Gynecologic Sys..

In the majority of instances, no douches are used over a prolonged period. The symphysis, perineum, and adjacent surfaces are not shaved or clipped carefully before operation. A cleansing enema is not necessary. Prophylactic antibiotics are administered.

Light general or intravenous anesthesia may be employed. Saddle-block or low spinal anesthesia is very satisfactory.

Vaginal procedures are carried out in the lithotomy position. After the induction of anesthesia, the patient's legs are raised simultaneously to avoid straining the sacroiliac joints and are fixed in stirrups. Whenever possible, the legs are elevated upward and backward to permit the assistant to be nearer the field of operation. The patient's hips are lifted well beyond the margin of the table to provide better exposure, to avoid unnecessary wetting of the patient, and to make possible the later introduction of the weighted speculum. The operating table is turned so that the light falls on the field and is focused on the introitus.

The surgeon or first assistant, wearing sterile gloves, places a folded sterile towel over the patient's symphysis as a guide to the upper margin of the field to be cleaned and a similar towel under the buttocks. The vulva and adjacent skin areas are scrubbed from above downward with pairs of gauze sponges held in gloved hands. The gauze sponges are saturated with a solution of water and a detergent with germicidal action, such as a povidone-iodine–containing scrub. In all, five pairs of sponges are used, each being discarded as it comes in contact with the anus. The vaginal vault is cleaned with six saturated sponges held in long sponge forceps. Four dry sponges are used to remove excess solution from the vaginal vault. The cleaned skin is blotted dry with a sterile towel. The anus may be excluded from the operative area by the use of a spray-on adhesive compound and the application of a piece of sterile, transparent plastic film. The footboard of the operating table is raised to a convenient level and serves as an instrument table for the surgeon. A sterile, fenestrated perineal drape is applied, and the bladder is emptied by catheterization.

Adequate exposure is obtained by introducing into the vagina either a weighted vaginal speculum or a self-retaining retractor, depending on the type and location of the operation to follow. A thorough pelvic examination is made as a preliminary to the technical procedures.

After the completion of the operation, the vagina and perineum are cleaned with sponges moistened with saline or a mild antiseptic solution. A sterile perineal pad is then applied and held in position by a T binder. When constant bladder drainage is desired, a retention catheter is inserted and held by adhesive tape anchored to the thigh. The drapes are removed, and the legs are withdrawn slowly and simultaneously from the stirrups to prevent disturbances in blood pressure and straining of the sacroiliac joints.

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