Procedures Flashcards
Pap smear
- Write detail on slide. Get equipment necessary (speculum, brush and spatula, fixative and slide cover)
- Warm speculum with water
- Insert speculum into vagina. Display cervix and fix the speculum
- With the spatula, rotate 1-2 times. Cytobrush - rotate once only. (If using broom, rotate 3-4 times)
- Wipe on slide and fix. Place in holder. Remove speculum
Colposcopy
- Def = examination of transformation zone of cervix under magnification (transformation zone = area in which the dysplastic changes occur)
- Vagina and vulva should also be examined
- 5% acetic acid used to identify dysplastic changes (stain white due to different glycogen content)
- Abnormal areas biopsied to confirm dysplasia
- Lugol’s iodine can also be used to identify dysplastic areas, and should be used to examine the vagina for evidence of dysplasia
Hysteroscopy - background
Telescope that is inserted into uterus via vagina and cervix to visualise the endometrial cavity, as well as the tubal ostia, endocervical canal, cervix and vagina
- Can be diagnostic or therapeutic
Hysteroscopy - indications
Performed for evaluation or treatment of:
- Abnormal uterine bleeding
- Endometrial thickening or polyps
- Submucosal and some intramural fibroids
- Intrauterine adhesions or mullerian anomalies
- Retained products of conception
Hysteroscopy - contraindications (3)
- Viable intrauterine pregnancy
- Acute pelvic infection (including genital herpes infection)
- Known cervical or uterine cancer
Hysteroscopy - risks/complications
- Uterine perforation
- Fluid overload
- Intraoperative haemorrhage
- Bowel or bladder injury
- Endomyometritis (infection)
TVT (tension-free vaginal tape) - general info
- Most commonly performed surgical procedure for urinary stress incontinence
- Polypropylene tape placed under mid-urethra via small vaginal incision, using local, regional or general anaesthesia
- Cystourethroscopy carried out to ensure no damage to the bladder or urethra
- Procedure is minimally invasive and most women return to normal activity withn 2 weeks
- Objective cure rate = around 95%
TVT - indications
- Symptomatic SUI + failed/declined conservative mx
2. Planned repair of prolapse of vaginal apex + suspected occult SUI
TVT - contraindications
- Current urinary tract infection
- Current pregnancy
- Anticoagulation
- Structures in the retropubic space that are in the path of sling placement (eg, vascular graft, bowel, transplanted pelvic kidney)
- Relative contraindication = plans for future pregnancy
TVT - complications
- Moderately high risk of bladder injuries (5-10%), but no long term sequelae if treated appropriately
- Bleeding into retropubic space
- Infection
- Voiding difficulties
- Tape erosion into vagina and urethra
Transobturator tape - overview (3)
- Polypropylene tape passed via transobturator foramen through transobturator and adductor muscles
- Main difference from TVT = retropubic space not entered; risk of bladder perforation is low
- Potential disadvantages = high risk of nerve trauma (chronic groin pain in up to 20% of pts)
Laparoscopy - indications
Dx + mx
1. Appendicitis in pregnancy
2. Endometriosis (dx + mx by coagulation, excision or ablation)
3. Ectopic pregnancy
4. PUL - if significant pain, tenderness or haemoperitoneum
5. Dx + mx of benign ovarian masses - laparoscopic cystectomy
______________
Dx
1. Chronic pelvic pain (NSAID resistant, pain resulting in days off work/school or hospitalisation)
2. Acute pelvic pain (avoid unnecessary laparoscopy, especially in a woman with a hx of chronic pain - perform other ix first, e.g. pelvic USS, CT, FBE, AXR… as appropriate)
3. Investigation of infertility, assessment of tubal patency
4. Investigation of fallopian tube mass
Mx
- Drainage of tubo-ovarian abscess in PID
- Total laparoscopic hysterectomy (?)
Laparoscopy - complications
- Vascular injury/haemorrhage
- Gastrointestinal injury/solid visceral injury
- Nerve injury
- Port-site hernia
- Surgical site infection
Hysterectomy - overview
- May be performed using abdominal, vaginal or laparoscopic approach
- Either total (uterus + cervix) or subtotal (supracervical) hysterectomy may be performed
- Ovaries may or may not be removed at time of hysterectomy
Hysterectomy - selection of route
- Vaginal hysterectomy preferred route bc of advantages and lower complication rates
- If vaginal hysterectomy not feasible bc limited vaginal access, size of uterus or major adhesive disease, then laparoscopic hysterectomy performed
- Abdominal hysterectomy or hysterectomy by laparotomy is reserved for all other cases
Abdominal hysterectomy - overview of procedure
- Position in the dorsal supine or lithotomy position (preferred by some surgeons so that a second assistant can stand between the patient’s legs)
- GA. Perform an examination under anesthesia (helps to confirm pelvic findings and guide the final choice of incision) (see “Pelvic examination under anesthesia”)
- Insert Foley bladder catheter
- Perform sterile preparation of the abdomen and vagina
- Place surgical draping
_____ - Skin incision - transverse or midline vertical; if previous scar present, may use this one
- Peritoneal cavity entered. Most surgeons prefer to use a self-retaining retractor
- Divide omental, intestinal or abdominal wall adhesions
- Ligate round ligament. Dissect broad ligament
- Identify ureters and dissect if necessary (for protection)
_____ - Conserve ovaries, or salpingoophorectomy
- Perivesical and perirectal dissection
- Uterine vessel ligation
- Cervical amputation and removal of uterus (if subtotal), or removal of uterus + cervix
- Vaginal cuff closure, final examination and closure
Hysterectomy - complications
- Haemorrhage
- Infection
- VTE
- Ureteral injury, bladder injury, urinary incontinence. Bowel injury, ileus
- Vaginal cuff dehiscence
Also - surgically induced menopause if BSO
+ risk of conversion to laparotomy for laparoscopic hysterectomy
Hysterectomy - indications
- Massive obstetric haemorrhage (last resort)
- Severe abnormal uterine bleeding (failure to respond to medical management and no desire for future children)
- Last resort tx for endometriosis
- Uterovaginal (apical) prolapse
- Uterine fibroids (for women who have either completed their family or are >45y)
____ - Cervical cancer
- Ovarian cancer (most cases)
- Atypical endometrial hyperplasia (once fertility not required)
- Endometrial cancer
- Gestational trophoblastic disease (salvage surgery in high risk patients following chemotherapy - ?)
Laparoscopic hysterectomy - overview of procedure
- Positioning and preparation (dorsal lithotomy position)
- GA. Examination + under anaesthesia
- Port placement - usually a primary port at the umbilicus and two accessory ports in the bilateral lower quadrants
- If pelvic/intra-abdominal adhesions present, adhesiolysis performed
- Identify ureters
______ - Conserve ovaries or perform BSO
- Ligate and divide round ligament
- Ligate uterine vessels
- Conservation or removal of cervix
- Suturing of vaginal cuff. Final examination and closure
