Pocket Obstetrics and Gynecology

Appendix: Common procedures and surgeries

INTRAUTERINE DEVICE INSERTION (IUD)

Levonorgestrel Intrauterine System (LNG-IUS) (Adapted from Bayer HealthCare Pharmaceuticals Inc., physician insert, 2009)

• Timing: Insert after Preg ruled out or after 1st trimester abortion or postpartum

• Preparation:

Informed consent, bimanual exam

Obtain cervical cx, cleanse cervix w/ an antiseptic solution

Consider paracervical block

Sound uterine cavity

• Procedure (sterile):

See http://www.mirena-us.com/hcp/placement-&-removal/precise-placement.jsp

Ensure slider on inserter is advanced all the way toward the device. Pull threads to draw device into insertion tube. Ensure arms are parallel to slider. Fix threads in the cleft at end of handle. Set flange to depth measured by uterine sound.

Hold the slider firmly. Apply gentle countertraction w/ tenaculum. Gently advance the insertion tube into the uterus until flange is 1.5–2 cm from external cervical os. While holding inserter, release device by pulling slider back until top of slider reaches mark. Advance inserter until flange touches cervix.

Release LNG-IUS by pulling the slider down all the way

Cut threads to 2–3 cm visible outside cervix

Consider US to verify position. Remove if not positioned appropriately. Do not reinsert same device.

String check ∼w after placement of IUD

ParaGard (Copper T 380A IUD) (Adapted from Teva Women’s Health, Inc., physician insert, 2010)

• Timing: Same as LNG-IUS. Can be used as emergency contraception w/i 5 d of unprotected intercourse.

• Preparation: Same as LNG-IUS

• Procedure:

See http://www.paragard.com/Pdf/ParaGard-PI.pdf

Load IUD into insertion tube by folding the 2 horizontal arms against the stem, & push tips of the arms securely into the inserter tube (<5 min from insertion)

Introduce white rod into the insertion tube until it touches the end of the IUD

Adjust the blue flange to the uterus cavity length. Advance insertion tube to uterine fundus (blue flange should be at external os).

Hold white rod steady & withdraw the insertion tube 1 cm to release IUD

Advance insertion tube to fundus

Hold the tube steady & withdrew rod

Withdraw tube completely. Trim threads to 3–4 cm.

Consider US to verify position. Remove if not positioned appropriately. Do not reinsert same device.

String check ∼4 w after placement of IUD

SUBDERMAL DEVICE INSERTION

Etonogestrel implant (Implanon) insertion (Adapted from Merck & Co Inc., physician insert, 2012)

• Timing: Same as LNG-IUS

• Preparation: Informed consent

• Procedure (sterile):

Position arm flexed at the elbow & externally rotated so that wrist is parallel to ear or her hand is positioned next to her head

Identify insertion site at the inner side of the nondominant upper arm about 8–10 cm (3–4 in) above the medial epicondyle of the humerus

Insert just under skin to avoid large bld vessels & nerves deeper in the subcutaneous tissue btw triceps & biceps muscles

Mark the spot where implant will be inserted. Mark a spot a few centimeters prox to the 1st mark as a direction guide.

Clean insertion site w/ an antiseptic solution; anesthetize area along insertion path. Remove implant applicator from package. Ensure implant needle & rod are sterile.

Look for the etonogestrel implant rod, (white cylinder inside the needle tip)

Lower the IMPLANON rod back into the needle by tapping it back into the needle tip. Remove the needle shield while holding the applicator upright.

Stretch the skin around the insertion site w/ thumb & index finger

At <20-degree angle, insert tip of the needle w/ bevel up

Lower applicator to a horizontal position. Lift the skin up w/ the tip of the needle.

While “tenting” the skin, insert the needle to its full length parallel to skin surface

Press the obturator support, turn obturator 90 degrees

Hold obturator fixed & fully retract cannula. Confirm that the implant has been inserted by palpation. Grooved tip of the obturator should be visible.

Consider pres dressing to minimize bruising

If not palpable, implant can be located w/ high-frequency US or MRI

Figure APP-2.1 Implanon insertion

BARTHOLIN ABSCESS INCISION AND DRAINAGE

• Indication: For rx of cystic enlargement or abscess formation. Will not prevent recurrence.

• Preoperatively:

Identify incision point (inner surface of abscess. INSIDE hymenal ring).

Obtain informed consent (risk of recurrence & poss need for additional procedures)

• Steps:

Infiltrate skin w/ local anesthesia

Incise using a scalpel w/ a no. 11 blade

Explore the inside of the cyst/abscess & open any loculations

A Word catheter can be used to reduce recurrence. Insert the deflated Word catheter into the cyst cavity & inject 2–3 mL of sterile saline through the catheter to inflate the balloon. Tuck end of Word catheter into the vagina.

LOOP ELECTROSURGICAL EXCISION PROCEDURE (LEEP)

• Indication: To better characterize glandular or squamous lesions after unsatisfactory initial w/u, by excising the transformation zone of the cervix

Figure APP-2.2 Word Catheter: After local anesthesia and preparation, use a stab incision to create a 1–1.5-cm deep opening in the cyst. Insert the tip of a Word catheter, and inflate the bulb with water or lubricating gel. Keep the catheter in place for 4 w. Marsupialization: Make a fusiform incision adjacent to the hymenal ring. Remove an oval wedge of vulvar skin and the underlying cyst wall. Suture the cyst wall to the adjacent vestibular skin.

• Preoperatively:

Colposcopic exam & biopsies

Exclude Preg (unless high suspicion of invasion), obtain informed consent

• Steps:

Ground pt, insert insulated speculum w/ smoke evacuation tubing. Select appropriately sized loop to excise transformation zone.

Use iodine or acetic acid to identify lesions

Consider paracervical block

Introduce loop 3–5 mm lateral to os at 90-degree angle to cervix. Activate current (cutting) prior to tissue contact.

Draw loop parallel to surface until opposite side of os is reached. Withdraw at 90-degree angle. Stop electrical current.

Perform an endocervical curettage or “top hat” excision

Obtain hemostasis using electrocautery or Monsel solution. Apply pres.

Tag specimen for orientation, & send to pathology

Figure APP-2.3 (1) To excise tissue, the loop is held just above the surface of the cervix and 2–5 mm lateral to the lesion, and current is applied before the loop contacts the cervix. (2) Draw the loop slowly through the tissue until the loop is 2–5 mm past the edge of the transformation zone on the opposite side. (3) Superficial fulguration is usually applied to the entire crater and to any spots of point hemorrhage.

ENDOMETRIAL BIOPSY

• Indications:

Used to exclude endometrial cancer in high-risk pts w/ abn uterine bleeding (>35 y, obese, FHx, PCOS, etc.), as part of w/u for glandular abnormality on Pap smears, or f/u after conservative mgmt of endometrial hyperplasia

Req before endometrial ablation, and often before hysterectomy

• Preoperatively: Exclude Preg, obtain informed consent

• Steps:

Perform speculum exam

Clean the cervix w/ Betadine. Consider tenaculum placement.

Advance endometrial sampling Pipelle through the cervical canal to the uterine fundus

Withdraw the stylet to apply suction; sample all 4 walls

AMNIOCENTESIS

• Indications:

Detection of lung maturity, genetic dx, & to exclude infection

Confirm rupture of membranes using the amnio-dye test (“tampon test”)

Relieve pres sx in polyhydramnios

• Preoperatively: Obtain informed consent

• Steps:

Use US to identify large amniotic fluid pocket away from the fetus

Advance spinal needle into amniotic fluid w/ sonographic guidance

Withdraw stylet, attach syringe, & draw back to obtain a fluid sample

COMMON GYNECOLOGIC SURGERIES

Dilatation and Curettage (Evacuation)

• Indications: Before endometrial ablation, for definitive sampling of endometrium, termination of Preg, or to remove retained products of conception

• Preoperatively:

Exclude Preg (unless for termination)

Obtain informed consent

Consider cervical softening w/ misoprostol

• Steps:

Ensure adequate anesthesia (general, regional, local), empty bladder

EUA for uterine position/size

Insert a speculum, apply tenaculum to anter lip of the cervix

Use dilators to gradually open the cervix. Optimal dilation depends on procedure.

May perform curettage w/ suction device, or w/ a sharp curette. For suction curettage, the curette size usually corresponds to the gestational age/uterine size.

Introduce the curette to fundus & sample all walls & fundus

Consider forceps to remove larger tissue fragments, or US guidance for difficult procedures

Bartholin cyst marsupialization with or without excision

• Indication: Recurrent cyst formation. Objective is to open a new ductal orifice.

• Preoperatively: Obtain informed consent

• Steps:

Start w/ 2–4-cm incision 1 cm lateral & parallel to hymenal ring near medial edge of labium minus

Incise the cyst wall & use Allis clamps to grasp the skin & cyst wall edges

Drain the cyst completely; open any loculations

Use interrupted stitches to suture the cyst wall to the adj skin edge

Consider cyst wall excision/bx for repeated recurrences or if high risk for malig

Cold Knife Conization (CKC)

• Indication:

To better characterize glandular or squamous lesions after unsatisfactory initial w/u by excising the transformation zone of the cervix

Generally reserved for more difficult cases & pts w/ recurrence after LEEP

A/w more obstetric complications compared to LEEP & Laser conization

• Preoperatively:

Colposcopic exam & biopsies are req before Surg

Exclude Preg (unless high suspicion for invasion)

Obtain informed consent

• Steps:

Adequate anesthesia, empty bladder

Use iodine or acetic acid for identification of the lesions

Inject vasopressin or dilute epi circumferentially into cervical stroma, lateral to line of resxn

Place sutures at 3 & 9 o’clock to manipulate the cervix

Make an incision that creates a 2–3-mm border around lesion. Ensure inclusion of the endocervical canal.

Perform endocervical curettage

Hemostasis w/ Monsel solution or electrocautery

Operative hysteroscopy

• Indications:

Eval & rx of polyps, myomata, adhesions, septa. Also tubal sterilization, removal of retained IUD or FB.

• Preoperatively:

Obtain informed consent, exclude Preg

In premenopausal women, consider performing during the early proliferative phase of the menstrual cycle, or treating w/ progestins to induce endometrial atrophy

In postmenopausal women, consider misoprostol if there is cervical stenosis

• Steps:

Adequate anesthesia, empty bladder

Perform EUA to determine uterine position/size

Insert speculum, apply tenaculum to the anter lip of the cervix

Use dilators to gradually open the cervix. Dilate to diameter of the hysteroscope.

Introduce the hysteroscope into the uterine cavity, survey cavity

Distention media include isotonic electrolyte (LR, NS) & nonelectrolyte (glycine, mannitol). Infusion pres should be ∼45–80 mmHg

Perform the indicated procedure

Monit fluid deficit. Plan completion of the case if the deficit reaches 750 cc; stop if 1500 cc (nonelectrolyte), or 2500 cc (electrolyte).

Endometrial ablation

• Indications: Heavy menstrual bleeding

• Preoperatively:

Exclude Preg

Exclude malig & hyperplasia by endometrial bx

Need to have a plan for contraception after ablation

Obtain informed consent

• Steps:

Adequate anesthesia, empty bladder, EUA

Insert a speculum, apply a tenaculum to the anter lip of the cervix

Sound the uterus

Use dilators to gradually open the cervix. Dilation determined by diameter of ablative device.

Consider hysteroscopic eval if concern for cavitary abnormalities (polyps, etc.)

Perform indicated procedure (variations include resectoscope, rollerball, thermal balloon, hydrothermal, radiofrequency, microwave, & cryoablation)

Monit fluid deficit if distending medium is used

Hysteroscopic tubal ligation

• Indications: Undesired fertility

• Preoperatively:

Exclude Preg

Best done during the proliferative phase of the cycle, or after rx w/ OCPs, DMPA, etc. to induce endometrial atrophy for visualization

Obtain informed consent

• Steps:

Adequate anesthesia, empty bladder, EUA

Insert a speculum, apply tenaculum to the anter lip of the cervix, sound the uterus

Use dilators to gradually open the cervix. Dilation determined by diameter of hysteroscope.

Currently, only approved system is the microinsert (Essure)

Cannulate each tubal ostium w/ Essure device. Follow package insert to deploy insert.

Pt must use contraception until tubal occlusion is documented by HSG (at 3 mo)

Operative laparoscopy

• Indications: Minimally invasive access to abd

• Preoperatively:

Decide entry point (eg, umbilical, LUQ) & method of entry (eg, Veress, open)

Obtain informed consent

• Steps:

General anesthesia w/ neuromuscular blockade, OG tube, Foley catheter, EUA

Consider inserting a uterine manipulator

Using a scalpel, make a skin incision large enough to accommodate the laparoscopic trocar

Abdominal trocars can be inserted in several ways:

Introduce the Veress needle into the abdominal cavity w/ the abdominal wall elevated. 2 “pops” can be felt as the needle passes through the fascia & peritoneum. Abdominal entry is confirmed by “saline drop test” or by measurement of entry pres; initial pres of <5 mmHg is reassuring. Insufflate abd w/ CO2 to max pres of 10–12 mmHg. Remove Veress needle. A trocar can then be inserted into the peritoneal cavity.

Direct trocar insertion – insert trocar directly w/o insufflation, w/ elevated abdominal wall

Optical access trocar entry – direct visualization of abdominal wall through trocar during insertion

Open entry (Hasson technique) – A 1–2-cm incision is made below the umbilicus. Dissect tissue to fascia, incise fascia, open peritoneum, & insert blunt trocar.

Systematically inspect the abd & pelvis

Perform procedure (hysterectomy, cystectomy, oophorectomy, etc.)

Desufflate abd, close fascia for incisions 10 mm or greater. Close skin.

Laparoscopic tubal ligation

• Indications: Permanent sterilization

• Preoperatively:

Informed consent

• Steps:

Adequate anesthesia w/ muscle relaxation, EUA, OG tube, empty bladder

Select the site & mode for laparoscopic entry

Systematic eval of the abd

Identify the tubes & follow them out to the fimbriated ends

Ligation can be performed w/ clips, rings, cautery, or excision. Salpingectomy is the most effective method of tubal ligation. See chapter 1.

Total abdominal hysterectomy

• Indications: Heavy uterine bleeding, symptomatic fibroids, pelvic organ prolapse,

Gynecologic malignancies

• Preoperatively:

Obtain informed consent

Endometrial bx (in setting of abn uterine bleeding), Pap smear

• Steps:

General anesthesia, preop antibiotic, EUA, Foley catheter

Abdominal entry through appropriate incision (midline, paramedian, Pfannenstiel, etc.)

Consider abdominal wall retractor & abdominal packing

Grasp the round ligaments, uteroovarian ligaments, & fallopian tubes w/ curved Kelly clamps to elevate the uterus & provide traction

Divide the round ligament btw 2 transfixion sutures & extend the incision down to the broad ligament

Dissect the broad ligament into anter & post leaves

Identify the ureter

Carry anter broad ligament incision inferomedially to the level of the vesicouterine fold. Open the post leaf toward the uterosacral ligaments.

For oophorectomy: Open a window in the broad ligament to isolate the IP ligament. Clamp the IP w/ 2 Heaney clamps & transect the IP btw them. Suture ligate the distal pedicle w/ a free tie & transfixion suture & the prox pedicle w/ a single free tie.

To preserve the ovaries: Isolate the fallopian tube & the uteroovarian ligament. Clamp across these 2 structures; cut, & suture ligate.

Rpt above steps on opposite side of uterus

Dissect the vesicouterine peritoneum off the anter uterus & cervix

Identify the uterine arteries & carefully dissect off the surrounding connective tissue. Use Heaney or Zeppelin clamps to come across the uterine vessels on either side; incorporate the vessel, not adj uterine or cervical tissue. Cut the vessels & doubly ligate.

Clamp cardinal ligament; transect, & doubly ligate

Pull uterus upward & clamp across uterosacral ligaments. Cut ligaments close to the uterus (avoiding ureters) & suture ligate.

Place 2, curved clamps immediately below the cervix. Cut above these clamps to remove the uterus & cervix.

Close vaginal cuff w/ figure-of-eight stitches. Incorporate uterosacral & cardinal ligaments into cuff repair for additional support.

Ensure hemostasis & close the abd

Vaginal hysterectomy

• Indications: See above

• Preoperatively:

Informed consent & endometrial bx/Pap smear

• Steps:

Adequate anesthesia, antibiotic. EUA, Foley catheter w/ pt in dorsal lithotomy.

Place weighted speculum & use Deaver retractors to expose the cervix

Grasp the anter & post lips of the cervix using 2 tenacula, or thyroid clamp

Inject vasopressin or lidocaine/epi around the cervicovaginal junction

Make an elliptical incision at the cervicovaginal junction

W/ downward traction, dissect bladder off cervix until anter peritoneum comes into view

Open the anter peritoneum & slide the anter Deaver into elevate bladder

Using upward traction, open the post peritoneum into the Pouch of Douglas

Pull the uterus outward & identify the uterosacral ligaments. Clamp ligaments; cut, & suture ligate.

Clamp, cut, & suture ligate the cardinal ligaments, uterine arteries, uteroovarian ligaments & round ligaments. If oophorectomy is performed, the IP ligaments are identified, clamped, cut, & suture ligated in place of the uteroovarian ligaments.

Ensure hemostasis. Close vaginal cuff using interrupted or running sutures. Incorporate uterosacral & cardinal ligaments into cuff repair for additional support.

COMMON OBSTETRIC SURGERIES

Cesarean section

• Indication: Need for immediate deliv, failure to progress in labor, or if pt not a candidate for labor/vaginal deliv (numerous indications)

• Preoperatively:

CBC, type & screen, informed consent

• Steps:

Adequate anesthesia (general, neuraxial, etc.)

Foley catheter, prophylactic Abx, pt should be supine w/ leftward tilt

Abdominal entry: Generally low, transverse, though sometimes vertical. Variations of low transverse incisions include:

Pfannenstiel (most common)—3 cm above the pubic symphysis & slightly curved upward. Fascia is incised transversely & dissected off underlying rectus muscles. Rectus muscles separated in the midline.

Maylard incision – 3–8 cm above the symphysis. Fascia incised transversely, inferior epigastric vessels are ligated, rectus muscles are divided transversely.

Cohen incision – 3–4 cm above the symphysis. Fascia incised in the midline, extension of the fascial incision, separation of rectus, & entry to peritoneum done bluntly.

Consider a bladder flap by incising the vesicouterine peritoneum in the midline, & extending the incision bilaterally. Use blunt or sharp dissection to expose the lower uterine segment.

Hysterotomy: Generally transverse in lower uterine segment, 2 cm above the bladder margin. Can extend bluntly or w/ bandage scissors. Alternatives include low vertical incision or classical incision (vertical incision extends to upper uterus).

Deliv: Slide hand below the infant’s head & elevate it to the level of the incision. Apply fundal pres to facilitate deliv. If breech, deliver legs, rotate body to deliver shoulders & arms, deliver head.

Deliver placenta w/ uterine massage or manually. Clear uterus of clot & placental tissue.

Close hysterotomy in 1 or 2 layers. The 1st layer closure is performed w/ a running, locking stitch. An imbricating, running stitch may then be used.

Reapproximate fascia w/ a running, delayed-absorbable or permanent suture

Close subcutaneous layer if >2 cm thick; close skin w/ subcuticular suture or staples

Tubal ligation at time of C-section

• Indication: Undesired fertility

• Preoperatively:

Obtain informed consent

Contraceptive counseling

• Steps:

Exteriorize uterus for easy identification of the tubes; follow tube out to fimbriated end

Modified Pomeroy: Grasp the isthmic portion of the tube ∼4 cm from the cornua w/ a Babcock clamp to elevate loop of the tube. Ligate the base of the loop w/ plain catgut. Divide the mesosalpinx in the center of the loop. The portion of the tube w/i the ligated loop is then excised.

Parkland method: Use a Babcock forceps to hold a segment of the tube about 3–4 cm from the cornua. Create a window in an avascular area of the underlying mesosalpinx. Doubly ligate the tube at the prox & distal end. Excise the segment of tube.

Irving method: Perform all steps of the Parkland method. Then, bury the prox end of the tube into a pocket created in the myometrium.

Uchida method: Dissect mesosalpinx off the fallopian tube & excise a segment of the tube. Suture mesosalpinx closed; bury the prox stump of the fallopian tube w/i mesosalpinx. The distal stump is left exteriorized.

Alternatively, total salpingectomy can be performed

Postpartum tubal ligation

• Indication: Undesired fertility

• Preoperatively: Obtain informed consent, including nonpermanent contraceptive options

• Steps:

General, spinal or epidural anesthesia, insert Foley catheter

Make small (2–4 cm), transverse, infraumbilical skin incision

Carry down to the fascia, incise fascia transversely, & enter peritoneum

Immediately postpartum, the uterine fundus sits just below the umbilicus. Identify fallopian tubes & follow out to fimbriated ends.

Ligate tubes (see above for options)

Ensure hemostasis

Close the fascia, subcutaneous layer if >2-cm thick, & skin

Cervical cerclage

• Indication: Recurrent Preg loss a/w cervical insufficiency, or cervical insufficiency diagnosed early in current Preg

• Preoperatively: Obtain informed consent, confirm viability, confirm intact membranes, rule out intra-amniotic infection

• Steps:

General, spinal, or epidural anesthesia

Empty bladder, position in lithotomy, place weighted speculum, use retractors to expose the cervix

Grasp the cervix w/ ring forceps

Use Mersilene tape, Prolene, or Ethibond suture

McDonald cerclage: W/ the suture, make a bite in the cervix from 12–10 o’clock as close to the junction w/ the rugated vaginal epithelium as poss. The next bites go from 8–6 o’clock, from 6–4, & from 2–12. Cinch tightly & tie. Leave a 2–3-cm tail so the stitch can be removed.

Shirodkar cerclage: Open the vesicocervical space by making a small incision at the cervicovaginal junction. Push the bladder up w/ careful dissection. Open the posterior rectovaginal space similarly. Hydrodissection before incision is sometimes useful. Use right angle allis clamps to pull the vessels lateral. Suture through cervix anterior-posterior in U-shaped fashion (two bites). Consider closing the mucosal incision.

Ensure hemostasis

Repair of obstetrical laceration

• Preoperatively: Ensure proper equipment & instruments available, as well as a good light source. If unable to fully visualize the laceration or source of bleeding, move pt to the OR.

• Steps:

Provide local anesthesia in the absence of an epidural

Examine the cervix, vagina, labia, & periurethral area

Rectal exam to evaluate for 3rd- & 4th-degree lacerations

Examine the cervix systematically. Repair w/ interrupted absorbable sutures.

Hemostatic 1st-degree lacerations do not require repair

For 2nd-degree lacerations, anchor suture 1–2 cm above the apex. Close the laceration w/ a running, locked stitch until the hymenal ring.

Pass the suture under the vaginal mucosa to the muscle layer of the perineal body

Close the muscle layer w/ a running stitch

Close the skin using subcuticular or interrupted sutures

Perform a rectal exam to ensure no suture material is in the rectum

Pudendal nerve block (see Figure 4.3)

• Indication:

To obtain analgesia necessary for deliv or repair of perineal lacerations

• Preoperatively:

Appropriate equipment & good light source

• Steps:

Use an Iowa trumpet & 20-gauge needle

Prepare 10 cc of 1% lidocaine w/o epi

Identify the spinous process of the ischium

Inject 2.5 cc above & below the spinous process on each side

Check for the anal reflex

Male circumcision

• Indication: Elective surgical procedure based on parental request

• Preoperatively:

Examine the infant & ensure:

Adequate shaft length (>1 cm)

No congen anomalies

No bleeding diathesis

Obtain informed consent

• Steps: The 3 major methods employ the GOMCO clamp, Hollister Plastibell, & Mogen clamp. The GOMCO clamp is the most widely used, & is a/w the fewest complications.

Provide local anesthesia & prep the skin

Determine the size of the bell that will be needed (edge of bell should reach the frenulum & minimally extended over the corona)

Apply 2 artery hemostats at 3 & 9 o’clock on the foreskin

Use a 3rd hemostat to open the space btw the glans & the foreskin, avoiding the 5 & 7 o’clock positions

The hemostat is then used to create a crush line on the dorsal aspect of the foreskin (>1 cm away from the coronal sulcus). Cut the crushed skin & retract the foreskin.

Place the bell over the glans, inside the foreskin

Inspect to make sure that the remaining shaft skin is symmetrical, & not under tension T

Tighten clamp, cut foreskin, & remove residual tissues

Wait for 5 min before opening the clamp

Inspect for bleeding & apply pres if needed

Use petroleum-soaked gauze around the edges of the foreskin

Ensure infant is able to urinate before discharge home

Dressing should remain for 12–24 h