---

PRASUTI TANTRA EVAM STREE ROGA

Complete Study Notes: Ayurvedic & Modern Gynecology

---

PART I: AYURVEDIC TOPICS

---

1. YONYARSHA (योन्यर्श) - Vaginal/Uterine Polyp-like Growths

Definition

---

NIDANA (Etiology)

---

SAMPRAPTI (Pathogenesis)

Nidana Sevana (Causative factors)
         ↓
Vitiation of Vatadi Tridosha
         ↓
Doshas reach Artavavaha Srotas
         ↓
Localise in Rakta (blood) + Mamsa (muscle) of Yoni
         ↓
Produce muscular sprouts/protuberances
with umbrella-like shape (Chatrakakara)
         ↓
YONYARSHA
(Foul smelling, unctuous, sticky, blood-mixed discharge)

• Dosha: Tridosha (Vata, Pitta, Kapha)
• Dushya: Rakta, Mamsa
• Srotas: Artavavaha Srotas
• Srotodushti: Sanga (obstruction), Siragranthi (nodule)
• Sthana: Yoni (vagina/uterus)
• Agni: Jatharagnimandya
• Rogamarga: Bahya (external)

---

BHEDA (Types/Classification)

---

LAKSHANA (Clinical Features)

• Protuberant growths in vaginal/uterine region
• Puti (foul smelling), Snigdha (unctuous), Picchila (sticky) discharge
• Blood-mixed discharge (Rakta Yukta Srava)
• Kandu (itching), Daha (burning), Shula (pain)
• Irregular/profuse menstruation (Pradara)

---

CHIKITSA (Treatment)

• Yoni Prakshalana (vaginal irrigation) with Triphala Kashaya + honey
• Yoni Pichu (tampons) with medicated oils

1. Tuttadi Lepa - Paste of copper sulphate (Tuttha), Gairika (red ochre), Symplocos racemosa (Lodhra), cardamom, purified realgar, arsenic trisulphide, Berberis aristata extract + alum + rock salt + honey - applied over growths
2. Gairikadi Yoni Poorana - Powder of red ochre + mango kernel + Embelia ribes (Jantugna) + turmeric + Berberis extract, mixed with honey, filled in vagina
3. Triphala Ghrita - Properly heated Triphala mixed with ghee; applied locally

• Chedana (excision of growth)
• Kshara Karma (chemical cauterization with alkaline preparation)
• Agnikarma (thermal cauterization - especially for Vataja and Kaphaja types)
• Lekhana (scraping)

• Healing oils medicated with Nyagrodha, mango, jasmine, Boswellia, Triphala herbs applied after surgical removal
• Soothing wash with Triphala decoction

---

---

2. YONIKANDA (योनिकंद) - Bartholin's Cyst/Abscess Equivalent

Definition

• Vataja Yonikanda → Early stage/malignant vaginal ulcers
• Pittaja Yonikanda → Acute suppuration stage of Bartholin's abscess
• Kaphaja Yonikanda → Chronic stage of Bartholin's abscess / simple Bartholin's cyst
• Sannipataja Yonikanda → Acute suppuration in chronic Bartholin's abscess

---

NIDANA (Etiology) - Ma.Ni. 63/1-2

दिवस्वप्नादतिक्रोधाद् व्यव्यामादतिमैथुनात् |
क्षताच्च नख दन्ताद्यैर्वाताद्याः कुपिता यदा ||

---

SAMPRAPTI (Pathogenesis)

Above Nidana → Vitiation of Vatadi Tridosha
                    ↓
       Dosha reach Artavavaha Srotas
                    ↓
    Localise in Rakta + Mamsa of Yoni-pradesha
                    ↓
    Blood + Pus formation at vulval region
                    ↓
    Nikucha (circular fruit-like) or
    Lakucha-shaped protuberance forms at vulva
                    ↓
           YONIKANDA
    (Puyashonitasankasha = pus + blood coloured discharge)

• Dosha: Vatadi Tridosha
• Dushya: Rakta, Mamsa
• Srotas: Artavavaha Srotas
• Sthana: Yoni (specifically lower vulval region)
• Udbhavasthana: Yonipradesha

---

BHEDA (Types) - 4 Types

---

LAKSHANA (Clinical Features)

पूयशोणितसंकाशं निकुचाकृतिसन्निभम् |
जनयन्ति यदा योनौ नाम्ना कन्दः स योनिजः ||

• Puyashonitasankasha: Pus and blood-like coloured mass
• Nikuchakrti shape: Round/fruit-like protuberance
• Located at lower vaginal wall/vulva (Yoni pratham-avrita)
• Discharge of pus ± blood

---

CHIKITSA (Treatment)

• Tridosha-specific internal medicines

• Incision and drainage (for abscess stage - Pittaja)
• Chedana + Kshara karma for fibrotic/cystic stage (Kaphaja)

---

---

PART II: MODERN GYNECOLOGY

---

3. BARTHOLINITIS, BARTHOLIN'S ABSCESS AND BARTHOLIN'S CYST

Anatomy

Anatomy of Bartholin's Gland:
━━━━━━━━━━━━━━━━━━━━━━━━━━━
Paired compound racemose glands
Located: Between hymen and labia minora bilaterally
Positions: 4 o'clock and 8 o'clock
Normal size: Pea-sized
Function: Provide moisture to vestibule (begin at puberty, involute with age)
Duct: Drains into posterior vestibule just lateral to hymenal ring

---

BARTHOLINITIS

• Escherichia coli (most common)
• Neisseria gonorrhoeae
• Chlamydia trachomatis
• Polymicrobial organisms

• Labial swelling, redness at 4 or 8 o'clock position
• Tenderness on palpation
• Purulent discharge from duct opening
• Dyspareunia, difficulty walking

• Swab and culture from duct
• STI screening (NAAT for gonorrhoea, chlamydia)
• Blood sugar (recurrent cases - rule out diabetes)

• Oral broad-spectrum antibiotics (amoxicillin-clavulanate, ciprofloxacin + metronidazole)
• Warm sitz baths
• Analgesics
• STI partner tracing if applicable

---

BARTHOLIN'S CYST

• Painless or mildly uncomfortable swelling at 4 or 8 o'clock
• Usually unilateral, soft, fluctuant mass
• 1-4 cm in diameter
• No fever or systemic symptoms
• May cause dyspareunia

• Clinical examination is usually sufficient
• Ultrasound: Confirms discrete fluid-filled collection
• In women >40 years: Biopsy of cyst wall (to exclude adenocarcinoma - rare but important)

---

BARTHOLIN'S ABSCESS

• Acute onset, rapidly enlarging painful mass at 4 or 8 o'clock
• Exquisitely tender, hyperemic, fluctuant mass
• Local warmth and erythema
• Difficulty sitting/walking
• Systemic symptoms (fever, chills) are RARE

• Labial abscess (requires gynaecological consultation)
• Skene's gland cyst
• Inclusion cyst
• Lipoma
• Adenocarcinoma (in women >40 years)

• Clinical diagnosis
• Ultrasound if diagnosis uncertain (confirms walled-off fluid collection - do NOT drain until well-defined)
• Culture and sensitivity of pus
• STI screening

---

MANAGEMENT OF BARTHOLIN'S ABSCESS/CYST

Incision and Drainage with Word Catheter (First-line)

STEPS OF WORD CATHETER PLACEMENT:
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
1. Position: Dorsal lithotomy
2. Identify: Area of maximal swelling/fluctuation
3. Local anaesthesia: 2-4 mL 1% lidocaine injection
   (topical or local infiltration)
4. Stab incision: #11 scalpel blade on MUCOSAL surface
   of vestibule, just lateral to hymenal ring
   - Keep incision small (few mm only - too large 
     will displace Word catheter)
   - Two clamps placed 3-5 mm apart help guide incision
5. Drain completely
6. Culture the fluid
7. Insert Word catheter (latex stem catheter, 
   ~size of #10 Foley, with inflatable balloon)
8. Inflate balloon with 2-4 mL normal saline/water
9. Tuck catheter end into vagina for comfort
10. Leave in place 4-6 weeks → allows epithelialization
    of track (marsupialization effect)
11. Remove catheter at 4-6 weeks

Marsupialization (Surgical Alternative)

STEPS OF MARSUPIALIZATION:
━━━━━━━━━━━━━━━━━━━━━━━━━
1. Regional/general anaesthesia
2. Elliptical incision on inner labial mucosa
3. Cyst wall opened and evacuated
4. Cyst wall edges sutured to vaginal mucosa (creating
   permanent opening so gland continues to drain)
5. Absorbable sutures (Vicryl 2-0 or 3-0)
6. No packing needed
7. Advantages: Lower recurrence than simple I&D

Other Options:

• Silver nitrate/Alcohol ablation of cyst cavity
• CO2 laser vaporization
• Bartholin gland excision - reserved for recurrent cases in postmenopausal women (sends specimen for histology to exclude carcinoma)

• Warm sitz baths 3x/day
• Analgesics
• Antibiotics only if associated cellulitis present
• Follow-up at 4-6 weeks for catheter removal

---

        VULVA - Schematic View
        ─────────────────────
        
        Clitoris (12 o'clock)
              ↑
    ___________↑___________
   |          |||          |
   |   Labium  ↕  Labium  |
   |   Majus      Majus   |
   |                       |
   | Labia Minora (inner)  |
   |                       |
   | ◄ 8 o'clock  4 o'clock ► |  ← Bartholin gland openings
   |                       |
   |     Hymenal ring      |
   |_______________________|
              ↓
           Perineum

---

---

4. UTERINE POLYPS - CERVICAL AND ENDOMETRIAL

A. CERVICAL POLYP

• Arise from hyperplastic endocervical mucosa
• Single or multiple; soft, red/purple, smooth or lobulated
• Stalk contains blood vessels → prone to bleeding
• Usually benign; malignant transformation <1%

• Often asymptomatic (incidental finding on speculum examination)
• Intermenstrual bleeding
• Post-coital bleeding
• Post-menopausal bleeding (requires investigation)
• Profuse vaginal discharge (mucopurulent)
• Visible cherry-red polyp protruding from cervical os

• Speculum examination (diagnosis)
• Colposcopy
• Pap smear
• Ultrasound (transvaginal) - rules out concurrent endometrial pathology
• Histopathology (after removal - mandatory)

• Avulsion polypectomy - Grasping the polyp with ring forceps and twisting/avulsing at stalk base (for small polyps accessible at os)
• Hysteroscopic polypectomy - For polyps with stalk high in cervical canal
• Dilatation and Curettage (D&C) - If endometrial involvement suspected
• Follow-up Pap smear after 6 weeks

---

B. ENDOMETRIAL POLYP (Including Fibroid Polyp)

1. Adenomatous polyp (glandular)
2. Fibrous/fibroid polyp (from submucosal fibroid becoming pedunculated)
3. Adenomyomatous polyp (mixed)
4. Atrophic polyp (post-menopausal)

• Pedunculated submucosal leiomyoma extends into endometrial cavity
• Uterus contracts forcefully to expel it → labour-like cramping
• Large vascular stalk attached in endocervical canal or endometrial cavity
• Can prolapse through cervical os

• Transvaginal ultrasound (TVS): Hyperechoic intracavitary lesion, "endometrial thickening"
• Saline infusion sonography (SIS): Best for defining polyp outline
• Hysteroscopy (Gold Standard): Direct visualization; directed biopsy
• D&C: Therapeutic and diagnostic
• MRI: For suspected fibroid polyp (distinguishes from leiomyoma)
• Histopathology: Mandatory to exclude endometrial carcinoma

DIAGNOSIS AND MANAGEMENT OF UTERINE POLYP:
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

Symptomatic polyp / Postmenopausal bleeding
              ↓
    Hysteroscopic Polypectomy
    (Gold standard - direct vision resection)
              ↓
    Histopathology (MANDATORY)
              ↓
    Benign? → Follow-up TVS at 6 months
    Atypical? → Consider hysterectomy
    
For fibroid polyp (prolapsed through os):
    Avulsion/twist at stalk → send for HPE
    If high stalk: Hysteroscopic resection
    D&C as follow-up

---

---

5. FIBROID UTERUS (UTERINE LEIOMYOMA)

Definition

Genetics/Molecular Pathology

• ~40% have chromosomal abnormalities (rearrangements of chromosomes 12q14, 6p)
• Mutations in MED12 gene in ~70% (encodes Mediator complex component)
• HMGC and HMGIY genes implicated
• Associated with HLRCC syndrome (germline FH mutations)

---

TYPES (Classification by Location)

TYPES OF FIBROID UTERUS:
━━━━━━━━━━━━━━━━━━━━━━━

              UTERUS (cross-section)
         ┌────────────────────────┐
         │   INTRAMURAL            │  ← Most common (within myometrium)
         │   (inside wall)        │
         │                        │
  ┌──────│────────────────────────│──────┐
  │SUB-  │                        │ SUB- │
  │SEROSAL                        │MUCOUS│
  │(under│                        │(under│
  │serosa│                        │ endo-│
  │- out-│   ENDOMETRIAL CAVITY   │metrium
  │side) │                        │-inside)
  └──────│────────────────────────│──────┘
         │                        │
         └────────────────────────┘
         
Additional types:
- Cervical fibroid (in cervix)
- Broad ligament fibroid
- Pedunculated fibroid (subserosal or submucosal on stalk)
- Intravenous leiomyomatosis (extremely rare)
- Parasitic fibroid (detached, attached to omentum)

---

CLINICAL FEATURES

• Enlarged irregular (knobbly) uterus on bimanual/abdominal palpation
• Uterus may be non-tender (unless degenerating)
• Firm, non-tender masses
• Pallor from anaemia

• Spontaneous abortion
• Fetal malpresentation
• Uterine inertia (failure to contract)
• Postpartum haemorrhage
• Red degeneration (carneous degeneration) - painful

1. Hyaline (most common - fibrosis, white)
2. Calcific (calcium deposits - "womb stone")
3. Cystic (liquefaction)
4. Red/Carneous (haemorrhagic - in pregnancy, painful)
5. Mucoid/Myxomatous
6. Fatty (Adipose)
7. Necrotic/Septic
8. Sarcomatous change (malignant - rare, <1%)

---

INVESTIGATIONS

---

MANAGEMENT OF FIBROID UTERUS

MANAGEMENT ALGORITHM:
━━━━━━━━━━━━━━━━━━━━━
Fibroid uterus confirmed
         ↓
Asymptomatic? → Watchful waiting + 6-monthly US
         ↓ (if symptomatic)
         ↓
    ┌────┴────┐
Medical    Surgical
    │            │
    ↓            ↓
GnRH agonists  ┌──────────────────┐
(Leuprolide    │  Type/location?  │
3-6 months)    └──────────────────┘
Tranexamic acid        │
Mifepristone     ┌─────┴────┐
NSAIDs       Wants      Completed
             fertility   family
                │            │
                ↓            ↓
          Myomectomy  Hysterectomy
          (abdominal  (definitive cure)
          /laparoscopic
          /hysteroscopic)

• GnRH agonists (Leuprolide/Goserelin): Reduce size by 30-50%; used 3-6 months pre-operatively to shrink fibroids and treat anaemia; side effects - menopausal symptoms
• Mifepristone (antiprogestogen)
• Ulipristal acetate (SPRM - selective progesterone receptor modulator)
• Tranexamic acid - reduces bleeding
• NSAIDS - dysmenorrhoea
• Iron supplementation - anaemia
• LNG-IUS (Mirena) - reduces menorrhagia

• Myomectomy - fibroids removed, uterus preserved (fertility-sparing)
• Hysterectomy - definitive; recommended if family complete
• Uterine Artery Embolization (UAE) - interventional radiology; coils/particles block uterine arteries
• Magnetic Resonance-guided Focused Ultrasound (MRgFUS) - non-invasive ablation
• Endometrial Ablation - for submucosal fibroids with menorrhagia (not for large fibroids)

---

---

6. BENIGN CONDITIONS OF OVARY

A. OVARIAN TUMOURS (Benign)

BENIGN OVARIAN TUMOURS:
━━━━━━━━━━━━━━━━━━━━━━

1. FUNCTIONAL CYSTS (non-neoplastic)
   a. Follicular cyst (most common in reproductive age)
   b. Corpus luteum cyst
   c. Theca-lutein cyst (associated with molar pregnancy)

2. EPITHELIAL TUMOURS (most common benign neoplasms)
   a. Serous cystadenoma
   b. Mucinous cystadenoma (can be very large)
   c. Endometrioma (chocolate cyst - endometriosis)
   d. Brenner tumour (transitional cell)

3. GERM CELL TUMOURS
   a. Mature cystic teratoma (dermoid cyst) - most common
      benign germ cell tumour; contains hair, teeth, sebum

4. SEX CORD-STROMAL TUMOURS
   a. Fibroma (associated with Meigs' syndrome)
   b. Thecoma

5. PARAOVARIAN CYSTS (from Wolffian duct remnants)

• Often asymptomatic (incidental USG finding)
• Pelvic pressure, heaviness
• Abdominal distension
• Menstrual irregularities
• Complications: Torsion (acute pain, nausea, vomiting), rupture (peritonitis), haemorrhage into cyst, infection

• TVS/Abdominal ultrasound (simple thin-walled cyst vs complex)
• CA-125 (elevated in malignancy; can be raised in endometrioma, PID)
• LFT (mucinous cysts)
• MRI for characterization
• CECT abdomen/pelvis (if malignancy suspected)

• Functional cysts <5 cm: Watchful waiting; reassess at 2-3 months (often resolve)
• Persistent/complex cysts: Laparoscopic cystectomy
• Postmenopausal women: Lower threshold for surgery

---

B. TUBO-OVARIAN MASS (TOM) / TUBO-OVARIAN ABSCESS (TOA)

Ascending infection (STI - N.gonorrhoeae, C.trachomatis,
anaerobes, E.coli, Bacteroides)
         ↓
Endometritis → Salpingitis → Oophoritis
         ↓
Exudate accumulates in tubo-ovarian complex
         ↓
TUBO-OVARIAN MASS (inflammatory)
         ↓ (if loculated with pus)
TUBO-OVARIAN ABSCESS

• Lower abdominal pain (bilateral > unilateral)
• Fever (>38°C), chills
• Nausea, vomiting
• Vaginal discharge (mucopurulent)
• Dyspareunia
• Bimanual: Tender adnexal mass, cervical motion tenderness

MANAGEMENT OF TUBO-OVARIAN MASS/ABSCESS:
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

TOA confirmed
     ↓
Hospitalise + IV antibiotics (per CDC guideline):
  Regimen A: Cefoxitin 2g IV q6h + Doxycycline 100mg q12h
  Regimen B: Clindamycin 900mg IV q8h + Gentamicin 2mg/kg loading
             then 1.5 mg/kg q8h
     ↓
Clinical improvement in 72 hours?
     │
   YES → Complete 14-day oral course
         (Clindamycin 450mg qid OR Doxycycline + Metronidazole)
     │
    NO → Surgery
         ↓
    Laparoscopic drainage (preferred)
    or CT-guided percutaneous drainage
    or Laparotomy with salpingo-oophorectomy
    (if rupture, no response to antibiotics)

• Rupture → peritonitis, septic shock (emergency laparotomy)
• Fitz-Hugh-Curtis syndrome (perihepatitis)
• Infertility (tubal damage)
• Ectopic pregnancy risk

---

---

7. PREMALIGNANT AND MALIGNANT LESIONS OF FEMALE REPRODUCTIVE ORGANS

Premalignant Lesions

Malignant Lesions by Site

• Squamous cell carcinoma (70-75%) - at squamocolumnar junction
• Adenocarcinoma (25%) - endocervical glands
• HPV 16, 18 are causative (>99% cervical cancers HPV-related)
• Staging: FIGO staging (IA to IVB)

• Type I: Endometrioid adenocarcinoma (oestrogen-dependent, better prognosis)
• Type II: Non-endometrioid (serous, clear cell - aggressive)

• Epithelial (most common - serous, mucinous, endometrioid, clear cell)
• Germ cell
• Sex cord-stromal

---

CERVICAL CANCER VACCINATION

VACCINATION SCHEDULE:
━━━━━━━━━━━━━━━━━━━━

Age 9-14 years: 2-dose schedule (0, 6 months)
Age 15+ years:  3-dose schedule (0, 1-2, 6 months)

Ideal: Before sexual debut (naïve to HPV)
Can be given up to age 26 (routine); ages 27-45 (shared decision)

• Prevents CIN 2/3, adenocarcinoma in situ, invasive cervical cancer
• Cross-protection against non-vaccine HPV types
• Does NOT treat existing HPV infection
• Pap smear surveillance continues even after vaccination
• Safe in all age groups; mild local reactions common
• Not for use in pregnancy (delay until after delivery)

---

---

PART III: SURGICAL PROCEDURES IN PRASUTI STREE ROGA

---

8. PREOPERATIVE PREPARATION (Purva Karma)

Modern Preoperative Preparation

• Complete history and physical examination
• Informed consent
• Pre-anaesthetic check-up (PAC)

• CBC, blood group and crossmatch
• RFT (renal function), LFT
• RBS, HbA1C (diabetes)
• Coagulation profile (PT, aPTT)
• Urine analysis, culture
• ECG (>40 years)
• Chest X-ray
• Pap smear, HPV test (if not done)
• Pregnancy test (β-hCG) - if applicable

• Optimise comorbidities (BP, diabetes)
• Bowel preparation (if bowel surgery anticipated)
• Vaginal preparation (Betadine/chlorhexidine)
• Antibiotic prophylaxis (IV Cefazolin 2g 1 hour before incision)
• DVT prophylaxis (LMWH + TED stockings for major surgeries)
• Skin preparation and shaving at operation site
• Foley catheter insertion (for pelvic surgeries)
• IV access, IV fluids

Ayurvedic Preoperative Preparation (Purva Karma)

• Prakriti (constitution) analysis
• Identify dominant vitiated dosha

• Internal (Abhyantara Snehana): Ghee/oils orally
• External (Bahya Snehana): Abhyanga (oil massage)

• Steam/sudation therapy to soften tissues, improve circulation

• Virechana (purgation) - pacifies Pitta
• Basti (enema) - pacifies Vata
• Vamana - if Kapha predominant

• Light diet (Laghu Ahara) for 2-3 days pre-operatively
• Avoid heavy, fried, spicy foods

• Reassurance, explanation of procedure
• Mantra, meditation for mental stability

---

9. POSTOPERATIVE CARE (Pashchat Karma)

Modern Postoperative Care

• Vital sign monitoring (BP, HR, RR, temp, SpO2)
• Fluid balance (I/O monitoring)
• Urine output monitoring (>0.5 mL/kg/hr)
• Pain management (IV analgesics - Morphine/Tramadol PCA)
• Antiemetics
• Continue IV antibiotics (if prescribed)
• Wound inspection
• VTE prophylaxis - early ambulation + LMWH

• Convert to oral intake (start with sips, progress)
• Switch IV to oral analgesia (NSAIDs + Paracetamol)
• Monitor for complications: fever, wound infection, haemorrhage, ileus
• Remove urinary catheter (24-48 hours for simple procedures; longer for complex)
• Gentle physiotherapy, deep breathing exercises

• Afebrile, haemodynamically stable
• Tolerating oral diet
• Pain controlled on oral analgesics
• Wound clean and dry
• Voiding well

• Wound check at 5-7 days
• Histopathology review
• Long-term hormone/nutrition counselling
• Pelvic floor physiotherapy (post-hysterectomy)

Ayurvedic Postoperative Care (Pashchat Karma)

• Vrana Shodhana (wound cleaning): Triphala Kashaya, Panchavalkala Kashaya for wound irrigation
• Vrana Ropana (wound healing): Application of Jatyadi Taila, Kumari (Aloe vera) gel
• Soothing diet (Pathya): Yusha (soup), light rice, easily digestible foods; avoid Vata-aggravating foods
• Snehana - gentle oil massage to reduce Vata, improve circulation
• Basti (medicated enema) - Vata pacification, important post-surgery
• Psychosocial support - Sattvavajaya (mental health support), Pranaayama

---

---

10. GRANTHI NIRHARANA - CYSTECTOMY

Types:

• Laparoscopic Cystectomy (preferred)
• Laparotomy Cystectomy (for large/complex cysts)
• Oophorectomy (if cyst occupies entire ovary or suspicion of malignancy)

Indications:

• Ovarian cyst >5 cm persisting >8-12 weeks
• Complex cyst (septations, solid areas, internal echoes)
• Symptomatic cyst (pain, pressure)
• Suspected dermoid (mature cystic teratoma)
• Endometrioma
• Cyst torsion

Steps of Laparoscopic Ovarian Cystectomy:

LAPAROSCOPIC CYSTECTOMY STEPS:
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

SETUP:
- General anaesthesia
- Patient: Dorsal lithotomy/supine, Trendelenburg position
- Bladder catheterised

PORT PLACEMENT:
- 10 mm umbilical port (laparoscope/camera)
- 5 mm right iliac fossa port
- 5 mm left iliac fossa/suprapubic port

PROCEDURE:
Step 1: Pneumoperitoneum with CO2 to 12-15 mmHg
Step 2: Insert trocar + laparoscope
Step 3: Survey pelvis - confirm cyst, note adhesions
Step 4: Grip ovary with atraumatic grasper
Step 5: Make incision on ovarian capsule (opposite pole from hilum)
         using scissors/monopolar/Harmonic scalpel
Step 6: Identify plane between cyst wall and normal ovarian cortex
Step 7: Strip the cyst by blunt/sharp dissection - "peeling" technique
Step 8: Maintain hemostasis (bipolar coagulation)
Step 9: Extract cyst in endobag (to prevent spillage - esp. for dermoid)
Step 10: Inspect for haemostasis; close ovarian defect 
          (± suture with Vicryl if needed; often left open to heal)
Step 11: Copious lavage of pelvis
Step 12: Remove ports under vision
Step 13: Close port sites >5 mm

SPECIMEN: Sent for histopathology

---

---

11. GARBHASHAYA ARBUDA NIRHARANA - MYOMECTOMY

• Symptomatic fibroids (menorrhagia, pressure symptoms)
• Infertility/recurrent miscarriage due to fibroids
• Rapid growth of fibroid
• Fibroid in significant location (submucosal, large intramural)
• Patient desires uterine conservation

Types:

1. Abdominal/Open Myomectomy
2. Laparoscopic Myomectomy
3. Hysteroscopic Myomectomy (for submucosal fibroids)
4. Vaginal Myomectomy (for prolapsed/pedunculated submucous fibroid through cervix)

Steps of Abdominal Myomectomy:

ABDOMINAL MYOMECTOMY STEPS:
━━━━━━━━━━━━━━━━━━━━━━━━━━━━

PREPARATION:
- Correct anaemia pre-operatively (Iron + GnRH agonist 3 months)
- Cross-match 2 units blood
- IV antibiotics (Cefazolin 2g pre-operatively)
- Consent for hysterectomy (if uncontrollable haemorrhage)

INCISION:
- Pfannenstiel (horizontal) or midline vertical (for large uterus)

STEPS:
1. Enter abdomen in layers
2. Identify uterus and all fibroids (palpate systematically)
3. Apply tourniquet/clamps to uterine vessels or inject
   dilute vasopressin (0.2 units/mL) into myometrium
   (reduces bleeding)
4. Incise serosa overlying the fibroid
5. Dissect and shell out fibroid (blunt + sharp) from
   pseudocapsule - crucial plane
6. Secure haemostasis at fibroid bed (figure-of-8 sutures,
   bipolar coagulation)
7. Close uterine defect in layers:
   - Inner layer: Interrupted Vicryl 1-0
   - Middle layer: Continuous Vicryl 1-0  
   - Outer layer (serosa): Running suture
8. Repeat for each fibroid
9. Washout pelvis
10. Close abdomen in layers

POST-OP:
- IV oxytocin infusion (reduce uterine bleeding)
- Monitor haemoglobin
- Adhesion prevention (anti-adhesion barrier gel/membrane)

RISKS:
- Haemorrhage (hysterectomy may be needed)
- Adhesion formation
- Recurrence of fibroids (30-50% at 5 years)
- Uterine rupture in subsequent pregnancy (scar)

• Performed under direct hysteroscopic vision
• Resectoscope + monopolar/bipolar loop
• No external incision; quick recovery
• Risk: Fluid overload (distension media), uterine perforation

---

---

12. LAPAROSCOPIC TUBAL LIGATION (LTL)

Timing:

• Interval sterilization (any time in menstrual cycle, ideally early follicular phase)
• Post-partum (within 48 hours of delivery)
• Post-abortion

Methods of Tubal Occlusion:

Steps of Laparoscopic Tubal Ligation:

STEPS OF LAPAROSCOPIC TUBAL LIGATION:
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

PRE-OPERATIVE:
- Informed consent (permanent/irreversible)
- Rule out pregnancy (urine β-hCG)
- IV antibiotics prophylaxis
- Bladder catheterisation
- GA or spinal anaesthesia

SETUP:
- Supine/dorsal lithotomy with Trendelenburg tilt
- Uterine manipulator placed per vaginam

PORT PLACEMENT:
- 10 mm umbilical port (camera)
- 5 mm suprapubic/iliac fossa port (working)

PROCEDURE:
Step 1: Create pneumoperitoneum (12-15 mmHg CO2)
Step 2: Insert trocar, introduce 0° or 30° laparoscope
Step 3: Inspect pelvis - identify uterus, both tubes
         (trace from cornua to fimbriae to confirm it IS the tube)
Step 4: Grasp the ISTHMIC portion of tube 
        (2-3 cm from cornua) - most avascular part
Step 5a (Filshie clip method):
        - Apply clip perpendicular to tube
        - Ensure complete occlusion
        - Apply to other side
Step 5b (Bipolar electrocoagulation):
        - Coagulate 2-3 cm segment of isthmus (at 25-35 W)
        - Divide with scissors
        - Repeat on other side
Step 5c (Falope ring/Silastic band):
        - Knuckle of tube drawn into applicator
        - Ring released over knuckle - strangulates tube loop
Step 6: Confirm bilateral occlusion
Step 7: Inspect for haemostasis
Step 8: Deflate pneumoperitoneum
Step 9: Remove ports under vision
Step 10: Close port sites

FAILURE RATE: 0.1-0.5% (Filshie clip < bipolar)

---

---

13. ABDOMINAL HYSTERECTOMY (Udaragata Garbhashaya Nirharana)

• Total Abdominal Hysterectomy (TAH): Remove uterus + cervix
• Subtotal/Supracervical Hysterectomy: Remove uterus, leave cervix
• TAH + BSO (Bilateral Salpingo-Oophorectomy): Uterus + cervix + tubes + ovaries
• Radical (Wertheim's) Hysterectomy: For cervical cancer; includes parametrium + upper vagina + pelvic lymph nodes

Steps of Total Abdominal Hysterectomy:

STEPS OF TOTAL ABDOMINAL HYSTERECTOMY:
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

PRE-OPERATIVE:
- Complete workup as above
- Bowel preparation (optional)
- Catheter, IV antibiotics
- GA or regional (spinal/epidural)

INCISION:
- Pfannenstiel (horizontal, cosmetic)
- Midline infra-umbilical (better exposure for large uterus)

STEP 1: Open abdomen - skin, fascia (Camper's, Scarpa's),
         rectus abdominis retracted, peritoneum opened

STEP 2: Explore abdomen - note adhesions, bowel, appendix

STEP 3: Pack bowel out of pelvis; expose uterus

STEP 4: Apply two Green-Armytage (vulsellum) forceps on
         uterine cornua (for traction)

STEP 5: Divide ROUND LIGAMENTS bilaterally (between clamps,
         ligate with Vicryl 1-0)

STEP 6: Open BROAD LIGAMENT anteriorly (vesicouterine fold)
         → bladder pushed down ("bladder flap")

STEP 7: Identify and divide INFUNDIBULOPELVIC LIGAMENTS
         (if oophorectomy planned) OR OVARIAN LIGAMENTS
         (if ovaries preserved) bilaterally

STEP 8: Skeletonise UTERINE VESSELS bilaterally:
         - Clamp, cut, ligate uterine artery + veins
           at level of internal os
         (Uterine artery runs at right angles to ureter - 
          "ureter is crossed by the uterine artery 
          - 'water under the bridge'")

STEP 9: CARDINAL LIGAMENTS and UTEROSACRAL LIGAMENTS:
         - Clamp, divide, ligate bilaterally
         - Progressive clamping down to cervicovaginal junction

STEP 10: VAGINAL VAULT: Incise anterior and posterior
          vaginal fornices; circumscribe the cervix
          → Uterus removed

STEP 11: CLOSE VAGINAL VAULT:
          - Angle sutures first (secure uterosacral ligaments
            to vaginal angles for vault support)
          - Continuous absorbable suture (Vicryl 1-0)

STEP 12: PERITONEALISE: Close pelvic peritoneum (optional)

STEP 13: HAEMOSTASIS check

STEP 14: CLOSE ABDOMEN in layers:
          - Peritoneum (optional)
          - Rectus sheath (Vicryl loop 1-0, continuous)
          - Subcutaneous fat
          - Skin (subcuticular Vicryl or clips)

IMPORTANT ANATOMICAL DANGER POINTS:
- Ureter (at infundibulopelvic ligament, at uterine artery)
- Bladder (during vesicouterine fold dissection)
- Bowel

---

---

14. VAGINAL HYSTERECTOMY (Yonimargagata Garbhashaya Nirharana)

Steps of Vaginal Hysterectomy:

STEPS OF VAGINAL HYSTERECTOMY:
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

POSITION: Dorsal lithotomy (exaggerated)
ANAESTHESIA: Spinal or GA
PREP: Catheter, vaginal preparation

STEP 1: Circumscribe cervix with scalpel
         (incise vaginal mucosa around cervix)
         Inject dilute epinephrine (1:200,000) for hydrodissection

STEP 2: ANTERIOR COLPOTOMY:
         Push bladder up; open vesicovaginal space anteriorly
         → Enter peritoneal cavity (anterior cul-de-sac)

STEP 3: POSTERIOR COLPOTOMY:
         Open Pouch of Douglas posteriorly
         (incise posterior vaginal wall → enter peritoneum)

STEP 4: Insert Doyen's retractor anteriorly, Sims' speculum
         posteriorly for exposure

STEP 5: UTEROSACRAL LIGAMENTS:
         Clamp, divide, ligate bilaterally
         (first pedicle - reduces uterine descent for better access)

STEP 6: CARDINAL LIGAMENTS:
         Clamp, divide, ligate bilaterally
         Progressive clamping as uterus descends

STEP 7: UTERINE VESSELS:
         Identify, clamp, divide, ligate bilaterally

STEP 8: ROUND LIGAMENTS, FALLOPIAN TUBES, OVARIAN LIGAMENTS:
         Clamp, divide, ligate (tubes/ovarian ligaments if ovaries
         preserved; infundibulopelvic ligaments if oophorectomy)

STEP 9: DELIVER THE UTERUS through vaginal incision
         (may morcellate or bisect large uterus)

STEP 10: INSPECT FOR HAEMOSTASIS

STEP 11: CLOSE VAGINAL VAULT:
          - Attach uterosacral ligaments to vaginal angles
            (McCall culdoplasty - prevents vault prolapse)
          - Close vaginal vault with Vicryl 1-0 continuous suture
          - Peritoneum closed or left open

STEP 12: VAGINAL PACK for 24 hours
STEP 13: Remove catheter at 24-48 hours

KEY DIFFERENCE from abdominal:
- Entire operation done through vagina
- Uterus delivered "upside down" (fundus last)
- No abdominal incision

---

---

15. DILATATION AND CURETTAGE (D&C) - Garbhashayamukha Vistrutikarana and Lekhana

• Garbhashayamukha Vistrutikarana = Dilatation of cervical os
• Lekhana = Curettage (scraping of endometrium)

• Abnormal uterine bleeding (AUB)
• Post-menopausal bleeding
• Endometrial/cervical polyp removal
• Incomplete abortion (evacuation)
• Missed abortion
• Hydatidiform mole evacuation
• Diagnostic (endometrial biopsy)
• Dysmenorrhoea investigation
• Pre-operative prior to hysterectomy

Steps of D&C:

STEPS OF DILATATION AND CURETTAGE (D&C):
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

POSITION: Lithotomy
ANAESTHESIA: GA (or paracervical block for outpatient)
PREP: Bladder emptied, vulva/vagina cleaned

STEP 1: BIMANUAL EXAMINATION under anaesthesia
         - Assess uterine size, position, mobility

STEP 2: EXPOSE CERVIX: Cusco's/Sims' speculum
         Anterior lip of cervix grasped with vulsellum forceps

STEP 3: SOUND THE UTERUS:
         Uterine sound passed gently through os to measure
         length and direction of uterine cavity (avoid perforation)

STEP 4: DILATE CERVIX:
         Hegar's dilators (graduated sizes 1-12)
         Start from size 1 - pass each dilator gently
         until required size reached (usually Hegar's 8-10)
         *** Always hold dilator like a pen; never force ***

STEP 5: CURETTE THE ENDOMETRIUM (Lekhana):
         - Introduce sharp (or blunt) curette
         - Systematic curettage in 4 quadrants
           (anterior wall → posterior wall → sides)
         - Figure-of-8 / windshield wiper motion
         - Continue until "gritty feel" = all endometrium removed

STEP 6: FRACTIONAL CURETTAGE:
         - Endocervical canal curetted FIRST (before dilation)
           then endometrial cavity
         - Separate specimens labelled "endocervical" 
           and "endometrial" → sent for histopathology

STEP 7: REMOVE INSTRUMENTS, inspect for bleeding
         Oxytocin given to contract uterus (if heavy ooze)

COMPLICATIONS:
- Uterine perforation (most common - silent, may need laparoscopy)
- Haemorrhage
- Cervical laceration
- Intrauterine adhesions (Asherman's syndrome)
- Infection → endometritis
- Incomplete evacuation

HYSTEROSCOPY-DIRECTED D&C:
- Gold standard - direct vision curettage
- Avoids blind miss of focal lesions
- Allows directed biopsy of suspicious areas

---

---

16. SURGICAL STERILIZATION - TUBECTOMY AND VASECTOMY

A. TUBECTOMY (Female Sterilization)

Modified Pomeroy's Technique (Minilaparotomy):

POMEROY'S TUBECTOMY STEPS:
━━━━━━━━━━━━━━━━━━━━━━━━━━

POSITION: Supine (post-partum: done at bedside within 48 hrs)
ANAESTHESIA: Local (ring block) ± sedation or spinal

STEP 1: Small 2-3 cm Pfannenstiel incision (interval)
         or infra-umbilical (post-partum - uterus still large)

STEP 2: Identify fallopian tube - trace from cornua to fimbriae
         (confirm it is tube, NOT round ligament)

STEP 3: Elevate midisthmic portion of tube with Babcock forceps
         → creates "knuckle" of tube

STEP 4: Tie base of knuckle with plain catgut (absorbable) - 
         figure-of-8 suture - ligation

STEP 5: Excise the loop above the ligature
         (removes ~1.5-2 cm of tube)

STEP 6: Send specimen for histopathology (confirmatory)

STEP 7: Repeat on other side

STEP 8: Close abdomen

POMEROY PRINCIPLE: Plain catgut absorbs → proximal and
distal ends separate → natural gap forms → sterilization

• Apply clip to isthmic portion through small incision
• Quicker, less tissue destruction
• Higher reversal success

---

B. VASECTOMY (Male Sterilization)

Steps of Conventional Vasectomy:

CONVENTIONAL VASECTOMY STEPS:
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

POSITION: Supine
ANAESTHESIA: Local (1% lignocaine injection to scrotal skin + vas sheath)
PREP: Scrotal skin cleaned and shaved

STEP 1: LOCATE VAS DEFERENS:
         "3-finger technique" - thumb + index + middle finger
         Fix vas deferens between fingers just below skin
         (cord-like structure in upper scrotum)

STEP 2: LOCAL ANAESTHESIA infiltration over the isolated vas

STEP 3: INCISION:
         Small vertical incision (1-2 cm) on scrotal skin
         overlying the vas deferens
         (Conventional: Two separate incisions for each vas, OR
          Midline single incision to access both)

STEP 4: DELIVER THE VAS:
         Identify and deliver vas through incision
         (distinguish from spermatic cord vessels - vas = firm cord)

STEP 5: OCCLUDE THE VAS (multiple techniques):
         a. Excise 1-2 cm segment + ligate both ends
            (suture ligation with Vicryl 0)
         b. Electrocoagulate both ends (fulguration)
         c. Clip both cut ends
         d. Fascial interposition (mucosa of ends buried in 
            different fascial planes - reduces failure rate)

STEP 6: SEND excised segment for histopathology

STEP 7: CLOSE SCROTAL SKIN (1-2 absorbable sutures)

STEP 8: Repeat for other side

NO-SCALPEL VASECTOMY (NSV - preferred method):
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
- Uses special ringed forceps to grasp vas through skin
- Pointed dissecting forceps pierce and stretch skin
- No incision - tiny puncture wound
- Lower complications (bleeding, infection, pain)
- WHO-endorsed technique

POST-PROCEDURE:
- Scrotal support for 48-72 hours
- Avoid heavy work for 1 week
- BACKUP CONTRACEPTION for 3 months or until
  SEMEN ANALYSIS confirms azoospermia (at 12 weeks
  or after 20 ejaculations)
- Failure rate: 0.1% (most commonly due to early coitus
  before cleared, or spontaneous recanalization)

---

---

SCHEMATIC SUMMARY DIAGRAMS

Bartholin Gland Pathology Spectrum:

BARTHOLIN PATHOLOGY PROGRESSION:
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

Normal gland (pea-sized, 4 or 8 o'clock)
        ↓ (obstruction)
   Bartholin's CYST
   (clear fluid, painless, soft)
        ↓ (infection)
  Bartholinitis → Bartholin's ABSCESS
  (pus, painful, fluctuant, hot, red)
        ↓
Treatment: Word Catheter / Marsupialization

Fibroid Classification Diagram:

UTERINE FIBROID TYPES:
━━━━━━━━━━━━━━━━━━━━━━

         PEDUNCULATED SUBSEROSAL
              ○ ↑
              | (stalk)
┌─────────────────────────────────┐
│ SUBSEROSAL ●                   │  (outer surface)
│ INTRAMURAL       ●             │  (within wall)
│           SUBMUCOSAL ●         │  (inner surface)
│              ↓                 │
│         [CAVITY]               │
└─────────────────────────────────┘
                ↓ (pedunculated submucosal)
                |
                ○ ← PROLAPSED SUBMUCOSAL FIBROID POLYP

Yonyarsha vs Yonikanda - Comparison:

YONYARSHA              vs         YONIKANDA
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Piles-like polyps                Bartholin-gland like cyst/abscess
anywhere in yoni                 specifically at vulval/lower vaginal wall
Umbrella-shaped                  Nikucha/Lakucha fruit-shaped
Foul discharge                   Pus + blood discharge
4 types (Vata/Pitta/Kapha/Sanni) 4 types (Vata/Pitta/Kapha/Sanni)
= Cervical/endometrial polyp     = Bartholin's cyst/abscess
Treatment: Kshara + Chedana      Treatment: I&D + Kshara karma

---

KEY TAKEAWAYS FOR EXAM

---