Incisions

The vertical midline incision avoids all major nerves, vessels and muscles by dividing the rectus sheath. It gives good access to the whole of the abdomen except the subdiaphragmatic areas, and is a very fast incision to make. Its principal drawback is that it heals slowly and suffers from a high incidence of wound dehiscence and incisional hernia. The development of improved sutures and technique has dramatically reduced these complications. A midline incision should always be closed using the ‘mass closure’ technique. This involves 1-cm-deep bites of the rectus muscle and peritoneum in a continuous closure, with sutures placed 1 cm apart. The suture material used does not affect the rates of dehiscence or infection, but incisional hernia is more common if braided absorbable material is used (Rucinski et al 2001). The same meta-analysis showed that incision pain and suture sinus formation are more common after non-absorbable material is inserted. Absorbable monofilament used in a continuous mass closure gave the best results.

The paramedian incision is only included for historical interest. The layered closure that was used improved strength when catgut sutures were employed, and reduced the incidence of dehiscence. It is inferior to the mass closure technique described above, and does not provide improved access to either side of the abdomen.

The majority of gynaecological surgery is performed through a transverse incision, usually a Pfannenstiel incision. By dividing each layer in a different direction, the function is well preserved. Even the muscle-cutting variants of the transverse incision heal more rapidly than vertical incisions. The cosmetic result is superior and, if correctly placed, access to the pelvis is good, although access to the pelvic brim is limited. This incision is difficult to extend if improved abdominal access is required.

The Maylard incision involves dividing all layers in the line of the skin incision and also divides the inferior epigastric vessels. The rectus sheath is not separated from the muscle and closure is in layers, leaving the muscle to be drawn together by the sheath. This incision provides improved access to the pelvic side wall when compared with the Pfannenstiel incision, and is useful for oncological surgery. Many centres now use this incision or a Pfannenstiel incision for radical hysterectomy (Orr et al 1995, Scribner et al 2001).

The Cherney incision is similar to the Pfannenstiel incision but the rectus muscles are divided 1 cm from their insertion into the symphysis pubis. The incision is closed in layers, but the muscle is repaired using a continuous suture in the membranous distal portion of the muscle. This incision can also be useful in oncological surgery or, if placed lower, is useful for complex urogynaecological procedures.

The Rutherford–Morrison incision involves dividing all layers in the line of the incision and is particularly useful for approaching ovarian masses in the second half of pregnancy. The incision is closed in layers and heals well.

Drains

Drains are used either therapeutically, to remove pus, infected material and products from an abscess, or to prevent accumulation of blood, pus, urine, lymph, bile or intestinal secretions. There is little evidence to support the use of prophylactic drains. In abdominal incisions, drains have been used in an attempt to reduce the incidence of haematoma and wound infection. Unfortunately, they tend to introduce organisms into an otherwise clean area and increase the incidence of wound infection (Cruise and Foord 1973). In addition, pelvic drains do not reduce infection following radical pelvic surgery (Orr et al 1987). Careful attention to haemostasis is preferable and drains should be avoided in most closures.

Closure of peritoneum

This practice has been questioned recently. Research in animal models has suggested that closure of the peritoneum increases rather than decreases peritoneal adhesions. Human studies support this finding, showing that closure of the pelvic peritoneum does not reduce the incidence of postoperative adhesions or obstruction (Table 8.1; Tulandi et al 1988). The peritoneum spreads rapidly across any raw areas left after surgery, although devascularized tissue, such as pedicles, are a focus for adhesion formation. Practice still varies with regard to peritoneal closure, although it probably results in increased adhesion formation (Royal College of Obstetricians and Gynaecologists 1998). However, if a suction drain is used in the wound, the peritoneum must be closed to avoid drawing the bowel into the wound.

Table 8.1 The effect of peritoneal closure on wound infection and adhesion formation.

Source: From Tulandi T, Hum HS, Gelfand MM 1988 Closure of laparotomy incisions with or without peritoneal suturing and second look laparoscopy. American Journal of Obstetrics and Gynecology 158:536, with permission of Elsevier.

Anatomical relations

The urinary and genital tracts are closely related in embryological development, and their anatomy and physiology, not surprisingly, are intertwined. The ureter develops from a bud on the posterolateral border of the mesonephric duct near the cloaca, which elongates and eventually fuses with the developing kidney. The ventral portion of the cloaca develops into the urethra, bladder and lower portion of the vagina.

The ureters enter the pelvis by crossing the common iliac arteries in the region of their bifurcation. They descend on the pelvic side wall, medial to the branches of the internal iliac arteries and lateral to the ovarian fossae. From there, they run on the anterior surface of the levator ani muscles lateral to the uterosacral ligaments to pass beneath the uterine arteries, 1–1.5 cm lateral to the cervix and vagina. The ureters then swing medially around the vagina, to enter the bladder 2–3 cm below the anterior vaginal fornix.

The ureter is accompanied by a plexus of freely anastomosing fine vessels running in the loose tissue surrrounding it. The blood supply in the upper portion is derived from the renal and ovarian vessels; in the middle third from branches of the aorta, common iliac and internal iliac arteries; and in the lower part from branches of the uterine, vaginal, middle haemorrhoidal and vesical arteries. The ureter may be mobilized extensively provided this plexus of vessels is preserved.

The ureter is at risk during gynaecological surgery in four regions: at the pelvic brim where it can be confused with the infundibulopelvic ligament; lateral to the ovarian fossa where it can be adherent to an ovarian mass; in the ureteric tunnel beneath the uterine artery; and anterior to the vagina where it runs into the bladder.

The ureter at the pelvic brim and ovarian fossa

At the pelvic brim, the infundibulopelvic ligament with the ovarian vessels also crosses the iliac vascular bundle, usually 1–2 cm distal to the bifurcation of the common iliac artery and the ureter (Figure 8.3). At this point, the ureter and the ovarian vessels are running in parallel in a similar plane and may be confused if care is not taken. Occasionally, the ureter may be duplex. Where the ureter runs lateral to the ovary, it will almost inevitably be associated with any inflammatory or malignant mass. Happily, it will lie on the lateral aspect of the mass where it can be identified and dissected free, usually without difficulty, although in patients with endometriosis, the ureter may be fixed in dense fibrosis.

Figure 8.3 Relationship of ureter to ovarian vessels in the infundibulopelvic ligament. Note how close the ureter lies to the ovarian vessels at the pelvic brim.

The key to the safe identification of the ureter on the pelvic side wall is to open the peritoneum and dissect in the retroperitoneal space. This is most easily done by dividing the round ligament between two clips, dividing the peritoneum in a cranial direction 1.5 cm lateral to the ovarian vessels and in a caudal direction down towards the uterovesical fold. The loose areolar tissue then encountered should be separated by blunt dissection with careful diathermy of any small vessels. The ureter will lie on the lateral aspect of the leaf of peritoneum reflected by this manoeuvre. At this stage, the infundibulopelvic ligament can be safely divided with the ureter under direct vision. If the anatomy of the pelvic side wall has been distorted, this technique will almost always allow the ureter to be identified and followed within the pelvis. If an ovarian mass is present, the ureter may be dissected free from the mass in this retroperitoneal plane.

The lower ureter

The third position where the ureter is at risk is in the ureteric tunnel, where the ureter crosses beneath the uterine artery but superior to the cardinal ligament and approximately 1–1.5 cm lateral to the angle of the vagina (Figure 8.4). It is possible to palpate the ureter in this position by gripping the paracervical tissue between one finger in the pouch of Douglas and the thumb placed laterally in front of the uterine pedicle. The ureter, which is felt as a firm cord running across the cardinal ligament, is surprisingly far lateral to the cervix if the bladder has been properly reflected and the anatomy is normal. However, adhesions, fibrosis or inadequate dissection may disrupt these relationships, causing the ureter to remain fixed near the lateral margin of the cervix.

Figure 8.4 Relationship of ureter to the uterine artery. This diagram shows the dissection performed for a radical hysterectomy, but illustrates the close relationship between the ureter and the uterine artery.

Damage to the ureter in this site is prevented by carefully reflecting the bladder and by not taking a large pedicle that includes both the uterine artery and the paracervical tissue. The author prefers to take the uterine artery relatively high, at the level of the internal os, which allows the parametrium to fall laterally, taking the ureter with it. The ureter can then be palpated again and a second pedicle taken medial to the first, to include the cardinal ligament.

In most cases, damage to the ureter occurs at this site because the pedicle slips or the original ligature is not adequate. This can be avoided by preparing the pedicle carefully before clamping it. Modern clamps, such as Roget’s or Zeppelin’s parametrial clamps, rarely slip, and ties should be placed accurately. If bleeding does occur, the ureter should be palpated again after replacing the clamp to ensure that it has not been included.

The ureter is occasionally damaged in its course across the anterior surface of the vagina. This may occur when taking a cuff of vagina, during a vaginal hysterectomy or colposuspension. When dissecting the upper vagina, it is important to keep in the correct plane close to the vaginal wall. Stitches placed either vaginally or abdominally in this area must be in tissue that has been accurately identified.

Repairing ureteric damage

If a ureter is damaged, the presence of the contralateral kidney should be checked. If the ureter has not been cut across but merely crushed or ligated in error, and this is recognized on the table, it is acceptable to remove the ligature and insert a stent into the ureter in the hope that a stenosis will not result. If the ureter is divided, repair will be necessary. In the past, gynaecologists have resorted to simply tying off the divided ureter but this is rarely justifiable now.

Repair of the ureter is technically demanding and may lead to long-term complications. It is not appropriate for a gynaecologist without urological training or extensive urological experience to undertake this. In principle, an end-to-end anastomosis can be performed for ureteric damage at the pelvic brim or above. The ureter is mobilized so that the ends can be brought together without tension. They are spatulated and the anastomosis performed using fine interrupted sutures over a Silastic stent (Figure 8.5). This is removed several weeks later. An alternative for damage at this level is to perform a uretero-ureteric anastomosis.

Figure 8.5 Reanastomosis of a divided ureter. A cleanly cut ureter may be reanastomosed by spatulating the ends and repairing it with fine sutures over a suitable splint. The splint is withdrawn from the bladder at a later date.

Reproduced with permission from Blandey J 1986 Operative Urology, 2nd edn. Blackwell Science, Oxford.

If the damage has occurred at the level of the ureteric tunnel or lower, the safest method of repair is to reimplant the ureter into the bladder. The bladder is opened between stay sutures. A submucosal tunnel is fashioned, taking care to avoid the other ureter. The distal end of the ureter is brought through the tunnel and, after spatulating the end, is sutured to the bladder mucosa. A couple of sutures into the serosal surface anchor the ureter to the outer layer of the bladder (Figure 8.6).

Figure 8.6 Reimplanation of the ureter. (A) After opening the bladder, a submucosal tunnel is made along the lateral posterior wall of the bladder. A thin rubber tube is slipped over the ends of the scissors. (B) The ureter is drawn through the tunnel with the rubber tube. (C) The end of the ureter is spatulated and sutured to the bladder mucosa with fine sutures. An indwelling stent may be left in place, although this is not usually necessary.

Reproduced with permission from Blandey J 1986 Operative Urology, 2nd edn. Blackwell Science, Oxford.

When damage has occurred higher on the pelvic side wall, the bladder can be elevated to the cut end of the ureter to allow reimplantation without tension, using either a psoas hitch or a Boari flap. In the former, an appropriate part of the bladder is elevated towards the end of the ureter. To facilitate this, the cystotomy is performed across the direction of elevation and is closed in the opposite direction to elongate the bladder. In addition, the contralateral superior vesical pedicle may be divided. The ureter is reimplanted as described previously and the bladder is fixed to the psoas muscle to relieve any tension. This technique will allow a ureter divided at any level in the pelvis up to the pelvic brim to be safely reimplanted (Figure 8.7).

Figure 8.7 The psoas hitch procedure. (A) The bladder is incised in the transverse axis. (B) The bladder is fixed to the psoas minor tendon to relieve tension and the ureter is reimplanted as described. The bladder is closed in the longitudinal axis.

Reproduced with permission from Blandey J 1986 Operative Urology, 2nd edn. Blackwell Science, Oxford.

The Boari flap is an alternative to the psoas hitch. A flap of bladder is elevated, the ureter is reimplanted into this and the flap is closed as a tube (Figure 8.8). This allows good elevation of the bladder at the expense of reduced bladder capacity.

Figure 8.8 Boari flap. (A) The superior vesical artery on the opposite side is divided. (B) The Boari flap is fashioned. A stent in the contralateral ureter may be helpful. (C) The ureter is reimplanted through a submucosal tunnel in the flap. (D) The Boari flap is closed and fixed to the psoas muscle to relieve tension.

Reproduced with permission from Blandey J 1986 Operative Urology, 2nd edn. Blackwell Science, Oxford.

Alternatively, a uretero-ureteric anastomosis to the opposite ureter can be performed. This has the disadvantage that both ureters may be compromised but may be the only method if access to the bladder is difficult.

Anatomical relations

The bladder, like the ureters, is intimately related to the genital tract by virtue of its embryological development. Repair of the bladder, however, is more straightforward and the results are very good. It is an extraperitoneal organ that is located behind the symphysis pubis and rests on the anterior part of the levator diaphragm, the anterior vaginal wall and the cervix. The trigone is at the level of the upper vagina, with the base of the bladder related to the anterior vaginal fornix and cervix. When full, the bladder rises out of the pelvis towards the level of the umbilicus and presents a hazard during abdominal incision. The bladder is also at risk in this position if it is adherent after previous surgery or during caesarean section in labour, when the lower segment of the uterus is lifted out of the pelvis, elevating the bladder with it.

Avoiding damage

The bladder must always be emptied prior to pelvic surgery and the peritoneum should be opened superiorly, away from the bladder, when making a transverse incision. It can be palpated as a thickening in the peritoneum, and if there is any doubt about its position, careful dissection should allow the detrusor muscle to be recognized before the mucosa is opened. Opening the peritoneum by blunt dissection with fingers will not necessarily protect the bladder, as it is possible to dissect bluntly into it. Similarly, the technique of tearing the parietal peritoneum open by ‘stretching’ the wound once the abdominal cavity has been opened can lead to damage to the top of the bladder, particularly after previous surgery.

An essential part of any hysterectomy is separation of the bladder from the cervix and upper vagina. This plane can be found after division of the uterovesical fold of peritoneum merely by pushing caudally with a swab applied firmly to the anterior surface of the cervix cranial to the bladder. This is very quick but inevitably leaves a few small bleeding points on the back of the bladder that may be difficult to find. In addition, the bladder is occasionally damaged by this manoeuvre, particularly after previous surgery.

An alternative approach is to use a combination of sharp and blunt dissection. After dividing the uterovesical fold of peritoneum, the scissors are held slightly opened to begin separation in this plane by pushing the bladder off the cervix. Small blood vessels can be recognized and diathermied before cutting, to maintain haemostasis at all times. Once the correct plane has been identified in the midline, the dissection is extended laterally to mobilize the ureters and can be continued as far as necessary down the vagina. Although a little more time consuming, this technique is safe and can be used on simple cases to gain experience for more difficult situations.

When performing the operation vaginally, the same plane needs to be defined and dissected. If the plane does not develop easily, it is important to use sharp dissection, as merely pushing on the bladder may tear a hole. A sound in the bladder may help to define the correct plane. Alternatively, a finger over the fundus of the uterus or over the broad ligament to the side, once the pouch of Douglas is opened, can define the uterovesical fold of peritoneum and clarify the correct plane for dissection.

The bladder can also be damaged during closure of the vaginal vault, particularly if it has not been sufficiently mobilized. Sutures may be placed through the detrusor muscle or even into the bladder itself, although this rarely causes problems (Meeks et al 1997). However, if this is recognized at the time of surgery, such stitches should be removed and the bladder mobilized to allow closure of the vault without including the bladder. If damage to the bladder has occurred, this should be repaired and the bladder drained as discussed below.

Repair of the bladder

Should a hole be made in the bladder, this can be repaired after the dissection of the bladder is complete. A stay stitch is usually placed at either end of the hole, and the incision is repaired in two layers using either chromic catgut or Vicryl. Care should be taken that the ureters are well away from the sutures, and, if there is any doubt, ureteral stents should be inserted. After repair, the bladder is drained with an indwelling catheter for 7–10 days. Provided the bladder is well mobilized and repaired without tension, an excellent result should be achieved.

Repair of the bladder is less likely to be successful after radical radiotherapy, and a high incidence of fistulae is seen in this situation. An additional blood supply is provided by interposing a flap of omentum.

Repair of bowel

Repair of damaged bowel may involve primary closure of a small hole or may be facilitated by the excision of a portion of unhealthy bowel and reanastomosis (Figure 8.9). Consideration should be given to a defunctioning colostomy proximal to anastomosis of large bowel, particularly if the blood supply to the bowel wall is compromised in any way. Factors that have a bearing on this decision are previous radiotherapy, bowel obstruction, gross infection of the operative field or other medical factors such as diabetes, steroid therapy, malignancy and advanced age. If no adverse factors are present, a colostomy may not be necessary. Small bowel usually heals without the need for defunctioning. If there is any doubt about the safety of a repair, a surgeon who specializes in bowel should be involved to help with the repair.

Figure 8.9 Small bowel repair. (A) Suture of small intestine with continuous all-layers suture. (B) Connell inverting suture. (C) Full-thickness sutures reinforced with inverting Lembert suture. (D) Purse-string suture of small intestinal perforation.

Damage to bowel

Blind insertion of the Veress needle and first trocar may lead to perforation of intra-abdominal and retroperitoneal structures. Bowel is rarely damaged unless it is adherent to the anterior abdominal wall, but great care must be taken if the patient has had a previous operation or intra-abdominal sepsis. In these cases, the initial trocar may be placed away from the site of the previous incision in an attempt to avoid fixed bowel. Alternatively, the abdomen may be entered using an open minilaparotomy technique and then the incision sealed around a blunt-ended trocar. Difficulty may be encountered in maintaining a good seal using this technique, but specially designed trocars reduce this problem. A new device is available that incises the tissue in front of a blunt-ended trocar 1 mm at a time, and allows visualization of the end of the instrument as it is being inserted. This may prove to be useful in the small number of cases where difficulty is anticipated.

A surgeon experienced in laparoscopic suturing may repair minor damage to the bowel endoscopically. In most cases, it is much safer to perform a laparotomy to allow careful inspection of the whole bowel and open repair of any damage. As it can be difficult to find the hole in the bowel subsequently, it is wise to leave the offending instrument in place until the abdomen is open.

Damage to blood vessels

When inserting the Veress needle and the first trocar, it is vital that these instruments are kept away from the major vessels. The position of the sacral promontory can be palpated and the instruments angled in such a way that they pass below the promontory and into the free space in the midline of the pelvis. While damage to a major blood vessel may be all too obvious, the bleeding may be predominantly retroperitoneal and difficult to see laparoscopically. If the patient’s blood pressure has dropped and pulse rate risen sufficiently to suggest the possibility of vascular damage, a laparotomy should be performed immediately. If the abdomen has to be opened in a hurry, one technique is to lift the laparoscope up to the anterior abdominal wall and cut down on to it, allowing immediate access.

Blood vessels in the abdominal wall may also be damaged. To reduce this risk, the abdominal wall is usually transilluminated to visualize vessels prior to insertion of the secondary trocars. The location of the inferior epigastric vessels should be recognized, as they will bleed profusely and this may be difficult to control. Minor bleeding around a trocar may be controlled either by leaving the trocar in place to tamponade the vessel, or by inserting a Foley catheter through the trocar, inflating the balloon with 30–50 ml of saline and withdrawing the trocar and balloon to apply pressure to the bleeding point. If the vessel requires suturing, this is facilitated by a long J-shaped needle.

Diathermy damage

Problems with laparoscopic use of diathermy stem either from the heat generated at the site of tissue destruction or from current finding an alternative path to earth through an adjacent organ. Tissue coagulated by diathermy becomes very hot and may retain its heat for several minutes. This heat will spread to underlying structures and adjacent organs, and may cause damage. Diathermied tissue must be allowed to cool before coming into contact with adjacent structures. A further problem is the rising impedance in desiccated, diathermied tissue. This may result in the current arcing to a nearby organ that offers a low-resistance path to earth. In a similar way, current may arc to nearby organs if the current is activated before the electrode is in contact with the tissue to be treated.