Dilatation and curettage b Dilatation and curettage (D & C) is a gynecological procedure in which the cervix is dilated and the lining of the uterus (endometrium) is scraped away. b Is one of the most common gynecological procedure.

Indication: A D&C may be either diagnostic or therapeutic (used to either diagnose or treat a uterine condition). Diagnostic: sample of endometrium is taken and sent for histopathological examintion. This is usually indicated in case of abnormal uterine bleeding. Possible reasons for abnormal uterine bleeding include: b b Hormonal imbalance. b b Uterine cancer b b Uterine polyps b b Endometrial hyperplasia

b Therapeutic: b molar pregnancy b Treat excessive bleeding after delivery by clearing out any placenta that remains in the uterus b Clear out any tissue that remains in the uterus after a miscarriage or abortion — to prevent infection or heavy bleeding b Remove cervical or uterine polyps, which are usually benign

Technique of D&C: b D & C is usually performed under general anesthesia, although local (paracervical block) or epidural anesthesia can also be used. b Patient in dorsal lithotomy position. b Pelvic examination for pelvic organs after sterilization. b speculum in the posterior vagina. b The cervix is grasped with single or double toothed tenaculum. b Determination of the endometrial cavity with the uterine sound. sound. b Dilatation of the cervix with graduated dilators. b Thorough curettage is done with a sharp curette.

Dilatation & curretage

For a D & C, the patient lies on her back, and a weighted retractor is placed in the vagina (A). A dilator (a series of tapering rods, each thicker than the previous one is used) to open the cervix (B), and a curette (a spoon- shaped instrument) is used to scrape the inside of the uterus (C).

Fractional curettage : b is curettage of the endocervix before the dilatation of the cervix and before curettage of the endometrial cavity, it’s important especially in postmenopausal women.it’s important to diagnose if endometrial ca has been extending to the cervix or not. dilatation of the cervix and before curettage of the endometrial cavity, it’s important especially in postmenopausal women.it’s important to diagnose if endometrial ca has been extending to the cervix or not.

Aftercare b A woman who has had a D & C performed in a hospital can usually go home the same day or the next day.  Many women experience backache and mild cramps after the procedure,  May pass small blood clots for a day or so. Vaginal staining or bleeding may continue for several weeks. b Most women can resume normal activities almost immediately. Patients should avoid sexual intercourse, douching, and tampon use for at least two weeks to prevent infection while the cervix is closing and to allow the endometrium to heal completely.

Risks b Bleeding b The primary risk after the procedure is infection. If a woman experiences any of the following symptoms, she should report them immediately to her doctor:  fever  heavy bleeding  severe cramps  foul-smelling vaginal discharge

b Rare complications include perforation of the uterus (which usually heals on its own) or causing injury to the bowel or bladder (which requires further surgery to repair). Perforation of the uterus is more likely to occur if : -The position of the uterus is not observed on bimanual examination under anasthesia. -The position of the uterus is not observed on bimanual examination under anasthesia. -There is infection. -There is infection. -There is pregnancy. -There is pregnancy. -There is cervical stenosis. -There is cervical stenosis. -There is intrauterine malignancies. -There is intrauterine malignancies. -There is postmenopausal atrophy. -There is postmenopausal atrophy.

 Extensive scarring of the uterus may occur after over-aggressive scraping during D & C, leading to a condition called Asherman's syndrome. The major symptoms of Asherman's syndrome are light or absent menstrual periods, infertility, and recurrent miscarriages. Scar tissue can be removed with surgery in most women, although approximately 20–30% of women will remain infertile after treatment. b D & C is a surgical operation that has certain risks associated with general anesthesia such as pulmonary aspiration.

Hysteroscopy b b Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows an endoscopic view of the endometrial cavity and tubal ostia for both the diagnosis and operative treatment of intrauterine pathology. b b During the last two decades, the role of hysteroscopy in modern gynecology has expanded rapidly with development of more effective hysteroscopic instruments and smaller endoscopes.

b b A hysteroscope is an endoscope that carries optical and light channels or fibers. It is introduced in a sheath that provides an inflow and outflow channel for insufflation of the uterine cavity. In addition, an operative channel may be present to introduce scissors, graspers or biopsy instruments.

5 mm telescope Obturator 6 mm Sheath for Diagnostic hysteroscopy Sheath for Operating Hysteroscopy Instruments required for Diagnostic Hysteroscopy

INSTRUMENTS b b Hysteroscopy requires a hysteroscope, light source, uterine distention medium, and in many cases a video camera system.

Distension media: b CO2 gas b Normal saline/ ringer lactate b Glycine The choice is dependent on the procedure, the patient’s condition, and the physician's preference. Fluids can be used for both diagnostic and operative procedures. However, CO2 gas does not allow the clearing of blood and endometrial debris during the procedure, which could make the imaging visualization difficult. If intrauterine electrosurgery is to be performed using monopolar equipment, the solution must be non- conductive so that electrical current is not dissipated.

Indication: Hysteroscopy is useful in a number of uterine conditions: b Gynecologic bleeding: b Gynecologic bleeding: Any abnormal uterine bleeding from the uterus can be investigated by hysteroscopy, including: Postmenopausal bleeding Irregular menstruation, intermenstrual bleeding, postcoital bleeding Persistent menorrhagia

b b Endometrial ablation b Asherman’s syndrome(i.e. intrauterine adhesions). Hysteroscopic adhesiolysis is the technique of lysing adhesions in the uterus using either microscissors (recommended) or thermal energy modalities. b. Polypectomy. b Endometrial polyp. Polypectomy. b for uterine fibroids b Myomectomy for uterine fibroids b Eg.septum b Congenital Uterine malformations Eg.septum b b Removal of embedded IUDs b b for those seeking sterilization, tubal occlusion devices can serve as an effective and safe method of contraception.

1 2 Picture No-1 of hysterosalpingography, shows a septate uterus. Picture No-2 shows the same septum at Hysteroscopy. Some times diagnostic hysteroscopy has to be converted in to operative hysteroscopy, in the same sitting

1 2 Picture No-1 shows tubal osteam from a distance. Uterine cavity looks quite red and healthy. Picture No-2 shows tubal osteam at a closer view. It looks normal.

Complications: It is most important to insure prevention of complications and their recognition, and their management, if they occur. Complication may occur due to 1.Instrumental procedure 2.Distension media. 3.Inadequate visualization 4.Anesthetic agent

Common complications include b b Uterine perforation: can be associated with damage to the bowel or intraperitoneal haemorrhage. b b Fluid absorption: fluid may be absorbed at the time of hysteroscopy. If excessive, it can result in hyponatraemia and hypo- osmolality, clinically characterized by nausea, vomiting, seizure, coma and even death. The amount of fluid absorbed is dependent on the volume infused and the infusion pressure. Accurate measurement of fluid defecit is needed throughout the procedure.

Contra indications of Hysteroscopy b b Acute and chronic upper genital tract infection. b b Recent uterine perforation. b b Pregnancy.

Laparoscopy: b Laparoscopic surgery, also called minimally invasive surgery (MIS), is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5– 1.5 cm) as opposed to the larger incisions needed in laparotomy. minimally invasive minimally invasive

Indication for laparoscopy in gynaecology : diagnostic and therapeutic indications: b Tubal sterilization. b Ectopic pregnancy. b Infertility. b Pelvic pain. b Endometriosis. b Myomectomy. b Urogynacologic procedures. b Hysterectomy (LAVH).

The patient is anaesthetized & placed in trendelenberg position. A small cut is made just below umbilicus & a Verres’ needle is introduced into the peritoneal cavity which is inflated with 2-3 litres of carbon dioxide. Simultaneous intra-abdominal pressure is recorded. A trocar for the telescope is then inserted & the laparoscope is introduced.

A second instrument, through another small channel may be necessary to help inspect the abdominal & pelvic contents & to allow cutting, diathermy or ligation. At the end of the procedure most of carbon dioxide is expelled by abdominal pressure & the patient can usually return home later that day.

Insufflation needle. When pressed against tissue such as fascia or peritoneum, the spring-loaded blunt obturator (inset) is pushed back into the hollow needle, revealing its sharpened end. When the needle enters the peritoneal cavity, the obturator springs back into position, protecting the intraabdominal contents from injury. The handle of the hollow needle allows the attachment of a syringe or tubing for insufflation of the distention gas.

b b Laparoscopic Tower. This tower comprises a monitor (A), a camera body or base unit (B) attached to a camera sensor; a light source (C) attached to a cable, which in turn will be connected with the endoscope; a still- image printer (D) and an insufflation machine (E). A video recorder is shown in (F).

Complications:  Insertion of Verres’ needle outside the peritoneal cavity leading to surgical emphysema  Injury to bowel  Injury to blood vessels  Injury to bladder or ureter  Complications of anaesthesia (Anesthetic complication are increased with pneumoperitoneum).

Advantages There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include: b Reduced hemorrhage, which reduces the chance of needing a blood transfusion. b Smaller incision, which reduces pain and shortens recovery time, as well as resulting in less post-operative scarring. b Less pain, leading to less pain medication needed. b Although procedure times are usually slightly longer, hospital stay is less, and often with a same day discharge which leads to a faster return to everyday living. b Reduced exposure of internal organs to possible external contaminants thereby reduced risk of acquiring infections.