42 Care of the obstetric and gynecologic surgical patient
Cerclage Procedure: Procedure for the treatment of incompetent cervix. The McDonald procedure involves the placement of a pursestring suture on the cervix at the level of the internal os. The Shirodkar’s procedure involves placement of a fascia lata (from the thigh) or a surgical band at the level of the internal os.
Cesarean Hysterectomy: Incision of the abdomen and the uterus, extraction of the infant and the placenta, and performance of a hysterectomy.
Cesarean Section (C-Section): Delivery of an infant through an incision made in the abdominal and uterine walls.
C-Section, Classic: A midline incision between the umbilicus and the symphysis pubis and an anterior incision through the uterine wall.
C-Section, Low Segment: An incision in the lower part of the uterus made after an abdominal incision.
Ectopic Pregnancy: Implantation of the fertilized ovum in any site other than the upper half of the uterus.
Uterine Aspiration (Suction Curettage): Dilation of the cervix and vacuum removal of the uterine contents.
LOWER GENITAL SURGERY, VAGINAL SURGERY, ABDOMINAL SURGERY (LAPAROTOMY AND LAPAROSCOPY)
Bartholin’s Duct Cyst: A cyst that results from chronic inflammation of one of the major vestibular glands at the vaginal introitus.
Bartholinectomy: Removal of a Bartholin duct cyst.
Cervical Conization: Removal of abnormal cervical tissue via scalpel, electrosurgical current, or laser.
Colporrhaphy: Repair of the vaginal wall. May be anterior, as for cystocele repair, or posterior, as for rectocele repair or enterocele repair specifically for a vaginal prolapse.
Culdoscopy: An operative diagnostic procedure in which an incision is made into the posterior vaginal cul-de-sac, through which a tubular instrument similar to a cystoscope is inserted for the purpose of visualization of the pelvic structures, including the uterus, fallopian tubes, broad ligaments, uterosacral ligaments, rectal wall, sigmoid colon, and sometimes the small intestine. A newer technique for this procedure is transvaginal hydrolaparoscopy, which uses normal saline solution and a camera attached to a small-diameter rigid endoscope.
Cystocele: Prolapse of the bladder into the anterior vaginal wall.
Dilation of the Cervix and Curettage of the Uterus (D&C): Introduction of instruments (dilators) through the vagina into the cervical canal and scraping of the uterus with a curette for removal of substances, including blood. This procedure is used for diagnostic purposes and for treatment of conditions such as incomplete abortion, abnormal uterine bleeding, and primary dysmenorrhea.
Enterocele: Defect in the continuity of the endopelvic fascia most commonly seen after hysterectomy when the anterior pubic fascia is not attached to the Denonvilliers fascia.
Hysterectomy: Removal of the uterus; can be vaginal (with or without laparoscopic assistance) or abdominal (via laparotomy).
Hysteroscopy: Direct visualization of the canal of the uterine cervix and cavity of the uterus with an endoscope called a hysteroscope.
Procidentia: Herniation of the uterus beyond the introitus.
Prolapse of the Uterus: Downward displacement of the uterus. Vaginal hysterectomy is often recommended for a prolapsed uterus when childbearing is no longer desired or when marked prolapse is present.
Rectocele: Prolapse of the rectum into the posterior vaginal wall.
Trachelorrhaphy: Removal of torn surfaces of the anterior and posterior cervical lips and reconstruction of the cervical canal.
Urethrocele: Prolapse of the urethra into the anterior vaginal wall.
Vaginal Plastic Operation (Anterior and Posterior Repair): Reconstruction of the vaginal walls (colporrhaphy), the pelvic floor, and the muscles and fascia of the rectum, urethra, bladder, and perineum. Used to correct a cystocele or rectocele, restore the bladder to its normal position, and strengthen the vagina and the pelvic floor.
Abdominal myomectomy: Removal of leiomyomas (fibroids) through a large or small incision; if this is done laparoscopically, then the abdominal cavity is visualized through a small incision, usually at the umbilicus after the establishment of a pneumoperitoneum. A video camera is attached to the eye piece of the laparoscope so that the surgeon and team can visualize the procedure while watching a video monitor; this provides a magnified view of the pelvis. If the robot is used, it is often set up after the umbilical trocar is in position.
Oophorectomy: Removal of an ovary.
Oophorocystectomy: Removal of an ovarian cyst.
Radical Hysterectomy: Removal of the uterus, the uterosacral and uterovesical ligaments, the upper third of the vagina, and all the peritoneum. This may or may not include removal of the fallopian tubes and ovaries.
Salpingectomy: Excision of the fallopian tube.
Salpingo-Oophorectomy: Removal of the fallopian tube and the associated ovary.
Salpingostomy (Tubal Plasty): Repair and opening of the fallopian tube to establish patency. This is often done in the case of a hydrosalpinx. Tubal plasty or tubal reanastomosis is used for removal of an obstructed portion of the tube and reconnection of each normal end of the tube after the obstruction has been removed to establish patency. Tubal reanastomosis increases the risk of ectopic pregnancy. Because the success rates of in vitro fertilization are so good, this procedure is seldom done anymore.
Total Abdominal Hysterectomy: Removal of the uterus, including the cervix (with or without the adnexa which refers to the tube and/or ovary), through an abdominal incision. Various types of hysterectomy include the following if done laparoscopically:
LTH or TLH: Laparoscopic total hysterectomy or total laparoscopic hysterectomy; the uterus is removed laparoscopically and the vaginal cuff is sutured laparoscopically.
LSH: Laparoscopic supracervical hysterectomy; the uterus is removed laparoscopically and the cervix remains. This is thought to be the hysterectomy with the least morbidity and the quickest recovery for the patient postoperatively.
LAVH: Laparoscopic assisted vaginal hysterectomy; the uterus is reached laparoscopically and removed vaginally. The vaginal cuff is sutured vaginally.
NOTE: If a robot is used, the robot must be disconnected for any tissue to be removed. One of the main reasons some physicians choose to use the robot is because they find suturing laparoscopically much easier with the robot.
Tubal Ligation: Interruption of fallopian tube continuity, which results in sterilization; this is most commonly done laparoscopically. The fallopian tube is cauterized or ligated, a clip is placed, or the tube is partially excised. Reversal procedures can be attempted with tubal reanastomosis using microsurgery; however, this is seldom done because the success rate of IVF is so high.
Traditionally, surgery on organs of reproduction usually involved an adult patient. However, in most recent years as girls reach puberty at earlier ages, it is becoming more frequent for young girls in their teens to have laparoscopic surgery for conditions such as endometriosis.1 In addition, the perianesthesia nurse may encounter pediatric or adolescent female patients who undergo gynecologic surgery for repair or correction of congenital or traumatic deformities or incapacitating pelvic pain from causes such as endometriosis, ovarian cyst, or appendicitis. Surgery on the female genitalia may be conveniently divided into three major categories: obstetric, lower genital and vaginal, and abdominal gynecologic surgery. Abdominal surgery is then subdivided into either what used to be referred to as traditional surgery in the form of a laparotomy, mini-laparotomy (could include hand assisted surgery through a mini type laparotomy incision), or into the category of operative laparoscopy (typically two or three small incisions or robotic surgery, which may include four to seven incisions). The area of operative laparoscopy in gynecologic surgery has expanded and includes the majority of benign gynecologic surgery. However, there are still a great number of laparotomies currently performed. Many surgeons who previously have not felt comfortable performing laparoscopic procedures are now doing so with the aid of the robot. There is much debate among gynecologists as to whether the learning curve is shorter with the use of the robot. Whether or not that is the case, the bigger questions are “Is the cost of the robot warranted?” and “With proper training, can these same procedures be done just as effectively without the robot?” The perianesthesia nurse must be aware of how the care of the patient differs with these various approaches.
Obstetric surgery
Care after specific procedures
Cesarean section
Cesarean sections are indicated for dystocia (usually caused by cephalopelvic disproportion); antepartum bleeding; some toxemic conditions; certain medical complications, especially diabetes mellitus; and previous cesarean section. The low-segment cesarean section is usually the procedure of choice. Anesthesia may be general inhalation, spinal, or local infiltration of the operative field. Postoperative care after cesarean section includes all care rendered to a patient who undergoes abdominal surgery and postpartum care.
On admission to the postanesthesia care unit (PACU), a report is given by the circulating nurse who transports the patient with the anesthesia provider to the PACU area. The patient’s vital signs should be monitored regularly in keeping with the PACU guidelines in the facility. As soon as condition permits, the patient can assume any position of comfort. Oxygen should be delivered and monitored with the use of pulse oximetry.2
