Novasure
- If it does not pass integrity test, remeasure cavity and reset novasure (If the cavity is estimated as smaller than it is, but it will not pass). If that does not work, then push the circular vacuum relief valve with a small dilator or the uterine sound.
http://www.novasure.com/sites/novasure/files/NovaSure_System__Guide_to_Troubleshooting.pdf
Partial Simple Vulvectomy:
Barkett (posterior fourchette lesion):
- Use surgical marking pen to note area of incision around lesion (wide local incision requires 1cm margin).
- Use scalpel to follow markings, then use bovie or metzembaum scissors to cut just below the skin (1-3mm deep)
- Mark 12 o'clock with suture, and send to lab.
- Use 2-0 vicryl in interrupted stitches to pull skin edges closer. This may require more than one layer of interrupted sutures.
- Close skin with 4-0 monocryl or vicryl.
- Cover incision with Silvadine cream.
- Send home with silvadine cream to apply twice daily and ice pack to be applied to perineum for first 36 hours postop.
**Brader postop instuctions for vulvectomy: 24 hrs of no ambulating, with a fan blowing up the sheet of the bed. No dressing until going home, but even then, leave open as much as possible.
**Daudi postop: curlex dressing with lidocaine gel on perineum.
Cold Knife Cone:
Brader:
- Figure 8 stay sutures at 3 and 9 o'clock (0 vicryl on CT1 or CT2)
- Use scalpel to cut circumferentially around os (1.5cm deep)
- Ball-tip cautery to cut area of cervix
- Cover pieces of gelfoam with monsels and pack cervix, then tie stay sutures across to hold packing in place.
Midurethral Sling:
Dr. Phelps:
- Uses mesh that stretches in one direction. She cuts it 30cm long in the direction that stretches, and a little over 1cm wide.
- Pass #1 prolene through each end 3 times.
- Complete cystoscopy before starting procedure (bladder scan with both 70 degree and 30 degree scopes). Then place foley.
- Mark suprapubic incisions 1-2cm above pubic symphysis and 2cm lateral to midline on each side, then make stab incisions.
- Inject 10 ml 1% lidocaine with epinephrine into the anterior vaginal wall below the urethra and around area of vaginal incision.
- Palpate neck of bladder and urethra around foley to determine mid-urethra (total urethra is 4cm in length on average)
- Make 2cm incision through the vaginal epithelium with the scalpel at this midpoint.
- Use tenotomy scissors or metzenbaum scissors to dissect 1cm in the lateral paraurethral space
- Places stamey needles (bent 30-45 degrees) from suprapubic incisions down through vaginal incision with finger place vaginally to palpate and guide needle by urethra.
- Perform cystoscopy with careful attention down at bladder neck to ensure no bladder injury is present.
- Thread the prolene on the mesh through the stamey needles on each side and pull up, to bring the mesh flat around mayo scissors, which are held closed under the urethra to avoid over- tightening (You will meet resistance as you pull mesh ends up through tissue layers until you see the end at the suprapubic skin).
- Cut the ends of mesh that are protruding through the suprapubic incisions.
- Close the vaginal epithelium with 2-0 vicryl in a running fashion.
- Close the suprapubic incisions with a subcuticular stitch.
- Place kerlex packing soaked in betadine into the vagina.
*Postop: at one hour postop, remove vaginal packing and foley catheter.
*If patient's spontaneous PVR is less than 200ml, then d/c home. If greater than 300ml, then straight cath.
Bennett:
TVT:
- Palpate foley to identify midurethra. Place allis' side horizontally at the midurethra and make incision with scalpel (1-2cm) between allis'.
- Make stab incisions with scalpel behind each allis to start dissection. Place finger vaginally (to palpate dissection) and use metz to dissect up to pubic bone bilaterally. Place trocar with sling through dissected plane to bone, follow close to bone toward the ipslateral shoulder and puncture through suprapubic skin.
- Before pulling mesh through, preform cystoscopy and take pictures at three places on each side of urethra to document no perforation (you can move white mesh trocar to see how close to bladder you are). Also take picture in urethra as you remove cystoscope.
- Pull mesh snuggle while foley is in place and mayo scissors (mesh at level of screw) are between mesh and urethra.
- CLose with 3-0 vicryl in running fashion. (if staying overnight, place packing and foley until next AM).
*For patients with ISD, make mesh slightly tighter by pulling around lower bladder of mayo scissors.
*Postop: PVR <150ml x2 before discharge.
Cystoscopy (by Dr. Stone, Urology):
- He scans with 2 scopes. He uses 30 degree first, which he inserts with the sheath, then starting at the dome where you see the air bubble. From the dome scan back to the bladder neck, then back to the dome, moving clockwise around the entire bladder (by turning the light cord) scanning from dome to bladder neck. Once complete scan has been done, replace the 30 degree with a 70 degree scope and scan in the same fashion with the 70 degree. When he is doing the scan he completes it twice with each scope.
Ovarian cystectomy (or paratubal cystectomy) during laparotomy:
Daudi:
- Midline vertical incision (start with minilap, around 4cm - consider keeping skin as small as possible, but extend fascial incision for better access)
- Place suture (4-0 prolene?) in purse string fashion using shallow bites around approx. 1cm area on surface of cyst near laparotomy. Assist holds ends of purse string and surgeon pierces in the middle of purse string with suction attached to sharp trocar (gallbladder trocar) while assist pulls tension of purse strings to keep fluid from leaking. Once cyst is drained, close cyst with purse string, then perform cystectomy.
TOT PROCEDURE
http://www.ethicon.com/sites/default/files/managed-documents/013172-160708_tvt_obturator_key_steps_r6_cf.pdf
Tuboplasty/Fimbrioplasty
Barkett (Togo - Abdominal approach):
- Identify fimbriated end of tube and perform adnexal lysis of adhesions as needed.
- Gently use lacrimal duct probe to check for adhesions within the tube if chromotubation is not able to be completed.
- If fimbriated end is severely adhered closed, cut off end with metzembaums or needle tip cautery so that tubal opening is identified.
- Make several radial incisions with needle tip cautery to recreate an open-ended tube.
- Use 5-0 prolene or PDS to suture through-and-through end of tube, and secured back to the serosal/muscularis layer, while avoiding entering the tube when securing back to the tube.
*Consider rechecking patency via chromotubation after fimbrioplasty.