Transcript GYN_procedures

OB-GYN Procedures
Operative Sequence
Colposcopy
Anatomy
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.
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.
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.
Colposcopy
•Wound Classification: 2
Operative Sequence
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1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
Colposcopy
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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.
Colposcopy
Begin your Operative Sequence
• Incision: any?
• Hemostasis: any? If
needed, pass off
your hand held
bovie.
Colposcopy
cont. Operative Sequence
• Dissection and
Exposure:
•Weighted
speculum with
a 5 ½ Triflex
glove for
visualization.
Colposcopy
cont. 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.
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.
Lugol’s Solution
• Lugol’s Solution is a medication that
causes abnormal tissue not to stain.
• Also called The Schiller's test
• 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.
•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.
Colposcopy
cont. Operative Sequence
• Hemostasis and Irrigation:
•All bleeding is controlled with
cautery/ball tip electrode.
• Use of warm Saline to irrigate.
• Closure: any?
Colposcopy
•Major
Arteries:
•Vaginal artery
uterine artery
Colposcopy
• Major Veins:
• vaginal venous
plexuses into the
internal iliac veins
• Major Nerves:
• uterovaginal
plexus
OB-GYN Procedures
Operative Sequence
Hysteroscopy
Hysteroscopy

Overall Purpose of Procedure:

to diagnose and treat causes of abnormal bleeding.
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.
Hysteroscopy
 Wound
Classification: 2
Operative Sequence
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1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
Hysteroscopy
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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.
Hysteroscopy
Begin your Operative Sequence

Incision: any?

Hemostasis: any? If
needed, pass off your
hand held bovie.
Hysteroscopy
cont. Operative Sequence

Dissection and
Exposure:
Weighted speculum
with a 5 ½ Triflex
glove for
visualization.
 Might possibly need
cervical dilators.

Hysteroscopy
cont. 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.
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Surgical Repair/Removal/Specimen Collection:
This depends on what is found.
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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.

Surgical Repair/Removal/Specimen
Collection:
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Nd:YAG: neodymium-doped yttrium aluminum garnet.
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are one of the most common types of laser
Is used in severing of endometrial and myometrial structures
Argon: is capable of transmitting through aqueous solutions and is
therefore useful during continuous irrigation hysteroscopy's.
Hysteroscopy
cont. Operative Sequence
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Hemostasis and Irrigation:

All bleeding is controlled with cautery/ball tip
electrode.

Use of warm Saline to irrigate.
Closure: any?
GYN Laparoscopic Procedures
Operative Sequence
Laparoscopy
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.
Laparoscopy
• Define the procedure:
• Abdominal exploration may be used to help diagnose many
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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
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)
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.
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.
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.
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.
ISTHMIC ECTOPIC
SALPINGECTOMY WITH ECTOPIC
PREGNANCY REMOVED FROM
THE TUBE
TYPES OF….
Cornual ectopic
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.
UNRUPTURED CORNUAL
ECTOPIC PREGNANCY
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.
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.
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.
SHORT MOVIE
Tubal Ectopic Pregnancy Laparoscopic Salphingotomy
Operative Sequence
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123456789-
Incision
Hemostasis
Dissection
Exposure
Procedure (Specimen Collection possible)
Hemostasis
Irrigation
Closure
Dressing Application
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.
Laparoscopy
Begin your Operative Sequence
• Incision: 15 kb on
#3 handle for
incision.
• 2 towel clips on
either side of
umbilicus.
• Veres Needle
Laparoscopy
cont. 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.
Laparoscopy
cont. Operative Sequence
• Dissection and
Exposure:
– 1 ports inserted periumbilical.
– Operative scope inserted
into trocar.
– Other ports possible
depending on what you
find!
– Have other trocars in room,
ready to open.
Laparoscopy
cont. Operative Sequence
• Exploration and Isolation:
– This entire step will depend on what procedure is
needed!
• Surgical
Repair/Removal/Specimen
Collection:
– This entire step will depend on what procedure is
needed!
Laparoscopy
cont. Operative Sequence
• Hemostasis and Irrigation:
– The intra-abdominal cavity is irrigated thoroughly with
normal saline.
– All bleeding is controlled with a cautery-capable endoinstrument of Surgeons choice.
– Special attention is focused on the liver bed. Highly
vascularized area.
– The abdomen should be examined for any possible
bowel injury or hemorrhage. All instruments and ports
should be carefully and slowly removed while the CO2 in the pneumoperitineum is released.
Laparoscopy
cont. Operative Sequence
• Closure:
– Closure will be surgeon specific. Some
Surgeons today will not close any layer other
than skin.
– Other surgeons will use a 0-Vicryl to close the
fascial/muscle layer and a 4-0 Monocryl for
skin.
– Skin staples are always an option.
Laparoscopy
• Major Arteries:
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Internal thoracic artery
The superior epigastric artery
Aorta
External iliac artery: the inferior
epigastric and deep circumflex arteries
Inferior phrenic artery, branch of the
abdominal aorta.
Lower posterior intercostal and
subcostal arteries, branches of thoracic
aorta.
Lumbar arteries, from abdominal aorta.
Laparoscopy
• Major Nerves:
– Inferior six thoracic
nerves
– The subcostal nerve
– The intercostal
nerves
GYN Laparoscopic Procedures
Operative Sequence
L.A.V.H.
(Laparoscopic Assisted
Vaginal Hysterectomy)
and
Vaginal Hysterectomy
LAVH
• Overall Purpose of Procedure:
– Laparoscopic Assisted Vaginal Hysterectomy
• Its greatest benefit is the potential to convert what would
have been an abdominal hysterectomy into a vaginal
hysterectomy. An abdominal hysterectomy requires both
a vaginal incision and a four to six inch long incision in
the abdomen, which is associated with greater postoperative discomfort and a longer recovery period than
for a vaginal procedure. Another advantage of the LAVH
may be the removal of the tubes and ovaries which on
occasion may not be easily removed with a vaginal
hysterectomy.
Advantages of LAVH
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Miniature Abdominal Incisions
Decreased Post Operative Pain
Shortened Post Operative Recovery
Fewer Post Operative Infections
Fewer Adhesions
Shortened Hospitalization (< 24 hours)
LAVH
• Define the procedure:
– LAVH combines laparoscopy and hysterectomy.
Laparoscopy is used to look into the abdomen at
the reproductive organs. Hysterectomy is surgery
to remove the uterus.
– Tiny instruments are inserted laparoscopically to
perform the procedure. Ligaments that support the
uterus are cut with these instruments, and the
uterus is removed vaginally.
Indications for LAVH
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Previous pelvic surgery
Endometriosis
Previous C.S.
Pelvic pain
Uterine myoma
Ectopic pregnancy
Acute or chronic pelvic inflammatory disease
Minimum uterine mobility & limited access
LAVH
• Wound Classification: 2
Operative Sequence
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1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
LAVH
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•
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Instrumentation: Laparoscopic Tray – open.
– Major/Minor Instrument Tray - a hold item.
What basic instruments will you expect to see in this tray?
Positioning: – Steep trendelenburg position for laparoscopic part.
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 from the
monitor.
LAVH
•
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 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.
LAVH
• Full Counts….do we need them?
WHY?
LAVH
Begin your Operative Sequence
• Incision: 15 or 11 kb
on #3 handle for
incision.
• 2 towel clips on either
side of umbilicus.
• Veres Needle
LAVH
cont. 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.
LAVH
cont. Operative Sequence
• Dissection and
Exposure:
– Multiple ports are
inserted to provide
instrument and
scope access.
LAVH
cont. Operative Sequence
• Exploration and Isolation:
– Patients abdomen is explored as
if performing a Laparoscopy.
LAVH
cont. Operative Sequence
• Surgical Repair /
Removal :
– Dissection of the broad
ligament is performed.
May use Maryland, L-hook,
Harmonic Scalpel, or
stapler.
– Next, dissection of the
Round ligament takes
place.
LAVH
cont. Operative Sequence
• Surgical Repair /
Removal/Specimen
Collection:
– MD must mobilize the bladder
from the lower uterine
segment.
• Surgeon has a couple of
option at this stage.
– They can close up top and
move below to remove the
uterus (Vaginal Hysterectomy)
OR………
– They will move below, remove
the uterus, then come back up
top.
LAVH
cont. Operative Sequence
• If the surgeon performs the second option
and comes back to the laparoscopic site:
– You must provide the surgeon with a clean gown
and glove.
– Surgeons will come back to check bleeding and to
ensure the vaginal cuff has been completely
closed after the uterus has been removed
vaginally.
– This will be the last step before closure.
LAVH
to Vag Hys
cont. Operative Sequence
• Surgeon has moved below:
– Case will proceed like a Vag Hys from this point
on!
Vaginal Hysterectomy
• Weighted speculum placed in vagina.
• The uterus is grasped with a single or double
toothed tenaculum for mobilization and
assistance in removal.
• Surgeon makes a circumferential incision at
the base of the cervix. This separates the
cervix from the vagina.
• If this were a straight Vag Hys, all the
ligaments that were cut from above would
have to be clamped and cut now.
Vaginal Hysterectomy
• You must do a closing count! WHY?
Vaginal Hysterectomy
• Removes the uterus vaginally
• Closes the peritoneum and
posterior vaginal wall.
• Packs with gauze and antibiotic
cream.
• Apply Peri-pad.
LAVH
and Vag Hys
cont. Operative Sequence
• Hemostasis and Irrigation:
– The intra-abdominal cavity is irrigated thoroughly with
normal saline.
– All bleeding is controlled with a cautery-capable endoinstrument of Surgeons choice.
– Special attention is focused on the liver bed. Highly
vascularized area.
– The abdomen should be examined for any possible
bowel injury or hemorrhage. All instruments and ports
should be carefully and slowly removed while the CO2 in the pneumoperitineum is released.
LAVH
cont. Operative Sequence
• Closure:
– Closure will be surgeon specific. Some Surgeons
today will not close any layer other than skin.
– Other surgeons will use a 0-Vicryl to close the
fascial/muscle layer and a 4-0 Monocryl for skin.
– Skin staples are always an option.
L.A.V.H. And TVH Movies
• Laparoscopic_Hyster • Notice the dissection
ectomy.mpg
of the ligaments and
the passage of the
• TVH Routine Case
uterus thru the vagina
and the end of the
case.
• Notice the lap
assisted suturing
techniques!