Download Clinical reproductive medicine and surgery

Chapter 24
Gynecological and
Obstetrical Surgery
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GYN and Obstetrics
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Review terms and definitions listed at
beginning of chapter
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Use your medical dictionary if necessary
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GYN and Obstetrics
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Female reproductive system.
The uterus and associated reproductive organs of the female reproductive system.
(From Thibodeau GA, Patton KT: Anatomy and physiology, ed 6, St Louis, 2007, Mosby.)
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GYN and Obstetrics
The uterine ligaments.
(Adapted from Moody FG: Atlas of ambulatory surgery, St Louis, 1999, Mosby.)
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GYN and Obstetrics
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Uterus
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Layers of uterus wall
• Endometrium
• Myometrium
• Perimetrium
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GYN and Obstetrics
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Uterus (cont.)
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Cervix
Inferior neck of the uterus, which extends into the
vaginal vault
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GYN and Obstetrics
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Uterus (cont.)
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Ligaments
• Broad ligaments
• Round ligaments
• Cardinal ligaments
• Uterosacral ligaments
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GYN and Obstetrics
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Fallopian tubes
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Communicate directly with uterus
 Four sections
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Interstitial
Isthmus
Ampulla
Infundibulum
Ovaries
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Female gonad or sex gland
 Produce female hormones
 Suspended by mesovarium
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GYN and Obstetrics
External Genitalia
External genital structures of the female.
(From Thibodeau GA, Patton KT: Anatomy and physiology, ed 5, St Louis, 2003, Mosby.)
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GYN and Obstetrics
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External genitalia
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Mons pubis
Labia majora
Labia minora
Clitoris
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GYN and Obstetrics
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External genitalia
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Vestibule
Hymen
Perineum
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GYN and Obstetrics
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Menstrual cycle
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Follicular phase
Ovulatory phase
Luteal phase
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GYN and Obstetrics
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Physical and history
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Menstrual history
 Obstetrical history
 Use of contraceptives
 History of previous infection
 Signs and symptoms
 Current medications
 Family history
 Social history
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GYN and Obstetrics
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Preoperative screening
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Ultrasound and sonohysterography
 Hysterosalpingography
 Magnetic resonance imaging
 Cervical and endometrial biopsy
 Culture
 Cone biopsy of the cervix
 Hysteroscopy
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GYN and Obstetrics
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Perioperative considerations
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Psychosocial considerations
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Reproductive ability is altered
Self-image may be altered
Sense of identity may be altered
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GYN and Obstetrics
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Perioperative considerations
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Positioning
Team positioning
Skin prep and draping
Instruments
Equipment and supplies
Drugs
Dye and stains
Uterotropic drugs
Sutures
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GYN and Obstetrics
Instruments
Speculums and retractors.
(From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 1999, Mosby.)
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GYN and Obstetrics
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Instruments (cont.)
Top to bottom: Hanks cervical dilator, sponge forceps, cervical tenaculum, Sims retractor. Right, uterine curettes.
(Courtesy Jarit Instruments, Hawthorne, NY)
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GYN and Obstetrics
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Instruments (cont.)
Pelvic retractors: O’Sullivan-O’Connor retractor with bladder blade.
(From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 1999, Mosby.)
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GYN and Obstetrics
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Instruments (cont.)
Uterine tissue clamps. A, Allis clamp. B, Allis-Adair clamp. C, D, Heaney clamps.
E, Single tooth tenaculum. E, Double-tooth tenaculum.
(From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.)
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GYN and Obstetrics
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Surgical techniques
Laparoscopy
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Patients leave hospital earlier
There is less pain
Procedure are effective
Advanced techniques and instruments allow for
complex procedures
Patient satisfaction is greater
Procedure is minimally invasive
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GYN and Obstetrics
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Surgical techniques
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Laparoscopy
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Preparing for laparoscopy
• Patient is placed in low lithotomy position
• Catheter is inserted to drain bladder
• Sterile uterine manipulator is inserted
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GYN and Obstetrics
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Diagnostic laparoscopy
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Involves insertion of a laparoscope
• Allows visualization of peritoneal cavity
Used to diagnose causes of abdominal and
pelvic pain, infertility, and pelvic masses
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GYN and Obstetrics
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Diagnostic laparoscopy (cont.)
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Also used for other procedures
• Adhesiolysis
• Tubal fulguration
• Fulguration of endometriotic implants
• Aspiration of cysts
• Tissue biopsy
• Aspiration of peritoneal fluid for cytological studies
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GYN and Obstetrics
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Laparoscopic tubal ligation
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Blocks the passage of ova through the tube
Techniques
• Coagulation
• Falope ring method
• Filshie clip
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GYN and Obstetrics
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Laparoscopic Tubal Ligation
Falope ring.
(From Falcone T, Hurd W: Clinical reproductive medicine and
surgery, Philadelphia, 2007, Mosby.)
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GYN and Obstetrics
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Laparoscopic Tubal Ligation
Filshie clip method.
(From Falcone T, Hurd W: Clinical
reproductive medicine and surgery,
Philadelphia, 2007, Mosby.)
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GYN and Obstetrics
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Open Tubal Ligation
Classic Irving technique of
open tubal ligation.
(From Falcone T, Hurd W: Clinical reproductive
medicine and surgery, Philadelphia, 2007 , Mosby.)
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GYN and Obstetrics
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Laparoscopic Management of an Ovarian
Mass
Removal of an ovarian cyst.
A, The cyst wall is dissected using a hydro dissector.
B, Dissection of the cyst wall is nearly completed.
C, The body of the cyst is grasped and removed from the ovary.
(From Goldberg JM, Falcone T: Atlas of endoscopic techniques in gynecology, Philadelphia, 2001, Saunders.)
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GYN and Obstetrics
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Microsurgical Tubal Anastomosis
The fallopian tube has been infused with methylene blue dye and incised sagitally.
This creates an anastomosis site free of adhesions.
(From Falcone T, Hurd W: Clinical reproductive medicine and surgery, Philadelphia, 2007, Mosby.)
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GYN and Obstetrics
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Microsurgical Tubal Anastomosis
B, Traction sutures are placed on the outer edge of the tube.
C, The tubal portions are approximated.
(From Falcone T, Hurd W: Clinical reproductive medicine and surgery, Philadelphia, 2007, Mosby.)
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GYN and Obstetrics
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Microsurgical Tubal Anastomosis
Anastomosis using the da Vinci robotic system.
(From Falcone T, Hurd: W Clinical reproductive medicine and surgery, Philadelphia, 2007, Mosby.)
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GYN and Obstetrics
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Laparoscopic-assisted vaginal hysterectomy
(LAVH)
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Surgical removal of uterus via laparoscopic
approach
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GYN and Obstetrics
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Laparoscopic-assisted vaginal hysterectomy
(LAVH) (cont.)
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Vaginal hysterectomy setup and laparoscopic
gear required
Hospital stay and recovery are shorter
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GYN and Obstetrics
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Abdominal hysterectomy (open)
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Uterus is surgically removed through abdominal
incision
Performed for benign fibromas, endometriosis,
and cancer
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GYN and Obstetrics
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Open Abdominal Hysterectomy
The anterior ligament has been clamped, cut, and tied, allowing access to the
broad ligament.
(Adapted from Gershenson DM, et al: Operative gynecology, ed 2, Philadelphia, 2001, Saunders.)
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GYN and Obstetrics
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Open Abdominal Hysterectomy
The tube and uteroovarian ligament are triple clamped; the ovarian vessels
are then divided.
(Adapted from Gershenson DM, et al: Operative gynecology, ed 2, Philadelphia, 2001, Saunders.)
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GYN and Obstetrics
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Open Abdominal Hysterectomy
The uterine vessels are triple clamped at the level of the internal cervical os.
(Adapted from Gershenson DM, et al: Operative gynecology, ed 2, Philadelphia, 2001, Saunders.)
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GYN and Obstetrics
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Open Abdominal Hysterectomy
The vagina is opened anteriorly, and a circumferential incision is made around
the vagina to free the uterine specimen.
(Adapted from Gershenson DM, et al: Operative gynecology, ed 2, Philadelphia, 2001, Saunders.)
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GYN and Obstetrics
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Endometrial cancer
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Cancer of the endometrium is the most common
type located within the female pelvis
Uterine leiomyoma
• Also known as a fibroid tumor or fibroid uterus
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GYN and Obstetrics
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Radical hysterectomy
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Also called Wertheim procedure
A Wertheim procedure is the dissection and wide
removal of
• Uterus
• Tubes
• Ovaries
• Supporting ligaments
• Upper vagina
• Lymph nodes in the pelvis
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GYN and Obstetrics
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Pelvic exenteration
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A pelvic exenteration procedure is the dissection and
wide removal of
• Uterus
• Tubes
• Ovaries
• Supporting ligaments, iliac vessels, and lateral branches
• Upper vagina
• Lymph nodes in the pelvis
• Rectum
• Distal sigmoid colon
• Bladder and ureters
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GYN and Obstetrics
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Hysteroscopy
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Technique using lighted fiberoptic endoscope for
diagnostic and operative procedures
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GYN and Obstetrics
A, Resectoscope used for therapeutic hysteroscopy. Note cutting-coagulation loop
on distal end. B, Fluid distension system for use with resectoscope. Note that fluid
pressure is regulated to prevent extravasation and subsequent fluid overload,
which may cause serious patient injury.
(Courtesy of Gyrus ACMI, Southborough, MA.)
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GYN and Obstetrics
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Laser and electrosurgery during hysteroscopy
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Nd:YAG (neodymium:yttrium aluminum garnet)
and argon lasers commonly used
• Argon laser transmits through aqueous solution
• Coagulation with laser is achieved on lower power
settings
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KTP-532 and tunable dye lasers also effective
Safety considerations primary
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GYN and Obstetrics
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Hysteroscopic endometrial ablation
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Coagulation of the endometrium of the uterus to
treat uterine bleeding
Hysteroscope is inserted into sheath before
insertion in uterine cavity
Main operating channel receives telescope; side
channels accept accessory instruments
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GYN and Obstetrics
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Hysteroscopic endometrial ablation (cont.)
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Main channel fitted with rubber gaskets that
prevent backflow of distension media
Allows surgeon to flush fluid and debris from
the uterus while operating
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GYN and Obstetrics
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Uterine balloon therapy
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Form of endometrial ablation
Ablation is used to treat abnormal uterine bleeding
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GYN and Obstetrics
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Myomectomy
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Removal of benign leiomyoma of the myometrium
to control bleeding and prevent pressure on
other structures in the pelvis
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GYN and Obstetrics
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Loop electrode excision procedure (LEEP)
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Core of tissue is removed from cervix to prevent
progression of cancer
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GYN and Obstetrics
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Dilation and curettage (D&C)
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Removal of the surface of the endometrium
through a transvaginal approach
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GYN and Obstetrics
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Abortion
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The spontaneous or induced termination
of pregnancy before the fetus has developed to
the stage of viability
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GYN and Obstetrics
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Vaginoplasty
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Surgical technique to repair surgical or congenital
defect of vagina
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GYN and Obstetrics
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Repair of rectovaginal fistula
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Abnormal tract between rectum and vagina
Surgical repair prevents fecal material from
draining into vagina
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GYN and Obstetrics
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Repair of vesicovaginal fistula
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The goal of this surgery is to incise the length of
the vesicovaginal fistula and remove the
epithelial tissue
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GYN and Obstetrics
Removal of Cystic Bartholin’s Gland
Appearance
and location
of Bartholin's
duct cyst.
An incision is
made into the
cyst or abscess
cavity.
(Adapted from Gershenson DM, et al: Operative gynecology, ed 2, Philadelphia, 2001, Saunders.)
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GYN and Obstetrics
Removal of Cystic Bartholin’s Gland (cont)
The cyst wall is sutured to the skin of the vestibule for drainage.
(Adapted from Gershenson DM, et al: Operative gynecology, ed 2, Philadelphia, 2001, Saunders.)
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GYN and Obstetrics
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Obstetrical complications
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Can occur at any time in perioperative phase
Include obstetrical problems and surgical
complications
Abruptio placentae
• Placenta prematurely separates from wall of uterus
Placenta previa
• Placenta is abnormally planted in lower uterine segment
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GYN and Obstetrics
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Obstetrical complications (cont.)
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Hypertension
• Diagnosis of pregnancy-induced high blood pressure
Nuchal cord
• Cord wrapped around the neck
Cord prolapse
• Delivery of the cord before the baby
Breech
• Presenting feet, knees, or buttocks first
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GYN and Obstetrics
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Obstetrical Complications (cont.)
Reasons for cesarean section.
(From Murray SS, McKinney ES, Gorrie TM: Foundations of
maternal-newborn nursing, ed 4, Philadelphia, 2006, Saunders.)
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GYN and Obstetrics
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Diagnostic testing
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Pregnancy test
Ultrasound
Routine blood test
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GYN and Obstetrics
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Vaginal (normal delivery)
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Normal spontaneous vaginal delivery
Dilation
Effacement
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Episiotomy
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Episiotomy repair
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Surgical repair of episiotomy wound made during
delivery
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GYN and Obstetrics
Cesarean Delivery
Through a Pfannenstiel skin incision, the uterus is opened in a low
transverse incision.
(From Murray SS, McKinney ES, Gorrie TM: Foundations of maternal-newborn nursing, ed 3, Philadelphia, 2002,
Saunders.)
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GYN and Obstetrics
Cesarean Section (cont.)
The fetal head is brought through the incision.
(From Murray SS, McKinney ES, Gorrie TM: Foundations of maternal-newborn nursing, ed 3, Philadelphia, 2002,
Saunders.)
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GYN and Obstetrics
Cesarean Section (cont.)
The mouth and nose are suctioned to remove secretions and blood
before the infant takes his or her first breath.
(From Murray SS, McKinney ES, Gorrie TM: Foundations of maternal-newborn nursing, ed 3, Philadelphia, 2002,
Saunders.)
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GYN and Obstetrics
Cesarean Section (cont.)
Heavy sutures are used to close the muscular layers of the lower
transverse uterine incision.
(From Murray SS, McKinney ES, Gorrie TM: Foundations of maternal-newborn nursing, ed 3, Philadelphia, 2002,
Saunders.)
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GYN and Obstetrics
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Tubal segmental resection for ectopic
pregnancy
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To remove embryo growing in Fallopian tube
• Salpingostomy
• Salpingectomy
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GYN and Obstetrics
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Potential sites for ectopic pregnancy.
(From Murray SS, McKinney ES, GorrieTM: Foundations of maternal-newborn nursing, ed 4, Philadelphia,
Saunders, 2006.)
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GYN and Obstetrics
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Salpingo-oophorectomy
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Removal of ovary and Fallopian tube
• For benign ovarian tumors, for potential prevention of
ovarian cancer, for endometriosis, or to remove very
large ovarian cysts
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