedures Similarly, outcomes from several of the suprapubic suspension procedures listed above have proved inadequate in the long term; these include the Marshall‐Marchetti‐Krantz procedure, the vagino‐ obturator shelf procedure and the paravaginal defect repair; these also are no longer recom mended and are not considered further.12 Burch colposuspension Burch described the procedure of urethrovaginal fixation to Cooper’s ligament in 1961.19 Following his report of his first nine years’ experience (albeit median follow‐up of only around one year),20 it became popular in the 1970s and remained the preferred procedure of many gynaecologists and urologists on both sides of the Atlantic until the mid‐1990s Although the eponymous title is well established, it is also described simply as ‘colposus pension’ in the UK or ‘retropubic urethropexy’ in the United States Although originally described as an open retro pubic space procedure, the laparoscopic approach to colposuspension was first described in 199121 and, more recently, the robotic procedure has been reported Outcomes are similar to the open proce dure at six months and five years.22,23 Although earlier discharge from hospital is anticipated fol lowing laparoscopic procedures, this was not seen in the UK COLPO trial.23 The laparoscopic proce dure should only be offered where skills in both urogynaecology and laparoscopic surgery are available;23 otherwise, the open procedure is appro priate and only this is described below Indications The aims of colposuspension are to relieve SUI and to elevate not only the bladder neck but also the bladder base, which makes it a suitable option when SUI and anterior vaginal wall prolapse coex ist It does, however, require reasonable vaginal capacity and mobility for satisfactory elevation of the lateral vaginal fornices It is therefore less likely to be effective if elevation is restricted by scarring from previous surgery or menopausal atrophy and where there is intrinsic urethral sphincter defi ciency; that is, where there is low urethral closure force without hypermobility Instruments The gynaecological general set shown in Chapter 3 is appropriate for most SUI surgery Additionally, the author’s practice is to use Gillies fine‐toothed dissecting forceps (or DeBakey forceps) and fine curved Metzenbaum scissors Many surgeons advocate the Denis Browne four‐ bladed ring retractor, although the author’s prefer ence is for the three‐bladed Millin prostatectomy/ bladder retractor This takes significantly less space and allows the procedure to be accomplished through a smaller incision The Turner‐Warwick needle holder is particularly useful for vaginal surgery since its curved handle means that the operator’s hand is offset from the field of view; the curved tipped version (being Operations for urinary incontinence curved in two planes) is also useful for manoeuvring a needle in inaccessible spaces or at awkward angles, such as into the ileopectineal ligament An adhesive urological (transurethral resection) drape, with a finger cot attached, allows aseptic manipulation vaginally, while the abdomen is open Anaesthesia General or regional anaesthesia are appropriate Prophylactic antibiotics should be administered at induction Prophylaxis against thromboembolic complications should be administered on the basis of preoperative risk assessment The operation Step 1: preparation The patient should be in a horizontal lithotomy position with legs in Lloyd‐ Davies stirrups, with the hips slightly flexed and abducted and knees slightly flexed (Figure 17.1) Preparation should be made as for any abdominal procedure; in addition, the vagina should be cleansed and an indwelling urethral catheter inserted and the balloon inflated to facilitate 197 identification of the bladder neck The urological drape is secured over the perineum Step 2: incision This should be a low transverse suprapubic (Pfannenstiel) incision, long enough for access into the retropubic space; 6–8 cm is usually adequate After incising the skin and rectus sheath, the Millin retractor is inserted Step 3: opening the retropubic space The bladder and urethra are gently separated from the posterior aspect of the symphysis to open up the retropubic space (Figure 17.2) This is usually achieved by blunt finger dissection, although if there has been previous retropubic surgery, sharp dissection using fine Metzenbaum scissors is required Step 4: identifying the paravaginal fascia An assistant uses a ‘swab on a holder’ or ‘sponge stick’ to retract the bladder medially The right‐handed surgeon (assuming they are standing on the patient’s left side) will use their left index finger in the vagina – covered by the urological drape – to Figure 17.1 Patient in a horizontal lithotomy position with legs in Lloyd‐Davies stirrups 198 Chapter 17 apply pressure upwards and laterally, at the level of the bladder neck (not the lateral vaginal fornix as is often described; Figure 17.3) The upward pressure from below, with the medial retraction above, is often sufficient to expose the white glistening layer of paravaginal fascia If neces sary, a ‘peanut’ swab or Kittner dissector can be used to achieve further separation, although the author’s preference is to use fine Metzenbaum scissors for this purpose, as they tend to be associated with less tissue trauma and bleeding (Figure 17.4) A number of venous sinuses may be encoun tered in this area; these are best avoided; diathermy may exacerbate bleeding so, if bleeding is trouble some, it is better to insert the suspensory sutures as quickly as possible, underrunning the vessels Step 5: inserting the suspensory sutures When there is adequate exposure of the fascia, two or three sutures of Ethibond (coated polyester; W975 Ethibond, 31 mm half‐circle round‐bodied needle) or 0‐PDS (polydioxanone; CT2 PDS, 26 mm half‐circle taper point needle) Figure 17.4 Tips of Metzenbaum scissors used to aid Figure 17.2 Retropubic space opened dissection of the paravaginal fascia (a) (b) Figure 17.3 The surgeon using their nondominant index finger in the vagina to apply pressure upwards and laterally, at the level of the bladder neck: (a) operative view; (b) sagittal section Operations for urinary incontinence are inserted into the fascia on each side; if nonabsorbable sutures are used, care must be taken not to penetrate into the vagina It is wise to check after each needle insertion that the vaginal drape has not been caught The first suture should be placed at the bladder neck and tied down on to the fascia This should control any venous bleeding but also provides a ‘pulley’ to facilitate subsequent tying The suture is then passed through the most proximate point on the ipsilateral ileopectineal ligament (Figure 17.5) The two ends are then secured with a small artery forceps until all sutures are in place The second and third sutures are each placed approximately 1 cm more cephalad and slightly more lateral than the previous suture Sutures should not be placed below the level of the blad der neck, as this may contribute to postoperative voiding difficulties These sutures are similarly tied down on to the fascia and then passed through the ileopectineal ligament, each sepa rated by approximately 1 cm along the ligament (Figure 17.6) Although an abnormal or acces sory obturator artery is said to be present in approximately 30% of people, a pubic branch of the inferior epigastric vessels invariably crosses the ileopectineal ligament; this should be seen as the upper landmark for suture insertion on the ligament When three sutures are in place on one side, steps and are repeated on the other side The Step 6: the place of cystoscopy Some surgeons advocate cystoscopy at this stage to exclude bladder wall injury or penetration by sutures or the possibility of other intravesical pathology; this has not been the author’s routine practice Figure 17.5 Sutures inserted into the paravaginal fascia on each side, using Turner‐Warwick needle holder Figure 17.6 Two or three sutures are inserted on each side, tied down onto the paravaginal fascia, and then passed through the ileopectineal ligament 199 200 Chapter 17 Step 7: tying the sutures When all the sutures are in place they are tied Tying is perhaps best done alternately, starting from the most caudal suture on one side, then the other side, then moving progressively in a cephalad direction until all are tied In early descriptions, it was standard practice to approximate the vaginal fascia directly on to the ileopectineal ligament by having an assistant apply pressure vaginally; this is not the author’s practice By using the ‘pulley’ suture as described above, the application of gentle traction to the suture limb placed through the ileopectineal ligament brings the vaginal fascia into proximity with the pelvic sidewall (not the ileopectineal ligament), where it can become fixed Some degree of ‘bow‐stringing’ of sutures is inevitable but does not detract from the effectiveness of the procedure, the emphasis being on achieving support without the necessity of extreme tension and elevation (Figure 17.7) Step 8: haemostasis and wound drainage Bleeding within the retropubic space is invariably venous and tying the suspensory sutures on to the fascia (as in step 5) or through the ligament (as in step 7) will usually provide adequate haemostasis However, it is a wise precaution to leave a vacuum drain in the retropubic space overnight postoperatively Step 9: wound closure The author’s preference is to use Vicryl (polyglactin; W9231 Vicryl, 40 mm half‐circle round‐bodied needle) to close the rectus sheath, and 2‐0 Prolene (polypropylene; W631 2‐0 Prolene, 65 mm straight reverse cutting needle, with beads and collars) as a subcutaneous skin closure Other concurrent surgery Hysterectomy While there is no benefit from concurrent hysterectomy, where it is indicated for other reasons it is best performed first, closing the parietal peritoneum prior to opening into retropubic space for colposuspension Vaginal vault or enterocoele It has long been recognized that women who have undergone colposuspension are at risk of subsequent vaginal vault or posterior wall prolapse.20 This has often been attributed to the fact that pelvic organ prolapse reflects a systemic connective tissue weakness and therefore inevitably occurs in more than one site in the same patient.24 The evidence from randomized controlled trial (RCT) outcomes, however, suggests that colposuspension may be a more specific risk factor, probably related to the altered angulation of the vagina and pressure transmission within the pelvis.25 For this reason, several authorities have sug gested that where an enterocoele is present, it should be corrected, irrespective of symptoms The Moschowitz procedure has been advocated in this context and was included in previous editions of this book This procedure was first described as a method to close off a deep pouch of Douglas in Figure 17.7 By using the ‘pulley’ suture the paravaginal fascia is brought into proximity with the pelvic sidewall but not directly on to the ileopectineal ligament; ‘bow‐stringing’ of sutures does not detract from the effectiveness of the procedure Operations for urinary incontinence conjunction with prolapse of the rectum.26 More recently it has been used to close the cul‐de‐sac during the course of several abdominal procedures A nonabsorbable suture material is used to place two or three purse‐string sutures around the peri toneum of the pouch of Douglas and close the hia tus between the uterosacral ligaments, taking care to avoid the pelvic ureter (Figure 17.8) The author’s view is that a simple purse‐string, or even a series of purse‐strings, in the peritoneum is unlikely to achieve much in terms of long‐term support; hence, I would never carry out the Moschowitz procedure My preference is to use an abdominal sacrocolpopexy (as described in Chapter 16) prior to the colposuspension in patients with a symptomatic vault prolapse or enterocoele In those with evidence of enterocoele but no rele vant symptoms, my preference is to carry out only the colposuspension and then review the signs and 201 symptoms subsequently Although one‐quarter to one‐third of patients may experience deterioration of findings or development of symptoms, up to three‐quarters will not Rectocele As noted above, women undergoing colposuspension are at risk of subsequent posterior wall prolapse and several authors have suggested that, where rectocele is present, it should be corrected at the time of colposuspension, irrespective of symptoms; indeed, this approach was also advocated in the previous edition of this book The current author’s view, however, is that rectocele should only be treated if causing significant symptoms (see Chapter 16) and its prophylactic management is therefore not justified Even where a rectocele is symptomatic before embarking on colposuspension, carrying out a posterior repair concurrently can actually be quite difficult, in view of the extent of anterior vaginal elevation The author’s current preference again is to carry out only the colposuspension and then review the signs and symptoms subsequently, carrying out a secondary posterior colporrhaphy only where necessary Postoperative management Postoperative bladder drainage may be by suprapu bic catheter This is best inserted after wound closure (see earlier section on bladder drainage) Patients in whom postoperative voiding difficulty is anticipated should be taught intermittent self‐cath eterization preoperatively; in this case, a Foley catheter should be inserted overnight and they can resume self‐catheterization when comfortable enough to so The wound drain can usually be removed on the first postoperative day and the patient should be able to mobilize and eat normally She can be dis charged home when voiding normally or able to manage her catheter regimen independently Figure 17.8 Moschowitz procedure for enterocoele closure; lowermost suture already tied, second in place, and position of third (incorporating uterosacral ligaments) shown as dotted line Operative complications Bladder or urethral injury Bladder injury was recorded in 3% of cases in one large RCT.27 Recognized bladder or urethral injury should be repaired with 2‐0 or 3‐0 Vicryl (polyglactin; W9350 2‐0 Vicryl, 26 mm half‐circle taper cut heavy needle or W9122 3‐0 Vicryl, 22 mm half‐circle taper cut needle); a single layer is usually adequate, provided that the repair is 202 Chapter 17 watertight and under no tension Catheterization should be continued for days or for 10–12 days if hysterectomy has been carried out concurrently Ureteric obstruction Injury to the ureters is uncommon, although ligation may occur if care is not taken to identify the paravaginal fascia clearly On occasion, especially if there is a large cystocele and additional sutures are inserted, distortion of the bladder base in the region of the ureterovesical junctions may result in kinking of the ureter(s) with consequent obstruction unilaterally or bilaterally (Figure 17.9) If suspected intraoperatively, cystoscopy with indigo carmine dye testing should be carried out If free efflux of dye is not seen, suspensory sutures should be removed in sequence until free flow is confirmed It is probably wise to leave a double‐J ‘pigtail’ stent in place in this situation but sutures can be replaced more laterally Where ureteric obstruction is suspected postop eratively, on the basis of loin pain, persistent nausea or, rarely, oliguria, investigation should be Figure 17.9 Intravenous urogram in patient with bilateral ureteric obstruction following colposuspension; point of obstruction visible, with hydroureter and hydronephrosis on the right; minimal function visible as faint nephro gram only on left carried out as a matter of urgency, with computed tomography urogram and isotope urography to evaluate relative function If ureteric stenting can be achieved either retrogradely or via percutane ous nephrostomy, drainage for a period of months may allow complete resolution; otherwise laparot omy and ureteric reimplantation would be required (see Chapter 26) Postoperative complications Voiding dysfunction Delay in resumption of spontaneous micturition may occur in up to 25% of patients, although in most this will resolve spontaneously if managed by the catheter regimen described above If voiding is delayed beyond five days, patients are best discharged with suprapubic or intermittent self‐catheterization Voiding dysfunction is also one of the most com mon longer‐term complications of colposuspen sion It is seen in up to 20% of patients, although those with early postoperative voiding difficulty are not necessarily those who go on to have longer‐ term problems This complication was seen more commonly in the past, when the vaginal fascia was elevated directly on to the ileopectineal ligament, and is certainly less of an issue with the technique described above Although several operative and pharmacological strategies have been tried in the past, it is best managed by instituting clean inter mittent self‐catheterization Bladder overactivity It has long been recognized that women who have detrusor overactivity preoperatively are less likely to have a favourable outcome from surgery for SUI than those with pure urodynamic stress incontinence (USI) That said, the rate of resolution of SUI symptoms in women with mixed USI and detrusor overactivity is not significantly different from that seen in those with pure USI Rates of resolution of overactive bladder symptoms between 24% and 90% have been reported.27 Although a number of women may develop new symptoms of overactive bladder or so‐called ‘de novo’ detrusor overactivity following surgery for USI, particularly by colposuspension, such surgery should not be considered contraindicated in women with mixed symptoms of SUI and overactive bladder or mixed urodynamic findings of USI and detrusor overactivity, provided that patients are fully counselled about possible outcomes 356 Chapter 27 Figure 27.11 Incising the abdominal wall fat, musculature and peritoneum Exteriorizing the bowel By passing a pair of Babcock tissue forceps through the stoma, the stapled proximal end of the sigmoid loop is drawn out of the orifice The loop is checked for undue tension then the line of staples is cut off and the edge of the bowel sutured to the skin (Figure 27.12) It is unnecessary to suture the edges of the aponeurosis and the peritoneum to the bowel The procedure is planned as a temporary stoma but, occasionally, when formed for intestinal obstruction in ovarian cancer, it is never reversed The technique is similar to that for a colostomy There are risks of dehydration and associated electrolyte imbalances early in the postoperative course and patients must be cautioned to be aware of the need to adequately hydrate and to need to notify their medical team if the output becomes difficult to manage Dietary consultation is often helpful as a preventive measure Applying the colostomy appliance The stoma bag is applied in theatre, making sure that it does not impinge on the midline incision The operation Closing the abdomen The abdomen is closed as described in Chapter 4 Opening the abdomen The abdomen is usually open when the decision to make an ileostomy is made The formation of a loop ileostomy The editors perform a temporary loop ileostomy in preference to a temporary colostomy The reasons are numerous but include the fact that there is more mobility with the mesentery of the small bowel and the contents are more fluid, reducing the risk of anastomosis breakdown when closed Making the stoma This is prepared as for the permanent colostomy Patients with advanced ovarian cancer are often sited preoperatively for both a potential ileostomy and colostomy Forming the loop The intended segment of terminal ileum is pulled through the stoma site using a Babcock tissue Operations on the intestinal tract for the gynaecologist 357 (a) Figure 27.13 Incising the ileum (b) Figure 27.12 (a) Removing the staple line and (b) suturing the edge to the skin forceps A bridge can be inserted to keep the loop in place but is not routinely used Opening the stoma The bowel is opened transversely at the distal part of the loop and the incision is extended to about half the circumference (Figure 27.13) The mucosa is inverted and a rosebud is formed, the greater prominence being the proximal segment of the loop (Figure 27.14) Removal of the bridge If used, the bridge can be removed after four to five days Figure 27.14 Forming a ‘rosebud’ Reversal of the ileostomy Reversal of the ileostomy is similar to that for the temporary colostomy, with the bowel repaired with a single‐layer closure Side‐to‐side anastomosis procedure Side‐to‐side anastomosis is the technique of bypassing a segment of bowel that is obstructed or grossly damaged by tumour or irradiation; it is a valuable technique for the surgeon to learn 358 Chapter 27 Preoperative preparation It may be difficult to achieve perfect preparation of the bowel if there is an element of obstruction Therefore, the surgeon must be prepared to decompress the bowel if necessary prior to performing the procedure lengths of bowel are lightly held using noncrushing clamps proximal to where the anastomosis is to be made (Figure 27.15) A small opening is made in each segment of bowel and the GIA instrument inserted and fired, producing a stapled communication between the two segments (Figure 27.16) The operation Opening the abdomen The incision can be any which gives adequate access to the entire abdomen and is capable of being extended when necessary Identifying the site of obstruction The surgeon must be prepared to spend some time in ascertaining the site of the obstruction and correctly identifying healthy bowel proximal and distal to the obstruction It is particularly important that the bypass anastomosis should not be performed using irradiated bowel Stapling the bowel One of the most common techniques necessary is to bypass the distal small bowel and the first part of the large bowel The healthy ileum is drawn to the transverse colon and laid alongside it The two Figure 27.15 Apposing the small and large bowel Figure 27.16 Forming a stapled communication between large and small bowel Operations on the intestinal tract for the gynaecologist The device is withdrawn and the two small openings closed with a single‐layered closure using a Vicryl or Monocryl suture The communication between the ileum and transverse colon will be approximately two fingers wide Reference 1 Salom E, Schey D, Peñalver M, et al The safety of incidental appendectomy at the time of abdominal hysterectomy Am J Obstet Gynecol 2003;189:1563–7 Further reading That one should develop the habit of reading outside the subject is particularly apposite in relationship to this chapter The gynaecologist must frequently pick up the latest ideas from his or her surgical colleagues and never be too proud to steal an idea or two 359 General Walsh CJ, Jamieson NV, Fazio VW Top Tips in Gastrointestinal Surgery Oxford: Blackwell Science; 1999 Incidental appendicectomy Cheng Y, Zhou S, Zhou R, et al Abdominal drainage to prevent intra‐peritoneal abscess after open appendectomy for complicated appendicitis Cochrane Database Syst Rev 2015;(2):CD010168 doi: 10.1002/14651858 CD010168.pub2 O’Hanlan K, Fisher DT, O’Holleran MS 257 incidental appendectomies during total laparoscopic hysterectomy JSLS 2007;11:428–31 C H APT ER 2 Reconstructive procedures General comments The degree to which reconstructive surgery is incorporated directly into one’s practice is determined by a number of factors Most important among them are training and experience Of lesser importance on a philosophical level, but perhaps of more importance on a practical level, are local hospital politics and standards of practice The degree to which one involves a plastic surgeon in undertaking these procedures will be influenced by all of the factors Most importantly, we should never forget that it is the patient who comes first and, whatever combination of surgeons is required to produce optimized care, this is what we should strive for, in whatever hospital or clinical setting in which we practice Fortunately, the need to undertake reconstructive surgical procedures in the practice of gynaecology and gynaecological oncology has decreased as the extent of primary radical surgery for vaginal and vulval cancers has been reduced Over the past 20 years, the use of chemoradiation has markedly reduced not only the need for primary surgery in advanced cases but, when required, also the extent of it A similar trend is noted in the treatment of primary early‐stage vulval cancer No longer are en bloc ‘butterfly’ incisions routinely used, incorporating large amounts of skin overlying the mons pubis and the skin bridges between the groins and the vulva Rather, these have been replaced with essentially radical excision or partial vulvectomy and lymph node sampling using sentinel nodes to minimize the need for radical dissection in this area as well Only in exenterative procedures for locally recurrent gynaecological cancers, generally speaking after chemoradiation failure, are reconstructive procedures commonly undertaken Once again, as our other treatment modalities have improved, the need for exenteration has also lessened Similarly, the need for wide excision of vulval intraepithelial neoplasia (stage II or III) has been decreased by the use of local ablative therapies, including but not limited to the carbon dioxide laser and argon beam coagulation Despite this, there is still a need for surgeons to be familiar with techniques to close vulval defects when primary closure fails Vulval reconstruction for localized benign disease, premalignant and early malignant disease Two commonly used methods to close defects in the areas of the vulva, perineum and vagina involve the use of rotational flaps and Z‐plasty The Lotus petal flap, first described in 1996 by Yii and Niranjan, is being used increasingly to fill vulval defects.1 These fasciocutaneous flaps are a versatile alternative to the many flaps available Z‐plasty (and other variations) The Z‐plasty uses the transposition of two or more triangular‐shaped flaps of skin in vulval repair to increase the length of an area of tissue which, on a practical level, can be used to cover small defects only; it is not a technique of much practical value in the field of gynaecology Elongation, once local Bonney’s Gynaecological Surgery, Twelfth Edition Alberto (Tito) de Barros Lopes, Nick M Spirtos, Paul Hilton, and John M Monaghan © 2018 John Wiley & Sons Ltd Published 2018 by John Wiley & Sons Ltd 361 362 Chapter 28 tissue conditions are taken into account, is somewhat predictable and is based on the angles of the flaps Flaps of 45 and 60 degrees are most commonly used and provide tissue elongation of 50% and 75%, respectively, without causing significant incisional tension More complicated techniques of a similar nature include the four‐ and five‐flap plasties.2 Rotational flaps Rotational flaps, such as the ‘lotus petal flaps’ are useful for closure of large defects, especially in the posterior aspect of the vulva.1 Full‐ and split‐thickness skin grafts (general considerations) Full‐thickness skin grafts are best used for vaginal reconstruction in women with vaginal agenesis or during vaginal reconstruction following exenterative surgery when the surgeon has chosen to use the omentum along with a skin graft instead of a myocutaneous graft Full‐thickness donor sites should be selected so primary closure can be accomplished without excess tension being placed on the suture line The inner thigh is ideal for the donor site for this purpose For split‐thickness grafts, donor sites should be smooth and, when possible, the cosmetic aspect given full consideration Common sites used include the buttocks and the lateral aspect of the thigh Full‐thickness grafts are best harvested freehand using either a no 10 or a no 15 Bard Parker blade All harvested grafts should be placed between saline‐soaked gauze Split‐thickness grafts should be harvested using a Brown power‐driven dermatome The skin should be cleaned, as should the donor site for a full‐thickness graft but, in addition, mineral oil should be applied to lubricate the skin and facilitate the smooth passage of the dermatome when harvesting the graft The dermatome should be set at 15/1000 of an inch in thickness The thickness can be checked by sliding a Bard Parker no 15 blade between the guard and blade of the dermatome The donor site should be treated with either adrenaline‐soaked sponges or thrombin spray, then covered with either Tegaderm or gauze permeated with petroleum jelly Depending on need, the graft either can be used intact with small periodic incisions made to ensure seromas not develop or it can be meshed to expand the graft by 1.5–3 times the size, thereby allowing for greater coverage After either suturing the graft to the host site with 4‐0 Monocryl or stapling it in place, it can be covered with bacitracin (1.25 cm in thickness), dressed and left for four to five days Other issues of particular importance include graft contraction and hyperpigmentation, which are more problematic with split‐thickness grafts It is for this reason that, when undertaking surgery for vaginal agenesis, a full‐thickness skin graft should be employed instead of a split‐thickness skin graft Additionally, it should be noted that this surgery can be facilitated by using laparoscopy to help identify and develop the proper space between the rectum and the bladder (see Chapter 8) Myocutaneous grafts The vast majority of myocutaneous grafts are used in the repair of pelvic defects related to the treatment or complications of treatment of gynaecological malignancies Historically, vaginal reconstruction has been accomplished using gracilis myocutaneous or bulbocavernosus grafts and, more recently, the rectus abdominus has become the choice of most gynaecological oncologists A modification of the standard rectus abdominus graft is the fleur‐de‐lys flap, as described by McCraw and colleagues,3 in which the associated defect somewhat resembles the stylized lily of the fleur‐de‐lys This defect requires much less tension on the suture or staple lines when reapproximating the subcutaneous tissues and skin Detailed descriptions of these procedures are beyond the scope of this text and readers are referred to McCraw et al.’s work.3,4 References Yii NW, Niranjan NS Lotus petal flaps in vulvo‐vaginal reconstruction Br J Plast Surg 1996;49:547–54 McGregor AD, McGregor IA Fundamental Techniques of Plastic Surgery and Their Surgical Applications 10th ed Edinburgh: Churchill Livingstone; 2000 Reconstructive procedures 3 McCraw JB, Massey FM, Shanklin KD, Horton CE Vaginal reconstruction with gracilis myocutaneous flaps Plast Reconstr Surg 1976;58:176–83 [The definition, history, experimental background, surgical technique, and clinical applications of compound gracilis myocutaneous flaps are presented.] 363 McCraw JB, Arnold PG McCraw and Arnold’s Atlas of Muscle and Musculocutaneous Flaps Cresskill, NJ: Hampton Press Publishing; 1986 See https://global‐help org/publications/books/help_mccrawmuscleatlas.pdf Index Note: Page numbers in italic denote figures, those in bold denote tables ABC (argon beam coagulator) 52 abdomen access, laparoscopy 46 abdominal cavity opening/closing 33–44 Cherney incision 43 closure of the abdomen 39–40 draping 34 exploration 37 extending the wound 39 intestines, packing away 37–38 Joel‐Cohen incision 42–43 Maylard incision 44 operative stance 33–34 peritoneal incision 35–36 Pfannenstiel incision 41–42 previous scars 38–39 rectus incision 35 subumbilical midline incision 34–36 transverse incisions 41–44 abdominal hysterectomy 128–130 abdominal sacrocolpopexy 183–184 ablative procedures cervix 90–94 complications 93–94 abscesses, vulval 64–66, 67 adhesion prevention/removal 31, 38–39, 77, 106 alcohol 11 anaesthesia laparoscopy 48 preparation for surgery 15–16 anaesthetist preoperative visit 12–13 antibiotics prophylactic antibiotics 14, 108, 263 urogenital fistulae 263 aortic injury, vascular surgery 332, 333 appendicectomy 349–350 variations in technique 350 argon beam coagulator (ABC) 52 Arista (Medafor Inc., Minneapolis, MN) 30 artery forceps 20 artificial urinary sphincter 224–225 augmentation cystoplasty, detrusor overactivity 227–228 Bartholin’s cysts 64–66, 67 basic skills bearing of the surgeon 4–6 biopsy cold‐knife cone biopsy 96–98 laser cone biopsy 96 vulva 63, 64 bladder catheterization, preparation for surgery 14–15 bladder drainage catheter management, postoperative care 56 stress urinary incontinence (SUI) 195–196 urogenital fistulae 263 bladder dysfunction, radical hysterectomy and pelvic node dissection 295 bladder injuries 336 bladder overactivity Burch colposuspension 202 synthetic mid‐urethral slings 210 bladder perforation, synthetic mid‐urethral slings 209 Boari–Ockerblad flap, ureter in the pelvis injuries 337, 339 Botulinum neurotoxin (BoNT), detrusor overactivity 226–227 bowel damage cervical dilatation 89 operative injuries management 351–354 synthetic mid‐urethral slings 209 bowel preparation for surgery 13–14 Burch colposuspension 196–203 anaesthesia 197 bladder overactivity 202 enterocoele 200–201 hysterectomy 200 indications 196 instruments 196–197 operation 197–200 operative complications 201–202 ‘post‐colposuspension syndrome’ 203 postoperative management 201 rectocele 201 ureteric obstruction 202 vaginal vault prolapse 200–201 voiding dysfunction 202 butterfly incision, vulva carcinoma 274–275, 276 Bonney’s Gynaecological Surgery, Twelfth Edition Alberto (Tito) de Barros Lopes, Nick M Spirtos, Paul Hilton, and John M Monaghan © 2018 John Wiley & Sons Ltd Published 2018 by John Wiley & Sons Ltd 365 366 Index caesarean section 147–156 B‐Lynch suture 156 classical caesarean section 154–156 Internal iliac ligation 156 lower‐segment caesarean section 147–154 massive postpartum haemorrhage 155–156 cameras laparoscopy 47–48 minimal access surgery (MAS) 47–48 cancer see oncology catheter management, postoperative care 56 cauterization of the cervix 92–93 cervical cancer laparoscopic radical hysterectomy with aortic and pelvic lymphadenectomy 297–299 lymphadenectomy 293–295, 297–299 radical hysterectomy and pelvic node dissection 286–297 radical trachelectomy 305–307 radical vaginal hysterectomy 299–305 surgery v chemotherapy 285 cervical conization 96–98 cervical dilatation 83–89 cervical incompetence 98–99 cervical rigidity/spasm, cervical dilatation 86 cervical stenosis, cervical dilatation 86 cervical stump excision 99–100 cervical vulsellum, cervical dilatation 85 cervix 83–100 dilatation of the cervix 83–89 Cherney incision, abdominal cavity opening/closing 43 circumferential repair, urogenital fistulae 254–257 classical caesarean section 154–156 clinic information, preparation for surgery cold coagulation, cervix 92 cold‐knife cone biopsy 96–98 colostomy 354–356 colpectomy 75–81 colpocleisis complete colpocleisis 186–188, 253–254 Le Fort’s colpocleisis 188–190 partial colpocleisis (Latzko) 253, 254 urogenital fistulae 251–254 colposuspension see Burch colposuspension comorbidities, postoperative care 56 complete colpocleisis 186–188 urogenital fistulae 251–254 congenital abnormalities of the vagina 74–75 consent for surgery 9–10 consent to surgical trials 10 ‘cough testing’, synthetic mid‐urethral slings 205–207 cryosurgery, cervix 90–92 cystoscopy stress urinary incontinence (SUI) 195, 199, 205, 207, 209, 210 synthetic mid‐urethral slings 205, 207, 209, 210 urogenital fistulae 233–236 cysts Bartholin’s cysts 64–66, 67 ovaries, retroperitoneal cyst removal 144–145 vaginal cysts 71–72 vulval cysts/abscesses 64–66, 67 detrusor overactivity operations, stress urinary incontinence (SUI) 225–228 diagnostic laparoscopy 48–51 dissecting forceps 19–20 documentation, preparation for surgery double uterus hysterectomy 115–116 drainage 31 draping abdominal cavity opening/closing 34 preparation for surgery 15 ectopic pregnancy 135–138 electrosurgery 29–30 emergency laparotomy 136–137 endocervical polyps removal 89–90 endometrial ablation 104–105 endometrial polyps 104 endometriosis, laparoscopic surgery 51–53 endometrium sampling 102 energy sources, laparoscopy 47 enterocoele, Burch colposuspension 200–201 Evicel (Johnson and Johnson) 30 excisional techniques 94–98 cervical conization 96–98 cervix 94–98 cold‐knife cone biopsy 96–98 laser cone biopsy 96 transformation zone, large loop excision 94–95 exenterative surgery 319–328 contraindications 320–321 empty pelvis 326–327 operation 322–327 palliative exenteration 320 patient assessment 320 patient selection 319 postoperative care 327 preoperative preparation 322 results of exenteration 327–328 types 321 extrauterine gestation 135–138 fallopian tubes 135–140 emergency laparotomy 136–137 extrauterine gestation 135–138 hysteroscopic sterilization 140 infertility correction 140 laparoscopic sterilization 139–140 ligation 139 resection 138–139 Index salpingectomy 136–138 sterilization 138–140 surgical management 136 false passage or diverticulum, cervical dilatation 86 fasting and carbohydrate treatment, preoperative 14 fat stitch, abdominal cavity opening/closing 39 Fenton’s operation 72–74 fibroid polyps removal 90 fibroids, uterine see uterine fibroids fistulae 58, 59 see also urogenital fistulae vesicovaginal fistulae 58, 296 FloSeal (Baxter) 30 fluid balance, urogenital fistulae 263 fractional curettage 104 full‐ and split‐thickness skin grafts 362 gastrointestinal complications 58–59 Gelfoam (Pfizer) 30–31 genitourinary tract injury, hysterectomy complication 124 gracilis muscle, urogenital fistulae 239, 241 gracilis myocutaneous graft, urogenital fistulae 241, 245 grafts full‐ and split‐thickness skin grafts 362 gracilis myocutaneous graft 241, 245 interposition grafts 239 labium majus ‘island’ graft 241, 244 Martius labial fat graft 188, 239, 240 myocutaneous grafts 362 peritoneal flap graft 239 skin grafts 239–241 urogenital fistulae 239–241 gynaecology training haemostatic agents 30–31 hair removal, preparation for surgery 14 history taking, preparation for surgery hymenal abnormalities 74–75 hysterectomy abdominal hysterectomy 128–130 Burch colposuspension 200 complications 124 double uterus hysterectomy 115–116 genitourinary tract injury 124 laparoscopic‐assisted vaginal hysterectomy 121–122 laparoscopic hysterectomy 130–131 laparoscopic radical hysterectomy with aortic and pelvic lymphadenectomy 297–299 McCall’s ‘culdeplasty’ combined with vaginal hysterectomy 174 radical hysterectomy and pelvic node dissection 286–297 radical vaginal hysterectomy 299–305 subtotal hysterectomy 116 367 total abdominal hysterectomy 107–115 total laparoscopic hysterectomy 122–124 uterine fibroids 128–133 vaginal cuff dehiscence 124 vaginal hysterectomy 116–122 vaginal hysterectomy, radical 299–305 vaginal hysterectomy combined with anterior and/or posterior colporrhaphy 174 vaginal vault prolapse 174 hysteroscopic myomectomy 105–106 hysteroscopic sterilization 140 ileus, gastrointestinal complication 58 iliac artery injury, vascular surgery 332–333 imperforate hymen 74–75 incontinence, stress urinary see stress urinary incontinence (SUI) infection surgery complication 56–57 urinary tract complication 58 infertility correction 140 information sheets and drawings, preparation for surgery 8–9 infundibulopelvic ligaments, total abdominal hysterectomy 108–109 initial visit, preparation for surgery 7–8 instruments 17–21 basic sets 18 insufflators, laparoscopy 46–47 interposition grafts 239 intestinal operations 349–359 appendicectomy 349–350 bowel preparation for surgery 13–14 colostomy 354–356 loop ileostomy 356–357 operation 351–352, 353 operative injuries management 351–354 side‐to‐side anastomosis 357–359 stoma formation 353–354 intravenous fluids, postoperative care 55–56 introitus enlargement, vaginal 72–74 Joel‐Cohen incision, abdominal cavity opening/ closing 42–43 juxtacervical fistula repair, urogenital fistulae 251 Keyes punch 63, 64 knots, surgical 25–28 labial fat, urogenital fistulae 239 labium majus ‘island’ graft, urogenital fistulae 241, 244 labium minus flap, urogenital fistulae 240 laparoscopic‐assisted vaginal hysterectomy 121–122 laparoscopic hysterectomy 130–131 laparoscopic myomectomy 132–133 laparoscopic ovarian cystectomy 144 368 Index laparoscopic radical hysterectomy with aortic and pelvic lymphadenectomy 297–299 laparoscopic sacrocolpopexy 184–185 laparoscopic sterilization 139–140 laparoscopic surgery endometriosis 51–53 oncology 53–54 postoperative recovery 54 vaginectomy 81 laparoscopic ureteroneocystotomy 340–341, 342 laparoscopy 45–54 abdomen access 46 anaesthesia 48 cameras 47–48 complications 51 diagnostic laparoscopy 48–51 endometriosis, laparoscopic surgery 51–53 energy sources 47 equipment 46–48 inserting the laparoscope 50–51 insufflators 46–47 light source 47 monitors 47–48 Palmer’s point entry 49–50 pneumoperitoneum 48–49 positioning the patient 45–46 preparation 48 problems 51 trocars 46–47 uterus 48 large‐bite technique, abdominal cavity opening/ closing 39 laser ablation, cervix 93 laser cone biopsy 96 Latzko (partial colpocleisis), urogenital fistulae 253, 254 Lawson‐Tait (vaginal dissection and repair in layers), urogenital fistulae 241–251 Le Fort’s colpocleisis 188–190 light source, laparoscopy 47 longitudinal vaginal septum 75 loop ileostomy 356–357 lower‐segment caesarean section 147–154 abdominal entry 148–149 aspiration pneumonitis 148 complications 153–154, 155 dangers 153–154 massive postpartum haemorrhage 155–156 uterine entry 149–153 lymphadenectomy cervical cancer 293–295, 297–299 laparoscopic radical hysterectomy with aortic and pelvic lymphadenectomy 297–299 radical hysterectomy and pelvic node dissection 293–295 uterine cancer 310 vulva carcinoma 271–273 lymph node assessment, vulva carcinoma 269–273 lymph node sampling, uterine cancer 310 marsupialization, vulval cysts/abscesses 65 Martius labial fat graft, urogenital fistulae 188, 239, 240 MAS see minimal access surgery mass closure technique, abdominal cavity opening/ closing 39 Maylard incision, abdominal cavity opening/closing 44 McCall’s ‘culdeplasty’ combined with vaginal hysterectomy 174 minimal access surgery (MAS) 45 cameras 47–48 monitors 47–48 mobility, urogenital fistulae 263 mobilization, postoperative care 56 monitors laparoscopy 47–48 minimal access surgery (MAS) 47–48 myocutaneous grafts 362 myomectomy laparoscopic myomectomy 132–133 open myomectomy 131–132 uterine fibroids 131–133 nerve damage, radical hysterectomy and pelvic node dissection 296–297 nerve injury, synthetic mid‐urethral slings 210 nodal metastases, uterine cancer 310 obstruction, gastrointestinal complication 58 omentum, urogenital fistulae 239, 261–262 oncology see also individual cancers cervical cancer 285–307 complications 53–54 exenterative surgery 319–328 fistulae 59 laparoscopic surgery 53–54 leaks 59 ovarian cancer 313–318 uterine cancer 309–311 vaginal cancer surgery 281–282 vulva carcinoma 269–279 open myomectomy 131–132 operation note, preparation for surgery 15–16 operative manipulation operative stance, abdominal cavity opening/ closing 33–34 oral contraception and hormone use 11 oral intake, postoperative care 55–56 outpatient hysteroscopy 102–104 outreach teams, postoperative care 56 ovarian cancer 313–318 operation 315–318 Index optimal cytoreductive status 315–318 surgical staging 313–315 ovarian conservation, uterine cancer 309–310 ovarian cystectomy 142–144 ovarian mass diagnosis 141 management 141–142 surgery 142 ovaries 141–145 retroperitoneal cyst removal 144–145 salpingo‐oophorectomy 144 pain relief, postoperative care 56 Palmer’s point entry, laparoscopy 49–50 parametritis, cervical dilatation 89 partial colpocleisis (Latzko), urogenital fistulae 253, 254 pathways of care, urogenital fistulae 263–264 patient information, preparation for surgery patient preparation, total abdominal hysterectomy 107–108 pedicle ties 26–27, 28 pelvic cellulitis, cervical dilatation 89 pelvic lymphocytes, radical hysterectomy and pelvic node dissection 296 pelvic node dissection, vulva carcinoma 276–277 pelvic organ prolapse 161–190 abdominal sacrocolpopexy 183–184 anterior colporrhaphy 162–165 central compartment procedures 173 complete colpocleisis 186–188 Le Fort’s colpocleisis 188–190 McCall’s ‘culdeplasty’ combined with vaginal hysterectomy 174 obliterative techniques 185 perineorrhaphy 170–171 posterior colporrhaphy 167 posterior colporrhaphy with enterocoele repair 171–173 transanal rectocele repair 170 transvaginal insertion of mesh 185 uterine sparing prolapse surgery 185 uterosacral ligament suspension 179–183 vaginal hysterectomy combined with anterior and/or posterior colporrhaphy 174 vaginal vault prolapse 174 pelvic packing, vascular surgery 334 perforation into the broad ligament, cervical dilatation 88–89 perforation of the uterus, cervical dilatation 87 peritoneal flap graft, urogenital fistulae 239 peritoneal incision, abdominal cavity opening 35–36 peritoneal washings, uterine cancer 310 peritonism, cervical dilatation 89 peritonitis, cervical dilatation 89 Pfannenstiel incision, abdominal cavity opening/ closing 41–42 physiotherapy, postoperative care 56 pneumoperitoneum, laparoscopy 48–49 port site haematoma, oncology 54 port site hernia, oncology 54 port site metastases, oncology 53–54 ‘post‐colposuspension syndrome’, Burch colposuspension 203 postoperative care catheter management 56 comorbidities 56 exenterative surgery 327 intravenous fluids 55–56 mobilization 56 oral intake 55–56 outreach teams 56 pain relief 56 physiotherapy 56 stoma therapists 56 surgery 55–56 thromboprophylaxis 55 urinary conduit formation 348 vulva carcinoma 273, 274, 278 wound monitoring 56 postoperative management Burch colposuspension 201 synthetic mid‐urethral slings 207–208 urogenital fistulae 263 postoperative recovery, laparoscopic surgery 54 preoperative activities anaesthetist visit 12–13 assessment and optimization 10–11 case review and meeting 12 discussion with patient 12 fasting and carbohydrate treatment 14 investigations 11–12 preparation, surgery 7–16 presacral bleeding, vascular surgery 333–334 preterm delivery, cervical dilatation 89 prolapse see pelvic organ prolapse prophylactic antibiotics 14, 108, 263 psoas hitch, ureter in the pelvis injuries 337, 339 radical hysterectomy and pelvic node dissection 286–297 bladder dysfunction 295 complications 295–297 history 286 lymphadenectomy 293–295 nerve damage 296–297 operation 288–293 pelvic lymphocytes 296 preoperative assessment 286–287 preparation for surgery 288 ureteric dysfunction 296 urinary tract infection 296 vesicovaginal fistulae 296 369 370 Index radical trachelectomy 305–307 radical vaginal hysterectomy 299–305 anatomical considerations 300 operation 301–304 Schuchardt incision 302 radiotherapy damage, urinary tract injuries 341 rapid access clinics 101 reconstructive procedures 361–362 full‐ and split‐thickness skin grafts 362 myocutaneous grafts 362 vulval reconstruction for localized benign disease, premalignant and early malignant disease 361–362 rectocele, Burch colposuspension 201 rectus incision, abdominal cavity opening 35 rectus sheath sling procedure (after Aldridge), stress urinary incontinence (SUI) 216–221, 221 retractors 20–21 retroperitoneal cyst removal 144–145 retropubic suburethral slings, stress urinary incontinence (SUI) 203–211, 215 risk concept, preparation for surgery round ligaments, total abdominal hysterectomy 108–110 sacral neuromodulation, stress urinary incontinence (SUI) 227 sacrocolpopexy abdominal 183–184 laparoscopic 184–185 sacrospinous ligament fixation, vaginal hysterectomy 174 salpingectomy 136–138 salpingo‐oophorectomy 144 saucerization (Sims), urogenital fistulae 251, 252 Schuchardt incision, radical vaginal hysterectomy 302 scissors 18, 19 ‘sedo‐anaesthesia’, synthetic mid‐urethral slings 203, 204 sentinel lymph node sampling, uterine cancer 310 sentinel node identification, vulva carcinoma 270–271 sepsis, surgery complication 57 sexual dysfunction, synthetic mid‐urethral slings 210–211 side‐to‐side anastomosis 357–359 Sims (saucerization), urogenital fistulae 251, 252 SIRS (systemic inflammatory response syndrome) 57 skin closure, abdominal cavity opening/closing 40–41 skin grafts see grafts skin preparation, preparation for surgery 15 small‐bite technique, abdominal cavity opening/ closing 39 smoking 11 sounding of the uterus, cervical dilatation 84–85 speed in operating stance, operative 33–34 staples 28–29 sterilization 138–140 fallopian tube ligation 139 fallopian tube resection 138–139 hysteroscopic sterilization 140 laparoscopic sterilization 139–140 stoma formation, intestinal operations 353–354 stoma therapists, postoperative care 56 stress urinary incontinence (SUI) 193–228 anterior colporrhaphy 196 artificial urinary sphincter 224–225 augmentation cystoplasty 227–228 bladder drainage 195–196 bladder neck supporting procedures 196–203 Botulinum neurotoxin (BoNT) 226–227 Burch colposuspension 196–203 choice of surgery 228 classification 193–194 cystoscopy 195, 199, 205, 207, 209, 210 detrusor overactivity operations 225–228 rectus sheath sling procedure (after Aldridge) 216–221, 221 retropubic suburethral slings 203–211, 215 sacral neuromodulation 227 suprapubic procedures 196 synthetic mid‐urethral slings 203–211 traditional sling operations 215 trans‐obturator foramen suburethral slings 211–215 urethral injection therapy 221–224 urethral sphincter augmentation 221–224 urethral supporting procedures 196–203 urinary diversion 228 urodynamic assessment 194–195 subtotal hysterectomy 116 subumbilical midline incision, abdominal cavity opening 34–36 SUI see stress urinary incontinence surgery complications 56–59 surgery preparation 7–16 surgical knots 25–28 surgical training 3–4 Surgicel (Johnson and Johnson) 30 sutures 21–24 synthetic mid‐urethral slings 203–211 anaesthesia 203 bladder overactivity 210 bladder perforation 209 bowel damage 209 ‘cough testing’ 205–207 cystoscopy 205, 207, 209, 210 indications 203 instruments 203 nerve injury 210 operation 203–207 operative complications 208–210 postoperative complications 210–211 postoperative management 207–208 Index ‘sedo‐anaesthesia’ 203, 204 sexual dysfunction 210–211 stress urinary incontinence (SUI) 203–211 tape exposure or extrusion 211 voiding dysfunction 210 systemic inflammatory response syndrome (SIRS) 57 tape exposure or extrusion, synthetic mid‐urethral slings 211 thrombin factor IIa (the common pathway) 30 thromboprophylaxis postoperative care 55 preparation for surgery 13 urogenital fistulae 263 Tisseel (Baxter Inc., Deerfield, IL) 30 tissue clamps 18, 19 total abdominal hysterectomy 107–115 total laparoscopic hysterectomy 122–124 trachelorrhaphy 98 traditional sling operations, stress urinary incontinence (SUI) 215 training opportunities transfixion stitches 27–28 transformation zone, large loop excision 94–95 trans‐obturator foramen suburethral slings, stress urinary incontinence (SUI) 211–215 transperitoneal repair, urogenital fistulae 261–262 transposition or rotational skin flap, urogenital fistulae 240 transvaginal insertion of mesh 185 transverse incisions, abdominal cavity opening/ closing 41–44 transverse vaginal septum 74–75 transvesical repair, urogenital fistulae 258–261 trocars, laparoscopy 46–47 ureteric dysfunction, radical hysterectomy and pelvic node dissection 296 ureteric fistulae 58 ureteric injuries 337–340 ureteric injuries above the pelvic brim 338–340 ureteric obstruction, Burch colposuspension 202 ureter in the pelvis injuries 337–338, 340 Boari–Ockerblad flap 337, 339 psoas hitch 337, 339 ureterovaginal fistula repair 262 ureter repair 336 urethral injection therapy stress urinary incontinence (SUI) 221–224 urethral sphincter augmentation 221–224 urethral reconstruction, urogenital fistulae 257–258 urethral sphincter augmentation 221–224 stress urinary incontinence (SUI) 221–224 urethral injection therapy 221–224 urinary conduit formation 342–348 operation 343–348 371 patient preparation 343 postoperative care 348 techniques 342 urinary diversion stress urinary incontinence (SUI) 228 urogenital fistulae 262–263 urinary incontinence 193–228 see also stress urinary incontinence urinary tract complications 58 urinary tract infection, radical hysterectomy and pelvic node dissection 296 urinary tract injuries 335–348 anatomical relationship 335 bladder injuries 336 delayed diagnosis of urinary tract damage 340–341 laparoscopic ureteroneocystotomy 340–341, 342 predisposing factors 335 preventing injuries 335–336 radiotherapy damage 341 ureteric injuries 337 ureteric injuries above the pelvic brim 338–340 ureter in the pelvis injuries 337–338, 340 ureter repair 336 urinary conduit formation 342–348 urogenital fistulae 231–264 abdominal procedures 258–262 anaesthesia 237–238 antibiotics 263 biochemistry 232–233 bladder drainage 263 circumferential repair 254–257 classification 232 colpocleisis 251–253 complete colpocleisis 251–253 cystoscopy 233–236 dye testing 233 evaluation 232–236 examination 233–236 fluid balance 263 gracilis muscle 239, 241 gracilis myocutaneous graft 241, 245 imaging 233 immediate management 236 instruments 238 interposition grafts 239 juxtacervical fistula repair 251 labial fat 239 labium majus ‘island’ graft 241, 243 labium minus flap 240 Latzko (partial colpocleisis) 253, 254 Lawson‐Tait (vaginal dissection and repair in layers) 241–251 Martius labial fat graft 188, 239, 240 microbiology 232–233 mobility 263 omentum 239, 261–262 372 Index urogenital fistulae (cont’d) partial colpocleisis (Latzko) 253, 254 pathways of care 263–264 peritoneal flap graft 239 postoperative management 263–264 preoperative preparation 237 presentation 232–236 principles of fistula repair 232 route of repair 237 saucerization (Sims) 251, 252 Sims (saucerization) 251, 252 skin grafts 239–241 suture materials 239 thromboprophylaxis 263 timing of repair 236 transperitoneal repair 261–262 transposition or rotational skin flap 240 transvesical repair 258–261 ureterovaginal fistula repair 262 urethral reconstruction 257–258 urinary diversion 262–263 vaginal dissection and repair in layers (Lawson‐Tait) 241–251 vaginal procedures 241–258 uterine cancer 309–311 lymphadenectomy 310 nodal metastases 310 ovarian conservation 309–310 peritoneal washings 310 radical surgery 311 sentinel lymph node sampling 310 surgical approach 309 uterine cavity 101–106 endometrium sampling 102 outpatient hysteroscopy 102–104 rapid access clinics 101 uterine fibroids 127–133 abdominal hysterectomy 128–130 classification 127, 128 hysterectomy 128–133 imaging 128 laparoscopic hysterectomy 130–131 management 128 myomectomy 131–133 symptoms 127 uterine sparing prolapse surgery 185 uterosacral ligaments, total abdominal hysterectomy 113 uterosacral ligament suspension, vaginal hysterectomy 179–183 uterus, laparoscopy 48 uterus operations 107–124 vaginal cancer surgery 281–282 vaginal cuff dehiscence, hysterectomy complication 124 vaginal cysts 71–72 vaginal dissection and repair in layers (Lawson‐Tait), urogenital fistulae 241–251 vaginal hysterectomy 116–122 combined with anterior and/or posterior colporrhaphy 174 laparoscopic‐assisted vaginal hysterectomy 121–122 McCall’s ‘culdeplasty’ combined with vaginal hysterectomy 174 sacrospinous ligament fixation 174 uterosacral ligament suspension 179–183 vaginal vault prolapse 174 vaginal introitus enlargement 72–74 vaginal procedures, urogenital fistulae 241–258 vaginal vault prolapse Burch colposuspension 200–201 hysterectomy 174 vaginectomy 75–81 vascular surgery 331–334 aortic injury 332, 333 iliac artery injury 332–333 pelvic packing 334 presacral bleeding 333–334 vena caval injury 333 vena caval injury, vascular surgery 333 venous thromboembolism (VTE) 13 vesicovaginal fistulae 58 radical hysterectomy and pelvic node dissection 296 voiding dysfunction Burch colposuspension 202 synthetic mid‐urethral slings 210 VTE (venous thromboembolism) 13 vulva 63–70 abscesses 64–66, 67 biopsy 63, 64 cysts 64–66, 67 vulva carcinoma 269–279 butterfly incision 274–275, 276 complications 273, 274, 278–279 excision of the vulval tumour 273–279 lymphadenectomy 271–273 lymph node assessment 269–273 pelvic node dissection 276–277 postoperative care 273, 274, 278 sentinel node identification 270–271 vulval reconstruction for localized benign disease, premalignant and early malignant disease 361–362 Z‐plasty (and other variations) 361–362 vulvectomy 66–70 WHO Surgical Safety Checklist 14 wound breakdown 57 wound dehiscence 57–58 wound monitoring, postoperative care 56 written consent 10 Z‐plasty (and other variations), vulval reconstruction 361–362 ... Healthcare; 20 06 pp 865–78 25 Ward KL, Hilton P Tension‐free Vaginal Tape versus colposuspension for primary urodynamic stress incon tinence: 5‐year follow‐up BJOG 20 08;115 (2) :22 6–33 22 9 26 Moschcowitz... large RCT .27 Recognized bladder or urethral injury should be repaired with 2? ??0 or 3‐0 Vicryl (polyglactin; W9350 2? ??0 Vicryl, 26 mm half‐circle taper cut heavy needle or W9 122 3‐0 Vicryl, 22 mm half‐circle... 4th ed Plymouth: Health Publications; 20 09 pp 1191? ?27 2 28 Galloway NT, Davies N, Stephenson TP The complica tions of colposuspension BJU Int 1987;60 (2) : 122 –4 29 Ulmsten U, Henriksson L, Johnson