Current Obstetrics & Gynaecology (2001) 11, 100 ^107

c 2001 Harcourt Publishers Ltd

doi:10.1054/cuog.2000.0164 available online at http://www.idealibrary.com on

Unintentional trauma during gynaecological surgery

I. Z. MacKenzie
John Radcli¡e Hospital, Oxford OX3 9DU, UK

KEYWORDS
bowel trauma, vascular
damage, bladder damage,
ureteric injury, lymphatic
obstruction, nerve injury
Summary With minor and major gynaecological surgery, unexpected damage to ad-
jacent structures or organs may occur, despite appropriate surgical care.It is important
to recognize which patients and which conditionsincrease the chances ofthis happening.
It is equally important for the surgeon to identify when such damage has been caused
and to know how to make good the repair. Some of this repair surgery should be
performed by the gynaecologist, while some is best managed by a specialist in the
appropriate ¢eld. Knowledge of the signs and symptoms of previously unrecognized
damage is essential for the surgeon, as is any long-term consequence of this
unintentional damage, so that the patient can be advised of future management.
c 2001Harcourt Publishers Ltd

INTRODUCTION cause unexpected damage.Thus all laparoscopies and la-

This article reviews the areas where potential unin-
tended damage may be caused to adjacent structures or
organs during the course of various gynaecological op-
erations. It does not include operations performed dur-
ing later pregnancy, but includes those performed to
terminate pregnancy during the ¢rst and second trime-
ster, and to deal with early failed pregnancies including
incomplete and missed abortion and ectopic gestations.
It concentrates on identifying the damage at the time of
surgery or during the immediate post-operative period,
but does not deal with the complications that result from
previously undiagnosed damage.
A major thrust of the review is to remind the reader
not only of the pitfalls that await the surgeon, but that
injury to structures or organs may occur when least ex-
pected. In addition, emphasis is placed upon the early di-
agnosis of the damage, since repair then is often easier
than at a later stage, and long-term sequelae are often
reduced.
As illustrated in Table 1, various types of injury have
been considered according to the general anatomical
area in which the primary gynaecological procedure is
being performed.
DAMAGE ASSOCIATED WITH
ANTERIOR ABDOMINAL WALL
INCISIONS
All operations which involve an incision into the perito-
neal cavity or retropubic space have the potential to
Correspondence to: IZM.Tel: 01865 221006; Fax: 01865 769141.
parotomies present a possible risk.
Vascular damage
Lower transverse suprapubic or Pfannenstiel incisions,
especially if required to be more expansive for radical
surgery and the removal of large pelvic tumours, can re-
sult in division or laceration of a major vessel within the
anterior abdominal wall. The inferior epigastric arteries
and veins are vulnerable as they pass from the external
iliac vessels at the midpoint of the inguinal ligaments to-
wards the umbilicus within the rectus abdominis muscles
on each side. Damage should usually be recognized at the
time by overt bleeding or rapid development of a haema-
toma, the traumatized vessel will require ligation; dia-
thermy may be su⁄cient, but care is necessary to
ensure satisfactory haemostasis. These vessels are also
at risk with incisions made in the iliac fossae for laparo-
scopic procedures, and the chances of this happening can
be reduced by trans-illuminating the abdominal wall
from within with the laparoscope to identify the course
of the vessels and avoid direct puncture.
Traumatized small vessels perforating the rectus ab-
dominis muscles may escape notice at laparotomy, espe-
cially when the abdominal wall is being closed. Some
surgeons advocate the routine use of a subrectus drain
inserted at the end of the laparotomy, although this does
not guarantee protection against a haematoma develop-
ing. The injury then becomes apparent during the early
post-operative recovery period with an enlarging sub-
rectus haematoma often most obvious during the sec-
ond or third postoperative day. Depending on the size
of the haematoma and degree of systemic upset, sponta-
neous discharge may occur through the healing incision,
UNINTENTIONALTRAUMA DURING GYNAECOLOGICAL SURGERY 101

Table 1 Types of gynaecological surgery and areas of possible unintended trauma

Abdominal wall Intra-abdominal Intra-uterine Intra-vaginal Vulval & inguinal

Haemorrhage H H H H H
Bowel damage H H H H
Bladder damage H H H
Ureteric damage H H
Nerve damage H H
Ano-rectal damage H H
Urethral damage H H
Lymphatic drainage H H

or surgical drainage may be necessary by re-opening the

incision with local or general anaesthetic. It is worth
considering the insertion of a tube or corrugated
drain into the haematoma cavity, secured at the skin
to allow further drainage. By this stage, it is unusual to
identify any speci¢c bleeding vessels to ligate or cauter-
ize, the active bleeding having ceased, assisted by tampo-
nade. The re-opened incision usually heals without
problem.
Lower midline incisions are less likely to result in vas-
cular damage providing that lateral dissection beneath
the rectus muscles is not too extensive.
Intraperitoneal drains, not incorporated into the la-
parotomy incision, are a further source of trauma. The
inferior epigastric vessels are vulnerable and it is appro- Figure 1 Principle of the repair of a full thickness injury to bo-
priate to pass the drain trocar from the peritoneum to wel or bladder.The ¢rst layer is repaired with aninterrupted ab-
the outside avoiding the landmarks for these vessels. In- sorbable suture, incorporating the mucosal layer and muscle
troducing the drain in the reverse direction increases the layers.The second layer, using interrupted Lembert sutures, in-
chances of damage to the underlying structures in the cludes the muscle and serosallayers, imbricating the deep layer.
iliac fossae, including the external iliac vessels. Insertion
of suprapubic catheters can lead to haematoma forma-
tion, but this should be avoided if the introducing needle Nerve damage
or trocar is inserted in the mid-line.
Femoral neuropathy can be caused with the use self-re-
taining abdominal retractors.The precise mechanism for
such damage is not clear, but direct pressure on the
nerve or exaggerated extension of the retractor blades
Bladder damage
may be responsible and is probably best avoided if possi-
Care with entry into the peritoneal cavity is needed with ble. The diagnosis is made some days after the surgery
transverse suprapubic and lower mid-line incisions, and with a complaint of numbness over the skin on the ante-
at laparoscopy with lower mid-line stab incisions, since rior surface of the upper thigh. Speci¢c action is not in-
an unintentional cystotomy may occur. Bladder drainage dicated, with the expectation that recovery of nerve
immediately prior to surgery or laparoscopic con¢rma- function will occur over a few months.
tion that it is not distended, will reduce the chances of
this happening. Providing the damage is recognized as it
should be, unless very small, repair in two layers with ab- TRAUMA DURING INTRA-
sorbable sutures as shown in Fig. 1 is required. Subse-
quent continuous bladder drainage by suprapubic or
ABDOMINALOPERATIONS
transurethral catheter, maintained on free £ow for 7^10 This may occur with any abdominal surgery, but is more
days, is wise, although the chances of a ¢stula forming are common in obese patients during radical operations
very small. and when anatomy is distorted by adhesions or large
102 CURRENT OBSTETRICS & GYNAECOLOGY

tumours. Awareness of possible coincidental damage

needs to be even greater in such cases than in the less
demanding cases.

Bowel damage
Opening the abdomen may cause damage to small and
large bowel especially if there are adhesions to the ante-
rior abdominal wall. Despite appropriate care incising
the parietal peritoneum, unavoidable damage may still
occur. It may also occur during laparoscopy or laparot-
omy with division of adhesions to gain access into the
pelvis by dissecting around large tumours or mobilizing
gynaecological organs for reconstruction or removal.
The damage may be caused with sharp or blunt dissec-
tion with scissors, scalpel, diathermy or laser. Recogni-
tion of the damage and the extent is obviously
important to assess the need for, and type of, repair.
The extent of the damage may be more extensive than
initially suspected if caused by laser or diathermy.
Small super¢cial lacerations usually require a purse-
string or single 2/0 absorbable suture layer incorporating
all layers except the mucosa; inverting the tissue will
provide the necessary closure.For full thickness damage,
a two-layer repair with the same suture should be used,
the ¢rst layer including all bowel wall layers and the sec-
ond using Lembert sutures to include the muscle and ser-
osal layers to invert the ¢rst suture line (see Fig.1). Some
surgeons advise the use of interrupted sutures and some
a non-absorbable second layer. It is essential not to re-
strict the bowel lumen by repairing longitudinal lacera-
tions in a transverse direction. For major bowel
damage, a resection may be necessary, especially if the
viability of a segment of bowel wall is suspect. Having iso-
lated the segment to be resected, non-crushing clamps
are applied, the segment removed and a two-layer repair
performed using the same principle as for full thickness
lacerations (see Fig. 2). Again it is imperative to ensure
no restriction to the lumen. Following completion of
the anastomosis, the defect in the bowel mesentery
needs to be repaired. If necessary, a peritoneal toilet
should be provided and antibiotics should probably be gi-
ven in most cases. In many instances, peritoneal drainage
is not required. If a large area of damage has been caused,
particularly involving the large bowel, a temporary de- Figure 2 Bowel re-anastomosis using the Gambee techni-
functioning colostomy might need to be formed, espe- que. After inserting an initial Lembert suture at the mesenteric
border, Gambee sutures are placed through all three tissue
cially if there is doubt about the integrity of the bowel,
layers, with knots tied within the lumen. Further Lembert su-
or the patency of the lumen, due to pre-existing disease tures then reinforce the repair, checking adequate patency of
beyond repair. the lumen.The mesenteric defect is then closed.

wall, the damage must be recognized and repaired to

Bladder damage
Inadvertent cystotomy may occur on opening the ab-
dominal wall or during bladder dissection of the anterior
cervix and upper vagina. As with breaches to the bowel
avoid a urinary ¢stula. Adequate mobilization of the
bladder immediately adjacent to the defect helps to se-
cure a satisfactory result, reducing tension on the repair.
Partial thickness lacerations can be strengthened with a
UNINTENTIONALTRAUMA DURING GYNAECOLOGICAL SURGERY
single 2/0 absorbable suture layer as a precaution. Full
thickness injuries should be repaired with two layers si-
milar to that described for bowel wall repair: the ¢rst
suture line of 2/0 absorbable suture includes the muscle
layer, possibly excluding bladder mucosa, and the second
uses a 2/0 absorbable suture Lembert suture into the
muscle layer and overlying serosa burying the ¢rst su-
ture line. As with bowel repair, opinions are divided on
the use of interrupted and continuous suturing. If the da-
mage was caused when dissecting the bladder o¡ the
anterior cervix and vagina, care must be taken to ensure
that a ureter has not been included in the repair. Cysto-
scopy and ureteric catheterization should be performed
if there is any doubt. An indwelling suprapubic or per ur-
ethram catheter is important to keep the bladder empty
to encourage healing.Removal after 7^10 days is best pre-
ceded by contrast studies to con¢rm a water-tight repair
has been achieved, particularly for damage around the
base of the bladder.
A transvesical suture may inadvertently be placed dur-
ing suprapubic bladder neck surgery. This should be re-
cognized by intra-operative cystoscopic examination
and removed. If left in situ, bladder irritation and calculi
may develop or a ¢stula form. Damage can also occur
with the insertion of suburethral slings; recognition and
removal is clearly essential, possibly with repair to the
bladder wall if there is a large defect.
Ureteric damage
The ureter is at risk: (a) at the pelvic brim where it over-
lies the bifurcation of the common iliac artery and the
infundibulo-pelvic ligament is divided to remove the
ovary; (b) as it passes around the pelvic side wall beneath
the parietal peritoneum which is divided at the base of
the broad ligament; and (c) most frequently as it passes
medially through the ureteric canal to reach the bladder
angle just beyond the uterine vessels, contiguous with
the lateral vaginal fornix. Damage to the ureter may be
from direct puncture or transection by scalpel, diather-
my or laser, or ischaemic necrosis from diathermy or
laser heat damage, or devascularisation by stripping the
vessels lying beside the ureter. Occlusion to the lumen
with resultant obstruction to urine £ow can be pro-
duced by an encircling suture or ligature, or kinking by
an extrinsic suture distorting the ureter, with conse-
quent oedema and obstruction.
Damage most commonly occurs with di⁄cult dissec-
tions in the presence of adhesions involving the pelvic
side-wall due to chronic pelvic in£ammatory disease or
endometriosis. Anatomical distortion making the ureter
more vulnerable may have occurred due to adhesions or
a large ovarian or uterine tumour involving one or other
broad ligament. Radical hysterectomy for malignant dis-
ease is a hazard to the ureter, although dissection around
103
the ureter is a fundamental part of the operation and
particular care is taken to protect the ureter.
Once recognized, sutures causing obstruction should
be removed and if there is doubt about the viability of
the wall of the ureter, the lumen should be stented by cy-
stoscopic guidance, or by ureterotomy. If the wall is badly
lacerated or the ureter completed transsected, manage-
ment depends upon the site of the damage. Damage
more than 6 cm from the bladder probably requires an
end-to-end anastomosis with 3/0 or 4/0 absorbable su-
ture over a stent, spatulating the ends if necessary to al-
low an oblique suture line to avoid stricturing. A single
layer should be su⁄cient, although the ureteric sheath
could also be repaired as a second layer; the stent needs
removing 4 ^ 6 weeks later. If the damage is within 6 cm of
the bladder insertion and the ureter reasonably mobile,
re-implantation into the bladder with a Boari £ap and
possibly a psoas hitch is probably the best option. This
involves tying o¡ the ureteric stump on the bladder wall,
performing a cystotomy, and making an entry portal into
the detrusor muscle, burrowing a tunnel within the mus-
cle and then making an exit portal through the bladder
mucosa. The distal end of the ureter is drawn through
the tunnel and into the bladder lumen, securing the pre-
viously split divided end of the ureter to the mucosa and
the external surface of the detrusor muscle where it en-
ters the bladder. Stenting of the ureter should be per-
formed. If a segment of ureter has been destroyed, an
end-to-side anastomosis to the other ureter may be ne-
cessary. If the damage is limited to a small defect to the
wall, ureteric stenting will probably allow healing with-
out further surgery. Unless the surgeon has previous ex-
perience of urinary tract repair, the assistance of a
urologist should be sought at an early stage. Antibiotic
prophylaxis should be considered.
Vascular damage
Major vessels in the pelvis, usually one of the iliac vessels,
may su¡er damage when dissection is required in the vi-
cinity. Pelvic lymphadenectomy of metastatic tumours
can be di⁄cult to acheive if local invasion has already oc-
curred. Once the vessel wall has been opened, consider-
able bleeding may follow which can be contained with
oversewing with a 4/0 polypropylene or similar suture;
compression above and below the damage, if possible,
will keep the operating site visible. Arterial repairs are
usually easier to e¡ect than vein repairs because of the
stronger tissues. Larger areas of damage may require the
insertion of a graft and the assistance of a vascular sur-
geon.
Seemingly uncontrollable bleeding can be provoked
during otherwise uncomplicated surgery. Laparoscopic
division of the utero-sacral ligaments, performed
as a treatment for severe dysmenorrhoea, can cause
104
bleeding not controlled by laparoscopic diathermy or
oversewing, and a laparotomy may be necessary to
achieve the desired haemostasis. Troublesome bleeding
from trans¢xed pedicles with ovarian conservation may,
on rare occasions, lead to removal of the ovary to isolate
and ligate the vessels in the infundibulo-pelvic ligament.
Particular care should be taken to identify the ureter in
this situation. Persistent bleeding from the uterine pedi-
cles can be very frustrating; repeated clamping and su-
turing can threaten the ureter in this di⁄cult situation
and isolation and ligation of the internal iliac artery or
its anterior branch might be a safer option.
Surgery in the Cave of Retzius, for operations to treat
urinary stress incontinence, can result in haematoma for-
mation. In most cases, no speci¢c action is required, the
bleeding being controlled by tamponade. Drainage of the
haematoma is not usually required.
Lymphatic damage
Although not strictly damage, many women will develop
lymphocysts or lymphocoeles above the inguinal liga-
ment following pelvic lymphadenectomy, as part of a ra-
dical hysterectomy for the treatment of cervical
malignancy. Such collections probably re£ect a thorough
node dissection, and as shown in Fig. 3, they can reach a
considerable size, even to the extent of causing compres-
sion on the ureter resulting in hydroureter and hydrone-
phrosis.These generally do not develop for some days or
weeks after surgery.
Osseous damage
Non-absorbable sutures securing the paraurethral tis-
sues to the periosteum over the posterior aspect of the
symphysis pubis, as in the Marshall ^Marchetti ^Krantz
urethropexy, can cause periostitis and chronic pain.
There is no clear explanation for this happening, and thus
no speci¢c action to be taken to prevent it occurring;
avoiding large deep sutures into the periosteum would
seem sensible.
TRAUMA DURING INTRAUTERINE
SURGERY
The greatest number of gynaecological operations in-
volve the passage of instruments through the previously
dilated cervix into the uterine cavity. Such procedures in-
clude diagnostic and therapeutic uterine curettage or
endometrial biopsy and hysteroscopy as an inpatient or
outpatient, operative hysteroscopy under general anaes-
thetic to resect the endometrial basement membrane,
polyps, submucous ¢broids and uterine septae, and eva-
cuation of retained products of conception or for thera-
peutic abortion.
CURRENT OBSTETRICS & GYNAECOLOGY
Cervical damage
Mechanical cervical dilatation, usually achieved by pas-
sing metal dilators of increasing diameters through the
cervical canal, may cause covert or overt tearing of the
cervix. Super¢cial tears from traction applied to a stabi-
lizing tenaculum may also occur as the instrument is
pulled o¡ the cervix, but they generally do not cause ser-
ious problems nor long-term compromise; persistent
bleeding from the area may require one of two absorb-
able haemostatic sutures. Lacerations involving underly-
ing stroma, which might amount to complete disruption
of the full length of the endocervical canal, can be caused
by forced mechanical dilatation against cervical resis-
tance. Such damage can be minimized by limiting the di-
latation to size Hegar10, which will reduce the chances of
overt tearing and covert damage which could result in
cervical incompetence during a subsequent pregnancy.
Minor lacerations occur in up to 3^ 4% cases but signi¢-
cant full thickness damage occurs in less than 1% cases.
Prior cervical preparation with local prostaglandins or
hygroscopic tents in pregnant patients can dramatically
reduce the force required to dilate the cervix and the
risk of cervical damage to less than 0.1% cases.The bene-
¢ts of such a strategy for the non-pregnant are less con-
vincing.
Full thickness lacerations should be repaired to reduce
the chances of compromise to cervical integrity. Absorb-
able sutures should be inserted to approximate the en-
docervical canal surface with a second layer opposing
the vaginal epithelium, including the underlying cervical
stroma. This restores the anatomy and provides the ne-
cessary haemostasis. Some recommend the use of non-
absorbable sutures for the second layer, but they need
removing 6 ^7 days later and there is no proven advan-
tage. An ignored full thickness laceration or unsuccessful
repair may result in a cervico-vaginal ¢stula with persis-
tent watery discharge, deep dyspareunia and postcoital
bleeding, with the need for a trachelorrhaphy at a later
date.
Uterine body trauma
Perforation of the uterus during cervical dilatation prob-
ably occurs more frequently than surgeons realize; there
are reports of this occurring during ¢rst trimester as-
piration termination at around 0.2^ 0.7% operations. Bi-
manual examination to delineate uterine size and
position at the start of the operation is an important in-
itial step to reduce the chances of this happening. Sound-
ing to determine the length of the utero-cervical canal
should also help, although a sound should be used with
great caution in the pregnant or recently pregnant
uterus, since the myometrium is soft, and the relatively
narrow sound can easily perforate the uterine wall. This
will usually be recognized when the instruments pass
UNINTENTIONALTRAUMA DURING GYNAECOLOGICAL SURGERY 105

through the cervix further than expected from the initi- Rectal damage
al examination. With di⁄cult cervical dilatation, a false
Full thickness damage to the rectal wall must be identi-
passage may be made in the cervical tissue, extending
¢ed, as with bowel damage within the abdomen; unrec-
into the myometrium. This probably occurs when the
ognized damage will probably result in a recto-vaginal
uterine position had been incorrectly assessed. Persis-
¢stula, which can be very challenging to repair. Careful
tence with the dilatation will ultimately result in the in-
struments entering the peritoneal cavity. identi¢cation of the extent of the damage with adequate
mobilization of the adjacent wall should be followed by a
If skilled high-resolution ultrasound services are avail-
careful repair in two layers with absorbable sutures.
able, con¢rmation of a perforation can be provided or
Further supporting absorbable sutures into the fascia of
reassurance given that the damage has not occurred
Denonvillier will give added support prior to repairing
and a laparoscopy avoided. If in doubt, it is better to in-
the vaginal epithelium. If the damage is extensive, a tem-
vestigate by laparoscopy unless the risks of this proce-
porary defunctioning colostomy should be considered.
dure in the individual patient are greater than average.
Sacrospinous ¢xation to correct a vaginal vault pro-
Perforation may be caused during diathermy resection
of endometrium or ¢broids. Division of the pedicle of a lapse may result in rectal trans¢xion, a greater risk using
the left than the right ligament. Care must be taken to
pedunculated intraluminal ¢broid that has prolapsed
avoid this happening although this may be di⁄cult if there
through the cervix could result in fundal damage if trac-
is marked ¢brosis and adhesions from previous infection
tion on the polyp caused inversion of the uterine fundus.
or surgery. The undetected suture is likely to result in a
The damage in these patients should be diagnosed by
recto-vaginal ¢stula.
hysteroscopic examination, and if the defect is small with
no overt bleeding, observation over 24 h can be advised.
If the defect is large or there is persistent bleeding, or
the damage was caused by diathermy, a laparoscopy
should be performed to assess the degree of uterine da-
Bladder damage
mage and to explore the bowel for damage and perform Unplanned cystotomy should also be recognized and re-
the necessary repair. paired at the time.The risks of a vesico-vaginal ¢stula are
In women undergoing pregnancy termination or surgi- much more likely than with fundal bladder trauma, and a
cal evacuation of retained products of conception, per- secure repair should be achieved as already described.
foration may ¢rst be suspected when fatty tissue of the
omentum, appendix epiploicae or bowel mesentery is
seen in the forceps or suction curette. A laparoscopy
should be performed to assess the degree of damage to Ureteric damage
the uterus, observe for active bleeding, and carefully in-
Division of, or obstruction to, the lumen of a ureter is
spect the bowel for damage. If the extent of the damage
really only a risk in women with a procidentia when the
is uncertain, a laparotomy will be required. The uterine
ureters and bladder can be markedly displaced from their
evacuation should be completed under laparoscopic con-
normal anatomical position. If recognized, immediate re-
trol to avoid further damage, but the bleeding uterine
pair is necessary and this will involve a laparotomy; for
defect needs oversewing with one or two layers of an
most gynaecologists, this will probably involve the assis-
absorbable 2/0 or 0 suture at laparotomy, carefully op-
tance of a urologist.
posing the uterine surface to reduce the chance of adhe-
sion formation. Advice should be given postoperatively
about the possibility of a weakened area at the site of
the perforation, should pregnancy be contemplated in
Urethral damage
the future. Whether labour should be discouraged re-
mains uncertain, however. This is most likely to occur during an anterior colporrha-
phy to correct a cysto-urethrocoele, especially if there
has been previous surgery. It may also occur with the dis-
section and excision of anterior wall vaginal cysts, para-
TRAUMA DURING VAGINAL urethral cysts or removal of a cyst of Skene’s tubule. A
urethral diverticulum, mistaken for a vaginal cyst, will
SURGERY result in unexpected urethral damage and could lead to
Surgery to the vagina risks damage to contiguous struc- ¢stula formation. As with the bladder, a two-layer repair
tures and organs, notably the rectum posteriorly and the with absorbable sutures is required followed by repair of
bladder and urethra anteriorly.With more extensive dis- the overlying vaginal epithelium. An indwelling urethral
section for gross degrees of uterine prolapse, the ureters or suprapubic catheter may improve the chances of heal-
are vulnerable. ing by primary intention and avoid further problems.
106
TRAUMA DURING VULVAL AND
INGUINAL DISSECTION
This includes major surgery as for a vulvectomy, excision
of vulval cysts and uncertain vulval swellings, and plastic
reconstructions or excision of tender scars of the peri-
neum and lymph node dissection.
Rectal damage
When surgery is performed on the perineum to correct
complications from damage sustained during childbirth,
there can be marked scarring leading to distortion of
anatomy. Incising the perineum should therefore be done
with particular care to avoid damage to the displaced
rectum above the anal canal. As with other bowel da-
mage, recognition is important with a repair of the wall
in two layers using absorbable sutures. It is believed that
tension should be avoided to improve the chances of suc-
cessful healing. The unintentional insertion of a suture
into the rectum during posterior colporrhaphy should
be identi¢ed and the suture removed; if left in place,
there is a risk of recto-vaginal or recto-perineal ¢stula.
Anal damage
If the anal sphincter is divided during the dissection, this
requires repair either as an end-to-end re-alignment or
using an overlapping technique; both procedures use ab-
sorbable suture material. Opinion is divided on the need
to con¢ne the bowel for the ¢rst 4 ^5 days after surgery,
rather than administering a laxative to reduce stool bulk
and thus trauma to the repaired sphincter. Antibiotic
prophylaxis may well be bene¢cial.
Vascular damage
The vulva has a very good blood supply in the region of
the clitoris and posteriorly around the Bartholin’s glands.
Dissections in these two areas, as in a vulvectomy or ex-
cision of Bartholin’s glands and cysts, can provoke
marked bleeding during the operation. Every e¡ort
should be made to control the bleeding by cautery, liga-
tion or trans¢xion, but a haematoma may still occur, and
further surgery may rarely be necessary to control the
bleeding. Spontaneous discharge of a haematoma may
occur although surgical drainage will occasionally be ne-
cessary. Systemic upset can develop with a posterior vul-
val haematoma, since the ischio-rectal fossa can
accommodate up to a litre of blood. Opening of the pre-
vious incision will release the haematoma and any active
bleeding vessels identi¢ed and ligated. A large-bore tube
drain or corrugated drain sutured into the cavity might
be considered for removal 1 or 2 days later. Damage to
the femoral vessels deep within the femoral triangle
CURRENT OBSTETRICS & GYNAECOLOGY
may occur with inguinal lymphadenectomy for vulval ma-
lignancy, and the help of a vascular surgeon may be re-
quired to insert a graft to correct the damage if simple
repair is not su⁄cient.
Nerve damage
Peripheral nerve damage will occur and every attempt
should be made to avoid dividing the lateral and anterior
femoral nerves that are visible during the dissection;
there is no reparative treatment, should the patient be-
come aware of an area of paraesthesia postoperatively.
Lymph drainage system damage
Lymphocysts are quite common sequelae to a thorough
block dissection of the super¢cial and deep inguinal
glands. Although drainage of such cysts can be per-
formed, this is probably best avoided. Infection may fol-
low and this can lead to persistent drainage.
Spontaneous resolution of lymphocysts usually occurs
although it may take many months. Chronically swollen
legs may, however, persist for long periods.
CONCLUSIONS
Despite appropriate preparation using very careful and
appropriate surgical techniques, unplanned damage may
still occur during routine as well as more di⁄cult gynae-
cological surgery. The most important aspect is to iden-
tify the damage and institute the appropriate ¢rst aid
treatment. The gynaecologist should not hesitate to en-
list the help of the appropriate surgical specialist to ad-
vise or perform the necessary repair and to o¡er advice
about further management and possible long-term con-
sequences to the patient.
Finally, it is always wise to explain the events to the
patient as soon as is reasonable after the operation, with
the o¡er of further information as and when available or
requested.
PRACTICE POINTS
. Aims: To be aware of situations where damage to
other organs or structures is a particular risk
. Management:To identify patients who represent an
added risk and take precautions to avoid
inadvertent damage.
. Objective: To be aware of the possible damage,
recognize it at the time, and know how to repair
the damage and advise the patient of any possible
future problems.
UNINTENTIONALTRAUMA DURING GYNAECOLOGICAL SURGERY
FURTHER READING
Wheelock J B, Krebs H-B. Repairing bowel injuries. In Gynaecological
Surgery 2nd Edition. Sanz L E (ed). Oxford: Blackwell Science, 1995;
331^337.
Harris W J. Early complications of abdominal and vaginal hysterectomy.
Obstetr Gynaecol Surv 1995; 50: 795^ 805.
Donnez J, Anaf V, Berliere M, Smets M, Nisolle M.Ureteral and bladder
injury during laparoscopic surgery. In An Atlas of Laser Operative
107
Laparoscopy and Hysteroscopy. Donnez J, Nisolle M (eds). London:
Parthenon 1994; 237^244.
Krebs H B. Intestinal injury in gynecologic surgery: a ten-year experi-
ence. Am J Obstet Gynecol 1986; 155: 509^514.
Blandy J P, Badenoch D F, Fowler C G, Jenkins B J,Thomas N W M. Early
repair of iatrogenic injury to the ureter or bladder after gynecologi-
cal surgery. J Urol 1991; 146: 761^765.