Discuss - Other complications Discuss - Myomectomy, Cystectomy Mechanism of perforation
Immediate trauma perforation
Later (secondary) perforation Partial uterine perforation- due placement of IUD Type A = partially in myometrium and also inside uterine cavity
Type B = IUD lies entirely within the myometrium
Type C = Device protruded into the peritoneal cavity, other part
still lie within the myometrium
Type D = situated all 3 compartments
uterine cavity myometrium peritoneal cavity Complete perforation due placement of IUD Uterine device remain near the uterus or it may move within the abdominal cavity Types of uterine perforation
Classification Benign = midline with blunt instrument, no suction Intermediate = perforation with suction on, no abdominal content are seen or serious bleeding Serious = perforation with suction on, and abdominal contents (bowel, omentum, etc) seen or heavy bleeding occurs Other complication of gynaecological procedures Dilation and curettage Salpingectomy Salpingostomy Myomectomy 1. (D&C) dilatation and curettage - Complications
Injury to ipsilateral ovary (laparoscopic salpingectomy)
Affect fertility and hormone function Ectopic pregnancy Trophoblastic tissue can persist (molar pregnancy) 3.Salpingostomy complications
Possible need for salpingectomy if the tube is irreparably damaged or bleeding
from the tube cannot be controlled Risk or persistent trophoblastic disease Bleeding 6. Oophorectomy (Ovary removal)- complications Bleeding Infection Damage nearby organ Rupture of tumour, spreading pontential cancerous cell Retention of ovary cell Small bowel obstruction 4. Myomectomy - complications Postoperative vaginal bleeding (common) Postoperative fever (common, particularly first 48 hours) Recurrence for myomectomies Abdominal myomectomy complication Complication of all usual complication of gynaecologic laparotomy (bleeding infection, visceral damage thromboembolism, intraoperative blood loss) Conversion of myomectomy to hysterectomy intraoperatively (most significant short term risk, when resconstructing the uterus is not possible due to many defects left by removal of multiple small fibroids or single large fibroid or to control of bleeding ) Laparoscopic myomectomy complication Injury to bladder,bowel, ureter and blood vessels (mainly due to placement of trocar) Uterine rupture in future labor (due to suboptimal defect closure) Hysteroscopic myomectomy complication Heamorrhage, uterine perforation, damage to the cervix excessive absorption of distention media into vascular system, which can cause metabolic disturbance (most serious potential complication), it causes pulmonary edema, hyponatremia, cerebral edema and death. 5. Ovarian cystectomy- complications Bleeding (intraoperative complication) Inadvertent cyst rupture (intraoperative complication) Example 1 = inadvertent spillage of contnets of endometriomas result in subsequent spread of the condition to other part of pelvis Example 2 = spillage of contents of cystic teratoma may result in peritoneal irritation Example 3 = rupture of malignant cystic structure (more serious), might result in tumour dissemination and affect patient survival. 7.Hysterectomy - complications
Ureteral injuries Bowel injury Bladder injury Heamorrhage (most serious postoperative complication) Infection (most common postoperative complication) Atelectasis, fallopian tube prolapse, thromboembolic disease, myocardial infarction, stroke, and renal failure. Early menopause (hormonal changes secondary to hesterectomy) Psychological effect Myomectomy Myomectomy
Definition Removal of leiomyomas (fibroids) from their surrounding myometrium.
Indication for myomectomy
Abnormal uterine bleeding Pelvic pain Infertility Recurrent miscarriage Myomectomy types of excision Indication for laparoscopic excision submucosal and intramural leiomyoma
Indication for Hysteroscopic excision
-Submucous leiomyomas
Indication abdominal myomectomy
-Tumour size (>5cm), number (>3), and location(Intraligamentous) - high risk of complication Myomectomy - preoperatively Patient evaluation - Assessment of leiomyoma size, number and location Examination Sonography (transabdominal, vaginal) MRI Hysteroscopy
Contraindication to the surgery hysterosopic myomectomy
Pregnancy Potential endometrial cancer Current reproductive tract infection Medical condition sensitive to fluid volume overload Myomectomy -preoperatively
Consent Risk of significant bleeding and transfusion Risk of uncontrolled heamorrhage Risk of extensive myometrial injury during tumour removal May need conversion to hysterectomy (risk convert into open surgery- especially multiple large masses or locate in broad ligament, near corneua, involvement of cervix) Postoperatively, risk of adhesion formation Leiomyomas recurrence (especially laparoscopic myomectomy, may missed small deep intramural leiomyomas, cause dont have surgeons tactile sensation) Possible next delivery be cesarean delivery (based on extent of myometrial disruption during myomectomy) Risk of bowel injury Myomectomy -preoperatively
Antibiotic prophylaxis (Iverson and coworker, 1996) Generally not required Analysis of open myomectomy, 54% received prophylaxis, infectious morbidity was not lowered compared to those which does not received antibiotic prophylaxis
Infertily patient (prevent potential adhesion formation which associate with pelvic infection.) = 1g, 1st or 2nd generation cephalosporine Myomectomy -preoperatively (other preparation) Bowel preparation Risk of bowel injury (especially patient with extensive adhesion)
Vaginal preparation Risk of conversion to hysterectomy (done prior surgical draping)
DVT prophylaxis If patient have DVT risk factors Laparoscopic myomectomy - intraoperative (surgical steps) Anesthesia and patient positioning Trocar and laparoscope insertion Use of vasopressin Serosal incision Tumour enucleation Bleeding Myometrial closure Serosal closure Leiomyoma removal Laparoscopically assisted myomectomy (LAM) Hysteroscopic myomectomy - intraoperative (surgical steps) Anesthesia and patient positioning Medium selection Cervical dilatation Instrument insertion Resection Intramural leiomyomas Fluid volume deficit Homostasis Laparoscopic myomectomy - postoperative Hospitalization 0-1 days Monitor for return of normal bowel function Monitor for fever (>38C) possible causes (atelectasis, myomectrial incisional hematomas and factors released with myometrial destruction) Postoperative activity (individualize, but vigorous exercise usually delayed until 4 weeks after surgery) Hysteroscopic myomectomy - postoperative Hopitalisation 0-1 days Spotting or light bleeding may follow surgery for 1-2 weeks Monitor for return of normal bowel function Monitor for fever (>38C) posibble causes (atelectasis, myomectrial incisional hematomas and factors released with myometrial destruction) Postoperative may resume diet and activity (individualize, but vigorous exercise usually delayed until 4 weeks after surgery) For patient desiring pregnancy, conception may be attempted in menstrual cycle after resection, unless the leiomyomas was broadbased or significant intramural component. (these patient advised for use barrier constraception for 3 cycles), women fail to conceive or continue have abnormal bleeding following resection, postoperative hysterosalpingography or hysteroscopy is recommede to evaluate for synechiae. Ovarian cystectomy Ovarian cystectomy
Definition Removal of ovarian cysts (usually prompted by patient symptoms or concerns of ovarian ma
Function & advantage
Remove ovarian pathology + preserve hormonal function and reproductive capacity Reduce postoperative adhesion formation Reconstruction of normal ovarian anatomy to aid transfer of ova to fallopian tube Ovarian cystectomy
Method Laparoscopically Laparotomy (when cyst is large, adhesive disease limits aaccess and mobility, or risk of malignancy is great)
Malignancy suspected when cyst:
Large >10cm Concurrent ascites Serum tumour markers are elevated Cysts content appear complex Borders appear irregular during imaging Ovarian cystectomy preoperative Consent Surgical risk Extensive bleeding from or injury to ovary Necessitates removal of the entire ovary Variable degree of ovarian reserve may be lost with ovarian cystectomy If ovrian suspected prior to surgery, possibility of surgical staging, including need for hysterectomy, omentectomy, and removal of both ovaries. Some chronic pain may persist (not relieve) despite of cystectomy. (especially ture in those with coexistent endometriosis) Patient preparation Antibitiotic typically not required preoperatively If hysterectomy is require during ovarian staging, antibiotic may be given intraoperatively Ovarian cystectomy - Intraoperative (surgical steps )
Anesthesia and patient positioning
Abdominal entry Ovarian incision Cyst dissection Cyst excision Cyst closure Incision closure Ovarian cystectomy postoperative Postoperative thrombotic and pulmonary complication Monitor return of normal bowel function and signs of ileus Reference Thank you!
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