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toby-mitchell
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Objectives• review anatomy/physiology
• female reproductive system• identify pathological conditions
• female reproductive system• differentiate between
• gynecological diagnostic procedures• describe basic surgical interventions
• colposcopy• describe intermediate surgical interventions
• cervical cone biopsy• LEEP
• describe basic surgical interventions• dilation and curettage• hysteroscopy
• describe intermediate surgical interventions• endometrial ablation
• Novasure• balloon therapy
• describe basic surgical interventions• diagnostic laparoscopy• laparoscopic tubal ligation• laparoscopy with oophorectomy
• describe advanced surgical interventions• microsurgical tubal anastomosis
• describe basic surgical interventions• vaginal hysterectomy• abdominal hysterectomy
• describe intermediate surgical interventions• laparoscopic assisted vaginal hysterectomy• robotic assisted vaginal hysterectomy
• describe advanced surgical interventions• myomectomy• radial hysterectomy
• Wertheim procedure• total pelvic exenteration
• describe basic surgical interventions• anterior and posterior repair• ablation of condylomata• marsupialization of Bartholin’s gland
• describe basic surgical interventions• labioplasty• vulvectomy
• review stages of labor• identify complications of pregnancy• sequence for vaginal deliveries• describe basic surgical interventions
• cesarean section
• describe intermediate surgical intervention• ectopic pregnancy
• describe basic surgical intervention• cerclage
• Shirodkar’s procedure• elective termination of pregnancies
• describe advanced surgical intervention• uterine radiation seeding procedures
• Cesium• assisted reproductive therapies
• IVF• GIFT
• endometrium• inner layer
• sloughed off• myometrium
• muscular layer• contracts during
• labor• perimetrium
• outer layer
Layers of the Uterus
• broad ligaments• ovarian ligaments• round ligaments• cardinal ligaments
• below broad• uterosacral ligaments
Uterine Ligaments
• fallopian tubes• interstitial section
• connect to body• uterus
• isthmus• middle
• ampulla• widened portion
• infundibulum• terminal end
• fimbriae
• follicular phase• day 1 to day 14• FSH/LH rise
• secretes estrogen• ova begin to develop
• ovulatory phase• day 14• 16 to 32 hours• estrogen drops• secretes progresterone
• release of ovum• luteal phase
• luteal phase• day 16• lasts 12 days• corpus luteum
• secretes• estrogen• progesterone
• triggers changes• endometrium
• implantation• menustration
Pathology of the Female Reproductive System
• gynecological cancers• endometrial cancer
• associated with• obesity• high levels of estrogen
• cervical cancer• most common• easily treated
• early stage• dysplasia
• progresses to• carcinoma in situ
• related to HPV
• ovarian cancer• leading cause of gynecological deaths
• spread directly and distally• vulvar cancer
• linked to condylomas (HPV)
• fibroid tumors• benign neoplasm
• uterus• treatment
• myomectomy• ovarian cysts
• persistant ovarian follicle• multiple incidents
• PCOS
• cystocele• herniation of bladder
• into vagina• rectocele
• herniation of rectum• into vagina
• enterocele• herniation of intestine
• into vagina
• menorrhagia• excessive bleeding
• during menustration• metrorrhagia
• excessive bleeding• between periods
• Papanicolaou (Pap) test• cytology study
• cervical smear• screen for cervical cancer
• cultures• STD’s• HPV
• colposcopy
Diagnostic Procedures
• surgical intervention• basic room setup• special considerations
• negative pregnancy test• position
• lithotomy• prep
• vaginal
• procedural steps• speculum inserted• cervix swabbed with 3% acetic acid• examined under light
• abnormal tissue• appear white
• paint with Iodine• Lugol’s solution
• healthy tissue• take up stain
• abnormal tissue• will not
• called Schiller’s test
• cone biopsy of the cervix• removes circumferential core of tissue
• around cervical canal• called LEEP
• loop electrosurgical excision procedure
• dilation of the cervix and curettage (D&C)• done for
• diagnostic purposes• abnormal uterine bleeding• incomplete abortion• prior to procedures performed
• via cervix
• surgical intervention• special considerations
• negative pregnancy test• preferred anesthesia
• general• position
• lithotomy• prep/drape
• vaginal
• procedural steps• Auvard inserted• cervix grasped
• tenaculum• depth and position
• determined with• uterine sound
• cervix dilated• Hegar or Hanks dilators
• suction D&C• done for
• induced abortion • elective
• noninduced abortion• incomplete• missed• threatened
• inevitable
• hysteroscope• visualize internal contour
• uterus• done to
• assess uterine cavity• polyps, tumors, adhesions
• special considerations• - pregnancy test
• surgical intervention• basic room setup• preferred anesthesia
• general• position
• lithotomy• prep/drape
• vaginal
• supplies• back table cover• raytecs
• equipment• camera/light source
• instrumentation• hysteroscope• D&C set
• hysteroscope• rigid or semi-rigid
• 12 to 30 degree angled lens• 0 degree is also available
• sheath• allow instrumentation• instillation of distention medium
• uterine distention• low viscosity fluids
• NS• except with cautery
• no longer use• CO2
• gas embolism
• Dextran 70• fluid extravasation
• procedural steps• D&C steps to dilation• insertion of hysterscope• inflation of uterus• polyp or adhesion found
• use resectoscope• spring-loaded handle• shaves and coagulates tissue
• endometrial ablation• done for
• dysfunction uterine bleeding• two techniques
• rollerball ablation• with resectoscope
• global endometrial ablation
• global endometrial ablation• NovaSure
• radiofrequency ablator• Therma-Choice
• silicone balloon catheter• filled with D5W• actived to 176°F• 10 minutes
• laparoscopy• diagnose
• abdominal/pelvic pain• evaluate
• pelvic masses• treat
• adhesions• cysts• ectopic pregnancy• tuboplasty
• surgical intervention• room setup
• separate setups• vaginal• abdominal
• preferred anesthesia• general
• position• low lithotomy
• procedural steps• begins with D&C
• Auvard• uterine tenaculum• dilator
• uterine manipulator inserted• methylene blue instilled
• chromotubation• gloves changed
• pneumoperitoneum• first port
• laparascope• secondary ports
• as needed• instrumentation
• surgeon manipulates uterus
• tubal ligation• fallopian tubes elevated
• Babcock• occluded by three methods
• transection and coagulation• bipolar cautery
• fallope ring• Silastic O ring
• filshie clip
• cyst dissected• cutting into the cortex
• outer covering of cyst• removed intact
• placed in retrieval bag• opened inside abdomen
• too large• reduced with a morcellator
• fallopian tube identified• damaged portion dissected
• iris scissors• patency assessed
• indigo carmine• insufflate
• Rubin’s test• reanastomosed
• 8-0 or 9-0 Prolene
• uterine fibroids• preserve fertility
• myomectomy• resectoscope
• uterine tumors• hysterectomy
• total• cervix and uterus
• subtotal• cervix left in place
• total abdominal hysterectomy• supine position• abdominal/vaginal prep• indwelling foley
• prevent injury to bladder• Pfannenstiel incision
• access gained into peritoneum• retractor inserted
• O and O• bowel isolated
• wet lap sponges• make note of
• number
• dissection carries• toward
• cervix• Jorgensen scissors
• uterine vessels• clamped• cut• ligated
• cervix
• ovaries removed• oophorectomy
• tubes removed• salpinectomy
• both• salpinoophorectomy
• both side• bilateral
• procedural steps• Auvard• cervix grasped
• tenaculum• circumferential incision cervix• vaginal wall dissected away
• sponge on stick
• laparoscopic assisted vaginal hysterectomy• two setups
• laparascope• vaginal
• position• lithotomy
• prep• vaginal/abdominal
• procedural steps• pneumoperitoneum• trocars• scope inserted• Harmonic scalpel available
• dissect• uterine ligaments
• bladder freed
• robotic assisted• insert uterine manipulator• laparascopic sequence• position
• steep Trendelenburg• robot
• docked
• radical hysterectomy• Wertheim
• anterior approach• remove uterus, cervix, vagina, fallopian tubes, ovaries, bladder
• ileal conduit• posterior approach
• posterior approach• removal of vagina, uterus, cervix vagina, fallopian tubes, ovaries, sigmoid colon, rectum
• colostomy
• pelvic exenteration• removal of
• rectum• distal sigmoid• urinary bladder• distal ureters• reproductive organs• lymph nodes• pelvic floor
• anterior-posterior repair• colporrhaphy• position
• lithotomy• prep
• vaginal• straight catheterized
• anterior portion• insert Auvard• grasp cervix• incise anterior vaginal wall
• edges grasped with Allis clamps• fanned out to distend edges• raytecs used for blunt dissection
• reaches bladder neck• ligate• cut away excess tissue
• vaginoplasty• create a functional vagina
• congenital• repair of vesicovaginal fistula
• tract connects• bladder to vagina
• repair of rectovaginal fistula• tract between
• rectum and vagina
• marsuplization of Bartholin Duct Cyst• cyst is excised
• resecting anterior wall• suturing cut edges
• cyst• adjacent edges of skin
• vulvectomy• simple
• labia major, minora, clitoris• removed en bloc
• one piece• skinning
• external skin from affected area• radical
• skin from abdomen/groin, labias, clitoris, terminal urethra, vagina, nodes, ligaments, veins
• simple vulvectomy• elliptical incision
• around vulva• vulva removed en bloc• posterior vaginal mucosa
• incised• sutured to strengthen pelvic floor
• radium implants• cancer of cervix and endometrium• lithotomy position• bladder drained• catheter inflated
• radiopaque medium• radium applicators used
• inserted vaginally
• pregnancy• false labor
• Braxton Hicks• true labor
• begin with bloody show• loss of mucous plug
• ends with dilation of cervix• stage one
• dilation of cervix• second stage
• crowning• ends with birth of infant
• birth of infant• third stage
• ends with delivery of placenta
• surgical technologist• follow patient’s progress
• dilation• effacement
• thinning of cervix• station
• measurement of descent• relation to ischial spine
• prepare OR for delivery
• vaginal delivery• lithotomy position• episiotomy
• prevent perineal lacerations• head delivered
• oral cavity/nares suctioned• bulb syringe• De Lee suction
• assesses umbilical cord• tight
• may clamp and cut• loose
• slip over infant’s head• head turned to floor
• upper shoulder delivered
• head turned to ceiling• lower shoulder delivered
• cord double clamped/cut• cord blood collected
• infant hand to • nurse/pediatrician
• maternal complications• pre-eclampsia
• hypertension• hyperreflexia• ketones urine• 4+ edema
• eclampsia• convulsions
• organic disease state• diabetes• cardiac disease• fibroids/ovarian tumors
• STD’s• previous c-sections
• fetal complications• malpresentation
• breech• butt first
• transverse• footling• vertex
• back of head
• failure to progress• #1 reason
• C-section• due to
• weak contractions• cephalopelvic disproportion
• mother’s pelvis too small• maternal/fetal complication
• placental complications• placenta previa
• implanted low in uterus• danger of placenta
• delivered first• placenta abruption
• separates prematurely• leads to fetal death
• preferred anesthesia• epidural
• position• supine with roll under right hip
• prepping• abdomen, vagina, inner thighs• foley catheter
• procedural steps• pfannenstiel incision• elevates peritoneum
• incision• Metzenbaum (Mayo) scissors
• bladder freed from uterus• bladder flap
• De Lee retractor
• uterus palpated• determine fetal position
• suction available• incision into uterus
• bandage scissors• suction baby
• bulb syringe
• baby delivered• umbilical cord
• clamped/cut• cord blood
• baby to pediatrician• placenta delivered• wound closed
• 4 counts
• complications of pregnancy• incompetent cervical os
• abortion• cervical cerclage• Shirodkar procedure
• TVC• synthetic band
• placed around• proximal cervix
• vaginal approach• TAC
• sutures• internal cervical os
• abdominal approach
• ectopic pregnancy• implantation outside uterus
• 95% fallopian tubes• ruptured
• open procedure• not ruptured
• laparascopic
• open repair• pfannenstiel incision• suction/irrigation ready• salpingectomy
• cross-clamp• fallopian tube
• resected• salpingostomy
• incision into fallopian tube• contents evacuated
• laparosopic resection of tubal pregnancy• pneumoperitoneum• trocars• identify site of pregnancy• incision into tube
• cautery tip• trophoblastic tissue removed
• Babcock