A thyroidectomy is an operation that involves the surgical removal of all or part of the thyroid gland.

Surgeons often perform a thyroidectomy when a patient has thyroid cancer or some other condition of the thyroid gland (such as hyperthyroidism). Other indications for surgery include cosmetic (very enlarged thyroid), or symptomatic obstruction (causing difficulties in swallowing or breathing). One of the complications of "thyroidectomy" is voice change and patients are strongly advised to only be operated on by surgeons who protect the voice by using electronic nerve monitoring. Most thyroidectomies are now performed by minimally invasive surgery using a cut in the neck of no more than 2.5 cms(1 inch). The thyroid produces several hormones, such as thyroxine (T4), triiodothyronine (T3) and calcitonin. After the removal of a thyroid patients usually take prescribed oral synthetic thyroid hormones to prevent the most serious manifestations of the resultant hypothyroidism. Less extreme variants of thyroidectomy include:
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"hemithyroidectomy" (or "unilateral lobectomy") -- removing only half of the thyroid "isthmectomy" -- removing the band of tissue (or isthmus) connecting the two lobes of the thyroid

A "thyroidectomy" should not be confused with a "thyroidotomy" ("thyrotomy"), which is a cutting into (-otomy) the thyroid, not a removal (-ectomy) of it. A thyroidotomy can be performed to get access for a median laryngotomy, or to perform a biopsy. (Although technically a biopsy involves removing some tissue, it is more frequently categorized as an -otomy than an ectomy because the volume of tissue removed is minuscule.)

Indications
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Malignancy (see Thyroid neoplasm) Cosmetic reasons Goiter which is untreatable by medical methods Severe hyperthyroidism refractory to conservative treatment Orbitopathy in Graves' disease Removal and evaluation of a thyroid nodule whose FNAC results are unclea

Complications
1. Hypothyroidism/Thyroid insufficiency in up to 50% of patients after ten years 2. Thyrotoxic crisis/Thyroid storm

3. Laryngeal nerve injury in about 1% of patients, in particular the recurrent laryngeal nerve: Unilateral damage results in a hoarse voice. Bilateral damage presents as laryngeal obstruction on removal of the tracheal tube and is a surgical emergency: an emergency tracheostomy must be performed. Recurrent Laryngeal nerve injury may occur during the ligature of the inferior thyroid artery. 4. Hypoparathyroidism temporary (transient) in many patients, but permanent in about 14% of patients 5. Anesthetic complications 6. Infection 7. Stitch granuloma 8. Haemorrhage/Hematoma o This may compress the airway, becoming life-threatening. A suture removal kit should be kept at the bedside throughout the postoperative hospital stay. 9. Surgical scar/keloid 10. Removal of parathyroids by mistake along with thyroids.

Tracheotomy
Among the oldest described surgical procedures, tracheotomy (also referred to as pharyngotomy, laryngotomy, and tracheostomy) consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea. The resulting stoma can serve independently as an airway or as a site for a tracheostomy tube to be inserted; this tube allows a person to breathe without the use of his or her nose or mouth. Both surgical and percutaneous techniques are widely used in current surgical practice.

Indications
In the acute setting, indications for tracheotomy include such conditions as severe facial trauma, head and neck cancers, large congenital tumors of the head and neck (e.g., branchial cleft cyst), and acute angioedema and inflammation of the head and neck. In the context of failed orotracheal or nasotracheal intubation, either tracheotomy or cricothyrotomy may be performed. In the chronic setting, indications for tracheotomy include the need for long-term mechanical ventilation and tracheal toilet (e.g. comatose patients, or extensive surgery involving the head and neck). In extreme cases, the procedure may be indicated as a treatment for severe Obstructive Sleep Apnea seen in patients intolerant of Continuous Positive Airway Pressure (CPAP) therapy.

Complications
In order to limit the risk of damage to the recurrent laryngeal nerves (the nerves that control the vocal folds), tracheotomy is performed as high in the trachea as possible.[citation needed] If only one

of these nerves is damaged, the patient will experience dysphonia; if both of the nerves are damaged, the patient will experience complete aphonia. A 2000 Spanish study of bedside percutaneous tracheostomy reported overall complication rates of 1015% and a procedural mortality of 0%,[10] which is comparable to those of other series reported in the literature from the Netherlands[11][12] and the United States.[13][14] A 2003 American cadaveric study identified multiple tracheal ring fractures with the Ciaglia Blue Rhino technique as a complication occurring in 100% of their small series of cases.[15] The comparative study above also identified ring fractures in 9 of 30 live patients[9] while another small series identified ring fractures in 5 of their 20 patients.[16] The long term significance of tracheal ring fractures is unknown.

Hysterectomy
A hysterectomy (from Greek hystera "womb" and ektomia "a cutting out of") is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total (removing the body, fundus, and cervix of the uterus; often called "complete") or partial (removal of the uterine body while leaving the cervix intact; also called "supracervical"). It is the most commonly performed gynecological surgical procedure. In 2003, over 600,000 hysterectomies were performed in the United States alone, of which over 90% were performed for benign conditions.[1] Such rates being highest in the industrialized world has led to the major controversy that hysterectomies are being largely performed for unwarranted and unnecessary reasons.[2] Removal of the uterus renders the patient unable to bear children (as does removal of ovaries and fallopian tubes) and has surgical risks as well as long-term effects, so the surgery is normally recommended when other treatment options are not available. It is expected that the frequency of hysterectomies for non-malignant indications will fall as there are good alternatives in many cases.[3] Oophorectomy (removal of ovaries) is frequently done together with hysterectomy to decrease the risk of ovarian cancer. However, recent studies have shown that prophylactic oophorectomy without an urgent medical indication decreases a woman's long-term survival rates substantially and has other serious adverse effects,[4] particularly in terms of inducing early-onset-osteoporosis through removal of the major sources of female hormonal production. This effect is not limited to pre-menopausal women; even women who have already entered menopause were shown to have experienced a decrease in long-term survivability post-oophorectomy.[5]

Indications
Hysterectomy is a major surgical procedure that has risks and benefits, and affects a woman's hormonal balance and overall health for the rest of her life. Because of this, hysterectomy is

normally recommended as a last resort to remedy certain intractable uterine/reproductive system conditions. Such conditions include, but are not limited to:
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Certain types of reproductive system cancers (uterine, cervical, ovarian, endometrium) or tumors, including uterine fibroids that do not respond to more conservative treatment options.[9] Severe and intractable endometriosis (growth of the uterine lining outside the uterine cavity) and/or adenomyosis (a form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall musculature), after pharmaceutical or other surgical options have been exhausted.[9] Chronic pelvic pain, after pharmaceutical or other surgical options have been exhausted.[9] Postpartum to remove either a severe case of placenta praevia (a placenta that has either formed over or inside the birth canal) or placenta percreta (a placenta that has grown into and through the wall of the uterus to attach itself to other organs), as well as a last resort in case of excessive obstetrical haemorrhage.[10] Several forms of vaginal prolapse.[9]

Occasionally, women will express a desire to undergo an elective hysterectomythat is, a hysterectomy for reasons other than the resolution of reproductive system conditions or illnesses. Some of the conditions under which a woman may request to have a hysterectomy (or have one requested for her if the woman is incapable of making the request) for non-illness reasons include:
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Prophylaxis against certain reproductive system cancers, especially if there is a strong family history of reproductive system cancers (especially breast cancer in conjunction with BRCA1 or BRCA2 mutation), or as part of recovery from such cancers. Part of overall gender transition for transmen.[11] Severe developmental disabilities, though this treatment is controversial at best, and specific cases of sterilization due to developmental disabilities have been found by statelevel Supreme Courts to violate the patient's constitutional and common law rights.[12]

Risks and side effects

Hysterectomy has like any other surgery certain risks and side effects.
[edit] Mortality and surgical risks

Short term mortality (within 40 days of surgery) is usually reported in the range of 1-6 cases per 1000 when performed for benign causes. Risks for surgical complications are presence of fibroids, younger age (vascular pelvis with higher bleeding risk and larger uterus), dysfunctional uterine bleeding and parity.[26] The mortality rate is several times higher when performed in patients that are pregnant, have cancer or other complications.[27]

Long term effect on all case mortality is relatively small. Women under the age of 45 years have a significantly increased long term mortality that is believed to be caused by the hormonal side effects of hysterectomy and prophylactic oophorectomy.[28] Approximately 35% of women after hysterectomy undergo another related surgery within 2 years. Ureteral injury is not uncommon and can range from 2.2% to 0.03 depending on whether the modality is abdominal, laparoscopic, or vaginal. The injury usually occurs in the distal ureter close to the infundibulopelvic ligament or as a ureter crosses below the uterine artery, often from blind clamping and ligature placement to control hemorrhage.[29]
[edit] Reconvalescence

Hospital stay is 3 to 5 days or more for the abdominal procedure and between 2 to 3 days for vaginal or laparoscopically assisted vaginal procedures. Time for full recovery is very long and independent on the procedure that was used. Depending on the definition of "full recovery" 6 to 12 months have been reported. Serious limitations in everyday activities are expected for a minimum of 4 months.
[edit] Unintended oophorectomy and premature ovarian failure

Removal of one or both ovaries is performed in a substantial number of hysterectomies that were intended to be ovariesparing.[30] The average onset age of menopause in those who underwent hysterectomy is 3.7 years earlier than average even when the ovaries are preserved.[31] This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy or due to missing endocrine feedback of the uterus. The function of the remaining ovaries is significantly affected in about 40% women, some of them even require hormone replacement treatment. Surprisingly, a similar and only slightly weaker effect has been also observed for endometrial ablation which is often considered as an alternative to hysterectomy. Substantial number of women develop benign ovarian cysts after hysterectomy.[32]
[edit] Premature menopause and its effects

Estrogen levels fall sharply when the ovaries are removed, removing the protective effects of estrogen on the cardiovascular and skeletal systems. This condition is often referred to as "surgical menopause", although it is substantially different from a naturally occurring menopausal state; the former is a sudden hormonal shock to the body that causes rapid onset of menopausal symptoms such as hot flashes, while the latter is a gradually occurring decrease of hormonal levels over a period of years with uterus intact and ovaries able to produce hormones even after the cessation of menstrual periods.

When only the uterus is removed there is a three times greater risk of cardiovascular disease. If the ovaries are removed the risk is seven times greater. Several studies have found that osteoporosis (decrease in bone density) and increased risk of bone fractures are associated with hysterectomies.[33][34][35][36][37][38] This has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting. Hysterectomies have also been linked with higher rates of heart disease and weakened bones. Those who have undergone a hysterectomy with both ovaries removed typically have reduced testosterone levels as compared to those left intact.[30] Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density,[39] while increased testosterone levels in women are associated with a greater sense of sexual desire.[40] Oophorectomy before the age of 45 is associated with a fivefold mortality from neurologic and mental disorders.[41]
[edit] Urinary incontinence and vaginal prolapse

Urinary incontinence and vaginal prolapse are well known adverse effects that develop with high frequency very long time after the surgery. Typically those complications develop 1020 years after the surgery.[42] For this reason exact numbers are not known and risk factors poorly understood, it is also unknown if the choice surgical technique has any effect. It has been assessed that the risk for urinary incontinence is approximately doubled within 20 years after hysterectomy. One long term study found a 2.4 fold increased risk for surgery to correct urinary stress incontinence following hysterectomy [43][44] The risk for vaginal prolapse depends on factors such as number of vaginal deliveries, the difficulty of those deliveries, and the type of labor the individual does.[45] Overal incidence is approximately doubled after hysterectomy.[46]
[edit] Effects on social life and sexuality

Some women find their natural lubrication during sexual arousal is also reduced or eliminated. Those who experience uterine orgasm will not experience it if the uterus is removed. The vagina is shortened and made into a closed pocket and there is a loss of support to the bladder and bowel.[specify]
[edit] Other rare problems

Hysterectomy may cause an increased risk of the relatively rare renal cell carcinoma. Hormonal effects or injury of the ureter were considered as possible explanations.[47][48] Removal of the uterus without removing the ovaries can produce a situation that on rare occasions can result in ectopic pregnancy due to an undetected fertilization that had yet to

descend into the uterus before surgery. Two cases have been identified and profiled in an issue of the Blackwell Journal of Obstetrics and Gynecology; over 20 other cases have been discussed in additional medical literature.[49]

Uterine myomectomy
From Wikipedia, the free encyclopedia (Redirected from Myomectomy) Jump to: navigation, search

Uterine myomectomy
Intervention

A laparoscopic myomectomy: The uterus has been incised and the myoma is held and about to be shelled out ICD-9-CM 68.29

Myomectomy, sometimes also fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy the uterus remains preserved and the woman retains her reproductive potential.

Indications
The presence of a fibroid does not mean that it needs to be removed. Removal is called for when the fibroid causes pain or pressure, abnormal bleeding, or interferes with reproduction.

Patients have many options in the management of uterine fibroids, including: observation, medical therapy (such a GNRH agonists), hysterectomy, uterine artery embolization, and highintensity focused ultrasound ablation. Despite these many options, the surgical approach of selected fibroid removal remains an important choice for those women who want or need to preserve the uterus for reproduction.

Complications and risks

Complications of the surgery include the possibility of significant blood loss leading to a blood transfusion, the risk of adhesion or scar formation around the uterus or within its cavity, and the possible need later to deliver via cesarean section.[7] It may not be possible to remove all lesions, nor will the operation prevent new lesions from growing. Development of new fibroids will be seen in 42-55% of patients undergoing a myomectomy.[8] There is some suggestion that myomectomy surgery is associated with a higher risk of uterine rupture in later pregnancy.[9]

Endometrial biopsy

Micrograph showing an endometrial biopsy with simple endometrial hyperplasia, where the gland-tostroma ratio is preserved but the glands have an irregular shape and/or are dilated. H&E stain.

The endometrial biopsy is a medical office procedure that is used to remove a sample of the lining of the uterus. The tissue subsequently undergoes a histologic evaluation which is supplied to the physician to aid in the diagnosis.

Indications
There are a number of indications for obtaining an endometrial biopsy in a non-pregnant woman:
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Women with chronic anovulation such as the polycystic ovary syndrome are at increased risk for endometrial problems and an endometrial biopsy may be useful to assess their lining specifically to rule out endometrial hyperplasia or cancer. In women with abnormal vaginal bleeding the biopsy may indicate the presence of abnormal lining such as endometrial hyperplasia or cancer. In patients with suspected uterine cancer, the biopsy may discover the presence of cancer cells in the endometrium or cervix.

In female infertility the assessment of the lining can determine, if properly timed, that the patient ovulated, however, the same information can be obtained by a blood test of the progesterone level.

Transvaginal ultrasonography is generally done before obtaining an endometrial biopsy as it may help in the gynecologic diagnosis, or even make the taking of a biospy superfluous if the lining is thin. If the endometrial lining is less than 5 mm thick on sonography, it is highly unusual to encounter endometrial cancer.[1] The test is usually done in women over age 35.[2] A more thorough histologic evaluation can be obtained by a dilatation and curettage, which requires anesthesia.

[edit] Contraindications
The procedure is contraindicated in pregnancy.[1] Therefore, women in the reproductive years may need a pregnancy test before a biopsy is taken to assure that the test is not done during a pregnancy. Other contraindications are pelvic inflammatory disease and coagulopathies.[1] An endometrial biopsy usually cannot be done as an office procedure in children, young women, women with vaginismus, or women with cervical stenosis. If necessary, an examination under anesthesia could be performed at which time a biopsy could be taken.

Risks
While procedure is generally considered safe, cramps or pelvic pain is a common if short-lived side effect. After the procedure, the patient may experience some bleeding. A uterine perforation or an infection are rare complications.[2]

Splenectomy
From Wikipedia, the free encyclopedia Jump to: navigation, search

Splenectomy
Intervention ICD-9-CM MeSH OPS-301 code: 41.43, 41.5 D013156 5-413

A splenectomy is a surgical procedure that partially or completely removes the spleen.

Indications
The spleen, similar in structure to a large lymph node, acts as a blood filter. Current knowledge of its purpose includes the removal of old red blood cells and platelets, and the detection and fight against certain bacteria. It is also known to function as a site for the development of new red blood cells from their hematopoietic stem cell precursors, and particularly in situations in which the bone marrow, the normal site for this process, has been compromised by a disorder such as leukemia. The spleen is enlarged in a variety of conditions such as malaria, mononucleosis and most commonly in "cancers" of the lymphatics, such as lymphomas or leukemia. It is removed under the following circumstances: 1. 2. 3. 4. When it becomes very large such that it becomes destructive to platelets/red blood cells For diagnosing certain lymphomas Certain cases of wandering spleen When platelets are destroyed in the spleen as a result of an auto-immune process (see also idiopathic thrombocytopenic purpura) 5. When the spleen bleeds following physical trauma 6. Following spontaneous rupture 7. For long-term treatment of congenital erythropoietic porphyria (CEP) if severe hemolytic anemia develops[1] 8. The spread of gastric cancer to splenic tissue 9. When using the splenic artery for kidney revascularisation in renovascular hypertension. 10. For long-term treatment of congenital pyruvate kinase (PK) deficiency

The classical cause of traumatic damage to the spleen is a blow to the abdomen during a sporting event. In cases where the spleen is enlarged due to illness (mononucleosis), trivial activities, such as leaning over a counter or straining while defecating, can cause a rupture.

Side effects
As splenectomy causes an increased risk of sepsis due to encapsulated organisms (such as S. pneumoniae and Haemophilus influenzae) the patient should receive the pneumococcal conjugate vaccine (Prevnar), Hib vaccine, and the meningococcal vaccine; see asplenia. These bacteria often cause a sore throat under normal circumstances but after splenectomy, when infecting bacteria cannot be adequately opsonized, the infection becomes more severe. An increase in blood leukocytes can occur following a splenectomy.[2][3] The post-splenectomy platelet count may rise to abnomormally high levels (thrombocytosis), leading to an increased risk of potentially fatal clot formation. There also is some conjecture that post-splenectomy patients may be at elevated risk of subsequently developing diabetes.[4] Splenectomy may also

lead to chronic neutrophilia. Splenectomy patients typically have Heinz bodies in their blood smears[5]