Gynecologic Procedures

Chapter 30 Gynecologic Procedures

Joseph C. Gambone

Gynecologic procedures are becoming less invasive and safer, and advances in surgical technique are resulting in more effective and efficient reproductive healthcare for women. Smaller and more flexible instrumentation for endoscopic procedures and the development of robotic techniques are examples of these recent advances.

The gynecologic surgeon should have a high level of training during residency, followed by an ongoing commitment to retraining and retooling as effective procedures are added or substituted for outdated ones. Training methods now include computer-assisted simulations of procedures, providing for greater patient safety while learning and retraining. All facilities should have an active quality assessment program to continuously evaluate the safety and appropriateness of gynecologic care, including surgery.

It is not the purpose of this chapter to qualify the reader as a gynecologic surgeon. It is, however, essential that students and residents become familiar with the basic principles of common gynecologic surgical procedures so that they can properly assist in the operating room and carry out perioperative care.

image Appropriateness of Gynecologic Procedures

Before any procedure or surgery begins, the most appropriate option (when more than one exists) for an individual patient must be selected, with optimal patient involvement in the decision-making process preceding informed consent.

At least 80% of gynecologic surgical procedures are considered to be elective; that is, there are other alternative treatments to be considered. The appropriateness of performing these procedures should be evaluated by physician and patient on an individual basis (Box 30-1). The trend toward minimal invasiveness in gynecologic surgery should not lead to minimal or questionable indications.

BOX 30-1 The PREPARED Checklist∗

P is the procedure
R is the reason or rationale
E is the expectation
P is the preference that the patient may have (e.g., to avoid surgery, or the side effects of medication)
A is the alternative(s)
R is the risk(s)
E is the expense (hospital costs and surgeon’s fees)
D is the decision to perform or not to perform the procedure

∗ PREPARED is a useful mnemonic checklist to assess preoperatively the appropriateness of a health-care procedure, including elective gynecologic surgery. An analysis of each gynecologic or other health-care procedure can be carried out and the patient completely and efficiently counseled using this format.

image Credentialing, Privileging,and Ongoing Training

The rapid introduction of new technology can present a challenge to the surgeon, who will need to keep up with the most advanced procedures, and to the institution, which is required to be certain that those who are granted surgical privileges have been properly trained and are currently qualified.

After a surgeon’s credentials (diplomas, training certificates, and licenses) have been properly verified, a useful classification for the purpose of privileging stratifies procedures into the following levels: level 1, procedures not requiring additional training after residency (e.g., dilatation and curettage [D&C], cervical conization, adnexal excision, and abdominal or vaginal hysterectomy); level 2, procedures requiring additional training (e.g., laparoscopic myomectomy); and level 3, procedures requiring advanced training and special skills generally acquired during subspecialty training (e.g., radical hysterectomy, tubal anastomosis, or oocyte harvesting).

As new procedures are incorporated into basic residency training, they can be reclassified.

image Informed Consent and General Risks Associated with Procedures

The patient should be thoroughly counseled about surgical risks as part of the process of informed consent (see Chapter 1). In general, risks fall into three categories: risks of anesthesia, intraoperative risks, and postoperative complications. Risks of anesthesia depend on the type of anesthesia used (awake sedation, regional anesthesia, or inhalation agents). Regional anesthesia carries the risk for infection, postprocedure spinal headache, and failure, in which case an inhalation agent must be added to the regional anesthetic. Inhalation agents may be associated with the risk for aspiration pneumonia, allergic reaction to the agent, and damage to teeth or airways if intubation is necessary. Stroke, myocardial infarction, and death can result. The intraoperative risks include excessive bleeding and unintended damage to organs or tissue. Postoperative risks include infection, persistent bleeding, and thrombosis, all of which can lead to significant morbidity or even mortality. The specific risks of each procedure are given later.

image Endometrial Sampling Procedures

One of the most common minor gynecologic surgical procedures is D&C: dilation of the cervix and curettage of the endometrium. Recent advances in office-based instrumentation for diagnosis (hysteroscopy, endometrial sampling [Figure 30-1], and ultrasonic evaluation of endometrial thickness) have resulted in an appropriate decrease in the use of D&C. However, if cancer of the cervix or endometrium is suspected, a thorough fractional curettage may be the best procedure to confirm its presence.

image

FIGURE 30-1 Endometrial sampling using the Pipelle instrument. A flexible hollow plastic tube is inserted and held in the uterine cavity as the stylet is withdrawn, creating a vacuum and resulting in aspiration of tissue.

INDICATIONS

D&C may be a diagnostic or a therapeutic procedure. A diagnostic D&C is performed for irregular menstrual bleeding, heavy menstrual bleeding, or postmenopausal bleeding, unless an endometrial biopsy has already revealed a diagnosis of malignancy. Irregularities in the contour of the endometrial cavity, either congenital (e.g., uterine septum) or acquired (e.g., submucous myomas), are sometimes determined during the operation. The finding of a thin endometrium on a transvaginal ultrasound (generally <5 mm) may eliminate the need for biopsy or D&C in some women. In patients younger than 40 years with irregular bleeding, hormonal manipulation preceded by office endometrial sampling frequently obviates the need for curettage.

The D&C may have a therapeutic effect in patients with heavy or irregular bleeding from endometrial hyperplasia, endometrial polyps, or small, pedunculated submucous myomas. Unwanted first-trimester pregnancies are usually evacuated by dilation and suction curettage, although nonsurgical techniques are now available.

TECHNIQUE

The operation is performed with the patient in the dorsal lithotomy position. Most D&Cs are now performed on an outpatient basis. Paracervical blocks and local anesthesia are frequently employed.

A pelvic examination is done under anesthesia, and after sterile preparation, a weighted speculum is placed in the posterior vagina. The cervix is grasped with a single-toothed or double-toothed tenaculum. A Kevorkian curette is used for curettage of the endocervical canal. The depth of the uterine cavity is determined with a uterine sound, and the cervix is then dilated with a set of graduated dilators. A small polyp or ovum forceps is introduced through the dilated cervix and gently rotated to remove any endometrial polyps. A thorough curettage is done with a sharp curette, proceeding with each stroke in either a clockwise or a counterclockwise manner to ensure that the entire uterine cavity has been covered.

COMPLICATIONS

The most common surgical complications of D&C are hemorrhage, infection, perforation of the uterus, and laceration of the cervix. Perforation of the uterus, even in experienced hands, is a not uncommon complication and occurs particularly with a retroverted uterus, during pregnancy, or in postmenopausal patients with endometrial cancer. As long as no bowel or large blood vessels are injured, careful observation and antibiotics may be all the therapy that is required.

Except in an acute emergency, such as an infected incomplete abortion, D&C should be done reluctantly in the presence of infection.

image Cervical Procedures

Conization of the cervix is a procedure in which a cone-shaped portion of the cervix is removed for diagnostic or occasionally therapeutic purposes. The section of the tissue surrounding the external os represents the base of the removed specimen. The apex is either close to the internal os (Figure 30-2A) or close to the external os (Figure 30-2B). Conization may also be performed in an office setting using loop electrosurgical excision (Figure 30-2C) or large loop excision of the transformation zone of the cervix. Loop excision should not be performed before identification of a cervical intraepithelial lesion that requires treatment by colposcopically directed punch biopsy.

image

FIGURE 30-2 Cone biopsy of the cervix. A: Diagnostic conization performed when the squamocolumnar junction is not fully visualized colposcopically. B: Therapeutic conization performed for disease involving the ectocervix and distal endocervical canal. C: Loop electrosurgical excision procedure. The goal of the procedure is to remove the cervical tissue to just above the squamocolumnar junction, including any visible lesions.

The technique of cryoablation is commonly used to treat condylomas of the cervix, vagina, and vulva. These procedures almost always are office based, and little if any anesthesia is required.

Laser instruments are sources of intense beams of light energy. The letters in the acronym laser stand for light amplification by the stimulated emission of radiation. When used in surgery, this radiant energy is converted inside the cell to thermal or acoustic energy, resulting in controlled vaporization or coagulation of tissue. Lasers come in longer wavelengths (carbon dioxide [CO2]) or shorter wavelengths (neodymium–yttrium-aluminum-garnet [Nd:YAG], potassium-titanyl-phosphate [KTP], and argon) that can be propagated along flexible optical fibers. This allows delivery of energy for cutting, vaporization, and coagulation to tissues in locations unreachable by a CO2 laser.

Because of the additional expense of laser equipment and the lack of evidence for improvements in outcome, the use of this technology has been decreasing in recent years. Nevertheless, laser technology has been applied to conization of the cervix, removal of leiomyomas (myomectomy), and destruction of the ectopic endometrial implants of endometriosis.

image Pelvic Endoscopy

Gynecologic endoscopy (laparoscopy and hysteroscopy) is widely used for the diagnosis and treatment of reproductive organ disease and dysfunction. Laparoscopy and hysteroscopy have largely moved from the hospital operating room to the freestanding surgical outpatient unit, and with smaller instruments (needle-scopes) and more refined fiberoptic technology, even into the office setting. Because of the expenseinvolved, the value of these techniques must be considered in terms of outcome, particularly the long-term health and functional status of the patient.

image Laparoscopy

The laparoscope is an instrument for viewing the peritoneal cavity. Both pelvic and upper abdominal structures can be inspected. The attachment of a video camera on the lens of the laparoscope allows more than one surgeon to view the operative site on a video screen and assist during procedures (Figure 30-3). Multiple puncture sites through the skin and into the abdominal cavity provide for the insertion of small rigid or flexible instruments directed toward the pelvis. Procedures that were once performed by laparotomy are now routinely carried out less invasively.

image

FIGURE 30-3 Laparoscopic view of female pelvis.

(Courtesy of B. Beller, MD, Eugene, Oregon.)

The indications for laparoscopy are both diagnostic and therapeutic. Laser technology can be applied to operative laparoscopic procedures both to excise and to vaporize areas of pathology.

Absolute contraindications to laparoscopy include bowel obstruction and large hemoperitoneum with hypovolemic shock. In patients who have had multiple previous laparotomies, a history of peritonitis, previous bowel surgery, or a lower midline abdominal incision, open laparoscopy is preferable. In these conditions, the peritoneal cavity is opened through a small subumbilical incision under direct vision before introduction of the trocar and sheath.

INDICATIONS

The following are indications for laparoscopy:

1. Tubal sterilization. The most common indication for the use of the laparoscope in gynecology is sterilization.
2. Ectopic pregnancy. The laparoscope is commonly used for the removal of tubal pregnancies that do not meet the criteria for medical therapy.
3. Pelvic infection. Although it is not routinely used for diagnosis of pelvic inflammatory disease (PID), the laparoscope can provide confirmation of a diagnosis when there is a diagnostic dilemma.
4. Infertility. Routine laparoscopic evaluation of the infertile woman is widely recommended but controversial because of a lack of controlled evidence of improved outcome. Advanced assisted reproductive techniques, such as in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT), may involve laparoscopic procedures, although the aspiration of oocytes for IVF is now most commonly performed transvaginally using ultrasonic guidance (see Chapter 34).
5. Pelvic pain. Acute and chronic pelvic pain can be investigated using the laparoscope.
6. Endometriosis. The laparoscope has become a widely used intervention for the diagnosis, staging, and treatment of ectopic endometrial tissue in both overtly symptomatic (pelvic pain) and silently symptomatic (infertility) patients. Laser coagulation, thermal vaporization, excision of endometriosis, and aspiration of endometriomas results in consistent, but sometimes temporary, improvement of pain and moderate improvement in fertility potential. Repeated procedures and the need for medical adjuvant treatment are common.
7. Ovarian neoplasms. Because of the need to rule out pelvic malignancies, the laparoscope can be used as a less invasive procedure to evaluate a persistent small adnexal mass. Laparoscopic ovarian cystectomy or salpingo-oophorectomy allows a tissue diagnosis to be made. Laparoscopic aspiration of cysts can be dangerous and may result in dissemination of an unsuspected ovarian cancer. Ovarian biopsy is seldom indicated, and in premenopausal patients with simple cystic enlargement, a trial of hormonal suppression or observation is indicated instead of immediate surgical intervention. Most such lesions are functional cysts that spontaneously regress. The laparoscope in expert hands has been advocated for staging and second-look procedures in patients with ovarian cancer. These procedures have become feasible since the advent of laparoscopic lymphadenectomy, but port-site recurrences are a potential problem.

Related posts:

  1. Hypertensive Disorders of Pregnancy
  2. Menstrual Cycle–Influenced Disorders
  3. Family Planning
  4. Congenital Anomalies and Benign Conditions of the Uterine Corpus and Cervix

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Jun 4, 2016 | Posted by in GYNECOLOGY | Comments Off on Gynecologic Procedures

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