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COMMON GYNECOLOGIC PROCEDURES AZZA AlYAMANI Department of Obestetrics and Gynecology. Common Gynecologic Procedures Aim of this presentation is : - PowerPoint PPT Presentation
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COMMON GYNECOLOGICCOMMON GYNECOLOGIC
PROCEDURESPROCEDURES
AZZA AlYAMANIAZZA AlYAMANI
Department of ObestetricsDepartment of Obestetrics
and Gynecologyand Gynecology
Common Gynecologic Common Gynecologic ProceduresProcedures
Aim of this presentation isAim of this presentation is : :
1. students become aware of the 1. students become aware of the basic principlesbasic principles of common gynecologic surgical procedures.of common gynecologic surgical procedures. 2. become familial with the 2. become familial with the instrumentsinstruments that used in that used in these procedures.these procedures. 3. and be aware of the 3. and be aware of the indicationsindications and and complicationscomplications of each procedure.of each procedure.
{1} Endometrial Sampling ( Dilatation & Curettage){1} Endometrial Sampling ( Dilatation & Curettage)
D & CD & C
** it is the most common minor gynecologic surgical it is the most common minor gynecologic surgical
procedure , it is used as procedure , it is used as diagnosticdiagnostic or or therapeutictherapeutic tool. tool.
** in spite of the advances in office – based evaluation of in spite of the advances in office – based evaluation of
the endometrium as US or hysteroscopy , a thoroughthe endometrium as US or hysteroscopy , a thorough
fractional curettage fractional curettage is is the the best procedure best procedure if endometrial or cervical cancer is suspected.if endometrial or cervical cancer is suspected.
IndicationsIndications
Diagnostic:Diagnostic:
1. abnormal uterine bleeding.1. abnormal uterine bleeding.
2. postmenopausal bleeding ,end. ca.2. postmenopausal bleeding ,end. ca.
3. irregularities of the endometrial cavity either3. irregularities of the endometrial cavity either
congenital ( uterine septum) or acquired congenital ( uterine septum) or acquired
(submucous fibroids or polyp)can be determined (submucous fibroids or polyp)can be determined
during the operation.during the operation.
Therapeutic:Therapeutic:
1. endometrial hyperplasia with heavy bleeding .1. endometrial hyperplasia with heavy bleeding .
2. removal of endometrial polyps or small 2. removal of endometrial polyps or small
pedunculated myomas.pedunculated myomas.
3. dilatation & evacuation in inevitable and missed3. dilatation & evacuation in inevitable and missed
abortion.abortion.
4. removal of missed intrauterine IUCD.4. removal of missed intrauterine IUCD.
Complications:Complications:
11.Perforation of the uterus..Perforation of the uterus.
it is not uncommon complication ,it occurs in :it is not uncommon complication ,it occurs in :
* RVF uterus.* RVF uterus.
* pregnancy.* pregnancy.
* postmenopausal è endometrial carcinoma.* postmenopausal è endometrial carcinoma.
22. Cervical laceration.. Cervical laceration.
33. Infection.. Infection.
44. Haemorrahge.. Haemorrahge.
Endometrial AblationEndometrial Ablation
iit is the t is the complete destruction of the endometriumcomplete destruction of the endometrium
down to the basal layer down to the basal layer , resulting in fibrosis of the uterine , resulting in fibrosis of the uterine
cavity and amenorrhoea ( 30% ) , however , patient cavity and amenorrhoea ( 30% ) , however , patient
satisfaction rates are over 70% . Iasatisfaction rates are over 70% . Ia
It indicated in women who have heavy menstrual It indicated in women who have heavy menstrual
bleeding that is impacting her life and do not have bleeding that is impacting her life and do not have
other problems that require hysterectomy .other problems that require hysterectomy .
Endometrial ablation is now well established as dayEndometrial ablation is now well established as day
case or outpatient procedure. case or outpatient procedure.
Endometrial Ablation is performed using the Endometrial Ablation is performed using the
resectoscope which is :resectoscope which is :
a hysteroscpe with a build in wire loop(or other shapea hysteroscpe with a build in wire loop(or other shape
device ) that uses device ) that uses high frequency electrical current high frequency electrical current toto
cut or coagulate tissue.cut or coagulate tissue.
Indications:Indications:
1. abnormal uterine bleeding. 2. benign lesions as small submucus myomas or endometrial polyps.
TechniqueTechnique
Established techniques carried out under direct Established techniques carried out under direct
hysteroscopic vision involve the use of fluid forhysteroscopic vision involve the use of fluid for
distention and irrigation .distention and irrigation .
These techniques are :These techniques are :
* laser ablation.* laser ablation.
* endometrial loop resection using electro diathermy.* endometrial loop resection using electro diathermy.
* roller ball electro diathermy.* roller ball electro diathermy.
roller ball electro diathermy. endometrial loop resectionroller ball electro diathermy. endometrial loop resection
using electro diathermy.using electro diathermy.
roller ball electro diathermyroller ball electro diathermy
Complications : 2%Complications : 2%
1. uterine perforation.1. uterine perforation.
2. hemorrhage.2. hemorrhage.
3. infections as endometritis & PID.3. infections as endometritis & PID.
4. bowel or urinary tract injury.4. bowel or urinary tract injury.
5. cervical lacerations & stenosis.5. cervical lacerations & stenosis.
5. distention medium hazards as:5. distention medium hazards as:
* gas embolism.* gas embolism.
* fluid overload.* fluid overload.
* anaphylactic shock.* anaphylactic shock.
Although the resectoscope provides excellent Although the resectoscope provides excellent results in experienced hands, the technique is results in experienced hands, the technique is
difficult to master. difficult to master.
because all the previous techniques are: because all the previous techniques are:
* operator dependent .* operator dependent .
* time consuming .* time consuming .
* carry risk of systemic fluid absorption.* carry risk of systemic fluid absorption.
* hemorrhage.* hemorrhage.
* uterine perforation è heat damage to adjacent* uterine perforation è heat damage to adjacent
structures.structures.
Other methods of ablation Other methods of ablation
Newer techniques have been developed with the Newer techniques have been developed with the
aim of reducing operator dependency and minimizingaim of reducing operator dependency and minimizing
risk . Of these , the best evaluated to date are :risk . Of these , the best evaluated to date are :
* * microwave ablationmicrowave ablation..
* * thermal balloon ablationthermal balloon ablation..
They have equivalent short-term efficacy with the They have equivalent short-term efficacy with the advantage of shorter operating times and fewer advantage of shorter operating times and fewer
complications.complications.
Microwave probe inserted Microwave probe inserted endometrium heated to 80 Cendometrium heated to 80 C day case procedureday case procedure 70 -80% satisfaction rates70 -80% satisfaction rates 95% return to normal 95% return to normal
Thermachoice ballon This uses a balloon placed in the uterine cavity through the cervix. Hot water is circulated inside the balloon to destroy the endometrium.
Thermachoice Balloon Ablation
Central element heats liquid circulated in balloon
87 degrees C for 8 minutes .
Limitations :
*uterine cavity size 6-10 cm ;
* can’t treat submucous myomas .
Hysterectomy Hysterectomy
it is the most commonly performed majorit is the most commonly performed major gynecologic operation , it can be performed either gynecologic operation , it can be performed either
Abdominally , vaginally or laparoscopically.Abdominally , vaginally or laparoscopically.
although some indications remain controversial ,although some indications remain controversial ,
high patient satisfaction levels and increasing high patient satisfaction levels and increasing
safety for the procedure have been reported .safety for the procedure have been reported .
Types of HysterectomyTypes of Hysterectomy 1. subtotal 1. subtotal
2. total 2. total
3. total è unilateral or bilateral salpingo ophrectomy .3. total è unilateral or bilateral salpingo ophrectomy .
4. radical4. radical
Indications :Indications :
A.A.Abdominal hysterectomy Abdominal hysterectomy
1. 1. invasiveinvasive uterine ,cervical ,ovarian and Fallopian cancer. uterine ,cervical ,ovarian and Fallopian cancer.
2. significant 2. significant pre invasive lesions pre invasive lesions of the cervix as CIN III of the cervix as CIN III or endometrial hyperplasia with atypia . or endometrial hyperplasia with atypia .
3. 3. pelvic pain pelvic pain
chronic endometriosis , chronic PID and ruptured chronic endometriosis , chronic PID and ruptured
tubo ovarian abscess.tubo ovarian abscess.
4. 4. fibroid fibroid uterus > 12 weeks in size.uterus > 12 weeks in size.
5. 5. AUBAUB unresponsive to other lines of treatments. unresponsive to other lines of treatments.
6. 6. pregnancy catastrophe pregnancy catastrophe as severe bleeding. as severe bleeding.
B. vaginal hysterectomyB. vaginal hysterectomy
1. utero vaginal prolapse .1. utero vaginal prolapse .
2. AUB with small uterus . 2. AUB with small uterus .
pre requesits to vaginal hysterectomy :pre requesits to vaginal hysterectomy :
* benign disease.* benign disease.
* uterus is mobile with some pelvic relaxation & no pelvic* uterus is mobile with some pelvic relaxation & no pelvic
adhesions .adhesions .
* uterus is < 12 weeks in size.* uterus is < 12 weeks in size.
C . Laparoscopic hysterectomyC . Laparoscopic hysterectomy
* < 10% of hysterectomies performed with the* < 10% of hysterectomies performed with the
use of laparoscopy.use of laparoscopy.
* it is used to assist in vaginal hysterectomy or * it is used to assist in vaginal hysterectomy or to convert an abdominal to a vaginal to convert an abdominal to a vaginal hysterectomy.hysterectomy.
TechniqueTechnique
1. supine position.1. supine position.
2. general anaesthesia .2. general anaesthesia .
3. a careful abdominal & pelvic exam. under3. a careful abdominal & pelvic exam. under
anaesthesia is carried out.anaesthesia is carried out.
4. incision 4. incision
* * vertical vertical
in obese , if endometriosis is anticipated and patientsin obese , if endometriosis is anticipated and patients
who have had several prior abdominal operations.who have had several prior abdominal operations.
* * transverse transverse
in restricted benign disease .in restricted benign disease .
5. exploration of the upper abdominal organs 5. exploration of the upper abdominal organs
especially the liver ,spleen and para-aortic lymphespecially the liver ,spleen and para-aortic lymph
nodes. nodes.
6. the abdominal viscera are packed up with towels.6. the abdominal viscera are packed up with towels.
7. 7. round ligament round ligament ..
each is clamped incised and ligated.each is clamped incised and ligated.
8. the vesico-uterine fold of peritoneum is incised8. the vesico-uterine fold of peritoneum is incised
transversely between the incised round lig. andtransversely between the incised round lig. and
the the bladder is reflected inferiorly bladder is reflected inferiorly ..
9. the two layers of the broad ligam. are separated9. the two layers of the broad ligam. are separated
and the and the ureters are explored and identifiedureters are explored and identified..
10. the 10. the infundibulo pelvic ligsinfundibulo pelvic ligs. with the ovarian . with the ovarian
vessels are clamped , cut and ligated. if thevessels are clamped , cut and ligated. if the
adnexa are to be removed.adnexa are to be removed.
11. the broad lig. is then incised towards the uterus11. the broad lig. is then incised towards the uterus
exposing the uterine vessels (skeletonized).exposing the uterine vessels (skeletonized).
12. the 12. the uterine vessels uterine vessels are clamped at the level of are clamped at the level of
internal cervical os , incised and ligated on eachinternal cervical os , incised and ligated on each
side. side.
13. medial to the ligated uterine vessels , the13. medial to the ligated uterine vessels , the
cardinal ligcardinal lig. on each side is clamped , incised. on each side is clamped , incised
and ligated. and ligated.
14. posteriorlly , the peritoneum between the 14. posteriorlly , the peritoneum between the
uterosacral lig. is incised transversely and uterosacral lig. is incised transversely and
the rectum is freed from the posterior aspectthe rectum is freed from the posterior aspect
of the cervix & upper vagina after the of the cervix & upper vagina after the
uterosacral lig. are clamped , incised & ligated.uterosacral lig. are clamped , incised & ligated.
15. the total uterus is removed by cutting across15. the total uterus is removed by cutting across
the vagina just below the cervix .the vagina just below the cervix .
16. the vaginal cuff is closed è absorbable sutures ,16. the vaginal cuff is closed è absorbable sutures ,
incorporating the cardinal & uterosacral ligs.incorporating the cardinal & uterosacral ligs.
into each lateral angle to avoid latter into each lateral angle to avoid latter
development of vault prolapse.development of vault prolapse.
Sites of ureteric injures Sites of ureteric injures ::
11. at clamping & incising the infundibulo pelvic. at clamping & incising the infundibulo pelvic
ligaments.ligaments.
22. at ligating the uterine vessels.. at ligating the uterine vessels.
33. at clamping & incising the cardinal ligs. if the . at clamping & incising the cardinal ligs. if the
urinary bladder is not sufficiently reflected urinary bladder is not sufficiently reflected
inferiorly.inferiorly.
Complications :Complications : A .A . Intra operative Intra operative
11. hemorrhage .. hemorrhage .
22. ureteric injuries.. ureteric injuries.
33. bladder and bowel injury.. bladder and bowel injury.
44. anesthetic complications.. anesthetic complications.
B.B. Post operative Post operative
11. wound infection ( 5 days postoperatively).. wound infection ( 5 days postoperatively).
22. UTI .. UTI .
33. thrombophlebitis and pulmonary embolism,. thrombophlebitis and pulmonary embolism,
( 7 – 12 days ).( 7 – 12 days ).
44. uretero vaginal fistula ( 5 – 21 days ).. uretero vaginal fistula ( 5 – 21 days ).
the the Novasure SystemNovasure System
Another new device,Another new device,
now available, and has a number of advantages now available, and has a number of advantages over other systems. It only takes a few minutes over other systems. It only takes a few minutes and has an excellent safety recordand has an excellent safety record