MODULE 15 Gynecology Surgery RPN20232.pdf

MODULE 15: Gynecology Suggested Readings Alexander’s Care of the Patient in Surgery ( 2022) Chapter 14 Tighe (2015) Instrumentation for the Operating Room Chapter 18 ORNAC Standar...

MODULE 15: Gynecology Suggested Readings Alexander’s Care of the Patient in Surgery ( 2022) Chapter 14 Tighe (2015) Instrumentation for the Operating Room Chapter 18 ORNAC Standards 2023 Learning Outcomes Explain relevant anatomy and basic procedural considerations for gynecological surgeries. Compare and contract minimally invasive gynecological procedures to open procedures. Explain the clinical pathway for obstetrical patients that are undergoing a surgical procedure. Gynecological surgeries may be performed for diagnostic, therapeutic or reproductive purposes. Conditions requiring surgery may include abnormal bleeding, benign or suspected tumours, infertility or the need to remove or repair weakened structures. A patient centered holistic approach with sensitivity to the particular needs for this population is essential for their perioperative care. Anatomy Cervix – consists of a supravaginal portion, which is closely associated with the bladder and ureters, and the vaginal portion which projects downward and backward into the vaginal vault which divides into four regions: anterior, posterior, right lateral and left lateral. The Cervix has an internal and external os, protecting the entrance to the uterus. Uterus – A pear-shaped organ in the pelvic cavity between the bladder and the rectum. The uterus is supported by its direct attachments to the vagina and from indirect attachments to nearby structures (rectum and pelvic diaphragm). The uterus is supported on each side by Ligament attachments: broad, round, cardinal, and uterosacral ligaments and levator ani muscles. Fallopian Tubes – Consists of musculomembraneous channel about 10 – 13 cm long, forming the canals through which the ova are conveyed to the uterus from the ovaries. Supported by the infundibulopelvic ligament. The right tube and ovary are in close relationship to the cecum and appendix. The left tube and ovary are near the sigmoid flexure. Module 15: Gynecology  Ectopic Pregnancy may occur in women where the pregnancy is in the tube. This can cause the tube to rupture causing hemorrhage and possibly loss of the fallopian tube. This is an emergency and can be repaired laparoscopically. Ovaries – Located on each side of the uterus, supported by ovarian ligament (uteroovarian). Essential for the implantation of the fertilized ovum and for the development of the embryo. Cysts may develop in the ovaries resulting in surgical intervention: ovarian cystectomy Vagina - A musculomembranous tube that carries the menstrual blood from the uterus, serves as the organ for sexual intercourse, and is the terminal portion of the birth canal. It has an anterior and posterior wall. The anterior wall is close to the bladder and urethra and the posterior wall is adjacent to the rectum. The lower half is surrounded by the elevator ani muscles. Perioperative Nursing Considerations Nursing Assessment The patient is asked about her gynecological history including health history related to; Pap smears, HPV testing and results, sexuality, past procedures eg. tubal ligation, hysterectomy, menstrual and obstetric history, infertility, menopause, pain, abnormal bleeding. The patient’s pain tolerance is assessed to determine her need for necessary teaching or tools for managing postoperative pain. Blood Replacement - Some patients may require extensive tissue dissection in highly vascular areas, resulting in the need for blood transfusion. Orders and availability of blood products must be confirmed pre-, intra-, and post-operatively. The RPN should be prepared in the scrub role Module 15: Gynecology with hemostatic agents, such as hemoclips, sutures, ties, sponges, Gelfoam, surgicel, etc to anticipate any critical surgical needs. Patient Positioning The surgical procedure determines the patient’s intraoperative position. Typically, patients undergoing open hysterectomies of tubal ligation are placed in a supine position with slight Trendelenburg tilt. Patients undergoing laparoscopic surgeries will be place in various lithotomy positions. Refer to the ORNAC Standards and the positioning performance checklist for appropriate practices. When patients are placed in lithotomy position, stirrups are used. The perioperative nurse must ensure the stirrups are fastened to the bed to support the patient’s legs. Hips should not be flexed greater than 90 degrees to prevent injuries to the sciatic and obturator nerves as well as hip joint and muscle strains. Removing the legs from the stirrups after surgery is a slow and coordinated process requiring adequate support from others. Lower the legs slowly to facilitate hemodynamic adjustment when blood shifts to lower extremities. This also prevents lumbosacral muscle strains. Instrumentation and Counting There are four surgical approaches in Gynecology, with varying instrumentation and counting requirements: Vaginal Open Vaginal and Open Laparoscopic Combined Laparoscopic and vaginal ie. Laparoscopically assisted vaginal hysterectomy (LAVH) Common instruments for vaginal approach: Weighted Speculum Tenaculum (to grab the cervix) Cervical dilators (Hegar) small – large Uterine sound (measure the depth of the uterus) Uterine curettes (sharp and blunt) Ovum forceps / sponge forceps Bonnie Tissue Forceps (specimen, swabbing, curetting) Dilation and Curretage Set (D and C) (vaginal hysterectomy/ repair, hysteroscopy, endometrial ablation) Module 15: Gynecology  A minor count is required for initial, closing, and final counts for all vaginal procedures Initial Count (minor) → Closing Count (minor) → Final Count (minor) Common instruments for Open, Laparoscopic, or combined approach: D and C set Basic laparotomy instrument set or basic hysterectomy or vaginal hysterectomy set Hysteroscope Laparoscopic Instrument set Balfour retractor or Sullivan- O’Connor (open hysterectomy only) Heaney hysterectomy forceps for clamping (also known as Maingots or Guilliams) Heaney needle driver (Special curved tip) Long curved and straight kochers Long curved mayo scissors (for tough tissue) Russian mayo Tissue forceps, Bonney heavy tissue forceps A major count and closing count is required for all open, laparoscopic, or combined cases An additional closing the vault count (minor) is required when the cervix is removed/entered. Initial Count (major) → Closing Vault Count ((minor, if indicated)) → Closing Count (major) → Final Count (minor) Equipment Forced-Air Warming Blankets - The large amount of skin exposure required for either a laparotomy or a laparoscopic approach presents a risk for hypothermia. Operating Room Table – A perioperative nurse or operator may need to adjust the position of the bed frequently throughout the procedure eg. Trendelenburg position. Ablation Equipment – Endometrial ablation is performed to treat abnormal uterine bleeding. It may be an alternative to hysterectomy in some patients with chronic menorrhagia. Carbon Dioxide Laser (CO2) and Argon Lasers – Used to treat extrauterine disease, such as pelvic endometriosis, cervical dysplasia, pelvic adhesions disease, and pre-malignant diseases of Module 15: Gynecology the vulva and vagina. Common laser approach is the Nd: YAG laser suing the blanching or dragging technique eg. Endometrial ablation. Hysteroscopy The endoscopic visualization of internal uterine cavity and tubal openings using 2 telescopes 30 degree and 0 degree. A medium, such as normal saline is required for straight hysteroscopy. The Valtchev's uterine mobilizer is often used with the Hysteroscope for Ablations as well as when doing a laparoscopic gynecological procedure, such as tubal ligation, LAVH, and diagnostic laparoscopies. It moves the uterus from side to side so laparoscopic procedures can be done (i.e. tubal work). Dye medium can be inserted into the uterus via the mobilizer and will escape out of the fallopian tubes. If dye is not visualized through the laparoscope it could indicate a blocked tube. It also acts as a mobilizer and can retroflex and antivert the uterus during gynae. Vaginal Surgeries Endometrial Ablation - Burning away the endometrium for Menorrhagia (previously the patient with a heavy period blood flow that was anemic had a hysterectomy. Procedural Considerations A Non-Electrolytic Ionic Medium is required, such as Cystosol, Mannitol, Glycine. These must be used throughout the procedure whenever burning tissue is involved, as normal saline will interfere with the electrical current of the cautery. This procedure can also be done with the Nd: YAG laser suing the blanching or dragging technique. Air or gas is not used in cooling the laser because of the risk of a gas or air embolism. During ablations the intake and output must be measured, as hyponatremia can be a complication of this procedure. Sign and symptoms for hyponatremia are: bradycardia, hypertension followed by hypotension, nausea, vomiting, agitation. Vaginal Hysterectomy - The removal of the uterus through an incision made in the vaginal wall and the pelvic cavity. The indication for this procedure is for small uteri with history of cancer as lymph node biopsies cannot be done. There is no abdominal incision. Surgical Count - Full count is required, as you are still going through peritoneum! Procedural Considerations Syringes for Local vasoconstrictors may be used to facilitate dissection and decrease bleeding. Module 15: Gynecology  Sutures are large size absorbable eg. 1 or 0 Vicryl Sometime an anterior or posterior repair is also done with this procedure. Vaginal repair instruments will be added. Indwelling urethral catheter/ suprapubic catheter post procedure, packing and a peripad. Vaginal Cystocele or Rectocele Repair (also known as Anterior or Posterior Colporrhaphy) – Done to restore the bladder and rectum to proper position. Cystocele - Herniation of the bladder causing the anterior wall to bulge forward. Rectocele - A protrusion of the anterior rectal wall (posterior vaginal wall) into the vagina. The levator muscles become stretched or torn and the herniation of the rectum causes the posterior wall to bulge forward sometimes entering the vaginal canal. Suture roof of vagina or floor of it more tightly. Surgical Count - Small or minor count for initial, closing, and final count (if only procedure performed). Procedural Considerations Syringes for Local vasoconstrictors may be used to facilitate dissection and decrease bleeding Peripad for dressing Laparoscopically- Assisted Vaginal Hysterectomy (LAVH) - The uterus is removed vaginally using endoscope for abdominal visualization. Procedural Considerations Team must always be ready to convert to an open Hysterectomy, if required. LAVH has all of the advantages of a vaginal hysterectomy, but also allows the surgeon to biopsy lymph nodes through the endoscopic portals and remove a larger uterus. The endo GIA stapler is used; positioned on the side of the uterus and fired twice on each side by stapling and cutting the tissue in between. The ureters are protected by the pneumoperitoneum, and are not at risk of being cut such as in the open or vaginal approach. Abdominal Hysterectomy - The removal of the uterus through an incision in the lower abdomen. Surgical Count – A major count is required for initial and closing count, minor count required for final count. Total Abdominal Hysterectomy (TAH) - The removal of the uterus and the cervix. Module 15: Gynecology Procedural Considerations The four sets of ligaments are cut (round, broad, uterosacral, and cardinal) If fallopian tubes and ovaries are being preserved, the Uteroovarian ligaments are doubly clamped together, incised and doubly tied with suture ligatures. Accidental severing of the ureters is to be avoided The cervix is considered contaminated, so instruments used are kept isolated Sutures are large size and absorbable eg. 1 or 0 Vicryl Surgical Count – A major count is required for initial and closing count, minor count required for closing of the vault, and final count. Radical Hysterectomy (Wertheim) - A wide removal of the uterus, cervix, fallopian tubes, ovaries, supporting ligaments, and upper vagina, together with all recognizable lymph nodes in the pelvis. Extensive dissection of ureters and bladder is also involved. Surgical Count: Full or Major counts for initial and closing count; small or minor count for final count. Procedural Considerations Performed for gynecological malignancy that has extended beyond the cervix and invaded the uterus, such as uterine cancer or cervical cancer (young people). Extra deep dissection will be required, and special long deep Wertheim instruments are used. Bilateral Salpingo-Oophorectomy (BSO) – The removal of the fallopian tubes and all or part of the associated ovaries. The ovaries are usually preserved for TAH and BSO in woman under the age of 45. The ovaries are removed in women 45 years and older as they become less functional beyond this age category. Vesicovaginal Fistula - An abnormal opening between the urinary bladder and vagina that results in continuous, involuntary dribbling (incontinence) of urine from the vagina. This may be caused by injury during gynecologic surgery, such as a previous hysterectomy caused by extensive dissection between the bladder and the uterus, unrecognized bladder laceration, inappropriate stitch placement, and / or devascularization injury to the tissues. Ovarian Cancer and Pelvic Exenterations – Removal of the rectum, the distal sigmoid colon, the urinary bladder, and the distal ureters, the internal iliac vessels and their lateral branches, all pelvic reproductive organs and lymph nodes, and the entire pelvic floor with the accompanying pelvic peritoneum, levator muscles, and perineum. Indicated for persisted carcinoma of the cervix, after radiation therapy – often metastasizes to the omentum. This procedure is also performed in males with Invasive Rectal Cancer. Module 15: Gynecology  Complete – Removal of all organs in pelvic cavity, including urinary bladder, urethra, rectum, and anus. Anterior- Removes organs from the urinary (bladder) and gynecologic systems Posterior – Removal of organs from the gastrointestinal (rectum) and gynecologic systems Procedural Considerations Aggressive cervical cancer is referred as the silent killer, as women (age 40-65 years) are often treated for something else when diagnosis is detected. Cancer in situ (CIS) usually develops between the age of 30 – 40 and becomes invasive at 40 – 65 years. A permanent colostomy/ ileostomy is created with urinary diversion (ureters are reimplanted into ileum and this creates urinary drainage). Surgical Count - Full or Major counts for initial and closing count; small or minor count for final count. Obstetrical Surgery The team is now faced with the challenge of caring for at least two patients; the mother and her child. Hazards of performing surgery on pregnant patients include fetal loss, fetal asphyxia, premature labor, premature rupture of the membranes, and thromboembolic events. Procedure Considerations Continuous monitoring of the feta heart rate Rapid sequence induction for a general anesthesia to prevent aspiration Be prepared with tocolytic medications eg. terbutaline – used to decrease uterine activity to prevent labor Ready access to neonatal resuscitation drugs and equipment (2nd trimester and beyond) Positioned with a lateral tilt or with wedge/pillow under right hip to provide uterine displacement and relieve pressure (if possible) C section case cart available Cervical Cerclage – Performed when incompetence of the cervix characterised by habitual mid- trimester spontaneous miscarriages. Surgical intervention (mechanical closure to the cervix using permanent sutures) is designed to prevent surgical dilation that results in the release of uterine contents. Vaginal Approach (Shirodkar or McDonald approaches) or abdominal/ laparoscopic approach (less common). Instruments and Counting D and C tray + Cervical Cerclage suture Module 15: Gynecology  Minor Count required Procedure Considerations Suture can then be removed in office at 36 weeks, or the child may be delivered via C-section. Shirodkar Technique - Submucosal placement of a purse-string type of suture/ligature of Mersilene, Dacron tape, heavy nylon suture, or plastic-covered braided-steel suture at the level of the internal os to close it. McDonald Technique – Uses a secure tie or tape placed horizontally and vertically across the cervix. Module 15: Gynecology