COMMON GYNECOLOGIC
PROCEDURES
AZZA AlYAMANI
Department of Obestetrics
and Gynecology
Common Gynecologic
Procedures
Aim of this presentation is :
1. students become aware of the basic principles
of common gynecologic surgical procedures.
2. become familial with the instruments that used in
these procedures.
3. and be aware of the indications and complications
of each procedure.
{1} Endometrial Sampling ( Dilatation & Curettage)
D&C
* it is the most common minor gynecologic surgical
procedure , it is used as diagnostic or therapeutic tool.
* in spite of the advances in office – based evaluation of
the endometrium as US or hysteroscopy , a thorough
fractional curettage is the best procedure
if endometrial or cervical cancer is suspected.
Indications
Diagnostic:
1. abnormal uterine bleeding.
2. postmenopausal bleeding ,end. ca.
3. irregularities of the endometrial cavity either
congenital ( uterine septum) or acquired
(submucous fibroids or polyp)can be determined
during the operation.
Therapeutic:
1. endometrial hyperplasia with heavy bleeding .
2. removal of endometrial polyps or small
pedunculated myomas.
3. dilatation & evacuation in inevitable and missed
abortion.
4. removal of missed intrauterine IUCD.
Technique
instruments
Steps of D&C
Complications:
1.Perforation of the uterus.
it is not uncommon complication ,it occurs in :
* RVF uterus.
* pregnancy.
* postmenopausal è endometrial carcinoma.
2. Cervical laceration.
3. Infection.
4. Haemorrahge.
Endometrial Ablation
it is the complete destruction of the endometrium
down to the basal layer , resulting in fibrosis of the uterine
cavity and amenorrhoea ( 30% ) , however , patient
satisfaction rates are over 70% . Ia
It indicated in women who have heavy menstrual
bleeding that is impacting her life and do not have
other problems that require hysterectomy .
Endometrial ablation is now well established as day
case or outpatient procedure.
Endometrial Ablation is performed using the
resectoscope which is :
a hysteroscpe with a build in wire loop(or other shape
device ) that uses high frequency electrical current to
cut or coagulate tissue.
Indications:
1. abnormal uterine bleeding.
2. benign lesions as small submucus myomas or
endometrial polyps.
Technique
Established techniques carried out under direct
hysteroscopic vision involve the use of fluid for
distention and irrigation .
These techniques are :
* laser ablation.
* endometrial loop resection using electro diathermy.
* roller ball electro diathermy.
roller ball electro diathermy.
endometrial loop resection
using electro diathermy.
roller ball electro diathermy
loop resection using electro diathermy
Complications :
2%
1. uterine perforation.
2. hemorrhage.
3. infections as endometritis & PID.
4. bowel or urinary tract injury.
5. cervical lacerations & stenosis.
5. distention medium hazards as:
* gas embolism.
* fluid overload.
* anaphylactic shock.
Although the resectoscope provides excellent
results in experienced hands, the technique is
difficult to master.
because all the previous techniques are:
* operator dependent .
* time consuming .
* carry risk of systemic fluid absorption.
* hemorrhage.
* uterine perforation è heat damage to adjacent
structures.
Other methods of ablation
Newer techniques have been developed with the
aim of reducing operator dependency and minimizing
risk . Of these , the best evaluated to date are :
* microwave ablation.
* thermal balloon ablation.
They have equivalent short-term efficacy with the
advantage of shorter operating times and fewer
complications.
Microwave probe inserted
 endometrium heated to 80 C
 day case procedure
 70 -80% satisfaction rates
 95% return to normal
Microwave machine
Thermachoice ballon
This uses a balloon placed in the uterine cavity
through the cervix. Hot water is circulated inside the
balloon to destroy the endometrium.
Thermachoice Balloon Ablation
Central element heats liquid circulated in balloon
87 degrees C for 8 minutes.
Limitations:
* uterine cavity size 6-10 cm;
* can’t treat submucous myomas .
Thermachoice ballon
FigThe
3 - Thermachoice
The Caveterm System
System
Hysterectomy
it is the most commonly performed major
gynecologic operation , it can be performed either
Abdominally , vaginally or laparoscopically.
although some indications remain controversial ,
high patient satisfaction levels and increasing
safety for the procedure have been reported .
Types of Hysterectomy
1. subtotal
2. total
3. total è unilateral or bilateral salpingo ophrectomy .
4. radical
Types of Abdominal
Hysterectomy
Radical Hysterectomy
Indications :
A. Abdominal hysterectomy
1. invasive uterine ,cervical ,ovarian and Fallopian cancer.
2. significant pre invasive lesions of the cervix as CIN III
or endometrial hyperplasia with atypia .
3. pelvic pain
chronic endometriosis , chronic PID and ruptured
tubo ovarian abscess.
4. fibroid uterus > 12 weeks in size.
5. AUB unresponsive to other lines of treatments.
6. pregnancy catastrophe as severe bleeding.
B. vaginal hysterectomy
1. utero vaginal prolapse .
2. AUB with small uterus .
pre requesits to vaginal hysterectomy :
* benign disease.
* uterus is mobile with some pelvic relaxation & no pelvic
adhesions .
* uterus is < 12 weeks in size.
C . Laparoscopic hysterectomy
* < 10% of hysterectomies performed with the
use of laparoscopy.
* it is used to assist in vaginal hysterectomy or
to convert an abdominal to a vaginal
hysterectomy.
Technique
1. supine position.
2. general anaesthesia .
3. a careful abdominal & pelvic exam. under
anaesthesia is carried out.
4. incision
* vertical
in obese , if endometriosis is anticipated and patients
who have had several prior abdominal operations.
* transverse
in restricted benign disease .
5. exploration of the upper abdominal organs
especially the liver ,spleen and para-aortic lymph
nodes.
6. the abdominal viscera are packed up with towels.
7. round ligament .
each is clamped incised and ligated.
8. the vesico-uterine fold of peritoneum is incised
transversely between the incised round lig. and
the bladder is reflected inferiorly .
9. the two layers of the broad ligam. are separated
and the ureters are explored and identified.
10. the infundibulo pelvic ligs. with the ovarian
vessels are clamped , cut and ligated. if the
adnexa are to be removed.
11. the broad lig. is then incised towards the uterus
exposing the uterine vessels (skeletonized).
12. the uterine vessels are clamped at the level of
internal cervical os , incised and ligated on each
side.
13. medial to the ligated uterine vessels , the
cardinal lig. on each side is clamped , incised
and ligated.
14. posteriorlly , the peritoneum between the
uterosacral lig. is incised transversely and
the rectum is freed from the posterior aspect
of the cervix & upper vagina after the
uterosacral lig. are clamped , incised & ligated.
15. the total uterus is removed by cutting across
the vagina just below the cervix .
16. the vaginal cuff is closed è absorbable sutures ,
incorporating the cardinal & uterosacral ligs.
into each lateral angle to avoid latter
development of vault prolapse.
Sites of ureteric injures :
1. at clamping & incising the infundibulo pelvic
ligaments.
2. at ligating the uterine vessels.
3. at clamping & incising the cardinal ligs. if the
urinary bladder is not sufficiently reflected
inferiorly.
Complications :
A . Intra operative
1. hemorrhage .
2. ureteric injuries.
3. bladder and bowel injury.
4. anesthetic complications.
B. Post operative
1. wound infection ( 5 days postoperatively).
2. UTI .
3. thrombophlebitis and pulmonary embolism,
( 7 – 12 days ).
4. uretero vaginal fistula ( 5 – 21 days ).
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