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INTRODUCTION

Common gynecologic procedures include dilation and curettage, hysteroscopy, laparoscopy, and hysterectomy. This chapter will review these procedures, including indications, contraindications, technique, and complications.

DILATION & CURETTAGE

Indications

The procedure of cervical dilation and uterine curettage (D&C) is usually performed for one of the following indications: diagnosis and treatment of abnormal uterine bleeding, management of abortion (incomplete, missed, or induced), or diagnosis of cancer of the uterus. The diagnosis of abnormal bleeding is discussed in Chapter 39, and D&C as a method termination of pregnancy is discussed in Chapter 60. This section will discuss the remaining therapeutic uses of D&C.

Preoperative Therapy & Anesthesia

Dilation of the cervix may be conducted under paracervical, regional, or general anesthesia, depending largely on the indication for the procedure. Perioperative antibiotic prophylaxis is not recommended, but venous thromboembolism prophylaxis should be used in patients age 40 years and older or with additional risk factors.

Technique

A. Cervical Dilation

Cervical dilation usually precedes uterine curettage but may be performed in a patient with cervical stenosis prior to insertion of an intrauterine contraceptive device (IUD) or radium device for treatment of cancer. Dilation may also precede hysterosalpingogram or hysteroscopy.

The patient is placed in the dorsal lithotomy position, with the back and shoulders supported and the extremities padded. The inner thighs, perineum, and vagina are sterilely prepared as for any vaginal operation; the surgeon and assistant should adhere to surgical principles of asepsis. A thorough pelvic examination under anesthesia is mandatory prior to performing cervical dilation, in order to determine the size and position of the cervix, uterus, and adnexa and the presence of any abnormalities. The patient voids normally before the operation if possible; urinary catheterization is used only if significant residual urine is suspected.

A right-angle retractor is placed anteriorly to gently retract the bladder. A weighted speculum is placed posteriorly to reveal the cervix. Under direct vision, the anterior lip of the cervix is grasped with a tenaculum, avoiding the vascular supply at 3 and 9 o’clock. The cervix is grasped firmly but with care taken not to compromise, or perforate, the endocervical canal. With gentle traction, the cervix can be brought down toward the introitus. Before proceeding further, a complete visual examination should be made of the cervix and the 4 vaginal fornices, because the latter areas (especially posteriorly) are otherwise difficult to examine. Areas that appear abnormal (even benign inclusion cysts) should be noted and followed as appropriate. Areas that are clearly abnormal should be biopsied. After the cervix and vagina are evaluated, the uterine cavity is examined. A uterine sound is gently inserted into the endocervix and then advanced through the uterine cavity and to the uterine fundus, in the plane of least resistance and most ...

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