Operative Gynaecology

Pre operative preparations:

Investigations Blood: Hb, haematocrit value, TC,DC, Platelet count, urea, creatinine,serum electrolytes Urine: Routine analysis for protein, sugar, casts, pus cells, culture & sensitivity

Chest X-ray & ECG:

for patients above 40 years of age. HIV, Hep.B screening

Fitness for surgery

correct anemia by haematinics,

blood transfusion
control of hypertension or diabetes control of infection , if present

Pre-operative work up
pt must be admitted about 1-2 days prior to operation. Special cases need earlier admission.

During this period re evaluation of the pt and

examination by the anesthetist should be done. Enquiry should be made about drug allergy. Any medication for diabetes or hypertension, this helps the anesthetist to modify the drug and

dose of anesthetic agents.

History of corticosteroid to be assessed.

Contnd
Any false tooth, contact lenses,
Informed consent to be obtained by the pt. Adequate explanation must be given regarding the surgery, outcome following surgery, potential risks, complications etc to reduce the anxiety & fear. Arrangement for blood transfusion must be made prior to surgery for major surgeries.At least 2 units of blood must be cross matched and kept ready.

Diet
Diet: Light diet is given on the previous evening and NPO from midnight & morning of the day of

operation.
Care of the bowel: Enema may be given to

empty the bowels on the previous evening.

Night sedation: To ensure good sleep at night prior to the day of operation, Diazepam 5-10 mg may be prescribed.

Local antiseptic care:

The abdomen from below the breasts upto the upper half of both thighs is shaved followed by cleaning with an antiseptic solution. A sterile

linen is placed over the area.

For vaginal operations shaving of pubic hair and

upto middle of both thighs

Morning medication (premedication)

Sedative like Diazepam 5-10 mg orally, is

given about 2 hours before the surgery.

Prophylactic antibiotics: To reduce the risk of infection, a broad spectrum antibiotic is selected to cover the gram +ve, gram ve and anaerobic

organisms.

Day care surgery

Includes selected surgical procedures, where patients are admitted, operated and discharged on the same day. Common gynecological operations: D& C Biopsy procedures EUA( examination under anesthesia) Endoscopic procedures like diagnostic hysteroscopy, Laparoscopy, sterilization, ovarian diathermy etc.

Benefits :
1. Increased patient turn over 2. reduced hospital stay 3. reduced inpatient work load 4. reduced cost

Post operative care

The pt is brought back to recovery room following surgery.

First 24 hours
Placement in bed- Flat on bed. head turned to one side

keep the pt warm with sheets and blankets

keep a watch on I.V fluids & urinary drainage. If spinal anesthesia is given, foot end to be raised for 12 hours. Keep the anesthetic tray ready to meet the emergencies. Keep a kidney tray at the bedside to collect any vomitus.

Observation:
vital signs half hourly until steady. Watch for bleeding. Fluid replacement: Blood transfusion if needed. Fluid and electrolytes replacement according to need

Pain control:
liberal analgesics to relieve pain & ensure sleep. Sedatives such as, Pethidine 100 mg or Morphine 15 mg at 6-8 hrs interval Adequate pain control ensures deep breathing, adequate oxygenation, early mobilization and reduced hospital stay.

PCA ( pt. controlled analgesia) infusion pumps

are also effective

Antibiotics:
I.V or I.M antibiotics for 48 hours followed by oral route for 3 days. Bladder care: Encourage to pass urine 8 hours after surgery if nursing measures fail, cathterisation

should be done under strict aseptic

precautions.

General care
early ambulation allow for free movements in bed. Deep breathing and movements of the

legs and arms to minimize leg vein

thrombosis & pulmonary embolism.

Sips of water to relieve the thirst

Second day:
vital signs 4th hourly abdominal auscultation for peristaltic movements & escape of flatus. vaginal plug to be removed in the morning. encourage walking a few steps. deep breathing exercises , leg & arm movements are encouraged. with the return of bowel sounds or passage of flatus, liquid diet is prescribed. antibiotics, sedatives and analgesics to be continued as prescribed.

Third day
ambulation to be continued move in the room & go to the toilet.

I.V. antibiotics are changed to oral route.

Light soft diet. Analgesics if required & sedatives at bed time. Self retaining catheter is removed after bladder training. Mild laxatives may be prescribed at bed time for movement

Fourth & fifth day

Routine observation of vital signs twice a day Normal diet Antibiotics are withdrawn on 5th day. If the bowels have not moved, low enema or mild suppository may be given. Sedative at bed time may be given.

Sixth or seventh day

The sutures are removed on the 6th or the 7th day Discharge planning: Abdominal wound is checked for evidence of sepsis, hematoma, or dehiscence. Note for any vaginal discharge

If vaginal operation is done, check the

wound, assess the state of healing

Advice on discharge:
Rest: light house hold work after 3 weeks outside work or office work after 6 weeks. Coitus: As soon as physically & psychologically fit, coitus is permissible, preferably 6 weeks after the postop check up. Post op check up: After 6 weeks to check for any complications Diet : A well balanced diet to build up resistance to infection

GYNAECOLGICAL OPERATIONS
Dialtation of cervix This is an operation to dilate the cervix.

Indications:
prior to amputation of cervix prior to hysteroscopy pyometra or hematometra prior to introduction of uterine curette and insertion of IUD, radium or laminaria tent. Spasmodic dysmenorrhoea.

Dilatation & curettage

This is an operative procedure whereby dilatation of the cervical canal followed by uterine curettage is done Indications; Diagnostic Infertility DUB Pathologic amenorrhea Endometrial tuberculosis Postmenopausal bleeding . Therapeutic DUB Endometrial polyp Removal of IUD Incomplete abortion

Complications:
Immediate: injury to the cervix uterine perforation injury to the gut

infection
Remote

cervical incompetence
secondary amenorrhea

Dilatation and insufflation ( D&I)

This is an operation of dilatation of cervix and introduction of air or CO2 into the uterine cavity to know the patency of the fallopian tubes (Rubin test) Indications: to note the tubal patency in: investigation of infertility following tuboplasty operation. Complications: air embolism rupture of the tube flaring up of existing infection pelvic endometriosis.

Hystero salpingography ( HSG)

HSG is an operative procedure whereby a radiographic study of the interior of the uterotubal anatomy by using a contrast media. Indications: to note the tubal patency in the investigation of infertility or following tuboplasty operation. to diagnose cervical incompetency to identify the translocated IUD To confirm the diagnosis of secondary abdominal pregnancy Complications: peritoneal irritation and pelvic pain vasovagal attack

cervical biopsy
This is the common diagnostic procedure
Types: surface: A bit of tissue is taken from the surface of the cervix. Punch biopsy: is taken from the suspected area or a four quadrant using punch biopsy forceps. Ring: whole of the squamo-columnar area of the cervix is excised with a special knife. Cone: the operation involves removal of cone of the cervix which includes entire squamocolumnar junction , stroma with glands and endo cervical mucus membrane. Wedge biopsy: is done when a definite growth is visible. An area nearer to the edge is the ideal place avoiding the necrotic area.

Thermal cauterisation
This is an operation whereby the eroded area of the cervix is destroyed either by thermo-regulation or red-hot cauterization.

Indication:
Cervical ectopy with troublesome

discharge.

Cryosurgery
This is a procedure whereby destruction of the tissue is effective by freezing. Indications: benign cervical lesions, leukoplakia condyloma accuminata of vulva as a palliative measure to arrest bleeding in case of carcinoma cervix or vulval carcinoma.

Perineoplasty
It is the reconstruction of the narrow vaginal interoitus to make it adequate for sexual function Indications: congenitally small interoitus rigid perineal body rigid hymenal ring

Narrowed interoitus following episiotomy or perineorraphy.

Amputation of cervix
It is an operative procedure whereby a part of the lower cervix is excised. Indications: congenital elongation

chronic cervicitis
as a component part of Fothergills operation

Abdominal hysterectomy
is the operation of removal of the uterus. When the uterus is removed abdominally , it is called hysterectomy Types: depending upon the extent of removal of the uterus and adjacent structures, the following types are described. Total hysterectomy- removal of the entire uterus Subtotal hysterectomy: removal of the body or corpus leaving behind the cervix. Pan hysterectomy: removal of the uterus along with removal of tubes and ovaries of both sides. The term hysterectomy with bilateral salpingo-oophorectomy

Indications: Total hysterectomy: Benign lesions: Dysfunctional uterine bleeding fibroid uterus tubo-ovarian mass endometriosis adenomyosis CIN( cervical intraepithelial neoplasis) benign ovarian tumor in perimenopausal age. Malignancy carcinoma cervix carcinoma ovary carcinoma endometrium uterine sarcoma chorio carcinoma

Contnd
Traumatic uterine perforation

cervical tear
rupture uterus Obstetrical Atonic PPH Morbid adherent placenta Hydatidiform mole above the age of 35 years.

Complications of hysterectomy
haemorrhage shock injury to adjacent organs like bladder, intestine or ureter. Anesthesia hazards Urinary retention Cystitis Anuria Incontinence Pyrexia due to infection Remote complications vault granulation vault prolapse prolapse of Fallopian tube through vault incisional hernia

Vaginal hysterectomy
This operation is also called as Ward Mayos operation.It involves removal of the uterus per vaginam mostly done in cases of uterine prolapse.

Indications:
utero-vaginal prolapse in post menopausal women genital prolapse with diseased uterus like DUB, unhealthy cervix or small submucous fibroid requiring hysterectomy. As an alternative to Fothergills operation where family is completed. As an alternative to abdominal hysterectomy in undescended uterus, or in selected cases where abdominal approach is unsafe.

Complications:
haemorrhage sepsis VVF following bladder injury RVF following rectal injury retention of urine infection

Fothergills or Manchester operation

This operation is designed to correct uterine descent associated with cystocele and rectocele

where preservation of the uterus is desirable.

Component steps of Fothergills operation: preliminary D&C

amputation of cervix
placation of Mackenrodts ligaments in front of the cervix anterior colporrhaphy colpo perineorrhaphy

Complications
hemorrhage injury to bladder & rectum

retention of urine
cystitis dyspareunia

cervical stenosis
infertility cervical in competency cervical dystocia in labour recurrence of prolapse.

Radical hysterectomy
This operation is done abdominally and is also known as Werthiems hysterectomy. This surgery includes removal of the uterus tubes and ovaries of both sides ( ovaries may be spared in young women) , upper 3/4th of vagina wide resection of the parametrium, periureteraltissue,superior vesical artery, cardinal and uterosacral ligaments, and thorough lymphadenectomy (parametrial, obturator, internal & external iliac groups)

Indications:
1. mainly done for invasive carcinoma of the cervix where radiotherapy is contraindicated. 2. associated PID 3. associatedmyoma, prolapse (procedentia). Ovarian tumor or genital fistula 4. vaginal stenosis 5. recurrence after irradiation 6. surgery is preferred for those with adenocarcinoma or adeno squamous carcinoma.

Risks
Major post operative complications as observed following total abdominal hysterectomy. Other complications include: 1. ureteric fistula 2. bladder dysfunction 3. cystitis and pyelonephritis 4. lymphocyst in the pelvis 5. lymphoedema of one or both legs 6. dyspareunia 7. recurrence

Endoscopic surgery ( Minimally invasive surgery, Minimal access surgery)

The range of surgical procedures in gynaecology that can be performed with the use of either a laparoscope or hysteroscope is designated as endoscopic surgery. Advantages: rapid post operative recovery less post operative pain reduced need of post operative analgesia shorter stay in hospital reduced cost quicker resumption of day to day activity. Less adhesion formation Minimal abdominal scars

Disadvantages:
risk of iatrogenic complications skilled surgeon is required.

Laparoscopy
Laparoscopy is a technique of visualization of peritoneal cavity by means of a fbre optic endoscope introduced through the abdominal wall. Indications diagnostic therapeutic

Diagnostic:
Infertility work up:

peri tubal adhesions

chromo per tubation

minimal endometriosis
ovulation stigma of the ovary

before reversal of sterilization operation

Contnd
Chronic pelvic pain to diagnose acute pelvic lesion ectopic acute appendicitis follow up of pelvic surgery tuboplasty ovarian malignancy evaluation of therapy in endometriosis.

Investigation protocol of amennorrhea

Diagnosis of suspected Mullerian abnormalities Uterine perforation

Therapeutic laparoscopy
Minor procedures: tubal sterilization adhesiolysis aspiration of simple ovarian cyst ovarian biopsy Major procedures: Ectopic pregnancy salpingostomy segmental resection salpingectomy salpingo- oopherectomy Endometriosisablation by diathermy or laser Ovary diathermy of PCOD drainage of endometriosis ovarian cystectomy

Contra indications for laparoscopy

severe cardio pulmonary disease patient hemodynamically unstable generalized peritonitis significant hemo peritoneum intestinal obstruction extensive peritoneal adhesion large pelvic tumors pregnancy more than 16 weeks previous peri umbilical surgery extreme obesity

Instruments required for laparoscopy

Telescope Veress needle for creating pneumoperitoneum by carbon dioxide Trocar & canula Light source Insufflator used to create controlled pneumo peritoneum as there is some amount of gas leak through the different parts. Cameras the telescope is connected with the camera lens and pictures are obtained from the monitor screen

Ancillary instruments:
Scissors for dissection & to cut tissues Grasping forceps Probes for manipulation of viscera( intestine and ovaries) Aspirator & irrigator for aspiration of fluid from the peritoneal cavity or ovarian cysts, irrigator for washing the peritoneal cavity Morcellator is needed when a large piece of tissue (myoma) is morcellated into small pieces so as to be removed through the laparoscopic sleeve. Uterine manipulator used for adequate visualization of the uterus and adnexae during operation

Complications of laparoscopy
Specific to laparoscopy: extra peritoneal insufflation: surgical emphysema cardiac arrhythmia injury to blood vessels injury to bowel injury to organs like bladder or ureter thermal injury gas embolism

anesthetic complications
Hypoventilation( pneumo peritoneum and Trendlenburg position lead to basal lung

compression and reduced diaphragmatic

exercusion) Hyper carbia and metabolic acidosis( when co2 is used for pneumo-peritoneum) Basal lung atelectasis

Others- oesophageal intubation, aspiration

and cardiac arrest.

Complications common to any surgical procedure: infection

haemorrhage
wound dehiscence

incisional hernia

Hysteroscopy
This is a procedure that allows direct visualization inside the uterus. It can be used for diagnostic as well as therapeutic purposes Indications: 1. Diagnostic: abnormal uterine bleeding menorrhagia post menopausal bleeding infertility - when associated with abnormal hystero salpingogram (filling defect, adhesions) recurrent spontaneous abortion - when suspected with Mullerian malformation. misplaced IUD to visualize the transformation zone with colpomicro hysteroscopy.

Contnd
polypectomy & myomectomy lysis of intrauterine adhesions endometrial ablation for patients with DUB endometrial resection Metroplasty removal of IUD , when thread is missing biopsy of suspected endometrium under direct vision cannulation of the Fallopian tube

sterilizationdestroying the interstitial portion of the tubes using Nd- YAG laser or electro coagulation.

Contraindications
pelvic infection pregnancy uterine bleeding causing poor visibility

Complications of hysteroscopy
a) Distension media

fluid overload
pulmonary edema, cerebral edema

hypo natraemia
neurological symptoms gas embolism

Contnd
b) operative procedures: uterine perforation

hemorrhage
injury to intra abdominal organs c) Electro-surgical thermal injury to intra abdominal organs due to laser or electricity. d) Others infection, anesthetic complications treatment failure. and

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