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COMMON GYNECOLOGIC PROCEDURES AZZA AlYAMANI Department of Obestetrics and Gynecology. Common Gynecologic Procedures Aim of this presentation is :

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slide1
COMMON GYNECOLOGIC

PROCEDURES

AZZA AlYAMANI

Department of Obestetrics

and Gynecology

slide2
Common Gynecologic

Procedures

Aim of this presentation is :

1. students become aware of the basic principles

of common gynecologic surgical procedures.

2. become familial with the instruments that used in

these procedures.

3. and be aware of the indications and complications

of each procedure.

slide3
{1} Endometrial Sampling ( Dilatation & Curettage)

D & C

* it is the most common minor gynecologic surgical

procedure , it is used as diagnostic or therapeutic tool.

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

the endometrium as US or hysteroscopy , a thorough

fractional curettage is the best procedure

if endometrial or cervical cancer is suspected.

slide4
Indications

Diagnostic:

1. abnormal uterine bleeding.

2. postmenopausal bleeding ,end. ca.

3. irregularities of the endometrial cavity either

congenital ( uterine septum) or acquired

(submucous fibroids or polyp)can be determined

during the operation.

slide5
Therapeutic:

1. endometrial hyperplasia with heavy bleeding .

2. removal of endometrial polyps or small

pedunculatedmyomas.

3. dilatation & evacuation in inevitable and missed

abortion.

4. removal of missed intrauterine IUCD.

slide6
Technique

instruments

slide11
Complications:

1.Perforation of the uterus.

it is not uncommon complication ,it occurs in :

* RVF uterus.

* pregnancy.

* postmenopausal è endometrial carcinoma.

2. Cervical laceration.

3. Infection.

4. Haemorrahge.

slide12
Endometrial Ablation

it is the complete destruction of the endometrium

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

cavity and amenorrhoea ( 30% ) , however , patient

satisfaction rates are over 70% . Ia

It indicated in women who have heavy menstrual

bleeding that is impacting her life and do not have

other problems that require hysterectomy .

Endometrial ablation is now well established as day

case or outpatient procedure.

slide13
1. abnormal uterine bleeding.

2. benign lesions as small submucus myomas or

endometrial polyps.

Endometrial Ablation is performed using the

resectoscope which is :

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

device ) that uses high frequency electrical current to

cut or coagulate tissue.

Indications:

slide14
Technique

Established techniques carried out under direct

hysteroscopic vision involve the use of fluid for

distention and irrigation .

These techniques are :

* laser ablation.

* endometrial loop resection using electro diathermy.

* roller ball electro diathermy.

slide16
roller ball electro diathermy. endometrial loop resection

using electro diathermy.

slide19
Complications : 2%

1. uterine perforation.

2. hemorrhage.

3. infections as endometritis & PID.

4. bowel or urinary tract injury.

5. cervical lacerations & stenosis.

5. distention medium hazards as:

* gas embolism.

* fluid overload.

* anaphylactic shock.

slide20
Although the resectoscope provides excellent results in experienced hands, the technique is difficult to master. 

because all the previous techniques are:

* operator dependent .

* time consuming .

* carry risk of systemic fluid absorption.

* hemorrhage.

* uterine perforation è heat damage to adjacent

structures.

slide21
Other methods of ablation  

Newer techniques have been developed with the

aim of reducing operator dependency and minimizing

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

* microwave ablation.

* thermal balloon ablation.

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

complications.

slide22
Microwave probe inserted
  • endometrium heated to 80 C
  • day case procedure
  • 70 -80% satisfaction rates
  • 95% return to normal
slide24
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 .
slide27
Hysterectomy

it is the most commonly performed major

gynecologic operation , it can be performed either

Abdominally , vaginally or laparoscopically.

although some indications remain controversial ,

high patient satisfaction levels and increasing

safety for the procedure have been reported .

slide28
Types of Hysterectomy

1. subtotal

2. total

3. total è unilateral or bilateral salpingoophrectomy .

4. radical

slide31
Indications :
  • Abdominal hysterectomy

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

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

3. pelvic pain

chronic endometriosis , chronic PID and ruptured

tubo ovarian abscess.

4. fibroid uterus > 12 weeks in size.

5. AUB unresponsive to other lines of treatments.

6. pregnancy catastrophe as severe bleeding.

slide32
B. vaginal hysterectomy

1. utero vaginal prolapse .

2. AUB with small uterus .

pre requesits to vaginal hysterectomy :

* benign disease.

* uterus is mobile with some pelvic relaxation & no pelvic

adhesions .

* uterus is < 12 weeks in size.

slide33
C . Laparoscopic hysterectomy

* < 10% of hysterectomies performed with the

use of laparoscopy.

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

slide34
Technique

1. supine position.

2. general anaesthesia .

3. a careful abdominal & pelvic exam. under

anaesthesia is carried out.

4. incision

* vertical

in obese , if endometriosis is anticipated and patients

who have had several prior abdominal operations.

* transverse

in restricted benign disease .

slide36
5. exploration of the upper abdominal organs

especially the liver ,spleen and para-aortic lymph

nodes.

6. the abdominal viscera are packed up with towels.

7. round ligament .

each is clamped incised and ligated.

8. the vesico-uterine fold of peritoneum is incised

transversely between the incised round lig. and

the bladder is reflected inferiorly .

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

and the ureters are explored and identified.

slide37
10. the infundibulo pelvic ligs. with the ovarian

vessels are clamped , cut and ligated. if the

adnexa are to be removed.

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

exposing the uterine vessels (skeletonized).

12. the uterine vessels are clamped at the level of

internal cervical os , incised and ligated on each

side.

13. medial to the ligated uterine vessels , the

cardinal lig. on each side is clamped , incised

and ligated.

slide40
14. posteriorlly , the peritoneum between the

uterosacrallig. is incised transversely and

the rectum is freed from the posterior aspect

of the cervix & upper vagina after the

uterosacrallig. are clamped , incised & ligated.

15. the total uterus is removed by cutting across

the vagina just below the cervix .

16. the vaginal cuff is closed è absorbable sutures ,

incorporating the cardinal & uterosacralligs.

into each lateral angle to avoid latter

development of vault prolapse.

slide41
Sites of ureteric injures :

1. at clamping & incising the infundibulo pelvic

ligaments.

2. at ligating the uterine vessels.

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

urinary bladder is not sufficiently reflected

inferiorly.

slide42
Complications :

A . Intra operative

1. hemorrhage .

2. ureteric injuries.

3. bladder and bowel injury.

4. anesthetic complications.

B. Post operative

1. wound infection ( 5 days postoperatively).

2. UTI .

3. thrombophlebitis and pulmonary embolism,

( 7 – 12 days ).

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

slide45
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