OBG Instruments - Live interaction from OT

Name: OBG Instruments - Live interaction from OT
Uploaded: 2022-05-15T07:33:04.000Z
Duration: 2 h 44 min 6 s

Understanding the Sim Speculum and Cusco Speculum

Overview of the Sim Speculum

The sim speculum consists of two blades with a groove in the middle, primarily used for diagnosing and visualizing the vagina and cervix.

It is always used in conjunction with an anterior vaginal wall retractor (AVR) to facilitate examination.

To minimize discomfort, it is recommended to warm the stainless steel instrument before use, especially in colder climates.

Procedure for Using Sim Speculum

The procedure involves introducing the speculum into the vagina, depressing the posterior vaginal wall, and lifting the anterior wall using AVR to visualize internal structures.

Common diagnostic uses include examining post-menopausal bleeding or performing Pap smears; therapeutic uses involve procedures like dilation and curettage (D&C), endometrial biopsy, or intrauterine device insertion/removal.

Introduction to Cusco Speculum

The cusco speculum features two valves that open when introduced; it is self-locking which allows hands-free operation during procedures.

This design enables practitioners to perform tasks such as taking Pap smears without needing an assistant.

Advantages and Disadvantages of Cusco Speculum

Key advantages include hands-free operation and usability even when patients are positioned away from the edge of the bed.

However, its restricted space limits maneuverability for additional instruments during procedures like D&C or endometrial biopsies.

Comparison Between Sim and Cusco Specula

While cusco speculum has limited uses mainly for Pap smears or cervical biopsies due to restricted view and space, sim speculum offers greater maneuverability for various procedures despite requiring assistance.

The sim speculum provides a better view of vaginal walls and includes a groove for drainage, making it versatile for both diagnostic and therapeutic applications.

Understanding Cervical Instruments in Gynecological Procedures

Dilation and Curettage Overview

To perform a dilation and curettage (D&C), it is essential to have a firm grip on the cervix to facilitate the introduction of other instruments.

The valvum, a long instrument with teeth at the ends, is considered traumatic as it can cause tissue damage when gripping the cervix.

The tenaculum, which has one sharp tooth at its end, is also used to hold the anterior lip of the cervix during procedures.

Indications for Holding Anterior vs. Posterior Lip of Cervix

The anterior lip of the cervix is typically held during procedures such as endometrial biopsy or manual vacuum aspiration for incomplete abortion.

In contrast, holding the posterior lip may be necessary when accessing the pouch of Douglas, particularly in cases like suspected ruptured ectopic pregnancy.

Accessing Pouch of Douglas

To access the pouch of Douglas, practitioners may lift the posterior lip of the cervix using a sim speculum for procedures like culdocentesis or colpotomy.

Culdocentesis involves inserting a needle into this area to check for blood in cases such as ruptured ectopic pregnancies.

Uterine Sound Usage

A uterine sound is introduced into the uterus to measure its length; it features gradations marked in centimeters and inches.

This measurement helps prevent uterine perforation during procedures by ensuring that instruments do not exceed measured lengths.

Instrument Selection Based on Patient Condition

When dealing with pregnant patients' soft cervixes during D&C or manual vacuum aspiration, less traumatic instruments like sponge-holding forceps are preferred over more invasive tools like valvums.

Sponge-holding forceps are designed with serrations but lack teeth, making them less likely to cause trauma compared to other gripping instruments.

Cervical Dilation Techniques in Medical Procedures

Overview of Cervical Dilators

Introduction to Hagar's dilators, which are mechanical cervical dilators used for accessing the uterine cavity during procedures like abortion.

Discussion on methods of cervical dilation, including medical (e.g., misoprostol) and surgical techniques (e.g., uterine sounding).

Methods of Dilation

Explanation of pharmacological techniques using prostaglandins, particularly PGE1 or misoprostol, for cervical dilation prior to surgical procedures.

Misoprostol can be administered through various routes: orally, vaginally, rectally, or submucosally at doses typically ranging from 200 to 600 micrograms.

Types of Mechanical Dilators

Description of different types of mechanical dilators available in clinical settings; Hagar's dilators are commonly used and numbered by diameter.

Gradation details: sizes increase either by 0.5 mm or directly by 1 mm increments; specific examples include sizes four and five up to eleven and twelve.

Guidelines for Dilation Based on Gestational Age

Controversy exists regarding how much to dilate based on gestational age; some sources suggest one number less than the gestational week while others recommend equal sizing.

For example, if a patient is eight weeks pregnant, some practitioners would use a size seven dilator while others might opt for size eight.

Suction Canulas and Their Use

Introduction to Carman's canula used after dilation; it features an aspirating hole designed for suctioning contents during procedures like MTP (medical termination of pregnancy).

Color-coded suction canulas are available based on size; they connect to suction apparatuses—either electrical or manual vacuum devices.

Manual Vacuum Aspiration Technique

Overview of manual vacuum aspiration developed for low-resource settings where electricity may not be reliable; consists of three main parts: valves creating suction, syringe with a lock mechanism, and plunger.

Step-by-step process: After cervix dilation with misoprostol or Hagar’s dilators, the loaded syringe is attached to the canula before releasing pressure to initiate suctioning.

Manual Vacuum Aspiration Techniques

Overview of Manual Vacuum Aspiration

The process involves releasing pressure to suction contents, which can be repeated as needed for effective evacuation.

During suction evacuation, rotatory or back-and-forth movements are employed, ensuring not to exceed the internal loss distance to prevent uterine perforation.

Comparison with Electrical Suction

Manual vacuum aspirators are preferred in low-resource settings due to their ease of use and independence from electricity.

In case of uterine perforation, manual suction will cease due to loss of negative pressure, reducing injury risk compared to continuous electrical suction.

Procedure Steps for 9 Weeks Pregnant Patient

Initial steps include using a sim speculum and valum to hold the cervix while dilating with HAR's dilator before performing suctioning.

After suctioning, a uterine curette is used to check if the procedure is complete by scraping the uterine walls.

Uterine Curette Details

A distinction is made between a uterine curette (small ends for scraping) and an anterior vaginal wall retractor (larger ends).

The sharp end of the curette is utilized in non-pregnant uteri for biopsies or therapeutic curage; the blunt end is used in pregnant cases.

Signs of Completion

Completion indicators include grating sensations on all uterine walls during scraping and cessation of products coming out.

Additional signs include bubbling indicating air entry, reduced bleeding, and difficulty introducing instruments as the uterus contracts post-procedure.

Alternative Instruments When Resources Are Limited

Use of Ovarian Forceps

In scenarios lacking standard instruments like MVA or electrical apparatuses, over forceps can be employed for product removal.

Ovarian forceps feature an egg-shaped end without a locking mechanism to allow free mobility during tissue retrieval.

Importance of Design Features

The absence of a lock on ovarian forceps minimizes trauma risk when inadvertently catching tissue during blind procedures.

Understanding Uterine Procedures and Instruments

Uterine Evacuation Techniques

The uterine endometrium and myometrium can be damaged during procedures, necessitating careful evacuation of products. This is crucial in cases of abortion or retained placental bits.

Curettage is employed not only for abortions but also to remove endometrial polyps or retained placenta post-delivery, highlighting its versatility in gynecological procedures.

Biopsy Techniques

Punch biopsy forceps are introduced as a key instrument for obtaining cervical biopsies from abnormal growths, either through colposcopy or visual inspection.

It is essential to take biopsies from the periphery of a growth rather than the center to avoid necrotic tissue, ensuring accurate pathology results and reducing the risk of missing malignancies.

Instrumentation in Vaginal Surgeries

The punch biopsy forceps create a "punched out" incision when taking samples, which are then sent for histopathology analysis.

A summary of instruments used in vaginal surgeries concludes with an emphasis on their specific applications and importance in diagnostic processes.

Transitioning to Abdominal Surgery Instruments

The discussion shifts towards abdominal surgical instruments, starting with basic tools before delving into specific surgical applications like cesarean sections.

Cleaning and Holding Instruments

Sponge holding forceps (or ring forceps) are utilized primarily for cleaning operative areas with antiseptic solutions; they can also hold structures during surgery without causing trauma.

These forceps serve multiple purposes, including assisting in removing adherent membranes during cesarean sections or managing retained placental bits effectively.

Clamping and Grasping Tools

Artery forceps come in various sizes and shapes (straight/curved), designed for clamping vessels during surgery. They are versatile tools essential for controlling bleeding.

Alice forceps feature serrated ends that provide a firm grip on tough tissues, making them suitable for holding structures securely during surgical procedures.

Instruments Used in Gynecological and Obstetric Surgeries

Overview of Surgical Instruments

The discussion focuses on surgical instruments used specifically in gynecological and obstetric surgeries, particularly during cesarean sections and hysterectomies.

The speaker emphasizes the importance of knowing various instruments, starting with the Alice forceps, which is primarily used to hold the rectus sheath and angles of the uterus during a cesarean section.

Key Instruments for D&C Procedures

For D&C (Dilation and Curettage), essential instruments include:

Sim speculum for visualization.

Tenaculum or Babcock's forceps to hold the cervix.

Uterine sound for measuring depth.

Hagar's dilators for dilation.

Carman's cannula or forceps for evacuation followed by uterine curettage.

Specific Forceps Utilization

Green Armitage forceps are highlighted as crucial for securing bleeding angles of uterine incisions during cesarean sections due to their large surface area that minimizes trauma.

Babcock's forceps are identified as ideal for handling delicate structures like fallopian tubes during procedures such as ligation or recanalization.

General Surgical Tools

Tissue cutting scissors are discussed as versatile tools used in various surgeries including cesarean sections and hysterectomies, allowing surgeons to extend incisions effectively.

Needle holders are introduced as essential tools for suturing, with variations including tooth and non-tooth types depending on surgical needs.

Retractors in Cesarean Sections

The DO abdominal wall retractor is emphasized as critical in cesarean sections to keep the urinary bladder away from the surgical field, preventing inadvertent injury while accessing the lower uterine segment.

Instruments and Steps in a Cesarean Section

Overview of Surgical Instruments

The procedure begins with cleaning the operative area using sponge-holding forceps.

An incision is made using a scalpel, specifically a BP handle and blade, to access the subcutaneous tissue and rectus sheath.

A transverse cut is made in the rectus sheath after holding it with Alice forceps; the skin incision is described as a pan-seal incision above the pubic symphysis.

Accessing Internal Structures

The underlying rectus muscle is separated to reveal the parietal peritoneum, which is then held with artery or Alice forceps before cutting into the peritoneal cavity.

Upon entering the peritoneal cavity, visibility of the uterus and lower uterine segment is achieved; this area is covered by visceral peritoneum that needs to be opened.

Delivering the Baby

A nick is made on the uterine incision to enter the uterine cavity for delivery.

After delivering the baby, umbilical cord clamping occurs using artery forceps before handing over to pediatric care.

Postpartum Procedures

Following placenta delivery, suturing begins at various layers: uterine incision, parietal peritoneum (may or may not be sutured), rectus sheath, and finally skin closure.

Instruments used include Alice forceps for holding angles of uterus during suturing; needle holder and other forceps are utilized throughout.

Additional Surgical Considerations

Emphasis on instruments like joins retractor for bladder displacement during surgery; clarity on steps taken from incision to suturing.

Suction Evacuation Guidelines

Timing for Suction Evacuation

Suction evacuation can be performed safely up until 12 weeks gestation in first trimester cases.

In some countries, suction evacuation extends up to 20 weeks in second trimester but local practices often limit it to 12–14 weeks due to medical management challenges beyond this period.

Myoma Screw Usage in Myomectomy

Introduction of Myoma Screw

The myoma screw features a screw-like end designed for use during myomectomies; it aids in traction when removing fibroids.

Application During Surgery

It’s inserted into fibroids post-incision over their capsule; effective traction allows better dissection from surrounding tissues.

Principles of Myomectomy

Key Principles Discussed

Discussion highlights essential principles necessary for performing myomectomies effectively while managing intraoperative bleeding risks.

Myomectomy and Hysterectomy Techniques

Principles of Myomectomy

Emphasizes the importance of making as few incisions as possible during myomectomy to minimize scarring and adhesions on the uterus.

Suggests using tunneling incisions for fibroid removal, with preferred vertical incisions on the anterior and posterior walls, while transverse incisions are recommended for the fundus.

Discusses methods to reduce blood loss during surgery, including the use of Bonnie's myomectomy clamp, vasopressin, oxytocin, and tranexamic acid.

Advises obliterating dead space post-fibroid removal with multiple layers of sutures; recommends a baseball suture technique to minimize visible sutures and reduce adhesion risk.

Mentions "Jeff's code" as a valuable resource for understanding myomectomy principles.

Surgical Instruments and Techniques

Notes that postgraduate students will be asked about specific surgical instruments like myoma screws in relation to myomectomy procedures.

Discusses suture techniques in cesarean sections, highlighting that both single-layer and double-layer closures are acceptable depending on practice standards.

Introduces various types of hysterectomy clamps (e.g., Heaney clamp), emphasizing their non-traumatic design suitable for holding tough structures.

Steps in Hysterectomy Procedures

Highlights that postgraduate examinations may focus on steps involved in abdominal versus vaginal hysterectomies, indicating a need for clarity on these processes.

Outlines initial steps in an abdominal hysterectomy: clamping, cutting, and ligating key ligaments such as the round ligament first.

Explains that if ovaries are preserved during hysterectomy, the ovarian ligament is clamped; if removed due to pathology or age considerations, the infundibular pelvic ligament is targeted instead.

Ligament Management During Hysterectomy

Clarifies which ligaments are clamped based on whether ovaries are being preserved or removed during hysterectomy procedures.

Describes how to manage ligaments when removing both uterus and ovaries by focusing on clamping the infundibular pelvic ligament alongside other relevant structures.

Understanding Uterine Surgery Techniques

Surgical Approach to the Urinary Bladder and Uterine Arteries

The urinary bladder is located anteriorly, requiring separation during surgery by opening the uterine cycle fold, similar to a cesarean section.

It is crucial to clamp, cut, and ligate the uterine arteries carefully due to their proximity to the ureters, which can be at risk of injury.

A mnemonic "water under the bridge" illustrates that the ureters run below while the uterine artery crosses above them.

When clamping uterine arteries, ensure clamps are applied perpendicular to the uterus at the level of the internal os for safety.

Skeletonizing tissue over uterine arteries provides better visibility; ligation should occur as close to the uterus as possible.

Ligament Management During Hysterectomy

After ligating both uterine arteries, attention shifts to clamping and cutting cardinal and utroacral ligaments before addressing cervical structures.

Two clamps are placed at angles where the cervix ends before cutting above them for uterus removal; this process is similar in abdominal and vaginal hysterectomies.

Transitioning from Abdominal to Vaginal Hysterectomy

In vaginal hysterectomy, entry into peritoneal cavity starts with separating bladder anteriorly and posteriorly entering Douglas pouch before proceeding upwards with ligation.

Introduction to Laparoscopic Surgery

Laparoscopy has become standard in gynecology for both diagnostic and therapeutic purposes; it allows various surgeries including hysterectomies and cystectomies.

The principle involves creating a pneumoperitoneum (gas-filled abdomen), enhancing visualization through magnification during procedures.

Overview of Laparoscopic Equipment

Key components of laparoscopic systems include a monitor for image display, camera system for capturing visuals inside, light source for illumination, and an insufflator for gas introduction into the abdomen.

Creating Pneumoperitoneum in Laparoscopic Surgery

Introduction to Pneumoperitoneum

The procedure begins with an incision, typically infraumbilical or supraumbilical, in the abdomen to create pneumoperitoneum.

A Veress needle is used for this purpose; it has a hollow structure with a blunt end and a sharp end, designed for safety during insertion.

Insertion Technique

The Veress needle is held at a 45° angle to avoid injury to major abdominal vessels like the aorta.

Upon correct insertion into the rectus sheath and peritoneal cavity, two clicks are heard as confirmation of proper placement.

Safety Mechanisms

The design includes safety features that prevent inadvertent injury to bowel or vascular structures during entry.

Signs indicating successful entry into the peritoneal cavity include intra-abdominal pressure readings below 10 mmHg and saline being sucked into the cavity when introduced.

Confirming Cavity Entry

Additional methods for confirming correct placement involve injecting saline; if correctly positioned, it will be drawn into the cavity.

If saline cannot be withdrawn after injection, it indicates that the needle is indeed within the abdominal cavity.

Establishing Ports for Surgery

Once confirmed inside the peritoneal cavity, tubing is attached to allow gas inflation until intra-abdominal pressure reaches around 20 mmHg before introducing ports.

A laparoscope is then inserted through a primary port; this instrument allows visualization of internal structures via an attached camera and light source.

Instrumentation Overview

The laparoscope connects to a camera system which projects images onto a screen for surgical guidance.

Following initial setup, trocars and cannulas are introduced; these instruments facilitate access while maintaining insufflation within the abdominal cavity.

Secondary Ports and Instruments

Multiple secondary ports (two to four depending on surgery type) are created for additional laparoscopic instruments such as graspers and scissors.

Primary port accommodates larger instruments like cameras while secondary ports handle smaller tools necessary for various surgical tasks.

Summary of Key Components

Essential components discussed include image systems, camera setups, light sources, insufflators, and techniques for creating pneumoperitoneum. Adjustments may be made based on patient history regarding previous surgeries.

Laparoscopic Surgery Techniques and Instruments

Introduction to Palmer's Point

Palmer's point is a safe area in the left upper abdomen, particularly useful for patients with previous surgeries. It serves as an entry point for introducing the Veress needle to create pneumoperitoneum.

Laparoscopic Port Creation

The primary port is created using a 10 mm trocar, through which the laparoscope is introduced. Secondary ports typically utilize 5 mm trocars for additional instruments.

After inserting the cannula through the secondary port, the trocar is removed, allowing access for various laparoscopic instruments while maintaining gas flow into the abdomen.

Operating Principles of Laparoscopic Surgery

Key components of laparoscopic surgery include an image monitor, camera system, light source, and gas insufflator. These elements are essential for visualizing and operating within the abdominal cavity.

Once pneumoperitoneum is established using a Veress needle, both primary and secondary ports are utilized to facilitate surgical procedures.

Energy Sources in Laparoscopy

Various energy sources are employed during laparoscopic procedures to coagulate or seal vessels: monopolar, bipolar, harmonic (ultrasonic), along with other instruments like Ligasure and EnSeal.

Unlike traditional surgery where clamping and suturing may be used, laparoscopic techniques focus on coagulation followed by cutting without extensive use of sutures.

Hysteroscopy Overview

A hysteroscope is introduced as a critical instrument for visualizing the uterine cavity. It features a thinner design compared to a laparoscope and can range from 2 mm to 5 mm in diameter.

Applications of Hysteroscopy

Hysteroscopy allows for diagnostic procedures such as directed biopsies in cases of abnormal uterine bleeding or removal of submucous fibroids via myomectomy.

The gold standard for endometrial biopsy involves hysteroscopic-guided techniques due to their precision in accessing uterine abnormalities.

Structure and Functionality of Hysteroscopes

Operative hystroscopes have dual sheaths (inner and outer), facilitating fluid introduction necessary for distending the uterine cavity during visualization.

Common distension media include normal saline, glycine, or mannitol; these fluids help visualize collapsed structures within the uterus effectively.

Instrumentation During Procedures

The hysteroscope setup includes channels that allow fluid entry/exit while also accommodating small instruments needed for interventions like polypectomy or addressing missing intrauterine devices.

Hysteroscopy Techniques and Instruments

Overview of Hysteroscopy Procedures

The speaker discusses the process of removing an intrauterine device (IUD) using a grasper, highlighting the importance of visual aids available on their Instagram channel for better understanding.

The speaker mentions that videos related to hysteroscopy techniques are also available on YouTube under the channel "OBG classes by Dr. Reena," providing resources for further learning.

Instrumentation in Hysteroscopy

The discussion includes various instruments used in hysteroscopy, such as those for visualizing the uterine cavity and performing operative procedures like polyp removal and adhesion treatment.

A significant instrument mentioned is the uterine manipulator, which is crucial during laparoscopic surgeries to manipulate the uterus for improved visualization.

Importance of Uterine Manipulator

The uterine manipulator is introduced through the vagina into the uterus, allowing movement in multiple directions to enhance surgical visibility during laparoscopic procedures.

This instrument helps define anatomical landmarks such as the vaginal vault and cervix, which are essential during surgery.

Discussion on Gaseous vs. Liquid Medium in Hysteroscopy

A question arises regarding why gaseous mediums cannot be used during certain hysteroscopic procedures; it’s noted that while CO2 can provide good visualization, it poses challenges if bleeding occurs.

Liquid mediums are preferred because they allow for inflow and outflow channels, maintaining visibility even if bleeding happens during operative procedures.

Conclusion and Engagement with Audience

The session concludes with positive feedback from participants who appreciated learning about live instruments; attendees are encouraged to reach out with any further questions or clarifications.