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  Understand the principles of gynecologic surgery

  
  
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  Appreciate risks for surgical complications, and the precepts to be followed

  
  
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  Know technical bail-out strategies for common scenarios

Gynecologic surgery has become much more diverse in the last 20 years. With the advent of minimally invasive surgery and increasing use of mesh and other graft materials, the ­number of procedures that a gynecologic surgeon must know has increased. No longer is it enough for a skilled gynecologic surgeon to know how to do an abdominal hysterectomy and a vaginal hysterectomy, and how to do a retropubic urethropexy or an anterior and posterior repair. A skilled gynecologic ­surgeon must also now know how to do laparoscopic surgery, ­hysteroscopic surgery, endometrial ablation, and how and when to use mesh grafts. A skilled surgeon must not only know how to do these procedures, but know the common intraoperative complications of these procedures and be prepared to manage them.

The advent of new procedures leads to new complications. New techniques lead to new technical errors. The skilled ­surgeon must know how to recognize these potential ­complications and errors and how to manage them—in other words, how to get out of trouble once it starts. It is always ­better to prevent ­complications than to manage them, but the only way to completely prevent operative complications is to never operate. Thus, the skilled surgeon must simultaneously work to prevent complications and to recognize and manage them when they occur.

Although new operations have new complications, the precepts of intraoperative management have not changed since the days of William Halsted and Howard Kelly.

Howard Kelly has been credited with establishing gynecology as a discipline in America. In his classic book Gynecology and Abdominal Surgery¹ he emphasized asepsis; careful preoperative preparation of the instruments, suture, surgeons, and assistants; proper positioning of the patient; adequate lighting and visualization; proper retraction; proper instruments for the planned procedure; and knowledge of the planned procedure. He described almost everything that is listed in the “time-out” safe surgical checklist used in operating rooms (ORs) today.

These principles and precepts are as applicable today as they were a century ago. A principle is a primary truth from which other truths can be derived. A precept is a commandment or direction given as a rule intended to regulate behavior or thought. Principles give rise to precepts. It is important for a surgeon to follow precepts, but it is more important to understand the principles on which the precepts are based. A skilled surgeon must know when to abandon a precept in order to ­follow the principle.

In this chapter, I will review principles and precepts for a gynecologic surgeon and some common complications of gynecologic and obstetric surgeries and how they can be managed by following these principles and precepts, using a ­case-based format. All of the cases are based on actual cases in my experience, but have been changed enough to de-identify the patient.

Case Study 13.1

The problem: Difficulty with anterior entry at vaginal hysterectomy.

The story: A woman is scheduled for vaginal hysterectomy for recurrent high grade squamous intraepithelial lesion (HSIL). She has had 2 LEEP procedures, the most recent 3 months prior. She has had 1 prior cesarean delivery. The cervix is flush with the vagina. The cervix is circumscribed and the posterior peritoneum is identified and entered. When attempting to dissect the anterior peritoneum away from the cervix, the surgeon encounters difficulty in finding the correct plane. The dissection is carried up bluntly but the anterior peritoneum cannot be definitely identified and the field is bloody. Sharp dissection is used with the Metzenbaum scissors and suddenly urine is seen in the operative field.

The patient’s outcome: In this case, the patient required additional repair of the bladder injury. Bladder injury is a recognized complication of vaginal hysterectomy, and the risk should have been part of the preoperative counseling. Preoperative counseling of potential risks makes postoperative disclosure much easier.

It is part of the skilled vaginal surgeon’s armamentarium to be able to repair a bladder injury. When a bladder injury occurs during the dissection for an anterior entry at vaginal hysterectomy, the injury is almost always in the dome of the bladder, above the trigone in the midline. Once the injury has occurred, it is important to identify the extent of the injury. Once the bladder is entered, you know where it is. The bladder can be dissected away from the uterus until the anterior peritoneum is found by dissecting between the bladder wall and the uterus.

The bladder must be dissected free of the uterus and the injury dissected away until it can be easily visualized. The injury will usually be transverse in the bladder and can be closed front to back (see Figure 13.1). Stay sutures are placed at either corner of the injury, and the bladder is closed in 2 layers of fine absorbable sutures. It is good to have sterile milk or formula (usually available in the nursery) to use to check the watertightness of the repair. The milk should be diluted with water until it is still opaque. The bladder is then filled and the suture line observed for leaks. If a leak is seen, an additional stitch may be required. Other dyes such as methylene blue or indigo carmine can be used, but they may stain the tissue at the suture line, making it difficult to tell if the repair is watertight if a second suture is needed. Cystoscopy should be performed at the end of the procedure to visualize the ureteral orifices and confirm ureteral jets.

What went wrong? Several precepts were not followed. These are meticulous hemostasis; adequate exposure; and knowing an alternative way to perform a surgery. Difficulty identifying the anterior peritoneum is a common problem facing the vaginal surgeon. When a patient has had prior LEEP procedures or prior cesarean deliveries, the surgeon should be prepared for possible difficulty in the anterior dissection and be careful to identify the bladder and the anterior peritoneum. A bloody operative field not only obscures vision, but also is a sign that the surgeon is not in the right plane. Inability to easily dissect the bladder away bluntly is also a sign that the surgeon is not in the right plane. Failure to adequately visualize the bladder and peritoneum was due to inadequate exposure.

How to prevent this error in the future? The first step in preventing this error is early recognition of the potential complication. Maintain meticulous hemostasis by adequately ligating the feeder vessels. Clamping and ligating the bladder pillars control bleeding and increase exposure. Dissecting the anterior cervix until the transverse fibers of the endopelvic fascia can be seen helps to identify the proper plane. If the anterior peritoneal reflection cannot be easily identified, clamping and dividing the uterosacral and cardinal ligaments can increase exposure as the dissection is carried upward.

Surgical pearls: If there is still difficulty identifying the anterior peritoneal reflection, a uterine sound can be used to aid in identification of the anterior peritoneal reflection. A malleable silver uterine sound (see Figure 13.2) is carefully bent into a hook (see Figure 13.3) until it can be introduced into the posterior colpotomy. The sound is then manipulated over the broad ligament until it can be brought to the anterior peritoneal reflection (see Figure 13.4). The tip of the sound should be easily visualized through the peritoneal reflection. If not, it can be palpated in the anterior incision to determine if the dissection is too deep or too shallow. Once the anterior peritoneal reflection is identified, it should be grasped with an Allis or similar clamp. If it is simply incised, the peritoneal reflection may retract back over the sound, making it difficult to find.

Case Study 13.2

The problem: Bleeding after vaginal hysterectomy/bilateral salpingostomy.

The story: A vaginal hysterectomy is performed for uterine prolapse. The uterus easily is pulled through the vaginal introitus under exam under anesthesia. The anterior and posterior colpotomies are performed without difficulty, and the uterus is removed without difficulty. After the utero-ovarian pedicles are ligated and divided and the uterus removed, the tubes are removed on either side by bringing them down with a Babcock clamp and clamping and ligating the mesosalpinx. The tubes are high in the pelvis, and some difficulty is encountered in pulling them down far enough to be ligated. After both tubes are removed, brisk bleeding is noted coming from the operative field. The bowel is packed away with a lap sponge, but the site of bleeding cannot be identified. The patient is noted to be hypotensive and tachycardic. Preparations are made for laparotomy. There is not a laparotomy tray in the room, and the circulating nurse is sent to find one. The anesthesiologist calls for blood to be brought to the OR and draws blood for hematocrit and clotting factors, but the circulating nurse is out of the room. The circulator returns to the OR with a laparotomy tray, and then 2 units of packed red blood cells (PRBC) are brought to the OR.

A laparotomy is performed and a large retroperitoneal hematoma is seen. It appears to be coming from the right side of the pelvis. A bleeding site is identified that could be from the right uterine artery or the right utero-ovarian/mesosalpinx. The patient is now hypotensive and tachycardic, and is bleeding from all incision sites. A clot tube is drawn and the blood is not clotted at 5 minutes or 10 minutes. A total of 4 units of PRBC have been given, and the hematocrit is now 22%. By holding pressure on a pack that covers the right side of the pelvis, the blood loss can be held to a minimum, but the patient appears to be in disseminated intravascular coagulation (DIC). Fresh frozen plasma and calcium are given.