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CST-103: Chapter 25: Gynecological and Obstetrical Surgery

Terms in this set (119)

Development of the embryo and fetus occurs when the ovum is fertilized by sperm, which normally occurs in the fallopian tube. The combination of chromosomal material from each completes the fertilization process. The egg passes through early embryonic development as it moves into the uterus and implants in the endometrium, about 10 days after fertilization. As the embryo grows, distinct developmental changes occur. The embryonic stage ends at week 8, and the fetal period begins. During development, fetal circulation begins shortly after conception. Changes in the endometrial cells provide nourishment and protection for the fetus. The placenta is a thick organ that adheres to the uterus on the maternal side. The fetal side contains large vessels within the structure's smooth membranes. The umbilical cord, which attaches to the placenta, contains the umbilical artery and vein and communicates directly with fetal circulation. Fetal membranes surround the growing fetus and are filled with amniotic fluid. The two membranes, the chorion and the amnion, are very close together. The amnion is continuous with the umbilical cord. The fluid-filled sack in which the fetus develops protects it against physical injury and also maintains thermoregulation. The watery environment allows the fetus to move and develop without restriction (Figure 25-20). Average normal gestation occurs over 40 weeks and is marked by predictable growth patterns that can be measured by ultrasound. Prenatal assessment is performed throughout gestation to ensure that fetal development progresses normally and to detect complications early. Abdominal ultrasound is routinely used to assess pregnancy
Surgical Goal
Laparoscopic-assisted vaginal hysterectomy (LAVH) is the removal of the uterus by a combined laparoscopic and vaginal approach.

It is the most common approach to hysterectomy.

The uterine ligaments, adhesions, and any other attachments are released through the abdominal portion of the procedure.

The vaginal cul-de-sac is opened, and the specimen is removed vaginally.

Pathology
The LAVH approach for hysterectomy can be performed for early-stage uterine malignancy, benign tumors, or endometriosis.

Endometriosis is a disease in which endometrial tissue develops anywhere outside the uterus, most often on the abdominal viscera.

The tissue remains responsive to hormonal changes and causes pain, bleeding, and scarring.

Conservative treatment focuses on pain management and hormone therapy.

Surgery may be necessary to remove endometrial tissue.

The cause of endometriosis is unknown.


Discussion
LAVH requires two setups, one for the laparoscopic portion and one for the vaginal approach.

The procedure is routinely performed with traditional minimally invasive techniques (described here) or using the da Vinci robotic system.

The principle techniques are the same for both procedures.

Refer to Chapter 24 for a discussion of basic robotic techniques.

The setup for the vaginal approach includes a vaginal hysterectomy set, ESU, and sutures for ligation and bladder flap closure.

Synthetic sutures (0 and 2-0) should be available. Long forceps (e.g., Russian or toothed forceps) are needed for closing the bladder flap.

Sponge forceps and 4 × 4 sponges are used until the bladder flap is closed.

The patient is placed in the lithotomy position, prepped, and draped for a combined abdominal-perineal approach.

Pneumoperitoneum is established, and three or four trocars are placed in the lower abdominal cavity.

The pelvis is examined carefully to determine the extent of disease.

Adhesions are released with the bipolar ESU during exploration to open up the pelvic space for thorough exploration and to prepare for uterine dissection.

The scrub should have Harmonic shears, a vessel-sealing system, suction, and irrigation available during exploration.

Endoscopic instruments (e.g., uterine clamps, probe, HF bipolar ESU, and monopolar ESU) should be available.

Preformed suture ligatures may be required if the uterine vessels are secured by the laparoscopic approach.

The surgeon divides the uterine ligaments and incises the uterovesical peritoneum.

If the uterine arteries are to be divided at this stage, this is performed by ligation with heavy synthetic sutures, a radiofrequency vessel-sealing system (see Chapter 18), or surgical staples.

The vessel bundles are then severed to free the uterus.

Note that it is more common for the vessels to be ligated from the vaginal incision.

Before shifting to the vaginal portion of the procedure, the surgeon incises the posterior cul-de-sac, creating communication between the pelvic cavity and the proximal vaginal vault.

The surgeon then shifts to the vaginal approach.

The uterine vessels are ligated and severed, and the specimen is delivered through the cul-de-sac.

Small bleeders are controlled with the ESU, and the bladder flap is closed with running suture of 2-0 or 3-0 absorbable synthetic material.

The laparoscope and trocars are removed, the pneumoperitoneum is released, and the abdominal incisions are closed with absorbable suture.

Note: A laparoscopic hysterectomy is performed using the steps just described, except that the procedure is completed laparoscopically.
The uterus is removed through a large trocar and specimen retrieval bag.
Surgical Goal
In dilation and curettage, sharp and smooth curettes are used to remove the surface of the endometrium through a transvaginal approach.

Pathology
A D & C may be performed for diagnostic purposes, to terminate a pregnancy, or to treat abnormal uterine bleeding.

Discussion
The patient is placed in the lithotomy position.

The bladder may be emptied with a straight catheter.

The patient is then prepped and draped for a vaginal procedure.

The surgeon stands or sits at the foot of the operating table.

The scrub should stand next to the surgeon.

To begin the procedure, the surgeon places an Auvard speculum in the vagina.

The surgeon then grasps the anterior lip of the cervix with a tenaculum and retracts it slightly forward and downward.

A uterine sound is inserted into the cervix to measure its depth and position.

This prevents accidental perforation during the procedure.

The surgeon dilates the cervix with a Hagar, Pratt, or Hank uterine dilator.

After cervical dilation, the surgeon places a Telfa dressing on the posterior edge of the vagina.

The uterus is then gently curetted, and the specimen is collected on the Telfa.

The technologist should have several types and sizes of curettes available, including smooth, sharp, and serrated.

When curettage is complete, the Telfa is removed and passed to the scrub.

Both the Telfa and specimen are placed in a container for pathological examination.

Techniques
1The uterine depth is measured with a uterine sound.

2 The cervix is dilated with graduated dilators.

3 Curettes are used to remove endometrial tissue.