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Operative Care
Published in S Paige Hertweck, Maggie L Dwiggins, Clinical Protocols in Pediatric and Adolescent Gynecology, 2022
VaginoscopyPositioning is the same as examination under anesthesia, as these procedures are frequently performed togetherCystoscope or hysteroscope can be used to perform vaginoscopy; size should be based on the size of the child with 3–5 mm scopes for smaller children and 6–10 mm scopes for older patientsSterile saline is most frequently used as the distension mediaGentle pressure on the labia will occlude the vaginal opening and allow for vaginal distension and visualization of the vagina and cervix
Pediatric Hematocolpos
Published in Botros Rizk, A. Mostafa Borahay, Abdel Maguid Ramzy, Clinical Diagnosis and Management of Gynecologic Emergencies, 2020
Omar M. Abuzeid, Mostafa I. Abuzeid
During the premenarchal period, once the diagnosis is confirmed on vaginoscopy in girls presenting with excessive vaginal discharge as a result of a small communication between the two vaginas, the vaginal septum should first be incised to drain any fluid in the hydrocolpos. This should be followed by resection of the vaginal septum and approximation of the vaginal mucosa using 2-0 Vicryl sutures in interrupted manned to secure hemostasis [39].
Genital injuries in children and adolescents
Published in Joseph S. Sanfilippo, Eduardo Lara-Torre, Veronica Gomez-Lobo, Sanfilippo's Textbook of Pediatric and Adolescent GynecologySecond Edition, 2019
Bindu N. Patel, Diane F. Merritt
Blunt forceful penetrating vaginal injuries can include lateral vaginal wall and posterior fornix lacerations, and a tear may extend along the vagina and enter the peritoneal cavity, avulsing the cervix from its attachment to the vagina. This is called vaginal rupture, or colporrhexis, and while it is rare, examples have been described.6 In such cases, the bowel, omentum, or fallopian tubes may eviscerate through the laceration (Figure 9.6). These patients present with vaginal bleeding and may be at risk of morbidity or death from exsanguination if not properly diagnosed and managed. If it is necessary to inspect the vagina of a trauma victim and a standard speculum is too large for a prepubertal child or young adolescent, vaginoscopy may be done. In this case, it is important to monitor the fluid deficit to avoid filling the abdomen or peritoneal cavity with saline through an unseen laceration extension. Perforations into the rectum or peritoneal cavity mandate an exploratory laparotomy or laparoscopy to determine whether other structures, such as the bowel or blood vessels, have been injured. Rectal injuries above the sphincter may mandate need for a diverting colostomy, and consultation with a pediatric surgeon is warranted.
Hysteroscopy in postmenopause: from diagnosis to the management of intrauterine pathologies
Published in Climacteric, 2020
R. Fagioli, A. Vitagliano, J. Carugno, G. Castellano, M. C. De Angelis, A. Di Spiezio Sardo
The most important factors for the success of diagnostic hysteroscopy are adequate instrumentation and a proper technical approach. The Royal College of Obstetrics and Gynaecology (RCOG) guidelines16 recommend the use of miniaturized hysteroscopes (2.7 mm with a 3–3.5 mm diameter of the external sheaths) for outpatient diagnostic hysteroscopy, as they significantly reduce patient discomfort. Accordingly, Giorda et al. found that the use of a 3.5-mm-diameter hysteroscope was associated with lower pain compared to a 5-mm instrument, specifically in postmenopausal women17. The operator should cautiously insert the hysteroscope into the vagina and drive the instrument to the posterior fornix until the external cervical os is clearly visualized. This technique, known as vaginoscopy, or the ‘no touch technique’, allows the atraumatic insertion of the hysteroscope into the external cervical os, without the aid of a speculum or tenaculum. This method reduces patient discomfort, allowing completion of the procedure also in cases of severe vaginal atrophy and in most cases of cervical stenosis18,19.
An update on research and outcomes in surgical management of vaginal mesh complications
Published in Expert Review of Medical Devices, 2019
Dominic Lee, Philippe E. Zimmern
Failing conservative management, any mesh extrusion/erosion into the urinary tract and or debilitating pelvic pain requires mesh removal. Varying approaches have been described to address these particularly challenging surgeries depending on the degree of exposure and institutional experience. Our practice is for maximal mesh removal as the exposed vaginal mesh is likely to be infected in our estimation. Each patient is placed in the dorsal lithotomy position, prepped, and draped in standard fashion. A thorough vaginoscopy is performed to confirm the location of mesh in all vaginal compartments (Figure 6). Ideally, this should be marked with a marking pen. Cystoscopy is performed at the commencement of the procedure and where necessary ureteric stents are placed for identification. Efflux of urine from both ureteric orifices is confirmed. A Lonestar retractor, headlights, and a weighted vaginal speculum are utilized for optimal operative exposure. If the posterior compartment is affected, we will routine placed a betadine-soaked pack into the rectum to facilitate the identification and recognize an injury during mesh removal surgery. The incision will vary depending on the site of the mesh exposure or location of pain for which the mesh is being removed. Vaginal sulcus incision, apical incision, or broad-based U-shaped incision can be considered. The goal is to allow for dissection laterally to gain maximal access to the mesh arm(s); in addition, a large vaginal flap allows for easier tissue interposition later if required. Once the mesh is identified, dissection is carried out superficially to undermine the vaginal wall from the mesh, and then with the mesh placed on tension with an Allis clamp, dissection can be continued laterally into the paravaginal space using long scissors or a long tip bovie cautery to aid in hemostasis as the dissection progresses to free the mesh.
Hysteroscopic evaluation of tubal peristaltic dysfunction in unexplained infertility
Published in Journal of Obstetrics and Gynaecology, 2018
Burak Yücel, Emine Demirel, Sefa Kelekci, Osama Shawki
HSC was performed during the late proliferative phase (from 11 to 13 days of menstruation). Continuous-flow hysteroscope with semi-rigid instruments and size with an outer diameter of 5 mm were used. Vaginoscopy was performed immediately before HSC without using a speculum and cervical dilatation. Uterine cavity contours and tubal ostia were viewed. We used diagnostic sheath with inflow and outflow channels. When we achieved a good panoramic view, we closed the inflow and slowly injected highly concentrated (%10) methylene blue from inflow channel. Hysteroscope was moved closer to each side of tubal ostia (∼1 or 1.6 centimetre to tubal ostium) to observe the better rhythmic movements of tubal ostium and flow of the dye via ostium. The passage of fluid was visible by reducing the pressure in the uterus. Highly concentrated methylene blue does not mix immediately with the distending media (Normal saline with 0.9% of NaCl, 308 mOsm/L) and therefore it can be observed in a good flowing way. Bilateral tubal peristalsis was assessed with rhythmic movements of the tubal ostium and highly concentrated methylene blue’s transport via tubal ostia and tubes (Figure 1). Each tubal ostium was observed for at least three minutes to assess the transport of the dye. HSC procedures were performed without any anaesthesia or sedation just before laparoscopies in the operating theatre because the type of anaesthesia may affect tubal peristalsis. After completion of the HSC procedure, uterine manipulator was inserted for chromopertubation and laparoscopy LSC was performed with general anaesthesia. Subsequently, tubal patency was evaluated for both tubes laparoscopically, giving methylene blue from uterine manipulator in the study group and before tubal ligation in the control group (chromopertubation). In general, observation in LSC patients with endometriosis was excluded from the study. Finally, bilateral tubal ligation was performed with unipolar coagulation and dividing by laparoscopic scissor in the control group.