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Once inside the abdomen erectile dysfunction homeopathic drugs best buy tadalafilo, the applicator trigger is drawn backward, the outer rod retracts, and the upper jaw o the clip reopens. Held within the applicator jaws, the open clip is positioned across the narrow isthmic portion o the allopian tube, 2 to 3 cm rom the cornu, and perpendicular to the long axis o the tube. The jaws are positioned around the tube in a manner that directs the tube deeply into the crux o the clip jaws. This aids in total occlusion o the tube as it is attened across the base o the closing clip. Additionally, the applicator tip and clip are positioned such that when closed, the clip incorporates a small portion o adjacent mesosalpinx. The clip application is inspected to ensure that it has completely encompassed the tube. This procedure can be used as a sterilization technique but is more commonly used to excise allopian tube ectopic pregnancies. Wound Closure Subsequent surgery completion steps ollow those o diagnostic laparoscopy (p. Minimally Invasive Surgery 1011 44 3 With surgical treatment o ectopic pregnancy, goals include hemodynamic support o the patient, removal o all trophoblastic tissue, repair or excision o the damaged tube, and preservation o ertility in those who desire it. For most women, the pre erred surgical approach or ectopic pregnancy management is laparoscopic. It provides a sa e and ef ective treatment o the af ected allopian tube while of ering the advantages o laparoscopy. For some, laparoscopic salpingostomy is desired to treat and retain the af ected tube. However, i ertility is not a consideration or i tubal damage or bleeding does not permit allopian tube salvage, then laparoscopic salpingectomy may be selected due to its lower risk o persistent trophoblastic tissue. Salpingectomy may also be used to remove hydrosalpinges in women undergoing in vitro ertilization. The abdomen is entered with laparoscopic techniques, and typically two or three accessory trocar sites are added (Chap. Kleppinger bipolar electrode orceps are placed across a proximal portion o the allopian tube. When zero amperage o low is noted, scissors can then cut the desiccated, blanched tube. The Kleppinger orceps are then advanced across the most proximal portion o mesosalpinx. This process serially moves rom the proximal mesosalpinx to its distal extent under the tubal ampulla. I salpingectomy is per ormed in the setting o an ectopic pregnancy, substantial bleeding may be encountered. T us, the patient is typed and crossmatched or packed red blood cells and other blood products as indicated. For those undergoing laparoscopic salpingectomy or ectopic pregnancy, V E prophylaxis is typically indicated due to the hypercoagulability associated with pregnancy (able 39-8, p. For prophylaxis in those with active bleeding, intermittent pneumatic compression devices are pre erred. T us, the potential or oophorectomy and its ef ects on ertility and hormone unction are discussed. I she has completed her childbearing or has ailed a prior sterilization procedure, then contralateral tubal ligation or bilateral salpingectomy may be acceptable at the time o surgery. Following any surgical treatment o ectopic pregnancy, trophoblastic tissue can persist. The risk o this is lower with salpingectomy compared with salpingostomy and is discussed more ully on page 1013. Depending on the size o the ectopic pregnancy or hydrosalpinges, an endoscopic retrieval bag may also be needed. For salpingectomy, the allopian tube and mesosalpinx require ligation and excision. This may be accomplished using bipolar instruments, Harmonic scalpel, or laparoscopic suture loop (Endoloop). These may not be readily available in all operating suites, and desired tools are requested prior to surgery. A H C 1012 Atlas of Gynecologic Surgery ectopic tissue can then be removed together. Larger tubal ectopic pregnancies may be placed in an endoscopic sac to prevent ragmentation as they are removed through the laparoscopic port site. Alternatively, larger ectopic pregnancies can be morcellated with scissors within an enclosed bag. Slow and systematic movement o the patient rom rendelenburg positioning to reverse rendelenburg can also assist in dislodging stray tissue and uid, which is then suctioned and removed rom the peritoneal cavity. In this technique, vessels within the mesosalpinx are rst electrosurgically coagulated and then cut. One or more o these may be pre erred based on the surrounding pelvic pathology or adhesions. The major concern with any o these tools is the amount o thermal spread to surrounding tissues. Alternatively, the vascular supply to the allopian tube within the mesosalpinx can be ligated. Absorbable and delayed-absorbable suture loops are available, and either is suitable or ligation. Until levels are undetectable, contraception is used to avoid con usion between persistent trophoblastic tissue and a new pregnancy. Last, patients are counseled regarding their increased risk o uture ectopic pregnancy. Minimally Invasive Surgery 1013 44 4 For patients with ectopic pregnancy, laparoscopic linear salpingostomy of ers the surgical advantages o laparoscopy and an opportunity to retain ertility by preserving the involved allopian tube. Accordingly, suitable candidates are women with an unruptured isthmic or ampullary ectopic pregnancy and desiring uture pregnancies. Success is mainly af ected by the amount o bleeding, by the ability to control it, and by the degree o tubal damage. The abdomen is accessed with laparoscopic techniques, and typically two or three accessory port sites are used. Once cannulas are in place, systematic inspection o the abdomen and pelvis is completed prior to the planned procedure. By means o a 22-gauge needle through one o the accessory ports or through a separate abdominal wall needle puncture, a solution o vasopressin is injected into the mesosalpinx beneath the ectopic pregnancy. I the serosal layer overlying the ectopic tissue is injected instead, then a smaller 25-gauge needle may be used. A monopolar needle tip electrode is set at a cutting voltage and used to create a 1- to 2-cm longitudinal incision. Importantly, with salpingostomy, a patient is counseled regarding the possible need or salpingectomy i the tube is irreparably damaged or bleeding rom the tube cannot be controlled. Also, rates o persistent trophoblastic disease are higher with salpingostomy compared with removal o the entire af ected tubal segment. Bleeding Because trophoblastic tissue is vascular, disruption during ectopic pregnancy removal can lead to severe hemorrhage. The ability o tubal muscularis to contract is minimal, and thus, bleeding during salpingostomy must be controlled with external modalities such as electrosurgical coagulation. Many devices are appropriate, and the microbipolar device is ef ective or achieving hemostasis while creating minimal thermal spread. Because o the potential systemic vasoconstrictive ef ects o vasopressin, intravascular injection is avoided. Another approach is to inject the solution into the portion o the tube to be incised. Additional complications and contraindications to vasopressin use are discussed on page 1023. Bene ts to vasopressin include less requent use o electrosurgery, shorter operating time, and lower conversion rates to laparotomy or surgery completion.

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Pediatr Dev Pathol 18(4):259 erectile dysfunction treatment photos discount tadalafilo 2.5 mg without prescription, 2015 Nistal M, Paniagua R, Gonzalez-Peramato P, et al: Kline elter syndrome and other anomalies in X and Y chromosomes. Fertil Steril 33(1):25, 1980 Ocal G: Current concepts in disorders o sexual development. Fertil Steril 99(2):470, 2013 Parazzini F, Cecchetti G: the requency o imper orate hymen in northern Italy. Am J Med Genet 89(4):224, 1999 Sivanesaratnam V: Unexplained unilateral absence o ovary and allopian tube. Obstet Gynecol 82(4 Pt 2 Suppl):655, 1993 Vecchietti G: [Creation o an artif cial vagina in Rokitansky-Kuster-Hauser syndrome]. Endocr Rev 21(3):245, 2000 Williams C, Nakhal R, Hall-Craggs M, et al: ransverse vaginal septae: management and long-term outcomes. J Obstet Gynaecol Br Commonw 71:511, 1964 Woel er B, Salim R, Banerjee S, et al: Reproductive outcomes in women with congenital uterine anomalies detected by three-dimensional ultrasound screening. However, there are obvious exceptions, such as the woman with bilaterally obstructed allopian tubes or the azoospermic male. In general, in ertility evaluation is or any couple that has ailed to conceive in 1 year. O particular note, ecundability is highly age-related, with a signi cant decrease beginning at approximately 32 years o age and more rapid decline a ter age 37 (American Society or Reproductive Medicine, 2014a). This decline in conception rates is associated with an increase in poor pregnancy outcomes, primarily due to increased aneuploidy rates. T us, most experts agree that evaluation is considered a ter only 6 months in women older than 35 years. Ideally, these issues are addressed prior to re erral to an in ertility specialist whenever possible. In ertility is de ned as the inability to conceive a ter 1 year o unprotected intercourse o reasonable requency. It can be subdivided into primary infertility, that is, no prior pregnancies, and secondary infertility, re erring to in ertility ollowing at least one prior conception. Conversely, ecundability is the ability to conceive, and data rom large population studies show that the monthly probability o conceiving is 20 to 25 percent. In those attempting conception, approximately 50 percent o women will be pregnant at 3 months, 75 percent will be pregnant at 6 months, and more than 85 percent will be pregnant by 1 year. O note, even without treatment, approximately hal o women will conceive in the second year o attempting. According to the National Survey o Family Growth, the percentage o married women who reported in ertility ell rom 8. In comparison, the percentage o women aged 15 to 44 years who had ever used in ertility services increased rom 9 percent in 1982 to 12 percent in 2002, with a peak o 15 percent in 1995 (Chandra, 2013, 2014). Interpretation o these data is complicated by ongoing changes in marriage rates, intentional delays in childbearing, and socioeconomic and educational status changes in a growing immigrant community. Nevertheless, well-publicized successes in in ertility treatment now give patients greater hope that medical intervention will help them achieve their goal. In the male system, sperm o adequate number and quality must be deposited at the cervix near the time o ovulation. Remembering these critical events can aid in developing an appropriate evaluation and treatment strategy. In general, in ertility can be attributed to the emale partner one third o the time, the male partner one third o the time, and both partners in the remaining one third. This approximation emphasizes the value o assessing both partners be ore instituting therapy. Estimates o the incidence o various causes o in ertility are shown in Table 19-1 (Abma, 1997; American Society or Reproductive Medicine, 2006). This time provides an excellent opportunity to educate regarding the normal conception process and methods to optimize their natural ertility. Such e orts may obviate the need or expensive and time-consuming interventions (American Society or Reproductive Medicine, 2013a). The chance o conception is increased rom the 5 days preceding ovulation through the day o ovulation (Wilcox, 1995). I the male partner has normal semen characteristics, a couple ideally has daily intercourse during this period to maximize the chance o conception. Although sperm concentrations will drop with increasing coital requency, this decrease is generally too small to signi cantly lower the chance o ertilization (Stan ord, 2002). Couples are also reminded to avoid oil-based lubricants, which are harm ul to sperm. Examples, such as the importance o coital position and the need to remain horizontal ollowing ejaculation, can add undue stress to an already stress ul situation and should be dispelled. Speci cally, questions cover menstruation (requency, duration, recent change in interval or duration, hot ushes, dysmenorrhea), prior contraceptive use, coital requency, and in ertility duration. A prolonged time to conception may suggest borderline ertility and may increase the chance o determining an etiology. Pregnancy complications such as miscarriage, preterm delivery, retained placenta, postpartum dilatation and curettage, chorioamnionitis, or etal anomalies are also recorded. Symptoms such as dyspareunia may point to endometriosis and a need or earlier diagnostic laparoscopy or the emale partner. This is also an excellent opportunity to ensure that all indicated vaccinations are current, as several are contraindicated once pregnancy is achieved (American Society or Reproductive Medicine, 2013d). Questions regarding medications include over-the-counter agents, such as nonsteroidal antiin ammatory drugs, that may adversely a ect ovulation. In those with a previously a ected child, 4 g is taken orally daily (American College o Obstetricians and Gynecologists, 2014b). Previous pelvic and abdominal surgeries, especially i linked to endometriosis or adhesion ormation, can lower ertility. As examples, operations or ruptured appendicitis or diverticulitis raise suspicion or pelvic adhesive disease or tubal obstruction or both. Prior uterine surgery can predispose to pain, bowel obstruction, or extra- or intrauterine adhesions with resultant in ertility. When planning surgery, reducing adhesion ormation is a priority, and meticulous surgical technique and minimally invasive surgical approaches are avored. However, no strong evidence exists that their use improves ertility, decreases pain, or lowers bowel obstruction rates (American Society or Reproductive Medicine, 2013b). Etiology of Infertility Male Ovulatory Tubal/uterine Other Unexplained 25% 27% 22% 9% 17% Social A social history ocuses on li estyle actors such as eating habits. An estimated 30 to 50 percent o women, depending on race and ethnicity, are overweight or obese. Most agree that this incidence is increasing (American Society or Reproductive Medicine, 2008c; Hedley, 2004). In these women, in ertility is primarily related to an increased incidence o ovulatory dys unction, but data also suggest that ecundity is lower among ovulatory obese women. Although dif cult to achieve, even modest weight reduction in overweight women is correlated with normalized menstrual cycles and subsequent pregnancies (Table 19-2). Accumulating data also suggest that cigarette smoking lowers ertility rates (American Society or Reproductive Medicine, 2012d). At least one th o reproductive-aged men and women in the United States smoke cigarettes (Centers or Disease Control and Prevention, 2014). The prevalence o in ertility is higher, and the time to conception is longer in women who smoke, or even those exposed passively to cigarette smoke. Smoking is associated with an increased miscarriage rate in both natural and assisted conception cycles. The mechanism or this is unclear, but the vasoconstrictive and antimetabolic properties o some cigarette smoke components such as nicotine, carbon dioxide, and cyanide may lead to placental insuf ciency.

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Int J Gynecol Pathol 13:283 impotence propecia safe tadalafilo 10 mg, 1994 Okada I, Nakagawa S, akemura Y, et al: Ovarian thecoma associated in the rst trimester o pregnancy. Am J Surg Pathol 29:143, 2005 Oliva E, Andrada E, Pezzica E, et al: Ovarian carcinomas with choriocarcinomatous dif erentiation. Ultrasound Obstet Gynecol 15:365, 2000 Paladini D, esta A, Van Holsbeke C, et al: Imaging in gynecological disease (5): clinical and ultrasound characteristics in broma and brothecoma o the ovary. Ultrasound Obstet Gynecol 34:188, 2009 Palenzuela G, Martin E, Meunier A, et al: Comprehensive staging allows or excellent outcome in patients with localized malignant germ cell tumor o the ovary. Ann Surg 248:836, 2008 Pavlakis K, Messini I, Vrekoussis, et al: Intraoperative assessment o epithelial and non-epithelial ovarian tumors: a 7-year review. Am J Surg Pathol 20:823, 1996 Piura B, Nemet D, Yanai-Inbar I, et al: Granulosa cell tumor o the ovary: a study o 18 cases. N Engl J Med 360:2719, 2009 Sharony R, Aviram R, Fishman A, et al: Granulosa cell tumors o the ovary: do they have any unique ultrasonographic and color Doppler ow eatures Int J Gynecol Cancer 23(2):249, 2013 Shimizu Y, Komiyama S, Kobayashi, et al: Success ul management o endodermal sinus tumor o the ovary associated with pregnancy. Obstet Gynecol 87:737, 1996 Suita S, Shono K, ajiri, et al: Malignant germ cell tumors: clinical characteristics, treatment, and outcome. A report rom the study group or Pediatric Solid Malignant umors in the Kyushu Area, Japan. J Pediatr Surg 37:1703, 2002 akemori M, Nishimura R, Yamasaki M, et al: Ovarian mixed germ cell tumor composed o polyembryoma and immature teratoma. Gynecol Oncol 69:260, 1998 alukdar S, Kumar S, Bhatla N, et al: Neo-adjuvant chemotherapy in the treatment o advanced malignant germ cell tumors o ovary. Gynecol Oncol 132(1):28, 2014 angir J, Zelterman D, Ma W, et al: Reproductive unction a ter conservative surgery and chemotherapy or malignant germ cell tumors o the ovary. Obstet Gynecol 101:251, 2003 eilum G: Classi cation o endodermal sinus tumour (mesoblastoma vitellinum) and so-called "embryonal carcinoma" o the ovary. Mod Pathol 18 (Suppl 2):S61, 2005 Uygun K, Aydiner A, Saip P, et al: Clinical parameters and treatment results in recurrent granulosa cell tumor o the ovary. Chin Med J 117:1592, 2004 Zagame L, Pautier P, Duvillard P, et al: Growing teratoma syndrome a ter ovarian germ cell tumors. Am J Surg Pathol 8:405, 1984 Zanagnolo V, Pasinetti B, Sartori E: Clinical review o 63 cases o sex cord stromal tumors. Eur J Gynaecol Oncol 25:431, 2004 Zanetta G, Bonazzi C, Cantu M, et al: Survival and reproductive unction a ter treatment o malignant germ cell ovarian tumors. The outlook or preservation o ertility and or success ul subsequent pregnancy outcomes is equally bright (Vargas, 2014; Wong, 2014). Although historically higher incidence rates have been reported in parts o Asia, some o this disparity may re ect discrepancies between population-based and hospital-based data collection (Chong, 1999; Kim, 2004; Matsui, 2003). Improved socioeconomic conditions and dietary changes may be partly responsible as well. T at said, certain Southeast Asian populations as well as Hispanics and Native Americans living in the United States do have increased incidences (Drake, 2006; Smith, 2003; T am, 2003). This association is much greater or complete moles, whereas the risk o partial molar pregnancy varies relatively little with age. Moreover, compared with the risk in those aged 15 years or younger, the degree o risk is much greater or women 45 years (1 percent) or older (17 percent at age 50) (Savage, 2010; Sebire, 2002a). One explanation relates to ova rom older women having higher rates o abnormal ertilization. Similarly, older paternal age has been associated with increased risk (La Vecchia, 1984; Parazzini, 1986). For example, previous spontaneous abortion at least doubles the risk o molar pregnancy (Parazzini, 1991). The requency in a subsequent conception is approximately 1 percent, and most cases mirror the same type o mole as the preceding pregnancy (Garrett, 2008; Sebire, 2003). Furthermore, ollowing two episodes o molar pregnancy, 23 percent o later conceptions result in another molar gestation (Berkowitz, 1998). These tumors require ormal staging and typically respond avorably to chemotherapy. These moles classically have swollen enlarged villi, some of which show cistern formation, that is, central cavitation within the large villi (black asterisks). Complete moles also typically show trophoblastic proliferation (yellow asterisk), which may be focal or widespread. Normal term placenta showing smaller, nonedematous villi and absence of trophoblastic proliferation. Many o these associations, however, are weak and could be explained by con ounding actors other than causality (Parazzini, 2002). Some epidemiologic characteristics di er markedly between complete and partial moles. For example, vitamin A de ciency and low dietary intake o carotene are associated only with an increased risk o complete moles (Berkowitz, 1985, 1995; Parazzini, 1988). Partial moles have been linked to higher educational levels, smoking, irregular menstrual cycles, and obstetric histories in which only male in ants are among the prior live births (Berkowitz, 1995; Parazzini, 1986). Hydatidi orm moles are categorized as either complete hydatidiform moles or partial hydatidiform moles (Table 37-2). Complete Hydatidiform Mole These molar pregnancies di er rom partial moles with regard to their karyotype, their histologic appearance, and their clinical presentation. The chromosomes, however, in these pregnancies are entirely o paternal origin, and thus, the diploid set is described as diandric. Speci cally, complete moles are ormed by androgenesis, in which the ovum is ertilized by a haploid sperm that then duplicates its own chromosomes a ter meiosis. One quarter o women will present with uterine size greater than dates, but the incidence o anemia is less than 10 percent. Moreover, hyperemesis gravidarum, preeclampsia, and symptomatic theca-lutein cysts are now rare (Soto-Wright, 1995). Last, plasma thyroxine levels are o ten increased in women with complete moles, but clinical hyperthyroidism is in requent. Partial moles may be formed if two sperm, either 23,X- or 23,Y -bearing, both fertilize a 23,X-containing haploid egg, whose genes have not been inactivated. Microscopically, complete moles display enlarged, edematous villi and abnormal trophoblastic proli eration. Macroscopically, these changes trans orm the chorionic villi into clusters o vesicles with variable dimensions. Indeed, the name hydatidiform mole literally stems rom this "bunch o grapes" appearance. In addition, hyperemesis gravidarum, preeclampsia, and theca-lutein cysts developed in approximately one quarter o women (Soto-Wright, 1995). These moles di er rom complete hydatidi orm moles clinically, genetically, and histologically. The degree and extent o trophoblastic proli eration and villous edema are decreased compared with those o complete moles. Moreover, most partial moles contain etal tissue and amnion, in addition to placental tissues. As a result, patients with partial moles typically present with signs and symptoms o an incomplete or missed abortion. The mole completely fills this uterine cavity, and calipers are placed on the outer uterine borders. Similarly, preeclampsia, theca-lutein cysts, hyperthyroidism, or other dramatic clinical eatures are rare.

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The short Auvard speculum is replaced by one with a longer blade erectile dysfunction reversible best order for tadalafilo, which enters the cul-de-sac. Each sequential clamp is placed medial to the prior pedicle to reduce ureteral injury risk. The uterine artery is identi ed on one side and clamped with a curved Heaney clamp. The clamp is placed nearly perpendicular to the long axis o the uterus and medial to the prior cardinal ligament pedicle. The tips should rmly abut the uterus to ensure enclosure o entire artery and vein(s) within the clamp. Following pedicle transection, a simple stitch is placed around the clamp and is secured at the clamp heel as the instrument is removed. Progressing cephalad, curved Heaney clamps are next placed across the round and uteroovarian ligaments and allopian tube. A ter transection, a simple stitch o 0-gauge delayed-absorbable suture is placed proximally around the clamp. A trans xing stitch is then sutured around the clamp and positioned distal to the rst stitch. With ovarian preservation, these sutures are cut short a ter con rming pedicle hemostasis. However, or adnexectomy, the trans xing suture tails may be kept long to allow gentle traction to bring the adnexa toward the vagina. This knowledge permits calm, persistent dissection through this dense tissue rather than prematurely reorienting dissection, which risks "digging" into the cervix. This method is particularly bene cial or patients with prior cesarean deliveries, who may have scarring between the bladder and cervix. With traction established, the bers are incised in the midline with Metzenbaum scissors. Bleeding vessels are requently encountered during initial dissection and are coagulated. A ter the initial bers are transected, gentle palpation with the index nger should indicate whether the upper part o the vesicocervical space has been reached. In the absence o scar tissue, these bers are easily broken, and gentle blunt dissection is advanced cephalad until the vesicouterine old is palpated. Alternatively, the entire vesicocervical space dissection can be completed with gentle blunt pressure rom an index nger covered in surgical gauze. Such pressure is directed against the cervix and cephalad toward the vesicouterine old. This old is a thin and transparent transverse peritoneal old at the upper border o the cervix. This peritoneum is grasped with atraumatic tissue orceps, placed on tension, and incised. In cases with di cult anterior entry, the surgeon may enter the posterior cul-de-sac and wrap an index nger anteriorly to palpate and accentuate the vesicouterine old or anterior entry. Following vesicouterine old incision, an index nger explores the opening to con rm peritoneal entry, exclude cystotomy, and identi y unanticipated pelvic pathology. This nger then guides a curved Deaver retractor into the opening to elevate the bladder and anterior vaginal wall. Outward traction on the Lahey-thyroid clamps pulls the supporting uterine ligaments into view. Such traction, along with upward bladder displacement, helps prevent ureteral injury. The uterosacral and cardinal ligaments are identied, clamped with a curved Heaney clamp, transected, and ligated with 0-gauge delayedabsorbable suture using a trans xing stitch. Once the knot o this pedicle is tied, the suture ends are not cut but kept long or later identi cation. The pedicle is doubly ligated with a simple suture rst placed proximally and then with a trans xing stitch placed distally. With ovarian preservation, some recommend consideration o bilateral salpingectomy to lower high-grade peritoneal and ovarian serous carcinoma rates. However, during vaginal hysterectomy, complete resection o the tube is typically more challenging than during abdominal approaches, and iatrogenic bleeding may lead to oophorectomy or conversion to laparotomy. I tube removal is desired, then adjunctive laparoscopic salpingectomy may be considered to ease sa e removal o the entire tube. In some cases, the uterine undus may be too large to deliver, and uterine debulking is required prior to ligation o the cornual attachments. One technique bisects the uterus using curved Mayo scissors, beginning at the cervix and moving toward the undus. Near completion, ngers placed through the anterior colpotomy incision and behind the undus help prevent scissor injury to adjacent organs. Once completed, one hal is elevated out o the operating eld and into the pelvic cavity, whereas the other is brought into view or clamp placement across the uteroovarian and round ligaments and allopian tube. Other methods either enucleate individual large leiomyomas or involve cervix-to- undus central coring to remove volume. Once bulk is diminished, a Heaney clamp may be placed around the cornual structures as described in Step 7. For this, the adnexa is grasped with a Babcock clamp and gently pulled in eriorly and toward the contralateral side o the incision. For this, the uterine corpus may be delivered through the posterior colpotomy incision to better expose these. This is coupled with upward traction rom the originally placed anterior wall retractor. Prior to clamp closure, the surgeon con rms that no bowel or omentum is incorporated and that the entire ovary lies distal to the clamp. A moist sponge stick and slight rendelenburg positioning can push the bowel away rom the operative eld. Surgeries for Benign Gynecologic Disorders interrupted or continuous running stitches o 0-gauge delayed-absorbable material. I short vaginal length is a concern, walls can be closed by a vertical suture line. For this, the interrupted or continuous running closure suture is initially passed through the anterior vaginal wall, through the ligament, through the posterior peritoneum, and nally through the posterior vaginal wall on one side. Suturing then progresses rom each side to the midline, or a single running suture may close the entire cu line. Also, the posterior peritoneum is incorporated with the closure to minimize risks o bleeding and cu hematoma. Excess traction on this pedicle is avoided to prevent avulsion or retraction o the ligament rom the clamp. In such cases, resultant retroperitoneal bleeding may be di cult to control vaginally. Electrosurgical coagulation or gure-o -eight sutures will typically control bleeding rom discrete points. I indicated or pre erred, a McCall culdoplasty may be per ormed (Section 45-22, p. Although diet and most activities are advanced quickly, intercourse is delayed or 6 weeks to permit vaginal cu healing. Evaluation and treatment o postoperative complications mirrors that or abdominal hysterectomy. Hilger and associates (2005) reported on 335 women who underwent trachelectomy between 1974 and 2003. In hal o them, trachelectomy was per ormed, on average, 26 years a ter supracervical hysterectomy. The cervix may be removed either vaginally or abdominally, but or most women without concurrent pelvic pathology, vaginal trachelectomy is pre erred (Pratt, 1976). With the resurgence o supracervical hysterectomy, now per ormed via laparoscopy, rates o trachelectomy or benign causes may rise. Radical trachelectomy or invasive cervical cancer is gaining acceptance and is described in Chapter 30 (p.

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Clinically erectile dysfunction help without pills purchase tadalafilo 5 mg line, an intentional cystotomy can be made to con rm patency o the ureteral ori ces, to assist with surgical dissection, or to place ureteral stents. The incision is ideally placed in the retropubic extraperitoneal portion o the bladder close to the apex. This avoids direct contact between the abdominopelvic viscera and the cystotomy site and minimizes the risk o stula ormation. The bladder wall consists o coarse bundles o smooth muscle known as the detrusor muscle, which extends into the upper part o the urethra. Although separate layers o the detrusor are described, they are not as well de ned as the layers o other viscous structures. The innermost layer o the bladder wall is plexi orm, which can be seen rom the pattern o trabeculations noted during cystoscopy. The mucosa o the bladder consists o transitional epithelium and underlying lamina propria. The bladder is divided into a dome and a base approximately at the level o the ureteral ori ces. The dome is thin walled and distensible, whereas the base is thicker and undergoes less distention during lling. These loops are two U-shaped bands o bers ound at the vesical neck, where the urethra enters the bladder wall. The pelvic ureter courses in the pelvic sidewall retroperitoneum and is discussed on page 816. The blood supply to the bladder arises rom the superior vesical arteries, which are branches o the patent portion o the umbilical artery. Other contributors are the middle and in erior vesical arteries, which, when present, o ten arise rom either the internal pudendal or the vaginal arteries. The nerve supply to the bladder arises rom the vesical plexus, a component o the in erior hypogastric plexus. An additional discussion o lower urinary tract innervation is ound in Chapter 23 (p. Clinically, chronic in ection o the paraurethral glands can lead to urethral diverticula. Due to the multiple openings o these glands along the length o the urethra, diverticula may develop at various sites along the urethra. It descends on the anterior sur ace o the sacrum or approximately 12 cm and ends in the anal canal a ter passing through the levator hiatus. The anterior and lateral portions o the proximal two thirds o the rectum are covered by peritoneum. The peritoneum is then re ected onto the posterior vaginal wall to orm the posterior cul-de-sac o Douglas, also termed rectouterine pouch. In women, the cul-de-sac is located approximately 5 to 6 cm rom the anal ori ce and can be palpated manually during rectal or vaginal examination. At its commencement, the rectal wall is similar to that o the sigmoid, but near its termination it becomes dilated to orm the rectal ampulla, which begins below the posterior cul-de-sac peritoneum. The rectum contains several, usually three, transverse olds called the plicae transversales recti, also termed valves o Houston. The largest and most constant o these olds is located anteriorly and to the right, approximately 8 cm rom the anal ori ce. These olds may contribute to ecal continence by supporting ecal matter above the anal canal. Clinically, in the empty state, the transverse rectal olds overlap each other, making it dif cult at times to manipulate an examining nger or endoscopy tube past this level. The urethral lumen begins at the internal urinary meatus within the bladder, and then courses through the bladder base or less than a centimeter. This region where the urethral lumen traverses the bladder base is called the bladder neck. They consist o two layers o smooth muscle, an inner longitudinal and an outer circular, which are in turn surrounded by a circular layer o skeletal muscle re erred to as the sphincter urethrae or rhabdosphincter. Approximately at the junction o the middle and lower third o the urethra, and just above or deep to the perineal membrane, two strap skeletal muscles called the urethrovaginal sphincter and compressor urethrae are ound. These muscles were previously known as the deep transverse perineal muscles in emales. T eir bers act cumulatively to supply constant tonus and to provide emergency re ex activity mainly in the distal hal o the urethra to sustain continence. Distal to the depth o the perineal membrane, the walls o the urethra consist o brous tissue, serving as the nozzle that directs the urine stream. The urethra has a prominent submucosal layer that is lined by hormonally sensitive strati ed squamous epithelium. Within the submucosal layer on the dorsal (vaginal) sur ace o the urethra is a group o glands known as the paraurethral glands, which open into the urethral lumen. Duct openings o the two most prominent glands, termed Skene glands, are seen on the inner sur ace o the external urethral ori ce (p. The urethra receives its blood supply rom branches o the in erior vesical/vaginal and internal pudendal arteries. Although still controversial, the pudendal nerve is believed to innervate the most distal part o the striated urogenital sphincter complex. O these, the retroperitoneal space o the pelvic sidewalls contains the internal iliac vessels and pelvic lymphatics, pelvic ureter, and obturator nerve. During surgery, entering the retroperitoneum at the pelvic sidewall can be used to identi y the ureter. Moreover, it is an essential step or many o the surgeries described in gynecologic oncology. The internal iliac and external iliac vessels and their corresponding lymph node groups lie within the pelvic sidewall retroperitoneal space. The internal iliac artery is ligated distal to the origin o its posterior division branches. These posterior division branches generally arise rom the posterolateral wall o the internal iliac artery at a site 3 to 4 cm rom its origin o the common iliac artery (Bleich, 2007). The pelvic ureter receives blood supply rom the vessels it passes: the common iliac, internal iliac, uterine, and superior vesical vessels. In contrast, the abdominal part o the ureter courses lateral to major vessels and accordingly, it receives most o its blood supply rom medially located vessels. Vascular anastomoses on the connective tissue sheath enveloping the ureter orm a longitudinal network o vessels. More than 50 percent o these injuries are not diagnosed intraoperatively (Ibeanu, 2009). The most common sites o injury include: (1) the pelvic brim area during in undibulopelvic ligament clamping; (2) the isthmic region during uterine artery ligation, (3) the pelvic sidewall during uterosacral ligament suturing, and (4) the lateral vaginal apex during vaginal cu clamping or suturing. It descends into the pelvis attached to the medial lea o the pelvic sidewall peritoneum. Along this course, the ureter lies medial to the internal iliac branches and anterolateral to the uterosacral ligaments. The ureter then traverses through the cardinal ligament approximately 1 to 2 cm lateral to the cervix. Near the level o the uterine isthmus, it courses below the uterine artery ("water under the bridge"). In this path, it runs close to the upper third o the anterior vaginal wall (Rahn, 2007). Presacral Space this retroperitoneal space lies between the rectosigmoid/posterior abdominal wall peritoneum and the sacrum. Laterally, this space is bounded by the internal iliac vessels and branches and by the ascia that covers the piri ormis muscle and sacral nerves. Contained within the loose areolar and connective tissue o this space are the superior hypogastric plexus, hypogastric nerves, and portions o the in erior hypogastric plexus. The presacral space contains an extensive and intricate venous plexus, termed the sacral venous plexus. This plexus is ormed primarily by the anastomoses o the middle and lateral sacral veins on the anterior sur ace o the sacrum.

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I the internal iliac is ligated at this site erectile dysfunction meds online buy tadalafilo with paypal, its posterior division theoretically should be spared (Bleich, 2007). Care is required in passing instruments beneath the artery because the thin-walled internal iliac vein is easily lacerated. Massive hemorrhage may be complicated by coagulopathy and uncontrollable microvascular hemorrhage. Specific Sites of Bleeding Infundibulopelvic Ligament During or a ter ligation o this vascular pedicle, a lacerated ovarian vessel may retract into the retroperitoneum to create a hematoma. In most cases, isolation o the bleeding vessel is required to halt hematoma expansion. For this, the pelvic sidewall peritoneum lateral to the ureter and the hematoma is opened, and the incision is extended cephalad to the upper pole o the hematoma. The upper pole o the hematoma is identi ed by a return to normal vessel caliber above the hematoma. The ovarian vessels are identi ed, and a closed Mixter right-angle clamp is placed beneath them. I large, the hematoma then is evacuated to minimize in ection risk (omacruz, 2001). In rare cases in which vascular or ureteral anatomy is unclear, an ovarian artery may require ligation as proximal as its aortic origin below the renal arteries (Masterson, 1995). This technique has been described in the management o hemorrhage in both gynecologic and obstetric cases. In other cases, or patients with persistent heavy bleeding despite attempts at control, pelvic packing with gauze and termination o the operation may be warranted. Rolls o gauze are packed against the bleeding site to provide constant local pressure. A ter administration o general anesthesia, packing is pulled slowly through a small opening le t in the incision. Alternatively, entire gauze rolls may be packed into the abdomen and removed during a second laparotomy (Newton, 1988). Space of Retzius and Presacral Venous Plexus the space o Retzius, also called the retropubic space, is o ten entered during urogynecologic procedures and contains important vascular structures such as the venous plexus o Santorini, the obturator vessels, and the aberrant obturator vessel. Approximately 2 percent o tension- ree vaginal tape procedures are complicated by bleeding in this space (Kolle, 2005; Kuuva, 2002). In contrast, the presacral venous plexus can be lacerated by dissection or suturing during sacrocolpopexy. Cut vessels may retract into the vertebral bone, and problematic bleeding can ollow. Internal Iliac Artery Ligation the internal iliac artery, also called the hypogastric artery, contains anterior and posterior divisions. Occlusion o the internal iliac artery decreases mean blood ow by 48 percent in branches distal to ligation, which in many cases slows hemorrhage su ciently to allow identi cation o speci c bleeding sites (Burchell, 1968). Fortunately, the emale pelvis has extensive collateral circulation, and the internal iliac artery shares arterial anastomoses with branches o the aorta, external iliac artery, and emoral artery. Several studies Major Pelvic Vessels High-volume pelvic vessels include the internal, external, and common iliac vessels, the in erior vena cava, and aorta. After opening the retroperitoneal space, the ureter is identified and retracted medially. A Mixter right-angle clamp is placed beneath the artery to receive a free tie for ligation. Although gynecologic surgeons may attempt to repair these injuries, excessive delay in obtaining vascular surgery assistance o ten leads to greater blood loss (Oderich, 2004). There ore, in many instances, pressure is applied, a vascular surgeon is consulted or repair, blood products are made available, and exposure is maximized. I a large vessel is punctured by a trocar or needle during laparoscopic entry, the instrument should remain in place to act as a plug while preparations or repair are made. As discussed earlier, internal iliac artery ligation does not lead to ischemia o central pelvic organs due to collateral blood supply. However, injury to the external or common iliac arteries requires repair to maintain blood supply to the lower extremity. Consultation with a vascular surgeon may be indicated depending on the degree o laceration and surgeon skill. Maneuvers that may extend the injury are avoided until appropriate assistance is available. On the le t, the common and external iliac arteries remain lateral to their respective veins. These arteries can be repaired by placing vascular clamps 2 to 3 cm proximal and distal to the tear, then closing the de ect with a continuous suture line using mono lament synthetic 5-0 suture (Gostout, 2002; omacruz, 2001). The proximal clamp is removed rst to allow air and debris to exit the suture line, and then the distal clamp is removed. Parametrial and Paravaginal Vessels During obstetric and gynecologic surgery, vessels supplying the uterus and vagina, especially venous plexuses, can be lacerated. At times, bleeding may not be easily identi ed and controlled by direct pressure, suturing, or clips. Alternatively, i resources are available, pelvic artery embolization is e ective in controlling pelvic hemorrhage. Despite these techniques, in rare persistent situations, pelvic packing and termination o surgery may be indicated. Greater losses, however, lead to worsening per usion, hypotension, and tachycardia. In these cases, blood trans usion in combination with uid resuscitation typically is indicated (Murphy, 2001). However, hematocrit values typically lag true losses, and values may re ect only the degree o hemorrhage. For example, ollowing a blood loss o 1000 mL, hematocrit levels typically all only 3 volume percent in the rst hour but usually show an 8 volume percent drop at 72 hours (Schwartz, 2006). Hemorrhage leads to global tissue hypoxia, anaerobic metabolism, and lactate production. I patients continue to have dropping base de cits despite aggressive resuscitation, ongoing hemorrhage is a concern (Davis, 1988). With acute hemorrhage, priorities include control o additional losses and replacement o su cient intravascular volume or tissue per usion and oxygenation. In hypoper used areas, progressive ailure o oxidative metabolism with lactate production leads to worsening systemic metabolic acidosis and eventual organ damage. O this volume, 15 percent can be lost by most patients with no changes in arterial pressure or heart rate. With losses o 15 to 30 percent (500 to 1000 mL or a 50-kg woman), tachycardia and narrowing o the pulse pressure are seen (Table 40-6). Peripheral vasoconstriction leads to pale, cool extremities and poor capillary re ll. In unanesthetized patients, Fluid Resuscitation I hypovolemia is identi ed, uid resuscitation begins with crystalloid solutions. I hypotension and tachycardia are present, rapid replacement is warranted, and 1 or 2 liters, as indicated, may be in used over several minutes. Intraoperative Considerations commonly, and their composition is described in Chapter 42 (p. For moderate hemorrhage, both per orm equally well as uid replacements (Healey, 1998). Although crystalloids have an immediate e ect to expand intravascular volume, a portion will extravasate into extracellular tissues. T us, in the setting o hemorrhage, crystalloid volume is administered in a 3:1 ratio to blood lost (Moore, 2004). In addition to or as an alternative to crystalloid solutions, colloids may be used or volume expansion. As a result, a greater portion remains intravascular and is not lost to extracellular extravasation. Despite this perceived advantage, studies comparing survival rates when crystalloids or colloids are administered nd no superiority with colloids but greater expense (Perel, 2013).

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Radiother Oncol 11:15 erectile dysfunction cause of divorce purchase tadalafilo 2.5 mg otc, 1988 Vale C, Chemoradiotherapy or Cervical Cancer Meta-Analysis Collaboration: Reducing uncertainties about the e ects o chemoradiotherapy or cervical cancer: a systematic review and meta-analysis o individual patient data rom 18 randomized trials. T at said, squamous neoplasia arises predominantly on the vestibule at the border between the vulvar keratinized strati ed squamous epithelium, which lies laterally, and the nonkeratinized squamous mucosa, which lies medially. The super cial space lies between Colles ascia (super cial perineal ascia) and the perineal membrane (deep perineal ascia). Within this space lie the ischiocavernosus, bulbospongiosus, and transverse perineal muscles and the highly vascular vestibular bulb and clitoral crus. During radical vulvectomy, dissection is carried to the depth o the perineal membrane. As a result, contents o this super cial urogenital triangle compartment that lie beneath the mass are removed during tumor excision. The lymphatics o the vulva and distal third o the vagina typically drain into the super cial inguinal node group. From here, lymph travels through the deep emoral lymphatics and the node o Cloquet to the pelvic nodal groups. Importantly, lymph can also drain directly rom the clitoris and upper labia to the deep emoral nodes (Way, 1948). Vulvar lymphatics cross at the mons pubis and the posterior ourchette but do not cross the labiocrural olds (Morley, 1976). T us, lesions ound within 2 cm o the midline may spread to lymph nodes on either side. This anatomy point in uences the decision or ipsilateral or bilateral node dissection, as discussed later. The super cial inguinal nodes cluster within the emoral triangle ormed by: the inguinal ligament, sartorius muscle, and adductor longus muscle. The deep emoral nodes lie within the borders o the ossa ovalis and just medial to the emoral vein. An inguino emoral lymphadenectomy typically re ers to removal o both super cial inguinal and deep emoral lymph nodes (Levenback, 1996). Advanced disease is ound mainly in older women, perhaps due to clinical and behavioral barriers that lead to diagnostic delays. T us, biopsy o any abnormal vulvar lesion is imperative to help diagnose this cancer early. In the United States, vulvar cancers carry a comparatively good prognosis with a 5-year relative survival rate o 78 percent (Stroup, 2008). For resectable disease, traditional therapy includes radical excision o the vulva plus inguinal lymphadenectomy or plus sentinel lymph node biopsy. For advanced stages, chemoradiation may be used either primarily or as an adjunct to surgery to aid tumor control. All o these treatments can result in extensive short- and long-term morbidity and dramatic anatomic and unctional de ormity. Accordingly, vulvar cancer management recently has trended toward more conservative surgery that preserves oncologic outcome, lessens morbidity, and improves psychosexual well-being. In 2014, approximately 4850 new vulvar cancers and 1030 cancer deaths were predicted (National Cancer Institute, 2014). This increase persists among all age groups and all geographic areas (Bodelon, 2009). A brisk chronic inflammatory infiltrate is present as is often the case with invasive squamous cell carcinoma. Portions of the surface epithelium extend deep and are cut tangentially (asterisks), giving the false impression of invasive tumor at these sites. Tumor shows classic diagnostic features of invasive squamous cell carcinoma that include a squamoid appearance, intercellular bridges, and brightly eosinophilic keratin pearls (arrows). Malignant melanoma is the second most common, but rare histologic subtypes may also be encountered (Table 31-1). Vulvar Cancer Histologic Subtypes Vulvar carcinomas Squamous cell carcinoma Adenocarcinoma Carcinoma of Bartholin gland Adenocarcinoma Squamous carcinoma Transitional cell V ulva Paget disease Merkel cell tumors V errucous carcinoma Basal cell carcinoma Vulvar malignant melanoma Vulvar sarcoma Leiomyosarcoma Malignant fibrous histiocytoma Epithelial sarcoma Malignant rhabdoid tumor Metastatic cancers to vulva Yolk sac tumors 50 years, and more than hal o cases develop in women older than 70. Kumar and associates (2009) described a hazard ratio o nearly 4 or death in women older than 50 years compared with younger women. Last, vulvar cancer pathology can be divided into two distinct age-dependent pro les. T ose that develop in younger women (< 55 years) tend to have the same risk pro le as other anogenital cancers. In contrast, older a ected women typically are nonsmokers and lack a history o prior sexually transmitted in ections. This tumor suppressor gene normally modulates cell death, and its mutation can be carcinogenic. As noted, the association is more prominent when coupled with other co actors such as smoking. In this group, vulvar cancer develops at a much younger age than in the general population, and more than 50 percent have a prior history o condyloma acuminata (Penn, 2002). Because o these links with vulvar cancer, we recommend that all immunocompromised women undergo thorough vulvar inspection and, when indicated, vulvoscopy and biopsy. Lichen sclerosus is a chronic vulvar in ammatory disease and is related to vulvar cancer development. Keratinocytes a ected by lichen sclerosus show a proli erative phenotype and can exhibit markers o neoplastic progression. As such, lichen sclerosus may be a precursor lesion in some invasive squamous vulvar cancers (Rol e, 2001). Several reports demonstrate that in a small percentage o women older than 30 years, untreated lesions can progress to invasive cancer within a mean o 4 years (Jones, 2005; van Seters, 2005). Although this progression cannot be conclusively validated, we recommend that patients with moderate and severe vulvar dysplasias receive early de nitive treatment (Chap. This aids identi cation o acetowhite areas and abnormal vascular patterns, which are characteristics o vulvar neoplasia. Specimens removed with a Keyes punch should be approximately 4 mm thick to include the sur ace epithelial lesion and the underlying stroma. Concurrent colposcopic examination o the cervix and vagina and care ul evaluation o the perianal area are recommended to diagnose any synchronous lesions or associated neoplasm o the lower genital tract. Cancer Patient Evaluation Following histologic diagnosis, a patient with vulvar cancer is assessed or the clinical extent o disease and or comorbid conditions. Mani estations can persist or weeks or months be ore diagnosis, as many patients may be embarrassed or may not recognize the signi cance o their symptoms. Lesion Evaluation Lesions may be raised, ulcerated, pigmented, or warty, but in younger women with multi ocal disease, a well-de ned mass is not always present. T us, the goal o evaluation is to obtain an accurate and de nitive pathologic diagnosis. For this, colposcopic examination o the vulva, termed vulvoscopy, can direct biopsy site selection. Although not a ormal part o surgical tumor staging, preoperative imaging may complement staging in those with larger tumors or with clinically suspected metastatic disease. T us, staging involves: (1) primary tumor resection to obtain tumor dimensions and (2) dissection o super cial and deep inguino emoral lymph nodes to evaluate tumor spread (Pecorelli, 2009). This system is used to direct treatment and predict prognosis (Van der Steen, 2010). At our institution, i a thorough physical examination is not possible because o patient discom ort or disease extent, an examination under anesthesia is per ormed. This may be coupled with cystourethroscopy, proctosigmoidoscopy, or both i suspicion o tumor invasion into the urethra, bladder, or anal canal is high. These include a high number o involved lymph nodes, large nodal metastasis size, extracapsular invasion, and xed or ulcerated nodes (Homesley, 1991; Origoni, 1992). But this stems mainly rom the positive correlation between lesion size and nodal metastasis rates (Homesley, 1993). However, increased nodal metastasis rates positively correlate with greater invasion rates. Surgical margins that are tumor- ree decrease local tumor recurrence rates, and traditionally a 1- to 2-cm tumor- ree margin is desired. More speci cally, two large retrospective series demonstrated that a tumor- ree surgical margin 8 mm yielded a high rate o local control. In contrast, i tumor was ound within this 8-mm margin, the recurrence rate was 23 to 48 percent (Chan, 2007; Heaps, 1990). Hence, when lesions are close to the clitoris, anus, urethra, or vagina, a 1-cm surgical tumor- ree margin may be used to preserve important anatomy yet still provide optimal resection.

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Advantageously erectile dysfunction at age 29 buy generic tadalafilo on-line, the uterosacral and cardinal ligaments, which are important to pelvic support, are retained. Speci cally, adhesions between the bladder and the lower uterine segment in the vesicouterine space or those in the cul-de-sac may make removal o the cervix di cult. Related to this, ureteral and bladder injury rates are decreased by avoiding di cult dissection. Certain contraindications to preserving the cervix are excluded prior to selecting supracervical hysterectomy. Examples include Pap test ndings o high-grade cervical dysplasia; endometrial hyperplasia with atypia or endometrial cancer; or a patient at risk or noncompliance with routine cervical cancer screening. Rates quoted in early studies are as high as 24 percent but are lower in more recent investigations and range rom 5 to 10 percent (Okaro, 2001; Sarmini, 2005; Schmidt, 2011; van der Stege, 1999). Overall rates o trachelectomy appear to mimic the bleeding rates above and are on a downward trend. In general, conversion to laparotomy may be necessary i exposure and organ manipulation are limited or i bleeding is encountered that cannot be controlled with laparoscopic tools and techniques. Many o these instruments may not be readily available in all operating suites, and desired tools should be requested prior to surgery. A ter tumor excision, removal may be accomplished by several techniques described in Steps 3, 4, and 5. The corpus is amputated rom the cervix at a point just below the internal cervical os and superior to the uterosacral ligaments. T at said, a large bulky uterus with minimal mobility may be di cult to adequately manipulate, may limit exposure during surgery, and may be challenging to extract. Complications related speci cally to laparoscopy include injury to the major vessels, bladder, and bowel during trocar placement (Chap. Following amputation, adjunctive coring or ablation o the endocervical canal also may be per ormed to decrease the risk o postoperative cyclic bleeding. Once amputated, the uterine corpus must be removed, and options include minilaparotomy, colpotomy, and enclosed morcellation. The bag containing the excised specimen is then brought to the sur ace and is anned open outside and around the minilaparotomy incision. This creates a closed environment where the specimen can be sharply divided manually with scissors or kni. First, or smaller specimens, a minilaparotomy incision ranging rom 1 to 4 cm can be made to extract the corpus. The uterine manipulator is used to ante ex the uterus, and an Allis clamp is placed on the posterior vaginal wall 2 to 3 cm rom the posterior cervicovaginal junction. The Allis clamp is pulled downward to create tension across the posterior vaginal wall. The posterior vaginal vault is then cut with curved Mayo scissors, and the cul-de-sac o Douglas is entered. Alternatively, a colpotomy may be created laparoscopically by incising the posterior cul-de-sac with a monopolar instrument, a harmonic scalpel, or Endo Shears near the cervicovaginal junction. A uterine manipulator is used to re ect the uterus anteriorly to create space or the colpotomy, and a sponge stick may be used vaginally to help delineate the space. I a laparoscopic instrument is already holding the specimen, this can be passed through the colpotomy and removed vaginally. This reduces the risk o inadvertent tissue dissemination during ragmentation, although long-term sa ety data are needed (Cohen, 2014; Einarsson, 2014). Following extraction, the vaginal incision is closed with interrupted stitches or a running suture line using 0-gauge delayedabsorbable suture. I colpotomy is used or specimen removal, a single prophylactic dose o antibiotics is administered. For this, a large containment bag that can house the insu ation gas, can con orm to the abdominal cavity, and can atten against the intraperitoneal organs is introduced into the abdomen. Once in the abdomen, it is un olded to allow the specimen and gas to be contained. During power morcellation, the corpus specimen is grasped securely with a toothed instrument such as a tenaculum and brought to the anterior abdominal wall. Because o the potential or surrounding organ injury, morcellators should not be moved toward the grasped tissue, but rather, those tissues should be brought to it. During this, the tenaculum holding the corpus is drawn up into the morcellator cylinder and well past the edge o the morcellating blade. Improved cutting is usually restored with this step and generally of ers enough blade li e to complete the procedure. Following morcellation, the gas is released, and bag and tissue ragments are removed. Limitations o currently available retrieval bags involve pouch size, working aperture diameter, tensile strength o the bag, and bag permeability. Points o bleeding are coagulated, and the surgeon may elect to reapproximate the anterior vesical and posterior cul-de-sac peritoneum to cover the cervical stump using 2-0 or 0-gauge delayedabsorbable suture. Alternatively, absorbable adhesion barriers (Interceed, Sepra lm) can be placed at the hemostatic surgical stump. With supracervical hysterectomy, there is no vaginal cuf that requires extended healing. Sexual intercourse, however, is delayed or 2 weeks ollowing surgery to allow adequate internal healing. A ter detachment, the specimen is removed vaginally or by tissue extraction techniques described on page 1031. I all actors are equal, vaginal hysterectomy is considered or women undergoing hysterectomy. These bene ts are dependent on a learning curve and may not be readily apparent (Schindlbeck, 2008). Moreover, longer operative times and higher rates o urinary tract injuries are negative balancing actors. Patient Preparation A blood sample is typed and crossmatched or potential trans usion. T at said, a wide bulky uterus with minimal mobility may be di cult to adequately manipulate, may limit exposure during surgery, and may be challenging to extract. Once a patient has been deemed eligible or a laparoscopic approach, the same preoperative evaluation as or an abdominal hysterectomy applies (Section 43-12, p. In addition, a uterine manipulator that has a cupping device or delineating the cervicovaginal junction is help ul or colpotomy and also or nal tissue extraction. I these are not available, a low-cost alternative is a right-angle retractor to delineate the anterior and posterior ornices or colpotomy. The patient is placed in low dorsal lithotomy position in booted support stirrups. The abdomen and vagina are surgically prepared, a Foley catheter is inserted, and an orogastric or nasogastric tube is placed. Speci cally, two trocars are placed beyond the lateral borders o the rectus abdominis muscle, whereas a third may be positioned centrally and cephalad to the uterine undus. Le t upper quadrant entry is considered or initial entry in cases with suspected periumbilical adhesions. With the cannulas and laparoscope inserted and the patient in rendelenburg position, a blunt laparoscopic probe aids bowel displacement. The ureters are o ten easily seen retroperitoneally, or the peritoneum may be opened to locate Consent Similar to an open approach, possible risks o this procedure include increased blood loss and need or trans usion, unplanned adnexectomy, and injury to other pelvic organs, especially bladder, ureter, and bowel. Complications related to laparoscopy include entry injury to the major vessels, bladder, and bowel (Chap. The ureters are also at greater risk during laparoscopic hysterectomies compared with other hysterectomy approaches (Harkki-Siren, 1998). In general, conversion to laparotomy may be necessary i exposure and organ manipulation is limited or i bleeding is encountered that cannot be controlled with laparoscopic tools and techniques. From this in ormation, the manipulatorcup size, which is small, medium, or large, is selected. The uterus is also sounded to determine cavity depth or correct manipulator placement. Once again de ated, it is passed through the cervical os to the undus and then reinated to hold the manipulator in place. Once in position, the proximal rim o the cup will delineate the cervicovaginal junction. A H C 1034 Atlas of Gynecologic Surgery monopolar hook, or plasma kinetic needle point.