VAGINAL HYSTERECTOMY

VAGINAL HYSTERECTOMY

Objective

•   In cases of tumor or bleeding from uterus.

•   removal of the uterus through a vaginal approach.

Position

Lithotomy.

Anesthesia

Epidural or general.

Procedure

   1.  A weighted vaginal speculum is placed in the vaginal canal.

   2.  Cervix is grasped with a tenaculum.

   3.  Dilatation and curettage may be performed.

   4.  An incision is made anterior to the cervix in the vaginal wall.

   5.  The bladder is reflected from the cervix using sharp, then blunt dissection.

   6.  Exposing the peritoneum of the anterior cul-de-sae, which is then incised, posteriorly.

   7.  Uterosacral ligaments are ligated and divided.

   8.  Uterus is placed on traction.

   9.  Uterine arteries are ligated and divided, and the uterus is delivered.

10.  The incisions into the cul-de-sac and vaginal apex are repaired.

11.  Uterosacral and round ligament stumps may be sutured to the angles of the vaginal vault closure.

12.  The vagina may be packed.

Instruments

•  General set-one                               10 (Fig. 8.51)

•  Artery forceps Spencer Wells (8 in)

•  Deep retractors (Deavor)                 2

•  Artery forceps (8 in) (Kocher)          6 (Fig. 8.55)

•  Vulsellum (Teale)                             2 (Fig. 10.30)

•  Scissors heavy curved (8 in) Mayo   1 (Fig. 8.32)

•  Auvards vaginal speculum (Fig. 10.33).

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DILATATION CURRETAGE

DILATATION OF THE CERVIX AND CURETTAGE

Objective

Dilatation and curettage is a gynecological operation having two distinct components:

•   To enlarge the cervical canal.

•   Removal (by scraping) of endocervical or endometrial tissue for histologic study.

Position

Lithotomy.

Anesthesia

Local, Epidural, General.

Procedure

   1.  Empty bladder.

   2.  Clean vulva, vagina and perineum.

   3.  Drape the parts with sterile towels, leaving the vulva exposed.

   4.  Expose the cervix with Sims’ speculum and anterior vaginal wall rectractor.

   5.  Catch the anterior lip of cervix with Vulsellum forceps.

   6.  Clean the cervical canal with cotton swab wrapped round a playfairs probe.

   7.  Pass a uterine sound to determine the size and direction of the uterine cavity.

   8.  Pass the dilators, well lubricated, steadily and gently, and in the direction of the cervicouterine axis, till their tips go beyond the internal os.

        a.  Do not pull on the cervix but use the Vulsellum to fix and steady the cervix in its normal position.

        b.  The cervix should be dilated enough to admit the sharp curette easily.

   9.  Steadying the cervix with the Vulsellum forceps.

        a.  Pass the sharp curette in the axis of the cervico-uterine canal till its tip touches the fundus of the uterus.

        b.  With steady pressure scrape down.

        c.  In the long axis starting with the anterior uterine wall and working systematically around the uterine cavity until the whole surface is scraped away.

        d.  A typical grating sensation is felt by the curette when the endometrium has been satisfactorily removed.

        e.  Collect the endometrium into a bowl containing sterile saline or a citrate solution.

10.  Gently massage the uterus between the two hands to remove all blood.

Instruments Required

D and C set.

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Para umbilical Hernia Repair

Paraumbilical Hernia

Objective

In case of umbilical hernia with:

•   Increase in size or

•   Presence of symptoms

•   To repair the defect.

Position

Supine.

Anesthesia

General.

Incision

Curved incision in the groove below the hernia.

Procedure

1.  Identify the anterior rectus sheath.

2.  Expose it around lower half of the circumference of the hernia.

3.  Excise the hernial sac protect skin if possible.

4.  Cut rectus sheath laterally for 2-3 one on each side and carry out a vest over parts repair using interrupted prolene sutures.

5.  Close wound in layers with drainage.

Instrument

Hernia set.

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Emergency I.H. Repair

Emergency Hernia Repair

Objective

To relive obstruction in case of:

•   Obstructed or strangulated hernia.

Procedure

1.  If the history is short, the sac will frequently be empty.

2.  There is no point in exploring the abdomen. Repair the hernia as for an elective repair.

3.  If bowel is present in the sac, incise sac and drain out exudate.

4.  Examine bowel and dilate the margins of the sac.

5.  If the bowel is viable, return it to the abdomen.

6.  If necessary, resect a gangrenous segment of bowel perform­ing on end to end anatomosis.

7.  Carry out a hernial repair.

8.  Close wound in layers.

Instruments

•   Hernia set

•           Gastrointestinal set

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