Common Gynecologic Procedures

1. Bimanual pelvic examination
Two fingers are placed in the vagina and the flat of the opposite hand is placed on the lower abdominal wall. Gentle palpation and manipulation should delineate the position, shape, mobility, tenderness, and size of the uterus and adnexal structures.

Indications: It is a part of routine pelvic exam and part of investigation for gynecologic pathology. Tenderness may be elicited on direct palpation or on movement/ stretching of pelvic structures (i.e. acute salpingitis or pelvic inflammatory disease [PID])

Drawbacks: Difficult to elicit any information on obese patients or uncooperative patients.

2. Cervical conization
It is a surgical procedure that involves excising a cone-shaped sample of tissue that includes the entire cervical transformation zone and a portion of the endocervical canal. The sample is then examined for any signs of malignancy.
Conization can be performed using a knife (cold knife cone), laser excision, and electrocautery (large loop excision of the transformation loop electrosurgical excision procedure.

Indications: It is used for either diagnostic or therapeutic reasons. The test is done when results of a cervical biopsy indicate precancerous cells in the area or cervical cancer. It may also be done if the cervical biopsy has not revealed the cause of an abnormal Pap smear.

Complications: An early complication is excessive bleeding. Infrequent complications include cervical stenosis or incompetence.


3. Colposcopy
It is the direct magnified inspection of the surface of the cervix, vagina, and vulva, using a light source and a binocular microscope.
Can be performed in the office and rarely requires any anesthesia.

Indications: Used to facilitate detailed evaluation of a suspect malignancy and to assist in directed biopsies of suspicious areas. It can also be used to detect inflammatory or infectious changes, and traumatic injuries to the cervix, vagina, and vulva.

4. Culdocentesis
It is the passage of a needle into the cul-de-sac to obtain fluid from the pouch of Douglas.
Not as commonly performed nowadays with advances in ultrasound technology.

Indications: It is a diagnostic procedure to check for abnormal fluid. Bloody fluid may indicate a ruptured ectopic pregnancy; pus-filled fluid indicates acute infection; ascetic fluid may indicate cancer.

Risks: There is a slight risk of puncturing any mass or uterine wall.

5. Dilation and curettage (D&C)
It is a process of opening and dilating the cervix using a series of graduated dilators followed by curettage, or scraping of the uterine lining.
It is generally performed under local or general anesthetic in the operating room.

Indications: It may be used to take an endometrial biopsy, remove polyps, other tumors, or excess endometrial lining, or to treat cases of incomplete spontaneous abortion.

Risks: If done roughly, uterine perforation may occur or scarring could develop leading to infertility

6. Dilation and evacuation (D&E)
It is a procedure used in the second trimester to remove the products of conception by first dilating the cervix and then using destructive grasping forceps. Vacuum aspiration may also be used to facilitate the removal.

Indications: It is used in pregnancy termination.

7. Hysterectomy
It is the removal of the uterus. It can be performed by entering the abdomen (abdominal hysterectomy) or extracting the uterus through the vagina (vaginal hysterectomy).
There are different types of hysterectomy:
Total: removal of all of the uterus and not the fallopian tubes or ovaries.
Subtotal or supracervical: body of the uterus is removed near the level of the internal cervical os, leaving the cervix in place
Radical: is a cancer surgery procedure where the uterus is removed with wide margins of surrounding
tissues.

Indications: It may be indicated for patients with benign or malignant changes in the uterine wall or cavity, for menstrual disturbances or abnormal bleeding, endometriosis, uterine prolapse, or chronic pelvic pain .
It is not recommended for the sole purpose of sterilization.

Advantages: Advantages include the elimination of future pregnancies, cessation of menses, and possibility of uterine and cervical cancer.

8. Hysterosalpingography
It is an x-ray of the uterus, fallopian tubes and abdominopelvic cavity that involves the injection of dye through the cervix.

Indications: It is useful to assess the size, shape, and anatomy of the uterine cavity for evaluation of infertility or genital anomalies.

Risks: There is a risk of infection of the uterus or pelvis, bleeding pain, and allergic reaction to the dye.

9. Hysteroscopy
A procedure involving the insertion of a small endoscope in the uterus which has a built-in viewing camera that allows direct visualization of the endocervix and endometrial cavity.

Indications: It is used for evaluation of bleeding or structural abnormalities which may cause infertility, or location of missing intrauterine devices; it is also used for therapeutic reasons (i.e., polypectomy, endometrial ablation, removal of the uterine septum)

10. Hysterosonogaphy
It is a new minimally invasive technique used to visualize the uterine cavity by use of ultrasound and slow infusion of sterile saline.

Indications: It is used to evaluate abnormal growths inside the uterus; abnormalities of the tissue lining the uterus (the endometrium); or disorders affecting deeper tissue layers.

11. Laparoscopy

It is the inspection and manipulation of tissue within the abdominal cavity using endoscopic instruments (camera).  The abdominal cavity is usually distended with carbon dioxide or nitrous oxide gas to facilitate viewing and prevent bowel injury.

Indications: It is used for diagnostic and therapeutic purposes. It can help in diagnosis of the source of pelvic pain, pelvic masses, infertility, and congenital abnormalities. It can treat endometriosis, lyse adhesions and be used to perform minimally invasive surgeries  (eg, bilateral salpingooophorectomy

[BSO])

12. Pap smear
It is a microscopic examination of cells scraped from the ectocervix and endocervix.
American College of Obstetrics & Gynecology  recommends annual Pap smear screenings from 3 years after the start of sexual intercourse but not later than age 21 years.
Women at risk should have annual Pap smears; women who have had three consecutive negative tests can be screened every 2–3 years.

Indications: Mainly used as a screening modality, it can detect cancerous or precancerous conditions of the cervix.