Chapter 41: Gynecology

1. Gynecologic causes of acute abdomen include pelvic inflammatory disease, tubo-ovarian abcess, ovarian torsion, ruptured ectopic pregnancy, and septic abortion. Pregnancy must be ruled out early in assessment of reproductive-age patients presenting with abdominal or pelvic pain.

2. The general gynecology exam must incorporate the whole physical examination in order to adequately diagnosis and treat gynecologic disorders.

3. Benign gynecologic pathologies that are encountered at the time of surgery include endometriosis, endometriomas, fibroids, and ovarian cysts.

4. It is critical that abnormal lesions of the vulva, vagina, and cervix are biopsied for diagnosis before any treatment is planned; postmenopausal bleeding should always be investigated to rule out malignancy.

5. Early-stage cervical cancer is managed surgically, whereas chemoradiation is preferred for stage IB2 and above.

6. Pregnancy confers important changes to both the cardiovascular system and the coagulation cascade. Trauma in pregnancy must be managed with these changes in mind.

7. Pelvic floor dysfunction (pelvic organ prolapse, urinary and fecal incontinence) is common; 11% of women will undergo a reconstructive surgical procedure at some point in their lives.

8. Radical hysterectomy has unique risks of ureteral fistula and bowel dysfunction.

9. Risk-reducing salpingo-oophorectomy (RRSO) should be considered in women with BRCA1 or BRCA2 mutations; RRSO and complete hysterectomy should be considered in women with Lynch syndrome.

10. Optimal debulking for epithelial ovarian cancer is a critical element in patient response and survival. The preferred primary therapy for optimally debulked advanced-stage ovarian epithelial ovarian cancer is intraperitoneal chemotherapy.

The female reproductive tract is a unique component of the body with a multitude of tightly regulated functions. Many of the activities normally ongoing, such as angiogenesis and physiologic invasion, are necessary in order for the reproductive organs to fulfill their purpose and are usurped in disease. Immune surveillance is modified by multiple mechanisms under investigation and regulated in a different fashion, in order to allow implantation, placentation, and development of the fetus. How this potential disruption of normal immune barriers is involved in pathologic events is incompletely understood.

The pelvis is a very complex area, with a multitude of spatially and temporally varied functions. It is a site where pathologies ranging from mechanical events, such as ovarian torsion or ruptured ectopic pregnancy, to infection, such as pelvic inflammatory disease, to mass effects, including leiomyomata and malignancy, can present with similar and even overlapping symptoms and signs. An acute abdomen presentation in a woman of child-bearing potential can range from pregnancy-related catastrophes to appendicitis.

The ongoing rupture, healing, angiogenesis, and regrowth of the ovarian capsule and endometrium during the menstrual cycle uses the same series of biological and biochemical events that are also active in pathologic events such as endometriosis and endometriomas, mature teratomas, dysgerminomas, and progression to malignancy. Genetic abnormalities, both germline and somatic, that may cause competence and/or promote disease are now being uncovered, especially in the progression to malignancy, in pharmacogenomics, and in surgical risks such as bleeding and clotting. Incorporation of genetic and genomic information in disease diagnosis and assessment is a wave for the near future and may alter how we diagnose and follow disease, in whom we increase our diligence in searching for disease, and ultimately how we use the drug and other therapeutic armamentarium available to the treating physician.

These points will be incorporated with surgical approaches into discussions of anatomy, diagnostic workup, infection, surgical and medical aspects of the obstetric patient, pelvic floor dysfunction, and neoplasms.

Clinical gynecologic anatomy centers on the pelvis (from Latin meaning basin). Aptly named, the bowl-shaped pelvis houses the confluence and intersection of multiple organ systems. Understanding those structural and functional relationships is essential for the surgeon and allows an appreciation for the interplay of sexual function and reproduction and a context for understanding gynecologic pathology.

Structure and Support of the Pelvis and Genitalia

The bony pelvis is comprised by the sacrum posteriorly and the ischium, ilium, and pubic bones anteromedially. It supports the upper body and transmits the stresses of weight bearing to the lower limbs in addition to providing anchors for the supporting tissues of the pelvic floor.¹ The opening of the pelvis is spanned by the muscles of the pelvic diaphragm (Fig. 41-1). The muscles of the pelvic sidewall include the iliacus, the psoas, and the obturator internus muscle (Fig. 41-2). These muscles contract tonically and include, from anterior to posterior, bilaterally, the pubococcygeus, puborectalis, iliococcygeus, and coccygeus muscles. The first two of these muscles contribute fibers to the fibromuscular perineal body. The urogenital hiatus is bordered laterally by the pubococcygeus muscles and anteriorly by the symphysis pubis. It is through this muscular defect that the urethra and vagina pass, and it is the focal point for the study of disorders of pelvic support such as cystocele, rectocele, and uterine prolapse.

Vasculature and Nerves of the Pelvis

The rich blood supply to the pelvis arises largely from the internal iliac arteries except for the middle sacral artery originating at the aortic bifurcation and the ovarian arteries originating from the abdominal aorta. The internal iliac, or hypogastric, arteries divide into anterior and posterior branches. The latter supply lumbar and gluteal branches. From the anterior division of the hypogastric arteries arise the obturator, uterine, pudendal, middle rectal, inferior gluteal, and superior and middle vesical arteries (see Fig. 41-2).

The major nerves found in the pelvis are the sciatic, obturator, and femoral nerves. Sympathetic fibers course along the major arteries, and parasympathetics form the superior and inferior pelvic plexus (Fig. 41-3). The pudendal nerve arises from S2-S4 and travels laterally, exiting the greater sciatic foramen, hooking around the ischial spine and sacrospinous ligament, and returning via the greater sciatic foramen. It travels through Alcock’s canal and becomes the sensory and motor nerve of the perineum (see Figs. 41-1 and 41-3). The motor neurons serve the tonically contracting urethral and anal sphincter, and direct branches from the S2-S4 nerves serve the levator ani muscles. During childbirth and other excessive straining, this tethered nerve (along with the levator ani muscles) is subject to stretch injury and at least partially responsible for many female pelvic floor disorders.

Vulva

The labia majora form the cutaneous boundaries of the lateral vulva and represent the female homologue of the male scrotum (Fig. 41-4). The labia majora are fatty folds covered by hair-bearing skin in the adult. They fuse anteriorly over the anterior prominence of the symphysis pubis, the mons pubis. The deeper portions of the adipose layers are called Colles’ fascia and insert onto the inferior margin of the perineal membrane, limiting spread of superficial hematomas inferiorly. Adjacent and medial to the labia majora are the labia minora, smaller folds of connective tissue covered laterally by non–hair-bearing skin and medially by vaginal mucosa. The anterior fusion of the labia minora forms the prepuce and frenulum of the clitoris; posteriorly, the labia minora fuse to create the fossa navicularis and posterior fourchette. The term vestibule refers to the area medial to the labia minora bounded by the fossa navicularis and the clitoris. Both the urethra and the vagina open into the vestibule. Skene’s glands lie lateral and inferior to the urethral meatus. Cysts, abscesses, and neoplasms may arise in these glands.

Erectile tissues and associated muscles are in the space between the perineal membrane and the vulvar subcutaneous tissues (see Fig. 41-1). The clitoris is formed by two crura and is suspended from the pubis. Overlying the crura are ischiocavernosus muscles, which run along the inferior surfaces of the ischiopubic rami. Extending medially from the inferior end of the ischiocavernosus muscles are the superficial transverse perinei muscles. These terminate in the midline in the perineal body, caudal and deep to the posterior fourchette. Vestibular bulbs lie just deep to the vestibule and are covered laterally by bulbocavernosus muscles. These originate from the perineal body and insert into the body of the clitoris. At the inferior end of the vestibular bulbs are Bartholin’s glands, which connect to the vestibular skin by ducts.

Vagina

The vagina is an elastic fibromuscular tube opening from the vestibule running superiorly and posteriorly, passing through the perineal membrane. The lower third is invested by the superficial and deep perineal muscles; it incorporates the urethra in its anterior wall and has a rich blood supply from the vaginal branches of the external and internal pudendal arteries. The upper two thirds of the vagina are not are not invested by muscles. This portion lies in opposition to the bladder base anteriorly and the rectum and posterior pelvic cul-de-sac superiorly. The cervix opens into the posterior vaginal wall bulging into the vaginal lumen.

Fibrovascular Ligaments and Avascular Tissue Planes

Figure 41-5 is a view of the internal genitalia as one would approach the pelvis from a midline abdominal incision. The central uterus and uterine cervix are supported by the pelvic floor muscles. They are suspended by the lateral fibrous cardinal, or Mackenrodt’s ligament, and the uterosacral ligaments, which insert into the paracervical fascia medially and into the muscular sidewalls of the pelvis laterally. Posteriorly, the uterosacral ligaments provide support for the vagina and cervix as they course from the sacrum lateral to the rectum and insert into the paracervical fascia. Emanating from the uterine cornu and traveling through the inguinal canal are the round ligaments, eventually attaching to the subcutaneous tissue of the mons pubis. The peritoneum enfolding the adnexa (tube, round ligament, and ovary) is referred to as the broad ligament, which separates the pelvic cavity into an anterior and posterior component.

The peritoneal recesses in the pelvis anterior and posterior to the uterus are referred to as the anterior and posterior cul-de-sacs. The latter is also called the pouch or cul-de-sac of Douglas. On transverse section, several avascular, and therefore important, surgical planes can be identified (Fig. 41-6). These include the lateral paravesical and pararectal spaces and, from anterior to posterior, the retropubic or prevesical space of Retzius and the vesicovaginal, rectovaginal, and retrorectal or presacral spaces.

These avascular tissue planes are often preserved and provide safe surgical access when the intraperitoneal pelvic anatomy is distorted by tumor, endometriosis, adhesions, or infection. As an example, the ureter is at significant risk of iatrogenic injury in the context of such pathology. Using the avascular retroperitoneal planes, the ureter can be traced into the pelvis as it crosses the distal common iliac arteries laterally into the pararectal space and then courses inferior to the ovarian arteries and veins until crossing under the uterine arteries into the paravesical space just lateral to the cervix. After traveling to the cervix, the ureters course downward and medially over the anterior surface of the vagina before entering the base of the bladder in the vesicovaginal space.

Uterus

The typically pear-shaped uterus consists of a fundus, cornua, body, and cervix. It lies between the bladder anteriorly and the rectosigmoid posteriorly. The endometrium lines the cavity and has a superficial functional layer that is shed with menstruation and a basal layer from which the new functional layer is formed. Sustained estrogenic stimulation can lead to hyperplastic changes or carcinoma. Adenomyosis is a condition in which benign endometrial glands infiltrate into the muscle or myometrium of the uterus. The myometrium is composed of smooth muscle, and the contraction of myometrium is a factor in menstrual pain and is essential in childbirth. The myometrium can develop benign smooth muscle neoplasms known as leiomyoma or fibroids.

Cervix

The cervix connects the uterus and vagina and projects into the upper vagina. The vagina forms an arched ring around the cervix described as the vaginal fornices—lateral, anterior, and posterior. The cervix is about 2.5 cm long with a fusiform endocervical canal lined by columnar epithelium lying between an internal and external os, or opening. The vaginal surface of the cervix is covered with stratified squamous epithelium, similar to that lining the vagina. The squamocolumnar junction, also referred to as the transformation zone, migrates at different stages of life and is influenced by estrogenic stimulation. The transformation zone develops as the columnar epithelium is replaced by squamous metaplasia. This transformation zone is vulnerable to human papillomavirus (HPV) infection and resultant dysplastic changes. These changes can be detected by microscopic assessment of a cervical cytologic (or Pap) smear. If the duct of a cervical gland becomes occluded, the gland distends to form a retention cyst or Nabothian follicle.

Fallopian Tubes

The bilateral fallopian tubes arise from the upper lateral cornua of the uterus and course posterolaterally within the upper border of the broad ligament. The tubes can be divided into four parts. The interstitial part forms a passage through the myometrium. The isthmus is the narrow portion extending out about 3 cm from the myometrium. The ampulla is thin-walled and tortuous with its lateral end free of the broad ligament. The infundibulum is the distal end fringed by a ring of delicate fronds or fimbriae. The fallopian tubes receive the ovum after ovulation. Peristalsis carries the ovum to the ampulla where fertilization occurs. The zygote transits the tube over the course of 3 to 4 days to the uterus. Abnormal implantation in the fallopian tube is the most common site of ectopic pregnancies. The tubes may also be infected by ascending organisms, resulting in tubo-ovarian abscesses.

Ovaries

The ovaries are attached to the uterine cornu by the proper ovarian ligaments, or the utero-ovarian ligaments. The ovaries are suspended from the lateral pelvis by their vascular pedicles, the infundibulopelvic (IP) ligaments or ovarian arteries. The IP ligaments are paired branches from the abdominal aorta arising just below the renal arteries. They merge with the peritoneum over the psoas major muscle and pass over the pelvic brim and the external iliac vessels. The ovarian veins ascend at first with the ovarian arteries, and then track more laterally. The right ovarian vein ascends to drain directly into the inferior vena cava, whereas the left vein drains into the left renal vein. Lymphatic drainage follows the arteries to the para-aortic lymph nodes. The ovaries are covered by a single layer of cells that is continuous with the mesothelium of the peritoneum. Beneath this is a fibrous stroma within which are embedded germ cells. At ovulation, an ovarian follicle ruptures through the ovarian epithelium.

Elements of a Gynecologic History

A complete history is a seminal part of any assessment (Table 41-1). Many gynecologic diseases can present with broad constitutional symptoms, occur secondary to other conditions, or be related to medications. A full history should include particular attention to family history; organ system history, including breast, gastrointestinal, and urinary tract symptoms; and a careful medication, anesthesia, and surgical history. The key elements of a focused gynecologic history include the following:

• Date of last menstrual period, if premenopausal

• History of contraceptive and postmenopausal hormone use

• Obstetrical history

• Age at menarche and menopause (method of menopause, e.g., drug, surgical)

• Menstrual bleeding pattern

• History of pelvic assessments, including cervical smear results

• History of pelvic infections, including HPV, and human immunodeficiency virus (HIV) status

• Sexual history (number of lifetime partners)

• Prior gynecologic surgery(s)

The Gynecologic Examination

For many women, their gynecologist is their primary care physician. When that is the case, it is necessary that a full medical and surgical history be taken and that, in addition to the pelvic examination, the minimum additional examination should include assessment of the thyroid, breasts, and cardiopulmonary system. The pelvic examination starts with a full abdominal examination. Inguinal node evaluation is performed before placing the patient’s legs in the dorsal lithotomy position (in stirrups). A flexible, focused light source is essential, and vaginal instruments including speculums of variable sizes and shapes including pediatric sizes (Graves and Pederson) are required to assure that the patient’s anatomy can be fully and comfortably viewed.

The external genitalia are inspected, noting the distribution of pubic hair, the skin color and contour, the Bartholin and Skene’s glands, and perianal area. Abnormalities are documented, and a map with measurements of abnormalities is drawn. A warmed lubricated speculum is inserted into the vagina and gently opened to identify the cervix if present, or the vaginal apex if not. If there is a concern that a malignancy is present, careful digital assessment of a vaginal mass and location may be addressed prior to speculum placement in order to avoid abrading a vascular lesion and inducing hemorrhage. The speculum would then be inserted just short of the length to the mass in order to view that area directly before advancing. An uncomplicated speculum exam includes examination of the vaginal sidewalls; assessment of secretions, including culture if necessary; and collection of the cervical cytologic specimen if indicated (see later section, Common Screening and Testing).

A bimanual examination is performed by placing two fingers in the vaginal canal; one finger may be used if patient has significant vaginal atrophy or has had prior radiation with stenosis (Fig. 41-7). Carefully and sequentially assess the size and shape of the uterus by moving it against the abdominal hand, and assess the adnexa by carefully sweeping the abdominal hand down the side of the uterus. The rectovaginal examination, consisting of one finger in the vagina and one in the rectal vault, is used to further examine and characterize the location, shape, fixation, size, and complexity of the uterus, adnexa, cervix, and anterior and posterior cul-de-sacs. The rectovaginal exam also allows examination of the uterosacral ligaments from the back of the uterus sweeping laterally to the rectal finger and the sacrum, and a stool sample for occult blood can be obtained during this exam.

It is critical that presurgical assessments include a full general examination. This is particularly important with potential oncologic diagnoses or infectious issues, in order to assure that the proposed surgery is both safe and appropriate. Complications such as sites of metastatic cancer or infection, associated bleeding and/or clotting issues and history, and drug exposure, allergies, and current medications must be addressed.

Common Screening and Testing

Cervical Preinvasive and Invasive Disease Screening

The most recent cervical cytology guidelines by the U.S. Preventative Services Task Force has increased the intervals for most women given the known natural history of HPV-related cervical dysplasia progression to cancer.² The very high negative predictive value of the HPV test allows for this change. The current recommendations call for cervical smear screening every 3 years in women age 21 to 65 years. If an HPV test performed at the same time also is negative, a Pap and HPV test combination does not need to be repeated in women age 30 to 65 for 5 years. HPV testing should not be performed as a screening test in women under age 30 due to the high prevalence of HPV, as well as the high likelihood of resolution of infection. Women with a history of cervical dysplasia or cancer need more frequent screening based on their diagnosis.

Microscopy of Vaginal Discharge

During a speculum exam, a cotton-tipped applicator is used to collect the vaginal discharge; it is smeared on a slide with several drops of 0.9% normal saline to create a saline wet mount. A cover slide is placed and the slide is evaluated microscopically for the presence of mobile trichomonads (Trichomonas vaginalis) or clue cells (epithelial cells studded with bacteria, seen in bacterial vaginosis; Table 41-2). A potassium hydroxide (KOH) wet mount is the slide application of the collected vaginal discharge with 10% KOH; this destroys cellular elements. The test is positive for vaginal candidiasis when pseudohyphae are seen (Table 41-2).

Chlamydia/Gonorrhea Testing

Nucleic acid amplification testing (NAAT) has emerged as the diagnostic test of choice for Neisseria gonorrhoeae and Chlamydia trachomatis. A vaginal swab, endocervical swab, and/or urine sample can be used for this test. The test can be completed within hours and has been found to be more sensitive than cultures.

β-Human Chorionic Gonadotropin (β-hCG) Testing

Qualitative urinary pregnancy tests for β-hCG are standard prior to any surgery in a woman of reproductive age and potential, regardless of contraception history. In addition, serum quantitative β-hCG testing is appropriate for evaluation of suspected ectopic pregnancy, gestational trophoblastic disease, or ovarian mass in a young woman. In the case of ectopic pregnancy, serial levels are required when a pregnancy cannot be identified in the uterine cavity. As a general rule, 85% of viable intrauterine pregnancies will have at least a 66% rise in the β-hCG level over 48 hours.

Common Office Procedures for Diagnosis

Vulvar/Vaginal Biopsy

Any abnormal vulvar or vaginal lesion including skin color changes, raised lesions, or ulcerations should be biopsied. Local infiltration with local anesthetic is followed by a 3- to 5-mm punch biopsy appropriate to the lesion. The specimen is elevated with Adson forceps and cut from its base with scissors. The vaginal biopsy can sometimes be difficult to perform because of the angle of the lesion. After injection with local anesthetic, traction of the area with Allis forceps and direct resection of the lesion with scissors or cervical biopsy instrument (Schubert, Kevorkian, etc.) can achieve an adequate biopsy.

Colposcopy and Cervical Biopsy

In cases of an abnormal Pap smear cytology, a colposcopy is performed for a histologic evaluation. A colposcope is used to achieve 2× to 15× magnification of the cervix. Once the cervix is visualized, cervical mucus, if present, is removed, and then 3% acetic acid is applied to the cervix for 1 minute. This application dehydrates cells and causes dysplastic cells with dense nuclei to appear white. The entire squamocolumnar junction is visualized during an adequate colposcopy. This area is seen as the transition from the smooth-appearing squamous ectocervix to the pink endocervical tissue. Acetowhite areas or areas with punctation, mosaicism, or atypical blood vessels seen during colposcopy may represent dysplasia or cancer and should be biopsied.

Endometrial Biopsy

Endometrial sampling should be performed before planned hysterectomy if there is a history of bleeding between periods, heavy and/or frequent menstrual periods, or postmenopausal bleeding. A patient with the potential for pregnancy should have a pregnancy test before the procedure. An endometrial pipelle is inserted after cervical cleaning, and the depth of the uterine cavity is noted. The endometrial specimen is obtained by pulling on the plunger within the pipelle, creating a small amount of suction. The pipelle is rotated and pulled back from the fundus to the lower uterine segment within the cavity to access all sides.³ Additional passes may be needed in order to acquire an adequate amount of tissue.

Evaluation for Fistula

When a patient presents with copious vaginal discharge, the provider must be concerned about a fistula with the urinary or gastrointestinal tract. A simple office procedure can be performed when there is a concern for a vesicovaginal fistula. A vaginal tampon is placed, followed by instillation of sterile blue dye through a transurethral catheter into the bladder; a positive test is blue staining of the tampon. If the test is negative, one can evaluate for a ureterovaginal fistula. The patient is given phenazopyridine, which changes the color of urine to orange. If a tampon placed in the vagina stains orange, the test is positive. Alternatively, the patient can be given an intravenous injection of indigo carmine.

Rectal fistula must be considered when a patient reports stool evacuation per vagina. It can be identified in a similar fashion using a large Foley catheter placed in the distal rectum through which dye may be injected or with the use of an oral charcoal slurry and timed examination. Common areas for fistulae are at the vaginal apex, at the site of a surgical incision, or around the site of a prior episiotomy or perineal repair after a vaginal delivery.

Vulvar Lesions

Many women suffer with undiagnosed symptoms of vulvar disease. Patients presenting with chronic vulvar symptoms should be carefully interviewed, examined, and a vulvar biopsy obtained whenever the diagnosis is in question, the patient is not responding to treatment, or premalignant or malignant disease is suspected. Vulvar conditions such as contact dermatitis, atrophic vulvovaginitis, lichen sclerosis, lichen planus, lichen chronicus simplex, Paget’s disease, Bowen’s disease, and invasive vulvar cancer are not uncommon. Systemic diseases like psoriasis, eczema, Crohn’s disease, Behçet’s disease, vitiligo, and seborrheic dermatitis may also involve the vulvar skin.

Vulvar Contact Dermatitis

This dermatitis is a common cause of acute or chronic vulvar pruritus and can be irritant or allergic.⁴ Irritant dermatitis usually results from overzealous hygiene habits, such as the use of harsh soaps and frequent douching. It is also common in patients with urinary or fecal incontinence, especially the elderly and the disabled. Allergic vulvar dermatitis is caused by a variety of allergens, such as fragrances and topical antibiotics. The mainstay of treatment is to identify and discontinue the offending agent or practice or providing a skin barrier in the case of incontinence.

Leukoplakias

There are three types of leukoplakia, a flat white abnormality. Lichen sclerosis is the most common cause of leukoplakia.⁴ It affects women 30 to 40 years of age. Classically, it results in a figure-of-eight pattern of white epithelium around the anus and vulva resulting in variable scaring and itching and, less commonly, pain. Diagnosis is confirmed with biopsy, and treatment consists of topical steroids. Lichen planus is a cause of leukoplakia with an onset in the fifth and sixth decades of life. Lichen planus, in contrast to lichen sclerosis, which is limited to the vulva and perianal skin, can involve the vagina and oral mucosa, and erosions occur in the majority of patients, leading to a variable degree of scaring. Patients usually have a history and dysuria and dyspareunia and complain of a burning vulvar pain. Histology is not specific, and biopsy is recommended. Treatment is with steroid ointments. Systemic steroids are indicated for severe and/or unresponsive cases. Lichen simplex chronicus is the third cause of leukoplakia but is distinguished from the other lichen diseases by epidermal thickening, absence of scaring, and a severe intolerable itch.⁴ Intense scratching is not uncommon and contributes to the severity of the symptoms and predisposes the cracked skin to infections. Treatment consists of cessation of the scratching, which sometimes requires sedation; elimination of any allergen or irritant; suppression of inflammation with potent steroid ointments; and treatment of any coexisting infections.

Bartholin’s Cyst or Abscess

Bartholin’s glands, great vestibular glands, are located at the vaginal orifice at the four and eight o’clock positions; they are rarely palpable in normal patients. They are lined with cuboidal epithelium and secrete mucoid material to keep the vulva moist. Their ducts are lined with transitional epithelium, and their obstruction secondary to inflammation may lead to the development of a Bartholin’s cyst or abscess. Bartholin’s cysts range in size from 1 to 3 cm and are detected on exam or are recognized by the patient. They occasionally result in discomfort and dyspareunia and require treatment. Cysts and ducts can become infected and form abscesses. Infections are often polymicrobial; however, sexually transmitted N. gonorrhoeae and C. trachomatis are sometimes implicated. Treatment consists of incision and drainage and placement of a Word catheter, a small catheter with a balloon tip, for 2 to 3 weeks to allow for formation and epithelialization of a new duct. Appropriate antibiotic therapy should be instituted. Recurrent cysts or abscesses are usually marsupialized, but on occasion necessitate excision of the whole gland. Marsupialization is done by incising the cyst or abscess wall and securing its lining to the skin edges with interrupted sutures.⁵ Cysts or abscesses that fail to resolve after drainage and those occurring in patients over age 40 should be biopsied to exclude malignancy.

Molluscum Contagiosum

Molluscum contagiosum presents with dome-shaped papules and is caused by the poxvirus. The papules are usually 2 to 5 mm in diameter and classically have a central umbilication. They are spread by direct skin contact and present on the vulva, as well as abdomen, trunk, arms, and thighs. Lesions typically clear in several months but can be treated with cryotherapy, curettage, or cantharidin, a topical blistering agent.

Genital Ulcer Syndromes

The frequency of the infectious etiologies of genital ulcers varies by geographic location. The most common causes of sexually transmitted genital ulcers in young adults in the United States are, in descending order of prevalence, herpes simplex virus (HSV), syphilis, and chancroid.⁶ Others infectious causes of genital ulcers include lymphogranuloma venereum and granuloma inguinale. Noninfectious etiologies include Behçet’s disease, neoplasms, and trauma. Table 41-3 outlines a rational approach to their evaluation and diagnosis.

Vulvar Condyloma

Condylomata acuminata (anogenital warts) are viral infections caused by HPV.⁷ Genital infection with HPV is the most common sexually transmitted infection in the United States today. HPV types 6 and 11 are the most common low-risk types and are implicated in 90% of cases of genital warts.⁸ High-risk types can be found in association with invasive cancers. Genital warts are skin-colored or pink and range from smooth flattened papules to verrucous papilliform lesions. Lesions may be single or multiple and extensive. Diagnosis should be confirmed with biopsy because verrucous vulvar cancers can be mistaken for condylomata.⁹ Treatment modalities range from patient-applied ointments to physician-applied agents and office procedures. If small, self-administered topical imiquimod 5% cream or trichloroacetic acid for in-office applications may be tried. Extensive lesions may require surgical modalities that include cryotherapy, laser ablation, cauterization, and surgical excision.

Paget’s Disease of the Vulva

Paget’s disease of the vulva is an intraepithelial disease of unknown etiology that affects mostly white postmenopausal women in their sixth decade of life. It causes chronic vulvar itching and is sometimes associated with an underlying invasive vulvar adenocarcinoma or invasive cancers of the breast, cervix, or gastrointestinal tract. Grossly, the lesion is variable but usually confluent, raised, erythematous to violet, and waxy in appearance. Biopsy is required for diagnosis; the disease is intraepithelial and characterized by Paget’s cells with large pale cytoplasm. Treatment is assessment for other potential concurrent adenocarcinomas, and then surgical removal by wide local resection of the involved area with a 2-cm margin. Free margins are difficult to obtain because the disease usually extends beyond the clinically visible area.^10,11 Intraoperative frozen section of the margins can be done; however, Paget’s vulvar lesions have a high likelihood of recurrence even after securing negative resection margins.

Vulvar Intraepithelial Neoplasia (VIN)

VIN is similar to its cervical intraepithelial neoplasia (CIN) counterpart and is graded on the degree of epithelial involvement as mild (VIN I), moderate (VIN II), severe (VIN III), or vulvar carcinoma in situ (Bowen’s disease).¹² Risk factors include HPV infection, prior VIN, HIV infection, immunosuppression, smoking, vulvar dermatoses such as lichen sclerosis, CIN, and cervical cancer. VIN can be unifocal or multifocal. Unifocal lesions commonly affect postmenopausal women and lack a clear association with HPV, while multifocal disease mostly affects younger reproductive-age females and has a strong association with HPV infection. Fifty percent of patients are asymptomatic, with vulvar pruritus being the most common complaint in those with symptoms. Lesions may be vague or raised and velvety with sharply demarcated borders. Diagnosis is made with a vulvar skin biopsy, and multiple biopsies are sometimes necessary. Colposcopy with application of 5% acetic acid and identification of the acetowhite lesions of VIN is a valuable diagnostic tool for subtle lesions and will help guide the biopsy. Evaluation of the perianal and anal area is important as the disease may involve these areas, particularly in immunocompromised and/or nicotine-addicted women. Once invasive disease is ruled out, treatment usually involves wide surgical excision; however, the initial treatment approach may include 5% imiquimod cream, CO₂ laser ablation, or cavitational ultrasonic surgical aspiration, and depends on the number of lesions and their severity. When laser ablation is used, a 1-mm depth in hair-free areas is usually sufficient, whereas hairy lesions require ablation to a 3-mm depth because the hair follicles’ roots can reach a depth of 2.5 mm. Unfortunately, VIN tends to recur in up to 30% of cases, and high-grade lesions (VIN III, carcinoma in situ) progress to invasive disease in approximately 10% of patients if left untreated.¹³

Vaginal Lesions

Vaginitis

(see Table 41-2).

Vulvovaginal symptoms are extremely common, accounting for over 10 million office visits per year in the United States. The causes of vaginal complaints are commonly infectious in origin, but they include a number of noninfectious causes, such as chemicals or irritants, hormone deficiency, foreign bodies, systemic diseases, and malignancy. Symptoms are commonly nonspecific and include abnormal vaginal discharge, pruritus, irritation, burning, odor, dyspareunia, bleeding, and ulcers. A purulent discharge from the cervix should always raise suspicion of these infections even in the absence of pelvic pain or other signs.

Normal vaginal discharge is white or transparent, thick, and mostly odorless. It increases during pregnancy, with use of estrogen-progestin contraceptives, or at mid-cycle around the time of ovulation. Complaints of foul odor and abnormal vaginal discharge should be investigated. Candidiasis, bacterial vaginosis, and trichomoniasis account for 90% of vaginitis cases. The initial workup includes pelvic examination, vaginal pH testing, microscopy, vaginal cultures if microscopy is normal, and gonorrhea/chlamydia NAAT (see earlier section, Common Screening and Testing).¹⁴ The pH of normal vaginal secretions is 3.8 to 4.4, which is hostile to growth of pathogens. A pH greater than or equal to 4.9 is indicative of a bacterial or protozoal infection. Treatment of vaginal infection before anticipated surgery is appropriate, particularly for bacterial vaginosis, which may be associated with a higher risk for vaginal cuff infections (Fig. 41-8).

Bacterial Vaginosis (BV)

BV accounts for 50% of vaginal infections. It results from reduction in concentration of the normally dominant lactobacilli and increase in concentration of anaerobic organisms like Gardnerella vaginalis, Mycoplasma hominis, Bacteroides species, and others.¹⁵ Diagnosis is made by microscopic demonstration of clue cells. The discharge typically produces a fishy odor upon addition of KOH (amine or Whiff test). Initial treatment is usually a 7-day course of metronidazole.

Vulvovaginal Candidiasis (VVC)

VVC is the most common cause of vulvar pruritus. It is generally caused by Candida albicans and occasionally by other Candida species. It is common in pregnant women, diabetics, patients taking antibiotics, and immunocompromised hosts. Initial treatment is usually with topical antifungals, although single-dose oral antifungal treatments are also common.

Trichomonas vaginalis

Trichomoniasis is a sexually transmitted infection of a flagellated protozoan and can present with malodorous, purulent discharge. It is typically diagnosed with visualization of the trichomonads during saline wet mount microscopy. Initial treatment is usually a 7-day course of metronidazole.

Gartner’s Duct Cyst

A Gartner’s duct cyst is a remnant of the Wolffian tract; it is typically found on the lateral vaginal walls. Patients can be asymptomatic or present with complaints of dyspareunia or difficulty inserting a tampon. If symptomatic, these cysts may be surgically excised or marsupialized. If surgery is planned, a preoperative magnetic resonance imaging (MRI) scan should be obtained to determine the extent of the cyst.

Vaginal Condyloma

The etiology and treatment of vaginal condyloma is similar to vulvar condyloma (see earlier section, Vulvar Condyloma).

Vaginal Intraepithelial Neoplasia

Vaginal intraepithelial neoplasia, or VaIN, is similar to VIN and is classified based on the degree of epithelial involvement as mild (I), moderate (II), severe (III), or carcinoma in situ.¹² Sixty-five percent to 80% of VaIN or vaginal cancers are associated with HPV infection. The majority of lesions are located in the upper one third of the vagina. Lesions are usually asymptomatic and found incidentally on cytologic screening. Diagnosis is made via guided biopsy of acetowhite lesions at the time of colposcopy. Lesions may appear flat or raised and white with sharply demarcated borders and may show vascular changes. The presence of aberrant vessels with marked branching is suggestive of invasive disease. VaIN is treated with laser ablation, surgical excision, or topical 5-fluorouracil therapy.

Cervical Lesions

Benign Cervical Lesions

Benign lesions of the cervix include endocervical polyps, Nabothian cysts (clear, fluid-filled cysts with smooth surfaces), trauma (such as delivery-related cervical tear or prior cervical surgery), malformation of the cervix, and cervical condyloma. For endocervical polyps, exploration of the base of the polyp with a cotton swab tip to identify that it is cervical and not uterine and to identify the stalk characteristics can help identify the appropriate surgical approach. Small polyps with identifiable base can be removed by grasping the polyp with ring forceps and slowly rotating it until separated from its base. Use of loop electro-excisional procedure (LEEP) is appropriate for larger lesions. Laser or other ablative procedures are appropriate for condyloma proven by biopsy.

Cervical Intraepithelial Neoplasia (CIN)

High-grade cervical dysplasia (CIN II or III) has a high chance of persistent HPV infection with risk of transformation to malignancy; thus an excisional procedure is usually indicated. This serves a therapeutic purpose by removal of dysplastic cells and a diagnostic purpose for histologic review to rule out concomitant early-stage cervical cancer. Either a LEEP or cold knife conization (CKC) may be used for surgical excision of the squamocolumnar junction (SCJ) and outer endocervical canal. Risks of both procedures include bleeding, postprocedure infection, cervical stenosis, and risk of preterm delivery with subsequent pregnancies. A looped wire attachment for a standard monopolar electrosurgical unit is used to perform a LEEP excision. Loops range in a variety of shapes and sizes to accommodate different sizes of cervix. Optimally, one pass of the loop should excise the entire SCJ. Hemostasis of the remaining cervix is achieved with the ball electrode and ferrous sulfate paste (Monsel’s solution).

Different from a LEEP, a cervical CKC does not use energy to excise the specimen. The advantage of this procedure is that the margin status is not obscured by cauterized artifact. This is important in cases of adenocarcinoma in situ and microinvasive squamous cell carcinoma, where margin status dictates the type of and indication for future therapy. During a CKC, a #11 blade is used to circumferentially excise the conical biopsy. Hemostasis is achieved with the ball electrode, Monsel’s solution, or suture.

HPV Vaccine

Two HPV vaccines have been developed and approved by the U.S. Food and Drug Administration (FDA).¹⁶ Gardasil is a quadrivalent vaccine that targets HPV genotypes 16 and 18, which cause approximately 70% of cervical cancers and about 50% of precancerous lesions (CIN II/III) worldwide, and HPV genotypes 6 and 11, which cause 90% of genital warts. Cervarix is a bivalent vaccine that targets HPV genotypes 16 and 18. In contrast to natural infection, the vaccine is highly immunogenic, activating both humoral and cellular immune responses. Vaccination generates high concentrations of neutralizing antibodies to HPV L1 protein, the antigen in both vaccines. It is thought that vaccination may provide protection against HPV infection through neutralization of virus by serum immunoglobulin that diffuses from capillaries to the genital mucosal epithelium.¹⁷

Several randomized clinical trials^18,19,20 involving approximately 35,000 young women have shown that both Gardasil and Cervarix prevent nearly 100% of the HPV subtype-specific precancerous cervical cell changes for up to 4 years after vaccination among women who were not infected at the time of vaccination; vaccination occurred before sexual debut. These major clinical trials have used prevention of CIN II/III and carcinoma in situ as the efficacy endpoints. Vaccination has not yet been shown to protect women who are already infected with HPV-16 or HPV-18 at the time of vaccination.

Current FDA approval applies to use in women who are between 9 and 26 years of age for the prevention of the following: cervical, vulvar, and vaginal cancer caused by HPV-16 or -18, genital warts caused by HPV-6 or -11, and lesions caused by HPV-6, -11, -16, or -18 (CIN I, II, and III; cervical carcinoma in situ; VIN; or VaIN II/III). The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination for females 11 to 12 years of age, maybe starting at age 9; catch-up vaccination is recommended for females 13 to 26 years of age who did not get all three doses when they were younger. Studies to evaluate the efficacy of the vaccine in healthy women 26 years of age and older with no prior exposure to HPV is ongoing, and additional information on the length of protection is forthcoming. In 2009, the FDA approved the quadrivalent vaccine for use to prevent genital warts in men and boys, and in 2011, the ACIP recommended that all males 11 to 12 years of age be vaccinated, stating that this may reduce some of the HPV-related burden suffered by women.

Immunocompromised women may receive the quadrivalent vaccine. Although the safety and immunogenicity of HPV vaccination in this population are not well established, the vaccine could be beneficial in these women since they are at increased risk for HPV-related cancers. Vaccination is not recommended for pregnant women, although neither vaccine has been shown to be causally associated with adverse outcomes in pregnant women or their fetuses. If pregnant women are vaccinated inadvertently, completion of the series should be delayed until after the pregnancy.

Cervical cancer screening continues to play an important role in detection and treatment of CIN II/III and prevention of cervical cancer in these high-risk patients. Cervical cancer screening continues to be of great importance since HPV immunization will not prevent approximately 25% to 30% of cervical cancers in HPV-naïve women and does not protect against the development of cancer in women already infected with carcinogenic HPV types.

Uterine Corpus

The average age of menarche, or first menstrual period, in the United States is 12 years and 5 months. Duration of normal menstruation is between 2 and 7 days, with a flow of less than 80 mL, cycling every 21 to 35 days.²¹ Nonpregnant patients, who present with heavy bleeding and are 35 years of age and older or have risk factors for endometrial cancer, must be ruled out for malignancy as the first step in their management (see earlier section, Endometrial Biopsy).

Abnormal Uterine Bleeding (AUB)

Abnormal uterine bleeding is described based on the bleeding pattern. Menorrhagia is prolonged (>7 days) or excessive (>80 mL daily) menstrual cycles occurring at regular intervals, and metrorrhagia is bleeding between menstrual periods. Menometrorrhagia is the occurrence of both. Intermenstrual bleeding, also known as spotting, is bleeding of variable amounts occurring between regular menstrual cycles. Poly-, oligo-, and amenorrhea are menstrual cycles of less than 21 days, longer than 35 days, or the absence of uterine bleeding for 6 months or a period equivalent to three missed cycles, respectively. Because there are many causes of AUB, they are divided into two categories: structural causes and nonstructural causes.²² Structural causes include polyps, adenomyosis, leiomyomata, and malignancy. Nonstructural causes can include coagulopathy, ovulatory dysfunction, endometrial effects, and iatrogenic causes.

Endometrial Polyps

Endometrial polyps are localized hyperplastic growth of endometrial glands and stroma around a vascular core forming sessile or pedunculated projections from the surface of the endometrium.²³ Endometrial polyps are rarely neoplastic (<1%) and may be single or multiple. Many are asymptomatic; however, they are responsible for about 25% of cases of abnormal uterine bleeding, usually metrorrhagia. Polyps are common in patients on tamoxifen therapy and in peri- and postmenopausal women. Up to 2.5% of patients with a polyp may harbor foci of endometrial carcinoma.²⁴ Diagnosis can be made with saline-infused hysterosonography, hysterosalpingogram, or direct visualization at the time of hysteroscopy. Definitive treatment, in the absence of malignancy, involves resection with an operative hysteroscope or by sharp curettage.

Adenomyosis

Adenomyosis refers to ectopic endometrial glands and stroma situated within the myometrium. When diffuse, it results in globular uterine enlargement secondary to hyperplasia and hypertrophy of the surrounding myometrium. Adenomyosis is very common, tends to occur in parous women, and is frequently an incidental finding at the time of surgery. Diagnosis is suspected in a parous woman with menorrhagia, dysmenorrhea, and diffuse globular uterine enlargement. MRI may reveal islands within the myometrium with increased signal intensity.²⁵ Hysterectomy is the only treatment, providing material for definitive pathologic diagnosis.

Uterine Leiomyomas

Leiomyomas, also known colloquially as fibroids, are the most common female pelvic tumor and occur in response to growth of the uterine smooth muscle cells (myometrium). They are common in the reproductive years, and by age 50, at least 60% of white and up to 80% of black women are or have been affected. Leiomyomas are described according to their anatomic location (Fig. 41-9) as intramural, subserosal, submucosal, pedunculated, cervical, and rarely ectopic.²¹ Most are asymptomatic; however, abnormal uterine bleeding caused by leiomyomas is the most common indication for hysterectomy in the United States. Other manifestations include pain, pregnancy complications, and infertility. Pain generally results from degenerating myomas that outgrew their blood supply or from compression of other pelvic organs such as the bowel, bladder, and ureters. High levels of pregnancy hormones frequently cause significant enlargement of pre-existing myomas, which may lead to significant distortion of the uterine cavity resulting in recurrent miscarriages, fetal malpresentations, intrauterine growth restriction, obstruction of the birth canal and the subsequent need for cesarean delivery, abruption, preterm labor, and pain from degeneration.

Bleeding is usually heavy and irregular (menometrorrhagia) and can be severe at times, requiring hospitalization. Examination reveals an enlarged irregular uterus and, in severe cases, a large solid pelvic mass extending to the upper abdomen. Diagnosis is usually made by transvaginal ultrasonography. Other diagnostic modalities, including MRI, computed tomography (CT), and hysterosalpingogram or saline-infused hysterosalpingography, are especially useful in the cases of submucosal and intrauterine myomas. Most are benign; malignant degeneration occurs in less than 1% of cases and is usually encountered in the menopausal years. Management options of leiomyomas are tailored to the individual patient depending on her age and desire for fertility and the size, location, and symptoms of the myomas. Conservative management options include oral contraceptive pills, medroxyprogesterone acetate, gonadotropin-releasing hormone (GnRH) agonists, uterine artery embolization, and myomectomy.^26,27,28 Uterine artery embolization is contraindicated in patients planning future pregnancy and frequently results in acute degeneration of myomas requiring hospitalization for pain control. Myomectomy is indicated in patients with infertility and those who wish to preserve their reproductive capacity. Hysterectomy is the only curative therapy. Treatment with GnRH agonists for 3 months prior to surgery is recommended in anemic patients and may allow them time to normalize their hematocrit, avoiding transfusions; GnRH also decreases blood loss at hysterectomy and shrinks the myomas by an average of 30%. The latter may make the preferred vaginal surgical approach more feasible.

Endometrial Hyperplasia

Endometrial hyperplasia is caused by chronic unopposed hyperestrogenic state (relative absence of progesterone) and is characterized by proliferation of endometrial glands resulting in increased gland-to-stroma ratio. It can be asymptomatic or, more commonly, result in abnormal vaginal bleeding. Hyperplasia can be either simple or complex, based on the architecture of the glands. Of greater importance is the presence or absence of nuclear atypia, described by the World Health Organization (WHO) classification.²⁹ Untreated endometrial hyperplasia progresses to malignancy in 1%, 3%, 8%, and 29% of cases of simple, complex, simple with atypia, and complex hyperplasia with atypia, respectively.³⁰ Simple and complex hyperplasias can be treated with progestins, and women should have repeat endometrial sampling in 3 to 6 months. Atypical hyperplasia is considered a premalignant condition and is treated ideally with simple hysterectomy. When a patient has a preoperative diagnosis of complex atypical hyperplasia, the likelihood of a concomitant endometrial cancer at hysterectomy is 38% to 60%.³¹ If preservation of fertility is desired or surgery contraindicated, treatment with high-dose progestins such as megestrol acetate 40 to 160 mg/d usually reverses these lesions. Close follow-up and repeated sampling are necessary.

Procedures Performed for Structural Causes of Abnormal Uterine Bleeding

Dilation and Curettage

The patient is placed on the operating table in a lithotomy position, and the vagina and cervix are prepared as for any vaginal operation. The cervix is grasped on the anterior lip with a tenaculum. Some traction on the cervix is necessary to straighten the cervical canal and the uterine cavity. A uterine sound is inserted into the uterine cavity, and the depth of the uterus is noted. The cervical canal is then systematically dilated beginning with a small cervical dilator. Most operations can be performed after the cervix is dilated to accommodate a number 8 or 9 Hegar dilator or its equivalent. Dilatation is accomplished by firm, constant pressure with a dilator directed in the axis of the uterus (Fig. 41-10). After the cervix is dilated to admit the curette, the endocervical canal should be curetted and the sample submitted separately from the endometrial curettings. The endometrial cavity is then systemically scraped with a uterine curette. Uterine perforation is the major complication of dilatation and curettage, diagnosed when the operator finds no resistance to a dilator or curette. Laparoscopy to identify any damage to vessels or bowel may be required. Curettage of the postabortal uterus must be approached carefully because the uterus is extremely soft and perforation can occur with very little warning. Using the largest curette available or suction curettage is a safer choice than a small curette, which tends to cause perforation with less pressure.

Hysteroscopy

Hysteroscopy, like laparoscopy, has gained widespread support for use both for diagnosis and treatment of intrauterine pathology and for ablation of the endometrium as an alternative to hysterectomy for the treatment of abnormal uterine bleeding. Scopes can have an objective lens that is offset from the long axis from 0° to 30°. The diagnostic hysteroscope usually has an external diameter of 5 mm. Some diagnostic sheaths allow passage of flexible instruments for biopsy and cutting. An operative hysteroscope is wider and usually has an integral unipolar or bipolar resecting loop identical to a urologic resectoscope. The loop can be replaced with a roller ball for endometrial ablation.

Several types of distention media exist and vary by electrolyte composition and osmolarity. High-viscosity (e.g., dextran 70), low-viscosity/electrolyte-poor (e.g., glycine and sorbitol), and low-viscosity/electrolyte-containing (e.g., normal saline and lactated Ringer’s solution) medias are commonly used for distension of the uterus during hysteroscopy.³² The use and safety profiles of these medias vary, however. Dextran 70 allows excellent visibility, but the manufacturer recommends that no more than 250 mL be absorbed because of the concern for pulmonary edema. Anaphylactic reactions and coagulopathy are rare complications that have been described.³³ Glycine and sorbitol allow the use of monopolar cautery during operative hysteroscopy. Large volume deficits have been associated with secondary hyponatremic hypervolemia due to their metabolism to free water after intravasation.³³ When fluid deficits reach 1000 to 1500 mL, the procedure should be terminated, and the patient’s serum electrolytes assessed. Patients who have excessive intravasation experience headache, nausea, vomiting, and agitation.³⁴ This manifestation can progress to pulmonary and cerebral edema. These patients require close monitoring and diuretic administration.

Unlike glycine and sorbitol, normal saline and lactated Ringer’s solution have physiologic osmolarity and contain sodium. Although excessive intravasation does not lead to hyponatremia, it can lead to volume overload. Media deficits of greater than 2500 mL should prompt conclusion of the procedure and assessment of electrolytes.³⁵ Fluid-management systems are available to monitor the amount of distension media lost during hysteroscopy. Media intravasation can be lessened by using the minimum intrauterine pressure needed to perform the hysteroscopy and by minimizing operating time. The physician must be aware that certain procedures such as endometrial ablation and resection of myomas open vascular channels and place the patient at increased risk for fluid overload.³³

Diagnostic Hysteroscopy

Following dilation of the cervix, a diagnostic hysteroscope is placed and the uterine cavity distended with the media of choice. Inspection of the cavity includes identifying the uterine fundus, cornua, and any other anomalies to include polyps, leiomyomas, or uterine septum.

Hysteroscopic Polypectomy or Myomectomy

If an intrauterine polyp is discovered, the base of the polyp is incised with hysteroscopic scissors, and the polyp is grasped with grasping forceps. The hysteroscope, sleeve, and polyp are removed simultaneously, because most polyps will not fit through the operating channel. Extremely large polyps may have to be removed piecemeal. Any residual base of the polyp may be removed with biopsy forceps. Pedunculated or submucosal leiomyoma can be removed safely hysteroscopically. Because myoma tissue is relatively dense, a power cutting instrument is required. The most common method is use of electrosurgery. A monopolar device may be used with an electrolyte-poor distention medium. Only bipolar devices may be used with normal saline or lactated Ringer’s solution. Both pedunculated and submucosal fibroids are shaved into small pieces with the hysteroresectoscope. Stalk resection should only be done to release a pedunculated fibroid if it is 10 mm or less in size; larger fibroids are difficult to remove in one piece without excessive cervical dilatation. Morcellation is much easier when the stalk is still attached for stability. Hysteroscopes with a morcellation attachment have been recently developed.³⁶

Endometrial Ablation

A common treatment for abnormal uterine bleeding in the absence of endometrial hyperplasia is ablation of the endometrium. Historically, this was performed with an operative hysteroscope using an electrosurgical “roller ball,” where the endometrium was destroyed down to the myometrium in a systematic fashion. Currently, hysteroscopic endometrial ablation has been widely supplanted by various devices, including heated free fluid, cryotherapy, thermal balloon, microwave, and radiofrequency electricity. Most ablation techniques result in amenorrhea in approximately half the patients and decreased menstruation in another third of the patients over the first year of therapy.³⁷

Myomectomy

Myomectomy (Fig. 41-11) is the removal of fibroids, and it can be treatment for abnormal uterine bleeding, bulk symptoms, or infertility. Hemostasis during myomectomy can be aided medically by direct injection of dilute vasopressin at the site of the intended uterine incision (10 U in 50 mL). It can be aided further through the placement of a Penrose drain around the base of the uterus, pulled through small perforations in the broad ligament lateral to the uterine blood supply on either side and clamped to form a tourniquet for uterine blood flow. An incision is then made through the uterine serosa into the myoma. The pseudocapsule surrounding the tumor is identified and the tumor is bluntly dissected out with scissors, or bluntly if open. Vessels to the myoma are dessicated with the electrosurgical unit. Several myomas may be removed through a single incision, depending on size. The uterine wounds are closed with absorbable sutures to obliterate the dead space and provide hemostasis. The uterine serosa is closed with a 3-0 absorbable suture, placed subserosally if possible. Because myomectomies are associated with considerable postoperative adhesion formation, barrier techniques are used to decrease adhesion formation.

During a laparoscopic myomectomy, hemostasis is assisted by intrauterine injection of dilute vasopressin (10 U in 50 mL) at the site of incision, similar to an open procedure. This is usually performed percutaneously with a spinal needle. Pedunculated leiomyomas can be excised at the base using scissors or a power instrument. Intramural leiomyomas require deep dissection into the uterine tissue, which must be closed subsequently with laparoscopic suturing techniques. Removing the specimen often requires morcellation, and power morcellators have been developed that significantly expedite this technique. Adhesion barriers are placed laparoscopically.

Total Abdominal Hysterectomy

(Fig. 41-12).

After the abdomen is entered, the upper abdomen is examined for evidence of extrapelvic disease, and a suitable retractor is placed in the abdominal incision. The uterus is grasped at either cornu with clamps and pulled up into the incision. The round ligament is identified and divided. The peritoneal incision is extended from the round ligament to just past the ovarian hilum, lateral to the infundibulopelvic ligament, if the ovaries are to be removed. The retroperitoneal space is bluntly opened, the ureter identified on the medial leaf of the broad ligament, and the infundibulopelvic ligament isolated, clamped, cut, and suture-ligated; a similar procedure is carried out on the opposite side. If the ovaries are to be left in situ, the ureter is identified and an opening below the utero-ovarian ligament and fallopian tube created. The fallopian tube and utero-ovarian ligament are clamped, cut, and ligated. The bladder is mobilized by sharply dissecting it free of the anterior surface of the uterus and cervix. Clamps are placed on the uterine vessels at the cervicouterine junction, and they are cut and suture-ligated. The cardinal ligaments are then serially clamped, cut, and ligated. Following division of the remaining cardinal ligaments, the uterus is elevated and the vagina clamped. The cervix is amputated from the vagina with scissors or a knife. Sutures are placed at each lateral angle of the vagina, and the remainder of the vagina is closed with a running absorbable suture. Pelvic reperitonealization is not necessary.

Transvaginal Hysterectomy

(Fig. 41-13).

Vaginal hysterectomy is the preferred approach in patients in whom the uterus descends and the pubic arch allows enough space for a vaginal operation. A bladder catheter can be placed before the procedure, and the patient is placed in a lithotomy position. A weighted vaginal speculum is placed in the vagina, and the cervix is grasped with a tenaculum and pulled in the axis of the vagina. Injection of the cervix and paracervical tissue with analgesic with epinephrine may be helpful in defining planes and decreasing obscuring bleeding. A circumferential incision may be made with a scalpel or scissors. The posterior cul-de-sac is identified and entered with scissors. A long weighted speculum is then placed through this opening into the peritoneal cavity. Metzenbaum scissors are used to dissect anteriorly on the cervix down to the pubocervical-vesical fascia, reflecting the bladder off the lower uterine segment. When the peritoneum of the anterior cul-de-sac is identified, it is entered with the scissors, and a retractor is placed in the defect. The uterosacral ligaments are identified, doubly clamped, cut, and ligated. Serial clamps are placed on the parametrial structures above the uterosacral ligament; these pedicles are cut and ligated. At the cornu of the uterus, the tube, round ligament, and utero-ovarian ligament of the ovary are doubly clamped and cut. The procedure is carried out usually concurrently on the opposite side, and the uterus is removed. The pelvis is inspected for hemostasis; all bleeding must be meticulously controlled at this point.

The pelvic peritoneum is closed with a running purse-string suture incorporating the uterosacral and ovarian pedicles, those that were held. This exteriorizes those areas that might tend to bleed. The sutures attached to the ovarian pedicles are cut. The vagina may be closed with interrupted mattress stitches, incorporating the uterosacral ligaments into the corner of the vagina with each lateral stitch. On occasion, the uterus, which is initially too large to remove vaginally, may be reduced in size by morcellation (Fig. 41-14). After the uterine vessels have been clamped and ligated, serial wedges are taken from the central portion of the uterus in order to reduce the uterine mass. This procedure will allow the vaginal delivery of even very large uterine leiomyomas.

Laparoscopic Hysterectomy

Laparoscopy has been used to augment vaginal hysterectomy to avoid laparotomy in patients with known pelvic adhesions, with endometriosis, or in whom the uterus is enlarged by leiomyoma. Although multiple variations in technique exist, there are three basic laparoscopic approaches for hysterectomy: laparoscopic-assisted vaginal hysterectomy (LAVH), total laparoscopic hysterectomy (TLH), and laparoscopic supracervical hysterectomy (LSH). The technically simplest is the LAVH. A multiple-port approach is used to survey the peritoneal cavity, and any pelvic adhesions are lysed. The round ligaments are then occluded and divided, and the uterovesical peritoneum and peritoneum lateral to the ovarian ligament are incised. The course of the ureter and any adhesions or implants, such as endometriosis that might place the ureter in the way of the surgical dissection, are carefully dissected. Next, the proximal uterine blood supply is dissected for identification and then occluded with a laparoscopic energy device. When the ovaries are removed, the infundibulopelvic ligaments containing the ovarian vessels are divided. If the ovaries are conserved, the utero-ovarian ligament and blood vessels are divided and occluded. In many cases, the posterior cul-de-sac is also incised laparoscopically and the uterosacral ligaments separated with an energy device. The amount of dissection that is done prior to the vaginal portion depends on individual patient characteristics and may include as little as ovarian and adhesion management to full dissection including bladder dissection, with only the last vaginal incision done by the vaginal approach. During a TLH, the vaginal incision is performed laparoscopically, and the vaginal incision may be closed with laparoscopic suturing. This procedure is used for the indications listed earlier and also when lack of uterine descent makes the vaginal approach impossible.

During an LSH, the uterine vessels are divided after the bladder is dissected from the anterior uterus. The ascending branches of the uterine arteries are occluded, and the entire uterine fundus is amputated from the cervix. The endocervix is either cauterized or cored out. The fundus is then morcellated and removed through a 12-mm abdominal port or through a special transcervical morcellator. The end result is an intact cervix, with no surgical dissection performed below the uterine artery. This approach avoids both a large abdominal incision and a vaginal incision. According to its advocates, this approach minimizes operating time, recovery time, and risk of both infection and ureteral injury. LSH has yet to be widely applied, in part out of concern for the subsequent risk of developing cancer in the residual cervical stump. In addition, women may develop bleeding from the remaining lower uterine segment that can be bothersome, even if preventive measures had been taken.

Benign Ovarian and Fallopian Tube Lesions

The most common ovarian benign findings include functional follicular cysts, endometriomas (due to ovarian endometriosis), and serous cystadenomas or cystadenofibromas. These can present with varying degrees or pelvic pain, or sometimes be completely asymptomatic. Ultrasound is the best initial imaging modality for evaluating ovarian abnormalities.

Ovarian Cystectomy

When a cystic lesion persists or causes pelvic pain, surgical intervention is usually justified. Performing a cystectomy with ovarian preservation is recommended in women who desire future fertility. Whether the cystectomy is performed laparoscopically or by laparotomy, the procedure is initiated with inspection of the peritoneal cavity, peritoneum, diaphragm, liver, and pelvis. In the absence of signs of malignancy, pelvic washings are obtained and the ovarian capsule is incised superficially sharply or with the electrosurgical unit. The cyst is shelled out carefully through the incision. During laparoscopy, it is placed in a bag, intact if possible, and the bag opening is brought through a 10-mm port. If a cyst should rupture before removal, contents are aspirated thoroughly, and the cyst wall is removed and sent for pathologic evaluation. The peritoneal cavity is copiously rinsed with Ringer’s lactate solution. This is especially important when a dermoid cyst is ruptured, because the sebaceous material can cause a chemical peritonitis unless all the visible oily substance is carefully removed. A cyst may need to be drained to facilitate removal, but only after bag edges are firmly out of the abdomen assuring no leakage within the abdomen. Hemostasis of the ovary is achieved with bipolar electrocoagulation, but the ovary is usually not closed. If there are solid growths within the cyst, it should be sent for frozen section to verify the absence of the malignancy. If malignancy is detected, immediate definitive surgery is recommended.

Removal of Adnexa

Indications for removal of adnexa include persistent ovarian cyst, pelvic pain, concern for malignancy, and risk reduction surgery in women with genetic predisposition for ovarian or endometrial cancers (BRCA1/2 mutation carrier, Lynch syndrome). In general, the peritoneum lateral to the infundibulopelvic (IP) ligament is incised in a parallel fashion to allow retroperitoneal dissection and identification of the ureter. Once this has been accomplished, the IP ligament is ligated with suture or an energy source (ultrasonic or bipolar). The remaining posterior leaf of the broad ligament is incised toward the uterus in a direction parallel to the utero-ovarian ligament, to avoid ureteral injury. The fallopian tube and utero-ovarian ligaments are then ligated with either suture or an energy source. If performed laparoscopically, the specimen or specimens are removed in a bag as described earlier.

Tubal Sterilization

As in diagnostic laparoscopy, a one- or two-port technique can be used. Fallopian tubes are occluded in the mid-isthmic section, approximately 3 cm from the cornua, using clips, elastic bands, or bipolar electrosurgery. With electrosurgery, approximately 2 cm of tube should be desiccated. Pregnancy rates after any of these techniques have been reported in the range of 3 per 1000 women.

Other Pelvic Pathology

Chronic Pelvic Pain

Chronic pelvic pain is defined as pain below the umbilicus that has lasted at least 6 months or causes functional disability, requiring treatment. While there can be gastrointestinal and urologic causes of chronic pelvic pain, gynecologic causes are frequently identified. Often, a surgical evaluation is needed for diagnosis and/or intervention. The most common gynecologic causes of chronic pelvic pain include endometriosis, adenomyosis, uterine leiomyomas, and adhesive disease.

Endometriosis

Endometriosis is the finding of ectopic endometrial glands and stroma outside the uterus. It affects 10% of the general population and is an incidental finding at the time of laparoscopy in more than 20% of asymptomatic women. It is especially prevalent in patients suffering from chronic pelvic pain (80%) and infertility (20%–50%).²¹ The pathophysiology of endometriosis is poorly understood; etiologic theories explaining dissemination of endometrial glands include retrograde menstruation, lymphatic and vascular spread of endometrial glands, and coelomic metaplasia. Endometriosis commonly involves the ovaries, pelvic peritoneal surfaces, and uterosacral ligaments. Other possible sites include the rectovaginal septum, sigmoid colon, intraperitoneal organs, retroperitoneal space, ureters, incisional scars, umbilicus, and even the thoracic cavity. Involvement of the fallopian tubes may lead to scarring, blockage, and subsequent infertility. Ovarian involvement varies from superficial implants to large complex ovarian masses called endometriomas or “chocolate cysts.” Endometriomas are found in approximately one third of women with endometriosis and are often bilateral.

While endometriosis can be totally asymptomatic, more commonly, women are symptomatic, and complaints vary from mild dyspareunia and cyclic dysmenorrhea to debilitating chronic pelvic pain with acute exacerbations at the time of menses. Less common manifestations include painful defecation, hematochezia, and hematuria if there is bowel and/or bladder involvement. Pelvic examination in symptomatic patients typically demonstrates generalized pelvic tenderness and nodularity of the uterosacral ligaments, and at times, a pelvic mass may be appreciated if an endometrioma is present. The severity of symptoms does not correlate with the degree of clinical disease present. Endometriosis can also cause increases in serum cancer antigen 125 (CA-125). Definitive diagnosis usually requires laparoscopy and visualization of the pathognomonic endometriotic implants. These appear as blue, brown, black, white, or yellow lesions that can be raised and at times puckered, giving them a “gunpowder” appearance. Biopsy is not routinely done but should be obtained if the diagnosis is in doubt.

Treatment is guided by severity of the symptoms and whether preservation of fertility is desired and varies from expectant, to medical, to surgical.^38,39 Expectant management is appropriate in asymptomatic patients. Those with mild symptoms can be managed with oral contraceptive pills and/or nonsteroidal anti-inflammatory analgesia; moderate symptoms are treated with medroxyprogesterone acetate. Severe symptoms are treated with GnRH agonists to induce medical pseudo-menopause.

Surgical management for endometriosis varies depending on the age and fertility desires of the patient. A diagnostic laparoscopy with biopsies may be indicated to confirm the diagnosis of endometriosis. If endometriosis is suspected, an operative laparoscopy with ablation of endometriotic implants usually decreases the severity of pelvic pain. Ablation of endometriotic implants can be performed with CO₂ laser or electrocautery and/or resection of deep endometriotic implants.³⁸ Endometriomas can cause pain and, if found, should be treated by ovarian cystectomy. Complete resection of the cyst wall is required because recurrence of the endometrioma is common after partial removal. Conservative surgical therapy in endometriosis patients with patent fallopian tubes results in pregnancy in about 50% of cases. Unfortunately, endometriosis is a chronic disease and conservative therapy, medical or surgical, provides only temporary relief, with the majority of patients relapsing with 1 to 2 years. Patients with severe debilitating symptoms who do not desire future fertility and have not responded to conservative management can undergo extirpative surgery to remove the uterus, ovaries, and fallopian tubes; this intervention is curative and should be considered.

Pelvic Adhesive Disease

Pelvic adhesions usually are related to previous surgery, endometriosis, or infection, the latter of which can be either genital (i.e., pelvic inflammatory disease) or extra-genital (e.g., ruptured appendix) in origin. Adhesions can be lysed mechanically with scissors if not vascular, harmonic scissors, or any of the power techniques as discussed elsewhere in this text. Postoperatively, adhesion barrier methods have been shown to decrease adhesion formation in both animal and human studies but have not been demonstrated to improve outcome in terms of either subsequent pregnancies or pain relief.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is an infection of the upper female genital tract involving the uterus, fallopian tubes, and ovaries resulting in endometritis, salpingitis, and oophoritis. It often involves contiguous pelvic organs, resulting in peritonitis, tubo-ovarian abscesses, and occasionally perihepatitis (Fitz-Hugh-Curtis syndrome). Long-term sequelae can include infertility, chronic pelvic pain, and increased risk of ectopic pregnancy.^40,41 PID is mostly a sexually transmitted ascending infection caused by N. gonorrhoeae and/or C. trachomatis, but numerous other organisms have been implicated, including normal vaginal flora. Screening for concomitant HIV infection is strongly recommended. Less commonly, PID may result from extension of other pelvic and abdominal infections, such as appendicitis and diverticulitis, or may be precipitated by a medical procedure, such as hysterosalpingography, endometrial biopsy, or dilation and curettage.

Differential diagnosis includes appendicitis, cholecystitis, inflammatory bowel disease, pyelonephritis, nephrolithiasis, ectopic pregnancy, and ovarian torsion.^40,41 The Centers for Disease Control and Prevention recommend treatment of suspected PID in patients with pelvic or lower abdominal pain who also exhibit cervical motion tenderness, uterine tenderness, or adnexal tenderness (Table 41-4). Transvaginal ultrasound may reveal thickened fluid-filled tubes with or without free pelvic fluid. Laparoscopic findings include swollen erythematous tubes with exudates. Criteria for hospitalization and intravenous antibiotic treatment include the following⁴²: surgical emergencies (e.g., appendicitis), infection during pregnancy, failure to respond to or inability to follow or tolerate outpatient oral medication regimens, severe illness with nausea and vomiting or high fever, and tubo-ovarian abscess.

First-line treatment for tubo-ovarian abscess includes broad-spectrum antibiotics and, sometimes, percutaneous drainage. Surgical intervention becomes necessary if medical therapy fails or if the abscess ruptures. Rupture is a surgical emergency with a high mortality rate if not recognized and managed promptly. In addition to management of the septic shock state, hysterectomy and bilateral salpingo-oophorectomy is the procedure of choice; however, conservative surgery must be considered in young patients desiring future fertility. The abdomen should be explored for metastatic abscesses, and special attention must be paid to bowel, bladder, and ureteral safety due to the friability of the infected tissue and the adhesions commonly encountered at the time of surgery. Placement of an intraperitoneal drain and mass closure of the peritoneum, muscle, and fascia with delayed-absorbable or permanent sutures is advised. Closure of the skin and subcutaneous layer should be avoided in patients with frank pus, and delayed primary closure or closure by secondary intention is recommended because of the high rate of wound infections. Conservative surgery, when feasible, may be attempted by laparoscopy and may involve unilateral salpingo-oophorectomy or drainage of the abscess and liberal irrigation of the abdomen and pelvis.

Many pregnant women will undergo invasive diagnostic procedures for prenatal diagnosis, and in the United States, nearly one third of all births are cesarean deliveries.⁴³ About 1 in 500 pregnant women will require surgery for nonobstetrical issues.^44,45 Diagnostic challenges and physiologic changes due to pregnancy, as well as the unique anesthesia risks and potential risks to the pregnancy, should be kept in mind whether the primary surgeon is an obstetrician gynecologist or a general surgeon (Table 41-5).⁴⁵

Trauma in the obstetric patient requires stabilization of the mother while considering the fetal compartment.^45,46 Trauma-related hypovolemia may be compounded by pregnancy-induced decreases in systemic vascular resistance and, when supine, the weight of the gravid uterus on the vena cava. When feasible, a left lateral tilt should be instituted to improve venous return to the right heart. Later in pregnancy, the small bowel is displaced into the upper abdomen, making it vulnerable to complex injury from penetrating upper abdominal trauma. Although the small bowel is displaced from the pelvis, the dramatic increase in pelvic blood flow can lead to rapid blood loss due to penetrating pelvic trauma, fractures, or avulsion of pelvic vessels. Gastric motility is decreased, increasing the risk of aspiration. Peritoneal signs may be attenuated by the stretching of the abdominal wall. Several coagulation factors are also increased in pregnancy, increasing the likelihood for thromboembolic events, but also giving the unsuspecting surgeon false security when low-normal levels are observed during resuscitative efforts. Although treating the maternal compartment is the primary concern, it should also be recognized that the fetus will be impacted significantly by maternal hypotension, as blood may be shunted away from the uterus. Only the third-trimester fetus has any ability to autoregulate in the context of decreased uterine blood flow and oxygen delivery.

Conditions and Procedures Performed Before Viability

Amniocentesis/Chorionic Villus Sampling

Amniocentesis is a procedure in which amniotic fluid is aspirated from the uterine cavity, typically under ultrasound guidance with a 20- to 22-gauge needle. Common indications include prenatal genetic testing, assessment of fetal lung maturity, and evaluation for intrauterine infection. Chorionic villus sampling (CVS) is performed for prenatal genetic testing. During the procedure, placental villi are obtained through transcervical or transabdominal access to the placenta. CVS is typically performed after 9 completed weeks of gestation, while genetic amniocentesis is offered between 15 and 20 weeks. Pregnancy loss attributable to genetic amniocentesis is 1 in 300 to 500. The rate is slightly higher after CVS due in large part to the higher background spontaneous pregnancy loss between 9 and 16 weeks of gestation.⁴⁷

Pregnancy Terminations

Although legal nonsurgical options are now available for early pregnancy termination, the safest and most commonly performed termination procedure is a cervical dilation and suction curettage. The uterine cervix is grasped with a tenaculum and then mechanically dilated with tapered rods occasionally using adjunctive prostaglandins, and an appropriately sized vacuum cannula is inserted into the uterus and rotated on its axis to remove the products of conception. Additional forceps can be used as needed and will be necessary in later second-trimester dilation and extractions. The most common complications are infection, hemorrhage due to uterine atony, cervical lacerations, uterine perforations, and inadvertent bowel injury from the vacuum cannula or forceps.

Cerclage

Cervical insufficiency is defined as painless cervical dilation leading to recurrent second-trimester pregnancy loss, or shortened cervical length as determined by transvaginal ultrasound, or advanced cervical change before 24 weeks gestation in a woman with either prior preterm birth/loss or significant risk factors for insufficiency. A cervical cerclage refers to a procedure in which suture or synthetic tape is used to circumferentially reinforce the cervix to improve pregnancy outcome in at-risk patients.⁴⁸ Shirodkar and McDonald techniques have been described^49,50; both involve transvaginally placing a nonabsorbable suture at the uterocervical junction to lengthen and close the cervix. A laparotomy can access the abdominal portion of the lower uterine segment for an abdominal cerclage for a patient with a severely shortened or absent cervix.

Ectopic Pregnancies

Extrauterine pregnancies are most commonly located along the fallopian tubes and on the ovary. Rarely, implantation can occur primarily on other abdominal organs or surfaces. A high index of suspicion and early diagnosis, typically using sensitive β-hCG assays and ultrasound, are the key to minimizing maternal morbidity and mortality. Early ectopic pregnancies can be managed medically with methotrexate, whereas advanced ectopic pregnancies and unstable women are managed by laparoscopy or laparotomy. Linear salpingostomy along the antimesenteric border and removal of the products of conception is a reasonable option. The tube should be removed (salpingectomy) if the oviduct has already ruptured and a large hemoperitoneum already exists.⁵¹

Conditions and Procedures Performed After Viability

Fetal Surgery

The Management of Myelomeningocele (MOMs) trial tested the safety and efficacy of fetal surgery for myelomeningocele between 2003 and 2010. During this procedure, surgeons expose the gravid uterus via low transverse or vertical incision and position the fetus manually within the uterus under ultrasound guidance with the myelomeningocele sac centered at the proposed hysterotomy site. The uterus is entered sharply between two full-thickness stay sutures, and the hysterotomy is extended 6 to 8 cm with a uterine stapling device. The myelomeningocele is closed in standard fashion under magnification. Early outcomes data revealed that fetal surgery reduced the risk of death or need for shunt placement during the first year of life and also improved mental development and motor function at 30 months of age. These outcomes in the fetal surgery arm were despite higher preterm delivery rates, and the trial was stopped early because of efficacy.⁵²

Obstetric Lacerations and Repair

The mean biparietal diameter of a term infant approaches 10 cm. The measured hiatus of the nulliparous vaginal introitus is approximately 2 cm. As a result, at the time of vaginal delivery, perineal lacerations and, with decreasing frequency, episiotomies are quite common. These lacerations involve, in varying degrees, the vaginal mucosa, the muscular elements inserting onto the perineal body, the levator ani, and in 4% to 5% of vaginal deliveries, the anal sphincter or anorectal mucosa.

Episiotomies and Perineal Laceration

First-degree tears involve only the perineal skin and may or may not need to be reapproximated. Second-degree tears involve the perineal body and can generally be repaired with some variation using a single continuous, nonlocking suture technique, typically a 2-0 or 3-0 synthetic delayed absorbable suture. The apex of the vaginal epithelial is approximated first including epithelium and underlying tissue to build up the rectovaginal septum. Upon reaching the hymenal ring, the perineal body and bulbocavernosus muscle are reapproximated, and a transition stitch is placed from the vaginal mucosa, which was repaired along a horizontal plane, to the deep perineal layer, which lies in a vertically oriented plane. A running closure is then completed incorporating the deep perineal tissues from the introitus to the extent of the perineal defect. At this point, the perineal skin is closed from inferior to superior in a subcuticular fashion and tied just inside the introitus.

Third-degree lacerations extend through the perineal body and involve the external anal sphincter, whereas fourth-degree lacerations involve the internal anal sphincter and rectal mucosa. When present, third- and fourth-degree lacerations should be repaired first before proceeding with the second-degree repair. This is accomplished by first closing the anal mucosa and then identifying and closing the internal anal sphincter in a second layer. The external anal sphincter is then identified, and the muscular cylinder is reconstructed by suturing the severed ends together using either an end-to-end or overlapping technique. Although these are typically straightforward layered closures, knowledge of the anatomy is important. Incomplete reconstruction, particularly of third- or fourth-degree lacerations, can contribute to future pelvic floor disorders, as well as the development of fistulae or incontinence.

Cervical and Vaginal Lacerations

Significant lacerations to the cervix or vagina may also occur during childbirth, particularly with instrumented deliveries or macrosomic infants. These lacerations may present as persistent bleeding, not readily recognized due to their location, and often in association with a firmly contracted uterus. Vaginal lacerations may be repaired primarily but should only be closed after deeper tissues are inspected to ensure no active bleeding. Cervical lacerations can be repaired in a running, locking fashion, ensuring that the apex of the laceration is incorporated in the closure. If the apex is challenging to reach, the closure can be started more distally using the suture to apply traction so that the apex may be closed.

Puerperal Hematoma

Trauma during childbirth can occasionally result in significant hematoma formation with or without a visible laceration. These hematomas may hide significant blood loss and most commonly occur in the vulva, paravaginal, and pelvic retroperitoneum. Typical presentation is pain and mass effect. Small hematomas can be managed conservatively with close observation and patient monitoring. Although there are no evidence-based size criteria, an unstable patient or expanding hematomas should prompt surgical intervention. After the hematoma is incised and drained, diffuse venous oozing is usually encountered rather than a single bleeding vessel. Hemostasis can be achieved using electrosurgery or fine absorbable suture, although caution must be used due to the proximity of bowel, bladder, and ureters to some hematomas. Pressure on the vulva or packing the vagina, rather than the hematoma cavity, may prevent further bleeding.

Cesarean Deliveries

Typical indications for cesarean delivery include nonreassuring fetal status, breech or other malpresentations, triplet and higher order gestations, cephalopelvic disproportion, failure to progress, placenta previa, and active genital herpes. Previous low transverse cesarean delivery is not a contraindication to subsequent vaginal birth after cesarean; however, much of the increase in cesarean delivery in the past decade is attributable to planned repeat cesareans. Cesarean deliveries typically are performed via a lower anterior (caudal) uterine transverse incision because there is decreased blood loss, and the uterine rupture rate with future pregnancies is about 0.5% (Fig. 41-15). A prior classical cesarean delivery is an absolute indication for a planned repeat cesarean delivery because of a high rate of uterine rupture during labor, unlike with the lower anterior uterine transverse incision. Abdominal access is obtained by a Pfannenstiel or Maylard incision. Once the abdomen is entered, a vesicouterine reflection is created if a low transverse uterine incision is planned. The uterine incision is then made and extended laterally, avoiding the uterine vessels. After amniotomy, the baby is delivered, and the uterus closed. Approximately 1000 mL of blood is typically lost during a cesarean delivery. Along with rapid closure of the uterine incision, uterotonics, such as intravenous oxytocin, are administered. A classical, vertical, uterine incision is made in certain very early viable gestations or in the case of certain transverse lies. Infection, excessive blood loss due to uterine atony, and urinary tract and bowel injuries are potential complications at the time of cesarean delivery. The risk of those injuries, as well as abnormal placentation (placenta accreta, increta, and percreta), rises with each subsequent cesarean delivery. Bleeding can only be controlled in some instances by performing a cesarean hysterectomy.

Postpartum Hemorrhage

Postpartum hemorrhage is an obstetrical emergency that can follow either vaginal or cesarean delivery. Hemorrhage is usually caused by uterine atony, trauma to the genital tract, or rarely, coagulation disorders. Management consists of mitigating potential obstetric causes while simultaneously acting to avert or treat hypovolemic shock. In the absence of atony, the genital tract should be thoroughly evaluated for trauma. Atony is the most common cause of postpartum hemorrhage. It is typically treated with fundal massage and uterotonics such as oxytocin, methylergonovine, carboprost tromethamine, and misoprostol. When aggressive medical management fails, surgical management may be necessary and life-saving.⁵³

Uterine Curettage

Retained products of conception may result in uterine atony. It may be possible to remove retained products via manual extraction or with ring forceps. Bedside ultrasound may be helpful in localization. When clinical suspicion is high, uterine curettage is indicated. A blunt, large curette, the banjo curette, is introduced, and removal of retained tissue typically results in contraction of the myometrium and cessation of bleeding.

Procedures Short of Hysterectomy

As bleeding from postpartum hemorrhage becomes increasingly acute, interventions short of hysterectomy should be carried out expeditiously while supporting the hemodynamic status of the patient and preparing for possible definitive surgery. A number of techniques for packing and tamponade of the uterus have been described, including a balloon device reported by Bakri and colleagues.⁵⁴ These are typically left in place for 24 to 36 hours and appear to be safe and often effective conservative measures short of laparotomy and hysterectomy. The B-Lynch compression suture may control bleeding of atony at the time of cesarean section. A suture is placed through the hysterotomy, around the fundus of the uterus anterior to posterior, and then through the posterior lower uterine segment, to the contralateral side. At this point, the steps are reversed, with the suture brought around the fundus posterior to anterior, through the contralateral side of the hysterotomy, and then tied in the midline to compress the uterus. Additional procedures described include the O’Leary uterine artery ligation and the hypogastric artery ligation. “O’Leary stitches” are a series of sutures placed around the branches of the uterine artery and through the myometrium, resulting in compression of the vessels against the uterus. Hypogastric artery ligation entails the isolation of the internal iliac artery at its bifurcation with the external iliac artery. The hypogastric artery is ligated at least 3 cm distal to the bifurcation to avoid compromising the posterior division.

Hysterectomy

A cesarean or postpartum (absent a prior cesarean delivery) hysterectomy involves the same steps as in a nonpregnant patient, but is distinctly different due to the engorged vessels and the pliability of the tissues. If a cesarean section has been performed, occasionally the incision can be used for traction to keep the vessels and tissues attenuated. Vascular pedicles should be secured with clamps, but not ligated until both uterine arteries have been secured, to fully control bleeding. Lack of typical anatomic landmarks requires careful identification of the ureters and the dilated cervix visually or by palpation, to separate them from the bladder and vagina (Fig. 41-16). This procedure is often done for life-threatening hemorrhage; thus, appropriate blood products, including packed red blood cells, fresh frozen plasma, platelets, and fibrinogen, should be on call and are usually required. Fibrinogen is typically elevated in a pregnant woman, such that a low-normal fibrinogen level can be a cause for alarm, and further fibrinogen may be required before consumptive coagulopathy reverses. A massive transfusion protocol is often helpful.

Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD) is characterized by abnormal trophoblastic proliferations most commonly related to a pregnancy event. Histologic types include hydatidiform moles, invasive moles, choriocarcinoma, and placental site trophoblastic tumors. It is an important gynecologic entity to consider when uterine size is significantly greater than expected for date in pregnancy, when bleeding occurs in pregnancy, or with abnormal bleeding after pregnancy loss, abortion, or full-term delivery. Diagnosis is usually made by ultrasound and measurement of serum β-hCG, followed by pathologic examination of curettage specimens. There are two subtypes of hydatidiform moles. Complete moles contain no fetal tissue and have a diploid karyotype. Partial moles contain fetal tissue and have triploid karyotypes. The chromosome pattern suggests paternal origin. These can be associated with theca lutein ovarian cysts often greater than 6 cm in diameter that are fragile; they should generally be followed without surgical intervention as they resolve with removal or treatment of the GTD. Metastatic GTD can present on the cervix, vagina, liver, or lung, and should not be managed surgically. Chemotherapy is primary therapy, and the incidence of bleeding complications is significant.

Primary surgery for diagnosis and initial therapy is a suction dilatation and curettage. Oxytocin is started either prior to anesthesia or immediately as the cervix is being dilated. The largest suction catheter possible (12 mm preferred) is gently inserted through the cervix and suction turned on, to allow the tissue to be removed and the uterus to rapidly decrease with less blood loss. Following this, a careful sharp curettage of the uterus is done acknowledging the increased risk for perforation. β-hCG is then followed weekly until normal for 3 weeks, then monthly for at least 6 months. Any increase in β-hCG should trigger further evaluation and consideration of chemotherapy.^55,56

Pelvic floor disorders can be categorized, from a urogynecologic perspective, into three main topics: female urinary incontinence and voiding dysfunction, pelvic organ prolapse, and disorders of defecation.⁵⁷ Approximately 11% of women will undergo surgery for incontinence or prolapse.⁵⁸ The normal functions of support, storage, and evacuation can be altered by derangements in neuromuscular function both centrally and peripherally and through acquired changes in connective tissue. Reconstructive surgeons aim to repair or compensate for many of these losses.

Evaluation

Diagnostic evaluations, in addition to the history and examinations described earlier, can aid in the diagnosis of many pelvic floor disorders. Cystoscopy, multichannel urodynamics, and/or fluoroscopic evaluation of the urinary tract can be obtained for patients with urinary incontinence or voiding dysfunction.⁵⁹ Defecography, anal manometry, and endorectal ultrasound may be useful for diagnosis of defecatory dysfunction. A standardized examination called the pelvic organ prolapse quantification (POP-Q)⁵⁹ helps to clarify which vaginal compartment, and therefore which specific structure, has lost its anatomic integrity in women with uterovaginal prolapse. Finally, dynamic MRI and pelvic floor electromyography have demonstrated growing utility for all three disorders.

Surgery for Pelvic Organ Prolapse

Many factors are important in determining which reconstructive operation is optimal for a given patient with pelvic organ prolapse. Surgical decisions are often based on case series and expert opinions that may not have universal applicability. However, the few reports with the highest level of evidence suggest that failure rates for prolapse reconstruction may be twice as high using the vaginal approach when compared with the abdominal route.^60,61

Colporrhaphy

Anterior colporrhaphy, also known as an “anterior repair,” is performed for a symptomatic cystocele. The procedure begins with incision of the anterior vaginal epithelium in a midline sagittal direction. The epithelium is dissected away from the underlying vaginal muscularis. The vaginal muscularis is plicated with interrupted delayed absorbable stitches, after which the epithelium is trimmed and reapproximated. The vaginal canal is therefore shortened and narrowed proportionate to the amount of removed epithelium. Posterior colporrhaphy is performed for a symptomatic rectocele. This procedure is performed in a similar manner, often including the distal pubococcygeus muscles in the plication. Recently, in attempts to decrease surgical failures alluded to earlier, many surgeons have opted to use grafts and meshes to augment these vaginally performed procedures. Unfortunately the apparent number of postoperative complications, including mesh erosion, pelvic pain and dyspareunia, prompted the FDA to publish a warning encouraging a much more limited use of vaginal mesh for prolapse repair until greater surveillance and more rigorous studies could be completed.⁶²

Sacrospinous and Uterosacral Ligament Fixations

Both the sacrospinous ligament fixation (SSLF) and uterosacral ligament fixation (USLF) procedures are vaginal procedures that suspend the apex of the vagina using native tissue for treatment of apical prolapse. The sacrospinous ligament is found embedded in and continuous with the coccygeus muscle, which extends from the ischial spine to the lateral surface of the sacrum. The procedure begins with entry into the rectovaginal space, usually by incising the posterior vaginal wall at its attachment to the perineal body. The space is developed to the level of the vaginal apex, and the rectal pillar is penetrated to gain access to the pararectal space. A long-ligature carrier is used to place sutures medial to the ischial spine, through the substance of the ligament-muscle complex. Structures at risk in this procedure include the pudendal neurovascular bundle, the inferior gluteal neurovascular bundle, lumbosacral plexus, and sciatic nerve. After the stitches are placed, the free ends are sewn to the undersurface of the vaginal cuff. The sacrospinous stitches are tied to firmly approximate the vagina to the ligament without suture bridging.

When using the uterosacral ligaments for repair of prolapse, it is important to recall that these structures are not “ligaments” in the true sense of the word, but rather condensations of smooth muscle, collagen, and elastin. Several support sutures are placed from the lateral-most portion of the vaginal cuff to the distal-most part of the ligament, and from the medial vaginal cuff to the proximal ligament. Intraoperative evaluation of the lower urinary tract is important to confirm the absence of ureteral compromise.

Colpocleisis

Colpocleisis is reserved for patients who are elderly, who do not wish to retain coital ability, and for whom there is good reason not to perform a more extensive reconstructive operation. A colpocleisis removes of part or all of the vaginal epithelium, obliterating the vaginal vault and leaving the external genitalia unchanged. The procedure can be performed with or without a hysterectomy. Successive purse-string sutures through the vaginal muscularis are used to reduce the prolapsed organs to above the level of the levator plate.

Sacrocolpopexy

The best procedure for patient with prolapse of the vaginal apex is an abdominal sacrocolpopexy. In these patients, the natural apical support structure, the cardinal-uterosacral ligament complex, is often damaged and attenuated. The abdominal placement, as opposed to vaginal placement, of graft material to compensate for defective vaginal support structures is well described.⁶³ Apical support defects rarely exist in isolation, and the sacrocolpopexy may be modified to include the anterior and posterior vaginal walls as well as the perineal body in the suspension. Sacrocolpopexies can be performed via laparotomy as well as via laparoscopy. Like rectopexies and low anterior resections, deep pelvic access is needed. Significant suturing at varied angles is required. The advent of the DaVinci robotic laparoscopic system has made visualization and adequate placement of the mesh and sutures easier to perform when using the minimally invasive approach.

During a sacrocolpopexy, a rigid stent (usually an EEA sizer) is placed into the vagina to facilitate its dissection from the overlying bladder and rectum and to allow the graft material to be spread evenly over its surface. A strip of synthetic mesh is fixed to the anterior and posterior vaginal walls. The peritoneum overlying the presacral area is opened, extending to the posterior cul-de-sac. The sigmoid colon is retracted medially, and the anterior surface of the sacrum is skeletonized. Two to four permanent sutures are placed through the anterior longitudinal ligament in the midline, starting at the S2 level and proceeding distally. The sutures are passed through the graft at an appropriate location to support the vaginal vault without tension. The peritoneum is then closed with an absorbable running suture. The most dangerous potential complication of sacrocolpopexy is sacral hemorrhage.

Surgery for Stress Urinary Incontinence

Stress incontinence is believed to be caused by lack of urethrovaginal support (urethral hypermobility) or intrinsic sphincter deficiency (ISD). ISD is a term applied to a subset of stress-incontinent patients who have particularly severe symptoms, including urine leakage with minimal exertion. This condition is often recognized clinically as the low pressure or “drainpipe” urethra. The urethral sphincter mechanism in these patients is severely damaged, limiting coaptation of the urethra. Standard surgical procedures used to correct stress incontinence share a common feature: partial urethral obstruction that achieves urethral closure under stress.

Burch Procedure

The most quoted description of this procedure is that of Tanagho in 1976.⁶⁴ The space of Retzius is approached extraperitoneally, from an abdominal approach, allowing the bladder to be mobilized from the surrounding adipose tissue and lateral pelvis. Overlying fat and blood vessels in the area of the vesical neck are cleared away. Two pairs of large-caliber nonabsorbable sutures, although the original description advocated delayed absorbable sutures, are placed through the periurethral vaginal wall, one pair at the midurethra and one at the urethrovesical junction. Each stitch is then anchored to the ipsilateral Cooper’s (iliopectineal) ligament. The sutures are tied with the operator’s nondominant hand placed vaginally to give preferential support to the urethrovesical junction relative to the anterior vaginal wall without overcorrection. Long-term outcome studies up to 10 years have shown that the Burch procedure yields cure rates of 80% to 85%.

Tensionless Sling

The tension-free vaginal tape (TVT) is a modified sling that uses a strip of polypropylene mesh. Unlike traditional sling procedures, the mesh is positioned at the midurethra, not the urethrovesical junction, and is not sutured or otherwise fixed into place. Advantages of TVT include the ability to perform the procedure under local anesthesia on an outpatient basis. Small subepithelial tunnels are made bilaterally to the descending pubic rami through an anterior vaginal wall incision. A specialized conical metal needle coupled to a handle is used to drive one end of the sling through the perineal membrane, space of Retzius, and through one of two small suprapubic stab incisions. The tape is set in place without any tension after bringing up the other end of the tape through the other side. Recently, multiple modifications have been made to carry the tape through the bilateral medial portions of the obturator space. Risks of the procedure include visceral injury from blind introduction of the needle, bleeding, and nerve and muscle injury in the obturator space. Additionally, voiding dysfunction and delayed erosion of mesh into the bladder or urethra have been seen.

Urethral Bulking Injections

A transurethral or periurethral injection of bulking agents is indicated for patients with intrinsic sphincter deficiency. Several synthetic injectable agents (e.g., polydimethylsiloxane, calcium hydroxylapatite) are now used because glutaraldehyde cross-linked (GAX) bovine dermal collagen is no longer commercially available.⁶⁵ Anesthesia is easily obtained by using intraurethral 2% lidocaine jelly and/or transvaginal injection of the periurethral tissues with 5 mL of 1% lidocaine. The material is injected underneath the urethral mucosa at the bladder neck and proximal urethra at multiple positions, until mucosal bulk has improved. Patients must demonstrate a negative reaction to a collagen skin test prior to injection. The long-term cure rate is 20% to 30%, with an additional 50% to 60% of patients demonstrating improvement.⁵⁷ Repeat injections are frequently necessary because of migration and dissolution of the collagen material.

Vulvar Cancer

Vulvar cancer is the fourth most common gynecologic cancer. The mean age at diagnosis is 65, although this has trended down over the last several decades.⁶⁶ Evidence supports an HPV-dependent pathway of carcinogenesis with risks factors similar to VIN in the majority of cases. A second pathway independent of HPV is associated with chronic inflammation and vulvar dystrophy.⁶⁷ Patients usually present with a vulvar ulcer or mass. Pruritus is a common complaint, and vulvar bleeding or enlarged inguinal lymph nodes are signs of advanced disease. Careful evaluation of the patient is necessary to rule out concurrent lesions of the vagina and cervix. Biopsy is required and should be sufficient to allow evaluation of the extent of stromal invasion. Vulvar carcinomas are squamous in 90% of cases. Other less common histologies include melanoma (5%), basal cell carcinoma (2%), and soft tissue sarcomas (1%–2%).

Spread of vulvar carcinoma is by direct local extension and via lymphatic microembolization. Hematogenous spread is uncommon except for vulvar melanoma. Lymphatic spread seems to follow a stepwise, predictable pattern traveling from superficial, above the cribriform fascia, to deep inguinofemoral nodes and ultimately to the pelvic and external iliac nodal basins (Fig. 41-17).^68,69 The node of Cloquet is an important sentinel node situated in the route of spread to the pelvic lymph nodes.

Staging and primary surgical treatment are typically preformed as a single procedure and tailored to the individual patient (Table 41-6). Surgical staging accounts for the most important prognostic factors including tumor size, depth of invasion, inguinofemoral node status, and distant spread. The most conservative procedure should be performed in view of the high morbidity of aggressive surgical management. This typically involves radical resection of the vulvar tumor targeting a 1- to 2-cm margin around the lesion, and carried to the deep perineal fascia of the urogenital diaphragm with an ipsilateral or bilateral inguinofemoral lymphadenectomy (Fig. 41-18). For tumors ≤2 cm in size with ≤1 mm invasion (International Federation of Gynecology and Obstetrics [FIGO] stage IA), lymphadenectomy may be safely omitted, and wide local or radical local excision is adequate. Patients with stage IB tumors have deeper invasion but negative nodes and therefore carry an excellent prognosis. Stage II includes patients with local extension and negative nodes, and therefore, these patients have a prognosis similar to other node-negative patients.

Stage III disease includes patients with lymph node metastases, and stage IV disease is either locally advanced or distant metastasis. Treatment options for stage III and IV disease include: (a) chemoradiation followed by limited resection if needed; (b) radical vulvectomy; and (c) radical vulvectomy coupled with pelvic exenteration. External-beam radiotherapy combined with radiosensitizing chemotherapy of cisplatin and 5-fluorouracil is emerging as the preferred initial management of advanced disease followed by limited surgical resection of residual disease.^70,71,72 Reconstruction of the vulva and groin, if needed, can be accomplished using grafts and rotational or myocutaneous flaps depending on the size and type of defect.

Inguinofemoral lymphadenectomy is indicated beyond clinical stage IA. Unilateral lymphadenectomy is recommended for lateralized lesions, and bilateral lymphadenectomy is recommended for central lesions that cross the midline or those involving the periclitoral area (Figs. 41-19 and 41-20). The role of vulvar sentinel lymph node biopsy is under investigation by the Gynecologic Oncology Group (GOG) and is in use by a growing number of gynecologic oncologists. Preliminary data are encouraging and may allow patients with negative sentinel nodes to avoid complete groin dissection and its attendant morbidity such as lower extremity lymphedema.

Nodal failure in the groin and pelvis is difficult to treat successfully, and attention to primary management of these areas is key. Postoperative adjuvant inguinal and pelvic radiotherapy is indicated when inguinal lymph nodes are positive and is superior to pelvic lymphadenectomy, which has been largely abandoned. It is also indicated when the vulvectomy margins are positive or close positive for disease and further surgical management is not anatomically feasible.

Vaginal Cancer

Vaginal carcinoma is a rare gynecologic malignancy and accounts for about 3% of cancers affecting the female reproductive system.⁶⁶ Squamous cell carcinomas account for 85% to 90% of cases; more than two thirds of vaginal cancers are diagnosed in women 60 years of age or older. Risk factors are similar to other HPV-related cervical and vulvar cancers. Rare clear cell carcinoma of the vagina is associated with in utero exposure to diethylstilbestrol (DES), which is now largely of historical interest due to aging of the exposed cohort.⁷³ Patients with vaginal cancer usually present with postmenopausal and/or postcoital bleeding and may also complain of vaginal discharge, vaginal mass, dysuria, hematuria, rectal bleeding, or pelvic pain, which may be indicative of advanced disease. Diagnosis is made via biopsy of suspicious lesions, which may require colposcopic guidance.⁶⁷

Vaginal cancer is staged clinically by pelvic exam, chest x-ray, cystoscopy, and proctoscopy (Table 41-7).⁷⁴ Vaginal cancer spreads by local extension to adjacent pelvic structures, by lymphatic embolization to regional lymph nodes, and less commonly via the hematogenous route. Lymphatic drainage is complex, but in general, lesions in the upper vagina drain to the pelvic lymph nodes, while lesions involving the lower third drain to the inguinofemoral lymph nodes.

Stage I disease, involving the upper vagina, may be treated surgically or with intracavitary radiation therapy.^68,69,75 Surgery consists of a radical hysterectomy, upper vaginectomy, and bilateral pelvic lymphadenectomy. Stage I disease in the mid to lower vagina is usually treated with radiation and concurrent chemotherapy. External-beam pelvic radiation is the mainstay of treatment for stage II to IV disease and may be followed by intracavitary and/or interstitial brachytherapy. Prognosis for treated early-stage disease is excellent, with 5-year survival rates greater than 90%. Advanced-stage disease, however, carries a poor prognosis, with 5-year survival rates of only 15% to 40%.

Cervical Cancer

General Principles

There are over 12,000 new cases of cervical cancer and over 4000 cervical cancer deaths annually in the United States. It is a major killer worldwide, causing 275,000 deaths annually.⁷⁶ Risk factors for cervical squamous cell carcinoma and adenocarcinoma, the two most common histologies, are largely related to acquisition of and immune response to carcinogenic subtypes of the HPV virus. The presence of inherited genetic variations that increase the likelihood of developing cervical cancer when exposed to oncogenic subtypes of HPV is under active investigation. Cervical screening is correlated with early identification and treatment of preinvasive disease.⁷⁷ Cervical cancer is most commonly identified in women with long intervals between screening or with no prior screening.

Early cervical cancer is usually asymptomatic, although irregular or postcoital bleeding may be present, particularly in more advanced disease. The diagnosis of cervical cancer is made by cervical biopsy, either of a gross lesion or a colposcopically identified lesion. Cervical cancer is staged clinically.⁷⁸ Staging and management options are outlined in Table 41-8.

Procedures for Cervical Cancer Treatment

Radical Hysterectomy

This procedure may be performed via laparotomy or, increasingly, via a minimally invasive (laparoscopic or robotic) approach.⁷⁹ The key elements are dissection of the pelvic and periaortic nodes and the dissection of the parametrium from the pelvic sidewall to allow en bloc removal with the uterus. The principle steps of an open procedure are demonstrated in Fig. 41-21. In contrast to a typical simple hysterectomy, the radical hysterectomy involves dissection much closer to the bowel, bladder, ureters, and great vessels, resulting in a higher complication rate to these organs. Additionally, disruption of the nerves supplying the bladder and the rectum, which traverse the cardinal and uterosacral ligaments, may result in temporary or long-term bladder and bowel dysfunction. Radical hysterectomies allow for the maintenance of the ovaries since the incidence of metastases to this area is very low, providing a clear advantage of surgery over radiation therapy in the younger patient.

Radical Trachelectomy

Interest in fertility preservation with stage IA1 and IA2 and stage IB1 lesions has led to the development of methods of radical trachelectomy with uterine preservation. This procedure depends on an adequate blood supply to the uterus from the ovarian anastomoses, as the cervical portion is removed. The lower uterine segment is closed with a cerclage and attached directly to the vaginal cuff. The rates of recurrence, pregnancy outcomes, and the best surgical candidates for this surgery are still under study.⁸⁰

Pelvic Exenteration for Recurrent Disease

(Fig. 41-22).

Cervical cancer recurrences after primary surgical management are treated with radiation. Surgery may be a consideration in selected patients with recurrent cervical cancer who have received maximal radiation therapy. If the recurrence is locally confined with no evidence of spread or metastatic disease, then pelvic exenteration may be considered. Attempted exenteration procedures are aborted intraoperatively if metastatic disease is found. Exenteration is tailored to the disease size and location and may be supralevator or extend below the levator ani muscle and require vulvar resection. Reconstruction of the pelvis may require a continent urinary pouch (if radiation enteritis is limited) or ileal conduit and colostomy, as well as rebuilding of the pelvic floor and vagina with grafts or myocutaneous flaps.

Uterine Cancer

Endometrial Cancer

Endometrial cancer is the most common gynecologic malignancy and fourth most common cancer in women.⁶⁶ It is most common in menopausal women in the fifth decade of life; up to 15% to 25% of cases occur prior to menopause, and 1% to 5% occur before age 40. Risk factors for the most common type of endometrial cancer include increased exposure to estrogen without adequate opposition by progesterone, either endogenous (obesity, chronic anovulation) or exogenous (hormone replacement). Additional risk factors include diabetes, Lynch II syndrome (hereditary nonpolyposis colorectal cancer), and prolonged use of tamoxifen. Tamoxifen is a mixed agonist/antagonist ligand for the estrogen receptor. It is an agonistic in the uterus and an antagonistic to the breast and ovary. Protective factors for endometrial cancer include smoking and use of combination oral contraceptive pills. Adenocarcinomas are the most prevalent histologic type.

Endometrial adenocarcinomas are divided into type I and type II, although there is a trend to return to histology as a divider. Type I tumors are estrogen-dependent endometrioid histology and have a relatively favorable prognosis. Type II endometrial cancers are estrogen-independent, aggressive, and characterized by nonendometrioid, serous, or clear cell histology.⁸¹ Postmenopausal bleeding is the most common presentation of type I disease and often permits early-stage diagnosis, resulting in a favorable prognosis. Abnormal bleeding should prompt endometrial evaluation and sampling, which is usually done with an office endometrial biopsy, although at times, it requires operative curettage or diagnostic hysteroscopy. Transvaginal ultrasonography (TVUS) often reveals a thickened endometrial stripe. An endometrial stripe measuring 5 mm or more in a postmenopausal patient raises concern and should be followed by endometrial sampling; patients with stripe of 4 mm or less rarely have occult malignancy, and TVUS may thus be used to triage patients before invasive endometrial sampling. Uterine cancer is surgically staged and is graded based on the degree of histologic differentiation of the glandular components (Table 41-9).⁷⁸ Grade is an important prognostic factor, independent of stage.

Treatment is surgical and most commonly involves hysterectomy, bilateral salpingo-oophorectomy, peritoneal cytology, pelvic and para-aortic lymphadenectomy, and resection of any gross disease.^68,69,75 Evidence supports equivalent oncologic outcomes with minimally invasive approaches.⁸² The utility of lymphadenectomy is an area of great controversy. The need for postoperative adjuvant radiation or chemotherapy is individualized based on the histology, stage, and risk factors such as age, lymphovascular space invasion, and histology. Early-stage patients are typically cured with surgery alone, whereas patients with high- or intermediate-risk factors, as defined by collaborative trials groups, commonly receive intracavitary brachytherapy to decrease local recurrence.^83,84 Patients with advanced disease and adverse histologies commonly receive platinum-based chemotherapy with or without radiation.

Lynch Syndrome

Lynch syndrome, a cancer family syndrome, also known as hereditary nonpolyposis colorectal cancer (HNPCC), is an autosomal dominant inherited predisposition to develop colorectal carcinoma and extracolonic cancers, predominantly including tumors of the uterus and ovaries, with rare but defined inclusion of breast cancer.⁸⁵ Genes involved in HNPCC are those required for proper single-strand DNA repair via the mismatch repair pathway; most commonly involved are MLH1, MSH2, and MSH6. The risk of colorectal carcinoma is as high as 75% by age 75. Affected female patients have a 40% and 10% lifetime risk of developing uterine and ovarian cancers, respectively. Surveillance has not been proven to identify early-stage disease in these patients, although it is recommended and should include annual cervical cytology, mammography, transvaginal ultrasonography, CA-125 measurements, and an endometrial biopsy. Risk reduction salpingo-oophorectomy with hysterectomy is now being recommended for women who have completed childbearing, ideally 5 to 10 years earlier than the first case of endometrial or ovarian cancer in the family.

Uterine Sarcomas

Uterine sarcomas arise from the uterine muscle and connective tissue elements and are typically aggressive tumors with a poorer prognosis compared to the more common endometrial carcinomas. The most common histopathologic types are endometrial stromal sarcomas, undifferentiated endometrial sarcomas, and leiomyosarcomas. Risk factors are challenging to assess but may include African American race, pelvic radiation, and tamoxifen exposure. Patients typically present with bleeding or mass effects, although some are discovered incidentally at the time of hysterectomy for other indications. Leiomyosarcoma is the most common uterine sarcoma, and hysterectomy with salpingo-oophorectomy is the treatment of choice. Lymph node metastases are rare in sarcomas in general, and in uterine sarcomas in the absence of palpable nodes or extrauterine disease. There are limited data to support cytoreduction when extrauterine disease is present. Benefits of adjuvant therapy are unknown. Advanced disease is typically treated with systemic chemotherapy.⁸⁶

Ovarian, Tubal, and Primary Peritoneal Cancer

Epithelial Ovarian, Tubal, and Primary Peritoneal Cancer

There were an estimated 22,280 new cases and 15,500 deaths due to ovarian cancers in 2012, yielding a fractional death rate of 70% and making ovarian cancer the most deadly of all women’s cancers.⁶⁶ One in 60 to 70 women in the United States will develop ovarian cancer during her lifetime, with a median age at diagnosis of 63 years. Symptoms for either benign or malignant ovarian tumors are nonspecific but frequent. Goff and colleagues, in a 2007 publication, described symptoms of bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms of urgency or frequency,⁸⁷ which form the basis of an ovarian cancer symptom index (Table 41-10), the use of which is endorsed by the Ovarian Cancer National Alliance, the Gynecologic Cancer Foundation, the Society of Gynecologic Oncologists, and the American Cancer Society. These symptoms, when newly developed and persistent or when representing a distinct change from a personal norm, should prompt an evaluation specifically targeted for identification of gynecologic malignancy.

High-grade, particularly serous epithelial cancers of the ovary, fallopian tube, and peritoneum are clinically similar and often combined under the rubric of epithelial ovarian cancer (EOC) in clinical practice, as well as in research and clinical trials. Risk factors for development of EOC include events that appear to increase the number of lifetime ovulations (e.g., early menarche, late menopause, nulliparity), whereas events that decrease the number of ovulations decrease risk (e.g., pregnancy, breastfeeding, oral contraceptives). Additionally, a history of tubal ligation or hysterectomy also decreases EOC risk. Family history of breast cancer and/or EOC is one of the strongest factors for lifetime risk of having breast cancer or EOC. Approximately 85% of ovarian cancer is sporadic; of the remaining 10% of cases, 75% of hereditary ovarian cancer has been attributed to mutations in the BRCA1 and BRCA2 genes, 7% to HNPCC, and the remainder to familial cancer of undefined genetic origin.⁸⁸ The lifetime risk of ovarian cancer in BRCA1 mutation carriers has been estimated at 40% to 60%, and it is 15% to 45% in BRCA2 carriers. The only confirmed prevention is risk-reducing salpingo-oophorectomy (RRSO).^89,90 The lifetime risk of ovarian or tubal malignancy is reduced to approximately 5% with RRSO, with the resultant cancer presenting as a primary peritoneal cancer.

Physical examination of patients with EOC may reveal evidence of metastatic disease, whereas a pelvic mass may be appreciated on exam. Ultrasound is particularly useful in the evaluation of a pelvic mass, whereas CT scan may detect evidence of metastatic disease. In the presence of a radiographically complex mass, CA-125 may provide further evidence for or against a possible ovarian malignancy. Concerning physical or radiographic exam findings should prompt referral to a gynecologic oncologist (see Table 41-10), as studies demonstrate inferior patient outcomes for women who have had primary surgery by nongynecologic oncologists.

The objectives of surgery in EOC are threefold. The first is to make the histologic diagnosis. The second is to assess the extent of disease through complete surgical staging (Tables 41-11 and 41-12). The third objective is (complete when feasible) surgical cytoreduction or debulking. An optimal cytoreduction is defined as no gross residual lesion greater than 1 cm, although outcomes are improved with complete resection of all gross disease. The extent of disease upon entering the abdomen and the residual disease upon completion of the debulking surgery are independent prognostic variables for patient outcome. When EOC is identified on frozen section and disease is grossly limited to the pelvis, complete staging with node dissection will upstage nearly one third of patients.⁹¹ Decisions about the benefits and risks of radical debulking for individual presentations and diverse pathology depend on the age and medical stability of the patient, as well as the pathologic type of the cancer. Conservative, fertility-sparing surgery can be considered for likely stage I, grade 1 EOC. In a patient who is medically compromised or in whom complete primary cytoreduction is unlikely, neoadjuvant chemotherapy followed by interval debulking may be more appropriate and is supported by a recent randomized controlled trial.⁹² Patients usually receive three cycles of platinum-based chemotherapy prior to debulking, and then three additional cycles after surgery.

Early-stage EOC has an excellent outcome. Low-grade, stage IA and IB disease can be cured in up to 90% to 95% of cases by a complete surgical procedure. The prevailing position in the United States is that such patients do not benefit from chemotherapy.⁹³ The standard of care for women with stages IC and II and all women with grade 3 or clear cell histology is adjuvant chemotherapy with three to six cycles of cisplatin or carboplatin in combination with paclitaxel or docetaxel.⁹⁴

Since GOG-111⁹⁵ was published in 1996, and through much of the subsequent decade, standard-of-care adjuvant therapy of advanced-stage EOC has been intravenous (IV) platinum and taxane. More recent trials have sustained that chemotherapy backbone but prompt an individualized, more nuanced approach. In 2006, the National Cancer Institute issued a Clinical Alert indicating that inclusion of intraperitoneal chemotherapy administration in adjuvant therapy should be considered first line for women with optimally cytoreduced (defined as no residual lesions >1 cm in diameter) EOC. This was the result of completion and analysis of three independent randomized clinical trials showing a significant survival advantage for intraperitoneal therapy.^96,97 It is unclear whether it is the site of drug administration and/or the doses and dose density used that contributed to the improved outcomes. The intraperitoneal port is usually a 9.6-French venous catheter, with the port placed over the right or left costal margin. The catheter is tunneled caudad with insertion through the fascia in the lower abdomen and the tip in the pelvis.

Patients who have suboptimally debulked advanced-stage disease and/or who are not candidates for intraperitoneal therapy should receive IV adjuvant chemotherapy. Interest has increased in both dose-dense IV chemotherapy dosing as well as incorporation of biologic agents. The Japanese Gynecologic Oncology Group phase III trial of carboplatin and weekly, dose-dense paclitaxel demonstrated significant improvement in both progression-free and overall survival⁹⁸; the U.S. study of this regimen is now maturing. Addition of the angiogenesis inhibitor, bevacizumab, to the standard carboplatin-paclitaxel backbone and its continuance in maintenance therapy provided a modest increase in progression-free survival without an overall survival advantage. Patients with bulky disease after primary surgery appeared to derive the greatest benefit in post-hoc analysis.^99,100

Secondary cytoreduction upon recurrence can be considered (Table 41-13). Patients who have had a disease-free period of at least 12 months, following an initial complete clinical response to surgery and initial chemotherapy, who have no evidence of carcinomatosis on imaging, and who have disease that can be completely resected are considered optimal candidates. A randomized controlled trial is ongoing to validate that current state of treatment. Debulking surgery done after subsequent relapses or in women with early recurrence has not been shown to result in an outcome benefit. Finally, surgery is used to palliate disease complications. The most common cause of palliative surgery is bypass of bowel obstruction.

Chemotherapy is the mainstay of therapy for recurrent EOC. Treatment approaches are based on platinum sensitivity¹⁰¹ (Table 41-14). Referral to an oncologist with specific expertise in chemotherapeutic treatment of ovarian cancer and access to clinical trials is important. In determining secondary and subsequent therapy, consideration of prior therapies, sites of disease, organs at risk from cancer, organs sustaining injury from prior therapy, and quality of life desires of the patient should be taken into consideration.

Ovarian Germ Cell Tumors

Ovarian germ cell tumors occur most commonly in women under age 30. Malignant forms often grow and disseminate rapidly and are symptomatic. The rapid growth may be accompanied by torsion producing an acute abdomen and need for emergent intervention. Because they are derived from primordial germ cells, many produce characteristic tumor markers. The most common benign germ cell neoplasm is the mature cystic teratoma; approximately 1% of teratomas contain a secondary malignancy arising from one of the components, most commonly squamous cell cancer. Immature teratomas comprise a significant proportion of malignant germ cell tumors and may be associated with elevated lactate dehydrogenase (LDH) or α-fetoprotein (AFP). Excluding teratomas, the most common malignant germ cell tumor is dysgerminoma, made up of pure undifferentiated germ cells. Bilaterality occurs in up to 15% of patients; lactate dehydrogenase is commonly elevated, and elevated β-hCG may occur. Staging, including removal of the involved ovary, biopsy of any suspicious areas, node dissection, and omentectomy, should be done initially but does not require hysterectomy or removal of the second ovary if fertility preservation is of concern and no extension of disease is observed. Evidence of extraovarian spread, such as nodal metastases, requires adjuvant chemotherapy. The cure rate remains high, near 90% with metastatic disease; recurrent disease is more difficult to eradicate.¹⁰²

Less common are malignant germ cell tumors, including endodermal sinus or yolk sac tumors, embryonal carcinomas, mixed germ cell neoplasms, polyembryomas, and choriocarcinomas. Endodermal sinus tumors may have elevated AFP levels in the blood, whereas embryonal and mixed germ cell tumors may have elevated β-hCG, LDH, or AFP. Tumor markers are useful to follow during definitive therapy. Early spread of these tumors occurs, and other than completely resected stage I, grade 1 immature teratoma, all others require adjuvant therapy with a platinum-containing regimen.¹⁰³

Ovarian Sex Cord-Stromal Tumors

Although rare, sex cord-stromal cell tumors are derived from cells that support and surround the oocyte and can present with symptoms referable to endocrine activity of the tumor. These include granulosa cell tumors (female differentiated), fibroma-thecomas, and Sertoli-Leydig cell tumors (male differentiated). Granulosa cell tumors are the most common in this group and are a low-grade malignancy with less than 3% bilaterality. They are treated with conservative surgery, similar to germ cell tumors in young women.¹⁰³ Hysterectomy and bilateral salpingo-oophorectomy are recommended for women who have completed childbearing. Nodal staging can be safely omitted in the absence of grossly involved nodes, and fertility preservation is possible in disease limited to one ovary, the most common presentation. Debulking surgery is recommended for more extensive disease. These tumors and the thecomas in the same class often stimulate estrogen production and can be found in association with endometrial hyperplasia and cancer (5%). Granulosa cell tumors can recur over a prolonged period given their low rate of proliferation and tendency for local or intraperitoneal recurrence. Inhibin has been shown to be elaborated by these tumors and often is followed to identify recurrence of the disease. The Sertoli-Leydig cell tumors can present with virilization as a primary symptom. Evaluation of the ovary when this symptom is found is always of value.

Hysteroscopy

See earlier section, Hysteroscopy, under Procedures Performed for Structural Causes of Abnormal Uterine Bleeding.

Laparoscopy

The standard method for gynecologic laparoscopy follows the same methods as all minimally invasive surgery. In general, a camera port is placed near the umbilicus. Sometimes it must be placed more cephalad if the patient has a larger fibroid uterus. Two additional ports are placed laterally, usually just superior and medial to the anterior superior iliac spines (ASIS). Sometimes one additional suprapubic port is placed for extra traction or instrumentation as described elsewhere in this text.

Complications Related to Gynecologic Surgery

Abdominal Wall Vessels

The vessel at greatest risk of injury during the lateral trocar placement is the inferior epigastric artery. The superficial epigastric vessels and the superficial circumflex iliac vessels can be injured as well (Fig. 41-23). The primary methods to avoid vessel injury are knowledge of the vessels at risk and their visualization prior to trocar placement, when possible. The superficial vessels often can be seen and avoided by transillumination of the abdominal wall with the laparoscope. In contrast, the larger inferior epigastric vessels cannot be seen by transillumination because of their deeper location; these vessels often can be seen laparoscopically and avoided as they course along the peritoneum between the lateral umbilical fold of the bladder and the insertion of the round ligament into the inguinal canal. Anatomic variation and anastomoses between vessels make it impossible to know the exact location of all the abdominal wall vessels. For this reason, other strategies also should be used to avoid vessel injury, including the use of trocars with conical tips rather than pyramid tips and the use of the smallest trocars possible lateral to the midline.

Intestinal Injury

Another potentially serious complication of laparoscopic surgery is injury to either small or large intestines. An unrecognized bowel injury may occur at the time of trocar insertion, especially if the patient has had previous abdominal procedures that often result in bowel adhesions to the anterior abdominal wall peritoneum. An open technique for placement of the first port is advocated to minimize the risk of bowel injury in patients who have undergone previous laparotomy. Some bowel injuries may not be seen during surgery because of the limited field of view. These injuries usually manifest 1 to 3 days after surgery, well after the patient has been released following these primarily outpatient procedures, and any patient concerns in this time period should be addressed seriously and rapidly.

Urologic Injuries

Bladder injury is an uncommon laparoscopic injury, occurring as a result of retroperitoneal perforation during lower trocar placement or during sharp dissection of the bladder from the lower uterine segment during hysterectomy. The latter of these two situations is usually recognized intraoperatively; the first sign of the former may be postoperative hematuria or lower-port incisional drainage. Once diagnosed, large defects require layered closure, whereas smaller defects usually close spontaneously within days or weeks with the aid of transurethral catheter drainage. Ureteral injury may occur as a result of any procedure that requires dissection or ligation of sidewall vessels, such as removal of adnexa, because the ureter is adjacent to the pelvic peritoneum in the area of the ovarian fossa (see Fig. 41-5). This complication also has been reported after fulguration of endometriosis on the pelvic sidewall. Another common cause of ureteral injury is hysterectomy, because the ureter is often located less than 2 cm from the cervix. This type of injury appears to be increased during laparoscopic hysterectomy, compared to abdominal or vaginal approaches. Ureteral injuries, including complete ligation, partial resection, or thermal injuries, usually will manifest within hours to days of surgery. Complete obstruction most often manifests as flank pain, whereas the first sign of partial or complete transection may be symptoms of intra-abdominal irritation caused by urine leakage. Transperitoneal thermal injuries resulting from fulguration of endometriosis may be similar to those after transection, but the appearance of symptoms may be delayed several days until tissue necrosis occurs.

Robotic Surgery

Over the last decade, there has been increased use of robotics for gynecologic surgery. With the DaVinci robotic system, the surgeon sits at a console and visualizes the operative field with three-dimensional optics. The laparoscopic instruments are “wristed” and move as the surgeon’s hands/fingers move the actuators at the console. Robotic surgery uses a camera port, two to three robotic ports, and an accessory port. More meticulous dissection, improved visualization, and ability to operate with lower intra-abdominal pressures make the robotic platform advantageous, especially in obese patients. Longer set-up time and increased cost, however, are distinct disadvantages. The use of robotic surgery has been described for virtually every gynecologic procedure that has been performed abdominally or laparoscopically.