Gynecologists focus on the female reproductive system…….. GYNECOLOGIC SURGERY Gynecologists focus on the female reproductive system……..

ANATOMY INTERNAL FEMALE ORGANS: VAGINA UTERUS CERVIX FALLOPIAN TUBES OVARIES **Situated in the “lesser pelvis” These organs are protected by the bones of “bony pelvis” and supported by the muscularity of the pelvic floor.

SUPPORT STRUCTURES OF THE FEMALE PELVIS

“Pelvic Girdle” Consists of: Iliac crest Ischia pubic bones sacrum

Pelvic Sagittal Plane

Pelvic “Floor” Consists of: Levator ani muscles and its 3 components Iliococcygeal Pubococcygeal Puborectalis

PELVIS Two distinct cavities : “false pelvis” “true pelvis”

“FALSE PELVIS” Little significance to gynecology and obstetrics Prominent attachment for pelvic musculature. Varies widely is size

“True Pelvis” Inlets = round Outlets = transversely oval- aids in the process of fetal delivery.

Pelvic Ligaments Cardinal Round Infundibulopelvic Loose configurations of : Areolar tissue Blood vessels Muscle fibers

“MOORINGS” (Anchors) Connective tissue are not static, they change with age, nutritional status, amount of exercise and hormonal fluctuations……

EXTERNAL GENITALIA “VULVA” No NOT a Volvo!!! Mons Pubis Labia Majora Labia Minora Clitoris Bartholins Glands Fourchette Perineum

“EXTERNAL GENITALIA” CONTINUED… External genitalia are vascularized and innervated by the clitoral, perineal and inferior hemorrhoidal branches of the pudendal artery and nerve.

“VESTIBULE” Cavity between the labia minora Contains the urethral meatus Inferior to the clitoris as well as the orifices of the vestibular glands (Bartholins glands)

“PERINEUM” Area between the inferior vaginal opening and anus Sensitive Branches of the pudendal nerve; 2nd , 3rd and 4th sacral portions of the spinal canal.

“VAGINA” Fibromuscular tube Increase in diameter in its internal projection Widest at its deepest region Acidic environment Ascends posterosuperiorly Bladder and urethra anteriorly; annular recess created by the cervical vaginal junction called the fornix Rectum and anal canal posteriorly Rich vascular supply derived from vaginal, uterine, internal pudendal and middle rectal branches of the internal iliac arteries

ANATOMICAL PELVIC PLANES----CROSS SECTION, SAGITTAL

“UTERUS” Hollow, thick walled and pear-shaped Between bladder and rectum Uterine appendages: (adnexa) - Fallopian tubes - Ovaries Superior 2/3 (corpus uteri) or body which narrows to a cylindrical lower section called uterine (cervix) Internal OS - At the junction between corpus uteri External OS - Where the cervix opens into the vagina Lined with endometrium Ligaments that extend to the pelvic walls suspend the uterus

“LIGAMENTS” LATERALLY = BROAD ANTERIORLY = CARDINAL POSTERIORLY = PUBIC INFERIORLY = SACRAL

Uterine and Uterine Appendages

“BROAD LIGAMENT Result of peritoneal folds Contains fallopian tubes

“ROUND LIGAMENT” Consists of ovarian ligaments Various blood vessels Nerves and lymphatics The round ligament passes through the inguinal ring to the skin and connective tissue of the labia majora. Arterial supply: is derived from the uterine branch of the paired internal iliac arteries

“FALLOPIAN TUBES” (uterine tubes) 4 PORTIONS: Fimbria Ampulla Isthmus Intramural region: Situated in the upper margin of the broad ligament Vascularity achieved by the ovarian and uterine arteries

“OVARIES” Paired, almond-shaped Lie on either side of uterus Production and expulsion of oocytes (eggs) Release of hormones (estrogen, and progesterone) Ovarian cycle stimulated by the release of LH & FSH from putuitary gland Supported at either end by suspensory ligament (suspensory) Ovarian ligament, lying in broad ligament, support the bulk of the ovaries Ovarian arteries, branching from the aorta

COMMON SURGICAL PROCEDURES Laparoscopy Hysterectomy with or without BSO -Vaginal -Abdominal D & C D & E A&P repair C-section

GENERAL OBSTETRIC AND GYNECOLOGICAL INSTRUMENTS Heaney needle holders Jorgenson scissors Episiotomy scissors (bandage scissors) Heaney-Ballantine clamps Tissue forceps with teeth OPERATING ROOM SET-UP, PT POSITIONING AND DRAPING Standard OR table -foot drop capabilities -sockets/brackets for leg holders -candy cane stirrups -Allen stirrups Lithotomy (most common) Mayostand-abdominal approach Backtable –vaginal approach Suction devices Kick buckets ESU Sterile handpieces Draping Under buttocks Leggings 4 towels and a lap sheet

Positioning and Draping? Equipment? Mayostand vs. Backtable Special Considerations Drugs – Oxytocin (pitocin, synotocin) used to induce labor. Carboprost (Hemabate) – oxytocic drug available in parenteral form, used to cause abortion; contracting uterus. Positioning and Draping? Equipment? Mayostand vs. Backtable Suction Devices, ESU

Cervical and intrauterine instrumentation Goodell uterine dialator Bozeman (many uses) uterine dressing forceps Uterine sound Uterine tenaculum Hegar uterine dialators Uterine curettes Abdominal and perineal retractors Deaver 2” blade Deaver 1” blade Dee Lee universal retractor Gelpi perineal ret. O’sullivan O’Connor abdominal ret Franz abdominal ret

Hegar Uterine Dialators

Bozeman Uterine Dressing Forceps Sims Uterine curettes Bozeman Uterine Dressing Forceps

Abdominal Perineal Retractors Franz Abdominal Retractor DeLee Universal Retractor