Atlas of Gynecologic Surgery E-Book

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Veröffentlichungsjahr: 2013

Beschreibung

A groundwork and milestone for an innovative, trendsetting, and international school of thought in gynecology.

A superb work of art as well as an outstanding clinical reference, this book continues the rich tradition of earlier editions by providing unparalleled coverage of the entire field of gynecologic surgery. This new fourth edition offers completely updated content, user-friendly features, and the cornerstone of the book: an art program of astounding quality. It is indispensable for gynecologic surgeons or residents who need to review, refresh, or fine-tune their skills in preparation for surgery, while being alerted to pitfalls and possible complications at every juncture.

Special features of the new 4th edition of this world-famous atlas:

• Nearly 1,200 stunning watercolor drawings that provide a visual depiction of operative steps unequalled in the literature
• Detailed, point-by-point descriptions of routine as well as more complex procedures
• Full coverage of abdominal, vaginal, and endoscopic approaches in sections on the adnexa, uterus, vulva/vagina, and pelvic floor
• Introduction of the new "Procedure Navigator" section, which facilitates a convenient search from disease to indication to medical or surgical treatment of choice
• A truly international perspective, with leading specialists from Europe and the United States sharing heir clinical experience and wisdom

Complete with expert foundational chapters on pre- and postoperative treatment, informed consent, instrumentation, indications and contraindications, risks and complications, and more, this book is both beautiful and informative. Its step-by-step didactic concept is ideal for residents-in-training, while its detailed description of both common and rare procedures makes it useful for experienced surgeons. For all specialists, Atlas of Gynecologic Surgery is a standard, must-have reference on curren

Leseprobe

Atlas of Gynecologic Surgery

Diethelm WallwienerSven Becker

Matthias W. BeckmannSara Y. BruckerKlaus FrieseKeith B. IsaacsonWalter JonatArnaud Wattiez

With contributions by

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

With the collaboration of

Ernst H. SchmidtRudy L. De Wilde

4th edition

1138 illustrations    23 tables

ThiemeStuttgart • New York

Library of Congress Cataloging-in-Publication Data is available from the publisher.

This book is an authorized translation of the 7th German edition published and copyrighted 2009 by Georg Thieme Verlag, Stuttgart. Title of the German edition: Atlas der gynäkologischen Operationen.

Translators:Gertrud Champe, Surry, Maine, USAGeraldine O'Sullivan, Dublin, Ireland

Illustrators:Reinhold Henkel, Heidelberg, GermanyKarl-Heinz Seeber, Tübingen, GermanyAndrea Schnitzler, Innsbruck, AustriaMarianne Lück, Hamburg, Germany

© 2014 Georg Thieme Verlag KG,Rüdigerstrasse 14, 70469 Stuttgart, Germanyhttp://www.thieme.deThieme Medical Publishers, Inc., 333 Seventh Avenue,New York, NY 10 001, USAhttp://www.thieme.com

Cover design: Thieme Publishing GroupTypesetting by Ziegler + Müller, Kirchentellinsfurt, GermanyPrinted in China by Everbest Printing Ltd, Hong Kong

ISBN 978-3-13-650704-9 EISBN 978-3-13-169684-7

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

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PREFACE

The Atlas of Gynecologic Surgery has a long and respected history, going back to its first German edition in 1960. Since that time, gynecology as a science and the repertory of gynecologic operations have changed and developed in many significant ways. The task of consolidating this constantly growing knowledge and transforming it, with the application of a multiplying number of techniques, into the best possible operative treatment for patients is becoming more and more challenging for physicians.

The principal goal of the present work was and is a structured presentation of both the scientist's and the craftsman's view of the various abdominal, vaginal, endoscopic and senologic operations in our field, a presentation that is lucid and placed in the right context.

This challenge, as well as the many changes and paradigm shifts occurring in the years since the last reworking of the English edition in 1997, called for a far-reaching revision of design and content. Thus, all aspects of this current edition have been changed and renewed.

The introductory chapters are followed by a topographical organization into sections treating the adnexa, uterus, vulva/vagina, and pelvic floor. There, where useful, a distinction is made between abdominal (open), vaginal, and endoscopic approaches. The chapters on surgical techniques begin with the simpler operations and move on to the more difficult techniques. At the same time, the Operation Navigator, newly developed especially for this book, facilitates a convenient search from the disease to the indication to the operation of choice (see the graphic on p. VI).

The Atlas of Gynecologic Surgery is known all over the world as a work rich in tradition that lays out the entire field of operative gynecology in detail and at the highest level. The collection of still-applicable illustrations from earlier editions and more than 500 new drawings contribute to the new composition of a work of excellent esthetic and didactic quality. The conceptual reworking and the new textual and graphic configuration of the work matured for almost a decade. Even until shortly before the book went to press, drawings were still being updated and relevant innovations were worked into the appropriate chapters.

For the English edition, two international editors have been invited. Their collaboration allows for a truly international perspective of current and classical gynecology. The result is a modern surgical authority with more than 1100 illustrations that gives a comprehensive and current picture of operative gynecology and obstetrics. We are convinced that this presentation will provide the reader with great pleasure and visual enjoyment.

The enormous challenge of bringing out this international work in rejuvenated form while retaining the tried and trusted core was met thanks to the intense joint involvement of the publisher, authors, and graphic artists.

In the production of this atlas we have been helped by many and many need to be thanked.

We would first like to thank Thieme Publishers for their courage to take on the re-edition of such an outstanding work both of science and of art. The tremendous success of the Atlas’ new edition in the German-speaking countries has already rewarded this initiative and the confidence put into traditional drawings in the context of surgical teaching.

We would also like to thank our medical artist, Reinhold Henkel, for over 10 years of close and highly creative collaboration. Reinhold Henkel passed away this year, and the world of medical art has lost an exceptional artist.

Countless hours of exciting work went into this Atlas. Combined with our obligations as directors of large university departments, we devote a tremendous amount of our time into what we love as gynecologic surgeons: creating a modern and lasting school of benign and gynecologic surgery.

It is more than appropriate at this point to appreciate the support of both of our families over the years. With a special thanks to Gabriele, Markus, and Christian, as well as Graziella, Nicholas, and Charlotte, we dedicate this book to our families and to our patients.

Diethelm Wallwiener, Tübingen

Sven Becker, Frankfurt

GRAPHIC ARTWORK

Why watercolor drawings in the era of multimedia images? The detailed and unique illustrations, particularly those of the two illustrators Andrea Schnitzler and Karl-Heinz Seeber, were always the special treasure of the traditional “Atlas of Gynecologic Surgery”. The history of medicine overall and that of surgery in particular is inconceivable without attractive and anatomically exact reproductions of the available knowledge. These range from the anatomical drawings of the Renaissance and the scientific diagrams of the 19th century to the great surgical atlases of the Viennese school and the American tradition (Brödel, Netter) and up to the present day. Many of the “classical” views have become the general property of the medical world so that hardly anyone now knows who first drew them and created a didactic work of art.

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

In the digital world, photography has often replaced graphic art, not least because it is easier and requires less effort to take a representative photo than to develop an illustration. Even today, however, a carefully and artistically planned drawing will be superior to a photo in most cases. Only a well-considered graphic illustration is capable of combining perfectly the exact anatomy, generalized pathology, a three-dimensional view, and didactic information. In a world permeated by digital information technology, the traditional picture produced by hand exerts an immediate effect through its inimitable “authenticity” and esthetic expression.

This, together with the unique quality of the drawings in the atlas, suggested continuing the work as a means of teaching operative surgery based on watercolor drawings.

For nearly a decade, drawings had been selected from the wealth of existing illustrations, and new watercolors were produced in minute and time-consuming detail. Like the authors and draftsmen of previous editions, the authors of this edition worked closely with and were involved in detailed discussions with Reinhold Henkel to obtain illustrations of optimal quality.

The editors

LIST OF CONTRIBUTORS

Harald Abele, MDDepartment of Obstetrics and GynecologyUniversity Clinic TübingenTübingen, Germany

Cornelia Bachmann, MDDepartment of Obstetrics and GynecologyUniversity Clinic TübingenTübingen, Germany

Sven Becker, MDProfessor and DirectorDepartment of Gynecology and ObstetricsUniversity Hospital FrankfurtFrankfurt, Germany

Matthias W. Beckmann, MDProfessor and DirectorDepartment of Obstetrics and GynecologyUniversity Clinic ErlangenErlangen, Germany

Sara Y. Brucker, MDDepartment of Obstetrics and GynecologyUniversity Clinic TübingenTübingen, Germany

Rudy Leon De Wilde, MDProfessorGynecological ClinicPius-HospitalOldenburg, Germany

Klaus Friese, MDProfessor and DirectorDepartment of Obstetrics and GynecologyUniversity ClinicMunich, Germany

Konstantinos Gardanis, MDHead of Outpatient Surgery CenterDepartment of Obstetrics and GynecologyUniversity Clinic TübingenTübingen, Germany

Eva-Maria Grischke, MDProfessorDepartment of Obstetrics and GynecologyUniversity Clinic TübingenTübingen, Germany

René Hornung, MDProfessor and Head PhysicianDepartment of Obstetrics and GynecologyKantonsspital St. GallenSt. Gallen, Switzerland

Keith B. Isaacson, MDMedical DirectorMinimally Invasive Gynecological Surgery UnitNewton-Wellesley HospitalNewton, MA, USA

Walter Jonat, MDProfessor and DirectorDepartment of Obstetrics and GynecologyUniversity ClinicKiel, Germany

Bernhard Krämer, MDDepartment of Obstetrics and GynecologyUniversity Clinic TübingenTübingen, Germany

Martin Oehler, MDProfessorDepartment of Gynaecological OncologyRoyal Adelaide HospitalAdelaide, SA, Australia

Christl Reisenauer, MDProfessorDepartment of Obstetrics and GynecologyUniversity Clinic TübingenTübingen, Germany

Ralf Rothmund, MDAssociate DirectorDepartment of Obstetrics and GynecologyUniversity Clinic TübingenTübingen, Germany

Ernst Heinrich Schmidt, MDProfessorGynecological HospitalBremen, Germany

Erich F. Solomayer, MDProfessor and DirectorDepartment of Gynecology, Obstetrics and Reproductive MedicineUniversity Clinic Homburg/SaarHomburg/Saar, Germany

Christian Wallwiener, MDDepartment of Obstetrics and GynecologyUniversity Clinic TübingenTübingen, Germany

Diethelm Wallwiener, MDProfessor and DirectorDepartment of Obstetrics and GynecologyUniversity Clinic TübingenTübingen, Germany

Markus Wallwiener, MDDepartment of Obstetrics and GynecologyUniversity Clinic HeidelbergHeidelberg, Germany

Arnaud WattiezProfessor and Gynecological DirectorIRCAD/EITS Institut de Recherche contre les cancers de l'Appareil DigestifStrasbourg, France

Wolfgang Zubke, MDDepartment of Obstetrics and GynecologyUniversity Clinic TübingenTübingen, Germany

CONTENTS

I. General Part

1.1 Pre- and Postoperative Treatment

1.1.1      Preoperative Treatment

Ambulant/In-patient Treatment

Informed Consent

Anesthesia

Laboratory and Imaging Tests

Preparation for Surgery

1.1.2      Postoperative Treatment

Ambulant Treatment

In-patient Treatment

1.2 Instruments

1.2.1      Abdominal Surgery

Scissors

Clamps

Needle Holders

Forceps

Grasping Instruments

Cutting Instruments

Retractors

1.2.2      Vaginal Surgery

Hegar Dilators

Forceps and Clamps

Curettes

Specula

1.2.3      Endoscopic Surgery

1.3 Sutures and Drains

1.3.1      Sutures

Suture Material

Knot-Tying Techniques

1.3.2      Drains

Closed Drain Systems without Suction

Closed Drain Systems with Suction

Open Drains without Suction

1.4 Positioning

1.4.1      Abdominal Procedures

1.4.2      Vaginal Procedures

1.4.3      Laparoscopic Procedures

II. Complications and Their Management

2.1 Bleeding Complications

2.1.1      Intraoperative Bleeding—Abdominal Procedures

2.1.2      Intraoperative Bleeding—Vaginal Procedures

2.1.3      Intraoperative Bleeding—Laparoscopic Procedures

2.1.4      Postoperative Bleeding

2.2 Inflammatory Complications

2.2.1      Wound Infection

2.2.2      Peritonitis/Sepsis

2.3 Injury to the Urinary Organs

2.3.1      Bladder Injuries

2.3.2      Ureteral Injuries

2.4 Gastrointestinal Tract Injury

2.4.1      Small-Bowel Injury

2.4.2      Large-Bowel Injury

2.5 Wound Dehiscence and Hernia

2.5.1      Wound Dehiscence

2.5.2      Hernias

III. Abdominal Wall

3.1 Laparotomy

3.1.1      Anatomical Basis

3.1.2      Opening the Abdomen

Median Vertical Laparotomy

Pfannenstiel Transverse Fascial Incision

Cohen Modification of the Transverse Fascial Incision (Misgav Ladach Method)

Cherney Suprapubic Transverse Fascial Incision—Transection of the Rectus Attachment

Suprapubic Maylard Incision

Separate Opening of Abdominal Layers with Longitudinal Fascial Incision

Infraumbilical Minilaparotomy

Technique in Cases of Morbid Obesity

3.1.3      Closure Techniques

Peritoneal Suture

Fascial Suture

Correction of Defects in the Abdominal Wall

Relief Sutures in Dehiscence of Abdominal Sutures

Skin/Subcutaneous Tissue

3.2 Laparoscopy

3.2.1      Anatomic Basis

3.2.2      Approach to the Abdominal Cavity

3.2.3      Insertion in Special Operations

3.2.4      Open Laparoscopy

3.2.5      Closure of Trocar Insertion Points

3.2.6      Laparoscopic Retrieval Techniques

IV. Adnexa

4.1 Preliminary Remarks about the Region

4.1.1      Topography of the Retroperitoneum

4.1.1.1   General Anatomy

4.1.1.2   Retroperitoneum_Nerves

4.1.1.3   Retroperitoneal Space_Vessels

4.1.1.4   Retroperitoneal Space_Course of the Ureter

4.1.1.5   Retroperitoneal Space_Lymph Nodes

4.1.2      Functional Pathology

4.1.2.1   Ovaries

4.1.2.2   Fallopian Tubes

4.1.3      Morphologic Pathology—Histology

4.1.4      Terminology and Diagnosis

4.1.4.1   Stages and Classification of Endometriosis

4.1.4.2   Stages of Fallopian Tube Carcinoma

4.1.4.3   Stages of Ovarian Cancer

4.2 Concepts for Surgical Treatment—Procedure Navigator

4.3 Surgical Techniques

Abdominal

4.3.1.1   Ovarian Wedge Resection, Ovarian Cystectomy, Removal of an Intraligamentous Cyst, Simple Oophorectomy

4.3.1.2   Open Salpingo-Oophorectomy

4.3.1.3   Open Salpingotomy/Salpingectomy in Ectopic Pregnancy

4.3.1.4   Open Sterilization Operations

4.3.1.5   Open Infertility Surgery

4.3.1.6   Abdominal Surgery of Endometriosis

4.3.1.7   Surgery of Malignant Adnexal Tumors/Debulking Operations

Vaginal

4.3.2.1   Vaginal Salpingo-Oophorectomy

Endoscopic

4.3.3.1   Laparoscopy—Diagnostic and Minor Operative Procedures

4.3.3.2   Laparoscopic Adhesiolysis

4.3.3.3   Laparoscopy of Pelvic Inflammatory Disease

4.3.3.4   Laparoscopic Fertility Surgery

4.3.3.5   Laparoscopic Sterilization

4.3.3.6   Laparoscopic Ovarian Cystectomy, Hydatid Removal

4.3.3.7   Laparoscopic Ovariopexy

4.3.3.8   Laparoscopic Operation for Ovarian Torsion

4.3.3.9   Laparoscopic Salpingo-Oophorectomy

4.3.3.10 Laparoscopic Removal of Cystic and Solid Adnexal Tumors

4.3.3.11 Laparoscopic Removal of an Ectopic Pregnancy

4.3.3.12 Laparoscopic Treatment of Endometriosis

V. Uterus

5.1 Preliminary Remarks about the Region

5.1.1      Topography of Pelvic Spaces

5.1.1.1   Classification of the Spaces

5.1.1.2   Paravesical Space

5.1.1.3   Pararectal Space

5.1.1.4   Obturator Fossa

5.1.1.5   Rectovaginal Septum

5.1.1.6   Presacral Space

5.1.1.7   Psoas Space

5.1.1.8   Pelvic Retroperitoneum—Nervous Structures

5.1.2      Functional Pathology—Developmental Disorders

5.1.3      Morphologic Pathology—Histology

5.1.4      Terminology and Diagnosis

5.1.4.1   Stages of Cervical and Endometrial Carcinoma

5.1.4.2   Classification of Gynecologic Malformations

5.2 Concepts for Surgical Treatment—Procedure Navigator

5.3 Surgical Techniques

Abdominal

5.3.1.1   Abdominal Myomectomy

5.3.1.2   Abdominal Hysterectomy

5.3.1.3   Abdominal Supracervical Hysterectomy

5.3.1.4   Abdominal Radical Hysterectomy

5.3.1.5   Abdominal Lymphadenectomy for a Malignancy of the Internal Genitalia: Para-aortic Lymphadenectomy

5.3.1.6   Cesarean Section

5.3.1.7   Postpartum Hysterectomy

5.3.1.8   Operations for Uterine Malformations

Vaginal

5.3.2.1   Minor and Diagnostic Procedures

5.3.2.2   Curettage and Polypectomy

5.3.2.3   Conization

5.3.2.4   Laser Therapy of the Cervix, Cryotherapy

5.3.2.5   Cervicectomy

5.3.2.6   Extirpation of the Cervical Stump

5.3.2.7   Vaginal Hysterectomy

5.3.2.8   Vaginal Hysterectomy for Uterine/Vaginal Prolapse

5.3.2.9   Radical Vaginal Hysterectomy

5.3.2.10 Suction Curettage in Abnormal Early Pregnancy

5.3.2.11 Operations for Cervical Insufficiency—Cerclage

Endoscopic

5.3.3.1   Diagnostic Hysteroscopy, Hysteroscopic Biopsy, Hysteroscopic Removal of a Lost IUP/IUD

5.3.3.2   Hysteroscopic Septum Dissection, Hysteroscopic Polypectomy, Hysteroscopic Myomectomy

5.3.3.3   Hysteroscopic Endometrium Ablation, Hysteroscopic Synechiolysis

5.3.3.4   Laparoscopic Myomectomy

5.3.3.5   Laparoscopic Hysterectomy

5.3.3.6   Laparoscopic Pelvic Lymphadenectomy

5.3.3.7   Laparoscopic Para-aortic Lymphadenectomy

5.3.3.8   Laparoscopic Hysterectomy for Uterine Malignancy

VI. Vulva and Vagina

6.1 Preliminary Remarks on the Region

6.1.1      Topography of the External Genitalia

6.1.1.1   External Vulva

6.1.1.2   Subcutaneous Parts of the Vulva: Superficial Perineal Space

6.1.1.3   Muscle and Aponeurotic Base of the Vulva

6.1.1.4   Blood Supply and Innervation of the Vulva and Vagina

6.1.1.5   Deep Muscle and Fascial Layer of the Vulvar Region

6.1.1.6   Inguinal Region

6.1.2      Functional Pathology—Developmental Disorders

6.1.3      Morphological Pathology—Histology

6.1.4      Terminology and Diagnosis

6.1.4.1   Staging and Treatment of Vulvar Cancer

6.1.4.2   Staging and Treatment of Vaginal Cancer

6.2 Concepts for Surgical Treatment—Procedure Navigator

6.3 Surgical Techniques

Abdominal

6.3.1.1   Inguinofemoral Lymphadenectomy

6.3.1.2   Surgical Treatment of Vaginal Carcinoma

Vaginal

6.3.2.1   Diagnostic Procedures on the Vulva and Vagina

6.3.2.2   Laser Surgery on the Vulva and Vagina

6.3.2.3   Surgery of Cysts of the Vulva and Vagina

6.3.2.4   Carcinoma in Situ in the Vaginal Stump

6.3.2.5   Nonradical Vulvectomy Techniques

6.3.2.6   Extended Local Excision of Vulvar Carcinoma

6.3.2.7   Radical Total Vulvectomy

Reconstructive and Plastic Surgery

6.3.3.1   Suture of Episiotomy and First- and Second-Degree Perineal Tears

6.3.3.2   Suture of Third- and Fourth-Degree Perineal Tears

6.3.3.3   Correction of Old Third- and Fourth-Degree Perineal Tears

6.3.3.4   Procedures on the Hymen and Introitus

6.3.3.5   Surgery of Vaginal Septa

6.3.3.6   Surgery on the Labia and Clitoris

6.3.3.7   Coverage of Defects in the Vulva and Vagina I—Transposition Flap and Bulbocavernosus Repair

6.3.3.8   Coverage of Defects in the Vulva and Vagina II—Myocutaneous Flaps

6.3.3.9   Neovagina

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

7.1 Preliminary Remarks about the Region

7.1.1      Topography of the Access Pathways

7.1.1.1   Vaginal Approach_Muscle Layers

7.1.1.2   Vaginal Approach_Connective Tissue Structures

7.1.1.3   Vaginal Approach_Vessels, Nerves, Ureter

7.1.1.4   Abdominal Approach_Muscle Layers

7.1.1.5   Abdominal Approach_Connective Tissue Structures

7.1.1.6   Abdominal Approach_Vessels, Nerves, Ureter

7.1.2      Positional Change of Urinary Bladder, Internal Genitalia, Rectum

7.1.2.1   Clinical Picture

7.1.2.2   Surgically Important Situations

7.1.3      Continence and Incontinence

7.1.3.1   Clinical Picture

7.1.3.2   Surgically Important Situations

7.2 Concepts for Surgical Treatment—Procedure Navigator

7.3 Surgical Techniques

Abdominal

7.3.1.1   Abdominal Retropubic Colposuspension Operation

7.3.1.2   Abdominal Paravaginal Colpopexy

7.3.1.3   Abdominal Colposacropexy (Colpocervicopexy)

7.3.1.4   Abdominal Enterocele Operations (Halban, Moschkowitz)

7.3.1.5   Abdominal Correction of a Vesicovaginal Fistula

Vaginal

7.3.2.1   Anterior Colporrhaphy

7.3.2.2   Vaginal Paravaginal Colpopexy

7.3.2.3   Posterior Colporrhaphy

7.3.2.4   Vaginal Sacrospinal Fixation

7.3.2.5   Vaginal Uterosacral Fixation

7.3.2.6   Vaginal Enterocele Repair

7.3.2.7   Colpocleisis

7.3.2.8   Suburethral Sling Operations

7.3.2.9   Suburethral Heterologous Tension-free Sling Operations (TVT, TVT-O)

7.3.2.10 Pelvic Floor Reconstruction with Mesh Implants

7.3.2.11 Peri- and Intraurethral Collagen Injection

7.3.2.12 Vaginal Correction of a Vesicovaginal Fistula

7.3.2.13 Vaginal Correction of a Rectovaginal Fistula

Endoscopic

7.3.3.1   Laparoscopic Retropubic Colposuspension

7.3.2.2   Laparoscopic Paravaginal Colpopexy

7.3.3.3   Laparoscopic Colposacropexy (Colpocervicopexy)

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

8.1 Exenterations

8.1.1      Development of Evisceration Surgery

8.1.2      Indications and Contraindications

8.1.3      Problems of Operation Technique

8.1.4      Errors and Failures

8.1.5      Operation Procedures

Starting the Operation and Preparation for Exenteration

Anterior Exenteration

Perineal Phase/Infralevator Exenteration

Reconstructive Aspects of Exenteration

Restoration of Bowel Continuity

Neovagina

8.1.6      Systematic Exenteration

8.1.7      Complications

8.1.8      Concurrent and Postoperative Treatment

8.1.9      Limits of the Method

8.2 Gynecology—Urology—Proctology

8.2.1      Gynecologic Urology

Urethral Caruncle

Urethral Prolapse

Urethral Diverticulum

Loss of the Urethra (Neourethra)

TeLinde Urethroplasty

Symmonds Urethral Reconstruction

Symmonds Myocutaneous Labial Flap

8.2.2      Special Urologic Procedures

End-to-End Anastomosis

Ureteroneocystostomy

Modified Boari Flap Operation

8.2.3      Gynecologic Proctology

Anatomy and Physiology

Proctological Examination Techniques

Disease Conditions

8.3 New Techniques

8.3.1      Electrosurgery

8.3.2      Vessel Sealing

8.3.3      BiClamp Technique

8.3.4      LigaSure

8.3.5      Argon Plasma Coagulator

8.3.6      SupraLoop

8.3.7      UltraCision/Harmonic Scalpel

8.3.8      CUSA

8.3.9      Robotic Surgery in Gynecology

Background/Technology

Indications, Contraindications, and Patient Selection

Preoperative Preparation and Patient Positioning

Trocar Placement and Docking/Undocking of the Robotic System

Surgical Techniques

List of Illustrations from Other Works

References

Index

   I. GENERAL PART

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

1.1 Pre- and Postoperative Treatment

Correct preoperative assessment and treatment together with optimal postoperative care contribute crucially to the success or failure of a procedure. The most important aspects are discussed in brief below.

1.1.1 Preoperative Treatment

Ambulant/In-patient Treatment

Preoperatively, the patient should be made aware of what to expect postoperatively: how will she be restricted, what pain is likely, what problems can occur? How much will she have to rely on help and assistance? These questions are becoming more and more important in the context of an aging population, particularly with regard to ambulant surgery. The patient should be given adequate information so that she can organize her postoperative affairs. The lenght of her hospitalization depends on the surgery performed, the patient's health status, her individual domestic care situation, and administrative issues.

Ambulant treatment. The legal foundation for ambulant treatment is based on assessment by a competent specialist. In many hospitals, this assessment is made jointly by the gynecologist and the anesthesiologist. From the anesthesiological perspective, American Society of Anesthesiologists (ASA) class 1 or ASA class 2 is a requirement.

As regards the patient's social history, it is necessary that the patient can be collected from the clinic by relatives or friends and then be looked after in an acceptable manner for 24 hours. Access to a telephone is a further consideration. The patient or her legal representative should be able to understand the planned operation in its entirety. The minimum criteria that must be met should be documented prior to discharge. These include:

Table 1.1.1 American Society of Anesthesiologists (ASA) risk classification

Type

Description

ASA 1

A normal healthy patient

ASA 2

A patient with mild systemic disease

ASA 3

A patient with severe systemic disease and reduced performance

ASA 4

A patient with an inactivating systemic disease that is a constant threat to life

ASA 5

A moribund patient who is not expected to survive the next 24 hours, regardless of the operation

Full possession of protective reflexes

Orientation in time and place

Stable circulation

No respiratory impairment

No acute postanesthesia vomiting

Ability to tolerate liquids orally

Adequate analgesia

Recourse claims with regard to the need for in-patient monitoring can usually be rejected when documentation is adequate. Nevertheless, it should be noted that an ambulant procedure is also in the patient's interest because she is soon removed from the increased risks of infection and thrombosis associated with hospitalization.

In-patient care. The duration of postoperative hospitalization is not uniformly regulated for the purposes of health insurance. There is usually a consensus on the minimum duration of hospitalization, but this does not always match medical need. The surgeon has to find a locally appropriate solution, together with hospital management and the payers. Certainly, postoperative hospitalization has become much shorter in the last 15 years.

Informed Consent

Legal Foundation

In legal terms, every operative procedure constitutes an assault, and many surgical measures actually meet the definition of aggravated assault. This may include, for example, loss of reproductive capacity. Medical treatment, and a surgical operation in particular, is clearly a physical injury according to the legislation in force. It is not culpable and not unlawful only when a competent patient has given informed consent or when there is a “justifiable emergency.” In addition to the definition of assault, the law of tort also defines when the injured party has a right to seek compensation for deliberate or negligent injury. Here, too, illegality is diminished only by a legally valid informed consent.

Informed Consent Requirements

Informed consent plays an important part in the surgeon's routine work. “Appropriate information” and legally correct consent are central to the physician's malpractice liability, both economically and legally. The content, time and form, and documentation of legally valid consent must meet certain requirements:

Typical risks of surgery. When deciding for or against the planned operation, the risks typical of the operation must be explained to the patient. Likewise, the possible consequences of not performing the operation must also be explained and documented. The patient must be given the oppportunity to make an informed decision. The law does not specify what risks have to be explained. If an operation is associated with serious risks, these must be listed even if they are unlikely. The less urgent the operation, the stricter are the informed consent requirements. For example, informed consent for cosmetic surgery should include all risks up to and including postoperative embolism and death. In a life-threatening situation, on the other hand, only the basic outlines of the risks need to be explained. It is important that the surgeon is aware of the concept of the “risks of the specific procedure.” This refers to risks that arise from the surgeon's experience (or inexperience) and from the quality of the clinic's facilities. The doctor is also obliged to provide information about alternative treatment methods.

Time and form of informed consent. The time and form of the informed consent should be chosen to allow the patient sufficient opportunity to think over her decision and if necessary discuss it with others. Experience has shown that this time is not on the day of the operation, so informed consent for elective surgery has to be obtained the day before surgery at the latest. Naturally, this does not apply in emergencies. In most doctors’ offices, ambulant surgery centers and hospitals, the patient is first given a printed form that explains the operation. The indispensable personal informed consent discussion can be based on this information form. Translators should be well versed in medical terminology. This is often not the case when relatives serve as translators.

Under-age children. In the case of under-age children, the consent of both parents with legal custody is necessary. Although the consent of one parent suffices in ordinary cases, the consent of all adult legal guardians should be obtained in the case of critical procedures with an ethically problematic background. If the parents refuse necessary treatment, an application must be made to the guardianship court. In emergencies, the physician may make the decision.

Impaired consent capacity. The capacity to give consent is a central point that must be heeded. If capacity is impaired by mental disability or disease, a legal representative may be appointed by the court to consent to the operation. This involves appointment of a guardian, a legal carer or representative for health matters. It is particularly important that dangerous or problematic procedures also require the approval of or a ruling by the guardianship court. Extreme caution is required with patients who are incapable of giving informed consent. Legal competencies must be clarified if time allows. In cases of doubt, a statement by an ethics committee, an expert lawyer or the responsible court should be obtained. The term “patient's presumed will” is used in this context.

Informed consent in obstetrics. Informed consent is particularly important in obstetrics. A rapidly evolving obstetric situation in an individual case does not alter the informed consent obligation. This applies, for example, to cesarean section, operative vaginal delivery, or fetal blood sampling. The woman in labor must be provided with information, and this must be documented.

Table 1.1.2 Basic requirements for legally valid informed consent

The patient must be capable of giving consent

In the case of under-age patients, either both parents or the legally appointed guardian must also give consent

In the case of a patient incapable of giving consent, the legal responsibility must be clarified before the operation

After providing information, in the case of elective surgery, the patient must have sufficient time to think about and discuss it. The informed consent should be obtained on the day before the planned operation at the latest

Risks typical of the operation must be explained

The role of the risks of the specific procedure (risks specific to the hospital and surgeon) is not yet clearly defined in legal rulings

Reasonable alternative treatment methods must be discussed

The less urgent the operation, the more detailed the informed consent

In the case of cosmetic surgery, virtually all risks must be discussed

Intraoperatively, the procedure must not extend beyond the possibilities discussed preoperatively

Obstetric patients must also be informed of every procedure, regardless of the clinical situation

The informed consent form can form the basis of the discussion, but does not replace it

Sterilization of minors is prohibited without exception

Intraoperative extension of an operation. Another critical point is intraoperative extension of a procedure. The operation may be extended only within the framework of the consent given by the patient. In clinically difficult situations, such as unclear adnexal findings or uncertain histology, the problem must be discussed in detail with the patient. A two-stage procedure may be advisable.

In addition, every practicing gynecologist should be aware that sterilization of a minor is not permissible, and there are rare exceptions to this rule.

Anesthesia

Type of Anesthesia

The type of anesthesia is a matter of negotiation between patient, gynecologist, and anesthesiologist. The choice includes local anesthesia techniques, oral or IV sedation, regional anesthesia methods such as spinal or epidural anesthesia, and general anesthesia. Combinations of these methods may also be employed. Certain operations require specific types of anesthesia: for instance, intubation anesthesia is currently the most frequent type for laparoscopy with CO2 insufflation, partly to counteract the increased abdominal pressure and diaphragmic irritation, and partly to counteract the CO2 surplus by adjusting ventilation. The combination of an epidural catheter with intubation anesthesia has become increasingly common. The advantages are easier control of anesthesia throughout the possibly prolonged surgery, e.g., during typical ovarian cancer operations, and the possibility of optimal postoperative analgesia. Local anesthesia with or without IV sedation is typical for ambulant surgery. Conization, curettage and diagnostic hysteroscopy can be performed under local anesthesia, although correct patient selection and a degree of experience with this method are important. The surgeon initially has to become accustomed to talking to the patient continuously during the procedure. While the type of anesthesia used for many operations also depends on local conditions and traditions, the international standard should be demanded strictly in obstetrics: intubation anesthesia is reserved in obstetrics for rare exceptional situations, which must always be justified. Spinal or epidural anesthesia is standard for cesarean section.

Table 1.1.3 Typical forms of anesthesia in gynecology

Operation

Form of anesthesia

Curettage

Local anesthesia, mask anesthesia vs. laryngeal mask

D & C

Mask anesthesia vs. laryngeal mask

Hysteroscopy, fractionated curettage

Mask anesthesia vs. laryngeal mask

Laparoscopy, short operation

Intubation anesthesia, possibly laryngeal mask

Laparoscopy, long operation

Intubation anesthesia

Tensionfree Vaginal Tape (TVT), Tensionfree Vaginal Tape Obturator (TVT-O)

Analgosedation and local anesthesia

Elective cesarean section

Emergency cesarean section

Spinal anesthesia

Intubation anesthesia vs. high epidural anesthesia (if sufficient)

Frozen section

Spinal anesthesia, high epidural anesthesia

Vaginal hysterectomy

Abdominal hysterectomy

Intubation anesthesia, possibly laryngeal mask, possibly spinal anesthesia

Intubation anesthesia

Typical ovarian cancer surgery/Wertheim operation

Intubation anesthesia and epidural catheter

Requirements

As a medical intervention, anesthesia is subject to the same provisions as the surgical procedure. The patient's informed consent the day before the operation is recommended. Consent given on the day of surgery can be problematic in the case of elective procedures. Technical administration of anesthesia, with the exception of local anesthesia, is the anesthesiologist's responsibility. Most gynecological procedures are of short duration and the patients’ status is usually ASA class 1 or 2. Long operations in very ill patients, which are performed, for example, in gynecological oncology, make much greater demands of the anesthesiologist. There have been important innovations in recent years, with which the gynecologic surgeon should be familiar. These include avoidance of intraoperative hypothermia, for example, by consistent use of heated underlays (little effect) or convection air heaters (good effectiveness), avoidance of fluid overload, avoidance of post-traumatic stress reactions by use of epidural anesthesia in combination with intubation anesthesia, and careful avoidance of postoperative nausea and vomiting.

Laboratory and Imaging Tests

Laboratory tests and diagnostic imaging procedures are important components of standard preoperative preparation. They must be established for each institution jointly by the gynecologic surgeon and the anesthesiologist. In recent years, the standards have increasingly been guided by the specific clinical situation.

Laboratory tests. A young healthy patient in whom curettage because of missed abortion is planned does not absolutely need a preoperative blood count, and recent cross-matching is not obligatory before an uncomplicated hysterectomy. Patients without a noteworthy history of bleeding do not need a coagulation screen prior to routine procedures in every case. An asymptomatic 70-year-old athlete may not require a preoperative chest radiograph, but a 40-year-old overweight chain smoker probably does. No categorical instructions can be given.

Imaging tests. The imaging procedures necessary for specific diseases will be discussed with the individual operation techniques. Imaging procedures that do not alter the operative approach should be rejected. Conversely, a pelvic tumor suspicious for malignancy should not be operated on without recent mammography, and hysterectomy should not be performed without recent cervical cytology.

Preparation for Surgery

Antibiotic Prophylaxis

Antibiotics depending on the procedure. Administration of prophylactic antibiotics immediately before abdominal procedures, especially cesarean section (when antibiotics are given after cutting the cord), is a rational measure confirmed by excellent studies. The aim is to reduce postoperative infections. Prophylactic antibiotic administration has also proven effective before major vaginal operations, especially vaginal hysterectomy and laparoscopic hysterectomy. On the other hand, the benefits of giving antibiotics before intrauterine procedures (curettage, hysteroscopy) have not been confirmed by studies. According to the available data, prophylactic antibiotics before elective laparoscopic procedures are not useful.

Antibiotics and time of administration. When prophylactic antibiotics are given, a single dose of an aminopenicillin (in combination with a β-lactamase inhibitor) or first- or second-generation cephalosporin within an hour before the start of the operation is recommended. Giving them at the same time as the skin incision has not been shown to be of equal value. A second dose is indicated when the operation lasts longer than 6 hours. Clindamycin is an alternative in the case of allergy.

Thrombosis Prophylaxis

Because of the incidence and pronounced morbidity of perioperative thrombosis and embolism in surgical patients, thrombosis prophylaxis merits particular emphasis. Thrombosis and embolism are the most important avoidable causes of perioperative morbidity and mortality. Thrombosis prophylaxis is particularly important in hospitalized pregnant women and postpartum patients, as their thrombosis risk is markedly higher than that of the age-matched non-pregnant population.

Heparin. Thrombosis prophylaxis is recommended for all hospitalized patients, for example, by means of low-molecular-weight heparin once a day. The dose can be increased when there are additional risk factors (obesity, long surgery, confinement to bed, malignant disease). Studies show that the optimal time of administration is before the start of the operation. Because of the theoretical increase in the tendency to bleeding, however, many surgeons prefer to start giving it only within the first 6 hours after the end of surgery. When paraspinal anesthetic techniques are employed, preoperative thrombosis prophylaxis is possible only outside a strict time window (usually 12 hours). The thrombosis prophylaxis should be adapted to the patient's risk classification during her hospitalization.

Other methods. “Antithrombotic” stockings are a nonpharmacological method of thrombosis prophylaxis, though their actual value depends greatly on precise fitting. Use of intermittent pneumatic compression is also an effective prophylactic tool. In any case, the most important antithrombotic measure is early patient mobilization, ideally on the day of the operation but on the first postoperative day at the latest. Bedside physiotherapy should be considered.

Preoperative Fasting

The rules on preoperative fasting from food and fluid have changed greatly in the last few years. The following minimum restrictions are demanded by progressive anesthesiologists for elective procedures, based on study-supported data:

No solid food and no nonclear fluids within 6 hours before the procedure

No roast or grilled foods within 8 hours before the procedure

Clear fluids (water, tea without milk, coffee without milk, fruit juice without pulp; high-carbohydrate fluids) up to 2 hours before the operation

The 6-hour rule also applies for smoking and chewing gum

The anesthesiologist may deviate from this in an individual case, depending on the underlying disease and chosen form of anesthesia. It is advisable to check whether these guidelines are supported by the anesthesiologists locally. Because of delayed gastric emptying associated with pregnancy, the above guidelines do not apply to the obstetrical population.

Bowel Preparation

Bowel preparation rules for major abdominal operations, especially when bowel resection may be anticipated, are subject to strong surgical traditions. Ultimately, the gynecologist must comply with the recommendations of his surgical colleagues. Interestingly, the available data do not support mechanical bowel preparation as regards the feared anastomotic leakage. Rather, consistent bowel preparation, which is associated with considerable effort and discomfort for both the patient and the nursing staff, appears to have a negative influence on the rate of leakage.

Hair Removal

There are clear data regarding hair removal in the operating area. Hair removal is not necessary for reasons of infection and hygiene, but it is not harmful. If it is done for surgical reasons, electric shaving (clipping) is considered superior to shaving with a razor. The timing does not appear to be important.

1.1.2 Postoperative Treatment

Postoperative management has changed greatly in the last 10 years. Ambulant surgery has become increasingly common and this trend will continue. However, the available data from visceral and thoracic surgery (“fast-track surgery”) will alter the postoperative management of hospitalized gynecological patients. The most important obstacles are the ideas and expectations of many doctors, the nursing staff, and particularly of the patients themselves. These ideas and expectations have developed over decades. Many patients still associate a long hospitalization with “good” care, although all available data demonstrate exactly the opposite. A “good” hospital stay as regards healing, low complication rates and rapid rehabilitation is nearly always a short hospital stay.

Ambulant Treatment

Monitoring. Postoperative monitoring after ambulant procedures is guided by the nature of the operation and anesthesia. Following immediate postoperative monitoring by the anesthetic staff (“recovery room”), the patients are looked after in a monitoring room attached to the ambulant operating room until they are discharged. A minimum period is not specified, but most gynecologists and anesthesiologists recommend observation for at least 2 hours after general anesthesia, and 4 hours after anesthesia with administration of morphine. Measurement of the vital signs (pulse, blood pressure) during ambulant postoperative observation is guided by the patient's condition. Measurement every 30 minutes provides adequate security in any case.

Discharge. Prior to discharge, the surgical and/or anesthetic staff must ensure that the patient can safely be discharged (see Chapter 1.1.1.1). A discussion must be held before discharge in which the patient is informed about the course of the operation, any particular postoperative features, and what she should do during the immediate postoperative period.

In-patient Treatment

Fast-track surgery. The perioperative care of hospitalized patients is currently undergoing important changes with the increasing data on the various benefits of active clinical management, which includes early mobilization, early enteral fluid intake and feeding in the form of “fast-track surgery.” As this approach has been tested especially in multimorbid patients undergoing abdominal surgery, the typical gynecology patient should be able to benefit even more. The crucial points of fast-track surgery are:

Elimination of pain

Combination of regional anesthesia and general anesthesia

Effective but low-opiate analgesia

Adapted fluid management

– Limitation of preoperative fasting from fluids

– Little or no intraoperative weight gain

– Low perioperative infusion volume

Temperature regulation—avoidance of hypothermia

Aggressive prevention of postoperative nausea and vomiting

Early postoperative intake of fluid and food (2nd postoperative hour)

Early mobilization (5th postoperative hour)

Early discharge

Modern perioperative management aims to reduce the initial fluid deficit with the patient allowed to drink clear fluids up to 2 hours before the operation. When a patient weighing 75 kg fasts completely for 10–14 hours, there is already a preoperative fluid deficit of 1500–2100 mL, based on a basal fluid requirement of 2 mL/kg body weight per hour. Intraoperative and postoperative fluid administration is restrictive.

Laboratory tests. Laboratory tests are guided by the operation and should be specified by the surgeon. If there is the slightest suspicion or suggestion of postoperative bleeding—even without clear clinical signs—regular hemoglobin and hematocrit measurements should dispel or confirm the suspicion. If the patient's clinical vital signs are not completely normal, the last blood count must not be the lowest. It is better to take one blood count too many than one blood count too few, especially as the body's considerable capacity for compensation can mask the clinical signs of significant bleeding, particularly in young and healthy patients.

Thrombosis prophylaxis. Postoperative thrombosis prophylaxis is particularly important. The most important additional risk factors for thrombosis and embolism are:

Malignant disease

Pregnancy

Advanced age—increasing risk

Thrombophilia (antiphospholipid syndrome, APC resistance/factor V Leiden mutation, antithrombin or protein C/S deficiency)

Contraceptives and hormone replacement therapy

Chronic venous insufficiency

Severe infection

Obesity (BMI > 30 kg/m2)

Heart failure NYHA III/IV

According to the Association of Medical Scientific Societies in Germany, a distinction is made between physical and pharmacological measures for thrombosis prophylaxis:

Physical measures include early mobilization, constant encouragement (and instruction) of the patient to perform exercises using the muscle pump, possibly as part of physiotherapy, and also well-fitting compression stockings and possibly intermittent pneumatic compression

Pharmacological thromboembolism prophylaxis in gynecology and obstetrics is now provided mainly by low-molecular-weight heparins. The dose should be adjusted to the patient's weight and risk depending on which of the low-molecular-weight heparins is used. The risk of heparin-induced thrombocytopenia (HIT) is very low with low-molecular-weight heparins. Regular blood count monitoring is not necessary, and a single measurement usually suffices. If heparin is not tolerated, the heparin-free heparinoid danaparoid is available

Food intake. Oral postoperative food intake should start about 2 hours after purely gynecological operations (water, tea). There is no objection to yogurt as an early food. The patient should eat the regular hospital diet on the first postoperative day. This regimen is encouraged in patients following colon and rectal resection and should not cause any problems in gynecological patients.

Drains. The decision on whether to insert drains is at the surgeon's discretion, and he or she should be guided by the clinical situation. Closed drainage systems are the minimum standard. There is no situation in which it is essential to place a drain. Some surgeons argue for dispensing completely with drains, and developments in recent years have been in this direction. As with many medical measures, the rule with drains is to use them sparingly and remove them early.

1.2 Instruments

No surgery is possible without the correct instruments. Although the number of instruments actually used is manageable, there are considerable differences from hospital to hospital and from operating room to operating room. Ultimately, the surgeon has to keep to the selection available in his institution. Different instruments are described in brief below, but this list does not claim to be complete. The names of the instruments are often historical and based on convention. The most common names and classifications are used below, but these can never be entirely comprehensive.

1.2.1 Abdominal Surgery

Abdominal surgery requires an arsenal of scissors, clamps, needle holders, and retractors of varying length and varying strength or fineness.

Scissors

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

Cooper Scissors

The Cooper scissors is a strong, curved, blunt-ended scissors, which is sometimes also called a fascia scissors but is used mostly for cutting sutures. The name probably goes back to Sir Astley Paston Cooper (1768–1841), an English physician, anatomist and surgeon, who also gave his name to the Cooper ligaments of the breast and the Cooper ligament of the anterior pelvic ring (pectineal ligament). Cooper, who studied with the French surgeon Francois Chopart (1743–1795) in revolutionary Paris, was regarded by his contemporaries as the most outstanding surgical teacher of his time.

Fig. 1.2-1 Cooper scissors.

Sims Scissors

The Sims scissors is very similar to the Cooper scissors. However, it also comes in an uncurved form. It is called after the American surgeon and gynecologist J. Marion Sims (1813–1884), who is regarded in the USA as the founder of modern gynecology. Sims's pioneering work on the surgical treatment of the then omnipresent obstetric fistula should be particularly emphasized; fistulas were a source of terrible suffering for affected women and became curable for the first time as a result of Sims's efforts. Nowadays, obstetric vesicovaginal or rectovaginal fistulas are a significant gynecological problem in developing countries. The fistula hospital in Addis Ababa established by the Australian physician couple Reg and Catherine Hamlin is world famous; its operative technique is based essentially on the approach developed by Sims.

Fig. 1.2-2 Sims scissors.

Metzenbaum Scissors

The Metzenbaum scissors is a fine, usually curved, pointed or blunt-ended dissecting scissors, and is among the most important dissecting instruments. The name derives from the American ENT surgeon Myron Firth Metzenbaum (1876–1944), who specialized in oral surgery and plastic reconstructive surgery of the nose and larynx. During his training, Metzenbaum—like numerous other American doctors of his time—worked in Vienna and London. In the USA, Metzenbaum was also one of the pioneers of ether anesthesia.

Fig. 1.2-3 Metzenbaum scissors.

Satinsky Scissors

The Satinsky scissors is a fine, highly angled, pointed or blunt-ended dissecting scissors which is used in gynecology as a cutting instrument in the lesser pelvis, classically when dividing the uterus from the vagina. The name comes from the American surgeon Victor Paul Satinsky (1912–1997), who worked especially as a cardiac surgeon. Satinsky, after whom a whole range of instruments is named, was a dazzling personality who devoted himself to a wealth of activities besides medicine, such as playing the clarinet, fencing, and writing poetry and plays (some of which were even produced in London). At the age of 80 years, Dr. Satinsky even obtained a black belt in aikido. He spent his academic career at Hahnemann Hospital in Philadelphia.

Fig. 1.2-4 Satinsky scissors.

Clamps

Hemostatic clamps are distinguished from purely tissue-grasping clamps. The surface of the jaws is serrated either longitudinally, parallel to the clamped tissue, or horizontally, perpendicular to the clamped tissue. Hemostatic clamps are characterized by longitudinal serration, for example, Wertheim clamp or other parametrial clamps. Horizontally serrated tissue-grasping clamps grip better in tissue. They are divided into tissue-sparing and tissue-destroying clamps.

Kocher Clamp

Kocher clamps come in every length and thickness and are usually straight. They are typical tissue-crushing clamps with a sharp barb and are suitable especially for gripping tough tissue such as fascia. The clamp is named for the Swiss surgeon Emil Theodor Kocher (1841–1917). He was the first surgeon to receive the Nobel Prize in medicine in 1909 (for his study on the physiology, pathology, and surgery of the thyroid gland). Kocher worked in almost every branch of surgery at a time when the foundations of modern operative surgery were laid with asepsis and hemostasis.

Fig. 1.2-5 Kocher clamp.

Mikulicz Clamp

Mikulicz clamps are somewhat finer than Kocher clamps and are curved. They are not suitable for clamping tissue but only for grasping a specific tissue, for example, the parietal peritoneum when closing the abdomen or the rectus fascia when opening it. It is named for Johann von Mikulicz (1850–1905), one of the best-known surgeons of his era. Mikulicz was a student of Theodor Billroth in Vienna, and subsequently university professor in Cracow, Königsberg and, from 1890, Breslau. His scientific work includes the first description of achalasia as a functional disorder of the lower esophageal sphincter, initial attempts at gastroscopy, introduction of local anesthesia to surgical practice, and important improvements in the technique of thyroid resection. From 1896 onward, Mikulicz promoted use of a face mask to improve intraoperative asepsis. His best-known assistant was Ferdinand Sauerbruch, who, under Mikulicz in Breslau, demonstrated the negative pressure chamber for surgery on the open lung.

Fig. 1.2-6 Mikulicz clamp.

Péan Clamp

The Péan clamp is a relatively atraumatic straight clamp which largely corresponds to the Kocher clamp but has no barb (no tapering) and is thus to a certain extent a straight Overholt clamp. It comes in all sizes and is suitable especially for clamping small vessels. Its name comes from the pioneering French surgeon Jule-Émile Péan (1830–1898). In 1878, Péan performed resection of the pylorus to treat gastric outlet stenosis for the first time. As was not unusual in those early days of academic surgery, the patient died after 4 days. Péan was also one of the first people to remove an ovarian cyst and perform a splenectomy, both pioneering procedures at that time.

Fig. 1.2-7 Péan clamp.

Kelly Clamp

The Kelly clamp is similar to the Péan clamp but the tips are slightly rounded and tapering. It can be straight or curved but is somewhat heavier than an Overholt clamp so it is less suitable for dissection. It is named after Howard Kelly (1858–1943), one of the most outstanding American gynecologists, who was a co-founder of the Johns Hopkins Hospital, where, with Halsted and Osler, he laid the foundations of modern American academic medicine and helped to establish gynecology as a branch of surgery. “Kelly plication,” an operation for urinary incontinence named after him, is no longer in common use.

Fig. 1.2-8 Kelly clamp.

Overholt Clamp

The Overholt clamp is a slightly curved clamp, with tapered jaws and rounded ends without serrations. It is an ideal atraumatic grasping instrument and can also be used as a hemostatic clamp for minor bleeding. Above all, it is an important dissecting instrument, which can be used to open and separate specific layers and spaces atraumatically. The name comes from the thoracic and pulmonary surgeon Richard Overholt (1901–1990), who was one of the most important people in the anti-smoking movement. He was far ahead of his time in recognizing the effect of smoking on the lungs when he performed lung operations on tuberculosis patients in the late 1930s and denouncing smoking again and again, against the prevailing medical opinion of the next 20 years. Overholt performed one of the first successful partial lung resections for lung cancer.

Fig. 1.2-9 Overholt clamp.

Halsted Clamp (Mosquito Forceps)

Halsted clamps are very fine hemostatic clamps, which are suitable especially for gripping small fragile structures. They are widely employed in surgery. Their name comes from the American surgeon William Halsted (1852–1922), who, together with the gynecologist Howard Kelly and the physician William Osler, the co-founders of the Johns Hopkins Hospital, was one of the fathers of modern American academic medicine. Halsted completed what was then the classical surgical training in America, including nearly 3 years in Vienna, Leipzig and Würzburg between 1878 and 1880, where one of his teachers was Billroth. Numerous principles of modern surgery, such as gentle operating, clean and tension-free wound closure, and the use of rubber gloves, go back to Halsted. He was one of the first to create surgical specialization in the fields of urology and orthopedics. Halsted is also regarded as one of the founders of the American clinical education system, where he largely adopted the European structures of that era. Like many doctors of his time, he developed a severe and lifelong addiction from his clinical experiments with cocaine as a local anesthetic, which initially ruined his promising career in New York. After several admissions to detoxification clinics, he got his second and crucial opportunity at the newly founded Johns Hopkins University in Baltimore. Here he also published the technique of radical mastectomy, which is named after him.

Fig. 1.2-10 Halsted forceps.

Parametrial (Wertheim) Clamp

Parametrial clamps are typical tissue-destroying clamps, which are used particularly in gynecology for clamping and ligating the vascular parametrial tissue bundle and the uterine artery which it contains. The name comes from the gynecological surgeon Ernst Wertheim (1864–1920), who for many years was the director of the gynecology clinic of Vienna University, where he was involved in developing the radical hysterectomy that bears his name to treat cervical cancer. He was the first to employ this operating technique successfully in a large number of patients.

Fig. 1.2-11 Wertheim parametrial clamp.

Fig. 1.2-12 Backhaus clamp.

Backhaus (Towel) Clamp

Backhaus clamps are small, sharp, traumatic clamps with which tissue is perforated and held. They are used especially on the skin, but cause small defects there. They are traumatic instruments, and some surgeons reject them or use them only as towel clamps.

The clamp is believed to be named for the gynecologist Carl Backhaus, head of the surgical department of the Augusta Hospital in Düsseldorf, Germany. He worked in the Pathology Institute of the Christian Albrecht University in Kiel in 1896/1897 and in the surgical department of Mainz City Hospital from 1897 to 1899. From 1900 to 1904 he worked with Rotter in the surgical department of the Hedwig Hospital in Berlin. He worked on improving asepsis of the operation field and on improving the surgery of large abdominal hernias by redoubling the hernial sac. He also improved the Bassini operation.

Needle Holders

Needle holders are among the most important and technically demanding instruments; gripping a needle securely and accurately requires an exact and precise mechanism. Although needle holders have finger holes like clamps and scissors, they can be opened and closed by the ball of the hand for optimal manipulation, which makes it possible to grasp the needle accurately. All needle holders work in the same way, and it is only the size that differs, according to the surgical situation.

Fig. 1.2-13 Needle holder.

Forceps

Forceps are among the most frequently used instruments. They are classified into surgical, traumatic (with barb), and anatomical, atraumatic (without barb) forceps, and which is used depends on the operative situation. There is also a large variety of electrocautery forceps.

DeBakey Forceps

The DeBakey forceps is the best-known atraumatic forceps, named after the American cardiac surgeon Michael DeBakey (1908–2008), who was one of the legends of 20th century cardiovascular surgery, not least because of his phenomenal longevity; he was a pioneer in the field of bypass and aneurysm surgery. At the age of 97 years he underwent surgery for a ruptured abdominal aortic aneurysm, more or less with the technique that he had introduced over half a century earlier.

Fig. 1.2-14 DeBakey forceps.

Surgical Forceps

The barbed traumatic surgical forceps has remained without an eponym.

Fig. 1.2-15 Surgical forceps.

Adson Forceps

Another instrument used internationally is the fine Adson forceps, which is used in gynecological surgery especially during skin suture. Alfred Washington Adson (1887–1951) was a pioneer and founder of neurosurgery in the USA. He worked especially at the Mayo Clinic, where he established the specialty. Adson undertook the first sympathectomy to treat high blood pressure and as therapy of Raynaud syndrome.

Fig. 1.2-16 Adson forceps.

Russian Forceps

Another forceps popular in gynecology, especially during pelvic and para-aortic lymphadenectomy, is known as a Russian forceps.

Fig. 1.2-17 Russian forceps.

Grasping Instruments

Ovary Grasping Forceps, Amnion Grasping Forceps

The ovary grasping forceps is a specific gynecological and obstetric grasping instrument, which is an atraumatic forceps very suitable for manipulating ovaries or fetal membranes.

Fig. 1.2-18 Ovary grasping forceps.

Babcock Forceps

The Babcock forceps is a strictly atraumatic grasping and fixing instrument used in open abdominal gynecology for grasping the tubes or ureters. It is called after William Wayne Babcock (1872–1962), one of the founding fathers of modern American surgery. After initially working as a gynecologist, he subsequently worked in general surgery. Important innovations in varicose vein surgery, treatment of thoracic aortic aneurysm, which was common at the time because of syphilis, and the surgery of rectal cancer go back to Babcock, who also played a crucial role in founding the American Board of Surgery. It should be emphasized that Babcock was one of the first surgeons to employ spinal anesthesia.

Fig. 1.2-19 Babcock clamp.

Cutting Instruments

Traditional scalpels are distinguished from electrical cutting implements. Conventional scalpels are designated according to an internationally accepted numbering system. The main blades used in gynecology are the number 11 (stab incision, laparoscopy), the number 21 (skin incision for abdominal operations), and the number 15 for small biopsies.

Fig. 1.2-20 Various blades. The numbering corresponds to the international nomenclature.

Retractors

There is a large range of surgical retractors, from the simplest retaining hook to modern self-retaining systems. For most doctors in training, acting as second assistant and providing retraction is their first contact with surgery. Only a few examples of retractors are described below.

Bladder Retractor

The bladder retractor is used a great deal, especially in gynecology. It is important in the classical step of dissecting the bladder off the anterior wall of the uterus during abdominal hysterectomy.

Fig. 1.2-21 Bladder retractor.

Roux Retractor

The Roux retractor is used frequently in gynecology, especially at the skin, during laparotomy, and when closing the abdomen. Its name comes from the Swiss general surgeon and gynecologist César Roux (1857–1934). Roux was a student of Langhans and Kocher in Berne. Apart from the retractor, he also gave his name to the Roux-en-Y technique in gastric bypass surgery.

Fig. 1.2-22 Roux retractor.

Fritsch Retractor

The Fritsch retractor is used especially during cesarean section for lateral retraction of the abdominal wall. It is called after the gynecologist and obstetrician Heinrich Fritsch (1844–1915). Fritsch, who was famous in his time as a surgeon and clinical teacher, worked as professor in the gynecology clinic in Breslau and finally in Bonn. He became well known internationally because of his textbooks on gynecology and obstetrics, which were translated into many languages.

Fig. 1.2-23 Fritsch retractor.

1.2.2 Vaginal Surgery

Many of the instruments used during vaginal surgery are the same as those used in abdominal surgery. Implements designed specifically for vaginal surgery are described below.

Hegar Dilators

Various series of dilators are available for dilating the cervical canal for diagnostic procedures in the uterus (curettage, hysteroscopy) or for managing disorders of early pregnancy. The best-known are Hegar dilators, called after Ernst Ludwig Hegar (1830–1914), first professor of gynecology and obstetrics in Freiburg, Germany and one of the pioneers of modern academic gynecology in Germany. Hegar introduced the steel dilators that bear his name as a substitute for the glass or hard rubber dilators used until then.

Fig. 1.2-24 Hegar dilators.

Forceps and Clamps

Vulsella Forceps

The vulsella forceps is a specifically gynecological instrument for hooking the cervix, an important step in almost all minor procedures on the uterus. Particularly during laparoscopic procedures, it is used additionally to fix the uterine manipulator, and has thus gained an important new role.

Fig. 1.2-25 Vulsella forceps.

Allis Clamp

The Allis clamp is an atraumatic forceps, widened in front, which is used in both abdominal and vaginal surgery. It is a classical instrument for stretching tissues during anterior and posterior colporrhaphy. Its name comes from the American surgeon Oscar Huntington Allis (1836–1931). He was a medical student at Jefferson Medical College in Philadelphia and then worked in the Presbyterian Hospital in Philadelphia as a co-founder of orthopedic surgery. He introduced the clamp that bears his name in 1883.

Fig. 1.2-26 Allis forceps.

Polyp Grasping Forceps

This instrument, used specifically in gynecology, does what its name suggests.

Fig. 1.2-27 Polyp grasping forceps.

Curettes

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

Bumm Curette

The blunt Bumm curette is called after the German gynecologist and obstetrician Ernst Bumm (1858–1925). Bumm became professor at the Charité in Berlin in 1910. In the scientific field, he was interested particularly in infection in obstetrics, which was an extremely important area of research at the time due to the high mortality caused by puerperal fever. Professor Bumm was renowned as a clinician. It is reported of a difficult delivery in Berlin that the doctor on duty wanted to calm the fearful patient by remarking “We'll just call Bumm [boom], “to which the woman asked skeptically: “Do you think that's likely to help?”

Fig. 1.2-28 Bumm curette.

Karman Curette

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

Fig. 1.2-29 Karman curettes.

Specula

The speculum is a specifically gynecological instrument, that allows optimal examination of the cervix and vagina, along with surgery in this region. Accordingly, there are various forms and versions.

Scherbak Speculum

The Scherbak self-retaining speculum with a weight on the posterior blade is an essential aid in cervical and uterine surgery. It is called after Leopold Scherbak, who practiced as a gynecologist in Brno in the early 20th century and introduced this instrument in an article published in 1907.

Fig. 1.2-30 Scherbak self-retaining speculum.

Breisky Speculum

Breisky vaginal specula are among the most important instruments in vaginal surgery. The name comes from August Breisky (1832–1889), who was professor of gynecology, first in Prague and then in Vienna, and one of the founders of modern academic gynecology.

Doyen Speculum