Atlas of Pelvic Surgery

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Dilatation and Curettage

Dilatation and curettage unrelated to pregnancy is best performed with the patient under general anesthesia to allow the gynecologist to perform a more thorough pelvic examination. The purpose of the operation is to remove as much hyperplastic, proliferative, and necrotic endometrium as possible to allow an accurate pathologic diagnosis to be made and to arrest dysfunctional uterine bleeding. Excessive bleeding will usually discontinue for at least several months. Physiologic Changes. Removal of the endometrium back to the stratum basale will not change the physiology of the hypothalamic-pituitary-ovarian axis in regard to ovulation. Points of Caution. Care must be taken in dilating the cervix to avoid peroration of the uterus. Technique

The patient is placed in the dorsal lithotomy position with the legs in appropriate gynecologic stirrups. A thorough bimanual examination, including a rectovaginal examination, should be performed prior to the procedure. The perineum and vagina should be washed with surgical soap. Shaving the perineal hair, however, is not necessary for this procedure.

Atlas of Pelvic Surgery

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Adequate exposure to the cervix can be achieved by the use of a Sims retractor. Some gynecologists prefer a weighted posterior retractor, but in most cases this is unnecessary. The procedure is begun by grasping the anterior lip of the cervix with a wide-mouthed Jacobs tenaculum. The endometrial cavity is sounded for both depth and direction.

The cervical canal is progressively dilated with Pratt dilators until a diameter of approximately 8 mm is reached.

A ureteral stone forceps is helpful in exploring the uterine cavity and searching for polyps. Polyps can frequently be missed by the sharp curet itself. If polyps are found, they should be removed by twisting them from their stalks.

A sharp curet is advanced through the dilated cervical canal to the fundus. The endometrial cavity is curetted with a systematic back-andforth movement of the curet so that all possible

Atlas of Pelvic Surgery

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They should be sent to the pathology laboratory in a separate specimen. endometrium is sampled.

The cervix should be stained with Lugol's solution, and four random quadrant biopsies should be taken from the squamocolumnar junction.