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1. MODERN ORGAN SAVING OPERATIONS IN GYNAECOLOGY BY-RACHIT KHERA (6532)

2. LEARNING OBJECTIVES ALL ARE ABLE TO UNDERSTAND : HYSTERECTOMY MYOMECTOMY DILATATION AND CURRETAGE OVARIAN CYSTECTOMY OOPHORECTOMY DILATATION AND INSUFFLATION CERVICAL BIOPSY THERMAL CAUTERIZATION CRYOSURGERY AMPUTATION OF CERVIX SALPHINGECTOMY HYSTEROSALPHINGOGRAPHY LAPAROSCOPY HYSTEROSCOPY

3. OPERATION O N UTERUS

4. HYSTERECTOMY ABDOMINAL H YS TER E C T OMY VAGINAL HYSTERECTOMY LAPAROSCOPIC ASSISTED VAGINAL HYSTERECTOMY

5. ABDOMINAL HY S TER E C T OMY

6. PRE OPERATIVE PROCEDURE Blood testing , review her medical records, confirm the diagnosis . Take patient’s consent, explain risk and procedures Place IV line and prophylactic antibiotics Catheterization Call for anaesthetist , prepare for operating room and prepare blood products.

7. STEPS OF HYSTERECTOMY Prepare the surgical field: Give anaesthesia preferably spinal Place patient in supine position Paint her abdomen with povidone iodine Drip the patient

8. There are three main approaches to a hysterectomy. The principles and steps for each approach are the same (but in a different order). Abdominal  – via an incision in the abdomen. Vaginal  – via incision through the superior part of the vagina. Laparoscopic  – via small incisions in the abdomen, and using laparoscopes and a uterine manipulator. Mobilisation  should be encouraged as soon as possible. Discharge is usually after 1-2 days for vaginal and laparoscopic hysterectomy, and 2-5 days for abdominal hysterectomy (depending on the type of incision – generally longer stay if midline incision). STEPS OF HYSTERECTOMY

9. DILATATION AND CURETTAGE (D&C) 1. **Preparation**: The patient is usually advised to refrain from eating or drinking for several hours before the procedure. 2. **Anesthesia**: Local or general anesthesia is administered to minimize discomfort. 3. **Dilation**: The cervix is gently dilated using instruments. 4. **Curettage**: A curette (a surgical instrument) is used to scrape the lining of the uterus or remove tissue. 5. **Completion**: The procedure typically lasts 15-30 minutes. Aftercare instructions are provided.

10. MYOMECTOMY Enucleation of myomata from the uterus, leaving behind a potentially functioning organ capable of future reproduction. Important consideration prior to myomectomy are : Size and numbers of fibroids Should be done mainly to preserve reproductive function, pregnancy rate (40-60%) Risk of recurrence / persistence (30-50%) Risk of persistence menorrhagia (1-5%)

11. PREOPERATIVE PROCEDURE Confirm the diagnosis (USG, MRI,HSG, endometrial biopsy, examination of the husband in case of infertility) Take consent, explain risk and procedures Blood investigations Preoperative treatment with Gnrh analogue – to reduce vascularity of the tumour Place IV line and antibiotic prophylaxis Call for anaesthetist, prepare operating room and keep blood products ready

12. INSTRUMENTS

13. BASIC STEPS Anesthesia: General or regional anesthesia is administered. Access: Depending on the size and location of the fibroids, access may be through: - Abdominal incision (open myomectomy ) - Laparoscopy (minimally invasive with small incisions) - Hysteroscopy (through the vaginal canal for fibroids inside the uterus) 3. Removal: The fibroids are surgically excised from the uterine wall. 4. Closure: The uterus is stitched back up, and the incisions are closed.

14. OPERATIONS ON OVARY

15. OVARIAN CYSTECTOMY Removal of ovarian tumour leaving behind the healty ovarian tissue Operation of choice especially in benign neoplasm of ovary in young woman

16. OVARIOTOMY /OOPHORECTOMY Removal of tumour along with healthy ovarian tissue Indicated when tumour is big and complicated by torsion or hemorrhage.

17. OPERATIONS ON FALLOPIAN TUBES

18. DILATATION AND INSUFFLATION (D&I) Dilatation of cervix followed by introduction of air or carbon dioxide into the uterine cavity to check for tubal patency. Indications are for infertility investigation and following tuboplasty . Contraindicated in case of pelvic infection Complications include all the risk from dilatation process and the following: Air embolism Rupture of the tube

19. PROCEDURE OF D&I Dilatation of cervix Insufflation cannula fitted with a tube and is introduced into the cervical canal Increase pressure in manometer gradually Auscultates over the flank For any hissing sound.

20. SALPINGECTOMY Surgical removal of fallopian tube Indications Ectopic (tubal) pregnancy Hydrosalpinx Infection and stricture of the tube Cancer of fallopian tube Prevention of ovarian cancer

21. OPERATIONS ON CERVIX

22. CERVICAL BIOPSY Excision of the cervix to remove small amount of tissue. TYPES OF CERVICAL BIOPSY Cone biopsy Punch biopsy Surface biopsy Wedge biopsy Ring biopsy

23. STEPS OF CONE BIOPSY Procedure is done with cold knife cone with the help of CO2 laser under colposcopic guidance. General anaesthesia Hemostatic sutures is placed at 3 and 9 oclock position Cut the cone, apex is kept below the internal os After cone is removed, a margin suture is placed at 12 oclock position for identification of the cone Routine endocervical curettage is done Cone margins are repaired by hemostatic sutures.

24. Operation to destroy eroded area on the cervix either by thermocoagulation or red hot cauterization Indication: cervical ectopy with troublesome discharge THERMAL CAUTERIZATION

25. Destruction of tissue by extreme freezing - produce cellular dehydration Indications : Cervical ectopy Benign cervical lesions Condyloma accuminata of vulva and VIN less than 2 cm As a palliative measure to arrest bleeding in Ca cervix CRYOSURGERY

26. Operative procedure whereby a part of lower cervix is excised. Indications Congenital elongation Chronic cervicitis with hypertrophied cervix (not relived by conventional therapy) As a component part of Fothergill’s to rectify the supravaginal elongation. AMPUTATION OF CERVIX

27. HYSTEROSALPHINGOGRAPHY (HSG) Operative procedure to assess interior anatomy of uterus and tubal patency

28. PROCEDURES Ask patient to empty bladder Position: dorsal position with buttocks on the edge Do internal examination Introduce posterior vaginal speculum Held anterior lip of cervix with Allis forceps Introduce uterine sound to see length and direction of uterine cavity HSG cannula fitted with syringe is introduced. (fill syringe with 5-10 ml of dye) Inject dye slowly Passage of dye into interior is observed by X-ray intensifier

29. LAPAROSCOPY Laparoscopy is a minimally invasive surgery performed on abdomen or pelvis through small incision with the aid of camera.

30. Telescope Veress needle Trocar and cannula Light source Imaging system Camera unit and monitor Insufflator BASIC INSTRUMENTS

31. HYSTEROSCOPY Procedure that allows direct visualization inside the uterus BASIC INSTRUMENTS Telescope Microhysteroscope Telescope sheath Distending media

32. REFERENCES https:// www.bmc.org /gynecology/common-procedures DC DUTTA ’ S TEXT BOOK OF GYNECOLOGY https:// www.hopkinsmedicine.org /health/treatment-tests-and-therapies/gynecology-surgery https:// www.mayoclinic.org /departments-centers/minimally-invasive-gynecologic-surgery/overview/ ovc-20424071