Principles of Gynecological procedures - PowerPoint Presentation

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Principles of Gynecological procedures

Done by: Abdallah Amjad

riyalat

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Most gynaecological

procedures were performed by surgeons

SO let’s memorize some anatomy ……………

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Oviduct

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1.Hysterectomy

Major inpatient surgical procedure

Performed under either

regional

or

GA

Can be performed :

1.Abdominally

2.Vaginally

3.Laproscopically

4.laproscopic-assisted

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INDICATIONS

Emergent indications:

Acute uterine uncontrollable bleeding

Conversion from another gynecological procedure.

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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)

INDICATIONS

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Types

Subtotal (

supracervical

)

Total(simple)

radical

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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

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TOTAL:

the most common procedure ,removes the corpus and cervix

Indications

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Radical

removal of uterus ,

cervix,surrounding

tissues like cardinal ligaments uterosacral ligaments and upper vagina

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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.

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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.

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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 vagina and 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 time will be less

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Vaginal vs Abdominal Hysterectomy

Characteristic

Abdominal hysterectomy

Vaginal hysterectomy

Length of stay (days)

3.99

2.76

Hemorrhage (percent)

3.4

2.4

Postoperative fever

4

0.8

Bladder injury

0.2

0.2

Other Complications

9.3

5.3

Median charge (dollars)

5604

4166

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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 premenopausal woman

).

Thromboembolism.

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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

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Pre & post Operative Assessment:

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Preoperative Care

full History

full Physical exam

Investigation

Counseling and acquiring an informed consent

Psychological preparation

Medical consultation

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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

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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.

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Investigations

-

not on a routine basis

.

-

risk-benefit ratio

of any ordered lab test ??*

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Age < 40

Age > 40

Minor surgery

CBC (

Hb

,

Plt

, WBC )

Blood group*

Control the chronic disease (DM, HTN, Thyroid)

Consent Form

Follow the same step

but you also have to do:

KFT

Random blood sugar

ECG

Chest X ray*

Major surgery

All above +

cross match

2 unit of blood

Beta HCG ?!!*

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When to stop the drugs before surgery?

Anticoagulants:

Warfarin

: Stop the drug, Daily INR* until normal

(target 1.5)

, then give LMWH

LMWH*

: must be stopped 12hrs prior to surgery

Anti-platelet (

Aspirin

): 7-10 days prior to surgery

Oral contraceptive

: 2-3 month prior to surgery.

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Preoperative Care Counseling

Counseling

is considered an important part of preoperative care…>>

The

PREPARED

Checklist

The

p

rocedure

The

R

eason or indication

Our

E

xpectations

The

p

reference that the patient may have

The

A

lternatives or options

The

R

isks and possible complication

The

E

xpense

The

D

ecision to perform or not to perform the procedure.

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General Risks Associated with Procedures

INTRA-OP

POST-OP

Late

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Intraoperative risks

include:

Anesthetic

complications * :

Intra op.

bleeding

unintended

damage

to organs or tissue

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Thank you