Comprehensive Guide to Colposcopy in OB-GYN Procedures

1. OB-GYN ProceduresOperative Sequence Colposcopy

2. Anatomy

3. Colposcopy • Overall Purpose of Procedure: • Colposcopy is a common gynecology follow-up for abnormal Pap smears. • A Pap smear checks for changes in the cells of the cervix (office procedure). • Intra-op - A test for cancer of the cervix, in which the cervix is stained with a solution of iodine and potassium iodide and turns dark brown in all noncancerous areas. Called a Schiller's test.

4. Colposcopy • Define the procedure: • Colposcopy is a medical diagnostic procedure to examine an illuminated, magnified view of the cervix and the tissues of the vagina and vulva. Many premalignant lesions and malignant lesions in these areas have discernible characteristics which can be detected thorough the examination. It is done using a colposcope, which provides an enlarged view of the areas, allowing the doctor to visually distinguish normal from abnormal appearing tissue and take directed biopsies for further pathological examination. The main goal of colposcopy is to prevent cervical cancer by detecting precancerous lesions early and treating them. • Squamous cell intraepithelial lesion (SIL) is the most common type of cervical cancer.

5. Others to look for. • Cervical Intraepithelial Neoplasia (abbreviated "CIN") is a cervical condition caused by a sexually transmitted virus called the Human Papilloma Virus. CIN is also called Cervical Dysplasia.

6. Colposcopy • Wound Classification: 2

7. Operative Sequence • 1- Incision • 2- Hemostasis • 3- Dissection • 4- Exposure • 5- Procedure (Specimen Collection possible) • 6- Hemostasis • 7- Irrigation • 8- Closure • 9- Dressing Application

8. Colposcopy • Instrumentation: GYN / D and C Instrument Tray. Colposcope. • What basic instruments will you expect to see in this tray? • Positioning: The patient is in lithotomy position, arms on arm boards, padded. • Prepping: Betadine Prep Kit. Start at the pubis, using a back and forth motion. Prep to iliac crest. Apply prep to the labia majora using only downward strokes, including anus. You will not return to previously prepped area after you cross the anus. Next, prep the inner aspects of the thighs. Start at the labia majora and move laterally towards knees. You will prepare the vaginal vault last. Make sure the person who is prepping has a sponge stick with a counted raytec on it. Use the sponge stick to to prep the cervix, vaginal rugae and exterior of the vagina. If catheterization is ordered, it is performed now. • Draping: 4 towels and a lap drape. You will need an under-buttocks drape as well as diamonds x2 (blue towels) and 1 normally folded blue towel. Ask about towel clips.

9. ColposcopyBegin your Operative Sequence • Incision: any? • Hemostasis: any? If needed, pass off your hand held bovie.

10. Colposcopycont. Operative Sequence • Dissection and Exposure: • Weighted speculum with a 5 ½ Triflex glove for visualization.

11. Colposcopycont. Operative Sequence • Exploration and Isolation: • The cervix is painted with acetic acid or an iodine solution (Lugols Solution or Schiller’s test,) to stain abnormal cervical cells.

12. Acetic acid • Acetic acid, commonly known as vinegar can be used to help identify areas of cervical dysplasia. This is not a color staining agent, however, it causes abnormal tissue to appear whiter than surrounding tissue. • It would be an alternative for someone with iodine sensitivities which is a component of a more commonly used color staining agent.

13. Lugol’sSolution • Lugol’s Solution is a medication that causes abnormal tissue not to stain. • Also called The Schiller's test

14. Surgical Repair/Removal/Specimen Collection: • The colposcope produces high magnification to allow examination of the cervix. • A local anesthetic can be injected into the cervical canal.

15. Surgical Repair Removal Specimen Collection: • MD may use a loop electrode to remove suspicious tissue from the cervix. • Will need ball type electrode to control bleeding. • May also use biopsy forceps to remove tissue.

16. Colposcopycont. Operative Sequence • Hemostasis and Irrigation: • All bleeding is controlled with cautery/ball tip electrode. • Use of warm Saline to irrigate. • Closure: any?

17. Colposcopy • Major Arteries: • Vaginal artery uterine artery

18. Colposcopy • Major Veins: • vaginal venous plexuses into the internal iliac veins • Major Nerves: • uterovaginal plexus

19. OB-GYN ProceduresOperative Sequence Hysteroscopy

20. Hysteroscopy • Overall Purpose of Procedure: • to diagnose and treat causes of abnormal bleeding.

21. Hysteroscopy • Define the procedure: • During diagnostic hysteroscopy the hysteroscope is used just to observe the endometrial cavity (inside of the uterus.) During operative hysteroscopy a type of hysteroscope is used that has channels in which it is possible to insert very thin instruments. These instruments can be used to remove polyps, to cut adhesions, and do other procedures.

22. Hysteroscopy • Wound Classification: 2

23. Operative Sequence • 1- Incision • 2- Hemostasis • 3- Dissection • 4- Exposure • 5- Procedure (Specimen Collection possible) • 6- Hemostasis • 7- Irrigation • 8- Closure • 9- Dressing Application

24. Hysteroscopy • Instrumentation: GYN / D and C Instrument Tray. Hysteroscopy tray with camera. • 30 degree scope, 0 degree scope, uterine sounds, resectoscope possible. • Positioning: The patient is in lithotomy position, arms on arm boards, padded. • Prepping: Betadine Prep Kit. Start at the pubis, using a back and forth motion. Prep to iliac crest. Apply prep to the labia majora using only downward strokes, including anus. You will not return to previously prepped area after you cross the anus. Next, prep the inner aspects of the thighs. Start at the labia majora and move laterally towards knees. You will prepare the vaginal vault last. Make sure the person who is prepping has a sponge stick with a counted raytec on it. Use the sponge stick to to prep the cervix, vaginal rugae and exterior of the vagina. If catheterization is ordered, it is performed now. • Draping: 4 towels and a lap drape. You will need an under-buttocks drape as well as diamonds x2 (blue towels) and 1 normally folded blue towel. Ask about towel clips.

25. HysteroscopyBegin your Operative Sequence • Incision: any? • Hemostasis: any? If needed, pass off your hand held bovie.

26. Hysteroscopycont. Operative Sequence • Dissection and Exposure: • Weighted speculum with a 5 ½ Triflex glove for visualization. • Might possibly need cervical dilators.

27. Hysteroscopycont. Operative Sequence • Exploration and Isolation: • The tip of the hysteroscope is placed into the vagina and gently moved through the cervix into the uterus. • Camera and cord have been passed off at or before this point. The uterus is seen on the monitor or thru the eye piece.

28. Surgical Repair/Removal/Specimen Collection:This depends on what is found. • The MD might want a resectoscope with a loop or roller ball electrode to remove tissue or tumors or to control bleeding within the uterus. • MD might want biopsy forceps for tissue removal. • MD might want a laser. • Most common are Nd:YAG and Argon.

29. Surgical Repair/Removal/Specimen Collection: • Nd:YAG: neodymium-doped yttrium aluminum garnet. • are one of the most common types of laser • Is used in severing of endometrial and myometrial structures • Argon: is capable of transmittingthrough aqueoussolutions and is therefore useful during continuous irrigation hysteroscopy's.

30. Hysteroscopycont. Operative Sequence • Hemostasis and Irrigation: • All bleeding is controlled with cautery/ball tip electrode. • Use of warm Saline to irrigate. • Closure: any?

31. GYN Laparoscopic ProceduresOperative Sequence Laparoscopy

32. Laparoscopy • Overall Purpose of Procedure: • An Exploratory Laparoscopy is performed to examine the abdominal cavity with the aid of a scope when less invasive measures, such as x-rays and CT scans, fail to confirm a diagnosis. • Operative scope may be utilized for this prcedure.

33. Laparoscopy • Define the procedure: • Abdominal exploration may be used to help diagnose many diseases and health problems, including: • Inflammation of the appendix (acute appendicitis) • Pockets of infection (retroperitoneal abscess, abdominal abscess, pelvic abscess) • Endometriosis • Inflammation of the fallopian tubes (salpingitis) • Scar tissue in the abdomen (adhesions) • Cancer of the ovary, colon, pancreas, liver

34. Laparoscopy • Inflammation of an intestinal pocket (diverticulitis) • Pregnancy outside of the uterus (ectopic pregnancy) • This surgery may also be used to determine the extent of certain cancers, such as Hodgkin's lymphoma (also known as Hodgkin's disease, a type of lymphoma characterized clinically by the orderly spread of disease from one lymph node group to another and by the development of systemic symptoms with advanced disease.) • Wound Classification: 1 (yet depends on what you do during the case)

35. Ectopic Pregnancy • Ectopic pregnancy means the pregnancy is not growing in its normal location inside the uterus. • 97% of the time, the ectopic pregnancy is located in the fallopian tube and the rest are found in the ovary, abdomen, cervix or other nearby structure.

36. Ectopic Pregnancy • The incidence of ectopic pregnancy varies with the population but is about one in every hundred pregnancies. • The incidence is higher among women with previous tubal disease, tubal surgery, previous ectopic pregnancy, assisted reproduction, and current IUD users.

37. Types of…. • Implantation in the distal half of the fallopian tube. • This represents the vast majority of all ectopics and is the type most likely to resolve spontaneously through "tubal abortion." The closer the ectopic is to the fimbriated end, the more likely it will be to outgrow its blood supply and be expelled out the end of the tube.

38. Types of…. • Isthmic ectopic • The isthmus is the narrowest portion of the tube, least distensible, and ectopics that grow here are more likely to rupture, and to rupture early in the course of the pregnancy.

39. Isthmic ectopic

40. Salpingectomy with ectopic pregnancy removed from the tube

41. Types of…. • Cornualectopic • These ectopics grow in the portion of the tube that passes through the uterine cornua. • These tend to rupture early and violently, with massive abdominal hemorrhage. Many of the fatalities due to ectopic pregnancy are from cornual pregnancies.

42. Unrupturedcornual ectopic pregnancy

43. Ovarian Pregnancy • In this case an egg cell is not guided into the tube, but is fertilized in the peritoneal cavity and then implants onto the ovary. • This causes the same symptoms as a tubal pregnancy and severe internal bleeding will eventually occur.

44. Intra Abdominal Pregnancy • An egg cell is not guided into the tube and is fertilized in the peritoneal cavity. • It implants any where in the peritoneal cavity. • These pregnancies can develop quite far and continue for months before it is diagnosed.

45. Cervical Pregnancy • Cervical pregnancy occurs when the fertilized egg cell passes through the cavity of the womb into the cervical canal and starts developing there. • The cervix can't accommodate a pregnancy and bleeding will eventually occur.

46. Short Movie • Tubal Ectopic Pregnancy Laparoscopic Salphingotomy

47. Operative Sequence • 1- Incision • 2- Hemostasis • 3- Dissection • 4- Exposure • 5- Procedure (Specimen Collection possible) • 6- Hemostasis • 7- Irrigation • 8- Closure • 9- Dressing Application

48. Laparoscopy • Instrumentation:Laparoscopic Tray – open. • Major/Minor Instrument Tray a hold item. • What basic instruments will you expect to see in this tray? • Positioning: The patient is in Lithotomy position, arms tucked at the side or on arm boards. Surgeon stands on the left side of the patient across form the monitor. Scrub between legs of patient. • Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Start at the umbilicus, normal prep. Move to the the pubis, using a back and forth motion. Prep to iliac crest. Apply prep to the labia majora using only downward strokes, including anus. You will not return to previously prepped area after you cross the anus. Next, prep the inner aspects of the thighs. Start at the labia majora and move laterally towards knees. You will prepare the vaginal vault last. Make sure the person who is prepping has a sponge stick with a counted raytec on it. Use the sponge stick to to prep the cervix, vaginal rugae and exterior of the vagina. If catheterization is ordered, it is performed now. • Draping: 4 towels and a lap drape. You will need an under-buttocks drape as well as diamonds x2 (blue towels) and 1 normally folded blue towel. You will need leggings. Ask about towel clips.

49. LaparoscopyBegin your Operative Sequence • Incision: 15 kb on #3 handle for incision. • 2 towel clips on either side of umbilicus. • VeresNeedle

50. Laparoscopycont. Operative Sequence • Hemostasis: Can be from multiple means. The pressure of the trocars entering the pneumoperitineum will stop most bleeding. Bovie: either from the handheld pencil or L (or J) Hook is also available.