Table Of ContentStuart L. Stanton (Ed.)
Principles of
Gynaecological Surgery
With 152 Figures
Springer-Verlag
London Berlin Heidelberg New York
Paris Tokyo
Stuart L. Stanton, FRCS, FRCOG,
Senior Lecturer, Department of Obstetrics and Gynaecology,
st. George's Hospital Medical School. London, and Consultant
Gynaecologist, St. George's and st. James's Hospitals, London
British Library Cataloguing in Publication Data
Stanton, Stuart L.
Principles of gynaecological surgery.
1. Gynecology, Operative
I. Title
618.1'059 RGI04
Library of Congress Cataloging-in-Publication Data
Principles of gynaecological surgery
Includes bibliographies and index.
1. Gynecology. Operative. 1. Stanton. Stuart L. [DNLM: 1. Genitalia. Female-surgery. WP 660 P957]
RG104.P75 1987 618.1'059 87-9524
ISBN-13: 978-1-4471-1448-2 e-ISBN-13: 978-1-4471-1446-8
DOl: 10.1007/978-1-4471-1446-8
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© Springer-Verlag Berlin Heidelberg 1987
Softcover reprint of the hardcover I st edition 1987
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2128/3916-543210
John Dickinson, PRCS, PRCOG (1909-
Obstetric physician, St. Thomas' Hospital, London
Gynaecological Surgeon, Hospitalfor Women, Soho Square, London
Visiting Gynaecologist, Potters Bar Hospital
Gynaecologist, Surgeon and Teacher: who first taught me
the intricacies of gynaecological surgery and whose sympathetic
approach, humour and patience have guided me thereafter
Preface
For a long time I have felt that the present gynaecological training for registrars lacked
familiarisation and understanding of the basic principles of surgery. This is due to several
factors. Firstly, the historical separation of gynaecology from general surgery which led to
our development as an independent speciality (and which Victor Bonney foretold to our
detriment when he opposed the formation of the College of Obstetricians and Gynaecologists
as a separate body from the College of Surgeons). Secondly, a vast improvement in medical
management of many gynaecological conditions has made surgical practice dull and an
unquestioning daily routine with little or no surgical instruction for many junior staff.
Thirdly, the arrival of subspecialisation has exacerbated this, as complicated surgery may
be referred out by the general gynaecologist. Finally, the trend in further education towards
writing an MD rather than taking an FRCS degree. The arguments for and against were set
out in an editorial in the British Journal of Obstetrics and Gynaecology (1983), later taken to
task in the ensuing correspondence. That editorial. together with the difficulty in finding
up-to-date articles on surgical principles in one volume, were the catalysts for this book.
With the help of colleagues from other disciplines, I have attempted to present recent
advances side-by-side with modern-day gynaecological practice.
In dividing this book into the three sections of preoperative, operative and postoperative,
I have chosen growing points and aspects of gynaecological surgery which we need to be
aware of as practising gynaecologists. Discussion with the patient is an important part of
preoperative preparation and vital in the prevention of litigation. I have long been concerned
with the elderly and disabled, who have very special needs relating to surgery which are
often neglected. Many recent advances have occurred with imaging techniques and an up
to-date synopsis of these advances and their indications are presented in the chapter on
imaging. The frequent encounter with a trainee who either failed to carry out an abdominal
laparotomy at the time of pelvic surgery or was unaware of a systematic approach to
laparotomy, motivated inclusion of a chapter on this topic. Surgical instruments can be
very personal items and in preparing this chapter I was conscious of much innovation in
surgical design which has not yet made its impact on our surgical practice. The remaining
chapters deal with diverse topics such as laser, microsurgery, complications of surgery
and psychiatric sequelae of surgery-all of which are reasonably within the ambit of
gynaecological training.
I am also conscious of the debt to those surgeons who taught me and to those books
which left their mark on me. I refer particularly to John Dickinson, to whom this book is
dedicated and who taught me and many others the rudiments of surgery and the patience
viii Preface
to assist. The opening words of Victor Bonney's Principles of Gynaecological Surgery are
surely a model for all time: "The keystones of the surgeon's bearing should be self-control
and, while it is his duty to keep a general eye upon all that takes place in the operating
theatre and without hesitation to correct mistakes, he should guard against becoming
irritable or losing his temper. The man who, when confronted with a difficulty, loses self
control. has mistaken his vocation, however dextrous he may be, or however learned in
the technical details of his art. The habit of abusing assistants, the instruments. or the
anaesthetists, so easy to acquire and so hard to lose, is not to be commended."
I would thank my colleagues at st. George's and St. James's Hospitals, those colleagues
who have referred patients to my care, and research fellows and registrars whose con
structive criticisms I welcome. I would also like to acknowledge the wisdom and surgical
experience of Harold Ellis who helped me in planning this volume.
I thank and acknowledge Robert Lane, whose high standard of illustration has made my
task much easier, Pat Philpott of the Department of Photography at st. James's Hospital
and Jon Larsson of the Audiovisual Department of st. George's Hospital, for professional
photographic skills, John Studd for the stimulating discussion on the FRes and the MD,
Michael Jackson, who as London Editor of Springer-Verlag has always been helpful, enthusi
astic and resourceful. and Nora Galvin, who has patiently typed and corrected manuscripts
and helped edit and collate the final text.
Finally, I thank those who taught me what to do and those who taught me what not to
do.
June, 1987 Stuart L. Stanton
Contents
A PREOPERATIVE
1 Preoperative Preparation of the Patient
Jean-Pierre Van Besouw, Andrew F. Kent and Stuart L. Stanton ................... 3
2 Management of the Elderly or Disabled Patient
Stuart L. Stanton. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 17
3 Prevention and Treatment of Thromboembolism
John Dormandy ............................................................ 23
4 Prevention and Treatment of Surgical Sepsis
Philip James Sanderson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 35
5 Recent Advances in Imaging
David Cosgrove, Elizabeth Bellamy and Malcolm Pearce. ......................... 45
6 Recent Advances in Anaesthesia and Analgesia
Anthony P. Rubin .......................................................... 73
B OPERATIVE
7 Operative Positions, Incisions and Closure
Timothy E. Bucknall and Stuart L. Stanton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 83
8 Scope of Laparotomy
John M. Monaghan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 109
9 Instruments Old and New
Stuart L. Stanton. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 125
10 Recent Advances in Suture Material
Timothy E. Bucknall. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. l39
11 Intestinal Injury and How to Cope
Michael Knight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 157
x Contents
12 Urological Injury and How To Cope
Anthony R. Mundy ....................................................... 171
13 Haemorrhage and How To Cope
John Dormandy. . . . ... . . . .. . . . . .. . . . . ... . . . ... . . . ... . . . . ... . . . . .. . . . ... .. 185
14 Microsurgery
Robert M.L. Winston. ... . . . ... . . . ... . . . . .. .. . . .. .. . . .. ... . . . . ... . . . .. . . .. 195
15 The Role of Laser
Joseph Jordan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 213
C POSTOPERATIVE
16 Intensive Care and Resuscitation: A Medical and Surgical Overview
Julian M. Leigh and Philippa Keyes-Evans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 229
17 Intestinal Complications and How To Cope
Michael Knight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 239
18 Urological Complications and How To Cope
Anthony R. Mundy ....................................................... 245
19 Catheters and Drains
Paul Hilton. ... . . . . ... . . . . ... . . . . ... .. . . .. .. . . .. .. . . .. .. . . . . . ... . . . ... . .. 257
20 Psychiatric Sequelae of Pelvic Surgery and Their Management
Dennis Gath and Susan Iles .............................................. " 285
Subject Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 301
Contributors
Elizabeth Bellamy, MB, BS, DMRD, FRCR, MRCP
Consultant Radiologist, Ashford Hospital, London Road, Ashford, Middlesex TWIS 3AA
Timothy E. Bucknall, MS, FRCS
Consultant General Surgeon, The General Hospital, Burton on Trent, Staffordshire DE14
3QH
David Cosgrove, MRCP
Consultant in Nuclear Medicine and Ultrasound, Royal Marsden Hospital, Downs Road,
Sutton, Surrey SM2 SPT
John Dormandy, FRCS
Consultant Surgeon, Department of Vascular Surgery, St. James's Hospital, Sarsfeld Road,
London SW12 8HW, and st. George's Hospital, London
Dennis Gath, DM, FRCP, FRCPsych
Clinical Reader in Psychiatry, University Department of Psychiatry. Warneford Hospital,
Oxford OX3 7JX
Paul Hilton. MD. BS. MRCOG
Senior Lecturer and Honorary Consultant. Department of Obstetrics and Gynaecology.
Princess Mary Maternity Hospital, Newcastle upon Tyne NE2 3BD
Susan Iles. MA. DPhil. BM. BCh. MRCPsych
Wellcome Research Fellow in Mental Health. Honorary Senior Registrar. University
Department of Psychiatry. Warneford Hospital, Oxford OX3 7JX
Joseph Jordan. MD. FRCOG
Consultant Gynaecologist, The Birmingham and Midland Hospital for Women. Showell
Green Lane. Sparkhill. Birmingham Bll 4HL
Andrew F. Kent. BSc(Hons). MB. BCh
General Practitioner trainee, Corbett House Surgery. Avondale Road. Bristol BSS 9QX
(formerly SHO in Gynaecology. St. James's Hospital, London)
xii Contributors
Philippa Keyes-Evans. MB. BS. DA. FF ARCS
Consultant Anaesthetist. Isle of Thanet District Hospital. St. Peter's Road. Margate. Kent
Michael Knight. MS. FRCS
Consultant Surgeon. St. George's Hospital. Blackshaw Road. London SW17 OQT. and st.
James's Hospital. London
Julian M. Leigh. MD. FFARCS
Consultant Anaesthetist. Director-Intensive Care Unit. Royal Surrey County Hospital.
Egerton Road. Park Barn. Guildford. Surrey GU2 5XX
John M. Monaghan. MB. ChB. FRCS (Ed). FRCOG
Consultant Surgeon. Regional Department of Gynaecological Oncology. Queen Elizabeth
Hospital. Sheriff Hill. Gateshead. Tyne and Wear NE9 6SX
Anthony R. Mundy. MS. FRCS. MRCP
Consultant Urological Surgeon. Guy's Hospital. St. Thomas Street. London SEI 9RT.
and Senior Lecturer. Institute of Urology. London
Malcolm Pearce. FRCS. MRCOG
Senior Lecturer. Department of Obstetrics and Gynaecology. st. George's Hospital Medical
School. Cranmer Terrace. London SW17 ORE
Anthony P. Rubin. MB. BChir. FFARCS
Consultant Anaesthetist. Charing Cross Hospital. Fulham Palace Road. London W6 8RF
Philip James Sanderson. PhD. FRCPath. MB. DipBact
Consultant Microbiologist. Department of Microbiology. Edgware General Hospital.
Edgware. Middlesex HAS OAD
Stuart L. Stanton. FRCS. FRCOG
Senior Lecturer and Consultant Gynaecologist. St. George's Hospital Medical School.
Cranmer Terrace. London SW17 ORE. and st. James's Hospital. London
Jean-Pierre Van Besouw. BSc(Hons). MB. BS. FFARCS(Eng)
Senior Registrar. Department of Anaesthetics. St. Bartholomew's Hospital. West Smithfield.
London ECI
Robert M. L. Winston. MD. FRCOG
Reader in Fertility Studies. Institute of Obstetrics and Gynaecology. Hammersmith Hospital.
Du Cane Road. London W12 OHS
