SUR 122

OBSTETRICAL&

GYNECOLOGICALSURGERY

OB-GYN Surgery

Female From beginning of menses

OB-GYN Specialists

Obstetricians: pregnancy Gynecologists: Breast Surgery (non-reconstructive) Bladder Tac related Surgeries: pubovaginal Sling, TVT (tension vaginal tape, A & P Repair, etc.) Can be both or one or the other

Fertility Specialists Oncology Gynecologist

Obstetrical & Gynecological Surgery

Reasons For: Diagnose abnormalities Treat abnormalities Pain relief Prevention of pregnancy Aide in conception for infertile couples Prevention of spontaneous abortion Cesarian delivery (abdominal) when

vaginal delivery not possible

The Female Reproductive System

Anatomy & Physiology Pathology Diagnostic & Pre-operative Testing Anesthesia & Medications Basic Supplies, Instrumentation, &

Equipment Positioning, Prep, & Draping Dressings, Drains, & Post-operative Care

Pelvis

Pelvic girdle Ilea Ischia Pubic bones Vertebral column Sacrum

Anatomy & Physiology

External Female Genitalia (Vulva) Mons pubis Labia majora Labia minora Urethral orifice Vaginal orifice Clitoris Hymen Perineum Anus

External genitalia

Labia minora form the clitoris and contain sebaceous glands

Vestibule is the cavity between the labia minora Contains urethral meatus and Bartholin’s

(vestibular) glands

Perineum is the area between vaginal opening and anus

Can stretch with delivery however is frequently cut with an incision called episiotomy to prevent spontaneous tears during vaginal delivery

Internal Structures

Vagina External Cervical Os Cervix Uterus Layers of:1. peritoneum2. myometrium3. endometrium Parts of:4. Body5. Fundus

Adnexa Fallopian Tubes Ovaries Supporting Structures

Vagina

Receptacle to penis Passageway for menstrual flow Lower portion is the birth canal

Uterus

Function: Site of menstruation Or Site of implantation

if implantation occurs then is the site of fetal development

Uterus

Parts of: Dome shaped portion=fundus Central portion=body Where narrows=cervix Internal cervical os=where uterus

and cervix meet External os=where cervix meets

vagina

Uterus

Lining of:1. Perimetrium=outside of uterus covered in a this

serous membrane lining2. Myometrium=-smooth muscle lining-middle layer-fetal support-during labor expels fetus with assistance of hormone oxytocin

3. Endometrium=inner lining2 parts:

a. stratum basalis permanent layerthin

b. Stratum functionalis-produced by s. basalis-temporary layer-shed w/menstruation-produces maternal portion of placenta

Uterus

Blood supply: Uterine artery and uterine vein

Ovaries

Function: Production and expulsion of oocytes (ova

or eggs) Release of hormones: estrogen and

progesterone

Are both endocrine and exocrine glands Exocrine produce eggs (ducts=fallopian

tubes) Endocrine portion produces estrogen and

progesterone

Ovaries

Attachments:1. Broad ligament-largest formed by a fold of

peritoneum-contains fallopian tube, round and

ovarian ligaments, blood vessels, lymphatics, and nerves

Suspensory ligament Ovarian ligament

Ovaries

2. Suspensory ligament-small peritoneum fold-holds ovaries at upper end-contains blood vessels and nerves3. Ovarian ligament -attaches ovaries at their lower end-is actually a thickening in the broad

ligament

Fallopian tubes

Egg is caught by finger-like projections called the fimbrae after it is released from the ovary

Funnel shaped end prior to fimbrae=infundibulum

Fallopian tubes

2 layers:1.Mucous membrane innermost Is lined with ciliated columnar

epithelial tissue Allows for movement of the egg Scarring from STDs can damage or

scar this lining rendering a female sterile

Fallopian tubes

2. Muscularis Smooth muscle Peristalsis or movement of the egg So… Egg movement through the fallopian

tubes occurs by cilia and peristalsis Fertilization must occur in the distal 1/3 of

the fallopian tubes for successful implantation into the uterus

Physiology

Ovarian cycle caused by anterior pituitary gland which secretes:

LH “ovulation hormone”

FSH levels must be low to allow ovulation Causes secretion of estrogen Menses is caused by a sudden decrease in

estrogen and progesterone triggered by no fertilization

Hormones

1. FSH Produced in anterior lobe pituitary Causes graafian follicular

development Causes estrogen secretion

Hormones

2. LH Produced in anterior lobe pituitary Continues follicular development Stimulates estrogen and

progesterone production Causes ovulation

Hormones

3. Estrogen Maintenance and development of

reproductive organs and female sex characteristics

Hormones

4. Progesterone Primary cause of endometrial

changes

With Prolactin (hormone) influences mammary glands to develop and secrete milk

Milk secretion and labor is stimulated by oxytocin (hormone)

Physiology

In the ovary > the big 4 hormones are increasing which develops a follicle

Follicle becomes a graafian follicle Graafian follicle rupture>egg released

into fallopian tubes Outer rind of graafian follicle becomes

corpus luteum

Physiology

2 possibilities: No fertilization=corpus luteum degenerates and

becomes corpus albicans and cycle starts over Fertilization=corpus luteum maintained four

months to suppress egg production and menstruation with estrogen and progesterone

Progesterone levels must be high enough to maintain endometrial lining to sustain pregnancy

Corpus luteum acts as a temporary endocrine gland

After four months placenta is developed and takes over

Obstetrics

Pregnancy (Obstetrics) Procedures

Cerlage (MacDonald or Shirodkar) Deliveries:1. Vaginal2. Cesarian sections (C-sections) Tubal ligations (sterilization

procedures) Emergent hysterectomy

Pregnancy Terminology

Labor Four stages of:1. True labor onset2. Cervical dilation

complete>birth3. Birth>placental

delivery4. Placental delivery

> stabilization of mother

Primapara1. 6-18 hours2. ½ - 3 hours (dilation 1

cm/hr)3. 0-30 min4. 6 hours Multipara 1. 2-10 hours2. 5-30 min (dilation

1.2cm/hr)3. 0-30 min4. 6 hours

Pregnancy Terminology

Braxton Hicks - “false labor” Bloody show – onset of labor Cervical dilation - cervical

measurement (0 to 8cm) Cervical Effacement – thinning of

cervix Crowning - neonate head

circumference at its largest point as it passes thru vulvar ring

Pregnancy Terminology

Descent – movement of fetus thru pelvis with contractions

Expulsion – delivery of infant Gravida - how many times a woman has been

pregnant Parity – number of time a woman has given birth Position – relationship between presenting infant

part & pelvis of mother (OA) most common Presentation – fetal part overlying pelvic inlet Station – measurement of the descent of the

infant’s presenting part thru the ischial spines

Presentation

Breech - buttocks first Transverse – crosswise Footling – feet Vertex – upper back of head

Obstetrical Complications

Placenta previa – placental implantation over cervix

Abruptio Placenta – premature placental separation

Obstetrical Complications

Abortions Missed Incomplete Imminent Spontaneous Voluntary

Pathology

Benign Cysts Polyps (pedunculated lesion) Fistulas Dysplasia Leiomyoma/Myoma/Fibroid Fibroma

Malignant Vulvar Vaginal Cervical Uterine Ovarian

Other Endometriosis Cystocele Rectocele (posterior colporrhaphy) Enterocele Ectopic Pregnancy Incompetent Cervix (cerclage)

Gynecological Procedures

Colposcopy Hysteroscopy D & C D & E Laparoscopy Hysterectomy Oophorectomy Salpingectomy Abdominal Hysterectomy1. subtotal2. total3. radical (Wertheim) Vaginal LAVH

A & P Repair Le Fort Bartholin’s Cyst (I & D)

Patient symptoms:

Abnormal bleeding Abdominal pain Absence of menses (amenorrhea) Excessive menses (menorrhagia) Painful menses (dysmenorrhea) Painful intercourse (dysparunia) Painful defication (dyschezia)

Pre-Operative & Testing Diagnostic

Physical exam UA, CBC, Blood Chemistry Pelvic exam Bi-manual exam Colposcopy PAP (papanicolaou smear) Schiller Test Biopsy Ultrasound MRI X-ray Laparoscopy D & C

Anesthesia

General Spinal MAC with IV Sedation

Medications

Oxytocics: Stimulate uterine contraction to

induce labor Post-delivery of baby and placental

contents to induce uterine contraction allowing for expulsion of excess tissue and clots

Post-delivery to prevent bleeding/hemorrhage

Medications

Lugol’s solution Iodine based Identification of abnormal vaginal

and or cervical tissue Tissue that is abnormal will not

stain Tissue that is normal will stain

brown Schiller’s Test

Medications

3% Acetic Acid Facilitates cervical visualization by removing

cervical mucous Used during a colposcopy Methylene blue Dye Diluted with NS Direct > Checks for tubal patency

(chromotubation) IV > excreted by the kidneys into the urine rules

out ureteral injury as abdominal procedure concludes

Medications

Antimicrobials Prophylactic IV ung (ointment) utilized with vaginal

packing materials

Medications

Hysteroscopy solutions (for uterine distention)

Dextrose 5% (D5W) Dextran 70% in dextrose

Glycine Sorbitol

Above may all be used with laser or cautery Hyskon (rarely used anymore due to ↑ laser use) No cautery or lasers may be used as would cause

systemic absorption>systemic side effects

Instruments

Major Tray Abdominal-Hysterectomy Tray D&C Tray Hysteroscopy Tray resectoscope & hysteroscope Laparoscopic Tray Camera/scope tray/scope warmer

Specific Vaginal Instruments

Auvard weighted speculum Graves speculum Sims vaginal speculum (single or double ended) Delivery forceps Goodell uterine dilator Sims uterine sound Bozeman uterine dressing forcep Hegar uterine dilators Heaney uterine dilators Emmett uterine tenaculum Sims uterine curettes (blunt/sharp)

Specific Abdominal Hysterectomy Instruments

Abdominal retractor tray richardsons, deavers, malleables, Balfour w/bladder blade O’Sullivan-O’Connor abdominal Retractor Franz Abdominal Retractor Heaney Hysterectomy Forceps Heaney-Ballentine Hysterectomy Forceps Heaney Needleholder Jorgenson Curved Scissors Lister Bandage Scissors Pennington Forceps

Specific Laparoscopy Instruments

Scope, Light cord (scope tray) Camera (camera sleeve if not sterile) Insufflation tubing (silastic tubing) Verres Needle (insufflation needle) Intrauterine cannula (chromotubation) Uterine manipulator Trocar Sleeves, Trocars Accessory Instruments: cautery adapted,

graspers, scissors, loop applicators, suturing devices, resectoscopes

Scope warmer Multi-fire laparoscopic staplers

Positioning

Lithotomy Supine Trendelenburg

OR table with foot-drop capacity Stirrups (candy cane, Allen, or Yellow Fins) Armboards Pillow/Headrest

Prep

Likely do abdomen first if combined with vaginal approach

Care to not allow pooling of prep solution in vagina especially if laser to be used

Draping

Impervious buttock drape (may have a port to attach to suction or just a “fluid-catch” bag

Leggings Perineal drape with fenestration Laparotomy sheet Combination perineal/laparotomy

drape

Dressings

Vaginal packing May be soaked in an antimicrobial

solution May be pre-medicated packing

(Iodophor) Perineal Pad Abdominal dressing surgeon choice Steri-strips, bandaids, telfa,

xeroform, 4x4s, ABD pad, primapore, tape (misc.)

Drains

Penrose Closed Wound Drains: Jackson-Pratt Hemovac

Post-operative Care

Foley Catheter (placed pre-operatively by circulator or surgeon)

Anti-embolic stockings Ted Hose Get OOB early to ambulate Performed in: physician offices, out-

patient centers (ASC), hospital ORs May be discharged same day or have one-

three day hospitalization depending on procedure

Post-Operative Complications

Infection Nicking ureters, bladder, or urethra Hemorrhage (major blood vessel

proximity) Adhesions Sciatic nerve damage due to spinal or

epidural placement Blood clot (thrombosis) DVT PE (pulmonary embolus)

Summary

Anatomy & Physiology Pathology Diagnostic & Pre-operative Testing Anesthesia & Medications Basic Supplies, Instrumentation, &

Equipment Positioning, Prep, & Draping Dressings, Drains, & Post-operative Care