IMLE Preparatory Course

Lecture 57
Obstetrics and Gynecology

Gynecologic Procedures
Hysterectomy
Gynecologic Laparoscopy
Dilatation & Curettage
Hysterectomy
Introduction
 In November 1843, Charles Clay performed the first
hysterectomy in Manchester, England. In 1929, Richardson,
MD, performed the first total abdominal hysterectomy
(TAH), in which the entire uterus and cervix were removed.
 Hysterectomy is the most commonly performed
gynecological surgical procedure
 600,000 hysterectomies are performed yearly (US)
 90% done for benign conditions
 Abdominal hysterectomy was more common than vaginal
hysterectomy (65% vs. 35%)
 Proportion of vaginal hysterectomies performed with
laparoscopic assistance doubled (from 13% to 28%)
Indications
 Fibroids, endometriosis, uterine prolapse – causes of
disabling pelvic pain
 Pelvic relaxation
 Abnormal uterine bleeding
 Malignant and premalignant disease (Uterine cancer,
ovarian cancer and some cases of cervical cancer)
Types of Hysterectomy
 Partial Hysterectomy
 Removes 2/3 of uterus

 Total Hysterectomy
 Removes uterus and cervix

 Radical Hysterecomty
 Removes uterus, cervix,
and vagina
Types of Incisions

Vertical Incision

Pfannenstiel Incision
 Abdominal Hysterectomy
 The uterus is removed through an incision in the
woman’s abdomen.
 Most invasive method
 Incision site at abdomen
 Hospital stay of 5-6 days
 Recovery time 6 weeks
 Possible retention of cervix
 Required for endometriosis and large fibroids
 Abdominal Hysterectomy

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Abdominal Hysterectomy

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 Abdominal Hysterectomy

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Abdominal Hysterectomy

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Abdominal Hysterectomy

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 Abdominal Hysterectomy

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Abdominal Hysterectomy

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 Abdominal Hysterectomy

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Abdominal Hysterectomy

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 Vaginal Hysterectomy
 The uterus is removed through the vagina.
 Less invasive than abdominal hysterectomy
 Incision site at inner vagina
 Hospital stay 1-3 days
 Recovery time 4-6 weeks
 Cervix cannot be preserved
 Vaginal Hysterectomy
 Patient positioning - dorsal lithotomy
 Bimanual pelvic examination is performed
 assess uterine mobility and descent
 confirm that no unsuspected adnexal pathology is
found
 A bladder catheter may be inserted
 some surgeons believe that a distended bladder helps
with recognition of a bladder injury and thus do not
use a catheter
Contraindications
Vaginal hysterectomy is contraindicated in only 10-20% of
cases, if:
 The uterine size is greater than 280 g
 There is a Hx of previous multiple abdominal or pelvic
surgeries
 There is a case of advanced uterine, cervical and/or ovarian
malignancies.
Vaginal Hysterectomy

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Vaginal Hysterectomy

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 Vaginal Hysterectomy

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 Vaginal Hysterectomy

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 Vaginal Hysterectomy

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 Vaginal Hysterectomy

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 Vaginal Hysterectomy

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Vaginal Hysterectomy

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Vaginal Hysterectomy

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 Vaginal Hysterectomy

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 Vaginal Hysterectomy

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Vaginal Hysterectomy

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Vaginal Hysterectomy

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Vaginal Hysterectomy

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Vaginal Hysterectomy

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 Vaginal Hysterectomy

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Laparoscopic Hysterectomy
 The uterus is removed in sections through small incisions
using a laparoscope
 Hospital stay 1-3 days
 Recover time is 4-6 weeks
 Longer duration of procedure
 Requires greater surgical expertise
 Urinary track injuries are more likely
 Fewer abdominal wall infections or febrile episodes
 Less blood loss
Indications for LAVH
 Need for adhesiolysis
 Need for treatment of endometriosis
 Need for management of large leiomyoma(s) to
facilitate uterine extraction
 Need for ligation of the infundibulopelvic
ligaments to facilitate oophorectomy
Total Laparoscopic Hysterectomy
 The entire procedure is performed laparoscopically
 uterus is extracted vaginally, or removed abdominally using
morcellation techniques
 After the uterus is removed, the vaginal cuff is closed using
laparoscopic suturing techniques

MORCELLATION IS NOT PERFORMED IF UTERINE

CANCER IS SUSPECTED
 Laparoscopic Supracervical
Hysterectomy
 LSH is performed in an identical fashion to TLH
 after occluding the ascending uterine vascular
pedicles
 cervix is amputated in a coring fashion
 beginning at the level of the internal os, down
into the endocervical canal
Robotic Hysterectomy

 3-dimensional image
 Greater articulation
 Eliminate hand
tremors
 Increased accuracy
and precision
 Robot Hysterectomy
 Superior laparoscopic magnification of an image
is achieved with robotic systems - surgical
precision

 Rotational movement of the robotic hands

facilitates manipulation of tissues and suturing

 Tasks like adhesiolysis, suturing, and knot tying

are enhanced with the robotic suturing system
Cx of Hysterectomy
 Surgical wound infection (SSI)
 Excessive bleeding
 Injury to the bowel, bladder, ureter, or major blood vessel
 Urinary tract infection.
 Early onset menopause
 Ovarian dyfxn
Gynecologic Laparoscopy
Laparoscopy

Laparoscopy is a transperitoneal
endoscopic technique that provides
excellent visualization of the pelvic
structures and often permits the diagnosis
and management of gynecologic disorders
without laparotomy.
 Indications- Diagnostic
1. Differentiation between ovarian, tubal, and uterine masses
2. Pelvic pain, eg, possible adhesions, endometriosis, ectopic
pregnancy etc.
3. Genital anomalies
4. Ascites, ovarian diseases versus cirrhosis.
5. Secondary amenorrhea of possible ovarian origin, eg,
polycystic ovarian syndrome
6. Pelvic injuries
7. Staging of Hodgkin's disease and lymphomas.
8. Diagnosis of occult cancer.
 Indications- Evaluation
1. Infertility, eg, tubal patency, ovarian biopsy.
2. "Second look" after tubal surgery or treatment of
endometriosis.
3. Assessment of pelvic and abdominal trauma.
4. Appraisal of bowel for viability after surgery, for mesenteric
thrombosis.
5. Study of pelvic nodes after lymphography.
6. Peritoneal washings for cytology study.
7. Peritoneal culture.
8. Evaluation of uterine perforation.
9. Evaluation of pelvic viscera to determine the feasibility of
vaginal hysterectomy.
Indications- Theraputic
1. Tubal sterilization:
2. Lysis of adhesions, with or without laser.
3. Fulguration (small growth destruction) of endometriosis
by laser or thermal cautery.
4. Aspiration of small unilocular ovarian cyst
5. Removal of extruded intrauterine device.
6. Uterosacral ligament division (denervation).
7. Treatment of ectopic pregnancy.
8. Myomectomy.
Indications- Theraputic
9. Salpingostomy for phimotic fimbriae.
10. Removal of tuboplastic hoods or splints.
11. Ova collection for in vitro fertilization.
12. GIFT (gamete intrafallopian transfer for fertilization).
13. Mini-wedge resection of ovary.
14. Biopsy of tumor, liver, ovary, spleen, omentum, etc.
15. Placement of intraperitoneal clips as markers for radiotherapy.
16. Oophorectomy.
17. Ovarian cystectomy.
18. Laparoscopic-assisted vaginal hysterectomy
19. Reconstructive surgery for pelvic organ prolapse and urinary
incontinence.
 Management of ectopic pregnancy
 Salpingotomy

 Used to preserve the tubes for

desired reproductivity.
 Done if the patient is
hemodynamicaly stable
 If size < 5 cm
 Location must be ampullary,
infundibular or isthmic.
 Contralateral tube either
normal or absent.
Contraindications & Risk Factors
 Hemodynamic instability resulting from a ruptured
ectopic pregnancy
 2nd trimester and beyond pregnancy (in the last few
years this has been changing)
 Generalized peritonitis
 Hypovolemic shock
 Severe cardiac and/or pulmonary disease (anesthetic
risk)
 Hemoglobin less than 7 g/dL
 Risk factors include obesity (extreme), increased age
and previous abdominal surgery Hx
Complications
Most are the result of the placements of the veress
and/or trocar into the abdominal cavity
 Intestinal Injury
 Urologic injury
 Retroperitoneal major vessel injury
 Subcutaneous Emphysema and Gas Embolisms
(uncommon but very serious Cx).
 Abdominal wall vessel injury (see picture)
 Incisional Hernia
Dilatation & Curettage
 Dilatation & Curettage
 Is the most common minor gynecologic surgical
procedure
 Used as diagnostic or therapeutic tool.
 In spite of the advances in office–based
evaluations of the endometrium such as US or
hysteroscopy, a thorough fractional curettage is
the best procedure if endometrial or cervical
cancer is suspected.
 Indications - Diagnostic
 Abnormal uterine bleeding: irregular bleeding, menorrhagia,
suspected malignant or premalignant condition
 Retained material in the endometrial cavity
 Evaluation of intracavitary findings from imaging procedures
(abnormal endometrial appearance due to suspected polyps or
fibroids)
 Evaluation and removal of retained fluid from the endometrial cavity
(hematometra, pyometra) in conjunction with evaluating the
endometrial cavity and relieving cervical stenosis
 Office endometrial biopsy insufficient for diagnosis or failed due to
cervical stenosis
 Endometrial sampling in conjunction with other procedures (eg,
hysteroscopy, laparoscopy)
 Indications - Therapeutic
 Removal of retained products of conception (eg,
incomplete abortion, missed abortion, septic
abortion, induced pregnancy termination)
 Suction procedures for management of uterine
hemorrhage
 Treatment and evaluation of gestational
trophoblastic disease
 Hemorrhage unresponsive to hormone therapy
 In conjunction with endometrial ablation for
histologic evaluation of the endometrium
A 25year-old woman primigravida is in the emergency room
complaining of lower pelvic pain and spotting for
the past week. Her last normal menstrual period was 7 weeks
ago. you have obtained a serum B-hCG. Which was
4000 IU\L and a transvaginal ultrasound was performed with
revealed no gestational sac in the endometrial cavity. No
adnexal masses and no free fluid in the cul de sac. The next
step in the management of this patient is:

A. Reassurance and repeat B-hCG in 14 days

B. Laparoscopy
C. Laparotomy
D. methotreaxate, single dose therapy
E. Dilatation and curettagge
A 25year-old woman primigravida is in the emergency room
complaining of lower pelvic pain and spotting for
the past week. Her last normal menstrual period was 7 weeks
ago. you have obtained a serum B-hCG. Which was
4000 IU\L and a transvaginal ultrasound was performed with
revealed no gestational sac in the endometrial cavity. No
adnexal masses and no free fluid in the cul de sac. The next
step in the management of this patient is:

A. Reassurance and repeat B-hCG in 14 days

B. Laparoscopy
C. Laparotomy
D. methotreaxate, single dose therapy
E. Dilatation and curettagge
Instruments
 Contraindications
Absolute contraindications to dilation and curettage
include the following:
 Viable desired intrauterine pregnancy
 Inability to visualize the cervical os
 Obstructed vagina
Relative contraindications to dilation and curettage include
the following:
 Severe cervical stenosis
 Cervical/uterine anomalies
 Prior endometrial ablation
 Bleeding disorder
 Acute pelvic infection (except to remove infected endometrial
contents)
 Obstructing cervical lesion
Complications
 Bleeding or hemorrhage
 Cervical laceration
 Uterine perforation
 Postprocedural infection
 Postprocedural intrauterine synechiae (adhesions)
 Anesthetic complications