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Obstetrics/Gynecological
Surgery
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Objectives review anatomy/physiology female reproductive system
identify pathological conditions differentiate between gynecological diagnostic procedures describe basic surgical interventions colposcopy describe intermediate surgical interventions cervical cone biopsy LEEP
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describe basic surgical interventions
dilation and curettage hysteroscopy describe intermediate surgical interventions endometrial ablation Novasure balloon therapy diagnostic laparoscopy laparoscopic tubal ligation laparoscopy with oophorectomy
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describe advanced surgical interventions
microsurgical tubal anastomosis describe basic surgical interventions vaginal hysterectomy abdominal hysterectomy describe intermediate surgical interventions laparoscopic assisted vaginal hysterectomy robotic assisted vaginal hysterectomy myomectomy radial hysterectomy Wertheim procedure total pelvic exenteration
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describe basic surgical interventions
anterior and posterior repair ablation of condylomata marsupialization of Bartholin’s gland labioplasty vulvectomy review stages of labor identify complications of pregnancy sequence for vaginal deliveries cesarean section
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describe intermediate surgical intervention
ectopic pregnancy describe basic surgical intervention cerclage Shirodkar’s procedure elective termination of pregnancies describe advanced surgical intervention uterine radiation seeding procedures Cesium assisted reproductive therapies IVF GIFT
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Layers of the Uterus endometrium inner layer sloughed off myometrium
muscular layer contracts during labor perimetrium outer layer Layers of the Uterus
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perimetrium abdominal peritoneum bladder forms a pouch cul-de-sac bladder flap
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cervix extends into vaginal vault opening cervical os external internal
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Uterine Ligaments broad ligaments ovarian ligaments round ligaments
cardinal ligaments below broad uterosacral ligaments
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fallopian tubes interstitial section connect to body uterus isthmus middle ampulla widened portion infundibulum terminal end fimbriae
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ovary supsended by mesovarium ovarian ligaments
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vagina recessed areas around cervix fornices
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vulva perineum Barthlin’s gland External Genatalia
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follicular phase day 1 to day 14 FSH/LH rise secretes estrogen ova begin to develop ovulatory phase day 14 16 to 32 hours estrogen drops secretes progresterone release of ovum luteal phase
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luteal phase day 16 lasts 12 days corpus luteum secretes estrogen progesterone triggers changes endometrium implantation menustration
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Pathology of the Female
gynecological cancers endometrial cancer associated with obesity high levels of estrogen Pathology of the Female Reproductive System
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cervical cancer most common easily treated early stage dysplasia progresses to carcinoma in situ related to HPV
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ovarian cancer leading cause of gynecological deaths spread directly and distally vulvar cancer linked to condylomas (HPV)
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fibroid tumors benign neoplasm uterus treatment myomectomy ovarian cysts persistant ovarian follicle multiple incidents PCOS
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endometriosis endometrial tissue outside the uterus causes pain bleeding scarring
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cystocele herniation of bladder into vagina rectocele herniation of rectum enterocele herniation of intestine
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uterine prolapse uterus bulges into vagina Bartholin gland cyst
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menorrhagia excessive bleeding during menustration metrorrhagia between periods
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Diagnostic Procedures
Papanicolaou (Pap) test cytology study cervical smear screen for cervical cancer cultures STD’s HPV colposcopy Diagnostic Procedures
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surgical intervention
basic room setup special considerations negative pregnancy test position lithotomy prep vaginal
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Patient and Team Position
This is your position Anesthesia The patient is here. Most gynecology procedures are performed with the patient in supine or lithotomy position. The surgical team operates from either side of the patient during open procedures. During vaginal procedures, the scrub is in an awkward position, with the back table placed at the foot of the patient behind the surgeons or at the side. This requires the scrub to either reach across the front of the surgeon and assistants or pass equipment between them. Neither option is satisfactory but one must be used to preserve aseptic technique. The only other option is for the scrub to work from an overhead table and pass instruments down to the surgeons. Your back table
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procedural steps speculum inserted cervix swabbed with 3% acetic acid examined under light abnormal tissue appear white
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paint with Iodine Lugol’s solution healthy tissue take up stain abnormal tissue will not called Schiller’s test
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cone biopsy of the cervix
removes circumferential core of tissue around cervical canal called LEEP loop electrosurgical excision procedure
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dilation of the cervix and curettage (D&C)
done for diagnostic purposes abnormal uterine bleeding incomplete abortion prior to procedures performed via cervix
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surgical intervention
special considerations negative pregnancy test preferred anesthesia general position lithotomy prep/drape vaginal
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supplies back table cover raytec telfa equipment stirrups instruments D&C set
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procedural steps Auvard inserted cervix grasped tenaculum depth and position determined with uterine sound cervix dilated Hegar or Hanks dilators
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biopsies endocervix endometrial uterine currette placed on Telfa
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suction D&C done for induced abortion elective noninduced abortion incomplete missed threatened inevitable
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after dilation of cervix
suction probe is used remove contents collected in bag
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hysteroscope visualize internal contour uterus done to assess uterine cavity polyps, tumors, adhesions special considerations - pregnancy test
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surgical intervention
basic room setup preferred anesthesia general position lithotomy prep/drape vaginal
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supplies back table cover raytecs equipment camera/light source instrumentation hysteroscope D&C set
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hysteroscope rigid or semi-rigid 12 to 30 degree angled lens 0 degree is also available sheath allow instrumentation instillation of distention medium
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uterine distention low viscosity fluids NS except with cautery no longer use CO2 gas embolism Dextran 70 fluid extravasation
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procedural steps D&C steps to dilation insertion of hysterscope inflation of uterus polyp or adhesion found use resectoscope spring-loaded handle shaves and coagulates tissue
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endometrial ablation done for dysfunction uterine bleeding two techniques rollerball ablation with resectoscope global endometrial ablation
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global endometrial ablation
NovaSure radiofrequency ablator Therma-Choice silicone balloon catheter filled with D5W actived to 176°F 10 minutes
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laparoscopy diagnose abdominal/pelvic pain evaluate pelvic masses treat adhesions cysts ectopic pregnancy tuboplasty
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surgical intervention
room setup separate setups vaginal abdominal preferred anesthesia general position low lithotomy
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procedural steps begins with D&C Auvard uterine tenaculum dilator uterine manipulator inserted methylene blue instilled chromotubation gloves changed
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pneumoperitoneum first port laparascope secondary ports as needed instrumentation surgeon manipulates uterus
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tubal ligation fallopian tubes elevated Babcock occluded by three methods transection and coagulation bipolar cautery fallope ring Silastic O ring filshie clip
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ovarian cyst oophorectomy/ovarian cystectomy benign or malignant Teratoma dermoid cyst arised from primordal germ cells hair, teeth, skin
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cyst dissected cutting into the cortex outer covering of cyst removed intact placed in retrieval bag opened inside abdomen too large reduced with a morcellator
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microsurgical tubal anastomosis (tuboplasty)
restore continuity to fallopian tube restore function infection primary cause scarring tubal ligation
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fallopian tube identified
damaged portion dissected iris scissors patency assessed indigo carmine insufflate Rubin’s test reanastomosed 8-0 or 9-0 Prolene
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uterine fibroids preserve fertility myomectomy resectoscope uterine tumors hysterectomy total cervix and uterus subtotal cervix left in place
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total abdominal hysterectomy
supine position abdominal/vaginal prep indwelling foley prevent injury to bladder Pfannenstiel incision
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access gained into peritoneum
retractor inserted O and O bowel isolated wet lap sponges make note of number
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uterus grasped Heaney pull it up and out pelvic cavity
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uterosacral ligaments
cardinal ligaments clamp X 2 cut suture Heaney NH
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fallopian tube ovarian ligament clamp X 2 cut ligated
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bladder freed uterus attached by peritoneal covering
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dissection carries toward cervix Jorgensen scissors uterine vessels clamped cut ligated
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vagina opened anteriorly
circumferential incision vagina
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uterus freed instruments in contact with cervix contaminated wound is closed
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ovaries removed oophorectomy tubes removed salpinectomy both salpinoophorectomy both side bilateral
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vaginal hysterectomy lithotomy position vaginal prep/drape bladder drained straight catheter
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procedural steps Auvard cervix grasped tenaculum circumferential incision cervix vaginal wall dissected away sponge on stick
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bladder freed from cervix
incision into peritoneum
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ligaments clamp, clamp, cut, suture uterosacral, cardinal, round ovarian, broad
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uterus removed bladder flap closed peritoneum closed perineal pad
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laparoscopic assisted vaginal hysterectomy
two setups laparascope vaginal position lithotomy prep vaginal/abdominal
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procedural steps pneumoperitoneum trocars scope inserted Harmonic scalpel available dissect uterine ligaments bladder freed
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vaginal portion cervix dissected away cuff sutured uterus removed clamps remain on cervix
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robotic assisted insert uterine manipulator laparascopic sequence position steep Trendelenburg robot docked
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sequence follows LAVH
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radical hysterectomy Wertheim anterior approach remove uterus, cervix, vagina, fallopian tubes, ovaries, bladder ileal conduit posterior approach
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posterior approach removal of vagina, uterus, cervix vagina, fallopian tubes, ovaries, sigmoid colon, rectum colostomy
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pelvic exenteration removal of rectum distal sigmoid urinary bladder distal ureters reproductive organs lymph nodes pelvic floor
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anterior-posterior repair
colporrhaphy position lithotomy prep vaginal straight catheterized
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anterior portion insert Auvard grasp cervix incise anterior vaginal wall edges grasped with Allis clamps fanned out to distend edges raytecs used for blunt dissection reaches bladder neck ligate cut away excess tissue
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posterior portion incises posterior vaginal wall similar to anterior tightens levator muscle
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vaginoplasty create a functional vagina congenital repair of vesicovaginal fistula tract connects bladder to vagina repair of rectovaginal fistula tract between rectum and vagina
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condyloma dessication of lesions laser ESU wear PPE
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marsuplization of Bartholin Duct Cyst
cyst is excised resecting anterior wall suturing cut edges cyst adjacent edges of skin
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vulvectomy simple labia major, minora, clitoris removed en bloc one piece skinning external skin from affected area radical skin from abdomen/groin, labias, clitoris, terminal urethra, vagina, nodes, ligaments, veins
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simple vulvectomy elliptical incision around vulva vulva removed en bloc posterior vaginal mucosa incised sutured to strengthen pelvic floor
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bilateral groin incisions
removal of nodes wound closed drain may need graft
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radium implants cancer of cervix and endometrium lithotomy position bladder drained catheter inflated radiopaque medium radium applicators used inserted vaginally
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Pregnancy
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pregnancy false labor Braxton Hicks true labor begin with bloody show loss of mucous plug ends with dilation of cervix stage one
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dilation of cervix second stage crowning ends with birth of infant birth of infant third stage ends with delivery of placenta
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delivery of placenta stage four ends with mother recovered
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surgical technologist
follow patient’s progress dilation effacement thinning of cervix station measurement of descent relation to ischial spine prepare OR for delivery
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vaginal delivery lithotomy position episiotomy prevent perineal lacerations head delivered oral cavity/nares suctioned bulb syringe De Lee suction
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assesses umbilical cord
tight may clamp and cut loose slip over infant’s head head turned to floor upper shoulder delivered
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head turned to ceiling lower shoulder delivered cord double clamped/cut cord blood collected infant hand to nurse/pediatrician
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delivery of placenta 20 minutes later give oxytocin episiotomy repaired
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baby scored APGAR respiration color heart rate reflex body tone 1 to 2
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complications maternal fetal maternal/fetal placental
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maternal complications
pre-eclampsia hypertension hyperreflexia ketones urine 4+ edema eclampsia convulsions
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organic disease state diabetes cardiac disease fibroids/ovarian tumors STD’s previous c-sections
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fetal complications malpresentation breech butt first transverse footling vertex back of head
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fetal distress internal fetal monitoring nuchal cord cord wrapped around neck heart rate decreases contractions prolaspe of umbilical cord
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failure to progress #1 reason C-section due to weak contractions cephalopelvic disproportion mother’s pelvis too small maternal/fetal complication
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placental complications
placenta previa implanted low in uterus danger of placenta delivered first placenta abruption separates prematurely leads to fetal death
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C-section surgical intervention room set up warm room isolette
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preferred anesthesia epidural position supine with roll under right hip prepping abdomen, vagina, inner thighs foley catheter
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procedural steps pfannenstiel incision elevates peritoneum incision Metzenbaum (Mayo) scissors bladder freed from uterus bladder flap De Lee retractor
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uterus palpated determine fetal position suction available incision into uterus bandage scissors suction baby bulb syringe
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baby delivered umbilical cord clamped/cut cord blood baby to pediatrician placenta delivered wound closed 4 counts
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complications of pregnancy
incompetent cervical os abortion cervical cerclage Shirodkar procedure
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TVC synthetic band placed around proximal cervix vaginal approach TAC sutures internal cervical os abdominal approach
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ectopic pregnancy implantation outside uterus 95% fallopian tubes ruptured open procedure not ruptured laparascopic
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open repair pfannenstiel incision suction/irrigation ready salpingectomy cross-clamp fallopian tube resected salpingostomy incision into fallopian tube contents evacuated
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laparosopic resection of tubal pregnancy
pneumoperitoneum trocars identify site of pregnancy incision into tube cautery tip trophoblastic tissue removed Babcock
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infertility invitro ferilization/IVF ova removed/fertilized/incubated transferred to uterus 48 hours gamete intrafallopian transfer laparoscopic procedure ova removed/analyzed ova/sperm placed in tube
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