This book is dedicated to the memory of Victor Bonney. It is also dedicated to Jane, Vicki, Roopal and Maggie for their support, understanding, patience and love, which they have shown us in our lives together.

Preface to the eleventh edition

Next year, Bonney’ s Gynaecological Surgery celebrates its 100th birthday, the first edition having been published in 1911 by Comyns Berkeley and Victor Bonney. In those 100 years, major advances in anaesthetics, transfusion services, antibiotics and instrument development have not only resulted in safer surgery for the patient but also have allowed increasing innovation in surgical procedures.

In gynaecology this is exemplified by the almost routine use of minimal access techniques in everyday practice, as well as the increasing surgical options in the urological and oncological subspecialties.

Despite these advances, many of the basic surgical principles remain unchanged, and this is highlighted by the retention in this edition of some of Bonney’ s original drawings 100 years on.

Three of the current editors have worked in the department of gynaecological oncology in Gateshead started by Stanley Way in 1948. It is therefore not surprising that this 11th edition reflects an evolution rather than a revolution from the 9th edition edited by John Monaghan in 1986, the preface of which follows this current preface.

As with previous editors, I have taken the liberty of removing elements from the last edition which are no longer relevant to current practice. The format has also changed and the current edition is divided into three sections. The first section, covering general principles and basic techniques, lays the foundation for any trainee wishing to develop into a competent gynaecological surgeon. The second section, presented by anatomical site, covers the common procedures undertaken in day-to- day benign gynaecology. The last section recognizes the two surgical subspecialties of urogynaecology and gynaecological oncology. Although several of the procedures described are currently undertaken by the experienced generalist as well as the specialist, this is becoming less common, especially in cancer surgery. This section also covers surgery for other sites that may arise during gynaecological surgery, either as a planned procedure or as the result of an unexpected finding or complication. Although rarely encountered in general gynaecology, and usually within the remit of one’ s surgical colleagues, it is important to understand the principles of the procedures involved.

As the senior editor I am indebted to John Monaghan and Raj Naik for their continued support and I am extremely grateful to Nick Spirtos for agreeing to join us in editing this current edition. His skills in both laparoscopic and radical open surgery are recognized internationally and his methodical approach to these procedures is reflected in his contributions to the book. I also wish to thank David Richmond and Gillian Fowler for their contributions to the section on urogynaecology.

Lastly, my thanks to Wiley- Blackwell and especially to publisher Martin Sugden for inviting me to lead on this edition of Bonney’ s Gynaecological Surgery . The support and encouragement of their team along with that of Lindsey Williams has made the whole process a pleasure.

Tito Lopes

Truro, Cornwall

September 2010

Preface to the ninth edition

The influence of Victor Bonney and his pupils upon gynaecological surgery has developed from the publication of the first edition of A Textbook of Gynaecological Surgery in 1911. The first to the fourth editions were the results of the collaboration of Bonney with Sir Comynus Berkeley. Following the death of the latter, Victor Bonney produced the fifth and sixth editions alone. Bonney’ s pupils Howkins and Macleod then produced the seventh edition. The death of Macleod signalled virtually the end of those practising surgeons who had been trained by Victor Bonney. The very successful eighth edition was prepared by John Howkins and Sir John Stallworthy. These two great figures of Commonwealth Gynaecology had worked together as junior colleagues during the last years of Bonney’ s clinical career.

When the eighth edition was published in 1974 many changes were incorporated into the text. However, in the next 10 years, an enormous number of new developments have occurred, possibly the greatest being a resurgence of interest in gynaecological surgery and the growth and establishment of gynaecological oncology as a recognized subspecialty. The present editor has only a tenuous link with Victor Bonney in that he has been greatly influenced in his career by the late Dr A.F. Anderson of Edinburgh and by Mr Stanley Way, both of whom spoke frequently with great affection and reverence of the master surgeon. Indeed it was Way who introduced me to the Bonney scissors, which instruments the reader will see referred to throughout this edition.

When asked by the medical editor of Bailli è re Tindall for my opinion of the eighth edition of Bonney’ s Gynaecological Surgery some 2 years ago, I replied that I thought that it was undoubtedly the leading textbook of gynaecological surgery in the world, but would nevertheless benefit from a major revision. I also jokingly said ‘Give me five years and I will do it for you’. The prompt rejoinder was ‘We will give you two years if you will take it on’. Little did I know at the time that I had been ‘set up’, as the Americans say. I felt hesitant at the prospect of making major changes to such a well- established book but realized that large - scale changes were necessary and also that if modern materials and instruments were to be incorporated, most of the drawings would require reworking.

It was also clear that no single surgeon could encompass all the skills of modern gynaecological surgery and that I would need assistance with three major sections. I have been delighted with the response and the quality of the contributions from Sir Rustam Feroze, Stuart L. Stanton and Professor John R. Newton. I am indebted to them.

Victor Bonney had skills far beyond those of mere mortals; to be able to operate to the highest level and then to be capable of transferring those ideas to paper as the most clear and concise drawings was an amazing talent. I have been especially fortunate in obtaining the services of Mr Douglas Hammersley, once head of graphics at the University of Newcastle upon Tyne, to illustrate all the chapters which have been rewritten. Doug has now moved to Norfolk to be a little closer to his chief interest, that of observing and drawing butterflies. I am sure that the reader will appreciate the outstanding quality of the drawings in this new edition, in particular the way in which they have captured the movement and dynamism of surgery. I am totally indebted to Doug for bringing to life my attempts at surgery.

This book is very much my own; the philosophy of the surgery is entirely mine and the responsibility for making such drastic alterations to this classic text are also mine. I do not make apologies as I feel that Bonney would have approved because I have attempted to keep his beloved gynaecological surgery moving forward. Indeed, even between the beginning and end of the 2- year writing period, new developments have occurred which have had to be incorporated into the text.

I have attempted to show that by adopting an economy of movement in surgery as well as in the text, operations can be performed cleanly and neatly, without ritual. Operations should flow with a style and a natural pace, rather like a well- choreographed dance. There should be no great crises and the procedure should not be performed to the point of total exhaustion for the surgeon and his staff. I have tried to show the enormous enthusiasm which I have for gynaecological surgery and the way in which I feel that it can become a source of great satisfaction and pride. I hope that a little of this enthusiasm is transmitted to the reader and that this book will bring forth new energies for the development of our fascinating subject.

The updating of this text has been for me an enormous honour and a great pleasure. I have had to clarify my thoughts on many aspects of surgery and take bold decisions to cut out large quantities of the previous edition, particularly the results and complications sections, which although historically interesting are not relevant to modern- day practice except as records of the past. Their repetition would simply occupy space.

This ninth edition hopefully reflects the most modern aspects of gynaecological surgery as well as retaining all that is still valuable and relevant from past editions. It also emphasizes the continuing role of gynaecological surgery in the management of a multitude of gynaeco-logical conditions, particularly highlighting the place of surgery in cancer care and the newer surgical technique relating to the infertile woman. The place of new tools such as the laser and staples has been added to the more standard instrumentation.

I would like to thank Bailli è re Tindall and in particular Dr Geoffrey Smaldon for his constant support. To all those who have assisted, guided and encouraged me during my career, occasionally allowing this stubborn, single- minded Yorkshireman to have his way, I am grateful.

Very special thanks must go to Mr Alan Evans who, as my senior registrar, painstakingly read all my first drafts and attempted to bring a Welsh view of the English language to bear upon my efforts.

I stand in great awe at the end of a long line of illustrious names in gynaecological surgery. I hope that I have done them justice in this the ninth edition of Bonney’ s Gynaecological Surgery.

John M. Monaghan

Newcastle upon Tyne

April 1986

Part 1



Introduction and prologue

Surgery remains only as safe as those wielding the scalpel.

Tito Lopes


Surgical training

Surgical training in gynaecology has seen dramatic changes in both the UK and the USA over the last 20 years.

When the current editors were in training, there were no restrictions to the number of hours that they could be asked to work. It was common to be resident on call every third night in addition to daytime work, which often resulted in a working week in excess of 110 hours. In the UK, adoption of the European Union Working Time Directive will mean that trainees will legally be allowed to work only 48 hours per week. In the USA, the working week for residents is limited to 80 hours.

Although the reduction in working hours is important for one’s work–life balance, it has inevitably had a major impact on surgical training. The concept of the surgical team or firm to which a trainee was attached has all but disappeared. The introduction of shift systems has made it difficult, and in some cases impossible, for trainees to attend the surgical and clinical sessions of their team.

At the same time, there has been a marked reduction in the number of hysterectomies performed as a result of more conservative management options for dysfunctional uterine bleeding. In the 9-year period from 1995 to 2004, there was a 46% reduction in the number of hysterectomy operations performed in NHS hospitals in England (Hospital Episode Statistics). In 2003, at the ‘Fellows’ ceremony at the Royal College of Gynaecologists, the then President stated that not every specialist gynaecologist would be expected to be able to perform a hysterectomy. With the increasing use of laparoscopic surgery in elective gynaecology, including for hysterectomy, the ‘open’ approach to gynaecological surgery, the surgical ‘bread and butter’ for trainees, is also on the decline. Equally, a large number of ectopic pregnancies are now managed conservatively so that trainees are lacking exposure to emergency laparoscopic surgery for tubal pregnancies.

Gynaecology training

Current training in the UK is a competency-based process and it is envisaged that the majority of trainees will take 7 years to complete the programme. As part of the training, the trainee must be competent in opening and closing a transverse incision before commencing his or her third year but need only be assessed for opening and closing a vertical abdominal incision in the advanced module for benign surgery in years 6 and 7. In these last two years the trainees are obliged advanced training skills modules, which include separate modules for benign abdominal, vaginal, laparoscopic and hysteroscopic surgery.

Basic skills and training opportunities

Trainees wishing to develop as gynaecological surgeons should attend appropriate courses including cadaver and live animal workshops. However, they are no substitute for learning the basic surgical skills, and picking up good habits, early in training; bad habits are difficult to lose at a later stage. As assistants, they should question any variations in technique among the surgeons. As surgeons, they should review every operation they perform to assess how they could have done better.

In relation to laparoscopic surgery, there is no excuse for trainees not practising with laparoscopic simulators that are often readily available or easy to construct. It is readily apparent to trainers which trainees have spent adequate time on simulators.

Sadly, a consequence of the new training is an inevitable lack of knowledge and experience of the ‘unusual’, with the all too frequent result of difficulties for both the patient and the surgeon. These difficulties are often manifest in an almost complete failure to appreciate the wide range of possibilities for management. Previous editors of this text have advocated that any surgery should be tailored to the specific needs of the patient and her condition. Unfortunately, when modern patients are managed they are in real danger of being treated by surgeons with a limited experience and a narrow range of skills which may be applied in a ‘one-size-fits-all’ pattern. In this text, we have attempted to provide a wide range of options for management which we would encourage all trainees to practise assiduously in order to give their patients the very best possible chances of a successful outcome.

Despite the recent changes in gynaecological training, the essence of surgery remains essentially unchanged. The editors have felt it appropriate in this 11th edition to retain the prologue written for the 9th and 10th editions by JM Monaghan based on that of the 1st edition of this series, A Textbook of Gynaecological Surgery, published in 1911 by Comyns Berkeley and Victor Bonney. It remains just as relevant today as it was a century ago.

Prologue: after Comyns Berkeley and Victor Bonney

The bearing of the surgeon

A surgeon when operating should always remember that the character of the work of his subordinates will be largely influenced by his own bearing. Whilst it is impossible to lay down definite rules suitable for all temperaments, nevertheless there are certain considerations which will prove useful to those embarking on a gynaecological career. Anyone who has taken the trouble to study the work of other operators cannot fail to have observed how variously the stress and strain of operating is borne by different minds and will deduce from a consideration of the strong and weak points of each operator some conception of the ideal.

The thoughtful surgeon, influenced by this study, will endeavour so to discipline himself so that he will strive constantly to achieve the ideal. By so doing, he will encourage all who work in the wards and theatres with him – young colleagues in training, anaesthetists, nurses, theatre assistants and orderlies – to appreciate the privileges and responsibilities of their common task. Expert co-ordinated teamwork is essential to the success of modern surgery. This teamwork has resulted in a significant lowering of operative morbidity and mortality.

However, it is important to recognize the enormous contribution to the safety of modern surgery made by other disciplines, especially anaesthesiology. The preoperative assessment and the postoperative care carried out by the anaesthetist has rendered surgery safer and has also allowed patients who would not in the past have been considered eligible for surgery to have their procedures performed successfully. The role of specialties such as haematology, biochemistry, microbiology, radiology, pathology and physiotherapy are also well recognized.

Bonney maintained that the keystone of a surgeon’ s bearing should be his self-control; and whilst it is his duty to keep a general eye on all that takes place in the operating theatre and without hesitation correct mistakes, he should guard against becoming irritable or losing temper. The surgeon who when faced with difficulties loses control has mistaken his vocation, however dextrous he may be, or however learned in the technical details of the art. The habit of abusing the assistants, the instruments or the anaesthetist, so easy to acquire and so hard to lose, is not one to be commended; the lack of personal confidence from which such behaviour stems will inevitably spread to other members of staff, so that at the very time the surgeon needs effective help it is likely to be found wanting. However, the converse of accepting poor standards of care and behaviour is not to be condoned. The continual presentation of inadequately prepared instrumentation should not be accepted. There is little excuse for staff or equipment to arrive in theatre in a state ill prepared for the task ahead. The whole team should look forward to a theatre session as a period of pleasure, stimulation and achievement, not as a chore and a period of misery to be suffered. The surgeon should also remember that he is on ‘display’ and his ability to cope with adversity as well as his manner when the surgery is going well will be keenly observed. The surgeon should teach continuously, pointing out to assistants and observers the small points of technique as well as related facts to the case in hand.

Bonney enjoined that the surgeon should not gossip; the present editors feel that day-to-day chitchat is not out of place in the operating theatre and is to be preferred to the media view of an operating theatre as a place of knife-like tension fraught with grave interpersonal relationships. However, the mark of the good surgeon and his team is that, at the time of stress, the noise level in theatre should fall rather than rise, as each member of the team goes about his or her task with speed and efficiency.

It is inevitable that at some point the surgeon will come face to face with imminent disaster; even the most stalwart individual will feel his heart sink at such a moment. The operator should always remember that at such moments if basic surgical principles are applied quickly and accurately the situation will be rapidly rescued. Hesitation and uncertainty will all too often terminate in disaster. A sturdy belief in his own powers and a refusal to accept defeat are the best assets of a calling which pre-eminently demands moral courage.

Before operating the surgeon should prepare by going over in his own mind the various possibilities in the projected procedure, so that there may be no surprises and he may all the better meet any eventuality. Likewise following the procedure it is valuable to go over in one’ s mind every step in the operation in order to analyse any deficiencies and difficulties experienced; it is only by this continuous self-assessment and analysis that the surgeon can from his own efforts improve his practice.

It is of increasing importance that the surgeon understands the need for meticulous record-keeping in order to build a comprehensive database for future analysis. The modern surgeon has to continually examine his and others’ work in order to practise to the highest possible standards. More and more guidelines are being generated; the surgeon has to be sure that his work meets the quality requirements of modern practice. Patients, purchasers and professional bodies wish to be able to access the best possible practices. Transparency of standards is essential to modern medical practice. The high – quality surgeon has little to fear from the implementation of guidelines and should look upon these times as opportunities for developing the highest quality of care.

Surgery is physically and mentally tiring. The surgeon should be sure to be adequately equipped in both these areas to meet the demands of theatre. It is important to remember that driving the staff on for long, tiring sessions is counterproductive; there is little merit in performing long procedures with an already exhausted staff. The surgeon’s hands and mind become less steady, his assistants less attentive and the nurses tired and disillusioned. It is under these circumstances that mistakes occur. It is important, however, not to be dogmatic about the ideal length either of individual operations or of operating lists. A full day in the operating theatre may suit one surgical team but be anathema to another.

Speed in operating

Speed, as an indication of perfect operative technique, is the characteristic of a fine surgeon, as striving for after-effect is the stock-in-trade of the charlatan. An operation rapidly yet correctly performed has many advantages over one as technically correct yet laboriously and tediously accomplished. The period over which haemorrhage may occur is shortened, the tissues are handled less and are therefore less bruised, the time the peritoneum is open and exposed is shortened, the amount and length of anaesthesia is shortened and the impact of the operative shock, which is an accumulation of all these factors, is lessened. Moreover, less strain is put upon the temper and legs of the operator and his assistants with the result that the interest of the latter and the onlookers is maintained at the highest level.

However, this speed must be tempered with attention to detail, particularly of haemostasis, and by a conscious effort not to unnecessarily handle tissue.

Operative manipulation

The surgeon should continually endeavour to reduce the number of manipulations involved in a procedure to the absolute minimum consistent with sound performance. If an operation is observed critically, one is struck by the vast number of unnecessary movements performed, the majority of which are due to the uncertainty and inexperience of the operator. In older surgeons, unless care is taken to analyse these movements and eliminate them they will become part of the habits and ritual of the procedure.

Minimizing trauma is of fundamental importance for uncomplicated wound healing. The art of gentle surgery must be developed (Moynihan). Sadly, many surgeons achieve speed by being rough with tissue, particularly by direct handling. This must be avoided at all costs, and the temptation to tear tissue with the hands rather than to delicately incise and dissect with instruments is to be eschewed. All operative manipulations should be gentle; force is occasionally essential but should be applied with accuracy, only to the tissue to be removed and for limited periods of time. The surgeon who tears and traumatizes tissue will see the error of his ways in the long recovery periods that his patients require and in the high complication rate.

Moynihan spoke in 1920 at the inaugural meeting of the British Association of Surgeons on ‘The Ritual of a Surgical Operation’, stating that ‘he [the surgeon] must set endeavour in continual motion, and seek always and earnestly for simpler methods and a better way. In the craft of surgery the master word is simplicity.’

Further reading

Berkeley C, Bonney V. A Text-book of Gynaecological Surgery. London: Gassell and Company, 1911. See

Hospital Episode Statistics. See /

Moynihan BGA. The ritual of a surgical operation. Br J Surg 1920; 8: 27–35.