4. Adnexa in Relation to Vaginal Surgery 19 Namita Grover, Shalini Rajaram Anatomy of Adnexa 19 Grades of Descent of Ovary 23

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1 contents Section 1: Surgical Anatomy of Female Genital Tract 1. Vulva: Anatomy, Blood Supply and Lymphatic Drainage 3 Asha Sharma, Amita Suneja Mons Pubis 3 Labia Majora 3 Labia Minora 3 Vestibule 3 Clitoris 4 Vaginal Orifice (Introitus) 4 Bulbs of the Vestibule 4 Greater Vestibular Glands (Glands of Bartholin) 5 Changes in Vulva with Age and Parity 5 Blood Supply 5 Nerve Supply 6 Lymphatic Drainage 6 2. Pelvic Diaphragm and Supports of Uterus 8 Shalini Rajaram Bony Pelvis 8 Muscles of the Pelvic Diaphragm 8 Levator Ani Muscles 8 Levator Plate 10 Nerve Supply 10 Perineal Membrane (Urogenital Diaphragm) 10 Perineal Body 10 Endopelvic Fascia and the Pelvic Ligaments 10 Cervical and Uppervaginal Support 11 Midvaginal Support 11 Distal Vaginal Support Uterus and Cervix: Relations, Blood Supply and Lymphatic Drainage 14 Neerja Goel, Ruchika Garg General Description 14 Structure 14 Changes in the Uterus with Age and Parity 15 Position of the Uterus 15 Supports of Uterus 16 Relations of the Uterus 16 Vascular Connections 16 Lymphatic 17 Clinical Correlations Adnexa in Relation to Vaginal Surgery 19 Namita Grover, Shalini Rajaram Anatomy of Adnexa 19 Grades of Descent of Ovary Applied Anatomy of Ureter in Relation to Vaginal Surgery 25 Shalini Rajaram, Sandhya Jain Embryology 25 Anatomy 25 Identification and Mobilization of the Ureter 26 Incidence of Injury and Conditions Making it Prone to Injury 27 Postoperative Recognition of Injury 30 Section 2: Preoperative Care, Operation Theater, Sutures and Instruments 6. Current Concepts in Preoperative Care 35 Rashmi Malik Choosing the Best Treatment Option 35 Consent 35 Preoperative Evaluation and Planning 35 Preoperative Preparation Thromboprophylaxis for Vaginal Surgery 43 Neerja Goel, Gunjan Singh Patient Factors 43 Recommendations for Thromboprophylaxis 43 General Recommendations 44 Specific Considerations during Gynecologic Surgery 44 Additional Coexisting Medical Conditions 44 Long Distance Travel after Surgery 44 Drugs used for Thromboprophylaxis 45 Patient Instructions Regarding Wearing the GCS 47 Intermittent Pneumatic Compression 47

2 xviii State-of-the-Art: Vaginal Surgery 8. Reducing Surgical Risk for HIV and Hepatitis B Infection 49 Shalini Rajaram, Asha Sharma Definition of Health Care Personnel and Exposure 49 Risk for Occupational Transmission 49 Precautions to Prevent Transmission of HIV and HBV 50 Precautions for Invasive Procedures 51 Special Precautions While Operating Upon a known HIV +Ve Patient 52 Sterilization and Disinfection 53 Management of Exposures 54 Summary of Management of Occupational Blood Exposures Operating Tables, OT Lighting and Positions for Vaginal Surgery 60 Medha Mohta, Tarun Bhagchandani Operating Tables 60 Control Mechanisms 61 Accessories 61 Positioning on Operating Table 63 Cleaning and Disinfection 65 Operating Theater Lighting Electrosurgical Units in Vaginal Surgery 69 Manpreet Singh, Namita Grover History of Electrosurgery 69 Fundamentals of Electrosurgery 69 Current Density and Electrode Geometry 71 Monopolar Electrosurgery 71 Bipolar Electrosurgery 72 Biological Effects of Electricity 72 Generators 73 Desiccation Techniques 73 Fulguration Techniques 74 Argon Beam Coagulator for Controlled Fulguration 74 Principles of Electrosurgery in Laparoscopy 75 Hysteroscopy 75 Loop Electrosurgical Excision Procedure 76 Leep Electrodes 78 Letz Conization 78 Recommendations to Avoid Electrosurgical Patient Complications Sutures and Suturing Techniques 80 Nitin Agarwal, Anshul Grover, Neerja Goel Ideal Suture Characteristics 80 Essential Suture Characteristics 80 Other Suture Characteristics 80 Suture Size 81 Absorbable Sutures 81 Nonabsorbable Sutures 81 Monofilament Versus Multifilament Sutures 81 Absorbable Sutures 82 Nonabsorbable Sutures 83 Suturing Techniques in Clinical Practice 84 Approximation of Cut Edges 84 Transfixation of Various Pedicles 87 Obliteration of Dead Space 87 Knot Tying Techniques 88 Alternative Methods of Wound Closure Instruments for Vaginal Surgery 91 Shalini Rajaram, Harsha Sharma, Nitin Agarwal Lighting 91 Operating Table 91 Retractors 92 Speculums 94 Hysterectomy Clamps 94 Section 3: Anesthesia, Blood Transfusion and Sterilization Techniques 13. Anesthetic Considerations for Vaginal Surgery 105 Ashok Kumar Saxena, Raman Azad, Nitin Jain Rationale for using Regional Anesthesia 105 Neuraxial Blocks for Vaginal Surgeries 105 Other Regional Techniques 109 Pudendal Nerve Block 110 Perineal Infiltration 111 General Anesthesia for Vaginal Surgeries 111 Postoperative Pain Relief Blood Transfusion: Guidelines, Recommendations and Complications 114 Nitin Jain, Ashok Kumar Saxena Indications for Transfusion 114 Autologous Blood Transfusion 114 Storage of Blood 115 Complications 115 Blood and Blood Component Therapy 117

3 Contents 15. Sterilization and Disinfection of Surgical Instruments and Endoscopes 120 AK Sethi, Deepti Agarwal Terminology 120 Rationalized Approach to Sterilization and Disinfection 121 Methods of Sterilization and Disinfection 124 Ethylene Oxide Gas 127 Hydrogen Peroxide Gas Plasma 128 Peracetic Acid 128 Formaldehyde 128 Ionizing Radiations 130 Glutaraldehyde 130 Orthophthalaldehyde 131 Alcohol 131 Chlorine and Chlorine Compounds 131 Superoxide Water 131 Phenolic Compounds 132 Boiling 132 Disinfection and Sterilization of Endoscopes 132 Disinfection and Sterilization of Equipment Related to Obstetrics and Gynecology 133 Quality Control 134 Section 4: Vulval Surgery 16. Vulval Disorders (Non-neoplastic and Premalignant), Biopsy Techniques and Wide Local Excision 141 Sudha Prasad, Shakun Tyagi International Society for Study of Vulval Disorders Classification of Non-Neoplastic Epithelial 141 International Society for Study of Vulval Disorders (2004) Classification of Squamous Vin 142 Vulval Biopsy 144 Treatment of Non-neoplastic and Premalignant Disorders of Vulva Hymenectomy, Labial Fusion Release, Introital Widening, Schuchardt s Incision 149 Neerja Goel, Rajni Gill Hymenectomy 149 Labial Fusion Release 150 Schuchardt s Incision 151 Introital Widening Bartholin s Gland Surgery: Incision and Drainage, Marsupialization and Excision 156 Rachna Agarwal, Gayathri R Background 156 Anatomy 156 Epid Emiology 156 Pathology 157 History 157 Physical Examination 157 Laboratory Studies 157 Differential Diagnosis 158 Management of Bartholin Gland Cyst and Abscess 159 Surgical Techniques for Treatment of Cyst/Abscess 160 Word Catheter Placement 160 Marsupialization 161 Biopsy/Excision 162 Technique of Excision 163 Pregnancy Simple Vulvectomy for Intraepithelial Neoplasia 166 Amita Suneja, Richa Agarwal Surgical Anatomy 166 Types of Vulvectomy 167 Simple Vulvectomy Radical Vulvectomy with Groin Dissection 173 K Chitrathara, Rema P Radical Vulvectomy 173 Management of Primary Lesion 173 Surgical Technique 174 Radical Vulvectomy 174 Groin Dissection 174 Technique Vestibulectomy for Vulvodynia 183 Rachna Agarwal, Pushpanjali Rai Dysesthetic Vulvodynia 183 Vulvar Vestibulitis Syndrome 184 Treatment for Vulvar Vestibulitis Syndrome 185 Section 5: Vaginal Surgery for Prolapse and Reconstructive Vaginal Surgery 22. Current Concepts of Pelvic Organ Prolapse: Evaluation and Choice of Procedure 193 KC Singh, SD Barman Concepts of Surgical Management 193 Surgery for Various Components of Pop 194 Laparoscopic Surgery 195 xix

4 xx State-of-the-Art: Vaginal Surgery 23. Surgical Correction of Anterior Compartment Defects 197 Sumita Mehta Defects of Anterior Vaginal Wall Support Site Specific Defect Theory 197 Types and Identification of Defects in Anterior Vaginal Wall 197 As a Part of Procidentia/Apical Prolapse Surgical Correction of Posterior Compartment Defects 205 Neerja Goel 25. Mesh in Vaginal Surgery 212 Bindiya Gupta, Shalini Rajaram Vaginal Mesh for Pelvic Organ Prolapse 212 Absorbable Mesh 213 Surgical Procedure for Perigee 214 Long-Term Complications Manchester Repair 218 Kiran Guleria Indications and Contraindications 218 Principles of Manchester/Fothergill Repair 218 Steps of Surgical Procedure 218 Complications Sacrospinous Hysteropexy 225 Sandhya Jain Technique of Hysteropexy (Combined with Anterior Colporrhaphy) Vaginal Hysterectomy and Enterocele Repair 228 AG Radhika Principles of the Surgery 228 Preoperative Preparation 228 Position of the Patient 228 Technique of Total Vaginal Hysterectomy 228 Enterocele Repair Sacrospinous Colpopexy 236 KC Singh, SD Barman Anterior Vaginal Wall Prolapse 236 Posterior Vaginal Wall Prolapse 236 Apical Prolapse 236 Use of Mesh 237 Sacrospinous Colpopexy 237 When Combined with Vaginal Hysterectomy 237 Posthysterectomy Apical Prolapse 239 Complications Posthysterectomy Vault Prolapse 241 Sumita Mehta, Ritu Khatuja Anatomy 241 Pathophysiology 241 Methods of Surgical Treatment 242 Transvaginal Sacrospinous Colpopexy Complete Perineal Tear 253 Harsha Khullar, SK Bhandari, Kanika Jain, Geeta Mehdiratta Definition and Classification of Perineal Tear 253 Mechanism of Continence 254 Why is it Important to Repair a Complete Perineal Tear? 255 Clinical Presentation and Recognition 255 Repair of 3rd and 4th Degree Perineal Tear Identification of Extent of Tear 255 Timing of Repair 255 Preoperative Preparation 256 Anesthesia 256 Suture Material 256 Methods of Repair of Complete Perineal Tear 256 Layered Method 256 Warren Flap Repair 257 Noble-Mengert-Fish Operation 257 Overlapping Sphincteroplasty 258 Postoperative Management 258

5 Contents xxi 32. Radical Vaginal Hysterectomy 261 Partha Basu Indications for Surgery 261 Surgical Technique Vaginectomy 272 K Chitrathara, Namrata Kachhara Vaginal Intraepithelial Neoplasia and Microinvasive Vaginal Carcinoma Colpocleisis 280 Neerja Goel, Seema Ummat Evaluation 280 Anesthesia 280 Partial Colpocleisis 281 Complete Colpocleisis 282 Complications 284 Outcome Culdocentesis and Colpotomy 286 Shalini Jain Culdocentesis 286 Interpretation 287 Colpotomy Skin and Muscle Grafts 289 Upender Sharma Congenital Absence of the Vagina 289 Vaginal Reconstruction after Ablative Surgery 293 Gracilis Flaps 293 Lymphedema of the Vulva Creation of Neovagina 297 Gita Radhakrishnan, Gunjan Singh Vaginal Agenesis 297 Methods for Creation of Neovagina 298 Mcindoe Procedure 298 Williams Vulvovaginoplasty 300 Bowel Vaginoplasty Excision of Transverse and Longitudinal Vaginal Septum 304 Sumita Mehta Transverse Vaginal Septum Fallopian Tube Prolapse and Tubal Ligation 310 Shalini Rajaram, Namita Grover Surgical Correction of Fallopian Tube Prolapse 310 Tubal Ligation: Vaginal Route 311 Section 6: Surgery of Cervix 40. Colposcopy 317 Sumita Mehta, Shruthi Bhaskaran, Vijay Zutshi Principle and Technique of Colposcopic Examination Cervical Biopsy Techniques 328 Neerja Goel, Madhu Bagaria Pap s Smear 328 Punch Biopsy 330 Wedge Biopsy 331 Cone Biopsy 331 Loop Electrosurgical Excision Procedure Ablative (Cryotherapy) and Excision (LEEP) Procedures for CIN 334 Neerja Bhatla, Shilpa Singla Ablative Techniques 334 Excisional Techniques 336 Loop Electrosurgical Excision Procedure 336

6 xxii State-of-the-Art: Vaginal Surgery 43. Cervical Incompetence and Cervical Cerclage Techniques 341 Kanwal Gujral, Nidhi Khera, Chandra Mansukhani Introduction and Historical Perspective 341 Shirodkar s Cerclage 342 Emergency Cerclage 347 Transabdominal Cervicoisthmic Cerclage 348 Lash and Lash Procedure 351 Laparoscopic Cervicoisthmic Cerclage 351 Section 7: Non-Descent Vaginal Hysterectomy 44. Preoperative and Peroperative Assessment 355 Surveen Ghumman Preoperative Ultrasound for Assessment 355 MRI 355 Laparoscopic Assessment 355 Peroperative Assessment Under Anesthesia 356 Peroperative Score Basic and Clampless Techniques 359 Shalini Rajaram, Neerja Goel, Geetika Trivedi Instruments 360 Operative Technique Position of Patient 361 Clampless Technique for NDVH Aqua Dissection in NDVH 370 Rachna Agarwal 47. Vessel Sealing System in NDVH 375 Sumita Mehta LigaSure Vessel Sealing System (Biclamp) Volume Reductive Vaginal Hysterectomy 378 Neerja Goel, Shalini Rajaram, Rachna Agarwal Discussion Technique of NDVH in Nulliparous, Obese and Women with Previous Surgeries 386 Shirish S Sheth, Kurush Paghdiwalla 50. Vaginal Oophorectomy 402 Namita Grover, Shalini Rajaram Prerequisites for Oophorectomy 402 Assessing Feasibility for Oophorectomy 402 Contraindications for Oophorectomy 403 Operative Technique 403 Complications of Surgery 404 Newer Methods Laparoscopic and Vaginal Adnexectomy 407 Alka Kriplani, Sumana G, Pradeep Kumar Garg Indications for Laparoscopic Assistance for Adnexectomy 407 Laparoscopic Adnexal Removal 408 Vaginal Endoscopic Oophorectomy 410 Section 8: Genital Fistulae, Rectal Prolapse and Stress Urinary Incontinence 52. Vesicovaginal Fistula 415 Rachna Agarwal, Shalini Rajaram, JB Sharma Presentation 416 Diagnostic Procedures 417 Treatment 417 Surgical Therapy 418 Electrocautery 424 Postoperative Details 426 Complications Rectovaginal Fistulae 430 Sanjay Gupta

7 Contents 54. Rectal Prolapse with Anal Incontinence 439 Nitin Agarwal, Arun Gupta 55. Stress Urinary Incontinence 444 Sumita Mehta, Shruthi Bhaskaran, Shalini Rajaram Terminologies Approved by ICS 444 Stress Urinary Incontinence 445 Pathophysiology of SUI 445 Management of SUI 446 Surgical Management of SUI 446 Surgical Technique 447 Techniques 449 Section 9: Postoperative Care 56. Postoperative Management in Vaginal Surgery 459 Shalini Rajaram, Rashmi Khatri 57. Complications of Vaginal Surgery 466 Vijay Zutshi, Sumita Mehta Complications of Various Surgical Procedures 470 Vulva 475 Endoscopic Surgeries 476 xxiii Index 479

CHAPTER 13 Gynaecological Procedures

CHAPTER 13 Gynaecological Procedures CHAPTER 13 Propunere noua clasificare proceduri folosind codificarea ICD-10-AM versiunea 3, 30 martie 2004 Gynaecological Procedures BLOCK 1240 Application, insertion or removal procedures on ovary 35518-00