Gynecology Topic 44. Gynecologic operation techniques (D&C, conization, hysterectomy, hysteroscopy)

I. Dilation and Curettage

Definition and Indications

• Dilation and curettage (D&C): Minor gynecologic operation where the cervix is dilated and endometrial tissue is removed by curette or suction.
• Diagnostic: AUB, postmenopausal bleeding, suspected endometrial hyperplasia/cancer, infertility evaluation, inconclusive endometrial assessment.
• Therapeutic: Stop excessive bleeding, remove small endometrial polyp, evacuate retained products of conception after abortion/miscarriage.
• Hysteroscopy-guided evaluation is preferred when focal intrauterine pathology is suspected.

Procedure

1. Anesthesia: General/IV sedation or paracervical block.
2. Dorsal lithotomy; bimanual examination to assess uterine size and position.
3. Insert speculum and grasp cervix with tenaculum.
4. Sound uterus to determine cavity length and direction.
5. Dilate cervical canal gradually using Hegar dilators.
6. Insert curette and scrape endometrium systematically, or use suction for retained products/miscarriage.
7. Collect tissue for histopathology and control bleeding.

Complications

• Uterine perforation.
• Cervical laceration; repeated/large dilation may contribute to cervical trauma.
• Hemorrhage.
• Infection / endometritis.
• Asherman syndrome: Intrauterine adhesions → Hypomenorrhea/amenorrhea + infertility.

II. Cervical Conization

Definition and Indications

• Conization: Excision of a cone-shaped portion of cervix including the transformation zone/squamocolumnar junction and endocervical canal.
• Diagnostic: Unsatisfactory colposcopy, discordance between Pap smear/colposcopy/biopsy, positive endocervical curettage, suspected microinvasion or glandular disease.
• Therapeutic: HSIL / CIN2-3, adenocarcinoma in situ in selected cases, selected stage IA1 cervical cancer when fertility preservation is appropriate.
• Corrected point: Stage IA1 disease here means microinvasive cervical cancer, not endometrial cancer.

Methods

• LEEP / LLETZ: Loop electrosurgical excision of the transformation zone; common outpatient method.
• Cold-knife conization: Scalpel excision; best margin assessment, useful for suspected glandular disease/microinvasion.
• Laser conization: Precise but equipment-dependent.
• Ablation/cryotherapy treats selected ectocervical lesions but gives no cone specimen.

Complications

• Hemorrhage, infection.
• Cervical stenosis.
• Cervical insufficiency/shortened cervix → Increased preterm birth risk, especially after deep or repeated excision.
• Pregnancy: Usually defer treatment until postpartum unless invasion is suspected; conization has bleeding and pregnancy-loss/preterm-birth risk.

III. Hysteroscopy

Definition and Indications

• Hysteroscopy: Endoscopic visualization of the endocervical canal, uterine cavity and tubal ostia; can be diagnostic or operative.
• Requires cavity distension, commonly with normal saline when bipolar instruments are used.
• Indications: AUB/postmenopausal bleeding, endometrial polyp, focal thickening, submucosal fibroid, infertility or recurrent pregnancy loss with suspected cavity pathology.
• Operative uses: Polypectomy, myomectomy, adhesiolysis in Asherman syndrome, uterine septum resection, removal of retained products/IUD/foreign body, endometrial ablation when fertility is not desired.

Contraindications and Complications

• Contraindications: Viable intrauterine pregnancy, active pelvic infection, severe medical instability; known malignancy only in planned oncologic evaluation.
• Complications: Uterine perforation, cervical laceration, bleeding, infection.
• Distension media complications: Fluid overload, electrolyte disturbance; gas embolism is rare.
• Thermal injury may occur during operative electrosurgery.

IV. Hysterectomy

Definition and Indications

• Hysterectomy: Surgical removal of the uterus; definitive operation causing permanent infertility.
• Benign indications: Symptomatic fibroids, adenomyosis, endometriosis, uterine prolapse, AUB unresponsive to conservative therapy, selected chronic pelvic pain/PID.
• Premalignant/malignant indications: Atypical endometrial hyperplasia/EIN, endometrial cancer, cervical cancer by stage, selected ovarian/fallopian tube cancer surgery.
• Obstetric emergency: Uncontrollable postpartum hemorrhage, uterine rupture, placenta accreta spectrum.

Types and Routes

1. Total hysterectomy: Corpus + cervix removed.
2. Subtotal / supracervical hysterectomy: Corpus removed, cervix retained.
3. Radical hysterectomy: Uterus + cervix + parametria + upper vagina; mainly selected cervical cancer stages.
4. With salpingectomy: Tubes removed; opportunistic salpingectomy may reduce ovarian cancer risk.
5. With bilateral salpingo-oophorectomy (BSO): Tubes + ovaries removed for adnexal/oncologic/high-risk indication or selected postmenopausal cases.

• Vaginal route: Preferred for benign disease when feasible, especially prolapse/mobile uterus.
• Laparoscopic/robotic route: Minimally invasive alternative when vaginal route is not feasible and safe.
• Abdominal route: Very large uterus, extensive adhesions, malignancy requiring open staging, emergency or complex cases.

Complications

• Bleeding, infection, wound/anesthetic complications, thromboembolism.
• Urinary tract injury: Bladder or ureter; also UTI/urinary dysfunction.
• Bowel/rectal, vascular or nerve injury.
• Vaginal vault prolapse after hysterectomy.
• If ovaries are removed before menopause: Surgical menopause → Vasomotor symptoms, osteoporosis and cardiovascular/metabolic considerations.