Case Paper Studies for Gynecology Residents - Operative Procedures

CASE PAPER 1: Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy (TAH + BSO)

PATIENT DETAILS

CHIEF COMPLAINTS

• Heavy menstrual bleeding for 2 years
• Dragging lower abdominal pain for 1 year
• Dysmenorrhea for 6 months

HISTORY OF PRESENT ILLNESS

PAST HISTORY

• No history of hypertension, diabetes, cardiac or respiratory disease
• No previous surgeries
• No known drug allergies

MENSTRUAL HISTORY

• Age at menarche: 13 years
• Cycle: previously 28/5, now irregular (24/7-10)
• Flow: heavy, with clots
• Dysmenorrhea: secondary, progressive

OBSTETRIC HISTORY

• P3L3: all full-term normal vaginal deliveries, no complications

FAMILY HISTORY

• No family history of gynecological malignancy

GENERAL EXAMINATION

• Conscious, cooperative, well-oriented
• Moderately built and nourished
• Pallor: present (moderate)
• No icterus, cyanosis, clubbing, lymphadenopathy, or pedal edema
• Pulse: 88/min, regular
• BP: 124/80 mmHg
• RR: 18/min
• Temperature: 98.4°F

SYSTEMIC EXAMINATION

• CVS: S1 S2 heard, no murmurs
• RS: Bilateral air entry equal, no added sounds
• CNS: No focal neurological deficit
• Abdomen: discussed below

ABDOMINAL EXAMINATION

• Inspection: Abdomen soft, no distension; no visible scar/mass
• Palpation: Uterus palpable at 16 weeks size, firm, irregular surface, non-tender, moves with respiration; lower border not reached
• Percussion: Dull over uterine mass; shifting dullness absent
• Auscultation: Bowel sounds present

PELVIC EXAMINATION

• Vagina: healthy
• Cervix: nulliparous os, healthy, no erosion/polyp/discharge

• Uterus: 16 weeks size, irregular, firm, anteverted, limited mobility
• Bilateral fornices: free and non-tender
• Adnexa: not separately palpable

• Rectovaginal septum: not thickened; parametria free

INVESTIGATIONS

DIAGNOSIS

PREOPERATIVE PREPARATION

1. Informed written consent obtained from patient; risks, benefits, and alternatives (including myomectomy, endometrial ablation, medical management) discussed
2. Anesthesia fitness obtained (ASA Grade II due to anemia)
3. Blood transfusion: 2 units packed cells transfused preoperatively; Hb rechecked = 10.2 g/dL
4. Injectable iron sucrose administered
5. Bowel preparation: light diet 24 hrs prior, enema evening before surgery
6. Skin preparation and shaving of operative site
7. IV access secured; IV fluids started
8. Foley's catheter inserted in OT
9. DVT prophylaxis: TED stockings applied; LMWH considered per anesthesia protocol
10. Prophylactic antibiotics: Inj. Cefazolin 1g IV administered 30 minutes before incision

OPERATIVE PROCEDURE

1. Patient positioned supine, painted and draped; Foley's catheter in situ draining clear urine
2. Pfannenstiel incision given (or midline vertical incision if uterus > 12 weeks) - skin, subcutaneous tissue, rectus sheath incised
3. Rectus muscles separated in midline; peritoneum opened
4. Systematic peritoneal survey: liver, spleen, bowel, appendix, omentum - unremarkable
5. Self-retaining retractor (Doyen/Balfour) placed
6. Uterus grasped with myoma screw/Museux forceps
7. Round ligaments bilaterally clamped, cut, and ligated with 1-0 Vicryl
8. Broad ligaments opened; vesico-uterine fold identified and reflected
9. Infundibulopelvic (IP) ligaments bilaterally doubly clamped, cut, and ligated (ovaries and tubes to be removed)
10. Bladder dissected off uterus using sharp and blunt dissection
11. Uterine vessels identified bilaterally; skeletonized at level of cervico-uterine junction; doubly clamped, cut, and ligated (Heaney's technique)
12. Cardinal (Mackenrodt's) ligaments and uterosacral ligaments bilaterally clamped, cut, and ligated, stepping down to vaginal vault
13. Vault opened anteriorly with scalpel; uterus, both tubes, and ovaries delivered
14. Vault closed with continuous locking 1-0 Vicryl suture; angles secured
15. Peritoneum closed with 2-0 Vicryl running suture
16. Hemostasis confirmed; no active bleeding
17. Abdomen irrigated with warm saline
18. Rectus sheath closed with 1-0 PDS; skin closed with staples/subcuticular suture
19. Specimen sent for histopathology

OPERATIVE FINDINGS

POSTOPERATIVE MANAGEMENT

• IV fluids: Ringer Lactate + Normal Saline alternating
• IV antibiotics: Inj. Cefazolin 1g TDS, Inj. Metronidazole 500mg TDS
• IV Tramadol / Diclofenac for pain
• Foley's catheter kept in situ
• NBM initially; allowed sips after return of peristalsis
• Monitor vitals every 2 hours
• Check drain output (if drain placed)

• Review vitals, wound site
• Urine output adequate - Foley's removed
• Soft diet started
• Patient mobilized with support

• Oral antibiotics transitioned (Tab. Amoxicillin-Clavulanate 625mg TDS, Tab. Metronidazole 400mg TDS)
• Wound: clean, dry, healing well; staples intact
• Bowel sounds present; passage of flatus

• Wound inspection and dressing
• Staples/sutures removed
• Patient ambulating independently

DISCHARGE SUMMARY

• Patient discharged on Day 7 in satisfactory condition
• Discharge medications:
  • Tab. Amoxicillin-Clavulanate 625mg TDS x 5 days
  • Tab. Metronidazole 400mg TDS x 5 days
  • Tab. Ibuprofen 400mg TDS SOS (with food)
  • Tab. Ferrous sulphate + Folic acid OD x 3 months
  • Calcium + Vitamin D supplementation (post BSO)
  • HRT counseling given; decision deferred to follow-up
• Advice on discharge:
  • Wound care: keep dry, no wetted dressings
  • No strenuous activity/lifting for 6 weeks
  • No sexual intercourse for 6-8 weeks until vault healed
  • Pelvic floor exercises to be started after 4-6 weeks
  • Follow-up at 2 weeks for HPE report
• Follow-up: OPD after 2 weeks

HISTOPATHOLOGY REPORT (Expected)

• Uterus: Multiple leiomyomata, benign
• Bilateral ovaries: Normal
• Endometrium: Proliferative / Disordered proliferative endometrium

CASE PAPER 2: Diagnostic and Operative Laparoscopy for Ectopic Pregnancy (Laparoscopic Salpingectomy)

PATIENT DETAILS

CHIEF COMPLAINTS

• Amenorrhea for 6 weeks
• Lower abdominal pain (right-sided) for 3 days
• Vaginal spotting for 2 days
• One episode of syncope (acute presentation)

HISTORY OF PRESENT ILLNESS

RISK FACTORS FOR ECTOPIC PREGNANCY

• Previous cesarean section (1)
• No prior history of PID, IUD use, tubal surgery, or infertility treatment
• No prior ectopic pregnancy

GENERAL EXAMINATION

• Conscious but anxious and pale
• Pulse: 106/min, thready
• BP: 96/60 mmHg (hypotensive - hemodynamically unstable)
• Cold clammy extremities
• Pallor: marked

ABDOMINAL AND PELVIC EXAMINATION

• Guarding and rigidity in lower abdomen
• Rebound tenderness present
• Cervical motion tenderness (Chandelier sign): positive
• Uterus: slightly enlarged, soft
• Adnexa (right): tender mass palpable; adnexa (left): free
• Posterior fornix: fullness and tenderness (suggesting haemoperitoneum)

INVESTIGATIONS (Emergency - done simultaneously with resuscitation)

DIAGNOSIS

PREOPERATIVE PREPARATION

1. Two large-bore IV lines secured; aggressive IV fluid resuscitation with RL
2. Blood sent for cross-match; 2 units PRBC arranged (auto-transfusion considered intraoperatively)
3. Informed consent obtained (noting emergency nature and risk to life; laparotomy may be needed if laparoscopy not feasible)
4. Anesthesia team alerted; emergency GA planned
5. Foley's catheter inserted
6. IV antibiotics: Inj. Cefazolin 1g IV + Inj. Metronidazole 500mg
7. NGT inserted (per anesthesia protocol for emergency)
8. Patient shifted to OT on priority

OPERATIVE PROCEDURE

1. Patient positioned; painted and draped; Foley's in situ
2. Veress needle inserted at Palmer's point (left subcostal); CO2 pneumoperitoneum achieved (12 mmHg)
3. 10mm primary trocar inserted at umbilicus (open Hasson technique preferred in emergency due to possible peritoneal adhesion from prior CS)
4. 0-degree/30-degree laparoscope introduced; peritoneal cavity visualized
5. Two 5mm secondary trocars placed in right and left iliac fossae under direct vision
6. Systematic survey:
   • Large volume haemoperitoneum (approximately 1000-1200 mL) present; clots visible
   • Right tube: swollen, ruptured at ampullary region; active bleeding from tear site
   • Right ovary: normal
   • Left tube and ovary: normal
   • Uterus: slightly bulky, no other pathology
7. Haemoperitoneum suctioned and evacuated using suction-irrigation device
8. Right infundibulopelvic pedicle (mesosalpinx) desiccated with bipolar forceps and cut; proceeding from fimbriated end to tubo-uterine junction
9. Proximal end of tube at cornual junction coagulated and cut
10. Right salpingectomy specimen retrieved through 10mm port in Endobag
11. Thorough peritoneal lavage with warm saline until effluent clear
12. Hemostasis confirmed
13. Port sites closed: fascia 10mm port closed with Vicryl; skin closed with absorbable sutures
14. Specimen sent for histopathology

OPERATIVE FINDINGS

POSTOPERATIVE MANAGEMENT

• IV fluids; blood transfusion 2 units PRBC intraoperatively
• Post-op vitals: BP stabilized to 110/70 mmHg; Pulse 88/min
• IV antibiotics continued for 48 hours
• Pain management: IV paracetamol + tramadol
• Monitor urine output
• Foley's catheter removed at 24 hours
• Diet: resumed day 1 post-op
• Anti-D immunoglobulin: NOT required (patient Rh positive); administer if Rh negative
• Counseling: regarding future fertility, risk of recurrence (10-15%), need for early scan in next pregnancy

DISCHARGE SUMMARY

• Discharged Day 3 in stable condition
• Discharge medications:
  • Oral antibiotics: Tab. Amoxicillin-Clavulanate x 5 days
  • Tab. Ibuprofen 400mg TDS SOS
  • Folic acid + Iron supplementation
• Advice:
  • No strenuous activity for 2 weeks
  • Early ultrasound in next pregnancy at 6-7 weeks to confirm intrauterine location
  • Follow-up serum beta-hCG weekly until undetectable
  • Contraception counseling (barrier preferred initially)
• Follow-up: OPD after 1 week with HPE report

HISTOPATHOLOGY REPORT (Expected)

• Right tube: Chorionic villi with trophoblastic tissue consistent with ectopic pregnancy; hemorrhagic salpingitis; tubal rupture site

KEY POINTS FOR RESIDENTS

1. Patient demographics and parity - always document LMP, menstrual history, obstetric history
2. Triad of symptoms relevant to the diagnosis (e.g., AUB triad, ectopic triad)
3. Risk factors specific to the condition
4. Bimanual pelvic examination findings - uterine size in weeks, adnexal findings, tenderness
5. Relevant investigations - including imaging, biopsy, tumor markers as applicable
6. Preoperative consent - document counseling about alternatives to surgery
7. Operative findings - always describe: uterus, both adnexa, pelvis systematically
8. Estimated blood loss
9. Specimen details and HPE submission
10. Postoperative recovery plan and discharge advice

• Berek & Novak's Gynecology: Hysterectomy indications, routes, and complications, pp. 1297-1298; p. 605
• Berek & Novak's Gynecology: Laparoscopic approach and infertility operations, p. 1298