PRINCIPLES OF GYNECOLOGICAL PROCEDURES DONE BY ABDALLAH AMJAD
PRINCIPLES OF GYNECOLOGICAL PROCEDURES DONE BY: ABDALLAH AMJAD RIYALAT
MOST GYNAECOLOGICAL PROCEDURES WERE PERFORMED BY SURGEONS • SO LET’S MEMORIZE SOME ANATOMY ……………
OVIDUCT
1. HYSTERECTOMY • MAJOR INPATIENT SURGICAL PROCEDURE • PERFORMED UNDER EITHER REGIONAL OR GA • CAN BE PERFORMED : 1. ABDOMINALLY 2. VAGINALLY 3. LAPROSCOPICALLY 4. LAPROSCOPIC-ASSISTED
INDICATIONS EMERGENT INDICATIONS: • ACUTE UTERINE UNCONTROLLABLE BLEEDING • CONVERSION FROM ANOTHER GYNECOLOGICAL PROCEDURE.
INDICATIONS ELECTIVE INDICATIONS: • UTERINE FIBROIDS (30%) • PELVIC ORGAN PROLAPSE (15%) • SEVERE AND INTRACTABLE ENDOMETRIOSIS (20%) • ADENOMYOSIS • PELVIC INFLAMMATION • NON-ACUTE ABNORMAL BLEEDING • MALIGNANT AND PREMALIGNANT CONDITIONS (ADNEXAL MASSES)
TYPES • SUBTOTAL (SUPRACERVICAL) • TOTAL(SIMPLE) • RADICAL
SUBTOTAL REMOVES ONLY THE CORPUS OF THE UTERUS LEAVING THE CERVIX IN PLACE ABSOLUTE CONTRAINDICATION TO SUBTOTAL HYSTERECTOMY • PRESENCE OF A MALIGNANT OR PREMALIGNANT CONDITION OF THE UTERINE CORPUS OR CERVIX
TOTAL: • THE MOST COMMON PROCEDURE , REMOVES THE CORPUS AND CERVIX Indications
RADICAL • REMOVAL OF UTERUS , CERVIX, SURROUNDING TISSUES LIKE CARDINAL LIGAMENTS UTEROSACRAL LIGAMENTS AND UPPER VAGINA
ABDOMINAL HYSTERECTOMY • THE PROCEDURE INVOLVES TAKING THREE PEDICLES: • THE INFUNDIBULOPELVIC LIGAMENT, WHICH CONTAINS THE OVARIAN VESSELS. • THE UTERINE ARTERY. • THE ANGLES OF THE VAULT OF THE VAGINA, WHICH CONTAIN VESSELS ASCENDING FROM THE VAGINA; THE LIGAMENTS TO SUPPORT THE UTERUS CAN BE TAKEN WITH THIS PEDICLE OR SEPARATELY.
VAGINAL HYSTERECTOMY • THE SAME STEPS ARE TAKEN BUT IN THE REVERSE ORDER. • IF THE UTERUS IS OF NORMAL SIZE, HYSTERECTOMY CAN BE PERFORMED VAGINALLY, EVEN IN THE ABSENCE OF SIGNIFICANT PROLAPSE.
LAPAROSCOPY • USED TO AID VAGINAL SURGERY, TERMED LAPAROSCOPIC-AIDED VAGINAL HYSTERECTOMY (LAVH) IN WHICH THE FIRST TWO STEPS ARE COMPLETED LAPAROSCOPICALLY AND THE THIRD VAGINALLY. • THE ENTIRE OPERATION CAN BE PERFORMED LAPAROSCOPICALLY, WITH THE UTERUS REMOVED THROUGH THE VAGINAAND THE OPEN VAULT CLOSED WITH LAPAROSCOPIC SUTURES, TERMED TOTAL LAPAROSCOPIC HYSTERECTOMY (TLH). ALTHOUGH AT THE MOMENT THE PROCEDURE TIME AND HENCE ANAESTHETIC MAY BE LONGER, POSTOPERATIVE PAIN AND RECOVERY LESS TIME WILL BE
VAGINAL VS ABDOMINAL HYSTERECTOMY Characteristic Abdominal hysterectomy Length of stay 3. 99 (days) 3. 4 Hemorrhage (percent) Postoperative fever 4 Vaginal hysterectomy 2. 76 2. 4 0. 8 Bladder injury 0. 2 Other Complications 9. 3 5604 4166 Median charge (dollars)
COMPLICATIONS OF HYSTERECTOMY • HAEMORRHAGE (INTRA- OR IMMEDIATE POSTOPERATIVE) • DEEP VEIN THROMBOSIS (PELVIC SURGERY). • NEW BLADDER SYMPTOMS (BOTH OVERACTIVE BLADDER AND STRESS INCONTINENCE). • HIGHER INCIDENCE OF VAGINAL PROLAPSE AFTER HYSTERECTOMY FOR ANY CAUSE • BLADDER INJURY (UNCOMMON). • URETERIC INJURY (RARE). • RECTAL INJURY (RARE). • VESICOVAGINAL OR RECTOVAGINAL FISTULA (CONSEQUENCE OF INJURY) (VERY RARE). • EARLY ONSET OF MENOPAUSAL SYMPTOMS (IF OVARIES LEFT IN SITU). • IMMEDIATE ONSET OF MENOPAUSAL SYMPTOMS (IF OVARIES REMOVED IN A
STUDY RESULT……. THE CHOICE OF ABDOMINAL OR VAGINAL ROUTE FOR HYSTERECTOMY HAS TO BALANCE THE BENEFITS AND RISKS OF EACH APPROACH IT IS NOW GENERALLY AGREED THAT VAGINAL SURGERY REQUIRES A SHORTER TIME IN HOSPITAL AND LESS RECOVERY TIME BEFORE FULL MOBILITY AND ACTIVITY IS RESUMED
PRE & POST OPERATIVE ASSESSMENT: 24
PREOPERATIVE CARE • FULL HISTORY • FULL PHYSICAL EXAM • INVESTIGATION • COUNSELING AND ACQUIRING AN INFORMED CONSENT • PSYCHOLOGICAL PREPARATION • MEDICAL CONSULTATION 25
HISTORY • PATIENT PROFILE • CHIEF COMPLAINT (TYPE OF SURGERY) • COMPLETE REVIEW OF SYSTEM; RESP. DISEASES, CVS DISEASE INCLUDING DVT, EXERCISE TOLERANCE • PAST MEDICAL* HISTORY; HYPERTENSION, DIABETES, BLEEDING DIATHESIS • TAKE DETAILED DRUG *HISTORY; ANTICOAGULANT, ASPIRIN, NSAID & ALLERGY TO DRUGS • SURGICAL AND ANESTHESIA HISTORY • GYNECOLOGICAL AND OBSTETRICAL HISTORY • SOCIAL HISTORY; ALCOHOL INTAKE, SMOKING 26
PHYSICAL EXAM -BASED ON HISTORY INFORMATION -PRE-ANESTHESIA PHYSICAL EXAMINATION : ( AN ASSESSMENT OF THE AIRWAY, LUNGS AND HEART, WITH DOCUMENTATION OF VITAL SIGNS) -UNEXPECTED ABNORMAL FINDINGS INVESTIGATED BEFORE ELECTIVE SURGERY. 27
INVESTIGATIONS -NOT ON A ROUTINE BASIS. - RISK-BENEFIT RATIO OF ANY ORDERED LAB TEST ? ? * Age < 40 o o Minor surgery CBC ( Hb, Plt, WBC ) Blood group* Control the chronic disease (DM, HTN, Thyroid) Consent Form Major surgery o All above + cross match 2 unit of blood Age > 40 Follow the same step but you also have to do: o KFT o Random blood sugar o ECG o Chest X ray* Beta HCG ? !!* 28
WHEN TO STOP THE DRUGS BEFORE SURGERY? 1. ANTICOAGULANTS: • WARFARIN: STOP THE DRUG, DAILY INR* UNTIL NORMAL (TARGET 1. 5), THEN GIVE LMWH • LMWH*: MUST BE STOPPED 12 HRS PRIOR TO SURGERY 2. ANTI-PLATELET (ASPIRIN): 7 -10 DAYS PRIOR TO SURGERY 3. ORAL CONTRACEPTIVE: 2 -3 MONTH PRIOR TO SURGERY. 29
PREOPERATIVE CARE COUNSELING IS CONSIDERED AN IMPORTANT PART OF PREOPERATIVE CARE…>> 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. 30
General Risks Associated with Procedures INTRA-OP POST-OP Late 31
INTRAOPERATIVE RISKS INCLUDE: 1. ANESTHETIC COMPLICATIONS * : 2. INTRA OP. BLEEDING 3. UNINTENDED DAMAGE TO ORGANS OR TISSUE 32
THANK YOU
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