Gynaecological surgery
GENERAL CONSIDERATIONS
INTRODUCTION
1. Unexpected gynaecological pathology may be found at an emergency abdominal operation or as an incidental lesion during surgery for an unrelated presentation. It is therefore advisable for the general surgeon to become familiar with this pathology and the operations that may need to be performed in an emergency. However, most elective gynaecological operations are of a specialized nature and should not be tried on an occasional basis.
2. Handle the pelvic organs especially gently when operating on premenopausal women. Careless surgery in the female pelvis will result in adhesions, which may considerably decrease a woman’s fertility.
3. Gynaecologists use the Pfannenstiel incision for many operations, but in emergencies dealt with by the general surgeon a midline or paramedian incision will often have been chosen because of the uncertain nature of the diagnosis. If access proves difficult, incise the medial one-third of the rectus abdominis muscles bilaterally, or ligate the inferior epigastric vessels and incise the full width of the rectus muscles (Maylard incision), or divide the rectus aponeurosis ½ cm above the symphysis pubis (Cherney incision).
4. Laparoscopy has been used as a diagnostic tool in acute pelvic pain for many years, as in general surgery. Minimal access surgery now includes a growing range of operative procedures, with the advantages of less postoperative pain, faster recovery and discharge, but it has not replaced laparotomy for many indications. It requires expertise and expensive equipment.
5. Ultrasound is well established as a diagnostic aid in gynaecological conditions, and in many cases exploratory surgery may be avoided where this is available.
6. Perform a pregnancy test on any female aged 12–50 with abdominal pain (with or without vaginal bleeding), as ectopic pregnancy is an important cause of maternal mortality.
Perioperative care
KEY POINTS
Special considerations in gynaecology
Ensure that your patient is thoroughly informed about the proposed procedure, and clearly document that consent has been given. Give a full explanation of expected (and rare) consequences, particularly if future fertility is likely to be affected. If the woman wishes, keep her partner informed as well. Use drawings, as they aid understanding (and file them in the hospital notes for medico-legal purposes).
Prepare
1. Positioning of patient. Vaginal operations are carried out in the lithotomy position. Laparoscopy is best carried out with the patient in Lloyd-Davies stirrups, with steep head-down tilt. Laparotomy is carried out with the patient supine and with 5–10° of head-down tilt.
2. Catheterization. Empty the bladder by catheterization before all open abdominal procedures and, if the patient has not passed urine immediately prior to surgery, before laparoscopy as well. Separate the labia and swab the urethral meatus with antiseptic solution. Without allowing the labia to close again, pass a silver or plastic catheter well into the bladder. Now let the labia approximate and press firmly and continuously suprapubically. When the urine flow ceases, gradually withdraw the catheter, taking care not to allow air to be sucked into the bladder.
BARTHOLIN’S ABSCESS (OR CYST)
Appraise
1. An abscess of the glands described in 1677 by the Copenhagen Professor Caspar Bartholin (1655–1738). It is an acutely painful condition, so deal with it as an emergency.
2. A sterile cyst may be dealt with electively by excision. Aim to remove (enucleate) the entire cyst, but if rupture occurs continue to remove the whole cyst cavity before obliterating the remaining space and closing the skin with interrupted 2/0 synthetic absorbable sutures.
3. The operation of marsupialization (Greek: marsypion = a pouch) is the procedure of choice for an abscess, since resection of the abscess cavity (as above) may cause considerable bleeding and recurrence is very likely following simple incision and drainage.
4. Ensure that the patient understands that the perineum is likely to be unsightly and very sore for a couple of weeks postoperatively.
Action
1. Make a vertical incision 1 cm long between the ipsilateral labium minor and hymenal remnants. Take a microbiological swab from the discharging pus.
2. Remove an elliptical area of skin and cyst wall from each side of the incision.
3. Break up loculations digitally.
4. Insert half a dozen or so fine synthetic absorbable sutures circumferentially to bring the cyst wall and skin into apposition, so leaving a wide ostium to the gland. Leave a gauze ribbon drain in the cavity for several hours.
REMOVAL OF PRODUCTS OF CONCEPTION FROM THE CERVICAL CANAL
Action
1. After taking a gynaecological history, where a woman is pregnant and has vaginal bleeding or abdominal pain, examine her sensitively with a bright focused light source and Cusco’s bivalve speculum, with gauze and metal sponge-forceps to hand.
2. Open the speculum after full insertion (applying pressure to keep it in place), allowing the cervix to be displaced into the area between the speculum blades.
3. Do not abandon the examination here if there is a lot of blood clot in the vagina. Use gauze held with sponge-forceps to sweep blood and clots from the vagina, and repeat with dry gauze until the vagina is dry, and you obtain a clear view of the vagina and cervix.
4. Look for purple or whitish material in an open cervix. These are products of conception, signifying an inevitable miscarriage. Stop heavy bleeding promptly by grasping this material firmly with the sponge forceps and applying continuous traction, removing the products.
5. Empty the vagina of blood again.
6. Observe the extent of bleeding onto a fresh sanitary pad for the next hour. The heavy bleeding almost always resolves with this intervention, but if not, perform dilatation and curettage (D&C) or evacuation of retained products of conception (ERPC).
DILATATION AND CURETTAGE (D&c), AND EVACUATION OF RETAINED PRODUCTS OF CONCEPTION (ERPC)
Appraise
1. You may need to perform a diagnostic dilatation and curettage (D&C) on a patient with intermenstrual or postmenopausal vaginal bleeding. Therapeutic D&C – or alternatively evacuation of retained products of conception (ERPC) – is performed for heavy prolonged bleeding associated with retained products of conception (RPOC) in the uterine cavity.
2. In women with persistent (greater than 1 week) light vaginal bleeding after the heavy bleeding of a miscarriage, ultrasound is generally of limited use in distinguishing endometritis with altered blood in the uterine cavity from RPOC. Give antibiotics, e.g. co-amoxiclav for 1 week, and only if bleeding persists perform D&C or ERPC.
3. If there are obvious substantial RPOC on ultrasound associated with fever, septic miscarriage/abortion is likely, and in this circumstance the myometrium will be at its softest and most liable to be perforated by ERPC. Give antibiotics intravenously for 1–2 days prior to ERPC unless in extremis.
Prepare
1. Gynaecologists usually perform hysteroscopy prior to a diagnostic D&C, as it allows visualization of the endometrium, polyps and submucous fibroids in situ. For gynaecologists skilled in its use, the operating hysteroscope allows resection of submucous fibroids, polyps or endometrium in the treatment of menorrhagia.
2. Any woman in the reproductive age group (12–50 years) who has heavy bleeding could have a threatened or an incomplete miscarriage. Order a pregnancy test on urine or blood and a transvaginal ultrasound scan of the uterus before she is taken to theatre. Also order a full blood count, and group and save. Blood transfusion is rarely necessary.
3. If the D&C is for missed or threatened miscarriage, give misoprostol 400 μg vaginally 1 hour preoperatively to prime (soften) the cervix. This may also cause uterine contraction and vaginal bleeding which will resolve once the D&C is completed.
4. Ask the anaesthetist to give 5–10 units of synthetic oxytocin (Syntocinon) intravenously immediately before commencing the operation, to reduce bleeding.
5. Thoroughly wash the vagina and perineum with iodine or chlorhexidine to prevent the introduction of infection. This may be achieved by using soaked gauze held by sponge-forceps. Drape the patient.
Access
1. Take great care to perform a thorough bimanual examination to determine the axis and size of the uterus (and to detect any adnexal swellings).
2. Insert a Sims’ speculum into the vagina posteriorly and grasp the anterior lip of the cervix with two vulsellum forceps.
3. Hold the cervix under tension. This straightens the axis of the uterus slightly and helps prevent uterine perforation.
Action
1. Gently pass a curved uterine sound in the direction of the uterine axis to confirm this axis and to determine the length of the uterine cavity. This step is best avoided in a pregnant uterus as the soft pregnant uterus is easily perforated by a sound.
2. Dilate the cervix progressively, increasing by 1 mm at a time, by passing metal dilators devised by Alfred Hegar (1830–1914, Professor of Gynaecology in Freiburg). You may need to press firmly to pass through the internal cervical os, but then be careful to reduce the pressure as soon as you overcome the resistance so as not to continue on and perforate the uterine fundus. This is achieved by holding the dilator not more than 2 cm from the cervix when applying pressure to overcome the resistance of the internal os, or by holding each dilator such that less of the dilator protrudes from your hand than the length of the sound measurement. If insertion of a dilator is difficult, go back to the previous dilator or consider using half-size dilators. Dilate up to 8 mm for a diagnostic D&C; 10 mm for a therapeutic D&C.
3. Pass a pair of polyp forceps, open them, twist through 180°, close them and withdraw any tissue present. Repeat two or three times in different planes or more frequently if there are retained products of conception.
4. Pass a curette, small and sharp in a non-pregnant woman, large and blunt in a patient who has been pregnant, until you reach the fundus of the uterus. With firm pressure on the uterine wall, withdraw the curette and collect the specimen on a swab. Repeat the manoeuvre by going systematically around the uterus, ensuring the cavity is completely empty. The surface of the cavity should feel like a fine sandpaper at the end. Send the curettings for histology.
5. ERPC using a suction curette is the method of choice to remove retained products of conception. It replaces steps 3 and 4 above, results in fewer introductions of instruments into the uterus and, therefore, may reduce the risk of perforation. Measure the suction curette against the sound measurement as in step 2, and insert gingerly between finger and thumb until any resistance is felt (this will tally with the sound measurement). The curette is now at the uterine fundus. Activate the suction and then rotate the suction curette rapidly whilst slowly withdrawing, thus tracing a spiral within the uterine cavity. Performing this a few times is almost always sufficient to empty the cavity safely without the need for further instrumentation.
6. If bleeding is heavy during therapeutic D&C or ERPC, then either the uterus is not yet empty, it is failing to contract, or a uterine perforation has occurred. Try ergometrine 500 μg intramuscularly, (or syntometrine if closer to hand), and if you are confident that perforation has not occurred, continue to check the cavity is empty with either a blunt curette or suction curettage. Very light bleeding signifies that the cavity is empty.
7. Give analgesia and metronidazole 1 g rectally at the end of the procedure, and azithromycin 1 g orally on the ward.
KEY POINTS
Preventing and managing uterine perforation
Postoperative
1. Discharge the patient with simple analgesia the same day in the absence of complications.
2. If there is evidence of infection such as offensive tissue, pyrexia or raised inflammatory markers, treat with broad-spectrum antibiotics in hospital.
3. If there is endometrial hyperplasia or likely carcinoma, refer the patient as soon as possible to a gynaecologist for staging and probable hysterectomy and bilateral salpingo-oophorectomy.
4. Remember to give anti-D within 48 hours to women whose blood group is Rhesus-negative after a miscarriage.
VAGINAL LACERATION
Action
1. After following steps 1 to 3 in the “Removal of products of conception from the cervical canal – Action” section above, use a continuous 2/0 polyglactin 910 suture to close the laceration and achieve haemostasis.
2. Unlike the removal of products of conception from the cervix, this usually requires a general anaesthetic.
LAPAROSCOPY
Appraise
1. This is a very useful and important diagnostic procedure where there is pelvic pain, both acute and chronic. It is particularly valuable in cases of suspected ectopic pregnancy.
2. You may find diagnostic laparoscopy useful in many situations, including the acute abdomen, the diagnosis of ascites, for direct liver biopsy and for peritoneal biopsy.
3. Do not attempt operative laparoscopy unless you are appropriately trained and suitable equipment is available, such as a light source, camera, optic, laparoscopic instruments, diathermy and irrigation.
4. It is contraindicated in the presence of generalized peritonitis, intestinal obstruction or ileus. Be particularly cautious when you suspect extensive adhesions. Pre-existing severe cardiorespiratory disease may also be a contraindication as the sustained increased intra-abdominal pressure of a pneumoperitoneum may further compromise the patient.
Prepare
1. Order a full blood count, group and save, pregnancy test and transvaginal ultrasound scan.
2. Ensure the patient understands that despite the small size of abdominal incisions, laparoscopy should still be regarded as major surgery, and has a small risk of serious complications (bowel, large vessel and ureteric injury requiring conversion to laparotomy and occasionally stoma formation).
Access
1. Place the patient flat in a semi-lithotomy position, with the legs in Lloyd-Davies stirrups.
2. Empty the bladder if the patient has not urinated in the previous hour, and perform a bimanual examination. Apply forceps and a Spackman cannula (or similar) to the cervix in order to allow manipulation of the uterus intraoperatively.
3. Make an incision in or just below the umbilicus; for a 5-mm diagnostic laparoscope a 5-mm incision is sufficient, but if operative laparoscopy is a possibility we prefer a 10-mm laparoscope and incision.
Action
1. Palpate the lower limit of the aorta prior to its bifurcation.
2. Grasp the Veress needle in the right hand with the fingers lying along the shaft of the needle to act as a stop to insertion of excessive needle length. Introduce almost vertically (but slightly towards the pelvis, away from the aortic bifurcation) through the umbilical skin incision. Take care not to allow the needle to deviate laterally so as not to injure the iliac vessels. It is helpful to hold up the lower abdominal wall between the left fingers and thumb to provide counter-traction to the introduction of the Veress needle; the left hand should also be used to elevate the anterior abdominal wall in thin patients. Two clicks are felt as the blunt spring-loaded obturator springs forwards to guard the cutting edge on breaching the rectus sheath and then the peritoneum. As soon as the tip is through the peritoneum, insert the needle only a little further, towards the pelvis.
3. Aspirate the needle with a syringe to check that neither a blood vessel nor a viscus has been entered. Then attach a syringe with 10 ml of physiological saline and remove the plunger to check that the saline passes into the peritoneal cavity by gravity alone.
4. Connect the needle to the carbon dioxide insufflator and start the gas flow. Ensure the initial pressure created is no greater than 10 mmHg (Pressure test). If not, immediately stop the gas flow.
5. Continue to insufflate such that the intra-abdominal pressure rises steadily to 20–25 mmHg, and then remove the Veress needle.
6. With your left hand pressing firmly down on the upper abdomen pass the large trocar and cannula into the peritoneal cavity, in the same direction as used for the Veress needle with a twisting motion. Ensure that the trocar is not inserted too deeply into the peritoneal cavity thereby endangering bowel or the retroperitoneal vessels.
7. Remove the trocar and insert the optic through the cannula; attach the fibreoptic light cable and, whenever possible, the video camera.
8. Insert a second port (5 mm) in order to pass a probe or atraumatic grasper to assist in demonstrating pelvic anatomy clearly. This may be suprapubic or well lateral of the inferior epigastric vessels. Injury to the epigastric vessels is the commonest complication of laparoscopy. Transilluminate the abdomen from within to identify the superficial vessels, and identify the inferior vessels lateral to the medial umbilical ligaments on a laparoscopic view of the anterior abdominal wall. If identification of these vessels is difficult, place the port either in the ‘safe triangle’ (area of the anterior abdominal wall between the symphysis pubis and umbilicus bounded laterally by the umbilical ligaments) or 2–3 cm medial to the anterior superior iliac spine of the pelvic bone.
9. The uterus can be moved by an assistant grasping the Spackman cannula to facilitate visualization of all parts of the pelvis. Ensure that both tubes including their distal ends, ovaries, ovarian fossae, the pouch of Douglas, and anterior and posterior surfaces of the uterus have been visualized.
10. If you detect no disease, look at the appendix, caecum and upper abdomen.
11. Make a decision as to whether operative laparoscopy, laparotomy or no further surgical procedure is necessary.
12. Insert further accessory ports if operative laparoscopy is required.
13. Decrease the pressure relief on the insufflator to 15 mmHg once all ports have been inserted.
14. Perform any necessary procedure. See below for how laparoscopy may be used to treat various conditions. Remove any necessary biopsies with biopsy forceps, using diathermy coagulation to obtain haemostasis.
15. When the procedure is completed, let out as much of the carbon dioxide as possible, remove the trocar and insert one skin suture in each incision.
OVARIAN OPERATIONS
Appraise
1. Ovarian cysts may cause acute abdominal pain because of rupture, haemorrhage or torsion, but a cyst of less than 5 cm diameter rarely causes pain unless secondary to endometriosis (ask about dyspareunia and dysmenorrhoea). Polycystic ovaries are not painful unless there is torsion.
2. Ovarian torsion is characterized by nausea in addition to pain, and infarction by raised inflammatory markers. Endometriotic cysts rarely undergo torsion as they are often stabilized by adhesions.
3. On other occasions you may discover a cyst incidentally on imaging, or whilst operating. If symptomatic at all, ovarian cancer usually presents with only mild non-specific abdominal symptoms.
4. Consider the differential diagnosis of pelvic tuberculosis in a patient from the developing world.
KEY POINTS
Decision making
Obtain a transvaginal ultrasound (which gives better images than an abdominal scan) if you suspect an ovarian cyst clinically. If confirmed, obtain a CA-125 serum, CEA (a differential diagnosis of a pelvic cyst is colorectal cancer), CA 19-9 (a differential diagnosis of ascites is pancreatic cancer), CRP, FBC, G&S, even if some of these results may only be available postoperatively. Also measure serum AFP (suggestive of a germ-cell tumour) and HCG (suggestive of choriocarcinoma when very high) in a young woman.
