Abdominal Hysterectomy pefinition {tis a surgical removal of the uterus, or only of the uterine Corpus in the case of subtotal hysterectomy, through an abdominal incision, Indications Common indication- Uterine leiomyoma Rare indications - + Endometriosis « Adenomyosis « Uterine (including cervical) cancer, +» Ovarian and tubal cancer + Pelvic inflammatory disease and Abnormal uterine bleeding. + Hysterectomy may also be performed as a life saving procedure in the management of major postpartum haemorrhage. Classification n= - Total hysterectomy and bilateral salpingo-oophorectomy — removal A hysterectomy can be classified by the amount of tissue resected : + Total hysterectomy — removal of the uterus and cervix. » Sub-total hysterectomy — removal of the body of the uterus only, I leaving the Cervix behind, of the werus, cervix, fallopian tubes and ovaries. Radical hysterectomy — removal of the uterus and cervity Vaginal cuffand part of or the whole of the fallopian tubes. * This procedure is carried out in selected cases of cervical on shepatien’s * The ovaries may be removed or may be left etiiad a Age, the parametrium, a2 gis ti Fc : Preoperative preparations 1, Obtaininginformed consent 2. Clinical and laboratory evaluation « Chest X-ray, ECG, pelvic USG + ABORH Hb%, KFT, HIV, HbSAg 3, Shavings of pubic hairs The pre-anaesthetic check ups For rule out any potential problems cither patient is fit for procedure or not, Preparation of the bowel Use laxative early in the morning before surgery to empty the rectum, Anaesthesia Usually general anaesthesia due to good airway control, good relaxation and a flexible duration, corresponding to surgical needs, Intexvenoas prophylactic antibiotics Single dose of propkytactic cephalosporin ofthe first or second yeeneration, jut ieee liom, has been shown to reduce substantially the infective Suepfeat testaiqne 5. Penitioning of the peje 2. Astivegfic rsesaces t len -tov nme, Chenet beg, shenild be inverted jn the bladder indication oe the size op aoe nO A idiom (degra 0 Vitel Sor erasuphe, a Narye fibroid users MAF Ken ippesente ae thse ‘ 8 remerves, goes 6 Gh ( ie Ni nny ase Wi tte Utero Japaro Th Picedy Lagpstny Sacnyyhy Big Coat Nesp,Surgical Procedures in Gynaecology d the bi paramctrial tissue is eer L Uterine vessels are ligated and tied L Paracervical tissue and utcrosacral ligaments are ligated and tied 1 Vagina is opened and the uterus and cervix removed L Vagina is usually closed with an absorbable suture L Hacrnostasis is confirmed at all pedicles L Abdomen is closed Saparoscopic Hysterectomy The above steps are identical for a total laparoscopic hysterectomy, € a Pcedure is performed through several very small incisions, using & laparoscope Soved 'yatcrcopic instruments. ‘The specimen (uterus, cervix +-tubes and un fey the vagina, essels with scissors for tirserss wy may be used for coagulation of blood ve ‘cael otin, Or nore modem energy devices may be used. The vagal eat Ptormically or vaginally. It can also be performed using a robotic P Vaginal Hysterectomy | — —_ he is te “azinal hysterectomy, no abdominal incisions are made and the procedus Sitirely through the vagina, , Veet : ia (spinal/ epidural). A ae hysterectomy may be performed under regional anaesthesia ¢ In M anaesthesia is not required. a the most A " following are : “np etectomy has a number of possible indications. ThE HM this is not an exhaustive list: Bipolar earephes arr Fart SS eee + Heavy menstrual bleeding « Pelvicpain : uid ovarian, uterine or cervical) | Cc « Risk reducing surgery, usually in cases of BRCA | or 2 mutations | syndrome, Procedure | | Local anaesthesia is infiltrated around the cervix (front and back, not laterally) | tL A circumferential incision is made around the cervix 4 The bladder is dissected off the cervix and reflected upwards | a iT | ‘The anterior peritoneum is opened by cutting the utero-vesical peritoneal fold 2 | The Pouch of Douglas is opened L The uterosacral ligaments are ligated and tied L The uterine arteries are ligated and tied + OF Lynch Theround ligaments are ligated and tied 132/189 The tubes and oy, i aries may be taken in this pedicle, or may be pre: servedSurgical Procedures in Gynaecology L The uterosacral ligaments may be fixed to the upper vagina prolapse of the vaginal vault Complications of hysterectomy « Damage to the bladder and/or the ureter and/or long-term disturbance to the bladder function . Damage to the bowel 267 to prevent + Haemorthage « Wound dehiscence « Pelvic infection and abscess Dilation and Curettage (D & C) Itis one of the most common gynaecological procedures. In this procedure, dilatation ofthe cervical canal followed by uterine curettage is done to remove the endometrium with a sharp or blunt curette. Indications Diagnostic Teer emanne) + Infertility +. DUB + DUB Endometrial polyp « Removal of UD » Incomplete abortion + Pathologic amenorrhoea + Endometrial tuberculosis + Endometrial carcinoma . Postmenopausal bleeding * Chorionepithelioma Procedure * The patient j nt is to empty the bladder. azepam sedation with ee ©Peration is done under general anaesthesia or unde . Sn Paracervical block. Se 18 placed in lithotomy position. | calantiseptic cleaning and draping done, manual re: 2 examination is performed. eo 132/189glee attr FTA « Posterior is introduced. ior vaginal speculum. / + The anterior lip of the cervix is held with an Allis tissue forceps ‘Anuterine sound is introduced to confirm the position and to note the length Of the . uterine cavity. ; + Cervical canal is dilated with graduated dilators. « When the dilator is introduced, the cervix is made stead by traction of the vulsellum, + Theuterine cavity is curetted by an uterine curette either in clockwise or. anticlockwise direction starting from the fundus down to internal os. + Inbenign lesion, sharp curette and in suspected mal ignancy, blunt curette is used, Vulsellum and the speculum are removed, 268 ‘The curetted material is preserved in 10 percent formol-saline (normal saline in suspected tubercular endometritis) labelled properly and sent for histolo gical ¢xamination, Complications + Injury to the cervix + Uterine perforation + Injury to the gut + Infection Ab Myomectomy Myomectomy is a type of surg ery used to remove uterine fibroids. Indications + Pesistent uterine bleeding despite medical therapy + Excessive pain or Pressure symptoms, * Size> 12 weeks, woman desirous to have a baby. + Unexplained infertility with distort + Rapidly growing myoma, + Subserous Pedunculated fibroid, Contra indications + Infected fibroid, + Growth ofmyoma, afler menopause a + Suspected malignant change (sarcoma), 133/189Surgical Procedures in: Gynaecology 269 , Parous women where hysterectomy is safer and is a definitive treatment | Function less fallopian tubes (bilateral hydro-salpinx, tubo-ovarian mass), . pelvic orEndometrial tuberculosis. : |, During pregnancy or during caesarean section pre-requisites . Hysteroscopy or hysterosalpingography - to exclude any submucous fibroid ora polyp or any tubal block. 7 + Diagnostic D + C — in cases of irregular cycles, not only to remove a polyp but also to exclude endometrial carcinoma. + Examination of the husband from fertility point of view (semen analysis). Types Amyomectomy can be done one of three ways: + Abdominal myomectomy - through abdomen + Laparoscopic myomectomy - less invasive + Hysteroscopic myomectomy - fibroids remove through cervix and vagina. Abdominal myomectomy + Use of Victor Bonney's specially designed clamp to reduce uterine artery blood flow. This clamp is placed around the uterine vessels and the round ligament the + Use of tourniquets - to occlude the uterine vessels and also to ovarian vessels at infundibulopelvic ligament. * During the procedure incision (horizontal or vertical 3 Would be taken under general anesthesia through lower * Incision is deepened through the myometrium and the ( mymoma is reached. oe ™yoma is trasped with a single tooth: . © the plane between the mymoma and |-4 cm just over, -pubic bone) ‘abdomen into uterus. seudo) capsule, till the jgsection is continued in lum and dissection is con Se Myoma is enducleated from its bea b issecti i : y sharp and blunt dissection. cieanteae figure-of eight sutures. Compyy 2 beds obliterated by interruP! . lications ° ce 133/189 * Excessive bleeding P é270 ee « Damage to nearby organs + Abole (perforation) in your uterus « Scar tissue that could block your fallopian tube or lead to fertility problems « New fibroids that require another removal procedure Metroplasty It is a reconstructive surgery used to repair congenital anomalies of the ‘uterus, including septate uterus and bicornuate uterus. ‘The surgery entails removing the abnormal tissue that separates the cornua of the uterus, then using several layers of stitches to create a normal shape. Cervical Cauterization Cervical Cauterization is a procedure that is used to destroy abnormal cells of the cervical os. It can be done through the use of heat, electricity, cold, corrosive chemicals or laser. Contra-indications « Acute cervicitis + Pregnancy + Acute PID + Suspected invasive carcinoma of cervix 1, Thermal Cauterization An operation whereb thermocoagulation or red Indications y the eroded area of the cervix is destroyed either bY hot cauterization, © Cervical ectopy with troublesome di ischage, + Abnormal pap smear, i 134/189 Procedure canal is dilated b i ° ae area is, cauterised by = Fabel eeecnt Starting from inside the cervical canal to rer D ata distance o ; $ Point giving linear radial SOK) eroded area. The strokes $" f lem. ie 1A PpSurgical Procedures in oe 1 The area is smeared with antibiotic ointment. . pealing 7 , Takes about 2-3 weeks for sloughing of the bum area, « Complete epithelialisation by squamous epithelium occurs by 6-8 weeks. 2. Cryosurgery « Destruction of the cervical tissue by freezing. Indications « Cervical intraepithelial neoplasia + Vaginal intraepithelial neoplasia « Vulval intraepithelial neoplasia (Not more than 2 cm in size). « Condyloma accuminata « Leucoplakia + Vault granulation tissue following hysterectomy. Principle + Itconsists of ‘Probe’, the tip of which is cooled to a temperature below freezing point (-60°C), | + Freezing produces cellular dehydration by crystallisation off ‘intracellular water and ultimately death of cells. + Carbondioxide, Nitrous oxide or Liquid nitrogen are used as £2. | Procedure | * Done without anaesthesia. | * The appropriate cryosurgery probe is applied to the cervix | mene good iceball extending 4-5 mm beyond the edge | «The ea is stopped. ¢ thawed and removed | and the freezing activated. ofthe probe is obtained, a in i freeze. Matg aly 2-3 minutes are required to obsins satisfactory 4 4 te Complete in 6 to 10 weeks. 1 Prosedure 134/189 *L 3 PoP electrosurgical excision procedure (LEE! oe rin wiretoop weit aiDass rig the procedure, there is uses 3% electri ‘’y the abnormal tissue.aagida att fat + Indication ‘« When a PAPsmear indicates there are abnormal cells on the surface of the cen: Mostof the time abnormal cells in cervix heal without treatment. sTVix, Complications of Cervical cauterization « Uterine cramping + Hotflashes + Headache + Profuse vaginal discharge « Stenosis of cervical canal. 135/189wy ae Investigative and Diagnostic Aids a9 STR) wpe nti anl es: ae }ptions are: + Repeat pap smear after 6 ‘months + If female is>30 years, do HPV-DNA testing + Ifpap smear report this time is >ASCUS, DNA testing is positive-colposcopyisdone + Best method of following ASCUS is immediate colposcopy (biopsy) vt * Colposcopy (Gold standard) + endocervical + If lesion is visible-Punch biopsy * Colposcopy (Gold standard) + endocervical * If lesion is visible-Punch biopsy Definitive Diagnostic Procedures for CIN mne to confirm Donetoconfirmfindings | Donetoconfirmfindimgs findings of abnormal of colposlopy if there isa abnormal pap’s when beth lesion pap smear when__| discrepency in pap smear is visible. ee Iesion is not visible. result and colposcopy. 2. Hysterosalpingography Itis a radiological examination that involves the ineeien ery tough the cervix in order to visualize the uterus and tubes, assess Indications Iningertili + Detect uterine abnormalities * Assessment of tubal patency * Evaluate results of tubal surgery Contraindications * Pelvic infection * Women known to have hydrosalpinges * Presence of adnexal mass(PID)- . * Pelvic tenderness on bimanual examination TBRARS98 argedta er FT OO OO Pre-diagnostic procedure Done in the first half of the cycle : + Antibiotics to be started | day prior to procedure and to complete 5 day course « eg. Doxycycline 100mg bd + Flagyl 400mg tds = Analgesia ; + Indocid 100mg, 30 minutes before procedure, to alleviate spasm when dye ig injected Equipment for an HSG 1. A radiographic fluoroscope room. 2. Digital fluoroscope. 3. Accessory Equipment- a sterile, disposable HSG tray having a vaginal speculum, basin, cotton balls, medicine cup, sterile gauze, sterile drapes, sponge-holding forceps, 10 ml syringes, 16 and 18 gauge needles, extension tubing, and lubricating jelly. In addition to the HSG tray, sterile gloves, an antiseptic solution, a cannula or balloon catheter, and contrast media are necessary. 4, Contrast Media - Two categories of radiopaque (positive) iodinated contrast media have been used in HSG. (@) Water-soluble iodinated contrast media, such as Omnipaque 300, is preferred, Itis absorbed easily by the patient, does not leave a residue within the reproductive tract, and provides adequate visualization. This medium docs, however, cause pain When injected within the uterine cavity, and the pain may persist for several hours after the procedure, (b) Oil-based contrast media thatallowed for maximal visualization of uterine structures. On average, approximately 5 ml is necessary to fill the uterine cavity, and an additional 5 ml is needed to demonstrate uterine tube patency, Steps ‘The operation is done in radiology department and without anaesthesia. a Gieei her bladder. She is placed in dorsal position with the buttocks + Internal examination is done, + Posterior vaginal speculum is introd ; Jor fh ix is held b: alls forcepsand anuterine scant Ma the anterior lip ofthe cervix is held by Hysterosalpii i i . C « Hyst Pingographic cannula ig fitted with a Syringe containing radio-opaque 159/189tse ‘eis um, ling ting aor (tis ive ain urs nal by uc | * Gynaecotogic procedures Investigative and Diagnostic aids _ either water soluble contrast medium, meglumine... 2 lowly. About 5-10 ml of the solution is introduced. The dyeis interior may be observed by Using a x-ray image intensifersnt os Sit he . The speculum and the allis forceps are remove, tabu ee npeya . radiographic views are taken the first one to show the fill re theother at the completion of the procedure(after] -1Smingee tern cavity and ‘The tubal patency is evidenced by peritoneal spillage, "ng tubal findings, Complications « Infection: 0.3%-1.3% in low risk settings and up to3% in high risk populations « Allergic reaction to dye: skin rash, itching, shortness of breath, swelling of the orin other parts of the body elling ofthe throat « Vasovagal reaction « Damage to uterus or fallopian tubes + Extravasation of contrast medium 3. Laparoscopy Laparoscopy is enhanced and more effective clinical practice of ‘gynaecology which provides a window to directly visualize pelvic anatomy as well as technique to perform many operations with less morbidity than laparotomy. Laparoscopy’ may be performed under local or general anesthesia. It is a technique which allows viewing (Diagnost {herapeutic) to be performed in abdominal organs through sue wih help of pneumoperitoneum . Indications ic) and surgical maneuvers jcal incision of < lem * Female sterilization (Tubectom s y) ian tube (morpbolO8y * Infertility -U, Jiagnostic tool to know meer and functionality) and any pathological condition e * Chronic pelvic pain / PID and endometrial cyst . r, . ies Removal of ectopic pregnancies * Tres ; 3 Treatment of endometriosis : Hysterectomy i: i Node dissections- angdaa eit fart « Correcting ovarian torsion. Contraindications + Generalized peritonitis « Hypovolemic shock + Severe cardiac disease « Hemoglobin less than 7 g/dL « Uterine size > 12 wks. + Multiple previous abdominal procedures + Extreme body weight Complications « Pneumoperitoneum + Extraperitonial emphysema + Gas may extend to the mediastinum and compromise cardiac function + Pneumo-omentum + Injury to abdominal organs * GI problem + Bladder injury: prevented by emptying the bladder 4. Colposcopy Colposcopy is a procedure that uses an instrument witha magnifying lens and a light, calleda colposcope, to examine the cervix and vagina for abnormalities. The colposcope magnifies the image many times, thus allowing the health care provider to see the tissues on the cervix and vaginal walls more clearly, Procedure . Patient is placed in lithotomy position, + The cervix is visualised using a cusco’s speculum, . Colposcopic (16 farm, examination of the cervix and vagina is done using low magnification . ane is then cleared of any mucous discharge using a swab soaked with normal N fe : oe the cervix is Wiped gently with 3% acetic acid and examination repeated- Acetic acid causes lation of nuck in which is hi ° ? Acetic acid ous iclear protein which is high in CP T+!- ~reven! mission of light through the epithelium which is visible as y 160/189| Investigative and Diagnoet, co dications nies , ppithelial cell abnormalities detected by ee. suspicious cervical lesions. , Vulvar or vaginal neoplasia, / , sexual partner of patients with genital tract neoplasia, « Unexplained vaginal bleeding. « Post coital bleeding. Colposcopic Directed Biopsy « Colposcopy is the Gold standard technique for evaluation ofan abnormal cervical cytology smear/pap smear. « The first step to visualize cervix under magnification. + Itis an outpatient procedure that is simple, quick and well tolerated. + It allows examination of the lower genital tract and anus with a microscope (magnification = 30 times). Method + Leukoplakia must be looked for before applying acetic and otherwise it gets confused with acetowhite areas. Biopsy sample should be taken. ‘ + Biopsy sample should also be taken from any rough area orraised ann + Any abnormal blood vessel pattern eg. reticular blood vessels, comma-shaped vessels or punctate blood vessels should be biopsied. are + Then 3-5% acetic acid should be applied on cervix getl but ial Principles aud i a ors producing epithelium * Application of acetic acid to normal epithelium: Glycogen Iposcopy. ceryj ervix does not produce any effect and it appears P * Application of acetic acid to dysplastic epithelium: normally | Ysplastic epithelium which have large nuclei wil oti chromatin (i.e, protein), acetic acid coal nal Sytoplasm, making the proteins opaque and WO" res) cay cia ‘Aceto white’ Ncerous cells appear white (known as AC om: Tei 1 * Application of. ‘acetic acid to metnplastic ent the acetic Leet ‘ve large nuclei and also show some ete bite but instea EN a ‘ . a. is very thin, it does not appee amretata aire Fear ee Indications of Colposcopy 1, Abnormal pap smear cytology 2. To locate abnormal areas 3. To obtain directed biopsies 4. Conservative therapy under colposcopy guidance 5. For follow up of cases treated conservatively Limitation of colposcopy Upper 2/3" of endocervix is, not visualized by colposcopy. 5. Endometrial Biopsy The endometrial biopsy is a medical procedure that involves taking a tissue sample of the lining of the uterus. The tissue subsequently undergoes histologic evaluation which aids the physician in forming a diagnosis Indications + Abnormal uterine bleeding postmenopausal bleeding, ovulation/anovulation, malignancy/hyperplasia, + Assessment of enlarged utereus, + Evaluation of Abnormal Pap smear with atypical cells favouring endometrial origin (AGUS). + Follow-up of previously diagnosed endometrial hyperplasi i I eg. hereditary ‘nonpolyposis colorectal cancer), a . Inappropriately thick endometrial striy i ipe found on U! caine. on US Endometrial dating + Pregnancy + Acute PID * Clotting disorders(coagulopathy) . Acute cervical or vaginal inf 2 . Cervical cancer Procedure ina tn) 2otbe given localized anesthesia. ‘Ospread the walls of the vagina apart to ven UseInvestigative and Diagnosis ids expose the cervix. The cervix will then be aneagacte : Be ‘Atenaculum, @ type of forceps, will hold the cervix aoe hin b The biopsy curette will be inserted into the uterine biopsy, issue wi fundus and with scrap G rotating motion some tissue will be removed, witha. ‘a q. The removed tissue will be placed in formalin or equivalent for preservation, e, The tissue will be sent to a laboratory, where it will be processed and tested. It will then be read microscopically by a pathologist who will Provide a histological diagnosis. 6. Cervical Biopsy | Acervical biopsy is the removal of tissue from the cervix, the lower third of the uterus to be analyzed for cellular abnormalities, precancerous conditions, or cervical cancer, Uses 1, Abiopsy is used to identify abnormal cells to rule out cancer. 2. Diagnose what stage it is at. 3. Italso helps whether a lump, tumour or growth is cancerous (malignant) or non- cancerous (benign). Method Itdepends on where the tissue sample is being taken from. Itmay involve having: es i lls or . a . fluid, a few cel Ahotlow needle put into the area being investigated o nN A), bone maTOW | small amount of tissue. This includes fine-needle aspire ‘spiration and thephine biopsy or core/needle biopsy: + An endoscopy, which enables a larger amount of tissue ‘ly, such as stomach or throat. * Surgery, which enables a larger section of tissue to es to be taken from inside beremoved- issue from iece of tissue Ls Pach Biopsy: A surgical procedure to rea ae ee gent areas | oa X. One or more punch biopsies may be P F s that uses Iaser or scale * Cone Biopsy or Conizati -Asurgicel procedure : mn ‘onization: atte eo si . Meations © a large cone-shaped piece of Hiss? in CIN. Ca8°S) i i yurpose im zk Conisation is done as diagnostic and therapeutic P326 put papbesusbiil Ra Se ee suitable for colonisation are: : . . a) Unsatisfactory colposcopic findings- The entire margins of the lesion are not visualised. b) Inconsistent findings colpascopic, cytology and directed biopsy. ; c) When biopsy cannot rule out invasive cancer from CIS or microinvasion, d) Positive endocervical curettage. Principle Steps (Cold Knife) of Cone biopsy 1. Con biopsy is done under general anaesthesia. 2. Blood loss is minimised with prior haemostatic sutures at 3 and 90’clock positions on the cervix by lighting descending cervical branches. 3. The cone is cut so as to keep the apex below the internal os. 4, After the cone is removed, a margin suture is placed at 12 0’clock position for identification of the cone. 5. Routine endocervical curette above the apex of the cone is performed and uterine curettage is done, if indicated. 6. Cone margins are repaired by haemostatic sutures, 7. The excised cervical tissue is sent for histological examination, If the margins of cone are involved in neoplasia, hysterectomy should be seriously considered either within 48 hrs or ata later date to Prevent infection, Complications + Secondary haemorrhage + Cervical stenosis leading to haematometra © Infertility © Diminished cervical mucuc © Cervical incompetence leadind to adverse pregnancy outcome * Midtrimester abortion or preterm labour, 7. Culdocentesis Culdocentesis i i fe E ; pouchofDougias, the transvaginal aspiration of peritoneal fluid from the cul-de-sac OF Indications 1. In su: nected disturbed ectopic Pregnancy or other causes producing haemo- 162/189Investigative and Diag ict, a pected cases of pelvic abscess, 307 2, Ins steP - The ‘Vagina is cleaned with Betadine. ginal speculum is inserted. i procedure is done under sedation, patient is put in lithotomy position. _ Aposterior Vai _ A18 gauge spinal needle fitted with a syringe is inserted at poi cervicovaginal junction in the posterior fornix. Point lem below the _ After inserting the needle to a depth of about 2cm, suction is applied as the needle isis withdrawn. _ If unclotted blood is obtained, the diagnosis of intraperitoneal bleeding is established. 8. Hysteroscopy Itisa technique which allows viewing and surgical maneuvers to be performed in the uterine cavity. It has many advantages that made it wide spread and fundamental diagnostic method in daily gynecological practice. Use 1. Diagnostic 2. Therapeutic Procedure . Preparation of the patient: ~ Detailed history and complete physical examination rual cycle, because ~ Itis preferable to do the procedure in the first part pees rose pregnancy there is less mucus (better viewing) and no chance of ~ Informed consent ~ Patient is placed in lithotomy position ~ Accurate bimanual examination to assess Volume), 2.Steps : * Clean cervix with antiseptics * Cervical forceps is placed on the front * Light source & CO, gas supply a" tion, morpholOey> the uterine (Post ibia ke to the instrument 149/129angitea at Poor # Insert hysteroscope into the cervical canal, which dilates from the Bas pressure. Indications 1. Used as a diagnostic tool: ; ~ Abnormal uterine bleeding caused by submucous and intramural myoma, endometrial polyps, endometrial atrophy. ~ Endometrial tumors. ~ Infertility related to Intrauterine adhesions (Asherman’s syndrome), Submucous fibroids, Endometrial polyps, Uterine malformation (it cannot differentiate between sepatate and bicorneate uterus). 2, Used as a therapeutic tool : ~ Endometrial ablation (using laser): Abnormal uterine bleeding but we should tule out cancerous or pre cancerous cause of bleeding. ~ Also used in patients with high risk for hysterectomy or the patient does not want to do the surgery. ~ Steroscopic Surgeries and Correct uterine malformation like septate uterus by resection of the septum. (bicorneate uterus is corrected by laparotomy using metroplasty). ~ Polypectomy. ~ Intrauterine adhesions. ~ Myomectomy: The main indication for hysteroscopic myomectomy is abnormal uterine bleeding caused by submucous myomas in infertile patients ~ Uterine anomaly Uterine polyp ~ Intrauterine adhesions ~ Endometrial carcinoma Contraindications + Pregnancy, . Current or recent pelvic infection, * Current vaginitis, cervicitis and endometritis, « Recent uterine: Perforation, « Active Bleeding, 3s“EH Investigative and Dj agnostic, Aids ications : co plies jon media: Fluid overload pulmo; i} f Dist emi neurological symptoms nary oedema, hal cede, jptraoperative complications: Uterine perforation «1% ’ semorthage either from perforation or Trauma by Tenacutum . Bait ‘Used to hold the Thermal damage. 9. Salpingoscopy Jn salpingoscopy, 4 firm telescope is inserted through the: abdominal ostium ofthe serine tube so that the tubal mucosa can be visualised by distending the lumen a infusion. The telescope is to be introduced through Laproscope. Salpingoscopy allows study of the physiology and anatomy of the tubal epithelium and permits more accurate selection of patients for IVF rather than tubal surgery. 10. X-ray Plain radiographs have a minor role in present day gynaecological practice. An shdominal radiograph is seldom used in the diagnosis of pelvic pathology. However, an incidental radiograph taken for other medical or: surgical conditions may reveal unsuspected pelvic pathology like presence of a tooth in a dermoid cyst. Calcification in a fibroid, an ovarian mass, presence ofapelvickidney and finally, hen sonography fails to locate a misplaced intrauterine contraceptive device (UCD) o +fureign body, a plain radiograph of the abdomen and pelvis helps to reveal ts prese ‘nd location. ‘ ateral views takenatrpacing Aplai is i i in radiograph of the pelvis in A-P and commonly Cu in present ies) es a inthe uterine cavity helps to locate an UCD ’s perforated the uterus and is located outside. 5 wile plain radiograph of the chest is required in i ne Fal he work? cae of metastasis in gynaecologic malignancies finally, ndertaking any major gynaecological surgery: § 11. Uitrasonoer#P0y iis modality 19d f on ; 7 ng tenonste Btaphy is generally the first and often i ical gr monitonne bolo te pelvic anatomy and document oe ero rransabdom cal changes. Ultrasound examinationsais ar Peart Pa ics di cam Advantages of ultrasound «+ Non-invasive technique. « Soft tissue imaging possible unlike X-rays. « No ionizing radiation, so it can be repeated. ; , 1, Transabdominal Ultrasonography : It is performed on a. patient witha full bladder, The distended bladder displaces the bowel loops and provides a window for visualizing the pelvic structures. A 3.5 to 5.0 MHz sector or curvilinear probe is used to obtain a global view of the pelvis. Following this initial scan, it is advisable to re-examine the patient on an empty bladder particularly if there has been any difficulty in differentiating between the bladder and a cystic mass in the pelvis. This step also provides useful information about the fixity of pelvic structures and the volume of residual urine present in the bladder after voiding. 2. Transvaginal Ultrasound : Transvaginal ultrasound uses vaginal probe to visualize the pelvis. The proximity of the probe to the pelvic organs and the use of higher frequency (5.0-7.5 MHz) transducer yield higher resolution images. This examination cannot be performed in women having the navrrow vagina and in menopausal women, The bladder need not be full before commencing this scan. It is recommended that a transabdominal scan should precede a TVS to obtain a better view of the pelvic pathology and abdominal tumour. Advantages of vaginal ultrasound over abdominal scanning are: « Full bladderis not required. « Better image. + In obese women, sound waves are attenuated by subcutaneous fat, and transabdominal scan gives a poor ‘image. Indications + To differentiate anormal from abnormal gestation in early pregnancy blighted ovum, molar pregnancy, incomplete abortion and retained products of gestation. + To diagnose multiple gestation, + Presence of UCD with pregnancy, + Diagnose haematocolpos and haematometra, Presence of an ectopic pregnancy, + Ovulation monitoring. 164/189a og Investigative and pj : BROStiC Aids fhra for : ation of | the uretl Presence of divers : a rind post-menopausal bleeding, steht ~ D to ‘tly, ‘Assessmen -esence of fibroids in the uterus tien confirm Pr ; ; rian pathology like presence of ona ln oT 4 To detect OVA } i Tamu 04 payer ovaries. . . . , To study the signs of malignancy in an ovarian tutnour? . Location ofa misplaced IUCD. ‘ sonosalpingography to demonstrate patency of the tubes and detec. sacs | polyps: . Fine needle asp’ iration cytology (FNAC) in Synaecological malignancy, . Postmenopausal bleeding to determine endometrial thickness f endometrial thickness « Falloposcopy- . To study the adnexal mass and endometriosis. Therapeutic Applications of Ultrasonography + Oocyte retrieval in IVF programme. + Draining of chocolate cyst/simple benign cyst of the ovary. « Draining of pelvic abscess. + Evacuation of molar pregnancy. re + Transcervical cannulation and sperm injection into the fallopian bein ae + Retrieval of intrauterine embedded IUCD. «coll ectopic * Injection of methotrexate into an ectopic gestational sacin an Pregnancy, suspected * Colour Doppler ultrasound is useful in sexs" Neovascularization and decreased resistant bs * 3Dand 4D ultrasound provides multiplanar rae used in vari @homalies. In gynaecology, this ultrasound is of Rares With great accuracy. Such asP a ®cyst, drainage of abscess and local injee pulsatile ins ge “T ; ie ae” the endometrial thickness its thee in postmenopausal bleeding:angles tr fear SS aaa ae 12. PET scan PET stands for Positron Emission Tomography coupled with Computerig, ed Tomography (CT). It isa safe scan that produces a 3D colour image, containing Precise information about the organs of body. Uses « Ithelps to diagnose a suspected cancer. + Itcanalso help to find out where and whether cancer has spread.