Anesthesia for GYN Surgery Flashcards
dilation and curettage (D&C)
- dilate cervix and curettage (scrape walls of) uterus to remove (or vacuum aspirate) products of conception, cysts or tumors
- POC only in 1st trimester
- sometimes have suction
- US on at same time to ensure all POC are removed (if not then could have bleeding)
anesthetic considerations D&C
- emotional state
- baseline CBC
- intraop H/H monitoring
- analgesia
- antiemetics
- uterine relaxation
- venous access
- volume
- have T&S
- position = lithotomy
dilation and evacuation (D&E)
- performed in 2nd trimester between 12-24 weeks of pregnancy
- miscarriage or elective pregnancy termination
- relatively same approach and considerations as D&C
- vacuum aspirator and forceps
- increased risk of bleeding compared to D&C
- have uterotonics on hand - pitocin, methergine, hemabate
uterotonic medications
- act directly on uterine smooth muscle
- increase tone, rate, and strength of rhythmic contractions
oxytocin (pitocin)
- naturally produced hormone
- secreted by the pituitary
- uterotonic, stimulates uterine contractions, labor onset –> postpartum
- 10-20 unit vial (dilute)
benefits of uterotonics
- prevent/treate PPH
- ripen cervix and induce labor
- manage incomplete or elective abortion
mifeprex (mifepristone)
- medical management of abortion at home if within 49 days and pass at home
- may come in for retained POC
- synthetic steroid made from norethindrone (active ingredient of norplant)
- only FDA approved non-surgical option for abortion during first 49 days of pregnancy
methergine
- semi-synthetic ergot alkaloid
- prevents and controls PPH
- 0.2 mg IM (ONLY IM)
- contraindication - HTN
hemabate (carboprost tromethamine)
- prostaglandin F2a
- 250 mcg (0.25 mg) IM
- IM ONLYYYY
- also used for elective abortion
- avoid with asthmatics –> can cause severe RAD
cervidil (dinoprostone), prepidil, prostin E2
- vaginal insert
- naturally occuring biomolecule (PGE2)
- stimulates PGF-2a (which sensitizes myometrium to oxytocin)
- cervical ripening + induce labor in that way
- 10 mg/insert
conization of cervix
excision of cylindrical (cone-shaped) wedge from the cervix
indications for conization of cervix
- definitive diagnosis of squamous or glandular intraepithelial lesions
- excluding microinvasive carcinomas
- conservative treatment of cervical intra-epithelial neoplasia (CIN)
methods for conization of cervix
- scalpel (cold-knife)
- laser (excision or vaporization)
- electrosurgical excision loop (LEEP)
- large loop excision of the transformation zone (LLETZ)
- combination (laser and completed with a cold-knife)
hysteroscopy
-visualization inside uterus to diagnose or treat uterine problems
hysteroscopy indications
- abnormal uterine bleeding
- fibroids
- polyps
- cancer
- biopsies
- remove adhesions
- sterilization
- locate IUD
hysteroscopy surgical procedure
- empty bladder (in and out cath)
- speculum into the vagina
- hysteroscope advanced through vagina, cervix and into uterus
- project image onto screen
- gas (CO2) or fluid (NS or LR) expands uterus
hysteroscopy risks
- uterine or cervical puncture/perf
- bleeding
- infection
- hypervolemia
- hyponatremic ecephalopathy
- cardiac asystole
- arrhythmia
- hypercarbia/acidosis/gas embolism
endometrial ablation
- treats heavy bleeding when medications unsuccessful (endometriosis)
- destroys endometrium
- stops or reduces menstrual flow
- not performed in post menopausal women
- no incisions
- surgical time - 30-60 min
endometrial ablation not advised for the following
- thin endometrium
- endometrial hyperplasia
- uterine cancer
- recent pregnancy
- current or recent uterine infection
endometrial ablation risks
- bleeding
- infection
- uterine or bowel perf
- internal burns
colposcopy
- typically office procedure; occasionally in OR
- view office in colposcope magnified 2-60x
colposcopy used to assess what?
- cervicitis
- uterine polyps
- pain
- bleeding
- cervical warts
tubal ligation
- fallopian tubes pulled through navel, cut and closed (sutures, bands, clips)
- performed post c-section; does not extend stay
tubal ligation anesthesia
- epidural
- spinal
- combined spinal-epidural
- GA
- IV sedation with LA
tubal ligation surgical time
30 min
tubal ligation risks
- bleeding
- infection
endometriosis
- endometrial growth outside uterus (ovaries, bowel, bladder, rectum, pelvic wall)
- responds to hormonal changes
- retrograde menstruation with suspected immune system explanation
- causes pain, irregular bleeding, adhesions, possible infertility
endometriosis treatment options
- hormone therapy
- surgical intervention - diagnostic lap, excision of endometrial tissue/ablation, hysterectomy, laparotomy
ectopic pregnancy
- fertilized egg attached outside of uterus (most commonly in fallopian tubes)
- second leading cause of maternal mortality
- rupture is life-threatening, may require salpingoectomy
- surgical excision of ectopic or medical management
ectopic pregnancy symptoms
- vaginal bleeding
- pelvic pain
- dizziness
- fainting
- weakness
- shoulder pain (rupture)
hysterectomy
- surgical removal of the uterus
- 2nd most common major surgery among women of childbearing age
- approach depends on reason for the surgical intervention and patient health status
hysterectomy is treatment for what?
- uterine fibroids
- endometriosis
- uterine prolapse
- abnormal uterine bleeding
- chronic pelvic pain
- cancer
three types of laparoscopic hysterectomy
- total laparoscopic hysterectomy
- laparoscopically assisted vaginal hysterectomy (LAVH)
- robot-assisted laparoscopic hysterectomy
laparoscopic hysterectomy advantages
- smaller incisions
- less pain
- shorter hospital stay
- shorter recovery
- less risk of infection and other post-op complications
laparoscopic hysterectomy disadvantages
- increased surgical time
- increased risk for bladder injury
- risks associated with pneumoperitoneum
radical hysterectomy
-removes uterus, cervix, ovaries, fallopian tubes, upper vagina, parametrium, pelvic lymph nodes
radical hysterectomy indications
- uterine, cervical or ovarian cancer
- endometriosis
- fibroids
- pelvic relaxation syndrome
radical hysterectomy surgical time
3-4 hours
radical hysterectomy incision
midline or low transverse
radical hysterectomy EBL
1500 mL
postoperative considerations for hysterectomy
- oophrectomy effects caused by lack of estrogen (hot flashes, vaginal dryness, sleep problems)
- earlier risk for osteoporosis than menopausal women
- positioning considerations
- treated with estrogen therapy (pill, injection, skin patch, vaginal cream, vaginal ring)
myomectomy
surgical procedure to remove uterine fibroids
myomectomy preop treatments
- multivitamins
- iron supplements
- gonadotropin releasing hormone agonist
- oral contraceptives
myomectomy anesthetic considerations
- type and corss
- intraop H&H
- IV fluid and blanket warming equipment
- third space fluid loss (open approach)
- surgical approach determine by type of fibroids
- general or regional
- prophylactic antithrombotics
second look laparotomy (SLL)
- diagnostic
- most accurate method of assessing disease status in ovarian cancer
- patients completed initial therapy, clinical free of disease
- negative SLL associated with improved survival
- same anesthetic considerations as staging laparotomy
anesthetic considerations for radical vulvectomy
- chemo
- bowel prep
- general, spinal, epidural
- PCA or epidural post op pain
- foley
modified dorsal lithotomy
- position used for radical vulvectomy
- legs extended
- hips abducted 30 degrees
- extended 5-10 degrees
- knees flexed 90 degrees
- potential for nerve injury
pelvic exenteration or evisceration
- remove all organs from pelvis
- indicated for advanced or recurrent pelvic cancer
- radical hysterectomy, total vaginectomy, bladder excision (urostomy), urinary diversion, bowel resection (colostomy)
- neovagina construction available
pelvic exenteration M&M
- 3-5% death intraop
- 5 year survival = 10%
surgical risks of pelvic exenteration
- hemorrhage
- sepsis
- wound dehiscence
- anastomotic breakdown at bowel
- urinary pouch
- ureteral sites
- DVT/PE
- stoma necrosis
- reconstructive flap necrosis
late complications of pelvic exenteration
- 33% of people experience
- fistula
- bowel obstruction
- ureteral stricture
- renal failure
- pyelonephritis
- chronic bowel obstruction
- increased risk renal disease post op due to UTI and obstruction
