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Treatment of the vaginal vault
See Chapter 7.
Suturing the peritoneal flaps
See Chapter 7.
Closing the abdominal cavity
See Chapter 6.
Hysterectomy for a central cervical
myoma by hemisection of the uterus
Central cervical myomas are frequently best removed
by hemisection of the uterus followed by hysterectomy,
a technique originally introduced by Rutherford
Morrison. This method is particularly indicated when
the tumour, either central or posterior, so raises the
bladder that, on the abdomen being opened, the
uterovesical pouch is found obliterated and the uterus
is so covered by the bladder that only its fundus presents. In such cases it is impossible to adopt the method
of transverse section of the capsule described before in
this chapter, as the intervening bladder cannot be sufficiently pushed down.
volsellum to the tumour and pulling on this with the left
hand (Fig. 8.8).
Securing the ovarian vessel
Directly the tumour has been raised from its bed, the
upper parts of the broad ligaments containing the ovarian vessels are brought into view. These are divided on
each side between two pairs of forceps in the usual way
(Fig. 8.9).
Clamping of the uterine vessels and removal of
the uterus
The tumour, together with the uterus, is drawn out of
the wound. The uterine vessels are then clamped on
each side and total hysterectomy performed by first
opening the anterior vaginal wall as described in
Chapter 7.
Ligating the vessels
See Chapter 7.
BONNEY’S GYNAECOLOGICAL SURGERY
80
Fig. 8.8 Enucleating the tumour.
Fig. 8.9 Clamping the ovarian vessels.
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Hysterectomy for a posterior
cervical myoma
There are two methods of dealing with a posterior cervical myoma, depending on its variety. If the rarer form
is present where the tumour, undermining the peritoneum at the bottom of the pouch of Douglas, strips
the serous membrane off the anterior face of the sacrum
and rectum, and pushes down between the vagina and
rectum, or by the side of the latter, the uterus will be
found to have been bodily elevated on the myoma in a
position of retroversion. In this case the bladder will be
found to overlie the front of the mass entirely, and the
best technique to adopt will be to bisect the uterus in
the manner previously described. The bisection will be
principally carried out on the posterior wall of the
uterus, as the presence of the bladder in front generally
prevents the incision being carried very far down on the
anterior wall.
If the tumour is of the commoner variety, namely that
which projects into the pouch of Douglas, the method
to be described should be followed.
The operation
Abdominal incision
The abdominal cavity is opened by the method
described above, taking the same care to avoid the
bladder.
Examining the abdomen and packing off the intestines
See Chapter 6.
Clamping and dividing the ovarian vessels and
round ligaments
See Chapter 7.
Separation of the anterior peritoneum and bladder
An incision is made from one round ligament to the
other at the level of the upper limit of the loose attachment of the peritoneum where it is stretched over the
tumour and the anterior surface of the uterus. The
peritoneum, together with the bladder, is now pushed
downwards with a swab as far as possible off the face of
the expanded supravaginal cervix as in Fig. 8.1.
Hemisection of the uterus
The operator then seizes the fundus on each side with
volsellum forceps; he hands the left pair of forceps to his
assistant and, grasping the right pair in his left hand,
steadies the uterus and divides its body in half with a
scalpel in the relatively avascular mid-line. The incision
is carried downwards well into the tumour so that the
plane of its capsule is easily distinguished (Fig. 8.10).
Enucleating the tumour
The capsule having been defined, the tumour is seized
with a volsellum and enucleated whole by means of the
fingers (Fig. 8.11).
Securing the uterine vessels and removing the uterus
The bisected uterine body and the collapsed cervix are
now easily pulled up, the uterine arteries secured in the
usual way, and total hysterectomy performed as
described in Chapter 7.
Closing the abdominal cavity
See Chapter 6.
HYSTERECTOMY FOR FIBROIDS
81
Fig. 8.10 Hysterectomy for a central cervical myoma by
hemisection of the uterus.
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the tumour, and the latter is enucleated down to its
lower pole. To effect this in difficult cases, the fingers
may have to be inserted a distance equal to almost the
whole length of the vagina. With large tumours the
removal of a central wedge, as previously described,
will facilitate their removal. In fact, a large mass of tumour can be removed safely in this way to give the surgeon far better access to the vessels.
Reflecting the anterior flap of peritoneum towards
the bladder
Next, the peritoneum over the anterior surface of the
supravaginal cervix is reflected as far as the attachment
of the bladder.
Clamping the uterine vessels and removing the uterus
Strong traction is now made on the tumour, which,
together with the freed uterus, can be easily pulled up
with a volsellum so that the uterine vessels on each side
are brought into view and then clamped (Fig. 8.13).
After this the uterus is removed by total hysterectomy,
first opening the anterior vaginal vault.
The operation
Opening the abdominal cavity
Comments previously made should be considered.
Examining the abdomen and packing off the intestines
See Chapter 6.
Clamping and dividing the ovarian vessels and
round ligaments
These are clamped, divided and tied as described in
Chapter 7.
Incising the peritoneum and capsule
The peritoneum and capsule at the junction of the
uterus are incised and reflected (Fig. 8.12).
Enucleation of the base of the tumour
The tumour having been pulled forward by the volsellum, the fingers are now forced between the capsule and
BONNEY’S GYNAECOLOGICAL SURGERY
82
Fig. 8.11 Enucleating the tumour.
Fig. 8.12 Hysterectomy for a posterior cervical myoma:
reflecting the posterior peritoneum.
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3 In the connective tissue surrounding the ovarian or
uterine vessels.
As a rule, tumours growing in the first two situations
are of small size, and can be enucleated as described in
Chapter 9. Tumours growing in the third situation frequently attain a large size; they distend the broad ligament so that the fallopian tube is stretched and lies
sessile on their upper surface as in a broad ligament
cyst. Having exhausted the capacity of the broad ligament, the tumour pushes its way upwards, stripping the
peritoneum off the lateral wall of the pelvis and iliac
fossa, and on the left side it often burrows between the
layers of the pelvic mesocolon, the bowel itself then
lying upon the tumour. If the operator is not familiar
with the anatomy of these tumours he may believe that
this condition of the bowel is due to adhesions, and may
abandon the attempt to remove the tumour, when, as a
matter of fact, a plane of easy cleavage lies between the
muscularis of the intestine and the surface of the
tumour. The ureter and vessels supplying the intestine
can be in danger and great care is necessary not to
damage either structure.
True tumours of the broad ligament can be distinguished by the fact that they are entirely separate from
the uterus, which they displace but do not deform.
Their relation to the uterine artery should be remembered; it lies beneath and on the inner side of the
tumour, while the ureter is displaced inwards, and will
be found running in the posterior peritoneal layer of
the broad ligament, after which it courses under the
tumour to reach the bladder.
There are two methods of dealing with true broad
ligament myomas. The tumour may be enucleated in
the manner described in Chapter 9. If the tumour is
very large, vascular or adherent, it may be necessary
also to remove the uterus, principally as a means of controlling the haemorrhage easily. This method will be
described in the operation for the second variety of
broad ligament myoma.
The second variety may be termed the ‘false’ broad
ligament myoma. In this case the tumour springs from
the lateral wall of the uterine body or of the cervix, and
bulges outwards between the layers of the broad ligament. The uterus is, therefore, an integral part of the
tumour. These tumours distend the broad ligament,
and at times raise the lateral pelvic peritoneum and
invade the mesocolon.
Besides its relation to the uterus, the second variety
differs from the first variety in that it displaces the uter-
Ligating the ovarian and uterine vessels
See Chapter 7.
Suturing the peritoneal flaps
See Chapter 7.
Difficulties and dangers
It is most important to get into the plane of cleavage
between the tumour and its capsule of expanded cervical muscle; otherwise, troublesome bleeding and risk to
the organs around will occur.
Hysterectomy for broad
ligament myomas
Broad ligament myomas are divisible into two classes.
The first variety is the true broad ligament myoma, and
springs from the muscle fibres normally found in the
mesometrium. Such tumours may, therefore, be found
in at least three situations:
1 In the round ligament.
2 In the ovariouterine ligament.
HYSTERECTOMY FOR FIBROIDS
83
Fig. 8.13 Clamping the uterine artery.
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Clamping the ovarian vessels on the diseased side
The index finger of the operator’s left hand is then
inserted between the cut edges of the peritoneum and
forced under the fallopian tube and ovarian vessels,
which are thus separated from the tumour. The upper
parts of the broad ligament and the round ligament are
then divided between forceps (Fig. 8.15).
Freeing the upper part of the tumour
The upper part of the tumour is now freed from its
attachments, leaving only its base.
Clamping the uterine vessels on the healthy side
The uterus and tumour are now strongly pulled over to
the side of the tumour and the uterine vessels on the
healthy side are clamped and divided, as in a standard
hysterectomy.
ine artery outwards and upwards, so that in extreme
cases the uterine and ovarian vessels are approximated
and run parallel on the top of the tumour. The ureter is
displaced outwards to the pelvic wall and, as a rule, lies
under the tumour, except in the rare lateral cervical
myomas already referred to, when, together with the
lateral angle of the bladder, it may be undermined by
the tumour and elevated on its upper surface. These
tumours can be enucleated, but when large or associated with other fibroids in the uterus it is often best to
deal with them by hysterectomy.
It is better, if possible, to begin the removal of the
tumour by attacking the healthy side of the uterus. The
reasons for this are first, that haemorrhage can
be better controlled and secondly, that the uterus itself
constitutes the firmest attachment of the tumour which
is elsewhere surrounded by cellular tissue and peritoneum. The greatest difficulty in these cases is the control of the uterine vessels on the side of the tumour, and
it is often impossible to secure them until the tumour is
removed from the field of view. The concluding stage of
its removal has, therefore, often to be effected as quickly as possible, and this is materially aided by the previous removal of the uterus and clamping of the uterine
vessels on the healthy side.
The operation
Opening the abdominal cavity
Comments previously made should be considered.
With a large tumour, the bladder may be elevated
towards the umbilicus and to avoid damaging it care
must be taken to open the peritoneal cavity at the top of
the incision. This must be extended upwards where
necessary.
Clamping and dividing the upper parts of the broad
ligament on the healthy side
This is carried out as though performing a standard
hysterectomy (see Chapter 7).
Stripping the anterior peritoneal flap
The peritoneum is incised across the uterus and
tumour; the incision, commencing at the healthy side
and passing across the tumour, divides the round ligament and is extended upwards to just short of the ovarian vessels. The peritoneum is now stripped from the
upper surface of the tumour as far as possible, and the
bladder is pushed down (Fig. 8.14).
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Fig. 8.14 Hysterectomy for a broad ligament myoma:
separating the peritoneum off the upper pole.
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Ligating the uterine and ovarian vessels and
round ligaments
This is easily performed and completes the removal
phase.
Closing the abdominal cavity (See Chapter 6)
Occasionally, a fibroid, lateral to the uterus, so displaces this organ downwards and to the opposite side
that the vessels on the healthy side cannot be reached in
the manner described. In such circumstances the
tumour must first be enucleated or partly enucleated
after the ovarian vessels spread out on its upper surface
have been clamped and divided. During enucleation the
fingers must be kept close to the tumour. The enucleation effected, the uterus rides up, and the vessels on the
healthy side become accessible. Because of probable
displacement of the ureter, it is necessary to define its
exact position in relation to the vessels before they
are clamped. This can be done, preferably by exposing
it to view as it runs on the posterior layer of the broad
Removing the uterus
The fundus of the uterus is drawn over towards the side
on which the tumour lies, and total hysterectomy is
performed.
Dividing and clamping the uterine vessels on the
diseased side
Just before the hysterectomy is completed, the uterine
vessels on the same side as the tumour come into view.
Remembering the proximity of the ureter, these vessels
should be defined clearly and clamped before they are
cut. If this is not done, an inexperienced operator troubled by the extent of the haemorrhage may inadvertently damage the ureter when endeavouring to control
the bleeding (Fig. 8.16).
Removal of the uterus and tumour
The assistant pulls the uterus strongly towards the side
of the tumour, and the operator, passing the fingers of his
left hand between the tumour and the base of the broad
ligament, frees its lower surface and thus enucleates it.
HYSTERECTOMY FOR FIBROIDS
85
Fig. 8.15 Separating the fallopian tube and ovarian vessels
from the tumour.
Fig. 8.16 Securing the uterine artery on the side of the
myoma.
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occur, vaginal examination 10 days or more after the
operation will usually reveal a mass in the area of the
broad ligament. It should be left alone and will slowly
absorb over a period of weeks.
Hysterectomy for a double uterus
The technique of hysterectomy for a double uterus does
not differ materially from that for the single organ except in certain particulars. When two complete organs
are present (uterus duplex), a pronounced fold of peritoneum exists (median raphe) which joins the bladder
to the rectum in the middle line, separates the two corpora and divides the uterorectal pouch into two lateral
compartments. This fold should be divided by the same
incision through the peritoneum that demarcates the
anterior peritoneal flap, and the operator must make
sure that the bladder is pushed well forward and the
rectum well backward before he proceeds with hysterectomy (Fig. 8.17).
With a double corpus and a single cervix (uterus
bicornis unicollis) the fold may not be present.
In uterus duplex, the two cervices, though complete
in themselves, are joined together by a block of tissue,
which is continued downwards as a median vaginal
septum. There is only one uterine artery to each half of
a double uterus.
Further reading
The editor would refer the student to the end of Chapter 9 for
further reading.
We would also recommend the readers to look into An Atlas
of Gynaecologic Oncology, Investigation and Surgery by
Smith, Del Priore, Curtin and Monaghan. Published by Martin Dunitz (2000).
ligament or by careful palpation. If in doubt, the ureter
at the brim of the pelvis should be identified and followed down from a position of anatomical certainty
and safety.
Difficulties and dangers
The operator must remember the various displacements to which the ureter is liable, and if he cannot be
sure of its exact position, must minimize the danger of
wounding it by keeping as close to the tumour as possible during enucleation. It is very important to ligate all
bleeding points left in the cavity after the removal of the
tumour, otherwise a large haematoma may form. If suction drainage is not instigated and haemorrhage does
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86
Fig. 8.17 Hysterectomy for a double uterus: dividing the
vesicorectal fold or median raphe.
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87
but as it grows develops anoxic areas in the centre of the
tumour which not infrequently undergo degeneration.
Fibroids lying more superficially may become pedunculated and may at times undergo torsion. They are frequently mistaken for ovarian tumours.
In pregnancy, fibroids may undergo ‘red degeneration’, which manifests itself as extreme pain in or close
to the uterus. This may be misdiagnosed as abruptio
placentae or acute appendicitis, depending on the
position of the pain. It is generally recommended that
fibroids should not be removed from the pregnant
uterus because of the risk of severe and uncontrollable
haemorrhage.
The procedure for removal of a myomatous polyp is
described in Chapter 5.
Indications for myomectomy
The sole purpose of myomectomy is to improve fertility;
it should never be used as a surgical exercise, nor to
preserve the uterus in the mistaken belief that such
an act will maintain the femininity or sexuality of the
patient. Unfortunately, more than two-thirds of women
who have had myomectomy are at risk of developing
menstrual irregularities or menorrhagia.
Instruments
The gynaecological general set described in Chapter 2 is
required, with the addition of two other valuable items:
1 Myoma screw; this device is rather like a large
corkscrew with a wide spiral which can be inserted into
particularly large fibroids in order to assist in manoeuvring the tumour.
Myomectomy and management of
fibroids in pregnancy
9
Myomectomy
The name of Victor Bonney will always be associated
with the development of myomectomy so as to preserve
uterine function. At the time he was working, a subtotal
hysterectomy was considered to be the treatment
of choice for fibroids. He demonstrated that fibroids
could be removed, the uterus preserved and successful
pregnancies achieved.
Fibroids or leiomyomas occur in approximately
20% of women; there is a clear relationship with
infertility and in those patients who have a myomectomy performed there is a marked improvement in
subsequent fertility. Fibroids are also frequently
seen in association with endometriosis; in neither of
these conditions is the causal relationship to infertility
clear.
The fibroid, a benign overgrowth of the muscular
elements of the uterine wall, may develop in any part
of the genital tract but almost always within the myometrium. Any effects of the fibroid will depend on the
position and size of the tumour. Fibroids which
impinge on the cavity of the uterus are most commonly
associated with infertility and, in later life, with
alterations of menstrual pattern produced by a combination of expansion of the endometrial surface and
irregularities of that surface.
Those tumours within the myometrium may grow to
a very large size and be entirely symptomless, growing
steadily and forming a false capsule by compressing
surrounding tissues. This false capsule allows the surgeon to enucleate the fibroid with ease using the tissue
planes so formed as a simple line of cleavage. The
fibroid picks up its blood supply from adjacent arteries,
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the uterus are more suitable for enucleation than those
in the posterior wall.
Anterior cervical myomas are well suited for enucleation, but posterior cervical tumours are much more
inaccessible and the bed which remains after their
removal may be difficult to reach. Central cervical
myomas usually enucleate very readily but their removal leaves an immensely elongated supravaginal
cervix, which may be more difficult to deal with
satisfactorily.
The uterus should be palpated very carefully in order
to detect seedling tumours, which, if overlooked,
would jeopardize the final success of the operation.
This step is best postponed until the larger tumours
have been disposed of or until the uterine cavity has
been explored, as this makes detection much easier.
Professor Joel-Cohen advocates routine opening of the
uterine cavity via an anterior incision; this greatly simplifies the procedure, giving an excellent view of the
cavity and allows easy access to the posterior wall
fibroids.
Haemostasis during the procedure
The principal objection to myomectomy in the past was
the bleeding over which the operator had little or no
control. Myomectomy to be ideal requires to be almost
bloodless, for profuse oozing from the bed of the tumour so hampers the operator that there is not sufficient time for the removal of the smaller tumours and a
neat reconstruction of the uterus afterwards before
there are signs of severe blood loss. By the use of the
clamp devised by Bonney, myomectomy can be performed on an almost bloodless uterus, so that not only
can the operator work as deliberately as he chooses, but
also, if in the end he should find it impossible to terminate the myomectomy satisfactorily, the patient,
having lost little or no blood, is in a perfectly good
condition for hysterectomy.
The clamp is usually applied from the pubic end of
the abdominal wound with the angle between the
blades and the shanks opening downwards to grip the
round ligaments (Fig. 9.1); otherwise, as the blades are
closed, they will slip down past the cervix on to the
upper end of the vagina and the uterine vessels will no
longer be controlled. In some instances the instrument
fits better in reverse, i.e. with the angle between the
blades and the shanks opening upwards. By the use of
this clamp the blood flowing through the uterine vessels
and the cervix is arrested.
2 Bonney’s myomectomy clamp; this is often of great
help in reducing the amount of bleeding during the procedure. It is applied across the base of the uterus at the
junction of the body and cervix uteri, softly occluding
the uterine arteries as they pass up the lateral side of the
uterus.
Preoperative preparation
As well as the general preparation of the patient for an
abdominal operation, it is often worthwhile carrying
out an ultrasound examination to differentiate between fibroids and ovarian pathology. An intravenous
urogram (IVU) is also of value in determining if there is
any evidence of displacement or obstruction to the
ureters by the fibroids.
It is important to have adequate blood crossmatched
prior to the procedure, as there is a considerable risk of
bleeding both during the operation and in the immediate postoperative period.
Anaesthesia
No special anaesthetics are required.
The operation
Opening the abdomen
The incision is made as described in Chapter 6.
Clearly, if the fibroid to be removed is very small,
having been previously identified and measured at
laparoscopy, then a low transverse incision may be
appropriate. It is possible to remove even the most
enormous fibroid through a transverse or Pfannenstiel
incision, but it is more a mark of the surgeon’s desire to
make the operation unnecessarily difficult rather
than any innate surgical skill. If the operation is likely to
be a ‘tour de force’ then the procedure is best carried
out with adequate access via a subumbilical mid-line
incision.
Delivery and inspection of the uterus
The uterus having been delivered as far as possible out
of the abdominal cavity, the size and position of the tumour or tumours should be studied (noting the number
as far as may be possible at this stage) to determine if
enucleation is feasible and, if so, where best to place the
incision or incisions.
Tumours situated in the anterior or lateral walls of
BONNEY’S GYNAECOLOGICAL SURGERY
88
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the application of pressure with a swab or small pack
for a few minutes, or an additional suture or two, inserted where required. Figure-of-eight sutures of Vicryl
are ideal for this purpose.
A tumour low down in the body of the uterus or in the
cervix prevents the clamp being applied. In such a case
the tumour must be enucleated first and the clamp applied afterwards. The intravenous injection of 0.25 mg
of ergometrine by the anaesthetist as the surgeon opens
the abdomen promotes uterine contractions in the nonpregnant as well as the pregnant uterus, and reduces the
vascularity so completely that a clamp is often not required. When the Bonney myomectomy clamp is not
available, a rubber catheter can be attached around the
cervix to achieve the same result.
Whether a clamp or a tourniquet is used, it should
not be left in position for periods of more than approximately 20 min without being released. If necessary,
after its temporary release, it can be reapplied following
compression of the uterus in a hot towel. The reason for
this release is that during an extended myomectomy
with its associated trauma, however gentle the surgeon
may be, there is a considerable accumulation of
histamine-like substances which are suddenly released
into the general circulation in large quantities after the
clamp is removed. This is undoubtedly one of the reasons why postoperative shock has in the past been more
of a sequel to myomectomy than to hysterectomy. If the
clamp is temporarily released during the course of a
long operation, these waste products will not accumulate and in most cases the body will be able to deal with
them satisfactorily. Moreover, the patient is under close
supervision by the anaesthetist during and after the first
release.
The primary incision in the uterus
The lower the incision is made in the uterus, the
stronger will be the subsequent scar. The relative
strength of a lower segment caesarean section scar
compared with that of a classical caesarean section scar
provides a reasonable comparison with the strength of
the uterus following myomectomy through a supracervical incision and one in the fundus. Whenever feasible,
therefore, the incision should be made in the mid-line of
the anterior wall of the uterus as low down as is possible
with adequate exposure of the tumour. It is a useful preliminary procedure to mobilize the peritoneum of the
uterovesical fold and reflect the bladder down sufficiently in the mid-line to facilitate a low incision of ap-
The vessels themselves are not injured, being too well
protected by the tissues in which they are embedded.
The flow of blood through the ovarian vessels is
arrested temporarily by ring forceps; all the vessels
going into the uterus being thus occluded, it is rendered
almost bloodless. When the clamp and forceps are
removed, on completion of the operation, the uterus
flushes up, but on returning to the abdominal cavity the
flush soon passes off, and if the slight oozing from the
suture holes does not then cease it can be stopped with
MYOMECTOMY/FIBROIDS IN PREGNANCY
89
Fig. 9.1 Bonney’s myomectomy clamp applied to the lower
uterus.
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