Vaginal Surgery Vaginal Surgery Michel Cosson Gynecological Surgeon Jeanne-de-Flandre Hospital, Lille, France Denis Querleu Gynecological Surgeon, Cancer Center of the Claudius-Regaud Institute, Toulouse, France Daniel Dargent Formerly Director of Gynecology and Obstetrics Edouard- Herriot Hospital, Lyon, France Illustrations by Guillaume Blanchet Boca Raton London New York Singapore This is a English translation of a book originally published in French, titled, Chirurgie Vaginale, authored by M.Cosson, D.Querleu, and D.Dargent, published by Masson, 2003, Issy-Les Maoulineaux, France Published in 2005 by Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487–2742 This edition published in the Taylor & Francis e-Library, 2006. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to http://www.ebookstore.tandf.co.uk/.” © 2005 by Taylor & Francis Group, LLC No claim to original U.S. Government works ISBN 0-203-02054-5 Master e-book ISBN International Standard Book Number-10: 0-8247-1984-0 (Print Edition) (Hardcover) International Standard Book Number-13: 978-0-8247-1984-5 (Print Edition) (Hardcover) This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the consequences of their use. No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access http://www.copyright.com/ (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923, 978–750–8400. CCC is a not-for- profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Catalog record is available from the Library of Congress Taylor & Francis Group is the Academic Division of T&F Informa plc. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com/ Preface To compose the preface of a work represents, for the person who is so honored, an exercise that is at once uplifting, dangerous and uncertain. Uplifting, because it gives the pleasurable but ephemeral impression of possessing an immense power of judgment. Dangerous, because he must summarize, with great economy, the main points of the elements of the matter without allowing his personal emotions to interfere. And uncertain because the one and real judge of the work will always be the reader himself. For the specific case of the subject of vaginal surgery, the task has been greatly facilitated by the level of excellence of the criteria of judgment. The subject: to have selected, the theme of gynecological surgery via vaginal access for a book with a pedagogical vocation has proven to be an excellent opportunity. In fact, gynecological surgery, after a long period of domination by the “abdominal approach” has benefited from two major aspects of its evolution: 1. The appearance of laparoscopy. This technique has radically changed a certain number of therapeutic procedures and has now found its place, precisely targeted but not exclusive. 2. The renaissance in France of vaginal surgery. Developed for many years in the Germanic countries, it has found its footing in France largely thanks to Daniel Dargent who, with his characteristic spirit of tenacity, successfully convinced a number of French surgical teams to adopt these techniques. The subject is treated, not as a partisan argument but rather as an update of all the possibilities available to this route of non-scarring surgical access, without, at the same time, refusing to recognize the role of recourse or partnership that laparoscopic techniques can play. The authors, Michel Cosson, Denis Querleu, Daniel Dargent, provide, with the strength of their credentials, a development of their experiences, their ideas, their convictions, and above all they demonstrate impressive objectivity that brings an appropriate perspective to tried and tested techniques. In addition, the authors have avoided the classic trap of wanting to present the very latest trends and instead focus with critical judgment on known and validated procedures, and not to place too much emphasis on innovative solutions that become somewhat widespread even before their validity has been properly shown. The editorial preparation of this work has been impeccable by its quality and the precision of its illustrations and documentation, but also for its concern to keep “glued” together the text with the act in order to facilitate the imaginative recreation of the surgical technique within a static document. With the points that they share in common, it is not surprising that these three names have been united under the authorship of this single book and this in despite of appearances. First of all, I count all three as friends, and two as former students, to find them together as accomplices for such an endeavor offers me both feelings of joy and inexpressible pride. They are, all three, passionate about surgery and more generally about the profession of a surgeon, rigorous in their approach, honest with themselves about their results, and perfectly convincing in their argumentation and demonstration. They have a common, permanent concern for the transmission to younger generations of their knowledge and know-how by stressing the quality of communication and conviviality. This work on surgery should be received as a manual and a constant companion, one of the most authentic methods of the teaching of medicine. All of the procedures discussed herein have the great advantage of being reproducible—even if a certain number of the operations (the Watkins, for example) are practiced by a relatively small number of practitioners—and thus earning the label of “sound surgical practice.” The authors have benefited from a solid gynaecology/obstetrics education, providing them with the profound knowledge and experience needed to relate to the aspirations, worries and hopes of women as they come to face their gynecologic life, especially when pathologies are concerned. This irreplaceable experience provides them with the astuteness required to make wise and qualified surgical decisions. One of the authors, in spite of his immense surgical talent, accepts the role as “regional gynaecologist”: apart from being a grand act of modesty, this is a wonderful tribute to the specialisation and, more simply, to women in general, regardless of what their expectations might be. Thus, by the collaboration of three talented players, this work represents the realisation of a dream that would have been inaccessible to a single author while still fully immersed in a surgical career. To all those practising or wishing to practise gynaecological surgery, it offers a global and human vision and an approach to woman’s surgery, without succumbing to the temptation of sub-dividing the field into rival specialisations. Furthermore, it is an ardent plea for an approach to surgery where the patient is more important than the surgical intervention. Finally, it is a most precious contribution to modern gynaecological surgery and to the spirit that will safeguard the medicine of tomorrow. Professor Cities Crépin Table of Contents Preface, v Gilles Crépin PART 1: Surgical environment 1: Immediate pre- and postoperative care, 3 D.Querleu 2: Positioning, 6 D.Querleu 3: Instrumentation, 10 D.Querleu 4: Specific anatomy and the creation of spaces, 14 D.Querleu PART 2: Simple hysterectomy 5: Vaginal hysterectomy, 29 M.Cosson 6: Techniques for reducing uterine volume, 56 M.Cosson 7: Simple trachelectomy, 68 D.Querleu 8: Annexectomy, 74 D.Querleu PART 3: Laparoscopic assistance 9: Laparoscopic assistance for the vaginal approach, 87 D.Querleu PART 4: Oncological surgery 10: The Schanta operation with preparatory laparoscopy, 100 D.Querleu 11: Radical trachelectomy, 120 D.Querleu 12: Colpectomy, 125 D.Querleu PART 5: Prolapse Techniques for curing genital prolapses, 134 M.Cosson, M.Cosson 13: Vaginal Colpohysterectomy, 138 M.Cosson 14: Anterior operational stages—Campbell intervention, 153 M.Cosson 15: Anterior operative stages—Paravaginal suspension to the tendinous arches 159 of the pelvic fascia, M.Cosson 16: Anterior operational stages—the “Plastron” technique, 165 M.Cosson 17: Posterior operational stages—Suspension of the vaginal vault according to 178 Richter, M.Cosson 18: Posterior operational stages—Myorrhaphy of the levator muscles, 195 M.Cosson 19: Posterior operational stages—Douglassectomy, 200 M.Cosson 20: Posterior operational stages—Perineal repair according to Musset, 205 M.Cosson 21: Uterine preservation—Richardson operation, 211 M.Cosson 22: Uterine preservation—Manchester