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Te Linde's Atlas of
Gynecologic Surgery

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GEOFFREY W. CUNDIFF, MD, FACOG, FACS, FRCPSC te
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Professor &: Head, Department of Obstetrics and Gynecology
University of British Columbia Faculty of Medicine
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Vancouver, British Columbia

RICARDO AZZIZ, MD, MPH, MBA


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Professor, Obstetrics, Gynecology, and Medicine


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President, Georgia Regents University


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CEO, Georgia Regents Health System


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ROBERT E. BRISTOW, MD, MBA, FACS


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Professor, Department of Obstetrics and Gynecology


Director, Gynecologic Oncology Services
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Philip J. DiSaia Chair in Gynecologic Oncology


University of California, Irvine- Medical Center
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Orange, California

I
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library of Congress Cataloging-in-Publication Data


te
Te Linde's atlas of gynecologic surgery f Geoffrey W. Cundiff ... [et al.].
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p.;cm.
Atlas of gynecologic surgery
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ir
•Reader is referred to the seminal text Te Linde's Operative Gynecology,
which this atlas complements" -Pref.
Includes bibliographical references and index.
ISBN 978-1-60831-068-5
s.
ns
I. Cundiff, GeoffreyW. II. Te Linde, Richard W. (Richard Wesley), 1894-1989. Te Linde's
9

operative gynecology. III. Title: Atlas of gynecologic surgery.


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[DNLM: 1. Gynecologic Surgical Procedures-Atlases. WP 17]


ia

RG104
618.1'059-dc23
hi

rs

2013013899
ta

Care has been taken to confirm the accuracy of the information presented and to
pe

describe generally accepted practices. However, the authors, editors, and publisher are not
responsible for errors or omissions or for any consequences from application of the
information in this book and make no warranty, expressed or implied, with respect to
p.

the currency, completeness, or accuracy of the contents of the publication. Application of the
information in a partirular situation remains the professional responsibility ofthe practitioner.
vi

The authors, editors, and publisher have exerted every effort to ensure that drug
selection and dosage set forth in this text are in accordance with current recommendations and
practice at the time of publication. However, in view of ongoing research, changes in
government regulations, and the constant flow of information relating to drug therapy and
drug reactions, the reader is urged to check the package insert for each drug for any change in
indications and dosage and for added warnings and precautions. This is partirularly important
when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in the publication have Food and Drug
Administration (FDA) clearance for limited use in restricted research settings. It is the
responsibility of the health care provider to ascertain the FDA status of each drug or device
planned for use in their clinical practice.

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10 9 8 7 6 5 4 3 2 1
To Cindy, Ash lee, Jonathon, and Mallory-for their unwavering love and support.
Ricardo Azziz

To my family-Michelle, Jackson, Chloe, and Haley-for your love, patience,


inspiration, and support.
Robert E. Bristow

To the women who have brought meaning and joy to my life, including
my patients, my colleagues, my mother, Peggy, daughters, Victoria and Adreanna,
and most importantly, my wife, Valerie.
Geoffrey W. Cundiff
Roxana Geoffrion, MDCM, FRCSC M. Jantlhan Salnik. MD
Assistant Professor Assistant Professor
Department of Obstetrics and Gynecology Director, Division of Urogynecology
Uniwnity of British Columbia Co-director, Center for Minimally Invasive Gynecologic Surgery
Urogynecologist Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology Cedars-Sinai Medical Center
St. Paufs Hospital The David Geffen School of Medicine
Vancouver, British Columbia, Canada Uniwnity of California - Los Angeles
Los Angeles, California
Melinda B. Henne. MD. MS
Assistant Professor fl'lnk F. Tu. MD. MPH
Department of Obstetrics and Gynecology Clinical Associate Professor
Uniform Services University of Health Sciences Division Director, Gynecological Pain and Minimally
Bethesda, Maryland lnvuire Surgery
Reproductive Endocrinologist Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology NorthShore University Health System
San Antonio Milit:aJy Medical Center Evanston, Illinois
San Antonio, Texas Department of Obstetrics and Gynecology
Uniwnity of Chicago, Pritzlcer School of Medicine
Darren l.aZIIre, MD, FRCSC Chicago, IL
Clinical Assistant Professor
Department of Obstetrics &: Gynecology
Uniwnity of British Columbia
Vancouver, Canada
Urogynecologist
Department of Obstetrics &: Gynecology
Peace Arch Hospital
White Rock, Canada

VII
Gynecology has always been a surgical specialty. yet the presented. The reader is referred to the seminal text Te
breadth and complexity of gynecologic surgery contin- Linde's Operative Gynecology, which this atlas comple-
ues to expand. The complex tluee-dimensional natw'e ments, for a more extensive discussion of the devel-
of pelvic anatomy and distinctive opportWlity for mul- opment, considerations, pros and cons, and risks and
tiple surgical approaches challenge the surgeon who is benefits of these procedures.
seeking to master the full breadth of the specialty. Add Instead, in this atlas we have aimed to provide a
novel techniques and technologies of recent years, and clear and detailed description of the steps involved
the challenge grows. Faced with this challenge, both in performing the procedures. To assist the readers
the gynecologist-in-training and those already in prac- in their comprehension, the prose is accompanied by
tice can benefit from readily accessible visual tools that meticulously accurate drawings. These illustrations
assist them in achieving mastery of their field. This is are rendered in an accessible style with color to maxi-
the goal of Te Linde's Atlas of Gynecologic Surgery. mize the surgeons' understanding. Many chapters also
Achieving quality and patient-centered care requires have narrated videos to provide further context for the
a surgeon to be flexible in utilizing the surgical tech- reader.
nique and approach that will best meet the patient's Whether this text is used to complement the
needs. Of course, no surgical technique should be descriptions and discussions presented in Te Linde's
offered until there is adequate evidence of both safety Operative Gynecology, or used as an initial introduction
and efficacy, as a patient cannot make an informed to a new surgical technique, or as a method to prepare
choice in the absence of such data. All of the tech- prior to carrying out a procedure not commonly per-
niques described in this text have ample evidence formed, we hope that this surgical atlas will become an
of safety and efficacy, although this evidence is not invaluable tool for all surgeons treating women.

IX
No project of this kind can be solely attributed to the Thirdly, we would like to acknowledge the patience
authors, or even the practitioners who kindly contrib- and support of our own office staff, who facilitated
uted to its writing. Rather, these feats are the result of the innumerable revisions and helped to coordinate
the efforts of many. And this text is no different. the myriad disparate pieces of the whole, including
Firstly, we should acknowledge the work of our col- Marlies Wagner, Sue Barber, and Tariq Leslie assisting
leagues who contributed to text, including Dr. Roxana Dr. Cundiff, and Lois Dollar, Jim Morrow, and Laura
Geoffrion, Dr. Melinda Henne, Dr. Darren Lazare, Sherrouse assisting Dr. Azziz.
Dr. Jonathon Solnik, and Dr. Frank Tu. We are also Fourthly, we all recognize that our expertise as sur-
indebted to Jennifer Smith, whose considerable artis- geons arises from the patient and dedicated efforts
tic skill allowed us to illustrate that which is hard to of our many surgical mentors and teachers, including
see with the naked eye. And to Chris Merillo, at Bio- Drs. John A. Rock. Alfred E. Bent, W. Allen Addi-
media Communications, for ensuring excellent videos son, Rick Bump, and Rick Montz. And no less, we are
and voice-overs to complement the text and Jennifeis eternally grateful for the trust of those many patients
drawings. who allowed us to care for them, providing us with a
Secondly, we must acknowledge the many editorial rich experience that we now share with the reader, as
staff members who made an effort to assist within the our patients are truly the drive, passion, and purpose
vagaries and ever-present changes of today's publishing behind this text.
world. Beginning with Sonya Seigafuse, Nicole Walz, And we rightfully should recognize the nnwavering
and Mark Flanders, and continuing with Rebecca support and encouragement of our families, without
Gaertner, Senior Acquisitions Editor, Wolters Kluwer whose care and support during the production of this
Health-Uppincott Williams & Wilkins, and Ashley text its reality would have been an impossibility.
Fischer, who we had the pleasure of seeing develop Finally, we would like to acknowledge you, the
from Editorial Assistant to Product Manager for Medi- reader, for caring enough about your patients to expand
cal Practice during the rather lengthy production of your understanding and hone your skills, and for being
this multifaceted project. We are also indebted to the willing to lead in the surgical care of women, now and
efforts of Louise Bierig, Developmental Editor, who in the future.
worked diligently to ensure the project kept moving Goeffrey W. Cundiff
forward. From an editorial point of view, this complex Ricardo Azziz
project certainly took a village! Robert E. Bristow

XI
CONTRIBUTORS VII
PREFACE IX
ACKNOWLEDGMENTS XI

~
a GYNECOLOGY
Chapter 1: Uterine Ablation Techniques 3
Frank.Tu

Chapter 2: Total Abdominal Hysterectomy 15


Robert E. BriJtow

Chapter3: Total Vaginal Hysterectomy 25


Roxana Geoffrion

Chapter 4: Total Laparoscopic Hysterectomy 35


Robert E. BriJtow

Chapter 5: Laparoscopic Supracervical Hysterectomy 43


Franklu

Chapter&: Laparoscopic Salpingostomy 51


Darren M. Lazare

Chapter7: laparoscopic Ovarian Cystectomy for Benign


Ovarian Tumors 57
M. Jonathon Solnik

Chapter 8: Laparoscopic Oophorectomy and


Sa Ipingo-oophorectomy 65
Frank.Tu

Chapter 9: Marsupialization of Bartholin Gland Cyst 73


M. Jonathon Solnik

J
Ill GYNECOLOGIC ONCOLOGY
Chapter 10: Radical Abdominal Hysterectomy 81
Robert E. BriJtow

Chapter 11: Pelvic Lymphadenectomy 91


Robert E. BriJtow

Chapter 12: Para-aortic Lymphadenectomy 97


Robert E. Bristow

XIII
xiv CONTENTS

Chapter 13: Simple Vulvectomy-Partial 105


Robert E. Bristow

Chapter 14: Simple Vulvectomy-Total 111


Robert E. Bristow

Chapter 15: Radical Vulvectomy 117


Robert E. Bristow

Chapter 16: Inguinal Lymphadenectomy 125


Robert E. Bristow

Chapter 17: Wide Radical Excision of the Vulva 133


Robert E. Bristow

Chapter 18: Surgery for Ovarian Cancer: Exploration and Staging 141
Robert E. Bristow

Chapter 19: Cytoreductive Surgery for Ovarian Cancer:


Radical Oophorectomy 149
Robert E. Bristow

Chapter20: Cytoreductive Surgery for Ovarian Cancer:


Upper Abdominal Procedures 159
Robert E. Bristow

Chapter21: Control of Pelvic Hemorrhage 173


Robert E. Bristow

REPRODUCTIVE SURGERY
Chapter22: The Microsurgical or Peritoneal Approach
to Conservative Reproductive Surgery 185
Ricardo Azziz

Chapter23: Microsurgical Tubal Reanastomosis 191


Ricardo Azziz, Melinda Henne, M. Jonatfton Solnik

Chapter24: Laparoscopic Salpingo-ovariolysis 209


M. Jonathon Solnik

Chapter25: Laparoscopic Ovarian Wedge Resection or


Diathermy (Drilling) 211
M. Jonathon Solnik

Chapter26: Hysteroscopic Metroplasty (Resection of


Intrauterine Septum) 223
M. Jonathon Solnik

Chapter27: Hysteroscopic Myomectomy 231


M. Jonathon Solnik. Ricardo Azziz

Chapter28: Abdominal Myomectomy and Uterine


Reconstruction for Intramural Myomas 241
M. Jonathon Solnik:, Ricardo Azziz

Chapter29: Hysteroscopic Adhasiolysis of Intrauterine Synechiae 255


M. Jonathon Solnik:, Ricardo Azziz
CONTENTS XV

Chapter30: Laparoscopic Resection of Ovarian Endometrioma 261


M. Jonathon Solnik, Ricardo Azziz

• UROGYNECOLOGY
Chapter31: Retropubic Mid-urethral Sling
Geoffrey W. Cundiff
271

Chapter32: Transobturator Midurethral Sling 283


Roxana Geoffrion

Chapter33: Cystocele Repair Using the Defect-directed Approach 291


Geoffrey W. Cundiff

Chapter34: Cystocele Repair Using Anterior Fascial Reinforcement 303


Geoffrey W. Cundiff

Chapter35: Uterosacral Suspension 315


Geoffrey W. Cundiff

Chapter36: Sacral Colpopexy 325


Darren M. Lazare

Chapter37: Rectocele Repair Using the


Defect-directed Approach 337
Geoffrey W. Cundiff

Chapter38: Overlapping Sphincteroplasty 345


Geoffrey W. Cundiff

APPENDIX 1: EXAMPLE OPERATIVE NOTE 355


INDEX 357
Chapter2 Total Abdominal Hysterectomy Robot Assisted Laparoscopic
Robart E. Bristow Microsurgical Tubal Reanastomosis
Chapter3 Total Vaginal Hysterectomy Melinda B. Henne, M. Jonathon Solnik

Roxana Gaoffrion Chapter26 Hysteroscopic Metroplasty


Chapter4 Total Laparoscopic Hysterectomy (Resection ol Intrauterine Septum)
M. Jonathon Solnilt
Robart E. Bristow

Chapter 5 Laparoscop ic Supracervical Chapter27 Hysteroscopic Myomectomy


M. Jonathon Solnik. Ricardo Azziz
Hysterectomy
FrankTu Chapter21 Abdominal Myomectomy and Uterine
Reconstruction lor Intramural Myomas
Chapter 10 Radical Abdominal Hysterectomy M. Jonathon Solnik. Ricardo Azziz
Robert E. Bristow
Laparoscopic Myomectomy
Chapter 11 Pelvic Lymphadenectomy M. Jonathon Solnilt
Robart E. Bristow
Chaptar31 Retropubic Mid-urethra Sling
Chapter 12 Para-aortic Lymphadenectomy GeoffreyW. Cundiff
Robert E. Bristow
Chapter33 Cystocele Repair Using the
Chaptar19 Cytoreductive Surgery for Ovarian Defect-directed Approach
Cancer. Radical Oophorectomy Geoffrey W. Cundiff
Robart E. Bristow
Chapter34 Cystocele Repair Using Anterior
Chaptar20 Cytoreductive Surgery for Ovarian Fascial Reinforcement
Cancer: Upper Abdominal Procedures GeoffreyW. Cundiff
Robert E. Bristow
Chapter35 Uterosacral Suspension
Cytoreductiva Surgery for Ovarian Geoffrey W. Cundiff
Cancer-Upper Abdominal Disease: Chapter38 Sacral Colpopexy
Diaphragm Darran M. L.azara
Robert E. Bristow
Chapter37 Rectocele Repair Using
Cytoreductive Surgery for Ovarian the Defect-directed Approach
Cancer-Upper Abdominal Disease: GaoffrayW. Cundiff
Transverse Colectomy
Robart E. Bristow Chapter38 Overlapping Sph i ncteroplasty
GeoffreyW. Cundiff
Chapter23 Microsurgical Tubal Reanastomosis
Ric1rdo Azziz, Melinda Henna, M. Jonathon Solnik

XVII
CHAPTER 1

Uterine Ablation
Techniques
Frank Tu

INTRODUCTION perforation. Women with intra-uterine devices (IUDs}


in place and, for selected procedures, the presence of
There is a long history of attempts to deliver energy to intramural leiomyomas and endometrial polyps may
the endometrial lining in order to reduce abnormal men- benefit from additional pre-ablation procedures.
strual bleeding-dating back to as early as the 1890s. Benefits of GEA have been supported by multiple
More recently, hysteroscopic resection or hysteroscopic head-to-head comparative trials against traditional
ablation has proven to be of significant value in ensur- transcervical endometrial resection, with patient sat-
ing the destruction of the endometrium and ameliora- isfaction ranging from 89% to 98% and amenorrhea
tion of menorrhagia and related symptoms. However, rates ranging from 14% to 55%. Patient satisfaction is
due to concerns about serious complications from fluid generally quite high with all the procedures, although
overload with conventional hysteroscopic endometrial it is important to note that one survey has suggested
resection for abnormal uterine bleeding, several global that women are willing to tolerate up to a 50% failure
endometrial ablation {GEA) devices were introduced rate with conservative management strategies in order
around the beginning of the new millennium. These to avoid hysterectomy. Despite the high overall satis-
GEA techniques use radiofrequency, thermal energy, or faction with virtually all devices, bipolar ablation has
microwave energy to destroy the endometrium, in order been shown in two head-to-head trials to deliver supe-
to reduce the amount of cyclical bleeding or, in some rior objective results compared to thermal balloon and
cases, even achieve complete amenorrhea. hydrothermablation, respectively. This may be in part
GEA is indicated for the treatment of dysfunctional due to differences in how patients are pretreated for
uterine bleeding. This can include comorbid leiomy- these procedures.
oma for certain devices, but typically a hysteroscopic The particular attractiveness of GEA over endome-
myomectomy might be a better treatment for a known trial resection is also evident in the number of cases
submucosal leiomyoma. There are several contraindi- that increasingly are done in the office or under local
cations to consider; these include ongoing pregnancy anesthetic. That being said, there is still a selective role
or desire for future pregnancy, cancer or premalig- for endometrial resection in the hands of experienced
nant change, untreated pelvic inflammatory disease, hysteroscopic surgeons, particularly in patients desir-
hydrosalpinx, history of classical cesarean section, or ing conservative therapy after failure of initial GEA.
transmural myomectomy. A woman with a cesarean Patients do need to be counseled about risks, includ-
section scar measuring less than 8 to 10 mm on ultra- ing the rare risk in women with a prior history of tubal
sound should be considered a relative contraindication ligation of "postablation tubal pain syndrome," central
for GEA or might consider having the procedure done hematometra, endometritis with rare reports of sep-
under ultrasound guidance to minimize the risk of sis, uterine perforation, and injury to adjacent pelvic

3
SECDON I GYNECOLOGY

organs. Minor side effects include temporary abdomi- performing the procedure during the early follicular
nal cramping in around 10% to 15% of patients treated phase or following a month of hormonal (e.g., pro-
and a few weeks of vaginal discharge in most patients. gestogen) pretreatment to thin the endometrial lining.
Effective means of contraception are needed if per- Although many patients are comfortable having this
manent sterilization has not already been assured, as done in the ambulatory setting using one of several
future gestational complications such as uterine dehis- available analgesic strategies, the clinician must select
cence, intrauterine growth restriction, and preterrn the best setting based on the examination and his/her
delivery have been described in unexpected pregnan- assessment of the patient's tolerance level (Box 1.1 ).
cies following GEA Unfortunately, GEA in a subset of To address the issue of a submucosal leiomyoma, or
women impairs cancer screening due to obliteration of to prevent future pregnancies, some clinicians perform
the endometrial cavity, which can obscure the abnor- concomitant procedures such as hysteroscopic myo-
mal bleeding that is a hallmark of endometrial cancer. mectomy, or tubal sterilization, or IUD placement at
the same time as GEA. The Her Option® cryoablation
system and MEN11 have indications for intracavitary
PREOPERATIVE CONSIDERATIONS leiomyoma up to 2 and 3 ern, respectively. Published
postmarketing experience from Kaiser Permanente sug-
The initial workup of menorrhagia should follow gen- gests that the use of office-based Hydrotherrnablatofii
erally accepted clinical practice and includes: (a) (HTA) can still be effective in the presence of either
excluding pregnancy. (b) completing a pelvic exam Type 0 or Type I myomas, although the reported failure
and pelvic ultrasonography, (c) obtaining confirma- rate of 23% at a mean follow-up of -2.5 years post-
tion of a recent negative PAP smear, (d) performing an procedure was markedly higher than their 3. 7% failure
endometrial biopsy to rule out cervical or endometrial rate in myoma-free patients. Similar efficacy has been
malignancy and pre-malignant changes to the uterus, reported for off-label use of Thermachoice* and Nova-
and (e) potentially performing a hysteroscopy to con- sure3. There is concern that an immediate prior myo-
firm the appropriateness of the size of the uterus and mectomy may weaken the uterine tissue and increase
the absence of intracavitary lesions that might limit the the risk of perforation or iatrogenic injury to abdomi-
effectiveness of GEA techniques. All methods, except nal organs. Placement of the tubal sterilization implant
for the Novasure® bipolar electrode array, recommend Essure® must be done after Novasure® ablation due to

Suggestions for in-office analgesic protocols for GEA procedures


Consider using a combination of the following agents to achieve multirnodal
pain management. Many practices use all of these in conjunction to achieve
optimal comfort. Patient selection is crucial.
1. Anti,inflammatory: administer 600 to 800 mg of oral ibuprofen every 6 hours
beginning in evening prior to procedure, followed by in-office intramuscular
injection of ketorolac 30 mg (at least 6 hours after previous NSAID dose)
2. Muscle relaxant/anxiolytic: oral diazepam 2 to 5 mg 60 minutes prior to
procedure
3. Cervical ripening agent: rnisoprostol 200 p,g at bedtime night prior to
procedme-not recommended if doing HfA in office due to concern for spill
4. Opioid analgesic: 5 to 10 mg of oral hydrocodone or oxycodone, or bella-
donna and opium rectal suppositories 16.2/30 or 16.2/60, 60 minutes prior
to procedure
5. In-office paracervical block with local anesthetic: must wait 5 to 10 minutes
to achieve effect
6. Patients should consider arranging for transportation to and from procedure
if any sedative agents are administered in the perioperative period
CHAPTER 1 Uterine Ablation Techniques>---~----

the metal content of the implants. While an IUD can of an intrauterine probe to - 80°C during two
be placed after GEA. it may be difficult to remove sub- freeze cycles of 4 and 6 minutes each, to treat
sequently due to the resulting fibrosis. each side of the uterine cavity (Figure 1.1 ).
The procedure is done under ultrasound guid-
ance and usually does not require preoperative
SURGICAL TECHNIQUE cervical dilation as the probe measures 5.5 mm
in diameter (and 22 em in length). Women with
1. GEA techniques: Patients are placed in slight uterine cavity lengths between 4 and 10 em (by
Trendelenburg position in stirrups and the perineum sounding) and a uterine volume of 300 ml or
prepped and draped in the usual fashion. Typically, less are considered appropriate candidates for
some sort of IV sedation is given or else office pro-
treatment with this device.
tocols for preoperative pain control are used. The The active probe is connected to a gas com-
bladder is emptied with a catheter if appropriate. pressor. On activation, a hermetically sealed gas
Preoperative antibiotics are usually unnecessary. mixture flows into the distal tip of the probe,
although patients should be counseled that endo- which pennits cooling and heating of the probe.
metritis can occur rarely after these procedures. The disposable probe is first tested in the air
A paracervical block is given at 4 and 8 o'clock if in- and confirmed to be able to reach - 50°C in
dicated and uterus is sounded to confirm appropri- a test freeze. Air is first cleared from the probe
ateness for each given device. A speculum is placed channel with a small volume (1-2 ml) of saline
and the cervix grasped with a tenaculum. and the probe is then inserted under ultra-
a. Her Option• (Cooper Surgical): The only sound guidance toward the right or left fun-
cryoprobe therapy approach among the five dus. A saline-filled 30-ml syringe is attached to
methods reviewed achieves biological effect the injection port on the probe, and 5 to 10 ml
on the endometrium by cooling the 3.5-cm tip injected into the cavity to optimize contact of

FIGURE 1.1 Her Option• (Cooper Surgical): The only cryoprobe therapy approach to endometrial abla-
tion, it achieves its biological effect on the endometrium by cooling the 3.5-<:m tip of an intr~uterin: probe
to -80°C during two freeze cycles of 4 and 6 minutes each, treating each side of the utenne cav1ty. The
procedure is done under ultrasound guidance.
- - - - !& SECDON I GYNECOLOGY

the probe against the endometrial tissue and attached to the injection port. Next the balloon
enhance sonographic visualization. is inserted into the endometrial cavity and filled
The surgeon begins the freeze cycle by depress- with enough D5W {up to 30 ml) to achieve a
ing the button on the probe. The formation of the stable intrauterine pressure of between 160 and
ucryozone" {a discrete dark area detected by ultra- I80 mml-lg (Figure 1.2}. The heating element
sonography at the perimeter of the echolucent is then activated to 87°C for 8 minutes to treat
cryoprobe) is monitored by ultrasound during the endometrial cavity. The system will automati-
the first 4-minute therapy cycle, which should be cally shut off if the intrauterine pressures reach
stopped and the heat button engaged if it reaches > 2I 0 nunHg or <45 mml-lg {such as with sudden
closer than 5 mm from the uterine serosal sur- loss of balloon integrity or uterine perforation) dur-
face. Five to I 0 ml of saline is injected into the ing a heating cycle; or balloon temperatures exceed
cavity through the probe after the heat cycle is >95°C for more than 2 seconds or <75°C for
completed before the probe is withdrawn into the I5 seconds. Original approval by the FDA was for
endocervical canal. The probe is then positioned uterine sizes between 4 and 12 em with nonnal
against the opposite cornua and a freeze cycle of cavity contour.
up to 6 minutes initiated, again using saline as
needed to unseat the probe. c. Hydmthennablato,. (HT~ Boston Scientific):
In many ways, a similar concept to the
b. Tbermachoice• (Ortho Women's Health): Thennachoice® family of products, the HTA
Thermachoice® features a heating element differs in that it achieves biological effect by
inside a silastic balloon that conforms to the directly exposing heated saline (at 90°C) to the
shape of the uterine cavity. The Thermachoice endometrial cavity. Over the course of I 0 min-
liP has a flelcible silastic balloon to optimize fit. utes, this similarly destroys the endometrium.
The balloon is fust checked for leaks out of the The cervical canal is dilated to 8 mm prior to
package by performing a filling test before place- inserting a clear 7.8-mm polycarbonate probe
ment with a D5W-filled 30-ml luer lock syringe (Figure 1.3). The procedure is performed

~ ---- ~

FIGURE 1.2. Thermachoice• (Ortho Women•s Health): Thermachoice• features a heating element that
is activated to 87°C for 8 minutes inside a silastic balloon that conforms to the shape of the uterine cavity.
CHAPTER 1 Uterine Ablation Techniques l~---

FIGURE 1.3 Hydrothermablato..- (HTA, Boston Scientific): The HTA differs from other methods of
uterine ablation in that it achieves biological effect by directly exposing heated saline (at 90°C) to the endo-
metrial cavity, over the course of 10 minutes. The procedure is performed under continuous visual guidance
by a 3-mm hysteroscope inserted directly through the polycarbonate working channel.

under continuous visual guidance by a 3-nun tenaculum stabilizer, and a ribbed cervical com-
hysteroscope inserted directly through the poly- ponent attached to the polycarbonate sheath
carbonate working channel. provide additional safeguard against external
A priming cycle of 2 minutes is first per- thermal injuries to the cervix, vagina, or legs.
formed at infusion rates of 300 mUmin. If
this initial safety check is confirmed (i.e., no d. Novasure•(Hologic;): The disposable Novasure®
evidence of leakage into the abdominal cavity) system features a 7.2-mm wide retractable
by the system software, a heating cycle brings bipolar electrode array that is inserted into the
the temperature gradually up to 80°C at which endometrial cavity to desiccate the endome-
time the treatment cycle begins at the same trium using radiofrequency {RF) current. As
flow rate. Subsequently, a cool-down phase to with HTA, the cervical canal needs to be first
45°C completes the treatment cycle. dilated to 8 mm. The concrete dimensions
Concerns regarding the procedure, including of the fan-like array require that the internal
the risk of hot fluid spilling retrograde into the endometrial cavity dimensions be determined
peritoneal cavity; are avoided by following stan- before ablation to allow proper output pro-
dard GEA contraindications, such as avoiding gramming of the RF generator (Figure 1.4).
use in women with prior classical cesarean sec- The length of the cavity needs to he estimated
tion or transmural myomectomy, and because by sounding, hysteroscopy, or ultrasonography.
the system keeps infusion pressures below The gun-like array assembly is first inserted
the opening (coaptation) pressure of the fallo- transcervically and the array is extended to fit
pian tubes {-55 nunHg). To further minimize between the cornu. The entire array is then
accidental burns, the onboard software initi- gently rocked back and forth, and from side
ates an automatic cooling phase if the cycle is to side, to optimally seat it within the cavity.
intemlpted for any reason. Insulated tubing, a The width and length dimensions must then
_ _ ___,8 SECDON I GYNECOLOGY

.~..;........., __+ - - Novasure fan slightly


extended after insertion
through the cervix

- --1-- - + - - - Novasure fan


fully extended

Treated
endometrium-~--~

FIGURE 1.4 Novasure• (Hologic): The disposable Novasure• system features a 7.2-mm wide retract-
able bipolar electrode array that is inserted retracted into the endometrial cavity. It is then extended fully
to desiccate the endometrium using radiofrequency (RF) current. The concrete dimensions of the fan-lik:e
array require that the internal endometrial cavity dimensions be determined before ablation to allow proper
output programming of the RF generator.
CHAPTER 1 Uterine Ablation Techniques'---__.,~----

be input manually into the RF generator. Only movements. Treatment times vary but typically
cavities between 4.0 and 6.5 em in length and are 3 to 5 minutes in a normal-sized uterus. The
> 2.5 em in width are approved for treatment MEA* is approved for use in larger uterine cav-
with the Novasure® system; treatment of cavi- ity lengths compared with the other GEA meth-
ties >4.5 em in width may not be effective. ods (up to 14 em). The original FDA trial also
Next, a cavity integrity test is performed using permitted submucosal myomas to be treated by
carbon dioxide infusion. If the intrauterine pres- this technology if they did not protrude more
sure can be maintained for 4 seconds, a treatment than 3 em into the cavity.
cycle can be initiated. The cause for a failed cavity
integrity test needs to be detennined and resolved 2. Hysteroscopic endometrial resection and
in order to safely move to initiation of the treat- ablation: Although first-line surgical management
ment phase. Occasionally; with a large multipa- of abnormal uterine bleeding in the United States
rous lax cervix, a tenaculum may need to be used has tilted heavily toward the GEA approaches,
to close the cervical canal arotmd the array and some clinicians continue to use the traditional re-
avoid leakage of C02 transcervically, which oth- sectoscopic ablations, and the availability of bipo-
erwise prevents the system from being activated. lar resectoscopes does simplify the teclmique while
When activated, the system continuously also providing an enhanced safety profile over the
measures the electrical impedance of the monopolar instruments. Historically. ND:YAG laser
target tissue; the impedance rises as the tissue fibers have also been used. For conservative man-
is desiccated. Once tissue impedance reaches agement after unsuccessful GEA, resectoscopic
50 ohms, or treatment reaches 2 minutes, the ablation allows direct visual treatment of areas of
cycle is terminated. Novasure® is the fastest of endometrium that remain viable.
the GEA methods. Furthermore, Novasure~s
effectiveness in its original FDA trial was docu- At least two bipolar systems, which permit the use
mented without requiring pretreatment thin- of isotonic distension medium, are available made
ning of the uterine lining. by Richard Wolf Medical Instruments Corporation
(Vernon Hill, IL) and Gynecare (Somerville, NJ).
e. Microwave Endometrial Ablation (MEA•, Both of these come with both a wire loop as well as
Microsulis Americas Inc.): In a variant of the a rollerball tip electrode. Because each of these has
RF bipolar treatment array (i.e., Novasure®), idiosyncratic power settings tied to a dedicated gen-
MEA® applies microwave energy at 9.2 Hz to erator, we will describe the technique specifically for
the uterine cavity using a transcervical wand the Gynecare Versapoint® system that the author uses;
to deliver temperatures of 75°C to 85°C to an however it is imperative that users be familiar with the
endometrial/myometrial depth of 5 to 6 mm instructions for their specific setup. The Versapoint~
{Figure 1.5). A preoperative ultrasound is sug- vaporizing electrode measures 4 mm wide and 4 mm
gested by the manufacturer to confirm a uniform in diameter, while the wire loop electrode has a diam-
uterine wall thickness of ~ 10 mm. In addition, eter of 2.5 mm. Either of these components attaches
an endometrial curettage immediately prior to to the working element and sits within the 9-mm hys-
the procedure should be avoided to minimize teroscopic sheath, which generally necessitates dilation
the risk of inadvertent perforation or transmural of the cervix {Figure 1.6). The goal is to use the elec-
injury. MEA® is also not recommended follow- trode to desiccate the endometrium to the basalis while
ing a prior endometrial ablation attempt, if the avoiding damage to the myometrium. Hysterscopically
uterine cavity is <6 em, or if the patient has had guided endometrial resection and ablation can be used
a prior classical cesarean section or other trans- as either primary treatment or for the treatment of a
mural uterine surgery. such as myomectomy. patient who has previously undergone a failed, usually
The cervix is dilated to 8. 5 mm, and the wand GEA, ablation procedure.
inserted and advanced until the tip reaches the For previously untreated endometrium, many surgeons
uterine fundus. The wand is then moved back use hormonal suppression {GnRH analogue, progestins)
and forth from cornua to cornua until the real, for 1 to 2 months to thin the lining preoperatively. The
time temperature reaches 70°C. The wand is area is treated circumferentially with the electrode intro-
then withdrawn slightly into the lower corpus duced near the ostia and then pulled back while the
and treatment continued with back and forth electrode is activated for brief segments, in overlapping
_ _ ___.J) SECDON I GYNECOLOGY

'' ''
' ''
\
'' '\
' \
'' '
' ' \
\
\
'' \ \
'
FIGURE 1.5 Microwave Endometrial Ablation (MEA•. Microsulis Americas Inc.): In a variant of the
RF bipolar treatment array, the MEA applies microwave energy at 9.2 Hz to the uterine cavity using a tran-
scervical wand to deliver temperatures of 75°C to 85°C to an endometriaVmyometrial depth of 5 to 6 mm.

rows Wltil the entire cone of each cornua has been suc- that periodically the tissue be removed to avoid
cessfully vaporized or desiccated (Figure 1.7). The obstructing the visualization of the cavity. The visual
endometrium of the cornua is thinnest and most awk- goal is blanching and ablation of the endometrium
ward to treat, so use of the vaporizing electrode, a ball down to the basalis, which appears as whiteness in
electrode, or a straightened-out wire loop permits gen- the treated area of the endometrial cavity indica-
tle treatment of this area. The anterior uterine wall is tive of the myometrium. Some surgeons also suggest
treated next, because desiccation can generate obscur- leaving a rim of untreated endometrium above the
ing bubbles. These bubbles can be removed from the os to minimize the development of hematometria.
cavity by occasionally pushing the scope up against the Alternately, a small series of published cases suggest
fundus, permitting evacuation through the hysteroscopic good patient satisfaction with only desiccation of one
outflow. Subsequently, the posterior wall is vaporized/ wall of the uterus, which may further minimize the
desiccated, again using the same technique of puUing risk of hematometria.
the electrode toward the os as it is being activated. If the patient is Wldergoing a secondary ablation, the
Use of either electrode is appropriate in these visualization obviously can be markedly impaired by
circumstances, although the advantage of using the scar and fibrosis, and the specific goals of ablation may
wire loop is that strips of tissue are available for be limited to the visually viable areas of endometrium.
pathological evaluation; the latter also does require An additional benefit of the hysteroscopic approach is
CHAPTER 1 Uterine Ablation Techniques 1..__ __

Bipolar ,___,
Hysteroscope vaporizing Bipolar
eleetrode loop resecting
electrode
FIGURE 1.6 Versapoinf:41 Resectoscopic System (Gynecare, Inc.): The Versapoinr- vaporizing electrode
measures 4 mm wide and 4 mm in diameter, while the wire loop electrode has a diameter of 2.5 mm. Either
of these components attaches to the working element and sits within the 9-mm hysteroscopic sheath, which
generally necessitates dilation of the cervix.

that when intrauterine pathology is encountered, a poly, the site of perforation, and subsequent treatment die,
pectomy or myomectomy may be performed. tated by findings. While gas embolism is an extraordi-
The risks of hysteroscopic ablation involve infec- narily rare event, it can create severe cardiopulmonary
tion, bleeding, perforation (at least I%), fluid over, collapse. Emergent recognition and coordination with
load, and postop hematometria (see Complications the anesthesia team and a vascular surgeon to evacuate
box on page 14). As with any operative hysteroscopic the gas bubble may avoid serious consequences includ-
procedure, recommended goals for monitored fluid ing death. Proposed steps to reduce this risk include
deficit should be respected, with 2,500 ml of isotonic limiting the degree of Trendelenberg tilt (head down
fluid being the absolute cutoff for a procedure, and relative to pelvis), and limiting the number of times the
potentially less for patients with cardiopulmonary com, hysteroscope is pulled in and out of the cervix.
promise. Surgeons are encouraged to rapidly move to
complete the hysteroscopic case at 1,500 ml deficits.
Active fluid monitoring systems are readily available to POSTOPERATIVE CONSIDERATIONS
ensure precise calculation of these deficits. To minimize
the chance of perforation, some surgeons use combined For most patients, GEA can be performed in the day
ultrasound or laparoscopic guidance. A suspected per- surgery setting as an outpatient and in selected cases
foration while an electrode is being used actively should in the ambulatory clinic setting. Observation in the
be investigated {usually laparoscopically) with careful postprocedure state usually for an hour or so is appro,
evaluation of the intestine and other pelvic organs at priate to ensure adequate pain control.
_ _ ___.2 SECDON I GYNECOLOGY

Treated area

FIGURE 1.7 Versapoint,e Resectoscopic System (Gynecare.lnc.) in use: The area is treated circumfer-
entially with the electrode introduced near the ostia and then pulled back while the electrode is activated for
brief segments, in overlapping rows until the entire cone of each cornua has been successfully vaporized or
desiccated. The endometrium of the cornua is thinnest and most awkward to treat, so use of the vaporizing
electrode, a ball electrode, or a straightened-out wire loop permits gentle treatment of this area.

Postoperative pain management is usually managed analgesia. Oral narcotics can then be used on an "as
adequately with nonsteroidal antHnflammatory drugs. needed" basis for pain spikes. No activity restrictions
A regular schedule of oral medication helps to mini- beyond the patient's personal comfort level are usu-
mize postoperative pain needs. by providing baseline ally needed. Patients should be instructed to avoid
CHAPTER 1 Uterine Ablation Techniques 1- ---
coitus for at least 1 week after the procedure and ide- The balloon probe was filled and confirmed to be in-
ally should be examined in the office evaluation before tact. The probe was then inserted into the endome-
resuming sexual intercourse. trial cavity and filled with enough D5W to achieve
a stable intrauterine pressure of between 160 and
Operative Note 180 mmHg. The heating element was activated to
87°C for 8 minutes to treat the endometrial cavity.
PROCEDURE: UTERINE ABLATION No pressure or temperature warnings were noted.
TECHNIQUES After cooldown the fluid was removed from the bal-
loon and the probe was removed.
The patient was taken to the operating room, where
Or
her identity was confirmed. After the establishment of
adequate anesthesia, patient was placed in the dor- 3. Hysteroscopic thermal endometrial ablation
sal lithotomy position, and a combined abdominal (Hydrothermablato...): The system was checked
and vaginal prep and sterile drape were performed. to ensure no leaks and the fluid management sys-
Arms were padded and tucked in military position, the tem was calibrated to the patient's bed position.
hip and ankles placed in neutral position, and knees The cervical canal was dilated to 8 mm and the
flexed to 90°C to minimize nerve compression. The probe then inserted under visual guidance. A prim-
operative team completed a "time-out" when universal ing cycle was first performed at infusion rates of
precautions where reviewed, including patient iden- 300 m1/min. After the safety check was executed,
tification and site of surgery. Team questions were the treatment cycle at 80°C was completed over
answered. A straight catheter was inserted to drain 10 minutes. After the cooldown phase to 45°C, the
the bladder. A vaginal speculum was placed and the probe was removed. The fluid tubing was kept away
anterior lip of the cervix grasped with a single-tooth from the patient at all times.
tenaculum. Uterine sound confirmed appropriate size Or
of the cavity. Preprocedure hysteroscopy using saline
4. Radiofrequency bipolar array endometrial
infusion confirmed appropriate cavity appearance
ablation (Novasure•): The cervical canal was di-
without masses or structural anomalies and both cor-
lated to 8 mm. The length of the cavity was deter-
nua were visualized.
mined to be appropriate by sounding. The array was
inserted into the uterine cavity up against the fundus,
Technique specific procedure notes and then seated and locked open in full extension by
are denoted below: rocking it gently back and forth against all four cardi-
nal surfaces of the uterine cavity. The resulting width
1. Endometrial cryoablation (Her Option•): The (3.5 em) and length (6 em) dimensions were pro-
disposable probe was tested and confirmed to be grammed into the RF generator. After the cavity in,
able to reach - 50°C in a test freeze. The probe was tegritywas confirmed with co~ infusion, a 90-second
cleared of air and then inserted under ultrasound treatment cycle was performed. The array was then
guidance toward the right fundus. The balloon was retracted and the probe removed from the patient.
filled with 5 ml of saline to optimize contact of the Or
probe against the endometrial tissue. The freeze
cycle was initiated and the formation of a cryozone
5. Microwave endometrial ablation (MEA•): The
monitored by transabdominal ultrasound for the ini- cervix was dilated to 8.5 mm, and repeat hysteroscopy
confirmed the absence of a perforation. The fluid was
tial 4-minute therapy cycle. The zone stayed 5 mm
then evacuated from the uterine cavity. The prepro-
from the uterine serosal surface at all times. The
probe was then positioned against the opposite cor- cedure temperature profile evaluation was reassuring.
The MEA applicator was inserted up to the uterine
nua and the second 6-minute freeze cycle initiated,
fundus. The device was then activated and the wand
again without excessive penetration of the cryozone
moved back and forth from cornua to cornua until the
into the myometrium by ultrasound guidance.
real-time temperature displayed on the control unit
Or reached 70°C. The wand was then withdrawn slightly
2. Thermal balloon ablation (Thermachoice•): A into the lower corpus and treatment continued with
vaginal speculum was placed and the anterior lip of back and forth movements until the black band was
the cervix grasped with a single-tooth tenaculum. visible at the external cervical os.
_ _ ___.j. SECDON I GYNECOLOGY

Or 3. Cahan WG. Cryosurgezy of the uterus: description of


technique and potential application. Am J Obstet Gyne-
6. Hysteroscopic global endometrial resection:
col1964;88:410-414.
The cervix was dilated to 9 mm. The Versapoint
4. Clark 1], Samuel N, Malick S, Middleton LJ, Daniels J,
bipolar resectoscope was inserted with saline infu~
Gupta JK Bipolar radiofrequency compared with ther~
sion. using a fluid management system. The roller- mal balloon endometrial ablation in the office: a random-
ball with settings of 170 W vapor cut 1 was used to ized controlled trial. Obstet Gynecol20 11;117: 109~ 118.
treat the ostia in overlapping radial rows until the 5. Cooper JM, Brady RM. Late complications of opera-
entire cone of each cornua was vaporized. Next the tive hysteroscopy. Obstet Gynecol Clin North Am
fundal endometrium was vaporized in overlapping 2000;27(2):367-374.
rows. The hysteroscope was removed and a wire 6. Glasser MH. Practical tips for office hysteroscopy
loop attached. Using the wire loop. the anterior and and second-generation "globaln endometrial ablation.
then posterior endometrial lining was excised using J Minim Invasive Gynecol2009;16:384-399.
desiccation, again on the 170 W vapor cut 1 mode. 7. Groenman PA. Peters LW, Rademaker BM. Bakkum EA.
Embolism of air and gas in hysteroscopic procedures:
For all surfaces. we vaporized/excised down to the
pathophysiology and implication for daily practice.
visibly white basalis layer. The hysteroscope was
J Minim Invasive Gynecol2008;15(2):241-247.
then withdrawn. All strips of endometrial tissue 8. Kleijn JH, Engels R, Bourdrez P, Mol BW, Bongers MY.
were then systematically evacuated with a suction Five-year follow up of a randomised controlled trial com-
curette. Repeat hysteroscopy confirmed no perfora~ paring NovaSure and ThermaChoice endometrial abla-
tion and an empty cavity. The final fluid deficit was tion. BJOG 2008;115:193-198.
within limits {800 rnl). 9. Lethaby A, Hickey M, Gany R, Penninx J. Endometrial
resection/ablation techniques for heavy menstrual bleed-
All instruments were removed. The tenaculum ing. Cochrane Database Syst Rev 2009:CDOO I 50 I.
site was inspected and noted to be hemostatic. The 10. McCausland AM, McCausland VM. Partial rollerball
patient was woken up and transferred to recovery endometrial ablation: a modification of total ablation to
in good condition. No complications were observed. treat menorrhagia without causing complications from
intrauterine adhesions. Am J Obstet Gynecoll999;180
(6 Pt 1):1512-1521.
11. Meyer WR, Walsh BW. Grainger DA. Peacock LM,
COMPLICATIONS Laffer FD, Steege JF. Thermal balloon and roUerball
ablation to tteat menorrhagia: a multicenter comparison.
• Uterine perforation-Infrequent (less than 5%) Obstet Gynecol1998;92:98-103.
• Fluid or electrolyte imbalance (see Table 27.1)- 12. PenninxJ P, Mol BW, Engels R, et al. Bipolarradiofrequency
Infrequent (less than 5%) endometrial ablation compared with hydrothermablation
• Hemorrhage and major vessel perforation- for dysfunctional uterine bleeding: a randomized con-
Rare (less than 1%) trolled trial. Obstet Gynecol20 10; 116:8 I 9-826.
• Postoperative infection (endometritis, 13. Practice Committee of American Society for Reproduc-
tive Medicine. Indications and options for endometrial
myometritis, adenexitis )-Rare (less than 1%)
ablation. Fertil Steril2008;90:S236-S240.
14. Sabbah R, Desaulniers G. Use of the NovaSure Imped-
ance Controlled Endometrial Ablation System in patients
with intracavitary disease: 12-month follow-up results of
Suggested Reading a prospective, single-ann clinical study. J Minim Invasive
I. Bourdrez P, Bongers MY, Mol BW. Treatment of dysfunc~ Gynecol2006;13(5):467-471.
tional uterine bleeding: patient preferences for endo- 15. Sowter MC, Lethaby A, Singla AA. Pre-operative endo-
metrial ablation, a levonorgestrel·releasing intrauterine metrial thinning agents before endometrial destruction
device, or hysterectomy. Fertil Steril2004;82: 160-I 66. for heavy menstrual bleeding. Cochrane Database Syst
2. Butler WJ. Carnovale DE. Normal and Abnonnal Uter~ Rev 2002:CDOOI124.
ine Bleeding. In: Rock JA, Jones HW, eds. Telinde's 16. Soysal ME, Soysal SK, Vicdan K Thermal balloon abla-
Operative Gytu!cology, Tenth Edition. Philadelphia, PA: tion in myoma-induced menorrhagia under local anes~
Lippincott Williams and Wilkins; 2011 :585-608. thesia. Gynecol Obstet Invest 2001;5I(2):128-133.
CHAPTER 2

Total Abdominal
Hysterectomy
Robert E. Bristow

INTRODUCTION include only the uterine corpus, called supracervical


hysterectom:y. The term subtotal hysternctom:y refers
Approximately 600,000 hysterectomies are performed to the supracervical type but is not the preferred ter-
annually in the United States, and more than one-third minology. There has been a recent increase in the
of women have had a hysterectomy by age 60 years. popularity of supracervical hysterectomy despite mul-
The most common diagnoses among women undergo- tiple randomized trials indicating no benefit over total
ing hysterectomy are uterine leiomyomata (41%), endo- hysterectomy in sexual function, bladder function, or
metriosis (18%), uterine prolapse (15%), and cancer or pelvic floor support. In the absence of adnexal pathol-
hyperplasia (12%). Other indications for hysterectomy ogy, the decision to perform prophylactic removal of
include adenomyosis, pelvic inflammatory disease, the ovaries and fallopian tubes should be addressed
chronic pelvic pain, and pregnancy-related conditions. individually and will depend on patient preference,
The uterus can be removed by a variety of dif- menopausal status, and the risk of subsequent ovarian
ferent approaches including the abdominal route cancer or other adnexal pathology that might require
(laparotomy), transvaginally, or using minimally inva- surgical intervention.
sive surgical techniques. Selection of the operative
approach is based on many factors including the physi-
cal properties and topography of the uterus and pelvis, PREOPERATIVE CONSIDERATIONS
the indication for surgery, patient body habitus and
medical comorbidities, and the presence or absence of In preparation for abdominal hysterectomy all patients
adnexal pathology. Abdominal hysterectomy allows the should undergo a comprehensive history and physical
greatest ability to manipulate distorted pelvic anatomy examination focusing on those areas that may indicate
or perform extensive adhesiolysis safely, and over 60% a reduced capacity to tolerate major surgery or place
of hysterectomies performed in the United States are the patient at elevated risk for postoperative compli-
still performed via the abdominal approach. Although cations. Routine laboratory testing should include a
abdominal hysterectomy is typically associated with complete blood count, serum electrolytes, a pregnancy
shorter operating times than minimally invasive surgi- test in reproductive-age women, age-appropriate health
cal approaches, it is also associated with a higher level screening studies, and an electrocardiogram for women
of incisional pain, greater risk of postoperative febrile aged 50 years and older. Specifically, all patients under-
morbidity and wound infection, longer hospital stay, going abdominal hysterectomy for a benign indication
and a more protracted recovery time. should have current Pap smear screening, and endo-
Hysterectomy may include removal of the uterine metrial biopsy should be performed prior to hyster-
corpus and cervix, termed total hysterectom:y, or may ectomy for abnormal uterine bleeding to rule out an

15
SECDON I GYNECOLOGY

unexpected endometrial hyperplasia or cancer diag- the uterine fundus encompassing the round ligament,
nosis. Preoperative imaging is not required; however, fallopian tube, and utero-ovarian ligament on each
a transvaginal pelvic ultrasound is useful to assess uter- side. The broad ligament is incised cephalad to the
ine topography and anatomy and determine whether round ligament, and the peritoneal incision extended
concurrent adnexal pathology is present. toward the pelvic brim parallel to the infundibulopel-
Preoperative mechanical bowel preparation (oral vic ligament. The external iliac arteiy is an important
polyethylene glycol solution or sodium phosphate solu- landmark and is identified on the medial surface of
tion with or without bisacodyl) can be utilized accord- the psoas muscle. The external iliac artery should be
ing to the surgeon's preference. Prophylactic antibiotics traced proximally to the bifurcation of the common
{Cephazolin I g, Cefotetan I g to 2 g, or Clindamycin iliac artery. The hypogastric (internal iliac} artery can
800 mg) should be administered 30 minutes prior to inci- then be located and followed as it courses deep along
sion, and thromboembolic prophylaxis (e.g., pneumatic the lateral pelvic wall. The uterine arteries originate
compression devices and/or subcutaneous heparin} from the hypogastric artery within the cardinal liga-
should be initiated prior to surgery. Surgical equipment ment. The round ligament is identified and a ligature of
for abdominal hysterectomy includes a standard pelvic 1~0 delayed absorbable suture placed midway between
surgery tray. Additional equipment may include a self- the uterus and pelvic sidewall, which is held long for
retaining retractor with or without a fixed arm attaching traction (Figure 2 .I). A large hemo-clip (or suture lig-
the retractor ring to the operating table, an electrosurgi.- ature) is placed medially (uterine side) to control back.--
cal unit (ESU or "Bovie"), and a vessel-sealing device. bleeding and the round ligament is divided. An incision
Following is a brief description of the surgical procedure is created in the anterior leaf of the broad ligament and
used (see also video: Total Abdominal Hysterectomy}. continued medially across the vesicouterine peritoneal
reflection or fold at the junction of the lower uterine
segment and cervix (Figure 2.2).
SURGICAL TECHNIQUE The pararectal space is developed by carefully dis-
secting, with a finger or large Kelly clamp, between the
General or regional anesthesia may be used for hypogastric artery (laterally) and the medial leaf of the
abdominal hysterectomy. The patient may be broad ligament peritoneum. The ureter is attached to
positioned in the dorsal low-lithotomy (perineolithotomy} the medial leaf of the broad ligament peritoneum and
position using Allen® Universal Stirrups (Allen Medical is most easily located at the pelvic brim in the region
Systems, Cleveland, OH) or supine on the operating of the bifurcation of the common iliac artery. The ure-
table. The low-lithotomy position is preferable, as it per- ter should be clearly visualized as it courses through
mits intraoperative bimanual examination to accurately the pararectal space toward the cardinal ligament. The
assess distorted pelvic anatomy and allows access to ureter can also be palpated along its course by placing
the perineum for colpotomy and cystoscopy. Abdominal the surgeon's thumb and index finger on opposite sides
entry and exposure can be achieved through either a of the medial leaf of the broad ligament peritoneum,
transverse or vertical incision, depending on clinical fac- straddling the infundibulopelvic ligament, and drawing
tors or the anticipated scope of the operation. The low the fingers upward. As the fingers cross the ureter, a
transverse Pfannenstiel incision is usually adequate for characteristic "snapn is felt. Visual confirmation of the
most cases of abdominal hysterectomy for benign indica- ureter's position is the preferred technique, however.
tions; howeve:r; if wide exposure is needed, the transverse If one or both adnexae are to be left in situ, the uterus
Cherney or Maylard incisions may be more appropriate. is placed on traction anteriorly and medially and a win-
The vertical midline incision offers the greatest flexibility dow created in the avascular space of Graves (between
and can be extended above the umbilicus if necessary. A the ureter and the infundibulopelvic ligament) in the
self-retaining retractor will optimize exposure and reduce medial leaf of the broad ligament peritoneum. Two
surgeon fatigue but is not a requirement. large, curved clamps (e.g., Kelly and Heaney) are
Once the abdomen has been opened, a thorough placed across the utero~ovarian ligament/fallopian tube
exploration of abdominal structures is conducted complex (the round ligament is not included) and the
before directing attention to the pelvis. Adhesions are pedicle divided and suture ligated. The adnexae may
divided and normal anatomy restored prior to pack- then be allowed to drop into the posterior pelvis or
ing the bowel out of the pelvis. The uterus is elevated packed into the paracolic gutters out of the sUigical
out of the pelvis and manipulated by two large Kelly field, with care taken not to injure the infundibulopel#
clamps placed across the broad ligament adjacent to vic ligament, for the remainder of the hysterectomy.
CHAPTER 2 Total Abdominal Hysterectomy 1lr -- - -

Broad ligament
FIGURE 2.1 Total abdominal hysteredomy: Ligation and division of the round ligament.

At the conclusion of the case, the adnexal pedicle can to allow sufficient space (at least 1 to 2 em) to safely
be sutured to the round ligament stump on each side place clamps between it and the infundibulopelvic
to avoid adherence to the vaginal cuff and resulting ligament. The infundibulopelvic ligament is doubly
dyspareunia. If the adnexae are re-approximated to the clamped, divided, and suture ligated with 1-0 delayed
round ligament stumps, the peritoneal defect lateral to absorbable suture (Figure 2.3). To optimize exposure
the infundibulopelvic ligament should be closed with for hysterectomy, the adnexae are moved out of the
a running, nonlocking stitch of 3-0 delayed absorbable field of vision by tying the sutures of the distal ends of
suture to prevent an internal small bowel herniation the divided infundibulopelvic ligaments to the clamps
and entrapment. holding the uterus. Alternatively, the adnexae can be
If one or both adnexae are to be removed, a win- detached from the uterus entirely and submitted as
dow is created in the avascular space of Graves and the separate specimens. The infundibulopelvic ligament
infundibulopelvic ligament dissected up to the level of can also be divided with a vessel-sealing device.
the pelvic brim. It is important to completely visualize Prior to approaching the uterine vessels, it is pref-
the ureter as it crosses the common iliac artery at the erable to mobilize the bladder so that unanticipated
pelvic brim, as this is a common area of ureteral injury bleeding from the uterine vasculature or cardinal liga-
during hysterectomy with salpingo-oophorectomy. If ment can be safely controlled with clamps without
necessary, the ureter is dissected from its attachments concern over bladder injury. With cephalad traction on
to the medial leaf of the broad ligament peritoneum the uterus, the lower border of the previously incised
SECDON I GYNECOLOGY

FIGURE 2.2 Total abdominal hysterectomy: The anterior leaf of the broad ligament is opened, exposing
the bladder.

vesicouterine peritoneal reflection is grasped with for- Attention is then directed toward dividing the uter-
ceps or Allis clamps and placed on caudad traction. The ine vessels and cardinal ligaments. Clamp placement
plane between the bladder and cervix is identified and across the uterine vessels and cardinal ligament is a
the loose areolar tissue sharply dissected with the ESU common area of ureteral injury during abdominal
or scissors to develop the vesicocervical space. Dissec- hysterectomy. The medial leaf of the broad ligament
tion should be concentrated over the cervix and avoid peritoneum is incised posteriorly and medially toward
drifting laterally into the bladder pillars, where trou- the uterosacral ligament, releasing the ureter laterally.
blesome bleeding may be encountered. The bladder Excess peritoneum and areolar tissue is carefully dis-
piUars also transmit the ureters from the cardinal liga- sected from around the uterine vessels, but overzeal-
ment to the bladder base. The bladder is usually easily ous efforts to "skeletonize" the uterine vessels should
separated from the cervix. However, at the level of the be avoided. The uterine vessels are secured with a
cervicovaginal junction the bladder is attached to the heavy curved clamp (Heaney, Zeppelin, or Masterson)
cervix by the transverse vesicocervical ligament, which placed perpendicular to the long axis of the uterus at
demarcates the vesicocervical space from the vesi- the level of the uterine isthmus (internal cervical os).
covaginal space. The dissection is continued through At the level of the uterine isthmus, the clamp will be
the vesicocervical ligament by using the ESU to super- 1.0 to 1. 5 em above the ureter as it traverses the car-
ficially incise the tissue 2 to 3 mm above the visible dinal ligament. The tip of the clamp is placed against
edge of the bladder in a curvilinear fashion, with gentle the uterus to ensure the uterine vessels are completely
downward counter-traction on the bladder with smooth encompassed. The clamp should be placed across
forceps. The bladder should be mobilized at least I em the pedicle as close to a 90° angle as possible, rather
below the cervicovaginal junction (Figure 2.4}. While than the diagonal, to minimize the amount of tissue
some surgeons prefer to bluntly mobilize the bladder incorporated in the pedicle. A second clamp (straight
with a spongestick, this maneuver can result in unnec- Kocher) is placed just above the Heaney clamp at a
essary trauma to the bladder and is not recommended. 45° angle to control back-bleeding from the uterine
CHAPTER 2 Total Abdominal Hysterectomy 11: - - - -

FIGURE 2.3 Total abdominal hysterectomy: Division of infundibulopelvic ligament.

side (Figure 2.5). The uterine vessels are divided divided (Figure 2.6) and ligated with a 1,Q delayed
and ligated with a 1,Q delayed absorbable suture. The absorbable suture placed in the same fashion as for
needle should be placed precisely at the lower border the uterine pedicle. Usually, two or three "bites" are
of the tip of the clamp; the suture is tied down as required to completely divide the cardinal ligament
the clamp is released. Some surgeons prefer to place down to the level of the cervicovaginal junction. In
a second suture in a transfixion stitch distal to initial this series of steps, the tip of the clamp is placed so
ligature; however, this is usually unnecessary. The as to slide off the lateral portion of the cervix as the
pedicle of the uterine,side back,cJamp is secured with clamp is closed, and the jaw of the clamp juxtaposed
a 1,Q suture ligature in a Heaney transfixion stitch to the cut edge of the previous pedicle to ensure that
and the clamp removed to clear the operative field. To all cardinal ligament tissue is incorporated in one of
reduce back,bleeding from the specimen during the the suture ligatures. Each subsequent .,bite" is placed
cardinal ligament dissection, the contralateral uterine medial to the previous pedicle to ensure that the ure-
vessel pedicle should be clamped, divided, and ligated ter remains lateral to the point of active dissection.
at this time. The same sequence of steps is repeated on the con-
The uterus should be maintained on upward trac, tralateral side.
tion using the long Kelly clamps holding the fundus The posterior cui de sac should be inspected to
throughout the case, as this will provide the best expo, determine the position of the rectum relative to
sure to the focal point of the operative field. Each car, the posterior cervix and vaginal wall. If the rectum
dinalligament is taken down with a series of pedicles. is adherent in this area and exposure to the poste-
A heavy straight clamp (e.g., Heaney, Zeppelin, and rior proximal vagina is inadequate, the rectovaginal
Masterson) is placed right next to the cervix, almost space should be developed and the rectum sharply
parallel to the long axis of the uterus, and the pedicle dissected free.
_ _ _,20 SECDON I GYNECOLOGY

Vesicouterine
peritoneal reftectlon

FIGURE 2.4 Total abdominal hysterectomy: Dissection of the bladder from the anterior lower uterine
segment and cervix.

A variety of techniques can be used to transect the prior to placement of the next stitch. This technique
uterus and cervix from the proximal vagina, depend- is well suited for the patient with a short cervix and
ing on the clinical situation and anatomy. The easiest clearly demarcated cui de sac. For patients with a
and most straightforward technique consists of plac- cervix that protrudes more than I to 2 em into the
ing heavy curved clamps (e.g., Heaney, Zeppelin, and vagina, this technique requires resection of a portion
Masterson} from each side below the cervix across the of the upper vagina (to have sufficient room to place
cervicovaginal junction, at right angles to the long axis clamps beneath) and results in unnecessary shorten-
of the uterus, and dividing the cervix from the upper ing of the vagina.
vagina with heavy curved scissors (Figure 2.7). To The technique of retrograde hysterectomy is an
avoid injury to the bladder, the bladder must he mobi- excellent alternative in the case of an elongated cervix
lized at least 1 em below the cervicovaginal junction to or obliterated cui de sac. In this method, an anterior
allow safe placement of these clamps and permit suf- colpotomy is created 0.5 to 1.0 em below the cervi-
ficient space for suture ligating the pedicles without covaginal junction using the ESU. An empty sponge-
incorporating the bladder. These clamps incorporate stick placed transvaginally and elevated against the
the lower cardinal ligaments, the lateral vagina, and anterior cervicovaginal junction delineates the anat-
the uterosacral ligaments. The vagina is closed with omy and provides a convenient starting point for the
a Heaney transfixion stitch of 1-0 delayed absorbable colpotomy. The cervicovaginal junction is circumfer-
suture at each angle and a series of figure-of-eight entially incised by placing a series of curved Heaney
stitches working toward the midline to complete the clamps, with each pedicle being clamped, divided,
closure (Figure 2.8). Each suture is held long and and secured with a Heaney transfixion stitch of 1-0
used to provide upward traction on the vaginal cuff delayed absorbable suture in sequence {i.e., each
Uterine pedicle

FIGURE 2.5 Total abdominal hysterectomy: Division of uterine vessels. The pedicle is ligated (inset).

pedicle is tied before the next clamp is placed}. The two clamps are placed across the posterior proximal
ties from each pedicle are held long and used to pro- vagina and the specimen excised. A simple method
vide upward traction on the vaginal cuff, optimizing for closing the vaginal cuff consists of placing a
exposure for placement of the next clamp. Grasping horizontal mattress stitch of 1-0 delayed absorb-
the cervix with a straight Kocher clamp and applying able suture on either side of the vaginal cuff, work-
upward traction will also improve exposure. The final ing from posterior to anterior, below the tip of the
_ _ _,22 SECDON I GYNECOLOGY

FIGURE 2.6 Total abdominal hysterectomy: Transection of the cardinal ligament. The pedicle is ligated (inset).
clamp, through the medial anterior vaginal wall, then
reversing direction and placing the needle through
the anterior lateral vaginal wall and exiting the poste-
rior lateral vaginal wall just beneath the "healn of the
clamp. The suture is tied as the clamp is released,
effectively securing the lower cardinal ligament,
lateral vagina, and uterosacral ligament in a single
stitch. The remainder of the vaginal cuff is closed
with several figure-of-eight stitches of 1-0 delayed
absorbable suture.
The pelvis is irrigated and all dissection areas
inspected to ensure hemostasis. The course and safety
of the ureters should be verified. If there is any concern
over a possible ureteral or bladder injury, cystoscopic
examination with intravenous methylene blue or indigo
cannine should be performed to assess the integrity of
the urinary tract. If the hysterectomy has been com-
plicated by distorted pelvic anatomy associated with
large uterine leiomyomata (especially broad ligament or
lower uterine segment), severe endometriosis, or malig-
nancy, cystoscopic examination of the lower urinary
tract should also be considered.

POSTOPERAJIVE CONSIDERATIONS
Bladder Postoperative care following abdominal hysterectomy is
FIGURE 2.7 Total abdominal hysterectomy: Transection similar to that for any other major abdominal surgery.
of the uterus and cervix from the proximal vagina. The overall incidence of morbidity is approximately

FIGURE 2.8 Total abdominal hysterectomy: Closure of the vaginal cuff.


_ _ _,2 j SECDON I GYNECOLOGY

17%, with most instances related to febrile morbidity


or infectious complications (e.g., pelvic abscess, vaginal COMPLICATIONS
cuff cellulitis, urinary tract infection, and pneumonia).
The risk of urinary tract injury is < 1%, but can vary • The most common sites of ureteral injury during
by surgical indication and complexity of procedure. An abdominal hysterectomy are (a) the pelvic brim
indwelling catheter is continued overnight and removed in proximity to the ovarian vessels (division of
on the first postoperative day wlless there is has been a infundibulopelvic ligament), (b) the parame-
bladder or ureteral repair. Diet can usually be advanced trium (division of uterine vascular and cardinal
rapidly according to patient tolerance and clinical exam- ligament pedicles), and {c) the bladder base
ination. Criteria for discharge include afebrile without (transection of cervix from proximal vagina).
evidence of uncontrolled infection, tolerating a normal • The most common cause of bladder injury is
diet without nausea or vomitin& satisfactory bowel and inadequate mobilization of the bladder from the
bladder function, and evidence of appropriate wound anterior cervix and proximal vagina, resulting in
healing. Postoperative activity should be individualized; injury to the bladder dome or base when placing
however, vaginal intercourse should be restricted for the cervicovaginal junction clamps or suturing
6 to 8 weeks and a pelvic examination should be per- closed the vaginal cuff.
fanned to confirm integrity of the vaginal cuff. • Febrile morbidity is not uncommon after ab-
dominal hysterectomy and may be unexplained;
Operative Note pelvic infection, abdominal wound infection,
urinary tract infection, and pneumonia are the
PROCEDURE: TOTAL ABDOMINAL most common causes of infectious morbidity.
HYSTERECTOMY
The uterus was grasped and elevated and the round
ligaments suture ligated and divided. The pelvic peri~ Suggested Reading
toneal sidewalls were incised parallel to the external
iliac vessels and the pararectal spaces developed with 1. BerekJS, Chalas E, Edelson M, Moore DH, Burke WM,
visualization of the ureters. The infundibulopelvic liga- Cliby WA, Berchuk A, Society of Gynecologic Oncolo-
gists Clinical Practice Committee. Prophylactic and
ments were isolated, doubly clamped, divided, and
risk-reducing bilateral salpingo-oophorectomy: recom-
ligated with 1~0 delayed absorbable suture. The vesi~ mendations based on risk of ovarian cancer. Obstet
couterine peritoneal reflection was incised and the Gynecol2010;1 16:733-743.
bladder reflected off of the anterior lower uterine seg- 2. Gimbel H, Zobbe v; Andersen BM, Filtenborg T,
ment, cervix, and proximal vagina. The uterine vascular Gluud C, Tabor A. Randomized controlled trial of total
pedicles were skeletonized, clamped, and ligated with compared with subtotal hysterectomy with 1-year follow-
1-0 delayed absorbable sutures. The cardinal ligaments up results. BJOG 2003;110:1088-1098.
were clamped, divided, and ligated with a series of I ~0 3. Mlikinen J, Johansson J, Tomis E, et al. Morbidity of
delayed absorbable suture ligatures down to the level I0, II 0 hysterectomies by type of approach. Hum Reprod
of the cervicovaginal junction. The proximal vagina 2001 ;16: 1473-1478.
was cross-clamped with curved Heaney clamps, after 4. Ribeiro SC, Ribeiro RM, Santos NC, Pinotti JA.
ensuring that the bladder was safely dissected free A randomized study of total abdominal, vaginal, and
laparoscopic hysterectomy. Int J Gynecol Obstet
from the upper vagina, and the specimen excised. The
2003;83:37-43.
vaginal angles, incorporating the lateral vagina, infe- 5. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I.
rior cardinal ligaments, and uterosacral ligaments were Outcomes after total versus subtotal abdominal hyster-
suture ligated with 1-0 delayed absorbable suture in ectomy. N Eng) Med 2002;347:1318-1325.
Heaney transfixion stitches, and the vaginal cuff closed 6. Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient
with a series of figure-of-eight stitches of 1-0 delayed hysterectomy surveillance in the United States 2000~
absorbable suture. 2004. Am J Obstet Gynecol2008;198:34el-34e7.
CHAPTER 3

Total Vaginal
Hysterectomy
Roxana Geoffrion

INTRODUCTION salpingo-oophorectomy is also feasible vaginally in most


cases and should not be considered a contraindication
After cesarean section, hysterectomy is the second most to performing a hysterectomy via the vaginal route.
commonly performed surgical procedtae in the United
States (US) and Canada. Despite the availability of con-
servative alternatives, hysterectomy rates and indica~ PREOPERATIVE CONSIDERATIONS
lions have not changed significantly over the past few
years. A hysterectomy rate of approximately 5 per 1,000 Patients should be counseled regarding alternatives to
US patients has stayed the same since 1995. In Canada, hysterectomy, such as uterine artery embolization for
rates vary from province to province, with the highest fibroids, hormonal treatments or endometrial abla-
rates (around 5 per 1,000) in Prince Edward Island and tion for menstrual disturbances, vaginal pessaries for
the lowest rates (around 2 per 1,000) in Nunavut. prolapse, gonadotropin-releasing hormone (GnRH)
Uterine fibroids provide the most common indica- analogue or pain management for endometriosis, and
tion for hysterectomy, followed by menstrual distur~ progestins for endometrial hyperplasia. Completion of
bances, prolapse, and endometriosis. Other benign childbearing and the use of a reliable method of con-
indications include dysmenorrhea and adenomyosis, traception until surgery should be confirmed with the
cervical dysplasia, endometrial hyperplasia, and pel~ patient. A history of cervical cytology should be care-
vic inflammatory disease. Vaginal hysterectomy only fully reviewed and abnormal results should be clarified.
accounts for approximately 20% of all hysterectomies Symptomatic pelvic organ prolapse and stress urinary
in the US, as laparotomy is by far the most common incontinence should he carefully assessed before sur-
route for hysterectomy. This is different from some gery, so that the merits of concurrent surgical manage-
European countries where one out of two hysterecto- ment at the time of hysterectomy can be discussed
mies is performed transvaginally. with the patient. Hysterectomy alone is not adequate
The vaginal route is associated with decreased surgical treatment of pelvic organ prolapse. If physi-
postoperative febrile morbidity, a shorter duration cal examination is inconclusive at determining the size
of hospital stay, and a speedier patient return to nor- and shape of the uterus or is indicative of additional
mal activities when compared to the abdominal route gynecologic pathology such as an adnexal mass, a pelvic
for hysterectomy. Intraoperative complications arise ultrasound should be obtained prior to determination
with similar or lesser frequency during vaginal when of surgical approach. If menstrual bleeding is irregular
compared to abdominal hysterectomies via lapa- or excessive, an endometrial biopsy should be obtained,
rotomy or laparoscopy. Whenever possible, vaginal especially in women over 35. An endometrial biopsy
hysterectomy should be the preferred route. Bilateral should also be obtained with postmenopausal bleeding.

25
_ _ _,26 SECDON I GYNECOLOGY

Typically, a vaginal hysterectomy is feasible if the be able to discontinue them prior to surgery. In these
uterine size does not exceed the size of a 12-weekgravid patients, there is a moderate risk of venous thrombo-
uterus. Consideration should be given to the use of a embolism based on this risk factor alone, so careful
GnRH analogue preoperatively if the uterine size can be prophylaxis against deep vein thrombosis should be
reduced enough to make the vaginal approach feasible. administered. Preoperative bowel preparation is not
A very narrow (less than 90°) pubic arch can make a necessary for vaginal hysterectomy.
vaginal approach challenging. The shape of the uterus Prophylactic antibiotics should be administered
should also be assessed. If the uterus is enlarged due to prior to incision. A first-generation cephalosporin
the presence of a pedunculated subserosal fibroid float- should be the first choice, but clindamycin, erythro-
ing above it, a vaginal hysterectomy may be feasible. mycin, or metronidazole are also acceptable choices
Conversely, if the fibroids are mainly intramural and give for those allergic to penicillin or cephalosporins. An
the uterus a cannonball shape or extend too far laterally assessment of risk for deep venous thromboembolism is
or into the cervix, a vaginal approach may be extremely indicated, and given the lithotomy position and length
challenging. The vaginal surgeon can rely on a variety of of case, some prophylactic measure, whether pharma-
techniques for uterine debulking intraoperatively (such ceutical or mechanical, is usually appropriate. We use
as bivalving. coring. and sequential myomectomy); sequential compression devices applied prior to surgery
however, these only become available once the uter- and maintained intraoperatively and postoperatively
ine artery pedicles have been divided. Consequently, until the patient is fully ambulatory. Consideration
the cardinal ligaments need to be sufficiently low and should be given to simultaneous postoperative antico-
accessible for clamping vaginally to improve feasibility agulation with heparin or low molecular weight heparin
of vaginal hysterectomy for an enlarged uterus. in patients at moderate risk for deep vein thrombosis.
Patients should also be counseled regarding sal- Heparin or low molecular weight heparin should be
pingectomy and oophorectomy at the time of vaginal given to patients at high risk for deep vein thrombosis.
hysterectomy. There is some evidence to suggest sal- Following is a brief description of the surgical proce-
pingectomy may decrease the lifetime incidence of dure used (see also video: Total Vaginal Hysterect<nwy).
ovarian cancer as some of these cancers may originate
in the Fallopian tubes. Currently, one out of two US
women undergoing hysterectomy for benign disease SURGICAL TECHNIQUE
also receives prophylactic oophorectomy. Prophylactic
bilateral oophorectomy seems to be harmful prior to In preparation for vaginal hysterectomy, the ~ ~·
age 55, as there is an 8.6% excess mortality by age 80. patient is placed in comfortable dorsal lithotomy 11&1
There is decreasing benefit of ovarian conservation position, with the edge of her hips just over the edge
until the age of 75, when excess mortality for oophorec- of the operating table. Hip hyperflexion and excessive
tomy is less than 1%. external rotation are avoided to prevent injury to the
A complete physical examination should be per- femoral and sciatic nerves. The patient's lower legs are
formed preoperatively and blood work, a chest X-ray elevated to allow enough space for surgeon and assistants
and electrocardiogram, as well as other investiga- to operate comfortably. A metallic shelf or Mayo tray can
tions should be ordered depending on patient-specific be used to hold instruments close to the surgical field,
health concerns. The patient should be assessed for as space is lacking for the scrub nurse to pass required
preoperative anemia, especially if the reason for hys- instruments back and forth easily (as during abdominal
terectomy is abnormal uterine bleeding. If anemia is cases). The patient's skin is prepared with a scrub solu-
present, iron supplements or GnRH analogue are help- tion from lower abdomen to upper medial thighs bilater-
ful to correct anemia prior to surgery. In cases of severe ally; an internal vaginal scrub is also required. Surgical
anemia, preoperative blood transfusion should be con- lights are directed onto the surgical field although a head
sidered. If intraoperative blood loss is expected to be lamp may be utilized for optimal visualization.
significant, such as in the case of large fibroids, cross- A pelvic examination under anesthesia is performed
matched packed red blood cells should be available for to assess the size and shape of the uterus and any pelvic
intraoperative transfusion. In any case, a preoperative pathology including pelvic organ prolapse. The bladder
Type and Screen is prudent. Drugs and supplements is emptied. Some surgeons prefer to leave a Foley cath-
that increase the risk of surgical bleeding should be eter in place for intraoperative bladder drainage, while
discontinued prior to surgery. Patients taking oral others prefer to perform the surgery with a full bladder,
contraceptives for abnormal uterine bleeding may not which facilitates recognition of inadvertent cystotomy.
A weighted speculum or a Jackson retractor is placed in then incised with scalpel or cautery circumferentially
the posterior vagina and lateral vaginal retractors such {Figure 3.2). As much as possible, the cutting instru-
as curved Deavers are used to facilitate exposure. ment at the cervicovaginal junction should be held
The cervix is visualized and grasped with a Lahey perpendicular to the cut tissues. A U- or V-shaped
thyroid clamp. Alternatively, two tenaculwns, one on incision is made at the back, with the apex of the inci-
the anterior and one on the posterior cervical lip, can sion extending into the posterior vaginal fornix behind
be used for downward traction on the cervix. The cervi- the junction of the two uterosacral ligaments. If this
cal clamp as well as Deaver retractors can be moved incision is made too distal on the posterior cervix,
around during the operation to provide optimwn expo- unnecessary bleeding will be encountered as the sur-
sure. The proper use of these instruments for traction geon struggles to find the right plane for the posterior
and countertraction is essential for the correct perfor- colpotomy.
mance of the operation. Pulling the cervix upward and A traction retractor is then placed in the midline
out assists in identification of the uterosacral ligaments anteriorly to retract the bladder upward; countertrac-
at the back of the uterus. Their three-dimensional ori- tion is provided by pulling downward on the anterior
entation is 45° downward, posteriorly and lateral to the cervix. The anterior colpotomy is started by finding
cervix. Downward traction on the cervix also protects the right plane between the cervix and bladder. Dis-
the ureters during placement of clamps on the pedicles. section in this plane can be performed with Metzen-
Next, the cervicovaginal junction is infiltrated baum scissors held at 45° against the anterior cervix
with saline or a vasoconstrictive agent circumferen- and with Debakie forceps holding the anterior vagi-
tially. {Figure 3.1) This facilitates dissection in the nal mucosa up. Gende finger dissection can be used
proper plane and also acts as an internal tourniquet, to identify the proper plane. Dissection in the wrong
decreasing blood loss. The cervicovaginal junction is plane and especially too deep within the cervix causes

FIGURE 3.1 Infiltration of local anesthetic at the cervicovaginal junction.


_ _ _,28 SECDON I GYNECOLOGY

FIGURE 3.2 Circumferential incision of the cervicovaginal junction.

brisk bleeding. As the dissection progresses superiorly, On occasion, if the anterior colpotomy proves to be
the bladder is lifted anteriorly by advancing and retract~ challenging, posterior colpotomy is performed first. If
ing the anterior Deaver retractor. The dissection is the uterus is small, the surgeon can insert the index
continued beneath the Deaver with Metzenbaum scis- and middle fingers of the nondominant hand through
sors until the fihny layer of peritoneum is encountered.
The peritonewn is then cut open to accommodate the
Deaver retractor, which is advanced intraperitoneally Peritoneum
through the anterior colpotomy (Figure 3.3). Visual-
ization of bowel loops or omentum through the ante-
rior colpotomy confirms that the peritoneal cavity has
been entered. Upward traction on the Deaver is used
to retract the bladder at all times during the rest of the
vaginal hysterectomy.
For the posterior colpotomy, the surgical assistant
holding the intraperitoneal Deaver applies upward
traction on the cervix. The posterior vaginal mucosa
is grasped at the proximal incised edge between the
uterosacral ligaments, and a posterior colpotomy is
performed with curved Mayo scissors (Figure 3.4}.
The posterior incision is then extended laterally up to
the attachment of the uterosacral ligament on each
side. Hemostasis is key at this point, as the posterior
cuff frequently bleeds. Hemostasis should be veri-
fied and achieved with cautery or a running suture
to avoid unnecessary blood loss throughout the rest
of the surgery. The posterior cul-de-sac is explored
with the surgeon's finger to identify any adhesions or
other pathology. A suture placed through the perito-
neum and epithelium of the cuff helps to define the FIGURE 3.3 Anterior colpotomy achieved through 1radion
cul-de-sac. on anterior retrador and sharp dissection.
from the uterosacral ligaments to the utero-ovarian
ligaments. The role of the assistant in providing opti~
mal retraction and visualization cannot be over stated.
The anterior retractor holds the bladder anteriorly, as
previously noted. The uterosacral ligaments are again
palpated and their three-dimensional orientation iden-
tified and a posterior (weighted or Jackson) speculum
is placed over the vaginal cuff into the cul-de-sac. A
lateral retractor is placed to retract the lateral vaginal
wall on the side where the first uterosacral pedicle is to
be clamped.
The uterus is initially held upward and away from
the side where the uterosacral ligament is being
clamped. Downward traction is essential to protect-
ing the ureter, which is on average 1.4 em lateral to
the uterine artery. As the first curved clamp is applied
onto the uterosacral ligament, the posterior tip should
minimally overlap the posterior cervix, then the ante-
FIGURE 3A Posterior colpotomy achieved through sharp rior tip is brought against the anterior cervix, also
entry into the cul-de-sac. minimally overlapping the cervix, then the handle is
directed superiorly to bring both tips together as the
clamp is closed (Figure 3.5). Clamp tips should slide
the posterior colpotomy and around the uterus over the off the body of the cervix. Some surgeons use the
top of the broad ligament. The anterior bladder reflec~ fingers of the nondominant hand to guide the clamp
tion is then palpated intraperitoneally and the border tips against the cervix, while palpating to ensure that
between the bladder and the anterior aspect of the no intra-abdominal structures are being incorporated
uterus is identified. The dominant hand is then used into the pedicle. Every effort should be made to catch
to dissect at this border with scissors and penetrate the the edge of the peritoneum both anteriorly and poste-
anterior peritoneum. riorly, as this insures that the clamp is fully isolating
The uterus is removed through sequential clamp- the broad ligament through which the uterine artery
ing, cutting, and suture-ligating pedicles bilaterally passes. The surgeon holding the cervical clamp should

FIGURE 3.5 Uterosacral ligament pedicle.


_ _ _,3_0 SECDON I GYNECOLOGY

swing it downwards as the uterosacral clamp is being previously tied pedicle. In tying down sutures, the most
applied; this is to allow visualization of the anterior tip efficient use of limited space is to push down the knot
of the clamp and to ensure that the bladder has not with the surgeon's contralateral index finger posterior
been incorporated. Clamps should be closed to the to the cervix.
last notch to avoid losing the pedicles. The uterosac- After ligating the uterine vessels bilaterally, if the
ral pedicles are then cut with curved Mayo scissors or uterus is large, there are several options to decrease
scalpel down to the tip of the clamp against the cervix. the uterine volume, thereby increasing space for fur-
Transfixion sutures are used to tie the uterosacral ped- ther pedicle placement. Bivalving, intrarnyometrial
icles, which are thick and relatively avascular. A 2-0 or coring, and sequential myomectomy are all options to
larger delayed absorbable suture is appropriate. We use allow easier delivery of the uterus through the vault.
2-0 polyglactin 910 because its multifilament nature Further clamps are placed sequentially on the broad
makes it easy to tie. Once the uterosacral ligament has ligament, and pedicles are cut and suture-ligated up
been suture-ligated, the suture should be clamped and to the utero-ovarian ligaments. The uterine fundus
held, and the same process applied to the contralateral is then carefully palpated to rule out any adhesions
uterosacral ligament. New surgeons should strive to of intestine or omentum at this location. A curved
develop ambidexterity in placing clamps as it provides Rogers clamp is then used to clamp the utero-ovarian,
a significant advantage to use the ipsilateral hand when round and Fallopian tube simultaneously. This can be
the hysterectomy is challenging. accomplished in either the up-down or the down-up
Successive clamps are placed on the cardinal liga- approach, but the tips should be visualized during clo-
ments, each followed by cutting and suture-ligating the sure to prevent inadvertent inclusion of bowel. Some
pedicles (Figure 3.6). The bottom jaw of each clamp surgeons doubly clamp the utero-ovarian artery, but
is placed behind the cervix into the posterior cul-de-sac we find this overcautious and compromising of limited
and may be guided by the surgeon's nondominant index space. Both sides may be clamped before cutting the
finger to avoid clipping intraperitoneal organs. The tip pedicles (Figure 3.7). The uterus is then completely
of the anterior jaw then slides off the anterior aspect of divided and delivered to the surgical scrub nurse.
the cervix as the clamp is closed. Generous bites on The thick pedicles at the top can be free-tied first
the cardinal ligaments should be avoided, given the to bunch the pedicle. Both pedicles are then suture-
ureters run approximately 1 em superior to the uterine ligated usually using a fore-and-aft stitch. The suture
vessels within these ligaments. Each clamp is placed as ends are held carefully for assessment of hemostasis. If
close to the uterus as possible and stays medial to the visualization is hampered by the presence of protruding

Uterosacral
ligament pedicle
FIGURE 3.6 Cardinal ligament pedicle.
Right uteroovarian through the vaginal vault ipsilaterally using a free nee-
ligament pedlcl&
dle. One ann is brought through the vaginal vault ante-
rior to the pedicle, while the other is brought through
the vaginal vault posterior to the pedicle (Figure 3.8).
These sutures are then tied and held to improve visual-
ization while closing the intervening cuff. If hemosta-
sis is adequate, the vaginal vault can be closed with a
simple running suture. A running locking absorbable
suture may be preferred if there is bleeding noted at
the cuff. Vaginal packing is inadequate to prevent cuff
bleeding, and is therefore not necessary unless vagi-
nal repairs are done simultaneously. A Foley catheter
needs to drain the urinary bladder and is inserted at
the end of the procedure if an indwelling catheter has
not been used.

POSTOPERATIVE CONSIDERATIONS
Left uteroovarian After isolated vaginal hysterectomy, the patient usu-
ligament pedlcl&
ally stays in hospital overnight. The Foley catheter
FIGURE 3.7 Uteroovarian pedicle.
is removed the next morning. Sequential compres-
sion devices are maintained until the patient is fully
small bowel loops, the small bowel is packed away ambulatory. Diet should be as tolerated, with early
using a moist lap sponge. All pedicles are inspected feeding preferable and left to the patient's discre-
for hemostasis. All pedicles should nm between the tion. Postoperative pain is usually manageable with
uterosacral ligament pedicle and utero-ovarian pedicle, oral Tylenol and anti-inflammatory medication used
so gentle traction of the utero-ovarian pedicle toward alternatively every 2 hours. Narcotics are used only
the contralateral side with simultaneous traction on if required by the patient. The patient should abstain
the uterosacral pedicle provides easy visualization of all from sexual intercourse and tampon use for 6 weeks
peclicles on that side. If bleeding vessels are enconn- postoperatively. Heavy physical activities should be
tered, cautery or sutures can be used for control. Alter- avoided during this healing period.
natively, shallow figure-of-eight sutures can be used
with caution, as the ureters are always in close proxim- Operative Note
ity laterally.
Once hemostasis is confirmed, the adnexal areas are PROCEDURE: TOTAL VAGINAL
palpated for any unrecognized pathology or adhesions HYSTERECTOMY
and visualized with gende traction on the tuboovarian
peclicles. If concurrent salpingectomy or adnexectomy The patient was taken to the operating room; her
is not planned, then the utero-ovarian pedicle can be identity and the surgical plan were confirmed dur-
cut and the vaginal vault closed. ing a preoperative briefing. After the establishment of
The apical support of the vaginal vault is provided adequate anesthesia, pneumatic compression devices
by the attachments of the uterosacral ligaments and were placed and antibiotic prophylaxis initiated. She
cardinal ligaments to the cervix. Removing the cervix, was placed in a dorsal lithotomy position, and the vagi-
therefore, compromises the nonnal apical support of nal field was prepped and draped. The operative team
the vaginal vault, unless the vaginal vault is reattached completed a time out.
to these ligaments. Some surgeons accomplish this A pelvic examination was conducted under anes-
by doing a concurrent McCall culdoplasty, although thesia, checking the size and shape of the uterus, and
if this approach is pursued, cystoscopy should be any accompanying pelvic pathology. A size 14 Foley
perfonned to ensure patency of the ureters, given a catheter was placed in the bladder for bladder drain-
reported 6% rate of obstruction. A simpler approach is age. A Jackson retractor was placed in the vagina and
to take the suture anns of the uterosacral pedicle back the cervix was grasped with a Lahey thyroid clamp. The
_ _ _1, 2 SECDON I GYNECOLOGY

Sutures from
uterosacral pedicle
brought 1hough vaginal
vault, tied, and held

Running suture to
close vaginal vault

FIGURE 3.8 Cuff closure with reattachment of the uterosacral ligament to the vaginal cuff.

cervicovaginal jWlction and uterosacral ligaments were on the uterosacral ligaments were clamped and held.
identified. The cervicovaginal junction was infiltrated The cardinal ligaments were clamped, cut and suture-
with 1% lidocaine with epinephrine, and circumferen- ligated sequentially using 2-0 polyglactin 910. The
tially incised. The vesicovaginal space was developed right utero-ovarian ligament, roWld ligament, and fal-
and an anterior colpotomy was performed. A Deaver lopian tube were clamped; those on the left were then
retractor was placed into the peritoneal cavity anteri- clamped. Both pedicles were then cut, free-tied and
orly to retract the bladder. Bowel loops were visualized, suture-ligated under direct visualization of adjacent
confirming intraperitoneal location. bowel loops and bladder. The uterus was delivered to
Posterior colpotomy was then performed. A stitch of the scrub nurse, placed in formalin, and delivered to
2-0 polyglactin 910 was placed through the peritoneum the Pathology Department for detailed evaluation.
and vaginal epithelium in the midline and held. Hemo- The adnexal areas were palpated, then directly visual-
swis of the posterior vaginal cuff was achieved using ized using gentle traction on the utero-ovarian pedicles.
electrocautery. The Jackson retractor was replaced All pedicles were then inspected for hemostasis, which
over the posterior vaginal cuff. Palpation of the cul-de- was found to be adequate. The vaginal vault was then
sac, the intraperitoneal uterosacral ligaments, and the closed. First, a free needle was used to bring one arm of
uterine fundus was carried out through the posterior the held uterosacral stitch through the anterior vaginal
colpotomy. cuff and the other through the posterior vaginal cuff,
The uterosacral ligaments were clamped, cut, and bilaterally. Both stitches were held and the intervening
suture-ligated using 2-0 polyglactin 910. The stitches cuff was closed using a simple running 2-0 polyglactin
910 suture. At the end of the procedure, hemostasis 3. Canadian Institute for Health Information. www.cihi.ca
was satisfactory. The patient was then cleaned, repo- 4. Falcone T, Walters MD. Hysterectomy for benign dis-
sitioned, extubated, and transported back to Recov- ease. Obstet Gynecol2008;111(3):753-767.
ery Room in stable condition. Sponge and instrument 5. Fanning J, Valea FA. Perioperative bowel manage-
counts were correct. Estimated blood loss for this pro- ment for gynecologic surge~y. Am J Obstet Gynecol
2011;205(4):309-314.
cedure was ... There were no obvious complications.
6. Nieboer TE, Johnson N, Lethaby A, et al. Surgical
approach to hysterectomy for benign gynaecologi-
cal disease. Cochrane Database Syst Rev 2009;8(3}:
COMPLICATIONS CD003677.
7. Parker WH. Bilateral oophorectomy versus ovarian con-
Intraoperative Postoperative servation: effects on long-term women's health. J Minim
Conversion to Combined-pulmonary Invasive Gynecol2010;17(2):161-166.
laparotomy-4% complications, return to 8. Parker WH, Broder MS, Liu Z, Shoupe D, Farquhar C,
OR, wound dehiscence, Berek JS. Ovarian conservation at the time of hys-
hematoma-2% terectomy for benign disease. Obstet Gynecol
2005;106(2):219-226.
Major hemorrhage
9. Stang A, Merrill RM, Kuss 0. Hysterectomy in Germany:
{req. transfusion)-3%
a DRG-based nationwide analysis, 2005-2006. Dtsch
Bladder injury-I% Arztebl Int 2011;108(30):508-514.
10. Thompson JD, Warshaw J. Hysterectomy. In: Rock JA,
Jones Howard W III, eds. TeLinde's Operative Gynecol-
ogy, 9th edition. Philadelphia, PA: Lippincott Williams &
Suggested Reading Wilkins; 2003:771-854.
I. AGOG Practice Bulletin 14. Management ofAnovulatory 11. Van Eyk N, van Schalkwykj; Infectious Diseases Com-
BlMding. Washington, DC: ACOG; 2000. mittee. Antibiotic prophylaxis in gynaecologic proce-
2. Camarmi M, Mistrangelo E, Febo G, Ferrero B, Deltetto F. dures. J Obstet Gynaecol Can 2012;34(4}:382-391.
Prophylactic bilateral oophorectomy during vaginal hys- 12. Wu)M, Wechter ME, Geller EJ, Nguyen TY. ViscoAG.
terectomy for benign pathology. Arch Gynecol Obstet Hysterectomy rates in the United States, 2003. Obstet
2009;280( 1):87-90. Gynecol2007;110:1091-1095.
CHAPTER 4

Total Laparoscopic
Hysterectomy
Robert E. Bristow

INTRODUCTION increasing. This chapter describes one variation of the


surgical approach to TI..H.
Reich and colleagues reported the first case of laparo~
scopically assisted vaginal hysterectomy in 1989. Since
that time, the use of laparoscopy to perform hysterec- PREOPERATIVE CONSIDERATIONS
tomy has increased concordant with the evolution of
surgical techniques and instrumentation. There are A number of laparoscopic instruments have been
several subdivisions of '1aparoscopic hysterectomy" developed to afford the laparoscopic surgeon the same
that are defined according to the extent of laparo- or similar functionality to that of open surgery. Several
scopic SUigery used to accomplish surgical removal different instruments can be used for vessel occlusion,
of the uterus. Vaginal hysterectomy (VH) assisted by including monopolar and bipolar grasping forceps,
laparoscopy includes laparoscopic lysis of adhesions Harmonic® scalpel (Ethicon Endo Surgery. Cincinnati,
or excision of endometriosis prior to vaginal hysterec- OH), stapling/cutting devices, vessel-sealing/cutting
tomy. Laparoscopically assisted vaginal hysterectomy devices (Ligasure"', Covidien, Mansfield, MA; Enseal~.
{LAVH} includes laparoscopic dissection down to but Ethicon Endo Surgery. Cincinnati, OH), and tools for
not including transection of the uterine arteries, with extracorporeal suturing.
the remainder of the dissection being done via the In preparation for TLH, all patients should undergo
vaginal approach. Laparoscopic hysterectomy (UI} a comprehensive history and physical examination,
extends the use of laparoscopy from LAVH to include focusing on those areas that may indicate a reduced
transection of the uterine arteries, while colpotomy and capacity to tolerate major surgery or the steep Tren~
division of the cardinal ligaments is performed vagi- delenbUig position necessary for pelviscopy. Routine
nally. Total laparoscopic hysterectomy (TLH) consists laboratory testing should include a complete blood
of complete laparoscopic excision of the uterus with count, serum electrolytes, age-appropriate health
laparoscopic closure of the vaginal cuff. screening studies, and electrocardiogram for women
The main advantage of laparoscopy for hysterec, aged 50 years and older. Preoperative imaging of the
tomy is to convert those cases that would otherwise pelvis (ultrasonography and computed tomography)
have to be performed via an abdominal approach to may be indicated to evaluate the extent of uterine
a minimally invasive procedure. The indications for pathology and associated anatomical changes for surgi-
laparoscopic hysterectomy are the same as those for cal planning purposes.
abdominal hysterectomy. Most minimally invasive Preoperative mechanical bowel preparation (oral
hysterectomies performed in the United States are polyethylene glycol solution or sodium phosphate solu-
either LAVH or LH, although the frequency of TLH is tion with or without bisacodyl) may facilitate pelvic

35
_ _ _,36 SECDON I GYNECOLOGY

exposure by making the small bowel and colon easier to The number and size of trocars used for TLH can
manipulate. Prophylactic antibiotics (Cephazolin 1 g, vary according to surgeon preference, but in general,
Cefotetan 1 to 2 g, or Clindamycin 800 mg} should be TLH requires a midline 12-mm port placed through or
administered 30 minutes prior to incision, and throm~ in close proximity to the umbilicus, and bilateral 5-mm
boembolic prophylaxis (e.g., pneumatic compression ports placed lateral to the lateral margin of the rectus
devices and subcutaneous heparin) should be initiated abdominis muscles. As dictated by uterine size and
prior to surgery. Following is a brief description of the pathology, a third 5~mm or second 12~mm port can be
surgical procedure used (see also video: Total Laparo- placed either midline in the lower abdomen or in the
scopic Hysterectomy). left or right upper quadrant equidistant between the
umbilical and lateral ports (Figure 4.1). Laparoscopic
suturing of the vaginal cuff usually requires a second
SURGICAL TECHNIQUE 12-mm port through which the suture and needle can
be introduced and extracted. Either a 10~ or 5~mm
~. General anesthesia is required. The patient laparoscope can be utilized through the umbilical port.
- should be positioned in low dorsal lithotomy posi~ The 5-mm scope has the advantage of being able to
tion using Allen-type stirrups (Allen Medical Systems, be temporarily relocated from the umbilical port to the
Cleveland, OH) with arms tucked. Care is taken to lateral abdominal ports for improved visualization dur-
avoid hyperextension at the elbows or external rotation ing the pelvic sidewall dissection in the presence of a
of the arms. The abdomen is prepped and a Foley cath- large myomatous uterus or broad ligament leiomyoma.
eter placed. Examination under anesthesia should pay Alternatively, a 30° laparoscope can be used instead
particular attention to uterine size and topography. Any of the 0° laparoscope for this purpose. The patient is
one of a variety of uterine manipulators can be used; placed in steep Trendelenburg position to facilitate dis-
however, using an instrument with a colpotomy ring or placement of the bowel out of the pelvis. Adhesions are
cup (e.g., V-Care®, Conmed Endosurgery, Utica, NY; taken down and normal anatomy is restored.
RUMP with KOH Colpotomizer, CooperSurgical, The lateral leaf of the broad ligament is opened
Trumbull, CT) will greatly facilitate incision of the between the round ligament and infundibulopelvic
proximal vagina. Alternatively, a laparoscopic tenacu- ligament, and the retroperitoneal space is developed
lum or transvaginal placement of a colon anastomosis- bluntly. The round ligament is cauterized and divided,
sizing instrument can be used to elevate the uterus and the lateral portion of the anterior leaf of the
during laparoscopic dissection. broad ligament is divided, incising the vesicouterine

12mm 0
0
5mm0

FIGURE 4.1 Totallaparoscopic hysterectomy: Port placement sites.


CHAPTER 4 Total Laparoscopic Hysterectomy 3lr -- - -

peritoneal reflection toward the uterine midline. Atten- traction (Figure 4.4). Cephalad displacement of the
tion is directed to the posterior lateral pelvis, and the uterine manipulator with colpotomy ring enhances
pararectal space is developed. The ureter should be visualization of bladder. Development of the bilateral
identified on the inner surface of the medial leaf of the para-vesicle spaces may also facilitate identification of
broad ligament or should be visualized transperitone- the bladder and the proper plane of dissection {vesi-
ally. The ureter is usually easier to locate at the level of covaginal space). Sharp dissection is used to carefully
the pelvic brim rather than deep within the pararectal mobilize the bladder off the anterior lower uterine
space (Figure 4.2). segment, cervix, and proximal vagina down to a level
To facilitate hysterectomy, management of approximately 1 em below the cervicovaginal junction
the adnexa should be addressed at this junc- {Figure 4.5).
ture. In the event of adnexal pathology or planned The uterine vessels are skeletonized by removing
salpingo-oophorectomy, removal of one or both adnexa excess fatty or areolar tissue. Exposure may be improved
is indicated. The infundibulopelvic ligament is grasped by incising the medial leaf of the broad ligament down
gently and placed on contralateral traction. A window to the level of the uterosacral ligament while keeping
is created in the medial leaf of the broad ligament the ureter under direct vision and retracting it laterally.
below the ovarian vessels and ventral to the ureter, The uterine vessels are coagulated and divided using a
maintaining direct visualization of the ureter. This combination of bipolar and monopolar cautery or aves-
incision can be extended to the uterine isthmus. The sel sealing-cutting device at the level of the uterine isth-
infundibulopelvic ligament is coagulated and divided mus (Figure 4.6). The cardinal ligaments are divided
using a combination of bipolar and monopolar cautery in a similar fashion down to the level of the cervicovagi-
or a vessel sealing-cutting device (Figure 4.3). If pres- nal junction (Figure 4.7}. Use of a uterine manipula-
ervation of the adnexa is planned, the fallopian tube tor with a colpotomy ring usually makes it unnecessary
and utero-ovarian ligament should be coagulated close to detach the utero-sacral ligaments from their attach-
to the uterine fundus and detached. The medial leaf of ments to the proximal vagina. If necessary, however,
the broad ligament can be incised down to a level just the utero-sacral ligaments can be divided at this point
ventral to the pelvic ureter to allow the adnexa to drop and incorporated into the vaginal cuff closure.
out of the field of dissection or be placed in the para- The colpotomy incision and extraction of the uterus
colic gutters to improve visualization. The procedure is can be accomplished in a variety of ways. This step is
repeated on the contralateral side. simplified by use of a uterine manipulator with col-
The bilateral incisions of the vesicouterine peri- potomy ring. These devices usually have a device
toneal reflection are united in the midline, and the component that occludes the distal vagina to maintain
bladder peritoneum is placed on ventral and caudal the pneumoperitoneum during colpotomy. In such

Blaclder

FIGURE 4.2. Total laparoscopic hysterectomy: The broad ligament is opened, and the ureter is clear1y
identified.
_ _ _,38 SECDON I GYNECOLOGY

Ovarian vessels
FIGURE 4.3 Total laparoscopic hysterectomy: The infundibulopelvic ligament is skeletonized, and the
ovarian vessels are coagulated and divided.

cases, the colpotomy incision can be initiated wherever branch of the uterine artery. In the absence of a vaginal
it is most convenient based on exposure, either ante- occlusive device, the anterior colpotomy incision is cre-
riorly, posteriorly, or laterally on the colpotomy ring at ated first, as subsequent anterior displacement of the
the cervicovaginal junction (Figure 4.8). The vaginal uterus will facilitate creation of the posterior colpotomy
incision is created using monopolar cautery and con- while simultaneously occlurung the anterior vaginal
tinued circumferentially around the cervicovaginal incision and preserving the pneumoperitoneum. Fol-
junction. Additional bipolar cautery may be required at lowing the circumscribing colpotomy, the uterus can be
the lateral vaginal angle to secure a descending vaginal delivered ttansvaginally, and a moist laparotomy pack

Vesicouterine
peritoneal reflection

FIGURE 4.4 Total laparoscopic hysterectomy: The vesicouterine peritoneal reflection is placed on
traction and incised.
CHAPTER 4 Total Laparoscopic Hysterectomy 39t - - - -

FIGURE 4.5 Totallaparoscopic hysterectomy: The vesicovaginal space is developed with sharp dissec-
tion, and the bladder is mobilized from the anterior proximal vagina. The colpotomy ring delineates the
cervicovaginal junction.

can be placed in the vagina to preserve the pneumo- interrupted or figure-of-eight stitches of 1-0 delayed
peritoneum during vaginal cuff closure. Alternatively, absorbable suture wtder direct vision or using an
the uterus can be left in the mid-vagina to prevent loss extended needle driving device (e.g., Carter-Thompson
of the pneumoperitoneum during closure and delivered Closure System®, Cooper Surgical, Trumbull, CT).
once the vaginal cuff is closed.
The vaginal cuff is closed laparoscopically using a run-
ning. locking stitch or series of figure-of-eight stitches of POSTOPERATIVE CONSIDERATIONS
0 or 2-0 absorbable suture in the same fashion as for
abdominal hysterectomy. Alternatively, the vaginal cuff The incidence of major complications with TI.R is 2.2%.
can be closed via the vaginal approach, although techni- Postoperative care is generally straightforward. Routine
cally this would be classified as a l.R. All laparoscopic thromboembolic prophylaxis is usually unnecessary, pro-
ports 10 mm in diameter or larger should be closed with vided the patient is fully ambulatory, and the procedure

Cervlcovaglnal

FIGURE 4.6 Totallaparoscopic hysterectomy: The uterine vessels are coagulated and divided at the level
of the uterine isthmus.
SECDON I GYNECOLOGY

cervtcc~VS.g!lnal Junction

Cardinal ligament

FIGURE 4.7 Totallaparoscopic hysterectomy: The cardinal ligament is coagulated and divided down to
the level of the cervicovaginal junction.

time was not prolonged. Diet can be advanced rapidly unless there has been a bladder injury or extensive dis-
the day of surgery. once the patient has recovered from section. Criteria for discharge include: afebrile without
the effects of anesthesia, and will allow for same-day evidence of uncontrolled infection, tolerating a normal
or next-day discharge in the majority of cases. Routine diet without nausea or vomiting. and satisfactory blad-
laboratory evaluation is unnecessary unless there has der function. The laparoscopic incision sites should
been significant blood loss or requirement for intrave- remain covered with a sterile dressing for 24 to 48 hours.
nous fluid replacement. A Foley catheter for bladder Protection of the vaginal incision is the same as for hys-
drainage may be left in place overnight for patient com- terectomy performed by any approach. and intercourse
fort or convenience. but this is not mandatory. and the should be avoided for a period of at least 6 to 8 weeks
catheter may be removed immediately postoperatively postoperatively. As with any type of laparoscopic surgery

Colpotomy ring

FIGURE 4.8 Totallaparoscopic hysterectomy: The colpotomy is created and the proximal vagina incised
circumferentially, using the colpotomy ring as a guide.
utilizing energy sources, an infrequent but important in a series of figure~of~eight stitches, with excel~
cause of postoperative morbidity is an \UU'ecognized lent reapproximation of tissue and hemostasis. The
thermal injwy to the small or large bowel, which can 12-mm laparoscopic trocar was withdrawn and the
result in delayed (48 to 72 hours} bowel perforation incision closed with a 1~0 delayed absorbable suture
and peritonitis. For this reason, patients presenting in a figure-of-eight stitch using the Carter-Thomp-
with delayed return of bowel function with abdominal son Closure System. The pneumoperitoneum was
distension, disproportionate abdominal pain, fever, and decompressed and the remaining laparoscopic tro~
leukocytosis should be carefully evaluated and observed cars were removed. Skin incisions were closed using
for signs of clinical deterioration. standard technique.

Operative Note
PROCEDURE: TOTAL COMPLICATIONS
LAPAROSCOPIC HYSTERECTOMY
• Development of the retroperitoneal spaces,
Examination under anesthesia was performed and with visualization of the ureters, and adequate
the uterine cavity was sounded to (describe findings). mobilization of the bladder &om the proximal
A uterine manipulator with colpotomy ring was placed vagina are important for minimizing the risk of
using standard technique. A 12~mm incision was ere~ urinary tract injury ( 1% to 2%).
ated in the umbilicus, and the verres needle was intro- • In the event of hemorrhage from the uterine or
duced, followed by insufflations of 2.5 L of C02 gas. ovarian vascular pedicles, avoid the indiscrirni~
The 12~mm laparoscopic trocar and trocar sheath nate use of thermal energy or blindly placing
were introduced into the abdominal cavity, followed sutures or hemo-clips. Achieve adequate
by the laparoscope. The abdomen and pelvis were visualization (suction/irrigation), identify critical
inspected with the following findings: (describe find- anatomy (e.g., ureter and bladder), and pre-
ings}. Additional 5-mm incisions were created in the cisely secure the source of bleeding.
right and left lower quadrants, lateral to the inferior • Unrecognized thermal injwy to the small or
epigastric vessels, and 5-mm laparoscopic trocars were large intestine can present as delayed bowel
introduced under direct visualization. perforation with delayed return of bowel func-
The round ligaments were grasped, and the broad tion, abdominal distension, disproportionate
ligament peritoneum was elevated and incised. The abdominal pain, fever, and leukocytosis.
retroperitoneal space was dissected and the pararec-
tal space developed, with visualization of the ureter.
A window was created in the avascular space of Graves
in the medial leaf of the broad ligament and the infun- Suggested Reading
dibulopelvic ligament was skeletonized, coagulated I. Harkki-Siren P, Sjoberg}, Kurki T. Major complications
using bipolar cautery, and divided with monopolar cau- of laparoscopy: a follow-up Pinnish study. Obstet Gyne-
tery (or a vessel-sealing device). The same procedures col1999;94:94-98.
were repeated on the contralateral side. 2. Olive DL, Parker WH, Cooper JM, Levine RL. The
The vesicouterine peritoneal reflection was incised MGL classification system for laparoscopic hysterec-
and the bladder sharply dissected off the anterior lower tomy. Classification committee of the American Asso-
uterine segment, cervix, and proximal vagina. The uter- ciation of GynWecologic Laparoscopists. JAm Assoc
ine vessels were then coagulated with bipolar cautery Gynecol Laparosc 2000;7:9-15.
and divided using monopolar cautery (or coagulated 3. Parker WH. Total laparoscopic hysterectomy. Obstet
and divided using a vessel-sealing device). The cardi- Gynecol Clin North Am 2000;27:431-440.
nal ligament was taken down in a similar fashion to 4. Reich H. Totallaparoscopic hysterectomy: indications,
techniques, and outcomes. Gun Opin Obstet Gynecol
the cervicovaginal junction. The same procedures were
2007;19:337-344.
repeated on the contralateral side. 5. Reich H, DeCaprio J, McGlynn F. Laparoscopic hyster~
A colpotomy was created using monopolar cau- ectomy. J Gynecol Surg 1989;5:213.
tery, and the cervicovaginal junction was circum- 6. Walsh CA, Walsh SR, Tang 1Y. Slack M. Total abdomi~
ferentially incised. The uterus, tubes, and ovaries nal hysterectomy versus totallaparoscopic hysterectomy:
were extracted transvaginally and intact. The vaginal a meta~analysis. Eur J Obstet Gynecol Reprod Bioi
cuff was closed with 2-0 delayed absorbable suture 2009;144:3-7.
CHAPTER 5

Laparoscopic Supracervical
Hysterectomy
Frank Tu

INTRODUCTION PREOPERATIVE CONSIDERATIONS


Hysterectomy is performed for a wide variety of female Initial workup of a uterine disorder such as sympto,
health indications, including symptomatic uterine matic uterine leiomyoma or menorrhagia should fol-
fibroids, uncontrolled uterine bleeding, persistent pel- low normal practice, including a history, physical
vic pain, and malignancy. In the United States, most exam, laboratory studies, and appropriate imaging.
hysterectomies continue to be performed by an abdom- A preoperative endometrial biopsy; when appropriate,
inal approach. However, laparoscopic approaches to may also reduce the risk of morcellating a malignant
hysterectomy need to be understood better, due to uterus. However, even with a rapidly enlarging uterus,
their improved recovery, reduced infection risk, and the risk of an undetected sarcoma is estimated at less
faster recovery relative to abdominal hysterectomy. than 0.1 %. Documentation of an up-to-date normal pap
The technique of laparoscopic hysterectomy has the smear, and a clear understanding of the patient's his-
same surgical risks as abdominal or vaginal approaches tory of cervical pathology; is essential. Careful patient
(see Complications box on page 50). The use of elec- selection is very important in completing a laparo-
trosurgery is more common when performing laparos- scopic hysterectomy in a timely; safe fashion. Roughly
copy, so the surgeon should strive to keep the active 80% of hysterectomies done are for uteri 12 weeks in
elements of all energy devices in clear view at all times size or less, and should not present problems for most
during the procedure to minimize the risk of an iatro- surgeons otherwise comfortable with operative laparo-
genic injwy. The reduced ability to retract tissue during scopic surgery. However, if uterine size is a concern,
laparoscopy also may be a source of increased compli- the most important issue is to determine how acces-
cations and prolonged operating time, and surgeons sible the uterine pedicles are to the laparoscopic sur-
should be aware of the number of tissue and uterine geon. A bimanual exam can determine whether the
retractors available in the modem operating room. The lower uterine segment is free, and usually the presence
decision to remove the ce:rvix or adnexa at the time of of subserosa! leiomyoma does not influence the likeli-
surgery must be individualized. However, with mod, hood of surgical success.
ern cervical screening methodology, only a minority of General contraindications to undergoing laparos-
women will need invasive cervical evaluation and far copy (cardiopulmonary compromise, history of severe
fewer a subsequent removal of the cervix after a lapa, pelvic infections, etc.) and relative contraindications
roscopic supracervical hysterectomy is performed. Per- {morbid obesity or multiple prior laparotomies, espe-
formance of a laparoscopic supracervical hysterectomy cially those involving bowel surgery} need to be consid-
may require that the surgeon be familiar with the use of ered before choosing the appropriate route of surgery,
the Iaparoscopic morcellator. but the vast majority of patients will be able to take

43
---....:M SECDON I GYNECOLOGY

advantage of the smaller incisions and faster outpatient A midline endoscopic camera (5 to 10 mm)
recovery of laparoscopic surgery. Preoperative bowel is used to guide the procedure, but can be
preparation in selected patients, based on the prefer- moved to offer alternate views, particularly of
ences of the surgeon or colorectal consultant, may be the ureters' courses. Choice of the initial entry
of value in high-risk patients where extensive bowel port needs to take into account prior surgical
dissection is anticipated. A single preoperative dose of scars, hut a midline infraumbilical or left upper
a third-generation cephalosporin as first-line prophy- quadrant (LUQ or Palmer's point) entry is the
laxis is recommended; alternatively, penicillin-allergic most commonly used. An orogastric tube should
patients can be given macrolide and aminoglycoside he used to decompress the stomach if the LUQ
combinations. Use of thromboembolic prevention approach is used. Particularly with larger uteri,
measures such as sequential compression devices, or where the fundus approaches 16-week size or
low-dose molecular weight heparin should be applied greater, a higher camera placement, usually 3 to
based on individual risk profiles. Following is a brief 4 em above the umbilicus, may afford a better
description of the surgical procedure used (see also view. The lower quadrant ports can be moved a
video: Laparoscopic Supracervical Hysterectomy). similar distance superiorly, but should still be
able to reach the lower pelvis. There are little
differences when choosing an open entry tech-
SURGICAL TECHNIQUE nique versus a closed approach, using insuffla-
tion needle preinsufflation followed by trocar
insertion, in reducing the risk of entry-associ-
a. Patient placement: With the patient in the
ated bowel or vascular injury. Surgeons should
~. dorsal lithotomy position on the operating room
use what they have the most experience with
. . table, care should be taken to ensure that the
and as dictated by the clinical circumstance.
knees, hips, and ankles are in neutral positions,
In general, we insufflate through a insufflation
with the hips slighdy ftexed, and the knees bent
needle placed through the umbilicus when it
at 90°. This will minimize the risk of nerve injury;
is accessible, even if the camera port will be
while also allowing full instrument mobility, par-
placed higher, to take advantage of the easier
ticularly when rotated low over the lower abdo-
entry into the peritoneal cavity due to the fusion
men. We prefer to pad and tuck the arms at the
of the abdominal fascia at this point.
patient's sides to reduce risk of ulnar nerve injury.
c. Retraction and initial inspection: We begin
b. Port and instrument placement: Three to
the procedure by using atraumatic graspers to
four laparoscopic ports are placed to allow full
bring the mesentery of the small bowel, the ileo-
use of endoscope, graspers, vessel sealers, and
cecal valve, and the rectosigmoid reflection of
a morcellator. Two lower lateral quadrant ports
the large bowel to above the sacral promontory,
should be placed, taking care to avoid the epi-
thus exposing the pelvic cavity. If obstructing
gastric vessels and the ilioinguinal and iliohypo-
adhesions need to he released, these should he
gastric nerves. If a suprapubic port is chosen, the
done carefully. Careful inspection of the entire
bladder can be retrofilled to identify its bound-
pelvic cavity and pelvic diaphragm should be
ary, or else a point 2 to 3 em above the symphy-
performed. Examining the peritoneum at close
sis pubis is selected. At least one I 0 em or larger
proximity to uncover occult disease should
port is usually needed for specimen retrieval.
be done first, as positive findings may dictate
We routinely use a uterine manipulator such
converting the case immediately. The ureters'
as a ZUMP'M {Cooper Surgical, Trumhall, CT),
courses should be identified next, and for com-
and define the vaginal fornices using fomiceal
plex cases, preemptive ureteral stenting may
delineation rings. Sponge sticks inserted into
facilitate identification and dissection from
the fornix are also a practical alternative when
dense periureteral scar tissue if necessary.
trying to dissect the bladder off the cervix. The
bladder is generally decompressed with a Foley d. Uterine dissection: The round ligaments are
during the entire case. Gas insuffiation tubing identified, and the uterus is retracted contralat-
attached to one of the ports allows continuous erally from the operating side. The round liga-
inflow of C02 during the case to maintain a ments can be desiccated and divided with either
pneumoperitoneum between 12 and 15 mmHg. a vessel-sealing device (monopolar, bipolar,
CHAPTER 5 Laparoscopic Supracervical Hysterectomy

ultrasonic), or they can he tied off and tran- The technique is then repeated on the contra-
sected sharply-most surgeons prefer to use lateral side, begirming with the transection of
the more efficient energy-based methods. The the round ligaments, opening of the broad liga-
broad ligament is then opened up anteriorly ment, isolation of the ovarian pedicle, and com-
and posteriorly with hhmt and sharp dissec- pletion of the bladder flap dissection.
tion parallel to the infundihulopelvic vessels as
e. Ligation of the uterine vessels: Now, with
far as needed. At this point the utero-ovarian
both uterine vessels exposed, the surrounding
ligaments (if the ovaries are to be preserved;
broad ligament tissue is skeletonized off these
Figure 5.1) or the infundibulopelvic ligaments
vessels using either electrosurgical desicca-
{if the ovaries are to he removed} are transected
tion or blunt and sharp dissection, in order to
{see also Chapter 8).
allow the ureter to pull away further laterally.
Once the utero-ovarian or infundihulopelvic
The uterine pedicle is exposed to the level of
vessels are controlled, the anterior leaf perito-
the uterosacral ligament insertion, just above
neum is opened up to begin the bladder flap,
the vaginal fornix and is readily visualized when
which is then undermined above the cervico-
a retractor is pushed cephalad transvaginally
uterine junction (Figure 5.2). This plane may
{Figure 5.4). The uterine vessels can he ligated
he harder to define in patients with a prior
at the level of the fornix either with electrosur-
cesarean section, and starting the dissection
gical clamps, or for surgeons with experience
laterally and using pressure from a forniceal
in suturing laparoscopically, a Heaney stitch
retractor placed vaginally will expose this plane
placed medial to the vessels adjacent to the
best (Figure 5.3). Dissection then exposes
cervix. Multiple bites, moving medially away
Denonvilliers vaginal fascia; for laparoscopic
from the ureter, may be necessary. The key to
supracervical hysterectomy this fascial plane
safe dissection in this area is to maintain ten-
does not need to he dissected more than 1 to 2
sion on the vaginal fornices, which not only per-
em below the level of the uterosacral ligaments
mits optimal visualization of the vessels hut also
and away from the bladder. If proceeding with
somewhat retracts the ureter laterally. Similarly,
a laparoscopic total hysterectomy, the dissec-
the contralateral uterine pedicle is desiccated,
tion of bladder should he continued caudad,
ligated, and divided. The uterus should now
away from the vaginal tissue and until the for-
turn a dusky color.
niceal delineator pushed cephalad (and which
can also be the surgeon's or assistanes fingers f. Removal of the uterus: At this point, if a total
placed transvaginally if necessary) is visible. hysterectomy is desired, the vaginal fornices are

FIGURE 5.1 Transection of the left utero-ovarian ligament with bipolar desiccating forceps.
SECDON I GYNECOLOGY

Round ligament

Left fallopian tube and avary

of broad ligament
FIGURE 5.2 With uterine fornices being defined with a vaginal retractor, the vesicouterine
peritoneal fold is developed and divided to free the bladder away from the uterus.

entered directly over the contour of a forn.iceal minimize the amotmt of thermal damage done
delineator, using an electrosurgical hook or an to the cuff as this is a speculated risk for cuff
ultrasonic shear. A laparoscopic scalpel or scis- dehiscence subsequently. If the ovaries are to
sors may also be used. but with somewhat more be removed, many surgeons suggest extracting
bleeding. The uterus can then be removed trans- them separately and laparoscopically, using a
vaginally and the cuff closed either laparoscopi- specimen bag, to avoid the accidental seeding of
cally or transvaginally. Care should be made to an occult ovarian malignancy into the pelvis.

Bladder Col1potcuny ring


Bipolar cut1ing forcep Bladder flap

FIGURE 5.3 The left anterior broad ligament is divided and bluntly dissected down to the level of
the bladder: Starting at the level of the round ligament in cases of previous scar allows identification of
the proper plane of dissection.
_ _ _ _ _ _ _ CHAPTER 5 Laparoscopic Supracervical Hysterectomy ~7,_____

Right uterine vessels Bipolar cutting forceps

FIGURE SA Right uterine vessels being ligated with bipolar desiccating forceps.

For supracervical hysterectomy, the cervix is instrument (Figure 5.5). The decision regard-
transected away from the uterine corpus, tak# ing whether to use a minilaparotomy incision
ing care to first remove any uterine manipula- versus a tissue morcellator to remove the uterus
tor that may be in place to avoid damage to the must be individualized. A reasonable rule of

Colpotomy ring
Cervix Monopolar hook

FIGURE 5.5 Uterus being transected from cervical stump using monopolar desiccation.
SECDON I GYNECOLOGY

Uterus Morcellator

FIGURE 5.6 Uterus is extracted via eledromechanical morcellation.

thumb to consider is that a morcellation of a if desired, the cervix and ovaries are removed,
uterus >700 g or > 18 week in size may take 30 any residual fragments sheared off the uterus
to 60 minutes, depending on the surgeon skill. should be retrieved to avoid the postoperative
In these cases, enlarging the suprapubic to a risk of parasitizing myomas, or worse, infection
5-cm Pfannenstiel incision may be warranted and sepsis, mobilizing the intestines to search
as an effective and efficient alternative. for hidden fragments along the pelvic gutters.
For the usual smaller, more manage- The pelvis is then carefully inspected under
able uteri, morcellation may be appropriate low-pressure conditions (around 6 mrnHg of
(Figure 5.6). An electromechanical morcel- intraabdominal pressure), and the pedicles are
lator is introduced through a 10 rnm or larger examined to confirm hemostasis. If bleeding
port, and a single tooth tenaculum is used to is noted, these vessels should be isolated and
introduce the uterine corpus into the rotating desiccated. Thorough irrigation of the cavity is
blades of the morcellator (usually selected to then performed. The surgeon may choose to
speeds -1,000 rpm). The assisting surgeon place an anti-adhesive barrier or imbricating
helps guide the orientation of the specimen sutures over the cervical stump. In a totallapa-
into the extraction port so that the tissue can be roscopic hysterectomy. the cuff may be closed
fed continuously and repeatedly into the mor- either laparoscopically {extracorporeal or intra-
cellator as one would unroll a ball of yarn. Care corporeal knot-tying technique) or vaginally. It
should be taken to avoid inadvertent slippage is important to take 1 ern bites of the cuff to
of the morcellator posteriorly toward the bowel minimize the risk of cuff dehiscence. The utero-
or for the bowel to be accidentally pulled up on sacral ligaments are generally incorporated into
the uterus toward the morcellator. After uterine the comer stitches to provide preventative vault
removal, the cervix and cervical canal can be support, and we generally use figure-of-eight
desiccated to minimize the chance of postpro- stitches rather than running the cuff closed,
cedural cyclical bleeding. while other surgeons have used running barbed
suture to further simplify closure. Cystoscopy
g. Postprocedural pelvic inspedion and to detect occult iatrogenic urogenital injury may
abdominal closure: Once the uterus and, be performed at the surgeon's discretion based
CHAPTER 5 Laparoscopic Supracervical Hysterectomy

on the patient's history and the course of the were answered. A Foley catheter was placed to drain
procedW"e. When the procedure is complete, the bladder. A forniceal delineator was placed trans-
the fascia of any port larger than 10 mrn is gen- vaginally around the cervix and a uterine manipula-
erally closed. The incisions are reapproximated tor was inserted into the uterus after the cervix was
following standard teclmiques, after as much dilated to the appropriate size.
as possible of the pneumoperitoneum has been All port sites were infiltrated with bupivacaine.
evacuated. A 5-mm incision was made in the infraumbilical skin
and the subcutaneous tissue bluntly dissected down
to the fascia with a Kelly clamp. A blunt insufflation
POSTOPERATIVE CONSIDERATIONS needle was then inserted gently into the abdomi-
nal cavity and low entry pressures confirmed. Three
Most patients undergoing a laparoscopic hyster- liters of C02 gas was then insufflated to achieve
ectomy, particularly a supracervical hysterectomy, pneumoperitoneum, and continuous insufflation was
require only an overnight stay; and in some cent- continued with a preset maximum of 15 rnrnHg. A
ers patients are discharged home the same day. 5-mm atraumatic, radially dilating trocar was then
Prolonged bladder drainage in not generally nec- inserted into the abdominal cavity through the infra-
essary for patients with normal bladder function, umbilical incision and safe entry confirmed by visu-
but some may benefit from overnight drainage. alization through the laparoscope. Additional 5-mm
Postoperative pain management is usually adequately RLQ and LLQ trocars were placed through incisions
managed with nonsteroidal anti-inflammatory drugs 1 ern medial and superior to the anterior superior
and occasional oral narcotics. If necessary a patient- iliac spine (ASIS). An 11-mm port was placed 3 em
controlled analgesia pump may be useful for over- above the symphysis pubis. The patient was then
night pain control. Diet can usually be advanced as placed in Trendelenburg position. Bipolar desiccat,
tolerated and ambulation encouraged the first day. ing forceps (at 35 W) were used during the case for
Patients should be instructed to avoid vigorous activ- vessel sealing. Tissue dissection was performed with
ity for the first 4 weeks after the procedure, although a combination of blunt dissection, sharp scissor dis-
many will return to work sooner. Avoiding intercourse section, and monopolar nonmedulated current desic-
for at least 1 month after surgery is recommended, cation at 30 W.
and possibly may be longer for patients at risk for The small and large bowels were retracted above
impaired healing (i.e., diabetics, obese) to minimize the sacral promontory to expose the posterior cul-
the risk of cuff dehiscence if a total hysterectomy has de-sac. The upper abdomen and the appendix were
been performed. visualized to confirm absence of incidental pathol-
ogy. The uterus was mobilized gently to confinn that
Operative Note the uterine vessels would be accessible and that the
anterior cul-de-sac and bladder reflection could be
PROCEDURE: LAPAROSCOPIC seen. The course of both ureters was identified from
SUPRACERVICAL HYSTERECTOMY the pelvic brim and traced down to the uterocervical
junction.
The patient was taken to the operating room, where The round ligaments were desiccated and divided
her identity was confirmed. After the establishment allowing entry into the broad ligament, which was
of adequate anesthesia, pneumatic sequential corn- bluntly dissected open. The utero-ovarian ligaments
pression devices were placed in the lower extterni- were identified to be away from the ureters on both
ties and antibiotic prophylaxis initiated. Patient was sides, and were then desiccated and divided. The
placed in the dorsal lithotomy position, and a com- ovaries were left in place. The anterior bladder flap
bined abdominal and vaginal prep and sterile drape was then mobilized sharply away from the round
was performed. Arms were padded and tucked in rniJi, ligaments to the peritoneal reflection, using the vagi-
tary position, and the hip and ankles placed in neutral nal forniceal delineator as a landmark. The bladder
position and knees flexed to 90° to minimize nerve flap was carefully dissected free from the underly,
compression. The operative team completed a "time ing cervix until the plane of Denonvilliers fascia was
out" when universal precautions where reviewed, exposed. Small bleeders were desiccated and divided
including patient identification, site of surgery; and as needed. The uterine vessels were skeletonized
need for prophylactic antibiotics. Team questions sharply on both sides at the level of the uterosacral
_ _ _,5_0 SECDON I GYNECOLOGY

ligament insertion. A bipolar clamp was then used Suggested Reading


to desiccate both uterine pedicles at this site. The
1. ACOG Committee Opinion No. 388 November
uterus blanched reflecting loss of blood flow.
2007: supracervical hysterectomy. Obstet Gynecol
A monopolar hook electrode was then used to 2007;I 10: 1215-I2I 7.
amputate the uterine corpus at 50 W of cutting cur- 2. Al-Talib A, Tulandi T. Pathophysiology and possible iat-
rent. Small bleeders were desiccated subsequently rogenic cause of leiomyomatosis peritonealis dissemi-
from the cervical stump. and a bipolar clamp was nata. Gynecol Obstet Invest 20I0;69:239-244.
inserted into the cervical canal to ablate any resid- 3. Brummer TH, Seppala Tf, Harkki PS. National learn-
ual endometrial tissue. The uterine corpus was then ing curve for laparoscopic hysterectomy and trends in
fed into an electromechanical morcellator inserted hysterectomy in Finland 2000-2005. Hum Reprod
through the midline suprapubic port and removed 2008;23:840-845.
from the patient in multiple passes. The marcella- 4. Garry R, Fountain J. Mason s. et al. The eVALuate
tor blade was monitored carefully at all times during study: two parallel randomised trials, one comparing
operation to avoid incidental injury to other pelvic laparoscopic with abdominal hysterectomy, the other
comparing laparoscopic with vaginal hysterectomy. BMJ
structures. Fragments of morcellated uterus were
2004;328:129.
carefully searched for in the pelvis and in the peri- 5. Howard FM. Laparoscopic Hysterectomy. In: Rock JA,
colic gutters. and any fragments encountered were Jones HW. eds. Telituk's Operative Gyn8cology, Tenth
removed to minimize the risk of parasitic myomas Edition. Philadelphia, PA: Lippincott Walliams and
and/or sepsis. Wilkins; 20I 1:763-774.
The pelvis was deflated to 6 mmHg of intra- 6. Hur HC, Guido RS. Mansuria SM, Hacker MR, San-
abdominal pressure and all pedicles inspected for filippo JS, Lee IT. Incidence and patient characteristics
hemostasis. Thorough irrigation of the pelvis was of vaginal cuff dehiscence after different modes of hyster-
performed with normal saline and evacuated. The ectomies. J Minim Invasive Gynecol2007;14:311-3I7.
pneumoperitoneum was released and as much CO2 7. Hutchins FL Jr, Reinoehl EM. Retained myoma after
as possible was evacuated. The fascia of all 10 mm laparoscopic supracervical hysterectomy with morcella-
tion. J AmAssoc Gynecol Laparosc 1998;5:293-295.
or larger ports was closed with braided absorbable
8. Ibeanu OA, Chesson RR, Echols KT. Nieves M.
suture and the skin incisions closed with subcuticu-
Busangu F, Nolan TE. Urinary tract injury during hys-
lar stitches. All instruments were removed from the terectomy based on universal cystoscopy. Obstet Gyne-
vagina and the Foley catheter left in overnight. The col2009;1 13:6-IO.
patient was extubated and transferred to recovery in 9. Nezhat C, Nezhat F. Seidman DS. Incisional hernias
good condition. No complications were observed. after operative laparoscopy. J Laparoendosc Adv Surg
TechA 1997;7:111-115.
I 0. Parker WH, Fu YS, BerekJS. Uterine sarcoma in patients
operated on for presumed leiomyoma and rapidly grow-
ing leiomyoma. Obstet Gynecol1994;83:414-418.
COMPLICATIONS
I 1. Reich H. DeCaprio J. McGLynn F. Laparoscopic hyster-
ectomy. J Gynecol Surg 1989;5:213-2I6.
• Bowel. bladder. ureteral injwy-Infrequent (less
I2. Smith LH, Waetjen LE. Paik CK. Xing G. Trends in
than 5%)
the safety of inpatient hysterectomy for benign con-
• Pelvic infection-Infrequent (less than 5%) ditions in California, 199I-2004. Obstet Gynecol
• Major vascular injury-Rare (less than 1%) 2008;I 12:553-561.
• Hemorrhage requiring transfusion-Rare (less 13. Wattiez A, Soriano D. Cohen SB, et al. The learning
than 1%) curve of total laparoscopic hysterectomy: comparative
• Vaginal cuff dehiscence-Rare (less than 1%) analysis of I 647 cases. J Am Assoc Gynecol Laparosc
2002;9:339-345.
CHAPTER 6

Laparoscopic
Salpingostomy
Darren M. Lazare

INTRODUCTION Outcomes and subsequent pregnancy rates are equiva-


lent to laparotomy. In a review of laparoscopy versus
Ectopic pregnancy remains a potentially fatal condition laparotomy in the management of ectopic pregnancy,
affecting 2% of reported pregnancies and accounting the rates of subsequent intrauterine pregnancies were
for 9% of all maternal deaths. Etiologic factors relate 61.0% and 61.4%, and the rates of ectopic pregnancy
to distal occlusive tubal disease, resulting either from were 15.5% and 15.4%, respectively. There is conflict-
inflammatory processes, such as endometriosis and ing data in the literature regarding persistent ectopic
pelvic inflammatory disease, or arising from tubal pregnancy in patients managed laparoscopically.
scarring related to previous tubal surgery or prior Laparoscopic management can be directed at
ectopic pregnancy. The result is a physical barrier to removing the tube with the gestation, salpingectomy,
fluid and follicular transport within the tube that can or removing the gestation and preserving the tube, sal-
cause hydrosalpinx, infertility, pelvic pain, and ectopic pingostomy. Fallopian tube preservation when future
pregnancy. fertility is desired remains the primary consideration
There have been dramatic improvements in the when performing a salpingostomy. The available evi-
management of ectopic pregnancy within the last few dence does not show different postsurgical pregnancy
decades. Ultrasonography has simplified the diagnosis rates for salpingostomy compared to salpingectomy,
and has allowed earlier diagnosis that often avoids tubal although there is a theoretical advantage to maintain-
rupture and resulting hemoperitoneum. Equally impor- ing both tubes when possible. There is also no evi-
tant is the development of medical treatment regimens dence that salpingostomy has a higher rate of persistent
that utilize methotrexate. In spite of these advances, ectopic pregnancy or other postsurgical complications,
there remain circumstances where surgical manage- which makes it a viable surgical option for patients
ment is required. Methotrexate is inappropriate for requiring surgical management who are seeking pre-
ectopic pregnancies in certain tubal locations or gesta, served fertility.
tions. Surgical treatment is also necessary for up to 10%
of patients unsuccessfully treated by methotrexate.
Within the context of surgical management of ecto- PREOPERATIVE CONSIDERATIONS
pic pregnancy in hemodynamically stable patients,
a laparoscopic approach is superior to laparotomy. Salpingostomy in the setting of ectopic pregnancy is
Advantages include lesser blood loss, decreased anal- most often performed as an emergency rather than
gesic requirements, shorter duration of hospital stay, elective case. As such, preoperative bowel preparation
quicker return to normal activity, improved cosmesis, is not possible and also not indicated. There is limited
and fewer postoperative intra-abdominal adhesions. evidence that perioperative antibiotic prophylaxis is

51
_ _ _,52 SECDON I GYNECOLOGY

valuable in settings with a high surgical site infection be performed. The fallopian tube; round and utero-
rate. A first-generation cephalosporin is an appropri- ovarian ligaments; and structw'es of the pelvic sidewall
ate choice, and either clindamycin or metronidazole is including the ureter, iliac artery, and vein may then
also an acceptable choice for those allergic to penicil- be identified. Adequate visualization is often the key
lin or cephalosporins. The use of prophylaxis against determinant to successful laparoscopic surgery. The
deep venous thromboembolism should be based on an principle of triangulation also applies whereby the sur-
assessment of risk and should include as risk factors geon's instruments are located at apices that are con-
the dorsal lithotomy position and anticipated length of tralateral to the pathological fallopian tube. We suggest
the case as well as patient-specific risks. The patient bilateral lower quadrant and an umbilical port for the
should be positioned in dorsal lithotomy position with laparoscope. A suprapubic port or lower quadrant port
legs in stirrups. General anesthesia is appropriate. A ipsilateral to the lesion may be added if further retrac-
Foley catheter should be placed during the surgery to tion by the surgical assistant is required (Figure 6.2).
drain the bladder and may be removed postoperatively Initial efforts are directed to assessing bleeding and
once the patient is able to ambulate independently. optimizing the surgical field. An attaumatic grasper
such as a laparoscopic Babcock or bowel grasper and
suction-irrigator through the lower quadrant ports helps
SURGICAL TECHNIQUE to assess and evacuate the hemoperitoneum. Once the
fallopian tube is adequately visualized, it may be gently
A uterine manipulator facilitates manipulation of elevated so as to demonstrate the portion of the tube
the uterus to maximize optimal access to the adnexa containing the ectopic pregnancy or hydrosalpinx.
laparoscopically. Surgery, therefore, typically begins As a means of preventative hemostasis, some sur-
with the vaginal placement of a uterine manipulator geons advocate the use of dilute vasopressin solution
(Figure 6.1). injected into the mesosalpinx. A typical recipe involves
Upon entry into the peritoneal cavity, the patient is combining 20 IU of vasopressin with 20 to 100 ml of
placed in moderate Trendelenburg position to facili- normal saline. A spinal needle inserted directly through
tate displacement of the small bowel above the pel- the skin or insufflation needle may be used to infiltrate
vic brim. Careful inspection of the insufflation needle 10 to 20 rnl of solution into the avascular peritoneum
insertion site, upper abdomen, and pelvis may then of the mesosalpinx.
A 1- to 2-crn incision is made over the distended
portion of the fallopian tube along the antirnesenteric
border using monopolar scissors or needle-point cau-
tery (Figure 6.3). Appropriate electrocautery settings
are cutting or blended current at 20 to 70 W. Upon
entering the tubal lumen, the suction irrigator may be
used with pressurized irrigation to dislodge the ecto-
pic pregnancy (Figure 6.4}. Often, an intraluminal

FIGURE 6.1 Placement of a uterine manipulator. FIGURE 6.2 Laparoscopic port placement.
ectopic pregnancy can he successfully evacuated using
hydrodissection in this fashion. In contrast, ext:ralumi-
nal pregnancies invade the tubal muscularis and are
more challenging to excise with hydrodissection. The
exttaluminal pregnancies occur more commonly in the
isthmic portion of the tube. Surgical manipulation of
the tube in this situation will likely result in hemor-
rhage and significant sca:rring of the tube. A salpingec-
tomy may be preferable under these circumstances.
Hemostasis at the edges of the tubal incision may
be achieved by judicious application of needle-point
cautery (Figure 6. 5). Irrigation helps to confirm that
bleeding has been controlled. Primary closure of the
fallopian tube incision offers no advantage and leads to
adhesion formation. Consequently, the salpingectomy
incision is left open to heal by secondary intention
once hemostasis has been achieved.
Once the tubal site is hemostatic, the surgeon
must remove the specimen. Small specimens may be
removed through a 10-mm trocar, while larger speci-
mens can be removed through a colpotomy. Regardless
of which site is used, a specimen removal bag helps to
FIGURE 6.3 Incising the tube along the antimesenteric insure that the entire specimen is removed.
portion of the distended tube. Creation of a colpotomy is facilitated by removal
of the uterine manipulator and placement of a sponge
stick in the posterior fornix. Dipping the sponge in

FIGURE 6.4 Hyclrodissection is used to dislodge the intraluminal ectopic gestation.


_ _ _,5J, SECDON I GYNECOLOGY

methylene blue dye facilitates visualization of sponge


during creation of the colpotomy. The cul-de-sac
should be evacuated to provide good visualization of the
sponge stick pushing into the laparoscopic field infe-
rior to the posterior cervix. A 1-cm transverse incision is
made into the posterior fornix using a monopolar probe
(Figure 6.6). This allows the specimen removal bag
to be advanced into the field, where the specimen is
dropped into the bag and removed (Figure 6. 7). The
colpotomy is then closed from the vaginal field using a
2-0 polygalactin 910 suture in a figure-of-eight suture.

POSTOPERATIVE CONSIDERATIONS
For patients who are hemodynamically stable prior to
surgery, a laparoscopic salpingostomy can be performed
in a day-surgery setting as an outpatient. Prolonged
bladder drainage is generally not necessary for patients
with normal bladder function, although an indwelling
catheter is appropriate until the patient is able to ambu-
late independendy. Nonsteroidal anti-inflammatory
medication is usually adequate postoperative analgesia.
Persistent ectopic pregnancy is observed in 8.3% of
ft'I:IUI\1:. u.:» nemo:.w:.t5 15 c:u;meveo wnn mteuae•pom' patients treated by laparoscopic salpingostomy, so it is
cautery.
important to draw a serum P-hCG a week after surge:ry.
A single intramuscular dose of methotrexate is usually
successful in treating persistent ectopic pregnancy if the
~-hCG level remains elevated. Patients are generally

FIGURE 6.6 Creation of a colpotomy.


Colpotomy

FIGURE 6.7 Removal of specimen using a specimen-removal bag via the colpotomy.

advised to avoid conceiving for three cycles following an Under direct visual guidance, 5,mm ports were placed
ectopic pregnancy {see Complications box on page 56). in the right and left lower quadrant and left paraumbili,
cal area. The abdomen was de,insufflated to 15 mmHg
Operative Note and the patient was placed in moderate Trendelenburg
position. Using a blunt probe and suction irrigator, the
PROCEDURE: LAPAROSCOPIC small bowel was moved above the pelvic brim. Hem~
SALPINGOSTOMY peritoneum was evacuated using the suction irrigator.
Inspection of the left adnexa, uterus, bladder perito-
The patient was taken to the operating room, where neum and cuf,de,sac revealed normal anatomy. The right
her identity was confirmed and the planned procedure fallopian tube was identified from the uterine cornua to
reviewed during a preoperative briefing. After the estab- fimbria, and an ectopic pregnancy was noted in the ampul,
lishment of adequate general anesthesia, the patient was lary portion of the tube. A Babcock grasper was intro-
placed in a dorsal lithotomy position, and the abdominal duced through the right lower quadrant port and the right
and vaginal fields were prepped and draped. Antibiotic tube was elevated. Using a bowel grasper through the left
prophylaxis was given intravenously. The operative team lower quadrant port to stabilize the tube, monopolar scis-
completed a time,out. sors were used to create a I -ern incision on the antimes,
Xylocaine 1% with epinephrine was injected into the enteric portion of the tube over the distended ectopic site.
umbilicus. A scalpel was used to perform a 5,mm umbil, The suction irrigator with pressurized irrigation was then
ical incision and the insufflation needle with C02 gas used to dislodge the pregnancy and the tissue was placed
running was inserted into the abdominal cavity. Initial in the cul-de-sac. Needle-point cautery was then used to
insertion pressure fell to below I 0 mmHg upon entry achieve hemostasis. Irrigation of the tube demonstrated
of the needle into intra,abdominal space, confirming tubal patency and confirmed hemostasis. The products
the intraperitoneal location. Insufflation was performed of conception were removed under direct visual guidance
until the intra-abdominal pressure reached 20 mmHg. through the left lower quadrant port.
The insufflation needle was removed and a 5,mm trocar The trocars were removed under direct visual guid-
was placed through the umbilical incision. The 5,mm ance and hemostasis was observed. The pneumoperi-
laparoscope was then inserted. Inspection of the initial toneum was released, and the operating room table
trocar insertion site demonstrated an atraumatic entry. was leveled. The 5-mm incisions were closed with thin
The upper abdomen was inspected; the liver edge, gall, adhesive strips. Sponge and instrument counts were
bladder, and stomach margin appeared normal. correct after removing vaginal instruments.
_ _ _,56 SECDON I GYNECOLOGY

The patient was returned to a supine position and a randomized ttial versus laparotomy. Fertil Steril
then transferred to the recovery room in stable condi- 1991;55:911-915.
tion. She tolerated the procedure well. 7. Lundorff P, Thorburn J, Hahlin M, Kallfelt B, Lindblom B.
Laparoscopic surgery in ectopic pregnancy: a random-
ized trial versus laparotomy. Acta Obstet Gynecol Scand
1991 ;70:343-348.
COMPLICATIONS 8. Mecke H, Semm K, Preys I, et al. Incidence of adhe-
sions in the true pelvis after pelviscopic operative
Intraoperative Postoperative treatment of tubal pregnancy. Gynecol Obstet Invest
Salpingectomy Shoulder-tip pain 1989;28:202-204.
Oophorectomy Wound infection 9. Murphy AA, Kettel LM, Nager CW, et al. Operative
Laparotomy Persistent laparoscopy versus laparotomy for the management
trophoblastic tissue of ectopic pregnancy: a prospective ttial. Fertil Steril
(4-8/100} 1992;57: 1180-I 185.
Injury to pelvic viscera: lncisional hernia I 0. Pouly JL, Mahnes H, Mage G, et al. Conservative laparo-
• Enterotomy scopic treatment of 321 ectopic pregnancies. Fertil Steril
1986;46:1093-1097.
• Cystotomy
I I. Reggiori A, Ravera M, Cocozz.a E, Andreata M, Mukasa H
• Uterus
Randomized study of antibiotic prophylaxis for general
Injury to blood vessels and gynaecological surgery from a single centre in rural
Ureteral injury Africa. Br J Surg 1996;83(3):356-359.
12. Seller DB, Gutmann J, Grant WD, Kamps CA, DeChemey
AH. Comparison of persistent ectopic pregnancy after
laparoscopic salpingostomy versus salpingostomy at
Suggested Reading laparotomy after ectopic pregnancy. Obstet Gynecol
I. BrumstedJ, Kessler C, Gibson C, Nakajima S, Riddick.DH, 1993;81 :378-382.
Gibson M. A comparison of laparoscopy and laparotomy 13. Stock L, Milad M. Surgical management of ectopic preg-
for the treatment of ectopic pregnancy. Obstet Gynecol nancy. Clin Obstet Gynecol2012;55(2):448-454.
1988;7 I :889-892. 14. Sultana CJ, Easley K, Collins RL. Outcome of laparo-
2. Henderson SR. Ectopic tubal pregnancy treated by scopic versus traditional surgery for ectopic pregnancies.
operative laparoscopy. Am J Obstet Gynecol 1989;160: Fertil Steril 1992;57:285-289.
1462--1469. 15. Turan V. Fertility outcomes subsequent to treatment
3. Hulka JF, Reich H. Textbook of Laparoscopy. 3rd ed. of tubal ectopic pregnancy in younger Turkish women.
Phlladelphia, PA: W.B. Saunders; 1998. J Pediatr Adolesc Gynecol 2011;24(5):251-255. Epub
4. Kazandi M, Turan V. Ectopic pregnancy; risk factors and 2011 Jun 29.
comparison of intervention success rates in tubal ecto- 16. Vermesh M, Silva PD, Rosen GF, SteinAL, Fossum GT,
pic pregnancy. Clin Exp Obstet Gynecol. 2011;38(1): Sauer MY. Management of unruptured ectopic gesta-
67-70. tion by linear salpingostomy: a prospective, randomized
5. Koninckx PR, Witters K, Rosens J, et al. Conservative clinical trial of laparoscopy versus laparotomy. Obstet
laparoscopic tteatment of ectopic pregnancies using the Gyne col1989;73:400-404.
C01-l.aser. Br J Obstet Gynaecol1991;98:1254-1259. 17. Yao, M and Tulandi T. Current status of surgical and
6. Lundorff P, Hahlin M, Kallfelt B, et al. Adhesion for- nonsurgical management of ectopic pregnancy. Fertl
mation after laparoscopic surgery in tubal pregnancy: Steril1997;67:421-433.
CHAPTER 7

Laparoscopic Ovarian
Cystectomy for Benign
Ovarian Tumors
M. Jonathon Solnik

INTRODUCTION but there is a definite role for expectantly manag-


ing patients who have been diagnosed with an ovar-
The decision to proceed with surgical exploration in a ian incidentaloma. Large cancer-screening studies
patient with a pelvic mass should be based on present- such as the Prostate, Lung, Colorectal and Ovarian
ing symptomatology or the potential for a reproduc- (PLCO) cancer-screening trial confirmed our inability
tive cancer. Ovarian cysts represent one of the most to adequately screen populations for ovarian cancer
conunon findings encountered on pelvic examination without incurring more harm onto patients with no
and ultrasonography, and the combination of historical real disease. For the purposes of this chapter, we are
intake and physical suggestion is often sufficient to the asswning surgical management of a benign process
physician and patient with a sound working diagnosis. for which ovarian cystectomy is planned.
Not infrequently, however, do we rely on ultrasound
features to confirm the diagnosis and provide appro-
priate counseling with regard to the risk of a pelvic PREOPERATIVE CONSIDERATIONS
malignancy. Such characteristics include size > 10 em,
bilaterality, complex sonographic appearance with For surgical planning. we find it useful to have a good
solid component (especially if Doppler flow is present understanding of what potential surgical obstacles exist
within solid areas), mural nodules, or ascites. Protocols for any given patient. For example, if a patient has sig-
with more detailed and quantifiable descriptors such nificant dysmenorrhea and is found to have a homo-
as morphology indices (Mis) have been validated, and geneously complex ovarian cyst, she is more likely to
more specific imaging modalities such as magnetic res- need extensive surgical resection for advanced-stage
onance imaging {MRI) have been proposed as better endometriosis. This may require a longer operating
predictors of malignancy than transvaginal ultrasound. room booking time, preoperative consultation with a
Notwithstanding. the Agency for Healthcare Research surgeon if rectal involvement is suspected, and perhaps
and Quality {AHRQ) reported on the various testing psychological preparedness on behalf of the surgeon.
parameters surrounding different means of measuring Alternatively. if the patient is young. asymptomatic and
risk of cancer and concluded that no individual test has a complex mass suggestive of a mature cystic tera-
was superior to the other. toma {Figure 7 .I), the approach to her surgery may
Patients may be categorized based on native risk be different. Being able to provide a younger woman,
factors, the presence of pain and whether the ovar- whose ultimate goal may be to preserve fertility, with an
ian cyst was documented incidentally. It may be more accurate diagnosis and treatment plan to either remove
appropriate to triage a symptomatic patient or one the cyst or ovary itself is critical during the preoperative
with features suggestive of a malignancy to surgery, period.

57
_ _ _,58 SECDON I GYNECOLOGY

endometrioma (see Chapter 10). If possible, use


of open-access technique will facilitate retrieval of
larger cysts due to the larger fascial defect created,
especially if cyst rupture is not desired.

2. Initial pelvic assessment: Upon entry into the


peritoneal cavity. the first step should be to obtain
pelvic washings with at least 200 ml of normal saline.
This should be done in order to best evaluate for a
priori microscopic, extra-ovarian seeding should the
mass represent a cancer. After the remaining ports are
placed, comprehensive evaluation of the abdomen
and pelvis should then ensue. Assuming a benign
FIGURE 7.1 Transvaginal ultrasound of a complex adnexal
process, the focus should then turn to the cyst itself.
mass consistent wi61 a mature cystic teratoma: Note the
normal-appearing ovarian stroma with antral follicles toward 3. Restoration of normal anatomic landmarks:
the left of the image with an echogenic focus to the right, The next step should then be to restore normal anat-
consistent with nondependent fluid, most likely representing
omy if distorted by adhesions, all the while iden-
sebaceous material.
tifying the course of both ureters and the sigmoid
colon, rectum, and larger vessels. Most ovarian or
If there is any concern of a possible malignancy, tubal adhesions may be dissected bluntly. but if
preoperative referral to and evaluation by a gynecologic more dense, then sharp dissection with minimal en-
oncologist is highly reconunended since the original plan ergy application may be required (see Chapter 24).
of an ovarian cystectomy may subsequently become a Once freed from its attachments, the ovarian cys~
staging procedure whereby preserving reproductive func~ tectomy can then be performed.
tion may or may not be an option. Involving the oncolo-
gist early in the process will ensure a more rapid response 4. Ovarian cystectomy: In general, once the ovar-
if malignancy is suspected or encountered at surgery. ian cyst is freed from surrounding adhesions
As indicated above, notwithstanding the technologies (Figure 7.2) in smaller cysts, an ovarian epithelial
we currently have in place, the ability to correctly pre- (cortical) incision should be directed along the lon-
dict cancer risk is imperfect, and an occult malignancy gitudinal axis of the ovary to avoid extension toward
may be uncovered during surgezy. How the gynecologist larger vessels (Figure 7.2b). We typically recom-
approaches mese varying scenarios changes based on mend use of cold scissors to incise the ovarian epi-
the environment where he or she works, along with the thelium since it minimizes injuzy to functional repro-
ready availability of an oncologist. If at the time of initial ductive tissue and allows clear access to the correct
surgical inspection, there is a suggestion of malignancy, surgical planes. In contrast to removal of an endo-
obtaining pelvic washings and terminating the proce- metrioma (see Chapter 30), the enucleation of a be-
dure may be warranted without addressing the mass if it nign ovarian cystectomy is relatively more simple.
appears unruptured. This will allow for expedited referral Alternatively. if the cyst is larger, and the amount of
and reoperation by the appropriate surgeon. If, however, thinned out and fibrotic ovarian epithelium overlying
the process appears to be disseminated, then biopsy of the cyst is significant, it may be preferable to incise
suspicious lesions should also be performed. In the ideal the cyst circumferentially at the interface between
setting, when an intraoperative oncology consult is avail- the normal ovarian cortex and the fibrotic epithelium,
able and preferably has been planned, and the patient thereby minimizing the amount of fibrotic material
appropriately counseled and consented, then staging left attached to the remaining ovazy (Figure 7 .2c).
could be performed concomitantly. In most cases, the epithelium overlying the cyst
can be incised superficially using cold scissors,
needle-tip cautery, or laser at what appears to be
SURGICAL TECHNIQUE the area where the ovarian cyst protrudes from the
ovary and the overlying ovarian cortex is evident.
1. Port and instrument placement: Initial port Once the ovarian cortex alone is incised superfi-
placement depends on the location and size of the cially at this site, the underlying cyst wall will be
mass, similar to when treating a patient with an readily visualized beneath. In this situation, the cyst
CHAPTER 7 Laparoscopic Ovarian Cystectomy for Benign Ovarian Tumors 59t - - - -

Right ovarian tumor


Left Right
round liga~nent round ligament

Right
Cyetwall I'OUfldllgament

I
FIGURE 7.2 Large right·sided ovarian cyst: (A). The normal ovarian epithelium is stretched as the
underlying neoplasm enlarges. (B). In smaller cysts, a longitudinal incision is made over the distal side of the
cyst, readying it for enucleation. (C). If the cyst is larger, and the amount of thinned out and fibrotic ovarian
epithelium overlying the cyst is significant, it may be preferable to incise the cyst circumferentially at the
interface between the normal ovarian cortex and the fibrotic epithelium, thereby minimizing the amount of
fibrotic material left attached to the remaining ovary. (Continued)
- - - !61) SECDON I GYNECOLOGY

Normal
ovarian cortex

c
FIGURE 7.2 (Continued)

wall should be grasped, and the cyst dissected away a suction/irrigation device may also facilitate this
from the overlying ovarian cortex in a careful cir~ dissection, since pressurized liquid will only travel
cumferential fashion. Less commonly. particularly along easily identifiable planes. Although a smaller
in those women with larger cysts, more pericystic epithelial incision may be more desirable to reduce
fibrosis may have occurred and the cyst wall and the risk of injuring the ovarian cortex and adhesion
ovarian capsule may be fused more extensively. in formation, it will also limit the surgeon's ability to
which case it may be necessary to resect back this enucleate larger cysts.
layer using cold scissors (to avoid fusing the layers Ovarian cystectomy should be a relatively blood-
by cauterization) until two distinct layers (ovarian less procedure if the correct planes are identified
cortex and cyst wall) are observed. In this situation, at the beginning (Figure 7.4). Surface capillaries
the risk of cyst rupture during resection increases may bleed, but typically stop without intervention,
significantly. whereas vessels within the cortex of the ovary may
Once the plane between the ovarian cortex and bleed more vigorously and may require energy to
the cyst wall is visualized, the two layers need to be control loss and minimize surface clots, which may
separated gently. dissecting the cyst wall from the influence adhesion formation. Hilar vessels do not
surrounding normal ovary. This process should be penetrate ovarian cyst walls, and so it is a common
done in a careful and organized manner, working cir- misconception that dissection of cysts approximat-
curnferentially; in an attempt to minimize the risk of ing this portion of the ovary poses added risk of
cyst rupture, particularly in the setting of a complex bleeding. If the correct planes are developed and
cyst or a mature cystic teratoma. Finally (see below), followed, excess bleeding will not occur.
if the cyst ruptures, the plane between the ovarian
cortex and the cyst wall is often readily evident at 5. Managing ovary cyst rupture and spillage:
the site of original incision transection (Figure 7.3 ). The risk of intraoperative spillage of cystic contents,
Once the plane between the ovarian cortex and more common when addressing an adnexal mass
the cyst wall is identified, one technique to free laparoscopically; should always be considered. This
the cyst wall from the ovary is to advance atrau- risk seems to increase with the size of the mass, al-
matic graspers into the undissected plane, open- though size alone should not prevent a skilled sur-
ing and withdrawing them. Aqua-dissection with geon &om approaching a cyst laparoscopically. Aside
cortex
FIGURE 7.3 If cyst rupture occurs. contained drainage with a suction probe placed from anterior
to posterior into the rupture site should be perfonned: The surgical planes between the ovarian cor-
tex and underlying cyst wall can now be more readily identified.

from the risk of upstaging a patient with a confined although none have been consistently proven. These
ovarian malignancy; there are other reasons that ex- include the development of pseudomyxoma peritonei
posure to cyst contents may increase morbidity, in patients with mucinous cystadenomas, most often

Right ovarian
cortex
FIGURE 7.4 Using a toothed grasped to manipulate the cyst wall. traction and countertraction
techniques are used to enucleate the cyst wall: Following the correct surgical planes, identified early in
the dissection. will minimize bleeding.
- - - !62 SECDON I GYNECOLOGY

encountered in patients having experienced preop- complex or solid components can then take place
erative cyst leakage, and foreign body reaction or in- without the risk of added peritoneal exposure, and
flammatory adhesiogenesis in patients with ruptured can be done with larger, hand-held instruments.
or leaking mature cystic teratomas. Alternatively, a colpotomy incision may be created
Regardless of what the cyst represents, enucle- with passage of a retrieval bag and delivery through
ation is facilitated with an intact cyst. However, if the vagina.
the cyst is simple and extremely large, intentional 7. Final inspection and closing steps: Once
rupture with contained drainage allow for easier the cyst has been delivered, reinspection of the
retrieval once resected from the ovarian cortex. ovarian defect should take place to ensure a he-
Some surgeons describe placing the secondary mostatic cortex. Intermittent bursts of bipo-
trocars directly into the ovarian cyst to allow for lar energy can be used to stop discrete areas of
a larger portal for drainage. However care should bleeding, but we recommend minimal energy ap-
be taken to avoid the trocar slip sliding upon entry plication to preserve maximum ovarian function.
and inadvertently perforating viscera. Less entry Once the surgical site is hemostatic and all irri-
force is typically used with newer, bladeless tro- gation used has been suctioned from the upper
cars, also limiting the ability to penetrate the ovary abdomen and pelvis, adhesion barriers such as
upon entry. Larger gauge needles may also be used Interceed® absorbable adhesion barrier (Ethicon
if attached to suction to slowly drain larger cysts Inc., Sommerville, NJ) can be wrapped around
with somewhat less spillage. Regardless of how the ovary to minimize the development of peri-
this is accomplished, if there is a fluid component ovarian adhesions (Figure 7.5), although in most
to the cyst, the contents should be collected sepa- cases no anti-adhesive is necessary. That said, ad-
rately for cytology if indicated. herence to microsurgical principles, with careful
If unplanned cyst rupture does occur, copi- tissue handling, minimal suture placement and
ous irrigation and removal of all visible contents, tissue cautery/desiccation/strangulation, careful
including careful inspection of the pericolic gutters, hemostasis, and appropriate and continuous irri-
should be performed. Keeping the aperture of the gation, remains the primary modality for reducing
cyst as anterior as possible, preventing extension of risk of postoperative adhesion formation.
the opening and placing the suction probe into the
cyst and draining the fluid component should all be
considered. If possible, placement of a retrieval bag POSTOPERATIVE CONSIDERATIONS
around the ovary may limit the degree of exposure
to cyst content for the duration of the procedure, Intra- and postoperative complications are infrequent
and can even be done while enucleating the cyst (see Complications box on page 64). Laparoscopic
itself. If at the time of rupture the cyst wall is clearly management of benign ovarian pathology should be
identified at the rupture site, traumatidtoothed considered an outpatient procedure, and few patients
graspers may be used to retract the cyst itself to require anything other than typical postsurgical follow-
avoid slippage. up. Subsequent imaging should be left to the discretion
of the surgeon, but if the cyst was felt to be completely
6. Removal of the ovarian cyst from the enucleated, then we do not typically perform a follow-
abdomen: Retrieval of the enucleated cyst often up ultrasound unless the patients present with new
poses the most frustrating portion of this procedure. symptomatology.
If large and unruptured, the retrieval bag should be
introduced and placed underneath the cyst so that Operative Note
by simple elevation of the bag anteriorly, the cyst
is scooped into the bag. We find it most useful to PROCEDURE: LAPAROSCOPIC
then deliver such cysts through open laparoscopic OVARIAN CYSTECTOMY FOR
technique since the fascial defect is often greater BENIGN OVARIAN TUMORS
than 2 em and is easily extendable while maintain-
ing the ability to conceal the incision. The cyst, The patient was taken to the operating room after
if unruptured, can then be intentionally ruptured proper informed consent was obtained. She was placed
with a scalpel and a suction probe placed over the in dorsal supine position and underwent successful
incision used to contain the drainage. Morcellating induction of general endotracheal anesthesia. Her legs
FIGURE 7.5 Placement of adhesion barriers should be considered, but adherence to microsurgi-
cal techniques may be all that is needed to minimize postoperative adnexal adhesion formation.

were placed in Yellofin stirrups and her arms tucked evidence of other insertional injuries were noted. We
appropriately to her side. She was prepped and draped could also see that there were no underlying injuries
in sterile fashion and time-out was then performed. to the bowel or blood vessels. Ancillary trocars were
Attention was first turned to the pelvis where a Foley then placed, first with 11-mm hladeless trocar in the
catheter was placed in the urinary bladder, followed by umbilicus proper, followed by three other 5-mm blade-
placement of a side-opening bivalved speculum into less trocars (two in the lower quadrant, lateral to the
the vagina. A single-tooth tenaculum was placed along epigastric inferior gastric vessels, and one between the
the anterior lip of the cervix to then allow for place- pubic symphysis and umbilicus). All had balloon-stay
ment of a uterine manipulator. devices to keep them within the peritoneal cavity given
We then turned our attention to the abdomen her high body mass index.
where, after orogastric suction was applied, we ini- The patient was then placed in Trendelenburg
tially attempted to obtain peritoneal access through a position and the procedure then continued. The
left upper quadrant entry; however, due to the obese right ovary was elevated and clearly appeared to con-
habitus of the patient it was difficult to confinn entry. tain a dermoid. Pelvic washings were obtained using
After a insufflation needle was placed, negative aspira- approximately 200 ml of normal saline. Using manop-
tion was performed, hut opening pressures remained alar scissors, the ovarian epithelium was incised along
7 to 8 mmHg. I was not comfortable with these pres- the long axis of the ovary to allow for eventual enucle-
sures, at which point we attempted access through the ation. Using traction-countertraction techniques with
umbilicus, and in a similar fashion opening pressures the suction irrigator device, multiple cystic structures
remained moderately high. Direct entry with a 5-mm were ultimately enucleated, and a small amount of
optical trocar was then performed in the left upper bleeding was noted; however, it was minimal as we
quadrant, and this was done successfully. maintained proper surgical planes. Incidental rupture
Once the peritoneal cavity was entered, pneumo- of one of the cysts did occur; however, spillage was
peritoneum was created with carbon dioxide to 15 contained. Cystic content exposure was minimized
mmHg, and inspection of the pelvis and abdomen was by placing EndoCatch hags to retrieve individual or
performed. It was noted that initially the trocar had clusters of cystic lesions to keep them within the
gone through a small window in the omentum, hut no pelvis during enucleation. The left ovary was found
---!&~ SECDON I GYNECOLOGY

to be normal on visual examination and preoperative Suggested Reading


ultrasound. Despite her habitus, her end-tidal CO~
I. ACOG Practice Bulletin, Management of Adnexal
was maintained within normal limits. We eventually
Masses. American College of Obstetricians and Gyne-
lowered insufflation pressures to 12 mmHg. cologists, Number 83. Ohstet Gynecol 2007;1 I0(1):
Once all lesions were enucleated from the right 201-14.
ovary, we then extended the umbilical incision to 2. Greenlee RT, Kessel B, Williams CR, et al. Prevalence,
facilitate retrieval of the four EndoCatch bags which incidence, and natural history of simple ovarian cysts
had been placed in the pelvis and now contained cyst among women >55 years old in a large cancer screening
fragments and contents. These were retrieved without trial. Am J Obstet Gynecol2010;202:373.e1-e9.
incident. At this point a Hasson trocar was then placed 3. Myers ER, Bastian LA, Havrilesky LJ, et al. Management
into the wnbilicus to maintain pneumoperitoneum. of adnexal mass. Evid Rep Technol Assess (FuU Rep)
We then irrigated the pelvis using several liters of 2006;(130}:I-145.
room-temperature isotonic solution to remove any cys- 4. Partridge E, Kreimer AR. Greenlee RT, et al. Results
tic content that had potentially leaked or was released from four rounds of ovarian cancer screening in a
r.mdomized trial. PLCO Project Team. Obstet Gynecol
during the procedure.
2009;113:775-782.
At this point, a small amount of bipolar energy was 5. Sanfilippo JS, RockJA. Surgery for benign disease of the
used to achieve hemostasis on the left ovarian cortex, ovary. In: Rock JA, Jones Hw, eds. Telinde's Operative
where a small amount of bleeding was noted. After all Gytrecology. Tenth Edition. Philadelphia, PA: Lippincott
irrigation had been suctioned from the abdomen and Williams and Wilkins; 2011:629-647.
pelvis, we wrapped each ovary with Interceed* and 6. Smith RW; Smith A, DeSimone CP, et al. Performance of
allowed them to fall back into the cul-de-sac. The umbil- the.American College of Obstetricians and Gynecologists'
ical fascial defect was reapproxirnated with two inter- ovarian tumor referral guidelines with a multivariate
rupted 0-Vicryl sutures using a fascial closure device. index assay. Obstet Gynecol20 11 ;117: 1298-1306.
The lateral quadrant trocar sites were also removed 7. Steinkampf MP, Azziz R. Laparoscopic ovarian and
under direct visualization to assure hemostasis. Pneu- parovarian surgery. In: Azzi:z. R, Murphy AA, eds.
Pmctical Manual of Operative Laparoscopr and Hyster-
moperitoneum was released, and C02 was evacuated
oscopy-Second Edition. New York, NY: Springer-Verlag;
to the extent possible; the remaining trocars were then
1997:147-162.
removed. All skin incisions were reapproximated with 8. Valentin L, Akrawi D. The natural history of adnexal
5-0 Monocryl in interrupted fashion for later removal. cysts incidentally detected at transvaginal ultrasound
The uterine manipulator and Foley catheter were then examination in postmenopausal women. Ultrasound
removed. The patient tolerated the procedure well, and Ohstet Gynecol 2002;20: 174-I 80.
was taken to recovery in stable condition. 9. van Nagell JR Jr, DePriest PD, Ueland FR, et al.
Ovarian cancer screening with annual transvaginal
sonography: findings of 25,000 women screened. Cancer
2007; 109: 1887-1896.
COMPLICATIONS
10. Van Nagell Jr, Gershenson DM. Ovarian cancer: Etio-
logy, Screening. and Surgery. In: Rock JA, Jones Hw, eds.
• De novo pelvic adhesion formation and adhe-
Telmde's Operative Gynecology, Tenth Edition. Philadelphia,
sion reformation-Freqtumt (greater than 10%
PA: Uppincott Williams and Wilkins; 20 I I: 1307-1339.
de novo adhesion formation, and as high as 90%
adhesion reformation if severe re-existing
adhesions)
• Spill of unsuspected ovarian cancer-Infrequent
(less than 5%)
• Postoperative infection (myometritis, adnexitis)-
Infreq:uent (less than 5%)
• Hemorrhage and major vessel perforation-
Rare (less than 1%)
CHAPTER 8

Laparoscopic
Oophorectomy and
Salpingo-oophorectomy
Frank Tu

INTRODUCTION removed at the time of oophorectomy, particularly in


patients with endometriosis, functionally active ovarian
Removal of one or both ovaries, with or without the remnants may subsequently cause symptoms includ-
adjacent fallopian tube, has evolved in recent years ing pain, and can be challenging to remove. Complete
beyond the management of acute conditions such as removal of both ovaries, of course, induces surgical
ovarian malignancy or torsed adnexa to encompass pro~ menopause with all attendant issues, including poten-
phylactic suzgery for women seeking to reduce their tial bone loss, hot flashes, and increased cardiovascu-
future risk of breast and ovarian cancer. Consequently. lar morbidity, some of which may be mitigated by the
laparoscopic approaches to adnexal removal in isola- use of hormone replacement therapy. The decision to
tion, or in conjunction with hysterectomy need to be remove both ovaries must be individualized by patient,
well understood by most gynecologic suzgeons. In addi- hut computer models suggest that women under the
tion to the above-listed indications, women with per- age of 65 likely benefit more from ovarian preservation
sistent lateralized abdominal or pelvic pain will often then bilateral oophorectomy, primarily due to reduced
request removal of one or both ovaries, although lim~ cardiovascular disease. Alternatively, women testing
ited evidence exists to confirm a long-term decrease in positive for BRCA1 or BRCA2 mutations have a 15%
pain symptoms, even when a persistent mass, such as to 40% lifetime risk of developing ovarian cancer. In
an endometrioma, or recurrent painful functional ovar, these patients prophylactic salpingo-oophorectomy
ian cysts are present. This is primarily due to current reduced the risk of ovarian cancer by 80% (95% confi-
limitations in preoperatively diagnosing the root cause dence interval, 42% to 93%) in one prospective study.
of chronic abdominal~pelvic pain. Similarly, removal of
both ovaries to achieve permanent hypoesttogenism as
a treatment for endometriosis in young women with PREOPERATIVE CONSIDERATIONS
multiple prior surgeries remains controversial, as some
postmenopausal women continue to develop recurrent An initial workup of a pelvic mass generally will include
disease. a history, physical exam, and pelvic ultrasound. Certain
The technique of laparoscopic oophorectomy or sal- findings (Table 8.1) are more frequently associated
pingo-oophorectomy when done safely poses minimal with an increased risk of malignancy. Unfortunately.
surgical risks (see Complications box on page 72). recent studies still indicate that current markers are
The opening of the pelvic side wall in order to dis- inadequate to predict the risk of an ovarian malignancy,
tance the ureter from the infundibulopelvic (IP) liga- and generally between 20 and 30 surgeries for benign
ment prior to ligation should largely eliminate the risk disease are performed for every one ovarian cancer
of ureteral injury. If the entire ovarian cortex is not that is identified, if routine screening of asymptomatic

65
- - - !66 SECDON I GYNECOLOGY

Table 8.1
Ultrasonographic Features Suggestive of Ovarian Malignancy
Features Score
Sassone et al. (1991)
Inner wall structure 1: Smooth
2: Irregularities ~3 mm
3: Papillarities >3 mm
4: Not applicable, mostly solid
Wall thickness 1: Thin ~3 mm
2: Thick >3 mm
3: Not applicable, mostly solid
Septa 1: No septa
2: Thin ~3 mm
3: Thick >3 mm
Echogenicity 1: Sonolucent
2: Low echogenicity
3: Low echogenicity with echogenic core
4: Mixed echogenicity
5: High echogenicity
Based on abnormal score defined as :?:9, test characterislics for this index are as follows: sensitivity 100%, specificity 83%,
positive predictive value 37%, and negative predictive value 100%.
DePriest at al. (1994)
Volume 0: <10 cm3
1: 10-50 cm 3
2: >50-200 cm3
3: >200-500 cm 3
4: >500 cm 3
Cyst wall structure smooth 0: <3 mm thickness
1: Smooth >3 mm thickness
2: Papillary projection <3 mm
3: Papillary projection .<!3 mm
4: Predominantly solid
Septa structure 0: No septal
1: Thin septal <3 mm
2: Thick septal3 mm to 1 em
3: Solid area .<! 1 em
4: Predominantly solid
Based on abnormal score defined as ~5. test characterislics for this index are as follows: sensitivity 89%, specificity 73%,
positive predictive value 46%, and negative predictive value 96%.

postmenopausal women is performed. Certain labo, dehydrogenase, oAetoprotein, and human chorionic
ratory tests may suggest particular malignancies (ele- gonadotropin levels are associated with the presence of
vated CA-125 is associated with an epithelial ovarian genn cell tumors in younger women; elevated levels of
malignancy in postmenopausal women; elevated lactic inhibin, estrogen, or testosterone are associated with
CHAPTER 8 Laparoscopic Oophorectomy and Salpingo~opborectomy &lr -- - -

sex-cord tumors at any ag~ee Chapter 18 for more course of the epigastric vessels, and the ilioinguinal
details). and iliohypogastric nerves. If a suprapubic port is
Those patients with higher risk features may benefit chosen, the bladder can be retrofilled to identify its
from a discussion of their surgical plan with a gyne- boundary, or else a point 2 em above the symphy-
cologic oncologist; who should consider simultane- sis pubis is selected. The bladder is generally de-
ous staging at the time of oophorectomy. In addition, compressed with a Foley catheter during the entire
selected individuals who are found to have a malig- case. One 10 em or larger port is needed usually for
nancy at the time of their initial laparoscopic surgery specimen retrieval. An optional uterine manipulator
may be able to undergo the staging laparoscopically. can be placed transcervically. Gas insufflation tub-
In younger patients, the decision to perform an ovar- ing connected to one of the ports allows continuous
ian cystectomy versus an oophorectomy should con- inflow of col during the case to maintain a pneu-
sider the relative risk of occult malignancy, as spill of moperitoneum between 12 and 15 mmHg.
a confined ovarian malignancy will affect subsequent A midline endoscopic camera {5 to 10 mm)
staging and potentially the use of adjuvant chemother- guides the procedure, but it can be placed through
apy. When anticipated, the risk of chemical peritonitis other ports to offer alternate views, particularly of
following intraoperative rupture of a mature teratoma the ureter's course. Choice of the initial entry port
should be discussed with patients as well, although needs to account for prior surgical scars, but a mid-
with aggressive irrigation at the time of spill the out- line infraumbilical and left upper quadrant (Palmer's
come of this is usually favorable. point) insertion are the most typical for safe entry.
Very large masses (>15 em) may dissuade many sur- In skilled hands, there are minimal differences in
geons from proceeding with an endoscopic approach to entry-associated bowel or vascular injuries when
the ovarian mass; however, suction aspirator systems choosing an open technique versus preinsufflation
that allow decompression of a large cyst while mini- with a insufflation needle followed by trocar inser-
mizing the risk of spillage may be sufficient to allow tion. Surgeons are generally best off using what they
mobilization of the mass and exposure of the adnexal have the most experience with and as dictated by
pedicles. Similarly, general contraindications (car- the clinical circumstance.
diopulmonary compromise, history of severe pelvic
infections, etc.) and relative contraindications (morbid
2. Retraction and initial inspection: We begin by
using atraumatic graspers to bring the mesentery
obesity, multiple prior laparotomies, especially with
of the small bowel, the ileocecal valve, and the rec~
bowel surgery, or pregnancy) to undergoing laparos-
tosigmoid reflection of the large bowel above the
copy need to be considered before choosing the route
sacral promontory, thus exposing the pelvic cavity.
of surgery. However, the vast majority of patients will
If obstructing adhesions need to be released, these
be able to take advantage of the smaller incisions and
should be done carefully. Inspection of the entire pel-
more rapid recovery from laparoscopic surgery. The use
vic cavity and pelvic diaphragm at close proximity to
of a preoperative bowel prep in select patients, based
the peritoneum for occult metastatic ovarian disease
on the preferences of local colorectal surgeons, may
should be done first, as positive findings may dictate
be applicable in high-risk patients, where bowel adhe-
converting the case immediately. The ovaries should
sions and/or dissection is anticipated. Premenopausal
be inspected next, and the feasibility of removal con-
patients undergoing removal of their sole remaining
finned. Washings of the pelvic peritoneum can be
ovary, or both ovaries, need to be counseled regard-
obtained using an irrigator and held until a frozen sec-
ing the onset of acute menopausal symptoms and the
tion, if performed, is complete. The ureters' courses
potential need for hormonal replacement.
should be identified. For complex cases, preemptive
ureteral stenting may facilitate identification of the
ureter and, if necessary, facilitate its subsequent dis-
SURGICAL TECHNIQUE section from dense scar tissue.
1. Port and instrument placement: Patients 3. Dissection and specimen removal: A contra-
should be placed in the dorsal lithotomy position for laterally introduced grasper brings the ovary toward
pelvic laparoscopy. Three to four laparoscopic ports the midline and slightly caudad, placing tension
are placed to allow use of an endoscope, graspers, on the IP ligament (Figure 8.1). If the ureter can
vessel sealers, and specimen retrieval bag. Two be readily visualized posterior and distant from the
lateral quadrant ports should be placed, avoiding the IP ligament, side-wall dissection is generally not
_ __,68 SECDON I GYNECOLOGY

Round ligament

Fallopian tube I
Left avar'f I Uterus

I I
Rectosigmoid Broad ligament
lnfundlbulopelvlc ligament
FIGURE 8.1 The left ovary retracted laterally in preparation for oophorectomy.

mandated. Otherwise the broad ligament can be malignancy. In this event, lateral dissection of the
opened up lateral to the IP ligament using an ipsi- ovary is carried out by transecting the tubo-ovarian
laterally placed scissors or electrosurgical dissec- peritoneum longitudinally along the top of the ovary,
tor. The space between the IP ligament and the taking care to avoid the underlying vessels.
ureter can then he readily identified and dissocted
4. Removal of the ovary from the abdomen:
open. The fully exposed IP can he ligated either us-
With the ovary freed, a specimen hag is introduced
ing desiccating current through a bipolar forceps
into the pelvic cavity through the 10 em or larger
(Figure 8.2), or for advanced surgeons, using con-
port, and the specimen is guided into the bag in its
ventional suture ligation techniques, using a free tie
entirety (Figure 8.5), and the bag is closed. Note
followed by a fixation suture on the pedicle side and
that with larger masses (8 em or greater), preemp-
spocimen side, respectively. After transection of the
tive decompression of the ovarian mass, if fluid
IP, the cut pedicles should he inspected for bleeding.
filled, is an option. However, this should be done by
The ovary is again retracted medially and the
a surgeon familiar with using a secure cyst aspirator
broad ligament dissection is extended sharply (using
system. The aspiration points are typically first har-
sharp scissors or energy-based cutting devices) along
nessed with an open pre-tied Roeder knot, which is
the lateral aspects of the ovary until the round liga-
cinched closed below the defect after the fluid has
ment is reached, taking care to visualize and avoid
been evacuated. The opening of the bag containing
the adjacent ureter. If a salpingo-oophorectomy is to
the specimen is pulled extraperitoneally, opened
he perfonned, the tube is first desiccated cauterized
outside the skin, and further dissection or aspira-
at its insertion to the uterus and then transected
tion of the cyst is performed if necessary to reduce
(Figure 8.3 ). The lateral peritoneal incision freeing
the specimen size to lesser than the diameter of the
the ovary is made lateral and parallel to the fallopian
port incision. Eventually, the bag(s) is completely
tube. At this time the utero-ovarian ligament can be
removed. If both ovaries are to be removed, the
biWltly exposed, ligated, and transected using either
contralateral adnexa are approached in an identical
current or two ligation sutures (Figure 8.4).
fashion.
Preservation of the adjacent fallopian tube is
an option for women who continue to plan child- 5. Final inspec:tion and closing steps: The pelvis
hearing and in whom there is low suspicion for is then carefully inspected under low pressure
CHAPTER 8 Laparoscopic Oophorectomy and Salpingo~opborectomy 69t - - - -

Fallopian tube Utero-ovarian ligament

Round ligament

ligament
FIGURE 8.2. The ovarian vessels are being ligated for a left salpingo-oophorectomy with bipolar
desiccating forceps.

(around 6 mmHg), and the pedicles are confirmed at this time or later, may be necessary. When the
to be hemostatic, or ligated again if bleeding is procedure is complete, the fascia of any ports larger
noted. Based on frozen section results and preop, than I 0 mm are closed, and the skin is reapproxi,
erative discussion with the patient, further staging, mated following standard teclmiques.

Utero-ovarian ligament
Fallopian tube transec:ted Round ligament

lnfundlbulopelvlc ovary
ligament transected
FIGURE 8.3 The fallopian tube transacted at the time of left salpingo-oophorectomy. exposing
utero-ovarian vessels.
70 SEcnON I GYNECOLOGY

Round ligament

Fallopian tube
tranaactad

FIGURE lA Transection of utero-ovarian vessels at the time of left salpingo·oophorectomy.

--Endobag

FIGURE 8.5 Extradion of exdsed left adnexa into specimen bag.


POSTOPERATIVE CONSIDERATIONS Additional 5-mrn RLQ and 11-mrn LLQ trocars were
placed through incisions I ern medial and superior to the
For most patients, laparoscopic salpingo-oophorectomy anterior superior iliac spine. The patient was then placed
can be performed as an outpatient in a same-day surgery in the Trendelenburg position. Bipolar desiccating forceps
setting. If it is combined with other procedures, then were used during the case for vessel sealing (35 W), and
an overnight stay may be more appropriate. Prolonged tissue dissection was done with a combination of blunt
bladder drainage is not generally necessary for patients dissection, sharp scissor dissection, and monopolar non-
with normal bladder function. Postoperative pain is modulated current desiccation set at 30 W.
usually adequately managed with nonsteroidal anti- The small and large bowels were retracted above the
inflammatory drugs. Oral narcotics can then be used sacral promontory to expose the posterior cul-de-sac.
on an "as needed" basis for episodes of increased pain. The upper abdomen and the appendix were visualized
Patients should be insttucted to avoid vigorous to confirm absence of incidental pathology. The uterus
activity for the first week or so after the procedure. was mobilized gently to visualize both anterior and
Some may return to work within a few days; others posterior cui-de-sacs. The course of both ureters was
may need 1 to 2 weeks off. In premenopausal women identified from the pelvic brim and traced down to the
who have had all of their ovarian tissue removed, side uterocervical junction. Pelvic washings were obtained
effects such as hot flashes may present acutely, and with a laparoscopic irrigator and then held until the fro-
use of estrogens, with (if uterus is present} or without zen specimen was returned.
progestins, can be highly effective. The left ovary was identified again as having a per-
sistent ovarian mass. It appeared to be sufficiently
Operative Note mobile to permit removal without excessive risk of
rupture. The ovary was then placed on tension to
PROCEDURE: LAPAROSCOPIC expose the IP ligament. A plane between the ureter
OOPHORECTOMY AND and the IP ligament was identified and sharply dis-
SALPINGO-OOPHORECTOMY sected open. The lateral aspect of the IP ligament
was likewise sharply divided from the broad liga-
The patient was taken to the operating room, where ment. The exposed IP pedicle was then desiccated
her identity was confirmed. After the establishment and divided using bipolar cutting forceps. Pulling
of adequate anesthesia, she was placed in the dorsal the ovary medially, it and the adjacent fallopian tube
lithotomy position, pneumatic sequential compres- were freed by incising the lateral peritoneum. The
sion devices were placed over the lower extremities, a utero-ovarian ligament and tubouterine insertion
combined abdominal and vaginal prep and drape was were desiccated and divided with bipolar cutting for-
performed. Arms were padded and tucked in military ceps. The freed ovary and tube was then placed into
position, the hip and ankle joints were placed in neutral an endoscopic specimen bag inserted through the
position, and the knees were flexed to 90° to minimize 11 mm port, and the bag was exteriorized through the
nerve compression. The operative team completed a skin. A needle was placed through the open end of
time-out. A Foley catheter was placed in the bladder. the bag and the ovarian cyst decompressed, allowing
A uterine manipulator was inserted into the uterus the specimen bag to be removed fully. It was sent for
after the cervix was dilated to the appropriate size. frozen section and returned as a benign tumor. The
All port sites were infiltrated with bupivacaine. washings were discarded.
A 5-mrn incision was made in the infraumbilical skin, and The pelvis was deflated to 6 mmHg and all pedicles
the subcutaneous tissue was bluntly dissected down to the inspected for confi.nned hemostasis. Thorough irriga-
fascia with a Kelly clamp. A blunt insufflation needle was tion of the pelvis was done with normal saline and all
then inserted gently into the abdominal cavity through the fluid evacuated. The pneumoperitoneum was released
umbilicus and low entty pressures were confumed. Three and as much C02 evacuated as possible. The fascia
liters of C02 gas was then insufflated into the abdomen of all 10 mm or larger ports was closed with braided
to achieve a pneumoperitoneum, and insufflation was absorbable suture and the skin incisions closed with
continued with a preset maximum of 15 nunHg. A 5-nun subcuticular stitches. All instruments were removed
atraurnatic radially dilating trocar was then inserted into from the vagina and the Foley catheter removed. The
the abdominal cavity through this site, and safe entry patient was extubated and transferred to recovery in
was confirmed by visualization through the laparoscope. good condition.
SECDON I GYNECOLOGY

dermoid cyst prevent granulomatous peritonitis? BJOG


COMPLICATIONS 2010;117:1027-1030.
4. Magtibay PM, Nyholm JL, Hernandez JL, Podratz
• Bowel, bladder, ureteral injury-Infrequent (less KC. Ovarian remnant syndrome. Am J Obstet Gynecol
than 5%) 2005;193:2062-2066.
• Major vascular injury-Rare (less than 1%) 5. Parker WH, Broder MS, Liu Z, Shoupe D, Farqu-
• Pelvic infection-Rare (less than 1%) har C, Berek JS. Ovarian conservation at the time
• Dissemination of unsuspected ovarian of hysterectomy for benign disease. Obstet Gynecol
malignancy-Rare (less than 1%) 2005;106:219-226.
6. Partridge E, Kreimer AR. Greenlee RT, et al. Results
• Hemorrhage requiring transfusion-Rare (less
from four rounds of ovarian cancer screening in a ran-
than 1%) domized trial. Obstet Gynecol2009;113:775-782.
• Ovarian remnant syndrome-Very rare (less 7. Sassone AM, Tunor-Tritsch IE, Artner A. Westhoff
than 0.5%) C, Warren WB. Transvaginal sonographic character-
• Premature menopause-Very rare (less than 0.5%) ization of ovarian disease: evaluation of a new scoring
system to predict ovarian malignancy. Obstet Gynecol
1991;78:70-76.
8. Sanfillipo JS, Rock JA. Surgery for benign disease of the
ovary. In: Rock JA. Jones Hw, eds. Telinde's Operative
Suggested Reading Gynecology, Tenth Edition. Philadelphia, PA: Lippincott
I. DePriest PD, Varner E, Powell J, et al. The efficacy of Williams and Wtlkins; 2011:629-646.
a sonographic morphology index in identifying ovar- 9. Van NageU Jr. Gershenson DM. Ovarian cancer: Etiol-
ian cancer: a multi-institutional investigation. Gynecol ogy, Screening, and Swgery. In: Rock )A, Jones HW,
Oncol1994;55:174-178. eds. Telinde's Operative Gynecology, Tenth Edition.
2. Finch A, Beiner M, Lubinski J, et al. Salpingo- Philadelphia, PA: Lippincott Williams and Wilkins;
oophorectomy and the risk of ovarian, fallopian tube, and 2011:1307-1339.
peritoneal cancers in women with a BRCA1 or BRCA2 10. Zanetta G, Ferrari L, Mignini-Renzini M, Vignali M,
Mutation. JAMA 2006;296: 185-192. Fadini R. Laparoscopic excision of ovarian dermoid cysts
3. Kondo W, Bourdel N, Cotte B, et al. Does preven- with controlled intraoperative spillage. Safety and effec-
tion of intraperitoneal spillage when removing a tiveness. J Reprod Med 1999;44:815-820.
CHAPTER 9

Marsupialization of Bartholin
Gland Cyst
M. Jonathon Solnik

INTRODUCTION benefit. Cultures, unless suspected for methicillin-


resistant Staphylococcus aureus, are not clinically use~
The Bartholin glands are bilateral glands located in ful. Simple I & D, without the placement of a Word
the vulva, normally less than 1 em in diameter, and catheter, should be avoided since this does not allow
secrete mucous to provide for vaginal lubrication. The for ongoing drainage, predisposing to recurrence.
Bartholin ducts, normally lined with transitional epi~ Either marsupialization or gland excision, represent-
thelium, open into the inner aspect of the introitus. ing more aggressive treatment of a Bartholin gland cyst,
A Bartholin gland may expand and dilate if the gland's are indicated for chronic gland cysts that are symptom-
duct becomes obstructed, most commonly after trau- atic. Marsupialization should be avoided during the
matic injury, or even after surgical repair of the poste- acute phase of infection. Marsupialization, in contrast
rior vaginal compartment; it occurs less commonly after to gland excision, preserves gland function and may
gonococcal infection. Management of women present- allow for adequate vaginal lubrication after release of
ing with symptomatic Bartholin gland cyst obstruction the obstruction.
typically depends on whether the obstruction of the
duct is acute and associated with inflammation and/or
abscess, or whether it is chronic and noninfected. Many PREOPERATIVE CONSIDERATIONS
women are not symptomatic and may not be aware of
such a cyst until noted on gynecologic examination. Marsupialization is reserved for patients with chronic,
A noninfected cyst normally ranges in size from 1 to symptomatic cysts and avoids complications associ-
3 em, does not cause pain, and may slowly regress and ated with gland excision, which is more lengthy and
re-expand over time (Figure 9.1). Alternatively, if it morbid. During the preoperative evaluation, a thorough
becomes infected, a Bartholin gland cyst can form an history should be obtained to ascertain risk factors for
abscess that will rapidly increase in size over several initial cause, postoperative complications, and potential
days and is vezy painful. In order to heal, a Bartholin recurrence. On examination, the size and location of the
gland cyst abscess usually must be drained. Acute infec, Bartholin gland should be documented, and the clinician
tion, resulting in a painful, pus-filled gland, should be should make certain that the process does indeed involve
treated by incision and drainage (I & D} and placement the Bartholin gland rather than the labia minora or other
of a Word catheter. Irrigation of the gland with sterile vaginal glands as the treatment may differ significantly.
saline and manual disruption of any loculations within Risks of the procedure should be reviewed, includ,
with a small curved clamp typically results in symptom- ing postoperative tenderness, drainage, as well as the
atic relief. Use of antibiotic irrigant or post-procedural need to refrain from coitus for at least 3 to 4 weeks to
antibiotics have not been shown to be of additional minimize irritation and trauma. The procedure should

73
SECDON I GYNECOLOGY

FIGURE 9.1 A left-sided uninfectecl Bartholin gland cyst (Figure 9.1A) can be seen best with lateral
retradion of the labia majora (Figure 9.11).

take place in an ambulatory surgery setting since away from the surrounding vaginal mucosa, in order
adequate anesthesia (local, regional, moderate seda· to better isolate the cyst and prepare it for suturing to
tion) and exposure are needed for marsupialization, as the submucosa. The cyst wall is then grasped with a
opposed to I & D and Word catheter placement, which toothed forceps and entered sharply. Once fluid con-
can easily be performed in the office setting. tents are drained and any intralocular adherences bro-
ken manually (Figure 9.3), the edges of the cyst wall
are sutured to the corresponding vaginal submucosa.
SURGICAL TECHNIQUE Several interrupted sutures of 2-0 delayed absorbable
sutures circumferentially around the edges of the open-
Patients are placed in lithotomy position using Allen ing are recommended and should not be tied under too
stirrups, and reexamination should take place once much tension, which may strangulate the submucosa
the patient is comfortable. Even if performed under and result in loosening of the sutures (Figures 9.4 and
regional or general anesthesia, local infiltration of the 9.5). In this fashion the gland opening created should
surrounding tissues with a long-acting anesthetic may remain open without a tendency to close on itself.
allow for clear planes of dissection and improved post-
operative comfort.
An elliptical incision is made overlying the cyst itself, POSTOPERATIVE CONSIDERATIONS
in the anteroposterior direction, inside the hymenal ring
{Figure 9.2). It should be of sufficient size (generally 2.5 Intra- and postoperative complications are infrequent
em in length and 1.5 em in width) to minimize the risk (see Complications box on page 77}. Routine analge-
that the opening will close with subsequent healing and sics and sitz baths (beginning 3 to 4 days post-procedure)
scar retraction. The cyst wall is identified and dissected should be prescribed. Pelvic rest should be maintained
Vaginal submucosa
Cyst wall Labia minora

FIGURE 9.2 A scalpel is used to make a 2.5 em vertical and elliptical incision overlying 1he cyst
itself, concealing the incision medial/cephalad to the hymenal ring.

for at least 3 to 4 weeks to allow for healing and minimize identified. A small amount (1 to 2 rnl) oflocal anesthetic
risk of secondary infection. Postoperative fibrosis may was used to infiltrate the medial border of the labia
occur, resulting in closure of the aperture made during minora to access the gland proper and conceal the even-
marsupialization and a recurrence of up to 10% to 15%. tual incision. Using a 15-blade scalpel, a 2 ern elliptical
incision was made inside the hymenal ring exposing the
Operative Note dilated gland wall. A mosquito clamp was used to dis-
sect the margins of the vaginal mucosa from the under-
PROCEDURE: MARSUPIALIZATION lying cyst wall, which was then entered sharply with
OF BARTHOLIN GLAND CYST the scalpel. A suction device was used to empty fluid
contents, and a small hemostat was used to confirm the
After successful induction of general anesthesia lack of loculations within the gland itself. Using several
with laryngeal mask airway, the patient was placed interrupted sutures of 2-0 braided, absorbable suture,
in lithotomy position with her legs in Allen-type the edges of the gland wall were sutured to the overlying
stirrups. She was prepped and draped, and a time vaginal mucosa to ensure sufficient opening to allow
out was performed. An in-and-out catheter was used ongoing drainage to minimize cyst reformation. Mini-
to drain her bladder. mal bleeding was encountered and no electrosurgery
The external genitalia were thoroughly examined and was needed to maintain a dry surgical field. The patient
an enlarged, 4-crn right-sided Bartholin gland cyst was tolerated the procedure well without complications.
76 SEcnON I GYNECOLOGY

FIGURE 9.3 Once the cyst is entered, the cavity is thoroughly irrigated and intralocular adherences
are broken manually or with a KeDy clamp.

FIGURE 9.4 Once irrigated, the cyst wall is sutured to the vaginal submucosa in a circumferential
fashion using absorbable suture.
FIGURE 9.5 A completed reapproximation is seen with the final suture being placed.

2. Brook I. Aerobic and anaerobic microbiology of


COMPLICATIONS Bartholin's abscess. Surg Gynecol Obstet 1989;169:32.
3. Downs MC, Randall HW Jr. The ambulatory surgical
• Recurrence-Frequent (up to 10% to 15%) management of Bartholin duct cysts. J Emerg Med
• Postoperative infection-Infrequent (less 1989;7:623.
than 5%) 4. Horowitz IR, Buscema ), Majmudar B. Surgical condi-
• Hemorrhage or major vessel perforation- tions of the Vulva. In: RockJA, Jones Hw, eds. Telinde's
Infrequent (less than 5%) Operative Gynecology, Tenth Edition. Philadelphia, PA:
Lippincott Williams and Wilkins; 2011 :480-507.
5. Thurman AR, Satterfield TM, Soper DE. Methicillin-
resistant Staphylococcus aureus as a conunon cause of
Suggested Reading vulvar abscesses. Obstet Gynecol 2008; 1 I 2:538.
L Bieker OP, Smalbraak D), Schutte MF. Bartholin's 6. Wren MW. Bacteriological findings in cultures of
clinical material from Bartholin's abscess. J Clin Pathol
abscess: the role of Chlamydia ttachomatis. Genitourin
Med 1990;66:24. 1977;30: 1025.
CHAPTER 10

Radical Abdominal
Hysterectomy
Robert E. Bristow

INTRODUCTION (Stages IA2-IIA) cervical cancer. The efficacy of


combined irradiation and low-dose chemotherapy
Radical hysterectomy is distinguished from sim~ for Stage IB2 disease has made this an uncommon
ple extrafascial hysterectomy by the dissection of indication for radical surgical treatment. Some cen-
the ureters from within the parametria and a wider ters also perform radical hysterectomy for Stage
resection of additional tissue surrounding the cer- liB cancer of the cervix. although this is rare in the
vix, usually for an early-stage cancer of the cervix. United States. Radical hysterectomy may be indi-
The first radical abdominal hysterectomy for cervi~ cated as completion surgery for patients with locally
cal cancer was performed in 1895 by John G. Clark advanced cervical cancer with centrally persistent
at the Johns Hopkins Hospital under the direction disease following definitive combined irradiation
of Howard A. Kelly. The vaginal approach to radi- and low-dose chemotherapy. Radical hysterectomy
cal hysterectomy was described by Schauta in 1902. is also a treatment option for patients with endo~
Ernst Wertheim contributed modifications to the metria! cancer extending to the cervix (clinical
procedure, and his published experience contributed Stage II disease) and may be required as part of a
greatly to the acceptance of radical hysterectomy as larger cytoreductive surgical effort for patients with
a viable treatment for women with early-stage cer- advanced ovarian cancer. The surgical principles of
vical cancer. Later modifications were introduced radical hysterectomy are also applicable to the oper~
by Okabayashi. Although recent attention has been ative management of a number of noncancerous
directed toward implementation of a more ana- gynecologic conditions including extensive endome-
tomically distinct classification system of radical triosis and uterine leiomyomata involving the cervix
hysterectomy, including nerve~sparing variants, the or lower uterine segment. Radical hysterectomy can
Piver-Rutledge classification system. introduced be performed with or without pelvic lymphadenec-
in 1974, is still commonly referenced. In practice, tomy or adnexectomy.
there are three basic variations of radical hyster- The typical route of approach to radical hyster-
ectomy. The Wertheim hysterectomy is the most ectomy is abdominal, laparoscopic, or robotically
commonly performed variant in the United States, assisted. Radical vaginal hysterectomy is uncom-
has the broadest applicability. and is described in monly performed in the United States. This chapter
the following section. The two most common varia- addressed the abdominal approach. although the same
tions are the modified radical hysterectomy and the basic principles apply whichever route is selected and
extended radical hysterectomy. are also applicable to conservative surgical approaches
The most common indication for radical hys- to early-stage cervical cancer for fertility preservation
terectomy is the surgical treatment of early-stage (radical trachelectomy).

81
82 SECTION II GYNECOLOGIC ONCOLOGY

PREOPERATIVE CONSIDERATIONS Either a low~transverse incision (Pfannenstiel, May~


lard, Cherney) or low vertical midline incision will
In preparation for radical hysterectomy, all patients provide satisfactory exposure for radical hysterectomy,
should undergo a comprehensive history and physi~ depending on patient body habitus. After abdominal
cal examination focusing on those areas that may entry and placement of a self-retaining retractor, adhe-
indicate a reduced capacity to tolerate major surgery sions are taken down, normal anatomy is restored, and
or disease~related characteristics (e.g., parametrial the bowel is packed out of the surgical field.
extension) that would contraindicate successful sur~ The uterus is elevated out of the pelvis and manipu-
gical resection. Routine laboratory testing should lated by two large Kelly clamps placed across the broad
include a complete blood count, serum electrolytes, ligament adjacent to the uterine fundus encompassing
age-appropriate health screening studies, and elec- the round ligament, fallopian tube, and utero-ovarian
trocardiogram for women aged 50 years and older. ligament on each side. The broad ligament is incised
Preoperative imaging of the pelvis and abdomen (com~ cephalad to the round ligament, and the peritoneal
puted tomography) is usually indicated to evaluate the incision extended above the pelvic brim parallel to the
extent of cervical pathology and associated extent of infundibulopelvic ligament. The common iliac artery
adenopathy for surgical planning purposes. is identified and traced distally to its bifurcation into
Preoperative mechanical bowel preparation (oral the external iliac artery and internal iliac (hypogastric)
polyethylene glycol solution or sodium phosphate artery, which courses deep along the lateral pelvic wall.
solution with or without bisacodyl) may facilitate pel- The uterine arteries originate from the hypogastric
vic exposure by making the small bowel and colon artery within the cardinal ligament. The round liga-
easier to manipulate but is not required. Prophylac ~ ment is identified and a ligature of 1-0 delayed absorb-
tic antibiotics (Cephazolin 1, Cefotetan 1 to 2 g, or able suture placed as far laterally toward the pelvic
Clindamycin 800 mg) should be administered 30 min~ sidewall as possible and held long for traction. A large
utes prior to incision, and thromboembolic prophylaxis hemo~clip (or suture ligature) is placed medially {uter~
{e.g., pneumatic compression devices and subcutane- ine side) to control back-bleeding, and the round liga-
ous heparin) should be initiated prior to surgery. The ment is divided. An incision is created in the anterior
instrumentation will necessarily vary according to leaf of the broad ligament and is continued medially
the approach selected. For abdominal hysterectomy, across the vesicouterine peritoneal reflection (or fold)
a self-retaining retractor (e .g., Bookwalter, Cadman at the junction of the lower uterine segment and cervix.
Division, Johnson & Johnson, Piscataway, NJ) with To perform radical hysterectomy safely and effi-
a fixed arm attaching the retractor ring to the operat~ ciently, six of the eight potential pelvic spaces should
ing table is advisable to optimize exposure, maximize be developed early in the operation-the paired
patient safety, and reduce surgeon fatigue. A variety of paravesical spaces, the paired pararectal spaces, the
instruments, in addition to the standard surgical arma~ vesicovaginal space, and the rectovaginal space. The
mentarium, can be used at the surgeon's discretion pararectal space is developed by carefully dissecting,
to facilitate the retroperitoneal dissection including with a finger or large Kelly clamp, between the hypo-
vessehealing devices, the argon beam coagulator, and gastric artery (laterally) and the medial leaf of the broad
surgical stapling devices. Following is a brief descrip- ligament peritoneum. The ureter is attached to the
tion of the surgical procedure used (see also video: medial leaf of the broad ligament peritoneum and is
Radical Abdominal Hysterectomy) . most easily located at the pelvic brim in the region of
the bifurcation of the common iliac artery. The ureter
should be dissected from its adventitial sheath using a
SURGICAL TECHNIQUE right angle clamp and placed within a vessel~Ioop for
traction. The paravesical space is identified by placing
Either general or regional anesthesia is accept~ upward traction on the round ligament ligature and the
able. The patient should be positioned in low lateral surface of the bladder with a Babcock clamp.
dorsal lithotomy position using Allen-type stirrups. The obliterated umbilical artery will appear as a thick
The abdomen is prepped and a Foley catheter placed. band of tissue running just lateral to the bladder, and it
Examination under anesthesia should pay particu~ demarcates the medial border of the paravesical space.
lar attention to the size and topography of the cervix, The paravesical space is developed with a finger or long
uterus, proximal vagina, parametria, and uterosacral Kelly clamp starting along the pelvic sidewall ante-
ligaments. rior to the cardinal ligament and dissecting anteriorly,
CHAPTER 10 Radical Abdominal Hysterectomy 83

External iliac artery Ureter


FIGURE 10.1 Radical abdominal hysterectomy: Development of the paravesical and pararectal spaces.

medially, and inferiorly. Both the pararectal and para- disease in the paracervical tissues. Local tumor exten-
vesical spaces are developed down to the level of the sion into the paracervical tissues is generally an indica-
pelvic floor (Figure 10.1). tion to abandon radical hysterectomy.
Depending on clinical indications, adnexectomy and The posterior leaf of the broad ligament is placed on
pelvic lymphadenectomy can be performed in conjunc- medial traction and the ureters are dissected from their
tion with radical hysterectomy. These techniques are attachments to the lateral side of the uterosacral ligaments
described in Chapters 2 and 12, respectively. If the using a right angle clamp to gently develop the correct
adnexa are to be preserved, they are detached from the plane outside the adventitial sheath. The ureter is com-
uterus and tucked into the upper abdomen. Otherwise, pletely mobilized from the medial leaf of the broad liga-
the infundibulopelvic ligaments are clamped, divided, ment peritoneum from the level of the pelvic brim down
secured with 1-0 delayed absorbable sutures, and the to its entrance into the parametrial tunnel of Wertheim
adnexa are tied to the Kelly clamps holding the uterus. {cardinal ligament). Early mobilization of the bladder will
The pelvic sidewalls are inspected and palpated for facilitate ureteral dissection through the cardinal and vesi-
evidence of metastatic nodal disease. The pelvic node couterine ligaments. The bladder is grasped at the edge of
dissection can be performed before or after the radi- the vesicouterine peritoneal incision and placed on ventral
cal hysterectomy. Clinically suspicious lymph nodes and caudad traction. Working in the midline, the electro-
should be excised and sent for frozen-section analysis. surgical unit is used to develop the vesicocervical space.
Some clinicians will abandon the radical hysterectomy At the level of the anterior vesicocervical jlUlction, the
if pelvic nodal metastases are documented, rationaliz- bladder is attached to the cervix by the vesicocervical liga-
ing that radiation therapy will be administered in any ment, which separates the vesicocervical space from the
case and that completing the hysterectomy will add to more caudal vesicovaginal space. The electrosurgical unit
the risk of morbidity. It is the author's preference to is used to divide the vesicocervical ligament and mobilize
complete the hysterectomy, provided the metastatic the bladder off of the proximal vagina. As the blaclcler is
pelvic nodal disease is completely resectable; however, mobilized caudally, the bladder pillars are defined at the
the radicality of the hysterectomy is scaled back to that anterolateral aspects of the cervix, appearing as a crescent-
of a moc:Ufied radical procedure to reduce the risk of shaped complex of muscle fibers and fibrovascular con-
complications associated with combined radical sur- nective tissue. The proximal component of the bladder
gery and adjuvant pelvic radiation therapy. The cardi- pillar-the vesicouterine ligament-transmits the ureter
nal ligament, or "web" of tissue between the paravesical from the parametrial tunnel of Wertheim to the bladder.
and pararectal spaces, is palpated to evaluate the local The bladder is mobilized to expose the proximal3 to 4 em
extension of cervical tumor and ensure the absence of ofvagina (Figure 10.2).
_ _ _84 SEcnON II GYNECOLOGIC ONCOLOGY

Bladder pillar Uterine artery


(Vesicouterine ligament)
FIGURE 10.2 Radical abdominal hysterectomy: Mobilization of the bladder from the proximal vagina
and definition parametria and bladder pillar anatomy.

The uterine artery is identified by tracing the hypo- anterior and posterior components of the vesicouterine
gastric artery distally or by locating the obliterated ligament attached to the hysterectomy specimen.
wnbilical artery and tracing it proximally. A right angle Once the ureters have been completely mobi-
clamp is used to skeletonize the lateral aspect of the lized from the pelvic brim to the bladder, attention is
uterine artery, which is then doubly ligated with 1~0 directed toward the posterior pelvis and cardinal liga~
delayed absorbable sutures or clipped and divided at ment. The pelvic wall peritonewn of the medial leaf of
its origin from the hypogastric artery (Figure 10.3). the broad ligament is incised down to the base of the
The medial suture is left long and used to apply upward uterosacral ligament at the level of the rectum. The rec-
traction on the uterine artery as it is dissected from the tovaginal space is entered by placing the rectosigmoid
underlying cardinal ligament and mobilized over the colon on dorsal traction and incising the peritoneal
ureter. The ureter is sharply dissected from its attach- Douglas cul-de-sac between the uterosacral ligaments.
ments within the parametrial tunnel and mobilized lat- A combination of sharp and blunt dissection is used to
erally, using the vessel-loop for traction. The uterine develop the correct plane within the thin areolar tissue
vein follows a more unpredictable course, and may run between the anterior rectal wall and posterior wall of
above or below the ureter. It is ligated separately and the vagina (Figure 10.5). The rectum should be mobi~
divided as far laterally as possible. lized caudally for a distance of 3 to 4 em. The uterosac-
The ureteral tunnel is developed within the vesico- ral ligaments are divided between clamps {or using the
uterine ligament (bladder piUars) by introducing a right electrosurgical unit or a vessel sealer-cutting device)
angle clamp along the superior and medial border of the close to the rectum, with the line of resection directed
ureter and gently spreading the tips of the clamp several toward a point 3 em below the cervicovaginal junction
times (Figure 10.4). The ureter should be maintained on the posterior vaginal wall.
on gentle backward traction to facilitate dissecting in the The proximal rectal pillar, which is a continuation
correct plane outside the adventitial sheath. The vesi- of the uterosacral ligament, and the anterior portion of
couterine ligament is then divided between fine-tipped the cardinal ligament are clamped as a unit and divided
clamps (Tonsil or right angle), and the anterior and paste~ at the level of the pelvic sidewall (Figure 10.6). In
rior '1eavesn are ligated with 2-0 or 3-0 delayed absorbable this way, the posterior portion of the cardinal ligament
sutures and divided. The ureter is completely released and the associated autonomic nerves to the bladder
from its attachments to the posterior leaf, rolled laterally, and rectum are preserved. It may be necessary to take
and dissected to the ureterovesical junction, leaving both these structures in a series of successive bites, rather
CHAPTER 10 Radical Abdominal Hysterectomy 85

FIGURE 10.3 Radical abdominal hysterectomy: Ligation and division of the uterine artery at its origin
from the hypogastric artery.

than a single unit, if the resulting tissue pedicle is heavy clamp (e.g., curved Heaney), each pedicle being
larger than 2 em. A clamp is placed across the paravagi- sequentially divided and secured with a Heaney trans-
nal tissue (paracolpos) such that the heel is juxtaposed fixion stitch of 1-0 delayed absorbable suture and held
to the pelvic wall and the tip of the clamp approxi- long for traction (Figure 10.8). The final two bites
mates the lateral vaginal wall 2 to 3 em below the incorporate the posterior-lateral vaginal wall and meet
cervicovaginal junction or lowermost extent of palpable in the midline, and the specimen is removed. The vagi-
tumor (Figure 10. 7). An anterior colpotomy is created nal cuff is closed with a series of figure-of-eight stitches
using the electrosurgical unit or scissors. An "empty" of 1-0 delayed absorbable sutures.
spongestick introduced transvaginally can assist in If pelvic lymphadenectomy was not done prior
selecting the appropriate site for colpotomy to ensure a to the radical hysterectomy, it is completed at this
2- to 3-cm margin of resection. The proximal vagina is time. If the adnexa have been preserved and there
circumferentially resected using a series of bites with a is a low likelihood of adjuvant pelvic radiation, the

Uterine artery
Bladder pillar
(vesicouterine ligament)

FIGURE 10.4 Radical abdominal hysterectomy: Dissection of the vesicouterine ligament (bladder pillar).
_ _ _ 86 SEcnON II GYNECOLOGIC ONCOLOGY

Posterior vaginal wall

Ureter
~~~- Uterosacral
ligament

Rectosigmoid colon
FIGURE 10.5 Radical abdominal hysterectomy: Posterior dissection showing uterosacral ligament and
rectovaginal space.

Rectal pillar and anterior


cardinal __.-;:;;;::;

FIGURE 10.6 Radical abdominal hysterectomy: Resection of the rectal pillar and anterior portion of
cardinal ligament as a unit.
CHAPTER 10 Radical Abdominal Hysterectomy 87

FIGURE 10.7 Radical abdominal hysterectomy: Resection of paravaginal tissue (paracolpos).

utero-ovarian ligament/fallopian tube complex ped- Radical hysterectomy variations


icle is suspended to the round ligament stump as
described in Chapter 2. If adjuvant pelvic radiation The modified radical hysterectomy is a scaled-back
is anticipated, the adnexa are transposed out of the version of the Wertheim procedure, achieving a
pelvis by widely mobilizing the infundibulopelvic wider margin of resection than a simple extrafascial
ligament pedicles and suturing the utero-ovarian liga- hysterectomy hut with reduced morbidity. In this vari-
ment/fallopian tube pedicles into the right and left ation: 1) the uterine vessels are divided at the point
paracolic gutters by tunneling beneath the cecum where they cross the ureter within the cardinal liga-
and ascending colon (on the right) and the sigmoid/ ment instead of at the pelvic wall, 2) the ureters are
descending colon {on the left). not completely extracted from the vesicouterine liga-
The pelvis is irrigated, and all dissection areas are ment, rather only the anterior leaf is resected with the
inspected to ensure hemostasis. The course and safety hysterectomy specimen, 3) the cardinal ligaments/
of the ureters should be verified. If there is any concern uterosacral ligaments are divided midway between the
over a possible ureteral or bladder injury, cystoscopic pelvic wall/rectum and uterus, and 4} only the upper 1
ex.a:n:tination with intravenous methylene blue or indigo to 2 em of vagina is removed.
carmine should he performed to assess the integrity of The extended radical hysterectomy (Meigs/Oka-
the urinary tract. Routine closed suction drainage of bayashi procedure) is indicated when a wider mar-
the pelvis is unnecessary hut may he utilized at the dis- gin of resection is desired (e.g., large cervical lesion)
cretion of the surgeon. and differs from the Wertheim procedure in the
88 SEcnON II GYNECOLOGIC ONCOLOGY

FIGURE 10.8 Radical abdominal hysterectomy: Cirtumferential resection of proximal vagina.

following ways: 1) the cardinal ligament (both ante- between 800 and 1,500 cc, and approximately
rior and posterior components) is completely tran- 50% of patients require intraoperative or postopera-
sected at the pelvic wall, independent of the rectal tive transfusion. Diet can usually be advanced rapidly
pillars, down to the pelvic floor, 2) the uterosacral according to patient tolerance and clinical examina-
ligaments and rectal pillars are divided at the level tion. Thromboembolic prophylaxis is continued until
of the rectum, and 3) the upper one-third to one- discharge or for a period of 4 to 6 weeks if the patient
half of the vagina is removed. Some clinicians also is at especially high risk for deep vein thrombosis. An
include the anterior division of the hypogastric artery indwelling Foley catheter is maintained 3 to 7 days
in the scope of resection. The extended radical hys- postoperatively. depending on the radicality of resec-
terectomy has a higher incidence of bladder, rectal, tion and timing of hospital discharge. Bladder function
and sexual dysfunction compared to the Wertheim is evaluated with a voiding trial by ensuring the blad-
operation. Prolonged (2 to 3 weeks) bladder drainage der is completely emptied and back-filling it with 300
is the norm. cc of saline solution through the Foley catheter. The
catheter is removed and the patient is asked to void.
If the residual volume is less than 75 cc (i.e., voided
POSTOPERATIVE CONSIDERATIONS volume <::!:225 cc), the catheter is not reinserted and
the patient is instructed on timed voiding (every 3 to
Postoperative care following radical abdominal hys- 4 hours) for the next several weeks. A failed voiding
terectomy is similar to that for any other major trial calls for reinsertion of the Foley catheter and
abdominal surgery. Estimated blood loss associ- re-examination in 4 to 7 days or instruction in inter-
ated with radical abdominal hysterectomy averages mittent self-catheterization. Criteria for discharge
CHAPTER 10 Radical Abdominal Hysterectomy 89

include: afebrile without evidence of uncontrolled The Douglas cul-de-sac was incised, and the recto-
infection, tolerating a normal diet without nausea or vaginal space was developed inferiorly for a distance
vomiting, satisfactory bowel function, and evidence of 4 em. The uterosacral ligaments were damped
of appropriate wonnd healing. Postoperative activity and divided anterior to the rectwn, and the pedicles
should be individualized; however, vaginal intercourse secured with 1-0 delayed absorbable sutures. The
should be restricted for 8 weeks and a pelvic examina- proximal rectal pillar and the anterior portion of the
tion should be performed to confirm the integrity of cardinal ligament were clamped as a unit and divided
the vaginal cuff. at the level of the pelvic sidewall and the pedicle
secured with a 1-0 delayed absorbable suture liga-
Operative Note ture. The same maneuvers were repeated on the con-
tralateral side. Curved Heaney clamps were placed
PROCEDURE: RADICAL ABDOMINAL across the paracolpos approximating the lateral vagi-
HYSTERECTOMY nal wall 3 em below the cervicovaginal junction. An
anterior colpotomy was created 3 em below the cer-
The uterus was grasped and elevated and the round vicovaginal junction using the electrosurgical unit
ligaments were suture ligated and divided laterally on over a spongestick introduced transvaginally. The
the pelvic wall. The pelvic peritoneal sidewalls were proximal vagina was circumferentially resected using
incised parallel to the external and common iliac ves- a series of bites with curved Heaney damps, each
sels, and the pararectal and paravesical spaces were pedicle being sequentially divided and secured with
developed down to the pelvic floor. The ureters were a Heaney transfixion stitch of 1-0 delayed absorbable
placed within vessel-loops for traction and dissected suture and held long for traction. The final two bites
from the pelvic brim down to the tunnel of Wertheim. incorporated the posterior-lateral vaginal wall and
Pelvic lymphadenectomy was performed (described in met in the midline, and the specimen was removed
Chapter 12). The :infundibulopelvic ligaments were intact. The vaginal cuff was closed with a series of
isolated, doubly clamped, divided, and ligated with 1-0 figure-of-eight stitches of 1-0 delayed absorbable
delayed absorbable suture or the utero-ovarian liga- sutures. The pelvis was irrigated and all dissection
ment/fallopian tube complexes were clamped, divided, areas inspected and noted to be hemostatic.
and ligated with 1-0 delayed absorbable suture and the
adnexa tucked above the pelvic brim out of the field of
dissection.
The vesicouterine peritoneal reflection was incised
and the bladder reflected off of the anterior lower uter- COMPLICATIONS
ine segment, cervix, and proximal 3 to 4 em of vagina.
The uterine artery was dissected to its origin at the • The overall incidence of intraoperative compli-
hypogastric artery, at which point it was doubly ligated cations (excluding major blood loss) is approxi-
with 1-0 delayed absorbable sutures and divided. The mately 7%, with the most common being major
uterine vein was divided in a similar fashion. The uter- vessel injury (2% to 3%), bladder injury ( 1% to
ine vascular pedicles were then reflected ventrally and 2%), and ureteral injury (1 %).
medially and the ureter dissected along the tunnel of • The overall incidence of postoperative
Wertheim and extricated from cardinal ligament. The morbidity is approximately 20%, with the
ureteral tunnel was further developed within the vesi- most common complications being infectious
couterine ligament. The anterior and posterior leaves morbidity (wonnd, urinary tract), thromboem-
of the vesicouterine ligament were divided between bolic events, lymphocyst formation, bladder
clamps and ligated with 3-0 delayed absorbable dysfunction, ureteral or bladder fistula, and
sutures. The ureter was completely mobilized from its ureteral stricture.
attachments to the vesicouterine ligament and rolled • Excessive resection of the proximal vagina
laterally, leaving both anterior and posterior leaves of should be avoided unless clearly indicated by
the vesicouterine ligament attached to the hysterec, clinical factors, as it is associated with a high
tomy specimen. The same maneuvers were repeated on incidence of sexual dysfunction.
the contralateral side.
_ _ _ 90 SEcnON II GYNECOLOGIC ONCOLOGY

Suggested Reading 3. Okabayashi H. Radical abdominal hysterectomy for


cancer of the cervix uteri. Surg Gynecol Obstet 1921;
I. Cibula D, Abu-Rustum NR, Benedetti-Panici P, et al. 33:335-341.
New classification system of radical hysterectom~ 4. Piver MS, Rutledge F, Smith JP. Five classes of extended
emphasis on a three-dimensional anatomic tem- hysterectomy for women with cervical cancer. Obstet
plate for parametrial resection. Gynecol Oncol 201 1; Gynecoll974;44:265-272.
122:264-268. 5. Queleu D, Morrow CP. Classification of radical hyster-
2. ClarkJG. A more radical method of perfonning hysterec- ectomy. Lancet Oncol2008;9:297-303.
tomy for cancer of the uterus. Bull Johns Hopkins Hosp 6. Wertheim E. A discussion on the diagnosis and treat-
1895;6:120-124. ment of cancer of the uterus. BMJ 1905;2:689-704.
CHAPTER 11

Pelvic Lymphadenectomy
Robert E. Bristow

INTRODUCTION Gynecologic Oncology Group requires documentation


of at least 4lymph nodes harvested from each side; how-
The pelvic lymph nodes may be a site of early meta~ ever, a minimum total pelvic colUlt of 11 lymph nodes
static spread of cervical, endometrial, and ovarian can- has been shown to correlate with clinical outcome in
cers. Consequently, surgical removal of pelvic lymph endometrial cancer. A median total pelvic node count
nodes is an important component of surgical staging for in excess of 30 lymph nodes is not uncommon but is
these cancers and may serve as a diagnostic procedure, also associated with a higher risk of complications. Pel~
a therapeutic procedure, or both. For cervical cancer, vic lymph node sampling is a more limited procedure
pelvic lymphadenectomy is considered both diagnostic within the same general anatomic boundaries as pel~
and therapeutic when performed in conjunction with vic lymphadenectomy; however, lymph node sampling
radical hysterectomy. Pelvic lymphadenectomy per- is not associated with the same diagnostic accuracy
formed for ovarian cancer apparently confined to the as lymphadenectomy and is not a reliable method of
pelvis has been associated with improved progression~ excluding lymph node metastasis. Lymph node sam-
free survival but does not impact overall survival. The pling is usually intended to remove any enlarged or
role of pelvic lymphadenectomy for endometrial cancer clinically suspicious nodes. Pelvic lymph node dissec-
has not been conclusively determined; however, kraowl~ tion is a vague term that may describe a procedure rang-
edge of lymph node status permits individualization of ing from lymph node sampling to lymphadenectomy.
adjuvant therapy. Finally, removal of gross lymphade~
nopathy for patients with ovarian and endometrial can-
cers may be required to achieve optimal or complete PREOPERATIVE CONSIDERATIONS
tumor cytoreduction.
Pelvic lymphadenectomy reflects complete or near- In preparation for pelvic lymphadenectomy, all patients
complete removal of all lymph node tissue within should undergo a comprehensive history and physical
well-defined anatomic boundaries. The important ana- examination focusing on those areas that may indicate
tomic landmarks are: proximal-the mid-portion of a reduced capacity to tolerate major surgery or place the
the common iliac artery; distal-deep circumflex iliac patient at elevated risk for postoperative complications.
vein; lateral-tendon of the psoas muscle and fascia Routine laboratory testing should include a complete
of obturator internus; medial-internal iliac (hypogas- blood count, serum electrolytes, age~appropriate health
tric} artery and ureter; and posterior-obturator nerve screening studies, a chest radiograph, and electrocardi-
or hypogastric vein (depending on the extent of resec- ogram for women aged 50 years and older. Preoperative
tion) (Figure 11.1 ). An adequate nodal yield from pel- computed tomography of the abdomen and pelvis (and
vic lymphadenectomy has been variably defined. The chest, depending on clinical indications) is helpful to

91
_ _ _ 92 SEcnON II GYNECOLOGIC ONCOLOGY

Mld-porUon of
oommon lilac

Internal iliac (hypogastric) artery


FIGURE 11.1 Pelvic lymphadenectomy: Anatomic boundaries of the dissection.

evaluate the extent of disease and for surgical planning procedures. Pelvic lymphadenectomy can be per-
purposes. formed through a variety of incisions: low trans-
Preoperative mechanical bowel preparation (oral verse, vertical midline, vertical lateral or paramedian,
polyethylene glycol solution or sodium phosphate }-incision, extraperitoneal, laparoscopic, or roboti-
solution with or without bisacodyl) is unnecessary for cally assisted. Similarly, the surgeon may choose from
pelvic lymphadenectomy but may be recommended a variety of instruments to perform pelvic lymphad-
according to the surgeon's preference for other concur- enectomy, including scissors, hemo-clips, the electro-
rent components of the procedure (e.g., hysterectomy). surgical unit, a vessel-sealing device, and the Argon
Prophylactic antibiotics (Cephazolin 1 g, Cefotetan 1 beam coagulator. The most important point, however,
to 2 g, or Clindamycin 800 mg) should be administered is to develop a routine and proceed through the dis-
30 minutes prior to incision, and thromboembolic pro- section in a systematic fashion to ensure anatomic
phylaxis (e.g., pneumatic compression devices and sub- consistency from one case to the next.
cutaneous heparin) should be initiated prior to surgery. A self-retaining retractor is placed with particu-
A self-retaining retractor (e.g., Bookwalter, Cadman lar attention to exposure of the pelvic sidewall and
Division, Johnson & Johnson, Piscataway, NJ) with elevation of the peritoneum in the area of the round
a fixed arm attaching the retractor ring to the operat- ligament to expose the distal external iliac node
ing table is advisable to optimize exposure, maximize Oackson's node). The lateral retractor blades should
patient safety, and reduce surgeon fatigue. Following is not be resting on the psoas muscle, as this can result
a brief description of the surgical procedure used (see in traumatic injury to the femoral nerve. Usually, the
also video: Pelvic Lymphad.enectomy). round ligaments would have been ligated and divided
as part of a preceding hysterectomy. The suture liga-
ture on the round ligament pedicle is elevated and
SURGICAL TECHNIQUE the pelvic wall peritoneum is opened lateral and
parallel to the external iliac and common iliac ves-
~' The patient may be positioned in the dor- sels. To improve exposure to the common iliac ves-
- sal low-lithotomy (perineal lithotomy) posi- sels, the descending and sigmoid colon are mobilized
tion using Allen Universal Stirrups (Allen Medical from its attachments to the left lateral pelvic wall
Systems, Cleveland, OH) or supine on the operating and paracolic gutter. On the right side, the perito-
table, depending on the requirements for concurrent neum surrounding the proximal ascending colon,
CHAPTER 11 Pelvic Lymphadenectomy 93

FIGURE 11.2 Pelvic lymphadenectomy: Operative view of pathway and sequence of dissection.

cecum, and terminal ileum is incised and the bowel


is packed cephalad. The psoas muscle and tendon,
genitofemoral nerve, external iliac and common iliac
vessels are visualized. The paravesical and pararectal
spaces are developed. The ureter is identified within
the pararectal space, mobilized &om its attachments
to the medial leaf of the broad ligament, and held
for traction with a vessel loop to improve exposure to
the pelvic wall.
The dissection begins at the midpoint of the com-
mon iliac artery and proceeds distally (Figure 11.2).
The nodal tissue along the psoas tendon lateral to
the artery is grasped and placed on upward traction,
and the ESU or scissor dissection used to delicately
separate the nodal tissue from the underlying artery's
adventitial sheath. The nodal tissue is rotated medi~
ally, proceeding from proximally to distally, until the
deep circumflex iliac vein is identified as it crosses
over the external iliac artery. The genitofemoral nerve
is frequently entangled in this portion of the specimen
and can usually be dissected free of the surrounding
nodal tissue and fat. Injury to the genitofemoral nerve
results in paresthesias to the upper anterior thigh and
lateral vulva. The entire length of the external iliac and
common iliac nodal bundle is mobilized medially and
dissected off the external iliac vein in a similar fash-
ion (Figures 11.3 and 11.4). The ventral portion of
the obturator space can be developed by continuing
this dissection along the dorsal surface of the exter~
nal iliac vein toward the fascia of obturator internus.
Alternatively, the obturator space can be developed
by gentle finger dissection along the pelvic sidewall
lateral to the external iliac vessels, placing the exter- FIGURE 11.3 Pelvic lymphadenectomy: Cross-sectional
nal iliac vessels on medial traction until the obturator view of pathway of dissection.
_ _ _ 94 SEcnON II GYNECOLOGIC ONCOLOGY

FIGURE 11.4 Medial mobilization of nodal bundle from external iliac vessels.

nerve is clearly visualized. A vein retractor is placed some surgeons prefer to separate the different nodal
beneath the external iliac vein to further expose the basins for separate pathologic processing.
contents of the obturator space. The obturator nerve Caution should be exercised in the region of the
is usually most easily identified within the caudal (dis~ obturator foramen, as 25% of patients will have an
tal} aspect of the obturator space. Once the obturator accessory obturator vein draining from the obturator
nerve has been clearly identified, the obturator space foramen directly into the undersurface of the external
dissection proceeds moving proximally toward the iliac vein. The accessory obturator vein is subject to
bifurcation of the common iliac vein. A combination avulsion injury from excessive ventral traction on the
of sharp (ESU or scissors) and blunt (Yankour sue~ external iliac vein. The internal iliac (hypogastric)
tion tip or fingers) is used to extricate the obturator vein runs along the lower lateral border of the obtura-
nodal bundle from around the obturator nerve, artery, tor space and can have a variable pattern of venous
and vein. The obturator nerve always enters the pelvis tributaries. Venous injury in the area of the axilla of
at the junction (axilla) of the external iliac and inter- the common iliac vein can be associated with profuse
nal iliac (hypogastric) vein (Figure 11.5}. With the hemorrhage, as this region represents the confluence
exception of the accessory obturator vein, all vascular of three venous drainage systems (external iliac, inter-
structures within the obturator fossa lie deep to the nal iliac, and common iliac). Repair of vascular injury
obturator nerve. All lymph~bearing tissue above the encountered during pelvic lymphadenectomy is dis~
obturator nerve is removed. The distal-most lymphatic cussed in Chapter 22.
pedicle should be clipped or ligated as it approaches The pelvis is irrigated and inspected for hemosta-
the obturator foramen. Nodal tissue beneath the sis. It is unnecessary to place a closed suction drain
obturator nerve can generally be removed without in the pelvis, and in fact drain placement has been
difficulty, although the obturator artery and vein my associated with increased morbidity. The peritoneal
need to be clipped and divided proximally and distally incision is left open.
to achieve satisfactory removal of nodal tissue and
maintain hemostasis. Finally, the nodal bundle, now
including common iliac, external iliac, and obturator POSTOPERATIVE CONSIDERATIONS
nodes, is mobilized medially from the obturator fossa
and dissected off the medial surface of the internal Postoperative care following pelvic lymphadenectomy
iliac (hypogastric) artery and excised (Figure 11.6). is similar to that for any other major abdominal sur-
It is generally easier to remove the entire pelvic nodal gery and is usually dictated by the extent of any con~
«package" en bloc rather than piecemeal, although current procedures (e.g., radical hysterectomy). The
CHAPTER 11 Pelvic Lymphadenectomy 95

Obturator intemus fascia

FIGURE 11.5 Pelvic lymphadenectomy: Visualization and dissection of the obturator nerve.

overall incidence of morbidity ranges from 2% to 25%, include neurological injury (obturator nerve trauma/
with most occurrences being related to lymphocyst transection, retractor blade trauma to the femoral
formation or febrile morbidity. Symptomatic (pain, nerve) and arterial thrombosis. Although rare, arte-
ureteral obstruction, venous obstruction, lower rial thrombosis of the external iliac artery can precipi-
extremity edema, and infection) lymphocyst forma~ tate catastrophic complications; consequently, lower
tion occurs in approximately 5% of cases and can extremity pulses should be monitored and recorded
almost always be successfully managed by percutane- for 24 hours postoperatively. An indwelling catheter is
ous drainage by interventional radiology. Uncommon continued overnight and removed on the first postop-
complications related to pelvic lymphadenectomy erative day unless there has been a bladder or ureteral

Obturator nerve

lntemallllac (hypogastric) anery


FIGURE 11.6 Pelvic lymphadenectomy: Dissection of nodal bundle from the surface of the hypogastric artery.
_ _ _ 96 SEcnON II GYNECOLOGIC ONCOLOGY

repair. Diet can usually be advanced rapidly according rotating the nodal bundle over the external iliac vessels.
to patient tolerance and clinical examination. Routine The dissection was continued along the undersurface
thromboembolic prophylaxis should be continued of the external iliac vein to the obturator intemus
at least until the patient is fully ambulatory. Criteria fascia, which demarcated the lateral border of dis-
for discharge include: afebrile without evidence of section. The obturator nerve was identified distally at
uncontrolled infection, tolerating a normal diet with- its entrance into the obturator foramen and followed
out nausea or vomiting. satisfactory bowel and bladder proximally to the bifurcation of the common iliac vein.
function, and evidence of appropriate wound healing. All lymph-bearing tissue above and below the obturator
nerve, down to the level of the hypogastric vein, was
Operative Note removed. The obturator artery and vein were clipped
and divided proximally and distally and included within
PROCEDURE: PELVIC the scope of the nodal resection. Finally, the nodal
LYMPHADENECTOMY bundle was placed on medial traction, and the remain-
ing nodal tissue surrounding the hypogastric artery was
Beginning at the midpoint of the common iliac artery dissected from its vascular attachments. Satisfactory
and vein, the lymph-bearing tissue was dissected from hemostasis was assured.
the underlying vessels distally down to the deep cir-
cumflex iliac vein. The lateral border of dissection
was demarcated by the psoas tendon, and all lymph-
bearing tissue medial to this was mobilized medially, Suggested Reading
I. Benedetti Panici P, Basile S, Angioli R. Pelvic and aortic
lymphadenectomy in cervical cancer: the standardiza-
COMPLICATIONS tion of surgical procedure and its clinical impact. Gyne-
col Oncol 2009; 113:284-290.
• The most common intraoperative complications 2. Benedetti Panici P, Basile S, Maneschi F, et al. System-
atic pelvic lymphadenectomy vs no lymphadenectomy in
associated with pelvic lymphadenectomy are
early-stage endometrial carcinoma: a randomized clinical
hemorrhage from venous or arterial injury.
trial. J Natl Cancer Inst 2008;100:1707-1716.
• Injury (trauma, transection) to the obturator 3. Benedetti Panici P, Maneschi F, Scanbia G, et al. Lym-
nerve is a rare complication of pelvic lymphad- phatic spread of cervical cancer: an anatomical and path·
enectomy. ological study based on 225 radical hysterectomies with
• Imprecise retractor blade placement can result in systematic pelvic and aortic lymphadenectomy. Gynecol
compression of the psoas muscle and traumatic Oncol1996;62:19-24.
injury to the underlying femoral nerve. 4. Cragun JM, Havrilesky LJ, Calingaert B, et al. Ret-
• Development of the paravesical and pararectal rospective analysis of selective lymphadenectomy in
spaces and tagging the ureter at the beginning apparent early-stage endometrial cancer. J Clin Oncol
of the procedure will minimize the risk of uri- 2005;23:36668-3675.
nary tract injury. 5. Jensen JK, Lucci JA III, DiSaia PJ, Manetta A, Berman
ML. To drain or not to drain: a retrospective study of
• The most common postoperative complica-
closed-suction drainage following radical hysterec-
tion associated with pelvic lymphadenectomy tomy with pelvic lymphadenectomy. Gynecol Oncol
is lymphocyst formation, which is usually 1993;51 :46-49.
asymptomatic but may be associated with pain, 6. Maggioni A, Benedetti Panici P, DeU'Anna T, et al.
ureteral obstruction, venous obstruction, leg Randomised study of systematic lymphadenectomy in
edema, or secondary infection. patients with epithelial ovarian cancer macroscopically
confined to the pelvis. Br J Cancer 2006;95:699-704.
CHAPTER 12

Para-aortic
Lymphadenectomy
Robert E. Bristow

INTRODUCTION vein; lateral-the psoas muscles and ureters; and


posterior-the anterior surface of the vertebral bod-
The para~aortic lymph nodes are a common site of ies. Within these boundaries, nine anatomic lymphatic
metastatic spread of ovarian cancer and endomettial zones are relevant to staging gynecologic cancers: right
cancer. Ovarian cancer has a predilection for lymphatic and left proximal common iliac, interiliac, precaval,
dissemination along the drainage routes of the ovarian right paracaval, aortocaval, preaortic, left para-aortic,
vessels to the high para-aortic lymph nodes in proximity and suprahilar (suprarenal) (Figure 12.1). Typically,
to the renal vessels. Endomettial cancer located in the each of these anatomic regions will yield between
uterine fundus may follow a similar spread pattern. In 3 and 6 lymph nodes, and the total lymph node count
contrast, endometrial cancer located in the lower uter- for para-aortic lymphadenectomy ranges from 10 to
ine segment or lower fundus will follow a more orderly 26 lymph nodes. The retrocaval and retroaortic nodal
lymphatic progression to the pelvic, common iliac, and basins are not routinely dissected during staging para-
low para-aortic (below the inferior mesenteric artery aortic lymphadenectomy. Some surgeons will limit the
[IMA]) lymph nodes before reaching the high para- cephalad extent of para-aortic lymphadenectomy to
aortic nodal basins. Consequently, surgical removal of the level of the IMA for selected cases of endometrial
para-aortic lymph nodes is an important component of cancer or cervical cancer. However, para-aortic lymph-
surgical staging for these cancers and may serve as a adenectomy for the purpose of staging ovarian can-
diagnostic procedure, a therapeutic procedure, or both. cer should extend to the level of the renal vessels and
The extent of dissection, however, should be tailored include resection of the gonadal vessels at their origin.
to the specific disease process. Removal of gross para- Para-aortic lymph node sampling is a more limited pro-
aortic lymphadenopathy for patients with ovarian and cedure within the same general anatomic boundaries
endometrial cancers may be required to achieve opti- as para-aortic lymphadenectomy but usually does not
mal or complete tumor cytoreduction. Para-aortic lym- extend above the IMA and is intended to remove any
phadenectomy may also be indicated for selected cases enlarged or clinically suspicious nodes.
of cervical cancer undergoing radical hysterectomy
when the common iliac lymph nodes are known to be
involved by metastatic disease. PREOPERATIVE CONSIDERATIONS
Para-aortic lymphadenectomy reflects complete
or near-complete removal of all lymph node tissue In preparation for para-aortic lymphadenectomy, all
within well-defined anatomic boundaries. The impor- patients should undergo a comprehensive history and
tant anatomic landmarks are: distal-the mid-portion physical examination focusing on those areas that may
of the common iliac arteries; proximal-the left renal indicate a reduced capacity to tolerate major surgery

91
98 SEcnON II GYNECOLOGIC ONCOLOGY

Suprahilar nodes

Right paracaval nod&S-


Left ovarian vein
'llo\---~-lnferlor
mesenteric artery
41------>,~ Preaortlc nodes

Precaval nodes

~-++-Common
iliac nodes

FIGURE 12.1 Para-aortic lymphadenectomy: Anatomic boundaries of the para-aortic lymphatic regions.

or place the patient at elevated risk for postopera~ retractor (e.g., Bookwalter, Cadman Division, Johnson
ti.ve complications. Routine laboratory testing should & Johnson, Piscataway, NJ} with a fixed arm attaching
include a complete blood count, serum electrolytes, the retractor ring to the operating table is advisable to
age-appropriate health screening studies, a chest radio- optimize exposure, maximize patient safety, and reduce
graph, and electrocardiogram for women aged 50 years surgeon fatigue. Following is a brief description of the
and older. Preoperative computed tomography of the surgical procedure used {see also video: Para-aortic
abdomen and pelvis (and chest, depending on clinical Lymphaderuxtcmy).
indications) is helpful to evaluate the extent of disease
and for swgical planning purposes.
Preoperative mechanical bowel preparation (oral SURGICAL TECHNIQUE
polyethylene glycol solution or sodium phosphate solu~
tion with or without bisacodyl) is unnecessary for para- ~ The patient may be positioned in the dorsal
aortic lymphadenectomy but may be recommended - low-lithotomy (perineal lithotomy) position
according to the surgeon's preference for other concur~ using Allen Universal Stirrups (Allen Medical Systems,
rent components of the procedure (e.g., hysterectomy Cleveland, OH) or supine on the operating table,
and ovarian cancer surgery). Prophylactic antibiotics depending on the requirements for concurrent proce-
(Cephazolin I, Cefotetan I to 2 g, or Clindamycin dures. Para-aortic lymphadenectomy can be performed
800 mg) should be administered 30 minutes prior to through a vertical midline incision extended above the
incision, and thromboembolic prophylaxis (e.g., pneu~ umbilicus to the mid-epigastrium (or higher), lapa-
matic compression devices and subcutaneous heparin) roscopically; or robotically assisted. In general, it is
should be initiated prior to surgery. A self~retaining not technically feasible to reach the high para-aortic
CHAPTER 12 Para-aortic Lymphadenectomy 99

nodes through any of the low transverse incisions abdominal retroperitoneum (Figure 12.2}. The first
(Pfannenstiel, Maylard, Cherney), although these may incision starts inferior to the cecum and is extended
be adequate for reaching the level of the IMA in thin along the right paracolic gutter up to and includ-
patients. The surgeon may choose from a variety of ing the hepatic flexure of the ascending colon. The
instruments to perfonn para-aortic lymphadenectomy second incision is a continuation of the first incision,
including scissors, hemo-clips, the electrosurgical unit beginning inferior to the cecum and extending along
(ESU) a vessel-sealing device, or the Argon beam coag- the base of the small bowel mesentery to the inferior
ulator. 4'mphatic pedicles of the proximal and distal duodenal fold. The third part of the duodenum should
margins of dissection should be controlled either with be carefully mobilized cephalad, exposing the abdom-
clips or a vessel-sealing device to reduce the risk of post- inal retroperitoneum up to the level of the renal ves-
operative lymphocyst fonnation. The specific choice of sels. The third incision is carried from the mid-point
instrumentation is less important than achieving proper of the sigmoid colon along the paracolic gutter of the
exposure and adhering to the anatomic boundaries of descending colon up to and including the splenic
dissection. flexuxe. This incision facilitates medial mobilization
Para-aortic lymphadenectomy is normally per- of the descending and sigmoid colon, which may be
formed following concurrent hysterectomy, and a necessary to access the proximal left common iliac
self-retaining retractor will already be in place. The nodes and left para-aortic nodes below the IMA. At
vertical midline incision should be extended to the this point, retractor blades can he placed to keep the
mid-epigastrium or above to allow adequate exposure. howe) out of the field of dissection, or the ascending
Three peritoneal incisions are created to expose the colon and small bowel can be exteriorized and placed

Inferior
duodenal folcl

FIGURE 12.2 Para-aortic lymphadenectomy: Three peritoneal incisions are created to expose the
abdominal retroperitoneum.
100 SEcnON II GYNECOLOGIC ONCOLOGY

inside a moistened laparotomy pack onto the patient's The focus turns medially to the interiliac, preaor-
abdominal wall. Placing the patient in Trendelenburg tic, and aortocaval, nodal basins. The areolar sheath
position will facilitate achieving proper exposure. The over the proximal left common iliac artery and aor-
uxeters should be identified and placed within vessel tic bifurcation is incised and the line of incision car-
loops for traction, if not done previously. ried cephalad along the lateral border of the anterior
The dissection begins by incising the areolar sheath surface of the aorta to the level of the left renal vein,
over the right common iliac artery and elevating the identifying the IMA in the process. The nodal tissue
proximal right common iliac fat pad off the underlying between the proximal common iliac arteries is ele-
artery and vein. Proceeding cephalad along the lateral vated off the underlying left common iliac vein and
margin of the vena cava, the right paracaval nodal tis- sacral promontory and resected. It is usually easiest to
sue is dissected laterally from the anterior surface of remove the preaortic and aortocavallymph nodes as a
the vertebral bodies up to the level of the left renal single unit. The lateral margin of the preaortic fat pad
vein. The lumbar arteries and veins will be encoun- inferior to the IMA is reflected medially and the tis-
tered, and these vessels should be preserved, if pos- sue dissected from the anterior surface of the aorta. As
sible. Next, the precaval fat pad and associated nodal the dissection proceeds cephalad toward the left renal
tissue are dissected by elevating the inferior extent of vein, the preaortic fat pad is rotated medially and left
the common iliac nodal tissue and separating the speci- attached to the aortocaval nodes, which are carefully
men from the underlying vena cava (Figure 12.3). In extirpated from the groove between the vena cava and
most cases, there is a delicate venous tributary running aorta (Figure 12.5). Lwnbar arteries and veins may
from the precaval nodes to the anterior surface of the be encountered in this area, and they should be pre-
vena cava (the .,fellow's vein"), which if tom will result served if possible. The proximal lymphatic tissue pedi-
in laceration of the vena cava and significant hemor- cle should be clipped just inferior to the left renal vein
rhage. The "fellow's veinn should be identified, clipped, before transecting the specimen, or it can be divided
and divided under direct vision (Figure 12.4}. The using a vessel-sealing device.
precaval nodes are elevated up to the level of the left Finally, attention is directed toward the left com-
renal vein and removed en bloc with the right common mon iliac and left para-aortic nodal basins. The space
iliac and right paracaval node bundle. Generally, it is beneath the IMA is developed bluntly and a fixed or
easiest to include the right ovarian vessels as part of the handheld thin malleable retractor inserted caudad to
specimen after ligating them with 2-0 delayed absorb- the IMA and placed on lateral traction. Tills maneu-
able suture ver is usually sufficient to expose the entire field of

FIGURE 12.3 Para-aortic lymphadenectomy: Dissection of the right paracaval and precaval lymph
nodes.
CHAPTER 12 Para-aortic Lymphadenectomy 101

Left ovarian vein pedicle


Left renal vein

FIGURE 12A Para-aortic lymphadenectomy: Identification of the "fellow's vein."

dissection. If e.xposme to the left common iliac and lateral surface of the aorta. The lymph-bearing tissue
left para-aortic nodal basins is inadequate, these areas lateral to the aorta is elevated and mobilized down to
can be approached from the left side by mobilizing the the anterior longitudinal ligament of the vertebral bod-
descending and sigmoid colon medially, as previously ies and removed up to the level of the left renal vein
described. Alternatively, the IMA can be doubly ligated (Figure 12.6). The left ovarian artery is usually divided
with 2-0 silk sutmes and divided. The areolar sheath at its origin and resected. The left ovarian vein should
along the lateral border of the left common iliac artery be identified at its juncture with the left renal vein,
is incised and the incision extended cephalad along the clipped (or suture ligated} and divided. The proximal

Left para-aortic nodal tissue

\
1..

/
Aortic bifurcation
Inferior mesenteric artery

FIGURE 12.5 Para-aortic lymphadenectomy: Dissection of the preaortic lymph nodes.


102 SECTION II GYNECOLOGIC ONCOLOGY

Aortic bif~1roa.tion Left oommon iliac artery


FIGURE 12.6 Para-aortic lymphadenectomy: Medial mobilization of the descending colon facilitates
exposure to the left common iliac and left para-aortic nodal basins.

lymphatic tissue pedicle is clipped prior to transecting POSTOPERATIVE CONSIDERATIONS


it just inferior to the left renal vein or divided using a
vessel~sealing device. Failure to secure the large, proxi~ Postoperative care following para-aortic lymphadenec-
mal lymphatic tissue pedicles in the aonocaval and tomy is similar to that for any other major abdominal
para-aortic regions can result in accumulation of lym- surgery and is usually dictated by the extent of the over-
phatic fluid {lymphocyst) or continued lymphatic leak- all operation. The incidence of morbidity is somewhat
age and formation of chylous ascites. difficult to separate from that associated with concur~
In the majority of cases, the above dissection sat~ rent procedures (e.g., ovarian cancer cytoreduction) but
isfies the requirement for para-aortic lymphadenec- ranges from 7% to 24%, with most occurrences being
tomy performed for staging purposes. On occasion, related to intraoperative/postoperative hemorrhage,
the dissection will need to be extended cephalad to lymphocyst fonnation, and paralytic ileus. 4'mphocyst
remove the suprahilar lymph nodes if they are grossly formation is rarely symptomatic, but may be associated
involved by metastatic ovarian cancer or endometrial with venous or ureteral compression and require percu-
cancer. In this case, the hepatic and splenic flexures taneous drainage by inteiventional radiology. Ureteral
of the transverse colon are completely mobilized, injury is uncommon. Patients undergoing extensive
allowing the ascending and descending colon to be manipulation of the bowel (exteriorization) are prone
reflected medially past the midline, with full expo- to slow return of bowel function, and diet advance~
sure of the abdominal retroperitoneum. Gerota fascia ment should be adjusted accordingly. An indwelling
surrounding the kidney is dissected from the renal catheter is continued overnight and removed when
hilum exposing the renal artery, vein, and ureter. The indicated for concurrent procedures. Routine thrombo-
suprahilar node-bearing tissue is meticulously dis- embolic prophylaxis should be continued at least until
sected from the underlying vascular structures, kid- the patient is fully ambulatory. Criteria for discharge
ney, and ureter. include: afebrile without evidence of uncontrolled
The surgical field is irrigated and inspected for infection, tolerating a normal diet without nausea or
hemostasis. The peritoneal incisions are left open, and vomiting, satisfactory bowel and bladder function, and
routine drain placement is unnecessary. evidence of appropriate wound healing.
CHAPTER 12 Para-aortic Lymphadenectomy 103

Operative Note proximal pedicle of dissection was secw-ed with a large


hemo-clip before being divided. The surgical field was
PROCEDURE: PARA-AORTIC irrigated and satisfactory hemostasis was assured.
LYMPHADENECTOMY
The peritoneum beneath the cecum was incised
cephalad along the right paracolic gutter and the COMPLICATIONS
hepatic flexure mobilized medially. The incision was
taken around the cecwn and extended along the base • The most common vascular injury is laceration
of the small bowel mesentery to the inferior duodenal of the "fellow's vein" on the anterior surface of
fold, and the third part of the duodenum was care~ the vena cava.
fully mobilized cephalad. An incision was created • Extensive manipulation of the bowel predis-
lateral to the proximal sigmoid colon and extended poses to postoperative paralytic ileus.
cephalad up to and including the splenic flexw-e. The • Proximal and distal lymphatic tissue pedicles
patient was placed in Trendelenburg position, and should be clipped, ligated, or divided using a
vessel~ sealing device to reduce the risk of lym~
the bowel was placed in a moist laparotomy pack and
exteriorized onto the abdominal walL The areolar tis- phatic fluid accwnulation (lymphocyst, chylous
sue overlying the midpoint of the right common iliac ascites).
artery was incised, and the right common iliac lymph~
bearing tissue was elevated. The lateral paracaval fat
pad was mobilized medially up to the level of the left
renal vein. The node-hearing tissue was carefully dis- Suggested Reading
sected cephalad along the surface of the vena cava up
I. Benedetti-Panici P, Maggioni A, Hacker N, et al System-
to the proximal margin of resection and removed en
atic aortic and pelvic lymphadenectomy versus resection
bloc. Communicating vessels were individually clipped
of bulky nodes only in optimally debulked advanced
and divided. Attention was directed toward the aorta, ovarian cancer: a randomized clinical trial. J Natl Cancer
where an incision was created in the areolar sheath at Inst 2005;97:560-566.
the bifurcation and extended cephalad along the ante- 2. Benedetti-Panici P, Scambia G, Baiocchi G, Matonti G,
rior surface of the aorta to the level of the left renal Capelli A, Mancuso S. Anatomical study of para-aortic
vein. The preaortic lymphatic tissue was mobilized and pelvic lymph nodes in gyn.ecologic malignancies.
medially across the anterior surface of the aorta, and Obstet Gynecoll992;79:498-502.
the dissection was extended to include the aortocaval 3. duBois A, Reuss A, Harter P, Pujade-Lauraine E, Ray-
lymph nodes up to the level of the left renal vein. The Coquard I, Pflsterer J, Arbeitsgemeinschaft Gynaekol-
proximal pedicle of the dissection was secured with a ogische Onkologie Studiengruppe Ovarialkarzinom,
large hemo-clip before being divided. The descending Groupe d'Investigateurs Nationaux pour I'Etude des
Cancers Ovariens. Potential role of lymphadenectomy in
colon was mobilized medially, and the areolar tissue
advanced ovarian cancer: a combined exploratory analy-
overlying the left common iliac artery incised. The inci-
sis of three prospectively randomized phase III multi-
sion was extended cephalad along the lateral border of center trials. J Clin Oncol2010;28:1733-1739.
the para~aortic nodal tissue up to the level of the left 4. Mariani A, Dowdy SC, Cliby WA, et al. Prospective
renal vein. The lymphatic tissue bundle was separated assessment of lymphatic dissemination in endometrial
from its attachments down to the anterior surface of cancer: a paradigm shift in surgical staging. Gynecol
the vertebral bodies and reflected cephalad, where the Oncol2008;109:11-18.
CHAPTER 13

Simple
Vulvectomy-Partial
Robert E. Bristow

INTRODUCTION excised, usually 3 to 5 rnrn, and that the full thiclmess


of the involved skin or mucosa is removed. Additional
The variations of simple (or superficial) vulvectomy can subcutaneous tissue may be excised to facilitate wound
be classified as partial or total, depending on the extent closure as needed. The surgical approach should be
of tissue excised. The purpose of partial simple vulvec- individualized and the extent of resection tailored to
tomy is to remove the skin and subcutaneous tissues the extent of disease. Usually, the vulvar lesion will be
of the vulva affected by disease. Contemporary sUigical sharply demarcated and frozen section examination of
treatment strives to preserve as much normal tissue as surgical margins is unnecessary. The exception may be
can he done safely without compromising the efficacy vulvar Paget disease; however, the accuracy and utility
of therapy and to achieve a cosmetic result, restoring of frozen section surgical margins to guide the extent of
the vulva to as close to a normal appearance as possible. resection in this setting is debated.
The indications for and sUigical principles of partial
simple vulvectomy are similar to those for total simple
vulvectomy described in Chapter 14. Partial simple vul- PREOPERATIVE CONSIDERATIONS
vectomy is indicated for the treatment of 1) extensive
vulvar intraepithelial neoplasia that is not amenable In preparation for partial simple vulvectomy, all patients
to ablative {e.g., co~ laser and cavitational ultrasonic should undergo a comprehensive history and physical
surgical aspirator) therapy or for lesions that require examination focusing on those areas that may indicate
complete pathological evaluation due to concern for an a reduced capacity to tolerate surgery or disease-related
underlying invasive cancer, 2) Paget disease of the vulva characteristics (e.g., primary lesion clinically suspicious
with no evidence of an underlying adenocarcinoma, 3) for invasive cancer, inguinal adenopathy) that would
selected cases of lichen sclerosis unresponsive to medi- contraindicate a conservative surgical approach. Routine
cal management, and 4) specific benign lesions such laboratory testing should include a complete blood
as extensive condyloma acuminata and hidradenitis count, serum electrolytes, age-appropriate health screen-
suppurativa. As partial simple vulvectomy is performed ing studies, and electrocardiogram for women aged
for preinvasive disease, concomitant inguinofemoral 50 years and older. Preoperative imaging is unnecessary.
lymphadenectomy is not indicated. Lower genital tract Prophylactic antibiotics (Cephazolin 1, Cefotetan
dysplasia may be multifocal; therefore, a thorough 1 to 2 g, or Clindamycin 800 mg) should be admin-
examination of the vulva, vagina, and cervix for preinva- istered 30 minutes prior to incision, and thromhoem,
sive and invasive disease is a prerequisite. bolic prophylaxis (e.g., pneumatic compression devices
Surgical principles for partial simple vulvectomy dic- and subcutaneous heparin} should he initiated prior to
tate only that a visibly disease-free margin of tissue be surgery if the procedure is expected to last more than

105
106 SEcnON II GYNECOLOGIC ONCOLOGY

30 minutes. The instrumentation required includes a of incision should give specific consideration to the
basic vaginal surgery set and candy-cane or Allen Uni- plan for wound closure and ensure that the wound can
versal Stirrups (Allen Medical Systems, Cleveland, be closed in a tension-free fashion. Primary closure
OH). Enemas should be administered the evening is achieved by raising the surroWlding vulvar skin as
before surgery, but a full mechanical bowel preparation advancement flaps and suturing it to the mucosa of the
is unnecessary. vestibule. If a tension-free closure is not achievable,
the woWld can be left open and covered with a nonad-
herent dressing to close by secondary intention.
SURGICAL TECHNIQUE The typical skin incision for total simple vulvectomy
(Chapter 14) is oval-shaped and extends from an ante-
Either general or regional anesthesia is acceptable. rior apex superior to the clitoris laterally through the
The patient should be positioned in dorsal lithotomy skin of the labia majora and medially to meet in the
position using Allen-type or candy-cane stirrups with midline at the perineal body (Figure 13.1 ). The inci-
the buttocks protruding slightly over the edge of the sion for partial simple vulvectomy will encompass one
operating table. The vulva and vagina are prepped and or more regions of vulva, encompassed by simple total
a Foley catheter is placed. Examination under anes- vulvectomy, defined by a midline axis and a transverse
thesia should pay particular attention to the size and axis through the introitus (Figure 13.1). As such, the
topography of the vulvar lesion, mobility of surrounding partial simple vulvectomy can be described as "ante-
tissues, the vagina and cervix {to exclude a synchronous rior," "posterior," ('extended posterior," "right or left
lesion), and the inguinofemorallymph nodes. hemivulvectomy," or some combination (e.g., "anterior,
The surgical margins are outlined with a surgical right hemivulvectomy"). For cases of extensive disease
marking pen, allowing a 3- to 5-mm margin of normal- on the posterior vulva and perianal region, the incision
appearing tissue in all directions. The resection is line extends posteriorly around the anus to the interg]u-
typically limited to the skin of the vulva and mucosa teal cleft as far as necessary to encompass the disease
of the vaginal vestibule. Surgical planning at the time ("extended posterior vulvectomy'').

Anterior partial
simple vul~ect~)mv

Extended posterior partial


simple vulvectomy
FIGURE 13.1 Delineation of incision lines for total simple vulvedomy and variants of partial
simple vulvedomy.
CHAPTER 13 Simple Vulvectomy-Partial 107

The following example is a left partial simple vulvec- in part or in its entirety, to facilitate re-approximating
tomy. The incision line should be injected with local the skin edges and achieve a tension-free closure.
anesthetic (1% plain lidocaine or 0.25% marcaine) to The dissection proceeds simultaneously from lateral
1) improve postoperative pain control and 2) help to medial and from anterior to posterior, down the mons
delineate the appropriate subcutaneous plane of dis- pubis and around the clitoris (or inclusive of the clito-
section. The proper plane of dissection is better ris, if clitorectomy is required}. Traction and counter-
defined anteriorly. As such, the incision and dissection traction should be applied by the surgeon and assistant
for partial simple vulvectomy is initiated anteriorly and using a series of Allis clamps to facilitate exposure of
the posterior dissection, which may be accompanied the correct plane of dissection. The medial incision is
by more blood loss secondary to less well-defined tis- extended inferiorly to meet the outline of the inner mar-
sue planes, is deferred to the end of the procedure. gin of resection. The skin incisions are then extended
The incision is initiated at the apex of the vulva and further posteriorly to the base of the labia majora or
carried laterally over the labia majora to a point mid- lower, depending on the extent of resection, and along
way between the apex and the perineal body as well the perineal body. Dissection with the ESU is in the
as down the midline, encompassing the disease with a subcutaneous plane and proceeds from lateral to medial
visibly disease-free margin. Generally, the knife blade and posterior to anterior, working toward the inner
is used for the skin incision to preserve interpretability resection margin at the introitus. Superficial branches
of the surgical margins of resection. The electrosurgi- of the internal pudendal artery are ligated and divided
cal unit (ESU) is used for all subsequent dissection to as they are encountered. The specimen is removed and
minimize blood loss. Using the ESU, the dissection hemostasis obtained by a combination of the ESU and
proceeds into the superficial subcutaneous tissue until 3-0 delayed absorbable sutures in figure-of-eight stitches
the plane between the skin and labial fat pad becomes (Figure 13.3). In circumstances with disease extend-
apparent (Figure 13.2). This is the correct plane of ing to the perianal region, the posterior resection mar-
dissection for simple partiaJ/total vulvectomy. The gins are carried around the anus to the intergluteal cleft.
labial fat pad should be spared to the greatest extent Closure of the underlying fatty tissue layer with
possible to preserve the normal contour of the vulva. interrupted stitches of 3-0 delayed absorbable suture
However, the labial fat pad may need to be sacrificed, (layered closure) has the dual advantage of obliterating

FIGURE 13.2 Partial simple vulvectomy: Anterior and lateral dissection in the subcutaneous plane.
108 SECTION II GYNECOLOGIC ONCOLOGY

Area of undennlnlng of
subcutaneous material
FIGURE 13.3 Surgical defect after completed partial simple vulvectomy.

dead space to reduce the chance of seroma formation POSTOPERATIVE CONSIDERATIONS


and redistributing tension from the skin closure into
the subcutaneous tissues. Anteriorly, the skin edges are The primary issues during the postoperative period
re-approximated in a vertical direction using a series of are local wound care and pain control. Ambulation
interrupted simple stitches or vertical mattress stitches should begin on postoperative day #1 or even the
of 2-0 delayed absorbable suture. Laterally, the vulvar evening of surgery for more limited resection cases.
skin is re-approximated to the mucosa of the vestibule, Forced constipation may be advantageous in the
again using a series of interrupted simple stitches or ver- case of extensive posterior or perianal dissection.
tical mattress stitches of 2-0 delayed absorbable suture Otherwise, no measures are required to restrict
(Figure 13.4). It is especially important to avoid ten- bowel movements. A stool softener should be pre-
sion on the suture line in the region of the urethra, as scribed routinely and continued for 1 to 2 weeks
this may distort the urethra and affect micturition and/or postoperatively. The perineum should be kept clean
continence. If a tension-free closure cannot be obtained and dry. Sitz baths are to be avoided, as they tend
in the periurethral region, the area should be left open, to macerate the tissue and increase the likelihood
dressed with Vaseline-impregnated gauze, and allowed of wound separation. The timing of Foley catheter
to heal by secondary intention. The posterior/lateral vag- removal should be tailored to the extent of resection
inal wall can be undermined, if necessary, and advanced and proximity to the urethra. If the margins of resec-
distally to reach the margin of the vulvar skin. tion are remote from the urethra and unlikely to be
If the defect is not able to be closed in a tension- exposed to urine during voiding, then the catheter
free fashion, the lateral vulvar tissue is undermined and is removed on postoperative day # 1. If the resection
advanced. The lateral vulvar tissue can be undermined involves the distal urethra or the margins are in close
out to the medial thigh. Reducing hip flexion and proximity, it may be advisable to leave the catheter
abduction may facilitate this process. Alternatively, one in place for several days until the raw wound edges
or more rotational flaps of skin and subcutaneous tissue have sealed. Discharge from the hospital is indi-
("rhomboid" flap} can be raised and advanced to cover cated once adequate pain control is achieved with
defects laterally or posteriorly, or a split-thickness skin oral analgesia and the patient is tolerating a regular
graft can be used to cover the defect. diet.
CHAPTER 13 Simple Vulvectomy-Partial 109

FIGURE 13A aosure of operative defect after partial simple vulvectomy.

Operative Note underlying subcutaneous tissue was re-approximated in


layers using interrupted stitches of 3-0 delayed absorbable
PROCEDURE: SIMPLE surure. The skin edges were re-approximated with 2-0
VULVECTOMY-PARTIAL delayed absorbable sutures in vertical mattress stitches.
The closure was tension-free and hemostatic.
The vulvar lesion was demarcated with a 3- to 5-mm mar-
gin of normal-appearing tissue using a swgical marking
pen prior to prepping and draping the vulva and perineum. COMPLICATIONS
The resection line was injected. with 0.25% marcaine
solution. The anterior vulvar incision was created using • Tension on the wotmd closure will lead to
the knife blade. The specimen was grasped with Allis wound breakdown with potential infection and
clamps and the ESU was used to develop the correct tissue necrosis.
plane of dissection in the subcutaneous tissue beginning • The most common complications after partial
anteriorly and working from lateral to medial and anterior simple vulvectomy are wotmd separation and
to posterior. The dissection was carried inferiorly, lateral infection, urinary tract infection, and thrombo-
to the clitoris, and around the lateral aspect of the introi- embolic events.
tus. Superficial branches of the internal pudendal arte:ry
were ligated and divided as they were encotmtered. The
posterior vulvar incision was extended using the knife Suggested Reading
blade and the subcutaneous tissue dissection continued
1. AyhanA, Tuncer ZS, Dogan L, Yuce K, Kucukali T. Skin-
using the ESU. The specimen was excised and hemosta-
ning vulvectomy for the treatment of vulvar intraepithe-
sis achieved using a combination of 3-0 delayed absorb-
lial neoplasia 2-3: a study of 21 cases. Eur J Gynecol
able surure ligarures and electrocautery. Oncol1998;19:5018-510.
The lateral skin and subcutaneous tissue of the vulva 2. Kaufman RH. lntraepithelial neoplasia of the vulva.
was undermined out to the medial thigh and an advance- Gynecol Oncol1995;56:8-21.
ment flap was raised. The posterior and lateral vaginal 3. Rettenmaier MA. Bennan ML, DiSaia PJ. Skinning vul-
margins or resection were similarly tmdermined to achieve vectomy for the treatment of multifocal vulvar intraepi-
satisfactory mobility for a tension-free closure. The thelial neoplasia. Obstet Gynecoll987;69:247-250.
CHAPTER 14

Simple
Vulvectomy-Total
Robert E. Bristow

INTRODUCTION of disease with regard to the clitoris. If the clitoris is


uninvolved by disease, it should be preserved.
The purpose of the total simple vulvectomy is removal
of the skin and subcutaneous tissues of the vulva. Total
simple vulvectomy is associated with a less appeal- PREOPERATIVE CONSIDERATIONS
ing cosmetic alteration in the vulva compared to the
partial resection procedure described in Chapter 13. In preparation for total simple vulvectomy, all patients
Total simple vulvectomy is indicated for treatment should undergo a comprehensive history and physi-
of: 1) extensive vulvar intraepithelial neoplasia that cal examination focusing on those areas that may
is not amenable to ablative (e.g., col laser and cavi- indicate a reduced capacity to tolerate surgery or
tational ultrasonic surgical aspirator} therapy or for disease-related characteristics (e.g., primary lesion
lesions that require complete pathological evaluation clinically suspicious for invasive cancer, and ingui-
to exclude an underlying invasive cancer, 2) Paget dis- nal adenopathy) that might dictate a more radical
ease of the vulva without suspicion for an underlying surgical approach. Routine laboratory testing should
adenocarcinoma, 3) selected cases of lichen sclerosis include a complete blood count, serum electrolytes,
unresponsive to medical management, and 4) specific age-appropriate health screening studies, and elec-
benign lesions such as extensive condyloma acwninata trocardiogram for women aged 50 years and older.
and hidradenitis suppurativa. As total simple vulvec- Preoperative imaging is unnecessary.
tomy is performed for preinvasive disease, concomitant Prophylactic antibiotics (Cephazolin 1, Cefotetan
inguinofemoral lymphadenectomy is not indicated. 1 to 2 g, or Clindamycin 800 mg) should be admin-
Lower genital tract dysplasia may be multifocal; there- istered 30 minutes prior to incision, and thromboem-
fore, a thorough examination of the vagina and cervix bolic prophylaxis (e.g., pnewnatic compression devices
for preinvasive and invasive disease is a prerequisite. and subcutaneous heparin} should be initiated prior to
As with partial simple vulvectomy, a visibly dis- SUigery. The instrumentation reqltired includes a basic
ease-free margin of the full thickness of vulvar skin vaginal surgery set and candy-cane or Allen Universal
and mucosa is all that is required, usually 3 to 5 mm. Stirrups (Allen Medical Systems, Cleveland, OH).
The classic total simple vulvectomy removes the vul- Enemas should be administered the evening before
var skin and superficial fat including the clitoris with surgery. Preoperative mechanical bowel preparation
prepuce, the labia minora, the labial fat pads, and the (oral polyethylene glycol solution or sodium phosphate
labia majora to the junction of the hair-bearing and solution with or without bisacodyl) is unnecessary
non-hair-bearing skin. Contemporary practice dictates unless an extensive resection is anticipated around the
a more individualized approach tailored to the extent anus including the anal skin.

111
112 SECTION II GYNECOLOGIC ONCOLOGY

SURGICAL TECHNIQUE The incision for total simple vulvectomy is initiated


at the apex of the vulva and carried laterally over the
Either general or regional anesthesia is acceptable. labia majora to a point midway between the apex and
The patient should be positioned in dorsal lithotomy the perineal body. Generally, the knife blade is used
position using Allen-type or candy-cane stirrups with for the skin incision to preserve interpretability of the
the buttocks protruding slightly over the edge of the surgical margins of resection. The electrosurgical unit
operating table. The vulva and vagina are prepped and (ESU) is used for all subsequent dissection to minimize
a Foley catheter placed. Examination under anesthesia blood loss. Using the ESU, the dissection proceeds
should pay particular attention to the size and topog- into the superficial subcutaneous tissue until the plane
raphy of the vulvar lesion(s), the vagina and cervix (to between the skin and labial fat pad becomes apparent
exclude a synchronous lesion), and the inguinofemo- (Figure 14.2). This is the correct plane of dissection
rallymph nodes. for simple partial/total vulvectomy. In the typical case,
The outer and inner surgical margins of dissection the labial fat pad will need to be removed to facilitate
are outlined with a surgical marking pen. The typi- a tension-free wound closure. However, if there is suf-
cal outer skin incision for total simple vulvectomy is ficient laxity in the lateral vulvar skin, the labial fat pad
oval shaped and extends from an anterior apex supe- may be preserved. The dissection proceeds from ante-
rior to the clitoris laterally through the skin of the rior to posterior (down the mons pubis) and from lateral
labia majora and medially to meet in the midline at to medial (across the labia majora). Traction and coun-
the perineal body (Figure 14. 1). For cases of exten- tertraction using a series of Allis clamps on the speci-
sive disease on the posterior vulva and perianal region, men and preserved vulvar tissue should be applied by
the incision line extends posteriorly around the anus the surgeon and assistant to facilitate exposure of the
to the intergluteal cleft as far as necessary to encom- correct plane of dissection.
pass the disease. The inner incision circumscribes the If clitorectomy is to be performed, the anterior
vaginal vestibule, extends around the urethra, and may dissection is extended inferiorly, removing a wedge-
extend anteriorly around the prepuce of the clitoris if shaped area of tissue (to facilitate closure) down to the
clitorectomy is not required. The incision line should suspensory ligament of the clitoris. The clitoris and its
be injected with local anesthetic ( 1% plain lidocaine associated vasculature are clamped and divided just
or 0.25% marcaine) for the purposes of postoperative beneath the skin and vestibular mucosa and suture
pain control and to help delineate the appropriate sub- ligated with 2-0 delayed absorbable suture. For sim-
cutaneous plane of dissection. ple vulvectomy, there is no need to dissect into the

Inner Incision

Total simple
vulvectomy----!

Extended total
simple vu ~teeltomy"""'!.,.£--..,i-1

FIGURE 14.1 Delineation of incision lines for total simple vulvectomy variations.
CHAPTER 14 Simple Vulvectomy-Total 113 _ __

Bisection line to
facilitate clitoral
preservation---r-1--~~~i\1

FIGURE 14.2 Total simple vulvectomy: Anterior and lateral dissection in the subcutaneous plane.

deeper tissue around the base of the clitoral shaft, as carried around the urethra and continued to the inner
the venous plexus in this area can produce troublesome incision on either side. The specimen is removed and
bleeding if injured. If clitorectomy is not required, the hemostasis obtained by a combination of the ESU and
anterior dissection in the subcutaneous tissue is car- 3-0 delayed absorbable sutures in figure-of-eight stitches.
ried down to the prepuce of the clitoris, which is then The most important aspect of closing the vulvar
circumscribed, and the incision line is extended later- defect is that the re-approximation of tissue edges he
ally and inferiorly to meet the inner incision. Bisecting tension-free. If necessary to facilitate closure, the labial
the anterior half of the specimen down to the clitoral fat pads and some of the anterior vulvar subcutaneous
prepuce may facilitate making the circumscribing inci- tissue may he removed. The subcutaneous tissue of the
sion for clitoral preservation (Figure 14.3). lateral vulva is undermined out the medial thigh and
Once this phase of the dissection has been completed, advanced to reach the mucosa of the vaginal vestibule.
the lateral skin incisions are extended further posteriorly The posterior and lateral vaginal walls can be under-
to the base of the labia majora or lower, depending on mined and advanced if necessary. Reduction of hip flex,
the extent of posterior vulvar resection, and across the ion and abduction will facilitate closure. Anterior to the
perineal body. Dissection with the ESU is in the subcu- urethra, the skin edges are re-approximated in a vertical
taneous plane and proceeds from lateral to medial and direction using a series of interrupted simple stitches
posterior to anterior, working toward the inner incision or vertical mattress stitches of 2-0 delayed absorbable
at the introitus. The superficial branches of the inter, suture. Closure of the underlying fatty tissue layer with
nal pudendal artery are ligated and divided as they are interrupted stitches of 3-0 delayed absorbable suture
encountered. A separate inner incision is created around {layered closure) has the dual advantage of obliterating
the urethral meatus and around the introitus just distal dead space to reduce the chance of seroma formation
to the hymenal ring (unless disease extends onto the and redistributing tension from the skin closure into
hymenal ring into the vagina canal). The lateral dissec, the subcutaneous tissues. Laterally, the vulvar skin is
tion plane is carried medially to connect with the inner re-approximated to the mucosa of the vestibule, again
incisions. Alternatively, if the specimen is split down using a series of intemlpted simple stitches or verti-
the midline during clitoral preservation, this incision is cal mattress stitches of 2,0 delayed absorbable suture.
114 SEcnON II GYNECOLOGIC ONCOLOGY

~I'T'~~~-HIIf;"-Urethral
meatus
--1--- Vagina

FIGURE 14.3 Surgical defect after completed total simple vulve<tomy.

Excessive dead space within the lateral subcutaneous no measures are required to restrict bowel movements.
tissue should be obliterated using the layered closure A stool softener should be prescribed routinely and con-
technique prior to skin closure. The posterior vulva tinued for 1 to 2 weeks postoperatively. The timing of
can be closed in either a vertical or transverse fashion, Foley catheter removal should be tailored to the extent
whichever produces the best cosmetic result with the of resection and proximity to the urethra. If the margins
least amount of tension (Figure 14.4). Tension on the of resection are remote from the urethra and unlikely to
suture line in the region of the urethra may distort the be exposed to urine during voiding, then the catheter
anatomy and affect micturition and/or continence. If can be removed on postoperative day #1. If the resec-
efforts to achieve a tension-free closure fail, the wound tion involves the distal urethra or the margins are in
can be left open and covered with a nonadherent dress- close proximity, it may be advisable to leave the catheter
ing to close by secondary intention. in place for several days until the raw wound edges have
sealed. Discharge from the hospital is indicated once
adequate pain control is achieved with oral analgesia
POSTOPERATIVE CONSIDERATIONS and the patient is tolerating a regular diet.

During the immediate postoperative period, specific


attention should be directed toward pain control and Operative Note
keeping the vulvar area clean and dry. Sitz baths are
not recommended, as they tend to macerate the tis- PROCEDURE: SIMPLE
sue and increase the likelihood of wound separation. VULVECTOMY-TOTAL
Ambulation should begin on postoperative day # 1.
Forced constipation for several days will help reduce the A smgical marking pen was used to delineate the vulvec-
risk of contamination of the surgical wound in the case tomy resection, beginning at the apex above the clitoris
of extensive posterior or perianal dissection. Otherwise, on the mons pubis, extending inferiorly and laterally along
CHAPTER 14 Simple Vulvectomy-Total 115 _ __

FIGURE 14.4 aosure of operative defect after total simple vulvectomy.

the junction of the hair-bearing and non-hair-bearing tis- the ESU, working from lateral to medial and from pos-
sue of the labia majora, crossing the perineal body and terior to anterior toward the inner incision line. Super-
meeting in the midline. A 3- to 5-nun margin of nonnal- ficial branches of the internal pudendal artery were
appearing tissue was ensured in all directions. A second, ligated and divided as they were encountered. The
inner incision was delineated with the swgical marking inner incision was completed using the cutting current
pen just distal to the hymenal ring and circumscribing the of the ESU and the specimen excised. Hemostasis was
urethra and clitoris. The vulva was prepped and draped achieved using a combination of 3..0 delayed absorbable
and a Foley catheter inserted. Both outer and inner inci- suture ligatures and electrocautery.
sion lines were injected with 0.25% marcaine solution. The anterior and lateral skin and subcutaneous tissue
The resection was initiated anteriorly by incising of the vulva were undermined out to the medial thigh.
the skin of the mons pubis and lateral vulva with the Intenupted simple stitches of 3-0 delayed absorbable
knife blade and extending the skin incision down to a suture were used to re-approximate the subcutaneous
level approximating the midpoint of the introitus. The tissue and fat anteriorly and laterally on either side of
specimen was grasped with Allis clamps and the ESU the vulva. Anteriorly, the skin edges were closed in a
was used to develop the correct plane of dissection in vertical direction using a series of vertical mattress
the subcutaneous tissue beginning anteriorly and work- sutures of 2-0 delayed absorbable suture down to the
ing from lateral to medial and anterior to posterior. clitoris. The lateral vulvar skin edges were re-approxi-
The labial fat pads were preserved. The anterior por- mated to the mucosa of the vestibule, again using a
tion of the specimen was bisected down the midline series of vertical mattress stitches or intenupted simple
to the level of the prepuce of the clitoris. 1his incision stitches of 2-0 delayed absorbable suture. The poste-
was carried inferiorly, circumscribing the clitoris and rior vaginal wall was undermined and advanced distally,
urethra to join the inner incision at the introitus. The and the posterior vulvar defect closed in a transverse
lateral vulvar incisions were extended posteriorly and direction using vertical mattress stitches of 2-0 delayed
medially across the perineal body using the knife blade. absorbable suture. The closure was tension-free and
The subcutaneous tissue dissection was continued with hemostatic.
116 SEcnON II GYNECOLOGIC ONCOLOGY

Suggested Reading
COMPLICATIONS
I. Black D, Tomos C, Soslow RA, Awtrey CS, Barakat RR,
• Tension on the wound closure should be Chi DS. The outcome of patients with positive margins
avoided, as this will lead to wound breakdown after excision for intraepithelial Paget's disease of the
vulva. Gynecol Oncol2007;104:547-550.
with potential infection and tissue necrosis.
2. Edwards CL, Tortolero-Luna G, Linares AC, et al. Vul-
• Total simple vulvectomy produces an undesir-
var intraepithelial neoplasia and vulvar cancer. Obstet
able cosmetic result and should not be under- Gynecol Clin North Am 1996;23:295-324.
taken if a more conservative resection will yield 3. Jones RW, Rowan DM, Stewart AW. Vulvar intraepithe-
adequate disease control. lial neoplasia: aspects of the natural history and outcome
• The most conunon complications after total on 405 women. Obstet Gynecol 2005; I06:13 I 9-1326.
simple vulvectomy are wound separation and
infection, urinary tract infection, and thrombo-
embolic events.
• Excessive deep dissection in the region of the
clitoral shaft can be associated with profuse
bleeding from the associated venous plexus.
CHAPTER

Radical Vulvectomy
Robert E. Bristow

INTRODUCTION Stages II-IVA: nonlateralized T2 lesions (>2 em in


maximal diameter), T3 lesions (adjacent spread to the
Radical vulvectomy has two major variations: en bloc lower urethra, vagina, or anus}, and T4 lesions (spread
radical vulvectomy and bilateral inguinal lymphad- to the upper urethra, bladder or rectal mucosa, or
enectomy and the technique with separate vulvar and pubic hone) not amenable to radical wide excision or
groin incisions. Historically, all cases of vulvar cancer combined chemoradiation. Additional indications may
were treated by the classic en bloc radical vulvectomy include extensive Paget disease of the vulva with an
popularized by Stanley Way in the 1950s and 1960s. underlying adenocarcinoma, advanced adenocarci-
This procedure demonstrated superior outcomes com- noma of the Bartholin gland with infiltration of vulvar
pared to simple vulvectomy and as a result became the soft tissues, locally advanced vulvar melanoma with-
therapeutic approach for virtually all cancers of the out evidence of regional or distant spread, and exten-
vulva. Advances in the understanding of disease etiol- sive verrucous carcinoma of the vulva (generally not
ogy, natural history, and prognostic factors precipitated treated with radiation therapy, which may aggravate
changes in practice focusing more on individualization the disease and lead to dedifferentiation). Extensive
of care and paralleled the more contemporary reali- hidradenitis suppurativa not amenable to more con-
zation that it is possible to adhere to the important servative resection may also he managed by radical
principles of wide excision of the prima:ry tumor and vulvectomy, although there is no requirement for for-
diagnostic/therapeutic removal of groin lymph nodes mal node dissection.
without performing radical vulvectomy with bilateral Traditionally, radical vulvectomy is defined by
inguinal lymphadenectomy on all patients. In addi- a visibly normal tissue resection margin of at least
tion, recent advances in irradiation therapy combined 2 em in all directions; the deep margins of resec-
with sensitizing chemotherapy have greatly reduced tion are the pubic aponeurosis anteriorly, the pubic
the requirement for radical vulvectomy as primaxy rami and superficial perineal fascia laterally, and
treatment of locally advanced vulvar cancer. Today, the the levator plate/ischiorectal fossa/anal sphincter
procedure using separate groin incisions (or wide radi- posteriorly. At least one study has suggested that a
cal excision, described in Chapter 17) is the preferred I em margin of uninvolved tissue prior to pathologi-
technique for most cases of locally advanced disease cal processing may be adequate, and this is particu-
not amenable to treatment with chemoradiation, since larly applicable to the areas of the perineal body/
it is associated with less risk of wound breakdown and rectovaginal septum and introitus/urethra, where a
overall morbidity. 2-cm surgical margin may he impractical due to the
The most common indication for radical vulvec- proximity of underlying or juxtaposed structures to
tomy is invasive squamous carcinoma of the vulva he retained.

111
118 SEcnON II GYNECOLOGIC ONCOLOGY

PREOPERATIVE CONSIDERATIONS and consists of a curvilinear incision connecting a point


2 em medial and 2 em inferior to each anterior superior
In preparation for radical vulvectomy; all patients iliac spine and extending along the superior border of
should undergo a comprehensive history and physical the mons pubis. Lateral incisions are created by extend-
examination focusing on those areas that may indicate ing downward along the groin crease into the labiocru-
a reduced capacity to tolerate surgery. The vagina and ral folds on each side. The lateral incisions are carried
cervix should be thoroughly evaluated to exclude a syn- into the posterior vulva and directed medially and ante-
chronous lesion or metastatic lesion. Routine laboratory rior to the anus tailored to the extent of disease.
testing should include a complete blood count, serum The procedure is best initiated by starting anteriorly,
electrolytes, age-appropriate health screening studies, with the patient's thighs flexed at a 15° angle in the Allen
and electrocardiogram for women aged 50 years and stirrups; the legs are repositioned into hyperflexion later to
older. Preoperative computed tomography imaging of facilitate the posterior dissection. Using the knife blade,
the abdomen and pelvis is advisable, particularly if the the skin of the anterior portion of the specimen is incised
groin nodes are clinically suspicious. A chest radiograph down to midpoint of the vulva. The electrosurgical unit
should be obtained, or alternatively computed tomogra- (ESU) is utilized for deeper dissection.
phy scanning can be extended to include the chest. The anterior curvilinear incision is extended into
Prophylactic antibiotics (Cephazolin 1, Cefotetan the deep tissues between the lower abdominal wall
1 to 2 g, or Clindamycin 800 mg) should be admin- and upper border of the mons pubis, through Camper's
istered 30 minutes prior to incision, and thromboem- fascia and Scarpa's fascia, exposing the lower border
bolic prophylaxis (e.g., pneumatic compression devices of the anterior rectus sheath fascia and inguinal liga-
and subcutaneous heparin) should be initiated prior to ments. An advancement flap of anterior abdominal wall
surgery. The instrumentation required includes a basic skin and subcutaneous fat is then raised superiorly
vaginal sUigery set and Allen Universal Stirrups (Allen from the anterior rectus sheath to facilitate incision
Medical Systems, Cleveland, OH). Enemas should be closure. This flap can be extended as far as the umbi-
administered the evening before surgery. Preopera- licus if necessary. Working inferiorly, the subcutane-
tive mechanical bowel preparation (oral polyethylene ous tissue is dissected off the underlying symphysis
glycol solution or sodium phosphate solution with or pubis, and the lateral incisions of each groin are car-
without bisacodyl) combined with forced constipation ried into the subcutaneous tissue and extended down
for a period of several days may facilitate healing by to the labiocrural folds, exposing the femoral triangle
reducing the likelihood of fecal contamination of the on each side {Figure 15.2). The superficial epigastric
incision in the immediate postoperative period if there and external pudendal vessels are ligated with 2-0 or
is an extensive posterior component to the dissection. 3-0 delayed absorbable suture and divided as they are
encountered. At this point, the bilateral inguinofemoral
lymphadenectomy is performed (Chapter 16).
SURGICAL TECHNIQUE Following completion of the inguin.ofemorallymph-
adenectomy, the anterior portion of the specimen is
Either general or regional anesthesia is acceptable. The undermined along the fascia of the anterior abdomi-
patient should be positioned in dorsal lithotomy posi- nal wall and medial thigh. Closed suction drains are
tion using Allen-type stirrups with the buttocks pro- placed in each groin and brought out through sepa-
truding slightly over the edge of the operating table. rate incisions in the lateral abdominal wall. The groin
The vulva, vagina, and thighs are prepped and a Foley incisions are closed in layers using interrupted simple
catheter is placed. Examination under anesthesia stitches of 3-0 delayed absorbable suture. The skin
should pay particular attention to the size and topogra- can be closed with staples or a series of vertical mat-
phy of the vulvar lesion, the vagina and cervix, and the tress sutures of 2-0 or 3-0 delayed absorbable sutures.
groin lymph nodes. The legs are repositioned into hyperflex:ion {45° or
more) to provide exposure for the lower vulvar dissec-
tion (Figure 15.3). The labiocrural fold incisions are
En bloc radical vulvectomy
extended lateral to the labial fat pads, past the perineal
En bloc radical vulvectomy includes removal of the body, and then directed medially around the anus and
vulva, mons pubis, and a contiguous "hom" of skin and meeting in the midline. The specimen is drawn sharply
underlying fatty tissue extending from the vulva over downward and separated from the symphysis pubis
each groin (Figure 15.1). The skin incision is outlined until the lower border of the pubic arch is reached.
CHAPTER 15 Radical Vulvectomy 119

FIGURE 15.1 En bloc radical vulvectomy: Extent of the incision encompassing the entire vulva and a
nhorn" of contiguous skin and subcutaneous tissue overlying each groin.

The dissection is taken down to the pubic aponeurosis Primary closure of the en bloc radical vulvectomy
and the suspensory ligament of the clitoris. the clitoral defect requires that the incision margins be approxi-
shaft. and clitoral vessels are clamped. divided. and the mated in a tension-free fashion. which is especially
pedicle(s) secured with ],0 delayed absorbable suture important in the areas of the urethra and vagina. If the
ligatures. defect cannot be closed without tension. one of a vari-
The lateral incisions are developed down to the pubic ety of rotational or pedicle-based flaps can be utilized;
arches and the specimen dissected from the inferior however, a discussion of these is beyond the scope of
urogenital diaphragm working medially. The inferior this text. The anterior extent of the defect was closed
pudendal vessels are ligated with z,o or 3,0 delayed following completion of the inguinal lymphadenectomy.
absorbable suture and divided. The inner vulvar inci, The thighs are taken out of hyperflexion and the lateral
sion is created circumscribing the urethra and vaginal margins of the defect are undermined along the fascial
introitus. The dissection is carried inferiorly along the investments of the anterior and medial thighs. The dis,
inferior fascia of the urogenital diaphragm and around tal vaginal wall can be undermined for a short distance
the urethra. which is identified by palpating the Foley circumferentially. but extensive dissection around the
catheter. The specimen is reflected inferiorly and dis, urethra should be minimized. The wound is closed in
sected off the perineal body (Figure 15.4). The poste- layers with deep sutures of 2-0 or 3-0 delayed absorbable
rior dissection is completed by working from lateral to suture to obliterate dead space. Closed suction drains
medial. carefully dissecting the deep vulvar tissue from can be placed prior to closing the deep tissue layer and
the external anal sphincter and meeting in the midline brought out through separate stab incisions. Anterior
at the posterior fourchette. to the urethra. the skin edges are re-approximated in
120 SEcnON II GYNECOLOGIC ONCOLOGY

Symphysis pubis
Diverticular process wllh
round ligament
Superficial epigastric
vessels ligated

FIGURE 15.2 En bloc radical vulvectomy: Anterior incision exposing abdominal wall and groin node
dissection beds.

Groin Incisions closed

FIGURE 15.3 En bloc. radical vulvectomy: Vulvectomy phase after closure of groin defects; the specimen
is dissected from the symphysis pubis.
CHAPTER 15 Radical Vulvectomy 121

Clitoral Y8SS&Is ligated

FIGURE 15A En bloc radic.al vulvectomy: Posterior dissection of vulvectomy phase.

a vertical direction. Closure of the skin and superficial Separate incision radical vulvectomy
fat is best accomplished by a series of interrupted verti~
cal mattress stitches of 2-0 delayed absorbable suture
Separate incision radical vulvectomy and bilateral groin
(Figure 15.5). If a tension-free closure cannot be lymph node dissection accomplishes the same surgical
obtained in the periurethral region, the area should be objective as the en bloc procedure without removing
left open, dressed with Vaseline-impregnated gauze, the skin overlying each groin or a bridge of skin and
and allowed to heal by secondary intention. subcutaneous fat between the central vulvar resection

FIGURE 15.5 En bloc radical vulvectomy: Primary closure.


122 SEcnON II GYNECOLOGIC ONCOLOGY

and each groin node dissection (Figure 15.6). For rectocele), urinary incontinence, and chronic lower
separate incision radical vulvectomy, the bilateral groin extremity lymphedema. Rarely. osteomyelitis of the
lymph node dissections are performed first (Chapter pubic bone can occur.
16); the incisions are closed and the legs repositioned If there are no concerns about disrupting the vul-
before proceeding to the vulvectomy. The outer and var closure, ambulation should be initiated as early as
inner surgical margins of dissection to encompass the possible in the postoperative period. To reduce ten-
central vulvar resection described above are outlined sion on the incision lines, the patient should be posi-
with a surgical marking pen. The knife blade is used tioned with the hips slightly flexed while in bed. As
to make the oval-shaped outer skin incision, which with simple vulvectomy, sitz baths should be avoided,
extends from an anterior apex in the mons pubis lat- and the vulvar area should be kept clean and dry.
erally through the skin of the labia majora and medi- Routine thromboembolic prophylaxis should include
ally to meet in the midline at the perineal body. The both mechanical and pharmacologic measures until
ESU is used for the remainder of the dissection. With the patient is fully ambulatory; pharmacologic prophy-
the exception of removing the "horns" of tissue in the laxis should be continued for a period of several weeks
en bloc radical vulvectomy, the dissection and closure thereafter. The Foley catheter is removed once the
for separate incision radical vulvectomy is the same as patient is ambulatory but may be continued for 7 days
described above. if there has been extensive periurethral dissection.
Diet can be advanced as tolerated. Forced constipa-
tion is unnecessary unless there has been a significant
POSTOPERATIVE CONSIDERATIONS posterior (perianal) dissection, and avoidance of fecal
contamination is desirable. Because of the risk of
Radical vulvectomy. whether en bloc or as separate lymphedema of the lower extremities, it is advisable to
incision, with bilateral inguinal lymphadenectomy is have the patient fitted for anti-edema stockings in the
associated with a substantial risk (75%) of early postop- immediate postoperative period.
erative complications, most notably wound breakdown
and infection, thromboembolic events, urinary tract
infection, and lower extremity lymphedema. Because
Operative Note
of the extensive nature of the en bloc resection, elderly PROCEDURE: RADICAL VULVECTOMY
patients or those with preexisting cardiovascular dis-
ease are prone to myocardial infarction and cerebro- The patient was positioned in dorsal lithotomy posi-
vascular accidents. Late complications include sexual tion in Allen-type stirrups with the buttocks pro-
dysfunction, pelvic floor relaxation (e.g., cystocele and truding slightly over the edge of the operating table

1-+-+--Extended posterior
resection

FIGURE 15.6 Separate incision radical vulvectomy: Lines of incision.


CHAPTER 15 Radical Vulvectomy 123 _ _ __

and the thighs flexed at 15°. The en bloc radical ESU to dissect the posterior vulvar tissue from the
vulvectomy incision was outlined with a marking pen underlying external anal sphincter and posterior four-
and extended from a point 2-cm medial and 2-cm chette. All dissection areas were irrigated, inspected,
inferior to each anterior superior iliac spine in a cur- and noted to be hemostatic.
vilinear fashion along the superior border of the mons To facilitate a tension-free closure, the lateral mar-
pubis. The lateral incisions were drawn along the gins of the vulvar resection were undermined along
groin creases bilaterally. through the labiocrural folds, the fascial investments of the anterior and medial
and into the posterior vulva meeting in the midline thighs. The anterior abdominal wall advancement
anterior to the anus. The anterior aspect of the inci- flap was drawn downward, and the vulvar defect was
sion was created with the knife blade and taken down closed in layers with deep sutures of 3-0 delayed
to the midpoint of the vulva. The ESU was used to absorbable suture to obliterate dead space. Anterior
take the dissection down to the anterior abdominal to the urethra, the skin edges were re-approximated
wall fascia and inguinal ligament and to mobilize the in a vertical direction using a series of interrupted
"horns" of subcutaneous tissue overlying each groin. vertical mattress stitches of 2-0 delayed absorbable
The superficial epigastric and external pudendal ves- suture. The lateral margins were re-approximated to
sels were ligated and divided. An advancement flap the vaginal introitus using interrupted vertical mat-
of anterior abdominal wall skin and subcutaneous fat tress stitches of 2-0 delayed absorbable suture, with
was created by undermining the upper margin of the care taken to avoid tension on the periurethral tissue.
incision superiorly. Bilateral groin lymphadenectomy The posterior vulva was closed using the same tech-
was performed with removal of the superficial ingui- nique, with the suture line oriented vertically and to
nal and deep femoral lymph nodes bounded by the either side of the anus.
femoral triangle (inguinal ligament, medial border of
the sartorius muscle, and lateral border of the adduc-
tor longus muscle). The thighs were then flexed and COMPLICATIONS
closed suction drains were placed in the node dis-
section beds and brought out through separate inci- • Wound breakdown with potential infection
sions in the lower lateral anterior abdominal wall. and tissue necrosis occur in as many as 60% of
The groin incisions were irrigated and the deep tissue patients undergoing en bloc radical vulvectomy.
was closed in layers with interrupted stitches of 3-0 • Thromboembolic events and lower extremity
delayed absorbable suture. The groin skin incisions lymphedema are common complications in the
were then closed with a series of vertical mattress early postoperative period.
stitches of 3-0 delayed absorbable suture. • Elderly patients undergoing radical vulvectomy
Attention was then directed to the vulvar resection. are susceptible to myocardial infarction and
The thighs were repositioned into hyperllex:ion to pro- cerebrovascular accidents.
vide adequate exposure. The labiocrural fold incisions • Late complications include sexual dysfunction,
were extended lateral to the labial fat pads into the pelvic relaxation, and chronic lower extremity
posterior vulva and medially, meeting in the midline lymphedema.
anterior to the anus. The anterior specimen was dis-
sected off the pubic aponeurosis and the clitoral shaft
and associated vessels were clamped, divided, and
ligated with 2-0 delayed absorbable suture. Laterally,
the dissection was developed down to the pubic arches
Suggested Reading
and carried medially along the inferior fascia of the 1. Hacker NF, Leuchter RS, Berek JS, Castaldo TW;
urogenital diaphragm. The inferior pudendal vessels Lagasse LD. Radical vulvectomy and bilateral inguinal
were clamped, divided, and ligated with 3-0 delayed lymphadenedomy through separate groin incisions.
Obstet Gynecoll981;58:574-579.
absorbable suture. An inner incision was created with
2. Heaps JM, Fu YS, Montz FJ, Hacker NF, Berek JS.
the knife blade circumscribing the urethra and vaginal
Surgical-pathologic variables predictive of local recur-
introitus. The ESU was used to extend the dissection rence in squamous ceU carcinoma of the vulva. Gynecol
into the subcutaneous tissue and unify the central dis- Oncoll990;38:309-314.
section plane with those of the lateral dissections on 3. Way S, Hennigan M. The late results of extended radical
either side. The specimen was drawn downward and vulvectomy for carcinoma of the vulva. J Obstet Gynae-
the posterior dissection was completed by using the col Br Commonw 1966;73:594-598.
CHAPTER 16

Inguinal Lymphadenectomy
Robert E. Bristow

INTRODUCTION thought to represent the secondary node basin before


drainage into the deep pelvic nodes occurs. The most
Inguinal lymphadenectomy is primarily indicated for proximal deep femoral node, Cloquet's node, is located
the diagnostic assessment and/or treatment (resec- in the femoral canal just beneath the inguinal ligament.
tion of gross adenopathy) of squamous carcinoma of Lymphatic drainage of the vulva follows a systematic
the vulva. Inguinal lymphadenectomy is an essential flow pattern from the posterior vulva to the anterior
component of therapy for almost all patients tmder- region on either side, always running medial to the
going primary surgery for vulvar cancer of squamous labiocrural fold. The mons pubis and anterior vulva
histology. With the exception of patients with low-risk contain drainage pathways to the contralateral groin
Stage IA disease (lateralized lesion, tumor size <2 em, (Figure 16.1). For lateralized lesions (;2!:2 em from
maximwn depth of invasion ~ 1 mm, absence of lym- the midline) in the mid- to posterior-vulva, a unilateral
phovascular space invasion, clinically negative groins), inguinal lymphadenectomy is sufficient unless there
either unilateral or bilateral inguinal lymphadenectomy are grossly suspicious or pathologically positive nodes
is indicated depending on the size, location, and later- in the ipsilateral groin. For lesions located <2 em from
ality of the primary lesion. Recent data indicate that the midline, lesions on the anterior vulva, and patients
sentinel lymph node biopsy may be a safe and accurate with grossly or pathologically positive ipsilateral groin
alternative to inguinal lymphadenectomy for patients nodes, a bilateral inguinal lymphadenectomy is the pro-
with Stage I and II squamous tumors. Inguinal lym- cedure of choice. The risk of pelvic node metastasis
phadenectomy is also indicated for patients with inva- increases c:Urectly with the size and nwnber of ingui-
sive adenocarcinoma of the vulva and vulvar melanoma nal nodes involved by disease. Approximately 25% to
as well as patients with invasive cancer of the lower 30% of patients with gross inguinal adenopathy and/or
one-third of the vagina. Rarely, inguinal lymphadenec- pathologic confirmation of disease in less than or equal
tomy is performed for the purpose of resecting gross to three nodes will have positive pelvic nodes. When
lymph node metastases and surrounding subclinical more than four groin nodes are positive for disease, the
nodal c:Usease as part of the therapeutic approach to risk of pelvic node spread increases to 60%.
selected patients with advanced ovarian or endometrial
cancers.
The superficial inguinal lymph nodes are almost PREOPERATIVE CONSIDERATIONS
always the primary node basin for cancers of the vulva
and usually include 8 to 10 lymph nodes. The deep Most patients undergoing inguinal lymphadenectomy
femoral nodes usually consist of three to five nodes, are will simultaneously require a radical vulvectomy or wide
located beneath the cribriform fascia, and are generally radical excision of the vulva and should be prepared

125
126 SEcnON II GYNECOLOGIC ONCOLOGY

FIGURE 16.1 Inguinal lymphadenectomy: Lpsilateral and contralateral vulvar lymphatic drainage pathways.

accordingly. All patients should undergo a comprehen- rotated and flexed at 15° or less to optimize exposme to
sive history and physical examination focusing on those the groin. A Foley catheter is placed as dictated by the
areas that may indicate a reduced capacity to tolerate operation for the primary lesion.
surgery. Routine laboratory testing should include a An 8- to 10-cm incision is drawn with a marking
complete blood count, serum electrolytes, age-appro· pen in the groin crease, 1 to 2 em below the ingui-
priate health screening studies, and electrocardiogram nal ligament, midway between the anterior supe-
for women aged 50 years and older. Preoperative com- rior iliac spine and the ipsilateral pubic tubercle
puted tomography imaging of the abdomen and pelvis is (Figure 16.2). It is useful to also mark the anatomic
advisable if the groin nodes are clinically suspicious or area of the femoral triangle by tracing a line from the
the primary lesion is large (>4 em). A chest radiograph anterior superior iliac spine to the medial femoral
should be obtained, or alternatively computed tomog- condyle (sartorius muscle) and a line from the pubic
raphy scanning can be extended to include the chest. tubercle to the lateral femoral condyle {adductor lon-
Prophylactic antibiotics (Cephazolin I g, Cefotetan gus muscle). The knife blade is used to create the
1 to 2 g, or Clindamycin 800 mg) should be admin- incision, which should be carried to a depth of approx-
istered 30 minutes prior to incision, and thromboem- imately 1 em, depending on patient body habitus and
bolic prophylaxis (e.g., pneumatic compression devices the amount of subcutaneous fat. The initial incision
and subcutaneous heparin) should be initiated prior to needs to be deep enough to facilitate creation of the
surgery. The instrumentation required includes a basic upper and lower skin/subcutaneous tissue flaps that
vaginal Sl.ligery set and Allen Universal Stirrups (Allen will not be so thin as to become devascularized. Once
Medical Systems, Cleveland, OH). Enemas should be the proper depth of incision has been attained, the skin
administered the evening before Sl.ligery. Preoperative and associated subcutaneous tissue are undermined
mechanical bowel preparation is not necessary unless using either the electrosurgical unit or sharp scissor
dictated by the extent of resection of the primary lesion. dissection. Superiorly, the tissue is undermined for a
to an extent at least 2 to 3 em above the superior mar-
gin of the inguinal ligament. The superficial epigas,
SURGICAL TECHNIQUE tric vessels are clamped, divided, and ligated with 3-0
delayed absorbable suture as they are encountered.
Either general or regional anesthesia is acceptable. The Inferiorly. the flap is raised for a distance of 8 em to
patient should be positioned in dorsal lithotomy posi- 10 em and encompasses the area of the femoral tri-
tion using Allen-type stirrups with the thighs externally angle previously demarcated. The lateral borders of
CHAPTER 16 Inguinal Lymphadenectomy 127_ _ __

--+--- Anterior supenor


iliac spine

• •

Anatomic area of
femorallrlangle
FIGURE 16.2 Inguinal lymphadenectomy: Line of incision; landmarks are the anterior superior iliac
spine and pubic tubercle.

the node dissection are defined by creating tunnels in empty space, and lymphatic space. The specimen is
the subcutaneous tissue underneath the preoperative reflected medially off the iliopsoas muscle (the femo-
markings delineating the medial and lateral margins ral nerve runs deep to this structure}, and the lateral
of the femoral triangle. The subcutaneous tunnels margin of the cribriform fascia is incised, exposing the
are developed with either gentle finger dissection or underlying femoral vessels. The femoral branch of the
a long Kelly clamp placed along the anatomic margin genitofemoral nerve runs parallel to the iliopsoas mus-
just above the fascia lata {Figure 16.3). cle along its medial margin and should be preserved.
The dissection begins at the superior margin of the The deep femoral nodal tissue beneath the cribriform
femoral triangle, where the node-containing fat pad is fascia is left attached to the superficial specimen and
elevated off the inguinal ligament. The dissection pro- resected en bloc. As the specimen is reflected medi-
ceeds systematically, working from superior to inferior ally off the femoral artery, the femoral vein is iden-
and from lateral to medial. The superficial circumflex tified and traced distally. The great saphenous vein
iliac vessels are located at the superior-lateral margin of enters the medial surface of the femoral vein and
the dissection and clamped, divided, and ligated with should be carefully dissected from within the super-
3-0 delayed absorbable suture (Figure 16.4). At the ficial and deep nodal fat pad and preserved if at all
superior-medial margin of the dissection, the superfi- possible (Figure 16.5). Preservation of the great
cial external pudendal vessels are identified, clamped, saphenous vein during inguinal lymphadenectomy has
divided, and ligated with 3-0 delayed absorbable suture. been shown to reduce both short- and long-term com-
As the dissection proceeds into the center of the plications without compromising treatment outcomes.
femoral triangle, the surgeon must be cautious of the The deep external pudendal artery is identified pass-
neural and vascular structures in this area. A use- ing just beneath the great saphenous vein as it enters
ful pneumonic for the location of the femoral nerve, the femoral vein. This arterial branch can be ligated
femoral artery, and femoral vein is N-A-V-E-L pro- with 3-0 delayed absorbable suture either medial or
ceeding from lateral to medial for nerve, artery, vein, lateral to the great saphenous vein, whichever location
128 SEcnON II GYNECOLOGIC ONCOLOGY

\\\ Ligated superficial

Pu

FIGURE 16.3 Inguinal lymphadenectomy: Raising superior and inferior skin flaps and development of
boundaries of femoral triangle dissection.

is more convenient. The most proximal of the deep skin flaps is re-approx:imated using a series of inter-
femoral nodes, Cloquet's node, is located within the rupted stitches of 3-0 delayed absorbable suture. The
femoral canal, just medial to the femoral vein, and skin incision can be closed with a series of vertical
should be removed if present and submitted separately mattress stitches of 3~0 delayed absorbable suture or
for pathologic analysis. The nodal fat pad is raised surgical clips. Placement of a pressure dressing may
until the medial margin of dissection, the adductor reduce the incidence and severity of postoperative
longus muscle, is reached. The dissection then pro~ lymphocyst formation and is left to the discretion of
ceeds toward the inferior margin, or apex, of the femo- the surgeon.
ral triangle, gently stripping the nodal tissue from the
underlying femoral vessels. Once the apex is reached,
a long Kelly clamp is placed across the distal aspect POSTOPERATIVE CONSIDERATIONS
of the specimen; the pedicle is divided and secured
with a ligature of 3-0 delayed absorbable suture and Patients Wldergoing inguinal lymphadenectomy are at
the specimen removed (Figure 16.6). increased risk for femoral deep vein thrombosis and
When a unilateral inguinal lymphadenectomy femoral artery thrombosis. Careful inspection of the
is planned for a small, lateralized lesion, the nodal lower extremities should be performed every 8 hours for
specimen should be sent for frozen section analy~ the first 48 hours. Both mechanical and pharmacologic
sis. If positive nodes are detected, the procedure is thromboembolic prophylaxis should be maintained
repeated on the contralateral side. The nodal dis- until the patient is fully ambulatory; the pharmacologic
section beds are irrigated and inspected for hemo- measure should be continued for a period of several
stasis. A closed-suction drain is placed and brought weeks thereafter. The patient may begin ambulation on
out through a separate stab incision in the lower postoperative day # 1 or as dictated by the extent of any
lateral abdominal wall. The groin defect is closed in concomitant vulvar resection. The woWld edges should
layers. The fatty tissue of the superior and inferior be inspected daily for the presence of necrosis. If the
CHAPTER 16 Inguinal Lymphadenectomy 129

Ligated superficial epigastric


artery and win

Anterior
supertor

~~

FIGURE 16.4 Inguinal lymphadenectomy: Anatomic boundaries and vascular structures of the superior
aspect of the dissection.

wound edges become dusky and necrotic, it can either Operative Note
be managed 1) conservatively with sterile dressings
with the expectation that the resulting defect will heal PROCEDURE: INGUINAL
by secondary intention or 2) by an immediate return to LYMPHADENECTOM Y
the operating room for excision of the necrotic wound
edges and reclosure of the incision. Anti-lymphedema The patient was positioned in dorsal lithotomy posi-
stockings should be fitted early in the postoperative tion in Allen,type stirrups with the buttocks protrud,
period, and while in bed the patient should keep her ing slightly over the edge of the operating table and the
legs elevated. Diet may be advanced as tolerated. The thighs flexed at 15°. A 10-cm incision in the groin crease,
closed suction groin drain may be removed once the 2 em below the inguinal ligament, was created using the
output is <20 cc/day. It is not uncommon for the drain knife blade. The incision was carried into the subcu-
output to increase in volume as the patient undertakes taneous fat for a distance of 1 em. The superior skin
progressively more vigorous ambulation, so the drains flap was raised and the dissection taken to the anterior
should not be removed prematurely. abdominal wall fascia above the inguinal ligament. The
130 SEcnON II GYNECOLOGIC ONCOLOGY

Iliopsoas musde wi1h


femoral nerve (under fascia)

Anterior superior

Uiac""\

Femoral artery
Deep external
pudendal artery

FIGURE 16.5 Inguinal lymphadenectomy: Medial mobilization of the nodal fat pad revealing the
underlying femoral vessels and gn:!at saphenous vein.

superficial epigastric vessels were clamped, divided, and from the underlying femoral vessels. The proximal deep
ligated with 3-0 delayed absorbable suture. The infe- femoral node (node of Cloquet) was removed from the
rior skin flap was raised in a similar fashion toward the femoral triangle and submitted separately. Care was
apex of the femoral triangle and the medial and lateral taken to preserve the great saphenous vein at its entrance
margins of the femoral triangle dissection was defined to the femoral vein. The dissection was carried medially
by developing subcutaneous tunnels with a large Kelly to the adductor longus muscle and then inferiorly. A
clamp. The superior aspect of the specimen was raised large Kelly clamp was placed across the specimen at the
off its attachments to the inguinal ligament and the apex of the femoral triangle and the pedicle divided and
superficial circumflex iliac vessels and superficial exter- secured with a ligature of 3-0 delayed absorbable suture.
nal pudendal vessels clamped, divided, and ligated. The nodal dissection bed was inigated and inspected
The dissection proceeded in a systematic fashion, for hemostasis. A closed-suction drain was placed and
working from superior to inferior and from lateral to brought out through a separate stab incision in the lower
medial. The femoral branch of the genitofemoral nerve lateral abdomen. The incision was closed in layers. The
was identified and preserved. The nodal fat pad was subcutaneous tissue was re-approximated with inter-
reflected medially off the iliopsoas muscle and the cribri- rupted stitches of 3-0 delayed absorbable suture. The
form fascia incised, exposing the deep femoral nodes and skin was closed with a series of vertical mattress stitches
femoral vessels. All nodal tissue was carefully stripped of 3-0 delayed absorbable suture. A dressing was applied.
CHAPTER 16 Inguinal Lymphadenectomy 131

Anterior superior
iliac spine

~ ~

Adductor
longus muscle-~~""

FIGURE 16.6 Inguinal lymphadenectomy: Completed dissection.

Suggested Reading
COMPLICATIONS
1. Hinten P, van der Einden LCG, Hendriks JCM, et al. Risk
• The most common early and late complications factors for short- and long-tenn complications after groin
associated with inguinal lymphadenectomy are surgeryforvulvarcancer. BrJCancer2011;105: 1279-1287.
2. Stehman FB, Bundy BN, Thomas G, et al. Groin dissec-
lower extremity lymphedema and lymphocyst
tion versus groin irradiation in carcinoma of the vulva.
fonnation.
IntJ Radiat Oncol Bioi Phys 1992;24:389-396.
• In the immediate postoperative period, the 3. Van der Zee AG, Oonk MH, de Hulla JA, et al. Sentinel
groin{s) should be examined every 8 hours for node dissection is safe in the treatment of early-stage
signs of femoral artery thrombosis and femoral vulvar cancer. J Clin Oncol2008;26:884-889.
deep vein thrombosis. 4. Zhang SH, SoodAK. Sorosky JL,Anderson B, Buller RE.
• Insufficient subcutaneous tissue on the superior Preservation of the saphenous vein during inguinal
and inferior skin flaps will lead to necrosis of the lymphadenectomy decreases morbidity in patients with
wound edges, which should be inspected daily. carcinoma of the vulva. Cancer 2000;89: 1520-1525.
CHAPTER 17

Wide Radical Excision


of the Vulva
Robert E. Bristow

INTRODUCTION preoperative irradiation combined with chemotherapy


followed by completion surgery. Radical wide exci-
The wide radical excision of the vulva procedure arose sion as an alternative to radical vulvectomy is generally
from the move toward individualized treatment for indicated for malignant tumors up to 2 em in diameter
patients with vulvar cancer in the wake of the universal without clinically apparent nodal involvement. For lat-
treatment period when all patients underwent en bloc eralized lesions (>2 em from the midline), radical wide
radical vulvectomy with bilateral inguin.al lymphad- excision is combined with unilateral inguinal lymphad-
enectomy popularized by Stanley Way in the 1950s and enectomy (Chapter 16). For midline lesions, lesions of
1960s (Chapter 15). In properly selected patients, radi- the anterior vulva or mons pubis, and cases with micro-
cal wide excision has been associated with recurrence scopically positive ipsilateral groin nodes, a bilateral
and survival outcomes similar to radical vulvectomy, inguinal lymphadenectomy is the procedure of choice.
while offering a substantial reduction in morbidity and
improved quality of life and self,image.
Although the scope of resection should be tailored to PREOPERATIVE CONSIDERATIONS
the individual patient's anatomy and lesion topography,
there are three major variations of wide radical exci- In preparation for wide radical excision of the vulva,
sion of the vulva: lateral, anterior, and posterior types. all patients should undergo a comprehensive history
Classically defined, radical wide excision of the vulva and physical examination focusing on those areas that
includes a 2-cm resection margin of visibly disease-free may indicate a reduced capacity to tolerate surgezy.
tissue in all dimensions. Depending on the anatomic The vagina and cervix should be thoroughly evaluated
region of resection, the deep margins of resection are to exclude a syncl:uonous lesion or metastatic lesion.
the pubic aponeurosis anteriorly, the pubic rami and Routine laboratory testing should include a complete
superficial perineal fascia laterally, the deep fascia of blood count, serum electrolytes, age-appropriate health
the vulva medially, and the levator plate/ischiorectal screening studies, and electrocardiogram for women
fossa/anal sphincter posteriorly. At least one study sug- aged 50 years and older. Preoperative computed tomog-
gests that a surgical margin of at least 1 em prior to tis- raphy imaging of the abdomen and pelvis is usually
sue fixation yields similar recurrence rates compared to unnecessary. A chest radiograph should be obtained.
the more traditional 2-cm specification. Obtaining ade- Prophylactic antibiotics (Cephazolin 1, Cefotetan
quate surgical margins can be particularly challenging I to 2 g, or Clindamycin 800 mg) should be admin-
in the area of the perineum and posterior fourchette. istered 30 minutes prior to incision, and thromboem-
If a satisfactory surgical margin cannot be achieved bolic prophylaxis (e.g., pneumatic compression devices
in these areas, the patient may be better treated with and subcutaneous heparin} should be initiated prior to

133
134 SEcnON II GYNECOLOGIC ONCOLOGY

surgery. The instrumentation required includes a basic


vaginal surgery set and Allen Universal Stirrups (Allen
Medical Systems, Cleveland, OH). Enemas should be
administered the evening before surgery. Preopera-
tive mechanical bowel preparation (oral polyethylene
glycol solution or sodium phosphate solution with or
without bisacodyl) combined with forced constipation
for a period of several days may facilitate healing by
reducing the likelihood of fecal contamination of the
A
incision in the immediate postoperative period if there
is an extensive posterior component to the dissection.

SURGICAL TECHNIQUE
Either general or regional anesthesia is acceptable. The
patient should be positioned in dorsal lithotomy posi-
tion using Allen-type stirrups with the buttocks pro·
truding slightly over the edge of the operating table.
The vulva, vagina, and thighs are prepped and a Foley
catheter is placed. Examination under anesthesia
should pay particular attention to the size and topogra-
phy of the vulvar lesion, the vagina and cervix, and the
groin lymph nodes. Generally; the inguinal lymphad-
enectomy (Chapter 16) is performed prior to the vulvar
B
resection and the thighs are initially positioned in 15°
of flexion and slightly externally rotated. The thighs are
repositioned into hyperflexion for the vulvar resection.
The surgical principles of wide radical excision
of the vulva are the same as for radical vulvectomy
(Chapter 15}; however, the specific anatomic boundaries
of resection and techniques are tailored to the anatomic
region of the vulva-anterior, lateral, or posterior location
(Figure 17.1 ). Lateralized lesions can he accompanied
by unilateral inguinal lymphadenectomy, while anterior
and posterior lesions require a bilateral inguinal lymph-
adenectomy. Wide local excision of the vulva is iUus-
trated in this chapter using the example of an anterior
lesion replacing the clitoris with extension into the left
hemi-vulva (i.e., anterior-lateral wide radical excision).
The skin incision is outlined and consists of a curvi-
linear triangular incision over the mons pubis, extend- c
ing through the labia majora bilaterally (inclusive of
the bilateral labia minora) to the level of the peri-
neal body on the left and to the mid-vulva on the left
(Figure 17.2). The inner incision is designed around
the introitus and between the urethral meatus and the
prepuce of the clitoris. To ensure adequate clearance FIGURE 17.1 Wide radical excision of the vulva: Types of
of the left-sided lateral extent of the lesion, the line resection: A-lateral excision with unilateral inguinal lymphad-
of resection is extended to include the distal vagina. enectomy, 8--anterior excision with bilateral inguinal lymph-
Anteriorly, the shaft, glans, and prepuce of the clitoris adenectomy, C-posterior excision with bilateral inguinal
are included in the scope of resection. lymphadenectomy.
CHAPTER 17 Wide Radical Excision of the Vulva 135 _ __

FIGURE 17.2 Wide radical excision of the vulva: Squamous cell carcinoma of 1he anterior and left lateral vulva.

The outer incision is created using the knife blade, fashion, which is especially important in the areas
and the dissection is taken into the subcutaneous tis, of the urethra and vagina. The thighs are taken out
sue using the electrosurgical wtit (ESU). Anteriorly, of hyperfle.xion and the lateral margins of the defect
the dissection is carried down to the aponeurosis over are undermined along the fascial investments of the
the symphysis pubis. The suspensory ligament of the anterior and medial thighs. The distal vaginal wall
clitoris is divided using the ESU. The clitoral shaft and can be undermined for a short distance circumfer-
associated vessels are clamped, divided, and the pedi- entially, but extensive dissection around the ure-
cle is secured with a transfixion stitch of 2-0 delayed thra should be minimized. A closed suction drain is
absorbable suture. Using Allis clamps to provide trac- placed in the deep subcutaneous space and brought
tion on the specimen and counter,traction on the out through a separate stab incision in the mons
wlva, the ESU is used to extend the lateral incisions pubis. Once adequate mobility of the remaining vul-
into the subcutaneous tissue (Figure 17.3). The lat- var tissue has been achieved, the defect is closed as
eral dissection on either side includes the entire labial an inverted "Y" in layers, with deep sutures of 2-0
fat pad, which is resected with the specimen and mobi- or 3-0 delayed absorbable suture to obliterate dead
lized medially to expose the deep margin of resection, space. Anterior to the urethra, the skin edges are
the adductor fascia and pubic ramus (Figure 17.4). re-approximated in a vertical direction. Closure of
The lateral incisions on either side are carried medi- the skin and superficial fat is best accomplished by
ally along the deep perineal fascia to the inner incision a series of interrupted vertical mattress stitches of
line previously demarcated with the marking pen. The 2-0 delayed absorbable suture {Figure 17.6). If a
inner incision is then completed using the ESU and tension,free closure cannot be obtained in the peri,
the specimen excised (Figure 1 7 .5}. urethral region, the area should be left open, dressed
Primary closure of the defect requires that the with Vaseline-impregnated gauze, and allowed to
incision margins be approximated in a tension-free heal by secondary intention.
136 SEcnON II GYNECOLOGIC ONCOLOGY

FIGURE 17.3 Wide radical excision of the vulva: The anterior and lateral incisions are extended into the
subcutaneous tissue, and the suspensory ligament of the clitoris is divided.

( 1 Adductor fascia
Pubic ramus
FIGURE 17.4 Wide radical excision of the vulva: The lateral incisions are extended to the pubic rami and
adductor fascia, and the labial fat pads are reflected medially as the specimen is dissected from the deep
perineal fascia.
CHAPTER 17 Wide Radical Excision of the Vulva 137 _ __

FIGURE 17.5 Wide radical excision of 1fte vulva: Completed resection.

FIGURE 17.6 Wide radical excision of the vulva: Closure of the defect in an inverted "Y" using a series
of vertical mattress sutures.
138 SECTION II GYNECOLOGIC ONCOLOGY

POSTOPERATIVE CONSIDERATIONS of the clitoris. The anterior and lateral aspects of the
incision were created with the knife blade, and the
Radical wide excision of the vulva with inguinal lym- ESU was used to develop the deeper planes of dis-
phadenectomy is associated with a 15% to 20% risk section. Anteriorly; the dissection was carried down
of early postoperative complications, most notably to the aponeurosis over the symphysis pubis, and the
wound breakdown and infection, thromboembolic suspensory ligament of the clitoris was divided using
events, urinary tract infection, and lower extremity the ESU. The clitoral shaft and associated vessels
lymphedema. Delayed complications occur in as were clamped, divided, and the pedicle secured with
many as 30% of patients and are usually related to a transfixion stitch of 2-0 delayed absorbable suture.
the groin dissection (lymphedema and lymphocyst), Allis clamps were used to provide traction on the spec-
although sexual dysfunction and pelvic relaxation imen and countertraction on the vulva. The lateral
may also occur. dissection on either side was taken into the subcuta-
If there are no concerns about disrupting the vul- neous tissues and included the entire labial fat pads,
var closure, ambulation should be initiated as early as which were resected with the specimen and mobilized
possible in the postoperative period. As with simple medially to expose the deep margin of resection, the
vulvectomy, sitz baths should be avoided, and the adductor fascia, and pubic ramus on either side. The
vulvar area should be kept clean and dry. Routine lateral incisions on either side were carried medially
thromboembolic prophylaxis should include both along the deep perineal fasc.ia to the inner incision
mechanical and pharmacologic measures until the line previously demarcated with the marking pen. The
patient is fully ambulatory; pharmacologic prophy- inner incision was completed using the ESU and the
laxis should be continued for several weeks thereaf- specimen excised.
ter. The Foley catheter is removed once the patient To facilitate a tension-free closure, the lateral mar-
is ambulatory but may be continued for 7 days if gins of the vulvar resection were undermined along the
there has been extensive periurethral dissection. Diet fascial investments of the anterior and medial thighs.
can be advanced as tolerated. Forced constipation is A closed suction drain was placed in the deep sub-
unnecessary unless there has been a significant pos- cutaneous space and brought out through a separate
terior (perianal) dissection, and avoidance of fecal stab incision in the mons pubis. The defect was closed
contamination is desirable. Because of the risk of as an inverted "Y" in layers, with deep sutures of 2~0
lymphedema of the lower extremities, it is advisable or 3-0 delayed absorbable suture to obliterate dead
to have the patient fitted for anti-edema stockings in space. Anterior to the urethra, the skin edges were
the immediate postoperative period. re-approximated in a vertical direction. Closure of the
skin and superficial fat was accomplished by a series
Operative Note of interrupted vertical mattress stitches of 2-0 delayed
absorbable suture.
PROCEDURE: WIDE RADICAL
EXCISION OF THE VULVA
COMPLICATIONS
The patient was positioned in dorsal lithotomy posi-
tion in Allen-type stirrups with the buttocks protrud- • Wound breakdown with potential infection
ing slightly over the edge of the operating table and occur in as many as 5% to 10% of patients
the thighs flexed at 15°. The inguinal lymphadenec- undergoing wide radical excision.
tomy was completed (described in Chapter 18) and • Thromboembolic events and lower extremity
the patient repositioned with the thighs in hyperflex- lymphedema are common complications in the
ion. The outer incision was demarcated with a mark- early postoperative period.
ing pen as a curvilinear triangle extending from the • Late complications are usually related to the
mons pubis through the labia majora bilaterally down inguinal lymphadenectomy (chronic lower
to the mid-vulva and carried medially to the introitus, extremity lymphedema), but sexual dysfunction
where the inner incision was designed circumferen- and pelvic relaxation may occur.
tially between the urethral meatus and the prepuce
CHAPTER 17 Wide Radical Excision of the Vulva 139

Suggested Reading 3. Farias-Eisner R, Cirisano PD, Grouse D, Leuchter RD.


Conservative and individualized surgery for early squa-
1. Burke 1W, Levenback C, Coleman RL, Morris M, mous carcinoma of the vulva: the treatment of choice
Silva EG, Gershenson DM. Surgical therapy of T1 and forstage I and II (TI-2NO-IMO) disease. Gynecol Oncol
T2 vulvar carcinoma; further experience with radical 1994;53:55-58.
wide excision and selective inguinal lymphadenectomy. 4. Heaps JM, Fu YS, Montz FJ, Hacker NF, Berek JS.
Gynecol Oncoll995;57:215-220. Surgical-pathologic variables predictive of local recur-
2. Disaia PJ, Creasman Wf, Rich WM. An alternate rence in squamous cell carcinoma of the vulva. Gynecol
approach to early cancer of the vulva. Am J Obstet Oncoll990;38:309-314.
Gynecol1979;133:825-832.
CHAPTER 18

Surgery for Ovarian Cancer:


Exploration and Staging
Robert E. Bristow

INTRODUCTION and retroperitoneal spaces and structures and are sum-


marized in Table 18.1. For most patients with ovarian
Approximately 15% to 30% of patients with epithe~ cancer, comprehensive staging will include hysterec-
lial ovarian cancers will have disease confined to the tomy and bilateral salpingo-oophorectomy. However, for
ova:ry or extraovarian pelvis and can be expected to a carefully selected group of young women with appar-
have a favorable long-term survival outcome. For these ent early-stage disease desiring to maintain child-bearing
patients, a comprehensive surgical staging procedure capacity, the uterus and normal~appearing contralateral
is important both for prognostic purposes as well as ovary may be preserved. Commonly accepted criteria for
detennining the prescription for adjuvant chemo- conservative surgical treatment are listed in Table 18.2.
therapy. In a classic study, Young and colleagues sys-
tematically restaged 100 patients referred to them
with apparent early-stage ovarian cancer. Thirty-one PREOPERATIVE CONSIDERATIONS
percent were found to have a more advanced stage,
and most (75%) of these patients had stage III disease. In preparation for surgery for a suspected ovarian can-
As these data indicate, there is a substantial likeli- cer, all patients should undergo a comprehensive his-
hood of finding metastatic disease if a formal staging tory and physical examination. Routine laboratory
surgery is performed in women with epithelial ovar- testing should include a complete blood count, serum
ian cancer apparently confined to the ovary or ovaries. electrolytes, age-appropriate health screening studies,
While most patients with borderline tumors, ovarian a chest radiograph, and electrocardiogram for women
genn cell tumors, and sex cord-stromal tumors will aged 50 years and older. Serum tumor markers are not
have early-stage disease, the information gleaned from a prerequisite; however, a preoperative serum CA 12 5
surgical staging is no less relevant. Consequently, a level is recommended, not so much for its diagnostic
gynecologic surgeon embarking upon exploratory sur- value, but rather to serve as a baseline level in the event
gery on a patient with a pelvic mass should be pre- that an ovarian cancer diagnosis is confirmed patho-
pared to perform comprehensive staging. logically. In young women, serum markers for germ
Staging for ovarian cancer is usually accomplished cell tumors may be appropriate if clinically indicated
via exploratory laparotomy. In experienced hands, lapa- (lactic dehydrogenase, human chorionic gonadotropin,
roscopic- or robotically assisted surgical staging is fea- a-fetoprotein). Preoperative computed tomography
sible and safe; however, the focus of this chapter is of the abdomen, pelvis, and chest is recommended
the more conventional open approach. The required to evaluate the possible extent of disease but is not
steps for ovarian cancer staging include an exploration, required. A preoperative mechanical bowel preparation
inspection, and selective biopsy of both intra-abdominal (oral polyethylene glycol solution or sodium phosphate

141
142 SEcnON II GYNECOLOGIC ONCOLOGY

Table 18.1
Components of Comprehensive Surgical Staging for Ovarian Cancer
• Peritoneal cytology (pelvis and upper abdomen)
• Careful and systematic abdominal exploration-inspect and palpate all peritoneal surfaces
• Omentectomy (infra-colic)
• Total abdominal hysterectomy and bilateral salpingo-oophorectomy
• Pelvic and para-aortic lymphadenectomy
• Random and directed peritoneal biopsies-posterior cul-de-sac, bladder reflection, both
pelvic sidewalls, and both paracolic spaces
• Biopsy or scrapings from the undersurface of both diaphragms
• Appendectomy in selected cases (e.g., mucinous histology)

solution with or without bisacodyl) can be used accord- followed by placement of a self-retaining retractor. This
ing to the surgeon's preference. Prophylactic antibiot- incision provides easy access to the deep pelvis and can
ics (Cephazolin 1 g, Cefotetan 1 to 2 g, or Clindamycin be easily extended to accommodate the required extra-
800 mg) should be administered 30 minutes prior to pelvic staging procedures. Transverse incisions are appro-
incision, and some form of thromboembolic prophy- priate for small, benign pathology or when dissection is
laxis {e.g., pneumatic compression devices and subcu- primarily limited to the pelvis. The main disadvantage of
taneous heparin) should be initiated prior to surgery. a transverse incision is limited access to the upper abdo-
A self-retaining retractor (e.g., Bookwalter, Godman men. If a surgeon makes a transverse incision and needs
Division, Johnson & Johnson, Piscataway, NJ}, with a access to the upper abdomen, either a separate vertical
fixed arm attaching the retractor ring to the operating incision ('f.-incision) must be made or the transverse
table, may be beneficial. incision can be extended upward laterally 0-incision).
H a P£annenstiel incision has been performed and the
pelvic exposure is inadequate, the incision should not be
SURGICAL TECHNIQUE converted to a Maylard incision (division of the rectus
abdominis muscles) because the ends of the rectus mus-
The patient may be positioned in the dorsal cles will retract beneath the previously dissected rectus
low-lithotomy (perineal lithotomy) position using Allen fascia and will not be easily re-approxirnated.
Universal Stirrups (Allen Medical Systems, Cleveland, A preliminary assessment is taken of the extent of
OH) or supine on the operating table. Abdominal entry disease, with particular attention to the primary tumor
and exposure are best achieved through a vertical midline and those areas at high risk for metastatic spread
incision extending from the pubic bone to the umbilicus (Figures 18.1 and 18.2). If ascites is present, it

Table 18.2
Criteria for Conservative Surgical Management of
Apparent Early-stage Ovarian Cancer
• Young patient desirous of future childbearing
• Patient and family consent and agree to close follow-up
• No evidence of dysgenetic gonads
• Specific situations:
Any unilateral malignant germ cell tumor
Any unilateral stromal tumor
Any unilateral borderline (low malignant potential) tumor
Stage Ia invasive epithelial tumor
CHAPTER 18 Surgery for OVarian Cancer: Exploration and Staging 143

Paracolic gutters

~--IH~M-F~+-Inferlor
mesenteric
artery

y
FIGURE 18.1 Ovarian cancer spread by the intraperitoneal route follows the pathway of perito·
neal fluid along the paracolic gutters to the subhepatic space and along the bowel mesenteric
surfaces: Lymphatic spread occurs to the pelvic and high para-aortic nodal basins, while hematogenous
spread is largely to the liver or lung parenchyma.

FIGURE 18.2 Pelvic spread of ovarian cancer can occur by direct extension to contiguous organs
or by noncontiguous peritoneal metastasis.
144 SEcnON II GYNECOLOGIC ONCOLOGY

should be aspirated and sent for cytologic examina- Staging biopsies


tion. When no ascites is present, peritoneal washings
Surgical biopsies are taken to evaluate for microscopic
with 100 to 150 cc of saline solution are obtained from
metastases in high-risk areas, which grossly appear
the pelvis, the paracolic gutters, and the right and
left upper quadrants. Careful and thorough inspec- normal. If no abnormalities on peritoneal surfaces are
noted, then directed biopsies of the peritoneum are
tion and palpation of the entire peritoneal cavity is
taken from the posterior cul-de-sac, bladder perito-
performed in a systematic fashion. The exploration
neum, bilateral pelvic sidewalls, both paracolic gutters,
begins with the right paracolic gutter, moves over the
and the undersurface of the diaphragm on both sides
right kidney and into the suprahepatic space followed
(Figure 18.3). Some surgeons prefer to take perito-
by careful inspection of the diaphragm and liver. The
gallbladder and Morrison's pouch are examined for neal scrapings from the diaphragms rather than biop-
sies, and put the specimen on a slide, fixed immediately
tumor implants. The porta hepatis should be carefully
with a preservative. Adhesions and any other abnormal
examined. The exploration proceeds to the left hemi-
diaphragm, left hepatic lobe, spleen, stomach, trans- appearing areas on the peritonewn or visceral surfaces
should be hiopsied.
verse colon, left kidney, and left paracolic gutter. The
lesser sac is entered on the left side of the gastrocolic
ligament (during omentectomy) to evaluate the stom-
Omentectomy
ach and pancreas. The entire small bowel and colon,
including both serosal and mesenteric surfaces, are In apparent early-stage ovarian cancer patients, sub-
carefully examined. During the initial examination, the clinical omental disease is detected in 5% to 10% of
retroperitoneal areas are palpated along the vascular cases. The vascular supply of the omentum comes from
structures in the pelvis and along the aorta and vena the right and left gastroepiploic arteries, which arise
cava up to the level of the renal vessels. The results from the gastroduodenal artery and the splenic artery.
from this exploration are carefully noted with regard to respectively. The omentum is elevated and the poste-
tumor size, extent, and location. Any other abnormali- rior reflection onto the transverse colon is incised to
ties are also recorded. enter the lesser sac (Figure 18.4). The lesser sac is
further developed by dissecting between the posterior
layer of the gastrocolic ligament and the anterior layer
Management of the primary tumor of the transverse mesocolon (Figure 18.5). During
this dissection, the middle colic artery must be pro-
The primary ovarian tumor and pelvis should be care-
fully examined, and both ovaries should be evaluated tected from injury. The russection is then continued
for size, presence of gross tumor, capsule rupture, bilaterally toward the hepatic and splenic flexures. On
external excrescences, and adherence to surrounding the left, hard traction should he avoided to avoid tear-
ing the splenic capsule. After the omentum has been
structures. If surgical findings are suggestive of a malig-
fully mobilized from the transverse colon, the right and
nant ovarian tumor, a unilateral salpingo-oophorectomy
left gastroepiploic vascular pedicles and the interven-
should be performed and submitted for frozen sec-
ing epiploic vessels are clamped, divided, and secured
tion evaluation. If bilateral ovarian masses are present,
with suture ligatures (2-0 delayed absorbable suture)
the more suspicious side should be removed initially.
or divided using a vessel-sealing device {Figure 18.6).
If frozen section analysis reveals a malignant epithe-
The gastroepiploic vascular arcade along the greater
lial tumor, then standard surgical therapy consists of
hysterectomy and bilateral salpingo-oophorectomy. In curvature of the stomach should not be sacrificed.
patients for whom fertility is not a concern, removal
of the contralateral ovary is justified even if it appears
Pelvic and para-aortic
normal, as it may harbor occult metastatic disease or
even a primary lesion. Hysterectomy is also recom-
lymphadenectomy
mended in most cases, as the uterus may be involved Assessment of the retroperitoneal nodes is a critical
by microscopic lymphatic or serosal metastasis and is part of the initial staging for ovarian cancer. The fre-
a potential site for a synchronous primary tumor of the quency of lymphatic spread in patients with apparent
endometriwn. The indications for conservative man- stage I ovarian cancer ranges from 5% to 20%. Ovarian
agement of the contralateral ovary and uterus were cancer drains preferentially to the high aortic nodes
described earlier. in the vicinity of the junction of the ovarian veins and
CHAPTER 18 Surgery for OVarian Cancer: Exploration and Staging 145 _ _ __

FIGURE 18.3 Peritoneal biopsy of the right paracolic gutter: The peritoneum is elevated with an Allis
clamp and excised with scissors or the electrosurgical unit.

the vena cava on the right side and the renal vein on lymphadenectomy are described in detail in Chapters
the left side (Figure 18.7). Therefore, the diagnostic 12 and 13.
aortic lymph node dissection should include the high
aortic and caval nodes as well as the lower aortic and
common iliac regions. Additionally, ovarian lymphatics
Appendectomy
drain from the hilus of the ovary and traverse the broad Appendectomy for ovarian cancer staging is indicated
ligament into the obturator, external, and common iliac when the primary tumor is of mucinous histology or
lymph nodes. The techniques of pelvic and para-aortic when there is grossly visible pathology involving the

FIGURE 18A Omentectomy: The omentum is elevated and the posterior reflection onto the transverse
colon incised to enter the lesser sac.
146 SEcnON II GYNECOLOGIC ONCOLOGY

Transverse mesocolon
FIGURE 18.5 Omentectomy: The lesser sac is further developed by dissecting between the posterior layer
of the gastrocolic ligament and the anterior layer of the transverse mesocolon.

appendix. The appendix is mobilized from any sur- need to be mobilized by incising the peritoneum
rounding attaclunents and grasped with a Babcock laterally. A window is created in the mesoappendix,
clamp. For a retrocecal appendix, the cecum may which is clamped, divided, and secured with a 2-0

Right gastroepiploic

FIGURE 18.6 Omentectomy: A series of clamps are placed across the right and left gastroepiploic vascu-
lar pedicles and the intervening epiploic arteries and veins, avoiding the gastroepiploic vascular arcade along
the greater curvature of the stomach.
CHAPTER 18 Surgery for OVarian Cancer: Exploration and Staging 147

Ri11Jt
ovarian artery

FIGURE 18.7 High para-aortic and para-caval lymph nodes to be removed in ovarian cancer staging.

delayed absorbable suture ligature (Figure 18.8).


The appendiceal base is clamped and the clamp
moved distally. The appendiceal base is doubly
suture ligated with 2-0 delayed absorbable or penna-
nent suture, and the appendix is divided between the
distal ligature and the clamp. Some gynecologic sur-
geons cauterize the exposed appendiceal mucosa or
invert the appendiceal stump.

POSTOPERATIVE CONSIDERATIONS
Postoperative c.a re after ovarian cancer staging is similar
to that for patients after any other major abdominal sur-
&CIY such as abdominal hysterectomy. Routine throm-
boembolic prophylaxis measures should be observed
until the patient is fully ambulatory. There is no need
for perioperative antibiotics beyond the standard preop-
erative dose. Postoperative complications occur in 12%
to 18% of patients following ovarian cancer staging and
include: ileus, wound cellulitis, urinary tract infection,
pneumonia, thromboembolic events, and hemorrhage.
Postoperative diet may be advanced with adequate FIGURE 18.8 Appendectomy.
148 SEcnON II GYNECOLOGIC ONCOLOGY

bowel SOWlds, but there is no need to wait until the Bilateral pelvic lymphadenectomy was then per-
passage of flatus. Criteria for discharge include afebrile formed by removing the lymph-bearing tissue along the
without evidence of uncontrolled infection, tolerating pelvic vessels extending proximally from the midpor-
a normal diet without nausea or vomiting, satisfactory tion of the conunon iliac artery down to the circum-
bowel and bladder function, and evidence of appropri- flex iliac vein. All lymph-bearing tissue from within
ate wound healing. The need for adjuvant chemother- the obturator fossa above the obturator nerve was also
apy is determined based on the individual pathologic removed. The ascending colon, cecum, and terminal
features (tumor histology and tumor grade) and stage ileum were widely mobilized and the base of the small
of disease. bowel mesentery incised up to the ligament of Treitt.
The descending colon and sigmoid colon were widely
Operative Note mobilized, fuJly exposing the abdominal retroperito-
neum. Bilateral para-aortic lymphadenectomy was
PROCEDURE: SURGERY FOR then performed with removal of the lymph-bearing tis-
OVARIAN CANCER: EXPLORATION sue from the midportion of the corrunon iliac artery up
AND STAGING to the level of the renal veins. Satisfactory hemostasis
was assured.
A vertical miclline incision was created and a self-
retaining retractor positioned. The pelvis and abdomen
were carefuJly explored visually and by palpation. The
primary ovarian tumor was (describe characteristics
such as size, presence of gross tumor, capsule rupture,
COMPLICATIONS
external excrescences, and adherence to surroWlding
• The overall incidence of postoperative morbidity
structures). The pelvic peritoneal surfaces, paracolic
ranges from 12% to 18%, most conunonly ileus
gutters, right and left hemidiaphragms, Morrison's
and infectious complications.
pouch, gallbladder fossa, liver surface and parenchyma,
• Excessive traction on the omentum during
infracolic omentum, gastrocolic ligament, lesser sac,
omentectomy may result in an avulsion injury
stomach, spleen, pancreas, para-aortic and pelvic nodal
to the splenic capsule.
basins were ... (describe the presence or absence of
tumor implants or other abnormalities).
Unilateral or bilateral salpingo-oophorectomy, with
or without abdominal hysterectomy, were accomplished
using standard technique (dictate details of specific pro- Suggested Reading
cedure). The omentum was brought into the incision,
1. Benedetti-Panici P, Greggi S, Maneschi F, et al. Ana-
and the dorsal peritoneal reflection onto the transverse tomical and pathological study of retroperitoneal
colon was incised and the lesser sac entered and devel- nodes in epithelial ovarian cancer. Gynecol Oncol
oped. The right and left gastroepiploic vascular pedicles 1993;51: 150-154.
were skeletonized, clamped, divided, and secured with 2. BeseT, Kosebay D, Kaleli S, et al. Appendectomy in
delayed absorbable suture ligatures. The intervening the surgical staging of ovarian carcinoma. Int J Gynaecol
epiploic vascular pedicles along the gastrocolic ligament Obstet 1996;53:249-252.
were skeletonized and individually clamped, divided, 3. Buchsbaum HJ, Brady MF, Delgado G, et al. Surgi-
and secured with delayed absorbable suture ligatures. cal staging of carcinoma of the ovaries. Surg Gynecol
Multiple peritoneal staging biopsies were obtained from Obstet 1989; 169:226-232.
the right and left pelvic sidewalls, the bladder perito- 4. Cass I, Li AJ, Runowicz CD, et al. Pattern of lymph
neum, the Douglas cul-de-sac, the bilateral paracolic node metastases in clinically unilateral stage I inva-
sive epithelial ovarian carcinomas. Gynecol Oncol
gutters, and the right and left hemidiaphragms. The
200 I ;80: 56-61.
appendix was grasped and brought into the incision. 5. Piver SM, Barlow J, Lele SB. Incidence of subclinical
A window was created in the mesoappendix, which metastasis in stage I and II ovarian carcinoma. Obstet
was clamped, divided, and secured with a 2-0 delayed Gynecoll978;52:100-104.
absorbable suture ligature. The appendiceal base was 6. Young RC, Decker DG, Wharton JT, et al. Staging lapa-
crushed with a clamp, double suture ligated with 2-0 rotomy in early ovarian cancer. JAm MedAssoc I 983;2
delayed absorbable, divided, and cauterized. 50:3072-3076.
CHAPTER 19

Cytoreductive Surgery for


Ovarian Cancer: Radical
Oophorectomy
Robert E. Bristow

INTRODUCTION one or both adnexae and their adjacent peritoneum,


cul-de-sac, posterior uterine serosa (if present), and
Metastatic spread of ovarian cancer to local pelvic the sigmoid colon; 3) the surgeon subjectively judges
sttuctures is a conunon occwrence, with International that complete removal of disease could not be effected
Federation of Gynecology and Obstetrics Stage liB-IV simple hysterectomy and salpingo-oophorectomy and
disease representing a majority (70%) of all patients piecemeal dissection, resection, or ablation of serosal
newly diagnosed with epithelial ovarian cancer. Survival and peritoneal metastases; 4) an overall optimal resec-
determinants are multi-factorial; however, the strongest tion would be otherwise achievable; and 5) the proce-
clinician-driven predictors of clinical outcome are the dure is not medically contraindicated.
administration of platinum-based chemotherapy and
the amount of residual tumor following primary sur-
gery; with complete tumor resection being associated PREOPERATIVE CONSIDERATIONS
with the most favorable survival outcome. Resection of
the primary tumor mass is a key component of the ini- In preparation for surgery for a suspected ovarian can-
tial cytoreductive surgical effort to achieve optimal (< 1 cer, all patients should undergo a comprehensive his-
em) or no gross residual disease. tory and physical examination focusing on those areas
In 1968 and 1973, Hudson and Chir described the that may indicate a reduced capacity to tolerate major
technique of "radical oophorectomy" designed for the surgery or place the patient at elevated risk for post·
intact removal of a fixed ovarian tumor en bloc with operative complications. Routine laboratory testing
attached peritoneum and surrounding structures. The should include a complete blood count, senun electro-
cardinal feature of the radical oophorectomy procedure lytes, age-appropriate health screening studies, a chest
is the retroperitoneal approach to ovarian cancer encas- radiograph, and electrocardiogram for women aged
ing the pelvic viscera, using the "false capsule" within the 50 years and older. Serum tumor markers are not a pre-
pouch of Douglas to effect en bloc ex:cision. The most requisite; however, a preoperative serum CA-125 level
commonly performed variant of radical oophorectomy is is recommended, not so much for its diagnostic value,
the Type II procedure, which includes en bloc modified but rather to serve as a baseline level in the event that
radical hysterectomy, bilateral salpingo-oophorectomy, an ovarian cancer diagnosis is confirmed pathologi-
rectosigmoid colectomy, and pan-pelvic peritonec- cally. Preoperative computed tomography of the abdo-
tomy. The indications for radical oophorectomy have men, pelvis, and chest is reconunended to evaluate the
been summarized by Eisenkop et al. as follows: I) gross extent of disease and for surgical planning purposes.
evidence of ovarian cancer supported by frozen section Because ovarian cancer surgery carries the possibil-
biopsy; 2) extensive confluent tumor involvement of ity of bowel resection or injury, preoperative mechanical

149
150 SEcnON II GYNECOLOGIC ONCOLOGY

bowel preparation (oral polyethylene glycol solution or colon. The paracolic gutter incisions are extended into
sodium phosphate solution with or without bisacodyl) is the pelvis, along the psoas muscles, moving ventro-
recommended according to the surgeon's preference. Pro- medially along the posterior margin of the symphysis
phylactic antibiotics (Cephazolin 1 g, Cefotetan 1 to 2 g, pubis. All pan-pelvic disease is circumscribed and
or Clindamycin 800 mg) should be administered 30 min- included within this peritoneal incision (Figure 19.1).
utes prior to incision, and thromboembolic prophylaxis The pelvic dissection proceeds in a centripetal fashion.
{e.g., pnewnatic compression devices and/or subcuta- The round ligaments should be located retroperitone-
neous heparin) should be initiated prior to surgery. Res- ally, ligated, and divided as laterally as possible.
ervation of an intensive care unit bed postoperatively is An early step of the pelvic operation is develop~
advisable if extensive or prolonged surgery is anticipated, ment of the retroperitoneal potential spaces. The pel-
and type and cross-matched blood should be available. vic viscera are separated from one another and the
Surgery for ovarian cancer requires access to both pelvic walls by eight potential spaces (Figure 19.2).
pelvic and abdominal structures, often simultaneously. These potential spaces are filled with fatty or areolar
A self-retaining retractor (e.g., Bookwalter, Cadman connective tissue and are two-dimensional until sur-
Division, Johnson &: Johnson, Piscataway, NJ) with a gically developed, thereby serving as natural cleavage
fixed arm attaching the retractor ring to the operating planes and allowing relatively bloodless isolation of
table is essential to optimizing exposure, maximizing diseased tissue or viscera. The pararectal and paravesi-
patient safety, and reducing surgeon fatigue. At the cal spaces are developed using a combination of sharp
surgeon's discretion, additional standard equipment and blunt dissection, exposing the cardinal ligament.
may include: an electrosurgical unit (ESU or "Bovie"), The ureters are identified within the pararectal space
vessel-sealing device, argon beam coagulator, cavitron and mobilized from their attachments to the medial
ultrasonic sUigical aspirator, and automated stapling leaf of the broad ligament, moving from the pelvic brim
devices. Following is a brief description of the surgical to the tunnel of Wertheim, and held for traction with
procedure used (see also video: Cytoreductive Surgery vessel loops. The central pelvic tumor mass should be
fvr Ovarian Cancer: Radical Oophorectomy). devascularized early in the course of the operation by
dividing the infundibulopelvic ligaments at or above
the pelvic brim.
SURGICAL TECHNIQUE The anterior pelvic peritoneum is grasped and
placed on traction with Allis clamps, and the retropu-
tm:: The patient may be positioned in the dorsal bic space of Retzuis is developed. A plane of dissection
- low-lithotomy (perineolithotomy) position using is established between the anterior pelvic peritoneum
Allen Universal Stirrups (Allen Medical Systems, and the bladder dome muscularis using the ESU or
Cleveland, OH) or supine on the operating table. The argon beam coagulator. The anterior pelvis is then
low-lithotomy position is preferable, as it permits intra- deperitonealized moving ventral to dorsal and lateral to
operative bimanual examination to accurately ascertain medial toward the uterus until the pubo-vesico-cervical
the extent of cul-de-sac tumor involvement and allows fascia is reached (Figure 19.3).
access to the perineum for resection and re-anasto- The uterine vascular pedicles are skeletonized, dou-
mosis of the rectosigmoid colon. Abdominal entry and bly ligated, and divided at the level of the ureters in the
exposure are best achieved through a midline xiphopu- fashion of a modified radical hysterectomy, allowing lat-
bic incision with placement of a self-retaining retrac- eral displacement of the ureters from the central speci-
tor. A preliminary assessment is taken of the extent of men (Figure 19.4). The ureters are extricated from
disease, with particular attention to the feasibility of within the bladder pillars by developing the ureteral
resecting upper abdominal disease. Directing initial twmels using a right angle clamp and dividing them
cytoreductive efforts toward bulky upper abdominal with the ESU or securing them with suture ligatures.
disease and exploring the abdominal retroperitoneum Division of the proximal sigmoid colon can be per-
will facilitate exposure to the pelvis and ensure a rea- formed whenever it is most convenient during the opera-
sonable likelihood of achieving an optimal (< I em) or tion, once it has been determined that bowel resection
complete (no macroscopic residual) overall resection is necessary to achieve an optimal surgical result. The
prior to undertaking the radical pelvic dissection. sigmoid colon is divided 2 to 3 em above the most proxi-
The Type II radical oophorectomy procedure is ini- mal extent of gross tumor in an area that is free of diver-
tiated by incising the paracolic gutters bilaterally and ticuli. A variety of methods can be used to divide the
mobilizing the cecum, terminal ileum, and sigmoid bowel; however, the Gastrointestinal anastomosis (GIA)
CHAPTER 19 Cytoreductive Surgery for Ovarian Cancer: Radical Oophorectomy 151 _ _ __

Perltoneallnclakln'
Peritoneal edge along
poeteriOt border Of
symphysiS pubiS

FIGURE 19.1 Radical oophorectomy: Circumscribing peritoneal incision with early deperitonealization of
pelvis. A circumscribing peritoneal incision extends from the paracolic gutters into the pelvis to encompass
the pan-pelvic disease.

stapling device (4.8 mm) is the most expedient and has incision, thus incorporating a "wedgen of colonic mesen-
the advantage of placing two rows of staples on either tery with the central pelvic tumor.
side of the divided bowel, thus controlling both proximal The deep dissection proceeds from the pararectal
and distal fecal contamination (Figure 19-5). To ensure spaces posteriorly and medially, behind the sigmoid
an adequate resection of mesocolon and associated mes- vessels and inferior mesenteric artery (continuing as
enteric lymph nodes, the peritoneal incision is extended the superior hemorrhoidal artery) toward the entrance
along the sigmoid mesentery from the point of proximal of the presacral space just caudal to the sacral prom-
bowel division medially toward the right sacroiliac joint ontory. Individual vessels within the sigmoid mesen-
to join the right-sided circumscribing pelvic peritoneal tery are isolated, clamped, and suture ligated as they

Vesicouterine
ligament

Uterine artery-Jt+-+-1.~-~....:.-::;;;:;:::.t~ Internal


cardlnalllgament~~~:..d iliac artery
~~ri+l--1-~~::::lir-fi---+\-.J+~-1-- Uten>sacral
ligament
Pararectal space -J~~~~
.~ -,~r-6-lt.._,.'-1-Rectum
Ureter---~~~ J

Presacral space

FIGURE 19.2 Eight potential spaces of the pelvis. The spaces are: retropubic space of Retzius,
paravesical spaces (2), vesicovaginal space, pararectal spaces (2), rectovaginal space, and presacral space.
152 SEcnON II GYNECOLOGIC ONCOLOGY

Anterior pelvic peritoneum


with tumor implants raised
off of bladder dome

FIGURE 19.3 Radical oophorectomy: Anterior pelvic peritonectomy, deperitonealization of bladder;. dis-
section of vesicovaginal space. The bladder is placed on traction and anterior pelvis is deperitonealized by
dissecting in the sub-peritoneal plane, exposing the underlying bladder.

Bladder retracted medially


FIGURE 19.4 Radical oophorectomy: Modified radical hysterectomy ureteral dissection. The uterine
vascular pedicle is developed with a right angle clamp, doubly suture ligated and divided at the level of
the ureter.
CHAPTER 19 Cytoreductive Surgery for Ovarian Cancer: Radical Oophorectomy 153

Urater------,~~,\1

Sigmoid
colon -J~;._,.~r.....,~o:.r~-

Bladder Peritoneum with tumor


FIGURE 19.5 Radical oophorectomy: Division of sigmoid colon. The proximal sigmoid colon and inferior
mesenteric vessels are divided and the sigmoid mesentery mobilized anteriorly.

are encountered. When the inferior mesenteric artery of a spongestick into the anterior vaginal fornix will
and vein are sacrificed, care must be taken to pre- facilitate selecting the proper site for incising the ante-
serve the left colic artery with its blood supply to the rior vaginal wall transversely with the ESU 1 to 2 em
descending colon. From a functional standpoint, the below the cervicovaginal junction, exposing the inner
pararectal and presacral potential spaces are unified vagina (Figure 19.6). The cervix is grasped with a
into one large posterior pelvic retroperitoneal space. Kocher clamp and retracted to expose the inner vagina.
The posterior pelvis is further mobilized by developing Heaney clamps are used to circumscribe the anterior
the presacral space caudally to the level of pelvic floor and lateral proximal vagina just below the level of the
musculature, where the presacral ligament is sharply cervix, dividing and securing each successive pedicle
divided in the midline with the ESU just below the with a suture ligature (Figure 19. 7).
sacral curvature. The dissection should remain ante- The posterior vaginal wall is incised with the ESU,
rior to the presacral fascia, as the presacral veins lie and the rectovaginal space is developed caudally,
just beneath and may produce troublesome bleeding if until the lowermost extent of the cul-de-sac tumor
injured. Once the presacral space has been adequately has been reached and bypassed for a distance of 2
developed, the lateral ligaments (or stalks) of the rec- to 3 em. The retrograde approach is continued by
tum, containing the middle hemorrhoidal vessels, are retracting the cul-de-sac twnor mass sharply upward,
divided between clamps and ligated, taken down with exposing the remaining cardinal ligament attachments
the ESU, or controlled with a vessel-sealing device to medial to the ureters, the uterosacral ligaments, and
achieve additional mobilization by detaching the rec- the rectal pillars, which are sequentially divided
tosigmoid colon from its attachments to the lateral between clamps and secured with suture ligatures or
pelvic wall. Any remaining mesorectal attachments taken down with electrocautery (Figure 19.8).
can be taken down with the ESU or divided between The bowel wall should be adequately cleared of
clamps. surrounding fat and any remaining mesorectal attach-
The bladder is sharply mobilized ventro-caudally to ments. The proximal rectum or rectosigmoid junction is
expose the proximal 2 to 3 em of vagina. The tumor- then divided 2 to 3 em distal to the lowermost extent of
laden peritoneum is retracted cephalad while the tumor between a TA (4.8 mm) stapler (Figure 19.9).
bladder is mobilized inferiorly off the anterior vaginal At this time, the vagina is closed with interrupted
wall. The hysterectomy is completed in a retrograde sutures or a running stitch, according to the surgeon's
fashion by first creating an anterior colpotomy. An preference. Following resection of the central pelvic
intraoperative bimanual examination or placement tumor, consideration should be given to performing
154 SEcnON II GYNECOLOGIC ONCOLOGY

Anterior pelvic 1umor on vesico-u1erine


I'!Rri~tvalcaum retracted upward

Cervlcc-vaglnal junction

Bladcler Amerior vagina


FIGURE 19.6 Radical oophorectomy: Retrograde hysterectomy. An anterior colpotomy is created using
the ESU over a spongestick placed in the anterior vaginal fornix, exposing the inner vagina.

any additional pelvic debulking procedures and pelvic Intestinal continuity can be re-established by a vari-
lymphadenectomy prior to re-establishing intestinal ety of methods using either automated stapling devices
continuity to reduce the risk of disrupting the intestinal or hand-sewn techniques. The use of automated sta-
anastomosis. pling devices is at least as safe as a conventional

Cervix retracted upward

FIGURE 19.7 Radical oophorectomy: Retrograde hysterectomy. The vaginal tube is circumscribed with
Heaney clamps, each pedicle is divided and secured in sequence with a transfixion stitch.
CHAPTER 19 Cytoreductive Surgery for Ovarian Cancer: Radical Oophorectomy 155 _ _ __

Rectovaginalspace
FIGURE 19.8 Radical oophorectomy: Retrograde hysterectomy. The posterior vaginal wall is incised and
the rectovaginal space is developed exposing the uterosacral ligaments/rectal pillars.

hand-sewn anastomosis (depending on the operator's end-to-side or side-to-side anastomosis may be more
skill and experience) and in many circumstances offers desirable under certain circumstances. The anasto-
distinct advantages. By and large, a stapled low rectal mosis selected is determined largely by the fit and sur-
anastomosis is faster, has comparable complication geon's preference.
rates, and is easy to perfonn given the limited access Irrespective of the type of procedure, a successful
to suturing in the deep pelvis. Although the end-to- colorectal anastomosis requires an adequate blood
end anastomosis is most corrunonly employed, an supply based on the premise that the lower/mid

Proldmal rectum

FIGURE 19.9 Radical oophorectomy: The proximal rectum is divided with a TA stapler to complete the
resection. The lateral ligaments of the rectum and mesorectum have been divided; the specimen is lifted
sharply upward, straightening the rectum to preserve maximal length prior to resection.
156 SEcnON II GYNECOLOGIC ONCOLOGY

rectum can be sustained by the inferior hemorrhoidal the stapler fired by squeezing the handles together
vessels and that the descending colon can be sustained until an audible crunch of the staples being engaged
by the left colic branch of the inferior mesenteric is heard, thus releasing two circular rows of staples
artery or the middle colic artery via the marginal artery and making a circumferential cut inside the innermost
of Drummond. The anastomosis should be watertight, staple ring. The handles are released and the wing nut
have meticulous hemostasis, and the absence of ten- rotated counterclockwise no more than one full turn.
sion on the anastomotic staple or suture line should The handpiece of the main CEEA instrument is then
be assured. rotated 90 degrees and gently moved ventrally, dor-
The transanal double-stapling technique using the sally, to the right, and to the left to release the stapled
circular end-to-end anastomosis (CEEA} is a safe and anastomosis from the surrounding colon soft tissue and
efficient method of re-establishing intestinal continu- withdrawn.
ity. The largest circular stapler (28 or 31 mm} that The security of the anastomosis is confirmed by
will be comfortably accommodated by both bowel seg- several means. First, the resection rings around the
ments should be used. The proximal colon is prepared cartridge shaft should be inspected to ensure two com-
by inserting a 2-0 polypropylene purse-string suture. plete donuts of colonic tissue. Second, the "water test"
The CEEA anvil is inserted and the purse-string suture or "bubble test" is performed by filling the pelvis with
is tied. The main CEEA instrument is lubricated and sterile water or saline and manually obstructing the
inserted into the rectum transanally and approximated proximal colon prior to insufflating the rectum with
against the staple line of the rectal stump. The wing 200 to 300 cc of air through a rigid sigmoidoscope or
nut is rotated clockwise until the trocar pierces the Asepto syringe. The presence of air bubbles indicates
closed rectum adjacent to or through the staple line. an anastomotic leak, which should be repaired by
The anvil shaft is inserted into the cartridge shaft of over-sewing the defect with interrupted stitches of 3-0
the main CEEA instrument until it engages with an delayed absorbable or silk suture. If the leak is inacces-
audible click (Figure 19.10). The wing nut is rotated sible for repair, the anastomosis must be taken down
clockwise until the color-bar indicator on the handle and repeated. Finally, some surgeons also recommend
indicates adequate compression of the bowel wall. The direct inspection of the anastomotic staple line for
safety on the main CEEA instrument is released and defects using a rigid sigmoidoscope.

FIGURE 19.10 Cin:ular end-to-end stapled anastomosis using the automated CEEA stapler: The
CEEA anvil is introduced into the proximal colon; the main CEEA instrument is passed transanally.
CHAPTER 19 Cytoreductive Surgery for Ovarian Cancer: Radical Oophorectomy 157

POSTOPERATIVE CONSIDERATIONS down to the pelvic floor. The sigmoid mesentery was
incised with electrocautery; sigmoid vessels and the
Postoperative, central hemodynamic monitoring and inferior mesenteric vessels pedicles were clamped,
intensive care unit admission are useful in selected divided, and suture ligated.
patients. Adequate intravenous access and monitor- The anterior pelvis was deperitonealized by dissect-
ing is essential to replace fluid deficits and maintain ing from the symphysis pubis toward the uterus, rais-
intravascular volume. In addition to third space losses, ing the peritoneum off the underlying detrusor muscle
intraoperative blood loss may be significant, requiring until the vesicovaginal space was reached. Ureteroly-
transfusion (approximately 30% of patients) for correc- sis was performed down to the tunnel of Wertheim
tion of anemia and/or coagulopathy. Patients should be and the uterine vascular pedicles skeletonized, dou-
monitored closely for metabolic and electrolyte abnor- bly suture ligated, and divided at the level of the ure-
malities. Selected patients may benefit from periopera- ters (midway between the uterus and pelvic sidewall)
tive fi-blockade to decrease cardiac comorbidity. bilaterally. The ureteral tunnels were developed with
Following radical oophorectomy, approximately a right angle clamp, suture ligated, and divided, leav-
35% of patients will experience minor morbidity (uri- ing the anterior leaves of the tunnels attached to the
nary tract infection, pneumonia, wound cellulitis, and specimen. The ureters were reflected further later-
ileus) and 13% will have significant morbidity (throm- ally and inferiorly away from uterus and central tumor
boembolic event and sepsis). Routine thromboembolic specimen.
prophylaxis with three daily doses of low-dose unfrac- An anterior colpotomy was created over a sponges-
tionated heparin is recommended. Alternatively, low- tick placed transvaginally, and Heaney clamps used to
dose unfractionated heparin may be combined with circumscribe the proximal antero-lateral vagina, first
pneumatic compression devices, or prophylactic doses dividing each pedicle and securing it with a transfixion
of low molecular weight heparin may be given. stitch. The posterior vaginal wall was incised and the
A Foley catheter should be maintained postoperatively rectovagi.nal space was developed caudally then crani-
and a voiding trial performed after 72 hours. Postopera- ally, mobilizing the associated tumor-laden cul-de-sac
tive diet may be advanced with adequate bowel sounds, peritoneum. The rectal pillars and mesorectal attach-
but there is no need to wait until the passage of flatus. ments were taken down with electrocautery or suture
Criteria for discharge include afebrile without evidence ligatures. The proximal rectum was cleared of sur-
of uncontrolled infection, tolerating a normal diet with- rounding fat and divided using a 4.8-mm TA stapling
out nausea or vomiting, satisfactory bowel and bladder device and the specimen excised.
function, and evidence of appropriate wound healing. A tension-free, stapled, circular, end-to-end anasto-
mosis between the midsigmoid colon and proximal rec-
Operative Note tum (coloproctostomy) was performed using the 31-mm
CEEA stapling device. Two complete donuts of tissue
PROCEDURE: CYTOREDUCTIVE were documented on the stapler anvil. The "water test"
SURGERY FOR OVARIAN CANCER: was performed to confirm an air,tight anastomosis.
RADICAL OOPHORECTOMY
A circumscribing incision was created around the pel-
vis along the psoas tendons bilaterally, over the round COMPLICATIONS
ligaments, and along the posterior border of the symph-
ysis pubis. The dissection was developed in a centrip- • The risk of massive hemorrhage can be limited
etal fashion, mobilizing the entire pelvic peritoneum by devascularizing the central pelvic tumor
from its retroperitoneal attachments. The pararectal early in the operation by ligating and dividing
and paravesical spaces were developed and the ure, the ovarian and uterine vessels.
ters identified and placed within vessel loops for trac- • Confining dissection to the retroperitoneal
tion. The infundibulopelvic ligaments were ligated and plane will limit the risk of unintended injury to
divided bilaterally above the pelvic brim. the bladder, ureters, and pelvic vasculature.
The sigmoid colon was cleared of surrounding fat • Significant tension or compromised blood supply
and divided at its midpoint, 3 em above the nearest increase the risk of colorectal anastomosis
gross tumor involvement, using the 4.8-mm CIA sta- breakdown.
pling device. The retrorectal space was developed
~~- 158 SECTION II GYNECOLOGIC ONCOLOGY

Suggested Reading 5. Eisenkop SM, Nalick RH, Teng NNH. MocUfied pos·
terior exenteration for ovarian cancer. Obstet Gynecol
I. Aletti GO, Podrat:z KC, )ones MB, Cliby WA. Role of 1991; 78:879-885'
rectosigmoidectomy and stripping of pelvic peritoneum 6. Hudson CN .A radical operation fodixed ovarian tumors.
in outcomes of patients with advanced ovarian cancer. ) Obstet Gynaecol Br Comrnonw 1968;75: 1155-1160.
) Am Coll Surg 2006;203:521~526. 7. Hudson CN, Chir M. SUigical treatment of ovarian
2. Bristow RE, del Cannen MG, Kaufman HS, Montz F). cancer. Gynecol Oncol1973;1:370-378.
Radical oophorectomy with primary stapled colorectal 8. Minig L, Biffi R, Zanagnolo V, et al. Early oral versus "tra-
aiUlstomosis for resection of locally advanced epithe- ditional" postopemtive feeding in gynecologic oncology
lial ovarian cancer. JAm Coli Surg 2003;197:565-574. patients undergoing intestinal resection: a randomized
3. Chi OS, Liao JB, Leon LF, et al. Identification of prog- controlled trial. Ann Surg Oncol 2009; 16: 1660-1668.
nostic factors in advanced epithelial ovarian carcinoma. 9. Mourton SM, Temple LK, Abu-Rustum NR, et al.
Gynecol Oncol2001;82:532-537. Morbidity of rectosigmoid resection and primary anas-
4. duBois A, Reuss A, Pujade-Lauraine E, Harter P, tomosis in patients undergoing primary cytoreductive
Ray-Coquard I, Pfisterer ). Role of surgical outcome surgery for advanced epithelial ovarian cancer. Gynecol
as prognostic factor in advanced epithelial ovarian Oncol2005;99:608~614.
cancer: a combined exploratory analysis of 3 prospec- 10. Richardson OL, Mariani A, Cliby WA. Risk factors for
tively randomized phase 3 multicenter trials. Cancer anastomotic leak after recto~igmoid resection for ovar-
2009;115: 1234-1244. ian cancer. Gynecol Oncol2006;103:667-672.
CHAPTER 20

Cytoreductive Surgery for


Ovarian Cancer: Upper
Abdominal Procedures
Robert E. Bristow

INTRODUCTION PREOPERATIVE CONSIDERATIONS


Approximately 70% of patients with epithelial ovarian In preparation for surgery for ovarian cancer, all
cancer will have advanced-stage disease at the time patients should undergo a comprehensive history and
of diagnosis. For this group, survival determinants are physical examination focusing on those areas that may
multifactorial; however, the strongest clinician-driven indicate a reduced capacity to tolerate major surgery or
predictors of clinical outcome are the administration place the patient at elevated risk for postoperative com-
of platinum-based chemotherapy and the amount of plications. Routine laboratory testing should include a
residual tumor following primary surgery, with com- complete blood count, serum electrolytes, age-appro-
plete tumor resection being associated with the most priate health-screening studies, a chest radiograph, and
favorable outcome. As many as 42% of patients with electrocardiogram for women aged 50 years and older.
Stage IIIC ovarian cancer will have bulky {>I em} Serum tumor markers are not a prerequisite; however, a
disease in the upper abdomen above the greater preoperative serum CA125 level is recommended, not
omentum. These patients often require a more exten- so much for its diagnostic value, but rather to serve as a
sive upper abdominal cytoreductive surgical effort to baseline level in the event that an ovarian cancer diag-
achieve optimal (s 1 em) or no gross residual disease nosis is confirmed pathologically. Preoperative com-
prior to initiating chemotherapy. For example, while puted tomography of the abdomen, pelvis, and chest is
the omentum represents the location of the largest recommended to evaluate the extent of disease and for
tumor site in many patients with advanced-stage ovar- surgical planning purposes.
ian cancer, direct invasion of the transverse colon and Because ovarian cancer surgery carries the possibil-
adjacent structures is not infrequent and dictates a ity of bowel resection or injury, preoperative mechani-
broader scope of surgical resection. Splenectomy may cal bowel preparation (oral polyethylene glycol
also be required, as tumor may extend from the greater solution or sodium phosphate solution with or without
omentum to affect the spleen in 5% to 30% of patients bisacodyl) is recommended according to the surgeon's
with advanced-stage disease. Similarly, metastatic preference. Prophylactic antibiotics {Cephazolin I g,
tumor spread to the diaphragm will be encountered in Cefotetan 1 to 2 g, or Clindamycin 800 mg) should be
18% to 4I% of patients with Stage III and N epithelial administered 30 minutes prior to incision, and throm-
ovarian cancer. As a result, a maximal surgical effort boembolic prophylaxis (e.g., pneumatic compression
is dependent on the surgeon's capacity to successfully devices and subcutaneous heparin} should be initi-
manage disease involving the structures of the upper ated prior to surgery. Reservation of an intensive care
abdomen. unit bed postoperatively is advisable if extensive or

159
160 SEcnON II GYNECOLOGIC ONCOLOGY

prolonged surgery is anticipated, and type and cross- the surrounding anatomy so that subsequent resec-
matched blood should be available. If splenectomy tion of isolated metastases can be accomplished with
is anticipated, a single one-time polyvalent pneumo- maximum safety.
coccal vaccination (Pneumovax) and vaccines against
Haemophilus influenza (Hib) and Neisseria menin-
gitidis {MenomWle) should be given 10 to 14 days
Omentectomy with en bloc transverse
preoperatively. In the circumstance of an unplanned
colectomy
splenectomy, the vaccines should be given 14 days Bulky omental disease extending to or infiltrat-
postoperatively. ing into the transverse colon or pericolonic soft
A self-retaining retractor (e.g., Bookwalter, Cod- tissue and mesentery necessitates partial or total trans-
man Division, Johnson and Johnson, Piscataway, verse colectomy en bloc with an omentectomy and
NJ) with a fixed arm attaching the retractor ring to resection of gastrocolic ligament, provided this compo-
the operating table is essential to optimize exposure, nent of the operation will make a significant contribu-
maximize patient safety, and reduce surgeon fatigue. tion to the overall surgical result of achieving minimal
At the surgeon's discretion, additional standard equip- residual disease. Tumor spread into the lesser sac and
ment may include an electrosurgical unit (ESU or involving the transverse colon mesentery is also an
«Bovie"), vessel-sealing device, argon beam coagulator indication for transverse colectomy.
(ABC), cavitron ultrasonic surgical aspirator (CUSA), En bloc omentectomy and transverse colectomy
and automated stapling devices. Following are brief begins by dividing the attachments of the omentum to
descriptions of the surgical procedures used (see also the lateral aspects of the transverse colon. The right
videos: Cytoreductive Surgery for Ovarian Cancer- and left gastroepiploic vascular pedicles are clamped,
Upper Abdt:mr.inal Disease: Transverse Colectomy; Sple- divided, and secured with suture ligatures or taken
nectomy; Diaphragm). down with a vessel-sealing device. The dorsal reflection
of the omentum onto the transverse colon is incised
with the ESU, and the potential space of the lesser sac
SURGICAL TECHNIQUE is developed (Figure 20.1 ). The transverse colon is
then completely mobilized by dividing the gastrocolic
The patient may be positioned in the dorsal ligament from the greater curvature of the stomach and
low-lithotomy (perineolithotomy) position using by taking town the hepatocystocolic, phrenicocolic,
Allen Universal Stirrups (Allen Medical Systems, and splenocolic ligaments to &ee the hepatic flexure
Cleveland, OH) or supine on the operating table. and splenic flexure, respectively (Figure 20.2).
Mechanical ventilation should be confirmed prior Once the omental attachments have been freed, the
to undertaking upper abdominal cytoreductive pro- en bloc tumor specimen to be resected is clearly delin-
cedures. Abdominal entry and exposure are achieved eated and the vascular supply to the remaining proxi~
through a midline xiphopubic incision, which can be mal and distal ends of the transverse colon inspected.
extended alongside the xyphoid process for additional The surgeon must make certain that the marginal
exposure, with placement of a self-retaining retrac- artery of Drummond is intact and will provide suffi-
tor positioned to provide finn, upward traction on cient blood supply to both ends of the planned anas-
the costal margins. A preliminary assessment is taken tomosis (transverse colocolostomy). The proximal and
of the extent of disease, with particular attention to distal segments of the involved section of transverse
the feasibility of resecting upper abdominal disease. colon are cleared of surrounding fat and divided with
Many surgeons prefer to begin the operation with the the Gastrointestinal anastomosis (GIA} stapling device
removal of the omentum, as it is usually extensively (Figure 20.3). A wedge-shaped section of transverse
involved with tumor and provides a convenient start~ colon mesentery is demarcated and incised, the middle
ing point for surgical extirpation of metastatic disease colic artery and vein identified, divided, and ligated,
in the upper abdomen. From an anatomic perspec- and the specimen removed (Figure 20.4). Any associ-
tive, contiguous extension to the transverse colon, ated arterial arcades are similarly individually divided
spleen, or diaphragm may require an en bloc resec- and suture ligated or controlled with electrocautery.
tion of one or a combination of these organs with If the marginal artery of Drummond is discontinuous
the omental tumor. Even if the omental disease does at the splenic flexure, the distal transverse colon and
not directly involve adjacent structures, its removal proximal descending colon should be included in the
will improve exposure and facilitate mobilization of scope of resection.
CHAPTER 20 Cytoreductive Surgery for Ovarian Cancer: Upper Abdominal Procedures 161

FIGURE 20.1 Omentectomy with partial transverse colectomy: The dorsal reflection of the omentum
onto the transverse colon is incised with the ESU, and the potential space of the lesser sac is developed.

Intestinal continuity is reestablished via either an creating a viable anastomosis, and additional mobiliza-
end-to-end or functional end-to-end stapled or hand- tion of the hepatic flexure and/or splenic flexure may be
sewn anastomosis. A functional end-to-end stapled required. Finally, the mesenteric defect is closed with
colocolostomy using the GIA and Thoraco-abdominal interrupted stitches of 2-0 delayed absorbable suture;
(TA) stapling devices is safe, efficient, and produces a however, the duodenojejunal junction should be care-
capacious anastomotic lumen (Figure 20.5). In addi- fully inspected to confirm that re-approximating the
tion to having an adequate blood supply. the avoid- colonic mesentery does not produce a functional stric-
ance of tension on the staple or suture line is critical to ture at this point.

1\.lmor Infiltrating the


Transverse colon aastroc:olic ligament He~tlc flexure

Symphysis XIphoid
pubis process

FIGURE 20.2 Omentectomy with partial transverse colectomy: The transverse colon is completely mobi-
lized by dividing the gastrocolic ligament from the greater curvature of the stomach and taking down the
hepatocystocolie, phrenicocolic, and splenocolic ligaments to free the hepatic and splenic flexures, respectively.
162 SEcnON II GYNECOLOGIC ONCOLOGY

FIGURE 20.3 Omentectomy with partial transverse colectomy: The proximal and distal segments of
the involved section of transverse colon are cleared of surrounding fat and divided with the GIA stapling
device; a wedge-shaped section of transverse colon mesentery is demarcated and incised.

Splenectomy The surgical approach to splenectomy is individual-


~ The most common location of ovarian cancer ized and may proceed anteriorly through the gastro-
. . involving the spleen is the hilum (65%), fol- splenic ligament, posteriorly through the lienorenal
lowed by the capsule (52%), and parenchyma (16%). ligament, or a combination of the two, depending

Middle colic vascular pedicle

FIGURE 20.4 Omentectomy with partial transverse colectomy: The middle colic artery and vein
identified, divided, and ligated, and the specimen removed.
CHAPTER 20 Cytoreductive Surgery for Ovarian Cancer: Upper Abdominal Procedures 163

ftexure
FIGURE 20.5 Omentectomy with partial transverse colectomy: A functional end-to-end stapled coloco-
lostomy using the GIA and TA stapling devices is safe, efficient, and produces a capacious anastomotic lumen.

on the location and extent of tumor growth. If the divided (Figure 20.6). The two to five short gastric
anterior surface of the spleen and splenic hilum are arteries running in the upper portion of the gastro-
not obscured by tumor, the anterior approach is the splenic ligament are serially ligated and divided or
most direct route to control the splenic blood sup- taken down with a vessel-sealing device. The stomach
ply. Following mobilization of the omentum, the sple- is retracted cephalad to reveal the lesser sac and pro-
nocolic, gastrocolic, and gastrosplenic ligaments are vide maximal exposure to the splenic vessels as they

Splenic flexure of colon


FIGURE 20.6 Splenectomy: Following mobilization of the omentum, the splenocolic, gastrocolic, and
gastrosplenic ligaments are divided. The two to five short gastric arteries running in the upper portion of
the gastrosplenic ligament are serially ligated and divided or tak:en down with the vessel-sealing device.
164 SEcnON II GYNECOLOGIC ONCOLOGY

Spleen Tumor at splenic hilum

FIGURE 20.7 Splenectomy: The stomach is retracted cephalad to reveal the lesser sac and provide maxi-
mal exposure to the splenic vessels as they enter the hilum.

enter the hilum (Figure 20. 7). The tortuous splenic At this juncture, placing the patient in reverse Tren-
artery can be identified along the superior border of delenburg position allows the spleen to descend into
the pancreas and traced distally toward the splenic the abdominal cavity and may improve exposure. The
hilum. Preliminary ligation of the splenic artery may spleen is brought anteriorly and rotated medially, expos-
be performed at this point to minimize the risk of ing the lienorenal ligament on the posterior lateral sur,
hemorrhage related to manipulation of the spleen face of the spleen. The lienorenal ligament is incised
during further mobilization and will also allow the with the ESU, allowing the spleen to be delivered into
spleen to decompress, making it smaller and easier the incision and exposing the posterior surface, splenic
to maneuver. The peritoneum overlying the splenic hilum, and the tail of the pancreas (Figure 20.9). If
artery is carefully incised, and a right angle clamp is necessary, the tail of the pancreas is gently dissected
introduced beneath the artery. The splenic artery is away from the splenic vessels. If not done previously,
doubly ligated with 2-0 silk sutures (Figure 20.8}. the splenic artery is carefully dissected from the

Pancreas

FIGURE 20.8 Splenectomy: The peritoneum overlying the splenic artery is carefully incised and a right
angle clamp introduced beneath the artery. The splenic artery is doubly ligated with 2-0 silk sutures.
CHAPTER 20 Cytoreductive Surgery for Ovarian Cancer: Upper Abdominal Procedures 165

Spleen rotated medially

UA11on1Nllllgament

Splenic flexure of colon retracted medially


FIGURE 20.9 Splenectomy: The lienorenal ligament is incised with the ESU, allowing the spleen to be
delivered into the incision and exposing the posterior surface, splenic hilum, and the tail of the pancreas.

adjacent splenic vein and pancreatic tail, doubly ligated The posterior approach to splenectomy is advan-
with 2-0 silk sutures, and divided. Some surgeons favor tageous when bulky omental disease with extensive
placing an additional transfixion stitch with 3-0 prolene tumor infiltration of the gastrocolic and gastrosplenic
suture through the tip of the proximal arterial pedicle ligaments obscures the splenic hilum and allows only
for added security. The spleen is gently compressed to limited surgical access to the splenic vessels via the
ensure decompression followed by double suture liga- anterior approach. In this technique, the stomach is
tion and division of the splenic vein (Figure 20.10). placed on medial traction, but no attempt is made to
Separate ligation of the splenic artery and splenic vein divide the gastrosplenic ligament at this juncture; the
reduces the risk of arteriovenous fistula formation. splenocolic ligament is divided, if not done previously.

Splenic artery ligated and divided

FIGURE 20.10 Splenectomy: The spleen is gently compressed to ensure decompression followed by
double suture ligation and division of the splenic vein.
166 SEcnON II GYNECOLOGIC ONCOLOGY

The spleen is rotated medially and anteriorly, and the Exposure of the right upper quadrant is achieved by
lienorenal ligament divided. The splenic artery and vein mobilizing the right lobe of the liver caudally and medi-
are individually ligated and divided, as described above. ally. The round ligament of the liver is divided between
As the final step, the specimen is fully rotated into the clamps and suture ligated; the proximal suture can be
incision, exposing the undersurface of the gastrosplenic held long and used to provide downward traction on
ligament. The short gastric vessels are then individually the liver. The membranous portion of the faliciforrn
ligated and divided or taken down with a vessel-sealing ligament is taken down with the ESU until it splits
device. A closed-suction drain is routinely placed in the into the anterior right and left coronary ligaments. The
splenic bed and the drain effluent monitored for amy- anterior right coronary ligament is carefully divided,
lase levels during the postoperative period if there is working just above the peritoneal reflection onto the
concern over an injury to the pancreatic tail. liver surface and moving from medial to lateral, with
care taken not to injure the underlying right hepatic
vein and inferior vena cava (Figure 20.11 ). Laterally,
Diaphragm peritonectomy with
the right triangular ligament is reached and divided
full-thickness resection with the ESU above the renal and adrenal peritoneal
~~ The right hemidiaphragm is more often involved reflection (Figure 20.12}. The right triangular liga-
. . than the left side due to the propensity of ovarian ment is formed by the confluence of the anterior and
cancer cells to accumulate in Morison pouch and the posterior right coronary ligaments, which along with
subhepatic recess. Extensive involvement of the dia- the vena cava form the boundaries of the bare area of
phragm by ovarian cancer military tumor spread or con- the liver. Once the ligamentous attachments have been
fluent tumor plaque is most effectively managed with divided and the bare area exposed, the liver is placed
diaphragm peritonectomy. Not infrequently, the tumor on downward traction with a moist laparotomy sponge
will partially or completely invade into or through the and rotated medially. Placing the patient in reverse
diaphragm muscle and a full-thickness resection of the Trendelenburg position allows the liver to descend into
diaphragm muscle will also be necessary. Additional the abdominal cavity and may improve exposure.
techniques include piecemeal resection, ablation with The peritonectomy is begun by grasping the peri-
the ABC, or aspiration with the CUSA toneal edge of the diaphragm with two or three Allis

FIGURE 20.11 Diaphragm peritonectomy with full-thickness resection: The anterior right coronary
ligament is divided, working just above the peritoneal reflection onto the liver surface and moving from
medial to lateral, with care tak:en not to injure the underlying right hepatic vein and inferior vena cava.
CHAPTER 20 Cytoreductive Surgery for Ovarian Cancer: Upper Abdominal Procedures 167

Liver retracted medially

Right
trlangular ligament
FIGURE 20.12 Diaphragm peritonectomy with full-thickness resection: Laterally, the right triangular
ligament is reached and divided with the ESU above the renal and adrenal peritoneal reflection.

clamps just beneath the right costal margin and placing Primary closure of the resulting diaphragmatic
it on traction. The ESU is used to create a curvilinear defect is possible in most cases; even large (I 0 em)
incision extending the length of the costal margin, work- defects can be repaired by re-approximating the
ing down to Morrison's pouch so that the full extent of rednndant diaphragm muscle edges. The edges (or
tumor involvement is included in the resection. The angles) of the long axis of the diaphragmatic defect
dissection is in the subperitoneal plane, carefully sepa- are held with Allis clamps and a series of inter-
rating the peritoneum from the underlying diaphragm rupted or figure-of-eight stitches of 2-0 prolene suture
muscle, and proceeds systematically from lateral to placed, working from each angle toward the middle
medial and from ventral to dorsal (Figure 20.13). of the defect. Prior to placement of the final stitch,
Because it is retroperitoneal, the bare area is virtually a 14-French Robinson catheter is inserted into the
always free of disease and will form the lower mar- pleural space and placed on continuous suction; as
gin of the peritonectomy or full-thickness resection the final suture is tied, the catheter is simultaneously
(Figure 20.14). Perforating branches of the inferior withdrawn, decompressing the pneumothorax and
phrenic artery and vein should be individually ligated as obviating the need for a chest tube (Figure 20.16).
they are encountered. This systematic approach ensures The "bubble test" is performed to confinn an air-tight
that the later stages of the procedures will be confined closure. The patient is placed in shallow Trendelen-
to the area of the central tendon. The central tendon burg position and the right upper quadrant filled with
is the thinnest portion of the diaphragm and the most saline solution. If air bubbles are identified during a
difficult from which to raise the peritoneum. When the mechanical inspiratory breath, a diaphragmatic defect
tumor is densely adherent to the diaphragm or invades is present and should be located and repaired. Rarely,
through the muscle to the pleural space, a full-thiclmess satisfactory closure of a large defect will require place-
resection of the diaphragm muscle is required. The ment of a prosthetic (polytetrafluoroethylene, woven
pleural space is entered and explored both digitally and Dacron, or Marlex mesh), which is sutured to the
visually to assess the extent of pleural involvement. The edges of the diaphragmatic defect circumferentially
anesthesiologist should be notified that the pleural cav- with interrupted stitches of 2-0 prolene suture. Occa-
ity has been entered. The involved portion of the dia- sionally, small penetrating lesions of the diaphragm
phragm muscle/central tendon is circumscribed with can be resected full-thickness using theTA (4.8 nun)
the ESU and removed (Figure 20.15). or Endo-GIA stapling devices. This technique is
168 SEcnON II GYNECOLOGIC ONCOLOGY

FIGURE 20.13 Diaphragm peritonectomy with full-thickness nssection: The dissection is in the sub-
peritoneal plane, carefully separating the peritoneum from the underlying diaphragm muscle, and proceeds
systematically from lateral to medial and from ventral to dorsal.

FIGURE 20.14 Diaphragm peritonectomy with full-thickness nssedion: The bare area of the liver is vir-
tually always free of disease and will form the lower margin of the peritonectomy or full-thickness resection.
CHAPTER 20 Cytoreductive Surgery for Ovarian Cancer: Upper Abdominal Procedures 169

FIGURE 20.15 Diaphragm peritonectomy with full-thickness resection: The involved portion of dia-
phragm muscle/central tendon is circumscribed with the ESU and removed.

FIGURE 20.16 Diaphragm peritonectomy with full-thickness resection: Prior to placement of the final
stitch, a 14-French Robinson catheter is inserted into the pleural space and placed on continuous suction;
as the final suture is tied, the catheter is simultaneously withdrawn, decompressing the pneumothorax and
obviating the need for a chest tube.
170 SEcnON II GYNECOLOGIC ONCOLOGY

generally only applicable to a tumor mass that has a infection, tolerating a normal diet without nausea or
relatively narrow or pedunculated ( 1 to 2 em} base. vomiting, satisfactory bowel and bladder function,
and evidence of appropriate wound healing. If not
done preoperatively, patients undergoing splenec-
POSTOPERATIVE CONSIDERATIONS tomy should receive the aforementioned vaccines
14 days postoperatively.
Postoperatively. central hemodynamic monitoring and
intensive care unit admission are useful in selected
patients. Adequate intravenous access and monitor-
Operative Note
ing are essential to replace fluid deficits and main- PROCEDURE: CYTOREDUCTIVE
tain intravascular volume. In addition to third space SURGERY FOR OVARIAN CANCER:
losses, intraoperative blood loss may be significant,
requiring transfusion for correction of anemia and/
UPPER ABDOMINAL PROCEDURES
or coagulopathy. Patients should be monitored
closely for metabolic and electrolyte abnormalities.
Omentectomy with partial transverse
Selected patients may benefit from perioperative
colectomy
~-blockade to decrease cardiac morbidity. Routine The colon attachments at the hepatic and splenic
thromboembolic prophylaxis with three daily doses flexures were taken down, with wide mobilization
of low-dose unfractionated heparin is recommended. of the ascending and descending colon. The dorsal
Alternatively. low-dose unfractionated heparin may reflection of the omentum onto the transverse colon
be combined with pneumatic compression devices, was incised and the lesser sac entered and developed.
or prophylactic doses of low molecular weight hepa- The right and left gastroepiploic vascular pedicles
rin may be given. were clamped, divided, and secured with 1-0 delayed
Patients undergoing diaphragm peritonectomy with absorbable suture. The hepatocystocolic ligament
or without full-thickness diaphragm resection should was divided and the gastrocolic ligament divided
have a chest radiograph in the recovery room to evalu- from the greater curvature of the stomach out to
ate the presence of a pneumothorax. Often, a small api- the gastrosplenic ligament using the vessel-sealing
cal pneumothorax can be identified. As these patients device. A continuous circuit of the marginal artery
do not have an air leak from the lung parenchyma, this of Drummond across the transverse colon was con-
will improve spontaneously. A daily chest radiograph firmed by trans-illumination. The transverse colon
be performed until resolution. Approximately 8% to was cleared of surrounding fat, 2- to 3-cm proximal
12% of patients will require a postoperative chest tube and distal to the extent of gross tumor involvement
or thoracentesis for a large (> 15%) pneumothorax or and divided using the GIA stapling device. The proxi-
pleural effusion. Perioperative complications associ- mal limb of the transverse colon was approximated to
ated with splenectomy include left-sided atelectasis the distal limb of the divided transverse colon using
or pneumonia, thromboembolic events, hemorrhage, 3-0 silk sutures and a transverse colocolostomy per-
splenic vein thrombosis, arteriovenous fistula between formed using the GIA and TA stapling devices. The
the splenic artery and vein, gastric fistula, pancreatitis resulting anastomosis was capacious, hemostatic, and
or pancreatic pseudocyst formation, and sepsis from tension-free.
encapsulated organisms. The overall postoperative
morbidity rate following transverse colectomy is 26%,
with a fistula rate of 5%. Splenectomy
When splenectomy or transverse colectomy The colon was widely mobilized by taking down the
includes resection of the gastrocolic ligament and hepatic and splenic flexures and dividing the hepato-
suture ligatures are placed flush along the greater cystocolic and splenicocolic ligaments. The right and
curvature of the stomach, postoperative gastric left gastroepiploic vascular pedicle were clamped,
decompression with a nasogastric tube is recom- divided, and secured with 1-0 delayed absorbable
mended for 72 hours to avoid gastric distension. suture, and the gastrocolic ligament divided from the
Otherwise, postoperative diet may be advanced greater curvature of the stomach using a vessel-sealing
with adequate bowel sounds, but there is no need device. The gastrosplenic ligament was taken down
to wait until passage of flatus. Criteria for discharge with the ESU, with the individual short gastric ves-
include: afebrile without evidence of uncontrolled sels being secured and divided with clamps and suture
CHAPTER 20 Cytoreductive Surgery for Ovarian Cancer: Upper Abdominal Procedures 171 _ _ __

ligatures or a vessel-sealing device. The spleen was


rotated medially and the lienorenal ligament divided. COMPLICATIONS
The tail of the pancreas was gently dissected from the
splenic hilum and the splenic vessels skeletonized. • Significant tension on the transverse colocolos-
The splenic artery was doubly ligated with 2-0 silk tomy or a discontinuous blood supply along the
suture and divided; a 3-0 prolene suture was placed transverse colon mesentery increase the risk of
in a transfixion stitch at the proximal stump of the anastomotic breakdown.
splenic artery. The splenic vein was clamped, divided, • Imprecise dissection of the splenic artery and
and doubly ligated with 2-0 silk suture and the speci- vein may lead to unrecognized injury to the
men excised. A closed suction drain was placed in the pancreatic tail and result in pancreatic leak or
left upper abdomen and brought out through a sepa- pseudocyst formation.
rate stab incision. • Incomplete evacuation of pneumothorax
following diaphragm resection will precipitate
respiratory decompensation upon removal of
Diaphragm peritonectomy with mechanical ventilation.
full-thickness resection
After ensuring satisfactory exposure, the round liga- Suggested Reading
ment of the liver was clamped, divided, and secured
I. Bristow RE, Peiretti M,Zanagnolo V, Salani R. Giuntoli RL,
with 1-0 delayed absorbable suture and the faliciform
Maggioni A. Transverse colectomy in ovarian cancer
ligament divided with the ESU. The anterior leaf of
surgical cytoreduction: operative technique and clinical
the right coronary ligament was taken down laterally. outcome. Gynecol Oncol2008;109:364-369.
with care taken to avoid the underlying right hepatic 2. Chi DS, Liao JB, Leon LF, et al. Identification of prog-
vein, until the right triangular ligament was reached nostic factors in advanced epithelial ovarian carcinoma.
and divided. The liver was rotated medially and cau- Gynecol Oncol2001;82:532-537.
dally, fully exposing the bare area of the liver. A curvi- 3. Cliby W. Dowdy S, Peitoza SS, Gostout BS, Podratz KC.
linear incision was created with the ESU just beneath Diaphragm resection for ovarian cancer; technique and
the right costal margin in the subperitoneal plane, short-termcomplications. Gynecol Oncol2004;94:655-660.
and the peritonectomy dissection carried from lateral 4. Dowdy SC, Lowen RT, Aletti G, Feotoza SS, Cliby W.
to medial and from anterior to posterior. At the point Assessment of outcomes and morbidity following dia-
of deep tumor penetration into the diaphragm mus- phragmatic peritonectomy for women with ovarian car·
cinoma. Gynecol Oncol2008;109:303-307.
cle, the pleural cavity was entered, and the portion of
5. duBois A. Reuss A, Pujade-Lauraine E, Harter P. Ray·
the diaphragm muscle involved with tumor (describe
Coquard I, PflstererJ. Role ofsurgical outcome as prognos-
measurements) was resected in its entirety using the tic factor in advanced epithelial ovarian cancer: a combined
ESU. The pleural cavity was inspected visually and explmatory analysis of 3 prospectively randomized phase 3
palpably and no other sites of disease were noted. multicenter trials. Cancer 2009;115: 1234-1244.
The diaphragmatic defect was closed with a series 6. Eisenhauer EL, Ahu-Rustum NR, Sonoda Y; et al. The
of figure-of-eight 2-0 prolene sutures. Prior to tying addition of extensive upper abdominal surgery to achieve
the final suture, a 14-French Robinson catheter was optimal cytoreduction improves survival in patients with
inserted into the pleural cavity and placed on contin- stages IIIC-N epithelial ovarian cancer. Gynecol Oncol
uous suction while the anesthesiologist delivered sev- 2006; 103: I 083-1090.
eral large mechanical inspiratory breaths, evacuating 7. Magtibay PM, Adams PB, Silverman MB, Cha SS,
the pneumothorax. The catheter was withdrawn from Podratz KC. Splenectomy as part of cytoreductive surgery
in ovarian cancer. Gynecol Oncol2006;102:369-374.
the pleural cavity as the final suture was tied. The
8. Tamussino KF, Urn PC, Webb MJ, Lee RA, Lesnick TG.
patient was placed in Trendelenburg position and
Gastrointestinal surgery in patients with ovarian cancer.
the right upper quadrant filled with saline solution Gynecol Oncol2001;80:79-84.
while several large mechanical inspiratory breaths 9. Zivanovic 0, Eisnehauer EL, Zhou Q, et al. The impact
were delivered. No air leaks were noted, ensuring an of bulky upper abdominal disease cephalad to the greater
air-tight closure. A closed suction drain was placed in omentum on surgical outcome for stage me epithelial
the right upper quadrant and brought out through a ovarian, fallopian tube, and primary peritoneal cancer.
separate stab incision. Gynecol Oncol2008;108:287-292.
CHAPTER 21

Control of Pelvic Hemorrhage


Robert E. Bristow

INTRODUCTION coagulation system and selectively employ intravascu-


lar embolization techniques by interventional radiology,
The most effective strategy to control pelvic hemor~ when appropriate, to control pelvic hemorrhage.
rhage is to prevent it in the first place through diligent
preoperative preparation, sound surgical judgment, and
the use of careful and meticulous surgical technique. PREOPERATIVE CONSIDERATIONS
Nevertheless, significant pelvic hemorrhage is a poten-
tial complication in any patient undergoing gynecologic Although significant hemorrhage is a risk in any sur-
or obstetrical surgery. Intraoperative, postoperative, or gical procedure, the presence of certain risk factors
postpartum bleeding can occur as a result of unexpected should prompt a higher level of anticipation and prepa-
or unrecognized vascular injury or an inability to control ration: I) any cesarean section, especially if it involves
excessive bleeding during a surgical procedure. Effective repeat surgery or a risk of uterine atony; 2) surgery
management of pelvic hemorrhage requires an expert for extensive pelvic malignancy, particularly involving
knowledge of pelvic anatomy and the relevant vascular deep pelvic structures or the pelvic retroperitonewn;
supply, as well as the coagulation system, with its intrin- 3) surgery for severe pelvic infection (e.g., tuba-ovarian
sic and extrinsic pathways. Immediate recognition and abscess) or endometriosis, with obliteration of normal
prompt response to pelvic hemorrhage can rninintize the tissue planes compounding the difficulty of dissection;
sequelae of this life-threatening complication. 4) obesity; 5) the presence of a large pelvic mass;
The pelvic surgeon will encounter a number of clini- 6) prior pelvic radiation treatment; and 7) coagula-
cal scenarios that may be complicated by significant tion dysfunction. In these circwnstances, the surgeon
pelvic hemorrhage, the more common of which include: can enhance his or her capacity to deal with hemor-
Wlcontrolled bleeding from a uterine incision, typically rhage, should it occur, by ensuring that the following
at cesarean section, diffuse central pelvic bleeding as a instrumentation is close at hand: additional suction
result of extensive surgery for malignancy or infection, devices, electrosurgical Wlit (ESU or "Bovie"), an argon
and direct injury or laceration of a pelvic artery or vein beam coagulator, vascular hemoclips (mediwn and
during extensive dissection {e.g., lymphadenectomy large), vascular clamps {e.g., "bulldog" and Satinsky),
and surgery for severe endometriosis). The pelvic sur- and fine (5-0) monofilament suture with a vascu-
geon should be familiar with the techniques of uterine lar needle. It may also be advisable to have access to
artery ligation, hypogastric (internal iliac} artery ligation hemostatic agents that can be used to help control
(HAL), repair of vascular injury, and packing outlined diffuse venous oozing such as oxidized, regenerated
in this chapter. In addition, the surgeon should be able cellulose (Surgicel®, Ethicon, San Angelo, TX), absorb-
to institute corrective measures for abnormalities in the able gelatin foam (Gelfoam®, Pfizer, New York, NY),

173
174 SEcnON II GYNECOLOGIC ONCOLOGY

microfibrillar collagen {Avitene®, Bard Davol, Murray structures (Figure 21.1 ). In the face of significant pel-
Hill, NJ), and fibrin glue (Floseal~~~'~ hemostatic matrix, vic hemorrhage, the initial effort should be directed at
Baxter, Deerfield, IL). Preparations should be made locating the source of bleeding and applying pressure
with the blood bank to ensme the availability of type either with a fingertip, a spongestick, or laparotomy
and cross-matched packed red blood cells as well as packs. Direct pressure will stem the hemorrhage and
component therapy {e.g., cryoprecipitate and platelets) allow the surgeon to get organized for more definitive
to replace specific deficiencies that may be associated management. The surgeon must resist the urge to try
with massive hemorrhage. and get the bleeding quickly under control by blindly
applying traumatic clamps, using electrocautery indis-
criminately, or placing sutmes or clips without precise
SURGICAL TECHNIQUE localization of the vascular injury.
After pressme control has been established, the sur-
A general prerequisite to the effective control of pelvic geon should quickly and efficiently: I) notify the anes-
hemorrhage is an expert knowledge of the pelvic vas- thesia team of the situation and consult with them on
culatme and the relationships to critical surrounding the proposed plan of management (including adequate

Aorta-------l-

--f--1--7-74- /A;4!-......,....:::::::==~~~+-+-+-I+-Lateral
sacral

Lateral
circumflex
Profunda femoral
FIGURE 21.1 Overview of pelvic arterial system.
CHAPTER 21 Control of Pelvic Hemorrhage 175 _ _ __

intravenous access and the possible need for ICU surface. To ligate the right uterine artery, the needle is
care postoperatively); 2) call for blood hank resources passed first through the avascular area of the broad lig-
(packed red blood cells, fresh frozen plasma, platelets, ament 2 to 3 em lateral to the uterine vessels, anterior
and whole blood) for possible transfusion; 3) gather to posterior, then it is brought anteriorly through the
the necessary instrumentation and equipment; and 4) myometrium 1 em medial to the uterine vessels, and
request additional surgical assistants or specialized per- the knot is tied on the ventral surface (Figure 21.2).
sonnel {e.g., vascular surgeon), if necessary. With proper placement of the ligatures at the level of
Next, the adequacy of exposure of the operative the uterine isthmus, there is negligible risk of bladder
field should be evaluated. Sufficient lighting should or ureteral injury and no need for extensive bladder
be assured. The adequacy of the incision and surgical mobilization or ureteral dissection. Generally, the liga-
approach should he reassessed; a vertical incision may tures should he placed below the level of the transverse
need to be extended, a Pfannenstiel incision may need uterine incision for maximal control of bleeding. If
to he converted to a Cherney incision, or a laparoscopic bleeding from the uterine incision persists, the collat-
or vaginal procedure may need to he converted to lapa- eral blood supply to the uterus from the ovarian vessels
rotomy. Retractors may need to he added or replaced. should be controlled by placing a No. 1 or 1-0 delayed
The surgical field should he cleared of excess instru- absorbable suture in a figure-of-eight stitch through the
mentation and packs, and any blood clot should be utero-ovarian ligament on each side.
evacuated. To the greatest extent possible, the surgeon
should normalize anatomy around the site of bleeding
and mobilize and retract nearby vulnerable structures
Hypogastric artery ligation
(e.g., bladder, ureter, and other vessels). At this point, HAL can be used to control hemorrhage from cesarean
the pressure control measures can be carefully with- section as well as any gynecologic surgery complicated
drawn to identify the source of hemorrhage and allow by bleeding from the central pelvis or parametria due
the surgeon to assess the situation and formulate an to small vessel injury. The procedure is effective for
appropriate plan of action (e.g., use of clamps, suture arterial bleeding from the vaginal apex. and in the broad
ligatures, electrosurgical sealing, hemostatic agents, or ligament. It is not effective for venous oozing anywhere
a combination of measures). in the pelvis. HAL was first described by Howard A.
Kelly at the Johns Hopkins Hospital in 1894, who per-
formed the procedure as an emergency measure to
Uterine artery ligation control massive pelvic bleeding in a patient undergo-
Uterine artery ligation is appropriate for cases of sig- ing hysterectomy for cervical cancer. Although Kelly
nificant bleeding from the uterine incision at cesarean hypothesized that bilateral HAL achieved hemostasis
section, either intraoperatively or postoperatively. and by "cutting off all pelvic circulation," Burchell later
uterine bleeding complicating an extensive abdominal conducted a series of elegant studies of the physiology
myomectomy procedure. The technique is straightfor- of HAL and concluded that the key mechanism was
ward and can rapidly arrest uncontrolled bleeding from actually a reduction in pulse pressure distal to the site
the cesarean section uterine incision. In their original of occlusion, which presumably allowed a clot to form
report, O'Leary and O'Leary reported a success rate of at the more distal site of vessel injury. In these stud-
over 90% in controlling postcesarean hemorrhage with ies, the pulse pressure distal to the point of ligation on
this technique, such that hysterectomy was necessary the ipsilateral side was reduced by 77% with unilateral
in just 4 of 90 cases. HAL. When bilateral HAL was performed, the pulse
Uterine artery ligation is most easily performed with pressure was decreased by 85%. Actual blood flow in
the surgeon standing on the patient's left side. The vessels distal to the point of ligation was reduced by
uterus is grasped and elevated with the surgeon's left just 48%. The reduction in pulse pressure may also
hand. To ligate the left uterine artery, a No. 1 or 1-0 reduce the amount of blood loss to the point where a
delayed absorbable or chromic catgut suture on a large specific vascular injury can be accurately localized and
needle is passed into and through the myometrium controlled.
1 em medial to the uterine vessels at the level of the The effectiveness of HAL in reducing arterial pulse
uterine isthmus, driving the needle from anterior to pressure distal to the site of ligation is dependent on
posterior. The needle is brought forward through the successful prevention of collateral circulation beyond
avascular area of the broad ligament 2 to 3 ern lateral the ligature via branches of the posterior division of
to the uterine vessels and the knot tied on the ventral the hypogastric artery. The branches of the posterior
176 SEcnON II GYNECOLOGIC ONCOLOGY

FIGURE 21.2 Uterine artery ligation.

division fonn a well-defined anastomotic network with psoas tendon, lateral to the external iliac artery and
the systemic arterial circulation proximal to the site parallel to the infundibulopelvic ligament and ovar-
of occlusion (iliolumbar/lumbar, lateral sacraVmiddle ian vessels. The round ligament should be ligated and
sacral, and superior gluteaVmedial circumflex femo- divided, if not done previously. The critical structures
ral) (Figure 21.1). Ligation of the hypogastric artery to be identified are the common iliac artery and vein,
above or proximal to the posterior division will allow the external iliac artery and vein, the hypogastric artery,
a redirection of arterial flow through these collateral and the ureter {Figure 21.3). The pararectal space
pathways, ultimately reaching the site of vessel injury should be carefully developed using a combination of
and bypassing the ligature. For this reason, it is criti- gentle blunt finger dissection and sharp dissection with
cal that the ligature be placed distal to the origin of a Kelly clamp. To open the pararectal space, the axis of
the posterior division. Anatomic studies conducted by dissection should first be directed dorsally, then cau-
Bleich and coworkers have shown that the posterior dally, and finally medially within the pelvis. The ureter
division and its branches arise from a common trunk in should be located on the medial peritoneal reflection
only 62% of cases, with the remaining cases having the and retracted with a retractor blade. Alternatively, the
branches arising independently from one another. In ureter can be placed within a vessel loop for traction
all cases, however, the branches of the posterior divi- out of harm's way. The common iliac artery should be
sion originate from the posterior and lateral surface of definitively identified and traced distally to the bifurca-
the hypogastric artery. The average distance from the tion into the external iliac artery and hypogastric artery.
bifurcation of the common iliac artery to the posterior This step is critical, because inadvertent ligation of the
division branches is 2.7 em, with a range of 0.2 to 5.6 common iliac artery or external iliac artery will result
em. Therefore, when performing HAL it is recom- in vascular compromise of the lower extremity. The
mended that the ligatures be placed 5 em distal to the hypogastric vein is located deep and lateral to the hypo-
common iliac artery bifurcation, which will spare the gastric artery along the pelvic wall, and may be read-
posterior division branches in 95% of patients. ily apparent. It is not necessary to specifically identify
The operative approach to HAL begins with achiev- the hypogastric vein, however, when performing HAL,
ing satisfactory exposure to the pelvic retroperitoneum as these efforts may injure the vein and compoWld
by opening the pelvic sidewall peritoneum along the the bleeding problem. Once the hypogastric artery
CHAPTER 21 Control of Pelvic Hemorrhage 177_ _ __

Pelvic siclawall peritoneal incision

FIGURE 21.3 Hypogastric artery ligation: Opening the pelvic sidewall, identification of critical structures.

has been clearly identified, a blunt-tipped right angle right angle clamp should be passed beneath the hypo-
clamp is carefully passed underneath the artery-, work- gastric artery- 5 em distal to its origin from the com-
ing from lateral to medial to minimize the risk of lacer- mon iliac artery- (Figure 21.4). Two ligatures of 1-0
ating the Wlderlying hypogastric vein. Lifting the artery delayed absorbable or silk suture are handed to the
from its bed with a Babcock clamp may be helpful. The right angle clamp and passed simultaneously arolUld

Hypogastric artery

tlc::iUKt :l1.4 "ypogmnc anery ugauon: U1Ssect1on tecnn1que.


178 SEcnON II GYNECOLOGIC ONCOLOGY

the hypogastric artery and sequentially tied, doubly are repaired using a continuous stitch of fine monofila-
ligating the artery to prevent recanalization. The artery ment suture (5-0 polypropylene} on a vascular needle.
should not be divided after ligation. The identical pro~ The suture line closure should be perpendicular to the
cedure is then performed on the contralateral side. long axis of the artery, such that repair does not result
in narrowing of the vessel lumen. Bites should be taken
approximately 2 mm from the laceration edge and
Repair of vascular injury be spaced approximately 2 rnm apart (Figure 21.5).
Arterial injury can occur anywhere in the pelvis but Following repair, the distal vessel loop or vascular
most conunonly involves the common iliac or external clamp is removed first to permit air or microernboli
iliac artery as a result of puncture or laceration dur- to exit through the suture line before removing the
ing pelvic lymphadenectomy or insertion of a lateral proximal vessel loop or clamp. Doppler examination
laparoscopic trocar. While the hypogastric artery can for pulsatile flow distal to the site of repair should be
be safely ligated without untoward effects, injury to performed and a lower extremity pulse confirmed intra~
the external or common iliac artery requires repair or operatively. Excessive manipulation of the external iliac
replacement. Small puncture or laceration injuries to or common iliac artery may result in dissection of an
the major pelvic arteries (common iliac and external atherosclerotic plaque or intimal hematoma leading to
iliac) should be controlled initially by finger pressure, lower extremity ischemia. These complications, as well
while additional equipment is gathered in prepara~ as large transmural arterial injuries requiring vessel
tion for repair. Definitive proximal and distal control replacement, are best managed by a vascular surgeon.
of the lacerated artery is achieved by occlusion with The most commonly encountered venous injuries
vessel loops. Alternatively, proximal and distal pressure during pelvic surgery are to the external iliac vein,
with spongesticks or placement of atraurn.atic vascular hypogastric vein, obturator vein, and presacral venous
clamps (e.g., Debakey) can be used to obtain control plexus. The external iliac, hypogastric, and obtura~
of the arterial blood flow. Mobilization of surrounding tor veins may be lacerated or punctured during pelvic
structures {bowel, ureter, and other vessels) may be lymphadenectomy or resection of a malignant or inflam-
necessary to permit adequate visualization and con~ matory process that has distorted the normal anatomy.
trol of both proximal and distal blood flow to the site Injury to the ventral or medial surface of the exter-
of injury. Small puncture or laceration injuries to the nal iliac vein can be controlled with digital pressure,
major pelvic arteries (common iliac and external iliac) spongesticks, one or more Allis clamps, or a peripheral

FIGURE 21.5 Repair of external iliac artery laceration with vessel loops.
CHAPTER 21 Control of Pelvic Hemorrhage 179

vascular clamp (e.g., Satinsky) while adequate suc- from behind the bifurcation of the common iliac vein.
tion and exposure are established. The defect is then The hypogastric vein should he repaired with a figure-
repaired with 5-0 monofilament suture on a vascular of-eight or running closure of fine (5-0) monofilament
needle in a figure-of-eight stitch or numing, nonlocking suture on a vascular needle. A small puncture injury
closure (Figure 21.6). As with arterial injury repair, may be controlled with one or two vascular hemoclips.
the axis of the suture line closure should be perpen- Application of multiple clips to the hypogastric vein
dicular to the long axis of the vein to prevent narrowing should he avoided, however, because if the hemorrhage
of the vessel lumen. Injury to the inferior surface of the is not successfully controlled, the presence of multi-
external iliac vein can occur at the entry point of the ple clips makes definitive suture repair more difficult.
accessory obturator vein (present in 25% of patients) Injury to the obturator vein most commonly occurs at
near the superior pubic ramus, requiring lateral rota- its entrance into the obturator canal, into which the
tion of the external iliac vein to obtain adequate expo- distal end of the vein may retract. Bleeding is controlled
sure, prior to suture repair or application of one or two by placing a figure-of-eight stitch of 5-0 monofilament
vascular hemoclips. suture at the opening of the canal, again taking care to
Injury to the hypogastric vein can be troublesome, avoid the obturator nerve.
given the complex venous drainage of the lower pel-
vis. Placement of crushing clamps should be avoided.
Rather, the precise bleeding site or sites should be
Management of hemorrhage from the
identified and repaired with figure-of-eight stitches of
deep pelvis and presacral space
fine monofilament suture. Laceration of the hypogastric Diffuse venous hemorrhage in the deep pelvis can be
vein in close proximity to its confluence with the exter- a significant clinical challenge because of the unpre-
nal and common iliac veins can be particularly difficult dictable anatomical pattern of venous plexuses and the
to control as a result of the three-way venous drainage; fragile nature of these vessels. Attempts at electroco-
successful repair is dependent upon achieving good agulation or to place sutures and hemoclips may only
visualization through distal occlusion of the hypogastric make the problem worse, and application of hemostatic
and external iliac veins and proximal occlusion of the agents may be unsuccessful in stemming the hemor-
common iliac vein (Figure 21. 7). The obturator nerve rhage. In these rare instances, the surgeon's best option
should he clearly identified as it emerges into the pelvis may be the "pack-and-go-back" approach, particularly if

External iliac
artery retracted
Extemallllac vein

FIGURE 21.6 Repair of external iliac vein laceration with placement of a Satinsky clamp to
control bleeding.
180 SEcnON II GYNECOLOGIC ONCOLOGY

Obturator nerve
Laceration In hypogastric vein

FIGURE 21.7 Repair of hypogastric vein laceration with occlusion of proximal and
distal venous blood flow.

the blood loss has been significant and the situation is immediate packing and compression for 5 to 7 minutes.
further complicated by coagulopathy.. In this approach, If bleeding persists, topical procoagulants may be of
laparotomy sponges are packed tightly in the pelvis. If some benefit. Floseal® hemostatic matrix (Baxter,
the procedure has been prolonged and the bowel dis- Deerfield, IL) combines collagen-derived particles and
tended, no attempt should be made to re-approximate topical thrombin that conform to irregular bleeding sur-
the fascia at this time. Rather, the skin can be closed faces such as the sacral foramina. Alternatively, ster-
with a running stitch of large caliber monofilament ile metal thumbtacks can be pressed directly over the
suture, or the incision left open and covered with ster- bleeding areas in the presacral fascia and pushed all the
ile towels and an adhesive biodrape. The patient is way into the sacrum or placed directly into each bleed-
transferred to the intensive care unit and stabilized, ing sacral foramen (Figure 21.8). Sacral foramina may
with correction of any coagulopathy and replacement also be occluded (packed) with bone wax prior to place-
of blood products. Provided the bleeding is controlled ment of sterile thumbtacks. Placement is facilitated by
after 24 to 48 hours, the patient is returned to the oper- loading the thumbtack into the end of a Kelly clamp to
ating room under anesthesia, the incision opened, the achieve sufficient leverage to penetrate the sacral bone.
packing removed, and any residual bleeding controlled
with standard techniques.
Significant hemorrhage from the presacral space is POSTOPERATIVE CONSIDERATIONS
a result of injury to the presacral venous plexus, which
includes the middle sacral, lateral sacral, and basiver- Postoperatively, patients experiencing massive pelvic
tebral veins. Bleeding from the basivertebral veins can hemorrhage should usually have central hemodynamic
be especially problematic, since they originate as open monitoring in an intensive care unit environment.
canals in the spongiosa of the sacral body, have very thin Fluid deficits should be replaced and intravascular vol-
walls, and have an adventitial layer that blends with the ume maintained, with additional transfusion of packed
periosteum as they emerge from the sacral foramina. red blood cells as needed. Attention should be directed
The venous plexus is usually lacerated when dissection toward correcting coagulopathy and avoiding hypother-
in the presacral space occurs beneath the plane of the mia, which causes platelet dysfunction. Patients should
presacral fascia (Waldeyer's fascia). Bleeding from the also be monitored closely for metabolic and electrolyte
presacral venous plexus is often aggravated by impre- abnormalities. Venous thromboembolism remains a sig-
cise placement of sutures or attempted electrocautery. nificant risk after gynecologic surgery, even after a mas-
Management of presacral bleeding should start with sive hemorrhagic event, so thromboembolic measures
CHAPTER 21 Control of Pelvic Hemorrhage 181

FIGURE 21.8 Placement of sterile thumbtack using a Kelly clamp to control presacral bleeding.

should be instituted as long as there is no evidence of Suggested Reading


active bleeding and when coagulopathy has been cor-
I. Bleich AT. Rahn DD, Wieslander CK, Wai CY, Roshan·
rected. If the external iliac artery has been repaired or
mvan SM, Corton MM. Posterior division of the internal
replaced, the ipsilateral lower extremity pulse should
iliac artery: anatomic variations and clinical implications.
be checked regularly using a Doppler probe. Am) Obstet Gynecol2007;197:658.e1-5.
2. Burchell RC. Internal iliac artery ligation. The J Lancet
Operative Note 1964;84:97-99.
3. Burchell RC. Physiology of intemal iliac artery ligation.
PROCEDURE: CONTROL OF PELVIC J Obstet Gynaecol Br Commonw 1968;75:642-651.
HEMORRHAGE 4. Kelly HA. Ligation of both internal iliac arteries for hem·
orrhage in hysterectomy for carcinoma uteri. Bull Johns
Not applicable. Hopkins Hosp 1894;5:53-54.
5. O'LearyJL, O'Leary)A. Uterine artery ligation forcontrolof
postcesarean section hemorrhage. Obstet Gynecol1974;
43:849-853.
COMPLICATIONS 6. Tomacruz RS, Bristow RE, Montz PJ. Management of
pelvic hemorrhage. Surg Clin N Amer 2001;81:925-948.
• Uterine artery ligation must be performed at the
level of the uterine isthmus to minimize the risk
of ureteral ligation or kinking.
• Optimizing exposure and lighting when control-
ling hemorrhage deep in the pelvis or on the
pelvic sidewall will minimize the risk of ureteral
injury or damage to the obrurator nerve.
• Potential complications of HAL include inad,
vertent ligation of the common iliac or external
iliac artery. laceration of the hypogastric vein,
ureteral injury, and lower extremity paresis.
CHAPTER

The Microsurgical or Peritoneal


Approach to Conservative
Reproductive Surgery
Ricardo Azziz

While surgeons often assume that microsurgical (also and which is designed to protect the human body against
called peritoneal) techniques are only to be used when harm and intrusion by foreign agents. It is relatively
doing microscopic surgery, that is surgery requiring tough. Alternatively, the peritonewn is embryonically
magnification because of the size of the organs being of mesodermic origin and is designed primarily to allow
operated upon (e.g., fallopian tube or vas deferens contiguous organs to slide over each other as the body
lumens} or size of the sutures being used (i.e., equal moves and to help contain infections. It is composed of a
to or smaller than 8-0 gauge), these approaches are single layer of nonkeratinized mesothelial cells overlying
actually valuable when doing any surgery that involves a rich network of tiny blood vessels, connective tissue,
preserving or restoring normal organs, and in par· and inflammatory cells. The mesothelium is composed
ticular reproductive organs. In fact, to a large degree of a single layer of flattened squamous-like cells with
the success of reproductive surgery (i.e., reconstruc- microvilli, peripheral vesicles, and discrete bundles of
tive/reparative surgery of or around the reproductive cytoplasmic microfilaments. The peritoneum is very del-
organs} principally lies in the ability of the surgeon to icate and easily damaged (Figure 22.1 ).
clearly understand the nature of the tissues that she/he As such, rubbing the peritoneum with a laparotomy
is operating upon and to maximize efforts to minimize sponge that is seemingly nonabrasive {although to test
the degree of tissue damage. The general principles of the true abrasiveness of these fabrics, try rubbing your
microsurgical surgery are reviewed briefly below. nose with one), such as when packing the bowel away
from the pelvis, will effectively destroy millions of peri-
toneal cells, denuding large areas of tissue. Likewise
UNDERSTANDING PERITONEAL when we allow this tissue to become desiccated as we
ANATOMY, HEALING, AND expose it to ambient air and forget to continuously irri-
ADHESION FORMATION gate, or macerate it as we repeatedly grasp and release
it with forceps or hemostat, or leave behind foreign
Much of the damage performed during surgery, in par- material, irritating fluids (e.g., dermoid or endometri-
ticular pelvic surgery, stems from the surgeon's lack of oma contents), or bacteria which result in inflamma-
understanding of peritoneal anatomy and the process tion and further damage to the peritoneum.
of peritoneal healing. Although beyond the purview of Second, fibrous tissue and adhesive bridges between
this atlas, a few principles are well worth remembering. tissues begin on a scaffold of fibrin. Fibrin is released
First, the peritoneum is not anatomically analogous by blood as it coagulates and by peritoneum as it is
to the skin (epidermis). The latter is composed of mul- damaged, and is quite adherent, covering and bridg-
tiple layers of squamous cells, the outermost of which ing damaged areas. In turn, fibrin is broken down
are keratinized emb:ryonically arising from the ectoderm, into fibrin split products (FSPs) by a process called

185
186 SEtnON Ill REPRODUCTIVE SURGERY

Skin

Eplderml•
Stratum splnosum

Mesothelial cells
Microvilli (sectional view)

Mesothelial cl?~~:::~?~~~~S~
cell layer
Basal layer-'(::9~~~~~~5!~2:1
FIGURE 22.1 Depidion of the relative anatomies of skin and peritoneum: Note that while skin is a
relatively tough multilayered keratinized protective coat designed to protect the human body against harm
and intrusion by foreign agents, peritoneum is very delicate and easily damaged, designed primarily to allow
contiguous organs to slide over each other as the body moves. Peritoneum is composed of a single layer of
flattened nonkeratinized mesothelial cells overlying a rich network. of tiny blood vessels, connective tissue,
and inflammatory cells.

fibrinolysis. Blood and peritoneal (mesothelial) cells healthy peritoneum rarely leads to the formation of
contain plasminogen, which is converted to the a more permanent adhesion. Alternatively, if fibrin
active enzyme, plasmin, through the action of plas- is formed and not resorbed sufficiently rapidly, the
minogen inhibitors (PAI1 and PAI:J In turn, plasmin fibrin bridge is then invaded by small blood vessels,
breaks down fibrin into the biologically inactive FSPs inflammatory cells, and fibroblasts that deposit col-
through the tissue plasminogen activator (tPA) path- lagen and other more permanent materials, leading
way. This process occurs within the first week of to the formation of an adhesive hand (an .,adhe-
smgery (Figure 22.2). sion"). For example, this would be observed if blood
If fibrin is removed rapidly through fibrinolysis, is deposited on a peritoneum surface that has been
then the peritoneum heals normally. For example, a damaged, such as a denuded and cauterized surface,
clot formed by free-flowing blood sitting on otherwise resulting in the formation of a fibrin band or bridge
CHAPTER 22 The Microsurgical or Peritoneal Approach to Conservative Reproductive Surgery 187

Fibrinolysis

Fibrin

tPA
Plasminogen--....;:..._Piasmin ----J-..
..1

Inhibition Fibrin split products


FIGURE 22.2 Fibrinolysis is a system for removal of fibrin: The peritoneal cells (mesothelial cells) con-
tain plasminogen, which is converted to the active enzyme, plasmin. The plasmin breaks down the fibrin
into the biologically inactive fibrin split products by the tissue plasminogen activator pathway (tPA). The
fibrinolytic system is modulated by plasminogen inhibitors (PAI 1 and PAI2), which may regulate individual
differences in fibrin removal.

that is resorbed less rapidly, allowing the fibrin to or adhesions) (Figure 22.3). It represents a race of
become organized and an adhesive band to form. sorts between these two processes. If the peritoneum
Third, peritoneum heals itself from below, not just is well perfused, well oxygenated, with a minimum
from side-to-side. When skin heals it does so by growing of nonresorbed fibrin, foreign materials, or dead tis-
cells from each side of the wound or break, which pro- sue, regeneration occurs rapidly, and the amount of
trude into the damaged area from side to side, eventu- fibrous tissue (adhesions} formed is minimized. Alter-
ally meeting in the middle. And this takes time, which natively, if tissue regeneration occurs slowly or not at
is why the scar (fibrosis tissue deposition} is always in all, and the remaining tissue is hypoxic or damaged,
the middle of the wound. The peritoneum, however, then most, or all, of the repair will be composed of
heals through the growth of colonies of cells, much like fibrous scar. Remember, the body must repair itself
bacteria grow in a petri dish, each colony growing radi- as fast as possible with whatever it has at hand.
ally outward and eventually covering the entire area. Anything that delays the regeneration of normal
The colonies arise from remaining mesothelial cells peritoneum, generally reducing oxygenation to the tis-
and from mesenchymal stem cells imbedded in the sue (i.e., causing hypoxia), for example by excessive
subperitoneum that differentiate into superficial peri- damage to the surrounding blood vessels, by swelling
toneal cells. This form of healing is much more effi- decreasing blood flow, by strangulation with sutures,
cient and rapid than side-to-side healing, and is most and so on, will delay the regeneration of new perito-
effective in the healing of large damaged surface areas, neum and allow fibrous tissue to develop instead,
such as the peritoneum. resulting in adhesion and scar formation.
However, this type of healing also depends heavily
on the health of the remaining tissues, which albeit
denuded, are not damaged further and are well oxygen-
ated. Hypoxia of the underlying tissues will result in a
PRINCIPLES OF MICROSURGICAL
slowing down of normal tissue healing, allowing adhe- TECHNIQUE
sions to form. And this is why excessive suturing to try
Understanding the tissue, and in particular the perito-
and create a "quilt" of peritoneum to cover denuded
neal surfaces that a reproductive surgeon is required to
areas, particularly when using running stitching, is not
operate upon, the principles of the microsurgical tech-
necessarily the optimum strategy to promote healthy
nique will include (see also Box 22.1):
peritoneal healing.
Overall, the healing of tissues, including the a. Minimization of tissue damage: Excess tis-
peritoneum, represents a balance between normal sue damage during reproductive surgery can be
tissue regeneration and the development of that caused by excessive manipulation of peritoneal
"all,purpose" repair tissue, fibrosis (i.e., scar tissue surfaces, absence of continuous irrigation and
188 SEtnON Ill REPRODUCTIVE SURGERY

Peritoneal Healing (approximately 5-7 days)

Perllonealln)ury
~
Increased vasc~lar permeability
lntlamm,ry exudate
,----Fibrin deposition----.

Normal peritoneal
healing
FIGURE 22.3 The steps of peritoneal healing are depicted: Injuries to the peritoneal surface can cause
stimulation of mast cells, resulting in the release of histamine and vasoactive kinins. These substances cause
an increase in capillary permeability that leads to the formation of an inflammatory exudate that, in turn,
results in deposition of fibrin. Fibrinolysis is vital to the removal of this fibrin deposit. Under ischemic condi·
tions that result from peritoneal injury, the tissue loses its abundant fibrinolytic activity. The fibrin is allowed
to persist as re-epithelization occurs. The fibrin becomes covered with a mesolethial surface and, in some
cases, actually undergoes endothelial cell migration and neovascularization. This process leads to adhesions.
Adhesion formation, therefore, requires both raw surface areas weeping fibrin exudate, as well as the fail·
ure to readily remove fibrin by fibrinolysis.

hydration, suturing that strangulates or decreases is complete. Thus, in addition to minimizing the
tissue perfusion, and excessive use of hemostatic amount of compromised tissue and the deposi-
or destructive energy. Thus, careful consideration tion of foreign materials, careful avoidance of
of where and when to use electrosurgery. or where, surgical site contamination, and vigilant postop-
which, and how sutures are placed, should be con- erative monitoring for signs of incipient infec-
tinuously assessed during surgery. tion, with rapid and aggressive response, will be
critical.
b. Minimization of excess fibrin accumulation:
In addition, it will be important to minimize
As noted, adhesions form on fibrin scaffolds. Thus,
the amo1mt of dead or necrotic tissue left behind.
meticulous irrigation and hemostasis should be
Leaving behind too much tissue that has been com-
maintained during microsurgical surgery. albeit not
promised and that will become necrotic ensures that
at the expense of excessive cauterization or sutur-
there is a ready focus of inflanunation and adhesion
ing. Expectant management, followed by gende
formation. Careful consideration of where sutures
washing of the tissues once a clot has had time to
are placed or what blood vessels have been compro-
fonn, is the preferred teclmique for most minor
mised will be critical to ensure that only a minimum
bleeding.
of damaged tissue is left behind.
c. Minimization of inflammation and infection:
Inflammation can result from infection, for~ d. Minimization of foreign body deposition:
eign body deposition, excess necrotic tissue, Foreign bodies include not only suture materials,
etc. Inflammation will result in tissue swelling, clips and the like, but also com starch, cloth fibers,
uneven tissue perfusion, tissue hypoxia, and the and other products from gloves, drapes, etc. These
deposition of inflammatory exudate, containing materials serve as irritants, increasing the forma-
a myriad of macrophage and inflammatory cell tion of adhesions. Careful washing of gloves before
products that accelerate the formation of fibrous surgery. minimizing the amo1mt and gauge of
tissue. Infection can also result in continued and sutures used, and avoiding the deposition of other
progressive tissue damage long after the surgery foreign materials is paramount.
. ,,••
CHAPTER 22 The Microsurgical or Peritoneal Approach to Conservative Reproductive Surgery 189

Principles of microsurgical/peritoneal approach


• Minimizing tissue damage, by:
• Minimizing manipulation of peritoneal surfaces
• Maintaining continuous irrigation and hydration of surfaces
• Avoiding suturing that strangulates or decreases tissue perfusion
• Avoiding excessive use of hemostatic or destructive energy
• Minimizing excess fibrin accumulation, by:
• Frequent irrigation of accumulating fibrin
• Maintaining meticulous hemostasis during surgery, albeit not at the
expense of excessive cauterization or suturing
• Minimizing risk and development of inflammation and infection, by:
• Minimizing the amount of compromised tissue and the deposition of
foreign materials
• Carefully avoiding surgical site contamination
• Vigilant postoperative monitoring for signs of incipient infection, with
rapid and aggressive response
• Reducing amount of dead or necrotic tissue left behind
• Reducing foreign body deposition, by:
• Minimizing the use, and the reactivity and diameter, of suture materials,
clips, and the like
• Reducing contamination by incidental materials, such as corn starch,
cloth fibers, etc.

Surgeons in general, pelvic surgeons in particular, Suggested Reading


and every single reproductive surgeon, should ensure
I. diZeregaGS. Peritoneum, peritonealhealing,andadhesion
that they keep in mind at all times the principles of
formation. In: diZerega GS, Gomel V. eds. Peritoneal
peritoneal anatomy and healing, microsurgery, as they Surgery. New York, NY: Springer~Verlag; 2000:14-23.
perform their procedures.
CHAPTER

Microsurgical Tubal
Reanastomosis
Ricardo Azziz, Melinda Henne, M. Jonathon Solnik

INTRODUCTION PREOPERATIVE CONSIDERATIONS


The microsurgical tubal (or "microtubal") reanas~ Factors affecting pregnancy success following MTR
tomosis (MTR) can be performed via laparotomy. include: a) total tubal length remaining (>4 em best);
minilaparotomy. or laparoscopy (either direct or by b) type of sterilization (Pomeroy, clip, and ring steri-
robotics), although the principles and precepts of lization best); c) site of reanastomosis (isthmic-isth-
the procedure remain the same. Surgeons today mic best); d) time from sterilization (the less time the
also need to understand the impact the advent of better); e) techniques employed (microsurgical tech~
advanced reproductive technologies, and in particu- nique best); f) surgeon expertise {best if done more
lar in vitro fertilization (IVF), has had on the care of than 50 cases); g) patient's age (younger the better);
patients with prior tubal ligation and the selection of and h) presence or absence of other infertility factors.
patients for MTR. In well-selected patients, MTR results in 60% to 80%
First, these procedures have created a viable option intrauterine pregnancy rates.
to MTR for many patients who have undergone a prior Thus, careful patient selection is critical prior to
tubal interruption, particularly for those women who are undertaking the procedure. Usually this should include
younger, are willing to undergo more than one IVF cycle a review of the prior tubal ligation (tubal interruption)
if necessary, and do not want more than one additional operative note, and the associated pathology report if
child. Alternatively, for women who have undergone a pertinent, along with a brief assessment of the couple's
tubal ligation and desire more than one child, are con- fertility potential. The latter should include a semen
cerned about the maternal and pediatric risks of mul- analysis, ovulation monitoring, and ultrasonographic
tiple pregnancies, or are older (- 38 years of age), MTR assessment of the uterine and pelvic anatomy. In
may prove to be a viable and useful alternative. Both women who are older, say over the age of 35 years, or
types of procedures are expensive if the full cost is bore who have begun to experience other concerning signs
by the patients, and so finances are also a factor in the or symptoms, including irregularity in menstrual cycles,
decision between MTR and IVF. vasomotor flushing or hirsutism, intermittent or persis-
Second, we should note that as the number of tent pelvic pain, and dyspareunia, a more comprehen~
patients who undergo IVF has increased, the number sive evaluation may be required.
of MTR procedures performed has declined, decreasing The presence of obesity should also be a consider-
the availability of skilled and experienced reproductive ation, as it not only impacts on the obstetrical outcome
surgeons. of any resulting pregnancy but also on the technical

191
192 SEtnON Ill REPRODUCTIVE SURGERY

ease and feasibility of the MTR itself, at least via lapa- (e.g., Pomeroy's tubal ligation), a description of what
rotomy or minilaparotomy. Thus, many reproductive tubal length was removed and confinnation of the same
surgeons advise obese patients to lose weight prior to by the pathologic report is also helpful. UnfortWlately,
an MTR, if age is not an issue. because the original operator is often focused primar-
Of importance, and beyond the scope of the current ily on destroying the fallopian tubes, not considering
discussion, is for the surgeon to recognize the various that the patient may change her mind and desire later
types of tubal ligation or interruption performed, as fertility, often little useful description is available in the
some are not amenable to reanastomosis. Only those tubal ligation operative note beyond the type of proce~
anastomoses in which relatively healthy and sufficient dure performed.
tubal segments are left behind should be attempted, In patients scheduled to undergo a laparoscopic
including those with a total tubal length of at least 4 em MTR, the absence of such information is offset by the
and in which the intramural and fimbriated portions of fact that at the time of surgery the operator will be able
the tube are preserved. For example, tubal ligation by to inspect the pelvis in a minimally invasive fashion.
funbriectomy or sterilization using cornual occlusion Alternatively, for those surgeons who are planning to
{e.g., using the Essure® and Adiana111 procedures} are perform the MTR via laparotomy, consideration should
not amenable to reanastomosis. Likewise, patients who be given to performing a concomitant initial laparos-
have Wldergone a monopolar "triple-bum" tubal inter- copy if the condition of the distal segment of the tubes
ruption often have so much destruction of the tube is unclear (e.g., in "triple~burn" procedures). In these
that MTR is not possible. circumstances, only if the tubal condition appears to
The condition of the intramural and proximate portions be favorable at laparoscopy should the surgeon proceed
of the occluded tube can be assessed preoperatively using with the laparotomy and MTR or laparoscopic MTR.
a hysterosalpingogram (HSG). Assessment of the proxi- For this the patient may be placed supine on the
mate portion of the tube is particularly critical in patients operating table, an insufflating needle placed through
who have Wide:rgone cauterization of the tubes, either as the umbilicus and a laparoscope placed as per routine.
the prima:ry interruption procedure or after the tubes have Manipulation of the uterus and adjacent structures
been severed. While the condition of the uterine cav~ through a vaginally placed sponge on a grasper, or via
ity today can be easily and less invasively assessed using a suprapubically placed probe, is usually sufficient to
transvaginal ultrasonography and/or sonohysterography, expose the tubal ligation sites. Performing the diagnos-
these procedures are not helpful in visualizing the intra- tic laparoscopy on a day separate from the MTR is not
mural/proximate portions of the occluded fallopian tube. recommended, due to the added costs and risks, except
If no portion of the occluded tube is visualized by when a more thorough discussion of the pelvic findings
HSG, it is possible that most, or all, of the intramural with the patient may alter the decision for surgery.
portion of the fallopian tube has been destroyed, often by
excessive use of electrosurgery at the time of the original
tubal ligation. If this is the case, the prognosis for a suc- SURGICAL TECHNIQUE
cessful MTR is significantly reduced. This information
wiD help in guide the surgeon at the time of the proce- The MTR is a microsurgical procedure, in other words
dure, allowing him/her to know how far back they may a reproductive surgery that utilizes sutures best viewed
need to resect the proximal portion of the tube before with magnification, that is, equal to or smaller than
a healthy lumen is identified; arrangements to have the 8-0G. These procedures usually call for the use of mag-
HSG films available for intraoperative examination at the nification of some type, either using magnifying loupes
time of the MfR should be made. This information may (1.7X to 6X) or an operating microscope (2X to 40X),
also help in counseling the patient concerning the best although the need for magnification obviously varies
method of approaching her secondary infertility. according to the surgeon's visual acuity. Some of us
The condition of the distal portion of the occluded/ even use loupes when performing macroscopic surgi-
interrupted fallopian tube may be guessed at preopera~ cal procedures, a response more to failing eyesight than
lively based on the description provided in the tubal the need for microsurgical technique.
ligation procedure note. This report should optimally However, the true basis of microsurgery, as dis-
note whether or not periadnexal or peritubal adhesions cussed in Chapter 22, is not the size of the sutures used
or endometriosis were observed and the condition of or the degree of magnification utilized. The success of
the tubal ostia and fimbria. In addition, particularly in reproductive microsurgery principally lies in the abil-
those procedures where a portion of the tube is resected ity of the surgeon to intimately understand the tissues
CHAPTER 23 Microsurgical Tubal Reanastomosis 193

that she/he is operating upon, thus minimizing the should be increased slightly. In addition a fine
degree of tissue damage. Reproductive surgeons should bipolar forceps (e.g., McPherson curved bipolar
be well acquainted with what is commonly called the uncoated forceps, 3 ~ inch in length with 5-mm
microsurgical technique, as its principles are applicable tips) should be available.
to surgery in general, and to reproductive organ sur- Continuous irrigation of the surgical site to mini-
gery in particular. Following we will review the surgical mize the risk of desiccation is critical to the success
technique of MTR step by step, initially describing of the procedure. This surgeon prefers the use of
the procedure when performed by laparotomy (see Lactate Ringer's as there is some evidence to indi-
s=- also video: Microsurgical Tubal &anastomosis). cate that this isotonic crystalloid solution causes
- However, during the entire procedure surgeons less peritoneal swelling than other solutions. To
should be fully aware and use all principals related to the extent possible the fluid should be warmed to
micro or peritoneal surgery. body temperature, but no more, to avoiding freez-
ing or scalding the peritoneal surfaces. Various filled
1. Ensuring all necessary instruments are avail- syringes with 20-ISG IV catheter {e.g., Angiocath®)
able and ready: In addition to the standard lapa- tips should be available for this purpose.
rotomy instruments, specialized instruments for Before beginning, the surgeon should also
microsurgery should be available. The microsurgeon examine and set up the operating microscope, if
should have intimate knowledge of the surgical in- one is available and to be used, fixing the height
struments used during an M1R (see Box 23.1 and and separation of the ocular pieces. The micro-
Figure 23.1) and should check them immediately scope should also be sterilely draped at this time.
before surgery to ensure they are available on the In addition, if magnifying loupes are to be used,
surgical table and are in good working condition, as they should be put on.
these delicate instruments are easily damaged during
sterilization and storage.
2. Preparation of the surgical field: Before pro-
ceeding further the surgeon should wash his/her
A needle or wire-tip monopolar electrosurgery
tip (0.3 mm or less) should be available and should gloves off with irrigating fluid, which is then dis-
carded, to remove any potential contaminating talc
be set to 10 W cutting current or less, depending
or, more commonly; corn starch.
on the electrosurgical unit, and the patient appro-
priately grounded. The tip should not become red a. Ensuring access: Ensuring adequate access
hot or melt when the current is turned on; oth- to and exposure of the surgical site is criti-
erwise the wattage should be reduced. Likewise, cal, and greatly depends on the patient's
if the instrument does not cut through fine adhe- body mass. In thinner patients access to the
sions, cauterizing them instead, the wattage surgical site can be achieved easily through

IIIEDIII
Specialized instruments necessary for microtubal reanastomosis
• Buxton uterine manipulator
• 22 to 20G IV catheter (e.g., Angiocath®) for transfundal chromotubation
• 20 to ISG IV catheter (e.g., Angi.ocath®) and 20 cc syringes for irrigation
• Electrosurgical wire-tip (0.3 mm or less) electrode
• Microbipolar (with tips 5 mm or less)
• Fine-tip suction probe
• Atraumatic tubal graspers
• Atraumatic ovarian graspers
• jeweler's forceps
• Micro-Adson forceps, with and without teeth
• Straight and curved iris scissors
• Microsurgical (microinfertility) scissors
• Locking and nonlocking microsuture holders (Castroviejo)
194 SEtnON Ill REPRODUCTIVE SURGERY

Shirodkar Buxton
uterine clamp uterine clamp

Fallopian
tube forceps

Needle electrode straight 0.3 mm

( Monopolar cautery with flna needle

'-<(:====r!l·~·II1
1=~1--1='"-
~lily blpol:rceps Micro Adeem with teeth
llii II ill I I $==
Straight and curved Jeweler's forceps
Iris sclssoi'B

FIGURE 23.1 Common microsurgical instruments used for MTR.

a small Pfannenstiel or minilaparotomy inci, surgeons consider marked obesity to be a rela,


sion. Alternatively. access to the pelvic cav, tive contraindication to MTR via laparotomy.
ity of an obese patient is more difficult, and and either suggest weight loss, if time and
may require a more extensive abdominal port, patient inclination permits, or performing the
including a Mallard incision. And even in this procedure via laparoscopy. Once an incision
setting, it may be difficult to operate on a has been made, the sides of the wound are
very obese patient due to the short length of often wrapped in lap packs to minimize bleed,
most microsurgical instruments. Thus, many ing into the surgical site.
CHAPTER 23 Microsurgical Tubal Reanastomosis 195

b. Examining the anastomosis sites and {chromopertubation) is readied. One method


surroundings: At this point the surgeon is to place a small pediatric Foley bulb into
should examine the surgical site, determine the the uterine cavity vaginally once the patient is
status of the tubes and adjacent pelvic organs, draped, and then chromotubating with indigo
ensure adequate exposure of the surgical field, carmine as needed via a syringe held by an
and arrange the surgical field. In most circum- assistant. While this is a simple method, this
stances, the surgeon should have detemrined the surgeon prefers to chromotubate through the
adequacy of the tubes for reanastomosis pre<lp" uterine fundus, in order to minimize the risk of
eratively; or at least before perfonning the lapa- tubal contamination by vaginal organisms.
rotomy (see above). However, the surgeon should First, a Buxton uterine manipulator is placed
verify his/her preoperative assessment directly. abdominally, which not only allows for atrau-
matic manipulation of the uterus during surgery
c. Exposing the anastomosis site and
but also can be used to clamp the cervical os
ensuring a surgical platform for the
closed (Figure 23.2}, allowing for transfun-
microsurgical reanastomosis: The bowel
dal chromotubation. Grasping the uterus at
is gently packed away from the pelvis, over the
its base, a 20G needle and IV catheter is then
pelvic brim, a procedure assisted by placing the
placed through the fundus of the uterus, at a
patient in moderate Trendelenburg. This sur-
point midway between each tubal insertion and
geon prefers to use laparotomy packs placed
in the direction of the uterine cavity, until a
inside sterile plastic sandwich bags, one per
gentle pop is felt when entering the cavity.
bag. thus protecting the peritoneum from abra-
A syringe containing indigo carmine is con-
sion by this material. It also allows the bagged
nected via an IV connector to the IV catheter,
laparotomy packs to be used as the surgical
after all air has been expressed from the line
platform upon which the anastomosis is per-
and the IV catheter needle has been removed.
formed (see below).
Proper placement of the IV catheter into the
d. Establishing an avenue for intraoperative uterine cavity can be verified when symmetric
chromotubation: Next, a method for intra- distention of the uterus is palpated (and often
operatively insufflating the tubes with a seen) as insufflation of dye via the syringe is pul-
dilute solution of saline and indigo carmine sated. A moderate amount of skill is necessary

FIGURE 23.2 Insertion of the transfundal chromotubation catheter, including top (A) and lateral
transverse (B) views.
196 SEtnON Ill REPRODUCTIVE SURGERY

to place the IV catheter transfwulally correctly a. Exposure and preparation of the proxi-
into the uterine cavity and, of course, a rela- mal (uterine side) stump: Exposure and
tively normal uterus is necessary. Only at this preparation of the tubal stumps can usually be
point is the surgeon ready to proceed with the accomplished by either direct visualization, or
actual tubal reanastomosis. better still using magnifying loupes. While an
operating microscope is not necessary for this
3. Preparation of tubal stumps and anastomo·
part of the procedure, it may be useful when
sis site anchoring: Microsurgery of the tubes,
opening the lumen in the distal ampulla of an
incluc:Ung dissection, preparation, and reanasto-
isthmic-ampullary reanastomosis (see below).
mosis, is best performed over a stable platform
of uniform height (to facilitate manipulation of i. Proximal isthmic segment In the vast
the tubes while keeping tissues in within the fo- majority of patients the proximal stwnp will be
cal length of the microscope. We use bagged 0.5 to 2 em in length, representing an isthmic
laparotomy packs placed into the cul-de-sac as a interruption. The distal portion of the proxi-
suitable and stable platform. mal tubal stump will be buried in the adhered
The preparation of the tubal stumps varies mesosalpinx that connects the proximal
according to the type of anastomosis to be per- and distal rubal stmnps. The tube should be
formed, whether it is isthmic-isthmic, arnpullary- grasped with a jewelers forceps, or preferably
arnpullary, or isthrnic-ampullary, and reference an atraumatic tubal grasper, and the occluded
to these types will be made below (Figure 23.3). distal end is released and cleared of surround-
Different types of anastomosis may be necessary for ing mesosalpinx and adhesions using the wire-
each side. Less frequently performed anastomoses, tip electtosw:gery (FJgUre 23.4A and B).
such as the cornual-isthmic or comual-arnpul- Care should be taken to not undermine
lary {i.e., anastomosing the intramural portion of excessively the tube during this process, a con-
the tubal lumen to the distal isthmic or arnpul- stant temptation, as the proximal stwnp will
lary lumen) will not be discussed further, as these have to be approximated to the distal stump
patients should preferably be treated by IVF. and anchored via the mesosalpinx (see below),
In preparing and opening the lumens of the which will be made more difficult if exces-
tubal segments for anastomosis, the surgeon should sive undermining of the tube has occurred
keep in mind two factors that will improve the suc- (Figure 23.4C). Furthermore, excessive
cess of the procedure. First, the proximal and dis- undermining will risk bleeding and may
tal lumen diameters opened should be as similar in compromise the inferior tubal blood vessels,
size as possible. Second, the tubes should be, and increasing the risk of tissue hypoxia. Hence,
should heal, as free of peritubal and tubo-ovarian it is preferable at this point to do less than too
adhesions as possible to maximize their mobility much. The surgeon can always undermine the
during ovulation. tubal stwnps further as needed.

FIGURE 23.3 nansverse tubal anatomy, indicating layers of muscle/serosa from intramural
seg ment to ostia.
CHAPTER 23 Microsurgical Tubal Reanastomosis 197

FIGURE 23.4 Exposure and preparation of tubal stumps. Before (A) and after correctly undermining
tubal stumps (B). Incorrectly/excessively undermined tubal stumps (C). Note tubal and uterine blood vessels.

The distal occluded stump of the tube is cut end of the tube will extrude in a coni-
then distended by gentle chromotubation. cal fashion, as muscularis expands outward
and the tip of the occluded isthmic stump (see Figure 23.6C). Trimming the endo-
grasped with a small Addison's (toothed) salpinx should be avoided; rather the surgeon
forceps and pulled outward. Using iris scis- should push the mucosal folds into the lwnen
sors placed perpendicular to the long axis when later performing the anastomosis.
of the tube, the occluded portion of the Chromotubation is gently continued and
tube is resected, in one single stroke if pos- if no obvious tubal patency is observed, the
sible (Figure 23.5A). Care should be taken tubal stump is regrasped at its tip, over the
not to tty and create a flat end. In fact, if site of the putative lumen, and another trans-
the transection has been done correctly the action performed. This process is repeated
198 SEtnON Ill REPRODUCTIVE SURGERY

FIGURE 23.5 Transection of occluded portion of tube. induding proximal isthmic stump (A) and
distal ampullary stump (B). This latter transection is facilitated if the surgeon distends the occluded distal
ampullary segment by inserting an IV catheter sleeve through the tubal fimbria and gently occluding the
surrounding ostia using digital pressure.

Wltil a patent and healthy (nonfibrotic) has a larger and more convoluted lumen due
tubal lumen is observed. Small bleeding to more extensive mucosal folds, than the isth-
encoWltered is managed expectantly, unless mus. Thus, continued gentle chromotubation
persistent, in which case irrigation is used to expand the occluded ampullru:y segment
to Wlcover the exact bleeding sites, which while transecting it is critical to ensure that
are then cauterized with wire-tip or micro- only the minimum amount of tissue required
bipolar electtosUigery. Care should be taken to open the lumen is removed. In fact, it gen-
to continuously irrigate the tissues. erally is best not to open the full tubal lumen,
but only enough for the lumen to be visible
ii. Proximal ampullary segment If the prox- and patent to chromotubation. The lumen
imal stump is ampullary (meaning the tube can always be opened further if necessary.
has been intem.1pted in the ampullary region,
b. Exposure and preparation of the distal
the diameter of the lumen will be larger than
stump: Attention is then paid to the distal
if it were istlunic. As the distal stump that the tubal stump. The occluded tip of the tube is
proximal ampullary stump will be reanasto-
covered by adhesions and mesosalpinx, and the
m.osed to will also be ampullary (see below), it
tube is grasped attawnatically, and freed using
may be best to await for exposure and prepara-
the wire-tip electrosurgery. Care not to exces-
tion of the distal segment before opening the
sively undermine the tube and to minimize
proximal lumen, to maximize the chances that
damage to the inferior tubal vessels, should
the tubal lumen will be as close in diameter
be made. At this point the occluded portion
as possible. In either case, a perpendicular
of the distal stwnp must be opened, and there
transection using iris scissors of the occluded
are various approaches to do so, depending on
portion of the proximal arnpullary stump will
what the proximal and distal segments of tubal
likely be the best approach to prepare this
stumps are, whether isthmic or arnpullary.
tubal segment for anastomosis.
However, we should remember that the i. Isthmic-isthmic segments: If both the
ampulla is less rigid (has less muscularis), and proximal and distal tubal segments are
CHAPTER 23 Microsurgical Tubal Reanastomosis 199

\ U\1
FIGURE 23.6 Isthmic-isthmic anastomosis. including anchor stitch placement (A); anastomosis of
the tubal muscularis (B and C); and tubal serosa and mesosalpinx closure (D). (Continued)

isthmic, then the distal stump should be ii. Ampullary-ampullary segments: The
prepared and opened in the same manner occluded ampullary stump is freed from over-
as the proximal isthmic stump (see above). lying adhesions and mesosalpinx, and the
The surgeon should test the tension on tension between the two stumps tested. If
freed stumps, by pulling the tubal ends to the distal segment of the tube is ampullary,
be anastomosed together. There should be the approach taken to open the lumen will
no tension. At this point, some surgeons depend on the size of the lumen on the proxi-
elect to thread a stent through the tubal mal tubal segment. If the proximal segment
ostia (see below) into the isthmic lumen to is also ampullary then a simple, single stroke
facilitate the subsequent reanastomosis. perpendicular transection may be appropriate.
200 SEtnON Ill REPRODUCTIVE SURGERY

FIGURE 23.6 (Continued)

However, before doing so the surgeon should can be clearly visualized, and a more con-
recognize that the distal ampullary lumen will trolled transection can be performed.
be larger than that of the proximal segment
iii Ampullary-isthmic segments: If the
Thus, care should be taken to only open a
distal segment is ampullary and the proxi-
section sufficient in size to match that of the
mal segment is isthmus, again the occluded
proximal segment. One way to visualize and
ampullary stump is freed from overlying
control for the size of the proximal lumen is
adhesions and mesosalpinx, and the ten-
to distend the tube by chromotubation (see
sion between the two stumps tested. In this
above}. Similarly, the surgeon can distend the
situation, the lumen of the ampullary seg-
occluded distal ampullary segment by insett-
ment needs to be opened in such a way as
ing an IV catheter sleeve through the tubal
to match as closely as possible the size of
fimbria and gently occluding the surrounding
the isthmic lumen (see below).
ostia using digital pressure (Figure 23.58).
The IV catheter is connected via an IV con, 4. Perfonning the reanastomosis: Once both oc,
nector to a syringe containing indigo car- eluded ends of the tubal segments are mobilized
mine, which the assistant gently injects. In and lumens open, the surgeon is ready to perform
this manner the outline of the tubal lumen the reanastomosis.
CHAPTER 23 Microsurgical Tubal Reanastomosis 201

a. Anchor stitch: The next step is to place the to ensure it is not accidentally pulled off and
anchor stitch so as to position both lumens to misplaced. If a needle of this size is lost in the
be reanastomosed facing each other as close as patient it generally cannot be detected by x-ray,
possible, without llllduly distorting the normal and in fact, may be left behind, as it often can-
anatomy. Much will depend on how well the not be located and the risk of organ damage is
tubal stumps were Wldermined. Generally, and as minimal. To minimize the risk of loss, it is best
noted above, it is best to leave sufficient mesosal- to continuously stick the needle back into the
pinx beneath the transected portions of the tubes foam pad of the suture package when not in use.
so as to allow proper positioning of the lumens Third, the needle should be grasped at its
(Figure 23.6A). This step can be performed by midpoint to insert, and the surgeon should
direct visualization or using magnifying loupes. ensure the needle is directed in the correct
The anchor stitch is placed through the direction before advancing into the tissue.
mesosalpinx as closely to the tubal lumens as The suture should be advanced progressively
possible, ensuring that the apposing lumens tluough the muscularis following the curvature
touch each other at the same height without of the needle. We should note that the needle
tension. Alternatively, the anchor stitch place- is quite fragile and easily bent or broken if an
ment should also allow sufficient tubal seg- attempt to redirect the path of the suture is
ment mobility for the anastomotic sutures to be made by trying to redirect the needle once it is
placed through tubal muscularis (see below). lodged in the tissue. Finally, the surgeon should
The stitch may have to be replaced more than avoid anything that could worsen hand tremor,
once before tying down, to ensure correct place- including excessively strenuous exercise, nico-
ment. The suture is placed through and through tine, and caffeine, in the hours prior to surgery.
the mesosalpinx, generally beginning and ending Finally, approximation of the overlying tubal
on the lateral aspect of the tube, so as to place serosa is generally accomplished with interrupted
the lmot away from the ovary and minimize the stitches, using either a 7-0 or 8-0 absorbable or
risk of tuba-ovarian adhesions, which could nonabsorbable suture on a noncutting needle.
compromise the free mobility of these organs at
the time of ovulation. Generally, a 3-0G or 4-0G i. Isthmic-isthmic reanastomosis: With the
absorbable or nonabsorbable minimally reactive two apposing isthmic lumens are touching
suture on a noncutting needle is used. without tension, isthmic-isthmic anastomo-
sis is accomplished in two layers (the inner
b. Reanastomosis: The reanastomosis portion of muscularis and outer serosal layers). The sur-
the tube involves the reconnection of the muscu- geon should push the endosalpinx into the
laris and the serosal layers of the tubal segments. lumen while perfonning the anastomosis,
While an operating microscope is not neces- rather than trimming the mucosal folds.
sary when performing an ampu.llary-ampullary To anastomose the inner layer, sutures are
reanastomosis, which can be easily performed placed through the tubal muscularis, begin-
using loupes, an operating microscope will be ning and ending on the outer aspect of the
useful when performing isthmic-isthmic and layer ("out-to-out"), so keep the knots away
isthmic-ampullary reanastomoses. from the lumen (Figure 23.68 and C).
We prefer to use 8-0 to 10-0 non-absorbable In general, placing the suture through the
monofilament suture on a cutting needle for tubal lumen should be avoided. Some sur-
the inner {muscularis) layers of the anastomo- geons find that a previously placed stent is
sis. The handling and control of sutures this helpful to visualize the lumen fully. Sutures
size requires skill and training, and there are a are placed in order, beginning at 6 o'clock
few nuances that should be kept in mind. First, (lower part of lumen), then 3 o'clock {in-
a demagnetizer should be available on the field, ner lateral aspect), 9 o'clock {outer lateral
since the microsurgical instruments (e.g., nee- aspect), and 12 o'clock (upper aspect).
dle holder) often become magnetized making it The muscularis sutures are tied using an in-
difficult to control the needle. stnunent tie, using the curved needle driver to
Second, care should be taken to keep the wrap the longer end of the suture three times
needle llllder direct visualization at all times, around a straight or curved jeweler's forceps,
202 SEtnON Ill REPRODUCTIVE SURGERY

then using the forceps to grasp the shorter end with two or three interrupted stitches
of the suture and pulling the throw through. (Figure 23.6D), beginning and ending
Three throws of the knot are placed, taking on the lateral aspect of the mesosalpinx,
care to lay each throw down in apposing direc- so as to leave the knot away from the ovary.
ticm to the one below. Some surge<>ns prefer
ii. Ampullary-ampullary anastomosis: Like
to not tie the sutures as they are being placed,
the istlunic-istlunic anastomosis (see above),
and tag them instead with rubber-shod hemo-
the ampullary-ampullary anastomosis can
stats until they are all placed. They are then
also be accomplished in two layers. However,
tied at the same time. Other sw:geons find it
the walls of the ampulla proper are thinner and
easier to maintain a clearer surgical field and
contain relatively less muscularis than that of
tie the sutures as they are placed.
the isthmus, and it may be easiest to perfonn
Once the muscularis sutures have been
the anastomosis using a single-layer closure
placed, gentle chromotubation is attempted
teclmique (Figure 23.7}. Four to five inter-
and spillage of dye through the tubal ostia
rupted 8-0 to 10-0 nonabsorbable stitches on
{i.e., tubal patency) should be observed. It
a cutting needle are placed through the full
is normal to have a small amount of leakage
thickness of the ampulla wall, .,out-to-out.n
around the anastomosis site.
The surgeon should try to minimize placing
The overlying tubal serosa is then approxi-
the sutures within the lumen, although may
mated using three or four interrupted stitches
not always be possible when ensuring a solid
{Figure 23.6D). Care should be taken not
anastomosis.
to place the sutures too deeply, risking oc-
cluding or distorting the anastomosed lumen. iii. lsthmic-ampullary anastomosis: One
Overzealous peritoneal suturing should be of the difficulties with this type of pro-
avoided, and if larger areas of peritoneum are cedure is the difference in the lumen
missing they should be left as is, rather than sizes of the isthmus and the ampulla.
place sutures under tension that may distort The easiest way to ensure relatively simi-
the tubal course and cause a greater degree of lar lumen sizes is to thread the tip of an
tissue strangulation. IV catheter (IBG) through the fimbriated
At this point, the peritoneal window opening of the tube. The catheter is con-
underlying the anastomosis site is closed nected to a syringe containing indigo carmine

FIGURE 23.7 Ampullary-ampullary anastomosis by single-layer anastomosis.


CHAPTER 23 Microsurgical Tubal Reanastomosis 203

{see above), with the needle removed (Fig- not to cut through the wall of the catheter,
ure 23.8A). The IV catheter should be and pushed through the occluded wall of
advanced so as to push the occluded end of the ampulla. The entire IV catheter is then
the tube outward, using periodic chromotu- advanced and surrotmding serosa resected
bation to help delineate the lumen and guide back using microscissors to expose a suffi-
the progress of the IV catheter. cient amount of the lumen so as to match the
When the IV catheter is tenting the size of the proximal isthmic lumen diameter.
occluded section of the ampulla and is as Once both the proximal and distal lumens
straight as possible, the catheter needle is are open, some surgeons elect to thread a stent
threaded through the sleeve, taking care (generally a colored nonabsorbahle flexible

FIGURE 23.8 lsthmic-ampullary anastomosis by (A) making small opening through 1he ocduded por-
tion of the proximal ampullary segment using an IV catheter needle often guided by the placement
of a stent, using a 0 gauge dyed monofilamentous suture (8 and C). The anastomosis is typically accom-
plished using simple interrupted sutures with 8-0 or 10.0 suture on a cutting needle (D and E). (Continued)
204 SEtnON Ill REPRODUCTIVE SURGERY

FIGURE 23.8 (Continued)

OG suture, such as 0-nylon) through the cath- thoroughly irrigated and suctioned. The anasto-
eter into the isthmic to facilitate the subse- mosed tubes and ovaries are carefully allowed to fall
quent reanastomosis (Figure 23.88 and C). into the cul-de-sac freely; checking for tension and
Stretching the suture first will make it easier misplacement. Some surgeons elect to also place an
to pass the stent through the lumens. Placing absorbable anti-adhesive barrier (e.g., Interceed®)
a stent may be particularly helpful when per- over the anastomoses. The pelvis is then closed in
forming a isthmic-ampullary reanastomosis. the usual fashion.
This type of anastomosis is often completed
in one layer (Figure 23.80 and E).
Assuming that the lumens are of simi- Laparoscopic microsurgical tubal
lar size, four or five interrupted sutures reanastomosis
"ouHo-out" (again using 8-0 to 10-0 non-
Laparoscopic microswgical tubal reversal, particularly
absorbable monofilament suture on a cut-
if robot-assisted, provides the ability to mimic the open
ting needle) are placed. Some degree of
approach while maintaining a closed environment. Like
dissection of the serosa overlying the tip
open microsurgery. the robot-assisted swgical approach
of the ampulla may be needed to allow its
allows for two-layer closure of the muscularis and ser-
suturing to the serosal layer of the isthmus.
osa with fine absorbable (or non-absorbable} sutures. It
Alternatively; if the distal ampulla lumen
also minimizes tissue desiccation, potentially reducing
is too large to match with the size of the
proximal isthmus opening, then the distal adhesion formation and improving swgical outcomes.
However, in general, similar intrauterine and ectopic
ampullary lumen can be narrowed by clos-
pregnancy rates occur following traditional laparoscopic
ing the opening partially using interrupted
sutures {Figure 23.9). Once completed, surgery and minilaparotomy.
Compared to traditional laparoscopy, robot-
any stent placed to guide the suturing
assistance affords greater ease of tissue manipulation
should be removed.
and less physical stress for the surgeons performing
5. Completing the procedure: Once both tubes the procedure. Compared outpatient minilaparotomy
have been reanastomosed and patency has been the robot-assisted laparoscopic tubal reanastomosis
confinned, all instruments and packs are removed requires greater surgical and anesthesia times, although
from the pelvis, and the pelvis and abdomen are return to normal -activity was shorter with the robotic
CHAPTER 23 Microsurgical Tubal Reanastomosis 205

FIGURE 23.9 In an isthmic-ampullary reanastomosis, if the distal ampulla lumen is too large to
match with the size of the proximal isthmus opening. then the distal ampullary lumen can be nal'-
rowed by closing the opening partially using interrupted sutures.

technique. (see also video: Robot Assisted Lapa1'0SCQ['ic POSTOPERATIVE CONSIDERATIONS


Microsurgical Tubal Reanastomosis}.
Intra- and postoperative complications are infrequent
Procedure in brief (see Complications box on page 207). Postoperative
1. The mesosalpinx is dissected from the underlying management should follow the general principals deter-
~ segments of fallopian tube to generate sufficient mined by the type of abdominal incision, including rapid
ll9a mobility in order to reduce subsequent tension arnbulation. Care should be given to watching for any
on the muscularis at the anastomosis site. signs of incipient infection, including low grade tem-
2. Transection of the muscularis/mucosal layers ex- peratures, and white count elevations. As even a small
posing the tubal lumina is performed sharply amount of infection around the anastomoses can signifi-
with scissors and bleeding vessels are cauterized. cantly reduce the success of the procedure, any sign of
Electrosurgical energy is not applied to the muco- developing infection should be treated aggressively.
sal or muscularis layers. Tubal patency can be con- Patients should be instructed to use barrier contracep-
finned by use of a stent and/or chromopertubation tion when having coitus in the first 60 postoperative days.
of the proximal segment. A stent may also be placed Pregnancy can then be attempted. They should also be
to align the juxtaposed tubal lumina as a guide for counseled regarding a higher rate of ectopic pregnancy,
approximating the muscularis. Some surgeons have which can be as high as 10% of all pregnancies following
advocated the use of a "suture-less" approach, basi- MTR. An HSG is performed three to four months postop~
cally entailing the use of a ttansuterine placed tubal eratively to further determine anastomosis success. If the
stent and the use of two external metallic clips to patient has not conceived within 12 months of surgery,
approximate the anastomosis site. consideration may be given to performing a laparoscopy,
3. The mesosalpinx is approximated with at least one and possible salpingo-ovariolysis if necessary.
interrupted absorbable suture to reduce tension
at the tubal anastomosis site and align the tubal Operative Note
lumina, which are approximated by circumfer-
ential interrupted absorbable suture. In general, PROCEDURE: MICROSURGICAL
the 6 o'clock suture is placed first, and the sub- TUBAL REANASTOMOSIS
sequent sutures are placed based on difficulty of
positioning and visualization, with the simplest The patient was placed supine upon the operating
sutures placed last. room table, and was prepped and draped in the usual
4. A second layer of similarly sized interrupted or sterile fashion. A Foley was placed to straight drain
running absorbable suture may be placed approxi- in the bladder. Time out was called and information
mating the serosa. Easy passage of a stent and/or reviewed. Gloves were washed in sterile water. At this
chromopertubation confinns tubal patency. point, a small transverse incision was made in the lower
206 SEtnON Ill REPRODUCTIVE SURGERY

abdomen, about 2 em above the pubic area. The inci- occluded tip of the distal istlunus was grasped, pulled
sion was carried down through the subcutaneous fat upward, and using straight iris scissors, the tube was
to the fascia. The fascia was incised transversely and transected in its entirety. At this point, using loupes,
dissected off the rectus muscle, upward to the umbili- the tubal lumen appeared to be evident. To confinn
cus and downward to the pubis. The rectus muscles patency of this area of the tube, an angiocath was
were separated in the midline and the perineal cav- threaded through the fimbriated portion of the tube
ity was entered digitally. The peritoneal incision was which was them compressed digitally. Chromotubation
then extended upward to the umbilicus and downward through this angiocath reviewed patency of the distal
toward the bladder. The edges of the incision were segment of the tube. Again small areas of bleeding
then wrapped with laparotomy packs to avoid bleeding around the isthmus were identified by irrigation and
from the incision into the abdomen; a Balfour retractor cauterized with microbipolar.
was placed into the abdomen. At this point, the uterus At this point an anchor stitch using 7-0 Vicryl
and adnexa were examined and the above findings were were placed at the base of the mesosalpinx in order to
noted. ensure that both tubal segments were brought together
A Buxton uterine manipulator was placed over the closely. This allowed the tubal stump to be approxi-
uterus and the cervix was compressed. A 20G angio- mated and also allowed sufficient mobility to perform
cath was placed through the fundus of the uterus and the anastomosis.
felt to have popped into the uterine cavity. The angio- Attention was paid to the left adnexa where a simi-
cath was now connected through an IV tubing to a lar process was performed. Both tubal stumps were
syringe containing dilute indigo carmine dye. Gentle freed, opened, and approximated using an anchor stitch
pressure was applied to the syringe which distended with 4-0 Vicryl. At this point, the operating microscope
the uterus uniformly suggesting that the angiocath was was now brought into the field. The focal length of the
placed correctly into the uterine cavity. At this point, microscope had been set prior to surgery to ensure that
the bowel was packed away from the pelvis using a lap the operating plane of the patient was visualized clearly
packs placed in sterile plastic bags. Furthermore, lap at all times.
packs in sterile plastic bags were placed into the cul- Under microscopic magnification the anastomo-
de-sac, elevating both adnexa including the ovaries. sis was then performed. Four 8-0 nylon sutures were
Continuous irrigation using Lactate Ringer's was placed, from out to in and then out again, taking care
performed throughout the entirety of the procedure, to not enter the lumen. The sutures were placed at
using an 18G angiocath connected to a 20-cc syringe. 6, 9, 3, and 12 o'clock. Chromotubation revealed tubal
Attention was given to the right adnexa. The isthmic patency with a small amount of leakage around the
stump was identified and grasped with Micro Adson anastomotic site. At this point the serosa of the tube
forceps with teeth and using wire-tip electrocau- was closed using interrupted sutures with 7-0 Vicryl.
tery, the occluded portion of the tube was freed of Chromotubation once again revealed tubal patency
overlying adhesions and mesosalpinx, attempting to with minimal to no leakage. The peritoneal window
preserve the underlying vessels. Likewise, the distal was now closed with three interrupted sutures using
portion of the isthmic stump was also elevated with 4-0 Vicryl, taking care not to injure the broad ligament
Adsons and freed from peritubal adhesions. The or mesosalpinx vessels and to leave the knot away from
intervening Yoon ring was also dissected free and the ovary. A similar procedure was performed on the
removed from the field. contralateral side.
At this point, using gentle pressure from the chro- Once the tubes were anastomosed, chromotubation
motubation syringe the proximal isthmic segment revealed them to be patent. No excessive bleeding was
was slightly distended. Using a Micro-Adson forceps noted. At this point, all lap packs were removed from
with teeth the tip of the occluded portion of the tube the pelvis after the adnexa were allowed to fall freely to
was grasped and the tube was transected perpendicu- the cul-de-sac. The pelvis was gently and thoroughly
lar to its long axis with straight iris scissors. Chro- irrigated. At this point the sponge count was correct
motubation indicated tubal patency with extrusion of and the peritoneal incision was closed using a running
indigo carmine dye. Small areas of bleeding on the suture using 2-0 Vicryl. The rectus fascia was closed
isthmus were irrigated, identified, and cauterized using interrupted sutures with 0 Vicryl. The subcuta-
using microbipolar forceps. neous fat was approximated using three interrupted
Attention was then placed to the distal isthmic sutures using 2-0 Plain. The skin incision was enclosed
segment. Using Micro-Adson forceps with teeth, the in a subcuticular fashion using 4-0 Vicryl. At this point,
CHAPTER 23 Microsurgical Tubal Reanastomosis 207

the patient went to the recovery room in good condi- 4. Gomel V. Reversal of tubal sterilization versus IVP in
tion without any complications. The estimated blood the era of assisted reproductive tedmology: a clinical
loss was approximately 50 cc. dilemma. Reprod Biomed Online 2007;15:403-407.
5. Gomel V, Taylor E. Reconstructive tubal surgery. In
Rock JA. Jones Hw, eds. Telindes Operative Gyneco~
Tenth Edition. Philadelphia, PA: Lippincott Williams and
COMPLICATIONS Wilkins; 2011:403-437.
6. Gordts S, Campo R, Puttemans P, Gordts S. Clinical fac-
• De novo pelvic adhesion formation-Infrequent tors determining pregnancy outcome after microsurgical
(less than 5%) tubal reanastomosis. Fertil Steril2009;92:1198-1202.
• Postoperative infection (myometritis and 7. Ketefian A, Hu J, Bartolucci M, Azziz R; Society of
adnexitis}--Infrequent (less than 5%) Reproductive Surgeons, Inc. Fifteen-year trend in the
• Hemorrhage and major vessel perforation- use of reproductive surgery in women in the United
Rare (less than 1%) States. Fertil Steril2009;92:727-735.
8. Kim SH, Shin CJ, Kim JG, Moon SY, Lee JY; Chang YS.
Microsurgical reversal of tubal sterilization: a report on
1,118 cases. Fertil Steril1997;68:865-870.
Suggested Reading 9. Rock JA, Bergquist CA. Kimball AW Jr, Zacur HA,
King TM. Comparison of the operating microscope and
1. Caillet M, Vandromme J, Rozenberg S, Paesmans M, Ioupe for microsurgical tubal anastomosis: a randomized
Germay 0, Degueldre M. Robotically assisted laparo- clinical trial. Fertil Steril 1984;41 :229-232.
scopic microsurgical tubal reanastomosis: a retrospective 10. RodgersAK, GoldbergJM, Hammel)P, Falcone T. Tubal
study. Fertil Steril2010;94:1844-1847. anastomosis by robotic compared with outpatient mini-
2. Deffi.eux X. Morin Surroca M, Faivre E, Pages F, laparotomy. Obstet Gynecol. 2007; I 09: 1375-1380.
Fernandez H, Gervaise A. Tubal anastomosis after 11. Wiegerinck MA, Roukema M, van Kessel PH, Mol BW.
tubal sterilization: a review. Arch Cynecol Obstet Sutureless re-anastomosis by laparoscopy versus
2011;283:1149-1158. microsurgical re-anastomosis by laparotomy for steril-
3. Glock JL, Kim AI-I, Hulka JF, Hunt RB, Trad FS, i2:ation reversal: a matched cohort study. Hwn Reprod.
Brumsted JR. Reproductive outcome after tubal 2005;20:2355-2358.
reversal in women 40 years of age or older. Fertil Steril
I 996;65:863-865.
CHAPTER

Laparoscopic
Salpingo-ovariolysis
M. Jonathon Solnik

INTRODUCTION PREOPERATIVE CONSIDERATIONS


Abdominal and pelvic adhesion formation remains a The ability to predict which patient will have preexist-
common phenomenon, affecting up to 90% of those ing pelvic adhesions is difficult, as the process of forma-
individuals who have undergone previous abdomi- tion seems to be variable, depending on the host. Risk
nal surgery. Adhesions have also been documented in factors, such as previous abdominal surgery, should be
those patients with no apparent risk factors. Adhesions thoroughly reviewed with patients when being counse-
occur following peritoneal injury, fibrin production, and led about a planned operation. Perioperative risks, such
dysfunctional repair of a process that would otherwise as visceral injury or need to convert to laparotomy, need
not result in adhesion formation (see Chapter 22). Risk to be clearly outlined.
factors include traumatic or inflammatory exposures A full understanding of the uterine and tubal anat-
that impede normal healing including thermal injury omy is critical prior to undertaking surgical repair of the
(e.g. electrosurgical applications), infection, foreign adnexa. While transvaginal sonography, with or without
body {e.g., suture), tissue ischemia (e.g., exposure to sonohysterography, will provide a three-dimensional
ambient air), blood, and radiation. assessment of the uterus and adnexa, hysterosalpin-
The global impact of adhesions is significant, result- gography (HSG), particularly using water-based con-
ing in gastrointestinal obstruction, implicated as a trast, gives the most accurate assessment of internal
potential contributor to chronic pain syndromes, and tubal anatomy, including the intramural portion. It is
complicating subsequent operations. Of most interest the opinion of this surgeon that a preoperative HSG is
to gynecologists and reproductive surgeons is the effect essential prior to undertaking salpingo-ovariolysis.
of adhesive disease on fertility. In fact, adhesions may Consideration to the primary entry point, especially
be to blame for approximately 20% of female-specific when performing a laparoscopic procedure, is often
infertility cases. This chapter focuses not only on the the first and possibly the most "at-risk" step, whether
laparoscopic techniques to treat, remove, and minimize it be at Palmer's point (left upper quadrant), or open
the recurrence of periadnexal adhesions, but also on (Hasson technique), or closed access through the
those surgical techniques that may reduce the risk of umbilicus. The use of preoperative mechanical bowel
de novo adhesion formation, in an effort to best pre- preparation in gynecologic surgery to reduce surgical
serve tubal function. Finally, the advent of in vitro fer- risks in patients with suspected adhesions remains an
tilization (IVF) has significantly changed our approach unanswered debate. However, it seems reasonable to
to reproductive failure secondary to pelvic adhesions; offer a bowel prep to patients who may be at high risk
this section will discuss those procedures that are cur- for bowel adhesions, particularly those involving the
rent in light of these developments. large intestine to the uterus or adnexa. We feel that

209
210 SEtnON Ill REPRODUCTIVE SURGERY

a clear diet the day preceding surgery followed by a


single Fleet® enema at night sufficiently empties the
distal colon, facilitating access to the deep pelvis. Ulti-
mately, however, it should be the surgeon's intent to
safely complete the procedure, whether adhesiolysis is
considered the primary procedure, or whether, adhe-
sions represent an obstacle to the intended procedure.

SURGICAL TECHNIQUE
FIGURE 24.1 Adhesiolysis c.an be facilitated using
Restoration of the anatomy and minimization of adhe- traction-countertraction. placing stretch on the adhe-
sion reformation with the aim of preserving repro- sion. and more clearly presenting the intervening tissue
ductive function remains the ultimate goal, and so planes.
meticulous dissection without the excessive use of
electrosurgery is often required.
stop spontaneously in short order without the need
1. General principles of adhesiolysis: Surgeons for energy. However, bipolar energy used sparsely is
should utilize all possible external factors that often sufficient to stop more significant bleeding.
may facilitate the dissection, such as fairly steep Monopolar energy should be avoided.
Trendelenburg positioning and an articulating uter-
2. Gaining pelvic exposure: The first objective
ine manipulator that reproduces the function of an
of adhesiolysis is to gain adequate exposure to
extra hand. Use of a microsurgical approach such
all reproductive organs, and to do so by destroy-
as gentle tissue handling. minimizing desiccation,
ing as few surgical planes as possible. Hence,
and limiting foreign body exposure have been well
dissection should proceed with patience, and it
described {see Chapter 22) as a means of reducing
is best performed using traction-countertraction
subsequent risk of adhesion formation, particularly
and incising with cold scissors, not electrosurgery.
to prevent the de novo formation of adhesions in
Furthermore, a careful understanding and mental
patients initially adhesion free.
visualization of the underlying anatomy is critical,
Adhesiolysis is facilitated using traction-coun-
which requires that the surgeon start his/her dis-
tertraction, placing stretch on the adhesion, and
section high up in the pelvis, where the anatomy
more clearly presenting the intervening tissue
may be adhesion free. When adequate exposure
planes. The organ to be preserved (e.g., tube)
has been obtained, the surgeon can then focus on
should be grasped with atraumatic graspers, which
the task of unencapsulating adhesions from the
should hold the organ sufficiently loosely to allow
ovaries and tubes.
it to escape without injury if excessive traction is
applied (Figure 24.1 ). Alternatively, the adhesion 3. Dissection of adnexa-bowel adhesions: If
to be removed can and should be grasped firmly, bowel or bowel appendages are adherent to the
perhaps using a toothed forceps. Often adhe- adnexa, the approach to the dissection should he
sions can be broken apart using blunt dissection. to free as much of bowel adherences as is neces-
However, thicker more fibrotic adhesions should sary, but not more. While we generally prefer to ex-
not be divided bluntly as this may predispose to cise adhesions, when operating on bowel it is best
unintended trauma; shatp dissection with scissors to incise the adhesive bands, erring on the side of
is recommended in this situation. leaving some of the adherence on the bowel serosa
Adhesions can either be incised or they can be rather than incising too close to the bowel serosa/
excised, depending on its structure and location. muscularis and risking subsequent perforation
When possible adhesions should he excised at each (Figure 24.2).
insertion and the scar tissue removed, rather than In general, when dissecting around bowel it is
simply divided. Hemostasis during dissection should best to mobilize adhesions beginning in areas that
be achieved by expectant management to the ~ent are less risky. For example, a blunt probe can be
possible. The vast majority of bleeding during adhe- sweeped along the anterior and posterior surface
sion dissection will he capillary in nature and will of the uterus, pressing towards the uterine body,
CHAPTER 24 Laparoscopic Salpingo-ovariolysis 211

4. Dissection of periovarian adhesions: Mobi-


lizing the ovary from adherences to the pelvic side-
wall requires access to the posterior aspect of the
ovary. This can be facilitated by placing a blunt
probe at the infundihulopelvic (IP) ligament reflec-
tion above the ovary (Figure 24.4 ). The blunt probe
is used to begin the dissection, advancing forward
and downward, using a sweeping downward motion
to break posterior ovarian adhesions. Eventually,
any adhesions remaining on the posterior aspect of
the ovary should be incised approaching the ovary
laterally. In addition, often the tubomesosalpingeal
reflection above the utero-ovarian ligament is rela-
FIGURE 24.2. To remove bowel or bowel appendages tively adhesion free, allowing the operator to pass
adherences it is best to incise the adhesive bands. rather a blunt probe into this area sweeping behind the
than excise the adhesions; the surgeon should aim to ovary and so breaking up filmy adhesions. Finally,
err on the side of leaving some of the adherence on the it is critical that the surgeon at all times during the
bowel serosa rather than incising too close to the bowel dissection of the ovary from the sidewall be aware of
serosa/muscularis and risking subsequent perforation. the course of the ureter; the ureter is best located
initially at the pelvic brim, where it crosses over the
to identify and stretch adhesions that can then be IP ligament (Figure 24.4).
incised/excised (Figure 24.3). The use of blunt Once the ovary is freed and mobile, it will be
dissection and electric energy in these areas should important to remove as many superficial adhesions
he avoided and, instead, gentle traction-counter- overlying the ovarian cortex as possible. Periovarian
traction and cold scissors should be used to expose adhesions will impede ovulation and release of the
and incise the adhesions, minimizing the risk of ovum and follicular fluid during ovulation, decreas-
injury. Surgeons should recognize that excessive ing fertility and potentially leading to the develop-
traction-countertraction can result in the bowel ment of persistent ovarian cysts. Superficial ovarian
wall tears, a defect that is not always apparent until cortex adhesions should be handled by grasping the
later perforation. adhesive bands fumly (e.g., using a biopsy forceps
Before completing the surgery, surgeons should with a central tooth or pin, and then peeling these
develop the habit of running the bowel laparoscopi- by pulling them along the ovarian surface until freed
cally to the extent possible to ensure that there are {Figure 24.5). Some surgeons recommend lightly
no adhered circular loops of bowel that may entrap, desiccating the adherent areas to facilitate removal
obstruct, and even strangulate another section of of the adhesions, but we prefer not to do so, as radi-
bowel at a later time. ated heat could destroy underlying ovi.

5. Dissection of peritubal adhesions: After the


ovaries have been mobilized, attention can then be
given to mobilizing up the tubes of peritubal adher-
ences. Care should be taken when doing so as to
use atraumatic tubal graspers and to not place ex-
cessive traction on such a delicate organ. We usu-
ally inject dilute indigo carmine through the uterine
manipulator (chromotubate) to first confirm filling
and patency of the oviducts. This maneuver may
not only allow the surgeon to decide how aggressive
he/she must be in restoring normal tubal anatomy,
hut will provide documentation of occlusion or pa-
FIGURE 24.3 In general. when disseding around bowel tency for future reproductive planning.
it is best to mobilize adhesions beginning in areas that Tubes that are obstructed at multiple internal sites
are less risky. and that also demonstrate periadnexal adherences
212 SEtnON Ill REPRODUCTIVE SURGERY

FIGURE 2.4.4 Freeing the ovary from sidewall adherences maybe made easier if the operator uses
a blunt probe to begin the dissection at the infundibulopelvic (1-P) ligament reflection above the
ovary at this point, advancing forward and downward, using a sweeping downward motion to
free the ovary from sidewall adhesions.

are usually not amenable to surgical repair. In these


cases, consideration should be given to removal
{salpingectomy) of the affected tube and subse~
quent IVF for fertility. Furthermore, care should be
taken to avoid dissection of the very vascular fun.
bria, unless adhesive bridges between fimbria ame-
nable to incising can be identified using a conical-tip
probe. A discussion of reconstructive procedures of
the tubal ostia, such as neosalpingostomy, is beyond
the scope of this section as these procedures have
become less relevant for the treatment of infertility
in the face of IVF.
When lysing adhesions between the tube and the
ovary, it is preferable to firmly grasp and put gentle
traction on the ovary to stretch the adhesions and
identify the dissection plane, placing less traction
FIGURE 24.5 Superficial ovarian cortex adhesions should on the tube (Figure 24.6). However, care should
be handled by grasping the adhesive bands firmly, for be taken to not excessively incise into the mesosal~
example by using a biopsy forceps with a central tooth pinx, as bleeding from mesosalpingeal vessels can
or pin, and then peeling these by pulling them along be difficult to control. Again, dissection should be
the ovarian surface until freed. initiated in an area that is not adhered.
CHAPTER 24 Laparoscopic Salpingo-ovariolysis 213

6. Antiadhesives: Adhesion formation/reformation any evidence of bowel perforation following surgery,


occurs in 55% to 90% of patients after reproductive and which can occur as late as 2 weeks after the pro-
pelvic surgery. Compared to laparotomy, laparos~ cedure. On occasion the wall of an adherent bowel
copy has been shown to reduce the risk of de novo may be injured dwing adhesiolysis, which can weaken
adhesions, but represents no clear advantage in re- and eventually rupture under distention or pressure.
ducing adhesion reformation. Although beyond the Prompt recognition and action is required to avoid a
context of this section the use of postoperative an- catastrophic complication.
tiadhesive adjuvants should be considered. To date Second~look laparoscopy and repeat adhesiolysis,
those that have received the most attention, and although advocated by some surgeons as a means of
provide the most data in randomized trials, are the improving the condition of the pelvis by permitting
adhesion barriers. Some of these can be placed lap- the breaking up of developing adhesions, has not been
aroscopically as needed (Interceed® and Prevens®) shown to improve conception rates.
(Figure 24.7), although none of the harriers is
specifically approved by the US FDA for lap~ Operative Note
scopic use. Overall, meticulous surgical technique
remains the gold standard for adhesion prevention. PROCEDURE: LAPAROSCOPIC
SALPINGO-OVARIOLYSIS
POSTOPERATIVE CONSIDERATIONS The patient was taken to the operating room after
proper informed consent had been obtained. She was
Intra- and postoperative complications are infrequent placed in the dorsal supine position, legs in Allen-type
(see Complications box on page 215), the most fre~ stiriUps. Her arms were then tucked appropriately at
quent of which is adhesion formation or more com- her side and she was prepped and draped in sterile
monly reformation. While patients should be followed fashion. A time out was then completed. Attention was
in standard fashion, swgeons should be vigilant for turned to the pelvis, where a Foley catheter was placed

Mesosalpinx
Adhesions
Uterus

FIGURE 24.6 When lysing adhesions between the tube and the ovary. it is preferable to finnly
grasp and put gentle tradion on the ovary to stretch the adhesions and identity the dissedion
plane. placing less tradion on the tube.
214 SEtnON Ill REPRODUCTIVE SURGERY

FIGURE 24.7 Relatively large pieces of the lnterceed• adhesion barrier can be placed laparoscopi-
cally: The laparoscope is withdrawn and the piece of barrier fabric is placed directly into the umbilical port,
beyond the pressure valve, using a small grasper. The laparoscope is then replaced into the umbilical sleeve,
pushing the fabric into the pelvis. The fabric is then handled using a grasper placed through an ancillary port.

in the urinary bladder and a uterine manipulator placed was achieved with carbon dioxide to a pressure of 15
to allow for chromopertubation. Attention was turned mmHg. Inspection of the trocar entry" site was thor-
to the abdomen where an intraumbilical skin incision oughly conducted and no evidence of insertional injury
was made with a scalpel and a insufflation needle was noted. Ancillary trocars were placed with two in
placed in that site. Negative aspiration test was per- the lower lateral quadrants, both 5 mm in diameter, lat-
formed, however, we could not confirm placement into eral to the inferior epigastric vessels. These were placed
the peritoneal cavity with opening pressures, and so under direct visualization without incident. Another
direct trocar placement with a 5 mm optical trocar was trocar 5 mm in diameter was placed between the pubic
performed with a 5 mm telescope. Pneumoperitoneum symphysis and umbilicus.
CHAPTER 24 Laparoscopic Salpingo-ovariolysis 215

Chromopertubation was performed upon initial


inspection, prior to manipulating adnexal structures to COMPLICATIONS
confirm the presence of preoperative spill. Prompt fill
and spill of the left oviduct was noted; however, spill of • De novo pelvic adhesion formation and
the right oviduct was incomplete and no spillage was adhesion reformation-Frequent (greater than
noted to occur despite normal appearing fimbria, con- 10% de novo adhesion formation, and as high
sistent with her preoperative HSG. as 90% adhesion reformation if severe re·existing
At this point, we focused our attention on the left adhesions)
adnexa, where approximately 1 hour was required to • Postoperative infection (myometritis, adenexitis}--
perform ovariolysis and tubolysis to allow for normal Infrequent (less than 5%)
and adequate visualization and mobilization of this • Hemorrhage and major vessel perforation-
adnexa. With extensive division of adhesions, we were Rare (less than 1%)
able to properly view the posterior cul-de-sac and then • Major organ perforation or injury (bowel, bladder,
begin our way to mobilize the right ovary, which was or ureter most frequently)-Rare (less than 1%)
noted to have an adnexal mass prior to surgery. Our • Postoperative bowel entrapment-Rare (less
approach to the left adnexal dissection was to follow than 1%)
any available surgical planes using traction and coun- • Nerve injury (generally positional)-Rare (less
tertraction techniques, cutting the more filmy adhe- than 1%)
sions with cold scissors. Small capillary bleeding was
noted, hut stopped without intervention. Sigmoid epi-
ploicae were initially noted to be adherent to the dis-
tal oviduct. Upon dividing these adhesions, we traced
the oviduct, which was noted to he normal in caliber, Suggested Reading
more distal until we reached the fimbriated edges, 1. Ahmad G, Duffy JM, Farquhar C, et al. Banier agents
realizing that this tube was currently patent. Blunt for adhesion prevention after gynaecological surgery.
dissection was also used when adhesions were filmy Cochrane Database Syst Rev 2008;(2):CD000475.
and without vessels. Thicker adhesions of the tube to 2. Alborzi S, Motazedian S, Parsanezhad ME. Chance of
the ipsilateral sidewall were also divided sharply and adhesion formation after laparoscopic salpingo-ovariolysis:
short bursts of focused bipolar energy were used to is there a place for second·look laparoscopy? JAm Assoc
stop more brisk bleeding. No subsequent eschar was Gynecol Laparosc 2003;10(2):172-176.
noted as a result of energy application. The course of 3. Carey M, BrownS. Infertility swgery for pelvic inflam-
matory disease: success rates after salpingolysis and
the left ureter was identified prior to the dissection
salpingostomy. Am J Obstet Gynecol 1987;156{2):
as was the mesocolon and sigmoid. No injuries were
296-300.
noted during dissection. 4. Gomel V, Taylor E. Reconstructive tubal surgery. In:
We then addressed the right adnexa by lysing adhe- Rock JA, Jones HW, eds. Telindes Operative Gyneca~
sions and performing a salpingectomy using bipolar Tenth Edition. Philadelphia, PA: Lippincott Williams
energy, then transecti.ng the desiccated portions with and Wilkins; 2011:403·437.
scissors. At the completion of the procedure the pel- 5. HershlagA, Diamond MP, DeChemey AH. Adhesiolysis.
vis was then observed for approximately 2 to 3 min- Clin Obstet Gynecol 199 I ;34:395·40 1
utes under low intra-abdominal pressures to ensure 6. Hesla JS, Rock JA. Laparoscopic tubal surgery and
hemostasis. The left adnexa was then wrapped in an adhesiolysis. In: Azziz R, Murphy M., eds. Practia~l
adhesion barrier (Interceed®) once hemostasis was con- Manual of Operative Laparoscopy and Hysteroscopy
fumed. Lateral trocar sites were observed after removal - Second Edition. New York, NY: Springer-Verlag;
1997:120-132.
to make certain no abdominal wall vessels were lacer-
7. Ketefian A, Hu J, Bartolucci M, Azziz R; Society of
ated. The remaining pneumoperitoneum was released
Reproductive Surgeons, Inc. Fifteen-year trend in the
and the primary trocar removed. The uterine manipu- use of reproductive surgery in women in the United
lator was removed and the Foley catheter replaced to States. Fertil Steril2009;92:727-735.
drain the bladder in the early postoperative period. All 8. Peterson HB, PollackAE, Warshaw JS. Tubal Steriliza-
skin incisions were reapproximated using 4-0 Vicryl in tion. In: Rock JA, Jones Hw, eds. Telinde's Operative
a subcuticular fashion. The patient was then extubated Gynecology. Tenth Edition. Philadelphia, PA: Lippincott
and taken to recovery in stable condition. Williams and Wilkins; 2011 :609·628.
216 SEtnON Ill REPRODUCTIVE SURGERY

9. Practice Committee of the American Society for Repro- 10. Semm K. Pelviscopic surgery: a key for conserving fer-
ductive Medicine, Society of Reproductive Surgeons. tility. Arm NY Acad Sci I 991;626:372-398.
Pathogenesis, consequences, and control of perito-
neal adhesions in gynecologic surgery. Fertil Steril
2007;88:21.
CHAPTER

Laparoscopic Ovarian Wedge


Resection or Diathermy
(Drilling)
M. Jonathon Solnik

INTRODUCTION mass, generally sparing the ovarian cortex. Alterna-


tively, bilateral ovarian diathermy focuses on destroy-
Oligo-anovulatory state and infertility often accompany ing discrete and relatively limited areas of the ovarian
the polycystic ovary syndrome (PCOS), due in large cortex. Nonetheless, studies evaluating the success of
part to increased androgen production from the stromal either procedure have reported similar success with
component of the ovary. Bilateral ovarian wedge resec- either ovarian wedge resection or ovarian diathermy,
tion (BOWR) by laparotomy as treatment for PCOS was with spontaneously occurring ovulatory cycles in up to
first described by Stein-Leventhal in 1935, who noted 90% of women treated. The endocrine changes found
restoration of menses and occasional spontaneous con- after ovarian surgery in PCOS women seem to be gov-
ceptions subsequent to the procedure. However, given erned by the ovaries themselves, and simply put, seem
the risk of postsurgical adnexal adhesions and ovarian to stem from any type of ovarian damage.
failure, and in light of the introduction of pharmaco- A recent Cochrane analysis indicated that laparo·
therapeutic agents used to induce ovulation, the pro· scopic ovarian diathermy is as successful as and more
cedure has generally fallen into disuse. Gonadotropin cost effective than gonadotropin therapy for ovulation
administration, however, poses increased risks for ovar- induction, without the added risk of OHSS and mul-
ian hyperstimulation syndrome (OHSS) and multiple tiple gestations. An economic evaluation demonstrated
gestations for patients with PCOS. A potential indica- that treating women with laparoscopic ovarian dia-
tion for surgical intervention, then, may be therapeutic thermy results in a significant reduction in both direct
failure to standard ovarian stimulation cycles. and indirect costs. Overall, for women with PCOS-
Unlike BOWR performed via laparotomy, lapa- related anovulatory infertility and who cannot tolerate
roscopic ovarian diathermy (i.e., "ovarian drilling") the risks or costs of gonadotropin ovulation induction,
results in fewer postoperative adverse outcomes such laparoscopic ovarian wedge resection or diathermy
as ovarian failure, trauma, surgical dead space, hema· (drilling) may represent a viable option.
toma formation, and adhesions. Furthermore, an effec-
tive alternative to ovarian drilling, which may unduly
compromise healthy ovarian cortex, is the laparoscopic PREOPERATIVE CONSIDERATIONS
BOWR, which has a lesser risk of postoperative peri-
ovarian adhesions than classic BOWR via laparotomy. Patients who are candidates for bilateral ovarian dia-
The exact mechanisms of action of this procedure on thermy are typically young and healthy, although some
ovulatory function are unclear. Laparoscopically per- may be glucose intolerant or overtly diabetic and may
formed ovarian wedge resection focuses on debulking require preoperative assessment by their internist.
the hyperplastic theca-stromal portion of the ovarian Not uncommonly do patients have lipid disorders or

217
218 SEtnON Ill REPRODUCTIVE SURGERY

fatty liver disease, but these typically do not preclude from the utero-ovarian ligament, with a grasping
an outpatient surgical procedure. forceps placed through the contralateral port. The
Commonly accepted surgical indications include grasper preferably should fix the ovary with limited
patients who have nonnal pelvic anatomy, nonnal male slippage and tearing (e.g., a grasper with a single
factor, and have either not responded to clomiphene central fixation pin), exposing the antimesenteric
citrate or gonadotropin ovulation induction, or have not aspect of the ovary (Figure 25.1). Maintaining the
conceived after three to six ovulation induction cycles fallopian tube away from the surgical site, behind
with either medication. Patients should also be coun- and lateral to the ovary, an incision is made longitu-
seled concerning the potential of postoperative periad- dinally along the long axis of the ovary using needle
nexal adhesions affecting fertility and the concept that rnonopolar cautery, laser, ultrasonic scalpel, or cold
the procedure itself will not generally be curative. laparoscopic scissors or scalpel (Figure 25.2).
Once the cortical incision is made, the grasper
holding the ovarian pole is released and then used
SURGICAL TECHNIQUE to grasp the ovarian stroma (Figure 25.3), which is
placed on traction through the ovarian incision. A
Laparoscopic wedge resection monopolar needle, laser, or scissors is then used to
progressively dissect out a wedge of approximately 5
1. Port and instrument placement: A$ per routine,
g of tissue (about a half thumb size) (Figure 25.4).
laparoscopic ports and instruments are placed so as
Once the tissue is removed, the distal ovarian pole
to access and manipulate each ovary separately. This
is regrasped and hemostasis of the resection bed is
operator prefers to place two 5-mm ports lateral to
attained by the use of energy delivered through the
the epigastric vessels, one each in the RLQ and
ovarian incision. However, with sufficient patience,
LLQ, and a single 10- to 12-mm suprapubic port.
little bleeding is generally encountered. The ovar-
2. Ovarian stromal resection: Once the pelvis and ian incision does not need to be closed. The speci-
abdomen are examined, and the cul-de-sac cleared men is then removed through the suprapubic port;
of bowel, an ovary is grasped at its distal pole, away a laparoscopic retrieval bag is usually unnecessary.

Round ligament

Fallopian tube Utero-ovarian ligament

FIGURE 25.1 The proximal portion of the ovary is grasped and retracted cephalad so as to expose
the antimesenteric border of the ovary on its longitudinal axis: The oviduct should be placed anterior
to the ovary to prevent inadvertent injury.
CHAPTER 25 Laparoscopic OVarian Wedge Resection or Diathermy (Drilling) 219

Ovarian stroma

FIGURE 25.2 Once fixed in position, the ovarian cortex is incised longitudinally with a needle-tip
electrosurgical instrument or laser.

Proposed wedge
resection In ovarian stroma
FIGURE 25.3 The initial grasper is replaced to place tension on the section to be excised, and a
scissors. needle-tip electrode. or laser is used to create the wedge resection of ovarian stroma.
220 SECTION Ill REPRODUCTIVE SURGERY

stroma

~ ..... ~. v
•J ,. • I •,

. :· ~·1, ' • • I •._ • • I

.. \ • c. \ ... ~ : ."

X.
;.::~~~:. ' .£"::·\
- 'l, ' ' ' ~ •I
• • • \ · ' . "":(J ..~
~
- J
- ...:. '
.
Ovarian stroma / • "·· .:~ : v
B Ovarian cortex
FIGURE 25.4A and B A monopolar needle, laser, or scissors is used to progressively dissect out a
wedge of approximately 5 g of tissue (about a half thumb size).
CHAPTER 25 Laparoscopic OVarian Wedge Resection or Diathermy (Drilling) 221

The same procedure is then repeated on the contra- modality (40 to 80 W. 25 to 200 mJ; superpulse
lateral side. 25 to 40 W) for ovarian drilling. The same proce-
dure is repeated on both ovaries.

A laparoscopic diathermy (ovarian


drilling) POSTOPERATIVE CONSIDERATIONS
Intra- and postoperative complications are infrequent
1. Port and instrument placement: Placement
(see Complications box on page 222}, the most fre-
of instrument ports is similar to that of the laparo-
scopic ovarian wedge resection (see above). quent of which is adhesion formation. There are no
special considerations other than the typical follow up
2. Ovarian diathermy: Once the pelvis and abdo- for women being treated for PCOS, such as clinical
men are examined, and the cul-de-sac cleared of symptomatology (hirsutism and acne}, ovulatory func-
bowel, the antimesenteric portion of the ovary is tion, and insulin and lipid levels.
exposed by manipulation using a probe or suction
tip placed through the contralateral port. A mo- Operative Note
nopolar needle or laser is used to "drill" the ovar-
ian cortex. If using the monopolar needle, the tip PROCEDURE: LAPAROSCOPIC
should be placed into the ovarian cortex to a depth OVARIAN WEDGE RESECTION OR
of about 3 mm, before activating the current. Ten to DIATHERMY (DRILLING)
fifteen sites are desiccated to a depth of 3 to 5 mm
at a power of 30 Won CUT setting (Figure 25.5), The patient was taken to the operating room after
although the number of sites may depend on the proper informed consent had been obtained. She
size of the ovary. There are no generally accepted was placed in the dorsal supine position, legs in
application times, but the surgeon should look for Allen-type stirrups. Her arms were then padded and
visual clues to minimize significant thermal spread. tucked at her side, and she was prepped and draped
Use of the C02 laser is another acceptable energy in sterile fashion. A time out was then completed.

FIGURE 25.5 For laparosc.opic ovarian diathermy (drilling), a monopolar needle is placed through
a suprapubic port, and the tip placed into the ovarian cortex to a depth of about 3 mm, before
adivating the current: Ten to fifteen sites are desiccated to a depth of 3-5 mm at a power of 30 W on
CUT setting generally suffices, although the number of sites may depend on the size of the ovary.
222 SEtnON Ill REPRODUCTIVE SURGERY

Attention was turned to the pelvis, where a Foley


catheter was placed in the urinary bladder, and a COMPLICATIONS
uterine manipulator was placed to allow for adequate
adnexal visualization. • De novo periovarian adhesion formation-
An insufflation needle was placed within the umbi- Infrequent (less than 5%, possibly higher 'With
licus and low opening pressures were documented. laparoscopic bilateral wedge resection)
Pneumoperitonium was achieved with carbon diox- • Postoperative infection (oophoritis, adnexitis)-
ide to a pressure of 15mmHg, at which point a 5mm Rare (less than 1%)
bladeless trocar was placed. Confinnation of place- • Hemorrhage or major vessel perforation-Rare
ment was done with a telescope. Inspection of the (less than 1%)
trocar entry site was thoroughly conducted and no • Major organ perforation or injury (bowel, bladder,
evidence of insertional injury was noted. Ancillary or ureter most frequently)-Rare (less than 1%)
trocars were placed with 2 in the lower lateral quad- • Postoperative bowel entrapment-Rare (less
rants, both 5 mm in diameter, lateral to the inferior than 1%)
epigastric vessels. These were placed under direct • Nerve injury (generally positional)-Rare (less
visualization without incident. Another trocar 5 mm in than 1%)
diameter was placed in between the pubic symphysis
and umbilicus.
The ovaries, which were otherwise mobile and non- Suggested Reading
adherent to their ipsilateral sidewalls, were enlarged I. Duleba AJ, Banaszewska B, Spac:z.ynski RZ, Paweb.yk L
with multiple peripheral follicles, consistent with pre- Success of laparoscopic ovarian wedge resection is
operative assessment of polycystic ovarian syndrome. related to obesity, lipid profile, and insulin levels. Fertil
After thorough inspection of the abdomen and pelvis, Steril2003;79(4):1008-1014.
a monopolar needle electrode was introduced from 2. Farquhar CM. An economic evaluation of laparo-
the right lower quadrant trocar to apply energy to scopic ovarian diathermy versus gonadotrophin ther-
the left ovary, which was elevated with an atraumatic apy for women with clomiphene citrate-resistant
grasper. The electrode was introduced into the ovar- polycystic ovarian syndrome. Curr Opin Obstet Gynecol
ian cortex 10 times, approximately 3 to 5 mm beyond 2005;17{4):347-353.
the epithelium, and monopolar current on low voltage 3. Farquhar C, Ulford R. Marjoribanks J, Vanderkerchove P.
Laparoscopic "drilling" by diathermy or laser for ovula-
setting (30 W) was applied for 5 seconds. Placement
tion induction in anovulatocy polycystic ovary syndrome.
of the electrode was such that we avoided overlap of Cochiane Database Syst Rev 2007;1ssue 3. Art. No.:
thermal insult. No excessive charring was noted as a CD001122. doi:l0.1002/14651858.CD001122.pub3.
result of the electrical current. Minimal, if any, bleed- 4. Hendriks ML, Ket JC, Hompes PG, Homburg R,
ing was noted. After completion, the right ovary was Lambalk CB. Why does ovarian smgery in PCOS help?
addressed in a similar fashion. Copious warmed iso- Insight into the endocrine implications of ovarian surgery
tonic irrigation was used to maintain moisture, which for ovulation induction in polycystic ovary syndrome.
was suctioned from the pelvis upon completion. Hum Reprod Update 2007;13(3):249-264.
Lateral trocar sites were observed after removal to 5. Johnson NP, Wang K. Is ovarian surgery effective for
make certain no abdominal wall vessels were lacer- androgenic symptoms of polycystic ovarian syndrome?
ated. The remaining pneumoperitoneum was released J Obstet Gynaecol2003;23(6):599-606.
6. Lunde 0, Djtc~seland 0, Gll!lttum P. Polycystic ovarian
and the primary trocar removed. The uterine manipu-
syndrome: a follow-up study on fertility and menstrual
lator had then been removed and the Foley catheter pattern in 149 patients I 5-25 years after ovarian wedge
replaced to drain the bladder in the early postopera- resection. Hum Reprod 2001;16(7):1479-1485.
tive period. All skin incisions were reapproximated 7. Sanfilippo JS, Rock JA. Surgery for benign disease of the
using 4-0 Vicryl in a subcuticular fashion. The patient Ovary.. In: Rock JA, Jones HW; eds. Telindes Operative
was then extubated and taken to recovery in stable Gyne.colagy, Tenth Edition. Philadelphia, PA: Lippincott
condition. Williams and Wilkins; 2011:763-774.
CHAPTER

Hysteroscopic Metroplasty
(Resection of Intrauterine
Septum)
M. Jonathon Solnik

INTRODUCTION septum and longitudinal vaginal septum. These anoma-


lies are differentiated from the arcuate uterus based on
Anomalies of the uterus occur in 3.8% to 4.3% of the the degree of intrauterine fundal defect (visualizing an
general population, depending on the actual indication imaginary line between the tubal ostia, the arcuate fun~
for study; the mean incidence for women with subfertil~ dus does not generally protrude more than 2 em into
ity falls in the range of 3.5% and increases significantly the intrauterine cavity, although there is no established
for those who have experience recurrent pregnancy loss distance that clearly differentiates arcuate uterus from
( -10% to 15%). Although no classification system has a small septate uterus.
been Wliversally accepted, the American Society for Continued debate exists over whether and when to
Reproductive Medicine (ASRM) grouped these anom~ proactively correct the septate uterus, since this defect
alies into seven types based on three main categories: may have a negative impact on reproductive outcome.
a) agenesis/hypoplasia, c) lateral fusion defects, and The adverse impact on reproduction may arise from
c) vertical fusion defects. Although most anomalies decreased vascularity of the septum itself, affecting the
observed fall into the ASRM classification (originally growth of an embryo implanted in the septum proper,
devised by Buttram and Gibbons), there are isolated diminished volume of the endometrial cavity, and sub~
anomalies that do not fit this system so easily, such as optimal implantation site options. Since the incidence
the complete (full) septum with duplicated cervices. of septate uteri in women with and without infertility
The uterine septum represents one of the most are similar, there is a large population of women with
common mtillerian anomalies encountered with a a septate uterus who will likely conceive and go on
mean incidence of 1% to 3% in the general popula~ to deliver a healthy infant without complications and
tion. This particular anomaly most likely occurs as a without the need for preconceptional surgical interven-
result of varying degrees of incomplete resorption of tion. Overall, the negative impact of a uterine septum
the midline septum between the two laterally fusing on the fecundability of asymptomatic women or those
mullerian ducts. Although the overwhelming majority with primary infertility seems quite modest.
of women with such anomalies are genotypic female Alternatively, case series suggest that women with a
(46, XX}, the etiology of this disorder has not been septate uterus appear to have a higher rate of adverse
clearly defined and it is felt to occur as a result of obstetrical outcomes, including spontaneous preg-
polygenetic and multifactorial processes. nancy loss and preterm delivery. Thus, if a septum is
A septate uterus is differentiated from other anoma- found in a patient with untested fertility, consideration
lies by its smooth fundal contour and two separate uter- may be given to proactively correct those who have not
ine cavities. The defect may range from a small midline yet demonstrated poor outcomes. Women with a sep-
septum to a larger defect resulting in a complete uterine tate uterus and who experience recurrent pregnancy

223
224 SEtnON Ill REPRODUCTIVE SURGERY

loss are also likely candidates for metroplasty since procedure, the procedure should be timed to occur
posttreatment obstetrical outcomes are comparable when the endometrium is at its thinnest, whether in the
to those of unaffected women. Finally, and although immediate postmenstrual period during a natural ovula-
the effect of this mtillerian anomaly on fecundability tory cycle or achieved by hormonal (e.g., progestogenic)
is not clear, the higher adverse pregnancy outcomes of suppression. Following are brief descriptions of the
women undergoing in vitro fertilization (IVF), such as surgical procedures used (see also videos: Hysteroscopic
preterm delivery, and the high cost of the treatment, Metropla.sty (Resection of Intmuterine Septum)).
suggest that patients who are scheduled for IVF and
are foWld to have a septate uterus would be considered
appropriate surgical candidates.
SURGICAL TECHNIQUE
Metroplasty was first described in 1953 as a proce-
dure that involved a wedge-like resection of the midline 1. Instrument selection: The surgeon per- ~
defect Qones metroplasty) and so it had a wider range forming a metroplasty should be experi- -
of application for various midline anomalies. It was per- enced in the performance of diagnostic and basic
formed by laparotomy, involved a fundal uterine incision, operative hysteroscopy, including understanding
and removal of the defect. These procedures carried an the instrumentation, distention media, energy
increase risk for morbidity, intra- and postoperative hem- sources, and risks and monitoring. The operator
orrhage, and reduced intra-cavitary volume, and neces- should use instruments with which he/she is most
sitated cesarean delivery. Alternatively, hysteroscopic comfortable with, although using a hysteroscope
metroplasty is a relatively straightforward ambulatoiy pro- with the smallest outer diameter is preferred in
cedure that obviates the majority of the aforementioned order to minimize the need for excessive cervical
risks while providing excellent outcomes. Its risks are low dilation. A 0° lens is helpful for on-axis visual-
enough that most surgeons feel comfortable offering this ization, especially when using an electrosurgical
procedure prophylactically to asymptomatic women. means of incising the septum; however, an angled
lens (12° or 30°) may allow for greater total visual-
ization of the uterine cavity (Figure 26.1).
PREOPERATIVE CONSIDERATIONS Preference should be given to the use of non-
electrosurgical means, such as a 3-mm rigid scissors
Establishing the correct preoperative diagnosis becomes placed through the operating channel of an operat-
pivotal in the evaluation and treatment of women with ing hysteroscope with an angled offset ocular or an
suspected mtillerian anomalies, particularly in women operative hysteroscope with a 5 to 7 French (-1.7 to
with prior poor reproductive or obstetrical outcomes. 2.3 mm) semi-rigid scissors, in order to avoid thermal
Historically, a combination of hysteroscopy and lapa- injury to the surrounding endomyometrium. An added
roscopy were used for diagnostic means, but the role of benefit when using semi-rigid scissors is the ability to
transvaginal ultrasound, with or without saline infusion utilize a narrower hysteroscopic outer sheath, smaller
{i.e., sonohysterography) and magnetic resonance imag- than the larger electrosurgical resectoscopes, which
ing (MRI) continue to be the studies of choice. are at least 9 mm in diameter (Figure 26.1).
MRI provides a comprehensive picture of the abdo- When the septum is qt.tite large, projecting toward
men and pelvis, allowing for a single modality to be used the level of the cervix, or when it is composed of
for the diagnosis of miillerian anomalies, especially since more muscular fibers, an electrosurgical option may
extra-uterine anomalies {e.g., isolated uterine remnant) be more useful in minimizing blood loss and expe-
are not uncommon in women with Wlilateral mti.llerian diting the procedure. A number of electrosurgical
defects. An MRI can also differentiate a muscular from instruments have been described including a simple
fibrous septum and may delineate cervical duplication resectoscopic loop, a specialized low-voltage forward
and the septate uterus from uterine didelphys. In turn, facing tip, and a bipolar loop electrode. Also used
the experienced ultrasonographer may also be able to are contact laser inserts (e.g., neodyrnium:yttrium-
differentiate many of the duplicative anomalies. While alurninum garnet [Nd:YAG]}. Although there may be
hysterosalpingography (HSG) represents the gold stan- physiologic benefit when using an isotonic fluid dis-
dard for evaluating the endometrial cavity and tubal tention media such as normal saline (which cannot
patency, it lacks the ability to establish the presence of be used with monopolar electrosurgical modalities),
more compkil: anomalies that may reqt.tire assessment there is no clear distinction among the various
of the external uterine contour or extrauterine phenom- energy modalities described with regards to efficacy
ena. Finally, as with any other operative hysteroscopic or risk of postoperative intrauterine synechiae.
CHAPTER 26 Hysteroscopic Metroplasty (Resection of Intrauterine Septum) 225

~o_o_o_oo____;~!------=--~
B

FIGURE 26.1 Equipment commonly used during hysteroscopic metroplasty, induding (A) a 3-mm
rigid scissors placed 1ftrough 1fte operating c:hannel of an operating hysteroscope with an angled
offset ocular, (B) an operative hysteroscope with a 5-7 French (-1.7 to 2.3 mm) semi-rigid scissors,
(C) a simple resectoscopic: loop with or without a forward facing tip, and (D) a bipolar loop electrode.

2. Procedure: After the patient is prepped and ac, inflow and outflow channels of a continuous flow
cess to the uterine cavity is achieved, the opera- hysteroscopic sheath can be used to obtain the
tor should first visualize both tubal ostia, which clearest view of the surgical site.
may be in different chambers depending on the When the septum is relatively small and narrow,
size of the septum (Figure 26.2B}. Once the the incision should begin at the apex (lowest point)
surgeon has been orientated to the cavity, the sep, of the septum, gradually reaching the fundus with
tum should be divided, using scissors, lasers, or the previously described endpoint (Figure 26.3).
electrosurgical means, at a point equidistant from Excessive incising to what appears to be a normal
the anterior and posterior walls of the uterine cav- fundal contour should be avoided since the septum
ity (Figure 26.3 ). The fibromuscular component tissue will retract, and so the myometrium may have
of the septum will retract into the surrounding already been breached. Furthermore, if excessive
wall once incised. The incision is progressively di- bleeding or oozing is noted during the surgery, the
rected towards the uterine fundus. Adjusting the procedure should be stopped. It is more prudent to

FIGURE 26.2 View of 1fte unresected septum by hysterosalpingography (A) and hysteroscopically
from the internal os (B).
226 SEtnON Ill REPRODUCTIVE SURGERY

--------

......___....
FIGURE 26.3 When the septum is relatively narrow, the incision should begin at the apex (lowest
point) of the septum, at a point equidistant from the anterior and posterior walls of the uterine
cavity (A): Both ostia should be kept in sight_ perhaps requiring moving the hysteroscope from side to
side, until the incision reaches the fundus (8). Care should be taken to ensure that the hysteroscope is either
angled anteriorly, for anteverted uteri, or posteriorly, for retroverted uteri, to ensure that the dissection fol-
lows the transverse curvature of the uterine cavity (C). (Continued)

leave a small portion of the sepnun, up to I em in Alternatively; when the septum is broader and the
length, rather than increasing risk by incising nor, operator must sweep from side to side in order to main,
mal myometrium. The endpoint of the procedure, tain visualization of the swgical dissection, narrower
regardless of approach or technique used, should be incisions should be made on each side of the septum
to be able to visualize both tubal ostia simultane, in gradual succession to the eventual endpoint, creat,
ously when viewed from the level of the internal os ing a narrow midline defect, which can then be tra,
(Figure 26.4A and B). versed more readily (Figure 26.5A and B).
CHAPTER 26 Hysteroscopic Metroplasty (Resection of Intrauterine Septum) 227

c With long septa that end at or near the internal


cervical os, it may be difficult to observe the low-
ermost portion of the septum to begin the hystero-
scopic incision. In these cases it may be useful to
begin the incision of the septum blindly, by transect-
ing the lower-most portion of the septum using Mayo
scissors placed into the uterine cavity transvaginally,
with one blade in each hom and the curvature of the
scissors matching that of the uterus (Figure 26.6).
In cases where the septum is complete and
involves the cervix, a Foley catheter can be advanced
into one cavity to aid in the dissection, with the sur-
geon creating a transverse incision to connect the
two cavities, followed by cephalad russection as is
typically perfonned (Figure 26.7).
When the cervix appears to be involved, some
smgeons have advocated sparing this portion of
the septum to minimize the risk of future cervical
incompetence. And although there is no substantive
FIGURE 26.3 (Continued) evidence to support this hypothesis, these patients
should be advised of this potential complication.
However, preserving the cervical portion of the
septum makes the procedure more complicated.

FIGURE 26A View of the resected septum from the internal os (A): The endpoint of the procedure,
regardless of approach or technique used, should be to be able to visualize both tubal ostia simultaneously
when viewed from the level of the internal os (B).
228 SEtnON Ill REPRODUCTIVE SURGERY

FIGURE 26.5 To incise broad·based septa, it may be necessary to incise the septum along one side
and then the other as seen by incising the lateral aspect of the septum on the patients right, with
the right tubal ostia in the background (A), thus progressively narrowing the defect. facilitating
transection (B).

Concurrent use of laparoscopic or ultrasonography conclusion of the mettoplasty. Adhesions are rarely
in this setting, although not mandatory, may be used encountered after metroplasty and are often filmy and
at the discretion of the operator depending on the likely of no consequence. In theory, herein lies the ben-
complexity of the case. The added risk of a lapa- efit of nonelectrosurgical means of metroplasty, since
roscopic intervention may outweigh its utility in a endometrial healing occurs more rapidly when less ther-
setting with no demonstrable benefit. mal injury occurs. If the scenario warrants and clinical
acumen suggests using a means (e.g., distended pedi-
atric Foley bulb) to maintain postoperative intrauterine
POSTOPERATIVE CONSIDERATIONS distention or reduce intrauterine bleeding. the use of
concomitant antibiotics is recommended. A postop-
In contrast to women being treated for intrauterine erative HSG or hysteroscopy may be considered one to
synechiae, there is no real benefit to placing an intrau- three cycles following the procedure to evaluate for cavi-
terine device or inflated pediatric Foley balloon at the tary distortion, with the potential operative benefit given
CHAPTER 26 Hysteroscopic Metroplasty (Resection of Intrauterine Septum) 229

FIGURE 26.6 With long septa that end at or near the internal cervical os, it may be useful to begin
the incision of the septum blindly, by transec:ting the loweflamost portion of the septum using
Mayo scissors placed into the uterine cavity transvaginally, with one blade in each horn and the
curvature of the scissors matching that of the uterus.

to hysteroscopy should adhesions or significant remain- and significant myometrial disruption is avoided, vagi-
ing septwn be encountered. nal delivery should be attempted. A more significant
The risk of uterine rupture following hysteroscopic complication, albeit rare, in the setting of an uncompli-
metroplasty is exceedingly low, although case reports cated metroplasty, is abnormal placentation (e.g., pla-
do exist. If the procedure is otherwise uncomplicated centa accreta or retained placenta).

FIGURE 26.7 When the septum is complete and involves the endocervix, a Foley catheter can be
advanced into one cavity to aid in the dissection, with the surgeon creating a transverse incision
to connect the two cavities. followed by cephalad dissection as is typically perfonned.
230 SEtnON Ill REPRODUCTIVE SURGERY

Operative Note COMPLICATIONS


PROCEDURE: HYSTEROSCOPIC
• Incomplete septwn. resection-Frequent ( 15%
METROPLASTY {RESECTION OF to 30%, depending on si'Z'£ oforiginal septum
INTRAUTERINE SEPTUM) • Fluid or electrolyte imbalance (see Table 27-l)-
Infrequent (less than 5%)
The patient was taken to the operating room after
• Uterine perforation-Infrequent (less than 5%)
proper informed consent was obtained. She was placed
• Intrauterine adhesions-Infrequent (less than 5%)
in dorsal supine position and underwent successful
• Postoperative infection (endometritis,
induction with general endotracheal anesthesia. Her
myometritis, and adnexitis )-Rare (less than 1%)
legs were placed in Yellofin stinups and her arms tucked
• Hemorrhage and major vessel perforation-
appropriately at her side in the event that we had to
Rare (less than 1%)
perform a laparoscopy. She was prepped and draped
in a sterile fashion. A time-out was then performed.
An labanTM film was placed over her abdomen since
the procedure was performed with ultrasound guid- Suggested Reading
ance, and was also draped in a sterile fashion.
Attention was turned to the pelvis where, after a I. Acien P. Incidence of Mullerian anomalies in fertile and
Foley catheter was placed in her urinary bladder, a infertile women. Hum Reprod 2007;12:1372-1376.
bivalve speculum was placed in her vagina and a single- 2. Grimbizis G, Camus M, Clasen K, Toumaye H,
De munck L, Devroey P. Hysteroscopic septum resec-
tooth tenaculum was placed along the anterior lip of
tion in patients with recurrent abortions or infertility.
the cervix. A 5-mm operating continuous sheath hys- Hum Reprod 1998;13:1188-1193.
teroscope was advanced through the cervical os under 3. Marabini A, Gubbini G, Stagnozzi R, Stefanetti M,
direct visualization using normal saline as a distention Filoni M, BoviceUi A. Hysteroscopic metroplasty. Ann N
medium. We carefully passed the hysteroscope into Y Acad Sci 1994;734:488-492.
the patienes left uterine cavity, visualized the ostia 4. March CM, Israel R. Hysteroscopic management of
,and withdrew slowly until we were able to visualize the recurrent abortion caused by septate uterus. Am J Obstet
patient's right uterine cavity. The septum came down Gynecoll987;156:834.
to the level of the mid cervix. 5. Mollo A, De Fr.mciscis P, Col.acurci N, et al. Hystero-
We first attempted to use hysteroscopic semi-rigid scopic resection of the septum improves the pregnancy
shears to incise the septum, but due to its fibromus- rnte of women with unexplained infertility: a prospective
controlled nial Fertil Steril2009;91:2628-2631.
cular nature, consistent with MRI findings, we were
6. Pabu~cu R, Gomel V. Reproductive outcome after hys-
unable to penetrate the tissue with this instrument.
teroscopic mettoplasty in women with septate uterus
A bipolar resectoscope was then advanced, placing a and otherwise unexplained infertility. Fertil Steril
twizzle device into the cavity. Using the equivalent low 2004;81:1675-1678.
voltage setting, the septum was incised progressively up 7. Proctor JA, Haney AF. Recurrent first trimester preg-
to the level of the fundus under continuous visualiza- nancy loss is associated with uterine septum but not
tion, both through the hysteroscope and by ultrasonog- bicornuate uterus. Fertil Steril2003;80:1212-1215.
raphy. At this point, we were able to see both ostia from 8. Raga F, Bauset C, Remohi J, et al. Reproductive impact
the level of the internal os, but did not proceed beyond of congenital Mullerian anomalies. Hum Reprod
the fibromuscular tissue that appeared to be more vas- 1997;12:2277-2281.
cular. Once we felt comfortable with the degree of uter- 9. Raga F, Casali EM, Bonilla-Musoles F. Expression of
ine resection, the procedure was terminated. Minimal vascular endothelial growth factor receptors in the endo-
menium of septate uterus. 2009;92:1085-1090.
eschar was noted from use of thermal energy. Our hys-
10. Rock JA, Breech LL. Surgery for anomalies of the mUlle-
teroscopic fluid deficit was approximately 1, 500 ml of
rian ducts. In: Rock JA, Jones HW; eds. TeLindes Opem-
normal saline. The patient tolerated the procedure well. tive Gyne.cology. lOth ed. Philadelphia, PA: Lippincott,
Although there was no excessive bleeding noted from Williams & Wilkins; 2008;539-584.
the cavity, a 10-French pediatric Foley was placed into 1I. Saravelos SH, Cocksedge KA, Li TC. Prevalence and
the fundus and instilled with 3.5 ml of normal saline, to diagnosis of congenital uterine anomalies in women with
be left in place for 1 week. The patient was extubated reproductive failure: a critical appraisal. Hum Reprod
and taken to recovery in stable condition. Update 2008;14(5):415-429.
CHAPTER

Hysteroscopic Myomectomy
M. Jonathon Solnik, Ricardo Azziz

INTRODUCTION Various methods of resecting submucosal fibroids


have been described using different energy modalities
Submucosal myomas, through anatomic distortion (Nd:YAG, monopolar and bipolar electrosUigi.cal tech-
of the uterine cavity, are implicated in the genesis of niques, hysteroscopic scissors, and mechanical resec-
heavier menstrual bleeding, and as an independent risk toscopes) with accommodating fluid distention media.
factor for infertility and pregnancy loss. For more than All have their inherent advantages and potential risks
3 decades, gynecologic SUigeons have been performing to patients. Ultimately, the surgeon's knowledge and
hysteroscopic resection of submucous myomas in order experience with each of these should dictate their use
to avoid more substantial and morbid, yet traditional in the setting of both basic and complex procedures.
and effective approaches such as laparotomy and hys-
terotomy. As for most surgeries, one of the most critical
considerations of this option remains patient selection. PREOPERATIVE CONSIDERATIONS
Expert hysteroscopists have described well-estab-
lished parameters to help guide surgeons in choosing Working in a confined space such as the endometrial
which patient will experience a more favorable out- cavity can pose many challenges, and a good under-
come, which include: older age, uterine size S 6 em, standing of these opposing forces will allow for a more
myoma size s 3 em, and projected operating time less successful outcome. Such variables include the num-
than 20 minutes. Various classifications have been ber, size, and exact location of the fibroids as well as
proposed to assess the feasibility of a hysteroscopic the parity of the patient and whether she has been
myomectomy {Boxes 27.1 and 27.2), although the instrumented in the past or suffered from infectious
classification originally proposed by Wamsteker and processes.
colleagues is the most commonly used. The hystero- It is critical for the surgeon to have an accurate three-
scopic approach to myomectomy is primarily appro· dimensional understanding of the uterine anatomy and
priate for submucous myomas with a majority, that is, its myomas prior to undertaking the surgery. Although
>50% (types 0 or I), of their volume protruding into the transvaginal ultrasound is an effective assessment tool
uterine cavity, a ratio that can he increased somewhat for women with abnormal uterine bleeding, further
by preoperative treatment with gonadotropin-releasing evaluation is often warranted prior to operative hyster-
hormone agonist (GnRH-a) treatment (see below). To oscopy. Sonohysterography has become an effective
venture outside of these basic guidelines or beyond office-based tool, which can clearly delineate intracavi-
self-recognized hysteroscopic experience invites not tary lesions, although in recent years office hysteros-
only greater risk of perioperative complications, but copy has become more commonplace, providing a clear
reduced efficacy of the procedure itself. view of the lesion that will facilitate operative planning.

231
232 SEtnON Ill REPRODUCTIVE SURGERY

•:rt•:4 , ,• •
European Society for Gynecological Endoscopy (ESGE) classification of
intramural myomas in preparation to hysteroscopic myomectomy
Type 0: Pedunculated submucous fibroids without significant intramural
extension
Type 1: When the submucous fibroid is sessile and the intramural part is
less than 50% of the myoma volume.
Type H: When the submucous myoma is sessile and the intramural portion
is 2:50% of the myoma volume
(Reprinted with penuission from Wamsteker K. Emanuel MH, de Kruif JH. Transcervical hysteroscopic
resection of submucous fibroids fur abnormal uterine bleeding: results regarding the degree of intJ:amural
extension. Obstet Gynecoll993;82:736-740.)

A less obvious advantage of sonohysterography is the described for the preoperative assessment of the uterine
ability to detect the percentage of the fibroid that is cavity, although its value has lessened considerably, with
intramural. Type II myomas (>50% intramural) are the introduction of the above imaging techniques, which
not only more difficult to resect and should only to be avoid radiation exposure and offer fewer risks, especially
approached by skilled surgeons, but also have a higher if tubal patency is not in question.
probability of requiring secondary procedures. Timing of the procedure is another aspect that
Magnetic resonance imaging, which provides high requires careful consideration, since a relatively atro-
resolution of soft tissues, remains an alternative preoper- phic endometrial lining with the least amount of shed-
ative imaging modality, especially for evaluating for other ding or bleeding makes for an easier procedure. The use
fibroids that may affect the surgeon's surgical approach. of preprocedural suppression with oral contraceptive
Historically, the use of hysterosalpingography has been pills or continuous progestins is generally sufficient if it

. ,,,, STEPW (lize, topography, .extension of the base in relation to the


uterine wall, and penetration into the myometrial wall) classification
of intramural myomas in preparation to hysteroscopic myomectomy

~
Extension lilleral
Size (cml Topography Penetration Tot al
of the base Wall

I
0 < 2 Low < 1/3 0
1 >2a5 Middle >1/3 - Zi3 < 50~,. +1
2' >5 Upper >213 >50~··

'Score • • • • •
Score Group Complexity and therapelllic options
0 to- 4 low ·complexity hysteroscopic myomectomy.
5 to- 6 II High complexity hysteros c o-pic myomectomy. Cons ider GnRH use?
Consider Two-step hysteroscopic myomectomy.
7 to- 9 II Consider allernative·s to the hysteroscopic technique

(Reprinted with pennissiou from Lasmar RB, Xinmei Z. Indman PD, Celeste RK. Di Spiezio Sardo A.
Feasibility of a new system of classification of submucous myomas: a multicenter study. Fertil Steril
201 1;95:2073-2077.}
CHAPTER 27 Hysteroscopic Myomectomy 233

is difficult to schedule the procedure in the early prolif- be informed whenever using vasoactive agents,
erative phase of the menstrual cycle, or the patient has which carry well-described cardiovascular risks.
unpredictable bleeding patterns. The cervix is then dilated with a series of Hanks
GnRH analogue are effective in reducing the vol- or Pratt dilators up to a diameter sufficient to
ume of the uterus and associated myomas, although accommodate the 9-mm outer sheath of a stan-
less so for submucous myomas, in the short term. In dard resectoscope. We prefer those longer dilators
the preoperative preparation of patients with submu- that have a gradually tapered tip, minimizing the
cous myomas, treatment with a GnRH analogue will need for forceful advancement and the risk of per-
assist in reducing the vascularity of the myometrium foration. Most continuous-flow resectoscopes use
and the risk of intraoperative bleeding. In addition, endoscopes with a 12° lens, providing a more in-
because GnRH analogue treatment reduces normal line view of the operation. The surgeon should be
myometrial volume to a greater degree than it reduces familiar with the specific resectoscope being used,
the volume of submucous myomas, assisting in extrud- be able to assemble it, select the power settings,
ing these myomas more clearly into the uterine cav- and problem solve issues that may arise.
ity and facilitating resection. Two to three months of Large caliber inflow (cystoscopy tubing) and out-
preoperative therapy with GnRH analogue is typically flow tubing are connected to a fluid-management
required (e.g., leuprolide 3.75 mglmonth). As these system that regulates intracavitary pressures and
agents have a stimulatory effect on endometrial activity monitors fluid deficits (Figure 27.1). Pressures are
in the first 2 to 3 weeks after administration, hysteros- selected based on the mean arterial pressure of the
copy should be avoided during this period of time. patient as a first line barrier to fluid intravasation,
Preoperative cervical ripening with vaginal pros- and should typically be no greater than 75 mmHg.
taglandins or laminaria may be useful in nulliparous The outflow tubing should be connected to both the
women or those at risk for cervical stenosis, as evident under buttocks drape/collection bag as well as to
on office examination. Most resectoscopes are at least the outflow adapter of the hysteroscope itself, using
9 mm in diameter and require significant cervical dila- a Y-shaped connector. This allows for continuous
tion in most patients, which if made easier, reduce the suction of debris-laden fluid from the endometrial
potential risk of cervical injury and uterine perforation. cavity and an accw-ate count of fluid lost. When
Following is a brief description of the surgical proce- continuous-flow sheaths are used, the oudlow port
dure used {see also video: Hysteroscopic Myomectomy). should always remain open to minimize the risk of
intravasation while resecting tissue and opening
potential vascular channels. Adjusting the degree
SURGICAL TECHNIQUE to which the outflow remains open may be help-
ful when the surgeon needs more relative cavitary
1. Patient positioning and preparation, and expansion or if bloody fluid needs to be purged.
instrument selection and placement: Patients If a hysteroscopic myomectomy is to be per-
formed without concomitant endometrial abla-
li are placed in lithotomy position; Trendelenburg
positioning should be avoided. Lingual mask
airways are frequently selected by anesthesiolo-
tion, we prefer to use a monopolar or bipolar loop
electrode (Figure 27.2). When using a mono-
gists, but in morbidly obese patients, in whom polar setup, nonelectrolyte-rich, nonconductive
airway occlusion is a concern, endotracheal intu- fluid media (3% sorbitol, 5% mannitol, or 1.5%
bation should be considered. After examination glycine) should be used to allow for transmission
under anesthesia, a side-opening bivalve specu- of current from the electrode to the tissue for
lum is placed in the vagina and the cervix identi- the desired response. These solutions have much
fied. After placing a single tooth tenaculum along higher impedance than does tissue, allowing elec-
the anterior lip of the cervix, the cervix is infil- trons to flow from the loop, through the media, into
trated with 10 cc dilute vasopressin (20 U diluted the tissue and back to the dispersive electrode (see
in 50 cc normal saline) with a 22G spinal needle Table 27.1). Alternatively, when using a bipolar
at the 4 o'clock and 8 o'clock positions, to reduce energy system, isotonic solutions such as normal
the risk of bleeding, and moreover, distention fluid saline or lactated ringers can be used, since they
intravasation. The needle is advanced approxi- have lower a impedance than does tissue. Since the
mately 1 em into the cervical stroma and the solu- active and return electrodes are in close proxim-
tion slowly injected. The anesthesiologist should ity to one another, electrons travel between them,
234 SEtnON Ill REPRODUCTIVE SURGERY

Fluid back to
ftuld management system
FIGURE 27.1 Continuous-flow resectoscope setup: The surgeon should be familiar with the specific
resectoscope being used, be able to assemble it, select the power settings, and problem solve issues that
may arise. Most continuous-flow resectoscopes use endoscopes with a 12° lens, providing a more in-line
view of the operation. Large caliber inflow (cystoscopy tubing) and outflow tubing an:! connected to a
fluid-management system that regulates intracavitary pressures and monitors fluid deficits. The outflow
tubing should be connected to both the underbuttocks drape/collection bag and the outflow adapter of the
hysteroscope itself, using a Y-shaped connector. When continuous-flow sheaths are used, the outflow port
should always n:!main open to minimize risk of intravasation while resecting tissue and opening potential
vascular channels.

passing through the media and not the tissue. The due to its ability to penetrate deeper into tissue
resultant active energy pocket allows for thermal while using a fine electrode. When using a bipolar
destruction. The risk of volume overload and elec- system, the ESU automatically detects which elec-
trolyte disturbances is significantly reduced when trode is connected and automatically sets the power
using isotonic solutions. level. The surgeon should still confirm settings as
Depending on which electrosurgical unit these may occasionally reset to zero.
(ESU) or generator is available, specific high volt-
age (former term CUT) and low voltage {former 2. Procedure: The hysteroscope is advanced through
term COAG) settings are selected. Current ESUs the dilated cervix under direct visualization, being
require lower power settings {Watts) to achieve the aware of the somewhat distorted view an angled
same response (80 to 90 W, CUT setting; 50 to 60 lens provides, with the inflow and outflow chan-
W, COAG setting) for loop electrodes. The cutting nels wide open. Once the entire cavity is visual-
setting is preferred for hysteroscopic myomectomies ized and tubal ostia are identified, the attachment
CHAPTER 27 Hysteroscopic Myomectomy 235

Monopolar loop

Bipolar loop

FIGURE 27.2 Monopolar loop and bipolar tip electrodes used for hysteroscopic myomectomy.

or base of the fibroid should be identified and used as a blunt probe, dissecting the remain-
inspected. If relatively pedWlculated, the surgeon ing portion of the fibroid from its pseudocapsu-
may attempt detaching the fibroid at the stalk and lar bed (Figure 27 .4). However, if a significant
retrieving the specimen with forceps. Otherwise, a portion of the myoma is within the myometrium,
loop electrode is advanced beyond the area to be the surgeon should be aware of the distance
resected (Figure 27 .3). Only at this point should between the underlying myometrium and serosa,
the generator be activated, while drawing back on especially if attached on a lateral wall. Entering
the electrode toward the lens (but not allowing the a principal uterine vessel may be devastating,
endoscope to advance toward the loop). This avoids and if the myometrium is too thin after resection
inadvertent injury beyond the fibroid and field of this could pose a risk for uterine rupture during
view. Sequential passes in an organized fashion, subsequent pregnancies. This is why an accurate
maintaining an even platform to resect is ideal. three-dimensional understanding of the uterus
The fibroid should be resected to its base, and its myomas is critical prior to undertaking
while minimizing thermal injury to nearby endo- the surgery.
metrium. If a mural component to the myoma Surgical complications and incomplete
is evident, then the tip of the electrode may be procedures arise when fibroids are larger than

Table 27.1
Hysteroscopic Fluid Distention Media
C02 gas Hyskon Glycine 1.5% Sorbitol3% Saline
Qualities Wider1ield Historical use Hypotonic Hypotonic Isotonic
of view Extremely viscous Electrolyte poor Electrolyte poor Electrolyte
rich
Pros Crystallizes Immiscible Monopolar only Monopolar only Inexpensive
[not in Nonconductive Higher
blood] No leaks deficits
Bipolar only
Cons 100 mmHg Ruins scope's' Can't use bipolar Can't use False sense
pressures Hard to push bipolar o1 security
Expensive
Max N/A SOOml 1,000 ml 1,000 ml 2-2.5l
fluid [100 ml becomes
deficit 640 ml]
Adverse Gas Coagulopathy Hyperammonemia Hyperglycemia Volume
events embolism Anaphylaxis Transient blindness l-heart
failure
236 SEtnON Ill REPRODUCTIVE SURGERY

FIGURE 27.3 The attachment or base of the myoma sho,.... entified and inspected. and a
loop eledrode advanced beyond the area to be resected: Sequem1al passes in an organized fashion,
maintaining an even platform to resect is ideal.

3 em and if concomitant endometrial ablation the myoma cannot be removed in entirety, it may
is performed. When resecting large fihroids, be left in place to degenerate within the uterus, or
the surgeon should pay close attention to ongo- he expelled during the first menstruation following
ing fluid deficit since time required to resect is the procedure. If surface bleeding is encountered,
typically increased. A VaporTrode®-type vapor- any electrode may he used to achieve hemostasis
izing electrode on low voltage setting may be using a high voltage current.
first used to reduce the fibroid volume without
producing fibroid debris that would otherwise
require retrieval throughout the case. Once at a
reasonable size, the loop can he placed to resect
POSTOPERATIVE CONSIDERATIONS
the remaining portion of the myoma.
Intra- and postoperative complications are infrequent
3. Removing the specimen: Fragments of tissue (see Complications box on page 238). The over-
that remain in the intrauterine cavity during the whelming majority of hysteroscopic myomectomies are
procedure can be removed by turning off the fluid performed on an outpatient basis, and most patients
inflow and withdrawing them through the outer are able to return to typical activities within a couple
resectoscope sheath. This technique has the ad- of days. They may experience some spotting, but heavy
vantage of minimizing the number of times the vaginal bleeding should prompt evaluation.
sheath is withdrawn from the uterus and cervix. If large submucous myomas or multiple myomas that
Alternately, ovum forceps, myoma graspers, or suc- occupied large surface areas of the endometrial cavity
tion curettage can he used to remove remaining were resected, patients are at risk for developing intra-
pieces of myoma (Figure 27.5). When retrieving uterine synechiae. In these situations, consideration
these myoma chips, both inflow and outflow chan- should he given to placing a 10-French pediatric Foley
nels should he closed to minimize influx of ambi- catheter into the uterine cavity, inflating the balloon to
ent air into the cavity. In uncommon cases, when no more than 4 cc. In theory, this could prevent opposing
CHAPTER 27 Hysteroscopic Myomectomy 237

FIGURE 27.4 If a mural compoh.... 1e tip of the electrode may


be used as a blunt probe. dissecting the ..... 10id from its pseudocapsular
bed: However, if a significant portion of the myoma is w ... 1m, the surgeon should be aware
of the distance between the underlying myometrium and serosa."-· 1 if attached on a lateral wall.

injured surfaces from adhering during the healing successful induction of general anesthesia. After
process. The catheter is maintained for approximately laryngeal mask airway placement, she was prepped
7 days, during which a prophylactic antibiotic (e.g., dox- and draped in a sterile fashion. A time-out was then
ycycline) should be given to prevent endometritis. performed. A catheter was used to drain her urinary
In anovulatory or hypoestrogenic patients, oral (e.g., bladder at which time a bivalve speculum was placed
1.25 mg of conjugated equine estrogens) or transder- in her vagina and a single tooth tenaculum placed
mal (0.1 mglday) short-term (3 to 4 weeks) estrogen along the anterior lip of the cervix. Dilute vasopres-
therapy may also be given to help expedite the repair of sin, 20 units in 50 ml of normal saline, I 0 ml in total,
the endometrial lining, potentially reducing adhesion was injected into the cervix to reduce the risk of fluid
formation. In general, the estrogen production of an absorption. The cervix was dilated sufficient to accom-
anovulatory patient, particularly if the procedure was modate a 9-mm resectoscope using normal saline as a
performed in the early follicular phase of the menstrual fluid distention medium. At this point we were able to
cycle, will be sufficient to stimulate healthy endome- visualize a fundal, type 0 fibroid, which was resected
trial growth. using loop electrode in serial fashion to the level of the
Recurrence rates are typically low, but patients at risk endomyometrium. The equivalent low voltage setting
include those with multiple fibroids, those who have a of 170 W was deployed. Fibroid chips were dispersed
larger tumor only able to be partially resected, and those to allow for clear visualization of the operative field.
who fail to conceive during the interval time frame. Both tubal ostia were then easily identified. Follow-
ing the dissection, a small 1.5-cm intramural fibroid
Operative Note along the posterior wall began to extrude at which
point it was enucleated with loop electrode. Under
PROCEDURE: HYSTEROSCOPIC low intracavitary pressures, we were able to see that
MYOMECTOMY there was a small perforating vessel that was pump-
ing. We switched electrodes to the VaporTrode using
The patient was taken to the operating room after 80 W to seal this vessel. Once the cavity was noted
proper informed consent was obtained, and was to be hemostatic, the procedure was completed. A
placed in the dorsal supine position and underwent 300,ml hysteroscopic fluid deficit was recorded. The
238 SECTION Ill REPRODUCTIVE SURGERY

FIGURE 27.5 Fragments of tissue that remain in tnt:~ ... ,rauterine cavity during the procedure can
ba removed by turning off the fluid inflow and withdrawing them through the outer resecto-
scope sheath. Alternately, ovum forceps, myoma graspers, or suction curettage can be used to remove
remaining pieces of myoma.

hysteroscope was withdrawn, visualizing the ceiVical removed. Silver nitrate application was required to
canal upon exit, and the single~tooth tenaculum was stop a small amount of bleeding from the anterior lip
of the cervix. The patient was awakened and taken to
recovery in stable condition.
COMPLICATIONS
• Recmrence of myoma-Itifmquent (less than 5%,
Suggested Reading
although may be higher ifmultipk fibroids remmred) l. Bradley LD, Complications in hysteroscopy: prevention,
• Intrauterine adhesion reformation-Infrequent treatment and legal risk. Curr Opin Obstet Gynecol
(less than 5%, although may he higher if multiple 2002; 14:409-415.
2. Breech LL, Rock JA. Leiomyomata uteri and myomec-
fibroids removed)
tomy. In: Rock JA, Jones HW, eds. TeLinde Operutive
• Uterine perforation-Infrequent (less than 5%)
Gynecowgy, Tenth Edition. Philadelphia, PA: Lippincott
• Hemorrhage and major vessel perforation-
Williams and Wilkins; 2011:687-726.
In.frequent (less than 5%) 3. Corson SL, Brooks PG, Serden SP, et al. Effects of
• Fluid or electrolyte imbalance vasopressin administration during hysteroscopic surgery.
(see Table 27.1}-Infrequent (less than 5%) J Reprod Med 1994;39:419-423.
• Postoperative infection (endometritis, 4. Hart R, Molnar BG, Magos A. Long term follow up of
myometritis, and adnexitis)-Rare (l&s than 1%) hysteroscopic myomectomy assessed by survival analy-
sis. Br J Obstet Gynaecoll999;106:700-705.
CHAPTER 27 Hysteroscopic Myomectomy 239

5. Lasmar RB, Xinmei Z, lndman PD, Celeste RK, Di 7. Wamsteker K, Emanuel MH, de Kruif JH. Transcer-
Spiezio Sardo A. Feasibility of a new system of classifica- vical hysteroscopic resection of submucous fibroids
tion of submucous myomas: a multicenter study. Fertil for abnormal uterine bleeding: results regarding
Steril2011;95:2073-2077. the degree of intramural extension. Obstet Gynecol
6. Olive DL. The surgical treatment of fibroids for infertil- 1993;82:736-740.
ity. Semin Reprod Med 2011;29:113-123.
CHAPTER

Abdominal Myomectomy and


Uterine Reconstruction for
Intramural Myomas
M. Jonathon Solnik, Ricardo Azziz

INTRODUCTION should fust be considered since bleeding disorders


related to fibroids tend to be ovulatory and heavy,
In recent years, there has been a shift toward offering representative of an anatomic, not endocrine, eti-
minimally invasive treatment options for women with ology. Other sources of pain should also be enter-
reproductive disorders. Fibroid-specific therapies have tained since treatment may be options other than
likewise evolved to include uterine fibroid emboliza- surgery. The role of fibroids in the setting of subfer-
tion and magnetic resonance imaging (MRI)-guided tility remains less clear, but there is sufficient evi-
focused ultrasound. Although any form of therapy dence to support myomectomy when the fibroid is
should only be directed toward women who are symp- submucosal in location, or intramural and distorting
tomatic, the prevalence of fibroids in reproductive- the endometrial cavity.
aged women and number of women treated annually Today there are a number of approaches that
remains high. Consequently. myomectomy remains the effectively destroy myomas more or less noninva-
mainstay for women who wish to preserve their ability sively (e.g., uterine artery embolization, high-inten-
to conceive or are themselves experiencing subfertility. sity focused ultrasound, and cryomyolysis), although
The objective of the clinician is to offer the approach these are appropriate only for women who do not
that will best treat the patient's condition while mini- desire subsequent fertility. Myomectomy and uter·
mizing the adverse surgical and reproductive outcomes ine reconstruction continues to be the procedure of
that may follow myomectomy. choice for women desiring fertility or the preservation
Women are often asymptomatic, and fibroids may of reproductive potential. Abdominal myomectomy
be detected during routine gynecologic examination remains the preferred surgical approach for women
or are incidentally noted on imaging studies ordered with multiple or larger tumors, and is the focus of
for unrelated indications. Others will have mass- this chapter.
related complaints such as heaviness, urinary fre- Alternative approaches such as laparoscopic-
quency, constipation, or low back pain. Diagnostic assisted (see below) or minilaparotomy myomec-
considerations then are reliant on the clinical acu- tomy provide effective treatment with well-described
men of the treating physician since functional com- advantages with regard to postoperative recovery,
plaints such as these may be visceral in origin, and but many women will not qualify as surgical can·
surgery will less likely result in effective resolution didates, and concerns regarding the potential for
of the patient's complaints. More reliable symptoms subsequent uterine rupture remain unanswered.
include abnormal uterine bleeding and dysmenor· Although abdominal myomectomy is often regarded
rhea, or cyclic cramping. If bleeding is irregular or as a single procedure, we need to understand that it
unpredictable, however, causes of oligo-anovulation also involves careful uterine reconstruction, perhaps

241
242 SECTION Ill REPRODUCTIVE SURGERY

the most important part of the surgery. In this chap- PREOPERATIVE CONSIDERATIONS
ter, we describe one method of performing an abdomi-
nal myomectomy, adhering to microsurgical principles Unlike many other surgical procedures, preoperative
(see Chapter 22) and restoring myometrial anatomy. counseling with regard to postoperative reproductive
To ensure optimum surgical results, surgeons outcomes is requisite in patients undergoing myomec-
should clearly understand the anatomy of the myome- tomy. Aside from the typical surgical risks, a thorough
trium and of myomas. Microscopically, leiomyomas are discussion should include the possibility of adnexal
composed of dense whorls of smooth muscle cells with adhesions resulting in obstructive processes, possible
minimal intervening collagen. The smooth muscle cells hydrosalpinx formation, and tubal-factor infertility. In
of leiomyomata have increased nuclear size, more mito- patients who are planning for advanced reproductive
chondria, and increased free ribosomes. Anatomically, techniques whereby tubal transport is less of a concern,
myomas are located throughout, and are classified as intrauterine synechiae (Asherman syndrome) remains
such, including submucosal (sessile and peduncu- a well-described phenomenon when the endometrial
lated), intramural, and subserosal (sessile, peduncu- cavity is breached upon enucleation of a myoma. A dis-
lated, intraligamentous, and parasitic}. Leiomyomas cussion regarding when to conceive and how to deliver
also degenerate, as they frequently outgrow their blood should the patient become pregnant should also take
supply, since blood vessels do not grow into the mass place, given the need for myometrial repair and risk of
(see below). Degeneration can be hyalinized, hemor- subsequent uterine rupture. Finally; patients should be
rhagic, carneous, cystic, or caseous. counseled that, because of the nature of myomas, try-
Most importantly, myomas are not truly encapsu- ing to safely create a "myoma-freen uterus may, in some
lated; rather they are surrounded by a layer of hyper- patients, not be a realistic goal.
trophied smooth cells of normal myometrium, forming Preoperatively, it will be most important for the sur-
a pseudocapsule, which contains flattened vessels geon to obtain an accurate three-dimensional picture
(venous lacunae) (Figure 28.1 ). This web of flattened of the uterine anatomy. Transvaginal ultrasound is an
vessels surrounds the fibroid, which will often outstrip effective assessment tool for women with abnormal
its blood supply and begin to degenerate. It is this latter uterine bleeding. However, further evaluation is often
anatomy that needs to be kept in mind when perform- warranted, which may include sonohysterography.
ing an abdominal myomectomy. Sonohysterography can clearly delineate intracavitary

A lnterslftlal

Abrold

FIGURE 28.1 Myomas an~ not truly encapsulated; rather they an11 surrounded by a layer of
hypertrophied smooth cells of normal myometrium. forming a pseudocapsule. which contains
flattened vessels (venous lacunae) (A): This web of flattened vessels surrounds the fibroid (B), which
will often outstrip its blood supply as it grows and begin to degenerate.
CHAPTER 28 Abdominal Myomectomy and Uterine Reconstruction for Intramural Myomas 243

lesions, and has the ability to detect the percentage remaining irritants. The uterus, cul~de~sac, and
of the fibroid that is intramural. Historically, the use adnexa are then gently palpated to obtain a clear
of hysterosalpingography (HSG) has been described picture of the uterine anatomy. complemented by
for the preoperative assessment of the uterine cavity, reference to preoperative imaging results. This will
although its value has lessened considerably, with the allow the surgeon to plan the surgical approach. It
introduction of the above imaging techniques, which may he useful to first deliver the myomatous uterus
avoid radiation exposure and offer fewer risks, especially upward through the incision, not only for surgical
if tubal patency is not in question.MRI, although use~ ease but also to fully identify all potential tumors for
fu1 in planning for an operative hysteroscopic or lapar~ resection. However, this may apose the uterus to a
scopic myomectomy, provides less value in the planning greater risk for peritoneal desiccation. Minimal use
of abdominal procedures. Images should be available in of laparotomy sponges to retract or grasp is recom~
the operating room to guide the myomectomy. mended, as these are quite abrasive.
Long~acting GnRH analogues (e.g., leuprolide Tactically. two issues should be considered. First,
3.75 mg/month x 3 months) can be used to reduce it is best to allow a readily accessible medium to
the size of myomas and uterine vascularity prior to a large-sized fibroid to remain until the end of the
the procedure. However, this therapy also may make procedure, as these fihroids can he grasped to facili~
it more difficult to detect the plane between normal, tate manipulation of the uterus. Alternatively. it may
albeit compressed myometrium, and myoma. In turn, be necessary to remove those fibroids that are easi,
since blood loss can be significant in cases with large est to access initially. permitting access to myomas
and numerous fibroids, consideration toward use that are in more difficult,t~reach locations.
of cell-saver devices should be given and planned A technique we have found useful to facili~
according to institutional policy. Following is a brief tate the identification of the endometrial layer at
description of the surgical procedure (see also video: myomectomy. particularly when the myomas are
Abdominal Myorn6ctomy and Uterine Reconstruction suspected of abutting the uterine cavity or there
for Intramural Myomas). is a possibility that the endometrial cavity will be
entered, is to instill indigo carmine or methylene
blue into the cavity. This will stain the endometrium
SURGICAL TECHNIQUE a bluish tint and will make it easier to identify entry
into the endometrial cavity and facilitates the iden~
tification of the incised endometrial edges for repair.
1. Operative access and patient preparation:
em=. The swgical approach typically begins with a Staining with dilute methylene blue (1 %) lasts Ion,
ger than with indigo carmine. Dye instillation can
. , . transverse abdominal incision (P£annenstiel or
be performed transvaginally. through the cervix, or
Maylard) unless exam under anesthesia reveals
via an angiocath placed through the uterine fundus,
pathology more safely approached through a midline
although this may be difficult when the uterine cav,
incision. Patients with deep posterior tumors, espe-
ity is significantly distorted by the myomas.
cially if large, may pose a formidable obstacle for the
Following, we initially describe the resection of
surgeon as these are not only difficult to visualize
an uncomplicated fundal or anterior myoma, fol,
(bony pelvic inlet, sigmoid/colon/rectum), but even if
lowed by uterine reconstruction. Subsequently. we
successfully enucleated, may he aceed.ingly difficult
address the removal of myomas in more difficult
to repair unless a lengthy fascial incision is made.
locations (e.g., posterior, cervical, pedunculated,
Patient habitus, such as those with a longer distance
cornual, interligamentous, intracavitary; and mul,
between anterior superior iliac spines and shorter
tiple adjacent myomas).
distance from the pubic symphysis to umbilicus may
favor a transverse incision regardless of size or loca- 2. Myomectomy of a fundal/anterior myoma:
tion of the fibroids. If a Pfannenstiel incision is first Once the uterus and tumors have been examined,
created, another option is to convert to a Cherney in, and the approach established, the first incision
cision, rather than Maylard, in order to preserve the is then planned. This incision should generally
vascular supply to the anterior rectus sheath. overlie the most pronounced area of the myoma,
Once the peritoneal cavity is entered, per repro- be directed transversely if well removed from the
ductive surgery principles (see Chapter 22), the interstitiaVcornual region of the uterus, as close
surgeon should wash his or her gloves with a moist, to the midline as possible. Transverse incisions
ened laparotomy sponge to remove any potential should not be used when operating close to the
244 SEtnON Ill REPRODUCTIVE SURGERY

uterine cornua, in order to prevent extension into must be carried deep into the myoma itself, prefer-
the intramural portion of the tubes. ably at least halfway the full width of the myoma.
The incision size should be kept to the minimum This technique allows the normal myometrium to
necessary, and should not be made to accommo- retract from the less elastic fibroid (Figure 28.2),
date the entire girth of the myoma, as morcellation and allows the surgeon to better identify the true
of the tumor should be used if necessary. A vaso- plane between the fibroid and normal (yet corn-
active agent (we suggest vasopressin [Pitressin®] pressed) myometrium for attaumatic and relative
20 U diluted in 50 cc of normal saline} is injected bloodless enucleation. Alternatively. if the incision
aroWld the area of the planned incision, both super- is not carried into the fibroid, then there is a high
ficially and deep into the myometrium. The anes- likelihood that the dissection will be started at the
thesiologist should be informed of the injection myometrial pseudocapsule, with all its flattened
before it is administered. Some surgeons use a rub- vessels, resulting in significant bleeding and damage
ber tourniquet placed through the broad ligament to normal myometrium
compressing the uterine vasculature at the level of Using a towel clamp or a Lahey traction forceps
the internal os, although this surgeon views that for external traction, a curved Kelly or Pean clamp
approach as excessively risky. can be used to dissect the fibroid in a multidirec-
A scalpel is used to incise the serosa and myome- tional approach, following the avascular planes
trium down to and into the fibroid itself. It is impor- between the myoma and the myometrial pseudo-
tant that the surgeon understand that the incision capsule (Figure 28.2). In a stepwise fashion, most

Pseudocapsule

FIGURE 28.2 The incision must be carried deep into the myoma itself, preferably at least halfway
the full width of the myoma. allowing the normal myometrium to retract from the less elastic
fibroid: This will allow the surgeon to better identify the true plane between the fibroid and normal (yet
compressed) myometrium for atraumatic and relative bloodless enucleation. A towel clamp or a Lahey trac-
tion forceps is used to grasp the fibroid for external traction, and a curved Kelly or Pean clamp can be used
to dissect the fibroid in a multi-directional approach, following the avascular planes between the myoma
and the myometrial pseudocapsule.
CHAPTER 28 Abdominal Myomectomy and Uterine Reconstruction for Intramural Myomas 245

fibroids may be removed intact. However, if myo- in the deeper layers of the myometrium to achieve
mas are large, serial wedge-type morcellation with a hemostasis of transected perimyomatous vessels.
scalpel should be considered (Figure 28.3). There On occasion, a particularly large vessel may have to
is no need to take out fibroids "intact," and in fact, be isolated and tied off.
the serosal incision should not be made as large The operator should strive to minimize the num-
as the myoma; it should be made just sufficient to ber of incisions. To remove multiple fibroids, the
allow for dissection of the myoma from its bed and serosal incisions should be planned strategically, in
to permit wedge morcellation. We do not recom- order to remove as many tumors through one incision
mend the use of Allis clamps to grasp the serosa or as possible, although this may require on occasion
myometrium for countertraction purposes as these that the operator transect normal vascular myome-
only create more injured surfaces and potential trium laterally, necessitating good hemostasis. Good
nidus for adhesion formation. palpation of the uterus during the procedure should
The blood supply to the fibroid is peripheral and be performed to ensure that no large tumors are
circumferential, rather than central (Figure 28.1). missed, particularly those lower in the uterus. And
Myomas flatten and stretch the arcuate vessels of surgeons should never forget to continuously irrigate
the uterus which run in a transverse pattern. If dis- the serosa with warmed isotonic solutions to main-
section through planes just exterior to the fibroid tain moisture throughout the procedure.
takes place, significant bleeding and oozing can
occur. Accordingly, most incisions should be made 3. Uterine reconstruction: Closure, repair, and
in a transverse fashion to reduce bleeding and make uterine reconstruction remain one of the most
for an easier closure. This is not always possible, crucial aspects of the procedure. Once intended
and proximity to the interstitial portion of the ovi- fibroids are removed, careful inspection of deeper
duct and vascular supply should take precedence. tumor beds should take place before closing any de-
Electrosurgery and electrocoagulation can be used fects to ensure hemostasis. We prefer to close the

FIGURE 28.3 If myomas are large. serial wedge-type morcellation with the scalpel should be
considered to aid extraction.
246 SEtnON Ill REPRODUCTIVE SURGERY

deep layers of myometrium using 0 gauge absorb- be best occluded using a single interrupted horizon-
able sutures on CT-1 or CT-2 needles. The defect tal mattress suture. At this point, after the uterus
is bridged in at least two layers of interrupted su- is fully hemostatic, the serosa should be reapproxi-
tures (Figure 28.4). While generally the sutures mated using 4-0 nonreactive absorbable suture
are tied as they are placed, in more irregular defects in a "subcuticular (subperitoneal)-type" fashion
it may be reasonable to tie them after all sutures (Figure 28.58); the objective of this suture is to
are placed. External pressure should be applied approximate the edges of the serosa without tension
manually to bring both sides of the incision together and without exposing foreign material to the perito-
while the interrupted sutures are placed; this may neal surface. This minimizes foreign body exposure
require significant pressure as the operator is trying that may occur with more typical running tech-
to bring together two parts of a strong muscle that niques, such as the baseball stitch closure.
have now contracted/retracted from the incision
4. Pedunculated subserosal myomas: It is rela-
site. This is a critical step, and the principal reason
tively easy to remove subserosa, although the most
why laparoscopic myomectomy, while effective for
difficult part of this removal is the repair of the se-
the removal of more superficial myomas, is less suc-
rosa. Tying the base of a pedunculated myoma is
cessful for the removal and subsequent reconstruc-
not acceptable (Figure 28.6A), unless a sufficient
tion of deeper and intramural myomas.
flap of peritoneum has been dissected off the base
Once the 2 to 3 deeper layers of sutures are
first, to allow for subsequent subperitoneal reap-
placed and the uterus has regained its generally nor-
proximation (Figure 28.68). It will also allow for
mal shape, the most superficial layer of myometrium
electrocoagulation without damaging the overlying
(but not including serosa) may be best closed in a
serosa.
running horizontal mattress stitch (Figure 28.5A),
which should aim to bring the edges of the myo- 5. Endometrial cavity entry during myomec-
metrium together at equal heights. This technique tomy: Many surgeons fear entering the endome-
occludes multiple parallel vessels with a single pass, trial cavity, being concerned that this places the
and also reapproximates the tissues reading them patient at greater risk of uterine rupture, mandat-
for serosal closure. This suture should be placed ing the need for a scheduled cesarean section. The
until hemostasis of deeper layers has been achieved. reality is, however, that any deep injury or incision
On occasion, a bleeding perimyomatous vessel may into the myometrium, whether there is endometrial

FIGURE 28.4 The deep layers of myometrium are closed using 0 gauge absorbable sutures and
the defect bridged in one or two layers of interrupted sutures: External pressure should be applied
manually to bring both sides of the incision together while the interrupted sutures are placed.
CHAPTER 28 Abdominal Myomectomy and Uterine Reconstruction for Intramural Myomas 247

A
Running horlzon1al
mattress stitch

B
Subcuticular suture

FIGURE 28.5 The superficial myometrium is dosed, preferably using a running horizontal mat-
tress stitch (A). and once the uten.ts is fully hemostatic. the serosa should be reapproximated
using 4.0 nonreadive absorbable suture in a •subcuticular (subperitoneal)-type• fashion (B): This
last stitch will approximate the edges of the serosa without tension and without exposing foreign material
to the peritoneal surface.

entry or not, should be considered a risk factor for running (if regular) absorbable 2-0 sutures. He/she
uterine rupture. As such it is much more important should then proceed to close the myometrium in
that the surgeon be alert to the possibility that en- layers, as described before. A poorly reconstructed
try into the endometrial cavity may/has occurred endometrial repair will place the patient at higher
when removing deeply placed myomas, and strive risk for intrauterine adhesions and adenomyosis at
to reconstruct the cavity appropriately. In fact {see the repair site.
below), a surgeon may intentionally breach the en-
dometrium during removal of a posteriorly placed 6. Managing difficult myomas: There are a num-
myoma. The surgeon should identify the endome- ber of reasons why a myomectomy may be more
trial edges and approximate them carefully using ei- difficult than described, including large number of
ther interrupted (if the tear is irregularly shaped} or myomas, large size myomas, and location of myomas
248 SECTION Ill REPRODUCTIVE SURGERY

FIGURE 28.6 It is relatively easy to remove subserosa. although the most difficult part of this
removal is the repair of the serosa. Tying the base of a pedunculated myoma is not acceptable (A),
unless a sufficient flap of peritoneum has been dissected off the base first, to allow for subsequent subperi-
toneal reapproximation (B).

(posterior, intracavitary, cervical, cornual, or intra- patients, not be a realistic goal, and patients
ligamentous). We will briefly review these surgical should be counseled in advance.
situations, and highlight means of addressing.
b. Very large fibroids or myomatous mass:
a. Large number of myomas: When a patient The risk of bleeding is higher and uterine recon-
has a large number of myomas three issues struction more difficult with very large fibroids
should be considered: a) How does the size or myomatous masses; however, these are issues
of the uterus affect my approach? b) How do that simply require greater attention to dis-
I minimize damage to the uterus? and c) Do I section. Alternatively, large masses will make
need to remove all fibroids? Below we address access and uterine mobilization more difficult.
the issue of mass size in managing myomas. In these events, the uterine fibroids may need to
Previously we have described means of remov- be addressed sequentially, beginning at the top
ing more than one myoma through one uterine or front aspect. Pedunculated uterine fibroids
incision, using lateral or sideway incisions to should be palpated for, extracted, and removed,
reach other fibroids. Most important, however, progressively allowing for greater uterine mobility.
is the decision of how many fibroids should be Large irregular masses also cause such a
removed and why. level of uterine distortion that it may be difficult
When addressing a large number of fibroids, for the operator to detennine landmarks. For
an excessively zealous approach may risk bleed- example, a large myomatous mass on the uterus
ing. infection, malreconstruction, and hyster- may have rotated the uterus in such a way that
ectomy. As such, the surgeon should approach exposes the uterine artery and vein directly
this (and any other surgery) by understanding anterior, heightening their chance of acciden-
what the individual patient desires are. For tal or iatrogenic injury. likewise, the location of
example, if near-tenn fertility is desired, it tubal insertion may be difficult to ascertain, and
may be possible to leave selected small tumors encourage the transection of the tube at this
behind. If excessive abnormal uterine bleeding site. Thus, in patients with a very large myo-
is a concern, then all fibroids around endome- matous mass it will be critical that the surgeon
trial cavity should be removed. However, trying begin by establishing (optimally visually, if not
to create a "myoma-free" uterus may, in some tactilely) insertion of adnexa, beginning with
CHAPTER 28 Abdominal Myomectomy and Uterine Reconstruction for Intramural Myomas 249

the origin and insertion of the infundibulopelvic the uterus is bivalved anteriorly using a longi-
and round ligaments, and so on. tudinal incision, preferably placed, at least in
part, beneath the bladder reflection. Once
c. Posterior wall myomas: Posterior wall myo- the endometrial cavity is entered and the cav-
mas of any significance are unfortunately quite ity walls retracted using army-navy retractors,
common. Obviously, easiest is to access them an incision is made in the posterior wall into
directly posteriorly. However, this carries a high the posterior fibroid, which is enucleated/
chance that adhesions will form between the morcellated in a fashion similar to what has
posterior uterine wall and the tubes and ovaries been described (Figure 28. 7). The uterus is
that rest normally in the cul-de-sac. This sur- reconstructed in layers, taking care to bring the
geon prefers, whenever possible, to approach endometrial layers together separately from the
posterior myomas anteriorly. That is to say. that myometrial repair.

FIGURE 28.7 Whenever possible. a posteriot~-wall fibroid should be approached anteriorly: The
uterus is bivalved anteriorly using a longitudinal incision. Once the endometrial cavity is entered and the cav-
ity walls are retracted using army-navy retractors, an incision is made in the posterior wall into the posterior
fibroid, which is then enucleated.
250 SEtnON Ill REPRODUCTIVE SURGERY

d. Intracavitary myomas: Intracavitary myo- will depend on the size and amount of adnexal
mas can be handled in a manner similar to that distortion. However, because these masses can
described for anterior approaches to posterior lift, stretch, and flatten out large broad ligament
myomas (see above). However, sole intracavi- vessels including the uterine artery and vein,
tary myomas should be best handled by hys- the best approach is to open the broad ligament,
teroscopic resection (see Chapter 27). using a small 1-cm incision over the uppermost
aspect of the mass and as usual, incising deeper
e. Cervical and cornual myomas: The decision
into the mass. Once this is done safely, further
to remove myomas that are in close proximity to
dissection of the mass should proceed through
either the cervix or the uterine cornua should be
careful blunt dissection, ensuring all normal tis-
made carefully; as their removal has significant
sue {and vessels) are pushed off the fibroid.
risks for bleeding (cervical) or infertility (cor-
nual). If a decision is made to proceed, a few 7. Final considerations and closure: Once all tu-
strategies should be kept in mind. First, removal mors are removed and the uterus is reconstructed.
of fi.broids &om the cornual region should be all irrigation is suctioned using a pool adaptor,
made through an incision away from the intra- minimizing use of laparotomy sponges, which can
mural portion of the tuballurne~ as one does not abrade serosal linings. Before replacing the uterus.
want to transect the lumen while removing the adhesion harriers may he placed. Although there
fibroid. Examination of the preoperative HSG is some evidence to support use of specific prod-
may prove helpful, as it may give a clue as to the ucts, there is no definitive indication or selection.
direction the lumen has deviated away from. In general, the preponderance of evidence points
Dissection of the fibroid should begin as toward the use of expanded polytetrafluoroethylene
medially as possible, incising into the myoma {GORE® PRECLUDE® Peritoneal Membrane) as
body laterally. The fibroid is then enucleated an effect harrier against adhesion formation during
taking care to protect as much of the surround- a myomectomy. However, adhering to microsurgi-
ing myometrium as possible, and minimizing the cal principles (see Chapter 22) and minimizing
use of electrosurgery. In general, myoma enucle- bleeding remains the best means of reducing adhe-
ation in the cornual region can be achieved safely sion formation.
without injuring the course of the tubal lumen.
However, the lumen is most apt to be injured
when repairing the defect, and so sutures should Laparoscopic myomectomy
he placed as far away from the cornual region Laparoscopic myomectomy represents a far from
and from the course of the tube as possible. novel procedure, originally described in 1991 by
Cervical myomas should be tackled carefully; Dr. Jean-Bernard Dubuisson after his first 43 cases.
and from as medially as possible. Generally. the More than two decades following this publication,
anterior portion of the broad ligament should the percentage of myomectomies performed laparo-
be opened, and the fibroid carefully dissected scopically remains low, in large part due to the tech-
away. Again, incising into the fibroid will help nical challenges and skills required (see also video:
identify the true myoma mass, although these Laparoscopic Myomectomy).
fihroids often lie outside the normal myome-
trium, in an intraligarnentous position, and are
Procedure in brief
generally clearly identifiable.
The procedure includes patient selection. iden- ~
Care should be taken to identify the uterine
tification of the myoma, enucleation, myome- -
arteries and the ureter supervening these before
trial reconstruction, and adhesion prevention. Since
fully enucleating the myoma and repairing any
the ultimate goal of any laparoscopic procedure is to
defect. If in doubt, a cystoscopy and ureteros-
closely replicate its laparotomy counterpart, it is likely
copy should be considered at the end of the
the reconstruction of the myometrium that represents
procedure if the course of the ureter was not
the most difficult task for most surgeons. With the con-
fully identified.
cern for uterine rupture during subsequent pregnancy;
f. lntraligamentous myomas: Intraligament- myometrial integrity has historically fallen under more
ous fibroids are rare, hut occasionally masquer- scrutiny with a laparoscopic approach. For this reason,
ade as an adnexal mass. The surgical approach a multiple-layered closure. which can often be difficult
CHAPTER 28 Abdominal Myomectomy and Uterine Reconstruction for Intramural Myomas 251

and tedious to accomplish, should never be replaced this portion of the procedure since resultant smoke
with a single-layered bulk closure. from cellular combustion can impede visualiza-
tion. Alternatively, suction tubing can be connected
1. Patient selection: Although there exists no stan-
from an ancillary trocar to a tightly sealed bottle of
dard as to which patient is a good candidate for
warmed solution. This can help since it creates a
laparoscopic myomectomy, beginning with rela-
passive outlet for smoke. If the surgeon is to avoid
tively easy cases will build skill sets and confidence.
electrosurgical instruments altogether, a laparo-
Transvaginal ultrasonography remains a good first
scopic scalpel is also available. High-voltage current
step in evaluating women with fibroid uterus; how-
should be avoided as it is less precise and causes
ever, pelvic MRI with contrast has clear advantages
more lateral thermal injury that could impact heal-
in that it will demonstrate more accurately the num-
ing and eventual integrity. No other energy source
ber, location, size, and 3D rendering that ultrasound
is typically required since hemostasis is ultimately
cannot. Since the surgeon cannot "feel to find" the
myoma during surgery, he or she becomes reliant on accomplished by suture material. For pedunculated
fibroids specifically, we do not recommend bipolar
visual cues that comes best from MRL This imag-
dessication of the stalk for two reasons. First, this
ing modality also allows for enhanced surgical plan-
ning in the operating room and ensures retrieval of results in significant thermal injury to serosa and
as many fibroids as is necessary for the intended possibly myometrium in the uterine corpus given
outcome. Furthermore, MRI may help detect other the proximity of the stalk. The eventual defect is
myometrial pathology such as adenomyosis, which then quite small with virtually no redundant tissue
may redirect how a patient is counseled regarding to reappraximate for either hemostasis or strength
of closure. Second, the stalk may contain large ves-
treatment options.
Many experts feel that some denomination of sels and may bleed if not desiccated well prior to
15 em is a good reference for selection purposes (an amputating. To improve all slll'gical aspects, we per-
isolated 15-cm fibroid, three 5-cm fihroids, or five form a circumferential incision along the base of
3-cm fibroids). Ultimately, this range will vary based the fibroid itself, resembling a wine cup and neck.
on surgeon experience. Location of the fibroid does The fibroid is shelled from its avascular planes,
not necessarily pose a limitation, hut small fihroids which results in less blood loss and leaves more
(less than 2 em) that are deeply intramural and in serosa for closure. All other fibroids are enucleated
the background of several larger fibroids are often and repaired as if the procedure were performed by
the most challenging to identify. laparotomy.
A laparoscopic tenaculum or corkscrew is used
2. Enucleation of the myoma: Port placement is to enucleate the fibroid in a similar manner to
potentially one of the most limiting steps if not per- abdominal myomectomy. Anterior fihroids tend to
formed in relationship to the individuals' anatomy. be more difficult to enucleate since laparoscopic
As gynecologists, we become familiar and comfort- instruments are linear and come from a cephalad
able with the umbilicus, but if the uterus extends position. There is less room for torque between an
beyond the umbilicus, then ports should move anterior fibroid and the anterior abdominal wall
cephalad, hut still be able to reach the lower pel- than there is from a posterior fibroid and the origi-
vis once the fibroids are enucleated. Surgeon pref- nation point of the trocar.
erence should dictate where the ancillary ports
are placed and depending on how they have been 3. Myometrial reconstrudion: Historically, myo-
trained to suture (ipsilateral vs. contralateral sutur- metrial beds are repaired in multiple layers of in-
ing technique). terrupted sutures, often using 0-caliher absorbable
Diluted vasopressin (we use 20 U in 100 ml of sutures. Two commercially available barbed sutures
normal saline) is injected into the myometrium and have recently been introduced, making the uterine
serosa until adequate blanching can been seen. repair much easier since the beds can he reapproxi-
Typically, a monopolar scissors or hook, using a low mated in a continuous fashion without the need
voltage current (CUT) on 60-W power setting is of tying knots. The small barbs also constrict the
used to incise the serosa and myometrium to and myometrium while being placed, allowing for a very
into the fibroid, similar to an open procedure. Smoke hemostatic repair (V-loc and Quill}. Morcellation
evacuation, which can be performed using a suction is performed with one of several available mecha-
irrigator in a pulsatile manner, can be helpful during nical devices. It is critical that a fibroid count is
252 SEtnON Ill REPRODUCTIVE SURGERY

maintained and that if multiple, each fibroid is Operative Note


tagged for later retrieval to avoid retained material.
The da Vinci robotic platform, introduced in PROCEDURE: ABDOMINAL
2003, has also enabled surgeons to perform more MYOMECTOMY AND UTERINE
complex procedures laparoscopically. The ability to RECONSTRUCTION FOR
suture with traditional instrumentation has been
replicated by the advanced pulley system deployed
INTRAMURAL MYOMAS
by this plat.fonn, allowing the surgeon to suture mul- The patient was placed supine upon the operating
tiple and deep defects and anterior fibroids compa-
room table, and was prepped and draped in the usual
rably as if sewn by laparotomy. Surgical outcomes
sterile fashion. A Foley was placed to straight drain
have demonstrated feasibility of this device, but in the bladder. Time out was called and information
long-term reproductive outcomes are not yet well
reviewed. A speculum was placed into the vagina and
established. Anecdotal findings have been promis-
the cervix exposed. A pediatric Foley was placed into
ing in that adhesion formation at time of cesarean the uterine cavity and the bulb was insufflated with
delivexy seems to be significantly reduced compared
air. The uterine cavity was insufflated with dilute 1%
to abdominal myomectomy. methylene blue dye. After instillation of the dye, the
Foley was decompressed and removed.
At this point, gloves were washed in sterile water
POSTOPERATIVE CONSIDERATIONS and a transverse incision was made in the lower abdo-
men, about 2 ern above the pubic area. The incision
Serious complications are infrequent (see Compli- was carried down through the subcutaneous fat to the
cations box on page 253), although adhesion forma- fascia. The fascia was incised transversely and dis-
tion at the site of the myomectomy is very frequent, sected off the rectus muscle, upward to the umbili-
and blood loss sufficient to significantly decrease cus and downward to the pubis. The rectus muscles
the hematocrit is frequent. The mainstay of postop- were separated in the midline and the perineal cav-
erative care revolves around analgesia. Unless sig- ity was entered digitally. The peritoneal incision was
nificant bleeding is encountered, we typically utilize then extended upward to the umbilicus and down-
nonsteroidal anti-inflammatory drugs such as IV/IM ward toward the bladder. The edges of the incision
ketorolac, but narcotic administration is almost inevi- were then wrapped with laparotomy packs to avoid
tably required. If selected, patient-controlled analge- bleeding from the incision into the abdomen; a Bal-
sic pumps are requested. Depending on the degree four retractor was placed into the abdomen. At this
of myometrial dissection, which can result in hema- point, the uterus and adnexa were examined and
toma formation and resultant pain, most patients will the above findings were noted. The bowel was then
remain in-house for 2 to 4 days. It is not uncommon packed away from the pelvis using a lap pack placed
for patients to experience low-grade fevers in the early in sterile plastic bags. Copious irrigation was main,
postoperative course, but concurrent evaluation for an tained throughout the procedure using warm lactated
infectious source is nonetheless warranted, especially Ringer's solution, instilled through an 18G angiocath
if they appear toxic. connected to a 20,cc. syringe.
Venous thromboembolic prophylaxis with sequential Attention was placed to the anterior uterine sur-
compression devices are maintained until the patient face. Dilute Pitressin (20 U diluted in 50 cc of nor-
is ambulatory, which is encouraged on postoperative mal saline) was injected into the myometrium over
day 1. Routine use of prophylactic antibiotics is not the bulging myoma, along the planned incision line;
recommended. Foley catheters are typically maintained blanching of the myometrium at the injection site was
overnight unless the patient is ambulating early. Postop- noted. Using a No. 15 scalpel, a small3-cm transverse
erative care is otherwise conducted in an individualized incision was made over the myoma, and the incision
manner. was carried deep into the body of the myoma. Apply-
Upon discharge, a discussion about the procedure, ing pressure on both sides of the uterus manually, the
recommendations for postoperative assessments (such as edge of the bivalved myoma was clearly seen separate
HSG), and modes of delivery should they conceive rou- from the overlying myometrium. Using Lahey clamps
tinely take place. In general, if there have been significant to grasp each edge of the cut myoma, traction was
breaches of the myometrial wall, a scheduled cesarean applied and the myoma was dissected away from its
section should be considered for subsequent delivery. myometrial bed using dissection with a cUIVed Kelly
CHAPTER 28 Abdominal Myomectomy and Uterine Reconstruction for Intramural Myomas 253

clamp. Bleeding was minimal. The myoma was morcel- fibroids, which were removed by making lateral inci-
lated into halves using the scalpel in order to remove sions through the principal anterior wall incision. The
the tissue without extending the myometrial incision. beds of the fibroids were closed with single interrupted
Care was taken to not enter the uterine cavity. sutures using 0-chromic.
At this point, attention was placed on removing the The anterior wall incision was now closed in lay-
posterior wall myoma. After lysing the filmy posterior ers. First, the anterior endometrial layer was approxi-
wall adhesions, a decision was made to remove the mated using interrupted sutures of 2-0 plain catgut,
myoma through the anterior wall incision. At this time ensuring that the knot was placed away from the
the anterior uterine incision was extended using the endometrial cavity. The myometrium was then closed
scalpel to 4 em, taking care to avoid excessive exten- in two layers, the first using vertical interrupted
sion into the lateral uterine vessels. The uterine cavity sutures with 0-chromic, and the second using inter-
was then exposed using bilateral retraction with army- rupted horizontal mattress sutures with 0-chromic.
navy retractors, and the endometrial cavity was entered Manual pressure was applied to the sides of the
transversely incising the endometrial lining, identified uterus through the repair in order to ensure exact
by its bluish tint. approximation of the incision. A final running hori-
The cavity was exposed through retraction and then zontal mattress layer using 2-0 chromic was placed
a transverse incision was made in the posterior wall of through the superficial layer of the myometrium.
the endometrial cavity with a long-handled scalpel and The serosa was then closed using a subserosal run-
the incision was carried into the body of the myoma. ning stitch with 4-0 Vicryl®. No excess bleeding was
Again the edges of the bivalved myoma were grasped noted. A decision was made not to use an adhesion
with a single-tooth tenaculum, and the myoma was barrier at the sites of the anterior incisions.
morcellated and fragments extracted through the ante- At this point, after the pelvis was carefully
rior uterine wall. Care was taken not to transect the inspected, irrigated copiously, and all blood products
posterior serosal wall, protecting the underlying bowel washed, all lap packs were removed from the pelvis
by placing a wide flat malleable retractor into the space. after the adnexa were allowed to fall freely to the cul-
Once the myoma had been removed in toto using de-sac. The pelvis was gently and thoroughly irrigated.
the tip of a curved Kelly for dissection, closure of the At this point the sponge count was correct and the
posterior wall was begun, first using two layers of inter- peritoneal incision was closed using a running suture
rupted horizontal mattress stitches using 0-chromic. using 2-0 Vicryl. The rectus fascia was closed using
With the myometrium closed, care was then taken intenupted sutures with 0 Vicryl. The subcutaneous
to approximate the posterior endometrial layer using fat was approximated using three interrupted sutures
interrupted using 2-0 plain catgut sutures, taking care using 2-0 Plain. The skin incision was enclosed in a
to leave the knots on the myometrial side of the layer. subcuticular fashion using 4-0 Vicryl. The patient
Attention was placed to the anterior intramural cor- went to the recovery room in good condition with-
nual fibroid. Careful inspection noted that the fallopian out any complications. The estimated blood loss was
tube inserted posterior to the myoma. A 1 em longitu- approximately 150 cc.
dinal incision was made with scalpel over the medial
edge of the myoma and carried laterally into the body
of the myoma. Once the myoma was bivalved, the cut
edges were grasped using a single-tooth tenaculum, and COMPLICATIONS
the myoma was carefully dissected from its myometrial
bed, taking care to not extend the dissection beyond • De novo pelvic adhesion formation and adhesion
the surface of the myoma. Once removed, the myome- reformation-Very frequent (greater than
trial incision was closed using two interrupted vertical 50% de novo adhesion formation, and as high
mattress sutures with 2-0 chromic, staying away from as 90% adhesion reformation if severe reexisting
the cornual area. The superficial layer of the myome- adhesions)
trium was now approximated using two 2-0 chromic • Hemorrhage or major vessel perforation requiring
interrupted superficial horizontal mattress sutures. The transfusion-Infrequent (less than 5%)
serosa was closed using a subserosa! running stitch • Postoperative infection (myometritis, adnexitis)-
with 4-0 Vicryl®. No excess bleeding was noted. Infrequent (less than 5%)
Attention was now placed to the anterior wall inci- • Major organ injury-Rare (less than 1%)
sion. Palpation revealed additional smaller anterior wall
254 SEtnON Ill REPRODUCTIVE SURGERY

Suggested Reading in preventing adhesions. Pertil Steril 1995;63(5): 102 I-


1026. Erratum in: Fertil Steril1995;64(3):668.
I. Barakat EE, Bedaiwy MA, Zimberg S, Nutter B, 6. Knochenhauer ES, Azziz R. Adenomyosis, leiomyomata
Nosseir M, Falcone T. Robotic-assisted, laparoscopic, and pelvic pain. In Blackwell RE, Olive DL, eds. Chronic
and abdominal myomectomy: a comparison of surgical Pelvic Pain: Evaluation and Management. New York, NY:
outcomes. Obstet Gynecol2011;117(2 Pt 1):256-265. Springer-Verlag; 1998:121-142.
2. Behera MA, Likes CE 3rd, Judd JP, Barnett JC, 7. Kumakiri J, Kikuchi I, Kitade M, et al. Association
Havrilesky LJ, Wu JM. Cost analysis of abdominal, lapa- between uterine repair at laparoscopic myomectomy and
roscopic, and robotic-assisted myomectomies. J Minim postopezative adhesions. Acta Obstet Gynecol Scand
Invasive Gynecol2012;19:52-57. 2011. doi:10.1111/j.l600-0412.2011.01339.x.
3. Breech LL, Rock )A. Leiomyomata uteri and myomec- 8. Nash K, Feinglass J, Zei C, et al. Robotic-assisted lapa·
tomy. In Rock JA, Jones HW, eds. Telindes Operative roscopic myomectomy versus abdominal myomectomy:
Gynecology, Tenth Edition. Philadelphia, PA: Lippincott a comparative analysis of surgical outcomes and costs.
Williams and Wilkins; 201 I :687-726. Arch Gynecol Obstet 2012;285:435-440.
4. Breech LL, Rock.JA. Leiomyomatous uteri and myomec- 9. Parker WH. Laparoscopic myomectomy and abdominal
tomy. In TeLindes Operative Gynecology. Philadelphia, myomectomy. Clin Obstet Gynecol2006;49:789~797
PA: Lippincott Williams and Wilkins; 2011. ISBN-I 0: 10. Parker WH. Uterine myomas: management. Fertil Steril
1451143680 I ISBN-13: 978-1451143683 I Publication 2007;88:255~271.
Date: July 28, 2011 I Edition: Tenth, Updated Edition. 11. Wechter ME, Stewart EA, Myers ER, et al. Leiomyoma·
5. Haney AF, Hesla J, Hurst BS, et al. Expanded polytetra- related hospitalization and surgery: prevalence and pre·
fluoroethylene (Gore-Tex Surgical Membrane) is supe- dieted growth based on population trends. Am J Obstet
rior to oxidized regenerated cellulose (Interceed TC7 +) Gynecol 2011 ;205 :492.e 1-5.
CHAPTER

Hysteroscopic Adhesiolysis of
Intrauterine Synechiae
M. Jonathon Solnik, Ricardo Azziz

INTRODUCTION these reasons, early diagnosis and surgical correction is


warranted since it is ideal to treat less mature adhesions
Intrauterine synechiae, albeit uncommon, affecting with less muscular component in order to preserve viable
approximately 1.5% of women Wldergoing hystero- endometrium. Other women at risk for intrauterine syn-
salpingography (HSG), and possibly more in at-risk echiae are those with opposing submucosal myomas who
patients, may present a challenging anatomical dilemma undergo concurrent hysteroscopic resection, and those
for women who wish to have children. For any type of who undergo abdominal myomectomy with breach into
adhesion, or synechiae to form in the body. two oppos- the endometrial cavity and inappropriate cavitary repair.
ing surfaces must be injured at some leveL Typically, Women with intrauterine adhesions appear to be
within any body cavity. these surfaces are comprised more at risk for subsequent infertility and pregnancy loss.
of single-cell layers, such as peritoneum or serosa, but The mechanism for these process likely sterns around
in the case of intrauterine synechiae, the injury occurs the finding that impaired endometrial perfusion has been
within the endometrium. It has been suggested that documented with less available surface area for implanta-
the probability of synechiae increases if the associated tion and subsequent embryonic development. Based on
injury or trauma is accompanied by an inflammato:ry these anatomic and physiologic distortions, reproductive
response, such as in the setting of a postabortal curet- capacity becomes our prima:ry interest. Categorizing the
tage for the indication of a septic abortion. extent of disease has not been uniform throughout the
Women at increased risk for intrauterine adhesions literature; however, the American Society of Reproduc-
include those who undergo postpartum or postabortal tive Medicine (ASRM) classification system published
curettage who subsequently experience menstrual com- in 1988 describes not only the extent and type of adhe-
plaints. According to Friedler, the incidence of adhe- sions, but also the impact on menstrual pattern since the
sions rose from 14% to 32% for curettage performed in more significant the burden, the more likely it is to affect
the second versus the third abortion. As such, it is our bleeding (see Table 29.1). Nevertheless, several such
recommendation to avoid vigorous curettage in any set- systems have been described, one not more predictive of
ting whether postabortal or for the indication of a men- pregnancy outcome than the other.
strual complaint. The basalis layer of the endometrium
is the most regenerative; however, during pregnancy, the
uterine wall is quite compliant and the basalis layer is PREOPERATIVE CONSIDERATIONS
more predisposed to significant injury during this time
period. Furthermore, after delive:ry, there may be more Prompt detection followed by surgical management
of an exaggerated healing response within the endo- continues to be the mainstay for treating both symp-
metrium, also predisposing to adhesion formation. For tomatic patients and those with infertility or recurrent

255
256 SEtnON Ill REPRODUCTIVE SURGERY

Table 29.1
ASRM Classification of Intrauterine Adhesions, 1988
Extent of cavity involved <113 113-2/3 >213
1 2 4
Type of adhesions Filmy Filmy & dense Dense
1 2 4
Menstrual pattern Normal Hypomenorrhea Amenorrhea
0 2 4
Prognostic classification HSG•score Hysteroscopy score
Stage I (Mild) 1-4
Stage II (Moderate) ~
Stage Ill (Severe) 9-12
Source: The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal
occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions.
Fertil Steril1988;49:944-55.
•All adhesions should be considered dense.

pregnancy loss. Historically, an HSG was used to diag- More advanced disease to include an obliterated cavity
nose synechiae, although this study suffers from higher poses a more significant surgical challenge and should only
false positive rates and does not necessarily quantify the be unde:ttake:n by skilled surgeons since the risk of uterine
extent of disease. In experienced hands, a transvaginal perforation and the inability to complete the procedure is
ultrasound may also serve to detect adhesions, but diag- relatively high. Lateral perforation toward the uterine vas-
nostic accuracy is enhanced with the use of sonohyster- cUlature poses significant risk. Surgical options include the
ography (with specificity and positive predictive values initial use of a Pratt dilator to help establish a lateral chan-
as high as 100% reported). Overall, however, operative nel from which to begin working (Figure 29.3). Ideally,
hysteroscopy allows for the most accurate and descrip- two passages are created laterally, toward the tubal ostia. As
tive means of diagnosis and provides the physician with a result of this quick maneuver, the resulting cavity resem-
the ability to concomitantly divide adhesions. bles that of a uterine septum. At this point, the surgeon
may use scissors or an electrosurgical electrode to incise
the midline obstacle toward the fundus. Movement &om
SURGICAL TECHNIQUE lateral to medial remains the safest approach regardless of
instrumentation selected. However, there is also a signifi-
The decision to surgically manage patients with intra- cant risk of creating a false passage with dilation. There
uterine synechiae ultimately depends on symptoms will be times when the ostia cannot be visualized, and if
(amenorrhea, poor reproductive outcomes). We prefer more muscular adhesions are encountered, the likelihood
to use a 5. 5-mm operative hysteroscope with semi-rigid of resuming normal menstrual function becomes lower.
cold scissors. Typically, we proceed to the operating The decision to terminate the procedure is similar to
room and use general anesthesia; however, specific that of a uterine septum in that it is always safer to be
centers have successfully implemented office-based less aggressive and lessen the risk of uterine perforation
tteatment. or thinning and weakening the myometrium, which
Early stage disease is frequently easy to manage may not be easy to identify in difficult cases. If brisk
by simply incising the synechiae in their horizontal bleeding is encountered, the procedure should come to
plane with cold scissors (Figure 29.IA). Lower seg- an end. Occasional visualization under low intrauter-
ment adhesions and more filmy adhesions are divided ine pressures may help identify an appropriate bleeding
first (Figure 29.IB), and dissection is continued in point. Some surgeons have described the use of con-
a cephalad direction, dividing more dense adhesions current ultrasonographic imaging, whether by transab-
later. The objective is to normalize the endometrial dominal ultrasound or by a laparoscopically deployed
cavity while preserving or restoring as much viable ultrasound probe to help move safely within such a
endometrium as can be accomplished (Figure 29.2). small cavity. The literature lacks supportive evidence,
CHAPTER 29 Hysteroscopic Adhesiolysis of Intrauterine Synechiae 257

Synechiae

FIGURE 29.1 Transverse (A) and hysteroscopic view (B) of moderate intrauterine adhesions.

but in difficult cases, we typically use a transabdominal be trimmed, taking care not to breach the lumen of the
probe to help visualize the fundus in a coronal plane. catheter. This is performed with the balloon inflated
so not to cut the air reservoir and inadvertently deflate
the balloon. While the balloon remains in place, we
POSTOPERATIVE CONSIDERATIONS administer Doxycycline I 00 mg by mouth twice daily to
minimize the risk of endometritis.
Intraoperative and postoperative complications are Depending on the patient's estrogenic status, con-
infrequent {see Complications box on page 259). The tinuous estrogen (e.g., conjugated estrogen 1.25 mg by
highest risk is that of recurrent intrauterine adhesions, mouth once to twice daily) may also be given for the first
which can range from 2% to 20% in all patients, and even 30 to 60 days following surgery to help promote endome-
higher in patients with severe adhesions (20% to 60%). trial growth, followed by progestin withdrawal. However,
The most commonly described methods for reducing the surgeons should note that oral estrogen in this dose may
risk of recurrent adhesions are the postoperative place- increase the risk of thrombi, and consideration should be
ment of an intrauterine device (IUD) or a pediatric Foley given to treating patients with 81 mg (baby) aspirin daily.
balloon. Currently, the most widely used technique is Furthermore, in patients who are yoWlger, not hypoes-
the placement of a 10-French Foley balloon, inflated to trogenernic, and regularly ovulating, the addition of oral
3 to 3.5 ml saline to keep opposing surfaces separated estrogen may not add little to their estrogen.
for at least 1 week following surgery. However, overin- All stated, none of the above postoperative rec-
flating the balloon may compromise the regenerative ommendations have been studied in a well-designed
process by excessively increasing intrauterine pressure fashion. Given the relatively low risk profile of these
and reducing blood flow to the endometrium. If using a recommendations, and the potential for improved out-
standard pediatric Foley, the tip of the catheter should comes, they are still often implemented.
258 SEtnON Ill REPRODUCTIVE SURGERY

Patients should be coWiseled toward vaginal delivery


if they conceive, although there may be a slight increased
risk for uterine ruptwe if excessive electrosurgical injury
or if a large perforation has occurred during the proce-
dure. Abnormal placentation has also been described
in such settings, but this is likely due to the preexisting
endometrial defect resulting from the primary process.

Operative Note
PROCEDURE: HYSTEROSCOPIC
Shaggy endometrium In
lower uterine segment
ADHESIOLYSIS OF INTRAUTERINE
SYNECHIAE
The patient was taken to the operating room after
proper informed consent had been obtained. She was
placed in the dorsal supine position, legs in Allen-type
stirrups. A time-out was then completed. Attention
FIGURE 29.2 Hysteroscopic view of uterine cavity after was turned to the pelvis, where a Foley catheter was
lysis of moderate inttauterine adhesions. placed in the urinary bladder and a sterile bivalve
speculum was placed in her vagina. The cervix was

FIGURE 29.3 nansverse view depiding the use of a Pratt dilator to ueate lateral passages to
facilitate lysis of intrauterine adhesions in uteri with severe intrauterine adhesions. However, there
is also a significant risk of creating a false passage with dilation.
CHAPTER 29 Hysteroscopic Adhesiolysis of Intrauterine Synechiae 259

grasped with a single-tooth tenaculum and the cer- the internal os demonstrated a mostly nonnal volume
vix was dilated up to a 16-French Pratt dilator. Using to the endometrial cavity, although only little normal
normal saline as a fluid distention media, a 5-mm appearing endometrium was documented.
operative hysteroscope was advanced through the cer- A I 0-French pediatric Foley was then advanced into
vix into the endometrial cavity with a 30° lens. Intra- the cavity after trimming the tip of the catheter, and
uterine pressures were maintained at 60 mmHg with the balloon filled with 3.5 ml of sterile saline. The tail
a fluid management system. of the catheter was tucked into the vagina.
The endometrial cavity was mostly obliterated with The patient was extubated and taken to recovery in
filmy and fibromuscular adhesions except for the right, stable condition.
where a channel up to the right tubal ostia was followed
and nonnal-appearing late proliferative endometrium
was documented. The hysteroscope was then removed
Suggested Reading
and a 14-French Pratt dilator was advanced through the I. American Fertility Society: The American Fertility Soci-
endocervix into the patient's endometrial cavity, direct- ety classification of adnexal adhesions, distal rubal occlu-
ing to her left. It was then withdrawn and the hystero- sion, tubal occlusion secondary to tubal ligation, tubal
scope readvanced. A channel along the patient's left pregnancies, Mullerian anomalies, and intrauterine
adhesions. Fertil Sterill988;49:944-955.
was then seen, hut the tubal ostia not visualized as the
2. Baggish, MS. Operative hysteroscopy. In: Rock JA, Jones
endometrium was not normal in appearance, hut rather
HW; eds. TeLinde Operative Gynecology, Tenth Edition.
shaggy in texture. Philadelphia, PA: Lippincott Williams and Wilkins;
A 5.5-French semi-rigid hysteroscopic scissors was 2011:687-726.
then advanced through the operating channel and the 3. Bennan JM. Intrauterine adhesions. Semin Reprod Med
remaining synechiae in the midline was incised mid- 2008;26:349-355.
plane up to the perceived fundus, somewhat less than 4. Capella-Allouc S, Morsad F, Rongieres-Bertrand C, etal.
flush with the right tubal ostia. The cavity was then Hysteroscopic treatment of severeAshennan's syndrome
viewed under lower intrauterine pressures and only and subsequent fertility. Hum Reprod 1999;1230-1233.
scant oozing was noted from the fundus. The view from 5. Deans R, Abbott J. Review of intrauterine adhesions.
J Minim Invasive Gynecol2010;17:555-569.
6. Fernandez H, Al-Najjar F, Chauveaud-Lambling A, Fry-
dman R, Gervaise A. Fertility after treatment of Asher-
man's syndrome stage 3 and 4. J Minim Invasive Gynecol
COMPLICATIONS 2006; 13:398-402.
7. Friedler S, Margaliaoth EJ, Kafka I, Yaffe H. Inci-
• Intrauterine adhesion reformation-Frequent dence of postabortion intrauterine adhesions evaluated
(2% to 60%, depending on severity oforiginal by hysteroscopy-a prospective study. Hum Reprod.
adhesions) 1993;8:442444.
• Uterine perforation-Infrequent (less than 5%, 8. Robinson JK, Colimon LM, Isaacson KB. Postoperative
although up to 10% in patients with severe adhesiolysis thempy for intrauterine adhesions (Asher-
adhesions) man's syndrome). Fertil Steril2008;90:409414.
9. Roy KK, Baruah J, Sharma JB, Kumar S, Kachawa G,
• Hemorrhage and major vessel perforation--
Singh N. Reproductive outcome follovv:inghysteroscopic
Infrequent (less than 5%, may he higher in
adhesiolysis in patients vv:ith infertility due to Ashennan's
patients with severe adhesions)
syndrome. Arch Gynecol Obstet 2010;281:355-361
• Fluid or electrolyte imbalance (see Table 1, 10. Thomson AJ, Abbott JA. Deans R, Kingston A, Vancail-
Chapter 27)-Infrequent (less than 5%) lie TG. The management of intrauterine synechiae. Curr
• Postoperative infection (endometritis, myome- Opin Obstet Gynecol2009;21:335-341
tritis, adnexitis )-Rare (less than 1%) 11. YU D, Wong YM, Cheong Y; Xia E, li TC. Ashennan
syndrome-one centwy later. Fertil Steril2008;89:759-779.
CHAPTER

Laparoscopic Resection of
Ovarian Endometrioma
M. Jonathon Solnik, Ricardo Azziz

INTRODUCTION is the procedure of choice. Hence simple drainage of


endometriomas should be avoided because the recur-
Surgical management of endometriosis ultimately rence rate is high.
depends on the desired therapeutic goals. It becomes
important to establish whether relief of pain, treat-
ment of subfertility, or both are patient priorities. PREOPERATIVE CONSIDERATIONS
Preservation of fertility would lead one to avoid overly
aggressive excisional treatment, which may result in As with any woman who has a docwnented pelvic
decreased ovarian reserve or increased postoperative mass, differential scenarios should he considered. The
adhesion formation. Ukewise, patients with pain due likelihood of uncovering a reproductive cancer in a
to fibrotic endometriosis may require more aggressive young woman is relatively low, and hallmark ultrasono-
treatment with resection of all palpable and visible graphic characteristics of an endometrioma are fairly
disease regardless of fertility. consistent. Nevertheless, if there is any suspicion of a
Resection of ovarian endometriomas represents malignancy; the possibility that an oophorectomy may
another aspect of surgical care, and often presents itself be required needs to be discussed during preoperative
in the setting of subfertility. Historically, most women counseling. In fact, during any procedure that involves
noted to have lesions suspicious for endometrioma on adnexal structures, especially when fertility is a primary
transvaginal ultrasound were offered ovarian cystectomy objective, we find it equally important to review this
as a part of the treatment paradigm for suhfertility. Most possibility, as well as the possibility of decreased ovar-
recent findings suggest that aggressive surgical manage- ian reserve even if the ovary is salvaged.
ment, particularly for smaller cysts (<5 em), may be
deferred in patients Wldergoing in vitro fertilization.
Studies which have addressed postoperative ovar- SURGICAL TECHNIQUE
ian reserve, whether resulting from the endometrioma
itself or from the resulting ovarian injw:y following sur- 1. Port and instrument placement: Initial port
gery, and response to gonadotropin stimulation, do not placement depends on the location and size of the
necessarily favor surgery. That said, for larger lesions, endometrioma. For example, if there is a larger
in symptomatic patients, or if a malignancy cannot be (> 10 em) lesion on the right, one could consider
excluded, surgical intervention remains the standard a left upper quadrant entry point in order to avoid
of care. It has been well established that complete inadvertent penetration of the lesion. We typically
enucleation and cystectomy rather than ablation of use a modified Hasson technique to gain perito,
cyst wall, results in significantly fewer recurrences and neal access through the umbilicus. This allows

261
262 SEtnON Ill REPRODUCTIVE SURGERY

for a larger fascial defect not provided by current


fiber-spreading bladeless trocars to allow for easier
retrieval of larger specimen.
2. Mobilization of endometrioma: The resection of
an endometrioma may be complicated by longstand-
ing inflammation and resultant fibrosis, predisposing
to ovarian injury and bleeding. which may require use
of energy modalities to establish hemostasis, resulting
in further damage to ovarian epitheliwn. Likely due
to the pathogenesis of endometrioma, these cysts are
often densely adherent to their ipsilateral sidewalls,
FIGURE 30.2 A left-sided endometrioma is adherent to
where the peritoneal lesion infiltrated the developing
its ipsilateral sidewall: A suction irrigator is used to elevate
follicle on the medial aspect of the ovary.
the ovary anteriorly while a blunt-tip scissors is used to dissect
Reestablishing the normal anatomic orientation the ovary from sidewall attachments.
and landmarks should be the initial step in the dis-
section of endometriomas, particularly if sigmoid
colon or other adhesions are present. The first step planes of dissection. Incidental cyst rupture often
is often to elevate the ovary and cyst anteriorly occurs during these efforts to expose the ovary in full.
while hugging the peritoneum of the ovarian fossa
3. Removal of the endometrioma: Once the
with a blunt grasper, suction irrigator, or blunt-tip
ovaries have been carefully inspected and visual-
scissor tips {Figures 30.1 and 30.2).
ized, small surface endometriomas (< 1 em) can be
If remaining in the proper surgical planes, the sur- 1
'decapitated" at the ovarian endometrioma junction
geon will avoid entry to retroperitoneal spaces and
and the base coagulated or vaporized. The result-
injury to the ureter or larger vessels. Use of blunt-
ing defect does not need to be reapproximated.
tip scissors to divide more dense adhesions may be
Alternatively, larger endometriomas are resected in a
required. Small bleeding and oozing may be encoun-
manner similar to that used at laparotomy. However,
tered,. hut often stops without additional effort.
when they become particularly large {> 10 em),
Extra-ovarian adhesions are often due to endometri-
managing them at laparoscopy may prove difficult
osis-associated inflammation. Copious irrigation, ide-
and should only be approached by those who have
ally with warmed isotonic irrigant, helps visualize the
specific surgical expertise.
Once adequately mobilized, the cyst, if it has
not already spontaneously drained, may be opened,
drained, and lavaged. The lining is inspected. With
larger or more chronic cysts, the cyst wall and ovar-
ian cortex are often fused extensively by fibrosis and
significant resection of the fused pseudocapsule
may be required in order to clearly expose the plane
between the normal ovarian cortex and the cyst
wall. In order to identify the proper plane of dissec-
tion, the edge of the cyst wall opening is circwn-
ferentially {Figure 30.3A) cut back to fully and
clearly expose "the cyst wall-ovarian cortex inter-
phase." This is preferably done with cold scissors
since electrosurgery, ultrasonic energy, or lasers may
tend to fuse the cortex and ovarian cyst wall. If the
dissection plane is not developed well, attempted
FIGURE 30.1 Laparoscopic view of a frozen pelvis result- cyst enucleation may result in unwanted bleeding
ing from advanced endometriosis with associated endo- during the enucleation of the cyst.
metrioma seen posterior to the uterus originating from Once identified, the plane between endome,
the right ovary: Loops of small intestine as well as colon are trioma wall and normal ovarian cortex is developed
intimately adherent to the right ovarian endometrioma. further by grasping the edge of the ovarian cortex
CHAPTER 30 Laparoscopic Resection of OVarian Endometrioma 263

Rupture site

FIGURE 30.3 Excising endometrioma: Once opened, the cyst lining is inspected, and the edge of the cyst
wall cut back circumferentially around the opening to fully and cle