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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_202_библиотеки_им_акад_М_И_Перельмана
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circumstances and therefore we will describe its closure. The peritoneum should be identified and raised by
straight tissue forceps attached to the mid points of the
wound on either side and at the lowest point. The surgeon then begins to appose the peritoneum from the uppermost part, using an absorbable suture of the modern
type such as Dexon or Vicryl. The suture is inserted in
a continuous manner, the assistant keeping an even
tension on the stitch so that the peritoneum is neither
bunched nor so slack that windows appear. The editor
often advises assistants that this should be a case of
appose and not necrose (Fig. 6.8a).
Closing the rectus sheath
The sheath is closed in the same line as the peritoneum
using a similar continuous absorbable suture (Fig.
6.8b).
Fat stitch
In very thin patients it is unnecessary to suture the fat.
However, in the majority of patients, fat stitches should
be used as a series of interrupted sutures to obliterate
any potential space (Fig. 6.9a). Critics state that it is
impossible to stitch fat. This may be so, but in women
Scarpa’s fascia is often well developed and is well
worthwhile suturing.
through it; if it is broad or there has been keloid formation, the old scar should be excised. Excision is most
easily performed by picking up the ends of the scar
using tissue forceps such as Littlewood’s forceps. With
the assistant holding the scar up the surgeon can cut
accurately down either side of it.
Adhesions to the old scar
Previous surgery markedly increases the risk of the
development of adhesions, particularly to the back
of the scar. Entry into the abdomen must therefore be
carried out in a circumspect way. If bowel is adherent to
the anterior abdominal wall it should not be separated
by pulling or rubbing with a swab. If there is no obvious
plane of separation, the ‘postage stamp’ technique
should be used. This involves removal of a ‘stamp’ of
peritoneum with the bowel so that there is no danger of
damage to the bowel wall.
Extension of the wound
This only applies to the mid-line and paramedian incisions. For the mid-line incision a lot has been written
about how to handle the umbilicus, varying from
cutting straight through to circumnavigation and even
a curious oblique incision. Extension can be easily and
accurately performed if the surgeon and his assistant
elevate the upper part of the wound using the index
fingers, and the surgeon cuts through all layers with a
knife, keeping the abdominal contents in full view. The
umbilicus is therefore easily circumnavigated using this
technique.
Closure of the abdomen
At the end of the surgical procedure, having made certain that there is no untoward bleeding, the abdominal
pack is removed; the swab, instrument and needle
count is carried out and reported and confirmed to be
satisfactory. There is no great advantage in bringing
down the omentum to lie in the pelvis unless there is a
wide defect in the peritoneum (see Chapter 12). The
abdominal wall can now be closed, maintaining the
patient in Trendelenburg whilst the various layers are
sutured.
Closing the peritoneum
There is considerable discussion as to whether the
abdominal peritoneum should be closed. There is no
absolute certainty as to the correct procedure in these
BONNEY’S GYNAECOLOGICAL SURGERY
60
Fig. 6.8 (a) Closing the peritoneum; (b) rectus sheath.
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(a)
(b)
thick tender scar. This may be reduced by using a nylon
subcuticular stitch, which is removed after a few days.
Variations in technique
Deep tension sutures. If there is a significant risk of
wound infection and/or breakdown, e.g. if there has
been wound soiling or there is extensive intraperitoneal
carcinoma, then it is prudent to support the wound as
much as possible. This is best done by using deep tension sutures. The sutures should be of a monofilament
material to reduce the introduction of further infection.
It is best to use a large curved atraumatic needle. The suture should pass through all layers, being placed wide
of the wound edges, so that when it is tied, following the
normal layered closure, the plastic tube spacers lie
across the wound edges (Fig. 6.11). Usually between
four and six deep tension sutures are required.
Mass closure. This technique, which uses a ‘far and
near’ continuous suture technique (Fig. 6.12), has
gained in popularity as it provides a simple strong closure with a very low dehiscence rate. Although not so
aesthetically satisfying, it is a sound closure system, especially for patients at high risk of wound breakdown.
Transverse or Pfannenstiel incision
The single most important value of this incision is
cosmetic. It is important for many women that their
abdomens should remain apparently untouched by the
surgeon’s knife, and using this technique the illusion
can be maintained. The incision follows Langer’s lines,
a short distance above the symphysis pubis, usually just
within the pubic hair line. Most minor pelvic surgery
can be easily performed through this incision and as
the surgeon develops his skills he will find that most
hysterectomies, minor tubal and ovarian surgery, and
lower segment caesarean sections come within the
compass of this route of access. In the author’s view, the
use of this incision for more radical surgery and particularly Wertheim’s hysterectomy should be eschewed,
although some clinicians do utilize it in these
circumstances.
This incision is also of particular value when operat-
ing on the extremely obese patient, for the area a short
distance above the symphysis pubis is often the thinnest part of the abdominal wall, and if the massive
abdominal pannus is lifted up and held out of the way
Wound drains
Unless there has been exceptional oozing from a very
deep abdominal wound, there is no necessity for drains.
Infection of the pelvis should always be drained
through a separate abdominal stab wound.
Skin closure
There are many techniques of skin closure varying from
metal clips through silk to stainless steel. In the editor’s
experience closure should be by interrupted and not
by a continuous method (Fig. 6.9b). This allows any
serous or bloody ooze to drain from the wound. The
materials which produce least skin reaction and scarring are monofilament materials such as nylon or, more
ideally, stainless steel staples in a preloaded stapling device (Fig. 6.10). It is the editor’s experience that subcuticular techniques, using absorbable sutures, produce a
OPENING AND CLOSING THE ABDOMEN
61
(b)
Fig. 6.9 (a) The fat stitch and skin closure; (b) the fat stitch
with interrupted stitches.
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(a)
BONNEY’S GYNAECOLOGICAL SURGERY
62
Fig. 6.10 Stapling the abdominal skin.
Fig. 6.11 Deep tension sutures.
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The incision
It is extremely important that the initial skin incision is
level and symmetrical. A skewed scar after this incision
is less acceptable than after any other. The landmarks of
the symphysis and the anterior superior iliac spines
must be accessible and not covered by drapes. The
drapes must be accurately and evenly placed so as not to
mislead the surgeon. The incision should be approximately 12 cm long for a hysterectomy, shorter for more
minor procedures. The initial cut is made cleanly
through the skin, slightly convex towards the pubis
(Fig. 6.13). The fat is incised down to the rectus sheath
and the aponeurosis of the external oblique muscle. As
the incision is completed, the surgeon should make
short cuts into the sheath on either side of the mid-line.
Small vessels in the fat are more numerous than in the
mid-line incision and must be clipped and tied or
diathermied. In particular, a large vein at each lateral
edges of the incision are often seen and should be
incised and tied unless they can be gently pushed on one
side. The techniques of tearing the fatty layers have
been advocated and although functionally satisfactory,
they are not aesthetically so.
by large Lane’s forceps, access to the abdomen is often
amazingly easy.
The incision is not advocated for extreme emergency
situations as it takes significantly longer to enter the
abdomen using this technique. The incision is also
more vascular than the mid-line alternative.
OPENING AND CLOSING THE ABDOMEN
63
Fig. 6.12 The mass closure technique.
Fig. 6.13 The Pfannenstiel
incision.
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BONNEY’S GYNAECOLOGICAL SURGERY
64
Fat stitch
This is particularly useful in this incision as Scarpa’s
fascia is well developed and easily defined. All subcuticular space should be obliterated if possible
since this vascular incision has a significant risk of
haematoma formation.
Wound drains
It is the editor’s impression that the transverse incision
requires drainage more frequently than the mid-line.
However, this is not a significant disadvantage and the
use of wound drains should not be regarded as a mark
of failure. If there is evidence of more oozing than usual,
and this may occur particularly after multiple entries in
the same site, the surgeon is well advised to utilize the
drainage procedure. As soon as drainage has ceased,
often within 24 h, the drain can be removed without
great discomfort to the patient, and without any
residual scarring.
Further reading
Te Linde RW, Mattingly RF. Operative Gynaecology, 4th edn.
Philadelphia: Lippincot, 1970. This is one of the great standard textbooks of gynaecological surgery with excellent
descriptions of the methods of entering and closing the
abdomen.
Joel-Cohen S. Abdominal and Vaginal Hysterectomy, 2nd edn.
London: William Heinemann, 1977. This covers the various
techniques in full and is a mine of useful information.
Incision of the aponeurosis
The short incisions in the rectus sheath are now extended for the full length of the skin incision using either a
scalpel or the Bonney’s dissecting scissors. The upper
and then the lower edges of the incision are now
grasped in turn by small artery forceps, elevated and the
underlying muscle separated from the sheath by a combination of blunt (swab) and sharp (scissors) dissection
(Fig. 6.14). Small vessels running parallel to the midline are clipped and tied. The rectus muscles are now
separated vertically and the peritoneum visualized.
Opening the peritoneum
This is performed in the same manner as for the midline incision, keeping a watchful eye on the upper limits
of the bladder. It is usually easy to see the upper limit of
the bladder by identifying urachus as it appears as a
narrow fibrous band in the mid-line. Grasping the
urachus and incising it is a simple way of entering
the peritoneal cavity.
Closure of the abdomen
Closing the abdomen
This is carried out as in the mid-line incision, using a
continuous absorbable suture material for the peritoneum and sheath. It is superfluous to suture the rectus
muscles together as the design of the wound gives adequate strength.
Fig. 6.14 Dissecting the rectus sheath.
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and Ellis, published by Baillière Tindall, London, Professor
Harold Ellis reviews the many factors which a surgeon must
take into account when making and closing an abdominal
wound (pp. 124–42).
We also recommed the readers to review chapter 9 in the
Atlas of Pelvic Surgery by C.R. Wheeless, published by
Williams & Wilkins, 3rd edition, 1997.
For the student who feels that a study of potential problems
is essential, the editor would recommend the early sections in
the text Complications of Surgery in General by J.A.R. Smith
(1984), published by Baillière Tindall, London. The author
extensively discusses the various techniques of opening and
closing the abdomen, listing all the advantages and disadvantages of each approach.
In the text Wound Healing for Surgeons (1984) by Bucknall
OPENING AND CLOSING THE ABDOMEN
65
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66
reviewed and preplanned in preadmission clinics,
which reduce the preoperative admission times
significantly.
It is essential that the patient fully understands the
scope of the surgery intended, particularly in relationship to the removal or preservation of the ovaries.
Occasionally, fashions concerning preservation or
removal of the cervix will appear. The patient must be
quite clear as to the extent of any surgery.
Preadmission clinics and early admission will be an
opportunity to go through the procedure with the patient. The blood should be taken for a full blood count,
grouping of the blood type and the preservation of the
sample in case a transfusion is required. Transfusion for
most hysterectomies is rarely required. Patients will be
reviewed and consented by the anaesthetist and any
extra investigations organized.
It remains traditional to shave the abdomen for
an abdominal procedure; in the author’s view this is
only necessary for the visible part of the pubic hair.
The traditional ‘through and through’ technique is
unnecessary. Conversely, for a vaginal hysterectomy,
only the pubic area needs shaving. It is important to
perform any shaving as close to surgery as practicable.
It is also unnecessary and potentially dangerous to over
clean the abdominal wall with antiseptics as recolonization with more malign bacteria may occur prior to
surgery.
The balance between late admission and reducing
preoperative tension is a fine one. A good night of sleep
before operation is advantageous and this may best be
achieved in the patient’s own bed. Some patients may
require sedation prior to surgery others will not.
Total abdominal hysterectomy
7
It is interesting that Bonney used the more correct title
for this chapter of ‘Abdominal total hysterectomy’; the
current editor has changed to the present form so that
the accepted abbreviation of TAH is consistent. This
operation remains the accepted basic procedure for
removing the uterus in the management of benign
disease; it is also used in oncological care for the
management of cervical intraepithelial neoplasia
(CIN), cancer of the corpus uteri and ovary.
Once a decision to perform a hysterectomy has been
made, the surgeon must decide and recommend to the
patient the most appropriate route. The choices available currently include abdominal, vaginal, laparoscopically assisted vaginal and subtotal. Various forms of
total laparoscopic hysterectomy are rarely indicated
or performed. The factors determining the choice are
discussed in Chapter 8.
The technique described here is inevitably a melange
of many influences upon the author, not least previous
editions of this book.
Instruments
The gynaecological general set described in Chapter 2 is
used.
Patient preparation
The patient is usually admitted as close to surgery
as possible; when the operation is planned for the
morning, the day before is the usual admission time.
If an afternoon list is planned, the morning of operation is most appropriate. Increasingly patients are
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Once the course of the ureter has been identified, the
index finger of the left hand can be used to elevate
the infundibulopelvic ligament allowing a clamp to be
placed either on the medial or the lateral side of the
ovary dependent on whether these structures are to be
preserved or removed (Fig. 7.2). If the ovaries are to
be removed they can be moved medially on the index
finger and a clamp applied directly to the vessels within
the infundibulopelvic ligament. If the ovaries are to be
preserved, the clamp is simply placed on the medial side
of the ovary and the tube and ovarian ligament are cut.
Ligation of the round and infundibulopelvic ligaments
It is useful to ligate these ligaments at an early stage in
the procedure to leave the operative field as clear as possible. The pedicles may be stitch ligatured or simply
tied, as is authors’ practice. The round ligament
tie can be ‘left long’ and attached to a small Spencer
Wells clip, thus maintaining tension on the peritoneum
The operation
Following general anaesthesia, the vulva and vagina
are cleaned and the bladder catheterized and emptied.
Usually if the hysterectomy is being performed as the
only procedure, and the patient is fit, an indwelling
catheter is not necessary. If the procedure is part of
the management of, for example, ovarian cancer an
indwelling catheter will greatly assist fluid assessment
both intraoperatively and postoperatively.
The use of intravaginal dyes or packs is superfluous.
Suturing and occlusion of the cervix when dealing with
corpus cancer is also quite unnecessary.
The incision
The choice of incision is dealt with in Chapter 6.
Exploration of the abdomen and pelvis
This important preamble is dealt with in Chapter 6.
Clamping and dividing the round and
infundibulopelvic ligaments
The uterus is elevated by placing the surgeon’s left hand
into the pouch of Douglas and lifting the body of the
uterus to put the uterosacral ligaments on the stretch. A
medium-sized straight pressure forcep is placed on
either side of the cornu to include the origins of the
tubes and the round ligament approximately 1 cm from
the uterine wall (Fig. 7.1). When the handles of the two
clamps are placed together and held in the left hand, the
whole uterus can be manoeuvred. When the uterus is
elevated, the round ligaments become prominent bands
passing anterolaterally behind the peritoneum towards
the inguinal ligament. The round ligaments are picked
up at roughly their mid points with a medium-sized
pressure clamp and then incised on their medial side
(Fig. 7.1). This clamp is handed to the assistant thus
opening the anterior part of the broad ligament. The
soft areolar tissue within the leaves of the broad
ligament is now revealed.
The author recommends that at this point the simple
manoeuvre of opening up the retroperitoneal space
down the point at which the ureter is visible is
an important practice which once learned can be
applied to virtually all pelvic procedures. This technique allows the ureter to be visualized in the upper
pelvic part of its course where it lies close to the infundibulopelvic ligament, a site of all too frequent
clamping of the ureter.
TOTAL ABDOMINAL HYSTERECTOMY
67
Fig. 7.1 Cutting the round ligaments.
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noeuvre will vary; the authors’ preferred choice is to use
the relatively blunt closed tips of the Monaghan scissors to gently push and occasionally incise the tissues
attaching the bladder to the uterus. If the surgeon begins close to the mid-line and gently separates, staying
close to the uterus and the cervix, a clean plane will
be identified. A thin gauze swab over the finger may be
used to push the angles of the bladder away from
the cervix if preferred (Fig. 7.4). This entire process
is assisted by the surgeon maintaining tension of the
uterus by gently drawing it upwards using the clamps
originally placed close to the cornu.
The lower limit of the cervix can be readily identified
by observing the indentation as the cervix ends and the
anterior fornix begins. It is important to be sure that the
lateral parts of the bladder are adequately reflected as
the ureters are very close to the upper vagina at this
point. If the patient has had a previous lower segment
caesarean section, the dissection may be more difficult
and will require significantly more sharp dissection in
order to release the scar tissue; this sharp dissection is in
fact less traumatic and fundamentally safer than blunt
pushing of the tissues. Close attention should be paid to
the tissue plane on the surface of the lower uterus and
laterally and assisting in ‘opening up’ the lateral broad
ligament space, providing improved access to the
parametrial tissues. NB: a clip should never be left
on a pedicle containing a blood vessel such as the
infundibulopelvic ligaments.
Reflecting the bladder
It is logical to incise the peritoneum overlying the bladder along the line of the uterovesical fold at the same
time as the round ligaments are divided. With the
scissors in the surgeon’s right hand and the assistant
elevating the peritoneum over the bladder with Mayo
toothed forceps, it is very simple to run the scissors
under the tented peritoneum separating the bladder
and then to incise the peritoneum in a curved line across
the front of the uterus to meet up with the round ligament on the opposite side (Fig. 7.3). If the level of incision is too high the peritoneum will not separate from
the front of the uterus and if too low bleeding will occur
from the small vessels on the surface of the bladder.
Once this incision is complete, the bladder can be
gently separated from the anterior surface of the uterus
and then the cervix. The technique to achieve this ma-
BONNEY’S GYNAECOLOGICAL SURGERY
68
Fig. 7.2 Cutting the infundibulopelvic ligament.
Fig. 7.3 Incising the uterovesical fold.
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anterior part at the level of the junction between the
corpus and the cervix; the fingers of the left hand pressing into the posterior fornix will cause the cervix to protrude forwards and the position of the anterior fornix
becomes more obvious. The effect of this step is to make
the application of clamps to the parametrium and the
paracervical tissue easier as well as causing the bladder
to drop ‘below’ the level of the cervix.
Clamping the uterine vessels and the vaginal angles
The uterine arteries arise from the anterior division of
the internal iliac arteries deep in the lateral pelvis at the
level of the obturator fossa. They then pass medially,
overlying the ureter as it approaches the lateral part of
the cervix. The artery divides close to the uterus at the
level of the internal os into a descending and an ascending branch. The ascending branch, which is larger, runs
close to the lateral sides of the uterus and can be seen as
it passes in a tortuous fashion from below upwards
feeding small branches into the substance of the uterine
corpus. This vessel is clamped by placing a pressure forcep with the tip abutting onto the myometrium at right
angles to the long axis and at roughly the mid point of
the length of the uterus (Fig. 7.5). The pedicle is divided
as close to the forcep as possible. The same procedure
is performed on the opposite side. A further forcep,
ideally one with longitudinal ridges such as a Zeppelin,
cervix, as this is the optimal and safest position for any
sharp dissection.
Where the uterus is a little immobile it often helps
if the surgeon puts the left hand into the pouch of
Douglas, bringing the thumb around the uterus to the
TOTAL ABDOMINAL HYSTERECTOMY
69
Fig. 7.4 Separating the bladder.
Fig. 7.5 Clamping the uterine artery.
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