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Comp
l
ications in
Gynecological Surger
y
P
eter O’Donovan
(
Ed.
)
om
p
l
i
cat
i
ons
i
n
Gynecolog
i
ca
l
urger
y
P
eter O’Donovan, MB, FRCOG, FRCS
(
ENG
)
Th
e Merit
C
entre
Bradford Royal Infi
rmary
B
ra
df
or
d,
West Yor
k
s
h
ir
e
UK
B
ritis
h
Li
b
rary Cata
l
oguing in Pu
bl
ication Dat
a
C
omp
l
ications in gyneco
l
ogica
l
surger
y
1. Generative organs, Fema
l
e—Surgery 2. Laparoscopic
sur
g
er
y
I. O’Donovan, Peter
J
.
6
1
8.
1
0
5
9
I
S
BN-13: 9781846288821
L
i
b
rary o
f
Congress Contro
l
Num
b
er: 200792570
8
I
S
BN: 978-1-84628-882-1 e-I
S
BN: 978-1-84628-883-8
©
Sprin
g
er-Ver
l
a
g
Lon
d
on Limite
d
2008
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y
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g
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oes not imp
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9
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d
ia
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pringer.com
C
o
ntent
s
ontributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
1 Prevention o
f
In
f
ection Fo
ll
owing Gyneco
l
ogica
l
S
ur
g
er
y
: The Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
R
onnie F. Lamont and S.V.Z. Hayne
s
2 Complications in G
y
necolo
g
ical Oncolo
gy
. . . . . . . . . . . . . 1
1
R
obin A.F. Craw
f
or
d
3 Laparoscopic Entr
y
Techniques: Consensus . . . . . . . . . . . 20
S
avita La
l
c
h
an
d
ani an
d
Kevin P
h
i
ll
ip
s
4 Complications of Laparoscopic Sur
g
er
y
f
or En
d
ometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
J
erem
y
T. Wrig
h
t
5
A
bd
omina
l
Woun
d
C
l
osure: How to
Avoi
d
Comp
l
ications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
P
atrick Ho
g
sto
n
6 Recent A
d
vances in A
dh
esion Prevention . . . . . . . . . . . . . 5
2
Gere S. diZere
g
a and Matthias Korel
l
7 W
h
at to Do W
h
en t
h
e Operation Is Over . . . . . . . . . . . . . . 6
1
ir
g
inia A. Beckett and Derek J. Tu
ff
nell
8 Laparoscop
i
c Sur
g
er
y
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
J
ose
p
h A. O
g
a
h
9 Urinar
y
Tract Complications . . . . . . . . . . . . . . . . . . . . . . . . 7
5
J
ose
p
h A. O
g
a
h
0 The Hi
g
h-Risk G
y
necolo
gy
Patient: Assessment
and Mana
g
ement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Guy W. G
l
over an
d
Pau
l
G.W. Cram
p
1 Complications in H
y
steroscopic Sur
g
er
y
: Prevention
an
d
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
P
au
l
McGurgan an
d
Peter O’Donova
n
https://t.me/med1917
2 Minimizin
g
the Risk of Sterilization Failure:
A
n Evi
d
ence-Base
d
A
pp
roac
h
. . . . . . . . . . . . . . . . . . . . . . . . 10
6
Rajes
h
Varma an
d
Janes
h
K. Gupta
3 Com
pl
ications o
f
Assiste
d
Re
p
ro
d
uction . . . . . . . . . . . . . . 127
K
ee J. Ong, T.C. Li, En
l
an Xia, an
d
Yu
h
ua Li
u
I
n
d
ex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
5
v
i C
o
ntent
s
https://t.me/med1917
C
o
ntri
bu
t
o
r
s
Vir
g
inia A. Beckett, MRCO
G
Bradford Teachin
g
Hospitals NHS
Fou
n
dat
i
o
n Tr
ust
Bradford
,
West Yorkshire
,
U
K
Paul G.W. Cram
p
, BSc, MB ChB,
M
RCP
,
FRCA
De
p
artment of Anaesthetic
s
Bradford Teachin
g
Hospitals NHS
Fou
n
dat
i
o
n Tr
ust
Bradford
,
West Yorkshire
,
U
K
Robin A.F. Craw
f
ord, MD, FRCS,
F
R
COG
Department of G
y
naecolo
gy
Cambrid
g
e Universit
y
Hospital
Addenbrookes Hos
p
ital)
Cambrid
g
e, UK
Gere S. diZerega, MD
University of Southern Californi
a
Keck School of Medicine
Department of Obstetrics and
Gy
necolo
gy
Livingston Reproductive Biology
L
aboratorie
s
Los An
g
eles, CA, USA
Guy W. G
l
over, MB C
h
B, FRCA
Department o
f
Anaest
h
esi
a
Bradford Royal Infi
rmary
Bradford, West Yorkshire, U
K
Janesh K. Gupta, MD, MSc,
F
R
COG
Department o
f
O
b
stetrics an
d
G
ynaeco
l
og
y
University o
f
Birming
h
am an
d
B
irming
h
am Women’s
H
ospita
l
Birming
h
am, West Mi
dl
an
d
s, U
K
S.V.Z. Ha
y
nes, MB, ChB, MRCOG
C
linical Research Fellow
Northwick Park Hos
p
ital and
S
t. Mark’s National Health
S
ervice Trust
Harrow
,
Middlesex
,
UK
Patrick Ho
g
ston, BSc(Hons), FRCS,
FR
COG
De
p
artment of Obstetrics and
G
y
naecolo
gy
St. Mar
y
’s Hospital
Portsmouth, Ham
p
shire, UK
Matthias Korell
,
MD
Fr
aue
nklinik im Kilinik
u
m
Duisber
g
Duisbur
g
, German
y
Savita Lalchandani
,
MRCOG
,
MRCPI (Obst/Gynae
)
Clinical Research Fellow in
Minimal Access Surgery
Universit
y
of Hull and Castle Hill
Hos
p
ital
Cottingham, UK
Ronnie F. Lamont, BSc, MB, ChB,
MD, FRCOG
Consultant and Reader in
O
b
stetrics an
d
Gynaeco
l
og
y
Department o
f
O
b
stetrics an
d
Gynaecology
Northwick Park Hospital and St.
Mar
k
’s Nationa
l
Hea
l
t
h
Service
Trust
Harrow, Middlesex, UK
T.C. Li, MD, P
h
D, MRCP, FRCOG
Roya
l
Ha
ll
ams
h
ire Hospita
l
Sheffi
eld, UK
https://t.me/med1917
v
iii C
o
ntri
bu
t
o
r
s
u
h
ua Liu, FRCOG, FRC
P
Hy
steroscop
i
c Cente
r
F
uxin
g
Hospita
l
B
eijing, C
h
ina
P
aul McGur
g
an, MB, BA, MRCOG,
M
R
C
P
I
U
niversit
y
of West Australi
a
K
in
g
Edward’s Memorial
H
os
p
ita
l
P
erth
,
West Australia
,
Australi
a
P
eter O’Donovan, MB, FRCOG,
F
RCS (ENG
)
T
he Merit Centre
Bradford Royal Infi
rmary
B
radford, West Yorkshire, U
K
J
osep
h
A. Oga
h
, MBBS, MRCO
G
D
epartment o
f
O
b
stetrics an
d
G
ynaeco
l
og
y
Bradford Royal Infi
rmary
B
ra
df
or
d
, West Yor
k
s
h
ire, U
K
K
ee J. On
g
, BMedSc, MB, BS,
M
Med(S
y
d), FRANZCOG
AC
H
J
essop Win
g
R
o
y
a
l
Ha
ll
ams
h
ire Hospita
l
Sheffi
eld, UK
Kevin P
h
i
ll
ips, MRCOG
Consu
l
tant O
b
stetrician an
d
Gynaeco
l
ogist
Cast
l
e Hi
ll
Hospita
l
Cottingham, UK
Dere
k
J. Tu
ff
ne
ll
, FRCOG
Department o
f
O
b
stetrics an
d
Gynaeco
l
ogy
Bra
df
or
d
Teac
h
ing Hospita
l
s NHS
Foun
d
ation Trust
Bra
df
or
d
, West Yor
k
s
h
ire, UK
Rajes
h
Varma, MA, MRCOG
C
l
inica
l
Lecturer
Department o
f
O
b
stetrics an
d
Gynaeco
l
ogy
Universit
y
o
f
Birmin
gh
am an
d
Birming
h
am Women’s Hospita
l
Birming
h
am, West Mi
dl
an
d
s, U
K
Jerem
y
T. Wrig
h
t, FRCOG
C
entre
f
or En
d
ometriosis an
d
P
el
vi
c
P
a
i
n
The Woking Nuffi
e
ld
Hospita
l
Wo
k
in
g
, Surre
y
, UK
E
nlan
X
ia
H
y
steroscopic Centre
Fuxin
g
Hospita
l
Bei
j
in
g
, China
https://t.me/med1917
1. Prevention of Infection Followin
g
necological Surger
y
: The Evidenc
e
Ronn
i
e F. Lamon
t
.V.
Z
. Hayne
s
efiniti
o
n
o
f Infecti
o
n
Terms such as infl
ammation, contamination, infection, sepsis, and febrile
mor
b
i
d
ity may mean
d
i
ff
erent t
h
ings to
d
i
ff
erent c
l
inicians. It is important,
therefore, that in audits of surgical outcomes, reports of research fi
ndings, and
comparisons of studies, terminology is defi
ne
d
; an examp
l
e o
f
t
h
is process is
given in Table 1.1. The defi
nitions of various systemic infl
ammatory responses
and their associated clinical fi
ndings and laboratory test results are shown in
Ta
bl
e 1.2.
atho
g
enesi
s
Th
e vagina contains more microorganisms t
h
an any ot
h
er site in t
h
e
b
o
dy
except t
h
e
b
owe
l
. Uterine manipu
l
ation t
h
roug
h
t
h
e vagina, e.g., surgica
l
ter
-
mination o
f
pregnancy (TOP), or operations t
h
at open t
h
e vagina, e.g.,
h
yster
-
ectomy, wi
ll
resu
l
t in contamination o
f
norma
ll
y steri
l
e sites
b
y
b
acteria t
h
at
are normally resident in the vagina. Whether these organisms become estab
-
lished and cause infection and infl
ammation depends on a mixture of surgical
an
d
h
ost-re
l
ate
d
f
actors, inc
l
u
d
ing
l
ow socioeconomic status, poor nutrition,
s
mo
k
ing, or preexisting me
d
ica
l
con
d
itions, suc
h
as impaire
d
immunocom
-
petence. T
h
ese ris
k
f
actors may
b
e interre
l
ate
d
, e.g.,
d
ia
b
etes, o
b
esity, increase
d
bl
oo
d
l
oss,
d
uration o
f
surgery, an
d
pro
l
onge
d
h
ospita
l
stay, an
d
many o
f
t
h
e
measures t
h
at can
b
e ta
k
en to re
d
uce t
h
e rate o
f
postoperative in
f
ectious
mor
b
i
d
ity
f
ocus on re
d
ucing t
h
e impact o
f
t
h
ese ris
k
f
actors. T
h
e ris
k
o
f
post
-
operative infection also depends on the virulence and size of the bacterial
inoculum. Normal vaginal fl
ora is composed mainly of organisms of low viru-
l
ence,
d
ominate
d
b
y
l
acto
b
aci
ll
i species, w
h
ic
h
,
b
y pro
d
ucing
l
actic aci
d
f
rom
g
l
ycogen in vagina
l
secretions, ren
d
er t
h
e pH o
f
t
h
e vagina very aci
d
(
<
4
.5
)
,
in w
h
ic
h
mi
l
ieu t
h
e growt
h
o
f
ot
h
er potentia
ll
y pat
h
ogenic organisms is
s
uppresse
d
.
At this low-acid pH, lactobacilli are particularly effi
cient at producing H
2
O
2
,
w
h
ic
h
is toxic to
b
acteria. Un
d
er con
d
itions w
h
ere t
h
ere is an increase in t
h
e
https://t.me/med1917
2
R.F. Lamont and S.V.Z. Ha
y
ne
s
Tab
le 1
.
1
.
Definition of Infection—Terminolog
y
Definiti
o
n
nflammation Localized protective response elicited b
y
injur
y
or tissue damage
C
ontamination Pathogenic microorganism(s) in normall
y
sterile tissue without an
in
f
lammator
y
response
n
f
ection Pathogenic microorganism(s) in normall
y
sterile tissue with a local
inflammator
y
response
S
epsis In
f
ection with a local and s
y
stemic in
f
lammator
y
response
ebrile morbidit
y
Temperature o
f
38.0°C on 2 occasions at
l
east 6
h
ours a
p
art,
excludin
g
the
f
irst 24 hours a
f
ter the procedure
S
ource
:
Adapted from and reproduced with kind permission from Tamussino [1].
T
able 1.2
.
Definitions of Systemic Inflammatory Response
s
C
l
inica
l
Fin
d
ings, La
b
orator
y
Definiti
o
n Test
s
S
ystemic Signs and symptoms of Fever, tachypnea, tachycardia
,
inflammatory disseminated infection or leukocytosis, or leukopenia
response toxin
s
S
epsis Infection with a local and Tachypnea
(
>
2
0 breaths/min)
systemic inflammatory Tachycardia (
>
9
0 bpm
)
response Hyperthermia or hypothermia
(
>
3
8.4°C or
<
35.6°C
)
S
evere sepsis Sepsis plus evidence of or
g
an Metabolic acidosis, acut
e
dysfunction encephalopathy, oliguria
,
hypoxemia, disseminate
d
intravascular coagulation
,
hypotension
S
eptic shock Infection with an H
y
potension (
90 mm H
g
, or
overwhelming s
y
stemic 40 mm Hg below baseline)
inflammator
y
response
leadin
g
to shoc
k
S
epsis s
y
ndrome or Sepsis plus evidence o
f
altered H
y
poxia, increased plasma
multiple-or
g
an or
g
an per
f
usion lactate, altered mental state,
s
y
n
d
rome o
l
iguria
S
ource
:
Re
p
roduced with kind
p
ermission from Tamussino [1].
alk
a
l
inity o
f
t
h
e vagina (
bl
ee
d
ing, semen,
d
ouc
h
ing) or a c
h
ange in t
h
e
d
e
l
icate
v
agina
l
ecosystem (
f
ew or poor-qua
l
ity
l
acto
b
aci
ll
i, anti
b
iotics, c
h
anges in
e
n
d
ocrine status, or p
h
age virus parasitization o
f
l
acto
b
aci
ll
i), muc
h
l
ess H
2
O
2
is pro
d
uce
d
. T
h
is resu
l
ts in a 1000-
f
o
ld
increase in ot
h
er organisms, particu
-
l
ar
l
y anaero
b
es t
h
at pro
d
uce
k
eto aci
d
s suc
h
as succinate. Succinate
bl
unts t
h
e
c
h
emotactic response o
f
neutrop
h
i
l
s an
d
re
d
uces t
h
eir
k
i
ll
ing a
b
i
l
ity. T
h
is
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