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Cover
Preface
PART 1: General
1. CHAPTER 1: Introduction and prologue
  1. Introduction
  2. Prologue: after Comyns Berkeley and Victor Bonney, (JM Monaghan)
  3. Further reading
2. CHAPTER 2: Preparation for surgery
  1. Clinic information
  2. Initial visit
  3. History taking and documentation
  4. Patient information
  5. Consent for surgery
  6. Preoperative assessment and optimization
  7. Preoperative investigations
  8. Preoperative case review and meeting
  9. Preoperative discussion with the patient regarding the scope of surgery
  10. Preoperative visit by the anaesthetist
  11. Thromboprophylaxis
  12. Bowel preparation
  13. In the operating theatre
  14. Anaesthesia
  15. References
  16. Further reading
3. CHAPTER 3: Instruments, operative materials and basic surgical techniques
  1. Instruments for major gynaecological procedures
  2. Editors’ picks
  3. Sutures
  4. Surgical knots and methods of tying
  5. Tying pedicles
  6. Staples
  7. Electrosurgery
  8. Haemostatic agents
  9. Adhesion prevention
  10. Drainage
  11. References
  12. Further reading
4. CHAPTER 4: Opening and closing the abdominal cavity
  1. Operative stance
  2. Draping the patient
  3. Instruments
  4. Subumbilical midline incision
  5. Transverse incisions
  6. Reference
  7. Further reading
5. CHAPTER 5: The laparoscopic approach in gynaecology
  1. Positioning of the patient
  2. Access to the abdomen
  3. Equipment
  4. Diagnostic laparoscopy
  5. Problems and complications associated with laparoscopy
  6. Laparoscopic surgery for endometriosis
  7. Laparoscopic surgery in gynaecological oncology
  8. Complications
  9. Postoperative recovery
  10. References
  11. Further reading
6. CHAPTER 6: Postoperative care and complications
  1. Postoperative care
  2. Complications of surgery
  3. References
  4. Further reading
PART 2: Anatomical
1. CHAPTER 7: Operations on the vulva
  1. Vulval biopsy
  2. Treatment of Bartholin’s cysts and abscesses
  3. Simple vulvectomy
  4. Further reading
2. CHAPTER 8: Operations on the vagina
  1. Vaginal cysts
  2. Procedures for enlargement of the vaginal introitus
  3. Congenital abnormalities of the vagina
  4. Vaginectomy: partial and complete
  5. Reference
  6. Further reading
3. CHAPTER 9: Operations on the cervix
  1. Dilatation of the cervix
  2. Removal of endocervical polyps and extruded fibroid polyps
  3. Ablative procedures
  4. Excisional techniques
  5. Trachelorrhaphy
  6. Cervical incompetence
  7. Excision of cervical stump
  8. References
  9. Further reading
4. CHAPTER 10: Operations on the uterine cavity
  1. Rapid access clinics
  2. Sampling of the endometrium
  3. Outpatient hysteroscopy
  4. Endometrial ablation
  5. Hysteroscopic myomectomy
  6. Reference
  7. Further reading
5. CHAPTER 11: Operations on the uterus
  1. Total abdominal hysterectomy
  2. Hysterectomy for a double uterus
  3. Subtotal hysterectomy
  4. Vaginal hysterectomy
  5. Laparoscopic‐assisted vaginal hysterectomy
  6. Total laparoscopic hysterectomy
  7. Complications of hysterectomy
  8. References
  9. Further reading
6. CHAPTER 12: Uterine fibroids
  1. Classification
  2. Symptoms
  3. Imaging
  4. Management
  5. Surgical management
  6. Hysterectomy for uterine fibroids
  7. References
  8. Further reading
7. CHAPTER 13: Operations on the fallopian tubes
  1. Extrauterine gestation
  2. Operations on the fallopian tubes for female sterilization
  3. Resection of the fallopian tube
  4. Operations for correction of infertility
  5. Reference
  6. Further reading
8. CHAPTER 14: Operations on the ovaries
  1. Diagnosis of an ovarian mass
  2. Management
  3. Surgery
  4. Ovarian cystectomy
  5. Salpingo‐oophorectomy
  6. Removal of a retroperitoneal cyst
  7. References
  8. Further reading
9. CHAPTER 15: Caesarean section
  1. Lower‐segment caesarean section
  2. Classical caesarean section
  3. Management of massive postpartum haemorrhage
  4. References
  5. Further reading
PART 3: Urogynaecology
1. CHAPTER 16: Operations for pelvic organ prolapse
  1. General considerations
  2. Anaesthesia
  3. Instruments
  4. Anterior colporrhaphy
  5. Posterior colporrhaphy
  6. Transanal rectocele repair
  7. Perineorrhaphy
  8. Posterior colporrhaphy with enterocoele repair
  9. Central compartment procedures
  10. Vaginal hysterectomy combined with anterior and/or posterior colporrhaphy
  11. Surgical management of vaginal vault prolapse after hysterectomy
  12. Sacrospinous ligament fixation
  13. Uterosacral ligament suspension
  14. Abdominal sacrocolpopexy
  15. Laparoscopic sacrocolpopexy
  16. Uterine sparing prolapse surgery
  17. Transvaginal insertion of mesh
  18. Obliterative techniques
  19. Complete colpocleisis
  20. Le Fort’s colpocleisis
  21. References
  22. Further reading
2. CHAPTER 17: Operations for urinary incontinence
  1. Classification of procedures
  2. The role of urodynamic assessment before surgery for stress urinary incontinence
  3. The place of cystoscopy during surgery for stress urinary incontinence
  4. The use of bladder drainage following surgery for stress urinary incontinence
  5. Urethral and bladder neck supporting procedures
  6. Retropubic suburethral slings: synthetic mid‐urethral slings
  7. Trans‐obturator foramen suburethral slings
  8. Retropubic suburethral slings: traditional sling operations
  9. Urethral sphincter augmentation
  10. Artificial urinary sphincter
  11. Operations for detrusor overactivity
  12. Whether, when and which operation?
  13. References
3. CHAPTER 18: Operations for urogenital fistulae
  1. Bonney’s principles of fistula repair
  2. Classification
  3. Presentation and evaluation
  4. Immediate management
  5. Timing of repair
  6. Route of repair
  7. Preoperative preparation
  8. Anaesthesia
  9. Instruments
  10. Suture materials
  11. Interposition grafts
  12. Skin grafts
  13. Vaginal procedures
  14. Other vaginal procedures
  15. Abdominal procedures
  16. Ureterovaginal fistula repair
  17. Urinary diversion
  18. Postoperative management
  19. References
PART 4: Oncology
1. CHAPTER 19: Surgery for carcinoma of the vulva
  1. Lymph node assessment
  2. Excision of the vulval tumour
  3. The operation
  4. Excision of the vulval tumour
  5. References
  6. Further reading
2. CHAPTER 20: Vaginal cancer surgery
  1. Treatment
  2. Wide excision
  3. Partial or total vaginectomy
  4. Exenteration
  5. Reference
  6. Further reading
3. CHAPTER 21: Cervical cancer
  1. Radical hysterectomy and pelvic node dissection
  2. Laparoscopic radical hysterectomy with aortic and pelvic lymphadenectomy
  3. Radical vaginal hysterectomy
  4. Radical trachelectomy
  5. References
  6. Further reading
4. CHAPTER 22: Uterine cancer
  1. Surgical approach
  2. Role of ovarian conservation
  3. Peritoneal washings
  4. Risk of nodal metastases and assessment of nodes
  5. Role of lymphadenectomy and sentinel lymph node sampling
  6. Radical surgery in advanced disease
  7. References
  8. Further reading
5. CHAPTER 23: Ovarian cancer
  1. General comments
  2. A systematic approach to achieving complete surgical staging in patients with clinical stage I or II disease
  3. A systematic approach to achieve optimal cytoreductive status in patients with advanced epithelial cancer of the ovary
  4. Reference
  5. Further reading
6. CHAPTER 24: Exenterative surgery
  1. Selection of patients for exenterative surgery
  2. Palliative exenteration
  3. Patient assessment
  4. Contraindications to exenteration
  5. Types of exenteration
  6. Preoperative preparation
  7. The operation
  8. Postoperative care
  9. Results of exenteration
  10. References
  11. Further reading
PART 5: Operations on other organs
1. CHAPTER 25: Vascular surgery: applications in gynaecology and gynaecological oncology
  1. Aortic injury
  2. Iliac artery injury
  3. Vena caval injury
  4. Presacral bleeding
  5. Pelvic packing
  6. Summary
  7. Further reading
2. CHAPTER 26: Management of injuries to the urinary tract
  1. Anatomical relationship
  2. Predisposing factors
  3. Preventing injuries
  4. Damage recognized at the time of operation
  5. Injuries to the ureter in the pelvis
  6. Ureteric injuries above the pelvic brim
  7. Management of the delayed diagnosis of urinary tract damage
  8. Radiotherapy damage
  9. Operations for the formation of a urinary conduit
  10. References
  11. Further reading
3. CHAPTER 27: Operations on the intestinal tract for the gynaecologist
  1. Appendicectomy
  2. Instruments
  3. Patient preparation
  4. Anaesthesia
  5. The operation
  6. Management of operative injuries of the intestine
  7. The formation of a stoma
  8. A permanent colostomy
  9. The formation of a loop ileostomy
  10. Side‐to‐side anastomosis procedure
  11. Reference
  12. Further reading
4. CHAPTER 28: Reconstructive procedures
  1. General comments
  2. Vulval reconstruction for localized benign disease, premalignant and early malignant disease
  3. Full‐ and split‐thickness skin grafts (general considerations)
  4. Myocutaneous grafts
  5. References
Index
End User License Agreement

List of Tables

Chapter 03
1. Table 3.1 Absorbable suture materials.
Chapter 10
1. Table 10.1 Classification of submucosal fibroids.
Chapter 12
1. Table 12.1 Uterine fibroid subclassification system. ³
Chapter 15
1. Table 15.1 The three components of management of massive postpartum haemorrhage.
Chapter 17
1. Table 17.1 Classification of stress urinary incontinence procedures.
2. Table 17.2 The author’s preferred technique for for ‘sedo‐anaesthesia’.
3. Table 17.3 Injectable substances developed for use as urethral bulking agents.
4. Table 17.4 Nonsurgical options for detrusor overactivity.
Chapter 21
1. Table 21.1 Complications of radical hysterectomy.

List of Illustrations

Chapter 03
1. Figure 3.1 Bonney gynaecological scissors.
2. Figure 3.2 (a) Monaghan gynaecological scissors. (b) Comparison of Bonney scissors (top) and Monaghan scissors (bottom).
3. Figure 3.3 Hysterectomy clamps.
4. Figure 3.4 Singley forceps.
5. Figure 3.5 DeBakey forceps.
6. Figure 3.6 Meigs–Navratil forceps.
7. Figure 3.7 Simple interrupted suture.
8. Figure 3.8 Vertical mattress suture.
9. Figure 3.9 Horizontal mattress suture.
10. Figure 3.10 Locked or blanket sutures.
11. Figure 3.11 Puckering sutures.
12. Figure 3.12 Purse‐string suture.
13. Figure 3.13 Purse‐string inverting sutures.
14. Figure 3.14 Reef knot.
15. Figure 3.15 (1–4) The single‐handed knot and (5, 6) forceps knot (after Bonney).
16. Figure 3.16 Tying a pedicle around Meigs forceps.
17. Figure 3.17 A disposable multiple clip applicator.
18. Figure 3.18 (a) Simple pedicle tie. (b) Single‐end transfixion tie. (c) Double‐ended transfixion tie.
Chapter 04
1. Figure 4.1 The subumbilical midline incision, incising the skin.
2. Figure 4.2 Incising the rectus sheath.
3. Figure 4.3 Separating the rectus muscles.
4. Figure 4.4 Incising the peritoneum.
5. Figure 4.5 Cutting the peritoneum along the full length of the wound.
6. Figure 4.6 The Balfour self‐retaining retractor.
7. Figure 4.7 The incision retracted using the Balfour and Morris retractors.
8. Figure 4.8 The mass closure technique.
9. Figure 4.9 Stapling the abdominal skin.
10. Figure 4.10 The Pfannenstiel incision.
11. Figure 4.11 Dissecting the rectus sheath.
Chapter 05
1. Figure 5.1 Needle insertion into the abdominal cavity to produce a pneumoperitoneum.
2. Figure 5.2 Insertion of the laparoscope via the trocar.
Chapter 07
1. Figure 7.1 (a) Biopsy of vulval lesion using a Keyes punch. (b) Resulting biopsy specimen.
2. Figure 7.2 Cruciate incision over abscess.
3. Figure 7.3 Wall of abscess sutured to skin.
4. Figure 7.4 Incising over the Bartholin’s cyst.
5. Figure 7.5 Enucleation of the cyst.
6. Figure 7.6 Removal of the cyst.
7. Figure 7.7 Obliteration of the cyst cavity.
8. Figure 7.8 Closure of the skin.
9. Figure 7.9 The incision for simple vulvectomy.
10. Figure 7.10 Removal of vulval skin.
11. Figure 7.11 Suturing the cut edges.
Chapter 08
1. Figure 8.1 Incising the introital skin.
2. Figure 8.2 Developing a flap of vaginal skin.
3. Figure 8.3 Making the posterior vertical incision.
4. Figure 8.4 Obliterating the space under the flap.
5. Figure 8.5 Suturing the skin edges together.
6. Figure 8.6 Releasing the vaginal edges.
7. Figure 8.7 Excising the vaginal skin at the vault.
8. Figure 8.8 Identifying the ureter in the right retroperitoneal space.
9. Figure 8.9 Dividing the uterine artery at the pelvic sidewall.
10. Figure 8.10 Dividing the roof of the ureteric tunnel.
11. Figure 8.11 Incising the peritoneum between the uterosacral ligaments.
12. Figure 8.12 Developing the rectovaginal space.
13. Figure 8.13 Removing the vaginal remnant.
Chapter 09
1. Figure 9.1 Lithotomy position.
2. Figure 9.2 Cervical vulsellum.
3. Figure 9.3 Passage of uterine sound.
4. Figure 9.4 Dilatation of the cervix.
5. Figure 9.5 Damage of the anterior wall in a retroverted gravid uterus.
6. Figure 9.6 Removal of small endocervical polyp.
7. Figure 9.7 Removal of a large myomatous polyp: incising the capsule.
8. Figure 9.8 Reflecting the capsule.
9. Figure 9.9 Enucleation of the tumour.
10. Figure 9.10 Excision of the pedicle.
11. Figure 9.11 The loop is laid over the transformation zone to encompass the lesion.
12. Figure 9.12 The wire is then ‘followed’ rather than pushed through the cervix.
13. Figure 9.13 Placing the lateral haemostats.
14. Figure 9.14 Cutting the cone biopsy.
15. Figure 9.15 Grasping the cone biopsy.
Chapter 10
1. Figure 10.1 Curettage of the uterine cavity.
Chapter 11
1. Figure 11.1 Cutting the round ligaments.
2. Figure 11.2 Cutting the ovarian ligament.
3. Figure 11.3 Incising the uterovesical fold.
4. Figure 11.4 Separating the bladder.
5. Figure 11.5 Clamping the uterine artery.
6. Figure 11.6 Clamping the parametrium.
7. Figure 11.7 Incising the vagina (showing all clamps in place).
8. Figure 11.8 Suturing the vaginal edge.
9. Figure 11.9 Hysterectomy for a double uterus: dividing the vesicorectal fold or median raphe.
10. Figure 11.10 Infiltration of subepithelial tissues.
11. Figure 11.11 Incision around the cervix.
12. Figure 11.12 Opening the pouch of Douglas.
13. Figure 11.13 Clamping of the ligaments.
14. Figure 11.14 Ligation of the divided pedicle.
15. Figure 11.15 Opening the uterovesical peritoneum.
16. Figure 11.16 Ligation of the uterine vessels.
17. Figure 11.17 Clamping the tubo‐ovarian pedicles.
Chapter 12
1. Figure 12.1 Bonney myomectomy clamp applied to the lower uterus.
Chapter 13
1. Figure 13.1 Total salpingectomy for a tubal pregnancy.
2. Figure 13.2 Removing an ampullary tubal pregnancy with conservation of the tube.
3. Figure 13.3 Ligation and resection of the fallopian tube.
Chapter 14
1. Figure 14.1 Incising the ovary over an ovarian cyst.
2. Figure 14.2 Removing the ovarian cyst intact.
3. Figure 14.3 Opening the peritoneum and identifying the ureter.
Chapter 15
1. Figure 15.1 Reflecting the peritoneum over the lower uterine segment.
2. Figure 15.2 Incising the uterovesical fold.
3. Figure 15.3 Separating the bladder from the lower segment.
4. Figure 15.4 Extending the lower‐segment incision (a) in a cephalad–caudad direction; and (b) in a transverse direction.
5. Figure 15.5 Attaching Green Armytage forceps to the lateral edges of the lower‐segment wound.
6. Figure 15.6 (a and b) Suturing the lower segment in two layers.
Chapter 16
1. Figure 16.1 Vaginal incision using ‘tunnelling’ technique. Note that the tips of the scissors must be kept against the vaginal skin to keep the plane of separation between the skin and the fascia.
2. Figure 16.2 Separation of pubocervical fascia from vaginal skin. Note that the plane is more easily extended by gentle traction on the fascia itself.
3. Figure 16.3 The plane of separation is further developed onto the cervix or (vaginal vault).
4. Figure 16.4 Insertion of plicating sutures into pubocervical fascia. Note that by using overlapping box sutures there is no possibility of gaps for further herniation.
5. Figure 16.5 Vaginal skin closure. Note that catching the underlying fascia in each bite helps to reduce dead space and limits the chance of haematoma.
6. Figure 16.6 Transverse incision at perineum. Note that if perineorrhaphy is planned, a transverse incision should be made between the two lateral forceps, otherwise a simple midline incision is made (dotted line).
7. Figure 16.7 Midline incision of vagina.
8. Figure 16.8 Separation of the vagina from the pre‐rectal fascia. Note that the plane is more easily extended by gentle traction on the fascia itself.
9. Figure 16.9 Interrupted sutures are placed in the pre‐rectal fascial. Note that the sutures should not be placed too laterally if a tension‐free repair is to be achieved.
10. Figure 16.10 Vaginal skin closure. Note that catching the underlying fascia in each bite helps to reduce dead space and limits the chance of haematoma.
11. Figure 16.11 Vaginal skin flaps are dissected off the underlying bulbocavernous and transverse perineal muscles.
12. Figure 16.12 Reconstruction of the perineal body. Note that the ideal direction of needle placement to secure the bulk of bulbocavernous and transverse perineal muscles is as shown in the magnified inset.
13. Figure 16.13 Closure of enterocoele sac with a series of purse‐string sutures.
14. Figure 16.14 Plicating sutures placed into uterosacral ligaments and peritoneum of the pouch of Douglas.
15. Figure 16.15 Suture ends are brought through the vaginal skin behind the vault, to be tied after skin closure.
16. Figure 16.16 Visualization of the right sacrospinous ligament. Note that the Breisky retractor on the patient’s right must rest on the ischial spine (not deeper), with traction in a lateral direction.
17. Figure 16.17 Placement of suture into sacrospinous ligament. Note that the suture is placed through (not around) the ligament; the hook is then manipulated into the notch on the Sims’ speculum and the suture retrieved using a nerve hook.
18. Figure 16.18 ‘Pulley‐stitch’ is used to fix the suspensory sutures to the vaginal skin just below the vaginal vault.
19. Figure 16.19 Three sutures placed through the uterosacral ligament on the right side.
20. Figure 16.20 Sutures (double‐armed), already through the ligament, are secured into the pubocervical and pre‐rectal fasciae.
21. Figure 16.21 Indigo carmine confirmed to efflux from ureteric orifice.
22. Figure 16.22 Tying the suspensory sutures, bringing the upper edges of the pubocervical and pre‐rectal fasciae together at the apex, in proximity to the ligaments at the vaginal vault. Note that if the sutures are tied after closure of the vaginal skin, they must be trimmed short, ensuring that the ends do not protrude through the vault incision.
23. Figure 16.23 Attachment of mesh to vaginal wall.
24. Figure 16.24 Attachment of mesh to sacral promontory.
25. Figure 16.25 A strip of vaginal epithelium is marked out, prior to excision using a no.12 scalpel blade.
26. Figure 16.26 Lembert sutures are used to invert the fascial layers.
27. Figure 16.27 Modified Martius labial fat graft may be used to fill dead space in the lower vagina.
28. Figure 16.28 Vaginal epithelium stripped from anterior and posterior walls prior to Le Fort’s procedure.
29. Figure 16.29 Having closed the vaginal skin over the vault around a drain tube, inverting Lembert sutures are used to approximate the fascia underlying the anterior and posterior vaginal walls.
Chapter 17
1. Figure 17.1 Patient in a horizontal lithotomy position with legs in Lloyd‐Davies stirrups.
2. Figure 17.2 Retropubic space opened.
3. Figure 17.3 The surgeon using their nondominant index finger in the vagina to apply pressure upwards and laterally, at the level of the bladder neck: (a) operative view; (b) sagittal section.
4. Figure 17.4 Tips of Metzenbaum scissors used to aid dissection of the paravaginal fascia.
5. Figure 17.5 Sutures inserted into the paravaginal fascia on each side, using Turner‐Warwick needle holder.
6. Figure 17.6 Two or three sutures are inserted on each side, tied down onto the paravaginal fascia, and then passed through the ileopectineal ligament.
7. Figure 17.7 By using the ‘pulley’ suture the paravaginal fascia is brought into proximity with the pelvic sidewall but not directly on to the ileopectineal ligament; ‘bow‐stringing’ of sutures does not detract from the effectiveness of the procedure.
8. Figure 17.8 Moschowitz procedure for enterocoele closure; lowermost suture already tied, second in place, and position of third (incorporating uterosacral ligaments) shown as dotted line.
9. Figure 17.9 Intravenous urogram in patient with bilateral ureteric obstruction following colposuspension; point of obstruction visible, with hydroureter and hydronephrosis on the right; minimal function visible as faint nephrogram only on left.
10. Figure 17.10 Dissection using fine Metzenbaum scissors to create a space paraurethrally into which the TVT™ needle may be safely introduced.
11. Figure 17.11 The introduction needle is ‘palmed’ in the operator’s left hand as it is eased in the plane between vagina and urethra.
12. Figure 17.12 The handle is then lowered and the needle passed through the retropubic space, to emerge from the suprapubic incision. (a) and (c) show the needle passed on the patient’s right side (in coronal plane), and (b) on the left (in sagittal plane).
13. Figure 17.13 Cystoscopic photograph, showing bladder perforation by introduction needle.
14. Figure 17.14 Check cystoscopy may be undertaken after each needle passage, but must as a minimum, must be carried out after the final needle passage, before tape adjustment (as in this image).
15. Figure 17.15 Metzenbaum scissors placed beneath the tape when adjustments are being made: (a) leakage apparent; (b) leakage resolved.
16. Figure 17.16 Cystoscopic photograph, showing bladder perforation by tape, with overlying encrustation.
17. Figure 17.17 Cystoscopic photograph, showing urethral perforation by tape. The open bladder neck can be seen in distance (outlined by dotted line) in the top left of the image; fibres of the tape are seen across the right side of the image.
18. Figure 17.18 The points for needle insertion marked, 1 cm lateral to the ischiopubic ramus, just below the adductor longus muscle tendon, on a horizontal line level with the clitoris.
19. Figure 17.19 The introducer is held vertically with the handle downwards as it is introduced through the skin incision.
20. Figure 17.20 The introducer is then passed around the ramus by rotation of the operator’s wrist.
21. Figure 17.21 The tape, once connected to the tip of the introducer, is pulled through into position by traction and rotation of the introducer in the reverse direction.
22. Figure 17.22 Rectus sheath sling marked and cut from aponeurosis: (a) as two strips cut transversely; (b) the incisions extended downwards in the midline, forming a T‐shape.
23. Figure 17.23 Vaginal incision for rectus sheath sling
24. Figure 17.24 The plane is developed by sharp dissection, and the endopelvic fascia is then perforated with scissors or a finger, to gain entry into the retropubic space from below.
25. Figure 17.25 A uterine packing forcep is passed from the vaginal incision upwards through the retropubic space, grasps the stay suture on one end of the sling and then brings the sling down into the vaginal dissection.
26. Figure 17.26 The two ends of the sling are secured in a ‘double‐breasted’ fashion.
27. Figure 17.27 A ‘Stamey’ needle is used to pass the sutures upwards through the retropubic space from below.
28. Figure 17.28 (a) Purely abdominal approach for insertion of alloplastic sling; the sling is drawn under the bladder neck. (b) Purely abdominal approach for insertion of alloplastic sling; here the sling is shown sutured the ileopectineal ligaments.
29. Figure 17.29 The paraurethral needle advanced parallel to the cystoscope until its position can be seen just below the bladder neck within the mucosa.
30. Figure 17.30 Three injection sites completed, creating the cystoscopic appearance of ‘prostatic lobes’.
31. Figure 17.31 Transurethral approach to urethral injection; endoscopic needle (arrowed) positioned just below bladder neck
32. Figure 17.32 Boston Scientific Corp AMS 800™ device.
33. Figure 17.33 The sphincter cuff is placed around the bladder neck ‐ this can be supplemented with an omental wrap (not shown); the pressure‐regulating balloon is positioned to the right side of the bladder; the control pump is shown here as it is about to be passed into the right labium majus.
34. Figure 17.34 Botulinum neurotoxin injected systematically around the bladder wall, avoiding the trigone.
Chapter 18
1. Figure 18.1 Dye testing with methylene blue: (a) before dye instillation; (b) after dye instillation, showing dye leaking from vesicovaginal and vesicovulval fistulae – arrowed.
2. Figure 18.2 Patient in exaggerated supine lithotomy position with steep head‐down tilt; note buttocks over end of table with a wedge or pillow to support lumbosacral spine, and shoulder supports to prevent patient from sliding.
3. Figure 18.3 Patient in prone lithotomy position with head‐up tilt.
4. Figure 18.4 Cystoscopic appearance of post‐hysterectomy fistula (identified by a probe passed through from the vagina), typically on the posterior bladder wall, in the midline above the inter‐ureteric bar.
5. Figure 18.5 Appearance of acute radiotherapy‐associated mid‐vaginal fistula.
6. Figure 18.6 Slough on anterior vaginal wall eight days following obstructed labour.
7. Figure 18.7 Author’s preferred set of fistula instruments.
8. Figure 18.8 Modified Martius labial fat graft dissected from right labium majus to overlie urethral reconstruction.
9. Figure 18.9 Gracilis muscle graft dissected from right thigh using a ‘step’ incision approach (a) above, prior to tunnelling to overlie fistula repair (b) below.
10. Figure 18.10 Transposition skin flap marked out on left side of vulva.
11. Figure 18.11 Transposition skin flap incised and mobilized.
12. Figure 18.12 Transposition skin flap sutured in place overlying residual vaginal defect (in this example reconstructed urethra); the donor site is also sutured.
13. Figure 18.13 Labium minus flap dissected on right side.
14. Figure 18.14 Longitudinal skin incision is made in the labium majus, incorporating a skin island of appropriate size for the defect to be filled.
15. Figure 18.15 Island graft passed subcutaneously to cover defect.
16. Figure 18.16 Gracilis muscle myocutaneous graft.
17. Figure 18.17 Large mid‐vaginal fistula with ureters in the edge of the fistula; ureteric catheters in place, brought out through the external urethral meatus.
18. Figure 18.18 Fistula circumcised as transverse ellipse, with lateral extension to facilitate mobilization.
19. Figure 18.19 Mobilization of vaginal skin edges from underlying bladder using bistoury blade.
20. Figure 18.20 Further mobilization with Chassar Moir scissors.
21. Figure 18.21 Blunt dissection away from the fistula edge using pledget.
22. Figure 18.22 Angles of the fistula are secured first with inverting sutures.
23. Figure 18.23 First layer of the bladder repair is completed with similar inverting sutures once the angles are secured.
24. Figure 18.24 Second layer is inserted so as to close off dead space by catching the back of the vaginal flaps.
25. Figure 18.25 After testing the integrity of the repair, interrupted mattress sutures close and evert the vaginal skin.
26. Figure 18.26 For saucerization, the fistula track is converted into a small crater.
27. Figure 18.27 The saucerized track is closed with single‐layer interrupted mattress sutures.
28. Figure 18.28 Transverse closure of juxtacervical fistula.
29. Figure 18.29 Partial colpocleisis by Latzko technique.
30. Figure 18.30 Circumferential fistula repair: the initial circumcision of the fistula is completed (dashed line) and then extended to separate the distal urethral stump and the bladder from underlying bone (dotted lines).
31. Figure 18.31 Circumferential fistula repair: the anterior (ventral) sutures have been inserted.
32. Figure 18.32 Circumferential fistula repair: after tying the ventral sutures, the posterior (dorsal) sutures are inserted and then tied.
33. Figure 18.33 Urethral reconstruction: a U‐shaped incision is made on the anterior vaginal wall, extending from the posterior edge of the fistula to the intended position of the external meatus.
34. Figure 18.34 Transvesical repair: the bladder is opened and a Millin’s retractor inserted.
35. Figure 18.35 Transvesical repair: the ureters have been catheterized and the fistula visualized with the aid of skin hooks.
36. Figure 18.36 Transvesical repair: the fistula is circumcised through the full thickness of the bladder wall.
37. Figure 18.37 Transvesical repair: further dissection of bladder wall from vagina is undertaken using a bistoury blade or Chassar Moir scissors.
38. Figure 18.38 Transvesical repair: the vagina is closed with a series of interrupted sutures, by working through the excised fistula track.
39. Figure 18.39 Transvesical repair: the bladder muscle is repaired with a layer of interrupted sutures working from the angles in towards the midline.
40. Figure 18.40 Transvesical repair: the mucosa and underlying superficial muscle are approximated with a continuous suture.
41. Figure 18.41 Transperitoneal repair: the incision extends from the dome around the fistula, resulting in a near bivalving of the bladder.
42. Figure 18.42 Transperitoneal repair: the fistula track is excised and further separation of bladder and vagina undertaken.
43. Figure 18.43 Transperitoneal repair: omental interposition flap; the omentum has been mobilized from the transverse colon and stomach and passed down the paracolic gutter to be placed over the vaginal closure.
Chapter 19
1. Figure 19.1 Single photon emission tomography/computed tomography allows for accurate localization of a right inguinal sentinel lymph node in a right lateral vulval cancer.
2. Figure 19.2 Gamma probe used to identify the area of greatest activity prior to surgery.
3. Figure 19.3 Sentinel incision (right) compared with crease incision in the left groin.
4. Figure 19.4 The triple incision technique: traditional Gateshead groin incision (right) and crease incision (left).
5. Figure 19.5 Butterfly skin incision.
6. Figure 19.6 Cutting the upper incision down to the external oblique aponeurosis.
7. Figure 19.7 Elevating the medial edge of the sartorius fascia and cleaning the femoral artery.
8. Figure 19.8 Clamping and dividing the saphenous vein below the cribriform fascia.
9. Figure 19.9 The completed groin dissection.
10. Figure 19.10 Clamping the inferior epigastric artery and Poupart’s ligament.
11. Figure 19.11 Removing the pelvic lymph nodes.
12. Figure 19.12 Repair of the inguinal ligament.
13. Figure 19.13 The vulval incision.
14. Figure 19.14 Completed repair of the vulval wound.
Chapter 21
1. Figure 21.1 Dividing the right ovarian ligament.
2. Figure 21.2 Identifying the uterine artery close to the pelvic sidewall.
3. Figure 21.3 Dividing the right uterine artery at its origin.
4. Figure 21.4 Identifying the ureteric tunnel.
5. Figure 21.5 (a and b) Separating the ureter from the roof of the ureteric tunnel.
6. Figure 21.6 Opening the space between the rectum and the vagina.
7. Figure 21.7 The rectum separated from the vagina, showing the arch of the uterosacral ligaments.
8. Figure 21.8 The position of the tissue clamps on the uterosacral (1) and cardinal (2) ligaments and the paracolpos (3).
9. Figure 21.9 Beginning of the pelvic node dissection.
10. Figure 21.10 The complete block of lymph nodes being removed from the external iliac vessels.
11. Figure 21.11 Completing the pelvic node dissection in the obturator fossa.
12. Figure 21.12 The Gyne Tube.
13. Figure 21.13 Comparison of relative anatomy of ureter and uterine artery between an abdominal and vaginal approach (a, artery; u, ureter).
14. Figure 21.14 Chrobak forceps.
15. Figure 21.15 Preparation of the vaginal cuff.
16. Figure 21.16 Vaginal incision.
17. Figure 21.17 Dissection of the rectum from the posterior vaginal wall.
18. Figure 21.18 Closure of the vaginal cuff.
19. Figure 21.19 Opening of the right paravesical space.
20. Figure 21.20 Joining the paravesical and pararectal spaces. Horizontal fascia exposed.
21. Figure 21.21 Displaying the right ureter.
22. Figure 21.22 Ligation and display of left uterine vessels.
23. Figure 21.23 Division of uterosacral ligaments.
24. Figure 21.24 Purse‐string suture to close the peritoneum.
Chapter 24
1. Figure 24.1 The limits of resection for (a) an anterior and (b) a total exenteration.
2. Figure 24.2 Packing the vagina.
3. Figure 24.3 Pelvic and para‐aortic node assessment.
4. Figure 24.4 Division of the round and infundibulopelvic ligaments and the beginning of the lateral pelvic dissection.
5. Figure 24.5 Deepening the lateral pelvic dissection to reveal the pelvic spaces.
6. Figure 24.6 The pelvic incision for an anterior exenteration.
7. Figure 24.7 Dividing the sigmoid colon with the GIA stapling device.
8. Figure 24.8 Exenteration clamps applied to the anterior division of the internal iliac arteries.
9. Figure 24.9 The perineal incisions for anterior and total exenterations.
10. Figure 24.10 Suture of the internal iliac arteries and lateral pelvic pedicle.
11. Figure 24.11 Development of the ‘omental pelvic floor’: (a) omental incision; (b) soft trampoline area.
Chapter 25
1. Figure 25.1 Incision for exposure of aorta and inferior vena cava.
2. Figure 25.2 Exposure of aortic injury.
Chapter 26
1. Figure 26.1 (a–c) Anastomosis of the ureter after either transection or resection of a short length of damaged ureter.
2. Figure 26.2 A correctly placed double pigtail stent (drawing kindly provided by Boston Scientific Corporation).
3. Figure 26.3 The psoas hitch.
4. Figure 26.4 The Boari–Ockerblad flap: developing the flap from the bladder wall.
5. Figure 26.5 The Boari–Ockerblad flap: suturing the flap to form a tube over the antiflux anastomosis.
6. Figure 26.6 Implantation of the ureter into the bladder wall.
7. Figure 26.7 The affected ureter is dissected free.
8. Figure 26.8 A cystotomy is created anteriorly.
9. Figure 26.9 Suture connected to the ureter is grasped by a Maryland dissector inserted through the urethra.
10. Figure 26.10 Placing of a double ‘J’ stent through the urethra.
11. Figure 26.11 Repair of the bladder using an Endo Stitch.
12. Figure 26.12 Bringing the ureters into an intraperitoneal position.
13. Figure 26.13 Choosing an ileal segment with a broad‐based arterial arcade.
14. Figure 26.14 Resecting the bowel segment with a GIA stapling device.
15. Figure 26.15 Reconstituting bowel continuity using the GIA stapling device.
16. Figure 26.16 Showing the isolated loop of bowel and the completed re‐anastomosed small bowel.
17. Figure 26.17 Joining the splayed out ends of the ureter and inserting the T tube.
18. Figure 26.18 Drawing the long arm of the T tube down the segment of the bowel.
19. Figure 26.19 Forming the ‘rosebud’ stoma.
Chapter 27
1. Figure 27.1 Dividing the appendix mesentery.
2. Figure 27.2 Removing the appendix.
3. Figure 27.3 Resection of a damaged segment of small bowel.
4. Figure 27.4 Suturing the serosa of the bowel segments.
5. Figure 27.5 Completing the serosal suture.
6. Figure 27.6 Apposing the mesenteric edges.
7. Figure 27.7 The site of incision for a temporary transverse colostomy.
8. Figure 27.8 Anchoring the loop of large bowel to the surface.
9. Figure 27.9 Dividing large bowel using the GIA stapling device.
10. Figure 27.10 Removing the skin disc at the stoma size.
11. Figure 27.11 Incising the abdominal wall fat, musculature and peritoneum.
12. Figure 27.12 (a) Removing the staple line and (b) suturing the edge to the skin.
13. Figure 27.13 Incising the ileum.
14. Figure 27.14 Forming a ‘rosebud’.
15. Figure 27.15 Apposing the small and large bowel.
16. Figure 27.16 Forming a stapled communication between large and small bowel.

Bonney’s Gynaecological Surgery

Preface

PART 1
General