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Operative gynecology

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Operative gynecology

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Operative gynecology

  1. 1. Benha University Hospital, Egypt ABOUBAKR ELNASHAR
  2. 2. 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 ABOUBAKR ELNASHAR
  3. 3. 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 ABOUBAKR ELNASHAR
  4. 4. 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 ABOUBAKR ELNASHAR
  5. 5. 6. Fractional curettage 7. Endocervical curettage 8. In pregnancy: Abortion: therapeutic, missed, incomplete, inevitable, septic Molar pregnancy Postabortive or postpartum bleeding ABOUBAKR ELNASHAR
  6. 6. Technique 1.Evacuate the bladder 2.Anesthesia 3.Vaginal speculum & grasp the cervix 4.Sounding 5.Dilate the cervix 6.Curette ABOUBAKR ELNASHAR
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  10. 10. 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 ABOUBAKR ELNASHAR
  11. 11. 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 ABOUBAKR ELNASHAR
  12. 12. ABOUBAKR ELNASHAR
  13. 13. 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 ABOUBAKR ELNASHAR
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  17. 17. 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 ABOUBAKR ELNASHAR
  18. 18. ABOUBAKR ELNASHAR
  19. 19. 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 ABOUBAKR ELNASHAR
  20. 20. 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 ABOUBAKR ELNASHAR
  21. 21. MYOMECTOMY Indication Symptomatizing patient who did not complete her family Types 1.Abdominal 2.Vaginal 3.Hysteroscopic: submucous <5cm 4.Laparoscopic: Pedunculated subserous ABOUBAKR ELNASHAR
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  26. 26. 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 ABOUBAKR ELNASHAR
  27. 27. II. Obstetric indications 1.Uncontrolled postpartum hemorrhage 2.Rupture uterus 3.Placenta accreta 4.Invasive mole 5.Couvelaire uterus ABOUBAKR ELNASHAR
  28. 28. Types 1.Abdominal 2.Vaginal 3.Laparoscopic ABOUBAKR ELNASHAR
  29. 29. Types of abdominal hysterectomy • Subtotal: removal of the uterus with preservation of 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 ABOUBAKR ELNASHAR
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  31. 31. ABOUBAKR ELNASHAR
  32. 32. • 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 ABOUBAKR ELNASHAR
  33. 33. Types 1. Extrafacial: removal of the uterus with its fascial layer. It is the operation usually performed 2. Intrafascial: The outer (endopelvic) fascia is left attached to the bladder. It is used when it is difficult to dissect the bladder from front of the cervix e.g. adhesions from previous CS. ABOUBAKR ELNASHAR
  34. 34. ABOUBAKR ELNASHAR
  35. 35. 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 ABOUBAKR ELNASHAR
  36. 36. 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. ABOUBAKR ELNASHAR
  37. 37.  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 ABOUBAKR ELNASHAR
  38. 38. • Indications: (ACOG, 1996) 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 (RCOG,2002). ABOUBAKR ELNASHAR
  39. 39.  Contraindications: 1.Uterine contractions. 2.Uterine bleeding 3.Chorioamnionitis 4.Premature rupture of membranes 5.Fetal anomaly incompatible with life ABOUBAKR ELNASHAR
  40. 40. Cerclage Before pregnancy After pregnancy Trans- vaginal Trans- AbdominalLash CervicoisthmicHefner McDonald Shirodkar Burried Un-burried shirodkar Modified shirodkarABOUBAKR ELNASHAR
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  43. 43.  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 ABOUBAKR ELNASHAR
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Operative gynecology

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