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1084 Section XIV • Gynecology

STEP 4: POSTOPERATIVE CARE

◆ Bladder drainage is maintained until the ﬁ rst postoperative day.

◆ Diet is advanced as tolerated.

◆ Early ambulation is encouraged.

STEP 5: PEARLS AND PITFALLS

◆ Avoid suturing through the middle of the uterine pedicle, because a vessel may be easily

pierced, leading to a retroperitoneal hematoma.

◆ In a patient with previous pelvic surgery or history of endometriosis or pelvic inﬂ ammatory

disease, a mechanical bowel preparation should be ordered to prepare for extensive bowel

lysis of adhesions.

◆ Use the appropriate-length instruments and sutures based on the depth of pelvis and weight

of the patient.

SELECTED REFERENCE

1. Rock JA, Jones HW (eds): TeLinde’s Operative Gynecology, 10th ed. Philadelphia, Lippincott Williams &

Wilkins, 2008.

1085

STEP 1: SURGICAL ANATOMY

◆ Figure 98-1 demonstrates the key anatomy of the uterus, fallopian tube, and ovary

(adnexa) as it pertains to the removal of the adnexa.

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

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

help maintain the normal uterine position. They are an important landmark in the open-

ing of the retroperitoneum for identiﬁ cation of the ureters.

◆ Utero-ovarian ligaments connect the uterus to the adnexa.

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

to the infundibulopelvic ligament on the medial leaf of the broad ligament. The ureter

must be identiﬁ ed before ligation of the infundibulopelvic ligament.

CHAPTER

Bilateral Salpingo-

Oophorectomy

Concepcion Diaz-Arrastia

Uterosacral

ligament

Infundibulopelvic

ligament

Ligament of

ovary

Uterus

Ovary

Fallopian tube

Round ligament

Broad ligament

Bladder

Ureter

FIGURE 98 –1

1086 Section XIV • Gynecology

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ The indications for salpingo-oophorectomy include excision of an ovarian mass or ovarian

cancer prophylaxis.

◆ Frozen section surgical consultation should be available for all cases of ovarian mass. If

intraoperative diagnosis of ovarian cancer is made, the surgeon and patient should be

prepared to proceed with ovarian cancer surgical staging or cytoreductive surgery as

indicated.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ In cases of a suspected ovarian mass, a vertical skin incision is recommended to allow for

excellent exposure, as well as the ability to extend the incision to the upper abdomen for

exploration, surgical staging, or cytoreductive surgery.

◆ A transverse Pfannenstiel incision or laparoscopic approach is acceptable for prophylactic

salpingo-oophorectomy. (See Chapter 97 for discussion of transverse incisions.)

2. DISSECTION

◆ The operative ﬁ eld is prepared by placing the patient in Trendelenburg position, inserting

a self-retaining retractor to expose the pelvis, and packing the intestines away from the

operative ﬁ eld with moist laparotomy pads.

◆ The uterus is grasped with atraumatic curved clamps placed on the uterine horns bilaterally

for upward traction.

◆ An L-shaped incision is made on the peritoneum of the posterior leaf of the broad ligament,

parallel and posterior to the round ligament and lateral to the infundibulopelvic ligament

(Figure 98-2). This avascular retroperitoneal space is developed by blunt dissection. The

external iliac artery is identiﬁ ed on the lateral leaf, and the ureter is identiﬁ ed on the medial

leaf, inferior to the infundibulopelvic ligament (Figure 98-3).

CHAPTER 98 • Bilateral Salpingo-Oophorectomy 1087

Infundibulopelvic

ligament

Ligament of ovary

Round ligament

Incision through

posterior leaf of

broad ligament

FIGURE 98 –2

Ureter

Infundibulopelvic ligament

FIGURE 98 –3

1088 Section XIV • Gynecology

◆ Under visualization of the ureter, the surgeon makes a window in the medial leaf of the

broad ligament, between the vascular infundibulopelvic ligament and the ureter, then

clamps and incises the infundibulopelvic ligament (Figure 98-4).

◆ Because of the vascularity of the infundibulopelvic ligament and the risk of an ascending

retroperitoneal hematoma, the surgeon ﬁ rst ligates the pedicle with a free tie then transﬁ xes

the pedicle with suture ligation (Figure 98-5).

CHAPTER 98 • Bilateral Salpingo-Oophorectomy 1089

Ovary

FIGURE 98 –5

Ovary

Fallopian tube

Infundibulopelvic ligament

FIGURE 98 –4

1090 Section XIV • Gynecology

◆ Under full visualization of the ureter, incise the medial leaf of the peritoneum/broad ligament

from the infundibulopelvic pedicle to the uterus (Figure 98-6). Ligate the utero-ovarian liga-

ment, which is the remaining attachment of the adnexa (Figures 98-7 and 98-8).

Posterior leaf

of broad ligament

Dividing fallopian

tube and ligament of

ovary

FIGURE 98 –8

FIGURE 98 –7

FIGURE 98 –6

CHAPTER 98 • Bilateral Salpingo-Oophorectomy 1091

3. CLOSING

◆ The abdominal wall is closed in layers. The anterior rectus fascia is closed in a continuous

mass closure.

STEP 4: POSTOPERATIVE CARE

◆ Bladder drainage is maintained until the ﬁ rst postoperative day.

◆ Diet is advanced as tolerated.

◆ Early ambulation is encouraged.

STEP 5: PEARLS AND PITFALLS

◆ Salpingo-oophorectomy in a menstruating woman will effect a surgical menopause, which

may cause severe hot ﬂ ashes and other sequelae of premature menopause.

◆ Mechanical bowel preparation is advised in patients undergoing surgery for an ovarian

mass.

SELECTED REFERENCE

1. Rock JA, Jones HW (eds): TeLinde’s Operative Gynecology, 10th ed. Philadelphia, Lippincott Williams &

Wilkins, 2008.

1092

STEP 1: SURGICAL ANATOMY

◆ Although rectovaginal ﬁ stulae may spontaneously arise from Crohn’s disease or malignancy,

most cases result from failed obstetric repairs and complications of posterior vaginal

prolapse repair operations.

◆ Successful repair requires a wide enough dissection to obtain a tension-free layered closure

of viable, well-vascularized tissue, using a pedicled Martius bulbocavernosus graft if

necessary.

◆ Although successful early secondary repair has been described, repair after postpartum

dehiscence is traditionally delayed for 3 months to allow maximal reinnervation and

vascularization of the wound.

◆ Numerous failed repairs may require a diverting colostomy before and 3 months following

reoperation to ensure adequate healing.

◆ Fistulae superior to the levator muscles may require an abdominal approach to achieve

adequate mobilization of tissue. In the pre-antibiotic era, the rectal advancement and

vaginal ﬂ ap operations had the advantage of avoiding a suture line in the rectum. However,

the use of these operations may make overlapping the retracted muscle of the anal sphinc-

ter more difﬁ cult.

◆ Preoperatively, all patients receive a bowel preparation and prophylactic antibiotics.

◆ Inﬁ ltration of the operative ﬁ eld with 20 U of vasopressin in 100 mL of normal saline or a

local anesthetic with epinephrine reduces blood loss and helps hydrodissect scarred tissue

planes.

CHAPTER

Repair of Rectovaginal Fistulae

Margie A. Kahn

CHAPTER 99 • Repair of Rectovaginal Fistulae 1093

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Most postpartum ﬁ stulae are accompanied by two quadrant anal sphincter defects identiﬁ -

able by perineal dimples at the 3 o’clock and 9 o’clock positions.

◆ In the worst cases, the vaginal mucosa directly abuts the rectal mucosa. If gross inspection

and palpation are equivocal, endoanal ultrasonography and anorectal manometry may be

used to identify the anatomic and functional signiﬁ cance of the defects. In the following

ﬁ gure, the normal sphincter is on the right.

◆ Extensive dissection to achieve anal overlapping sphincteroplasty can interfere with the

neurovascular bundles at the 4 o’clock and 8 o’clock positions (Figure 99-1).

Inferior anal nerve

Superficial perineal

nerve

Pudendal nerve

Deep perineal

nerve

Dorsal nerve of clitoris

Anal sphincter muscle

Transverse perineal

muscle

Clitoris

Bulbocavernosus or

Bulbospongiosus

muscle

Ischiocavernosus

muscle

FIGURE 99 –1