Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

Подождите немного. Документ загружается.

1062 Section XIII • Amputations

◆ Posterior laterally, the tensor fasciae latae muscle is incised below the anterior aspect of the

gluteus maximus. This muscle is divided at its insertion to the gluteal tuberosity. The glu-

teus medius and minimus, piriformis, gemellus, and obturator externus muscles are divided

near their insertion to the greater trochanter. The capsule of the hip joint is opened to

expose the neck and head of the femur (see Figure 96-5).

◆ The sciatic nerve is transected high, just below the piriformis muscle, and allowed to retract

beneath this muscle (Figure 96-6). The insertions of the obturator internus and quadratus

femoris to the greater trochanter are divided. The origins of the hamstring muscles are

divided off the ischial tuberosity: semimembranosus, semitendinosus, and long head of the

biceps. The extremity can be removed once the ligamentum capitis femoris is divided

between the head of the femur and the acetabulum (Figure 96-7).

◆ The wound is irrigated and a suction drainage catheter is positioned in the resection bed.

CHAPTER 96 • Hip Disarticulation 1063

Muscle Closure over Acetabulum

FIGURE 96 –7

Acetabulum

Resection Bed

FIGURE 96 –6

1064 Section XIII • Amputations

3. CLOSING

◆ The posterior muscles (quadratus femoris) can be approximated to anterior muscles

(iliopsoas) to cover the exposed acetabulum using 2-0 Vicryl interrupted absorbable sutures

(see Figure 96-7).

◆ The residual obturator externus and gluteus muscles can be reapproximated together. The

posterior ﬂ ap is longer so that the ﬂ ap can be brought anteriorly and sutured to the anterior

ﬂ ap.

◆ The deeper subcutaneous tissues are ﬁ rst reapproximated, and then the skin can be sutured

or stapled (Figure 96-8). This closure should be tension free to minimize ﬂ ap necrosis.

Skin closure

FIGURE 96 –8

CHAPTER 96 • Hip Disarticulation 1065

STEP 4: POSTOPERATIVE CARE

◆ After the closed-suction drain and sutures are removed, the patient should be ﬁ tted for a

prosthetic limb and referred to physical therapy for early ambulation.

STEP 5: PEARLS AND PITFALLS

◆ When possible, all muscles are transected at their origin or insertion to minimize blood

loss. Viable muscles are used to cover the exposed acetabulum. Phantom limb pain may be

managed in conjunction with experts in pain management and rehabilitation medicine.

SELECTED REFERENCES

1. Boyd HB: Anatomic disarticulation of the hip. Surg Gynecol Obstet 1947;84:346-349.

2. Slocum DB: An Atlas of Amputations. St. Louis, Mosby, 1949.

3. Sugarbaker PH, Nicholson TH: Atlas of Extremity Sarcoma Surgery. Philadelphia, JB Lippincott

Company, 1984.

1068

STEP 1: SURGICAL ANATOMY

◆ Figures 97-1 and 97-2 demonstrate the anatomy of the female pelvis as it pertains to

gynecologic surgery.

◆ The bladder is attached to the anterior lower uterine segment and cervix at the anterior

reﬂ ection of the visceral peritoneum.

◆ The uterine arteries insert into the uterus laterally at the level of the internal cervical os.

◆ The ureters cross over the bifurcation common iliac arteries and are found inferior to the

infundibulopelvic ligament on the medial leaf of the broad ligament. As the ureter con-

tinues on its course to the bladder, it passes under the uterine artery 1 to 2 cm lateral to

the insertion of the uterine artery at the level of the internal cervical os (see Figure 97-1).

◆ Figure 97-2 demonstrates the key ligaments of the uterus.

◆ The infundibulopelvic ligament carries the blood supply to the ovaries.

◆ The utero-ovarian ligament attaches the uterus to the adnexal structures, fallopian tubes,

and ovaries.

◆ Round ligaments are insubstantial anterior lateral attachments of the uterine fundus that

help maintain the normal uterine position.

◆ Cardinal ligaments attach the entire length of the cervix to the pelvic sidewall. These

sturdy ligaments supply most of the uterine support.

◆ Uterosacral ligaments attach the cervix to the sacrum.

CHAPTER

Abdominal Hysterectomy

Concepcion Diaz-Arrastia

CHAPTER 97 • Abdominal Hysterectomy 1069

Infundibulopelvic ligament

Ureter

Ovary

Fallopian tube

Round ligament

Uterine artery

and ureter

Cardinal ligament

Uterus

Internal iliac

artery

External iliac

artery

Uterine artery

Bladder

Ureter

FIGURE 97 –1

Uterosacral

ligament

Infundibulopelvic

ligament

Ligament of ovary

Uterus

Ovary

Fallopian tube

Round ligament

Broad ligament

Bladder

Ureter

FIGURE 97 –2

1070 Section XIV • Gynecology

◆ Figure 97-3 demonstrates the parts of the uterus.

◆ The uterine corpus has two horns laterally.

◆ The internal cervical os is where the uterine arteries enter the uterine body.

◆ The external cervical os is at the junction with the vagina.

◆ Figure 97-4 demonstrates the cervicovesical potential space that separates the bladder from

the cervix.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Several laboratory tests should be documented as part of the preoperative evaluation for a

hysterectomy.

◆ Pap smear to exclude invasive cervical carcinoma

◆ Negative pregnancy test in women of reproductive age

◆ Endometrial biopsy revealing no malignancy in a woman with abnormal uterine bleeding

◆ Indications for concomitant bilateral salpingo-oophorectomy (BSO) should be discussed

with the patient. In general, BSO is recommended in any woman older than the age of

40 to 45 years or in a younger woman with familial or hereditary breast or ovarian cancer

risk or severe endometriosis.

◆ Prophylactic antibiotics are indicated because the peritoneal cavity is contaminated by the

vaginal incision to remove the cervix.

CHAPTER 97 • Abdominal Hysterectomy 1071

Internal os

Uterine corpus

External os

Cervix

Cervicovesical

space

FIGURE 97 –3

FIGURE 97 –4

1072 Section XIV • Gynecology

STEP 3: OPERATIVE STEPS

1. INCISIONS

◆ A vertical skin incision allows for excellent exposure, as well as the ability to extend the

incision to the upper abdomen, at the expense of cosmetic result and an increased rate of

wound complications.

◆ A transverse skin incision allows for adequate exposure in the pelvis. Three transverse inci-

sions are available to the pelvic surgeon, depending on the body habitus of the patient and

the uterine pathology. Figure 97-5, A, depicts the skin incision for all transverse incisions,

1 to 2 cm above the symphysis pubis extending approximately 6 cm to both sides of the

rectus abdominis muscles. This incision is carried down to the anterior rectus sheath or

fascia (Figure 97-5, B). The fascia is then incised, also transversely, for the length of the

incision. After the fascial incision, the procedures diverge.

◆ The Pfannenstiel skin incision is the most popular transverse skin incision and is appropri-

ate for removal of a normal-sized uterus. The rectus muscles are dissected from the anterior

rectus sheath in both the cephalad and caudad directions (Figure 97-5, C). The posterior

rectus sheath is then opened vertically at the midline (Figure 97-5, D), the rectus muscles

are retracted laterally, and the exposed peritoneum is opened the length of the incision to

expose the pelvis.

Pubic tubercle

Pyramidalis muscle

Pfannenstiel incision

Inferior epigastric artery

Rectus abdominis muscle

FIGURE 97–5

CHAPTER 97 • Abdominal Hysterectomy 1073

Rectus sheath

Inferior epigastric

vessels

Transversalis

fascia

FIGURE 97 –5, cont’d