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Additional Procedures at Caesarean Section − Salpingectomy, Myomectomy, Ovarian Surgery and Hysterectomy
Salpingectomy
Sterilization is a common procedure performed at caesarean section. An increasing awareness of the tubal origin of serous carcinoma has led to an increased focus on opportunistic salpingectomy as a risk-reducing measure for ovarian cancer. The incidence of salpingectomy at caesarean section has increased over the last 10 years. A number of studies have demonstrated that salpingectomy is safe, does not compromise ovarian function and adds approximately 10 minutes to a routine caesarean section.
Operative Procedure
The uterus is generally exteriorized once the hysterotomy has been closed after caesarean section. The fallopian tube is elevated to identify avascular windows in the mesosalpinx which can be fenestrated using a scissors or monopolar diathermy ( Fig. 27.1 ). The vascular component of the mesosalpinx arcade is ligated close to the fallopian tube using small artery clips, with care taken to completely resect the tubal fimbria and avoid large collateral uterine veins. 2-0 Vicryl ties are used to secure the pedicles and the tube is divided 1–2 cm from the cornua to avoid excessive bleeding.
Myomectomy
Traditional teaching has been to avoid myomectomy at the time of caesarean section; however, a recent meta-analysis suggests that a peripartum myomectomy may be safe. It is the authors’ preference to avoid myomectomy at caesarean section, as the majority of myomas regress in the postpartum state. It is possible to remove a pedunculated fibroid, but care should be taken to achieve meticulous haemostasis, ideally by ligation of the pedicle using a hysterectomy clamp, which can then be secured using a 1-0 Vicryl suture, tied front and back. It is best to avoid removal of submucosal, intramural or subserosal fibroids at the time of caesarean section.
Ovarian Surgery
Ovarian surgery is rarely performed at caesarean section; however, ovarian cystectomies may occasionally be deemed necessary, particularly if a teratoma or large cyst is identified. In the unlikely event of identifying an overtly malignant ovary, a small biopsy should be taken to confirm the diagnosis. Oophorectomy may be necessary if there has been a traumatic injury with associated haemorrhage.
Surgical Procedure
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