1. SUR 122
OBSTETRICAL
&
GYNECOLOGICAL
SURGERY

2. OB-GYN Surgery
Female
From beginning of menses

3. OB-GYN Specialists Obstetricians: pregnancy Gynecologists:
Breast Surgery (non-reconstructive)
Bladder Tac related Surgeries:
pubovaginal Sling, TVT (tension
vaginal tape, A & P Repair, etc.)
Can be both or one or the other
Fertility Specialists
Oncology Gynecologist
Pubovaginal sling and TVT are bladder suspension procedures for incontinence when bladder descends into vagina. Pubovaginal sling can be done thru abdomen or vagina. TVT done laparoscopically usually in conjunction with A & P Repair. TVT stands for tension free vaginal tape also use cystoscope to place for r/o of inadvertant urethral or bladder puncture.

4. Obstetrical & Gynecological Surgery
Reasons For:
Diagnose abnormalities
Treat abnormalities
Pain relief
Prevention of pregnancy
Aide in conception for infertile couples
Prevention of spontaneous abortion
Cesarian delivery (abdominal) when vaginal delivery not possible

5. The Female Reproductive System
Anatomy & Physiology
Pathology
Diagnostic & Pre-operative Testing
Anesthesia & Medications
Basic Supplies, Instrumentation, & Equipment
Positioning, Prep, & Draping
Dressings, Drains, & Post-operative Care

6. Pelvis
Pelvic girdle
Ilea
Ischia
Pubic bones
Vertebral column
Sacrum

7. Anatomy & Physiology External Female Genitalia (Vulva) Mons pubis
Labia majora
Labia minora
Urethral orifice
Vaginal orifice
Clitoris
Hymen
Perineum
Anus

8. External genitalia
Labia minora form the clitoris and contain sebaceous glands
Vestibule is the cavity between the labia minora
Contains urethral meatus and Bartholin’s (vestibular) glands
Perineum is the area between vaginal opening and anus
Can stretch with delivery however is frequently cut with an incision called episiotomy to prevent spontaneous tears during vaginal delivery

10. Internal Structures Vagina External Cervical Os Cervix Uterus
Layers of:
perimetrium
myometrium
endometrium
Parts of:
Body
Fundus
Adnexa
Fallopian Tubes
Ovaries
Supporting Structures

11. Vagina Receptacle to penis Passageway for menstrual flow
Lower portion is the birth canal

13. Uterus Function: Site of menstruation Or
Site of implantation if implantation occurs then is the site of fetal development

14. Uterus Parts of: Dome shaped portion=fundus Central portion=body
Where narrows=cervix
Internal cervical os=where uterus and cervix meet
External os=where cervix meets vagina

15. Uterus
Lining of:
Perimetrium=outside of uterus covered in a this serous membrane lining
Myometrium=
-smooth muscle lining
-middle layer
-fetal support
-during labor expels
fetus with assistance of
hormone oxytocin
3. Endometrium=inner lining 2 parts:
stratum basalis permanent layer thin
Stratum functionalis
-produced by s. basalis
-temporary layer
-shed w/menstruation
-produces maternal portion of placenta

16. Uterus
Blood supply:
Uterine artery and uterine vein

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

19. Ovaries Function: Production and expulsion of oocytes (ova or eggs)
Release of hormones: estrogen and progesterone
Are both endocrine and exocrine glands
Exocrine produce eggs (ducts=fallopian tubes)
Endocrine portion produces estrogen and progesterone

20. Ligaments Attachments: Broad ligament
-largest formed by a fold of peritoneum
Attached uterus, ovaries and fallopian tubes to the pelvis
-contains fallopian tube, blood vessels, lymphatics, nerves, suspensory (round) ligaments,
and ovarian ligaments

21. Ligaments 2. Cardinal ligament
Continuation (base of) of broad ligament
Considered most important “cardinal”
Provides uterine and apical vaginal support
Also called utero-sacral ligament

22. Ovaries 3. Suspensory (round) ligament -small peritoneal fold
-holds or “suspends” ovaries at upper end (laterally) anchoring it to pelvis
-contains blood vessels and nerves
4. Ovarian ligament
-anchors ovaries at their lower end medially to the uterus
-is actually a thickening in the broad ligament

24. Fallopian tubes
Egg is caught by finger-like projections called the fimbrae after it is released from the ovary
Funnel shaped end prior to fimbrae=infundibulum

25. Fallopian tubes 2 layers: 1.Mucous membrane innermost
Is lined with ciliated columnar epithelial tissue
Allows for movement of the egg
Scarring from STDs can damage or scar this lining rendering a female sterile

26. Fallopian tubes 2. Muscularis Smooth muscle
Peristalsis or movement of the egg
So…
Egg movement through the fallopian tubes occurs by cilia and peristalsis
Fertilization must occur in the distal 1/3 of the fallopian tubes for successful implantation into the uterus

27. Physiology
Ovarian cycle caused by anterior pituitary gland which secretes:
LH “ovulation hormone”
FSH levels must be low to allow ovulation
Causes secretion of estrogen
Menses is caused by a sudden decrease in estrogen and progesterone triggered by no fertilization
Luteinizing hormone and follicle stimulating hormone. Corpus luteum produces some estrogens, but primarily progesterone

28. Hormones LH Produced in anterior lobe pituitary gland
Ovulation hormone
Continues follicular development
Stimulates estrogen and progesterone production
Regulates ovulation and menstrual cycle (works with FSH to do this)

29. Hormones 1. FSH Produced in anterior lobe pituitary gland
Causes graafian follicular development
Causes estrogen secretion
Helps LH control ovulation and menstrual cycle

30. Hormones
Estrogen
Maintenance and development of reproductive organs and female sex characteristics

31. Hormones Progesterone
Primary cause of endometrial changes & maintenance for pregnancy
Hormone of pregnancy
With Prolactin (hormone) influences mammary glands to develop and secrete milk
Milk secretion and labor is stimulated by oxytocin (hormone)

32. Physiology
In the ovary > the big 4 hormones are increasing which develops a follicle
Follicle becomes a graafian follicle
Graafian follicle rupture>egg released into fallopian tubes
Outer rind of graafian follicle becomes corpus luteum

33. Physiology 2 possibilities:
No fertilization=corpus luteum degenerates and becomes corpus albicans and cycle starts over
Fertilization=corpus luteum maintained four months to suppress egg production and menstruation with estrogen and progesterone
Progesterone levels must be high enough to maintain endometrial lining to sustain pregnancy
Corpus luteum acts as a temporary endocrine gland
After four months placenta is developed and takes over

34. Obstetrics

35. Pregnancy (Obstetrics) Procedures
Cerlage (MacDonald or Shirodkar)
Deliveries:
Vaginal
Cesarian sections (C-sections)
Tubal ligations (sterilization procedures)
Emergent hysterectomy
Cerclage-suture removed prior to delivery.

36. Pregnancy Terminology
Labor
Four stages of:
True labor onset
Cervical dilation complete>birth
Birth>placental delivery
Placental delivery > stabilization of mother
Primapara
6-18 hours
½ - 3 hours (dilation 1 cm/hr)
0-30 min
6 hours
Multipara
2-10 hours
5-30 min (dilation 1.2cm/hr)
0-30 min
6 hours
True labor is NOT Braxton Hicks contractions. Varies depending on whether mother primapara or multipara.

37. Pregnancy Terminology
Braxton Hicks - “false labor”
Bloody show – onset of labor
Cervical dilation - cervical measurement (0 to 8cm)
Goes to 10cm, but at 10cm, your baby is through the cervix!
Cervical Effacement – thinning of cervix
Crowning - neonate head circumference at its largest point as it passes thru vulvar ring

38. Pregnancy Terminology
Descent – movement of fetus thru pelvis with contractions
Expulsion – delivery of infant
Gravida - how many times a woman has been pregnant
Parity – number of times a woman has given birth
Position – relationship between presenting infant part & pelvis of mother
Presentation – fetal part overlying pelvic inlet
Station – measurement of the descent of the infant’s presenting part thru the ischial spines
Parity twins indicate monparity. Nulliparus = no births. OA occiput anterior. Presentation should be head, may be breech (buttocks) or compound (more than one part)

39. Presentation Breech - buttocks first Transverse – crosswise
Footling – feet
Vertex – upper back of head

40. More Terms Dystocia- Difficult labor Meconium-neonatal stool
DeeLee suction catheter-used to suction amniotic fluid tainted with meconium to prevent meconium aspiration syndrome

41. Gravita and Parity Clarification
Gravida-times pregnant
Parity-number of times given birth
Nulliparous-not given birth regardless of gravita
Primagravida-first pregnancy
Twins/Multiples count as G-1 P-1
May hear GTPAL
G-gravity, T-term pregnancy, P-preterm pregnancy, A-abortion/miscarriage, L-live births

42. Obstetrical Complications
Placenta previa – placental implantation over cervix
Abruptio Placenta – premature placental separation

44. NORMAL PLACENTA
ABRUPTIO PLACENTA

45. Obstetrical Complications
Abortions
Missed
Incomplete
Imminent
Spontaneous
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.

46. Pathology Malignant Vulvar Vaginal Benign Cervical Cysts Uterine
Ovarian
Other
Endometriosis
Adenomyosis
Cystocele
Rectocele (posterior colporrhaphy)
Enterocele
Ectopic Pregnancy
Incompetent Cervix (cerclage)
PID (Pelvic Inflammatory Disease)-1° cause STDs
Benign
Cysts
Polyps (pedunculated lesion)
Fistulas
Dysplasia
Leiomyoma/Myoma/Fibroid
Fibroma
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 tumor; Fibroma=connective tissue tumor; Dysplasia=abnormal tissue growth; endometriosis uterine tissue growth outside of uterus: adenomyosis is myometrial endometriosis-thickening of myometrium due to abnormal uterine myometrial growth

47. Vesico refers to the bladder
Vesico refers to the bladder. Vesico-vaginal fistula is between the vagina and the bladder Vesico-uterine pouch is between top of bladder and bottom of uterus/peninsula like area Are plnes/spaces. See pg. 481 Caruthers

48. Gynecological Procedures
Colposcopy
Hysteroscopy
D & C
D & E
Laparoscopy
Hysterectomy Oophorectomy Salpingectomy
Abdominal Hysterectomy
subtotal
total
radical (Wertheim)
Vaginal
LAVH
A & P Repair
Le Fort
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).

49. Patient symptoms: Abnormal bleeding Abdominal pain
Absence of menses (amenorrhea)
Excessive menses (menorrhagia)
Painful menses (dysmenorrhea)
Painful intercourse (dysparunia)
Painful defication (dyschezia)
Abnormal bleeding is the most common symptom of uterine cancer
Dysmenorrhea, dysparunia, dyschezia most common SX of endometriosis

50. Pre-Operative & Testing Diagnostic
Physical exam
UA, CBC, Blood Chemistry
Pelvic exam
Bi-manual exam
Colposcopy
PAP (papanicolaou smear)
Schiller Test
Biopsy
Ultrasound
MRI
X-ray
Laparoscopy
D & C

51. Anesthesia
General
Spinal
MAC with IV Sedation

52. Medications Hormones: Pitocin/Synostocin/Oxytocin
Stimulate uterine contraction to induce labor
Post-delivery of baby and placental contents to induce uterine contraction allowing for expulsion of excess tissue and clots
Post-delivery to prevent bleeding/hemorrhage
Oxytocin is a hormone that normally functions to induce labor normally/body not producing enough may need synthetic supplement

53. Medications Carboprost (Hemabate)
Induce abortion at weeks gestation
Prevent uterine hemorrhage post-delivery or abortion when nothing else is working

54. Medications Diagnostic Agents: 1. Lugol’s solution Iodine based
Identification of abnormal vaginal and or cervical tissue
Tissue that is abnormal will not stain
Tissue that is normal will stain brown
Schiller’s Test
Think what happens with betadine hand scrub, your skin is normal tissue so the betadine stains it with its iodine component.

55. Medications 2. 3% Acetic Acid
Facilitates cervical visualization by removing cervical mucous for a colposcopy
Used with CO2 cervical laser surgery (cone bx.)
Can replace Lugol’s if iodine allergy
Causes abnormal tissue to appear “whiter” than surrounding tissue
3. Methylene blue
Dye
Diluted with NS
Direct > Checks for tubal patency (chromotubation)
IV > excreted by the kidneys into the urine rules out ureteral injury as abdominal procedure concludes
Colposcopy visualization/biopsy of vaginal vault and cervix

56. Medications Antimicrobials Prophylactic IV
ung (ointment) utilized with vaginal packing materials
Erythromycin ung in neonates eyes prevent conjunctivitis

57. Medications Chemical Hemostatics: Monsel’s solution
Applied to bleeding surface after cervical cone biopsy
MUST NOT confuse with Lugol’s!
Bottles are similar
If you use Monsel’s prior to Lugol’s by accident, the area of cervical dysplasia will be damaged by cauterization effects

58. Medications 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)
Hyskon is very viscous and requires soaking to prevent drying of this on the instruments
No cautery or lasers may be used as would cause systemic absorption>systemic side effects

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

60. 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

61. 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

62. 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

63. Positioning Lithotomy Supine Trendelenburg
OR table with foot-drop capacity
Stirrups (candy cane, Allen, or Yellow Fins)
Armboards
Pillow/Headrest

64. Prep Likely do abdomen first if combined with vaginal approach
Care to not allow pooling of prep solution in vagina especially if laser to be used

65. Draping
Impervious buttock drape (may have a port to attach to suction or just a “fluid-catch” bag
Leggings
Perineal drape with fenestration
Laparotomy sheet
Combination perineal/laparotomy drape

66. Dressings Vaginal packing May be soaked in an antimicrobial solution
May be pre-medicated packing (Iodophor)
Perineal Pad
Abdominal dressing surgeon choice
Steri-strips, bandaids, telfa, xeroform, 4x4s, ABD pad, primapore, tape (misc.)

67. Drains
Penrose
Closed Wound Drains:
Jackson-Pratt
Hemovac

68. Post-operative Care
Foley Catheter (placed pre-operatively by circulator or surgeon)
Anti-embolic stockings
Ted Hose
Get OOB early to ambulate
Performed in: physician offices, out-patient centers (ASC), hospital ORs
May be discharged same day or have one- three day hospitalization depending on procedure
Focus on prevention of DVT/blood clots due to lithotomy slows circulation in lower extremities

69. Post-Operative Complications
Infection
Nicking ureters, bladder, or urethra
Hemorrhage (major blood vessel proximity)
Adhesions
Sciatic nerve damage due to spinal or epidural placement
Blood clot (thrombosis)
DVT
PE (pulmonary embolus)

70. Summary Anatomy & Physiology Pathology
Diagnostic & Pre-operative Testing
Anesthesia & Medications
Basic Supplies, Instrumentation, & Equipment
Positioning, Prep, & Draping
Dressings, Drains, & Post-operative Care