operative gynaecology

7/29/2019 Operative Gynaecology

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Operative

Gynaecology


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Pre operative preparations:

Investigations

Blood: Hb, haematocrit value, TC,DC, Platelet

count, urea, creatinine,serum electrolytes

Urine: Routine analysis for protein, sugar, casts,

pus cells, culture & sensitivity

Chest X-ray & ECG:

for patients above 40 years of age.

HIV, Hep.B screening


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Fitness for surgery

correct anemia by haematinics,

blood transfusion

control of hypertension or

diabetes

control of infection , if present


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Pre-operative work up

pt must be admitted about 1-2 days prior to

operation. Special cases need earlier admission.

During this period re evaluation of the pt and

examination by the anesthetist should be done.

Enquiry should be made about drug allergy.

Any medication for diabetes or hypertension,

this helps the anesthetist to modify the drug anddose of anesthetic agents.

History of corticosteroid to be assessed.


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ContndAny false tooth, contact lenses,

Informed consent to be obtained by the pt.Adequate explanation must be given regarding

the surgery, outcome following surgery,

potential risks, complications etc to reduce theanxiety & fear.

Arrangement for blood transfusion must be made

prior to surgery for major surgeries.At least 2units of blood must be cross matched and kept

ready.


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Diet

Diet: Light diet is given on the previous evening

and NPO from midnight & morning of the day of

operation.

Care of the bowel: Enema may be given toempty the bowels on the previous evening.

Night sedation: To ensure good sleep at night

prior to the day of operation, Diazepam 5-10 mg

may be prescribed.


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Local antiseptic care:

The abdomen from below the breasts upto the

upper half of both thighs is shaved followed by

cleaning with an antiseptic solution. A sterile

linen is placed over the area.

For vaginal operations shaving of pubic hair and

upto middle of both thighs


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Morning medication

(premedication)

Sedative like Diazepam 5-10 mg orally, is

given about 2 hours before the surgery.

Prophylactic antibiotics:

To reduce the risk of infection, a broad

spectrum antibiotic is selected to cover the

gram +ve, gram ve and anaerobicorganisms.


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Day care surgery

Includes selected surgical

procedures, where patients are admitted,

operated and discharged on the same day.

Common gynecological operations:

D& C

Biopsy procedures

EUA( examination under anesthesia)

Endoscopic procedures like diagnostic

hysteroscopy, Laparoscopy, sterilization,

ovarian diathermy etc.


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Benefits :

1. Increased patient turn over

2. reduced hospital stay

3. reduced inpatient work load

4. reduced cost


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Post operative careThe pt is brought back to recovery room following

surgery.

First 24 hours

Placement in bed- Flat on bed.

head turned to one side

keep the pt warm with sheets and blankets

keep a watch on I.V fluids & urinary drainage.

If spinal anesthesia is given, foot end to be raised for 12hours.

Keep the anesthetic tray ready to meet the emergencies.

Keep a kidney tray at the bedside to collect any vomitus.


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Observation:

vital signs half hourly until steady.

Watch for bleeding.

Fluid replacement:

Blood transfusion if needed.

Fluid and electrolytes replacement

according to need


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Pain control:

liberal analgesics to relieve pain & ensure sleep.

Sedatives such as, Pethidine 100 mg or

Morphine 15 mg at 6-8 hrs interval

Adequate pain control ensures deep breathing,

adequate oxygenation, early mobilization and

reduced hospital stay.PCA ( pt. controlled analgesia) infusion pumps

are also effective


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Antibiotics:

I.V or I.M antibiotics for 48 hours followedby oral route for 3 days.

Bladder care:

Encourage to pass urine 8 hours after

surgery

if nursing measures fail, cathterisationshould be done under strict aseptic

precautions.


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General care

early ambulation

allow for free movements in bed.

Deep breathing and movements of the

legs and arms to minimize leg vein

thrombosis & pulmonary embolism.

Sips of water to relieve the thirst


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Second day:

vital signs 4th hourly

abdominal auscultation for peristaltic

movements & escape of flatus.

vaginal plug to be removed in the morning.

encourage walking a few steps.

deep breathing exercises , leg & arm

movements are encouraged.

with the return of bowel sounds or passageof flatus, liquid diet is prescribed.

antibiotics, sedatives and analgesics to be

continued as prescribed.


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Third day

ambulation to be continued

move in the room & go to the toilet.

I.V. antibiotics are changed to oral route.

Light soft diet.

Analgesics if required & sedatives at bed

time.

Self retaining catheter is removed after

bladder training.

Mild laxatives may be prescribed at bed

time for movement


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Fourth & fifth day

Routine observation of vital signs twice a day

Normal diet

Antibiotics are withdrawn on 5th day.

If the bowels have not moved, low enema or

mild suppository may be given.

Sedative at bed time may be given.


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Sixth or seventh day

The sutures are removed on the 6th or the

7th day

Discharge planning:

Abdominal wound is checked for evidence

of sepsis, hematoma, or dehiscence.

Note for any vaginal discharge

If vaginal operation is done, check the

wound, assess the state of healing


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Advice on discharge:Rest:

light house hold work after 3 weeks outsidework or office work after 6 weeks.

Coitus:

As soon as physically & psychologically fit,

coitus is permissible, preferably 6 weeks after

the postop check up.

Post op check up:

After 6 weeks to check for any complications

Diet :

A well balanced diet to build up resistance to

infection


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GYNAECOLGICAL OPERATIONS

Dialtation of cervix

This is an operation to dilate the cervix.

Indications:

prior to amputation of cervix

prior to hysteroscopy

pyometra or hematometra

prior to introduction of uterine curette andinsertion of IUD, radium or laminaria tent.

Spasmodic dysmenorrhoea.


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Dilatation & curettageThis is an operative procedure whereby dilatation of thecervical canal followed by uterine curettage is done

Indications;

Diagnostic

Infertility

DUB

Pathologic amenorrhea

Endometrial tuberculosisPostmenopausal bleeding

.

Therapeutic

DUBEndometrial polyp

Removal of IUD

Incomplete abortion


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Complications:

Immediate:

injury to the cervix

uterine perforation

injury to the gut

infection

Remote

cervical incompetence

secondary amenorrhea


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Dilatation and insufflation ( D&I)This is an operation of dilatation of cervix

and introduction of air or CO2 into the uterine

cavity to know the patency of the fallopian tubes(Rubin test)

Indications:

to note the tubal patency in:

investigation of infertility

following tuboplasty operation.

Complications:

air embolismrupture of the tube

flaring up of existing infection

pelvic endometriosis.


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Hystero salpingography ( HSG)HSG is an operative procedure whereby a

radiographic study of the interior of the utero-

tubal anatomy by using a contrast media.Indications:

to note the tubal patency in the investigation ofinfertility or following tuboplasty operation.

to diagnose cervical incompetency

to identify the translocated IUD

To confirm the diagnosis of secondary

abdominal pregnancyComplications:

peritoneal irritation and pelvic pain

vasovagal attack


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cervical biopsyThis is the common diagnostic procedure

Types:

surface: A bit of tissue is taken from thesurface of the cervix.

Punch biopsy: is taken from the suspected areaor a four quadrant using punch biopsy forceps.

Ring: whole of the squamo-columnar area of thecervix is excised with a special knife.

Cone: the operation involves removal of cone ofthe cervix which includes entire squamo-columnar junction , stroma with glands andendo cervical mucus membrane.

Wedge biopsy: is done when a definite growthis visible. An area nearer to the edge is the ideal

place avoiding the necrotic area.


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Thermal cauterisation

This is an operation whereby the

eroded area of the cervix is destroyed

either by thermo-regulation or red-hot

cauterization.

Indication:

Cervical ectopy with troublesomedischarge.


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Cryosurgery

This is a procedure whereby

destruction of the tissue is effectiveby freezing.

Indications:

benign cervical lesions,

leukoplakia

condyloma accuminata of vulva

as a palliative measure to arrest

bleeding in case of carcinoma cervix

or vulval carcinoma.


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Perineoplasty

It is the reconstruction of the narrow vaginal

interoitus to make it adequate for sexual

function

Indications:

congenitally small interoitus

rigid perineal body

rigid hymenal ringNarrowed interoitus following episiotomy or

perineorraphy.


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Amputation of cervix

It is an operative procedure whereby

a part of the lower cervix is excised.

Indications:

congenital elongation

chronic cervicitis

as a component part of Fothergillsoperation


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Abdominal hysterectomy

is the operation of removal of the uterus.

When the uterus is removed abdominally , it is called

hysterectomy

Types: depending upon the extent of removal of the uterus

and adjacent structures, the following types are

described.

Total hysterectomy- removal of the entire uterus

Subtotal hysterectomy: removal of the body or corpus

leaving behind the cervix.

Pan hysterectomy: removal of the uterus along with

removal of tubes and ovaries of both sides. The term

hysterectomy with bilateral salpingo-oophorectomy


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Indications:

Total hysterectomy:

Benign lesions:

Dysfunctional uterine bleedingfibroid uterus

tubo-ovarian mass

endometriosis

adenomyosisCIN( cervical intraepithelial neoplasis)

benign ovarian tumor in perimenopausal age.

Malignancy

carcinoma cervixcarcinoma ovary

carcinoma endometrium

uterine sarcoma

chorio carcinoma


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Contnd

Traumatic

uterine perforation

cervical tear

rupture uterus

Obstetrical

Atonic PPH

Morbid adherent placentaHydatidiform mole above the age of 35 years.


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Complications of hysterectomy

haemorrhage

shock

injury to adjacent organs like bladder, intestine orureter.

Anesthesia hazards

Urinary retentionCystitis

Anuria

Incontinence

Pyrexia due to infection

Remote complications

vault granulation

vault prolapse

prolapse of Fallopian tube through vault

incisional hernia


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Vaginal hysterectomyThis operation is also called as Ward Mayos

operation.It involves removal of the uterus per

vaginam mostly done in cases of uterine prolapse.

Indications:

utero-vaginal prolapse in post menopausal women

genital prolapse with diseased uterus like DUB,unhealthy cervix or small submucous fibroid

requiring hysterectomy.

As an alternative to Fothergills operation where

family is completed.

As an alternative to abdominal hysterectomy in

undescended uterus, or in selected cases where

abdominal approach is unsafe.


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Complications:

haemorrhage

sepsis

VVF following bladder injury

RVF following rectal injury

retention of urine

infection


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Fothergills or Manchester operation

This operation is designed to correct uterine

descent associated with cystocele and rectocele

where preservation of the uterus is desirable.

Component steps ofFothergills operation:

preliminary D&C

amputation of cervix

placation ofMackenrodts ligaments in front of the

cervix

anterior colporrhaphy

colpo perineorrhaphy


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Complicationshemorrhage

injury to bladder & rectumretention of urine

cystitis

dyspareunia

cervical stenosis

infertility

cervical in competency

cervical dystocia in labour

recurrence of prolapse.


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Radical hysterectomyThis operation is done abdominally and is

also known asWerthiem

s hysterectomy.This surgery includes

removal of the uterus

tubes and ovaries of both sides ( ovaries may be

spared in young women) ,upper 3/4th of vagina

wide resection of the parametrium,

periureteraltissue,superior vesical artery,cardinal and uterosacral ligaments,

and thorough lymphadenectomy (parametrial,obturator, internal & external iliac groups)

I di ti


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Indications:1. mainly done for invasive carcinoma of the

cervix where radiotherapy is

contraindicated.

2. associated PID

3. associatedmyoma, prolapse (procedentia).

Ovarian tumor or genital fistula

4. vaginal stenosis

5. recurrence after irradiation

6. surgery is preferred for those withadenocarcinoma or adeno squamous

carcinoma.


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RisksMajor post operative complications as

observed following total abdominalhysterectomy.

Other complications include:

1. ureteric fistula

2. bladder dysfunction3. cystitis and pyelonephritis

4. lymphocyst in the pelvis

5. lymphoedema of one or both legs

6. dyspareunia

7. recurrence

E d i ( Mi i ll i i


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Endoscopic surgery ( Minimally invasive

surgery, Minimal access surgery)The range of surgical procedures in

gynaecology that can be performed with the useof either a laparoscope or hysteroscope isdesignated as endoscopic surgery.

Advantages:

rapid post operative recovery

less post operative pain

reduced need of post operative analgesia

shorter stay in hospital

reduced cost

quicker resumption of day to day activity.

Less adhesion formation

Minimal abdominal scars


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Disadvantages:

risk of iatrogenic complications

skilled surgeon is required.


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Laparoscopy

Laparoscopy is a technique of visualization

of peritoneal cavity by means of a fbre

optic endoscope introduced through the

abdominal wall.

Indications

diagnostic

therapeutic


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Diagnostic:

Infertility work up:

peri tubal adhesions

chromo per tubation

minimal endometriosis

ovulation stigma of the ovary

before reversal of sterilization operation

Contnd


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Contn d

Chronic pelvic pain

to diagnose acute pelvic lesionectopic

acute appendicitis

follow up of pelvic surgery

tuboplasty

ovarian malignancy

evaluation of therapy in endometriosis.

Investigation protocol of amennorrhea

Diagnosis of suspected Mullerian abnormalities

Uterine perforation

Th ti l


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Therapeutic laparoscopyMinor procedures:

tubal sterilization

adhesiolysisaspiration of simple ovarian cyst

ovarian biopsy

Major procedures:

Ectopic pregnancy

salpingostomy

segmental resection

salpingectomy

salpingo- oopherectomy

Endometriosisablation by diathermy or laser

Ovary

diathermy of PCODdrainage of endometriosis

ovarian cystectomy

C f


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Contra indications for laparoscopy

severe cardio pulmonary disease

patient hemodynamically unstablegeneralized peritonitis

significant hemo peritoneum

intestinal obstructionextensive peritoneal adhesion

large pelvic tumors

pregnancy more than 16 weeksprevious peri umbilical surgery

extreme obesity


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Instruments required for laparoscopy

Telescope

Veress needle for creating pneumo-peritoneum by carbon dioxide

Trocar & canula

Light source

Insufflator used to create controlled

pneumo peritoneum as there is some

amount of gas leak through the different

parts.Cameras the telescope is connected with

the camera lens and pictures are obtained

from the monitor screen

Ancillary instruments:


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Ancillary instruments:Scissors for dissection & to cut tissues

Grasping forceps

Probes for manipulation of viscera( intestine and

ovaries)

Aspirator & irrigator for aspiration of fluid from the

peritoneal cavity or ovarian cysts, irrigator forwashing the peritoneal cavity

Morcellator is needed when a large piece of

tissue (myoma) is morcellated into small pieces so

as to be removed through the laparoscopic sleeve.Uterine manipulator used for adequate

visualization of the uterus and adnexae during

operation


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Complications of laparoscopy

Specific to laparoscopy:

extra peritoneal insufflation: surgicalemphysema

cardiac arrhythmia

injury to blood vesselsinjury to bowel

injury to organs like bladder or ureter

thermal injurygas embolism

th ti li ti


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anesthetic complications

Hypoventilation( pneumo peritoneum and

Trendlenburg position lead to basal lung

compression and reduced diaphragmatic

exercusion)

Hyper carbia and metabolic acidosis( when

co2 is used for pneumo-peritoneum)

Basal lung atelectasisOthers- oesophageal intubation, aspiration

and cardiac arrest.

C li ti t


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Complications common to any

surgical procedure:

infection

haemorrhage

wound dehiscence

incisional hernia

Hysteroscopy


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HysteroscopyThis is a procedure that allows direct visualization

inside the uterus. It can be used for diagnostic as well as

therapeutic purposesIndications:

1. Diagnostic:

abnormal uterine bleeding

menorrhagia

post menopausal bleeding

infertility - when associated with abnormal hysterosalpingogram (filling defect, adhesions)

recurrent spontaneous abortion - when suspectedwith Mullerian malformation.

misplaced IUD

to visualize the transformation zone with colpomicrohysteroscopy.

Contnd


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Contn d polypectomy & myomectomy

lysis of intrauterine adhesions

endometrial ablation for patients with DUB

endometrial resection

Metroplasty

removal of IUD , when thread is missing

biopsy of suspected endometrium under direct

vision

cannulation of the Fallopian tube

sterilizationdestroying the interstitial portion of

the tubes using Nd- YAG laser or electro

coagulation.


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Contraindications

pelvic infection

pregnancy

uterine bleeding causing poor visibility


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Complications of hysteroscopy

a) Distension media

fluid overload

pulmonary edema, cerebral edema

hypo natraemia

neurological symptomsgas embolism

Contnd


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Contn d

b) operative procedures:

uterine perforation

hemorrhage

injury to intra abdominal organs

c) Electro-surgical

thermal injury to intra abdominal organs

due to laser or electricity.

d) Others

infection, anesthetic complications and

treatment failure.


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operative gynaecology

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