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BONNEY’S GYNAECOLOGICAL SURGERY
200
The material of which all these devices are constructed is inert and remains with the patient for the rest of
her life, although on occasions following fibrosis of the
surrounding tissues they can dislodge from the fallopian tubes and can be seen lying within the pouch of
Douglas.
It is said that the advantage of these mechanical
obstructive devices is that they damage only a small
portion of the tube so that it is relatively straightforward to reconstruct the tubes in the future, giving a realistic prospect of pregnancy. The authors would stress
that it should not be the policy of any doctor to recommend sterilization techniques on the basis that they
may be reversed; all patients embarking on a sterilization operation must do so in the knowledge that the
procedure is permanent.
Further reading
Why Women Die 1997–1999: The fifth report of the confiden-
tial enquiries into maternal deaths in the United Kingdom.
London: RCOG, 2001.
References
Ectopic pregnancy is multifactorial in its aetiology. Breen JL
(1970) A 21-year survey of 654 ectopic pregnancies (Am J
Obstet Gynecol 106:1004–19) reviews the disease process,
particularly predisposing factors and site of ectopic.
Bronson RA (1977) Tubal pregnancy and infertility (Fertil
Laparoscopic methods
The technique of laparoscopy is described in Chapter
17. The ease with which the tubes can be visualized
and manipulated has virtually eliminated the need to
perform open tubal ligation procedures.
After introduction of the laparoscope and an additional trocar/introducer into the abdominal cavity,
various appliances can be used to perform the tubal
occlusion procedure.
Shortly after the first use of laparoscopy, there developed a great vogue for diathermy of the tubes and
resection of the diathermied area. Although this
technique has been successfully used to sterilize many
thousands of women, it is potentially dangerous and
has been superseded by the application of tubal occlusion devices to the tubes using applicators specially
designed for this purpose.
The devices include the Falope rings, small Silastic
rings which are applied by drawing the fallopian tubes
up into a hollow applicator and then releasing the
ring from the end of the applicator so that the ring lies
firmly around the loop of tube. These techniques carry
the same disadvantages as the Pomeroy operation.
The Hulka and Filshie clips are small locking devices,
which are applied to the tubes using special applicators,
and if applied appropriately will seal the tubes completely. Despite common practice, it is not recommended that the clips be applied in pairs to each tube because
of the potential risk of a symptomatic hydrosalpinx
developing between the two clips.
Fig. 18.4 Ligation and resection of the
fallopian tube.
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Details of the technique of clip sterilization is contained in
the original articles by Hulka et al and Filshie et al.
Hulka JF, Omran KF, Lieberman BA and Gordon AG.
Laparoscopic sterilization with the spring clip: instrumentation, development and current clinical experience. Am J Ob-
stet Gynecol 1979;135: 1016–20.
Filshie GM, Casey D, Pogmore JR, Dutton AG, Symmonds
EM and Peake AB. The titanium/silicone rubber clip for female sterilisation. Br J Obstet Gynaecol 1981;88:655–62.
Steril 28:221–8) demonstrates the high risk of ectopic pregnancy arising in those women who have undergone surgery on
the fallopian tubes with a view to correcting infertility.
Nicholas Kadar has reappraised the aetiology, diagnosis
and treatment of ectopic pregnancy in a chapter in the
Progress in Obstetrics and Gynaecology series (vol. 3, 1983)
John Studd (ed.), published by Churchill Livingstone.
One of the original references to silicone rubber ring sterilization (Falope ring) is Yoon IB, Wheeless CR and King TMA
(1974) Preliminary report on a new laparoscopic sterilization
approach. The silicone rubber band technique. Am J Obstet
Gynecol 120: 132–6.
EXTRAUTERINE GESTATION/STERILIZATION
201
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202
papillae, thickened septae, bilateral lesions and ascites
are suggestive of malignancy, as is an increased blood
flow on doppler studies. In these cases an abdominal
ultrasound scan should also be performed to assess the
upper abdomen (liver, omentum and para-aortic lymph
nodes) for evidence of malignant spread.
The determination of serum levels of the tumour
marker CA125 is also useful in differentiating benign
from malignant cysts, especially in the postmenopausal
woman. The authors currently use the ultrasound
findings combined with a serum CA125 level and
menopausal status to calculate the risk of malignancy
index (RMI) to differentiate benign from malignant
lesions. Those with a RMI of >200 are at increased
risk of malignancy and are managed by gynaecological
oncologists, whilst those with RMI <200 are managed
by the gynaecologist.
Surgery
The role of surgery for an ovarian cyst is its removal
and histological diagnosis. In women under 40 years
of age, benign cysts should be managed using ovarianpreserving procedures, but above that age an
oophorectomy may be more appropriate. If there is
doubt about the nature of the cyst, frozen section of the
cyst should be undertaken.
Since the last edition of this textbook, laparoscopic
surgery has become the gold standard in the treatment of
benign ovarian masses in many centres, with laparotomy being reserved for the treatment of malignant
tumours. However, the laparoscopic management of
ovarian cysts has been controversial because of the con-
Operations for benign
ovarian disease
19
Ovarian cysts are said to be the fourth most common
gynaecological cause for hospital admissions. They are
classified as non-neoplastic functional cysts such as follicular or corpus luteum cysts, or neoplastic cysts. Their
ratios vary with age but approximately:
1 25% are functional cysts.
2 40% are benign cystadenomas.
3 15% are dermoid cysts (benign).
4 10% are endometriotic cysts.
5 10% are malignant cystadenocarcinomas.
The rapid development of ultrasound technology
and its increasing use in routine gynaecological practice
has led to an increased diagnosis of ovarian cysts in
women of all age groups. In premenopausal women the
majority of lesions are benign functional cysts which
usually disappear with menstruation or can be managed conservatively by suppression of ovulation with
the combined oral contraceptive pill. Persistent cysts
or those suspicious of malignancy require surgical
removal. In recent years there has been an increasing
use of the laparoscope for assessment and removal of
adnexal cysts thought to be benign in nature.
Diagnosis of an ovarian mass
The normal ovary is usually palpable in the premenopausal woman but barely palpable in the postmenopausal. Consequently, almost any enlargement
should be looked upon with suspicion and warrants
further investigation. Transvaginal sonography is the
investigation of choice not only in the detection of the
ovarian cyst, but also in the assessment of potential
malignancy. Features such as multiple cysts, solid areas,
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meticulously performed as described in Chapter 6, together with the collection of washings from the peritoneal cavity. If there is any free fluid in the abdomen its
presence should be recorded and it should be removed
before washings are taken and sent separately for
cytology. Washings are best carried out by instilling
100–200 ml of normal saline into the pelvis and along
the paracolic gutters and then collecting the fluid using
a large syringe. NB: it is not unusual to find a small
quantity (20–50 ml) of fluid in the peritoneal cavity in
association with benign lesions.
Extraction of the enlarged ovary
If the cyst is large, it is easily delivered from the wound;
if the cyst is relatively small, or the tubes and infundibulopelvic ligaments are resistant, the procedure can be
performed within the abdomen, using a self-retaining
retractor to give adequate access.
Incising the capsule of the cyst
It is often possible to identify the edge of the normal
ovarian tissue running along the lower part of the
ovary. If this is so, the knife should be lightly run along
this line (Fig. 19.1); the plane of cleavage will readily
cern of accelerating intraperitoneal dissemination of an
unsuspected ovarian cancer. Although the evidence for
this is not overwhelming, definitive surgery in this situation should be undertaken within 2–3 weeks and the trocar sites should be excised as part of the procedure. With
careful preoperative assessment and appropriate selection of cases the situation should arise infrequently.
The principles of laparoscopic surgery for ovarian
cysts are similar to that at open surgery, but the approach and technique differ and have been described in
Chapter 17.
Ovarian cystectomy
Victor Bonney gave this name to the procedure whereby the cyst is removed without compromising the function of the ovary. The same technique is used for the
enucleation of a small solid ovarian tumour such as a
fibroma.
For ovarian cystectomy to be successfully carried
out, the mass to be enucleated must have a capsule (a
characteristic of most benign tumours), the most common exception being endometriotic cysts, which rarely
have a recognizable capsule and can usually only be
separated from the ovary by sharp dissection.
The benign tumours of the ovary which are amenable
to the technique include:
1 Benign teratomas (dermoids).
2 Serous cystadenomas.
3 Corpus luteum cysts.
4 Fibromas.
The procedure should always be considered in young
women where ovarian preservation is to be desired,
particularly where the cysts are bilateral and total loss
of the ovaries would produce a premature climacteric.
The operation (laparotomy)
Opening the abdominal cavity
This is described in Chapter 6. The decision to use
either the transverse or the longitudinal incision will
obviously depend on the size of the ovarian cyst and
whether there is any possibility of the tumour being
malignant. If there is any likelihood that the mass is
malignant, a vertical incision must be carried out.
Exploration of the abdomen
The examination of the entire abdominal cavity is
BENIGN OVARIAN DISEASE
203
Fig. 19.1 Incising the capsule of an ovarian cyst.
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5 mm trocars are inserted either side of the lower abdomen for instrumentation and occasionally a further
suprapubic port may be necessary. Using a 5mm
laparoscope increases the flexibility as it can be inserted
into any port.
Exploration of the abdomen
This is identical to the open approach and washings
should also be taken for cytology. If there is any suspicion of malignancy, a biopsy should be performed and
the operation abandoned with referral to a gynaecological oncologist, or if appropriate converted to a
laparotomy.
Incising the capsule of the cyst
Using laparoscopic scissors and forceps an attempt is
made to find a plane of cleavage to remove the cyst
intact. For large cysts and where there is difficulty finding a plane, the cyst may be punctured and the fluid
aspirated. This should be performed in an endobag
inserted through the umbilical port to avoid leakage
into the peritoneal cavity. The cyst lining is examined
for any areas suspicious of malignancy and if not the
cyst wall is excised. Haemostasis is obtained and there
is no need to repair the ovary.
Removal of the ovarian cyst
The ovarian cyst is placed in an endobag and removed
through the umbilical port which may need to be extended or the cyst is aspirated in the bag before removal. It is frequently simple to insert the Verres needle
through the entrance to the endobag which has been
brought out of the port and then by applying countertraction the needle can be inserted cleanly into the cyst
and the fluid content extracted. This procedure
eliminates contamination of the port by the cyst or its
contents.
Port closure
The umbilical port site is closed in layers.
Removal of a retroperitoneal cyst
The majority of retroperitoneal (or broad ligament)
cysts are ovarian cysts which have grown retroperitoneally. This is more likely to occur after hysterectomy
with ovarian conservation when the ovaries frequently
become retroperitoneal structures.
become apparent and should now be developed using
blunt dissection either with the handle of the scalpel, or,
as the authors prefer, with Monaghan’s scissors, using
the blunt points to separate and develop the plane.
The incision is now carried further around the cyst
The cyst is gently peeled back from the normal ovarian
tissue (Fig. 19.2) until all that is left is a thin strip of
normal ovary which is cut with the scissors.
Repair of the remaining ovarian tissue
Usually, there is a thin rim of redundant capsule which
should be resected back to the thicker normal ovarian
stroma. The edges of the ovarian tissue are brought
together using fine interrupted sutures.
Abdominal closure
The ovary is returned to the abdomen and the wound
closed as described in Chapter 6.
The operation (laparoscopy)
Insertion of trocars
Unless contraindicated, a 12 mm trocar is inserted into
the umbilicus either by an open technique or following
insufflation followed by the laparoscope. Two further
BONNEY’S GYNAECOLOGICAL SURGERY
204
Fig. 19.2 Removing the ovarian cyst intact.
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small veins which lie in the same position. If oozing
does occur, tissue must not be blindly clamped; the best
technique is to insert a swab into the bleeding space, applying a little pressure and wait for 2 min, taking care to
inform the scrub nurse that a swab has been inserted
and is marked up. When the swab is removed the whole
field is dry and the small bleeding points can be identified and ligated. If the cyst is ovarian in origin one can
either perform a cystectomy or oophorectomy.
Dealing with the peritoneum
After the cyst or ovary has been removed and
haemostasis secured, no attempt is made to repair the
pelvic peritoneum.
Abdominal closure
The abdomen is closed in the manner described in
Chapter 6.
Difficulties and dangers
If the safeguards mentioned above are taken with respect to the ureters and to the uterine vessels, then this
procedure should not produce any problems. Haemorrhage may be troublesome and the anatomy distorted
and discoloured, making identification of structures
problematic.
Proper identification of all structures will make this
a simple procedure, ‘short cuts tend to make long
operations’.
The exact position of the ureter will vary depending
on the size and extent of the retroperitoneal extension
of the cyst, stressing the vital importance of identifying
the ureter at an early stage in the procedure and
following it for the full length of its course across the
cyst. Clear identification and separation of the ureter
will remove the most important danger in this
procedure.
The operation
Identification of the cyst
Having opened the abdomen as described in Chapter 6,
the cyst is palpated and its limits defined.
Opening the peritoneum and identifying the ureter
The safest area to open the peritoneum is between the
fallopian tube and the round ligament. The peritoneum
is incised and the edges picked up (Fig. 19.3). The incision is now curved posteriorly so that by separating between the cyst and the lateral pelvic side wall, using the
fingers, the ureter can be isolated as it courses in the
peritoneum over the cyst. Usually, the plane of cleavage
is easily found and the cyst is rapidly circumnavigated.
Enucleation
If the cyst is not ovarian in origin it usually shells out
without great difficulty, but if it has burrowed below
the uterine artery this can be sacrificed together with
BENIGN OVARIAN DISEASE
205
Fig. 19.3 Opening the peritoneum and
identifying the ureter.
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superseded as first-line management by the use of
clomiphene and the human gonadotropins.
The operation consists of delivering the ovary and
taking out a longitudinal ‘orange segment’ of the
ovarian tissue. The two halves of the ovary are then
reapposed using interrupted Vicryl or nylon sutures
(Fig. 19.4).
Further reading
M Canis from Clermont Ferrand, France has one of the largest
experiences in laparoscopic surgery for adnexal masses having
managed over 1600 cases and published widely on the subject.
Recent articles include:
Canis M, Botchorishvili R, Manhes H, Wattiez A, Mage G,
Pouly JL and Bruhat MA. Management of adnexal masses:
role and risk of laparoscopy. Semin Surg Oncol 2000;
19:28–35.
Canis M, Rabischong B, Houlle C, Botchorishvili R, Jardon K.
Safi A, Wattiez A, Mage G, Pouly JL and Bruhat MA. Laparoscopic management of adnexal masses: a gold standard? Curr
Opin Obstet Gynecol 2002;14:423–8.
Variations
It is possible for an ovarian cyst to grow downwards
and forwards into the broad ligament so that it mimics
a true broad ligament cyst. The management is as described above except that the cyst will have a pedicle
which must be identified, clamped and cut.
Wedge resection of the ovary
This procedure had a much greater vogue in the past,
possibly out of misdiagnosis and a failure to understand that an ovary with multiple small follicular cysts
is in no way abnormal. Unfortunately, small cysts on
the ovary are often all that is found when laparotomies
are performed for unattributable pelvic pain. It is very
doubtful whether these small cysts can ever be blamed
for the pain which has provoked the laparotomy. Puncturing of the cysts or wedge resection of the ovary was
often performed.
The procedure was also popularized in the manage-
ment of Stein–Leventhal syndrome but has now been
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206
Fig. 19.4 Wedge resection of the ovary.
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207
Preparation of the patient
The patient should be prepared as for any laparotomy,
but with certain special considerations:
1 All patients with a suspected ovarian mass should
have a preoperative risk of malignancy index (RMI)
calculated to determine the likelihood of the mass being
of malignant origin. The RMI is calculated using a
simple and useable formula that incorporates a combination of ultrasound scan features of the ovarian
mass, the serum CA125 tumour marker result and the
menopausal status.
2 If the RMI result is suggestive of malignancy, then the
patient is best referred to a gynaecological oncology
centre for treatment.
3 Various other tumour markers including carcinoembryonic antigen (CEA), CA199 and CA153 should
also be considered to determine the possibility of the
ovarian mass being due to metastatic spread from another site. In young patients, the clinician should be
alerted to the possibility that the ovarian mass is of
germ cell type, and include a-fetoprotein, human chorionic gonadotropin (HCG) and lactate dehydrogenase
(LDH) serum estimations as part of their tumour
marker screen.
4 The bowel should be prepared prior to surgery for
possible resection by use of a low-residue diet together
with large bowel clearance and a non-absorbable antibiotic for 2 days prior to surgery. Stoma siting is
advisable as the patient will not be thankful for a troublesome stoma, which might have been better placed.
5 A chest X-ray is necessary to exclude obvious chest
metastases and pleural effusions, which may require
drainage prior to surgery.
Operations for malignant
ovarian disease
20
Surgery for malignant ovarian disease can be the most
challenging of surgical procedures in gynaecological
practice. The disease invariably presents late in its
course, at which point there is widespread peritoneal
dissemination of tumour. Currently, the standard treatment consists of a combination of primary surgical debulking in an attempt to achieve complete or optimal
cytoreduction, followed by a course of chemotherapy.
Recent evidence has also confirmed the significant
value of surgical cytoreduction as an interval procedure
during the course of chemotherapy if optimal debulking was either not performed or not achievable in the
primary setting. In addition, surgical cytoreduction of
recurrent disease would appear to be of significant
benefit not only in relieving symptoms, but also in
improving outcome survival.
These operations are best performed under the
auspices of a gynaecological oncology centre by highly
trained, accredited gynaecological oncologists who
are more able to achieve maximum cytoreduction,
and are better placed to provide the multidisciplinary
care that is required to allow the greatest likelihood of
cure.
Ovariotomy
Ovariotomy was first performed successfully in 1809
by McDowell in the USA, replacing the procedure of
tapping of ovarian cysts with a potentially curative
operation. The term ovariotomy or ovariectomy is
limited to the removal of a diseased ovary, whether
benign or malignant.
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appropriate bowel stapling devices, a pair of Babcock’s
tissue forceps, some iodine solution and a surgiclip
device.
The operation
The incision
This must be of an adequate size to remove the ovarian
mass intact. It must be possible to lengthen the wound
easily and quickly, and allow a full visual inspection of
the entire abdomen. These requirements indicate that
there is no place for the low transverse or Pfannenstiel
incision.
Exploration of the abdomen
This is carried out in a meticulous manner, paying
particular attention to the leaves of the diaphragm, the
liver, the para-aortic lymph nodes and the omentum as
well as a complete pelvic assessment. Ideally, these findings should be recorded on a ‘tick sheet’ in theatre.
Peritoneal washings
If present, a small amount of ascitic fluid should be sent
for cytological assessment. In addition, the amount of
ascitic fluid removed should be recorded. In the absence
of ascites, peritoneal washings should be performed
from within the pelvis, both paracolic gutters and the
upper abdomen, in association with the performance of
smears obtained from both diaphragmatic leaves.
Tapping of the cyst
This section is only retained to reaffirm that there is
no place for the tapping of ovarian cysts; every effort
should be made to remove the cyst intact and the
wound lengthened to accommodate this removal.
Delivery of the ovarian mass
As many ovarian tumours reach an enormous size before the patient presents for treatment, it is not infrequently found that there are adhesions to bowel and
other peritoneal surfaces (Fig. 20.1). Where the mass is
carcinomatous, there may be direct extension of the
tumour into surrounding structures. At the time of the
preliminary examination, the extent of these adhesions
must be noted. The cyst must be released from its adhesive attachments before delivery from the abdomen.
This process often involves considerable manoeuvring
of the mass and extension of the wound will often ren-
6 Preoperative drainage of ascites should be avoided as
much as possible, as port site tumour implantations can
be particularly symptomatic to the patient and will
require excision during the cytoreductive surgical
procedure.
7 When there is little doubt about the diagnosis, there
is virtually no need for preoperative assessment by
intravenous urogram (IVU), CT scan, MRI, barium
enema or colonoscopy/sigmoidoscopy.
8 A full blood count is mandatory as many women
are anaemic at presentation, and if not adequately dealt
with this can exacerbate the problems associated with
the significant blood loss that often accompanies the
complex and prolonged procedures required during
the cytoreductive surgical intervention.
9 A biochemical profile is also required as many patients show considerable fluid, electrolyte and protein
derangement at presentation. An experienced anaesthetist is invaluable during the perioperative period
as management of fluid balance often requires a cocktail of ingredients first to optimize the patient, and
secondly to maintain optimization during this crucial
period.
10 Nutritional status is often neglected in these
patients. Assesment by dietitians can usually identify
those most at risk, thereby allowing intervention during the perioperative period by the use of various forms
of supplementation.
11 An indwelling transurethral urinary catheter
should be inserted to allow adequate monitoring of
fluid balance during surgery and the early postoperative period.
Anaesthesia
As so many patients who come to ovariotomy have
late-stage carcinoma of the ovary with associated embarrassment of their cardiopulmonary function due to
ascites and pleural effusions, it is important to use careful anaesthetic techniques. The authors prefer light
general anaesthesia combined with epidural or spinal
analgesia; this allows complete relaxation without the
toxic effects of full muscle relaxant general anaesthesia.
Instruments
The instruments in the gynaecological general set
outlined in Chapter 2 will be required together with
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Examination of the opposite ovary
If the patient is young and there is no suspicion of
malignancy, the opposite ovary should be preserved
and an ovarian cystectomy performed on the diseased
side. However, if the ovarian mass shows any suggestions of malignancy, the authors advocate removal of
the entire diseased ovary, which should be sent for
immediate frozen section analysis, a technique that has
been shown to be extremely accurate and useful under
these circumstances. If the mass is confirmed to be malignant, it is mandatory that a full staging procedure is
carried out. This would include removal of any suspicious intraperitoneal tissues, systematic bilateral pelvic
and para-aortic lymphadenectomy, complete omentectomy and multiple random peritoneal biopsies from
various sites within the abdominal and pelvic cavity. If
subsequent fertility is not a relevant issue, the staging
procedure should be combined with a total abdominal
hysterectomy and removal of the remaining ovary and
both fallopian tubes. If immediate frozen section analysis is not available, an alternative approach would be to
close the abdomen after removal of the diseased ovary
der a difficult task simple. Once adhesions are clear, the
surgeon should elevate the cyst with the left hand; at the
same time, the assistant can gently depress the sides of
the wound so that the mass delivers through the wound
(Fig. 20.2). Great care should be taken not to tear the
pedicle, which, although large, contains many delicate
veins.
Often, very large tumours are multicystic with large
bosselated projections; it is easier to deliver these
tumours by rotating the cyst so that one projection
at a time is delivered from the wound.
There is no merit in attempting to force a large mass
through a small wound and rupturing the capsule; if the
tumour is malignant, the prospects for the patient will
be significantly reduced.
MALIGNANT OVARIAN DISEASE
209
Fig. 20.1 Separation of adhesions from an ovarian
carcinoma.
Fig. 20.2 Delivery of the ovarian cyst from the wound.
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