CH 46 Therapeutic Gynecologic Procedures

Question 1

Dilation and Curettage

Answer 1

cervical dilation and uterine curettage. Used for diagnosis and treatment of abnormal uterine bleeding, management of abortion, or diagnosis of CA of the uterus

Question 2

Endometrial polypectomy

Answer 2

uterine cavity is explored with polyp forceps prior to diagnostic or therapeutic endometrial curettage. done to remove polyps prior to curettage to preserve the histologic integrity needed to differentiate benign uterine polyps from neoplasia

Question 3

Endometrial curettage

Answer 3

diagnostic and therapeutic. indicated for treatment of complications of pregnancy, including incomplete or missed abortion, postpartum retention of products of conception, and placental polyps. also useful for menorrhagia and to stop acute bleeding.

Question 4

Endometrial biopsy

Answer 4

diagnostic

Question 5

hysteroscopy indications

Answer 5

for pre/post menopausal bleeding, endometrial ablation, thickening, polyps, submucosal myomas, endocervical lesions, mullerian abnormalities, intrauterine adhesions, retained IUD or foreign body, sterilization, retained products of conception

Question 6

Hysteroscopy contraindications

Answer 6

viable intrauterine pregnancy, active pelvic infection, uterine/cervical CA, heavy bleeding limiting visual field.

Question 7

Laparoscopy

Answer 7

transperitoneal endoscopic technique that gives great visualization of pelvic structures and permits diagnosis of gyn disorders and pelvic surgery without laparotomy.

Question 8

Cautery

Answer 8

laparoscopic sterilization with electrical cautery is one of most common lap sterilization methods. fallopian tube burned at 2 to 3 different locations

Question 9

Silastic bands

Answer 9

tubal occlusion using silastic bands or rings. higher preg rate than cautery but fewer ectopics. Mechanical problems in placement of bands and bleeding are commin

Question 10

Sterilization clips

Answer 10

tube occlusion with clips (Hulka or Flishie) has wide range of failure. only small portion of tube is damaged, so successful reversal is possible.

Question 11

Interval Partial Salpingectomy

Answer 11

failure rate of 20/1000 over 10 years

Question 12

Postsurgical care

Answer 12

may be sent home following full recovery from anesthesia in 1-2 hours. Extensive surgery (like lap hysterectomy) may need 1-2 day hospital stay. Pain should be minimal and pt may go home with simple oral analgesic. Most common complaint: shoulder pain secondary to subdiaphragmatic accumulation of gas. Resume activity (except sex) the next day. Follow up in 1-2 weeks.

Question 13

Complications post surgery (vascular injuries and intestinal injury)

Answer 13

Major vessel injuries can occur causing catastrophic bleeding (look out for large retroperitoneal hematoma) Need immediate conversion to laparotomy and may need transfusion; intestinal injury are uncommon but have 5% mortality rate. cause of injury is sharp object or thermal burn (look out for leukopenia, low fever, normal leukocyte count, pain, nausea, vomiting)

Question 14

Complications post surgery (urinary, hernia, subcutaneous emphysema, shoulder pain)

Answer 14

Urinary injuries usually occur during lap assisted vaginal hysterectomy, Ventral hernia may occur but is less common with laparoscopy . subcutaneous emphysema may occur and is fine UNLESS it is in the face, neck or chest (pneumothorax or pneumomediastinum). Shoulder pain may occur due to pain from diaphragmatic irritation, treat with mild analgesics

Question 15

hysteroscopic microinsert placement

Answer 15

tubal sterilization technique consisting of a fallopian tube implant and a delivery catheter. hysterosalpingogram should be done 3 months afterwards to confirm closure of fallopian tubes. use other contraception until then. 64 in 50000 pregnancies

Question 16

Vasectomy

Answer 16

done under local anesthesia via small incision in upper outer aspect of the scrotum. Sutures placed on vas demarcating a 1-1.5 cm segment that is then excised. the ends are tucked back into the scrotal sac and the incision is closed. This is done on both sides. No scalpel version too. ejaculates are free of sperm in 2 months usually

Question 17

Hysterectomy

Answer 17

complete surgical removal of uterus. Most common gyn surgery and second most common major operation performed in the US. Indicated for gyn CA, benign GYN conditions and OB complications

Question 18

When to choose vaginal hysterectomy

Answer 18

gynecoid pelvis, uterine size 12 weeks gestation or smaller, hx of significant heart or lung issues, previous tubal ligation or c section

Question 19

When to choose abdominal hysterectomy

Answer 19

pelvic findings suggesting adnexal disease, hx of GI complaints

Question 20

Indication for supracervical hysterectomy

Answer 20

difficulty dissecting cervix, distorted anatomy secondary to pelvic inflammatory dz or endometriosis, compromised medical condition