Operative Gynecology

Objectives

• to be able to discuss the process that happens before a patient is scheduled

for a gynecologic operation

• to understand the preoperative process before the patient is admitted

• to discuss the postoperative complications possible after laparotomy
• to know the different instruments needed to properly be able to perform a
surgical procedure
References

• Rock, Te Linde’s, Operative Gynecology 10th edition

History of Operative Gyecology

• the 1st know successful gynecologic operation was for a removal of an ovarian
tumor performed by Ephraim McDowell in 1809.

• James Marion Sims invented a technique to cure vesicovaginal fistulas in the

middle of the 19th century

• this two operations, removal of ovaries & repair of vesicovaginal fistulas where
the beginning of the field of operative gynecology as it is known today
Principles of Contemporary Medical Ethics

1. Autonomy: every individual has the right to self-determination

2. Nonmaleficence: “do no harm”, prevent harm and to refrain from harmful acts

3. Beneficence: to do good on behalf of others, requires the performance of

positive acts to advance the well-being of others

4. Justice: treat all persons fairly, in the oligations of physicians in allocation of

scarce medical resources
Principles of Contemporary Medical Ethics

• This principle-based ethics model are held with equal importance

• however in many clinical situations, the solution to complex ethical dilemmas
require the balance and prioritization of one over the other
Importance of PreOperative Care
Factors influencing surgical outcome besides skills and techniques

• An appropriate preoperative evaluation

• the ability to accurately assess and diagnose gynecologic pathology, defects
and injury
• Appropriate patient selection
• the ability to determine when surgical intervention is a necessary course of
action
• Appropriate discussion w/ patient regarding benefits and risk of surgery
• ability to communicate to the patient both shor- and long term complications
in a manner that could be understood
• An ability to work with others to obtain health care plan needs
PreOperative Care
Purpose

1. decrease surgical morbidity

2. minimiza expensive delays and cancellations on the day of
surgery
3. evaluate and optimize patient health status
4. facilitate planning of anesthesia & preoperative care
5. reduce patient anxiety through education
6. obtain informed consent
PreOperative Care

• Careful History & complete Physical Examination is done

• this prevents unnecessary surgery decisions
• if condition is not urgent, the decision to de major surgery on the
1st visit is not recommended
• Good gynecologic history also provides valuable clue relating to
the physical findings on your patient.
PreOperative Evaluation
Outcome of pelvic surgery depends on:

• The skill and judgement of the gynecologic surgeon

• ability to surgically correct the gynecologic abnormality/ disease
process
• severity, stability and reversibility of concurrent medical/surgical
pathologies
• availability of experienced support professionals for consultation,
specifically: anesthesia, medicine and surgery
PreOperative Evaluation
Guidelines for the preoperative evaluation of gyn patients

• Uncomplicated gyn pathology w/ uncomplicated medical/ surgical

status
• Complicated gynecologic pathology w/ uncomplicated medical/
surgical status
• Uncomplicated/ complicated gynecologic pathology w/ a
complicated medical/ surgical status
PostOperative Care
Post Op complications

• most important factors in defining outcome of the 1st 72 hours

following surgery is monitoring of the following functions
• renal
• cardiovascular
• respiratory
PostOperative Care
Post Op complications

• Post op morbidity can be minimized by appropriate post op

assessment that includes:
• identify patients at risk for venous thromoboemboli complications
• Optimized patient nutrition to improve wound healing and decrease
post op recovery time
PostOperative Care
Post Op complications: Thromboembolic disease

• Risk Factors for Vascular complications:

• Age
• Immobility
• Previous VTE
• varicose veins
• severe diabetes
• cardiac failure
• COPD
• underlying thrombophilia
PostOperative Care
Post Op complications: Thromboembolic disease

• Prophylaxis for VTE:

• Low dose unfractionated Heparin
• Low dose unfractionated Heparin plus Dihydroergotamine
• Compression stockings with early ambulation
PostOperative Care
Post Op complications: Pulmonary disease

• Most important complications:

• Atelectasis
• Pneumonia
• Pulmonary Thromboembolic disease
• Respiratory Failure
PostOperative Care
Post Op complications: Pulmonary disease

• Risk Factors
• > 60 yo
• Cancer
• Congestive Heart Failure
• Smoking w/in 8 weeks of surgery
• Upper abdominal incision
• Vertical incision
• Incision length > 20 cm
PostOperative Care
Post Op complications: Pulmonary disease

• Effects of Anesthesia on Respiratory Physiology

• Reduced ventilatory response to O2 and CO2
• Rhythmic rapid shallow breathing pattern
• Reduced functional residual capacity
• Diaphragmatic dysfunction
• Atelectasis
• Ventilation-perfusion mismatching
• Blunting of hypoxic pulmonary vasoconstriction
• Impairment in mucociliary clearance
PostOperative Care
Post Op complications: Pulmonary disease

• Effects of Upper Abdominal Surgery on Respiratory Physiology

• Reduction in lung volumes
• Residual volume
• Total lung capacity
• Functional residual capacity
• vital capacity
• Reflex inhibition of phrenic nerve
• Increased neck & intercostal inspiratory accessory muscle use
• Tonic & phasic contraction of abdominal expiratory muscles
PostOperative Care
Post Op complications: Pulmonary disease

• Prevention and Treatment of Atelectasis

• Smoking cessation 8 weeks before elective surgery
• Laparoscopic procedure
• Deep breathing exercises
• Mobilization
• Adequate analgesia
• Selective gastric decompression
PostOperative Care
Post Op complications: Pulmonary disease

• Postoperative Pneumonia
• Hospital-acquired pneumonia
• develops 48 hours or more after hospital admission
• hospital stays increase by about 11 days
• due to a wide variety of bacterial organism w/ occasional viral
or fungal pathogen in immunocompetent patients
PostOperative Care
Post Op complications: Pulmonary disease

• Postoperative Pneumonia
• Hospital-acquired pneumonia
• early-onset HAP
• occurs w/in 1st 4 days of hospitalization
• better prognosis
• due to antibiotic-susceptible pathogens
• late-onset HAP
PostOperative Care
Post Op complications: Pulmonary disease

• Postoperative Pneumonia
• Hospital-acquired pneumonia
• early-onset HAP
• late-onset HAP
• occurs on or after 5 days of hospitalization
• more likely to be multidrug-resistant pathogen
• associated w/ increase morbidity and mortality
PostOperative Care
Post Op complications: Pulmonary disease

• Interventions to decrease risk for HAP

• Strict adherence to infection control procedures
• Early removal of invasive devices
• Semirecumber positioning of the patient
• Restriction of acid suppression therapy
• Restrictive RBC transfusion strategy
• Strict control of hyperglycemia
PostOperative Care
Urinary Management

• bladder atony
• most common problem
• due to:
• overdistension
• reluctance to void
• Management:
• urinary bladder catheter x 5 days or more for vaginal plastic
surgery
PostOperative Care
GastroIntestinal Tract Mangement

• management is individualized
• Uncomplicated surgery: may have regular diet 1st post op day if
• (+) bowel sounds:
• (-) abdominal distension
• (-) nausea
• Preoperative & Postoperative parenteral nutrition for
• seriously ill patients
• malnourished
• had concomitant extensive bowel surgery
PostOperative Care
GastroIntestinal Tract Mangement
PostOperative Care
Post Op orders

• carried out after patient:

• has fully recovered from anesthesia
• is stable to be transferred to ward
• prior to transfer to ward patient has to be evaluated to determine
stability of the patients condition
• Frequency of physician rounds is based on severity of the
condition
PostOperative Care
Post Op orders

• Post op orders must contain evaluation of:

• vital signs
• catheter drainage if (+)
• NGT
• Peritoneal
• urinary bladder catheter
• Pulmonary status
• Abdominal condition
• Laboratory & Radiologic evaluation is also individualized
PostOperative Care
Post Op orders: Basic
Sample
PostOperative Infections
Prevention & Management

• Febrile Morbidity
• not all febrile episodes are infectious in nature
• most frequent definition:
• temperature elevation of 38 C or higher
o

• recorded on two occasions at least 6 hours apart

• > 24 hours after the surgical procedure
• 1st 24 hours excluded due to the uncommon operative site
infections w/in 24 hours, unless:
• preexisting infection at the operative site
• gross site contamination
PostOperative Infections
Prevention & Management

• Most common source of bacteria causing postoperative infection is

the vagina
• Factors affecting vaginal flora:
• age
• sexual activity
• stage of menstrual cycle
• use of antibiotics or immunosuppressive medication
• invasive procedure: surgery itself alters the vaginal flora
PostOperative
Infections
Prevention & Management
PostOperative Infections
Categories of Infection

• Cuff Cellulitis
• infection of the surgical margin in the upper vagina after the
uterus have been removed
• late onset of symptoms
• infection site is:
• indurated
• erythematous
• edematous
PostOperative Infections
Categories of Infection

• Cuff Cellulitis
• Initial symptoms:
• lower abdominal pain
• pelvic pain
• back pain
• fever
• abnormal vaginal discharge
• PE: vaginal cuff is hyperemic, indurate and with tenderness
PostOperative Infections
Categories of Infection

• Infected Vaginal cuff Hematoma or Cuff Abscess

• presents wi:
• fever early in the post op course
• lower abdominal and vaginal cuff tenderness
• (+) tender, fluctuant mass near the cuff
• occasional purulent drainage from the cuff
PostOperative Infections
Categories of Infection

• PostOperative Ovarian Abcess

• presents with:
• fever
• abdominal and pelvic pain
• after discharge
• Ruptured abscess is considered a surgical emergency w/
laparotomy and excision and drainage of abcess
• Anaerobes are the predominant bacteria
PostOperative Infections
Categories of Infection

• Septic Pelvic thrombophlebitis

• diagnosis of exclusion
• made after patient becomes unresponsive to antibiotic treatment
• enhanced by:
• venous stasis
• vascular injury
• bacterial contamination of blood vessels
PostOperative Infections
Categories of Infection

• Septic Pelvic thrombophlebitis

• Classic form
• associated w/ abdominal surgery
• occurs 2 - 4 days after surgery
• presents w/ fever, tachycardia, GI distress, unilateral
abdominal pain
• Diagnosis confirmed by CT scan or MRI
PostOperative Infections
Categories of Infection

• Septic Pelvic thrombophlebitis

• Treatment:
• heparin x 7 - 10 days
• Antibiotics
• lysis of fever occurs w/in 24 - 48 hours but treatment continued
up to 48 hours after patient becomes afebrile & Clinically well
PostOperative Infections
Categories of Infection

• Wound Infection
• Organ/ space surgical site infection (SSI)
• occurs in any area opened or manipulated during surgery
• must develop w/in 30 days from procedure
• superficial and deep incision infection
PostOperative Infections
Categories of Infection

• Urinary Tract Infection

• frequent gyne postoperative infection
• presents with:
• low-grade fever
• dysuria
• frequent
• urgency
• urinalysisL
• > 100,000 colonies/ml of urine clean catch
• > 10,000 colonies/ml for catheterized specimens
PostOperative Infections
Categories of Infection

• Factors to be considered prior to antibiotic treatment:

• Pelvic infections are polymicrobial in etiology
• most frequent organisms are aerobic organisms
• Enterococci may occassonaly cause sepsis
• Choice of antibiotic is made empirically before culture results
• timing of onset of infection may be an indicator of the pathogen
group
• single agents ay be ineffective as multiple agents in treating
preoperative infections
PostOperative Infections
Categories of Infection

• Antibiotic Treatment:
• Gentamycin (gold standard)
• 2 mg/kg loading dose then 1.5 mg/kg maintenance +
• Clindamycin 900 mg every 8 hours
• amino glycoside, ampicillin or both are given to overcome
resistance or
• Metronidazole 500 mg q 6 hour + levofloxacin 500 mg OD
• Parenteral antibiotic is continued until patient is afebrile x 24 - 48
hours at which antibiotics may be discontinued our continued w/ oral
antibiotics
• Reevaluate patient if w/o improvement within 72 hours of treatment
PostOperative Infections
Prevention of Infection

• Careful hand washing

• avoid contact w/ septic patients before proceeding to the operating
room
• avoid consecutive contact w/ patients w/o hand washing
• minimize OR exposure for infected personnel
PostOperative Infections
Prevention of Infection

• Antibiotic Prophylaxis to be effective must be:

• operative procedure has a significant risk for contamination
• antibiotic used mist be effective against expected pathogen
• antibiotic is not routinely being used
• tissue levels of antibiotic must be optimal at the time of bacterial
contamination
PostOperative Infections
Prevention of Infection

• Choice of Antibiotics:
• Cefazolin
• most commonly used
• a
• for cardiac patients w/ risk for endocarditis
• combination of:
• ampicillin 2 gas +gentamicin 1.5 mg/m ) 2

• if allergic to ampicillin may give vancomycin at 1 gm x 1 - 2

hours
• 2nd dose is recommended 6 hours after
PostOperative Infections
Prevention of Infection

• Choice of Antibiotics:
• Cefazolin
• most commonly used
• a
• for cardiac patients w/ risk for endocarditis
• combination of:
• ampicillin 2 gas +gentamicin 1.5 mg/m ) 2

• if allergic to ampicillin may give vancomycin at 1 gm x 1 - 2

hours
• 2nd dose is recommended 6 hours after
PostOperative Infections
Prevention of Infection

• Choice of Antibiotics:
• Cefazolin
• most commonly used
• a
• for cardiac patients w/ risk for endocarditis
• combination of:
• ampicillin 2 gas +gentamicin 1.5 mg/m ) 2

• if allergic to ampicillin may give vancomycin at 1 gm x 1 - 2

hours
• 2nd dose is recommended 6 hours after
Wound Healing, Suture Material & Instruments
Wound Healing

• responsible for emergently sealing the wound and ultimately

provide long term structural support for the injured organ
• but healing may also bring disease if an organ is unable to function
Wound Healing, Suture Material & Instruments
Physiology of Wound Healing

• Involved Biological processes:

• inflammation
• epithelialization
• fibroplasia
• wound contraction
• scar maturation
Wound Healing, Suture Material & Instruments
Physiology of Wound Healing

• Involved Biological • Initial response of injury

processes: • divided into
• inflammation • vascular response
• epithelialization • cellular response
• fibroplasia • initiated by:
• wound contraction • histamines
• scar maturation • kinins
• proteolytic enzymes from the
injured tissue
Wound Healing, Suture Material & Instruments
Physiology of Wound Healing

• Involved Biological • immediately after injury: vascular

processes: response
• inflammation • transient vasoconstriction of local
• epithelialization blood vessels: 5 - 10 mins
• fibroplasia • vasodilation follows w/ increase
• wound contraction vascular permeability leading to
• scar maturation edema
Wound Healing, Suture Material & Instruments
Physiology of Wound Healing

• Involved Biological • immediately after injury: cellular

processes: response
• inflammation • migration of leukocytes to injury
• epithelialization • PMN predominate for 3 days
• fibroplasia • active phagocytosis of bacteria,
• wound contraction foreign proteins & necrotic derby
• scar maturation • PMN dies and becomes part of
wound exudate
• released enzymes breakdown
material not phagocytosed
Wound Healing, Suture Material & Instruments
Physiology of Wound Healing

• Involved Biological • immediately after injury: cellular

processes: response
• inflammation • accumulated exudate/ pus
• epithelialization develops even w/ (-) bacteria
• fibroplasia • but may get contaminated by
• wound contraction bacteria leading to poor wound
• scar maturation healing and prolonged
inflammation
Wound Healing, Suture Material & Instruments
Physiology of Wound Healing

• Involved Biological • occurs by migration and maturation

processes: of cells from deeper basal layers of
• inflammation the epithelium
• epithelialization • repair is longer if it involves deeper
• fibroplasia structures like:
• wound contraction • blood vessels: hemostasis is
• scar maturation initiated
• sutured wounds: epithelialization
produces a watertight seal w/in 24
hours of injury
Wound Healing, Suture Material & Instruments
Physiology of Wound Healing

• Involved Biological • epithelium is initially thin and easily

processes: detached
• inflammation • final epithelial healing is
• epithelialization accompanied by differentiation and
• fibroplasia maturation of themigprated cells
• wound contraction and scar formation through
fibroplasia
• scar maturation
Wound Healing, Suture Material & Instruments
Physiology of Wound Healing

• Involved Biological • process where wounds regains

processes: strength
• inflammation • results from collagen production
• epithelialization needed to form a fibrous scar
• fibroplasia • process starts w/ mesenchymal
• wound contraction cells differentiating into fibroblasts
• scar maturation • fibroblasts migrate to injury, and
proliferate producing fibrils
• fibrils bond together to form
collagen bundles
Wound Healing, Suture Material & Instruments
Physiology of Wound Healing

• Involved Biological • collagen bundle formation results

processes: to significant tensile strength for the
• inflammation wound
• epithelialization • occurs only after 4 - 5 days from
• fibroplasia injury
• wound contraction
• scar maturation
Wound Healing, Suture Material & Instruments
Physiology of Wound Healing

• Involved Biological • occurs after collagen formation.

processes: • process of bringing closer together
• inflammation tissue that was injured - known as
• epithelialization contraction
• fibroplasia • begins after 5 days from injury
• wound contraction • correspond to fibroplasia stage of
• scar maturation wound healing
Wound Healing, Suture Material & Instruments
Physiology of Wound Healing

• Involved Biological • bulk scar formed during fibroplasia

processes: consisting of randomly oriented
• inflammation soluble collagen fibers
• epithelialization • discorded fibers are replaced with
• fibroplasia orderly arranged fibers producing
• wound contraction denser and stronger scar
• scar maturation
Wound Healing, Suture Material & Instruments
Surgical Wound Healing

• Primary Intention • occurs if wound layers are

• Secondary Intention reapproximated following injury
• Third Intention • allows healing to:
• occur in a minium time
• no separation of wound edges
• minimal scar formation
• desired mode of healing for
surgical incisions
Wound Healing, Suture Material & Instruments
Surgical Wound Healing

• Primary Intention • wounds left open

• Secondary Intention • has a higher resistance to infection
• Third Intention • heals by a combination of:
• contraction
• granulation tissue formation
• healing is slow
• excessive scar tissue
Wound Healing, Suture Material & Instruments
Surgical Wound Healing

• Primary Intention • also known as delayed primary

• Secondary Intention closure
• Third Intention • used when:
• after post wound breakdown
• alternative to 2o intention
• used for grossly contaminated
wound
• closure of wound between 3 - 6
days after injury
Wound Healing, Suture Material & Instruments
Suture Material

• sutures are divided into size categories based on diameter

• increasing diameter sutures larger than 0 are numbered in
increasing numerical order (ex. 1,2,3)
• decreasing diameter smaller than 0 are numbered by an
increasing number of 0. (ex. 0,00,000)
• often called 1-0 (0), 2-0 (00), 3-0 (000)
Wound Healing, Suture Material & Instruments
Suture Material

• sutures classification:
• absorbable
• lose majority of its tensile strength before 60 days from use
• divided into:
• natural
• synthetic
• non-absorbable
Wound Healing, Suture Material & Instruments
Suture Material

• sutures classification:
• absorbable
• non-absorbable
• maintains majority of its tensile strength > 60 days from use
• subdivided into:
• Class I: silk or synthetic fiber
• Class II: cotton or linen fiber or coated natural or synthetic
fibers
• Class III: monofilament or multifilament metal wire
Wound Healing, Suture Material & Instruments
Choice of Suture for Fascial Closure

• Tensile strength is critical

• most common cause of dehiscence is sutures pulling through
fascia
• material should maintain a tensile strength greater than that of the
fascia through critical healing period
• use the smallest suture able to provide the necessary tensile
strength
• Fascial incisions regain strength slowly
Wound Healing, Suture Material & Instruments
Choice of Suture for Fascial Closure

• Tensile strength
• 10% : 1 week post operative day
• 25% : 2 weeks post operative day
• 30% : 3 weeks post operative day
• 40% : 4 weeks post operative day
Wound Healing, Suture Material & Instruments
Choice of Suture for Fascial Closure

• majority of fascial dehiscence occurs 2 and 12 days post op

• mean: 7 - 8 days
• Sutures used:
• Chromic 1 and Chromic 0
• Polyglycolic acid & Polyglactin 910
Wound Healing, Suture Material & Instruments
Surgical Needles

• eye of needle is the point of attachment for sutures

• Eyes are classed as:
• Closed: similar to household sewing needles
• French: needles have a lit w/ ridges inside the slit to catch & hold
the suture
• Swaged or Eyeless needles: sutures are mechanically attached
to the end of the needle to form a contiguous unit
Wound Healing, Suture Material & Instruments
Surgical Needles

• Shape of the body or shaft

• Longitudinal
• used when tissue is easily accessible
• rarely used in gynecology
• half-curved/ ski
• used to close skin
• primarily used to facilitate laparoscopic suturing
• curved
• compound
Wound Healing, Suture Material & Instruments
Surgical Needles

• Shape of the body or shaft

• Longitudinal
• half-curved/ ski
• curved
• requires less space for maneuvering
• ideal for surgical procedures
• commonly named based on the percentage of a circle they complete
• compound
• originally developed for anterior segment ophthalmic surgery
• not used in gynecologic surgery
Wound Healing, Suture Material & Instruments
Surgical Needles

• Curved needles:
• 1/2 circle needle is a half of a full circle
• 3/8 circle most commonly used in surgical procedures
• the less of an arc the needle completed, the more shallow a bite
the needle takes
Wound Healing, Suture Material & Instruments
Surgical Needles

• Needle Points
• Cutting point
• used for tough tissue such as skin
• Tapered point
• used in easily penetrated tissue such as bowel or peritoneum
Wound Healing, Suture Material & Instruments
Surgical Needles

• Needle Holders
• two common types:
• Wagensteen (straight)
• Heaney (angled)
• useful in vaginal surgery
Wound Healing, Suture Material & Instruments
Surgical Knots

• types:
• Flat knots
• formed with half hitches tied with equal tension on the ends of
the suture
• Surgeons knot: formed by adding an additional loop to the 1st
throw of the half hitch
• most secure and most desirable knot
• Sliding knots
Wound Healing, Suture Material & Instruments
Surgical Knots

• types:
• Flat knots
• Sliding knots
• there’s a tendency for the knot to slip
Thank you for your attention!!