TAH operation -Tips for safe surgery

Abd step 4:-Decide whether you will be performing  Extra-fiscal  or intra-fascial TAH??  There are several types of (total 5 types) and preoperative decision will be worth but things has to flexible  to put clamps remaining as close to uterus as possible 6) to pull up uterus firmly when putting the clamps particularly at paracervical  ligaments.. 10) No clamping in late pelvic walls –firm pressure with gauze by a male asstt for 7-10 minutes will hopefully stops all oozing and spurts will be readily visible as soon as pressing Mop/ gauze pc on a swab holder is removed. In case there is B) Do not put loose gauze pieces fir swabbing inside the abdomen or to find out a bleeding point at vault –always clam pie by A forceps otherwise such may be kept inside & forgotten though Manu such gauze pieces may but not always  find a  path from vault ,

Repair of cystocele ? enteorocle /. Puranadare R heath fix with valet to in frail wine to priest value prolapse Additila surgeron.  Appendix if necessary except possibly  retro caecal may avoid initially,

. If there is oozing in lateral pelvic walls-not to put clamp. Instead pack the area with mop-put firm pressure for about 4-5 minutes. Most oozing will stop. If you are attached to some medical collegeà -then view some radical hysterectomy/ combined abdomino-vaginal hysterectomy. Or else U can watch videos from U-tubes,

 6 C) ENDOMETRIOSIS(SUBPERITONEAL ENDOMETRIOSOS CAUSING-Rec impl failure, Unresponsive endo ,LUF LPD) .Abd drain when in  there is some oozing and vault is closed in gross PLID., Stage II, IV endometriosis. F) May put a sub cut drain while closing if she is obese, T) Thromboprphylaxis.

Write the O T notes clearly and I prefer to hand over a copy to relatives duly signed though many do so after all is well say after one month, many don’t hand over video recordings in diffi Laparoscopy pass 2 months if something wrong is demonstrated in type of instruments use and conversations at OT about defects in diathermy, not having adequate distension, scolding the first / second Asstt for improper placement of primary pert, So my advice will be not to e=avid audio component of video  of in Laparoscopy or even in Laparotomy unless that is a teaching video, in Endobag  is one of them,

Physiotherapy, Lungs exercise, early ambulation,

Books to read after passing MD.DNB_ A) Gynaecology & Obstet for PG course-Dan forth B) Operative Gynae –I prefer in addition to Victor Bonney (I poses his own editions) but after=the death of that great man others are editing ,That book is excrement for myomectomy & ovarian cystectomy, But other operative procedures may read A) Te Lined Operative Obstet( 2 vol) &B)bedeck& Novak Ed by J Sere ,16 th Ed (I suppose) Both are excellent books once U start reading U may forget your lunch!!!

For vaginal cases: - Adequate Normal saline infiltration with the knowledge of anesthetist / dilute xylocaine infiltration so that the planes of cleavage are easy delineated/ Place clamps as close to uterus as possible- here too firm downward traction by Asstt towards floor of OT / opening the POD first/ clamping the pubocervical fascia as first clamp will/ Initially avoid cases where there is minimal mobility of uterus/ who had PFR operation earlier/.

Can we prescribe mefenamic acid and Tranexamic acid concomitantly to control obstinate AUB? Such unusual combination Ry came to my mind because an unmarried lady aged 24 yrs, reported to me yesterday. She is suffering from menorrhagia for last two years and has visited multiple specialists without much relief. There is nothing abnormal in systemic examination and there are no H/O bruises. At the initial years there was no H/O menorrhagia .Her hematological profile is essentially normal except Hb% is ranging from 8- 9 gm% but other parameters including bleeding & coagulation profiles are normal. Clinical feature does not match with pelvic endometriosis/Adenomyosis, though MRI is due.

 Metabolic & endocrine profiles and 2-D USG are normal carried repeatedly does not reveal any abnormality. ET is 5-7 mm. No evidence of polyp. Hysteroscopy is due as is due culture of menstrual blood for Koch’s. Chest X-ray is normal. High dose of OCP/ Norethisterone alone were prescribed without much relief.

My second question pertaing to the above mentioned case can we prescribe Mifepristone in this age group if mefenamic acid and Tranexamic acid combination also fail. What about the role of Ulipristal in this case? Any member has experience in using Mifepristone or Ulipristal in similar clinical settings? Kindly opine. Tips from senior members please