Gynaecology Surgery ppt RPN Student Copy. 20231.pdf

Gynaecology Surgery S425 RPN PERIOPERATIVE PROGRAM Learning Outcomes Explain relevant anatomy and basic procedural considerations for gynecological surgeries. Compare and contrast minimally invasive gynecological procedures to open procedures. Explain the clinical pathway for obstetrical pa...

Gynaecology Surgery S425 RPN PERIOPERATIVE PROGRAM Learning Outcomes Explain relevant anatomy and basic procedural considerations for gynecological surgeries. Compare and contrast minimally invasive gynecological procedures to open procedures. Explain the clinical pathway for obstetrical patients that are undergoing a surgical procedure. Introduction Gynecological surgeries are performed for: Diagnostic Therapeutic Reproductive purposes Patient centered care and practicing in a holistic and sensitive manner is imperative for the needs of this patient population. Anatomy Anatomy Uterus, cervix, ovaries and fallopian tubes in relation to other important anatomical structures Blood Supply Internal Iliac Artery branches from common iliac artery Uterine Artery Additional branches from the aorta: Ovarian artery Vaginal Artery Superior rectal artery Nerve supply Autonomic nerves in the pelvis from the superior hypogastric plexus Lymphatics Pelvic lymph nodes follow the major vessels Iliac and Preaortic nodes Anatomy - Uterus Pelvic Cavity – Uterus Directly attached to the vagina; supported by uterine ligaments Fundus is positioned below the pelvic rim Body of the uterus is the corpus Serous layer Myometrium Endometrium Uterine ligaments are surgical landmarks Notice the different layers of the uterus: Endometrial (lining) Myometrium (where fibroids are often found) Ligaments Hold up the uterus in the abdominal cavity Ligaments are important landmarks during surgery Clamped and cut 4 Ligaments: Broad Cardinal Uterosacral Round  Fallopian Tubes and Ovaries Known as adnexa Egg released by ovary and travels to uterus through peristalsis in the fallopian tube Fertilization occurs in the fallopian tube The longitudinal folds of the fallopian tube seen in cross section. A: Infundibulum B: Ampulla C: Isthmus Perioperative Nursing Considerations Patient history related to gynecological disorders and diseases Pain tolerance Positioning: Lithotomy Surgical Count – Minor vs Major **Vault count Surgical approaches Open and MIS instrumentation Instrumentation Dilation and Curettage (D&C) Set Up Weighted Speculum - inserted into the vagina Tenaculum - to grab the cervix Hegar Dilators – dilate cervix Uterine sound – to measure the depth of the uterus Uterine curettes – sharp and blunt; take specimen Ovum forceps or sponge forceps Bonnie Tissue Forceps ( specimen, swabbing, curetting) Sponges are counted Specimen (tissue from curette is collected on a 4x4) removed and sent to pathology (formalin) D & C Tray Instrumentation Open/Laparoscopic Basic instrument set up Hysteroscope A: Heaney hysterectomy forceps for clamping B: Heaney needle driver (Special curved tip) Equipment Ablation Equipment Carbon Dioxide Laser (CO2) and Endometrial ablation is Argon Lasers performed to treat abnormal Used to treat extrauterine uterine bleeding disease such as pelvic endometriosis. Common laser approach is the Nd: YAG laser Surgical Interventions Dilation and Curettage Hysteroscopy Endometrial Ablation Vaginal hysterectomy Cystocele or Rectocele LAVH Abdominal Hysterectomy Ovarian Cancer Obstetrics D&C Completed with another gynecology procedure such as: Hysteroscopy Endometrial ablation - DUB, fibroids Cone Biopsy - abnormal pap smear Vaginal Hysterectomy - uterine prolapse LAVH Hysteroscopy Used for diagnostic purposes for uterine disorders Visualization of uterine cavity Need: D and C set up Hysteroscope: 0 and 30 degree for visualization Light cord Medium used is ____________ Endometrial Ablation Done for excessive vaginal bleeding called Menorrhagia Procedure involves burning away the endometrium Goal: to reduce menstrual flow Need to us a medium that is safe to use cautery: Non-Electrolytic Ionic Medium i.e. Cystosol Procedure Considerations D & C and Hysteroscope set up Resectoscope (to remove the endometrial layer) ESU Safe Medium fluids: Non electrolytic isotonic fluid Measure intake and output Complication is _____________ S&S: Bradycardia, hypertension followed by hypotension, nausea, vomiting, agitation Lithotomy position Scope attached to camera Hysterectomy 1. Vaginal 2. Laparoscopic Assisted Vaginal Hysterectomy (LAVH) 3. Abdominal a) Partial/Subtotal b) Total Abdominal c) Radical Hysterectomy d) Bilateral Salpingo – Oophorectomy (BSO) Vaginal Hysterectomy Removal of uterus through an incision in the vaginal wall and pelvic cavity For small uterus and history of cancer Uterine Prolapse Nursing Considerations Lithotomy Position with stirrups Catheter pre op Sutures Count Instrumentation Vaginal hysterectomy set Abdominal set PRN Heaney retractors, heaney needle drivers, weighted speculums, kochers Surgeon sits between patient’s legs with tray on bottom of OR table Scrub nurse stands slightly behind surgeon **Be mindful of sterile technique! Neutral zone and clear pathway to pass instruments is imperative. Procedure Considerations Weighted speculum inserted in vagina Incision in vaginal wall around the cervix Clamp and cut ligaments and tissues around the uterus C- U- R- B- Remove the fundus of the uterus through the vagina with tenaculum Vaginal Cystocele or Rectocele Also known as Anterior or Posterior Colporrhaphy Colporrhaphy is a surgical procedure to repair pelvic organ prolapse Often part of Vaginal Hysterectomy Heavy absorbable suture used for repair: _________________  Cystocele Herniation of the bladder (prolapsed bladder) causing the anterior wall to bulge forward Anterior Repair with heavy absorbable suture Cystocele Repair  Rectocele A protrusion of the anterior rectal wall (posterior vaginal wall) into the vagina Sometimes enters the vaginal canal Posterior Repair with heavy absorbable suture Rectocele Repair Laparoscopic Assisted Vaginal Hysterectomy (LAVH) Uterus is removed vaginally using an endoscope for abdominal visualization Alternative to TAH or vaginal hysterectomy Allows for biopsies of lymph nodes through endoscopic ports Remove larger uterus Uterine mobilizer (Valtchev*) -used to antevert/retrovert the uterus for better visualization of anatomical structures LAVH Application of bipolar to coagulate the fallopian tube before cutting Ligasure may be used Laparoscopy Use Laparoscopy in Gynaecology Surgery can also be used for: Diagnostic – for pelvic pain, infertility – check patency of tubes Tubal ligation Ovarian Cystectomy Ectopic Pregnancy *Both Monopolar and Bipolar may be used in Laparoscopic Gynae surgery! Pneumoperitoneum Closed pneumoperitoneum is achieved using a ____________ Volume used: 2.5 – 4L A 10- 12mm trocar is needed for the camera insertion Insufflator tubing will be attached to the 10-12mm port to maintain the pressure Risk of gas embolism if pressure exceeds 16mmHg!  10- 12mm trocar for the camera insertion 5 mm trocar for diagnostic 5 mm trocar x 2 if additional surgical interventions planned Procedural Considerations LAVH Endo GIA stapler used Positioned on the side of the uterus and fired twice on each side by stapling and cutting the tissue in between Ureters are protected by the pneumoperitoneum = no risk to be cut compared to open or vaginal approach Team must always be ready to convert to an open Hysterectomy  Abdominal Hysterectomy TAH = Total Abdominal Hysterectomy Removal of uterus and cervix Partial /Subtotal Abdominal Hysterectomy Removal of uterus only TAH and Bilateral Salpingo-Oophorectomy (BSO) Removal of uterus, cervix, fallopian tubes and ovaries Radical Removal of uterus, cervix, fallopian tubes and ovaries, upper vagina and lymph nodes **Tubes and Ovaries are preserved in women