Table Of ContentComplications in
Gynecological Surgery
Peter O’Donovan (Ed.)
Complications in
Gynecological
Surgery
Peter O’Donovan, MB, FRCOG, FRCS(ENG)
The Merit Centre
Bradford Royal Infifi rmary
Bradford, West Yorkshire
UK
British Library Cataloguing in Publication Data
Complications in gynecological surgery
1. Generative organs, Female—Surgery 2. Laparoscopic
surgery
I. O’Donovan, Peter J.
618.1′059
ISBN-13: 9781846288821
Library of Congress Control Number: 2007925708
ISBN: 978-1-84628-882-1 e-ISBN: 978-1-84628-883-8
© Springer-Verlag London Limited 2008
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Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
1 Prevention of Infection Following Gynecological
Surgery: The Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Ronnie F. Lamont and S.V.Z. Haynes
2 Complications in Gynecological Oncology . . . . . . . . . . . . . 11
Robin A.F. Crawford
3 Laparoscopic Entry Techniques: Consensus . . . . . . . . . . . 20
Savita Lalchandani and Kevin Phillips
4 Complications of Laparoscopic Surgery
for Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Jeremy T. Wright
5 Abdominal Wound Closure: How to
Avoid Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Patrick Hogston
6 Recent Advances in Adhesion Prevention . . . . . . . . . . . . . 52
Gere S. diZerega and Matthias Korell
7 What to Do When the Operation Is Over . . . . . . . . . . . . . . 61
Virginia A. Beckett and Derek J. Tuffnell
8 Laparoscopic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Joseph A. Ogah
9 Urinary Tract Complications . . . . . . . . . . . . . . . . . . . . . . . . 75
Joseph A. Ogah
10 The High-Risk Gynecology Patient: Assessment
and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Guy W. Glover and Paul G.W. Cramp
11 Complications in Hysteroscopic Surgery: Prevention
and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Paul McGurgan and Peter O’Donovan
vi Contents
12 Minimizing the Risk of Sterilization Failure:
An Evidence-Based Approach . . . . . . . . . . . . . . . . . . . . . . . . 106
Rajesh Varma and Janesh K. Gupta
13 Complications of Assisted Reproduction . . . . . . . . . . . . . . 127
Kee J. Ong, T.C. Li, Enlan Xia, and Yuhua Liu
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Contributors
Virginia A. Beckett, MRCOG S.V.Z. Haynes, MB, ChB, MRCOG
Bradford Teaching Hospitals NHS Clinical Research Fellow
Foundation Trust Northwick Park Hospital and
Bradford, West Yorkshire, UK St. Mark’s National Health
Service Trust
Paul G.W. Cramp, BSc, MB ChB, Harrow, Middlesex, UK
MRCP, FRCA
Department of Anaesthetics Patrick Hogston, BSc(Hons), FRCS,
Bradford Teaching Hospitals NHS FRCOG
Foundation Trust Department of Obstetrics and
Bradford, West Yorkshire, UK Gynaecology
St. Mary’s Hospital
Robin A.F. Crawford, MD, FRCS, Portsmouth, Hampshire, UK
FRCOG
Department of Gynaecology Matthias Korell, MD
Cambridge University Hospital Frauenklinik im Kilinikum
(Addenbrookes Hospital) Duisberg
Cambridge, UK Duisburg, Germany
Gere S. diZerega, MD Savita Lalchandani, MRCOG,
University of Southern California MRCPI (Obst/Gynae)
Keck School of Medicine Clinical Research Fellow in
Department of Obstetrics and Minimal Access Surgery
Gynecology University of Hull and Castle Hill
Livingston Reproductive Biology Hospital
Laboratories Cottingham, UK
Los Angeles, CA, USA
Ronnie F. Lamont, BSc, MB, ChB,
Guy W. Glover, MB ChB, FRCA MD, FRCOG
Department of Anaesthesia Consultant and Reader in
Bradford Royal Infifi rmary Obstetrics and Gynaecology
Bradford, West Yorkshire, UK Department of Obstetrics and
Gynaecology
Janesh K. Gupta, MD, MSc, Northwick Park Hospital and St.
FRCOG Mark’s National Health Service
Department of Obstetrics and Trust
Gynaecology Harrow, Middlesex, UK
University of Birmingham and
Birmingham Women’s T.C. Li, MD, PhD, MRCP, FRCOG
Hospital Royal Hallamshire Hospital
Birmingham, West Midlands, UK Sheffifi eld, UK
viii Contributors
Yuhua Liu, FRCOG, FRCP Kevin Phillips, MRCOG
Hysteroscopic Center Consultant Obstetrician and
Fuxing Hospital Gynaecologist
Beijing, China Castle Hill Hospital
Cottingham, UK
Paul McGurgan, MB, BA, MRCOG,
MRCPI Derek J. Tuffnell, FRCOG
University of West Australia Department of Obstetrics and
King Edward’s Memorial Gynaecology
Hospital Bradford Teaching Hospitals NHS
Perth, West Australia, Australia Foundation Trust
Bradford, West Yorkshire, UK
Peter O’Donovan, MB, FRCOG,
Rajesh Varma, MA, MRCOG
FRCS (ENG)
Clinical Lecturer
The Merit Centre
Department of Obstetrics and
Bradford Royal Infifi rmary
Gynaecology
Bradford, West Yorkshire, UK
University of Birmingham and
Birmingham Women’s Hospital
Joseph A. Ogah, MBBS, MRCOG Birmingham, West Midlands, UK
Department of Obstetrics and
Gynaecology Jeremy T. Wright, FRCOG
Bradford Royal Infifi rmary Centre for Endometriosis and
Bradford, West Yorkshire, UK Pelvic Pain
The Woking Nuffifield Hospital
Kee J. Ong, BMedSc, MB, BS, Woking, Surrey, UK
MMed(Syd), FRANZCOG
ACH Enlan Xia
Jessop Wing Hysteroscopic Centre
Royal Hallamshire Hospital Fuxing Hospital
Sheffifield, UK Beijing, China
1. P revention of Infection Following
Gynecological Surgery: The Evidence
Ronnie F. Lamont
S.V.Z. Haynes
Definition of Infection
Terms such as inflflammation, contamination, infection, sepsis, and febrile
morbidity may mean different things to different clinicians. It is important,
therefore, that in audits of surgical outcomes, reports of research fifindings, and
comparisons of studies, terminology is defifined; an example of this process is
given in Table 1.1. The defifi nitions of various systemic inflfl ammatory responses
and their associated clinical fifi ndings and laboratory test results are shown in
Table 1.2.
Pathogenesis
The vagina contains more microorganisms than any other site in the body
except the bowel. Uterine manipulation through the vagina, e.g., surgical ter-
mination of pregnancy (TOP), or operations that open the vagina, e.g., hyster-
ectomy, will result in contamination of normally sterile sites by bacteria that
are normally resident in the vagina. Whether these organisms become estab-
lished and cause infection and inflfl ammation depends on a mixture of surgical
and host-related factors, including low socioeconomic status, poor nutrition,
smoking, or preexisting medical conditions, such as impaired immunocom-
petence. These risk factors may be interrelated, e.g., diabetes, obesity, increased
blood loss, duration of surgery, and prolonged hospital stay, and many of the
measures that can be taken to reduce the rate of postoperative infectious
morbidity focus on reducing the impact of these risk factors. The risk of post-
operative infection also depends on the virulence and size of the bacterial
inoculum. Normal vaginal flfl ora is composed mainly of organisms of low viru-
lence, dominated by lactobacilli species, which, by producing lactic acid from
glycogen in vaginal secretions, render the pH of the vagina very acid (<4.5),
in which milieu the growth of other potentially pathogenic organisms is
suppressed.
At this low-acid pH, lactobacilli are particularly effifi cient at producing HO,
2 2
which is toxic to bacteria. Under conditions where there is an increase in the
2 R.F. Lamont and S.V.Z. Haynes
Table 1.1. Definition of Infection—Terminology
Definition
Inflammation Localized protective response elicited by injury or tissue damage
Contamination Pathogenic microorganism(s) in normally sterile tissue without an
inflammatory response
Infection Pathogenic microorganism(s) in normally sterile tissue with a local
inflammatory response
Sepsis Infection with a local and systemic inflammatory response
Febrile morbidity Temperature of >38.0°C on 2 occasions at least 6 hours apart,
excluding the first 24 hours after the procedure
Source: Adapted from and reproduced with kind permission from Tamussino [1].
alkalinity of the vagina (bleeding, semen, douching) or a change in the delicate
vaginal ecosystem (few or poor-quality lactobacilli, antibiotics, changes in
endocrine status, or phage virus parasitization of lactobacilli), much less HO
2 2
is produced. This results in a 1000-fold increase in other organisms, particu-
larly anaerobes that produce keto acids such as succinate. Succinate blunts the
chemotactic response of neutrophils and reduces their killing ability. This
Table 1.2. Definitions of Systemic Inflammatory Responses
Clinical Findings, Laboratory
Definition Tests
Systemic Signs and symptoms of Fever, tachypnea, tachycardia,
inflammatory disseminated infection or leukocytosis, or leukopenia
response toxins
Sepsis Infection with a local and Tachypnea (>20 breaths/min)
systemic inflammatory Tachycardia (>90 bpm)
response Hyperthermia or hypothermia
(>38.4°C or <35.6°C)
Severe sepsis Sepsis plus evidence of organ Metabolic acidosis, acute
dysfunction encephalopathy, oliguria,
hypoxemia, disseminated
intravascular coagulation,
hypotension
Septic shock Infection with an Hypotension (<90 mm Hg, or
overwhelming systemic 40 mm Hg below baseline)
inflammatory response
leading to shock
Sepsis syndrome or Sepsis plus evidence of altered Hypoxia, increased plasma
multiple-organ organ perfusion lactate, altered mental state,
syndrome oliguria
Source: Reproduced with kind permission from Tamussino [1].
