Gynecological surgical techniques

Abdominal surgery

Abdominal gynecological surgery, or surgery performed "open sky", it was, for many years, the approach most often used in gynecological surgery. Most surgical procedures were performed in this way, except for some (such as uterine prolapse) that they were performed vaginally. In actuality, indications of abdominal surgery are much more limited.

Open surgery still has a number of indications:

  • Patients with a history of multiple surgeries
  • Patients with chronic inflammatory conditions or.
  • Pelvis congeladas
  • Patients with adhesions

Various incisions in abdominal surgery can be performed:

  • Incision Pfannenstiehl
  • Transverse abdominal incision
  • Incisión abdominal longitudinal media Infra o supra-infraumbilical

Various methods can be performed:

  • Total abdominal hysterectomy
  • Subtotal abdominal hysterectomy
  • Miomectomia
    • Adnexal surgery
    • adnexectomy
    • cystectomy
    • salpingectomia
    • adhesiolisis
  • Surgery of deep endometriosis: rectovaginal septum, ligament-sacred womb, peritoneal lesions,
  • Promotofijación
  • Surgery of uterine malformations.
  • Surgery of pelvic inflammatory disease
  • Ligation hypogastric vessels.

Vaginal surgery

The vagina is surgically gynecological par excellence. From the historical point of view, the vaginal route was preferred in the nineteenth century against abdominal surgery, due to longer survival and lower morbidity and mortality was achieved. In the late nineteenth century, mortality was much higher in the abdominal approach due, fundamentally, the largest number of infections compared with vaginal.

Thanks to the progress made in medicine, -in the fields of antisepsis and sterilization, anesthesia, antibioterapia , possibility transfundir-, abdominal surgery came into use over vaginal, especially in Anglo-Saxon countries.
The vaginal route was relegated to prolapse surgery. Only in some European schools, as the central European and French, and in some centers in Spain, vaginal surgery remains for other indications.

Indications of vaginal hysterectomy:

  • Uterine prolapse. vaginal hysterectomy for uterine prolapse is the most common indication.
    Very heavy periods or menorrhagia
  • Adenomiosis (endometriosis in utero).
  • Uterine fibroids
  • Endometrial cancer.
  • Cervical cancer

At first, provided there is no contraindication for vaginal, Hysterectomy can be performed by this way whatever the indication.

Contraindications for vaginal:

  • Vaginal stenosis
  • Narrow pelvis
  • Fixed uterus, without lowering
  • Increased uterine size. In these cases morcellement or hemisection technique can be performed to reduce the size of the surgical specimen.
  • Adnexectomy need in ovarian cyst.
  • Surgeon inexperience.

Advantages of the vaginal:

  • It is a technique Extraperitoneal.
  • No abdominal wound
  • Ileum
  • Minor wound infection
  • Lower risk of hernias
  • Minor thromboembolism irrigation
  • Reduced risk of abdominal adhesions.
  • Possibility of regional anesthetic technique.
  • Shorter operative time.
  • Faster recovery


  • Minor surgical field
  • No display adnexal pathology

Procedures that can be performed vaginally:

  • Total vaginal hysterectomy Simple
  • Surgical treatment of prolapse
  • Culdoplastia de Mc Call
  • Surgical correction of the enterocele
  • Plastia vaginal anterior
  • Colpoperineoplastia
  • Prolapsed vaginal cuff fixing the sacrospinous.
  • Clesis
  • Manchester operation
  • Surgery urinary incontinence: transobturadoras bands slings books tensión ALL (trans obturador tape)

Hysteroscopic surgery

Hysteroscopy is a minimally invasive surgical technique which aims to examine the inside of the uterine cavity and cervical canal. It involves inserting the hysteroscope, elongated and thin with a light inside the instrument and a camera that sends images to a monitor.

The hysteroscope is inserted through the vagina and through os, penetrates into the cervical canal and uterine cavity. It distends the uterine cavity with liquid (saline, glycine), o con gas (CO2).

Exist 2 types histerocopia:

  • Histerocopia diagnostics. It can be performed on an outpatient basis or in hospital all day. Sometimes local anesthesia can be but is not necessary in other. A hysteroscope used small caliber
  • Operative hysteroscopy. Its size is thicker (9 mm) and requires dilation of the cervix. The hysteroscope, also called resectoscope, It presents a work item, including electrodes ( asa, Trackball, needle). It works with continuous flow system fisológico serum or glycine and high frequency electricity.

Indications of hysteroscopic surgery

  • Directed biopsies
  • Resection of endometrial polyps
  • Adhesiolysis
  • Tubal sterilization
  • Myomectomy
  • IUD removal
  • Resection of uterine septum
  • Resection / endometrial ablation (in disuse)

Miomectomía histeroscópica:

Myomectomy is, with polypectomy, one of the most common indications of hysteroscopic surgery.

It is suitable to perform myomectomy fibroid types 0 Y 1 classification of Wanstaker and Blok, (1993). The type 0 es un mioma completamente submucoso, located entirely in the endometrial cavity. It can be pediculazo or sessile.

The type 1 includes submucosal endometriomas are more than 50% by volume.

The type 3 It should not have the operation for hysteroscopy, as more than 50% its volume is not intramural and submucosal.

Laparoscopic surgery

Laparoscopic surgery is defined as one that uses a gateway for small and displayed by an optical and a camera connected to a monitor.

In the beginning, laparoscopy is used to diagnostic procedures, primarily in Human Reproduction.

The indications for laparoscopic surgery, en general, They are no different from those of open surgery; what is different is the way to access the field.

Laparoscopy has been a drastic change in the way we operate, which it is different from conventional surgery. It is called minimally invasive surgery, that allows greater surgical interventions less aggressive and faster postoperative recovery.

Laparoscopic surgery is based on the vision and implementation of the internal genitalia through small holes < 1-2 cm diameter and insufflation gas into the peritoneal cavity.


  • Optical System: It is small in size and is connected to a camera with a cold light source, which transmits the image to a monitor or screen.
  • Insuflador de gas. The most commonly used gas is CO2. It is inert, colorless, It is not soluble in plasma and nonflammable. It is easily removed by respiration. The inflow and the gas pressure can be programmed to maintain the abdominal cavity with the proper strain.
  • Monitor. It allows the surgical team to visualize the intervention. It is bidimensional, but there are also 3D.
  • Trocars. They are about intrtrumentos shaped hollow cylinders 5-10 mm diameter passing through the abdominal cavity. Through them qurúrgico optics and instruments are introduced ( tweezers, scissors, aspirador-irrigador).
  • Unlike CO2 pneumoperitoneum laparoscopic approach the approach "open". You can have systemic complications such as hypercapnia, respiratory acidosis, tachycardia, decreased glomerular filtration rate, tachycardia, pulmonary hypertension, decreased venous return, cardiac output, and oxygen saturation.
  • Is absolute contraindication to pneumoperitoneum cardiac decompensation. They are relative contraindications: chronic obstructive pulmonary disease and diaphragmatic hernia.

Advantages of laparoscopic surgery:

  • Conservation of the abdominal wall
  • Little visceral manipulation
  • Minor scars
  • Sharper vision
  • Minor postoperative complications
  • Shorter hospital stay
  • Faster recovery


  • It requires specific training
  • Handling technology and instrumentation
  • Loss of tactile sensation
  • Loss of field of vision, dimensional vision. In laparoscopy 2D.


  • Conversion to open surgery if the findings warrant.(adhesions, indented, drilling)
  • Hemorrhage
  • Subcutaneous emphysema
  • Aritmias
  • Hypercapnia
  • Tendency to hypercoagulability
  • Cutaneous metastases in the abdomen input port in cancer surgery.
  • Visceral electrical injuries

Variants of laparoscopic surgery:

  • SILS single port surgery (Single Incision Laparoscopic Surgery)
  • Single Port laparoscopy.
  • NOTES Natural Orifice Transluminal Endoscopic Surgery.
  • Laparoscopic surgery with robotic assistance
  • 3D laparoscopy, which allows three-dimensional view.

Technical input in the abdomen:

  • Laparoscopy Closed, by Veress needle
  • Laparoscopy open. It is the safest technique to prevent injury of great vessels.
  • Gasless laparoscopy
  • Other techniques: optical trocars, Veress OPTIC, change the thread etc..

Place input

In general most entry techniques access to the cavity just below the navel.
There are other possible locations such as puncture subcostal (punto de Palmer), Other more rare as suprapubic aspiration, in vaginal fornix .

Removal of surgical specimens

The pieces should be removed in a bag which is inserted through one of the trocars.
Sometimes there are high-volume surgical specimens. one morcellation can be performed with an electric morcellator, or removing the piece from the pouch of Douglas.

The Spanish Agency for Medicines and Health Products (AEMPS) Note that making morcellation in cases where malignancy is diagnosed or there is a suspicion of malignancy.

a complete preoperative study recommends including the potential risk factors. (Age, lesion growth, symptoms)

If you finally decide to make morcellation, must inform the patient of the potential risk of peritoneal dissemination, with worse prognosis, if diagnosed neoplasms, en especial sarcomas. Extraction bags available not fully protected in these cases.

Breast Surgery

Breast surgery can be performed for benign causes, infectious or breast cancer.

Incisions in breast surgery:

  • periareolar
  • arciform. It takes place in the upper quadrants of the breast
  • radial. In the lower quadrants
  • submammary
  • axillary, which may be longitudinal or transverse
  • Stewart incision
  • incision Halsead. In disuse.

The chosen incision must meet certain requirements:

  • provide sufficient space to remove the tumor
  • allow good cosmetic result of the intervention
  • It is recommended that the incision along the lines called Langer.

Surgery of benign processes:

  • Intraductal papilloma. Often show signs of bleeding from the nipple or telorragia. The procedure is called piramidectomia
    • Fibroadenoma . Their removal is indicated in
    • fibroadenomas desk of 30.35 mm
    • Rapid growth
    • Cosmetic changes in the breast
    • consumer
    • atypia on biopsy or lack of clinical correlation- Radiation
    • patient anxiety
  • Other benign tumors.
  • Breast abscess. Sometimes it is necessary to perform a debridement and drainage
  • Fistulización periareolar recidivante. It is a benign entity characterized by recur multiple times. Surgical drainage and antibiotics do not resolve the problem in some
  • Sometimes. You can perform a removal of the fistula tract.

Surgical techniques in breast cancer:

  • Tumorectomía o lumpectomía
  • Wide excision
  • Quadrantectomy
  • Mastectomy
  • Selective sentinel node biopsy
  • Axillary lymphadenectomy

Oncoplastic surgery in the conservative treatment of breast cancer

The conservative surgery for breast cancer has been shown to produce the same survival than radical treatment, and get local control of the disease, provided free margins are achieved and intraoperative radiotherapy post operative or associate ( Intrabeam)

The surgery has two objectives Oncoplastic:

  • Cancer target. Get local control of cancer
  • Aesthetic goal: cause the least disturbance of breast aesthetic and alter the patient's body image.

It is estimated that more than one 20% Women who undergo conservative breast cancer tatamiento present important deformities that will require remedial treatment.

They are risk factors for worse aesthetic results:

  • The need to remove ore 20% the volume of the breast
  • Excision of tumor in lower quadrants or internal.
  • Effects of postoperative radiotherapy.

Oncoplastic surgery aims to prevent deformities:

  • without deformity after breast surgery / with breast volume asymmetry regarding contralateral breast
  • breast deformity can be corrected by surgery after partial reconstruction of the breast tissue itself.

Major deformities or cases requiring mastectomy are not included.

The oncoplastic techniques attempt to prevent deformities Oncoplastic performing a technique in initial breast cancer surgery, performing an immediate remodeling affects breast and breast cancer, sometimes the contrataleral.

The indication of conservative treatment of breast cancer depends on:

  • tumor size
  • breast volume.
  • location of the tumor in the breast.

Main technical oncoplastic conservative:

  • Mamoplastia vertical de rama única
  • Mammoplasty with double branch
  • Mamoplastia vertical de pedicuro inferior
  • Breast lower rotation
  • Mamoplastia horizontal
  • Mamoplastia lateral
  • Retroareolar tumors or central location. Sometimes it is necessary to carry out the removal of the nipple-areola complex.

They can be made:

  • central resections without breast remodeling
  • central resections with breast remodeling. Technique Grisotti.