gynae proceedures

Question 1

what is a hysterectomy?

Answer 1

surgical removal of uterus

Question 2

what is the difference between a:

a) total hysterectomy?
b) sub total hysterectomy?
c) total hysterectomy and bilateral salpingoophorectomy
d) radical hysterectomy?

Answer 2

total - removal of uterus and cervix
subtotal - removal of uterus but not cervix
total + salpingoophorectomy = removal or uterus, cervix and fallopian tubes and ovaries

radical - removal of uterus, cervix, parametrium, vaginal cuff and part or all of fallopian tubes (for certain types of cervical cancer)

Question 3

how can a hysterectomy be performed?

Answer 3

abdominal open - pfannenlsteil incision or midline incision. requires general anaesthetic

vaginal - incision made through superior part of vagina and removed via the vaginal. local or regional anaesthetic, mainly used for prolapse repair

laparoscopically and then removed vaginally. requires general

Question 4

which artery is tied during hysterectomy?

Answer 4

uterine vessels

round ligaments can also be tied but not essential

Question 5

when can a lady be discharged after a hysterectomy?

Answer 5

1-2 days if laparoscopic or vaginal

2-5 days if abdominal

Question 6

what are the indications for a hysterectomy?

Answer 6

heavy menstrual bleeding 
pelvic pain 
uterine prolapse (vaginal hysterectomy)
gynae malignancy
prophylaxis against malignancy e.g. BRCA or lynch syndrome 
major post partum haemorrhage

Question 7

what are the complications of a hysterectomy?

Answer 7

as for any surgical procedure: bleeding, infection, anaesthetic risk, pain

common:
- damage to bladder and/or ureter
- haemorrhage requiring transfusion

uncommon:

• long term disturbance to bladder function
• damage to bowel - constipation
• wound dehiscence
• pelvic infection
• VTE

early menopause - due to reduced blood supply to ovaries
often lymph nodes are removed too and this can have added complications of paraesthesia or lymphoedema of legs.
for vaginal hysterectomies - can get vaginal adhesions - gauze helps to reduce this

increases risk of prolapse

Question 8

what is endometrial ablation?

Answer 8

endometrium of uterus is destroyed

Question 9

what are the indications for endometrial ablation?

Answer 9

heavy menstrual bleeding with no identifiable cause

Question 10

what are the different techniques for endometrial ablation?

Answer 10

usually hysteroscopy first to assess for best method

e.g. 
balloon ablation
transcervical resection of endometrium (TCRE)
microwave energy
bipolar mesh

Question 11

how is transcervical resection of the endometrium performed?

Answer 11

general anaesthetic

resectoscope (operating hysteroscope) used to destroy and remove endometrium using diathermy

Question 12

how is balloon ablation of endometrium performed?

Answer 12

A balloon filled with heated fluid sits inside the uterus for a pre-specified time to destroy the endometrium.
local or general anaesthetic
cervical dilation is required

Question 13

how is microwave energy used for endometrial ablation

Answer 13

intrauterine device is used to deliver microwave energy into the endometrial cavity to destroy the endometrium
local anaesthetic
does not require cervical dilation

Question 14

how is a bipolar mesh used in endometrial ablation?

Answer 14

bipolar mesh inserted into uterus, expanded and energy delivered to endometrium
requires cervical dilation
local or general anaesthetic

Question 15

what are the contraindications to endometrial ablation?

Answer 15

woman who want future pregnancies

endometrial hyperplasia or malignancy

Question 16

do women need contraception after endometrial ablation?

Answer 16

yes - because pregnancy is still possible and there is risk of complications e.g. placenta praevia or accreta

Question 17

what are the complications of endometrial ablation?

Answer 17

small risk of fluid overload and hyponatraemia
uterine perforation - rare
bowel/bladder injury - rare
inflammation and tissue necrosis - scarring and obstructed outflow - pelvic pain

Question 18

what is tension free vaginal tape?

Answer 18

A procedure whereby a synthetic tape is placed around the urethra to form a sling to support the urethra and prevent leakage
used in incontinence
inserted under general anaesthetic and woman is catheterised.
good short term cure but not long term

Question 19

what are the indications for tension free vaginal tape?

Answer 19

stress urinary incontinence

Question 20

what are the complications of tension free vaginal tape?

Answer 20

bladder perforation
damage to pelvic blood vessels
sometimes can lead to urinary retention but usually this is not long term
some women have urgency and frequency after
groin and suprapubic pain - short term

Question 21

what are the alternatives to tension free vaginal tape?

Answer 21

mid urethral tape
open colposuspension
anterior vaginal repair
bulking agents injected into bladder neck
autologous rectal fascial sling
create artificial sphincter around bladder neck