Vaginal procedures

Rakan Telfah

Cervical conization

Dilation & Curettage

Cervical cerclage

Colporrhaphy

Cervical conization

AKA Cone biopsy refers to the excision of a cone shaped portion of the cervix surrounding the endocervical canal and including the entire transformation zone .

Removal of cone of the cervix which includes entire Squamocolumnar junction, stroma with glands and endocervical mucous membrane.

Techniques : • Cold Knife • LEEP (Loop Electrical Excision Procedure) or “Hot Knife” • CO2 Laser

Procedure – Under GA

– Blood loss is minimized with sutures at 3 and 9 o'clock positions on the cervix

by ligating the

descending cervical branches .

– After the cone is removed, a margin suture is placed at 12 o'clock for

identification of the cone

– Routine endocervical curette above the apex of the cone is performed and

uterine curettage is done if indicated .

– Then we use Sturmdorf suture to cover the cone .

Cone biopsy

Sturmdorf suture

Diagnostic indications Therapeutic

indications

Contraindications

– Unsatisfactory Colposcopic findings

– Inconsistent findings (Colposcopic,

Cytology and directed biopsy)

– Positive endocervical curettage for

CIN II and III

– When biopsy cannot rule out invasive

cancer from carcinoma in-situ

– Biopsy shows microinvasion

– to exclude gross invasive carcinoma

Treat CIN || and ||| During pregnancy

- significant (>500

mL) bleeding.

- 30% 🡪 delayed

post op hemorrhage

- 10% 🡪 fetal loss

complications

– Intraoperative bleeding

– Postoperative bleeding

– Infection

– Late Complications (cervical insufficiency and cervical stenosis.)

– complications in pregnancy (mentioned above)

Dilation & Curettage – it's a procedure to remove tissue from inside the uterus.

– The "dilation" refers to dilation of the cervix, "Curettage"

refers to the scraping or removal of tissue lining the uterine

cavity (endometrium) with a surgical instrument called a

curette

Diagnostic indications Therapeutic indications Contraindications

- Abnormal uterine bleeding

- Retained material in the

endometrial cavity.

- Evaluation of intracavitary

findings from imaging

procedures

- abnormal endometrial

appearance due to

suspected polyps or fibroids

Suction procedures for

management of uterine

hemorrhage.

- Treatment and evaluation of

gestational trophoblastic

disease.

- Hemorrhage unresponsive

to hormone therapy

Absolute:

- Viable desired intrauterine

pregnancy.

- Inability to visualize the

cervical os.

- Obstructed vagina.

– Relative:

- Severe cervical stenosis.

- Cervical/uterine anomalies.

- Bleeding disorder.

Complications:

- Bleeding or hemorrhage.

- Cervical laceration.

- Uterine perforation.

Procedure Anesthesia (general or regional)

Gradually, the cervix is widened with metal dilators to

about the size of a large pencil.

The curette, is inserted into the uterine cavity and is

used to gently scrape the lining of the uterus .

Cervical cerclage Cervical cerclage, also known as a cervical stitch, is a

treatment for cervical weakness, when the cervix starts to

shorten and open too early during a pregnancy causing either

a late miscarriage or preterm birth .

Indications Contraindications Complications

Cervical insufficiency .

Dilated or shortened

cervix early in pregnancy

.

Elective cerclage is

usually performed

between 12-18 weeks.

Active labor

Active vaginal

bleeding

Abruptio placenta

Premature rupture of

membranes

Chorioamnionitis

PROM after elective cerclage occurs

in approximately 2% of cases .

ROM intraoperatively or in the

immediate postoperative period in

nonelective cerclage, 58%.

Increased frequency of uterine

contractions .

Cervical dystocia or cervical trauma

in labor have been reported in fewer

than 5% .

Procedure (McDonald’s Cerclage)

- the cervix is exposed and grasped by Allis' or Babcock forceps.

- A purse string suture is inserted around the exo-cervix as high as possible to

approximate to the level of the internal os.

- Five or six bites are made .

- The stitch is pulled tight enough to close the internal os.

- The knot being made in front of the cervix and the end left long enough to

facilitate subsequent division.

colporrhaphy Colporrhaphy is the surgical repair of a defect in the vaginal wall, including a

cystocele (when the bladder protrudes into the vagina) and a rectocele (when the

rectum protrudes into the vagina).

During the colporrhaphy operation, a midline incision is made in the vaginal canal.

This incision gives the surgeon access to repair and restructure the weakened

underlying pelvic floor tissue that caused the prolapse.

The incision is sutured with strong, absorbable stitches. General, regional or local

anesthesia may be used depending on which option the physician believes is best

for the patient.

Risks and considerations

- Adverse reactions to anesthesia

- Excessive bleeding

- Post-operative infection, including bladder infection (more common in patients

receiving catheters)

- Painful intercourse

- Urinary incontinence

- Constipation.

- women planning on having children, or having additional children, should

postpone surgical treatment until they are no longer planning on getting pregnant.

Recovery and results

In recovery period, a catheter is inserted in the bladder, and a pack is placed in

the vagina to reduce bleeding. Both are generally removed within 48 hours.

In 70-90 % of cases, colporrhaphy successfully repairs pelvic organ prolapse.

patients are often able to fully return to their normal activities upon healing,

including sexual intercourse.

Heavy lifting, vigorous exercise are best avoided.

After three to four weeks of recovery, patients may resume light activities such as

driving and walking.

Patients generally reach full strength and recovery approximately three months

after surgery.

Common vaginal incisions 1) For vaginal prolapse : Midline incision is used, this allows

the skin to be reflected and to gain access to the fascia and

underlying tissues.

2) For vaginal hysterectomy : the vaginal mucosa around the

cervix is excised to gain access to the uterosacral ligaments

and vesicouterine space and pouch of Douglas.

– The morbidity associated with vaginal incisions is very low;

many patients experience almost no pain after vaginal

surgery.

– adhesion bands can form between the anterior and

posterior vagina, which can be troublesome and interfere with

intercourse .

Surgical sutures Surgical suture materials are essential elements :

1) Allows secure knot tying without slippage

2) Provokes little tissue reaction

3) Does not increase the risk of infection

4) Retains enough tensile strength

5)can be wholly reabsorbed by the body

Preoperative care All information should be given to the patient about success rate, outcome ,

recovery time.

– Full History

– Full Physical exam

– Investigation

– Counseling and acquiring an informed consent

– Psychological preparation

– Medical consultation

Counseling (The PREPARED Checklist)

– The Procedure

– The Reason or indication

– Our Expectations

– The Preference that the patient may have

– The Alternatives or options

– The Risks and possible complication

– The Expense

– The Decision to perform or not to perform the procedure.

Post op care & recovery – vital signs will have regular (usually 4 hourly) observations in the first 24 hours.

– Most patients will be given intravenous fluids for the first 12–24 hours after

surgery until they can resume eating and drinking.

– Pain must be assessed thoroughly , particularly pain that is more than one

would expect from a recent surgical wound or which is in a different site.

– Encourage mobilization and oral intake at the earliest opportunity.

– Single-dose antibiotic prophylaxis is usually give intraoperatively for all

gynaecological surgery.

– Usually 6 weeks is recommended before resumption of full activity and

intercourse after major surgery.

– For less major surgery a gradual resumption of activity from about 4 weeks is

acceptable.