Vaginal, abdominal hysterectomy: expert shares tips for surgical contingencies.(Gynecology)

LAKE BUENA VISTA, FLA. -- Drawing from a half century of surgical experience, Dr. Marvin H. Terry Grody shared his surgical pearls at a conference on gynecologic surgery sponsored by the Cooper University Hospital.

"We should use our experience," said Dr. Grody, senior attending consultant of the division of female pelvic medicine and reconstructive surgery at the Camden, N.J., hospital. Dr. Grody's surgical pearls include:

* Keloid scars. Do not try to excise a keloid scar from a prior surgery, because the keloid will come back. Cut just inside the outer edges with a sharp scalpel and a steady hand. Close with a running, subcuticular, very narrow bore, rapidly absorbable, synthetic suture.

* Vaginal hysterectomy. If the weighted speculum keeps falling out of an obese woman during vaginal hysterectomy, place two sutures to hold the buttocks together over the hanging stem of the speculum. When further use of the speculum is not needed, cut the sutures and remove it.

* Abdominal hysterectomy. When performing an abdominal hysterectomy on a very obese woman, start vaginally. Deflect the bladder off the cervix. Dissect above the cul-de-sac. Clamp, cut, and tie off the cardinal uterosacral complex. At that point, go above. Make a transverse incision and go in and use a corkscrew to remove the uterus. With jelly around the outside and good traction and good retraction of the abdominal wall. you can lift the uterus out because you have detached it from down below, said Dr. Grody, who is also a professor at the Robert Wood Johnson Medical School at Camden.

Use a wide Pfannenstiel or a Cherney incision rather than a vertical, longitudinal incision to remove a large uterus abdominally. Inject vasoconstrictor substances bilaterally. Reduce the volume of the uterus by wedges and then take it out through the abdominal wall.

* Organ entry. If the rectum is penetrated during a difficult posterior dissection, leave it open. Now you know where you are. Finish the dissection. Clean the area and lavage it lavishly to keep the area as bacteria free as possible. Then close the rectum in the standard fashion and finish the operation as usual.