SUR 104 unit 3
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fertility medicine combines what to achieve and maintain pregnancy?
gynecology and endocrinology
size and shape of uterus
3 inches long and 2 inches deep
what does uterus do?
houses and protects the fetus during pregnancy
what is uterus composed of?
- thick muscular tissue
- suspended by ligaments that completely enclose the organ
superior portion of the uterus
middle portion of uterus
lower portion of uterus
lines the uterus and changes under hormonal influence and with pregnancy
thick muscular layer that is continuous with the muscles of the vagina and fallopian tubes
outer serous layer of the uterus
which uterine layer contracts during childbirth and menses?
pouch formed by reflection of abdominal peritoneum over bladder
fold of peritoneum over bladder
ligaments that suspend uterus from pelvic wall
ligaments that lie above the broad ligaments near the fallopian tubes that help suspend uterus anteriorly
ligaments that lie below broad ligaments and provide primary support for uterus
ligaments that curve along bottom of the uterus and attach it to the sacrum
how many sections do fallopian tubes have?
section of fallopian tubes that connects to the uterus
midportion section of fallopian tubes
widened portion of fallopian tube
terminal end of fallopian tube
small projections that extend from the end of fallopian tube that direct ovum toward infundibulum during ovulation
ligament that suspends fallopian tube from upper margin of pelvis
secrete female hormones
peritoneal tissue that suspends ovaries - attached to uterus by ovarian ligaments
how many eggs do ovaries contain?
approximately 1 million
fibrous outer layer of ovary - contains follicles that hold ova
inner core of ovary composed of connective and vascular tissue
development and release of ova are influenced by what?
what hormones does pituitary gland stimulate?
LH and FSH
recessed areas around cervix
incision of the perineum during the second stage of labor to prevent tearing
hormonal and physical changes that occur regularly from the onset of menarche until menopause
what is ovarian cycle controlled by?
complex feedback system involving hormones of pituitary, hypothalamus, and ovaries
phases of ovarian cycle
- follicular phase
- ovulatory phase
- luteal phase
- this phase lasts from day 1 to day 14
- levels of FSH and LH rise
- begins approximately 14 days from start of cycle and lasts from 16 to 32 hours
- estrogen level falls
- progesterone is secreted by follicle and causes by release of ovum
- begins approximately on day 16 and lasts approximately 12 days
- corpus luteum secretes estrogen and progesterone, which changes endometrium
- FSH and LH levels fall, CL regresses and endometrial lining shed
medical assessment for procedures is derived from?
- menstrual history
- obstetrical history
- use of contraceptives
- history of previous infection
- signs and symptoms
- current medications and allergies
- family history
- social history
excessive bleeding during menstruation
most common type of vulvar cancer
squamous cell carcinoma
most common and easily treated cancer of reproductive tract with early diagnosis
- cervical cancer
- detection done with Pap smear and culposcopy
cancer associated with obesity and high levels of circulating estrogen
condition in which endometrial tissue develops anywhere outside uterus
benign neoplasm arising from the uterine smooth muscle tissue and attached to the uterine body
- also called fibroid tumor
herniation of rectum
herniation of bladder
uterus bulging into vagina resulting from weakness and stretching of the cardinal ligaments
what is injected into the uterine cavity during a sonohysterography?
normal saline, lactated Ringer solution, or 1.5% glycine
what is injected into the fallopian tubes and uterus for hysterosalpingography?
radiological contrast medium
what type of cells are tested for cervical cancer?
Pap smear procedure
epithelial cells are collected from the internal cervical os with a delicate plastic "brush," which is then swirled in prep solution
microscopic examination and biopsy of the cervix
what happens during a colposcopy?
the cervix is painted with acetic acid, which causes preinvasive cells to appear white, which are biopsied with forceps
what is treated with cone biopsy?
- epithelial carcinoma of cervix
- severe dysplasia
what does a cone biopsy involve?
removal of a circumferential core of tissue around the cervical canal
procedure in which conization is performed using a local anesthetic and electrosurgical loop filament
LEEP (loop electrosurgical excision procedure)
what happens during hysteroscopy?
- semirigid or rigid hysteroscope is used to examine the interior of the uterus and to perform selected operative procedures
- uterus is filled with a clear fluid to increase visibility
most GYN procedures are performed with the patient in what positions?
supine or lithotomy
critical safety considerations for lithotomy position
- protect the patient's modesty and dignity at all times
- all patients wear antiembolism stockings or sequestial pressure device
- raise both legs simultaneously and slowly by 2 people
- make sure hips are slightly externally rotated
- raise or lower legs only after ACP advised it is safe
- make sure hands are not near table break
- lower legs simultaneously and slowly
during open abdominal procedures, where does a right-handed surgeon stand?
at the patient's left side
during laparoscopic procedures, how is patient positioned?
low lithotomy position with one assistant positioned at the foot of the table
how is pregnant patient positioned during a laparoscopic procedure?
modified left lateral position to prevent hypotension from pressure on the vena cava by the fetus
combined abdominal/vaginal procedure prepping
- perineal prep is performed first
- always prepare 2 sites sequentially, not simultaneously
- separate prep kit and gloves required for each site
instruments used for procedures of fallopian tubes
- atraumatic graspers and delicate dissecting instruments
- bipolar electrosurgical unit (rather than monopolar)
- microinstruments used to anastomose the tubes
instruments used for fibrous ligaments
require tight, strong clamps that do not slip
instruments used for uterus
heavy dissecting scissors and toothed or grooved clamps for resection
- specialized for reproductive structures
- Babcock or other atraumatic forceps
- Harmonic shears
- monopolar hook dissector
- vessel-sealing system
open GYN procedure instruments
genearl surgery setup with uterine clamps, plus additional atraumatic clamps, long instruments, Harmonic shears and high-frequency vessel-sealing system
transvaginal pelvic procedure instruments
vaginal speculums and long instruments including uterine clamps and heavy dissecting scissors
transcervical procedure instruments
graduated cervical dilators, uterine sounds, forceps, sharp and smooth curettes, ample supply of sponges
what is used during colposcopy for staining the cervix during the Schiller test?
drug that causes constriction of blood vessels when injected
what drug is used in emergency cardiac response and may be injected into the uterus during hysterectomy or into a benign uterine tumor to prevent bleeding?
what drug is administered after delivery of the fetus and placenta to prevent postpartum hemorrhage?
what drug is an ergot alkaline administered after abortion to enhance uterine contractions and control uterine bleeding?
type of sutures used for uterine ligaments and vessels
absorbable synthetic 0 to 2-0 Vicryl taper needle
type of sutures used for bladder reflection
absorbable synthetic 2-0 to 3-0 small taper needle
type of sutures for ovary
absorbable synthetic 3-0 to 4-0 small taper needle
type of sutures for fallopian tube repair/anastomosis
inert monofilament or braided 5-0 to 7-0
type of sutures for vaginal vault
absorbable synthetic 2-0 to 3-0 medium curved needle
type of sutures for plastic procedures of vulva
Nylon, Prolene or other monofilament, 3-0, 4-0; 3/8 cutting needle
during laparoscopic pelvic surgery, when is the uterine manipulator passed through the cervical os?
after complete abdominal and vaginal prep, and immediately before surgery
what is maryland dissector used for?
what body parts are prepped for laparoscopy?
abdomen, perineum and vagina
what is often performed in conjunction with a laparoscopy?
- surgeon elevates abdominal wall by inserting 2 sharp towel clips on either side of umbilicus lifting wall away from retroperitoneal vessels
- nick is made in periumbilical region with scalpel
- Veress needle inserted into periumbilical incision
- saline injected into needle port
- negative pressure pulls saline into abdomen
what are patients observed for postoperatively after laparoscopy?
- signs of embolism, infarct, and hemorrhage
- patients experience shoulder pain for several days postop (referred pain from diaphragm)
first procedure to be performed with laparoscope
3 methods of tubal ligation
- transection and coagulation
- fallope ring
- filshie clip
transection and coagulation method
- fallopian tube grasped with Babcock forceps
- HF bipolar unit severs tube and coagulates free ends
fallope ring method
- surgeon inserts ring applicator through trocar and withdraws loop of fallopian tube into applicator
- Silastic ring is ejected over the loop which is then released back into pelvis
how does fallope ring work?
causes local ischemia and eventual necrosis of loop of tissue
filshie clip method
- filshie applicator is inserted through single port
- clip applied over fallopian tube and clamped
- through minilaparotomy incision or after cesarean section
- fallopian tube severed and ligated
- stump buried in uterine serosa with absorbable sutures
why is exploratory laparoscopy performed?
to confirm pathology of ovarian mass
removal of ovary
removal of ovarian cyst
ovarian tumor that arises from one of the germ layers of developing embryo
teratoma (dermoid cyst)
- 50 mL to 100 mL of normal saline introduced into abdomen
- fluid is then aspirated and retained as a specimen
how does surgeon remove a cyst?
- incises cortex without rupturing with fine scissors or ESU pencil
- cortex is removed using blunt dissection
- atraumatic grasper may be used to facilitate removal
- suction-irrigator may be used to separate cyst from cortex
- bipolar ESU controls bleeders
- specimen placed in specimen retrieval bag and delivered through 10-mm trocar port
how is cyst removed if it is too large for retraction?
can be reduced with a morcellator and the pieces can be brought out through bag opening
how is a teratoma removed?
intact by sharp dissection
what frequently occurs as a result of an infection that spreads from lower genital tract to uterus, fallopian tubes and ovaries?
obstruction of the fallopian tube
causal organism of PID?
usually Chlamydia trachomatis or Neisseria gonorrhoeae
what is instilled transcervically to establish patency of the fallopian tube during tubal anastomosis?
indigo carmine or methylene blue dye
what types of sutures are used for tubal anastomosis?
Nylon or polypropylene 8-0 or 9-0 suture with a tapered needle
removal of uterus by a combined laparoscopic and vaginal approach
- laparoscopic-assisted vaginal hysterectomy
- most common approach to hysterectomy
why is LAVH approach performed?
- benign tumors
- early stage uterine malignancy
procedure in which uterus and cervix is surgically removed through pelvic incision
total abdominal hysterectomy
patient position for TAH
dissection and wide removal of uterus, tubes, ovaries, supporting ligaments, upper vagina, and pelvic lymph node chains
why is radical hysterectomy performed?
to treat pelvic malignancy
most common type of cancer in female reproductive tract
excess proliferation of tissue
primary symptom of endometrial cancer
how is a diagnosis of endometrial cancer made?
radical hysterectomy instruments
long dissecting instruments (right-angle clamps, long Metzenbaum scissors, toothed forceps, and long, curved hemostats)
sutures for radical hysterectomy
size 0 and 2-0 synthetic absorbable material
what is patient closely monitored for after radical abdominal or pelvic surgery?
- urinary output
complete removal of rectum, distal sigmoid colon, urinary bladder and distal ureters, and internal iliac vessels and their lateral branches
why is pelvic exenteration performed?
to treat metastatic cancer
why is operative hysteroscopy indicated?
intrauterine pathology, such as polyps, leiomyoma, adhesions, and septal defects of the uterus
what is done to obtain a clear view of the uterine wall for hysteroscopy?
uterine cavity is distended with fluid
what type of fluid is used to distend bladder for hysteroscopy?
isotonic solution such as normal saline
what happens if electrolytic solutions are used with the monopolar circuit?
electricity would be dispersed throughout the fluid and might cause patient burns
low serum sodium level
rigid or semirigid
what does a rigid scope incorporate?
12- to 30-degree angled lens at the distal tip
how is the hysteroscope used?
it is inserted into the uterus with the sheath in place
what kind of light source is included on hysteroscope equipment?
fiberoptic light cable and xenon light source
what is a uterine resectoscope used for?
to remove polyps, subcutaneous leiomyomas, and uterine adhesions
destruction and scarification of the endometrium to render it nonfunctional
3 common ablation methods
- rollerball ablation
- intrauterine device
variety of global ablation methods
- NovaSure - radiofrequency energy - automatically stops when dangerous
- ThermaChoice UBT - silicone balloon catheter that distends adn begins a warming cycle up to 188.6 F (87 C) (takes 8 min)
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