Gynecologic and Obstetric Surgery Challenges and Management Options

Gynecologic and obstetric surgery is a craft that requires sound knowledge and skills. The specifics of each individual case must be understood to enable the best surgical management approach and to minimize complications. This resource book offers insightful management options to many of the challenges a gynecologic or obstetric surgeon may face before, during and after an operation.

Divided into two sections, the book first covers general preoperative, intraoperative and postoperative challenges and, second, specific surgical procedures. It provides advice on both general gynecologic and obstetric operations, as well as subspecialist areas such as reproductive surgery, urogynecology and gynecologic oncology.

The chapters are concise, beginning with illustrative case histories followed by background, management options, and any preventative approaches. Designed to guide the surgeon to safe practice throughout all stages, they offer practical and step-by-step help.

Arri Coomarasamy, MBChB, MD, FRCOG. Professor of Gynaecology, Institute of Metabolism and System Research, University of Birmingham. Consultant Gynaecologist and Sub-specialist in Reproductive Medicine and Surgery, Birmingham Women's Hospital, Birmingham, United Kingdom.

Mahmood I. Shafi, MBBCh, MD, DA, FRCOG. Consultant Gynecological Surgeon and Oncologist, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.

G. Willy Davila, MD, FACOG. Center Director, Women's Health Institute (Florida), Chairman, Department of Gynecology, Head, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston/Fort Lauderdale, Florida, United States.

K. K. Chan, MBBS, FRCS, FRCOG. Emeritus Consultant Gynecological Oncologist, Pan-Birmingham Gynecological Cancer Centre, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust. Birmingham, United Kingdom.

Contributors, x

Preface, xv

List of Abbreviations, xvi

Part I: General Preoperative, Intraoperative, and Postoperative Challenges

Section 1: Preoperative Care
Editors: Phil Moore and Arri Coomarasamy

1 Patient with Poor ASA Score, 3
Phil Moore

2 Patient on Medication, 6
Arri Coomarasamy

3 Patient with Ischemic Heart Disease, 9
Sohail Q. Khan and Jonathan N. Townend

4 Patient with Arrhythmias, 13
Sanoj Chacko and Joseph de Bono

5 Patient with a Pacemaker or Implantable Defibrillator, 17
Howard Marshall

6 Patient with Complex Congenital Heart Disease (Fontan Circulation), 20
Yaso Emmanuel and Sara A. Thorne

7 Hypertensive Patient, 22
Aarthi R. Mohan and Catherine Nelson-Piercy

8 Patient with Respiratory Disease, 25
Heinke Kunst

9 Patient with Diabetes, 28
Arri Coomarasamy and Dukaydah van der Berg

10 Patient with Thyroid Disease, 30
Ramy Labib and Shiao-yng Chan

11 Patient with Renal Disease, 33
Khalid Hasan

12 Patient with Liver Disease, 35
Joanna K. Dowman and Philip N. Newsome

13 Patient with Rheumatologic Diseases, 38
Amita A. Mahendru and Justin Chu

14 Patient with Hematologic Disorders, 41
Chieh Lin Fu

15 Patient at High Risk of Venous Thrombosis, 44
Ian A. Greer

16 Patient on Anticoagulant Therapy, 47
Sophie Lee and Will Lester

17 Patient on Steroid Therapy, 50
Shaista Nazir and John Ayuk

18 Patient with Epilepsy, 54
Danita Jones and Virgilio Salanga

19 Patient with a Psychiatric Condition, 56
Idnan Yunas

20 Patient with Organ Transplant, 59
Sarah Winfield

21 Patient with Hepatitis B or C, 61
Firas Al-Rshoud and Arri Coomarasamy

22 Patient with HIV, 64
Firas Al-Rshoud and Arri Coomarasamy

23 Obese Patient, 67
Phil Moore

24 Patient with Poor Nutritional Status, 69
Phil Moore

25 Pregnant Patient Requiring Non-obstetric Surgery, 71
Arri Coomarasamy

Section 2: Intraoperative Care
Editors: Arri Coomarasamy and Mahmood I. Shafi

26 Transverse Incision on the Abdomen Inadequate for Surgery, 77
Arri Coomarasamy

27 Previous Multiple Abdominal Scars, 79
Mohammed Khairy and Arri Coomarasamy

28 Patient with Previous Mesh Incisional Hernia Repair Requiring a Laparotomy, 83
Christopher Smart and Chris Keh

29 Patient with Previous Mesh Incisional Hernia Repair Requiring a Laparoscopy, 86
Emanuele Lo Menzo, Samuel Szomstein, and Raul J. Rosenthal

30 Unexpected Pathology: Ovarian Cyst, 89
Mohan Kumar

31 Unexpected Pathology: Abnormal Appearance of the Uterus, 92
Arri Coomarasamy

32 Unexpected Pathology: Severe Pelvic Adhesions, 94
Stephen E. Zimberg and Michael L. Sprague

33 Unexpected Pathology: Abnormal Appearance of Bowel, 97
Olivia Will and Justin Davies

34 Unexpected Pathology: Retroperitoneal Mass, 100
Mohamed Mehasseb

35 Bladder Injury, 103
Arri Coomarasamy and Richard Popert

36 Ureteric Injury, 106
Arri Coomarasamy and Richard Popert

37 Small and Large Bowel Injury, 111
Howard Joy

38 Inferior Epigastric Vessel Injury, 116
Manas Chakrabarti and Sudha Sundar

39 Bleeding from Retracted Pedicular (Pelvic Sidewall) Vessels, 119
Michael L. Sprague and Stephen E. Zimberg

40 Massive Hemorrhage, 121
Karen Louise Moores, William Parry-Smith, and Martyn Underwood

41 Broken Needle, 125
Joanne Kathleen Ritchie, Anuradha Radotra, and Martyn Underwood

42 Lost Swab, Needle or Instrument, 127
Joanne Kathleen Ritchie, Martyn Underwood, and William Parry-Smith

Section 3: Postoperative Care
Editors: Arri Coomarasamy and Janesh Gupta

43 Postoperative Care, 131
Janesh Gupta, Robbert Soeters, and Aaron Ndhluni

44 Excessive Nausea and Vomiting after Surgery, 133
Phil Moore

45 Excessive Abdominal Pain after Surgery, 136
Manjeet Shehmar

46 Bowel Damage: Postoperative Presentation, 139
Ketan Gajjar and Mahmood I. Shafi

47 Wound Infection, 142
Pallavi Latthe and James Gray

48 Wound Dehiscence, 147
T. Justin Clark

49 Late Wound Failure: Incisional Hernia, 150
Saloney Nazeer

50 Necrotizing Fasciitis, 153
Tariq Ahmad

51 Management of Surgical Drains, 156
Ahmed M. El-Sharkawy and Sherif Awad

52 Shocked Patient, 159
Manjeet Shehmar

53 Breathless Patient: Postoperative Pulmonary Complications, 162
Heinke Kunst

54 Confused Postoperative Patient, 165
Idnan Yunas

55 Patient with Poor Urine Output, 167
Amelia Davison and Jackie A. Ross

56 Electrolyte Imbalance, 170
Manjeet Shehmar and Arri Coomarasamy

57 Swollen Leg, 174
Edwin Stephen, Indrani Sen, and Tim Lees

58 Cardiorespiratory Arrest, 177
Jennie Kerr

PART II: Operations and Challenges

Section 4: General and Minimal Access Gynecology
Editors: T. Justin Clark, Kiong K. Chan, and Arri Coomarasamy

59 Difficulty in Dilating the Cervix: Cervical Stenosis and Cervical Closure, 183
Arri Coomarasamy

60 Uterine Perforation, 186
Arri Coomarasamy

61 Surgical Uterine Evacuation: Excessive Bleeding, 189
Rajesh Varma

62 Surgical Uterine Evacuation in a Woman with Multiple Fibroids, 191
Rajesh Varma

63 Use of Excessive Distension Media at Hysteroscopy, 194
Arri Coomarasamy

64 Hysteroscopy: Endometrial Resection and Ablation in the Abnormal Uterine Cavity, 197
Alessandro Conforti and Adam Magos

65 Laparoscopy in a Pediatric Patient, 199
Suketu M. Mansuria, Cara R. King, and Arri Coomarasamy

66 Safe Laparoscopic Entry in a Thin Patient, 202
Janesh Gupta and Justin Chu

67 Laparoscopy: Unable to Gain Entry, 205
Mohamed Mehasseb

68 Surgical Emphysema, 208
Arri Coomarasamy

69 Venous Air Embolism, 210
Anneke Chu and Jennie Kerr

70 Laparoscopy: Problems with Monopolar Diathermy, 213
Thomas G. Lang and Resad Pasic

71 Laparoscopy: Problems with Bipolar Diathermy, 216
Thomas G. Lang and Resad Pasic

72 Laparoscopy: Bladder Injury, 218
Peter L. Rosenblatt

73 Laparoscopy: Ureteric Injury, 221
Peter L. Rosenblatt

74 Bowel Injury During Laparoscopy: Intraoperative Presentation, 224
Alan Lam

75 Bowel Injury After Laparoscopy: Late Presentation, 227
Alan Lam

76 Blood Vessel Injury at Laparoscopy, 230
Elizabeth Ball

77 Laparoscopy for Large Ovarian Cyst, 233
T. Justin Clark

78 Laparoscopy for an Ovarian Cyst in Pregnancy, 235
T. Justin Clark

79 Laparoscopic Removal of Rectovaginal Endometriosis, 238
Alan Lam

80 Laparoscopic Myomectomy, 242
Ertan Saridogan

81 Total Laparoscopic Hysterectomy, 245
Alan Farthing

82 Laparoscopic Hysterectomy for a Large Fibroid Uterus, 247
Alan Lam

83 Laparoscopy: Difficulty in Tissue Retrieval, 250
Su-Yen Khong and Alan Lam

84 Surgery for Cornual or Interstitial Pregnancy, 253
Ayesha Mahmud and Yousri Afifi

85 Surgery for Cervical Ectopic Pregnancy, 256
Bassel H. Al Wattar and Yousri Afifi

86 Surgery for Cesarean Scar Pregnancy, 259
T. Justin Clark

87 Surgery for Adnexal Torsion, 262
Mohamed Otify and Jackie A. Ross

88 Laparoscopic Appendectomy, 264
Edward Rawstorne, Christopher Smart, and Chris Keh

89 Laparoscopic Surgery: When to Convert to Laparotomy?, 267
Mohamed Mehasseb

90 Laparoscopy: Port-site Herniation, 269
Ayesha Mahmud and Yousri Afifi

Section 5: Reproductive Surgery
Editors: Arri Coomarasamy and Mahmood I. Shafi

91 Uterine Septum, 275
Basim Abu-Rafea and Khaldoun Sharif

92 Surgery for Intrauterine Adhesions, 278
Mohan Kumar

93 Myomectomy: Breach of the Endometrial Cavity, 280
Masoud Afnan and Arri Coomarasamy

94 Myomectomy: Multiple Large Fibroids, 282
Justin Chu and Arri Coomarasamy

95 Myomectomy: Massive Intraoperative Hemorrhage, 284
Neelam Potdar and Arri Coomarasamy

96 Vaginal Myomectomy, 287
Adam Magos

97 Surgery for Proximal Tubal Blockage, 289
Spyros Papaioannou

98 Surgery for Distal Tubal Disease, 292
Lynne Robinson, Hemant N. Vakharia, and Yousri Afifi

99 Reversal of Sterilization, 295
Hemant N. Vakharia, Lynne Robinson, and Yousri Afifi

100 Surgery for Congenital Abnormalities of the Genital Tract, 299
Naomi S. Crouch

101 Surgical Sperm Retrieval, 304
David Muthuveloe and Y. Zaki Almallah

Section 6: Urogynecologic Surgery
Editors: Pallavi Latthe and G. Willy Davila

102 Sling Procedures: Bladder Injury, 309
Fidan Israfil-Bayli and Philip Toozs-Hobson

103 Sling Procedures: Urethral Injury, 311
Gamal M. Ghoniem

104 Sling Procedures: Retropubic Hematoma, 314
Fidan Israfil-Bayli and Philip Toozs-Hobson

105 Sling Procedures: Bowel Injury, 316
Fidan Israfil-Bayli and Philip Toozs-Hobson

106 Sling Procedures: Voiding Dysfunction after Stress Urinary Incontinence Surgery, 318
Margarita M. Aponte and Victor W. Nitti

107 Sling Procedures: Tape Erosion into the Bladder, 321
Samuel J.S. Grimsley and Y. Zaki Almallah

108 Sling Procedures: Sexual Dysfunction, 323
Swati Jha and Ranee Thakar

109 Sling Procedures: Persistent Urine Leakage, 325
Luis Manuel Espaillat-Rijo and G. Willy Davila

110 Difficult Vaginal Hysterectomy, 329
G. Willy Davila

111 Vaginal Hysterectomy: Difficulty in Entering the Posterior Pouch, 332
Alfredo Jijon and G. Willy Davila

112 Salpingo-oophorectomy at the Time of Vaginal Hysterectomy, 335
Alfredo Jijon and G. Willy Davila

113 Bladder Injury During Anterior Vaginal Repair or Vaginal Hysterectomy, 338
Pallavi Latthe, Suneetha Rachaneni, and Mohammed Belal

114 Difficult Sacrocolpopexy, 341
Orfhlaith E. O’Sullivan and Barry A. O’Reilly

115 Difficult Sacrospinous Fixation, 345
Smita Rajshekhar and Rohna Kearney

116 Recurrent Pelvic Organ Prolapse, 348
Monika Vij and Robert Freeman

117 Colpocleisis, 351
Kalaivani Ramalingam and Ash Monga

118 Uterine Suspension Procedures: Laparoscopic Hysteropexy, 353
Natalia Price and Simon Jackson

119 Mesh Tape Exposure Following Tension-free Vaginal Tape, 356
Helen Bolton and Mark Slack

120 Vaginal Vault Evisceration, 360
Swati Jha

121 Complications in Laparoscopic Pelvic Floor Surgery, 362
Nir Haya and Christopher Maher

122 Robotic Urogynecology Procedures, 367
Orfhlaith E. O’Sullivan and Barry A. O’Reilly

123 Complications in Robotic Pelvic Floor Surgery, 370
Amie Kawasaki

124 Neovagina, 372
Lynsey Hayward and G. Willy Davila

125 Vaginal Stricture After Pelvic Organ Prolapse Surgery, 375
Ted M. Roth, G. Rodney Meeks and G. Willy Davila

126 Urethral Diverticula and Other Periurethral Masses, 378
Bhavin Patel and Kathleen C. Kobashi

127 Vesicovaginal Fistulae, 382
Karolynn T. Echols,Tamara V. Toidze, and Edward Stanford

128 Urethrovaginal Fistulae, 386
Sohier Elneil

129 Rectovaginal Fistulae, 389
Claire Burton and Simon Radley

130 Secondary Anal Sphincter Repair, 392
Steven D. Wexner and Emanuela Silva

Section 7: Gynecologic Oncology
Editors: Kavita Singh, Mahmood I. Shafi, and Kiong K. Chan

131 Large Loop Excision of the Transformation Zone, 399
Mahmood I. Shafi

132 Knife Cone Biopsy, 401
Najum Qureshi

133 Staging Procedures: Examination Under Anesthesia, Cystoscopy, Sigmoidoscopy, and Biopsy Techniques, 403
Mahmood I. Shafi

134 Radicality of Surgery for Cervical Cancer, 406
Mahmood I. Shafi

135 Pelvic and Para-aortic Lymphadenectomy in Gynecologic Cancers, 408
Kavita Singh and Rami Fares

136 Trachelectomy for Treatment of Cervical Cancer, 412
Kavita Singh and Janos Balega

137 Laparoscopic Radical Surgery for Cervical Cancer, 414
Mohamed Mehasseb

138 Groin and Retroperitoneal Lymphocele, 416
David M. Luesley

139 Laparotomy for a Pelvic Mass of Uncertain Nature, 418
Mahmood I. Shafi

140 Gynecologic Cancer Extending to the Bowel, 420
Kiong K. Chan

141 Omental Procedures: Supracolic Omentectomy, Infracolic Omentectomy, and Omental Biopsy, 423
Kiong K. Chan

142 Diaphragmatic Surgery in Advanced Ovarian Cancer, 425
Ariella Jakobson-Setton and Kavita Singh

143 Fine-needle Aspiration Biopsy of Superficial Groin Lymph Node, 428
Moji Balogun

144 Vulval Surgery: Wide Local Excision and Vulvectomy, 431
Mahmood I. Shafi

145 Sentinel Node Biopsy in Gynecologic Cancer, 433
Kavita Singh

146 Groin Lymphadenectomy, 435
Ketan Gajjar

147 Plastic Surgical Techniques in Vulval or Perineal Procedures, 438
Mahmood I. Shafi

148 Vaginectomy, 441
Janos Balega and Kavita Singh

149 Urinary Diversion, 443
John Parkin

150 Pelvic Exenteration, 446
Kavita Singh

151 Gynecologic Cancer and Concurrent Pregnancy, 449
Nirmala Rai Talapadi and Sudha Sundar

Section 8: Obstetric Surgery
Editors: Pallavi Latthe, Kiong K. Chan, and Arri Coomarasamy

152 Ovarian Cyst Identified at Cesarean Section, 455
Kiong K. Chan and Ioannis Gallos

153 Laparoscopy in Pregnancy, 457
Kevin J.E. Stepp and Anjana Nair

154 Cervical Cerclage, 459
Ayesha Mahmud and Yousri Afifi

155 Cesarean Section in a Woman with Fibroids, 463
Andrew Prentice

156 Cesarean Section at the Limits of Viability, 465
Catherine Aiken and Jeremy Brockelsby

157 Difficult Delivery of the Fetal Head During Cesarean Section, 468
Parveen Abedin

158 Surgical Management of Massive Obstetric Hemorrhage from the Uterus, Cervix, or Vagina, 470
Phil Steer

159 Surgical Management of Placenta Praevia, 475
Vibha Giri and Mohan Kumar

160 Surgical Management of Placenta Accreta, 479
Vibha Giri and Mohan Kumar

161 Surgical Management Options for Shoulder Dystocia: Zavanelli Maneuver, Abdominal Rescue, Symphysiotomy, and Cleidotomy, 482
Syeda Batool Mazhar and Asia Nazir

162 Uterine Inversion, 485
Phil Steer

163 Episiotomy and Second-degree Tear, 488
Khaled M.K. Ismail and Sara S. Webb

164 Obstetric Anal Sphincter Tear, 490
Natalie P. Nunes, Helen Stevenson, and Matthew Parsons

165 Pregnancy and Female Genital Mutilation, 493
Naomi Low-Beer and Gubby Ayida

166 Destructive Operations on a Dead Fetus, 496
Hany Abdel-Aleem

167 Development of a Basic Obstetric Theater Facility in a Low-resource Setting, 499
Zahida Qureshi and Alfred Murage

Section 9: Miscellaneous
Editors: Mahmood I. Shafi and Arri Coomarasamy

168 Enhanced Recovery, 505
Manjeet Shehmar

169 Major Surgery in a Jehovah’s Witness Patient, 507
Martyn Underwood and William Parry-Smith

170 Termination of Pregnancy at Advanced Gestation, 509
Rohan Chodankar and Janesh Gupta

171 Cervical Fibroids: Techniques for Myomectomy and Hysterectomy, 511
Deborah R. Karp

172 Hysterectomy for Broad Ligament Fibroids, 514
Kiong K. Chan

173 Hysterectomy for a Double Uterus, 516
Kiong K. Chan

174 Cervical Stump Excision, 518
Kiong K. Chan

175 Surgery for Ovarian Remnant, 520
Kiong K. Chan and Arri Coomarasamy

176 Surgery for Missing Intrauterine Contraceptive Device, 522
Toh Lick Tan

177 Management of Imperforate Hymen, Transverse and other Vaginal Septa, 525
Jane MacDougall

178 Benign Lesions in the Groin and Vulva, 528
Jennifer Byrom

179 Cystic Structure in the Upper Vagina, 531
Ted M. Roth and G. Rodney Meeks

180 Adnexal Masses in Infants and Children, 533
Rachel J. Miller and Kris Ann P. Schultz

181 Nerve Injuries Associated with Gynecologic and Obstetric Surgery, 536
Djavid Alleemudder

182 Consent Challenges, 540
William Parry-Smith and Martyn Underwood

183 Dealing with Complaints, 542
Mahmood I. Shafi

184 Dealing with Litigation, 544
Rebekah Ley and Mahmood I. Shafi

Index, 547

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