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Te Linde's Operative Gynecology TWELFTH EDITION

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When you have to be right

Te Linde’s Operative Gynecology, Twelfth Edition, remains your authoritative resource on the comprehensive perioperative care of gynecologic patients. New features in this edition include a primer on anesthesia, a chapter on positioning for pelvic surgery, a practical review of pediatric gynecology, and a section on the use of surgical instruments. All chapters have been updated to reflect contemporary gynecologic practice and the latest minimally invasive surgical approaches. New illustrations are included and each chapter includes step-by-step descriptions of surgical techniques. Today’s best surgeons and teachers offer a readable, intuitive, and concise reference for trainees as well as the experienced gynecologist.

Features include:

The same readable, easy-to-digest presentation you’ve come to expect from Te Linde’s.

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More than 1,300 color illustrations, photographs and line drawings.

NEW

A completely restructured table of contents that reflects the needs of today’s novice and experienced surgeons – ideal for quick reference and as a clinical refresher.

NEW

• An intuitive, chronological structure, covering relevant topics from preoperative preparation through postoperative care, as well as an expansive section on gynecologic procedures and surgical management of selected conditions. • The same readable, easy-to-digest presentation you’ve come to expect from Te Linde’s. • Expanded “Steps in the Procedure” boxes are supplied for all surgical chapters – a favorite feature that provides clear, easy-to-follow roadmaps for each procedure.

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Te Linde's Operative Gynecology

TWELFTH EDITION

by Victoria L Handa and Linda Van Le

ISBN 978-1-4963-8644-1 Pages 848 Price £143.00 / €164.00 Sample Chapter 1 Preview

When you have to be right

CONTR I BUTOR S

Melinda G. Abernethy, MD, MPH Associate Professor Department of Obstetrics and Gynecology Director, Division of Female Pelvic Medicine and Reconstructive Surgery Western Michigan University Homer Stryker MD School of Medicine Kalamazoo, Michigan Nadeem R. Abu-Rustum, MD Chief Attending

Vance A. Broach, MD Assistant Attending Gynecology Service, Department of Surgery Memorial Sloan Kettering Cancer Center Assistant Professor Department of Surgery Weill Cornell Medical College New York, New York Jubilee Brown, MD Professor and Associate Director Gynecologic Oncology Levine Cancer Institute, Atrium Health Charlotte, North Carolina Amy G. Bryant, MD, MSCR Associate Professor Division of Family Planning Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina James J. Burke II, MD Associate Professor The Donald G. Gallup, MD, Scholar of Gynecologic Oncology Director Gynecologic Oncology Mercer University School of Medicine Savannah, Georgia Ronald T. Burkman, MD Professor Emeritus Department of Obstetrics and Gynecology Tufts University School of Medicine Division of Minimally Invasive Surgery Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina Paula M. Castaño, MD, MPH Associate Professor Department of Obstetrics and Gynecology Columbia University Irving Medical Center New York-Presbyterian Hospital New York, New York Baystate Medical Center Springfield, Massachusetts Erin T. Carey, MD Assistant Professor Division Director

Gynecology Service, Department of Surgery Memorial Sloan Kettering Cancer Center Professor Department of Surgery Weill Cornell Medical College New York, New York Marisa R. Adelman, MD Assistant Professor Division of General Gynecology Department of Obstetrics and Gynecology University of Utah School of Medicine Salt Lake City, Utah Arnold P. Advincula, MD, FACOG, FACS Levine Family Professor of Women’s Health

Vice-Chair, Department of Obstetrics & Gynecology Chief of Gynecology, Sloane Hospital for Women Columbia University Medical Center New York-Presbyterian Hospital New York, New York Ted L. Anderson, MD, PhD Betty and Lonnie S. Burnett Professor Vice Chairman for Clinical Operations and Quality Director, Division of Gynecology Department of Obstetrics and Gynecology Vanderbilt University Medical Center Nashville, Tennessee Caroline C. Billingsley, MD Assistant Professor Division of Gynecology Oncology Department of Obstetrics and Gynecology University of Cincinnati College of Medicine Cincinnati, Ohio Linda D. Bradley, MD Professor of Surgery Vice Chair, OB/GYN & Women’s Health Institute Director, Center of Menstrual Disorders

Cleveland Clinic Cleveland, Ohio

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vii

Contributors

Chi Chiung Grace Chen, MD, MHS Associate Professor

Tommaso Falcone, MD Cleveland Clinic Lerner College of Medicine Case Western Reserve University Professor and Chief Academic Officer, Cleveland Clinic London Department of Obstetrics and Gynecology

Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Mindy S. Christianson, MD Assistant Professor Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland

Cleveland Clinic Cleveland, Ohio Tola B. Fashokun, MD Assistant Professor

Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Rajiv B. Gala, MD Associate Professor Department of Obstetrics and Gynecology University of Queensland/Ochsner Clinical School Vice-Chairman

Leslie H. Clark, MD Assistant Professor Division of Gynecologic Oncology Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina Sarah L. Cohen, MD, MPH Assistant Professor Harvard Medical School Director of Research and Fellowship Program Director, Division of Minimally Invasive Gynecology Brigham and Women’s Hospital Boston, Massachusetts Marlene M. Corton, MD, MSCS Professor Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology Director, Anatomy Educator and Research University of Texas Southwestern Medical Center Dallas, Texas Geoffrey Cundiff, MD Dr. Victor Gomel Professor

Ochsner Health System New Orleans, Louisiana Antonio R. Gargiulo, MD Associate Professor of Obstetrics, Gynecology and Reproductive Biology Harvard Medical School Center for Infertility and Reproductive Surgery Brigham and Women’s Hospital Medical Director of Robotic Surgery Brigham Health Boston, Massachusetts Dana R. Gossett, MD, MSCI Professor Director, Obstetrics, Gynecology and Gynecologic Subspecialties Department of Obstetrics, Gynecology, and Reproductive Sciences University of California San Francisco San Francisco, California Cara Grimes, MD, MAS Associate Professor New York Medical College Chief of Advanced Urogynecology and Female Pelvic Medicine and Reconstructive Surgery Westchester Medical Center Valhalla, New York Robert E. Gutman, MD Associate Professor Department of Obstetrics and Gynecology and Urology Georgetown University Program Director, Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology Medstar Washington Hospital Center Washington, District of Columbia

Head, Obstetrics & Gynaecology University of British Columbia Vancouver, British Columbia, Canada John O. L. DeLancey, MD Norman F. Miller Professor of Gynecology Department of Obstetrics and Gynecology Professor of Urology

University of Michigan Ann Arbor, Michigan

Jennifer E. Dietrich, MD, MSc Professor Department of Obstetrics and Gynecology and Pediatrics Chief of Pediatric and Adolescent Gynecology Texas Children’s Hospital Division Director Pediatric and Adolescent Gynecology Baylor College of Medicine Houston, Texas

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viii

Contributors

Victoria L. Handa, MD, MHS Professor, Gynecology and Obstetrics Director, Division of Female Pelvic Medicine and Reconstructive Surgery Chair, Department of Gynecology and Obstetrics, Johns Hopkins Bayview Medical Center Deputy Director, Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Department of Obstetrics and Gynecology Ohio State University College of Medicine Section chief, Pediatric and Adolescent Gynecology Nationwide Children’s Hospital Columbus, Ohio Mitchel Hoffman, MD Professor Department of Oncologic Sciences Geri Hewitt, MD Clinical Professor

Christina Lewicky-Gaupp, MD Associate Professor Medical Director, PEAPOD Perineal Clinic Director, Resident Surgical Education and Simulation Department of Obstetrics and Gynecology Division of Female Pelvic Medicine and Reconstructive Surgery Northwestern University Feinberg School of Medicine Chicago, Illinois Jaime Bashore Long, MD Assistant Professor Department of Obstetrics and Gynecology Division of Female Pelvic Medicine and Reconstructive Surgery Pennsylvania State College of Medicine Hershey, Pennsylvania Michelle Louie, MD, MSCR Assistant Professor Division of Minimally Invasive Gynecologic Surgery Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina Obianuju Sandra Madueke-Laveaux, MD, MPH Assistant Professor Department of Obstetrics and Gynecology The University of Chicago Medicine Chicago, Illinois David C. Mayer, MD Division Chief of Obstetric Anesthesia Professor Departments of Anesthesiology and OB/GYN University of North Carolina School of Medicine Chapel Hill, North Carolina Christine P. McKenzie, MD Assistant Professor Department of Anesthesiology University of North Carolina School of Medicine Chapel Hill, North Carolina Magdy Milad, MD, MS Professor Department of Obstetrics and Gynecology Northwestern University Chief, Gynecology and Gynecologic Surgery Department of Obstetrics and Gynecology Northwestern Memorial Hospital Chicago, Illinois Jessica E. Morse, MD, PhD Assistant Professor Division of Family Planning Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina

Morsani College of Medicine University of South Florida Senior Member Department of Gynecologic Oncology Moffitt Cancer Center Tampa, Florida

Howard W. Jones III, MD † Betty and Lonnis S Burnett Professor of Obstetrics and Gynecology

Division of Gynecologic Oncology Director of Gynecologic Oncology Vanderbilt University School of Medicine Nashville, Tennessee

Chava Kahn, MD, MPH Instructor

Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Kimberly Kenton, MD, MS Professor, Obstetrics & Gynecology and Urology Chief, Female Pelvic Medicine & Reconstructive Surgery Northwestern University Feinberg School of Medicine Chicago, Illinois

Lindsay M. Kuroki, MD Assistant Professor Division of Gynecologic Oncology

Department of Obstetrics and Gynecology Washington University School of Medicine St. Louis, Missouri

David M. Kushner, MD John and Jeanne Flesch Professor of Gynecologic Oncology Department of Obstetrics and Gynecology University of Wisconsin School of Medicine and Public Health Madison, Wisconsin

† Deceased

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Contributors

Margaret G. Mueller, MD Assistant Professor

Matthew T. Siedhoff, MD, MSCR Associate Professor Director, Center for Minimally Invasive Gynecologic Surgery Department of Obstetrics and Gynecology Cedars-Sinai–University of California, Los Angeles Los Angeles, California David E. Soper, MD Paul B. Underwood, Jr. Professor Department of Obstetrics and Gynecology Medical University of South Carolina Charleston, South Carolina John T. Soper, MD Catherine Sou-Mei Young Distinguished Professor of Gynecologic Oncology Division of Gynecologic Oncology Department of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina Ryan J. Spencer, MD, MS Assistant Professor Division of Gynecologic Oncology Department of Obstetrics and Gynecology University of Wisconsin School of Medicine and Public Health Madison, Wisconsin Gretchen S. Stuart, MD, MPHTM Professor of Obstetrics and Gynecology Chief, Division of Family Planning Director, Fellowship in Family Planning University of North Carolina School of Medicine Chapel Hill, North Carolina Laurie S. Swaim, MD Professor of Obstetrics and Gynecology Director Division of Gynecologic and Obstetric Specialists Baylor College of Medicine Chief of Gynecologic Services Pavilion for Women at Texas Children’s Hospital Houston, Texas Edward Tanner, MD Associate Professor Chief of Gynecologic Oncology Northwestern Medicine Northwestern University Feinberg School of Medicine Chicago, Illinois Arthur Jason Vaught, MD Assistant Professor Departments of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland

Division of Female Pelvic Medicine and Reconstructive Surgery Departments of Obstetrics and Gynecology and Urology Northwestern University Feinberg School of Medicine Chicago, Illinois

David G. Mutch, MD Ira C. and Judith Gall Professor Vice-Chair of Obstetrics and Gynecology Division of Gynecologic Oncology Department of Obstetrics and Gynecology Washington University School of Medicine St. Louis, Missouri Kristin E. Patzkowsky, MD Assistant Professor

Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Annette Perez-Delboy, MD, MBA Associate Professor Department of Obstetrics and Gynecology Columbia University College of Physicians and Surgeons New York, New York Anna Powell, MD, MS Assistant Professor Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland John A. Rock, MD, MHCM Senior Vice President, Health Affairs Founding Dean Emeritus, Herbert Wertheim College of Medicine Professor of Obstetrics and Gynecology Department of Obstetrics and Gynecology Florida International University Miami, Florida Ritu Salani, MD, MBA Associate Professor Division of Gynecologic Oncology Department of Obstetrics and Gynecology The Ohio State University College of Medicine Columbus, Ohio Heather Z. Sankey, MD, CPE, MEd Professor and Chair Department of Obstetrics and Gynecology University of Massachusetts Medical School-Baystate Baystate Health Springfield, Massachusetts Howard T. Sharp, MD Professor Vice-Chair for Clinical Activities Department of Obstetrics and Gynecology University of Utah Health Sciences Salt Lake City, Utah

Karen C. Wang, MD Assistant Professor

Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland

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Contributors

Renée M. Ward, MD Assistant Professor Department of Obstetrics and Gynecology Vanderbilt University Medical Center Nashville, Tennessee Katharine O’Connell White, MD, MPH Associate Professor Vice-Chair of Academics Department of Obstetrics and Gynecology Boston University School of Medicine Director, Fellowship in Family Planning Boston Medical Center Boston, Massachusetts E. James Wright, MD Associate Professor Department of Urology Johns Hopkins University School of Medicine Baltimore, Maryland

Jason D. Wright, MD Sol Goldman Associate Professor Chief, Division of Gynecologic Oncology Vice Chair of Academic Affairs Department of Obstetrics and Gynecology Columbia University College of Physicians and Surgeons New York, New York Emmanuel E. Zervos, MD Professor of Surgery Director of Cancer Services Division of Surgical Oncology East Carolina Brody School of Medicine Greenville, North Carolina

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CONTENTS

Contributors vi Foreword xi Preface xiii Preface from First Edition xiv SECTION I Preparing for Surgery

SECTION I I I Perioperative and Postoperative Care of the Gynecologic Patient

11 Postoperative Care of the Gynecologic Patient 200 Rajiv B. Gala

1 Surgical Anatomy of the Female Pelvis 2 Marlene M. Corton and John O. L. DeLancey

SECTION IV Contemporary Gynecologic Surgical Procedures

2 Preoperative Care of the Gynecologic Patient 43

Karen C. Wang and Victoria L. Handa

12 Dilation and Curettage 218

Ronald T. Burkman and Heather Z. Sankey

SECTION I I Principles of Gynecologic Surgery 3 Anesthesia Primer for the Gynecologist 60 David C. Mayer and Christine P. McKenzie

13 Hysteroscopy 228

Mindy S. Christianson and Kristin E. Patzkowsky

14 Surgical Management of Abortion and Its Complications 255 Gretchen S. Stuart and Chava Kahn

4 Patient Positioning for Pelvic Surgery 78 Kimberly Kenton and Margaret G. Mueller

15 Surgery for Benign Vulvar Conditions 273 Heather Z. Sankey and Ronald T. Burkman

5 Surgical Techniques, Instruments, and Suture 91 John T. Soper 6 Principles of Electrical and Laser Energy Applied to Gynecologic Surgery 109 Ted L. Anderson and Magdy Milad

16 Tubal Sterilization 288

Amy G. Bryant and Jessica E. Morse

17 Surgery of the Ovary and Fallopian Tube 307 Sarah L. Cohen and Antonio R. Gargiulo

18 Myomectomy 324

7 Incisions for Gynecologic Surgery 128 James J. Burke II

Linda D. Bradley and Tommaso Falcone

19 Vaginal Hysterectomy 348 Tola B. Fashokun and Victoria L. Handa

8 Surgical Control of Pelvic Hemorrhage 156 David G. Mutch and Lindsay M. Kuroki

20 Abdominal Hysterectomy 364 Laurie S. Swaim

21 Laparoscopic and Robotic-Assisted Hysterectomy 387 Ted L. Anderson and Jubilee Brown

10 Principles of Robotic Surgery 189

Arnold P. Advincula and Obianuju Sandra Madueke-Laveaux

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xvi

CONTENTS

SECTION V Gynecologic Oncology

SECTION VI I Management of Selected Gynecologic Conditions 33 Postoperative Infections in Gynecologic Surgery 608 Anna Powell and David E. Soper 34 Perioperative Shock in the Gynecologic Patient 621 Arthur Jason Vaught

22 Surgery for Preinvasive Disease of the Cervix 406 Leslie H. Clark 23 Surgery for Preinvasive and Invasive Disease of the Vulva and Vagina 414 David M. Kushner and Ryan J. Spencer

24 Surgery for Endometrial Cancer 432 Edward Tanner

35 Management of Intraoperative Injury to the Urinary Tract 633 E. James Wright

25 Surgery for Cervical Cancer 448 Nadeem R. Abu-Rustum and Vance A. Broach

36 Operative Complications of

26 Surgery for Ovarian Cancer 472 Ritu Salani and Caroline C. Billingsley

the Gastrointestinal Tract 651 Mitchel Hoffman and Emmanuel E. Zervos

SECTION VI Surgery for Pelvic Floor Disorders 27 Transvaginal Apical Suspensions for Uterovaginal Prolapse 492 Robert E. Gutman

37 Surgical Management of Pelvic Pain and Endometriosis 671 Matthew T. Siedhoff and Erin T. Carey 38 Surgical Management of Pelvic Inflammatory Disease 686 Matthew T. Siedhoff and Michelle Louie

28 Sacrocolpopexy 513

39 Surgical Management of Ectopic Pregnancy 695 Katharine O’Connell White and Paula M. Castaño

Geoffrey Cundiff and Victoria L. Handa

29 Colporrhaphy and Enterocele Repair 522 Cara Grimes 30 Midurethral Slings and Surgery for Stress Urinary Incontinence 543 Renée M. Ward

40 Surgical Management of Reproductive Tract Anomalies 714 Jennifer E. Dietrich 41 Pediatric and Adolescent Gynecologic Surgery 732 Geri Hewitt SECTION VI I I Surgery for Obstetrical Complications 42 Surgery For Obstetrical Hemorrhage 748 Jason D. Wright and Annette Perez-Delboy

31 Colpocleisis 568 Melinda G. Abernethy

32 Vesicovaginal and Rectovaginal Fistula 578

Chi Chiung Grace Chen and Jaime Bashore Long

43 Repair of Episiotomy and Complex Perineal Lacerations 765 Dana R. Gossett and Christina Lewicky-Gaupp

Index 773

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CHAPTER 1

Surgical Anatomy of the Female Pelvis Marlene M. Corton and John O. L. DeLancey

The Abdominal Wall Skin and Subcutaneous Tissue Musculoaponeurotic Layer Neurovascular Supply of the Abdominal Wall Other Lumbar Plexus Branches Vulva and Erectile Structures Subcutaneous Tissues of the Vulva Superficial Compartment Pudendal Nerve and Vessels Terminal Branches of Pudendal Nerve Autonomic Innervation to Erectile Structures Lymphatic Drainage Medial Thigh Compartment

The Pelvic Floor Perineal Membrane Perineal Body Posterior Triangle: Ischioanal Fossa Anal Sphincters Levator Ani Muscles Pelvic Viscera Genital Structures Lower Urinary Tract

Extraperitoneal Surgical Spaces Anterior and Posterior Cul-De-Sacs Retropubic/Prevesical Space Vesicovaginal and Vesicocervical Space Rectovaginal Space Region of the Sacrospinous Ligament and Greater Sciatic Foramen Retroperitoneal Spaces and Lateral Pelvic Wall Retroperitoneal Structures above the Pelvic Brim Presacral Space Pelvic Retroperitoneal Space Lymphatics

Sigmoid Colon and Rectum Pelvic Connective Tissue Uterine Ligaments Vaginal Connective Tissue Attachments and Extraperitoneal Surgical Spaces Urethral Support

apparent. Closer to the rectus sheath, the fibrous tis- sue predominates relative to the fat, and this portion of the subcutaneous layer is called the membranous layer (formerly Scarpa fascia ). The fatty and membra- nous layers are not discrete or well-defined layers but represent regions within the subcutaneous tissue. The membranous layer is best developed laterally and is not seen as a well-defined layer during midline verti- cal incisions. It is most evident at the lateral borders of low transverse incisions, just above the rectus sheath. Musculoaponeurotic Layer Deep to the subcutaneous tissue is a layer of muscle and fibrous tissue (“fascia”) that holds the abdominal vis- cera in place and controls movement of the lower torso ( FIGS. 1.1 and 1.2 ) The muscles of this layer can be con- sidered in two groups: the vertical muscles in the mid- line (rectus abdominis and pyramidalis) and the more lateral flank muscles (the external oblique, internal oblique, and transversus abdominis). The fascia, prop- erly called the rectus sheath, is created by the broad, sheetlike tendons of these muscles, which form aponeu- roses that unite with their corresponding member of the other side.

THE ABDOMINAL WALL The superior border of the abdominal wall is the lower edge of the rib cage (ribs 7 through 12). The inferior margin is formed by the iliac crests, inguinal ligaments, and pubic bones. It ends posterolaterally at the lumbar spine and its adjacent muscles. Knowledge of the lay- ered structure of the abdominal wall allows the surgeon to enter the abdominal cavity with maximum efficiency and safety. A general summary of these layers is pro- vided in TABLE 1.1 and discussed below. Skin and Subcutaneous Tissue The fibers in the dermal layer of the abdominal skin are oriented in a predominantly transverse direction follow- ing a gently curving upward line. This predominance of transversely oriented fibers results in more tension on the skin of a vertical incision and in a wider scar. Deep to the skin lies the subcutaneous tissue of the abdomen. This tissue is made of globules of fat held in place and supported by a series of branching fibrous septa. In the more superficial portion of the subcuta- neous tissue, called the fatty layer (formerly Camper fascia ), fat predominates, and fibrous tissue is less

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CHAPTER 1 Surgical Anatomy of the Female Pelvis

or inscriptions. These are fibrous interruptions within the muscle that firmly attach it to the rectus abdomi- nis sheath. In general, they are confined to the region above the umbilicus, but they can be found below it. At these fibrous interruptions, the rectus sheath is attached to the rectus muscle and thus the two structures are dif- ficult to separate (e.g., during a Pfannenstiel incision). The pyramidalis muscles arise from the pubic bones anterior to the rectus abdominis and insert into the mid- line linea alba several centimeters above the symphysis. Their development varies considerably among individu- als. Their strong attachment to the midline makes separa- tion here difficult by blunt dissection. Flank Muscles Lateral to the rectus abdominis muscles lie the broad, flat muscles of the flank. Their aponeurotic insertions join to form the rectus sheath, which covers the rectus abdominis muscles. Because of its importance, the rec- tus sheath is further discussed below. The most superficial of these muscles is the external oblique. Its fibers run obliquely anteriorly and inferi- orly from their proximal origin on the lower eight (5 through 12) ribs to the broad distal insertions of their aponeuroses on the iliac crest, pubic tubercle, and linea alba. The inferior margin of the external oblique apo- neurosis is thickened, and its free posterior edge forms the inguinal ligament. The fibers of the internal oblique muscle fan out superiorly and medially from their origin in the anterior two thirds of the iliac crest, the lateral part of the inguinal ligament, and the thoracolumbar fascia to their distal attachments on the inferior borders

TABLE 1.1 Abdominal Wall Layers Skin Subcutaneous tissue Fatty layer (Camper fascia) Membranous layer (Scarpa fascia) Musculoaponeurotic layer

Rectus Abdominis and Pyramidalis Muscles Each paired rectus abdominis muscle originates from the sternum and cartilages of ribs 5 through 7 and inserts into the anterior surface of the pubic bone. Each muscle has three to four tendinous intersections Arcuate line—lower limit of the posterior layer, approximately one third of the distance from the umbilicus to the pubic crest. Below this line, posterior surface of rectus abdominis muscles in contact with transversalis fascia Transversalis fascia Preperitoneal fat Peritoneum Rectus sheath—formed by aponeuroses of the external oblique, internal oblique, and transversus abdominis muscles (flank muscles). Invests rectus abdominis and pyramidalis muscles (ver- tical muscles). Fuse in the midline at the linea alba and laterally at the linea semilunaris. Anterior layer—formed by external oblique and internal oblique (split) aponeuroses Posterior layer—formed by internal oblique (split) and transver- sus abdominis aponeuroses

External oblique

Internal oblique

Anterior sup. iliac spine

Inguinal ligament Superficial inguinal ring

Pyramidalis

FIGURE 1.1 External oblique, internal oblique, and pyramidalis muscles. (The original illustration is in the Max Brödel Archives in the Department of Art as Applied to Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. Used with permission.)

Round lig.

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SECTION I Preparing for Surgery

Sheath of rectus (anterior layer)

External oblique

Sheath of rectus (posterior layer)

Arcuate line

Internal oblique

Transversalis fascia

Inguinal ligament

FIGURE 1.2 Abdominal wall mus- cles and rectus sheath. (The original illustration is in the Max Brödel Archives in the Department of Art as Applied to Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. Used with permission.)

Round lig.

Rectus cut

Pyramidalis

of ribs 10 through 12, the pecten pubis via the conjoint tendon, and the linea alba. In most areas, the fibers of the internal oblique are perpendicular to the fibers of the external oblique muscle; however, in the lower abdomen, the internal oblique fibers arch somewhat more caudally and run in a direction similar to those of the external oblique muscle. As the name transversus abdominis implies, the fibers of the deepest of the three flat muscles have a primarily transverse orientation. They arise from the costal cartilages of the lower six (7 through 12) ribs, the thoracolumbar fascia, the iliac crest, and the lat- eral third of the inguinal ligament. Their distal attach- ments are to the pubic crest, the pecten pubis via the conjoint tendon, and the linea alba. The caudal portion of the transversus abdominis muscle is fused with the internal oblique muscle to form the inguinal falx, also called the conjoint tendon. This fusion explains why, during transverse incisions of the lower abdomen, only two layers are discernible at the lateral portion of the incision. The aponeurotic fibers of the conjoint tendon attach to the pubic crest and pecten pubis. This tendon lies immediately behind the superficial inguinal ring, and along with the transversalis fascia, forms the pos- terior wall of the inguinal canal. A weakening of the conjoint tendon can lead to a direct inguinal hernia. The inferior free edge of the transversus abdominis and internal oblique muscle fibers form the superior bound- ary (roof) of the inguinal canal.

Although the fibers of the flank muscles are not strictly parallel to one another, their primarily trans- verse orientation and the transverse pull of their attached muscular fibers place vertical suture lines in the rectus sheath under more tension than transverse ones. For this reason, vertical incisions are more prone

to dehiscence. Rectus Sheath

The muscle fibers of the external oblique become apo- neurotic approximately at the midclavicular line. In the lower abdomen, this demarcation gradually devel- ops more laterally ( FIG. 1.3 ). At its inferior margin, the muscle fibers of the internal oblique extend farther toward the midline than do the muscle fibers of the external oblique. Because of this, fibers of the internal oblique muscle are found underneath the aponeurotic portion of the external oblique muscle during a low transverse incision ( FIG. 1.4 ). In addition, between the internal oblique and trans- versus abdominis muscles lies a neurovascular plane, which corresponds to a similar plane in the intercostal spaces. This plane contains the nerves and arteries that supply the anterolateral abdominal wall. In the anterior part of the abdominal wall, these nerves and vessels exit the neurovascular plane and lie mostly in the subcuta- neous tissue. Although not often possible, the nerves should be identified and spared, and strategies used to avoid injury within the neurovascular plane should be

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CHAPTER 1 Surgical Anatomy of the Female Pelvis

Branch of 6th intercostal n.

7th intercostal n.

Branch of 9th intercostal n.

External oblique m. Internal oblique m.

Intercostal n.

12th intercostal n.

Branch of 12th intercostal n.

External oblique m.

Transverse abdominins m. Ilio-inguinal n.

Lateral cutaneous nerve of thigh

Ilio-inguinal n.

Iliohypogastric n.

Anterior cutaneous nerve of thigh (from femoral n.)

FIGURE 1.3 Nerve supply to the abdominal wall. Right : Deep innervation to the transverse abdomi- nis, internal oblique, and rectus muscles. Left : Superficial distribution, including cutaneous nerves, after penetration and innervation of the external oblique muscle and fascia. Innervation of the groin and thigh also is shown.

EO IO TA

In lower abdomen, internal oblique (IO) fibers extend more medially than EO

FIGURE 1.4 Cross sections of lower abdominal wall above and below the arcuate line. 1 , external oblique; 2 , internal oblique; and 3 , transversus abdominis muscle. A: Above the arcuate line (linea semicircularis): the anterior fascial sheath of the rectus muscle (in gray ) is derived from the external oblique and split aponeurosis of internal oblique muscles. The posterior sheath is formed by apo- neurosis of the transversus abdominis muscle and split aponeurosis of the internal oblique muscle. B: Lower portion of the abdominal wall, below the arcuate line: The rectus muscle does not have a posterior fascial sheath, while all of the fascial aponeuroses form the anterior rectus muscle sheath. The rectus muscle is in direct contact with the transversalis fascia.

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SECTION I Preparing for Surgery

I used. For example, low transverse fascial incisions often used for gynecologic surgery should not extend beyond lateral margins of rectus muscles to avoid nerve and inferior epigastric vessel injury. In addition, suture pur- chases that extend lateral to the edges of incision should be avoided as they may entrap the iliohypogastric and/ or ilioinguinal nerve, which may lead to denervation injury or pain as described later (under ilioinguinal and iliohypogastric sections below). Many specialized aspects of the rectus sheath are impor- tant to the surgeon ( FIG. 1.4 ). In its lower one fourth, the sheath lies entirely anterior to the rectus muscle. Above that point, it splits to lie both anterior and posterior to the rectus muscle, thus forming the anterior and posterior layers of the rectus sheath. The transition between these two arrangements occurs at the arcuate line, approxi- mately one third of the distance from the umbilicus to the pubic crest, which lies medial to the pubic tubercle. Superior to this line, the midline ridge of the rectus sheath, the linea alba, unites the anterior and posterior layers of the sheath. Sharp dissection is usually required to separate these layers in the midline during a Pfannenstiel incision. Below the arcuate line, the rectus abdominis muscles are in contact with the transversalis fascia. A vertical incision that extends to or above the umbilicus therefore requires incision of the posterior sheath. The lateral border of the rectus muscle is marked by the linea semilunaris, a curved tendinous line that extends from the cartilage of the ninth rib to the pubic tubercle. It is formed by the internal oblique aponeu- rosis at its line of division to enclose the rectus mus- cle and is reinforced anteriorly by the external oblique and transversus abdominis aponeurosis. The linea semilunaris is not always where the three layers of flank muscles fuse: above the arcuate line, the inter- nal oblique muscle aponeurosis splits to contribute to the anterior and posterior layers of the rectus sheath, while below the arcuate line, the transversalis fascia lies immediately posterior to the rectus muscles. During a transverse lower abdominal incision, the external and internal oblique aponeuroses are often separable near the midline. A hernia through the linea semilunaris is called a Spigelian hernia or lateral–ventral hernia. The inguinal canal lies at the lower edge of the mus- culofascial layer of the abdominal wall. It is superior and parallel to the inguinal ligament. The midinguinal point is halfway between the pubic symphysis and the anterosuperior iliac spine. The femoral pulse can be palpated here. The inguinal canal has two openings, the superficial and deep inguinal rings. In the embryological stage, the canal is lined by an outpocketing of the peri- toneum (processus vaginalis) and the abdominal mus- culature. Failure of the processus vaginalis to regress can lead to an indirect inguinal hernia, where the peri- toneal sac or potentially loops of bowel enter the ingui- nal canal through the deep inguinal ring, lateral to the inferior epigastric vessels. Through the inguinal canal,

in the woman, the round ligament extends to its termi- nation in the labium majus. In addition, the ilioinguinal nerve and the genital branch of the genitofemoral nerve pass through the canal. Transversalis Fascia, Peritoneum, and Bladder Reflection Deep to the muscular layers and superficial to the peri- toneum lies the transversalis fascia, a layer of fibrous tissue that lines the abdominopelvic cavity. It is visible during abdominal incisions as the layer just underneath the rectus abdominis muscles suprapubically ( FIG. 1.2 ). It is separated from the peritoneum by a variable layer of extraperitoneal adipose tissue, sometimes called the preperitoneal fat. The transversalis fascia is frequently incised or bluntly dissected off the bladder to take the tissues in this region “down by layers.” This is the layer of tissue that is last penetrated to gain extraperitoneal entry into the retropubic space. The peritoneum is a single layer of epithelial cells and supporting connective tissue called the serosa that lines the abdominal cavity and covers the abdominopelvic organs. The infraumbilical part of the anterolateral abdominal wall is characterized by five peritoneal folds ( FIG. 1.5 ) that converge toward the umbilicus. The sin- gle median umbilical fold extends from the apex of the bladder to the umbilicus and covers the median umbili- cal ligament, a fibrous remnant of the urachus. Lateral to this are paired medial umbilical folds, which cover the medial umbilical ligaments, formed by the occluded part of the umbilical arteries. The lateral umbilical folds cover the inferior epigastric arteries and veins and, if transected, can lead to significant bleeding. The reflection of the bladder onto the abdominal wall is triangular in shape, with its apex blending into the median umbilical ligament. Because the apex is highest in the midline, incision in the peritoneum lateral to the midline is less likely to result in bladder injury. Umbilical Area The umbilicus is an important surgical landmark and the most common point of entry during endoscopic surgery. All layers of the anterolateral abdominal wall fuse at the umbilicus (see FIG. 1.5 ). The umbilicus usu- ally lies at a vertical level corresponding to the junction between the third and fourth lumbar vertebrae. This is also the level at which the iliac veins join to form the vena cava and at which the abdominal aorta bifurcates. The skin around the umbilicus is innervated by the 10th thoracic spinal nerve (T10 dermatome). The umbilicus contains the umbilical ring, a defect in the linea alba through which the fetal umbilical vessels passed to and from the umbilical cord and placenta. The umbilical ring provides a window through which umbilical her- nias may develop. The round ligament of the liver and median umbilical and medial umbilical ligaments vari- ably attach to the ring with inconsistent arrangements.

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CHAPTER 1 Surgical Anatomy of the Female Pelvis

Parietal peritoneum

Falciform lig.

Ligmentum teres

Umbilicus

Median umbilical lig.

Posterior rectus sheath

Medial umbilical lig.

Inf. epigastric artery and vein

FIGURE 1.5 Intraperitoneal view of anterior abdominal wall, demonstrating five peritoneal folds: the median umbilical fold (covering the median umbilical ligament), paired medial umbilical folds (covering the medial umbilical ligaments), and the lateral umbilical folds (cov- ering the inferior epigastric arteries and veins). Note all umbilical peritoneal folds (ligaments) merge at the umbilicus.

Lateral umbilical lig.

Deep inguinal ring

Bladder

Round lig.

Vagina

The umbilical fascia is formed by a thickening in the transversalis fascia behind the umbilicus, with possible contributions from the upward extension of the bladder visceral fascia (umbilicovesical fascia). Neurovascular Supply of the Abdominal Wall Vessels of the Abdominal Wall Knowledge of the course of the abdominal wall blood vessels helps the surgeon anticipate their location dur- ing abdominal incisions or insertion of laparoscopic trocars ( FIG. 1.6 ). The blood vessels that supply the abdominal wall can be separated into those that supply the skin and subcutaneous tissues and those that supply the musculofascial layer. Three groups of vessels provide blood supply to the skin and subcutaneous tissues. The superficial epigastric vessels run a diagonal course in the sub- cutaneous tissue from the femoral vessels toward the umbilicus, beginning as a single artery that branches extensively as it nears the umbilicus. Its position can be anticipated midway between the skin and muscu- lofascial layer, in a line between the palpable femoral pulse and the umbilicus. The external pudendal artery runs a diagonal course medially from the femoral artery to supply the region of the mons pubis. It has many midline branches, and bleeding in its territory of distribution is heavier than that from the abdomi- nal subcutaneous tissues. The superficial circumflex iliac vessels course laterally from the femoral vessels toward the flank. The blood supply to the lower abdominal wall’s deeper musculofascial layer parallels the subcutaneous vessels. The inferior epigastric and the deep circumflex

iliac arteries branch from the external iliac, and their course parallels that of their superficial counterparts (see FIG. 1.6 ). The deep circumflex iliac artery lies between the internal oblique and transversus abdominis muscle. The inferior epigastric artery and its two veins originate lateral to the rectus muscle. They run diagonally toward the umbilicus and intersect the muscle’s lateral border

0 5 10 15 20cm

Superficial vessels

Deep vessel

Superficial epigastric

Inferior epigastric

Superficial circumflex iliac

B B

FIGURE 1.6 Normal variation in epigastric vessels. A , B , and C designate safe spots for laparoscopic trocar insertion. Dotted lines indicate lateral border of the rectus muscle. (Reprinted fromHurd WW, Bude RO, DeLancey JOL, et al. The location of abdominal wall blood vessels in relationship to abdominal landmarks appar- ent at laparoscopy. Am J Obstet Gynecol 1994;171(3):642–646, with permission. Copyright © 1994, Elsevier.)

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SECTION I Preparing for Surgery

I midway between the pubis and umbilicus. Below the point at which the vessels pass under the rectus, they are found lateral to the muscle and deep to the transversa- lis fascia. After crossing the lateral border of the rectus muscle, they lie on the muscle’s dorsal surface, between it and the posterior rectus sheath. As the vessels enter the rectus sheath, they branch extensively, so that they no longer represent a single trunk. The angle between the inferior epigastric vessels and the lateral border of the rectus muscle forms the apex of the inguinal triangle (Hesselbach triangle), the base of which is the ingui- nal ligament. This triangle represents the area through which direct inguinal hernias protrude medial to the inferior epigastric vessels. Around the umbilical area, the inferior epigastric artery anastomoses with the supe- rior epigastric, a branch of the internal thoracic artery. Lateral laparoscopic trocars are placed in a region of the lower abdomen where injury to the inferior epigastric and superficial epigastric vessels can easily occur. The inferior epigastric arteries and the super- ficial epigastric arteries run similar courses toward the umbilicus. Knowing the typical location of these blood vessels helps in choosing insertion sites that

will minimize their injury, reducing the potential for hemorrhage and hematomas. Just above the pubic symphysis, the vessels lie approximately 5.5 cm from the midline, whereas at the level of the umbili- cus, they are 4.5 cm from the midline (see FIG. 1.6 ). Therefore, placement either lateral or medial to the line connecting these points minimizes potential vas- cular injury. In addition, the location of the inferior epigastric vessels can often be directly seen through the peritoneal layer laparoscopically (see FIG. 1.5 ), and during laparoscopic procedures, the superficial epi- gastric vessels can often be identified in thin patients by transillumination. The round ligament is traced to its point of entry into the deep inguinal ring, rec- ognizing that the vessels lie just medial to this point ( FIG. 1.7 ). Nerves of the Abdominal Wall The innervation of the abdominal wall (see FIG. 1.3 ) arises from the abdominal extension of intercostal nerves 7 through 11, subcostal nerve (T12), and iliohy- pogastric and ilioinguinal nerves (both L1). Dermatome T10 lies at the umbilicus.

Inferior epigastric artery and vein

Deep circumflex iliac artery and vein

Internal inguinal ring and round ligament

Ilio-inguinal nerve

External iliac artery External iliac vein Ovarian artery and vein

Femoral canal FIGURE 1.7 Sagittal view of female pelvis, showing inguinal anatomy. Note that the inferior epigas- tric artery and vein lie just medial to the round ligament as it enters the deep inguinal ring. (The original illustration is in the Max Brödel Archives in the Department of Art as Applied to Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. Used with permission.)

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CHAPTER 1 Surgical Anatomy of the Female Pelvis

Other Lumbar Plexus Branches The genitofemoral nerve (L1 and L2) and lateral cutane- ous nerve of the thigh (L2 and L3) can be injured dur- ing gynecologic surgery. The genitofemoral nerve lies on the anterior surface of the psoas muscle ( FIG. 1.9 ), where pressure from a retractor can damage it and lead to anesthesia in the medial thigh and lateral labia. This nerve can also be injured during pelvic lymphadenec- tomy and ureteral reimplantation with psoas hitch. The lateral cutaneous nerve courses over the iliacus muscle and passes under the inguinal ligament just medial to the anterosuperior iliac spine. It can be compressed either by a retractor blade lateral to the psoas or by excessive flexion of the hip in the lithotomy position, causing anes- thesia over the anterior and lateral thigh. Meralgia par- esthetica is a term often used when pain is also present. The largest branch of the lumbar plexus, the femo- ral nerve (L2–L4) can also be injured during gyneco- logic surgery. In the greater (false) pelvis, it emerges from the inferolateral surface of the psoas muscles (see FIG. 1.9 ). It then passes under the inguinal ligament to provide innervation to the anterior thigh compartment muscles and sensation to the anterior thigh and medial leg ( FIG. 1.10 ). Femoral nerve injury during abdominal procedures can result from nerve compression by the

5 10cm

Inferior epigastric vessels

Ant. Sup. iliac spine

Ilioinguinal n.

Iliohypogastric n. Ant. Inf. iliac spine

Pubic symphysis

The cutaneous sensory innervation of the abdominal wall is derived from the intercostal nerves and the iliohy- pogastric and ilioinguinal nerves. After giving off a lat- eral abdominal cutaneous branch, each intercostal nerve pierces the lateral border of the rectus sheath. There it pro- vides a lateral branch that ends in the rectus muscle. This branch then passes through the muscle and perforates the rectus sheath to supply the subcutaneous tissues and skin as anterior abdominal cutaneous branches. Incisions along the lateral border of the rectus lead to denervation of the muscle, which can render it atrophic and weaken the abdominal wall. Elevation of the rectus sheath off the muscle during the Pfannenstiel incision stretches the perforating nerve, which is sometimes ligated or cauter- ized to provide hemostasis from the accompanying artery. This may leave an area of cutaneous anesthesia. The iliohypogastric and ilioinguinal nerves ( FIG. 1.8 ) pass medial to the anterosuperior iliac spine in the abdominal wall. The former supplies the skin of the suprapubic area. The latter supplies the lower abdomi- nal wall, and by sending a branch through the ingui- nal canal, it supplies the upper portions of the labia majora (anterior labial nerves) and medial portions of the thigh. The ilioinguinal and iliohypogastric nerves can be entrapped or cut during closure of a transverse incision or insertion of accessory trocars in the lower abdomen. This may lead to chronic pain syndromes that may manifest months to years after surgery. The risk of iliohypogastric and ilioinguinal nerve injury can be minimized if lateral trocars are placed superior to the anterosuperior iliac spines and if low transverse fascial incisions are not extended beyond the lateral borders of the rectus muscles. FIGURE 1.8 Nerve and vessel locations on anterior abdominal wall relative to surgically important landmarks. (Redrawn from Rahn DD, Phelan JN, Roshanravan SM, et al. Anterior abdom- inal wall nerve and vessel anatomy: clinical implications for gynecologic surgery. Am J Obstet Gynecol 2010;202(3):234. e1–234.e5. Copyright © 2010 Elsevier. With permission.)

4 5 6

7 8 9 10

External oblique m. Internal oblique m.

Transversus abdominis m. Lateral cutaneous n. of the thigh

Round ligament with ilio-inguinal n. & genital branch of genitofemoral n. (cut) exiting superficial inguinal ring

FIGURE 1.9 Nerves of the lumbar plexus: 1 , sciatic nerve; 2 , femoral nerve; 3 , lateral cutaneous nerve of the thigh; 4 , ilio- inguinal nerve; 5 , iliohypogastric nerve; 6 , subcostal nerve; 7 , sympathetic trunk and ganglion; 8 , genitofemoral nerve; 9 , femoral branch of genitofemoral nerve; and 10 , genital branch of genitofemoral nerve. (Reprinted with permission from Bigeleisen PE, Gofeld M, Orebaugh SL. Ultrasound-guided regional anesthesia and pain medicine , 2nd ed. Philadelphia, PA: Wolters Kluwer, 2015. Figure 35.9.)

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