Bonney's Gynaecological Surgery E-Book

Tito Lopes

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 810

Veröffentlichungsjahr: 2018

Beschreibung

Surgery is a core element of the clinical practice of gynaecology. Bonney's Gynaecological Surgery has been a firm favourite for gynaecological surgical practice since 1911. Specifically tailored for trainees in obstetrics and gynaecology, the text focuses on the most commonly performed procedures. The 12th edition will include a colour photo section. With greater emphasis on fundamental clinical skills and major updates on laparoscopic and robotic surgery, this classic text will be brought right up to date for the current trainee or junior consultant physician. Each chapter follows a consistent plan, guiding the reader through each procedure from anatomy and indications to post-op considerations and complications. The text is also accompanied by surgical illustrations of unparalleled quality, ensuring that this volume will remain a valuable resource for all clinicians specializing in gynaecological surgery.

Leseprobe

Table of Contents

Cover

Preface

PART 1: General

CHAPTER 1: Introduction and prologue

Introduction

Prologue: after Comyns Berkeley and Victor Bonney, (JM Monaghan)

Further reading

CHAPTER 2: Preparation for surgery

Clinic information

Initial visit

History taking and documentation

Patient information

Consent for surgery

Preoperative assessment and optimization

Preoperative investigations

Preoperative case review and meeting

Preoperative discussion with the patient regarding the scope of surgery

Preoperative visit by the anaesthetist

Thromboprophylaxis

Bowel preparation

In the operating theatre

Anaesthesia

References

Further reading

CHAPTER 3: Instruments, operative materials and basic surgical techniques

Instruments for major gynaecological procedures

Editors’ picks

Sutures

Surgical knots and methods of tying

Tying pedicles

Staples

Electrosurgery

Haemostatic agents

Adhesion prevention

Drainage

References

Further reading

CHAPTER 4: Opening and closing the abdominal cavity

Operative stance

Draping the patient

Instruments

Subumbilical midline incision

Transverse incisions

Reference

Further reading

CHAPTER 5: The laparoscopic approach in gynaecology

Positioning of the patient

Access to the abdomen

Equipment

Diagnostic laparoscopy

Problems and complications associated with laparoscopy

Laparoscopic surgery for endometriosis

Laparoscopic surgery in gynaecological oncology

Complications

Postoperative recovery

References

Further reading

CHAPTER 6: Postoperative care and complications

Postoperative care

Complications of surgery

References

Further reading

PART 2: Anatomical

CHAPTER 7: Operations on the vulva

Vulval biopsy

Treatment of Bartholin’s cysts and abscesses

Simple vulvectomy

Further reading

CHAPTER 8: Operations on the vagina

Vaginal cysts

Procedures for enlargement of the vaginal introitus

Congenital abnormalities of the vagina

Vaginectomy: partial and complete

Reference

Further reading

CHAPTER 9: Operations on the cervix

Dilatation of the cervix

Removal of endocervical polyps and extruded fibroid polyps

Ablative procedures

Excisional techniques

Trachelorrhaphy

Cervical incompetence

Excision of cervical stump

References

Further reading

CHAPTER 10: Operations on the uterine cavity

Rapid access clinics

Sampling of the endometrium

Outpatient hysteroscopy

Endometrial ablation

Hysteroscopic myomectomy

Reference

Further reading

CHAPTER 11: Operations on the uterus

Total abdominal hysterectomy

Hysterectomy for a double uterus

Subtotal hysterectomy

Vaginal hysterectomy

Laparoscopic‐assisted vaginal hysterectomy

Total laparoscopic hysterectomy

Complications of hysterectomy

References

Further reading

CHAPTER 12: Uterine fibroids

Classification

Symptoms

Imaging

Management

Surgical management

Hysterectomy for uterine fibroids

References

Further reading

CHAPTER 13: Operations on the fallopian tubes

Extrauterine gestation

Operations on the fallopian tubes for female sterilization

Resection of the fallopian tube

Operations for correction of infertility

Reference

Further reading

CHAPTER 14: Operations on the ovaries

Diagnosis of an ovarian mass

Management

Surgery

Ovarian cystectomy

Salpingo‐oophorectomy

Removal of a retroperitoneal cyst

References

Further reading

CHAPTER 15: Caesarean section

Lower‐segment caesarean section

Classical caesarean section

Management of massive postpartum haemorrhage

References

Further reading

PART 3: Urogynaecology

CHAPTER 16: Operations for pelvic organ prolapse

General considerations

Anaesthesia

Instruments

Anterior colporrhaphy

Posterior colporrhaphy

Transanal rectocele repair

Perineorrhaphy

Posterior colporrhaphy with enterocoele repair

Central compartment procedures

Vaginal hysterectomy combined with anterior and/or posterior colporrhaphy

Surgical management of vaginal vault prolapse after hysterectomy

Sacrospinous ligament fixation

Uterosacral ligament suspension

Abdominal sacrocolpopexy

Laparoscopic sacrocolpopexy

Uterine sparing prolapse surgery

Transvaginal insertion of mesh

Obliterative techniques

Complete colpocleisis

Le Fort’s colpocleisis

References

Further reading

CHAPTER 17: Operations for urinary incontinence

Classification of procedures

The role of urodynamic assessment before surgery for stress urinary incontinence

The place of cystoscopy during surgery for stress urinary incontinence

The use of bladder drainage following surgery for stress urinary incontinence

Urethral and bladder neck supporting procedures

Retropubic suburethral slings: synthetic mid‐urethral slings

Trans‐obturator foramen suburethral slings

Retropubic suburethral slings: traditional sling operations

Urethral sphincter augmentation

Artificial urinary sphincter

Operations for detrusor overactivity

Whether, when and which operation?

References

CHAPTER 18: Operations for urogenital fistulae

Bonney’s principles of fistula repair

Classification

Presentation and evaluation

Immediate management

Timing of repair

Route of repair

Preoperative preparation

Anaesthesia

Instruments

Suture materials

Interposition grafts

Skin grafts

Vaginal procedures

Other vaginal procedures

Abdominal procedures

Ureterovaginal fistula repair

Urinary diversion

Postoperative management

References

PART 4: Oncology

CHAPTER 19: Surgery for carcinoma of the vulva

Lymph node assessment

Excision of the vulval tumour

The operation

Excision of the vulval tumour

References

Further reading

CHAPTER 20: Vaginal cancer surgery

Treatment

Wide excision

Partial or total vaginectomy

Exenteration

Reference

Further reading

CHAPTER 21: Cervical cancer

Radical hysterectomy and pelvic node dissection

Laparoscopic radical hysterectomy with aortic and pelvic lymphadenectomy

Radical vaginal hysterectomy

Radical trachelectomy

References

Further reading

CHAPTER 22: Uterine cancer

Surgical approach

Role of ovarian conservation

Peritoneal washings

Risk of nodal metastases and assessment of nodes

Role of lymphadenectomy and sentinel lymph node sampling

Radical surgery in advanced disease

References

Further reading

CHAPTER 23: Ovarian cancer

General comments

A systematic approach to achieving complete surgical staging in patients with clinical stage I or II disease

A systematic approach to achieve optimal cytoreductive status in patients with advanced epithelial cancer of the ovary

Reference

Further reading

CHAPTER 24: Exenterative surgery

Selection of patients for exenterative surgery

Palliative exenteration

Patient assessment

Contraindications to exenteration

Types of exenteration

Preoperative preparation

The operation

Postoperative care

Results of exenteration

References

Further reading

PART 5: Operations on other organs

CHAPTER 25: Vascular surgery: applications in gynaecology and gynaecological oncology

Aortic injury

Iliac artery injury

Vena caval injury

Presacral bleeding

Pelvic packing

Summary

Further reading

CHAPTER 26: Management of injuries to the urinary tract

Anatomical relationship

Predisposing factors

Preventing injuries

Damage recognized at the time of operation

Injuries to the ureter in the pelvis

Ureteric injuries above the pelvic brim

Management of the delayed diagnosis of urinary tract damage

Radiotherapy damage

Operations for the formation of a urinary conduit

References

Further reading

CHAPTER 27: Operations on the intestinal tract for the gynaecologist

Appendicectomy

Instruments

Patient preparation

Anaesthesia

The operation

Management of operative injuries of the intestine

The formation of a stoma

A permanent colostomy

The formation of a loop ileostomy

Side‐to‐side anastomosis procedure

Reference

Further reading

CHAPTER 28: Reconstructive procedures

General comments

Vulval reconstruction for localized benign disease, premalignant and early malignant disease

Full‐ and split‐thickness skin grafts (general considerations)

Myocutaneous grafts

References

Index

End User License Agreement

List of Tables

Chapter 03

Table 3.1 Absorbable suture materials.

Chapter 10

Table 10.1 Classification of submucosal fibroids.

Chapter 12

Table 12.1 Uterine fibroid subclassification system.

3

Chapter 15

Table 15.1 The three components of management of massive postpartum haemorrhage.

Chapter 17

Table 17.1 Classification of stress urinary incontinence procedures.

Table 17.2 The author’s preferred technique for for ‘sedo‐anaesthesia’.

Table 17.3 Injectable substances developed for use as urethral bulking agents.

Table 17.4 Nonsurgical options for detrusor overactivity.

Chapter 21

Table 21.1 Complications of radical hysterectomy.

List of Illustrations

Chapter 03

Figure 3.1 Bonney gynaecological scissors.

Figure 3.2 (a) Monaghan gynaecological scissors. (b) Comparison of Bonney scissors (top) and Monaghan scissors (bottom).

Figure 3.3 Hysterectomy clamps.

Figure 3.4 Singley forceps.

Figure 3.5 DeBakey forceps.

Figure 3.6 Meigs–Navratil forceps.

Figure 3.7 Simple interrupted suture.

Figure 3.8 Vertical mattress suture.

Figure 3.9 Horizontal mattress suture.

Figure 3.10 Locked or blanket sutures.

Figure 3.11 Puckering sutures.

Figure 3.12 Purse‐string suture.

Figure 3.13 Purse‐string inverting sutures.

Figure 3.14 Reef knot.

Figure 3.15 (1–4) The single‐handed knot and (5, 6) forceps knot (after Bonney).

Figure 3.16 Tying a pedicle around Meigs forceps.

Figure 3.17 A disposable multiple clip applicator.

Figure 3.18 (a) Simple pedicle tie. (b) Single‐end transfixion tie. (c) Double‐ended transfixion tie.

Chapter 04

Figure 4.1 The subumbilical midline incision, incising the skin.

Figure 4.2 Incising the rectus sheath.

Figure 4.3 Separating the rectus muscles.

Figure 4.4 Incising the peritoneum.

Figure 4.5 Cutting the peritoneum along the full length of the wound.

Figure 4.6 The Balfour self‐retaining retractor.

Figure 4.7 The incision retracted using the Balfour and Morris retractors.

Figure 4.8 The mass closure technique.

Figure 4.9 Stapling the abdominal skin.

Figure 4.10 The Pfannenstiel incision.

Figure 4.11 Dissecting the rectus sheath.

Chapter 05

Figure 5.1 Needle insertion into the abdominal cavity to produce a pneumoperitoneum.

Figure 5.2 Insertion of the laparoscope via the trocar.

Chapter 07

Figure 7.1 (a) Biopsy of vulval lesion using a Keyes punch. (b) Resulting biopsy specimen.

Figure 7.2 Cruciate incision over abscess.

Figure 7.3 Wall of abscess sutured to skin.

Figure 7.4 Incising over the Bartholin’s cyst.

Figure 7.5 Enucleation of the cyst.

Figure 7.6 Removal of the cyst.

Figure 7.7 Obliteration of the cyst cavity.

Figure 7.8 Closure of the skin.

Figure 7.9 The incision for simple vulvectomy.

Figure 7.10 Removal of vulval skin.

Figure 7.11 Suturing the cut edges.

Chapter 08

Figure 8.1 Incising the introital skin.

Figure 8.2 Developing a flap of vaginal skin.

Figure 8.3 Making the posterior vertical incision.

Figure 8.4 Obliterating the space under the flap.

Figure 8.5 Suturing the skin edges together.

Figure 8.6 Releasing the vaginal edges.

Figure 8.7 Excising the vaginal skin at the vault.

Figure 8.8 Identifying the ureter in the right retroperitoneal space.

Figure 8.9 Dividing the uterine artery at the pelvic sidewall.

Figure 8.10 Dividing the roof of the ureteric tunnel.

Figure 8.11 Incising the peritoneum between the uterosacral ligaments.

Figure 8.12 Developing the rectovaginal space.

Figure 8.13 Removing the vaginal remnant.

Chapter 09

Figure 9.1 Lithotomy position.

Figure 9.2 Cervical vulsellum.

Figure 9.3 Passage of uterine sound.

Figure 9.4 Dilatation of the cervix.

Figure 9.5 Damage of the anterior wall in a retroverted gravid uterus.

Figure 9.6 Removal of small endocervical polyp.

Figure 9.7 Removal of a large myomatous polyp: incising the capsule.

Figure 9.8 Reflecting the capsule.

Figure 9.9 Enucleation of the tumour.

Figure 9.10 Excision of the pedicle.

Figure 9.11 The loop is laid over the transformation zone to encompass the lesion.

Figure 9.12 The wire is then ‘followed’ rather than pushed through the cervix.

Figure 9.13 Placing the lateral haemostats.

Figure 9.14 Cutting the cone biopsy.

Figure 9.15 Grasping the cone biopsy.

Chapter 10

Figure 10.1 Curettage of the uterine cavity.

Chapter 11

Figure 11.1 Cutting the round ligaments.

Figure 11.2 Cutting the ovarian ligament.

Figure 11.3 Incising the uterovesical fold.

Figure 11.4 Separating the bladder.

Figure 11.5 Clamping the uterine artery.

Figure 11.6 Clamping the parametrium.

Figure 11.7 Incising the vagina (showing all clamps in place).

Figure 11.8 Suturing the vaginal edge.

Figure 11.9 Hysterectomy for a double uterus: dividing the vesicorectal fold or median raphe.

Figure 11.10 Infiltration of subepithelial tissues.

Figure 11.11 Incision around the cervix.

Figure 11.12 Opening the pouch of Douglas.

Figure 11.13 Clamping of the ligaments.

Figure 11.14 Ligation of the divided pedicle.

Figure 11.15 Opening the uterovesical peritoneum.

Figure 11.16 Ligation of the uterine vessels.

Figure 11.17 Clamping the tubo‐ovarian pedicles.

Chapter 12

Figure 12.1 Bonney myomectomy clamp applied to the lower uterus.

Chapter 13

Figure 13.1 Total salpingectomy for a tubal pregnancy.

Figure 13.2 Removing an ampullary tubal pregnancy with conservation of the tube.

Figure 13.3 Ligation and resection of the fallopian tube.

Chapter 14

Figure 14.1 Incising the ovary over an ovarian cyst.

Figure 14.2 Removing the ovarian cyst intact.

Figure 14.3 Opening the peritoneum and identifying the ureter.

Chapter 15

Figure 15.1 Reflecting the peritoneum over the lower uterine segment.

Figure 15.2 Incising the uterovesical fold.

Figure 15.3 Separating the bladder from the lower segment.

Figure 15.4 Extending the lower‐segment incision (a) in a cephalad–caudad direction; and (b) in a transverse direction.

Figure 15.5 Attaching Green Armytage forceps to the lateral edges of the lower‐segment wound.

Figure 15.6 (a and b) Suturing the lower segment in two layers.

Chapter 16

Figure 16.1 Vaginal incision using ‘tunnelling’ technique. Note that the tips of the scissors must be kept against the vaginal skin to keep the plane of separation between the skin and the fascia.

Figure 16.2 Separation of pubocervical fascia from vaginal skin. Note that the plane is more easily extended by gentle traction on the fascia itself.

Figure 16.3 The plane of separation is further developed onto the cervix or (vaginal vault).

Figure 16.4 Insertion of plicating sutures into pubocervical fascia. Note that by using overlapping box sutures there is no possibility of gaps for further herniation.

Figure 16.5 Vaginal skin closure. Note that catching the underlying fascia in each bite helps to reduce dead space and limits the chance of haematoma.

Figure 16.6 Transverse incision at perineum. Note that if perineorrhaphy is planned, a transverse incision should be made between the two lateral forceps, otherwise a simple midline incision is made (dotted line).

Figure 16.7 Midline incision of vagina.

Figure 16.8 Separation of the vagina from the pre‐rectal fascia. Note that the plane is more easily extended by gentle traction on the fascia itself.

Figure 16.9 Interrupted sutures are placed in the pre‐rectal fascial. Note that the sutures should not be placed too laterally if a tension‐free repair is to be achieved.

Figure 16.10 Vaginal skin closure. Note that catching the underlying fascia in each bite helps to reduce dead space and limits the chance of haematoma.

Figure 16.11 Vaginal skin flaps are dissected off the underlying bulbocavernous and transverse perineal muscles.

Figure 16.12 Reconstruction of the perineal body. Note that the ideal direction of needle placement to secure the bulk of bulbocavernous and transverse perineal muscles is as shown in the magnified inset.

Figure 16.13 Closure of enterocoele sac with a series of purse‐string sutures.

Figure 16.14 Plicating sutures placed into uterosacral ligaments and peritoneum of the pouch of Douglas.

Figure 16.15 Suture ends are brought through the vaginal skin behind the vault, to be tied after skin closure.

Figure 16.16 Visualization of the right sacrospinous ligament. Note that the Breisky retractor on the patient’s right must rest on the ischial spine (not deeper), with traction in a lateral direction.

Figure 16.17 Placement of suture into sacrospinous ligament. Note that the suture is placed through (not around) the ligament; the hook is then manipulated into the notch on the Sims’ speculum and the suture retrieved using a nerve hook.

Figure 16.18 ‘Pulley‐stitch’ is used to fix the suspensory sutures to the vaginal skin just below the vaginal vault.

Figure 16.19 Three sutures placed through the uterosacral ligament on the right side.

Figure 16.20 Sutures (double‐armed), already through the ligament, are secured into the pubocervical and pre‐rectal fasciae.

Figure 16.21 Indigo carmine confirmed to efflux from ureteric orifice.

Figure 16.22 Tying the suspensory sutures, bringing the upper edges of the pubocervical and pre‐rectal fasciae together at the apex, in proximity to the ligaments at the vaginal vault. Note that if the sutures are tied after closure of the vaginal skin, they must be trimmed short, ensuring that the ends do not protrude through the vault incision.

Figure 16.23 Attachment of mesh to vaginal wall.

Figure 16.24 Attachment of mesh to sacral promontory.

Figure 16.25 A strip of vaginal epithelium is marked out, prior to excision using a no.12 scalpel blade.

Figure 16.26 Lembert sutures are used to invert the fascial layers.

Figure 16.27 Modified Martius labial fat graft may be used to fill dead space in the lower vagina.

Figure 16.28 Vaginal epithelium stripped from anterior and posterior walls prior to Le Fort’s procedure.

Figure 16.29 Having closed the vaginal skin over the vault around a drain tube, inverting Lembert sutures are used to approximate the fascia underlying the anterior and posterior vaginal walls.

Chapter 17

Figure 17.1 Patient in a horizontal lithotomy position with legs in Lloyd‐Davies stirrups.

Figure 17.2 Retropubic space opened.

Figure 17.3 The surgeon using their nondominant index finger in the vagina to apply pressure upwards and laterally, at the level of the bladder neck: (a) operative view; (b) sagittal section.

Figure 17.4 Tips of Metzenbaum scissors used to aid dissection of the paravaginal fascia.

Figure 17.5 Sutures inserted into the paravaginal fascia on each side, using Turner‐Warwick needle holder.

Figure 17.6 Two or three sutures are inserted on each side, tied down onto the paravaginal fascia, and then passed through the ileopectineal ligament.

Figure 17.7 By using the ‘pulley’ suture the paravaginal fascia is brought into proximity with the pelvic sidewall but not directly on to the ileopectineal ligament; ‘bow‐stringing’ of sutures does not detract from the effectiveness of the procedure.

Figure 17.8 Moschowitz procedure for enterocoele closure; lowermost suture already tied, second in place, and position of third (incorporating uterosacral ligaments) shown as dotted line.

Figure 17.9 Intravenous urogram in patient with bilateral ureteric obstruction following colposuspension; point of obstruction visible, with hydroureter and hydronephrosis on the right; minimal function visible as faint nephrogram only on left.

Figure 17.10 Dissection using fine Metzenbaum scissors to create a space paraurethrally into which the TVT™ needle may be safely introduced.

Figure 17.11 The introduction needle is ‘palmed’ in the operator’s left hand as it is eased in the plane between vagina and urethra.

Figure 17.12 The handle is then lowered and the needle passed through the retropubic space, to emerge from the suprapubic incision. (a) and (c) show the needle passed on the patient’s right side (in coronal plane), and (b) on the left (in sagittal plane).

Figure 17.13 Cystoscopic photograph, showing bladder perforation by introduction needle.

Figure 17.14 Check cystoscopy may be undertaken after each needle passage, but must as a minimum, must be carried out after the final needle passage, before tape adjustment (as in this image).

Figure 17.15 Metzenbaum scissors placed beneath the tape when adjustments are being made: (a) leakage apparent; (b) leakage resolved.

Figure 17.16 Cystoscopic photograph, showing bladder perforation by tape, with overlying encrustation.

Figure 17.17 Cystoscopic photograph, showing urethral perforation by tape. The open bladder neck can be seen in distance (outlined by dotted line) in the top left of the image; fibres of the tape are seen across the right side of the image.

Figure 17.18 The points for needle insertion marked, 1 cm lateral to the ischiopubic ramus, just below the adductor longus muscle tendon, on a horizontal line level with the clitoris.

Figure 17.19 The introducer is held vertically with the handle downwards as it is introduced through the skin incision.

Figure 17.20 The introducer is then passed around the ramus by rotation of the operator’s wrist.

Figure 17.21 The tape, once connected to the tip of the introducer, is pulled through into position by traction and rotation of the introducer in the reverse direction.

Figure 17.22 Rectus sheath sling marked and cut from aponeurosis: (a) as two strips cut transversely; (b) the incisions extended downwards in the midline, forming a T‐shape.

Figure 17.23 Vaginal incision for rectus sheath sling

Figure 17.24 The plane is developed by sharp dissection, and the endopelvic fascia is then perforated with scissors or a finger, to gain entry into the retropubic space from below.

Figure 17.25 A uterine packing forcep is passed from the vaginal incision upwards through the retropubic space, grasps the stay suture on one end of the sling and then brings the sling down into the vaginal dissection.

Figure 17.26 The two ends of the sling are secured in a ‘double‐breasted’ fashion.

Figure 17.27 A ‘Stamey’ needle is used to pass the sutures upwards through the retropubic space from below.

Figure 17.28 (a) Purely abdominal approach for insertion of alloplastic sling; the sling is drawn under the bladder neck. (b) Purely abdominal approach for insertion of alloplastic sling; here the sling is shown sutured the ileopectineal ligaments.

Figure 17.29 The paraurethral needle advanced parallel to the cystoscope until its position can be seen just below the bladder neck within the mucosa.

Figure 17.30 Three injection sites completed, creating the cystoscopic appearance of ‘prostatic lobes’.

Figure 17.31 Transurethral approach to urethral injection; endoscopic needle (arrowed) positioned just below bladder neck

Figure 17.32 Boston Scientific Corp AMS 800™ device.

Figure 17.33 The sphincter cuff is placed around the bladder neck ‐ this can be supplemented with an omental wrap (not shown); the pressure‐regulating balloon is positioned to the right side of the bladder; the control pump is shown here as it is about to be passed into the right labium majus.

Figure 17.34 Botulinum neurotoxin injected systematically around the bladder wall, avoiding the trigone.

Chapter 18

Figure 18.1 Dye testing with methylene blue: (a) before dye instillation; (b) after dye instillation, showing dye leaking from vesicovaginal and vesicovulval fistulae – arrowed.

Figure 18.2 Patient in exaggerated supine lithotomy position with steep head‐down tilt; note buttocks over end of table with a wedge or pillow to support lumbosacral spine, and shoulder supports to prevent patient from sliding.

Figure 18.3 Patient in prone lithotomy position with head‐up tilt.

Figure 18.4 Cystoscopic appearance of post‐hysterectomy fistula (identified by a probe passed through from the vagina), typically on the posterior bladder wall, in the midline above the inter‐ureteric bar.

Figure 18.5 Appearance of acute radiotherapy‐associated mid‐vaginal fistula.

Figure 18.6 Slough on anterior vaginal wall eight days following obstructed labour.

Figure 18.7 Author’s preferred set of fistula instruments.

Figure 18.8 Modified Martius labial fat graft dissected from right labium majus to overlie urethral reconstruction.

Figure 18.9 Gracilis muscle graft dissected from right thigh using a ‘step’ incision approach (a) above, prior to tunnelling to overlie fistula repair (b) below.

Figure 18.10 Transposition skin flap marked out on left side of vulva.

Figure 18.11 Transposition skin flap incised and mobilized.

Figure 18.12 Transposition skin flap sutured in place overlying residual vaginal defect (in this example reconstructed urethra); the donor site is also sutured.

Figure 18.13 Labium minus flap dissected on right side.

Figure 18.14 Longitudinal skin incision is made in the labium majus, incorporating a skin island of appropriate size for the defect to be filled.

Figure 18.15 Island graft passed subcutaneously to cover defect.

Figure 18.16 Gracilis muscle myocutaneous graft.

Figure 18.17 Large mid‐vaginal fistula with ureters in the edge of the fistula; ureteric catheters in place, brought out through the external urethral meatus.

Figure 18.18 Fistula circumcised as transverse ellipse, with lateral extension to facilitate mobilization.

Figure 18.19 Mobilization of vaginal skin edges from underlying bladder using bistoury blade.

Figure 18.20 Further mobilization with Chassar Moir scissors.

Figure 18.21 Blunt dissection away from the fistula edge using pledget.

Figure 18.22 Angles of the fistula are secured first with inverting sutures.

Figure 18.23 First layer of the bladder repair is completed with similar inverting sutures once the angles are secured.

Figure 18.24 Second layer is inserted so as to close off dead space by catching the back of the vaginal flaps.

Figure 18.25 After testing the integrity of the repair, interrupted mattress sutures close and evert the vaginal skin.

Figure 18.26 For saucerization, the fistula track is converted into a small crater.

Figure 18.27 The saucerized track is closed with single‐layer interrupted mattress sutures.

Figure 18.28 Transverse closure of juxtacervical fistula.

Figure 18.29 Partial colpocleisis by Latzko technique.

Figure 18.30 Circumferential fistula repair: the initial circumcision of the fistula is completed (dashed line) and then extended to separate the distal urethral stump and the bladder from underlying bone (dotted lines).

Figure 18.31 Circumferential fistula repair: the anterior (ventral) sutures have been inserted.

Figure 18.32 Circumferential fistula repair: after tying the ventral sutures, the posterior (dorsal) sutures are inserted and then tied.

Figure 18.33 Urethral reconstruction: a U‐shaped incision is made on the anterior vaginal wall, extending from the posterior edge of the fistula to the intended position of the external meatus.

Figure 18.34 Transvesical repair: the bladder is opened and a Millin’s retractor inserted.

Figure 18.35 Transvesical repair: the ureters have been catheterized and the fistula visualized with the aid of skin hooks.

Figure 18.36 Transvesical repair: the fistula is circumcised through the full thickness of the bladder wall.

Figure 18.37 Transvesical repair: further dissection of bladder wall from vagina is undertaken using a bistoury blade or Chassar Moir scissors.

Figure 18.38 Transvesical repair: the vagina is closed with a series of interrupted sutures, by working through the excised fistula track.

Figure 18.39 Transvesical repair: the bladder muscle is repaired with a layer of interrupted sutures working from the angles in towards the midline.

Figure 18.40 Transvesical repair: the mucosa and underlying superficial muscle are approximated with a continuous suture.

Figure 18.41 Transperitoneal repair: the incision extends from the dome around the fistula, resulting in a near bivalving of the bladder.

Figure 18.42 Transperitoneal repair: the fistula track is excised and further separation of bladder and vagina undertaken.

Figure 18.43 Transperitoneal repair: omental interposition flap; the omentum has been mobilized from the transverse colon and stomach and passed down the paracolic gutter to be placed over the vaginal closure.

Chapter 19

Figure 19.1 Single photon emission tomography/computed tomography allows for accurate localization of a right inguinal sentinel lymph node in a right lateral vulval cancer.

Figure 19.2 Gamma probe used to identify the area of greatest activity prior to surgery.

Figure 19.3 Sentinel incision (right) compared with crease incision in the left groin.

Figure 19.4 The triple incision technique: traditional Gateshead groin incision (right) and crease incision (left).

Figure 19.5 Butterfly skin incision.

Figure 19.6 Cutting the upper incision down to the external oblique aponeurosis.

Figure 19.7 Elevating the medial edge of the sartorius fascia and cleaning the femoral artery.

Figure 19.8 Clamping and dividing the saphenous vein below the cribriform fascia.

Figure 19.9 The completed groin dissection.

Figure 19.10 Clamping the inferior epigastric artery and Poupart’s ligament.

Figure 19.11 Removing the pelvic lymph nodes.

Figure 19.12 Repair of the inguinal ligament.

Figure 19.13 The vulval incision.

Figure 19.14 Completed repair of the vulval wound.

Chapter 21

Figure 21.1 Dividing the right ovarian ligament.

Figure 21.2 Identifying the uterine artery close to the pelvic sidewall.

Figure 21.3 Dividing the right uterine artery at its origin.

Figure 21.4 Identifying the ureteric tunnel.

Figure 21.5 (a and b) Separating the ureter from the roof of the ureteric tunnel.

Figure 21.6 Opening the space between the rectum and the vagina.

Figure 21.7 The rectum separated from the vagina, showing the arch of the uterosacral ligaments.

Figure 21.8 The position of the tissue clamps on the uterosacral (1) and cardinal (2) ligaments and the paracolpos (3).

Figure 21.9 Beginning of the pelvic node dissection.

Figure 21.10 The complete block of lymph nodes being removed from the external iliac vessels.

Figure 21.11 Completing the pelvic node dissection in the obturator fossa.

Figure 21.12 The Gyne Tube.

Figure 21.13 Comparison of relative anatomy of ureter and uterine artery between an abdominal and vaginal approach (a, artery; u, ureter).

Figure 21.14 Chrobak forceps.

Figure 21.15 Preparation of the vaginal cuff.

Figure 21.16 Vaginal incision.

Figure 21.17 Dissection of the rectum from the posterior vaginal wall.

Figure 21.18 Closure of the vaginal cuff.

Figure 21.19 Opening of the right paravesical space.

Figure 21.20 Joining the paravesical and pararectal spaces. Horizontal fascia exposed.

Figure 21.21 Displaying the right ureter.

Figure 21.22 Ligation and display of left uterine vessels.

Figure 21.23 Division of uterosacral ligaments.

Figure 21.24 Purse‐string suture to close the peritoneum.

Chapter 24

Figure 24.1 The limits of resection for (a) an anterior and (b) a total exenteration.

Figure 24.2 Packing the vagina.

Figure 24.3 Pelvic and para‐aortic node assessment.

Figure 24.4 Division of the round and infundibulopelvic ligaments and the beginning of the lateral pelvic dissection.

Figure 24.5 Deepening the lateral pelvic dissection to reveal the pelvic spaces.

Figure 24.6 The pelvic incision for an anterior exenteration.

Figure 24.7 Dividing the sigmoid colon with the GIA stapling device.

Figure 24.8 Exenteration clamps applied to the anterior division of the internal iliac arteries.

Figure 24.9 The perineal incisions for anterior and total exenterations.

Figure 24.10 Suture of the internal iliac arteries and lateral pelvic pedicle.

Figure 24.11 Development of the ‘omental pelvic floor’: (a) omental incision; (b) soft trampoline area.

Chapter 25

Figure 25.1 Incision for exposure of aorta and inferior vena cava.

Figure 25.2 Exposure of aortic injury.

Chapter 26

Figure 26.1 (a–c) Anastomosis of the ureter after either transection or resection of a short length of damaged ureter.

Figure 26.2 A correctly placed double pigtail stent (drawing kindly provided by Boston Scientific Corporation).

Figure 26.3 The psoas hitch.

Figure 26.4 The Boari–Ockerblad flap: developing the flap from the bladder wall.

Figure 26.5 The Boari–Ockerblad flap: suturing the flap to form a tube over the antiflux anastomosis.

Figure 26.6 Implantation of the ureter into the bladder wall.

Figure 26.7 The affected ureter is dissected free.

Figure 26.8 A cystotomy is created anteriorly.

Figure 26.9 Suture connected to the ureter is grasped by a Maryland dissector inserted through the urethra.

Figure 26.10 Placing of a double ‘J’ stent through the urethra.

Figure 26.11 Repair of the bladder using an Endo Stitch.

Figure 26.12 Bringing the ureters into an intraperitoneal position.

Figure 26.13 Choosing an ileal segment with a broad‐based arterial arcade.

Figure 26.14 Resecting the bowel segment with a GIA stapling device.

Figure 26.15 Reconstituting bowel continuity using the GIA stapling device.

Figure 26.16 Showing the isolated loop of bowel and the completed re‐anastomosed small bowel.

Figure 26.17 Joining the splayed out ends of the ureter and inserting the T tube.

Figure 26.18 Drawing the long arm of the T tube down the segment of the bowel.

Figure 26.19 Forming the ‘rosebud’ stoma.

Chapter 27

Figure 27.1 Dividing the appendix mesentery.

Figure 27.2 Removing the appendix.

Figure 27.3 Resection of a damaged segment of small bowel.

Figure 27.4 Suturing the serosa of the bowel segments.

Figure 27.5 Completing the serosal suture.

Figure 27.6 Apposing the mesenteric edges.

Figure 27.7 The site of incision for a temporary transverse colostomy.

Figure 27.8 Anchoring the loop of large bowel to the surface.

Figure 27.9 Dividing large bowel using the GIA stapling device.

Figure 27.10 Removing the skin disc at the stoma size.

Figure 27.11 Incising the abdominal wall fat, musculature and peritoneum.

Figure 27.12 (a) Removing the staple line and (b) suturing the edge to the skin.

Figure 27.13 Incising the ileum.

Figure 27.14 Forming a ‘rosebud’.

Figure 27.15 Apposing the small and large bowel.

Figure 27.16 Forming a stapled communication between large and small bowel.

Guide

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This book is dedicated to the memory of Victor Bonney.

It is also dedicated to Jane, Vicki, Lucia, and Maggie for their support, understanding, patience and love, which they have shown us in our lives together.

Bonney’s Gynaecological Surgery

TWELFTH EDITION

Alberto (Tito) de Barros Lopes, MB ChB, FRCOG

Honorary Clinical Senior Research FellowUniversity of Exeter Medical SchoolRetired Consultant Gynaecological OncologistNorthern Gynaecological Oncology CentreQueen Elizabeth Hospital, GatesheadRoyal Cornwall Hospital, Truro, UK

Nick M. Spirtos, MD, FACOG

Clinical Professor, University of Nevada Las Vegas School of MedicineMedical Director, Women’s Cancer Center of NevadaLas Vegas, NV, USA

Paul Hilton, MD, FRCOG

Guest Clinical Senior Lecturer, Newcastle UniversityRetired Consultant Gynaecologist & UrogynaecologistNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon Tyne, UK

John M. Monaghan, MB, FRCS (Ed), FRCOG

Retired Senior Lecturer in Gynaecological OncologyUniversity of Newcastle Upon TyneRetired Gynaecological OncologistRegional Department of Gynaecological OncologyQueen Elizabeth Hospital, Gateshead, UK

This twelfth edition first published 2018 © 2018 by John Wiley & Sons Ltd

Edition HistoryJohn Wiley & Sons Ltd (11e, 2011)

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Alberto (Tito) de Barros Lopes, Nick M. Spirtos, Paul Hilton, and John M. Monaghan to be identified as the authors in this work has been asserted in accordance with law.

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Library of Congress Cataloging‐in‐Publication Data

Names: de Barros Lopes, Alberto (Tito), author. | Spirtos, Nick M., author. | Hilton, Paul (Urogynaecologist), author. | Monaghan, John M., author.Title: Bonney’s gynaecological surgery / Alberto (Tito) de Barros Lopes, Nick M. Spirtos, Paul Hilton and John M. Monaghan.Other titles: Gynaecological surgeryDescription: 12th edition. | Hoboken, NJ : Wiley, 2017. | Preceded by Bonney’s gynaecological surgery. 11th ed. / Tito Lopes ... [et al.]. c2011. | Includes bibliographical references and index. |Identifiers: LCCN 2017056122 (print) | LCCN 2017056804 (ebook) | ISBN 9781119266921 (pdf) | ISBN 9781119266914 (epub) | ISBN 9781119266785 (hardback)Subjects: | MESH: Gynecologic Surgical Procedures | Genitalia, Female–surgeryClassification: LCC RG104 (ebook) | LCC RG104 (print) | NLM WP 660 | DDC 618.1–dc23LC record available at https://lccn.loc.gov/2017056122

Cover Design: WileyCover Image: Courtesy of Chris Kevern

Preface

“The human form is a very delicate organization. It is not a thing which should be meddled with by people who do not know it as intimately as it is possible to know it”

Sir Watson Cheyne, Scottish surgeon and bacteriologist (1852–1932)

It is now more than 100 years since Comyns Berkeley and Victor Bonney published the first edition of what became the bible of gynaecological surgery in the UK. It is also over 30 years since, in 1984, one of the current editors, John Monaghan, was asked to take on the ninth edition as a major revision; little did he realise that he would continue as an editor for another three editions. Over these 30 years much has changed, not only in gynaecology and gynaecological surgery but also in the way in which we access information both textually and visually, with the invention of the World Wide Web in 1989 and the founding of YouTube in 2005.

What makes this textbook so successful is that it continues to be published in print well into the first quarter of the 21st century? Sir Watson Cheyne’s statement reminds us that one should not undertake surgery without knowing the subject intimately, and ‘Bonney’ provides the foundation for developing the skills needed to become a competent if not a great gynaecological surgeon.

This edition continues the format introduced in the last edition, being divided into sections, the first section covering general principles and basic techniques, the second section, presented by anatomical site, covers the common procedures undertaken in day‐to‐day benign gynaecology and the remaining sections concentrate on the two surgical subspecialties of urogynaecology and gynaecological oncology. The editorial team has changed slightly from the previous edition, bringing in the internationally recognized skill of Paul Hilton to write the section on urogynaecology, which includes over 100 new drawings.

All the chapters have been updated based on new technologies and level 1 and 2 evidence. Over 160 references and articles, published since the last edition, have been added and these include 13 randomized controlled trials, 30 Cochrane reviews and over 20 specialist guidelines.

We would like to thank Wiley‐Blackwell for inviting us to produce this edition of Bonney’s Gynaecological Surgery. We also thank the production team for their assistance in the pleasant process of communicating our views of gynaecological surgery. Our special thanks go to Chris Kevern who produced the cover photograph for this edition.

Finally, we each thank the others in our editorial team for their skill, companionship and friendship which has not been impaired by production of this latest edition of ‘Bonney’.

The EditorsNovember 2017

PART 1General

CHAPTER 1Introduction and prologue

Surgery remains only as safe as those wielding the scalpel.

Tito Lopes

Introduction

Surgical training

Surgical training in gynaecology has seen dramatic changes in both the UK and the USA over the past 20–30 years. When the current editors were in training, there were no restrictions on the number of hours that they could be asked to work. It was common to be resident on call every third night in addition to daytime work, which often resulted in a working week in excess of 110 hours. In the UK, the European Working Time Directive was extended to junior doctors in 2004 thereby reducing the working week to an average of 48 hours. In the United States, the Accreditation Council for Graduate Medical Education in 2003 required duty hours to be limited to 80 hours per week.

Although the reduction in working hours is important for one’s work–life balance as well as patient safety, it inevitably has had a major impact on surgical training. The concept of the surgical team or firm to which a trainee was attached has all but disappeared. The introduction of shift systems has made it difficult, and in some cases impossible, for trainees to attend the surgical and clinical sessions of their team. This has resulted in some trainees failing to comprehend the continuity of care of a surgical patient, running the risk of producing technicians rather then doctors.

At the same time, there has been a marked reduction in the number of hysterectomies performed as a result of more conservative management options for dysfunctional uterine bleeding. In the nine‐year period from 1995 to 2004, there was a 46% reduction in the number of hysterectomy operations performed in NHS hospitals in England and between 2008 and 2012 there was a further 7% fall in hysterectomies in the UK.

With the increasing use of laparoscopic surgery in elective gynaecology, including for hysterectomy, the ‘open’ approach to gynaecological surgery, traditionally the surgical ‘bread and butter’ for trainees, is also on the decline. Equally, a large number of ectopic pregnancies are now managed conservatively meaning that trainees are lacking exposure to emergency laparoscopic surgery for tubal pregnancies.

It is vital that standard safe techniques continue to be taught to all trainees. Thus, although many procedures have been translated into minimal access operations the principles and practice of the open version must be learned alongside the minimal access approach. This is especially relevant wherever a minimal access procedure has to be translated into an open procedure because of difficulties and complications experienced during the operation. It is a concern of the editors that the ‘unusual’ is not being experienced on a satisfactory scale by trainees. Nothing can replace time spent in the operating room for building up skills and confidence in dealing with the unusual and unexpected. A recent comment by a president of a Royal College compared the time limited training of a surgeon to the limitless time application of an Olympic athlete. Very few gold medals would be won if the Working Time Directive was followed!

Gynaecology training

Current training in the UK is a competency‐based process and it is envisaged that the majority of trainees will take seven years to complete the programme. In the last two years of training, the trainees are required to undertake a minimum of two of twenty available advanced training skills modules or they can apply for subspecialty training in gynaecological oncology, maternal and fetal medicine, reproductive medicine or urogynaecology. It is disappointing that as part of the current training programme the trainee must be deemed competent in opening and closing a transverse incision at caesarean section before commencing his or her second year but need only be assessed as competent for opening and closing a vertical abdominal incision if undertaking the advanced module for benign surgery in years six and seven.

Basic skills and training opportunities

Trainees wishing to develop as gynaecological surgeons should attend appropriate courses, including cadaver and live animal workshops. However, these are no substitutes for learning the basic surgical skills and picking up good habits, early in training; bad habits are difficult to lose at a later stage. As assistants, they should question any variations in technique among the surgeons. As surgeons, they should review every operation they perform to assess how they could have done better.

In relation to laparoscopic surgery, there is no excuse for trainees not practising with laparoscopic simulators, which are often readily available and easy to construct. It is readily apparent to trainers which trainees have spent adequate time on simulators.

Sadly, a consequence of the new training is an inevitable lack of knowledge and experience of the ‘unusual’, with the all too frequent result of difficulties for both the patient and the surgeon. These difficulties are often manifest in an almost complete failure to appreciate the wide range of possibilities for management. Previous editors of this text have advocated that any surgery should be tailored to the specific needs of the patient and her condition. Unfortunately, modern patients are in real danger of being treated by surgeons with a limited experience and a narrow range of skills which may be applied in a ‘one size fits all’ pattern. In this text, we have attempted to provide a wide range of options for management, which we would encourage all trainees to practise assiduously to give their patients the very best possible chance of a successful outcome.

Despite the recent changes in gynaecological training, the essence of surgery remains essentially unchanged. The editors have, as with previous editions, felt it appropriate to retain the prologue written for the 9th and 10th editions by JM Monaghan based on that of the 1st edition of this series, A Text‐book of Gynaecological Surgery, published in 1911 by Comyns Berkeley and Victor Bonney. It remains just as relevant today as it was a century ago.

Prologue: after Comyns Berkeley and Victor Bonney, (JM Monaghan)

The bearing of the surgeon

A surgeon when operating should always remember that the character of the work of his subordinates will be largely influenced by his own bearing. While it is impossible to lay down definite rules suitable for all temperaments, nevertheless there are certain considerations which will prove useful to those embarking on a gynaecological career. Anyone who has taken the trouble to study the work of other operators cannot fail to have observed how variously the stress and strain of operating is borne by different minds and will deduce from a consideration of the strong and weak points of each operator some conception of the ideal.

The thoughtful surgeon, influenced by this study, will endeavour to discipline himself so that he will strive constantly to achieve the ideal. By so doing, he will encourage all who work in the wards and theatres with him – young colleagues in training, anaesthetists, nurses, theatre assistants and orderlies – to appreciate the privileges and responsibilities of their common task. Expert coordinated teamwork is essential to the success of modern surgery. This teamwork has resulted in a significant lowering of operative morbidity and mortality.

However, it is important to recognize the enormous contribution to the safety of modern surgery made by other disciplines, especially anaesthesiology. The preoperative assessment and the postoperative care carried out by the anaesthetist has rendered surgery safer and has also allowed patients who would not in the past have been considered eligible for surgery to have their procedures performed successfully. The role of specialties such as haematology, biochemistry, microbiology, radiology, pathology and physiotherapy are also well recognized.

Bonney maintained that the keystone of a surgeon’s bearing should be his self‐control; and while it is his duty to keep a general eye on all that takes place in the operating theatre and without hesitation correct mistakes, he should guard against becoming irritable or losing temper. The surgeon who when faced with difficulties loses control has mistaken his vocation, however dexterous he may be, or however learned in the technical details of the art. The habit of abusing the assistants, the instruments or the anaesthetist, so easy to acquire and so hard to lose, is not one to be commended; the lack of personal confidence from which such behaviour stems will inevitably spread to other members of staff, so that at the very time the surgeon needs effective help it is likely to be found wanting. However, the converse of accepting poor standards of care and behaviour is not to be condoned. The continual presentation of inadequately prepared instrumentation should not be accepted. There is little excuse for staff or equipment to arrive in theatre in a state ill prepared for the task ahead.

The whole team should look forward to a theatre session as a period of pleasure, stimulation and achievement, not as a chore and a period of misery to be suffered. The surgeon should also remember that he is on ‘display’ and his ability to cope with adversity as well as his manner when the surgery is going well will be keenly observed. The surgeon should teach continuously, pointing out to assistants and observers the small points of technique as well as related facts to the case in hand.

Bonney enjoined that the surgeon should not gossip; the present editors feel that day‐to‐day chitchat is not out of place in the operating theatre and is to be preferred to the media view of an operating theatre as a place of knife‐like tension fraught with grave interpersonal relationships. However, the mark of the good surgeon and his team is that, at the time of stress, the noise level in theatre should fall rather than rise, as each member of the team goes about his or her task with speed and efficiency.

It is inevitable that at some point the surgeon will come face to face with imminent disaster; even the most stalwart individual will feel his heart sink at such a moment. The operator should always remember that at such moments if basic surgical principles are applied quickly and accurately the situation will be rapidly rescued. Hesitation and uncertainty will all too often terminate in disaster. A sturdy belief in his or her own powers and a refusal to accept defeat are the best assets of a calling which pre‐eminently demands moral courage.

Before operating, the surgeon should prepare by going over in his or her own mind the various possibilities in the projected procedure, so that there may be no surprises and he or she may all the better meet any eventuality. Likewise, following the procedure it is valuable to go over in one’s mind every step in the operation in order to analyze any deficiencies and difficulties experienced; it is only by this continuous self‐assessment and analysis that surgeons can from their own efforts improve their practice.

It is of increasing importance that the surgeon understands the need for meticulous record‐keeping in order to build a comprehensive database for future analysis. The modern surgeon has to continually examine his and others’ work in order to practice to the highest possible standards. More and more guidelines are being generated; the surgeon has to be sure that his work meets the quality requirements of modern practice. Patients, purchasers and professional bodies wish to be able to access the best possible practices. Transparency of standards is essential to modern medical practice. The high‐quality surgeon has little to fear from the implementation of guidelines and should look upon these times as opportunities for developing the highest quality of care.

Surgery is physically and mentally tiring. The surgeon should be sure to be adequately equipped in both these areas to meet the demands of theatre. It is important to remember that driving the staff on for long, tiring sessions is counterproductive; there is little merit in performing long procedures with an already exhausted staff. The surgeon’s hands and mind become less steady, the assistants less attentive and the nurses tired and disillusioned. It is under these circumstances that mistakes occur. It is important, however, not to be dogmatic about the ideal length either of individual operations or of operating lists. A full day in the operating theatre may suit one surgical team but be anathema to another.

Speed in operating

Speed, as an indication of perfect operative technique, is as characteristic of a fine surgeon, as striving for after‐effect is the stock‐in‐trade of the charlatan. An operation rapidly yet correctly performed has many advantages over one as technically correct yet laboriously and tediously accomplished. The period over which haemorrhage may occur is shortened, the tissues are handled less and are therefore less bruised, the time the peritoneum is open and exposed is shortened, the amount and length of anaesthesia is shortened and the impact of the operative shock, which is an accumulation of all these factors, is lessened. Moreover, less strain is put upon the temper and legs of the operator and assistants with the result that the interest of the latter and the onlookers is maintained at the highest level. However, this speed must be tempered with attention to detail, particularly of haemostasis, and by a conscious effort not to unnecessarily handle tissue.

Operative manipulation

The surgeon should continually endeavour to reduce the number of manipulations involved in a procedure to the absolute minimum consistent with sound performance. If an operation is observed critically, one is struck by the vast number of unnecessary movements performed, the majority of which are due to the uncertainty and inexperience of the operator. In older surgeons, unless care is taken to analyze these movements and eliminate them they will become part of the habits and ritual of the procedure.

Minimizing trauma is of fundamental importance for uncomplicated wound healing. The art of gentle surgery must be developed (Moynihan). Sadly, many surgeons achieve speed by being rough with tissue, particularly by direct handling. This must be avoided at all costs, and the temptation to tear tissue with the hands rather than to delicately incise and dissect with instruments is to be eschewed. All operative manipulations should be gentle; force is occasionally essential but should be applied with accuracy, only to the tissue to be removed and for limited periods of time. The surgeon who tears and traumatizes tissue will see the error of his ways in the long recovery periods that his patients require and in the high complication rate.

Moynihan spoke in 1920 at the inaugural meeting of the British Association of Surgeons on ‘The ritual of a surgical operation’, stating that ‘he [the surgeon] must set endeavour in continual motion, and seek always and earnestly for simpler methods and a better way. In the craft of surgery the master word is simplicity’.

Further reading

Berkeley C, Bonney V.

A Text‐book of Gynaecological Surgery

. London: Cassell and Company, 1911. Available at the Internet Archive

https://archive.org/details/atextbookgyncol00bonngoog

(accessed 10 October 2017). This copy is a 1913 reprint of the first edition.

Hospital Episode Statistics. NHS Digital. Available at

www.hesonline.nhs.uk

(accessed 21 September 2017).

Moynihan BGA. The ritual of a surgical operation.

Br J Surg

1920;8:27–35.

Eurostat. Surgical operations and procedures statistics. October 2016. Available at

http://ec.europa.eu/eurostat/statistics‐explained/index.php/Surgical_operations_and_procedures_statistics

(accessed 21 September 2017).