Common gynaecological procedures - PowerPoint Presentation

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Common gynaecological procedures

Khozama

Jehad

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Hysteroscopy

Is

the inspection of the uterine cavity by

telescope with

access through the cervix.

It

allows for the diagnosis of intrauterine pathology

(

outpatient

hysterscopy

)

and

serves as a method for surgical intervention

(operative hysteroscopy)

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Hysteroscope

A

hysteroscope

is an endoscope that carries

optical and light channels

or fibers. It is introduced in a sheath that provides an inflow and outflow channel for insufflation of the uterine cavity. In addition, an

operative channel

may be present to introduce scissors, graspers or biopsy instruments

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https://www.youtube.com/watch?v=iiUWsA7SD3E

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Two main types : rigid and

flexible

The

flexible

hysteroscope

is most commonly used for

office hysteroscopy

. It is notable for its flexibility, with a tip that deflects over a range of 120-160°.

Its most appropriate use is to accommodate the

irregularly shaped uterus and to navigate around intrauterine lesions

. It is also used for diagnostic and operative procedures.

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Rigid hysteroscope

most

commonly 1 to 5 mm in diameter for

diagnostic procedures.

and

operative

hysteroscopes

typically range from 8 to 10 mm in diameter

may be more effective than diagnostic D&C in detecting intrauterine pathology such as

endometrial polyps ,fibroid or submucous

myomata.

Can be used for directed endometrial biopsy

Under local-intravenous or general anesthesia

During insertion, the flexible contour accommodates to the cervix more easily than does a rigid scope of a similarly small diameter.

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Indications

Any

abnormal bleeding from the uterus

can be investigated by hysteroscopy, including:

Postmenopausal

bleeding

.

Irregular menstruation,

intermenstrual

bleeding and postcoital bleeding. Persistent

heavy menstrual bleeding

Persistent discharge. Suspected

uterine malformations.Suspected Asherman’s syndrome.Essure

hysteroscopic

sterilization(

Essure

contraceptive

tubal

occlusion

device

 

)

An

operating

hysteroscope

can also be used to resect endometrial pathology

such

as fibroids and polyps

and

uterine

septums

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Preparation for hysteroscopy

Detailed medical history and clinical assessment

is important before the procedure. Before the exam is performed, a

careful bimanual

examination

is recommended to assess uterine position, shape and volume.

Pregnancy should be excluded

in relevant cases and the procedure should be avoided if

infection

is suspected.

Patient Informed consent

should be obtained after explanation of the procedure.

In women of reproductive age, it is preferable to do

the procedure in the first few days after the period finishes

as the endometrium is thin and proper assessment is easier.

The

instruments and gauze are placed on a sterile tray accessible

to the operator.

Most

hysteroscopies

are done in

lithotomy position

with the buttocks of the patient at the edge of the operating table to allow movement of the

hysteroscope

during the procedure.  

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How to carry out diagnostic hysteroscopy

Clean and drape the patient

Perform bimanual examination

Insert speculum.

Administer local

anaesthetic

if required.

Grasp anterior lip of cervix with

tenaculum

.

Dilate cervix if required (better avoided).

Place tip of

hysteroscope

against external cervical os.

Start uterine distension.

Gradually guide

hysteroscope

into uterine cavity under vision.

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uterine distension

The use of media is critical for panoramic inspection of the uterine cavity. The medium opens the potential space of the otherwise narrow uterine

cavity

,

using

either

gas

(CO2) or

fluid

(NS).

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Carbon dioxide (CO

2

):

is rapidly absorbed and easily

cleared

from the body by respiration. The gas easily flows

through

narrow channels in small-diameter scopes

**Disadvantages

:

Bubble formation reduces

visibility

Risk of gas embolismDeaths have been reported at high flow rates

Shoulder tip painBleeding reduces visibility in operative hysteroscopy as there isn't continuous irrigation as with fluid distension

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2- normal saline

The

advantage of

Normal

saline

over

gas is

the

symmetric distention of the uterus with fluid and

its effective ability to flush blood, mucus, bubbles,and

small tissue fragments out of the visual field

.**Disadvantages

:Images not as clear as with CO2, but acts as lavage in the presence of bleedingOverload

or excessive absorption can occur leading to

pulmonary

oedema

and congestive cardiac failure

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Complications

Perforation of the

uterus.

Cervical

damage – if cervical dilatation is

necessary.

If

there is infection present, hysteroscopy can cause ascending

infection.Bleeding

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Laparoscopy

Laparoscopy allows visualization of the peritoneal cavity.

This

involves

insertion of a needle called a

Veress

needle

into a suitable puncture point in the umbilicus …

together

with

insufflation with either CO2 or nitrous oxide

to distend the abdomen and left the abdomen away from the viscera ,

Under

general anesthesia .The

majority of instruments used for diagnostic laparoscopy are 5 mm in diameter, and 10 mm for therapeutic

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Upon

completion of the

procedure

hemostasis

is checked, the gas is released from the peritoneal cavity and the instruments are withdrawn.

The

small skin incisions are closed with a clip or single

subcuticular

suture

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Indications

Suspected

ectopic

pregnancy.

Ovarian

cyst accident and acute pelvic

pain.

Undiagnosed

pelvic

pain.

Tubal

patency

testing.

Sterilization.

ovarian cystectomy or oophorectomy

Endometriosis

(

for the diagnosis, staging, and treatment of ectopic endometrial tissue in both overtly symptomatic (pelvic pain) and silently symptomatic (infertility) patients.)

more extensive laparoscopic work is now performed for hysterectomy, lymph node biopsy,

omentectomy

and myomectomy.

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https://www.youtube.com/watch?v=WFS-IUxVQL0&t=33s

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Complications

Complications are

uncommon

, but

include:

damage

to any of the intra-abdominal structures

, such as bowel and major blood vessels.

The

bladder is always emptied prior to the procedure to avoid bladder injury

.

Incisional hernia

has been reported.

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Thank

you