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Surgery_Schwartz_11902 | Surgery_Schwartz | into small pieces with the hysteroresectoscope. Stalk resection should only be done to release a pedunculated fibroid if it is 10 mm or less in size; larger fibroids are difficult to remove in one piece without excessive cervical dilatation.44Subserosal, or pedunculated fibroids may require an open or laparoscopic approach depending on the size and location or the leiomyoma. In addition to vasopressin, hemostasis can be further managed through the placement of a Penrose drain around the base of the uterus, pulled through small perforations in the broad ligament lateral to the uterine blood supply on either side and clamped to form a tourniquet for uterine blood flow. An incision is then made through the uterine serosa into the myoma. The pseudocapsule surrounding the tumor is identified, and the tumor is bluntly dissected out with scissors, or bluntly if open. Vessels to the myoma are dessicated with the electrosurgical unit. Several myomas may be removed through a single incision, | Surgery_Schwartz. into small pieces with the hysteroresectoscope. Stalk resection should only be done to release a pedunculated fibroid if it is 10 mm or less in size; larger fibroids are difficult to remove in one piece without excessive cervical dilatation.44Subserosal, or pedunculated fibroids may require an open or laparoscopic approach depending on the size and location or the leiomyoma. In addition to vasopressin, hemostasis can be further managed through the placement of a Penrose drain around the base of the uterus, pulled through small perforations in the broad ligament lateral to the uterine blood supply on either side and clamped to form a tourniquet for uterine blood flow. An incision is then made through the uterine serosa into the myoma. The pseudocapsule surrounding the tumor is identified, and the tumor is bluntly dissected out with scissors, or bluntly if open. Vessels to the myoma are dessicated with the electrosurgical unit. Several myomas may be removed through a single incision, |
Surgery_Schwartz_11903 | Surgery_Schwartz | and the tumor is bluntly dissected out with scissors, or bluntly if open. Vessels to the myoma are dessicated with the electrosurgical unit. Several myomas may be removed through a single incision, depending upon size. The uterine incisions are then closed with absorbable sutures to obliterate the dead space and provide hemostasis. The uterine serosa is closed with a 3-0 absorbable suture, placed subserosally if possible. Because myomectomies are associated with considerable postoperative adhesion formation, barrier techniques are used to decrease adhesion formation.During a laparoscopic myomectomy, hemostasis is assisted by intrauterine injection of dilute vasopressin (10 U in 50 mL) at the site of incision, similar to an open procedure. This is usually performed percutaneously with a spinal needle. Pedunculated leiomyomas can be excised at the base using scissors or a power instrument. Intramural leiomyomas require deep dissection into the uterine tissue, which must be closed | Surgery_Schwartz. and the tumor is bluntly dissected out with scissors, or bluntly if open. Vessels to the myoma are dessicated with the electrosurgical unit. Several myomas may be removed through a single incision, depending upon size. The uterine incisions are then closed with absorbable sutures to obliterate the dead space and provide hemostasis. The uterine serosa is closed with a 3-0 absorbable suture, placed subserosally if possible. Because myomectomies are associated with considerable postoperative adhesion formation, barrier techniques are used to decrease adhesion formation.During a laparoscopic myomectomy, hemostasis is assisted by intrauterine injection of dilute vasopressin (10 U in 50 mL) at the site of incision, similar to an open procedure. This is usually performed percutaneously with a spinal needle. Pedunculated leiomyomas can be excised at the base using scissors or a power instrument. Intramural leiomyomas require deep dissection into the uterine tissue, which must be closed |
Surgery_Schwartz_11904 | Surgery_Schwartz | a spinal needle. Pedunculated leiomyomas can be excised at the base using scissors or a power instrument. Intramural leiomyomas require deep dissection into the uterine tissue, which must be closed subsequently with laparoscopic suturing techniques. Removing the specimen may require morcellation; this should be performed after placement of the specimen in a bag. Although power morcellators were previously used for this purpose, an FDA warning in 2014 has virtually eliminated their use. Severe complications including damage to surrounding bowels and vascular structures caused by the spinning blade of the morcellator were reported. Multiple reports of benign tissues such as leiomyoma and endometriosis scattering and dispersing onto abdominal organ surfaces lead-ing to inflammation, infection, and intestinal obstruction often requiring additional surgical interventions and treatments were made. The unintentional dissemination of malignant cells wors-ens prognosis if an undiagnosed | Surgery_Schwartz. a spinal needle. Pedunculated leiomyomas can be excised at the base using scissors or a power instrument. Intramural leiomyomas require deep dissection into the uterine tissue, which must be closed subsequently with laparoscopic suturing techniques. Removing the specimen may require morcellation; this should be performed after placement of the specimen in a bag. Although power morcellators were previously used for this purpose, an FDA warning in 2014 has virtually eliminated their use. Severe complications including damage to surrounding bowels and vascular structures caused by the spinning blade of the morcellator were reported. Multiple reports of benign tissues such as leiomyoma and endometriosis scattering and dispersing onto abdominal organ surfaces lead-ing to inflammation, infection, and intestinal obstruction often requiring additional surgical interventions and treatments were made. The unintentional dissemination of malignant cells wors-ens prognosis if an undiagnosed |
Surgery_Schwartz_11905 | Surgery_Schwartz | and intestinal obstruction often requiring additional surgical interventions and treatments were made. The unintentional dissemination of malignant cells wors-ens prognosis if an undiagnosed malignancy (most frequently leiomyosarcoma) was morcellated. Although contained morcel-lation (in a bag) may reduce these risks, informed consent to the patient is prudent.45Total Abdominal Hysterectomy (Fig. 41-12) After the abdomen is entered, the upper abdomen is examined for evi-dence of extrapelvic disease, and a suitable retractor is placed in the abdominal incision. The uterus is grasped at either cornu with clamps and pulled up into the incision. The round ligament is identified and divided. The peritoneal incision is extended from the round ligament to just past the ovarian hilum, lat-eral the infundibulopelvic ligament, if the ovaries are to be removed. The retroperitoneal space is bluntly opened, the ure-ter identified on the medial leaf of the broad ligament, and the | Surgery_Schwartz. and intestinal obstruction often requiring additional surgical interventions and treatments were made. The unintentional dissemination of malignant cells wors-ens prognosis if an undiagnosed malignancy (most frequently leiomyosarcoma) was morcellated. Although contained morcel-lation (in a bag) may reduce these risks, informed consent to the patient is prudent.45Total Abdominal Hysterectomy (Fig. 41-12) After the abdomen is entered, the upper abdomen is examined for evi-dence of extrapelvic disease, and a suitable retractor is placed in the abdominal incision. The uterus is grasped at either cornu with clamps and pulled up into the incision. The round ligament is identified and divided. The peritoneal incision is extended from the round ligament to just past the ovarian hilum, lat-eral the infundibulopelvic ligament, if the ovaries are to be removed. The retroperitoneal space is bluntly opened, the ure-ter identified on the medial leaf of the broad ligament, and the |
Surgery_Schwartz_11906 | Surgery_Schwartz | hilum, lat-eral the infundibulopelvic ligament, if the ovaries are to be removed. The retroperitoneal space is bluntly opened, the ure-ter identified on the medial leaf of the broad ligament, and the Brunicardi_Ch41_p1783-p1826.indd 179718/02/19 4:34 PM 1798SPECIFIC CONSIDERATIONSPART IIinfundibulopelvic ligament isolated, clamped, cut, and suture-ligated; a similar procedure is carried out on the opposite side. If the ovaries are to be left in situ, the ureter is identified and an opening below the utero-ovarian ligament and fallopian tube created. The fallopian tube and utero-ovarian ligament are clamped, cut, and ligated. The bladder is mobilized by sharply dissecting it free of the anterior surface of the uterus and cervix. Clamps are placed on the uterine vessels at the cervicouterine junction, and the vessels are cut and suture-ligated. The cardinal ligaments are then serially clamped, cut, and ligated. Follow-ing division of the remaining cardinal ligaments, the uterus is | Surgery_Schwartz. hilum, lat-eral the infundibulopelvic ligament, if the ovaries are to be removed. The retroperitoneal space is bluntly opened, the ure-ter identified on the medial leaf of the broad ligament, and the Brunicardi_Ch41_p1783-p1826.indd 179718/02/19 4:34 PM 1798SPECIFIC CONSIDERATIONSPART IIinfundibulopelvic ligament isolated, clamped, cut, and suture-ligated; a similar procedure is carried out on the opposite side. If the ovaries are to be left in situ, the ureter is identified and an opening below the utero-ovarian ligament and fallopian tube created. The fallopian tube and utero-ovarian ligament are clamped, cut, and ligated. The bladder is mobilized by sharply dissecting it free of the anterior surface of the uterus and cervix. Clamps are placed on the uterine vessels at the cervicouterine junction, and the vessels are cut and suture-ligated. The cardinal ligaments are then serially clamped, cut, and ligated. Follow-ing division of the remaining cardinal ligaments, the uterus is |
Surgery_Schwartz_11907 | Surgery_Schwartz | junction, and the vessels are cut and suture-ligated. The cardinal ligaments are then serially clamped, cut, and ligated. Follow-ing division of the remaining cardinal ligaments, the uterus is elevated and the vagina clamped. The cervix is amputated from the vagina with scissors or a knife. Sutures are placed at each lateral angle of the vagina, and the remainder of the vagina is closed with a running or interrupted absorbable suture. Pelvic reperitonealization is not necessary.Transvaginal Hysterectomy (Fig. 41-13) Vaginal hysterectomy is the preferred approach in patients in whom the uterus descends and the pubic arch allows enough space for a vaginal operation. A bladder catheter can be placed before the procedure and the patient is placed in a lithotomy position. A weighted vaginal speculum is placed in the vagina, and the cervix is grasped with a tenaculum and pulled in the axis of the vagina. Injection of the cervix and paracervical tissue with analgesic with epinephrine may be | Surgery_Schwartz. junction, and the vessels are cut and suture-ligated. The cardinal ligaments are then serially clamped, cut, and ligated. Follow-ing division of the remaining cardinal ligaments, the uterus is elevated and the vagina clamped. The cervix is amputated from the vagina with scissors or a knife. Sutures are placed at each lateral angle of the vagina, and the remainder of the vagina is closed with a running or interrupted absorbable suture. Pelvic reperitonealization is not necessary.Transvaginal Hysterectomy (Fig. 41-13) Vaginal hysterectomy is the preferred approach in patients in whom the uterus descends and the pubic arch allows enough space for a vaginal operation. A bladder catheter can be placed before the procedure and the patient is placed in a lithotomy position. A weighted vaginal speculum is placed in the vagina, and the cervix is grasped with a tenaculum and pulled in the axis of the vagina. Injection of the cervix and paracervical tissue with analgesic with epinephrine may be |
Surgery_Schwartz_11908 | Surgery_Schwartz | is placed in the vagina, and the cervix is grasped with a tenaculum and pulled in the axis of the vagina. Injection of the cervix and paracervical tissue with analgesic with epinephrine may be helpful in defining planes and decreasing obscuring bleeding. A circumferential incision may be made with a scalpel or scissors. The posterior cul-de-sac is identified and entered with scissors. A long, weighted speculum is then placed through this opening into the peritoneal cavity. Metzenbaum scissors are used to dissect anteriorly on the cervix down to the pubocervical-vesical fascia, reflecting the bladder off the lower uterine segment. When the peritoneum of the anterior cul-de-sac is identified, it is entered with the scissors, and a retractor is placed in the defect. The uterosacral ligaments are identified, doubly clamped, cut, and ligated. Serial clamps are placed on the parametrial structures above the uterosacral ligament; these pedicles are cut and ligated. At the cornu of the | Surgery_Schwartz. is placed in the vagina, and the cervix is grasped with a tenaculum and pulled in the axis of the vagina. Injection of the cervix and paracervical tissue with analgesic with epinephrine may be helpful in defining planes and decreasing obscuring bleeding. A circumferential incision may be made with a scalpel or scissors. The posterior cul-de-sac is identified and entered with scissors. A long, weighted speculum is then placed through this opening into the peritoneal cavity. Metzenbaum scissors are used to dissect anteriorly on the cervix down to the pubocervical-vesical fascia, reflecting the bladder off the lower uterine segment. When the peritoneum of the anterior cul-de-sac is identified, it is entered with the scissors, and a retractor is placed in the defect. The uterosacral ligaments are identified, doubly clamped, cut, and ligated. Serial clamps are placed on the parametrial structures above the uterosacral ligament; these pedicles are cut and ligated. At the cornu of the |
Surgery_Schwartz_11909 | Surgery_Schwartz | are identified, doubly clamped, cut, and ligated. Serial clamps are placed on the parametrial structures above the uterosacral ligament; these pedicles are cut and ligated. At the cornu of the uterus, the tube, round ligament, and utero-ovarian ligament of the ovary are doubly clamped and cut. The procedure is carried out usually concurrently on the opposite side, and the uterus is removed. The pelvis is inspected for hemostasis; all bleeding must be meticulously controlled at this point.The pelvic peritoneum is closed with a running purse-string suture incorporating the uterosacral and ovarian pedicles, those that were held. This exteriorizes those areas that might tend to bleed. The sutures attached to the ovarian pedicles are cut. The vagina may be closed with interrupted mattress stitches, ABCDEFFigure 41-11. Myomectomy.Brunicardi_Ch41_p1783-p1826.indd 179818/02/19 4:34 PM 1799GYNECOLOGYCHAPTER 41Figure 41-12. Hysterectomy.BladderBladderRound ligamentRound ligamentFallopian | Surgery_Schwartz. are identified, doubly clamped, cut, and ligated. Serial clamps are placed on the parametrial structures above the uterosacral ligament; these pedicles are cut and ligated. At the cornu of the uterus, the tube, round ligament, and utero-ovarian ligament of the ovary are doubly clamped and cut. The procedure is carried out usually concurrently on the opposite side, and the uterus is removed. The pelvis is inspected for hemostasis; all bleeding must be meticulously controlled at this point.The pelvic peritoneum is closed with a running purse-string suture incorporating the uterosacral and ovarian pedicles, those that were held. This exteriorizes those areas that might tend to bleed. The sutures attached to the ovarian pedicles are cut. The vagina may be closed with interrupted mattress stitches, ABCDEFFigure 41-11. Myomectomy.Brunicardi_Ch41_p1783-p1826.indd 179818/02/19 4:34 PM 1799GYNECOLOGYCHAPTER 41Figure 41-12. Hysterectomy.BladderBladderRound ligamentRound ligamentFallopian |
Surgery_Schwartz_11910 | Surgery_Schwartz | ABCDEFFigure 41-11. Myomectomy.Brunicardi_Ch41_p1783-p1826.indd 179818/02/19 4:34 PM 1799GYNECOLOGYCHAPTER 41Figure 41-12. Hysterectomy.BladderBladderRound ligamentRound ligamentFallopian tubeFallopian tubeOvaryBADCFEOvarian ligamentUterinevesselsUreterUreterCardinalligamentUterusBrunicardi_Ch41_p1783-p1826.indd 179918/02/19 4:34 PM 1800SPECIFIC CONSIDERATIONSPART IIincorporating the uterosacral ligaments into the corner of the vagina with each lateral stitch. On occasion, the uterus, which is initially too large to remove vaginally, may be reduced in size by morcellation (Fig. 41-14). After the uterine vessels have been clamped and ligated, serial wedges are taken from the central portion of the uterus in order to reduce the uterine mass. This procedure will allow the vaginal delivery of even very large uterine leiomyomas.Laparoscopic Hysterectomy The advantages of laparoscopy over laparotomy include decreased postoperative pain, shorter hospital stays, and reduced blood | Surgery_Schwartz. ABCDEFFigure 41-11. Myomectomy.Brunicardi_Ch41_p1783-p1826.indd 179818/02/19 4:34 PM 1799GYNECOLOGYCHAPTER 41Figure 41-12. Hysterectomy.BladderBladderRound ligamentRound ligamentFallopian tubeFallopian tubeOvaryBADCFEOvarian ligamentUterinevesselsUreterUreterCardinalligamentUterusBrunicardi_Ch41_p1783-p1826.indd 179918/02/19 4:34 PM 1800SPECIFIC CONSIDERATIONSPART IIincorporating the uterosacral ligaments into the corner of the vagina with each lateral stitch. On occasion, the uterus, which is initially too large to remove vaginally, may be reduced in size by morcellation (Fig. 41-14). After the uterine vessels have been clamped and ligated, serial wedges are taken from the central portion of the uterus in order to reduce the uterine mass. This procedure will allow the vaginal delivery of even very large uterine leiomyomas.Laparoscopic Hysterectomy The advantages of laparoscopy over laparotomy include decreased postoperative pain, shorter hospital stays, and reduced blood |
Surgery_Schwartz_11911 | Surgery_Schwartz | delivery of even very large uterine leiomyomas.Laparoscopic Hysterectomy The advantages of laparoscopy over laparotomy include decreased postoperative pain, shorter hospital stays, and reduced blood loss. Laparoscopy has been used to augment vaginal hysterectomy to avoid laparotomy in patients with known pelvic adhesions, endometriosis, or to ensure removal of the entire ovary if oophorectomy is planned or an adnexal mass is present. Over 20% of benign hysterec-tomies performed in the United States are estimated to be per-formed laparoscopically.46Although multiple variations in technique exist, there are three basic laparoscopic approaches for hysterectomy: lapa-roscopic-assisted vaginal hysterectomy (LAVH), total lapa-roscopic hysterectomy (TLH), and laparoscopic supracervical hysterectomy (LSH). The technically simplest is the LAVH. A multiple-port approach is used to survey the peritoneal cavity, and any pelvic adhesions are lysed. The round ligaments are then occluded and | Surgery_Schwartz. delivery of even very large uterine leiomyomas.Laparoscopic Hysterectomy The advantages of laparoscopy over laparotomy include decreased postoperative pain, shorter hospital stays, and reduced blood loss. Laparoscopy has been used to augment vaginal hysterectomy to avoid laparotomy in patients with known pelvic adhesions, endometriosis, or to ensure removal of the entire ovary if oophorectomy is planned or an adnexal mass is present. Over 20% of benign hysterec-tomies performed in the United States are estimated to be per-formed laparoscopically.46Although multiple variations in technique exist, there are three basic laparoscopic approaches for hysterectomy: lapa-roscopic-assisted vaginal hysterectomy (LAVH), total lapa-roscopic hysterectomy (TLH), and laparoscopic supracervical hysterectomy (LSH). The technically simplest is the LAVH. A multiple-port approach is used to survey the peritoneal cavity, and any pelvic adhesions are lysed. The round ligaments are then occluded and |
Surgery_Schwartz_11912 | Surgery_Schwartz | (LSH). The technically simplest is the LAVH. A multiple-port approach is used to survey the peritoneal cavity, and any pelvic adhesions are lysed. The round ligaments are then occluded and divided, and the uterovesical peritoneum and peritoneum lateral to the ovarian ligament are incised. The course of the ureter and any adhesions or implants, such as endometriosis that might place the ureter in the way of the surgical dissection, are carefully dissected. Next, the proximal uterine blood supply is dissected for identification and then occluded with a laparoscopic energy device. When the ova-ries are removed, the infundibulopelvic ligaments containing the ovarian vessels are divided. If the ovaries are conserved, the utero-ovarian ligament and blood vessels are divided and occluded. In many cases, the posterior cul-de-sac is also incised laparoscopically and the uterosacral ligaments separated with an energy device. The amount of dissection that is done prior to the vaginal portion | Surgery_Schwartz. (LSH). The technically simplest is the LAVH. A multiple-port approach is used to survey the peritoneal cavity, and any pelvic adhesions are lysed. The round ligaments are then occluded and divided, and the uterovesical peritoneum and peritoneum lateral to the ovarian ligament are incised. The course of the ureter and any adhesions or implants, such as endometriosis that might place the ureter in the way of the surgical dissection, are carefully dissected. Next, the proximal uterine blood supply is dissected for identification and then occluded with a laparoscopic energy device. When the ova-ries are removed, the infundibulopelvic ligaments containing the ovarian vessels are divided. If the ovaries are conserved, the utero-ovarian ligament and blood vessels are divided and occluded. In many cases, the posterior cul-de-sac is also incised laparoscopically and the uterosacral ligaments separated with an energy device. The amount of dissection that is done prior to the vaginal portion |
Surgery_Schwartz_11913 | Surgery_Schwartz | many cases, the posterior cul-de-sac is also incised laparoscopically and the uterosacral ligaments separated with an energy device. The amount of dissection that is done prior to the vaginal portion depends on individual patient characteristics and operator comfort with the vaginal approach, and it may include as little as ovarian and adhesion management to full dissection, including bladder dissection, with only the last vaginal incision done by the vaginal approach. During a TLH, the vaginal inci-sion is performed laparoscopically, and the vaginal incision may be closed with laparoscopic suturing. This procedure is used for the indications listed earlier and also when lack of uterine descent makes the vaginal approach impossible.VaginaVaginaGIHCardinalligamentVaginaFigure 41-12. (Continued)Brunicardi_Ch41_p1783-p1826.indd 180018/02/19 4:34 PM 1801GYNECOLOGYCHAPTER 41During an LSH, the uterine vessels are divided after the bladder is dissected from the anterior uterus. The | Surgery_Schwartz. many cases, the posterior cul-de-sac is also incised laparoscopically and the uterosacral ligaments separated with an energy device. The amount of dissection that is done prior to the vaginal portion depends on individual patient characteristics and operator comfort with the vaginal approach, and it may include as little as ovarian and adhesion management to full dissection, including bladder dissection, with only the last vaginal incision done by the vaginal approach. During a TLH, the vaginal inci-sion is performed laparoscopically, and the vaginal incision may be closed with laparoscopic suturing. This procedure is used for the indications listed earlier and also when lack of uterine descent makes the vaginal approach impossible.VaginaVaginaGIHCardinalligamentVaginaFigure 41-12. (Continued)Brunicardi_Ch41_p1783-p1826.indd 180018/02/19 4:34 PM 1801GYNECOLOGYCHAPTER 41During an LSH, the uterine vessels are divided after the bladder is dissected from the anterior uterus. The |
Surgery_Schwartz_11914 | Surgery_Schwartz | 180018/02/19 4:34 PM 1801GYNECOLOGYCHAPTER 41During an LSH, the uterine vessels are divided after the bladder is dissected from the anterior uterus. The ascending branches of the uterine arteries are occluded, and the entire uterine fundus is amputated from the cervix. The endocervix is either cauterized or cored out. The fundus is then morcellated and removed an abdominal port. The end result is an intact cer-vix, with no surgical dissection performed below the uterine artery. This approach avoids both a large abdominal incision and a vaginal incision. The risks of LSH including subsequent bothersome bleeding from the remaining endometrium or endo-cervix and cancer risk from the residual cervical stump combin-ing with concerns about power morcellation (see earlier section, “Myomectomy”) have made this procedure less attractive.Benign Ovarian and Fallopian Tube LesionsThe most common ovarian benign findings include functional follicular cysts, endometriomas (due to ovarian | Surgery_Schwartz. 180018/02/19 4:34 PM 1801GYNECOLOGYCHAPTER 41During an LSH, the uterine vessels are divided after the bladder is dissected from the anterior uterus. The ascending branches of the uterine arteries are occluded, and the entire uterine fundus is amputated from the cervix. The endocervix is either cauterized or cored out. The fundus is then morcellated and removed an abdominal port. The end result is an intact cer-vix, with no surgical dissection performed below the uterine artery. This approach avoids both a large abdominal incision and a vaginal incision. The risks of LSH including subsequent bothersome bleeding from the remaining endometrium or endo-cervix and cancer risk from the residual cervical stump combin-ing with concerns about power morcellation (see earlier section, “Myomectomy”) have made this procedure less attractive.Benign Ovarian and Fallopian Tube LesionsThe most common ovarian benign findings include functional follicular cysts, endometriomas (due to ovarian |
Surgery_Schwartz_11915 | Surgery_Schwartz | have made this procedure less attractive.Benign Ovarian and Fallopian Tube LesionsThe most common ovarian benign findings include functional follicular cysts, endometriomas (due to ovarian endometriosis), and serous cystadenomas or cystadenofibromas. These can present with varying degrees or pelvic pain, or sometimes be completely asymptomatic. Ultrasound is the best initial imaging modality for evaluating ovarian abnormalities.Ovarian Cystectomy. When a cystic lesion persists or causes pelvic pain, surgical intervention is usually justified. Perform-ing a cystectomy with ovarian preservation is recommended in women who desire future fertility. Whether the cystectomy is performed laparoscopically or by laparotomy, the procedure is Figure 41-13. Vaginal hysterectomy.Brunicardi_Ch41_p1783-p1826.indd 180118/02/19 4:34 PM 1802SPECIFIC CONSIDERATIONSPART IIinitiated with inspection of the peritoneal cavity, peritoneum, diaphragm, liver, and pelvis. In the absence of signs of | Surgery_Schwartz. have made this procedure less attractive.Benign Ovarian and Fallopian Tube LesionsThe most common ovarian benign findings include functional follicular cysts, endometriomas (due to ovarian endometriosis), and serous cystadenomas or cystadenofibromas. These can present with varying degrees or pelvic pain, or sometimes be completely asymptomatic. Ultrasound is the best initial imaging modality for evaluating ovarian abnormalities.Ovarian Cystectomy. When a cystic lesion persists or causes pelvic pain, surgical intervention is usually justified. Perform-ing a cystectomy with ovarian preservation is recommended in women who desire future fertility. Whether the cystectomy is performed laparoscopically or by laparotomy, the procedure is Figure 41-13. Vaginal hysterectomy.Brunicardi_Ch41_p1783-p1826.indd 180118/02/19 4:34 PM 1802SPECIFIC CONSIDERATIONSPART IIinitiated with inspection of the peritoneal cavity, peritoneum, diaphragm, liver, and pelvis. In the absence of signs of |
Surgery_Schwartz_11916 | Surgery_Schwartz | 180118/02/19 4:34 PM 1802SPECIFIC CONSIDERATIONSPART IIinitiated with inspection of the peritoneal cavity, peritoneum, diaphragm, liver, and pelvis. In the absence of signs of malig-nancy, pelvic washings are obtained, and the ovarian capsule is incised superficially sharply or with the electrosurgical unit. The cyst is shelled out carefully through the incision. During laparos-copy, it is placed in a bag, intact if possible, and the bag opening is brought through a 10-mm port. If a cyst should rupture before removal, contents are aspirated thoroughly, and the cyst wall is removed and sent for pathologic evaluation. The peritoneal cavity is copiously rinsed with Ringer’s lactate solution. This is especially important when a dermoid cyst is ruptured because the sebaceous material can cause a chemical peritonitis unless all the visible oily substance is carefully removed. A cyst may need to be drained to facilitate removal, but only after bag edges are completely out of the abdomen | Surgery_Schwartz. 180118/02/19 4:34 PM 1802SPECIFIC CONSIDERATIONSPART IIinitiated with inspection of the peritoneal cavity, peritoneum, diaphragm, liver, and pelvis. In the absence of signs of malig-nancy, pelvic washings are obtained, and the ovarian capsule is incised superficially sharply or with the electrosurgical unit. The cyst is shelled out carefully through the incision. During laparos-copy, it is placed in a bag, intact if possible, and the bag opening is brought through a 10-mm port. If a cyst should rupture before removal, contents are aspirated thoroughly, and the cyst wall is removed and sent for pathologic evaluation. The peritoneal cavity is copiously rinsed with Ringer’s lactate solution. This is especially important when a dermoid cyst is ruptured because the sebaceous material can cause a chemical peritonitis unless all the visible oily substance is carefully removed. A cyst may need to be drained to facilitate removal, but only after bag edges are completely out of the abdomen |
Surgery_Schwartz_11917 | Surgery_Schwartz | a chemical peritonitis unless all the visible oily substance is carefully removed. A cyst may need to be drained to facilitate removal, but only after bag edges are completely out of the abdomen assuring no leakage within the abdomen. Hemostasis of the ovary is achieved with bipolar electrocoagulation, but the ovary is usually not closed. If there are solid growths within the cyst, it should be sent for frozen section to verify the absence of the malignancy. If malignancy is detected, immediate definitive surgery is recommended.Removal of Adnexa. Indications for removal of adnexae include persistent ovarian cyst, pelvic pain, concern for malig-nancy, and risk reduction surgery in women with genetic predis-position for ovarian or endometrial cancers (BRCA1/2 mutation carrier, Lynch syndrome). In general, the peritoneum lateral to the infundibulopelvic (IP) ligament is incised in a parallel fashion to allow retroperitoneal dissection and identification of the ureter. Once this has been | Surgery_Schwartz. a chemical peritonitis unless all the visible oily substance is carefully removed. A cyst may need to be drained to facilitate removal, but only after bag edges are completely out of the abdomen assuring no leakage within the abdomen. Hemostasis of the ovary is achieved with bipolar electrocoagulation, but the ovary is usually not closed. If there are solid growths within the cyst, it should be sent for frozen section to verify the absence of the malignancy. If malignancy is detected, immediate definitive surgery is recommended.Removal of Adnexa. Indications for removal of adnexae include persistent ovarian cyst, pelvic pain, concern for malig-nancy, and risk reduction surgery in women with genetic predis-position for ovarian or endometrial cancers (BRCA1/2 mutation carrier, Lynch syndrome). In general, the peritoneum lateral to the infundibulopelvic (IP) ligament is incised in a parallel fashion to allow retroperitoneal dissection and identification of the ureter. Once this has been |
Surgery_Schwartz_11918 | Surgery_Schwartz | In general, the peritoneum lateral to the infundibulopelvic (IP) ligament is incised in a parallel fashion to allow retroperitoneal dissection and identification of the ureter. Once this has been accomplished, the IP ligament is ligated with suture or an energy source (ultrasonic or bipolar). The remaining posterior leaf of the broad ligament is incised toward the uterus in a direction parallel to the utero-ovarian liga-ment to avoid ureteral injury. The fallopian tube and utero-ovarian ligaments are then ligated with either suture or an energy source. If performed laparoscopically, the specimen(s) is/are removed in a bag as described earlier.Tubal Sterilization. As in diagnostic laparoscopy, a oneor two-port technique can be used. Fallopian tubes are occluded in the mid-isthmic section, approximately 3 cm from the cornua, using clips, elastic bands, or bipolar electrosurgery. With elec-trosurgery, approximately 2 cm of tube should be desiccated. Pregnancy rates after any of these | Surgery_Schwartz. In general, the peritoneum lateral to the infundibulopelvic (IP) ligament is incised in a parallel fashion to allow retroperitoneal dissection and identification of the ureter. Once this has been accomplished, the IP ligament is ligated with suture or an energy source (ultrasonic or bipolar). The remaining posterior leaf of the broad ligament is incised toward the uterus in a direction parallel to the utero-ovarian liga-ment to avoid ureteral injury. The fallopian tube and utero-ovarian ligaments are then ligated with either suture or an energy source. If performed laparoscopically, the specimen(s) is/are removed in a bag as described earlier.Tubal Sterilization. As in diagnostic laparoscopy, a oneor two-port technique can be used. Fallopian tubes are occluded in the mid-isthmic section, approximately 3 cm from the cornua, using clips, elastic bands, or bipolar electrosurgery. With elec-trosurgery, approximately 2 cm of tube should be desiccated. Pregnancy rates after any of these |
Surgery_Schwartz_11919 | Surgery_Schwartz | approximately 3 cm from the cornua, using clips, elastic bands, or bipolar electrosurgery. With elec-trosurgery, approximately 2 cm of tube should be desiccated. Pregnancy rates after any of these techniques have been reported Figure 41-14. Uterine morcellation through the vagina.in the range of 3 per 1000 women. Complete removal of the fal-lopian tube (salpingectomy) at the time of tubal sterilization for the purposes of ovarian cancer prevention has recently become more common.47A transvaginal tubal occlusion technique may also be used for tubal sterilization. A routine hysteroscopy is first performed to inspect the cavity and identify the tubal ostia. The tubal insert introducer sheath is then placed into the working channel of the hysteroscope. The insert is then threaded into the fallopian tube. Following this procedure, the patient must undergo a hys-terosalpingogram to confirm tubal occlusion at 3 months post procedure. Prior to the hysterosalpingogram, the patient is | Surgery_Schwartz. approximately 3 cm from the cornua, using clips, elastic bands, or bipolar electrosurgery. With elec-trosurgery, approximately 2 cm of tube should be desiccated. Pregnancy rates after any of these techniques have been reported Figure 41-14. Uterine morcellation through the vagina.in the range of 3 per 1000 women. Complete removal of the fal-lopian tube (salpingectomy) at the time of tubal sterilization for the purposes of ovarian cancer prevention has recently become more common.47A transvaginal tubal occlusion technique may also be used for tubal sterilization. A routine hysteroscopy is first performed to inspect the cavity and identify the tubal ostia. The tubal insert introducer sheath is then placed into the working channel of the hysteroscope. The insert is then threaded into the fallopian tube. Following this procedure, the patient must undergo a hys-terosalpingogram to confirm tubal occlusion at 3 months post procedure. Prior to the hysterosalpingogram, the patient is |
Surgery_Schwartz_11920 | Surgery_Schwartz | the fallopian tube. Following this procedure, the patient must undergo a hys-terosalpingogram to confirm tubal occlusion at 3 months post procedure. Prior to the hysterosalpingogram, the patient is coun-seled to use a reliable birth control method. Transvaginal tubal sterilization has been associated with perforation of the uterus and/or fallopian tubes, identification of inserts in the abdominal or pelvic cavity, persistent pain, and suspected allergic or hyper-sensitivity reactions.Other Benign Pelvic PathologyChronic Pelvic Pain. Chronic pelvic pain is defined as pain below the umbilicus that has lasted at least 6 months or causes functional disability, requiring treatment. While there can be gastrointestinal and urologic causes of chronic pelvic pain, gynecologic causes are frequently identified. Oftentimes, a surgical evaluation is needed for diagnosis and/or intervention. The most common gynecologic causes of chronic pelvic pain include endometriosis, adenomyosis, uterine | Surgery_Schwartz. the fallopian tube. Following this procedure, the patient must undergo a hys-terosalpingogram to confirm tubal occlusion at 3 months post procedure. Prior to the hysterosalpingogram, the patient is coun-seled to use a reliable birth control method. Transvaginal tubal sterilization has been associated with perforation of the uterus and/or fallopian tubes, identification of inserts in the abdominal or pelvic cavity, persistent pain, and suspected allergic or hyper-sensitivity reactions.Other Benign Pelvic PathologyChronic Pelvic Pain. Chronic pelvic pain is defined as pain below the umbilicus that has lasted at least 6 months or causes functional disability, requiring treatment. While there can be gastrointestinal and urologic causes of chronic pelvic pain, gynecologic causes are frequently identified. Oftentimes, a surgical evaluation is needed for diagnosis and/or intervention. The most common gynecologic causes of chronic pelvic pain include endometriosis, adenomyosis, uterine |
Surgery_Schwartz_11921 | Surgery_Schwartz | identified. Oftentimes, a surgical evaluation is needed for diagnosis and/or intervention. The most common gynecologic causes of chronic pelvic pain include endometriosis, adenomyosis, uterine leiomyomas, and adhesive disease.Endometriosis Endometriosis is the finding of ectopic endo-metrial glands and stroma outside the uterus. It affects 10% of the general population, and it is an incidental finding at the time of laparoscopy in more than 20% of asymptomatic women. Chronic pelvic pain (80%) and infertility (20–50%) are the two most common symptoms.27 The pathophysiology of endometrio-sis is poorly understood; etiologic theories explaining dissemi-nation of endometrial glands include retrograde menstruation, lymphatic and vascular spread of endometrial glands, and coe-lomic metaplasia. Endometriosis commonly involves the ova-ries, pelvic peritoneal surfaces, and uterosacral ligaments. Other possible sites include the rectovaginal septum, sigmoid colon, intraperitoneal organs, | Surgery_Schwartz. identified. Oftentimes, a surgical evaluation is needed for diagnosis and/or intervention. The most common gynecologic causes of chronic pelvic pain include endometriosis, adenomyosis, uterine leiomyomas, and adhesive disease.Endometriosis Endometriosis is the finding of ectopic endo-metrial glands and stroma outside the uterus. It affects 10% of the general population, and it is an incidental finding at the time of laparoscopy in more than 20% of asymptomatic women. Chronic pelvic pain (80%) and infertility (20–50%) are the two most common symptoms.27 The pathophysiology of endometrio-sis is poorly understood; etiologic theories explaining dissemi-nation of endometrial glands include retrograde menstruation, lymphatic and vascular spread of endometrial glands, and coe-lomic metaplasia. Endometriosis commonly involves the ova-ries, pelvic peritoneal surfaces, and uterosacral ligaments. Other possible sites include the rectovaginal septum, sigmoid colon, intraperitoneal organs, |
Surgery_Schwartz_11922 | Surgery_Schwartz | Endometriosis commonly involves the ova-ries, pelvic peritoneal surfaces, and uterosacral ligaments. Other possible sites include the rectovaginal septum, sigmoid colon, intraperitoneal organs, retroperitoneal space, ureters, incisional scars, umbilicus, and even the thoracic cavity. Involvement of the fallopian tubes may lead to scarring, blockage, and subse-quent infertility. Ovarian involvement varies from superficial implants to large complex ovarian masses called endometriomas or “chocolate cysts.” Endometriomas are found in approximately one-third of women with endometriosis and are often bilateral.While endometriosis can be totally asymptomatic, com-plaints vary from mild dyspareunia and cyclic dysmenorrhea, to debilitating chronic pelvic pain with dysmenorrhea. Less com-mon manifestations include painful defecation, hematochezia, and hematuria if there is bowel and/or bladder involvement. Catamanial pneumothorax has been reported from endometrio-sis implanted in the pleura. | Surgery_Schwartz. Endometriosis commonly involves the ova-ries, pelvic peritoneal surfaces, and uterosacral ligaments. Other possible sites include the rectovaginal septum, sigmoid colon, intraperitoneal organs, retroperitoneal space, ureters, incisional scars, umbilicus, and even the thoracic cavity. Involvement of the fallopian tubes may lead to scarring, blockage, and subse-quent infertility. Ovarian involvement varies from superficial implants to large complex ovarian masses called endometriomas or “chocolate cysts.” Endometriomas are found in approximately one-third of women with endometriosis and are often bilateral.While endometriosis can be totally asymptomatic, com-plaints vary from mild dyspareunia and cyclic dysmenorrhea, to debilitating chronic pelvic pain with dysmenorrhea. Less com-mon manifestations include painful defecation, hematochezia, and hematuria if there is bowel and/or bladder involvement. Catamanial pneumothorax has been reported from endometrio-sis implanted in the pleura. |
Surgery_Schwartz_11923 | Surgery_Schwartz | include painful defecation, hematochezia, and hematuria if there is bowel and/or bladder involvement. Catamanial pneumothorax has been reported from endometrio-sis implanted in the pleura. Pelvic examination in symptomatic patients typically demonstrates generalized pelvic tenderness, nodularity of the uterosacral ligaments, and at times a pelvic mass may be appreciated if an endometrioma is present. The severity of symptoms does not correlate with the degree of clini-cal disease present. Endometriosis commonly causes of eleva-tions in serum CA-125. Definitive diagnosis usually requires laparoscopy and visualization of the pathognomonic endome-triotic implants. These appear as blue, brown, black, white, or yellow lesions that can be raised and at times puckered giving Brunicardi_Ch41_p1783-p1826.indd 180218/02/19 4:34 PM 1803GYNECOLOGYCHAPTER 41Table 41-4Centers for Disease Control and Prevention recommended treatment of pelvic inflammatory disease (2015)RECOMMENDED | Surgery_Schwartz. include painful defecation, hematochezia, and hematuria if there is bowel and/or bladder involvement. Catamanial pneumothorax has been reported from endometrio-sis implanted in the pleura. Pelvic examination in symptomatic patients typically demonstrates generalized pelvic tenderness, nodularity of the uterosacral ligaments, and at times a pelvic mass may be appreciated if an endometrioma is present. The severity of symptoms does not correlate with the degree of clini-cal disease present. Endometriosis commonly causes of eleva-tions in serum CA-125. Definitive diagnosis usually requires laparoscopy and visualization of the pathognomonic endome-triotic implants. These appear as blue, brown, black, white, or yellow lesions that can be raised and at times puckered giving Brunicardi_Ch41_p1783-p1826.indd 180218/02/19 4:34 PM 1803GYNECOLOGYCHAPTER 41Table 41-4Centers for Disease Control and Prevention recommended treatment of pelvic inflammatory disease (2015)RECOMMENDED |
Surgery_Schwartz_11924 | Surgery_Schwartz | 180218/02/19 4:34 PM 1803GYNECOLOGYCHAPTER 41Table 41-4Centers for Disease Control and Prevention recommended treatment of pelvic inflammatory disease (2015)RECOMMENDED INTRAMUSCULAR/ORAL REGIMENSCeftriaxone 250 mg IM in a single dosePLUSDoxycycline 100 mg orally twice a day for 14 dayswith* or withoutMetronidazole 500 mg orally twice a day for 14 daysORCefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dosePLUSDoxycycline 100 mg orally twice a day for 14 dayswith or withoutMetronidazole 500 mg orally twice a day for 14 daysOROther parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime)PLUSDoxycycline 100 mg orally twice a day for 14 dayswith* or withoutMetronidazole 500 mg orally twice a day for 14 daysRECOMMENDED PARENTERAL REGIMENSCefotetan 2 g IV every 12 hoursPLUSDoxycycline 100 mg orally or IV every 12 hoursORCefoxitin 2 g IV every 6 hoursPLUSDoxycycline 100 mg orally or IV every 12 hoursORClindamycin 900 | Surgery_Schwartz. 180218/02/19 4:34 PM 1803GYNECOLOGYCHAPTER 41Table 41-4Centers for Disease Control and Prevention recommended treatment of pelvic inflammatory disease (2015)RECOMMENDED INTRAMUSCULAR/ORAL REGIMENSCeftriaxone 250 mg IM in a single dosePLUSDoxycycline 100 mg orally twice a day for 14 dayswith* or withoutMetronidazole 500 mg orally twice a day for 14 daysORCefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dosePLUSDoxycycline 100 mg orally twice a day for 14 dayswith or withoutMetronidazole 500 mg orally twice a day for 14 daysOROther parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime)PLUSDoxycycline 100 mg orally twice a day for 14 dayswith* or withoutMetronidazole 500 mg orally twice a day for 14 daysRECOMMENDED PARENTERAL REGIMENSCefotetan 2 g IV every 12 hoursPLUSDoxycycline 100 mg orally or IV every 12 hoursORCefoxitin 2 g IV every 6 hoursPLUSDoxycycline 100 mg orally or IV every 12 hoursORClindamycin 900 |
Surgery_Schwartz_11925 | Surgery_Schwartz | PARENTERAL REGIMENSCefotetan 2 g IV every 12 hoursPLUSDoxycycline 100 mg orally or IV every 12 hoursORCefoxitin 2 g IV every 6 hoursPLUSDoxycycline 100 mg orally or IV every 12 hoursORClindamycin 900 mg IV every 8 hoursPLUSGentamicin loading dose IV or IM (2 mg/kg), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3–5 mg/kg) can be substituted.ALTERNATIVE PARENTERAL REGIMENAmpicillin/Sulbactam 3 g IV every 6 hoursPLUSDoxycycline 100 mg orally or IV every 12 hours*The addition of metronidazole to treatment regimens with third-generation cephalosporins should be considered until the need for extended anaerobic coverage is ruled out.Data from Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines: Pelvic Inflammatory Disease.them a “gunpowder” appearance. Biopsy is not routinely done but should be obtained if the diagnosis is in doubt.Treatment is guided by severity of the symptoms and whether preservation of | Surgery_Schwartz. PARENTERAL REGIMENSCefotetan 2 g IV every 12 hoursPLUSDoxycycline 100 mg orally or IV every 12 hoursORCefoxitin 2 g IV every 6 hoursPLUSDoxycycline 100 mg orally or IV every 12 hoursORClindamycin 900 mg IV every 8 hoursPLUSGentamicin loading dose IV or IM (2 mg/kg), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3–5 mg/kg) can be substituted.ALTERNATIVE PARENTERAL REGIMENAmpicillin/Sulbactam 3 g IV every 6 hoursPLUSDoxycycline 100 mg orally or IV every 12 hours*The addition of metronidazole to treatment regimens with third-generation cephalosporins should be considered until the need for extended anaerobic coverage is ruled out.Data from Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines: Pelvic Inflammatory Disease.them a “gunpowder” appearance. Biopsy is not routinely done but should be obtained if the diagnosis is in doubt.Treatment is guided by severity of the symptoms and whether preservation of |
Surgery_Schwartz_11926 | Surgery_Schwartz | Disease.them a “gunpowder” appearance. Biopsy is not routinely done but should be obtained if the diagnosis is in doubt.Treatment is guided by severity of the symptoms and whether preservation of fertility is desired and varies from expectant, to medical, to surgical.48,49 Expectant management is appropriate in asymptomatic patients. Those with mild symp-toms can be managed with oral contraceptive pills and/or non-steroidal anti-inflammatory analgesia; moderate symptoms are treated with medroxyprogesterone acetate. Severe symptoms are treated with gonadotropin releasing hormone (GnRH) ago-nists to induce medical pseudomenopause.Surgical management for endometriosis varies depend-ing on the age and fertility desires of the patient. A diagnos-tic laparoscopy with biopsies may be indicated to confirm the diagnosis of endometriosis. If endometriosis is suspected, an operative laparoscopy with ablation of endometriotic implants usually decreases the severity of pelvic pain. Ablation of | Surgery_Schwartz. Disease.them a “gunpowder” appearance. Biopsy is not routinely done but should be obtained if the diagnosis is in doubt.Treatment is guided by severity of the symptoms and whether preservation of fertility is desired and varies from expectant, to medical, to surgical.48,49 Expectant management is appropriate in asymptomatic patients. Those with mild symp-toms can be managed with oral contraceptive pills and/or non-steroidal anti-inflammatory analgesia; moderate symptoms are treated with medroxyprogesterone acetate. Severe symptoms are treated with gonadotropin releasing hormone (GnRH) ago-nists to induce medical pseudomenopause.Surgical management for endometriosis varies depend-ing on the age and fertility desires of the patient. A diagnos-tic laparoscopy with biopsies may be indicated to confirm the diagnosis of endometriosis. If endometriosis is suspected, an operative laparoscopy with ablation of endometriotic implants usually decreases the severity of pelvic pain. Ablation of |
Surgery_Schwartz_11927 | Surgery_Schwartz | to confirm the diagnosis of endometriosis. If endometriosis is suspected, an operative laparoscopy with ablation of endometriotic implants usually decreases the severity of pelvic pain. Ablation of endo-metriotic implants can be performed with CO2 laser or elec-trocautery, and/or resection of deep endometriotic implants.48 Endometriomas can cause pain and if found should be treated by ovarian cystectomy. Complete resection of the cyst wall is required as recurrence of the endometrioma is common after partial removal. Unfortunately, endometriosis is a chronic dis-ease, and conservative therapy, medical or surgical, provides only temporary relief, with the majority of patients relapsing with 1 to 2 years. For patients with severe debilitating symp-toms who do not desire future fertility and have not responded to conservative management extirpative surgery to remove the uterus, ovaries, and fallopian tubes; this intervention is curative and should be considered.Although endometriosis is | Surgery_Schwartz. to confirm the diagnosis of endometriosis. If endometriosis is suspected, an operative laparoscopy with ablation of endometriotic implants usually decreases the severity of pelvic pain. Ablation of endo-metriotic implants can be performed with CO2 laser or elec-trocautery, and/or resection of deep endometriotic implants.48 Endometriomas can cause pain and if found should be treated by ovarian cystectomy. Complete resection of the cyst wall is required as recurrence of the endometrioma is common after partial removal. Unfortunately, endometriosis is a chronic dis-ease, and conservative therapy, medical or surgical, provides only temporary relief, with the majority of patients relapsing with 1 to 2 years. For patients with severe debilitating symp-toms who do not desire future fertility and have not responded to conservative management extirpative surgery to remove the uterus, ovaries, and fallopian tubes; this intervention is curative and should be considered.Although endometriosis is |
Surgery_Schwartz_11928 | Surgery_Schwartz | have not responded to conservative management extirpative surgery to remove the uterus, ovaries, and fallopian tubes; this intervention is curative and should be considered.Although endometriosis is not generally thought to be a premalignant lesion, there is an increased risk of type I ovar-ian cancer in women with a history of endometriosis.50 Molecu-lar evidence that endometriosis is likely a precursor lesion to clear cell carcinoma and endometrioid carcinomas includes the presence of mutations in both PIK3CA and ARID1A in benign endometriotic lesions in close proximity, suggesting that loss of expression of these genes likely occurs early in the development of endometrioid carcinomas.51,52Pelvic Adhesive Disease Pelvic adhesions usually are related to previous surgery, endometriosis, or infection, the latter of which can be either genital (i.e., pelvic inflammatory disease) or extragenital (e.g., ruptured appendix) in origin. Adhesions can be lysed mechanically and preferably with | Surgery_Schwartz. have not responded to conservative management extirpative surgery to remove the uterus, ovaries, and fallopian tubes; this intervention is curative and should be considered.Although endometriosis is not generally thought to be a premalignant lesion, there is an increased risk of type I ovar-ian cancer in women with a history of endometriosis.50 Molecu-lar evidence that endometriosis is likely a precursor lesion to clear cell carcinoma and endometrioid carcinomas includes the presence of mutations in both PIK3CA and ARID1A in benign endometriotic lesions in close proximity, suggesting that loss of expression of these genes likely occurs early in the development of endometrioid carcinomas.51,52Pelvic Adhesive Disease Pelvic adhesions usually are related to previous surgery, endometriosis, or infection, the latter of which can be either genital (i.e., pelvic inflammatory disease) or extragenital (e.g., ruptured appendix) in origin. Adhesions can be lysed mechanically and preferably with |
Surgery_Schwartz_11929 | Surgery_Schwartz | infection, the latter of which can be either genital (i.e., pelvic inflammatory disease) or extragenital (e.g., ruptured appendix) in origin. Adhesions can be lysed mechanically and preferably with minimal cautery.Pelvic Inflammatory Disease. Pelvic inflammatory disease (PID) is an inflammatory disorder of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually transmitted organisms, especially N gonorrhoeae and C trachomatis, are implicated in many cases although microorganisms that comprise the vaginal flora (e.g., anaerobes, G vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) have been implicated as well. PID can additionally result from extension of other pelvic and abdominal infections, such as appendicitis and diverticulitis, or may be precipitated by medical procedure, such as hysterosalpingography, endometrial biopsy, or dilation and | Surgery_Schwartz. infection, the latter of which can be either genital (i.e., pelvic inflammatory disease) or extragenital (e.g., ruptured appendix) in origin. Adhesions can be lysed mechanically and preferably with minimal cautery.Pelvic Inflammatory Disease. Pelvic inflammatory disease (PID) is an inflammatory disorder of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually transmitted organisms, especially N gonorrhoeae and C trachomatis, are implicated in many cases although microorganisms that comprise the vaginal flora (e.g., anaerobes, G vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) have been implicated as well. PID can additionally result from extension of other pelvic and abdominal infections, such as appendicitis and diverticulitis, or may be precipitated by medical procedure, such as hysterosalpingography, endometrial biopsy, or dilation and |
Surgery_Schwartz_11930 | Surgery_Schwartz | of other pelvic and abdominal infections, such as appendicitis and diverticulitis, or may be precipitated by medical procedure, such as hysterosalpingography, endometrial biopsy, or dilation and curettage.53,54The presentation of PID can be subtle. Differential diagnosis includes appendicitis, cholecystitis, inflammatory bowel disease, pyelonephritis, nephrolithiasis, ectopic pregnancy, and ovarian torsion. Long-term sequelae can include infertility, chronic pelvic pain, and increased risk of ectopic pregnancy. Because of the severity of these sequelae, presumptive treatment is recommended in young, sexually active women experiencing pelvic or lower abdominal pain, when no cause for the illness other than PID can be identified and if cervical motion tenderness, uterine tenderness, or adnexal tenderness is present on examination. Because of the psychosocial complexity associated with a diagnosis of PID, additional criteria should be used to enhance the specificity of the minimum | Surgery_Schwartz. of other pelvic and abdominal infections, such as appendicitis and diverticulitis, or may be precipitated by medical procedure, such as hysterosalpingography, endometrial biopsy, or dilation and curettage.53,54The presentation of PID can be subtle. Differential diagnosis includes appendicitis, cholecystitis, inflammatory bowel disease, pyelonephritis, nephrolithiasis, ectopic pregnancy, and ovarian torsion. Long-term sequelae can include infertility, chronic pelvic pain, and increased risk of ectopic pregnancy. Because of the severity of these sequelae, presumptive treatment is recommended in young, sexually active women experiencing pelvic or lower abdominal pain, when no cause for the illness other than PID can be identified and if cervical motion tenderness, uterine tenderness, or adnexal tenderness is present on examination. Because of the psychosocial complexity associated with a diagnosis of PID, additional criteria should be used to enhance the specificity of the minimum |
Surgery_Schwartz_11931 | Surgery_Schwartz | adnexal tenderness is present on examination. Because of the psychosocial complexity associated with a diagnosis of PID, additional criteria should be used to enhance the specificity of the minimum clinical criteria when possible. These include the following: oral temperature >101°F (>38.3°C); abnormal cervical mucopurulent discharge or cervical friability; presence Brunicardi_Ch41_p1783-p1826.indd 180318/02/19 4:34 PM 1804SPECIFIC CONSIDERATIONSPART IIof abundant numbers of white blood cells on saline microscopy of vaginal fluid; elevated erythrocyte sedimentation rate; elevated C-reactive protein; and laboratory documentation of cervical infection with N gonorrhoeae or C trachomatis. Laparoscopy can be used to obtain a more accurate diagnosis of salpingitis and a more complete bacteriologic diagnosis and is often useful in ruling out other causes of peritonitis. Laparoscopic findings may include swollen erythematous tubes with purulent exudates.55Several outpatient parenteral | Surgery_Schwartz. adnexal tenderness is present on examination. Because of the psychosocial complexity associated with a diagnosis of PID, additional criteria should be used to enhance the specificity of the minimum clinical criteria when possible. These include the following: oral temperature >101°F (>38.3°C); abnormal cervical mucopurulent discharge or cervical friability; presence Brunicardi_Ch41_p1783-p1826.indd 180318/02/19 4:34 PM 1804SPECIFIC CONSIDERATIONSPART IIof abundant numbers of white blood cells on saline microscopy of vaginal fluid; elevated erythrocyte sedimentation rate; elevated C-reactive protein; and laboratory documentation of cervical infection with N gonorrhoeae or C trachomatis. Laparoscopy can be used to obtain a more accurate diagnosis of salpingitis and a more complete bacteriologic diagnosis and is often useful in ruling out other causes of peritonitis. Laparoscopic findings may include swollen erythematous tubes with purulent exudates.55Several outpatient parenteral |
Surgery_Schwartz_11932 | Surgery_Schwartz | diagnosis and is often useful in ruling out other causes of peritonitis. Laparoscopic findings may include swollen erythematous tubes with purulent exudates.55Several outpatient parenteral and oral antimicrobial regi-mens have been effective in achieving clinical and microbio-logic cure. Hospitalization for intravenous antibiotics may be necessitated in cases of where surgical emergencies cannot be ruled out, tubo-ovarian abscess is identified, pregnancy, severe illness (nausea and vomiting, or high fever), inability to follow or tolerate an outpatient oral regimen; or failure of outpatient oral antimicrobial therapy. Treatment of a tubo-ovarian abscess may include placement of a percutaneous drain in addition to intravenous antibiotics.55Surgical intervention becomes necessary if medical therapy fails or if the patient becomes unstable. Hysterec-tomy and bilateral salpingo-oophorectomy is the procedure of choice; however, conservative surgery must be considered in young patients | Surgery_Schwartz. diagnosis and is often useful in ruling out other causes of peritonitis. Laparoscopic findings may include swollen erythematous tubes with purulent exudates.55Several outpatient parenteral and oral antimicrobial regi-mens have been effective in achieving clinical and microbio-logic cure. Hospitalization for intravenous antibiotics may be necessitated in cases of where surgical emergencies cannot be ruled out, tubo-ovarian abscess is identified, pregnancy, severe illness (nausea and vomiting, or high fever), inability to follow or tolerate an outpatient oral regimen; or failure of outpatient oral antimicrobial therapy. Treatment of a tubo-ovarian abscess may include placement of a percutaneous drain in addition to intravenous antibiotics.55Surgical intervention becomes necessary if medical therapy fails or if the patient becomes unstable. Hysterec-tomy and bilateral salpingo-oophorectomy is the procedure of choice; however, conservative surgery must be considered in young patients |
Surgery_Schwartz_11933 | Surgery_Schwartz | therapy fails or if the patient becomes unstable. Hysterec-tomy and bilateral salpingo-oophorectomy is the procedure of choice; however, conservative surgery must be considered in young patients desiring future fertility. The abdomen should be explored for metastatic abscesses, and special attention must be paid to bowel, bladder, and ureteral safety due to the friabil-ity of the infected tissue and the adhesions commonly encoun-tered at the time of surgery. Placement of an intraperitoneal drain and mass closure of the peritoneum, muscle, and fascia with delayed-absorbable sutures is advised. Conservative sur-gery, when feasible, may be attempted by laparoscopy and may involve unilateral salpingo-oophorectomy or drainage of the abscess and liberal irrigation of the abdomen and pelvis.53PREGNANCY-RELATED SURGICAL CONDITIONSMany pregnant women will undergo invasive diagnostic proce-dures for prenatal diagnosis, and in the United States, nearly one-third of all births are cesarean | Surgery_Schwartz. therapy fails or if the patient becomes unstable. Hysterec-tomy and bilateral salpingo-oophorectomy is the procedure of choice; however, conservative surgery must be considered in young patients desiring future fertility. The abdomen should be explored for metastatic abscesses, and special attention must be paid to bowel, bladder, and ureteral safety due to the friabil-ity of the infected tissue and the adhesions commonly encoun-tered at the time of surgery. Placement of an intraperitoneal drain and mass closure of the peritoneum, muscle, and fascia with delayed-absorbable sutures is advised. Conservative sur-gery, when feasible, may be attempted by laparoscopy and may involve unilateral salpingo-oophorectomy or drainage of the abscess and liberal irrigation of the abdomen and pelvis.53PREGNANCY-RELATED SURGICAL CONDITIONSMany pregnant women will undergo invasive diagnostic proce-dures for prenatal diagnosis, and in the United States, nearly one-third of all births are cesarean |
Surgery_Schwartz_11934 | Surgery_Schwartz | SURGICAL CONDITIONSMany pregnant women will undergo invasive diagnostic proce-dures for prenatal diagnosis, and in the United States, nearly one-third of all births are cesarean deliveries.56 About 1 in 500 pregnant women will require surgery for nonob-stetrical issues.57,58 Diagnostic challenges and physiologic changes due to pregnancy, as well as the unique anesthesia risks and potential risks to the pregnancy, should be kept in mind whether the primary surgeon is an obstetrician, gynecologist, or a general surgeon (Table 41-5).58Trauma in the obstetric patient requires stabilization of the mother while considering the fetal compartment.58,59 Trauma-related hypovolemia may be compounded by pregnancy-induced decreases in systemic vascular resistance, and when supine, the weight of the gravid uterus on the vena cava. When feasible, a left lateral tilt should be instituted to improve venous return to the right heart. Later in pregnancy, the small bowel is dis-placed into the upper | Surgery_Schwartz. SURGICAL CONDITIONSMany pregnant women will undergo invasive diagnostic proce-dures for prenatal diagnosis, and in the United States, nearly one-third of all births are cesarean deliveries.56 About 1 in 500 pregnant women will require surgery for nonob-stetrical issues.57,58 Diagnostic challenges and physiologic changes due to pregnancy, as well as the unique anesthesia risks and potential risks to the pregnancy, should be kept in mind whether the primary surgeon is an obstetrician, gynecologist, or a general surgeon (Table 41-5).58Trauma in the obstetric patient requires stabilization of the mother while considering the fetal compartment.58,59 Trauma-related hypovolemia may be compounded by pregnancy-induced decreases in systemic vascular resistance, and when supine, the weight of the gravid uterus on the vena cava. When feasible, a left lateral tilt should be instituted to improve venous return to the right heart. Later in pregnancy, the small bowel is dis-placed into the upper |
Surgery_Schwartz_11935 | Surgery_Schwartz | gravid uterus on the vena cava. When feasible, a left lateral tilt should be instituted to improve venous return to the right heart. Later in pregnancy, the small bowel is dis-placed into the upper abdomen, making it vulnerable to complex injury from penetrating upper abdominal trauma. Though small bowel is displaced from the pelvis, the dramatic increase in pel-vic blood flow can lead to rapid blood loss due to penetrating pelvic trauma, fractures, or avulsion of pelvic vessels. Gastric motility is decreased increasing the risk of aspiration. Peritoneal signs may be attenuated by the stretching of the abdominal wall. Several coagulation factors are also increased in pregnancy, increasing the likelihood for thromboembolic events, but also giving the unsuspecting surgeon false security when low-normal levels are observed during resuscitative efforts. Only the third 5Table 41-5Physiologic changes due to pregnancyCardiovascular changes Increased cardiac output Increased blood | Surgery_Schwartz. gravid uterus on the vena cava. When feasible, a left lateral tilt should be instituted to improve venous return to the right heart. Later in pregnancy, the small bowel is dis-placed into the upper abdomen, making it vulnerable to complex injury from penetrating upper abdominal trauma. Though small bowel is displaced from the pelvis, the dramatic increase in pel-vic blood flow can lead to rapid blood loss due to penetrating pelvic trauma, fractures, or avulsion of pelvic vessels. Gastric motility is decreased increasing the risk of aspiration. Peritoneal signs may be attenuated by the stretching of the abdominal wall. Several coagulation factors are also increased in pregnancy, increasing the likelihood for thromboembolic events, but also giving the unsuspecting surgeon false security when low-normal levels are observed during resuscitative efforts. Only the third 5Table 41-5Physiologic changes due to pregnancyCardiovascular changes Increased cardiac output Increased blood |
Surgery_Schwartz_11936 | Surgery_Schwartz | when low-normal levels are observed during resuscitative efforts. Only the third 5Table 41-5Physiologic changes due to pregnancyCardiovascular changes Increased cardiac output Increased blood volume Increased heart rate Decreased blood pressure Decreased systemic vascular resistance Decreased venous return from lower extremitiesRespiratory changes Increased minute ventilation Decreased functional residual capacityGastrointestinal changes Decreased gastric motility Delayed gastric emptyingCoagulation changes Increased clotting factors (II, VII, VIII, IX, X) Increased fibrinogen Increased risk for venous thromboembolismRenal changes Increased renal plasma flow and GFR Ureteral dilationReproduced with permission from Gabbe S NJ, Simpson J: Obstetrics: Normal and Problem Pregnancies, 6th ed. Philadelphia, PA: Elsevier/Saunders; 2012.trimester fetus has any ability to autoregulate in the context of decreased uterine blood flow and oxygen delivery. In the third trimester, perimortem | Surgery_Schwartz. when low-normal levels are observed during resuscitative efforts. Only the third 5Table 41-5Physiologic changes due to pregnancyCardiovascular changes Increased cardiac output Increased blood volume Increased heart rate Decreased blood pressure Decreased systemic vascular resistance Decreased venous return from lower extremitiesRespiratory changes Increased minute ventilation Decreased functional residual capacityGastrointestinal changes Decreased gastric motility Delayed gastric emptyingCoagulation changes Increased clotting factors (II, VII, VIII, IX, X) Increased fibrinogen Increased risk for venous thromboembolismRenal changes Increased renal plasma flow and GFR Ureteral dilationReproduced with permission from Gabbe S NJ, Simpson J: Obstetrics: Normal and Problem Pregnancies, 6th ed. Philadelphia, PA: Elsevier/Saunders; 2012.trimester fetus has any ability to autoregulate in the context of decreased uterine blood flow and oxygen delivery. In the third trimester, perimortem |
Surgery_Schwartz_11937 | Surgery_Schwartz | ed. Philadelphia, PA: Elsevier/Saunders; 2012.trimester fetus has any ability to autoregulate in the context of decreased uterine blood flow and oxygen delivery. In the third trimester, perimortem cesarean delivery should be considered as part of maternal resuscitation in cases of maternal hemodynamic collapse. Though treating the maternal compartment is the pri-mary concern, it should also be recognized that the fetus will be impacted significantly by maternal hypotension, as blood may be shunted away from the uterus.Conditions and Procedures Performed Before ViabilityAmniocentesis/Chorionic Villus Sampling. Noninvasive prenatal testing has for the most part replaced invasive fetal testing. Amniocentesis is a procedure in which amniotic fluid is aspirated from the uterine cavity and sent for genetic or labora-tory testing typically under ultrasound guidance with a 20to 22-gauge needle. This procedure may be used to confirm abnor-mal noninvasive testing.Miscarriage and Pregnancy | Surgery_Schwartz. ed. Philadelphia, PA: Elsevier/Saunders; 2012.trimester fetus has any ability to autoregulate in the context of decreased uterine blood flow and oxygen delivery. In the third trimester, perimortem cesarean delivery should be considered as part of maternal resuscitation in cases of maternal hemodynamic collapse. Though treating the maternal compartment is the pri-mary concern, it should also be recognized that the fetus will be impacted significantly by maternal hypotension, as blood may be shunted away from the uterus.Conditions and Procedures Performed Before ViabilityAmniocentesis/Chorionic Villus Sampling. Noninvasive prenatal testing has for the most part replaced invasive fetal testing. Amniocentesis is a procedure in which amniotic fluid is aspirated from the uterine cavity and sent for genetic or labora-tory testing typically under ultrasound guidance with a 20to 22-gauge needle. This procedure may be used to confirm abnor-mal noninvasive testing.Miscarriage and Pregnancy |
Surgery_Schwartz_11938 | Surgery_Schwartz | sent for genetic or labora-tory testing typically under ultrasound guidance with a 20to 22-gauge needle. This procedure may be used to confirm abnor-mal noninvasive testing.Miscarriage and Pregnancy Terminations. Spontaneous pregnancy loss is common. Although the miscarriage rate among women who know they are pregnant is roughly 10% to 20%, if the start of pregnancy is set to fertilization, rates are as high as 50%. Chromosomal abnormalities are the underlying cause of miscarriage and are present in over half of cases. Patient may report cramping, bleeding and passage of tissue. If products of conception are not passed, diagnosis can be made by transvagi-nal ultrasound if an empty gestational sac is identified or an embryo is noted to not have a heartbeat. Treatment can include expectant management, medical management with misoprostol, or surgical management with dilation and curettage.60Half of all pregnancies in the United States are unintended, and many of these are undesired. | Surgery_Schwartz. sent for genetic or labora-tory testing typically under ultrasound guidance with a 20to 22-gauge needle. This procedure may be used to confirm abnor-mal noninvasive testing.Miscarriage and Pregnancy Terminations. Spontaneous pregnancy loss is common. Although the miscarriage rate among women who know they are pregnant is roughly 10% to 20%, if the start of pregnancy is set to fertilization, rates are as high as 50%. Chromosomal abnormalities are the underlying cause of miscarriage and are present in over half of cases. Patient may report cramping, bleeding and passage of tissue. If products of conception are not passed, diagnosis can be made by transvagi-nal ultrasound if an empty gestational sac is identified or an embryo is noted to not have a heartbeat. Treatment can include expectant management, medical management with misoprostol, or surgical management with dilation and curettage.60Half of all pregnancies in the United States are unintended, and many of these are undesired. |
Surgery_Schwartz_11939 | Surgery_Schwartz | management, medical management with misoprostol, or surgical management with dilation and curettage.60Half of all pregnancies in the United States are unintended, and many of these are undesired. Additional reasons for termi-nation of pregnancy include fetal anomalies such as trisomies, fetal infections, and maternal health. Medical terminations are Brunicardi_Ch41_p1783-p1826.indd 180418/02/19 4:34 PM 1805GYNECOLOGYCHAPTER 41available up to 10 weeks of gestation, and surgical terminations can be performed to viability. Rates of pregnancy termination have been declining due decreasing access to abortion ser-vices and widespread availability of long-acting contraceptives (LARC). LARCs are safe, effective, easy to use and protect against unintended pregnancy for up to 10 years.61Up to 15 weeks’ gestation, manual vacuum aspiration can be used following cervical dilation to mechanically evacuate the fetus or embryo, placenta, and membranes by suction using a manual syringe. | Surgery_Schwartz. management, medical management with misoprostol, or surgical management with dilation and curettage.60Half of all pregnancies in the United States are unintended, and many of these are undesired. Additional reasons for termi-nation of pregnancy include fetal anomalies such as trisomies, fetal infections, and maternal health. Medical terminations are Brunicardi_Ch41_p1783-p1826.indd 180418/02/19 4:34 PM 1805GYNECOLOGYCHAPTER 41available up to 10 weeks of gestation, and surgical terminations can be performed to viability. Rates of pregnancy termination have been declining due decreasing access to abortion ser-vices and widespread availability of long-acting contraceptives (LARC). LARCs are safe, effective, easy to use and protect against unintended pregnancy for up to 10 years.61Up to 15 weeks’ gestation, manual vacuum aspiration can be used following cervical dilation to mechanically evacuate the fetus or embryo, placenta, and membranes by suction using a manual syringe. |
Surgery_Schwartz_11940 | Surgery_Schwartz | to 15 weeks’ gestation, manual vacuum aspiration can be used following cervical dilation to mechanically evacuate the fetus or embryo, placenta, and membranes by suction using a manual syringe. Alternatively, cervical dilation and suction curettage can be performed. The uterine cervix is grasped with a tenaculum, then mechanically dilated occasionally using adjunc-tive prostaglandins, and an appropriately sized vacuum cannula is inserted into the uterus and rotated on its axis to remove the products of conception. Dilation and extraction is performed for pregnancies in the second trimester. The additional cervical dilation required at greater gestational ages is usually a two-step (often over 2 days) process. Osmotic dilators are placed within the cervix a day prior to the procedure and expand as water is absorbed, passively dilating the endocervical canal. These are removed immediately prior to the procedure and mechanical dilation is then performed as needed. Forceps are then used | Surgery_Schwartz. to 15 weeks’ gestation, manual vacuum aspiration can be used following cervical dilation to mechanically evacuate the fetus or embryo, placenta, and membranes by suction using a manual syringe. Alternatively, cervical dilation and suction curettage can be performed. The uterine cervix is grasped with a tenaculum, then mechanically dilated occasionally using adjunc-tive prostaglandins, and an appropriately sized vacuum cannula is inserted into the uterus and rotated on its axis to remove the products of conception. Dilation and extraction is performed for pregnancies in the second trimester. The additional cervical dilation required at greater gestational ages is usually a two-step (often over 2 days) process. Osmotic dilators are placed within the cervix a day prior to the procedure and expand as water is absorbed, passively dilating the endocervical canal. These are removed immediately prior to the procedure and mechanical dilation is then performed as needed. Forceps are then used |
Surgery_Schwartz_11941 | Surgery_Schwartz | expand as water is absorbed, passively dilating the endocervical canal. These are removed immediately prior to the procedure and mechanical dilation is then performed as needed. Forceps are then used to remove fetal parts. Curettage of the postabortal uterus must be approached carefully because the uterus is extremely soft and perforation can occur with very little warning. Complications are rare (particularly when contrasted to the risks of pregnancy and term delivery) but include infection, hemorrhage due to uterine atony, cervical lacerations, uterine perforations, and inadvertent bowel injury from the vacuum cannula or forceps.Cerclage. Cervical insufficiency is defined as painless cervical dilation leading to recurrent second trimester pregnancy loss, or shortened cervical length as determined by transvaginal ultra-sound, or advanced cervical change before 24 weeks’ gestation in a woman with either prior preterm birth/loss or significant risk factors for insufficiency. A cervical | Surgery_Schwartz. expand as water is absorbed, passively dilating the endocervical canal. These are removed immediately prior to the procedure and mechanical dilation is then performed as needed. Forceps are then used to remove fetal parts. Curettage of the postabortal uterus must be approached carefully because the uterus is extremely soft and perforation can occur with very little warning. Complications are rare (particularly when contrasted to the risks of pregnancy and term delivery) but include infection, hemorrhage due to uterine atony, cervical lacerations, uterine perforations, and inadvertent bowel injury from the vacuum cannula or forceps.Cerclage. Cervical insufficiency is defined as painless cervical dilation leading to recurrent second trimester pregnancy loss, or shortened cervical length as determined by transvaginal ultra-sound, or advanced cervical change before 24 weeks’ gestation in a woman with either prior preterm birth/loss or significant risk factors for insufficiency. A cervical |
Surgery_Schwartz_11942 | Surgery_Schwartz | by transvaginal ultra-sound, or advanced cervical change before 24 weeks’ gestation in a woman with either prior preterm birth/loss or significant risk factors for insufficiency. A cervical cerclage refers to a procedure in which suture or synthetic tape is used to circum-ferentially reinforce the cervix to improve pregnancy outcome in at-risk patients.62 Shirodkar and McDonald techniques have been described63,64; both involve transvaginally placing a non-absorbable suture at the uterocervical junction to lengthen and close the cervix. An abdominal cerclage of the lower uterine segment performed laparoor by laparotomy can be considered for a patient with a severely shortened or absent cervix who has previously failed a transvaginal cerclage.Ectopic Pregnancies. Extrauterine pregnancies are most com-monly located along the fallopian tubes but can also implant on the ovary. Rarely, implantation can occur primarily on other abdominal organs or peritoneal surfaces. A high index of | Surgery_Schwartz. by transvaginal ultra-sound, or advanced cervical change before 24 weeks’ gestation in a woman with either prior preterm birth/loss or significant risk factors for insufficiency. A cervical cerclage refers to a procedure in which suture or synthetic tape is used to circum-ferentially reinforce the cervix to improve pregnancy outcome in at-risk patients.62 Shirodkar and McDonald techniques have been described63,64; both involve transvaginally placing a non-absorbable suture at the uterocervical junction to lengthen and close the cervix. An abdominal cerclage of the lower uterine segment performed laparoor by laparotomy can be considered for a patient with a severely shortened or absent cervix who has previously failed a transvaginal cerclage.Ectopic Pregnancies. Extrauterine pregnancies are most com-monly located along the fallopian tubes but can also implant on the ovary. Rarely, implantation can occur primarily on other abdominal organs or peritoneal surfaces. A high index of |
Surgery_Schwartz_11943 | Surgery_Schwartz | are most com-monly located along the fallopian tubes but can also implant on the ovary. Rarely, implantation can occur primarily on other abdominal organs or peritoneal surfaces. A high index of suspi-cion and early diagnosis typically includes an abnormal rise in b-hCG assays and presence of an adnexal mass on transvaginal ultrasound. Early ectopic pregnancies can be managed medi-cally with a methotrexate injection; however, close follow-up with twice-weekly b-hCG testing is required. Laparoscopy is the definitive management and can be used either as primary treatment or when medical management fails. The tube should be removed (salpingectomy) in its entirety if the ectopic is iden-tified within the fallopian tube. This can be performed using a vessel sealing device or even an endo-loop and endo-shears. Laparotomy is reserved for unstable patients with a known hemoperitoneum where Kelly clamps can be placed along the mesosalpinx to control bleeding. Cornual ectopic pregnancies may | Surgery_Schwartz. are most com-monly located along the fallopian tubes but can also implant on the ovary. Rarely, implantation can occur primarily on other abdominal organs or peritoneal surfaces. A high index of suspi-cion and early diagnosis typically includes an abnormal rise in b-hCG assays and presence of an adnexal mass on transvaginal ultrasound. Early ectopic pregnancies can be managed medi-cally with a methotrexate injection; however, close follow-up with twice-weekly b-hCG testing is required. Laparoscopy is the definitive management and can be used either as primary treatment or when medical management fails. The tube should be removed (salpingectomy) in its entirety if the ectopic is iden-tified within the fallopian tube. This can be performed using a vessel sealing device or even an endo-loop and endo-shears. Laparotomy is reserved for unstable patients with a known hemoperitoneum where Kelly clamps can be placed along the mesosalpinx to control bleeding. Cornual ectopic pregnancies may |
Surgery_Schwartz_11944 | Surgery_Schwartz | and endo-shears. Laparotomy is reserved for unstable patients with a known hemoperitoneum where Kelly clamps can be placed along the mesosalpinx to control bleeding. Cornual ectopic pregnancies may require wedge resection of the uterine serosa and myo-metrium, which is then closed in two layers.65 Linear salpin-gostomy along the antimesenteric border and removal of the products of conception is now rarely used due to low rates of postoperative tubal function and high recurrent ectopic pregnan-cies presumably due to scarring.Conditions and Procedures Performed After ViabilityObstetric Lacerations and Repair. At the time of vaginal delivery, perineal lacerations are common. These lacerations involve, in varying degrees, the vaginal mucosa, the muscular elements inserting onto the perineal body, the levator ani, and in 4% to 5% of vaginal deliveries, the anal sphincter or anorectal mucosa. Although episiotomies were historically cut prophy-lactically to prevent unstructured tearing of | Surgery_Schwartz. and endo-shears. Laparotomy is reserved for unstable patients with a known hemoperitoneum where Kelly clamps can be placed along the mesosalpinx to control bleeding. Cornual ectopic pregnancies may require wedge resection of the uterine serosa and myo-metrium, which is then closed in two layers.65 Linear salpin-gostomy along the antimesenteric border and removal of the products of conception is now rarely used due to low rates of postoperative tubal function and high recurrent ectopic pregnan-cies presumably due to scarring.Conditions and Procedures Performed After ViabilityObstetric Lacerations and Repair. At the time of vaginal delivery, perineal lacerations are common. These lacerations involve, in varying degrees, the vaginal mucosa, the muscular elements inserting onto the perineal body, the levator ani, and in 4% to 5% of vaginal deliveries, the anal sphincter or anorectal mucosa. Although episiotomies were historically cut prophy-lactically to prevent unstructured tearing of |
Surgery_Schwartz_11945 | Surgery_Schwartz | body, the levator ani, and in 4% to 5% of vaginal deliveries, the anal sphincter or anorectal mucosa. Although episiotomies were historically cut prophy-lactically to prevent unstructured tearing of the perineum, this practice has fallen out of favor as the benefit of episiotomy has not been demonstrated.Perineal Laceration First-degree tears involve only the perineal skin and may or may not need to be reapproximated. Second-degree tears involve the perineal body and can gener-ally be repaired with some variation using a single continuous, nonlocking suture technique, typically a 2-0 or 3-0 synthetic delayed absorbable suture. The apex of the vaginal epithelial is approximated first including epithelium and underlying tissue to build up the rectovaginal septum. Upon reaching the hymenal ring, the perineal body and bulbocavernosus muscle are reap-proximated, and a transition stitch is placed from the vaginal mucosa, which was repaired along a horizontal plane, to the deep perineal | Surgery_Schwartz. body, the levator ani, and in 4% to 5% of vaginal deliveries, the anal sphincter or anorectal mucosa. Although episiotomies were historically cut prophy-lactically to prevent unstructured tearing of the perineum, this practice has fallen out of favor as the benefit of episiotomy has not been demonstrated.Perineal Laceration First-degree tears involve only the perineal skin and may or may not need to be reapproximated. Second-degree tears involve the perineal body and can gener-ally be repaired with some variation using a single continuous, nonlocking suture technique, typically a 2-0 or 3-0 synthetic delayed absorbable suture. The apex of the vaginal epithelial is approximated first including epithelium and underlying tissue to build up the rectovaginal septum. Upon reaching the hymenal ring, the perineal body and bulbocavernosus muscle are reap-proximated, and a transition stitch is placed from the vaginal mucosa, which was repaired along a horizontal plane, to the deep perineal |
Surgery_Schwartz_11946 | Surgery_Schwartz | ring, the perineal body and bulbocavernosus muscle are reap-proximated, and a transition stitch is placed from the vaginal mucosa, which was repaired along a horizontal plane, to the deep perineal layer, which lies in a vertically-oriented plane. A running closure is then completed incorporating the deep peri-neal tissues from the introitus to the extent of the perineal defect. At this point, the perineal skin is closed from inferior to superior in a subcuticular fashion and tied just inside the introitus.Third-degree lacerations extend through the perineal body and involve the external anal sphincter, while fourth-degree lac-erations involve the internal anal sphincter and rectal mucosa. When present, thirdand fourth-degree lacerations should be repaired first before proceeding with the second-degree repair. This is accomplished by first closing the anal mucosa, and then identifying and closing the internal anal sphincter in a second layer. The external anal sphincter is then | Surgery_Schwartz. ring, the perineal body and bulbocavernosus muscle are reap-proximated, and a transition stitch is placed from the vaginal mucosa, which was repaired along a horizontal plane, to the deep perineal layer, which lies in a vertically-oriented plane. A running closure is then completed incorporating the deep peri-neal tissues from the introitus to the extent of the perineal defect. At this point, the perineal skin is closed from inferior to superior in a subcuticular fashion and tied just inside the introitus.Third-degree lacerations extend through the perineal body and involve the external anal sphincter, while fourth-degree lac-erations involve the internal anal sphincter and rectal mucosa. When present, thirdand fourth-degree lacerations should be repaired first before proceeding with the second-degree repair. This is accomplished by first closing the anal mucosa, and then identifying and closing the internal anal sphincter in a second layer. The external anal sphincter is then |
Surgery_Schwartz_11947 | Surgery_Schwartz | the second-degree repair. This is accomplished by first closing the anal mucosa, and then identifying and closing the internal anal sphincter in a second layer. The external anal sphincter is then identified, and the muscular cylinder is reconstructed by suturing the severed ends together using either an end-to-end or overlapping technique. Although these are typically straightforward layered closures, knowledge of the anatomy is important. Incomplete reconstruc-tion, particularly of thirdor fourth-degree lacerations, can contribute to future pelvic floor disorders, as well as the devel-opment of fistulae or incontinence.Cervical and Vaginal Lacerations Significant lacerations to the cervix or vagina may also occur during childbirth, particu-larly with instrumented deliveries or macrosomic infants. These lacerations may present as persistent bleeding, not readily rec-ognized due to their location, and often in association with a firmly contracted uterus. Vaginal lacerations may be | Surgery_Schwartz. the second-degree repair. This is accomplished by first closing the anal mucosa, and then identifying and closing the internal anal sphincter in a second layer. The external anal sphincter is then identified, and the muscular cylinder is reconstructed by suturing the severed ends together using either an end-to-end or overlapping technique. Although these are typically straightforward layered closures, knowledge of the anatomy is important. Incomplete reconstruc-tion, particularly of thirdor fourth-degree lacerations, can contribute to future pelvic floor disorders, as well as the devel-opment of fistulae or incontinence.Cervical and Vaginal Lacerations Significant lacerations to the cervix or vagina may also occur during childbirth, particu-larly with instrumented deliveries or macrosomic infants. These lacerations may present as persistent bleeding, not readily rec-ognized due to their location, and often in association with a firmly contracted uterus. Vaginal lacerations may be |
Surgery_Schwartz_11948 | Surgery_Schwartz | infants. These lacerations may present as persistent bleeding, not readily rec-ognized due to their location, and often in association with a firmly contracted uterus. Vaginal lacerations may be repaired primarily but should only be closed after deeper tissues are inspected to insure no active bleeding. Cervical lacerations can be repaired in a running, locking fashion, insuring that the apex of the laceration is incorporated in the closure. If the apex is challenging to reach, the closure can be started more distally using the suture to apply traction so that the apex may be closed.Brunicardi_Ch41_p1783-p1826.indd 180518/02/19 4:34 PM 1806SPECIFIC CONSIDERATIONSPART IIPuerperal Hematoma Trauma during childbirth can occasion-ally result in significant hematoma formation with or without a visible laceration. These hematomas may hide significant blood loss and most commonly occur in the vulva, paravaginal, and pelvic retroperitoneum. Typical presentation is pain and mass effect. | Surgery_Schwartz. infants. These lacerations may present as persistent bleeding, not readily rec-ognized due to their location, and often in association with a firmly contracted uterus. Vaginal lacerations may be repaired primarily but should only be closed after deeper tissues are inspected to insure no active bleeding. Cervical lacerations can be repaired in a running, locking fashion, insuring that the apex of the laceration is incorporated in the closure. If the apex is challenging to reach, the closure can be started more distally using the suture to apply traction so that the apex may be closed.Brunicardi_Ch41_p1783-p1826.indd 180518/02/19 4:34 PM 1806SPECIFIC CONSIDERATIONSPART IIPuerperal Hematoma Trauma during childbirth can occasion-ally result in significant hematoma formation with or without a visible laceration. These hematomas may hide significant blood loss and most commonly occur in the vulva, paravaginal, and pelvic retroperitoneum. Typical presentation is pain and mass effect. |
Surgery_Schwartz_11949 | Surgery_Schwartz | a visible laceration. These hematomas may hide significant blood loss and most commonly occur in the vulva, paravaginal, and pelvic retroperitoneum. Typical presentation is pain and mass effect. Small hematomas can be managed conservatively with close observation and patient monitoring. Though there are no evidence-based size criteria, an unstable patient or expand-ing hematomas should prompt surgical intervention. After the hematoma is incised and drained, diffuse venous oozing is usu-ally encountered rather than a single bleeding vessel. Hemo-stasis can be achieved using electrosurgery or fine absorbable suture, though caution must be used due to the proximity of bowel, bladder, and ureters to some hematomas. Pressure on the vulva or packing the vagina, rather than the hematoma cavity, may prevent further bleeding.Cesarean Deliveries. Typical indications for cesarean deliv-ery include nonreassuring fetal status, breech or other malpre-sentations, triplet and higher order gestations, | Surgery_Schwartz. a visible laceration. These hematomas may hide significant blood loss and most commonly occur in the vulva, paravaginal, and pelvic retroperitoneum. Typical presentation is pain and mass effect. Small hematomas can be managed conservatively with close observation and patient monitoring. Though there are no evidence-based size criteria, an unstable patient or expand-ing hematomas should prompt surgical intervention. After the hematoma is incised and drained, diffuse venous oozing is usu-ally encountered rather than a single bleeding vessel. Hemo-stasis can be achieved using electrosurgery or fine absorbable suture, though caution must be used due to the proximity of bowel, bladder, and ureters to some hematomas. Pressure on the vulva or packing the vagina, rather than the hematoma cavity, may prevent further bleeding.Cesarean Deliveries. Typical indications for cesarean deliv-ery include nonreassuring fetal status, breech or other malpre-sentations, triplet and higher order gestations, |
Surgery_Schwartz_11950 | Surgery_Schwartz | prevent further bleeding.Cesarean Deliveries. Typical indications for cesarean deliv-ery include nonreassuring fetal status, breech or other malpre-sentations, triplet and higher order gestations, cephalopelvic disproportion, failure to progress in labor, placenta previa, and active genital herpes. Previous low transverse cesarean deliv-ery is not a contraindication to subsequent vaginal birth after cesarean; however, much of the increase in cesarean delivery in the past two decades is attributable to planned repeat cesareans. Cesarean deliveries typically are performed via a lower anterior (caudal) uterine transverse incision because there is decreased blood loss, and the uterine rupture rate with future pregnancies is about 0.5% (Fig. 41-15). A prior classical cesarean delivery is an absolute indication for a planned repeat cesarean delivery because of a high rate of uterine rupture during labor, unlike with the lower anterior uterine transverse incision. Abdominal access is | Surgery_Schwartz. prevent further bleeding.Cesarean Deliveries. Typical indications for cesarean deliv-ery include nonreassuring fetal status, breech or other malpre-sentations, triplet and higher order gestations, cephalopelvic disproportion, failure to progress in labor, placenta previa, and active genital herpes. Previous low transverse cesarean deliv-ery is not a contraindication to subsequent vaginal birth after cesarean; however, much of the increase in cesarean delivery in the past two decades is attributable to planned repeat cesareans. Cesarean deliveries typically are performed via a lower anterior (caudal) uterine transverse incision because there is decreased blood loss, and the uterine rupture rate with future pregnancies is about 0.5% (Fig. 41-15). A prior classical cesarean delivery is an absolute indication for a planned repeat cesarean delivery because of a high rate of uterine rupture during labor, unlike with the lower anterior uterine transverse incision. Abdominal access is |
Surgery_Schwartz_11951 | Surgery_Schwartz | an absolute indication for a planned repeat cesarean delivery because of a high rate of uterine rupture during labor, unlike with the lower anterior uterine transverse incision. Abdominal access is obtained by a Pfannenstiel, Maylard or vertical inci-sion. Once the abdomen is entered, a vesicouterine reflection is created if a low transverse uterine incision is planned. The uter-ine incision is then made and extended laterally, avoiding the uterine vessels. After amniotomy, the baby is delivered, and the uterus is closed. Approximately 1000 mL of blood is typically lost during a cesarean delivery. Along with rapid closure of the uterine incision, uterotonics, such as intravenous oxytocin, are administered. A classical, vertical, uterine incision is made in EDABCFigure 41-15. Uterine incisions for cesarean delivery. (Reproduced with permission from Gabbe S, Niebyl J, Simpson J: Obstetrics: Normal and Problem Pregnancies, 5th ed. Philadelphia, PA: Elsevier/ Churchill Livingstone; | Surgery_Schwartz. an absolute indication for a planned repeat cesarean delivery because of a high rate of uterine rupture during labor, unlike with the lower anterior uterine transverse incision. Abdominal access is obtained by a Pfannenstiel, Maylard or vertical inci-sion. Once the abdomen is entered, a vesicouterine reflection is created if a low transverse uterine incision is planned. The uter-ine incision is then made and extended laterally, avoiding the uterine vessels. After amniotomy, the baby is delivered, and the uterus is closed. Approximately 1000 mL of blood is typically lost during a cesarean delivery. Along with rapid closure of the uterine incision, uterotonics, such as intravenous oxytocin, are administered. A classical, vertical, uterine incision is made in EDABCFigure 41-15. Uterine incisions for cesarean delivery. (Reproduced with permission from Gabbe S, Niebyl J, Simpson J: Obstetrics: Normal and Problem Pregnancies, 5th ed. Philadelphia, PA: Elsevier/ Churchill Livingstone; |
Surgery_Schwartz_11952 | Surgery_Schwartz | incisions for cesarean delivery. (Reproduced with permission from Gabbe S, Niebyl J, Simpson J: Obstetrics: Normal and Problem Pregnancies, 5th ed. Philadelphia, PA: Elsevier/ Churchill Livingstone; 2007.)certain very early viable gestations, or in the case of certain transverse lies or abnormal placentation. Infection, excessive blood loss due to uterine atony, and urinary tract and bowel inju-ries are potential complications at the time of cesarean delivery. The risk of those injuries, as well as abnormal placentation (pla-centa accreta, increta, and percreta) rises with each subsequent cesarean delivery. Bleeding can only be controlled in some instances by performing a cesarean hysterectomy.Postpartum Hemorrhage. Postpartum hemorrhage is an obstetrical emergency that can follow either vaginal or cesarean delivery. Hemorrhage is usually caused by uterine atony, trauma to the genital tract, or rarely, coagulation disorders. Hemorrhage may also be caused by abnormal placentation (also | Surgery_Schwartz. incisions for cesarean delivery. (Reproduced with permission from Gabbe S, Niebyl J, Simpson J: Obstetrics: Normal and Problem Pregnancies, 5th ed. Philadelphia, PA: Elsevier/ Churchill Livingstone; 2007.)certain very early viable gestations, or in the case of certain transverse lies or abnormal placentation. Infection, excessive blood loss due to uterine atony, and urinary tract and bowel inju-ries are potential complications at the time of cesarean delivery. The risk of those injuries, as well as abnormal placentation (pla-centa accreta, increta, and percreta) rises with each subsequent cesarean delivery. Bleeding can only be controlled in some instances by performing a cesarean hysterectomy.Postpartum Hemorrhage. Postpartum hemorrhage is an obstetrical emergency that can follow either vaginal or cesarean delivery. Hemorrhage is usually caused by uterine atony, trauma to the genital tract, or rarely, coagulation disorders. Hemorrhage may also be caused by abnormal placentation (also |
Surgery_Schwartz_11953 | Surgery_Schwartz | or cesarean delivery. Hemorrhage is usually caused by uterine atony, trauma to the genital tract, or rarely, coagulation disorders. Hemorrhage may also be caused by abnormal placentation (also called mor-bidly adherent placenta). Management consists of mitigating potential obstetric causes while simultaneously acting to avert or treat hypovolemic shock. In the absence of atony, the genital tract should be thoroughly evaluated for trauma. Atony is the most common cause of postpartum hemorrhage. It is typically treated with fundal massage and uterotonics such as oxytocin, methylergonovine, carboprost tromethamin, and misoprostol. When aggressive medical management fails, surgical manage-ment may be necessary and life-saving.66Uterine Curettage Retained products of conception may result in uterine atony. It may be possible to remove retained prod-ucts via manual extraction or with ring forceps. Bedside ultra-sound may be helpful in localization. When clinical suspicion is high, uterine | Surgery_Schwartz. or cesarean delivery. Hemorrhage is usually caused by uterine atony, trauma to the genital tract, or rarely, coagulation disorders. Hemorrhage may also be caused by abnormal placentation (also called mor-bidly adherent placenta). Management consists of mitigating potential obstetric causes while simultaneously acting to avert or treat hypovolemic shock. In the absence of atony, the genital tract should be thoroughly evaluated for trauma. Atony is the most common cause of postpartum hemorrhage. It is typically treated with fundal massage and uterotonics such as oxytocin, methylergonovine, carboprost tromethamin, and misoprostol. When aggressive medical management fails, surgical manage-ment may be necessary and life-saving.66Uterine Curettage Retained products of conception may result in uterine atony. It may be possible to remove retained prod-ucts via manual extraction or with ring forceps. Bedside ultra-sound may be helpful in localization. When clinical suspicion is high, uterine |
Surgery_Schwartz_11954 | Surgery_Schwartz | uterine atony. It may be possible to remove retained prod-ucts via manual extraction or with ring forceps. Bedside ultra-sound may be helpful in localization. When clinical suspicion is high, uterine curettage is indicated. A blunt, large curette, banjo curette, is introduced and removal of retained tissue typi-cally results in contraction of the myometrium and cessation of bleeding.Procedures Short of Hysterectomy As bleeding from post-partum hemorrhage becomes increasingly acute, interventions short of hysterectomy should be carried out expeditiously while supporting the hemodynamic status of the patient and prepar-ing for possible definitive surgery. A number of techniques for packing and tamponade of the uterus have been described, including a balloon device reported by Bakri and colleagues.67 These are typically left in place for 24 to 36 hours and appear to be safe and often effective conservative measures short of laparotomy and hysterectomy. The B-Lynch compression suture may | Surgery_Schwartz. uterine atony. It may be possible to remove retained prod-ucts via manual extraction or with ring forceps. Bedside ultra-sound may be helpful in localization. When clinical suspicion is high, uterine curettage is indicated. A blunt, large curette, banjo curette, is introduced and removal of retained tissue typi-cally results in contraction of the myometrium and cessation of bleeding.Procedures Short of Hysterectomy As bleeding from post-partum hemorrhage becomes increasingly acute, interventions short of hysterectomy should be carried out expeditiously while supporting the hemodynamic status of the patient and prepar-ing for possible definitive surgery. A number of techniques for packing and tamponade of the uterus have been described, including a balloon device reported by Bakri and colleagues.67 These are typically left in place for 24 to 36 hours and appear to be safe and often effective conservative measures short of laparotomy and hysterectomy. The B-Lynch compression suture may |
Surgery_Schwartz_11955 | Surgery_Schwartz | These are typically left in place for 24 to 36 hours and appear to be safe and often effective conservative measures short of laparotomy and hysterectomy. The B-Lynch compression suture may control bleeding of atony at the time of cesarean section. A suture is placed through the hysterotomy, around the fundus of the uterus anterior to posterior, and then through the posterior lower uterine segment, to the contralateral side. At this point, the steps are reversed with the suture brought around the fundus posterior to anterior, through the contralateral side of the hys-terotomy, and then tied in the midline to compress the uterus. Additional procedures described include the O’Leary uterine artery ligation and the hypogastric artery ligation. “O’Leary stitches” are a series of sutures placed around the branches of the uterine artery and through the myometrium, resulting in compression of the vessels against the uterus. Hypogastric artery ligation entails the isolation of the internal | Surgery_Schwartz. These are typically left in place for 24 to 36 hours and appear to be safe and often effective conservative measures short of laparotomy and hysterectomy. The B-Lynch compression suture may control bleeding of atony at the time of cesarean section. A suture is placed through the hysterotomy, around the fundus of the uterus anterior to posterior, and then through the posterior lower uterine segment, to the contralateral side. At this point, the steps are reversed with the suture brought around the fundus posterior to anterior, through the contralateral side of the hys-terotomy, and then tied in the midline to compress the uterus. Additional procedures described include the O’Leary uterine artery ligation and the hypogastric artery ligation. “O’Leary stitches” are a series of sutures placed around the branches of the uterine artery and through the myometrium, resulting in compression of the vessels against the uterus. Hypogastric artery ligation entails the isolation of the internal |
Surgery_Schwartz_11956 | Surgery_Schwartz | around the branches of the uterine artery and through the myometrium, resulting in compression of the vessels against the uterus. Hypogastric artery ligation entails the isolation of the internal iliac artery at its bifurcation with the external iliac artery. The hypogastric artery is ligated at least 3 cm distal to the bifurcation to avoid compromising the posterior division.Postpartum/Cesarean Hysterectomy A cesarean or postpar-tum (absent a prior cesarean delivery) hysterectomy involves the same steps as in a nonpregnant patient, but it is distinctly different due to the engorged vessels and the pliability of the tis-sues. If a cesarean section has been performed, occasionally the Brunicardi_Ch41_p1783-p1826.indd 180618/02/19 4:34 PM 1807GYNECOLOGYCHAPTER 41incision can be used for traction to keep the vessels and tissues attenuated. Vascular pedicles should be secured with clamps, but not ligated until both uterine arteries have been secured, to fully control bleeding. Lack of | Surgery_Schwartz. around the branches of the uterine artery and through the myometrium, resulting in compression of the vessels against the uterus. Hypogastric artery ligation entails the isolation of the internal iliac artery at its bifurcation with the external iliac artery. The hypogastric artery is ligated at least 3 cm distal to the bifurcation to avoid compromising the posterior division.Postpartum/Cesarean Hysterectomy A cesarean or postpar-tum (absent a prior cesarean delivery) hysterectomy involves the same steps as in a nonpregnant patient, but it is distinctly different due to the engorged vessels and the pliability of the tis-sues. If a cesarean section has been performed, occasionally the Brunicardi_Ch41_p1783-p1826.indd 180618/02/19 4:34 PM 1807GYNECOLOGYCHAPTER 41incision can be used for traction to keep the vessels and tissues attenuated. Vascular pedicles should be secured with clamps, but not ligated until both uterine arteries have been secured, to fully control bleeding. Lack of |
Surgery_Schwartz_11957 | Surgery_Schwartz | traction to keep the vessels and tissues attenuated. Vascular pedicles should be secured with clamps, but not ligated until both uterine arteries have been secured, to fully control bleeding. Lack of typical anatomic landmarks requires careful identification of the ureters and the dilated cervix visu-ally or by palpation, to separate from the bladder and vagina (Fig. 41-16). This procedure is often done for life-threatening hemorrhage, thus appropriate blood products, including packed red blood cells, fresh frozen plasma, platelets, and fibrinogen should be on call and are usually required. Fibrinogen is typi-cally elevated in a pregnant woman, such that a low-normal fibrinogen level can be cause for alarm, and further fibrinogen may be required before consumptive coagulopathy reverses. A massive transfusion protocol is helpful.Abnormal Placentation. Placenta accreta describes the clinical condition when the placenta invades and is inseparable from the uterine wall. When the chorionic | Surgery_Schwartz. traction to keep the vessels and tissues attenuated. Vascular pedicles should be secured with clamps, but not ligated until both uterine arteries have been secured, to fully control bleeding. Lack of typical anatomic landmarks requires careful identification of the ureters and the dilated cervix visu-ally or by palpation, to separate from the bladder and vagina (Fig. 41-16). This procedure is often done for life-threatening hemorrhage, thus appropriate blood products, including packed red blood cells, fresh frozen plasma, platelets, and fibrinogen should be on call and are usually required. Fibrinogen is typi-cally elevated in a pregnant woman, such that a low-normal fibrinogen level can be cause for alarm, and further fibrinogen may be required before consumptive coagulopathy reverses. A massive transfusion protocol is helpful.Abnormal Placentation. Placenta accreta describes the clinical condition when the placenta invades and is inseparable from the uterine wall. When the chorionic |
Surgery_Schwartz_11958 | Surgery_Schwartz | massive transfusion protocol is helpful.Abnormal Placentation. Placenta accreta describes the clinical condition when the placenta invades and is inseparable from the uterine wall. When the chorionic villi invades the myometrium, the term placenta increta is used; whereas placenta percreta describes invasion through the myometrium and serosa, and even into adjacent organs such as the bladder. Abnormal placentation has increased in parallel to the cesarean section rate in the United States. When cytotrophoblasts invade decidualized endometrium and encounter a uterine scar, they do not encounter the normal myometrial signals to stop invasion. In the setting of a placenta previa, the presence of a uterine scare is a particular risk for placenta accreta with rates of 11%, 40%, and 61% for one, two, or three prior cesarean deliveries, respectively.68 Ultrasound or MRI can assist in the diagnosis, depending on the experience and comfort of the imager.69,70Women at risk for abnormal | Surgery_Schwartz. massive transfusion protocol is helpful.Abnormal Placentation. Placenta accreta describes the clinical condition when the placenta invades and is inseparable from the uterine wall. When the chorionic villi invades the myometrium, the term placenta increta is used; whereas placenta percreta describes invasion through the myometrium and serosa, and even into adjacent organs such as the bladder. Abnormal placentation has increased in parallel to the cesarean section rate in the United States. When cytotrophoblasts invade decidualized endometrium and encounter a uterine scar, they do not encounter the normal myometrial signals to stop invasion. In the setting of a placenta previa, the presence of a uterine scare is a particular risk for placenta accreta with rates of 11%, 40%, and 61% for one, two, or three prior cesarean deliveries, respectively.68 Ultrasound or MRI can assist in the diagnosis, depending on the experience and comfort of the imager.69,70Women at risk for abnormal |
Surgery_Schwartz_11959 | Surgery_Schwartz | for one, two, or three prior cesarean deliveries, respectively.68 Ultrasound or MRI can assist in the diagnosis, depending on the experience and comfort of the imager.69,70Women at risk for abnormal placentation should ideally be identified during pregnancy and be prepared for cesarean sec-tion followed by cesarean hysterectomy. Since the blood supply to the gravid uterus is 500 cc per minute, these surgeries have the potential to have very high blood loss, which can then lead to the development of disseminated intravascular coagulation. Over 50% of cases require more than 4 units of blood transfused. BladderUreter identifiedClamps on uterine vesselsFigure 41-16. Demonstration of location of distal ureter and bladder, and their relationship to uterine vessels. (Reproduced with permission from Nichols DH: Gynecologic and Obstetric Surgery, Vol. 1. Philadelphia, PA: Elsevier; 1993.)Unintentional bladder or ureteral injuries are common as well due to impaired visualization and poor | Surgery_Schwartz. for one, two, or three prior cesarean deliveries, respectively.68 Ultrasound or MRI can assist in the diagnosis, depending on the experience and comfort of the imager.69,70Women at risk for abnormal placentation should ideally be identified during pregnancy and be prepared for cesarean sec-tion followed by cesarean hysterectomy. Since the blood supply to the gravid uterus is 500 cc per minute, these surgeries have the potential to have very high blood loss, which can then lead to the development of disseminated intravascular coagulation. Over 50% of cases require more than 4 units of blood transfused. BladderUreter identifiedClamps on uterine vesselsFigure 41-16. Demonstration of location of distal ureter and bladder, and their relationship to uterine vessels. (Reproduced with permission from Nichols DH: Gynecologic and Obstetric Surgery, Vol. 1. Philadelphia, PA: Elsevier; 1993.)Unintentional bladder or ureteral injuries are common as well due to impaired visualization and poor |
Surgery_Schwartz_11960 | Surgery_Schwartz | from Nichols DH: Gynecologic and Obstetric Surgery, Vol. 1. Philadelphia, PA: Elsevier; 1993.)Unintentional bladder or ureteral injuries are common as well due to impaired visualization and poor dissection planes. For these reasons, patients with suspected placenta accreta should be delivered in a tertiary care center with a multidisciplinary team that has the capacity for massive blood transfusion pro-tocol. While some sites have implemented protocols involving interventional radiology with placement of occlusive balloons in the uterine arteries prior to delivery, these protocols have not been shown to decrease morbidity or overall blood loss. Postop-erative embolization should be available. Even with scheduled delivery in a well-resourced setting with a highly experienced and prepared multidisciplinary team, the morbidity of abnormal placentation is high. ICU stays are common, and maternal mor-tality as high as 7% has been reported.69Delayed hysterectomy where the placenta is left | Surgery_Schwartz. from Nichols DH: Gynecologic and Obstetric Surgery, Vol. 1. Philadelphia, PA: Elsevier; 1993.)Unintentional bladder or ureteral injuries are common as well due to impaired visualization and poor dissection planes. For these reasons, patients with suspected placenta accreta should be delivered in a tertiary care center with a multidisciplinary team that has the capacity for massive blood transfusion pro-tocol. While some sites have implemented protocols involving interventional radiology with placement of occlusive balloons in the uterine arteries prior to delivery, these protocols have not been shown to decrease morbidity or overall blood loss. Postop-erative embolization should be available. Even with scheduled delivery in a well-resourced setting with a highly experienced and prepared multidisciplinary team, the morbidity of abnormal placentation is high. ICU stays are common, and maternal mor-tality as high as 7% has been reported.69Delayed hysterectomy where the placenta is left |
Surgery_Schwartz_11961 | Surgery_Schwartz | multidisciplinary team, the morbidity of abnormal placentation is high. ICU stays are common, and maternal mor-tality as high as 7% has been reported.69Delayed hysterectomy where the placenta is left in situ after delivery of the baby if there is not significant bleeding and the mother is stable is advocated by certain centers but remains controversial.71 The risks of leaving the placenta in utero include later hemorrhage, infection, and sepsis. Planned hysterectomy at 6 to 12 weeks postpartum is recommended unless subsequent fertility is strongly desire.69-71PELVIC FLOOR DYSFUNCTIONPelvic floor disorders can be categorized, from a urogyneco-logic perspective, into three main topics: female urinary incontinence and voiding dysfunction, pelvic organ pro-lapse, and disorders of defecation.72 Approximately 11% of women will undergo surgery for incontinence or prolapse.73 The normal functions of support, storage, and evacuation can be altered by derangements in neuromuscular function both | Surgery_Schwartz. multidisciplinary team, the morbidity of abnormal placentation is high. ICU stays are common, and maternal mor-tality as high as 7% has been reported.69Delayed hysterectomy where the placenta is left in situ after delivery of the baby if there is not significant bleeding and the mother is stable is advocated by certain centers but remains controversial.71 The risks of leaving the placenta in utero include later hemorrhage, infection, and sepsis. Planned hysterectomy at 6 to 12 weeks postpartum is recommended unless subsequent fertility is strongly desire.69-71PELVIC FLOOR DYSFUNCTIONPelvic floor disorders can be categorized, from a urogyneco-logic perspective, into three main topics: female urinary incontinence and voiding dysfunction, pelvic organ pro-lapse, and disorders of defecation.72 Approximately 11% of women will undergo surgery for incontinence or prolapse.73 The normal functions of support, storage, and evacuation can be altered by derangements in neuromuscular function both |
Surgery_Schwartz_11962 | Surgery_Schwartz | Approximately 11% of women will undergo surgery for incontinence or prolapse.73 The normal functions of support, storage, and evacuation can be altered by derangements in neuromuscular function both cen-trally and peripherally and through acquired changes in connec-tive tissue. Reconstructive surgeons aim to repair or compensate for many of these losses.EvaluationDiagnostic evaluations, in addition to the history and examina-tions previously described, can aid in the diagnosis of many pel-vic floor disorders. Cystoscopy, multichannel urodynamics, and/or fluoroscopic evaluation of the urinary tract can be obtained for patients with urinary incontinence or voiding dysfunction.74 Defecography, anal manometry, and endorectal ultrasound may be useful for diagnosis of defecatory dysfunction. A standard-ized examination called the pelvic organ prolapse quantifica-tion (POP-Q)74 helps to clarify which vaginal compartment, and therefore which specific structure, has lost its anatomic integrity | Surgery_Schwartz. Approximately 11% of women will undergo surgery for incontinence or prolapse.73 The normal functions of support, storage, and evacuation can be altered by derangements in neuromuscular function both cen-trally and peripherally and through acquired changes in connec-tive tissue. Reconstructive surgeons aim to repair or compensate for many of these losses.EvaluationDiagnostic evaluations, in addition to the history and examina-tions previously described, can aid in the diagnosis of many pel-vic floor disorders. Cystoscopy, multichannel urodynamics, and/or fluoroscopic evaluation of the urinary tract can be obtained for patients with urinary incontinence or voiding dysfunction.74 Defecography, anal manometry, and endorectal ultrasound may be useful for diagnosis of defecatory dysfunction. A standard-ized examination called the pelvic organ prolapse quantifica-tion (POP-Q)74 helps to clarify which vaginal compartment, and therefore which specific structure, has lost its anatomic integrity |
Surgery_Schwartz_11963 | Surgery_Schwartz | examination called the pelvic organ prolapse quantifica-tion (POP-Q)74 helps to clarify which vaginal compartment, and therefore which specific structure, has lost its anatomic integrity in women with uterovaginal prolapse. Finally, dynamic MRI and pelvic floor electromyography has growing utility for all three disorders.Surgery for Pelvic Organ ProlapseMany factors are important in determining which reconstruc-tive operation is optimal for a given patient with pelvic organ prolapse. Surgical decisions are often based on case series and expert opinions that may not have universal applicability. How-ever, the few reports with the highest level of evidence sug-gests that failure rates for prolapse reconstruction may be twice as high using the vaginal approach when compared with the abdominal route.75,76Colporrhaphy. Anterior colporrhaphy, also known as an “anterior repair,” is performed for a symptomatic cystocele. The procedure begins with incision of the anterior vaginal epithelium | Surgery_Schwartz. examination called the pelvic organ prolapse quantifica-tion (POP-Q)74 helps to clarify which vaginal compartment, and therefore which specific structure, has lost its anatomic integrity in women with uterovaginal prolapse. Finally, dynamic MRI and pelvic floor electromyography has growing utility for all three disorders.Surgery for Pelvic Organ ProlapseMany factors are important in determining which reconstruc-tive operation is optimal for a given patient with pelvic organ prolapse. Surgical decisions are often based on case series and expert opinions that may not have universal applicability. How-ever, the few reports with the highest level of evidence sug-gests that failure rates for prolapse reconstruction may be twice as high using the vaginal approach when compared with the abdominal route.75,76Colporrhaphy. Anterior colporrhaphy, also known as an “anterior repair,” is performed for a symptomatic cystocele. The procedure begins with incision of the anterior vaginal epithelium |
Surgery_Schwartz_11964 | Surgery_Schwartz | route.75,76Colporrhaphy. Anterior colporrhaphy, also known as an “anterior repair,” is performed for a symptomatic cystocele. The procedure begins with incision of the anterior vaginal epithelium 6Brunicardi_Ch41_p1783-p1826.indd 180718/02/19 4:34 PM 1808SPECIFIC CONSIDERATIONSPART IIin a midline sagittal direction. The epithelium is dissected away from the underlying vaginal muscularis. The vaginal muscularis is plicated with interrupted delayed absorbable stitches, after which the epithelium is trimmed and reapproximated. The vaginal canal is therefore shortened and narrowed proportionate to the amount of removed epithelium. Posterior colporrhaphy is performed for a symptomatic rectocele. This procedure is performed in a similar manner, often including the distal pubococcygeus muscles in the plication. Recently, in attempts to decrease surgical failures alluded to previously, many surgeons have opted to utilize grafts and meshes to augment these vaginally performed procedures. | Surgery_Schwartz. route.75,76Colporrhaphy. Anterior colporrhaphy, also known as an “anterior repair,” is performed for a symptomatic cystocele. The procedure begins with incision of the anterior vaginal epithelium 6Brunicardi_Ch41_p1783-p1826.indd 180718/02/19 4:34 PM 1808SPECIFIC CONSIDERATIONSPART IIin a midline sagittal direction. The epithelium is dissected away from the underlying vaginal muscularis. The vaginal muscularis is plicated with interrupted delayed absorbable stitches, after which the epithelium is trimmed and reapproximated. The vaginal canal is therefore shortened and narrowed proportionate to the amount of removed epithelium. Posterior colporrhaphy is performed for a symptomatic rectocele. This procedure is performed in a similar manner, often including the distal pubococcygeus muscles in the plication. Recently, in attempts to decrease surgical failures alluded to previously, many surgeons have opted to utilize grafts and meshes to augment these vaginally performed procedures. |
Surgery_Schwartz_11965 | Surgery_Schwartz | in the plication. Recently, in attempts to decrease surgical failures alluded to previously, many surgeons have opted to utilize grafts and meshes to augment these vaginally performed procedures. Unfortunately, the apparent number of postoperative complications, including mesh erosion, pelvic pain, and dyspareunia, prompted the FDA to publish a warning encouraging a much more limited use of vaginal mesh for prolapse repair until greater surveillance and more rigorous studies could be completed.77Sacrospinous and Uterosacral Ligament Fixations. Both the sacrospinous ligament fixation (SSLF) and uterosacral ligament fixation (USLF) procedures are vaginal procedures that suspend the apex of the vagina using native tissue for treatment of apical prolapse. The sacrospinous ligament is found embedded in and continuous with the coccygeus muscle, which extends from the ischial spine to the lateral surface of the sacrum. The procedure begins with entry into the rectovaginal space, usually by | Surgery_Schwartz. in the plication. Recently, in attempts to decrease surgical failures alluded to previously, many surgeons have opted to utilize grafts and meshes to augment these vaginally performed procedures. Unfortunately, the apparent number of postoperative complications, including mesh erosion, pelvic pain, and dyspareunia, prompted the FDA to publish a warning encouraging a much more limited use of vaginal mesh for prolapse repair until greater surveillance and more rigorous studies could be completed.77Sacrospinous and Uterosacral Ligament Fixations. Both the sacrospinous ligament fixation (SSLF) and uterosacral ligament fixation (USLF) procedures are vaginal procedures that suspend the apex of the vagina using native tissue for treatment of apical prolapse. The sacrospinous ligament is found embedded in and continuous with the coccygeus muscle, which extends from the ischial spine to the lateral surface of the sacrum. The procedure begins with entry into the rectovaginal space, usually by |
Surgery_Schwartz_11966 | Surgery_Schwartz | in and continuous with the coccygeus muscle, which extends from the ischial spine to the lateral surface of the sacrum. The procedure begins with entry into the rectovaginal space, usually by incising the posterior vaginal wall at its attachment to the perineal body. The space is developed to the level of the vaginal apex and the rectal pillar is penetrated to gain access to the pararectal space. A long-ligature carrier is used to place sutures medial to the ischial spine, through the substance of the ligament-muscle complex. Structures at risk in this procedure include the pudendal neurovascular bundle, the inferior gluteal neurovascular bundle, lumbosacral plexus, and sciatic nerve. After the stitches are placed, the free ends are sewn to the undersurface of the vaginal cuff. The sacrospinous stitches are tied to firmly approximate the vagina to the ligament without suture bridging.When using the uterosacral ligaments for repair of prolapse, it is important to recall that these | Surgery_Schwartz. in and continuous with the coccygeus muscle, which extends from the ischial spine to the lateral surface of the sacrum. The procedure begins with entry into the rectovaginal space, usually by incising the posterior vaginal wall at its attachment to the perineal body. The space is developed to the level of the vaginal apex and the rectal pillar is penetrated to gain access to the pararectal space. A long-ligature carrier is used to place sutures medial to the ischial spine, through the substance of the ligament-muscle complex. Structures at risk in this procedure include the pudendal neurovascular bundle, the inferior gluteal neurovascular bundle, lumbosacral plexus, and sciatic nerve. After the stitches are placed, the free ends are sewn to the undersurface of the vaginal cuff. The sacrospinous stitches are tied to firmly approximate the vagina to the ligament without suture bridging.When using the uterosacral ligaments for repair of prolapse, it is important to recall that these |
Surgery_Schwartz_11967 | Surgery_Schwartz | stitches are tied to firmly approximate the vagina to the ligament without suture bridging.When using the uterosacral ligaments for repair of prolapse, it is important to recall that these structures are not “ligaments” in the true sense of the word, but rather condensations of smooth muscle, collagen, and elastin. Several support sutures are placed from the lateral-most portion of the vaginal cuff to the distal-most part of the ligament, and the medial vaginal cuff to the proximal ligament. Intraoperative evaluation of the lower urinary tract is important to confirm the absence of ureteral compromise.Colpocleisis. Colpocleisis is reserved for patients who are elderly, who do not wish to retain coital ability, and for whom there is good reason not to perform a more extensive recon-structive operation. A colpocleisis removes of part or all of the vaginal epithelium, obliterating the vaginal vault and leaving the external genitalia unchanged. The procedure can be performed with or | Surgery_Schwartz. stitches are tied to firmly approximate the vagina to the ligament without suture bridging.When using the uterosacral ligaments for repair of prolapse, it is important to recall that these structures are not “ligaments” in the true sense of the word, but rather condensations of smooth muscle, collagen, and elastin. Several support sutures are placed from the lateral-most portion of the vaginal cuff to the distal-most part of the ligament, and the medial vaginal cuff to the proximal ligament. Intraoperative evaluation of the lower urinary tract is important to confirm the absence of ureteral compromise.Colpocleisis. Colpocleisis is reserved for patients who are elderly, who do not wish to retain coital ability, and for whom there is good reason not to perform a more extensive recon-structive operation. A colpocleisis removes of part or all of the vaginal epithelium, obliterating the vaginal vault and leaving the external genitalia unchanged. The procedure can be performed with or |
Surgery_Schwartz_11968 | Surgery_Schwartz | operation. A colpocleisis removes of part or all of the vaginal epithelium, obliterating the vaginal vault and leaving the external genitalia unchanged. The procedure can be performed with or without a hysterectomy. Successive purse-string sutures through the vaginal muscularis are used to reduce the prolapsed organs to above the level of the levator plate.Sacrocolpopexy. The procedure with the lowest risk of recurrence for patients with prolapse of the vaginal apex is an abdominal sacral colpopexy. In these patients, the natural apical support structure, the cardinal–uterosacral ligament complex, is often damaged and attenuated. The abdominal placement, as opposed to vaginal placement, of graft material to compensate for defective vaginal support structures is well described.78 Api-cal support defects rarely exist in isolation, and the sacrocol-popexy may be modified to include the anterior and posterior vaginal walls as well as the perineal body in the suspension. Sacrocolpopexies | Surgery_Schwartz. operation. A colpocleisis removes of part or all of the vaginal epithelium, obliterating the vaginal vault and leaving the external genitalia unchanged. The procedure can be performed with or without a hysterectomy. Successive purse-string sutures through the vaginal muscularis are used to reduce the prolapsed organs to above the level of the levator plate.Sacrocolpopexy. The procedure with the lowest risk of recurrence for patients with prolapse of the vaginal apex is an abdominal sacral colpopexy. In these patients, the natural apical support structure, the cardinal–uterosacral ligament complex, is often damaged and attenuated. The abdominal placement, as opposed to vaginal placement, of graft material to compensate for defective vaginal support structures is well described.78 Api-cal support defects rarely exist in isolation, and the sacrocol-popexy may be modified to include the anterior and posterior vaginal walls as well as the perineal body in the suspension. Sacrocolpopexies |
Surgery_Schwartz_11969 | Surgery_Schwartz | support defects rarely exist in isolation, and the sacrocol-popexy may be modified to include the anterior and posterior vaginal walls as well as the perineal body in the suspension. Sacrocolpopexies can be performed via laparotomy as well as via laparoscopy or robotically. Like rectopexies and low anterior resections, deep pelvic access is needed. Significant suturing at varied angles is required. The advent of the DaVinci robotic laparoscopic system has made visualization and adequate place-ment of the mesh and sutures easier to perform when using the minimally invasive approach.During a sacrocolpopexy, a rigid stent (usually an EEA sizer) is placed into the vagina to facilitate its dissection from the overlying bladder and rectum and to allow the graft material to be spread evenly over its surface. A strip of synthetic mesh is fixed to the anterior and posterior vaginal walls. The peritoneum overlying the presacral area is opened, extending to the poste-rior cul-de-sac. The sigmoid | Surgery_Schwartz. support defects rarely exist in isolation, and the sacrocol-popexy may be modified to include the anterior and posterior vaginal walls as well as the perineal body in the suspension. Sacrocolpopexies can be performed via laparotomy as well as via laparoscopy or robotically. Like rectopexies and low anterior resections, deep pelvic access is needed. Significant suturing at varied angles is required. The advent of the DaVinci robotic laparoscopic system has made visualization and adequate place-ment of the mesh and sutures easier to perform when using the minimally invasive approach.During a sacrocolpopexy, a rigid stent (usually an EEA sizer) is placed into the vagina to facilitate its dissection from the overlying bladder and rectum and to allow the graft material to be spread evenly over its surface. A strip of synthetic mesh is fixed to the anterior and posterior vaginal walls. The peritoneum overlying the presacral area is opened, extending to the poste-rior cul-de-sac. The sigmoid |
Surgery_Schwartz_11970 | Surgery_Schwartz | its surface. A strip of synthetic mesh is fixed to the anterior and posterior vaginal walls. The peritoneum overlying the presacral area is opened, extending to the poste-rior cul-de-sac. The sigmoid colon is retracted medially, and the anterior surface of the sacrum is skeletonized. Two to four permanent sutures are placed through the anterior longitudinal ligament in the midline, starting at the S2 level and proceeding distally. The sutures are passed through the graft at an appropri-ate location to support the vaginal vault without tension. The peritoneum is then closed with an absorbable running suture. The most dangerous potential complication of sacrocolpopexy is sacral hemorrhage.Surgery for Stress Urinary IncontinenceStress incontinence is believed to be caused by lack of urethro-vaginal support (urethral hypermobility) or intrinsic sphincter deficiency (ISD). ISD is a term applied to a subset of stress-incontinent patients who have particularly severe symptoms, including | Surgery_Schwartz. its surface. A strip of synthetic mesh is fixed to the anterior and posterior vaginal walls. The peritoneum overlying the presacral area is opened, extending to the poste-rior cul-de-sac. The sigmoid colon is retracted medially, and the anterior surface of the sacrum is skeletonized. Two to four permanent sutures are placed through the anterior longitudinal ligament in the midline, starting at the S2 level and proceeding distally. The sutures are passed through the graft at an appropri-ate location to support the vaginal vault without tension. The peritoneum is then closed with an absorbable running suture. The most dangerous potential complication of sacrocolpopexy is sacral hemorrhage.Surgery for Stress Urinary IncontinenceStress incontinence is believed to be caused by lack of urethro-vaginal support (urethral hypermobility) or intrinsic sphincter deficiency (ISD). ISD is a term applied to a subset of stress-incontinent patients who have particularly severe symptoms, including |
Surgery_Schwartz_11971 | Surgery_Schwartz | support (urethral hypermobility) or intrinsic sphincter deficiency (ISD). ISD is a term applied to a subset of stress-incontinent patients who have particularly severe symptoms, including urine leakage with minimal exertion. This condition is often recognized clinically as the low pressure or “drainpipe” urethra. The urethral sphincter mechanism in these patients is severely damaged, limiting coaptation of the urethra. Standard surgical procedures used to correct stress incontinence share a common feature: partial urethral obstruction that achieves ure-thral closure under stress.Burch Procedure. Despite the wide acceptance of midurethral sling procedures, a retropubic urethropexy procedure called the Burch procedure is still performed for stress incontinence.79 The space of Retzius is approached extraperitoneally, from an abdominal approach, allowing the bladder to be mobilized from the surrounding adipose tissue and lateral pelvis. Two pairs of large-caliber nonabsorbable sutures are | Surgery_Schwartz. support (urethral hypermobility) or intrinsic sphincter deficiency (ISD). ISD is a term applied to a subset of stress-incontinent patients who have particularly severe symptoms, including urine leakage with minimal exertion. This condition is often recognized clinically as the low pressure or “drainpipe” urethra. The urethral sphincter mechanism in these patients is severely damaged, limiting coaptation of the urethra. Standard surgical procedures used to correct stress incontinence share a common feature: partial urethral obstruction that achieves ure-thral closure under stress.Burch Procedure. Despite the wide acceptance of midurethral sling procedures, a retropubic urethropexy procedure called the Burch procedure is still performed for stress incontinence.79 The space of Retzius is approached extraperitoneally, from an abdominal approach, allowing the bladder to be mobilized from the surrounding adipose tissue and lateral pelvis. Two pairs of large-caliber nonabsorbable sutures are |
Surgery_Schwartz_11972 | Surgery_Schwartz | extraperitoneally, from an abdominal approach, allowing the bladder to be mobilized from the surrounding adipose tissue and lateral pelvis. Two pairs of large-caliber nonabsorbable sutures are placed through the peri-urethral vaginal wall, one pair at the midurethra and one at the urethrovesical junction. Each stitch is then anchored to the ipsi-lateral Cooper’s (iliopectineal) ligament. The sutures are tied to give preferential support to the urethrovesical junction relative to the anterior vaginal wall without overcorrection. Long-term outcome studies up to 10 years have shown the Burch procedure yields cure rates of 80% to 85%.Tensionless Sling. The tension-free vaginal tape (TVT) is a modified sling that uses a strip of polypropylene mesh. Unlike traditional sling procedures, the mesh is positioned at the midurethra, not the urethrovesical junction, and it is not sutured or otherwise fixed into place. Advantages of TVT include the ability to perform the procedure under local | Surgery_Schwartz. extraperitoneally, from an abdominal approach, allowing the bladder to be mobilized from the surrounding adipose tissue and lateral pelvis. Two pairs of large-caliber nonabsorbable sutures are placed through the peri-urethral vaginal wall, one pair at the midurethra and one at the urethrovesical junction. Each stitch is then anchored to the ipsi-lateral Cooper’s (iliopectineal) ligament. The sutures are tied to give preferential support to the urethrovesical junction relative to the anterior vaginal wall without overcorrection. Long-term outcome studies up to 10 years have shown the Burch procedure yields cure rates of 80% to 85%.Tensionless Sling. The tension-free vaginal tape (TVT) is a modified sling that uses a strip of polypropylene mesh. Unlike traditional sling procedures, the mesh is positioned at the midurethra, not the urethrovesical junction, and it is not sutured or otherwise fixed into place. Advantages of TVT include the ability to perform the procedure under local |
Surgery_Schwartz_11973 | Surgery_Schwartz | mesh is positioned at the midurethra, not the urethrovesical junction, and it is not sutured or otherwise fixed into place. Advantages of TVT include the ability to perform the procedure under local anesthesia on an outpatient basis. Small subepithelial tunnels are made bilater-ally to the descending pubic rami through an anterior vaginal wall incision. A specialized conical metal needle coupled to a handle is used to drive one end of the sling through the peri-neal membrane, space of Retzius, and through one of two small suprapubic stab incisions. The tape is set in place without any Brunicardi_Ch41_p1783-p1826.indd 180818/02/19 4:34 PM 1809GYNECOLOGYCHAPTER 41tension after bringing up the other end of the tape through the other side. Recently, multiple modifications have been made to carry the tape through the bilateral medial portions of the obtu-rator space (TVT-O). Risks of the procedure include visceral injury from blind introduction of the needle, bleeding, and nerve and | Surgery_Schwartz. mesh is positioned at the midurethra, not the urethrovesical junction, and it is not sutured or otherwise fixed into place. Advantages of TVT include the ability to perform the procedure under local anesthesia on an outpatient basis. Small subepithelial tunnels are made bilater-ally to the descending pubic rami through an anterior vaginal wall incision. A specialized conical metal needle coupled to a handle is used to drive one end of the sling through the peri-neal membrane, space of Retzius, and through one of two small suprapubic stab incisions. The tape is set in place without any Brunicardi_Ch41_p1783-p1826.indd 180818/02/19 4:34 PM 1809GYNECOLOGYCHAPTER 41tension after bringing up the other end of the tape through the other side. Recently, multiple modifications have been made to carry the tape through the bilateral medial portions of the obtu-rator space (TVT-O). Risks of the procedure include visceral injury from blind introduction of the needle, bleeding, and nerve and |
Surgery_Schwartz_11974 | Surgery_Schwartz | to carry the tape through the bilateral medial portions of the obtu-rator space (TVT-O). Risks of the procedure include visceral injury from blind introduction of the needle, bleeding, and nerve and muscle injury in the obturator space. Additionally, voiding dysfunction and delayed erosion of mesh into the bladder or urethra has been seen.Urethral Bulking Injections. A transurethral or periurethral injection of bulking agents is indicated for patients with intrin-sic sphincter deficiency. Several synthetic injectable agents, such as polydimethylsiloxane and calcium hydroxylapatite are now used, as glutaraldehyde cross-linked (GAX) bovine dermal collagen is no longer commercially available.80 Anesthesia is easily obtained by using intraurethral 2% lidocaine jelly and/or transvaginal injection of the periurethral tissues with 5 mL of 1% lidocaine. The material is injected underneath the urethral mucosa at the bladder neck and proximal urethra at multiple positions, until mucosal bulk | Surgery_Schwartz. to carry the tape through the bilateral medial portions of the obtu-rator space (TVT-O). Risks of the procedure include visceral injury from blind introduction of the needle, bleeding, and nerve and muscle injury in the obturator space. Additionally, voiding dysfunction and delayed erosion of mesh into the bladder or urethra has been seen.Urethral Bulking Injections. A transurethral or periurethral injection of bulking agents is indicated for patients with intrin-sic sphincter deficiency. Several synthetic injectable agents, such as polydimethylsiloxane and calcium hydroxylapatite are now used, as glutaraldehyde cross-linked (GAX) bovine dermal collagen is no longer commercially available.80 Anesthesia is easily obtained by using intraurethral 2% lidocaine jelly and/or transvaginal injection of the periurethral tissues with 5 mL of 1% lidocaine. The material is injected underneath the urethral mucosa at the bladder neck and proximal urethra at multiple positions, until mucosal bulk |
Surgery_Schwartz_11975 | Surgery_Schwartz | of the periurethral tissues with 5 mL of 1% lidocaine. The material is injected underneath the urethral mucosa at the bladder neck and proximal urethra at multiple positions, until mucosal bulk has improved. Patients must dem-onstrate a negative reaction to a collagen skin test prior to injec-tion. The long-term cure rate is 20% to 30%, with an additional 50% to 60% of patients demonstrating improvement.72 Repeat injections are frequently necessary because of migration and dissolution of the collagen material.Mesh in Reconstructive Pelvic Surgery. As noted earlier, pelvic reconstructive surgery frequently uses polypropylene mesh to augment procedures in the hopes of providing long-lasting repair. However, use of permanent mesh is associated with complications, most notably mesh erosion. In 2011, the FDA issued an updated statement to stipulate the risks when using transvaginally inserted mesh for prolapse.81 Ultimately, this has led to categorizing transvaginal mesh products as class | Surgery_Schwartz. of the periurethral tissues with 5 mL of 1% lidocaine. The material is injected underneath the urethral mucosa at the bladder neck and proximal urethra at multiple positions, until mucosal bulk has improved. Patients must dem-onstrate a negative reaction to a collagen skin test prior to injec-tion. The long-term cure rate is 20% to 30%, with an additional 50% to 60% of patients demonstrating improvement.72 Repeat injections are frequently necessary because of migration and dissolution of the collagen material.Mesh in Reconstructive Pelvic Surgery. As noted earlier, pelvic reconstructive surgery frequently uses polypropylene mesh to augment procedures in the hopes of providing long-lasting repair. However, use of permanent mesh is associated with complications, most notably mesh erosion. In 2011, the FDA issued an updated statement to stipulate the risks when using transvaginally inserted mesh for prolapse.81 Ultimately, this has led to categorizing transvaginal mesh products as class |
Surgery_Schwartz_11976 | Surgery_Schwartz | 2011, the FDA issued an updated statement to stipulate the risks when using transvaginally inserted mesh for prolapse.81 Ultimately, this has led to categorizing transvaginal mesh products as class III devices in 2016. In addition to appropriate patient selection, and extensive informed consent, the American Urogynecologic Society recommends appropriate training to perform the proce-dures and manage the complications.82,83GYNECOLOGIC CANCERVulvar CancerVulvar cancer is the fourth most common gynecologic cancer. The mean age at diagnosis is 65, though this has trended down over the last several decades.84 Evidence supports an HPV-dependent pathway of carcinogenesis with risk factors similar to VIN in approximately 60% of cases. A second pathway inde-pendent of HPV is associated with chronic inflammation, vul-var dystrophy.85 Patients usually present with a vulvar ulcer or mass. Pruritus is a common complaint, and vulvar bleeding or enlarged inguinal lymph nodes are signs of advanced | Surgery_Schwartz. 2011, the FDA issued an updated statement to stipulate the risks when using transvaginally inserted mesh for prolapse.81 Ultimately, this has led to categorizing transvaginal mesh products as class III devices in 2016. In addition to appropriate patient selection, and extensive informed consent, the American Urogynecologic Society recommends appropriate training to perform the proce-dures and manage the complications.82,83GYNECOLOGIC CANCERVulvar CancerVulvar cancer is the fourth most common gynecologic cancer. The mean age at diagnosis is 65, though this has trended down over the last several decades.84 Evidence supports an HPV-dependent pathway of carcinogenesis with risk factors similar to VIN in approximately 60% of cases. A second pathway inde-pendent of HPV is associated with chronic inflammation, vul-var dystrophy.85 Patients usually present with a vulvar ulcer or mass. Pruritus is a common complaint, and vulvar bleeding or enlarged inguinal lymph nodes are signs of advanced |
Surgery_Schwartz_11977 | Surgery_Schwartz | inflammation, vul-var dystrophy.85 Patients usually present with a vulvar ulcer or mass. Pruritus is a common complaint, and vulvar bleeding or enlarged inguinal lymph nodes are signs of advanced disease. Careful evaluation of the patient is necessary to rule out con-current lesions of the vagina and cervix. Biopsy is required and should be sufficiently deep to allow evaluation of the extent of stromal invasion. Vulvar carcinomas are squamous in 90% of cases. Other less common histologies include melanoma (5%), basal cell carcinoma (2%), and soft tissue sarcomas (1–2%).Spread of vulvar carcinoma is by direct local extension and via lymphatic microembolization. Hematogenous spread is uncommon except for vulvar melanoma. Lymphatic spread seems to follow a stepwise, predictable pattern traveling from superficial, above the cribriform fascia, to deep inguinofemo-ral nodes and ultimately the pelvic, external iliac, nodal basin Superficial inferiorepigastric v.Superficialexternalpudendal | Surgery_Schwartz. inflammation, vul-var dystrophy.85 Patients usually present with a vulvar ulcer or mass. Pruritus is a common complaint, and vulvar bleeding or enlarged inguinal lymph nodes are signs of advanced disease. Careful evaluation of the patient is necessary to rule out con-current lesions of the vagina and cervix. Biopsy is required and should be sufficiently deep to allow evaluation of the extent of stromal invasion. Vulvar carcinomas are squamous in 90% of cases. Other less common histologies include melanoma (5%), basal cell carcinoma (2%), and soft tissue sarcomas (1–2%).Spread of vulvar carcinoma is by direct local extension and via lymphatic microembolization. Hematogenous spread is uncommon except for vulvar melanoma. Lymphatic spread seems to follow a stepwise, predictable pattern traveling from superficial, above the cribriform fascia, to deep inguinofemo-ral nodes and ultimately the pelvic, external iliac, nodal basin Superficial inferiorepigastric v.Superficialexternalpudendal |
Surgery_Schwartz_11978 | Surgery_Schwartz | from superficial, above the cribriform fascia, to deep inguinofemo-ral nodes and ultimately the pelvic, external iliac, nodal basin Superficial inferiorepigastric v.Superficialexternalpudendal v.Superficial femorallymph nodesGreat saphenous v.Fossa ovalisSuperficialcircumflex iliac v.Superficial inguinallymph nodesInguinal ligamentExternalinguinal ringRound ligamentFigure 41-17. Lymphatic drainage of the vulva delineated by Stanley Way.(Fig. 41-17).86,87 The node of Cloquet is an important sentinel node situated in the route of spread to the pelvic lymph nodes.Staging and primary surgical treatment are typically pre-formed as a single procedure and tailored to the individual patient (Table 41-6). Surgical staging accounts for the most important prognostic factors including tumor size, depth of invasion, inguinofemoral node status, and distant spread. The most conservative procedure should be performed in view of the high morbidity of aggressive surgical management. This typi-cally | Surgery_Schwartz. from superficial, above the cribriform fascia, to deep inguinofemo-ral nodes and ultimately the pelvic, external iliac, nodal basin Superficial inferiorepigastric v.Superficialexternalpudendal v.Superficial femorallymph nodesGreat saphenous v.Fossa ovalisSuperficialcircumflex iliac v.Superficial inguinallymph nodesInguinal ligamentExternalinguinal ringRound ligamentFigure 41-17. Lymphatic drainage of the vulva delineated by Stanley Way.(Fig. 41-17).86,87 The node of Cloquet is an important sentinel node situated in the route of spread to the pelvic lymph nodes.Staging and primary surgical treatment are typically pre-formed as a single procedure and tailored to the individual patient (Table 41-6). Surgical staging accounts for the most important prognostic factors including tumor size, depth of invasion, inguinofemoral node status, and distant spread. The most conservative procedure should be performed in view of the high morbidity of aggressive surgical management. This typi-cally |
Surgery_Schwartz_11979 | Surgery_Schwartz | depth of invasion, inguinofemoral node status, and distant spread. The most conservative procedure should be performed in view of the high morbidity of aggressive surgical management. This typi-cally involves radical resection of the vulvar tumor targeting a 1 to 2 cm margin around the lesion, and carried to the deep perineal fascia of the urogenital diaphragm with and ipsilateral or bilateral inguinofemoral lymphadenectomy (Fig. 41-18). For tumors ≤2 cm in size with ≤1 mm invasion (FIGO stage IA), lymphadenectomy may be safely omitted, and wide local or Table 41-62009 FIGO staging of vulvar carcinomaIATumor confined to the vulva or perineum, ≤2 cm in size with stromal invasion ≤1 mm, negative nodes1BTumor confined to the vulva or perineum, >2 cm in size or with stromal invasion >1 mm, negative nodesIITumor of any size with adjacent spread (1/3 lower urethra, 1/3 lower vagina, anus), negative nodesIIIATumor of any size with positive inguino-femoral lymph nodes(i) 1 lymph node | Surgery_Schwartz. depth of invasion, inguinofemoral node status, and distant spread. The most conservative procedure should be performed in view of the high morbidity of aggressive surgical management. This typi-cally involves radical resection of the vulvar tumor targeting a 1 to 2 cm margin around the lesion, and carried to the deep perineal fascia of the urogenital diaphragm with and ipsilateral or bilateral inguinofemoral lymphadenectomy (Fig. 41-18). For tumors ≤2 cm in size with ≤1 mm invasion (FIGO stage IA), lymphadenectomy may be safely omitted, and wide local or Table 41-62009 FIGO staging of vulvar carcinomaIATumor confined to the vulva or perineum, ≤2 cm in size with stromal invasion ≤1 mm, negative nodes1BTumor confined to the vulva or perineum, >2 cm in size or with stromal invasion >1 mm, negative nodesIITumor of any size with adjacent spread (1/3 lower urethra, 1/3 lower vagina, anus), negative nodesIIIATumor of any size with positive inguino-femoral lymph nodes(i) 1 lymph node |
Surgery_Schwartz_11980 | Surgery_Schwartz | mm, negative nodesIITumor of any size with adjacent spread (1/3 lower urethra, 1/3 lower vagina, anus), negative nodesIIIATumor of any size with positive inguino-femoral lymph nodes(i) 1 lymph node metastasis ≥5 mm(ii) 1–2 lymph node metastasis(es) of <5 mmIIIB(i) 2 or more lymph nodes metastases ≥5 mm(ii) 3 or more lymph nodes metastases <5 mmIIICPositive node(s) with extracapsular spreadIVA(i) Tumor invades other regional structures (2/3 upper urethra, 2/3 upper vagina), bladder mucosa, rectal mucosa, or fixed to pelvic bone(ii) Fixed or ulcerated inguino-femoral lymph nodesIVBAny distant metastasis including pelvic lymph nodesModified with permission from Pecorelli S: Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium, Int J Gynaecol Obstet. 2009 May;105(2):103-104.Brunicardi_Ch41_p1783-p1826.indd 180918/02/19 4:34 PM 1810SPECIFIC CONSIDERATIONSPART IIradical local excision are adequate. Patients with IB tumors have deeper invasion but negative nodes and | Surgery_Schwartz. mm, negative nodesIITumor of any size with adjacent spread (1/3 lower urethra, 1/3 lower vagina, anus), negative nodesIIIATumor of any size with positive inguino-femoral lymph nodes(i) 1 lymph node metastasis ≥5 mm(ii) 1–2 lymph node metastasis(es) of <5 mmIIIB(i) 2 or more lymph nodes metastases ≥5 mm(ii) 3 or more lymph nodes metastases <5 mmIIICPositive node(s) with extracapsular spreadIVA(i) Tumor invades other regional structures (2/3 upper urethra, 2/3 upper vagina), bladder mucosa, rectal mucosa, or fixed to pelvic bone(ii) Fixed or ulcerated inguino-femoral lymph nodesIVBAny distant metastasis including pelvic lymph nodesModified with permission from Pecorelli S: Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium, Int J Gynaecol Obstet. 2009 May;105(2):103-104.Brunicardi_Ch41_p1783-p1826.indd 180918/02/19 4:34 PM 1810SPECIFIC CONSIDERATIONSPART IIradical local excision are adequate. Patients with IB tumors have deeper invasion but negative nodes and |
Surgery_Schwartz_11981 | Surgery_Schwartz | 180918/02/19 4:34 PM 1810SPECIFIC CONSIDERATIONSPART IIradical local excision are adequate. Patients with IB tumors have deeper invasion but negative nodes and therefore carry an excellent prognosis. Stage II includes patients with local exten-sion and negative nodes and therefore carry a prognosis similar to other node-negative patients.Stage III disease includes patients with lymph node metas-tases, and stage IV disease is either locally advanced or distant metastasis. Treatment options for stage III and stage IV dis-ease include (a) chemoradiation followed by limited resection if needed; (b) radical vulvectomy; and (c) radical vulvectomy coupled with pelvic exenteration. External beam radiotherapy combined with radiosensitizing chemotherapy of cisplatin and 5-fluorouracil (5-FU) is emerging as the preferred initial management of advanced disease, followed by limited surgical resection of residual disease.88-90 Reconstruction of the vulva and groin, if needed, can be | Surgery_Schwartz. 180918/02/19 4:34 PM 1810SPECIFIC CONSIDERATIONSPART IIradical local excision are adequate. Patients with IB tumors have deeper invasion but negative nodes and therefore carry an excellent prognosis. Stage II includes patients with local exten-sion and negative nodes and therefore carry a prognosis similar to other node-negative patients.Stage III disease includes patients with lymph node metas-tases, and stage IV disease is either locally advanced or distant metastasis. Treatment options for stage III and stage IV dis-ease include (a) chemoradiation followed by limited resection if needed; (b) radical vulvectomy; and (c) radical vulvectomy coupled with pelvic exenteration. External beam radiotherapy combined with radiosensitizing chemotherapy of cisplatin and 5-fluorouracil (5-FU) is emerging as the preferred initial management of advanced disease, followed by limited surgical resection of residual disease.88-90 Reconstruction of the vulva and groin, if needed, can be |
Surgery_Schwartz_11982 | Surgery_Schwartz | (5-FU) is emerging as the preferred initial management of advanced disease, followed by limited surgical resection of residual disease.88-90 Reconstruction of the vulva and groin, if needed, can be accomplished using grafts and rota-tional or myocutaneous flaps depending on the size and type of defect.Inguinofemoral lymphadenectomy is indicated beyond clinical stage IA. Unilateral lymphadenectomy is recom-mended for lateralized lesions or bilateral for central lesions that cross the midline, or those involving the periclitoral area (Figs. 41-19 and 41-20). Complications of complete inguino-femoral lymphadenectomy include wound dehiscence or infec-tion and lymphedema. Sentinel lymph node biopsy (SLNB) is an alternative to inguinofemoral lymphadenectomy for selected patients with stage I or II disease and no palpable inguinofemo-ral nodes. SLNB appears to be effective in detecting inguino-femoral lymph node metastases without increasing the risk of groin recurrence while avoiding the | Surgery_Schwartz. (5-FU) is emerging as the preferred initial management of advanced disease, followed by limited surgical resection of residual disease.88-90 Reconstruction of the vulva and groin, if needed, can be accomplished using grafts and rota-tional or myocutaneous flaps depending on the size and type of defect.Inguinofemoral lymphadenectomy is indicated beyond clinical stage IA. Unilateral lymphadenectomy is recom-mended for lateralized lesions or bilateral for central lesions that cross the midline, or those involving the periclitoral area (Figs. 41-19 and 41-20). Complications of complete inguino-femoral lymphadenectomy include wound dehiscence or infec-tion and lymphedema. Sentinel lymph node biopsy (SLNB) is an alternative to inguinofemoral lymphadenectomy for selected patients with stage I or II disease and no palpable inguinofemo-ral nodes. SLNB appears to be effective in detecting inguino-femoral lymph node metastases without increasing the risk of groin recurrence while avoiding the |
Surgery_Schwartz_11983 | Surgery_Schwartz | or II disease and no palpable inguinofemo-ral nodes. SLNB appears to be effective in detecting inguino-femoral lymph node metastases without increasing the risk of groin recurrence while avoiding the morbidities associated with complete inguinofemoral lymphadenectomy. Several prospec-tive studies support this approach.91,92 However, it is recognized that successful SLNB depends on operator experience. Surgeons with limited experience in SLNB (have performed fewer than 10 of these procedures) may choose to perform complete groin node dissection or use this procedure only for tumors that are less than 2 cm in size.Nodal failure in the groin and pelvis is difficult to treat successfully, and attention to primary management of these areas is key. Postoperative adjuvant inguinal and pelvic radio-therapy is indicated when inguinal lymph nodes are positive and is superior to pelvic lymphadenectomy, which has been largely abandoned. It is also indicated when the vulvectomy margins are | Surgery_Schwartz. or II disease and no palpable inguinofemo-ral nodes. SLNB appears to be effective in detecting inguino-femoral lymph node metastases without increasing the risk of groin recurrence while avoiding the morbidities associated with complete inguinofemoral lymphadenectomy. Several prospec-tive studies support this approach.91,92 However, it is recognized that successful SLNB depends on operator experience. Surgeons with limited experience in SLNB (have performed fewer than 10 of these procedures) may choose to perform complete groin node dissection or use this procedure only for tumors that are less than 2 cm in size.Nodal failure in the groin and pelvis is difficult to treat successfully, and attention to primary management of these areas is key. Postoperative adjuvant inguinal and pelvic radio-therapy is indicated when inguinal lymph nodes are positive and is superior to pelvic lymphadenectomy, which has been largely abandoned. It is also indicated when the vulvectomy margins are |
Surgery_Schwartz_11984 | Surgery_Schwartz | radio-therapy is indicated when inguinal lymph nodes are positive and is superior to pelvic lymphadenectomy, which has been largely abandoned. It is also indicated when the vulvectomy margins are positive or close positive for disease and further surgical management is not anatomically feasible.Vaginal CancerVaginal carcinoma is a rare gynecologic malignancy and accounts for about 3% of cancers affecting the female repro-ductive system.84 Squamous cell carcinomas account for 85% to 90% of cases; more than two-thirds of vaginal cancers are diagnosed in women 60 years of age or older. Risk factors are similar to other HPV-related cervical and vulvar cancers. Rare clear cell carcinoma of the vagina is associated to in utero expo-sure to diethylstilbestrol (DES), which is now largely of his-torical interest due to aging of the exposed cohort.93 Patients with vaginal cancer usually present with postmenopausal and/or postcoital bleeding and may also complain of vaginal discharge, vaginal | Surgery_Schwartz. radio-therapy is indicated when inguinal lymph nodes are positive and is superior to pelvic lymphadenectomy, which has been largely abandoned. It is also indicated when the vulvectomy margins are positive or close positive for disease and further surgical management is not anatomically feasible.Vaginal CancerVaginal carcinoma is a rare gynecologic malignancy and accounts for about 3% of cancers affecting the female repro-ductive system.84 Squamous cell carcinomas account for 85% to 90% of cases; more than two-thirds of vaginal cancers are diagnosed in women 60 years of age or older. Risk factors are similar to other HPV-related cervical and vulvar cancers. Rare clear cell carcinoma of the vagina is associated to in utero expo-sure to diethylstilbestrol (DES), which is now largely of his-torical interest due to aging of the exposed cohort.93 Patients with vaginal cancer usually present with postmenopausal and/or postcoital bleeding and may also complain of vaginal discharge, vaginal |
Surgery_Schwartz_11985 | Surgery_Schwartz | interest due to aging of the exposed cohort.93 Patients with vaginal cancer usually present with postmenopausal and/or postcoital bleeding and may also complain of vaginal discharge, vaginal mass, dysuria, hematuria, rectal bleeding, or pelvic pain, which may be indicative of advanced disease. Diagnosis is made via biopsy of suspicious lesions, which may require colposcopic guidance.85Figure 41-18. Extent of modified radical hemivulvectomy for stages I and II squamous cancer of the vulva.Superficial femoral nodesCribriformfasciaDeep femoral nodesFemoral a.Femoral n.Sartorius m.Iliopsoas m.FemurEpidermuslateralmedialAdductor longusPectineus m.Femoral v.Camper’s fasciaFigure 41-19. The anatomy of the inguinal triangle by cross-section.Pubic tubercleFemoral v.Sapheno-femoraljunctionFigure 41-20. Landmarks for choosing an incision for an inguinal lymphadenectomy.Brunicardi_Ch41_p1783-p1826.indd 181018/02/19 4:34 PM 1811GYNECOLOGYCHAPTER 41Vaginal cancer is staged clinically by pelvic | Surgery_Schwartz. interest due to aging of the exposed cohort.93 Patients with vaginal cancer usually present with postmenopausal and/or postcoital bleeding and may also complain of vaginal discharge, vaginal mass, dysuria, hematuria, rectal bleeding, or pelvic pain, which may be indicative of advanced disease. Diagnosis is made via biopsy of suspicious lesions, which may require colposcopic guidance.85Figure 41-18. Extent of modified radical hemivulvectomy for stages I and II squamous cancer of the vulva.Superficial femoral nodesCribriformfasciaDeep femoral nodesFemoral a.Femoral n.Sartorius m.Iliopsoas m.FemurEpidermuslateralmedialAdductor longusPectineus m.Femoral v.Camper’s fasciaFigure 41-19. The anatomy of the inguinal triangle by cross-section.Pubic tubercleFemoral v.Sapheno-femoraljunctionFigure 41-20. Landmarks for choosing an incision for an inguinal lymphadenectomy.Brunicardi_Ch41_p1783-p1826.indd 181018/02/19 4:34 PM 1811GYNECOLOGYCHAPTER 41Vaginal cancer is staged clinically by pelvic |
Surgery_Schwartz_11986 | Surgery_Schwartz | for choosing an incision for an inguinal lymphadenectomy.Brunicardi_Ch41_p1783-p1826.indd 181018/02/19 4:34 PM 1811GYNECOLOGYCHAPTER 41Vaginal cancer is staged clinically by pelvic exam, chest X-ray, cystoscopy, and proctoscopy (Table 41-7).94 Vaginal cancer spreads by local extension to adjacent pelvic structures, by lymphatic embolization to regional lymph nodes, and, less commonly, via the hematogenous route. Lymphatic drainage is complex, but in general, lesions in the upper vagina drain to the pelvic lymph nodes while lesions involving the lower third drain to the inguinofemoral lymph nodes.Stage I disease, involving the upper vagina, may be treated surgically or with intracavitary radiation therapy.86,87,95 Surgery consists of a radical hysterectomy, upper vaginectomy, and bilateral pelvic lymphadenectomy. Stage I disease in the mid to lower vagina is treated with radiation and concurrent chemo-therapy. External beam pelvic radiation is the mainstay of treat-ment for stages | Surgery_Schwartz. for choosing an incision for an inguinal lymphadenectomy.Brunicardi_Ch41_p1783-p1826.indd 181018/02/19 4:34 PM 1811GYNECOLOGYCHAPTER 41Vaginal cancer is staged clinically by pelvic exam, chest X-ray, cystoscopy, and proctoscopy (Table 41-7).94 Vaginal cancer spreads by local extension to adjacent pelvic structures, by lymphatic embolization to regional lymph nodes, and, less commonly, via the hematogenous route. Lymphatic drainage is complex, but in general, lesions in the upper vagina drain to the pelvic lymph nodes while lesions involving the lower third drain to the inguinofemoral lymph nodes.Stage I disease, involving the upper vagina, may be treated surgically or with intracavitary radiation therapy.86,87,95 Surgery consists of a radical hysterectomy, upper vaginectomy, and bilateral pelvic lymphadenectomy. Stage I disease in the mid to lower vagina is treated with radiation and concurrent chemo-therapy. External beam pelvic radiation is the mainstay of treat-ment for stages |
Surgery_Schwartz_11987 | Surgery_Schwartz | pelvic lymphadenectomy. Stage I disease in the mid to lower vagina is treated with radiation and concurrent chemo-therapy. External beam pelvic radiation is the mainstay of treat-ment for stages II to IV and may be followed by intracavitary Table 41-7FIGO staging of vaginal carcinoma0Carcinoma in situ; intraepithelial neoplasia grade 3ITumor limited to the vaginal wallIITumor has involved the subvaginal tissue but has not extended to the pelvic wallIIITumor extends to the pelvic wallIVTumor has extended beyond the true pelvis or has involved the mucosa of the bladder or rectumIVATumor invades bladder and/or rectal mucosa and/or direct extension beyond the true pelvisIVBDistant metastasisand/or interstitial brachytherapy. Prognosis for treated early stage disease is excellent with more than 90% 5-year survival rates. Advanced stage disease, however, carries a poor progno-sis with only 15% to 40% 5-year survival rates.Cervical CancerGeneral Principles. There are over 12,000 new cases | Surgery_Schwartz. pelvic lymphadenectomy. Stage I disease in the mid to lower vagina is treated with radiation and concurrent chemo-therapy. External beam pelvic radiation is the mainstay of treat-ment for stages II to IV and may be followed by intracavitary Table 41-7FIGO staging of vaginal carcinoma0Carcinoma in situ; intraepithelial neoplasia grade 3ITumor limited to the vaginal wallIITumor has involved the subvaginal tissue but has not extended to the pelvic wallIIITumor extends to the pelvic wallIVTumor has extended beyond the true pelvis or has involved the mucosa of the bladder or rectumIVATumor invades bladder and/or rectal mucosa and/or direct extension beyond the true pelvisIVBDistant metastasisand/or interstitial brachytherapy. Prognosis for treated early stage disease is excellent with more than 90% 5-year survival rates. Advanced stage disease, however, carries a poor progno-sis with only 15% to 40% 5-year survival rates.Cervical CancerGeneral Principles. There are over 12,000 new cases |
Surgery_Schwartz_11988 | Surgery_Schwartz | 90% 5-year survival rates. Advanced stage disease, however, carries a poor progno-sis with only 15% to 40% 5-year survival rates.Cervical CancerGeneral Principles. There are over 12,000 new cases of cervical cancer and over 4000 cervical cancer deaths annually in the United States.96 It is a major killer worldwide causing 275,000 deaths annually.97 Risk factors for cervical squamous cell and adenocarcinoma, the two most common histologies, are largely related to acquisition of and immune response to carcinogenic subtypes of the HPV virus. Cervical screening is correlated with early identification and treatment of preinvasive disease.98 Cervical cancer is most commonly identified in women with long intervals between screenings, or with no prior screening. It is also associated with early age at first intercourse, multiple sexual partners, smoking, and oral contraceptive use.Early cervical cancer is usually asymptomatic, though irregu-lar or postcoital bleeding may be present, | Surgery_Schwartz. 90% 5-year survival rates. Advanced stage disease, however, carries a poor progno-sis with only 15% to 40% 5-year survival rates.Cervical CancerGeneral Principles. There are over 12,000 new cases of cervical cancer and over 4000 cervical cancer deaths annually in the United States.96 It is a major killer worldwide causing 275,000 deaths annually.97 Risk factors for cervical squamous cell and adenocarcinoma, the two most common histologies, are largely related to acquisition of and immune response to carcinogenic subtypes of the HPV virus. Cervical screening is correlated with early identification and treatment of preinvasive disease.98 Cervical cancer is most commonly identified in women with long intervals between screenings, or with no prior screening. It is also associated with early age at first intercourse, multiple sexual partners, smoking, and oral contraceptive use.Early cervical cancer is usually asymptomatic, though irregu-lar or postcoital bleeding may be present, |
Surgery_Schwartz_11989 | Surgery_Schwartz | early age at first intercourse, multiple sexual partners, smoking, and oral contraceptive use.Early cervical cancer is usually asymptomatic, though irregu-lar or postcoital bleeding may be present, particularly in more advanced disease. The diagnosis of cervical cancer is made by cervical biopsy, either of a gross lesion or a colposcopically-identified lesion. Cervical cancer is staged clinically due to the high disease burden in the developing world.99 Despite the prog-nostic value of clinical staging, in the developed world, surgical and radiologic staging is used to determine the extent of tumor spread and identify lymph node involvement. Lymph node metastasis is common and one of the most important prognostic factors in this disease, and positron emission tomography scans are useful in pretreatment planning and determination of radia-tion fields for women with locally advanced disease. Staging and management options are outlined in Table 41-8.7Table 41-82009 FIGO cervical cancer | Surgery_Schwartz. early age at first intercourse, multiple sexual partners, smoking, and oral contraceptive use.Early cervical cancer is usually asymptomatic, though irregu-lar or postcoital bleeding may be present, particularly in more advanced disease. The diagnosis of cervical cancer is made by cervical biopsy, either of a gross lesion or a colposcopically-identified lesion. Cervical cancer is staged clinically due to the high disease burden in the developing world.99 Despite the prog-nostic value of clinical staging, in the developed world, surgical and radiologic staging is used to determine the extent of tumor spread and identify lymph node involvement. Lymph node metastasis is common and one of the most important prognostic factors in this disease, and positron emission tomography scans are useful in pretreatment planning and determination of radia-tion fields for women with locally advanced disease. Staging and management options are outlined in Table 41-8.7Table 41-82009 FIGO cervical cancer |
Surgery_Schwartz_11990 | Surgery_Schwartz | in pretreatment planning and determination of radia-tion fields for women with locally advanced disease. Staging and management options are outlined in Table 41-8.7Table 41-82009 FIGO cervical cancer staging and management optionsSTAGEDESCRIPTIONOPTIONS FOR MANAGEMENT0Carcinoma in situAdenocarcinoma in situ: simple hysterectomy, may be followed for fertility preservation if all margins negative on coneSquamous cell carcinoma in situ: local excision with LEEP or cone or laser ablationIConfined to the cervixA1: Confined to the cervix, diagnosed only by microscopy with invasion of ≤3 mm in depth and lateral spread ≤7 mmA2: Confined to the cervix, diagnosed with microscopy with invasion of >3 mm and <5 mm with lateral spread ≤7 mmB1: Clinically visible lesion or greater than A2, ≤4 cm in greatest dimensionB2: Clinically visible lesion, >4 cm in greatest dimensionA1 and some A2: fertility preservation through large cone followed by close monitoring, followed by hysterectomyB1 and B2: | Surgery_Schwartz. in pretreatment planning and determination of radia-tion fields for women with locally advanced disease. Staging and management options are outlined in Table 41-8.7Table 41-82009 FIGO cervical cancer staging and management optionsSTAGEDESCRIPTIONOPTIONS FOR MANAGEMENT0Carcinoma in situAdenocarcinoma in situ: simple hysterectomy, may be followed for fertility preservation if all margins negative on coneSquamous cell carcinoma in situ: local excision with LEEP or cone or laser ablationIConfined to the cervixA1: Confined to the cervix, diagnosed only by microscopy with invasion of ≤3 mm in depth and lateral spread ≤7 mmA2: Confined to the cervix, diagnosed with microscopy with invasion of >3 mm and <5 mm with lateral spread ≤7 mmB1: Clinically visible lesion or greater than A2, ≤4 cm in greatest dimensionB2: Clinically visible lesion, >4 cm in greatest dimensionA1 and some A2: fertility preservation through large cone followed by close monitoring, followed by hysterectomyB1 and B2: |
Surgery_Schwartz_11991 | Surgery_Schwartz | greatest dimensionB2: Clinically visible lesion, >4 cm in greatest dimensionA1 and some A2: fertility preservation through large cone followed by close monitoring, followed by hysterectomyB1 and B2: radical hysterectomy or chemoradiation; radical trachelectomy with uterine preservation for childbearing is under investigation for highly selected patients with small lesionsIIA1: Involvement of the upper two-thirds of the vagina, without parametrial invasion, ≤4 cm in greatest dimensionA2: >4 cm in greatest dimensionB: Parametrial involvementFor some IIA radical hysterectomy may be consideredIIA and B: chemoradiation is preferredIIIA. Involvement of the lower third of the vaginaB. Involvement of a parametria to the sidewall or obstruction of one or both ureters on imagingChemoradiationIVA. Local involvement of the bladder or rectumB. Distant metastasesA. ChemoradiationB. Chemotherapy with palliative radiation as indicatedData from Pecorelli S: Revised FIGO staging for carcinoma of the | Surgery_Schwartz. greatest dimensionB2: Clinically visible lesion, >4 cm in greatest dimensionA1 and some A2: fertility preservation through large cone followed by close monitoring, followed by hysterectomyB1 and B2: radical hysterectomy or chemoradiation; radical trachelectomy with uterine preservation for childbearing is under investigation for highly selected patients with small lesionsIIA1: Involvement of the upper two-thirds of the vagina, without parametrial invasion, ≤4 cm in greatest dimensionA2: >4 cm in greatest dimensionB: Parametrial involvementFor some IIA radical hysterectomy may be consideredIIA and B: chemoradiation is preferredIIIA. Involvement of the lower third of the vaginaB. Involvement of a parametria to the sidewall or obstruction of one or both ureters on imagingChemoradiationIVA. Local involvement of the bladder or rectumB. Distant metastasesA. ChemoradiationB. Chemotherapy with palliative radiation as indicatedData from Pecorelli S: Revised FIGO staging for carcinoma of the |
Surgery_Schwartz_11992 | Surgery_Schwartz | Local involvement of the bladder or rectumB. Distant metastasesA. ChemoradiationB. Chemotherapy with palliative radiation as indicatedData from Pecorelli S: Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium, Int J Gynaecol Obstet. 2009 May;105(2):103-104.Brunicardi_Ch41_p1783-p1826.indd 181118/02/19 4:34 PM 1812SPECIFIC CONSIDERATIONSPART IIProcedures for Cervical Cancer Treatment. Certain cervical cancers that are confined to the cervix may be treated surgically. Very small lesions (less than 7 mm wide, less than 3 mm deep) with no LVSI may be treated with simple hysterectomy. In a woman who desires future fertility, a cone biopsy with negative surgical margins may be an acceptable alternative. Any tumor larger than this (larger than stage IA1) should be treated with radical hysterectomy or in special cases radical trachelectomy for fertility preservation. Some authors advocate a large cone biopsy with lymph node dissection for stage IA2 tumors in patients | Surgery_Schwartz. Local involvement of the bladder or rectumB. Distant metastasesA. ChemoradiationB. Chemotherapy with palliative radiation as indicatedData from Pecorelli S: Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium, Int J Gynaecol Obstet. 2009 May;105(2):103-104.Brunicardi_Ch41_p1783-p1826.indd 181118/02/19 4:34 PM 1812SPECIFIC CONSIDERATIONSPART IIProcedures for Cervical Cancer Treatment. Certain cervical cancers that are confined to the cervix may be treated surgically. Very small lesions (less than 7 mm wide, less than 3 mm deep) with no LVSI may be treated with simple hysterectomy. In a woman who desires future fertility, a cone biopsy with negative surgical margins may be an acceptable alternative. Any tumor larger than this (larger than stage IA1) should be treated with radical hysterectomy or in special cases radical trachelectomy for fertility preservation. Some authors advocate a large cone biopsy with lymph node dissection for stage IA2 tumors in patients |
Surgery_Schwartz_11993 | Surgery_Schwartz | with radical hysterectomy or in special cases radical trachelectomy for fertility preservation. Some authors advocate a large cone biopsy with lymph node dissection for stage IA2 tumors in patients who desire future fertility, though this recommenda-tion is somewhat controversial. Tumors that are greater than 4 cm in size are most often treated with chemoRT even if they Figure 41-21. Radical hysterectomy.BAUterusOvaryFallopian tubeCRound ligamentVesicouterinefoldUterinevesselsEDPararectalspaceLymphnodesParavesical spaceFExternal iliac vesselsInternal iliac arteryGHISuperior vesicalarteryUterine arteryare confined to the cervix, given the high likelihood of need for postoperative radiotherapy due to cervical risk factors.Radical Hysterectomy This procedure may be performed via laparotomy, or increasingly via a minimally invasive (laparo-scopic or robotic) approach.100 The key elements are dissection of the pelvic and periaortic nodes and the dissection of the para-metrium from the | Surgery_Schwartz. with radical hysterectomy or in special cases radical trachelectomy for fertility preservation. Some authors advocate a large cone biopsy with lymph node dissection for stage IA2 tumors in patients who desire future fertility, though this recommenda-tion is somewhat controversial. Tumors that are greater than 4 cm in size are most often treated with chemoRT even if they Figure 41-21. Radical hysterectomy.BAUterusOvaryFallopian tubeCRound ligamentVesicouterinefoldUterinevesselsEDPararectalspaceLymphnodesParavesical spaceFExternal iliac vesselsInternal iliac arteryGHISuperior vesicalarteryUterine arteryare confined to the cervix, given the high likelihood of need for postoperative radiotherapy due to cervical risk factors.Radical Hysterectomy This procedure may be performed via laparotomy, or increasingly via a minimally invasive (laparo-scopic or robotic) approach.100 The key elements are dissection of the pelvic and periaortic nodes and the dissection of the para-metrium from the |
Surgery_Schwartz_11994 | Surgery_Schwartz | or increasingly via a minimally invasive (laparo-scopic or robotic) approach.100 The key elements are dissection of the pelvic and periaortic nodes and the dissection of the para-metrium from the pelvic sidewall to allow en bloc removal with the uterus. The principle steps of an open procedure are demon-strated in Fig. 41-21. In contrast to a typical simple hysterectomy, the radical hysterectomy involves dissection much closer to the bowel, bladder, ureters, and great vessels, resulting in a higher complication rate to these organs. Additionally, disruption of the Brunicardi_Ch41_p1783-p1826.indd 181218/02/19 4:35 PM 1813GYNECOLOGYCHAPTER 41MUreterVaginaJKOvary and ligamentFallopian tubeUreterLUterosacralligamentFigure 41-21. (Continued)nerves supplying the bladder and the rectum, which traverse the cardinal and uterosacral ligaments, may result in temporary or long-term bladder and bowel dysfunction. Radical hysterecto-mies allow for the maintenance of the ovaries since the | Surgery_Schwartz. or increasingly via a minimally invasive (laparo-scopic or robotic) approach.100 The key elements are dissection of the pelvic and periaortic nodes and the dissection of the para-metrium from the pelvic sidewall to allow en bloc removal with the uterus. The principle steps of an open procedure are demon-strated in Fig. 41-21. In contrast to a typical simple hysterectomy, the radical hysterectomy involves dissection much closer to the bowel, bladder, ureters, and great vessels, resulting in a higher complication rate to these organs. Additionally, disruption of the Brunicardi_Ch41_p1783-p1826.indd 181218/02/19 4:35 PM 1813GYNECOLOGYCHAPTER 41MUreterVaginaJKOvary and ligamentFallopian tubeUreterLUterosacralligamentFigure 41-21. (Continued)nerves supplying the bladder and the rectum, which traverse the cardinal and uterosacral ligaments, may result in temporary or long-term bladder and bowel dysfunction. Radical hysterecto-mies allow for the maintenance of the ovaries since the |
Surgery_Schwartz_11995 | Surgery_Schwartz | which traverse the cardinal and uterosacral ligaments, may result in temporary or long-term bladder and bowel dysfunction. Radical hysterecto-mies allow for the maintenance of the ovaries since the incidence of metastases to this area is very low, providing a clear advantage of surgery over radiation therapy in the younger patient.Radical Trachelectomy Interest in fertility preservation with stages IA1 and 2, and stage IB1 lesions has led to the develop-ment of methods of radical trachelectomy with uterine preserva-tion. This procedure depends on an adequate blood supply to the uterus from the ovarian anastamoses, as the cervical portion is removed. The lower uterine segment closed with a cerclage and attached directly to the vaginal cuff. The rates of recurrence, pregnancy outcomes, and the best surgical candidates for this surgery are still under study,101 but there are sufficient numbers and experience, both obstetric and surgical, to suggest that this procedure is oncologically | Surgery_Schwartz. which traverse the cardinal and uterosacral ligaments, may result in temporary or long-term bladder and bowel dysfunction. Radical hysterecto-mies allow for the maintenance of the ovaries since the incidence of metastases to this area is very low, providing a clear advantage of surgery over radiation therapy in the younger patient.Radical Trachelectomy Interest in fertility preservation with stages IA1 and 2, and stage IB1 lesions has led to the develop-ment of methods of radical trachelectomy with uterine preserva-tion. This procedure depends on an adequate blood supply to the uterus from the ovarian anastamoses, as the cervical portion is removed. The lower uterine segment closed with a cerclage and attached directly to the vaginal cuff. The rates of recurrence, pregnancy outcomes, and the best surgical candidates for this surgery are still under study,101 but there are sufficient numbers and experience, both obstetric and surgical, to suggest that this procedure is oncologically |
Surgery_Schwartz_11996 | Surgery_Schwartz | the best surgical candidates for this surgery are still under study,101 but there are sufficient numbers and experience, both obstetric and surgical, to suggest that this procedure is oncologically safe and allows live births.Pelvic Exenteration for Recurrent Disease (Fig. 41-22) Cervical cancer recurrences after primary surgical management are treated with radiation. Surgery may be a consideration in selected patients with recurrent cervical cancer who have received maximal radiation therapy. If the recurrence is locally confined with no evidence of spread or metastatic disease, then pelvic exenteration may be considered. Attempted exenteration procedures are aborted intraoperatively if metastatic disease is found. Exenteration is tailored for the disease size and location and may be supralevator or extend below the levator ani muscle and require vulvar resection. Reconstruction of the pelvis may require a continent urinary pouch (if radiation enteritis is limited) or ileal conduit | Surgery_Schwartz. the best surgical candidates for this surgery are still under study,101 but there are sufficient numbers and experience, both obstetric and surgical, to suggest that this procedure is oncologically safe and allows live births.Pelvic Exenteration for Recurrent Disease (Fig. 41-22) Cervical cancer recurrences after primary surgical management are treated with radiation. Surgery may be a consideration in selected patients with recurrent cervical cancer who have received maximal radiation therapy. If the recurrence is locally confined with no evidence of spread or metastatic disease, then pelvic exenteration may be considered. Attempted exenteration procedures are aborted intraoperatively if metastatic disease is found. Exenteration is tailored for the disease size and location and may be supralevator or extend below the levator ani muscle and require vulvar resection. Reconstruction of the pelvis may require a continent urinary pouch (if radiation enteritis is limited) or ileal conduit |
Surgery_Schwartz_11997 | Surgery_Schwartz | or extend below the levator ani muscle and require vulvar resection. Reconstruction of the pelvis may require a continent urinary pouch (if radiation enteritis is limited) or ileal conduit and colostomy, as well as rebuilding of the pelvic floor and vagina with grafts or myocutaneous flaps.Uterine CancerEndometrial Cancer. Endometrial cancer is the most com-mon gynecologic malignancy and fourth most common cancer in women.96 It is most common in menopausal women in the fifth decade of life; up to 15% to 25% of cases occur prior to menopause, and 1% to 5% occur before age 40. Risk factors for the most common type of endometrial cancer include increased exposure to estrogen without adequate opposition by progester-one, either endogenous (obesity, chronic anovulation) or exog-enous (hormone replacement). Additional risk factors include diabetes, Lynch II syndrome (hereditary nonpolyposis coli syn-drome), and prolonged use of tamoxifen. Tamoxifen is a mixed agonist/antagonist ligand for | Surgery_Schwartz. or extend below the levator ani muscle and require vulvar resection. Reconstruction of the pelvis may require a continent urinary pouch (if radiation enteritis is limited) or ileal conduit and colostomy, as well as rebuilding of the pelvic floor and vagina with grafts or myocutaneous flaps.Uterine CancerEndometrial Cancer. Endometrial cancer is the most com-mon gynecologic malignancy and fourth most common cancer in women.96 It is most common in menopausal women in the fifth decade of life; up to 15% to 25% of cases occur prior to menopause, and 1% to 5% occur before age 40. Risk factors for the most common type of endometrial cancer include increased exposure to estrogen without adequate opposition by progester-one, either endogenous (obesity, chronic anovulation) or exog-enous (hormone replacement). Additional risk factors include diabetes, Lynch II syndrome (hereditary nonpolyposis coli syn-drome), and prolonged use of tamoxifen. Tamoxifen is a mixed agonist/antagonist ligand for |
Surgery_Schwartz_11998 | Surgery_Schwartz | replacement). Additional risk factors include diabetes, Lynch II syndrome (hereditary nonpolyposis coli syn-drome), and prolonged use of tamoxifen. Tamoxifen is a mixed agonist/antagonist ligand for the estrogen receptor. It is an ago-nistic in the uterus and an antagonistic to the breast and ovary. Protective factors for endometrial cancer include smoking and use of combination oral contraceptive pills. Adenocarcinomas are the most prevalent histologic type.Endometrial adenocarcinomas have historically been divided into type I and type II tumors with five classic histologic subtypes. Type I tumors are estrogen-dependent endometrioid Brunicardi_Ch41_p1783-p1826.indd 181318/02/19 4:35 PM 1814SPECIFIC CONSIDERATIONSPART IIFigure 41-22. Pelvic exenteration.histology and have a relatively favorable prognosis; they can be broken down further by presence or absence of microsatellite instability. Type II endometrial cancers are estrogen-independent, aggressive, and characterized by | Surgery_Schwartz. replacement). Additional risk factors include diabetes, Lynch II syndrome (hereditary nonpolyposis coli syn-drome), and prolonged use of tamoxifen. Tamoxifen is a mixed agonist/antagonist ligand for the estrogen receptor. It is an ago-nistic in the uterus and an antagonistic to the breast and ovary. Protective factors for endometrial cancer include smoking and use of combination oral contraceptive pills. Adenocarcinomas are the most prevalent histologic type.Endometrial adenocarcinomas have historically been divided into type I and type II tumors with five classic histologic subtypes. Type I tumors are estrogen-dependent endometrioid Brunicardi_Ch41_p1783-p1826.indd 181318/02/19 4:35 PM 1814SPECIFIC CONSIDERATIONSPART IIFigure 41-22. Pelvic exenteration.histology and have a relatively favorable prognosis; they can be broken down further by presence or absence of microsatellite instability. Type II endometrial cancers are estrogen-independent, aggressive, and characterized by |
Surgery_Schwartz_11999 | Surgery_Schwartz | favorable prognosis; they can be broken down further by presence or absence of microsatellite instability. Type II endometrial cancers are estrogen-independent, aggressive, and characterized by nonendometrioid, serous or clear cell, histology, or carcinosarcoma.102 Emerging data, however, suggest that the molecular features could provide reproducible subtypes that have the potential to guide and refine treatment. The most comprehensive molecular study of endometrial cancer to date has been The Cancer Genome Atlas, which included a combination of whole genome sequencing, exome sequencing, microsatellite instability assays, copy number analysis, and proteomics.103 Molecular information was used to classify 232 endometrial cancer patients into four groups: POLE ultramutated, MSI hypermutated, copy number low, and copy number high that correlated with progression-free survival.103 Two practical pared-down classification systems to identify four molecular subgroups with distinct prognostic | Surgery_Schwartz. favorable prognosis; they can be broken down further by presence or absence of microsatellite instability. Type II endometrial cancers are estrogen-independent, aggressive, and characterized by nonendometrioid, serous or clear cell, histology, or carcinosarcoma.102 Emerging data, however, suggest that the molecular features could provide reproducible subtypes that have the potential to guide and refine treatment. The most comprehensive molecular study of endometrial cancer to date has been The Cancer Genome Atlas, which included a combination of whole genome sequencing, exome sequencing, microsatellite instability assays, copy number analysis, and proteomics.103 Molecular information was used to classify 232 endometrial cancer patients into four groups: POLE ultramutated, MSI hypermutated, copy number low, and copy number high that correlated with progression-free survival.103 Two practical pared-down classification systems to identify four molecular subgroups with distinct prognostic |
Surgery_Schwartz_12000 | Surgery_Schwartz | copy number low, and copy number high that correlated with progression-free survival.103 Two practical pared-down classification systems to identify four molecular subgroups with distinct prognostic outcomes have been described.104,105Postmenopausal bleeding is the most common presenta-tion of endometrial cancer and often permits early stage diag-nosis, resulting in a favorable prognosis. Abnormal bleeding should prompt endometrial evaluation and sampling, which is usually done with an office endometrial biopsy, though at times requires operative curettage or diagnostic hysteroscopy. Transvaginal ultrasonography (TVUS) often reveals a thickened endometrial stripe. An endometrial stripe measuring 5 mm or more in a postmenopausal patient with vaginal bleeding raises concern and should be followed by endometrial sampling; patients with stripe of 4 mm or less rarely have occult malig-nancy, and TVUS may thus be used to triage patients before invasive endometrial sampling. Even with a | Surgery_Schwartz. copy number low, and copy number high that correlated with progression-free survival.103 Two practical pared-down classification systems to identify four molecular subgroups with distinct prognostic outcomes have been described.104,105Postmenopausal bleeding is the most common presenta-tion of endometrial cancer and often permits early stage diag-nosis, resulting in a favorable prognosis. Abnormal bleeding should prompt endometrial evaluation and sampling, which is usually done with an office endometrial biopsy, though at times requires operative curettage or diagnostic hysteroscopy. Transvaginal ultrasonography (TVUS) often reveals a thickened endometrial stripe. An endometrial stripe measuring 5 mm or more in a postmenopausal patient with vaginal bleeding raises concern and should be followed by endometrial sampling; patients with stripe of 4 mm or less rarely have occult malig-nancy, and TVUS may thus be used to triage patients before invasive endometrial sampling. Even with a |
Surgery_Schwartz_12001 | Surgery_Schwartz | followed by endometrial sampling; patients with stripe of 4 mm or less rarely have occult malig-nancy, and TVUS may thus be used to triage patients before invasive endometrial sampling. Even with a normal endometrial stripe, endometrial sampling should be performed for persistent postmenopausal bleeding. Uterine cancer is surgically staged and is graded based on the degree of histologic differentiation of the glandular components (Table 41-9).99 Grade is an important prognostic factor, independent of stage.Treatment is surgical, and most commonly involves hysterectomy, bilateral salpingo-oophorectomy, peritoneal cytology, and resection of any gross disease.87 Evidence supports equivalent oncologic outcomes with minimally invasive approaches.106 The inclusion and utility of lymphadenectomy remains an area of controversy. If a lymph node dissection is performed, it may be performed via laparotomy or laparoscopy. Generally, the bilateral pelvic and para-aortic lymph nodes are removed. | Surgery_Schwartz. followed by endometrial sampling; patients with stripe of 4 mm or less rarely have occult malig-nancy, and TVUS may thus be used to triage patients before invasive endometrial sampling. Even with a normal endometrial stripe, endometrial sampling should be performed for persistent postmenopausal bleeding. Uterine cancer is surgically staged and is graded based on the degree of histologic differentiation of the glandular components (Table 41-9).99 Grade is an important prognostic factor, independent of stage.Treatment is surgical, and most commonly involves hysterectomy, bilateral salpingo-oophorectomy, peritoneal cytology, and resection of any gross disease.87 Evidence supports equivalent oncologic outcomes with minimally invasive approaches.106 The inclusion and utility of lymphadenectomy remains an area of controversy. If a lymph node dissection is performed, it may be performed via laparotomy or laparoscopy. Generally, the bilateral pelvic and para-aortic lymph nodes are removed. |
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