Foreword In the early 1940s, Richard Te Linde hand wrote, page by page, in longhand the first edition of Te Linde's Operative Gynecology. His week was full. Two days spent in the operating room with usually five or six major cases scheduled, 3 days in the office, and grand rounds on Saturday morning until noon made for a busy week. At home after a long day's work and in a half-reclining position necessitated by a hip fracture while ice skating in earlier years, he wrote a description of the operations he himself had used to correct various gynecologic disorders. The first edition, published in 1946 following the end of World War II, comprised 725 pages, all written by Dr. Te Linde himself. The present eleventh edition, 70 years later, has more than twice the number of pages and involves 50 authors. Times have changed and Te Linde's text has changed with it. The first edition in 1946 was widely read. Enhancing its attractiveness were the illustrations and the superb line drawings by artists trained under Max Brödel, the German medical artist brought to Baltimore by Howard A. Kelly (Kelly clamp), the founding gynecologic chairman at Johns Hopkins. The use of drawings rather than photographs has continued through the various editions, including the eleventh edition. In this latest edition, most of the drawings have been colorized to even more clearly portray the location of blood vessels, ligaments, other structures, and surgical techniques. The text and illustrations are also supplemented by on line access to video demonstrations of selected vaginal surgeries. The frequency of gynecologic operations per unit of population is declining. This is due to a number of factors, including alternate treatments for myomas, hormonal control of abnormal bleeding, alternatives to surgical treatment for infertility, and the decrease in the number of children per family, as well as the relatively high incidence of cesarean sections, all of which preserve the pelvic structures and therefore greatly reduce the need for surgical repair of musculofascial pelvic defects. In today's environment, the gynecologic surgeon, particularly the young gynecologic surgeon, may have less personal experience with the many surgical procedures now available and the complications that can occur. This requires advanced preoperative preparation by discussions with colleagues, residents, and fellows considering the indications for surgery, choice of techniques, and potential problems, all supplemented by an authoritative volume at hand. This, of course, is the Te Linde. In the eleventh edition, there has been one entirely new chapter concerning robotic surgery, which is becoming more and more frequently used. This chapter is by Jed Delmore and Kevin E. Miller. But even though the titles of the other chapters remain largely unchanged, the freshness and contemporary aspect of the book has been maintained by having 82% of the chapters written by new and authoritative contemporary specialists. Finally, the long experience in the operating room of John Rock and Howard Jones III ensures that the 50-odd authors speak from practical experience. It is this personal, vast surgical experience which Richard Te Linde expressed in the first edition and which has continued to the present day that makes Te Linde's Operative Gynecology such a valuable text for every gynecologic surgeon. Howard W. Jones Jr Norfolk, Virginia September 2014 Preface Even as surgical techniques continue to evolve and new techniques are introduced, basic surgical principles remain. With this new eleventh edition of Te Linde's Operative Gynecology, the reader will find an increased emphasis on minimally invasive techniques of gynecologic surgery, but there remains a strong surgical foundation based on the correct diagnosis of the clinical condition, a complete and careful preoperative evaluation and counseling, a thorough understanding of the anatomy and physiology, and a thoughtful plan for postoperative recovery with appropriate expectations. The authors are all skilled and experienced surgeons who have had careers of surgical instruction, who not only guide the reader through the well-illustrated technique of surgery but also discuss the foundations of surgery. In this new edition, we have included a new chapter on robotic surgery, and the chapter on electrosurgical techniques has been extensively updated to include vessel sealing instruments. The chapter on professional liability has been completely redone with new authors and an emphasis on risk prevention. The eleventh edition also boasts many new authors who have brought some fresh, new ideas and approaches to this classic text. Thirty-five of the fifty-one chapters have new authors who have reorganized and updated much of the diagnostic evaluation and management approaches to various gynecologic conditions. The editors have taken pains to select the best surgeons and the best teachers so that the textbook continues to maintain Richard Te Linde's comfortable reading style and the helpful, practical “surgical pearls,” which will improve the skills of both the junior resident and the experienced gynecologic surgeon. Definitions, summary, questions/answers, and best surgical practices continue to be an important component of each chapter. In addition, where appropriate, contributing authors have added a “stepwise approach” to the performance of a specific gynecologic operation. Illustrations have always been an important aspect of Te Linde's Operative Gynecology, and the excellent line drawing of Leon Schlossberg, P. L. Malone, John Deutch, and Jennifer Smith have contributed much to success of previous editions. In the eleventh edition, 167 new surgical illustrations have been added to the text and both old and new drawings have been colorized to add to the clarity and contrast of the illustrations and to provide a brighter, more modern look to the book. The compact disc that accompanies the textbook features good teaching examples of both a standard abdominal and vaginal hysterectomy—surgical techniques that are all too often neglected in today's market-driven push to perform surgery using the robot or through a single laparoscopic trocar. All of the techniques discussed and illustrated in this text are based on the extensive experience of the authors and editors, but it is important to appreciate that every patient and every situation is unique. Readers must exercise good clinical judgment. The authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application or any other information in this book and make no warranty, expressed or implied, with respect to the contents of this publication. Such a text requires enormous contributions from many experts. The authors and editors sincerely thank all the contributors. Special acknowledgment to the Lippincott Williams & Wilkins editorial team of Rebecca Gaertner, Executive Editor; Jamie Elfrank, Senior Acquisitions Editor; and Tom Conville, Development Editor. We also commend Rob Flewell, Certified Medical Illustrator, whose artistic skills significantly enhance this edition. A special thanks to Maria Medranda, Sandra Allen, Laura Creel, Lynne Black, and Julie Smith for their editorial assistance. As always, we are deeply indebted to the many authors who labored so hard to incorporate their experience into the previous editions of this text. This eleventh edition would not be possible without their contributions. We cannot help but include a special work of thanks to Dr. Richard W. Te Linde who we were both fortunate to know and to the previous editors, Drs. Richard F. Mattingly and John D. Thompson from whom we learned so much. We sincerely hope that you and your patients will benefit from the combined experience and dedication of the many contributors to this and the many previous editions of Te Linde's Operative Gynecology. Howard W. Jones III, MD John A. Rock, MD Preface from First Edition Gynecology has become a many-sided specialty. No longer is it simply a branch of general surgery. In order to practice this specialty in its broad sense, the gynecologist must be trained in a comprehensive field. He must be a surgeon, expert in his special field, he must be trained in the fundamentals of obstetrics, he must have the technical skill to investigate female urologic conditions, he must have an understanding of endocrinology as it applies to gynecology, he should be well grounded in gynecologic pathology, and finally, he must be able to recognize and deal successfully with minor psychiatric problems that arise so commonly among gynecologic patients. With this concept of the specialty in mind, this book has been written. It then becomes apparent, when one seeks training in gynecology beyond the simplest fundamentals such as are taught to undergraduates, that special works are necessary for training those who intend to practice it. The author is a firm believer in the system of long hospital residencies for training young men in the various surgical specialties when their minds are quick to grasp ideas and their fingers are nimble. This volume has been written particularly for this group of men. Unfortunately, there is a paucity of good gynecologic residencies in the United States in the sense that the author has in mind. Many positions bear the name of residency but fail to give the resident sufficient operative work to justify the name. Another excellent method of development of the young gynecologist is an active assistantship to a well-trained, mature gynecologist. If the assistant is permitted to stand at the operating table opposite his chief day after day, eventually he will acquire skill and judgment which he himself will be able to utilize as an operator. When such a preceptor system is practiced, it is important that the assistant be given some surgery of his own to do while he is still young. If a man is forced to think of himself only as a perennial assistant, this frame of mind will kill his ability to accept responsibility of his own. However, many must learn their operative gynecology under less favorable circumstances than those of the fortunate resident or assistant. This volume should be of value to those who, by self-instruction, must acquire a certain degree of operative skill. Finally, it must be admitted that more gynecology is practiced today by general surgeons in this country than by gynecologists. Although this is not ideal, circumstances make it necessary, and much of this gynecologic surgery is well done. It is hoped that many general surgeons will use this volume as a reference book. In connection with general surgery, it is only fair to say that much has come to gynecology by way of general surgeons of the old school, who practiced general surgery in the broadest sense. Now that gynecology and/or obstetrics has become a specialty unto itself, it is well in our training of men not to swing too far from general abdominal surgery. In spite of the most careful preoperative investigation, mistakes in diagnosis will be made, and at times, the gynecologist will be called upon to take care of general surgical conditions in the region of lower abdomen and the rectum. With this in mind, the author has included in this volume a consideration of a few of the commoner general surgical conditions occasionally encountered incidentally with gynecology or by mistaken diagnosis. Operative Gynecology is written with the primary purpose of describing the technique of the usual and some of the rare operative procedures. It also includes indications for and against operations as well as pre- and postoperative care of patients. Although gynecology is divided into several fields, these fields interlock so that it has been found impossible to compose a volume on gynecologic surgery to the exclusion of the other divisions of the specialty. Gynecologic pathology, for instance, is the bedrock upon which good gynecologic surgery is practiced. Without an understanding of it, surgery becomes merely a mechanical job, and errors in surgical judgment are inevitable. Hence, it has become necessary to include in this volume a minimum of gross and microscopic pathology, as it applies directly to the surgical subject under consideration. Also, some consideration is given to psychology and psychiatry in relation to gynecologic surgery. The author believes that getting the young woman on whom a hysterectomy must be done into the proper frame of mind to accept it is as important as possessing the technical skill to perform the operation. Richard W. Te Linde Baltimore, Maryland, 1946 Editors Howard W. Jones III MD Professor of Obstetrics and Gynecology Director of Gynecologic Oncology Vanderbilt University School of Medicine Nashville, Tennessee John A. Rock MD Senior Vice President, Health Affairs Dean, Herbert Wertheim College of Medicine Professor of Obstetrics and Gynecology Department of Obstetrics and Gynecology Florida International University Miami, Florida Contributors Nadeem R. Abu-Rustum, MD Professor Department of Obstetrics and Gynecology Weill Cornell Medical Center Director, Minimally Invasive Surgery Gynecology Service, Department of Surgery Memorial Sloan-Kettering Cancer Center New York, New York Rony A. Adam, MD Professor Division of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology Vanderbilt University Medical Center Nashville, Tennessee Marisa R. Adelman, MD Assistant Professor Department of Obstetrics and Gynecology University of Utah Salt Lake City, Utah Kaled Alektiar, MD Member, Attending Physician Department of Radiation Oncology Memorial Sloan-Kettering Cancer Center New York, New York Paul M. Allen, MD, MHA, MPH, FACOG Consultant in Health Care Management, Accreditation, and Medicare ASC Certification for Ambulatory Surgery Centers Los Angeles, California Ted L. Anderson, MD, PhD Betty and Lonnie S. Burnett Professor Vice Chair for Gynecology Department of Obstetrics and Gynecology Vanderbilt University Medical Center Nashville, Tennessee Alicia Armstrong, MD, MHSCR Professor Department of Obstetrics and Gynecology Uniformed Services University of the Health Sciences Bethesda, Maryland Adjunct Professor Department of Obstetrics and Gynecology Howard University School of Medicine Washington, District of Columbia Chief, Gynecologic Services National Institute of Child Health and Human Development National Institute of Health Bethesda, Maryland Richard R. Barakat, MD Professor Department of Obstetrics and Gynecology Weill Cornell Medical College Chief, Gynecology Service Department of Surgery Ronald O. Perelman Chair in Gynecologic Surgery Vice Chairman, Clinical Activities Department of Surgery Memorial Sloan-Kettering Cancer Center New York, New York Matthew D. Barber, MD, MHS Professor Department of Obstetrics and Gynecology Cleveland Clinic Lerner College of Medicine Vice Chair for Clinical Research Department of Obstetrics, Gynecology, and Women's Health Institute Cleveland Clinic Cleveland, Ohio Jack B. Basil, MD Chairman Department of Obstetrics and Gynecology Good Samaritan Hospital Cincinnati, Ohio Kelly A. Bennett, MD Associate Professor Department of Obstetrics and Gynecology Vanderbilt University Medical Center Director, Junior League Fetal Center at Vanderbilt Department of Obstetrics and Gynecology Monroe Carell Junior Children's Hospital at Vanderbilt Nashville, Tennessee Eric J. Bieber, MD, MSHCM President, Community Hospitals—West Region President, University Hospitals Accountable Care Organization Clinical Professor of Reproductive Biology Case Western Reserve University School of Medicine Shaker Heights, Ohio Lesley L. Breech, MD Associate Professor Department of Pediatric and Adolescent Gynecology Department of Obstetrics and Gynecology University of Cincinnati Division Director Pediatric and Adolescent Gynecology Department Cincinnati Children's Hospital Medical Center Cincinnati, Ohio Diana Broomfield, MD, MBA, FACOG, FACS Chief, Division of Reproductive Endocrinology and Infertility Department of Obstetrics and Gynecology Howard University Washington, District of Columbia Medical Director Department of Reproductive Endocrinology and Infertility Maryland IVF Columbia, Maryland Joseph Buscema, MD Clinical Associate Professor Department of Obstetrics and Gynecology University of Arizona Tucson, Arizona James J. Burke, II MD The Donald G. Gallup, MD, Scholar of Gynecologic Oncology Associate Professor and Director, Gynecologic Oncology ACI Surgical Associates Mercer University School of Medicine Savannah, Georgia William J. Butler, MD Professor and Chairman Department of Obstetrics and Gynecology Mercer University School of Medicine Director Central Georgia Fertility Institute Medical Center of Central Georgia Macon, Georgia David Carnovale, MD Associate Professor Clerkship Director Mercer University School of Medicine Department of Obstetrics and Gynecology Director of Assisted Reproductive Technologies Central Florida Fertility Institute The Medical Center of Central Georgia Macon, Georgia Dennis S. Chi, MD Professor Department of Obstetrics and Gynecology Weill Cornell Medical Center Deputy Chief Gynecology Service Department of Surgery Memorial Sloan-Kettering Cancer Center New York, New York Chi Chiung Grace Chen, MD Assistant Professor Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland Mindy S. Christianson, MD Assistant Professor Division of Reproductive Endocrinology and Infertility Department of Gynecology and Obstetrics Johns Hopkins University School of Medicine Baltimore, Maryland