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Gynecologic procedures, in general, carry less risk than other abdominal surgical procedures because of the minimal amount of manipulative trauma to the alimentary tract and the patient's generally good condition. However, the same general principles apply here as in any major surgical operation, and the patient's condition must be appraised carefully.

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The obese patient should diet sufficiently to obtain a more normal weight before elective procedures are done. Secondary anemia is corrected preoperatively. Urinary complaints are investigated by analysis of the catheterized specimen of urine and endoscopic and roentgenographic studies when indicated. Bowel preparation, including enemas, is individualized. Antibiotics are given when sepsis is suspected. A cleansing enema is given and may be followed by an antiseptic vaginal douche. Prophylactic antibiotics are indicated for major vaginal and abdominal procedures.

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A general anesthetic is satisfactory. Spinal or continuous spinal anesthesia may be used if desired.

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Many major gynecologic procedures can now be performed via minimally invasive techniques, which include laparoscopic and robotic approaches. A lower midline incision is made, and the lower angle of the wound is held open with a superficial retractor to permit a free dissection of the fascia until the location of the midline is absolutely ascertained.

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Some operators prefer the transverse incision (Pfannenstiel), which is a convex incision following the lines of skin cleavage just above the symphysis. The upper skin flap may be dissected from the underlying rectus muscles, and the usual midline incision of the muscles and peritoneum is made. When an extensive exposure is required, it is better to use a Mallard incision which cuts across the recti muscles or a Cherney incision which detaches these muscles from the symphysis. An increased number of blood vessels require ligation by this approach in comparison to the midline incision, most notably, the inferior epigastric vessels.

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The fascia is incised, scissors being employed at the lower angle of the wound to open the fascia down to the symphysis. The medial edge of presenting rectus muscles is freed and pushed laterally with the scalpel handle. Although few bleeding points are encountered in the midline, all must be clamped and tied or controlled by electrocoagulation. As the incision progresses, its margins are protected with gauze pads. The peritoneum, before being incised, is picked up to one side of the urachus with toothed forceps alternately by the operator and first assistant as in any abdominal procedure. The urachus, which can be seen through the peritoneum as a thickened cord, should be left intact, since it is not only vascular but also exerts traction on the bladder, inviting its accidental opening.

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A self-retaining retractor is substituted for the superficial ones, although deep individual retractors may be used if a shifting of the retraction is desired to procure the maximum exposure as the operation progresses. Careful inspection is made to ensure that no intestine is caught in the retractor. When a ...

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