Dilatation and Curettage
Dilatation and curettage (D & C) is one of the most commonly performed operations in the world. The most informative method for performing this procedure is to combine it with a diagnostic hysteroscopy. No data support the contention that hysteroscopy spreads endometrial cancer cells to any extent greater than other diagnostic studies (e.g., D & C, endometrial biopsy). Furthermore, no evidence suggests that the cells will metastasize.
A standard instrument table is set up and includes diagnostic hysteroscopic equipment (Fig. 10–1A–C). Before the D & C is performed, an examination under anesthesia (EUA) is done to demarcate the position and size of the uterus, as well as the presence or absence of adnexal masses. After the vulva and vagina have been prepared, the patient is draped while in the lithotomy position. A Sims retractor or weighted speculum is placed along the posterior wall of the vagina. The anterior lip of the cervix is grasped with a single-toothed tenaculum (Fig. 10–2). The uterus is carefully sounded. The passed sound stops when it encounters resistance to forward movement, which occurs when the tip of the sound comes in contact with the uterine fundus. Next, with the use of tapered dilators (Pratt or Hanks), the cervix is progressively dilated (Fig. 10–3). Dilatation should be limited to the amount required for the widest portion of the curette to pass easily into the uterine cavity (Fig. 10–4). Systematic curettage is carried out by scraping the endometrium from fundus to cervix starting at 12 o’clock on the anterior uterine wall, working around to 3 o’clock, then 6 o’clock on the posterior uterine wall, and via 9 o’clock, making it back to 12 o’clock again (Fig. 10–5A–C). A nonadherent sponge is placed into the posterior vaginal fornix to catch the curettings as they emit from the cervix (Fig. 10–6). When the surgeon judges that the uterine cavity has been completely curetted, the procedure stops.
If a diagnosis of endometrial or endocervical cancer is suspected, a fractional curettage should be performed. The appropriate order of this operation is to curette the endocervical canal first; this is followed by curettage of the endometrial cavity (Fig. 10–7A, B). The individual specimens are separately placed into individually labeled bottles.
At the terminus of the case, the uterus can be resounded or directly viewed by hysteroscopy. The purpose of the preceding exercise is to determine whether the uterus has been perforated.
FIGURE 10–1 A. The instruments required for dilatation and curettage are shown here. The equipment in the background is hysteroscopic and includes the Baggish Hyskon hand pump (in the basket) (Cook OB/GYN). B. A variety of sharp curettes are available; however, the serrated curette in the center is the most effective device. To the left of the serrated curette is an endocervical canal curette (Kevorkian). To the left of the Kevorkian curette is a malleable uterine sound. C. Hanks or Pratt dilators are tapered and produce the least trauma in cervical dilatation.
FIGURE 10–2 A Sims retractor is placed along the posterior wall of the vagina. The cervix is held with a single-toothed tenaculum.
FIGURE 10–3 The cervix is systematically dilated.
FIGURE 10–4 Dilatation should be continued until the cervical canal has been sufficiently enlarged to accommodate the head of the curette.
