Obstetrics/GynecologicalSurgery

Objectives• review anatomy/physiology

• female reproductive system• identify pathological conditions

• female reproductive system• differentiate between

• gynecological diagnostic procedures• describe basic surgical interventions

• colposcopy• describe intermediate surgical interventions

• cervical cone biopsy• LEEP

• describe basic surgical interventions• dilation and curettage• hysteroscopy

• describe intermediate surgical interventions• endometrial ablation

• Novasure• balloon therapy

• describe basic surgical interventions• diagnostic laparoscopy• laparoscopic tubal ligation• laparoscopy with oophorectomy

• 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

• describe advanced surgical interventions• myomectomy• radial hysterectomy

• Wertheim procedure• total pelvic exenteration

• describe basic surgical interventions• anterior and posterior repair• ablation of condylomata• marsupialization of Bartholin’s gland

• describe basic surgical interventions• labioplasty• vulvectomy

• review stages of labor• identify complications of pregnancy• sequence for vaginal deliveries• describe basic surgical interventions

• cesarean section

• 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

• endometrium• inner layer

• sloughed off• myometrium

• muscular layer• contracts during

• labor• perimetrium

• outer layer

Layers of the Uterus

• perimetrium• abdominal peritoneum

• bladder• forms a pouch

• cul-de-sac• bladder flap

• cervix• extends into vaginal vault• opening

• cervical os• external• internal

• broad ligaments• ovarian ligaments• round ligaments• cardinal ligaments

• below broad• uterosacral ligaments

Uterine Ligaments

• fallopian tubes• interstitial section

• connect to body• uterus

• isthmus• middle

• ampulla• widened portion

• infundibulum• terminal end

• fimbriae

• ovary• supsended by mesovarium

• ovarian ligaments

• vagina• recessed areas

• around cervix• fornices

External Genatalia

vulva

Barthlin’s gland

perineum

• 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

• luteal phase• day 16• lasts 12 days• corpus luteum

• secretes• estrogen• progesterone

• triggers changes• endometrium

• implantation• menustration

Pathology of the Female Reproductive System

• gynecological cancers• endometrial cancer

• associated with• obesity• high levels of estrogen

• cervical cancer• most common• easily treated

• early stage• dysplasia

• progresses to• carcinoma in situ

• related to HPV

• ovarian cancer• leading cause of gynecological deaths

• spread directly and distally• vulvar cancer

• linked to condylomas (HPV)

• fibroid tumors• benign neoplasm

• uterus• treatment

• myomectomy• ovarian cysts

• persistant ovarian follicle• multiple incidents

• PCOS

• endometriosis• endometrial tissue

• outside the uterus• causes

• pain• bleeding• scarring

• cystocele• herniation of bladder

• into vagina• rectocele

• herniation of rectum• into vagina

• enterocele• herniation of intestine

• into vagina

• uterine prolapse• uterus bulges into

• vagina

• Bartholin gland cyst

• menorrhagia• excessive bleeding

• during menustration• metrorrhagia

• excessive bleeding• between periods

• Papanicolaou (Pap) test• cytology study

• cervical smear• screen for cervical cancer

• cultures• STD’s• HPV

• colposcopy

Diagnostic Procedures

• surgical intervention• basic room setup• special considerations

• negative pregnancy test• position

• lithotomy• prep

• vaginal

The patient is here.

Your back table

This is your positionAnesthesia

Patient and Team Position

• procedural steps• speculum inserted• cervix swabbed with 3% acetic acid• examined under light

• abnormal tissue• appear white

• paint with Iodine• Lugol’s solution

• healthy tissue• take up stain

• abnormal tissue• will not

• called Schiller’s test

• cone biopsy of the cervix• removes circumferential core of tissue

• around cervical canal• called LEEP

• loop electrosurgical excision procedure

• dilation of the cervix and curettage (D&C)• done for

• diagnostic purposes• abnormal uterine bleeding• incomplete abortion• prior to procedures performed

• via cervix

• surgical intervention• special considerations

• negative pregnancy test• preferred anesthesia

• general• position

• lithotomy• prep/drape

• vaginal

• supplies• back table cover• raytec• telfa

• equipment• stirrups

• instruments• D&C set

• procedural steps• Auvard inserted• cervix grasped

• tenaculum• depth and position

• determined with• uterine sound

• cervix dilated• Hegar or Hanks dilators

• biopsies• endocervix• endometrial

• uterine currette• placed on Telfa

• suction D&C• done for

• induced abortion • elective

• noninduced abortion• incomplete• missed• threatened

• inevitable

• after dilation of cervix• suction probe is used

• remove contents• collected in bag

• hysteroscope• visualize internal contour

• uterus• done to

• assess uterine cavity• polyps, tumors, adhesions

• special considerations• - pregnancy test

• surgical intervention• basic room setup• preferred anesthesia

• general• position

• lithotomy• prep/drape

• vaginal

• supplies• back table cover• raytecs

• equipment• camera/light source

• instrumentation• hysteroscope• D&C set

• hysteroscope• rigid or semi-rigid

• 12 to 30 degree angled lens• 0 degree is also available

• sheath• allow instrumentation• instillation of distention medium

• uterine distention• low viscosity fluids

• NS• except with cautery

• no longer use• CO2

• gas embolism

• Dextran 70• fluid extravasation

• 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

• endometrial ablation• done for

• dysfunction uterine bleeding• two techniques

• rollerball ablation• with resectoscope

• global endometrial ablation

• global endometrial ablation• NovaSure

• radiofrequency ablator• Therma-Choice

• silicone balloon catheter• filled with D5W• actived to 176°F• 10 minutes

• laparoscopy• diagnose

• abdominal/pelvic pain• evaluate

• pelvic masses• treat

• adhesions• cysts• ectopic pregnancy• tuboplasty

• surgical intervention• room setup

• separate setups• vaginal• abdominal

• preferred anesthesia• general

• position• low lithotomy

• procedural steps• begins with D&C

• Auvard• uterine tenaculum• dilator

• uterine manipulator inserted• methylene blue instilled

• chromotubation• gloves changed

• pneumoperitoneum• first port

• laparascope• secondary ports

• as needed• instrumentation

• surgeon manipulates uterus

• tubal ligation• fallopian tubes elevated

• Babcock• occluded by three methods

• transection and coagulation• bipolar cautery

• fallope ring• Silastic O ring

• filshie clip

• 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

• fallopian tube identified• damaged portion dissected

• iris scissors• patency assessed

• indigo carmine• insufflate

• Rubin’s test• reanastomosed

• 8-0 or 9-0 Prolene

• uterine fibroids• preserve fertility

• myomectomy• resectoscope

• uterine tumors• hysterectomy

• total• cervix and uterus

• subtotal• cervix left in place

• total abdominal hysterectomy• supine position• abdominal/vaginal prep• indwelling foley

• prevent injury to bladder• Pfannenstiel incision

• access gained into peritoneum• retractor inserted

• O and O• bowel isolated

• wet lap sponges• make note of

• number

• uterus grasped• Heaney

• pull it up and out• pelvic cavity

• uterosacral ligaments• cardinal ligaments

• clamp X 2• cut• suture

• Heaney NH

• fallopian tube• ovarian ligament

• clamp X 2• cut• ligated

• bladder freed• uterus

• attached by• peritoneal covering

• dissection carries• toward

• cervix• Jorgensen scissors

• uterine vessels• clamped• cut• ligated

• cervix

• vagina opened anteriorly• circumferential incision

• vagina

• uterus freed• instruments in contact with cervix

• contaminated• wound is closed

• ovaries removed• oophorectomy

• tubes removed• salpinectomy

• both• salpinoophorectomy

• both side• bilateral

• vaginal hysterectomy• lithotomy position• vaginal prep/drape• bladder drained

• straight catheter

• procedural steps• Auvard• cervix grasped

• tenaculum• circumferential incision cervix• vaginal wall dissected away

• sponge on stick

• bladder freed from cervix• incision into peritoneum

• ligaments• clamp, clamp, cut, suture

• uterosacral, cardinal, round• ovarian, broad

• uterus removed• bladder flap closed• peritoneum closed• perineal pad

• laparoscopic assisted vaginal hysterectomy• two setups

• laparascope• vaginal

• position• lithotomy

• prep• vaginal/abdominal

• procedural steps• pneumoperitoneum• trocars• scope inserted• Harmonic scalpel available

• dissect• uterine ligaments

• bladder freed

• vaginal portion• cervix dissected away• cuff sutured• uterus removed

• clamps remain on cervix

• robotic assisted• insert uterine manipulator• laparascopic sequence• position

• steep Trendelenburg• robot

• docked

• sequence follows• LAVH

• radical hysterectomy• Wertheim

• anterior approach• remove uterus, cervix, vagina, fallopian tubes, ovaries, bladder

• ileal conduit• posterior approach

• posterior approach• removal of vagina, uterus, cervix vagina, fallopian tubes, ovaries, sigmoid colon, rectum

• colostomy

• pelvic exenteration• removal of

• rectum• distal sigmoid• urinary bladder• distal ureters• reproductive organs• lymph nodes• pelvic floor

• anterior-posterior repair• colporrhaphy• position

• lithotomy• prep

• vaginal• straight catheterized

• 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

• posterior portion• incises posterior vaginal wall• similar to anterior• tightens levator muscle

• vaginoplasty• create a functional vagina

• congenital• repair of vesicovaginal fistula

• tract connects• bladder to vagina

• repair of rectovaginal fistula• tract between

• rectum and vagina

• condyloma• dessication of lesions

• laser• ESU

• wear PPE

• marsuplization of Bartholin Duct Cyst• cyst is excised

• resecting anterior wall• suturing cut edges

• cyst• adjacent edges of skin

• 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

• simple vulvectomy• elliptical incision

• around vulva• vulva removed en bloc• posterior vaginal mucosa

• incised• sutured to strengthen pelvic floor

• bilateral groin incisions• removal of nodes

• wound closed• drain

• may need graft

• radium implants• cancer of cervix and endometrium• lithotomy position• bladder drained• catheter inflated

• radiopaque medium• radium applicators used

• inserted vaginally

Pregnancy

• pregnancy• false labor

• Braxton Hicks• true labor

• begin with bloody show• loss of mucous plug

• ends with dilation of cervix• stage one

• dilation of cervix• second stage

• crowning• ends with birth of infant

• birth of infant• third stage

• ends with delivery of placenta

• delivery of placenta• stage four

• ends with mother recovered

• surgical technologist• follow patient’s progress

• dilation• effacement

• thinning of cervix• station

• measurement of descent• relation to ischial spine

• prepare OR for delivery

• vaginal delivery• lithotomy position• episiotomy

• prevent perineal lacerations• head delivered

• oral cavity/nares suctioned• bulb syringe• De Lee suction

• assesses umbilical cord• tight

• may clamp and cut• loose

• slip over infant’s head• head turned to floor

• upper shoulder delivered

• head turned to ceiling• lower shoulder delivered

• cord double clamped/cut• cord blood collected

• infant hand to • nurse/pediatrician

• delivery of placenta• 20 minutes later

• give oxytocin• episiotomy repaired

• baby scored• APGAR

• respiration• color• heart rate• reflex• body tone

• 1 to 2

• complications• maternal• fetal• maternal/fetal• placental

• maternal complications• pre-eclampsia

• hypertension• hyperreflexia• ketones urine• 4+ edema

• eclampsia• convulsions

• organic disease state• diabetes• cardiac disease• fibroids/ovarian tumors

• STD’s• previous c-sections

• fetal complications• malpresentation

• breech• butt first

• transverse• footling• vertex

• back of head

• failure to progress• #1 reason

• C-section• due to

• weak contractions• cephalopelvic disproportion

• mother’s pelvis too small• maternal/fetal complication

• placental complications• placenta previa

• implanted low in uterus• danger of placenta

• delivered first• placenta abruption

• separates prematurely• leads to fetal death

• C-section• surgical intervention

• room set up• warm room

• isolette

• preferred anesthesia• epidural

• position• supine with roll under right hip

• prepping• abdomen, vagina, inner thighs• foley catheter

• procedural steps• pfannenstiel incision• elevates peritoneum

• incision• Metzenbaum (Mayo) scissors

• bladder freed from uterus• bladder flap

• De Lee retractor

• uterus palpated• determine fetal position

• suction available• incision into uterus

• bandage scissors• suction baby

• bulb syringe

• baby delivered• umbilical cord

• clamped/cut• cord blood

• baby to pediatrician• placenta delivered• wound closed

• 4 counts

• complications of pregnancy• incompetent cervical os

• abortion• cervical cerclage• Shirodkar procedure

• TVC• synthetic band

• placed around• proximal cervix

• vaginal approach• TAC

• sutures• internal cervical os

• abdominal approach

• ectopic pregnancy• implantation outside uterus

• 95% fallopian tubes• ruptured

• open procedure• not ruptured

• laparascopic

• open repair• pfannenstiel incision• suction/irrigation ready• salpingectomy

• cross-clamp• fallopian tube

• resected• salpingostomy

• incision into fallopian tube• contents evacuated

• laparosopic resection of tubal pregnancy• pneumoperitoneum• trocars• identify site of pregnancy• incision into tube

• cautery tip• trophoblastic tissue removed

• Babcock

• 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