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Colposcopy OB-GYN Procedures Operative Sequence. Anatomy.

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Presentation on theme: "Colposcopy OB-GYN Procedures Operative Sequence. Anatomy."— Presentation transcript:

1 Colposcopy OB-GYN Procedures Operative Sequence

2 Anatomy

3 Colposcopy Overall Purpose of Procedure : Colposcopy is a common gynecology follow-up for abnormal Pap smears. A Pap smear checks for changes in the cells of the cervix (office procedure). Intra-op - A test for cancer of the cervix, in which the cervix is stained with a solution of iodine and potassium iodide and turns dark brown in all noncancerous areas. Called a Schiller's test.

4 Colposcopy Define the procedure : Colposcopy is a medical diagnostic procedure to examine an illuminated, magnified view of the cervix and the tissues of the vagina and vulva. Many premalignant lesions and malignant lesions in these areas have discernible characteristics which can be detected thorough the examination. It is done using a colposcope, which provides an enlarged view of the areas, allowing the doctor to visually distinguish normal from abnormal appearing tissue and take directed biopsies for further pathological examination. The main goal of colposcopy is to prevent cervical cancer by detecting precancerous lesions early and treating them. Squamous cell intraepithelial lesion (SIL) is the most common type of cervical cancer.

5 Others to look for. Cervical Intraepithelial Neoplasia (abbreviated "CIN") is a cervical condition caused by a sexually transmitted virus called the Human Papilloma Virus. CIN is also called Cervical Dysplasia.

6 Colposcopy Wound Classification : 2

7 Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure 5- Procedure (Specimen Collection possible) 6- Hemostasis 7- Irrigation 8- Closure 9- Dressing Application

8 Colposcopy Instrumentation : GYN / D and C Instrument Tray. Colposcope. What basic instruments will you expect to see in this tray? Positioning : The patient is in lithotomy position, arms on arm boards, padded. Prepping : Betadine Prep Kit. Start at the pubis, using a back and forth motion. Prep to iliac crest. Apply prep to the labia majora using only downward strokes, including anus. You will not return to previously prepped area after you cross the anus. Next, prep the inner aspects of the thighs. Start at the labia majora and move laterally towards knees. You will prepare the vaginal vault last. Make sure the person who is prepping has a sponge stick with a counted raytec on it. Use the sponge stick to to prep the cervix, vaginal rugae and exterior of the vagina. If catheterization is ordered, it is performed now. Draping : 4 towels and a lap drape. You will need an under-buttocks drape as well as diamonds x2 (blue towels) and 1 normally folded blue towel. Ask about towel clips.

9 Colposcopy Begin your Operative Sequence Incision : any? Hemostasis : any? If needed, pass off your hand held bovie.

10 Colposcopy cont. Operative Sequence Dissection and Exposure : Weighted speculum with a 5 ½ Triflex glove for visualization.

11 Colposcopy cont. Operative Sequence Exploration and Isolation: The cervix is painted with acetic acid or an iodine solution (Lugols Solution or Schiller’s test,) to stain abnormal cervical cells.

12 Acetic acid Acetic acid, commonly known as vinegar can be used to help identify areas of cervical dysplasia. This is not a color staining agent, however, it causes abnormal tissue to appear whiter than surrounding tissue. It would be an alternative for someone with iodine sensitivities which is a component of a more commonly used color staining agent.

13 Lugol’s Solution Lugol’s Solution is a medication that causes abnormal tissue not to stain. Also called The Schiller's test

14 Surgical Repair/Removal/Specimen Collection : The colposcope produces high magnification to allow examination of the cervix. A local anesthetic can be injected into the cervical canal.

15 Surgical Repair Removal Specimen Collection: MD may use a loop electrode to remove suspicious tissue from the cervix. Will need ball type electrode to control bleeding. May also use biopsy forceps to remove tissue.

16 Colposcopy cont. Operative Sequence Hemostasis and Irrigation: All bleeding is controlled with cautery/ball tip electrode. Use of warm Saline to irrigate. Closure : any?

17 Colposcopy Major Arteries: Vaginal artery uterine artery

18 Colposcopy Major Veins: vaginal venous plexuses into the internal iliac veins Major Nerves: uterovaginal plexus

19 Hysteroscopy OB-GYN Procedures Operative Sequence

20 Hysteroscopy Overall Purpose of Procedure: Overall Purpose of Procedure: to diagnose and treat causes of abnormal bleeding. to diagnose and treat causes of abnormal bleeding.

21 Hysteroscopy Define the procedure: Define the procedure: During diagnostic hysteroscopy the hysteroscope is used just to observe the endometrial cavity (inside of the uterus.) During operative hysteroscopy a type of hysteroscope is used that has channels in which it is possible to insert very thin instruments. These instruments can be used to remove polyps, to cut adhesions, and do other procedures. During diagnostic hysteroscopy the hysteroscope is used just to observe the endometrial cavity (inside of the uterus.) During operative hysteroscopy a type of hysteroscope is used that has channels in which it is possible to insert very thin instruments. These instruments can be used to remove polyps, to cut adhesions, and do other procedures.

22 Hysteroscopy Wound Classification: 2 Wound Classification: 2

23 Operative Sequence 1- Incision 1- Incision 2- Hemostasis 2- Hemostasis 3- Dissection 3- Dissection 4- Exposure 4- Exposure 5- Procedure (Specimen Collection possible) 5- Procedure (Specimen Collection possible) 6- Hemostasis 6- Hemostasis 7- Irrigation 7- Irrigation 8- Closure 8- Closure 9- Dressing Application 9- Dressing Application

24 Hysteroscopy Instrumentation: GYN / D and C Instrument Tray. Hysteroscopy tray with camera. Instrumentation: GYN / D and C Instrument Tray. Hysteroscopy tray with camera. 30 degree scope, 0 degree scope, uterine sounds, resectoscope possible. 30 degree scope, 0 degree scope, uterine sounds, resectoscope possible. Positioning: The patient is in lithotomy position, arms on arm boards, padded. Positioning: The patient is in lithotomy position, arms on arm boards, padded. Prepping: Betadine Prep Kit. Start at the pubis, using a back and forth motion. Prep to iliac crest. Apply prep to the labia majora using only downward strokes, including anus. You will not return to previously prepped area after you cross the anus. Next, prep the inner aspects of the thighs. Start at the labia majora and move laterally towards knees. You will prepare the vaginal vault last. Make sure the person who is prepping has a sponge stick with a counted raytec on it. Use the sponge stick to to prep the cervix, vaginal rugae and exterior of the vagina. If catheterization is ordered, it is performed now. Prepping: Betadine Prep Kit. Start at the pubis, using a back and forth motion. Prep to iliac crest. Apply prep to the labia majora using only downward strokes, including anus. You will not return to previously prepped area after you cross the anus. Next, prep the inner aspects of the thighs. Start at the labia majora and move laterally towards knees. You will prepare the vaginal vault last. Make sure the person who is prepping has a sponge stick with a counted raytec on it. Use the sponge stick to to prep the cervix, vaginal rugae and exterior of the vagina. If catheterization is ordered, it is performed now. Draping: 4 towels and a lap drape. You will need an under-buttocks drape as well as diamonds x2 (blue towels) and 1 normally folded blue towel. Ask about towel clips. Draping: 4 towels and a lap drape. You will need an under-buttocks drape as well as diamonds x2 (blue towels) and 1 normally folded blue towel. Ask about towel clips.

25 Hysteroscopy Begin your Operative Sequence Incision: any? Incision: any? Hemostasis: any? If needed, pass off your hand held bovie. Hemostasis: any? If needed, pass off your hand held bovie.

26 Hysteroscopy cont. Operative Sequence Dissection and Exposure: Dissection and Exposure: Weighted speculum with a 5 ½ Triflex glove for visualization. Weighted speculum with a 5 ½ Triflex glove for visualization. Might possibly need cervical dilators. Might possibly need cervical dilators.

27 Hysteroscopy cont. Operative Sequence Exploration and Isolation: Exploration and Isolation: The tip of the hysteroscope is placed into the vagina and gently moved through the cervix into the uterus. The tip of the hysteroscope is placed into the vagina and gently moved through the cervix into the uterus. Camera and cord have been passed off at or before this point. The uterus is seen on the monitor or thru the eye piece. Camera and cord have been passed off at or before this point. The uterus is seen on the monitor or thru the eye piece.

28 Surgical Repair/Removal/Specimen Collection: This depends on what is found. Surgical Repair/Removal/Specimen Collection: This depends on what is found. The MD might want a resectoscope with a loop or roller ball electrode to remove tissue or tumors or to control bleeding within the uterus. The MD might want a resectoscope with a loop or roller ball electrode to remove tissue or tumors or to control bleeding within the uterus. MD might want biopsy forceps for tissue removal. MD might want biopsy forceps for tissue removal. MD might want a laser. MD might want a laser. Most common are Nd:YAG and Argon. Most common are Nd:YAG and Argon.

29 Surgical Repair/Removal/Specimen Collection: Surgical Repair/Removal/Specimen Collection: Nd:YAG : neodymium-doped yttrium aluminum garnet. Nd:YAG : neodymium-doped yttrium aluminum garnet. are one of the most common types of laser are one of the most common types of laser Is used in severing of endometrial and myometrial structures Is used in severing of endometrial and myometrial structures Argon: is capable of transmitting through aqueous solutions and is therefore useful during continuous irrigation hysteroscopy's. Argon: is capable of transmitting through aqueous solutions and is therefore useful during continuous irrigation hysteroscopy's.

30 Hysteroscopy cont. Operative Sequence Hemostasis and Irrigation: Hemostasis and Irrigation: All bleeding is controlled with cautery/ball tip electrode. All bleeding is controlled with cautery/ball tip electrode. Use of warm Saline to irrigate. Use of warm Saline to irrigate. Closure : any? Closure : any?

31 Laparoscopy Laparoscopy GYN Laparoscopic Procedures Operative Sequence

32 Laparoscopy Overall Purpose of Procedure: Overall Purpose of Procedure: – An Exploratory Laparoscopy is performed to examine the abdominal cavity with the aid of a scope when less invasive measures, such as x-rays and CT scans, fail to confirm a diagnosis. –Operative scope may be utilized for this prcedure.

33 Laparoscopy Define the procedure: Define the procedure: Abdominal exploration may be used to help diagnose many diseases and health problems, including: Abdominal exploration may be used to help diagnose many diseases and health problems, including: Inflammation of the appendix (acute appendicitis) Inflammation of the appendix (acute appendicitis) Pockets of infection (retroperitoneal abscess, abdominal abscess, pelvic abscess) Pockets of infection (retroperitoneal abscess, abdominal abscess, pelvic abscess) Endometriosis Endometriosis Inflammation of the fallopian tubes (salpingitis) Inflammation of the fallopian tubes (salpingitis) Scar tissue in the abdomen (adhesions) Scar tissue in the abdomen (adhesions) Cancer of the ovary, colon, pancreas, liver Cancer of the ovary, colon, pancreas, liver

34 Laparoscopy Inflammation of an intestinal pocket (diverticulitis) Inflammation of an intestinal pocket (diverticulitis) Pregnancy outside of the uterus (ectopic pregnancy) Pregnancy outside of the uterus (ectopic pregnancy) This surgery may also be used to determine the extent of certain cancers, such as Hodgkin's lymphoma (also known as Hodgkin's disease, a type of lymphoma characterized clinically by the orderly spread of disease from one lymph node group to another and by the development of systemic symptoms with advanced disease.) This surgery may also be used to determine the extent of certain cancers, such as Hodgkin's lymphoma (also known as Hodgkin's disease, a type of lymphoma characterized clinically by the orderly spread of disease from one lymph node group to another and by the development of systemic symptoms with advanced disease.) Wound Classification: 1 (yet depends on what you do during the case) Wound Classification: 1 (yet depends on what you do during the case)

35 Ectopic pregnancy means the pregnancy is not growing in its normal location inside the uterus. 97% of the time, the ectopic pregnancy is located in the fallopian tube and the rest are found in the ovary, abdomen, cervix or other nearby structure. ECTOPIC PREGNANCY

36 The incidence of ectopic pregnancy varies with the population but is about one in every hundred pregnancies. The incidence is higher among women with previous tubal disease, tubal surgery, previous ectopic pregnancy, assisted reproduction, and current IUD users. ECTOPIC PREGNANCY

37 Implantation in the distal half of the fallopian tube. This represents the vast majority of all ectopics and is the type most likely to resolve spontaneously through "tubal abortion." The closer the ectopic is to the fimbriated end, the more likely it will be to outgrow its blood supply and be expelled out the end of the tube. TYPES OF….

38 Isthmic ectopic The isthmus is the narrowest portion of the tube, least distensible, and ectopics that grow here are more likely to rupture, and to rupture early in the course of the pregnancy. TYPES OF….

39 ISTHMIC ECTOPIC

40 SALPINGECTOMY WITH ECTOPIC PREGNANCY REMOVED FROM THE TUBE

41 Cornual ectopic These ectopics grow in the portion of the tube that passes through the uterine cornua. These tend to rupture early and violently, with massive abdominal hemorrhage. Many of the fatalities due to ectopic pregnancy are from cornual pregnancies. TYPES OF….

42 UNRUPTURED CORNUAL ECTOPIC PREGNANCY

43 In this case an egg cell is not guided into the tube, but is fertilized in the peritoneal cavity and then implants onto the ovary. This causes the same symptoms as a tubal pregnancy and severe internal bleeding will eventually occur. OVARIAN PREGNANCY

44 An egg cell is not guided into the tube and is fertilized in the peritoneal cavity. It implants any where in the peritoneal cavity. These pregnancies can develop quite far and continue for months before it is diagnosed. INTRA ABDOMINAL PREGNANCY

45 Cervical pregnancy occurs when the fertilized egg cell passes through the cavity of the womb into the cervical canal and starts developing there. The cervix can't accommodate a pregnancy and bleeding will eventually occur. CERVICAL PREGNANCY

46 Tubal Ectopic Pregnancy Laparoscopic Salphingotomy SHORT MOVIE

47 Operative Sequence 1- Incision 1- Incision 2- Hemostasis 2- Hemostasis 3- Dissection 3- Dissection 4- Exposure 4- Exposure 5- Procedure (Specimen Collection possible) 5- Procedure (Specimen Collection possible) 6- Hemostasis 6- Hemostasis 7- Irrigation 7- Irrigation 8- Closure 8- Closure 9- Dressing Application 9- Dressing Application

48 Laparoscopy Instrumentation: Laparoscopic Tray – open. Instrumentation: Laparoscopic Tray – open. –Major/Minor Instrument Tray a hold item. What basic instruments will you expect to see in this tray? What basic instruments will you expect to see in this tray? Positioning : The patient is in Lithotomy position, arms tucked at the side or on arm boards. Surgeon stands on the left side of the patient across form the monitor. Scrub between legs of patient. Positioning : The patient is in Lithotomy position, arms tucked at the side or on arm boards. Surgeon stands on the left side of the patient across form the monitor. Scrub between legs of patient. Prepping : Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Start at the umbilicus, normal prep. Move to the the pubis, using a back and forth motion. Prep to iliac crest. Apply prep to the labia majora using only downward strokes, including anus. You will not return to previously prepped area after you cross the anus. Next, prep the inner aspects of the thighs. Start at the labia majora and move laterally towards knees. You will prepare the vaginal vault last. Make sure the person who is prepping has a sponge stick with a counted raytec on it. Use the sponge stick to to prep the cervix, vaginal rugae and exterior of the vagina. If catheterization is ordered, it is performed now. Prepping : Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Start at the umbilicus, normal prep. Move to the the pubis, using a back and forth motion. Prep to iliac crest. Apply prep to the labia majora using only downward strokes, including anus. You will not return to previously prepped area after you cross the anus. Next, prep the inner aspects of the thighs. Start at the labia majora and move laterally towards knees. You will prepare the vaginal vault last. Make sure the person who is prepping has a sponge stick with a counted raytec on it. Use the sponge stick to to prep the cervix, vaginal rugae and exterior of the vagina. If catheterization is ordered, it is performed now. Draping : 4 towels and a lap drape. You will need an under-buttocks drape as well as diamonds x2 (blue towels) and 1 normally folded blue towel. You will need leggings. Ask about towel clips. Draping : 4 towels and a lap drape. You will need an under-buttocks drape as well as diamonds x2 (blue towels) and 1 normally folded blue towel. You will need leggings. Ask about towel clips.

49 Laparoscopy Begin your Operative Sequence Incision: 15 kb on #3 handle for incision. Incision: 15 kb on #3 handle for incision. 2 towel clips on either side of umbilicus. 2 towel clips on either side of umbilicus. Veres Needle Veres Needle

50 Laparoscopy cont. Operative Sequence Hemostasis: Can be from multiple means. The pressure of the trocars entering the pneumoperitineum will stop most bleeding. Bovie: either from the handheld pencil or L (or J) Hook is also available. Hemostasis: Can be from multiple means. The pressure of the trocars entering the pneumoperitineum will stop most bleeding. Bovie: either from the handheld pencil or L (or J) Hook is also available.

51 Laparoscopy cont. Operative Sequence Dissection and Exposure: Dissection and Exposure: –1 ports inserted peri- umbilical. –Operative scope inserted into trocar. –Other ports possible depending on what you find! –Have other trocars in room, ready to open.

52 Laparoscopy cont. Operative Sequence Exploration and Isolation: Exploration and Isolation: –This entire step will depend on what procedure is needed! Surgical Repair/Removal/Specimen Collection: Surgical Repair/Removal/Specimen Collection: –This entire step will depend on what procedure is needed!

53 Laparoscopy cont. Operative Sequence Hemostasis and Irrigation: Hemostasis and Irrigation: –The intra-abdominal cavity is irrigated thoroughly with normal saline. –All bleeding is controlled with a cautery-capable endo- instrument of Surgeons choice. –Special attention is focused on the liver bed. Highly vascularized area. –The abdomen should be examined for any possible bowel injury or hemorrhage. All instruments and ports should be carefully and slowly removed while the CO- 2 in the pneumoperitineum is released.

54 Laparoscopy cont. Operative Sequence Closure: Closure: –Closure will be surgeon specific. Some Surgeons today will not close any layer other than skin. –Other surgeons will use a 0-Vicryl to close the fascial/muscle layer and a 4-0 Monocryl for skin. –Skin staples are always an option.

55 Laparoscopy Major Arteries: Major Arteries: –Internal thoracic artery –The superior epigastric artery –Aorta –External iliac artery: the inferior epigastric and deep circumflex arteries –Inferior phrenic artery, branch of the abdominal aorta. –Lower posterior intercostal and subcostal arteries, branches of thoracic aorta. –Lumbar arteries, from abdominal aorta.

56 Laparoscopy Major Nerves: Major Nerves: –Inferior six thoracic nerves –The subcostal nerve – The intercostal nerves

57 L.A.V.H. (Laparoscopic Assisted Vaginal Hysterectomy) and Vaginal Hysterectomy GYN Laparoscopic Procedures Operative Sequence

58 LAVH Overall Purpose of Procedure: – Laparoscopic Assisted Vaginal Hysterectomy Its greatest benefit is the potential to convert what would have been an abdominal hysterectomy into a vaginal hysterectomy. An abdominal hysterectomy requires both a vaginal incision and a four to six inch long incision in the abdomen, which is associated with greater post- operative discomfort and a longer recovery period than for a vaginal procedure. Another advantage of the LAVH may be the removal of the tubes and ovaries which on occasion may not be easily removed with a vaginal hysterectomy.

59 Advantages of LAVH Miniature Abdominal Incisions Decreased Post Operative Pain Shortened Post Operative Recovery Fewer Post Operative Infections Fewer Adhesions Shortened Hospitalization (< 24 hours)

60 LAVH Define the procedure: –LAVH combines laparoscopy and hysterectomy. Laparoscopy is used to look into the abdomen at the reproductive organs. Hysterectomy is surgery to remove the uterus. –Tiny instruments are inserted laparoscopically to perform the procedure. Ligaments that support the uterus are cut with these instruments, and the uterus is removed vaginally.

61 Indications for LAVH Previous pelvic surgery Endometriosis Previous C.S. Pelvic pain Uterine myoma Ectopic pregnancy Acute or chronic pelvic inflammatory disease Minimum uterine mobility & limited access

62 LAVH Wound Classification: 2

63 Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure 5- Procedure (Specimen Collection possible) 6- Hemostasis 7- Irrigation 8- Closure 9- Dressing Application

64 LAVH Instrumentation: Laparoscopic Tray – open. –Major/Minor Instrument Tray - a hold item. What basic instruments will you expect to see in this tray? Positioning: – Steep trendelenburg position for laparoscopic part. The patient is in Lithotomy position, arms tucked at the side or on arm boards. Surgeon stands on the left side of the patient across from the monitor.

65 LAVH Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Start at the umbilicus, normal prep. Move to the the pubis, using a back and forth motion. Prep to iliac crest. Apply prep to the labia majora using only downward strokes, including anus. You will not return to previously prepped area after you cross the anus. Next, prep the inner aspects of the thighs. Start at the labia majora and move laterally towards knees. You will prepare the vaginal vault last. Make sure the person who is prepping has a sponge stick with a counted raytec on it. Use the sponge stick to prep the cervix, vaginal rugae and exterior of the vagina. If catheterization is ordered, it is performed now. Draping: 4 towels and a lap drape. You will need an under-buttocks drape as well as diamonds x2 (blue towels) and 1 normally folded blue towel. You will need leggings. Ask about towel clips.

66 LAVH Full Counts….do we need them? WHY?

67 LAVH Begin your Operative Sequence Incision: 15 or 11 kb on #3 handle for incision. 2 towel clips on either side of umbilicus. Veres Needle

68 LAVH cont. Operative Sequence Hemostasis: Can be from multiple means. The pressure of the trocars entering the pneumoperitineum will stop most bleeding. Bovie: either from the handheld pencil or L (or J) Hook is also available.

69 LAVH cont. Operative Sequence Dissection and Exposure: –Multiple ports are inserted to provide instrument and scope access.

70 LAVH cont. Operative Sequence Exploration and Isolation: –Patients abdomen is explored as if performing a Laparoscopy.

71 LAVH cont. Operative Sequence Surgical Repair / Removal : –Dissection of the broad ligament is performed. May use Maryland, L-hook, Harmonic Scalpel, or stapler. –Next, dissection of the Round ligament takes place.

72 LAVH cont. Operative Sequence Surgical Repair / Removal/Specimen Collection: –MD must mobilize the bladder from the lower uterine segment. Surgeon has a couple of option at this stage. –They can close up top and move below to remove the uterus (Vaginal Hysterectomy) OR……… –They will move below, remove the uterus, then come back up top.

73 LAVH cont. Operative Sequence If the surgeon performs the second option and comes back to the laparoscopic site: –You must provide the surgeon with a clean gown and glove. –Surgeons will come back to check bleeding and to ensure the vaginal cuff has been completely closed after the uterus has been removed vaginally. –This will be the last step before closure.

74 LAVH to Vag Hys cont. Operative Sequence Surgeon has moved below: –Case will proceed like a Vag Hys from this point on!

75 Vaginal Hysterectomy Weighted speculum placed in vagina. The uterus is grasped with a single or double toothed tenaculum for mobilization and assistance in removal. Surgeon makes a circumferential incision at the base of the cervix. This separates the cervix from the vagina. If this were a straight Vag Hys, all the ligaments that were cut from above would have to be clamped and cut now.

76 Vaginal Hysterectomy You must do a closing count! WHY?

77 Vaginal Hysterectomy Removes the uterus vaginally Closes the peritoneum and posterior vaginal wall. Packs with gauze and antibiotic cream. Apply Peri-pad.

78 LAVH and Vag Hys cont. Operative Sequence Hemostasis and Irrigation: –The intra-abdominal cavity is irrigated thoroughly with normal saline. –All bleeding is controlled with a cautery-capable endo- instrument of Surgeons choice. –Special attention is focused on the liver bed. Highly vascularized area. –The abdomen should be examined for any possible bowel injury or hemorrhage. All instruments and ports should be carefully and slowly removed while the CO- 2 in the pneumoperitineum is released.

79 LAVH cont. Operative Sequence Closure: –Closure will be surgeon specific. Some Surgeons today will not close any layer other than skin. –Other surgeons will use a 0-Vicryl to close the fascial/muscle layer and a 4-0 Monocryl for skin. –Skin staples are always an option.

80 L.A.V.H. And TVH Movies Laparoscopic_Hyster ectomy.mpgLaparoscopic_Hyster ectomy.mpg TVH Routine Case Notice the dissection of the ligaments and the passage of the uterus thru the vagina and the end of the case. Notice the lap assisted suturing techniques!


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