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GYNECOLOGIC SYSTEM: ROUTINE FOR OPEN ABDOMINAL PROCEDURES

Gynecologic procedures for benign disease 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.

PREOPERATIVE PREPARATION

Obese patients 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.

ANESTHESIA

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

OPERATIVE PREPARATION

Hair removal from the abdomen is accomplished with skin clippers. The skin is prepared in routine manner. Surgical preparation of the vagina is performed. A preoperative antibiotic is administered prior to incision. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.

INCISION AND EXPOSURE

Many major gynecologic procedures now can be performed via minimally invasive techniques, which include laparoscopic and robotic approaches. When a laparotomy is required, a midline incision is preferred when access to the upper abdomen is anticipated. Three variations of lower transverse incisions are available for procedures limited to the pelvis.

A lower midline incision is made from the level of the symphysis and carried to a level below or above the umbilicus, as determined by the surgical goals. The lower angle of the wound is held open with a superficial retractor to permit dissection of the fascia until the location of the midline is absolutely ascertained. The fascia is incised sharply, the natural plane between the rectus muscles is separated, and the peritoneum is identified, lifted away from the intraperitoneal contents, and incised.

Most open gynecologic procedures for benign indications can be approached via a low transverse incision. The most common is the Phannensteil, which is a convex incision following the lines of skin cleavage just above the symphysis. The upper flap includes the skin, subcutaneous tissue, and rectus fascia and is dissected from the underlying rectus muscles, and the usual midline incision of the muscles and peritoneum is made. When an extensive exposure is required from a low transverse incision, it is preferable to use a Mallard incision, which cuts across the rectus muscles, or a Cherney incision, which detaches these muscles from the symphysis. An increased number of blood vessels require ligation by this approach in ...

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