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Atlas of Gynecologic Surgery

Diethelm Wallwiener
Sven Becker

Matthias W. Beckmann
Sara Y. Brucker
Klaus Friese
Keith B. Isaacson
Walter Jonat
Arnaud Wattiez

With contributions by
H. Abele, C. Bachmann, K. Gardanis, E.-M. Grischke, R. Hornung, B. Krmer,
M. Oehler, C. Reisenauer, R. Rothmund, E. F. Solomayer, C. Wallwiener,
M. Wallwiener, W. Zubke

With the collaboration of


Ernst H. Schmidt
Rudy L. De Wilde

4th edition

1138 illustrations
23 tables

Thieme
Stuttgart New York
Library of Congress Cataloging-in-Publication Data is available from the publisher. Important note: Medicine is an ever-changing science undergoing continual development. Re-
search and clinical experience are continually expanding our knowledge, in particular our
This book is an authorized translation of the 7th German edition published and knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or
copyrighted 2009 by Georg Thieme Verlag, Stuttgart. Title of the German edition: application, readers may rest assured that the authors, editors, and publishers have made every
Atlas der gynkologischen Operationen. effort to ensure that such references are in accordance with the state of knowledge at the time
of production of the book.
Translators: Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the
Gertrud Champe, Surry, Maine, USA part of the publishers in respect to any dosage instructions and forms of applications stated in
Geraldine OSullivan, Dublin, Ireland the book. Every user is requested to examine carefully the manufacturers leaflets accompany-
ing each drug and to check, if necessary in consultation with a physician or specialist, whether
Illustrators: the dosage schedules mentioned therein or the contraindications stated by the manufacturers
Reinhold Henkel, Heidelberg, Germany differ from the statements made in the present book. Such examination is particularly impor-
Karl-Heinz Seeber, Tbingen, Germany tant with drugs that are either rarely used or have been newly released on the market. Every
Andrea Schnitzler, Innsbruck, Austria dosage schedule or every form of application used is entirely at the users own risk and respon-
Marianne Lck, Hamburg, Germany sibility. The authors and publishers request every user to report to the publishers any discrep-
ancies or inaccuracies noticed. If errors in this work are found after publication, errata will be
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2014 Georg Thieme Verlag KG, Some of the product names, patents, and registered designs referred to in this book are in fact
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New York, NY 10 001, USA This book, including all parts thereof, is legally protected by copyright. Any use, exploitation,
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ISBN 978-3-13-650704-9
EISBN 978-3-13-169684-7
PREFACE
The Atlas of Gynecologic Surgery has a long and respected history, going back to its The result is a modern surgical authority with more than 1100 illustrations that
first German edition in 1960. Since that time, gynecology as a science and the reper- gives a comprehensive and current picture of operative gynecology and obstetrics.
tory of gynecologic operations have changed and developed in many significant We are convinced that this presentation will provide the reader with great pleasure
ways. The task of consolidating this constantly growing knowledge and transform- and visual enjoyment.
ing it, with the application of a multiplying number of techniques, into the best pos-
sible operative treatment for patients is becoming more and more challenging for The enormous challenge of bringing out this international work in rejuvenated form
physicians. while retaining the tried and trusted core was met thanks to the intense joint in-
volvement of the publisher, authors, and graphic artists.
The principal goal of the present work was and is a structured presentation of both V
the scientists and the craftsmans view of the various abdominal, vaginal, endoscop- In the production of this atlas we have been helped by many and many need to be
ic and senologic operations in our field, a presentation that is lucid and placed in the thanked.
right context.
We would first like to thank Thieme Publishers for their courage to take on the re-
This challenge, as well as the many changes and paradigm shifts occurring in the edition of such an outstanding work both of science and of art. The tremendous suc-
years since the last reworking of the English edition in 1997, called for a far-reaching cess of the Atlas new edition in the German-speaking countries has already reward-
revision of design and content. Thus, all aspects of this current edition have been ed this initiative and the confidence put into traditional drawings in the context of
changed and renewed. surgical teaching.

The introductory chapters are followed by a topographical organization into sections We would also like to thank our medical artist, Reinhold Henkel, for over 10 years of
treating the adnexa, uterus, vulva/vagina, and pelvic floor. There, where useful, a close and highly creative collaboration. Reinhold Henkel passed away this year, and
distinction is made between abdominal (open), vaginal, and endoscopic approaches. the world of medical art has lost an exceptional artist.
The chapters on surgical techniques begin with the simpler operations and move on
to the more difficult techniques. At the same time, the Operation Navigator, newly Countless hours of exciting work went into this Atlas. Combined with our obliga-
developed especially for this book, facilitates a convenient search from the disease tions as directors of large university departments, we devote a tremendous amount
to the indication to the operation of choice (see the graphic on p. VI). of our time into what we love as gynecologic surgeons: creating a modern and last-
ing school of benign and gynecologic surgery.
The Atlas of Gynecologic Surgery is known all over the world as a work rich in tradi-
tion that lays out the entire field of operative gynecology in detail and at the highest It is more than appropriate at this point to appreciate the support of both of our fam-
level. The collection of still-applicable illustrations from earlier editions and more ilies over the years. With a special thanks to Gabriele, Markus, and Christian, as well
than 500 new drawings contribute to the new composition of a work of excellent es- as Graziella, Nicholas, and Charlotte, we dedicate this book to our families and to our
thetic and didactic quality. The conceptual reworking and the new textual and patients.
graphic configuration of the work matured for almost a decade. Even until shortly
before the book went to press, drawings were still being updated and relevant inno- Diethelm Wallwiener, Tbingen
vations were worked into the appropriate chapters. Sven Becker, Frankfurt

For the English edition, two international editors have been invited. Their collabora-
tion allows for a truly international perspective of current and classical gynecology.
Searching by body region
(e.g. adnexa, uterus, pelvic floor)
All pertinent information is summarized in one chapter.

Preliminary Remarks about the Region


Page 192202

Concepts for Surgical Treatment


Procedure Navigator
Page 203220

Surgical Techniques
VI Page 221355

Abdominal Vaginal Endoscopic

Introduction to specific
characteristics of the body region
Topography of the approach
(abdominal, vaginal, endoscopic)
Search for a selected operation
Orientation based on uniformly structured tables

Indications and Contraindications

Operation Risks and Informed Consent

Guide to selecting a method Operation Planning


From the disease to the indication to the intervention.
Procedure
What are the options? The operation of choice!

Complications

Concurrent and Postoperative Treatment

Limits of the Methods


GRAPHIC ARTWORK
Why watercolor drawings in the era of multimedia images? The detailed and This, together with the unique quality of the drawings in the atlas, suggested con-
unique illustrations, particularly those of the two illustrators Andrea Schnitzler and tinuing the work as a means of teaching operative surgery based on watercolor
Karl-Heinz Seeber, were always the special treasure of the traditional Atlas of Gyne- drawings.
cologic Surgery. The history of medicine overall and that of surgery in particular is
inconceivable without attractive and anatomically exact reproductions of the avail- For nearly a decade, drawings had been selected from the wealth of existing illustra-
able knowledge. These range from the anatomical drawings of the Renaissance and tions, and new watercolors were produced in minute and time-consuming detail.
the scientific diagrams of the 19th century to the great surgical atlases of the Vien- Like the authors and draftsmen of previous editions, the authors of this edition
nese school and the American tradition (Brdel, Netter) and up to the present day. worked closely with and were involved in detailed discussions with Reinhold Henkel
Many of the classical views have become the general property of the medical to obtain illustrations of optimal quality. VII
world so that hardly anyone now knows who first drew them and created a didactic
work of art. The editors

Thieme, the publisher of the atlas, deliberately continued the esthetic tradition of
the work in commissioning Reinhold Henkel, an outstanding draftsman and artist,
to provide illustrations for the new edition.

In the digital world, photography has often replaced graphic art, not least because it
is easier and requires less effort to take a representative photo than to develop an
illustration. Even today, however, a carefully and artistically planned drawing will
be superior to a photo in most cases. Only a well-considered graphic illustration is
capable of combining perfectly the exact anatomy, generalized pathology, a three-
dimensional view, and didactic information. In a world permeated by digital infor-
mation technology, the traditional picture produced by hand exerts an immediate
effect through its inimitable authenticity and esthetic expression.
LIST OF CONTRIBUTORS
Harald Abele, MD Eva-Maria Grischke, MD
Department of Obstetrics and Gynecology Professor
University Clinic Tbingen Department of Obstetrics and Gynecology
Tbingen, Germany University Clinic Tbingen
Tbingen, Germany
Cornelia Bachmann, MD
Department of Obstetrics and Gynecology Ren Hornung, MD
University Clinic Tbingen Professor and Head Physician
Tbingen, Germany Department of Obstetrics and Gynecology IX
Kantonsspital St. Gallen
Sven Becker, MD St. Gallen, Switzerland
Professor and Director
Department of Gynecology and Obstetrics Keith B. Isaacson, MD
University Hospital Frankfurt Medical Director
Frankfurt, Germany Minimally Invasive Gynecological Surgery Unit
Newton-Wellesley Hospital
Matthias W. Beckmann, MD Newton, MA, USA
Professor and Director
Department of Obstetrics and Gynecology Walter Jonat, MD
University Clinic Erlangen Professor and Director
Erlangen, Germany Department of Obstetrics and Gynecology
University Clinic
Sara Y. Brucker, MD Kiel, Germany
Department of Obstetrics and Gynecology
University Clinic Tbingen Bernhard Krmer, MD
Tbingen, Germany Department of Obstetrics and Gynecology
University Clinic Tbingen
Rudy Leon De Wilde, MD Tbingen, Germany
Professor
Gynecological Clinic Martin Oehler, MD
Pius-Hospital Professor
Oldenburg, Germany Department of Gynaecological Oncology
Royal Adelaide Hospital
Klaus Friese, MD Adelaide, SA, Australia
Professor and Director
Department of Obstetrics and Gynecology Christl Reisenauer, MD
University Clinic Professor
Munich, Germany Department of Obstetrics and Gynecology
University Clinic Tbingen
Konstantinos Gardanis, MD Tbingen, Germany
Head of Outpatient Surgery Center
Department of Obstetrics and Gynecology
University Clinic Tbingen
Tbingen, Germany
List of Contributors

Ralf Rothmund, MD Diethelm Wallwiener, MD


Associate Director Professor and Director
Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology
University Clinic Tbingen University Clinic Tbingen
Tbingen, Germany Tbingen, Germany

Ernst Heinrich Schmidt, MD Markus Wallwiener, MD


Professor Department of Obstetrics and Gynecology
Gynecological Hospital University Clinic Heidelberg
Bremen, Germany Heidelberg, Germany

Erich F. Solomayer, MD Arnaud Wattiez


Professor and Director Professor and Gynecological Director
Department of Gynecology, Obstetrics and Reproductive Medicine IRCAD/EITS Institut de Recherche contre les cancers de l'Appareil Digestif
University Clinic Homburg/Saar Strasbourg, France
Homburg/Saar, Germany
Wolfgang Zubke, MD

X Christian Wallwiener, MD Department of Obstetrics and Gynecology


Department of Obstetrics and Gynecology University Clinic Tbingen
University Clinic Tbingen Tbingen, Germany
Tbingen, Germany
CONTENTS
I. General Part

1.1 Pre- and Postoperative Treatment 1


1.1.1 Preoperative Treatment 1
Ambulant/In-patient Treatment 1
Informed Consent 2
Anesthesia 3
Laboratory and Imaging Tests 4
Preparation for Surgery 4 XI
1.1.2 Postoperative Treatment 5
Ambulant Treatment 5
In-patient Treatment 6
1.2 Instruments 7
1.2.1 Abdominal Surgery 7
Scissors 7
Clamps 8
Needle Holders 10
Forceps 11
Grasping Instruments 11
Cutting Instruments 12
Retractors 12
1.2.2 Vaginal Surgery 13
Hegar Dilators 13
Forceps and Clamps 13
Curettes 14
Specula 15
1.2.3 Endoscopic Surgery 16
1.3 Sutures and Drains 18
1.3.1 Sutures 18
Suture Material 18
Knot-Tying Techniques 19
1.3.2 Drains 20
Closed Drain Systems without Suction 20
Closed Drain Systems with Suction 21
Open Drains without Suction 21
1.4 Positioning 21
1.4.1 Abdominal Procedures 21
1.4.2 Vaginal Procedures 22
1.4.3 Laparoscopic Procedures 22
Contents

II. Complications and Their Management

2.1 Bleeding Complications 25


2.1.1 Intraoperative BleedingAbdominal Procedures 25
2.1.2 Intraoperative BleedingVaginal Procedures 26
2.1.3 Intraoperative BleedingLaparoscopic Procedures 26
2.1.4 Postoperative Bleeding 26
2.2 Inflammatory Complications 28
2.2.1 Wound Infection 28
2.2.2 Peritonitis/Sepsis 28
2.3 Injury to the Urinary Organs 29
2.3.1 Bladder Injuries 29
2.3.2 Ureteral Injuries 29
2.4 Gastrointestinal Tract Injury 32
2.4.1 Small-Bowel Injury 32
2.4.2 Large-Bowel Injury 33
XII
2.5 Wound Dehiscence and Hernia 34
2.5.1 Wound Dehiscence 34
2.5.2 Hernias 35

III. Abdominal Wall

3.1 Laparotomy 37
3.1.1 Anatomical Basis 37
3.1.2 Opening the Abdomen 38
Median Vertical Laparotomy 38
Pfannenstiel Transverse Fascial Incision 39
Cohen Modification of the Transverse Fascial Incision (Misgav Ladach Method) 40
Cherney Suprapubic Transverse Fascial Incision
Transection of the Rectus Attachment 42
Suprapubic Maylard Incision 42
Separate Opening of Abdominal Layers
with Longitudinal Fascial Incision 43
Infraumbilical Minilaparotomy 44
Technique in Cases of Morbid Obesity 44
3.1.3 Closure Techniques 44
Peritoneal Suture 44
Fascial Suture 44
Correction of Defects in the Abdominal Wall 47
Relief Sutures in Dehiscence of Abdominal Sutures 48
Skin/Subcutaneous Tissue 48
3.2 Laparoscopy 49
3.2.1 Anatomic Basis 49
3.2.2 Approach to the Abdominal Cavity 50
3.2.3 Insertion in Special Operations 53
3.2.4 Open Laparoscopy 53
3.2.5 Closure of Trocar Insertion Points 54
3.2.6 Laparoscopic Retrieval Techniques 54
Contents

IV. Adnexa

4.1 Preliminary Remarks about the Region 60


4.1.1 Topography of the Retroperitoneum 60
4.1.1.1 General Anatomy 60
4.1.1.2 Retroperitoneum _ Nerves 61
4.1.1.3 Retroperitoneal Space _ Vessels 62
4.1.1.4 Retroperitoneal Space _ Course of the Ureter 63
4.1.1.5 Retroperitoneal Space _ Lymph Nodes 64
4.1.2 Functional Pathology 64
4.1.2.1 Ovaries 64
4.1.2.2 Fallopian Tubes 65
4.1.3 Morphologic PathologyHistology 65
4.1.4 Terminology and Diagnosis 66
4.1.4.1 Stages and Classification of Endometriosis 66
4.1.4.2 Stages of Fallopian Tube Carcinoma 66
4.1.4.3 Stages of Ovarian Cancer 67 XIII
4.2 Concepts for Surgical TreatmentProcedure Navigator 68
4.3 Surgical Techniques 82
Abdominal 82
4.3.1.1 Ovarian Wedge Resection, Ovarian Cystectomy, Removal of
an Intraligamentous Cyst, Simple Oophorectomy 82
4.3.1.2 Open Salpingo-Oophorectomy 86
4.3.1.3 Open Salpingotomy/Salpingectomy in Ectopic Pregnancy 90
4.3.1.4 Open Sterilization Operations 96
4.3.1.5 Open Infertility Surgery 100
4.3.1.6 Abdominal Surgery of Endometriosis 106
4.3.1.7 Surgery of Malignant Adnexal Tumors/Debulking Operations 111
Vaginal 131
4.3.2.1 Vaginal Salpingo-Oophorectomy 131
Endoscopic 134
4.3.3.1 LaparoscopyDiagnostic and Minor Operative Procedures 134
4.3.3.2 Laparoscopic Adhesiolysis 139
4.3.3.3 Laparoscopy of Pelvic Inflammatory Disease 142
4.3.3.4 Laparoscopic Fertility Surgery 146
4.3.3.5 Laparoscopic Sterilization 151
4.3.3.6 Laparoscopic Ovarian Cystectomy, Hydatid Removal 155
4.3.3.7 Laparoscopic Ovariopexy 160
4.3.3.8 Laparoscopic Operation for Ovarian Torsion 163
4.3.3.9 Laparoscopic Salpingo-Oophorectomy 166
4.3.3.10 Laparoscopic Removal of Cystic and Solid Adnexal Tumors 170
4.3.3.11 Laparoscopic Removal of an Ectopic Pregnancy 175
4.3.3.12 Laparoscopic Treatment of Endometriosis 182
Contents

V. Uterus

5.1 Preliminary Remarks about the Region 192


5.1.1 Topography of Pelvic Spaces 192
5.1.1.1 Classification of the Spaces 192
5.1.1.2 Paravesical Space 193
5.1.1.3 Pararectal Space 193
5.1.1.4 Obturator Fossa 194
5.1.1.5 Rectovaginal Septum 194
5.1.1.6 Presacral Space 195
5.1.1.7 Psoas Space 195
5.1.1.8 Pelvic RetroperitoneumNervous Structures 196
5.1.2 Functional PathologyDevelopmental Disorders 197
5.1.3 Morphologic PathologyHistology 198
5.1.4 Terminology and Diagnosis 199
5.1.4.1 Stages of Cervical and Endometrial Carcinoma 199
XIV 5.1.4.2 Classification of Gynecologic Malformations 201
5.2 Concepts for Surgical TreatmentProcedure Navigator 203
5.3 Surgical Techniques 221
Abdominal 221
5.3.1.1 Abdominal Myomectomy 221
5.3.1.2 Abdominal Hysterectomy 225
5.3.1.3 Abdominal Supracervical Hysterectomy 232
5.3.1.4 Abdominal Radical Hysterectomy 235
5.3.1.5 Abdominal Lymphadenectomy for a Malignancy
of the Internal Genitalia: Para-aortic Lymphadenectomy 246
5.3.1.6 Cesarean Section 250
5.3.1.7 Postpartum Hysterectomy 256
5.3.1.8 Operations for Uterine Malformations 259
Vaginal 262
5.3.2.1 Minor and Diagnostic Procedures 262
5.3.2.2 Curettage and Polypectomy 265
5.3.2.3 Conization 268
5.3.2.4 Laser Therapy of the Cervix, Cryotherapy 272
5.3.2.5 Cervicectomy 275
5.3.2.6 Extirpation of the Cervical Stump 280
5.3.2.7 Vaginal Hysterectomy 283
5.3.2.8 Vaginal Hysterectomy for Uterine/Vaginal Prolapse 294
5.3.2.9 Radical Vaginal Hysterectomy 298
5.3.2.10 Suction Curettage in Abnormal Early Pregnancy 308
5.3.2.11 Operations for Cervical InsufficiencyCerclage 311
Endoscopic 315
5.3.3.1 Diagnostic Hysteroscopy, Hysteroscopic Biopsy,
Hysteroscopic Removal of a Lost IUP/IUD 315
5.3.3.2 Hysteroscopic Septum Dissection, Hysteroscopic Polypectomy,
Hysteroscopic Myomectomy 319
5.3.3.3 Hysteroscopic Endometrium Ablation, Hysteroscopic Synechiolysis 324
5.3.3.4 Laparoscopic Myomectomy 329
5.3.3.5 Laparoscopic Hysterectomy 335
5.3.3.6 Laparoscopic Pelvic Lymphadenectomy 342
5.3.3.7 Laparoscopic Para-aortic Lymphadenectomy 348
5.3.3.8 Laparoscopic Hysterectomy for Uterine Malignancy 352
Contents

VI. Vulva and Vagina

6.1 Preliminary Remarks on the Region 358


6.1.1 Topography of the External Genitalia 358
6.1.1.1 External Vulva 358
6.1.1.2 Subcutaneous Parts of the Vulva: Superficial Perineal Space 359
6.1.1.3 Muscle and Aponeurotic Base of the Vulva 359
6.1.1.4 Blood Supply and Innervation of the Vulva and Vagina 361
6.1.1.5 Deep Muscle and Fascial Layer of the Vulvar Region 362
6.1.1.6 Inguinal Region 363
6.1.2 Functional PathologyDevelopmental Disorders 364
6.1.3 Morphological PathologyHistology 364
6.1.4 Terminology and Diagnosis 366
6.1.4.1 Staging and Treatment of Vulvar Cancer 366
6.1.4.2 Staging and Treatment of Vaginal Cancer 367
6.2 Concepts for Surgical TreatmentProcedure Navigator 368
XV
6.3 Surgical Techniques 378
Abdominal 378
6.3.1.1 Inguinofemoral Lymphadenectomy 378
6.3.1.2 Surgical Treatment of Vaginal Carcinoma 383
Vaginal 386
6.3.2.1 Diagnostic Procedures on the Vulva and Vagina 386
6.3.2.2 Laser Surgery on the Vulva and Vagina 388
6.3.2.3 Surgery of Cysts of the Vulva and Vagina 391
6.3.2.4 Carcinoma in Situ in the Vaginal Stump 395
6.3.2.5 Nonradical Vulvectomy Techniques 397
6.3.2.6 Extended Local Excision of Vulvar Carcinoma 402
6.3.2.7 Radical Total Vulvectomy 405
Reconstructive and Plastic Surgery 412
6.3.3.1 Suture of Episiotomy and First- and Second-Degree Perineal Tears 412
6.3.3.2 Suture of Third- and Fourth-Degree Perineal Tears 424
6.3.3.3 Correction of Old Third- and Fourth-Degree Perineal Tears 429
6.3.3.4 Procedures on the Hymen and Introitus 433
6.3.3.5 Surgery of Vaginal Septa 437
6.3.3.6 Surgery on the Labia and Clitoris 441
6.3.3.7 Coverage of Defects in the Vulva and Vagina ITransposition Flap
and Bulbocavernosus Repair 447
6.3.3.8 Coverage of Defects in the Vulva and Vagina IIMyocutaneous Flaps 451
6.3.3.9 Neovagina 459
Contents

VII. Pelvic Floor Position Changes of the Internal Genitalia and Incontinence

7.1 Preliminary Remarks about the Region 476


7.1.1 Topography of the Access Pathways 476
7.1.1.1 Vaginal Approach _ Muscle Layers 476
7.1.1.2 Vaginal Approach _ Connective Tissue Structures 478
7.1.1.3 Vaginal Approach _ Vessels, Nerves, Ureter 479
7.1.1.4 Abdominal Approach _ Muscle Layers 480
7.1.1.5 Abdominal Approach _ Connective Tissue Structures 482
7.1.1.6 Abdominal Approach _ Vessels, Nerves, Ureter 483
7.1.2 Positional Change of Urinary Bladder, Internal Genitalia, Rectum 483
7.1.2.1 Clinical Picture 483
7.1.2.2 Surgically Important Situations 485
7.1.3 Continence and Incontinence 486
7.1.3.1 Clinical Picture 486
7.1.3.2 Surgically Important Situations 487
XVI 7.2 Concepts for Surgical TreatmentProcedure Navigator 489
7.3 Surgical Techniques 499
Abdominal 499
7.3.1.1 Abdominal Retropubic Colposuspension Operation 499
7.3.1.2 Abdominal Paravaginal Colpopexy 503
7.3.1.3 Abdominal Colposacropexy (Colpocervicopexy) 506
7.3.1.4 Abdominal Enterocele Operations (Halban, Moschkowitz) 510
7.3.1.5 Abdominal Correction of a Vesicovaginal Fistula 512
Vaginal 518
7.3.2.1 Anterior Colporrhaphy 518
7.3.2.2 Vaginal Paravaginal Colpopexy 522
7.3.2.3 Posterior Colporrhaphy 526
7.3.2.4 Vaginal Sacrospinal Fixation 532
7.3.2.5 Vaginal Uterosacral Fixation 536
7.3.2.6 Vaginal Enterocele Repair 539
7.3.2.7 Colpocleisis 542
7.3.2.8 Suburethral Sling Operations 545
7.3.2.9 Suburethral Heterologous Tension-free Sling Operations (TVT, TVTO) 548
7.3.2.10 Pelvic Floor Reconstruction with Mesh Implants 554
7.3.2.11 Peri- and Intraurethral Collagen Injection 561
7.3.2.12 Vaginal Correction of a Vesicovaginal Fistula 563
7.3.2.13 Vaginal Correction of a Rectovaginal Fistula 571
Endoscopic 575
7.3.3.1 Laparoscopic Retropubic Colposuspension 575
7.3.2.2 Laparoscopic Paravaginal Colpopexy 579
7.3.3.3 Laparoscopic Colposacropexy (Colpocervicopexy) 582
Contents

VIII. Gynecologic Oncology, Urogynecology, Proctogynecology: New Surgical Techniques

8.1 Exenterations 589


8.1.1 Development of Evisceration Surgery 589
8.1.2 Indications and Contraindications 589
8.1.3 Problems of Operation Technique 590
8.1.4 Errors and Failures 590
8.1.5 Operation Procedures 591
Starting the Operation and Preparation for Exenteration 591
Anterior Exenteration 593
Perineal Phase/Infralevator Exenteration 598
Reconstructive Aspects of Exenteration 600
Restoration of Bowel Continuity 603
Neovagina 604
8.1.6 Systematic Exenteration 605
8.1.7 Complications 606
8.1.8 Concurrent and Postoperative Treatment 606 XVII
8.1.9 Limits of the Method 606
8.2 GynecologyUrologyProctology 607
8.2.1 Gynecologic Urology 607
Urethral Caruncle 607
Urethral Prolapse 607
Urethral Diverticulum 609
Loss of the Urethra (Neourethra) 611
TeLinde Urethroplasty 613
Symmonds Urethral Reconstruction 614
Symmonds Myocutaneous Labial Flap 616
8.2.2 Special Urologic Procedures 617
End-to-End Anastomosis 618
Ureteroneocystostomy 619
Modified Boari Flap Operation 621
8.2.3 Gynecologic Proctology 626
Anatomy and Physiology 626
Proctological Examination Techniques 628
Disease Conditions 628
8.3 New Techniques 633
8.3.1 Electrosurgery 633
8.3.2 Vessel Sealing 633
8.3.3 BiClamp Technique 634
8.3.4 LigaSure 634
8.3.5 Argon Plasma Coagulator 634
8.3.6 SupraLoop 634
8.3.7 UltraCision/Harmonic Scalpel 634
8.3.8 CUSA 635
8.3.9 Robotic Surgery in Gynecology 635
Background/Technology 635
Indications, Contraindications, and Patient Selection 635
Preoperative Preparation and Patient Positioning 636
Trocar Placement and Docking/Undocking of the Robotic System 636
Surgical Techniques 637
Contents

List of Illustrations from Other Works 639

References 640

Index 641

XVIII
I.
G E N E R A L PA R T
I
1
A surgical operation is the last stage in a long chain of diagnostic steps and pens automatically or of its own accord. In addition to his or her knowledge
therapeutic decisions, and it is the interplay between them that provides the of disease and treatment, buttressed by experience, the surgeon must also be
conditions for a successful outcome. Before, during, and after the operation, intimately aware of the medical and technical aspects of surgical treatment.
the patient and surgeon are in a highly technical world in which nothing hap- Moreover, a surgical procedure often has legal and administrative implications.

1.1 Pre- and Postoperative Treatment

Correct preoperative assessment and treatment together with optimal post- siological perspective, American Society of Anesthesiologists (ASA) class 1 or
operative care contribute crucially to the success or failure of a procedure. The ASA class 2 is a requirement.
most important aspects are discussed in brief below.
As regards the patients social history, it is necessary that the patient can be
collected from the clinic by relatives or friends and then be looked after in an
acceptable manner for 24 hours. Access to a telephone is a further considera-
1.1.1 Preoperative Treatment tion. The patient or her legal representative should be able to understand the
planned operation in its entirety. The minimum criteria that must be met
should be documented prior to discharge. These include:
Ambulant/In-patient Treatment

Preoperatively, the patient should be made aware of what to expect postoper-


Table 1.1.1 American Society of Anesthesiologists (ASA) risk classification
atively: how will she be restricted, what pain is likely, what problems can oc-
cur? How much will she have to rely on help and assistance? These questions Type Description
are becoming more and more important in the context of an aging population, ASA 1 A normal healthy patient
particularly with regard to ambulant surgery. The patient should be given ade-
ASA 2 A patient with mild systemic disease
quate information so that she can organize her postoperative affairs. The lenght
of her hospitalization depends on the surgery performed, the patients health ASA 3 A patient with severe systemic disease and reduced performance
status, her individual domestic care situation, and administrative issues.
ASA 4 A patient with an inactivating systemic disease that is a constant
threat to life
Ambulant treatment. The legal foundation for ambulant treatment is based on
ASA 5 A moribund patient who is not expected to survive the next 24 hours,
assessment by a competent specialist. In many hospitals, this assessment is
regardless of the operation
made jointly by the gynecologist and the anesthesiologist. From the anesthe-
I General Part P r e - a n d P o s t o p e r a t i v e Tr e a t m e n t

Full possession of protective reflexes threatening situation, on the other hand, only the basic outlines of the risks
Orientation in time and place need to be explained. It is important that the surgeon is aware of the concept
Stable circulation of the risks of the specific procedure. This refers to risks that arise from the
No respiratory impairment surgeons experience (or inexperience) and from the quality of the clinics fa-
No acute postanesthesia vomiting cilities. The doctor is also obliged to provide information about alternative
Ability to tolerate liquids orally treatment methods.
Adequate analgesia
Time and form of informed consent. The time and form of the informed consent
Recourse claims with regard to the need for in-patient monitoring can usually should be chosen to allow the patient sufficient opportunity to think over her
be rejected when documentation is adequate. Nevertheless, it should be noted decision and if necessary discuss it with others. Experience has shown that this
that an ambulant procedure is also in the patients interest because she is soon time is not on the day of the operation, so informed consent for elective surgery
removed from the increased risks of infection and thrombosis associated with has to be obtained the day before surgery at the latest. Naturally, this does not
hospitalization. apply in emergencies. In most doctors offices, ambulant surgery centers and
hospitals, the patient is first given a printed form that explains the operation.
In-patient care. The duration of postoperative hospitalization is not uniformly The indispensable personal informed consent discussion can be based on this
regulated for the purposes of health insurance. There is usually a consensus information form. Translators should be well versed in medical terminology.
I on the minimum duration of hospitalization, but this does not always match This is often not the case when relatives serve as translators.

2 medical need. The surgeon has to find a locally appropriate solution, together
with hospital management and the payers. Certainly, postoperative hospi- Under-age children. In the case of under-age children, the consent of both par-
talization has become much shorter in the last 15 years. ents with legal custody is necessary. Although the consent of one parent suf-
fices in ordinary cases, the consent of all adult legal guardians should be ob-
tained in the case of critical procedures with an ethically problematic back-
Informed Consent ground. If the parents refuse necessary treatment, an application must be
made to the guardianship court. In emergencies, the physician may make the
Legal Foundation decision.

In legal terms, every operative procedure constitutes an assault, and many Impaired consent capacity. The capacity to give consent is a central point that
surgical measures actually meet the definition of aggravated assault. This may must be heeded. If capacity is impaired by mental disability or disease, a legal
include, for example, loss of reproductive capacity. Medical treatment, and a representative may be appointed by the court to consent to the operation. This
surgical operation in particular, is clearly a physical injury according to the leg- involves appointment of a guardian, a legal carer or representative for health
islation in force. It is not culpable and not unlawful only when a competent matters. It is particularly important that dangerous or problematic procedures
patient has given informed consent or when there is a justifiable emergency. also require the approval of or a ruling by the guardianship court. Extreme cau-
In addition to the definition of assault, the law of tort also defines when the in- tion is required with patients who are incapable of giving informed consent.
jured party has a right to seek compensation for deliberate or negligent injury. Legal competencies must be clarified if time allows. In cases of doubt, a state-
Here, too, illegality is diminished only by a legally valid informed consent. ment by an ethics committee, an expert lawyer or the responsible court should
be obtained. The term patients presumed will is used in this context.

Informed Consent Requirements Informed consent in obstetrics. Informed consent is particularly important in
obstetrics. A rapidly evolving obstetric situation in an individual case does not
Informed consent plays an important part in the surgeons routine work. Ap- alter the informed consent obligation. This applies, for example, to cesarean
propriate information and legally correct consent are central to the physicians section, operative vaginal delivery, or fetal blood sampling. The woman in labor
malpractice liability, both economically and legally. The content, time and must be provided with information, and this must be documented.
form, and documentation of legally valid consent must meet certain require-
ments:

Typical risks of surgery. When deciding for or against the planned operation, the
risks typical of the operation must be explained to the patient. Likewise, the
possible consequences of not performing the operation must also be explained
and documented. The patient must be given the oppportunity to make an in-
formed decision. The law does not specify what risks have to be explained. If an
operation is associated with serious risks, these must be listed even if they are
unlikely. The less urgent the operation, the stricter are the informed consent
requirements. For example, informed consent for cosmetic surgery should in-
clude all risks up to and including postoperative embolism and death. In a life-
I General Part P r e - a n d P o s t o p e r a t i v e Tr e a t m e n t

Table 1.1.2 Basic requirements for legally valid informed consent Table 1.1.3 Typical forms of anesthesia in gynecology

The patient must be capable of giving consent Operation Form of anesthesia


In the case of under-age patients, either both parents or the legally appointed Curettage Local anesthesia, mask anesthesia vs.
guardian must also give consent laryngeal mask
In the case of a patient incapable of giving consent, the legal responsibility must be
D&C Mask anesthesia vs. laryngeal mask
clarified before the operation
After providing information, in the case of elective surgery, the patient must have Hysteroscopy, fractionated curettage Mask anesthesia vs. laryngeal mask
sufficient time to think about and discuss it. The informed consent should be
Laparoscopy, short operation Intubation anesthesia, possibly
obtained on the day before the planned operation at the latest
laryngeal mask
Risks typical of the operation must be explained
Laparoscopy, long operation Intubation anesthesia
The role of the risks of the specific procedure (risks specific to the hospital and
surgeon) is not yet clearly defined in legal rulings Tensionfree Vaginal Tape (TVT), Analgosedation and local anesthesia
Tensionfree Vaginal Tape Obturator
Reasonable alternative treatment methods must be discussed
(TVT-O)
The less urgent the operation, the more detailed the informed consent
Elective cesarean section Spinal anesthesia
In the case of cosmetic surgery, virtually all risks must be discussed
Emergency cesarean section Intubation anesthesia vs. high epidural
Intraoperatively, the procedure must not extend beyond the possibilities discussed anesthesia (if sufficient) I
preoperatively
Frozen section Spinal anesthesia, high epidural 3
Obstetric patients must also be informed of every procedure, regardless of the
anesthesia
clinical situation
The informed consent form can form the basis of the discussion, but does not Vaginal hysterectomy Intubation anesthesia, possibly laryn-
replace it geal mask, possibly spinal anesthesia

Sterilization of minors is prohibited without exception Abdominal hysterectomy Intubation anesthesia

Typical ovarian cancer surgery/ Intubation anesthesia and epidural


Wertheim operation catheter

Intraoperative extension of an operation. Another critical point is intraoperative curettage and diagnostic hysteroscopy can be performed under local anesthe-
extension of a procedure. The operation may be extended only within the sia, although correct patient selection and a degree of experience with this
framework of the consent given by the patient. In clinically difficult situations, method are important. The surgeon initially has to become accustomed to talk-
such as unclear adnexal findings or uncertain histology, the problem must be ing to the patient continuously during the procedure. While the type of anes-
discussed in detail with the patient. A two-stage procedure may be advisable. thesia used for many operations also depends on local conditions and tradi-
tions, the international standard should be demanded strictly in obstetrics: in-
In addition, every practicing gynecologist should be aware that sterilization of tubation anesthesia is reserved in obstetrics for rare exceptional situations,
a minor is not permissible, and there are rare exceptions to this rule. which must always be justified. Spinal or epidural anesthesia is standard for ce-
sarean section.

Anesthesia
Requirements
Type of Anesthesia
As a medical intervention, anesthesia is subject to the same provisions as the
The type of anesthesia is a matter of negotiation between patient, gynecologist, surgical procedure. The patients informed consent the day before the opera-
and anesthesiologist. The choice includes local anesthesia techniques, oral or IV tion is recommended. Consent given on the day of surgery can be problematic
sedation, regional anesthesia methods such as spinal or epidural anesthesia, in the case of elective procedures. Technical administration of anesthesia, with
and general anesthesia. Combinations of these methods may also be employed. the exception of local anesthesia, is the anesthesiologists responsibility. Most
Certain operations require specific types of anesthesia: for instance, intubation gynecological procedures are of short duration and the patients status is usu-
anesthesia is currently the most frequent type for laparoscopy with CO2 insuf- ally ASA class 1 or 2. Long operations in very ill patients, which are performed,
flation, partly to counteract the increased abdominal pressure and diaphrag- for example, in gynecological oncology, make much greater demands of the an-
mic irritation, and partly to counteract the CO2 surplus by adjusting ventilation. esthesiologist. There have been important innovations in recent years, with
The combination of an epidural catheter with intubation anesthesia has be- which the gynecologic surgeon should be familiar. These include avoidance of
come increasingly common. The advantages are easier control of anesthesia intraoperative hypothermia, for example, by consistent use of heated underlays
throughout the possibly prolonged surgery, e.g., during typical ovarian cancer (little effect) or convection air heaters (good effectiveness), avoidance of fluid
operations, and the possibility of optimal postoperative analgesia. Local anes- overload, avoidance of post-traumatic stress reactions by use of epidural anes-
thesia with or without IV sedation is typical for ambulant surgery. Conization,
I General Part P r e - a n d P o s t o p e r a t i v e Tr e a t m e n t

thesia in combination with intubation anesthesia, and careful avoidance of


postoperative nausea and vomiting. Preparation for Surgery

Antibiotic Prophylaxis
Laboratory and Imaging Tests
Antibiotics depending on the procedure. Administration of prophylactic antibi-
Laboratory tests and diagnostic imaging procedures are important components otics immediately before abdominal procedures, especially cesarean section
of standard preoperative preparation. They must be established for each insti- (when antibiotics are given after cutting the cord), is a rational measure con-
tution jointly by the gynecologic surgeon and the anesthesiologist. In recent firmed by excellent studies. The aim is to reduce postoperative infections. Pro-
years, the standards have increasingly been guided by the specific clinical sit- phylactic antibiotic administration has also proven effective before major vagi-
uation. nal operations, especially vaginal hysterectomy and laparoscopic hysterecto-
my. On the other hand, the benefits of giving antibiotics before intrauterine
Laboratory tests. A young healthy patient in whom curettage because of missed procedures (curettage, hysteroscopy) have not been confirmed by studies. Ac-
abortion is planned does not absolutely need a preoperative blood count, and cording to the available data, prophylactic antibiotics before elective laparo-
recent cross-matching is not obligatory before an uncomplicated hysterectomy. scopic procedures are not useful.
Patients without a noteworthy history of bleeding do not need a coagulation
I screen prior to routine procedures in every case. An asymptomatic 70-year- Antibiotics and time of administration. When prophylactic antibiotics are given,

4 old athlete may not require a preoperative chest radiograph, but a 40-year-old a single dose of an aminopenicillin (in combination with a lactamase inhib-
overweight chain smoker probably does. No categorical instructions can be giv- itor) or first- or second-generation cephalosporin within an hour before the
en. start of the operation is recommended. Giving them at the same time as the
skin incision has not been shown to be of equal value. A second dose is indicat-
Imaging tests. The imaging procedures necessary for specific diseases will be ed when the operation lasts longer than 6 hours. Clindamycin is an alternative
discussed with the individual operation techniques. Imaging procedures that in the case of allergy.
do not alter the operative approach should be rejected. Conversely, a pelvic tu-
mor suspicious for malignancy should not be operated on without recent
mammography, and hysterectomy should not be performed without recent Thrombosis Prophylaxis
cervical cytology.
Because of the incidence and pronounced morbidity of perioperative thrombo-
sis and embolism in surgical patients, thrombosis prophylaxis merits particular
emphasis. Thrombosis and embolism are the most important avoidable causes
of perioperative morbidity and mortality. Thrombosis prophylaxis is particu-
larly important in hospitalized pregnant women and postpartum patients, as
their thrombosis risk is markedly higher than that of the age-matched non-
pregnant population.

Table 1.1.4 Patient-adapted laboratory tests

Procedure Patient characteristics Laboratory tests, imaging, electrocardiograph (ECG)

Ambulant hysteroscopy No relevant medical history No tests

Ambulant laparoscopy No relevant medical history No tests

Ambulant procedure Patient > 50 years ECG if appropriate

Hysterectomy as in-patient procedure Patient > 50 years, smoker Laboratory tests (blood count, electrolytes)
ECG
Chest radiograph

Malignancy as in-patient procedure No relevant medical history Laboratory tests (blood count, electrolytes, crossmatch)
ECG
Chest radiograph

Vaginal pelvic floor reconstruction Patient < 60 years, no relevant medical history Laboratory tests (blood count)
as in-patient procedure
I General Part P r e - a n d P o s t o p e r a t i v e Tr e a t m e n t

Heparin. Thrombosis prophylaxis is recommended for all hospitalized patients,


for example, by means of low-molecular-weight heparin once a day. The dose Hair Removal
can be increased when there are additional risk factors (obesity, long surgery,
confinement to bed, malignant disease). Studies show that the optimal time of There are clear data regarding hair removal in the operating area. Hair removal
administration is before the start of the operation. Because of the theoretical in- is not necessary for reasons of infection and hygiene, but it is not harmful. If it
crease in the tendency to bleeding, however, many surgeons prefer to start giv- is done for surgical reasons, electric shaving (clipping) is considered superior to
ing it only within the first 6 hours after the end of surgery. When paraspinal shaving with a razor. The timing does not appear to be important.
anesthetic techniques are employed, preoperative thrombosis prophylaxis is
possible only outside a strict time window (usually 12 hours). The thrombosis
prophylaxis should be adapted to the patients risk classification during her
hospitalization. 1.1.2 Postoperative Treatment
Other methods. Antithrombotic stockings are a nonpharmacological method Postoperative management has changed greatly in the last 10 years. Ambulant
of thrombosis prophylaxis, though their actual value depends greatly on pre- surgery has become increasingly common and this trend will continue. How-
cise fitting. Use of intermittent pneumatic compression is also an effective pro- ever, the available data from visceral and thoracic surgery (fast-track sur-
phylactic tool. In any case, the most important antithrombotic measure is early gery) will alter the postoperative management of hospitalized gynecological
patient mobilization, ideally on the day of the operation but on the first post- patients. The most important obstacles are the ideas and expectations of I
operative day at the latest. Bedside physiotherapy should be considered. many doctors, the nursing staff, and particularly of the patients themselves. 5
These ideas and expectations have developed over decades. Many patients still
associate a long hospitalization with good care, although all available data
Preoperative Fasting demonstrate exactly the opposite. A good hospital stay as regards healing,
low complication rates and rapid rehabilitation is nearly always a short hospital
The rules on preoperative fasting from food and fluid have changed greatly in stay.
the last few years. The following minimum restrictions are demanded by pro-
gressive anesthesiologists for elective procedures, based on study-supported
data: Ambulant Treatment
No solid food and no nonclear fluids within 6 hours before the procedure
No roast or grilled foods within 8 hours before the procedure Monitoring. Postoperative monitoring after ambulant procedures is guided by
Clear fluids (water, tea without milk, coffee without milk, fruit juice with- the nature of the operation and anesthesia. Following immediate postoperative
out pulp; high-carbohydrate fluids) up to 2 hours before the operation monitoring by the anesthetic staff (recovery room), the patients are looked
The 6-hour rule also applies for smoking and chewing gum after in a monitoring room attached to the ambulant operating room until
they are discharged. A minimum period is not specified, but most gynecolo-
The anesthesiologist may deviate from this in an individual case, depending on gists and anesthesiologists recommend observation for at least 2 hours after
the underlying disease and chosen form of anesthesia. It is advisable to check general anesthesia, and 4 hours after anesthesia with administration of mor-
whether these guidelines are supported by the anesthesiologists locally. Be- phine. Measurement of the vital signs (pulse, blood pressure) during ambulant
cause of delayed gastric emptying associated with pregnancy, the above guide- postoperative observation is guided by the patients condition. Measurement
lines do not apply to the obstetrical population. every 30 minutes provides adequate security in any case.

Discharge. Prior to discharge, the surgical and/or anesthetic staff must ensure
Bowel Preparation that the patient can safely be discharged (see Chapter 1.1.1.1). A discussion
must be held before discharge in which the patient is informed about the
Bowel preparation rules for major abdominal operations, especially when bow- course of the operation, any particular postoperative features, and what she
el resection may be anticipated, are subject to strong surgical traditions. Ulti- should do during the immediate postoperative period.
mately, the gynecologist must comply with the recommendations of his surgi-
cal colleagues. Interestingly, the available data do not support mechanical bow-
el preparation as regards the feared anastomotic leakage. Rather, consistent
bowel preparation, which is associated with considerable effort and discomfort
for both the patient and the nursing staff, appears to have a negative influence
on the rate of leakage.
I General Part P r e - a n d P o s t o p e r a t i v e Tr e a t m e n t

Thrombosis prophylaxis. Postoperative thrombosis prophylaxis is particularly


In-patient Treatment important. The most important additional risk factors for thrombosis and em-
bolism are:
Fast-track surgery. The perioperative care of hospitalized patients is currently Malignant disease
undergoing important changes with the increasing data on the various benefits Pregnancy
of active clinical management, which includes early mobilization, early enteral Advanced ageincreasing risk
fluid intake and feeding in the form of fast-track surgery. As this approach has Thrombophilia (antiphospholipid syndrome, APC resistance/factor V Lei-
been tested especially in multimorbid patients undergoing abdominal surgery, den mutation, antithrombin or protein C/S deficiency)
the typical gynecology patient should be able to benefit even more. The crucial Contraceptives and hormone replacement therapy
points of fast-track surgery are: Chronic venous insufficiency
Elimination of pain Severe infection
Combination of regional anesthesia and general anesthesia Obesity (BMI > 30 kg/m2)
Effective but low-opiate analgesia Heart failure NYHA III/IV
Adapted fluid management
Limitation of preoperative fasting from fluids According to the Association of Medical Scientific Societies in Germany, a dis-
Little or no intraoperative weight gain tinction is made between physical and pharmacological measures for throm-
I Low perioperative infusion volume bosis prophylaxis:

6 Temperature regulationavoidance of hypothermia Physical measures include early mobilization, constant encouragement
Aggressive prevention of postoperative nausea and vomiting (and instruction) of the patient to perform exercises using the muscle
Early postoperative intake of fluid and food (2nd postoperative hour) pump, possibly as part of physiotherapy, and also well-fitting compression
Early mobilization (5th postoperative hour) stockings and possibly intermittent pneumatic compression
Early discharge Pharmacological thromboembolism prophylaxis in gynecology and obstet-
rics is now provided mainly by low-molecular-weight heparins. The dose
Modern perioperative management aims to reduce the initial fluid deficit with should be adjusted to the patients weight and risk depending on which of
the patient allowed to drink clear fluids up to 2 hours before the operation. the low-molecular-weight heparins is used. The risk of heparin-induced
When a patient weighing 75 kg fasts completely for 1014 hours, there is al- thrombocytopenia (HIT) is very low with low-molecular-weight heparins.
ready a preoperative fluid deficit of 15002100 mL, based on a basal fluid re- Regular blood count monitoring is not necessary, and a single measure-
quirement of 2 mL/kg body weight per hour. Intraoperative and postoperative ment usually suffices. If heparin is not tolerated, the heparin-free heparin-
fluid administration is restrictive. oid danaparoid is available

Laboratory tests. Laboratory tests are guided by the operation and should be Food intake. Oral postoperative food intake should start about 2 hours after
specified by the surgeon. If there is the slightest suspicion or suggestion of purely gynecological operations (water, tea). There is no objection to yogurt as
postoperative bleedingeven without clear clinical signsregular hemoglobin an early food. The patient should eat the regular hospital diet on the first post-
and hematocrit measurements should dispel or confirm the suspicion. If the operative day. This regimen is encouraged in patients following colon and rec-
patients clinical vital signs are not completely normal, the last blood count tal resection and should not cause any problems in gynecological patients.
must not be the lowest. It is better to take one blood count too many than one
blood count too few, especially as the bodys considerable capacity for compen- Drains. The decision on whether to insert drains is at the surgeons discretion,
sation can mask the clinical signs of significant bleeding, particularly in young and he or she should be guided by the clinical situation. Closed drainage sys-
and healthy patients. tems are the minimum standard. There is no situation in which it is essential
to place a drain. Some surgeons argue for dispensing completely with drains,
and developments in recent years have been in this direction. As with many
medical measures, the rule with drains is to use them sparingly and remove
them early.
I General Part Instruments

1.2 Instruments

No surgery is possible without the correct instruments. Although the number Sims Scissors
of instruments actually used is manageable, there are considerable differences
from hospital to hospital and from operating room to operating room. Ulti- The Sims scissors is very similar to the Cooper scissors. However, it also comes
mately, the surgeon has to keep to the selection available in his institution. Dif- in an uncurved form. It is called after the American surgeon and gynecologist
ferent instruments are described in brief below, but this list does not claim to J. Marion Sims (18131884), who is regarded in the USA as the founder of mod-
be complete. The names of the instruments are often historical and based on ern gynecology. Simss pioneering work on the surgical treatment of the then
convention. The most common names and classifications are used below, but omnipresent obstetric fistula should be particularly emphasized; fistulas were
these can never be entirely comprehensive. a source of terrible suffering for affected women and became curable for the
first time as a result of Simss efforts. Nowadays, obstetric vesicovaginal or rec-
tovaginal fistulas are a significant gynecological problem in developing coun-
tries. The fistula hospital in Addis Ababa established by the Australian physi-
1.2.1 Abdominal Surgery cian couple Reg and Catherine Hamlin is world famous; its operative technique
is based essentially on the approach developed by Sims. I
Abdominal surgery requires an arsenal of scissors, clamps, needle holders, and 7
retractors of varying length and varying strength or fineness.

Scissors

Standard scissors come in straight and slightly curved forms. In addition, the
ends of the blades may be pointed or blunt.

Cooper Scissors

The Cooper scissors is a strong, curved, blunt-ended scissors, which is some-


times also called a fascia scissors but is used mostly for cutting sutures. The
name probably goes back to Sir Astley Paston Cooper (17681841), an English
physician, anatomist and surgeon, who also gave his name to the Cooper liga-
ments of the breast and the Cooper ligament of the anterior pelvic ring (pectin-
eal ligament). Cooper, who studied with the French surgeon Francois Chopart
(17431795) in revolutionary Paris, was regarded by his contemporaries as the
most outstanding surgical teacher of his time.

Fig. 1.2-1 Cooper scissors. Fig. 1.2-2 Sims scissors.


I General Part Instruments

Metzenbaum Scissors Clamps

The Metzenbaum scissors is a fine, usually curved, pointed or blunt-ended dis- Hemostatic clamps are distinguished from purely tissue-grasping clamps. The
secting scissors, and is among the most important dissecting instruments. The surface of the jaws is serrated either longitudinally, parallel to the clamped tis-
name derives from the American ENT surgeon Myron Firth Metzenbaum sue, or horizontally, perpendicular to the clamped tissue. Hemostatic clamps
(18761944), who specialized in oral surgery and plastic reconstructive sur- are characterized by longitudinal serration, for example, Wertheim clamp or
gery of the nose and larynx. During his training, Metzenbaumlike numerous other parametrial clamps. Horizontally serrated tissue-grasping clamps grip
other American doctors of his timeworked in Vienna and London. In the USA, better in tissue. They are divided into tissue-sparing and tissue-destroying
Metzenbaum was also one of the pioneers of ether anesthesia. clamps.

Kocher Clamp

Kocher clamps come in every length and thickness and are usually straight.
They are typical tissue-crushing clamps with a sharp barb and are suitable es-
I pecially for gripping tough tissue such as fascia. The clamp is named for the

8 Swiss surgeon Emil Theodor Kocher (18411917). He was the first surgeon to
receive the Nobel Prize in medicine in 1909 (for his study on the physiology,
Fig. 1.2-3 Metzenbaum scissors.
pathology, and surgery of the thyroid gland). Kocher worked in almost every
branch of surgery at a time when the foundations of modern operative surgery
were laid with asepsis and hemostasis.

Satinsky Scissors

The Satinsky scissors is a fine, highly angled, pointed or blunt-ended dissecting


scissors which is used in gynecology as a cutting instrument in the lesser pel-
vis, classically when dividing the uterus from the vagina. The name comes from
the American surgeon Victor Paul Satinsky (19121997), who worked especial-
ly as a cardiac surgeon. Satinsky, after whom a whole range of instruments is
named, was a dazzling personality who devoted himself to a wealth of activi-
ties besides medicine, such as playing the clarinet, fencing, and writing poetry
and plays (some of which were even produced in London). At the age of 80 Fig. 1.2-5 Kocher clamp.

years, Dr. Satinsky even obtained a black belt in aikido. He spent his academic
career at Hahnemann Hospital in Philadelphia.

Mikulicz Clamp

Mikulicz clamps are somewhat finer than Kocher clamps and are curved. They
are not suitable for clamping tissue but only for grasping a specific tissue, for
example, the parietal peritoneum when closing the abdomen or the rectus fas-
cia when opening it. It is named for Johann von Mikulicz (18501905), one of
the best-known surgeons of his era. Mikulicz was a student of Theodor Billroth
in Vienna, and subsequently university professor in Cracow, Knigsberg and,
from 1890, Breslau. His scientific work includes the first description of achala-
Fig. 1.2-4 Satinsky scissors. sia as a functional disorder of the lower esophageal sphincter, initial attempts
at gastroscopy, introduction of local anesthesia to surgical practice, and impor-
tant improvements in the technique of thyroid resection. From 1896 onward,
Mikulicz promoted use of a face mask to improve intraoperative asepsis. His
best-known assistant was Ferdinand Sauerbruch, who, under Mikulicz in Bres-
lau, demonstrated the negative pressure chamber for surgery on the open lung.
I General Part Instruments

Fig. 1.2-6 Mikulicz clamp.

Pan Clamp
Fig. 1.2-8 Kelly clamp.

The Pan clamp is a relatively atraumatic straight clamp which largely corre-
sponds to the Kocher clamp but has no barb (no tapering) and is thus to a cer-
tain extent a straight Overholt clamp. It comes in all sizes and is suitable espe- I
cially for clamping small vessels. Its name comes from the pioneering French Overholt Clamp 9
surgeon Jule-mile Pan (18301898). In 1878, Pan performed resection of
the pylorus to treat gastric outlet stenosis for the first time. As was not unusual The Overholt clamp is a slightly curved clamp, with tapered jaws and rounded
in those early days of academic surgery, the patient died after 4 days. Pan was ends without serrations. It is an ideal atraumatic grasping instrument and can
also one of the first people to remove an ovarian cyst and perform a splenecto- also be used as a hemostatic clamp for minor bleeding. Above all, it is an impor-
my, both pioneering procedures at that time. tant dissecting instrument, which can be used to open and separate specific
layers and spaces atraumatically. The name comes from the thoracic and pul-
monary surgeon Richard Overholt (19011990), who was one of the most im-
portant people in the anti-smoking movement. He was far ahead of his time in
recognizing the effect of smoking on the lungs when he performed lung oper-
ations on tuberculosis patients in the late 1930s and denouncing smoking
again and again, against the prevailing medical opinion of the next 20 years.
Overholt performed one of the first successful partial lung resections for lung
cancer.

Fig. 1.2-7 Pan clamp.

Kelly Clamp

The Kelly clamp is similar to the Pan clamp but the tips are slightly rounded
and tapering. It can be straight or curved but is somewhat heavier than an Fig. 1.2-9 Overholt clamp.
Overholt clamp so it is less suitable for dissection. It is named after Howard Kel-
ly (18581943), one of the most outstanding American gynecologists, who was
a co-founder of the Johns Hopkins Hospital, where, with Halsted and Osler, he
laid the foundations of modern American academic medicine and helped to es- Halsted Clamp (Mosquito Forceps)
tablish gynecology as a branch of surgery. Kelly plication, an operation for
urinary incontinence named after him, is no longer in common use. Halsted clamps are very fine hemostatic clamps, which are suitable especially
for gripping small fragile structures. They are widely employed in surgery.
Their name comes from the American surgeon William Halsted (18521922),
who, together with the gynecologist Howard Kelly and the physician William
Osler, the co-founders of the Johns Hopkins Hospital, was one of the fathers of
modern American academic medicine. Halsted completed what was then the
classical surgical training in America, including nearly 3 years in Vienna, Leip-
zig and Wrzburg between 1878 and 1880, where one of his teachers was Bill-
I General Part Instruments

Fig. 1.2-12 Backhaus clamp.

Fig. 1.2-10 Halsted forceps.


Backhaus (Towel) Clamp

Backhaus clamps are small, sharp, traumatic clamps with which tissue is perfo-
I roth. Numerous principles of modern surgery, such as gentle operating, clean rated and held. They are used especially on the skin, but cause small defects

10 and tension-free wound closure, and the use of rubber gloves, go back to Hal- there. They are traumatic instruments, and some surgeons reject them or use
sted. He was one of the first to create surgical specialization in the fields of them only as towel clamps.
urology and orthopedics. Halsted is also regarded as one of the founders of
the American clinical education system, where he largely adopted the Europe- The clamp is believed to be named for the gynecologist Carl Backhaus, head of
an structures of that era. Like many doctors of his time, he developed a severe the surgical department of the Augusta Hospital in Dsseldorf, Germany. He
and lifelong addiction from his clinical experiments with cocaine as a local an- worked in the Pathology Institute of the Christian Albrecht University in Kiel
esthetic, which initially ruined his promising career in New York. After several in 1896/1897 and in the surgical department of Mainz City Hospital from
admissions to detoxification clinics, he got his second and crucial opportunity 1897 to 1899. From 1900 to 1904 he worked with Rotter in the surgical depart-
at the newly founded Johns Hopkins University in Baltimore. Here he also pub- ment of the Hedwig Hospital in Berlin. He worked on improving asepsis of the
lished the technique of radical mastectomy, which is named after him. operation field and on improving the surgery of large abdominal hernias by re-
doubling the hernial sac. He also improved the Bassini operation.

Parametrial (Wertheim) Clamp


Needle Holders
Parametrial clamps are typical tissue-destroying clamps, which are used par-
ticularly in gynecology for clamping and ligating the vascular parametrial tis- Needle holders are among the most important and technically demanding in-
sue bundle and the uterine artery which it contains. The name comes from struments; gripping a needle securely and accurately requires an exact and
the gynecological surgeon Ernst Wertheim (18641920), who for many years precise mechanism. Although needle holders have finger holes like clamps
was the director of the gynecology clinic of Vienna University, where he was and scissors, they can be opened and closed by the ball of the hand for optimal
involved in developing the radical hysterectomy that bears his name to treat manipulation, which makes it possible to grasp the needle accurately. All nee-
cervical cancer. He was the first to employ this operating technique successful- dle holders work in the same way, and it is only the size that differs, according
ly in a large number of patients. to the surgical situation.

Fig. 1.2-11 Wertheim parametrial clamp.

Fig. 1.2-13 Needle holder.


I General Part Instruments

Forceps Adson Forceps

Forceps are among the most frequently used instruments. They are classified Another instrument used internationally is the fine Adson forceps, which is
into surgical, traumatic (with barb), and anatomical, atraumatic (without used in gynecological surgery especially during skin suture. Alfred Washington
barb) forceps, and which is used depends on the operative situation. There is Adson (18871951) was a pioneer and founder of neurosurgery in the USA. He
also a large variety of electrocautery forceps. worked especially at the Mayo Clinic, where he established the specialty. Adson
undertook the first sympathectomy to treat high blood pressure and as therapy
of Raynaud syndrome.
DeBakey Forceps

The DeBakey forceps is the best-known atraumatic forceps, named after the
American cardiac surgeon Michael DeBakey (19082008), who was one of the
legends of 20th century cardiovascular surgery, not least because of his phe-
nomenal longevity; he was a pioneer in the field of bypass and aneurysm sur-
gery. At the age of 97 years he underwent surgery for a ruptured abdominal
Fig. 1.2-16 Adson forceps.
aortic aneurysm, more or less with the technique that he had introduced over I
half a century earlier. 11
Russian Forceps

Another forceps popular in gynecology, especially during pelvic and para-aor-


tic lymphadenectomy, is known as a Russian forceps.

Fig. 1.2-14 DeBakey forceps.

Surgical Forceps
Fig. 1.2-17 Russian forceps.

The barbed traumatic surgical forceps has remained without an eponym.

Grasping Instruments

Ovary Grasping Forceps, Amnion Grasping Forceps

The ovary grasping forceps is a specific gynecological and obstetric grasping in-
strument, which is an atraumatic forceps very suitable for manipulating ova-
Fig. 1.2-15 Surgical forceps. ries or fetal membranes.

Fig. 1.2-18 Ovary grasping forceps.


I General Part Instruments

Babcock Forceps Retractors

The Babcock forceps is a strictly atraumatic grasping and fixing instrument used There is a large range of surgical retractors, from the simplest retaining hook to
in open abdominal gynecology for grasping the tubes or ureters. It is called after modern self-retaining systems. For most doctors in training, acting as second
William Wayne Babcock (18721962), one of the founding fathers of modern assistant and providing retraction is their first contact with surgery. Only a
American surgery. After initially working as a gynecologist, he subsequently few examples of retractors are described below.
worked in general surgery. Important innovations in varicose vein surgery,
treatment of thoracic aortic aneurysm, which was common at the time because
of syphilis, and the surgery of rectal cancer go back to Babcock, who also played Bladder Retractor
a crucial role in founding the American Board of Surgery. It should be empha-
sized that Babcock was one of the first surgeons to employ spinal anesthesia. The bladder retractor is used a great deal, especially in gynecology. It is impor-
tant in the classical step of dissecting the bladder off the anterior wall of the
uterus during abdominal hysterectomy.

I
12

Fig. 1.2-19 Babcock clamp.

Fig. 1.2-21 Bladder retractor.

Cutting Instruments

Traditional scalpels are distinguished from electrical cutting implements. Con- Roux Retractor
ventional scalpels are designated according to an internationally accepted
numbering system. The main blades used in gynecology are the number 11 The Roux retractor is used frequently in gynecology, especially at the skin, dur-
(stab incision, laparoscopy), the number 21 (skin incision for abdominal oper- ing laparotomy, and when closing the abdomen. Its name comes from the Swiss
ations), and the number 15 for small biopsies. general surgeon and gynecologist Csar Roux (18571934). Roux was a student
of Langhans and Kocher in Berne. Apart from the retractor, he also gave his
name to the Roux-en-Y technique in gastric bypass surgery.

Fig. 1.2-20 Various blades. The numbering corresponds to the international nomenclature. Fig. 1.2-22 Roux retractor.
I General Part Instruments

Fritsch Retractor Forceps and Clamps

The Fritsch retractor is used especially during cesarean section for lateral re- Vulsella Forceps
traction of the abdominal wall. It is called after the gynecologist and obstetri-
cian Heinrich Fritsch (18441915). Fritsch, who was famous in his time as a The vulsella forceps is a specifically gynecological instrument for hooking the
surgeon and clinical teacher, worked as professor in the gynecology clinic in cervix, an important step in almost all minor procedures on the uterus. Partic-
Breslau and finally in Bonn. He became well known internationally because of ularly during laparoscopic procedures, it is used additionally to fix the uterine
his textbooks on gynecology and obstetrics, which were translated into many manipulator, and has thus gained an important new role.
languages.

I
13

Fig. 1.2-23 Fritsch retractor.

Fig. 1.2-25 Vulsella forceps.

1.2.2 Vaginal Surgery


Allis Clamp
Many of the instruments used during vaginal surgery are the same as those
used in abdominal surgery. Implements designed specifically for vaginal sur- The Allis clamp is an atraumatic forceps, widened in front, which is used in
gery are described below. both abdominal and vaginal surgery. It is a classical instrument for stretching
tissues during anterior and posterior colporrhaphy. Its name comes from the
American surgeon Oscar Huntington Allis (18361931). He was a medical stu-
Hegar Dilators dent at Jefferson Medical College in Philadelphia and then worked in the Pres-
byterian Hospital in Philadelphia as a co-founder of orthopedic surgery. He in-
Various series of dilators are available for dilating the cervical canal for diagnos- troduced the clamp that bears his name in 1883.
tic procedures in the uterus (curettage, hysteroscopy) or for managing disor-
ders of early pregnancy. The best-known are Hegar dilators, called after Ernst
Ludwig Hegar (18301914), first professor of gynecology and obstetrics in Frei-
burg, Germany and one of the pioneers of modern academic gynecology in
Germany. Hegar introduced the steel dilators that bear his name as a substitute
for the glass or hard rubber dilators used until then.

Fig. 1.2-26 Allis forceps.

Fig. 1.2-24 Hegar dilators.


I General Part Instruments

Polyp Grasping Forceps Karman Curette

This instrument, used specifically in gynecology, does what its name suggests. The Karman curette is a plastic aspirating curette which can be used to remove
products of conception from the uterus. The method has become accepted in-
ternationally as standard compared with simple mechanical curettage, as the
safety and simplicity of the procedure represent an important benefit. Its
name comes from the American Harvey Karman, an interesting personality
from the American abortion movement. Karman was not a doctor and his role
in the area of abortion is controversial. Although many untruths about him are
in circulation, he appears to have been the actual developer of the Karman cu-
rette.

Fig. 1.2-27 Polyp grasping forceps.

I Curettes
14
Curettes are used in gynecology for scraping out the uterus, either for diagnosis
or for treatment. They come in all sizes and different shapes. Sharp curettes for
diagnostic procedures are distinguished from blunt curettes, which are used in
the pregnant uterus.

Bumm Curette

The blunt Bumm curette is called after the German gynecologist and obstetri-
cian Ernst Bumm (18581925). Bumm became professor at the Charit in Ber-
lin in 1910. In the scientific field, he was interested particularly in infection in
obstetrics, which was an extremely important area of research at the time due
to the high mortality caused by puerperal fever. Professor Bumm was re- Fig. 1.2-29 Karman curettes.

nowned as a clinician. It is reported of a difficult delivery in Berlin that the doc-


tor on duty wanted to calm the fearful patient by remarking We'll just call
Bumm [boom], to which the woman asked skeptically: Do you think thats
likely to help?

Fig. 1.2-28 Bumm curette.


I General Part Instruments

Specula

The speculum is a specifically gynecological instrument, that allows optimal


examination of the cervix and vagina, along with surgery in this region. Ac-
cordingly, there are various forms and versions.

Scherbak Speculum

The Scherbak self-retaining speculum with a weight on the posterior blade is


an essential aid in cervical and uterine surgery. It is called after Leopold Scher-
bak, who practiced as a gynecologist in Brno in the early 20th century and in-
troduced this instrument in an article published in 1907. Fig. 1.2-31 Breisky vaginal specula.

I
medical world of his time. He famously attempted to implant excised and 15
heat-treated tumor tissue on the contralateral side in a patient terminally ill
with breast cancer, in order to obtain an anti-tumor vaccination effect. The
operating table he developed is regarded as the precursor of all of todays mod-
ern operating tables. Doyen was also one of the first to work with suction ma-
chines and electrocautery devices for hemostasis (and to render tumors ne-
crotic). Doyen became famous (and notorious) worldwide by filming his oper-
ations; these were the first films ever of operations and were shown
internationally. He believed firmly in the educational value of the films but
could not prevent them from being shown to a paying public as sensations.
The films were lost during and after World War I. As a general and gynecologi-
cal surgeon, an experimental scientist, and as the first cineaste in the history of
medicine, Doyen is one of the unjustly forgotten fathers of modern medicine.

Fig. 1.2-30 Scherbak self-retaining speculum.

Breisky Speculum

Breisky vaginal specula are among the most important instruments in vaginal
surgery. The name comes from August Breisky (18321889), who was profes-
sor of gynecology, first in Prague and then in Vienna, and one of the founders of
modern academic gynecology.

Doyen Speculum

The Doyen vaginal speculum is another variant. It is called after the French sur-
geon Eugne-Louis Doyen (18591916). Doyen, who gave his name to a range
of instruments, was one of the most famous surgeons of his time. He must have
been an extremely fast surgeon, and his outstanding manual skills were famous
far beyond France. His experiments in oncology and tumor biology were vi-
sionary from todays point of view but they discredited him in the academic Fig. 1.2-32 Doyen vaginal speculum.
I General Part Instruments

1.2.3 Endoscopic Surgery


Many endoscopic instruments are technical modifications of traditional surgi-
cal instruments. On the other hand, specific and completely new instruments
have been designed for endoscopic surgery. Besides new grasping instruments,
this especially involves the different types of electrocautery forceps. A selection
is described below, particularly of instruments known by an eponym.

Verres Needle

The Verres needle is the most frequently employed needle throughout the
world for creating the CO2 pneumoperitoneum during laparoscopy. It has a Fig. 1.2-34 Endoscopic scissors. The illustration shows, from above, a suture scissors, a straight
central blunt-ended obturator, which is advanced by a spring after the perito- scissors, and a Metzenbaum scissors.

neum has been entered, thus avoiding injury of internal organs. Gas is intro-
I duced through a lateral opening in the advanced obturator. The abdominal

16 wall is elevated from the loops of bowel, creating a space into which the sur- Endoscopic Grasping Forceps
geon can advance the umbilical optical trocar blindly into the abdomen. The
Hungarian physician Janos Veress (19031979) developed the needle in the Blunt grasping forceps which can grip tissue atraumatically are distinguished
1930s for ascites aspiration and for safe creation of a pneumothorax, which at from sharp grasping forceps, which fix the gripped tissue better but produce
that time was a common form of treatment of pulmonary tuberculosis, which local tissue trauma. As with many laparoscopic instruments, the basic principle
was then extremely widespread. The name can be spelled in different ways, is the same, but the technical design depends on the manufacturer. Two named
and Verres himself used different spellings: Verres, Veress and Veres. instruments, the Manhes and Vancaille forceps, are used quite widely. Hubert
Manhes (born in 1937) is one of the French pioneers of laparoscopic gynecolo-
gy. Thierry Vancaille is a Belgian gynecological laparoscopist, who has worked
in France, the USA and Australia, among other countries, and has expanded the
horizons of what is possible laparoscopically, especially in the area of pelvic
floor surgery.

Fig. 1.2-33 Verres needle.

Endoscopic Scissors

Although many endoscopic instruments were developed specifically for hys-


teroscopy or laparoscopy, numerous classical instruments are also found, in
an adapted form. An example is the laparoscopic Metzenbaum dissecting scis-
sors, one of the most important instruments for dissection during operative
laparoscopy, and the suture scissors, a form developed specially for endoscopy.

Fig. 1.2-35 Endoscopic grasping forceps. The Overholt forceps, Vancaille forceps, and a
illustration shows, from above, Manhes forceps, fenestrated grasping forceps.
I General Part Instruments

Coagulation Forceps Uterine Manipulators

Although laparoscopic suturing is a basic technique of advanced laparoscopy, Uterine manipulators are among the most important basic instruments in
endoscopy uses coagulation as a hemostatic technique to a far greater extent. laparoscopy. Precise manipulation of the uterus is of crucial importance, partic-
Accordingly, a variety of different electrocautery forceps has become estab- ularly in laparoscopic hysterectomy or laparoscopic lymphadenectomy.
lished. Placement and selection of the correct manipulator are especially important.
The manipulators shown here are known as destructive manipulators; they
are used during hysterectomy and to a varying degree they allow intra-
abdominal displacement of the uterus and division of the uterus from the
vagina with or without a vaginal cuff.

I
17

Fig. 1.2-36 Endoscopic coagulation forceps. lation forceps, and a fenestrated coagulation
The illustration shows, from above, a Hirsch for- forceps.
ceps, a fine coagulation forceps, a Kelly coagu-

Fig. 1.2-37 Uterine manipulators. The illustration shows, from above, a Tintara, a Hohl manipula-
tor, and a Clermont-Ferrand manipulator.
I General Part Sutures and Drains

1.3 Sutures and Drains

Surgical suture materials and surgical drains are part of routine surgical work. miliar in antiquity. These suture materials, particularly catgut, are no longer
Only the most important aspects are listed here. used today in European gynecology. The synthetic suture materials in common
use today are classified as absorbable or nonabsorbable, and monofilament or
polyfilament.

1.3.1 Sutures Modern surgical sutures are usually firmly swaged to atraumatic needles. In
gynecology, atraumatic needles are used in over 95% of all operations. Trau-
Suture Material matic needles, where the suture material has to be threaded, are now reserved
for exceptional situations.
The history of surgical sutures goes back a long way, with varying degrees of
success. In the middle of the 19th century, organic suture materials (catgut, Although there are standards in most hospitals, though often not set down in
actually made from sheep intestine or silk thread) were introduced together writing, the surgeon can always decide which type and strength of suture he or
I with the principles of asepsis, though some of these materials were already fa- she will use, and when, within certain guidelines.

18
Table 1.3.1 Sutures in gynecology and obstetrics

Trade name Substance Properties Manufacturer Examples of use

Biosyn Polyester consisting of glycolide (60%), Absorbable Tyco Skin suture


dioxanone (14%) and trimethylene Monofilament
carbonate (26%)

Dexon Polyglycolic acid Absorbable Tyco


Poly- or monofilament
Maxon Polymer consisting of polyglycolic acid Absorbable (slowly) Tyco Fascial suture
(62%) and trimethylene carbonate (38%) Monofilament

Monocryl Polyglecaprone 25 Absorbable (slowly) Ethicon Skin suture


Monofilament

PDS Polydioxanone Absorbable (slowly) Ethicon Fascial suture


Monofilament

Serafit Polyglycolic acid Absorbable Serag-Wiessner


Polyfilament

Vicryl (different Polymer consisting of glycolide Absorbable (moderately fast) Ethicon The most widely used
coated subforms) and polyglactin Polyfilament absorbable surgical suture

Dacrofil Polyester Nonabsorbable Braun Fixation of a Redon drain


Polyfilament

Ethibond Polyethylene terephthalate Nonabsorbable Ethicon Colposacropexy, vaginal suture


with polybutylate coating Polyfilament

Mersilene Polyethylene terephthalate Nonabsorbable Ethicon Sacrospinal fixation


Polyfilament

Prolene Polypropylene Nonabsorbable Ethicon Skin closure


Polyfilament

Seralon Polyamide Nonabsorbable Serag-Wiessner


Monofilament

Terylene Polyester Nonabsorbable Serag-Wiessner Paravaginal or for


Polyfilament colposacropexy

Ticron Polyethylene terephthalate Nonabsorbable Tyco


Monofilament
I General Part Sutures and Drains

Knot-Tying Techniques

Correct knotting is one of the gynecological surgeons basic tools. The classical
simple, surgical, or instrument knots are used in vaginal and open abdominal
procedures. In laparoscopy, a distinction is made between intracorporeal and
extracorporeal knot-tying.

Simple and Surgical Knots

The manual technique of surgical knot-tying is best learned by demonstration


and practice. The same techniques are used in abdominal and vaginal surgery.
Handling needles and tying sutures are a natural part of the operation. The
number of throws needed to tie a knot securely depends on the suture material
and the stress to which it is subjected. More throws are generally required for
monofilament, stressed sutures than with Vicryl, where three to four throws I
should suffice. 19

Laparoscopic Knot-Tying Techniques


Fig. 1.3-1 Instruments for intracorporeal su- transferred into the abdomen, where it is tight-
Suturing and knot-tying are somewhat more difficult in laparoscopy, as they turing. Ski-shaped needles and straight needles ened. Rder loops are even simpler accessory
are not performed directly manually, but indirectly with laparoscopic instru- (top) can be introduced and removed directly instruments; these already include the slip
through the trocar. These needles therefore of- knot but their use is limited because of the spe-
ments, while watching the monitor. Nevertheless, mastery of suturing tech-
ten come connected with endo-knot systems, cific loop. Finally, different hemostatic clip sys-
nique is essential for advanced laparoscopic surgery, for uterine reconstruction which incorporate a disposable knot pusher tems are available, which are used in endoscop-
after myomectomy, for vaginal closure after hysterectomy, and for repairing with which a slip knot tied extracorporeally is ic surgery.

bladder or bowel injuries.

Intracorporeal knotting technique. For intracorporeal suturing, a regular and When inserting the needle, it should not be gripped directly with the laparo-
therefore economical needle and suture are introduced into the abdominal scopic needle holder but approximately 35 cm distally along the suture,
cavity. The suture is then placed intracorporeally in the normal way and the drawing it into the abdomen through a trocar hole (after removing a size 5
knot is tied with instruments. The technique requires some practice. Transfer- or 10 accessory trocar). Although the needle has a greater circumference than
ring the needle into and out of the abdomen sometimes causes problems. the trocar defect, it can usually be introduced easily into the abdomen even in

Fig. 1.3-2 Intracorporeal knotting technique. The technique corresponds to instrumental knot-ty- dangling needle is not hazardous. When tightening the knot, ensure that the suture runs in the correct
ing during open surgery. The intra-abdominal suture should not be too long for ease of manipulation. direction. Direct manipulation with the needle must be avoided here as considerable force occurs (due
Caution: when tying the knot, the needle should not be gripped for manipulation. A needle fixed in a to the lever effect of the long laparoscopic instruments) and the needle could break off the suture and
needle holder is a dangerous instrument, which can injure bowel and veins especially in the pelvis. As get lost. Intracorporeal knot-tying is the most versatile form of laparoscopic knotting.
soon as the suturing sequence is finished, the needle is let go and the suture only is manipulated. The
I General Part Sutures and Drains

Fig. 1.3-4 Extracorporeal knotting tech- limits the choice of needle size and type. The
I nique. The needle must be inserted and knot can then be tied manually and pushed
20 brought out through the same trocar, which into the abdomen.

evacua was the foundation of the otherwise sparse surgical treatment options
Fig. 1.3-3 Removing the needle with the in- one of the accessory trocars (part of the needle before the 19th century. Drains as surgical instruments extended this principle
tracorporeal knotting technique. The needle is usually projects beyond the trocar) and re- to artificially opened body cavities and became standard in most open proce-
grasped by the suture a little behind the end of moved carefully together with the trocar.
dures. During the last 20 years there has been a move away from routine use
the needle, introduced as far as possible into
of drains. This can also be interpreted as a result of the improvements in hemo-
stasis brought about by the expansion of electrosurgery. Randomized studies
have demonstrated the lack of benefit and indeed the danger of drains as an
obese patients. Once the needle is in the abdomen, the suture is drawn in from entry portal for infections. In gynecology and obstetrics, drains are used espe-
the abdominal side by additional grasping instruments and can then be short- cially for immediate postoperative observation of secondary hemorrhage in
ened as desired. The trocar is then inserted again. To remove the needle, it is the wound area, and to prevent fluid collection in the wound area in very obese
again grasped a little behind the end of the needle, inserted into one of the ac- patients. It must always be queried whether the drain is really necessary.
cessory trocars if possible (part of the needle usually projects beyond the tro- Drains should never be placed to be on the safe side or because its always
car) and removed carefully together with the trocar. The projecting part of the been done that way. Three drainage systems are used in gynecological sur-
needle virtually never leads to injuries and the needle is retrieved securely and gery.
easily from the abdominal wall. The next needle can then be introduced
through the trocar port. Caution: if the needle is bent in order to introduce or
retrieve it, it can break and some or all of it may get lost. An alternative, at least Closed Drain Systems without Suction
in very slim patients, is to pass the needle in and out directly through the ab-
dominal wall. The most important intra-abdominal drain is the Robinson drain. Suction
drains cannot be used within the abdomen as suctioned bowel might become
Extracorporeal knotting technique. Some authors prefer extracorporeal sutur- necrotic, and in any case the drain will be blocked. The Robinson drain is a
ing techniques. Intracorporeal placement of the needle is identical technically, closed wound drainage system. The drain tube is placed at the lowest point of
but the needle must be introduced and removed through the same trocar, the wound cavity and fixed to the abdominal wall with a nonabsorbable suture.
which limits the choice of needle size and type. The knot can then be tied man- Abdominal Robinson drains should be removed as soon as possible. Like all
ually in comfort and pushed into the abdomen. drains, the Robinson drain is not brought out through the wound but through
the intact abdominal wall lateral to the wound. After incising the skin, the ab-
dominal wall is penetrated with an Overholt clamp which is then used to bring
the drain out of the abdomen. Robinson drains can also be placed after laparo-
1.3.2 Drains scopic procedures. They are then simply pushed into the abdomen through one
of the accessory trocars.
Before the introduction of asepsis to surgery by the English surgeon Joseph Lis-
ter (18271912), followed over 50 years later by the antibiotic era, drainage of
suppurating infections was often the only possible intervention: Ubi pus, ibi
I General Part Positioning

Closed Drain Systems with Suction

Redon drain. The Redon drain is the most frequently used closed suction drain-
age system in gynecological abdominal surgery. This is a relatively fixed type of
drainage, which is attached to a suction bottle that can be exchanged. It is
closed with a clamp that is opened only after it is connected to the actual drain.
The suction helps the skin layers to come together and heal faster. It is fixed to
the skin by a nonabsorbable suture. The drain is usually removed when less
than a certain volume of fluid, often 40 mL over 24 hours, is drained. The
name comes from the French surgeon Henri Redon (18881974).

Easy-flow drain. The smallest version of the closed drainage systems. The suc-
tion is achieved manually in this case also.

Open Drains without Suction I


21
Open drains are used only in rare, exceptional cases. They are not used for the
abdominal cavity because of the risk of infection. They are employed only after
incision of a vulvar abscess to prevent premature closure of the wound. This of-
ten means insertion of a tab. The best-known version is the Penrose drain,
called after the American gynecologist Charles Bingham Penrose (18621925).

Fig. 1.3-5 Intra-abdominal Robinson drain nealization shown in the illustration shows
placed after abdominal hysterectomy. Intra-ab- how rarely they are routinely used nowadays.
dominal drains have become rare. The perito-

1.4 Positioning

The positioning of the patient during the operation is an important aspect of Abdominal access. Open abdominal procedures can be performed with the pa-
safe treatment, along with preoperative preparation and postoperative moni- tient in simple supine position with the legs extended. In English-speaking
toring. Numerous complications such as nerve damage, pressure points, or countries, abdominal hysterectomies and cesarean sections are usually per-
electrical current marks are a result of incorrect positioning. Correct position- formed in this way, with the legs abducted temporarily before surgery for dis-
ing is the joint responsibility of the operating room nurses, the anesthesia team infection and insertion of a bladder catheter. The arms are placed on arm rests
and ultimately the surgeon. Only a few hospitals have special positioning on both sides to provide optimal access for the anesthetists. The risk of hyper-
nurses, whose routinely acquired knowledge might avoid many complications. extension of the shoulder should be noted. In German-speaking countries, the
With shorter turnaround times on the one hand and longer operating times on possibility of vaginal access is regarded as important during abdominal opera-
the other (cancer surgery, pelvic floor surgery), correct positioning is becoming tions and cesarean section. Alternatively, the legs can be placed in leg supports,
more and more important. which are lowered relatively far after disinfection and catheter insertion, or the
legs can remain extended but with the hips abducted. In both cases, it is possi-
ble for a second assistant to be positioned between the legs. When leg supports
are used, it is important to ensure correct positioning and padding. The foot,
1.4.1 Abdominal Procedures knee and contralateral shoulder should form one axis. There must be no con-
tact with the head of the fibula. The surgeon must personally check this. When
Abdominal procedures are still the most common ones in gynecology in most the legs are extended, pads should be used to ensure positioning without areas
hospitals, although laparoscopic and vaginal procedures are impinging on their of tension and pressure. During long operations, the patients temperature can
predominance. be controlled with heat pads and convection heaters. Correct insulation of the
patient from the operating table warrants particular attention. Excessively
wet disinfection should be avoided and the patient must never lie on any-
I General Part Positioning

thing damp that might conduct electricity. Fluid can collect in the sacral area,
particularly during vaginal disinfection, unless towels are used to ensure dry-
ness.

Abdominovaginal access. Many procedures in gynecology can require abdomi-


novaginal access, whether planned or unplanned. The simplest positioning for
this is achieved by using mobile leg supports. Both areas are disinfected before-
hand. The same important positioning principles apply as in purely abdominal
surgery: adequate electrical insulation from the operating table, arms out-
stretched, adequate padding of the legs, and straight footkneecontralateral
shoulder axis.

1.4.2 Vaginal Procedures


I Correct positioning during vaginal procedures must first ensure the patients

22 safety, but must also provide the surgeon and assistant with operative access
in a particular way. The usual principles apply for patient safety: arms out- Fig. 1.4-1 Correct positioning of the operat- tion greatly or make it possible in the first place.
stretched without hyperextension, and legs on leg supports, checking for max- ing team is very important especially in long A separate assistant for guiding the camera al-
and complex laparoscopic procedures. De- lows the first assistant to work more effectively
imum possible abduction. The required mobility must be ensured, especially in pending on personnel, guiding the uterus over during the operation. Naturally, such a large
patients with hip problems or a hip replacement. Alternatively, the feet can be a uterine manipulator can facilitate the opera- team is only rarely available.

placed in foot stirrups. It must be ensured that the suspended legs do not touch
the positioning rods. From the surgeons point of view, the pelvis must over-
hang the lower edge of the operation table sufficiently. It must be possible to
position a freely mobile weighted speculum. Adequate height, adequate leg ab-
duction and adequate leg inclination will also achieve a reasonably acceptable
working position for the assistants. In critical situations, in particular, poor po-
sitioning can interfere considerably with the operation. These rules apply to a
lesser extent for simple vaginal procedures performed without assistants, such
as curettage, suction curettage, and hysteroscopy.

1.4.3 Laparoscopic Procedures


As laparoscopy becomes more widely used in oncology and complicated endo-
Fig. 1.4-2 Positioning for laparoscopic sur- ty of the patients weight when she is in the
metriosis surgery, positioning gives rise to particular problems. Even for short
gery. Both arms are by the patients sides, and head-down position required for the operation.
procedures, laparoscopy involves correct positioning of the legs. These must be the padded shoulder supports take the majori-
lowered to the level of the abdomen during the operation, and this should be
tried out before draping in order to reveal any problems that will no longer be
apparent after draping. On the other hand, many operations require a some- At the start of the operation, that is, when the Verres needle is introduced, the
times extremely low head position. Padded shoulder supports that can be fixed patient should be in a head-down position of about 15. The abdominal wall is
to the operating table are therefore essential. A large proportion of the patients then usually horizontal. The head-down position can then be increased if nec-
weight lies on the shoulders, especially in the relaxed state. This means that essary after creation of the pneumoperitoneum and insertion of the optical
both arms must be beside the patients sides, which makes working easier for trocar and obligatory inspection of the upper abdomen. The height of the oper-
both the surgeon and the first assistant. The first assistant cannot be expected ating table is particularly important. Prolonged laparoscopic surgery when the
to work for several hours with the patients arm outstretched. Moreover, if one table is too high is very uncomfortable for the surgeon. The laparoscopy instru-
arm is outstretched, the asymmetric positioning risks damaging the shoulder ments should be manipulated with the arms comfortably at about the level of
girdle and brachial plexus. the surgeons abdomen and hips. Mobile steps may be necessary.
II.
COMPLIC ATIONS AND
THEIR MANAGEMENT
II
25
Complications occur with every type of surgery. Only someone who does not most important cause of incorrect preoperative decisions is clinical inexpe-
operate at all will have no complications. Complications should be discussed rience.
openly, even if this is difficult. This applies all the more when complications
are frequent. Many complications are avoidable. The most common cause of se- The technical intraoperative aspects of complications are dealt with below,
rious intraoperative complications is an operation that is inappropriate for the where fundamental and ever-recurring principles are involved. Complications
patient. Most complications therefore have their origin preoperatively. The are also discussed in detail in conjunction with individual operations.

2.1 Bleeding Complications

Severe and hemodynamically significant bleeding that requires transfusion is


one of the most important complications of surgery. Two factors are particular- 2.1.1 Intraoperative Bleeding
ly stressful for a patient having any operation: prolonged surgical time and ma- Abdominal Procedures
jor blood loss. Ideally, therefore, surgery should be performed swiftly. Speed
and limited blood loss are not necessarily complementary, however, because Common gynecological open abdominal procedures include hysterectomy
careful, bloodless operating is time-consuming. On the other hand, major when the uterus is very large, cancer surgery, and nonlaparoscopic operations
bleeding leads to loss of anatomical overview, prolongs the operation, and can for endometriosis. The most important sources of bleeding are usually the
contribute indirectly to injury of other structures. Every surgeon will have to ovarian arteries in the infundibulopelvic ligament (suspensory ligament of the
find an individual compromise for the patients benefit. The clinical end result ovary) and the two uterine arteries. Only adequately dissected vessels can be
of uncontrolled bleeding is shock and thus a life-threatening situation. clamped and ligated securely. Careful dissection of the bladder, bowel, and ad-
hesions as well as exact visualization of the ureters are therefore the most im-
portant prerequisites for rapid control of unexpected bleeding. The rule is that
an operation step that involves a risk of bleeding should always be the last step
after the site has been safely dissected. A good operative technique prevents
bleeding, and poor visualization favors bleeding. Bleeding in the region of the
pelvic wall, in particular, can require complete ureterolysis and lateral division
of the uterine artery at its origin from the internal iliac artery.
II Complications and Their Management Bleeding Complications

2.1.3 Intraoperative Bleeding


Laparoscopic Procedures
Abdominal-wall vessels. Bleeding during laparoscopic procedures can be due to
injury of abdominal-wall vessels. To avoid this, transillumination can be used to
avoid the superficial epigastric artery and direct laparoscopic visualization of
the inferior epigastric arteries should be performed before placing the acces-
sory trocars laterally.

Operative site. Bleeding at the operation site must be avoided from the outset
during laparoscopy. Hemostasis by means of compression is not possible in
practice to prevent small arteries from bleeding copiously. Compression can
be performed with a blunt instrument or with a sponge placed through a
10 mm trocar sleeve. Even small amounts of blood impair visualization, which
is crucial in laparoscopic surgery. Coagulation is the most important tool for
II laparoscopic hemostasis. A bloody field leads to troublesome tissue carbon-

26 ization and further impairment of vision, which can lead to thermal damage to
the bowel and ureters.

Fig. 2.1-1 Therapeutic or preventive ligature though there are no large studies, clinical expe-
of the internal iliac artery may be useful in ob- rience has shown that this intervention has no
stetrics, especially in the event of atonic sec-
ondary hemorrhage and disseminated coagula-
detrimental side effects. Technically, it is neces-
sary to dissect the course of the ureter, expose
2.1.4 Postoperative Bleeding
tion disorders, and also in oncology when adhe- the bifurcation of the common iliac artery, dis-
sion of malignant tissue to the internal iliac sect and undermine the internal iliac artery, Significance. All postoperative hemorrhages, whether after abdominal, vaginal,
artery is suspected. Each of these cases is an ex- and finally draw a ligature through with an
treme situation. Nevertheless, there should be Overholt clamp.
or laparoscopic surgery, have two things in common: first, they are unpredict-
no hesitation when it is clinically necessary. Al- able and are usually a surprising complication. Secondly, they must be identi-
fied promptly. Unrecognized postoperative bleeding continues to be an impor-
tant cause of mortality.

2.1.2 Intraoperative Bleeding Clinical features. The capacity for compensation of young and generally healthy
Vaginal Procedures patients is frequently considerable. Young patients remain asymptomatic for a
long time even with severe postoperative bleeding. Even tachycardia can be a
Bleeding after vaginal operations can be particularly undesirable on account of surprisingly late symptom. The onset of the inevitable decompensation when
the limited access. the situation is not recognized can be all the faster and more dramatic. The final
stage of postoperative bleeding is shock.
Vaginal margin. During a vaginal hysterectomy, there may be considerable
bleeding from the vaginal margin even at the start of the operation. On the Tachycardia is the leading symptom of hemodynamically significant blood loss.
one hand, suction should be readily available to optimize vision; on the other Besides the objective clinical parameters, the overall situation should be ob-
hand, initial hemostatic techniques such as circular injection of the ectocervix served with regard to central nervous system (CNS) symptoms, especially in
with a vasoconstrictor substance (liquid tourniquet) may help. An old hemo- young patients: of all the organs, the brain reacts most sensitively to hypoper-
static technique consists of a continuous suture (gathering) of the posterior fusion. Essentially, if bleeding is suspected, the patients hematocrit and hemo-
vaginal margin right at the start of the operation. globin should be monitored until hemodynamically significant bleeding can be
ruled out with certainty. If the patient is stabilized clinically, an arteriogram
Parametrial resection margin. The basic rules of careful clamping and secure lig- with embolization can be useful. Moreover, if suspected bleeding cannot defi-
ature apply for hemostasis of the parametrial resection margin, especially the nitely be ruled out or controlled, operative revision is warranted without delay.
vascular part. Moving toward the ovarian ligament itself and the immediately
adjacent uterine branch of the ovarian artery, it must then be ensured that ex-
cessive traction on the uterus does not lead to tearing of the tissue bridge with
bleeding retraction of the artery. The transfixion ligatures in the sacrouterine
ligament and ovarian ligament (or infundibulopelvic ligament in the case of ad-
nexectomy) are left long so that the entire series of parametrial divisions be-
tween them can be inspected and additional sutures can be placed if necessary.
II Complications and Their Management Bleeding Complications

II
27

Fig. 2.1-2 Exact knowledge of vascular anato- avoiding bleeding from the inferior epigastric
my in the anterior abdominal wall is helpful for arteries.

Fig. 2.1-4 Another possible means of hemo- abdomen which is then pulled toward the ab-
stasis in the abdominal wall, which avoids trans- dominal wall from the inside and clamped on
fixion sutures, is transmural compression with the outside.
an inflatable bladder catheter pulled into the

Fig. 2.1-3 If bleeding in the anterior abdomi- ion sutures from the outside with a large Fig. 2.1-5 Minor sites of bleeding and bleed- In slim patients; heat injury to the overlying skin
nal wall nevertheless occurs and cannot be con- needle. These are then removed after 24 hours ing at the larger trocar entry sites at the end must be avoided.
trolled by coagulation from within the abdo- to avoid scarring and ugly skin retraction. of the operation can be coagulated from inside.
men, it is possible to place hemostatic transfix-
II Complications and Their Management Inflammatory Complications

Table 2.1.1 Criteria of different forms of shock

Shock class I Shock class II Shock class III Shock class IV

Blood loss (mL) < 750 7501500 15002000 > 2000

Percentage of total volume (%) < 15% 15%30% 30%40% > 40%

Heart rate (beats/min) < 100 > 100 > 120 > 140

Blood pressure Normal, sometimes raised Normal Reduced (mean pressure < 60 mmHg) Reduced

Respiratory rate Normal Slightly increased Moderate to severe tachypnea Severe tachypnea, respiratory
insufficiency

Urine excretion (mL/h) > 30 2030 515 Anuric

CNS symptoms Normalanxious/excited Anxious/excited Confusion Lethargy

II
28 2.2 Inflammatory Complications

Although the surgeon is confronted at operation with infective situations when Clinical features. The symptoms of wound infection are pyrexia, more pain than
dealing with abscesses or pelvic inflammatory processes, these constitute normal in the wound area, and erythema and increased temperature of the
operative complications when they occur postoperatively. wound area.

Treatment. Early wound infections can often be treated by adequate antibiotic


cover. If an abscess develops or a hematoma becomes infected or spontaneous
2.2.1 Wound Infection wound opening is immanent, operative measures are indicated. These usually
comprise opening the wound, drainage of hematomas and abscesses, cleansing
Wound infections can occur in all areas of gynecological surgery: as an infec- and excision of necrotic tissue. These procedures can be very unpleasant and
tion of the skin incision after laparotomy, as infections of the trocar entry sites painful, so they should be performed under anesthesia. After several days of
or infections of the vaginal stump, or after vaginal and vulvar procedures. open wound management, secondary wound closure is usually possible when
the area is clean and infection has subsided. Allowing the wound to granulate
Risk factors. Apart from operative factors such as long operation duration, ma- should be reserved only for exceptional situations.
jor intraoperative blood loss, or opening of the vagina, there are a number of
other risk factors such as obesity, smoking, immunosuppressive drugs, pre-ex- Necrotizing fasciitis. Necrotizing fasciitis is a rare, special form of wound infec-
isting infection, or diabetes mellitus. Postoperative hematoma or seroma for- tion. This is a severe and potentially fatal skin and soft tissue infection due to
mation in the vicinity of the wound further increases the risk of a wound infec- streptococci, rarely staphylococci, which leads to extensive necrosis and rapid
tion. deterioration in the patients general condition. The treatment consists mainly
of resection of the entire affected area.
Prevention. The most important preventive measures for reducing wound
complications in the skin and vagina are:
Preoperative antibiotic prophylaxis (cephalosporin)
Short operation time, with good assistance 2.2.2 Peritonitis/Sepsis
Avoidance of major blood loss
Optimal hemostasisavoidance of hematomas Apart from superficial wound infection or infection of the vaginal stump, post-
Avoidance of excessive tissue trauma, e.g., excessive electrocoagulation operative peritonitis and sepsis have become rare events. At the end of the 19th
Closure of unphysiological spaces (dead space) by suture or drain, if nec- century, before the introduction of antibiotics, they were among the most im-
essary portant causes of postoperative death. Following the introduction of intraoper-
Strict intraoperative asepsis: sterile operating field; adequate scrubbing-up ative asepsis and associated aids such as surgical gloves, this source of morbid-
of surgeon, assistant, and instrument nurse; compliance with rules regard- ity and mortality was reduced to a minimum even before the introduction of
ing jewelry, short fingernails, gowning, face mask; adequate distance from antibiotics.
onlookers
II Complications and Their Management Injury to the Urinary Organs

Causes. Peritonitis and sepsis are today more often the cause and indication for postoperative pyrexia of clinically uncertain cause when a suppurative process
surgery as a consequence of the original operation, for example, spread of a cannot be definitely ruled out necessitates revision to obtain a secure diagnosis.
tubo-ovarian abscess, ruptured appendicitis, or perforated sigmoid diverticuli-
tis. Nevertheless, especially in elderly and immunosuppressed patients, the of- Pelvic thrombophlebitis. A special form of postoperative infection involves diag-
ten subtle signs of systemic infection and thus life-threatening sepsis must be nosis by exclusion of septic pelvic thrombophlebitis, the incidence of which is
watched for. Apart from infections at the operation site, sepsis may have an in- reported as 0.1%0.5% after gynecological operations. If pyrexia persists on an-
fectious cause such as pneumonia orin particularinadequately treated uri- tibiotic therapy and the patient is otherwise asymptomatic, without clinical or
nary tract infection (urosepsis). Severe infections can also occur in postpartum imaging evidence of suppuration, and this diagnosis is suspected, anticoagula-
patients after prolonged deliveries and if chorioamnionitis has been present tion with low-molecular-weight heparin can be started in addition to antibiot-
prepartum (endomyometritis). As when secondary bleeding is suspected, ic therapy.

2.3 Injury to the Urinary Organs


II
The ureter, bladder, and urethra are in an exposed location in classical gyneco- and this is achieved in the intraperitoneal part of the bladder by the second 29
logical operations. Iatrogenic urethra injuries are extremely rare. Bladder and row of peritoneal sutures. In any case, the bladder should be drained initially
ureter injuries occur more often, depending on the surgeons operative experi- for a certain time by both transurethral and suprapubic catheters, depending
ence and on the degree of difficulty of the operation. Very extensive pelvic floor on the extent of the bladder injury.
reconstructions, oncological operations, radical hysterectomy, and radical en-
dometriosis surgery are associated with a high risk. Intraoperative injuries
should be corrected immediately. Unnoticed injuries, strictures, or thermal in-
juries, which only become symptomatic later, are more problematic. 2.3.2 Ureteral Injuries
Sites of predilection. The classic gynecologic injury to the ureter occurs at the
pelvic inlet, close to the infundibulopelvic ligament, during simple abdominal
2.3.1 Bladder Injuries hysterectomy for benign disease, usually during hemostasis. Only about 50% of
ureteral injuries are recognized during surgery. From this fact alone, it is appar-
Sites of predilection. The most frequent site of bladder injury during abdominal ent that the best protection against ureteral injury is exact visualization of the
surgery is the roof of the bladder at the site of the peritoneal reflection on the ureter. The more complicated the site and operation, the more this applies.
anterior abdominal wall. The injury occurs when the abdomen is entered too Other sites of predilection for ureter injuries are the ovarian fossa during sur-
far inferiorly or when a laparotomy is incautiously extended downward. An- gery of adherent adnexal tumors, the paracervical or paravaginal segment
other trouble spot during abdominal surgery is the part of the bladder lying di- when the uterine artery is transfixed, and the juxtavesical location when the
rectly next to the cervix, which must be dissected off bluntly. Injuries in this bladder is mobilized.
area can also occur during vaginal surgery.
Prevention of ureter injury. In abdominal operations, the ureters should be iso-
Treatment. Injuries that are sufficiently distant from the ureteral ostia can be lated and looped with rubber bands, thus marking them for the duration of the
managed relatively easily with sutures. When the injuries are close to or in- operation. One of the interesting characteristics of the ureter is that, once it has
volve the ureters, there is a risk of ureter stenosis if they are managed incor- been exposed, it immediately disappears again into the surrounding tissue if
rectly. A urological opinion is essential and in extreme cases the ureter even it is not marked. The widely practiced palpation of the ureter does not pro-
has to be reimplanted. vide the same security as direct visualization, especially in complicated proce-
dures. When dissecting the ureter, the specific blood supply should be noted;
The closure technique is guided by the thickness of the bladder wall, which var- superior to where it crosses the iliac vessels, the blood supply comes from the
ies from patient to patient. Injuries of the muscularis only, without opening of medial side, but inferior to this, it comes from the lateral aspect. Accordingly,
the bladder lumen, are closed with interrupted sutures (PDS, Vicryl, 30 or the upper part of the ureter should be dissected from the lateral aspect and
20) and covered by the previously dissected peritoneum as a second layer. the lower part from the medial aspect to spare the blood supply as much as
The same procedure is recommended for a muscular bladder wall when the lu- possible. Preoperative imaging of the ureter has not reduced the rates of injury
men is entered. If the bladder lumen has been opened and the bladder wall is any more than prophylactic ureteral stenting. Heat injuries are particularly im-
thin, the first row of sutures closes the mucosa and muscularis together with a portant. These occur especially during laparoscopic surgery. Heat injuries are
30 inverting, atraumatic, continuous, absorbable suture. The second row of usually not recognized at operation and lead to ureteral necrosis and leakage
sutures closes the peritoneum. An extramucosal suture is possible and indicat- only in the postoperative period. Direct repair from delayed necrosis is more
ed only when the bladder wall is highly muscular. Watertight closure is crucial, difficult because of the inflammatory processes, than when the injury is diag-
II Complications and Their Management Injury to the Urinary Organs

II Fig. 2.3-1 First row of sutures to repair a blad- when the tissues are very thin. Interrupted su- Fig. 2.3-2 The first row of sutures is covered confirmed by carefully filling the bladder, if nec-
der injury: mucosa and muscularis can be su- tures usually allow more anatomical approxi- by interrupted peritoneal sutures. The repair essary with blue solution.
30 tured together without difficulty. Forced spar- mation. Continuous suture is an alternative. should now be watertight, and this should be
ing of the mucosa is not necessary, especially

Fig. 2.3-3 When the bladder muscle is weak, sue that heals well. A good repair that respects
an inverting continuous suture is a possible al- the anatomy is more important than the exact
ternative. Overall, the bladder is a tolerant tis- technique.
Fig. 2.3-4 An important component of every der direct vision if the abdomen is still open or
bladder repair is double drainage through an in- with a moderately filled bladder after closure.
dwelling transurethral catheter and an indwell- In the case of a vaginal operating field it is
nosed immediately. It is important to know that the average zone of heat injury ing suprapubic catheter. The latter is placed un- placed under cystoscopic vision.

produced by most endoscopic coagulation instruments is approximately 2 mm


but can be up to 5 mm.

Treatment. Injuries to the upper and middle thirds of the ureter are corrected
primarily by end-to-end uretero-ureterostomy over a stent. In the lower third,
that is, approximately 68 cm from the bladder, ureteral injuries are all too of-
ten associated with markedly reduced vascularization. A simple end-to-end
anastomosis often becomes necrotic and leaky secondarily. Many of the ureter-
al injuries are repaired in some countries by urologists (Chapter 8.2, Gyneco-
logic Urology).
II Complications and Their Management Injury to the Urinary Organs

II
31

Fig. 2.3-5 Ureteral injuries also occur during lowed by distancing of the adnexa from the pel- Fig. 2.3-6 Avoidance of heat injuries, here in a terior abdominal wall. This provides the maxi-
endoscopic operations, especially at the pelvic vic wall by drawing it medially and toward the simple salpingectomy: the dissected tube is be- mum distance from the ureter.
rim when the infundibulopelvic ligament is co- anterior abdominal wall, are particularly impor- ing correctly drawn medially and toward the an-
agulated. Initial dissection and distancing, fol- tant.

Fig. 2.3-7 Diagram of ureter reconstruction and urine diversion depending on the level
of injury.
II Complications and Their Management G a s t r o i n t e s t i n a l Tr a c t I n j u r y

2.4 Gastrointestinal Tract Injury

Bowel injuries are rare during standard gynecologic procedures for benign dis-
ease. They occur more often during procedures for gynecologic cancer, espe- 2.4.1 Small-Bowel Injury
cially typical ovarian carcinoma surgery and extensive endometriosis opera-
tions. However, every form of gynecologic abdominal surgery can require a During adhesiolysis, the small bowel is at high risk of injury because of the del-
large degree of bowel adhesiolysis. This applies especially for laparoscopy: the icate structure of its wall. It can be perforated even by traction.
art of gynecologic laparoscopy is the art of laparoscopic adhesiolysis, which
prepares the site for the actual operation. The laparoscopists skill as a surgeon Prevention. Dissection of scar tissue must therefore take place toward the scar
is directly proportional to his or her skill at (intestinal) adhesiolysis. While ad- tissue. The surgical motto should be: Better a scar on the bowel than bowel at
hesiolysis of the colon is usually possible without injuring the bowel, division the scar. There is no dissection plane for small-bowel adhesions.
of small-bowel adhesions often results in serosal defects, and perforations may
occur even with the most careful dissection. Each surgeon must decide if these Treatment. Defects are always closed transversely to the long axis of the bowel.
II can be managed directly with or without the assistance of an abdominal sur- Serosal defects are closed by seroserous interrupted sutures using atraumatic

32 geon. absorbable material, and perforating injuries are closed by seromuscular, ex-
tramucosal interrupted sutures, also with absorbable atraumatic suture mate-
rial (40, 30).

Suture of more major injuries without stenosis may not be possible. In this
case, the affected bowel segment must be resected. Vital, well perfused, and
uncrushed wound margins are crucial for healing of a bowel suture. Wound
margin excision may be unavoidable.

Fig. 2.4-1 Seromuscular, extramucosal interrupted sutures with absorbable atraumatic suture Fig. 2.4-2 Closure of a wide perforation of the bowel lumen transversely to the long axis of the
material (40, 30). bowel.
II Complications and Their Management G a s t r o i n t e s t i n a l Tr a c t I n j u r y

sorbable atraumatic 40 or 30 suture material has proved to be effective. The


2.4.2 Large-Bowel Injury suture technique is similar to that used for the small bowel, that is, the serosa
and submucosa are taken with the needle entering and exiting in the mucosal
Iatrogenic injuries of the large bowel can be managed by simple oversewing as plane. Larger defects of the wall should preferably be closed transversely,
long as the perfusion of the bowel wall is not impaired. If the wound margins although the risk of significant stenosis is less in the large bowel.
have been crushed, sparing freshening of the bowel wall is recommended. Ab-

II
33

Fig. 2.4-3 Seromuscular bowel suture. The cluding the submucosa. The exit site on the
needle passes through the entire bowel wall in- luminal side is in the plane of the mucosa.

Fig. 2.4-4 During laparoscopic operations, it transrectal methylene blue or transrectal CO2
can sometimes be difficult to localize a bowel insufflation can be a last resort.
injury exactly. When it is highly suspected,
II Complications and Their Management Wound Dehiscence and Hernia

2.5 Wound Dehiscence and Hernia

Wound dehiscence occurs in the immediate postoperative period and can in- The mechanical and purely local factors include technical problems such as
volve all the layers of the abdominal wall as well as the skin. Hernias are late knot breakage and suture rupture, though these have become very rare with
complications, which sometimes only become symptomatic years after the ac- modern suture materials. Sutures can tear out of the tissue due to excessive su-
tual operation. The skin remains intact. ture tension and also because the suture is too close to the wound margin. Not
infrequently, infection of the laparotomy wound paves the way for partial or
complete abdominal wound dehiscence. For this reason, laparotomy should
be performed under antibiotic protection, for example, with cephalosporins
2.5.1 Wound Dehiscence as standard prophylaxis. Suture rupture is favored by the increased intra-ab-
dominal pressure associated with postoperative ileus, vomiting, and develop-
Causes. The causes of disorders of wound healing, abdominal wall dehiscences, ment of ascites. Respiratory failure associated with chronic obstructive lung
and hernias, which are long-term consequences, can be of both local and sys- disease is of particular significance. These patients have to use their abdominal
II temic origin. wall for breathing and thus expose the laparotomy incision to added mechani-

34 cal stress. When preoperative lung function is impaired to less than 70% of ex-
pected, local and systemic postoperative complications must be anticipated. A
marked improvement can be achieved with respiratory preparation by means
of physiotherapy and inhalations of parasympatholytic and sympathomimetic
agents, possibly in combination with short-term use of steroids.

The systemic influences on wound healing include malnutrition with protein


loss, uremia, icterus, diabetes mellitus, anemia, vitamin C deficiency, and
long-term steroid medication. Protein deficiency is associated with a distur-
bance of cellular immunity. Adjuvant cytostatic drugs have only a negligible in-
fluence on wound healing. However, if surgery is necessary in the course of
chemotherapy, prophylactic antibiotics should be given. Overall, postoperative
wound dehiscence is a multifactorial event in severely ill patients, which can be
influenced only to a limited degree.

Treatment. Management of complete wound dehiscence with exposed bowel


includes antibiotic cover and an immediate attempt to cover the defect surgi-
cally with fascial closure. Because of the infective situation, the skin is usually
left open and closed secondarily after the fascia has healed securely. Tension-
free approximation of the fascial margins is crucial; this requires sutures placed
well away from the margins, and possibly additional tension-reducing sutures.

Fig. 2.5-1 Relieving sutures over plastic areas so that no ischemic necrosis occurs. The
plates. They reduce the tension in the wound. sutures are extraperitoneal.
The inevitable pressure is distributed over large
II Complications and Their Management Wound Dehiscence and Hernia

Treatment. The basic principle of surgical incisional hernia repair is always the
2.5.2 Hernias same, but the procedure differs somewhat in individual cases. The incision is
continued as far as healthy muscle fascia. The hernial sac is dissected sharply
Hernias are among the most common complications of abdominal surgery. As from the healthy tissue and opened cautiously at a free site. Division of the ad-
they often occur long after the actual surgery and usually lead to direct consul- hesions between the sac contents can result in serosal defects on the bowel,
tation with a general surgeon, the gynecologic surgeon often remains unaware which must be managed appropriately. Resection of a segment of bowel may
of them. The incidence of hernias, for example, is reported as up to 1% after be necessary with extensive injuries. Scarred and adherent parts of omentum
midline laparotomy, and up to 10% after postoperative wound infections. are also resected. The hernial sac with the poor-quality scar tissue is resected.
The hernial orifice is closed by a continuous suture either through all layers or
Forms of surgery. An incisional hernia is defined as divarication of the fascial in layers, depending on the size and structure of the tissue. When the hernia is
margins while the peritoneum remains intact (as a hernial sac), with intact very large and the abdominal wall is weak, fascial doubling or insertion of a
skin, with or without prolapse of bowel loops into the subcutaneous tissue. subfascial plastic mesh may be necessary.
The hernial sac is usually greatly adherent to the skin and abdominal wall. The
origin of an incisional hernia is incomplete healing of the fascial layers because
of the usual risk factors such as local infection, obesity, increased intra-abdom-
inal pressure, suture breakdown, or corticosteroid therapy, to name only a few.
Over time, the hernia can enlarge and become symptomatic due to incarcera- II
tion of segments of bowel. Acquired umbilical hernia is a special form of hernia, 35
which can be a concern for the gynecologist during a vertical laparotomy.
III.
ABDOMINAL WALL
III
37
For the gynecologic surgeon, there are three possible approaches to the inter- surgery can occur in this area including postoperative hemorrhage, postopera-
nal genital organs and to gynecologic diseases of the abdominal cavity: open tive infections, and hernias. Only confident knowledge of the anatomy and fea-
abdominal, laparoscopic, and vaginal. In both the open abdominal approach tures of the abdominal wall permits adequate access to the surgical field and
and laparoscopic access, the abdominal wall must first be opened either by lap- thus ensures safe, efficient surgery.
arotomy or by puncture with a trocar. Numerous complications of gynecologic

3.1 Laparotomy

Opening the abdominal wall by laparotomy is one of the fundamental surgical Lateral umbilical ligament. This contains both obliterated umbilical arteries
procedures of gynecology. Since the beginnings of gynecologic surgery with from their turning point at the anterior border of the pelvis to the umbili-
the first ovariotomies in the mid 19th century, it has been the major access cus and is an important guide when the pelvic wall is opened in oncologic
pathway at the start of every nonvaginal operation. But in the last 20 years, lap- operations.
arotomy has lost this central importance. In the course of the minimally inva- Inferior epigastric vessels. These run somewhat further laterally in a cranial
sive revolution and in the context of minimally traumatic surgery, the endo- direction to the lateral third of the rectus muscles. Cranially they anasto-
scopic or laparoscopic approach and the vaginal approach have been preferred. mose with the internal thoracic vessels. Care must be given to this artery
Laparotomy is used when there is no alternative. Nevertheless, it remains the during insertion of the lateral auxiliary trocar.
technique of choice in obstetrics, for cesarean section, in typical ovarian cancer Superficial epigastric artery. This runs even further laterally in the abdom-
operations, and for very large myomas or uteruses. inal wall and is usually clearly visible with transillumination during lapa-
roscopy.

For the gynecologic surgeon, usually only the rectus abdominis muscle is visi-
3.1.1 Anatomical Basis ble and relevant. Its tendinous sheath creates a connection with the other mus-
cles named above. Above the arcuate line, which runs just below the umbilicus,
In addition to skin and subcutaneous fat, the anterior abdominal wall consists the anterior rectus sheath is formed by the aponeurosis of the external oblique
of four muscles and their aponeurosisthe rectus abdominis, external oblique, muscle and the external lamina of the aponeurosis of the internal oblique mus-
internal oblique, and transverse abdominal muscles. There are additional cle, and the posterior rectus sheath is formed by the internal lamina of the apo-
structures in the abdominal wall running from medial to lateral: neurosis of the internal oblique muscle and the aponeurosis of the transverse
Urachus (embryonic urinary duct, rudiment of a structure that is only func- abdominal muscle. Below the arcuate line, all the aponeuroses of the lateral
tional in the embryo). It is usually obliterated and runs into the bladder me- abdominal muscles lie in front of the rectus muscle, where they form the rectus
dially, in a caudal direction. fascia which is well known to the gynecologic surgeon.
III Abdominal Wall Laparotomy

III
38

Fig. 3.1-1 Anatomy of the anterior abdominal bilical ligament), 3 = lateral umbilical fold (infe- Fig. 3.1-2 Possibilities for incision of the anterior abdominal wall: 1 = longitudinal incision laparot-
wall, ventral view with the most important rior epigastric vessels), 4 = round ligament of omy; 2, 3 = transverse laparotomy.
structures: 1 = median umbilical fold (obliterat- the uterus (lig. teres uteri), 5 = transverse vesi-
ed urachus), 2 = medial umbilical fold (obliter- cal fold, 6 = supravesicular fossa, 7 = paravesic-
ated umbilical artery, clinically also lateral um- ular fossa, U = uterus, V = urinary bladder.

lar to the median line. The interiliac incision is reserved for exceptional situa-
tions (e.g., morbid obesity).

3.1.2 Opening the Abdomen


Median Vertical Laparotomy
There are many possible ways to orient the incision on the anterior abdominal
wall. For open oncologic operations, the vertical laparotomy is standard. To After exact marking of the incision along a symphysisumbilicusxyphoid line,

achieve sufficient exposure, particularly in ovarian cancer and advanced endo- with a curve around the umbilicus, the skin is incised with the scalpel. In the

metrial cancer, the incision must be extended significantly above the umbili- area of the umbilicus, attention must be given to later precise apposition. It is

cus, often as far as the xyphoid. Paramedian incisions are obsolete. At present, recommended to extend the skin incision caudally as far as the symphysis. The

transverse laparotomy is usually performed with a suprasymphyseal trans- easiest way to cut through the subcutaneous fat tissue down to the fascia is

verse incision about 2 cm above the symphysis. It is the standard approach, for with electrocautery. Lateral traction is helpful; ideally, electrocautery does

instance, for cesarean section. Some authors prefer a slightly curved skin inci- not cut but separates the layers along their natural separation lines. Alterna-

sion along the skin cleavage lines, others favor a straight incision, perpendicu- tively, a scalpel can be used for the dissection. The fascia should be dissected
along the median line on one side, 12 cm distant of the skin incision to make
closure easier. Excessive lateral clean-up of the fascia should be avoided.
III Abdominal Wall Laparotomy

III
Fig. 3.1-4 Pfannenstiel technique. The level skin incision is made with a knife. Optionally,
of the incision is 2 cm or two fingerbreadths the subcutaneous fat tissue and the fascia of
39
above the symphysis. Alternatively, a straight Scarpa found in it in various degrees of distinct-
or a slightly curved incision along the Langer ness can be cut with the scalpel (cesarean sec-
skin lines is a possibility. Precise marking is rec- tion) or electrocautery (gynecologic proce-
ommended. Attention must be given to sym- dure). The fascia are then dissected out laterally
metry, especially on a pregnant abdomen. The and incised.

Fig. 3.1-3 Precise location of the median line able for blunt separation. Underneath can be
requires experience. Stretching the still-closed seen the actual preperitoneal fat tissue and
fascia caudocranially can be helpful. If the inci- the peritoneum, which is raised with forceps
sion is correct, the preperitoneal fat tissue ap- and then carefully opened with scissors or scal-
pears under the fascia, exactly medial to the pel. If the opening cut is too deep, there is a risk
two rectus bellies. If this is not the case, the me- of injuring the dome of the bladder. In case of
dian line between the rectus bellies must be intestinal adhesions, there is a possibility of in-
identified by careful dissection. A median line juring the intestine.
that has not been previously operated is suit-

Pfannenstiel Transverse Fascial Incision

The most frequent gynecologic laparotomy is the suprasymphyseal transverse


skin incision with preparation of the abdominal wall according to Pfannenstiel.
The Pfannenstiel incisionnamed after the German gynecologist Hans Her-
mann Johannes Pfannenstiel (18621909), who was professor in Giessen and Fig. 3.1-5 The fascial incision is extended lat- the poorly stretchable fascia that determines
Kieldoes not refer primarily to the transverse skin incision but to the trans- erally with strong Cooper or Sims scissors. Espe- the size of the access, rather than the skin inci-
cially in cesarean section, it is the opening of sion. The rectus muscle is spared.
verse fascial incision with subsequent dissection of both rectus muscle bellies
from the fascia, both caudally and cranially. This permits the rectus bellies to be
pushed aside, providing access to the pelvic basin.
III Abdominal Wall Laparotomy

III
40 Fig. 3.1-6 In the classical Pfannenstiel tech- muscles, which may be more or less developed, Fig. 3.1-7 The Kocher clamps are then trans- mobility of the rectus bellies. This is especially
nique, the caudal edge of the fascia is grasped from the powerful rectus fascia. In diastasis rec- ferred to the cranial edge of the fascial incision important for patients who have had previous
with Kocher clamps and raised, enabling sepa- ti, which is often seen in pregnant women, care and the rectus bellies separated in a cranial di- surgeries, in whom high access to the abdomi-
ration of the rectus bellies and the pyramidal must be taken to avoid injuring the bladder. rection, until right below the umbilicus. This nal cavity provides more security against blad-
step is particularly important because this is der or intestinal injuries.
the principal method for achieving the lateral

Cohen Modification of the Transverse Fascial Incision


(Misgav Ladach Method)

In recent years, it has become more common in cesarean sections to open the
abdominal wall largely with blunt dissection techniques and to reduce closure
techniques to a fascial suture and skin closure. This approach is suitable for
pregnant women because of the loose condition of the connective tissue; it is
limited to patients who have not had previous surgeries. The technique is
based on modification of the transverse laparotomy according to Joel Cohen
and is also known as the Misgav Ladach method after the hospital in Jerusalem
where it was further developed by Michael Stark. The primary advantage of the
technique is its speed, which can be particularly useful for urgent or emergent
cesarean section. Moreover, numerous studies confirm that this surgical proce-
dure has a slightly more advantageous postoperative course, with earlier mobi-
lization and less postoperative pain. This effect is most likely due not so much
to the dissection technique for opening the abdominal wall as to the frugal use
of suture material in closing the abdominal wall.

Fig. 3.1-8 The midline between the rectus If entry is too caudal, there is a risk of injuring
bellies can usually be easily seen. After the peri- the dome of the bladder. Where there are intes-
toneum is exposed it is raised with two forceps tinal adhesions, intestinal lesions are also possi-
and opened with a sharp cut (knife or scissors). ble.
III Abdominal Wall Laparotomy

Fig. 3.1-9 Modified Cohen/Misgav Ladach manner with a scalpel. Then the subcutaneous
method. Cohen used a very high transverse in- fat tissue is sharply transected, strictly in the
cision (almost interiliac), but the updated modi- midline, as far as the fascia. Instead of hooks,
fied technique begins with a low transverse lap- abdominal sponges have proved useful in com-
Fig. 3.1-10 The fascia is incised medially for ened. This is usually already an indicator as to
arotomy beginning about 2 cm above the pressing small hemorrhages. Hemostasis is re-
about 23 cm, just far enough that a finger whether this technique can be successfully uti- III
symphysis. The skin is opened in the traditional quired only in exceptional cases.
can be inserted on either side between fascia lized in the patient. In the original Misgav La-
and muscle. Then the subcutaneous fat remain- dach technique, the tissues slide apart slightly. 41
ing on the fascia is separated by symmetric lat- If a tug against this movement is necessary, sur-
eral tension and the fascia is exposed at the gery should continue according to convention-
same time. Caution: if the tension is too strong al techniques.
the skin incision can be unintentionally wid-

Fig. 3.1-11 After the subcutaneous fat tissue second hand can enter. Naturally these steps
has been separated from the fascia, the right are carried out in parallel on both sides. The fas-
and left index fingers are inserted into the fas- cia is split in a lateral direction by a repeated
cial defect thus created, right and left of the simultaneous pull by the surgeon and the first
midline. First a working space between rectus assistant.
muscle and rectus fascia is enlarged before the

Fig. 3.1-12 In the classic technique, the sur- formed by inserting two to three fingers of
geon then hooks two fingers of each hand me- both hands on both sides (surgeon and first as-
dially, at the cranial and caudal edges and ex- sistant), which allows the final incision to be
erts caudocranial tension, which releases the completely opened out once more and evaluat-
rectus bellies from the fascia. The peritoneum ed for width. For a cesarean section, the retrac-
is opened bluntly by perforation with the index tors (e.g., Fritsch hooks) are then inserted. The
finger cranially. The peritoneal widening is per- uterotomy is performed with a scalpel cut.
III Abdominal Wall Laparotomy

Cherney Suprapubic Transverse Fascial Incision Suprapubic Maylard Incision


Transection of the Rectus Attachment
If the intention from the start is to obtain maximal access to the lower pelvic
If access by the Pfannenstiel method seems insufficient, it can be retroactively basin or the lower abdominal cavity, the abdominal wall can be prepared with
enlarged using the Cherney technique by detaching the rectus muscle at its ap- a Maylard incision. Classically, this preparation was also used with the interiliac
oneurotic attachment to the symphysis. The additional space obtained by this skin incision, which is very rarely used today. Some authors consider the May-
procedure is considerable. lard incision as an access option in radical hysterectomy for cervical cancer,
especially when a para-aortic lymph nodectomy is probably not necessary.

III
42

Fig. 3.1-13 Cherney technique. The rectus ter the fascia has been opened transversely Fig. 3.1-14 When the operation is complet- rupted sutures. The fascia is then closed in the
muscle is separated at its aponeurotic attach- and the rectus muscle has been released, later- ed, the tendinous ends of the rectus muscles usual manner. There are usually no problems
ment to the symphysis. The additional space al transection of the muscle bellies must be are reconnected to their tendinous attachment with healing.
obtained by this procedure is considerable. Af- avoided. at the symphysis with cross-sutures or inter-

Fig. 3.1-15 Maylard technique. The tech- cia is opened transversely and then the underly-
nique begins with a conventional transverse ing muscle is also cut transversely with electro-
Fig. 3.1-16 Because of the caudocranial sure of the rectus fascia, which requires that
skin incision. The decisive step in the Maylard cautery. An Overholt elevator placed behind
course of the muscle fibers, a sufficient suture the muscle has not been previously separated
preparation is the transverse transection of rec- the muscle prevents an excessively deep inci-
in this direction is not possible. Therefore, the from the fascia. The muscular defect then heals
tus muscles together with their fascial sheath. sion. The inferior epigastric vessels are located
transected muscle itself is not reapposed, but as an additional tendinous intersection. An ad-
There is no separation of muscle and fascia as laterally. They must be definitively isolated and
it is reapposed indirectly by conventional clo- ditional drain is not required.
in the Pfannenstiel technique. Usually, the fas- separately ligated.
III Abdominal Wall Laparotomy

longitudinal fascial incision that can be extended relatively far cranially, giving
Separate Opening of Abdominal Layers generous access to the lower pelvis. Another important advantage, especially in
with Longitudinal Fascial Incision reoperations, is that the Pfannenstiel technique, with its often copious adhe-
sions (after dissection of the rectus bellies from the fascia), can be avoided. A
Another possibility for laparotomy is the combination of a transverse abdomi- disadvantage is the risk of a seroma in the subcutaneous fat tissue dissected
nal incision with a longitudinal incision of the fascia. This provides an advanta- from the fascia.
geous combination of a cosmetically favorable transverse skin incision and a

III
43

Fig. 3.1-17 Suprasymphyseal skin incision the umbilicus. Electrocautery is recommended Fig. 3.1-18 The rectus aponeurosis is split in linea alba is seen exactly in the midline as an ap-
about 2 cm above the upper edge of the for the dissection. This preparation should con- the linea alba. Here it is particularly important oneurotic strand. If this is transected exactly in
symphysis, followed by separation of the sub- centrate especially on the midline. The less the to operate precisely in the midline. If craniocau- the middle, the gap between the two rectus
cutaneous fat tissue from the fascia, in a specif- dissection extends laterally, the smaller will be dal tension is applied to the rectus fascia, the bellies is immediately found.
ic technique, caudally and cranially, almost to the wound cavity.

Fig. 3.1-19 After the rectus bellies are secure- made too far caudally there is a risk of bladder
ly moved aside in the midline, the peritoneum injuries, and if there have been previous opera-
is pulled up with forceps and opened with dis- tions there is a risk of intestinal injuries.
secting scissors or a knife. If the opening is

Fig. 3.1-20 Abdominal wall closure with a important element of abdominal closure here,
continuous fascioperitoneal all-layer suture. as in all other techniques, is the exact apposi-
Monofilament 0 or 1 suture is recommended. tion of the fascia. A widely used technique is uti-
Interrupted sutures are more time consuming lization of double-loop PDS suture material.
and have no additional advantage. The most
III Abdominal Wall Laparotomy

Technique in Cases of Morbid Obesity

No other risk factor makes abdominal surgery so difficult as obesity. Even sim-
ple operations can become a challenge. All postoperative complications in the
area of the abdominal wall occur more frequently: seromas, hematomas, infec-
tions, and disorders of wound healing as well as hernias. A decisive factor in
surgery is sufficient assistance, retractors that are large enough, an incision
long enough to maximize the size of the difficult approach, and the correct
choice of approach. Occasionally a high transverse interiliac Maylard incision
can avoid the need to divide the pannus. However, there are some primary on-
cologic diseases that leave no alternatives to vertical laparotomy. In extreme
cases, concomitant abdominoplasty can be considered. Closure is done by the
usual procedure. For obese abdominal walls, insertion of subcutaneous Redon
drains is recommended.
Fig. 3.1-21 Insertion of a subcutaneous drain tages. Depending on its thickness, the subcuta-
III is optional for most patients. Where there is a neous fat tissue should be apposed, as here,
high risk of postoperative bleeding or in the along the Scarpa fascia or subcorially. Meticu-
44 case of highly adipose abdominal walls, studies lous subcutaneous hemostasis is particularly
have shown that drainage has certain advan- important. 3.1.3 Closure Techniques
Several aspects of closure of the abdominal layers have been discussed earlier
in the chapter, along with the laparotomy techniques. In the following, partic-
ularly important points are discussed further.

Peritoneal Suture

Most surgeons no longer suture the visceral peritoneum as studies have dem-
onstrated no advantages. The disadvantages of closing the peritoneum are lon-
ger operating time and increased formation of adhesions. Data regarding su-
ture of the parietal peritoneum are not as conclusive: the success of the opera-
tion does not depend on whether or not the peritoneum is sutured. In the
original Misgav Ladach method, the peritoneum was purposely not sutured;
the only action taken was to position the major omentum in front of the uterus.
Some recent studies have shown that closure of the parietal peritoneum, in
contrast to closure of the visceral peritoneum, may in fact reduce adhesions,
Fig. 3.1-22 Infraumbilical minilaparotomy. the fascia, craniocaudal transection of the fas- which can be especially important if the abdominal cavity has to be opened
Immediately postpartum, with a peridural cath- cia, and entry into the abdominal cavity are as again.
eter in place, an additional local anesthetic is in- close as possible to the umbilicus. After inser-
jected periumbilically. Alternatively, the proce- tion of retractors, the postpartum uterus, still
dure can be performed under spinal anesthe- extending as far as the umbilicus, is manipulat-
sia. A curved skin incision is made slightly ed until the tubes are visualized and can be
below the umbilicus. Preparatory exposure of brought into the surgical field.
Fascial Suture

The closure of the fascia is the most important aspect of vertical laparotomy.
After all, hernia formation is the most frequent long-term complication of ab-
dominal surgery. As gynecologic patients with the diagnosis of scar hernia are
Infraumbilical Minilaparotomy usually referred directly to an abdominal surgeon many years after the primary
surgery, this problem is often underestimated in gynecology. In abdominal sur-
Infraumbilical minilaparotomy is a special case. Its application is restricted to gery, a long-term hernia rate is at least greater than 10%.
immediately postpartum tubal ligation (maximally up to 48 hours after deliv-
ery). The patient should receive information about this procedure sufficiently
in advance before delivery.
III Abdominal Wall Laparotomy

III
Fig. 3.1-23 Suturing the visceral peritoneum sions; suturing the parietal peritoneum may
45
is associated with increased formation of adhe- possibly reduce the occurrence of adhesions.

Interrupted Suture Everett Suture (Double Loop)

Fig. 3.1-24 Because of improvements in su- wound closure, single sutures may, however, Fig. 3.1-25 At present, the continuous suture dle. The greater the ratio of thread length to
ture materials, the fascia no longer has to be be placed, set off from each other by clamps, is the most commonly used. In this procedure, wound length (optimal 4 : 1 or more), the bet-
closed with interrupted sutures. Continuous and then, with simultaneous apposition of the peritoneum and fascia are sutured together. ter the wound resists an increase of intra-ab-
closure with a PDS suture is faster and just as wound edges, separately knotted. The fascia is grasped 12 cm. The suture inter- dominal pressure postoperatively. Many sur-
secure. In rare cases of difficult abdominal val should be equal to the distance from the geons favor PDS suture (monofilament), single
edge of the wound to the insertion of the nee- or as a double loop.
III Abdominal Wall Laparotomy

III
46

Fig. 3.1-26 The wound is stretched up to length in the suture. The figure shows a con- Fig. 3.1-27 In making a continuous suture, it fascia away from the overlying subcutaneous
30% by postoperative abdominal distension. tinuous double-loop PDS fascialperitonealall is important to bite edges of the fascia and the fat tissue can be useful. No fat tissue should be
To prevent strangulation and ischemia of the layer suture. peritoneum frequently and broadly. For this interposed between the fascial edges.
tissue, there must be an appropriate reserve procedure, cautious partial dissection of the

Fig. 3.1-28 The ends of the incision can be ture material and the correct technique. It is Fig. 3.1-29 In the double-loop procedure, at Fig. 3.1-28) so that it can be knotted together
marked with interrupted corner sutures. Suffi- not only difficult but also dangerous to close the end of the suture line, one of the threads with the second thread, which has been pulled
cient relaxation of the patient until the end of the abdomen of a patient who is already push- must be cut away from the needle (see through once more.
fascial closure is as important as the correct su- ing.
III Abdominal Wall Laparotomy

Smead Jones Technique Correction of Defects in the Abdominal Wall

Sometimes women, especially multiparas, who are about to undergo a laparot-


omy are diagnosed preoperatively with a small umbilical hernia or with a rec-
tus diastasis. At the patients request, these defects can be corrected when the
abdominal wall is being sutured without a significant increase in operating
time, especially in the case of rectus diastasis. In umbilical hernia, the hernial
sac is dissected from the skin of the umbilicus and resected. The hernial open-
ing is closed in three steps: peritoneum together with the posterior lamina of
the rectus sheath, exposed rectus muscles, and finally the anterior lamina of
the rectus sheath.

III
47

Fig. 3.1-30 The SmeadJones technique is the other side (far). The second loop grasps Fig. 3.1-32 In diastasis recti, it is often neces- tension, an alternative is to open the rectus
also known as the farnear technique. First only the two fascial edges (near). Numerous sary to find the rectus muscles lying far apart to sheath in the midline so that the posterior and
fascia, rectus muscle, and peritoneum are variations of this technique are used. the sides and join them in the midline. If this is anterior laminas of the rectus sheath can then
pierced on one side and, in reverse order, on not possible because of inferior tissue quality or be separately sutured.

Pfannenstiel Suture

Fig. 3.1-31 Closure of the fascia after a Pfan- first (0 suture) in the cut edge facing the sur-
nenstiel laparotomy is the same as the closure geon. A suture at the center can be helpful for
technique after all transverse fascial incisions. It apposition but is not obligatory. The suture it-
is recommended to make the corner suture self is continuous.
III Abdominal Wall Laparotomy

Relief Sutures in Dehiscence of Abdominal Sutures Skin/Subcutaneous Tissue

The rare but dreaded postoperative complication of dehiscence of abdominal Gynecologic surgery makes high demands on the skin closure. This applies par-
sutures often occurs in association with postoperative wound infection, usually ticularly to the cosmetic closure of laparotomy. In order to avoid separation of
on the 6th to 8th postoperative day. In high-risk patients (e.g., diabetes, cortico- the subcorium skin layers and thus an unesthetic widening of the scar, double-
steroid therapy, obesity, cachexia) there is the possibility of inserting addition- row wound closure is recommended. The subcorium is adjusted with inter-
al all-layer extraperitoneal relief sutures, using plastic plates, either prophylac- rupted sutures, which places the highest resistance capacity of the suture pre-
tically or in secondary closure. cisely at the thorax. The epithelium is then sutured with a continuous absorb-
able or nonabsorbable suture. Staples are used only in oncologic vertical lapa-
rotomy. In the end, every surgeon must make decisions individually and set
priorities.

III
48

Fig. 3.1-33 Plastic plates decrease tension in mized by enlarging the contact surface. A fur-
the wound area. In this way, the inevitable pres- ther advantage of these support sutures is
sures are distributed over large surface areas so that the tensile stress that would otherwise be
that no ischemic necrosis is likely to occur borne by the fascia is spread over larger areas of
around the suture. The pressure can be mini- the abdominal wall. Fig. 3.1-34 In gynecology, interrupted su- terrupted back-stitch sutures used in general
tures in the skin are used almost exclusively in surgery are the vertical back-stitch sutures of
the vulva. In such cases, the simple single-layer Donati (above) and Allgwer (below).
interrupted suture is sufficient. The classic in-
III Abdominal Wall Laparoscopy

Fig. 3.1-35 Skin closure with staples is a safe tual skin suture do not occur. Unfortunately, Fig. 3.1-36 The esthetic execution of a classic looking suture is an important component of
and, most of all, rapid alternative. It is standard this early removal is not always possible in continuous intracutaneous suture is the first a successful operation. Absorbable or nonab-
in longitudinal laparotomies, especially in on- the clinical routine. With continuous closure, test of manual skill for every beginning gyne- sorbable monofilament suture is used.
cology. Supposedly, if the staples are removed this problem does not occur. cologic surgeon. An expeditious and good-
early, the unesthetic markings lateral to the ac-
III
49

3.2 Laparoscopy

In laparoscopy, the integrity of the abdominal cavity is not destroyed, which


eliminates one of the chief causes of complications in abdominal surgery.
From wound infection to suture dehiscence to keloid formation and the most
frequent complication of abdominal surgery, scar herniation, all known com-
plications occur less frequently after laparoscopy. As many postoperative com-
plications, such as thrombosis, embolism, and pneumonia, are the result of im-
mobilization and the chief cause of this is the painful laparotomy suture, lapa-
roscopy has brought fundamental changes to routine surgical practice. These
advantages apply to all patients, especially older or obese women. Never-
theless, the abdominal wall is an obstacle in laparoscopy too. In particular, the
initial blind entry with the CO2 insufflation needle (Verres needle) and the
trocar for the optics represent their own specific source of complications.

3.2.1 Anatomic Basis


In addition to the fundamental anatomic configuration of the anterior abdom-
inal wall (Chapter 3.1.1), the laparoscopic surgeon must be familiar with the
important vessels of the abdominal wall. Although it is theoretically possible
Fig. 3.2-1 Vascular trees in the abdominal rior abdominal wall (lateral epigastric fold). The
for small skin vessels to bleed, it is chiefly the inferior epigastric vessels and wall (diagram). The course of the inferior epi- most important protection against injury to
the superficial epigastric vessels that can be damaged on puncture. gastric artery is represented on the patients this powerful artery, which can cause signifi-
right side. A branch of the transition zone exter- cant bleeding and hematomas, is first, consis-
nal iliac artery/femoral artery, the artery runs tent lateral placement of the working trocars
relatively rapidly toward the midline and be- on a line about 2 cm medial to the sagittal line
tween the rectus muscle and the underlying through the anterior superior iliac spine and
peritoneum, lying over the rectus muscle second, straight puncture with a trocar perpen-
more or less on the abdominal side. Its course dicular to the skin. Subcutaneous roaming
is below the lateral third of the rectus muscle. with the trocar by tangential puncture must be
It is almost never possible to visualize the artery avoided. The less regular course of the superfi-
by transillumination/diaphanoscopy. Some- cial epigastric artery is shown on the patients
times, but not always, it can be seen as a pulsat- left side. This artery can usually be seen and
ing cord on laparoscopic inspection of the ante- avoided by transillumination/diaphanoscopy.
III Abdominal Wall Laparoscopy

3.2.2 Approach to the Abdominal Cavity


Correct entry into the abdominal cavity is among the most important steps in
laparoscopy. It begins with the umbilical incision and introduction of the
Verres needle and includes introduction of the optic and working trocars.

III
50

Fig. 3.2-2 Umbilical incision. A vertical, intra- Caution: in slim patients, this can result directly Fig. 3.2-3 Placement of the Verres needle. cases, e.g., with an obese patient, the surgeon
umbilical incision is recommended as the tech- in an opening of the abdominal cavity. It is im- Maximal elevation of the abdominal wall in a and first assistant grasp to the right and left of
nically and cosmetically most reasonable ap- portant to keep the incision rather tight, as oth- ventral direction and puncture with the Verres the umbilicus to do the displacement together.
proach. As shown here highly magnified, the erwise the optical trocar can slide into the ab- needle at a 90 angle. Usually optimal position- It is important to create the tension correctly, in
umbilicus is pulled upward and ventrally with dominal cavity and cause significant technical ing of the abdominal wall occurs when the sur- order to permit entry at a 90 angle.
two forceps. The surface of the skin is incised. difficulties. geon manages the displacement alone. In rare
III Abdominal Wall Laparoscopy

III
51

Fig. 3.2-5 Placement of the optical trocar. is advanced exactly in the midline toward the
After establishment of pneumoperitoneum at lower pelvis. It is often difficult to raise the ab-
a relatively high entry pressure of 15 dominal wall again because it is distended, and
20 mmHg, the tautly bulging abdominal wall is this is not necessary with this technique. The in-
punctured at the umbilicus with a size 10 tro- tra-abdominal pressure can be reduced during
car. After the fascia is hooked up, the trocar the operation.

Fig. 3.2-4 When inserting the Verres needle, and safe entry with the Verres needle and tro- Fig. 3.2-6 An alternative proposed by some needed with the Verres needle. Another alter-
it must be kept in mind that the more obese car is often only possible when the direction of authors is direct entry with a 10 mm trocar. native is open laparoscopy, which some sur-
the patient, the more possible and necessary it puncture is strictly perpendicular. In a slim pa- This technique is said to provide the same de- geons use as the routine approach, even for
is for the puncture to be perpendicular. In obe- tient this would very likely lead to injury of the gree of safety and saves the insufflation time previously operated patients.
sity the umbilicus roams in a caudal direction large vessels, but that is not the case for obese
on the abdominal wall in relation to the aorta, patients.
and in extremely obese patients a successful
III Abdominal Wall Laparoscopy

III
52

Fig. 3.2-7 Placement of the working trocars. trocar, care must be taken not to injure the Fig. 3.2-9 After a vertical laparotomy, pa- An alternative entry point is the Palmer point,
Depending on the operation, the trocars may bladder. Emptying the bladder with a transure- tients have the great advantage, on the one about the width of two fingers below the left
have to be shifted in a cranial direction and, thral catheter is recommended. The lateral tro- hand, of avoiding a second laparotomy. On the costal arch on the medioclavicular line. A re-
for this reason, placement too far in the caudal cars should be located lateral to the lateral um- other hand, it is precisely in the midline that sig- quirement for this approach is a reliably emp-
direction can make the surgical procedure sig- bilical fold with the inferior epigastric vessels nificant adhesions occur that can lead to intes- tied stomach through an indwelling gastric
nificantly more difficult if the uterus is large or running in it. Unfortunately this fold cannot al- tinal damage during a laparoscopic approach. tube.
the cysts are large. In laparoscopic procedures, ways be seen as illustrated, next to the medial
the operation should always proceed away umbilical fold (obliterated umbilical vessels)
from oneself and never toward oneself. In and the median umbilical fold (urachus). In ev-
placing the median, suprasymphyseal auxiliary ery case the rule that applies is: lateral is safe.

Fig. 3.2-8 Classic positioning of the optical case they are placed quite laterally, approxi-
trocar and three working trocars. For conven- mately at the level of the anterior superior iliac
tional operative laparoscopies, for example, crest. This sharply reduces the incidence of vas-
ovarian cyst surgery, the lateral auxiliary trocars cular complications in the abdominal wall.
are placed relatively far caudally, but in every
III Abdominal Wall Laparoscopy

3.2.3 Insertion in Special Operations


Operative laparoscopy should be performed with three auxiliary insertions in
addition to the umbilical trocar: two instrument trocars laterally and one in-
strument trocar above the symphysis. Every surgeon develops an individual
puncture technique which is then modified according to the requirements of
the operation and the specific characteristics of the patient:
In myoma enucleation, the auxiliary trocars are placed more in the cranial
direction, depending on the size of the myoma
In supracervical hysterectomy, the lateral auxiliary trocars must be placed
sufficiently high and to the sides to achieve an advantageous angle of ap-
proach to each of the respective uterine arteries
In pelvic lymphadenectomy, placing the lateral trocars to the side can im-
pede dissection in the obturator fossa. On the other hand, a sufficiently lat-
eral position, for example, in suturing the vaginal stump, can be helpful
In para-aortal laparoscopic lymphadenectomy, surgery proceeds in a crani- III
al direction. The suprasymphyseal trocar becomes the optics trocar. In indi- 53
vidual cases the surgeon must decide whether additional lateral punctures
will be necessary for retraction of the intestine

Traditionally, large trocars (size 10 and over) are placed in the midline. Incor-
rect insertion of the trocars can add complications to an operation that is al-
ready difficult. However, there is no hard and fast configuration for the
placement of trocars; rather, it is governed largely by the patients anatomy.
Fig. 3.2-10 If open laparoscopy is really to in- ly large, usually directly infraumbilical skin inci-
Thus, for instance, the distance from symphysis to umbilicus, compared with
crease the safety of the procedure, a sufficient- sion is required.
the distance from symphysis to xyphoid, is a very variable dimension. In the
last analysis, optimal trocar placement is the product of experience and surgi-
cal intuition.

3.2.4 Open Laparoscopy


Traditionally, open laparoscopy has been considered a safer technique than di-
rect entry with the Verres needle where there is strong suspicion of intraperi-
toneal adhesions, for example, after vertical laparotomy or similar procedures.
This idea has gained broad currency, which has forensic consequences. Un-
fortunately there are not many studies to confirm the claim. An alternative to
open laparoscopy is entry at the Palmer point (see Fig. 3.2-9). Studies have
demonstrated that the risk of intestinal injury is the same with open and closed
entry techniques; however, the rate of vascular injury is lower with the open
technique. When there are intestinal adhesions immediately below the umbil-
icus, intestinal injury occurs with the same frequency from direct puncture
with the Verres needle and trocar as from open laparoscopy.

Fig. 3.2-11 Laparotomy adapted to the situation: small retractors are needed to help expose the
various layers.
III Abdominal Wall Laparoscopy

III
54 Fig. 3.2-13 After the fascia is isolated and fascia. Then the peritoneum, the last layer, is
transected, it is pulled aside with hooks and opened, ideally with optimal visualization. The
held with sutures that hold the special trocar special trocar for open laparoscopy (Hasson tro-
for open laparoscopy in place and can be used car) is inserted and fixated with the fascial su-
at the end of the operation for closure of the tures.

Fig. 3.2-12 Largely sharp dissection of the in- section should proceed toward the umbilicus as
dividual layers where particularly the dense fas- this area, where all the layers of the anterior ab-
cial layer of the rectus abdominis muscle must dominal wall blend into the thin subumbilical
be isolated and transected. With a skin incision plate, provides the easiest access to the abdom-
lying slightly (12 cm) below the umbilicus, dis- inal cavity.

3.2.5 Closure of Trocar Insertion Points 3.2.6 Laparoscopic Retrieval Techniques


Specific closure of fascial defects caused by size 5 trocars medially or laterally or In laparoscopy, retrieval of pathologic adnexal masses is a challenging situa-
by size 10 trocars medially is not necessary. Size 10 trocars placed laterally or tion. Large adnexal tumors suspected of being malignant should not be resect-
trocars with a greater diameter placed in the midline create defects that must ed or fragmented laparoscopically because there is a danger of spreading cells
be closed. In addition to the simple deep fascial interrupted suture, in which in the abdominal cavity. If a malignancy is present, this can lead to worsening
esthetically unpleasing puckering of the skin must be avoided, a large number of the prognosis in the long term (stage change from 1a/b to 1c). Although this
of different suture techniques have been developed, in some of which the nee- effect can be minimized by a prompt, adequate staging laparotomy and stan-
dle enters parallel to the trocar. These are not routinely used. dard chemotherapy, dissemination of cells should be avoided. Most laparo-
scopic samples are already classified as benign on macroscopic view. If the
finding is classified as not definitely benign, laparoscopic retrieval techniques
are used.
III Abdominal Wall Laparoscopy

III
55

Fig. 3.2-14 Use of recovery systems. These intra-abdominal dissemination of cells. If reduc- Fig. 3.2-15 Recovery pouches are used in var- (and then emptying) with irrigation fluid can be
systems can easily be introduced into the ab- tion of the tumor is not practical, the point of ious forms and techniques. For optimal unfold- helpful.
dominal cavity through a size 10 trocar. They entry of the trocar must be enlarged in order ing of the pouch and positioning, partial filling
permit such procedures as intra-abdominal to remove the recovery pouch safely from the
puncture of cysts or tumor reduction without abdominal cavity.

Fig. 3.2-17 Sometimes the sample can be re- they can tear open with a strong pull. For large
covered directly in the recovery pouch through tumors and where there is a strong suspicion of
the point of entry of the trocar. Modern recov- malignancy, the common recovery techniques
ery pouches have high tensile strength, but are usually not optimal.

Fig. 3.2-16 For simple collection of a pathologic sample, there should be an ample opening for
the recovery pouch.
III Abdominal Wall Laparoscopy

III
56

Fig. 3.2-18 Puncture of a cyst in the recovery pouch. Fig. 3.2-19 Fragmentation of the pouch con- recovery pouch. The recovery pouch is reserved
tents. Obvious malignancies should not be op- for cases in which it is not certain that the sam-
erated on laparoscopically or removed with a ple is benign.

Fig. 3.2-20 Expansion of the fascial defect. If ing from the point of insertion of the trocar, is Fig. 3.2-21 If appropriate, the fascia is ex- is the removal of solid tumors through a trans-
safe puncture or fragmentation in the recovery first freed by blunt dissection. Often a small ex- panded by cutting, under visual control. A fre- vaginal Douglas opening. The problem with
pouch is not possible, the fascial defect has to pansion is sufficient. quently taught but seldom applied technique this method is the risk of losing gas.
be expanded. For this purpose, the fascia, start-
IV.
ADNEXA

Preliminary Remarks about the Region


Pages 6067

Concepts for Surgical TreatmentProcedure Navigator


Pages 6881

Surgical Techniques
Pages 82189
4.1 Preliminary Remarks
about the Region
IV
60

The adnexa include the ovaries and fallopian tubes. The ovaries are the origin ade. The fallopian tubes are an important organ in fertility and sterility and as
of numerous functional and morphologic disorders because of their central im- the focus of inflammatory diseases or ectopic pregnancy. Infrequently, they can
portance for reproduction and hormone production. Because of the signifi- be the seat of neoplastic morphologic changes. Here too, developments in re-
cance of estrogen production in overall metabolism, bone metabolism, and productive medicine have led to new surgical approaches.
the risk of breast cancer, new therapeutic approaches and views have devel-
oped in recent years that have also modified surgical treatment of the ovaries. Because of its anatomic location, the topic of adnexal surgery offers a good op-
The extensive introduction of laparoscopy has brought about fundamental portunity for presenting the anatomy of the extended retroperitoneum, which
changes in management of the many cystic or tumorous changes in the ovaries. is important for the gynecologic surgeon.
The therapy of ovarian cancer has been optimized several times in the last dec-

4.1.1 Topography of the Retroperitoneum

4.1.1.1 General Anatomy

Anatomically, the retroperitoneum is not sharply defined. In principle, it in- The retroperitoneum of the posterior wall of the abdomen, cranial to the com-
cludes the peritoneum-covered anatomic structures that constitute the poste- mon and external iliac vessels, is usually reserved for the gynecologic oncolo-
rior wall of the abdominal cavity and the pelvic space and are thus located dor- gist. Although this retroperitoneal space seems like a closed book to the begin-
sal to the abdominal cavity. Depending on the definition, the wall of the pelvic ner, the anatomy of the zone is actually easily understandable. The surgeon
basin, well known to the gynecologic surgeon, may also be designated as retro- encounters it especially in the context of para-aortic and paracaval lymphade-
peritoneal. Commentary on these retroperitoneal portions of the pelvis is nectomy. Its lateral boundary is the frame created by the colon (ascending co-
found in the anatomic presentation of the pelvic spaces (Chapter 5, Uterus). lon on the right side, descending colon on the left). Whereas the ascending and
They are only briefly presented here, together with a description of the course descending large intestine are secondarily retroperitoneal, the transverse co-
of important nerve structures. lon is located intraperitoneally. Cranially, the easily accessible portion of the
retroperitoneal space can be extended by simply pushing aside the duodenum
as far as the renal veins that usually form the most cranial border of the lym-
phadenectomy.
IV Adnexa 4.1 Preliminary Remarks about the Region

1
2

8 4

IV
Fig. 4-1-1 The retroperitoneum above the
pelvis in the classical anatomic presentation.
ian vein; 3 = left and right ovarian arteries; 4 =
left ureter; 5 = inferior mesenteric artery with
61
The relevant structures are drawn as seen branching into the superior rectal artery and
through the peritoneum. In obese patients, the sigmoid arteries, among others; 6 = right
they naturally remain hidden before the perito- ureter; 7 = bifurcation of the aorta; 8 = inferior
neum is opened; 1 = left renal vein; 2 = left ovar- vena cava.

4.1.1.2 Retroperitoneum Nerves

The pelvic retroperitoneal space is traversed by the internal iliac vessels and iliac vessels. It is often described as lying directly on the levator plate. Nerve fi-
their terminal branches, the lateral umbilical ligament, the superior vesical ar- bers of the inferior hypogastric plexus lead anterolaterally to the intestine as
tery, the uterine artery and vein, the obturator vessels and the accompanying the pelvic plexus and from inferolateral and laterodorsal to the bladder and
obturator nerve, and naturally by the ureter. Deep in the pelvic retroperitoneal the internal genitalia. These terminal branches, accompanying the visceral
space and not normally encountered by the gynecologic surgeon lie the branches of the internal iliac artery, reach the organs of the pelvis where they
branches of the sacral plexus (L5S3), from which the superior and inferior form nerve networks, also called the rectal plexus, uterovaginal plexus, and
gluteal nerves, the posterior cutaneous femoral nerve, the sciatic nerve, and vesical plexus.
the pudendal nerve arise.
The nerve strands of the hypogastric branch/nerve associated with the inferior
The components of the autonomic nervous system, difficult to see intraop- hypogastric plexus (running in the sacrouterine ligament) and of the splanch-
eratively, are functionally important. Emerging from the celiac plexus, nerve nic nerves (running in the cardinal ligament) are at particular risk when these
filaments run caudally along the anterolateral walls of the aorta, picking up fi- ligaments are transected in a radical hysterectomy.
bers from the inferior mesenteric ganglion and the lumbar sympathetic trunk.
Table 4.1.1 Motor and sensory innervation of the pelvis and genitalia
At the bifurcation of the aorta, these filaments unite into the superior hypogas-
tric plexus, also known as the presacral nerve, that lies on the sacral promon- Nerve Innervation
tory, directly under the peritoneum. This divides into two nerve strands (right Pudendal nerve Motor: external anal sphincter, external urethral
(S2S4) sphincter
and left hypogastric branches) that run medial to the internal iliac vessels deep
Sensory: genitalia, anal region
into the inferior hypogastric plexus. In addition to receiving preaortic visceral
(sympathetic) fibers, the superior hypogastric plexus is supplied by the lumbar Superior gluteal nerve Motor: gluteus medius, gluteus minimus,
tensor fasciae latae
splanchnic nerves (parasympathetic system).
Inferior gluteal nerve Motor: gluteus maximus
The inferior hypogastric plexus is thus supplied with sympathetic fibers via the
Posterior cutaneous Sensory: skin of the lower gluteal region,
right and left hypogastric branches from the sacral sympathetic trunk, T11L2, skin of the dorsal thigh
nerve of thigh
and with parasympathetic fibers via the delicate nerve filaments of the pelvic
splanchnic nerves, S2S4. It supplies the autonomic innervation of the pelvic Sciatic nerve Motor: ischiocrural muscles, all muscles distal
to the knee joint
organs over its distribution network, also known as the pelvic plexus. The infe-
Sensory: lateral calf and foot
rior hypogastric plexus lies deep in the pelvis bilaterally, medial to the internal
IV Adnexa 4.1 Preliminary Remarks about the Region

IV 4
62
3 Fig. 4-1-2 Representation of the position and Finally, representation of the continuation,
relationship of the superior hypogastric plexus close to the organs, as rectal plexus, uterovagi-
(1) with the connections from the para-aortic nal plexus, and vesical plexus (3) in the ligamen-
plexuses, the lumbar portion of the sympathet- tous structures of the sacrouterine ligament
ic trunk, and the lumbar splanchnic nerves as (hypogastric nerve) and the cardinal ligament
well as the inferior hypogastric plexus (2) with (pelvic splanchnic nerves); 4 = pelvic plexus; 5
tributaries from the sacral portion of the sym- = lumbosacral plexus.
pathetic trunk and the pelvic splanchnic nerves.

4.1.1.3 Retroperitoneal Space Vessels

The dominant vascular structures are the inferior vena cava and the aorta and orrhages from the vena cava that can only be coagulated with difficulty and
after their respective bifurcationthe common iliac arteries and the right therefore must sometimes be carefully sutured. Careful stepwise dissection of
and left common iliac veins. Major branches of these principal vessels are, the precaval lymphatic and fat tissue with constant coagulation of even the fin-
from the bifurcation upward, the inferior mesenteric artery, which usually est vessels prevents these hemorrhages. The number of these perforators de-
branches 57 cm above the bifurcation of the aorta, directly from its anterior creases significantly from caudal to cranial. The lumbar arteries and veins
wall, usually offset 23 mm to the left. (The inferior mesenteric vein runs back that branch dorsolaterally from the inferior vena cava and the abdominal aorta
to the portal vein, and therefore the vena cava has no corresponding branch are important vessels at the most dorsal border of the surgically accessible ret-
here.) The inferior mesenteric artery is usually spared by the gynecologic sur- roperitoneum; they can be damaged in very aggressive lymphadenectomy or
geon, but if necessary, and usually without negative consequences, it can be removal of clinically affected lymph nodes, for example, in the interaortocaval
transected even when a deep intestinal anastomosis in the pelvis after partial space.
sigmoid/rectum resection is planned. Further cranial to the branching of the in-
ferior mesenteric artery, the two ovarian arteries branch directly from the an-
terior wall of the aorta at a sharp angle in a lateral caudal direction, attach
themselves to the ovarian veins and thus pass caudally in the infundibulopelvic
ligament to the adnexa. The ovarian arteries are rather delicate structures ana-
tomically that are often only noticed during dissection and can then be easily
coagulated. In contrast, the ovarian veins are more voluminous and easily seen,
especially when they are ligated caudally; they must be distinguished from the
ureter. The right ovarian vein runs to the anterior side of the inferior vena cava
while the left vein usually leads to the left renal vein. This junction usually
forms the cranial and left lateral border of complete para-aortic and paracaval
lymphadenectomy. The small perforator veins from the inferior vena cava,
running directly into the precaval lymphatic and fat tissue, are very important
in dissection even though extremely delicate. If tension is placed on them, they
can tear off during precaval lymphadenectomy and lead to direct, small hem-
IV Adnexa 4.1 Preliminary Remarks about the Region

4
IV
3 63

Fig. 4-1-3 The dissection seems difficult at ty; attention must be paid to the ureters lateral- Fig. 4-1-4 Of particular importance for a giv- iliac artery, and superior vesical artery, to
first, not because of the number of vessels but ly, to the duodenum cranially and the anterior en dissection is the blood supply of the ureter, name the most important. The exact course of
because of their course in the retroperitoneal wall of the vena cava dorsally; 1 = left ureter; which is provided by the vessels of the richly these small vessels is anatomically very incon-
fat tissue. However, their anatomy is astonish- 2 = left ovarian artery/vein; 3 = superior vesical vascularized adventitia. Small vessels from ev- stant, but not the general direction from which
ingly constant (the typical course of the most artery; 4 = uterine artery; 5 = internal iliac ery artery that is passed or crossed by the ure- the ureter is supplied: from medial above the
important vessels is represented here). Bleed- artery. ter supply this adventitial network: renal artery, crossing of the iliac vessels, from lateral below
ers can usually be coagulated without difficul- ovarian artery, common iliac artery, internal the crossing.

4.1.1.4 Retroperitoneal Space Course of the Ureter

The most important structure for the gynecologic surgeon in the retroperito- Pelvic section. In the pelvis itself, the ureters run close to the medial peritoneal
neal space is the ureter. It must be exposed to view along its course in hyster- lamina, posterior to the ovarian vessels, and continue to medially, toward the
ectomy, lymphadenectomy, removal of the infundibulopelvic ligament, and cervix, under the uterine arteries that extend into the uterus, and into the para-
mobilization of sigmoid and cecum. The total length of the ureter is between metrium. Usually the distance from the internal cervical aperture laterally to
25 and 30 cm. This length is divided by the edge of the pelvis into 1215 cm ab- the ureter is given as about 2 cm. From here, the ureter runs in a dense connec-
dominal and pelvic segments. tive tissue sheath, also known as the Wertheim tunnel, that consists of the fi-
brous tissue of the cardinal ligament. Immediately after it crosses under the
Abdominal segment. The abdominal segment of the ureter runs anterior to the uterine artery, the ureter again approaches the cervix in an anterocaudal direc-
psoas muscle and posterior to the ovarian vessels. The right ureter runs lateral- tion, in the so-called ureteral knee. Here it is particularly difficult to dissect the
ly to the inferior vena cava and crosses the common iliac artery to the right at uterus free in a radical hysterectomy. The remaining path runs even more
the level of its division into external and internal iliac arteries. The left ureter sharply medially and slightly anterocaudal, where the ureter enters the vesical
runs lateral to the aorta, and posterior to the inferior mesenteric artery, the trigone lying on the vagina, somewhat anterior to the vaginal fornix.
ovarian vessels, and the descending colon. At the left brim of the pelvis, because
of the course of the sigmoid but in particular because of the physiologic perito-
neal adhesions between the sigmoid and left infundibulopelvic ligament and
the left wall of the pelvis, the ureter is often only visible after release of these
structures as the first step in ureterolysis.
IV Adnexa 4.1 Preliminary Remarks about the Region

4.1.1.5 Retroperitoneal Space Lymph Nodes

Diagnostic lymphadenectomy in surgical staging and therapeutic lymphade-


nectomy of microscopically or macroscopically affected lymph nodes are
among the most important techniques of gynecologic oncology. The postoper-
1
ative development of lymphedema is an important long-term complication of
gynecologic surgery with an approximate incidence of 5%15% in cervical, en-
dometrial, and ovarian cancer as well as up to 30%40% in cancer of the vulva.
The precise anatomic distribution of the lymph nodes in the pelvis is quite var-
iable but, from the surgeons point of view, follows relatively precisely the
course of the internal, external, and common iliac vessels, as well as of the aorta 2
and inferior vena cava. A distinction is usually made between pelvic and para-
aortic lymphadenectomy.

3
Pelvic lymphadenectomy. In pelvic lymphadenectomy, the nodes removed are
IV the lymph nodes along the external iliac artery and vein up to their entrance

64 into the lacuna vasorum, the lymph nodes of the obturator fossa ventral to the
obturator nerve, and, from this point, the lymph nodes along the internal iliac
vessels to the iliac bifurcation. Dissection of the lymph nodes along the com-
mon iliac vessels is also a part of pelvic lymphadenectomy. A total of 15 lymph
nodes must be removed from this space, which represents a thorough but not
ultraradical lymphadenectomy. Removing more than 15 lymph nodes entails a
higher risk of lymphedema in the lower extremities. Where there is underlying
oncologic disease, a 10% incidence of lymphedema, including mild cases, is
considered acceptable.

Para-aortic and paracaval lymphadenectomy. In para-aortic and paracaval lym- Fig. 4-1-5 The presentation follows the cus- sels, which are easy to expose by dissection;
phadenectomy, the ureters are displaced to the side, the abdominal aorta is ex- tomary anatomic illustrations. It is important 1 = cranial limit of the lymphadenectomy; 2 =
to note the close association of the individual, paracaval and para-aortic lymph nodes; 3 =
posed, the branching of the inferior mesenteric artery is exposed, and the aorta
hard-to-represent lymph nodes with the ves- lymph nodes of the common iliac vessels.
is dissected free in a cranial direction as far as the crossing of the left anterior
renal vein, by removal of the lymphatic and fat tissue. Similarly, complete dis-
section of the inferior vena cava to this cranial boundary is sufficient. In the
process, the right ovarian artery and vein must (again) be ligated or coagulated. should also be removed. Ultraradical removal of the interaortocaval lymph
Here too, removal of 10 lymph nodes is required. According to the rather sparse nodes as well as of the retrocaval and retroaortic lymph node chains does not
literature, the removal of these additional nodes does not elevate the incidence seem absolutely necessary.
of lymphedema. Especially in ovarian cancer, all clinically affected lymph nodes

4.1.2 Functional Pathology

4.1.2.1 Ovaries

The gynecologic surgeon is responsible for managing ovarian cysts which are liferation phase (and often continue this function in the form of pathologic tu-
most often functional in nature. Persistent follicular cysts and symptomatic mors) and theca cells. Theca cells, particularly in the theca interna zone, par-
corpus luteum cysts are the most frequently occurring examples and will likely ticipate in the production of important estrogen precursors and are an integral
resolve spontaneously. Nonfunctional endometriotic cysts, as well as serous part of follicle formation and, as theca lutein cells in the corpus luteum, of pro-
and mucinous cystadenomas, are common examples of ovarian tumors that re- gesterone formation.
quire surgical removal.
Persistence of follicles. Persistent follicle cysts or corpus luteum cysts are the
Hormone-producing cells. The hormone-producing cells within the ovary are most frequent nonneoplastic functional ovarian tumors. When follicles persist
classified as granulosa cells and are the main producers of estrogen in the pro- over a period of 68 weeks, increased amounts of estrogen can be continuously
IV Adnexa 4.1 Preliminary Remarks about the Region

released, leading to significant bleeding disorders. The diagnosis of functional the principal target organ, the endometrium, can lead to hyperplastic and pro-
cyst is always a diagnosis based on suspicion that can only be confirmed in the liferative changes, up to and including endometrial cancer.
clinical course by spontaneous resolution of the cyst. Whether and when
change in a cyst in the adnexa must be further investigated by standard inter- 4.1.2.2 Fallopian Tubes
vention laparoscopy depends on the subjective symptoms, suspicion of an in-
flammatory event, the age of the patient, the length of the observation period, The fallopian tubes are an important point of origin of functional diseases that
and the size of the cyst and duration of persistence. The following require in- play a large role in general gynecology: adnexitis as a result of ascending infec-
vestigation: tions, usually initially sexually transmitted, is frequently an indication for diag-
Postmenopausal, cystic space-occupying lesions, regardless of their size nostic laparoscopy because of acute or chronic pain. In the long term, further
Cysts larger than 5 cm therapeutic challenges are presented by secondary formation of adhesions
Persistent cysts that are still detectable after two menstrual cycles and resulting infertility. Another consequence of often subclinical changes in
Symptomatic cysts the fallopian tubes is extrauterine pregnancy (EUP), which today is treated al-
Loculated cysts with internal echoes most exclusively with laparoscopy. Diagnosis of EUP in premenopausal women
Cysts with associated elevated tumor markers is very important, as it is the chief cause of death in the first trimester of preg-
Cystic changes in patients with other malignancies nancy. As the chief approach for permanent sterilization, the fallopian tubes are
worldwide one of the most frequent target organs for surgical procedures. In
Hormone-producing neoplasms. Hormone-producing neoplasms are very rare. addition to the classic laparoscopic sterilization techniques, new hysteroscopic IV
sterilization approaches, also involving treatment by obliteration of the tubal
The most frequently occurring estrogen-producing neoplastic tumor is the 65
granulosa cell tumor. In these tumors, unphysiologic estrogen stimulation of lumen, are coming into use.

4.1.3 Morphologic PathologyHistology


The ovaries consist of an epithelial sheath originating from the peritoneum and Table 4.1.2 Histopathology of ovarian neoplasms (representative selection according
to the World Health Organization [WHO])
a connective tissue stroma in which are found the ova and also various cells of
the so-called sex cord stroma. All these cell types can develop into benign, ma- Type Examples
lignant, and sometimes borderline neoplasms. The histopathologic differential
Epithelial/peritoneal Serous cystadenoma, serous cystadenocarcinoma
diagnosis of ovarian diseases is therefore one of the most demanding areas of coat Mucinous cystadenoma, mucinous cystadeno-
pathology. The peak frequencies of the various tumors are strongly age depen- carcinoma
dent. Endometrioid tumors
Clear cell tumors
Transitional cell tumors (Brenner tumors)
Tumors. Epithelial tumors represent about 70% of all ovarian tumors and con-
Squamous epithelial carcinomas
stitute almost 90% of all malignant tumors. Most epithelial neoplasms are se-
rous tumors followed by mucinous and endometriotic tumors, and less fre- Sex cord stromal cells Granulosa cell tumors, thecomas
quently occurring, clear cell, transitional cell, and mixed cell type tumors. Tu- Sertoli cell tumors

mors of epithelial origin can be benign, malignant, or borderline. In sex cord Gynandroblastomas
Steroid cell tumors
stromal tumors, originating in granulosa cells and thecal cells, the most com-
mon forms are granulosa cell tumors, thecomafibroma tumors, and andro- Germ cells Dysgerminomas
blastomas (SertoliLeydig cell tumors). Germ cells can become dysgermino- Teratomas
mas, teratomas, chorionic carcinomas, and so-called endodermal sinus tumors Yolk sac tumors

(yolk sac tumors). The mature cystic teratoma (dermoid) is the most frequently Connective tissue cells Fibromas
occurring (benign) ovarian tumor in young women. Fibrosarcomas
Leiomyomas
Endometriosis. An important disease in the functionalmorphologic border Metastatic tumors Krukenberg tumor (metastasis of a mucinous
area is endometriosis, which often manifests clinically as a cystic ovarian tumor primary tumor of the gastrointestinal tract,
historically of a gastric cancer)
(endometrioma). The various forms and degrees of severity as well as the cor-
Metastatic breast cancer
responding therapeutic approaches are discussed in this chapter, even though
Metastasis of an endometrial cancer
the problematic forms of endometriosis extend far beyond the adnexa.
Metastasis of a pancreatic cancer
IV Adnexa 4.1 Preliminary Remarks about the Region

4.1.4 Terminology and Diagnosis

4.1.4.1 Stages and Classification of Endometriosis Table 4.1.3 Classification of endometriosis according to the American Society of Re-
productive Medicine

There are numerous classifications of endometriosis, three of which are pre- Endometriosis < 1 cm 13 cm > 3 cm
sented here. Peritoneum
Superficial 1 2 4
ASRM classification. The severity of endometriosis is categorized according to Deep 2 4 6
the Revised American Society for Reproductive Medicine Classification of En-
dometriosis dating from 1996. Points are assigned depending on the involve- Ovary
ment of the peritoneum, the ovaries, and the tubes. The endometriosis is clas- Right superficial 1 2 4
sified into one of four stages depending on the total of points assigned: mild, Right deep 4 16 20
moderate, severe, or extensive. The widespread ASRM classification documents Left superficial 1 2 4
only superficially visible intraperitoneal endometriosis. The deep extent of the Left deep 4 16 20
IV endometriosis that can be diagnosed by gynecologic palpation or imaging pro-
Olbiteration of the Partial = 4 Complete = 40
66 cedures is insufficiently reflected in the ASRM score.
pouch of Douglas
Adhesions < >
ENZIAN score. The ENZIAN score was introduced in 2003 as an alternative clas-
of the region of the region of the region
sification system (Tab. 4.1.4). Aim is to document pronounced findings of en-
Ovary
dometriosis and to classify them in stages (Stages 14) according to symptoms.
Right slight 1 2 4
The ENZIAN score, as a supplement to the ASRM classification, can more pre-
Right dense 4 8 16
cisely record deeply infiltrating, retroperitoneal endometriosis and direct it to
Left slight 1 2 4
suitable stage-adapted therapy.
Left dense 4 8 16

AAGL Endometriosis Classification. This classification was published in 2013 and Fallopian tube
has a greater association with pain and infertility than the ASRM classification Right slight 1 2 4
and the ENZIAN score and will likely be the standard method of endometriosis Right dense 4 8 16
classification at the time of this publication. Left slight 1 2 4
Left dense 4 8 16
Fallopian tube 16 16
4.1.4.2 Stages of Fallopian Tube Carcinoma completely blocked

Endometriosis stage Points


Fallopian tube carcinoma is rare and represents only about 0.3% of all genital
I (minimal) 15
cancers. Often it cannot be clinically distinguished from ovarian cancer. The
treatment is identical. The staging corresponds almost exactly to the Fdra- II (slight) 615

tion Internationale de Gyncologie et dObsttrique (FIGO) classification of III (moderate) 1640

ovarian cancer. IV (serious) > 40

Table 4.1.4 ENZIAN score

Stage 1 E1a = isolated endometriotic nodule E1b = isolated endometriotic nodule E1bb = bilateral infiltration of the E1c = isolated endometriotic nod-
in the pouch of Douglas peritoneum < 1 cm at the sacrouterine ligament sacrouterine ligament < 1 cm ule in the rectovaginal space

Stage 2 E2a = infiltration of the upper third E2b = infiltration of the sacrouterine E2bb = bilateral infiltration of the E2c = infiltration of the rectum
of the vagina ligament > 1 cm sacrouterine ligament > 1 cm < 1 cm

Stage 3 E3a = infiltration of the middle third E3b = infiltration of the cardinal E3bb = bilateral infiltration of the E3c = infiltration of the rectum
of the vagina ligament (without hydronephrosis) cardinal ligaments 13 cm without stenosis

Stage 4 E4a = infiltration of the uterus and/or E4b = infiltration of the cardinal E4bb = bilateral infiltration of the E4c = infiltration of the rectum
the lower third of the vagina ligament as far as the pelvic wall cardinal ligaments as far as the pelvic > 3 cm and/or stenosis of the
and/or hydronephrosis walls rectum

FA = adenomyosis of the uterus FB = deep infiltration of the urinary FU = infiltration of the ureter FI = intestinal involvement
bladder (opposite rectum/sigmoid)

FO = other localization, x = unknown stage

a = involvement of pouch of Douglas/vagina; b = involvement of the sacrouterine ligament, cardinal ligament; c = involvement of the rectum, sigmoid.
IV Adnexa 4.1 Preliminary Remarks about the Region

4.1.4.3 Stages of Ovarian Cancer

All malignant ovarian tumors are classified according to the same FIGO/TNM correspond to the standard procedures established in the guidelines; some of
system. For precise evaluation of the prognosis, histologic classification and them are options that can be appropriately applied in individual cases.
grading are also required. The surgical possibilities presented here currently

Table 4.1.5 Stages of ovarian cancer according to FIGO (Fdration internationale de gyncologie et d'obsttrique)

Stage Extent Possible operations


I Cancer is strictly limited to the ovaries (Peritoneal cytology and peritoneal biopsies are standard in all stages
and are no longer separately listed)

IA Limited to one ovary, no ascites, capsule intact, To spare fertility and in clearly premenopausal patients: hysteroscopy,
no tumor on the surface of the ovary fractionated curettage, unilateral adnexectomy, contralateral biopsy of ovary,
infracolic omentectomy, pelvic and para-aortic lymphadenectomy
Otherwise: hysterectomy, bilateral adnexectomy, pelvic and para-aortic
lymphadenectomy, omentectomy
Laparoscopic procedure is possible but opinions vary
IV
IB Limited to both ovaries, no ascites, capsule intact, Fertility sparing not advised
no tumor on the surface of the ovary Hysterectomy, bilateral adnexectomy, pelvic and para-aortic lymphadenectomy,
67
omentectomy
Laparoscopic procedure is possible but opinions vary

IC Tumor I A or I B, but with ruptured capsule, Fertility sparing not advised


positive peritoneal cytology; tumor on the ovarian surface Hysterectomy, bilateral adnexectomy, pelvic and para-aortic lymphadenectomy,
omentectomy

II Cancer affects one or both ovaries with spread Vertical laparotomy, hysterectomy, bilateral adnexectomy, pelvic and para-aortic lym-
to the pelvic space phadenectomy, omentectomy, resection or destruction of all visible tumor fragments

II A Spread to uterus and tubes Vertical laparotomy, hysterectomy, bilateral adnexectomy, pelvic and para-aortic
lymphadenectomy, omentectomy
Resection or destruction of all visible tumor fragments

II B Spread to pelvic peritoneum Vertical laparotomy, hysterectomy, bilateral adnexectomy, pelvic and para-aortic
lymphadenectomy, omentectomy
Resection or destruction of all visible tumor fragments, including resection of bladder
peritoneum and resection of lesions within the pouch of Douglas, if involved

II C II A or II B with positive peritoneal cytology As for II B

III Peritoneal metastasis outside the pelvis and/or affected Vertical laparotomy, hysterectomy, bilateral adnexectomy, pelvic and para-aortic
retroperitoneal/inguinal lymph nodes; superficial liver lymphadenectomy, omentectomy
metastases are still stage III Resection or destruction of all visible tumor fragments: typical ovarian cancer debulking

III A Tumor macroscopically present in lower pelvis with microscopically Vertical laparotomy, hysterectomy, bilateral adnexectomy, pelvic and para-aortic
detectable seeding to abdominal peritoneum and negative lymph lymphadenectomy, infragastric omentectomy
nodes Resection or destruction of all visible tumor fragments: typical ovarian cancer debulking

III B Tumor macroscopically visible in lower pelvis with seeding Vertical laparotomy, hysterectomy, bilateral adnexectomy, pelvic and para-aortic
to abdominal peritoneum < 2 cm and negative lymph nodes lymphadenectomy, infragastric omentectomy
Resection or destruction of all visible tumor fragments: typical ovarian cancer debulking

III C Abdominal seeding > 2 cm and/or positive retroperitoneal/ Most frequent clinical stage: typical ovarian cancer surgery.
inguinal lymph nodes Objective: only microscopic tumor residue
Vertical laparotomy, hysterectomy, bilateral adnexectomy, pelvic and para-aortic
lymphadenectomy, infragastric omentectomy
Resection or destruction of all visible tumor fragments, including diaphragmatic
peritoneum
Intestinal resection in 30%, splenectomy in 10%

IV Spread to extra-abdominal organs (distant metastases, Individualized operation in the case of exclusively pleural involvement, if appropriate,
metastases to hepatic parenchyma) including pleural effusion operation typical for ovarian cancer
with positive cytology
4.2 Concepts for Surgical
TreatmentProcedure Navigator
IV
68

Therapeutic Goals

The ovaries and fallopian tubes are the origin of numerous functional disorders
as well as benign and malignant tissue changes. The therapeutic goal is either
to re-establish the physiologic situation or to remove the diseased organ. The
surgical treatment possibilities range from minimally invasive diagnosis to typ-
ical ovarian cancer debulking surgery. In the following, the various surgical ap-
proaches to the most important pathologic changes are summarized.
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

AnatomicMorphologic Procedure Navigator

Functional diseases Endometriosis


ADNEXA

Endometriotic cysts
Benign neoplasms
Pouch of Douglas endometriosis
Malignant neoplasms Endometriosis, infertility, pain
Sterilization/refertilization
Ectopic pregnancy

Functional Diseases Endometriosis Endometriotic Cysts

Endometriosis is a frequent disease with an incidence of up to Surgical Repertory Abdominal approach and cystectomy IV
20% of women of reproductive age. Both the objective severity only in exceptional situations with 69
of the disease and the subjective pain vary strongly from patient associated diseases or deep, infiltrating
to patient. A cardinal symptom is initially pain associated with endometriosis p. 82
menstrual periods. Findings on imaging are unremarkable or ho- Laparoscopic cystectomy or cyst
mogeneous with the exception of echo-dense ovarian cysts fenestration p. 155
(chocolate cysts) which can be seen via a sonographic image of
the ovary. Histologically, endometriosis is defined as endometri-
al glands and stroma outside the uterus. These are hormone-sen- Operation of Choice
sitive cells and subject to cyclical changes. The two competing
theories of pathogenesis are the theory of intra-abdominal Laparoscopic diagnosis and histologic
spread and implantation in retrograde menstruation and the confirmation of endometriosis
theory of local metaplasia. Over 90% of all endometriosis is found If necessary adhesiolysis and mobilization
in the peritoneal cavity. On or in the ovary, cyclically active endo- of adnexa frequently retracted into the pouch
metrium can lead to the growth of endometriotic cysts, filled of Douglas
with old menstrual blood that present a relatively typical sono- Evaluation of the need for further, radical
graphic picture, but can be confused with a hemorrhagic corpus interventions (in two stages)
luteal cyst. The hemorrhagic corpus luteal cyst will resolve spon- Opening of the endometriotic cyst, resection
taneously, while it is unlikely the endometrioma will resolve or coagulation of the endometrioid tissue
without surgical intervention.
Abdominal treatment. Where laparoscopy is available, abdominal
therapy of advanced stage endometriosis should be reserved for
exceptional cases, such as cases with associated deep, infiltrating
endometriosis that require intestinal resection or an experi-
enced laparoscopic surgeon is not available.
Vaginal treatment. Ovarian endometriomas cannot be removed
vaginally. Local vaginal foci of endometriosis are rare. More fre-
quently deep, infiltrating endometriosis of the rectovaginal sep-
tum receives combined abdominal and vaginal treatment.
Laparoscopic treatment. Primary diagnosis and therapy of all
stages of endometriosis is preferentially performed laparoscop-
ically. Primary ovarian cysts that are not suspected of being ma-
lignant but that require treatment should be investigated laparo-
scopically and optimally treated by this method.
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

Functional Diseases Endometriosis Pouch of Douglas Endometriosis

The pouch of Douglas and the rectovaginal septum are the prin- Surgical Repertory Transverse laparotomy and
cipal localization of deep, infiltrating endometriosis, with or resection of endometriosis p. 106
without infiltration of the rectosigmoid muscularis and/or mu- Laparoscopy and endometriosis
cosa. Although the hormone-sensitive endometrioid tissue is resection p. 182
the cause of the disease, the pathologic correlate after a number
of years often consists only of fibrotic scar tissue plaques that
must be removed if symptomatic. Because of the significant Operation of Choice
number of adhesions and the widespread loss of layers, the sur-
gery is technically demanding and usually includes extensive Laparoscopic evaluation, adhesiolysis, histologic
ureterolysis as far as the Wertheim tunnel (within the cardinal confirmation, exposure of the course of the
ligament), moving the ureters aside; partial resection of the sac- ureter, opening of rectovaginal septum, and
routerine ligaments and lesions within the pouch of Douglas; radical endometriosis resection, if necessary
and a resection of the disease within the rectovaginal septum. with interdisciplinary surgical approach
IV In cases where the endometriotic lesions are invading the intes- (partial intestinal resection and reanastomosis)
70 tinal serosa, muscularis, and mucosa, a partial intestinal resec-
tion, or discectomy, or a segmental resection with end-to-end/
lateral anastomosis is required. Although severe endometriosis
is associated with an elevated risk of ovarian cancer or primary
peritoneal cancer, it is nevertheless considered a non-malignant
disease. Therefore, it is the patients symptoms that must be
treated, not the objective, demonstrable disease. This is especial-
ly true for highly invasive surgical interventions entailing possi-
ble complications. Hysterectomy or even adnexectomy should
not be planned as a first line measure in premenopausal women
desiring to maintain their fertility.
Abdominal. In abdominal procedures, a transverse laparotomy is
performed and the endometriosis is resected. If necessary, resec-
tion of lesions within the pouch of Douglas and/or resection of a
portion of the intestine must be performed.
Vaginal. In cases of endometriosis infiltrating the vagina or deep
endometriosis in the rectovaginal septum, the approach is often
a combination of vaginal and abdominal (partial resection with
vaginal approach).
Laparoscopic. The laparoscopic procedure, like the abdominal
operation, includes endometriosis resection and, where neces-
sary, resection of lesions within the pouch of Douglas and/or
partial intestinal resection.
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

Functional Diseases Endometriosis Endometriosis, Infertility, and Pain

The clinical spectrum of endometriosis is broad and the clinical Surgical Repertory Hysteroscopy, diagnostic laparoscopy
picture is not always correlated with the surgical stage of the dis- and chromopertubation, laparoscopic
ease. Often mild forms, i.e., those not associated with severe scar- endometriosis treatment p. 134, 182
ring, primarily exhibit pain and reduced fertility that has also In conditions of chronic pain and
been demonstrated in studies. This must be clarified first of all after exhaustion of other options,
with diagnostic laparoscopy combined with a diagnosis of infer- where appropriate, laparoscopic,
tility. In particular, the possible factor of tubes narrowed by ad- abdominal, or vaginal
hesions must be checked and other causes of infertility must be hysterectomy p. 225, 283, 335
ruled out. Even small endometriotic foci should be treated. Re-
section of the lesions is preferable to coagulation since many of
these lesions are deeper than expected and only the surface can Operation of Choice
be visualized. In patients with chronic pain, the overall situation
must be discussed. Here the patients wish for definitive therapy First laparoscopic clarification,
by hysterectomy and adnexectomy can be beneficial if the pa- where necessary also of infertility, IV
tient has completed childbearing. then a renewed decision process 71
Abdominal. An abdominal approach is not the operation of together with the patient
choice either for patients with infertility as the primary problem
or for patients in chronic pain. At the patients wish, abdominal
hysterectomy, with or without removal of the adnexa, may be
appropriate.
Vaginal. In patients suffering from chronic dysmenorrhea with
no intention of having more children (and without severe endo-
metriosis), vaginal hysterectomy is a possible operation. Where
there is a suspicion of endometriosis, a laparoscopic evaluation
of the abdominal cavity should at least be considered.
Laparoscopic. Laparoscopy is the technique of choice for an exact
diagnosis, clarification of infertility, grading of the endometrio-
sis, and, where appropriate, immediate treatment of the endo-
metriosis.
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

Functional diseases Endometriosis


ADNEXA Sterilization/refertilization
Benign neoplasms
Possibilities for sterilization
Malignant neoplasms Fertility surgery
Ectopic pregnancy

Functional Diseases Sterilization/Refertilization Possibilities for Sterilization

Every year, about 135 million children are born worldwide. Hu- Surgical Repertory Laparoscopic partial or total
mane and safe obstetric help for mother and child is one of the salpingectomy p. 151
noblest tasks of our field. Regardless of the cultural sphere, ad- Laparoscopic tubal ligation
vances in society, economic as well as social, lead to a more con- with clips or silastic rings p. 151
scious view of the family unit. The more respect a prosperous so- Laparoscopic tubal ligation p. 151
IV ciety allots to the life of each individual, the more pronounced Tubal ligation/destruction during

72 the concept of parental responsibility. This is accompanied by a cesarean section p. 96


wish for secure contraception and, when there is no desire for Postpartum tubal ligation by
additional children, by the wish for definitive prevention of preg- infraumbilical minilaparotomy p. 96
nancy. It is interesting to note that these mechanisms seem to be Hysteroscopic insertion of
completely independent of ethnic and cultural traditions. Pro- a tube-occluding stent
viding secure and, if desired, permanent means of contraception,
is thus another highly responsible task of gynecology, especially
with regard to its significance for the social status of the individ- Operation of Choice
ual woman. The surgical approach to this task is based on func-
tional or structural suppression of the fallopian tubes. Laparoscopic tubal coagulation
Abdominal. A partial or complete salpingectomy or tubal ligation
can be performed during a cesarean section. A partial salpingec-
tomy is also possible immediately after a vaginal delivery, by
means of an infraumbilical minilaparotomy.
Vaginal. Although transvaginal surgical sterilization techniques
that open the pouch of Douglas have long been in existence,
they have not become routine. It may be that a new chapter will
be opened by hysteroscopic insertion of transluminal stents that
occlude the tube internally. This is a safe method for the future
that can be implemented on an outpatient basis.
Laparoscopy. Laparoscopic sterilization by partial salpingectomy,
ligation of the tubes with clips or rings, or coagulation of the
tubes are the sterilization methods of choice.
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

Functional Diseases Sterilization/Refertilization Fertility Surgery

The failure to have children can have many causes. In addition to Surgical Repertory Transverse laparotomy and tubal
hormonal irregularity, structural uterine pathologies (submu- reanastomosis p. 100
cosal myoma, uterine malformations) or pathologic changes in Surgery of uterine malformations p. 259
the tubal factor (postinfectious conditions and tubal stenosis, ad- Laparoscopic diagnosis and
hesions, sactosalpinx) can play a role. Many of these changes chromopertubation p. 134
could be treated. At present, the solutions offered by reproduc- Laparoscopic tubal reanastomosis p. 146
tive medicine usually have priority in fertility problems. The
classical surgical fertility procedure of tubal anastomosis has
largely given way to concomitant fertility surgery such as myo- Operation of Choice
mectomy, opening or removal of sactosalpinges, and laparoscop-
ic diagnosis of the underlying problem. Laparoscopic diagnosis, chromopertubation,
Abdominal. Abdominal surgery with transverse laparotomy and associated techniques (adhesiolysis,
open tubal reanastomosis has long been the standard fertility salpingotomy/salpingectomy)
surgery but because the success rate is never certain in individu- If tubal reanastomosis is desired: IV
al cases, and because it is an extremely invasive procedure, it is open procedure with surgical microscope 73
now reserved for special cases.
Vaginal. Trans-Douglas endoscopy, a primarily diagnostic, outpa-
tient procedure, is an established technique but not (yet) in
widespread use.
Laparoscopic. In addition to diagnostic laparoscopy and chromo-
pertubation for assessment of the tubal factor, laparoscopic tubal
reanastomosis is an alternative to the reproductive medicine
techniques. It is technically demanding, but its degree of inva-
siveness is acceptable.
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

Endometriosis
ADNEXA
Functional diseases
Sterilization/refertilization
Benign neoplasms
Ectopic pregnancy
Malignant neoplasms Tubal pregnancy
Extratubal ectopic pregnancy

Functional Diseases Ectopic Pregnancy Tubal Pregnancy

The incidence of EUP is listed at 1020 per 1000 pregnancies. In Surgical Repertory Exploratory laparotomy, hemostasis,
95%97% of cases, this will be a tubal pregnancy. Before introduc- salpingotomy, salpingectomy p. 90
tion of a comprehensive diagnosis of pregnancy by hCG detec- Laparoscopic salpingotomy
tion in the urine or serum and transvaginal ultrasound, EUP was vs. salpingectomy p. 175
usually only noticed after rupture as an acute abdomen with ac-
IV companying symptoms of shock. Exploratory laparotomy with

74 salpingectomy of an already largely destroyed tube was stan- Operation of Choice


dard. The earlier diagnosis together with laparoscopy led to the
current standard of minimally invasive and tube-sparing diagno- Diagnostic laparoscopy
sis and treatment. In an asymptomatic patient, the following ap- Tube-sparing laparoscopic salpingotomy
plies: from a serum hCG value above 1500 IU/L and a uterine
cavity seen as empty in vaginal sonography, without previous se-
vere bleeding, there is a suspicion of an EUP. Sonography primar-
ily provides evaluation of the uterine cavity. The EUP can be seen
sonographically; unremarkable adnexa never rule out EUP.
Abdominal. At present, laparotomy is an exceptional procedure
for salpingectomy or salpingotomy.
Vaginal. Previously, puncture of the pouch of Douglas with aspi-
ration of blood was an important diagnostic step.
Laparoscopic. Laparoscopic treatment is the standard for diagno-
sis and therapy, from the patient with an acute abdomen to the
asymptomatic patient with hemoperitoneum. Salpingotomy or
salpingectomy are the surgical treatments.
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

Functional Diseases Ectopic Pregnancy Extratubal Ectopic Pregnancy

Over 95% of all extrauterine pregnancies are tubal pregnancies Surgical Repertory Exploratory laparotomy
Of the remaining 5%, most are pregnancies in the horns of the and resection of the EUP p. 90
uterus (2%4%) or in the ovaries (0.5%). Cervical pregnancies oc- Laparoscopic diagnosis
cur in 0.1% of cases. If diagnosis is made early enough, therapy and resection p. 175
consists of laparoscopic resection of the pregnancy and, when
appropriate, concomitant resection of a portion of the uterus
and subsequent reconstruction of the uterus. Cervical pregnan- Operation of Choice
cies are treated with drugs and surgery, as the individual case re-
quires. Peritoneal, mesenteric, or hepatic pregnancies occur only Laparoscopic diagnosis
sporadically, worldwide, and must be approached individually and resection of the EUP
with medication (chemotherapy, e.g., methotrexate) and inter-
disciplinary surgery as the case requires.

IV
75
Functional diseases Functional cysts
ADNEXA

Follicular cysts, corpus luteum cysts


Benign neoplasms
Persistent cysts
Malignant neoplasms Benign neoplasms
Inflammatory adnexal tumors

Benign Neoplasms Functional Cysts Follicular Cysts, Corpus Luteum Cysts

Ovarian cysts are among the most frequently encountered prob- Surgical Repertory Abdominal exploration in
lems in gynecology. A large proportion of adnexal cysts that can confirmed malignancy p. 111
be visualized sonographically are physiologic. The decisive fac- Vaginal extirpation as part
tors are operability on the one hand and the risk of malignancy of a vaginal hysterectomy p. 131
in complex cysts on the other hand. It is always true that post- Laparoscopic management/
menopausal cysts, independently of their size, should always be Laparoscopic cyst extirpation p. 155
investigated, as there is no physiologic explanation for them.
While many feel all these cysts in postmenopausal women
should be surgically removed, others agree that small (< 4 cm) Operation of Choice
stable simple cysts that do not change in size can be monitored
by ultrasound in patients with a normal CA125. In a patient Laparoscopic diagnosis and
with normally active ovaries (premenopausal), simple cysts larg- laparoscopic cyst extirpation
er than 5 cm should be investigated if they persist for more than
two cycles. Complex loculated cysts and cysts with polypoid or
solid portions must always be evaluated diagnostically and his-
tologically. The most frequent functional cyst type is the simple
follicular cyst filled with serous fluid and the corpus luteum cyst
that sometimes can only be distinguished from an endometriotic
cyst histologically.
Abdominal. Abdominal exploration is only indicated in strong Vaginal. Vaginal cyst extirpation is
primary suspicion of a malignancy (complex cystic findings, as- usually only performed as part of a
cites, elevated CA125). As on occasion Chlamydia infections or vaginal hysterectomy.
endometriosis can simulate such a combination, diagnostic lapa- Laparoscopic. Diagnostic laparoscopy
roscopy should be the primary approach at the slightest suspi- and therapeutic laparoscopic cyst ex-
cion of an underlying oncologic disease. tirpation are the methods of choice.
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

Benign Neoplasms Functional Cysts Persistent Cysts

Complex adnexal cysts such as loculated cysts, cysts with inter- Surgical Repertory Laparoscopic investigation p. 155
nal echoes, polypoid structures or solid portions, and cysts with
associated ascites or elevated CA125 are definitely worth investi-
gating. In postmenopausal patients, even simple cysts should be Operation of Choice
promptly investigated. Persistent simple adnexal cysts can be
persistent follicular cysts, often associated with bleeding anoma- Laparoscopy and laparoscopic cyst
lies, but also paratubal cysts. At a size upwards of 5 cm and with extirpation, if necessary with recurrence,
persistence, investigation is advisable, especially if the cyst fails postmenopausal/perimenopausal patient,
to disappear over a number of cycles. in case of family and/or personal history
of breast cancer/ovarian cancer, combined
with adnexectomy

IV
76
Functional diseases Functional cysts
ADNEXA

Benign neoplasms
Benign neoplasms
Serous and mucous cystomas
Malignant neoplasms Benign sex cord stromal and germ cell tumors
Rare histologies
Inflammatory adnexal tumors

Benign Neoplasms Benign Neoplasms Serous and Mucous Cystomas

Serous and mucous cystadenomas are true epithelial benign ne- Surgical Repertory Vertical laparotomy and
oplasms that are chiefly noticed in vaginal sonography as com- adnexectomy combined with
plex loculated adnexal tumors, often with internal echoes or sol- hysterectomy, depending on
id and polypoid portions. Usually there are no signs of either as- the clinical situation p. 86, 111
cites or elevated CA125. In differential diagnosis, and taking into Laparoscopic diagnosis, combined,
account the patients age, they must be distinguished from depending on the clinical situation,
blood-filled cysts, dermoid cysts, borderline tumors, and early with laparoscopic cystectomy/
ovarian cancers, but a definite distinction can only be made by adnexectomy and retrieval
the pathologist. On the basis of the sonographic findings, these of the tumor p. 134, 170
adnexal tumors always require investigation. The critical ques-
tion is the surgical approach. Cystadenomas can be huge, as
they grow slowly and do not metastasize. Tumors with a weight Operation of Choice
of more than 10 kg and a diameter of over 50 cm have been de-
scribed, but these cases have become rare as a result of improved Laparoscopic evaluation of the finding
medical care. If no evidence of malignancy, laparoscopic
Abdominal. Where there is serious suspicion of malignancy, ex- adnexectomy or cystectomy in young patient
ploratory vertical laparotomy is the approach of choice. This Laparoscopic. Method of choice for If necessary, two-stage procedure in the short
makes an immediate total operation possible, with adnexectomy evaluation, especially in unclear sit- term
and if appropriate, hysterectomy as well as pelvic and para-aortal uations. Intraoperative decision re-
lymphadenectomy and omentectomy, depending on the onco- garding cystectomy vs. adnexectomy
logic situation. The advantage is the technically simple and rup- or laparoscopic procedure or extirpa-
ture-free removal of the tumor. tion by laparotomy.
Vaginal. The vaginal approach, for example, as part of a vaginal
hysterectomy, should not be selected in case of a complex adnex-
al tumor.
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

Benign Neoplasms Benign Neoplasms Benign Sex Cord Stromal and Germ Cell Tumors

Sex cord stromal tumors constitute about 4% of all ovarian tu- Surgical Repertory Where malignancy is certain,
mors. They originate in the various hormonally active cells of vertical laparotomy and typical
the ovary. The most frequently occurring tumor is the granulosa ovarian cancer surgery p. 111
cell tumor, a tumor that is almost always estrogen-producing Otherwise, primary laparoscopic
and of unclear status. Much rarer are thecomafibroma tumors, procedure and intraoperative
androblastomas (also known as SertoliLeydig cell tumors), decision p. 134, 155, 170
some of which are androgen-producing, and gynandroblasto-
mas, a combination of the above-named types. Germ cell tumors
constitute about 15% of all ovarian tumors. The most frequently Operation of Choice
occurring form is the mature cystic teratoma that is also called
dermoid and is the most frequent (benign) ovarian tumor of the Laparoscopic cystectomy/adnexectomy
third decade of life. Much rarer are malignant germ cell tumors
such as immature malignant teratomas, dysgerminomas, endo-
dermal sinus tumors, and embryonic carcinomas. As always, the IV
final classification is histologic. Management of these neoplasms, 77
appearing clinically as complex adnexal tumors, is governed by
the general rules of laparoscopic adnexal surgery. If there is a
suspicion of malignancy, and if laparoscopic removal without
rupture does not seem possible: laparotomy. In case of accidental
rupture and malignancy on frozen section: oncologically ade-
quate completion of the operation within 7 days.

Benign Neoplasms Benign Neoplasms Rare Histologies

While clinical management of the adnexal tumor, depending on Surgical Repertory Exploratory laparotomy in case
the patients age and the suspicion of malignancy, can be difficult of malignancy or a borderline situation p. 111
from case to case, the treatment after a confirmed histopatholog- Laparoscopic management of
ic diagnosis follows clear guidelines. Ovarian malignancies are benign tissue, borderline tissue
treated with typical ovarian cancer surgery with the goal of max- or early ovarian cancer (FIGO I) p. 170
imal tumor reduction in combination with hysterectomy, adnex-
ectomy, pelvic and para-aortic lymphadenectomy, and omentec-
tomy. In early ovarian cancers as well as borderline tumors, Operation of Choice
equivalent staging can be performed by laparoscopy as a matter
of principle. There are no clinical studies available yet on this Laparoscopic management of benign
subject. Nonmalignant tumors can definitely be treated laparo- tissue
scopically. In cases of benign neoplasia, depending on the pa-
tients age, (unilateral) adnexectomy should be considered be-
cause of the risk of recurrence. In all benign tumors, preservation
of the ovary is definitely possible. Special care should be taken
with metastases of other malignancies in the ovary, particularly
breast cancer metastases. For every suspicious finding in the ad-
nexa, an updated check-up of the breasts by mammography/so-
nography is obligatory. Some rare histologies are ovarian fibro-
ma, ovarian myomas, and lymphatic and neuronal tumors.
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

Functional diseases Functional cysts


ADNEXA Benign neoplasms
Benign neoplasms
Inflammatory adnexal tumors
Malignant neoplasms Adnexitis
Tubo-ovarian abscess

Benign Neoplasms Inflammatory Adnexal Tumors Adnexitis

Inflammatory diseases of the internal genitalia such as adnexitis Surgical Repertory Exploratory laparotomy in situations
are frequent and extremely varied in their clinical presentation: where laparoscopic surgery is not
both completely asymptomatic fallopian tube inflammation and possible or a laparoscopy is not
typical adnexitis with pain in the lower abdomen, abnormal possible and there is an urgent
inflammatory parameters, pain on displacement of cervix in indication for surgery p. 82
IV gynecologic examination, and fever or tubo-ovarian abscess Laparoscopy for confirmation

78 with accompanying peritonitis and extensive systemic involve- of diagnosis before antibiotic
ment are possible. The danger of adnexitis without suspected therapy (smears, microbiology) p. 134
suppuration is, on the one hand, the possibility of abscess forma-
tion and intraperitoneal spread in the course of the disease, and
on the other hand, even with a specific clinical picture, the risk of Operation of Choice
irreversible damage to the fallopian tubes with resulting tubal
sterility or increased risk of tubal pregnancies. The diagnostic Diagnostic laparoscopy
gold standard is diagnostic laparoscopy, which can also establish
a differential diagnosis between adnexitis, appendicitis, sigmoid
diverticulitis, or abscess.
Abdominal. Exploratory laparotomy is only performed if laparos-
copy is impossible.
Vaginal. In these cases, the vaginal approach is not appropriate.
Laparoscopic. Laparoscopy is the method of choice for diagnosis
and treatment.

Benign Neoplasms Inflammatory Adnexal Tumors Tubo-Ovarian Abscess

Pyosalpinx and tubo-ovarian abscesses are end stages of relaps- Surgical Repertory Exploratory laparotomy where
ing or particularly aggressive forms of adnexitis that, without ad- laparoscopy is impossible and
equate treatment, can become life-threatening diseases. The the finding urgently requires surgery p. 82
combination of a sonographically complex cystic finding and Laparoscopic opening of abscess p. 142
corresponding abdominal or pelvic pain with a clinically and bio-
logically inflammatory process is a tubo-ovarian abscess until
this has been ruled out laparoscopically. In differential diagnosis, Operation of Choice
appendicitis, sigmoid diverticulitis, and necrotizing myoma can
be considered. Laparoscopic opening of abscess,
Abdominal. Open abdominal access should be avoided primarily irrigation, and limited adhesiolysis
and can only be recommended if laparoscopy is impossible and
the finding urgently requires surgery.
Vaginal. In the past, pouch of Douglas abscesses were transvagi-
nally punctured and also partially drained.
Laparoscopic. Laparoscopy is the method of choice for diagnosis
and treatment by opening, draining and irrigating the abscess.
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

ADNEXA
Functional diseases Epithelial tumors
Malignant sex cord stromal tumors
Benign neoplasms
Malignant germ cell tumors
Malignant neoplasms Rare histologies

Malignant Neoplasms Epithelial Tumors Diagnostic laparoscopy when diagnosis


is uncertain or there is suspicion of
Epidemiology. In over 80% of cases, the unspecific general term Surgical Repertory a nonovarian primary lesion (pancreas,
ovarian cancer denotes serous epithelial ovarian carcinoma. gastrointestinal tract), for histologic
Ovarian cancer is the fifth most frequent form of cancer in wom- differential diagnosis p. 134
en, after breast, lung, colon, and pancreatic cancer. A womans Laparoscopic procedure in early
lifetime risk of contracting ovarian carcinoma is about 1.4%, stages (FIGO I A, B) is controversial
with an annual incidence of 5 per 100 000 women. The average At the patients request, fertility can
age of the patient with ovarian cancer is 60 years. In women un- be spared in FIGO stage I A: unilateral
der 30 years of age, the annual incidence is 3 per 100 000; in adnexectomy, pelvic and para-aortic IV
women over 75 years of age it is 54 per 100 000. lymphadenectomy, omentectomy, 79
Risk factors. Genetic factors play an important role in the risk of peritoneal sample excision, hysteroscopy,
contracting the disease; about 10% of cases have a hereditary ba- fractionated curettage
sis (mutations of the BRCA1 and BRCA2 genes). In addition to sig- Vertical laparotomy and typical
nificant ethnic differences, the individual risk can be assessed ovarian cancer surgery p. 111
from the reproductive history: protective factors are a larger
number of births and the use of oral contraceptives. Sterility
and the treatment of sterility increase the risk of ovarian carcino- Operation of Choice
ma. A higher socioeconomic status is associated with an elevated
risk. Other classic risk factors are early menarche and late meno- Vertical laparotomy and typical ovarian cancer
pause. The theory of traumatic ovulation has received great at- operation with hysterectomy, adnexectomy,
tention in recent years. At the least, it is the beginning of an ex- omentectomy, pelvic and para-aortic lym-
planation for the risk factors listed above. In addition to ovula- phadenectomy, cytology, peritonectomy,
tion inhibitors, hysterectomy, tubal ligation, and oophorectomy and removal of all visible tumor fragments,
reduce the risk of contracting the disease, although the effect of if necessary with partial intestinal resection
hysterectomy and tubal ligation have not yet been explained. Be- and splenectomy and resection of the
cause there are no screening methods, ovarian cancer is detected diaphragmatic peritoneum
only at an advanced stage (FIGO III/IV) in over 50% of patients.
Therapy. Therapy consists of a combination of radical removal of
all visible intra-abdominal tumor fragments (R0 resection) with
postoperative polychemotherapy, usually a combination of a
platinum-containing chemotherapeutic agent and a taxane. If
tumor fragments larger than 2 cm remain, there is no sustained
survival advantage over and above the short-term improvement
of quality of life provided by the operation. This said, the typical
operation for ovarian cancer is one of the most demanding intra-
abdominal surgeries and often lasts many hours. For this reason
alone, an interdisciplinary approach seems advisable.
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

Epithelial tumors
ADNEXA
Functional diseases
Malignant sex cord stromal tumors
Benign neoplasms
Malignant germ cell tumors
Malignant neoplasms Rare histologies

Malignant Neoplasms Malignant Sex Cord Stromal Tumors Diagnostic laparoscopy for evaluation of
suspicious adnexal findings Where there is
Sex cord stromal tumors arise from granulosa cells and theca Surgical Repertory suspicion of inoperable malignancy, decision
cells as well as their luteinized derivatives. The terminology between laparoscopic adnexectomy and re-
comes from the widely accepted common embryonic derivation moval of the unruptured tissue in the retrieval
of the cells. Although many different neoplasms can arise from bag (if technically possible) vs. vertical
these cells, including tumors with testicular differentiation (Ser- laparotomy and adnexectomy
toli cell tumors), from a clinical standpoint, granulosa cell tumors After the frozen section diagnosis has been
have the greatest importance. Adult granulosa cell tumors con- made, decision regarding one-step or two-step
IV stitute 1%2% of all and about 10% of malignant ovarian tumors. procedure (in laparoscopy) or in laparotomy.
80 Usually they appear in postmenopausal patients aged 5055 Performance of the typical ovarian cancer sur-
years. Classical estrogen-producing tumors, granulosa cell tu- gery similar to treatment of epithelial ovarian
mors are associated with conditions ranging from endometrial cancer: hysterectomy, adnexectomy, omentec-
hyperplasia to endometrial cancer, which has an incidence in tomy, pelvic and para-aortic lymphadenectomy
this connection described as being up to 50%. Exact histologic Fertility-sparing operation at patients request
classification as benign or malignant is not possible for stage in FIGO stage I A. A purely laparoscopic proce-
I granulosa cell tumors. Only as the disease progresses can the dure in early stages is possible in principle but
malignant potential of the tumor be observed. A small propor- is negatively evaluated by some surgeons
tion will have an intra-abdominal recurrence, often after many In an unequivocal clinical situation and ad-
years, but the great majority have a benign course. Consequently, vanced stage, vertical laparotomy and typical
the granulosa cell tumor is also known as the 5% tumor: 5% of ovarian cancer surgery with hysterectomy,
tumors are bilateral, 5% recur, and 5% are associated with endo- adnexectomy, omentectomy, pelvic and para-
metrial cancer. Therefore, in peri/postmenopausal patients, a aortic lymphadenectomy, peritonectomy
complete staging operation with hysterectomy, bilateral adnex-
ectomy, omentectomy, and pelvic and para-aortic lymphade-
nectomy is justified. In contrast, in the premenopausal patient, Operation of Choice
the preservation of the contralateral adnexa is justified (if the bi-
opsy sample is unremarkable), as well as retention of the uterus Vertical laparotomy and ovarian cancer
if the endometrium is histologically unremarkable. operation with hysterectomy, adnexectomy,
omentectomy, pelvic and para-aortic lym-
phadenectomy, cytology, peritonectomy
and removal of all visible tumor fragments,
if necessary with partial intestinal resection
and splenectomy as well as resection of the
diaphragmatic peritoneum
IV Adnexa 4 . 2 C o n c e p t s f o r S u r g i c a l Tr e a t m e n t P r o c e d u r e N a v i g a t o r

Epithelial tumors
ADNEXA
Functional diseases
Malignant sex cord stromal tumors
Benign neoplasms
Malignant germ cell tumors
Malignant neoplasms Rare histologies

Malignant Neoplasms Malignant Germ Cell Tumors Diagnostic laparoscopy for evaluation of suspi-
cious adnexal findings. Where there is suspicion
Germ cell tumors arise from the primitive germ cells present in Surgical Repertory of malignancy that cannot be eliminated, deci-
the ovary, from which the ova develop. Germ cell tumors are sion between laparoscopic adnexectomy and
classified into three groups: the histologically uniform dysgermi- removal of the unruptured tissue in the retrieval
nomas; tumors with embryonic differentiation, histologically bag (if technically possible) vs. vertical
consisting of portions of different germ layers (teratomas); and laparotomy and adnexectomy
tumors of extraembryonic differentiation (chorionic carcinoma, After the frozen section diagnosis has been
yolk sac tumors). Germ cell tumors constitute about 20% of all made, decision regarding one-step or two-step
ovarian tumors. They occur especially during the first 6 decades procedure (in laparoscopy) or in laparotomy. IV
of life. In children and adolescents, 60% of all ovarian tumors are Typical ovarian cancer surgery similar to treat- 81
germ cell tumors and about one-third of these are malignant. In ment of epithelial ovarian cancer: hysterectomy,
adults, more than 90% of germ cell tumors in the form of mature adnexectomy, omentectomy, pelvic and para-
cystic teratomas (dermoid) are benign. These are usually re- aortic lymphadenectomy
moved laparoscopically. Historical fears of the consequences of If patient requests maintenance of fertility and
rupture of a (benign) dermoid have proved to be unjustified. is at FIGO stage I A, fertility-sparing operation.
The surgical technique chiefly spares the ovary. Where the find- A purely laparoscopic procedure in early stages
ings are malignant, surgery is usually performed in two stages. is possible in principle but is negatively evaluat-
Here the therapeutic approach is always individualized, except ed by some surgeons
for patients who do not wish for more children and are thus can- In an unequivocal clinical situation and
didates for a typical ovarian carcinoma operation. In case of advanced stage, vertical laparotomy and
doubt, regardless of the wish to preserve the uterus and/or ad- typical ovarian cancer surgery with hyster-
nexa, there should always be a staging in the form of an omen- ectomy, adnexectomy, omentectomy,
tectomy, pelvic and para-aortic lymph node staging, and perito- pelvic and para-aortic lymphadenectomy,
neal biopsies. peritonectomy

Operation of Choice

Vertical laparotomy and ovarian cancer


operation with hysterectomy, adnexectomy,
omentectomy, pelvic and para-aortic lym-
phadenectomy, cytology, peritonectomy,
and removal of all visible tumor fragments,
if necessary with partial intestinal resection
and splenectomy and resection of the diaphrag-
matic peritoneum
4.3 Surgical Techniques

IV
82

Abdominal 4.3.1.1 Ovarian Wedge Resection, Ovarian Cystectomy,


Removal of an Intraligamentous Cyst, Simple Oophorectomy

Aims and Methods


Minor adnexal surgery for benign disease is the province of laparoscopy. In
countries with the technical facilities for laparoscopy, laparotomy for benign
adnexal disease without a specific reason can be regarded as obsolete. None-
theless, it is interesting to compare the open with the laparoscopic technique.
Many surgeons have now never operated on diseases like this through a lapa-
rotomy. A description of the open technique is also justified because rare situa-
tions can arise that require open access. An example is when the increase in in-
tra-abdominal pressure and the Trendelenburg position required for laparo-
scopic procedures are not possible from the cardiopulmonary point of view
and are likely to cause greater stress for the patient than laparotomy. Other sit-
uations that necessitate an open procedure arise when the gynecologist is
called in because of incidental ovarian lesions discovered during laparotomy
performed by specialists in other fields or when adnexal surgery has to be per-
formed during pregnancy after 1820 weeks.
IV Adnexa O v a r i a n We d g e Re s e c t i o n , O v a r i a n Cy s t e c t o my, Re m ov a l o f a n I n t r a l i g a m e n to u s Cy s t , S i m p l e O o p h o r e c to my

Draping: abdominal window


Indications and Contraindications Anesthesia: intubation anesthesia, possibly spinal anesthesia/
epidural anesthesia
Indications
If an endoscopy unit is available, there are no specific indications for open Special Instruments
surgery of ovarian lesions that are often apparent only on ultrasonography. Laparotomy set
A primary open procedure for adnexal tumors can be considered only when Retractors
they are very large and suspicious for malignancy on ultrasonography or in the
overall context. However, there are rare cases of underlying cardiopulmonary
disease where increased intra-abdominal pressure and the Trendelenburg posi- Procedure
tion are impossible. Open access is legitimate in these cases, following detailed
consultation with the anesthesiologists and confirmation of the indication. Preparation
Basic indications for surgery regardless of the access route include persistent 1. Induction of anesthesia
cysts larger than 5 cm in the premenopausal period that do not disappear after 2. Supine positioning with/without the legs abducted
23 cycles, all postmenopausal cystic changes, clinically symptomatic adnexal
3. Skin preparation, bladder catheter, sterile draping: abdominal access
changes, and also smaller cysts and tumors if they cannot be ruled out with
4. Laparotomy; when indication is nonmalignant, the abdominal wall is
certainty as the cause of acute symptoms, any suspicion of ovarian torsion,
opened through a transverse Pfannenstiel incision
suspicious adnexal changes that cannot be classified with certainty, and solid
adnexal tumors. Regardless of the ultrasonographic appearance, ascites and Operation
elevated CA125 are indications for investigation. Removal of the ovaries may
also be indicated as a prophylactic or therapeutic procedure in breast cancer Ovarian wedge resection IV
or high-risk patients. 1. As a historical operation, the effectiveness of ovarian wedge resection was
always disputed. In principle, it meant reducing the androgen-secreting 83
Contraindications ovarian stroma in polycystic ovary syndrome (PCO syndrome, Stein
The possibility of performing laparoscopy is a contraindication to open surgery; Leventhal syndrome). Nevertheless, representative ovarian biopsy or
laparoscopy is not indicated when there is a high level of suspicion that a malig- partial ovarian resection is a procedure that may be indicated in individual
nant process is present, unless adequate oncologic surgery can be provided cases and is almost always performed laparoscopically.
immediately. 2. Important indications are contralateral biopsy in the case of unilateral
malignant disease when preservation of fertility is desired, and as a
fertility-preserving procedure in young women prior to systemic chemo-
therapy (cryopreservation).
Operation Risks and Informed Consent
3. Atraumatic removal must be ensured technically, especially when
The main risk of adnexal procedures, especially when adnexal tumors are obtaining tissue for cryopreservation. Resection must be performed
involved, is loss of the fallopian tube or ovary. In benign conditions, the ovary without use of electrocoagulation.
should always be preserved, especially in young women. Two-stage surgery 4. Individual bleeding points on the remainder of the ovary can be managed
should be performed if necessary. An exception is a completely necrotic ovary by coagulation. Ovarian reconstruction is not performed endoscopically.
following prolonged torsion. The patients future fertility may be impaired Electrocautery usually results in re-forming of the ovary.
anyway as a result. General risks such as bleeding, injuries to the bowel, bladder 5. Exact reapproximation by suture is esthetically attractive but takes time and
and blood vessels, andparticularly during oophorectomy and adnexectomy does not appear to confer any functional benefit.
of the ureter must be discussed. The risks of laparotomy, such as delayed wound
healing, suture dehiscence, hernia, and postoperative adhesions, are additional Ovarian cystectomy
complications of open surgery, which must also be explained. The role of the 1. In premenopausal patients, almost all benign ovarian tumors (persistent
ovary in the postmenopausal period is controversial. Supporters of organ- functional cysts, serous and mucinous cysts, dermoids and fibromas, and
preserving procedures point to the continued androgen secretion of the post- endometriotic cysts) can be removed with preservation of the ovary.
menopausal ovary. Precise enucleation of the intact cyst is often possible; after opening the
cyst, the walls of the collapsed cyst have to be removed in full from the
residual ovary.
Operation Planning 2. Before starting the actual cystectomy, abdominal washings should be re-
moved for cytology. Depending on the situation, this can be supplemented
1. Medical history, clinical examination, documentation
by cytology of the cyst fluid.
2. Ultrasonography and exclusion of other gynecologic disease
3. Classic enucleation is usually not possible with endometriotic cysts.
3. Discussion of the operation and access route; explicit specification of the
In this case, the cyst is opened and drained, scarred endometriotic tissue
possibility of adnexectomy/oophorectomy
is resected, and residual endometriosis is coagulated.
4. Consent to the procedure
4. Dermoids in particular (mature cystic teratomas) can be enucleated with
5. Anesthesiologic preoperative investigations depending on the patients age preservation of the ovary. However, none of the dermoid should be left
and local practice behind as otherwise there is a risk of recurrence.
6. Thrombosis prophylaxis: low-molecular-weight heparin (LMWH), 5. Sometimes the intact cyst can be enucleated in full easily. The critical step
antithrombosis stockings (ATS) is opening the ovarian wall (cortex) without simultaneously opening the
7. Antibiotic prophylaxis: 1st or 2nd generation cephalosporin < 30 minutes cyst, which usually lies directly underneath. The plane of dissection is
before surgerystandard with laparotomy then between the wall of the ovary and the wall of the cyst. Meticulous
8. Usually easy, sometimes moderately difficult surgery, depending on dissection as close to the cyst wall as possible is required for all ovarian
access; takes 12 hours, depending on location; surgeon and one assistant cystectomies and should not be performd bluntly by traction and counter-
traction or with hydrodissection. These latter techniques risk the removal
Anesthesia and Positioning of normal ovarian tissue and reducing ovarian reserve.
Positioning: supine with or without the legs abducted; access to the 6. If the cyst is opened, which occurs relatively often at some stage during
vagina is usually not necessary but is preferred by many dissection and is not a problem with benign lesions, the collapsed cyst
gynecologists in principle must be removed systematically from the remaining healthy ovary.
IV Adnexa 4.3 Surgical Techniques

7. Meticulous hemostasis, usually by means of electrocoagulation, should Enucleation of an intraligamentous paraovarian cyst
be ensured, especially after cystectomies. However, excessive electro- 1. Intraligamentous paraovarian cysts, which can sometimes attain conside-
coagulation will damage the residual ovary and should be avoided. rable dimensions, are nearly always benign tumors. Very careful dissection
8. Ovarian reconstruction by suture is usually not necessary unless the two is required when removing them to avoid injuring the ureter, which some-
walls of the cortex do not approximate spontaneously. Organ-preserving times follows an atypical course. Injury of the uterine arteries, which run
surgery is possible in postmenopausal women also. The procedure should toward the uterus at its base, should also be avoided.
always be discussed in detail preoperatively and the decision should be 2. The peritoneum is incised over the cyst at a suitable site. The cyst is shelled
documented clearly. out bluntly as far as possible, partly by spreading movements with scissors
Oophorectomy and possibly with the fingers. The ureter must always be identified.
1. Oophorectomy is indicated, for example, when the ovary is completely 3. When visualization is poor and there are dense adhesions, it is useful to
necrotic following torsion, and prophylactic oophorectomy is warranted expose the ureter from above first, and then follow it in the inferior direc-
in a high-risk oncologic situation. In an individual case, complete salpingo- tion.
oophorectomy may be regarded as more rational. This is the case especi- 4. If the fallopian tube is extremely stretched when the cyst is very large,
ally with benign ovarian disease in the postmenopausal period. it sometimes has to be removed also.
2. In the open technique, the mesovarium is grasped with one or more
clamps and divided with scissors, and the clamps are replaced by suture
ligatures.

IV
84

Special Technique Ovarian Wedge Resection, Ovarian Cystectomy,


Removal of an Intraligamentous Cyst, Simple Oophorectomy

Fig. 4.3-1 Wedge resection of the ovary. ervation of fertility is desired; recently, in addi- Fig. 4.3-2 Reconstruction of the ovary with confer any functional or postoperative benefit
The indications are contralateral biopsy when tion, removal of ovarian tissue for cryopreserva- submerged interrupted sutures in the stroma and is no longer regarded as standard nowa-
the ipsilateral pathology is not benign and pres- tion prior to systemic chemotherapy. and a continuous subcortical suture. Reap- days.
proximation of the ovary does not appear to
IV Adnexa 4.3 Operation Techniques

IV
85

Fig. 4.3-3 Ovarian cystectomy. Circular inci- than 5 cm in size. Cysts and dermoids can usual- Fig. 4.3-4 Enucleation of an ovarian cyst, the cyst is opened, it must be separated
sion around an ovarian cyst: sharp resection ly be enucleated readily. The first step is to find mainly by blunt dissection with scissors. Ideal- carefully and completely from the rest of the
must always be employed for solid tumors. Be- the dissection plane between the cortex and ly, this layer is dissected without opening the ovary. Precise hemostasis is important to avoid
nign cysts in premenopausal patients should be the cyst wall. cyst to preserve maximum ovarian tissue. After postoperative bleeding and hematomas.
resected only if they persist and are greater

Fig. 4.3-5 Oophorectomy. The mesovarium sions are present, the ovary should first be mo- Fig. 4.3-6 Enucleation of an intraligamen- in difficult salpingo-oophorectomies, in both
is grasped with clamps and suture ligated. Op- bilized fully. Sometimes this may even require tous paraovarian cyst. Incision of the peritone- laparoscopic and open surgery. Tumors and
posing clamps should also be placed if neces- dissection and opening of the pelvic wall with um for enucleation of an intraligamentous cysts are often immediately adjacent to the
sary to avoid opening an ovarian tumor. The ureterolysis. paraovarian cyst. Exposure of the ureter can ureter.
clamp is replaced by suture ligature. If adhe- be critically important in this situation and also
IV Adnexa 4.3 Surgical Techniques

Complications Concurrent and Postoperative Treatment


Ureteral injury: this is extremely rare with cysts and tumors within mobile
Depending on the underlying disease, postoperative care should be routine.
ovaries. Adhesions between the ovary and the pelvic sidewall, pouch of
Discussion of the operation performed and operation findings is particularly
Douglas, and posterior wall of the uterus often make the operation difficult
important.
and necessitate ureterolysis.
Secondary hemorrhage: this is rare but can represent a particular danger
after removal of large ovarian cysts, as, despite good hemostasis, they can
lead to persistent and ultimately hemodynamically significant bleeding.
Limits of the Methods
Loss of an ovary: this complication should always be discussed preopera- Dermoid cysts are not an indication for laparotomy or removal of the entire
tively, even though it is a rare event. ovary. Fears of toxic peritonitis have proved to be unfounded. Respect for
ovarian integrity and the patients wishes are critically important for the opera-
tive approach.

Abdominal 4.3.1.2 Open Salpingo-Oophorectomy


IV
86
Aims and Methods
As with all open surgery on the ovary, the indications for open salpingo-ooph-
Indications and Contraindications
orectomy have been greatly narrowed by operative laparoscopy. Very large cys-
tic tumors, adnexal conditions requiring surgery after week 1820 of gestation, Indications
the presence of contraindications to laparoscopy, and highly suspicious adnex- Complete excision of the tube and ovary is performed either for therapeutic
al masses where the overall context (clinical features, imaging, and possibly tu- (ovarian tumors, chronic recurrent inflammation) or prophylactic reasons
(postmenopausal hysterectomy, surgery of endometrial carcinoma, high-risk
mor markers such as raised CA125 levels) suggest a malignant condition are in-
oncologic situation with regard to breast cancer). A decision is made to remove
dications for open removal of the fallopian tube and ovary. However, in the lat- the tube and ovary together if the tube is also diseased or excision of the adnexa
ter cases, diagnostic laparoscopy should always be considered when the as an entire complex (e.g., following inflammation or endometriosis) is techni-
cally simpler. Leaving behind a nonfunctioning tube does not make sense.
situation is unclear; acute Chlamydia infections, tubo-ovarian abscesses, and
extensive endometriosis can present as cysts visible on ultrasonography and Contraindications
with elevated CA125. The decision to remove the adnexa in full should be Salpingo-oophorectomy is contraindicated especially in patients who still want
made reluctantly, especially in the premenopausal period, and all the more be- to have children. This desire for children, the patients age, and the precise
cause longer-term hormone replacement is no longer an unrestricted option. pathology must be weighed carefully with the patient.

The situation is different after menopause; in this case, the doctor and patient
should make a joint rational decision. Supporters of organ preservation after
Operation Risks and Informed Consent
menopause argue in favor of continued androgen production and its conse-
The possible differential diagnosis of every pathologic condition in the adnexa
quences for libido and cognitive function. However, this is opposed by the sub-
must be explained to the patient. The alternatives of cystectomy, ovarian biopsy,
jective nature of these endpoints and the reduction in further morbidity origi- and oophorectomy or salpingo-oophorectomy must be discussed in detail.
nating in the ovaries. When there is a large, potentially malignant adnexal tumor, extending the
operation must be discussed. In such cases, the abdominal access route, usually
a vertical laparotomy, must be decided. The diagnostic laparoscopylaparotomy
sequence should be at least considered. Life-changing procedures that cannot
be reversed, such as removal of both ovaries and possibly of the uterus, require
detailed discussion, particularly with young premenopausal women. The speci-
fic risks of the operation itself are injury to the ureter in the region of the infun-
dibulopelvic ligament in particular, and also bowel injury, especially when the
sometimes physiologic adhesions between the sigmoid colon and left pelvic
wall cannot be divided completely.
IV Adnexa Open Salpingo-Oophorectomy

Operation Planning Procedure


1. Medical history, clinical examination, documentation
Preparation
2. Ultrasonography and exclusion of other pathologic gynecologic conditions:
recent cervical cytology, recent mammography in the over-50s, and recent 1. Anesthesia
measurement of tumor markers (CA125, CEA) when an adnexal tumor is 2. Supine positioning with the legs abducted or lithotomy position
present 3. Skin preparation, bladder catheter, sterile draping: abdominal access
3. Discussion of the operation and access route; explicit specification of the 4. Laparotomy, transverse vs. vertical depending on pathology and discussion
procedure in the case of malignancy and with regard to preserving the with the patient; when malignancy is suspected, primary vertical laparoto-
contralateral ovary. Determination of the incision for primary laparotomy my is recommended (accurate preoperative documentation is
4. Consent to the procedure important).
5. Anesthesiologic preoperative investigations depending on the patients
Operation
age and local practice
1. The abdomen is opened, the operation site is exposed, and abdominal
6. Thrombosis prophylaxis: LMWH, ATS
washings are removed for cytology.
7. Antibiotic prophylaxis: 1st or 2nd generation cephalosporin < 30 minutes
2. The bowel is dissected adequately and distanced (especially on the left
before surgerystandard with laparotomy
side, the sigmoid colon is often bound to the infundibulopelvic ligament
8. Easy to moderately difficult surgery, depending on access and site;
by physiologic adhesions), and the ureter is distanced from the vascular
takes 12 hours, depending on location; surgeon and one assistant
infundibulopelvic ligament as a prerequisite for safe adnexectomy.
Anesthesia and Positioning 3. Opening the peritoneum over the psoas muscle is the critical first step
both for dividing bowel adhesions and for visualizing the ureter. On the IV
Positioning: supine with legs abducted; possible access to the vagina
one hand, it is possible to distance the bowel in the cranial direction from 87
is important with a view to single-stage surgery of
the opened peritoneal margin so that its avascular adhesions can be ex-
malignancy
posed optimally on the inferior aspect; on the other hand, the ureter can
Draping: abdominal window
also be distanced posteriorly where it crosses the common iliac vessels,
Anesthesia: intubation anesthesia, combined with epidural anesthesia away from the infundibulopelvic ligament, which is anterior to them.
in the event of vertical laparotomy, as decided by the
4. After exposure of the ureter, the peritoneum is fenestrated posterior to
anesthetist
the ovarian vessels, and the infundibulopelvic ligament is doubly clamped,
Special Instruments divided, and ligated. Compared with a suture ligature, the advantage of a
double ligature (with a safety ligature) of the infundibular vessels in the
Laparotomy set
cranial direction is that this avoids the risk of accidentally piercing the
Retractors vessels and thus giving rise to a retroperitoneal hematoma. The infundi-
bulopelvic ligament should be dissected until it is easy to place a secure
ligature.
5. The adnexa are divided from the uterus; an opening should be made in the
peritoneum here to avoid injuries and bleeding from the ascending uterine
vessels.
6. With very large and highly mobile ovarian tumors, the pedicle, consisting
of the tube, ovarian ligament, and infundibulopelvic ligament, can be
grasped with two clamps from either side, divided, and suture ligated. The
ureter is rarely endangered in this situation but this can only be ruled out
if the ureter has been demonstrated beforehand. Nonetheless, this tech-
nique is the fastest and safest method for removing very large and usually
suspect ovarian tumors from the operation field without rupturing them.
The ureter must then be demonstrated secondarily. If necessary, clamps
should be placed on the resected specimen.
7. Visualization of the ureter is more important at open surgery than during
laparoscopy: the magnification of the anatomy and the greater proximity
of the surgeon to the site often permit exact subperitoneal localization of
the course of the ureter at laparoscopy, together with adequate distancing
of the adnexa from the pelvic wall by traction.
IV Adnexa 4.3 Surgical Techniques

Special Technique Open Salpingo-Oophorectomy

IV
88

Fig. 4.3-7 Opening the peritoneum lateral partly postinflammatory bowel adhesions in
to the adnexa, exposure of the ureter, fenes- this region should be noted. These can be divid-
tration of the peritoneum, and clamping of ed more easily after fenestration of the perito-
the ovarian vessels. The partly physiologic and neum.

Fig. 4.3-9 Aspiration of a large ovarian cyst. of FIGO stage I A to stage I C, the prognostic sig-
An important advantage of laparotomy com- nificance of which is unclear. In fact, large tu-
pared with laparoscopy, though not uncontro- mors can also rupture when the open tech-
versial in the literature, is that it is possible to nique is used, especially if there are extensive
remove large tumors from the abdomen with- adhesions. The aspiration shown here should
out rupturing them, thus avoiding conversion be reserved for exceptional cases.

Fig. 4.3-8 The removal of a pedicled adnexal large and fairly mobile adnexal tumors. The ure-
tumor: clamping of the tube and ovarian lig- ter is then usually at an adequate distance and
ament on the one hand and the infundibulo- can be exposed subsequently when the unrup-
pelvic and broad ligaments on the other. This tured tumor has been removed.
simple technique is recommended for very
IV Adnexa Open Salpingo-Oophorectomy

IV
89

Fig. 4.3-10 Mobilizing an adnexal mass by variable physiologic or embryonic adhe- Fig. 4.3-11 Mobilizing an adnexal mass by ament and the vascular anastomosis with the
sharp dissection from the bowel. Although sions to the sigmoid colon cause problems in blunt separation from the pelvic wall. When uterus have been divided, many tumors can be
many problematic adhesions are due to infec- the left lower abdomen and at the left wall of there are adhesions between the adnexa and mobilized bluntly from the pelvic wall, as
tion or previous surgery, the individually very the pelvis during left adnexectomy. the pelvic wall, dissection can be at the limit of shown here, unless a malignant infiltrating pro-
visualization, especially posteriorly, i.e., to the cess is present.
deep pelvic wall. After the infundibulopelvic lig-

Complications Concurrent and Postoperative Treatment


Ureteral and bowel injury: the incidence of ureteral injuries is well below
Depending on the patients age, hormone replacement may be necessary after
1%, which underlines the fundamental safety of the operation in experi-
bilateral adnexectomy. When prescribing hormone replacement therapy, the
enced hands. Bowel injuries are even rarer.
patients age, subjective feelings, individual breast cancer risk, and wishes must
Unexpected malignant or borderline process on histology: the incidence be taken into account. When removal is unilateral and in postmenopausal pa-
of ovarian carcinoma in bland cysts larger than 3 cm in the premenopausal tients, nothing more than ordinary postoperative care is required.
period is 0.3% at most. If the tumor is removed in full and without rupture,
further management can be tailored to the patients age and desire for
children. If rupture has occurred, completion of the operation within a
week is recommended.
Limits of the Method
Complications of the access route: most complications such as postopera- Open salpingo-oophorectomy often forms part of other open abdominal proce-
tive wound infection, scarring, and incisional hernias are the result of an dures. The only reason for not operating laparoscopically is the FIGOI A/FIGOI C
open technique, and this is also the most troublesome subjective aspect of problem, which as yet has not been solved satisfactorily.
the operation for the patient.
IV Adnexa 4.3 Surgical Techniques

Abdominal 4.3.1.3 Open Salpingotomy/Salpingectomy in Ectopic Pregnancy

Aims and Methods


EUP is among the most frequent and most dangerous complications of early
Operation Risks and Informed Consent
pregnancy and contributes to global maternal mortality. Some 95% 97% of
EUPs are located in the uterine tube, 2% 4% in the cornual part of the uterus, When the diagnosis is clear clinically, on ultrasonography, and on laboratory
tests, the patient must be informed about the situation and about the general
0.5% in the ovary, 0.1% are cervical, and far less than 0.1% are abdominal. With
risks of the procedure such as hemorrhage or injury to neighboring organs. The
the increasing incidence of pregnancy after assisted reproduction, it should be problem of tube-preserving surgery vs. salpingectomy must also be discussed.
noted that the overall rate of EUP has increased. The treatment of tubal preg- The patients wishes are taken into account, depending on her desire for future
pregnancy. However, if tube-preserving surgery is decided on, detailed discus-
nancy in particular is discussed below.
sion of the risk of recurrence (approximately 10% 15%) is required. If the diag-
nosis is not clear, discussion of the overall situation must be even more detailed
Symptomatic or nonsymptomatic, ruptured or nonruptured tubal pregnancy and, depending on the clinical signs, watchful waiting should be weighed
can today be diagnosed and treated by laparoscopy. Laparotomy should be per- against an invasive diagnostic procedure. As an acute emergency situation can
arise, logistical questions such as the time needed to reach the hospital should
IV formed only when laparoscopy is not possible for technical, logistical, or med-
also be considered. If an open abdominal procedure is decided on, this should be
90 ical reasons. Laparoscopy also provides optimal treatment possibilities when explained to the patient. Drug treatment in the form of systemic methotrexate
hemoperitoneum is present, as tubal bleeding can usually be halted rapidly by is quite widespread in the United States. Apart from the treatment of very early,
targeted coagulation. The primary aim of treatment in every case is tube pres- nonruptured tubal pregnancies, methotrexate has proved effective especially in
the treatment of persistent trophoblastic tissue or persistent hCG levels after
ervation. Successful pregnancy rates are always greater after the tube is pre-
tube-preserving surgery.
served than after salpingectomy.

Operation Planning
1. Medical history, clinical examination to assess urgency, vaginal ultra-
Indications and Contraindications sonography as a crucial diagnostic investigation
The diagnosis provides the indication for surgery of EUP. EUP is diagnosed with 2. Qualitative (urine) and quantitative (serum hCG) pregnancy test
virtual certainty from the combination of a serum hCG level greater than 3. Laboratory tests: blood count to assess acute bleeding and cross-match
1500 IU/L and an empty uterine cavity on vaginal ultrasonography. Assessment if ruptured tubal pregnancy is suspected clinically. The blood group must
of the cavity when the hCG level is less than 1500 IU/L is more difficult. A be determined with a view to possible anti-D prophylaxis if the patient is
definite diagnosis is not possible in an asymptomatic patient. Purely ultrasono- rhesus negative
graphic diagnosis must also be regarded very critically. In rare cases when the 4. Detailed discussion, especially when the diagnosis is not entirely clear
uterine cavity is empty, a definite tubal pregnancy can be detected because of 5. Determination of operative procedure: tube preservation vs. primary
positive cardiac activity. Conversely, an EUP cannot be ruled out if it is not dem- salpingectomy
onstrated by ultrasonography. In the differential diagnosis, routine ultrasono- 6. Consent to the procedure
graphy often cannot distinguish an EUP without embryonic structures with
7. Anesthesiologic preoperative investigations; especially when bleeding is
certainty from, for example, a corpus luteum. Hasty surgery in an asymptomatic
suspected, the anesthesiologists should be informed in good time
patient when hCG levels are less than 1500 IU/L is not advisable. A normal or
8. Antibiotic prophylaxis as with laparotomy: cephalosporin approximately
abnormal early pregnancy might be present, which is not yet visible on ultra-
30 minutes before the start of the operation, thrombosis prophylaxis: ATS
sound, orin the worst casea tubal pregnancy that cannot yet be distinguished
even on direct inspection. If pain is mild, the overall situation should be ex- 9. Easy to moderately difficult surgery, depending on the location of the
plained to the patient, and diagnostic laparoscopy without insertion of a uterine EUP and presence of hemorrhage; usually takes a little over 1 hour
manipulator should be discussed, with clinical observation and possibly aspira- (because of the laparotomy); surgeon and one assistant
tion of the pouch of Douglas if laparoscopy is impossible. Intervention is required
Anesthesia and Positioning
when the patient is clinically unstable, with a falling hemoglobin level and posi-
tive pregnancy test. The diagnostically unclear situation when the hCG level is Positioning: lithotomy position; depending on the clinical situation
less than 1500 IU/L is a relative contraindication. The rare possibility of simul- and depending on the intraoperative findings. The possibil-
taneous presence of an intrauterine pregnancy and EUP (incidence 1 : 10 000), ity of curettage can also be discussed with the patient,
which is very difficult to diagnose, should be considered. especially when the hCG levels do not provide clarity.
Draping: abdominal window
Anesthesia: intubation anesthesia

Special Instruments
Laparotomy set
Monopolar needle for salpingotomy
IV Adnexa Open Salpingotomy/Salpingectomy in Ectopic Pregnancy

Partial salpingectomy
Procedure 1. When the pregnancy is in the rigid isthmic part of the tube, this is often
largely destroyed by the ectopic pregnancy tissue. Coagulation of bleeding
Preparation points after removal through a salpingotomy leads to further tube destruc-
1. Intubation anesthesia; in contrast to laparoscopy, spinal or epidural tion. Partial salpingectomy with primary or secondary reanastomosis may
anesthesia is possible for laparotomy, but it is seldom used in Germany be a better approach.
2. Positioning: lithotomy position 2. The EUP is excised widely to ensure that all trophoblastic tissue is re-
3. If hemoperitoneum and acute bleeding are suspected, blood should be moved. A monopolar needle may be used. The larger vessels running in
drawn for cross-matching, and donor blood and possibly fresh frozen the mesosalpinx should be spared.
plasma should be available 3. The tube stumps are ligated and the edge of the mesosalpinx is sutured
4. Skin preparation, bladder catheter, sterile draping: abdominal access carefully if secondary tubal reanastomosis is planned. Alternatively, the
tube can be reconstructed immediately by end-to-end anastomosis (Chap-
Operation ter 4.3.1.5), though this is usually difficult because of the acute tissue
1. Usually a small suprapubic transverse laparotomy is performed through reaction. Accordingly, the risk of recurrence must be discussed pre- or
a Pfannenstiel or Maylard incision; alternatively, longitudinal opening of postoperatively.
the fascia.
Salpingectomy
2. A self-retaining retractor is inserted, blood is aspirated if necessary, the
1. When the patients family is complete and at her express wish, salpingec-
bowel is packed away and the tubal pregnancy is visualized.
tomy can be performed as definitive treatment of tubal pregnancy.
Type of operation 2. A clear field of vision should be obtained; especially if a hemoperitoneum
1. The type of operation depends on the location and size of the tubal preg- is present, widespread clamping may be necessary to achieve hemostasis. IV
nancy, the condition of the tube, and on whether or not the patient desires 3. The tube is elevated with an instrument at the fimbrial end, and the
further pregnancies. Unlike in the past, tube-preserving surgery is usually mesosalpinx is clamped and ligated from the fimbrial side. Ensure that the 91
preferred today, if technically possible. clamps are placed close to the base of the tube so as not to interfere with
2. If the tube is not ruptured and the patient wishes for further pregnancies, the ovarian vessels along the mesovarium.
the following options are available, depending on the location of the tubal 4. Wedge excision of the isolated tube from the myometrium of the uterine
pregnancy: aspiration or expression from the infundibulum, salpingotomy horn is performed. To avoid bleeding from tubal vessels close to the uterus,
in the region of the ampulla, or segmental resection when it is located at the first row of sutures (2 0) can be placed beforehand. To reinforce the
the isthmus. suture and compression, the excision site at the uterine horn can be
3. If the patient no longer desires children, salpingectomy is reasonable. covered with the round ligament.
4. Even when the tube is ruptured, tube preservation is possible in principle, 5. Alternatively, the tube is simply excised somewhat distal to the uterus,
depending on the clinical situation. depending on the location of the tubal pregnancy.
5. In the event of an interstitial or cornual pregnancy, cornual resection is
possible, possibly with secondary implantation at a later time. Primary
tube preservation is difficult in this case.
6. With ovarian pregnancies, excision with preservation of the ovary usually
suffices.
7. If tubal pregnancy occurs after failed tubal sterilization, bilateral salpingec-
tomy is indicated as the same condition can occur again on the other side.
Salpingotomy
1. Linear, antimesenteric salpingotomy, ideally with electrocautery, is the
classic operation technique for EUP in the ampullary part of the tube.
2. Injection of a vasoconstrictor substance in the region of the mesosalpinx
can reduce the number of bleeding points requiring coagulation after
removal of the EUP and forms part of the atraumatic surgical approach.
3. Atraumatic fixation and stabilization of the tube is a requirement for safe
linear salpingotomy. The incision is made over the most prominent part
of the tube on the antimesenteric side.
4. The tubal pregnancy is removed from the tube by light pressure from with-
out or alternatively by using hydrodissection with irrigation. The gestational
tissue can usually be removed in this way as the tube and trophoblast have
already separated somewhat.
5. As much trophoblastic tissue as possible must be removed but, on the other
hand, none of the tube should be removed. Copious irrigation helps to dif-
ferentiate between gestational tissue and regressive tube wall.
6. After the conceptus has been removed, hemostasis must be achieved with as
little electrocoagulation as possible. Careful irrigation helps in identifying
bleeding points and coagulating them accurately.
7. After optimal hemostasis, the tube can remain open for secondary healing.
Suture approximation does not appear to confer any functional benefit.
IV Adnexa 4.3 Surgical Techniques

Special Technique Open Salpingotomy/Salpingectomy In Ectopic Pregnancy

IV
92

Fig. 4.3-12 Salpingotomy. Infiltrating the The illustration shows a classical ampullary Fig. 4.3-13 Incision of the tube with electro- nest part of the tube or through the site of
mesosalpinx with ornipressin solution. This EUP. The incision line, where possible in the cautery, on the antimesenteric surface where rupture. The electrocautery is a suitable instru-
step is not essential but can assist hemostasis. antimesosalpinx surface, is shown. possible but alsoas shown hereover the thin- ment for this step.

Fig. 4.3-14 Removal of the trophoblastic tis- and bloody due to highly infiltrating tissue. An
sue with forceps. The salpingotomy must open atraumatic technique is important especially
the tube completely. An over-hesitant incision is at this stage, for example, by using hydrodissec-
counter-productive. Removal of the pregnancy tion.
may be very easy but can also be very difficult

Fig. 4.3-15 Hemostasis with electrocautery. ulation as possible but as much as necessary.
Ideally, no further electrocoagulation would Irrigation often allows the bleeding points to
now be used. Unfortunately, numerous bleed- be located precisely for targeted coagulation.
ing points often persist, which have to be con-
trolled according to the adage of as little coag-
IV Adnexa Open Salpingotomy/Salpingectomy In Ectopic Pregnancy

IV
Fig. 4.3-16 Closure of the salpingotomy function, the frequency of future intrauterine Fig. 4.3-17 When the pregnancy is located cessful, the fimbriae can be incised with elec- 93
wound with fine interrupted sutures. Closing pregnancies, or the recurrence rate of extra- right at the end of the tube, an attempt can trocautery as in the classic salpingotomy tech-
the tube provides an esthetic conclusion but uterine pregnancies. be made to remove the pregnancy by milking nique.
does not appear to have any influence on tube the tube or by hydrodissection. If this is unsuc-

Fig. 4.3-18 Removal of the trophoblastic tis- traumatic forceps. Frequent irrigation helps to Fig. 4.3-19 Closure of the salpingotomy coagulation. The suture shown here or closure
sue with forceps. Here, too, the procedure distinguish trophoblastic tissue from regressing wound with fine interrupted sutures. Optimal of the salpingotomy wound is optional.
should be as atraumatic as possible, for exam- tubal tissue. hemostasis should first be achieved by targeted
ple, by hydrodissection and avoiding use of
IV Adnexa 4.3 Surgical Techniques

IV
94

Fig. 4.3-20 Partial salpingectomy. The fur- coagulation of the tube if the rather rigid tube Fig. 4.3-21 Partial salpingectomy with pri- tube after excision of the segment of tube con-
ther toward the isthmic part of the tube the has not been completely destroyed already by mary or ideally secondary reanastomosis is an taining the pregnancy. The main vessels in the
pregnancy is located, the more difficult it be- the ectopic pregnancy. The incision line is indi- option that is rarely indicated but worth consid- mesosalpinx should be spared.
comes to preserve the tube by linear salpingot- cated. ering. This shows ligature of the stumps of the
omy. Hemostasis can rapidly become complete

Fig. 4.3-22 Primary reconstruction of the er time. This applies particularly in clinically un- Fig. 4.3-23 Salpingectomy. The mesosalpinx An opposing clamp is not usually necessary; 3
tube by end-to-end anastomosis. Alternatively, stable situations after tube rupture and hemo- is clamped after elevation of the end of the 4 steps usually suffice to remove the tube com-
the tube ends can be ligated, the mesosalpinx peritoneum. tube. The clamp should be applied close to the pletely from the mesosalpinx.
sutured, and reanastomosis performed at a lat- tube so as not to injure the mesovarian vessels.
IV Adnexa Open Salpingotomy/Salpingectomy In Ectopic Pregnancy

IV
95

Fig. 4.3-24 The tube is removed in several as completely as possible, but on the other
portions as close as possible to its base. How hand, unnecessary dissection toward the uter-
far dissection is continued toward the uterus ine origin of the tube should be avoided, as
depends on the extent of the tubal pregnancy. this area is highly liable to bleed.
On the one hand, the tube should be resected

Fig. 4.3-26 The wedge excision wound is gion, the wound at the uterine horn can also
closed with a cross suture. Particularly when be covered by suturing the round ligament
there are problems with hemostasis in this re- over it.

Fig. 4.3-25 If necessary, the tube can be re- Alternatively, the tube can be coagulated and
sected as far as the uterus. In this case, divided directly at its origin from the uterus, as
placement of hemostatic sutures is worthwhile. in laparoscopic salpingectomy.
IV Adnexa 4.3 Surgical Techniques

Complications Concurrent and Postoperative Treatment


Intraoperative complications: hemorrhage in excess of bleeding caused
The most important element in postoperative management is following the
by the rupture, injury to neighboring organs or other complications of this
hCG levels until they reach zero, so that any trophoblastic persistence and pro-
nature are rare.
liferation can be detected promptly. In this connection, it is also necessary to
Trophoblast persistence: when the tube is preserved, trophoblast persis-
examine the histology promptly as it may not be possible to assess the macro-
tence can be expected in roughly 10% of cases, which may be temporary or
scopic appearance with certainty. If hCG elevation persists, treatment with me-
may require further intervention; this is why it is essential to monitor the
thotrexate or salpingectomy can be considered as alternatives. If the patient is
postoperative hCG levels until they reach zero.
rhesus negative, anti-D prophylaxis must not be forgotten.
Recurrence: the most important complication after both tubal preservation
and unilateral salpingectomy is recurrent ipsilateral or contralateral tubal
pregnancy. Recurrence rates of 15%30% are reported.
Limits of the Methods
Reduced fertility: a reduction in fertility is another important complica-
tion, not of the operation but of the underlying disease. However, this The method of choice today is laparoscopy, even (and indeed especially) in
depends less on the tubal pregnancy itself than on the coexistence of risk critical clinical situations, as it provides the fastest access into the abdomen.
factors for this. In the absence of such risk factors, the success rate of a Targeted coagulation of the usually clearly demarcated bleeding is possible
normal pregnancy is almost 90%, regardless of the operative technique while the patient is stabilized by infusion and transfusion.
(tube preservation vs. salpingectomy). If risk factors are present, the
success rate is only about 60% and is even lower after salpingectomy. If
both tubes are defective, in-vitro fertilization (IVF) offers the only possib-
IV ility of becoming pregnant.
96

Abdominal 4.3.1.4 Open Sterilization Operations

Aims and Methods


Reliable and definitive contraception is an important function of gynecology
Indications and Contraindications
from the medical and sociocultural point of view. Of the many methods of con-
traception, surgical and permanent techniques will be described below. The Indications
decision not to have any (more) children is always a highly personal one. Med- The primary indication is the womans well-considered wishes, following ap-
ical indications for sterilization are extremely rare and must always be dis- propriate counseling. There are no compelling medical indications. Implantable
progesterone systems such as Norplant (active substance: levonorgestrel) or
cussed precisely with the patient. Long-term but not final alternatives, which
Implanon are suitable long-term alternatives to tubal ligation techniques for
are almost as reliable, are now available. The importance of the psychologic practically all patients, especially patients with severe cardiovascular disease,
or theoretical possibility of pregnancy should not be underestimated even in and probably also for those with known thrombophilia. Contraindications to
laparoscopy provide specific indications for an open abdominal procedure. The
the presence of serious underlying disease or an objective physiologic near-im-
main indication for postpartum partial salpingectomy through an infraumbilical
possibility of successful pregnancy. Although the patients wishes are crucial, minilaparotomy is a wish for sterilization immediately after delivery, which was
this does not mean that her doctor should not advise her. It is known that formulated and documented during pregnancy.
very young women in particular regret sterilization relatively often after sup-
Contraindications
posedly completing their families. The aim of each technique is permanent and
Every permanent form of sterilization is contraindicated in a patient who is am-
safe prevention of further pregnancies with few side effects. The standard pro-
bivalent or under external pressure. The treating doctor must react to the situa-
cedure is laparoscopic tubal ligation. Open techniques can also be employed as tion with particular sensitivity. Another contraindication is when the patient is
part of cesarean section. Besides laparoscopic sterilization techniques, immedi- unable to decide or give informed consent, for example, women with more or
ate postpartum partial salpingectomy through an infraumbilical minilaparoto- less severe intellectual disability. In cases of doubt, an ethics committee de-
cision or ruling by a competent family court may be required.
my has also become an accepted technique.
IV Adnexa Open Salpingotomy/Salpingectomy In Ectopic Pregnancy

Operation Risks and Informed Consent Procedure


Besides the usual risks such as infection, pain, hemorrhage, and injury of inter- Preparation
nal organs, the patient must be clear about three facts before the procedure: 1. In the postpartum situation: ensure epidural anesthesia is adequate, or
Forever: sterilization is permanent and is practically irreversible. spinal anesthesia if an epidural catheter is not in situ. Intubation anesthe-
Not 100%: sterilization is the safest method of contraception long-term, but sia or epidural anesthesia in the nonperipartum situation
pregnancy can occur at any time. 2. Positioning: lithotomy position
Increased risk of tubal pregnancy: if pregnancy occurs, it is an EUP in
3. Skin preparation, bladder catheter, sterile draping: abdominal access
almost 40% of cases.

Beyond these three facts, the most important risk of sterilization is that the pa- Operation
tient will regret the procedure later. This regret should be addressed specifically, 1. If a wish for sterilization has been expressed during pregnancy, this can be
especially in women aged less than 30 years. As nearly every sterilization is performed postpartum immediately after a cesarean section following
an elective procedure, the informed consent must be especially careful. Sterili- suture of the uterotomy or after spontaneous delivery using the analgesia
zations performed just after the end of pregnancy (delivery or abortion) have a provided by the epidural catheter if it is still in place, or with spinal anes-
somewhat higher failure rate. Patients must therefore be informed of this. thesia.
Minilaparotomy after spontaneous delivery
1. Access is through a curved infraumbilical incision. As the postpartum
Operation Planning uterus is high in position, the origins of the tubes can be delivered into the
1. Detailed history of the family status, information about the procedure minilaparotomy from without by dislocating the uterus, and they can then
and its consequences, and counseling with regard to alternatives be ligated. This technique can be difficult in very obese patients.
IV
2. Documentation of this information and counseling 2. A slightly curved transverse skin incision about 3 cm long is made just 97
3. Exclusion of gynecologic problems and pathology below (approximately 1 cm) the umbilicus, and this is extended deeply as
4. Decision on and discussion of the technique far as fascia. Bleeding from cutaneous vessels must be coagulated. The
5. Consent to the procedure fascia is exposed with small retractors.

6. Anesthesiologic preoperative investigations according to the local practice 3. The fascia and the peritoneum immediately beneath it, which is adherent
at least next to the umbilicus, are opened and the retractors are advanced
7. If appropriate, the procedure is planned in the first half of the cycle so that
into the abdominal cavity.
undiagnosed pregnancy can be ruled out with certainty
4. By manipulating the fundus, which is usually at the umbilicus at this time,
8. Easy surgery; takes < 1 hour; surgeon and possibly one assistant
the origin of the tube on one side is sought. The physiologic laxity of the
Anesthesia and Positioning abdominal wall is used to move the laparotomy window. The tubes are
visualized, identified with certainty by finding the fimbrial ends, and
Positioning: lithotomy position or supine
divided by one of the techniques described below.
Draping: abdominal window
Anesthesia: epidural or spinal anesthesia for peripartum procedure, Sterilization techniques
otherwise intubation anesthesia or epidural anesthesia 1. Pomeroy tubal sterilization (partial resection): the Pomeroy method is par-
ticularly easy and quick to perform, and can be done equally well through
Special Instruments a postpartum subumbilical incision and following cesarean section. The
Small laparotomy set failure rates appear to be similar after electrocoagulation, rings, and clips.
Small retractors for infraumbilical minilaparotomy 2. The middle part of the tube is elevated with Babcock forceps. The resulting
loop is ligated with a rapidly absorbed suture (traditionally catgut, which
is no longer universally available) and resected.
3. The removed piece of tube should be 12 cm long and should not be divid-
ed too close to the ligature as otherwise the vessels can retract and bleed.
4. After the ligature dissolves, the two stumps of the tube retract and move
apart. 34 cm of tube are destroyed with this technique.
5. LabhardtUchida tubal sterilization: this technique is somewhat more com-
plicated and difficult than the Pomeroy technique. It is suitable especially
for postpartum sterilization following cesarean section.
6. The tube is elevated with two Babcock forceps at the junction between the
isthmus and ampulla. 12 mL of saline are injected beneath the serosa,
possibly with added epinephrine. The serosa of the tube is incised on the
antimesenteric side over a distance of about 2 cm and the tube is shelled
out. Previous ligature of the vessel supplying this segment of the tube,
located in the broad ligament, is recommended.
7. The tube is ligated on both sides and roughly 1.5 cm of tube is resected.
The incised serosa between the two tube stumps is closed with a fine
continuous suture (4 0), burying the end of the tube nearer to the uterus
between the peritoneal layers of the mesosalpinx. 34 cm of tube are
destroyed.
IV Adnexa 4.3 Surgical Techniques

Special Technique Open Sterilization Operations

Fig. 4.3-27 Postpartum sterilization. Curved postpartum; otherwise, involution of the uterus
subumbilical excision (minilaparotomy), fol- makes it impossible to find the tubes by manip-
lowed by a longitudinal (as shown) or trans- ulation of the uterus. The ability to visualize the
verse incision of the fascia. The procedure tubes with certainty is the limiting factor of this
IV must be performed within the first 48 hours technique.

98

Fig. 4.3-28 Dislocation of the tube, for ex- tual partial salpingectomy is performed in the
ample, by means of a ureter hook or Babcock isthmus region using the Pomeroy technique
forceps (critical point of the operation). The (forming a loop and resecting the loop) or a
tube must then be exposed as far as the end simple partial salpingectomy.
of the fimbriae for secure identification. The ac-

Fig. 4.3-29 Pomeroy technique. A loop of for example, Babcock forceps. Excessive trac-
tube is formed (12 cm long) and ligated with tion can cause tears and bleeding from the
a rapidly dissolving suture at its base. The tube mesosalpinx.
has to be held with an atraumatic instrument,
IV Adnexa Open Sterilization Operations

IV
99

Fig. 4.3-30 Resection of a segment of the the original description, particular importance Fig. 4.3-31 LabhardtUchida technique. the often troublesome hemostasis toward the
loop of tube ligated at its base. The stumps was attached to a rapidly absorbable suture so Subserosal injection of saline, with added epi- mesosalpinx and prevents accidental coagula-
can be lightly coagulated for hemostasis. In that the stumps can move apart. nephrine if the surgeon wishes. This facilitates tion of the vessels running in it.

Fig. 4.3-32 Enucleation of the tube from its ature of the tube on both sides and excision of Fig. 4.3-33 Continuous serosal suture after layers of the mesosalpinx. The vessels of the
serosal covering after an initial antimesosal- approximately 1.5 cm of tube. resection of the tube segment. The end closer mesosalpinx are spared, if possible.
pingeal incision about 2 cm long. Separate lig- to the uterus is buried between the peritoneal
IV Adnexa 4.3 Surgical Techniques

Complications Concurrent and Postoperative Treatment


Pregnancy: the likelihood of becoming pregnant again after tubal steriliza-
The patient should be aware that she should consult a doctor promptly if preg-
tion depends on the patients age and on the technique employed. In the
nancy is suspected to rule out tubal pregnancy. The reaction But I cant get
largest available studies, the techniques of partial salpingectomy presented
pregnant can have serious consequences.
here have resulted in a cumulative 10-year pregnancy rate of up to 10% in
women under the age of 30 and just less than 4% in women over the age of
35. Overall, the probability of suffering a tubal pregnancy is described as
1.2% 1.8% over 10 years depending on whether the patients were under Limits of the Method
or over 30 years of age. In women who wish to have the procedure reversed, the chances of success de-
Influence on the menstrual cycle: the available data do not suggest that pend on the extent and location of the destroyed segment of the tube. The best
the menstrual cycle is influenced by tubal sterilization. chance of success is when the tube defect is in the region of the isthmus and the
Wrong decision: after 10 yearsdepending on the source5% 20% of remaining vital segments of the tube together are over 5 cm long. If the residual
women have regretted the decision for permanent sterilization at least tube length is less than 3 cm, refertilization surgery is not usually useful. The
once, with hindsight. The younger the patient, the more likely that she younger the patient was at the time of sterilization, the more often refertilization
will subsequently regret the procedure. by tube reconstruction is desired. When discussing the risks and alternatives,
vasectomy for the womans partner should not be forgotten.

IV
100
Abdominal 4.3.1.5 Open Infertility Surgery

Aims and Methods


If pregnancy does not occur in a relationship, this can cause severe stress for
Indications and Contraindications
both partners. The causes of infertility in women and men are varied. Uterine
causes such as synechiae, septa and submucous myomas, tubal causes such as Indications
tubal stenosis, postinflammatory tube occlusion, and general intra-abdominal The optimal indication for tubal surgery is tubal infertility confirmed by diag-
causes such as adhesions and endometriosis can be treated surgically. The tra- nostic hysteroscopy and laparoscopy, and also by laparoscopic chromopertuba-
tion, after exclusion of other factors in infertility. Classic and especially suitable
ditional technique of tube reconstruction will be discussed below, initially
situations are previous sterilization, proximal tubal occlusion, terminal tubal
through an open abdominal approach. About 30% 40% of cases of female infer- occlusion, and tube phimosis. Infertility factors such as submucous myomas or
tility are attributed to primary tubal infertility. Considerable success and preg- intrauterine septa that can be treated endoscopically should also be managed
that way. The partner should also be investigated. Ideally, the patient is young
nancy rates of up to 50% 60% after tubal reconstruction have been achieved by
and the tubal dysfunction should be manageable. This applies particularly after
consistent introduction of microsurgery, that is, use of an operating micro- tubal ligation or partial salpingectomy for sterilization.
scope, and extremely fine sutures (70 and 80). However, these results are of-
Contraindications
ten limited to patients below the age of 30 with only mild tubal pathology. The
success rates are 1020% in women aged over 35 years with advanced tubal pa- Contraindications are not purely medical and anesthetic but include absence of
laparoscopic assessment of the site and absence of investigation of the partner.
thology or greatly shortened tubes postoperatively. Whether a patient should
Other relative contraindications, because of the very low success rates, are
be subjected to laparotomy on this account has always been controversial. Par- tuberculosis of the tube, severely sclerosed rigid tubes, recently operated tubes
ticularly to avoid stressful surgical interventions, IVF has become the standard without an ampulla or without a fimbrial end, a postoperative tube length of
treatment of female infertility, together with the intracytoplasmic sperm injec- less than 4 cm, and very prominent or thick-walled hydrosalpinx. Ultimately,
the patient has to decide what success rate is acceptable for her, when weighed
tion (ICSI) technique for male infertility, with similar or even better results, de- against the perioperative risks. The psychologic effect must not be ignored.
pending on age group and the initial tube condition. This means that surgical
experience with the technique is slowly being forgotten. Thus, microsurgical
tube reconstruction was and is a technique that demonstrated good success Operation Risks and Informed Consent
rates in individual cases but needs to be regarded critically and possibly rede- Besides the not inconsiderable risks of laparotomy such as pain, scarring,
fined, especially when performed using the new laparoscopic technique. Other delayed wound healing, hernia, or hemorrhage, the markedly increased risk of
tubal pregnancy after tubal reconstruction is a major risk. Following laparo-
fertility assistance techniques, such as salpingoneostomy and fimbrioplasty,
scopic evaluation of the operation site, the patient must be informed in detail
are also discussed below. Here, too, success in an individual case should be con- about the success rates that can be expected and about the alternatives provi-
trasted with the risk of tubal pregnancy and the feasibility of conservative re- ded by other reproductive medicine measures such as IVF.
productive medicine measures.
IV Adnexa Open Infertility Surgery

8. Under the operating microscope or using loupes, any adhesions on the


Operation Planning tube and fibrotic tissue between the two parts of the tube are excised
1. Medical history, reproductive medicine and endocrine investigation of the with the microelectrode on the mesosalpinx. The tube vessels are ligated
causes of infertility (6 0 suture).
2. Comprehensive reproductive medicine investigation of the patients 9. The isthmic end of the tube is freshened bit by bit with a small scalpel
partner until healthy tissue is reached. Oozing sites are coagulated. A probe is in-
3. Diagnostic hysteroscopy and laparoscopy to evaluate the site. Ideally, the serted from the fimbrial end and the sealed end of the ampullary part of
laparoscopy should be performed by the surgical team. Theoretically, it the tube over it is excised.
would be possible to perform laparoscopy and laparotomy at the same 10. For accurate approximation of the tube luminum, it is helpful to insert a
session. However, a two-stage procedure is better for counseling and plan- splint as guide catheter. However, some surgeons omit the splint so as not
ning to injure the mucosa.
4. Exclusion of other gynecologic pathology 11. The two wound surfaces are fixed by a retaining suture (60) in the meso-
5. Detailed discussion of the overall situation, the anticipated chances of salpinx.
success and possible reproductive medicine alternatives 12. The tube is anastomosed in two layers with an absorbable or nonabsorb-
6. Anesthesiologic preoperative investigations depending on the patients able suture (80 or 9 0). Suture of the muscularis begins on the mesen-
age and local practice teric side at 6 oclock; 46 sutures are placed, with the knots on the outside.
To traumatize the tissue as little as possible, it should not be grasped with
7. Thrombosis prophylaxis: LMWH, ATS
forceps when passing the needle through it, but the needle should be
8. Antibiotic prophylaxis: 1st or 2nd generation cephalosporin < 30 minutes
pushed through using counter-pressure. Caution: it is advisable to tie the
before surgery
sutures only when they have all been placed.
9. Difficult surgery; takes 35 hours; surgeon and one assistant
13. The peritoneum of the tube and mesosalpinx is closed fully with a row of IV
Anesthesia and Positioning interrupted sutures or two semicircular continuous sutures, starting on 101
the antimesenteric side.
Positioning: level supine position with legs abducted for primary open
14. After completing the anastomosis, the splint is removed, usually from the
abdominal access; heated underlays and warm-air covers
fimbrial end. Tube patency is checked by intrauterine injection of dye.
for longer operations
15. Problems can occur when there is disparity between the tube lumina and
Draping: abdominal window
diameters. A possible solution is to narrow the larger opening (e.g., in the
Anesthesia: intubation anesthesia, possibly epidural anesthesia
ampullary segment of the tube) by a few transverse sutures on the mesen-
Special Instruments teric side. Conversely, the smaller opening in the isthmic segment can be
slit for approximately 3 mm on the antimesenteric side, thereby enlarging
Laparotomy set
it. The corners are capped. Finally, the sutures in the muscularis can be
Operating microscope, suitable microsurgical instruments
placed closer together on the isthmic side and further apart on the ampul-
Sutures: microsurgical suture material (40 to 90) lary side.
16. In individual cases it can be necessary to anastomose the healthy part of
the tube directly to the intramural part. First, a vasoconstrictor substance
Procedure is injected generously into the uterine fundus. The uterine horn is then
resected bit by bit until the open lumen of the intramural segment of the
Preparation tube is reached and dye emerges. Resection must be continued as long as
1. Intubation anesthesia fibrotic tissue is still encountered on the cut surface around the tube
2. Positioning: simple supine positioning with legs abducted but level is lumen. The same technique is then used to open the lumen of the distal
usually adequate. Optimal positioning must be ensured when classic leg segment of the tube. A plastic splint assists accurate approximation, which
supports are used, especially during long operations can be difficult especially when placing the sutures in the uterine horn.
3. Skin preparation, bladder catheter, sterile draping: abdominal access 17. Numerous complicated techniques such as tubocornual (intramural) anas-
tomosis in the opened uterus or tubouterine implantation at the uterine
Operation horn after punching out the cornual part of the tube, along with implan-
Tubal reanastomosis tation techniques on the posterior wall of the uterus, must be regarded
critically nowadays in view of the alternative of IVF, especially as they
The important basic principles and requirements for microsurgical operation
result in a high risk of scarring, which does not promote fertility.
technique are described below:
1. An adequately large abdominal incision is made to obtain good access to Fertility assistance
the operation area. 1. Adhesiolysis and fimbrioplasty are the most important additional tech-
2. The genital organs are elevated by packing the vagina and/or pouch of niques; today, these are within the domain of laparoscopy. The aim is
Douglas with moist towels, ideally in a plastic cover. mobilization of the tube without injuring its serosa. Tube mobility is an
important aspect of fertility overall. Identification of residual fimbriae,
3. The adnexa are laid on a silastic sheet for anastomosis, fimbrioplasty, and
meticulous dissection, and accurate hemostasis are paramount. Adhesions
salpingoneostomy.
between the fimbriae and the ovary must be divided, ensuring that the
4. The area is constantly and repeatedly irrigated with lactated Ringer
fimbrio-ovarian ligament is well vascularized.
solution to prevent the tissue from drying out.
2. Salpingoneostomy is indicated when the fimbrial end of the tube is closed
5. Careful hemostasis is achieved, either with a fine unipolar microelectrode
(tube phimosis) with sactosalpinx or hydrosalpinx. The first step in re-
or with bipolar forceps.
opening the closed end of the tube is finding the tubes dimple. Retro-
6. All peritoneal defects should be reperitonealized as far as possible, grade filling of the tube as in chromopertubation can sometimes be
if necessary transplanting a peritoneal flap from the abdominal wall. helpful. After opening the tube in the often avascular region of the dimple,
7. All splints should be removed at the end of the operation, as they can cross-incisions (radial splitting) are made. The aim is to make stellate
cause infections and fibrosis if they remain in place longer. incisions from within between any folds of mucosa still present. Finally,
the resulting pointed flaps are everted and fixed with interrupted sutures
(8 0). Use of the finest possible suture material in the tube is particularly
important.
IV Adnexa 4.3 Surgical Techniques

Special Technique Open Fertility Operations

IV
102

Fig. 4.3-35 Tubotubal anastomosis. The men is crucial. Acceptable data are available
wound surfaces are approximated by a retain- only for this technique. The operation starts
ing suture in the mesosalpinx. Working under with careful adhesiolysis and mobilization,
the operating microscope in the open abdo- avoiding serosal defects on the tubes.

Fig. 4.3-34 Testing tube patency by trans- provised during surgery. One alternative is the
mural injection of dye into the cavity with conventional uterine sound used for laparo-
the cervix clamped. Various special instru- scopic chromopertubation and another is a bal-
ments have been developed and can also be im- loon catheter introduced transcervically.
IV Adnexa Open Fertility Operations

IV
103

Fig. 4.3-36 The muscularis is sutured by four be helpful for precise approximation. All the Fig. 4.3-37 Serosal sutures with the aim of splint is usually removed from the fimbrial
interrupted sutures. To obtain tube ends for ap- muscularis sutures are placed first and then closing the peritoneum of the tube and meso- end. Tube patency is checked by intrauterine
proximation, freshening the tube stumps bit by tied. salpinx completely with a row of interrupted su- dye injection.
bit with a scalpel is recommended. A splint can tures. When the anastomosis is complete, the

Fig. 4.3-38 Interstitial anastomosis. Bit by A splint is inserted from the fimbrial end. The Fig. 4.3-39 The two wound surfaces are ap- tures through the concave uterine horn can be
bit resection of the uterine horns after gener- lumen of the distal tube segment is opened proximated by a retaining suture in the meso- difficult. The mesosalpinx should be closed be-
ously injecting with a vasoconstrictor sub- with the same technique. salpinx and anastomosed with four sutures forehand.
stance. All fibrotic material must be removed. (8 0) through the muscularis. Passing the su-
IV Adnexa 4.3 Surgical Techniques

IV Fig. 4.3-40 Final appearance after complete


closure of the serosa by interrupted sutures
tion; leaving it in place longer can lead to re-
newed obliteration because of local inflamma-
104 (80). The splint is removed after the opera- tory processes.

Fig. 4.3-41 Fertility support by adhesiolysis. the tube must be avoided. The resulting serosal
Removal of strands of adhesions with the mi- defects lead directly to new adhesions. The rule
croelectrode. Any form of blunt dissection of is that adhesions must be divided sharply.

Fig. 4.3-42 Fertility support by salpingosto- and avascular lines running toward it from all Fig. 4.3-43 Introduction of a Teflon rod or the Teflon rod. This is continued until further
my. Incision of the dimple of the hydrosalpinx sides. If necessary, retrograde filling of the the blunt end of the irrigation needle through stellate incisions can be made from the inside
with the microelectrode. This can usually be tube (chromopertubation) can make opening the opening. Radial incision of avascular ad- between the mucosal folds that are still pres-
identified by the characteristic vascular ar- easier. hesion lines with the microelectrode against ent.
rangement: an avascular center, with vessels
IV Adnexa Open Fertility Operations

IV
105

Fig. 4.3-44 Eversion of the stellate mucosal irrigation. A generous incision is recom- Fig. 4.3-45 Fixing the opened and everted with the forceps. The sutures are placed in such
tips and radial fixation to the serosa of the am- mended: an incision that is too small, with inad- ostium of the tube to the serosa. The sutures a way that the tips remain free where possible
pulla with a few interrupted sutures (80). equate eversion of the fimbriae, often leads to are placed with the counter-pressure technique (neofimbriae).
Hemostasis is particularly important and is reocclusion. so that the easily injured mucosa is not gripped
achieved by accurate electrocoagulation under

Fig. 4.3-46 If the tube wall is rigid (thick-wal- fishmouth transverse incision or cruciate inci- Fig. 4.3-47 Everting and fixing the mucosal very stiff, this segment of the tube must be re-
led sactosalpinx), the ampullary part of the sion is recommended. The mucosal tips are tips produced by a cruciate incision. When sected. Following hemostasis, the free tube
tube is opened by a cruciate incision. It is often everted and fixed to the serosa with interrupted there are extensive honeycomb-like adhesions end is everted and fixed.
not possible to find avascular incision lines. A sutures. in the ampulla and/or the wall of the tube is
IV Adnexa 4.3 Surgical Techniques

Complications Limits of the Method


General complications specific to access: these include delayed wound With the successful conservative reproductive medicine techniques now avail-
healing, scarring, hemorrhage, and injuries, for example, of the bowel or able, fertility surgery, especially tubal reconstruction, has been somewhat for-
urinary organs. gotten. The temptation to use the established microsurgical techniques laparo-
Failure of the operation: although successful pregnancy rates of up to 70% scopically, thus avoiding laparotomy, has increased. It is certain that acceptable
are reported when the initial situation is optimal, the average rate after success rates were always sparse in the literature and exist only for open micro-
microsurgery is probably only 50% and falls to below 20% when the initial surgical techniques. In the largest series of nearly 700 patients, live birth rates
situation is poor. of 50% 60% were achieved. Ampullary anastomoses have lower success rates
Tubal pregnancy: this is the other most important complication; the inci- (40%), while isthmic anastomoses have higher success rates (75%). The highest
dence is reported in the literature as 4% 10%. operation success rate was 85% after ring or clip sterilization, when performed
within 5 years after sterilization. The superiority of the microsurgical compared
with the conventional technique has been demonstrated again and again. The
Concurrent and Postoperative Treatment poorest results are seen after salpingoneostomy. In this case, microsurgery has
resulted in live birth rates of only 20%30%. This success rate can be even lower
Apart from the usual perioperative antibiotic treatment, other approaches such depending on the size of the hydrosalpinx, the condition of the fimbriae, the
as intraperitoneal or systemic administration of corticosteroids have not been presence or absence of rugae (on hysterosalpingogram), and the extent of the
generally accepted. The same holds for the use of adhesion barriers. adhesions.

IV
106

Abdominal 4.3.1.6 Abdominal Surgery of Endometriosis

Aims and Methods


Characteristics. Endometriosis is one of the most common benign gynecologic ed as the most effective treatment. In symptomatic endometriosis, all palpated
diseases. It occurs in sexually mature women and is hormone-dependent (es- and macroscopically visible endometriotic lesions should first be completely
trogens). The disease is often called a chameleon. This refers to the nonspecific excised. Depending on the superficial and deep extent of the peritoneal endo-
symptoms, the varying degrees of severity, and the many locations of the dis- metriosis, this can be achieved by bipolar coagulation, laser, or monopolar scis-
ease. One of the most frequent symptoms is pain, for example, chronic diffuse sors. Accompanying adhesions should be divided to restore the normal anato-
pelvic pain, dysmenorrhea, dyspareunia, or pain on defecation. Other symp- my as far as possible. The treatment of symptomatic deep endometriosis con-
toms can be bleeding disorders, contact bleeding, bowel evacuation disorders, sists of resection. Because of the usually marked fibrosis of these endometriotic
and infertility. The most frequent locations are the ovaries and the pelvic peri- lesions, the widespread involvement of neighboring organs, and the fusion of
toneum (peritoneum in the pouch of Douglas, ovarian fossae, uterosacral liga- the original anatomic layers, these procedures are extremely complex and
ments). Endometriosis is a benign disease but can infiltrate and interfere with comparable to cancer surgery. When the rectum, sigmoid colon, bladder, or
other organs. The bowel is affected most often. The rectum is often infiltrated ureter is involved, an interdisciplinary procedure is reasonable, as complete re-
by pronounced endometriosis low in the rectovaginal septum. The severity of section of the endometriosis is the primary aim in these cases. Technical ad-
endometriosis is classified according to the Revised American Society for Re- vances in medicine and the increasing level of surgical training mean that min-
productive Medicine Classification of Endometriosis, 1996, or alternatively by imally invasive operation techniques are becoming ever more important in en-
the more recent ENZIAN classification, 2003, and the AAGL Classification of En- dometriosis surgery, compared with the open abdominal approach.
dometriosis, 2013 (p. 66).

Treatment. The exact etiology of endometriosis is unknown. The hypothesis of


retrograde menstruation and implantation contrasts with the theory of local
metaplasia. For this reason, the reported reccurence rates of endometriosis
range from 5%20% within five years in menstruating women. The treatment
of endometriosis depends on the symptoms, the patients age, the severity,
the location, and the desire to preserve fertility. Opinions are divided on the
usefulness of pre- or postoperative hormone treatment. Gestagens as well as
gonadotropin-releasing hormone (GnRH) agonists are used for medical thera-
py in simple and more severe cases. The Cochrane review of these therapies
suggests that the success in similar for these two medications. The aim of endo-
metriosis surgery is to prolong the symptom-free period and, where neces-
sary, restore fertility. Operative removal of the endometriotic lesions is regard-
IV Adnexa Open Fertility Operations

Indications and Contraindications Procedure


Indications Preparation
Abdominal endometriosis surgery should be performed only when strictly indi- 1. Intubation anesthesia
cated. It is usual to confirm the presence of severe endometriosis by laparoscopy 2. Positioning: as with all prolonged operations, great attention must be paid
initially, in addition to thorough gynecologic investigation and diagnostic imag- to positioning with padding of exposed sites and provision of adequate
ing. Many authors even require histologic confirmation of ectopic endometrium warmth
via laparoscopy. The indications for abdominal or combined abdominal and 3. Examination under anesthesia
vaginal surgery are severe forms of endometriosis, when endoscopic access is 4. Skin preparation, bladder catheter, sterile draping: abdominal access
not possible, and when conservative treatment has been unsuccessful, as is
usually the case with advanced endometriosis. Operation
1. Suprapubic transverse incision.
Contraindications
2. Exposure and opening of the fascia.
Surgery is contraindicated in patients without symptoms, regardless of the 3. Blunt or sharp incision of the peritoneum.
extent of the endometriosis, in pregnancy, and in patients with severe bleeding 4. Insertion of self-retaining retractor.
tendencies. Complex procedures have significant risks of complications and
5. Exploration of the abdomen and pelvis by inspection and palpation to
these risks need to be explained to the patient so that she can make an informed
establish the endometriotic lesions.
decision between the benefits and risks and determine whether or not surgery
6. If bowel adhesions are present, these are divided with dissecting scissors.
is appropriate.
7. The bowel is moved to and packed in the upper abdomen with abdominal IV
packs.
8. Depending on their size, small superficial endometriotic nodules are elec- 107
Operation Risks and Informed Consent
trocoagulated, vaporized with the CO2 laser, or excised with a scalpel.
Informed consent must be particularly detailed in view of the benign nature of Caution: injury to the ureters or bowel must be avoided.
the disease and because ultimately the procedure is elective. Besides general 9. When optimization of fertility is desired, a combination of blunt and sharp
operation risks (bleeding, infections, delayed wound healing), the possibility salpingo- and ovariolysis is employed.
of pain persisting must be discussed. The development of adhesions must be 10. Ovarian endometriomas are removed with a scalpel or electrosurgically.
explained, as must the risk of injury to the uterus, adnexa, ureters, bowel, and
Extensive endometriosis of the peritoneum of the pouch of Douglas
bladder. The need to remove organs if they are injured or severely affected by
endometriosis must be discussed in particular detail. The possibility of recur- 1. The course of the ureters is exposed bilaterally, placing a sling around the
rence and potential need for further surgery should also be discussed. ureters.
2. The involved peritoneum is resected meticulously from lateral to medial
with dissecting scissors.
Operation Planning Endometriosis of the posterior vaginal fornix
1. Medical history, accurate pain history, clinical examination with vaginal 1. The affected vaginal fornix is opened sharply.
and rectovaginal palpation, documentation 2. The endometriotic nodules including the affected vaginal mucosa are ex-
2. Diagnostic imaging (ultrasonography, MRI) cised with dissecting scissors (slight counter-pressure from a finger in the
3. With bowel involvement and/or hydronephrosis: proctocolonoscopy or vagina can be helpful).
urologic investigation 3. The opening in the vagina is closed with interrupted or Z sutures (suture
4. Discussion of the extent of the operation, if necessary interdisciplinary, material: absorbable, braided, 10 or 00).
determination of the procedure, discussion of relevant topics (fertility and Mild endometriosis of the anterior wall of the rectosigmoid colon
organ preservation) 1. An incision around the endometriosis foci in the rectosigmoid is made
5. Consent to the procedure with a scalpel.
6. Anesthesiologic preoperative investigations according to local practice 2. The endometriotic nodules including the affected anterior wall of the rec-
7. Thrombosis prophylaxis: LMWH, ATS tosigmoid are excised with dissecting scissors.
8. Preoperative laxatives for bowel preparation 3. The anterior wall of the rectosigmoid is butt-closed by interrupted sutures
9. Antibiotic prophylaxis: 1st or 2nd generation cephalosporin 30 minutes (suture material: absorbable, braided, or monofilament 30).
before surgery, with the addition of metronidazole for bowel procedures Severe endometriosis of the rectosigmoid colon
if appropriate
1. The rectosigmoid is mobilized.
10. Difficult surgery; takes 34 hours; surgeon and at least one assistant
2. The affected area of rectosigmoid is resected using staplers.
Anesthesia and Positioning 3. Rectosigmoid end-to-end anastomosis is done with a stapler.
Positioning: level supine position with legs abducted, and with legs Conclusion of the operation
on supports if abdominoperineal access is required; 1. Repeat check for completeness of endometriosis clearance.
access to the vagina and rectum should be readily available 2. Careful hemostasis, with insertion of a Robinson drain if necessary.
Draping: abdominal window 3. The abdomen is closed in the usual way.
Anesthesia: intubation anesthesia

Special Instruments
Laparotomy set
Long instruments, stapler
IV Adnexa 4.3 Surgical Techniques

Special Technique Abdominal Surgery of Endometriosis

IV
108

Fig. 4.3-49 Removal of an ovarian endome- plete excision is possible, besides opening and
trioma by incising around the endometriosis destroying the diseased tissue. If optimization
on the surface of the ovary with a scalpel or of fertility is desired, partly blunt and partly
electrosurgically. Genuine endometriomas do sharp salpingolysis and ovariolysis may be indi-
not have a classical capsule so that only com- cated beforehand.

Fig. 4.3-48 Depending on their size, small su- significance of small endometriotic nodules for
perficial endometriotic nodules are electroco- pain symptoms is unclear. The trend is rather
agulated, vaporized with the CO2 laser or ex- toward excision than to possibly superficial
cised with a scalpel. Caution: at critical sites and incomplete destruction which sometimes
there is a risk of ureteral or bowel injury. The does not eliminate the scar tissue.

Fig. 4.3-50 Removal of an ovarian endome- the ovaries also destroys healthy ovarian tissue.
trioma by enucleation of the endometriosis In patients close to menopause or who suffer
in full with dissecting scissors. Residual endo- particularly severely, removal of the ovaries as
metriotic cells can be destroyed on the one an additional curative measure may be consid-
hand by extensive coagulation. On the other ered.
hand, excessive coagulation in the region of

Fig. 4.3-51 The abdomen is explored extensive foci of endometriosis in the pouch of
carefully by inspection and palpation for precise Douglas and on the pelvic walls. Often, it is not
localization of the endometriosis. The bowel is the dark foci typical of endometriosis that pre-
then replaced in the upper abdomen and dominate but rather the plaquelike scars that
packed away. The illustration shows multiple result from the endometriosis itself.
IV Adnexa Abdominal Surgery of Endometriosis

IV
109

Fig. 4.3-52 Involvement of the rectovaginal cal sites in the rectovaginal septum are the pos- Fig. 4.3-53 When the peritoneum of the shown), or conventionally from the lateral as-
septum is diagnosed on examination under an- terior vaginal wall and the anterior wall of the pouch of Douglas is extensively affected by en- pect, as in oncologic operations (lateral to the
esthesia. The deep extent of the endometriotic rectosigmoid. dometriosis, which also involves the uterosacral infundibulopelvic ligament). After opening the
nodules can be established by palpation. Typi- ligaments, exposure of the ureter is essential. peritoneum, the ureter is exposed, a loop is
The ureter can be dissected from the medial placed around it, and its course is followed until
aspect, i.e., directly in the medial layer (as it crosses the uterine artery.

Fig. 4.3-54 Exposure of the endometriosis distancing from the posterior wall of the uter- Fig. 4.3-55 Incision of the peritoneum of The incision should not be made too close to
in the rectovaginal septum with counter- us, and level 2 allows distancing from the rec- the pouch of Douglas after exposure, dissec- the uterus as the septum is then difficult to ex-
pressure from a finger in the vagina. The ar- tosigmoid. Alternatively, dissection from the tion, and looping of both ureters. The aim is pose. On the other hand, the rectum must not
rows show the areas through which the endo- vaginal aspect is also possible. to open and dissect the rectovaginal septum. be injured either.
metriosis can be dissected free. Level 1 allows
IV Adnexa 4.3 Surgical Techniques

IV
110

Fig. 4.3-56 When the posterior fornix of the be helpful. If the anterior wall of the rectosig- Fig. 4.3-58 The opened vagina is closed with ment, 3 0). Finally, it is important to perform
vagina is involved, this is opened with a scalpel moid is involved, an incision is first made interrupted sutures or Z sutures (absorbable, a thorough inspection to ensure complete re-
and the endometriosis is excised in full with dis- around the endometriosis and it is then excised braided, 10 or 00) and the anterior wall of moval of the endometriosis and careful hemo-
secting scissors, including the affected vaginal completely including the affected anterior wall the rectosigmoid is butt joined with interrupt- stasis; a Robinson drain can be placed if neces-
mucosa. At this stage of dissection, simulta- of the rectosigmoid (using scissors or monopo- ed sutures (absorbable, woven or monofila- sary.
neous vaginal examination by the surgeon can lar needle).

Fig. 4.3-57 When there is major involvement moid is then resected using staplers (left); final-
of the rectosigmoidwhich is often apparent ly, rectosigmoid end-to-end anastomosis is per-
only at operationthe rectosigmoid is first mo- formed with a stapler (right).
bilized and the affected region of the rectosig-
IV Adnexa S u r g e r y o f M a l i g n a n t A d n e x a l Tu m o r s / D e b u l k i n g O p e r a t i o n s

Complications Concurrent and Postoperative Treatment


General complications specific to access: secondary hemorrhage, infec-
Postoperatively, the outcome of the surgery should not be assessed until after
tions, or delayed wound healing may have to be managed by reoperation
about 3 months. If the endometriotic lesions have been removed in full, patients
or antibiotic treatment.
are usually asymptomatic. If the patient had failed to have children despite
Ureteral injuries: these can occur due to electrocoagulation or laser
wishing for them, pregnancy should be attempted promptly. After fertility-
vaporization of endometriotic lesions close to the ureter.
preserving surgery for severe endometriosis, pregnancy carried to term can be
Anastomotic or suture leakage in the rectosigmoid: this complication expected in about half the patients. Opinions differ regarding the usefulness of
occurs in roughly 5% of cases. It can be managed by a temporary ileostomy postoperative medical treatment. Following complete resection of severe endo-
for 810 weeks, with subsequent closure. metriosis, treatment with GnRH analogues immediately after the operation
Dysfunction of defecation or bladder voiding: these are very rare compli- does not demonstrate any benefit. If symptoms persist postoperatively, ovula-
cations following resection of very deep endometriotic lesions in the tion inhibitors, gestagens, or GnRH analogues can be employed.
rectovaginal septum.
Abscesses: they can arise in the region of the tubes and ovaries after
tubo-ovariolysis. Laparoscopic revision with drainage under antibiotic Limits of the Method
protection can treat this problem.
When the open abdominal approach is employed, every method allowed by
Recurrence: further symptomatic deep endometriosis can occur if lesions
open access (inspection and palpation) should be fully exploited in order to
are overlooked and left behind. The recurrence rate is 14% 22%.
remove the endometriosis completely. The risk of recurrence increases greatly
when residual endometriosis is left behind. Nevertheless, caution is warranted,
especially when there are marked endometriotic nodules extending bilaterally IV
in the pararectal area as far as the walls of the pelvis. Radical excision of these
nodules increases the risk of major bladder dysfunction because parasympathet- 111
ic nerve fibers that innervate the bladder can be injured. Involvement of the
supporting structures (parametrium, paracolpium) and the pelvic wall increases
the risk of ureteral injury.

Abdominal 4.3.1.7 Surgery of Malignant Adnexal Tumors/Debulking Operations

Aims and Methods


Characteristics. The ovaries are the site of numerous malignant neoplasms, tage of a radical operation disappears when residual tumors greater than 2 cm
which arise in the different cell types that are physiologically present there: in diameter are left behind. The typical ovarian cancer operation is based on a
epithelium (peritoneum, celomic epithelium), germ cells (oocytes), sex cord wealth of data showing that cytoreduction of malignant tissue and standard
stromal cells (e.g., granulosa cells, theca cells), and connective tissue cells. chemotherapy with six cycles of carboplatin and taxol prolongs the patients
Ovarian cancer of epithelial origin is most common, accounting for nearly 70% recurrence-free survival, sometimes by years. The best treatment effect is ob-
of all ovarian malignancies. They are classified as serous, mucinous, endome- tained by a combination of maximal cytoreduction and optimal chemotherapy.
trioid, and clear-cell adenocarcinomas, with serous adenocarcinoma account- Because of the ultraradical approach, the treatment of ovarian cancer is usually
ing for over half. The term ovarian cancer usually refers to this disease. From interdisciplinary. If the goal of optimal cytoreduction is pursued, this will ne-
the epidemiologic point of view a womans lifetime risk of developing ovarian cessitate bowel resection in about 30%, exposure of the diaphragm in
cancer is about 1 : 70. Among cancer deaths, it is in fifth place, after lung cancer, 15% 20%, and splenectomy in up to 10%. The abdominal surgeons and possibly
breast cancer, colon cancer, and pancreatic cancer. Because there is no effective urologists involved need to have an oncologic understanding of this disease,
screening method and early symptoms are absent or very slight and nonspecif- which metastasizes mainly intra-abdominally. In a patient who has had opti-
ic, it is usually diagnosed at an advanced stage, which helps to explain the so- mal surgery and postoperative treatment, survival times of 5060 months can
bering 5-year survival rate of only 30% 40%. be achieved in advanced FIGO stage III. The surgical treatment approach must
focus on this valuable gain in time.
Treatment. The basic surgical approach for all ovarian malignancies is the same,
regardless of the histologic type: adnexectomy, hysterectomy, pelvic and para-
aortic lymphadenectomy, omentectomy, and maximum reduction of the visi-
ble tumor (debulking, complete peritonectomy), if possible with no further
tumor visible macroscopically (R0). If achieving this aim requires bowel resec-
tion, splenectomy, diaphragm and peritoneal resection, or partial bladder re-
section, these measures are reasonable if they allow the desired R0 situation
to be attained. The available studies show that the significant survival advan-
IV Adnexa 4.3 Surgical Techniques

6. Negative peritoneal cytology (I A)


Indications and Contraindications 7. Negative biopsy of the contralateral ovary and negative omental biopsy
(I A)
Indications
8. Negative staging in the form of omentectomy, pelvic and para-aortic
The indication for a typical ovarian cancer operation is histologically confirmed lymphadenectomy (I A)
ovarian carcinoma. The clinician is usually confronted with a straightforward
Points 48 confirm stage I A. If these criteria are followed, the risk of recurrence
diagnostic situation, consisting of a suspicious pelvic tumor, ascites, and a mark-
is very low and virtually identical compared with the total operation.
edly raised CA125 tumor marker. Because of the patients historynonspecific
gastrointestinal symptoms are often the reason for consulting a physiciana CT
of the abdomen is usually performed, which raises the suspicion of a diffuse
infiltrating process. When the clinical situation is clear, primary vertical lapa-
Operation Risks and Informed Consent
rotomy is indicated as the next step. However, every gynecologic surgeon can Typical ovarian cancer surgery is one of the operations with the greatest morbid-
report situations, often in younger patients, when they were surprised at oper- ity and mortality in gynecology. This is partly due to the extent of the operation,
ation by severe endometriosis or a subacute Chlamydia infection. Any form of but also partly to the patients often poor initial health status. Classification of the
intraperitoneal irritation leads to an increase in CA125, and CT imaging is less patient into one of the ASA groups (see Chapter 1) has a crucial influence on the
than optimal, especially for demonstrating pelvic organs. Diagnostic laparoscopy frequency of peri- and postoperative complications, which occur in between
is therefore recommended when there is the least doubt about the diagnosis 4 and 50% of patients, depending on severity and ASA classification. The overall
and the subsequent surgery, especially in premenopausal patients. Depending mortality is 1% 2%, and this is determined by the initial clinical situation rather
on the overall clinical situation and the patients age and wishes, further surgery than the extent of the operation. The postoperative course is often markedly bet-
can then be performed in one or two stages. Diagnostic sampling of lesions ter after a long but successful (R0) operation than after a short procedure that
IV suspicious for malignancy must be strictly avoided. leaves a large residual tumor. The complications range from urinary tract infec-
tions to delayed wound healing, thrombosis, anemia requiring transfusion,
112 Contraindications
postoperative ileus, myocardial ischemia, pneumonia, and pulmonary embolism.
An intraperitoneal metastatic process of primary peritoneal or nonovarian The transfusion rate is between 20% and 30%, partly because of the chemotherapy,
origin may be a contraindication to an ultraradical procedure. Ovarian breast which ideally will start within 34 weeks postoperatively. The underlying disease
cancer metastases, diffuse peritoneal metastases from pancreatic cancer, or a or suspected disease should be explained to the patient. The patient should un-
metastatic gastrointestinal tumor can imitate ovarian cancer clinically. The derstand why such an extended operation is being recommended. The postoper-
Krukenberg tumor, which is an ovarian metastasis from the now rare gastric ative course should be discussed and the importance of early mobilization should
cancer, is a familiar example. Therefore, typical ovarian cancer surgery should be understood preoperatively. The possibility of a stoma should be explained. This
not be performed without adequate breast investigation (mammography, breast is required in fewer than 2% of cases when there is optimal collaboration with the
ultrasonography). The possibility of intraoperative frozen section by a pathol- abdominal surgeons, but is a standard procedure.
ogist experienced in gynecologic pathology together with a discriminating
intraoperative procedure can help to avoid an inappropriately radical operation
with corresponding morbidity from which the patient will not benefit. Intra- Operation Planning
operative differentiation is sometimes impossible. In this case, an individual
1. Medical history, suspected diagnosis (clinical evidence, imaging, CA125),
decision must be made.
assessment of comorbidities and operability
The most important contraindication to typical ovarian cancer surgery of any 2. Exclusion of other gynecologic comorbidities: Pap smear, assessment of
stage is that it is not routine for the surgical team. This is a reflection not so the endometrium (ultrasonography, possibly hysterectomy, curettage)
much of the individual surgeons technical skills but rather of the frequency 3. Exclusion of breast disease: mammography, breast ultrasonography
with which the operation is performed in a hospital.
4. Chest radiograph, standard laboratory tests, cross-matching
Advanced extra-abdominal metastasis of the ovarian cancer, i.e., diffuse intra- 5. Anesthesiologic assessment
hepatic and/or pulmonary metastases confirmed by imaging, is a relative contra- 6. Consultation with abdominal surgery and/or urology if appropriate;
indication. A malignant pleural effusion is not a contraindication for debulking routine colonoscopy is not necessary as the operation team must be
surgery, although individual authors now demand thoracoscopic assessment to prepared for bowel resection during every procedure
rule out solid pleural metastases that would increase the residual tumor volume
7. Discussion of the extent of the operation, postoperative course and
to more than 2 cm. Another relative contraindication is the multimorbid patient,
convalescence
whose natural life expectancy does not significantly exceed that of the inade-
8. Consent to the procedure
quately operated ovarian cancer patient, and the patient who cannot be given
postoperative chemotherapy. 9. Thrombosis prophylaxis: LMWH, ATS
10. Bowel preparation according to local practice
A particularly difficult contraindication for a prolonged ultraradical operation
11. Antibiotic prophylaxis: 1st or 2nd generation cephalosporin < 30 minutes
is the impossibility of successful cytoreduction, i.e., to a residual tumor size of
before surgery, metronidazole for (planned) bowel operation
less than 2 cm. It has long been known that up to 80% of cases classified else-
where as inoperable can be operated optimally in centers experienced in 12. Difficult surgery, takes 48 hours or more, surgeon and ideally two
oncology. Systematic inspection of the abdomen at the start of the operation, assistants; surgical and urologic consultation should be rapidly available
paying special attention to the mesentery and sigmoid mesocolon, the supra-
Anesthesia and Positioning
renal lymph nodes, and liver hilum helps to provide a correct assessment of the
Positioning: level supine position with legs abducted; access to the
critical sites of metastasis at the outset. Often, the answer to the question of
vagina should be readily available; positioning on heated
operability only becomes apparent in the course of the operation.
underlays and with warm air covers is essential; potential
It can be difficult to decide on the indication in a very young patient who has pressure sites require particular attention
not yet completed her family; 7% 8% of all epithelial ovarian malignancies Draping: abdominal window; transvaginal examination should be
occur in women of childbearing age under 35 years. The conditions for fertility- possible at any time
preserving surgery are:
Anesthesia: intubation anesthesia with additional epidural anesthesia
1. Stage I A
2. Well-differentiated serous, mucinous, endometrioid, or clear-cell tumor Special Instruments
(G1) Laparotomy set, self-retaining retractor, appropriate instruments
3. Young woman without children Suture material and appropriate instruments for collaborating depart-
4. Tumor completely encapsulated and without adhesions ments (surgery, urology)
5. No infiltration of the capsule, lymphatic tissue, or mesovarium (I A) Staplers for gastrointestinal anastomoses and resections
IV Adnexa S u r g e r y o f M a l i g n a n t A d n e x a l Tu m o r s / D e b u l k i n g O p e r a t i o n s

fundibulopelvic ligament is then divided separately and ligated after re-


Procedure moval of the large suspected tumor.
3. With early ovarian cancer which is to undergo radical surgery or when ade-
Preparation quate staging is performed, the operation follows this sequence: removal of
1. Epidural anesthesia followed by intubation anesthesia washings for cytology, removal of the suspicious adnexal lesion for frozen
2. Positioning: as in all lengthy operations, great attention must be paid to section, peritoneal biopsies from all four quadrants, omentectomy (when
positioning: padding of exposed sites, provision of adequate warmth. malignancy is confirmed, total infragastric omentectomy including the
A supine position with abducted legs is recommended splenic part is reasonable), hysterectomy and excision of the remainder of
3. Skin preparation, bladder catheter, sterile draping: abdominal access the adnexa, and pelvic and para-aortic lymphadenectomy. Systematic in-
spection at the start of the operation or after removal of the suspicious ad-
Operation nexal lesion is particularly important. It is advisable to proceed in a fixed
order: greater omentum, parietal peritoneum, ileocecal region, right para-
Every ovarian cancer confronts the surgeon with a new and unique appearance
colic gutter, ascending colon, liver, dome of diaphragm, transverse colon,
that depends on the patients individual anatomy and the metastasis pattern of
stomach, lesser omentum, spleen, descending colon, left paracolic gutter,
the disease. It is therefore difficult to describe typical ovarian cancer surgery
the entire small bowel, the mesentery, sigmoid mesocolon, and retro-
step by step. The most important first step is not to be awed by the operation
peritoneal space. Washings should be obtained from several sites, along
site. Ultimately, behind every operation site distorted by tumor and adhesions
with representative peritoneal biopsies from all four quadrants.
there is normal clear anatomy with a limited number of vital structures. The
first rule therefore is to restore normal anatomy. Faced with both an advanced 4. The technique of abdominal hysterectomy in the early stage corresponds
cancer and a FIGO stage I tumor, certain steps should be performed in the to total hysterectomy for benign disease (extrafascial hysterectomy,
following order: Chapter 5). Pelvic and para-aortic lymphadenectomy is described in detail
1. The standard access for all gynecologic malignancies treated by open sur-
in Chapter 5. Only omentectomy is described here. IV
5. Omentectomy: even in a nonmetastatic situation, the anatomy of the
gery is the midline vertical laparotomy. Extending the skin incision inferi-
greater omentum is a combination of constant and individual features. The
113
orly a short distance over the symphysis markedly improves access to the
pelvis. The fascia should be split as far as the symphysis. How far the lapa- origin of the omentum on the greater curvature of the stomach is constant,
rotomy is extended superiorly depends ultimately on the extent of the as is its crossing of the transverse colon to the anterior surface of which
disease in the upper abdomen. The incision should extend as far as the the omentum is inserted, and its variable inferior extent. Apart from its
xiphoid if diaphragmatic disease is excised, if the omentum is dissected size, its extension to right and left is highly variable individually. On the
as far as the splenic hilum, or if extensive para-aortic lymphadenectomy right, the omentum can extend from the curvature of the stomach as far
is necessaryi.e., in a large number of cases. as the gallbladder or be adherent to the ascending colon in the inferior
direction. Particularly the omental bursa, which can nearly always be
2. The operation site and operability must be assessed. Whether optimal
opened easily in left lateral direction, can be partially or wholly obliterated
cytoreduction is possible in an individual patient can often be determined
in the right lateral direction by adhesions to the omentum (gastrocolic
only in the course of the operation. Nevertheless, there are certain critical
ligament) and to the mesentery of the transverse colon. There are also
tumor locations that can prevent successful cytoreduction, for example,
great individual differences toward the left side. The most lateral point of
intrahepatic disease, involvement of the porta hepatis, involvement of the
origin on the left of the curvature of the stomach, the extent of the omen-
root of the mesentery, or extensive bowel involvement with the risk of
tum that extends to the splenic hilum, and the degree of adhesion to the
short bowel syndrome if all segments containing tumor are removed. At
left colic flexure and descending colon are variable.
the initial inspection, particular attention should be paid to these locations,
as far as possible. However, extensive adhesiolysis and dissection are often 6. When malignancy is confirmed histologically, omentectomy is required,
required initially, until normal anatomy is obtained, before many of even when the omentum is macroscopically normal. Rapid infracolic
these important regions can be assessed at all. omentectomy or partial omentectomy or omental biopsy no longer
meets the oncologic standard. However, omentectomy is often time-con-
3. It is worth dividing the operation site into different regions, which are ap-
suming because of the individual anatomy. Operating in the left upper
proached separately, each requiring different knowledge and techniques:
abdomen toward the splenic hilum and left colic flexure requires practice
first the pelvis and lower abdomen; then the area framed by the colon
and is often associated with complex dissection, clamping, and ligature.
with the mid abdomen, para-aortic region, and omentum; then the right
Mobilization of the splenic flexure of the colon may be necessary.
upper abdomen with the liver and right hemidiaphragm; and finally the
left upper abdomen with the stomach, spleen, pancreas, and left hemi- 7. The omentectomy should start where the greater omentum crosses the
diaphragm. transverse colon. By reflecting the omentum upward, its insertion on
the anterior of the colon comes under tension and can be opened by fine
4. An important first step usually consists of obtaining adequate tumor
dissection. Use of an electric scalpel is recommended as this can be used
tissue for histologic frozen section to confirm the diagnosis. Omental
safely even in proximity to the bowel. The area of physiologic adhesion
(partial) resection may be appropriate for this.
between the omentum and the transverse colon istheoreticallynearly
Typical ovarian cancer surgery is described below, first for early cancer without avascular. Sharp electric dissection is therefore possible for the most part.
abdominal metastases. The steps of the procedure for advanced disease are then Smaller vessels, which can bleed copiously, must be coagulated. The first
presented. aim of this dissection is to enter the omental bursa, which is usually
Early ovarian cancer (FIGO I) achieved toward the left.
1. At the early stage, which is limited to a suspicious ovary, the first step 8. In the second step, the omentum has to be freed from its adhesions toward
must be to remove the adnexal tumor safely from the abdominal cavity the right. This can be easy if it is inserted exclusively into the transverse
without rupture. The ability to remove a large adnexal tumor from its colon and not far to the right, but can also be difficult and time-consuming
adhesions to the pelvic wall without rupturing it is a function of the sur- with dissection of adhesions to the gallbladder, ascending colon andpar-
geons experience and patience. However, mobile tumors can often be ticularly problematicin the region of the gastric outlet, where the omen-
excised by placing strong forceps directly on the infundibulopelvic and tum and the mesentery of the transverse colon immediately behind it (the
ovarian ligaments. posterior wall of the omental bursa) can be adherent.
2. If there has been previous surgery at the site or when the situation is un- 9. The omental tissue is more vascular laterally. Overholt clamps should be
clear, it is advisable to open the peritoneum over the ipsilateral psoas used, especially where the anatomy is not clear.
muscle and expose the course of the ureter where it crosses the iliac 10. In total infragastric omentectomy, the omentum is divided directly at the
vessels. When the ureter has been distanced sufficiently, the ovarian tumor greater curvature of the stomach. The gastroepiploic vessels running along
can first be removed provisionally with strong clamps. The remaining in-
IV Adnexa 4.3 Surgical Techniques

the curvature must be divided. This is possible either directly on the stom- 10. The medial layer of the peritoneum anterior to the ureter is divided as far
ach or at some distance from the curvature, sparing the vascular arcade. as the vicinity of the uterus, which creates maximum adnexal mobility.
11. This gradual division from the greater curvature is then continued system- The original incision in the visceral peritoneum is extended caudally over
atically into the left upper abdomen, where the omentum can extend to a the psoas muscle by extending the division of the round ligaments and
very variable degree as far as the splenic hilum. Adequate opening of the continuing the incision in a caudomedial direction into the peritoneum of
abdomen is essential. The direction of dissection from above is: gradual the vesicouterine pouch. The aim is to move the bladder caudally in the
division of the omentum from the stomach, where it is highly vascular, classic way. Depending on involvement of the bladder peritoneum, this
through Overholt clamps and, from below, gradual division of the ad- step may have to be modified in the form of peritonectomy.
hesions to the transverse colon, left colic flexure and descending colon. 11. The adnexal tumors are divided in isolation from the uterus, depending on
The surgeon has to operate from the patients left side. Caution: excessive size, and sent for frozen section (to confirm the diagnosis).
traction on the adherent omentum can lead to dangerous tears of the 12. Further operation strategy in the pelvis is guided by involvement of the
spleen. It is advisable in every case to mobilize the spleen forward some- peritoneum over the bladder and lining the pouch of Douglas. If there is
what from the left upper abdomen initially and pack it with a moist ab- only slight involvement, the pelvis can be rendered tumor-free by simple
dominal towel so that it can be moved further forward into the dissection hysterectomy. If involvement is extensive, gradual resection of the bladder
field, reducing the traction forces on it. peritoneum, if necessary after filling the bladder, and resection of lesions
Advanced ovarian cancer within the pouch of Douglas may be necessary.
1. Unlike the situation in early ovarian cancer, in advanced ovarian cancer 13. Various points must be noted if resection of lesions within the pouch of
the anatomy is nearly always greatly altered. Even access to the abdominal Douglas is performed. On the one hand, the rectovaginal septum has to be
cavity can be difficult when the omentum contains metastases and is ad- opened as part of the hysterectomy and the rectum has to be separated
herent to the anterior abdominal wall. This is why an upper laparotomy, from the posterior vaginal wall. On the other hand, the ureters have to be
IV i.e., opening the parietal peritoneum above the umbilicus, often provides dissected completely in their lateral course and separated from the utero-
sacral ligaments. Dissecting the pararectal space and extensive mobilization
114 easier access.
of the rectum facilitates dissection of the pouch of Douglas peritoneum,
2. The anterior abdominal wall is dissected free, as otherwise a self-retaining
which often extends close to the anterior wall of the rectosigmoid. The
retractor cannot be inserted and further operation is not possible. As no
starting point for dissection for resection of lesions within the pouch of
important structures originate from the anterior abdominal wall, omental
Douglas is therefore the opened rectovaginal septum from below and the
adhesions, and also adnexal tumors and bowel adhesions, can be divided
pararectal space laterally. It is important to assess the rectosigmoid colon it-
by sharp dissection.
self; an extensive separate resection of lesions within the pouch of Douglas
3. Washings should be obtained for cytology as soon as possible. Large
is useful only if the rectosigmoid itself can be preserved in this region.
volumes of ascites often have to be aspirated immediately after opening
14. The pelvis can nearly always be rendered tumor-free by an experienced
the peritoneum, so suction must be readily available. The anesthetist
gynecologic oncologist together with an abdominal surgeon (rectosigmoid
must be prepared for the fluid fluctuations.
resection). A continuity-preserving anastomosis is possible in over 98% of
4. The liver and right hemidiaphragm, splenic region, and left hemidia-
cases.
phragm are inspected and palpated, the small bowel and small-bowel mes-
15. The operation in the pelvis concludes with pelvic lymphadenectomy, i.e.,
entery are inspected, and the pelvis is inspected and palpated to assess the
removal of the lymph node chains along the external, internal, and
adnexal tumor or tumors and their often complex relations to the bowel,
common iliac vessels and in the obturator fossa.
pouch of Douglas, uterus, and pelvic walls.
16. Mid abdomen. The omentum, which is often entirely infiltrated, lies on the
5. It is important to obtain a representative sample early for frozen section.
surface. The question here is whether the metastatic omentum can still be
Provisional partial omental resection may be useful.
separated from the transverse colon or whether partial bowel resection is
6. When the anatomy is clear overall, early omentectomy is recommended
necessary from the outset. It is often possible to dissect the omentum
so that the extensive resection margins can be checked once more for
carefully off the colon, though this is time consuming, as the tumor respects
hemostasis at the end of the operation.
the muscularis layer of the bowel in this region for a relatively long time.
7. Pelvis and lower abdomen. If the patient is regarded as operable overall, the
17. The para-aortic and paracaval regions are also located in the mid
typical ovarian cancer operation begins at the most suitable site for this.
abdomen. The technique of (open) para-aortic lymphadenectomy is de-
With a vertical laparotomy and generous access, a primary retroperitoneal
scribed in detail in Chapter 5. Lymphadenectomy in ovarian cancer is an
approach should always be preferred, if possible. When the anatomy is
important prognostic criterion, at least with early carcinomas. In addition,
unclear in the pelvis, with large tumors adherent to the pelvic walls or dif-
lymph node metastases appear to be influenced very little by current che-
fuse infiltration of the peritoneum of the pouch of Douglas and bladder,
motherapy, as suggested by the results of second-look laparotomies after
primary retroperitoneal access over the psoas muscle is the only way.
chemotherapy. Retroperitoneal metastases are therefore a possible cause
As a typical ovarian cancer usually respects the peritoneal barrier, a plane
of recurrence after clearance of tumor from the abdominal cavity.
of dissection is usually found here even in extreme cases.
18. Metastatic bowel or mesenteric deposits must be excised (with dissecting
8. The peritoneum is elevated and incised over the psoas. Coagulation can
scissors) orin the mesenterydestroyed by electrocoagulation or argon
be used if necessary as the peritoneal edges often bleed. The peritoneal in-
beam laser. These metastases are often noninfiltrating so they can be re-
cision is extended cranially and caudally, bluntly or sharply. The external
moved with scissors without injuring the bowel.
iliac vessels are exposed at the medial border of the psoas and the course
19. Right upper abdomen. Typical ovarian cancer surgery achieves its aim only
of the ureter is then dissected along the internal iliac artery. Marking the
if all macroscopically visible and palpable tumor deposits are removed.
ureters with Silastic tape provides additional security and is recommen-
This applies particularly to tumor seeding on the diaphragm. The first step
ded. On the right side, it is now possible to start dissecting the cecum in
to allow better assessment is complete division of the falciform (round)
the cranial direction, and on the left side the sigmoid colon is mobilized in
ligament of the liver. If further tumor is found in the right upper abdomen,
parallel.
the liver has to be mobilized along the right triangular ligament.
9. After marking the ureters, the infundibulopelvic ligament is isolated,
20. The most rational approach is peritonectomy along the muscular dia-
clamped, and ligated anterior to the ureter. Stab incisions should be avoi-
phragm. The risk of accidentally opening the pleural cavity must be accept-
ded. A double ligature is recommended. On the left side, the sigmoid colon,
ed. The defect is closed with interrupted sutures. The last knot is tied with
which is usually adherent to the left infundibulopelvic ligament and left
maximum lung insufflation (by agreement with the anesthetist). A chest
pelvic wall, must be further distanced. Before dividing and ligating it, a
drain is usually not necessary.
long stretch of the infundibulopelvic ligament on both sides should be
distanced cranial to the ureter and ligated high. 21. Removal of superficial liver metastases (or rather deposits) is often pos-
sible and not too difficult technically. Genuine parenchymal metastases
IV Adnexa S u r g e r y o f M a l i g n a n t A d n e x a l Tu m o r s / D e b u l k i n g O p e r a t i o n s

would require a more major procedure, the usefulness of which must be fundibulopelvic ligament and left ureter and also over the left common
decided in the individual case. However, this significantly increases the iliac vessels, the sigmoid mesocolon is divided toward the promontory.
morbidity and mortality of the operation. This critical dissection step (caution: ureter injury typically occurs at this
22. Left upper abdomen. Left-sided diaphragm excision and peritonectomy point) can be done over Overholt clamps or using electrocautery.
is required more rarely. Following splenectomy, it is technically easier than 5. The aim of this dissection is to enter the rectosigmoid presacral space,
the operation on the right side. If the spleen is preserved, it should be mo- where a plane that is nearly always tumor-free can usually be dissected
bilized out of the danger zone by pushing towels under it. readily down to the pelvic floor. This avascular space (caution is warranted
23. When the bed of the spleen is markedly involved by tumor and tumor toward the sacrum especially because of the presacral venous plexus) is
masses are predominant in the left of the omentum, splenectomy should then joined with the classical retroperitoneal spaces, which have been dis-
be considered. Splenectomy will be necessary in somewhat fewer than sected from the lateral aspect (especially the pararectal space), so that the
10% of all typical ovarian cancer operations. It should always be done if it block of tissue containing the rectosigmoid, uterus, adnexa, and tumor can
will ensure the oncologic success of the operation. be isolated in the medial direction.
6. The last step is the often time-consuming dissection of the bladder down-
Small-bowel resection and stapled anastomosis
ward from the front of the uterus. The bladder peritoneum is often infil-
1. The exact resection margins are determined.
trated by tumor on the surface but this rarely extends into the bladder
2. Mesenteric vascularization is assessed, for example, by transillumination. itself so that the bladder muscularis can usually be spared when dissecting
3. The segment of bowel is isolated by gradual division of the triangle of mes- the areas infiltrated with tumor toward the uterus.
entery that corresponds to it. Various techniques can be used: dissection 7. This centralized tumor mass is then resected en bloc after gradual division
over Overholt clamps, Ultracision, Ligasure, etc. of the vagina and distal excision of the anorectal tube of bowel with the
4. Dissection of the junction between mesentery and bowel must be particu- GIA stapler. The vagina is closed with interrupted sutures and the rectal
larly careful, with complete isolation of an adequate segment of bowel. stump is reanastomosed to the adequately mobilized descending colon IV
Microhemorrhages often occur close to the bowel and these can be con- side-to-end using a transanal circular stapler.
trolled by targeted coagulation (caution: bowel necrosis) or fine trans- 115
Liver mobilization and right upper abdomen
fixion sutures (30, 40).
1. Liver mobilization is an important requirement for upper abdominal sur-
5. The small-bowel segment is removed using a GIA stapler. An adequate
gery, especially on the right. In over two-thirds of advanced ovarian
safety margin must be ensured, but, on the other hand, adequate distal
cancers, tumor deposits are found in the region of the right hemidia-
and proximal mobility is required for anastomosis.
phragm. There are two dangers from the technical point of view: (1) injury
6. Side-to-side anastomosis is performed using the stapler. The antimesen-
to the liver capsule must be avoided as hemostasis on the liver surface
teric sides of the bowel are approximated. If necessary, a second row of
poses problems; (2) injury to the hepatic veins which drain into the
sutures can be placed over the row of staples.
inferior vena cava immediately below the diaphragm must also be avoided.
7. The distal end is also closed with the stapler. There should be four rows of Because of the proximity of the right atrium, injuries in this region can
staples. have catastrophic consequences and are often extremely difficult to manage.
8. The opening in the mesentery is sutured closed.
2. Liver mobilization begins with a standard step in every typical ovarian
Rectosigmoid resection and stapled anastomosis cancer operation: division of the falciform ligament, the thickened caudal
1. An important step, required in over one-third of ovarian cancer operations, part of which is also called the round ligament of the liver. The round liga-
is sigmoid resection followed by side-to-end anastomosis over a transanal ment can be divided over Overholt clamps or with electrocautery. The thin
circular stapler. This step is often faster and more efficient than tedious falciform ligament passing cranially is then divided in caudal direction
dissection of peritoneal infiltrates in the pelvis or meticulous dissection of with a scalpel or electrocautery over the dissection finger, paying atten-
the segment of sigmoid colon involved by the adnexal tumor. Unnecessary tion to the proximity of the hepatic veins in the inferior part. This step
bowel anastomoses should be avoided but, on the other hand, the total provides optimal vision of the right hemidiaphragm before actual liver
duration of the procedure must be borne in mind. mobilization and should form part of every initial exploration.
2. The first step can be dissection of the pararectal fossa, following high 3. The next step in liver mobilization starts with mobilization of the ascend-
division of the infundibulopelvic ligaments and lateral displacement of the ing colon from its secondary retroperitoneal position. This is important
ureters. However, complete obliteration of the pelvis by tumor often re- especially to allow complete removal of peritoneal tumor deposits in the
quires en-bloc resection of the rectosigmoid and uterus. The first step is right abdominal wall. The right renal capsule is exposed. Complete dissec-
then dissection of the sigmoid colon above the tumor mass and presacral tion of the kidney should be avoided.
dissection into the pelvis, followed by classical retroperitoneal dissection 4. Actual liver mobilization then starts; this consists of freeing the liver from
from the lateral aspect with the aim of centralizing the tumor. Dissection its adhesions with the retroperitoneum and diaphragm (the bare area).
is then continued inferiorly from the lateral aspect to below the tumor, Approaching from the right lateral direction, the risk of hepatic vein injury
where the rectum and vagina are divided. is least but is never entirely absent. The degree of mobilization is guided
3. When dissecting the sigmoid colon from above, which is the method of by the tumor load. The medial limit of mobilization is the lateral margin of
choice with a large pelvic tumor, the first step consists of division of the the inferior vena cava and the duodenal C.
lateral physiologic adhesions between the sigmoid colon and the posterior 5. The aim of liver mobilization is safe and radical peritonectomy over the
abdominal wall, which amounts virtually to reversal of the secondary right hemidiaphragm. Liver mobilization provides optimal access to the
retroperitonealization of the descending colon. Dividing the adhesions peritoneal fold on the liver surface, which is often a site of predilection for
renders the mesentery more visible so that the sigmoid colon with its tumor deposits.
mesentery can now be skeletonized from the medial aspect. The inferior Opening the lesser omentum
mesenteric artery is usually divided, but the cranial branches that originate
1. Opening the lesser omentum is an important step in completing the upper
close to the aorta (Riolan anastomosis) should be preserved to provide an
abdominal part of a typical ovarian cancer operation. The lesser omentum
optimal blood supply to the left colic flexure and the remaining part of the
extends from the lesser curvature of the stomach toward the liver and
descending colon.
covers the important structures at the porta hepatis, i.e., the common bile
4. Part of the colon is dissected completely free from the mesentery as usual duct, the hepatic artery, and the portal vein. These are located postero-
so that the GIA stapler can be used. Microhemorrhages often occur close to
laterally to the right of the lesser omentum. The abdominal aorta runs cen-
the bowel and these are controlled by very accurate bipolar coagulation or trally in the space covered by the lesser omentum; it gives off the celiac
by hemostatic 40 sutures. When the anatomy is unclear during dissection trunk and superior mesenteric artery relatively close to one other.
above, i.e., anterior to the retroperitoneal structures such as the left in-
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2. From what has been said, it is apparent that dissection deep in the space to the left abdominal wall (diaphragmocolic ligament) and to the splenic
covered by the lesser omentum is one of the most demanding and hazard- hilum itself (splenocolic ligament). Although there are no major vessels
ous steps in abdominal surgery. Surgeons who perform oncologic proce- here, the region is well vascularized overall so that great attention must be
dures for gastrointestinal tumors assert that this is a site of predilection for paid to hemostasis by gradual meticulous dissection. The tail of the pan-
bulky lymph node metastases, although this is not documented in studies. creas, with its highly variable anatomy, is posterior and sometimes extends
as far as the splenic hilum.
Mobilization of the left colic flexure and splenectomy
5. Optimal mobilization of the left colic flexure during typical ovarian cancer
1. One of the most important steps in gynecologic cancer surgery is mobili-
surgery uses a two-sided procedure, with mobilization in a cranial and me-
zation of the descending colon including the left colic flexure. This step
dial direction along the bowel margin from the left and below; starting on
enables the descending colon to be reanastomosed to the rectal stump
the right, the omental bursa is opened as part of infracolic omentectomy so
following rectosigmoid resection, allows clean completion of total omen-
that the appropriate dissection plane at the bowel margin is also exposed
tectomy, and finally, facilitates splenectomy if this is necessary because
from the medial side.
of tumor at the splenic hilum.
6. Mobilization of the left colic flexure allows total omentectomy to be com-
2. Dissection begins on the left pelvic wall at the pelvic inlet. The physiologic
pleted safely. The greater omentum often extends far to the left side where it
adhesions here pull the antimesenteric border of the rectosigmoid to a
adheres to the transverse colon. This also provides safe access to the spleen.
very variable degree toward the left pelvic wall, the left round ligament or
even the left inguinal canal. These adhesions, which vary in thickness but 7. Further dissection of the spleen then requires division of the adhesions be-
are always avascular if dissected correctly, must be divided sharply. It is tween the greater curvature of the stomach and the spleen (gastrosplenic
particularly important not to open the retroperitoneum and psoas space, ligaments) and of secondary adhesions between the spleen and the left
contrary to what gynecologic surgeons are used to do. Dissection remains hemidiaphragm.
on the peritoneal covering of the posterior abdominal wall and is always 8. The spleen is gradually dissected as far as its hilum from the aforementioned
IV continued upward close to the lateral antimesenteric margin of the bowel. structures, which are often difficult to distinguish when they are merged
together in an individual case. Dissection at the splenic hilum should keep
116 Retroperitonealand therefore incorrectdissection would cross the ureter,
close to the spleen as accidental injury to the distal tail of the pancreas is
which runs there, and the infundibulopelvic ligament leading to the left kid-
ney. In fact, premature opening of the left retroperitoneal space makes it particularly dangerous. Unperceived injuries can lead to leakage of pancre-
more difficult to find the correct plane for mobilizing the descending colon. atic enzymes, extensive local inflammatory reactions, and the development
3. Some surgeons advocate dissecting the left colic flexure initially by man- of problematic pancreatic pseudocysts.
ually dislocating the spleen from its deep position below the left hemi- 9. The splenic artery, which is often surprisingly delicate, and the branching
diaphragm and placing a moistened laparotomy sponge behind the spleen splenic vein are found at the splenic hilum. Ideally, these vessels are dis-
to prevent it from sliding back. This reduces tensile forces on the splenic sected deliberately and then ligated, electrocoagulated, or occluded with
capsule during dissection, avoiding accidental splenic injury. clips. Most surgeons place a drain in the left upper abdomen following sple-
4. The most demanding part of the dissection involves the left colic flexure nectomy so that local bleeding and inflammatory reactions can be observed
itself, which is connected by various avascular strands of connective tissue and diverted promptly in the postoperative period.

Special Technique Surgery of Malignant Adnexal Tumors/Debulking Operations

Fig. 4.3-59 Access for large tumor masses in usually allows an operative approach even in Fig. 4.3-60 The peritoneal incision is extend- the craniocaudal direction. The course of the
the pelvis. The classic approach to the internal an extremely difficult situation, which can then ed cranially and caudally over the psoas muscle ureter is exposed more medially along the inter-
reproductive organs is often unsuitable for typ- be continued gradually until the pelvis is com- (bluntly or sharply). The external iliac artery can nal iliac artery. These spaces are nearly always
ical ovarian cancer surgery. Access through the pletely tumor free. also be exposed at the medial edge of the tumor free and readily accessible to dissection.
peritoneum located above the psoas muscle psoas bluntly or by advancing a sponge stick in
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Fig. 4.3-61 Visualization of the ureterim- ligament anterior to the ureter. The ovarian ves- Fig. 4.3-62 The ureter (here marked by a soft bleeding from the tumor, the already exposed
mediate and permanent marking with Silastic sels are distanced from the ureter by opening plastic band) is followed, starting from this ac- internal iliac artery can be ligated, though this
band is recommendedfollowed by exposure the medial layer of peritoneum and ligated, as cess. In individual cases, ligation of the uterine is not often necessary with careful dissection.
of the ovarian vessels in the infundibulopelvic shown here. artery at its origin from the internal iliac artery Gradual access for hysterectomy and adnexec-
may be useful. If there is unexpectedly severe tomy is thus achieved.

Fig. 4.3-64 The vagina is opened directly af- opened directly with an electric scalpel under
ter adequately dissecting the bladder off it in palpatory control, for example, over a finger in-
the caudal direction. Use of an electric scalpel serted in the vagina.
is recommended. The vaginal wall can then be

Fig. 4.3-63 Retrograde hysterectomy and behind is impossible, retrograde dissection


bowel resection when the pouch of Douglas from in front is a feasible alternative. From the
is obliterated. The focus of an infiltrating pro- lateral aspect, the ureters should be exposed
cess in the pelvis is often a tumor that com- andif possiblethe uterine artery should be li-
pletely obliterates the pouch of Douglas and gated at its origin from the internal iliac artery.
grows into the rectosigmoid. If dissection from
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Fig. 4.3-65 Retrograde dissection of the va- Simultaneous rectal or rectovaginal examina-
gina (by clamping and ligating) and entry tion allows optimal location of the rectum and
into the rectovaginal septum from in front. dissection can be adapted accordingly.

Fig. 4.3-66 An attempt can sometimes be grade hysterectomy. This is only one example Fig. 4.3-67 The final goal is a tumor-free pel- of great importance for safe resection of lesions
made to find a plane between the tumor mass of how unconventional techniques are em- vis, which appears as illustrated here after hys- within the pouch of Douglas. Unlike what is
and rectosigmoid, starting from the rectovagi- ployed during cancer operations. terectomy and resection of lesions within the shown here, the ureters must be completely
nal septum, and perform a complete retro- pouch of Douglas, with the bilaterally mobilized dissected free, right up to where they enter
ureters. The rectum can also be mobilized start- the parametrium.
ing from the pararectal space. This step is often
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Fig. 4.3-68 Alternatively, an en-bloc resection divides the bowel and closes the stumps at the Fig. 4.3-69 Schematic conclusion of the en- dissection and division of the rectal pillars later-
can be attempted from the start, if it proves im- same time. A requirement for this step, natural- bloc resection of uterus and rectum is shown. ally with ligature of the rectosigmoid vascular
possible to distinguish the uterus, tumor, and ly, is complete dissection of the ureters bilater- A further requirement, besides ligature of the supply.
rectosigmoid. The illustration shows use of a ally and complete exposure of the paravesical blood supply of the uterus laterally, is gradual
stapler designed especially for the pelvis, which and pararectal space.

Fig. 4.3-70 Pelvic peritonectomy and hyster- teriorly, along the external iliac vessels bilateral-
ectomy. Surgery of advanced ovarian cancer ly, and beside and over the rectosigmoid poste-
an example of alternative operation steps: the riorly. This corresponds in essence to the previ-
line of peritoneal incision in the pelvis outside ously described retroperitoneal approach.
the metastases: over the roof of the bladder an-
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Fig. 4.3-71 Separation of the left layer of vide subsequent access for pelvic lymphadenec- Fig. 4.3-72 After dissecting the tumor-in- front to back (retrograde hysterectomy). The
peritoneum from the pelvic wall, identifica- tomy. At this point, the ureters should be dis- volved bladder peritoneum and the vesicouter- bladder is rarely affected by a typical ovarian
tion of the ureter and division of the infundi- sected in the accepted manner (see initial draw- ine fold, the uterine arteries are divided, the an- cancer and can be dissected free directly. Small
bulopelvic ligament. This completes the classic ings) so that they can be pushed laterally terior vaginal wall is incised, and the lateral bladder injuries are managed immediately.
first retroperitoneal stage of the typical ovarian during further resection of lesions within the vaginal walls and parametria are clamped from
cancer operation. The opened spaces also pro- pouch of Douglas.

Fig. 4.3-73 The uterus is divided in the vagi- the lateral course of the ureters bilaterally is re-
nal fornices and the vagina is closed. The perito- quired. The retrograde procedure is shown
neum of the pouch of Douglas is mobilized be- again here but is only performed when simple
hind the vaginal stump on the lateral pelvic normal hysterectomy, as described in Chap-
walls and from the rectosigmoid. Exposure of ter 5, is not technically feasible.
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Fig. 4.3-74 After dividing the peritoneum in nectomy describes this accurately: excision of Fig. 4.3-75 If there is deep tumor infiltration It is possible to achieve continuity in most pa-
the entire pelvis, the uterus is removed en bloc the peritoneum involved macroscopically by of the wall of the rectosigmoid, the affected tients through use of modern transanal stapler
with the adnexa and entire tumor mass includ- the tumor. In gynecologic oncology, this is a segment of bowel is resected and the operation systems, which may even require coloanal anas-
ing the pelvic peritoneum. Optimal operation technique that has been established and em- specimen is removed en bloc. Bowel continuity tomosis.
site with tumor-free pelvis. The term perito- ployed for years. is then restored by an end-to-end anastomosis.

Fig. 4.3-76 Appendectomy. With all muci- dix is first dissected adequately from any Fig. 4.3-77 Double ligature of the appendix. ture is placed after placing the clamp some-
nous malignant ovarian tumors including muci- adhesions until it is sufficiently mobilized and Cecum mobilization is sometimes necessary for what more distally. The appendix is then divid-
nous borderline tumors, appendectomy is re- the anatomy is completely clear. Following dis- safe appendectomy. The anatomy must be ed along the clamp.
quired as part of complete staging. The appen- section, the mesentery is divided separately. clear before appendectomy. The second liga-
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Fig. 4.3-78 The appendix is divided with a this might lead to inflammatory complications,
scalpel after a single ligature of the remaining or too short, which might lead to slipping of
stump. The stump must not be too long, as the ligature.

Fig. 4.3-80 Omentectomy. Simpler infracolic can be performed as a prelude to total omen-
is distinguished from complex infragastric total tectomy. Omentectomy can largely be per-
omentectomy. Total omentectomy should be formed with an electric scalpel. Gradual divi-
performed if malignancy is confirmed. When vi- sion of the lateral parts over Overholt clamps
sualization is difficult, infracolic omentectomy is recommended.

Fig. 4.3-79 The stump is buried with a purse- completely when the suture is tightened. This
string suture. A 3 0 suture is placed around the traditional step is no longer demanded by all
appendix stump. The stump is then buried abdominal surgeons.
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Fig. 4.3-81 When the omentum is reflected shown here is also opened in left lateral direc-
cranially, the site of insertion on the transverse tion with the transverse mesocolon as posterior
colon appears as a fine and usually avascular wall. Identification of the bursa is essential for
layer that can be opened with an electric scal- safe infragastric omentectomy.
pel or dissecting scissors. The omental bursa

Fig. 4.3-82 Infragastric omentectomy (after bridges are isolated with Overholt clamps,
identification of the omental bursa) can be per- clamped, divided, and ligated. Bleeding should
formed either with or without sparing of the be avoided. When the omentum is involved by
gastroepiploic arcade. The vascular tissue metastases, the anatomy can be very difficult.
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Fig. 4.3-83 Segmental bowel resection can is shown; this is the most efficient but also the Fig. 4.3-84 The triangle of mesentery is first of the anastomosis. Transillumination helps to
be required for oncologic reasons (tumor in- most expensive method or reanastomosis. The excised by gradually dividing the stumps of identify larger vessels. The mesentery is one of
volvement) or it may be necessitated by exten- first step is to establish the wedge that will be the mesenteric vessels conventionally. The rule the best perfused tissues in the body. Careful
sive division of adhesions or by traumatized resected, taking into account the mesenteric is to preserve the mesenteric vessels as far as dissection and hemostasis are crucial.
portions of bowel. The pure stapler technique blood supply. possible so as not to endanger the blood supply

Fig. 4.3-85 The dissected piece of bowel is fi- at the level of the stapler. Dissection of the Fig. 4.3-86 The remaining ends are joined the size of the anastomosis is adequate. In the
nally excised over a GIA stapler, which cuts and mesentery close to the bowel is demanding on side-to-side on their antimesenteric aspect small bowel, there is less risk of stenosis with a
closes both ends simultaneously. It is important account of microhemorrhages, as excessive co- over the GIA stapler. An additional row of su- side-to-side anastomosis than with the end-to-
that no mesenteric fat extends into the bowel agulation can damage the remaining bowel. tures is optional. It is important to ensure that end technique.
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Fig. 4.3-87 The distal and still patent ends are now closed with a simple stapler used as shown. Fig. 4.3-88 One of the key steps in ovarian cancer surgery is the combined resection of uterus,
ovaries, and rectosigmoid in the presence of an infiltrating tumor. As shown, the gynecologic on-
cologist will first approach a difficult and obliterated pelvis by dissecting the pelvic sidewalls from a
retroperitoneal approach, allowing lateral mobilization of the pelvic tumor mass. The retroperito-
neal space is entered safely from lateral to medial, starting over the psoas space and going medially
over the large pelvic vessels until the ureter is reached. Ureteral dissection is a key part, allowing for
complete pelvic peritonectomy and complete resection of the pouch of Douglas

Fig. 4.3-89 Once it is clear that rectosigmoidal resection is necessary (as will be the case in per- Fig. 4.3-90 The next step is the dissection of the mesentery of the sigmoid colon. If possible, the
haps 30%40% of all ovarian cancer debulking surgeries), the next step is the classic mobilization of interior mesenteric artery should be spared, but often it has to be sacrificed. In most patients, this
the descending colon, including mobilization of the left colic flexure to provide for sufficient mobil- will not lead to intra- or postoperative problems. Very old and heavily artheriosclerotic patients may
ity with regard to the subsequent re-anastomosis. This step must avoid the retroperitoneal space experience problems, but these patients might not be candidates for ultraradical surgery to begin
familiar to the gynecologic surgeon and requires some practice. It is important to remember that with. Care should be taken to spare the anastomosis of Riolan.
the ascending and descending colons are only attached to the retroperitoneum and can both be
intraperitonealized, provided the right plane of dissection is used.
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Fig. 4.3-91 After sufficient mobilization of mor mass. This usually necessitates a dissection
the bowel and ligation of the adjoining mesen- of the presacral space. The key is to dissect dor-
tery, the proximal bowel resection is performed sal of the rectum to an area clearly below the
using a stapler technique as shown. The dis- tumor to allow for en-bloc resection.
sected bowel is mobilized towards the pelvic tu-

Fig. 4.3-92 At this point, the pelvic tumor the rectum posteriorly. The vagina is tran-
mass has been mobilized laterally and posteri- sected just below the cervix until only the rec-
orly. The final step is to allow for anterior mobi- tum remains. In a final step, the rectum is divid-
lization by dissecting the bladder caudally off ed using the classical stapler technique and the
the uterus. The uterus can then be devascular- tumor-mass, including uterus, ovaries and rec-
ized laterally. The pelvic mass now remains at- tosigmoid is removed.
tached only through the vagina anteriorly and

Fig. 4.3-93 View after complete resection of the pelvis and lower abdomen are concerned.
all tumor and complete deperitonealization of Limits to complete resection remain in the
the pelvis. Technically, though often challeng- area of the intestinal mesentery and in the up-
ing, complete resection of all visible tumor can per abdomen.
be achieved in almost 100% of cases as far as
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Fig. 4.3-95 Actual liver mobilization is then ued medially as far as the duodenal C. Metastat-
begun by mobilizing the ascending colon above ic depostis are often found at this site directly
Fig. 4.3-94 A standard step in every explora- ligament of the liver to provide optimal vision the fatty kidney capsule. Dissection is contin- inferior to the liver
tion in typical ovarian cancer surgery consists into the right upper abdomen.
of division of the round ligament and falciform

Fig. 4.3-97 Liver mobilization is often, but tion, which proceeds from anteromedial to pos-
not always, required for sufficient peritonecto- terolateral. The frequent transdiaphragmatic
Fig. 4.3-96 The most difficult part of liver sible as far as the lateral margin of the inferior my in the right upper abdomen. This step, metastases are usually located very close to
mobilization consists of sharp division of the liv- vena cava. which is not illustrated, starts at the edge of the liver and are accessible to resection only fol-
er from the bare area, which is technically pos- the laparotomy incision with deperitonealiza- lowing adequate mobilization.
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128
Fig. 4.3-98 An understanding of the basic tal infragastric omentectomy, the garland of Fig. 4.3-99 Gradual and meticulous dissec- mine the ultimate resection status, but techni-
anatomy of the lesser omentum is crucial: the veins in the lesser curvature should be spared tion of the lesser omentum, which may be in- cally it is one of the most demanding tech-
epiploic foramen, which is frequently described to ensure venous drainage of the stomach. volved by tumor, then allows inspection of the niques in gynecologic oncology. This illustra-
in anatomy textbooks, cannot always be dem- The porta hepatis in the right posterolateral po- lymph node chain superior to the renal veins. tion shows two prominent lymph nodes at the
onstrated in reality, especially in the oncologic sition and the axis of the great vessels directly This region must often be assessed to deter- porta hepatis and in para-aortic location.
situation. Critical structures are located at the posteriorly are even more important.
level of the lesser omentum; especially after to-

Fig. 4.3-100 The initial appearance is shown. As a first step, it is helpful to dislocate forward
The tissue layers and strands in the region of the entire block of tissue including the spleen,
the stomach, spleen, colon, and pancreas, which is particularly sensitive to traction, by
which are complex anyway, become even placing a moist laparotomy sponge under the
more problematic due to the often massive tu- left hemidiaphragm. It is also important to ob-
mor infiltration into the left-hand parts of the tain good exposure through an adequate inci-
omentum where it involves the entire region. sion continued as far as the xiphoid.
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Fig. 4.3-102 This dissection from the lateral ful. Traction on the spleen must be avoided.
aspect must be all the more cautious as the in- The region of the tail of the pancreas is entered.
ferior pole of the spleen is approached. The At the same time, dissection from the medial
avascular layers can sometimes be divided aspect started as part of omentectomy is con-
sharply after adequate preparatory thinning; tinued, and this requires opening of the omen-
Fig. 4.3-101 To locate and divide structures in the oncologic situation. Mobilization begins electrothermal dissection (for example, using tal bursa.
such as the phrenocolic ligament, the gastro- in the left lower abdomen. Along an avascular Ultracision or LigaSure) can sometimes be help-
splenic ligament, and the lienorenal ligament, plane, the secondarily retroperitoneal sigmoid
to name only the most important, the first colon and descending colon are mobilized in
step is mobilization of the left colic flexure, the peritoneal direction. The retroperitoneum
which is at least helpful but usually essential must on no account be opened.
for complete omentectomy and splenectomy

Fig. 4.3-103 Three lines of dissection toward ing the left lateral extensions of the mesocolon.
the splenic hilum are produced. The first is Finally, as shown here, the gastrosplenic liga-
from lateral and inferior to the spleen, mobiliz- ment, which contains numerous vessels, is di-
ing the left colic flexure. The second is from the vided, starting from the omental bursa and
medial aspect from the omental bursa along the omentectomy dissection line close to the
the superior border of the transverse colon stomach.
where special care must be taken to avoid injur-
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Fig. 4.3-104 The operation site after removal cause of the proximity of the tail of the pan- Fig. 4.3-105 The last step is isolation of the of highly toxic pancreatic enzymes, local in-
of the omentum: often, parts of the omentum creas, the splenic vessels should be isolated supplying vessels, which can be ligated by clips, flammatory reactions, and the development of
extend as far as the splenic hilum or the omen- close to the hilum. However, dissection too ligatures and electrocautery. It is crucial to pre- pancreatic pseudocysts. It is advisable to place
tum can be only incompletely distinguished close to the hilum can make accurate ligation vent secondary hemorrhage in this region. The a Robinson drain in the left upper abdomen to
from the gastrosplenic ligament. The largely difficult because both the splenic artery and only other danger is accidental injury to the monitor hemostasis and any leaks from the
isolated spleen is fixed to the retroperitoneal splenic vein divide into a number of branches. sometimes narrow extended tail of the pan- pancreas.
space by the phrenicosplenic ligament. Be- creas. Even minor injuries can lead to leakage

Inadequate tumor reduction: the most important risk of the operation is


Complications that at the end of the surgery the tumor volume is not adequately reduced
Loss of fluid (ascites) and blood: especially during prolonged operations, because the extent of the tumor was not seen from the start. Nevertheless,
the losses can be high, if only because of the time factor. Fluid management the seriousness of the disease always justifies an attempt at optimal de-
must take these losses into account, and blood transfusions and bulking.
plasma factors must be readily available. Bowel dysfunction: the delayed return of bowel function or even ileus is a
Secondary hemorrhage: there is a risk of secondary hemorrhage immedi- frequent postoperative problem. Here, too, bowel function usually resumes
ately postoperatively on account of the extensive operation site. faster in the patient who has had optimal surgery than after a suboptimal
Anastomotic leak: leakage from the gastrointestinal anastomoses is operation.
another specific risk. Lymphedema: lymph cysts and lymphedema of the legs are late complica-
Injuries of internal organs: injuries to vessels (veins), ureter, bowel, and tions of lymphadenectomy.
bladder are usually recognized and treated at operation.
Positioning-related injuries, thrombosis, and embolism: these are the
result of the lengthy operation. The postoperative risk can be reduced by
carefully checking the patients positioning, including during the operation,
along with rapid postoperative mobilization combined with prophylactic
anticoagulation and ATS and possibly use of intermittent pneumatic com-
pression.
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Concurrent and Postoperative Treatment Limits of the Method


Depending on the extent of the operation and fluid shifts, postoperative venti- The limits of what is classified by the surgeon as operable depend not on the
lation may be necessary, and the preoperative planning must allow for this operation site but on the experience and skills of the surgeon and oncologic
(i.e., provision of a bed in the intensive care unit). When epidural anesthesia is operating team. Ovarian cancers should therefore be managed only by surgical
in place, immediate extubation usually does not cause any problem. Observa- teams experienced in this area, even in centers well versed in oncology. The
tion in an intermediate care unit immediately after the operation is advised. technical limits of the method have therefore become fluid. They often become
Rapid mobilization and prompt resumption of diet in line with modern knowl- apparent only at the first, second, or third operation for recurrence. Even with
edge of gastrointestinal surgery are important. Drains should be removed as early ovarian cancer, a systematic staging operation is the minimum standard.
soon as possible, and so should the bladder catheter. Postoperative antibiotic On restaging in an oncology center, 20% 40% of stage I cases operated by non-
therapy should be guided by the specific situation. When histologic confirma- oncologists prove to be FIGO stage III. In these cases, tumor deposits are found
tion of the diagnosis is obtained, planning should start for chemotherapy, possibly especially on the diaphragm (11%), the omentum (3%), the pelvic lymph nodes
in the framework of current studies. Detailed discussion with the patient postop- (8%), para-aortic lymph nodes (10%), and in the form of positive peritoneal
eratively is essential as soon as she is fully receptive again. cytology (33%). Since the 1980s, survival rates of 60% 70% after complete cyto-
reduction have been reported, but these fall to 40% when there are residual
Secondary operations are performed more and more often. An important indi- tumors up to 1 cm in size, and practically zero when the residual tumors are
cation for the second operation is accurate staging or debulking after an inade- over 7 cm. Chemotherapy does not replace optimal surgery but leads synergis-
quate primary procedure. Surgery prior to chemotherapy is of crucial impor- tically to the best possible treatment outcome.
tance for the patients long-term survival. The increased morbidity due to two
operations should be avoided, when possible, but has to be accepted if an inade-
quate primary procedure was performed. The classic second look operation IV
after the conclusion of chemotherapy is no longer performed routinely. The
significance of secondary cytoreduction after neoadjuvant treatment when the
131
tumor is initially regarded as inoperable is not yet clearly defined. The decision
must be made individually. Finally, because of the longer survival times, the
number of secondary cytoreductions performed because of late recurrence is
increasing. Again, the positive effect of optimal cytoreduction plus chemo-
therapy is also apparent in this situation, particularly in the case of platinum-
sensitive recurrences, which make the greatest technical demands on the
operating team.

Vaginal 4.3.2.1 Vaginal Salpingo-Oophorectomy

Aims and Methods


Vaginal removal of the adnexa is not a separate operation but is performed
Indications and Contraindications
with vaginal hysterectomy (Chapter 5.3.2.7). Whether the adnexa, and espe-
cially the ovaries, are removed depends on the indication for surgery and the Indications
patients age and menopausal status. In post- or perimenopausal patients, the An example of an indication for salpingo-oophorectomy as part of a vaginal
decision is almost entirely up to the patient, who should be provided with de- hysterectomy is endometrial carcinoma, when the ovaries should be removed
as they are an early site of predilection for metastases. In early carcinoma of the
tailed information and counseling by her gynecologist. The question of wheth-
cervix (stages I A and I B1), the rate of ovarian metastasis is less than 1% (squa-
er and to what extent the ovaries still have a relevant endocrine function after mous epithelial carcinoma) and less than 2% (adenocarcinoma), so that the
estrogen and progesterone production has ceased is controversial. Some au- ovaries can be left in an obviously premenopausal patient. As most oncologic
surgery is performed via laparotomy or laparoscopy, this question arises only
thors point to the undoubted continued production of testosterone and its
rarely with vaginal hysterectomy. The decision should also be discussed in detail
importance for libido and sense of self in general. There are obvious major in- with the patient when malignant disease is present. Laparoscopic lymphadenec-
dividual differences in both the objective and subjective relevance of this tomy usually provides an opportunity to assess the ovaries and if necessary
knowledge. obtain representative biopsies. In this situation, removal of the adnexa should
be advised in the perimenopausal or postmenopausal patient. The premeno-
pausal patient with a personal history or high-risk family history of breast
cancer and ovarian cancer represents a special case. These points should always
be enquired about and discussed in preparation for surgery. Depending on the
patients age and wishes, therapeutic (for hormone-sensitive breast cancer) or
prophylactic adnexectomy can be performed. It should be noted that this refers
to management of the adnexa when hysterectomy is indicated.
IV Adnexa 4.3 Surgical Techniques

Contraindications
Adnexectomy is contraindicated in young premenopausal women and in all
Procedure
women who have not given express consent beforehand. Whether adnexectomy Preparation
should be performed in postmenopausal women is controversial. Studies do not
1. Vaginal adnexectomy is performed as part of vaginal hysterectomy.
demonstrate any survival advantage with prophylactic adnexectomy. Every
The operation preparation depends on this context (Chapter 5.3.2.7)
gynecologic oncologist can recall an ovarian cancer in a 60-year-old patient
who had hysterectomy (without adnexectomy) 5 years previously. And every Operation
gynecologic surgeon is familiar with the special challenges of an adnexal tumor,
1. The adnexa are exposed adequately after the uterus has been excised.
particularly on the left side, following hysterectomy (without adnexectomy).
This step can be simple: the readily visualized ovaries and tubes are then
mobilized forward with the fenestrated atraumatic ovary grasping forceps
until a clamp can be advanced over the infundibulopelvic ligament.
Operation Risks and Informed Consent 2. When the infundibulopelvic ligaments have been ligated securely, the ad-
Overall, the risks of the operation are not significantly increased by the adnexec- nexa are divided with scissors. The divided vascular stump is suture ligated.
tomy. In individual cases, it can be difficult to remove very atrophic ovaries dis- A safety ligature over an Overholt clamp placed subsequently is optional.
placed out of the pelvis. In these cases, the indication for adnexectomy should be 3. If the adnexa are not readily visible, optimal visualization must first be
re-examined. Accordingly, a preoperative agreement is often made with the ensured. A Trendelenburg position, possibly packing the bowel away with
patient to remove the adnexa if this can be done without difficulty. The specific a strip, assists vision into the pelvis and thus of the pelvic walls. Optimal
risks of vaginal adnexectomy are, in particular, injury to the ureter, which runs relaxation of the patient at this time is essential but is not always guaran-
posterior to the infundibulopelvic ligament, and immediate or postoperative teed. Long Breisky specula additionally optimize exposure of the pelvic
IV hemorrhage from a retracted or inadequately ligated infundibulopelvic ligament. wall.
The informed consent should document the discussion and decision on whether 4. Starting from the origin of the tube, which is usually involved in ligature
132 the hysterectomy is to be performed with or without adnexectomy. of the round ligament, the tube is followed gradually with an atraumatic
fenestrated clamp (ovary grasping forceps). This leads the way to the ovaries.
5. If it becomes clear when visualizing the adnexa that removal will be tech-
Operation Planning nically difficult because of high-grade atrophy and a particularly cranial
1. Medical history, clinical and gynecologic examination, further investiga- position, the decision must be reviewed according to the preoperative
tion according to the underlying pathology discussions.
2. Investigation of malignant disease (hysteroscopy, fractionated curettage, 6. When indicated, adnexectomy from the vaginal approach is nearly always
colposcopy, cervical biopsy); clear histologic confirmation of the diagnosis, possible, but sometimes requires considerable dissection.
if indicated
3. Urogynecologic investigation (urodynamics) if warranted by the history
and indication Complications
4. Determination of the procedure with regard to the adnexa and docu- Performing vaginal adnexectomy directly after vaginal hysterectomy
mentation of the discussion and decision presents hardly any increased risks to the patient.
5. Consent to the procedure Secondary hemorrhage: the risk of secondary hemorrhage from the sepa-
6. Anesthesiologic preoperative investigations depending on the patients rately ligated infundibulopelvic ligament and of ureteral injury in this
age and local practice region is very slightly greater than after simple vaginal hysterectomy.
Especially because of the risk of bleeding, the tightness of the (suture) liga-
7. Thrombosis prophylaxis: LMWH, ATS
tures must be optimal. A safety ligature should be used if necessary. At the
8. Antibiotic prophylaxis: 1st or 2nd generation cephalosporin < 30 minutes
end of the procedure and before closing the vagina, hemostasis must be
before surgery
ensured along the resection line, starting at the uterosacral ligament and
9. Moderately difficult extension of vaginal hysterectomy; takes an additional continuing via the uterine artery stumps to the ligature of the infundibulo-
1045 minutes; surgeon and two assistants pelvic ligament.
Anesthesia and Positioning
Positioning: as for vaginal hysterectomy: lithotomy position
Concurrent and Postoperative Treatment
Draping: vaginal window
Anesthesia: intubation anesthesia with additional epidural anesthesia In premenopausal women, the possibility of hormone replacement should be
discussed following removal of the adnexa, depending on the underlying disease
Special Instruments and breast cancer risk. Patients who have already had breast cancer should not
Vaginal operation set use hormone replacement therapy.
Long Breisky specula, sufficiently long clamps

Limits of the Method


When absolutely indicated, adnexectomy should always be performed with
vaginal hysterectomy, even though this part of the procedure can be complex.
IV Adnexa Vaginal salpingo-oophorectomy

Special technique Vaginal salpingo-oophorectomy

IV
133

Fig. 4.3-106 Joint clamping and division of readily after hysterectomy has been complet- Fig. 4.3-107 Clamping and division of the ed gradually, similarly to the uterus. It is impor-
the round ligament and infundibulopelvic lig- ed. The adnexa can be inspected and the infun- round ligament. Although exact identification tant to avoid retraction of the vessel stumps. If
ament. The adnexa can usually be visualized dibulopelvic ligament can be isolated. of the illustrated structures is an exception, the round ligament is seen separately, dividing
the adnexal stumps can be clamped and divid- it can increase the mobility of the adnexa.

Fig. 4.3-108 Clamping and division of the the infundibulopelvic ligament. After division
infundibulopelvic ligament. After division of of the adnexa, the clamp is replaced by a suture
the round ligament, the adnexa can be pulled ligature. If necessary, a safety ligature can be
downward. It is then usually possible to clamp placed through an Overholt clamp.
IV Adnexa 4.3 Surgical Techniques

Endoscopic 4.3.3.1 LaparoscopyDiagnostic and Minor Operative Procedures

Aims and Methods


Laparoscopy has fundamentally changed the operative range of gynecology in
Operation Planning
the last 20 years. Few technical innovations in the last 100 years have benefited
1. Medical history, clinical examination, ultrasonography
modern medicine as much as the possibility of rapid and safe access to the ab- 2. Establishment and documentation of the indication for laparoscopic inves-
dominal cavity, whether it involves management of adnexal abnormalities, di- tigation
agnosis and treatment of tubal pregnancy, diagnostic investigation of infec- 3. Discussion about the extent of the operation and intraoperative possibili-
tions of the internal genital organs, or assessment of acute or chronic pain ties, and decision on a one- or two-stage procedure
4. Establishment of the procedure regarding the adnexa if pathology is found,
states. Laparoscopy is the standard procedure today, especially for minor pro-
depending on the patients age and wishes
cedures. When the surgeon has sufficient experience the complication rate is 5. Consent to the procedure
low, and the patient can often go home the same day. Examples of routine di- 6. Anesthesiologic preoperative investigations depending on the patients
agnostic laparoscopic procedures are described below. Although many laparo- age and local practice
IV scopic procedures are relatively easy to perform technically, the demands 7. For minor laparoscopic procedures without opening of the vagina, anti-
biotic prophylaxis is unnecessary
134 made on the surgeon even with these minor indications can be high, for ex-
8. Usually easy surgery taking 0.51 hour; surgeon and ideally one
ample, after previous surgery or when post-inflammatory adhesions are pres- assistant
ent. The limit of laparoscopy is the individual surgeons ability to perform com-
petent laparoscopic adhesiolysis, which in turn is achieved only by constant Anesthesia and Positioning
Positioning: legs on supports, which should be lowered preoperatively
practice of the procedure.
by way of trial (Trendelenburg position) to simulate the
intraoperative situation after draping. Caution: intra-
operative lowering of the legs fixed to leg supports alters
the positioning at a time when the exact position of the
Indications and Contraindications legs can no longer be seen because of the sterile draping.
A trial lowering of the legs during sterile skin preparation is
Indications therefore advised. Both arms are placed by the patients
The indications for laparoscopic surgery are as numerous as the gynecologic sides, paying special attention to protection of the hands,
diseases of the internal genitalia in general and the adnexa in particular. The and shoulder supports are placed. This is the only way to
classic indications include, for example, acute or chronic pain states that enable the first assistant to perform efficient operative
require diagnostic investigation, persistent ovarian cysts, suspected adhesions laparoscopy. In addition, the patients weight is placed
or endometriosis as the cause of subjective symptoms, and assessment of infer- symmetrically on both shoulders during the necessary
tility and diagnosis of tubal factors by chromopertubation. Rare problems such Trendelenburg position. Patient positioning should allow
as removal of a perforated/lost intrauterine device (IUP/IUD) are also the domain adequate positioning of the surgeon, if necessary on a
of laparoscopy. footstool, when the operating table is lowered as far as
possible during the operation
Contraindications Draping: abdominal window
Contraindications to a laparoscopic procedure are rare if the technical and logis- Anesthesia: intubation anesthesia
tical requirements are met. Especially in multimorbid and obese patients, lapa-
roscopy is the least traumatic form of investigation of the abdomen. The same Special Instruments
applies for patients who have had several laparotomies in the past, who should Laparoscopy set with insufflator, camera, and monitor
be spared a further laparotomy as far as possible. In very rare cases of severe Electrical instruments
forms of heart failure or marked valvular heart disease, laparoscopy may be Suction irrigator device
contraindicated because of the increased intra-abdominal pressure and Trende-
lenburg position. From the anesthesiologic point of view, too, the scope for lapa-
roscopic techniques expands markedly as they are more frequently performed.

Operation Risks and Informed Consent


The risks of simple laparoscopy are identical in principle to the risks of conven-
tional laparotomy: infection; delayed wound healing; injuries to vessels, bowel,
ureters, and bladder; and acute and postoperative hemorrhage, which may re-
quire transfusion. Secondary laparotomy is rarely required, but it should always
be discussed and informed consent should be obtained. Because of its minimally
traumatic approach, laparoscopy is also very suitable for a two-stage procedure in
unclear cases; this involves primary laparoscopy with subsequent discussion of
the findings, with possible subsequent laparotomy. All the possibilities should be
discussed preoperatively with the patient. Temporary postoperative shoulder
pain is typical after laparoscopy, and can be very severe in some patients.
IV Adnexa LaparoscopyDiagnostic and Minor Operative Procedures

Management of a simple ovarian cyst


Procedure 1. Most simple ovarian cysts, particularly in premenopausal patients, are
benign and are therefore highly suitable for laparoscopic management.
Preparation
2. The criteria of benign cysts are: patient aged less than 50 years of age,
1. Intubation anesthesia no ascites, cyst unilateral and mobile, diameter less than 58 cm, single
2. Lithotomy position; change to specific laparoscopy Trendelenburg position chamber on ultrasonography, smooth-walled, sharply demarcated without
(see above) after insertion of the camera trocar (umbilical) and check of internal echoes, normal CA125 level.
positioning by the surgeon 3. Before actual aspiration, washings should be obtained from the pouch
3. Skin preparation, insertion of a uterine manipulator (optional), bladder of Douglas for cytology, which are examined separately from the cyst
catheter, sterile draping: abdominal window aspirate. Assessment of the aspirate (clear vs. cloudy) allows preliminary
differentiation, for example, as regards a dermoid cyst.
Operation
4. When a cyst appears benign, it is aspirated directly with a sharp aspirating
1. Access to the abdominal cavity: sagittal incision in the base of the umbili- needle. Caution: any sharp aspiration involves a risk of injuring neigh
cus. Only the skin is opened. Caution: if entry is too deep, there is a risk of boring organs. The sharp needle must therefore be first inserted carefully
penetrating the abdominal cavity, and if the incision is too large, the opera- under vision and secondly the abnormal ovary must be fixed securely.
tion may be made unnecessarily difficult by the optical trocar constantly
5. Particularly in the case of clinically functional cysts discovered during
slipping into the abdominal cavity.
other procedures, various options are available: photo documentation,
2. The most effective mode of entry is with a Verres needle with continuous simple aspiration, fenestration of the cyst with biopsy and marsupiali-
gas flow: both the initial low intra-abdominal pressure and gentle insuf- zation, and possibly complete cyst excision in the case of persistent or
flation provide the surgeon with information about correct placement, symptomatic ovarian cysts, which will be described in the section on
together with the typical feeling when the abdomen is entered success- laparoscopic ovarian cystectomy (Chapter 4.3.3.6) . IV
fully and liver percussion dullness is lost in the right upper abdomen (after
insufflation of roughly 300 mL CO2). When entering, the surgeon ideally Ovarian biopsy 135
pulls up the abdominal wall so that the Verres needle is inserted at a 90 1. Biopsy of a macroscopically normal ovary may be useful as part of the
angle to the fascia and at a 45 angle to the horizontal slim patient. This investigation of endocrine problems. It is usually indicated during ovary-
angle must be steeper if the patient is obese. preserving operations for malignant disease.
3. After the pneumoperitoneum has been created successfully, the optical 2. In critical oncologic situations ovarian wedge resection, which goes
trocar is inserted. If an insufflation pressure of 1520 mmHg is used initial- beyond simple biopsy, allows at least an attempt at a more definite histo-
ly, it is usually possible to insert the optical trocar directly and without logic assessment. When ovarian tissue is obtained for cryopreservation,
lifting the abdominal wall further. for example, prior to systemic chemotherapy of nonovarian malignancies,
wedge excision is performed entirely without electrocoagulation.
Simple adhesiolysis
1. Laparoscopic adhesiolysis is not an end in itself but is guided by the Management of polycystic ovary (ovarian drilling)
patients complaints and should provide optimal access to the actual 1. Although the recommendations on the treatment of polycystic ovary syn-
operation area by normalizing the anatomy. drome (SteinLeventhal syndrome) are not uniform and medical treatment
2. Adhesiolysis can be the most difficult part of a laparoscopy, regardless predominates, the traditional surgical treatment methods will be described
of whether an ovarian cyst is being removed or adnexectomy or hyster- here, the basic aim of which is reduction of active ovarian tissue, either
ectomy is being performed. This also demonstrates the useful limits of by wedge resection or by punctate destruction of ovarian tissue by electro-
laparoscopy: individually weighing up what is technically possible and coagulation (ovarian drilling).
what is meaningful. Some adhesiolysis can be performed faster through Management of a perforated IUP/IUD
a laparotomy. However, the basic rule is that a difficult laparoscopic 1. Perforation of the wall of the uterus occurs rarely during IUP/IUD insertion
adhesiolysis will also always be a difficult open adhesiolysis. with partial or complete loss of the coil. The injury should then be assessed
3. The technique of adhesiolysis is shown in detail in Chapter 4.3.3.2. Ideally, immediately by laparoscopy and the coil should be removed from the
the adhesiolysis will follow the avascular path of least resistance. The in- abdomen.
strument of choice is usually (monopolar) scissors.
4. Recent or fine adhesions can sometimes be divided by passive traction or
pressure. This is the case, for example, with the typical adhesions between
the ovary and the pouch of Douglas in endometriosis.
5. Obviously vascular adhesions should not be coagulated with monopolar
diathermy, especially when close to bowel, but always with bipolar cur-
rent, and they should then be divided.
6. Electrocoagulation should be used as sparingly as possible during adhesiol-
ysis as it often leads to loss of the ideal plane and the space for dissection
becomes smaller due to the tissue contraction caused by coagulation.
7. Only adequate adhesiolysis creates the necessary distance from critical
structures such as bowel (rectosigmoid) and ureter. Inadequate adhesioly-
sis and hence inadequate distancing may result in unnoticed thermal
injury to the bowel.
IV Adnexa 4.3 Surgical Techniques

Special Technique LaparoscopyDiagnostic and Minor Operative Procedures

IV
136

Fig. 4.3-109 Adhesiolysis. The ability to per- can be necessary when postinflammatory and Fig. 4.3-110 Bipolar electrocoagulation of cleation or cesarean section. Omental adhe-
form safe laparoscopic adhesiolysis (here with endometriotic adhesions are present. Adhe- the adherent omentum. Omental adhesions sions are always well vascularized so that adhe-
scissors) is an important requirement for opera- sions are usually (but not always) avascular. In- to the adnexa or uterus result from severe in- siolysis here requires alternating bipolar coagu-
tive management of many gynecologic prob- creased bleeding can therefore indicate devia- flammatory processes such as abscesses, and lation and sharp division.
lems. The illustration shows ovariolysis, which tion from the optimal plane. also occur postoperatively after myoma enu-

Fig. 4.3-111 The coagulated omentum is di- vessels can often no longer be securely identi- Fig. 4.3-112 Aspiration of an ovarian cyst. portant steps. Only cysts classified as benign
vided with scissors. Careful coagulation is im- fied as the source of bleeding, is associated The cyst is entered with a sharp aspiration nee- clinically, ultrasonographically and macroscopi-
portant especially when the omentum is adher- with an increased risk of gastrointestinal tract dle under constant vision; fixing the ovary and cally are aspirated.
ent. Later hemostasis when the omentum is injury. cyst properly and direct puncture are the im-
again lying over the bowel, when the retracted
IV Adnexa LaparoscopyDiagnostic and Minor Operative Procedures

IV
137

Fig. 4.3-113 Biopsy of an opened ovarian Excision biopsy can also be performed. In cryo- Fig. 4.3-114 Bipolar electrocoagulation of tion is too extensive, healthy ovarian tissue is
cyst. Smaller, incidentally discovered ovarian preservation of ovarian tissue, wedge resection the cyst margin for hemostasis and marsupial- lost. Accurate coagulation of bleeding points is
cysts are usually functional and can be left or of the ovary is performed without electroco- ization. Ovarian tissue is suitable for hemosta- sometimes easier after visualization under irri-
aspirated. Biopsy of the opened cyst may be ap- agulation. sis by electrocoagulation. However, if coagula- gation.
propriate. Suitable biopsy forceps can be used.

Fig. 4.3-115 Ovarian biopsy with punch for- eral process is not present when preservation Fig. 4.3-116 Ovarian drilling. Polycystic ova- clined but is still regarded as a final treatment
ceps. Ovarian biopsy as a diagnostic measure of the contralateral ovary is desired. Partial ry after multiple punctures with the monopolar option for temporary reduction of pathologic
is reserved for exceptional cases in endocrinolo- ovarian resection is becoming increasingly im- electric scalpel. The popularity of targeted de- androgen levels. Postoperative adhesions be-
gy. In oncology, it is required in the case of uni- portant for cryopreservation in young patients struction of ovarian tissue by wedge excision tween the bowel and ovaries have been de-
lateral conditions to ensure that an occult bilat- prior to systemic chemotherapy. oras illustratedby ovarian drilling has de- scribed.
IV Adnexa 4.3 Surgical Techniques

Complications
The general complications of laparoscopy do not differ from those of any
surgery: delayed wound healing, even though this is very rare because of
the extremely small wound areas, bleeding, injury to neighboring organs
(bowel, bladder, ureter, blood vessels), and very rarely the need for a trans-
fusion.
Specific complications of laparoscopy include, for example, injuries to
the abdominal wall vessels; the inferior epigastric artery, which runs pos-
teriorly in the inner third of the rectus abdominis muscle, is not rendered
visible by transillumination. Injury to it is avoided by placing the trocars
well laterally, especially in the part of the abdomen below the anterior
superior iliac spine. The second vessel at risk is the superficial epigastric
artery, which is visible on transillumination. If bleeding from the abdomi-
nal-wall vessels occurs, temporary cross-sutures can be placed (removed
after 24 hours) or the bladder catheter technique can be used (see
Chapter 2).
Injuries to the bowel or, even more rarely, to retroperitoneal vessels on
blind entry with the Verres needle: the incidence of these lesions is repor-
ted as 1 : 1000 for bowel and is even rarer for vascular injury. Laparotomy
IV is usually necessary if vascular injuries occur, while isolated bowel injuries
can often be simply oversewn.
138
Typical postoperative pains in the shoulder girdle should be discussed with
the patient preoperatively. Problems such as subcutaneous emphysema
resolve rapidly postoperatively and only occur after long laparoscopic pro-
cedures lasting several hours.

Concurrent and Postoperative Treatment


Fig. 4.3-117 Removal of an intra-abdominal bleeding from the site of perforation is usually
IUP/IUD following perforation. Diagnostic lap- slight and can be treated by targeted coagula-
Depending on the logistical and administrative guidelines, minor laparoscopic
aroscopy and laparoscopic removal of the lost tion. procedures can be performed as ambulant or in-patient procedures depending on
IUP/IUD rarely have to be performed. Uterine the individual case. If there is a risk of secondary hemorrhage, in-patient moni-
toring for 2448 hours suffices. Occult bowel injuries, usually thermal, usually
only become symptomatic 34 days postoperatively. The patient must therefore
be given a list of serious warning signs, which should lead her to return to the
hospital (e.g., pyrexia, abdominal pains, and vomiting).

Limits of the Method


The limits of laparoscopy are the limits of meaningful laparoscopic adhesiolysis.
Old contraindications to laparoscopic management such as ruptured tubal
pregnancy with hemoperitoneum or dermoid cyst are now outdated as a result
of routine clinical practice. However, appropriate training for several years in
a center well versed in laparoscopy should be a requirement for successful use
of laparoscopic techniques.
IV Adnexa Laparoscopic Adhesiolysis

Endoscopic 4.3.3.2 Laparoscopic Adhesiolysis

Aims and Methods


Laparoscopic adhesiolysis is usually a means to an end. As in laparotomy, the
Operation Planning
important principle of surgery in laparoscopy too is normalization of the anat-
1. Medical history, clinical examination depending on the underlying disease;
omy to allow adequate and purposeful surgery. Postoperative and postinflam- imaging methods are unsuitable for demonstrating adhesions
matory adhesions often make access to the ovaries and fallopian tubes difficult, 2. Determination of the indication
and also to the uterus, the pelvic and para-aortic lymph nodes, the pouch of 3. Discussion about the extent of the operation; when there are specific
risks such as previous surgery or known inflammatory conditions, the
Douglas, and the vesicouterine pouch. Adhesions to the anterior abdominal
difficulties that can be expected with adhesions should be discussed in
wall make access to the abdomen difficult and in extreme cases they can even detail
make laparoscopy impossible. Again and again, adhesions are themselves the 4. Establishment of the procedure regarding the adnexa, depending on the
cause of pain and removing them, ideally laparoscopically, is part of the treat- patients age. Recurrent ovarian cysts in patients who have had hyster-
ment. While the fundamental laparoscopic techniques of ovarian cystectomy, ectomy can repeatedly require substantial and risky procedures on the
adnexa. The possibility of a definitive solution should be considered, par-
adnexectomy, and hysterectomy are easy to learn, the limit of what is possible ticularly with surgery of recurrence and if the patient is of a suitable age
IV
laparoscopically is found in the area of adhesiolysis, with a long and demand- 5. Consent to the procedure 139
ing learning curve. More complicated adhesiolysis is not possible endoscopical- 6. Anesthesiologic preoperative investigations depending on the patients age
ly without a degree of safety in the retroperitoneum and in laparoscopic ure- and local practice

teral exposure. 7. Thrombosis prophylaxis: LMWH (depending on the patients risk profile
and the extent of the procedure), ATS
8. Antibiotic prophylaxis: not absolutely necessary with purely laparoscopic
procedures
9. Depending on operation site, easy or extremely difficult surgery, taking
Indications and Contraindications
an unpredictable amount of time; surgeon and one assistant
Indications
Anesthesia and Positioning
The indications for adhesiolysis depend on the indication for the main opera- Positioning: legs on supports, which should be lowered preoperative-
tion. Even during chromopertubation, adequate assessment of the left adnexal ly by way of trial (Trendelenburg position) to simulate the
region is often possible only when the individually highly variable physiologic intraoperative situation after draping. Caution: intra-
adhesions between the sigmoid colon and left pelvic wall have been divided. operative lowering of the legs fixed to leg supports alters
The adhesions can be even greater following hysterectomy so that extensive the positioning at a time when the exact position of the
division of adhesions to the pelvic wall is often necessary prior to later adnexec- legs can no longer be seen because of the sterile draping.
tomy. When chronic pain states are investigated, postoperative adhesions after A trial lowering of the legs during sterile skin preparation
cesarean section, appendectomy, or previous, sometimes open, ovarian cyst is therefore advised. Both arms are placed by the pa-
excision are often suspected as the diagnosis. The diagnosis can only be confir- tients sides, paying special attention to protection of the
med laparoscopically, and the more the adhesions correspond to the pain symp- hands, and shoulder supports are placed. This is the
toms, the more often is laparoscopic division of the adhesions associated with only way to enable the first assistant to perform efficient
subjective improvement. Finally, adhesions can limit tube motility and thus operative laparoscopy. In addition, the patients weight
contribute to infertility. Laparoscopy performed according to appropriate guide- is placed symmetrically on both shoulders during the ne-
lines should ensure improved tubal and ovarian mobility as a result of salpingol- cessary Trendelenburg position. Patient positioning
ysis and ovariolysis. should allow adequate positioning of the surgeon, if
necessary on a footstool, when the operating table is
Contraindications
lowered as far as possible during the operation
Most adhesions diagnosed at operation are asymptomatic. The most important Draping: abdominal window
contraindications are the result of this: cosmetic removal of adhesions should Anesthesia: intubation anesthesia
be avoided. Asymptomatic adhesions that do not pose any risk for the bowel
do not have to be removed, especially as every adhesiolysis involves a risk of Special Instruments
injuring bowel, bladder, and ureters. Laparoscopy set with insufflator, camera, and monitor
Electrical instruments
Suction irrigator device
Operation Risks and Informed Consent
The risks of adhesiolysis are those of any operation (e.g., bowel injury, injury to
the bladder or ureter, vascular injury, hemorrhage). During lengthy laparoscopies,
added risks are thrombosis and positional injury. Particularly in the case of
patients with chronic pain, patients must also be informed of the risk of pain
persisting after adhesiolysis, the formation of new adhesions, or even potential
worsening of their symptoms.
IV Adnexa 4.3 Surgical Techniques

5. Dissecting the anterior abdominal wall is the first priority, as further


Procedure operation is possible only with optimal access to the abdominal cavity.
Adhesions from the omentum and/or bowel to the midline are often diffi-
Preparation cult to assess because of the limited visibility. Use of a working lens (lens
1. Intubation anesthesia channel and working channel in one trocar) is sometimes necessary.
2. Lithotomy position; change to specific laparoscopy Trendelenburg position 6. Principle of adhesiolysis: the adhesion should ideally be assessed from at
(see above) after insertion of the camera trocar (umbilical) and check of least two sides before it is divided. Either the optic must move around the
positioning by the surgeon adhesion or the position of the adhesion may be changed by traction and
3. Skin preparation, insertion of a uterine manipulator, bladder catheter, pressure.
sterile draping: abdominal window 7. Pragmatic understanding of adhesiolysis: the adhesions always extend
a bit further than initially assumed, and the bowel is always a bit closer
Operation than initially thought.
1. Access to the abdominal cavity: sagittal incision in the base of the umbili- 8. Adhesiolysis should be continued without current and without irrigation
cus. Only the skin is opened. Caution: if entry is too deep, there is a risk of as long as possible, by dissecting in the avascular plane. If more major
penetrating the abdominal cavity, and if the incision is too large, the opera- bleeding occurs, the avascular plane has probably been left. Caution:
tion may be made unnecessarily difficult by the optical trocar constantly omental adhesions are an exception; these are nearly always well vascu-
slipping into the abdominal cavity. larized and accordingly have to be coagulated carefully.
2. The most effective mode of entry is with a Verres needle with continuous 9. The scissors is the most important instrument for dividing adhesions:
gas flow: both the initial low intra-abdominal pressure and gentle insuf- spreading dissecting movements alternate with cutting under vision.
flation provide the surgeon with information about correct placement, to- Adhesions are put under traction and counter-traction and then divided.
IV gether with the typical feeling when the abdomen is entered successfully 10. A retroperitoneal approach with exposure of the course of the ureter can
and liver percussion dullness is lost in the right upper abdomen (after
140 insufflation of roughly 300 mL CO2). When entering, the surgeon ideally
be useful when adhesions to the pelvic wall are extreme.
11. The exact limits of adhesions to the bladder can be illustrated by filling
pulls up the abdominal wall so that the Verres needle is inserted at a 90
the bladder; during extensive dissection in the pouch of Douglas, simul-
angle to the fascia and at a 45 angle to the horizontal slim patient. This
taneous transrectal digital examination can demonstrate the exact bound-
angle must be steeper if the patient is obese.
aries of the rectum.
3. After the pneumoperitoneum has been created successfully, the optical
12. Minor bleeding from the retroperitoneal fat often ceases spontaneously.
trocar is inserted. If an insufflation pressure of 1520 mmHg is used ini-
tially, it is usually possible to insert the optical trocar directly and without
lifting the abdominal wall further.
4. The anatomy and the extent of the adhesions are assessed. If there are ad-
hesions between the omentum or bowel and the anterior abdominal wall,
check whether accessory incisions can be made. If necessary, insert the
camera through a suprapubic incision or through the infracostal Palmer
point in the left upper abdomen (Chapter 3.2.2).

Special Technique Laparoscopic Adhesiolysis

Fig. 4.3-118 Dissection during adhesiolysis olysis; it can create the space necessary for dis-
with the tractioncounter-traction cutting section by spreading movements and present
technique. Besides the straight or slightly the tissue layers to the scissors. The frequent
curved (Metzenbaum) scissors, the atraumatic adhesions between the sigmoid colon and left
grasping forceps is the most important acces- pelvic wall are divided close to the parietal peri-
sory instrument. It is suitable for blunt adhesi- toneum but without opening this.
IV Adnexa Laparoscopic Adhesiolysis

IV
141
Fig. 4.3-120 Adhesions medial to the ovary or symptoms, mobilization of the ovary may
that have to be divided during ovariolysis are also be necessary for adnexectomy. The most
usually avascular. Caution: when approaching difficult situation is often dissection of left-sid-
the uterus, be aware of the proximity of the ed ovarian cysts after previous hysterectomy.
Fig. 4.3-119 Irrigation blurs the layers and only when it is absolutely necessary to restore
uterine artery and vein anteriorly. Medial to In this case, depending on the patients age, ad-
impairs image quality. The ideal laparoscopy is optimal visualization. Irrigation can sometimes
the ovary, the ureter is sufficiently distant. Be- nexectomy should always be considered.
performed without irrigation. Even when visual- assist the technique of hydrodissection, help
sides therapeutic ovariolysis to treat infertility
ization of the site is lost because of major to separate layers, and act as a blunt instru-
bleeding or collection of blood, targeted suc- ment to support adhesiolysis.
tion should be used initially. Irrigation is used

Fig. 4.3-121 Exposure of known structures, steps. More than any other laparoscopic gyne- Fig. 4.3-120 The last and most difficult step larized. However, hemostasis by electrocoagu-
for example, the ovarian ligament, is an impor- cologic technique, complicated laparoscopic in fimbriolysis and ovariolysis is mobilization of lation directly on the tube or even on the fim-
tant step in adhesiolysis/salpingolysis/ovarioly- adhesiolysis requires much experience and the tube from the corresponding ovary. The brial ends is counterproductive as regards
sis. Largely normal anatomy should be re- practice. fimbrial ends are often difficult to distinguish future fertility. In addition, the physiologic ad-
stored as a prerequisite for further operative within the adhesions, and immediately adja- hesions between tube and ovary should be re-
cent adhesions are relatively highly vascu- spected.
IV Adnexa 4.3 Surgical Techniques

Complications Concurrent and Postoperative Treatment


Injuries: the more extensive the adhesions, the more difficult it is to divide
Numerous commercially available liquid or solid adhesion barriers have been
them and the higher the complication rates with regard to bowel injuries,
tested clinically in recent years. While some have shown respectable results de-
and injuries to the bladder, ureters, or blood vessels. Conversely, however,
spite the inherently difficult study conditions, a conclusive assessment of their
timid and inadequate adhesiolysis with insufficient distancing of the bowel
value is not yet possible in view of the extreme variability in the individual
prior to adnexectomy can markedly increase the risk of thermal bowel in-
tendency to form adhesions. Several studies have shown that adhesion barriers
jury.
impair wound healing, which is undesirable particularly after myomectomy or
Recurrence: the most important risk of laparoscopic adhesiolysis also is
similar procedures.
recurrence of new adhesions. The greater the peritoneal defects produced,
the greater the likelihood of new adhesions.
Ileus: inconsistent (i.e., incomplete) bowel adhesiolysis can increase the
risk of ileus.
Limits of the Method
Not everything that is possible laparoscopically is useful. Although laparoscopic
adhesiolysis has many advantages because of the magnification and the greater
closeness of the operation field to the surgeon and is always the operation of
choice for pure adhesiolysis, intra-abdominal adhesions can sometimes be
treated faster and more effectively as part of other operations through a laparot-
omy. Commensurate means and the time factor should be considered, not least
in the patients interest.
IV
142

Endoscopic 4.3.3.3 Laparoscopy of Pelvic Inflammatory Disease

Aims and Methods


Pelvic inflammatory diseaseand its distinction from appendicitis and sigmoid
Indications and Contraindications
diverticulitisis one of the most common gynecologic emergencies and can of-
The indications for diagnostic investigation are lower abdominal pain of unclear
ten be enormously important because it occurs in young women and may have
cause, even when the uterus and adnexa appear normal on vaginal ultrasound
a long-term negative effect on fertility, especially when it is severe. The condi- and the inflammatory parameters (leukocytes, Creactive protein [CRP]) are
tion ranges from the frequently unrecognized mild or subclinical Chlamydia negative. When there are clinical or laboratory signs of inflammation (pyrexia,
pain on cervical motion, leukocytosis, raised CRP), prompt diagnostic laparoscopy
adnexitis to febrile, painful adnexitis, acute pyosalpingitis and tubo-ovarian
is necessary. Laparoscopy is clearly indicated in the presence of cystic or solid
abscess, and suppurative inflammatory masses in the pelvis with potentially adnexal tumors, when tubo-ovarian abscess is suspected. There are no contra-
life-threatening concurrent peritonitis. indications, but possible reasons for modifying this approach include pregnancy
and a differential diagnosis that includes suspected nongynecologic problems
such as appendicitis or sigmoid diverticulitis. Genuine inflammatory diseases
Early and correct diagnosis is crucial initially, followed by drainage of abscess
of the adnexa are extremely rare in pregnancy, so laparoscopy should not be
cavities and restoration of normal anatomy, and targeted antibiotic therapy. immediately considered for diagnosis. Appendicitis and diverticulitis can be
Laparoscopy plays a central part in the treatment of inflammatory adnexal tu- diagnosed laparoscopically and can also be treated in the case of appendicitis.
mors, although empirical treatment when the diagnosis is suspected continues Acute, nonperforated sigmoid diverticulitis should preferably be treated conser-
vatively. Genuine contraindications to a primary laparoscopic approach are
to be controversial. Because it is widely available and very safe, diagnostic lap-
extremely rare and are usually due to severe underlying medical disease.
aroscopy should be performed in every form of lower abdominal pain of uncer-
tain cause, especially in young patients, before starting blind antibiotic ther-
apy. The diagnosis of mild pelvic inflammatory disease can be confirmed with Operation Risks and Informed Consent
laparoscopy, the site can be assessed, Chlamydia and general bacterial swabs As in all acute and emergency situations, both the risks of the procedure (e.g.,
can be taken, and the chances of long-term fertility can be assessed. Blunt divi- delayed wound healing, injury of internal organs, hemorrhage) and the possible
sion of adhesions predominates in advanced inflammation. Severe acute and complications if the operation is not performed must be discussed; these in-
clude overlooking the correct diagnosis, spread of the inflammation, and loss or
chronic abscesses and pelvic masses are among the most difficult findings. All impairment of fertility.
abscesses and encapsulated fluid collections must be opened and drained. Ad-
hesiolysis in this situation serves only to allow an approximate assessment of
the anatomy. Further operative measures are required at a second stage.
IV Adnexa Laparoscopy of Pelvic Inflammatory Disease

Operation
Operation Planning 1. Access to the abdominal cavity: sagittal incision in the base of the umbili-
1. Medical history, clinical examination to assess the differential diagnosis, cus. Only the skin is opened. Caution: if entry is too deep, there is a risk of
especially of primary abdominal surgical disease penetrating the abdominal cavity, and if the incision is too large the opera-
2. Gynecologic examination including a specific swab for Chlamydia and tion may be made unnecessarily difficult by the optical trocar constantly
plain swab for trichomonads slipping into the abdominal cavity.
3. Vaginal ultrasonography to assess the adnexa with regard to tubo-ovarian 2. The most effective mode of entry is with a Verres needle with continuous
abscesses gas flow: both the initial low intra-abdominal pressure and gentle insuf-
4. These clinical investigations should be guided by the patients pain; when flation provide the surgeon with information about correct placement,
there are clear pain symptoms, an appropriate gynecologic examination in together with the typical feeling when the abdomen is entered success-
particular should be performed fully and liver percussion dullness is lost in the right upper abdomen (after
5. Laboratory tests: leukocytes and CRP, coagulation screen if sepsis is sus- insufflation of roughly 300 mL CO2). When entering, the surgeon ideally
pected pulls up the abdominal wall so that the Verres needle is inserted at a 90
angle to the fascia and at a 45 angle to the horizontal slim patient. This
6. Detailed discussion of the suspected diagnosis. The sexual history is ob-
angle must be steeper if the patient is obese.
tained. If there is a history of risk contacts, testing for other sexually trans-
missible diseases (HIV, hepatitis B) or baseline status may be necessary 3. After the pneumoperitoneum has been created successfully, the optical
trocar is inserted. If an insufflation pressure of 1520 mmHg is used ini-
7. Anesthesiologic preoperative investigations depending on the patients
tially, it is usually possible to insert the optical trocar directly and without
age and local practice, and on urgency
lifting the abdominal wall further.
8. Thrombosis prophylaxis: LMWH, ATS
4. Inspection and photo documentation starting in the upper abdomen; if
9. Antibiotics should not be given until intraoperative swabs have been taken
appropriate, documentation of Chlamydia perihepatitis (Fitz-HughCurtis IV
or the suspected diagnosis is confirmed
10. Easy surgery that does not take long when performed as a diagnostic pro-
syndrome). 143
5. At least three working trocars are required.
cedure; inflammatory masses in the pelvis can sometimes result in a very
6. Chlamydia and general bacterial swabs are taken from the ends of the
difficult, complex and time-consuming operation; surgeon and one assis-
tubes (and not only from the mass in the pouch of Douglas); remove
tant
washings for cytology.
Anesthesia and Positioning 7. The further operative procedure depends on the operation site; if the ad-
Positioning: legs on supports, which should be lowered preoperatively nexitis is mild and adhesions have not formed, photo documentation and
by way of trial (Trendelenburg position) to simulate the microbiologic swabs suffice. The procedure can be concluded. Otherwise,
intraoperative situation after draping. Caution: intra- the procedure is as described for a typical tubo-ovarian abscess.
operative lowering of the legs fixed to leg supports alters the 8. With a tubo-ovarian abscess, the adnexa are usually displaced in the ova-
positioning at a time when the exact position of the legs rian fossa toward the pouch of Douglas and the posterior wall of the uterus.
can no longer be seen because of the sterile draping. A trial When the abscess is advanced, it can be impossible to distinguish the tube
lowering of the legs during sterile skin preparation is and ovary with certainty. In that situation, excision should be avoided as it
therefore advised. Both arms are placed by the patients may lead to irreversible changes in addition to the inflammatory damage.
sides, paying special attention to protection of the hands, 9. Omental adhesions can usually be divided bluntly. Sharp dissection is
and shoulder supports are placed. This is the only way to rarely necessary, but if it is performed, the omentum displaced into the
enable the first assistant to perform efficient operative upper abdomen must be inspected carefully for bleeding.
laparoscopy. In addition, the patients weight is placed 10. The tubo-ovarian abscess is often directly adjacent to the rectosigmoid
symmetrically on both shoulders during the necessary colon. Particularly in the case of an inflammatory mass, the individual
Trendelenburg position. Patient positioning should allow anatomic structures can be separated from one another only with diffi-
adequate positioning of the surgeon, if necessary on a culty. The sigmoid colon and adnexa can be separated by blunt dissection
footstool, when the operating table is lowered as far as to a certain degree. Because the bowel wall is thick in this region, acci-
possible during the operation dental injuries of the rectosigmoid during blunt adhesiolysis are rare but
Draping: abdominal window not impossible. Caution: sharp dissection is not advisable when the ana-
Anesthesia: intubation anesthesia tomic relations are unclear.
11. Particular caution is required when dissecting small-bowel loops involved
Special Instruments in the inflammatory mass. The wall of the small bowel is thin and sensitive
Laparoscopy set and, even with gentle blunt traction, the serosa can tear off or the bowel
Suction irrigator drainage, laparoscopic swab device, Robinson drain lumen can be torn open. Division of adhesions between small-bowel loops
Sufficient blunt grasping forceps is one of the most difficult steps in dissection overall, as the serosa is
directly adherent with the opposing surface and there is no remaining
anatomic plane that can be dissected (unlike the large bowel). An attempt
to dissect in the plane will probably lead to opening the small bowel.
Procedure
The simple motto when dissecting the small bowel is: better ovary on the
Preparation bowel than bowel on the ovary.
1. Intubation anesthesia 12. The purpose of the often very difficult and largely blunt adhesiolysis is to
open all major abscess cavities and restore the anatomy as far as necessary
2. Lithotomy position; change to specific laparoscopy Trendelenburg position
for understanding the abscess location and for secure diagnosis. Particul-
(see above) after insertion of the camera trocar (umbilical) and check of
arly in abscess surgery, there is also such a thing as too much, i.e., when
positioning by the surgeon
the bowel, blood vessels, or even the ureters are injured unnecessarily.
3. Skin preparation, insertion of a uterine manipulator. Caution: pelvic
13. The operative aim is achieved when the pouch of Douglas is clearly located
masses can involve the uterus, or the wall of the uterus can be relaxed so
and the posterior wall of the uterus is well visualized, when the adnexa
that there is an increased risk of perforation. The manipulator may be
can be distinguished with certainty, both from the bowel and at their
omitted. Bladder catheter, sterile draping: abdominal window
origin from the uterus, and when all abscesses have been decompressed
and adequately opened.
14. It is necessary to leave a Robinson drain. The use of postoperative irriga-
tion and suction systems is not evidence based.
IV Adnexa 4.3 Surgical Techniques

Special Technique Laparoscopy of Pelvic Inflammatory Disease

IV
144

Fig. 4.3-124 In acute and subacute situa- portant instrument in this situation. Sharp and
tions, adhesions are usually not yet fibrotic and possibly unnecessarily destructive dissection is
Fig. 4.3-123 The most important task of lapa- sions? Can appendicitis be ruled out? Are other can be divided bluntly. Hydrodissection can not advisable in unclear situations. However,
roscopy initially is diagnosis of the current inflammatory processes present in the abdo- also be helpful. The suction irrigator is an im- the rule is to restore the normal anatomy.
symptoms. Is there an acute, subacute, or sup- men? A swab and cytology should ideally be ob-
purating inflammation? How are the adhe- tained before giving systemic antibiotics.

Fig. 4.3-126 When the view into the pelvis is abscess, the tube and ovary can often no longer
free and the pouch of Douglas has been ade- be distinguished from one another. The abscess
quately dissected, mobilization of the adnexa cavity usually tears open during blunt dissec-
or adnexal mass can begin. With a tubo-ovarian tion of the adnexa out of the obturator fossa.

Fig. 4.3-125 Omental adhesions must always ty. Sharp dissection is required only when blunt
be divided as otherwise the pelvis cannot be as- dissection is no longer helpful. This can often
sessed adequately. The cecum must also be be the case in the region of the sensitive small
mobilized out of the pelvis. Primary or second- bowel.
ary appendicitis must be ruled out with certain-
IV Adnexa Laparoscopy of Pelvic Inflammatory Disease

IV
145

Fig. 4.3-127 All abscess cavities must be and ovary can usually be better distinguished
opened and drained. The contents (pus, inflam- when the tension of the inflamed and fibrotic
matory serous fluid) are removed. Release of surfaces is reduced by drainage of the abscess
Fig. 4.3-128 Adnexectomy or salpingectomy obtain informed consent. After drainage of the
the abscesses usually leads to further normali- cavities.
is not advisable in the acute situation. Salpin- abscess cavities, targeted antibiotic therapy
zation of the anatomy. In particular, the tube
gectomy may be indicated only for recurrent usually leads to full recovery, though possibly
and mainly unilateral sactosalpingitis after pro- with impaired fimbrial function.
viding the patient with detailed information to

Complications Concurrent and Postoperative Treatment


Infection of the port sites. With all intra-abdominal inflammation, spread
Antibiotic therapy, intravenous initially, is the mainstay. After clinical and labora-
of infection to the trocar ports is, at least theoretically, a more frequent
tory improvement has occurred, antibiotics should be continued orally for at least
complication, though in practice it is very rare.
710 days. Rapid subsidence of pyrexia, an improvement in clinical symptoms,
Bowel and ureteral injury. Other complications, especially with suppura-
and a fall in leukocytosis and CRP level are critical. The antibiotic therapy should
ting infections, are injuries to the bowel (especially small bowel) and
include an antibiotic effective against Chlamydia; a broad-spectrum antibiotic
ureters during dissection of the unclear anatomy. Because of the concur-
and an antibiotic specifically effective against anaerobes should also be given be-
rent inflammation, adequate primary closure of these injuries, especially
cause abscesses are generally polymicrobial. Aminoglycosides such as gentamicin
in the colon, is often not possible so that a temporary colostomy is neces-
are particularly effective against Gram-negative bacteria, and clindamycin or
sary in extreme cases. This too is a rare complication.
metronidazole are effective against Chlamydia; a first- or second-generation
Recurrence. Especially in the presence of extensive suppurating infections, cephalosporin is recommended as a broad-spectrum antibiotic. As always, the
individual abscess cavities may be overlooked or may seal over again if drain should be removed early (second day). Thrombosis prophylaxis (LMWH,
they are not opened adequately. If, in rare cases, the antibiotic therapy ATS) and rapid mobilization are essential. If sepsis or incipient sepsis with sys-
cannot sterilize the inflamed tissue, clinically problematic recurrences can temic involvement is suspected, monitoring in the intensive care unit is indicated.
occur. As an alternative to a further attempt at laparoscopic treatment,
laparotomy can be performed as a last resort, with adnexectomy or total
operation, depending on the patients age and family status. This was the
common treatment in the preantibiotic era.
Limits of the Method
Infertility. With pelvic inflammatory disease, impairment of fertility is Before the introduction of effective antibiotics tubo-ovarian abscesses and sup-
always a possible long-term complication, not of the operation but of the purative diseases of the internal genitalia were an important cause of often
underlying disease. The treating doctor can be reproached with this dramatic morbidity, and often led to the patients death. The combination of
complication only if he fails to carry out diagnostic and therapeutic inter- laparoscopy and intravenous antibiotics provides the physician with an ex-
vention. The extent of the inflammation correlates with the future impair- tremely effective mode of treatment. Early laparoscopy, early diagnosis, and
ment of fertility. early, effective, and targeted antibiotic therapy are the optimal means of
avoiding a chronic suppurating course, which can often have life-changing
consequences for the patient.
IV Adnexa 4.3 Surgical Techniques

Endoscopic 4.3.3.4 Laparoscopic Fertility Surgery

Aims and Methods


The wish to have a child of ones own is one of the core human needs. If a want-
Contraindications
ed pregnancy does not occur within a relationship, this causes severe stress for
Apart from purely medical and anesthesiologic considerations, the absence
both partners. Infertility in both women and men has a variety of causes. Uter- of laparoscopic assessment of the site and an uninvestigated partner are other
ine causes such as synechiae, septa, and submucous myomas; causes involving contraindications. Laparoscopic investigation and management in a single pro-
the fallopian tubes such as stenosis and post-inflammatory occlusion; and gen- cedure is also feasible but can be difficult logistically. Because of the very low
success rates, relative contraindications for tubal reanastomosis include tuber-
eral intra-abdominal causes like adhesions and endometriosis can be managed
culosis of the tube; highly sclerosed and rigid tubes; short, previously operated
surgically. Intra-abdominal problems such as adhesions and tubal stenosis are tubes without an ampulla or fimbrial end; tube length of less than 4 cm after
particularly suitable for a laparoscopic approach. Laparoscopy has a role in as- surgery; and very dilated or thick-walled hydrosalpinx. Ultimately, the patient
sisting fertility by correcting factors that reduce fertility such as adhesions in must be aware of the limitations of the technique when deciding what success
rate is acceptable for her. The psychologic effect must not be ignored.
the region of the tubes. On the other hand, laparoscopy is an attractive alterna-
IV tive to the increasingly forgotten microsurgical tubal reanastomosis techniques

146 performed through a laparotomy. With the mediocre success rates and the Operation Risks and Informed Consent
good results of conservative reproductive medicine alternatives, these tech-
The most important advantage of the laparoscopic approach is that it has lower
niques are no longer clinically routine, especially on account of the increasingly postoperative morbidity than laparotomy. Nevertheless, classic complications
unacceptable (and possible counter-productive) morbidity of the open abdom- such as delayed wound healing, pain, and injury to the bowel, bladder, ureters,
inal approach. Laparoscopic tubal reanastomosis is described below. The suc- and blood vessels should be discussed. During lengthy laparoscopies, positional
injuries and thrombosis are further risks. The specific risk of the procedure,
cess achieved with the open technique under optimal conditions (i.e., pregnan-
which requires informed consent, is the increased risk of tubal pregnancy fol-
cy rates of up to 50% 60%) has so far been hardly been approached in small lowing tube reconstruction. After diagnostic laparoscopy the patient should be
case series using the endoscopic technique. However, the success rate depends informed in detail about her individual situation, the anticipated success rates,
and the alternatives provided by other reproductive medicine procedures such
significantly on patient selection. Good results have been seen almost exclu-
as IVF.
sively in patients under the age of 30 years with mild tubal pathology. This
type of patient is encountered rather seldom in reproductive medicine. In
women over the age of 35 with advanced tube pathology or tubes with great Operation Planning
postoperative shortening, the success rates for laparotomy vary between 1. Medical history, reproductive medicine and endocrinologic investigation
of the causes of infertility
10 and 20%. Whether a patient should undergo laparotomy because of this
2. Comprehensive reproductive medicine investigation of the partner
was always controversial, but this provides the indication for laparoscopic tu-
3. Diagnostic hysteroscopy and laparoscopy to investigate the site. It is an ad-
bal reconstruction; the very low overall morbidity of the minimally invasive vantage if the laparoscopy is performed by the surgical team that will later
approach may justify an attempt at treatment although the prospect of success perform the reanastomosis. It is theoretically possible to perform the lapa-
is small from the outset. roscopic procedure in a single stage, but a two-stage procedure is recom-
mended to allow better counseling and planning
4. Exclusion of other gynecologic pathology
5. Detailed discussion of the overall situation, the anticipated prospects of
success and possible reproductive medicine alternatives
Indications and Contraindications
6. Anesthesiologic preoperative investigations depending on the patients
Indications age and local practice

The optimal indication for tubal surgery is tubal infertility confirmed by diag- 7. Thrombosis prophylaxis: LMWH, ATS
nostic hysteroscopy and laparoscopy, along with laparoscopic chromopertuba- 8. Antibiotic prophylaxis: 1st/2nd generation cephalosporin < 30 minutes
tion, after other factors in infertility have been ruled out. Classic and especially before surgery.
suitable situations are previous sterilization, proximal tubal occlusion, occlusion 9. Difficult surgery (reanastomosis) as rare and technically very demand-
at the end of the tube, and tubal phimosis. Causes of infertility that can be ing; takes 36 hours; surgeon and one or two assistants
managed hysteroscopically, such as submucous myomas or intrauterine septa,
should have been treated. The partner must also be investigated. Ideally, the pa-
tient is young and the impaired tube function should be manageable. This is the
case, for example, after tubal ligation or partial salpingectomy for sterilization.
IV Adnexa Laparoscopy of Pelvic Inflammatory Disease

Anesthesia and Positioning 5. At least three working trocars, inserted sufficiently laterally and high to
Positioning: legs on supports, which should be lowered preoperatively allow comfortable manipulation of the needle holder. A 10-mm trocar
by way of trial (Trendelenburg position) to simulate the may be inserted suprapubically for safe introduction and removal of the
intraoperative situation after draping. Caution: intra- (small) needles.
operative lowering of the legs fixed to leg supports alters Fertility-supporting proceduresadhesiolysis
the positioning at a time when the exact position of the 1. The principles of laparoscopic adhesiolysis (Chapter 4.3.3.2) also apply
legs can no longer be seen because of the sterile draping. here, in particular, restoration of normal anatomy. This means that the
A trial lowering of the legs during sterile skin preparation adnexa are mobilized from the uterus, pouch of Douglas, and pelvic wall,
is therefore advised. Both arms are placed by the patients and the fallopian tubes from the ovaries. Under physiologic conditions,
sides, paying special attention to protection of the hands, the mobile fimbriae of the tube wander over the ovarian surface to the
and shoulder supports are placed. This is the only way to graafian follicle that is about to ovulate.
enable the first assistant to perform efficient operative
2. Although it is usually possible to mobilize the adnexa, mobilization of the
laparoscopy. In addition, the patients weight is placed
fimbriae is difficult and often not well visualized as the fimbrial end of the
symmetrically on both shoulders during the necessary
tube bleeds easily and should be coagulated as little as possible. Blunt dis-
Trendelenburg position. Patient positioning should allow
section is not useful as strands of adhesions between parts of the fimbriae
adequate positioning of the surgeon, if necessary on a
have to be identified and divided specifically. Bleeding points should be
footstool, when the operating table is lowered as far as
visualized under irrigation and, after waiting for natural hemostasis, they
possible during the operation. Heated underlays and
are coagulated if they persist.
warm-air covers may be used if necessary
Draping: abdominal window Fertility-supporting proceduresfimbrioplasty/salpingostomy

Anesthesia: intubation anesthesia 1. In more than two-thirds of cases, pathologic changes in the tubes affect IV
the distal part, which is particularly important for fertility. A distinction is
Special Instruments made between complete and incomplete occlusion of the distal end of the 147
Laparoscopy set tube.
Monofilament suture material: PDS 7 0 for the tubes, somewhat stronger 2. When the occlusion is incomplete, an attempt is made to reopen the fim-
for the mesosalpinx briae by fimbriolysis or fimbrioplasty and evert the tube as far as possible.
On the one hand, the long-term success rates are better, but on the other
Special fine needle holder, fine dissecting scissors (curved), monopolar mi-
hand, bleeding occurs more often when the mucosa is preserved.
croneedle, fine atraumatic grasping forceps. Unlike in most laparoscopic
procedures, specific endoscopic instruments for microsurgery are actually 3. When the end of the tube is completely occluded and the prospects of
needed for tubal anastomosis. success are only moderate, salpingostomy may be performed. The tube is
opened at its most distal point (dimple). The often coexisting sactosal-
pinx is drained. The distal end of the tube is opened adequately by a
stellate incision. The aim is artificial reconstruction of the fimbriae. Dissec-
Procedure tion must therefore continue as far as the residual mucosa. The mobilized
Preparation tube ends are then everted and fixed either by suture (40/6 0) or coagu-
lation of the edges (flowering).
1. Intubation anesthesia
4. The prospects of success depend more on the patients age and the original
2. Lithotomy position; change to specific laparoscopy Trendelenburg position
condition of the operation site than on the (micro)surgical technique.
(see above) after insertion of the camera trocar (umbilical) and check of
positioning by the surgeon Laparoscopic tubal reanastomosis
3. Skin preparation, insertion of a uterine manipulator suitable for perform- 1. Laparoscopic tubal reanastomosis attempts to combine the tried and
ing intrauterine chromopertubation, bladder catheter, sterile draping: tested principles of microscope-assisted microsurgery through a laparo-
abdominal window tomy with the benefits of minimally invasive laparoscopy and thus con-
tribute to a renaissance of the increasingly forgotten tubal surgery. Isolated
Operation single-center series suggest success rates that are comparable with the
1. Access to the abdominal cavity: sagittal incision in the base of the umbili- open technique. The basic rules are identical.
cus. Only the skin is opened. Caution: if entry is too deep, there is a risk 2. The stenotic part of the tube is excised. The length of tube remaining has
of penetrating the abdominal cavity, and if the incision is too large, the a crucial influence on the long-term chances of success of the operation,
operation may be made unnecessarily difficult by the optical trocar con- so excision should be as sparing as possible. At the same time, however,
stantly slipping into the abdominal cavity. vital and intact tube ends with mucosa must be dissected free at both ends.
2. The most effective mode of entry is with a Verres needle with continuous The monopolar microneedle or curved (micro)scissors are suitable dissect-
gas flow: both the initial low intra-abdominal pressure and gentle insuf- ing instruments. Injury of the vascular arcades that run directly along the
flation provide the surgeon with information about correct placement, tube in the mesosalpinx must be strictly avoided.
together with the typical feeling when the abdomen is entered success- 3. The patency of the proximal part of the tube should be documented by
fully and liver percussion dullness is lost in the right upper abdomen (after chromopertubation. The diameter of the dissected distal part of the tube
insufflation of roughly 300 mL CO2). When entering, the surgeon ideally should not differ too greatly from that of the proximal part. The patency of
pulls up the abdominal wall so that the Verres needle is inserted at a 90 the distal part of the tube should be tested by retrograde filling. Some au-
angle to the fascia and at a 45 angle to the horizontal slim patient. This thors suggest introducing a stent into the tube, but this step is optional.
angle must be steeper if the patient is obese. 4. Epinephrine solution is injected into the tissue to be dissected to optimize
3. After the pneumoperitoneum has been created successfully, the optical hemostasis.
trocar is inserted. If an insufflation pressure of 1520 mmHg is used initial- 5. The mesosalpinx is reapproximated (PDS 6 0). A sufficiently large trocar
ly, it is usually possible to insert the optical trocar directly and without (10 mm) and extreme care and concentration are required for introducing
lifting the abdominal wall further. and removing the small needles so that they do not get lost. The mesosal-
4. Inspection and photo documentation, starting in the upper abdomen pinx sutures relieve the anastomosis, which should be tension free.
IV Adnexa 4.3 Surgical Techniques

6. The tube is anastomosed by sutures through all layers or only through the Laparoscopy in polycystic ovary syndrome
muscle layer, tied outside the tube at 6, 12, 9, and 3 oclock. Alternatively, 1. Our understanding of polycystic ovary syndrome as a systemic metabolic
a three-suture technique can be used (6, 10, and 2 oclock). The knots and endocrine disease has changed greatly in recent years, as have the
should be located outside the tube. Including the mucosa in the sutures possibilities for conservative treatment. Nevertheless, androgen reduction
does not appear to have a negative influence on the pregnancy rate. The and normalization of the luteinizing hormone/follicle-stimulating hormone
suture at 6 oclock is tied immediately, but the 12 oclock suture can be left (LH/FSH) ratio after partial destruction of ovarian cortical tissue is well
untied until the sutures at 3 and 9 oclock have been tied. documented.
7. Patency (but not 100% leak-tightness) is tested by chromopertubation. 2. The available laparoscopic techniques include classic wedge resection,
8. Finally, the serosa on the tube is reapproximated by three to four sutures which may take the form of ovarian biopsy, electrocoagulation, and laser
over the muscle anastomosis. destruction. The aim of each technique is to reduce the juxtacortical
polycystic tissue in the ovary.

IV
148 Special Technique Laparoscopic Fertility Surgery

Fig. 4.3-129 Fertility-supporting procedures the tube is usually adherent to the ovarian fossa Fig. 4.3-130 Mobilization of a tube that is ad- lead to bleeding in the region of the fimbriae.
adhesiolysis. The first step in fertility-sup- and can be dissected out in cranioanterior di- herent to the ovary is more difficult. Only sharp If this is the case, natural hemostasis should be
porting adhesiolysis is mobilization of the ad- rection by partly blunt and partly sharp mobili- dissection is possible as blunt traction can lead awaited initially before persistent bleeding
nexa in their entirety from the pelvic wall and zation. The course of the ureter should be not- to tears of the tube that bleed heavily. How- points are visualized and coagulated directly
uterus. Both in post-inflammatory situations ed; it runs immediately beneath the peritone- ever, sharp dissection with scissors will always with simultaneous irrigation.
and in endometriosis, the ovary together with um of the lateral pelvic wall.
IV Adnexa Laparoscopic Fertility Surgery

IV
149

Fig. 4.3-131 Fertility-supporting procedures isting sactosalpinx (which also causes problems Fig. 4.3-132 The three- or four-point stellate or a monopolar electrode is used while the
fimbrioplasty. The prospects of successful during subsequent IVF treatment), and second- opening of the distal part of the tube shown tube is grasped and stretched atraumatically.
pregnancy are not good when the tubes are ly to attempt to restore tube patency and thus previously starts, if possible, from the dimple Dissection must be continued as far as the
completely occluded distally. Salpingostomy the at least theoretical possibility of pregnancy. of the phimotically closed tube. Either scissors (well vascularized) tubal mucosa.
has two aims: firstly, to relieve the often coex-

Fig. 4.3-133 The dissected parts of the tube edge (flowering). The aim is to restore a per-
wall are either fixed with sutures to the rest of manently open fimbrial infundibulum. Many
the tube or are made to retract and evert by tar- smaller bleeding points cease spontaneously af- Fig. 4.3-134 Laparoscopic tubal reanasto- spared as far as possible, but some of it usually
geted and extremely sparing coagulation of the ter a short time. mosis. The first step in laparoscopic tubal re- has to be excised. Microsurgical techniques and
anastomosis is excision of the stenotic or ligat- special endoscopic microinstruments are an ad-
ed part of the tube. The mesosalpinx should be vantage.
IV Adnexa 4.3 Surgical Techniques

IV
150

Fig. 4.3-136 Laparoscopy in PCO. The aim of an biopsy or wedge resection, this can be done
laparoscopic PCO treatment is destruction of by point electrocoagulation with a monopolar
polycystic ovarian cortical tissue. Besides ovari- needle (ovarian drilling).
Fig. 4.3-135 The illustration shows the anas- nique, first closing the defect in the mesosal-
tomotic technique with the sutures passing pinx, thenif possiblethe muscle tube (which
only through muscle. Including the mucosa is then tested for patency), and finally the se-
does not appear to have a detrimental effect rosa. With good visualization, the muscle layer
on the pregnancy rate. The muscle tube is ap- and serosa can also be approximated jointly.
proximated with a three- or four-suture tech-

Complications Limits of the Method


Specific complications. These are mainly shoulder pain, positional injuries With the successful conservative reproductive medicine techniques now avail-
(paresis) after very long operations, and subcutaneous emphysema. These able, fertility surgery, especially tube reconstruction, has been somewhat for-
usually regress rapidly. gotten. The temptation to perform the established microsurgical techniques
Failure of the operation. There are few data on the laparoscopic technique. laparoscopically and thus avoid laparotomy has increased. It is certain that ac-
However, a single-center study found pregnancy rates of up to 80% in ceptable success rates were also sparse in the literature and referred particularly
nearly 200 patients after laparoscopic tubal reanastomosis. to open microsurgical techniques. Live birth rates of 50% 60% were achieved in
Tubal pregnancy. This is the most important other complication. The the largest series of almost 700 patients. Ampullary anastomoses have lower
figures reported in the literature are 210% after microsurgical tubal success rates (40%) and isthmic ones have higher success rates (75%). The success
anastomosis and up to 50% after salpingostomy and fimbrioplasty. rate of 85% was highest after ring or clip sterilization when the operation was
Lost needles. With the laparoscopic technique, loss of the tiny needles is performed within 5 years after the sterilization. The superiority of the micro-
a feared complication. Introducing and removing the needles, which expe- surgical to the conventional technique was demonstrated repeatedly. The
rience has shown to be the most dangerous moment, requires extreme poorest results are seen after salpingoneostomy, which achieved live birth rates
care and concentration. of 20%30% with microsurgery. Depending on the size of the hydrosalpinx, the
condition of the fimbriae, the presence or absence of rugae (hysterosalpingogra-
phy), and the extent of the adhesions, this success rate may be even lower. As
Concurrent and Postoperative Treatment the laparoscopic approach is similar to the microsurgical approach as regards
visualization of the operation field, similar results should be achievable with
There are no specific treatment instructions apart from the usual perioperative the same technique. This was confirmed prospectively in at least one study. In
care. Prophylactic antibiotics are continued for up to 5 days on the basis of general this connection, the new endoscopic robotic operation systems might be of
considerations. There are no guidelines on how long healing takes and when particular interest as they might allow virtually identical reproduction of the
pregnancy should be attempted. A waiting period of 12 cycles probably suffices. microsurgical operation conditions.
IV Adnexa Laparoscopic Sterilization

Endoscopic 4.3.3.5 Laparoscopic Sterilization

Aims and Methods


Reliable and definitive contraception is an important function of gynecology
Operation Risks and Informed Consent
from the medical and sociocultural point of view. Of the many methods of con-
traception, surgical and permanent techniques are described below. The deci- Besides the usual risks such as infection, pain (for example, temporary post-
operative shoulder pain), hemorrhage, and injury of internal organs, the patient
sion not to have any (more) children is always a highly personal decision. Med-
must be clear about three facts before the procedure:
ical indications for sterilization are extremely rare and must always be dis- Forever: sterilization is permanent and is practically irreversible.
cussed precisely with the patient. Long-term but not final alternatives, which Not 100%: sterilization is the safest method of contraception long-term, but
are almost as reliable, are now available. The importance of the psychologic pregnancy can occur at any time.
Increased risk of tubal pregnancy: if pregnancy occurs, it is extrauterine
or theoretical possibility of pregnancy should not be underestimated even in
in almost 40% of cases.
the presence of serious underlying disease or an objective physiologic near-im-
Beyond these three facts, the most important risk of sterilization is that the pa-
possibility of successful pregnancy. Although the patients wishes are crucial,
tient will regret the procedure later. This risk should be addressed specifically,
this does not mean that her doctor should not advise her. It is known that especially in women aged less than 30 years. As nearly every sterilization is IV
very young women in particular regret sterilization relatively often after sup- an elective procedure, the informed consent must be especially careful. Sterili-
zations performed just after the end of pregnancy (delivery or abortion) have
151
posedly completing their families. The aim of each technique is permanent and
a somewhat higher failure rate. Patients must therefore be informed of this.
safe prevention of further pregnancies with few side effects. The most wide- Temporary postoperative shoulder pain is a specific risk of laparoscopy.
spread technique globally is laparoscopic interruption of tubal function. Open
techniques are now employed almost exclusively during cesarean section. Var-
ious laparoscopic sterilization techniques are available, ranging from coagula- Operation Planning
1. Detailed history of the family status, information about the procedure and
tion of the tubes, through partial or total salpingectomy to tubal ligation with
its consequences, and counseling with regard to alternatives
silicon rings or metal clips; this wide range is described below.
2. Documentation of this information and counseling
3. Exclusion of gynecologic problems and pathology
4. Decision on and discussion of the technique
5. Consent to the procedure
Indications and Contraindications
6. Anesthesiologic preoperative investigations according to the local practice
Indications 7. If appropriate, the procedure is planned in the first half of the cycle so that
undiagnosed pregnancy can be ruled out with certainty
The primary indication is the womans well considered wishes, following appro-
8. Easy surgery provided adhesiolysis is not required; takes < 1 hour;
priate counseling. A wish for definitive sterilization expressed after adequate re-
surgeon and possibly one assistant
flection is the indication for the procedure. There are practically no compelling
medical indications. Implantable progesterone systems such as Norplant (active
Anesthesia and Positioning
substance: levonorgestrel) or Implanon, and the Mirena coil as an alternative,
Positioning: legs on supports, which should be lowered preoperatively
can be considered as long-term alternatives to tubal ligation techniques for
by way of trial (Trendelenburg position) to simulate the
many patients, probably even patients with thrombophilia and cardiovascular
intraoperative situation after draping. Caution: intra-
disease.
operative lowering of the legs fixed to leg supports alters
Contraindications the positioning at a time when the exact position of the
legs can no longer be seen because of the sterile draping.
Every permanent form of sterilization is contraindicated in a patient who is A trial lowering of the legs during sterile skin preparation
ambivalent or under external pressure. The treating doctor must react to the is therefore advised. Both arms are placed by the pa-
situation with particular sensitivity. Another contraindication is when the tients sides, paying special attention to protection of the
patient is unable to decide or give informed consent, for example, if she has hands, and shoulder supports are placed. This is the only
some level of intellectual disability. In cases of doubt, an ethics committee way to enable the first assistant to perform efficient ope-
decision or ruling by a competent family court may be required. rative laparoscopy. In addition, the patients weight is
placed symmetrically on both shoulders during the
necessary Trendelenburg position. Patient positioning
should allow adequate positioning of the surgeon, if
necessary on a footstool, when the operating table is
lowered as far as possible during the operation
Draping: abdominal window
Anesthesia: intubation anesthesia

Special Instruments
Laparoscopy set
Coagulation forceps, grasping forceps, scissors
IV Adnexa 4.3 Surgical Techniques

4. Coagulation should lead to complete blanching of the tissue. Excessive


Procedure coagulation leading to carbonization, apparent as brown-black discolora-
tion, should be avoided. Carbonization often leads to tissue breakage and
Preparation unnecessary bleeding when the coagulation forceps is removed.
1. Intubation anesthesia 5. The use of automatically controlled or feedback-controlled coagulation
2. Lithotomy position; change to specific laparoscopy Trendelenburg position forceps that measure current and/or tissue resistance and switch off after
(see above) after insertion of the camera trocar (umbilical) and check of adequate coagulation is particularly useful.
positioning by the surgeon 6. Additional division of the coagulated tube is not necessary.
3. Skin preparation, bladder catheterization or insertion of an indwelling
Ligation techniques
catheter, insertion of a uterine manipulator (important for optimal expo-
1. Sterilization techniques involving application of clips or rings are employed
sure, stretching, and distancing of the tubes toward the sidewall of the
widely in English-speaking countries, but are not often used in German-
pelvis), sterile draping: abdominal window
speaking countries. The Filshi clip and silicon ring are shown here as
Operation examples. These methods should be avoided particularly immediately
following pregnancy (risk of bleeding).
1. Access to the abdominal cavity: sagittal incision in the base of the umbili-
cus. Only the skin is opened. Caution: if entry is too deep there is a risk of 2. Application of Filshi clips is particularly demanding as they have to be
penetrating the abdominal cavity, and if the incision is too large the opera- placed on the isthmic part of the tube strictly at a right angle. Caution: it is
tion may be made unnecessarily difficult by the optical trocar constantly essential to grasp the entire tube. The relatively high failure rates seen in
slipping into the abdominal cavity. large retrospective studies are attributed especially to insufficiently careful
application.
2. The most effective mode of entry is with a Verres needle with continuous
IV gas flow: both the initial low intra-abdominal pressure and gentle insuf- 3. The most important advantage of the Filshi clip is the point occlusion of
flation provide the surgeon with information about correct placement, the tube with minimal tissue destruction and necrosis, which promises
152 together with the typical feeling when the abdomen is entered success- better prospects of success, at least theoretically, if reversal of the opera-
fully and liver percussion dullness is lost in the right upper abdomen (after tion is desired later, compared with destruction of a long segment of the
insufflation of roughly 300 mL CO2). When entering, the surgeon ideally tube. However, the technique must still be regarded as permanent.
pulls up the abdominal wall so that the Verres needle is inserted at a 90 4. The silicon ring can be used especially in combination with a working
angle to the fascia and at a 45 angle to the horizontal slim patient. This optical trocar. A special instrument is required for applying the rings. This
angle must be steeper if the patient is obese. is a grasping forceps which is loaded with the two silicon rings before it
3. After the pneumoperitoneum has been created successfully, the optical is introduced into the abdomen. Sufficiently mobile tubes bilaterally are
trocar is inserted. If an insufflation pressure of 1520 mmHg is used initial- required for simple application. Exact placement in the isthmic part is
ly, it is usually possible to insert the optical trocar directly and without crucial in this case also.
lifting the abdominal wall further. 5. The tube is surrounded with the arms that form part of the applicator
4. Inspection of the mid and upper abdomen, Trendelenburg position, and pulled up and placed under tension to form a small loop. The silicon
inspection of the pelvis and lower abdomen. ring is then pushed over the loop of tube with the applicator. When done
correctly, this results in a loop of tube ligated at its base.
5. Depending on the technique employed, the optical trocar can also be used
as a working laparoscope. A further suprapubic port can then be omitted. 6. With time, both silicon rings and Filshi clips become covered with perito-
However, this greatly limits the laparoscopic possibilities, for example, for neum so that later they are apparent only as a very inconspicuous nodular
inspection (by foregoing a second working axis) and, on the other hand, thickening.
a 10-mm trocar through a second port is necessary when a Filshi clip or Partial salpingectomy
silicon ring is used. 1. Confirmation of sterilization by histologic examination of excised portions
Coagulation technique of tube is no longer required from the medicolegal point of view. More
1. A frequently employed technique is bipolar coagulation. The bipolar elaborate techniques such as total salpingectomy or fimbriectomy, unless
coagulation forceps is introduced through the accessory suprapubic port additionally indicated, are regarded as obsolete or unnecessary. Neverthe-
and the isthmic part of the tube relatively close to the uterus is coagulated less, laparoscopic partial salpingectomy with excision of a 23 cm segment
over a distance of at least 23 cm. of the tube, similarly to the procedures described under open abdominal
techniques, is regarded as a feasible alternative.
2. When the anatomy is normal, one additional accessory port suffices. When
the situation is unclear and laparoscopic adhesiolysis is required initially, 2. In this case, a combination of coagulation, which is necessary anyway for
further accessory ports should be located lateral to the epigastric vessels. hemostasis, and excision (scissors) is recommended, with removal of a
Especially when using electrical instruments, adequate distance from the segment of tube for histologic examination.
bowel is extremely important, especially the sigmoid colon, which is often
adherent to the left infundibulopelvic ligament and the left pelvic wall and,
more rarely, the cecum, which is sometimes displaced in the inferomedial
direction.
3. When performing coagulation, the tube must be grasped completely,
which is always more difficult toward the ampullary partwhich is why
the isthmus, as the narrowest part of the tube, is always the first point of
approach for all sterilization techniques. On the other hand, unnecessary
coagulation in the mesovarium should be avoided because this can injure
the uterine anastomoses of the ovarian artery and interfere with the blood
supply of the ovary. Complete exposure as far as the fimbriae is required
to identify the tube with certainty.
IV Adnexa Laparoscopic Sterilization

Special Technique Laparoscopic Sterilization

IV
153

Fig. 4.3-138 The final condition of the tube stretch of the tube is destroyed, later recon-
after sloughing of the coagulation necrosis is struction is difficult. The use of monopolar
shown. When performed adequately, the 10- coagulation techniques has today been com-
year success rates are 98% 99%, especially in pletely replaced by the use of bipolar coagula-
women aged over 35 years. Because a long tion forceps.

Fig. 4.3-137 Coagulation technique. Bipolar grasped, but on the other hand, the tubal
electrocoagulation of the tube at the junction branch of the ovarian artery shown here should
of the isthmus and ampulla. Coagulation in the not be unnecessarily coagulated by excessive
isthmic region is particularly important. At least coagulation into the mesovarium. Tissue desic-
23 cm in total should be coagulated. On the cation (blanching) is desirable, in contrast to
one hand, the entire tube volume must be carbonization (brownblack discoloration).

Fig. 4.3-139 Tube coagulation in the pres- cially of the sigmoid colon. Caution: the prox-
ence of adhesions is shown. In this case, there imity of the bowel is often assessed incorrectly
is a risk of thermal damage of neighboring or- when visualization is poor.
gans because of insufficient distancing espe-
IV Adnexa 4.3 Surgical Techniques

IV
154

Fig. 4.3-140 Ligation techniques. A spring it surrounds the tube completely. Because the Fig. 4.3-141 Application of a silicon ring. isthmoampullary junction. Sufficiently mobile
clip is applied using an applicator. The Filshi tube destruction is only over a short distance, This technique is particularly widespread in de- tubes are a requirement. A working optical tro-
clip is a titanium clip with silicon coating on the refertilization chances are at least theoreti- veloping countries because of its technical sim- car can be used with this technique.
the inside of the clip jaws. It is important to ap- cally somewhat better than with the other plicity and low cost. The tube is grasped at the
ply the clip at a right angle to the tube and that techniques.

Fig. 4.3-142 When using the special endo- the silicon ring is pulled over the loop of fallopi- Fig. 4.3-143 The illustration shows the silicon strangulation. Rigid and vulnerable tubes, for
scopic applicator with the two silicon rings al- an tube. Caution: manipulation with excessive ring (Silastic ring) after successful application in example, in the puerperium, can be easily in-
ready mounted on it, the bluntly hooked tube tension can lead to tissue tears and bleeding. the isthmic part of the tube. Pain may occur jured and bleed during application of the ring.
is drawn into the tube of the applicator, where temporarily due to ischemia as a result of the Ring sterilization destroys 23 cm of the tube.
IV Adnexa Laparoscopic Sterilization

Complications Concurrent and Postoperative Treatment


Operation failure: in large retrospective studies, the probability of be-
The patient should be aware that she should consult a doctor promptly if preg-
coming pregnant after laparoscopic tubal sterilization was dependent
nancy is suspected, to rule out tubal pregnancy. She should never be lulled into
especially on the patients age. 10-year pregnancy rates of 2%5% have
a false sense of security by believing that she cannot become pregnant at all.
been described, especially with the demanding clip techniques (Filshi clip).
In women who were older than 35 years at the time of sterilization, the
10-year failure rates were well below 2%, and this did not vary between
the individual techniques. Limits of the Method
Tubal pregnancy: the probability of suffering a tubal pregnancy is reported Roughly 1% 3% of sterilized women wish to have the procedure reversed. The
accordingly as 1.8% and 1.2% over 10 years, depending on age (under or prospects of successful reversal depend on the extent and location of the de-
over 30 years of age). stroyed segment of the tube. They are greatest when the tube defect is in the
Other complications: the available data do not suggest that the menstrual region of the isthmus and the vital segments of the tube together are over 5 cm
cycle is influenced by tubal sterilization. Postoperative pain occurs in long. If the residual tube length is less than 3 cm, refertilization surgery is not
10% 20% of patients and is usually temporary. usually advisable. The younger the patient was at the time of sterilization, the
Regretting the procedure: after 10 years, depending on the source, more often the desire for refertilization by tube reconstruction occurs. Destruc-
5% 20% of women have regretted the decision to undergo permanent tion of the tube is least with clip and ring sterilization and is most extensive
sterilization. The younger the patient, the more likely that she will sub- with electrocoagulation. Pregnancy rates following refertilization surgery of
sequently regret the procedure. Data also indicate that sterilizations per- 80% after clip sterilization, 70% after ring sterilization, 40% 70% after excision
formed in the context of elective pregnancy terminations are more often methods, and only 20% 60% after electrocoagulation are described in the litera-
regretted retrospectively. ture. IV
155

Endoscopic 4.3.3.6 Laparoscopic Ovarian Cystectomy, Hydatid Removal

Aims and Methods


Symptomatic and asymptomatic ovarian cysts or adnexal cysts diagnosed on
Indications and Contraindications
ultrasonography are among the most frequent diagnoses in gynecology. Ac-
cordingly, minimally invasive assessment and treatment of these cysts consti- Indications
tute one of the most frequent laparoscopic procedures overall. Surgery is indi- Cysts with a smooth outline on ultrasonography are removed if they are symp-
cated in premenopausal patients if the cyst persists through several cycles, in- tomatic or persistent. An observation period of 23 menstrual cycles should
be allowed to rule out a functional cyst. Another factor is the size of the cyst.
creases in size, is symptomatic, and when there are additional diagnostic
A diameter of 5 cm is usually given as the limit, because bigger cysts will prob-
criteria such as solid areas or a suspected dermoid or endometriotic cyst. Cysts ably not regress spontaneously. Symptomatic adnexal conditions should be as-
with a diameter exceeding 5 cm rarely regress spontaneously. Laparoscopic sessed laparoscopically as soon as possible to rule out ovarian torsion. Dermoids
(mature cystic teratomas) are the most common nonfunctional tumors in young
cystectomy is appropriate only for benign lesions because of the high rate of
women and are often diagnosed preoperatively because of their typical mor-
cyst fluid spillage and the need for surgical staging in malignant disease. In phology on ultrasound. Surgical treatment is always indicated. Endometriotic
postmenopausal patients, every persistent cyst warrants investigation but not cysts also have a typical ultrasonographic appearance, which can also be mim-
necessarily surgery. The possibility of adnexectomy, which allows use of one of icked by hemorrhage into a cyst. Surgery is always indicated.

the retrieval techniques (e.g., retrieval bag), should be considered. The most Contraindications
frequent histopathologic diagnoses are persistent functional cyst, corpus lu-
Very early pregnancy is a contraindication to laparoscopic investigation of
teum cyst, dermoid (mature cystic teratoma), and ovarian endometriotic cyst. lesions that appear benign on ultrasonography. If they are bilateral, benign
Benign neoplasms such as serous and mucinous cystadenomas are less com- theca lutein cysts that regress completely after pregnancy must be considered.
mon and require discriminating management, depending on the patients age, A unilateral cyst can be a corpus luteum of pregnancy. Laparoscopy early in the
second trimester can be considered for lesions that warrant surgery (week
because of the potential risk of recurrence and the risks of bilaterality. Other 1418 of pregnancy), as the perioperative risk is then lowest after the end of
important diagnoses are hydatid cysts of Morgagni and paratubal cysts, which embryogenesis but laparoscopy is still technically possible. Other contraindica-
can reach a considerable size and cannot be distinguished from ovarian cysts tions to laparoscopic surgery are clear ultrasonographic or clinical criteria of
malignancy. In the postmenopausal period, the indication for preserving the
on ultrasonography. The aim of every laparoscopic operation is complete re-
ovaries must be considered critically, and they should only be preserved after
moval of the cyst sac, preserving the (residual) ovary. Endometriotic cysts usu- comprehensive investigation.
ally cannot be identified as a separate cyst anatomically. In this case, ovarioly-
sis, opening of the cyst, and endometriosis resection are generally performed.
IV Adnexa 4.3 Surgical Techniques

Special Instruments
Operation Risks and Informed Consent Laparoscopy set

Despite careful preoperative diagnostic investigations and an obviously benign Suction irrigator system for hydrodissection and aspiration of cyst
cyst at operation, in rare cases surgery can start on a malignant tumor (or at least a contents
tumor with borderline malignancy) and the cyst may be opened. The change from Spoon forceps, retrieval bag, and morcellator for appropriate removal
stage I a to I c is associated in some, though not all studies with a worse long-term of the cyst sac from the abdominal cavity
prognosis, which is minimized by prompt (< 7 days) typical ovarian cancer sur-
gery and postoperative chemotherapy, but possibly not entirely corrected. None-
theless, it is not reasonable to perform a laparotomy for every dermoid. This ex- Procedure
tremely rare possibility and also the possibility of a two-stage procedure should
be discussed with the patient. Larger cysts that have already been present for Preparation
some time may lead to limited function of the residual ovary. Depending on the 1. Intubation anesthesia
patients age, complete oophorectomy/adnexectomy should always be discussed 2. Lithotomy position; change to specific laparoscopy Trendelenburg position
as a surgical option. Ovarian cystectomy is a low-risk operation. Apart from the (see above) after insertion of the camera trocar (umbilical) and check of
usual specific risks of laparoscopy and the ever present possibility of ureteral, positioning by the surgeon
bowel, and vascular injury, there is a danger of secondary hemorrhage from the 3. Disinfection of the vulva, vagina, and operation field. Examination under
residual ovary, especially with large cysts. When surgery on the cyst includes anesthesia. Insertion of a catheter and if possible, insertion of a uterine
preservation of the ovary, the surgeon should point out the risk of recurrence. manipulator after measuring the length of the sound
This also applies for endometriotic cysts.
Operation
IV
1. Access to the abdominal cavity: sagittal incision in the base of the umbili-
156 Operation Planning cus. Only the skin is opened. Caution: if entry is too deep there is a risk of
1. Medical history and family history, clinical examination and transvaginal penetrating the abdominal cavity, and if the incision is too large the opera-
ultrasonography: document whether papillary structures, septa (and tion may be made unnecessarily difficult by the optical trocar constantly
whether their margins are clearly distinct), solid areas and/or ascites are slipping into the abdominal cavity.
present. Special attention should be paid to whether the cyst is persistent 2. The most effective mode of entry is with a Verres needle with continuous
or increasing in size and whether there is a known personal or family gas flow: both the initial low intra-abdominal pressure and gentle insuf-
history of gynecologic malignancies flation provide the surgeon with information about correct placement,
2. Pregnancy test, measurement of CA125 if appropriate. Caution: CA125 is together with the typical feeling when the abdomen is entered success-
normal in up to 50% of cases in stage I, and on the other hand, CA125 can fully and liver percussion dullness is lost in the right upper abdomen (after
also be elevated in inflammatory disease with peritoneal involvement insufflation of roughly 300 mL CO2). When entering, the surgeon ideally
and in endometriosis. If malignancy is suspected, operative laparoscopic pulls up the abdominal wall so that the Verres needle is inserted at a 90
cystectomy is not the operation of choice angle to the fascia and at a 45 angle to the horizontal slim patient. This
3. Discussion of the extent of the operation and recovery period. Explicit angle must be steeper if the patient is obese.
specification of ovary preservation, and determination of further manage- 3. After the pneumoperitoneum has been created successfully, the optical
ment in the event of (borderline) malignancy trocar is inserted. If an insufflation pressure of 1520 mmHg is used initial-
4. Consent to the procedure ly, it is usually possible to insert the optical trocar directly and without
lifting the abdominal wall further.
5. Anesthesiologic preoperative investigations depending on the patients
age and local practice 4. Inspection of the upper and mid abdomen; photo documentation
6. Thrombosis prophylaxis: LMWH, ATS 5. The second port is in midline suprapubic location. The level of the incision
depends on the size of the cyst. The third and fourth ports are located
7. Antibiotic prophylaxis is not absolutely necessary with operative lapa-
lateral to the epigastric vessels following transillumination. After placing
roscopy without opening of the vagina
the patient in Trendelenburg position and moving the loops of bowel out
8. Easy to moderately difficult surgery; takes < 1 hour; surgeon and one
of the pouch of Douglas with atraumatic forceps, the operation site is as-
assistant
sessed and photographed, and fluid is removed from the pouch of Douglas
Anesthesia and Positioning for cytology. The adnexal cyst is assessed macroscopically for evidence of
malignancy.
Positioning: legs on supports, which should be lowered preoperatively
6. Bowel and sigmoid adhesions and adhesions between the adnexa and
by way of trial (Trendelenburg position) to simulate the
pelvic wall are divided, if indicated. This mobilizes the ovary sufficiently
intraoperative situation after draping. Caution: intra-
to allow exposure of the actual cyst and also provides rapid access to the
operative lowering of the legs fixed to leg supports alters
infundibulopelvic ligament in the event of bleeding complications. The
the positioning at a time when the exact position of the
course of the ureter should always be inspected transperitoneally, which is
legs can no longer be seen because of the sterile draping.
usually easy on the right, but is not always successful on the left.
A trial lowering of the legs during sterile skin preparation
is therefore advised. Both arms are placed by the patients 7. The ovary is mobilized forward with the assistants aid so that free access
sides, paying special attention to protection of the hands, to the antimesenteric pole of the cyst is obtained. The cyst is aspirated
and shoulder supports are placed. This is the only way to for cytology. The site of aspiration can be coagulated. Although the cyst
enable the first assistant to perform efficient operative could theoretically be removed intact, this dissecting technique usually
laparoscopy. In addition, the patients weight is placed proves to be time consuming and tends to lead to opening of the cyst any-
symmetrically on both shoulders during the necessary way. This is not the case with dermoid cysts, which can often be removed
Trendelenburg position. Patient positioning should allow readily from the ovary in full.
adequate positioning of the surgeon, if necessary on a 8. The cyst is opened with scissors, after coagulation if necessary, and the
footstool, when the operating table is lowered as far as interior is inspected. The actual cystectomy is then performed: the func-
possible during the operation. tional ovarian tissue is grasped with atraumatic forceps through the lateral
Draping: abdominal window ports. The cyst sac can sometimes by separated from the ovarian tissue
with the suction irrigator system (hydrodissection). The cyst sac usually
Anesthesia: intubation anesthesia
has to be separated gradually from healthy ovarian tissue using a traction
and counter-traction technique. When dissecting in this way, it is helpful
if the instrument is moved constantly on the cyst so that it is as close as
IV Adnexa L a p a r o s co p i c O v a r i a n Cy s t e c to m y, H y d a t i d Re m ov a l

possible to the forceps on the functional ovarian tissue. This provides the 11. The (frequent) bleeding from the base of the cyst is coagulated. This ap-
best traction for separating the cyst from the fixed areas and keeps these plies especially when dissecting in the region of the ligament and hilum of
intact as long as possible, which greatly facilitates removal in one piece. the ovary. After the cyst sac has been resected in full, hemostasis is com-
If the cyst sac has already been opened, separation from the remaining pleted with bipolar forceps. The cyst bed and wound edges on the intact
tissue is easier if it is rolled up with the grasping forceps. ovary are coagulated as necessary. This often results in the residual ovary
9. Classic enucleation of endometriomas is usually not possible. In this regaining its shape. Isolated bleeding points can be demonstrated using
case, the cyst is opened and drained, the scarred endometriotic tissue is irrigation and can be coagulated directly with bipolar forceps.
resected, and residual endometriosis is coagulated. Many endometriotic 12. Ovarian reconstruction by suture is not usually necessary but may be
cysts are adherent to the pelvic wall deep in the pelvis. The cyst is often useful if the ovarian tissue is greatly spread apart.
opened even during ovariolysis. 13. The cyst sac is removed; this is often possible through the 5-mm accessory
10. Dermoids (mature cystic teratomas) in particular can be enucleated with trocars. For larger cysts, a 10-mm trocar can be inserted above the sym-
preservation of the ovary, and the dermoid can often be removed in full physis and the spoon forceps introduced. Morcellation is rarely necessary
and in one piece. It is important that none of the dermoid remains behind and is not problematic with clinically and macroscopically benign cysts.
as otherwise there is a risk of recurrence. Even large dermoids can be trea- 14. Final irrigation is performed depending on the procedure. It can be helpful
ted readily laparoscopically. The sebum-like cyst contents can be removed to position the operated ovary so that it floats in the irrigation fluid
from the abdomen by copious irrigation. Concern about chemical perito- welling up in the pouch of Douglas. Minimal residual bleeding is visible
nitis has proved unfounded. If possible, the fluid cyst contents can be aspi- as fine streaks and can be coagulated.
rated with the suction irrigator system. Because dermoid cysts in particular 15. Before removing the instruments, the irrigation fluid is aspirated, and the
are bilateral in up to 10% of cases, accurate inspection of the contralateral operation site including the ureters is inspected with concluding photo
ovary is necessary. documentation.
IV
157

Special Technique Laparoscopic Ovarian Cystectomy, Hydatid Removal

Fig. 4.3-144 Cyst removal. After coagulation tion plane is obtained between the ovary and Fig. 4.3-145 When the correct plane has ovarian stroma cautiously with atraumatic for-
of the surface, the ovarian wall (cortex) is cyst, which can be used for in-toto removal. been dissected between the walls of the ovary ceps. A combination of conventional dissec-
opened with an antimesosalpingeal incision Needle aspiration of fluid at the same site is and cyst, the intact cyst can sometimes be tion, sharp dissection, and hydrodissection is
over a puncture site in the center. If opening of also possible. enucleated by hydrodissection. The suction usually necessary. Some surgeons also use lapa-
the cyst wall underneath is avoided, a dissec- and irrigation tube is introduced through the roscopic swabs for dissection.
central puncture site; the surgeon grasps the
IV Adnexa 4.3 Surgical Techniques

IV
158

Fig. 4.3-146 When the cyst content has al- that are still fixed is recommended. The atrau- Fig. 4.3-147 After cyst enucleation followed tion of the ovary with sutures is not usually nec-
ready been aspirated, the opened cyst sac is matic grasping forceps exposes the ovarian by bipolar electrocoagulation of the ovarian essary and is only required if the walls gape far
grasped with the traumatic forceps and rolled stroma so that the correct dissection plane is wound bed and wound edges, the remaining apart, which is usually seen after removal of
up. If the cyst sac is large, grasping areas of it not lost. tissue usually regains its shape well. Reconstruc- very large cysts.

Fig. 4.3-148 Removal of a hydatid. Bipolar ligament. If the cysts are pedicled, they can be Fig. 4.3-149 Division of the coagulated hy- vaginal ultrasonography (cyst persistence?),
electrocoagulation of the pedicle of the hyda- removed easily after electrocoagulation. Injury datid pedicle with scissors. A small pedicled they should always be removed. When electro-
tid. Hydatid cysts can become very big and of the stretched tube must be avoided with hydatid is a typical incidental finding. To avoid coagulating the pedicle, accidental coagulation
can be located in the mesosalpinx or within a large intraligamentous cysts. postoperative misunderstanding on repeated of the fimbrial ends must be avoided.
IV Adnexa L a p a r o s co p i c O v a r i a n Cy s t e c to m y, H y d a t i d Re m ov a l

IV
159

Fig. 4.3-150 Removal of a dermoid. The first ry can be stabilized for this step by grasping it Fig. 4.3-151 The ovarian stroma is grasped tex and cyst wall. The advantage of this dissec-
step in removing a dermoid cyst is finding the with atraumatic forceps in the region of the with atraumatic forceps and the suction irriga- tion is that the cyst remains intact and can then
dissection plane between the cortex and the ovarian ligament. Particularly in the case of der- tor system is introduced through the central be removed entire with the aid of a retrieval
cyst wall. The incision is made after bipolar elec- moid cysts, premature opening or rupture of puncture site. Hydrodissection takes place ex- bag.
trocoagulation of the ovarian surface. The ova- the capsule should be avoided. actly in the dissection plane between the cor-

Complications
Adhesiolysis. Endometriotic cysts in particular can be associated with ex-
tensive adhesions in the pelvis. Difficult division of bowel adhesions and
mobilization of the ureter may be necessary, which in turn involve a risk
of injuries of these structures, especially the ureter.
Hemorrhage. Secondary hemorrhage from the residual ovary after cyst
removal is rare but can occur especially after extirpation of large cysts and
in severe cases can even cause hemodynamic effects.
Organ loss. The loss of functioning ovarian tissue or even loss of the entire
organ due to coagulation is possible.
Recurrence. Recurrence is possible even after a short time if cyst removal
has been incomplete, but endometriotic cysts can also recur after
adequate treatment.

Concurrent and Postoperative Treatment


Mobilization of the patient and catheter removal are possible immediately after
the procedure. No other special rehabilitation or protective measures are re-
quired. If functional cysts recur, temporary medical suppression of ovulation can
be discussed.

Limits of the Method


If there are severe adhesions following previous surgery, conversion to laparoto-
my may be necessary. The often difficult situation of a left-sided ovarian cyst
after hysterectomy should be noted in particular. Only adnexal cysts that
Fig. 4.3-152 The cyst sac is exposed by con- the region of the ovarian ligament can be elec- appear benign clinically and macroscopically should be removed laparoscopi-
tralateral traction with atraumatic forceps. In trocoagulated to avoid bleeding and divided cally. If they are not definitely benign, adnexectomy and removal in a retrieval
this phase, the still fixed fibers particularly in sharply if necessary.
bag should be considered. Suspected or definitely malignant lesions must not
be treated by laparoscopic cystectomy.
IV Adnexa 4.3 Surgical Techniques

Endoscopic 4.3.3.7 Laparoscopic Ovariopexy

Aims and Methods


Laparoscopic ovariopexy is the term for laparoscopic relocation of the ovaries
Operation Planning
with preservation of their blood supply through the infundibulopelvic liga-
1. Planning laparoscopic ovariopexy forms part of the overall oncologic con-
ment prior to radiotherapy in the pelvis. The aim is to remove the ovaries cept and is subordinate to this in every respect. The appropriate diagnostic
from the radiation field to preserve their long-term function. Functional de- investigations should be complete and (chemo)radiotherapy in the pelvis
should be indicated
struction of the ovaries, which is irreversible in over 50% of cases, can be avoid-
2. Discussion of the extent of the operation and its usefulness in the indivi-
ed, especially in patients under the age of 40. The laparoscopic technique al-
dual case
lows a minimally invasive approach so that the oncologic treatment schedule 3. The decision rests with the patient. However, in suitable cases, the patient
is not altered. The available options are lateral transposition to the side wall of should be informed of the treatment options. Only an informed patient can
the pelvis and medial transposition behind the uterus, depending on the indi- decide

cation. Laparoscopic ovariopexy prior to (chemo)radiotherapy forms part of a 4. Consent to the procedure and planning with regard to radiotherapy
5. Anesthesiologic preoperative investigations depending on the patients
IV wider approach, which has developed in recent years because of the improved
age and local practice
160 survival times with malignant diseases overall; cure of the (young) patient is 6. Thrombosis prophylaxis: LMWH, ATS
the overriding concern, but her hormonal and reproductive future is also taken 7. Antibiotic prophylaxis is not absolutely necessary.
into account, and this includes an attempt to preserve fertility. Like cryopreser- 8. Moderately difficult surgery because rare; takes 12 hours; surgeon and
vation of ovarian tissue prior to chemotherapy, laparoscopic ovariopexy is a one assistant

gynecologic oncology procedure in the widest sense. Anesthesia and Positioning


Positioning: legs on supports, which should be lowered preoperatively
by way of trial (Trendelenburg position) to simulate the
intraoperative situation after draping. Caution: intra-
Indications and Contraindications operative lowering of the legs fixed to leg supports alters
the positioning at a time when the exact position of the
Indications legs can no longer be seen because of the sterile draping.
Laparoscopic ovariopexy is indicated when pelvic radiotherapy is necessary in A trial lowering of the legs during sterile skin preparation
patients below the age of 40 years. The classic situation is cervical cancer, is therefore advised. Both arms are placed by the patients
though a good or acceptable overall prognosis is implicit. Other rare indications sides, paying special attention to protection of the hands,
are tumors in the pelvis that warrant radiotherapy, such as rectal and anal and shoulder supports are placed. This is the only way to
cancers that can occur in young patients and have a good prognosis in the early enable the first assistant to perform efficient operative
stages, or lymphomas (e.g., Hodgkin disease), for which local radiotherapy is in- laparoscopy. In addition, the patients weight is placed
dicated. It is important especially to think of the possibility of ovarian transposi- symmetrically on both shoulders during the necessary
tion. A nononcologic indication for lateral ovariopexy is adhesion prevention Trendelenburg position. Patient positioning should allow
after extensive ovariolysis, for example, during surgery of endometriosis. adequate positioning of the surgeon, if necessary on a
Lateral fixation may be useful to prevent the ovary from growing back into footstool, when the operating table is lowered as far as
the dissected pouch of Douglas and ovarian fossa. possible during the operation
Draping: abdominal window
Contraindications Anesthesia: intubation anesthesia
The contraindications to ovarian transposition are a poor prognosis and, usually,
postmenopausal status. Other contraindications are malignant diseases that Special Instruments
require removal of the ovaries. The immediate premenopausal situation is a Normal instruments for operative laparoscopy: grasping forceps, dissecting
relative contraindication, and it is not indicated in patients aged over 40 as the scissors, and coagulation forceps
clinical success rates do not justify the (low) risks of the procedure. Important: clips for exact marking of the transposed ovaries

Operation Risks and Informed Consent


Besides the general intra- and perioperative risks (bleeding, infection, delayed
wound healing, ureteral injury) of this not absolutely essential operation, which
must be weighed in detail against the advantages of preserving hormonal activity,
the specific risks such as thrombosis and infarction in the manipulated infundi-
bulopelvic ligament must also be discussed. Atypical pain symptoms with ovula-
tion, cyst formation, and possibly the need for later oophorectomy, should also be
discussed.
IV Adnexa Laparoscopic Ovariopexy

5. The mobilized adnexa is moved to a little beyond the lateral border of


Procedure the psoas muscle and fixed with at least two nonabsorbable sutures. The
suture passes through the ovary to fix it securely. The transposed ovary is
Preparation marked with radiodense clips so that it can be identified with certainty
1. Intubation anesthesia when radiotherapy is being planned.
2. Lithotomy position; change to specific laparoscopy Trendelenburg position 6. A tunneling technique can be used from the outset to prevent the sutures
(see above) after insertion of the camera trocar (umbilical) and check of from tearing out, which is observed relatively often. The peritoneum is
positioning by the surgeon not opened completely in the lateral direction but a tunnel is dissected
3. Skin preparation, bladder catheter, sterile draping, possibly insertion of a under the peritoneum from the lateral fixation site toward the adnexa,
uterine manipulator which are then drawn laterally through the tunnel.
7. Unilateral ovariopexy suffices in principle. This applies particularly for
Operation high lateral ovariopexy, which is demanded by some authors. To trans-
1. Access to the abdominal cavity: sagittal incision in the base of the umbili- port the ovary safely out of the pelvis, the adnexa are moved as far as the
cus. Only the skin is opened. Caution: if entry is too deep, there is a risk of level of the umbilicus. This requires retrograde laparoscopy (with a supra-
penetrating the abdominal cavity, and if the incision is too large, the opera- pubic optical trocar) as in laparoscopic para-aortic lymphadenectomy, and
tion be may made unnecessarily difficult by the optical trocar constantly very extensive cranial mobilization of the cecum and ascending colon.
slipping into the abdominal cavity. Because of the unaccustomed anatomy, this technique must be regarded as
2. The most effective mode of entry is with a Verres needle with continuous difficult.
gas flow: both the initial low intra-abdominal pressure and gentle insuf- 8. Ovariopexy on the left side is guided by the difficult anatomy there. The
flation provide the surgeon with information about correct placement, to- main problem is that the ovarian vessels in the infundibulopelvic ligament
gether with the typical feeling when the abdomen is entered successfully disappear relatively soon under the vascular sigmoid mesocolon. Mobiliza- IV
and liver percussion dullness is lost in the right upper abdomen (after in- tion of the sigmoid to expose the blood supply is much more difficult on
sufflation of roughly 300 mL CO2). When entering, the surgeon ideally pulls the left than on the right side. The basic steps are identical: the perito-
161
up the abdominal wall so that the Verres needle is inserted at a 90 angle neum is opened, the ureter is exposed, mobilization begins distally, the
to the fascia and at a 45 angle to the horizontal slim patient. This angle sigmoid is dissected cranially along the Toldt fascia, the adnexa are trans-
must be steeper if the patient is obese. posed laterally with or without peritoneal tunneling, and the ovary is
3. After the pneumoperitoneum has been created successfully, the optical fixed with sutures and marked with clips.
trocar is inserted. If an insufflation pressure of 1520 mmHg is used initial- Medial ovariopexy
ly, it is usually possible to insert the optical trocar directly and without
1. Medial transposition of the ovaries can be considered in lymphoma or
lifting the abdominal wall further.
nongynecologic diseases that require primary radiation of the pelvic lym-
4. Selection of accessory trocar ports sufficiently cranial to allow an optimal phatic drainage pathways along the large pelvic vessels but not removal
operating angle to the adnexa and infundibulopelvic ligament. of the uterus.
Lateral ovariopexy 2. This technically simple procedure consists of fixation of the ovaries to
1. The aim of lateral ovariopexy is transposition of the ovaries to the lateral each other in the midline by at least two nonabsorbable sutures.
pelvic wall. 3. The operation is reversible after the conclusion of the radiation. Its effec-
2. The situation prior to lateral ovariopexy usually involves previous (radical) tiveness is controversial and the literature is sparse.
hysterectomy or a planned radiation field in the center of the pelvis. In this Ovariopexy to prevent adhesions
case, the uterine fixation points of the adnexa (origin of the tube, ovarian
1. Fixing the ovary, for example, to the round ligament, is also technically easy;
ligament, broad ligament) have already been divided. These steps still have
this is intended simply to prevent regrowth of ovarian adhesions in the
to be performed if the uterus has not been removed.
ovarian fossa or lateral pouch of Douglas following ovariolysis, for example,
3. The bowel must be distanced sufficiently on both right and left. On the during endometriosis surgery.
right side, the peritoneum is opened over the psoas muscle as in laparo-
scopic pelvic lymphadenectomy. Starting from this point, the cecum and
appendix are mobilized in the cranial direction. The course of the ureter
is displayed in the medial layer of peritoneum and the infundibulopelvic
ligament is identified.
4. Starting from the uterine resection sites, the medial layer of peritoneum
is divided in the cranial direction, exactly between the ureter and the
ovarian vessels in the infundibulopelvic ligament. The peritoneal incision
may have to be extended cranially along the iliac vessels over the point
where the ureter crosses them to provide sufficient distance between the
ureter and the infundibulopelvic ligament and so that the infundibulo-
pelvic ligament can be mobilized cranially. Caution: too little mobilization
of the infundibulopelvic ligament leads to kinking when it is lateralized
and to an increased risk of thrombosis.
IV Adnexa 4.3 Surgical Techniques

Special Technique Laparoscopic Ovariopexy

IV
162

Fig. 4.3-153 Lateral ovariopexy. Situation darily with the ovarian blood supply. The next Fig. 4.3-154 Mobilization of the ovarian ar- cum and appendix must be mobilized suffi-
when the uterus is preserved for radiation. The stage of dissection of the mesovarium cranially tery and vein running in the infundibulopelvic ciently in the cranial direction. Particularly at
fallopian tube and ovarian ligament are divided is helped by opening the peritoneum over the ligament starts with division of the medial layer the pelvic brim, separation of the overall well
where they join the uterus, following coagula- site where the ureter crosses the iliac vessels of peritoneum. The course of the ureter must vascularized and easily bleeding infundibulopel-
tion. Theoretically, the tube can be removed and ureterolysis. be located exactly. At the same time, the ce- vic ligament from the ureter is not easy.
by salpingectomy, but this may interfere secon-

Fig. 4.3-155 It is important to avoid kinking thors even demand fixation of the adnexa later- Fig. 4.3-156 Medial ovariopexy. The techni- mal anatomy is largely preserved, while the dis-
the vessels. If possible, the ovaries should be ally at the level of the umbilicus, which requires cally much simpler medial ovarian transposition advantage is the disputed radiation safety of
moved even further, at least as far as the lateral retrograde laparoscopy with mobilization of can be considered in the case of malignant dis- the method. Following adequate ovariolysis,
border of the psoas muscle. This is the case es- the cecum and ascending colon, as with para- ease of the pelvic lymphatic drainage path- the ovaries are fixed to one another in the mid-
pecially when percutaneous radiation is aortic lymphadenectomy. ways; this can be reversed after the conclusion line with nonabsorbable sutures.
planned in addition to brachytherapy. Some au- of the radiotherapy. The advantage is that nor-
IV Adnexa L a p a r o s c o p i c O p e r a t i o n f o r O v a r i a n To r s i o n

Complications Concurrent and Postoperative Treatment


General complications. These include vascular injuries, especially in the in-
The specific oncologic therapy is paramount. If possible, preservation of ovarian
fundibulopelvic ligaments, which can necessitate adnexectomy in isolated
function should be part of the radiotherapy plan. A requirement is exact marking
cases, and this should be mentioned specifically when obtaining informed
of the transposed adnexa and close collaboration between the surgeon and the
consent.
radiation oncologist. Pre- and postoperative FSH measurements document the
Organ injuries. Bowel and ureteral injuries are further risks on account of
baseline situation and should be repeated regularly in the long term. In routine
the difficult dissection region.
gynecologic follow-up, the new location of the ovaries must also be clear to all
Long-term risks. Local pain, atypical cysts that may require secondary involved in (transabdominal) ultrasound scans.
adnexectomy, and thrombosis or infarction of the transposed adnexa may
occur in the long term.
Ovarian failure. Particularly with percutaneous radiation in the pelvic re- Limits of the Method
gion, a long-term success rate of approximately 60% 70% for preservation
of ovarian function is found repeatedly in the literature. There is thus a Ovariopexy is not a frequent operation, and case numbers in publications rarely
continued risk of radiation-induced ovarian failure despite transposition. even reach three figures. The indication should be decided on an individual
basis. It is important to think of the possibility and, if appropriate, refer the
patient to a center familiar with complex laparoscopic techniques. Despite the
greater complexity, current data favor lateral transposition.

IV
163

Endoscopic 4.3.3.8 Laparoscopic Operation for Ovarian Torsion

Aims and Methods


Acute or subacute lower abdominal pain is one of the most common emergen-
Indications and Contraindications
cy conditions in gynecology. If pregnancy has been ruled out, the differential
diagnosis consists of acute inflammatory disease (adnexitis, tubo-ovarian ab- Indications
scess), an ovarian cyst that is painful because of increasing size, a ruptured Unclear, acute lower abdominal pain, probably of gynecologic origin,
with a negative pregnancy test
and possibly bleeding cyst, and a range of nongynecologic diagnoses such as
Slightly or markedly enlarged ovary at the same time
appendicitis, sigmoid diverticulitis, or gastrointestinal infection. In a not incon-
Suspected reduction of the ovarian blood supply on Doppler ultra-
siderable proportion of cases, psychologic or psychosomatic problems must be sonography
considered as a diagnosis of exclusion. A further important differential diagno- Marked signs of inflammation suggest adnexitis or tubo-ovarian abscess,
sis, especially when the ovaries are enlarged at the same time by cysts or tu- though these are also indications for early laparoscopic diagnosis and treatment.
mors, and particularly in the absence of obvious signs of inflammation, is ovar- Caution: the necrosis that occurs after torsion can lead to secondary infection.

ian torsion. Twisting of the adnexa around its anatomic vascular axis leads to Contraindications
stasis, which is usually venous, with resulting ischemia and necrosis. Although
There are practically no contraindications to diagnostic laparoscopy for unclear
rare overall (accounting for less than 3% of all gynecologic emergencies), ovar- abdominal pain symptoms, especially when the clinical signs warrant investiga-
ian torsion as a laparoscopic diagnosis of exclusion is one of the reasons why tion. In rare cases, laparoscopic access can pose problems. The decision on the
best procedure must be made jointly with anesthesiologist colleagues.
early laparoscopic investigation is desirable in the case of lower abdominal
and pelvic pain of uncertain cause. When there is complete torsion of the ovary Pregnancy is not a contraindication to investigation when the symptoms warrant