Bonney’s Gynaecological Surgery This book is dedicated to the memory of Victor Bonney. It is also dedicated to our wives Maggie, Jane and Rupal for their support, understanding, patience and love which they have shown us in our lives together Bonney’s Gynaecological Surgery John M. Monaghan MB ChB, FRCS(Ed), FRCOG Consultant Surgeon Whitton Grange Whitton Northumberland England Alberto (Tito) de Barros Lopes Consultant Gynaecological Oncologist Northern Gynaecological Oncology Centre Queen Elizabeth Hospital Sheriff Hill Gateshead Raj Naik Consultant Gynaecological Oncologist Northern Gynaecological Oncology Centre Queen Elizabeth Hospital Sheriff Hill Gateshead TENTH EDITION Blackwell Science © 2004 by Blackwell Science Ltd a Blackwell Publishing Company Blackwell Science, Inc., 350 Main Street, Malden, MA 02148-5020, USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Science Asia Pty, 550 Swanson Street, Carlton, Victoria 3053, Australia The right of the Author to be identified as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. First published 1911 Eighth edition 1974 (Baillière Tindall) Ninth edition 1986 (Baillière Tindall) Tenth edition 2004 Blackwell Science Ltd Library of Congress Cataloging-in-Publication Data Monaghan, John M. Bonney’s gynaecological surgery. —10th ed. / John M. Monaghan, Tito Lopes, Raj Naik. p. ; cm. Includes bibliographical references and index. ISBN 0-632-05419-0 1. Generative organs, Female —Surgery. [DNLM: 1. Gynaecologic Surgical Procedures. 2. Genitalia, Female —surgery. WP 660 M734b 2004] I. Title: Gynaecological surgery. II. Lopes, Tito. III. Naik, Raj. IV. Bonney, Victor, 1872–1953. Gynaecological surgery. V. Title. RG104.B65 2004 618.1¢059 —dc22 2004020780 ISBN 0-632-05419-0 A catalogue record for this title is available from the British Library Set in 9 on 11.5 Sabon by SNP Best-set Typesetter Ltd., Hong Kong Printed and bound in India by Gopsons Papers Ltd, New Delhi Production Editor: Rebecca Huxley Commissioning Editor: Stuart Taylor Editorial Assistant: Katrina Chandler Production Controller: Mirjana Misina For further information on Blackwell Publishing, visit our website: http://www.blackwellpublishing.com Contents Preface to the tenth edition, vii Preface to the ninth edition, ix 1 Introduction and prologue, 1 2 Instruments, operative materials and basic surgical techniques, 5 3 Patient assessment, consent and preparation for surgery, 19 4 Operations on the cervix, 27 5 Operations on the uterine cavity, 47 6 Opening and closing the abdominal cavity, 54 7 Total abdominal hysterectomy, 66 8 Total hysterectomy for cervical and broad ligament fibroids, 74 9 Myomectomy and the management of fibroids in pregnancy, 87 10 Vaginal hysterectomy and radical vaginal hysterectomy (Schauta and Coelio-Schauta procedures), 95 11 Radical hysterectomy and pelvic node dissection, 110 12 Pelvic exenteration, 123 13 Operations on the vulva, 133 14 Operations on the vagina, 146 15 Operations for the correction of urinary fistulae, 162 16 Operations for the correction of infertility, 168 John R. Newton 17 Laparoscopy and other minimal access surgery, 187 18 Management of extrauterine gestation and sterilization procedures, 196 19 Operations for benign ovarian disease, 202 20 Operations for malignant ovarian disease, 207 21 Operations for urinary incontinence, 216 Stuart L. Stanton 22 Operations for prolapse of the uterus and vagina, 238 23 Operative procedures for therapeutic abortion, 253 24 Caesarean section, 257 25 The management of cancers complicating pregnancy, 266 26 Operations on the intestinal tract for the gynaecologist, 272 27 Presacral neurectomy, 283 28 The formation of a urinary diversion, 286 29 The management of injuries to the urinary tract, 294 Index, 301 v However in spite of all these setbacks, some of which are almost medieval in their arbitrariness, surgeons around the world continue to innovate, inspire and de- velop this exciting field for the benefit of their patients. Much of the change reflected in the tenth edition is a combination of innovation from surgeons working closely with the surgical instrument industry. This com- bination has encouraged change and advancement and out of the difficulties identified above have developed new method of teaching with live demonstrations, ani- mal work where possible and the use of simulators of increasing sophistication. The surgeon continues to demonstrate that eternal desire to improve. Like all art, surgery is going through another diffiult phase which we hope can be alleviated by the production of this tenth edition which continues to extol the virtues of simple minimalistic surgery. I am also grateful for the contribution from Stuart Stanton and John Newton. My thanks to Jane Fallows and Roger Hulley for their contribution to the artwork. Rebecca Huxley has kept my nose firmly to the grind- stone once we started to move, she certainly has made the difficult phases of this book much easier to negoti- ate; many thanks. John M. Monaghan Whitton Grange 2004 Preface to the tenth edition vii Unfortunately the tenth edition of this famous text has been a little slow in arriving. The pressures on a surgeon in modern clinical practice have reduced markedly the time available for ‘extra’ work. As the senior editor I am extremely grateful for the contributions made to this edition by my colleagues Tito Lopes and Raj Naik, without their assistance this edition would have been even longer in the gestation. Surgery remains an art form with a tinge of science to leaven the advances. Even though we have seen enormous advances in the medical treatment of a num- ber of conditions previously diagnosed or treated by surgical means, the role of surgery remains vitally important. In many circumstances, particularly in gynaecological oncology, gynaecological urology, the management of the disordered pelvic floor and of advanced endometriosis, surgery continues to be the mainstay of treatment. The need to teach surgery remains a high priority but with a significant reduction in working hours, an in- crease in the numbers of junior doctors and pressures from patients not to be treated as ‘guinea pigs’; gaining a weight of surgical experience has become increasing- ly difficult. There are now very few countries where the teacher can utilise live animals for training. Cadaver experience is also becoming increasingly complex to access due to changes in consent rules and personal privacy laws. I thought that it was undoubtedly the leading textbook of gynaecological surgery in the world, but would nevertheless benefit from a major revision. I also jok- ingly said ‘Give me five years and I will do it for you’. The prompt rejoinder was ‘We will give you two years if you will take it on’. Little did I know at the time that I had been ‘set up’, as the Americans say. I felt hesitant at the prospect of making major changes to such a well- established book but realized that large-scale changes were necessary and also that if modern materials and instruments were to be incorporated, most of the drawings would require reworking. It was also clear that no single surgeon could encom- pass all the skills of modern gynaecological surgery and that I would need assistance with three major sections. I have been delighted with the response and the quality of the contributions from Sir Rustam Feroze, Stuart L. Stanton and Professor John R. Newton. I am indebted to them. Victor Bonney had skills far beyond those of mere mortals; to be able to operate to the highest level and then to be capable of transferring those ideas to paper as the most clear and concise drawings was an amazing talent. I have been especially fortunate in obtaining the services of Mr Douglas Hammersley, once head of graphics at the University of Newcastle upon Tyne, to illustrate all the chapters which have been rewritten. Doug has now moved to Norfolk to be a little closer to his chief interest, that of observing and drawing butterflies. I am sure that the reader will appreciate the outstanding quality of the drawings in this new edition, in particular the way in which they have captured the movement and dynamism of surgery. I am totally indebted to Doug for bringing to life my attempts at surgery. Preface to the ninth edition ix The influence of Victor Bonney and his pupils upon gynaecological surgery has developed from the publication of the first edition of A Textbook of Gynaecological Surgery in 1911. The first to the fourth editions were the results of the collaboration of Bonney with Sir Comynus Berkeley. Following the death of the latter, Victor Bonney produced the fifth and sixth editions alone. Bonney’s pupils Howkins and Macleod then produced the seventh edition. The death of Macleod signalled virtually the end of those practising surgeons who had been trained by Victor Bonney. The very successful eighth edition was prepared by John Howkins and Sir John Stallworthy. These two great figures of Commonwealth Gynaecology had worked together as junior colleagues during the last years of Bonney’s clinical career. When the eighth edition was published in 1974 many changes were incorporated into the text. However, in the next 10 years, an enormous number of new devel- opments have occurred, possibly the greatest being a resurgence of interest in gynaecological surgery and the growth and establishment of gynaecological oncology as a recognized subspecialty. The present editor has only a tenuous link with Victor Bonney in that he has been greatly influenced in his career by the late Dr A.F. Anderson of Edinburgh and by Mr Stanley Way, both of whom spoke frequently with great affection and reverence of the master surgeon. Indeed it was Way who introduced me to the Bonney scissors, which instruments the reader will see referred to throughout this edition. When asked by the medical editor of Baillière Tindall for my opinion of the eighth edition of Bonney’s Gynaecological Surgery some 2 years ago, I replied that