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^ Other endoscopic operations and manipulations

Drainage of small pelvis. Indications: acute inflammatory process small pelvis, pelvioperitonitis. During operations organs of small pelvi examined and drainages-microirrigators (polyethylene, rubber tubes, with meter from 2 to 7 mm) are introduced. After introduction, microirrigator is to skin of anterior abdominal wall by silk ligature, once or twice a day medic usually antibiotics are introduced through it. Every time after introductioi sterile bandage is putted.

Ovarian biopsy. Indications: infertility as a result of functional ovi insufficienty, scleropolycystic changes in ovaries, suspicion on malignant tin of ovaries. The ovary is put into the field of vision by manipulator, by bi< forceps its tissue is clenched, separated and taken out. Elcctroeoagulalio biopsy place is held. Taken, material is fixed in the formalin solution and sen the histological research.

Ovariectomy. Indications for the operation arc polycystic ovaries, suspu on malignant neoplasm. Ligature in the form of the loop is lead to the ovary ovary is stretch through it, the loop is tighten. Ovarian ligaments are ligated. Ovary is removed from abdominal cavity.

Removal of myomatous nodes. The operation is recommended at presence of small subserous myomatous nodes. The nodes on thin pedicle are clenched by manipulator, a pedicle is cut and coagulated

^ During pelvioscopy one should made dissection of adhesions, check uterine tubes permeability; during hysteroscopy—polyps and knots of: myomatous nodes are removed, adhesions in uterine cavity are intrauterine contraceptives are taking away, electrocoagulation of ducts are performed.


HYSTEROSCOPY

Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy).

Method

A hysteroscope is an endoscope that carries optical and light channels or fibers. It is introduced in a sheath that provides an inflow and outflow channel for insufflation of the uterine cavity. In addition, an operative channel may be present to introduce scissors, graspers or biopsy instruments. A hysteroscopic resectoscope is similar to a transurethral resectoscope and allows entry of an electric loop to shave off tisse, for instance to eliminate a fibroid. A contact hysteroscope is a hysteroscope that does not use distention media.

^ Insufflation media

The uterine cavity is a potential cavity and needs to be distended to allow for inspection. Thus during hysteroscopy either fluids or CO2 gas is introduced to expand the cavity. The choice is dependent on the procedure, the patient’s condition, and the physician's preference. Fluids can be used for both diagnostic and operative procedures. However, CO2 gas does not allow the clearing of blood and endometrial debris during the procedure, which could make the imaging visualization difficult. Gas embolism may also arise as a complication. Since the success of the procedure is totally depending on the quality of the high-resolution video images in front of surgeon's eyes, CO2 gas is not commonly used as the distention medium.

Electrolytic solutions include normal saline and lactated Ringer’s solution. Current recommendation is to use the electrolytic fluids in diagnostic cases, and in operative cases in which mechanical, laser, or bipolar energy is used. Since they are conducting electricity, these fluids should not be used with monopolar electrosurgical devices. Non-electrolytic fluids eliminate problems with electrical conductivity, but can increase the risk of hyponatremia. These solutions include glucose, glycine, dextran (Hyskon), mannitol, sorbitol and a mannitol/sorbital mixture (Purisol). Water was once used routinely, however, problems with water intoxication and hemolysis discontinued its use by 1990. Each of these distention fluids is associated with unique physiological changes that should be considered when selecting a distention fluid. Glucose is contraindicated in patients with glucose intolerance. Sorbitol metabolizes to fructose in the liver and is contraindicated if a patient has fructose malabsorption. High-viscous Dextran also has potential complications which can be physiological and mechanical. It may crystallize on instruments and obstruct the valves and channels. Coagulation abnormalities and adult respiratory distress syndrome (ARDS) have been reported. Glycine metabolizes into ammonia and can cross the blood brain barrier, causing agitation, vomiting and coma. Mannitol 5% should be used instead of glycine or sorbitol when using monopolar electrosurgical devices. Mannitol 5% has a diuretic effect and can also cause hypotension and circulatory collapse. The mannitol/sorbitol mixture (Purisol) should be avoided in patients with fructose malabsorption.

Procedure

Hysteroscopy has been done in the hospital, surigal centers and the office. It is best done when the endometrium is relatively thin, that is after a menstruation. Typically hysteroscopic intervention is done under general endotracheal anesthesia or Monitored Anesthesia Care (MAC), but a short diagnostic procedure can be performed with just a paracervical block using the Lidocaine injection in the upper part of the cervix. The patient is in a lithotomy position.

After cervical dilation, the hysteroscope with its sheath is guided into the uterine cavity, the cavity insufflated, and an inspection is performed. If abnormalities are found, an operative hysteroscope with a channel to allow specialized instruments to enter the cavity is used to perform the surgery. Typical procedures include endometrial ablation, submucosal fibroid resection, and endometrial polypectomy. Hysteroscopy has also been used to apply the Nd:YAG laser treatment to the inside of the uterus.

When fluids are used to distend the cavity, care should be taken to record its use (inflow and outflow) to prevent fluid overload and intoxication of the patient.

Indications

Hysteroscopy is useful in a number of uterine conditions:

  • Asherman's syndrome (i.e. intrauterine adhesions). Hysteroscopic adhesiolysis is the technique of lysing adhesions in the uterus using either microscissors (recommended) or thermal energy modalities. Hysteroscopy can be used in conjunction with laparascopy or other methods to reduce the risk of perforation during the procedure.

  • Endometrial polyp. Polypectomy.

  • Gynecologic bleeding

  • Endometrial ablation (Some newer systems specifically developed for endometrial ablation such as the Novasure do not require hysteroscopy)

  • Myomectomy for uterine fibroids.

  • Congenital Uterine malformations (also known as Mullerian malformations). Eg.septum,

  • Evacuation of retained products of conception in selected cases.

  • Removal of embedded IUDs.

The use of hysteroscopy in endometrial cancer is not established as there is concern that cancer cells could be spread into the peritoneal cavity.

Hysteroscopy has the benefit of allowing direct visualization of the uterus, thereby avoiding or reducing iatrogenic trauma to delicate reproductive tissue which may result in Asherman's syndrome.

Hysteroscopy allows access to the utero-tubal junction for entry into the fallopian tube; this is useful for tubal occlusion procedures for sterilization and for falloposcopy.

Complications

A possible problem is uterine perforation when either the hysteroscope itself or one of its operative instruments breaches the wall of the uterus. This can lead to bleeding and damage to other organs. If other organs such as bowel are injured during a perforation, the resulting peritonitis can be fatal. Furthermore, cervical laceration, intrauterine infection (especially in prolonged procedures), electrical and laser injuries, and complications caused by the distention media can be encountered. The use of insufflation media can lead to serious and even fatal complications due to embolism or fluid overload with electrolyte imbalances.

The overall complication rate for diagnostic and operative hysteroscopy is 2% with serious complications occurring in less than 1% of cases.


^ ABDOMINAL GYNECOLOGICAL OPERATIONS

For performing of abdominal gynecological operations most frequently lower midline laparotomy and incision by Pfannenshtiel are used.

Midline vertical laparotomy

Midline vertical laparotomy provides a sufficient access to organs of small pelvis, gives a possibility to have a view of other organs of abdominal cavity by widening the dissection up, one can carry out the revision of all the organs of abdominal cavity and to conduct necessary interventions. That's why this access is used when during operation there are foreseen technical difficulties (in case of peritonitis, internal bleeding, big tumors etc).

Technique. Along the middle abdominal line (linea alba) the skin and hypodermic fat is dissected with scalpel from pubis towards umbilicus. An incision size depends on the volume of surgical intervention, in case of tumor removal — from its size. The aponeurosis is dissected. At first a small cut with scalpel is made, then it continues with scissors. The muscles are disconnected. The peritoneum is grasped with two anatomic pincers and is cutted between them with scalpel, then incision is continued up and down with scissors. While continuing the incision towards pubic tubercle, one must be careful for preventing damaging of urinary bladder. To prevent it, only area, that is translucent, under the sight control is dissected.

Stitches on abdominal wall layer-by-layer in reverse order are putted.


^ Laparotomy by Pfannenshtiel

Advantages of this kind of incision is absence of cosmetic defect, especially in case of stitching with subcuticular (cosmetic) suture, better healing of the wound, there never happen such complications as eventration because wound layers are dissected in different directions.

Skin and subcutaneous fat are cut along the suprapubic fold on distance 2-3 cm from pubic symphysis. In inguinal regions from both sides of incision there pass the superficial epigastric arteries, damaging of which should be avoided, and if they dissect them, it is necessary ligate them immediately. Aponeurosis is cutted slightly with scalpel from both sides from the white line, then the incision is continued with scissors into both sides of wound. The upper edge of aponeurosis in the wound center is clenched with Kocher's forceps and pulling it up they snip it off with scissors from the white-line towards umbilicus, as far as skin dissection allows. Muscles of anterior abdominal wall are not dissected, they are separated in longitudinal direction, as it midline vertical laparotomy. Peritoneum is clenched with two pincers rutted in longitudinal direction at first with scalpel, and then with scissors. Taking into consideration the indisputable advantages of this approach, necessary to note, that in ease of Pfannenshtiel incision appearing of subfasi haematoma, difficult access to organs of small pelvis are observed frequently during the operation some problems such as the necessity of abdominal ca\ revision, big size of the tumor are appeared, it is impossible to extent of I incision.


Salpingo-oophorectomy

Salpingectomy is carried out in case of ectopic pregnancy, purulent proces; in the tube. Adnexa are removed in case of ovarian tumors, because the li belongs to the structure of its surgical pedicle. In case of tuboovarian tumors, the result of inflammatory process ovary and tube adhere between themself. li technically impossible to remove only the tube or only the ovary in this cai Basic indications to oophorectomy are its tumors.

Ovarian tumors have the so-called "pedicle". Ovarian and infundibulopi vicum ligaments, part of broad uterine ligament, vessels and nerves, that pass them belong to the structure of anatomic pedicle. Uterine tube also belongs the structure of surgical pedicle of the tumor.

In case of complication in the form of tumor pedicle torsion, vessels, th belong to structure of surgical pedicle are pinched, blood supply is disturbe that's why cystoma's capsule swells are infiltrates with blood. Tumor acquires purple colour, enlarges in size. Peculiarity of surgical intervention in case < cystoma's crus torsion is that forceps should be applied beneath the torsion plac to prevent getting into woman's blood toxic products and thromboplasl substances, that have appeared in cystoma after its blood supply disturbance, is forbidden to untwist the pedicle in no circumstances!

Stages of the operation:

  • disinfecting of skin

  • midline vertical or transverse incision of anterior abdominal wall

  • introduction of retractor and separation of intestinal bowels

  • grasping with hand and exteriorization out of uterine tube

  • application of Kocher's forceps on mesentery of uterine tube and its utcrin end (at adnexectomy forceps are applied on infundibulopclvicum ligameni uterine end of the tube and ovarian ligament,

  • removal of uterine lube (adnexa), suturing and tubal ligation

  • peritonization of the slump

  • lavage of abdominal cavity

  • report of operating nurse about the presence of all the instruments and serviettes

  • suturing of abdominal wound

  • catheterization of urinary bladder


EXAMPLE OF THE OPERATIVE NOTES in removal of uterine adnexa (adnexectomy) at ovarian tumor on pedicle

Indications for the operation: ovarian cystoma.

Anesthetization: endotracheal anesthesia with Nitrous oxide and Oxygen mixture, and neuroleptanalgesia.

  • Operation passing. The operative field has been processed with 2% iodine spirit solution and by 70% ethyl alcohol, edged by sterile surgical garb. Anterior abdominal is incised layer-by-layer by midline vertical incision. Before cutting the peritoneum, the wound is edged by sterile serviettes and isolated from hypo­dermic fat. Bowels are separated by serviettes.

  • During examination of small pelvis ovarian tumor 20x 15 cm in size was found, Tumor is exteriorized into the wound. It was determined, that the tumor takes ib origin from the right ovary, has a long pediclewhich contains ovarian, infundibulo pelvicum ligaments, uterine tube. The uterus and left adnexa are not changed Kocher's forceps are put on the tumor pedicle. The tumor and uterine tube an cutted off. Catgut suture is laid on the stump. Peritonization by round ligament oi uterus is made.

  • Lavage of abdominal cavity is conducted. Calculation of serviettes anc instruments is made. All are presented.

  • The incisional wound of anterior abdominal wall is sutured layer-by-layer peritoneum, muscles, aponeurosis — by continuous vicryl suture, skin anc hypodermic fat — by interrupted silk suture.

  • Asepsis bandage is dressed.

  • There was no bleeding during the operation.

  • Operation duration — 40 min.

  • Name of the performed operation: right-side adnexectomy.

  • Macropreparation: removed tumor is a pseudomucinous polycystic cystomi with tubercular surface and thick viscous yellow content, 20x 15 cm in size. Inter nal envelope of the tumor is smooth. The capsule is sent on histological research

  • Postoperative diagnosis — pseudomucinous cystoma of the right ovary.



Ovarian resection (ovariotomy)

The operation is performed in case of scleropolycystic ovarian syndrom t< normalize menstrual function and renewing of the reproductive ones. Stages of the operation:

  • disinfecting of skin

  • midline vertical or transverse incision of anterior abdominal wall

  • introduction of retractor and examination of genital organs

  • separation of intestinal bowels

  • ovarian fixation by fenestrated forceps

  • cutting off pathologically altered ovarian tissue by scalpel

  • putting of interrupted suture on ovary (an operating nurse gives suture needl and catgut)

  • lavage of abdominal cavity



EXAMPLE OF THE OPERATIVE NOTES in the wedge-shaped ovarian resection

Indications for the operation: scleropolycystic ovarian syndrom, primary infertility.

Anesthetization: endotracheal anesthesia with Nitrous oxide and Oxygen mixture, and neuroleptanalgesia.

^ Operation passing. An operative field has been processed by 2% Iodine spirit solution and by 70% Ethyl alcohol, edged by sterile surgical garb.

Laparotomy by Pfannenshtiel. Before opening peritoneal cavity, the wound is edged by sterile serviettes and isolated from hypodermic fat. Bowels have been separated by serviettes.

Findings during the examination of small pelvis are the following: uterus is not altered, normally developed, occupies central position in the cavity of small pelvis. Both ovaries are whitish in colour, their dimension exceeds normal considerably, surface is smooth. Both uterine tubes are without pathological changes.

Both ovaries aren exteriorized out of abdominal cavity into the wound. About 2/3 of tissue from both ovaries are removed by wedge-shaped cut in hilus direction. Ovarian surfaces are jointed by interrupted catgut sutures. There was no bleeding.

Lavage of abdominal cavity has been conducted. Calculation of serviettes and instruments — all are present.

The incisional wound of anterior abdominal is sutured layer-by-layer: peritoneum and muscles — by continuous, aponeurosis — by interrupted catgut suture, skin and hypodermic fat — by interrupted cosmetic suture.

Asepsis bandage has been dressed.

There was no bleeding during the operation.

Operation duration is 20 min.

^ Name of the performed operation: wedge-shaped ovarian resection.

Postoperative diagnosis — scleropolycystic ovarian syndrome.


Tubal patency renewing operations

Salpingolysis, salpingostomy, implantation of uterine tube into the uterus refer to these operations.

Salpingolysis is the operation, in which lysis of uterine tube adhesions is performed. Adhesions create barriers on ovum migration way. During the examination of small pelvis organs the adhesions, are found. They are dissecting trying not to damage the peritoneum of the tube.

^ Implantation of the uterine tube into uterus is carried out in case ol occlusion of some of its part. In that case the occlured part of the tube is removed and passable one is transplanted into the uterus, previously creating the hole ii its wall.

It is necessary to note, that these operations are ineffective and rarel) renewing reproductive function.


Subtotal hysterectomy

The operation of subtotal hysterectomy is performed most frequently ii case of benign uterine tumors (fibromyoma).

Stages of the operation:

  • disinfecting of skin

  • midline vertical or transverse incision of anterior abdominal wall

  • introduction of retractor and examination of organs of small pelvis

  • separation of intestinal bowels

  • applying of globular forceps on the uterus and its exteriorization into the wound

application of forceps, dissecting, stitching and ligation of the round ligamen of uterus, ovarian ligament, uterine tubes (in case of removal of

the uterus with its adnexa, round ligaments and infundibulopelvicum ovarian ligaments) are cutting

  • dissecting of the vesico-uterine peritoneal fold and separating of urinary bladder down by swab

  • application of forceps, transection and ligation with stitching vascular fascicles from both sides

  • separating of uterine body from the cervix (a nurse gives to surgeon a tampon, moistened by solution of Betadine, for processing of cervical canal, after processing a tampon together with dressing forceps is thrown away)

  • suturing of cervical stump

  • lavage of abdominal cavity

  • report of operating nurse about presence of all instruments and serviettes

  • suturing of abdominal wound

  • catheterization of urinary bladder


EXAMPLE OF THE OPERATIVE NOTES in subtotal hysterectomy

Indications for the operation: uterine fibromyoma, its submucous form, menorrhagia.

Anesthetization: endotracheal anesthesia with Nitrous oxide and Oxygen mixture, and neuroleptanalgesia.

^ Operation passing. An operative field has been processed by 2% iodine spirit solution and by 70% ethyl alcohol, edged by sterile surgical garb. Anterior abdominal wall has been incised layer-by-layer, by midline vertical incision. Before cutting the peritoneum, a wound is edged by sterile serviettes, hypodermic fat is isolated.

The wound's edges are parted by retractor. The organs of abdominal cavity are separated by serviettes. The uterus is clenched by Museux's forceps and exteriorized out of abdominal cavity.

During the examination of organs of small pelvis it has been found that uterus is normal, 10x12 cm in dimensions, on its anterior wall myomatous node on wide pedicle is situated, other nodes in uterine wall are present. Adnexa are not altered.

Two forceps are applied on the right and left round uterine ligaments. Liga­ments between them are dissected, forceps are replaced by ligatures. Forceps are applied on ovarian ligament and uterine tube from both sides. The ligaments are cut, forceps are replaced by ligatures. Peritoneum in region of vesico-uterine fold are cut and exfoliated down together with urinary bladder. On the level of the interrnalled uterine os to the right uterine artery is clenched by forceps, cut ligatures are put. By analogy the same thing is made on the left side. Above the ligated vessels by wedge-shaped incision the uterus is separated from the cervix On the cervical stump catgut stitches are put. Peritonization by leaf of broad uterine ligament with continuous catgut suture is carried out.

Serviettes are removed from abdominal cavity. Lavage of abdominal cavity is conducted. Calculation of serviettes and instruments: all are present. The incision wound of anterior abdominal wall is sutured layer-by-layer: peritoneum and muscles — by continuous, aponeurosis — by interrupted catgui suture, skin and hypodermic fat — by interrupted silk suture. Asepsis bandage has been dressed. ' Bleeding during the operation — 200 ml. Operation duration — 1 hour 20 minutes.

^ Name of executed operation: subtotal hysterectomy without adnexa. Macropreparation: the uterus is tuberculosis, 10x12 cm in dimensions, on . its anterior wall there is situated the myomatous node on wide pedicle, multiple interstitial and two submucous nodes. Removed uterus is sent to the histological research.

^ Postoperative diagnosis — multiple uterine fibromyoma.

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