1. Principles of Gynecological procedures
Done by: Abdallah Amjad riyalat

2. Most gynaecological procedures were performed by surgeons
SO let’s memorize some anatomy ……………

5. Oviduct

6. 1.Hysterectomy Major inpatient surgical procedure
Performed under either regional or GA
Can be performed :
1.Abdominally
2.Vaginally
3.Laproscopically
4.laproscopic-assisted

7. INDICATIONS Emergent indications:
Acute uterine uncontrollable bleeding
Conversion from another gynecological procedure.

8. INDICATIONS Elective indications: Uterine Fibroids (30%)
Pelvic organ prolapse (15%)
Severe and intractable endometriosis (20%)
Adenomyosis
Pelvic inflammation
Non-acute abnormal bleeding
Malignant and premalignant conditions (adnexal masses)

10. Types
Subtotal (supracervical)
Total(simple)
radical

11. SUBTOTAL Absolute contraindication to subtotal hysterectomy
removes only the corpus of the uterus leaving the cervix in place
Absolute contraindication to subtotal hysterectomy
presence of a malignant or premalignant condition of the uterine corpus or cervix

13. TOTAL:
the most common procedure ,removes the corpus and cervix
Indications

15. Radical
removal of uterus ,cervix,surrounding tissues like cardinal ligaments uterosacral ligaments and upper vagina

16. abdominal hysterectomy
The procedure involves taking three pedicles:
The infundibulopelvic ligament, which contains the ovarian vessels.
The uterine artery.
The angles of the vault of the vagina, which contain vessels ascending from the vagina; the ligaments to support the uterus can be taken with this pedicle or separately.

17. Vaginal hysterectomy
The same steps are taken but in the reverse order.
If the uterus is of normal size, hysterectomy can be performed vaginally, even in the absence of significant prolapse.

18. laparoscopy
Used to aid vaginal surgery, termed laparoscopic-aided vaginal hysterectomy (LAVH) in which the first two steps are completed laparoscopically and the third vaginally.
The entire operation can be performed laparoscopically, with the uterus removed through the vagina and the open vault closed with laparoscopic sutures, termed total laparoscopic hysterectomy (TLH). Although at the moment the procedure time and hence anaesthetic may be longer, postoperative pain and recovery time will be less

19. Vaginal vs Abdominal Hysterectomy
Characteristic
Abdominal hysterectomy
Vaginal hysterectomy
Length of stay (days)
3.99
2.76
Hemorrhage (percent)
3.4
2.4
Postoperative fever 4
0.8
Bladder injury
0.2
Other Complications
9.3
5.3
Median charge (dollars)
5604
4166

21. Complications of hysterectomy
Haemorrhage (intra- or immediate postoperative)
Deep vein thrombosis (pelvic surgery).
New bladder symptoms (both overactive bladder and stress incontinence).
Higher incidence of vaginal prolapse after hysterectomy for any cause
Bladder injury (uncommon).
Ureteric injury (rare).
Rectal injury (rare).
Vesicovaginal or rectovaginal fistula (consequence of injury) (very rare).
Early onset of menopausal symptoms (if ovaries left in situ).
Immediate onset of menopausal symptoms (if ovaries removed in a premenopausal woman).
Thromboembolism.

23. Study result…….
The choice of abdominal or vaginal route for hysterectomy has to balance the benefits and risks of each approach It is now generally agreed that vaginal surgery requires a shorter time in hospital and less recovery time before full mobility and activity is resumed

24. Pre & post Operative Assessment:

25. Preoperative Care full History full Physical exam Investigation
Counseling and acquiring an informed consent
Psychological preparation
Medical consultation

26. History Patient Profile Chief Complaint (type of surgery)
Complete review of system; Resp. diseases, CVS disease including DVT, exercise tolerance
Past medical* history; Hypertension, diabetes, Bleeding diathesis
Take detailed drug *history; Anticoagulant, Aspirin, NSAID & allergy to drugs
surgical and anesthesia history
Gynecological and obstetrical history
Social History; Alcohol intake, smoking
-you should know any risk factor that may affect the surgery. _you have to know the antidote for each drug

27. Physical Exam -Based on History information
-Pre-anesthesia physical examination : ( an assessment of the airway, lungs and heart, with documentation of vital signs)
-Unexpected abnormal findings  investigated before elective surgery.
General exam and vital signs  Respiratory and cardiovascular exam (Diseases of the cardiovascular and respiratory systems are the most relevant in respect of fitness for anesthesia and surgery)  Abdominal exam

28. Investigations
-not on a routine basis. - risk-benefit ratio of any ordered lab test ??*
Age < 40
Age > 40
Minor surgery
CBC ( Hb, Plt, WBC )
Blood group*
Control the chronic disease (DM, HTN, Thyroid)
Consent Form
Follow the same step but you also have to do:
KFT
Random blood sugar
ECG
Chest X ray*
Major surgery
All above + cross match 2 unit of blood
should be ordered only when indicated by the ( patient’s medical status, drug therapy, or the nature of the procedure)
should be consider
-blood group (should be done in all pt)
Blood glucose: DM, vascular disease
Urinalysis: DM, UTI
AGE > 40
LFT: liver disease, alcoholism, hepatitis
KFT: major surgery, hypotension is expected, nephrotoxic drugs will be used, age above 50
Coagulation screen: Hx of coagulation disorder, alcohol abuse, liver dx, anticoagulants
CXR: smokers ? >40, provide a valuable preoperative baseline, Hx of CVS disease? , pulmonary disease?, thyroid enlargement?, lung tumor?
___________________________________________________________________________________________________________________ actually we should check for pregnancy in all surgeries
Beta HCG ?!!*

29. When to stop the drugs before surgery?
Anticoagulants:
Warfarin: Stop the drug, Daily INR* until normal (target 1.5), then give LMWH
LMWH*: must be stopped 12hrs prior to surgery
Anti-platelet (Aspirin): 7-10 days prior to surgery
Oral contraceptive: 2-3 month prior to surgery.
benefits of unfractionated heparin : short duration of action ( 1.5 hours) – has an antidote ( protamine sulfate )
____________________________________________________________________________________________ In healthy people an INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking warfarin for disorders such as atrial fibrillation or a blood clot in the leg or lung

30. Preoperative Care Counseling
Counseling is considered an important part of preoperative care…>>
The PREPARED Checklist
The procedure
The Reason or indication
Our Expectations
The preference that the patient may have
The Alternatives or options
The Risks and possible complication
The Expense
The Decision to perform or not to perform the procedure.

31. Late INTRA-OP POST-OP General Risks Associated with Procedures
In general, risks fall into three categories:
Intra-operative complications
Post-operative complications
Late -complications
Late
INTRA-OP
POST-OP

32. Intraoperative risks include: Anesthetic complications * :
Intra op. bleeding
unintended damage to organs or tissue
Depends on the type of anesthesia used (awake sedation, regional anesthesia, or inhalation agents). Regional; infection, post procedure spinal headache, and failure (an inhalation agent must be added) Inhalation; aspiration pneumonia, allergic reaction to the agent, and damage to teeth or airways if intubation is necessary . Stroke, myocardial infarction, and death can result

33. Thank you