- Email: [email protected]
Unintentional trauma during gynaecological surgery
Current Obstetrics & Gynaecology (2001) 11, 100 ^107
c 2001 Harcourt Publishers Ltd doi:10.1054/cuog.2000.0164 available online at http://www.idealibrary.com on
Unintentional trauma during gynaecological surgery I. Z. MacKenzie John Radcli¡e Hospital, Oxford OX3 9DU, UK
KEYWORDS bowel trauma, vascular damage, bladder damage, ureteric injury, lymphatic obstruction, nerve injury
Summary With minor and major gynaecological surgery, unexpected damage to adjacent structures or organs may occur, despite appropriate surgical care.It is important to recognize which patients and which conditionsincrease the chances ofthis happening. It is equally important for the surgeon to identify when such damage has been caused and to know how to make good the repair. Some of this repair surgery should be performed by the gynaecologist, while some is best managed by a specialist in the appropriate ¢eld. Knowledge of the signs and symptoms of previously unrecognized damage is essential for the surgeon, as is any long-term consequence of this unintentional damage, so that the patient can be advised of future management.
c 2001Harcourt Publishers Ltd
INTRODUCTION This article reviews the areas where potential unintended damage may be caused to adjacent structures or organs during the course of various gynaecological operations. It does not include operations performed during later pregnancy, but includes those performed to terminate pregnancy during the ¢rst and second trimester, and to deal with early failed pregnancies including incomplete and missed abortion and ectopic gestations. It concentrates on identifying the damage at the time of surgery or during the immediate post-operative period, but does not deal with the complications that result from previously undiagnosed damage. A major thrust of the review is to remind the reader not only of the pitfalls that await the surgeon, but that injury to structures or organs may occur when least expected. In addition, emphasis is placed upon the early diagnosis of the damage, since repair then is often easier than at a later stage, and long-term sequelae are often reduced. As illustrated in Table 1, various types of injury have been considered according to the general anatomical area in which the primary gynaecological procedure is being performed.
DAMAGE ASSOCIATED WITH ANTERIOR ABDOMINAL WALL INCISIONS All operations which involve an incision into the peritoneal cavity or retropubic space have the potential to
Correspondence to: IZM.Tel: 01865 221006; Fax: 01865 769141.
cause unexpected damage.Thus all laparoscopies and laparotomies present a possible risk.
Vascular damage Lower transverse suprapubic or Pfannenstiel incisions, especially if required to be more expansive for radical surgery and the removal of large pelvic tumours, can result in division or laceration of a major vessel within the anterior abdominal wall. The inferior epigastric arteries and veins are vulnerable as they pass from the external iliac vessels at the midpoint of the inguinal ligaments towards the umbilicus within the rectus abdominis muscles on each side. Damage should usually be recognized at the time by overt bleeding or rapid development of a haematoma, the traumatized vessel will require ligation; diathermy may be su⁄cient, but care is necessary to ensure satisfactory haemostasis. These vessels are also at risk with incisions made in the iliac fossae for laparoscopic procedures, and the chances of this happening can be reduced by trans-illuminating the abdominal wall from within with the laparoscope to identify the course of the vessels and avoid direct puncture. Traumatized small vessels perforating the rectus abdominis muscles may escape notice at laparotomy, especially when the abdominal wall is being closed. Some surgeons advocate the routine use of a subrectus drain inserted at the end of the laparotomy, although this does not guarantee protection against a haematoma developing. The injury then becomes apparent during the early post-operative recovery period with an enlarging subrectus haematoma often most obvious during the second or third postoperative day. Depending on the size of the haematoma and degree of systemic upset, spontaneous discharge may occur through the healing incision,
UNINTENTIONALTRAUMA DURING GYNAECOLOGICAL SURGERY
101
Table 1 Types of gynaecological surgery and areas of possible unintended trauma
Haemorrhage Bowel damage Bladder damage Ureteric damage Nerve damage Ano-rectal damage Urethral damage Lymphatic drainage
Abdominal wall
Intra-abdominal
Intra-uterine
Intra-vaginal
Vulval & inguinal
H H H
H H H H
H H
H H H H
H
H H H H
or surgical drainage may be necessary by re-opening the incision with local or general anaesthetic. It is worth considering the insertion of a tube or corrugated drain into the haematoma cavity, secured at the skin to allow further drainage. By this stage, it is unusual to identify any speci¢c bleeding vessels to ligate or cauterize, the active bleeding having ceased, assisted by tamponade. The re-opened incision usually heals without problem. Lower midline incisions are less likely to result in vascular damage providing that lateral dissection beneath the rectus muscles is not too extensive. Intraperitoneal drains, not incorporated into the laparotomy incision, are a further source of trauma. The inferior epigastric vessels are vulnerable and it is appropriate to pass the drain trocar from the peritoneum to the outside avoiding the landmarks for these vessels. Introducing the drain in the reverse direction increases the chances of damage to the underlying structures in the iliac fossae, including the external iliac vessels. Insertion of suprapubic catheters can lead to haematoma formation, but this should be avoided if the introducing needle or trocar is inserted in the mid-line.
Bladder damage Care with entry into the peritoneal cavity is needed with transverse suprapubic and lower mid-line incisions, and at laparoscopy with lower mid-line stab incisions, since an unintentional cystotomy may occur. Bladder drainage immediately prior to surgery or laparoscopic con¢rmation that it is not distended, will reduce the chances of this happening. Providing the damage is recognized as it should be, unless very small, repair in two layers with absorbable sutures as shown in Fig. 1 is required. Subsequent continuous bladder drainage by suprapubic or transurethral catheter, maintained on free £ow for 7^10 days, is wise, although the chances of a ¢stula forming are very small.
H H H H
Figure 1 Principle of the repair of a full thickness injury to bowel or bladder.The ¢rst layer is repaired with aninterrupted absorbable suture, incorporating the mucosal layer and muscle layers.The second layer, using interrupted Lembert sutures, includes the muscle and serosallayers, imbricating the deep layer.
Nerve damage Femoral neuropathy can be caused with the use self-retaining abdominal retractors.The precise mechanism for such damage is not clear, but direct pressure on the nerve or exaggerated extension of the retractor blades may be responsible and is probably best avoided if possible. The diagnosis is made some days after the surgery with a complaint of numbness over the skin on the anterior surface of the upper thigh. Speci¢c action is not indicated, with the expectation that recovery of nerve function will occur over a few months.
TRAUMA DURING INTRAABDOMINALOPERATIONS This may occur with any abdominal surgery, but is more common in obese patients during radical operations and when anatomy is distorted by adhesions or large
102
CURRENT OBSTETRICS & GYNAECOLOGY
tumours. Awareness of possible coincidental damage needs to be even greater in such cases than in the less demanding cases.
Bowel damage Opening the abdomen may cause damage to small and large bowel especially if there are adhesions to the anterior abdominal wall. Despite appropriate care incising the parietal peritoneum, unavoidable damage may still occur. It may also occur during laparoscopy or laparotomy with division of adhesions to gain access into the pelvis by dissecting around large tumours or mobilizing gynaecological organs for reconstruction or removal. The damage may be caused with sharp or blunt dissection with scissors, scalpel, diathermy or laser. Recognition of the damage and the extent is obviously important to assess the need for, and type of, repair. The extent of the damage may be more extensive than initially suspected if caused by laser or diathermy. Small super¢cial lacerations usually require a pursestring or single 2/0 absorbable suture layer incorporating all layers except the mucosa; inverting the tissue will provide the necessary closure.For full thickness damage, a two-layer repair with the same suture should be used, the ¢rst layer including all bowel wall layers and the second using Lembert sutures to include the muscle and serosal layers to invert the ¢rst suture line (see Fig.1). Some surgeons advise the use of interrupted sutures and some a non-absorbable second layer. It is essential not to restrict the bowel lumen by repairing longitudinal lacerations in a transverse direction. For major bowel damage, a resection may be necessary, especially if the viability of a segment of bowel wall is suspect. Having isolated the segment to be resected, non-crushing clamps are applied, the segment removed and a two-layer repair performed using the same principle as for full thickness lacerations (see Fig. 2). Again it is imperative to ensure no restriction to the lumen. Following completion of the anastomosis, the defect in the bowel mesentery needs to be repaired. If necessary, a peritoneal toilet should be provided and antibiotics should probably be given in most cases. In many instances, peritoneal drainage is not required. If a large area of damage has been caused, particularly involving the large bowel, a temporary defunctioning colostomy might need to be formed, especially if there is doubt about the integrity of the bowel, or the patency of the lumen, due to pre-existing disease beyond repair.
Bladder damage Inadvertent cystotomy may occur on opening the abdominal wall or during bladder dissection of the anterior cervix and upper vagina. As with breaches to the bowel
Figure 2 Bowel re-anastomosis using the Gambee technique. After inserting an initial Lembert suture at the mesenteric border, Gambee sutures are placed through all three tissue layers, with knots tied within the lumen. Further Lembert sutures then reinforce the repair, checking adequate patency of the lumen.The mesenteric defect is then closed.
wall, the damage must be recognized and repaired to avoid a urinary ¢stula. Adequate mobilization of the bladder immediately adjacent to the defect helps to secure a satisfactory result, reducing tension on the repair. Partial thickness lacerations can be strengthened with a
UNINTENTIONALTRAUMA DURING GYNAECOLOGICAL SURGERY
single 2/0 absorbable suture layer as a precaution. Full thickness injuries should be repaired with two layers similar to that described for bowel wall repair: the ¢rst suture line of 2/0 absorbable suture includes the muscle layer, possibly excluding bladder mucosa, and the second uses a 2/0 absorbable suture Lembert suture into the muscle layer and overlying serosa burying the ¢rst suture line. As with bowel repair, opinions are divided on the use of interrupted and continuous suturing. If the damage was caused when dissecting the bladder o¡ the anterior cervix and vagina, care must be taken to ensure that a ureter has not been included in the repair. Cystoscopy and ureteric catheterization should be performed if there is any doubt. An indwelling suprapubic or per urethram catheter is important to keep the bladder empty to encourage healing.Removal after 7^10 days is best preceded by contrast studies to con¢rm a water-tight repair has been achieved, particularly for damage around the base of the bladder. A transvesical suture may inadvertently be placed during suprapubic bladder neck surgery. This should be recognized by intra-operative cystoscopic examination and removed. If left in situ, bladder irritation and calculi may develop or a ¢stula form. Damage can also occur with the insertion of suburethral slings; recognition and removal is clearly essential, possibly with repair to the bladder wall if there is a large defect.
Ureteric damage The ureter is at risk: (a) at the pelvic brim where it overlies the bifurcation of the common iliac artery and the infundibulo-pelvic ligament is divided to remove the ovary; (b) as it passes around the pelvic side wall beneath the parietal peritoneum which is divided at the base of the broad ligament; and (c) most frequently as it passes medially through the ureteric canal to reach the bladder angle just beyond the uterine vessels, contiguous with the lateral vaginal fornix. Damage to the ureter may be from direct puncture or transection by scalpel, diathermy or laser, or ischaemic necrosis from diathermy or laser heat damage, or devascularisation by stripping the vessels lying beside the ureter. Occlusion to the lumen with resultant obstruction to urine £ow can be produced by an encircling suture or ligature, or kinking by an extrinsic suture distorting the ureter, with consequent oedema and obstruction. Damage most commonly occurs with di⁄cult dissections in the presence of adhesions involving the pelvic side-wall due to chronic pelvic in£ammatory disease or endometriosis. Anatomical distortion making the ureter more vulnerable may have occurred due to adhesions or a large ovarian or uterine tumour involving one or other broad ligament. Radical hysterectomy for malignant disease is a hazard to the ureter, although dissection around
103
the ureter is a fundamental part of the operation and particular care is taken to protect the ureter. Once recognized, sutures causing obstruction should be removed and if there is doubt about the viability of the wall of the ureter, the lumen should be stented by cystoscopic guidance, or by ureterotomy. If the wall is badly lacerated or the ureter completed transsected, management depends upon the site of the damage. Damage more than 6 cm from the bladder probably requires an end-to-end anastomosis with 3/0 or 4/0 absorbable suture over a stent, spatulating the ends if necessary to allow an oblique suture line to avoid stricturing. A single layer should be su⁄cient, although the ureteric sheath could also be repaired as a second layer; the stent needs removing 4 ^ 6 weeks later. If the damage is within 6 cm of the bladder insertion and the ureter reasonably mobile, re-implantation into the bladder with a Boari £ap and possibly a psoas hitch is probably the best option. This involves tying o¡ the ureteric stump on the bladder wall, performing a cystotomy, and making an entry portal into the detrusor muscle, burrowing a tunnel within the muscle and then making an exit portal through the bladder mucosa. The distal end of the ureter is drawn through the tunnel and into the bladder lumen, securing the previously split divided end of the ureter to the mucosa and the external surface of the detrusor muscle where it enters the bladder. Stenting of the ureter should be performed. If a segment of ureter has been destroyed, an end-to-side anastomosis to the other ureter may be necessary. If the damage is limited to a small defect to the wall, ureteric stenting will probably allow healing without further surgery. Unless the surgeon has previous experience of urinary tract repair, the assistance of a urologist should be sought at an early stage. Antibiotic prophylaxis should be considered.
Vascular damage Major vessels in the pelvis, usually one of the iliac vessels, may su¡er damage when dissection is required in the vicinity. Pelvic lymphadenectomy of metastatic tumours can be di⁄cult to acheive if local invasion has already occurred. Once the vessel wall has been opened, considerable bleeding may follow which can be contained with oversewing with a 4/0 polypropylene or similar suture; compression above and below the damage, if possible, will keep the operating site visible. Arterial repairs are usually easier to e¡ect than vein repairs because of the stronger tissues. Larger areas of damage may require the insertion of a graft and the assistance of a vascular surgeon. Seemingly uncontrollable bleeding can be provoked during otherwise uncomplicated surgery. Laparoscopic division of the utero-sacral ligaments, performed as a treatment for severe dysmenorrhoea, can cause
104
bleeding not controlled by laparoscopic diathermy or oversewing, and a laparotomy may be necessary to achieve the desired haemostasis. Troublesome bleeding from trans¢xed pedicles with ovarian conservation may, on rare occasions, lead to removal of the ovary to isolate and ligate the vessels in the infundibulo-pelvic ligament. Particular care should be taken to identify the ureter in this situation. Persistent bleeding from the uterine pedicles can be very frustrating; repeated clamping and suturing can threaten the ureter in this di⁄cult situation and isolation and ligation of the internal iliac artery or its anterior branch might be a safer option. Surgery in the Cave of Retzius, for operations to treat urinary stress incontinence, can result in haematoma formation. In most cases, no speci¢c action is required, the bleeding being controlled by tamponade. Drainage of the haematoma is not usually required.
Lymphatic damage Although not strictly damage, many women will develop lymphocysts or lymphocoeles above the inguinal ligament following pelvic lymphadenectomy, as part of a radical hysterectomy for the treatment of cervical malignancy. Such collections probably re£ect a thorough node dissection, and as shown in Fig. 3, they can reach a considerable size, even to the extent of causing compression on the ureter resulting in hydroureter and hydronephrosis.These generally do not develop for some days or weeks after surgery.
Osseous damage Non-absorbable sutures securing the paraurethral tissues to the periosteum over the posterior aspect of the symphysis pubis, as in the Marshall ^Marchetti ^Krantz urethropexy, can cause periostitis and chronic pain. There is no clear explanation for this happening, and thus no speci¢c action to be taken to prevent it occurring; avoiding large deep sutures into the periosteum would seem sensible.
CURRENT OBSTETRICS & GYNAECOLOGY
Cervical damage Mechanical cervical dilatation, usually achieved by passing metal dilators of increasing diameters through the cervical canal, may cause covert or overt tearing of the cervix. Super¢cial tears from traction applied to a stabilizing tenaculum may also occur as the instrument is pulled o¡ the cervix, but they generally do not cause serious problems nor long-term compromise; persistent bleeding from the area may require one of two absorbable haemostatic sutures. Lacerations involving underlying stroma, which might amount to complete disruption of the full length of the endocervical canal, can be caused by forced mechanical dilatation against cervical resistance. Such damage can be minimized by limiting the dilatation to size Hegar10, which will reduce the chances of overt tearing and covert damage which could result in cervical incompetence during a subsequent pregnancy. Minor lacerations occur in up to 3^ 4% cases but signi¢cant full thickness damage occurs in less than 1% cases. Prior cervical preparation with local prostaglandins or hygroscopic tents in pregnant patients can dramatically reduce the force required to dilate the cervix and the risk of cervical damage to less than 0.1% cases.The bene¢ts of such a strategy for the non-pregnant are less convincing. Full thickness lacerations should be repaired to reduce the chances of compromise to cervical integrity. Absorbable sutures should be inserted to approximate the endocervical canal surface with a second layer opposing the vaginal epithelium, including the underlying cervical stroma. This restores the anatomy and provides the necessary haemostasis. Some recommend the use of nonabsorbable sutures for the second layer, but they need removing 6 ^7 days later and there is no proven advantage. An ignored full thickness laceration or unsuccessful repair may result in a cervico-vaginal ¢stula with persistent watery discharge, deep dyspareunia and postcoital bleeding, with the need for a trachelorrhaphy at a later date.
Uterine body trauma
TRAUMA DURING INTRAUTERINE SURGERY The greatest number of gynaecological operations involve the passage of instruments through the previously dilated cervix into the uterine cavity. Such procedures include diagnostic and therapeutic uterine curettage or endometrial biopsy and hysteroscopy as an inpatient or outpatient, operative hysteroscopy under general anaesthetic to resect the endometrial basement membrane, polyps, submucous ¢broids and uterine septae, and evacuation of retained products of conception or for therapeutic abortion.
Perforation of the uterus during cervical dilatation probably occurs more frequently than surgeons realize; there are reports of this occurring during ¢rst trimester aspiration termination at around 0.2^ 0.7% operations. Bimanual examination to delineate uterine size and position at the start of the operation is an important initial step to reduce the chances of this happening. Sounding to determine the length of the utero-cervical canal should also help, although a sound should be used with great caution in the pregnant or recently pregnant uterus, since the myometrium is soft, and the relatively narrow sound can easily perforate the uterine wall. This will usually be recognized when the instruments pass
UNINTENTIONALTRAUMA DURING GYNAECOLOGICAL SURGERY
through the cervix further than expected from the initial examination. With di⁄cult cervical dilatation, a false passage may be made in the cervical tissue, extending into the myometrium. This probably occurs when the uterine position had been incorrectly assessed. Persistence with the dilatation will ultimately result in the instruments entering the peritoneal cavity. If skilled high-resolution ultrasound services are available, con¢rmation of a perforation can be provided or reassurance given that the damage has not occurred and a laparoscopy avoided. If in doubt, it is better to investigate by laparoscopy unless the risks of this procedure in the individual patient are greater than average. Perforation may be caused during diathermy resection of endometrium or ¢broids. Division of the pedicle of a pedunculated intraluminal ¢broid that has prolapsed through the cervix could result in fundal damage if traction on the polyp caused inversion of the uterine fundus. The damage in these patients should be diagnosed by hysteroscopic examination, and if the defect is small with no overt bleeding, observation over 24 h can be advised. If the defect is large or there is persistent bleeding, or the damage was caused by diathermy, a laparoscopy should be performed to assess the degree of uterine damage and to explore the bowel for damage and perform the necessary repair. In women undergoing pregnancy termination or surgical evacuation of retained products of conception, perforation may ¢rst be suspected when fatty tissue of the omentum, appendix epiploicae or bowel mesentery is seen in the forceps or suction curette. A laparoscopy should be performed to assess the degree of damage to the uterus, observe for active bleeding, and carefully inspect the bowel for damage. If the extent of the damage is uncertain, a laparotomy will be required. The uterine evacuation should be completed under laparoscopic control to avoid further damage, but the bleeding uterine defect needs oversewing with one or two layers of an absorbable 2/0 or 0 suture at laparotomy, carefully opposing the uterine surface to reduce the chance of adhesion formation. Advice should be given postoperatively about the possibility of a weakened area at the site of the perforation, should pregnancy be contemplated in the future. Whether labour should be discouraged remains uncertain, however.
TRAUMA DURING VAGINAL SURGERY Surgery to the vagina risks damage to contiguous structures and organs, notably the rectum posteriorly and the bladder and urethra anteriorly.With more extensive dissection for gross degrees of uterine prolapse, the ureters are vulnerable.
105
Rectal damage Full thickness damage to the rectal wall must be identi¢ed, as with bowel damage within the abdomen; unrecognized damage will probably result in a recto-vaginal ¢stula, which can be very challenging to repair. Careful identi¢cation of the extent of the damage with adequate mobilization of the adjacent wall should be followed by a careful repair in two layers with absorbable sutures. Further supporting absorbable sutures into the fascia of Denonvillier will give added support prior to repairing the vaginal epithelium. If the damage is extensive, a temporary defunctioning colostomy should be considered. Sacrospinous ¢xation to correct a vaginal vault prolapse may result in rectal trans¢xion, a greater risk using the left than the right ligament. Care must be taken to avoid this happening although this may be di⁄cult if there is marked ¢brosis and adhesions from previous infection or surgery. The undetected suture is likely to result in a recto-vaginal ¢stula.
Bladder damage Unplanned cystotomy should also be recognized and repaired at the time.The risks of a vesico-vaginal ¢stula are much more likely than with fundal bladder trauma, and a secure repair should be achieved as already described.
Ureteric damage Division of, or obstruction to, the lumen of a ureter is really only a risk in women with a procidentia when the ureters and bladder can be markedly displaced from their normal anatomical position. If recognized, immediate repair is necessary and this will involve a laparotomy; for most gynaecologists, this will probably involve the assistance of a urologist.
Urethral damage This is most likely to occur during an anterior colporrhaphy to correct a cysto-urethrocoele, especially if there has been previous surgery. It may also occur with the dissection and excision of anterior wall vaginal cysts, paraurethral cysts or removal of a cyst of Skene’s tubule. A urethral diverticulum, mistaken for a vaginal cyst, will result in unexpected urethral damage and could lead to ¢stula formation. As with the bladder, a two-layer repair with absorbable sutures is required followed by repair of the overlying vaginal epithelium. An indwelling urethral or suprapubic catheter may improve the chances of healing by primary intention and avoid further problems.
106
TRAUMA DURING VULVAL AND INGUINAL DISSECTION This includes major surgery as for a vulvectomy, excision of vulval cysts and uncertain vulval swellings, and plastic reconstructions or excision of tender scars of the perineum and lymph node dissection.
Rectal damage When surgery is performed on the perineum to correct complications from damage sustained during childbirth, there can be marked scarring leading to distortion of anatomy. Incising the perineum should therefore be done with particular care to avoid damage to the displaced rectum above the anal canal. As with other bowel damage, recognition is important with a repair of the wall in two layers using absorbable sutures. It is believed that tension should be avoided to improve the chances of successful healing. The unintentional insertion of a suture into the rectum during posterior colporrhaphy should be identi¢ed and the suture removed; if left in place, there is a risk of recto-vaginal or recto-perineal ¢stula.
CURRENT OBSTETRICS & GYNAECOLOGY
may occur with inguinal lymphadenectomy for vulval malignancy, and the help of a vascular surgeon may be required to insert a graft to correct the damage if simple repair is not su⁄cient.
Nerve damage Peripheral nerve damage will occur and every attempt should be made to avoid dividing the lateral and anterior femoral nerves that are visible during the dissection; there is no reparative treatment, should the patient become aware of an area of paraesthesia postoperatively.
Lymph drainage system damage Lymphocysts are quite common sequelae to a thorough block dissection of the super¢cial and deep inguinal glands. Although drainage of such cysts can be performed, this is probably best avoided. Infection may follow and this can lead to persistent drainage. Spontaneous resolution of lymphocysts usually occurs although it may take many months. Chronically swollen legs may, however, persist for long periods.
Anal damage If the anal sphincter is divided during the dissection, this requires repair either as an end-to-end re-alignment or using an overlapping technique; both procedures use absorbable suture material. Opinion is divided on the need to con¢ne the bowel for the ¢rst 4 ^5 days after surgery, rather than administering a laxative to reduce stool bulk and thus trauma to the repaired sphincter. Antibiotic prophylaxis may well be bene¢cial.
Vascular damage The vulva has a very good blood supply in the region of the clitoris and posteriorly around the Bartholin’s glands. Dissections in these two areas, as in a vulvectomy or excision of Bartholin’s glands and cysts, can provoke marked bleeding during the operation. Every e¡ort should be made to control the bleeding by cautery, ligation or trans¢xion, but a haematoma may still occur, and further surgery may rarely be necessary to control the bleeding. Spontaneous discharge of a haematoma may occur although surgical drainage will occasionally be necessary. Systemic upset can develop with a posterior vulval haematoma, since the ischio-rectal fossa can accommodate up to a litre of blood. Opening of the previous incision will release the haematoma and any active bleeding vessels identi¢ed and ligated. A large-bore tube drain or corrugated drain sutured into the cavity might be considered for removal 1 or 2 days later. Damage to the femoral vessels deep within the femoral triangle
CONCLUSIONS Despite appropriate preparation using very careful and appropriate surgical techniques, unplanned damage may still occur during routine as well as more di⁄cult gynaecological surgery. The most important aspect is to identify the damage and institute the appropriate ¢rst aid treatment. The gynaecologist should not hesitate to enlist the help of the appropriate surgical specialist to advise or perform the necessary repair and to o¡er advice about further management and possible long-term consequences to the patient. Finally, it is always wise to explain the events to the patient as soon as is reasonable after the operation, with the o¡er of further information as and when available or requested.
PRACTICE POINTS . Aims: To be aware of situations where damage to other organs or structures is a particular risk . Management:To identify patients who represent an added risk and take precautions to avoid inadvertent damage. . Objective: To be aware of the possible damage, recognize it at the time, and know how to repair the damage and advise the patient of any possible future problems.
UNINTENTIONALTRAUMA DURING GYNAECOLOGICAL SURGERY
FURTHER READING Wheelock J B, Krebs H-B. Repairing bowel injuries. In Gynaecological Surgery 2nd Edition. Sanz L E (ed). Oxford: Blackwell Science, 1995; 331^337. Harris W J. Early complications of abdominal and vaginal hysterectomy. Obstetr Gynaecol Surv 1995; 50: 795^ 805. Donnez J, Anaf V, Berliere M, Smets M, Nisolle M.Ureteral and bladder injury during laparoscopic surgery. In An Atlas of Laser Operative
107
Laparoscopy and Hysteroscopy. Donnez J, Nisolle M (eds). London: Parthenon 1994; 237^244. Krebs H B. Intestinal injury in gynecologic surgery: a ten-year experience. Am J Obstet Gynecol 1986; 155: 509^514. Blandy J P, Badenoch D F, Fowler C G, Jenkins B J,Thomas N W M. Early repair of iatrogenic injury to the ureter or bladder after gynecological surgery. J Urol 1991; 146: 761^765.
c 2001 Harcourt Publishers Ltd doi:10.1054/cuog.2000.0164 available online at http://www.idealibrary.com on
Unintentional trauma during gynaecological surgery I. Z. MacKenzie John Radcli¡e Hospital, Oxford OX3 9DU, UK
KEYWORDS bowel trauma, vascular damage, bladder damage, ureteric injury, lymphatic obstruction, nerve injury
Summary With minor and major gynaecological surgery, unexpected damage to adjacent structures or organs may occur, despite appropriate surgical care.It is important to recognize which patients and which conditionsincrease the chances ofthis happening. It is equally important for the surgeon to identify when such damage has been caused and to know how to make good the repair. Some of this repair surgery should be performed by the gynaecologist, while some is best managed by a specialist in the appropriate ¢eld. Knowledge of the signs and symptoms of previously unrecognized damage is essential for the surgeon, as is any long-term consequence of this unintentional damage, so that the patient can be advised of future management.
c 2001Harcourt Publishers Ltd
INTRODUCTION This article reviews the areas where potential unintended damage may be caused to adjacent structures or organs during the course of various gynaecological operations. It does not include operations performed during later pregnancy, but includes those performed to terminate pregnancy during the ¢rst and second trimester, and to deal with early failed pregnancies including incomplete and missed abortion and ectopic gestations. It concentrates on identifying the damage at the time of surgery or during the immediate post-operative period, but does not deal with the complications that result from previously undiagnosed damage. A major thrust of the review is to remind the reader not only of the pitfalls that await the surgeon, but that injury to structures or organs may occur when least expected. In addition, emphasis is placed upon the early diagnosis of the damage, since repair then is often easier than at a later stage, and long-term sequelae are often reduced. As illustrated in Table 1, various types of injury have been considered according to the general anatomical area in which the primary gynaecological procedure is being performed.
DAMAGE ASSOCIATED WITH ANTERIOR ABDOMINAL WALL INCISIONS All operations which involve an incision into the peritoneal cavity or retropubic space have the potential to
Correspondence to: IZM.Tel: 01865 221006; Fax: 01865 769141.
cause unexpected damage.Thus all laparoscopies and laparotomies present a possible risk.
Vascular damage Lower transverse suprapubic or Pfannenstiel incisions, especially if required to be more expansive for radical surgery and the removal of large pelvic tumours, can result in division or laceration of a major vessel within the anterior abdominal wall. The inferior epigastric arteries and veins are vulnerable as they pass from the external iliac vessels at the midpoint of the inguinal ligaments towards the umbilicus within the rectus abdominis muscles on each side. Damage should usually be recognized at the time by overt bleeding or rapid development of a haematoma, the traumatized vessel will require ligation; diathermy may be su⁄cient, but care is necessary to ensure satisfactory haemostasis. These vessels are also at risk with incisions made in the iliac fossae for laparoscopic procedures, and the chances of this happening can be reduced by trans-illuminating the abdominal wall from within with the laparoscope to identify the course of the vessels and avoid direct puncture. Traumatized small vessels perforating the rectus abdominis muscles may escape notice at laparotomy, especially when the abdominal wall is being closed. Some surgeons advocate the routine use of a subrectus drain inserted at the end of the laparotomy, although this does not guarantee protection against a haematoma developing. The injury then becomes apparent during the early post-operative recovery period with an enlarging subrectus haematoma often most obvious during the second or third postoperative day. Depending on the size of the haematoma and degree of systemic upset, spontaneous discharge may occur through the healing incision,
UNINTENTIONALTRAUMA DURING GYNAECOLOGICAL SURGERY
101
Table 1 Types of gynaecological surgery and areas of possible unintended trauma
Haemorrhage Bowel damage Bladder damage Ureteric damage Nerve damage Ano-rectal damage Urethral damage Lymphatic drainage
Abdominal wall
Intra-abdominal
Intra-uterine
Intra-vaginal
Vulval & inguinal
H H H
H H H H
H H
H H H H
H
H H H H
or surgical drainage may be necessary by re-opening the incision with local or general anaesthetic. It is worth considering the insertion of a tube or corrugated drain into the haematoma cavity, secured at the skin to allow further drainage. By this stage, it is unusual to identify any speci¢c bleeding vessels to ligate or cauterize, the active bleeding having ceased, assisted by tamponade. The re-opened incision usually heals without problem. Lower midline incisions are less likely to result in vascular damage providing that lateral dissection beneath the rectus muscles is not too extensive. Intraperitoneal drains, not incorporated into the laparotomy incision, are a further source of trauma. The inferior epigastric vessels are vulnerable and it is appropriate to pass the drain trocar from the peritoneum to the outside avoiding the landmarks for these vessels. Introducing the drain in the reverse direction increases the chances of damage to the underlying structures in the iliac fossae, including the external iliac vessels. Insertion of suprapubic catheters can lead to haematoma formation, but this should be avoided if the introducing needle or trocar is inserted in the mid-line.
Bladder damage Care with entry into the peritoneal cavity is needed with transverse suprapubic and lower mid-line incisions, and at laparoscopy with lower mid-line stab incisions, since an unintentional cystotomy may occur. Bladder drainage immediately prior to surgery or laparoscopic con¢rmation that it is not distended, will reduce the chances of this happening. Providing the damage is recognized as it should be, unless very small, repair in two layers with absorbable sutures as shown in Fig. 1 is required. Subsequent continuous bladder drainage by suprapubic or transurethral catheter, maintained on free £ow for 7^10 days, is wise, although the chances of a ¢stula forming are very small.
H H H H
Figure 1 Principle of the repair of a full thickness injury to bowel or bladder.The ¢rst layer is repaired with aninterrupted absorbable suture, incorporating the mucosal layer and muscle layers.The second layer, using interrupted Lembert sutures, includes the muscle and serosallayers, imbricating the deep layer.
Nerve damage Femoral neuropathy can be caused with the use self-retaining abdominal retractors.The precise mechanism for such damage is not clear, but direct pressure on the nerve or exaggerated extension of the retractor blades may be responsible and is probably best avoided if possible. The diagnosis is made some days after the surgery with a complaint of numbness over the skin on the anterior surface of the upper thigh. Speci¢c action is not indicated, with the expectation that recovery of nerve function will occur over a few months.
TRAUMA DURING INTRAABDOMINALOPERATIONS This may occur with any abdominal surgery, but is more common in obese patients during radical operations and when anatomy is distorted by adhesions or large
102
CURRENT OBSTETRICS & GYNAECOLOGY
tumours. Awareness of possible coincidental damage needs to be even greater in such cases than in the less demanding cases.
Bowel damage Opening the abdomen may cause damage to small and large bowel especially if there are adhesions to the anterior abdominal wall. Despite appropriate care incising the parietal peritoneum, unavoidable damage may still occur. It may also occur during laparoscopy or laparotomy with division of adhesions to gain access into the pelvis by dissecting around large tumours or mobilizing gynaecological organs for reconstruction or removal. The damage may be caused with sharp or blunt dissection with scissors, scalpel, diathermy or laser. Recognition of the damage and the extent is obviously important to assess the need for, and type of, repair. The extent of the damage may be more extensive than initially suspected if caused by laser or diathermy. Small super¢cial lacerations usually require a pursestring or single 2/0 absorbable suture layer incorporating all layers except the mucosa; inverting the tissue will provide the necessary closure.For full thickness damage, a two-layer repair with the same suture should be used, the ¢rst layer including all bowel wall layers and the second using Lembert sutures to include the muscle and serosal layers to invert the ¢rst suture line (see Fig.1). Some surgeons advise the use of interrupted sutures and some a non-absorbable second layer. It is essential not to restrict the bowel lumen by repairing longitudinal lacerations in a transverse direction. For major bowel damage, a resection may be necessary, especially if the viability of a segment of bowel wall is suspect. Having isolated the segment to be resected, non-crushing clamps are applied, the segment removed and a two-layer repair performed using the same principle as for full thickness lacerations (see Fig. 2). Again it is imperative to ensure no restriction to the lumen. Following completion of the anastomosis, the defect in the bowel mesentery needs to be repaired. If necessary, a peritoneal toilet should be provided and antibiotics should probably be given in most cases. In many instances, peritoneal drainage is not required. If a large area of damage has been caused, particularly involving the large bowel, a temporary defunctioning colostomy might need to be formed, especially if there is doubt about the integrity of the bowel, or the patency of the lumen, due to pre-existing disease beyond repair.
Bladder damage Inadvertent cystotomy may occur on opening the abdominal wall or during bladder dissection of the anterior cervix and upper vagina. As with breaches to the bowel
Figure 2 Bowel re-anastomosis using the Gambee technique. After inserting an initial Lembert suture at the mesenteric border, Gambee sutures are placed through all three tissue layers, with knots tied within the lumen. Further Lembert sutures then reinforce the repair, checking adequate patency of the lumen.The mesenteric defect is then closed.
wall, the damage must be recognized and repaired to avoid a urinary ¢stula. Adequate mobilization of the bladder immediately adjacent to the defect helps to secure a satisfactory result, reducing tension on the repair. Partial thickness lacerations can be strengthened with a
UNINTENTIONALTRAUMA DURING GYNAECOLOGICAL SURGERY
single 2/0 absorbable suture layer as a precaution. Full thickness injuries should be repaired with two layers similar to that described for bowel wall repair: the ¢rst suture line of 2/0 absorbable suture includes the muscle layer, possibly excluding bladder mucosa, and the second uses a 2/0 absorbable suture Lembert suture into the muscle layer and overlying serosa burying the ¢rst suture line. As with bowel repair, opinions are divided on the use of interrupted and continuous suturing. If the damage was caused when dissecting the bladder o¡ the anterior cervix and vagina, care must be taken to ensure that a ureter has not been included in the repair. Cystoscopy and ureteric catheterization should be performed if there is any doubt. An indwelling suprapubic or per urethram catheter is important to keep the bladder empty to encourage healing.Removal after 7^10 days is best preceded by contrast studies to con¢rm a water-tight repair has been achieved, particularly for damage around the base of the bladder. A transvesical suture may inadvertently be placed during suprapubic bladder neck surgery. This should be recognized by intra-operative cystoscopic examination and removed. If left in situ, bladder irritation and calculi may develop or a ¢stula form. Damage can also occur with the insertion of suburethral slings; recognition and removal is clearly essential, possibly with repair to the bladder wall if there is a large defect.
Ureteric damage The ureter is at risk: (a) at the pelvic brim where it overlies the bifurcation of the common iliac artery and the infundibulo-pelvic ligament is divided to remove the ovary; (b) as it passes around the pelvic side wall beneath the parietal peritoneum which is divided at the base of the broad ligament; and (c) most frequently as it passes medially through the ureteric canal to reach the bladder angle just beyond the uterine vessels, contiguous with the lateral vaginal fornix. Damage to the ureter may be from direct puncture or transection by scalpel, diathermy or laser, or ischaemic necrosis from diathermy or laser heat damage, or devascularisation by stripping the vessels lying beside the ureter. Occlusion to the lumen with resultant obstruction to urine £ow can be produced by an encircling suture or ligature, or kinking by an extrinsic suture distorting the ureter, with consequent oedema and obstruction. Damage most commonly occurs with di⁄cult dissections in the presence of adhesions involving the pelvic side-wall due to chronic pelvic in£ammatory disease or endometriosis. Anatomical distortion making the ureter more vulnerable may have occurred due to adhesions or a large ovarian or uterine tumour involving one or other broad ligament. Radical hysterectomy for malignant disease is a hazard to the ureter, although dissection around
103
the ureter is a fundamental part of the operation and particular care is taken to protect the ureter. Once recognized, sutures causing obstruction should be removed and if there is doubt about the viability of the wall of the ureter, the lumen should be stented by cystoscopic guidance, or by ureterotomy. If the wall is badly lacerated or the ureter completed transsected, management depends upon the site of the damage. Damage more than 6 cm from the bladder probably requires an end-to-end anastomosis with 3/0 or 4/0 absorbable suture over a stent, spatulating the ends if necessary to allow an oblique suture line to avoid stricturing. A single layer should be su⁄cient, although the ureteric sheath could also be repaired as a second layer; the stent needs removing 4 ^ 6 weeks later. If the damage is within 6 cm of the bladder insertion and the ureter reasonably mobile, re-implantation into the bladder with a Boari £ap and possibly a psoas hitch is probably the best option. This involves tying o¡ the ureteric stump on the bladder wall, performing a cystotomy, and making an entry portal into the detrusor muscle, burrowing a tunnel within the muscle and then making an exit portal through the bladder mucosa. The distal end of the ureter is drawn through the tunnel and into the bladder lumen, securing the previously split divided end of the ureter to the mucosa and the external surface of the detrusor muscle where it enters the bladder. Stenting of the ureter should be performed. If a segment of ureter has been destroyed, an end-to-side anastomosis to the other ureter may be necessary. If the damage is limited to a small defect to the wall, ureteric stenting will probably allow healing without further surgery. Unless the surgeon has previous experience of urinary tract repair, the assistance of a urologist should be sought at an early stage. Antibiotic prophylaxis should be considered.
Vascular damage Major vessels in the pelvis, usually one of the iliac vessels, may su¡er damage when dissection is required in the vicinity. Pelvic lymphadenectomy of metastatic tumours can be di⁄cult to acheive if local invasion has already occurred. Once the vessel wall has been opened, considerable bleeding may follow which can be contained with oversewing with a 4/0 polypropylene or similar suture; compression above and below the damage, if possible, will keep the operating site visible. Arterial repairs are usually easier to e¡ect than vein repairs because of the stronger tissues. Larger areas of damage may require the insertion of a graft and the assistance of a vascular surgeon. Seemingly uncontrollable bleeding can be provoked during otherwise uncomplicated surgery. Laparoscopic division of the utero-sacral ligaments, performed as a treatment for severe dysmenorrhoea, can cause
104
bleeding not controlled by laparoscopic diathermy or oversewing, and a laparotomy may be necessary to achieve the desired haemostasis. Troublesome bleeding from trans¢xed pedicles with ovarian conservation may, on rare occasions, lead to removal of the ovary to isolate and ligate the vessels in the infundibulo-pelvic ligament. Particular care should be taken to identify the ureter in this situation. Persistent bleeding from the uterine pedicles can be very frustrating; repeated clamping and suturing can threaten the ureter in this di⁄cult situation and isolation and ligation of the internal iliac artery or its anterior branch might be a safer option. Surgery in the Cave of Retzius, for operations to treat urinary stress incontinence, can result in haematoma formation. In most cases, no speci¢c action is required, the bleeding being controlled by tamponade. Drainage of the haematoma is not usually required.
Lymphatic damage Although not strictly damage, many women will develop lymphocysts or lymphocoeles above the inguinal ligament following pelvic lymphadenectomy, as part of a radical hysterectomy for the treatment of cervical malignancy. Such collections probably re£ect a thorough node dissection, and as shown in Fig. 3, they can reach a considerable size, even to the extent of causing compression on the ureter resulting in hydroureter and hydronephrosis.These generally do not develop for some days or weeks after surgery.
Osseous damage Non-absorbable sutures securing the paraurethral tissues to the periosteum over the posterior aspect of the symphysis pubis, as in the Marshall ^Marchetti ^Krantz urethropexy, can cause periostitis and chronic pain. There is no clear explanation for this happening, and thus no speci¢c action to be taken to prevent it occurring; avoiding large deep sutures into the periosteum would seem sensible.
CURRENT OBSTETRICS & GYNAECOLOGY
Cervical damage Mechanical cervical dilatation, usually achieved by passing metal dilators of increasing diameters through the cervical canal, may cause covert or overt tearing of the cervix. Super¢cial tears from traction applied to a stabilizing tenaculum may also occur as the instrument is pulled o¡ the cervix, but they generally do not cause serious problems nor long-term compromise; persistent bleeding from the area may require one of two absorbable haemostatic sutures. Lacerations involving underlying stroma, which might amount to complete disruption of the full length of the endocervical canal, can be caused by forced mechanical dilatation against cervical resistance. Such damage can be minimized by limiting the dilatation to size Hegar10, which will reduce the chances of overt tearing and covert damage which could result in cervical incompetence during a subsequent pregnancy. Minor lacerations occur in up to 3^ 4% cases but signi¢cant full thickness damage occurs in less than 1% cases. Prior cervical preparation with local prostaglandins or hygroscopic tents in pregnant patients can dramatically reduce the force required to dilate the cervix and the risk of cervical damage to less than 0.1% cases.The bene¢ts of such a strategy for the non-pregnant are less convincing. Full thickness lacerations should be repaired to reduce the chances of compromise to cervical integrity. Absorbable sutures should be inserted to approximate the endocervical canal surface with a second layer opposing the vaginal epithelium, including the underlying cervical stroma. This restores the anatomy and provides the necessary haemostasis. Some recommend the use of nonabsorbable sutures for the second layer, but they need removing 6 ^7 days later and there is no proven advantage. An ignored full thickness laceration or unsuccessful repair may result in a cervico-vaginal ¢stula with persistent watery discharge, deep dyspareunia and postcoital bleeding, with the need for a trachelorrhaphy at a later date.
Uterine body trauma
TRAUMA DURING INTRAUTERINE SURGERY The greatest number of gynaecological operations involve the passage of instruments through the previously dilated cervix into the uterine cavity. Such procedures include diagnostic and therapeutic uterine curettage or endometrial biopsy and hysteroscopy as an inpatient or outpatient, operative hysteroscopy under general anaesthetic to resect the endometrial basement membrane, polyps, submucous ¢broids and uterine septae, and evacuation of retained products of conception or for therapeutic abortion.
Perforation of the uterus during cervical dilatation probably occurs more frequently than surgeons realize; there are reports of this occurring during ¢rst trimester aspiration termination at around 0.2^ 0.7% operations. Bimanual examination to delineate uterine size and position at the start of the operation is an important initial step to reduce the chances of this happening. Sounding to determine the length of the utero-cervical canal should also help, although a sound should be used with great caution in the pregnant or recently pregnant uterus, since the myometrium is soft, and the relatively narrow sound can easily perforate the uterine wall. This will usually be recognized when the instruments pass
UNINTENTIONALTRAUMA DURING GYNAECOLOGICAL SURGERY
through the cervix further than expected from the initial examination. With di⁄cult cervical dilatation, a false passage may be made in the cervical tissue, extending into the myometrium. This probably occurs when the uterine position had been incorrectly assessed. Persistence with the dilatation will ultimately result in the instruments entering the peritoneal cavity. If skilled high-resolution ultrasound services are available, con¢rmation of a perforation can be provided or reassurance given that the damage has not occurred and a laparoscopy avoided. If in doubt, it is better to investigate by laparoscopy unless the risks of this procedure in the individual patient are greater than average. Perforation may be caused during diathermy resection of endometrium or ¢broids. Division of the pedicle of a pedunculated intraluminal ¢broid that has prolapsed through the cervix could result in fundal damage if traction on the polyp caused inversion of the uterine fundus. The damage in these patients should be diagnosed by hysteroscopic examination, and if the defect is small with no overt bleeding, observation over 24 h can be advised. If the defect is large or there is persistent bleeding, or the damage was caused by diathermy, a laparoscopy should be performed to assess the degree of uterine damage and to explore the bowel for damage and perform the necessary repair. In women undergoing pregnancy termination or surgical evacuation of retained products of conception, perforation may ¢rst be suspected when fatty tissue of the omentum, appendix epiploicae or bowel mesentery is seen in the forceps or suction curette. A laparoscopy should be performed to assess the degree of damage to the uterus, observe for active bleeding, and carefully inspect the bowel for damage. If the extent of the damage is uncertain, a laparotomy will be required. The uterine evacuation should be completed under laparoscopic control to avoid further damage, but the bleeding uterine defect needs oversewing with one or two layers of an absorbable 2/0 or 0 suture at laparotomy, carefully opposing the uterine surface to reduce the chance of adhesion formation. Advice should be given postoperatively about the possibility of a weakened area at the site of the perforation, should pregnancy be contemplated in the future. Whether labour should be discouraged remains uncertain, however.
TRAUMA DURING VAGINAL SURGERY Surgery to the vagina risks damage to contiguous structures and organs, notably the rectum posteriorly and the bladder and urethra anteriorly.With more extensive dissection for gross degrees of uterine prolapse, the ureters are vulnerable.
105
Rectal damage Full thickness damage to the rectal wall must be identi¢ed, as with bowel damage within the abdomen; unrecognized damage will probably result in a recto-vaginal ¢stula, which can be very challenging to repair. Careful identi¢cation of the extent of the damage with adequate mobilization of the adjacent wall should be followed by a careful repair in two layers with absorbable sutures. Further supporting absorbable sutures into the fascia of Denonvillier will give added support prior to repairing the vaginal epithelium. If the damage is extensive, a temporary defunctioning colostomy should be considered. Sacrospinous ¢xation to correct a vaginal vault prolapse may result in rectal trans¢xion, a greater risk using the left than the right ligament. Care must be taken to avoid this happening although this may be di⁄cult if there is marked ¢brosis and adhesions from previous infection or surgery. The undetected suture is likely to result in a recto-vaginal ¢stula.
Bladder damage Unplanned cystotomy should also be recognized and repaired at the time.The risks of a vesico-vaginal ¢stula are much more likely than with fundal bladder trauma, and a secure repair should be achieved as already described.
Ureteric damage Division of, or obstruction to, the lumen of a ureter is really only a risk in women with a procidentia when the ureters and bladder can be markedly displaced from their normal anatomical position. If recognized, immediate repair is necessary and this will involve a laparotomy; for most gynaecologists, this will probably involve the assistance of a urologist.
Urethral damage This is most likely to occur during an anterior colporrhaphy to correct a cysto-urethrocoele, especially if there has been previous surgery. It may also occur with the dissection and excision of anterior wall vaginal cysts, paraurethral cysts or removal of a cyst of Skene’s tubule. A urethral diverticulum, mistaken for a vaginal cyst, will result in unexpected urethral damage and could lead to ¢stula formation. As with the bladder, a two-layer repair with absorbable sutures is required followed by repair of the overlying vaginal epithelium. An indwelling urethral or suprapubic catheter may improve the chances of healing by primary intention and avoid further problems.
106
TRAUMA DURING VULVAL AND INGUINAL DISSECTION This includes major surgery as for a vulvectomy, excision of vulval cysts and uncertain vulval swellings, and plastic reconstructions or excision of tender scars of the perineum and lymph node dissection.
Rectal damage When surgery is performed on the perineum to correct complications from damage sustained during childbirth, there can be marked scarring leading to distortion of anatomy. Incising the perineum should therefore be done with particular care to avoid damage to the displaced rectum above the anal canal. As with other bowel damage, recognition is important with a repair of the wall in two layers using absorbable sutures. It is believed that tension should be avoided to improve the chances of successful healing. The unintentional insertion of a suture into the rectum during posterior colporrhaphy should be identi¢ed and the suture removed; if left in place, there is a risk of recto-vaginal or recto-perineal ¢stula.
CURRENT OBSTETRICS & GYNAECOLOGY
may occur with inguinal lymphadenectomy for vulval malignancy, and the help of a vascular surgeon may be required to insert a graft to correct the damage if simple repair is not su⁄cient.
Nerve damage Peripheral nerve damage will occur and every attempt should be made to avoid dividing the lateral and anterior femoral nerves that are visible during the dissection; there is no reparative treatment, should the patient become aware of an area of paraesthesia postoperatively.
Lymph drainage system damage Lymphocysts are quite common sequelae to a thorough block dissection of the super¢cial and deep inguinal glands. Although drainage of such cysts can be performed, this is probably best avoided. Infection may follow and this can lead to persistent drainage. Spontaneous resolution of lymphocysts usually occurs although it may take many months. Chronically swollen legs may, however, persist for long periods.
Anal damage If the anal sphincter is divided during the dissection, this requires repair either as an end-to-end re-alignment or using an overlapping technique; both procedures use absorbable suture material. Opinion is divided on the need to con¢ne the bowel for the ¢rst 4 ^5 days after surgery, rather than administering a laxative to reduce stool bulk and thus trauma to the repaired sphincter. Antibiotic prophylaxis may well be bene¢cial.
Vascular damage The vulva has a very good blood supply in the region of the clitoris and posteriorly around the Bartholin’s glands. Dissections in these two areas, as in a vulvectomy or excision of Bartholin’s glands and cysts, can provoke marked bleeding during the operation. Every e¡ort should be made to control the bleeding by cautery, ligation or trans¢xion, but a haematoma may still occur, and further surgery may rarely be necessary to control the bleeding. Spontaneous discharge of a haematoma may occur although surgical drainage will occasionally be necessary. Systemic upset can develop with a posterior vulval haematoma, since the ischio-rectal fossa can accommodate up to a litre of blood. Opening of the previous incision will release the haematoma and any active bleeding vessels identi¢ed and ligated. A large-bore tube drain or corrugated drain sutured into the cavity might be considered for removal 1 or 2 days later. Damage to the femoral vessels deep within the femoral triangle
CONCLUSIONS Despite appropriate preparation using very careful and appropriate surgical techniques, unplanned damage may still occur during routine as well as more di⁄cult gynaecological surgery. The most important aspect is to identify the damage and institute the appropriate ¢rst aid treatment. The gynaecologist should not hesitate to enlist the help of the appropriate surgical specialist to advise or perform the necessary repair and to o¡er advice about further management and possible long-term consequences to the patient. Finally, it is always wise to explain the events to the patient as soon as is reasonable after the operation, with the o¡er of further information as and when available or requested.
PRACTICE POINTS . Aims: To be aware of situations where damage to other organs or structures is a particular risk . Management:To identify patients who represent an added risk and take precautions to avoid inadvertent damage. . Objective: To be aware of the possible damage, recognize it at the time, and know how to repair the damage and advise the patient of any possible future problems.
UNINTENTIONALTRAUMA DURING GYNAECOLOGICAL SURGERY
FURTHER READING Wheelock J B, Krebs H-B. Repairing bowel injuries. In Gynaecological Surgery 2nd Edition. Sanz L E (ed). Oxford: Blackwell Science, 1995; 331^337. Harris W J. Early complications of abdominal and vaginal hysterectomy. Obstetr Gynaecol Surv 1995; 50: 795^ 805. Donnez J, Anaf V, Berliere M, Smets M, Nisolle M.Ureteral and bladder injury during laparoscopic surgery. In An Atlas of Laser Operative
107
Laparoscopy and Hysteroscopy. Donnez J, Nisolle M (eds). London: Parthenon 1994; 237^244. Krebs H B. Intestinal injury in gynecologic surgery: a ten-year experience. Am J Obstet Gynecol 1986; 155: 509^514. Blandy J P, Badenoch D F, Fowler C G, Jenkins B J,Thomas N W M. Early repair of iatrogenic injury to the ureter or bladder after gynecological surgery. J Urol 1991; 146: 761^765.