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State-of-the-Art Vaginal Surgery
Shalini Rajaram, Neerja Goel
SECTION I: SURGICAL ANATOMY OF FEMALE GENITAL TRACT
1:
Vulva: Anatomy, Blood Supply and Lymphatic Drainage
MONS PUBIS
LABIA MAJORA
Labia Minora
Vestibule
Clitoris
VAGINAL ORIFICE (INTROITUS)
Hymen Vaginae
External Urethral Orifice
BULBS OF THE VESTIBULE
GREATER VESTIBULAR GLANDS [GLANDS OF BARTHOLIN]
CHANGES IN VULVA WITH AGE AND PARITY
Blood Supply [Fig. 1.3]
Nerve Supply [Fig. 1.3]
CLINICAL APPLICATION
Lymphatic Drainage [Fig. 1.5]
CONCLUSIONS
2:
Pelvic Diaphragm and Supports of Uterus
INTRODUCTION
The Bony Pelvis
Muscles of the Pelvic Diaphragm
Levator Ani Muscles
Pubococcygeus
Puborectalis
Iliococcygeus
The Urogenital Hiatus
Levator Plate
Nerve Supply
Perineal Membrane (Urogenital Diaphragm)
Perineal Body
Endopelvic Fascia and the Pelvic Ligaments
Cervical and Uppervaginal Support
Midvaginal Support
Distal Vaginal Support
CONCLUSIONS
3:
Uterus and Cervix: Relations, Blood Supply and Lymphatic Drainage
GENERAL DESCRIPTION
STRUCTURE
Corpus (Including Fundus)
Isthmus
Cervix
CHANGES IN THE UTERUS WITH AGE AND PARITY
THE POSITION OF THE UTERUS
SUPPORTS OF UTERUS
THE RELATIONS OF THE UTERUS
VASCULAR CONNECTIONS
Arterial [Fig. 3.5]
Venous
LYMPHATIC
Cervix
Corpus
CLINICAL CORRELATIONS
4:
Adnexa in Relation to Vaginal Surgery
ANATOMY OF ADNEXA
The Ovaries
Epoöphoron (Parovarium; Organ of Rosenmüller)
Paroöphoron
Structure
Tubal Anatomy
Segments of the Fallopian Tube
Structure
Embryology
Histology
Vasculature
Innervation
Surgical Aspects for the Vaginal Surgeon
GRADES OF DESCENT OF OVARY
CONCLUSIONS
5:
Applied Anatomy of Ureter in Relation to Vaginal Surgery
INTRODUCTION
Embryology
Anatomy
Surgical Anatomy in Relation to Vaginal/ Radical Vaginal Surgery
Identification and Mobilization of the Ureter
Section of the Cardinal Ligament (Proximal Parametrium)
Incidence of Injury and Conditions Making it Prone to Injury
Prevention of Ureteric Injuries
Preoperative Evaluation
Intraoperative Evaluation
Postoperative Recognition of Injury
Management of Ureteric Injuries
CONCLUSIONS
SECTION II: PREOPERATIVE CARE, OPERATION THEATRE, SUTURES AND INSTRUMENTS
6:
Current Concepts in Preoperative Care
CONCLUSIONS
7:
Thromboprophylaxis for Vaginal Surgery
INTRODUCTION
Patient Factors
Recommendations for Thromboprophylaxis
General Recommendations
Specific Considerations during Gynecologic Surgery
Additional Coexisting Medical Conditions
Long Distance Travel after Surgery
Drugs Used for Thromboprophylaxis
Major Side Effects of Heparin
Non-Pharmacological Measures for Thromboprophylaxis
Patient Instructions Regarding Wearing the GCS
Step-by-Step Method to put on the Stockings
Additional Points to be taken Care of during Wearing GCS
Intermittent Pneumatic Compression3,6,7
CONCLUSIONS
8:
Reducing Surgical Risk for HIV and Hepatitis B Infection
INTRODUCTION
Definition of Health Care Personnel and Exposure
Risk for Occupational Transmission
Precautions to Prevent Transmission of HIV and HBV
Universal Precautions
Precautions for Invasive Procedures
Special Precautions while Operating upon a known HIV +ve Patient
Sterilization and Disinfection
Management of Exposures
Evaluation of the Exposure and the Exposure Source
Evaluation of the Exposure
Evaluation of the Exposure Source
Known Sources
Unknown Sources
Treatment of an Exposure Site
Exposure Report
Clinical Evaluation and Baseline Testing of Exposed HCP
Management of Exposures to HBV
Management of Exposures to HIV
PEP for HIV
Use of PEP When HIV Infection Status of Source Person is Unknown
Agents for PEP
Toxicity Associated with PEP
Recommendations for the Selection of Drugs for HIV PEP
Follow-up of HCP Exposed to HIV
Postexposure Testing
SUMMARY OF MANAGEMENT OF OCCUPATIONAL BLOOD EXPOSURES
HBV Exposures
HCV Exposures
HIV Exposures
9:
Operating Tables, OT Lighting and Positions for Vaginal Surgery
INTRODUCTION
Operating Tables
Parts
Control Mechanisms
Accessories
Armboard/armrest (Fig. 9.1)
Wrist or Arm Strap
Patient Restraint Strap
Stirrups
Leg Supports/Padded Knee Crutches
Gas Spring Assisted Stirrups
Bowel
Long Gynecologic Section
Anaesthesia Screen (Fig. 9.1)
Infusion Rod
Positioning on Operating Table
Lithotomy Position (Figs 9.6 and 9.7)
Knee-Chest Position
Reverse Lithotomy with Head-up Tilt
Modified Lithotomy with Trendelenburg (Lloyd-Davies Position)
Cleaning and Disinfection
Operating Theatre Lighting
Types of Operating Lights (Luminaires)
Multi-Reflector Luminaires (Fig. 9.12)
Multi-Lamp Luminaires (Fig. 9.13)
CONCLUSIONS
10:
Electrosurgical Cautery Units
INTRODUCTION
Fundamentals of Electrosurgery
Current Density and Electrode Geometry (Figs 10.5 to 10.8)
Electrode Size
Monopolar Electrosurgery1, 4
Bipolar Electrosurgery1,2
Biological Effects of Electricity (Fig. 10.11)
Generators
Desiccation Techniques
Fulguration Techniques1
Argon Beam Coagulator (ABC) for Controlled Fulguration (Fig. 10.14)
Principles of Electrosurgery in Laparoscopy
Common Procedures where Electrosurgical Units Play Vital Role
Electrophysics Applied to Hysteroscopy1
Hysteroscopic Myomectomy6
Endometrial Ablation (Figs 10.17B to D)
Complications of Diagnostic/Operative Hysteroscopy11–13
Loop Electrosurgical Excision Procedure (LEEP)
Electrophysics in LEEP
LEEP Electrodes (Figs 10.18 and 10.19)
Large Loop Excision of Transformation Zone (LLETZ) (Fig. 10.20)
Recommendations to Avoid Electrosurgical Patient Complications
CONCLUSIONS
11:
Sutures and Suturing Techniques
INTRODUCTION
Ideal Suture Characteristics
Essential Suture Characteristics
Other Suture Characteristics
Suture Size
Absorbable Sutures
Non-absorbable Sutures
Monofilament Versus Multifilament Sutures
Absorbable Suture
Natural
Synthetic
Nonabsorbable Sutures
Natural
Synthetic
Polypropylene (Prolene)
Suture Selection
SUTURING TECHNIQUES IN CLINICAL PRACTICE
APPROXIMATION OF CUT EDGES9,10
Simple Interrupted Sutures
Technique
Simple Running Sutures
Technique
Running Locked Sutures
Technique
Vertical Mattress Sutures
Technique
Far-Near Near-Far Modified Vertical Mattress Suture
Technique
Horizontal Mattress Sutures
Technique
Running Subcuticular Sutures
Technique
TRANSFIXATION OF VARIOUS PEDICLES11
Vascular Pedicles
Anchoring Pedicles
OBLITERATION OF DEAD SPACE
Purse String Suture
Technique
Technique
KNOT TYING TECHNIQUES
Flat Knots
Sliding Knots
ALTERNATIVE METHODS OF WOUND CLOSURE
Steri-Strips
Staples
Tissue Adhesive
CONCLUSIONS
12:
Instruments for Vaginal Surgery
INTRODUCTION
Lighting
Operating Table
Retractors
Deaver Retractor
Heaney Retractor
Breisky-Navratil Retractor
Richardson Retractor
Self-retaining Retractor
Sims' Anterior Vaginal Wall Retractor
Speculums
Sims' Speculum
Cusco Speculum
Auvard Speculum
Hysterectomy Clamps
Heaney Clamp
Kocher Clamp
Maingot Clamp
Needles and Needle Holders
Shape
Attachment to the Suture
Size
Needle Holder
Surgical Knives
Scissors
Grasping Forceps
Cervical Dilators
Hegar Dilators
Hank Dilators
Pratt Dilators
Sponge Holding Forceps
Vulsellum
Simpson's Uterine Sound
Dittel's Bladder Sound
CONCLUSIONS
SECTION III: ANESTHESIA, BLOOD TRANSFUSION AND STERILIZATION TECHNIQUES
13:
Anesthetic Considerations for Vaginal Surgery
GENERAL ANESTHESIA FOR VAGINAL SURGERIES
POSTOPERATIVE PAIN RELIEF
CONCLUSION
14:
Blood Transfusion: Guidelines, Recommendations and Complications
INTRODUCTION
Indications for Transfusion
Autologous Blood Transfusion
Storage of Blood
Complications
1. Changes in Oxygen Transport
2. Coagulopathy
3. Dilution Thrombocytopenia
4. Low Factors V and VIII
5. Disseminated Intravascular Coagulation
6. Hemolytic Transfusion Reaction
7. Citrate Intoxication and Hyperkalemia
8. Temperature
9. Acid Base Abnormalities
10. Shock Lung and ARDS
11. Transfusion Reactions
12. Transmission of Infections
13. Transfusion Associated Graft vs Host Disease
14. Transfusion Related Acute Lung Injury
Blood and Blood Component Therapy
1. Whole Blood (CPD Adenine 1)
2. Red Cell Concentrate (Packed Red Cells)
3. Red Cell Suspension
4. Leucocyte Depleted Red Cells
5. Platelet Concentrates
6. Fresh Frozen Plasma (FFP)
Cryoprecipitate
CONCLUSIONS
15:
Sterilization and Disinfection of Surgical Instruments and Endoscopes
INTRODUCTION
Terminology
Sterilization
Disinfection
Cleaning
Decontamination
Germicide
Bacteriostatic
Biological Indicators
Chemical Indicators
RATIONALISED APPROACH TO STERILIZATION AND DISINFECTION
Cleaning of Equipment
Pre-cleaning
Cleaning
Final Rinsing
Drying
Lubricating
Storage after Cleaning
METHODS OF STERILIZATION AND DISINFECTION
Steam
Types of Steam Sterilizers
Monitoring Steam Sterilization
Chemical Check
Biological Check
Mechanical or Physical Check
Dry Heat
ETHYLENE OXIDE “GAS”
Monitoring Of ETO Sterilization Process
Biological Check
Physical Check
Chemical Check
HYDROGEN PEROXIDE GAS PLASMA
PARACETIC ACID
FORMALDEHYDE
IONIZING RADIATIONS
GLUTARALDEHYDE
ORTHO-PHTHALADEHYDE
ALCOHOL
CHLORINE AND CHLORINE COMPOUNDS
SUPEROXIDE WATER
PHENOLIC COMPOUNDS
BOILING
DISINFECTION AND STERILIZATION OF ENDOSCOPES
DISINFECTION AND STERILIZATION OF EQUIPMENT RELATED TO OBSTETRICS AND GYNAECOLOGY
QUALITY CONTROL81
Mechanical/Electronic Indicators
Chemical Indicators
Biological Indicators
Sterilizer Maintenance
Record Keeping
SECTION IV: VULVAL SURGERY
16:
Vulval Disorders (Non-neoplastic and Premalignant), Biopsy Techniques and Wide Local Excision
INTRODUCTION
International Society For Study Of Vulval Disorders (ISSVD) Classification of Non-Neoplastic Epithelial Disorders of Vulva1
Non-neoplastic Epithelial Disorder
Lichen Sclerosus
Squamous Cell Hyperplasia
Lichen Planus
Vulval Intraepithelial Neoplasia (VIN)
ISSVD (2004) Classification of Squamous VIN6
Paget's Disease of Vulva
History and Examination
VULVAL BIOPSY
Indications of Vulval Biopsy
Cold Knife Biopsy
Keyes Punch Biopsy
Treatment of Non-neoplastic and Premalignant Disorders of Vulva
General Advice for all Vulval Disorders
Lichen Sclerosus (LS)
Squamous Cell Hyperplasia
Lichen Planus of Vulva
Vulval Intraepithelial Neoplasia (VIN)
Paget's Disease of Vulva
CONCLUSIONS
17:
Hymenectomy, Labial Fusion Release, Introital Widening, Schuchardt's Incision
HYMENECTOMY
Definition
Patient Selection and Indications
Operative Procedure
Precaution
Postoperative Management
Complications
LABIAL FUSION RELEASE
Definition
Patient Selection and Indication
Operative Procedure
Postoperative Management
SCHUCHARDT'S INCISION
Definition
Patient Selection and Indications
Operative Procedure
Precaution
Complications
INTROITAL WIDENING
Definition
Patient Selection and Indications
Preoperative Preparation
Operative Procedures
Fenton's Operation
Short Median Episiotomy Sutured Transversely
Complex Postepisiotomy Vestibular Scarring
Postoperative Care
CONCLUSIONS
18:
Bartholin's Gland Surgery: Incision and Drainage, Marsupialization and Excision
INTRODUCTION
Background
Anatomy
Epidemiology
Pathology
History
Physical Examination
Laboratory Studies
Differential Diagnosis (Table 18.2)12
Management of Bartholin Gland Cyst and Abscess
Surgical Techniques for Treatment of Cyst/Abscess
Needle Aspiration
Incision and Drainage
WORD Catheter Placement
Marsupialization
Recent Techniques
Biopsy/Excision
Technique of Excision
Pregnancy
CONCLUSIONS
19:
Simple Vulvectomy for Intraepithelial Neoplasia
INTRODUCTION
Surgical Anatomy
Types of Vulvectomy
Skinning Vulvectomy
Simple Vulvectomy
Radical Vulvectomy
Modified Radical Vulvectomy
Simple Vulvectomy
Preoperative Preparation
Operative Procedure
Closure
Vulval Reconstruction
Postoperative Care
Complications and Side Effects of Vulvar Surgery
CONCLUSIONS
20:
Radical Vulvectomy with Groin Dissection
INTRODUCTION
RADICAL VULVECTOMY
History
MANAGEMENT OF PRIMARY LESION
SURGICAL TECHNIQUE
Preoperative Preparation
Anaesthesia
RADICAL VULVECTOMY
Technique
GROIN DISSECTION
Sentinel Lymph Node Dissection in Vulvar Cancer
Method
Indications of Groin Dissection
Incision
TECHNIQUE (FIGS 20.5 TO 20.13)
Pelvic Lymphadenectomy
Closure of Defect on Vulvectomy and Groin Defect
Postoperative Care
Complications
Immediate Complications
Chronic Complications
CONCLUSIONS
21:
Vestibulectomy for Vulvodynia
VULVAR VESTIBULITIS SYNDROME (VVS)
Anatomical Aspects
Pathology and Etiology
Symptomatology
Diagnosis
TREATMENT FOR VVS
Surgery
Surgical Procedure
Pre-requisites before Surgery
Steps of Total Vestibulectomy2
Complications
Conclusions
SECTION V: VAGINAL SURGERY FOR PROLAPSE AND RECONSTRUCTIVE VAGINAL SURGERY
22:
Current Concepts of Pelvic Organ Prolapse: Evaluation and Choice of Procedure
CONCLUSIONS
23:
Surgical Correction of Anterior Compartment Defects
TECHNIQUE OF PARAVAGINAL REPAIR
ANTERIOR COLPORRHAPHY
TRANSVERSE APICAL DEFECT REPAIR
USE OF GRAFT MATERIAL
CONCLUSIONS
24:
Surgical Correction of Posterior Compartment Defects
CONCLUSIONS
25:
Manchester Repair
INTRODUCTION
Indications and Contraindications
Principles of Manchester/Fothergill Repair
Steps of Surgical Procedure
Modification of Procedure
Shirodhkar's Modification of Manchester Operation
Complications
CONCLUSIONS
26:
Vaginal Hysterectomy and Enterocele Repair
ENTEROCELE REPAIR
Primary Enterocele Repair and Prevention
Principles of Repair
During Vaginal Hysterectomy
Vault Prolapse (Enterocele following Hysterectomy)
Sacrospinous Colpopexy6
Complications of Vaginal Hysterectomy
Management of Bladder and Rectal Injuries during Vaginal Hysterectomy
Bladder Injury
Steps of Repair
Rectal Injury
Early Postoperative Complications
Late Complications
CONCLUSIONS
27:
Sacrospinous Colpopexy
CONCLUSIONS
28:
Posthysterectomy Vault Prolapse
INTRODUCTION
Anatomy
Pathophysiology
Methods of Surgical Treatment
Preoperative Workup
Transvaginal Sacrospinous Colpopexy
Anatomy
Surgical Steps
Complications
Advantages
Bilateral Iliococcygeal Fixation
Anatomy
Surgical Steps
Complications
Advantages
Disadvantages
Bilateral Uterosacral Ligament Vaginal Vault Suspension
Anatomy
Surgical Steps
Complication
Advantages
Vaginosacral Colpopexy (VSC)
Anatomy
Surgical Steps
Complications
Advantages
Posterior Intravaginal Slingoplasty (IVS)
Anatomy
Surgical Steps
Complications
Advantages
Transvaginal Mesh Repair
Surgical Steps
Complications
Colpectomy
Surgical Steps
Disadvantages
CONCLUSION
29:
Complete Perineal Tear
INTRODUCTION
Definition and Classification of Perineal Tear
Mechanism of Continence
Why is it Important to repair a Complete Perineal Tear?
Etiological Factors
Clinical Presentation and Recognition
Repair of 3rd and 4th Degree Perineal Tear Identification of Extent of Tear
Timing of Repair
Preoperative Preparation
Anaesthesia
Suture Material
Methods of Repair of Complete Perineal Tear
Layered Method (Fig. 29.5)
Procedure
Advantages of Continuous Sutures over the Interrupted Suture
WARREN FLAP REPAIR (FIG. 29.6)
Advantages of Warren Flap Repair Method
Noble Mengert Fish Operation (Fig. 29.7)
Procedure
Overlapping Sphincteroplasty
Postoperative Management
Follow-up
Reducing Risk of Perineal Tears
CONCLUSIONS
30:
Radical Vaginal Hysterectomy
INTRODUCTION
Indications for Surgery
Surgical Technique
Extra-Peritoneal Lymphadenectomy
Radical Vaginal Hysterectomy
CONCLUSIONS
31:
Vaginectomy
INTRODUCTION
VAGINAL INTRAEPITHELIAL NEOPLASIA AND MICROINVASIVE VAGINAL CARCINOMA
Squamous Cell Carcinoma of the Vagina
Clear Cell Adenocarcinoma
Verrucous Carcinoma
Vaginal Leiomyosarcoma
Melanoma
Preoperative Work-up
Preoperative Preparation
Radical Vaginectomy
Follow-up Care
CONCLUSIONS
32:
Colpocleisis
INTRODUCTION
Evaluation
Anesthesia
Partial Colpocleisis
Steps
Complete Colpocleisis
Steps
Complications
Outcome
CONCLUSIONS
33:
Culdocentesis and Colpotomy
INTRODUCTION
Definition
Indications
Materials Required
Interpretation
Advantages
Complications
Colpotomy
Indications for Posterior Colpotomy
Colpotomy Drainage of Pelvic Abscess
Complications
CONCLUSIONS
34:
Skin and Muscle Grafts
INTRODUCTION
CONGENITAL ABSENCE OF THE VAGINA
History
Diagnosis
Surgical Techniques
Full-thickness Skin Grafts
Split-Thickness Skin Grafts
Mcindoe Technique
Intermittent Perineal Pressure: Frank Technique
Intestinal Flaps
Complications and Comparisons
VAGINAL RECONSTRUCTION AFTER ABLATIVE SURGERY
History
Surgical Technique
GRACILIS FLAPS
Stenosis
Vaginal Fistulas
Lymphedema of the Vulva
Exstrophy
CONCLUSIONS
35:
Creation of Neovagina
INTRODUCTION
VAGINAL AGENESIS
Presenting Complaints
Diagnostic Workup
Timing of Treatment
Psychological Preparation
Methods for Creation of Neovagina
Non-surgical
Surgical Intervention
The McIndoe Procedure10–13
Steps of Surgery13
Taking the Graft
Creating Neovaginal Space
Preparing Vaginal Form
Sewing the Graft over Vaginal Form
Postoperative Care
Complications and Modifications done to Avoid them
Williams Vulvovaginoplasty13,14
The Vecchietti Operation13,15,16
Bowel Vaginoplasty7,13
Treatment Strategies
CONCLUSIONS
36:
Excision of Transverse and Longitudinal Vaginal Septum
INTRODUCTION
Transverse Vaginal Septum
Pathophysiology
Symptomatology
Preoperative Investigations
Excision of Transverse Vaginal Septum
Surgical Steps
Excision of High Transverse Vaginal Septum
Surgical Steps
Z-Plasty
Surgical Steps
Complications
Longitudinal Vaginal Septum
Symptomatology
Excision of Longitudinal Septum
Surgical Steps
Complications
CONCLUSIONS
37:
Fallopian Tube Prolapse and Tubal Ligation
INTRODUCTION
Surgical Correction of Fallopian Tube Prolapse4
Tubal Ligation: Vaginal Route
SECTION VI: SURGERY OF CERVIX
38:
Cervical Biopsy Techniques
INTRODUCTION
Indications of Biopsy
Pap's Smear
Indication for Pap's
Method 2 (Figs 38.2A to D)
Reporting of Pap's Smear3
Organisms
Other Non-neoplastic Findings (Optional to Report; List Not Inclusive)
Other
Atypical
Atypical Glandular Cells, Favor Neoplastic (Specify Endocervical or NOS)
Endocervical Adenocarcinoma in Situ
Adenocarcinoma
Other Malignant Neoplasms (specify)
Educational Notes and Suggestions (Optional)
Punch Biopsy
Instruments Used4
Technique (Fig. 38.3)
Wedge Biopsy
Technique (Figs 38.4A to C)
Cone Biopsy
Indications for Cone Biopsy1
Technique (Figs 38.5A and B)
Postoperative Care
Normal Results
Risks/Complications
Advantages
Loop Electrosurgical Excision Procedure (LEEP)
Advantages of LEEP
CONCLUSIONS
39:
Ablative (Cryotherapy) and Excision (LEEP) Procedures for CIN
INTRODUCTION
ABLATIVE TECHNIQUES
Cryotherapy: Technique
EXCISIONAL TECHNIQUES
Advantage of Excisional Techniques
Loop Electrosurgical Excision Procedure
Indications of LEEP
Contraindications
Absolute
Relative
Technique of LEEP
Analgesia
Method
Procedure of LEEP
Advantages of LEEP
Disadvantages of LEEP
Post-LEEP Complications
Success Rates
Follow-up
40:
Cervical Incompetence and Cervical Cerclage Techniques
INTRODUCTION AND HISTORICAL PERSPECTIVE
Diagnosis
Non-Pregnant State
During Pregnancy
Indications for Cervical Encerclage
Contraindications
Preoperative Evaluation
SHIRODKAR'S CERCLAGE
Modified Shirodkar Operation
Advantage
Disadvantages
McDonald's Cerclage
Principle
Technique as Originally described by McDonald3
Advantages and Disadvantages
Wurm's Technique
Procedure
EMERGENCY CERCLAGE
TRANSABDOMINAL CERVICOISTHMIC CERCLAGE (TCIC)
Technique
Mahran's Technique as Modified by Novy26
Advantages of Modified Technique
LASH AND LASH PROCEDURE
LAPAROSCOPIC CERVICOISTHMIC CERCLAGE
Complications
Postoperative Care
Efficacy of Cervical Cerclage: Emerging Controversies
SECTION VII: NON-DESCENT VAGINAL HYSTERECTOMY
41:
Basic and Clampless Techniques
INTRODUCTION
Indications and Contraindications
Instruments
Special Instruments
Suture Material
Operative Technique
Position of Patient
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Step 10
Clampless Technique for NDVH
Steps 1–6
Step 7
Step 8
Step 9
Step 10
Step 11 and 12
CONCLUSIONS
42:
Volume Reductive Vaginal Hysterectomy
INTRODUCTION
Volume Reductive Surgeries
Bisection7
Myomectomy/Enucleation7
Morcellation7
Intramyometrial Coring7
Preoperative Evaluation of Large Uteri before Vaginal Hysterectomy by Ultrasound
Steps of Volume Reduction Procedure in NDVH in Representative Cases
A Case of Multiple Intramural Fibroids
Steps of Morcellation in Case Adenomyosis by Slicing Method9
Pryor Technique of Uterine Morcellation2 (Figs 42.8A to D)
Steps of Intramyometrial Coring3 (Figs 42.9 to 42.11)
DISCUSSION
CONCLUSIONS
43:
Technique of NDVH in Nulliparous, Obese and Women with Previous Surgeries
INTRODUCTION
Common
Uncommon
Vaginal Hysterectomy for Nulliparous Women
Vaginal Hysterectomy for Previous Surgery
Vaginal Hysterectomy in Obese Women
Prerequisites Examination under Anesthesia
Preoperative Sonography
Trial (Tentative) Vaginal Hysterectomy
Place of Laparoscopy
Technique of Nondescent Vaginal Hysterectomy
Access to the Anterior Pouch-vesico-uterine Peritoneum
Uterocervical Broad Ligament Space
Surgical Technique in Previous Cesarean Section
Access to the Posterior Pouch: Recto-vaginal Peritoneum:Technique does not Differ in Nullipara, Past Pelvic Surgery or Obesity
Severance of Uterine Supports and Lateral Connections
Debulking
Prophylactic Oophorectomy or Salpingo-oophorectomy at Vaginal Hysterectomy
CONCLUSIONS
44:
Laparoscopic and Vaginal Adnexectomy
INTRODUCTION
Indications for Laparoscopic Assistance for Adnexectomy
VAGINAL OOPHORECTOMY
Conventional Technique
Newer Techniques
Roeder's Loop/Ovarian Stapling
LAPAROSCOPIC ADNEXAL REMOVAL
Advantages of Laparoscopic Management
Techniques of Laparoscopic Adnexectomy
VAGINAL ENDOSCOPIC OOPHORECTOMY
CONCLUSIONS
SECTION VIII: GENITAL FISTULAE, RECTAL PROLAPSE AND STRESS URINARY INCONTINENCE
45:
Vesicovaginal Fistula
INTRODUCTION
Aetiology
Prevalence
Symptomatology
Examination
Treatment
Principles of Fistula Repair
Technique
CONCLUSIONS
Acknowledgement
46:
Rectovaginal Fistulae
INTRODUCTION
Etiology
Symptoms of RVF
Clinical Examination
Examination Under Anesthesia (EUA)
Contrast Radiography and Endoscopy
Issue of Continence
Classification of RVF
Management of RVF
Principles of Management
Surgical Procedures
Transanal Approaches
Transperineal Approaches
Transvaginal Approaches
Abdominal Procedures
Tissue Transposition Procedures
CONCLUSIONS
47:
Rectal Prolapse with Anal Incontinence
INTRODUCTION
Clinical Features
Investigations
Treatment
Perineal Operations
CONCLUSIONS
48:
Surgery for Stress Urinary Incontinence
INTRODUCTION
Definition of Cure
Quality of Life Issues
Better Understanding of Pathophysiology
SURGICAL TECHNIQUES
Burch Colposuspension
Laparoscopic Colposuspension
Slings
Results of Sling Surgery
The Tension Free Vaginal Tape (TVT) Procedure
Trans Obturator Tape (TOT) Procedure
Anterior Colporrhaphy
Injectable Peri-uriurethral Bulking Agents
POSTOPERATIVE COMPLICATIONS
FACTORS AFFECTING THE OUTCOME OF SURGERY
CONCLUSIONS
SECTION IX: POSTOPERATIVE CARE
49:
Postoperative Management in Vaginal Surgery
INTRODUCTION
Postoperative Instructions
Fluid Replacement
Diet and Bowel Action
Postoperative Analgesia
Antibiotic Prophylaxis
Management of Catheters
Care of Suprapubic Catheter
Management of Drains
Wound Care
Mobilization and Physiotherapy
Prophylaxis for Venous Thrombosis
Postoperative Care of Elderly
Discharge from the Hospital
Follow-up
CONCLUSIONS
50:
Complications of Vaginal Surgery
INTRODUCTION
General Complications
Risk of Anaesthesia
Haemorrhage
Infection
Causes for Postoperative Infections
Prevention of the Infection can be done either Preoperatively or Intraoperatively
Preoperative Prevention
Intraoperative Prevention
Injuries
Ureteric Injuries
Bladder Injury
Bowel Injury
Nerve Injury
Pain
Urinary Retention
Bladder Instability
Stress Incontinence
Thromboembolic Complications
Specific Complications
Complications due to Lithotomy Position
Symptoms and Signs
Prevention
Treatment
Neurovascular Complications
Vaginal Stenosis
Enterocele and Other Prolapse
COMPLICATIONS OF VARIOUS SURGICAL PROCEDURES
Minor Procedures
Dilatation and Curettage
Loop Electro-surgical Excisional Procedure (LEEP)
Electrocautery and Cryotherapy
Cold Knife Cone Biopsy
Vaginal Myomectomy
Excision of Vaginal Wall Cyst
Trachelorraphy
Colpotomy
Pyometra
Episiotomy
Cerclage Operation
Major Procedures
Manchester Repair
Vaginal Hysterectomy without Repair
Intraoperative Complications
Postoperative Complications
Vaginal Hysterectomy with Anterior Colporrhaphy and Colpo-perineorrhaphy
Radical Vaginal Hysterectomy
Early Complications
Late Complications
Vaginoplasty
McIndoe-Jayes Operation
William's Vaginoplasty
Vaginal Septae Excision
Vaginal Vault Prolapse
McCall Culdoplasty
Sacrospinous Ligament Fixation
High Ureterosacral Ligament Suspension with Fascial Reconstruction
LeFort Partial Colpocleisis
Surgery for Urinary Incontinence
Urinary Stress Incontinence
Inverted Burch Operation
Vesico-Vaginal Fistula (VVF)
Surgery for Chronic Inversion
VULVA
Bartholin Cystectomy
Marsupialization
Simple Vulvectomy
Early Complications
Late Complications
Radical Vulvectomy
Early Complications
Late Complications
ENDOSCOPIC SURGERIES
Laparoscopic Assisted Vaginal Hysterectomy (LAVH)
Hysteroscopy
Intraoperative Complications
Postoperative Complications
CONCLUSIONS
INDEX
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