Table Of ContentForeword
In the early 1940s, Richard Te Linde hand wrote, page by page, in longhand the first edition of Te Linde's
Operative Gynecology. His week was full. Two days spent in the operating room with usually five or six major
cases scheduled, 3 days in the office, and grand rounds on Saturday morning until noon made for a busy week.
At home after a long day's work and in a half-reclining position necessitated by a hip fracture while ice skating in
earlier years, he wrote a description of the operations he himself had used to correct various gynecologic
disorders.
The first edition, published in 1946 following the end of World War II, comprised 725 pages, all written by Dr. Te
Linde himself. The present eleventh edition, 70 years later, has more than twice the number of pages and
involves 50 authors.
Times have changed and Te Linde's text has changed with it.
The first edition in 1946 was widely read. Enhancing its attractiveness were the illustrations and the superb line
drawings by artists trained under Max Brödel, the German medical artist brought to Baltimore by Howard A. Kelly
(Kelly clamp), the founding gynecologic chairman at Johns Hopkins.
The use of drawings rather than photographs has continued through the various editions, including the eleventh
edition. In this latest edition, most of the drawings have been colorized to even more clearly portray the location
of blood vessels, ligaments, other structures, and surgical techniques. The text and illustrations are also
supplemented by on line access to video demonstrations of selected vaginal surgeries.
The frequency of gynecologic operations per unit of population is declining. This is due to a number of factors,
including alternate treatments for myomas, hormonal control of abnormal bleeding, alternatives to surgical
treatment for infertility, and the decrease in the number of children per family, as well as the relatively high
incidence of cesarean sections, all of which preserve the pelvic structures and therefore greatly reduce the need
for surgical repair of musculofascial pelvic defects.
In today's environment, the gynecologic surgeon, particularly the young gynecologic surgeon, may have less
personal experience with the many surgical procedures now available and the complications that can occur. This
requires advanced preoperative preparation by discussions with colleagues, residents, and fellows considering
the indications for surgery, choice of techniques, and potential problems, all supplemented by an authoritative
volume at hand. This, of course, is the Te Linde.
In the eleventh edition, there has been one entirely new chapter concerning robotic surgery, which is becoming
more and more frequently used. This chapter is by Jed Delmore and Kevin E. Miller.
But even though the titles of the other chapters remain largely unchanged, the freshness and contemporary
aspect of the book has been maintained by having 82% of the chapters written by new and authoritative
contemporary specialists.
Finally, the long experience in the operating room of John Rock and Howard Jones III ensures that the 50-odd
authors speak from practical experience. It is this personal, vast surgical experience which Richard Te Linde
expressed in the first edition and which has continued to the present day that makes Te Linde's Operative
Gynecology such a valuable text for every gynecologic surgeon.
Howard W. Jones Jr
Norfolk, Virginia
September 2014
Preface
Even as surgical techniques continue to evolve and new techniques are introduced, basic surgical principles
remain. With this new eleventh edition of Te Linde's Operative Gynecology, the reader will find an increased
emphasis on minimally invasive techniques of gynecologic surgery, but there remains a strong surgical
foundation based on the correct diagnosis of the clinical condition, a complete and careful preoperative
evaluation and counseling, a thorough understanding of the anatomy and physiology, and a thoughtful plan for
postoperative recovery with appropriate expectations. The authors are all skilled and experienced surgeons who
have had careers of surgical instruction, who not only guide the reader through the well-illustrated technique of
surgery but also discuss the foundations of surgery.
In this new edition, we have included a new chapter on robotic surgery, and the chapter on electrosurgical
techniques has been extensively updated to include vessel sealing instruments. The chapter on professional
liability has been completely redone with new authors and an emphasis on risk prevention. The eleventh edition
also boasts many new authors who have brought some fresh, new ideas and approaches to this classic text.
Thirty-five of the fifty-one chapters have new authors who have reorganized and updated much of the diagnostic
evaluation and management approaches to various gynecologic conditions. The editors have taken pains to
select the best surgeons and the best teachers so that the textbook continues to maintain Richard Te Linde's
comfortable reading style and the helpful, practical “surgical pearls,” which will improve the skills of both the
junior resident and the experienced gynecologic surgeon.
Definitions, summary, questions/answers, and best surgical practices continue to be an important component of
each chapter. In addition, where appropriate, contributing authors have added a “stepwise approach” to the
performance of a specific gynecologic operation.
Illustrations have always been an important aspect of Te Linde's Operative Gynecology, and the excellent line
drawing of Leon Schlossberg, P. L. Malone, John Deutch, and Jennifer Smith have contributed much to success
of previous editions. In the eleventh edition, 167 new surgical illustrations have been added to the text and both
old and new drawings have been colorized to add to the clarity and contrast of the illustrations and to provide a
brighter, more modern look to the book. The compact disc that accompanies the textbook features good teaching
examples of both a standard abdominal and vaginal hysterectomy—surgical techniques that are all too often
neglected in today's market-driven push to perform surgery using the robot or through a single laparoscopic
trocar.
All of the techniques discussed and illustrated in this text are based on the extensive experience of the authors
and editors, but it is important to appreciate that every patient and every situation is unique. Readers must
exercise good clinical judgment. The authors, editors, and publisher are not responsible for errors or omissions
or for any consequences from application or any other information in this book and make no warranty, expressed
or implied, with respect to the contents of this publication.
Such a text requires enormous contributions from many experts. The authors and editors sincerely thank all the
contributors. Special acknowledgment to the Lippincott Williams & Wilkins editorial team of Rebecca Gaertner,
Executive Editor; Jamie Elfrank, Senior Acquisitions Editor; and Tom Conville, Development Editor. We also
commend Rob Flewell, Certified Medical Illustrator, whose artistic skills significantly enhance this edition. A
special thanks to Maria Medranda, Sandra Allen, Laura Creel, Lynne Black, and Julie Smith for their editorial
assistance.
As always, we are deeply indebted to the many authors who labored so hard to incorporate their experience into
the previous editions of this text. This eleventh edition would not be possible without their contributions. We
cannot help but include a special work of thanks to Dr. Richard W. Te Linde who we were both fortunate to know
and to the previous editors, Drs. Richard F. Mattingly and John D. Thompson from whom we learned so much.
We sincerely hope that you and your patients will benefit from the combined experience and dedication of the
many contributors to this and the many previous editions of Te Linde's Operative Gynecology.
Howard W. Jones III, MD
John A. Rock, MD
Preface from First Edition
Gynecology has become a many-sided specialty. No longer is it simply a branch of general surgery. In order to
practice this specialty in its broad sense, the gynecologist must be trained in a comprehensive field. He must be
a surgeon, expert in his special field, he must be trained in the fundamentals of obstetrics, he must have the
technical skill to investigate female urologic conditions, he must have an understanding of endocrinology as it
applies to gynecology, he should be well grounded in gynecologic pathology, and finally, he must be able to
recognize and deal successfully with minor psychiatric problems that arise so commonly among gynecologic
patients. With this concept of the specialty in mind, this book has been written. It then becomes apparent, when
one seeks training in gynecology beyond the simplest fundamentals such as are taught to undergraduates, that
special works are necessary for training those who intend to practice it. The author is a firm believer in the
system of long hospital residencies for training young men in the various surgical specialties when their minds
are quick to grasp ideas and their fingers are nimble. This volume has been written particularly for this group of
men. Unfortunately, there is a paucity of good gynecologic residencies in the United States in the sense that the
author has in mind. Many positions bear the name of residency but fail to give the resident sufficient operative
work to justify the name. Another excellent method of development of the young gynecologist is an active
assistantship to a well-trained, mature gynecologist. If the assistant is permitted to stand at the operating table
opposite his chief day after day, eventually he will acquire skill and judgment which he himself will be able to
utilize as an operator. When such a preceptor system is practiced, it is important that the assistant be given
some surgery of his own to do while he is still young. If a man is forced to think of himself only as a perennial
assistant, this frame of mind will kill his ability to accept responsibility of his own. However, many must learn their
operative gynecology under less favorable circumstances than those of the fortunate resident or assistant. This
volume should be of value to those who, by self-instruction, must acquire a certain degree of operative skill.
Finally, it must be admitted that more gynecology is practiced today by general surgeons in this country than by
gynecologists. Although this is not ideal, circumstances make it necessary, and much of this gynecologic surgery
is well done. It is hoped that many general surgeons will use this volume as a reference book.
In connection with general surgery, it is only fair to say that much has come to gynecology by way of general
surgeons of the old school, who practiced general surgery in the broadest sense. Now that gynecology and/or
obstetrics has become a specialty unto itself, it is well in our training of men not to swing too far from general
abdominal surgery. In spite of the most careful preoperative investigation, mistakes in diagnosis will be made,
and at times, the gynecologist will be called upon to take care of general surgical conditions in the region of
lower abdomen and the rectum. With this in mind, the author has included in this volume a consideration of a few
of the commoner general surgical conditions occasionally encountered incidentally with gynecology or by
mistaken diagnosis.
Operative Gynecology is written with the primary purpose of describing the technique of the usual and some of
the rare operative procedures. It also includes indications for and against operations as well as pre- and
postoperative care of patients. Although gynecology is divided into several fields, these fields interlock so that it
has been found impossible to compose a volume on gynecologic surgery to the exclusion of the other divisions of
the specialty.
Gynecologic pathology, for instance, is the bedrock upon which good gynecologic surgery is practiced. Without
an understanding of it, surgery becomes merely a mechanical job, and errors in surgical judgment are inevitable.
Hence, it has become necessary to include in this volume a minimum of gross and microscopic pathology, as it
applies directly to the surgical subject under consideration. Also, some consideration is given to psychology and
psychiatry in relation to gynecologic surgery. The author believes that getting the young woman on whom a
hysterectomy must be done into the proper frame of mind to accept it is as important as possessing the technical
skill to perform the operation.
Richard W. Te Linde
Baltimore, Maryland, 1946
Editors
Howard W. Jones III MD
Professor of Obstetrics and Gynecology
Director of Gynecologic Oncology
Vanderbilt University School of Medicine
Nashville, Tennessee
John A. Rock MD
Senior Vice President, Health Affairs
Dean, Herbert Wertheim College of Medicine
Professor of Obstetrics and Gynecology
Department of Obstetrics and Gynecology
Florida International University
Miami, Florida
Contributors
Nadeem R. Abu-Rustum, MD
Professor
Department of Obstetrics and Gynecology
Weill Cornell Medical Center
Director, Minimally Invasive Surgery
Gynecology Service, Department of Surgery
Memorial Sloan-Kettering Cancer Center
New York, New York
Rony A. Adam, MD
Professor
Division of Female Pelvic Medicine and Reconstructive Surgery
Department of Obstetrics and Gynecology
Vanderbilt University Medical Center
Nashville, Tennessee
Marisa R. Adelman, MD
Assistant Professor
Department of Obstetrics and Gynecology
University of Utah
Salt Lake City, Utah
Kaled Alektiar, MD
Member, Attending Physician
Department of Radiation Oncology
Memorial Sloan-Kettering Cancer Center
New York, New York
Paul M. Allen, MD, MHA, MPH, FACOG
Consultant in Health Care Management, Accreditation, and Medicare ASC Certification for Ambulatory Surgery
Centers
Los Angeles, California
Ted L. Anderson, MD, PhD
Betty and Lonnie S. Burnett Professor
Vice Chair for Gynecology
Department of Obstetrics and Gynecology
Vanderbilt University Medical Center
Nashville, Tennessee
Alicia Armstrong, MD, MHSCR
Professor
Department of Obstetrics and Gynecology
Uniformed Services University of the Health Sciences
Bethesda, Maryland
Adjunct Professor
Department of Obstetrics and Gynecology
Howard University School of Medicine
Washington, District of Columbia
Chief, Gynecologic Services
National Institute of Child Health and Human Development
National Institute of Health
Bethesda, Maryland
Richard R. Barakat, MD
Professor
Department of Obstetrics and Gynecology
Weill Cornell Medical College
Chief, Gynecology Service
Department of Surgery
Ronald O. Perelman Chair in Gynecologic Surgery
Vice Chairman, Clinical Activities
Department of Surgery
Memorial Sloan-Kettering Cancer Center
New York, New York
Matthew D. Barber, MD, MHS
Professor
Department of Obstetrics and Gynecology
Cleveland Clinic Lerner College of Medicine
Vice Chair for Clinical Research
Department of Obstetrics, Gynecology, and Women's Health Institute
Cleveland Clinic
Cleveland, Ohio
Jack B. Basil, MD
Chairman
Department of Obstetrics and Gynecology
Good Samaritan Hospital
Cincinnati, Ohio
Kelly A. Bennett, MD
Associate Professor
Department of Obstetrics and Gynecology
Vanderbilt University Medical Center
Director, Junior League Fetal Center at Vanderbilt
Department of Obstetrics and Gynecology
Monroe Carell Junior Children's Hospital at Vanderbilt
Nashville, Tennessee
Eric J. Bieber, MD, MSHCM
President, Community Hospitals—West Region
President, University Hospitals Accountable Care Organization
Clinical Professor of Reproductive Biology
Case Western Reserve University School of Medicine
Shaker Heights, Ohio
Lesley L. Breech, MD
Associate Professor
Department of Pediatric and Adolescent Gynecology
Department of Obstetrics and Gynecology
University of Cincinnati
Division Director
Pediatric and Adolescent Gynecology Department
Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio
Diana Broomfield, MD, MBA, FACOG, FACS
Chief, Division of Reproductive Endocrinology and Infertility
Department of Obstetrics and Gynecology
Howard University
Washington, District of Columbia
Medical Director
Department of Reproductive Endocrinology and Infertility
Maryland IVF
Columbia, Maryland
Joseph Buscema, MD
Clinical Associate Professor
Department of Obstetrics and Gynecology
University of Arizona
Tucson, Arizona
James J. Burke, II MD
The Donald G. Gallup, MD, Scholar of Gynecologic Oncology
Associate Professor and Director, Gynecologic Oncology
ACI Surgical Associates
Mercer University School of Medicine
Savannah, Georgia
William J. Butler, MD
Professor and Chairman
Department of Obstetrics and Gynecology
Mercer University School of Medicine
Director
Central Georgia Fertility Institute
Medical Center of Central Georgia
Macon, Georgia
David Carnovale, MD
Associate Professor
Clerkship Director
Mercer University School of Medicine
Department of Obstetrics and Gynecology
Director of Assisted Reproductive Technologies
Central Florida Fertility Institute
The Medical Center of Central Georgia
Macon, Georgia
Dennis S. Chi, MD
Professor
Department of Obstetrics and Gynecology
Weill Cornell Medical Center
Deputy Chief
Gynecology Service
Department of Surgery
Memorial Sloan-Kettering Cancer Center
New York, New York
Chi Chiung Grace Chen, MD
Assistant Professor
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Mindy S. Christianson, MD
Assistant Professor
Division of Reproductive Endocrinology and Infertility
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
