Common Gynecologic Procedures

Objectives:
1. aware of the basic principles
of common gynecologic surgical
procedures.
2. become familiar with the instruments
used in these procedures.
3. To know the indications and
complications of each procedure.

Endometrial Biopsy
Indications
Abnormal uterine bleeding: -

-postmenopausal bleeding,
malignancy/hyperplasia,
ovulation/anovulation, HRT
Evaluation of patient with one year of presumed

menopausal amenorrhea

Assessment of enlarged utereus (combined with US and neg H

Monitoring adjuvant hormonal tx (tamoxifen)
Evaluation of infertility

Indications
Abnormal Pap smear with atypical cells favoring

endometrial origin (AGUS)

Follow-up of previously diagnosed endometrial hyperplasia

Cancer screening (e.g., hereditary nonpolyposis colorectal ca

Inappropriately thick endometrial stripe found on US
Endometrial dating

The International Federation of Gynecology and

Obstetrics (FIGO)

--Approved a new classification system (PALM-COEIN)

for causes of Abnormal Uterine Bleeding (AUB) non gravid wome
reproductive age.
The new system, which is published in the June 2011 issue of the
International Journal of Gynecology & Obstetrics,

PALM- objective structural criteria

P polyp
A adenomyosis
L leiomyoma,
M malignancy and hyperplasia).
COEIN - unrelated to structural abnormalities
C coagulopathy
O ovulatory dysfunction
E endometrial
I iatrogenic
N not visually classified

Contraindications of Endometrial Biopsy

Pregnancy
Acute PID
Clotting disorders (coagulopathy)
Acute cervical or vaginal infections
Cervical cancer

Sterile Tray for the Procedure

Sterile gloves
Sterile vaginal speculum
Uterine sound
Sterile metal basin containing sterile c
soaked in povidone-iodine solution
Endometrial suction catheter
Cervical tenaculum
Ring forceps (for wiping the cervix with
Sterile 4 x 4 gauze (to wipe off gloves

FIGURE 1. Endometrial suction

catheter.
(A) The catheter tip is inserted
into the uterus fundus or until
resistance is felt.
(B) Once the catheter is in the
uterus cavity, the internal piston is
fully withdrawn.
(C) A 360-degree twisting motion
is used as the catheter is moved
between the uterus fundus and
the internal os.

Follow Up
Normal endometrial
Proliferative

(estrogen effect or preovulatory)

Secretory (progesterone effect or postovulatory
Atrophic endometrium
Hormonal

therapy

Cystic or simple hyperplasia w/o atypia

Progress

to cancer is < 5%
Hormonal manipulation (medroxyprogesterone
[Provera], 10 mg daily for five days x 3months)
Close follow-up w/ repeat EBx in 3-12 months

Follow-Up
Atypical complex hyperplasia
Progresses

to cancer in 30 to 45 %
D&C to exclude endometrial cancer
Consider hysterectomy for complex or
high-grade hyperplasia.
Endometrial carcinoma
Referral

to a gynecologic oncologist for

definitive surgical therapy

Pitfalls/Complications
The Catheter Won't Go Up into the Uterus Easily in

Perimenopausal Patients.
Insert

an osmotic laminaria (seaweed) 3-mm dilator

in the patient morning of procedure.

Patients Report Cramping Associated with the

Procedure.
NSAIDS

before procedure
Topical anesthetic
The Procedure Should Not Be Performed in

Pregnant Patients.
R/O

pregnancy in all women of childbearing age.

Pitfalls/Complications
Infection Occurs Following the Procedure.
Adhere

to strict sterile technique

Antibiotics
The Pathologist Reports That the Specimens

Have Insufficient Sample for Diagnosis.

Use a second pass
The Tenaculum Causes Discomfort When

Applied to the Cervix.

Topical anesthetic

Endometrial Sampling ( Dilatation & Curettage)

D&C
* the most common minor gynecologic surgical
procedure tool
- diagnostic or therapeutic
- In Abnormal uterine bleeding where tendometrial or
cervical cancer is suspected a thorough
- fractional curettage is the best procedure
.

Indications
Diagnostic:
1. abnormal uterine bleeding.
2. postmenopausal bleeding ,endometrial . ca.
3. irregularities of the endometrial cavity either
congenital seen on USG
( uterine septum) or acquired
(submucous fibroids or polyp)
can be determined during the operation.

Therapeutic:

1. endometrial hyperplasia with heavy bleeding

2. removal of endometrial polyps or small
pedunculated myomas.
3. dilatation & evacuation/ completion curettage
in incomplete abortion, inevitable and missed
abortion.
4. removal of missed intrauterine IUCD.

Technique
instruments

Steps of D&C

Complications:
1.Perforation of the uterus.
it is not uncommon complication
* pregnancy.
* postmenopausal endometrial
carcinoma.
2. Cervical laceration.
3. Infection.
4. Hemorrhage.

Endometrial Ablation
- complete destruction of the endometrium
down to the basal layer , resulting in fibrosis
of the uterine cavity and amenorrhoea ( 30% )
patient satisfaction rates are over 70%
- indicated in women with heavy menstrual
bleeding, w/ biopsy results negative for
malignancy or no other problems that
require hysterectomy .
Endometrial ablation is now well established as day
case or outpatient procedure.

Endometrial Ablation make use of the

resectoscope w/c is a part of hysteroscope
w/c has a wire loop device
- uses high frequency electrical current to
cut or coagulate tissue.

Technique
Established techniques carried out
under direct hysteroscopic vision and uses
fluid for distention and irrigation .
These techniques are :
* laser ablation.
* endometrial loop resection using
electro diathermy.
* roller ball electro diathermy.

roller ball electro diathermy.

endometrial loop resection

using electro diathermy.

roller ball electro diathermy

loop resection using electro diathermy

Complications :

2%

1. uterine perforation.
2. hemorrhage.
3. infections as endometritis & PID.
4. bowel or urinary tract injury.
5. cervical lacerations & stenosis.
5. distention medium hazards as:
* gas embolism.
* fluid overload.
* anaphylactic shock.

Although the resectoscope provides excellent

results in experienced hands, the technique is
difficult to master.

because all the previous techniques are:

* operator dependent .
* time consuming .
* carry risk of systemic fluid absorption.
* hemorrhage.
* uterine perforation heat damage to adjacent
structures.

Other methods of ablation

Newer techniques have been developed
with the aim of reducing operator dependency
and minimizing risk .
other techniques of ablation are :
* microwave ablation.

* thermal balloon ablation.

They have equivalent short-term efficacy
with the advantage of shorter operating times an
a
fewer complications.

Microwave probe inserted

endometrium heated to 80 C
day case procedure
70 -80% satisfaction rates
95% return to normal

Microwave machine

Thermachoice ballon
- uses a balloon placed in the uterine cavity
through the cervix.
- Hot water is circulated inside the balloon
destroy the endometrium
- temp of 87 C for 8 mins.
Limitations: uterine cavity size: 6-10 cms
cannot treat submucous myoma
.

Thermachoice ballon

The Thermachoice System

Fig 3 - The Caveterm System

Hysterectomy
- it is the most commonly performed major
gynecologic operation ,
- it can be performed either
Abdominally , vaginally or laparoscopically.
- some indications remain controversial ,
high patient satisfaction levels with increasing
safety for the procedure have been reported .

Types of Hysterectomy
1. subtotal
2. total
3. total unilateral or bilateral salpingo ophrectomy .
4. radical

Types of Abdominal
Hysterectomy

Radical Hysterectomy

Indications :
A.

Abdominal hysterectomy

1. invasive uterine ,cervical ,ovarian and Fallopian ca

2. significant pre invasive lesions of the cervix as CIN
or endometrial hyperplasia with atypia .
3. pelvic pain
chronic endometriosis , chronic PID and ruptured
tubo ovarian abscess.
4. fibroid uterus > 12 weeks in size.
5. AUB unresponsive to other lines of treatments.
6. pregnancy catastrophe as severe bleeding.

B. vaginal hysterectomy
1. utero vaginal prolapse .
2. AUB with small uterus .
pre requesits to vaginal hysterectomy :
* benign disease.
* uterus is mobile with some pelvic relaxation
& no pelvic adhesions .
* uterus is < 12 weeks in size.

C . Laparoscopic hysterectomy
* < 10% of hysterectomies performed
with the use of laparoscopy.
* it is used to assist in vaginal hysterectomy
or to convert an abdominal to a vaginal
hysterectomy.

Technique
1. supine position.
2. general anaesthesia .
3. a careful abdominal & pelvic exam. under
anaesthesia is carried out.
4. incision

* vertical
in obese , if endometriosis is anticipated and patien
who have had several prior abdominal operations.
* transverse
in restricted benign disease .

5. exploration of the upper abdominal organs

especially the liver ,spleen and para-aortic lymph
nodes.
6. the abdominal viscera are packed up with towels.
7. round ligament .
each is clamped incised and ligated.
8. the vesico-uterine fold of peritoneum is incised
transversely between the incised round lig. and
the bladder is reflected inferiorly .
9. the two layers of the broad ligam. are separated
and the ureters are explored and identified.

10. the infundibulo pelvic ligs. with the ovarian

vessels are clamped , cut and ligated. if the
adnexa are to be removed.
11. the broad lig. is then incised towards the uterus
exposing the uterine vessels (skeletonized).
12. the uterine vessels are clamped at the level of
internal cervical os , incised and ligated on each
side.
13. medial to the ligated uterine vessels , the
cardinal lig. on each side is clamped , incised
and ligated.

14. posteriorlly , the peritoneum between the

uterosacral lig. is incised transversely and
the rectum is freed from the posterior aspect
of the cervix & upper vagina after the
uterosacral lig. are clamped , incised & ligated.
15. the total uterus is removed by cutting across
the vagina just below the cervix .
16. the vaginal cuff is closed absorbable sutures ,
incorporating the cardinal & uterosacral ligs.
into each lateral angle to avoid latter
development of vault prolapse.

Sites of ureteric injures :

1. at clamping & incising the infundibulo pelvic

ligaments.
2. at ligating the uterine vessels.
3. at clamping & incising the cardinal ligs. if th
urinary bladder is not sufficiently reflected
inferiorly.

Complications :
A . Intra operative
1. hemorrhage .
2. ureteric injuries.
3. bladder and bowel injury.
4. anesthetic complications.

B. Post operative
1. wound infection ( 5 days postoperatively).
2. UTI .
3. thrombophlebitis and pulmonary embolism,
( 7 12 days ).
4. uretero vaginal fistula ( 5 21 days ).

Thank you

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