Chapter 13: Technical Errors and Bail-Out Strategies in Gynecologic Surgery

INTRODUCTION

• Understand the principles of gynecologic surgery

• Appreciate risks for surgical complications, and the precepts to be followed

• Know technical bail-out strategies for common scenarios

STATE OF THE ART

Gynecologic surgery has become much more diverse in the last 20 years. With the advent of minimally invasive surgery and increasing use of mesh and other graft materials, the ­number of procedures that a gynecologic surgeon must know has increased. No longer is it enough for a skilled gynecologic surgeon to know how to do an abdominal hysterectomy and a vaginal hysterectomy, and how to do a retropubic urethropexy or an anterior and posterior repair. A skilled gynecologic ­surgeon must also now know how to do laparoscopic surgery, ­hysteroscopic surgery, endometrial ablation, and how and when to use mesh grafts. A skilled surgeon must not only know how to do these procedures, but know the common intraoperative complications of these procedures and be prepared to manage them.

The advent of new procedures leads to new complications. New techniques lead to new technical errors. The skilled ­surgeon must know how to recognize these potential ­complications and errors and how to manage them—in other words, how to get out of trouble once it starts. It is always ­better to prevent ­complications than to manage them, but the only way to completely prevent operative complications is to never operate. Thus, the skilled surgeon must simultaneously work to prevent complications and to recognize and manage them when they occur.

Although new operations have new complications, the precepts of intraoperative management have not changed since the days of William Halsted and Howard Kelly.

Howard Kelly has been credited with establishing gynecology as a discipline in America. In his classic book Gynecology and Abdominal Surgery¹ he emphasized asepsis; careful preoperative preparation of the instruments, suture, surgeons, and assistants; proper positioning of the patient; adequate lighting and visualization; proper retraction; proper instruments for the planned procedure; and knowledge of the planned procedure. He described almost everything that is listed in the “time-out” safe surgical checklist used in operating rooms (ORs) today.

These principles and precepts are as applicable today as they were a century ago. A principle is a primary truth from which other truths can be derived. A precept is a commandment or direction given as a rule intended to regulate behavior or thought. Principles give rise to precepts. It is important for a surgeon to follow precepts, but it is more important to understand the principles on which the precepts are based. A skilled surgeon must know when to abandon a precept in order ...