GYN PEARLS OF EXXCELLENCE 2019
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Index
Severe Postpartum Endometritis
Ovarian Conservation at the Time of Hysterectomy
Endometrial Ablation
Laparoscopic Sterilization
Laparoscopic Port Site Hernias
Fluid Management at Hysteroscopy
Glycemic Control in Diabetic Patients Undergoing Gynecologic Surgery
Prevention of Complications in Women with Diabetes Undergoing Surgery
Surgery in Morbidly Obese Patients
Hysteroscopic Bowel Injury
The Management of Borderline Ovarian Tumors in Young Nulliparous Women
Perioperative Management of Women with Chronic Obstructive Airway Disease and Asthma
Surgical Management of Women with Hypertension
Management of Vaginal Cysts
Management of Large Rectoceles in Geriatric Patients
Evaluation of Stress Urinary Incontinence
Surgical Management of Stress Urinary Incontinence
Non-surgical Management of Stress Urinary Incontinence
Management of Postoperative Ileus
Perioperative Management of Anticoagulation in Gynecologic Patients
Complications of TVT and TOT
Evaluation of the Adnexal Mass in an Older Woman
Management of Women on Hormonal Therapy or Contraception in Women Undergoing Surgery
Evaluation of Dyspnea and Management of Pulmonary Embolism After Surgery
Management of Grade 1 Adenocarcinoma of the Endometrium
Management of Evisceration of the Vaginal Cuff
Perforation with Uterine Sound and Suction Cannula during a D&C
Diagnosis and Management of Cervical Ectopic Pregnancy
Proximal Tubal Occlusion
Management of Bilateral Tubo-ovarian Abscesses in Young Nulligravida
Management of a Lost Pedicle at the Time of a Vaginal Hysterectomy
Management of Lateral Uterine Perforation at the Time of Hysteroscopy
Management of Ureteral Injuries
Avoiding Trocar Injuries Associated with Laparoscopic Surgery
Surgical Management of Endometriosis
Desired Pregnancy after Essure Placement
Postoperative Urinary Fistulae
Complications of Gynecologic Laparoscopic Surgery
Adnexal Masses in Adolescents
1
Severe Postpartum Endometritis
Author: Taimur Chaudhry, MD
Mentor: Lisa Keder, MD
Editor: Peter Schnatz, MD
Patients with postpartum endometritis who have failed initial broad-spectrum antibiotic therapy
(including persistent temperatures over 38° Celsius after 48 hours) or who are critically ill, have
severe postpartum endometritis. In these cases, further work-up to confirm the diagnosis is
warranted while more intensive therapy is initiated.
General risk factors for infection include obesity, diabetes, smoking and immunosuppression.
Risk fac-tors specific to obstetrics are Group B Streptococcus carrier status, presence of sexually
transmitted infections, chorioamnionitis, prolonged rupture of membranes, multiple cervical
exams, operative vaginal delivery, and cesarean delivery. Retained products of conception or a
retained cerclage could also serve as a nidus for persistent infection. After vaginal delivery,
particularly an operative delivery, an infected vulvar hematoma should be considered. After
cesarean section, an infected hematoma, pelvic abscess, or injury to visceral structures such as
bowel or bladder is possible. These etiologies can be evaluated via CT scan of the abdomen and
pelvis. Patients should also be evaluated for other infectious or inflammatory etiologies,
including pyelonephritis, appendicitis, pancreatitis or cholecystitis. Atypical organisms such as
Mycoplasma, Ureaplasma, herpes simplex virus and Clostridium perfringens should be
considered in patients with severe or resistant endometritis. Also, if the clinical picture
improves, but fevers persist, septic pelvic thrombophlebitis should be considered. Consultation
with an infectious disease specialist may be valuable in refractory fever.
As the diagnosis is being re-evaluated, the patient should be continued on broad-spectrum
antibiotics with polymicrobial coverage. If sepsis is diagnosed, it should be managed according
to established rapid response protocols that include blood and urine cultures, lactate levels and
early fluid resuscitation. Escalation of care to an ICU may be indicated. Consideration should be
given to performing a postpartum D&C if products of conception are suspected or if the patient’s
condition is not improving. In rare cases, the uterine infection may not respond to medical
management and the patient is at increased risk for severe maternal morbidity or mortality due to
peritonitis, severe sepsis and septic shock. This is most often due to endomyometritis,
myonecrosis or secondary to an intra-abdominal abscess. If abscess is identified, drainage by
surgical exploration or interventional radiology may be appropriate. Lack of response may lead
to further surgical intervention including a laparotomy with “wash out” or occasionally a
hysterectomy.
An important organism to consider is Group A Streptococcus (GAS) or Streptococcus pyogenes.
This is a virulent organism that produces exotoxin and can result in rapid development of high
fever, invasive disease with tissue necrosis, and maternal death. GAS typically presents with
abdominal pain, fever, tachycardia and sometimes hypotension. The latter finding is consistent
with toxic shock syndrome, which carries significant mortality. GAS is also implicated in the
rare but life-threatening development of necrotizing fasciitis. This may result as a complication
of severe endometritis. A high index of suspicion, aggressive medical and surgical debridement,
and source control may avoid catastrophic out-comes.
2
Ovarian Conservation at the Time of Hysterectomy
Author: James Casey, MD
Mentor: Amanda Murchison, MD
Editor: Maureen Farrell, MD
With hysterectomy representing a common opportunity for removal of the ovaries, a general
approach to conservation or removal should focus on risk stratification. Placing aside known
pathology of the ovary at the time of hysterectomy, the removal of otherwise normal appearing
ovaries is a balance of acute surgical risks and long-term health implications with ovarian
removal versus retention. An individualized discussion with patients regarding the risks and
benefits of ovarian removal versus conservation should occur with patients prior to
hysterectomy.
The baseline lifetime risk for ovarian cancer is 1.4% in the general population. Elective bilateral
oophorectomy will significantly reduce, though not entirely eliminate, ovarian cancer risk.
Oophorectomy will also reduce the risk of breast cancer when performed in premenopausal
women. Patients with known hereditary genetic abnormalities such as BRCA 1/2 or Lynch
syndrome should consider ovarian removal as dictated by current guidelines, taking care to
include further dissection of the ovarian vessels or consult additional expertise with a
gynecologic oncologist. Women with a strong family history of gynecologic, colon, and/or breast
cancers should be screened to see if they qualify for genetic testing. If an obstetrician–
gynecologist does not have the necessary knowledge or expertise to counsel a patient
appropriately, referral to a genetic counselor should be considered. Protective effects to reduce
ovarian cancer risk include oral contraceptive use, breastfeeding, and previous tubal ligation or
salpingectomy. It is unclear if removal of a single ovary changes overall ovarian cancer risk and
is not routinely performed for this indication. When ovaries are retained, re-operation in the
future for ovarian malignancy is rare, and ovarian operation for any indication in the future
appears to be less than 10%.
Elective ovarian removal at hysterectomy also involves short and long-term risks. An ovarian
remnant will occur following 3-4% of cases. Unlike salpingectomy alone, ovarian removal does
generally confer a small added operative complication risk. Additional surgical time in the
operating room with oophorectomy is largely dependent on existing pathology and highly
variable. In women less than age 50, elective ovarian removal is associated with increased rates
of all-cause mortality, and there are theoretical risks for increased mortality with removal
through age 65. This mortality risk appears to be largely mitigated with estrogen therapy through the average
age of menopause. Additional risks associated with bilateral oophorectomy include
increased rates of cardiovascular disease, osteoporosis, glaucoma, acute vasomotor symptoms,
and sexual dysfunction with higher rates associated with earlier age of removal. While risks and
benefits must be weighed for each individual case, current trends lean towards ovarian
conservation in the setting of otherwise normal appearing ovaries at the time of hysterectomy
through age 65.
3
Endometrial Ablation
Author: Sara Whetstone, MD, MHS
Mentor: Meg Autry, MD
Editor: Daniel Breitkopf, MD
Endometrial ablation can be performed by several different minimally invasive procedures which
cause surgical destruction of the endometrium to treat abnormal uterine bleeding (AUB). The
techniques for endometrial ablation are grouped into 2 major categories: resectoscopic and
nonresectoscopic. Resectoscopic endometrial ablation, often referred to as first generation, relies on
direct hysteroscopic visualization of the endometrial cavity. Non-resectoscopic techniques,
known as second generation, use various energy sources including bipolar radiofrequency and
heated water to accomplish global endometrial destruction. Both types of procedures appear
equivalent in reduction of menstrual bleeding and patient satisfaction. Approximately 30-40% of
women report amenorrhea at 1 year and and 50% at 2-5 years following ablation. Patient
satisfaction with the procedure is quite high, ranging from 80-90%.
Endometrial ablation is primarily intended to treat premenopausal women with heavy menstrual
bleeding (HMB) who do not desire future fertility. Women who choose endometrial ablation
often have failed or declined medical management. Absolute contraindications to endometrial
ablation include pregnancy, known or suspected endometrial hyperplasia or cancer, desire for
future fertility, active pelvic infection, IUD currently in situ, and being post-menopausal. In
general, endometrial ablation should be avoided in patients with congenital uterine anomalies,
severe myometrial thinning, and uterine cavity lengths that exceed the capacity of the ablative
technique (usually greater than 10-12 cm). Progestin therapy or correction of anovulation is
recommended instead of endometrial ablation for women with chronic anovulation because of
concerns about hyperplasia.
Women who desire endometrial ablation should be made aware of all medical and surgical
options to treat AUB. Women should be informed that amenorrhea is not guaranteed with
endometrial ablation and that reduction or normalization of menstrual flow is more likely.
Endometrial ablation is an effective alternative to hysterectomy for AUB. Risks of the
procedure in general and related to the specific ablative technique should be reviewed preoperatively, including
failure and post-ablation pain. Approximately 25% of patients who have
had an endometrial ablation undergo a hysterectomy within 5 years of their ablation for treatment
of persistent AUB or pain. Predictors of treatment failure include age < 45, parity > 5, pre-operative
dysmenorrhea, and a history of tubal ligation. Women who have had a tubal ligation
are at risk of post-ablation tubal sterilization syndrome, a condition characterized by cyclic
pelvic pain due to residual active endometrium near the cornua leading to obstructed
hematometra.
The pre-operative evaluation requires assessment of the structure and histology of the
endometrium. Women should have endometrial sampling prior to ablation. The uterine cavity
should be evaluated for length and presence of structural anomalies and intracavitary lesions,
which can be done with uterine sounding, ultrasound, saline infusion sonogram, or hysteroscopy.
Women who elect to proceed with endometrial ablation must be counseled about the need for
contraception as ablation does not reliably prevent pregnancy. Pregnancies following ablation
have been associated with adverse outcomes including fetal malpresentation, preterm delivery,
growth restriction, abnormal placentation, and perinatal mortality.
4
Laparoscopic Sterilization
Author: Tera Howard, MD, MPH
Mentor: Todd Jenkins, MD
Editor: Abimbola Famuyide, MBBS
Female permanent sterilization is the most common form of contraception in the United States
and is used by nearly half of all married couples. Laparoscopic sterilization is performed under
general anesthesia as an outpatient procedure. It allows for inspection of the abdomen and pelvis
and can be useful in patients presenting with concurrent pelvic pain. It is immediately effective
and patients can return quickly to normal activity.
Before undergoing laparoscopic sterilization, the patient should be counseled about its permanent
nature and the risk of regret, in particular when performed on patients under 30 years of age.
Surgical complications occur in 0.9-1.6 per 100 cases and include bowel or bladder injury from
electrocautery, unintended conversion to laparotomy, and blood transfusion. Deaths from
laparoscopic sterilization are rare and are most frequently related to risks of general anesthesia
from hypoventilation or cardiopulmonary arrest. Although 5-year cumulative failure rate from
laparoscopic sterilization is less than 1%, one third of post procedure pregnancies are ectopic in
location. Long term, patients may experience changes in menstrual pattern attributable to
advancing age and or discontinuation of hormonal contraception. Tubal ligation does not change
menstrual pattern.
Alternatives to laparoscopic sterilization include all forms of contraception, especially male
sterilization and long acting reversible contraception (LARC) methods. Vasectomy is safer, more
effective, and less expensive than female sterilization. LARC methods are at least as effective as
female permanent sterilization and in some cases more effective. An adequately counseled
patient should never be denied a sterilization procedure solely based on age or parity. Once fully
counseled, patients can be offered laparoscopic sterilization separate from a pregnancy (interval
sterilization) or concomitantly with a first trimester or a second trimester abortion. For interval
sterilization, it is important that the patient is on a reliable form of contraception leading up to
the procedure or that the procedure is performed during the follicular phase of the menstrual
cycle. Otherwise, the patient may have a luteal phase pregnancy.
Laparoscopic sterilization can be achieved by complete occlusion of a segment of the fallopian
tube using mechanical devices such as the spring clip, silicone band, silicone lined titanium clips,
bipolar electrocoagulation, or by partial or complete tubal excision. Mechanical methods should
be performed on normal fallopian tubes. For silicone band application, the tubes have to be long
enough to be drawn into the applicator device. Bipolar electrocautery is preferred to monopolar
energy because of lower risk of thermal bowel injury. A 3 cm section of the isthmic portion
must be completely coagulated for optimal efficacy. Partial or complete salpingectomies are
suitable for patients with peritubal or tubal pathology. Observational studies suggest ovarian
cancer risk reduction following partial or total salpingectomy in both women with average
cancer risks and in those with BRCA 1 and BRCA 2 mutations. Salpingectomy also reduces the
risk of pelvic inflammatory disease. Concerns regarding loss of ovarian function following
salpingectomy are unsubstantiated.
5
Laparoscopic Port Site Hernias
Author: Nicole Scott, MD, FACOG
Elizabeth Ferries-Rowe, MD, FACOG
Trocar site hernias occur in approximately 1% of laparoscopies. While rare, trocar site hernias
are preventable. Risk factors for trocar site hernia include increasing age and BMI. Higher
rates are observed with pyramidal trocars when compared to conical or blunt. Open entry
(Hasson) technique is also associated with increased risk. Umbilical and midline trocar incisions
have higher rates compared to lateral placement. The strongest risk factor for development is use
of port sites measuring > 10 mm.
Prevention of trocar site hernias is primarily through the use of smaller trocars and fascial
closure of larger trocar incisions. Several techniques have been described for fascial closure of
trocar sites. Direct closure with a delayed absorbable suture is possible in thinner patients. The
fascia must be included in closure. A 5/8” circle needle can be used when visualization of the
fascia is difficult. A commercial fascial closure device may be used when visualization is
especially difficult.
Trocar site hernias are categorized as early- and late-onset. Early-onset hernias typically present
within 2 to 12 days of the surgery, usually with a painful bulge at the trocar. Early onset hernias
do not contain peritoneum. Early onset hernias typically contain small bowel and cause
obstruction, although in some instances only the anti-mesenteric border of the bowel wall
protrudes (Richter’s hernia) and may become ischemic in the absence of obstruction. Bowel
obstruction or Richter’s hernia with acute pain suggestive of ischemia are surgical emergencies
and should be immediately repaired. Computed tomography may be helpful in confirming the
presence of small intestine, but is not necessary for diagnosis if clinical signs, symptoms, and
history suggest a hernia. If diagnosed early, reduction of the hernia contents and appropriate
fascial closure is sufficient. However, if the bowel has been incarcerated for a long period of
time, a bowel resection may be necessary. General surgery consultation is warranted if there is
concern for bowel strangulation. Late-onset hernias are typically diagnosed between 13-30 days
after the initial surgery. They typically contain only peritoneum and present as a painless bulge
at the prior trocar site. Repair is indicated if the bulge causes discomfort or interferes with daily
activities.
6
Fluid Management at Hysteroscopy
Author: Michelle Meglin, MD
Mentor: Ashlyn Savage, MD
Editor: Abimbola Famuyide, MD
During hysteroscopy, systemic absorption of uterine distension fluid occurs largely through
disrupted endometrial and myometrial venous sinuses as a result of the pressure gradient
between the uterine cavity and open sinuses or vessels. Higher intrauterine pressure, longer
procedure duration, deep myometrial penetration, and large uteri are associated with increased
fluid absorption. The lowest intrauterine pressure that provides adequate visualization should be
used, and when possible that pressure should be below the mean arterial pressure.
Distension media are categorized by viscosity, tonicity, and electrolyte status. Normal saline is a
low viscosity, isotonic solution, with electrolytes, and is best suited for use with bipolar
electrocautery or mechanical instruments. It cannot be used with monopolar electrocautery due
to current dispersion by activated ions in the media. Monopolar electrocautery requires use of
electrolyte-free fluids including hypotonic (1.5% glycine and 3% sorbitol) and isotonic solutions
(5% mannitol).
Excessive absorption of hypotonic electrolyte free fluids, such as 1.5% glycine and 3% sorbitol,
can cause hypo-osmolality, hyponatremia, cerebral edema, hypotonic encephalopathy, permanent
neurologic injury, heart failure, pulmonary edema, and death. While 5% mannitol is less likely to
cause hypo-osmolality, it can lead to hyponatremia. Premenopausal women are more likely to
have permanent brain damage or die from hyponatremic encephalopathy than post-menopausal
women. Excessive absorption of normal saline is not associated with hyponatremia; however, it
can cause volume overload, right-sided heart failure, pulmonary edema, and death.
Fluid deficit can be estimated by manual calculation or by use of an automated fluid
management system. With manual calculation, the volume of fluid collected in the perineal bag
is subtracted from the known quantity infused every 15 minutes during the procedure. There are
limitations with manual calculation, so automated fluid management systems that use calibrated
electronic weighing scales are preferred.
When using hypotonic solutions, the maximum allowed fluid deficit is 1000mL for healthy
patients and 750mL for elderly patients or those with medical comorbidities. For normal saline,
the maximum allowed fluid deficit is 2,500mL for healthy patients and 750mL for those with
cardiovascular disease. The procedure should be terminated when approaching the allowable
fluid deficit. In the event of a rapid increase in fluid deficit, the occurrence of a uterine
perforation should be considered.
Fluid absorption can be reduced by pre-operative treatment with GnRH agonists and
intraoperative injection of dilute vasopressin (0.05 U/mL). If excessive absorption of fluid occurs
with a hypotonic fluid, serum electrolytes should be obtained and the patient should be evaluated
for volume overload. Asymptomatic hyponatremia can be treated with fluid restriction and
careful monitoring of urine output. Treatment of symptomatic hyponatremia requires infusion of
3% sodium chloride (0.5-2mL/kg/hr) and management by a multidisciplinary team including a
specialist in intensive care. Fluid overload from normal saline can be managed by fluid
restriction; IV furosemide (20-40mg) is indicated if there is clinical or radiological evidence of
pulmonary edema.
7
Glycemic Control in Diabetic Patients Undergoing Gynecologic Surgery
Author: Joseph Peterson, MD
Mentor: Julie DeCesare, MD
Editor: Christine Isaacs, MD & Elizabeth Ferris-Rowe, MD
Patients with diabetes undergoing surgery are at increased risk of morbidity and mortality from
their hypermetabolic stress response, preoperative catabolic state, altered nutritional status,
changes in circulation, immobility, and glucose and electrolyte derangements.
As morbidity increases dramatically when preoperative blood glucose levels are elevated, all
patients with diabetes should have an HgbA1C checked within three months of their intended
procedure. Prior to surgery, care should be coordinated with the patient’s primary care provider
or endocrinologist and an anesthesia consultation obtained to optimize glycemic control and
other medical comorbidities. When possible, the patient’s diet and medications should be
adjusted so they maintain a predominantly euglycemic state in the weeks before surgery. Fasting
and postprandial blood glucoses should be checked as necessary to achieve euglycemia.
The goal for the day of surgery is to avoid both hypoglycemia and excessive hyperglycemia.
Patients with Type 1 diabetes may enter a ketoacidotic state even at low levels of hyperglycemia.
Cancellation of surgery should be considered in non-emergent cases where blood glucoses are
400-500 mg/dL.
No standardized, evidence-based algorithm for diabetes management exists for gynecologic
surgery. Due to the risk of metabolic acidosis, metformin and other oral hypoglycemic agents
should be withheld the day of surgery. On the morning of surgery, the patient should receive
50% of their usual NPH dose or 60-80% of their usual long-acting insulin analog (e.g. glargine
or detemir) or pump basal insulin dose.
Surgery induces a stress response with catecholamine and cortisol release, which reduces
sensitivity to insulin. This induced catabolic state can lead to keto- and gluconeogenesis as well
as the breakdown of glucagon, proteins, and fats, leading to hyperglycemia and ketosis. To
manage this during surgery, the patient should be placed on a variable rate intravenous infusion
of insulin or a sliding scale protocol if they will miss more than one meal. Medium and short
acting insulins can be used for minor procedures. Insulin infusion is preferred for longer, more
complex procedures. Type 1 diabetic patients should be maintained with a basal rate. Active
evaluation and management of blood glucose intraoperatively is important to counteract the
physiologic changes inherent to the use of anesthetics, sedatives, and analgesics.
In the perioperative period, the target glucose range should be 80-180 mg/dl, as this has been
associated with lower rates of mortality. Tighter glycemic control does not appear to improve
outcomes and risks hypoglycemia. Blood glucose monitoring should occur at least every 4-6
hours while patients remain NPO with additional short-acting insulin administered as needed.
Some medications commonly used in the peri-operative period can influence glycemic control.
Etomidate, benzodiazepines, and opiates typically decrease the hyperglycemic response while
most volatile anesthetic agents increase it. Regional anesthesia use is preferred because it has
less impact on glucose and insulin metabolism.
If available, a diabetes specialist team should be utilized for care in the post-operative period.
The patient’s usual diabetes management should be resumed as soon as feasible, generally once
she is eating well. Diet should be advanced the same was as in nondiabetic patients.
8
Prevention of Complications in Women with Diabetes Undergoing Surgery
Author: Tara E Kelly, MD
Mentor: Julie DeCesare, MD
Editor: Regan Theiler, MD
Diabetes mellitus (DM) is a common and increasingly prevalent chronic medical condition with
an incidence of one in 11 persons worldwide. Approximately half of these cases are
undiagnosed.
Routine screening for diabetes is not recommended at time of preoperative evaluation. However,
it is appropriate to test women who meet American Diabetes Association (ADA) or U.S.
Preventive Services Task Force (USPSTF) screening criteria and who have not been recently
tested. If DM is diagnosed preoperatively, the patient should be evaluated for the presence of
diabetes-related complications.
In diabetic patients, surgical stress leads to worsening insulin resistance, decreased peripheral
glucose utilization, impaired insulin secretion, and increased protein catabolism causing
hyperglycemia and possible ketosis in Type 1 diabetics. General anesthesia is associated with a
larger stress response compared with regional anesthesia. The extent of this response is also
dependent on the complexity and duration of the surgery as well as postoperative factors. A
preoperative risk assessment should be performed for patients at high risk for ischemic heart
disease and with autonomic neuropathy or renal failure.
Glycemic control is critical, and is covered in a separate Pearl (see Glycemic Control in Women
with Diabetes Undergoing Surgery).
Multiple strategies exist to prevent cardiovascular complications in a patient with diabetes.
Patients with indications for chronic use of beta-blockers (hypertension, atrial fibrillation,
angina, heart failure, or a history of myocardial infarction) should be continued on them
preoperatively. Diabetic patients with chronic hypertension should have their blood pressure
optimized. Since diabetes confers an increased risk of cardiovascular events, lipid-lowering
therapy should be considered preoperatively.
Patients with diabetic gastroparesis should receive a prokinetic agent prior to the administration
of general anesthesia to decrease aspiration risk. Attempts should be made to minimize opioid
use to prevent additional decreased motility.
It is important to avoid hypotension in patients with diabetic kidney disease (formerly referred to
as nephropathy). Surgery results in large fluid shifts, which can lead to ischemic renal injury, and which is more
likely in the setting of pre-existing diabetic kidney disease. Non-steroidal antiinflammatory drugs (NSAIDS)
should be used cautiously.
Patients with diabetic autonomic neuropathy are at increased risk of peripheral neuropathy.
Surgical positioning and cushioning should be optimized.
Postoperatively, diabetic patients have an increased risk of infections and wound complications.
Prevention strategies include attention to aseptic technique and adherence to proper antibiotic
prophylaxis with appropriate dose adjustment for weight. Because patients with diabetes are at
risk for poor wound healing, surgeons should optimize intraoperative temperature control with
the use of blankets or forced-air warming systems. Hypothermia can lead to peripheral insulin
resistance, hyperglycemia, decreased wound healing, and infection.
9
Surgery in Morbidly Obese Patients
Author: Bani M. Ratan, MD
Mentor: Sireesha Reddy, MD
Editor: Peter Schnatz, MD
Preoperative preparation for obese patients requires attention to health conditions more common
with obesity, including coronary artery disease (CAD), hypertension, diabetes mellitus, and
obstructive sleep apnea (OSA). Anesthesia consultation is appropriate when these conditions are
suspected. A physical exam revealing a short, thick neck with limited range of motion can be
indicative of a difficult intubation. Women with risk factors for CAD (hypertension, diabetes,
smoking, family history of CAD) should have a 12-lead electrocardiogram performed. Pre- and
post-operative glycemic control improves outcomes in patients, especially those with diabetes.
Women with OSA are at increased risk for perioperative complications, such as oxygen
desaturation, acute respiratory failure, post-operative cardiac events, and intensive care unit
admission. As in normal weight women, surgery should be performed utilizing the least invasive
approach.
Perioperative management focuses on minimizing complications such as thromboembolism and
infection. Obesity is an independent risk factor for venous thromboembolism (VTE). Sequential
compression devices (SCDs), low molecular weight (LMW) heparin, and low-dose
unfractionated heparin (UFH) are options for VTE prevention. The preferred method of
prophylaxis is based on stratification by procedure type and duration, age, and presence of other
VTE risk factors. Mechanical prophylaxis (SCDs) or pharmacologic methods alone are
appropriate in obese patients that are moderate risk, while a combination should be used in
patients at high risk. LMW heparin is preferred; however UFH is a suitable alternative in
patients who have a contraindication to LMW heparin or where cost is a concern. Due to
decreased tissue antibiotic concentrations, two grams of prophylactic cefazolin is recommended
in patients over 80 kg, with an increase to 3 grams in patients over 120 kg.
Obese patients are at increased risk for soft-tissue pressure injuries and nerve injuries. For
laparoscopy, safe patient positioning includes careful padding, arms tucking with extenders if
needed, and using anti-skid material on the bed. Steep Trendelenburg must be used with caution
as the increased weight of the abdominal contents can inhibit adequate ventilation. Long trocars
and specialized instruments are often needed to navigate the increased abdominal wall depth.
Caudal migration of the umbilicus necessitates consideration of alternate entry points for
laparoscopic procedures such as the left upper quadrant. The use of self-retaining and other
specialized retractors can aid in exposure during vaginal and abdominal surgery. The panniculus
can distort abdominal skin tissue at laparotomy. Incisions should be avoided within the
overlapping fold of the panniculus because of increased infection and poor wound healing.
Wound healing adjuncts (vacuum-assisted closure) can also be used. It is also imperative that
you have an operating bed that can support your patient’s weight.
Post-operatively, risk-reducing strategies include early ambulation, incentive spirometry, and
consideration of extended VTE prophylaxis. Treatment with low molecular weight heparin for
two to four weeks post-operatively is recommended for cancer patients and those with comorbid
conditions such as immobility, history of VTE, inherited or acquired thrombophilia, or age > 60
years. Patients with OSA should not be discharged until baseline oxygen saturation is achieved
on room air.
10
Hysteroscopic Bowel Injury
Author: Makeba Williams, MD, FACOG, NCMP
Mentor: Lisa Keder, MD, MPH
Editor: Dan Breitkopf, MD
Although hysteroscopic complications are rare, uterine perforation can cause serious injury to
adjacent structures. Compared to diagnostic procedures, operative hysteroscopy elevates the risk
of uterine corpus perforation 16-fold, and increases the risk of electrical, mechanical, or thermal
injury to the bowel or viscera. Hysteroscopic morcellators used for myoma resection can breach
the myometrium and injure the bowel. Monopolar or bipolar resectoscopes may result in thermal
injury if an activated electrode perforates the myometrium. Early recognition of injuries would
help to prevent severe morbidity or mortality.
Visualizing bowel or suspected bowel contents through the hysteroscope raises the concern for
bowel injury. The procedure should be aborted and the operative instruments withdrawn using
hysteroscopic guidance. If only blunt instruments, such as cervical dilators, have been used prior
to recognition of a fundal perforation, and only minimal bleeding is seen by hysteroscopy,
observation is typically appropriate. Perforations occurring elsewhere and those caused by
sharp, electrosurgical or suction instruments require urgent surgical evaluation. Laparoscopy,
with the hysteroscope left in the uterus, aids in identifying the perforation site. The surrounding
bowel and viscera should be methodically evaluated for injury. Laparotomy may be required to
evaluate for thermal damage since this type of injury may be difficult to see on simple visual
inspection. If an injury is detected, depending on their skill and comfort level with bowel
surgery, the gynecologist should consider general surgery consultation. If no bowel damage is
visualized or expectant management is selected due to low likelihood of injury, patients should
be advised of symptoms of peritonitis such as nausea, vomiting, fever, or pain, may not occur
immediately and can develop up to 2 weeks later. Patients should be given strict precautions for
follow-up since delays in diagnosis can lead to serious morbidity and mortality.
To reduce the risk of perforation and subsequent bowel injury, the surgeon should:
• Visualize active electrodes and oscillating blades at all times
• Refrain from advancing active surgical instruments while operating in the endometrial
or myometrial spaces
• Avoid resecting into the myometrium
Ultrasound guidance may be helpful in difficult cases to both guide dilation of a stenotic cervix
and monitor the position of the instruments used in the operation. Alternatively, concomitant
laparoscopy provides direct visualization of nearby viscera, and displaces bowel. Laparoscopy
may be considered in patients who have had prior uterine surgeries, have extensive adhesive
disease, or who will need deep myometrial resection.
11
The Management of Borderline Ovarian Tumors in Young Nulliparous Women
Author: Erica L. Berry D.O., FACOG
Mentor: Maureen E. Farrell M.D., FACOG
Editor: Abimbola O. Famuyide MBBS, FRCOG, FACOG
Borderline ovarian tumors, previously known as low-malignant potential (LMP) tumors, make
up nearly 20% of ovarian epithelial cancers and have an excellent prognosis regardless of stage
at diagnosis. Borderline ovarian tumors are typically diagnosed in women during their 40’s,
significantly earlier than invasive carcinomas. These tumors have not been shown to have
hereditary component.
Borderline tumors often share ultrasound findings with malignant tumors including papillary
projections, thickened septations, and multicystic components. However, a significant percentage
of borderline tumors present as unilocular cysts on ultrasound, and close to 80% of borderline
tumors are initially managed by gynecologic specialists.
Surgery is the recommended management for borderline ovarian tumors. The choice between a
laparoscopic or open approach is based on the size of the mass, as well as prior surgical history
and skill level of the primary surgeon. A laparoscopic approach is reasonable and preferred in
most patients. If an open approach is chosen, then a midline vertical incision is necessary if
surgical staging in the upper abdomen becomes necessary.
Most gynecologic surgeons diagnose a borderline ovarian tumor either with intraoperative frozen
section or on final operative pathology. Intraoperatively, peritoneal washings should be
performed prior to pelvic mass excision, and the mass should be excised intact without spillage
into the peritoneal cavity. Premenopausal patients who have not completed childbearing may
undergo unilateral adnexectomy or cystectomy with preservation of the uterus and the
contralateral ovary. Of note, agreement between frozen and final pathology has been reported to
be a low as 55%, so the need to make management decisions after incomplete staging is
relatively common.
Intraoperative or post-operative consultation should be obtained from a gynecologic oncologist
to determine the need for additional surgery. Intraoperatively, the pelvis and abdominal viscera
need to be carefully inspected to exclude any visible invasive disease and suspicious areas must
be biopsied. Although the weight of evidence does not support routine surgical staging of
borderline tumors, the National Comprehensive Cancer Network (NCCN) provides detailed
algorithms for limited versus comprehensive surgical staging and post-surgical care of borderline
ovarian tumor patients. Borderline ovarian tumor staging procedures typically include
hysterectomy, bilateral salpingo-oophorectomy, pelvic washings, omentectomy, diaphragm
stripping, and removal of any visible disease. Lymph node sampling is not typically performed in
the staging of borderline tumors, but can be considered in select cases. In the event that only a
cystectomy is performed and final pathology results are consistent with borderline tumor, a
gynecologic oncologist can counsel the patient regarding possible reoperation to remove the
affected adnexa with possible surgical staging vs. surveillance.
Fertility-sparing surgical management of borderline ovarian tumors in young nulliparous women
is preferred, and should be planned unless the patient decides otherwise. Relapse rates of up to
15% have been noted with unilateral oophorectomy and up to 30% with unilateral cystectomy,
but relapse is typically borderline rather than malignant and is highly curable with reoperation.
Cystectomy preserves the maximum amount of ovarian stroma, the benefits of which must be
weighed against the morbidity of additional treatment of recurrence.
12
Perioperative Management of Women with Chronic Obstructive Airway Disease and Asthma
Author: Roopina Sangha, M.D., MPH
Editor: Timothy Klatt, M.D.
The overall incidence of postoperative pulmonary complications is 5-10%, but patients with
poorly controlled chronic obstructive airway disease (COPD) and asthma are at increased risk
with up to 40% risk for pneumonia and 70% for atelectasis. Patient related risks include poorly
controlled COPD or asthma, age greater than 65, functional dependence, American Society of
Anesthesiologists class 2 or higher, pulmonary hypertension, obesity, smoking, steroid use,
congestive heart failure, obstructive sleep apnea (OSA), excessive alcohol intake, serum albumin
< 3g/dl, and current upper respiratory tract infection. Procedure related risk factors include
abdominal (especially upper abdominal) surgery, emergency or prolonged surgery (>3-4 hours),
use of general anesthesia, and use of long acting neuromuscular blockade.
There is insufficient evidence to support routine use of preoperative pulmonary function tests,
arterial blood gases, or chest radiographs in well controlled COPD/asthma patients. However,
those with worsening pulmonary symptoms or multiple risk factors may benefit from preoperative
testing and should be referred to a pulmonary specialist.
Risk reducing strategies for patients with multiple risk factors should be initiated in the perioperative
period. Multiple strategies should be employed in high risk patients including smoking
cessation beginning at least 8 weeks before the procedure, delaying elective surgery for 2 to 3
weeks in those with recent or ongoing respiratory infections, and completing treatment with
appropriate antibiotics. Underlying COPD or asthma should be optimized, which may require
intensifying therapy with inhaled bronchodilators and steroids. Patients should be free of
wheezing, bronchitis flares, and bronchiectasis at the time of surgery. Use of systemic
glucocorticoids is recommended if peak expiratory flow (PEF) is <80% of predicted or the
patient’s personal best.
Intra-operative management of patients with COPD or asthma involves use of rapid acting beta
agonists at time of intubation to prevent bronchospasm (2-4 puffs inhaled or nebulized 30
minutes prior) and administration of stress dose steroids for women who have taken at least
prednisone 20mg/day or its equivalent for at least 3 weeks within the 6 months prior to surgery.
Obese patients and those with OSA using continuous positive airway pressure (CPAP) machines
may not tolerate laparoscopy due to effects of pneumoperitoneum and Trendelenburg position,
and should be counseled about potential for conversion to open surgery. Use of epidural or spinal
anesthesia when feasible may confer lower risk. Routine use of nasogastric tubes should be
avoided.
Effective risk reducing strategies in the post- operative period include early ambulation, optimal
pain control, lung expansion via deep breathing exercises and incentive spirometry, and CPAP.
CPAP therapy is particularly advantageous in patients with OSA and those who are unable to
perform effort dependent lung expansion maneuvers.
13
Surgical Management of Women with Hypertension
Author: Mostafa Borahay, MBBS
Mentor: Daniel M. Breitkopf, MD
Editor: Abimbola O. Famuyide, MD
Approximately 1 in 3 adults in the United States have a diagnosis of systemic hypertension, and
almost half of them have uncontrolled blood pressure. Hypertension is a risk factor for
perioperative cardiovascular events including myocardial ischemia, infarction, and heart failure.
Patients with uncontrolled hypertension are at risk for intraoperative exaggerated hemodynamic
lability, in addition to exacerbation of pre-existing end organ damage. Induction of anesthesia
triggers sympathetic activation that may raise systemic blood pressure (BP) by 20 to 30 mm Hg
in normotensive patients, and up to 90 mm Hg in untreated patients. Prolonged anesthesia can
lower BP due to direct inhibition by anesthetics and inhibition of sympathetic tone. Generally,
hypertension is considered a minor risk factor and should not trigger postponement of surgery.
Factors that may indicate the need to postpone surgery include systolic BP >180 mmHg,
diastolic BP >110 mmHg, and non-treated underlying or associated comorbidities.
Preoperative optimization includes evaluation and control of blood pressure. Evaluation should
include determination of severity of hypertension, functional status, and assessment of other risk
factors, such as diabetes, smoking, coronary artery disease, and target organ damage (e.g. left
ventricular and renal dysfunction). Functional status is an important predictor of perioperative
outcome and can guide further workup. It is often appropriate to proceed with surgery in highly
functional asymptomatic patients without further cardiovascular testing. Cardiac studies such as
pharmacologic stress testing can benefit patients with unknown or poor functional capacity. Poor
functional capacity is defined as <4 metabolic equivalents (METs), consistent with inability to
climb a flight of stairs.
In most situations, chronic oral antihypertensive therapy should be continued and taken on the
morning of surgery with a sip of water. Abrupt cessation of beta blockers and clonidine can lead
to rebound hypertension. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II
receptor blockers (ARBs) can blunt renin activation and cause intraoperative hypotension. These
agents should be omitted on the morning of surgery and restarted postoperatively as soon as
feasible. Particular attention should be paid to hypokalemia in patients using diuretics.
Traditionally, beta blockers were started preoperatively for cardioprotection; however, care
should be exercised as some trials showed increased risk of hypotension, bradycardia, and stroke.
Patients on long-term beta blockers are usually advised to continue them.
Intraoperatively, close cardiovascular monitoring is recommended, occasionally including the
use of invasive techniques such as arterial lines. Excessive shifts in intravascular volume should
be avoided by paying close attention to blood loss and fluid administration.
Postoperatively, hypertensive patients are prone to exaggerated hypertensive responses to stimuli
such as pain and bladder distention. Continuation of antihypertensives, appropriate pain
management, and close monitoring are important. Parenteral antihypertensives may be needed,
particularly in hypertensive emergencies.
14
Management of Vaginal Cysts
Author: Sarah Shaffer, DO
Mentor: Thomas Gellhaus, MD
Editor: Eduardo Lara-Torre, MD
Vaginal cysts occur in 1% of all women. Most are benign, asymptomatic, discovered
incidentally, and should be managed expectantly. Common benign causes of vaginal cysts
include embryonic remnants of the Mullerian (paramesonephric) or Wolffian (mesonephric)
system; the latter are also called Gartner’s duct cysts. Differentiation between them has little
prognostic significance and they are managed similarly. Anatomic abnormalities mimicking
vaginal cysts include pelvic organ prolapse (e.g. cystocele) as well as bladder and urethral
anomalies.
Vaginal inclusion cysts and foreign body granulomas are often related to prior repair of
obstetrical lacerations or other vaginal surgery and have a different appearance than embryologic
remnants. Urethral diverticula may initially present as a vaginal mass as can rarer findings such
as a vaginal endometrioma, fibroma, or myoma. Malignancy in a vaginal cyst is rare;
adenocarcinoma is reported to occur in 6-9% of urethral diverticula.
The appearance and location on physical exam assists in determining the etiology of the vaginal
cyst. Embryologic remnants are usually small (<2cm) but stable in size and soft with definite
borders. They can occur anywhere in the vaginal mucosa with Gartner’s duct cysts commonly
located along the lateral vaginal walls. Urethral diverticula are identified in the midline of the
anterior vaginal wall. Inclusion cysts, granulomas, and the other rare causes noted are solid with
definite borders and can occur anywhere in the vagina. Laboratory studies are rarely helpful, and
in general, should not be part of the evaluation. When imaging is required (e.g. to aid in surgical
planning) pelvic or perineal ultrasound remains the first choice. If ultrasound is inadequate, an
MRI is indicated.
Most vaginal cysts, including embryologic remnants, inclusion cysts, and granulomas, can be
managed expectantly. If found incidentally and the patient is asymptomatic, serial physical
exams to evaluate for stability are appropriate. The patient should have no signs or symptoms of
infection or malignancy. Expectant management is also appropriate for vaginal fibromas and
myomas.
If a vaginal cyst is acutely changing, is symptomatic, or concerning for an infectious or
malignant source, surgical intervention should be considered. A urethral diverticulum can be
expectantly managed if symptoms are mild or absent. If complicated by abscess, empiric
antibiotics should accompany aspiration of the urethral diverticulum until culture and sensitivity
results are available. A symptomatic or recurrent urethral diverticulum may require MRI imaging
or cystoscopy prior to surgical excision.
15
Management of Large Rectoceles in Geriatric Patients
Author: Anne Garrison, MD
Mentor: Tiffany Moore-Simas, MD
Editor: Julie Decesare, MD
Patients with rectoceles may be asymptomatic or have symptoms such as splinting, pelvic
pressure, dyspareunia, constipation, fecal incontinence, and defecatory dysfunction. Rectocele
extent does not necessarily correlate with the severity of symptoms.
No treatment is required for asymptomatic or mildly symptomatic elderly patients. Effective
management of constipation is important. Treatment is necessary if hydronephrosis, nonresolving vaginal
erosions, or obstruction develop.
Nonsurgical treatment options should be discussed. Pelvic examination should assess the extent
of prolapse in all compartments and include rectovaginal exam, assessment of the anal sphincter,
and neurologic evaluation of the area. A pessary can be offered regardless of prolapse stage.
Numerous vaginal pessaries are available, and data do not support one type of pessary over
another for women with rectoceles.
Pelvic floor muscle rehabilitation and symptom-directed therapy may be offered. Pelvic floor
physical therapy is typically performed once or twice weekly over a 2 to 3-month period,
supervised by an experienced therapist or practitioner.
Indications for surgical management include desire for definitive correction, difficulty with
intercourse, recurrent ulcerations from pessary use, or unacceptable incontinence. Decision to
perform surgery must balance the surgical risks against the potential benefits. Perioperative risk
is increased in older patients with concomitant medical problems and careful preoperative
assessment and management of identified conditions should be performed. Pre-operative defect
assessment including evaluation for presence of co-existing enterocele, sigmoidocele, and apical
defects can inform the surgical approach. Dyspareunia should be assessed in sexually active
patients.
There is no consensus regarding the optimal surgical approach. Historically, the primary surgical
therapy is posterior colporrhaph, often including a perineorrhaphy. The surgeon should maintain
adequate vaginal caliber for sexually active patients. Plication of the levator ani muscles may
also be performed. Other techniques include defect-directed repair and posterior fascial
replacement via transanal, laparoscopic, and abdominal approaches. Obliterative procedures
(colpocleisis) can be offered to women at high risk for complications with reconstructive
procedures who do not desire vaginal intercourse.
Caution should be exercised using mesh for prolapse repair. A variety of graft materials and
meshes have been studied in clinical trials, and it is not clear that any material is superior, or that
repair with mesh provides added benefit compared to surgery without mesh. Complications
reported to the FDA for mesh prolapse repairs include mesh erosion and contraction, pain,
infection, bleeding, dyspareunia, fistula, and vascular and organ injury. Many complications
require additional interventions including hospitalization and medical or surgical treatment.
16
Evaluation of Stress Urinary Incontinence
Author: William D. Po, MD Mentor: Christopher M. Zahn, MD Editor: Vanessa Gregg, MD
There are several different types of urinary incontinence: stress, urge, chronic urinary retention
(overflow), mixed, and others. An appropriate evaluation is essential to determine appropriate
treatment options. In general, the evaluation should include history, urinalysis, physical exam,
demonstration of stress incontinence, assessment of urethral mobility, and the measurement of a
post-void residual (PVR) volume.
Differentiating complicated from uncomplicated stress urinary incontinence (SUI) is important.
Uncomplicated SUI is defined as leakage on valsalva or physical exertion without symptoms
associated with urgency or retention, and is classically associated with absence of infection and
voiding symptoms. In addition to stress incontinence, complicated SUI may include urgency,
retention, and voiding symptoms, and patients may have comorbid conditions that impact
continence. Many patients will also have undergone prior anti-incontinence surgery.
A careful history includes precipitating events, frequency, severity, pad use, and effects on the
activities of daily living. Other questions regarding the presence and frequency of nocturia,
urgency, hesitancy, slow stream, feeling of incomplete empting, and dysuria may be asked as
well. There are many validated questionnaires available to assist in completing the history;
voiding diaries may also be used. Medication history (assessing medications and agents that
may affect bladder function), medical history (assessing the presence of conditions such as
diabetes and neurologic disorders), and gynecologic, past surgical, and obstetrical histories should be obtained.
The physical exam should assess for factors that may contribute to the patient’s symptoms, such
as a urethral diverticulum or a fistula. Any pelvic organ prolapse will need to be evaluated and
reduced to determine if SUI is being masked. Pelvic organ prolapse that extends past the hymen
may necessitate multichannel urodynamic testing.
Depending on history and exam, a urinalysis to identify urinary tract infection may be the only
necessary laboratory evaluation.
Before surgery is performed, stress urinary incontinence should be objectively demonstrated.
Visualizing leakage with a cough is diagnostic (with a full bladder or at least 300 ml of fluid and
the patient standing if needed). However, a delay in leakage may be due to cough-induced
detrusor over-activity. If there is a delay or if leakage is not demonstrated, multichannel testing is
recommended.
Surgical outcomes are more successful in patients with urethral mobility. The cotton swab test is
positive when there is a 30 degree or greater displacement from the horizontal when the patient is
in the supine lithotomy position and straining.
A post void residual volume of less than 150 ml can help exclude a bladder-emptying
abnormality or chronic urinary retention (overflow incontinence). An abnormal volume may
necessitate multichannel testing. Simple office cystometry with a catheter and syringe can aid in
determining post void residual, basic bladder capacity, and ensuring at least 300 ml for valsalva
leakage testing. Multichannel urodynamic testing is not needed with uncomplicated SUI prior to surgery.
In cases of complicated SUI, multichannel urodynamic testing is typically indicated. The goal of
multichannel evaluation is to objectively monitor bladder function and dysfunction so the appropriate treatment
can be precisely determined. Multichannel evaluation can measure changes to intra-abdominal and intra-vesical
pressures, and measure detrusor activity. Uroflowmetry can be performed to assess the voiding rate, pattern,
and capacity. Filling cystometry (cystometrogram [CMG]) measures pressure and volume in the bladder during
filling, storage in the context of sensation, and compliance. The competency of the urethra is assessed by the
valsalva leak point pressure (VLPP) and the urethral pressure profile (UPP). Electromyography may be performed
to confirm proper coordination between the bladder and pelvic floor muscles.
17
Surgical Management of Stress Urinary Incontinence
Author: Anitra D. Beasley MD, MPH Mentor: Laurie S. Swaim MD Editor: Christopher M. Zahn, MD
Stress urinary incontinence (SUI), defined as involuntary leakage of urine during coughing,
laughing, sneezing, or physical activity, affects 35% of all women. Bothersome SUI can be
managed surgically or non-surgically. Because SUI surgery is associated with operative
morbidity, post-procedure voiding difficulty, and development of worsening urge incontinence,
surgical intervention is traditionally reserved for patients whose symptoms persist despite
conservative therapy.
Anti-incontinence procedures are classified as slings, retropubic urethropexy procedures, or
artificial sphincters. The National Institute for Health Care and Excellence considers synthetic
midurethral slings, retropubic urethropexy (colposuspension), and autologous rectus fascial
slings as first-line surgical therapy. Selection of a surgical approach depends on many factors,
including the need for an abdominal procedure for other pelvic disease, concomitant pelvic organ
prolapse, and the health status of the patient. The most current evidence supports using a vaginal
approach when possible. Artificial sphincters are procedures of last resort and should not be
used unless the patient has failed previous surgical interventions.
Before midurethral slings, the surgeries of choice were retropubic urethropexy procedures, with
either the Marshall-Marchetti-Krantz (MMK) procedure, Burch procedure, or a pubovaginal
bladder neck sling. Both the MMK and Burch are performed via a suprapubic approach and are
designed to limit the mobility of the pubocervical fascia. Burch procedures achieve this support
with periurethral sutures to the iliopectineal, or Cooper’s, ligament and MMK procedures to the
pubic periosteum. Because of the rare but serious complication of osteitis pubis, the MMK
procedure is rarely performed.
Midurethral vaginal tape slings with permanent mesh are as effective as retropubic
colposuspension and bladder neck slings but have a shorter operative time and a lower risk for
most postoperative complications. They are now the most commonly used surgical procedure
for stress incontinence. The retropubic tension-free vaginal tape (TVT) and transobturator tape
(TOT) midurethral slings have similar success rates but different risk profiles. In general, the
most common complications are pain, vaginal mesh erosion, infection, recurrent incontinence,
dyspareunia, bleeding, organ perforation, neuromuscular problems, and vaginal scarring. When
compared to the transobturator approach, a retropubic approach is associated with a higher risk
of bladder and vaginal perforation, vascular injury, and voiding dysfunction, but TOT is
associated with a higher risk of groin pain compared to the retropubic approach. Although
controversy exists about the role of synthetic mesh used in the vaginal repair of pelvic organ
prolapse, there are substantial safety and efficacy data that support the role of synthetic mesh
midurethral slings as a primary surgical treatment option for stress urinary incontinence in
women.
Autologous fascia slings may be considered in patients who decline synthetic materials, have
severe SUI and a nonmobile, fixed urethra, are undergoing urethral reconstruction, or who have
complications from prior mesh. Rectus fascia or fascia lata slings perform as well or better than
their midurethral counterparts but also have higher complication rates. Single incision minislings are gaining
popularity and were developed to shorten operative time and move the
midurethral sling procedure into the ambulatory setting. They follow the basic procedure for a
midurethral sling, but use an anchor system rather than tissue resistance for support. Compared
to midurethral slings, minislings have lower success rates, lower patient satisfaction, and higher
reoperation rates.
18
Non-surgical Management of Stress Urinary Incontinence
Author: Natalie A. Bowersox, MD Mentor: Christine R. Isaacs, MD Editor: Tiffany Moore Simas, MD
Stress urinary incontinence (SUI) is defined as the involuntary leakage of urine with cough,
sneeze, or other activities that increase intraabdominal pressure. This problem affects up to 35%
of women and often negatively impacts their quality of life.
An evaluation for SUI should include history, physical examination, urinalysis, demonstration of
leak with cough or Valsalva, assessment of urethral mobility, and measurement of post-void
residual (PVR) volume. If urinary incontinence is not demonstrated with the cough test, a nonmobile urethra is
present, or if the incontinence appears multifactorial in etiology, multichannel
urodynamic testing may be appropriate.
Lack of urethral sphincter function is known as intrinsic sphincter deficiency (ISD). ISD may be
present with a hypermobile or fixed, non-mobile urethra. ISD may be caused by neuromuscular
damage or trauma, including prior surgery. In ISD, the sphincter can no longer coapt, and
incontinence may be severe. Urodynamic evaluation typically demonstrates either low maximal
urethral closure pressure or low leak-point pressures.
Initial treatment of SUI should include a review of co-morbidities and medications that may be
aggravating SUI such as the use of diuretics, narcotics, antihistamines, and anti-cholinergic
medications.
Lifestyle modifications should follow. Weight loss has been shown to help decrease symptoms
of SUI. Reducing consumption of beverages that contain alcohol, caffeine, and carbonation as
well as limiting consumption of excess amounts of liquids (>64 ounces of liquids daily),
managing constipation, and quitting smoking can help alleviate or reduce symptoms.
Kegel exercises (voluntary contractions of the pelvic floor muscles) done regularly and with
proper technique have been shown to be successful at managing SUI. Supervised pelvic physical
therapy with use of biofeedback or the use of vaginal weighted cones placed in the vagina and
held in place while contracting the pelvic floor, can also improve symptoms.
The use of pessaries has been shown to be successful about 50% of the time. Success with
pessaries tends to be in patients whose SUI is related to specific activities who can use a pessary
to resume the activities without leaking urine.
When SUI is associated with vaginal atrophy, local estrogen treatment has been shown to
improve symptoms. It may take up to twelve weeks for patients to notice benefit. While several
other medications have been evaluated for the specific treatment of SUI, there are currently no
FDA approved drugs for this purpose.
For patients with ISD, injection of bulking agents into the proximal periurethral tissue
(transurethrally or periurethrally) may be used. These agents may also be used for genuine SUI
in women in whom operative intervention may be especially hazardous, as second-line therapy
after surgery has failed, or when incontinence persists with a non-mobile bladder neck. Cure
rates vary, depending on the indication, differences in injection techniques, types of material
used, length of follow-up, and type of incontinence treated.
If patients continue to have bothersome symptoms of SUI following non-surgical management,
surgical interventions may be recommended and high cure rates can be achieved.
19
Management of Postoperative Ileus
Author: Sarah Appleton, MD
Mentor: L. Chesney Thompson, MD
Editor: Martin E. Olsen, MD
Postoperative ileus is a absent or abnormal peristalsis after surgery causing a functional
obstruction without mechanical blockage. A physiologic ileus can occur up to 72 hours after
surgery. When the ileus is prolonged, creating patient discomfort, intolerance of oral intake, and
prolonged hospitalization, it must be differentiated from other postoperative complications and
managed appropriately.
Many risk factors for postoperative ileus exist, including prolonged abdominal or pelvic surgery,
laparotomy (which necessitates more bowel manipulation), lower gastrointestinal surgery,
intraabdominal infection, intraoperative bleeding, and narcotic use. Enhanced Recovery After
Surgery (ERAS) protocols incorporate efforts to prevent postoperative ileus through preoperative
and postoperative interventions.
A patient with ileus after surgery typically complains of bloating, increasing abdominal pain,
nausea, vomiting, intolerance of oral diet, and absent or minimal flatus. The differential
diagnosis for these symptoms includes ileus, small bowel obstruction, bowel injury, intraabdominal or
retroperitoneal bleeding, and intra-abdominal abscess. Laboratory evaluation is
warranted including a complete blood count, electrolytes, creatinine, blood urea nitrogen,
amylase, lipase, and liver function tests. Plain abdominal films can assist in differentiating ileus
from small bowel obstruction. Patients with ileus will have dilated loops of bowel and air in the
colon and rectum, whereas those with a small bowel obstruction will have air fluid levels and
may demonstrate a transition point. A transition point is represented on imaging as the area
between dilated loops of small bowel followed abruptly by decompressed small bowel distally.
Once the diagnosis of ileus has been established, conservative treatment should be initiated. The
patient should have nothing by mouth and volume should be maintained with intravenous fluids.
Electrolytes, including magnesium, should be monitored and replaced as appropriate.
Hypokalemia may cause exacerbation of the ileus. Close observation is recommended to assess
for deterioration or a lack of improvement. Narcotic medications should be minimized as they
may prolong the recovery process. Nonsteroidal anti-inflammatory drugs may be used to manage
pain.
Patients with persistent vomiting or significant abdominal distention may benefit from
decompression of the bowel with a nasogastric tube. The nasogastric tube should be removed
when the output of the nasogastric tube is minimal, and the bowel demonstrates return of
function. If a patient experiences further decompensation or does not improve after 24-48 hours
of supportive therapy, additional evaluation, including consideration of computed tomography of
the abdomen and pelvis, is warranted to assess for other postoperative complications.
20
Perioperative Management of Anticoagulation in Gynecologic Patients
Author: Christopher M. Zahn, MD Editor: Eduardo Lara-Torre, MD
For patients using chronic antithrombotic therapy undergoing gynecologic surgery, interruption of therapy to
reduce bleeding risk must be balanced against risk of thromboembolism. Patients may benefit from “bridging”
therapy, in which a short-acting anticoagulant (low-molecular weight heparin [LMWH] or unfractionated
heparin) is used in the perioperative period. The decision to use bridging therapy depends on individualized risk
assessment, including patient preferences and the potential use of multidisciplinary input.
Risk Stratification
Risk assessment may include use of an instrument such as the CHADS2 (Congestive Heart Failure-HypertensionAge-Diabetes-Stroke) score to predict risk of stroke. Risk of bleeding and of thromboembolism may also be
predicted; Tables 2-4 in ACOG Committee Opinion # 610 define risk and the associated recommended
management protocols for perioperative anticoagulation. Other considerations include the type of
thromboembolism (arterial or venous) and individual patient characteristics (such as age, BMI, mobility), which
may upgrade or downgrade recommendations. Patients with a personal history of thromboembolism more than
12 months before their planned surgery may avoid anticoagulation unless the patient has an active malignancy.
Patients with a mechanical heart valve may be at high risk; consultation with a cardiologist to define risk and
management is generally advised.
Bridging Protocols
Bridging protocols may incorporate LMWH or unfractionated heparin, and are generally divided
into low- and high-dose regimens. Low-dose is considered “prophylactic”, involving once- (e.g.
40 mg enoxaparin) or twice-daily (e.g. 30 mg enoxaparin) LMWH or subcutaneous heparin
(5,000 – 7,500 IU twice daily). High dose (“therapeutic”) regimens include LMWH (1 mg/kg
twice daily or 1.5 mg/kg once daily) or intravenous unfractionated heparin to achieve an APTT
1.5 – 2 times control. Therapeutic dosing regimens have been the most widely studied for bridging therapy.
Preoperative Timing
Vitamin K antagonist (warfarin) therapy is typically stopped 5 days before surgery, and bridging
therapy (if used) is started. Patients with higher INR on vitamin K antagonist therapy may need
to stop earlier. INR should be checked the day before surgery; if not normalized, oral Vitamin K
(1 -2 mg) is recommended. When using bridging therapy, therapeutic dosing is stopped 24 hours
before surgery when using LMWH, and 6 hours for intravenous unfractionated heparin.
Subcutaneous unfractionated heparin should be stopped the night before the procedure.
Thromboprophylaxis should be administered with pneumatic compression devises and possibly
prophylactic heparin dosing depending on the risks of thromboembolism and bleeding.
Postoperative Timing
If adequate hemostasis is present, vitamin K antagonist therapy may begin 12 – 24 hours postoperatively.
Patients receiving bridge therapy with therapeutic dosing, and who have undergone surgery with a high risk of
bleeding, may re-start therapy 48 – 72 hours postoperatively. Bridging therapy is continued until the INR reaches
a therapeutic range.
Antiplatelet Therapy (aspirin, clopidogrel)
Bridging therapy is typically not recommended for patients on antiplatelet agents. For patients
using aspirin at high risk of a cardiovascular event, aspirin should be continued because the
benefit outweighs the risk of bleeding. Patients at low risk should stop aspirin 7 – 10 days before
surgery and re-start it with a similar schedule to the vitamin K antagonist recommendations.
Clopidogrel should be stopped 5 – 7 days before surgery, and therapeutic dose re-started 12 – 24
hours postoperatively.
Newer Agents
Less is known about perioperative management for patents using target-specific anticoagulants such as
rivaroxaban, apixaban, and dabigatran. Possible schemes include stopping therapy 5 days before surgery with
bridging therapy, or stopping 1 – 5 days before without bridging therapy. Consultation with a hematologist,
cardiologist, or primary care provider may be beneficial for managing these patients.
Emergent Surgery
Women receiving vitamin K antagonists may require vitamin K (1 – 2 mg) to reverse the anticoagulation effects
and decrease the delay for surgery. IV heparin may be used as bridging therapy if the nature and urgency of the
procedure allow.
21
Complications of TVT and TOT
Author: Aaron Goldberg, MD Mentor: Ellen Brock, MD Editor: Eduardo Lara-Torre, MD
Tension-free transvaginal tape (TVT) and transobturator tape (TOT) are polypropylene mesh
“slings” placed in a midurethral position to treat stress incontinence. TVT incorporates a
retropubic approach with the tape exiting the anterior abdominal wall along the superior border
of the pubic symphysis. TOT is placed via the obturator foramina, exiting in the groin. Both are
generally safe with success rates approaching 80%. There are several complications:
• Bladder perforation is more common with TVT due to passage of needles through the
retropubic space. Intra-operative cystoscopy is required for timely diagnosis. If
perforation is identified, the needle should be removed and careful re-insertion may be
attempted. Foley catheter drainage is often recommended for at least 24 hours and
antibiotics may be indicated.
• Transient urinary retention/incomplete emptying is common, typically caused by urethral
obstruction from the mesh. An intra-operative stress test may help reduce this problem in
awake patients, allowing loosening of the mesh as needed. This is not possible with
general anesthesia. Management with post-operative catheter drainage with voiding trials
every 2-3 days is recommended. Most cases resolve within 10-14 days. Persistent urinary
problems occur in 1-2% of patients, often requiring surgical release of the mesh. Most of
these patients have preservation of continence.
• Urge Incontinence/urgency occurs in approximately 25% of patients with TVT, but is
less common with the TOT. Initially, patients can be managed expectantly or with
behavioral or pharmacologic therapy. Most patients will have partial or complete
resolution within 4-6 weeks
• Post-operative infection may occur as either a urinary tract infection or wound infection.
Patients with pain, erythema, fever, or other evidence of infection must be carefully
evaluated for either wound infection or urinary tract infection. Antibiotics are typically
effective, but removal of the mesh may be necessary for refractory cases.
• Hemorrhage due to venous or arterial injury during needle passage may result in postoperative hematomas
that can usually be managed conservatively. Rapid intra- or postoperative hemodynamic instability may be
evidence of major vascular injury and rapid intervention is mandatory.
• Mesh erosion may occur despite appropriate mesh placement. Evidence of bladder or
urethral erosion includes hematuria, recurrent urinary tract infections, and pain. Vaginal
erosion symptoms include pelvic pain, discharge, and dyspareunia. Mesh excision is
often required, although conservative approaches may be appropriate.
• Vaginal injury is more common with TOT due to the course of the needle near the
vaginal fornices. Primary repair intra-operatively resolves most problems.
• Pain/nerve injury is more common with TOT due to puncture of the muscular pelvic
sidewall. Initial management is conservative. Mesh excision may be required for
refractory cases.
• Bowel injury is a rare but potentially catastrophic complication that remains hard to
recognize intra-operatively.
TVT and TOT are generally safe and effective minimally invasive interventions for stress
incontinence. Long term, 4-8% of patients may experience reoperation for stress incontinence,
tape erosion or extrusion, or groin pain. Careful adherence to correct surgical technique and
respect for pelvic anatomy will help prevent most complications. Appropriate and timely
intervention will minimize the long-term sequelae when complications do occur.
22
Evaluation of the Adnexal Mass in an Older Woman
Author: Todd R. Griffin, MD Editor: Martin E. Olsen, MD
The evaluation and management of an adnexal mass in an older woman is an important clinical
challenge. Adnexal masses arise in gynecologic and non-gynecologic sites. Primary ovarian
lesions include functional cysts and neoplastic cysts and masses (benign, borderline, and
malignant). Ovarian cysts are not unusual during perimenopause and menopause. Most are
benign. Age is the most significant risk factor for ovarian cancer, with a lifetime risk for ovarian
cancer of 1 in 70. Adnexal masses can be found in the course of evaluation for symptoms or
incidentally on exam or imaging. The use of tumor markers and imaging for early detection of
cancer in asymptomatic women has not been shown to reduce mortality. Given the risks
associated with surgery for false-positive results of screening, the screening of asymptomatic
women is not recommended.
The goal is to identify malignancy while minimizing unnecessary intervention. Ultrasound is the
imaging modality of choice. It offers the ability to characterize the ovarian mass, whether simple,
multilocular, cystic/solid or solid. MRI may be used in addition to ultrasound in the
differentiation of benign versus malignant lesions, but the additional cost may not be justifiable.
CT and or PET-CT imaging is useful for preoperative imaging of lesions highly suspicious for
ovarian cancer to optimize surgical planning, but have a limited role in the initial evaluation of
adnexal masses.
Serum markers such as Cancer Antigen 125 (CA 125), Human Epididymis 4 (HE4) and newer
Multivariate Index Assays (OVA1) are added tools to evaluate adnexal masses. CA 125 can be
elevated in both benign and malignant conditions. CA125 and HE4 together may have improved
diagnostic value. The clinical significance of OVA1 is not clear. Measuring LDH, Β-HCG, and
AFP is of limited value in older women as most cancers in this age group are epithelial in origin.
Primary management of ovarian cancer by a gynecologic oncologist has improved survival rates.
Currently ACOG and Society of Gynecologic Oncology recommend that patients presenting
with the following be referred to a gynecologic oncologist:
1. Ascites
2. Evidence of metastasis
3. First degree relative with breast or ovarian cancer
4. Premenopausal patient with CA 125 > 200
5. Postmenopausal patient with CA 125 > 35
6. Fixed / nodular pelvic mass
Asymptomatic simple unilocular cysts up to 10cm in size have less than 1% risk of malignancy
and should be followed with ultrasound imaging in 4 to 6 months. Resolution will occur in up to
two thirds of patients. Multilocular and solid/cystic masses are seen in up to 3.2% of
postmenopausal woman. Women with asymptomatic multilocular or solid/cystic lesions less than
5cm and a normal CA 125 can undergo repeat imaging and CA 125 in 4 weeks. If the size of the
mass or CA 125 increases, surgery is appropriate. If the mass shrinks, CA 125 falls, or if the
clinical picture is unchanged, the patient can be followed conservatively with ultrasound at 3-6
months. Although evidence based guidance is lacking, if all parameters have been stable for 18
to 24 months, repeat scans and marker levels can be discontinued. If the tumor is ≥ 5cm or there
is any evidence of papillary projections or ascites, the patient should be referred to a gynecologic
oncologist.
23
Management of Women on Hormonal Therapy or Contraception in Women Undergoing Surgery
Author: Amanda Murchison, MD
Editor: Regan Theiler, MD
Hormone therapy and use of combination hormonal contraceptives are associated with an
increased risk of venous thromboembolism. Menopausal women taking estrogen plus
progesterone therapy are twice as likely to experience a venous thromboembolic event compared
to women not on hormone therapy. Women on combination hormonal contraceptives are four
times more likely than nonusers to develop venous thromboembolism.
Venous thromboembolism and pulmonary embolism are serious complications of surgery
causing significant morbidity and mortality. To date, no studies exist that show preoperative
discontinuation of menopausal hormone therapy reduces venous thromboembolism, so this
should not be routine practice. Some studies show a small increase in postoperative venous
thromboembolism in reproductive aged combination oral contraceptive users. It is not necessary
to discontinue combination hormonal contraceptives prior to brief surgeries, including minor
laparoscopic procedures such as tubal sterilization, as they are associated with a low venous
thromboembolism risk. When women of reproductive age undergo major surgical procedures,
the risk of stopping a combined hormonal contraceptive to decrease the venous
thromboembolism risk will need to be weighed against the risk of unintended pregnancy. It takes
six weeks or more for procoagulant changes associated with combination hormonal
contraceptives to return to baseline after their discontinuation. For women on combination
hormonal contraceptives undergoing major surgery, perioperative venous thromboembolism
prophylaxis with mechanical and/or pharmacologic methods should be based on procedure type
and duration, age of the patient, and venous thromboembolism risk factors. Heparin prophylaxis
should be considered.
24
Evaluation of Dyspnea and Management of Pulmonary Embolism After Surgery
Author: Sabrina N. Wyatt, MD Mentor: Todd Jenkins, MD Editor: Lara-Torre, MD & Regan Theiler, MD
The differential diagnosis for dyspnea in a patient after gynecologic surgery or cesarean delivery
should include atelectasis, pneumonia, and pulmonary thromboembolism (PTE). Atelectasis is
the most common cause, occurring in 15-20% of patients after abdominal surgery. It is usually
the result of limited deep breathing due to postoperative pain and immobility. Preventive
strategies such as incentive spirometry and early ambulation should be encouraged.
Pneumonia should be considered in patients with dyspnea and clinical signs of infection
including fever, leukocytosis, and purulent sputum. Evaluation should include a chest
radiograph to determine if an infiltrate is present. Management of pneumonia includes initiation
of intravenous antibiotics.
Acute PTE has various presentations depending on the size and location of the thrombus.
Despite perioperative prevention strategies based on risk stratification, thromboembolic events
still occur, and dyspnea accompanied by tachycardia, hypoxia, pleuritic chest pain, hemoptysis,
and/or cough are the most common symptoms. Hemodynamic stability should also be
considered.
Clinical symptoms of PTE are nonspecific. An
assessment tool, such as the modified Wells
criteria, may be of benefit. A score greater than 4.0
(high
probability) is considered a positive
result (PTE likely). If the patient is stable and PTE is
considered likely, CT pulmonary
angiography should be performed. While CT
pulmonary angiography is sensitive and specific
for identifying PTE (83% and 96%, respectively),
initial
alternate testing utilizing D-dimer,
Doppler ultrasound, or both may be indicated in
patients
in whom there is an uncertain clinical
suspicion (low or intermediate probability).
Management of a patient with a suspected PTE should focus on the clinical status and
resuscitative efforts required. Hypoxemia requires oxygen supplementation and can require
intubation if severe. Hypotension may occur. Management should include intravenous fluids in
small amounts (500 mL), and vasopressor support if necessary. In severe cases, thrombolytic
therapy may be considered. However, the mainstay of PTE treatment is anticoagulation.
Immediate anticoagulation should be initiated during evaluation when there is a high clinical
suspicion (>4) and where diagnostic assessment will be delayed more than four hours. Options
for initial anticoagulation include subcutaneous low molecular weight heparin (LMWH),
intravenous unfractionated heparin (UFH), and subcutaneous UFH. The choice of therapy
depends on factors such as the risk of postoperative bleeding and renal function. The transition
to oral anticoagulation with warfarin or rivaroxaban should begin within 24-48 hours in those at
low risk for bleeding. Depending on the agent used, monitoring for therapeutic efficacy may be
needed. There is no single recommendation for the length of time oral anticoagulation should be
continued. Many times, it is stopped after 3-6 months, but should be continued for a longer
period of time if other predisposing conditions are present.
25
Management of Grade 1 Adenocarcinoma of the Endometrium
Mentor: Laurie S. Swaim, MD
Editor: Natalie Ann Bowersox, MD
Surgery is the cornerstone of treatment for endometrial carcinoma except for select
premenopausal patients desiring fertility, and patients with significant medical comorbidities. In
patients with known grade 1 adenocarcinoma, standard therapy includes a total hysterectomy,
bilateral salpingo-oophorectomy, pelvic washings for cytology, and possibly lymphadenectomy.
Patients with grade 1endometrioid lesions with less than 50% myometrial invasion and tumor
size of 2 cm or less seem to be at low risk of lymph node metastases and may not require a
systematic lymphadenectomy. Patients with greater than 50% myometrial invasion or cervical
extension should have complete surgical staging. In patients with stage 1a, grade 1 disease, no
further therapy is indicated.
Traditionally, surgical staging has been performed by laparotomy. However, advances in
minimally invasive surgery have made it the preferred approach for endometrial cancer surgical
staging. Some patients may additionally require adjuvant radiation therapy. Consultation with a
surgeon experienced in the management of endometrial cancer, such as a Gynecologic
Oncologist, is advised.
Vaginal hysterectomy alone is generally considered to be suboptimal treatment in patients with
endometrial carcinoma as it does not allow for evaluation of the abdomen and lymph nodes.
However, vaginal hysterectomy with concurrent bilateral salpingo-oophorectomy may be
considered for patients in whom abdominal and laparoscopic procedures are contraindicated.
Additionally, while radiation therapy alone produces inferior results when compared to surgical
management, it can be used as primary therapy in patients with significant medical
comorbidities. Progestin therapy may be considered in patients who are not able to tolerate
either surgery or radiation therapy.
Young women who desire future fertility may be candidates for medical management. Potential
candidates should have low-risk disease (grade 1 or 2, limited to the uterus), be willing to adhere
to progestin therapy and surveillance, and understand the risk of progressive disease. While the
optimal treatment duration and surveillance is unknown, endometrial biopsy every three months
is a common approach to monitor response. When offering conservative management, it is
important to remember that women who appear to have low-risk disease may actually have more
aggressive disease. Disease may progress despite medical therapy. Even in cases without
recurrence, hysterectomy is recommended following completion of childbearing.
26
Management of Evisceration of the Vaginal Cuff
Author: Aaron Goldberg, MD
Mentor: David Chelmow, MD
Editor: Abimbola Famuyide, MD, MBBS
Vaginal cuff dehiscence, a rare complication of vaginal hysterectomy, is the full or partial separation of the edges
of the vaginal cuff. Evisceration is dehiscence with prolapse of abdominal contents. These complications
typically happen within days, but may occur up to several months following hysterectomy. The incidence has
recently increased, with estimates ranging from 0.11% to 0.75% of hysterectomies. Vaginal hysterectomy has
the lowest rate. The rate after abdominal hysterectomy is slightly higher than after vaginal hysterectomy. Total
laparoscopic and robotic hysterectomies have the highest rates, greater than laparoscopic assisted vaginal
hysterectomy.
The increased risk in laparoscopic and robotic procedures likely arises from differences in either laparoscopic
suturing technique or the use of electrosurgical energy for colpotomy. Excessive energy application for
colpotomy may lead to devascularization and poorer wound healing. The risk appears significantly reduced
when the cuff is closed vaginally, regardless of hysterectomy approach.
Although cuff dehiscence can occur after defecation or sexual intercourse, most cases occur spontaneously.
Other risk factors include prior or current radiation therapy, immunosuppressive medications, and cancer.
Symptoms of cuff dehiscence include vaginal bleeding or discharge, pain, pressure, and changed bowel habits.
The presence of these symptoms in a recent post-operative hysterectomy patient warrants immediate
evaluation. The speculum and bimanual exams must be performed carefully as evisceration of bowel may occur
in up to two-thirds of patients with cuff dehiscence.
Vaginal cuff dehiscence is a surgical emergency. Patients should be taken to the operating room immediately
for repair. A moist sterile towel should be placed on prolapsed bowel or omentum. Intravenous fluid hydration
and broad-spectrum antibiotics should be started immediately. Traditionally, patients with evisceration were
managed via laparotomy and abdominal closure of the cuff. Experience is growing with minimally invasive and
vaginal replacement and closure. Protruding contents must be carefully inspected for injury. If there is evidence
of trauma or ischemia, or if bowel contents cannot be easily reduced, an abdominal or laparoscopic procedure is
appropriate and consultation with a surgeon with experience in bowel repair should be obtained to determine if
bowel repair or resection is necessary. If the prolapsed material appears undamaged, contents should be gently
replaced through the cuff after copious irrigation. Any necrotic or devascularized bowel or vagina should be
resected. The vaginal cuff can be closed either abdominally or vaginally, with interrupted or figure-of-8 delayed
absorbable sutures incorporating the full thickness of the vagina. No large series exist to guide management,
but use of a vaginal drain is reasonable, particularly if infection is present at the time of the procedure. Given
the high risk of subclinical infection, continuation of broad spectrum antibiotics for at least 24 hours
postoperatively is reasonable. Antibiotics should be continued until any clinically apparent infection has been
fully treated.
27
Perforation with Uterine Sound and Suction Cannula during a D&C
Author: Eugene C. Toy, MD
Editor: Eduardo Lara-Torre, MD
Uterine perforation is one of the more common complications of cervical dilation and uterine curettage. The
incidence is increased for a pregnant or recently postpartum uterus (5%), and is less for premenopausal (0.3%)
and postmenopausal women (2.6%). Other risk factors include a retroverted uterus, nulliparity, advanced
gestational age, and infection.
Perforation can occur during cervical dilation, uterine sounding, or during the curettage. Injury is suspected
when there is a sudden loss of resistance and the unanticipated advancement of the instrument beyond the
length of the uterine cavity. The surgeon should quickly assess for possible life-threatening injury to vascular or
visceral structures. The type of instrument (blunt, sharp, or suction), awareness of the patient’s anatomy, size
and location of the perforation, and possible injury to bowel structures are other important considerations.
Perforation with the blunt sound or dilator through the uterine fundus is generally asymptomatic and rarely
carries short or long term consequences. Blunt probe injury in the midline in a patient with normal anatomy can
be observed. Observation for 1-3 hours for bleeding, changes in vital signs, or signs of peritonitis is usually
sufficient. If the D&C procedure needs to be completed, sonographic guidance can help assure that instruments
remain within the uterine cavity.
A perforation through the cervix is more prone to complications, even with a blunt probe. A perforation
anteriorly may damage the bladder, posteriorly damage the rectum, or laterally injure vascular structures.
Cystoscopy, rectal examination, and laparoscopy should be considered in these cases.
When the location of perforation is unknown or possibly lateral, one can observe for a few hours. If there is
concern for a complication related to the perforation, management options include hysteroscopy to assess
injury location and laparoscopy to evaluate for intraabdominal complications. External bleeding may not be
evident. Clinicians should be watchful for signs of intraabdominal, retroperitoneal, and broad ligament
hemorrhage.
If a sharp curette penetrates the uterine wall, the risk of injury to bowel is dependent on the amount of
curetting. With immediate recognition and avoidance of any curetting, bowel injury is unlikely. However,
intraabdominal injury should be suspected if fat or other tissue is retrieved with the curette. In contrast, a
suction curette perforation, even with minimal penetration into the abdominal cavity, can lead to bowel injury.
Laparoscopy is usually recommended to examine for injury and to complete the procedure if needed. Even after
a normal laparoscopic examination after suction curette perforation, the patient should be observed for and
counseled about signs of peritonitis.
28
Diagnosis and Management of Cervical Ectopic Pregnancy
Author: Paula Amato, MD
Editor: Vanessa Gregg. MD
Cervical ectopic pregnancy is the rare implantation of a pregnancy in the endocervical canal and
accounts for less than 1% of all ectopic pregnancies. Patients usually present with vaginal
bleeding, which can be profuse and is often painless. Other clinical signs may include a soft,
disproportionately large cervix and an hourglass-shaped uterus. If a physical exam is performed,
the cervix may be bigger than the uterine fundus. The differential diagnosis also includes
incomplete abortion and pregnancy implanted in a cesarean or hysterotomy scar.
Transvaginal ultrasound is an important component of the diagnosis. Sonographic criteria
include an empty uterus, an enlarged barrel-shaped cervix, a gestational sac within the cervical
canal with or without cardiac activity, peritrophoblastic Doppler blood flow to the cervix, and an
absent “sliding sign” (the intracervical sac fails to slide along the cervical canal when gentle
pressure is applied to the cervix with the vaginal transducer). The presence of cardiac activity or
peritrophoblastic blood flow to the cervix is strongly suggestive of a cervical ectopic pregnancy.
Once cervical pregnancy is thought likely, bimanual examination should be avoided.
Early diagnosis and treatment is critical to avoid serious complications such as severe
hemorrhage and the need for hysterectomy. The most appropriate treatment depends on the
clinical presentation. If the patient is hemodynamically stable, medical management with
systemic single dose or multi-dose methotrexate (MTX) is the therapy of choice. The risk of
MTX failure must be weighed against the significant risk of hemorrhage with surgical
management of cervical pregnancies. MTX may be administered for cervical pregnancy in the
presence of factors such as cardiac activity, advanced gestational age, a gestational sac >4 cm,
and βhCG level >5,000 mIU/ml, which are relative contraindications to its use for tubal ectopic
pregnancy.
If fetal cardiac activity is present, intra-amniotic injection of potassium chloride injection has
been associated with successful avoidance of hysterectomy in 80% of cases. Dilation and
curettage carries a significant risk of severe hemorrhage. Preoperative uterine artery
embolization (UAE) may be useful to help control hemorrhage or in the management of bleeding
complications.
In patients who are hemodynamically unstable or fail medical management, surgical therapy is
indicated and requires dilation and curettage. In addition to UAE, the risk of hemorrhage may
also be reduced by transvaginal ligation of the cervical branches of the uterine arteries, cervical
cerclage, or intracervical vasopressin injection. Postoperative bleeding can often be controlled
with tamponade using a Foley catheter, hemostatic sutures in the implantation site, UAE,
bilateral uterine or internal iliac artery ligation, or hysterectomy. Data on future pregnancy
outcomes after cervical ectopic pregnancy are limited. Hysterectomy may be considered as an
initial option in women who have completed their childbearing.
29
Proximal Tubal Occlusion
Author: Daniel R. Grow, MD
Editor: Rebecca McAlister, MD
Proximal tubal occlusion is a common finding on hysterosalpingogram, occurring in up to 15%
of studies. The occlusion is seen at the utero-tubal junction, where radiographic contrast fails to
enter the isthmic fallopian tube. In a high proportion of cases, the proximal occlusion may be
functional. Occlusion is an important finding because tubal peristalsis is necessary for gamete
transport. The interstitial portion of the fallopian tube is a complex region anatomically where
the myometrium of the uterus transitions into the three layers of muscle that make up the
fallopian tube. Instrumentation of the uterus during the HSG procedure often leads to bilateral
tubal spasm and non-filling of the tubes. However, the occlusion may be due to a number of
pathologic conditions such as acute or chronic salpingitis, salpingitis isthmica nodosa, cornual
fibroids, pelvic adhesive disease, endometritis, prior ectopic pregnancy, and adenomyosis. SIS
detects the accumulation of fluid in the pelvis by ultrasound as evidence of tubal patency, but the
false positive rate for the diagnosis of tubal occlusion may exceed that of HSG.
Many techniques have been described to overcome tubal occlusion. These include transcervical
tubal cannulation by fluoroscopy, simultaneous hysteroscopy and laparoscopy, transcervical
balloon tuboplasty, falloposcopy, and more recently, saline infusion sonohysterography (SIS).
All of these methods have some utility, but most require anesthesia and significant experience.
The simplest way to confirm the presence of pathologic proximal tubal occlusion may be to
repeat the HSG a month later. In a study of 40 patients with proximal tubal occlusion seen on the
initial examination, repeat HSG demonstrated patency in 60% of cases. HSG requires no
anesthesia, minimal lost time from work, and may be the best approach to evaluate for tubal
patency. It does require some operator skill, as it is possible for factors such as excessive uterine
manipulation, cold contrast, or intrauterine trauma to precipitate tubal spasm and temporary
occlusion of the isthmic region of the fallopian tube.
Office hysteroscopy is not clinically useful. Three-dimensional ultrasound alone can help detect
the presence of fibroids, but does not assess tubal patency.
If it is confirmed that the fallopian tubes are occluded, in vitro fertilization is often the best
treatment option. Pregnancy rates after IVF for tubal disease are age-related, but the nationally
reported live birth rate per cycle for patients under age 35 is approximately 40% (SART).
30
Management of Bilateral Tubo-ovarian Abscesses in Young Nulligravida
Author: May Blanchard, MD
Editor: Eduardo Lara-Torre, MD
Tubo-ovarian abscess (TOA) occurs in 15% of cases of pelvic inflammatory disease (PID), and
33% of patients with PID requiring admission. PID and TOAs are polymicrobial infections of
anaerobic and aerobic bacteria. While Neisseria gonorrhoeae and Chlamydia trachomatis are
thought to facilitate the infection, they are rarely recovered from an abscess. The most commonly
isolated organisms from TOAs are Escherichia coli and Bacteroides species. Organisms that
make up the vaginal flora (e.g., anaerobes, Gardnerella vaginalis, Haemophilus influenzae,
enteric Gram-negative rods, and Streptococcus agalactiae) may be associated with PID and
TOA. In addition, cytomegalovirus, Mycoplasma hominis, Ureaplasm urealyticum, and
Mycoplasma genitalium may also play a role in the pathogenesis. Mortality associated with TOA
has decreased dramatically over the last 50 years. However, the morbidity associated with TOA
remains significant, with complications that including infertility, ectopic pregnancy, and chronic
pelvic pain.
The CDC recommends at least 24 hours of inpatient observation during parenteral antibiotic
therapy in women with TOAs. In young nulligravidas, the approach should focus on preserving
ovarian and tubal function to maintain fertility potential, and the non-surgical approach should be
considered as part of the initial intervention. Although antibiotic therapy is first line treatment in
PID, the addition of aspiration may be appropriate in cases of tubo-ovarian abscess. In one
study, women with abscesses of less than 10 cm were randomized to antibiotics alone or in
combination with transvaginal aspiration. Women treated with drainage had shorter average
hospital stay and were less likely to require surgical intervention.
Broad spectrum antibiotics are the appropriate initial management for unruptured TOAs. The
2015 Center for Disease Control and Prevention Sexually Transmitted Diseases (CDC)
Treatment Guidelines recommend inpatient intravenous antibiotics for at least 24 hours with
cefotetan or cefoxitin, plus doxycycline administered orally when possible. Gentamicin and
clindamycin are recommended for patients with penicillin allergies. Upon discontinuation of
parenteral therapy, the CDC recommends a total of 14 days of clindamycin or metronidazole
given with doxycycline. Oral therapy and hospital discharge are acceptable when the patient has
had a favorable clinical response to therapy including resolution of fever for more than 24 hours
and improvement of pain. If an IUD is present, it may be kept in place unless the patient has
failed to improve after 48-72 hours of antibiotics.
If the patient fails to respond to parenteral antibiotics in 48 to 72 hours, drainage or surgery
should be considered. Treatment with antibiotics results in failure in approximately 25% of
cases. Need for invasive intervention may be associated with TOA size. Drainage may be
accomplished by CT or ultrasound guidance through the abdomen, vagina, rectum, or gluteus
muscle. Transvaginal drainage of TOA combined with antibiotics has a success rate of 90-93%,
and avoids surgery and major procedure-related complications that could lead to removal of
reproductive organs.
31
Management of a Lost Pedicle at the Time of a Vaginal Hysterectomy
Author: Eugene C. Toy, MD
Editor: Rebecca McAlister, MD
Clinically significant bleeding occurs in 1-2% of vaginal hysterectomies; subclinical hematomas,
identified by sonography, may be seen in up to 15% of cases. Risk factors include an enlarged
uterus, lack of descent, distorted anatomy, and a narrow subpubic arch. The most common site of
bleeding is the vaginal vault. However, an unsecured or inadequately ligated pedicle can also
lead to hemorrhage.
When a pedicle is lost at the time of vaginal hysterectomy, the pedicle should be assumed to be
vascular until proven otherwise. A systematic approach is based on: 1) the magnitude or
potential magnitude of hemorrhage, 2) the ability to secure the lost pedicle, and 3) the ability to
ascertain possible retroperitoneal bleeding. The anesthesia team should be informed, and
intravenous fluids or blood should be administered as needed. The lost pedicle can be
approached vaginally, abdominally, or laparoscopically.
If the lost pedicle contains a major artery such as the uterine or ovarian (during oophorectomy),
then gross and profuse hemorrhage may be noted. Unless the bleeding vessel is immediately
adjacent to the surgical field and easily clamped, the best management of profuse hemorrhage is
to proceed to laparotomy, or laparoscopy if resources are immediately available. The tissue and
vessels often retract into the retroperitoneal space and the patient may lose significant blood
during transvaginal evaluation. During laparotomy, pressure may be applied to the area of
bleeding prior to retroperitoneal space exploration. Identification of the ureters may be required.
When there is no overt bleeding and the patient is hemodynamically stable, the surgeon may try
to locate the pedicle vaginally, but this may be difficult. If the pedicle is lost during the initial
operative steps such as near the uterosacral ligament, it is usually easily clamped. Indiscriminate
clamping, especially when tissue has retracted and is not easily visualized, can lead to bowel or
urinary tract injury. The anatomical location of the lost pedicle may be approximated by
comparing with the contralateral side. Even if the pedicle is unsecured, the remainder of the
hysterectomy can be performed if the patient is stable, facilitating vaginal exploration.
When the pedicle remains “lost,” laparoscopy is generally performed to assure hemostasis and
assess for possible retroperitoneal bleeding. Lack of apparent bleeding is not evidence of
hemostasis. During laparoscopy, a systematic search for bleeding should be undertaken
bilaterally. Retroperitoneal hematomas should be surgically repaired. A non-expanding
hematoma should not be assumed to be “hemostatic.”
In rare circumstances when bleeding cannot be controlled surgically, arterial embolization or
pelvic packing are options. Postoperatively, the patient should be monitored closely for signs of
volume depletion, dropping hemoglobin level, and possible intra-abdominal or vaginal bleeding.
32
Management of Lateral Uterine Perforation at the Time of Hysteroscopy
Author: Jeffrey M. Rothenberg, MD
Editor: Eduardo Lara-Torre, MD
Lateral uterine perforation at the time hysteroscopy is a rare, but potentially dangerous
complication. The overall rate of hysteroscopic complications is low and diagnostic procedures
have a lower rate than operative. Most perforations occur during insertion of the hysteroscope,
tend to be located in the fundus, and are usually self-limited and less serious. Procedure type
affects risk, and adhesiolysis has higher complication rate than polypectomy.
The uterine artery is the main source of blood to the uterus, along with anastomoses from the
vaginal artery. Severe bleeding from lateral uterine perforations, albeit rare, can have
catastrophic consequences. These perforations can be managed by laparoscopy or laparotomy,
and may require emergent hysterectomy. The risks are related to the underlying cause of the
damage to the lateral wall. If there is any concern for damage to surrounding organs, the
threshold for directly visualizing the pelvis and bowel should be low. Lateral wall uterine
perforations can lead to the development of a retroperitoneal hematoma, and cervical
perforations can result in significant immediate or delayed bleeding. Laparoscopy or laparotomy
may be needed to determine the extent of damage, including bowel or bladder injury.
Laparoscopic suturing of a perforation, placement of sutures during laparotomy, hysterectomy,
or uterine artery embolization may be necessary. Keeping an open line of communication with
the anesthesia team is also critical, especially as fluid overload or embolism may accompany the
perforation. Any damage to the uterine vasculature may increase the chance of fluid overload as
there is now an easier portal of entry for the distention media.
33
Management of Ureteral Injuries
Author: Larry J. Copeland, MD Editor: Abimbola O. Famuyide, MD
Ureteral injuries are relatively uncommon, and may be more common with gynecologic than
other types of abdominopelvic surgery. The incidence of ureteral injury ranges from < 0.1% to
over 1% depending on the surgery being performed and approach, including laparoscopy, robotic
assisted surgery and laparotomy. Reported rates of ureteral injury are higher for abdominal
hysterectomy than for vaginal hysterectomy. A recent Cochrane meta-analysis of surgical
approach to hysterectomy for benign gynecological diseases showed higher risks of urinary tract
injuries from laparoscopic hysterectomy compared to abdominal approach; however, no
differences were found in rates between robotic and laparoscopic or between laparoscopic and
vaginal approaches because of low event rates. Risk factors include prior surgery, malignancy,
infection, a large uterus, endometriosis, and pelvic organ prolapse.
Prevention of injury is critical; however, there are no well-established methods for most surgical
settings. Preoperative stenting has not been generally shown to reduce risk of injury. Lighted
stents have been described, but have not been well-studied in gynecology. Intraoperative
identification is key to avoid permanent injury. Ureteric identification is best accomplished by
incising the peritoneum lateral to the infundibulopelvic ligament and dissecting the avascular
space (peri-rectal space) bounded medially by ureter, laterally by the internal iliac artery, and the
cardinal ligament at the apex; the ureter can be traced on the medial leaf of the broad ligament as
it courses through to the ureteric tunnel. This dissection will suffice for most gynecologic
procedures involving removal of adnexal structures.
Ureteric injuries can be related to kinking, contusion, crush injury, laceration, transection,
ligation, devascularization, or thermal injury. Diagnosis is best accomplished in the acute setting,
although the majority of injuries may not be diagnosed until later. If injury is suspected,
intraoperative evaluation including careful evaluation for type and extent of injury, cystoscopy,
and possible ureteral catheterization is indicated. In the acute or near postoperative period,
retrograde pyelography is the most sensitive study. If undiagnosed, the most common presenting
signs and symptoms include abdominal pain, ileus, possible peritonitis, leukocytosis, and fever.
Flank pain may or may not be present. If ureteral injury is suspected postoperatively, cystoscopy
or retrograde pyelography should be performed. CT-IVP may be used if these studies cannot be
conducted.
In gynecologic surgery, the distal aspect is the most commonly injured location, typically near
the bladder at the proximity of the ureter and uterine artery. Other locations may include near the
pelvic brim and near the utero-ovarian ligament.
Some injuries, such as incomplete obstruction and kinking, may be treated with stent placement.
If suture has caused the obstruction, suture removal may be required. For more significant
injuries, including crush injuries and transection, the surgical approach depends on the location.
For distal injuries, ureteroneocystotomy is appropriate, in which the distal ureter is re-implanted
into the bladder. The re-implanted ureter is stented and the bladder drained; the stent is typically
left in place for 6 weeks. An abdominal drain (such as a J-P drain) should be placed in the event
an anastomotic leak may occur. A psoas hitch may be necessary to avoid tension on the reimplanted ureter.
More proximal ureteral injuries may necessitate a ureteroureterostomy, usually for small (2-3
cm) defects in which the injured ureter may be resected and a primary anastomosis performed. In
a proximal injury in which the distal segment cannot be used, a Boari flap (creating a “tubular”
flap to function as a “distal ureter”) may be needed. If the length of damaged ureter prevents
consideration of a ureteroneocystotomy or ureteroureterostomy, then a transureteroureterostomy
may be indicated, in which the injured ureter is anastomosed into the contralateral ureter. Finally,
in extreme cases, renal autotransplantation or the use of “substitute” materials such as
gastrointestinal segments may be necessary.
34
Avoiding Trocar Injuries Associated with Laparoscopic Surgery
Author: David E. Soper, MD Editor: Abimbola O. Famuyide, MD
Up to half of major intraoperative complications associated with laparoscopy, including major
vascular injury, occur at the time of surgical entry. Half of all bowel injuries occur during entry,
with the small intestine at highest risk. Insertion of the Veress needle and primary trocar for
initial entry account for 40% of complications and the majority of fatalities.
The usual site of entry into the abdomen is in the midsagittal plane at the lower margin of the
umbilicus. For safe insertion, instruments need to be placed parallel to the long axis of the patient
so that the tip remains in the midline. Deviations of as little as 20 mm from parallel place the
instrument tip almost 4 cm from the midline. Patients should NOT be in Trendelenburg position
during initial trocar insertion.
In non-obese women, the Veress needle or trocar should be inserted at 45 degrees from the
horizontal plane of a patient’s spine. At this angle, the abdominal wall thickness varies from 2 to
3 cm and distance to the major vessels averages 6 to 10 cm. In obese patients, the needle or
trocar can be placed close to 90 degrees from the horizontal plane. At this angle, the distance to
the vessels averages 13 cm.
The Veress needle should be open when inserted. The surgeon can feel or listen for two clicks
(the double click test) as the needle is placed through the anterior abdominal wall (click #1 =
anterior rectus sheath, click #2 = the peritoneum). The needle should be freely movable at a
fulcrum located within the anterior abdominal wall (waggle test). A drop of saline can be placed
in the open needle hub and the abdominal wall lifted (hanging drop test). If the drop is drawn
into the needle, it suggests that the tip is within the abdominal cavity.
Many surgeons prefer to insert the primary trocar after insufflation of the abdomen to 25 to 30
mm Hg. This stiffens the anterior abdominal, preventing the umbilicus from being depressed
toward the major vessels.
Open laparoscopy avoids blind placement by incising the periumbilical fascia and peritoneum
and advancing a blunt trocar directly into the peritoneal cavity. Intra-umbilical incision leverages
the shortest access point to the peritoneal cavity where the parietal peritoneum and fascia are
tethered. Although open technique reduces the risk of major vascular injury, small bowel injuries
can occur especially in the setting of intra-peritoneal adhesions.
In direct trocar insertion, the primary trocar is placed without prior insufflation and may avoid
injuries associated with Veress needle placement, but not decrease overall risk of injury.
Alternatively, left upper quadrant insertion at Palmer’s Point can be used. This point is located 3
cm below the middle of the left costal margin. The Veress needle is inserted perpendicular to the
patient’s skin. A small diameter scope can be placed, and other trocars then placed under direct
visualization. This is especially helpful in patients who have had prior abdominal surgery.
For insertion of secondary ports, transillumination can help to identify superficial vessels, but
they are difficult to see in the obese patient. The inguinal ring can be identified by tracing the
round ligament into the pelvic sidewall and the inferior epigastric arteries visualized arising from
the inguinal ring and coursing lateral to the medial umbilical ligament. When laparoscopic
landmarks are not visible, secondary trocars should be placed 5 cm superior to the midpubic
symphysis and 8 cm lateral to the midline to avoid the epigastric vessels. This location is often
directly over the external iliac vessels and can be further laterally situated in the obese patients or
carbon dioxide inflated abdomen, so care should be taken to control the direction, depth, and
speed during insertion. The trocar should be placed as close to possible to perpendicular to the
abdominal wall and peritoneum. A more oblique insertion can make entry into the peritoneal
cavity more difficult as the distance from insertion site to peritoneal cavity increases. Once the
trocar sleeve is through the peritoneum, the sheath can be further advanced under direct
observation, preventing injury to the underlying structures.
Prior to incision of the skin and trocar insertion, injection of local anesthetic using a 1.5 inch
needle along the projected trocar insertion allows identification of where the needle will enter the
peritoneum and provides perioperative anesthesia.
35
Surgical Management of Endometriosis
Author: Robert S. Schenken, MD Editor: Natalie Ann Bowersox, MD
Endometriosis may be strongly suspected based on clinical presentation, but laparoscopy remains
the gold standard for a definitive diagnosis. In patients with pain that is not improved with
medical management, surgery affords an opportunity for both diagnosis and treatment. Surgical
therapy may be conservative or definitive. Conservative therapy may include fulguration, laser
ablation or excision of endometrial implants, lysis of adhesions, repair of tubal damage,
uterosacral nerve ablation, and presacral neurectomy. Excision or ablation has been found to
significantly reduce pain symptoms over laparoscopy alone, so endometriosis should be treated
at the time of diagnosis. The decision to excise or ablate is based on the location of the lesion and
the comfort level of the surgeon. There is no data showing superiority of one modality over the
other. In patients with ovarian endometriomas, excision of the entire cyst wall should be
performed. Incision and drainage or ablation is not recommended due to the three-fold higher
rate of recurrence and reoperation. Pain relief is achieved in most patients who undergo
laparoscopic ablation or resection of endometriosis and adhesiolysis. However, the risk of
recurrence is estimated to be as high as 40 percent at 10 years follow-up and about 20 percent of
patients will undergo additional surgery within two years.
Laparoscopic surgery and uterosacral nerve ablation (LUNA) disrupts the parasympathetic
ganglia in the uterosacral ligaments, which carry pain signals from the uterus, cervix, and other
pelvic structures. Randomized controlled trials have shown that LUNA at the time of
laparoscopy does not decrease pain, dysmenorrhea, dyspareunia, or dyschezia, so LUNA is not
recommended. Presacral neurectomy (PSN) excises the presacral neural plexus, which carries
pain signals from the uterus and cervix. A randomized controlled trial of laparoscopic surgery
with or without PSN showed that the severity, but not the frequency of pelvic pain,
dysmenorrhea, and dyspareunia was significantly less at 12 months in women undergoing PSN.
The term deep infiltrating endometriosis (DIE) describes infiltrative disease that involves the
uterosacral ligaments, rectovaginal septum, bowel, ureters, or bladder. Medical therapy of
symptomatic DIE is usually ineffective or transiently effective, with high recurrence rates. There
is no consensus on the extent of resection necessary to treat DIE. Extensive dissection in the
rectovaginal septum, rectal or bladder wall, or bowel resection is often necessary. Hysterectomy
and bilateral salpingoophorectomy alone is inadequate for definitive therapy if endometriosis
involving the bowel is left untreated.
Medical therapy after conservative surgery is recommended for patients with pelvic pain to
reduce recurrence of pain and reoperation rates. First line therapies include either combined
hormonal contraceptives or continuous progestins. Continuous combined hormonal
contraceptives decrease recurrent dysmenorrhea for up to 24 months after surgery. Progestin
therapy such as norethindrone acetate, depo medroxyprogesterone acetate (DMPA), and the
levonorgestrel releasing intrauterine system (LNG-IUS) have all been shown to decrease pain
recurrence rates.
Definitive surgical therapy (hysterectomy with or without bilateral salpingo-oophorectomy),
should be reserved for women with severe symptoms who have completed childbearing. A
retrospective analysis of patients undergoing hysterectomy for endometriosis showed higher
rates of recurrent pain (62% vs. 11%) and need for reoperation (11% vs. 4%) in patients with
retained ovarian tissue compared to those with bilateral oophorectomy. In premenopausal
patients undergoing hysterectomy with bilateral oophorectomy for endometriosis, estrogen
therapy (ET) is recommended to reduce symptoms of hypoestrogenism, reduce bone loss, and
decrease cardiovascular morbidity. Starting ET immediately after surgery does not increase
recurrence or reoperation rates.
36
Desired Pregnancy after Essure Placement
Author: Roger Smith, MD Editor: Martin E. Olsen MD
While permanent methods of sterilization should be considered just that, permanent, patients and
their partners can and do change their minds. Pregnancies after permanent sterilization
procedures can occur spontaneously. In the clinical studies of the Essure device, approximately 1
out of every 7 women were not able to have the device placed in both fallopian tubes during the
first placement procedure. Adherence to the recommended confirmatory hysterosalpingogram
(HSG) at 3 months has been reported to vary widely, from as low as 13% to greater than 85%. At
routine 3-month follow-up, 4% of the women who did receive placement in both tubes were
found to have the inserts in an incorrect position, including having too much or too little of the
device within the tube, expulsion from the tube, or perforation through the tube or uterine wall.
In these cases, the device cannot and should not be trusted for contraception. Even with
hysterosalpingography that confirms correct placement and apparent tubal occlusion, late
pregnancies have been reported. The exact frequency of subsequent pregnancy is not known,
though in clinical studies the device was shown to be 99.74% effective at 5 years of follow-up, if
the recommended HSG confirmed tubal occlusion. Women who undergo sterilization by Essure
or incisional tubal ligation are more likely to have an ectopic pregnancy if they spontaneously
conceive.
Options for pregnancy are even more limited after Essure than after traditional methods of
sterilization. With procedures performed on the mid-portions of the fallopian tube, tubal
reanastomosis, bridging or excising the damaged portions were traditionally attempted. This
approach has been generally abandoned because of poor conception rates, increased rates of
ectopic implantation and improved successes with in vitro fertilization (IVF). IVF offers the
ability to bypass the obstructed fallopian tube regardless of site of obstruction. There are no data
on the safety or effectiveness of IVF after Essure. Because the procedure for introducing the
conceptus following IVF may snag the portion of the device that is in the uterus or the devices
could interfere with successful implantation of the fertilized egg, a slightly higher failure rate
might be expected. The risks of the Essure devices to the fetus or mother are unknown if
pregnancy is achieved, as is the rate of continuation of the pregnancy. There are reports of
successful pregnancy following hysteroscopic extraction of the implants, but given the degree of
tubal scarring caused by the device placement and damage caused by the removal, successful
conception or an intrauterine pregnancy would not be assured. Interestingly, an off-label use of
Essure in the management of hydrosalpinx has been described as an alternative to salpingectomy
in patients with hydrosalpinx who desire in-vitro fertilization. In these descriptions, Essure
replaces salpingectomy as a mechanism to treat hydrosalpinx and improve in vitro fertilization
rates.
37
Postoperative Urinary Fistulae
Author: Larry J. Copeland, MD
Editor: Abimbola Famuyide, MD, MBBS
Although it has been estimated that the risk of injury to the urinary tract is 0.3% during pelvic
surgery, particularly hysterectomy, many of these injuries are occult. When routine cystoscopy is
performed following hysterectomy, intra-operative diagnosis of bladder or ureteral injury may be
optimized.
While fistulae can result following surgery in an anatomically normal field, the most common
risk factor associated with urinary fistulae after pelvic surgery is anatomical distortion. Common
causes include embryologic anomalies (e.g. double ureters), prior surgeries (e.g. cesarean
delivery, renal transplant), fibroids (especially paracervical), severe endometriosis, severe acute
or chronic inflammatory disease (including fibrosis from prior surgery or radiation), and cancer.
Fistulae also are more common with abdominal and laparoscopic hysterectomies.
When recognized at the time of surgery, injuries should be repaired immediately if possible.
Occult injuries to the bladder or ureters may lead to leakage of urine outside of the collection
system, usually tracking to the vaginal cuff, resulting in either a vesicovaginal or ureterovaginal
fistula.
Preventive strategies are important. During surgical procedures, optimal exposure of adjacent
anatomical structures should be maximized. In general, sharp, rather than blunt dissection is
advised, especially for the vesicouterine plane following one or more cesarean deliveries. While
some suggest placement of ureteral stents preoperatively, others contend that they increase the
risk of injury to the ureter. In general, ureteral stents are not required to aid in the identification
of normal anatomy.
If fluid of uncertain origin is pooling in the vaginal vault in a postoperative patient, it can be sent
for a creatinine level. A result significantly above the serum creatinine confirms that the fluid is
urine.
The simplest diagnostic test for a vesicovaginal fistula is the “tampon test”. Sponges or tampons
are placed in the vagina and the bladder is filled with an identifiable fluid, usually methylene
blue or Indocyanine Green (Indigo Carmine is no longer available). The patient is then asked to
walk for a short interval before being examined. The presence of blue or green dye on the
tampon or sponge suggests a defect from the bladder to the vagina. If there is no staining, but a
urinary fistula is strongly suspected, phenazopyridine 200 mg orally may be administered.
Orange staining, usually within 1-2 hours, confirms the diagnosis of a ureterovaginal fistulae.
Further imaging should be performed to evaluate for possible ureteral obstruction.
Many small vesicovaginal fistulae will close if the bladder is continuously drained with a Foley
catheter. If a ureteral defect is noted, it may also spontaneously heal if a stent can be placed. If
conservative management is not possible or successful, surgical intervention may be necessary to
resolve the defect. These procedures are usually carried out 3-4 months after the injury.
38
Complications of Gynecologic Laparoscopic Surgery
Author: Robert S. Schenken, MD Editor: Abimbola O. Famuyide MBBS, FRCOG, FACOG
Complications of gynecologic laparoscopy occur in 3 to 6 per 1000 cases, proportional to the
complexity of the case. Approximately one-third to one-half occurs during initial access. There
are multiple approaches to achieve intra-abdominal entry. Although there seems to be no
significant outcome differences, there may be an increase incidence of minor complications such
as subcutaneous emphysema, preperitoneal insufflation, omental injury, and omental emphysema
with the Veress needle technique. The open technique is also associated with successful entry
more often. Approximately one-fourth of all injuries and one-half of bowel injuries are
recognized postoperatively. Risk factors include prior abdominal surgery, endometriosis, pelvic
infection, bowel distention, large pelvic masses, adhesions, cardiopulmonary disease and
diaphragmatic hernias.
Complications related to the pneumoperitoneum include subcutaneous emphysema and, less
commonly, pneumomediastinum and pneumothorax. Subcutaneous emphysema is usually selflimited. Gas
embolism and cardiac arrhythmia from excessive absorption of CO2 are extremely
rare, but potentially fatal.
The reported rate of vascular injury is 0.1 to 6.4 per 1,000 laparoscopies, and may be associated
with mortality. The majority occur with abdominal entry. Injuries may involve abdominal wall
vessels (particularly the inferior epigastric vessels with lateral trocar placement), omentum,
mesenteric vessels, middle sacral artery, iliac vessels, inferior vena cava and aorta. Delayed
bleeding from trocar sites may occur when the tamponade by the trocar or pneumoperitoneum
are removed. Retroperitoneal bleeding may also be masked. Clinically stable hematomas may
be observed; expanding hematomas require exploration and suture ligation. Minimal bleeding
from omental and pelvic vessels may be controlled with fulguration or suturing. Injury to major
vessels requires the initial application of pressure, exploration, and repair; assistance from
vascular surgeons is often beneficial. Several techniques are described to control inferior
epigastric injury, including balloon tamponade using a Foley catheter, suture ligation, or fascial
closure devices. Cautery is ineffective.
Bowel injuries represent nearly half of all major complications; a significant proportion may be
unrecognized. Approximately half are associated with abdominal entry, with the small bowel
most commonly affected. The large bowel is most commonly injured after entry. Perforation of
the stomach may occur with an upper abdominal or umbilical site insertion, especially if the
stomach is not decompressed. Management of an intraoperatively recognized injury may
involve expectant management or suture for very small injuries such as puncture wounds from a
Veress needle. Full-thickness injuries require repair, typically in two layers. Thermal injuries
may be more difficult to recognize, and may require oversewing or resection depending on the
extent of the injury. Bowel injury should be suspected if the patient’s postoperative course does
not steadily improve, especially in the presence of persistent nausea, emesis, abdominal pain,
distention, and fever. Free intra-abdominal air on abdominal radiography is not helpful for
diagnosis. When bowel injury is likely, repeat laparoscopy or laparotomy should be performed
without delay.
Bladder injury is most commonly associated with suprapubic trocar insertion or dissection at the
time of hysterectomy. Signs of a bladder injury include blood and gas in the Foley bag. Injuries
may be confirmed by retrograde filling of the bladder with dye. Small bladder injuries may be
managed expectantly with bladder drainage; larger and thermal-associated injuries require
layered repair, with attention to avoiding ureteral compromise. Ureteral injuries may not be
identified intraoperatively. If a ureteral injury is identified, repair may range from stenting
(minor injuries) to mobilization, resection, reanastomosis, or reimplantation, depending on the
extent and location of the injury.
The frequency of trocar site bowel herniation is approximately 1%. Ten mm or larger trocar
sites require fascial closure; however, herniation may still occur. Wound infection is rare.
39
Adnexal Masses in Adolescents
Author: Robert S. Schenken, MD Editor: Eduardo Lara-Torre, MD
The prevalence of adnexal masses in adolescents is unknown. While the diagnosis of a “ruptured
ovarian cyst” is common for adolescents presenting with abdominal and pelvic pain, often this
default diagnosis represents only the ultrasound findings of a normal cystic follicle and does not
truly explain the pain. Less than 25% of ovarian neoplasms in adolescents are malignant.
The differential diagnosis includes:
• Ovary: functional cysts (follicular, corpus luteum); endometriosis; benign neoplasms
(teratomas, serous and mucinous cystadenoma); malignant neoplasms (germ cell, sexcord or stromal tumor,
epithelial carcinoma); torsion
• Tube: tubo-ovarian abscess, hydrosalpinx, ectopic pregnancy, paratubal cyst, torsion.
• Vagina/Uterus: Anomalies (obstructing longitudinal vaginal septum, Mullerian anomalies, imperforate hymen)
• Gastrointestinal: appendiceal abscess
• Other: Peritoneal inclusion cysts, pelvic kidney
Adolescents with adnexal masses can present with symptoms, although even large masses may
be asymptomatic. Abdominal pain may be due to torsion, cyst rupture, or hemorrhage into a cyst
and/or abdominal cavity. Other symptoms may include abdominal distention or endocrine
manifestations such as precocious puberty, uterine bleeding, amenorrhea, or virilization. Cyclic
pain could suggest other conditions and should be investigated based on presentation. Nausea
and vomiting with acute or intermittent pain may occur with torsion. Acute pain may suggest a
ruptured or hemorrhagic ovarian cyst, ectopic pregnancy, or tubo-ovarian or appendiceal abscess.
Their menstrual cycle, sexual activity, contraceptive practices and sexually transmitted infections
exposure should be discussed and confidentiality obtained.
Pelvic examination may not be appropriate or revealing in adolescents who are not sexually
active or those with severe pain. It may be possible to palpate the adnexa on rectal examination.
Initial laboratory testing must include βhCG, as adolescents may not acknowledge consensual or
non-consensual sexual activity. Other relevant laboratory testing may include CBC, gonorrhea
and chlamydia, and tumor markers. Imaging is critical in the evaluation and would typically
start with ultrasound; MRI or CT may be required. Ultrasound can be transvaginal or
transabdominal, with the latter preferred in patients who are not sexually active. Morphologic scoring systems
to assess malignant potential may be used, but have not been validated in
adolescents. Ultrasound findings of a sonolucent cyst with smooth walls and the absence of
thick septations or solid components indicate a low risk of malignancy. MRI is the preferred
imaging modality after an initial ultrasound for suspected vaginal and uterine anomalies.
Management of asymptomatic functional cysts up to 10 cm may be expectant with serial
ultrasound imaging. Oral contraceptives do not hasten resolution of existing cysts but may
prevent new ones from forming. Patients with suspected hemorrhagic cysts should be followed
expectantly if clinically stable and the pain can be managed medically. Torsion requires prompt
surgical intervention to preserve ovarian function. Additional adnexal pathology is found in over
half of patients with the diagnosis of torsion. Certain neoplasms may require surgical
intervention, and a gynecologic oncologist should be involved when imaging and laboratory
testing suggests malignancy. A hydrosalpinx may be managed expectantly if it has the
characteristic ultrasound appearance of a sonolucent, elongated, extraovarian structure. Paratubal
and inclusion cysts appearing as extraovarian, sonolucent structures may also be followed with
serial ultrasound imaging. If surgical intervention is needed, attempt should be made to use
minimally invasive techniques and preserve ovarian function if possible. Anomalies resulting in
menstrual outflow obstruction are managed surgically.
40