Introduction to GYN Surgeries

Outline Female Anatomy Pathology Miscellaneous Procedure Overview Instrumentation Review Laparoscopy (diagnostic or operative) Hysteroscopy D & C (dilation & curettage) D & E (dilation & evacuation) Suction Curettage

FEMALE ANATOMY Fallopian tubes are open to the abdomen=problem with venereal disease/can wreak havoc

Pathology Benign Malignant Other Vulvar Vaginal Cervical Uterine Ovarian Other Endometriosis - the presence and growth of functioning endometrial tissue in places other than the uterus that often results in severe pain Cystocele - herniation of bladder into vagina Rectocele (posterior colporrhaphy) - herniation of rectum into vagina Enterocele - herniation of cul-de-sac of Douglas/includes loops of intestines into vagina Ectopic Pregnancy - The implantation and subsequent development of a fertilized egg outside the uterus Incompetent Cervix (cerclage) - Benign Cysts Polyps (pedunculated lesion) Fistulas Dysplasia= abnormal tissue growth Leiomyoma/Myoma/Fibroid - smooth muscle tumor Fibroma - connective tissue tumor Cystocele= herniation of bladder into vagina, Rectocele= herniation of rectum into vagina; Enterocele=herniation of cul-de-sac of Douglas/includes loops of intestines into vagina; myoma=smooth muscle; Dysplasia=abnormal tissue growth

(PID) Pelvic inflammatory disease (PID) is a general term that refers to infection of the uterus (womb), fallopian tubes (tubes that carry eggs from the ovaries to the uterus) and other reproductive organs. It is a common and serious complication of some sexually transmitted diseases (STDs), especially Chlamydia and Gonorrhea. PID can damage the fallopian tubes and tissues in and near the uterus and ovaries. PID can lead to serious consequences including infertility, ectopic pregnancy (a pregnancy in the fallopian tube or elsewhere outside of the womb), abscess formation, and chronic pelvic pain.

Endometriosis

Ectopic Pregnancy

Pedunculated Myoma

Prolapsed Uterus

Rectocele

Gynecological Procedures Colposcopy Hysteroscopy D & C D & E Laparoscopy Hysterectomy Oophorectomy Salpingectomy Abdominal Hysterectomy subtotal total radical (Wertheim) Vaginal LAVH A & P Repair - repair-reconstruction vagina, pelvic floor, muscles, fascia, of rectum, urethra, bladder, perineum to cystocele and rectocele to restore bladder and rectum to normal position Bartholin’s Cyst (I & D) Colposcopy viewing cervix/biopsies. A & P repair-reconstruction vagina, pelvic floor, muascles, fascia, of rectum, urethra, bladder, perimneum to cystocele and rectocele to restore bladder and rectum to normal position. Le Fort corrects uterine prolapse (elderly).

Bartholin Gland Cyst

Instruments Major Tray Abdominal-Hysterectomy Tray D&C Tray Hysteroscopy Tray resectoscope & hysteroscope Laparoscopic Tray Camera/scope tray/scope warmer

Specific Vaginal Instruments Auvard weighted speculum Graves speculum Sims vaginal speculum (single or double ended) Delivery forceps Goodell uterine dilator Sims uterine sound Bozeman uterine dressing forcep Hegar uterine dilators Heaney uterine dilators Emmett uterine tenaculum Sims uterine curettes (blunt/sharp) pp. 488-493

Specific Abdominal Hysterectomy Instruments Abdominal retractor tray richardsons, deavers, malleables, Balfour w/bladder blade O’Sullivan-O’Connor abdominal Retractor Franz Abdominal Retractor Heaney Hysterectomy Forceps Heaney-Ballentine Hysterectomy Forceps Heaney Needleholder Jorgenson Curved Scissors Lister Bandage Scissors Pennington Forceps

Specific Laparoscopy Instruments Scope, Light cord (scope tray) Camera (camera sleeve if not sterile) Insufflation tubing (silastic tubing) Verres Needle (insufflation needle) Intrauterine cannula (chromotubation) Uterine manipulator Trocar Sleeves, Trocars Accessory Instruments: cautery adapted, graspers, scissors, loop applicators, suturing devices, resectoscopes Scope warmer Multi-fire laparoscopic staplers

Laparoscopy Definition-Visualization of the peritoneal cavity through the anterior abdominal wall (For optimal visualization must have pneumoperitoneum) Procedures-Diagnosis, Evaluation, Intervention Laser and Electrosurgery may be used

Laparoscopy Continued Instruments: Verres Needle Silastic Tubing with connector Trocar and Sleeve x 2 Laparoscope Laparoscopic scissors Light Cord Laparoscopic graspers Camera Bipolar forceps (Kleppinger) Biopsy forceps Ball and Loop Electrodes

Laparoscopy Procedure Small incision at umbilicus Abdominal tissue elevated with a towel clip or pinched up and a Veres needle is inserted into the peritoneal cavity, attach a 10ml syringe to it with about 3ml of NS (The surgeon uses it to determine whether he is clear of vessels or bowel) Silastic tubing is attached (you have thrown off one end to hook up to the insufflator) The peritoneum is filled with carbon dioxide or nitrous oxide gas (separates organs for optimal visibility) Any time that insufflation or fluids are involved you need to be aware of mediums, maximum volumes, settings, flow rate and outflow rate

Laparoscopic Procedure Continued Veres needle withdrawn and operating laparoscope inserted (accomodates Kleppinger or scissors) Trocars inserted (sleeve may or may not be used) Ports established to accommodate camera in one (umbilical incision) and other instruments needed in the other (May reattach silastic tubing to one of the trocar sleeves and not use a veres needle) Procedure done (May involve two more trochars, one in LLQ and one in RLQ) One trochar may accommodate LR irrigation/suction apparatus/Other may accommodate graspers Items removed, sleeve may be left to allow gas to escape or may be sucked out with suction

Laparoscopic Procedure Continued Skin is closed with a 3-0 Vicryl PS-2 cutting (May use a 3-0 SH Vicryl taper prior to skin closure depending on abdominal thickness Steri-strips may be used and Bandaids are applied to the incision sites A peri-pad is placed for the patient Keep in mind that depending on the procedure performed, there may be laser, cautery, other suture, a knot pusher for tying, endoscopic staplers, etc. needed

Hysteroscopy Definition-Endoscopic visualization of the uterine cavity and openings or orifices to the fallopian tubes Introduced vaginally Used for diagnosis and intervention Diagnosis/Intervention: abnormal bleeding, endometriosis, IUD removal, infertility evaluation, polyps, sterilization, and adhesions Laser/electrosurgery may be used Biopsy forceps, scissors, etc. may be used

Hysteroscopy Procedure Graves Speculum (other speculum) Lubrication available (NS or K-Y) Anterior edge of cervix is grasped with a tenaculum and pulled forward Depth of cavity may be measured with a uterine sound or modified grasper with sound Cervix may be dilated with Pratt, Hanks, or Hegar dilators Scope/irrigator is inserted (uterus is distended with Sorbitol, NS, Dextran (Hyskon), or Dextose solution) Uterine cavity is explored

Hysteroscopy Procedure Continued Depending on findings or procedure, may use biopsy forceps, cautery, scissors, resectoscope with roller ball, laser, or tubal occlusive devices. Biopsies will need to be collected on a piece of telfa If Hyskon/Dextran is used clean instruments immediately as it will harden and make instruments difficult to clean

Hysteroscopy Irrigation Hysteroscopy solutions (for uterine distention) Dextrose 5% (D5W) Dextran 70% in dextrose Glycine Sorbitol Above may all be used with laser or cautery Hyskon (rarely used anymore due to ↑ laser use) No cautery or lasers may be used as would cause systemic absorption>systemic side effects

Obstetrical Complications Abortions Missed - parts of non-living conception and in uterus more than 2 months Incomplete - products of conception retained in uterus Imminent - about to abort Spontaneous - abortion occurs without being induced Voluntary Missed-conception parts of non-living and in uterus more than 2 months. Incomplete-products of conception retained in uterus. Imminent- about to abort. Spontaneous- abortion occurs without being induced.

D & C Definition- dilation and curettage Use diagnostic and therapeutic Diagnostic: dysmenorrhea, endometriosis, rule out pregnacy before sterilization, infertility Therapeutic: polyps, evaculate retained placenta post-child birth, IUD retrieval, placement of radioactive devices for treatment of cancers, incomplete miscarriage/abortion

D&C Procedure Speculum (Graves, other) Local anesthesia may be injected if the patient is awake Cervix is grasped with tenaculum and dilated with Pratt, Hanks, or Hegar dilators Uterine sound may be used to determine depth of the uterine cavity Smooth, sharp, or Heany uterine curettes will be used to clean out the uterine cavity Suction may be used in conjuction or solo Tissue may be sent for culture place it on a piece of telfa Peri-pad placed

D&E Definition- D & C performed after the thirteenth week of pregnancy Procedure the same as a D & C

Suction Curettage Definition-Suction/vacuum aspiration of the uterus Used in therapeutic abortions, incomplete abortions, or miscarriages Procedure: Speculum, tenaculum, dilators, suction apparatus, curettes may be needed, peri-pad placed

Summary Female Anatomy Pathology Miscellaneous Procedure Overview Instrumentation Review Laparoscopy (diagnostic or operative) Hysteroscopy D & C (dilation & curettage) D & E (dilation & evacuation) Suction Curettage