COMMON GYNECOLOGICCOMMON GYNECOLOGIC

PROCEDURESPROCEDURES

AZZA AlYAMANIAZZA AlYAMANI

Department of ObestetricsDepartment of Obestetrics

and Gynecologyand Gynecology

Common Gynecologic Common Gynecologic ProceduresProcedures

Aim of this presentation isAim of this presentation is : :

1. students become aware of the 1. students become aware of the basic principlesbasic principles of common gynecologic surgical procedures.of common gynecologic surgical procedures. 2. become familial with the 2. become familial with the instrumentsinstruments that used in that used in these procedures.these procedures. 3. and be aware of the 3. and be aware of the indicationsindications and and complicationscomplications of each procedure.of each procedure.

{1} Endometrial Sampling ( Dilatation & Curettage){1} Endometrial Sampling ( Dilatation & Curettage)

D & CD & C

** it is the most common minor gynecologic surgical it is the most common minor gynecologic surgical

procedure , it is used as procedure , it is used as diagnosticdiagnostic or or therapeutictherapeutic tool. tool.

** in spite of the advances in office – based evaluation of in spite of the advances in office – based evaluation of

the endometrium as US or hysteroscopy , a thoroughthe endometrium as US or hysteroscopy , a thorough

fractional curettage fractional curettage is is the the best procedure best procedure if endometrial or cervical cancer is suspected.if endometrial or cervical cancer is suspected.

IndicationsIndications

Diagnostic:Diagnostic:

1. abnormal uterine bleeding.1. abnormal uterine bleeding.

2. postmenopausal bleeding ,end. ca.2. postmenopausal bleeding ,end. ca.

3. irregularities of the endometrial cavity either3. irregularities of the endometrial cavity either

congenital ( uterine septum) or acquired congenital ( uterine septum) or acquired

(submucous fibroids or polyp)can be determined (submucous fibroids or polyp)can be determined

during the operation.during the operation.

Therapeutic:Therapeutic:

1. endometrial hyperplasia with heavy bleeding .1. endometrial hyperplasia with heavy bleeding .

2. removal of endometrial polyps or small 2. removal of endometrial polyps or small

pedunculated myomas.pedunculated myomas.

3. dilatation & evacuation in inevitable and missed3. dilatation & evacuation in inevitable and missed

abortion.abortion.

4. removal of missed intrauterine IUCD.4. removal of missed intrauterine IUCD.

TechniqueTechnique

instrumentsinstruments

Steps of D&CSteps of D&C

Complications:Complications:

11.Perforation of the uterus..Perforation of the uterus.

it is not uncommon complication ,it occurs in :it is not uncommon complication ,it occurs in :

* RVF uterus.* RVF uterus.

* pregnancy.* pregnancy.

* postmenopausal è endometrial carcinoma.* postmenopausal è endometrial carcinoma.

22. Cervical laceration.. Cervical laceration.

33. Infection.. Infection.

44. Haemorrahge.. Haemorrahge.

Endometrial AblationEndometrial Ablation

iit is the t is the complete destruction of the endometriumcomplete destruction of the endometrium

down to the basal layer down to the basal layer , resulting in fibrosis of the uterine , resulting in fibrosis of the uterine

cavity and amenorrhoea ( 30% ) , however , patient cavity and amenorrhoea ( 30% ) , however , patient

satisfaction rates are over 70% . Iasatisfaction rates are over 70% . Ia

It indicated in women who have heavy menstrual It indicated in women who have heavy menstrual

bleeding that is impacting her life and do not have bleeding that is impacting her life and do not have

other problems that require hysterectomy .other problems that require hysterectomy .

Endometrial ablation is now well established as dayEndometrial ablation is now well established as day

case or outpatient procedure. case or outpatient procedure.

Endometrial Ablation is performed using the Endometrial Ablation is performed using the

resectoscope which is :resectoscope which is :

a hysteroscpe with a build in wire loop(or other shapea hysteroscpe with a build in wire loop(or other shape

device ) that uses device ) that uses high frequency electrical current high frequency electrical current toto

cut or coagulate tissue.cut or coagulate tissue.

Indications:Indications:

1. abnormal uterine bleeding. 2. benign lesions as small submucus myomas or endometrial polyps.

TechniqueTechnique

Established techniques carried out under direct Established techniques carried out under direct

hysteroscopic vision involve the use of fluid forhysteroscopic vision involve the use of fluid for

distention and irrigation .distention and irrigation .

These techniques are :These techniques are :

* laser ablation.* laser ablation.

* endometrial loop resection using electro diathermy.* endometrial loop resection using electro diathermy.

* roller ball electro diathermy.* roller ball electro diathermy.

roller ball electro diathermy. endometrial loop resectionroller ball electro diathermy. endometrial loop resection

using electro diathermy.using electro diathermy.

roller ball electro diathermyroller ball electro diathermy

loop resection using electro diathermyloop resection using electro diathermy

Complications : 2%Complications : 2%

1. uterine perforation.1. uterine perforation.

2. hemorrhage.2. hemorrhage.

3. infections as endometritis & PID.3. infections as endometritis & PID.

4. bowel or urinary tract injury.4. bowel or urinary tract injury.

5. cervical lacerations & stenosis.5. cervical lacerations & stenosis.

5. distention medium hazards as:5. distention medium hazards as:

* gas embolism.* gas embolism.

* fluid overload.* fluid overload.

* anaphylactic shock.* anaphylactic shock.

Although the resectoscope provides excellent Although the resectoscope provides excellent results in experienced hands, the technique is results in experienced hands, the technique is

difficult to master. difficult to master. 

because all the previous techniques are: because all the previous techniques are:

* operator dependent .* operator dependent .

* time consuming .* time consuming .

* carry risk of systemic fluid absorption.* carry risk of systemic fluid absorption.

* hemorrhage.* hemorrhage.

* uterine perforation è heat damage to adjacent* uterine perforation è heat damage to adjacent

structures.structures.

Other methods of ablation  Other methods of ablation  

  

Newer techniques have been developed with the Newer techniques have been developed with the

aim of reducing operator dependency and minimizingaim of reducing operator dependency and minimizing

risk . Of these , the best evaluated to date are :risk . Of these , the best evaluated to date are :

* * microwave ablationmicrowave ablation..

* * thermal balloon ablationthermal balloon ablation..

They have equivalent short-term efficacy with the They have equivalent short-term efficacy with the advantage of shorter operating times and fewer advantage of shorter operating times and fewer

complications.complications.

Microwave probe inserted Microwave probe inserted endometrium heated to 80 Cendometrium heated to 80 C day case procedureday case procedure 70 -80% satisfaction rates70 -80% satisfaction rates 95% return to normal 95% return to normal

Microwave machineMicrowave machine 

Thermachoice ballon This uses a balloon placed in the uterine cavity through the cervix.  Hot water is circulated inside the balloon to destroy the endometrium.

Thermachoice Balloon Ablation

Central element heats liquid circulated in balloon

87 degrees C for 8 minutes .

Limitations :

*uterine cavity size 6-10 cm ;

* can’t treat submucous myomas .

 

The Thermachoice SystemFig 3 - The Caveterm System

   Thermachoice ballon

      

Hysterectomy Hysterectomy

it is the most commonly performed majorit is the most commonly performed major gynecologic operation , it can be performed either gynecologic operation , it can be performed either

Abdominally , vaginally or laparoscopically.Abdominally , vaginally or laparoscopically.

although some indications remain controversial ,although some indications remain controversial ,

high patient satisfaction levels and increasing high patient satisfaction levels and increasing

safety for the procedure have been reported .safety for the procedure have been reported .

Types of HysterectomyTypes of Hysterectomy 1. subtotal 1. subtotal

2. total 2. total

3. total è unilateral or bilateral salpingo ophrectomy .3. total è unilateral or bilateral salpingo ophrectomy .

4. radical4. radical

Types of Abdominal Types of Abdominal HysterectomyHysterectomy

Radical HysterectomyRadical Hysterectomy

Indications :Indications :

A.A.Abdominal hysterectomy Abdominal hysterectomy

1. 1. invasiveinvasive uterine ,cervical ,ovarian and Fallopian cancer. uterine ,cervical ,ovarian and Fallopian cancer.

2. significant 2. significant pre invasive lesions pre invasive lesions of the cervix as CIN III of the cervix as CIN III or endometrial hyperplasia with atypia . or endometrial hyperplasia with atypia .

3. 3. pelvic pain pelvic pain

chronic endometriosis , chronic PID and ruptured chronic endometriosis , chronic PID and ruptured

tubo ovarian abscess.tubo ovarian abscess.

4. 4. fibroid fibroid uterus > 12 weeks in size.uterus > 12 weeks in size.

5. 5. AUBAUB unresponsive to other lines of treatments. unresponsive to other lines of treatments.

6. 6. pregnancy catastrophe pregnancy catastrophe as severe bleeding. as severe bleeding.

B. vaginal hysterectomyB. vaginal hysterectomy

1. utero vaginal prolapse .1. utero vaginal prolapse .

2. AUB with small uterus . 2. AUB with small uterus .

pre requesits to vaginal hysterectomy :pre requesits to vaginal hysterectomy :

* benign disease.* benign disease.

* uterus is mobile with some pelvic relaxation & no pelvic* uterus is mobile with some pelvic relaxation & no pelvic

adhesions .adhesions .

* uterus is < 12 weeks in size.* uterus is < 12 weeks in size.

C . Laparoscopic hysterectomyC . Laparoscopic hysterectomy

* < 10% of hysterectomies performed with the* < 10% of hysterectomies performed with the

use of laparoscopy.use of laparoscopy.

* it is used to assist in vaginal hysterectomy or * it is used to assist in vaginal hysterectomy or to convert an abdominal to a vaginal to convert an abdominal to a vaginal hysterectomy.hysterectomy.

TechniqueTechnique

1. supine position.1. supine position.

2. general anaesthesia .2. general anaesthesia .

3. a careful abdominal & pelvic exam. under3. a careful abdominal & pelvic exam. under

anaesthesia is carried out.anaesthesia is carried out.

4. incision 4. incision

* * vertical vertical

in obese , if endometriosis is anticipated and patientsin obese , if endometriosis is anticipated and patients

who have had several prior abdominal operations.who have had several prior abdominal operations.

* * transverse transverse

in restricted benign disease .in restricted benign disease .

5. exploration of the upper abdominal organs 5. exploration of the upper abdominal organs

especially the liver ,spleen and para-aortic lymphespecially the liver ,spleen and para-aortic lymph

nodes. nodes.

6. the abdominal viscera are packed up with towels.6. the abdominal viscera are packed up with towels.

7. 7. round ligament round ligament ..

each is clamped incised and ligated.each is clamped incised and ligated.

8. the vesico-uterine fold of peritoneum is incised8. the vesico-uterine fold of peritoneum is incised

transversely between the incised round lig. andtransversely between the incised round lig. and

the the bladder is reflected inferiorly bladder is reflected inferiorly ..

9. the two layers of the broad ligam. are separated9. the two layers of the broad ligam. are separated

and the and the ureters are explored and identifiedureters are explored and identified..

10. the 10. the infundibulo pelvic ligsinfundibulo pelvic ligs. with the ovarian . with the ovarian

vessels are clamped , cut and ligated. if thevessels are clamped , cut and ligated. if the

adnexa are to be removed.adnexa are to be removed.

11. the broad lig. is then incised towards the uterus11. the broad lig. is then incised towards the uterus

exposing the uterine vessels (skeletonized).exposing the uterine vessels (skeletonized).

12. the 12. the uterine vessels uterine vessels are clamped at the level of are clamped at the level of

internal cervical os , incised and ligated on eachinternal cervical os , incised and ligated on each

side. side.

13. medial to the ligated uterine vessels , the13. medial to the ligated uterine vessels , the

cardinal ligcardinal lig. on each side is clamped , incised. on each side is clamped , incised

and ligated. and ligated.

14. posteriorlly , the peritoneum between the 14. posteriorlly , the peritoneum between the

uterosacral lig. is incised transversely and uterosacral lig. is incised transversely and

the rectum is freed from the posterior aspectthe rectum is freed from the posterior aspect

of the cervix & upper vagina after the of the cervix & upper vagina after the

uterosacral lig. are clamped , incised & ligated.uterosacral lig. are clamped , incised & ligated.

15. the total uterus is removed by cutting across15. the total uterus is removed by cutting across

the vagina just below the cervix .the vagina just below the cervix .

16. the vaginal cuff is closed è absorbable sutures ,16. the vaginal cuff is closed è absorbable sutures ,

incorporating the cardinal & uterosacral ligs.incorporating the cardinal & uterosacral ligs.

into each lateral angle to avoid latter into each lateral angle to avoid latter

development of vault prolapse.development of vault prolapse.

Sites of ureteric injures Sites of ureteric injures ::

11. at clamping & incising the infundibulo pelvic. at clamping & incising the infundibulo pelvic

ligaments.ligaments.

22. at ligating the uterine vessels.. at ligating the uterine vessels.

33. at clamping & incising the cardinal ligs. if the . at clamping & incising the cardinal ligs. if the

urinary bladder is not sufficiently reflected urinary bladder is not sufficiently reflected

inferiorly.inferiorly.

Complications :Complications : A .A . Intra operative Intra operative

11. hemorrhage .. hemorrhage .

22. ureteric injuries.. ureteric injuries.

33. bladder and bowel injury.. bladder and bowel injury.

44. anesthetic complications.. anesthetic complications.

B.B. Post operative Post operative

11. wound infection ( 5 days postoperatively).. wound infection ( 5 days postoperatively).

22. UTI .. UTI .

33. thrombophlebitis and pulmonary embolism,. thrombophlebitis and pulmonary embolism,

( 7 – 12 days ).( 7 – 12 days ).

44. uretero vaginal fistula ( 5 – 21 days ).. uretero vaginal fistula ( 5 – 21 days ).

Thank you Thank you

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