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Gynaecological

procedure

Lim Kuan Yan

Taylors University Lakeside Campus


Learning outcome

Describes types of uterine perforation


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

Uterine bleeding/ heamorrhage


Cervical laceration
Uterine perforation
Postprocedural infection
Postprocedural intrauterine scynechiae (intrauterine adhesion)
Anaesthetic complication
2.salpingectomy -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

Indication (Iverson,1996, periti, 1988, Sawin, 2000)


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!