Though popularly used, evidence has proved that steroids are not useful for prevention of adhesions in fertility-conserving surgeries. Dextran can cause anaphylaxis, and its use is not preferred.

Adept has found to be useful as adhesion prevention agent. Interceed is oxidised regenerated cellulose. Evidence shows no definite benefit of using adhesion prevention agents in caesarean section.

Scientific Impact Paper No 39. The use of adhesion prevention agents. Obstetr Gynaecol. 2013.

The advantages that transverse incisions offer are that they are less painful, have better cosmetic results, interfere less with postoperative respiration and have greater strength. The disadvantages being that there is greater blood loss and injury to nerves and muscle which can result in potential spaces with haematoma or seroma. Also, there is compromised view of upper abdominal cavity.

Skin preparation is done before all surgical procedures. Preoperative showering with antiseptics reduces the infection rate in clean wound (1.3 % versus 2.3 %). Wound infection rate of 0.6 % is seen with depilatory preparation, as with procedure done with no hair removal. Hair removal is done to prevent interference with wound approximation in certain incisions. Same scalpel can be safely used for both superficial and deep incisions.

Raghavan R, Arya P, Arya P, China S. Abdominal incisions and sutures in obstetrics and gynaecology. Obstet Gynaecol. 2014;16:13–8.

Injury occurs most frequently in the lower third of the ureter (51 %), followed by the upper third (30 %) and the middle third (19 %).

The most common sites of injury are:

Most studies show the most common site of injury to be lateral to the uterine vessels, but Daly et al. report this to be at the ovarian fossa. During laparoscopy, the ureter is injured most frequently adjacent to the uterosacral ligaments.

Jha S, Coomarasamy A, Chan KK. Ureteric injury in obstetric and gynaecological surgery. Obstet Gynaecol. 2004;6:203–8. doi:10.​1576/​toag.​6.​4.​203.​27016

Three main types of suture include the nonabsorbable, slowly absorbable and the rapidly absorbable. These can be further divided into monofilament or braided sutures. The incidence of wound infection is low with monofilament sutures. Silk and polyester are examples of braided non-reabsorbable sutures. Silk has higher tissue reaction, lower tensile strength as compared to nylon. Polypropylene has the least tissue reaction ability.

The incidence of wound dehiscence and hernia is similar for nonabsorbable and slowly absorbable sutures. The incidence of prolonged wound pain and suture sinus is significantly higher with a nonabsorbable suture.

Raghavan R, Arya P, Arya P, China S. Abdominal incisions and sutures in obstetrics and gynaecology. Obstet Gynaecol. 2014;16:13–8.

Self-retaining abdominal retractors can cause a femoral neuropathy—either by direct pressure on the nerve or exaggerated extension of the retractor blades. The diagnosis is made some days after the surgery with a complaint of numbness over the skin on the anterior surface of the upper thigh. Specific action is not indicated, as there are no serious sequelae and symptoms will usually spontaneously resolve over a few months. Obturator nerve injury causes numbness in the inner thigh and difficulty in adduction of hip joint causing gait difficulties and posture instability. Pudendal nerve entrapment also known as Alcock canal syndrome can cause pain in genital area and urinary and faecal incontinence sometimes.

Sciatic nerve and peroneal nerve are usually not encountered in gynaec surgeries.

Morrion J, MacKenzie I. Avoiding and managing complications during gynaecological surgery. Obstet Gynaecol Reprod Med. 17;4:105–11.

There are two types of staple: nonabsorbable and absorbable. The nonabsorbable staple (Proximate; Ethicon Endo-Surgery, Inc., Blue Ash, OH, USA) is made of stainless steel and has the highest tensile strength of any wound closure material. Staples have a low tissue reactivity. Prior to stapling, it is useful to grasp the wound edges with forceps to evert the tissue so as to prevent inverted skin edges.

Additionally, contaminated wounds closed with staples have a lower incidence of infection compared with those closed with sutures. Disadvantages of staples include the potential for staple track formation, bacterial migration into the wound bed and discomfort during staple removal. The absorbable staple (Insorb; Incisive Surgical, Inc., Minneapolis, MN, USA) is a novel device which deploys U-shaped absorbable staples into the dermal layer of tissue.

These staples contain an absorbable copolymer of predominantly polylactide and a lesser component of polyglycolide. They maintain 40 % of their strength at 14 days and are completely absorbed over a period of months (tissue half-life of 10 weeks). The Insorb staples are associated with a significantly lower infection rate.

Raghavan R, Arya P, Arya P, China S. Abdominal incisions and sutures in obstetrics and gynaecology. Obstet Gynaecol. 2014;16:13–8.

FFP at a dose of 12–15 ml/kg should be administered for every 6 units of red cells during major obstetric haemorrhage. Subsequent FFP transfusion should be guided by the results of clotting tests if they are available in a timely manner, aiming to maintain prothrombin time (PT) and activated partial thromboplastin time (APTT) ratios at less than 1.5 x normal.

Green to guideline blood transfusion in Obstetrics. 2015.

Iatrogenic nerve injury following gynaecological surgery occurs more commonly than is recognised and is a significant cause of postoperative neuropathy.

Neuropathy results when there is a disruption to the blood supply of the nerve caused by injury. Three types of microvascular changes occur with nerve injury. Neuropraxia is the result of external nerve compression leading to a disruption of conduction across a small portion of the axon. Nerve recovery takes weeks or months once remyelination occurs.

Axonotmesis is caused by profound nerve compression or traction. Damage occurs to the axon only, with preservation of the supporting Schwann cells. Regeneration is possible because supporting Schwann cells remain intact. Recovery time is longer than neuropraxia.

The most severe form of injury is termed neurotmesis, and it results from complete nerve transection or ligation, where both the axon and Schwann cells are disrupted. Regeneration is rendered impossible, and without restorative surgery, prognosis is usually poor

Kuponiyi O, Alleemudder DI, Latunde-Dada A, Eedarapalli P. Nerve injuries associated with gynaecological surgery. Obstet Gynaecol. 2014;16:29–36.

Because of the high risk of bowel being densely adherent to the underside of a midline incision, using closed entry techniques (i.e. with a Veress needle) in women with a midline scar is absolutely contraindicated. Most gynaecologists feel comfortable using closed entry techniques in women with a previous transverse suprapubic incision, but, in view of the known 20 % chance of periumbilical adhesions, perhaps we should be considering alternative entry techniques more often. Not only is there an increased risk of periumbilical adhesions, but adherence of the greater omentum to the underside of a Pfannenstiel incision can pull the transverse colon down, making it more at risk from the Veress needle and primary trocar.

Hasson first described his open entry technique in 1974. Although it is the preferred entry method for most general surgeons, the technique has never really been embraced with much enthusiasm by gynaecologists. It is certainly the entry technique that should be used in all thin women, as it will avoid accidental injury to the great vessels on the posterior abdominal wall.