Vaginal procedures
Transcript of Vaginal procedures
Cervical conization
AKA Cone biopsy refers to the excision of a cone shaped portion of the cervix surrounding the endocervical canal and including the entire transformation zone .
Removal of cone of the cervix which includes entire Squamocolumnar junction, stroma with glands and endocervical mucous membrane.
Techniques : • Cold Knife • LEEP (Loop Electrical Excision Procedure) or “Hot Knife” • CO2 Laser
Procedure – Under GA
– Blood loss is minimized with sutures at 3 and 9 o'clock positions on the cervix
by ligating the
descending cervical branches .
– After the cone is removed, a margin suture is placed at 12 o'clock for
identification of the cone
– Routine endocervical curette above the apex of the cone is performed and
uterine curettage is done if indicated .
– Then we use Sturmdorf suture to cover the cone .
Diagnostic indications Therapeutic
indications
Contraindications
– Unsatisfactory Colposcopic findings
– Inconsistent findings (Colposcopic,
Cytology and directed biopsy)
– Positive endocervical curettage for
CIN II and III
– When biopsy cannot rule out invasive
cancer from carcinoma in-situ
– Biopsy shows microinvasion
– to exclude gross invasive carcinoma
Treat CIN || and ||| During pregnancy
- significant (>500
mL) bleeding.
- 30% 🡪 delayed
post op hemorrhage
- 10% 🡪 fetal loss
complications
– Intraoperative bleeding
– Postoperative bleeding
– Infection
– Late Complications (cervical insufficiency and cervical stenosis.)
– complications in pregnancy (mentioned above)
Dilation & Curettage – it's a procedure to remove tissue from inside the uterus.
– The "dilation" refers to dilation of the cervix, "Curettage"
refers to the scraping or removal of tissue lining the uterine
cavity (endometrium) with a surgical instrument called a
curette
Diagnostic indications Therapeutic indications Contraindications
- Abnormal uterine bleeding
- Retained material in the
endometrial cavity.
- Evaluation of intracavitary
findings from imaging
procedures
- abnormal endometrial
appearance due to
suspected polyps or fibroids
Suction procedures for
management of uterine
hemorrhage.
- Treatment and evaluation of
gestational trophoblastic
disease.
- Hemorrhage unresponsive
to hormone therapy
Absolute:
- Viable desired intrauterine
pregnancy.
- Inability to visualize the
cervical os.
- Obstructed vagina.
– Relative:
- Severe cervical stenosis.
- Cervical/uterine anomalies.
- Bleeding disorder.
Complications:
- Bleeding or hemorrhage.
- Cervical laceration.
- Uterine perforation.
Procedure Anesthesia (general or regional)
Gradually, the cervix is widened with metal dilators to
about the size of a large pencil.
The curette, is inserted into the uterine cavity and is
used to gently scrape the lining of the uterus .
Cervical cerclage Cervical cerclage, also known as a cervical stitch, is a
treatment for cervical weakness, when the cervix starts to
shorten and open too early during a pregnancy causing either
a late miscarriage or preterm birth .
Indications Contraindications Complications
Cervical insufficiency .
Dilated or shortened
cervix early in pregnancy
.
Elective cerclage is
usually performed
between 12-18 weeks.
Active labor
Active vaginal
bleeding
Abruptio placenta
Premature rupture of
membranes
Chorioamnionitis
PROM after elective cerclage occurs
in approximately 2% of cases .
ROM intraoperatively or in the
immediate postoperative period in
nonelective cerclage, 58%.
Increased frequency of uterine
contractions .
Cervical dystocia or cervical trauma
in labor have been reported in fewer
than 5% .
Procedure (McDonald’s Cerclage)
- the cervix is exposed and grasped by Allis' or Babcock forceps.
- A purse string suture is inserted around the exo-cervix as high as possible to
approximate to the level of the internal os.
- Five or six bites are made .
- The stitch is pulled tight enough to close the internal os.
- The knot being made in front of the cervix and the end left long enough to
facilitate subsequent division.
colporrhaphy Colporrhaphy is the surgical repair of a defect in the vaginal wall, including a
cystocele (when the bladder protrudes into the vagina) and a rectocele (when the
rectum protrudes into the vagina).
During the colporrhaphy operation, a midline incision is made in the vaginal canal.
This incision gives the surgeon access to repair and restructure the weakened
underlying pelvic floor tissue that caused the prolapse.
The incision is sutured with strong, absorbable stitches. General, regional or local
anesthesia may be used depending on which option the physician believes is best
for the patient.
Risks and considerations
- Adverse reactions to anesthesia
- Excessive bleeding
- Post-operative infection, including bladder infection (more common in patients
receiving catheters)
- Painful intercourse
- Urinary incontinence
- Constipation.
- women planning on having children, or having additional children, should
postpone surgical treatment until they are no longer planning on getting pregnant.
Recovery and results
In recovery period, a catheter is inserted in the bladder, and a pack is placed in
the vagina to reduce bleeding. Both are generally removed within 48 hours.
In 70-90 % of cases, colporrhaphy successfully repairs pelvic organ prolapse.
patients are often able to fully return to their normal activities upon healing,
including sexual intercourse.
Heavy lifting, vigorous exercise are best avoided.
After three to four weeks of recovery, patients may resume light activities such as
driving and walking.
Patients generally reach full strength and recovery approximately three months
after surgery.
Common vaginal incisions 1) For vaginal prolapse : Midline incision is used, this allows
the skin to be reflected and to gain access to the fascia and
underlying tissues.
2) For vaginal hysterectomy : the vaginal mucosa around the
cervix is excised to gain access to the uterosacral ligaments
and vesicouterine space and pouch of Douglas.
– The morbidity associated with vaginal incisions is very low;
many patients experience almost no pain after vaginal
surgery.
– adhesion bands can form between the anterior and
posterior vagina, which can be troublesome and interfere with
intercourse .
Surgical sutures Surgical suture materials are essential elements :
1) Allows secure knot tying without slippage
2) Provokes little tissue reaction
3) Does not increase the risk of infection
4) Retains enough tensile strength
5)can be wholly reabsorbed by the body
Preoperative care All information should be given to the patient about success rate, outcome ,
recovery time.
– Full History
– Full Physical exam
– Investigation
– Counseling and acquiring an informed consent
– Psychological preparation
– Medical consultation
Counseling (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.
Post op care & recovery – vital signs will have regular (usually 4 hourly) observations in the first 24 hours.
– Most patients will be given intravenous fluids for the first 12–24 hours after
surgery until they can resume eating and drinking.
– Pain must be assessed thoroughly , particularly pain that is more than one
would expect from a recent surgical wound or which is in a different site.
– Encourage mobilization and oral intake at the earliest opportunity.
– Single-dose antibiotic prophylaxis is usually give intraoperatively for all
gynaecological surgery.
– Usually 6 weeks is recommended before resumption of full activity and
intercourse after major surgery.
– For less major surgery a gradual resumption of activity from about 4 weeks is
acceptable.