GYN
Total Laparoscopic Hysterectomy:
Three 5mm trocars.
- V-care or advincula uterine manipulator
- Harmonic device
- Suction/irrigator
- 0 barbed suture (9" 0 Stratafix suture with V-34 needle) with self-righting needle driver and dolphin nose grasper.
- Finish with "poor man's cysto"...200-250ml of H2O back filled through foley, then look with laparoscope.
Vaginal Hysterectomy:
- Heaney and devour retractors, short and long weight speculum
- Leahy forceps for cervix
- Heaney clamps for pedicles. Allis clamps for during vaginal cuff closure.
- 0 vicryl pop-offs and free ties (for adnexa)
Abdominal Hysterectomy:
- O'Sullivan-O'Connor retractor
- 0 vicryl pop-offs and free ties (of adnexa)
- Heaney clamps, until uterine and cardinal ligaments, then Zeppelins
- Right angle clamps nose to nose across cervicovaginal junctions
- Heaney suture including uterosacrals at corners, then u-stitch in midline
- For vertical: close with loop PDS in modified Smead-Jones for fascia/rectus/peritoneum
- For pfannensteil: same as c/s.
- 4-0 monocryl on PS2 for skin
Anterior or Posterior Repair:
- Vaginal hysterectomy tray
- 2-0 vicryl for imbricating sutures.
- 2-0 vicryl for vaginal mucosa closure
If perineorrhaphy: *0 vicryl for levatorplasty, Then 2-0 vicryl for remaining reapproximation and skin closure.
Uterosacral Ligament Suspension:
- 0 Vicryl and 0 Prolene on CT needles.
- After TVH, use uterosacral Pedicles tags to identify ligaments.
- If during LAVH, tag ligaments before removing uterus and cervix.
Colpocleisis:
- Vaginal hysterectomy tray
- 0 vicryl to create tunnel around red rubber catheter
- 2-0 vicryl to re-approximate raw edges and close vaginal epithelium.
Adnexal Mass (ovarian cystectomy/oopherectomy):
12 trocar in umbilicus, bilateral 5mm trocars.
- Hulka or acorn uterine manipulator.
- Enseal for saplingo-oophorectomy.
- Monopolar scissors and Maryland grasper for cystectomy.
- Place adnexal in bag, and remove through umbilicus.
- Close umbilicus with Carter-Thomason
OR
Gelpoint single site if saplingo-oophorectomy (for normal BMI).
**Postmenopausal or history of adhesions/indications for complications...midline vertical incision.
Ectopic:
- Salpingostomy - Enseal, monopolar hook, suction-irrigator, 2, 5mm trocars and one 8mm trocar, Hulka or acorn uterine manipulator.
*suction-irrigator alternative: Use laparoscopic trumpet, attach suction tubing to one valve and cysto tubing with normal saline to the other valve.
Hysteroscopy:
- Regular and long weighted speculum, Sims, Single-tooth tenaculum
- Hanks dilators, rings forceps, and allis clamps
- Myosure hysteroscope, hysteroscopic biopsy forceps and scissors
- 2-0 chromic for cervical lacerations
Cervical Conization:
LEEP:
- Setting: 60watt, blended current.
- If BMI 40 or greater, or IUD in place, LEEP in OR.
*IUD (place strings into fox swab handle to protect them from being cut)
- Ball-tip cautery for hemostasis
Cold Knife Cone:
- After conization, dip gel thrombin in monsel's solution and pack into cervix. Use 2-0 chromic on CT1 to tie figure of eight across os to hold thrombin in place.
OB
Cesarean Section:
0 monocryl for uterine closure, with imbricating layer if no tubal ligation.
2-0 vicryl to close peritoneum (consider including rectus).
2-0 chromic to re-approximation if diastasis rectify is present.
0 vicryl for fascia.
2-0 vicryl for subcutaneous for > or < BMI.
4-0 monocryl on PS-2 for subcuticular layer.
- If tubal: modified pomeroy with 0 chromic.
Postpartum Tubal:
0 chromic free ties
0 vicryl
4-0 monocryl
2 Kelly or Heaney clamps in case of hemorrhage from pedicle/slipped knot
Operative Delivery:
Forceps: default Simpsons (molded head), Tucker-McLane (rounded head), Piper (breech)
- Apply extra lubrication to vaginal introitus, dip forces blades in warm water
- Slide first blade in posterior vaginal and allow to slide into place on maternal left with end of force blade curved back away from face
- Slide second blade in across from where first blade lies in place.
- Steady traction during pushes. Maintain position between pushes.
Vacuum:
3rd/4th Degree Laceration:
- Bolus epidural or pudendal block (1% lidocaine, w/out epinephrine - 1 cm medial and inferior to the ischial spine)
- Anal mucosa: 4-0 monocryl, running subcuticular
- Anal sphincter: 2-0 vicryl in figure of 8 fashion
- Remainder of repair with 3-0 vicryl rapids in usual fashion for second degrees.
*Ceftin (Cefuroxime) 1.5g IV once (second gen cephalosporin) or 2g Ancef (cefazolin) and 500mg metronidazole
*Home with Colace x10days
OFFICE
*Pre-procedure: Write script for patient to take 1mg Xanax, 1 Norco 10/325 after patient arrives at office. Take 800mg Ibuprofen 30min -1 hr before schedule procedure time.
*For office procedures, have needle driver with 2-0 chromic or similar suture available.
Hysteroscopy:
- During pelvic exam before hysteroscopy, push q-tip 1-2cm into cervical os, if patient does not tolerate well, schedule hysteroscopy in OR.
- Rigid scope:
- Inject local at 12 o'clock for single tooth tenaculum.
- Paracervical block with 1% lidocaine with epinephrine (5ml at 2, 4, 8, 10 o'clock) let sit for 2-3 minutes before starting procedure.
- Gently dilate with Hanks dilators.
- Complete scope. If Novasure, estimate cavity size with scope.
- Flexible scope:
- Have single-tooth tenaculum available.
- Do not use paracervical block or tenaculum unless necessary.
LEEP:
- Speculum with vaginal sidewall retractor.
- Inject 1%lidocaine with epinephrine around face of cervix, start at 12, 3, 6 and 9 o'clock, then additional injections in between until cervix is blanched.
- Colposcopy without, then with acetic acid to identify areas to include in LEEP and which loop to use. Consider lugol's solution.
- Complete LEEP with 60w blended current.
- Complete ECC with Kevorkian curette, then endobrush to remove tissue.
- Ball-tip cautery for hemostasis, then apply morsel's.
Colposcopy:
- Only use paracervical block for patient that do not tolerative speculum exams well.
- Tischler (rounded) and Kevorkian (square) biopsy forceps available.
- Silver nitrate first, then morsel's if needed.
Vulvar Biopsy:
- 1% lidocaine with epinephrine, small wheel just beneath skin
- 4mm Punch biopsy, or pickups and scissors (pulls up middle of biopsy area with pickups and use scissors to excise.
- Silver nitrate first.
- 3-0 or 4-0 monocryl if needed.
Pelvic floor injections:
- Use pudendal kit or 20 to 22 gauge spinal needle on syringe with finger-grip/"control syringe"
*See urinary/pelvic pain interventions page for medications
Bladder Instillations:
- 8 French straight catheter, 40ml syringe
- iodine swabs
*See urinary/pelvic pain interventions page for medications
PREOP Orders:
- 300mg gabapentin and toradol 30mg 2 hr before surgery for all majors.
*0.25% bupivacaine with epi, approx. 5ml at each trocar site before incision, infiltrating down to fascia.
POSTOP Orders:
- Laparoscopic and Vaginal Hyst:
- Foley out in 2 hrs if same day discharge (6hrs or when ambulating if staying overnight), hep-lock IV when tolerating orals and adequate UOP.
- Scheduled Toradol 30mg q6h and scheduled acetaminophen 1000mg q6hr with prn oxycodone 5mg q4hr.
- IV Dilaudid 1mg q2hr prn for severe pain.
- Consider 300mg gabapentin TID while inpatient (especially for hx of chronic pain or patient desires to avoid Narcotics.
- Abdominal Hyst:
- Foley out POD#1 at 6AM. hep-lock POD#1 AM if tolerating orals and adequate UOP.
- Scheduled Toradol 30mg q6h and acetaminophen 1000mg q6h while inpatient.
- Dilaudid PCA 0.2mg/10min until POD#1 AM. Start Oxycodone (5mg-10mg q4h prn) 1 hr before stopping PCA.
- Gabapentin TID x5 days.
All overnight postops:
- Standing prn orders: Zofran 4mg q6hr IV (severe N/V: Phenergen 25mg q8hr IV), simethicone 80mg chews, famotidine 20mg BID, Colace 100mg BID, ambien 5mg qbedtime