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Coronary vein
1
Esophageal
varices
Short gastrics
2
Portal vein
Right
gastroepiploic
vein
Superior
mesenteric vein
Inferior
vena cava
3
Renal vein
Spleen
Splenic
vein
Left
gastroepiploic vein
Incision
4
Stomach
Pancreas
Right
gastroepiploic
vein
Middle
colic vein
Superior
mesenteric vein
Superior
mesenteric vein
373
PLATE
176
DETAILS OF PROCEDURE Freeing up the splenic vein from
its pancreatic bed is usually quite di cult because of the many delicate veins
draining into it from the pancreas. Less bleeding may occur if the vessels are
ligated on both the pancreatic and the splenic vein side before they are divided.
Before division of the splenic vein, its relationship to the superior mesenteric
vein should be con rmed, and the inferior mesenteric vein should be ligated
(figure 5). e mobilization of the splenic vein may be enhanced by dividing it near where it joins the superior mesenteric vein (figure 6). However,
before the splenic vein is divided, the renal vein should be completely prepared for the anastomosis, since occlusion of the splenic vein increases the
pressure in the retroperitoneal collateral veins in this area. Freeing up the
renal vein requires delicate dissection in order to avoid injury to venous collaterals with resultant blood loss. e le adrenal vein and the gonadal vein
are usually divided and securely ligated to ensure safe and adequate mobilization of the renal vein. It is not necessary to clamp the renal artery, since there
are adequate venous collaterals to decompress the kidney despite complete
occlusion of the renal vein.
Following division of the splenic vein, the mesenteric end is carefully
closed with a continuous arterial suture (figure 7). e coronary
vein is sometimes readily visualized at this point and may be divided and
ligated just above its junction with the portal vein.
One of the major problems in this procedure is the proper placement of
the anastomosis between the splenic and le renal veins. e mobility of the
splenic vein may need to be increased if it does not easily reach the renal vein
at the proposed site of anastomosis. A wide anastomosis is essential, without
twisting or angulation of the splenic vein. Following application of an occluding
vascular clamp, an oblique window is excised from the wall of the renal vein,
unless its size is especially small. e end of the splenic vein is tailored obliquely
to t the opening in the renal vein. It may be wise to split the end of the splenic
vein for a centimeter or more to avoid tension on the anastomosis.
S S (W)
e splenic vein may be anchored to the renal vein at either angle, and
the posterior anastomosis is completed with a continuous arterial suture (figure 8). Interrupted arterial sutures are used in the
anterior closure to minimize the splitlike character of the ori ce and allow
increased distensibility of the anastomosis (figure 9). e noncrushing
vascular clamp on the splenic vein is released just before the nal anterior suture is tied to remove air and ush out any blood clots. A suture is
taken around the coronary vein above the lesser curvature if it has not been
ligated from below. is suture may include the le gastric artery, but it
should be far enough away from the stomach to avoid accidental inclusion
of the vagus nerves.
Venous pressures are taken in the splenic, renal, and superior mesenteric
veins. Early elevations in pressure are common but do not indicate occlusion
of the anastomosis provided that the splenic vein feels so to compression
and palpation reveals a thrill within the renal vein. e eld of operation is
rechecked carefully for evidence of uncontrolled oozing or active bleeding.
e completed venous drainage outlet is illustrated in figure 10.
CLOSURE Because of the possibility of ascites, a watertight closure of the
peritoneum and general wound closure without drainage are indicated.
Retention sutures are frequently employed. ese should not penetrate the
peritoneal cavity because of the danger of leakage from ascites.
POSTOPERATIVE CARE Nasogastric suction should be continued a er
operation. Some gastric bleeding can be anticipated during the early postoperative period. Fluids during operation as well as in the early postoperative period should be restricted, with regulation based on hourly urinary
output determinations and central venous pressure measurements. Diuretic
therapy may be indicated to ensure a good urinary output. Ascites is a more
likely development following this procedure than following other types of
portosystemic decompression. ■
374
5
Gonadal
vein
7
Superior
mesenteric vein
Portal vein
Splenic
vein
Pancreas
Renal vein
Stump inferior
mesenteric vein
Splenic vein
6
Gonadal
vein
Division of
splenic vein
Proposed
opening in
renal vein
Left
adrenal vein
9
Gonadal vein
Left
renal vein
Inferior
mesenteric
vein
Inferior
vena cava
Gonadal vein
Inferior
8
vena cava
Renal vein
Short gastrics
Splenic vein
10
Splenic vein
Coronary vein
Portal vein
Splenic vein
Left
adrenal
vein
Superior mesenteric
Right gastroepiploic
Inferior vena cava
375
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GYNECOLOGIC
PROCEDURES
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G S—R
A P
Gynecologic procedures, in general, carry less risk than other abdominal
surgical procedures because of the minimal amount of manipulative trauma
to the alimentary tract and the patient’s generally good condition. However,
the same general principles apply here as in any major surgical operation,
and the patient’s condition must be appraised carefully.
PREOPERATIVE PREPARATION e obese patient should diet su ciently
to obtain a more normal weight before elective procedures are done. Secondary anemia is corrected preoperatively. Urinary complaints are investigated by analysis of the catheterized specimen of urine and endoscopic
and roentgenographic studies when indicated. Bowel preparation, including enemas, is individualized. Antibiotics are given when sepsis is suspected. A cleansing enema is given and may be followed by an antiseptic
vaginal douche. Prophylactic antibiotics are indicated for major vaginal and
abdominal procedures.
ANESTHESIA A general anesthetic is satisfactory. Spinal or continuous
spinal anesthesia may be used if desired.
INCISION AND EXPOSURE Many major gynecologic procedures can
now be performed via minimally invasive techniques, which include laparoscopic and robotic approaches. A lower midline incision is made, and
the lower angle of the wound is held open with a super cial retractor to
permit a free dissection of the fascia until the location of the midline is
absolutely ascertained.
Some operators prefer the transverse incision (Pfannenstiel), which is
a convex incision following the lines of skin cleavage just above the symphysis. e upper skin ap may be dissected from the underlying rectus
muscles, and the usual midline incision of the muscles and peritoneum is
made. When an extensive exposure is required, it is better to use a Mallard
incision which cuts across the recti muscles or a Cherney incision which
detaches these muscles from the symphysis. An increased number of blood
vessels require ligation by this approach in comparison to the midline incision, most notably, the inferior epigastric vessels.
e fascia is incised, scissors being employed at the lower angle of the
wound to open the fascia down to the symphysis. e medial edge of presenting rectus muscles is freed and pushed laterally with the scalpel handle.
Although few bleeding points are encountered in the midline, all must be
clamped and tied or controlled by electrocoagulation. As the incision progresses, its margins are protected with gauze pads. e peritoneum, before
being incised, is picked up to one side of the urachus with toothed forceps
alternately by the operator and rst assistant as in any abdominal procedure. e urachus, which can be seen through the peritoneum as a thickened cord, should be le intact, since it is not only vascular but also exerts
traction on the bladder, inviting its accidental opening.
A self-retaining retractor is substituted for the super cial ones, although
deep individual retractors may be used if a shi ing of the retraction is desired
to procure the maximum exposure as the operation progresses. Careful
inspection is made to ensure that no intestine is caught in the retractor.
When a self-retaining retractor is used, the smooth blade is inserted and
the whole apparatus is adjusted.
Unless contraindicated by infection in the pelvis, a general abdominal exploration is carried out. e surgeon moistens his or her hands in
saline and systematically explores the abdomen and nally the pelvis. e
surgeon’s operative note should contain a description of the ndings, especially the presence or absence of gallstones. If a large uterus with extensive
involvement by bromyomata is encountered, it may be advantageous to
deliver the uterus through the abdominal opening before the introduction
of the self-retaining retractor. Large ovarian cysts, if benign and not grossly
adherent, may be reduced in size by aspirating their contents through a trocar, great caution being used to avoid contamination from their contents.
If the surgeon suspects ovarian malignancy, the organ is removed intact
and a frozen section is performed. Additionally, the surgeon should perform a saline peritoneal lavage for cytology and biopsy of the pelvic, lateral
abdominal and diaphragmatic peritoneal surface. Comprehensive staging
of ovarian cancer also includes a pelvic periaortic lymph node dissection,
infracolic node removal, and sampling of the iliac and preaortic lymph
nodes. A tenaculum is applied to the fundus of the uterus to maintain traction while the intestines are walled o completely with several moist gauze
pads. To accomplish this, the intestines are retracted upward by the le
hand as the gauze pads are directed inward and upward by long, smooth
dressing forceps, the packing being continued until the pelvis is free of
small intestine. e pouch of Douglas is emptied of intestines, other than
the rectosigmoid, and is likewise protected by a gauze pack. To maintain
these packs in position, a moderate-sized smooth retractor is sometimes
placed in the midline at the umbilical end of the wound.
CLOSURE Before the abdominal closure is started, the site of operation
is nally inspected for evidence of bleeding, and the appendix may be
removed. A search is made for needles, instruments, and sponges, and a
correct count is reported before closure is started. e sigmoid and omentum are returned to the pelvis. A er the peritoneum has been closed, the
patient is gradually returned from the Trendelenburg position to horizontal
to release tension on the wound and to permit stabilization of the blood
pressure while the patient is under the surgeon’s direct supervision. A routine abdominal wall closure is done (Plates , , and ). e surgeon inspects
as well as palpates the fascial suture line to ensure a secure closure.
POSTOPERATIVE CARE When conscious, the patient is placed in a com-
fortable position. e uid balance is maintained with L of glucose in
lactated Ringer’s solution the day of operation and each day therea er until
uids and food are tolerated by mouth. If constant gastric suction is necessary, saline and potassium are added a er the rst day to accurately replace
the losses by gastric intubation. e measured blood loss during surgery
may be replaced if it exceeds mL and the patient is hemodynamically
unstable. Signi cant anemia can be tolerated in a healthy patient given the
additional support of supplemental oxygen, colloid expansion (Hespan),
and bed rest. In addition to surgical site infection prophylaxis, additional
antibiotics are not routinely administered.
e patient should be ambulated at the earliest possible time. Ambulation
in contrast to dangling is advisable. e inlying Foley catheter is removed in
to hours, depending upon the extent of the surgical procedure and
the patient’s general condition. If repeated catheterizations are necessary, the
amount of residual urine should be recorded and the catheterized specimens
examined for evidence of infection. If infection is found, the appropriate
antibiotics are given. Sterile perineal care is observed. Elastic stockings may
be worn, especially if varicose veins are prominent or there has been a history of phlebitis. ■
379
PLATE
177
INDICATIONS A total abdominal hysterectomy is most commonly per-
formed for benign conditions of the uterus including leimyoma, adenomyosis, endometriosis, pelvic in ammatory disease, and dysfunctional uterine
bleeding. Other indications include malignancies of the cervix, uterus and
ovaries.
POSITION (See preceding Gynecologic System—Routine for Abdominal
Procedures.)
OPERATIVE PREPARATION Routine vaginal and abdominal preparation
is given. e patient is catheterized, and an indwelling Foley catheter, No.
to French, is inserted with in ation of the balloon. e catheter is
anchored by adhesive tape to the inner aspect of the thigh. e vagina is
cleansed with a soap solution containing hexachlorophene or a povidoneiodine–containing liquid cleanser. A large gaping cervix may be closed with
several absorbable sutures. No sponge is placed in the vagina.
INCISION AND EXPOSURE (See Gynecologic System—Routine for Abdom-
inal Procedures.)
DETAILS OF PROCEDURE Whenever conditions will permit, the uterus
is pulled upward toward the umbilicus, exposing the anterior uterine surface and allowing incision of the peritoneum at the cervicovesical fold
(figure 1). is loose layer of peritoneum is picked up with toothed forceps and incised transversely with scissors close to its attachment to the
uterus (figure 2). e operator uses sharp and blunt dissection to establish
the avascular posterior leaf of the broad ligament opening a space in which
the round ligament and fallopian tube are isolated (figure 2). Should a
very large and irregularly shaped uterus be encountered, it may be easier to
apply clamps to the adnexa and to start from above downward. It is noteworthy that in many instances the cervicovesical fold of the peritoneum
may be incised, and the adnexa may be isolated more easily, even in the
presence of an interligamentous broid, a er the nger has been passed
through the avascular space.
When it is desirable to remove a tube, ovary, or both, they are grasped
with forceps and re ected medially (figure 3). When the pelvic structures are considerably relaxed, a pair of Ochsner clamps may be applied to
include the infundibulopelvic and round ligaments, saving as much of the
T A H
round ligaments as possible (figure 3). A suture of absorbable suture is
taken in the round ligament and the edge of the peritoneum adjacent to the
ovarian vessels to prevent retraction of the contents. Usually, curved clamps
are applied in pairs beneath the tube and ovary, especially if it appears that
there is too much tissue for one clamp (figure 3), and their contents are
tied with mattress sutures.
SUPRAVAGINAL HYSTERECTOMY
DETAILS OF PROCEDURE For supravaginal hysterectomy, the operation
proceeds as in total abdominal hysterectomy except that the uterine arteries
may be ligated higher on the cervix. Technically, this is an easier and safer
operation to perform, as the uterine artery suture ligatures are placed further away from the ureters. It requires, however, that the patient be compliant with lifelong gynecologic examinations that include cervical Pap tests.
e cervix is kept in position by Teale or similar forceps at the lateral margins and is divided at the level of the internal os, or lower (figure 4). e
cervical canal must be coned out completely from above for microscopic
examination. e procedure also serves as prophylaxis against the eventual development of carcinoma in the retained cervical stump. e cervical
stump then is closed transversely by placing with a cervix-cutting needle
several gure-of-eight sutures of absorbable suture, one in each lateral
angle and one or more in the central portion. ese sutures must be placed
su ciently deep to secure complete hemostasis.
TOTAL ABDOMINAL HYSTERECTOMY
A er the ovarian vessels have been tied, the clamps on either side of the fundus are removed so the operator can palpate the region of the cervix with two
ngers to determine its length and the position of the bladder. e bladder is
sharply dissected away (figure 5). It is advantageous to divide the tissue over
the cervix with scalpel or scissors until a de nite avascular cleavage plane is
established. Blunt dissection should be used sparingly and only in the midline
directly over the cervix, or troublesome bleeding will be induced from tearing
vessels in the broad ligament. Sharp dissection will permit the bladder to be
directed forward and downward until the operator’s thumb and index nger
can compress the vaginal wall below the cervix (figure 6).
CONTINUES
380
Round
ligament
Tube
and
ovary
1
Bladder
Avascular space of
broad ligament
2
Uterine
vessels
Posterior leaf of
broad ligament
3
4
Supracervical hysterectomy
Ovarian
artery
5
Tube and
ovary
removed
Conization of cervix
6
Vaginal wall
Freeing of bladder
from cervix
381
PLATE
178
POSTOPERATIVE CARE e surgeon then holds the uterus
forward and makes certain that the rectum is not adherent to the upper
portion of the vagina. Should the rectum be adherent to the vagina, it is
sharply dissected free to avoid possible injury. is is a critical step if a total
hysterectomy is to be performed. A er the relative position of the ureters
has been identi ed, a moist gauze sponge is loosely introduced into the
pouch of Douglas to prevent any intestine from coming into the eld of
operation. e uterus is rotated slightly to the right in preparation for the
application of a pair of straight Ochsner clamps (figure 7). e straight
Ochsner clamps are applied from the side at a -degree angle to the cervix to include a small bite of cervical tissue. e second clamp is similarly
placed to cm above the rst to ensure a good pedicle of tissue for double
ligation. e Ochsner clamps should never be directed downward parallel
to the cervix because of possible injury to the ureter. It is important to note
in figure 7a, how these clamps are applied at an angle to the cervix with
a sliding motion, which pulls the uterine vessels into the clamp. Now the
uterine vessels are divided with curved scissors (figure 7). If the uterus
is quite large, a half-length clamp may be a xed to the vessels higher up
along its wall to prevent troublesome backbleeding as the uterine vessels
are divided. e paracervical tissue is divided with scissors to a point just
below the level of the lower Ochsner clamp to develop a free pedicle that
can be tied easily (figure 8). Failure to carry the incision beyond the tip of
the distal clamp hinders accurate ligation of the uterine vessel pedicle, and
troublesome bleeding results. A trans xing suture, a, of absorbable suture
is tied as the lower Ochsner clamp is slowly withdrawn, and a second similar suture, b, is taken toward the severed end of the pedicle (figure 8). e
development of an easily tied pedicle that includes the uterine artery is one
of the most important steps in abdominal hysterectomy.
T A H
A er a similar procedure has been concluded on the opposite side, Teale
forceps are applied to the paracervical tissue between the cervix and the
uterine vessels (figure 9). e peritoneum on the posterior cervical wall
is incised and pushed gently downward. Frequently, the incision is carried
entirely around the anterior wall of the cervix, and the tissues are pushed
downward by blunt dissection until the cer vix can be palpated easily through
the thinned-out vaginal vault. With the uterus held forward, an incision is
made into the vagina posteriorly, and the vaginal vault is divided by long,
curved scissors as close to the cervix as possible, or desirable, according
to the disease present (figure 10). As the cervix is freed from the vaginal
vault, the anterior and posterior vaginal walls are approximated with Teale
forceps to include the full thickness of the vaginal wall as well as its posterior peritoneal surface (figure 11). e lateral angles of the vaginal vault
are rst closed with gure-of-eight sutures of absorbable suture on cutting needles (figure 12), following which one or more sutures are placed
at the middle portion to ensure complete closure and hemostasis. e most
likely place for troublesome bleeding is at the outer angles of the vagina
near the ligated uterine vessels. Accurate and rm closure of the angles is
imperative (figure 12). Upward traction on the vaginal vault is released to
determine whether any bleeding occurs.
CLOSURE e sigmoid and omentum are returned to the pouch of Douglas.
A er the peritoneum is closed, the patient is returned to the horizontal position while the fascia and skin are being closed. A patient should never be taken
from high Trendelenburg position and placed directly in bed. Only in rare
instances is drainage instituted either through the vagina or abdominal wall.
POSTOPERATIVE CARE (See Gynecologic System—Routine for Abdominal
Procedures.) ■
382
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