Gynecologic Procedures

Chapter 30 Gynecologic Procedures



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followed by an ongoing commitment to retraining and retooling as effective procedures are added or substituted for outdated ones.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 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 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.



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 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.



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:








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

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