(BQ) Part 1 book “Bonney’s gynaecological surgery” has contents: Instruments, operative materials and basic surgical techniques, uterine fibroids, operations on the fallopian tubes, caesarean section, operations on the ovaries, operations on the fallopian tubes, postoperative care and complications,… and other contents.
Bonney’s Gynaecological Surgery 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 Fellow University of Exeter Medical School Retired Consultant Gynaecological Oncologist Northern Gynaecological Oncology Centre Queen Elizabeth Hospital, Gateshead Royal Cornwall Hospital, Truro, UK Nick M Spirtos, MD, FACOG Clinical Professor, University of Nevada Las Vegas School of Medicine Medical Director, Women’s Cancer Center of Nevada Las Vegas, NV, USA Paul Hilton, MD, FRCOG Guest Clinical Senior Lecturer, Newcastle University Retired Consultant Gynaecologist & Urogynaecologist Newcastle upon Tyne Hospitals NHS Foundation Trust Newcastle upon Tyne, UK John M Monaghan, MB, FRCS (Ed), FRCOG Retired Senior Lecturer in Gynaecological Oncology University of Newcastle Upon Tyne Retired Gynaecological Oncologist Regional Department of Gynaecological Oncology Queen Elizabeth Hospital, Gateshead, UK This twelfth edition first published 2018 © 2018 by John Wiley & Sons Ltd Edition History John 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 Registered Office(s) John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Office 9600 Garsington Road, Oxford, OX4 2DQ, UK For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand Some content that appears in standard print versions of this book may not be available in other formats Limit of Liability/Disclaimer of Warranty The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make This work is sold with the understanding that the publisher is not engaged in rendering professional services The advice and strategies contained herein may not be suitable for your situation You should consult with a specialist where appropriate Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages 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 surgery Description: 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–surgery Classification: LCC RG104 (ebook) | LCC RG104 (print) | NLM WP 660 | DDC 618.1–dc23 LC record available at https://lccn.loc.gov/2017056122 Cover Design: Wiley Cover Image: Courtesy of Chris Kevern Set in 8.5/12pt Meridien by SPi Global, Pondicherry, India 10 9 8 7 6 5 4 3 2 1 Contents Preface, vii Part 3: Urogynaecology 16 Operations for pelvic organ prolapse, 161 Part 1: General 17 Operations for urinary incontinence, 193 Introduction and prologue, 18 Operations for urogenital fistulae, 231 Preparation for surgery, Instruments, operative materials and basic surgical techniques, 17 Opening and closing the abdominal cavity, 33 Part 4: Oncology 19 Surgery for carcinoma of the vulva, 269 The laparoscopic approach in gynaecology, 45 20 Vaginal cancer surgery, 281 Postoperative care and complications, 55 21 Cervical cancer, 285 22 Uterine cancer, 309 Part 2: Anatomical 23 Ovarian cancer, 313 For the general gynaecologist and gynaecologist in training 24 Exenterative surgery, 319 Operations on the vulva, 63 Part 5: Operations on other organs Operations on the vagina, 71 Operations on the cervix, 83 10 Operations on the uterine cavity, 101 11 Operations on the uterus, 107 12 Uterine fibroids, 127 13 Operations on the fallopian tubes, 135 14 Operations on the ovaries, 141 15 Caesarean section, 147 25 Vascular surgery: applications in gynaecology and gynaecological oncology, 331 26 Management of injuries to the urinary tract, 335 27 Operations on the intestinal tract for the gynaecologist, 349 28 Reconstructive procedures, 361 Index, 365 v Preface “The human form is a very delicate organization It is not a thing which should be meddled with by people who 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 and 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 Editors November 2017 vii PART General C H APT ER 1 Introduction 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 Bonney’s Gynaecological Surgery, Twelfth Edition Alberto (Tito) de Barros Lopes, Nick M Spirtos, Paul Hilton, and John M Monaghan © 2018 John Wiley & Sons Ltd Published 2018 by John Wiley & Sons Ltd Chapter 1 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 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 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 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 Operations for pelvic organ prolapse 177 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 inferomedial direction within the pubococcygeus muscle, from approximately o’clock to o’clock in the operative field (Figure 16.16) Step 3: Insertion of the sacrospinous stitch If the Miya hook is used, it is important that it is loaded from the inner aspect of the curve outwards, otherwise it will not be possible to remove the hook without removing the suture needle The author’s preference is for PDS (polydioxanone; W9374 PDS, 40 mm half‐circle needle) suture; I have previously used, and others still advocate, a nonabsorbable suture such as Ethibond (coated polyester) but see comment below headed ‘Attachment of the sutures to the vagina’ By approximating the handles of the Miya hook and simultaneously elevating the whole device, the suture is placed through (not around) the ligament, 2 cm medial to the right ischial spine (Figure 16.17) The tip of the hook is then manipulated into the notch on the Sims’ speculum, the suture retrieved using a nerve hook and the Miya hook then disengaged The application of firm traction to the suture length will test the correctness of its placement and should move the whole pelvis slightly on the operating table A second suture is then inserted, medial to the first, for additional support If any of the alternative devices listed above are used for placement of the suture, the manufac turer’s instructions for suture mounting should be followed With the direct visualization tech nique described, the risk of rectal injury should be minimal; if a blind technique is used, rectal examination should be undertaken before the sutures are tied, to exclude injury Step 4: Attachment of the sutures to the vagina The two sutures are then secured to the vaginal skin approximately 2 cm below the vault, on either side of the incision A ‘pulley‐stitch’ is 178 Chapter 16 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 fashioned with each suture, passing one end freely through the skin while securing the other with a double hitch or Aberdeen knot (Figure 16.18) The advantage of using an absorbable suture is that it can be tied within the vagina; if a nonabsorbable suture is used, it must be knotted on the under surface and buried beneath the vaginal skin to limit the risk of suture erosion, sinus formation and persistent vaginal discharge Step 5: Closure and completion of the posterior repair If posterior repair is to be carried out concurrently, it is completed at this stage and the posterior vaginal wall is then closed, as previously described The suspensory sutures are then tied by employing their pulley mechanism; traction is applied to the free end, which allows the fixed end to bring the vaginal vault into proximity with the ligament The suture is then tied while maintaining traction The sutures should be trimmed but leaving ends of at least 2 cm length within the vagina Postoperative care As with other procedures for prolapse, the author’s practice is to insert an indwelling urethral urinary catheter overnight postoperatively; vaginal pack ing is not required routinely Postoperative pain control should be managed as for any procedure; if buttock pain is a particular prob lem, nonsteroidal anti‐inflammatory drugs orally or rectally should be prescribed for regular use Patients should be advised to avoid penetrative sexual intercourse until after postoperative review; if PDS is used for the suspensory sutures, it retains tensile strength for up to weeks but may still have a brittle feel within the vagina for considerably Operations for pelvic organ prolapse 179 Figure 16.18 ‘Pulley‐stitch’ is used to fix the suspensory sutures to the vaginal skin just below the vaginal vault longer than this; this may be a cause of dyspareunia for both partners Uterosacral ligament suspension As with sacrospinous ligament fixation, the utero sacral ligament procedure can be undertaken imme diately following vaginal hysterectomy, although it is most typically used for the treatment of vaginal vault prolapse after hysterectomy.14 Step 1: The incision If anterior and/or posterior colporrhaphy are to be undertaken at the same operation, these procedures should be carried out first; a single midline incision from bladder neck to perineal body, thus including the anterior wall, vault and posterior wall, is preferred On completion of the colporrhaphies, the upper edge of the plicated pubocervical and pre‐rectal fasciae are each marked with two Allis or Littlewood’s tissue forceps Step 2: Identification of the uterosacral ligaments If not previously opened, the enterocoele sac is incised at this stage and the bowel packed out of the operative field The remnants of uterosacral ligaments can be difficult to locate but may be apparent as dimples at the angles of the vault scar; they are more appropriately identified after opening the peritoneum, posterior and medial to the ischial spines at the o’clock and o’clock positions An Allis clamp is used to apply traction to each ligament in turn and the contralateral index 180 Chapter 16 Figure 16.19 Three sutures placed through the uterosacral ligament on the right side finger used to trace the strong suspensory tissue towards the sacrum One Breisky–Navratil retractor is used to retract the rectum medially and a second, or a curved Deaver retractor, is used to hold up the bowel and surgical pack cephalically Step 3: Suturing of the uterosacral ligaments With a long, straight needle driver, a double‐armed nonabsorbable braided suture Ethibond (coated polyester; X524H Ethibond 26 mm taper point needle), is placed through the ligament on the sacral side of the ischial spine In an effort to minimize the risk of injury to the ureter, the needle should be passed lateral to medial, the points of needle entry always being medial and posterior to the ischial spines Two additional sutures are then placed proximally along the ligament (i.e on the sacral side) Each suture is secured by a small artery forcep; either racking the forceps in order on a long straight clamp or using labelled clamps on each of the sutures can help to ensure that the operator does not lose track of which is which (Figure 16.19) The same procedure is then carried out on the opposite side Once all the suspensory sutures are in place, the double‐armed sutures are hitched into the superior aspect of the pubocervical and pre‐rectal fasciae (Figure 16.20) The suture most distally on the uterosacral ligaments (i.e closest to the surgeon) is secured most laterally into the fascia The more proximal sutures are placed more medially in the fascia Step 4: Check cystoscopy Before the suspensory sutures are tied, cystoscopy should be carried out to exclude the possibility of compromise to ureteric drainage The anaesthetist is asked to give 5 ml indigo carmine dye intravenously; if dye is not seen at the ureteric orifices within 10 minutes, the most distal suture on the Operations for pelvic organ prolapse 181 12 Figure 16.20 Sutures (double‐armed), already through the ligament, are secured into the pubocervical and pre‐rectal fasciae affected side(s) should be removed then the next and so on, until efflux is seen (Figure 16.21) Once dye is seen, traction should be placed on the most distal suture and if this slows or stops the flow of dye, again the lowermost suture should be removed As long as at least two suspensory remain, with bilateral ureteric efflux, no further action is necessary; otherwise sutures should be replaced more distally along the uterosacral ligaments Step 5: Tying the suspensory sutures Once the surgeon is confident that the ureters are not compromised, the sutures are then tied in the sequence in which they were placed, bringing the upper edges of the pubocervical and pre‐rectal fasciae together at the apex, in proximity to the uterosacral ligaments at the vaginal vault (Figure 16.22) Step 6: Wound closure The anterior and posterior vaginal skin edges are then approximated commencing at the vault and working to the bladder neck and perineal body, respectively, using a continuous locking 2‐0 Vicryl (polyglactin) suture (W9350 2‐0 Vicryl, 26 mm half‐circle taper cut heavy needle) As noted previously, catching the underlying fascia in each bite of the suture, helps to reapproximate the skin against the underlying fascia, reduces the dead space and limits the chance of haematoma collection An alternative method is to close the vaginal skin first, leaving the suspensory sutures pro truding through the vault, to be tied at the end of the procedure This makes access to close the vaginal incision easier but perhaps adds to the risk of stitch sinus formation from the 182 Chapter 16 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 not protrude through the vault incision Operations for pelvic organ prolapse onabsorbable suture material If this technique n is chosen, the sutures must be trimmed short, ensuring that the ends not protrude through the vault incision Postoperative care As with other procedures to treat prolapse, the author’s practice is to insert an indwelling urethral urinary catheter overnight postoperatively; vaginal packing is not required routinely Abdominal sacrocolpopexy The principle of sacrocolpopexy is to support the vaginal vault and restore the vaginal axis using interposition of mesh or sutures, between the upper vagina and the anterior sacral ligament Anaesthesia Regional or general anaesthesia is suitable for this abdominal procedure Patient preparation The patient should be in a modified lithotomy Trendelenburg position with legs in the stirrups slightly apart, the hips and knees slightly flexed and the hips abducted, so that an assistant can stand between them Care should be taken to avoid pressure points, particularly the peroneal nerve Preparation should be made as for any abdominal procedure In addition, the vagina should be cleansed and an indwelling urethral catheter inserted The degree of prolapse should be assessed to determine the need for concomitant anterior or posterior repairs The author’s preference is to insert a ‘rectal probe’ into the vagina, which can be used to manipulate the vault during the procedure and aid dissection of the rectum and bladder from the vaginal vault Instruments The gynaecological general set shown in Chapter 3 is used An adhesive urological drape (with a finger cot attached) allows aseptic manipulation vaginally, while the abdomen is open; a rectal probe may also help to manipulate the vaginal vault Many different alloplastic and allogeneic meshes, either as preformed devices or cut from sheets, have been employed for sacrocolpopexy; the 183 author’s preference has been to fashion an appro priate size and shape for each patient from a sheet of Prolene (polypropylene) or UltraPro (Monocryl/ Prolene, poliglecaprone/polypropylene) The operation Step 1: The incision Entry through a Pfannenstiel incision is preferred; although rarely required for sacrocolpopexy, access can be improved by modifying this into a Cherney incision, separating the rectus muscles from the pubic bones Step 2: Preparation of the vaginal vault Any intraperitoneal adhesions from prior surgery are divided and dissection is continued to give access to the vaginal vault Using gentle pressure through the urological drape, the inverted vagina is repositioned; the rectal probe may then be placed into the vagina, making it easier to palpate via the abdomen The peritoneum overlying the vaginal vault is incised, taking care to avoid injury to the bladder The plane between the posterior vaginal wall and rectum is developed as far down as necessary; this usually separates without difficulty, although pararectal veins may be troublesome as the pelvic floor is approached The bladder base may also be dissected off the upper part of the anterior vaginal wall; this is likely to be more adherent and sharp dissection is essential Step 3: Preparation of the sacral promontory The sigmoid colon is packed over to the left side of the pelvis to allow access to the sacral promontory The overlying peritoneum is incised, exposing the longitudinal ligament at the level of the promontory Care should be taken to avoid the median sacral vessels; the veins in particular can be difficult to control if injured The retroperitoneum is then opened from the level of the vaginal incision round to the sacral incision; alternatively, a tunnel can be created beneath the peritoneum between the sacral and vaginal incisions Step 4: Placement of the mesh The appropriate length and width of mesh is measured to reach the sacral promontory without tension while allowing the vagina to lie anatomically against the pelvic floor; extension down the posterior wall needs to be accommodated It has 184 Chapter 16 not been the author’s practice to extend the mesh down the anterior vaginal wall routinely, although if this extension is planned, either additional length should be allowed or, alternatively, a double length of mesh may be used The mesh can be secured in place from either upper or lower ends, depending on access; usually the lower end is preferred Commencing at the lower aspects of the posterior vaginal wall moving progressively towards the vault, the mesh is sutured to the vaginal tissues using several rows of interrupted slowly absorbable sutures of 3‐0 PDS (polydioxanone; W9132 3‐0 PDS, 31 mm half‐circle round‐bodied needle); (nonabsorbable sutures are used by some surgeons, although this carries a risk of suture erosion and sinus formation) The extent to which the mesh extends down the posterior vaginal wall will depend on the clinical evaluation at the time The mesh is attached to the vaginal vault and if appropriate, on to the upper anterior vaginal wall (Figure 16.23) Extension of the mesh far down the anterior wall is best avoided, because of the risk of exacerbating lower urinary tract symptoms and of mesh erosion The mesh is then reflected towards the sacrum The length of mesh used is gauged as noted above It is attached to the anterior sacral ligament using several interrupted nonabsorbable sutures of Ethibond (coated polyester) or staples (W975 Figure 16.24 Attachment of mesh to sacral promontory Ethibond, 31 mm half‐circle round‐bodied needle; Figure 16.24) The positioning and mobility of the vagina should be confirmed; if it is satisfactory, any excess mesh length is excised and discarded If the tissues are thought to be too mobile, a ‘tuck’ can be taken in the mesh with a series of interrupted sutures rather than taking the attachment down The author’s preference is to close the peritoneum over the entire area; some surgeons not this, but care must be taken to ensure that bowel cannot herniate beneath the mesh Step 5: Closure of the abdominal wall The abdominal wall is closed as described in Chapter Vaginal examination is undertaken to assess the need for further repair, although this is rarely necessary; posterior repair is best avoided at the same time because of the increased risk of mesh erosion Laparoscopic sacrocolpopexy Figure 16.23 Attachment of mesh to vaginal wall Abdominal sacrocolpopexy can also be undertaken laparoscopically or robotically, offering a minimal access approach to vault suspension The procedure follows the same steps as for open sacrocolpopexy, although staples or screws are more often used to attach the mesh to the sacrum The laparoscopic approach may have the benefit of shorter recovery and hospital stay for the patient and allows better visualization of the pelvic floor; this comes at the Operations for pelvic organ prolapse expense of longer operating time and increased cost Current evidence suggests that the efficacy of sacrocolpopexy carried out by open and laparo scopic approaches are equivalent The latter should, however, only be offered where advanced skills in both urogynaecology and laparoscopic surgery are available Uterine sparing prolapse surgery There is increased interest in prolapse procedures that preserve the uterus Specifically, the techniques of sacrocolpopexy and sacrospinous fixation have been modified to allow preservation of the uterus by sacrohysteropexy and sacrospinous cervicopexy The 2016 iteration of the Cochrane review on surgery for apical vaginal prolapse could reach no clear conclusions on the relative merits of vaginal hysterectomy compared to uterine sparing surgery, although the authors highlighted one trial which found that awareness of prolapse was less likely after hysterectomy than after abdominal sacrohys teropexy.15 Nevertheless, there are several reasons why women may request these procedures and these should be explored in full In particular, where women wish to retain their uterus for fertility, the risks of further pregnancy and delivery on their pelvic floor function should be considered Transvaginal insertion of mesh The surgical treatment of prolapse is associated with a significant risk of recurrence Reoperation rates of up to 30% have been reported,3 although the rate was less than 2% in the author’s personal audit referred to above; up to 10% is perhaps realistic.16 The use of mesh to augment surgical repair has become standard in the management of hernia and an obvious corollary was seen to be the application of mesh augmentation in prolapse surgery However, it has become clear that there are particular issues with the use of mesh in the vagina in terms of sex ual, bladder and bowel function, in addition to con cern about mesh erosion or infection, given the operative field The implanted materials used have been most commonly synthetic (alloplastic) or bio logical (allogeneic); the implant may be trimmed to size and shape from a sheet of mesh; alternatively, 185 one of several specifically designed ‘mesh kits’ may be used The implant is secured to the underlying fascia by a series of sutures at the apex (in the region of the cervix or vaginal vault), laterally to the pelvic sidewalls and sacrospinous ligaments and inferiorly (in the region of the bladder neck) With the mesh kits, additional support is provided by a number (two or four, depending on the device used) of addi tional mesh limbs, similar to mid‐urethral slings in structure, introduced by long needles through the obturator foramen or the perineum According to the type and degree of prolapse present, the whole mesh or only part of it may be inserted The use of mesh for sacrocolpopexy for vaginal vault prolapse (and mid‐urethral tapes for stress uri nary incontinence), is supported by evidence from good quality randomized controlled trials Evidence to support the routine use of transvaginal mesh, however, is limited Concern over adverse events has resulted in many thousands of medicolegal claims and several national and international reviews in the United States, Europe and the UK While these are not entirely consistent in their conclusions and rec ommendations, the general view is that there is minimal evidence of benefit17 and growing concern over adverse events,17,18 such that robust governance arrangements must apply in the decision to use mesh for pelvic organ prolapse,19–21 which should in any case be restricted to complex cases.19–21 Undoubtedly the most robust evidence in this context comes from the PROSPECT study,22 which concluded that, within the first two years of surgery, augmentation of a vaginal repair with (synthetic) mesh or (biological) graft material did not improve women’s outcomes in terms of effec tiveness, quality of life, adverse effects or any other outcome in the short term, but more than one in ten women had a mesh complication.22 Obliterative techniques The aim of prolapse surgery, as stated earlier, is to restore normal vaginal anatomy, while maintain ing or improving normal bladder, bowel and sexual functions The further requirement, to define the patient’s goals and expectations from surgery and to reconcile these with what might be achievable, cannot be overemphasised There is a group of women for whom the need to achieve a high likelihood 186 Chapter 16 of relief from the discomfort and incapacity from procidentia, at minimal risk, outweighs the loss of sexual function For these women, an obliterative, as opposed to restorative, approach to surgery may be appropriate In the author’s personal audit of 1713 women with surgically managed prolapse referred to ear lier, only 19 (1%) women, aged 60–84 years, were treated by colpocleisis; adverse events were mini mal and all were happy with the outcome of their surgery A technique of partial colpocleisis, the Latzko procedure, is used in the treatment of vesicovaginal fistula; complete colpocleisis (used in women with prior hysterectomy)23 or the Le Fort’s procedure (used in women who still have a uterus), are options in the treatment of prolapse Complete colpocleisis Anaesthesia Although most commonly undertaken using general or regional anaesthesia, colpocleisis can be carried out under local anaesthesia if other forms of anaesthesia are contraindicated Patient preparation No specific preoperative preparation is required; it is preferable to administer an enema or supposi tories if the bowel has not moved in the previous 24 hours The standard lithotomy position is employed; a head‐down tilt is not necessary The operation Step 1: The incision Ultimately the whole of the vaginal epithelium will be removed; some descriptions have this all done as a single step, working from the vestibule to the vault The author’s preference is to remove the epithelium in strips, working sequentially from the vault towards the introitus; this reduces the potential for blood loss from the underlying tissues The majority of patients in whom this proce dure is appropriate are elderly, postmenopausal and have often had their prolapse protruding beyond the vulva for many years; hence, e stablishing the correct plane for dissection can be difficult The injection of local anaesthetic and adrenaline (1% lidocaine or 0.5% bupivacaine with adrenaline 1:200 000) into the subepithelial space can be helpful in delineating the tissue planes and reduce bleeding The success of the procedure is dependent on retaining the maxi mum amount of fascia and care should be taken not to disrupt the fascial layer by excessive hydrodissection The area to be stripped initially is marked with a scalpel and then removed, leaving as much underlying connective tissue as possible; this often requires a combination of cutting and ‘shaving’ with a sharp scalpel, such as no 10, 12, or 12D Swann Morton blades (Figure 16.25) Step 2: The fascial closure Although some close the fascia with a series of purse‐string sutures (which undoubtedly saves time), the author’s preference is not to rely on single knots for the closure but to use several rows of interrupted inverting Lembert‐type sutures As with colporrhaphy, 3‐0 PDS (polydioxanone; W9132 3‐0 PDS, 31 mm half‐circle round‐bodied needle) is preferred (Figure 16.26) Step 3: Continuing the excision and closure Further strips of vaginal epithelium, 3–4 cm in width, are stripped and then the fascia inverted, as described above, until the area of the lower vagina in the region of the bladder neck is approached Here, it is important to ensure that the underlying tissues are not coming under excessive tension; if this were to happen, the risk of subsequent stress urinary incontinence (from tenting the bladder neck open posteriorly) or defaecatory difficulty (from drawing the anterior rectal wall forward) may be increased If this appears to be a real risk, an interposition graft such as a modified Martius labial fat graft might be considered (see Chapter 18; Figure 16.27) Step 4: The skin closure As the introitus is reached, skin flaps are created by undermining rather than excising the lowermost strip of vaginal epithelium The introitus is then closed with interrupted mattress sutures of 2‐0 Vicryl (polyglactin; W9350 2‐0 Vicryl, 26 mm half‐circle taper cut heavy needle) 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 188 Chapter 16 Figure 16.27 Modified Martius labial fat graft may be used to fill dead space in the lower vagina Postoperative care The operation A urethral catheter is inserted overnight Early mobilization is encouraged Patients can be dis charged home as soon as they are passing urine and stool normally Step 1: The incision Rather than excising the whole of the vaginal epithelium, in the Le Fort’s procedure, rectangles are excised from the anterior and posterior walls However, rather than measure the segment to be excised, it is important to ensure that an adequate amount of skin is left to fashion the channel; this should allow for a size 14–16 French gauge Foley or suction catheter, which (allowing for suturing) means leaving a strip of at least 3 cm on either side and over the top of the vagina (Figure 16.28) Once marked out, the technique of excision is as described above for complete colpocleisis Le Fort’s colpocleisis In women who still retain their uterus, where there may be a risk of later vaginal discharge or bleeding, the colpocleisis may be modified by the creation of a drainage channel over the top and around the sides of the vagina – Le Fort’s procedure.24 Operations for pelvic organ prolapse 189 Figure 16.28 Vaginal epithelium stripped from anterior and posterior walls prior to Le Fort’s procedure Step 2: Closure of the skin across the top of the vagina The first part of the closure in the Le Fort’s procedure is the skin across the top of the vagina This is achieved by undermining the remaining skin from the cervix and then rolling it into a tube over the drain with interrupted sutures of 2‐0 Vicril (polyglactin; W9350 2‐0 Vicryl, 26 mm half‐circle taper cut heavy needle) Step 3: The fascial closure Again, several rows of interrupted inverting Lembert‐type sutures of 3‐0 PDS (polydioxanone; W9132 3‐0 PDS, 31 mm half‐circle round‐bodied needle) are used to approximate the fascia underlying the anterior and posterior vaginal walls (Figure 16.29) As the vagina progressively inverts, further interrupted sutures of 2‐0 Vicril (polyglactin) are used to continue the closure of the lateral vaginal channels Step 4: The introital skin closure As the introitus is reached, skin flaps are created by undermining the vaginal epithelium The introitus is then closed with interrupted mattress sutures of 2‐0 Vicryl (polyglactin; W9350 2‐0 Vicryl, 26 mm half‐circle taper cut heavy needle) 190 Chapter 16 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 Postoperative care Again, a urethral catheter is left in place overnight and early mobilization is encouraged Patients can be discharged home as soon as they are passing urine and stool normally The vaginal drain tube is removed prior to discharge References 1 Dolan LM, Hilton P Obstetric risk factors and pelvic floor dysfunction 20 years after first delivery Int Urogynecol J Pelvic Floor Dysfunct 2010;21(5):535–44 Mant J, Painter R, Vessey M Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study Br J Obstet Gynaecol 1997;104(5): 579–85 Olsen AL, Smith VJ, Bergstrom JO, et al Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence Obstet Gynecol 1997;89(4):501–6 Hospital Episode Statistics Department of Health 2016 Available from: http://www.hesonline.nhs.uk (accessed October 2017) Bump RC, Mattiasson A, Bo K, et al The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction Am J Obstet Gynecol 1996;175(1):10–17 Hilton P, Robinson D Defining cure Neurourol Urodyn 2011;30(5):741–5 Glazener CMA, Cooper K Anterior vaginal repair for urinary incontinence in women (first published 2000; last updated 2009) Cochrane Database Syst Rev 2001;(1):CD001755 doi: 10.1002/14651858.CD001755 Nieminen K, Hiltunen KM, Laitinen J, et al Transanal or vaginal approach to rectocele repair: a prospective, randomized pilot study Dis Colon Rectum 2004;47(10): 1636–42 McCall ML Posterior culdeplasty; surgical correction of enterocele during vaginal hysterectomy; a prelimi nary report Obstet Gynecol 1957;10(6):595–602 10 Amreich J [Etiology and surgery of vaginal stump prolapses] Wien Klin Wochenschr 1951;63(5):74–7 11 Richter K [The surgical treatment of the prolapsed vaginal fundus after uterine extirpation A contribution on Amreich’s the sacrotuberal vaginal fixation] Geburtshilfe Frauenheilkd 1967;27(10):941–54 12 Alevizon SJ, Finan MA Sacrospinous colpopexy: management of postoperative pudendal nerve entrap ment Obstet Gynecol 1996;88(4 II Suppl):713–15 Operations for pelvic organ prolapse 13 Miyazaki FS Miya hook ligature carrier for sacrospinous ligament suspension Obstet Gynecol 1987;70(2):286–8 14 Shull BL, Bachofen C, Coates KW, Kuehl TJ A trans vaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments Am J Obstet Gynecol 2000;183(6):1365–73 15 Maher C, Feiner B, Baessler K, et al Surgery for women with apical vaginal prolapse Cochrane Database Syst Rev 2016;(10):CD012376 doi: 10.1002/14651858.CD012376 16 Clark AL, Gregory T, Smith VJ, Edwards R Epidemiologic evaluation of reoperation for surgically treated pelvic organ prolapse and urinary incontinence Am J Obstet Gynecol 2003;189(5):1261–7 17 US Food and Drug Administration Urogynecologic Surgical Mesh: Update on Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse Washington DC: FDA; 2011 18 Medicines and Healthcare products Regulatory Agency A Summary of the Evidence on the Benefits and Risks of vaginal Mesh Implants London: MHRA; 2014 19 European Commission Scientific Committee on Emerging and Newly Identified Health Risks Opinion on the Safety of Surgical Meshes used in Urogynecological Surgery Luxembourg: SCENIHR; 2015 20 NHS England Acute Care Policy and Strategy Unit Mesh Working Group Interim Report London: NHS; 2015 21 Scottish Independent Review of the Use, Safety and Efficacy of Transvaginal Mesh Implants in the Treatment of Stress Urinary Incontinence and Pelvic Organ Prolapse in Women Final Report Edinburgh: Scottish Government; 2017 22 Glazener C, Breeman S, Elders A, et al Clinical effective ness and cost‐effectiveness of surgical options for the management of anterior and/or posterior vaginal wall prolapse: two randomised controlled trials within a com prehensive cohort study Results from the PROSPECT study Health Technol Assess 2016;20(95):1–452 23 DeLancey JO, Morley GW Total colpocleisis for v aginal eversion Am J Obstet Gynecol 1997;176(6):1228–35 24 Tauber R The modern technic of the Le Fort opera tion Ann Surg 1947;125(3):334–40 Further reading The literature on pelvic floor dysfunction and its surgical management is rapidly expanding, but to date is largely of poor quality The list above includes some of the sem inal contributions cited in this chapter The interested reader might also consult the latest updates of relevant Cochrane reviews (www.cochranelibrary.com) and interventional procedures and clinical guidance from the National Institute for Health and Care Excellence (NICE; www.nice.org.uk/guidance) listed below 191 Cochrane reviews Hagen S, Stark D Conservative prevention and manage ment of pelvic organ prolapse in women Cochrane Database Syst Rev 2011;(12):CD003882 doi: 10.1002/ 14651858.CD003882.pub4 Maher C, Feiner B, Baessler K, et al Surgery for women with anterior compartment prolapse Cochrane Database Syst Rev 2016;11:CD004014 doi: 10.1002/14651858 CD004014.pub6 Maher C, Feiner B, Baessler K, et al Surgery for women with apical vaginal prolapse Cochrane Database Syst Rev 2016;10:CD012376 doi: 10.1002/14651858 CD012376 Maher C, Feiner B, Baessler K, et al Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse Cochrane Database Syst Rev 2016;2:CD012079 doi: 10.1002/14651858.CD012079 National Institute for Health and Care Excellence guidance Although the following guidelines remain extant at the time of going to press, updates are always in development Infracoccygeal Sacropexy Using Mesh for Uterine Prolapse Repair Interventional Procedures Guidance IPG280 January 2009 Infracoccygeal Sacropexy Using Mesh to Repair Vaginal Vault Prolapse Interventional Procedures Guidance IPG581 June 2017 Surgical Repair of Vaginal Wall Prolapse Using Mesh Interventional Procedures Guidance IPG267 June 2008 Sacrocolpopexy Using Mesh to Repair Vaginal Vault Prolapse Interventional Procedures Guidance IPG583 June 2017 Urinary Incontinence in Women: Management Clinical Guideline CG171 September 2013; last updated November 2015 Uterine Suspension Using Mesh (Including Sacrohysteropexyx to Repair Uterine Prolapse Interventional Procedures Guidance IPG584 June 2017 The following guideline remain extant at the time of going to press, although an update is development and is planned to cover both urinary incontinence and pelvic organ prolapse National Collaborating Centre for Women’s and Children’s Health Urinary Incontinence: The Management of Urinary Incontinence in Women Commissioned by the National Institute for Health and Care Excellence 2nd ed London: RCOG; 2013 ... LCCN 2 017 056804 (ebook) | ISBN 97 811 192669 21 (pdf) | ISBN 97 811 19266 914 (epub) | ISBN 97 811 19266785 (hardback) Subjects: | MESH: Gynecologic Surgical Procedures | Genitalia, Female? ?surgery Classification:... on the vagina, 71 Operations on the cervix, 83 10 Operations on the uterine cavity, 10 1 11 Operations on the uterus, 10 7 12 Uterine fibroids, 12 7 13 Operations on the fallopian tubes, 13 5 14 Operations... Wiley, 2 017 | Preceded by Bonney’s gynaecological surgery 11 th ed / Tito Lopes [et al.] c2 011 | Includes bibliographical references and index | Identifiers: LCCN 2 017 05 612 2 (print) | LCCN 2 017 056804