1. Principles of Gynecological Procedures
AMER SALAMAT

2. OBJECTIVES
AMER PART: Anatomical revision of female Genitalia , and Hysterectomy.
ALA’A PART: Cervical Conization, Cervical Cerclage, Colporaphy, Dilation & Curettage.
LEEN PART: Hysteroscopy, Laparoscopy Cystoscopy, Myotectomy, Hysterosalpingogram (HSG)

3. Female External Reproductive Organs

4. Uterus

5. Oviduct And Ovarian

6. Infundibulum
Ovary
Fimbriae
Ampula
Isthmus

7. Hysterectomy

8. Is an operation to remove a woman's uterus, and it is one of the commonest surgical procedures in gynaecology.
It is commonly performed for heavy or painful or irregular periods, when medical treatment or less invasive surgery such as endometrial ablation has failed.

9. INDICATIONS: Emergent Indications: Elective Indications:
1)Acute uterine uncontrollable bleeding.
2)Conversion from another gynecological procedure.
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)

11. Types
I. Subtotal (supracervical)
II. Total(simple)
III. Radical

12. SUBTOTAL
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 both the corpus and cervix of the uterus.
Total hysterectomy is also known as simple hysterectomy
Indications: Benign conditions such as uterine myomas, endometriosis, chronic PID, stage I endometrial cancer, and bleeding that is unresponsive to more conservative measures

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

17. Routes:
1. Abdominal 2. Vaginal 3. Laproscopic 4. Laproscopic-assisted -Performed either under Regional or General Anaesthesia. .

18. Abdominal Hysterectomy
The procedure involves taking three pedicles:
1. The infundibulopelvic ligament:
which contains the ovarian vessels.
2. The uterine artery.
3. 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.

19. 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.
In prolapse surgery, hysterectomy is commonly performed vaginally as part of the correction of anatomical prolapse.

20. 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. LAVH, laparoscopic-aided vaginal hysterectomy; TLH, total laparoscopic hysterectomy.

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

26. So..
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.

27. Pre and post Operative Assessment
Preoperative Care:
Full History and Physical Examination.
Investigation.
Counseling and acquiring an informed consent.
Psychological preparation.
Medical consultation.

28. History Patient Profile Chief Complaint (type of surgery).
Review of system:
Resp. diseases, CVS disease including DVT, exercise tolerance.
Gynecological and obstetrical history.
Past medical history: Hypertension, diabetes, Bleeding diathesis.
Take detailed drug history: Aspirin, Anticoagulant, NSAID & allergy to drugs.
Surgical and anesthesia history.
Social History; Alcohol intake, smoking

29. Physical Examination
 Build on the information gathered during the history.
-Pre-anesthesia physical examination : ( an assessment of the airway, lungs and heart, with documentation of vital signs)
-Unexpected abnormal findings  investigated before elective surgery.

30. Investigations Risk-benefit ratio of any ordered lab test ? Beta HCG?
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
Beta HCG?

31. Drugs? When to stop before the operation!
Anti-platelet (Aspirin): 7-10 days prior to surgery.
2.Oral contraceptive: 2-3 month prior to surgery.
3.Anticoagulants:
Warfarin: Stop the drug, Daily INR* until normal (target 1.5), then give LMWH.
LMWH*: must be stopped 12hrs prior to surgery

32. 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.

33. Intraoperative risks:
Include:
Anesthetic complications.
Intra op. bleeding.
Unintended damage to organs or tissue.

34. Smile..Take A Breath
To Be Continued…