Residents are often told to read up on the surgery—indications, contraindications, steps involved, complications, etc., before they come to the operation theater to witness or to assist in a case. Many seniors proudly declare that they read all about the surgery before they come to the operation theatre even to this day.

But for beginners, it is only after they see the dissection happening live, only after they get to palpate the structures in a live surgery, are they in a position to understand what the textbook description actually means. To be the first assistant to a senior surgeon who patiently describes each step and allows a beginner touch and feel every structure is a unique learning experience that cannot be compensated by reading books or watching videos. It is possible to conceptualize and comprehend only when one is the first assistant and has seen a senior perform the surgical dissection live.

The first challenge in a badly distorted case is how to enter the pelvis, because the bowels are densely adherent to each other, to the anterior abdominal wall, and to the pelvic structures. Bowels can get injured while opening the peritoneum itself because the bowel loops could be adherent to the overlying peritoneum right under the incision site. This can be avoided by opening the peritoneum bluntly using fingers or preferably by holding a fold of peritoneum with two artery forceps about a centimeter apart. One can then feel with thumb and index finger if there is any other structure felt below and open the peritoneum by making a small nick and then extending the peritoneal opening in the direction where there are no adherent underlying structure. In laparoscopy, one can insert the camera port by the open method and then insert the side ports under direct vision. Even in a badly distorted case, it is fairly easy to distinguish the small intestine from the large intestine. The presence of three white bands, teniae coli, that run along the length of the large bowel helps to distinguish the large intestine from the small intestine. The caliber of the bowel should not be the criteria. Even in gynecological surgeries, it is possible to come across a hugely dilated small intestine due to adhesions. The segment above the partial obstruction is dilated, whereas the intraperitoneal parts of the large intestine (caecum, transverse colon, sigmoid, and rectum), which lie distal to the point of subacute obstruction, can be collapsed and be of a smaller caliber than the proximal part of small intestine. The distinguishing feature is the presence of teniae coli. The large intestine can be collapsed and may be of the same caliber of the small intestine in patients who have been given a good preoperative bowel preparation. Therefore, the presence of teniae coli must be looked for. In some cases of PID, there can be a large hydrosalpinx—the fallopian tube can be hugely distended and can look like a segment of the small intestine. One has to be careful while dissecting and separating the structures; only after the dissection is complete, the fallopian tube can be identified by locating the fimbrial end. Sometimes the fimbria is not made out due to adhesions or pus. In such situations, the fallopian tube can be confirmed by noting that the entire lengths of the small and large intestines are separate from the fallopian tube (There may not be a uterus if the patient has undergone hysterectomy previously. So if the fimbrial end is necrotic, then there may not be a uterus at the cornual end).

And while separating the bowel adhesions, one has to be careful to dissect along the antimesenteric border, lest the mesentery, mesosigmoid, and mesocolon are trimmed away from the bowel segment. It is advisable to call another gynecologist with greater expertise in adhesiolysis, irrespective of his or her age for assistance. Remember calling another surgeon of a different specialty midway, when the dissection has begun and has its own problems. If the condition is entirely gynecological, it conveys a lack of skill in the gynecologist to other specialists. To patient’s relatives, it will appear that the gynecologist has committed a blunder. Has some problem or an injury occurred? Why is another surgeon being called now? But calling a fellow gynecologist by and large will not create such an impression. It would only suggest that more assistance is required.

Not that one must not seek the help of other surgeons but first call a fellow gynecologist if possible. A fellow gynecologist with experience and expertise will know the gynecological indication for which the surgery is being done, for example, why is the adhesiolysis being done, does the patient wish to preserve her fertility, etc. A fellow gynecologist by virtue of being in the same specialty will be able to help the primary gynecologist manage the postoperative problems including handling patient’s concerns. A surgeon of a different specialty will only be concerned with that limited territory alone. For example, if a urologist has been called to repair an injured ureter, the urologist will follow-up with the repair procedure only. But had there been an experienced fellow gynecologist right from the beginning of the surgery, then the ureteric injury might possibly have been avoided. And the fellow gynecologist colleague will be duty bound to help the primary consultant with everything—postoperative problems, explaining the condition to patient and relatives, possible loss of fertility potential, etc. How can one expect a surgeon of another specialty to help in this regard? Why would any surgeon other than a fellow gynecologist be interested in issues like (loss of) fertility, future child bearing, etc.?

But as a note of caution, do not hesitate to call the right person, a fellow gynecologist or a urologist, or a general surgeon, but do not call a surgeon of a different specialty just because one fears competition, or because one does not want fellow gynecologists to know about one’s cases.

When the anatomy is distorted or when tissues are friable or when there are dense adhesions, one must do sharp dissection and not blunt dissection. This is to be followed very strictly especially when one is close to vital structures. The logic being that a neat and clean cut is easier to repair. Never try to shell out what could be a segment of bowel. Never try to strip two layers of bowel stuck to one another or to the anterior abdominal wall. Or for that matter, never try to peel off a segment of bowel stuck to the uterus or ovary. The small intestine if torn can be repaired by closing in two layers or by resection of the damaged segment followed by anastomosis of the two cut ends [1]. The large intestine does not share the same privilege. Unless it is a very small rent, the general rule is colostomy, and this will not be an easy situation to handle. What if the patient is young mother, the only bread earner of the family, a young student preparing for an important examination, a deeply religious person who needs to go to a place of worship, a cook who has to enter the kitchen—How can a person with a colostomy perform these roles?

And remember, colostomy will need to be closed at a later date, which means another procedure under anesthesia. Closure of an intestinal rent without showing it to a surgeon is strongly discouraged (preferably call a surgeon to do the repair) ; it might result in leaks which will become evident on finding bile and/or fecal stained drain fluid postoperatively.

Another rule to be kept in mind is that one must not use cautery excessively and indiscriminately when close to vital structures. Check if the metal instrument is touching or is in contact with any other structure, or is it in contact with another mental instrument like the retractor before buzzing it. The thermal damage due to cautery extends well beyond the visibly charred area. Things may look fine at the time of closure, but the damaged tissues will slough away and a ureterovaginal fistula (evident by continuous trickle of urine in the vagina) or a bowel perforation with fecal/biliary peritonitis will occur about 5 days after surgery. Not just the viscera, even skin burns are known to occur leading to poor wound healing, due to carelessness while using cautery [2, 3]. If the forceps touches the metal retractor, there can be an extensive charring—remember the business end of the retractor can be broad, and the amount of avoidable damage can be extensive.

Do not apply clamps blindly and take deep stitches to secure bleeders without checking what is held in the pedicle. This is a common cause of ureteric injuries [4, 5]. Apply pressure with a mop. Hold the structures with atraumatic instruments—Babcock or an artery forceps. Then trace the ureter and make sure it is away from the bleeding point. And then apply cautery catching the bleeder points only, or take stitches or apply a free tie once it is certain that no vital structure is included in the pedicle. A less commonly encountered postoperative complication is a vesicovaginal fistula or a ureterovaginal fistula becoming obvious after the fifth postoperative day. The patient complains of watery leak or a continuous trickle of urine from the vagina. This is because a part of bladder, or the ureter, was damaged by cautery, or was included in sutures during surgery. This most commonly happens when the bladder is not well separated during hysterectomy, and as a result has suffered thermal damage due to cautery being applied close to it’s tissue, or because a part of it has been included in the sutures, or both. The damaged tissue sloughs away over the next few days, resulting in the formation of a fistulous track, usually a week after the surgery.

Therefore, identifying and repairing the damage during primary surgery is undoubtedly a better situation to be in than encountering a shock a week later (while all along one was feeling very happy for having accomplished a challenging case successfully). But better still would be to avoid damage to a vital structure in the first place by correctly identifying the structure before applying cautery or taking a stitch.

How to confirm the presence of a small bowel perforation? A fairly large rent is obvious. A generous amount of warm saline must be poured into the peritoneal cavity. Let the bowel loops submerge in the pool of saline. If one sees gas bubbles coming out, there has to be a rent in a gas-filled organ. Gas being lighter than water will come out and can be seen as bubbles in a pool of saline. Just like how puncture in a tire tube was located before the age of tubeless tires! This technique is also used by surgeons after performing resection anastomosis of the bowel. If air bubbles are seen coming out of the site of bowel anastomosis after it is submerged in a saline-filled kidney tray or pelvis, then it means that the anastomosis is not water tight.

In case of suspected rectal or sigmoid injury, fill the pelvis with saline and ask an assistant to blow a jet of air using an asepto syringe through the anus from below. If air bubbles are seen in the pelvis, it means there must be a rent in the rectum or the sigmoid.

Once the bowel loops have been separated from one another and the access to the pelvis gained, the intended gynecological procedure can be performed. During residency, gynecologists are taught very well the steps one should follow to avoid ureteric injuries. Most residents are very well aware of these by the end of their residency.

Well, it is a bit embarrassing for gynecologists that gynecological surgery is the most common cause of ureteric injury, and this has not changed over the years. So how does one locate the ureter? Unlike the small and large intestine, ureters are not intraperitoneal in any part of their course? Even in a case with no anatomic distortions, they can be exposed only by opening the retroperitoneum. If there are no adhesions or if there is no collection in the pouch of Douglas, they can be seen transperitoneally. 

It is quite easy to locate and identify the ureters. One has to divide the round ligament, which has been described by many standard textbooks as the most consistent landmark in a female pelvis. Following this, one has to separate the two folds of the broad ligament extending laterally. Blunt dissection would be preferable at this stage, but not when the tissues are densely adherent to each other. One of the cardinal rules, never force open a space should be kept in mind. The gloved fingers can be inserted, and the loose areolar tissues are gently separated. Once the external iliac artery is located, go upwards, and the ureter can be seen crossing the bifurcation of the common iliac artery. The ureter then runs medially along the fold of the broad ligament and passes below the uterine artery—water under the bridge; it then takes a sharp medial turn at the level of the ischial spine to enter the trigone of bladder.

The arteries are seen pulsating, whereas the ureter shows peristalsis if stimulated with a blunt atraumatic forceps. The question of confusing the ureters with a vein does not arise. The veins are blue, and the external iliac vein runs under the external iliac artery. Do not touch the vein with any pointed instrument. They being thin walled can tear, and a vascular surgeon will have to be called urgently. The bleeding, dark red in color, will soon fill the entire pelvis. Just put a mop and apply pressure, and call the vascular surgeon.

If the ureter is seen adherent to the mass/fibroid, then use sharp dissection. Ask for a tape and take the ureter on this and lateralize it. Remember; do not apply cautery on the ureter. Hold the bleeder with a fine tip forceps and lift it away from the ureteric surface before buzzing it. The tip of the forceps should be away from the ureteric serosa, while cauterization.

One instrument that gynecologists must use more often is the right-angled forceps, also called mixter. This instrument cannot be replaced by any other, or done away with. For many steps, like taking the ureter on the tape, passing the stout silk under the internal iliac artery for internal iliac artery ligation, mobilizing the ureter out of the tunnel of Wertheim, and sometimes even for adhesiolysis, right-angled forceps is a must.

One can also take the external iliac artery on tape (if the adnexal mass lies close to it), but never do that with a vein. There is an instrument called a vein hook to gently lift the vein and to expose its under surface. Remember there could be a tributary of the vein in the under surface which could get torn and lead to a very difficult situation.

Always feel the ureter with your thumb and index finger, sometimes the ureter can be better felt than seen. Some seniors describe the ureter as a cord that slips between fingers. Once this feeling is registered in mind, one will never forget the tactile feel of the ureters.

If ureteric or bladder injury is suspected, checking the color of urine for the presence of blood is not always reliable since blood-stained urine can happen even when there is extensive handling and due to rough retraction. Deaver’s retractor is the preferred retractor for most gynecologists for pelvic surgery. Doyen’s retractor on the other hand is suitable for caesarean sections. If rough handling is the cause of hematuria, then delayed removal of Foley catheter would be advocated since some amount of denervation might have occurred (e.g., if the ureters have been taken on a tape and have been lateralized). Bladder atonia/hyponia may result postoperatively, and the patient may not feel bladder fullness and may have difficulty in voiding. The author once had an unusual experience. In one case, there was blood in the urine bag, but no ureteric or bladder injury had occurred. This was during a case of radical hysterectomy. When urologists were called, they confirmed the absence of any injury. However, clots had formed in the bladder due to rough retraction by the novice second assistant. The clots were flushed out, and continuous irrigation of bladder was performed by placing a three-way Foley catheter.

To confirm any ureteric injury, one has to trace the ureters on both sides and look if any sutures or cautery burn marks are in the vicinity of the ureters. Gently stimulate the ureters with a blunt instrument and check for peristalsis. As mentioned before, the color of urine can be blood stained even without crushing, ligation, and transection injuries. A complete ligation of the ureter with a deep stitch is something that happens only when one holds a very thick chunk of tissue in a pedicle and takes a deep stitch without checking what is in the chunk of tissue which has been held. This is a very gross mistake, since one of the cardinal rules is never take a deep stitch in the pelvis without knowing what could be inside the pedicle; one never knows what one could be ligating. Theoretically, this might not result in blood-stained urine because the entire lumen has been closed by a tight stitch, and the ureteric wall has not been pierced. But the urine output postoperatively will be very low, and the patient will have severe flank pain on the affected side.

Just as mere presence of blood-stained urine does not mean ureteric or bladder injury, the mere finding of low urine output also does not mean ureteric injury. Low urine output might be because of anemia and dehydration. Fluid replacement is usually underestimated. The total output from all the drains should be taken into account. If the output is at least one third the input, then it is reassuring, provided that the total urine output is at least 30 mL/h, or the 24 h urine output is more than 500 mL [6]. Also if the urine is concentrated, it means that kidneys are able to concentrate urine, it is unlikely ureters are injured in the absence of other findings. But remember, sudden appearance of hematuria a week after surgery followed by dribbling means a fistula, even if the patient had no specific symptoms immediately after surgery.

Locating the bladder is not difficult. Just try and locate the bulb of the Foley catheter. One can inflate the bulb with greater amount of distilled water, so that a hugely distended bulb can serve as a visible landmark throughout the surgery. If the Foley bulb is visible, then it is obvious that there is a rent in the bladder. But whenever a bladder injury is suspected, the time-honored technique of confirming the rent is to do retrograde filling with saline stained with methylene blue. If bluish saline is seen pouring into the pelvis, then there is no doubt that the bladder is injured [4, 5].

Call a urologist if posterior wall, trigone, or ureters are damaged. Only the dome of the bladder can safely be closed by the gynecologist himself/herself.

Now, should a gynecologist ask for stenting of the ureters prior to surgery in all difficult cases [4, 5]? Well, gynecologist must know how to locate and trace the ureters. The number of cases where the operating gynecologist will get rude shock on the operating table will be far more than cases where a prophylactic preoperative stenting has been performed for a broad ligament or a cervical leiomyoma. In many patients, preoperative imaging shows nothing to suggest a badly distorted anatomy. Is it advisable or feasible to prophylactically stent the ureters preoperatively in all cases? The answer clearly is no. The operating gynecologist must be able to locate and trace the ureter from the point of entry into the pelvis, that is, from the point where the ureter crosses the bifurcation of common iliac artery to the trigone of bladder.

Now, how do we locate the ureter in case of laparoscopy where we do not have the luxury of feeling it with our fingers? What beginners are taught is apply the grasper/harmonic as close as possible to the ovaries while cutting the infundibulopelvic ligaments. In case of large ovarian masses, this precaution alone might not be enough. Follow the same techniques, and divide the round ligament. Use a hook and split open the folds of the broad ligament, and enter the retroperitoneal space. Use a hook and separate the loose areolar tissues. Hook the tissue and lift it, making sure there is nothing under it. Once the ureters are located, safely catch the infundibulopelvic ligament. And if the case is difficult and one cannot call a more experienced colleague, never hesitate to convert it into a laparotomy. Never apply cautery blindly. In case of laparoscopy, remember the role of an assistant is much more than in laparotomy. One needs far more able assistants for laparoscopic surgeries than when compared to laparotomy. One cannot compromise by having a shaky hand holding the camera. The placement of ports should be correct. Instruments should never cross each other and create what is often described as “sword fight in the abdomen.”

Now lastly, what to do when there is no round ligament? How do we locate the ureter in such situations where there is no visible trace of the round ligaments? This can be due to adhesions following previous surgery.

In such situations, hold a fold of posterior peritoneum in the lateral side of pelvis and feel with fingers if there is any tubular structure underneath. Make a small nick on the posterior peritoneum and open the retroperitoneal space. Gently extend the incision on the posterior peritoneum, making sure there is no structure underneath. Try to locate the bifurcation of the common iliac artery with ureter crossing it.

Lastly another time-honored dictum is in pelvic surgery, do not forcibly open a space and do not create a space, the bottom of which cannot be seen. Should torrential bleeding occur, it will be very difficult to control it. It may not be possible to open a space due to many reasons—previous surgery, radiation, presence of malignancy with parametrial extension (think whether has anything been missed out in the preoperative evaluation), induration due to pelvic infection, or maybe one is simply not in the correct plane!

Let us now study some photographs taken during live surgeries which illustrate the problems one can encounter when the anatomy is distorted and vital structures cannot be identified easily, and the dissection techniques one must follow in order to proceed further. The description is in third person and present continuous. The directions mentioned in the description, for example-the arrow pointing to the right shows-, the arrow pointing down shows-, etc. is with respect to the photograph and not with respect to the anatomy of the patient being operated. This is because the photographs have been taken from an angle that provided the best view and clarity during surgery.

Fundamental Precautions While Doing Hysterectomy (Fig. 3.1a–f)

1. 1.
   
   
   

   The specimen, the uterus, is held with clamps applied on both sides with the assistant giving moderate upward traction (Fig. 3.1a). The ureters being retroperitoneal structures will tend to fall down as the specimen is pulled up by the assistant. The second assistant is retracting the bladder with help of Deaver’s retractor. Both the round ligaments have been divided and a stay suture has been applied. On the left side, the tip of the artery forceps can be seen holding the stay suture of the left round ligament. On the right side, one might be able to appreciate the rectus muscle has been partially divided transversely to facilitate better exposure.

   
   
    

1. 2.
   
   
   

   Applying clamps as close as possible to the specimen (Fig. 3.1b) —one can see, the infundibulopelvic ligament has been clamped as close as possible to the ovary. The medial most clamp has been applied just along the ovarian margin, and a stout artery forceps has been applied between the two clamps. Now the infundibulopelvic ligament will be cut between the medical clamp and the artery forceps.

   
   

   It is safer to first tie the cut infundibulopelvic ligament with a free tie before taking a transfixing suture medial to the free tie. This is because, sometimes, the tissues are very thin and friable. A stitch through a friable tissue will cut through, and if the clamps slip, it will lead to torrential hemorrhage. Remember, the ovarian artery which is present in the infundibulopelvic ligament is a direct branch of the descending aorta. Should the clamps slip, the artery will retract, and it may not be easy to locate the cut end of the bleeding artery. It might also require extending the incision or converting the laparoscopy to laparotomy. The ureters can be located very close to the infundibulopelvic ligament, and this is a common site where the ureter gets injured. Blind and hurried attempts to secure hemostasis, is the commonest cause of ureteric injuries.

   
   

   Another reason for applying a free tie before transfixing the infundibulopelvic ligaments is that, if the needle pricks a vessel in the pedicle and if a hematoma occurs as a result, its extension is limited by the free tie which has already been applied. Some gynecologists do not transfix the infundibulopelvic ligament at all. They just double ligate the infundibulopelvic ligament.

   
   

   Throughout the surgery, the surgeon holds the pedicles while cutting and taking stitches. The first assistant holds the specimen with one hand and releases the clamps/cuts the sutures with the other. The second assistant facilitates exposure by holding the retractors as required and suctions out the cautery smoke and collected blood/fluid.

   
   

   The assistant cauterizes the bleeders which have been held by the surgeon only after the surgeon has given the signal by saying “Touch.” This is to avoid cauterizing any other tissue which may have been held by the forceps. The surgeon should also specify if cautery should be applied only as “touch and go,” especially near vital structures like the bowel, ureter, base of bladder, etc. The assistant should also check if any metal structure is in contact with the cautery current before cauterizing; because if this happens, it will lead to extensive burns and possibly catastrophic damage.

   
   
    

1. 3.
   
   
   

   After the uterovesical fold has been excised, and the bladder pushed down, incise the posterior peritoneum of the uterus as well (Fig. 3.1c). This step is called the “skeletonization” of the uterine artery. The tortuous uterine artery can be seen after this step has been accomplished. This is another important step which helps to prevent ureteric injury. The ureter being retroperitoneal falls lower down once the posterior peritoneum of the uterus has been incised and released.

   
   
    

1. 4.
   
   
   

   Both, the uterovesical fold of peritoneum and the posterior peritoneum have been incised (Fig. 3.1d). Skeletonization of the uterine artery has been done. The uterine vessels can be seen at the level of the isthmus as shown by arrow pointing up. The uterine artery has a descending cervical branch and the upper branch anastomoses with the uterine branch of ovarian artery in the mesosalpinx.

   
   

   Uterine clamps can now safely be applied; the ureters are very much down below. One can be sure that only the uterine vessels will be included in the clamp.

   
   

   Skeletonization should not be skipped due to fear that it will cause “more bleeding” or that “so much of dissection” is not necessary. Small bleeders can be held with a fine tip forceps and cauterized, making sure that only the bleeding point is held and that there is no vital structure close to the held tissue. In Fig. 3.1d, one bleeding vessel on the anterior isthmus has been cauterized close to the specimen as shown by the cautery burn mark. The bladder has been pushed done and away from the operating field. And there is a bleeding vessel medial to the burn mark which needs to be cauterized. The spurt of bleeding can be appreciated. The arrow pointing down shows the posterior peritoneum. And one can see some bleeding is present along the cut margin of the peritoneum.

   
   
    

1. 5.
   
   
   

   Uterine artery is clamped after skeletonization (Fig. 3.1e). The bladder has been pushed well below. The clamps have been applied at the level of the isthmus, as close to the specimen as possible, preferably by “overriding” the cervix. But this may not be possible if the cervix is necrotic as in cases of a large endocervical fibroid with secondary infection.

   
   
    

1. 6.
   
   
   

   All the subsequent clamps are applied medial to the previous pedicle (Fig. 3.1f). One can see the uterine artery has been clamped, cut, and ligated. The uterosacral clamp has been applied medial to the uterine artery pedicle. The arrow is pointing to the uterine artery pedicle. It is not advisable to keep a stay suture over the uterine artery or any vascular pedicle. Constant pulling of the stay suture can lead to the suture coming out or becoming loose—both will lead to hemorrhage which can manifest after the abdominal closure has been done. But in Fig. 3.1f, the uterine suture has been held temporarily for the purpose of taking the photograph—to make sure that the uterosacral clamp is applied medially and not lateral to it.

   
   
    

Bowel Dissection (Fig. 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 3.10, 3.11, 3.12, 3.13, 3.14, 3.15, 3.16 and 3.17)

One can see the loop of small intestine adherent to the lower part of the anterior abdominal wall above where the Allis forceps has been applied (Fig. 3.2a). Care has to be taken while opening the peritoneum. Carelessness while opening the peritoneum can lead to a bowel rent, which may be quite big requiring a major repair procedure.

Figure 3.2b is the close up view of the same case, i.e. Fig. 3.2a. Sharp dissection is being done using tissue cutting scissors. Never try to peel off/separate well-organized adhesions with a peanut or with wet or dry gauze. The arrow is pointing to the plane from where the dissection can begin.

Small intestine adherent to the anterior abdominal wall just below the level of umbilicus (Fig. 3.3)—if laparoscopy was planned, imagine the damage that would have occurred while inserting a Veress needle or during direct trocar insertion. An open method of inserting the camera port is safer, though not foolproof. The subsequent ports should be inserted under direct vision taking care that instruments do not end up crossing each other.

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