Hacker & Moore's Essentials of Obstetrics and Gynecology: With STUDENT CONSULT Online Access,5th ed.

Chapter 30

Gynecologic Procedures

Joseph C. Gambone

Gynecologic procedures are becoming less invasive and safer, and advances in surgical technique are resulting in more effective and efficient reproductive healthcare for women. Smaller and more flexible instrumentation for endoscopic procedures and the development of robotic techniques are examples of these recent advances.

The gynecologic surgeon should have a high level of training during residency, followed by an ongoing commitment to retraining and retooling as effective procedures are added or substituted for outdated ones. Training methods now include computer-assisted simulations of procedures, providing for greater patient safety while learning and retraining. All facilities should have an active quality assessment program to continuously evaluate the safety and appropriateness of gynecologic care, including surgery.

It is not the purpose of this chapter to qualify the reader as a gynecologic surgeon. It is, however, essential that students and residents become familiar with the basic principles of common gynecologic surgical procedures so that they can properly assist in the operating room and carry out perioperative care.

image Appropriateness of Gynecologic Procedures

Before any procedure or surgery begins, the most appropriate option (when more than one exists) for an individual patient must be selected, with optimal patient involvement in the decision-making process preceding informed consent.

At least 80% of gynecologic surgical procedures are considered to be elective; that is, there are other alternative treatments to be considered. The appropriateness of performing these procedures should be evaluated by physician and patient on an individual basis (Box 30-1). The trend toward minimal invasiveness in gynecologic surgery should not lead to minimal or questionable indications.

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BOX 30-1 The PREPARED Checklist

P is the procedure

R is the reason or rationale

E is the expectation

P is the preference that the patient may have (e.g., to avoid surgery, or the side effects of medication)

A is the alternative(s)

R is the risk(s)

E is the expense (hospital costs and surgeon’s fees)

D is the decision to perform or not to perform the procedure

 PREPARED is a useful mnemonic checklist to assess preoperatively the appropriateness of a health-care procedure, including elective gynecologic surgery. An analysis of each gynecologic or other health-care procedure can be carried out and the patient completely and efficiently counseled using this format.

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image Credentialing, Privileging,and Ongoing Training

The rapid introduction of new technology can present a challenge to the surgeon, who will need to keep up with the most advanced procedures, and to the institution, which is required to be certain that those who are granted surgical privileges have been properly trained and are currently qualified.

After a surgeon’s credentials (diplomas, training certificates, and licenses) have been properly verified, a useful classification for the purpose of privileging stratifies procedures into the following levels: level 1, procedures not requiring additional training after residency (e.g., dilatation and curettage [D&C], cervical conization, adnexal excision, and abdominal or vaginal hysterectomy); level 2, procedures requiring additional training (e.g., laparoscopic myomectomy); and level 3, procedures requiring advanced training and special skills generally acquired during subspecialty training (e.g., radical hysterectomy, tubal anastomosis, or oocyte harvesting).

As new procedures are incorporated into basic residency training, they can be reclassified.

image Informed Consent and General Risks Associated with Procedures

The patient should be thoroughly counseled about surgical risks as part of the process of informed consent (see Chapter 1). In general, risks fall into three categories: risks of anesthesia, intraoperative risks, and postoperative complications. Risks of anesthesia depend on the type of anesthesia used (awake sedation, regional anesthesia, or inhalation agents). Regional anesthesia carries the risk for infection, postprocedure spinal headache, and failure, in which case an inhalation agent must be added to the regional anesthetic. Inhalation agents may be associated with the risk for aspiration pneumonia, allergic reaction to the agent, and damage to teeth or airways if intubation is necessary. Stroke, myocardial infarction, and death can result. The intraoperative risks include excessive bleeding and unintended damage to organs or tissue. Postoperative risks include infection, persistent bleeding, and thrombosis, all of which can lead to significant morbidity or even mortality. The specific risks of each procedure are given later.

image Endometrial Sampling Procedures

One of the most common minor gynecologic surgical procedures is D&C: dilation of the cervix and curettage of the endometrium. Recent advances in office-based instrumentation for diagnosis (hysteroscopy, endometrial sampling [Figure 30-1], and ultrasonic evaluation of endometrial thickness) have resulted in an appropriate decrease in the use of D&C. However, if cancer of the cervix or endometrium is suspected, a thorough fractional curettage may be the best procedure to confirm its presence.

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FIGURE 30-1 Endometrial sampling using the Pipelle instrument. A flexible hollow plastic tube is inserted and held in the uterine cavity as the stylet is withdrawn, creating a vacuum and resulting in aspiration of tissue.

INDICATIONS

D&C may be a diagnostic or a therapeutic procedure. A diagnostic D&C is performed for irregular menstrual bleeding, heavy menstrual bleeding, or postmenopausal bleeding, unless an endometrial biopsy has already revealed a diagnosis of malignancy. Irregularities in the contour of the endometrial cavity, either congenital (e.g., uterine septum) or acquired (e.g., submucous myomas), are sometimes determined during the operation. The finding of a thin endometrium on a transvaginal ultrasound (generally <5 mm) may eliminate the need for biopsy or D&C in some women. In patients younger than 40 years with irregular bleeding, hormonal manipulation preceded by office endometrial sampling frequently obviates the need for curettage.

The D&C may have a therapeutic effect in patients with heavy or irregular bleeding from endometrial hyperplasia, endometrial polyps, or small, pedunculated submucous myomas. Unwanted first-trimester pregnancies are usually evacuated by dilation and suction curettage, although nonsurgical techniques are now available.

TECHNIQUE

The operation is performed with the patient in the dorsal lithotomy position. Most D&Cs are now performed on an outpatient basis. Paracervical blocks and local anesthesia are frequently employed.

A pelvic examination is done under anesthesia, and after sterile preparation, a weighted speculum is placed in the posterior vagina. The cervix is grasped with a single-toothed or double-toothed tenaculum. A Kevorkian curette is used for curettage of the endocervical canal. The depth of the uterine cavity is determined with a uterine sound, and the cervix is then dilated with a set of graduated dilators. A small polyp or ovum forceps is introduced through the dilated cervix and gently rotated to remove any endometrial polyps. A thorough curettage is done with a sharp curette, proceeding with each stroke in either a clockwise or a counterclockwise manner to ensure that the entire uterine cavity has been covered.

COMPLICATIONS

The most common surgical complications of D&C are hemorrhage, infection, perforation of the uterus, and laceration of the cervix. Perforation of the uterus, even in experienced hands, is a not uncommon complication and occurs particularly with a retroverted uterus, during pregnancy, or in postmenopausal patients with endometrial cancer. As long as no bowel or large blood vessels are injured, careful observation and antibiotics may be all the therapy that is required.

Except in an acute emergency, such as an infected incomplete abortion, D&C should be done reluctantly in the presence of infection.

image Cervical Procedures

Conization of the cervix is a procedure in which a cone-shaped portion of the cervix is removed for diagnostic or occasionally therapeutic purposes. The section of the tissue surrounding the external os represents the base of the removed specimen. The apex is either close to the internal os (Figure 30-2A) or close to the external os (Figure 30-2B). Conization may also be performed in an office setting using loop electrosurgical excision (Figure 30-2C) or large loop excision of the transformation zone of the cervix. Loop excision should not be performed before identification of a cervical intraepithelial lesion that requires treatment by colposcopically directed punch biopsy.

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FIGURE 30-2 Cone biopsy of the cervix. A: Diagnostic conization performed when the squamocolumnar junction is not fully visualized colposcopically. B: Therapeutic conization performed for disease involving the ectocervix and distal endocervical canal. C: Loop electrosurgical excision procedure. The goal of the procedure is to remove the cervical tissue to just above the squamocolumnar junction, including any visible lesions.

The technique of cryoablation is commonly used to treat condylomas of the cervix, vagina, and vulva. These procedures almost always are office based, and little if any anesthesia is required.

Laser instruments are sources of intense beams of light energy. The letters in the acronym laser stand for light amplification by the stimulated emission of radiation. When used in surgery, this radiant energy is converted inside the cell to thermal or acoustic energy, resulting in controlled vaporization or coagulation of tissue. Lasers come in longer wavelengths (carbon dioxide [CO2]) or shorter wavelengths (neodymium–yttrium-aluminum-garnet [Nd:YAG], potassium-titanyl-phosphate [KTP], and argon) that can be propagated along flexible optical fibers. This allows delivery of energy for cutting, vaporization, and coagulation to tissues in locations unreachable by a CO2 laser.

Because of the additional expense of laser equipment and the lack of evidence for improvements in outcome, the use of this technology has been decreasing in recent years. Nevertheless, laser technology has been applied to conization of the cervix, removal of leiomyomas (myomectomy), and destruction of the ectopic endometrial implants of endometriosis.

image Pelvic Endoscopy

Gynecologic endoscopy (laparoscopy and hysteroscopy) is widely used for the diagnosis and treatment of reproductive organ disease and dysfunction. Laparoscopy and hysteroscopy have largely moved from the hospital operating room to the freestanding surgical outpatient unit, and with smaller instruments (needle-scopes) and more refined fiberoptic technology, even into the office setting. Because of the expenseinvolved, the value of these techniques must be considered in terms of outcome, particularly the long-term health and functional status of the patient.

image Laparoscopy

The laparoscope is an instrument for viewing the peritoneal cavity. Both pelvic and upper abdominal structures can be inspected. The attachment of a video camera on the lens of the laparoscope allows more than one surgeon to view the operative site on a video screen and assist during procedures (Figure 30-3). Multiple puncture sites through the skin and into the abdominal cavity provide for the insertion of small rigid or flexible instruments directed toward the pelvis. Procedures that were once performed by laparotomy are now routinely carried out less invasively.

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FIGURE 30-3 Laparoscopic view of female pelvis.

(Courtesy of B. Beller, MD, Eugene, Oregon.)

The indications for laparoscopy are both diagnostic and therapeutic. Laser technology can be applied to operative laparoscopic procedures both to excise and to vaporize areas of pathology.

Absolute contraindications to laparoscopy include bowel obstruction and large hemoperitoneum with hypovolemic shock. In patients who have had multiple previous laparotomies, a history of peritonitis, previous bowel surgery, or a lower midline abdominal incision, open laparoscopy is preferable. In these conditions, the peritoneal cavity is opened through a small subumbilical incision under direct vision before introduction of the trocar and sheath.

INDICATIONS

The following are indications for laparoscopy:

1. Tubal sterilization. The most common indication for the use of the laparoscope in gynecology is sterilization.

2. Ectopic pregnancy. The laparoscope is commonly used for the removal of tubal pregnancies that do not meet the criteria for medical therapy.

3. Pelvic infection. Although it is not routinely used for diagnosis of pelvic inflammatory disease (PID), the laparoscope can provide confirmation of a diagnosis when there is a diagnostic dilemma.

4. Infertility. Routine laparoscopic evaluation of the infertile woman is widely recommended but controversial because of a lack of controlled evidence of improved outcome. Advanced assisted reproductive techniques, such as in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT), may involve laparoscopic procedures, although the aspiration of oocytes for IVF is now most commonly performed transvaginally using ultrasonic guidance (see Chapter 34).

5. Pelvic pain. Acute and chronic pelvic pain can be investigated using the laparoscope.

6. Endometriosis. The laparoscope has become a widely used intervention for the diagnosis, staging, and treatment of ectopic endometrial tissue in both overtly symptomatic (pelvic pain) and silently symptomatic (infertility) patients. Laser coagulation, thermal vaporization, excision of endometriosis, and aspiration of endometriomas results in consistent, but sometimes temporary, improvement of pain and moderate improvement in fertility potential. Repeated procedures and the need for medical adjuvant treatment are common.

7. Ovarian neoplasms. Because of the need to rule out pelvic malignancies, the laparoscope can be used as a less invasive procedure to evaluate a persistent small adnexal mass. Laparoscopic ovarian cystectomy or salpingo-oophorectomy allows a tissue diagnosis to be made. Laparoscopic aspiration of cysts can be dangerous and may result in dissemination of an unsuspected ovarian cancer. Ovarian biopsy is seldom indicated, and in premenopausal patients with simple cystic enlargement, a trial of hormonal suppression or observation is indicated instead of immediate surgical intervention. Most such lesions are functional cysts that spontaneously regress. The laparoscope in expert hands has been advocated for staging and second-look procedures in patients with ovarian cancer. These procedures have become feasible since the advent of laparoscopic lymphadenectomy, but port-site recurrences are a potential problem.

8. Myomectomy. Laparoscopic myomectomy remains controversial because of the possibility that smaller leiomyomas will be removed because they can be rather than because they should be. Advocates of the procedure recommend that fibroids larger than 6 cm not be removed using the laparoscope.

9. Urogynecologic procedures. Urethropexy can be performed laparoscopically, with reported success rates comparable to procedures performed percutaneously (see Chapter 23).

10. Hysterectomy. The laparoscope has been used by some to replace an abdominal procedure (laparoscopic hysterectomy), to assist in a vaginal hysterectomy, and to convert an abdominal hysterectomy to a vaginal hysterectomy. Adoption of laparoscopic hysterectomy has been limited, with fewer than 10% of hysterectomies performed with the use of this instrument.

TECHNIQUE

The procedure is performed with the patient in a modified dorsal lithotomy position (i.e., with knee crutches), usually under general anesthesia. An intrauterine manipulator is inserted to help in the visualization of the pelvic organs. A pneumoperitoneum is created by inserting a spring-loaded needle, such as a Veress needle, into the peritoneal cavity through the subumbilical fold, and insufflation with either CO2 or nitrous oxide. The trocar and surrounding sheath are then inserted through a small subumbilical incision.

The lighted telescope is inserted into the sheath and advanced slowly. With the patient in the Trendelenburg position (tilted with the upper body lower than the pelvis), visualization of pelvic organs confirms that the peritoneal cavity has been entered. Gas may be added intermittently and automatically to maintain a sufficient pneumoperitoneum. To perform a second puncture, which is sometimes necessary, especially in laparoscopic surgical procedures, the abdominal wall is transilluminated to identify the position of the inferior epigastric vessels, and a 4- to 6-mm trocar and sheath are inserted under laparoscopic guidance through a small incision at the pubic hairline. A probe or other surgical instrument (e.g., surgical scissors) is passed through the second sheath.

On completion of the procedure, hemostasis is checked, the gas is released from the peritoneal cavity, and the instruments are withdrawn. The small skin incisions are closed with a clip or single subcuticular suture.

COMPLICATIONS

Insufflation of the abdominal wall may occur from failure to enter the peritoneal cavity with the Veress needle. Perforation of a viscus, especially adherent bowel, may occur at the time of insertion of the trocar and sheath. Once the instruments have been successfully introduced into the peritoneal cavity, lack of adequate hemostasis or coagulation burns of a viscus may occur. A poor pneumoperitoneum increases the risk for these complications.

Bowel burns during fulguration are the most serious complication of laparoscopy, although the most common complications are related to the anesthesia. Bowel burns result either from direct contact with the bowel or from a unipolar spark and are usually not detected at the time of the procedure. Several days later, bowel perforation with peritonitis may become evident. The increased use of bipolar instruments has diminished the occurrence of this serious complication. There is an increased risk for anesthetic complications in a patient with a pneumoperitoneum.

image Hysteroscopy

INDICATIONS AND USES

During the past 100 years, the hysteroscope has seen progressive improvements in light sources, optical systems, distending media, and electronic equipment,and the instrument now has a wide variety of indications and benefits in clinical gynecology. Hysteroscopy has substantially improved accuracy when compared with x-ray hysterography, and in some cases it may be more effective than diagnostic D&C in detecting intrauterine pathology such as endometrial polyps or submucous myomata.

HYSTEROSCOPIC INSTRUMENTATION

The hysteroscope (Figure 30-4) is a telescope consisting of light bundles and a sheath through which the telescope is inserted. For pure diagnostic use, the telescope is inserted alone, whereas for operative capabilities, it is inserted in conjunction with other instruments.

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FIGURE 30-4 A: Surgeon preparing to insert a hysteroscope (in right hand) through the vagina. B: View of an intrauterine polyp (center) as seen through the hysteroscope. These lesions can be removed during the procedure.

(A, From Goldberg JM, Falcone T: Atlas of Endoscopic Techniques in Gynecology. London, WB Saunders, 2000, p 185; B, from Goldberg JM, Falcone T: Atlas of Endoscopic Techniques in Gynecology. London, WB Saunders, 2000.)

Two different types of telescopes are used today: rigid and flexible fiberoptic. Rigid telescopes are most commonly 1 to 5 mm in diameter for diagnostic procedures, and operative hysteroscopes typically range from 8 to 10 mm in diameter and contain a working element through which operative instruments are inserted.

Operating instruments such as rigid or flexible scissors, graspers, biopsy forceps, or even laser fibers are inserted through operating channels, which may be part of the outer sheath, or through separate devices interposed between the telescope and the outer sheath, which are called bridges. In addition to the standard operating instruments, some bridges have attachable electrodes and finger-controlled mechanisms to allow the performance of precision intrauterine surgery.

The uterine cavity needs distention for adequate visualization through the hysteroscope. Different distention media such as carbon dioxide gas and both low- and high-viscosity fluid may be used. It is critically important for the surgeon to know which media are compatible with electrosurgical or laser energy sources and which are prone to fluid overload or anaphylactic shock during the procedure.

OFFICE-BASED VS HOSPITAL-BASED HYSTEROSCOPY

Telescopes have become progressively narrower and can now be safely inserted into the cervical canal with minimal pain. Several manufacturers have small office-based telescopes that use physiologic low-viscosity distention fluids such as saline or Ringer’s lactate. These allow the performance of hysteroscopy with little more than a paracervical block in patients who are bleeding, and they do not cause the shoulder pain and uterine spasm that often accompany use of carbon dioxide as a distention medium. At present, a significant number of hysteroscopies are performed as office procedures.

OPERATIVE PROCEDURES

Infertility

When abnormalities such as intrauterine synechiae or septa are found, hysteroscopic correction is associated with a high rate of success. Synechiae, almost always the result of trauma such as curettage or other uterine surgery, may vary from mild to severe, obliterating only a small part or almost all of the endometrial cavity. One third of patients with intrauterine synechiae have no apparent menstrual abnormalities. Hysteroscopic scissors are most commonly used for incision of the adhesions, although lasers or electrical knife electrodes may also be used. In infertile patients, conception rates up to 60% and a reduction of pregnancy wastage by 50% may be expected after incision of synechiae.

Probably the most rewarding of all hysteroscopic procedures is the excision of an intrauterine septum,a congenital anomaly that occurs in up to 1% of women. Usually performed as an outpatient procedure, excision of the septum is a relatively short procedure, with minimal bleeding and minimal risks. It is best performed with mechanical scissors as opposed to electrical or laser devices to limit the spread of thermal injury to adjacent healthy myometrium.

In most cases, it is desirable to monitor the depth of incision by concomitant laparoscopy or ultrasonography to reduce the risk for uterine perforation.

Abnormal Uterine Bleeding

The hysteroscopic evaluation of the patient with abnormal uterine bleeding frequently uncovers the presence of submucous myomas or endometrial polyps.

Small endometrial polyps can be removed easily using hysteroscopic scissors or grasping forceps inserted through an accessory channel of the operating hysteroscope, or they can be removed blindly with a polyp forceps followed by hysteroscopic reinspection to ensure complete removal. Because the endocervical canal is rarely dilated larger than 10 mm to accommodate the operating instruments, polyps or myomas that are significantly larger than this must be morcellated before removal. The use of mechanical methods for morcellation (scissors) is almost impossible, owing to their delicate construction and their small size. The urologic resectoscope has been used to morcellate or vaporize all or part of such lesions. Electrodes composed of thin wires, roller balls, roller cylinders, and grooved vaporization tips, coupled with continuous (cutting) electrical waveforms, allow simple removal of such lesions.

Endometrial Ablation

Endometrial ablation is the destruction of the uterine lining for the treatment of chronic menorrhagia. It is performed when more conservative treatments, such as hormonal therapy and curettage, are unsuccessful and when the more radical alternative of hysterectomy is undesirable or contraindicated.

Two general methods of endometrial ablation have emerged. The first type requires hysteroscopic visualization and employs electrical or laser energy to shave, vaporize, or coagulate the endometrial surface.

After a preoperative drug regimen to suppress the endometrial thickness (danazol or leuprolide), hysteroscopic laser surgery can be performed on an outpatient basis under general or regional anesthesia in about 1 hour. A hysteroscope is introduced into the uterus and a fiberoptic delivery system is passed through the operating channel. Resectoscopic endometrial ablation has become a more popular technique than laser ablation, and it appears to be at least as effective; its advantages are a significantly shorter operating time and much less expensive equipment.

Amenorrhea occurs in up to 70% of patients after resectoscopic ablation, whereas hypomenorrhea occurs in more than 90% of cases. Continued excessive bleeding is believed to be more likely when multiple myomas or severe adenomyosis exists.

A more recent method of endometrial ablation does not require hysteroscopic visualization. These techniques use either a reservoir for the delivery of heat to the endometrial surface or microwave energy directed at the endometrium to render it unresponsive to hormonal stimulation. Because they are narrower than operative hysteroscopes and their attachments and can be inserted blindly into the uterine cavity, these methods are intended for office use and for use by surgeons who may not have the experience or skills needed for laser or resectoscopic surgery.

COMPLICATIONS OF OPERATIVE HYSTEROSCOPY

Operative hysteroscopy generally comprises procedures that are relatively simple and safe, resulting in few complications. The overall complication rate is about 2%, with major complications (perforation, hemorrhage, fluid overload, bowel or urinary tract injury) occurring in less than 1% of procedures. The most significant risks of operative hysteroscopy are perforation of the uterus, excessive bleeding, and distention medium hazards (e.g., gas embolism, fluid overload, anaphylactic shock). Much less frequent and less serious complications include infections (e.g., endometritis, pelvic inflammatory disease), traumatic cervical lacerations, and postoperative cervical stenosis.

image Hysterectomy

Hysterectomy is the most commonly performed major gynecologic operation and among the top five most commonly performed major surgical procedures in the United States. It can be performed either abdominally or vaginally. Although some indications for hysterectomy remain controversial, high patient satisfaction levels and increasing safety for the procedure have been reported.

Table 30-1 provides a useful list of indications for abdominal or vaginal hysterectomy.

TABLE 30-1 HYSTERECTOMY: INDICATION LIST WITH CRITERIA

ACUTE CONDITION

A-1

Pregnancy catastrophe (e.g., severe hemorrhage)

A-2

Severe infection (e.g., ruptured tubo-ovarian abscess)

A-3

Operative complication (e.g., uterine perforation)

BENIGN DISEASE

B-1

Leiomyomas

 

Symptomatic (e.g., bleeding, pressure)

 

Asymptomatic (≥12 wk size, confuses adnexal evaluation)

B-2

Endometriosis (distinct endometriosis, unresponsive to hormonal suppression or conservative surgery)

B-3

Adenomyosis (with symptomatic menometrorrhagia unresponsive to treatment)

B-4

Chronic infection (e.g., recurrent pelvic inflammatory disease)

B-5

Adnexal mass (e.g., ovarian neoplasm)

B-6

Other (operator defined, criteria specified)

CANCER OR SIGNIFICANT PREMALIGNANT DISEASE

C-1

Invasive disease of reproductive organs

C-2

Significant preinvasive disease of the uterus (CIN-3 or adenomatous hyperplasia of the endometrium with cellular atypia)

C-3

Cancer of adjacent or distant organ (gastrointestinal, genitourinary, or breast cancer)

DISCOMFORT (NO CONFIRMING TISSUE PATHOLOGY EXPECTED)

D-1

Chronic pelvic pain (negative laparoscopy and nonsurgical treatment attempted)

D-2

Pelvic relaxation (symptomatic)

D-3

Recurrent uterine bleeding (unresponsive to hormone regulation, curettage, or endometrial ablation—normal-sized uterus)

D-4

Other (operator defined, criteria specified)

EXTENUATING CIRCUMSTANCES (NOT SPECIFICALLY INDICATED BUT POSSIBLY JUSTIFIED—REQUIRES PREOPERATIVE PEER REVIEW)

E-1

Sterilization (extenuating circumstances)

E-2

Cancer prophylaxis (e.g., recurrent CIN after cone biopsy or persistent adenomatous hyperplasia of the endometrium without atypia)

E-3

Other—listing extenuating circumstances

CIN, cervical intraepithelial neoplasia.

 Denotes indications for which tissue pathology is not expected to confirm the preoperative diagnosis.

Data from Gambone JC, Lench JB, Slesinski MJ, et al: Validation of hysterectomy indications and the quality assurance process. Obstet Gynecol 73:1045, 1989.

ABDOMINAL HYSTERECTOMY

A total abdominal hysterectomy is the most commonly performed procedure for benign uterine disease and involves the “simple” excision of the uterine corpus and cervix. It may be performed intrafascially, in which case the surgeon stays safely within the endopelvic fascia that surrounds the cervix and upper vagina, or extrafascially, in which case the investing fascia of the cervix and upper vagina is removed with the specimen. A subtotal hysterectomy excises the uterine corpus, usually at the level of the internal cervical os. A radical hysterectomy involves the wide excision of the parametrial tissue laterally (Figure 30-5), along with the uterosacral ligaments posteriorly, after the rectum is dissected free and after each ureter is dissected out of its tunnel beneath the uterine artery.

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FIGURE 30-5 Types of hysterectomy: extrafascial, intrafascial, and radical. Note the extensive amount of parametrial tissue that is removed in a radical hysterectomy.

Indications

The indications for total abdominal hysterectomy may include such benign conditions as uterine myomas, endometriosis, chronic PID, stage I endometrial cancer, and uterine bleeding that is unresponsive to more conservative measures. In some cases, a subtotal hysterectomy may be preferred if the bladder is densely adherent to the front of the cervix. Some women may request a subtotal hysterectomy because of possible involvement of the cervix in the sexual response.

radical hysterectomy is indicated for stage Ib and occasionally stage IIa cervical cancer. Endometrial cancer with gross cervical involvement may also be managed by radical hysterectomy.

In women who undergo hysterectomy at or after menopause, the uterine adnexa (fallopian tubes and ovaries) are usually removed. However, there are few studies weighing the risks and benefits of removing these normal organs. Before menopause, the option of preserving the ovaries at the time of hysterectomy vs the expense and possible dangers of hormonal replacement therapy must be thoroughly discussed with the patient preoperatively. In general, the ovaries are preserved at hysterectomy for benign disease before menopause unless there is a strong family history of breast or ovarian cancer. The choice of incidental oophorectomy, along with incidental appendectomy, awaits a thorough, prospective quality-of-life analysis (economic and medical) to guide gynecologic surgeons and their patients.

Technique

Abdominal hysterectomy is carried out with the patient in the supine position, usually under general anesthesia. First, a thorough pelvic and abdominal examination under anesthesia is carried out and recorded. The choice of incision depends on the indication for the procedure. A vertical incision is advisable in patients who have had several prior abdominal operations, are extremely obese, or in whom extensive adhesions or endometriosis is anticipated. In patients with restricted benign disease, incisions along the lines of Langer (transverse in the lower abdomen) achieve a better cosmetic result. The various lower abdominal incisions and their anatomy are discussed in Chapter 3and depicted in Figure 3-12.

After making the abdominal incision into the peritoneal cavity, the upper abdomen is manually explored with special reference to the liver, gallbladder, stomach, spleen, and para-aortic lymph nodes, and a reference to each must be recorded in the operative note. The intestines are inspected in cases of cancer with careful attention to mesenteric lymph nodes and the vermiform appendix. The patient is then placed in the Trendelenburg position, and the abdominal viscera are packed out of the pelvis with laparotomy tapes.

Each round ligament is clamped, incised, and ligated. The peritoneum on both sides is incised lateral to the infundibulopelvic ligament. This allows entry to the retroperitoneum between the leaves of the broad ligament exposing the ureter and pelvic vessels. The vesicouterine fold of the peritoneum is incised transversely between the incised round ligaments, and the bladder (adherent to the peritoneum) is reflected inferiorly off the fascia of the lower uterine segment, cervix, and upper vagina.

If the adnexa are to be removed, the ureters are identified, and the infundibulopelvic ligaments with the ovarian vessels are clamped, cut, and tied. The medioposterior leaf of the broad ligament is incised toward the uterus, thus exposing the uterine artery and veins as they course superiorly toward the utero-ovarian vascular anastomosis just below the ovarian ligament. If the uterine adnexa are to be preserved, the ovarian ligaments are clamped, incised, and ligated on each side.

The uterine vessels thus exposed are stripped of their adventitial tissue (skeletonized), clamped at the level of the internal cervical os, incised, and securely ligated bilaterally. The ligated uterine vessels are reflected laterally, allowing access to the cardinal ligament (of Mackenrodt). Staying medial to the ligated uterine vessels, the cardinal ligament on either side is clamped, incised, and ligated with a transfixion ligature. It may take several bites to free the cardinal ligaments from the lower cervix and upper vagina.

The peritoneum just below the posterior surface of the cervix is incised transversely between the uterosacral ligaments, and the rectum is reflected from the posterior aspect of the cervix and upper vagina. The uterosacral ligaments are clamped, incised, and ligated, which frees them from the cervix and upper vagina. The total uterus (corpus and cervix) is removed by cutting across the vagina just below the cervix, with care taken to sufficiently reflect the urinary bladder and rectum inferiorly to avoid injury. The vaginal cuff is normally closed with absorbable sutures, incorporating the cardinal and uterosacral ligaments into each lateral angle of the vagina to preclude the later development of a vaginal vault prolapse. If the uterosacral ligaments are widely separated, they may be plicated to prevent the formation of an enterocele. Progressive circular sutures (of Moschowitz) may be placed to obliterate a particularly large pouch of Douglas, which also portends an increased risk for enterocele.

Three points in the procedure present a particular risk for injury to the ureter: (1) as the infundibulopelvic ligaments are clamped and incised, (2) as the uterine vessels are ligated, and (3) as the cardinal ligaments are clamped if the urinary bladder is not sufficiently reflected inferiorly. Use of the retroperitoneal approach, with identification of the ureters bilaterally and careful reflection of the bladder inferiorly, prevents ureteric injury.

VAGINAL HYSTERECTOMY

Vaginal hysterectomy, if feasible, is preferable to the abdominal approach because it avoids a visible scar, is associated with less pain, affords an opportunity to correct pelvic relaxation, and generally requires less postoperative hospitalization and disability.

Indications

Ideally, vaginal hysterectomy is elected for benign disease when the uterus is mobile, is less than 12 gestational weeks in size, is characterized by some pelvic relaxation, and is expected to contain few or no adhesionsfrom endometriosis, PID, or multiple prior lower abdominal operations. The procedure is most commonly performed in association with the correction of uterine prolapse, cystocele, rectocele, or enterocele in postmenopausal women.

The advent of laparoscopically assisted vaginal hysterectomy has greatly expanded the indications for the vaginal approach by freeing up adnexal adhesions, facilitating simultaneous removal of the tubes and ovaries, and identifying conditions that would not safely be managed at the time of vaginal hysterectomy.

Technique

The principles of the operation are similar to those of abdominal hysterectomy except that ligation of the ligaments and vessels proceeds in the reverse order. The patient is placed in the dorsolithotomy position after induction of anesthesia. The bladder is emptied, and a thorough pelvic examination is performed. A weighted vaginal retractor is placed in the vagina, a tenaculum is placed on the cervix, and the uterus is drawn down toward the vaginal introitus and tested for descent and mobility. A transverse incision is made through the vaginal epithelium between the uterosacral ligaments at the posterior junction of the cervix and vagina. The peritoneum of the cul-de-sac is bluntly mobilized and sharply entered. Adhesions of the cul-de-sac and posterior uterine wall are excluded by finger exploration. The uterosacral ligaments are clamped, cut, and ligated, allowing additional descent of the uterus.

At this point, the vaginal epithelial incision is extended circumferentially around the cervix, and the bladder is advanced superiorly along the anterior uterine wall, exposing the anterior uterovesical fold of the peritoneum, which is sharply entered. The pubocervical ligaments (bladder pillars) containing the ureters are bluntly displaced laterally and the cardinal ligaments are clamped, cut, and ligated, allowing further descent of the uterus.

An angle retractor (e.g., Heaney, Deaver) is placed into the opening of the anterior vesicouterine fold of the peritoneum, and the urinary bladder is retracted anteriorly. The uterine vessels are clamped, usually with a Heaney clamp, ensuring that the tips of the clamp include the peritoneal edge both anteriorly and posteriorly and that the tips are snug against the lateral uterine wall to include all the uterine vessels. The clamped vessels are cut and securely ligated.

Downward traction on the uterus should allow full exposure of the round ligaments, fallopian tubes, ovarian ligaments, and utero-ovarian vascular anastomoses, and these structures are clamped as a group on each side, cut free of the uterus, and securely ligated. Because these pedicles are quite bulky, especially in premenopausal patients, it is wise to double clamp and ligate them, first with a loop hemostatic ligature and then with a transfixion ligature.

If the adnexa are to be removed, the suspensory ligament of the ovary is addressed instead of the ovarian ligament. With Allis clamps, the fimbriated end of the fallopian tube and ovary are drawn inferiorly into the operative field, which brings the suspensory ligament of the ovary into full view, allowing it to be clamped, cut, and ligated, while taking special care to avoid the adjacent ureter. To visualize the ureter more clearly, the round ligament may be initially and separately clamped and ligated, which opens up the lateral extraperitoneal space. This phase of the procedure may be quite difficult in a premenopausal primigravida with good pelvic support, and is most readily achieved laparoscopically.

The peritoneum is then closed with a pursestring suture or one or more transverse U-sutures, leaving the pedicles in an extraperitoneal position. As with an abdominal hysterectomy, the uterosacral ligaments may be plicated with one or more sutures to avoid an enterocele. The ovarian and round ligaments may be sutured together in the midline, but this is optional because they add little or no pelvic support. The cardinal ligaments, however, should each be sutured to the lateral aspect of the vaginal cuff to provide vaginal support, to increase vaginal depth, and to prevent the later development of a vaginal vault prolapse. The cardinal ligaments should not be sutured together across the midline because that might shorten the vagina. The vaginal epithelium is then closed with interrupted absorbable sutures. If the bladder pillars have been plicated to correct a cystocele or if a urethropexy has been employed to correct stress incontinence, catheter drainage of the bladder may be employed for 24 to 48 hours postoperatively.

COMPLICATIONS OF HYSTERECTOMY

Complications associated with any abdominal or pelvic surgery include anesthetic complications, hemorrhage, atelectasis, wound infection, urinary tract infection, thrombophlebitis, and pulmonary embolism. Atelectasis occurs most commonly in the first 24 to 48 hours and can be prevented and treated with aggressive pulmonary toilet. Wound infection usually occurs about 5 days postoperatively and is associated with redness, tenderness, swelling, and increased warmth around the wound.

Treatment may require systemic antibiotics, open-ing the incision, draining the discharge, local débridement, and wound care. Urinary tract infection can occur at any time in the postoperative period,and urine for microscopy and culture should be obtained from any patient with a postoperative fever. Thrombophlebitis (with possible subsequent pulmonary embolism) is manifested by fever and leg swelling or pain; it usually occurs 7 to 12 days postoperatively. Pulmonary embolism may occur even in the absence of signs of thrombophlebitis. Wound disruption after abdominal hysterectomy with evisceration of intestines is generally heralded by a profuse serous discharge from the wound (peritoneal fluid) 4 to 8 days after surgery. When evisceration is suspected, the wound should be explored in the operating room.

The most common intraoperative complication of abdominal or vaginal hysterectomy is bleeding from the infundibulopelvic or utero-ovarian pedicles, the uterine vascular pedicle, or the vaginal cuff. When postoperative hemorrhage occurs, bleeding from the vaginal cuff can sometimes be identified and controlled vaginally. If bleeding is sufficient to cause hypotension, laparotomy may be required to tie off the bleeding vascular pedicle.

Infection is common to both procedures and is manifested by fever and lower abdominal pain. Examination often reveals tenderness and induration of the vaginal cuff, which is indicative of pelvic cellulitis. This can usually be treated with antibiotic therapy. Administration of prophylactic cephalosporin perioperatively has proved beneficial in controlling infection in vaginal hysterectomies performed in premenopausal patients.

Injury to the ureter is the most serious complication of hysterectomy and usually occurs during the abdominal procedure, particularly during a difficult dissection for PID, endometriosis, or pelvic cancer. Ureteral injury can also occur during a vaginal hysterectomy. If not detected intraoperatively, fever and flank pain can develop postoperatively, and a ureterovaginal fistula or urinoma may become apparent 5 to 21 days after surgery. If noted intraoperatively, a ureteral injury can be repaired by implanting the proximal cut end of the ureter into the bladder or by anastomosing the proximal and distal ends of the transected ureter over a ureteric stent.

Intraoperative injury to the rectum or bladder, if recognized, should be repaired immediately. If a bladder repair is necessary, an indwelling catheter (suprapubic or transurethral) should be left on free drainage for 5 to 7 days. On rare occasions it may be necessary to protect the repair of an extensive rectal injury with a temporary loop colostomy.

image Robotic Surgery in Gynecology

The role of computer-assisted or robotic surgery in gynecology is evolving. Prospective studies are needed to compare the efficacy of this technology to conventional methods. In 2005, the da Vinci surgical system (Intuitive Surgical, Sunnyvale, Calif) received U.S. Food and Drug Administration approval (Figure 30-6). As this new technology is introduced to improve surgical performance, its limitations (such as lack of tactile feedback and increased cost) will need to be addressed. Robotic-assisted instrumentation is being used for hysterectomy, pelvic reconstructive surgery, and gynecologic oncology.

image

FIGURE 30-6 A to C: The da Vinci computer-assisted robotic surgical system. Note the console from which the surgeon directs the movement of the instruments.

(From Townsend CM, et al.: Sabiston Textbook of Surgery, 18th ed. Philadelphia, Saunders, 2008.)

SUGGESTED READING

Abstracts of the Global Congress of Minimally Invasive Gynecology, 36th Annual Meeting of the American Association of Gynecologic Laparoscopists, Washington, DC. J Minim Invasive Gynecol 14(6 Suppl):S1-S154, 2007.

Advincula A.P., Song A. The role of robotic surgery in gynecology. Curr Opin Obstet Gynecol. 2007;19:331-336.

American College of Obstetricians and Gynecologists (ACOG). Technology Assessment in Obstetrics and Gynecology. Hysteroscopy. Washington, DC: ACOG, 2005. pp 350–353

Hart R., Karthigasu B., Drishnan A. The benefits of virtual reality simulator training for laparoscopic training. Curr Opin Obstet Gynecol. 2007;19:297-302.

Reich H. Total laparoscopic hysterectomy: Indications, tech-niques and outcomes. Curr Opin Obstet Gynecol. 2007;19:337-344.