IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN NURSING CARE MANAGEMENT 104

PERI OPERATIVE REVIEW OF TOTAL ABDOMINAL HYSTERECTOMY BILATERAL SALPHINGO OOPHORECTOMY,

PRESENTED TO: HEIDI ALFEREZ, RN, MN

PRESENTED BY: PAULINE ANNE MARIE C. CEZAR

FEBRUARY 2013

INTRODUCTION Total Abdominal Hysterectomy Bilateral Salphingo Oophorectomy (TAHBSO) is the removal of entire uterus, the ovaries, fallopian tube and the cervix. TAHBSO is usually performed in the case of uterine and cervical cancer. This is the most common kind of hysterectomy. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately known as surgical menopause. Internationally, Total Abdominal Hysterectomy Bilateral Salphingo Oophorectomy (TAHBSO) is the second most frequently performed major surgical procedure for women of reproductive age in the United States. Approximately 600,000 hysterectomies are performed annually in the United States and an estimated 20 million U.S. women have had a hysterectomy. During 20002004 the overall hysterectomy rate for United States female civilian residents was 5.4. per 1,000 women. During this time period, the overall rate of hysterectomy decreased slightly. Hysterectomy rates were highest in women aged 4044 years. The three conditions most often associated with hysterectomy were uterine leiomyoma ("fibroid tumors"), endometriosis, and uterine prolapse. (http://www.cdc.gov/reproductivehealth/womensrh/hysterectomy.htm) Most functional ovarian cysts occur during childbearing years. And most of those cysts are not cancerous. Women who are past menopause (ages 50-70) with ovarian cysts have a higher risk of ovarian cancer.

ANATOMY AND PHYSIOLOGY

CERVIX - lower narrow section of the uterus through which it connects with the vagina. FALLOPIAN TUBE - canal through which the egg travels from the ovary to the uterus. Fertilization of the egg by the spermatozoon normally takes place in the upper section of the tube.

OVARY - Female genital gland that produces eggs and the sex hormones estrogen and progesterone. UTERUS - Hollow muscular organ receiving the egg and, once fertilized, enabling its development and expulsion at the end of pregnancy.

VAGINA - The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal.

PATHOPHYSIOLOGY OF OVARIAN CYST Follicular cysts develop in response to gonadotrophic stimulation and as a variation of the normal physiological process of follicle growth and atresia. It is unclear whether a dominant follicle fails to rupture or an immature follicle fails to undergo atresia. The lining granulosa cells undergo luteinisation, and hyalinised connective tissue envelopes the growing cyst. Corpus luteum cysts evolve from mature Graafian follicles approximately 2 to 4 days after ovulation occurs. Vascularisation takes place and a spontaneous capillary bleed fills the cystic cavity, creating pressure. Rupture is possible at this point. Eventually, the blood is replaced by clear serous fluid. Theca lutein cysts arise from ovarian theca lutein cells and luteinised granulosa cells responding to stimulation by gonadotrophins or beta-hCG. Fibromas represent neoplastic growth of undifferentiated fibrous stroma. Transitional cell (Brenner) tumours arise from metaplasia of celomic epithelium into uroepithelium, which may result in an inclusion-type cyst. Benign and malignant ovarian tumours stain immunohistochemically for somatostatin.

MEDICAL MANAGEMENT Most ovarian cysts will go away on their own. If the client dont have any bothersome symptoms, especially if the havent yet gone through menopause, the doctor may advocate ''watchful waiting.'' The doctor wont treat the client. But the doctor will check the client every one to three months to see if there has been any change in the cyst. Birth control pills may relieve the pain from ovarian cysts. They prevent ovulation, which reduces the odds that new cysts will form. Surgery is an option if the cyst doesnt go away, grows, or causes pain. There are two types of surgery: Laparoscopy uses a very small incision and a tiny, lighted telescope-like instrument. The instrument is inserted into the abdomen to remove the cyst. This technique works for smaller cysts. Laparotomy involves a bigger incision in the stomach. Doctors prefer this technique for larger cysts and ovarian tumors. If the growth is cancerous, the surgeon will remove as much of the tumor as possible. This is called debulking. Depending on how far the cancer has spread, the surgeon may also remove the ovaries, uterus, fallopian tubes, omentum -- fatty tissue covering the intestines -- and nearby lymph nodes. Other treatments for cancerous ovarian tumors include: Chemotherapy -- drugs given through a vein (IV), by mouth, or directly into the abdomen to kill cancer cells. Because they kill normal cells as well as

cancerous ones, chemotherapy medications can have side effects, including nausea and vomiting, hair loss, kidney damage, and increased risk of infection. These side effects should go away after the treatment is done.

Radiation -- high-energy X-rays that kill or shrink cancer cells. Radiation is either delivered from outside the body, or placed inside the body near the site of the tumor. This treatment also can cause side effects, including red skin, nausea, diarrhea, and fatigue. Radiation is not often used for ovarian cancer.

Surgery, chemotherapy, and radiation may be given individually or together. It is possible for cancerous ovarian tumors to return. If that happens, you will need to have more surgery, sometimes combined with chemotherapy or radiation.

DIAGNOSIS The obstetrician/gynecologist may feel a lump while doing a routine pelvic exam. Most ovarian growths are benign. But a small number can be cancerous. Thats why its important to have any growths checked. Postmenopausal women in particular should get examined. That's because they face a higher risk of ovarian cancer. Tests that look for ovarian cysts or tumors include: Ultrasound. This test uses sound waves to create an image of the ovaries. The image helps the doctor determine the size and location of the cyst or tumor. Other imaging tests. Computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) are highly detailed imaging scans. The doctor can use them to find ovarian tumors and see whether and how far they have spread. Hormone levels. The doctor may take a blood test to check levels of several hormones. These include luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol, and testosterone. Laparoscopy. This is a surgical procedure used to treat ovarian cysts. It uses a thin, light-tipped device inserted into your abdomen. During this surgery, the surgeon can find cysts or tumors and may remove a small piece of tissue (biopsy) to test for cancer. CA-125. If the doctor thinks the growth may be cancerous, he might take a blood test to look for a protein called CA-125. Levels of this protein tend to be higher in some -- but not all -- women with ovarian cancer. This test is

mainly used in women over age 35, who are at slightly higher risk for ovarian cancer.

If the diagnosis is ovarian cancer, the doctor will use the diagnostic test results to determine whether the cancer has spread outside of the ovaries. If it has, the doctor will also use the results to determine how far it has spread. This diagnostic procedure is called staging. This helps the doctor plan treatment.

ROLES OF SCRUB AND CIRCULATING NURSE Scrub Nurse: Set up the sterile field. Perform surgical counts with circulating nurse. Gown and glove surgical team. Monitor the field for breaks in aseptic technique. Request additional sterile supplies and equipment per surgeon's request. Have a sound surgical knowledge base to anticipate the surgeon's needs (instruments, suture material, equipment, medications, irrigations, and so forth). Safely handle sharps. Prepare wound dressings.

Circulating Nurse: Assist anesthesia provider with induction. Assist surgeon with patient positioning. Participate in surgical "time out" (verify correct patient, correct procedure, consent matches procedure, correct surgical site, correct position, and correct implant, when applicable). Assess skin, then apply cautery grounding pad to appropriate site. Connect suction, cautery, and other equipment needed. Issue sterile fluids and medications onto the sterile field.

Monitor the sterile field, equipment, and anesthesia so you can troubleshoot quickly. Issue sterile supplies, and additional equipment as requested, onto the sterile field. Monitor the traffic flow through the OR suite. Complete documentation on OR record and OR surgery charge sheet. Perform intraoperative surgical counts of instruments, sharps, sponges, and miscellaneous items with the scrub person. Prepare specimens for pathology. Assist with wound and drain dressings.

PROCEDURE PROPER (with Instrumentation) Before the procedure: The physician will explain the hysterectomy procedure to the client and offers to ask any questions that the patient might have. The patient will be asked to sign a consent form that gives permission to do the procedure. In addition to a complete medical history, the physician may perform a complete physical examination to ensure that the patient is in good health before undergoing the procedure. Patient may undergo blood tests or other diagnostic tests. The patient will be asked to fast for eight hours before the procedure, generally after midnight. During the procedure: Generally, Total Abdominal Hysterectomy Bilateral Salphingo Oophorectomy follows this process: Patient will be asked to remove any jewelry or other objects that may interfere with the procedure. Patient will be asked to remove clothing and be given a gown to wear. If there is excessive hair at the surgical site, it may be clipped off. An intravenous (IV) line will be inserted. Patient will be positioned on the operating table in supine position.

The anesthesiologist will continuously monitor heart rate, blood pressure, breathing, and blood oxygen level during the procedure. A catheter (thin, narrow tube) will be inserted into your bladder to drain urine.

The skin over the surgical site will be cleansed with an antiseptic solution. The incision will be made vertically from the navel to the pubic bone or horizontally across the lower abdomen. The surgeon will discuss which incision is preferable in your particular situation prior to the procedure.

After the incision has been made through the layers of skin, muscle, and other tissue, the physician will inspect the organs and other structures in the abdomen and pelvis.

The tissues connecting the uterus to blood vessels and other structures in the pelvis will be carefully cut away.

The uterus will be removed, along with any other structures such as the ovaries, fallopian tubes, and cervix, as required by your situation.

The incision will be closed with surgical stitches or staples.

Instruments: Adson Forceps with tooth - used to hold tissue near the skin surface. Allis Clamp - used to grasp tissue, used to grasp biopsy tissue. Babcock Clamp - used to grasp delicate tissues at the level of the peritoneum or bowel. Needle Holder - Fine needle holder used for suturing.

Curved Mayo Scissors - used for cutting dense tissue (fascia, uterus, linea alba) or suture. let the curve work for you (better visibility while cutting and mobility)

Deaver Retractor - retracting & exposing Heaney-Ballentine Clamp - Curved or straight with short jaws and longitudinal serrations, one or two teeth Metzenbaum Scissor used for cutting Zeppelin Clamp; Z-Clamp LEEP Ball Electrode - Metallic ball tip used for cervical cautery Tissue Forceps - fine tip forceps with tooth Straight and Curved Kelly Clamps - Soft tissue dissecting, serrations are horizontal and only go halfway up the jaw, for occlusion, hemostasis. Mixter used to clamp hard to reach vessels and to place sutures behind or around vessel. Schnidtz De Bakey used to grasp delicate tissue. Self Retaining Retractor retract wound edges during deep abdominal procedures. Army Navy retract shallow or superficial insisions. Richardson retract deep abdominal or chest incisions. Malleable or Ribbon Retractor used to retract deep wounds, may be bent to various shapes.

BIBLIOGRAPHY Book Sources: Doenges, M. et al (2006). Nurses Pocket Guide. 10th Edition. F. A. Davis Company, Philadelphia, Pennyslvania Deglin, J. D. et al (2005). Daviss Drug Guide For Nurses. 9th Edition. F. A. Davis Company Smeltzer, S. et al (2010). Brunner and Suddarths Textbook of Medical Surgical Nursing. 12th Edition. Wolters Kluwer Health/ Lippincott Williams and Wilkins Online Sources: http://www.surgeryencyclopedia.com/Pa-St/Post-SurgicalPain.html#bsurgery.about.com http://surgery.about.com/od/ingandsurgery/ss/SurgeryAnxiety.htm (http://www.cdc.gov/reproductivehealth/womensrh/hysterectomy.htm