Table Of ContentShaw’s Textbook of
Operative Gynaecology
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Shaw’s Textbook of
Operative Gynaecology
Seventh Edition
Editors:
Marcus E. Setchell CVO MB B.Chir (Cantab) FRCS (Eng & Edin) FRCOG
Surgeon-Gynaecologist to HM Th e Queen,
Consultant Gynaecologist, King Edward VII Hospital, and London Clinic,
Consultant Obstetrician, Portland Hospital & Lindo Wing, St. Mary’s Hospital, London
Honorary Consultant Obstetrician and Gynaecologist, St. Bartholomew’s, Homerton and Whittington Hospitals, London
Formerly Examiner, Royal College of Obstetricians and Gynaecologists, Universities of Cambridge, London,
and University of Colombo, Sri Lanka
Royal Society of Medicine: President, Section of Obstetrics and Gynaecology, 1994
Clinical Specialist Adviser (Gynaecology), National Patient Safety Agency, 2003–6
Professor John H. Shepherd MBBS (Lond) FRCSEng FRCOG
Consultant Surgeon & Gynaecological Oncologist, Th e Royal Marsden Hospital, London
Honorary Consultant Gynaecologist, King Edward VII Hospital, London
Honorary Consultant Gynaecological Surgeon, St. Bartholomew’s and Th e Royal London Hospitals, London
Emeritus Professor of Surgical Gynaecology, St. Bartholomew’s and Th e Royal London School of Medicine,
Queen Mary Westfi eld, University of London
Gold Medal MRCOG exam. 1978, Fulbright Hays Scholarship 1979, American Cancer Society Fellowship 1979–1981
Victor Bonney Award 1982, Victor Bonney Lecturer RCOG 1998, Hunterian Professor RCS, 2006–2007
William Meredith Fletcher Shaw Lecturer, RCOG 2012
Royal Society of Medicine, Section of Obstetrics & Gynaecology, President 2006, Society of Pelvic Surgeons, President 2008,
International Federation of Obstetrics and Gynaecology (FIGO), Member Committee Gynaecological Oncology 1985–1998
Editorial Committee for Annual Report of Gynaecological Cancer 1993–2001
UK Co-ordinating Committee for Cancer Research, Chairman of Gynaecology Sub-committee 1994–1997
British & Irish Association of Robotic Gynaecological Surgeons, President 2010–2013
Visiting Professorships: America, Australia, Singapore, Hong Kong, China, Middle East, India and Europe
Consulting Editor:
Christopher N. Hudson MB M.Chir (Cantab) FRCS (Eng & Glas) FRCOG FRANZCOG
Consulting Obstetric and Gynaecological Surgeon, St. Bartholomew’s and Homerton Hospitals
Emeritus Professor of Obstetrics and Gynaecology, St. Bartholomew’s and the Royal London School of Medicine
Former Professor of Obstetrics and Gynaecology, University of Sydney and Director of Obstetrics and Gynaecology, Westmead Hospsital;
sometime Hon. Consultant University of Ibadan, Nigeria
Hunterian Professor 1969, Victor Bonney Lecturer 1980, Royal College of Surgeons of England
William Meredith Fletcher Shaw Lecturer, Royal College of Obstetricians and Gynaecologists, 1999
Paul Hendrickse Lecturer, University of Ibadan 1982
Sub-Editor:
Tom E. Setchell BMBS (Notts) MRCOG
Consultant Minimal Access Gynaecological Surgeon and Obstetrician
St. Mary’s Hospital, Imperial NHS Trust
London, UK
ELSEVIER
A division of
Reed Elsevier India Private Limited
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Shaw’s Textbook of Operative Gynaecology, 7/e
Setchell, Shepherd & Hudson
ELSEVIER
A division of
Reed Elsevier India Private Limited
Mosby, Saunders, Churchill Livingstone, Butterworth-Heinemann and
Hanley & Belfus are the Health Science imprints of Elsevier.
© 2013 ME Setchell, JH Shepherd & CN Hudson
First Edition 1954
Second Edition 1960
Third Edition 1968
Fourth Edition 1977
Fifth Edition 1983
Sixth Edition 2001
Seventh Edition 2013
All rights are reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise without the prior permission of the publisher.
ISBN: 978-81-312-1160-1
Medical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures, equipment and the use
of drugs become necessary. The author, editors, contributors and the publisher have, as far as it is possible, taken care to ensure that the
information given in this text is accurate and up-to-date. However, readers are strongly advised to confirm that the information, especially
with regard to drug dose/usage, complies with current legislation and standards of practice. Please consult full prescribing information before
issuing prescriptions for any product mentioned in this publication.
Published by Elsevier, a division of Reed Elsevier India Private Limited.
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Printed and bound at EIH Unit Ltd. Press, Manesar.
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Preface
The preface to the sixth edition of Shaw’s Textbook of Operative Gynaecology opened by raising questions about the long-term viabil-
ity of operative surgery books in a world where advances in information technology were dramatically changing the way in which
information is disseminated, with profound effects on methods of learning and teaching. Despite the continuing pace of progress
in the development and application of digital technology, the demand still remains for a state-of-the-art book, which can live on a
bookshelf or in the operating theatre. It is therefore, no surprise, that the publishers have sought a new edition, when the book is
fast approaching the age of expected retirement, it being almost 60 years since the first edition* was published.
The globalisation of publishing had seen the rights of the work transferred to B. I. Churchill Livingstone in New Delhi in 1993.
That company has now been absorbed into the very large international publishing company, Elsevier. It is entirely appropriate for
the publication of this book to continue to be in Delhi, as the technology and skills of publication and printing have risen to such
high standards in India. Demography, economics and historical medical associations make it sensible to produce a hard copy book
close to where the market is greatest. Nevertheless, it is predicted that the book will continue to be in demand by postgraduate
trainees and consultants in the UK, Europe, Africa and the Middle Eastern countries, as well as Australia and New Zealand and
many other parts of the world. We are fortunate that Elsevier’s worldwide organisation means that the book can be distributed liter-
ally all over the world.
The last edition’s Preface also acknowledged the increasing sub-specialisation within medicine generally, and notably in gynae-
cological surgery. The benefits to the patient of being cared for by sub-specialists and their teams have become increasingly appar-
ent, and most sizeable departments throughout the world have now embraced this principle. The sub-specialties of Gynaecological
Oncology, Fertility and Reproductive Medicine, Gynaecological Urology and Pelvic Floor are now well developed, whilst minimal
access surgery, endometriosis and fibroid treatment, fistula surgery and many other specialist areas of gynaecology are becoming
recognised as disciplines where patient care improves if there is a concentration of the workload to a smaller number of individual
surgeons. This has led to a major change in the authorship structure of the book. We have commissioned a large number of experts
in the sub-specialties to review and rewrite much of the material. In previous editions, the majority of the contributors were
members of the staff of St. Bartholomew’s Hospital, but writers have now been recruited from many other centres of excellence. We
welcome them warmly and thank them for their contribution of time, skill and energy.
Inevitably this has led to some loss of consistency in style, but the Editors feel that any disadvantage of this is far outweighed by
the intense experience that the sub-specialist authors bring to their subjects. No longer can a surgeon simply quote their preferences
for a particular technique based on individual experience, but must write from a position of knowledge of objective evidence-based
outcome measures. All authors have been encouraged to give attention to the prevention and management of complications within
their specialist area. These new chapters are complemented by many new colour digital photographs, which with modern technology
can be inserted at any chosen point in the text.
There are also major changes in the editorship of this seventh edition. Professor Christopher N. Hudson who has been an Editor
of the last three editions becomes Consulting Editor. His contribution to this book has been considerable. He trained under, and
worked with, Mr. John Howkins (qv below) and was appointed Co-editor in 1977. His long association and working experience with
departments in Africa and other tropical countries have brought special expertise to the surgical management of fistulae and obstet-
ric trauma. As one of the first gynaecological cancer specialists, he has also brought particular expertise to this area. We are grateful
for his continuing guidance and for retaining authorship of the chapter on Surgical Anatomy.
The senior Editor (MES) trained at a time when gynaecological trainees at the end of their apprenticeship were expected to be
able to carry out the whole panoply of gynaecological operations, including surgery for cancer, pelvic floor repairs, infertility, as well
as benign hysterectomy, myomectomy and endometriosis, and the new procedures of diagnostic laparoscopy and laparoscopic ster-
ilisation. In addition, holding the Fellowship of one or more of the surgical colleges, and/or the acquisition of a postgraduate MD
or PhD by thesis, were almost mandatory before becoming a Consultant. Although consultants were expected to be generalists by
and large, many took on a “special interest” according to the needs of their department. In this writer’s first Consultant post, the
inheritance of an established tertiary practice for adolescent and paediatric gynaecology on joining the staff of St. Bartholomew’s
Hospital called for some rapid learning, and subsequent needs of the Department led to the unlikely combination of heading up the
pregnancy termination service and Assisted Conception Unit simultaneously.
Not surprisingly, the need for sub-specialist appointments was soon recognised and St. Bartholomew’s Hospital was fortunate in
being able to appoint a sub-specialist in gynaecological oncology who had undergone a full sub-specialist training programme in
the USA in the shape of Mr. (now Professor) John Shepherd. His appointment to co-editorship is therefore most welcome, and his
revision and updating of the gynaecological cancer chapters has been particularly valued.
A matter for discussion between the publishers and editors in future editions will be the extent to which the book should become
an online publication, perhaps with associated digital recordings of operative procedures.
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Preface
We hope the book will continue to be a training manual for generalist trainees and serve as a learning aid during their operative
training experience, as well providing in-depth knowledge of some operations that they may never expect to perform unless they
proceed to sub-specialist training. For those who do, knowledge and know-how of the more specialised operations described will
be invaluable. In addition, those generalists who may take a special interest in aspects of benign gynaecology will find detailed
descriptions of laparoscopic surgery helpful.
Acknowledgments
Most of the new artwork has been provided by Mrs. Joanna Cameron, to whom we are most grateful. We also thank our non-
gynaecological colleagues who have provided chapters on anaesthesia, oncology, imaging and radiotherapy, as well as medico-legal
aspects.
Much of the typing and incorporation of editorial amendments has been carried out by Katherine Fletcher, Medical Secretary.
The editors also acknowledge the help of their personal secretaries, and wives and families whose computer skills have supple-
mented their basic skills. The authors and editors also acknowledge that many hours of “family time” have been sacrificed to make
completion of this task possible. We are especially grateful to Mr. Tom Setchell who has been co-opted as Sub-Editor. Finally, we are
grateful to the whole team of our publishers, Elsevier, Delhi for their tolerant patience, help and encouragement to see this project
to conclusion.
2012 MES
JHS
*Historical Note
Wilfred Shaw MD FRCS FRCOG, the first author and Editor of this textbook was born in 1897. He was educated at Cambridge
University and St. Bartholomew’s Hospital, where his academic brilliance was recognised by the award of many prizes. His medical
training was interrupted by the First World War where he served in a destroyer as ‘Surgeon Probationer’, delaying his qualification
as a doctor until 1921. His MD thesis from Cambridge on the oestrogen-producing cells of the ovary resulted in the Prize for the
best thesis, and he went on to gain many other prestigious awards. Unusually for the times, he undertook postgraduate training in
Vienna, Berlin, Gratz and Dublin. He was a foundation member of the Royal College of Obstetricians and Gynaecologists, and was
appointed to the staff of St. Bartholomew’s Hospital in 1930. He was a brilliant and innovative surgeon, devising many new opera-
tions as well as writing papers on ovarian physiology and histology. His hobbies included Astrophysics, English history and poetry,
and horticulture, becoming an expert in fruit tree grafting. He developed a serious illness in 1951, which he knew would be fatal.
In forced retirement, he proceeded to write his Textbook of Operative Gynaecology, which was published shortly after his death in
1953 at the age of 55.
Of great significance is the death of former Editor, Mr. John Howkins in 2003. Born in 1907, he qualified from the Middlesex
Hospital in 1932. His training was interrupted by the Second World War where he served in the Royal Air Force. After the war, he
was appointed Consultant Gynaecologist to St. Bartholomew’s Hospital, joining Mr. Wilfred Shaw. On retirement in 1970, he
became a sheep farmer in Wales, a second career that he enjoyed for 30 years. His contribution and interest in this book had
continued for almost 50 years, and this long experience will be greatly missed. Some blocks of his text remain intact as their clarity
and eloquence cannot be surpassed. We have also retained a substantial number of the illustrations from previous editions because
of the clarity of many of these beautifully executed drawings that provide examples of the historical development of medical art and
surgical teaching.
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Contributors
Adam Balen Bertie Leigh Christian Barnick
MD DSc FRCOG Hon FRCPCH FRCOG ad eundem MBBS FRCOG
Professor of Reproductive Medicine and Senior Partner Consultant Obstetrician & Gynaecologist
Surgery, Leeds Teaching Hospitals Hempsons, London, UK Homerton University Hospital,
Leeds Centre for Reproductive Medicine, London, UK
Leeds, UK
Christine Schembri
Alan Farthing Bhavna Gami Deguara
MD FRCOG BSc (Hons) MSc MBBS MD
Consultant Gynaecological Surgeon Academic FY2 in Surgery Clinical Research Fellow
Imperial College NHS Trust Department of Biosurgery & Surgical Reproductive Medicine Department
London, UK Technology, Faculty of Medicine St. Bartholomew’s Hospital,
Imperial College London, UK London, UK
Christopher N. Hudson
Anju Sahdev Carl Chow MB MChir (Cantab) FRCS (Eng &
MBBS MRCP FRCR MBBS BSc MRCOG Glas) FRCOG FRANZCOG
Consultant Radiologist & Senior Lecturer Consultant Obstetrician & Gynaecologist Consulting Obstetric &
St. Bartholomew’s Hospital Kingston Hospital NHS Trust Gynaecological Surgeon
Barts Health NHS Trust, London, UK London, UK St. Bartholomew’s & Homerton Hospitals
Emeritus Professor, Obstetrics & Gynaecology
St. Bartholomew’s and the Royal London
School of Medicine and Dentistry
Axel Walther Caroline E. Everden Claire Mellon
MA MRCP PhD MBBS MRCOG MBChB MRCOG
Consultant Medical Oncologist Obstetrics & Gynaecology Consultant Obstetrician & Gynaecologist
Head of Research, Bristol Haematology and Specialist Trainee Th e Whittington Hospital NHS Trust
Oncology Centre London, UK
Honorary Senior Lecturer, University of Bristol
University Hospitals Bristol, UK
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Contributors
Clive Spence-Jones Erik Mayer John H. Shepherd
FRCS FRCOG PhD FRCS (Urol) FRCS, FRCOG
Consultant Gynaecologist & Obstetrician Clinical Lecturer in Surgery & Senior Consultant Surgeon/Gynaecological
Th e Whittington Hospital NHS Trust Registrar in Urology Oncologist, Royal Marsden Hospital, London
London, UK Department of Surgery & Cancer Hon. Consultant Gynaecological Surgeon,
Imperial College London, UK St. Bartholomew’s and Royal London Hospital
Colin Davis Gabriel PR Browne Justin Vale
MBBS MD FRCOG MB BCh BAO DA(UK) FRCA FFICM MS FRCS
Consultant Obstetrician & Gynaecologist Consultant in Anaesthesia & Reader in Urology and
St. Bartholomew’s Hospital, Intensive Care Medicine Consultant Urological Surgeon
London, UK Royal Marsden Hospital NHS Trust, Department of Surgery & Cancer
London, UK Imperial College London, UK
Marcus E. Setchell
Dudley Robinson Jane V. Borley CVO MA MB BCh (Cantab)
MBBS MD FRCOG BSc MBBS MRCOG FRCS (Eng & Edin) FRCOG
Consultant Urogynaecologist Clinical Research Fellow Consultant Obstetrician & Gynaecologist
Honorary Senior Lecturer Imperial College London, UK King Edward Vll Hospital, Th e London Clinic
Kings College Hospital and Portland Hospitals, London
London, UK Hon. Consultant, St. Bartholomew’s,
Homerton and Whittington Hospitals,
London, UK
Emma Kirk John Butler Martin Gore
MD MRCOG MBBS BSc MRCOG PhD FRCP
Senior Registrar in Obstetrics & Gynaecological Oncology Fellow Consultant Medical Oncologist
Gynaecology St. Bartholomew’s and Royal Medical Director
Whittington Hospital NHS Trust Marsden Hospitals Royal Marsden Hospital
London, UK London, UK London, UK
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Contributors
Rodney H. Reznek
Melanie EB Powell MA MB.chB FRANZCR (Hon) Tom Setchell
MD FRCR FRCP FFR RCSI (Hon) FRCP FRCR BMBS MRCOG
Consultant Clinical Oncologist, Emeritus Professor of Diagnostic Imaging Consultant Obstetrician & Gynaecologist
St. Bartholomew’s Hospital Barts Cancer Institute, Barts and Th e London St. Mary’s Hospital
Honorary Clinical Senior Research Lecturer, School of Medicine and Dentistry Imperial College NHS Trust
Barts Cancer Institute, London, UK Queen Mary University of London, UK London, UK
Varunee Wirasinghe
Millie B. Light Tariq Miskry MB BChir (Cantab) MA
MBChB (Edin) MRCP FRCR MBBS MRCOG FRCA (London)
Specialist Registrar in Clinical Oncology Consultant Obstetrician & Gynaecologist Specialist Registrar Anaesthetics,
St. Bartholomew’s Hospital St. Mary’s Hospital Hammersmith Hospital & Queen Charlotte’s
London, UK Imperial College NHS Trust and Chelsea Hospital
London, UK Imperial College NHS Trust
Paul Ziprin
MD FRCS (Gen Surg)
Senior Lecturer and Consultant Surgeon
Department of Biosurgery & Surgical
Technology
Faculty of Medicine, Imperial College
London, UK
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