Common Gynecologic Procedures

Objectives: 1. aware of the basic principles of common gynecologic surgical procedures. 2. become familiar with the instruments used in these procedures. 3. To know the indications and complications of each procedure.

Endometrial BiopsyIndications

Abnormal uterine bleeding: -

-postmenopausal bleeding, malignancy/hyperplasia, ovulation/anovulation, HRT

Evaluation of patient with one year of presumed

menopausal amenorrhea

Assessment of enlarged utereus (combined with US and neg HCG)

Monitoring adjuvant hormonal tx (tamoxifen)

Evaluation of infertility

Abnormal Pap smear with atypical cells favoring

endometrial origin (AGUS)

Follow-up of previously diagnosed endometrial hyperplasia

Cancer screening (e.g., hereditary nonpolyposis colorectal cancer)

Inappropriately thick endometrial stripe found on US

Endometrial dating

Indications

The International Federation of Gynecology and Obstetrics (FIGO)

--Approved a new classification system (PALM-COEIN) for causes of Abnormal Uterine Bleeding (AUB) non gravid women reproductive age. The new system, which is published in the June 2011 issue of the International Journal of Gynecology & Obstetrics,

PALM- objective structural criteria P polyp A adenomyosis L leiomyoma, M malignancy and hyperplasia).

COEIN - unrelated to structural abnormalities C coagulopathy O ovulatory dysfunction E endometrial I iatrogenic N not visually classified

Contraindications of Endometrial BiopsyPregnancy Acute PID Clotting disorders (coagulopathy) Acute cervical or vaginal infections Cervical cancer

Sterile Tray for the Procedure Sterile gloves Sterile vaginal speculum Uterine sound Sterile metal basin containing sterile cotton balls

soaked in povidone-iodine solution Endometrial suction catheter Cervical tenaculum Ring forceps (for wiping the cervix with cotton balls) Sterile 4 x 4 gauze (to wipe off gloves or equipment)

FIGURE 1. Endometrial suction catheter. (A) The catheter tip is inserted into the uterus fundus or until resistance is felt. (B) Once the catheter is in the uterus cavity, the internal piston is fully withdrawn. (C) A 360-degree twisting motion is used as the catheter is moved between the uterus fundus and the internal os.

Follow UpNormal endometrialProliferative (estrogen effect or preovulatory) Secretory (progesterone effect or postovulatory)Atrophic endometriumHormonal therapy Cystic or simple hyperplasia w/o atypiaProgress to cancer is < 5%Hormonal manipulation (medroxyprogesterone

[Provera], 10 mg daily for five days x 3months) Close follow-up w/ repeat EBx in 3-12 months

Follow-UpAtypical complex hyperplasiaProgresses to cancer in 30 to 45 %D&C to exclude endometrial cancerConsider hysterectomy for complex or high-grade hyperplasia. Endometrial carcinomaReferral to a gynecologic oncologist for

definitive surgical therapy

Pitfalls/ComplicationsThe Catheter Won't Go Up into the Uterus Easily in

Perimenopausal Patients.Insert an osmotic laminaria (seaweed) 3-mm dilator

in the patient morning of procedure.

Patients Report Cramping Associated with the

Procedure.NSAIDS before procedureTopical anesthetic

The Procedure Should Not Be Performed in

Pregnant Patients. R/O pregnancy in all women of childbearing age.

Pitfalls/ComplicationsInfection Occurs Following the Procedure.Adhere to strict sterile techniqueAntibiotics

The Pathologist Reports That the Specimens

Have Insufficient Sample for Diagnosis.Use a second pass

The Tenaculum Causes Discomfort When

Applied to the Cervix. Topical anesthetic

Endometrial Sampling ( Dilatation & Curettage) D & C

* the most common minor gynecologic surgical procedure tool - diagnostic or therapeutic - In Abnormal uterine bleeding where tendometrial or cervical cancer is suspected a thorough - fractional curettage is the best procedure .

Indications Diagnostic: 1. abnormal uterine bleeding. 2. postmenopausal bleeding ,endometrial . ca. 3. irregularities of the endometrial cavity either congenital seen on USG ( uterine septum) or acquired (submucous fibroids or polyp) can be determined during the operation.

Therapeutic:

1. endometrial hyperplasia with heavy bleeding . 2. removal of endometrial polyps or small pedunculated myomas. 3. dilatation & evacuation/ completion curettage in incomplete abortion, inevitable and missed abortion. 4. removal of missed intrauterine IUCD.

Technique instruments

Steps of D&C

Complications:

1.Perforation of the uterus. it is not uncommon complication * pregnancy. * postmenopausal endometrial carcinoma. 2. Cervical laceration. 3. Infection. 4. Hemorrhage.

Endometrial Ablation

- complete destruction of the endometrium down to the basal layer , resulting in fibrosis of the uterine cavity and amenorrhoea ( 30% ) patient satisfaction rates are over 70%

- indicated in women with heavy menstrual bleeding, w/ biopsy results negative for malignancy or no other problems that require hysterectomy .

Endometrial ablation is now well established as day case or outpatient procedure.

Endometrial Ablation make use of the resectoscope w/c is a part of hysteroscope w/c has a wire loop device - uses high frequency electrical current to cut or coagulate tissue.

Technique

Established techniques carried out under direct hysteroscopic vision and uses fluid for distention and irrigation .

These techniques are : * laser ablation. * endometrial loop resection using electro diathermy. * roller ball electro diathermy.

roller ball electro diathermy. endometrial loop resection using electro diathermy.

roller ball electro diathermy

loop resection using electro diathermy

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.

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 heat damage to adjacent structures.

Other methods of ablation Newer techniques have been developed with the aim of reducing operator dependency and minimizing risk . other techniques of ablation are : * microwave ablation. * thermal balloon ablation. They have equivalent short-term efficacy with the advantage of shorter operating times and fewer complications.

Microwave probe inserted endometrium heated to 80 C day case procedure70 -80% satisfaction rates95% return to normal

Microwave machine

Thermachoice ballon - uses a balloon placed in the uterine cavity through the cervix. - Hot water is circulated inside the balloon to destroy the endometrium - temp of 87 C for 8 mins. Limitations: uterine cavity size: 6-10 cms cannot treat submucous myoma.

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5.bin

6.bin

Thermachoice ballon

The Thermachoice System

Fig 3 - The Caveterm System

Hysterectomy

- it is the most commonly performed major gynecologic operation , - it can be performed either Abdominally , vaginally or laparoscopically.

- some indications remain controversial , high patient satisfaction levels with increasing safety for the procedure have been reported .

Types of Hysterectomy 1. subtotal 2. total 3. total unilateral or bilateral salpingo ophrectomy . 4. radical

Types of Abdominal Hysterectomy

Radical Hysterectomy

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.

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.

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.

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 .

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.

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.

14. posteriorlly , the peritoneum between the uterosacral lig. is incised transversely and the rectum is freed from the posterior aspect of the cervix & upper vagina after the uterosacral lig. 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 absorbable sutures , incorporating the cardinal & uterosacral ligs. into each lateral angle to avoid latter development of vault prolapse.

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.

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 ).

Thank you

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