SURGICAL MANAGEMENT

CYSTECTOMY Cystectomy is a medical term for surgical removal of all or part of the urinary bladder. It may also be rarely used to refer to the removal of a cyst, or the gallbladder. The most common condition warranting removal of the urinary bladder is bladder cancer.[1] After the bladder has been removed, an Ileal conduit urinary diversion is necessary. An alternative to this method is to construct a pouch from a section of ileum or colon, which can act as a form of replacement bladder, storing urine until the patient desires to release it, which can be achieved by either abdominal straining or self catheterisation. Future treatment for this condition may involve a full replacement with an artificial bladder. Mayo surgeons most commonly perform a cystectomy to treat bladder cancer that has spread into the bladder wall. They may also perform a cystectomy to treat recurring superficial or treatmentresistant bladder cancer, as well as other conditions. Options may include:

Partial cystectomy. In this procedure, also called a segmental cystectomy, surgeons remove the tumor and only a portion of the bladder. Doctors perform this procedure when your bladder will likely be able to continue to work normally. Radical cystectomy. In a radical cystectomy, surgeons remove your entire bladder. This is more common than a partial procedure because bladder cancer is often found when the disease is so advanced that partial removal isn't possible. For men, radical cystectomy usually involves removing the bladder, prostate and glands that help produce semen (seminal vesicles). For women, radical cystectomy usually involves removing the uterus, ovaries and sometimes part of the vagina. If you undergo this surgery, you may also have lymph nodes removed for examination. Removal of the lymph nodes has been shown to improve survival for people undergoing cystectomy.

For both radical and partial cystectomy, surgeons can perform the procedure using one of these methods:

Traditional (open) procedure. Surgeons use a traditional abdominal incision. Minimally invasive robotic surgery. During robotic surgery, the surgeon uses a computer that remotely controls small instruments attached to a robot, with improved precision. The surgeon works while viewing highly magnified 3-D images of your body on a monitor. Use of several smaller incisions can decrease scarring and speed recovery.

http://www.mayoclinic.org/cystectomy/types.html

BILATERAL TUBAL LIGATION What is a Bilateral Tubal Ligation? A Bilateral Tubal Ligation (BTL) is a surgical procedure that involves blocking the fallopian tubes to prevent the ovum (egg) from being fertilized. It can be done by cutting, burning or removing sections of the fallopian tubes or by placing clips on each tube. When is it used? A BTL is used when a woman wants to prevent pregnancy. It is considered a permanent form of birth control, although in some cases it can be reversed. There can be damage to the tubes after reversal, so this decision should not be made quickly. How do I prepare for a BTL? You will have this procedure in the outpatient surgery center or in the main hospital if you have just delivered a baby. You will not be able to eat or drink anything after midnight the day before your surgery. This procedure is done laparoscopically or immediately following a cesarean section. If you are taking any medications, you should discuss these with your doctor to see when you should stop them. What happens during the procedure? You will be given general anesthesia which will put you to sleep. One incision will be made in the umbilicus (belly button) and three small incisions will be made in the lower abdomen. Gas is pumped into the abdomen in order to help Dr. Hardy see the uterus, ovaries and fallopian tubes. A laparoscope is a telescopic instrument that is used to locate the fallopian tubes. Once the tubes are exposed, a small section of each tube is cut free and removed. The severed ends are ligated burned with a cautery tool or clips may be placed on each tube. The skin is closed with sutures that will dissolve and steristrips on the outside that may be removed after 1 week. What happens after the procedure? You will be moved to the recovery room while the anesthesia is wearing off. Your pain will be controlled with pain medications and any side effects will be addressed. You will be able to go home that day if you were scheduled for an outpatient surgery. If you have this procedure done after delivery, you will be discharged according to your postpartum care. You may experience pain that radiates to your shoulder. This is caused from the gas that was used during the procedure. You may use an electric heating pad, drink warm beverages and walk to help alleviate this pain. You may bathe and shower as usual. You may wash the incision gently with mild unscented soap. You will be given prescription pain medication to use for 2 to 7 days after the procedure. A stool softener may also help alleviate or prevent constipation. You will be given 2 weeks to recover from the procedure. Avoid sex or exercising until your postoperative appointment. You may resume driving after you are not taking any narcotic pain medication What are the benefits of this procedure? You do not have the risks associated with hormones for birth control. You have a more permanent form of birth control. http://www.atlanticobgyn.com/bilateral-tubal-ligation/ PROCEDURE Tubal ligation is considered major surgery requiring the patient to undergo general anesthesia. It is advised that women should not undergo this surgery if they currently have or have had a history of bladder cancer. After the anesthesia takes effect, a surgeon will make a small incision at each side of, but just below the navel in order to gain access to each of the 2 fallopian tubes. With traditional tubal ligation, the surgeon severs the tubes, and then ties (ligates) them off thereby preventing the travel of eggs to the uterus. Other methods include using clips or rings to clamp them shut, or

severing and cauterizing them. Tubal ligation is usually done in a hospital operating-room setting. The corresponding male surgical sterilization procedure known as Vasectomy is considered minor surgery done with local anesthesia and typically done in an out-patient setting. TUBAL LIGATION METHODS Bipolar Coagulation. The most popular method of laparoscopic female sterilization, this method uses electrical current to cauterize sections of the fallopian tube. Monopolar Coagulation. Less common than Bipolar Coagulation, Monopolar Coagulation uses electrical current to cauterize the tube together, but also allows radiating current to further damage the tubes as it spreads from the coagulation site. Many cases involve a cutting of the tubes after the procedure. Fimbriectomy. By removing a portion of the fallopian tube closest to the ovary, fimbriectomy eliminates the ovarys ability to capture eggs and transfer them to the uterus. Irving Procedure. This procedure calls for placing two ligatures (sutures) around the fallopian tube and removing the segment of tubing between the ligatures. Then to complete the procedure, the ends of the fallopian tubes are connected to the back of the uterus and the connective tissue respectively. Tubal Clip. The tubal clip (Filshie Clip or Hulka Clip) technique involves the application of a permanent clip onto the fallopian tube. Once applied and fastened, the clip disallows transference of eggs to the ovary. Tubal Ring. The silastic band or tubal ring method involves a doubling over of the fallopian tubes and application of a silastic band to the tube. Pomeroy Tubal Ligation. In this method of tubal ligation, a loop of tube is strangled with a suture. Usually, the loop is cut and the ends cauterized or burned. This type of tubal ligation is often referred to as cut, tied, and burned. Essure Tubal Ligation. In this method of tubal ligation, two small metal and fiber coils are placed in the fallopian tubes. After insertion, scar tissue forms around the coils, blocking off the fallopian tubes and preventing sperm from reaching the egg. Adiana Tubal Ligation. In this method of tubal ligation, two small silicone pieces that were placed in the fallopian tubes. During the procedure, the health care provider heated a small portion of each fallopian tube and then inserted a tiny piece of silicone into each tube. After the procedure, scar tissue formed around the silicone inserts, blocking off the fallopian tubes and preventing sperm from reaching the egg. The procedure can no longer be performed due to a lawsuit and judgment brought by the company responsible for Essure.[10] http://en.wikipedia.org/wiki/Tubal_ligation

Prepared by: BERNAFLOR N. PIELAGO BSN III-B

HYSTERECTOMY Abdominal hysterectomy is a surgical procedure that removes your uterus through an incision in your lower abdomen. Your uterus or womb is where a baby grows if you're pregnant. A partial hysterectomy removes just the uterus, and a total hysterectomy removes the uterus and the cervix. Sometimes a hysterectomy includes removal of one or both ovaries and fallopian tubes, a procedure called total hysterectomy with salpingo-oophorectomy (sal-ping-go-o-of-uh-REK-tuh-me). Hysterectomy can also be performed through an incision in the vagina (vaginal hysterectomy) or by a laparoscopic or robotic surgical approach which uses long, thin instruments passed through small abdominal incisions. Abdominal hysterectomy may be recommended over other types of hysterectomy if you have a large uterus or if your doctor wants to check other pelvic organs for signs of disease. Types of Hysterectomies:

Total Hysterectomy involves removing both the body of the uterus and the cervix, which is the lower part of the uterus. Hysterectomy can be abdominally, vaginally and laparoscopically. Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy involves removing the uterus, cervix, bilateral fallopian tubes and ovaries. Subtotal Hysterectomy only the upper part of the uterus is removed, but the cervix is not. Tubes and ovaries may or may not be removed. Radical Hysterectomy is reserved for serious disease such as cancer. The entire uterus and usually both tubes and ovaries as well as the pelvic lymph nodes are removed through the abdomen. Since cancer is unpredictable, other organs or parts of other systems are sometimes removed as well.

Purpose

After a Hysterectomy, a woman can no longer have children and menstruation stops. If you have cancer of the uterus or ovaries or hemorrhage (uncontrollable bleeding) of the uterus, this operation may save your life. The operation is done as a treatment and to improve the quality of life:

Complications

Bleeding Infection Blood clots Damage to organs Hernia formation Large scars Reaction to the anesthesia

What to expect before the procedure

You must be admitted a day before the scheduled procedure Consents must be secured Nothing by mouth for 8 hours prior to the time of the procedure If ordered by the physician, cleaning or fleet enema will be given for further bowel preparation.

You will also meet with the anesthesiologist to go over details of the method of anesthesia to be used. Insertion of Intravenous Line You will undergo diagnostic exams as ordered by the physician like Complete blood count, blood typing and urinalysis. Pre-operative medicines and antibiotics will be administered. Instructions regarding change of gown, removal of jewelries, dentures, contact lenses, hair accessories, nail polish, and make up will be given. An hour before the scheduled operation, you will be wheeled down to the delivery room. Abdominoperineal prep (shaving) will be done. What to expect during the procedure Prior to the time of operation, you will be wheeled in to the operating room where a surgical nurse will do the necessary preparations such as placement of cardiac leads, hooking to the cardiac monitor, oxygen administration thru nasal cannula, and placement of leggings Before the procedure, for verification that the right patient and right procedure will be done, Signing in will be called, wherein you will be asked to state in your full name, date of birth, name of your surgeon and anesthesiologist, as well as the procedure to be done. After the induction of anesthesia, a curtain will be raised over your mid section and you arms will be outstretched in order for the anesthesiologist and nurse to have access to your I.V. A Foley catheter will be inserted. This is not a painful procedure, and if you have an anesthesia in you won't feel it at all. Once a sufficient level of anesthesia has been reached, the initial cut into the skin will be made. The surgeon will then explore the abdominal cavity for disease or trauma. Alternatively, samples of various tissues and/or fluids may be removed for further analysis. What to expect after the procedure After the surgeon closes, you will be wheeled into recovery where you will be observed for two hours as the anesthetic wears off. You will be hooked to the cardiac monitor to check your vital signs, and you will also be hooked to the oxygen. Since Hysterectomy is a major operation, discomfort and pain from the surgical incision are greatest during the first few days after surgery, but medicine is available to reduce these symptoms. Post-operative medicines will be given to you. Depending upon the nature of your surgery and your doctor's assessment of your pain, you probably will be given a pain drip to address the pain. Turning from side to side is advised. A tight abdominal binder is applied to support the incision. The foley catheter will remain until further orders. Nothing per mouth as ordered by the physician/s, usually for 24 hours or after passed out of flatus. After the recovery period, you will be examined and will be transferred to your room if there are no complications. Discharge instructions will be given to you by your bedside nurse.

At Home:

During the first two weeks, avoid tiring activities such as lifting of heavy objects. Slowly increase your activities. Begin with light chores, short walks, and some driving. Depending on your job, you may be able to return to work. To promote healing, eat a diet rich in fruits and vegetables. Try to avoid constipation by:

o o o

Eating high-fiber foods Drinking plenty of water Using stool softeners if needed

Take proper care of the incision site. This will help to prevent an infection. Follow your doctor's instructions When to call your doctor After you leave the hospital, contact your doctor if any of the following occurs:

Fever or chills Redness, swelling, increasing pain, excessive bleeding, or any discharge from the incision site Increasing pain or pain that does not go away Your abdomen becomes swollen or hard to the touch Diarrhea or constipation that lasts more than 3 days Bright red or dark black stools Dizziness or fainting Nausea and vomiting Cough, shortness of breath, or chest pain Pain or difficulty with urination Swelling, redness, or pain in your leg

TOTAL ABDOMINAL HYSTERECTOMY WITH AND WITHOUT BILATERAL SALPINGOOOPHORECTOMY Total abdominal hysterectomy is utilized for benign and malignant disease where removal of the internal genitalia is indicated. The operation can be performed with the preservation or removal of the ovaries on one or both sides. In benign disease, the possibility of bilateral and unilateral oophorectomy should be thoroughly discussed with the patient. Frequently, in malignant disease, no choice exists but to remove the tubes and ovaries, since they are frequent sites of micrometastases. In general, the modified Richardson technique of intrafascial hysterectomy is used. The purpose of the operation is to remove the uterus through the abdomen, with or without removing the tube and ovaries.