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Causes and management the reversible causes of cardiac arrest are denoted by the 4 "H"s and four "T"s Table fifty eight. In the pregnant patient, causes may be pregnancy-related or a results of conditions unrelated to pregnancy. In pregnancy, the more than likely causes of cardiac arrest are cardiac disease, hypovolemia because of sepsis, hemorrhage, or thromboembolism [4]. Other pregnancy-related causes embrace amniotic fluid embolism, drug overdose, anaphylaxis, intracerebral hemorrhage, and eclampsia [2]. Pregnant sufferers are more susceptible to hypoxic mind injury than non-pregnant sufferers because of a better oxygen consumption and decrease oxygen retailer. Delivering the fetus reduces oxygen consumption and improves venous return, thereby enhancing cardiac output by as much as 80% [1]. A perimortem cesarean section should be performed in women at greater than 20 weeks of gestation. Perimortem cesarean part should start at four min into the arrest, in order that supply has been achieved by 5 min [1�3,5,6]. Perimortem cesarean part ought to happen on the scene of the resuscitation, and tools (at least a scalpel and two cord clamps) must be instantly available on the cardiac arrest trolley. A classical incision is used because it provides faster entry to the uterus [1] however a transverse incision could additionally be used if the operator is more acquainted with this system [2]. Releasing the insufflating fuel usually restores venous return and thereby improves heart fee. Atropine or glycopyrrolate could additionally be given by the anesthetist to increase heart price. Less widespread causes embrace amniotic fluid embolism, drug overdose, anaphylaxis, intracerebral hemorrhage, and eclampsia. The affected person and her family may also want a debrief, and may require ongoing help. Documentation is essential; assigning a scribe through the arrest will help accurate documentation of events later. Cardiac arrest staff should be referred to as, and cardiopulmonary resuscitation must begin immediately. Deficiencies in provision of cardiopulmonary resuscitation throughout simulated obstetric crises. Case historical past 2: In preparation for a fibroid resection, the surgeon attempts to dilate the cervical canal to 10 mm, however is unable to advance past a dimension 7 Hegar dilator. In the presence of ongoing issue, an alternate approach for accessing the uterine cavity could must be considered and the energy of the indication for the procedure reviewed. Rather than persevering, the procedure could must be rescheduled after cervical preparation utilizing mechanical or chemical agents. Background Cervical dilatation to 10 mm and infrequently even as a lot as 12 mm may be essential for operative procedures corresponding to surgical handle ment of miscarriage, termination of being pregnant, and resection of submucous fibroids or the endometrium. The surgical devices need to move freely in and out of the uterus; a good or stenosed cervix will hinder the operation, and should improve the danger of complications. Dilatation of the cervix dangers traumatizing the genital tract; cervical laceration, "false passage" creation, and uterine perforation can arise leading to substantial bleeding and damage to adjacent constructions (Chapter 60). Application of a tenaculum on the anterior lip of the cervix may help to apply light traction to straighten the cervicouterine canal and scale back resistance to the insertion of a dilator or minihysteroscope. If the patient is awake, she must be warned in advance a couple of sharp sensation that always results from application of a tenaculum; very slow software of the tenaculum can minimize the discomfort. Cervical counter-traction Cervical dilatation Semiflexible and graduated "osfinding" probes or graduated rigid cervical dilators can be used to dilate the cervix. A good "acoustic window" may be created for the abdominal ultrasound by filling the bladder with 200 mL of sterile water or saline. Management Cervical stenosis If cervical stenosis is identified, a number of management steps may be taken. These embrace the appliance of countertraction by putting a tenaculum forceps on the ectocervix, probing of the cervical canal with a small dilator (preferably beneath abdominal Use of a 0� "endon" flexible or inflexible minihysteroscope can enable the operator to trace the cervical canal safely and assess any acute contortions in the canal. Diagnostic singleflow minihysteroscopy systems can be found, typically incorporating a 1.

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In an empty abdomen, the mucosa and submucosa are organized into numerous folds known as gastric - rugae (ru-je). Gastric pits receive secretions from gastric glands that stretch deep into the mucosa. Structure the abdomen could additionally be subdivided into 4 areas: the cardia, fundus, physique, and pyloric part. The cardia (closest to the heart) is a relatively small space that receives food from the esophagus. The fundus expands superior to the level of the cardia and serves as a brief lived storage space. Mucous neck cells, situated close to the opening to the gastric pit, secrete mucus to coat and defend the mucosa from the action of digestive secretions. Chief cells, positioned in the deepest parts of the gastric glands, secrete the digestive enzymes pepsinogen (inactive type of pepsin), gastric lipase, and rennin. Small amounts of chyme are released intermittently into the duodenum by the relaxing of the pyloric sphincter. These nerve impulses also, together with food in the abdomen and abdomen stretching, stimulate sure stomach cells to secrete a hormone referred to as gastrin. Gastrin is absorbed into the blood and is carried to gastric glands, growing their secretions (figure 15. Control of Gastric Secretion the rate of gastric secretion is controlled by each neural and hormonal means and is a good example of a positivefeedback mechanism. Gastric juice is produced constantly, however its secretion is significantly elevated every time food is on the means in which to , or already in, the abdomen. The sight, smell, or considered appetizing food, food in the mouth, or food in the stomach stimulates the transmission of Digestion and Absorption Food entering the stomach is totally mixed with gastric juice by ripplelike, mixing contractions of the abdomen wall. Gastric ulcers end result from persistent erosion of the alkaline mucus that coats the abdomen lining. Most recurring gastric ulcers are caused by an acid-resistant bacterium, Helicobacter pylori, which erodes the protective mucosa, permitting gastric juice to attack deeper cells. Treatment entails antibiotics to kill the micro organism and medicines to scale back gastric secretion. The pancreas is a small, pennant-shaped gland positioned posterior to the pyloric part of the abdomen. It is linked by a duct to the duodenum, roughly 10 cm distal to the pyloric sphincter. The majority of the cells throughout the pancreas secrete pancreatic juice, which is the digestive (exocrine) operate of the pancreas. Pancreatic juice is collected by tiny ducts that merge to kind giant ducts, which enter the pancreatic duct. The pancreatic duct extends the length of the pancreas and often varieties a smaller accessory pancreatic duct. The pancreatic duct joins with the bile duct the place they each empty their secretions into the duodenum. Their widespread opening is managed by the hepatopancreatic sphincter, which dilates to permit pancreatic juice and bile to enter the duodenum. The accent pancreatic duct allows pancreatic juice to enter the duodenum independently of bile (figure 15. Pepsin acts on proteins and breaks these advanced molecules into shorter amino acid chains called peptides. However, peptides are nonetheless a lot too giant to be absorbed and require further digestion in the small intestine. The gastric juice of infants incorporates two distinctive enzymes that help to improve the digestion of milk proteins and lipids. Rennin (ren-in) curdles milk proteins, which retains them in the abdomen longer and makes them extra simply digested by pepsin. Gastric lipase acts on triglycerides and breaks them into fatty acids and monoglycerides. Except for a number of substances such as water, minerals, some medication, and alcohol, little absorption happens in the stomach.

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Management of cardiac arrest the cardiac arrest staff should be referred to as, including an obstetrician and a neonatologist. Good-quality basic life support (chest compressions and ventilation) ought to proceed throughout the arrest. The 0� distal lens allows easier navigation of the cervical canal as a outcome of the course of view, with the cervical canal centrally visualized, equates to the Entry with a mini-hysteroscope Gynecologic and Obstetric Surgery: Challenges and Management Options, First Edition. It is essential to keep away from trauma and bleeding from the endocervical canal as this can impair the views and predispose to false passages and perforations. Slow advancement of the hysteroscope will allow the distension media to open up the canal, thus lowering resistance to the instrument and likelihood of cervical canal damage. As the hysteroscope is advanced, it is important to take notice of any turns and twists in the canal, because this information will be informative if blind dilatation is subsequently wanted. It could also be possible to suture if the bleeding vessel(s) can be seen immediately or after splitting the cervix to identify the bleeding vessel(s) [1]. A bleeding cervical or uterine artery branch also can trigger a hematoma that can prolong into the broad ligament. Intracervical vasopressin A randomized trial discovered that intracervical injection of 20 mL of dilute vasopressin answer (0. Resolution of the instances Case history 1 A thorough pelvic examination to consider the size and the position of the cervix and the uterus is needed. Gentle probing with a small dilator, os finder, or minihysteroscope (with saline flow turned on) can take away flimsy adhesions and establish the exterior cervical os. A concomitant pelvic ultrasound scan can present data on the location and axis of the cervical tract to facilitate these measures. Where the external cervical os is obliterated, slicing into the cervix beneath direct hysteroscopic vision should be undertaken. Deeper cervical excision to establish the cervical canal ought to rarely, if ever, be required and solely by appropriately experienced practitioners after different choices described on this chapter have been exhausted. Case historical past 2 Intracervical injection of dilute vasopressin may assist additional dilatation. Despite various remedial measures, it is probably not attainable to dilate beyond a sure diameter in some women. In such conditions, modifying the method to use smaller instruments or an altogether totally different strategy could additionally be essential. For small submucous fibroids, ablation utilizing bipolar electrodes placed down smaller diameter continuousflow operating methods (typically <6 mm) can be an various choice to resection. If the purpose of the procedure is to obtain an endometrial pattern, then ultrasoundguided transvaginal endometrial aspiration is an alternative option [3]. However, if the woman has a history of menstrual bleeds, then this means that she has an open cervical canal; inspecting her throughout menstruation might assist establish the os and the cervical canal. Gentle probing with a dilator, os finder or hysteroscope (with saline circulate turned on) might remove the flimsy adhesions identifying the exterior cervical os and canal. An belly ultrasound could be useful in helping to find the cervical tract and to decrease the risk of making a false passage. If these approaches are unsuccessful, the chances are the woman has a closed cervical canal. Often a cervical "dimple" is visible and this can be helpful to help information hysteroscopic scissors or bipolar electrodes, which can be utilized to reduce into the ectocervix revealing the cervical canal. Alternative approaches to facilitate entry to the endocervical canal can embody excision of a part of the cervix with diathermy knives [4], loops, or lasers [5]. These procedures ought to be performed by an skilled surgeon who ought to take particular care to not damage bladder, bowel, or blood vessels. If bleeding continues regardless of these measures, then placement of one or two cervical sutures will often resolve the problem. Be ready Liaise with the operating room workers, and make sure the following are available on the day of operating: minihysteroscope (3 mm), ideally with 0� distal finish; ultrasound machine with belly probe; small dilators, together with lacrimal duct dilators; semiflexible os finders; and smalldiameter instruments, corresponding to a 7mm resectoscope or a 5mm continuousflow hysteroscope down which 5 Fr scissors or bipolar electrodes can be used. Chapter fifty nine: Difficulty in Dilating the Cervix: Cervical Stenosis and Cervical Closure 185 Cervical preparation There is some evidence that misoprostol can soften the cervix and help cervical dilatation. A typical routine is four hundred g of oral or vaginal misoprostol 12�24 hours before the process [6]. A single 2�4 mm diameter laminaria japonica inserted into the cervical canal on the day before surgery may additionally be effective in softening and dilating the cervix. In postmenopausal women, utility of vaginal estrogen for a month earlier than the process may enable simpler dilatation by reversing atrophic changes throughout the lower genital tract.

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Use of thermal, grasping or suction gadgets can cause harm to bowel, bladder, ureter, or major blood vessels. Uterine rupture in a future being pregnant is feasible and some authors have advised a low threshold for cesarean sections in women with a past history of uterine perforations [1]. Uterine perforation can lead to rapid accumulation of large volumes of distension media within the abdomen (Chapter 63). If the perforation includes the lateral uterine walls, then the risk of severe intra-abdominal hemorrhage must be thought of. A full evaluation of the bowel, bladder, broad ligaments, and ureters is required, and if essential assistance from common surgeons or urologists ought to be sought. The uterine perforation and any organ damage could be repaired by laparoscopy or laparotomy. Bowel harm could also be difficult to establish intraoperatively and postoperatively, and should only manifest 1 or 2 weeks later. Patients should subsequently be warned of danger signs (vomiting, abdominal ache, bloating, modified bowel habits, and fever) and instructed to contact emergency companies at once. Lateral wall cervical or lower uterine perforations Such perforations can lead to uterine artery harm and broad ligament hematoma. A laparotomy is needed if the affected person is unstable or if the adnexal mass from broad ligament hematoma continues to prolong (on ultrasound scan), and a hysterectomy may be necessary to avert catastrophic outcomes. Completion of the unique procedure When perforation happens will probably be difficult to obtain proper uterine distension, and thus non-urgent original procedures. The affected person may be reviewed later and plans may be made for alternative non-surgical options or rescheduling of surgical procedure after no less than 6 weeks to permit time for tissue therapeutic. Occasionally it may be possible to complete the operation with direct laparoscopic steering, after restore of the uterine perforation. Case historical past 2 Abandon the procedure, and administer broad-spectrum intravenous antibiotics. Perform laparoscopy or laparotomy to repair the uterine perforation and any bowel harm. Complete the termination of being pregnant with laparoscopic or laparotomic visualization of the uterus. Case historical past 3 the likely prognosis is injury of the uterine artery, and broad ligament hematoma is likely. Cervical preparation with prostaglandins or laminaria might help with cervical dilatation where difficulties are anticipated (Chapter 59). Difficult cervical dilatation and endometrial or fibroid resection are greatest carried out under ultrasound steering. Some use laparoscopic guidance in an effort to keep away from an harm throughout resection, however laparoscopy merely confirms an harm after it has occurred; ultrasound, however, may give contemporaneous details about uterine wall thickness because the resection progresses [2]. Transabdominal scanning requires an acoustic window and this could be achieved by filling the bladder with sterile saline [2]. Complex instances, for example a second-trimester surgical termination, should be performed by a senior surgeon. Non-surgical options, for example medical administration of terminations at superior gestations, may avoid many issues. Ultrasoundguided approaches are notably suited to surgical administration of miscarriages and terminations. Observe the patient for 2�4 hours; if the affected person is properly, she could be discharged, with clear directions on what symptoms ought to trigger her to seek medical review. The D&C can be rescheduled 6�8 weeks later and the utilization of cervical preparation with a course of native estrogen thought-about. Prevention � Risk assessment and pelvic examination for uterine size and place. Perforation with thermal, avulsion or suction devices � Abandon the procedure and give antibiotics. Management � Consider the likelihood and location of damage and any associated organ damage. Perforation with non-thermal and non-grasping instruments � Abandon the process. Lateral wall cervical or lower uterine perforations � If hemodynamically unstable, resuscitate the patient. A pelvic ultrasound identifies a miscarriage in preserving with a being pregnant of 10 weeks of gestation.

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Counseling ought to embody the small threat (approximately 1%) of conversion of myomectomy to hysterectomy should there be uncontrollable hemorrhage during surgery. Correction of anemia Many patients with a quantity of giant fibroids also endure with menorrhagia and are due to this fact extra more likely to have iron-deficiency anemia. On the day of surgical procedure the surgeon should ensure that there are blood products available. The selective progesterone receptor modulator ulipristal acetate 5 mg orally as soon as every day for 3 months has also been discovered to scale back the dimensions of fibroids before surgical intervention [11]. Ultrasound can be used to map the fibroids, but is of restricted value when multiple fibroids are current; in such patients, ultrasound provides poor views of the endometrium and deeper fibroids. Counseling It is necessary to provide applicable counseling about the advantages and dangers of surgical procedure. Immediate risks embody bleeding, blood the key step to surgical success is to achieve enough exposure. For a large a quantity of fibroid uterus, it might be essential to carry out a midline laparotomy. Some gynecologic surgeons insist that any myomectomy could be performed via a lower transverse incision. The method they suggest is to take away the decrease uterine fibroids first, and convey the higher uterus into view. The incision might end on the umbilicus or might need to be extended above the extent of the umbilicus relying on the scale of the uterus. After sufficient entry is achieved the uterus is usually exteriorized so that access to the entire uterus can be gained and a radical visible examination and palpation of all the tumors could be carried out. The bowel ought to be avoided the working site with heat moist massive swabs. Care must be exercised to avoid intravascular injection of vasopressin, and enough warning ought to be given to the anesthetist previous to injection. Some operators choose to also use mechanical means to cut back blood flow to the uterus. The use of intraoperative cell salvage also wants to be thought-about to scale back the requirements for heterologous blood merchandise [14]. Management Preoperative steps � Appropriate counseling about different therapies, risks of surgery, and consequences of myomectomy. Uterine incision the site and size of uterine incisions must be carefully considered. The incision must be made to permit for maximum access to as many fibroids as possible for enucleation; nevertheless, the incision must also be sited away from the fallopian tubes to reduce the chance of tubal damage. The orientation of uterine incisions can even reduce blood loss; it has been advised that horizontal incisions lead to decreased blood loss (by avoiding the uterine arcuate vessels) compared with vertical incisions [15,16]. Multiple incisions immediately over each fibroid can lead to higher adhesion formation; on the other hand, trying to attain multiple fibroids by way of a single uterine incision could cause higher bleeding due to the trauma of digital tunneling by way of the myometrium. Intraoperative issues � Adequate entry is vital; contemplate midline laparotomy. Choose incisions that permit entry to the utmost number of fibroids, but with out undue "tunneling"; use horizontal incisions if potential; keep away from incisions close to the fallopian tubes. Management of uterine fibroids in the patient pursuing assisted reproductive technologies. Role of vaginal sonography and hysterosonography in the endoscopic therapy of uterine myomas. A randomized comparision of vasopressin and tourniquet as hemostatic agents throughout myomectomy. Traditional surgical approaches to uterine fibroids: belly myomectomy and hysterectomy. Does pre- and post-operative metronidazole treatment decrease vaginal cuff an infection rate after stomach hysterectomy amongst women with bacterial vaginosis This level is commonly deeper than many operators count on and can be discovered by securing the fibroid with the myoma screw or tenaculum and advancing the incision deeper till the fibroid comes into view.

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This may be at the time of the first surgery or as an interval process, and would rely upon the condition of the patient, well being of pelvic tissues, intestinal viability, and the expertise of the working surgeon. If main surgical procedure is required to correct the first defect, definitive pelvic restore is best carried out as an elective process at a later date. Another advantage of a two-stage procedure is that it allows an intensive reassessment after full recovery to consider the necessity for any further surgical procedure, permits the decision of irritation and therapeutic of the tissues, and minimizes the chance of postoperative an infection. Management � Immediate management contains offering intravenous fluid therapy and broad-spectrum antibiotics, wrapping the bowel or eviscerated organ with moist saline packs, and arranging surgical restore. Enterocele formation submit hysterectomy could probably be avoided by a concurrent McCall culdoplasty. In view of the elevated risk of vaginal vault problems after total laparoscopic hysterectomies compared with other routes of hysterectomy, the following are some suggestions to consider [2]. Incidence and patient traits of vaginal cuff dehiscence after totally different modes of hysterectomies. During the insertion of the 5-mm secondary trocar in left iliac fossa the inferior epigastric vessels have been traversed. When the inferior epigastric artery is tough to visualize, intraabdominal landmarks can be useful (Chapter 38). Background Laparoscopic pelvic floor surgery may be sophisticated with port-site (Chapter 38) and other vessel bleeding (Chapter 76), damage to urinary bladder (Chapter 72), ureter (Chapter 73) or bowel (Chapter 74) throughout dissection and creation of retroperitoneal, rectovaginal and vesicovaginal spaces, in addition to varied different complications outlined in Sections 2 and four of this book. Perforation of the inferior epigastric artery will produce retroperitoneal or intraperitoneal bleeding. Perforation of the superficial epigastric artery will result in intramuscular or subcutaneous bleeding. Superficial epigastric artery Superficial circumflex iliac artery Inferior epigastric artery Deep circumflex iliac artery (b) port placement in the transverse (a) and coronal (b) views in relation to anterior belly wall vasculature. The presacral fascia covers and protects the underlying plexus, which consists of venous networks both on and beneath the surface of the sacral periosteum. Inadvertent manipulation may tear the fascia and cause damage of underlying thin-walled veins, which are devoid of valves. It is properly documented that typical measures for hemostasis are ineffective in managing presacral hemorrhage [2]. Bowel damage the incidence of bowel accidents at gynecologic laparoscopy is reported to be about 0. Approximately half of these injuries occur throughout entry [5�7], and the massive and small bowel are equally concerned [8,9]. The reported rates of intraoperative analysis of bowel injury range from 43 to 61% [10,11]. A massive meta-analysis of 28 research discovered that thermal injury to the bowel was the commonest explanation for non-entry-related bowel injuries. Bladder injury Inadvertent cystotomy has been reported in 4% of laparoscopic colposuspensions [15] and 2% of laparoscopic sacrocolpopexy, and could be recognized and repaired intraoperatively without sequelae [16�18]. Ureteric harm Ureteric accidents following pelvic floor surgical procedure are reported in 3% of circumstances [19,20]. Early recognition and remedy of ureteral injuries are necessary to forestall morbidity. It is necessary to not take away the offending trocar, as a result of this denotes the location of the injured artery, which can turn out to be troublesome to visualize as the hematoma spreads. The trocar can then be eliminated over the catheter, and agency traction must be utilized to tamponade the site; the catheter may be secured with an umbilical wire clamp in a single day. The first step is to apply immediate direct strain over the bleeding site using a small tampon gauze for 5 min. Packing has the disadvantage of reoperation for elimination of the packs, with the risk of rebleeding [21]. Trocar injury to the bowel mandates cautious inspection of the entire bowel to guarantee no through-and-through accidents have occurred. Small defects of the serosal or muscularis layers may be repaired utilizing continuous or interrupted 3-0 delayed absorbable sutures.

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Management affected person preparation the affected person was seen and examined by a gynecologic oncologist after which recommended collectively with a gynecologic oncology scientific nurse specialist. The imaging instructed that it might be attainable to get hold of total macroscopic clearance of tumor, so it was agreed that the affected person should be recommended a laparotomy with a view to primary debulking surgical procedure if the operative findings confirmed that complete debulking was achievable. The affected person was recommended concerning the risk of bowel surgical procedure, together with the formation of a stoma. Written consent was obtained and preparations have been made for admission for surgical procedure and for preoperative bowel preparation to be carried out at residence. Intravenous fluid infusion was instituted quickly after admission to be able to minimize dehydration introduced on by a mix of starvation and bowel preparation. This allowed easy access to the anus which might be required for using an anastomosis gun. The vagina and perineum have been ready with aqueous povidone iodine and the whole of the stomach prepared with alcoholic Hibitane up to and together with the lower thorax. A 10-cm midline incision was made under the umbilicus to permit an early assessment of the unfold of the tumor. A 25-cm diameter left ovarian tumor was found attached to the sigmoid colon and the left pelvic sidewall. There was disease greater than 2 cm in diameter involving the omentum, the sigmoid colon, the pelvic peritoneum, the pouch of Douglas, the peritoneum overlying the bladder, the uterus, and the tubes and proper ovary. Following mobilization of the splenic flexure, a complete omentectomy was carried out (Chapter 141). The pelvic peritoneum was incised on the stage of the pelvic brim and an extraperitoneal approach was used to determine the ovarian pedicles and the ureters. After the ureters were mobilized away, the pedicles have been divided between barely curved Zeppelin clamps. The proximal ends were doubly ligated first with a 2-0 Vicryl tie after which with a 2-0 Vicryl suture. The pelvic peritoneum was additional dissected, which included lifting it off the dome of the bladder because the bladder wall itself was not involved. It was apparent that the involvement of the sigmoid colon and the pouch of Douglas would require an anterior resection of the upper rectum and a sigmoid colectomy. Consequently, the sigmoid colon and the descending colon were mobilized up to and including the splenic flexure. The sigmoid colon mesenteric vessels and the sigmoid mesentery have been divided as a lot as the sigmoid serosa. The posterior part of the pelvic peritoneum was then mobilized Gynecologic and Obstetric Surgery: Challenges and Management Options, First Edition. The pelvic tumor was further mobilized by dividing the uterine vessels between barely curved Zeppelin clamps and ligating them with 2-0 Vicryl sutures. Care was taken to "skeletonize" these vessels in order that no pelvic peritoneum was included in the clamps, thereby performing an extraperitoneal hysterectomy. The cardinal ligaments had been clamped with straight Zeppelin clamps, divided and ligated with 2-0 Vicryl sutures. The anterior vaginal wall was picked up and incised between two Littlewoods forceps. The vaginal angles have been clamped with barely curved Zeppelin clamps and transfixed with 2-0 Vicryl sutures. The posterior vaginal wall was incised and the rectovaginal area was dissected and the uterus left hooked up to the rectosigmoid. The rectum was mobilized using a mix of diathermy and Roberts artery forceps to clamp lateral vascular pedicles, containing branches of the middle rectal arteries. When the wall of the higher rectum was clearly outlined by dissection, the rectum was divided just below the reflection of the peritoneum from the anterior rectal wall. The rectum was cut free with a scalpel, allowing the entire specimen to be removed. A figure-of-eight suture was inserted medial to each of the vaginal angles to ligate the vaginal vessels. The descending and transverse colon have been mobilized to ensure that the proximal finish of resected bowel would reach the rectal stump without pressure.

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Laparoscopy is carried out by open or closed method; a 12-mm primary trocar is inserted at the umbilicus, and a 0� or 30� telescope is launched, adopted by facet ports, which are inserted underneath vision. For open surgical route a traditional extended vertical midline incision from the symphysis pubis as much as halfway between the umbilicus and xiphisternal junction is carried out. The round ligament is recognized, cut and secured, adopted by opening of the broad ligament which is incised in a cephalad path lateral and parallel to the infundibulopelvic ligament. The obliterated umbilical artery is recognized and retracted medially to access the paravesical area, which is located between the bladder medially and the lateral pelvic wall [2]. The harvest is carried out alongside the nerves and vessels right down to their entry into the obturator foramen and up to the common iliac bifurcation. The fascia alongside the psoas muscle is incised laterally in order to avoid injury to the genitofemoral nerve, which is found over the muscle lateral to the external iliac vessels and typically overlying them. The lymph nodes are dissected from the lateral, entrance, and medial elements of the iliac vessels right down to the deep circumflex iliac vein, which is the inferior boundary of dissection. Then the vessels are retracted medially and the psoas laterally to remove the lateral lymph nodes. The lymph nodes medial to the inner iliac vessels are harvested, with attention paid to bleeding that can outcome from chopping uterine, vaginal, and superior vesical vessels. If the lymphadenectomy is prolonged to embody the widespread iliac nodes, then consideration ought to be targeted on the ureter which could be injured as it crosses the widespread iliac bifurcation at the pelvic brim. In addition, the peritoneum along the small intestinal mesentery must be incised from the ileocecal junction, passing through the sacral promontory as a lot as the duodenojejunal junction. The right ureter is then lateralized and the paracaval lymph nodes medial to it and the lymph nodes along the right ovarian vessels are dissected, with particular attention to the lumbar vessels that can cause troublesome bleeding. Dissection of the left para-aortic lymph nodes is extra challenging because the left ureter is closely related to the sigmoid mesocolon and the inferior mesenteric artery. The inferior mesenteric artery arises from the anterolateral side of the aorta on the degree of L3, and can be easily injured. The lymphoareolar tissue along the left ovarian vessels ought to be traced and excised as much as its insertion within the left renal vein. Meticulous and systematic surgical method is important to decrease the risk of complications. Key pointS Challenge: Pelvic and para-aortic lymphadenectomy in gynecologic cancers. It facilitates staging, offers details about prognosis, and determines the kind of adjuvant remedy. Prevention � Most of the lymphatic complications after surgery subside with conservative treatment. Management � Systematic full lymphadenectomy is preferred over selective lymphadenectomy for accurate staging of most cancers. Pelvic lymphadenectomy in cervical most cancers: surgical anatomy and proposal for a new classification system. Role of various approaches to the stomach retroperitoneum for lymphadenectomy in sufferers with gynaecologic cancers. Surgical options range from simple cone biopsy, trachelectomy, easy hysterectomy to radical hysterectomy. Factors that affect the choice of surgical therapy embrace stage, histologic kind, dimension of tumor, depth of tumor invasion, presence or absence of lymphovascular invasion, and future fertility wishes of the patient. There are various kinds of trachelectomy and totally different surgical approaches to the process. Trachelectomy might be simple or radical; easy trachelectomy includes supravaginal amputation of cervix, whereas radical trachelectomy entails elimination of cervix with the parametrium and vaginal cuff. This operation has subsequently been performed in other centers with comparable survival outcomes to the normal strategy of radical Wertheim hysterectomy. The shortfalls of this operation are the need for stringent case choice, and the lack of long-term follow-up knowledge on cancer recurrence, influence on fertility, and subsequent pregnancies.

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Write the names of the organs that match the capabilities in the spaces at the right. Functions of the Urinary System Indicate whether every statement is true (T) or false (F). Write the names of the constructions that match the statements in the areas on the right. Urine formation begins with 1, which forces 1) 2) 3) 4) 5) 6) water and diffusible solutes from blood plasma into the glomerular 2. As the tubular fluid strikes along the renal tubule, useful solutes are returned to blood in the three by four and sure solutes are moved from blood into the tubular fluid by 5. A decrease in the glomerular filtration price causes the 1 advanced to secrete 2, 4 mechanism. The which triggers the 3 end product of those reactions is 5, which will increase systemic blood stress by 6 arterioles, stimulating 7 secretion by the posterior lobe of the pituitary gland, and stimulating 8 secretion by the adrenal cortex. Urine formation depends upon maintenance of the blood strain inside the peritubular capillaries. Negatively charged ions and positively charged ions are electrochemically attracted to one another. The lively reabsorption of sodium ions will increase the rate of water reabsorption by osmosis. This reflex causes rhythmic involuntary contractions of the 3 and opens the involuntarily controlled 4 5 urethral sphincter. Characteristics of Urine Indicate whether each statement is true (T) or false (F). Electrolyte balance is basically maintained by the lively reabsorption of negatively charged ions. Buffers are chemical compounds in body fluids that either mix with or release hydrogen ions. The manufacturing of carbon dioxide by metabolizing cells tends to make the blood more alkaline. Kidneys help to regulate the pH of body fluids by secreting excess hydrogen ions into the glomerular filtrate. Water and electrolyte steadiness in physique fluids is essential for normal cell functioning. Aldosterone is secreted by the adrenal cortex when the focus of K+ in the blood is reduced. Electrolyte concentrations in the blood affect the motion of water into cells by osmosis. Atrial natriuretic peptide promotes the reabsorption of sodium ions and the excretion of water to decrease blood quantity. Disorders of the Urinary System Write the names of the issues matching the statements within the spaces at the proper. She can be suggested to take a 30-minute walk every morning and afternoon and to elevate her ft greater than her head for 20-minute intervals morning and afternoon. Trace the trail of sperm from a testis to the external surroundings by putting the numbers of the ducts within the spaces below. Male Sexual Response Write the phrases that complete the sentences within the areas at the proper. Sexual stimulation causes 1 nerve impulses 1) that stimulate 2 of the arterioles and 3 of 2) the venules serving the erectile tissue in the penis. At the same time, the 5 glands secrete an alkaline fluid that neutralizes the 6 of the 7, urethra. Continued sexual stimulation leads to 3) 4) 5) 6) 7) 8) 9) which is characterised by a sensation of sexual pleasure and 8, the forcing of 9 out the urethra. In the area under, report the numbers of the features which are the male secondary sex characteristics.