Procedures

Question 1

Pap smear

Answer 1

1. Write detail on slide. Get equipment necessary (speculum, brush and spatula, fixative and slide cover)
2. Warm speculum with water
3. Insert speculum into vagina. Display cervix and fix the speculum
4. With the spatula, rotate 1-2 times. Cytobrush - rotate once only. (If using broom, rotate 3-4 times)
5. Wipe on slide and fix. Place in holder. Remove speculum

Question 2

Colposcopy

Answer 2

1. Def = examination of transformation zone of cervix under magnification (transformation zone = area in which the dysplastic changes occur)
2. Vagina and vulva should also be examined
3. 5% acetic acid used to identify dysplastic changes (stain white due to different glycogen content)
4. Abnormal areas biopsied to confirm dysplasia
5. Lugol’s iodine can also be used to identify dysplastic areas, and should be used to examine the vagina for evidence of dysplasia

Question 3

Hysteroscopy - background

Answer 3

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

Question 4

Hysteroscopy - indications

Answer 4

Performed for evaluation or treatment of:

1. Abnormal uterine bleeding
2. Endometrial thickening or polyps
3. Submucosal and some intramural fibroids
4. Intrauterine adhesions or mullerian anomalies
5. Retained products of conception

Question 5

Hysteroscopy - contraindications (3)

Answer 5

1. Viable intrauterine pregnancy
2. Acute pelvic infection (including genital herpes infection)
3. Known cervical or uterine cancer

Question 6

Hysteroscopy - risks/complications

Answer 6

1. Uterine perforation
2. Fluid overload
3. Intraoperative haemorrhage
4. Bowel or bladder injury
5. Endomyometritis (infection)

Question 7

TVT (tension-free vaginal tape) - general info

Answer 7

1. Most commonly performed surgical procedure for urinary stress incontinence
2. Polypropylene tape placed under mid-urethra via small vaginal incision, using local, regional or general anaesthesia
3. Cystourethroscopy carried out to ensure no damage to the bladder or urethra
4. Procedure is minimally invasive and most women return to normal activity withn 2 weeks
5. Objective cure rate = around 95%

Question 8

TVT - indications

Answer 8

1. Symptomatic SUI + failed/declined conservative mx

2. Planned repair of prolapse of vaginal apex + suspected occult SUI

Question 9

TVT - contraindications

Answer 9

1. Current urinary tract infection
2. Current pregnancy
3. Anticoagulation
4. Structures in the retropubic space that are in the path of sling placement (eg, vascular graft, bowel, transplanted pelvic kidney)
5. Relative contraindication = plans for future pregnancy

Question 10

TVT - complications

Answer 10

1. Moderately high risk of bladder injuries (5-10%), but no long term sequelae if treated appropriately
2. Bleeding into retropubic space
3. Infection
4. Voiding difficulties
5. Tape erosion into vagina and urethra

Question 11

Transobturator tape - overview (3)

Answer 11

1. Polypropylene tape passed via transobturator foramen through transobturator and adductor muscles
2. Main difference from TVT = retropubic space not entered; risk of bladder perforation is low
3. Potential disadvantages = high risk of nerve trauma (chronic groin pain in up to 20% of pts)

Question 12

Laparoscopy - indications

Answer 12

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

5. Drainage of tubo-ovarian abscess in PID
6. Total laparoscopic hysterectomy (?)

Question 13

Laparoscopy - complications

Answer 13

1. Vascular injury/haemorrhage
2. Gastrointestinal injury/solid visceral injury
3. Nerve injury
4. Port-site hernia
5. Surgical site infection

Question 14

Hysterectomy - overview

Answer 14

1. May be performed using abdominal, vaginal or laparoscopic approach
2. Either total (uterus + cervix) or subtotal (supracervical) hysterectomy may be performed
3. Ovaries may or may not be removed at time of hysterectomy

Question 15

Hysterectomy - selection of route

Answer 15

1. Vaginal hysterectomy preferred route bc of advantages and lower complication rates
2. If vaginal hysterectomy not feasible bc limited vaginal access, size of uterus or major adhesive disease, then laparoscopic hysterectomy performed
3. Abdominal hysterectomy or hysterectomy by laparotomy is reserved for all other cases

Question 16

Abdominal hysterectomy - overview of procedure

Answer 16

1. Position in the dorsal supine or lithotomy position (preferred by some surgeons so that a second assistant can stand between the patient’s legs)
2. GA. Perform an examination under anesthesia (helps to confirm pelvic findings and guide the final choice of incision) (see “Pelvic examination under anesthesia”)
3. Insert Foley bladder catheter
4. Perform sterile preparation of the abdomen and vagina
5. Place surgical draping
   _____
6. Skin incision - transverse or midline vertical; if previous scar present, may use this one
7. Peritoneal cavity entered. Most surgeons prefer to use a self-retaining retractor
8. Divide omental, intestinal or abdominal wall adhesions
9. Ligate round ligament. Dissect broad ligament
10. Identify ureters and dissect if necessary (for protection)
    _____
11. Conserve ovaries, or salpingoophorectomy
12. Perivesical and perirectal dissection
13. Uterine vessel ligation
14. Cervical amputation and removal of uterus (if subtotal), or removal of uterus + cervix
15. Vaginal cuff closure, final examination and closure

Question 17

Hysterectomy - complications

Answer 17

1. Haemorrhage
2. Infection
3. VTE
4. Ureteral injury, bladder injury, urinary incontinence. Bowel injury, ileus
5. Vaginal cuff dehiscence

Also - surgically induced menopause if BSO

+ risk of conversion to laparotomy for laparoscopic hysterectomy

Question 18

Hysterectomy - indications

Answer 18

1. Massive obstetric haemorrhage (last resort)
2. Severe abnormal uterine bleeding (failure to respond to medical management and no desire for future children)
3. Last resort tx for endometriosis
4. Uterovaginal (apical) prolapse
5. Uterine fibroids (for women who have either completed their family or are >45y)
   ____
6. Cervical cancer
7. Ovarian cancer (most cases)
8. Atypical endometrial hyperplasia (once fertility not required)
9. Endometrial cancer
10. Gestational trophoblastic disease (salvage surgery in high risk patients following chemotherapy - ?)

Question 19

Laparoscopic hysterectomy - overview of procedure

Answer 19

1. Positioning and preparation (dorsal lithotomy position)
2. GA. Examination + under anaesthesia
3. Port placement - usually a primary port at the umbilicus and two accessory ports in the bilateral lower quadrants
4. If pelvic/intra-abdominal adhesions present, adhesiolysis performed
5. Identify ureters
   ______
6. Conserve ovaries or perform BSO
7. Ligate and divide round ligament
8. Ligate uterine vessels
9. Conservation or removal of cervix
10. Suturing of vaginal cuff. Final examination and closure