Gynecologic Procedures

Before any procedure or surgery begins, the most appropriate option (when more than one exists) for an individual patient must be selected, with optimal patient involvement in the decision-making process preceding informed consent.

At least 80% of gynecologic surgical procedures are considered to be elective; that is, there are other alternative treatments to be considered. The appropriateness of performing these procedures should be evaluated by physician and patient on an individual basis (Box 30-1). The trend toward minimal invasiveness in gynecologic surgery should not lead to minimal or questionable indications.

The rapid introduction of new technology can present a challenge to the surgeon, who will need to keep up with the most advanced procedures, and to the institution, which is required to be certain that those who are granted surgical privileges have been properly trained and are currently qualified.

After a surgeon’s credentials (diplomas, training certificates, and licenses) have been properly verified, a useful classification for the purpose of privileging stratifies procedures into the following levels: level 1, procedures not requiring additional training after residency (e.g., dilatation and curettage [D&C], cervical conization, adnexal excision, and abdominal or vaginal hysterectomy); level 2, procedures requiring additional training (e.g., laparoscopic myomectomy); and level 3, procedures requiring advanced training and special skills generally acquired during subspecialty training (e.g., radical hysterectomy, tubal anastomosis, or oocyte harvesting).

As new procedures are incorporated into basic residency training, they can be reclassified.

The patient should be thoroughly counseled about surgical risks as part of the process of informed consent (see Chapter 1). In general, risks fall into three categories: risks of anesthesia, intraoperative risks, and postoperative complications. Risks of anesthesia depend on the type of anesthesia used (awake sedation, regional anesthesia, or inhalation agents). Regional anesthesia carries the risk for infection, postprocedure spinal headache, and failure, in which case an inhalation agent must be added to the regional anesthetic. Inhalation agents may be associated with the risk for aspiration pneumonia, allergic reaction to the agent, and damage to teeth or airways if intubation is necessary. Stroke, myocardial infarction, and death can result. The intraoperative risks include excessive bleeding and unintended damage to organs or tissue. Postoperative risks include infection, persistent bleeding, and thrombosis, all of which can lead to significant morbidity or even mortality. The specific risks of each procedure are given later.

One of the most common minor gynecologic surgical procedures is D&C: dilation of the cervix and curettage of the endometrium. Recent advances in office-based instrumentation for diagnosis (hysteroscopy, endometrial sampling [Figure 30-1], and ultrasonic evaluation of endometrial thickness) have resulted in an appropriate decrease in the use of D&C. However, if cancer of the cervix or endometrium is suspected, a thorough fractional curettage may be the best procedure to confirm its presence.

FIGURE 30-1 Endometrial sampling using the Pipelle instrument. A flexible hollow plastic tube is inserted and held in the uterine cavity as the stylet is withdrawn, creating a vacuum and resulting in aspiration of tissue.

Conization of the cervix is a procedure in which a cone-shaped portion of the cervix is removed for diagnostic or occasionally therapeutic purposes. The section of the tissue surrounding the external os represents the base of the removed specimen. The apex is either close to the internal os (Figure 30-2A) or close to the external os (Figure 30-2B). Conization may also be performed in an office setting using loop electrosurgical excision (Figure 30-2C) or large loop excision of the transformation zone of the cervix. Loop excision should not be performed before identification of a cervical intraepithelial lesion that requires treatment by colposcopically directed punch biopsy.

FIGURE 30-2 Cone biopsy of the cervix. A: Diagnostic conization performed when the squamocolumnar junction is not fully visualized colposcopically. B: Therapeutic conization performed for disease involving the ectocervix and distal endocervical canal. C: Loop electrosurgical excision procedure. The goal of the procedure is to remove the cervical tissue to just above the squamocolumnar junction, including any visible lesions.

The technique of cryoablation is commonly used to treat condylomas of the cervix, vagina, and vulva. These procedures almost always are office based, and little if any anesthesia is required.

Laser instruments are sources of intense beams of light energy. The letters in the acronym laser stand for light amplification by the stimulated emission of radiation. When used in surgery, this radiant energy is converted inside the cell to thermal or acoustic energy, resulting in controlled vaporization or coagulation of tissue. Lasers come in longer wavelengths (carbon dioxide [CO₂]) or shorter wavelengths (neodymium–yttrium-aluminum-garnet [Nd:YAG], potassium-titanyl-phosphate [KTP], and argon) that can be propagated along flexible optical fibers. This allows delivery of energy for cutting, vaporization, and coagulation to tissues in locations unreachable by a CO₂ laser.

Because of the additional expense of laser equipment and the lack of evidence for improvements in outcome, the use of this technology has been decreasing in recent years. Nevertheless, laser technology has been applied to conization of the cervix, removal of leiomyomas (myomectomy), and destruction of the ectopic endometrial implants of endometriosis.

Gynecologic endoscopy (laparoscopy and hysteroscopy) is widely used for the diagnosis and treatment of reproductive organ disease and dysfunction. Laparoscopy and hysteroscopy have largely moved from the hospital operating room to the freestanding surgical outpatient unit, and with smaller instruments (needle-scopes) and more refined fiberoptic technology, even into the office setting. Because of the expenseinvolved, the value of these techniques must be considered in terms of outcome, particularly the long-term health and functional status of the patient.

The laparoscope is an instrument for viewing the peritoneal cavity. Both pelvic and upper abdominal structures can be inspected. The attachment of a video camera on the lens of the laparoscope allows more than one surgeon to view the operative site on a video screen and assist during procedures (Figure 30-3). Multiple puncture sites through the skin and into the abdominal cavity provide for the insertion of small rigid or flexible instruments directed toward the pelvis. Procedures that were once performed by laparotomy are now routinely carried out less invasively.

FIGURE 30-3 Laparoscopic view of female pelvis.

(Courtesy of B. Beller, MD, Eugene, Oregon.)

The indications for laparoscopy are both diagnostic and therapeutic. Laser technology can be applied to operative laparoscopic procedures both to excise and to vaporize areas of pathology.

Absolute contraindications to laparoscopy include bowel obstruction and large hemoperitoneum with hypovolemic shock. In patients who have had multiple previous laparotomies, a history of peritonitis, previous bowel surgery, or a lower midline abdominal incision, open laparoscopy is preferable. In these conditions, the peritoneal cavity is opened through a small subumbilical incision under direct vision before introduction of the trocar and sheath.