OPERATIVE GYNECOLOGY

Objectives

• to enumerate the different common operative

procedures performed in the practice of OB GYN
• To known the appropriate indications in the use of each
procedure
References

• Lantz, Comprehensive Gynecology, 6th edition

• Cummins, William’s Obstetrics, 24th edition
Operative Procedures: Obstetrics

• Episiotomy
• Forceps
• Ventouse/Vacuum
• Version
• Suction evacuation
• Cesarean section
Operative Procedures: Gynecology

• Salphingectomy
• Oophorectomy
• Hysterectomy
Basic Requirements

1. Anesthesia
2. Lithotomy Position
3. Full surgical asepsis
4. Empty the bladder
5. Vaginal examination
Basic Requirements
• General/Local
1. Anesthesia
• May be performed with IV Diazepam
2. Lithotomy Position sedation

3. Full surgical asepsis

4. Empty the bladder
5. Vaginal examination
Basic Requirements
• patient is properly positioned
1. Anesthesia
• both lower extremities are supported by
2. Lithotomy Position a stir up
• properly draped
3. Full surgical asepsis
4. Empty the bladder
5. Vaginal examination
Basic Requirements
1. Anesthesia • Surgeon is to wear sterile mask, gown &
gloves
2. Lithotomy Position
• Vulva & vagina is to be
3. Full surgical asepsis swabbed with antiseptic
4. Empty the bladder solution

5. Vaginal examination • Cervix is cleaned with povidone iodine

solution

• Perineum is to be draped by sterile towel &

the legs withleggings
Basic Requirements
1. Anesthesia • ambulant patients are instructed to empty
the bladder before she is placed on the table
2. Lithotomy Position
• for non ambulant patients, catheterization is
3. Full surgical asepsis performed
4. Empty the bladder
5. Vaginal examination
Basic Requirements
1. Anesthesia • Size of uterus
• Position of uterus
2. Lithotomy Position • State of dilatation ofcervix

3. Full surgical asepsis

4. Empty the bladder
5. Vaginal examination
Dilatation and Evacuation

• Dilatation of the cervix

• Evacuation of the products of conception
Dilatation and Evacuation: Types

• One Stage operation

1. Incomplete abortion: (most common)
2. Inevitable abortion
3. Medical termination of pregnancy (6-8 weeks)
4. Hydatidiform mole in the process ofexpulsion
• Two Stage
 Dilatation and Evacuation: Types

• One Stage operation

• Two Stage
1. Induction of 1st trimester abortion: most common
2. Missed abortion: uterus 8-10 weeks
3. Hydatidiform mole with unfavorable cervix
Dilatation and Evacuation:
• Instruments used for the procedure:
• Hawkin Ambler dilator
• Sim’s speculum
• Allis forceps
• Ovum forceps
• Curette
Curetage procedure

Allis forceps

Curette

Sim’s posterior vaginal speculum

Procedure: One Stage operation

1. vaginal speculum inserted

2. anterior lip of the cervix grasp using allis forces
3. cervical dilated using Hawking Ambler dilator
4. contents of endometrial cavity evacuated using ovum
forceps
5. blunt curettage followed by sharp curettage
6. all instruments removed
 Procedure: Two Stage operation
1st Stage: slow dilatation of cervix
may be achieved by:
• Insert laminaria tents or lamicel (MgSO4 sponge) in to the
cervical canal — effect is slow dilatation
• intravaginal insertion of Misoprostol (PGE1) 400mcg 3 hrs
before surgery (lesser side effect)
Procedure of slow dilatation

1. vaginal speculum inserted

2. laminaria tents grasped by allis forceps
3. laminaria inserted to cervical canal
4. pack vagina with OS to prevent spontaneous expulsion
of tents
5. prophylactic antibiotics
• Doxycycline 100 mg BID x 3 days plus
• Metronidazole 400 mg BID x 3 days
 Procedure: Two Stage operation
2nd Stage: rapid dilatation of cervix
a. 1st phase remove the tents
1. vaginal speculum inserted
2. remove vaginal packs
3. laminaria removed by ovum forceps
4. vaginal speculum removed
b. 2nd phase
1. patient is anesthetized
2. Proceed with one (1) stage operation
3. IV oxytocin drip + Methergine IM
4. continue with antibiotics x 5 days
Complications of Dilatation & Evacuation
• Immediate • Late
1. Excessive hemorrhage 1. Pelvic inflammation
2. Injury 2. Infertility
3. Shock 3. Cervical incompetence
4. Perforation 4. Uterine synechiae
5. Sepsis
6. Hematometra
7. Increased morbidity
8. Cont. of pregnancy (1 % )
Suction Curettage
 Objective of procedure
• sucked out the products of conception in the uterus with the
help of a cannula and fitted to a suction apparatus
 Indications for the procedure

• Medical Termination of Pregnancy during 1st trimester

• Inevitable abortion
• Recent incomplete abortion
• Hydatidiform mole
 Initial Procedure

1.Apply Sim’s posterior vaginal speculum

2.Anterior lips of cervix is grasped by an Allis forceps
3.Cervical canal is gradually dilated by graduated metal
dilators up to one size less than the suction cannula
Alternative Procedure
1.Use of laminaria tent 12 hrs before or Misoprostol
400mcg PV 3 hrs prior to surgery is introduced
2.and hold by assistant
 Main Procedure

1.Injection Methergine 0.2mg IV prior to procedure

2.Appropriate size suction cannula introduced into the uterus
3.tip of cannula to be placed in the middle of the uterine cavity
4.Pressure of suction is raised to 400- 600 mmHg
5.Cannula is moved up & down and rotated 360o
6.Suction bottle is inspected for the products of conception &
blood loss
 When to Stop the Procedure

• no more material is being sucked

• gripping of the cannula by the contracting uterus
• grating sensation
• appearance of bubbles in the cannula orin the transparent
tubing
 Main Procedure

7. Vacuum should be broken before withdrawing the cannula

8. Better to curette the uterine cavity with small flushing curette at the
end of suctioning
9. Cannula is reintroduced to suck out any remaining tissues
10. All Instruments are removed
 Complications

▪ Similar complications as mentioned in D + E operation may

occur
▪ Use of plastic cannula can minimize uterine perforation
▪ Blood loss & incomplete evacuation are less likely with
pregnancy of 8 weeks or less
▪ Use of USG during procedures shortens the operativetime and
reduces complications
Episiotomy
 Definition

A surgically planned incision on the perineum &

posterior vaginal wall during the 2nd stage of labor
 Objective

• To surgically enlarge the vaginal introitus to facilitate:

• to effect easy & safe deliveryof the fetus
• to minimize overstretching & rupture of perineal
muscles & fascia
• to reduce stress & strain on the fetal head
 Indications
▪ Elastic/rigid perineum
• arrest/delay in descent of the presenting part as in elderly primigravidae
▪ Operative delivery
• forceps delivery
• ventouse delivery
▪ Anticipating perineal tear
• big baby
• face to pubis delivery
• breech delivery
• shoulder dystocia
▪ Previous perineal surgery
• pelvic floor repair
• perineal reconstructive surgery
 When to perform episiotomy
• Bulging thinned perineum during contraction just prior
to crowning (3-4cm of head visible)
• Drawback when performing:
• Early episiotomy: increase in blood loss
• Late episiotomy fails to:
• prevent invisible lacerations of the perineal body
• protect pelvic floor
 Advantages of episiotomy
Maternal
• easier to repair
• heals better
• helps reduce the duration of 2nd stage
• reduces trauma to the pelvic floor
• reduces future incidence of prolapse & urinary incontinence
Fetal
• Minimize intracranial injuries in:
• premature babies
• after-coming head in vaginal breech deliveries
Types of episiotomy
• Mediolateral
• Median/Midline
• Lateral
• ‘J’ shaped
Types of episiotomy
• Mediolateral • starts from the fourchette
• Median/Midline • can be directed to the right or to
the left
• Lateral • direction is about 45o from the
• ‘J’ shaped midline
• follows a straight line about 2.5
cm in length
Types of episiotomy
• Mediolateral • Incision starts from the fourchette
• directed posteriorly along the
• Median/Midline
midline of the perineal body for
• Lateral about 2.5cm
• ‘J’ shaped
Types of episiotomy
• Mediolateral • Incision starts about 1cm away
from fourchette
• Median/Midline • can extend to the right or left
• Lateral • Extends diagonally
• ‘J’ shaped • Complications:
• injury to batholin’s duct
• Not currently being used
• TOTALLY CONDEMNED
Types of episiotomy
• Mediolateral • Incision begins in the fourchette
• Directed posteriorly along the
• Median/Midline
midline for about 1.5cm
• Lateral • Then directed downwards &
• ‘J’ shaped outwards along 5-7 o’clock
position to avoid anal sphincter
• Drawback:
• Apposition is not perfect & the
repaired wound tends to be
puckered
mediolateral

lateral

‘J’shaped median
 Advantages Disadvantages
mediolateral • The muscles arenot cut • Extension if occurs, may involve the
• Less blood loss rectum
episiotomy
• Repair is easy • Not suitable for manipulative
• Postoperative comfort is maximum delivery or in
• Healing is superior • abnormal presentation or position.
• Wound disruption is rare
• Dyspareunia is rare

median • Relative safety from rectal • Apposition of the tissues is not so

involvement from extension good
episiotomy
• If necessary, the incision can be • Blood loss is little more
extended • Postoperative discomfort is more
• Relative increased incidence
of wound disruption
• Dyspareunia is comparatively more
 Episiotomy Procedure
• Perineum is thoroughly swabbed with
1. Preliminaries antiseptic (povidone-iodine) lotion and
2. Incision draped properly
• Subcutaneous infiltration of Local anesthesia
3. Repair • the perineum, in the line of proposed incision is
infiltrated with 10mL of 1% solution of lidocaine
 Episiotomy Procedure
• 2 fingers are placed in the vagina between
1. Preliminaries the presenting part & the posterior vaginal
wall
2. Incision
• scissors are introduced between the perineum
3. Repair and the presenting part

• Incision is made at the height of a

uterine contraction
 Episiotomy Procedure
• Timing
1. Preliminaries • Done soon after expulsion of placenta
2. Incision • Oozing - controlled by applying pressure with a
sterile gauze swab
3. Repair • Bleeding – controlled by artery forceps
• Early repair prevents sepsis & eliminates the
patient’sprolonged apprehension of‘stitches’
 Episiotomy Procedure
▪ Preliminaries:
1. Preliminaries ▪ Lithotomy position
2. Incision ▪ A good light source from behind is needed
▪ Perineum & wound area are cleansed with
3. Repair antiseptic solution
▪ Blood clots are removed from vagina & wound
area
▪ Patient is draped properly repair should be
done under strict aseptic precautions
▪ If the repair is obscured by oozing of blood
from above, a vaginal pack may be inserted &
is placed high up
 Episiotomy Procedure

1. Preliminaries ▪ Repair
▪ Done in 3 layers
2. Incision
▪ Principles to be followed are:
3. Repair •Perfect hemostasis
•To obliterate the dead space
•Suture without tension
▪ Orders:
•Vaginal mucosa & submucosal
tissues
•Perineal muscles
•Skin & subcutaneous tissues
 Post-Operative Care
▪ Dressing
▪ The wound is to be dressed each time following urination &defecation
▪ To keep area clean & dry
▪ Swabbing with cotton swabs soaked in antiseptic powder or ointment (Furacin or
Neosporin)
▪ Comfort
▪ To relieve pain in the area, magnesium sulfate compress or application of infrared heat
may be used
▪ Ice packs reduces swelling & pain also
▪ Analgesic drugs (Ibuprofen) may be given when required
▪ Ambulation
▪ Patient is allowed to move out of the bed after 24 hours
▪ Prior to that, she is allowed to roll over on to her side or even to sit but only with thighs
apposed
▪ Removal of stitch
▪ When wound is sutured by catgut or Dexon which will be absorbed, the sutures need
not be removed
▪ If non-absorbable material (silk/nylon) is used, the stitches are to be cut on 6th day
Complications
Immediate

• Extension of the incision

• Vulval hematoma
• Wound dehiscence
• Incontinence
Remote

• Dyspareunia
• Chance ofperineal lacerations
• Scar endometriosis (rare)
Forceps
 Indications
MATERNAL
• Exhaustion
• Prolonged second stage
• Cardiac / pulmonary disease

FETAL
• Failure of the fetal head to rotate
• Fetal distress
• Control of the fetal head in vaginal beech delivery
 CLASSIFICATION OF FORCEPS DELIVERY

• Outlet: Wrigley’s
• Outlet & Low forceps: Simpson or Elliot
• Midforceps & outlet: Tucker McLane
• Midforceps & rotation: Kielland
• After coming head in breech: Piper
Parts of a Forceps
Complications
Maternal
• trauma to soft tissue
• 3rd/4th degree laceration
• bleeding from lacerations
• trauma to urethra & bladder
 Complications
Fetal
• bruising & laceration to the face
• Injury to the fetal scalp
• cephalohematoma
• retinal hemorrhage
• skull fracture
• permanent nerve damage / Facial nerve
VACUUM/VENTOUSE
Indications
MATERNAL
• Exhaustion
• Prolonged second stage
• Cardiac / pulmonary disease

FETAL
• Failure of the fetal head to rotate
• Fetal distress
• Should not be used for preterm, face presentation or breech
90
Complications

Maternal
• Vaginal laceration due to entrapment of
vaginal mucosa between suction cup & fetal
head
 Complications
Fetal
• Scalp injuries:
• abrasion & lacerations
• scalp necrosis
• Cephalohematoma
• Intracranial hemorrhage: Subgaleal hematoma
• Birth asphyxia: related to extraction force & time
• Retinal hemorrhage

• Neonatal jaundice
Hysterotomy
 Operative procedure of…

• extracting the product of conception out of the womb before 28th

week by cutting through the anterior wall of the uterus
• form of abortion inwhich the uterus is opened through an
abdominal incision and the fetus is removed
• similar to a caesarean section, but requiring a smaller
incision
Indications

• Fibroids inthe lower uterine segment

• obstructingevacuation
• Midtrimester MTP where other methods have failed or is
contraindicated
• Cervical cancerwith pregnancy
• Women with multiple previous cesarean delivery
• due to risk of placenta accreta
• Completely low lying placenta
• placenta previa
• Uterine anomalies
Cesarean Section
Definition

a surgical procedure in which one or more

incisions are made through a mother's abdomen
(laparotomy) and uterus (hysterotomy) to
deliver one or more babies.
 Abdominal Incisions
1.Vertical Incision
• Vertical incisions are very rare.
• quickest to make
• greater chance of dehiscence

2. The horizontal or Pfannenstiel Incision

• Incised on top of the pubic hair or just over the hair line
• cosmetically better & stronger
• less chance of dehiscence
• exposure not as good
 Indications for C-section
▪ Prolonged labour
▪ Dystocia or failure to progress in labor
▪ Breech presentation
▪ Those performed out of concern for fetal well-being
▪ Failed labour induction
▪ failed instrumental delivery (by forceps or ventouse)
▪ Uterine rupture
▪ Multiple births
▪ Previous transverse Caesarean section
Post Partum Hysterectomy
 Definition
• hysterectomy is the surgical removal of the uterus
• Hysterectomy may be:
• Total
• entire body of the uterus is removed
• Partial
• amputate the body of the uterus above the level of the cervix
• most commonly performed gynecologic surgical procedure
Indications

▪ Intrauterine infection
▪ Grossly defective scar
▪ Markedly hypotonic uterus
▪ Laceration of major vessels
▪ Large myomas
▪ Severe cervical dysplasia
▪ Carcinoma in situ
▪ Placenta previa, accreta
Thank you for your attention!!