Atlas of Gynecologic Surgery Diethelm Wallwiener Sven Becker Matthias W. Beckmann Sara Y. Brucker Klaus Friese Keith B. Isaacson Walter Jonat Arnaud Wattiez With contributions by H. Abele,C. Bachmann, K.Gardanis,E.-M.Grischke,R. Hornung,B. Krämer, M. Oehler,C. Reisenauer,R.Rothmund, E. F.Solomayer,C. Wallwiener, M. Wallwiener,W.Zubke With the collaboration of ErnstH. Schmidt RudyL.De Wilde 4th edition 1138 illustrations 23tables Thieme Stuttgart· NewYork LibraryofCongressCataloging-in-PublicationDataisavailablefromthepublisher. Importantnote:Medicineisanever-changingscienceundergoingcontinualdevelopment.Re- search and clinical experience are continually expanding our knowledge, in particular our Thisbookisanauthorizedtranslationofthe7thGermaneditionpublishedand knowledgeofpropertreatmentanddrugtherapy.Insofarasthisbookmentionsanydosageor copyrighted2009byGeorgThiemeVerlag,Stuttgart.TitleoftheGermanedition: application,readersmayrestassuredthattheauthors,editors,andpublishershavemadeevery AtlasdergynäkologischenOperationen. efforttoensurethatsuchreferencesareinaccordancewiththestateofknowledgeatthetime ofproductionofthebook. Translators: Nevertheless,thisdoesnotinvolve,imply,orexpressanyguaranteeorresponsibilityonthe GertrudChampe,Surry,Maine,USA partofthepublishersinrespecttoanydosageinstructionsandformsofapplicationsstatedin GeraldineOʼSullivan,Dublin,Ireland thebook.Everyuserisrequestedtoexaminecarefullythemanufacturersʼleafletsaccompany- ingeachdrugandtocheck,ifnecessaryinconsultationwithaphysicianorspecialist,whether Illustrators: thedosageschedulesmentionedthereinorthecontraindicationsstatedbythemanufacturers ReinholdHenkel,Heidelberg,Germany differfromthestatementsmadeinthepresentbook.Suchexaminationisparticularlyimpor- Karl-HeinzSeeber,Tübingen,Germany tantwithdrugsthatareeitherrarelyusedorhavebeennewlyreleasedonthemarket.Every AndreaSchnitzler,Innsbruck,Austria dosagescheduleoreveryformofapplicationusedisentirelyattheuserʼsownriskandrespon- MarianneLück,Hamburg,Germany sibility.Theauthorsandpublishersrequesteveryusertoreporttothepublishersanydiscrep- anciesorinaccuraciesnoticed.Iferrorsinthisworkarefoundafterpublication,erratawillbe postedatwww.thieme.comontheproductdescriptionpage. ©2014GeorgThiemeVerlagKG, Someoftheproductnames,patents,andregistereddesignsreferredtointhisbookareinfact Rüdigerstrasse14,70469Stuttgart,Germany registeredtrademarksorproprietarynameseventhoughspecificreferencetothisfactisnot http://www.thieme.de alwaysmadeinthetext.Therefore,theappearanceofanamewithoutdesignationaspropriet- ThiemeMedicalPublishers,Inc.,333SeventhAvenue, aryisnottobeconstruedasarepresentationbythepublisherthatitisinthepublicdomain. 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PrintedinChinabyEverbestPrintingLtd,HongKong ISBN978-3-13-650704-9 EISBN 978-3-13-169684-7 P R E FAC E TheAtlasofGynecologicSurgeryhasalongandrespectedhistory,goingbacktoits The result is a modern surgical authority with more than 1100 illustrations that firstGermaneditionin1960.Sincethattime,gynecologyasascienceandthereper- givesacomprehensiveandcurrentpictureofoperativegynecologyandobstetrics. tory of gynecologic operations have changed and developed in many significant Weareconvincedthatthispresentationwillprovidethereaderwithgreatpleasure ways.Thetaskofconsolidatingthisconstantlygrowingknowledgeandtransform- andvisualenjoyment. ingit,withtheapplicationofamultiplyingnumberoftechniques,intothebestpos- sibleoperativetreatmentforpatientsisbecomingmoreandmorechallengingfor Theenormouschallengeofbringingoutthisinternationalworkinrejuvenatedform physicians. whileretainingthetriedandtrustedcorewasmetthankstotheintensejointin- volvementofthepublisher,authors,andgraphicartists. Theprincipalgoalofthepresentworkwasandisastructuredpresentationofboth V thescientist’sandthecraftsman’sviewofthevariousabdominal,vaginal,endoscop- Intheproductionofthisatlaswehavebeenhelpedbymanyandmanyneedtobe icandsenologicoperationsinourfield,apresentationthatislucidandplacedinthe thanked. rightcontext. WewouldfirstliketothankThiemePublishersfortheircouragetotakeonthere- Thischallenge,aswellasthemanychangesandparadigmshiftsoccurringinthe editionofsuchanoutstandingworkbothofscienceandofart.Thetremendoussuc- yearssincethelastreworkingoftheEnglisheditionin1997,calledforafar-reaching cessoftheAtlas’neweditionintheGerman-speakingcountrieshasalreadyreward- revisionofdesignandcontent.Thus,allaspectsofthiscurrenteditionhavebeen edthisinitiativeandtheconfidenceputintotraditionaldrawingsinthecontextof changedandrenewed. surgicalteaching. Theintroductorychaptersarefollowedbyatopographicalorganizationintosections Wewouldalsoliketothankourmedicalartist,ReinholdHenkel,forover10yearsof treating theadnexa,uterus,vulva/vagina,andpelvicfloor.There,whereuseful,a closeandhighlycreativecollaboration.ReinholdHenkelpassedawaythisyear,and distinctionismadebetweenabdominal(open),vaginal,andendoscopicapproaches. theworldofmedicalarthaslostanexceptionalartist. Thechaptersonsurgicaltechniquesbeginwiththesimpleroperationsandmoveon tothemoredifficulttechniques.Atthesametime,theOperationNavigator,newly CountlesshoursofexcitingworkwentintothisAtlas.Combinedwithourobliga- developedespeciallyforthisbook,facilitatesaconvenientsearchfromthedisease tionsasdirectorsoflargeuniversitydepartments,wedevoteatremendousamount totheindicationtotheoperationofchoice(seethegraphiconp.VI). ofourtimeintowhatweloveasgynecologicsurgeons:creatingamodernandlast- ingschoolofbenignandgynecologicsurgery. TheAtlasofGynecologicSurgeryisknownallovertheworldasaworkrichintradi- tionthatlaysouttheentirefieldofoperativegynecologyindetailandatthehighest Itismorethanappropriateatthispointtoappreciatethesupportofbothofourfam- level.Thecollectionofstill-applicableillustrationsfromearliereditionsandmore iliesovertheyears.WithaspecialthankstoGabriele,Markus,andChristian,aswell than500newdrawingscontributetothenewcompositionofaworkofexcellentes- asGraziella,Nicholas,andCharlotte,wededicatethisbooktoourfamiliesandtoour thetic and didactic quality. The conceptual reworking and the new textual and patients. graphicconfigurationoftheworkmaturedforalmostadecade.Evenuntilshortly beforethebookwenttopress,drawingswerestillbeingupdatedandrelevantinno- DiethelmWallwiener,Tübingen vationswereworkedintotheappropriatechapters. SvenBecker,Frankfurt FortheEnglishedition,twointernationaleditorshavebeeninvited.Theircollabora- tionallowsforatrulyinternationalperspectiveofcurrentandclassicalgynecology. Searching by body region (e.g.adnexa,uterus,pelvicfloor) Allpertinentinformationissummarizedinonechapter. PreliminaryRemarksabouttheRegion Page192–202 ConceptsforSurgicalTreatment— ProcedureNavigator Page203–220 SurgicalTechniques VI Page221–355 Abdominal Vaginal Endoscopic Introduction to specific characteristics of the body region Topographyoftheapproach (abdominal,vaginal,endoscopic) Search for a selected operation Orientationbasedonuniformlystructuredtables IndicationsandContraindications OperationRisksandInformedConsent Guide to selecting a method OperationPlanning Fromthediseasetotheindicationtotheintervention. Procedure Whataretheoptions?Theoperationofchoice! Complications ConcurrentandPostoperativeTreatment LimitsoftheMethods GR APHIC ARTWORK Why watercolor drawings in the era of multimedia images? The detailed and This,togetherwiththeuniquequalityofthedrawingsintheatlas,suggestedcon- uniqueillustrations,particularlythoseofthetwoillustratorsAndreaSchnitzlerand tinuing the work as a means of teaching operative surgery based on watercolor Karl-HeinzSeeber,werealwaysthespecialtreasureofthetraditional“AtlasofGyne- drawings. cologicSurgery”.Thehistoryofmedicineoverallandthatofsurgeryinparticularis inconceivablewithoutattractiveandanatomicallyexactreproductionsoftheavail- Fornearlyadecade,drawingshadbeenselectedfromthewealthofexistingillustra- ableknowledge.TheserangefromtheanatomicaldrawingsoftheRenaissanceand tions,andnewwatercolorswereproducedinminuteandtime-consumingdetail. thescientificdiagramsofthe19thcenturytothegreatsurgicalatlasesoftheVien- Like the authors and draftsmen of previous editions, the authors of this edition neseschoolandtheAmericantradition(Brödel,Netter)anduptothepresentday. workedcloselywithandwereinvolvedindetaileddiscussionswithReinholdHenkel Many of the “classical” views have become the general property of the medical toobtainillustrationsofoptimalquality. VII worldsothathardlyanyonenowknowswhofirstdrewthemandcreatedadidactic workofart. Theeditors Thieme,thepublisheroftheatlas,deliberatelycontinuedtheesthetictraditionof theworkincommissioningReinholdHenkel,anoutstandingdraftsmanandartist, toprovideillustrationsforthenewedition. Inthedigitalworld,photographyhasoftenreplacedgraphicart,notleastbecauseit iseasierandrequireslessefforttotakearepresentativephotothantodevelopan illustration.Eventoday,however,acarefullyandartisticallyplanneddrawingwill besuperiortoaphotoinmostcases.Onlyawell-consideredgraphicillustrationis capableofcombiningperfectlytheexactanatomy,generalizedpathology,athree- dimensionalview,anddidacticinformation.Inaworldpermeatedbydigitalinfor- mationtechnology,thetraditionalpictureproducedbyhandexertsanimmediate effectthroughitsinimitable“authenticity”andestheticexpression.