Vaginal and Laproscopic Vaginal Surgery

210 Pages·2004·14.472 MB·English

by  Daniel Dargent, Denis Querleu, Marie Plante, Karina Reynolds

Vaginal and Laparoscopic
Vaginal Surgery
Vaginal and
Laparoscopic Vaginal
Surgery
Daniel Dargent MD
Professor of Gynecology and Obstetrics
Claude Bernard University, Lyon
Head, Department of Gynecology and Obstetrics
Hopital Édouard Herriot
Lyon
France
Denis Querleu MD
Professor of Oncology
University Paul Sabiter, Toulouse and
Head of Department of Surgery
Institut Claudius Regaud
Toulouse
France
Marie Plante MD
Gynecology Service
L’Hôtel-Dieu de Québec
Laval University
Quebec City
Canada
Karina Reynolds MD FRCS MRCOG
Senior Lecturer and Honorary Consultant
Department of Gynaecological Oncology
St Bartholemew’s Hospital and Queen Mary University
London
UK
CRC Press
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Contents
Preface vii 9 Vesico- and rectovaginal fistulas 131
Upper colpocleisis described by Latzko.
Acknowledgments ix Vaginal flaps for lower fistulas. Perineal
bipartition and reconstruction described
by Musset.
1 Introduction 1
10 Vaginal surgery in obstetrics 141
2 Anatomy 3 Vaginal Cesarean section. Vaginal isthmic
Anatomy of the uterus and the organs cerclage. Cervical closure as described by
situated close to it. Fascia and free spaces Saling.
between the genital organs and the organs
located close to them. Ligaments and free
11 Laparoscopic assistance for
spaces between the pelvic organs and the
vaginal surgery 147
pelvic walls. Urogenital and pelvic
Definitions and concepts. Place of
diaphragms.
laparoscopic assistance in different
situations. Conclusion.
3 Instruments 15
Positioning the patient on the table.
12 Laparoscopic vaginal radical
The instruments and the way to use them.
hysterectomy 151
Technique. Postoperative course and
4 Perioperative care 19
complications. Indications and
Anesthesia. Prevention of hemorrhage. contraindications. Future.
Prevention of thrombosis. Prevention of
infection. Conclusion.
13 Laparoscopic vaginal radical
trachelectomy 187
5 Surgery of the cervix: conization 31
Technique. Postoperative course.
Technique. Postoperative course and
Indications and contraindications.
complications. Indications and
Oncological outcome. Obstetric
postoperative management.
outcome. Conclusion.

6 Colpotomy 41
14 Laparoscopic vaginal colpoplasty or
Technique. Postoperative course and
colpopoiesis 201
complications. Indications and
Technique. Postoperative course and
contraindications.
complications. Indications.
7 Vaginal hysterectomy 47
Technique. Postoperative course/ Index 207
complications. Indications and
contraindications. Future.
8 Genital prolapse 87
Technique. Postoperative course and
complications. Indications and
contraindications.
Preface
The vaginal approach to abdominal surgery first Vaginal Surgeryis that the latter works: every surgeon
emerged in the late 1820s but it was only towards the with basic training will be able, after reading this
end of the nineteenth century that further attempts book, to perform the vaginal and laparoscopic vaginal
were made, and the technique began to be established. operations herein.
This vaginal approach has subsequently been in
competition with laparotomy and, more recently, To increase the chances of success for the reader who
laparoscopy, to gain favor as the method of choice. The desires to enter or re-enter the field of this “renewed
aim of this book is to guide surgeons through some of ancient surgery,” selected operations are featured and
the core techniques in vaginal surgery, and to highlight are described in complete and full detail so that every
situations where taking a joint laparoscopic vaginal surgeon, including those with no previous training in
approach can be most beneficial to the patient. vaginal surgery, is able to become a “vaginalist.” The
figures do not skip any surgical steps of the operations
This book is the surgical counterpart of the leaflets presented and the figure legends clarify the surgical
distributed by some furniture dealers who sell their procedures as the reader progresses from one figure to
commodities in “flat packs” to be assembled by the the next. Thus the book can be read as an abundantly
consumer at home. The difference between such illustrated textbook or as a “comic strip” integrated
leaflets and this book of Vaginal and Laparoscopic with a comprehensive text on operative gynecology.
Acknowledgments
Mr Nacer Youcef deserves more than a mere mention Mr Dominique Duval produced all the drawings and
in “Acknowledgments” even if he is at the top of the did a job of outstanding quality. He belongs to the very
list. He took more than 95% of the photographs in this select group of true medical artists that still operate
textbook. He is therefore the first editor of this tome, today in this new hi-tech world. Many thanks go to
which aims to demonstrate in a precise way the him.
details of each of the described operations. We are also
grateful to Professor Michel Roy who provided the ERBE Elektromedizin GmbH, Tubingen, Germany is
pictures for the chapter on “Laparoscopic vaginal rad- thanked for its sponsorship.
ical trachelectomy”; to Professor Georges Mellier who
provided the pictures for the “inverted Burch proce- We are indebted to the Royal College of Surgeons of
dure”; and to Mr Vincent Dargent who took the great Edinburgh who awarded the Autosuture Travelling
photographs of the instruments. Fellowship in Minimally Invasive Surgery to Karina
Reynolds in 1998, thus supporting her numerous
Dr Francois Saunier who revised Chapter 4, and Dr Jo visits to Lyon, Paris, Lille and Toulouse.
Osborne who translated Chapter 7 (initially written in
French), deserve our gratitude, as does Ms Martine
Arnaud who typed and laid out the initial manuscript.
1
Introduction
Vaginal surgery is the mother of abdominal surgery. wasmirrored in the national survey undertaken in the
Over past centuries, the only operations not resulting USA at the end of the twentieth century. The difference
in patient death were those performed through the inmortality rates persists but is no longer at the percent
vaginal route on the female reproductive organs. These level but rather estimated in units in ten thousands
were also the only operations that could improve (1in 10000 versus 1 in 30000). It is obviously a strong
patient welfare at that time. This approach to surgery argument for favoring vaginal surgery. But this argu-
was empirical until the French surgeon Joseph ment is not the only one. Vaginal surgery is not only
Recamier performed the first well-standardized less dangerous; it is also more patient-friendly.
vaginal hysterectomy on July 26, 1829 at Hotel Dieu in
Paris. The patient was a 50-year-old woman with a Vaginal surgery not only reduces the risk of casualty
bulky cervical cancer. Recamier incised the anterior but also significantly diminishes postoperative
fornix of the vagina transversely, then the vesicouter- morbidity. Furthermore, it improves postoperative
ine peritoneal cul de sac and drew the fundus down- recovery, which is less painful, shorter and
ward. He divided the broad ligaments and then, has the advantage of leaving no visible scars. This
having put ligatures around them, divided the uterine advantage can appear trivial but in fact from both
arteries and the paracervical ligaments before separat- the psychological and medical viewpoints is not.
ing the uterus from the posterior fornix of the vagina. It Preservation of body image is an important aspect of
was the first time an intra-abdominal organ was global welfare. On the other hand laparotomy is itself
removed following principles that remain the basis of a source of rare but awkward complications such as
extirpative surgery today. The patient survived the seroma, hematoma, abscess, wound leakage and
surgery, was discharged after 20 days and was still incisional hernia.
alive 1 year later.
Today, laparoscopy is taking the place of laparotomy
The first success of Recamier was followed by a series as a competitor of vaginal surgery. After laparoscopic
of failures and it is only at the end of that (nineteenth) surgery, recovery is fast and there is no alteration in
century that new attempts were made. At about the body image. Incisional problems are few. However,
same time, chloroform and antisepsis encouraged other types of problems due to either the approach
renewed surgical boldness and the abdominal itself (introduction of trocars) or to the insufflation of
approach for hysterectomy was introduced (Freund C0 it necessitates (hypercapnia, hemodynamic prob-
2
1878). This was in competition with the vaginal lems) can occur. The Austrian surgeon Kurt Richter
approach, which French surgeons continued to use used to say that the risk of performing hysterectomy
electively (Pean, Second, Doyen, Richelot and by laparotomy was equivalent to adding up the risks
others). Casualties were three times lower in the case of two operations: laparotomy and hysterectomy.
series gathered by the vaginalists (10 versus 30%). This aphorism applies to laparoscopy as well. The
Nevertheless, vaginal surgery, which was at the risks of laparoscopy differ from the risks of laparo-
beginning the procedure of choice, progressively lost tomy. They are few and their prevention is possible
its place as postoperative casualties became fewer but they will never be totally erased. At the end of the
and fewer thus making the difference between day, the vaginal approach, in all situations where it
techniques less obvious to the individual surgeon can be used, is surely the best choice for the patient:
assessing his own practice. training in this ancestral surgery must continue.
Nowadays the difference between the vaginal and The ambition of this book is neither to compile the
abdominal approaches has not disappeared. This descriptions one can find in the numerous textbooks
1
2 Introduction
that fill the libraries of our venerable universities nor can gain from the application of the latest technolo-
to encourage the reader to believe that the descrip- gies. The best example is the new bipolar coagulation
tions herein are the fruit of an original personal elabo- technology that improves vaginal surgery in the field
ration. The techniques we describe are the ones the where laparoscopy is the more competitive, i.e. less
oldest of the editors has selected after having deeply tissue damage and less postoperative pain. On the
scrutinized the ancient literature and, above all, hav- other hand an important place will be devoted to
ing personally visited the giants who maintained the laparoscopy in its role of assisting vaginal surgery.
vaginal tradition in middle Europe after the Second Infact, the laparoscopically assisted vaginal hysterec-
World War: Navratil in Graz, Centaro in Padova, Käser tomy, which is the paradigm of so-called laparoscopic
in Bâle, Novak in Ljubjana, Richter in Bruck an der vaginal surgery, has only a limited place today. In the
Mur and then in Munich and others. The youngest current state of the art, if one chooses to use the
members of the editorial staff have adopted these laparoscope in a patient with poor vaginal access, it
techniques, consolidated over almost four decades. is best to perform the operation from beginning to
These are the only ones that will be described, but end under laparoscopic guidance. But there are
they will be described in full detail and, thanks to the circumstances where neither the purely laparoscopic
liberal generosity of the publisher, illustrated with approach nor the purely vaginal approach is
numerous photographs. We think that this editorial adequate. The management of uterine cancer is an
approach will be of most use to the reader. example. Other situations do exist which make
the laparoscopic vaginal approach the approach of
In spite of our belief in the immutability of the rules choice. These situations are tackled and the technical
of vaginal surgery, we will not ignore the benefits one details are presented in the following chapters.
2
Anatomy
There is no question of describing here the anatomy the keystone of “pelvic organ harmony.” First, we
of the female genital organs in the same way as it is describe the organ itself and the relationship between
described in textbooks devoted to human anatomy. it and neighboring organs. Then we move to a
The aim of this “fake” text of anatomy is two-fold: description of the anatomically preformed free spaces
first, to describe the anatomy as it appears to the eye (the so-called avascular spaces) one has to identify
of the gynecologist, and second, to describe the and use as working spaces in order to isolate the
anatomy as the surgeon transforms it. organs from each other. We then finish with a
description of the so-called ligaments one must iden-
Since Vesale (1514–1564), anatomy is described as it tify in order to either divide them if one intends to
is seen when the subject is placed in the supine posi- remove the uterus or to repair them if one intends to
tion in front of the anatomist: the urinary bladder is restore the pelvic architecture. In each of these sec-
in front of the vagina, the uterus is above the bladder tions the static anatomy is described first followed by
and so on. For gynecologists assessing the anatomy of the modifications that surgery imposes on this
a subject lying on a table in the so-called lithotomy anatomy (Figures 2.1–2.3). And finally, the text ends
position, the classical terminology is no longer with a description of the urogenital and pelvic
appropriate; for this reason one has to replace the diaphragms, which provide the surgeon with the
terms “in front of” and “behind,” i.e. the adjectives approach to the uterus and to neighboring organs.
“anterior” and “posterior” by the adjectives “ventral”
and “dorsal.” Likewise, the words “above” and
“below,” i.e. the adjectives “superior” and “inferior”
by the adjectives “cephalic” or “cranial” and Anatomy of the uterus and the
“podalic” or “caudal.” We will, in this text, try not to
organs situated close to it
forget this, but occasionally we will, bad habits being
more difficult to lose than good ones.
The corpus of the uterus is totally intraperitoneal.
The anatomy the surgeon is confronted with is quite Inthe usual anteverted position it lies in contact with
different from classical anatomy. The live organs are the bladder dome from which it is separated by the
different from organs congealed by fixation or by vesicouterine cul de sac of the pelvic peritoneum.
freezing and thawing. Moreover as soon as the first The uterine leaf of the cul de sac is adherent to the
incision is made the relationship between the differ- isthmus. The vesical leaf is separated from the blad-
ent anatomical structures changes. As far as vaginal der by loose cellular tissue. The opposite aspect of
surgery is concerned the transformation starts even the uterus is separated from the rectum by the
before this moment: the relationship between the rectouterine peritoneal cul de sac, which is occupied
pelvic organs changes as soon as the retractors are by the free part of the sigmoid colon, the last ileal
putin place. The moment the cervix is placed under loops and, occasionally, the very first part of the
traction the anatomical architecture is almost inver- cecum. The uterine leaf of the peritoneal cul de sac is
ted. Then incisions and subsequent maneuvers adherent to the myometrium. It also covers the dorsal
completely transform the situation. part of the isthmus, the dorsal surface of the cervix
and the dorsal vaginal fornix before reflecting onto
The description we give in the following paragraphs the ventral surface of the rectum to which it is
is focused on the uterus because hysterectomy is the strongly adherent. It is only at the very bottom of the
most commonly performed operation in the vaginal cul de sac that a loose cellular tissue covers the fascia
surgery repertoire and the uterus is often identified as delineating the outside surface of the peritoneum.
3
4 Anatomy
(a) (a)
(b) (b)

Figure 2.1 (a) Artist’s impression of a sagittal slice of the Figure 2.2 (a) Retracting the perineal body with an
female pelvis focusing on the vesicovaginal fascia (septum) appropriate retractor (Chapter 3), the ventral vaginal wall
and rectovaginal fascia (septum). Between the vesical and and the ventral lip of the uterine cervix become visible. The
vaginal walls there are dense (septa) and loose areas of loose part of the connective tissue interposed between the
connective tissue. The dense part (septum) is close to the vesicovaginal septum and the bladder wall involves three
vagina and the loose part is between the septum and the areas that are more dense: one dorsal to the urethra, one at
bladder and/or the rectum. The vagina is separated from the the level of the inter-ureteric line and one just below the
bladder by two spaces one of which is demonstrated by base of the utero-vesical fold of peritoneum. (b) External
sharp dissection (surgical space) and the other by blunt view of thefemale genitalia having retracted the perineal
dissection (anatomical space). (b)External view of the body.
female genitalia.
The cervix is partly intraperitoneal and supravaginal lowest third is separated from the bladder by the
and partly retroperitoneal and intravaginal. The ven- ventral fornix of the vagina. The dorsal lip of
tral lip of the cervix is in contact with the dorsal the cervix is intravaginal in its lower two-thirds as
aspect of the bladder floor. This contact is direct with the insertion of the vagina onto the cervix is situated
the two deepest thirds (see later) of the cervix as the 3cm higher dorsally than it is ventrally.