To be read for juniors
only:-: Tips for abdominal
hysterectomy: -Problems & Solutions: Here I go :-Are you ready to
hear?? Tip 1:-A good, detail &
honest counseling couple days before the O T is scheduled, will hopefully avoid any litigation later.:- Problems &
Solutions: Tip 2- Preoperative selection of cases within your capability: - Which are the cases to be
avoided by the beginners? Avoid obese, post-CS cases Post-laparotomy
cases initial stages of your career. Because in such cases there are
possibilities of adhesions & oozing-at operation. Additionally, one should
initially avoid where endometriosis is the preoperative clinical diagnosis.
Problems & Solutions:
Tip 3: Problems & Solutions: Counseling part: - Type of skin incision: Counsel preoperatively: -
In difficult cases (extensive endometriosis or a big lump –Cx myoma in
particular, it will be prudent for the beginners to put paramedan vertical
incision thereby allowing extending up upwards. & Preoperatively-be sure
abbot the movabiity of uterus and palpate POD to exclude any nodules or
possible bowel adhesion or adhesions of Ovaries at back of uterus..
. Problems &
Solutions: Tip :4:- AS mentioned a good & honest counseling
will make a healthy bondage between a Gynae surgeon & relatives hopefully
will avoid any litigation later. To explain well ahead better on the previous
day that there may be slight Risk of bowel / bladder / ureter injury should be
discussed in terms of possibility and assure the relatives due care will be
taken such specialist will be present nearby and arrive at OT (preferably by
side gate!!) by five minutes time after a mobile call or sending a messenger
from OT. Tip 6 have through Preop investigations including ECG, Echo & you you
should scrutinize the reports and ask about false teeth / any past operation.
Explain to her about the proposed surgery she is going to have in local
language. All pros & cons and follow up should be communicated to her about
present surgery,
Tip: 5:- - Always take a
written consent if you remove ovaries and counsel well ahead about HRT...
.Tip 6:-Counsel that you may change the incision to
vertical & have to put interrupted silk/Nylon stitch in the skin while
closing the skin & may be unable to carry out Subcuticular stitch as may be
requested for by the pt., Tip-7:: Get gut prepared:-Tip 8:- Seek help of other Depts.-G I
& urosrgeons: - in cases with fixed lump get gut prepared
preoperatively and inform your friends at surgery dep’t and reschedule the time
when he is free. Ask also urologist help as when required & also to inform
a friendly but more experienced senior
Gynecological surgeon to stay nearerby-a
person who won’t disclose what went wrong (if there be any) at OT-any mistake that U may have done will not be
disclosed by that Gynae sir friend,.
Tip : 9:--Selection of anesthetists & Asstt
< Possibility of blood bank is not closed at OT hours , in rural settings
ensure that generator man is readily available & not has gone outside
campus to gossip at tea shop and sufficient
diesel is in his stoic,.
At OT ::Step1:-:- Identify
your identity as well as patient
identity and ask her name see that it matchers with her BHT (Bed Head ticket).
To enquire her what about the nature of operatiin she is going to face. Keep
your hand on her forehead and reassure her. A gentle talk with due respect to
her personality will build up a good rapport in the following days. If all are
well then only you may offer your green signal to anesthetist & Asstt to
scrub up.
At OT ::step2:- Second
duty at OT is counting of )
In all laparotomy or even in CS use fix no of mops ,artery, Allis, gauze
pieces, Long clams, -I insist on two mops including in Radicals & 6 each
for Spencer A forces Allis, Clamps etc Always ask OT sister to have the total
mops recorded on the mop by red cotton thread, though in some centers radio opaque material is
impregnated over mops. If mops are
numbered by cotton thread it is a good practice that before you open the abd
tell the sly no mops in a loud voice and OT sister (Circulating Nurse) will
verify such with a black board where it is written-duty of circulating nurse. Voce
the exact sly no of Mop U are been served, Sometimes a frienslku anesthetist
may keep record of bomber of mop dayhop no 5 & 19, like that instrument...Count
Abdominal
skin incision should be liberal.
At OT step 2:-type of skin
incision: - Those who are trained in “Ms Cutting incision”-MAY USE THAT as the
exposure will be better. What is peculiar in Ms Cutting is in addition to
excellent exposure one can work with minimal relaxation. During years of your residency may read from
Op Books about details of 5 types of abd incisions and may have practice or view
someone doing what is Ms Cutting incision is. In this type of incision where
only medial 1/3 rd of either rectus is cut thereby avoiding injury to Infr.
Epigastric vessels but a note of caution, in ms cutting one is not allowed to
dissect the sheath off the ant wall of Ms as we do in other cases. This will
cause tearing of perforating branches of Infr epigastric vessels which lie just
beneath the R sheath, 3) Vertical incision-When ?? .
At OT step 3: After opening the abd in
non-CS cases it is fair practice if you
practice from your beginning of carrier
to insulate your palm undersurface of liver, Diaph Pylorus Liver surfaced porta GB , Omentum
,Paratactic bodes, Location of kidneys < app ,It hastate 40 seconds as U
practice ,& hopefully anesthetist will excuse you, H) If in doubt then some fluid from POD or paracolic gutter for
pap stain in suspected cases of Ov tumours I) Similarly liberal biopsy from
different part of peritoneum in subfertility
cases for Genexpert or minimal -Insist on adequate relaxation
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