CST 201 Chapter 17: Obstetric and Gynecologic Surgery Comprehensive Study Notes

 # Big Picture: Obstetric and Gynecologic (OB-GYN) Surgery

• Obstetrics (OB): Focused on the care of the pregnant patient, fertility issues, labor, delivery, and procedures specifically connected to childbirth.
      * Examples: Cervical cerclage, cesarean section, episiotomy, and tubal procedures performed after delivery.
• Gynecology (GYN): Focused on the care of the female reproductive system outside of pregnancy.
      * Examples: D&C (Dilation and Curettage), hysteroscopy, laparoscopy, hysterectomy, myomectomy, colporrhaphy, LEEP (Loop Electrosurgical Excision Procedure), and vulvectomy.
• CST Exam Core Focus: The Certified Surgical Technologist (CST) must master pelvic anatomy, patient positioning, specific incisions, instrument sets, procedure sequences, specimen handling, contamination control, and proactive anticipation of the surgeon's needs.
• Most Common Positions:
      * Supine: Utilized for abdominal cases.
      * Lithotomy: Utilized for vaginal and combined vaginal/abdominal cases.
      * Trendelenburg: Used to move bowel contents cephalad (toward the head) to out of the pelvis for improved visualization.
• Core Surgical Pattern: Expose -> Identify anatomy -> Clamp or dissect -> Cut -> Ligate or control bleeding -> Remove/repair -> Irrigate/count/close.
• Critical Safety Considerations:
      * Nerve Protection: Prevent peroneal nerve injury during lithotomy through proper padding and movement.
      * Bladder Protection: Use of a Foley catheter to decompress the bladder.
      * Fluid Management: Prevent fluid overload during hysteroscopy.
      * Fire/Burn Safety: Adhering to laser precautions and managing light cords on the surgical field.

Equipment, Supplies, and Room Setup

• Stirrups (Allen, Candy Cane): Essential for the lithotomy position. Legs must be raised and lowered simultaneously. Adequate padding is required to avoid peroneal nerve injury and pressure sores.
• OR Table Features: Must have foot-drop capability for vaginal access and Trendelenburg capability to improve pelvic exposure.
• Mayo Stand and Back Table: Setup resembles general surgery for abdominal cases but includes specialty GYN instruments.
• Kick Bucket: Used for sponges and waste specifically during vaginal procedures.
• Suction Devices: Yankauer tips used for general suction; speed is necessary for handling blood, amniotic fluid, and irrigation.
• Monitoring Equipment: Fetal and maternal monitors are used in obstetric cases. The CST must recognize that fetal distress may escalate the case urgency.
• Overhead Radiant Warmer: Dedicated for newborn care immediately following a C-section or delivery.
• Catheterization: Foley catheters or straight red rubber catheters are used to decompress the bladder and prevent accidental injury during pelvic maneuvers.

Detailed Positioning, Prep, and Draping

• Supine Position:
      * Uses: Total Abdominal Hysterectomy (TAH), C-section, open tubal procedures, and open pelvic surgeries.
      * Safety Point: Protect heels and pressure points. For C-sections, place a roll under the right hip to reduce pressure on the vena cava.
• Lithotomy Position:
      * Uses: D&C, hysteroscopy, vaginal hysterectomy, episiotomy repair, and colporrhaphy.
      * Safety Point: Raise and lower both legs simultaneously. Pad stirrups to prevent peroneal nerve injury.
• Trendelenburg Position:
      * Uses: Laparoscopy, TAH, Laparoscopically Assisted Vaginal Hysterectomy (LAVH), and robotic hysterectomy.
      * Safety Point: Organs fall cephalad to improve visualization. Ensure the patient is secured to the table before adopting a steep Trendelenburg angle.
• Low Lithotomy with Arms Tucked:
      * Uses: Often employed for LAVH and robotic cases.
      * Safety Point: Verify equipment, padding, and arm positioning prior to docking the robot or draping.
• Wide Prep:
      * Uses: Used for laparoscopic cases that may convert to open surgery or abdominal/vaginal combination cases.
      * Safety Point: Sterile prep should be wide as extra access may be required. Prevent prep solution from pooling or trapping under the patient.

Comprehensive Pelvic Anatomy

• Uterus (Hystero): A muscular organ where pregnancy develops; removed during hysterectomy. Muscle contraction in this organ controls postpartum bleeding.
• Endometrium: The inner lining of the uterus. It is scraped during a D&C and destroyed during endometrial ablation. It thickens according to the menstrual cycle.
• Myometrium: The muscular layer of the uterus. It contracts during labor and post-delivery; Oxytocin (Pitocin) stimulates this layer.
• Cervix: The lower neck of the uterus containing the internal and external os. It is stabilized with a tenaculum and dilated for D&C/D&E. Cerclage is used to reinforce a weak cervix.
• Internal Os: The opening from the uterus into the cervical canal. Cerclage is placed near this level.
• External Os: The opening from the cervix into the vagina. This area is passed by curettes and dilators and is exposed by the Auvard speculum.
• Adnexa: Refers to the ovaries, fallopian tubes, and supporting structures. These are visualized during laparoscopy and removed during salpingo-oophorectomy.
• Fimbriae: Finger-like projections at the end of the fallopian tube near the ovary that catch the egg. Indigo carmine dye is observed here to check for tubal patency during tuboplasty.
• Perineum: The area between the posterior vaginal opening and the anus. It is incised during an episiotomy. Inadequate repair can lead to fistula, pain, sepsis, and postpartum bleeding.

Pelvic Ligaments: Functions and Surgical Clues

• Broad Ligament: The largest supporting ligament; its anterior and posterior leaves enclose vessels and viscera. It holds the uterus in place and contains the round and ovarian ligaments.
• Round Ligament: Attaches to the uterus, travels through the groin, and inserts toward the labia. It stretches during pregnancy and is clamped/divided early in TAH to gain access.
• Cardinal Ligament: Located on the lateral side of the uterus from the cervix. It carries the uterine arteries and veins (primary blood supply). It carries a major bleeding risk and is removed in radical hysterectomy.
• Infundibulopelvic (IP) Ligament (Suspensory Ligament of Ovary): Extends from the ovary to the pelvic side wall. It contains the ovarian vessels and requires careful clamping. Do not confuse with the ovarian ligament.
• Ovarian Ligament: Connects the ovary to the uterus just below the fallopian tubes. It lies within the broad ligament and supports the ovary but does not contain main ovarian vessels.
• Uterosacral Ligament: Attaches the cervix to the sacrum to support the uterus posteriorly.
      * TAH Sequence: Last ligament clamped.
      * Vaginal Hysterectomy Sequence: First ligament clamped.

OB-GYN Instrumentation Guide

• Jorgenson Scissors: Used in TAH to cut ligaments (specifically the vaginal cuff) after clamping.
• Heaney Hysterectomy Clamp: Curved clamp used for uterine vessels and ligaments in the clamp-cut-tie sequence.
• Zeppelin Hysterectomy Clamp: A long clamp used for deep pelvic tissues and vessels.
• Heaney Needle Holder: Specialized for deep pelvic suturing and ligation.
• O'Connor-O'Sullivan Retractor: A self-retaining abdominal retractor for exposure in open pelvic surgery.
• Curved Kocher: A traumatic clamp with teeth used on tough structures or for traction.
• Grasping Forceps: Russian forceps are for heavier tissue; Long and Short tissue forceps are used based on tissue type.
• Auvard Weighted Speculum: Provides hands-free weighted vaginal retraction to expose the cervix.
• Graves Vaginal Speculum: A bivalve speculum for visualization.
• Schroeder Single-Tooth Tenaculum: A sharp instrument used to grasp the cervix, typically at the $12$ o'clock position.
• Sims Uterine Sound: Measures uterine depth to reduce the risk of perforation during dilation.
• Hegar Dilators: Used to gradually dilate the cervix.
• Sims / Kevorkian Curette: Scrapes or samples endocervical or endometrial tissue.
• Kevorkian Biopsy Forceps: Specialized for obtaining cervical tissue samples.
• Forceps/Retractors for Delivery: DeLee or Luikart forceps (OB delivery forceps); DeLee universal retractor for vaginal exposure.
• Deschamps Ligature Carrier: Used to pass tape/ligature around the cervix during cerclage.
• Microsurgery (Tuboplasty): Rhoton micro forceps, micro scissors, micro needle holders, and bipolar coagulating forceps (for precise coagulation).

Diagnostic Procedures in GYN Surgery

• Diagnostic Laparoscopy:
      * Purpose: Visualization of pelvic organs (uterus, ovaries, tubes, ectopic pregnancy, endometriosis).
      * Setup: Lithotomy with slight Trendelenburg. Foley catheter insertion. Uterine manipulator (e.g., HUMI) placed in cervix.
      * CST Note: Requires a separate small setup and glove change if proceeding to an intervention. Place light source on standby when the scope is outside the abdomen.
• Hysteroscopy:
      * Purpose: Visual exam of the uterine cavity to diagnose/treat polyps, myomas, or bleeding.
      * Setup: Lithotomy. Use sterile technique to prevent SSI.
      * Fluid Warning: Monitor flow and total volume of media (Carbon dioxide, sorbitol, glycine, dextran/Hyskon) to prevent fluid overload.
• Hysterosalpingogram (HSG):
      * Purpose: Imaging of the uterus and tubes using contrast/dye to check for cavity issues and tubal patency (infertility workup).
• Colposcopy:
      * Purpose: Visual exam of the cervix using magnification. May use acetic acid or Lugol's solution (Schiller’s test) to guide biopsy of abnormal tissue.

Obstetric Procedure: Cervical Cerclage

• Purpose: Reinforcement of an incompetent cervix that shortens or dilates too early, preventing preterm delivery.
• Timing: Performed in late second trimester or early third trimester.
• McDonald Procedure: Mersilene tape/suture placed in a purse-string fashion around four quadrants of the cervix.
• Shirodkar Procedure: A more complex, deeper procedure involving a transverse incision in the vaginal mucosa; heavy tape is passed with a ligature carrier around the cervix.
• Abdominal Cerclage: Transabdominal approach used for a short cervix or when vaginal approach is unsuitable.
• Instrumentation: D&C tray, Deschamps ligature carrier, and heavy tape (Mersilene).

Obstetric Procedure: Cesarean Section (C-Section)

• Definition: Delivery of the fetus via incisions in the abdominal wall and uterus.
• Indications: Fetal distress, cephalopelvic disproportion (CPD), malrotation, toxemia/hypertension, multiple pregnancy, placenta previa, prolapsed cord, active herpes simplex, or previous C-section.
• Position: Supine with a roll under the right hip to reduce pressure on the vena cava.
• Incision: Pfannenstiel (low transverse incision).
• Supplies: Bulb syringe, two cord clamps, cord blood container, radiant heater, and two suction tubes with Yankauer tips.
• Medication: Oxytocin (Pitocin) used post-delivery to induce uterine contraction and support hemostasis.
• Count Requirements: Four counts ($4$) total: before skin incision, before uterine closure, before abdominal cavity closure, and before skin closure.
• Procedure Steps:
      1. Prep/Drape: Confirm suction, clamps, bulb syringe, and baby supplies.
      2. Skin Incision (Pfannenstiel): Pass knife, pickups, cautery, and sponges.
      3. Open Abdomen and Uterus: Ready suction for blood and amniotic fluid; prepare retractors.
      4. Deliver Baby: CST prepares bulb syringe and cord clamps immediately.
      5. Cord Clamped/Cut: Two clamps placed; cord blood collected.
      6. Placenta Delivered: CST prepares basin for specimen; monitor sponges.
      7. Uterine Closure: Pass needle holder and suture; perform second count.
      8. Abdominal Closure: Perform third and fourth counts.

Obstetric Procedure: Episiotomy and Repair

• Definition: Intentional perineal incision to ease birth or prevent uncontrolled tearing.
• Position: Lithotomy.
• Suture: Absorbable suture is used.
• Complications of Poor Repair: Postpartum hemorrhage, sepsis, rectovaginal fistula, and coital pain.

Tubal Sterilization and Tuboplasty

• Tubal Ligation: Sterilization via resection, cautery, clips (Filshie or Hulka), or bands. Pomeroy is a common technique.
• Tuboplasty: Restoration of patency after sterilization or obstruction.
      * Equipment: Major laparotomy set, microsurgical instruments (Rhoton), bipolar forceps, ESU needle tip, operating microscope/loupes, and low molecular weight dextran irrigation.
      * Dye Test: Indigo carmine is injected to test patency; dye should appear at the fimbrial end.

External Genitalia Procedures

• Bartholin Gland Duct Cyst Marsupialization: Incision and drainage (I&D) of an abscess followed by suturing the cyst wall to the incision edges to allow continuous drainage. Considered a contaminated/dirty wound class.
• Vulvectomy:
      * Simple: Partial/complete removal of the vulva.
      * Radical: Involves groin exploration and lymph node removal for cancer treatment.
• Labiaplasty: Reshaping the labia minora. Techniques include amputation, central wedge resection, or Z-plasty. Risks include necrosis or painful neuroma.

Cervical and Uterine Treatment Procedures

• D&C (Dilation and Curettage):
      * Purpose: Diagnose/treat heavy bleeding ($menorrhagia$, $metrorrhagia$) or incomplete abortion.
      * Sequence: Auvard speculum -> Tenaculum -> Sims sound -> Dilators -> Curette.
      * Specimens: Endocervical curettings (ECC) and Endometrial curettings (EMC) must be kept separate on Telfa.
• D&E (Dilation and Evacuation): Performed after the $13th$ week of pregnancy to evacuate uterine contents.
• DVC (Dilation Vacuum Curettage): Early pregnancy termination or evacuation using suction.
• LEEP (Loop Electrical Excision Procedure): Removes abnormal cervical tissue using a wire loop and electricity. Uses Schiller’s test (Lugol’s solution) to identify tissue (normal tissue stains dark brown).
• Cold Knife Conization: Removal of a cone-shaped tissue sample from the cervix using a scalpel (no electricity).
• Endometrial Ablation: Destroys the lining for chronic menorrhagia.
      * Balloon Ablation: Balloon filled with $D5W$ heated to approximately 86^{\circ}\text{C} for approximately 10\text{min}.

Abdominal Incisions in OB-GYN

• Pfannenstiel: Low transverse; common for C-section/GYN.
• Maylard: Transverse; cuts the rectus muscle for more exposure.
• Cherney: Transverse; detaches the rectus tendon.
• Midline: Fast vertical entry for emergencies.

Hysterectomy Master Breakdown

• Total Abdominal Hysterectomy (TAH):
      * Approach: Wound Class II. Instrument isolation for the vaginal cuff (clean-to-dirty).
      * Ligament Order in TAH:
          1. Round Ligament (clamped/divided to mobilize uterus).
          2. Ovarian/Infundibulopelvic (IP) Ligament (carries ovarian vessels).
          3. Uterine Artery (primary uterine blood supply).
          4. Cardinal Ligament (contains uterine vessels).
          5. Uterosacral Ligament (last ligament clamped).
• Radical Hysterectomy (Wertheim Procedure): En bloc removal of uterus, ovaries, tubes, ligaments, upper vagina, and pelvic lymph nodes. Often for cervical cancer.
• Vaginal Hysterectomy: Uterus removed via vagina. Uterosacral ligaments are double-clamped FIRST.
• LAVH/Robot-Assisted: Minimal access; specimen usually removed vaginally. Robot docking limits patient access.

Pelvic Exenteration

• Definition: Radical en bloc resection of reproductive structures, bladder, and rectosigmoid for recurrent cervical cancer.
• Diversions:
      * Colostomy: Created using the sigmoid colon on the left side of the abdomen.
      * Ileostomy/Urinary Diversion: Stoma created on the right side of the abdomen.

Pelvic Floor Repairs

• Cystocele: Bladder prolapse into the vagina; repaired via Anterior Colporrhaphy.
• Rectocele: Rectal prolapse into the vagina; repaired via Posterior Colporrhaphy.

Additional Clinical Facts

• Pudendal Block: Local anesthetic near the pudendal nerve for perineal pain relief.
• Culdocentesis: Needle aspiration of the cul-de-sac of Douglas to confirm ectopic pregnancy.
• Nuchal Cord: Umbilical cord wrapped around the baby's neck.
• Placental Abruption: Premature separation of the placenta; hemorrhage risk.
• Placenta Previa: Placenta blocks the cervical opening.
• Eclampsia: Pregnancy-induced hypertension accompanied by seizures.

Questions & Discussion

• Q: What position improves pelvic visualization?
      * A: Trendelenburg.
• Q: Why is a Foley used?
      * A: To decompress the bladder and prevent injury.
• Q: What ligament is last in TAH?
      * A: Uterosacral.
• Q: What ligament is first in vaginal hysterectomy?
      * A: Uterosacral.
• Q: What ligament carries the uterine arteries?
      * A: Cardinal Ligament.
• Q: What ligament contains ovarian vessels?
      * A: Infundibulopelvic (IP) / Suspensory ligament.
• Q: What is the medication for uterine contraction?
      * A: Oxytocin (Pitocin).
• Q: What dye is used for tubal patency?
      * A: Indigo carmine.
• Q: What specimens in D&C must be separate?
      * A: ECC and EMC.
• Q: Where is a colostomy created in pelvic exenteration?
      * A: Left abdomen.
• Q: Where is the urinary diversion stoma created?
      * A: Right abdomen.