Transcript
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Operative
Gynaecology
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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
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Fitness for surgery
correct anemia by haematinics,
blood transfusion
control of hypertension or
diabetes
control of infection , if present
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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 anddose of anesthetic agents.
History of corticosteroid to be assessed.
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ContndAny 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 theanxiety & fear.
Arrangement for blood transfusion must be made
prior to surgery for major surgeries.At least 2units of blood must be cross matched and kept
ready.
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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 toempty 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.
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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
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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 anaerobicorganisms.
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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.
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Benefits :
1. Increased patient turn over
2. reduced hospital stay
3. reduced inpatient work load
4. reduced cost
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Post operative careThe 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 12hours.
Keep the anesthetic tray ready to meet the emergencies.
Keep a kidney tray at the bedside to collect any vomitus.
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Observation:
vital signs half hourly until steady.
Watch for bleeding.
Fluid replacement:
Blood transfusion if needed.
Fluid and electrolytes replacement
according to need
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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
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Antibiotics:
I.V or I.M antibiotics for 48 hours followedby oral route for 3 days.
Bladder care:
Encourage to pass urine 8 hours after
surgery
if nursing measures fail, cathterisationshould be done under strict aseptic
precautions.
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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
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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 passageof flatus, liquid diet is prescribed.
antibiotics, sedatives and analgesics to be
continued as prescribed.
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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
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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.
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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
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Advice on discharge:Rest:
light house hold work after 3 weeks outsidework 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
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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 andinsertion of IUD, radium or laminaria tent.
Spasmodic dysmenorrhoea.
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Dilatation & curettageThis is an operative procedure whereby dilatation of thecervical canal followed by uterine curettage is done
Indications;
Diagnostic
Infertility
DUB
Pathologic amenorrhea
Endometrial tuberculosisPostmenopausal bleeding
.
Therapeutic
DUBEndometrial polyp
Removal of IUD
Incomplete abortion
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Complications:
Immediate:
injury to the cervix
uterine perforation
injury to the gut
infection
Remote
cervical incompetence
secondary amenorrhea
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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 embolismrupture of the tube
flaring up of existing infection
pelvic endometriosis.
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Hystero salpingography ( HSG)HSG is an operative procedure whereby a
radiographic study of the interior of the utero-
tubal anatomy by using a contrast media.Indications:
to note the tubal patency in the investigation ofinfertility or following tuboplasty operation.
to diagnose cervical incompetency
to identify the translocated IUD
To confirm the diagnosis of secondary
abdominal pregnancyComplications:
peritoneal irritation and pelvic pain
vasovagal attack
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cervical biopsyThis is the common diagnostic procedure
Types:
surface: A bit of tissue is taken from thesurface of the cervix.
Punch biopsy: is taken from the suspected areaor a four quadrant using punch biopsy forceps.
Ring: whole of the squamo-columnar area of thecervix is excised with a special knife.
Cone: the operation involves removal of cone ofthe cervix which includes entire squamo-columnar junction , stroma with glands andendo cervical mucus membrane.
Wedge biopsy: is done when a definite growthis visible. An area nearer to the edge is the ideal
place avoiding the necrotic area.
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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 troublesomedischarge.
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Cryosurgery
This is a procedure whereby
destruction of the tissue is effectiveby 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.
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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 ringNarrowed interoitus following episiotomy or
perineorraphy.
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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 Fothergillsoperation
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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
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Indications:
Total hysterectomy:
Benign lesions:
Dysfunctional uterine bleedingfibroid uterus
tubo-ovarian mass
endometriosis
adenomyosisCIN( cervical intraepithelial neoplasis)
benign ovarian tumor in perimenopausal age.
Malignancy
carcinoma cervixcarcinoma ovary
carcinoma endometrium
uterine sarcoma
chorio carcinoma
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Contnd
Traumatic
uterine perforation
cervical tear
rupture uterus
Obstetrical
Atonic PPH
Morbid adherent placentaHydatidiform mole above the age of 35 years.
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Complications of hysterectomy
haemorrhage
shock
injury to adjacent organs like bladder, intestine orureter.
Anesthesia hazards
Urinary retentionCystitis
Anuria
Incontinence
Pyrexia due to infection
Remote complications
vault granulation
vault prolapse
prolapse of Fallopian tube through vault
incisional hernia
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Vaginal hysterectomyThis 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.
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Complications:
haemorrhage
sepsis
VVF following bladder injury
RVF following rectal injury
retention of urine
infection
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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 ofFothergills operation:
preliminary D&C
amputation of cervix
placation ofMackenrodts ligaments in front of the
cervix
anterior colporrhaphy
colpo perineorrhaphy
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Complicationshemorrhage
injury to bladder & rectumretention of urine
cystitis
dyspareunia
cervical stenosis
infertility
cervical in competency
cervical dystocia in labour
recurrence of prolapse.
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Radical hysterectomyThis operation is done abdominally and is
also known asWerthiem
s 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)
I di ti
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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 withadenocarcinoma or adeno squamous
carcinoma.
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RisksMajor post operative complications as
observed following total abdominalhysterectomy.
Other complications include:
1. ureteric fistula
2. bladder dysfunction3. cystitis and pyelonephritis
4. lymphocyst in the pelvis
5. lymphoedema of one or both legs
6. dyspareunia
7. recurrence
E d i ( Mi i ll i i
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Endoscopic surgery ( Minimally invasive
surgery, Minimal access surgery)The range of surgical procedures in
gynaecology that can be performed with the useof either a laparoscope or hysteroscope isdesignated 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
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Disadvantages:
risk of iatrogenic complications
skilled surgeon is required.
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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
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Diagnostic:
Infertility work up:
peri tubal adhesions
chromo per tubation
minimal endometriosis
ovulation stigma of the ovary
before reversal of sterilization operation
Contnd
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Contn d
Chronic pelvic pain
to diagnose acute pelvic lesionectopic
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
Th ti l
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Therapeutic laparoscopyMinor procedures:
tubal sterilization
adhesiolysisaspiration of simple ovarian cyst
ovarian biopsy
Major procedures:
Ectopic pregnancy
salpingostomy
segmental resection
salpingectomy
salpingo- oopherectomy
Endometriosisablation by diathermy or laser
Ovary
diathermy of PCODdrainage of endometriosis
ovarian cystectomy
C f
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Contra indications for laparoscopy
severe cardio pulmonary disease
patient hemodynamically unstablegeneralized peritonitis
significant hemo peritoneum
intestinal obstructionextensive peritoneal adhesion
large pelvic tumors
pregnancy more than 16 weeksprevious peri umbilical surgery
extreme obesity
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Instruments required for laparoscopy
Telescope
Veress needle for creating pneumo-peritoneum 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:
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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 forwashing 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
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Complications of laparoscopy
Specific to laparoscopy:
extra peritoneal insufflation: surgicalemphysema
cardiac arrhythmia
injury to blood vesselsinjury to bowel
injury to organs like bladder or ureter
thermal injurygas embolism
th ti li ti
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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 atelectasisOthers- oesophageal intubation, aspiration
and cardiac arrest.
C li ti t
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Complications common to any
surgical procedure:
infection
haemorrhage
wound dehiscence
incisional hernia
Hysteroscopy
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HysteroscopyThis is a procedure that allows direct visualization
inside the uterus. It can be used for diagnostic as well as
therapeutic purposesIndications:
1. Diagnostic:
abnormal uterine bleeding
menorrhagia
post menopausal bleeding
infertility - when associated with abnormal hysterosalpingogram (filling defect, adhesions)
recurrent spontaneous abortion - when suspectedwith Mullerian malformation.
misplaced IUD
to visualize the transformation zone with colpomicrohysteroscopy.
Contnd
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Contn d 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.
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Contraindications
pelvic infection
pregnancy
uterine bleeding causing poor visibility
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Complications of hysteroscopy
a) Distension media
fluid overload
pulmonary edema, cerebral edema
hypo natraemia
neurological symptomsgas embolism
Contnd
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Contn d
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 and
treatment failure.
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THANK- YOU
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