Hans-B. Krebs

Intestinal injury in gynecologic surgery: a ten-year experience.

From 1973 to 1982, a total of 128 incidents of intestinal injury were recorded in patients undergoing gynecologic operations. Of all lacerations, 37% occurred during entrance into the peritoneal cavity, 35% during lysis of adhesions or performance of pelvic or abdominal dissections, 10% during laparoscopy, 9% during vaginal operations, and 9% during dilatation and curettage and dilatation and evacuation. Injury involved the small intestines in 75% and the large intestines in 25% of the cases. Sixty-nine percent of all lacerations were minor, and 31% were major. Seventy-two percent of the lacerations occurred during uncomplicated gynecologic operations. All lacerations were repaired with one or more of four basic procedures: one- or two-layer closure of intestinal lacerations, partial bowel resection, intestinal reanastomosis, and colostomy. It is suggested that gynecologists acquire basic knowledge in the prevention of intestinal injury and the principles of repair of intestinal lacerations. The role of animal surgical laboratories for the training of residents practicing gynecologic surgery is emphasized.

Loop electrosurgical excision procedures for cervical dysplasia: Experience in a community hospital

OBJECTIVE The study was undertaken to evaluate the use of the loop electrosurgical excision procedure as an outpatient hospital or surgicenter procedure. STUDY DESIGN The records of 358 patients treated for cervical intraepithelial neoplasia at a large community hospital over a 1-year period were reviewed. RESULTS The specimens obtained by loop electrosurgical excision procedure and laser cone excision were comparable in size but smaller than those by means of cold-knife conization. Seventy-two percent of loop electrosurgical excision procedure specimens consisted of two to eight tissue fragments (mean 3.4). In addition, 48% of the loop electrosurgical excision procedure specimens and 38% of laser cones had moderate or severe thermal artifacts. Fragmentation and cautery damage precluded orientation of tissue and evaluation of margins in 19% of the cases. CONCLUSIONS The advent of the loop electrosurgical excision procedure has shifted the management of cervical intraepithelial neoplasia from the office to the outpatient surgery centers. This negates and, in fact, reverses the advantage of loop electrosurgical excision procedure over other methods in regard to cost and convenience through evaluating and treating a patient with cervical intraepithelial neoplasia in one office visit. Loop electrosurgical excision procedures provide specimens that are inferior compared with cold-knife cones; therefore the role of loop electrosurgical excision procedure for the management of cervical intraepithelial neoplasia outside the office appears limited.

The Maylard incision in gynecologic surgery.

Abstract The transverse muscle-splitting Maylard incision was used in 175 gynecologic patients who required pelvic-abdominal surgery. One hundred fifty-three patients (87%) had pelvic malignancy; other indications for operation included uterine myomas, endometriosis, tuboovarian abscess, and benign ovarian cysts. Exposure was excellent: 54% of patients underwent pelvic lymphadenectomy and 17% underwent paraaortic lymphadenectomy. Twelve patients (6.9%) had wound complications, but there was neither long-term morbidity nor mortality associated with the incision. Fifty-six patients (32%) received preoperative or postoperative pelvic radiation therapy with no detrimental effect on wound healing. The Maylard incision is cosmetic, strong, easily learned, and has an acceptable complication rate. Unless a vertical incision is indicated, the Maylard technique is preferred when optimal exposure and accessibility to the pelvis are required. (Ann J OesTET GYNECOL 1990;163:1554-7.)

Treatment of advanced cervical cancer by combination of bleomycin and mitomycin-C

A combination of bleomycin and mitomycin‐C, reported as extraordinarily effective in a previous clinical trial, was used to treat 20 patients with advanced cervical cancer. Seven partial remissions (35%) and one complete remission (5%) were observed. Six of the partial remissions were of short duration (less than four months); the only patient with complete remission was still alive without evidence of disease ten months after initiation of chemotherapy. Nonresponders had a mean survival time of 6.6 months and responders 8.0 months. The treatment results confirm some efficacy of the drug regimen, although in our hands it did not live up to the high expectations raised by others.

Radical hysterectomy: Current management guidelines☆☆☆★

Over the past 11 years (January 1985 through December 1996) the senior authors (B.F.H. and H.B.K.) have performed 205 radical hysterectomies. The most notable trend observed was a marked decrease in length of stay from 12.8 days to 3.5 days. Contributing factors include use of the Maylard incision, placement of suprapubic Foley catheters, discontinuation of drains, early oral feeding, admission to the hospital on the day of surgery, and initiation of a critical care pathway. All criteria for short-stay radical hysterectomy were established by 1994. With continued modification of surgical technique and use of the critical care pathway, short stay has become our standard of care for radical hysterectomy. Complications are minimal, with neither long-term morbidity nor mortality associated with the short stay. In addition, significant cost savings occur, which benefits the patient, hospital, and the health care system.

Para-aortic lymphocyst

Although numerous articles regarding the etiology, incidence, complications, and management of pelvic lymphocysts have been published in the American literature since 1958, there has been no mention of para-aortic lymphocyst as a complication of para-aortic node dissection. Two recent cases of symptomatic para-aortic lymphocyst have prompted a review of our para-aortic node dissection technique when this procedure is not combined with a more extensive pelvic lymphadenectomy. Our modification in technique is to use retroperitoneal para-aortic drainage by constant pressure-controlled suction following closure of the posterior parietal peritoneum, and the results in our first 15 patients are presented. There were no complications related to the drainage technique. Abdominal ultrasound and intravenous urography have proved to be excellent diagnostic tools in the initial evaluation and subsequent follow-up of para-aortic lymphocytes.

The Role of Surgical Drains

The earliest recorded use of surgical drainage was by Hippocrates (400 b.c.), who used cannulas to treat empyema.1 Claudius Galen (200 b.c.), whose teachings were held infallible for the next 1500 years, described tubes for the management of ascites.2

The Maylard Incision in Gynecologic Surgery

The transverse muscle-splitting Maylard incision was used in 175 gynecologic patients who required pelvic-abdominal surgery. One hundred fifty-three patients (87%) had pelvic malignancy; other indications for operation included uterine myomas, endometriosis, tuboovarian abscess, and benign ovarian cysts. Exposure was excellent: 54% of patients underwent pelvic lymphadenectomy and 17% underwent paraaortic lymphadenectomy. Twelve patients (6.9%) had wound complications, but there was neither long-term morbidity nor mortality associated with the incision. Fifty-six patients (32%) received preoperative or postoperative pelvic radiation therapy with no detrimental effect on wound healing. The Maylard incision is cosmetic, strong, easily learned, and has an acceptable complication rate. Unless a vertical incision is indicated, the Maylard technique is preferred when optimal exposure and accessibility to the pelvis are required.

The Swan-Ganz catheter and its application in the gynecologic patient

Swan-Ganz catheters were used in the pre- and postoperative management of 22 gynecologic patients admitted to the Surgical Intensive Care Unit, University of Miami School of Medicine. Primary indications include preoperative assessment of fluid and volume status, evaluation of patients with severe heart disease, and management of multisystem organ failure. Seventeen patients required ventilatory assistance and 15 patients required vasoactive drugs as determined by Swan-Ganz measurements. With a low complication rate and highly reliable cardiopulmonary data, the Swan-Ganz catheter should be considered routinely in the optimal management of the critically ill or high-risk gynecologic patient.