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Total hysterectomy

In case of total hysterectomy uterus together with the cervix is removed. This operation is performed in patients with uterine tumors in case of pathological changes in its cervix. The uterus is removed with or without its adnexa.

^ Stages of the operation:

  • disinfecting of vagina, introduction of a tampon, moistened with alcohol, into vagina

  • disinfecting of skin of anterior abdominal wall

  • 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 round ligament of uterus, ovarian ligament, uterine tubes, (in case of uterine removal with its adnexa round ligaments and infundibulopelvic ovarian ligaments are cutted)

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

  • application of forceps, dissection and ligation with stitching of vasculn fascicles from both sides

  • application of forceps, dissection and ligation with stitching of utcrinosacra ligaments

  • additional separating of urinary bladder

  • cutting and bandaging of vaginal branches of uterine vessels (an opera) in j nurse gives long Kocher's forceps)

  • separating of the uterus from vaginal vaults (at the moment o dissecting of vaginal cavity, an operating nurse gives the surgeon narrov gauze ribbon, 30 cm in length, moistened by 70% alcohol, whicli surgeoi introduces into vagina by means of long dressing forceps, which is throwi away just after use)

  • round suturing of the vaginal stump. All the instruments, that were used oi this stage of the operation, are thrown away immediately

  • peritonization

  • lavage of abdominal cavity

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

  • suturing of abdominal wound

  • leading out the urine by catheter

  • removing the tampon and processing of vagina


EXAMPLE OF THE OPERATIVE NOTES in total hysterectomy

Indications for the operation: fibromyoma, menorrhagia, cervical erosion. Anesthetization: endotracheal anesthesia with nitrous oxide and oxygen mixture, and neuroleptanalgesia.

Operation passing. The operative field is processed by 2% iodine spirit solution and by 70% ethyl alcohol and edged by sterile surgical garb. Anterior abdominal wall is incised in layers by midline vertical incision. Before cutting the peritoneum, the 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 examination of organs of small pelvis the following are found: uterus is irregular, 12x16 cm in dimensions, it is deformed by 2 myomatous nodes. Adnexa are not altered. On the right and left round uterine ligaments, ovarian ligaments and uterine tubes two forceps are applied. Ligaments between them and tubes are dissected, forceps are replaced by ligatures. Vesico-uterine peritoneal fold is cut and pulled down together with urinary bladder. Along the uterine edge forceps are applied on vessels bundles from both sides, after this they are dissected and ligated by vicryl. Forceps are applied on uterosacral ligaments, their dissection and ligation are made. Additionally urinary bladder is separated, forceps are applied on the cardinal uterine ligaments, they are dissected and ligated. Vaginal branch of the right uterine artery is clenched by forceps on the level of vaginal vault, then it is dissected and ligated. By analogy the same thing is made on the left side. A wall of anterior vaginal vault is fixed by Kocher's forceps, its cut is made. A tampon is removed from vagina. The wound edges and mucous membrane of vagina have been processed by 1% spirit iodine solution. The tampon is putted into vagina through the the vault. Cervix is exteriorized into the wound, uterus together with its cervix is separated from the vaults on the level of the top third of vagina. Edges of vagina wound are fixed by Kocher's forceps. Catgut stitches are put on the edges of vagina. Peritonization by leaf of broad uterine ligament with continuous catgut suture is carried out.

The serviettes arc removed from the abdominal cavity. Lavage of abd< cavity is conducted. Calculation of serviettes and instruments is done: present.

The incision wound of anterior abdominal wall is sutured in layers: neum and muscles — by continuous, aponeurosis — by interrupted catgut; skin and hypodermic fat — by interrupted silk suture.

Asepsis bandage is dressed. Bleeding during the operation is 200 ml ration duration is 1 hour 30 minutes.

^ Name of the performed operation: total hysterectomy without adnc

Macropreparation: the uterus is irregular, 12x16 cm in dimensions, med by 2 myomatous nodes. On the cervix there is erosion. Removed ut sent to histological research.

Postoperative diagnosis — Multiple uterine fibromyoma.


Conservative myomectomy

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

  • putting of traction suture on the uterus and its exteriorization into the \

  • incision of uterine wall under myomatous node, hemostasis

  • husking the node by scissors and swab, hemostasis

  • suturing the uterine wall (node's bed)

  • peritonization by continuous catgut suture

  • introduction of contractile agents into the uterus (operating nurse pr the syringe with Oxytocin, Methylergometrine in advance)

  • lavage of abdominal cavity

  • report of the operating nurse about the presence of all the instrumen serviettes

  • suturing of abdominal wound

  • catheterization of urinary bladder


^ EXAMPLE OF THE OPERATIVE NOTES

in conservative myomectomy

Indications for the operation: subserous fibromyoma. Anesthetization: endotracheal anesthesia.

Operation passing. The operative field is processed by 2% spirit Iodine solution and by 70% ethyl alcohol, edged by sterile surgical garb. Anterior abdominal wall is incised in layers, by middle vertical incision. After cutting the peritoneum, the wound is edged by sterile serviettes, hypodermic fat is isolated. During the examination of organs of small pelvis it is found: uterine dimen­sions are 10x12 cm, in the region of its fundus there is situated a myomatous node on the rather narrow pedicle. Adnexa are not altered.

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.

Incision of the serous membrane in node's region is performed. The node is exfoliated partially by sharp, partially by obtuse way. Careful hemostasis, suturing uterine wall by continuous serous-muscular vicryl suture is performed. The serviettes are removed from the abdominal cavity. Lavage of the abdominal cavity is performed. Calculation of serviettes and instruments — all are present. The incision wound of anterior abdominal wall is sutured in layers: peritoneum and muscles — by continuous, aponeurosis — by interrupted catgut suture, skin and hypodermic fat — by interrupted silk suture. Asepsis bandage is dressed. Bleeding during the operation — 300 ml. Operation duration — 50 minutes.

Name of the performed operation: conservative myomectomy. Macropreparation: myomatous node on the rather narrow pedicle. Removed material is sent for histological research.

Postoperative diagnosis — subserous uterine fibromyoma.


^ VAGINAL OPERATIONS

In gynecological practice some operations are performed through vagina. First of all these are the operations connected with descence and prolapse of genitals — the plastic operations and hysterectomy through vagina in case of its full prolapse, and also operations on the cervix on account of old ruptures, ectropion and other pathology of cervix, in case of which the conservative methods have no effect, and removing of the whole uterus is inexpedient.

Patient's position on the operation table during the performing of the vaginal operations is the same, as on gynecological chair: leg-holders are fastened to the table, a woman lay down on back with bent in hip and knee joints legs, legs arc fixed to the leg-holders.

The surgeon and the first assistant seat on the chairs, the second assi stands to the right from the patient. Processing of the operation field: at vagina is processed with tampon, moistened by 70% ethyl alcohol, then by < tampon with alcohol a pubic tubercle, labia major, perineum, lower part of a men, internal and back surface of thighs to their midst are processed.

^ Cone-shaped cervical amputation by Shturmdorf

The operation is performed in case of glandular-muscular hypertropl cervix, that develops in the result of the chronic cervicitis, at cervical elong in patients with descence and prolapse of uterus.

Stages of the operation: (fig. 189)i

  • disinfecting of external genitals and vagina

  • visualizing of the cervix in specula

  • fixation of anterior and posterior lip of the cervix by tenaculum

  • dilation of cervical canal by Hegar's dilators to N° 8

  • circular incision of cervical mucous membrane (by scalpel)

  • putting of two catgut stitches on the cervix for its fixation

  • cone-shaped amputation of the cervix, hemostasis;

  • basic catgut stitches are put on the cervix (catgut N° 6, threads length 25-30 cm)

  • additional catgut stitches are putting on the cervix (catgut N° 4)

  • processing the cervix by iodine and withdrawal of vaginal speculum

Wedge-shaped cervical amputation by Shreder

The operation is recommended in case of cervical deformation by old and its considerable hypertrophy, and also it is a kind of treatment of cervix cancer states.

Stages of the operation:

  • disinfecting of external genitals and vagina

  • visualizing of the cervix in specula

  • fixation of anterior and posterior lip of the cervix by two globular Ion

  • dilation of cervical canal by Hegar's dilators to JV» 10;

  • symmetric incision of the cervix by scissors on and left and right sid that cuts should not reach vaginal vaults;

  • wedge-shaped incision of anterior cervical lip and its forming;

  • wedge-shaped illusion ol posterior cervical lip and its forming;

  • putting in catgut stitches on the cervix for junction of its anterior and posterior lips;

  • processing of the cervix by iodine and withdrawal of vaginal speculum

The plasty of anterior vaginal wall (anterior colporrhaphy)

The operation is performed in case of descence or prolapse of uterus for renewing of anatomic and functional correlation of small pelvis organs. It is combined with the operation of perineal integrity renewing, (fig. 190, 191)

Stages of the operation:

  • disinfecting of external genitals and vagina

  • visualizing of the cervix in specula and its fixation by tenaculum

  • infiltration of tissues by 0,25% Novoeaine solution (for easing of tissues separation)

  • incision of anterior wall of the vagina and separating ends of vaginal fla| scalpel

  • separating of urinary bladder from the cervix (by scissors and swab)

  • putting of catgut stitches on urinary fascia (catgut N° 3-4)

  • putting of continuous catgut suture on vaginal wall

  • catheterization of urinary bladder

  • processing the suture by 1% iodine solution and withdrawal of instruments


The plasty of posterior vaginal wall and muscles of pelvic floor (colpoperineorrhaphy) Stages of the operation:

• disinfecting of external genitals and vagina

• application of Kocher s forceps on borders of the piece, that has to be
separated

  • infiltration of tissues by 0,25% Novocaine solution (for easing of tissues separation)

  • incision of vaginal wall and perineal skin, separating of flap' ends

  • dissecting of scars and fascia by scalpel in lateral corners of the wound and uncovering the levators

  • putting of catgut stitches on levators (operating nurse gives catgut N°6)

  • putting of continuous catgut suture on vaginal wall (catgut N°4)

  • tying the sutures on the levators

  • putting of sutures on superficial muscles (catgut N°3)

  • putting of silk sutures on perineal skin

  • processing of sutures by iodine solution


EXAMPLE OF THE OPERATIVE NOTES in prolapse of vaginal walls

Indications for the operation: prolapse of vagina walls.

Anesthetization: endotracheal anesthesia with Nitrous oxide and Oxygen mixture, and neuroleptanalgesia, additional infiltrative anesthesia by 0,25% Novo­caine solution.

Operation passing. In position of the patient for gynecological operation after processing the external genitals and inner surface of thighs by 2% Iodine spirit solution and by 70% Ethyl alcohol, operating field is edged by sterile surgical garb. Vagina is disclosed in specula, mucosa is processed by 1% Iodine spirit solution. The cervix is fixed by Museux's forceps, displaced forward and down

The Ist stage: Anterior colporrhaphy. Kocher's forceps arc applied on uterine wall and pulled up on distance 1.5 cm from external orifice of urethra. The cervix is pulled down. Because of tension during this in the anterior vaginalwall is formed a discoid flap, the sharpened end of which is turned up to extern orifice of urethra, sharpened base is situated near the transition fold of anterii vaginal wall mucosa. The flap is separated and removed. Urinary bladder separated. Catgut sutures are putted on its base. The edges of vaginal wound a: joined by the interrupted catgut sutures.

The 2nd stage. Colpoperineorrhaphy (On the borders of perine; skin and mucous membrane of vagina in the region of posterior commissure tw Kocher's forceps are applied. An incision is done between them. The edges ( vagina wall are clenched by forceps, stretched, a scar tissue between back wa of vagina and rectum is cutted by scissors. Paravaginal and pararectal tissue are separated by scissors up to the top of vagina. Three-angled flap is cut out from the separated posterior vaginal wall. On m. levator ani, aftc their mobilizing, two silk seams are putted. The edges of vaginal wound ar joined by interrupted catgut stitches; the edges of perineum skin — by interruptci silk suture.

Wound toilet. Asepsis bandage.

Blood loss during operation is 100 ml. Operation duration is 50 min.

Postoperative diagnosis: prolapse of vaginal walls, incomplete uterine pro lapse.

Name of performed operation: Anterior and posterior colporrhaphy wit! perineorrhaphy, or colpoperineorrhaphy.


^ MINOR GYNECOLOGICAL OPERATIONS


Cervical biopsy

Necessary instruments: Sim's speculum, tenaculum, scalpel (or concho-tome), needleholder, needle, catgut 3, dressing forceps, pincers. Stages of the operation:

  • disinfecting of external genitals and vagina

  • visualizing the cervix in specula and its fixation by tenaculum

  • cutting offby scalpel a part of pathologically changed tissue of the cervix on border of non-altered tissue

  • putting of sutures on the cervix (catgut N3)

  • processing of the cervix by iodine solution

  • material fixation, filling in the order and sending it into laboratory

Culdocentesis

Necessary instruments: Sim's speculum, tenaculum, long punction ncc syringe, dressing forceps, pincers. Stages of the operation:

  • disinfecting of external genitals and vagina

  • visualizing the cervix in specula and its fixation with tenaculum by posterior lip

  • executing of local anaesthesia

  • puncture of back vault of vagina by long needle and aspirating through it the content of abdominal cavity

  • withdrawal the needle, processing the place of puncture by Iodine, taking off the tenaculum, removing of speculum

Uterine sounding

Necessary instruments: Sim's speculum, tenaculum, uterine sound, dress forceps, pincers

Stages:

  • disinfecting genitals and vagina

  • visualizing the cervix in speculum and its fixation with tenaculum

  • introduction of uterine sound into the uterus and examination of its cavity

  • pulling the sound out of uterine cavity

  • processing the cervix by iodine, removing instruments



Dilation and curettage (D&C)


Necessary instruments: Sim's speculum, tenaculum, uterine sound, Hegar's dilators, curettes N 1,2,4, dressing forceps, pincers

Stages of the operation:

• disinfecting of external genitals and vagina;

• visualizing the cervix in specula and its fixation with tenaculum
by anterior lip

• abrasion of mucous membrane of cervical canal with small curette

  • sounding the uterine cavity

  • dilation the cervical canal by Hegar's dilators (if necessary)

  • abrasion of mucous membrane from the uterine cavity

  • taking the tenaculum away, processing of the cervix by iodine, removing of instruments

  • separately material fixation from cervical canal and uterine cavity, filling in the order and sending it into the laboratory



5.3. Control questions

  1. Determination of hysteroscopy.

  2. Preparation and realization of гістероскопічних operations, conduct, complication.

  3. Determination of laparoscopy.

  4. Preparation and realization of operations, post-surgery conduct, complication, prophylaxis.

  5. Methods of operative treatment of gynaecological pathology.

  6. Rehabilitation of patients which carried operations.

  7. Prophylaxis of complications.


^ 5.4. Final stage

Current activity of every student is estimated during employment, eventual control is standardized, the analysis of success of students is conducted, the estimation of activity of every student is declared and proposed in the magazine of account of visits and success of students. Students are shortly informed of theme of next class.


Control questions:

  1. What are laparoscopy and hysteroscopy?

  2. What shows and протипокази to the endoscopic operations?

  3. What terms of implementation of laparoscopy and hysteroscopy?

  4. What technique of execution of laparoscopy and hysteroscopy?

  5. What tool is used for realization of laparoscopy and hysteroscopy?

  6. What inspection must be executed before realization endoscope




  1. What indications and contra-indications to the endoscopic operations?

  2. What terms of implementation of laparoscopy and hysteroscopy?

  3. What technique of execution of laparoscopy and hysteroscopy?

  4. What tool is used for realization of laparoscopy and hysteroscopy?

  5. What inspection must be executed before realization of endoscopic operations?

  6. What possible complications during realization and after endoscopic operations?

  7. What operations are executed on muliebrias?

  8. What technique of execution of gynaecological operations?




  1. What possible complications during realization and after endoscopic operations?

  2. What operations are executed on muliebrias?

  3. What technique of execution of gynaecological operations?



7. Recommended literature

Basic:

  1. Запорожан В.М. Obstetrics and gynaecology / of В.М.Запорожан - К: "Health", 2000. - С. 172-177.

  2. Айламазян Е.К. Obstetrics: Учебник for медицинских вузов / of Е.К.Айламазян is С-Петербург, 2007 - 528 С.


Additional

  1. Хміль С.В., Kuchma З.М., Романчук Л. І. Gynaecology. Ternopil, 1999, 538с.

  2. A practical manual of Laparoscopy And minimally invasive Gynecology: A clinical cookbook Second edition Resad p. Pasic, Ronald l. Levine. – Informa Healthcare. – 2009. – 455 p.


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