Gynecologic and Obstetric Surgery

Obstetric and gynecologic surgery is a craft that requires sound knowledge and skills.  The knowledge and skills will need to be applied to the specifics of each surgical patient to enable the best surgical management and minimize complications. This resource book offers insightful management options to many of the challenges a gynecologic or obstetric surgeon may face before, during or after an operation. Designed to guide the surgeon to safe practice throughout all stages of surgical management, it offers case studies, management options with tips and tricks, and ideas for prevention of complications. Key points and summaries are provided at the end of each chapter for elevator reading , i.e., quick brushing up of facts on the way to facing a
challenge.

Divided into two sections the book first covers general pre, intra and post–operative challenges and, second, specific operative procedures within the specialist areas in obstetrics and gynecology.

Contents

PART I: GENERAL PRE, INTRA, and POST OPERATIVE CHALLENGES

SECTION 1: PRE–OPERATIVE CARE

1 Patient with poor ASA score

2 Patient on medication

3 Patient with ischaemic heart disease

4 Patient with Arrhythmias

5 Patient with a pace–maker or implantable defibrillator

6 Patient with complex congenital heart disease (a Fontan Circulation)

7 Hypertensive patient

8 Patient with respiratory disease

9 Patient with diabetes

10 Patient with thyroid disease

11 Patient with renal disease

12 Patient with liver disease

13 Patient with rheumatologic diseases

14 Patient with hematologic disorders

15 Patient at high risk of venous thrombosis

16 Patient on anti–coagulant therapy

17 Patient on steroid therapy

18 Patient with epilepsy

19 Patient with a psychiatric condition

20 Patient with organ transplant

21 Patient with Hep B or Hep C

22 Patient with HIV

23 Obese patient

24 Patient with poor nutritional status

25 Pregnant patient requiring non–obstetric surgery

SECTION 2: INTRA–OPERATIVE CARE

26 Transverse incision on the abdomen inadequate for surgery

27 Patient with multiple abdominal scars

28 Patient with previous mesh incisional hernia repair requiring a laparotomy

29 Patient with previous mesh incisional hernia repair requiring a laparoscopy

30 Unexpected pathology: ovarian cyst

31 Unexpected pathology: abnormal appearance of the uterus

32 Unexpected pathology: severe pelvic adhesions

33 Unexpected pathology: abnormal appearance of bowel

34 Unexpected pathology: retro–peritoneal mass

35 Bladder injury

36 Ureteric injury

37 Small and large bowel injury

38 Inferior epigastric vessel injury

38 Inferior epigastric vessel injury

39 Bleeding from retracted pedicular (pelvic sidewall) vessels

40 Massive haemorrhage

41 Broken needle

42 Lost swab, needle or instrument

SECTION 3: POST–OPERATIVE CARE

43 Post–operative care

44 Excessive nausea and vomiting after surgery

45 Excessive abdominal pain after surgery

45 Excessive abdominal pain after surgery

46 Bowel damage: postoperative presentation

47 Wound infection

48 Wound dehiscence

49 Late wound failure: incisional hernia

50 Necrotising fasciitis

51 Surgical drains

52 Shocked patient

53 Breathless patient: post–operative pulmonary complications

53 Breathless patient: post–opertaive pulmonary complications

54 Confused post–operative patient

55 Patient with poor urine output

56 Electrolyte imbalance

57 The swollen leg

58 Cardiorespiratory arrest

PART II: OPERATIONS and CHALLENGES

SECTION 4: GENERAL and MINIMAL ACCESS GYNECOLOGY

59 Difficulty in dilating a cervix:  Cervical stenosis and cervical closure

60 Uterine perforation

61 Surgical uterine evacuation: excessive bleeding

62 Surgical uterine evacuation in a woman with multiple fibroids

63 Use of excessive distension media at hysteroscopy

64 Hysteroscopy: endometrial resection and ablation in the abnormal uterine cavity

65 Laparoscopy in a pediatric patient

66 Safe laparoscopic entry in a thin patient

67 Laparoscopy: unable to gain entry

68 Surgical emphysema

69 Venous Air Embolism

70 Laparoscopy: problems with monopolar diathermy

71 Laparoscopy: problems with bipolar diathermy

72 Laparoscopy: bladder injury

73 Laparoscopy: ureteric injury

74 Bowel injury during laparoscopy: intraoperative presentation

75 Bowel injury after laparoscopy: late presentation

76 Blood vessel injury at laparoscopy

77 Laparoscopy for large ovarian cyst

78 Laparoscopy for an ovarian cyst in pregnancy

79 Laparoscopic removal of recto–vaginal endometriosis

80 Laparoscopic myomectomy

81 Total laparoscopic hysterectomy

82 Laparoscopic hysterectomy for a large fibroid uterus

83 Laparoscopy: difficulty in tissue retrieval

84 Surgery for cornual or interstitial pregnancy

85 Surgery for cervical ectopic pregnancy

86 Surgery for caesarean scar pregnancy

87 Surgery for adnexal torsion

88 Laparoscopic appendicectomy

89 Laparoscopic surgery: When to convert to laparotomy?

90 Laparoscopy: late complication Port site herniation

SECTION 5: REPRODUCTIVE SURGERY

91 Uterine septum division

92 Surgery for intrauterine adhesions

93 Myomectomy: breach of the endometrial cavity

94 Myomectomy: multiple large fibroids

95 Myomectomy: massive intraoperative haemorrhage

96 Vaginal myomectomy

97 Surgery for proximal tubal blockage

98 Surgery for distal tubal blockage

99 Reversal of female sterilisation

100 Surgery for congenital abnormalities of the genital tract

101 Surgical sperm retrieval

SECTION 6: UROGYNECOLOGIC SURGERY

102 Sling procedures: bladder injury

103 Sling procedures: urethral injury

104 Sling procedures: retropubic haematoma

105 Sling procedures: bowel injury

106 Sling procedures: voiding dysfunction after stress urinary incontinence surgery

107 Sling procedures: tape erosion into bladder

108 Sling procedures: sexual dysfunction

109 Sling procedures: persistent urine leakage

110 Difficult vaginal hysterectomy

111 Vaginal hysterectomy: difficulty in entering the posterior pouch

112 Salpingo–oopherectomy at the time of vaginal hysterectomy

113 Bladder injury during anterior vaginal repair or vaginal hysterectomy

113 Bladder injury at anterior repair

113 Bladder injury at anterior repair

113 Bladder injury at anterior repair

113 Bladder injury at anterior repair

113 Bladder injury at anterior repair

114 Difficult sacrocolpopexy

115 Difficult sacrospinous fixation

116 Recurrent pelvic organ prolapse

117 Colpocleisis

118 Uterine suspension procedures: Laparoscopic hysteropexy

119 Mesh  tape exposure following tension free vaginal tape (TVT)

120 Vaginal vault evisceration

121 Complications in laparoscopic pelvic floor surgery

122 Robotic urogynecology procedures

123 Complications in robotic pelvic floor surgery

124 Neovagina

125 Vaginal stricture after pelvic organ prolapse surgery

126 Urethral diverticula and other periurethral masses

127 Vesico–vaginal fistulae

128 Urethro–vaginal fistulae

129 Recto–vaginal fistulae

130 Secondary anal sphincter repair

SECTION 7: GYNECOLOGIC ONCOLOGY

131 Large loop excision of the transformation zone (LLETZ)

132 Knife cone biopsy

133 Staging procedures: examination under anaesthesia, cystoscopy, sigmoidoscopy and biopsy techniques

134 Radicality of surgery for cervical cancer

135 Pelvic and para–aortic lymphadenectomy in gynecologic cancers

136 Trachelectomy for treatment of cervical cancer

137 Laparoscopic radical surgery for cervical cancer

138 Groin and retroperitoneal lymphocele

139 Laparotomy for a pelvic mass of uncertain nature

140 Gynecologic cancer extending to the bowel

141 Omental procedures: supracolic omentectomy, infracolic omentectomy, omental biopsy

142 Diaphragmatic surgery in advanced ovarian cancer

143 Fine needle aspiration; biopsy of superficial groin lymph node

144 Vulval surgery: wide local excision and vulvectomy

145 Sentinel node biopsy in gynecologic cancer

146 Groin lymphadenectomy

147 Plastic surgical techniques used in vulval or perineal procedures

148 Vaginectomy

149 Urinary diversion

150 Pelvic exenteration

151 Gynecologic cancer and concurrent pregnancy

SECTION 8: OBSTETRIC SURGERY

152 Ovarian cyst identified at caesarean section

153 Laparoscopy in pregnancy

154 Cervical cerclage

155 Caesarean section in a woman with fibroids

156 Caesarean section at the limits of viability

157 Difficult delivery of the fetal head during caesarean section

158 Surgical management of massive obstetric haemorrhage from the uterus, cervix or vagina

159 Surgical management of placenta praevia

160 Surgical management of placenta accreta

161 Surgical management options for shoulder dystocia: Zavanelli maneuver, abdominal rescue, symphsiotomy and cleidotomy

162 Uterine inversion

163 Episiotomy and second degree tear

164 Obstetric anal sphincter tear

165 Pregnancy and female genital mutilation

166 Destructive operations on a dead fetus

166 Destructive operations on the fetus

167 Setting up of a basic obstetric theatre facility in a low–resource setting

SECTION 9: MISCELLANEOUS

168 Enhanced recovery

169 Major surgery in a Jehovah s Witness patient

170 Termination  of pregnancy at advanced gestation

171 Cervical fibroids: techniques for myomectomy and hysterectomy

172 Hysterectomy for broad ligament fibroids

173 Hysterectomy for a double uterus

174 Cervical stump excision

175 Surgery for ovarian remnant

176 Surgery for a missing intrauterine contraceptive device

177 Management of imperforate hymen, transverse and other vaginal septa

178 Benign lesions in the groin and vulva

179 Cystic structure in the upper vagina

180 Adnexal masses in infants and children

181 Nerve injuries associated with gynecologic and obstetric surgery

182 Consent challenges

183 Dealing with complaints

184 Dealing with litigation

Arri Coomarasamy is a Professor of Gynaecology at the School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, and a Consultant in Gynaecology, Reproductive Medicine and Surgery, Birmingham Women's Hospital Foundation Trust, Birmingham.

Mahmood I. Shafi is Consultant Gynaecological Surgeon and Oncologist, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.