COMMON GYNECOLOGIC PROCEDURES AZZA AlYAMANI

1. COMMON GYNECOLOGIC PROCEDURES AZZA AlYAMANI Department of Obestetrics and Gynecology

2. Common Gynecologic Procedures Aim of this presentation is : 1. students become aware of the basic principles of common gynecologic surgical procedures. 2. become familial with the instruments that used in these procedures. 3. and be aware of the indications and complications of each procedure.

3. {1} Endometrial Sampling ( Dilatation & Curettage) D & C * it is the most common minor gynecologic surgical procedure , it is used as diagnostic or therapeutic tool. * in spite of the advances in office – based evaluation of the endometrium as US or hysteroscopy , a thorough fractional curettage is the best procedure if endometrial or cervical cancer is suspected.

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

5. Therapeutic: 1. endometrial hyperplasia with heavy bleeding . 2. removal of endometrial polyps or small pedunculatedmyomas. 3. dilatation & evacuation in inevitable and missed abortion. 4. removal of missed intrauterine IUCD.

6. Technique instruments

8. Steps of D&C

11. Complications: 1.Perforation of the uterus. it is not uncommon complication ,it occurs in : * RVF uterus. * pregnancy. * postmenopausal è endometrial carcinoma. 2. Cervical laceration. 3. Infection. 4. Haemorrahge.

12. Endometrial Ablation it is the complete destruction of the endometrium down to the basal layer , resulting in fibrosis of the uterine cavity and amenorrhoea ( 30% ) , however , patient satisfaction rates are over 70% . Ia It indicated in women who have heavy menstrual bleeding that is impacting her life and do not have other problems that require hysterectomy . Endometrial ablation is now well established as day case or outpatient procedure.

13. 1. abnormal uterine bleeding. 2. benign lesions as small submucus myomas or endometrial polyps. Endometrial Ablation is performed using the resectoscope which is : a hysteroscpe with a build in wire loop(or other shape device ) that uses high frequency electrical current to cut or coagulate tissue. Indications:

14. Technique Established techniques carried out under direct hysteroscopic vision involve the use of fluid for distention and irrigation . These techniques are : * laser ablation. * endometrial loop resection using electro diathermy. * roller ball electro diathermy.

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

17. roller ball electro diathermy

18. loop resection using electro diathermy

19. 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.

20. 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 è heat damage to adjacent structures.

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

22. Microwave probe inserted • endometrium heated to 80 C • day case procedure • 70 -80% satisfaction rates • 95% return to normal

23. Microwave machine

24. Thermachoice ballon This uses a balloon placed in the uterine cavity through the cervix.  Hot water is circulated inside the balloon to destroy the endometrium. • Thermachoice Balloon Ablation • Central element heats liquid circulated in balloon • 87 degrees C for 8 minutes. • Limitations: • * uterine cavity size 6-10 cm; • * can’t treat submucous myomas .

26. Thermachoice ballon

27. Hysterectomy it is the most commonly performed major gynecologic operation , it can be performed either Abdominally , vaginally or laparoscopically. although some indications remain controversial , high patient satisfaction levels and increasing safety for the procedure have been reported .

28. Types of Hysterectomy 1. subtotal 2. total 3. total è unilateral or bilateral salpingoophrectomy . 4. radical

29. Types of Abdominal Hysterectomy

30. Radical Hysterectomy

31. 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.

32. 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.

33. 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.

34. 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 .

36. 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.

37. 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.

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

41. 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.

42. 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 ).

43. Thank you

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