Transcript Vaginal Procedures

• Amenorrhea -absence of menstruation
• Anteversion- turning forward; inclining
forward as a whole without bending
• Carcinoma in situ -noninvasive cancer
located in a small area of the epithelial
layer
• Cesarean section
-removal of the
fetus by abdominal incision into the uterus
• Chromotubation • Clitoris -an organ of sensitive, erectile
tissue located anterior to the vaginal orifice
and in front of the urethral meatus.
• Conization - excision of a cone of tissue
• Curette -an open spoon-shaped
instrument used to scrape tissue from a
surface
• Cystocele -herniation of the bladder into the
vaginal canal
• Dilation -act of stretching or enlarging an organ
or part of the body
• Dilation and curettage (D&C) • Dilation (widening of cervical canal) by
insertion of probes of increasing sizes.
• Curettage – scraping the inner lining of the
uterus; to remove the lining of the uterus
• Dysplasia -abnormal growth or development
• Ectopic pregnancy -a pregnancy that occurs
when the fetus lodges in a location other than
the uterus
• Endometriosis
-presence of functioning
endometrial tissue in places where it is not
normally found
• Enterocele -herniation of the cul-de-sac of
Douglas which usually contains loops of small
intestine
• Episiotomy -incision into the perineum during
normal labor to prevent lacerationsand to
facilitate delivery with less trauma
• Excision-surgical removal of a portion of a
structure or organ; to cut out
• Presentation -manner in which the fetus is
positioned in relation to the cervix
• Rectocele -herniation of the rectum into the
vaginal canal
• Retroversion -a turning backward, as of the
uterus
• Salpingooophorectomy -removal of the ovary
and the fallopian tubes
• Stress incontinence - inability of the body to
control the evacuative function because of
physical stress on body parts involved
• Tubal ligation -sterilization; blocking of the
fallopian tubes by burning or cutting them and
tying them off.
• Uterus -womb; organ that holds the embryo and
fetus as it develops
• Vaginal vault -the dome or upper part of the
vagina
• Vestibular glands - these glands release
mucus into the vestibule and help to keep it
moist and lubricated, facilitating intercourse
• Vulva -external genitalia (reproduction organs)
of female collectively
Purposes of obstetrics and
gynecological surgery
• To diagnose abnormal conditions
• To treat abnormal conditions
• To assist infertile couples to conceive
Type of Abortions
• Missed abortion – Product of conception (fetus)
is nonliving and is retained in the uterus for 2
mos. or longer.
• Incomplete abortion -part of the product of
conception has been retained in the uterus
• Imminent abortion - patient is about to abort
• Spontaneous abortion -abortion occurring
without having been induced
• Voluntary interrupted abortion - abortion
performed because patient wants to terminate
pregnancy
Obstetrical Complications
• ectopic pregnancy - fertilized ovum
becomes implanted outside the uterus
• incompetent cervical os - [cervical os =
cervical opening before placenta previa]
• placenta previa - placenta is abnormally
implanted in the lower uterine segment
» and may completely cover the os cervix
Gynecological complications
• Amenorrhea absence of
menstruation
• Lesions areas of pathologically
altered tissue that may occur on or in
» all reproductive structures and may be malignant or
benign
• sexually transmitted diseases communicable diseases in both men and
women
Diagnostic techniques used by
Gynecologists
• Colpotomy (vaginotomy) a cutting
operation in the vagina
• Conization of the cervix - biopsy taken
with a scalpel or cervitome to include the
» squamo-columnar junction of the ectocervix and
tapered to include the endocervical canal to the level
of the internal os
• hysterosalpingography - insertion of a
water-soluble radiopaque dye into the
» cervical canal to study the structure and function of
the uterus and tubes in the evaluation of infertility
• hysteroscopy direct visualization of the
interior of the uterus to diagnose
» or treat disease via a fiberoptic scope
• laparoscopy endoscopic visualization of
the peritoneal cavity through the
» anterior abdominal wall after the establishment of a
pneumoperitoneum
• Schiller’s test staining the vaginal vault
and cervical squamous epithelium with
» an iodine solution to pinpoint abnormal tissues which do
not stain brown as normal tissues do
Abdominal Procedures
• Anterior exenteration - removal of the reproductive
organs, distal part of the
» ureters, bladder, and vagina with resulting diversion of ureters to
an ileal conduit for cancer of the cervix, vagina, or vulva with
extension to the bladder
• cesarean section removal of the fetus by
abdominal incision into the uterus
• laparoscopy
endoscopic visualization of the
peritoneal cavity through the
» anterior abdominal wall primarily used as a diagnostic procedure,
but which may also be used for other procedures such as
aspiration of cysts, release of adhesions, tissue biopsies, and
tubal ligations
• Marshall-Marchetti-Krantz (MMK) - suspension of the
bladder to the
» symphysis pubis to correct stress incontinence
• myomectomy removal of fibromyomas
from the uterine wall for pressure
» symptoms in women desiring children
(C-section)
• oophorectomy - removal of an ovary
• oophorocystectomy - removal of an ovarian
cyst
• posterior exenteration • radical hysterectomy en bloc dissection
and removal of all pelvic lymph nodes
» and wide removal of uterus, tubes, ovaries, supporting
ligaments, and upper vagina
• salpingectomy
removal of a fallopian
tube
• salpingo-oophorectomy removal of a tube and all
or part of the associated ovary
• salpingostomy
establishing an artificial
opening in a fallopian tube in which the
» fimbriated extremity has been closed by inflammation
• subtotal hysterectomy - removal of body of uterus,
leaving the cervix in place
• total hysterectomy - removal of entire uterus, including
the corpus and the cervix
• tubal ligation - interruption of fallopian tube continuity
designed to sterilize
» the patient
Vaginal Procedures
• D&C Dilation & Curettage is the dilation
of the os cervix and curetting of endocervical
» and/or endometrial tissue to obtain tissue for microscopic
examination, to halt uterine bleeding, to terminate
pregnancy, or to remove tissue following an incomplete or
missed abortion
• Suction curettage
vacuum aspiration of
intrauterine contents performed for
» termination of pregnancy or for early incomplete
spontaneous abortion
• conization of the cervix - excision of cone of
tissue from the cervix to remove a
» cancerous lesion or tissue for biopsy
• Marsupialization of Bartholin’s duct cyst or
abscess -- removal or incision of the cyst
» through the vaginal outlet and drainage of the area
• Anterior and posterior repair -- reconstruction of
the vaginal walls, the pelvic floor, and
– the muscles and fascia of the rectum, urethra, bladder, and
perineum to correct a cystocele and a rectocele and to
reestablish the support of the anterior and posterior vaginal
walls and thereby restore the bladder and rectum to their
normal positions
• Shirodkar or MacDonald cerclage operation postconceptional placement of a collar-type
» ligature at the level of the internal os to close it for
incompetence of the cervix
• Vaginal hysterectomy -- removal of the uterus
through an incision made in the vaginal
» wall and the pelvic cavity
• Simple vulvectomy -removal of the labia majora
and labia minora, possibly the glans clitoris,
– and occasionally the perianal area with a plastic closure for
treatment of carcinoma in situ of the vulva
• LeFort operation (Colpocleisis) procedure
which obliterates the vagina by denuding and
» approximating the anterior and posterior walls to correct
uterine prolapse; generally performed only on elderly
patients
• Hysteroscopy direct visualization of the
interior of the uterus to diagnose or treat
– disease via a fiberoptic scope
• Laparoscopic assisted vaginal hysterectomy removal of the uterus through an incision
» in the vaginal wall and pelvic cavity, with the addition of a n
endoscope for visualization.
• Trachelorrhphyremoval of torn surfaces of
the interior and posterior cervical
» lips and reconstruction of the cervical canal when surfaces
are free of infection and women are past child bearing age.
» (med. Dict. = suture of a laceration of the uterine cervix)
Most common lasers
• – Argon
»
»
»
»
CO2
ND:YAG
Applications of lasers for Gyneclogical surgery –
Eradication of Bartholin’s duct abscess
Types of Genital Fistulas
• rethrovaginal fistula
between urethra & vagina
fistual
• Vesicovaginal fistula
between cervix & vagina ????
fistual
• Rectovaginal fistula
between rectum & vagina
fistual
-
Special features of obstetrics
and gynecologic operations
• Patient is catheterized in OR (if not beofre) to prevent the bladder
from becoming distended during the surgical procedure and to
record urinary output.
• Spinal or general anesthesia is primarily used.
• Vaginal procedures are usually performed with the patient in
lithotomy position.
• Because of hazards of infection, separate sterile setups for vaginal
& abdomen performed concurrently.
• Medicated vaginal packing may be inserted following certain
procedures.
• In the abdominal approach, supine or Trendelenburg position is
used.
• Instrumentation for abdominal procedures includes basic laparatomy
setup with the addition of long instruments for deep manipulations
within the pelvis and/or laparoscopic instruments.
Basic OB/GYN medications and
solutions
• Lugol’s solution - strong iodine solution
applied to vaginal tissue and the cervix
» to identify abnormal tissue
• methylene blue - dye used diluted in
normal saline during chromotubation
» to check for patency
Specialized abdominal
hysterectomy instruments
• O’Sullivan-O’Connor retractor
• Heaney hysterectomy forceps or HeaneyBallentine forceps
• Heaney needleholder (curved at end)
• Jorgenson scissors (long) (curved)
Specialized vaginal instruments
• Auvard vaginal speculum, weighted
• Graves self-retaining vaginal speculum
(duck bill)
• Uterine sound
• Leep loop electrodes - used to take 1 cervical
biopsy at the cervical
» canal providing hemostasis at same time
• Uterine forceps
• Hysteroscope set
• Uterine manipulator
end of cervical canal to allow
inserted into the
» for the manipulation of the uterus during laparoscopic
procedure & some require suction during procedure
• entrauterine cannula
uterine
manipulators; methylene blue administered
» into the tube
• Benton forceps
used to clamp edges of
the uterus after delivery
» of infant during C-section
Procedure for D & C
• With the patient in the lithotomy position, surgeon inserts
a weighted speculum
• into the vaginal outlet and grasps the cervix with a tenaculum.
• Surgeon carefully introduces a graduated sound into the
cervix to determine the depth and direction of the uterine
cavity and therefore precent perforation during the
procedure.
• Surgeon uses curette of choice to obtain an endocervical
tissue specimen.
• Surgeon passes endocervical specimen to technologist.
Two specimens are usually taken and must be kept
separate and labeled as such.
• Surgeon slowly dialates the cervix using Hegar or Hanks
uterine dilators.
• Surgeon places a Telfa strip over the
speculum.
• Surgeon gently curettes uterus, allowing
the endometrial specimen to collect on the
Telfa.
• Surgeon passes endometrial specimen to
technologist, and removes the speculum.
• Surgeon or scrun person dresses
perineum with a perineal pad.
Procedure for Repair of a
Cystocele and Rectocele
• Patient is placed in lithotomy position, prepped, and
circulator performs a
• straight catherization.
• Surgeon inserts a weighted speculum into the vaginal
outlet, grasps the cervix
• with a tenaculum, and brings it forward.
• Surgeon makes an incision in the anterior vaginal wall.
• Incision edges are grasped with several clamps and
retracted.
• Surgeon deepens the incision with sharp and blunt
dissection, and advances the
• incision through the vaginal wall and into the fascia that lies behind
it using additional clamps as needed.
• When bladder neck is reached, surgeon places several
absorbable sutures,
• size 0, through the fascia, thus tightening the tissue to prevent the
bulging.
• Surgeon excises the vaginal mucosa, and approximates
the vaginal walls with
• absorbable sutures to complete the anterior repair.
• To begin the posterior repair, surgeon places 2 Allis
clamps on each side of the vaginal outlet on the
posterior side.
• Assistant offers traction with the clamps while surgeon
makes a transverse incision in the mucosa.
• Surgeon deepens the incision with curved Mayo or
Metzenbaum scissors to the level of the rectum.
• To correct the bulging of the rectum, surgeon brings the
levator muscles together with interrupted absorbable
sutures, size 2-0.
• Surgeon excises the excess vaginal mucosa, and
reconstructs the vaginal wall with interrupted absorbable
sutures, size 2-0 swaged to a small needle.
• Surgeon usually inserts a Foley or suprapublic
catheter, and dresses the vagina with medicated
packing.
Vaginal Hysterectomy
• Patient is placed in the lithotomy position,
prepped, and bladder is drained.
• Surgeon grasps the cervix with a uterine
tenaculum, and makes a circular incision
• around the cervix using the knife or curved Mayo scissors.
• Surgeon double-clamps, divides, and ligates the
first set of ligaments with absorbable
• suture ligatures of size 1 or 0 mounted or
swaged to a heavy tapered needle.
• Surgeon picks up the posterior peritoneum with toothed
tissue forceps and incises it
• with the knife or scissors.
• Surgeon detaches the peritoneal attachment to the
bladder with Mayo scissors.
• Surgeon continues mobilization of the uterus using long
tissue forceps and long
• dissecting scissors.
• When uterus is mobilized, surgeon delivers it to the
technologist as a specimen.
• Surgeon reperitonealizes the bladder, closes the
peritoneum, inserts a Foley catheter,
• and may dress the wound with a perineal pad.
Procedure for Abdominal
Hysterectomy
• Patient is placed in supine position, prepped, abdominally and
vaginally and a Foley
• catheter is inserted.
• Surgeon incises abdomen using a lower midline incision or
Pfannanstiel incision, and
• deepens the incision through the subcutaneous tissue with the deep knife or
electrosurgical pencil.
• Surgeon nicks fascia with the knife, incises with curved Mayo
scissors, grasps fascial
• margin with two or more Kocher clamps, and separates fascia from
underlying muscle using blunt dissection.
• Surgeon divides the muscle layer manually.
• Surgeon nicks peritoneum with the knife, lengthens with
Metzenbaum scissors, and places in wound a self-retaining retractor
such as O’Connor-O’Sullivan or Balfour.
• Surgeon packs bowel away from the uterus with moist lap sponges.
• Surgeon isolates the uterus by severing it from the
uterine ligaments, ovaries, and fallopian tubes by
double-clamping, dividing, and ligating with absorbable
sutures.
• Surgeon separates the uterus and the bladder using
Mayo scissors and tissue forceps by dissecting the
peritoneal covering away from the bladder.
• Surgeon mobilizes uterus, places long Allis or Kocher
clamps around the margin of the vaginal cuff, and then
divides it from the vagina using long scissors or the long
knife to completely free the uterus.
• Surgeon passes uterus to technologist as a
specimen and places all instruments that have
come in contact with the cervix or vagina in the
designated basin.
• Surgeon closes vaginal vault usually with the
same type of suture used on the uterine
ligaments while a sponge count is taken.
• Surgeon reperitonealizes the bladder flap with 20 or 3-0 absorbable swaged suture.
• Surgeon closes the layers of the abdomen using
sutures of choice.
Procedure for Laparoscopy
• Patient is placed in a modified lithotomy position
with lowered stirrups, is vaginally
• and abdominally prepped, and the bladder is drained.
• Technologist gloves surgeon.
• Surgeon inserts uterine manipulator into the
cervix.
• Circulator removes surgeon’s gloves and
technologist gowns and gloves the surgeon.
• Surgeon makes a small nick in the abdominal
wall close to the umbilicus.
• Surgeon inserts an insufflation needle through the
incision and attaches a 10-cc syringe filled with saline
solution so the surgeon can aspirate to make sure that a
blood vessel has not been punctured.
• Surgeon attaches a length of flexible tubing to the needle
while one end of the tubing is passed to the circulator,
who connects it to the insufflator.
• Circulator activates the insufflator and the abdomen is
slowly filled with carbon dioxide which creates a
pneumoperitoneum.
• When sufficient gas has entered the abdomen, surgeon
withdraws the needle
• Technologist dips scope in hot water or antifogging
solution wipes the lens with soap so the scope’s lenses
do not fog.
• Surgeon inserts the laparoscope into the sleeve and
connects the light source cable.
• Surgeon examines the abdominal contents for disease
or injury, and then performs whatever additional
procedure is decided upon, if needed.
• Surgeon allows gas to escape through the sleeve,
removes the sleeve, closes the incision(s) with
subcuticular absorbable suture, and dresses with
adhesive-bandages (Band-Aids).
Hysterectomies
• allows for easier removal of the tubes and
ovaries (& appendix)
• At the same time
• Provides better exposure
• Is operation of choice for leiomuomata, adenomyosis, &
uterine cancer
• Is indicated for fibroid tumors that may be too large to
remove vaginally
• Is a cleaner procedure since it is not near the anal area
• Allows for exploration of abdominal organs, esp. if cancer is
suspected
Vaginal
• leaves no visible incision scar
• Is indicated for prolapse of the
uterus
• Procedure requires least amount
of time
• Recovery period requires less
time
Laparoscopic assisted vaginal
hysterectomy
• Lease minimal scars at puncture
sites
• Leaves no visible incision scar
• Is indicated for prolapse of the
uterus
• Provides better exposure
• Recovery period requires less time
• Allows for exploration of abdominal
organs, esp. if cancer is suspected
Procedure for a Cesarean
Section
• When the patient is placed in the supine
position, her right hip may be elevated.
• When spinal anesthesia is used, the patient
will be prepped after being Anesthetized with
general or spinal and then prepped.
• Surgeon enters through lower midline
incision or pfannenstiel.
• Assistant retracts downward with bladder
retractor.
• Assistant pushes firmly on the upper
abdomen while surgeon grasps newborns
head and takes it upward.
Procedure for a Cesarean
Section cont.
• Cord samples
• Four blood samples are taken
• Surgeon manually takes the placenta and places on
the field.
• Surgeon closes uterus using preferred clams and
suture while first count is taken.
• Surgeon closes layers of abdomen with suture of
choice.
• Note: After the newborn is delivered, he/she is
normally handed over to the
• Pediatrician for neonatal care and assessment