What is a hysteroscopy and curettage and what is it used for?
Light tube through cervix and into uterus
Curette then scrapes tissue from uterus
After may have backache or cramps, small clots and light vaginal bleeding for a few weeks
Uses: investigate heavy periods, unusual vaginal bleeding, postmenopausal bleeding, pelvic pain, repeated miscarriages or difficulty getting pregnant. Look for fibroids. Remove dislodged IUDs
Diagnostic laparascopies can help diagnose certain gynaecological conditions. What are some operative laparoscopies?
- Ovarian Cystectomy
- Endometriosis removal
- Myomectomy (can also be open)
- Hysterectomy (can also be open)
What are the different classifications of hysterectomies?
- Total hysterectomy: uterus and cervix
- Sub-total hysterectomy: body of uterus only, leaving cervix behind
- Total hysterectomy and bilateral salpingo-oophorectomy: removal of uterus, cervix, fallopian tubes and ovaries.
- Radical hysterectomy: uterus and cervix, the parametrium, a vaginal cuff and part of or the whole of the fallopian tubes. For cervical cancer
What are the different approaches for a hysterectomy?
- Abdominal
- Vaginal
- Laparoscopic
What are the steps of an abdominal hysterectomy?
Low transverse or midline incision depending on size of the uterus
- Round ligaments divided.
- If the tubes and ovaries are to be removed, the infundibulopelvic ligaments are ligated and tied (the ureters should be identified first).
- The uterovesical peritoneal fold is divided and the bladder reflected down past the cervix.
- The parametrial tissue is divided.
- The uterine vessels and ligated and tied.
- The paracervical tissue and uterosacral ligaments are ligated and tied.
- The vagina is opened and the uterus and cervix removed.
- The vagina is usually closed with an absorbable suture.
- Haemostasis is confirmed at all pedicles.
- The abdomen is closed.
What anaesthetic is used for a hysterectomy?
- General for abdominal and laparoscopic
- Regional for vaginal
What are some examples of indications for a hysterectomy?
- Heavy menstrual bleeding
- Pelvic pain
- Uterine prolapse
- Gynaecological malignancy (usually ovarian, uterine or cervical)
- Risk reducing surgery, usually in cases of BRCA 1 or 2 mutations, or Lynch syndrome
- Major postpartum haemorrhage
What are some complications with a hysterectomy?
General: haemorrhage, infection, pain
- Damage to the bladder and/or the ureter
- Damage to the bowel
- Return to theatre because of bleeding/wound dehiscence
- Pelvic abscess/infection
- VTE/PE
- Early menopause by 1-2 years if ovaries left
What is a myomectomy?
Surgery to remove fibroids
It may be considered as an alternative to a hysterectomy if want to have children in the future
Can be done open or laparoscopically
What is an endometrial ablation?
Destroys the endometrium treat people with heavy menstural bleeding with no apparent cause
Hysteroscopy is done first to determine suitability for procedure
Only done if not planning to have anymore children and should take contraception afterwards as if become pregnant (low chance) can have high risks e.g placenta praevia/accreata
What are the different methods used for endometrial ablation?
Transcervical Resection of the Endometrium (TCRE): Diathermy loop, needs general anaesthetic, time consuming
Balloon Ablation: A balloon filled with heated fluid sits inside the uterus for a pre-specified length of time to destroy the endometrium. Needs cervical dilation. More suitable for irregularly shaped endometrium
Microwave Energy: IUD with microwave energy destroys endometrium. 72 seconds, no cervical dilation needed
Bipolar Mesh: bipolar energy mesh is inserted into the uterus, expanded and then energy delivered to the endometrium, needs cervical dilation
What are some contraindications for endometrial ablation?
- Those who still want children
- Endometrial hyperplasia
- Malignancy
What are some complications with endometrial ablation?
- Electrolyte disturbance due to fluid overload
- Uterine Perforation
- Pelvic pain due to scarring
What is a tension free vaginal tape?
Used to treat stress incontinence
Synthetic tape placed around the urethra to form a sling to support it and prevent leakage
What procedure needs to be performed after a tension free vaginal tape and why?
Cystoscopy to check no bladder perforation
What are some complications of tension free vaginal tape?
Long term effectiveness of these is unknown so need to counsel
- Bladder perforation
- Damage to pelvic blood vessels or viscera.
- Urinary retention
- Urgency
- Groin pain
- Vaginal tape erosions
What are some alternatives to a tension free vaginal tape?
- Mid urethral tape: trans-obturator tape (TOT)
- Open colposuspension
- Autologous rectus fascial sling
- Anterior vaginal repair
- Injection of bulking agents into the bladder neck
How is a pipelle biopsy done?
Used to biopsy endometrium
Use speculum and put pipelle through endocervical canal
Pipelle will suction out endometrial tissue and then put into preservative and send for histology
How is the Nexplanon implant inserted?
Small, flexible 40mm plastic rod with barium in so can be seen via x-ray
Usually done in first 5 days of the menstrual cycle, and is effective immediately. If inserted after that window, it takes 7 days so use condoms for this time
Local anaesthetic to upper arm. Metal device pierces skin and positions implant sub-dermally
What are some contraindications for the contraceptive implant?
- Already pregnant
- St John’s Wort
- Arterial disease, history of stroke or serious heart disease.
- Liver disease
- Breast cancer
- Unexplained vaginal bleeding
What are some advantages and disadvantages of the progesterone implant?
How long after IUD/IUS insertion is it effective as a contraceptive?
IUD - Immediately
IUS - Immediate if within first 7 days of cycle, otherwise 1 week
How is an IUD/IUS inserted?
- Do STI screening 2 weeks before as STI is CI
- Perform bimanual examination is performed
- Insert speculum and cervical dilator
- Small plastic T-shaped device then pushed through the cervix into the uterus. Cut strings so sit in vagina so woman can check to ensure device not expelled
What are some indications for an IUD/IUS?
- Long term contraceptive
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4 - Operations and Procedures41
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7 - Vaginal and Vulval Disorders inc Urinary Incontinence71
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