Obstetric and Gynecologic Surgery
Obstetric and gynecologic surgery refers to procedures that are performed to treat a variety of conditions affecting the female reproductive organs. The main structures of the reproductive system are the vagina, the uterus, the ovaries, and the fallopian tubes.
Obstetrics is the branch of medicine that focuses on women during pregnancy, childbirth, and the postpartum period. Gynecology is a broader field, focusing on the general health care of women and treating conditions that affect the female reproductive organs. Medical doctors who choose to specialize in obstetrics and gynecology must undergo at least four years of post-medical school training (called a residency) in the areas of women's general health, pregnancy, labor and delivery, preconceptional and postpartum care, prenatal testing, and genetics. Obstetrician-gynecologists (also called OB-GYNs) may also subspecialize in the areas of gynecologic oncology (the treatment of cancers that affect the reproductive system), maternal-fetal medicine (the care of high-risk pregnancies), reproductive endocrinology and infertility (the study and treatment of the reproductive glands and hormones and the causes of infertility), and urogynecology (treatment of urinary tract and pelvic disorders).
There are a wide range of surgical procedures that have been developed to treat the various conditions that affect the female reproductive organs.
THE VAGINA. The vagina is the muscular canal that extends from the opening of the vulva (the external female genitals) to the cervix, the lower part of the uterus.
The vagina is the outlet for menstrual blood and is also where the penis is inserted during sexual intercourse.
Some common surgical procedures that are performed on the vagina include:
- Episiotomy. A surgical incision made in the perineum (the area between the vagina and anus) to expand the opening of the vagina to prevent tearing during delivery.
- Colporrhaphy. Surgical repair of the vagina may be necessary after childbirth, sexual assault, or other injuries.
- Colpotomy. This incision into the wall of the vagina may be used to excise ovarian cysts, perform tubal ligation, or remove uterine fibroids.
- Colposcopy. A colposcope is a specialized instrument used to visualize the vagina and cervix, to diagnose abnormalities, or to test for the presence of precancerous or cancerous cells.
THE UTERUS. The uterus is the hollow, muscular organ at the top of the vagina. The cervix is the neck-shaped opening at the lower part of the uterus, while the fundus is the rounded upper portion. The endometrium is the inner lining of the uterus; it is where a fertilized egg will implant during the early days of pregnancy. The endometrium normally sheds during each menstrual cycle if the egg released during ovulation has not been fertilized. The myometrium is the middle muscular layer of the uterus; it is the myometrium that rhythmically contracts during labor contractions.
Some common surgical procedures that are performed on the uterus include:
- Myomectomy. A procedure in which myomas (uterine fibroids) are surgically removed from the uterus.
- Cesarean section. A surgical procedure in which incisions are made through the woman's abdomen and uterus to deliver her baby.
- Cervical cerclage. The cervix is stitched closed to prevent a miscarriage or premature birth.
- Cervical cryosurgery. Cryosurgery freezes and destroys an area of the cervix in which precancerous cells have been found.
- Induced abortion. The intentional termination of a pregnancy before the fetus can live independently.
- Hysterectomy. The removal of part or all of the uterus may be done to treat uterine cancer, fibroid tumors, endometriosis, uterine prolapse, or other conditions of the uterus.
- Hysterotomy. This incision into the uterus is done during a cesarean section, open fetal surgery, and some second-trimester abortions.
- Dilatation and curettage. D&C is a gynecological procedure in which the cervix is dilated (expanded) and the lining of the uterus (endometrium) is scraped away.
THE OVARIES. The ovaries are egg-shaped structures located to each side of the uterus. It is within the ovaries that the female egg develops. A mature egg is released from one of the ovaries approximately every 28 days during a process called ovulation.
The surgical procedures that are performed on the ovaries include:
- Oophorectomy. One or both ovaries may be removed during this procedure to prevent or treat ovarian or other cancers, to remove large ovarian cysts, or to treat endometriosis.
- Cystectomy. An ovarian cystectomy may be used to remove part of an ovary to treat ovarian tumors or cysts.
THE FALLOPIAN TUBES. The fallopian tubes are the structures that carry a mature egg from the ovaries to the uterus. These tubes, which are about 4 in (10 cm) long and 0.2 in (0.5 cm) in diameter, are found on the upper outer sides of the uterus, and open into the uterus through small channels. It is within a fallopian tube that fertilization, the joining of the egg and the sperm, takes place.
Some common surgical procedures that are performed on the fallopian tubes include:
- Salpingostomy. An incision is made in the fallopian tube, often to excise an ectopic pregnancy.
- Salpingectomy. One or both fallopian tubes are removed in this procedure. It may be used to treat ruptured or bleeding fallopian tubes (as a result of ectopic pregnancy), infection, or cancer.
- Tubal ligation. A permanent form of birth control in which a woman's fallopian tubes are surgically cut or blocked off to prevent pregnancy.
THE VULVA. The external female genital organs (or vulva) include the labia majora, two lips or folds that enclose the labia minora. The labia minora, in turn, are two lips or folds that enclose the clitoris, a small sensitive organ with a high number of nerve endings.
Some examples of surgeries that affect the vulva are:
- Vulvectomy. The vulva may be partially or completely removed, as in the case of vulvar cancer.
- Laceration or hematoma repair. Vulvar hematoma (a localized collection of blood) or laceration may result from a "straddle" injury, sexual assault, or childbirth. Severe hematomas may need surgical drainage.
Obstetric and gynecologic anesthesia
There are a number of options available to women for pain relief during obstetric or gynecologic surgery. Pain medications given intravenously (into a vein) or intramuscularly (into a muscle) help to decrease the amount of pain during childbirth or certain procedures, although they will generally not completely eliminate pain.
Regional anesthesia, either a spinal or an epidural, is the preferred method of pain relief during childbirth and certain surgical procedures such as cesarean section, tubal ligation, cervical cerclage, and others that do not require the patient to be unconscious. The benefits of regional anesthesia include allowing the patient to be awake during the surgery, avoiding the risks of general anesthesia, and allowing early contact between mother and child in the case of a cesarean section. Spinal anesthesia involves inserting a needle into a region between the vertebrae of the lower back and injecting numbing medications. An epidural is similar to a spinal except that a catheter is inserted so that numbing medications may be administered as needed. Some women experience a drop in blood pressure when a regional anesthetic is administered; this can be countered with fluids and/or medications.
In some instances, use of general anesthesia may be indicated. General anesthesia can be more rapidly administered in the case of an emergency (e.g. severe fetal distress). If the mother has a coagulation disorder that would be complicated by a drop in blood pressure (a risk with regional anesthesia), general anesthesia is an alternative. General anesthesia is also used for some of the more complicated and prolonged obstetric and gynecologic surgeries.
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American Board of Obstetrics and Gynecology. 2915 Vine Street, Dallas, TX 75204. (214) 871-1619. <http://www.abog.org>.
American College of Obstetricians and Gynecologists. 409 12th St., SW, PO Box 96920, Washington, DC 20090-6920. <http://www.acog.org>.
Gynecologic Surgery Society. 2440 M Street, NW, Suite 801, Washington, DC 20037. (202) 293-2046. <http://www.gynecologicsurgerysociety.org>.
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Stephanie Dionne Sherk