Table Of ContentErtan Sarıdoğan, Gokhan Sami Kilic, Kubilay Ertan (Ed.)
Minimally Invasive Surgery in Gynecological Practice
Minimally Invasive
Surgery in
Gynecological
Practice
Practical Examples in Gynecology
Ertan Sarıdoğan, Gokhan Sami Kilic,
Kubilay Ertan (Ed.)
Editors
Assoc. Prof. Dr. Ertan Sarıdoğan
University College London Hospital
Elizabeth Garrett Anderson Wing
25 Grafton Way
London WC1E 6DB
UK
Prof. Dr. Gokhan Sami Kilic
University of Texas Medical Branch
Dept. of Obstetrics & Gynecology
301 University Boulevard
Galveston
TX 77555-0587
USA
Prof. Dr. Kubilay Ertan
Dep. of Obstetrics & Gynecology
Hospital of Leverkusen
51375 Leverkusen
Germany
ISBN 978-3-11-053073-5
e-ISBN (PDF) 978-3-11-053520-4
e-ISBN (EPUB) 978-3-11-053362-0
Library of Congress Control Number: 2019950551
Bibliographic information published by the Deutsche Nationalbibliothek
The Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed
bibliographic data are available in the Internet at http://dnb.dnb.de.
© 2020 Walter de Gruyter GmbH, Berlin/Boston
Cover image: Courtesy of Alexander di Liberto
Typesetting: Compuscript Ltd., Shannon, Ireland
Printing and binding: CPI books GmbH, Leck
www.degruyter.com
Foreword
Change alone is eternal, perpetual, immortal.
Schopenhauer
I am pleased to have this opportunity to pen some words at the beginning of this
interesting book “Minimally Invasive Surgery in Gynecological Practice.” The book is
comprehensive, well written and illustrated by internationally recognized authors in
their field.
The book covers the field within 26 chapters starting from the basics-
retroperitoneal anatomy, preoperative imaging, anesthesia, principles of electrosur-
gery, laparoscopic entry techniques, suturing, and adhesions- followed by chapters
on procedures including hysterectomy, myomectomy, endometriosis, benign adnexal
masses, tubal microsurgery, cesarean section scars, Müllerian anomalies, followed by
three chapters on urogynecology; three chapters on cancer-cervical, endometrial and
ovarian, one on Neuropelveology, a new expanding field, three chapters on hysteros-
copy, two chapters on complications – laparoscopic and hysteroscopic-, and one on
endometrial ablation.
Medicine is a permanently developing field that experienced a significant accel-
eration in the last five decades. In medicine, progress frequently follows scientific
innovations and improvements in technology. That laparoscopy provided a surgical
access became evident in the early seventies. The advantages of laparoscopic access
as opposed to conventional laparotomy in performing a gynecologic procedure were
already evident more than 30 years ago. Operating within a closed peritoneal cavity
eliminates the need to use surgical pads and decreases the potential for bacterial
and foreign body contamination. The surgeon can achieve excellent illumination,
visibility, and magnification by bringing the distal end of the laparoscope close to
the area of interest. The pressure effect of the pneumoperitoneum diminishes venous
oozing and permits spontaneous coagulation of minor vessels. In addition, there are
the well-known advantages for the patient associated with the avoidance of a large
abdominal incision.
In the 70’s hysteroscopy was described as “a technique looking for an indica-
tion.” The impact of hysteroscopy in our specialty has been radical. This came about
when hysteroscopy started to be used as a new mode of surgical access into the
uterus. This revolutionized and greatly simplified many procedures that previously
required a laparotomy and a hysterotomy to access the uterine cavity: lysis of severe
uterine synechiae, metroplasty for septate uterus, excision of symptomatic intra-
uterine fibroids. These, after all, are common conditions; hysteroscopy has simplified
these procedures and significantly reduced their morbidity. Direct access to the uterus
led to the introduction of interventions such as endometrial excision and endome-
trial ablation that offer a less invasive, yet effective alternative to hysterectomy in the
https://doi.org/10.1515/9783110535204-202
vi Foreword
treatment of abnormal (dysfunctional) uterine bleeding refractory to medical
treatment.
Both laparoscopic and hysteroscopic surgery are “minimal access surgery”, but
what is minimal is only the access; not the procedure, the level of skill required, nor
the potential of the rate and the degree of complications. Hence, proper training, use
of proper surgical technique and vigilance are of foremost importance.
Schopenhauer said it so well: “change alone is eternal, perpetual, immortal.”
Professor Victor Gomel
Vancouver
January 2020
Preface
“One must examine what concerns it, not only on the basis of the conclusion and the
premises on which the argument rests, but also on the basis of things said about it.”
Aristotle says in Nicomachean Ethics. Our common aim as the Editors is to improve
the quality of women’s health globally. Surgical practice continues to evolve fast and
it brings new advantages by improving efficacy and reducing risks. As the technology
advances rapidly and new evidence on safety and effectiveness is gathered, we feel
obligated to cover all aspects of minimally invasive gynecologic surgery in a fair, bal-
anced way to include laparoscopic, robotic-assisted, and hysteroscopic approaches.
That is what we set out to achieve in this book.
Our target audience are those who wish to further extend their knowledge in
minimally invasive gynecology. Our priority is to provide practical guidance to the
reader. The Editors are from Great Britain, United States and Germany and the chapter
authors represent a broad international experience. They are well respected leaders
who are shaping current practice and have been invited to contribute to this book
due to their expertise in their respective fields. Our previous positive experience with
De Gruyter press led us to work with them again as we expand our portfolio from
robotic surgery to all aspects of minimally invasive gynecology.
We have spent countless hours writing and editing this comprehensive text.
We would like to extend our appreciation to our families for encouraging us. We could
not have done it without their support.
https://doi.org/10.1515/9783110535204-203
Contents
Foreword v
Preface vii
Principal contributing authors xix
Mohamed Mabrouk, Diego Raimondo, Manuela Mastronardi and
Renato Seracchioli
1 Practical fundamentals of retroperitoneal spaces for safe pelvic surgery:
possible answers to difficult questions 1
1.1 Does a general gynecologist need to know about retroperitoneal
pelvic anatomy? 1
1.2 W hat are the superficial anatomical landmarks of retroperitoneum? 1
1.3 Is there a general scheme for the retroperitoneal space? 3
1.4 How to develop retroperitoneal spaces easily 5
1.4.1 Surgical tips and tricks 6
1.4.1.1 Round ligament exit 6
1.4.1.2 Exit lateral or medial to the IP ligaments at the pelvic brim 6
1.4.1.3 Vesico-uterine exit 8
1.4.1.4 Prevesical exit 9
1.4.1.5 Rectovaginal exit 12
1.4.1.6 Retrorectal exit 13
References 15
Elisabeth Bean and Davor Jurkovic
2 P reoperative imaging for minimally invasive surgery in gynecology 17
2.1 Introduction 17
2.2 Role of preoperative imaging in specific conditions 18
2.2.1 Pelvic adhesions 18
2.2.2 Endometriosis 18
2.2.3 Differential diagnosis of pelvic tumors 20
2.2.4 Uterine fibroids 22
2.2.5 Benign dermoid cysts 22
2.2.6 Ectopic pregnancy 24
2.3 Conclusion 24
References 26
Alexis McQuitty
3 A nesthetic considerations for minimally invasive surgery 28
3.1 Introduction 28
3.2 Consequences of CO PNP 28
2
3.3 Consequences of patient positioning 29
3.4 Anesthetic management 31
x Contents
3.5 Pain control 33
3.6 Management of complications 34
3.7 Summary 34
References 35
Mohsen El-Sayed and Ertan Sarıdoğan
4 Principles and safe use of electrosurgery in minimally
invasive surgery 38
4.1 Applied physics 38
4.2 Thermal tissue effects 38
4.3 Monopolar devices 40
4.4 Factors modifying electrosurgical tissue effects 40
4.5 Conventional bipolar devices 41
4.6 Advanced bipolar devices 42
4.7 Combination energy devices 42
4.8 Complications 42
4.8.1 Lateral thermal spread 42
4.8.2 Pedicle effect 43
4.8.3 Inadvertent activation 43
4.8.4 Residual heat 43
4.8.5 Insulation failure 43
4.8.6 Direct coupling 44
4.8.7 Capacitive coupling 44
4.8.8 Antenna coupling 45
4.9 Technological developments and safe electrosurgery 45
4.9.1 Isolated generators and return electrode monitoring technology 45
4.9.2 Active electrode monitoring 45
4.10 Electrosurgery in single incision laparoscopic surgery 45
4.11 Electrosurgery in hysteroscopic surgery 46
4.12 Electrosurgery and electromagnetic interference 47
4.13 Surgical smoke 47
4.14 Key points for safe electrosurgical use 48
4.14.1 Monopolar instruments 48
4.14.2 Bipolar instruments 48
References 48
Nisse V. Clark and Jon I. Einarsson
5 Laparoscopic entry techniques 50
5.1 Introduction 50
5.2 Techniques 50
5.2.1 General principles 50
5.2.2 Veres needle 51
5.2.3 Direct trocar 52
5.2.4 Direct vision 52
