When gynecologist should yell for a general surgeon


View Point

With an apology to the Gynaecologists

When gynecologist should yell
for a general surgeon

Prof. Altaf Husain Rathore, FRCS
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In 1966 while attending a course for Part-II FRCS at Royal College of Surgeons Edinburgh, a professor of gynecology and obstetric from Edinburg Royal infirmary said jokingly that a gynecologist does six operations.

1. Removal of the products of conception.
2. Removal of the uterus.
3. Removal of right ovary.
4. Removal of left ovary.
5. Cut the right ureter.
6. Cut the left ureter.

Prof. Altaf Husain Rathore

But this is just a top of an iceberg, because so many other viscera like bladder, small intestine, large intestine are also closely related to the uterus besides ureter which can get injured during gynecological operation. They are more liable to get injured when patient already has been operated before, or has got adhesions, or whenever the operator is an un-experienced or non-qualified gynecologist. Besides hemorrhage during operation, left over sponges in the peritoneal cavity are also not uncommon problems which gynecologist can face. On these occasions one should not be shy to call a general surgeon or another colleague for the help because the life of the patient is more important than a false prestige.

Hemorrhage: Bleeding during caesarian section outside the uterus usually comes from the broad ligament when a junior gynecologist tries to deliver the head of the baby through a small incision in the lower segment which gets torn and injures veins laterally lying in the broad ligament. To avoid this situation one should give bigger incision and if not enough then make a T extension but do not stretch the wound too much. If the bleeding is from the uterine cavity due to placenta accreta or some blood dyscrazia or DIC then there are three options besides massive blood transfusion.

1. Emergency hysterectomy.
2. Bilateral internal iliac artery ligation.
3. Packing of the uterine cavity.

One senior gynecologist used to retain 5 to 15 Foley’s catheters through the os in the uterus and inflate the balloons to maximum, which is worth trying.

Injury to Ureter: This injury occurs during hysterectomy that is why every gynecologist is very conscious and scared about it. Once, a qualified gynecologist called me during the operation because she was not sure about one structure whether it was a right ureter. Actually it was a thickened right umbilical ligament. Ureter is a retopenitoneal structure crossing the common iliac vessels. How to avoid this injury is the classical care during operation that always remain near the uterus as possible as you can during ligation of the uterine artery. One professor of urology in Edinburgh was very dogmatic that one should retain a ureteric catheter on each side (done endoscopically by urologist) before every hysterectomy specially in difficult one. If you have recognized the damage during operation put a few interrupted non absorbable sutures if it is a partial tear. I always prefer to re-implant the ureter in the bladder and if defect is long use Boari’s technique. Always retain a stent or a ureteric catheter or baby feeding tube in it for at least 7 days in the ureter. If you have ligated the ureter and discovered a few days after the operation then confirm it by ultrasound, I.V.U and retrograde pyelogram and repair it as soon as possible by the above technique.

Injury to the urinary bladder: It is not an uncommon injury after rupture of uterus and placenta accrete. Some junior gynecologist injure it during abdominal and vaginal hysterectomy. If it is not recognized it may result in to VVF. One patient referred to me had haematurea during the menstruation. She had her seventh C Section by an unqualified gynecologist to have a male baby and had ruptured uterus. A tear in the bladder should be repaired properly in two layers by continuous non absorbable 20 suture. It is better to retain a suprapubic catheter in the bladder besides the urethral Foley’s catheter. Keep the Foley’s for at least 14 days. Try to put a patch of omentum between bladder and uterus.

Injury to the intestine: Small intestine specially ileal injury is also not uncommon. It is better to repair it immediately with 20 or 30 vicryl suture in with two continuous layers. If one is not confident about this repair bring the injured loop of intestine out through a separate incision in right or left iliac fossa (Iliostomy or colostomy) or bring out the loop proximal to the injury and open it up after the end of the operation.

False Kidney: Few times I have been called during abdominal hysterectomy to confirm a soft swelling in the pelvis which the gynecologist thought was a pelvic kidney. They were actually retroperitoneal cervical fibroids. One should remember normally there are only two kidneys lying in the lumber region. In doubt they should put their hand in the peritoneal cavity and feel the kidneys lying higher up on each side of the vertebral column. In horse shoe kidney the isthmus is lying in the midline crossing the vertebra joining each side of the kidney. Pelvic ectopic kidneys are rare and they do not join any structure. If you trace the cervical fibroid it joins the lowest part of uterus like wing of a bee.Other post operative complications like VVF, UVF, RVF, faecal fistula, left over sponges can be dealt later on when patient’s general health improves at least six weeks after the operation.

In conclusion every surgeon gets some complications during his life times. If he claims that he never got any complication he is either a liar or had no experience. Even the legendary gynecologist of Pakistan like Col Sami, Prof. Sial, Prof. Bilqees, Prof. Rashid latif, Prof. Saad Rana, Prof. Samad Chaudhary, Prof. (Miss) Siddiqii, Prof. Zubeda Aziz, Prof. Memmon and Prof Fredion Setna could not claim that they never had any operative complications in their life time. The important thing is to recognize the damage and deal with it even if you have to call a general surgeon who is a jack of all trades of surgery and master of abdominal, breast, thyroid and the skin surgery.