Common Gynaecological Operation

Myomectomy A myomectomy is an operation to remove fibroids while preserving the uterus. For women who have fibroid symptoms and want to have children in the future, myomectomy is the best treatment option. Myomectomy is very effective, but fibroids can re-grow) recurrence). The younger the patient is and the more fibroids she has at the time of myomectomy, the more likely is the recurrence in the future.

Indications Abnormal uterine bleeding, causing anemia Severe pelvic pain Large or multiple (Palpable per Abdomen) Pressure Symptoms (Urinary tract symptoms) Postmenopausal or rapid growth Obscuring evaluation of adnexa Indications in Infertility: Deformity of Endometrial Cavity Distortion of Fallopian Tubes Fibroid associated with Unexplained Infertility 3

Approach: A myomectomy can be performed in several different ways depending on the size, number and location of the fibroids: Abdominally (open) Laparoscopic Hysteroscopic Primarily for submucosal fibroids Vaginal Primarily for pedunculated submucous fibroids 4

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Abdominal Myomectomy Technique: 1. Localization of myoma. 2. Non- crushing clamp or Torniquet. 3. Anterior midline incision. 4. enucleation. 5. Repairing the defect. 6

Abdominal Myomectomy Technique Place non crushing clamp across the ovarian and uterine arteries to minimise blood loss or use a tourniquet. Bonney-1920’s – Uterine Artery Clamp 7

Palpate the uterus for any remaining fibroids. Attempt to remove all fibroids through a single midline incision if possible (Avoids vascular structures laterally. An anterior incision is preferred to minimize the risk of later adhesion of bowel & retroversion. ). Tissue surrounding the fibroid is compressed tightly forming a pseudocapsule No vascular bundle enters the myoma Identification of and dissection along this plane will minimize blood loss Cleavage planes may be altered in those who have been pretreated with GnRH analogue. Palpate the uterus for any remaining fibroids.

Remove all myomas with single anterior midline incision is the choice.

Repairing defect Multi layered approach Deep sutures to close dead space Second imbricating layer Close serosa with a “baseball stitch” May require removal of excess myometrial tissue to allow adequate closure Apply a sheet of adhesive barrier over the incision line to avoids adhesion formation. 10

Repairing the defect by multilayered Approach. -Deep space suturing -second imbricating layer -serosa with baseball suturig

Baseball like suturing

Morbidity Intra operative: Haemorrhage Visceral Damage Need for Hysterectomy Post operative: Myoma Fever – 33% Sequelae: Recurrence / Retreatment – 4-27% Adhesions Uterine Rupture in Labour (Rare)

Myomectomy Biggest complication is blood loss 14

Why Is Myomectomy Not Preferred? Reputation as “bloody” operation Fibroid recurrence is possible risk Adhesion formation “Hysterectomy usually is a simpler procedure than multiple myomectomy, as well as the procedure to which most gynecologists are more accustomed” (Te Linde: Operative Gynecology, Seventh Edition) However, hysterectomy risks include: Ureteral injury (0.1 - 0.5%) Changes in libido (25-33%) and orgasm Depression Decreased time to ovarian failure 

Laparoscopic Myomectomy Limitations of laparoscopic myomectomy: Special Equipment & Special skill required Difficult in: Broad Ligament / Cervical/ deeply embedded Size >8cm Number >3 fibroids Separate incisions needed Closure of dead space & haemostasis difficult Weaker scar Increased Operating Time & Blood Loss Inherent Complications of Laparoscopic surgery

Laparoscopic myomectomy of intramural fibroid

Hysterectomy A hysterectomy is an operation to remove a woman's uterus. A woman may have a hysterectomy for different reasons, including: Uterine fibroids that cause pain, bleeding, or other problems Uterine prolapse, Cancer of the uterus, cervix, or ovaries Severe and intractable endometriosis and/or adenomyosis after pharmaceutical or other surgical options have been exhausted.    Abnormal vaginal bleeding that persists despite treatment Chronic pelvic pain, after pharmaceutical or other surgical options have been exhausted. Postpartum to remove either a severe case of placenta praevia or placenta percreta, as well as a last resort in case of excessive obstetrical haemorrhage

Types of hysterectomy: Hysterectomy, in the literal sense of the word, means merely removal of the uterus. However other organs such as ovaries, fallopian tubes and the cervix are very frequently removed as part of the surgery. Radical hysterectomy or Wertheim’s hysterectomy  : complete removal of the uterus, cervix, upper vagina, and parametrium. Indicated for cancer. Lymph nodes, ovaries and fallopian tubes are also usually removed in this situation. Total hysterectomy : Complete removal of the uterus and cervix. Subtotal hysterectomy : removal of the uterus, leaving the cervix in situ.

Despite speculation that there might be different sexual outcomes depending on whether hysterectomy was subtotal, or total abdominal, this difference has not been supported by recent studies It is obvious that supracervical hysterectomy does not eliminate the possibility of having cervical cancer since the cervix itself is left intact. Those who have undergone this procedure must still have regular Pap smears to check for cervical dysplasia or cancer

Approach: There are several approaches that can be used for hysterectomy: Abdominal hysterectomy Vaginal hysterectomy Laparoscopic-assisted vaginal hysterectomy: Using laparoscopic surgical tools, a surgeon removes the uterus through an incision in the vagina.  Robot-assisted laparoscopic hysterectomy: This procedure is similar to a laparoscopic hysterectomy, but the surgeon controls a sophisticated robotic system of surgical tools from outside the body. Advanced technology allows the surgeon to use natural wrist movements and view the hysterectomy on a three-dimensional screen.  

Vaginal hysterectomy: The main indication is second or third degree uterine prolapse. There is trend nowadays to prefer vaginal to abdominal hysterectomy because the morbidity &postoperative discomfort are less.

The contraindications: 1.Presence of genital tract malignancy 2.A uterus larger than 14 weeks in size 3.Narrow subpubic arch 4.Previous abdominal procedures where 5.bowel may be adherent to uterus or tubes 6.Uncertain ovarian pathology

The epithelium around the cervix is circumscribed ,the bladder freed &dissected upwards &the uterovesical peritoneal pouch is entered . The cervix is lifted forwards &peritoneum of the rectouterine pouch of Douglas identified & opened, the uterosacral ligaments are ligated. Next the uterine artery &cardinal ligaments are identified & ligated. Finally the ovarian pedicles are similarly identified & ligated. The uterus is removed & associated anterior or posterior vaginal wall prolapse are repaired &the vault closed.

Abdominal hysterectomy: The same pedicles as in vaginal hysterectomy are clamped but in reverse order i.e. ovarian followed by uterine, followed by cardinal ligaments.

Technique of abdominal hysterectomy: -patient is supine under GA. -skin incision: transverse lower abdominal incision. vertical incision.

The uterus is elevated & clamps placed across the broad ligament.

-the round ligament is clamped, incised and ligated . The round ligament is transected and the broad ligament is incised and opened.

-the peritoneum lateral to the infundibulopelvic ligament is incised exposing the ureter and the vesicouterine pouch is opened reflecting the bladder away from the uterus ,the ovarian ligament is clamped ,incised and ligated. The incision in the anterior broad ligament is extended along the vesicouterine fold.

Ligation of the utero–ovarian ligament

Dissection of the vesicouterine plane to mobilize the bladder.

Ligation of the uterine blood vessels. medioposterior leaf of the broad ligament is incised exposing the uterine artery. -The uterine artery is clamped and ligated at the level of the internal os. Ligation of the uterine blood vessels.

Incision of the rectouterine peritoneum and mobilization of the rectum from the posterior cervix.

Ligation of the cardinal ligament. -The cardinal ligament is clamped ,incised and ligated medial to the uterine artery and also the uterosacral ligament . Ligation of the cardinal ligament.

-the uterus with the cervix is removed by cutting across the vagina just below the cervix . Removal of the uterus by transection of the vagina.

the vaginal cuff is normally closed with absorbable sutures incorporating the uterosacral and the cardinal ligament to prevent development of vaginal vault prolapse . Vaginal cuff closure incorporating the uterosacral and cardinal ligaments.

complications Anaesthesia complications Primary haemorrhage due to slip ligature Secondary haemorrhage due to infection Damage to ureter ,bladder,or bowel Infection with pelvic abscess Late ;adhesion with intestinal obstruction.

-There is three points in the procedure presents particular risk to injure the ureter : As the infundibulopelvic ligament are clamped incised and clamped. As the uterine vessels are ligated. As the cardinal ligament is ligated if the bladder is not reflected inferiorly enough.

The course of the ureter and its relationship to the sites of greatest vulnerability.

Ovarian Cystectomy Enucleation of a cyst from the overy is frequently carried out for benign cyst in women below 40 years of age. The incision into the ovarian capsule must be made very carefully to prevent rupture of the cyst. Once the cyst is enucleated,the ovary is carefully recostructed with meticulous hemostasis to avoid ovarian hematoma. Ovarian cystectomy is performed in those benign conditions of the ovary in which a cyst can be removed and when it is desirable to leave a functional ovary in place. This is particularly true in women of reproductive age.

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