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12/25/2018

Operative gynaecological procedure

By :
Dr.Hanaa Al-Heidery

DILATATION & CURETTAGE


Indications
A. Dilatation of the cervix
1. A preliminary to curettage
2. Prior to hysteroscopy
3. As a step of other operations e.g. cervical
amputation or Fothergill repair

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4. Insertion of IUD in stenotic cervix


5. Introduction of intracervical or intrauterine radium
6. Cervical stenosis
7. Spasmodic dysmenorrhea
8. Drainage of pyometra or haematometra

B. Curettage of the uterine cavity


1. Diagnosis & treatment of abnormal uterine
bleeding
2. Diagnosis of endometrial cancer
3. Diagnosis & treatment of endometrial hyperplasia,
endometrial polypi & submucous myoma
4. To detect ovulation & its defects in infertility
5. Removal of IUCD

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6. Fractional curettage
7. Endocervical curettage
8. In pregnancy:
Abortion: therapeutic, missed, incomplete,
inevitable, septic
Molar pregnancy
Postabortive or postpartum bleeding

Technique
1. Evacuate the bladder
2. Anesthesia
3. Vaginal speculum & grasp the cervix
4. Sounding
5. Dilate the cervix
6. Curette

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ABOUBAKR ELNASHAR

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Complications
1. Cervical laceration
2. Cervical incompetence
3. Perforation of the uterus
4. Spread of infection
5. Asherman syndrome
6. Persistence of bleeding: missing of an
endometrial polyp or remnants of conception

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Perforation of the uterus


Diagnosis: Sound, dilator or curette is passed
beyond the pre-determined length of the uterus.
Management:
1. Avoid the part where perforation occurred (no
necessarily to stop)
2. Observation: hemorrhage, peritonitis
3. Laparotomy: intestine is exposed for possible injury,
uterine wound is sutured, peritoneal cavity is lavaged
& drained

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ANTERIOR COLPORRHAPHY
Indications: Cystocele
Steps: 1. Anterior vaginal wall incision
2. The anterior vaginal wall is separated
from the bladder & the bladder is pushed to
its normal position as a pelvic organ

3. Plication of the the pubovesical fascia beneath


the bladder to form a shelf
4. Redundant vaginal wall is removed
5. Vagina is closed in the midline

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Posterior colpoperineoraphy
Indication: Rectocele
Steps
1. Incision at the mucocutaneous junction.
2. The posterior vaginal wall is separated from the rectum
3. The 2 levator ani are approximated in front of the rectum
4. Redundant vaginal wall is removed
5. The superficial perineal muscles are approximated in the
midline
6. The vagina is closed
7. The skin of the perineum is closed

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FOTHERGILLS OPERATION
Indication
Combined vaginal & uterine prolapse with supravaginal
elongation of the cervix Steps

1. Dilatation & curettage: Dilatation to cover the

cervical stump. Curettage to exclude uterine


pathology
2. Anterior colporrhaphy: repair cystocele

3. Amputation of the cervix: restore the normal


length of the cervix
4. Shortening & approximating of the
Mackenrodt ligaments in front of the cervix:
elevate the uterus & pull the cervix
posteriorly to correct the retroversion
5. Posterior colpoperineoraphy: repair
rectocele & to strengthen the lax pelvic floor
to prevent recurrence

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MYOMECTOMY
Indication
Symptomatizing patient who did not complete her
family
Types
1. Abdominal
2. Vaginal
3. Hysteroscopic: submucous <5cm
4. Laparoscopic: Pedunculated subserous

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HYSTERECTOMY
Indications
I. Gynecological:
1. Fibroid
2. Advanced endometriosis &
adenomyosis
3. Malignant tumors of the cervix, body, tubes or
ovary
4. Recurrent DUB not responding to conservative
treatment
5. Chronic pyometra
6. Chronic inversion of the uterus

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II. Obstetric indications


1.Uncontrolled postpartum hemorrhage
2.Rupture uterus
3.Placenta accreta
4.Invasive mole
5.Couvelaire uterus

Types
1.Abdominal
2.Vaginal
3.Laparoscopic

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Types of abdominal hysterectomy


• Subtotal: removal of the uterus with of
preservation the cervix
• Total: removal of the uterus & cervix
• Pan: total with bilateral salpingo-
oophrectomy

Radical: removal of the uterus, cervix, parametrial
tissue, endopelvic fascia, uterosacral ligaments &
pelvic lymph nodes

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• Cesarean hysterectomy:
• removal of the uterus after C.S e.g. atonic postpartum
hemorhage or placenta accreta.
• Hysterectomy-en-toto: Removal of the uterus with a
contained dead fetus without opening the uterus to
decrease blood loss e.g. couvelaire uterus

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Steps
1. Division & ligation of the round ligaments
2. Division & Ligation of the tubes & ovarian
ligaments if the ovaries will be left, or the infundibulo-
pelvic ligaments if the ovaries will be removed.
3. Incise the peritoneum of the vesicouterine pouch
by extending the incision in the anterior leaf of the
broad ligament, then dissect the bladder downward

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3. Clamp the uterine arteries & divide them


4. Uterosacral ligaments & Mackenrodtks ligaments
are divided & ligated.
5. The vagina is divided from its attachment to the
cervix.

Indications
(1) Prophylactic (elective). Suspected
cervical incompetence. Cerclage at 14
weeks {early miscarriage caused by
other factors}.
(2) Urgent (therapeutic)
Asymptomatic women with sonographic evidence of
cervical shortening and/or funneling
(3) Emergency (salvage) cervical cerclage

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• Indications:

1. History compatible with incompetent cervix AND


2. Sonogram demonstrating funneling OR
3. Clinical evidence of extensive obstetric trauma
to cervix

Cerclage
should only be considered when the history of
miscarriage is preceded by spontaneous rupture
of membranes or painless cervical dilatation

Contraindications:
1.Uterine contractions.
2.Uterine bleeding
3.Chorioamnionitis
4.Premature rupture of membranes
5.Fetal anomaly incompatible with life

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Cerclage

Before After
pregnancy pregnancy

Trans-
Trans- Abdominal
Lash
vaginal

Hefner Cervicoisthmi
McDonald Shirodkar

Burried Un-burried shirodkar

Modified
shirodkar

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Technique
No bladder dissection, and the cervix is closed using
four or five bites with the needle to create a purse
string around the cervix. placed high on the cervix,
with a non-absorbable suture or a 5 mm band of
permanent suture.
Burried technique
(Jenning, 1972)
The successive bites reenter the cervix at the
previous point of exit, so the suture remains
submucosal. Vaginal discharge & vaginitis are
less

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