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on methodological meeting

of Department of Obstetrics and Gynecology

with course of Infant and Adolescent Gynecology

“___”______________________ 201_ year

protocol #

T.a.the Head of the department


________________ O.A. Andriyets

Methodological instruction

for practical lesson

The indications, contra-indications, terms and technical features of gynecological operations. Endoscopic methods of diagnostics and treatment in gynaecology. Preparation and post-surgery management of gynaecological patients in case of urgent and planned operative interventions. Principles and methods of anaesthesia and reanimation during gynaecological operations. Major and minor gynecological operations"

Module 4: Obstetrics and gynecology

Context module 12: Gynecological diseases

Subject: Obstetrics and Gynecology

6th year of studying

2nd medical faculty

Number of academic hours – 5.5

Methodological instruction developed by:

ass.prof. Andriy Berbets

Chernivtsi – 2010

^ 1. Methodical background of theme

With introduction of endoscopic operative methods of treatment in practical medicine frequency and amount of complications went down considerably, duration of stay of patients in permanent establishment, genesial prognoses became better. The study of basic endoscopic operations, methods of their implementation, technical features of tool allows to capture in practice realization of operative interventions taking into account testimonies and contra-indications to those or other methods, and development according to plan of realization of operations. The important constituent of this employment is prognostication of possible complications, determination of subjects of doctor for their warning in case of occurring of complications is their timely diagnostics and treatment.

^ 2. Educational purpose

A student must know:

  1. Types of endoscopic operations which are used in obstetrics and gynaecology.

  2. Terms of realization of operation.

  3. Technique of execution of operation.

  4. Indications and contra-indications to operation.

  5. Complications, related to technical implementation of operations and anaesthetic providing.

  6. Principles and methods of anaesthesia during endoscopic operations.

A student must be able:

  1. To define terms, shows and contra-indications to realization of endoscopic operations depending on a clinical situation.

  2. To pick up the set of tools for implementation of laparoscopy and hysteroscopy.

  3. To lay down protocol of endoscopic operations.

  4. To prepare a patient to the operation, depending on urgency and to develop according to plan of her implementation.

  5. To conduct a post-surgical supervision, in good time to diagnose appearance of complications.

  6. To determine a necessity and volume of methods of anesthesia and reanimation during gynaecological operations.

A student must master:

  1. Technique of execution of endoscopic operations (on a phantom).

  2. Record of protocol of laparoscopic operation and hysteroscopy

  3. A plan of inspection of women before an urgent or planned operation .

^ 3. Educator purpose

The students of professional responsibility have forming for the somatic and genesial health of woman, in the case of the use of endoscopic operations in obstetrics - responsibility for a mother and fruit. Bringing up of principles in a relations doctor-doctor, doctor-patient, medical relatives of patient.

^ 5.1. Preparatory stage

At the beginning of class teacher acquaints students with the basic tasks. For control of initial level of knowledge test questions should be used.

5.2. Basic stage (table of contents of theme)

Minimally invasive, laparoscopic surgery is, and must always be, considered major surgery. Therefore, it is important to carefully prepare the patient for surgery both psychologically as well as physically. The surgeon must also be prepared by adequate training and practice in the techniques that are necessary to complete the procedure in a safe and efficient manner. Patient preparation begins with the initial decision to perform laparoscopic surgery, and although it is tempting to convert most procedures to a minimally invasive route, the surgeon must consider if the particular pathology should be approached in this manner and is in the best interest of the patient. Just as importantly, the surgeon must honestly evaluate his/her own ability and training.

Surgical interventions in gynecological practice is used only when the conservative methods of treatment have been tried. There is a possibility, that the conservative methods of treatment will be of no use and operation is the only way for the patient's convalescence, and sometimes for saving her life.

Each operation is performed according to the certain indications.

Indications are the aggregate of causes which determine the necessity of some surgical intervention.

Indications for the operation have to be carefully thought out by a doctor and written down into the case history. It is also necessary to take into account the presence of contra-indications, and only after analysis of all the data one should decide the question about the kind and volume of the operation, taking into account woman's age, presence of children, desire to have children later or on the contrary, contra-indications to pregnancy according to the health state. Operation has not only to remove the cause of the disease, but also to preserve functions of woman's organism — menstrual, sexual and reproductive. "The final aim of any operation is neither the destruction of the sore organ or its removal, but the renewing of the integrity and all its functions", — wrote A.P. Gubarev.

Extraordinary important is the correct diagnostics. It is necessary to use all possibilities of the clinic or any other gynecological permanent establishment in order to reveal diseases of genitals or concomitant diseases, that can be contra­indications for narcosis or operation itself, to prepare a woman properly for the operation and to avoid annoying unexpectedness during surgical intervention, which sometimes make a surgeon change in advance determined plan and operation volume. Establishing, that there are absolutely no contra-indications to surgical treatment of this patient, a surgeon must choose the most appropriate operation method namely for this patient.

Taking into account mentality peculiarities of the patient, that is being pre­pared for operation, and her protection from traumatizing and stress is the first and foremost task of all the surgical gynecological department staff. Insufficient tact in attitude to patient, indifference can make worse the results of the perfectly executed in technical plan operation. One should remember, that it is very hard for a patient

to dispose herself to necessity of surgical intervention psychologically, and even women with strong nervous system are afraid of the operation. That's why the behaviour of a doctor and everybody, who communicates with the patient has to be positive, mood must be optimistic. The patient must not have doubts about the necessity of the operation and its positive effect on her health. Patients, which are hospitalized in planned order, should be accommodated in one ward with those, who recover after operation and on the contrary, they must be isolated from the recently operated patients. Comfortable atmosphere in department, attentive attitude of medical staff, clearness of prescriptions execution create favourable psychological climate and facilitate anxious time of operation waiting.

However, it is impossible to take into account only psychotherapeutic effect of a word, it is necessary to conduct medicinal therapy, to provide full value daily and especially night rest. With this aim Novopassit, Valerian drops, Sedu­xen, Sibazon, Relanium, Trancsen during the day and especially before going to bed are recommended.


The operational unit of gynecological clinic consists of such parts: pre­operative room, rooms for patient preparation, material room, operating-room.

Preoperative room. In this room the surgeon and his assistants wash the hands, dress in operation clothes, aprons, masks. The operation brigade is ready to dress sterile surgical coats and to begin the operation.

^ Room for preparation of patient for surgery. It is recommended to prepare a patient for operation in room, that is situated near the operating-room. It deprives the patients of negative emotions from the contemplation of the operating room.

A material room is set for keeping of operation linen, gauze, cotton wool, instruments. This room is to be isolated from the other rooms. Materials into operating-room are given through special window.

Operating-room. There must be at least two operating rooms in surgical gynecological department: "clean" and "purulent", because in practice occurs that aid to both non-infected and infected patients should be given.

"Clean" operating room has to be larger, 1-2 surgical tables can be situated in it. In "purulent" operating room not only patients with the fixed diagnosis of purulent process in genital organs are operated, but also those that subject to surgical intervention for emergent indications, because a pus presence can be diagnosed in insufficiently examinated patients during the operation. Then operating-room should be carefully cleaned up and disinfected.

Demands on cleaning:

  • Operating-room, preoperative and material rooms are situated in the zone of sterile health regimen. A zone of sterile regimen needs keeping special demands previous cleaning is dusting the furniture, devices and floor bel beginning of each workday

  • current cleaning (keeping of cleantiness and order in the operatinj — during the operations the gauze balls, serviettes, instruments, th dentally have fallen down on the floor are cleared away; if a liquid the floor, it must be wiped off immediately

  • postoperative cleaning — during intervals between operations

  • finishing cleaning — at the end of the workday: floor washing, humid out walls, window-sills, furniture with disinfectants use. Cleaning i irrespective of the fact, whether there were operations in present day,

  • general cleaning (disinfection of the operational unit) is made once i

After cleaning the operating-room is decontaminated by means of lamp for an hour.

Sufficient illumination is of particular importance. It is necessary member, that abdominal operations on internal genital organs are made in the pelvis cavity that's why the illumination by means of operating s lamp is high-effective. During vaginal operations it is better to use the so gynecological lamps, that in addition to daylight allow to focus the I horizontal direction and to enlighten the operative field well.

Temperature in operating-room is to be kept within 20-25°C. Sui ventilation or air-conditioning are also necessary.


The main kind of sterilization is thermal decontamination. Large m of microorganisms can exist only in certain thermal conditions, and vcrj top temperature for majority of vegetating microbes is 50°C. The spores, pre by heat-resistant membrane, can endure a higher temperature. Highly sei microorganisms (non-spore-forming bacteria, viruses, fungi) perish temperature of 100°C for 2 minutes, at temperature 121-132°C (steam pressure) — for 1 min, in case of action of dry heat (temperature is 160-1 — for 1-3 min. Light-resistant flora (hepatitis virus, pathogene of gas-gaiij perish accordingly in 5, 1-2, 1-4 minutes. Clostridia, Anthrax bacillus pei 10 min. at boiling, in case of action of higher temperature — in 1-4 min. A resistant spore-forming flora (Clostridium tetani, CI. botulini) perish in 30 minutes at boiling, at steam under pressure action — in 12-25 minutes, at i of dry heat — 30-60 min.

Burning. In the flume of binning alcohol (600°C) all the microorganisms that are situated on the smooth face of scalpels, scissors, trays etc are perished. However, to reach decontaminating of other metallic instruments, especially of complicated form, it is required to warm them to the temperature of red heat, after which the material becomes fragile and is unfit for use. Also high temperature is reached only on flame surface, and the instruments, submerged into alcohol, under flame are not warmed to the necessary for sterilization temperature, that's why this method is inexpedient for use in permanent establishment. It can be used only in the case of the extreme situations, when there exists a threat to patient's life, and other methods of sterilization are not accessible.

^ Sterilization by dry heat. Apparatus for dry heat sterilization are used for decontaminating of laboratory glassware — Petri dishes, retorts, test-tubes, metal instruments — mirrors, spatulas, curettes, dressing forceps, metallic catheters etc. Sterilization is held at the temperature 180-200°C. A sterilization process continues for 2 hours, from which about an hour is necessary for warming-up the device to 180°C, 40 minutes — on sterilization itself, 20 minutes on cooling the

temperature to 80-90°C.

The disadvantage of this method is a long duration of working cycle, suit­ability only for decontaminating of heat-resistant materials.

Boiling. It is used for sterilization of surgical instruments. Sterilizer is filled with distilled water, 2 g of Sodium hydrocarbonate per each 100 ml of water is added. Boiling continues for 30 minutes. For contemporary conditions this method is used rarely, but in some situations it is necessary.

Sterilization by steam underpressure. The method of using the raised steam pressure allows to get higher temperature, at which microorganisms' spores perish. At pressure of 1 atmosphere the temperature reaches 120°C, sterilization time is 45 minutes; pressure in 2 atmospheres provides a steam temperature 133°C, sterilization time is 20 minutes.

In steam sterilizers the so-called autoclaves bandaging material, surgical garb, serviettes, instruments are sterilized. Sterilization is carried out in sterilizer box and then the material is putted into autoclave. Into the sterilizer box a sterility indicator is putted also, that allows to check, whether there was reached the temperature, necessary for decontaminating. The holes in sterilizer box have to be opened. During sterilization process the staff controls pressure and temperature in device. After finishing the sterilization time autoclave is turned off. When the pressure falls down to atmospheric, drums are taken out from device and the holes at once for preventing steam condensate on the material are closed. Sterilization in autoclaves needs complicated apparatus, that's why it is carried out in special rooms. This method for contemporary conditions is effective and basic in surgical permanent establishments.

Autoclaves, like any other device working under pressure, are potential source of danger because of explosion possibility. Aspecially trained staff is allowed to work with autoclaves.

Laparoscopy and hysteroscopy instruments with optical parts have separate rules of sterilization.

^ A sterilization control is carried out by means of bacteriological, technical and thermal methods.

Bacteriological method is the most exact, but it has only retrospective value, because results can be received only in 1-2 days.

Technical methods. Control of pressure-gauges and thermometers indexes in the autoclave take place during sterilization.

Thermal control is based on the ability of some substances to discolour or to fuse under the action of the temperature. Mikulich test is very old but still rather widespread. They write the word "Sterile" on a peace of paper, smear it with 10% starch solution. When the starch gets dry, they smear it over with Lugol's iodine solution. A paper becomes dark, the word "Sterile" becomes invi­sible. At temperature 100°C a compound of starch and Lugol's iodine solution are ruined and inscription becomes visible. This test for contemporary conditions is unconvincing, because a considerably higher temperature in the autoclaves is used.

Tests with powdery substances have higher effectiveness. At the fixed tem­perature they fuse and transform into compact mass. Most frequently the following substances are used: sulfur (melting temperature 111-120°C), antipyrine— 113°C, resorcin — 110-119°C, benzoic acid— 121°C, urea — 132°C, phenacetin — 134- 135°C. For control of dry heat sterilization thiourea — melting temperature 111-120°C, siccine acid — 180-184°C, ascorbic acid— 187-192°C are used.

A very comfortable method is using of coloured ribbons, that change their colour depending on the temperature.

If temperature-indicator does not discolour after finishing the sterilization time, material is considered to be nonsterile and nonsuitable for use.


  1. Metal instruments, glassware are sterilized by boiling in distilled water during 30 min; in 15% Sodium hydrocarbonate solution in distilled water during 15 min or in air sterilizers at temperature 120° during 45 minutes.

  2. The wares from polymeric materials are sterilized by immersion into disinfectant with the following washing in water. Disinfectants and their action time are the following:

  • Chloramine B 0,25% — 30 min

  • Chlorhexidine gluconate 1 % — 30 min

  • Sulfochlorantinc 0,2% — 30 min

  • Desoxone (13%) – 30 min

  1. The workplace surfaces are processed by means of double wiping with disinfectant with 15-min interval of spraying – action time is 60 min.

Disinfectants: Chloramine B 0,75% with 0,5% Solution of detergent, Chlorhexidine gluconate 1 %, Sulfochlorantine 0,2%.

  1. Rubber wares (ice pack, rubber tubes of different devices) are processed by double wiping with disinfectant with 15-min interval and the following washing in water. Disinfectants: Chloramine B 1 %, Hydrogen peroxide 3%, Chlorhexidine gluconate 1%, Sulfochlorantine 0,2%.

  2. Sounds, rubber catheters are sterilized by boiling in distilled water during 30 min, in 15% Sodium hydrocarbonate solution in distilled water during 15 min, or by means of autoclaving — saturated steam under pressure at temperature 110°C.

  3. Stethophonendoscopes, tape-line are wiped twice by Chloramine B 0,5% or Chlorhexidine 1% with 15-min interval.

  4. They immerse thermometers immerse into solution of Chloramine B 0,5% for 30 min; Hydrogen peroxide 3% for 30 min; Chlorhexidine gluconate 0,5% for 30 min; Sulfochlorantine 0,2% for 30 min.

  5. Oil-clothes — aprons, sacks, mattresses are wiped with by Chloramine B 1% solution, Chlorhexidine gluconate 1%; Sulfochlorantine 0,2%.

  6. Bed oil-cloth are immersed into Chloramine B 1% solution for 30 min; Chlorhexidine gluconate 1% for 60 min; Sulfochlorantine 0,2% for 30 min, Sodium hypocloride 0,25% for 15 min.


During preparation of the patient for the planned surgery a careful clinical-laboratory examination including clinical blood test, biochemical blood test, analysis of blood on syphilis and AIDS, determination of blood type and rhesus-factor, analysis of hemostasis system, general urine analysis, investigation of vaginal microflora, smears from external surface of cervix and its canal on atypical cells, ECG, X-ray examination of chest are made.

Patient is examined by stomatologist (if it is necessary he sanifies the oral cavity), by therapeutist, anesthetist. For indications the patient is consulted by oculist, neuropathologist, at presence of varicose veins or thrombophlebitis — by vascular surgeon. In case of finding of deviations from norm, correction is made — treatment of anaemia, sanitation of vagina. For patients with malignant tumors concerning the additional methods of examination the X-ray examination of stomach and bowels, proctosigmoidoscopy and chromocystography, in case of infertility, endometriosis, uterine corpus tumors — hysterosalpingography or contrasting sonography are carried out. Inoculation of vaginal discharge for research of microflora and its sensitiveness to antibiotics is made.

Especially importuni is the preparation of the aged patients for operation, i with cardiac-vascular pathology, with malignant tumors. Suitable preparatioi prescribing of vasodilators, hypotensive, diuretic agents, cardiac glycoside; cocarboxylase, vitamins allows to prevent complications on the part of cardial vascular system and provides a favorable duration of operative and postoperali v period.

On the day before operation a woman does not take shower, she may onl drink a glass of sweet tea, in the morning — no breakfast, she is made a clcansinj, shaving a hair from pubis and external genitals, giving a purgative enema, mak in hygienic douche. Just before the operation the woman empties urinary bladder, permanent catheter for the operation time is inserted.

Patients' preparation to vaginal operations, or to operations with acccs through anterior abdominal wall (hysterectomy) has some peculiarities. Previous! for such patients sanitation of vagina to reaching the 1st degree of vaginal eontei is made: syringing of vagina with antiseptic solutions, introduction of tampon with medical emulsions. In operation day vagina is processed with alcohol and sterile tampon is introduced. In case of presence of decubital ulcers on the eervi in patients with uterine prolapse it is necessary to reach their healing. Absenc of infection in vagina considerably decreases the risk of postoperative purulent inflammatory complications development.

In the evening before the operation the patient is given sleeping-dnij^ (Phenobarbital0,l-0,2g, Nitrazepam 0,005-0,01g,Noxyron — 0,25-0,5 g), trail quilizers (Seduxen — 0,0lg, Nozepam — 0,0lg, Elenium — 0,005g). For p;i tients with excitable nervous system tranquilizers are prescribed repeatedly hours before the operation.

For 30-40 min before operation premedication is made: Atropine or Methii cin — 0,5-0,8 mg, narcotic analgesics (Promedol — 20 mg, Fentanyl — 0,1 mj Talamonal — 2 ml), antihistamines (Dimedrol — 0,02 g) are used for this.

Preparation of the patient for urgent surgery in majority of cases is greatl limited in time (sometimes up to several minutes). If circumstances allow, emp tying of bowels by means of purgative enema (in case of bleeding enema i contra-indicated) is carried out. Before the operation, that is performed undo endotracheal anesthesia, if the patient had meals not long before, it is neeessar to make gastric lavage or aspiration of gastric contents with aim of Mendclson' syndrome prophylaxy (regurgitation can happen during the operation and acr stomach contents can get into trachea and lungs). If it is necessary hair on ptibi is shaved. If possible, the patient takes a shower. Obligatorily emptying of'urinur bladder or introduction of permanent catheter is carried out.

Premedication is made immediately in operating-room, mentioned ubov medications are introduced intravenously.

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