Gynecologic and obstetric surgery is a craft that requires sound knowledge and skills. The specifics of each individual case must be understood to enable the best surgical management approach and to minimize complications. This resource book offers insightful management options to many of the challenges a gynecologic or obstetric surgeon may face before, during and after an operation.
Divided into two sections, the book first covers general preoperative, intraoperative and postoperative challenges and, second, specific surgical procedures. It provides advice on both general gynecologic and obstetric operations, as well as subspecialist areas such as reproductive surgery, urogynecology and gynecologic oncology.
The chapters are concise, beginning with illustrative case histories followed by background, management options, and any preventative approaches. Designed to guide the surgeon to safe practice throughout all stages, they offer practical and step-by-step help.
Arri Coomarasamy, MBChB, MD, FRCOG. Professor of Gynaecology, Institute of Metabolism and System Research, University of Birmingham. Consultant Gynaecologist and Sub-specialist in Reproductive Medicine and Surgery, Birmingham Women's Hospital, Birmingham, United Kingdom.
Mahmood I. Shafi, MBBCh, MD, DA, FRCOG. Consultant Gynecological Surgeon and Oncologist, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
G. Willy Davila, MD, FACOG. Center Director, Women's Health Institute (Florida), Chairman, Department of Gynecology, Head, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston/Fort Lauderdale, Florida, United States.
K. K. Chan, MBBS, FRCS, FRCOG. Emeritus Consultant Gynecological Oncologist, Pan-Birmingham Gynecological Cancer Centre, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust. Birmingham, United Kingdom.
Gynecologic and obstetric surgery is a craft that requires sound knowledge and skills. The specifics of each individual case must be understood to enable the best surgical management approach and to minimize complications. This resource book offers insightful management options to many of the challenges a gynecologic or obstetric surgeon may face before, during and after an operation. Divided into two sections, the book first covers general preoperative, intraoperative and postoperative challenges and, second, specific surgical procedures. It provides advice on both general gynecologic and obstetric operations, as well as subspecialist areas such as reproductive surgery, urogynecology and gynecologic oncology. The chapters are concise, beginning with illustrative case histories followed by background, management options, and any preventative approaches. Designed to guide the surgeon to safe practice throughout all stages, they offer practical and step-by-step help.
Arri Coomarasamy, MBChB, MD, FRCOG. Professor of Gynaecology, Institute of Metabolism and System Research, University of Birmingham. Consultant Gynaecologist and Sub-specialist in Reproductive Medicine and Surgery, Birmingham Women's Hospital, Birmingham, United Kingdom. Mahmood I. Shafi, MBBCh, MD, DA, FRCOG. Consultant Gynecological Surgeon and Oncologist, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. G. Willy Davila, MD, FACOG. Center Director, Women's Health Institute (Florida), Chairman, Department of Gynecology, Head, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston/Fort Lauderdale, Florida, United States. K. K. Chan, MBBS, FRCS, FRCOG. Emeritus Consultant Gynecological Oncologist, Pan-Birmingham Gynecological Cancer Centre, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust. Birmingham, United Kingdom.
Gynecologic and Obstetric Surgery Challenges and Management Options 3
Contents 7
Contributors 12
Preface 17
List of Abbreviations 18
PART I General Preoperative, Intraoperative, and Postoperative Challenges 23
Section 1 Preoperative Care 23
Chapter 1 Patient with Poor ASA Score 25
Background 25
Management 25
Prevention of complications 26
References 27
Further reading 27
Chapter 2 Patient on Medication 28
Background 28
Medication and anesthesia interactions 28
Stress hormones 28
Poor gastrointestinal function 28
Clotting complications 28
Management 28
Medications on the day of the operation 28
Drugs that need to be continued and discontinued 28
Restarting medications 30
Resolution of the case 30
Prevention 30
References 30
Further reading 30
Chapter 3 Patient with Ischemic Heart Disease 31
Background 31
Coronary revascularization prior to non-cardiac surgery 31
PCI with BMS versus DES 31
Coronary stents and antiplatelet therapy 31
Bleeding risk with dual antiplatelet therapy 32
Management 32
Resolution of the case 32
Prevention 33
References 33
Chapter 4 Patient with Arrhythmias 35
Background 35
Definition and classifications 35
Management 35
Risk stratification 35
Antiarrhythmic therapy 36
Indications for urgent cardioversion 36
Perioperative management 36
Elective surgery 37
Emergency surgery 37
New-onset perioperative AF 37
Resolution of the case 37
References 38
Further reading 38
Chapter 5 Patient with a Pacemaker or Implantable Defibrillator 39
Background 39
Management 39
Identifying the type of device 39
Assessing pacemaker function 40
Disabling implantable defibrillator function 40
Planning of diathermy 40
Prevention 40
References 41
Further reading 41
Chapter 6 Patient with Complex Congenital Heart Disease (Fontan Circulation) 42
Background 42
Management 42
Further reading 43
Chapter 7 Hypertensive Patient 44
Background 44
Management 44
Assess risk 44
Look for cause 45
Optimize antihypertensive treatment 45
Continue antihypertensive treatment 45
Laparoscopic surgery in the hypertensive patient 45
Emergency surgery in the hypertensive patient 45
Postoperative care 45
References 45
Further reading 46
Chapter 8 Patient with Respiratory Disease 47
Background 47
Atelectasis 47
Management 47
Assess the extent and stability of the respiratory disorder 47
Optimize the management of the respiratory disorder 47
Cessation of smoking 48
Consider intraoperative steps to reduce risk 48
Arrange lung expansion interventions 48
Postoperative care 48
Resolution of the case 48
References 49
Chapter 9 Patient with Diabetes 50
Background 50
Management 50
Hyperglycemia 50
Hypoglycemia 50
Prevention 50
Reference 51
Further reading 51
Chapter 10 Patient with Thyroid Disease 52
Background 52
Hyperthyroidism 52
Hypothyroidism 52
Goiter 53
Management 53
Hyperthyroidism 53
Hypothyroidism 53
Goiter 53
Prevention 53
References 54
Chapter 11 Patient with Renal Disease 55
Background 55
Management 55
Identify important risk factors 55
Check blood pressure 55
Perform baseline investigations 55
Avoid nephrotoxic drugs 55
Monitor fluid and electrolyte balance 56
Discuss with anesthetist 56
Prevention 56
Further reading 56
Chapter 12 Patient with Liver Disease 57
Background 57
Management 57
Preoperative management 57
Intraoperative management 58
Postoperative management 58
Resolution of the case 58
Prevention 58
References 59
Chapter 13 Patient with Rheumatologic Diseases 60
Background 60
Management of patients with rheumatoid arthritis 60
Drug management 60
Musculoskeletal risks 61
Cardiorespiratory risks 61
Venous thromboembolism risks 61
Wound care 61
Resolution of the case 61
Other rheumatologic disorders 61
References 62
Further reading 62
Chapter 14 Patient with Hematologic Disorders 63
Anemia 63
Background and management 63
Thrombocytopenia 63
Background and management 63
Bleeding disorders 63
Background and management 63
Venous thrombosis 64
Background and management 64
Resolution of the case 64
References 65
Chapter 15 Patient at High Risk of Venous Thrombosis 66
Background 66
Gynecologic surgery 66
Obstetric surgery 66
Management 66
Specific high-risk gynecologic situations 67
Specific high-risk obstetric situations 67
Resolution of the case 67
References 67
Chapter 16 Patient on Anticoagulant Therapy 69
Background 69
Management 69
Preoperative care 69
Postoperative care 69
Special circumstances 69
Anticoagulation in an obstetric patient 70
Resolution of the cases 70
Case history 1 70
Case history 2 70
Reference 71
Further reading 71
Chapter 17 Patient on Steroid Therapy 72
Background 72
Normal physiology of hypothalamic–pituitary–adrenal axis 72
Effect of surgery and stress on HPA axis 72
HPA axis suppression 72
Management 72
Perioperative management: to replace or not to replace? 72
Steroid replacement regimens 73
Prevention (of complications) 74
References 74
Chapter 18 Patient with Epilepsy 76
Background 76
Management 76
Preoperative management 76
Intraoperative management 76
Postoperative management 76
Further reading 77
Chapter 19 Patient with a Psychiatric Condition 78
Background 78
Management 78
Assessment 78
Capacity and consent 78
Medical management 78
Postoperative considerations 79
Prevention 79
References 79
Chapter 20 Patient with Organ Transplant 81
Background 81
Management 81
Preoperative management 81
Postoperative care 81
Cesarean section in a renal transplant patient 81
References 82
Chapter 21 Patient with Hepatitis B or C 83
Background 83
Hepatitis B 83
Hepatitis C 83
Transmission risk from needlestick injury 84
Management 84
Management of patients with HBV or HCV infection 84
Prevention of transmission of HBV and HCV from the patient to healthcare workers 84
HBV post-exposure management 84
HCV post-exposure management 84
References 85
Chapter 22 Patient with HIV 86
Background 86
Perioperative risks in HIV patients 86
Risk of transmission to healthcare workers 86
Management 86
Preoperative assessment 86
Preoperative management 86
Postoperative management 86
Resolution of the case 87
Prevention of transmission of HIV from the patient to HCWs 87
Post-exposure management 87
References 88
Chapter 23 Obese Patient 89
Background 89
Management 89
Preoperative preparation 89
Intraoperative management 89
Postoperative management 90
Prevention 90
Further reading 90
Chapter 24 Patient with Poor Nutritional Status 91
Background 91
Management 91
Prevention 92
Further reading 92
Chapter 25 Pregnant Patient Requiring Non-obstetric Surgery 93
Background 93
Physiologic changes in pregnancy 93
Testing in pregnancy 93
Management 93
Patient positioning and fetal monitoring 93
Surgical approach 93
Postoperative care 94
Resolution of the case 94
Prevention 94
References 95
Section 2 Intraoperative Care 97
Chapter 26 Transverse Incision on the Abdomen Inadequate for Surgery 99
Background 99
Management 99
Making more room by modifying the incision 99
Reducing the size of the uterus by performing a myomectomy 100
Prevention 100
References 100
Chapter 27 Previous Multiple Abdominal Scars 101
Background 101
Management 101
Pre-admission care 101
Preoperative care 101
Intraoperative care 102
Postoperative care 103
References 103
Chapter 28 Patient with Previous Mesh Incisional Hernia Repair Requiring a Laparotomy 105
Background 105
Types of mesh and surgical approach 105
Mesh types 105
Surgical techniques 106
Management 106
Surgical technique for entry to the abdomen 106
Closure of the abdominal wall 106
References 107
Chapter 29 Patient with Previous Mesh Incisional Hernia Repair Requiring a Laparoscopy 108
Background 108
Management 108
Patient positioning 108
Abdominal access 108
Lysis of adhesions 109
Postoperative management 109
Prevention 110
References 110
Chapter 30 Unexpected Pathology: Ovarian Cyst 111
Background 111
Management 111
To biopsy or not? 111
When to operate on the ovary without consent 111
Investigations for cysts diagnosed before an operation 111
Common cysts and their management 112
Resolution of the cases 112
Case history 1 112
Case history 2 112
Prevention 112
Reference 113
Chapter 31 Unexpected Pathology: Abnormal Appearance of the Uterus 114
Background 114
Management 114
Enlarged uterus 114
To biopsy or not? 114
Abnormal serosal surface 115
Resolution of the cases 115
Case history 1 115
Case history 2 115
Prevention 115
References 115
Chapter 32 Unexpected Pathology: Severe Pelvic Adhesions 116
Background 116
Adhesion formation 116
Risks of adhesions 116
Management 116
Entry into abdomen through a virginal area 116
Adhesiolysis 116
Lighted ureteral stent 117
Prevention of adhesions 117
Conclusion 117
References 118
Chapter 33 Unexpected Pathology: Abnormal Appearance of Bowel 119
Background 119
Management 119
Appendicitis 119
Diverticular disease and diverticulitis 119
Meckel’s diverticulum 120
Inflammatory bowel disease 120
Bowel adhesions and strictures 120
Bowel tumors 120
Hernias 120
Resolution of the case 120
Prevention 121
Conclusion 121
References 121
Chapter 34 Unexpected Pathology: Retroperitoneal Mass 122
Background 122
Anatomy of the retroperitoneum 122
Management 123
Prevention 124
References 124
Chapter 35 Bladder Injury 125
Background 125
Site and mechanism of injury 125
Management 125
Diagnosis of bladder injury 125
Instruments and sutures 125
Bladder repair 126
Management of urinary leak 126
Resolution of the cases 127
Case history 1 127
Case history 2 127
Case history 3 127
Prevention 127
References 127
Chapter 36 Ureteric Injury 128
Background 128
Sites and mechanism of injury 128
Management 128
Diagnosis 128
Management of intraoperatively diagnosed ureteric injury 129
Management of postoperatively diagnosed ureteric injury 130
Resolution of the cases 131
Case history 1 131
Case history 2 131
Case history 3 131
Prevention 131
References 132
Chapter 37 Small and Large Bowel Injury 133
Background 133
Site and mechanism of injury 133
Management (see also Chapters 74 and 75) 133
Choice of operative approach for repair 133
Management of intraoperatively diagnosed small bowel injury 134
Management of intraoperatively diagnosed large bowel injury 135
Stoma 135
Management of postoperatively diagnosed bowel injury 135
Postoperative management 136
Resolution of the cases 136
Case history 1 136
Case history 2 136
Case history 3 136
Prevention 136
Reference 137
Chapter 38 Inferior Epigastric Vessel Injury 138
Background 138
Anatomy 138
Management 138
Prevention 139
References 140
Chapter 39 Bleeding from Retracted Pedicular (Pelvic Sidewall) Vessels 141
Background 141
Management (see Chapter 40) 141
Identify and secure the retracted pedicle and vessel 141
Ligation of anterior division of the internal iliac artery 141
Arterial embolization 142
Pelvic packing 142
Prevention 142
References 142
Chapter 40 Massive Hemorrhage 143
Background 143
Classification of hemorrhagic shock 143
Management 143
Immediate steps 143
Transfusion of blood and blood products 143
Medical drug interventions 144
Massive obstetric hemorrhage 144
Massive gynecologic hemorrhage 144
Postoperative care 145
Resolution of the cases 145
Case history 1 145
Case history 2 145
Prevention 145
How to avoid massive hemorrhage and vessel injury 145
References 146
Chapter 41 Broken Needle 147
Background 147
Management 147
Intraoperative 147
Postoperative 147
Prevention 148
References 148
Chapter 42 Lost Swab, Needle or Instrument 149
Background 149
Swabs 149
Instruments and needles 149
Management 149
Intraoperative 149
Postoperative 150
Prevention 150
Preoperative 150
Intraoperative 150
Preventive WHO guidelines 150
References 150
Section 3 Postoperative Care 151
Chapter 43 Postoperative Care 153
Background 153
Prevention and management 154
Resolution of the case 154
References 154
Chapter 44 Excessive Nausea and Vomiting after Surgery 155
Background 155
Anatomy and physiology of the vomiting reflex 155
Management 155
Assess and treat causes of PONV 155
Use antiemetic drugs 155
Further reading 157
Chapter 45 Excessive Abdominal Pain after Surgery 158
Background 158
Management 158
Assess the patient 158
Get the necessary expert help 158
Bowel trauma (see Chapter 37) 158
Ileus 159
Constipation 159
Bladder or ureteric trauma 159
Urinary retention 159
Urinary tract infection 159
Sepsis 159
Pelvic collection 159
Ischemic trauma 159
Hemorrhage 159
Surgically unrelated causes 159
Prevention 159
References 160
Chapter 46 Bowel Damage: Postoperative Presentation 161
Background 161
Mode of colonic injury 161
Mode of small bowel injury 161
Presentation 161
Role of imaging 162
Management (see Chapter 37) 162
Resolution of the case 162
Postoperative care 162
Prevention 162
References 163
Chapter 47 Wound Infection 164
Background 164
Risk factors for wound infection 164
Classification of wound infections 164
Management 164
Management of early-onset infections 165
Management of late-onset infections 165
Review of antibiotic therapy 165
Wound care 166
Prevention 167
Prophylactic antibiotics 167
Surgical technique 167
References 168
Chapter 48 Wound Dehiscence 169
Background 169
Risk factors for wound dehiscence 169
Management 169
Care of superficial dehiscence 169
Management of full-thickness wound dehiscence 169
Negative pressure wound therapy 170
Postoperative care 170
Prevention 170
References 171
Chapter 49 Late Wound Failure: Incisional Hernia 172
Background 172
Management 172
To repair or not to repair 172
Surgical technique 172
Prevention 173
Prophylactic care to avoid risk of late wound failure [6] 173
References 174
Chapter 50 Necrotizing Fasciitis 175
Background 175
Management 175
Diagnosis 175
Clinical management 176
Surgical management 176
References 177
Chapter 51 Management of Surgical Drains 178
Background 178
Indications and morbidities associated with surgical drains 178
Types of surgical drains 178
Management 179
Resolution of the case 179
References 180
Chapter 52 Shocked Patient 181
Background 181
Diagnosis 181
Management 182
Assess airway, breathing, and circulation 182
Administer fluids and/or blood 182
Consider using a vasopressor 182
Treat the cause of shock 182
Resolution of the case 183
References 183
Chapter 53 Breathless Patient: Postoperative Pulmonary Complications 184
Background 184
Management 184
Investigations 184
Management of pulmonary complications 185
Resolution of the case 185
References 186
Chapter 54 Confused Postoperative Patient 187
Background 187
Management 187
Assessment 187
Conservative management 188
Medical management 188
Follow-up 188
Prevention 188
References 188
Chapter 55 Patient with Poor Urine Output 189
Background 189
Prevention 189
Management 190
Review the clinical history 190
Assessment 190
Resolution of the cases 190
Case history 1 190
Case history 2 190
Case history 3 191
References 191
Chapter 56 Electrolyte Imbalance 192
Background 192
Management 192
Potassium 192
Hyperkalemia 193
Hypokalemia 193
Other electrolyte imbalances 193
Resolution of the case 193
References 195
Chapter 57 Swollen Leg 196
Background 196
Management 196
Assessment 196
Management of deep vein thrombosis 197
Management of acute arterial insufficiency 197
Management of varicose veins 197
Management of lymphedema 197
Prevention of venous thromboembolism 197
References 198
Chapter 58 Cardiorespiratory Arrest 199
Background 199
Prevention 199
Management of cardiac arrest 199
Chest compressions and ventilation 199
Pregnant patient 199
Causes and management 200
Perimortem cesarean section 200
Laparoscopic patient 201
Post-arrest issues 201
References 201
PART II Operations and Challenges 203
Section 4 General and Minimal Access Gynecology 203
Chapter 59 Difficulty in Dilating the Cervix: Cervical Stenosis and Cervical Closure 205
Background 205
Management 205
Cervical stenosis 205
Cervical closure 206
Hemorrhage from cervical trauma 206
Resolution of the cases 206
Case history 1 206
Case history 2 206
Case history 3 206
Prevention 206
Be prepared 206
Cervical preparation 207
References 207
Chapter 60 Uterine Perforation 208
Background 208
Risks of perforation 208
Management 208
Perforation with non-thermal and non-grasping instruments 208
Perforation with thermal, avulsion, or suction instruments 209
Lateral wall cervical or lower uterine perforations 209
Completion of the original procedure 209
Resolution of the cases 209
Case history 1 209
Case history 2 209
Case history 3 209
Prevention 209
References 210
Chapter 61 Surgical Uterine Evacuation: Excessive Bleeding 211
Background 211
Management 211
General measures 211
Diagnose and treat cause 211
Excessive genital tract bleeding not responding to above measures 212
Prevention 212
Further reading 212
Chapter 62 Surgical Uterine Evacuation in a Woman with Multiple Fibroids 213
Background 213
Management 213
Conduct the surgical ERPC under continuous ultrasound surveillance 213
Maximize surgical access and identify the cervix 213
Employ strategies to overcome cervical obstruction 213
Consider use of flexible uterine catheter insertion under concurrent ultrasound guidance 213
Contemplate hysterotomy or hysterectomy 214
Prevention 214
Pelvic examination prior to ERPC 214
Medical management 214
Pre-procedure cervical softening 214
Arrange for availability of portable ultrasound and flexible suction catheters for time of planned ERPC 214
Further reading 215
Chapter 63 Use of Excessive Distension Media at Hysteroscopy 216
Background 216
Complications of excessive distension media 216
Management 216
Resolution of the cases 217
Case history 1 217
Case history 2 217
Prevention 217
References 218
Chapter 64 Hysteroscopy: Endometrial Resection and Ablationin the Abnormal Uterine Cavity 219
Background 219
Management 219
Choice of surgical technique 219
Endometrial preparation 219
Treatment setting 220
Technique 220
References 220
Chapter 65 Laparoscopy in a Pediatric Patient 221
Background 221
Management 221
Consenting 221
Instruments 221
Patient positioning 222
Risks of laparoscopy and management 222
Resolution of the cases 223
Case history 1 223
Case history 2 223
Prevention 223
References 223
Chapter 66 Safe Laparoscopic Entry in a Thin Patient 224
Background 224
Management 224
Safe transumbilical laparoscopic entry 224
Special considerations in a thin patient 224
Resolution of the case 225
References 226
Chapter 67 Laparoscopy: Unable to Gain Entry 227
Background 227
Management 227
The morbidly obese woman 227
Women with previous laparotomy (Chapter 27) 228
Prevention 228
Aspiration test 228
Hanging drop test 228
Gas insufflation test 228
Resolution of the cases 229
Case history 1 229
Case history 2 229
References 229
Chapter 68 Surgical Emphysema 230
Background 230
Complications of surgical emphysema 230
Management 230
Diagnostic features 230
Treatment 230
Resolution of the cases 230
Case history 1 230
Case history 2 231
Prevention 231
References 231
Chapter 69 Venous Air Embolism 232
Background 232
Pathophysiology 232
Diagnosis 232
Prevention 233
Management 233
Resolution of the cases 233
Case history 1 233
Case history 2 233
References 234
Chapter 70 Laparoscopy: Problems with Monopolar Diathermy 235
Background 235
Basics of energy 235
Prevention 236
Preoperative measures 236
Intraoperative measures 236
Resolution of the case 237
References 237
Chapter 71 Laparoscopy: Problems with Bipolar Diathermy 238
Background 238
Prevention 238
Application of bipolar energy 238
Advanced bipolar instruments 239
Management 239
References 239
Chapter 72 Laparoscopy: Bladder Injury 240
Background 240
Prevention 240
Primary prevention 240
Secondary prevention (see Chapter 35) 241
Tertiary prevention 241
Management (see Chapter 35) 241
References 242
Chapter 73 Laparoscopy: Ureteric Injury 243
Background 243
Anatomy of the ureters 243
Prevention 243
Identification of the ureters 243
Risk reduction 243
Ureteral stenting 244
Surgical techniques 244
Management (see Chapter 36) 244
Detection 244
Treatment (see Chapter 36) 244
References 245
Chapter 74 Bowel Injury During Laparoscopy: Intraoperative Presentation 246
Background 246
Management (see Chapter 37) 246
Recognition of bowel injury 246
Steps after recognizing the bowel injury 246
Postoperative care 247
Prevention 247
Further reading 248
Chapter 75 Bowel Injury After Laparoscopy: Late Presentation 249
Background 249
Management (see Chapter 37) 249
Investigations 249
Conservative management 250
Role of laparoscopy 250
Laparotomy 250
Prevention 250
Further reading 251
Chapter 76 Blood Vessel Injury at Laparoscopy 252
Background 252
Prevention 252
Anatomic considerations at entry 252
Anatomic considerations at secondary port placement 252
General preoperative considerations 252
Positioning of the patient 253
Choice of mode of access 253
Veress needle and trocar insertion 253
Intraoperative anatomic and spatial awareness 253
Insertion of the secondary ports 253
Operating near large vessels 253
Management (see Chapters 38, 40 and 121) 253
What should be done when large vessel injury occurs? 253
What should be done when an abdominal wall injury occurs? 254
References 254
Chapter 77 Laparoscopy for Large Ovarian Cyst 255
Background 255
Management 255
Management of a simple cyst 255
Management of a dermoid cyst 256
References 256
Chapter 78 Laparoscopy for an Ovarian Cyst in Pregnancy 257
Background 257
Management (see Chapter 25) 257
Management decisions 257
Conservative management 257
Surgical management 258
Resolution of the cases 258
Case history 1 258
Case history 2 258
References 258
Chapter 79 Laparoscopic Removal of Rectovaginal Endometriosis 260
Background 260
Management 260
Diagnosis 260
Expectant management 260
Medical treatment 260
Surgical management 260
Surgical treatment 261
Reference 263
Further reading 263
Chapter 80 Laparoscopic Myomectomy 264
Background 264
Management 264
Preoperative patient selection 264
Preoperative medical treatment to reduce thesize of fibroids 264
Port placement 265
Intraoperative vasoconstrictive agents 265
Surgical technique 265
Prevention of complications 266
References 266
Chapter 81 Total Laparoscopic Hysterectomy 267
Background 267
Management 267
Evidence 268
References 268
Chapter 82 Laparoscopic Hysterectomy for a Large Fibroid Uterus 269
Background 269
Management 269
Entering the abdomen without causing trauma to the uterus 269
Maximizing view of the operative field and range of instrumentation 269
Ensuring adequate uterine maneuverability 270
Avoiding back-bleeding from the uterus 270
Ensure adequate bladder dissection off the cervix 270
Ensuring adequate ureteric dissection before coagulation of the uterine arteries 270
Colpotomy under laparoscopic visualization 270
Removal of the specimen 270
Prevention 270
References 271
Chapter 83 Laparoscopy: Difficulty in Tissue Retrieval 272
Background 272
Management 273
Prevention 274
References 274
Chapter 84 Surgery for Cornual or Interstitial Pregnancy 275
Background 275
Prevention 275
Management 275
Laparoscopic approach 275
Hysteroscopic approach 276
Postoperative management 276
References 277
Chapter 85 Surgery for Cervical Ectopic Pregnancy 278
Background 278
Epidemiology 278
Diagnosis 278
Management 278
Medical management 278
Surgical management 279
Interventional radiology 279
References 279
Chapter 86 Surgery for Cesarean Scar Pregnancy 281
Background 281
Management 281
Medical treatment combined with surgical sac aspiration 281
Uterine curettage 282
Hysteroscopic evacuation 282
Vaginal removal 282
Laparoscopic removal 282
Open surgical removal 282
Hysterectomy 282
Prevention 282
References 283
Chapter 87 Surgery for Adnexal Torsion 284
Background 284
Management 284
Preoperative preparation 284
Surgical approach 285
Surgical treatment options 285
Follow-up 285
References 285
Chapter 88 Laparoscopic Appendectomy 286
Background 286
Management 286
Surgical technique 286
Complicated appendicitis or appendicular anatomy 287
Prevention 287
Potential iatrogenic injury 287
References 288
Chapter 89 Laparoscopic Surgery: When to Convert to Laparotomy? 289
Background 289
Management 289
Adhesions 289
Very large pelvic mass (see Chapter 82) 289
Obesity 289
Hemorrhage 289
Anesthesia 290
Prevention 290
References 290
Chapter 90 Laparoscopy: Port-site Herniation 291
Background 291
Risk factors 291
Prevention 292
Port insertion and closure techniques 292
Operative factors 292
Wound infection 292
Detection of undetected hernia 292
Management 292
References 293
Section 5 Reproductive Surgery 295
Chapter 91 Uterine Septum 297
Background 297
Management 297
Diagnosis 297
When to treat? 297
Preoperative preparation 297
Concomitant laparoscopy 297
Choice of instrument 298
Operative technique 298
Completion of the procedure: when to stop? 298
Postoperative care 298
References 298
Chapter 92 Surgery for Intrauterine Adhesions 300
Background 300
Management 300
Adhesiolysis technique 300
Adhesion prevention after adhesiolysis 300
Regenerating endometrium 301
Test of treatment 301
Prevention 301
References 301
Chapter 93 Myomectomy: Breach of the Endometrial Cavity 302
Background 302
Management 302
Repair of endometrial cavity 302
Testing the uterine cavity 302
Prevention 302
References 303
Chapter 94 Myomectomy: Multiple Large Fibroids 304
Background 304
Management 304
Preoperative considerations 304
Intraoperative considerations 304
Postoperative considerations 305
References 305
Chapter 95 Myomectomy: Massive Intraoperative Hemorrhage 306
Background 306
Management 306
Abdominal myomectomy (laparotomy) 306
Laparoscopic myomectomy 307
Hysteroscopic myomectomy 307
Prevention 307
References 307
Chapter 96 Vaginal Myomectomy 309
Background 309
Management 310
Vaginal myomectomy procedure 310
Conclusion 310
References 310
Chapter 97 Surgery for Proximal Tubal Blockage 311
Background 311
Management 311
Preoperative management 311
Equipment 311
Patient preparation 311
Technique 311
Postoperative care 313
Tubal spasm 313
Pregnancy results 313
References 313
Chapter 98 Surgery for Distal Tubal Disease 314
Background 314
Classification of tubal disease 314
Management 314
Types of tubal surgery 314
Prevention 315
References 316
Chapter 99 Reversal of Sterilization 317
Background 317
Management 317
Reversal technique 317
Outcomes 318
Prognostic factors 318
Assisted conception 318
Prevention 319
References 319
Chapter 100 Surgery for Congenital Abnormalities of the Genital Tract 321
Background 321
Normal development 322
Obstructive anomalies 322
Vaginal and uterine agenesis 322
Management 322
Diagnosis 322
Management of obstructive anomalies 322
Management of uterine and vaginal septa 323
Management of vaginal agenesis 323
References 324
Chapter 101 Surgical Sperm Retrieval 326
Background 326
Etiology 326
Management 326
Microdissection testicular sperm extraction 326
References 327
Section 6 Urogynecologic Surgery 329
Chapter 102 Sling Procedures: Bladder Injury 331
Background 331
Management 331
Bladder perforation 331
Late sling erosion (see Chapter 107) 331
Prevention 332
References 332
Chapter 103 Sling Procedures: Urethral Injury 333
Background 333
Presentation 333
Risk factors 334
Management 334
Intraoperatively diagnosed urethral injury 334
Postoperatively diagnosed urethral injury 334
Resolution of the case 334
Prevention 335
References 335
Chapter 104 Sling Procedures: Retropubic Hematoma 336
Background 336
Management 336
Diagnostic evaluation 336
Treatment 336
Prevention 337
References 337
Chapter 105 Sling Procedures: Bowel Injury 338
Background 338
Presentation 338
Management (see Chapter 37) 338
Immediate intraoperative management 338
Management of late bowel perforation 338
Prevention 338
References 339
Chapter 106 Sling Procedures: Voiding Dysfunction after Stress Urinary Incontinence Surgery 340
Background 340
Clinical presentation 340
Management 340
Evaluation 340
Treatment 340
References 342
Chapter 107 Sling Procedures: Tape Erosion into Bladder 343
Background 343
Clinical presentation 343
Prevention 343
Management 343
Diagnosis 343
Treatment 343
References 344
Chapter 108 Sling Procedures: Sexual Dysfunction 345
Background 345
Management 345
Mesh exposure 345
Non-exposed mesh 346
Prevention 346
References 346
Chapter 109 Sling Procedures: Persistent Urine Leakage 347
Background 347
Potential causes for sling failure 347
Management 348
Assessment 348
Treatment 348
References 350
Chapter 110 Difficult Vaginal Hysterectomy 351
Background 351
Management 351
Enlarged uterus 351
Undescended uterus 352
Previous cesarean section(s) 352
Obliterated anterior or posterior cul de sac 352
Cervical hypertrophy 352
Very large bulky cervix 352
Adnexal masses 352
Thick pelvic adhesions 353
Nulliparity 353
Anatomic barriers to TVH 353
Adjunctive procedures of value 353
Further reading 353
Chapter 111 Vaginal Hysterectomy: Difficulty in Entering the Posterior Pouch 354
Background 354
Management 354
Assessment 354
Posterior cul-de-sac entry 354
The difficult-to-enter posterior cul-de-sac 356
Alternative options 356
References 356
Chapter 112 Salpingo-oophorectomy at the Time of Vaginal Hysterectomy 357
Background 357
Factors influencing success of BSO at the time of TVH 357
Management 357
Techniques used for vaginal BSO 357
Complications of vaginal BSO 358
Transvaginal endoscopy 358
References 359
Chapter 113 Bladder Injury During Anterior Vaginal Repair or Vaginal Hysterectomy 360
Background 360
Etiology 360
Prevention 360
Management (see Chapter 35) 360
Diagnosis 360
Treatment 360
References 362
Chapter 114 Difficult Sacrocolpopexy 363
Background 363
Surgical management of vaginal vault prolapse 363
Vaginal surgery 363
Abdominal approach 363
Intraoperative challenges during sacrocolpopexy 365
Resolution of the case 365
References 366
Chapter 115 Difficult Sacrospinous Fixation 367
Background 367
Management 367
Preoperative management 367
Sacrospinous ligament fixation technique 367
Challenges and complications 368
Prevention 368
References 369
Chapter 116 Recurrent Pelvic Organ Prolapse 370
Background 370
Incidence 370
Risk factors 370
Management 370
Conservative management 370
Surgical management 370
References 371
Chapter 117 Colpocleisis 373
Background 373
Management 373
Preoperative management 373
Surgical technique 373
Partial colpocleisis 374
References 374
Chapter 118 Uterine Suspension Procedures: Laparoscopic Hysteropexy 375
Background 375
Management 376
Surgical technique (Figure 118.2) 376
Outcomes 376
Disadvantages 377
Fertility following uterine preservation surgery 377
NICE guidelines 377
Resolution of the cases 377
Case history 1 377
Case history 2 377
References 377
Chapter 119 Mesh Tape Exposure Following Tension-free Vaginal Tape 378
Background 378
Management 379
Management of urinary obstruction secondary to TVT (see Chapter 106) 379
Management of vaginal mesh exposure 380
Prevention 380
References 381
Chapter 120 Vaginal Vault Evisceration 382
Background 382
Management 382
Immediate management 382
Surgical management 382
Postoperative management 383
Prevention 383
References 383
Chapter 121 Complications in Laparoscopic Pelvic Floor Surgery 384
Background 384
Trocar site bleeding 384
Presacral bleeding 385
Bowel injury 385
Bladder injury 385
Ureteric injury 385
Management 385
Management of trocar site bleeding 385
Management of presacral bleeding 386
Management of bowel injury (see Chapters 37, 74 and 75) 386
Management of bladder injury (see Chapters 35 and 72) 387
Management of ureteric injury (see Chapters 36 and 73) 387
References 387
Chapter 122 Robotic Urogynecology Procedures 389
Background 389
Sacrocolpopexy 389
Hysteropexy 389
Vesicovaginal fistula repair 389
Resolution of the case (see Chapter 118) 389
Challenges associated with robot-assisted surgery 390
References 390
Chapter 123 Complications in Robotic Pelvic Floor Surgery 392
Background 392
Recurrent pelvic organ prolapse 392
Patient positioning 392
Mesh or graft complications 392
Management 392
The patient 392
The operating room team 393
The procedure 393
Resolution of the case 393
References 393
Chapter 124 Neovagina 394
Background 394
Case history 1 (see Chapter 100) 394
Case history 2 394
Evaluation 394
Management 394
Non-surgical management 394
Surgical creation of a neovagina 395
Postoperative care 395
References 396
Further reading 396
Chapter 125 Vaginal Stricture After Pelvic Organ Prolapse Surgery 397
Background 397
Location 397
Importance of postoperative intercourse 397
Prevention 397
Prepare perineal tissue 397
Minimize vaginal mucosal trimming 398
Avoid over-plication of soft tissue 398
Manage mucosal tears rationally 398
Consider using vaginal dilators 398
Management 398
Local estrogen 398
Transection and cautery of the defect base 398
Band transection and suturing in the operating room 398
Other alternatives 399
References 399
Chapter 126 Urethral Diverticula and Other Periurethral Masses 400
Background 400
Clinical evaluation 400
Management 401
Urethral diverticulum 401
Leiomyoma 402
Skene gland 402
Gartner’s duct 402
Vaginal wall cyst 402
Urethral prolapse 402
Urethral caruncle 402
Sterile abscess 402
References 403
Chapter 127 Vesicovaginal Fistulae 404
Background 404
Prevention 404
Management 404
Diagnosis 404
Conservative management 405
Abdominal, laparoscopic, or robotic repair 405
Vaginal repair 406
Vascular pedicles 406
Postoperative management 406
References 407
Chapter 128 Urethrovaginal Fistulae 408
Background 408
Management 408
Diagnosis 408
Classification 409
Treatment 409
Complications 409
Prevention 410
References 410
Chapter 129 Rectovaginal Fistulae 411
Background 411
Management 411
Preoperative evaluation 411
Surgical approach 411
Prevention 412
Obstetric practice 412
Bartholin or perineal abscess 412
Posterior vaginal wall surgery 412
References 413
Chapter 130 Secondary Anal Sphincter Repair 414
Background 414
Management 414
Overlapping sphincteroplasty 414
Resolution of the case 415
References 417
Section 7 Gynecologic Oncology 419
Chapter 131 Large Loop Excision of the Transformation Zone 421
Background 421
Management 421
Hemostasis 422
Postoperative care 422
Resolution of the case 422
Prevention 422
Further reading 422
Chapter 132 Knife Cone Biopsy 423
Background 423
Management 423
Hemostasis 423
Resolution of the case 424
Prevention 424
References 424
Chapter 133 Staging Procedures: Examination Under Anesthesia, Cystoscopy, Sigmoidoscopy, and Biopsy Techniques 425
Background 425
Management 425
Cystoscopy 425
Sigmoidoscopy 426
Cervical biopsies 427
Prevention 427
Further reading 427
Chapter 134 Radicality of Surgery for Cervical Cancer 428
Background 428
Management 428
Prevention 429
References 429
Chapter 135 Pelvic and Para-aortic Lymphadenectomy in Gynecologic Cancers 430
Background 430
Surgical routes for lymphadenectomy 430
Surgical anatomy of pelvic lymph nodes 430
Surgical anatomy of para-aortic lymph nodes 430
Management 431
Pelvic lymphadenectomy 431
Para-aortic lymphadenectomy 432
Complications of lymphadenectomy 432
References 433
Chapter 136 Trachelectomy for Treatment of Cervical Cancer 434
Background 434
Management 434
Patient selection 434
Surgical technique 434
Outcomes 435
References 435
Further reading 435
Chapter 137 Laparoscopic Radical Surgery for Cervical Cancer 436
Background 436
Management 436
Preparation 436
Surgical technique 436
Management of lymph nodes 436
Complications of laparoscopic radical hysterectomy 437
Prevention 437
References 437
Chapter 138 Groin and Retroperitoneal Lymphocele 438
Background 438
Management 438
Presentation and evaluation 438
Management of groin lymphoceles 438
Management of retroperitoneal lymphoceles 439
Prevention 439
References 439
Chapter 139 Laparotomy for a Pelvic Mass of Uncertain Nature 440
Background 440
Management 440
Technique 441
Prevention 441
Reference 441
Further reading 441
Chapter 140 Gynecologic Cancer Extending to the Bowel 442
Background 442
Management 442
Patient preparation 442
Surgical technique 442
Prevention 443
Further reading 444
Chapter 141 Omental Procedures: Supracolic Omentectomy, Infracolic Omentectomy, Omental Biopsy 445
Background 445
Management 445
Resolution of the cases 445
Further reading 446
Chapter 142 Diaphragmatic Surgery in Advanced Ovarian Cancer 447
Background 447
Hepatophrenic anatomy 447
Management 447
Types of diaphragm surgery in ovarian cancer cytoreductive surgery 448
Surgical technique 448
Complications 449
Prevention 449
References 449
Chapter 143 Fine-needle Aspiration Biopsy of Superficial Groin Lymph Node 450
Background 450
Management 450
References 451
Chapter 144 Vulval Surgery: Wide Local Excision and Vulvectomy 453
Background 453
Management 453
Assessment 453
Surgical management 453
Resolution of the cases 453
Case history 1 453
Case history 2 453
Postoperative management 454
Prevention 454
Further reading 454
Chapter 145 Sentinel Node Biopsy in Gynecologic Cancer 455
Background 455
Management 455
SLN detection in vulval cancer 456
SLN detection in cervical cancer 456
SLN detection in endometrial cancer 456
References 456
Chapter 146 Groin Lymphadenectomy 457
Background 457
Management 457
Assessment 457
Planning of surgery 457
Surgical technique 458
Survival rates 458
Complications 459
Resolution of the cases 459
Case history 1 459
Case history 2 459
Prevention 459
References 459
Chapter 147 Plastic Surgical Techniques in Vulval or Perineal Procedures 460
Background 460
Management 460
V-Y flap 460
Rotational flap 460
Rhombic transposition flap 461
Prevention 461
References 462
Chapter 148 Vaginectomy 463
Background 463
Management 463
Diagnostic work-up 463
Preparation for surgery 463
Technique: vaginal simple vaginectomy 463
Technique: abdominal or laparoscopic vaginectomy after hysterectomy 463
Risks and risk-reduction strategies 464
Resolution of the case 464
References 464
Chapter 149 Urinary Diversion 465
Background 465
Management 465
Complications of urinary diversion procedures 465
Operative technique for ileal conduit 466
Resolution of the case 466
References 467
Chapter 150 Pelvic Exenteration 468
Background 468
Management 468
Case selection for pelvic exenteration 468
Contraindications for exenteration 469
Preoperative preparations 469
Surgical procedure 469
Postoperative management 469
Resolution of the case 469
Quality of life after exenterative surgery 469
References 470
Chapter 151 Gynecologic Cancer and Concurrent Pregnancy 471
Background 471
Management 471
Management of suspected cervical cancer 471
Management of suspected ovarian cancer 472
References 472
Section 8 Obstetric Surgery 475
Chapter 152 Ovarian Cyst Identified at Cesarean Section 477
Background 477
Management 477
Women under general anesthesia 477
Women under regional anesthesia 477
Avoiding spillage during cystectomy 477
Resolution of the case 478
References 478
Chapter 153 Laparoscopy in Pregnancy 479
Background 479
Physiologic concerns of laparoscopy and pregnancy (Chapter 25) 479
Fetal concerns with laparoscopy 479
Management (Chapters 25 and 78) 479
Timing of intervention 479
Patient positioning 480
Entry techniques 480
Intraoperative recommendations 480
Fetal monitoring 480
Postoperative management 480
References 480
Chapter 154 Cervical Cerclage 481
Background 481
Criteria for offering cervical cerclage 481
Approaches for cervical cerclage 481
Management 481
Transvaginal cervical cerclage 481
Surgical technique for transvaginal cerclage [5] 482
Transabdominal cerclage 482
Postoperative care 483
References 484
Chapter 155 Cesarean Section in a Woman with Fibroids 485
Background 485
Management 485
Preoperative management 485
Intraoperative management 485
Postpartum management 486
References 486
Chapter 156 Cesarean Section at the Limits of Viability 487
Background 487
Management 487
Preoperative management 487
Optimization of surgical approach 487
Method of uterine incision 487
Minimizing fetal injury 488
Prevention 488
References 489
Chapter 157 Difficult Delivery of the Fetal Head During Cesarean Section 490
Background 490
Management 490
“Push” method 490
Reverse breech extraction method 490
Patwardhan technique 490
Fetal Pillow® 490
Evidence 491
References 491
Chapter 158 Surgical Management of Massive Obstetric Hemorrhage from the Uterus, Cervix, or Vagina 492
Background 492
Management 492
Repairing trauma to the vagina or cervix 492
Surgical management of uterine bleeding 492
Prevention 496
References 496
Chapter 159 Surgical Management of Placenta Praevia 497
Background 497
Management 497
Timing of delivery 497
Mode of delivery 497
Preoperative preparations 497
Incision 497
Management of hemorrhage 498
Resolution of the case 499
References 499
Chapter 160 Surgical Management of Placenta Accreta 501
Background 501
Management 501
Diagnosis 502
Preoperative planning 502
Incision 502
Uterine conservation 502
Delivery with hysterectomy 502
Focal accreta 502
Fundal or posterior accreta 502
Placenta percreta with bladder invasion 502
Follow-up of women who have uterus-conserving surgery 502
Prevention 502
References 503
Chapter 161 Surgical Management Options for Shoulder Dystocia: Zavanelli Maneuver, Abdominal Rescue, Symphysiotomy, and Cleidotomy 504
Background 504
Management 504
Cephalic replacement (Zavanelli maneuver) 504
Abdominal rescue 504
Symphysiotomy 504
Cleidotomy 505
Prevention 505
References 505
Chapter 162 Uterine Inversion 507
Background 507
Management 507
Non-surgical methods 507
Surgical methods 508
Prevention 508
References 509
Chapter 163 Episiotomy and Second-degree Tear 510
Background 510
Management 510
Perform an episiotomy 510
Repair techniques for episiotomy and second-degree tear 511
Complications of episiotomy 511
References 511
Chapter 164 Obstetric Anal Sphincter Tear 512
Background 512
Management 512
Surgical technique 512
Postoperative care 513
Guidance for next pregnancy 513
Resolution of the case 513
Prevention 513
References 514
Chapter 165 Pregnancy and Female Genital Mutilation 515
Background 515
Classification 515
Management 515
Surgical technique 515
Intrapartum care 516
Postpartum care 516
References 516
Chapter 166 Destructive Operations on a Dead Fetus 518
Background 518
Management 518
Craniocentesis 518
Craniotomy 519
Postoperative care 519
References 520
Chapter 167 Development of a Basic Obstetric Theater Facility in a Low-resource Setting 521
Background 521
The basic obstetric OT 521
Physical infrastructure 521
Design of the OT 522
Basic surgical equipment and supplies 522
Anesthetic equipment 522
Neonatal equipment 522
Staffing 522
Autoclave room 522
Quality measures 523
References 523
Section 9 Miscellaneous 525
Chapter 168 Enhanced Recovery 527
Background 527
Management 527
Preoperative management 527
Care on admission 527
Intraoperative management 527
Immediate postoperative management 528
Hospital recovery 528
Prevention 528
References 528
Chapter 169 Major Surgery in a Jehovah’s Witness Patient 529
Background 529
Management 529
Obstetric patients (Case history 1) 529
Gynecologic patients (Case history 2) 530
References 530
Chapter 170 Termination of Pregnancy at Advanced Gestation 531
Background 531
Management 531
Pre-abortion management 531
Medical termination of pregnancy 531
Surgical termination of pregnancy 531
Post-abortion care 532
Further reading 532
Chapter 171 Cervical Fibroids: Techniques for Myomectomy and Hysterectomy 533
Background 533
Management 533
Fertility-sparing surgery 534
Hysterectomy 534
References 535
Chapter 172 Hysterectomy for Broad Ligament Fibroids 536
Background 536
Management 536
Operative technique 536
Further reading 537
Chapter 173 Hysterectomy for a Double Uterus 538
Background 538
Management 538
Preoperative investigations 538
Surgical route and incision 538
Operative technique 538
References 539
Chapter 174 Cervical Stump Excision 540
Background 540
Management 540
Preoperative preparation 540
Laparoscopic entry 540
Conversion to laparotomy 540
Laparotomy 541
Prevention 541
References 541
Chapter 175 Surgery for Ovarian Remnant 542
Background 542
Management 542
Diagnosis 542
Treatment 543
Resolution of the case 543
Prevention 543
References 543
Chapter 176 Surgery for Missing Intrauterine Contraceptive Device 544
Background 544
Management 544
Hysteroscopy 544
Laparoscopy 545
Laparotomy 545
Combined hysteroscopy and laparoscopy (with or without cystoscopy) 546
Other interventions 546
Prevention 546
References 546
Chapter 177 Management of Imperforate Hymen, Transverse and other Vaginal Septa 547
Background 547
Classification and embryology 547
Examination and investigations 547
Management 548
Surgery for an imperforate hymen 548
Surgery for a transverse vaginal septum 548
Other vaginal septa 548
References 549
Chapter 178 Benign Lesions in the Groin and Vulva 550
Background 550
Management 550
Preparation 550
Biopsy technique 550
Cysts and abscesses 551
Surgical techniques 551
References 552
Chapter 179 Cystic Structure in the Upper Vagina 553
Background 553
Management 553
Assessment 553
Surgical technique 553
Prevention 554
References 554
Chapter 180 Adnexal Masses in Infants and Children 555
Background 555
Clinical presentation and evaluation in infants 555
Clinical presentation and evaluation in children 555
Differential diagnosis 555
Management 556
Management in infants 556
Management in children 556
References 556
Chapter 181 Nerve Injuries Associated with Gynecologic and Obstetric Surgery 558
Background 558
Management 559
Prevention 560
References 561
Chapter 182 Consent Challenges 562
Background 562
Management 562
Resolution of the cases 563
Case history 1 563
Case history 2 563
References 563
Chapter 183 Dealing with Complaints 564
Background 564
Management 564
Prevention 565
Further reading 565
Chapter 184 Dealing with Litigation 566
Background 566
Management 566
Prevention 567
Further reading 567
Index 569
EULA 578
| Erscheint lt. Verlag | 27.1.2016 |
|---|---|
| Sprache | englisch |
| Themenwelt | Medizin / Pharmazie ► Medizinische Fachgebiete ► Chirurgie |
| Medizin / Pharmazie ► Medizinische Fachgebiete ► Gynäkologie / Geburtshilfe | |
| Schlagworte | Chirurgie u. chirurgische Spezialgebiete • Geburtshilfe • Gynäkologie • Gynäkologie u. Geburtshilfe • Gynaecology • Gynäkologie • Gynäkologie u. Geburtshilfe • gynecology • Laparoscopic • Medical Science • Medizin • Obstetrics • Obstetrics & Gynecology • post-operative • pre-operative • Reproductive • Surgery • Surgery & Surgical Specialities • Urogynecologic |
| ISBN-13 | 9781118298596 / 9781118298596 |
| Informationen gemäß Produktsicherheitsverordnung (GPSR) | |
| Haben Sie eine Frage zum Produkt? |
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