Gynekologicko - porodnická klinika Lékařské fakulty MU a FN Brno head of the department: doc. MUDr. Vít Weinberger, Ph.D Surgery in gynecology Obstetrics and Gynecolgy https://muni.brandcloud.pro/storage/10488/images/620x/49d0c631906bdfd14af652571fd2b858.png?87d88502 5df2c5c13a2eca6c9cc41e9a Eliška Gazárková Adobe Systems Why? •acute life-saving surgery / planned operation •relief of symptoms (pain, bleeding, discomfort, incontinence, ..) •treatment of infertility •oncological indications • Introduction Adobe Systems Classification by approach: •Abdominal •Vaginal •Endoscopic •Small interventions (Outpatient / one-day surgery) •Obstetrics • Introduction Adobe Systems Indication •proper gynecological examination (incl. anamnesis, objective examination, ultrasound, CT, MR, others) •goal setting (talking to the patient!!!, what we / patient expect?, what we can offer?) • need for surgery? choosing the right approach correct indication successful operation – • Introduction Adobe Systems Preoperative management •pre-op examination (lab, internal, ARO, others if needed) •preparation – Treatment of infections vag, uro, focuses – Bowel preparation (diet, enema, laxative) – Prevention of trombembolism, ATB prophylaxis – Securing the urinary tract (stent) – Timing (after menzes) • multidisciplinary approach (urologist, surgeon) • Introduction Adobe Systems Perioperative management •Premedication (anxiolytics, hypnotics, ATB), iv line, catheterizaton •Position – horizontal (abdominal surgery) – gynecological position = hip flection, adduction (laparoscopy, small interventions, vaginal surgery) – Trendelenburg = head down (laparoscopy) •Anesthesia – general, spinal, local, analgesia •Preparation of the operating field (desinfection, sterile cover) • Introduction Adobe Systems ̶ Obsah obrázku interiér, místnost, stůl, vsedě Popis se vygeneroval automaticky. Obsah obrázku interiér, osoba, stůl, vsedě Popis se vygeneroval automaticky. Obsah obrázku osoba, žena, muž, držení Popis se vygeneroval automaticky. Obsah obrázku interiér, místnost, malé, stůl Popis se vygeneroval automaticky. Adobe Systems Desinfection •Ribs – upper third of the thighs •external genitalia, vagina (diluted solution) • • Introduction Obsah obrázku interiér, jídlo, stůl, vsedě Popis se vygeneroval automaticky. Obsah obrázku ovoce, oranžová, vsedě, jídlo Popis se vygeneroval automaticky. Adobe Systems •Small diagnostic-therapeutic procedures •Resection operations •Urogynecological operations •Vaginal hysterectomy • Operations of outer genitalia and perineum • Operations of vaginal introitus area • Operations of vagina • Operations of cervix • Operations of uterus • Vaginal surgery Adobe Systems •Diagnostic (visualization, biopsy, puncture) •Therapeutic •Excision (vulva, vagina, cervix = conization) •Uterine abrasion (curettage) •Uetrine revision •Puncture of the cyst vaginally •Hysteroscopy (diagnostic + surgical) • • Small interventions (Outpatient / one-day surgery) Adobe Systems •Uterine abrasion (curettage) •endometrial biopsy of the cervix and uterine cavity separately •histological verification + treatment of bleeding •Dilatation of cervix is needed •I: hypermenorrhoea, menometrorrhagia, postmenopausal bleeding/spotting, suspected ultrasound image (high endometrium) • • Small interventions (Outpatient / one-day surgery) Adobe Systems •Uterine revision (surgical abortion) •Procedure to remove residual tissue after incomplete spontaneous abortion or missed abortion (surgical abortion procedure) •Dilatation of cervix is often needed •Ultrasound control •curette, vacuum-aspiration curette •I: residues after abortion, missed abortion, anembryomola, residues after delivery, patient's wish to terminate the pregnancy (12th g.w.) Small interventions (Outpatient / one-day surgery) Adobe Systems •Puncture of the cyst vaginally •Procedure to aspirate the contents of the cyst (ovarian) vaginally •Ultrasound navigation •Diagnostics – cytology (malignant cells?) •Therapy – immediate relief of symptoms, minimally invasive, but often relapse! (main and permanent solution is surgery - removal of the cyst) •I: symptomatology – (pain, discomfort, incontinence, urinary retention, ..) – acute relief (no/minimal preparation) x a patient who cannot undergo surgery suspected malignancy Small interventions (Outpatient / one-day surgery) Adobe Systems •Hysteroscopy •Endoscopic procedure that allows to look inside uterine cavity in order to diagnose and treat •Hysteroscope – device (thin, lighted tube) that is inserted inside of the uterus – rigid / flexible, outer diameter 3 - 9 mm – optical cable + channel for instruments (loop, curette, needle) – distention media – fluid, (gas) • targeted biopsy, disruption of adhesions, resection of septum, polyps, fibroids, removal of foreign bodies (IUD) under visual control •I: sterility, infertility, abnormal uterine bleeding, suspect ultrasound findings, uterine polyps Small interventions (Outpatient / one-day surgery) Adobe Systems •Conization •Diagnostic + therapeutic procedure •conus shape resection of cervix •„cold knife“ conisation (scalpel), electrocoagulation loop / needle, laser conisation (CO2) •I: prekancerosis (CIN) •(trachelectomy – fertility sparing, therapy cervical Ca, "high radical conisation") Small interventions (Outpatient / one-day surgery) Adobe Systems •urinary incontinence surgery •TVT, implants, artificial sfincter •Vaginal plastics •operations of descents and prolapse Urogynecological vaginal operations Adobe Systems Obsah obrázku interiér, stůl, vsedě, malé Popis se vygeneroval automaticky. •endoscopic method, access and view of the abdominal wall, minimal disruption of the abdominal wall •Diagnostic (visualization, biopsy) / Therapeutic •Planned / urgent •DGL (diagnostic laparocopy), ovarian / fallopian tube surgery, uterine surgery, hysterectomy •minimaly invasive, short hospital admition and reconvalescence •infraumbilical incision – insuflation of CO2 (Verres needle, cca 3,5l) + port with optics •Instrumental ports • • • Laparoscopy Adobe Systems Indication DGL planned •Sterility – chromopertubation (dye test), uterus and ovary shape •Chronic pelvic pain (adhesions, chronic inflamation, endometriosis, ..) •Patological structures in small pelvis (onko) urgent •acute pain and/or haemoperitoneum (adnexal torsion, cyst rupture, ectopic pregnancy, ..) •uterine wall perforation (during curretage, HSK) • • Laparoscopy Obsah obrázku interiér, vsedě, stůl, mísa Popis se vygeneroval automaticky. Adobe Systems Indication Ovarian / fallopian tube surgery •cysts – exstirpation, resection •inflamation – adnextumor, pyosalpinx; suspicious findings, ectopic gravidity, torsion, hydrosalpinx, endometriosis, onko-prophylaxis, sterilization – salpingectomy, ovarektomy, adnexectomy (uni/bilateral) Uterine surgery •Fibroids – symptomatic, infertility – enucleation; endometriosis, ademomyosis, congenital malformations – metroplasty Hysterectomy (LAVH / TLH) •Abnormal uterine bleeding, gynecological malignancy, large myomatosis, endometriosis, descensus, onko-prophylaxis Laparoscopy Adobe Systems •Therapeutic / Diagnostic (visualization, biopsy) – probatory laparotomy (onco) •Planned / urgent •similar indications as laparoscopy + oncosurgery (radical procedures, lymphadenectomy) •Suprapubical – Pfannenstiel incision –Esthetic, time consuming, limited access to abdomen •Infraumbilical – lower middle –Umbilicus – symphysis, good access to abdomen –Large tumors, oncological surgery, emergency surgery – • Laparotomy Obsah obrázku oblečení, hledání, stůl, držení Popis se vygeneroval automaticky. Obsah obrázku oblečení, stůl, vsedě, malé Popis se vygeneroval automaticky. Adobe Systems •Simplex (just the uterus) •With salpingectomy (usually) •With adnexectomy (ovarectomy) (postmenopausal patient) •Radical (+ removal of parameteria, lymphadenectomy) •In case of malignancy •Partial (supracervical) – rarely •I: abnormal uterine bleeding, gynecological malignancy, myomatosis, endometriosis, descensus, onko-prophylaxis • Hysterectomy Adobe Systems •Vaginal (if uterine descensus/prolaps) •can be performed under spinal anesthesia •early mobilization, rapid recovery •bad adnexal and abdomen visibility, bleeding •LAVH / TLH •laparoscopically assisted vaginal hysterectomy – vaginal stump suture vaginally •total laparoscopic hysterectomy – vaginal stump suture laparoscopically •Abdominal • Hysterectomy Adobe Systems •Infection - of surgical wound, vaginal stump, urinary •Bleeding / haematoma - intraabdominal, vaginal •Dehiscence •Urological problems - incontinence, urinary tract injuries •Hernia in a scar •GIT injury, preforation •Trombosis – – • Complications gynecological operations Adobe Systems • • • Thank you​ for your attention! Adobe Systems • • • Appendix ;) Laparoscopy * Laparoscopy – operative •Surgical spectrum equal to laparotomy * planned –sterility - adhesiolysis, tubal neostomy (MCH-LSK), SE, – myomektomy, drilling of ovaries –endometriosis - exstirpation of cysts, adhesiolysis –Exstirpation of benign tumors (suspetious Ca - tomy) –UVP sec. Burch –Vecchieti´s vaginal neoplasty * urgent –Acute pain – cyst exstirpation, adnexal detorsion –GEU - SE, eventualy more conservative operations –Uterus perforation – coagulation or suture Laparoscopy – operative •Laparoscopic lymphadenectomy * Variety of operations in oncogynaecology –renesance of radical vaginal hysterectomy –Additional to radical trachelectomy when Ca cerv. uteri •Stage T1a2 and wish to stay fertile * LAVH (LSK asisted vaginal hysterectomy) –Variety of LSK surgery part – up to total LSK HYE –Release of imobile uterus – otherwise vaginaly unoperable –Choice of AE of vaginaly unavailable ovaries –Findings correlation and conversion to laparotomy * controversion – by hand asssisted LSK operations Laparoscopy – instruments * Veress needle * Trocars (preferably with optics) * Probe * Forceps - variety (atraumatic etc.) * Scissors (several types) * Coagulation - bipolar, monopolar (CAVE!!) * Aquapurator * Staplers (clips) * Extracorporal sutures Laparoscopy – complications (7 %) * Peroperative (unsufficient pre-op, mistakes) –perforation - GIT, bladder –Urether disection –Bleeding (insertion of ports, during surgery) •CAVE monopolar coagulation !!! –Anaesthasia compresion * Post-operative –bleeding, trauma, infection –Anaesthasia, internal medicine * Late complications –Adhesions, fistula, necrosis, hernia, infections, MTS 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 DSC02725 Momectomy 56 DSC02729 57 DSC02730 58 DSC02732 59 DSC02735 60 DSC02737 61 DSC02744 62 DSC02746 63 DSC02751 64 DSC02752 65 DSC02755 66 DSC02759 67 DSC02766 68 DSC02771 69 DSC02772 Abdominal gynaecol. operations * Urogynaecological operations (Abdominal gynaecol. operations, indications & types of operations) * Urine stress incontinence * Descens or hypermobility of uretrovesical junction * * urethrovesicopexis (UVP) sec. Burch –Golden standard for operative solution of incontinence –Preparation of Retzi space –Tightening of urethrovesical junction toward lig. iliopectineum Cooperi –80-90% succes Uterine descensus and deviations operation (Abdominal gynaecol. operations, indications & types of operations) * Today – abdominal approach rare, preferably vaginal approach * Operation of uterine retroversion – rare indication * * ventrosuspension sec. Dolérise –If retroversion – fixation of lig. Rotundum to fascia of musculi recti abdominis –Shortening of lig. Rotundum sec. Baldy & Webster Surgery of vaginal prolaps after hysterectomy (Abdominal gynaecol. operations, indications & types of operations) –Vaginal prolapse - possible hysterectomy complication –Prolaps often associated with cysto - rekto - enterocele –Possibility of vaginal approach * * Ventrofixation of vaginal pouch –Suturing to fascia of musculi recti abdominis –Possibility to combine with reduction of Douglas pouch sec. Moschowitz * Sacropexy of vaginal pouch –Fixation to presacral periosteum, fysiological vaginal inclination Oncogynaecological operations (Abdominal gynaecol. operations, indications & types of operations) * explorative laparotomie () * Ca corporis uteri – operate –radical hysterektomy gr. I (sec. Te Linde) + AE bilat. – + omentectomie + LNE + APPE –obesity, polymorbidity – limits of operation * Ca cervicis uteri – operate up to stage IIa included –radical hysterektomy gr. III (sec. Wertheim) + LNE –adnexa ??? * Ca ovarii - maximal debulking surgery –radical hysterektomy gr. I + AE bilat. + omentectomy + LNE – + APPE –IDS, ESO Complications of abdominal operations * Infection –Operation wound - hematoma, abscess, dehiscence, eventually evisceration - High risk in obese women –Abdominal cavity – risk of infection from vagina, bowel injury •peritonitis, inter intestinal loops absces, ileus, fistula –ATB profylaxis preoperatively, vaginal desinfection, operative technique •ATB: prefer cefalosporins I. generation (or PNC) + Metronidazole * Haemorage –In abdominal cavity, in operation wound (horizontal incision) –Vessel damage, tumors, coagulopathy, heparinisation, DIC •Haemorrhagic shock –Operation technique, bleeding stopping, dreinage •If vessel damage - cooperation with surgeon (vascular surgeon) Complications of abdominal operations * Urological troubles –cathetrisation, damage to urether or bladder •fistula - ureterovaginal, vesicovaginal (after radical surgery) •Stress incontinence (after radical surgery) –pre & post-op ATB th., urine derivation (suprapubic dreinage) –Pre-op preparation - IVU, urether cathetrisation * Wound hernia – often in lower midline laparotomy * Lymfocysts - 1-25% after radical surgery with LNE * TEN – oncological patients, pregnancy, obesity –pre-op preparation –operation technique –Post-op treatment Instruments and sutures (Abdominal gynaecol. operations) •Instruments similar to surgical * Retractors: –Framed – squared –automatic, Horálek´s (for minilaparotomy) * Needle holder:prefered Boseman (also long variations) * Pliers: Museaux, „edged“ pean, „american“ * Sutures: economical limits vs. prefered –Silon, Vicryl, Safil, Ethibond, skin – intradermal suture with straight needle Vaginal operations * Desinfection (Vaginal gynaecol. operations) * Carefull desinfection –Treatment for coplitis before surgery –Control of desinfection concentration!!! (mucous membranes) * Betadine 10% –Iodine solution - diluted –For skin also undiluted * Octenisept – alcohol solution without iodine Operations of outer genitalia & perineum (Vaginal gynaecol. operations, indications & types of surgery) * Fistula operations –perineovaginal and perineorectal •For bad healing (suture) of perineum – episiotomy, etc. * Operations of congenital diseases of genitalia –Variaty of anomalies –Co-operation with surgeon, urologist, plastic, etc. * Injuries of vulva –Laceration - contusion, covered injury - hematoma Operations of vaginal introitus area (Vaginal gynaecol. operations, indications & types of surgery) * Hymenal asymetry –Hymenal atresia, rupture and bleeding after defloration * Stenosis of vaginal introitus –Suture of episiotomy, plastic operations of vagina * Pseudocysts, absces of Bartholin gland –Incision and dreinage –marsupialisation –exstirpation (or chemical extirpation - Lapis infern.) Operations of vagina (Vaginal gynaecol. operations, indications & types of surgery) * Benign tumors of vagina and vaginal adenosis * Injury - coitus, foreign body * Precancerose and carcinoma –Operatively curable only few tumors –radical colpectomy – difficult to perform * Operations of vaginal congenital diseases –Resection of vaginal septum –Operation therapy of vaginal agenesis - sy Rokitanski - Küster •Vecchietti´s operation – nowadays most common •Combination of vaginal surgery and laparoscopy Operations of vagina (Vaginal gynaecol. operations, indications & types of surgery) * Operations of vaginal wall descensus (and uterus) –kolporrhaphy anterior –kolpoperineoplastic with suture of levators ani * Operations of vaginal prolaps • (enterocele, elytrocele, Froriepy´s prolaps) –vaginofixation sec. Amreich (I,II) - Richter •Fixation of vagina to sacrospinal or sacrotuberal lig. * Paliative operations of vaginal prolaps –semikolpokleisis sec. Labhardt –kolpokleisis sec. Kahr •Elderly women operations (vita sexualis non vult) Operations of cervix (Vaginal gynaecol. operations, indications & types of surgery) * Conisation – diagnostic-therapeutic procedure –Conus shape resection of cervix * Prekancerosis (CIN, CIS) – most common indication –„cold knife“ conisation –LEEP, LLETZ, SWETZ (if not a carcinoma) –laser conisation (CO2) * Cervix deformation - delivery –tracheloplastics – sec. Emmeta * „Microinvasive“ cervical Ca - trachelektomy –„high“ radical conisation (if family planning) Operations of uterus (Vaginal gynaecol. operations, indications & types of surgery) * Vaginal hysterektomy (or LAVH) –previous indications (adnexal mass, uterus Ca) - abandoned –Decrease of abdominal operations, today renesance •Departments with „vaginal“ school - domination –Todays indications – similar to abdominal hysterectomy •Typical for uterus descens or cysto-rectocele •Radical surgery (sec. Schauty) if carcinoma - rare –advant: spinal anaest., mobilisation, food intake, healing process –disadvant: bad adnexal and abdomen visibility, bleeding * Other uterus operations - myomectomy Complications (Vaginal gynaecol. operations) * Infections –Rather rare then in abdominal oper. (obesity not a case) •Infected haematome –Risk of bowel injury – necessity to treat –ATB profylaxis pre-op, vaginal desinfection, operation technique •ATB: cefalosporin I. gen (or PNC) + Metronidazol * Bleeding –Low visibility of abdominal cavity, venous plexus –Vessel injury, koagulopathy, heparinisation, DIC •Haemorrhagic shock –Operation technique, stop of bleeding, drainage * Complications (Vaginal gynaecol. operations) * Urologic troubles •cathetrisation, damage to urether or bladder •fistula - ureterovaginal, vesicovaginal –Deterioration or urine incontinence development, urine retention •incontinence after correction of prolapse – ofter paradox –Pre-op and post-op ATB therapy –Suture of bladder injury, long term urine derivation (suprapubic, minicathetr) * Trombembolic disease – lower risk vs abdominals –Pre-op. preparation, op. technique, post-op treatment * Decrease in size of vagina, genital deformation Instruments and sutures (Vaginal gynaecol. operations) * Mirrors –Anterior and posterior, lateral, Breisky mirrors * Pliers –American one tooth forceps, „sondoamerican“ –Solid „edge“ pean forceps * Medications –Remestyp – vasopresor •Beware of post-treatment bleeding * Sutures –Often only silon and slowly resorvable Vicryl * Hysteroscopy Hysteroscopy * Types of anaesthesia –paracervical block – diagnostic – one day surgery –analgosedation –asleep – operational hysteroscopy * Complications and risks –Fluid overload syndrom (1- 5%) •Movement of distentional medium into main stream (intravasation), hemodilution •hyponatremia, vomitus, cerebral edema, edemy, circulation failure –Infection (2- 4%) –Perforation (1- 3,7%) –Bleeding (0,4 - 5%) Hysteroscopy * Diagnostic procedures –sterility (within IVF), infertility - SLL after septum resection •vizualisation HSG suspitious findings –relapse of abnormal uterine bleeding –Suspitious findings of endometrium on USG (TMX) •Follow up of endometrial hyperplasia * Operational procedures –Guided biopsy of suspetious lessions –Intrauterine adhesiolysis, septal resection, polyps and fibroids resection –resection and endometrial ablation –IUD part removal –Transcervical sterilisation – * Rigid diagnostic hysteroscope Obrázek7.png Flexible diagnostic hysteroscope Obrázek8.png Operative resectoscope Obrázek9.png Normal hysteroscopic findings Normal tubal entrance Submucose fibroid Resection of submucose fibroid Resection of submucose fibroid Uterine septum Endometrial polyp in the area of uterine septum Intracervical adhesion Endometrial polyp Endometrial carcinoma Da Vinci – robotic surgery da Vinci Surgical System med 5718362159426794 Da Vinci – Console * 3D view * Ergonomic operational position – also for long lasting operations ( sitting) * Single surgeon procedure * Gentle hand motorics console response * Setting of motorics * *