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Hello, Ron, welcome to this evening's tutorial on obstetrics and gynecology. Um Just before we begin, I'm going to pop a few polls in the chat, um which I'd ask if you can complete just while waiting um to begin. Ok. And just for these poles scale one is low confidence, low preparedness and scale five is like maximum knowledge, maximum preparedness. Mhm. Great with that will begin. Um So as I said this evening's tutorial is um on obstetrics and gynecology and this is part of an SSC five series covering surgically relevant anatomy. This evening, the tutorial will be delivered by myself, Jane and Kayla. Um Just a little bit of housekeeping. Please use the chat to ask any questions. This session is currently being recorded as well. So bear that in mind and the slides will be available on meal after the event. Um Be aware that the sites do contain sensitive content, although we will issue a warning before any graphic images are shown. Um And as I mentioned, please do fill in the polls in the chat with one being um the lowest ranking of confidence and five being the maximum ranking of confidence or preparedness. Um And also if you attend six of the eight sessions that will be running, you will get free student affiliate membership worth 15 lbs. And also just a reminder that this series is in collaboration with E SSS and aim as well. So please do follow our social media for that. Um In today's tutorial, we're going to be covering three main um operations in areas of obstetrics and gynecology, cesarean section, pelvic floor repair, and Hysterectomy. Um We'll be starting with a brief introduction to the specialty. I'll highlight some common specialty cases, then we'll work through each of the three cases and finish with some MC QS. So what is obstetrics and gynecology? Um Obstetricians deal with the more complicated pregnancies and births, unlike midwives who generally deal with uh the more straightforward births and they perform procedures such as Cesarean sections, which we'll see in today's tutorial and gynecologists deal specifically in women's health and treat women of all ages pregnant or not pregnant. Um And this could be anything from laparoscopic surgery to advising on fertility treatment. And this image here just highlights an overview of specialty training from the Royal College of Obstetrics and Gynecology. And I'd recommend seeing their website for further detail and this slide just covers some of the most common er cases in O ND. Um some of which we'll be covering today. Now, case one Cesarean section. So an obstetric case to begin with. Um Cesarean section is the delivery of a fetus through a surgical incision in the lower abdomen and uterus. And I'll be covering some of the indications for C section, the preoperative operative and postoperative management and the relevant anatomy as well. So, clinical indications for cesarean section can be classified as either elective or planned or emergency. And there's normally four categories used to stage indications. Categories 1 to 3 are emergency and category four is elective or planned. And you can see here some of the category four elective indications such as multiple pregnancy, previous C section. Um and these are usually planned after 39 weeks of pregnancy. And this is um to reduce the risk of transient tachypnea of the newborn. Um for which you'd also give IV steroids to the mother as well. And these three parts of the table show the emergency categories for cesarean section of um making the decision. And this is instances where there's an immediate threat of life to the woman or the fetus, such as if the umbilical cord prolapses or there's a suspected uterine rupture. Category two, you'd aim to deliver within 75 minutes. Um and this is where there's maternal or fetal compromise, but it's not immediately life threatening. And then category three, the least of the emergency um descriptions, there's no maternal for you to compromise, but you do really need to get early delivery for baby. And this just shows some of the epidemiology for um births in England specifically. And this data was actually renewed and released today um by NHS maternity statistics and it's shown over time, the proportion of births in England by Cesarean section has been increasing. And as of 2022 to 23 year, 23% of births were performed by C section compared to 43% by spontaneous which is decreasing and 33% induced, which is the same as the previous year that the study was taken. So, in terms of preoperative management for C section, as with a lot of surgeries, there are straightforward things you'd cover such as doing an FBC and a group and save um anticipating potential C section, blood loss, um which averages 500 to 1000 mL. You'd want to give an H two receptor antagonist which reduces the risk of a condition called Mendelssohn Syndrome, which is an aspiration of gastric contents into the lungs. Um You'd also want to calculate a risk score for E TVT E, which is um applicable to any surgical patient, but especially in pregnancy as pregnancy is a hypercoagulable state. So the risk increases, but there are other factors that increase the risk even more. And um there's mechanical um prophylactic for BTE such as antithromboembolic stockings that you can give and also medical such as low molecular weight heparin as directed by the risk score. Um before surgery or just at the start of surgery, you'd insert a foley urinary catheter to drain the bladder because as we'll see, um a big thing you want to avoid in C section is injuring the um bladder. And so, by draining the bladder, this decreases the size of the bladder and reduces that risk. And then of course, administering antibiotics. So, in terms of the operative approach, um you commonly use regional um spinal anesthetic. Um sometimes mums are put under general anesthetic, but this tends to be reserved for more um emergency or particularly traumatic situations. Um And in pregnant women in general, and this applies in the operating theater too, you do not want the woman to lie completely horizontal. Um Instead you want to have the woman on a slight left tilt. And this is because um beyond about 20 weeks of pregnancy, the weight of the fetus can compress um the aorta and vena cava as well. So putting them on, on a tilt, reduces the compression um and avoids potential hypertension or reduced cardiac output. Um The two types of skin incision you can use are phang or gel cohen. But most commonly you might see phal which is um almost a semicircular incision just above the pubic synthesis. Then you dissect down through the abdominal layers which we will explore shortly um through the visceral peritoneum. As I mentioned, you want to avoid perforating the bladder. So you use a retractor to move that out of the way. Um you incise into the uterus deliver baby while your helpful assistant applies firm fal pressure. And at this point, the anesthetist will help deliver IV Oxytocin to assist with placental removal. Um And then you close the uterine cavity in two layers. Um the rectus sheath with a running suture and the skin with a subcutaneous uh nonabsorbable suture. Although sometimes I've seen in operations as well, they will um suture up the uterus and other layers depending on how large the baby um is, how big the mum is and how complicated the surgery was and postoperative as well. You'd monitor observations, monitor lock, which is the normal vaginal blood loss, post delivery and ensure that there's no PPH postpartum hemorrhage. You'd encourage early mobilization to avoid increasing vte risk and most women will be discharged 2 to 4 days postoperatively and handled by their GP or community midwife in terms of complications. As I mentioned, postpartum hemorrhage is a big one, which is a blood loss of greater than 500 mils in the 1st 24 hours after um birth of the baby if it's a primary PPH. Um there's also other um complications such as uterine ane um injury to structure, such as the bladder or bowel, as I mentioned, VTE as I mentioned, um there's potential harm to the baby as well. Um And then later complications include things like infection, urinary trauma, um scar complications as well because you are making considerable scar with the pal incision. Um and different ef effusions or adhesions and um potential negative psychological sequelae because it is a slightly more traumatic experience for the mum sometimes compared to vaginal delivery. So now moving on to the gross anatomy of um uterus. Now, I will caveat this by saying on um complete anatomy. There aren't any images of a gravid or pregnant um abdomen or uterus. So for the purposes of just understanding where the uterus lies, this is um a non pregnant woman, but where applicable, I've included images of pregnant anatomy too. So just to visualize the uterus is normally located within the pelvis. As you can see, it's anterior to the rectum and immediately posterior to the bladder. So, in between those two structures and along with as pregnancy progresses, it increases in size around 20 weeks of pregnancy on abdominal palpation, the fundus or top of the uterus will be about the level of the umbilicus. And at term, it will be just below the zip sternum or your breast bone. And at that point, it's the most anterior abdominal organ. Now important as you're incising and dissecting through the layers to get to baby. Um These are the layers of the abdominal wall you're working through. So you start more superficially with the skin. Then there are two layers of um fascia that you reach er campus fascia, which is a superficial layer of subcutaneous tissue. And then beneath that scarps fascia, which is a deeper membranous layer. You have the rectus sheath which overlie the rectus abdominis muscles you can see here are two longitudinal muscles. Um So you often pull those apart and dissect between them. And beneath that you have the abdominal parietal peritoneum. Um And then you get to the visceral peritoneum. This just shows a transverse section through the layers and you can see um the skin and the rectus sheath just there. And then once you've incised through the layers of the abdominal wall to the visceral peritoneum, you get to the uterus. Now, the uterus is not normally green, but this is um how complete anatomy helpful shows and helps you distinguish the different layers of the uterus. So if it's green, that highlights the anatomy we're showing. Um so the outermost layer of the uterus is the perimetrium. Then deep to that you have the myometrium, which is the thickest mus, most muscular layer of the uterus. And then most deep you have the endometrium, which is the inner line of the uterus into which the placenta implants. Now, in terms of neurovascular supplying the uterus, the parasympathetic fibers of the uterus are derived from the pelvic splanchnic nerves which are shown here, which originate from S 2 S3 and S four, they arise from the uterovaginal plexus um which is a division of the inferior hypergastric plexus. And you can see the uterovaginal plexus just here. Um the afferent sensory fibers ascend through the inferior hypergastric plexus and enter the spinal cord at levels T 1011 12 and L1. And this just highlights the inferior hypergastric plexus here and relevant to our anesthetist as well in the room. Um when administering epidural anesthesia, such as for ac section, this provides therefore a nerve block to these fibers. Um and you can see at the level of L3 L4, the epidural needle is inserted and I'm briefly covering the main blood supply to the uterus. This is via the uterine arteries that you can see on the left here. These travel medially in the base of the broad ligament, which is just highlighted in green here which overlies the fallopian tubes. Um and they, the uterine arteries ascend along the lateral aspect of the uterus and anastomose with the ovarian arteries also. So now moving on to our patient case. Um So today, we are seeing Missus Sarah Ryan, who's a 41 year old pregnant female and she presents to the emergency department with a three hour history of sudden acute onset abdominal pain, which is now constant and she also has 30 minutes of vaginal bleeding, although this is only about 50 mils of blood loss and is presented as a bit of spotting on a sanitary towel. Um Her BP is low at 88/59 and her heart rate is tachycardic at 120 BPM. Um Important to remember, BP is slightly low at any rate during pregnancy, especially in the 1st and 2nd trimester. Um But in the third trimester, this normally increases slightly closer to normal and this is a low BP even in pregnancy. Um She has a preexisting medical history of eczema and hypertension, which importantly was there before pregnancy and hasn't arisen gestationally. Um her previous obstetric history, she is currently 38 plus two weeks gestation. She is a Gravida three Paris two, which means she's currently pregnant. Um She's had three total pregnancies, two previous vaginal deliveries. Um She's currently takes topical hydrocortisone for her eczema and she's on oral labetalol, which is one of the um two medications commonly used for hypertension in pregnancy. The other one being Nifedipine. Um if the patient's asthmatic, um she's a current smoker and has 15 pack years and has continued to smoke through pregnancy and she occasionally uses cocaine although it has been advised against this. Uh So in the ed A CTG, um which is uh measures the fetal heart rate and also the contractions around the uterus is performed and this shows fetal distress and a clinical diagnosis of placental abruption is made placental abruption. If you remember, there are four categories of indication for C section, placental abruption is category one, which means that Mrs Ryan needs an emergency C section in the next 30 minutes. So now we head to the operating theater. Um and firstly, you are faced with er a surgical scrubbing sink and you note that you have, er, quite sensitive skin a bit like Missus Ryan, you have a bit of eczema. And so you're wondering which surgical scrubbing solution is most appropriate to use? So I'm just going to pop a poll in the chat now. And if you can vote as to which scrubbing solution you should use. And based on the most folks, that's, that's the way we'll go. Right. So the current consensus is, um iodine. So if we go with the iodine, so you scrub your hands using the proper hand washing technique and don your surgical gown because iodine was the correct onset. Um If you have more sensitive skin, generally, iodine is preferable to chlorhexidine. Although I have heard some surgeons say that it's a bit like marmite. You either love or hate it. Some people do iodine, some people do chlorhexidine, but in general iodine is the one to go with and this is chlorhexidine, which you should not use because it would break you out in an itchy rash. So this is the surgical team you are presented with. If you were here last week, you'll notice it's the same team and remarkably, they're not only plastic surgeons but also O and G surgeons as well and we'll be meeting them throughout our operation today. So now, er, contact warning before the procedure starts. The scribbler nurse lets you know that you might see some things you haven't seen before blood and gore. Um So the operating theaters in which c sections take place are often warmer because that's helpful for baby when they're born. And so you might start to feel a bit woozy if you need to pop out of the theater at any point and grab a snack or drink and log on, log off this er, tutorial temporarily. You are absolutely ok to do so. So, Missus Ryan has now been anesthetized by our lovely anesthetist and is wheeled into theater where you help position her at a supine in a supine position with a left halt of 15 degrees. On the once the consultant is ready to commence the first incision, she turns to you to ask what type of incision should be performed for a Cesarean section, got paramedian pel or grill and I've just seen message in the chat about no sound if you're struggling to hear, I suggest just logging off the webinar and logging back in again. It's ok. So the overwhelming consensus is F ST so that is correct. And the consultant smiles and nods her head. Uh Pharyngeal incision is generally preferred to a more vertical incision. Reminder that pharyngeal is more semicircular. Um and that is because you are less likely to damage the placenta or rupture the uterus and generally it is less risky and women recover better so well done. So now, um we're dissecting through the layers of fascia, er the campus fascia, the scar is fascia. Um and you get to the muscular layer. The consultant is about to vertically dissect through the underlying muscle. So the surgical reg turns to you to ask, what is the muscle layer that lies just below the fascia? That's either rectus abdominis or pyramidalis. So that is an overwhelming response um for rectus abdominis so well done. It looks like you're all going to be budding obstetricians. Uh the consultant beams and says that's right. It is the rectus abdominis which goes down the middle of the abdomen to hold the internal organs in place each pair of muscles. Remember it looks like two strips separated by connective tissue known as the linear alba and a fibrous compartment called the rectus sheath, which lies superficially on top. So well done, the consultant continues with the surgery using bipolar diathermy to dissect through the rectus sheath and rectus abdominis muscles, the viscerous per visceral peritoneum is inside and a doyen retractor is used to protect the bladder because we do not want to injure the bladder. And you now have a clear view of Missus Ryan's gravid uterus. So I have another question, which is a free text, just typing in the chat. Er what is the most superficial layer of the uterus that you can now see and just for those interested on the image, um this retractor isn't one commonly seen in the UK. I think they use it in some other countries um called America, but this was a good image. I found to visualize the uterus but it's quite a funky looking lay retractor. Yep, just pop, pop a message in the chat. What is the most superficial layer of the uterus? You can now see great. I'm seeing some responses already and er you are correct. So the most superficial layer of the uterus is the perimetrium reminder we have the perimetrium, the muscular myometrium beneath and then most deep is the endometrium. So, a small transverse incision is made in the lower uterine segment um during which er the consultant delivers the baby while the surgical reg applies firm fundal pressure to help get baby out and the baby is born hooray. Um But we're not finished yet. We need to um stitch up this lady. Um So another free text answer if you pop in the chat, what two layers do we need? Do? Should the uterine cavity now be closed with? And what is the most appropriate suturing technique? For example, like sim simple or continuous interrupted and such spark in the chat seems a bit harder for those budding surgeons out there? Great. So I've seen some people say locking or continuous. Um and you're correct. So the first layer that you'd close is the rectus sheath, which is with a continuous or running suture. Um So just continuous like that with no breaks. Um And then after you've done the rectus sheath, you will close the skin. Um And this is with subcutaneous, nonabsorbable sutures or staples. So, subcutaneous because it helps make the scar look a bit nicer for the woman and it's nonabsorbable and typically the sutures will be removed at a later date by um the midwife or the GP in the community. So well done for answering that. Excellent. So we have successfully delivered um Missus Ryan's baby and she and her baby are off for recovery, but you are a very keen be um opposite Guyanese student and you see that there's a pelvic floor repair next. Um So what do we do? We are going to hit the books and we're going to learn about pelvic floor repair. So I'm going to hand over now. Do we give them a break now or in my case? Yeah, we could give a couple of minutes break if people would like that. I was hoping we could reach like 730. So it's just easier to keep time. But ok, so I'll give one or two minutes and then you hop on Kylo whenever you're ready. All right, Patrice, I won't be able to see the chat answers when I share my screen. Do you mind just shouting them out to me? Wood? Yeah, I can do that. Yeah, sounds great. Thank you. I guess is not sure we have. Can you guys see that? Yeah, that's good. All right, then we'll get started. Hi. Hi, everyone. Um I'm Kayla and today for this case, we'll be covering pelvic floor repair. So you might remember me from the last tutorial I covered um uh breast reconstruction. Um So it is a bit of a change of pace for me. So in this case, we'll be covering pelvic floor repair. It's common indications the anatomy of the pelvic floor and the pre peri and the postoperative considerations. So, the most common indication for a pelvic organ prolapse is a pelvic sorry. No, I the most common indication for a pelvic floor repair is a pelvic organ prolapse, which is where the muscles and ligaments of the pelvic floor are weakened, having lost their support structure, the pelvic organs and shift ie prolapse from their usual position into the vagina. So let's quickly cover prolapse first, talking about risk factors. So, risk factors include childbirth and pregnancy. As the pelvic floor muscles stretch and weaken the larger the baby, the more the muscles have to stretch and the weaker the likely to become um collagen abnormalities like Avis DDOS and joint hyper mobility leads to weak ligaments uh holding up the pelvic organs, menopause leads to reduced muscle, muscle bulk across the whole body, which includes the pelvic floor and increased intraabdominal pressure and heavy lifting against the pelvic floor. There may be iatrogenic causes like a hysterectomy which should be covering later which can damage the musculature and supporting structures. Now, with how the prolapse actually presents, it's usually asymptomatic and prolapsing organs itself don't actually cause pain. However, the patients may have this uncomfortable sensation of something coming down. And if the prolapse is large enough, it can impinge on the surrounding structures like the urethra and bowel leading to difficulty voiding or passing stools. Um, there may be ulceration where the prolapse is in contact with the patient's underwear and the friction then causes ablations and bleeding with management. If it's not bothering the patient, nothing has to be done. But of course, you'd want to counsel the patient on the different management options. Um So this would be often lifestyle advice, um such as weight loss and smoking cessation as well as pelvic floor, physiotherapy to strengthen the muscles and improve symptoms. Um particularly any associated urinary and bowel um bowel problems. Um A pessary is a device such as these that comes in many shapes and sizes that you insert into the vagina to provide artificial support. Just a reminder, it's not curative, but it does provide some symptom relief and you would also offer surgery, one of which is called pelvic floor effect. So we very briefly covered the risk factors presentation and management of relapse. Let's take a look at the relevant anatomy you needed for our case later. So to do this, um let's first cover the types of prolapse. There are several types depending on which part of the pelvic floor is weakened. The anterior compartment highlighted here in blue contains the bladder and urethra. So a urethral prolapse would be a urethra cele and a bladder prolapse, which is the most common is a cystocele. The apical compartment highlighted in green contains the uterus cervix and vagina. If the top of the vagina weakens and prolapses, that's a vault prolapse. And a uterine prolapse is uh is where the uterus prolapses. The posterior compartment highlighted in purple hair contains the rectum and the prolapse of that would be a rectocele. An enterocele is a prolapse of the small bowel up here, which may be in the apical or high posterior compartment and on which part of the bowel prolapses. So we'll quickly look at the pelvic, we'll quickly look at the pelvic bones which provide the framework for all the pelvic structures to derive a sport is the general overview from complete anatomy and it sorry it on the pubic synthesis here. That's just because complete anatomy wouldn't let me show this on the diagram for some reason, I'm sorry, that looks horrible. But here's some more in depth photos from from teaching anatomy. So the important bits that you need to know are the isi in green and the um pubis in yellow. So the pubis is made up, made up of the pubic body and the inferior and superior rami. Um Again, this is where the majority of the pelvic floor muscles, fascia and ligaments originate and insect. That's why they're so important for this part. There's also, as I said, this is the pubic synthesis here and this is the cartilaginous joint between the left and right pubic body. This stabilizes the pelvis and also allows the pelvic bones to separate during pregnancy because obviously, if there's a baby you need to get out. So looking at the musculature, there are three main components, the lobate a coccygeus and the fascia. These form a sling around the pelvic outlet and when contracted support the lower bowel genital tract and lower urinary tract. the coccygeus highlighted here um lies posterior to elevate and I this heart muscles and originates from the ischial spines, elevates, allies, compos of the pubertal, also called the pub uh Enis, the pubococcygeus and the ilio coccygeus. So the puborectalis and the pubic coccygeus originate from the posterior surface of the pubis. While the ilio coccygeus like the coccygeus originates from the is. Now, I've said before that it's the weakening of the muscles that predispose to a prolapse. But it's actually the defects in the fascia, the connective tissue resulting from the muscles weakening that leads to the prolapse itself. So, the vagina bladder, urethra and rectum are all covered and supported by this connective tissue. The urethra and the bladder are covered by the pubic cervical fascia. Um while the rectum is enclosed by the rectovaginal fascia, um bulging into vagina. Now, thinking of what I've said before about the types of prolapse, you can probably guess that the defect in the pubic cervical fascia would lead to a cystocele and urethrocele as in, as in a prolapse of the bladder and urethra. While a defect in the rectovaginal fascia would lead to a rectocele, the cervix and the uterus and vaginal cuff is supported by the cardinal and uterosacral ligaments. Uh defects in either of these leads to a uterine or a vault prolapse. The uterosacral ligaments anchor the cervix to the sacrum um and pelvic fascia. So while they're strong in young women with aging menopause and multiple deliveries, they stretch detach and weaken and therefore commit to a uterine or prolapse. The, the cardinal ligaments are thicker concentrations of the pelvic fascia and in circle the cervix. As you can see here to provide support, we fuse with the sacral ligaments poster to form this cardinal sacral cardinal sacral uterine complex. Again, somewhere along the lines of anatomy and o other important ligaments in this area will be discovered, uh will be discussed in the next case. So with the anatomy of the pelvic floor cover, let's meet our patient who is Missus Sarah Thompson, who's a 48 year old woman. She has a one month history of feeling something coming down and discomfort with leaking urine, on coughing, sneezing, and laughing and there's no relevant past medical or drug history. Um She has had three Children all together vaginally. She's up to date with her smears. Um you know, a a fine on that and she's also a competitive weightlifter. I think back on those risk factors and on examination, we found that she has a cystocele with no palpable bladder that's relevant because that shows she's not in urinary mutation. So we discussed the management options with her including surgery. She refused conservative management because she just wants it fixed for now. Um, and just to have the anterior vaginal wall repair after having been counseled on risks and benefits. So, as has been discussed before, you would do a preoperative assessment, ideally a few weeks before surgery to assess the patient's fitness of surgery. Um but on the day, the patient would fast to prevent aspiration of stomach contents. Um Thrombo, uh thrombo, prophylaxis, antibiotics to prevent infection, and then you would also drain the bladder because a full bladder will obviously be enlarged and get in the way of the structures that the surgeon needs to reach. These are the steps of the anterior vaginal wall repair which I'll talk about in a case. So I won't go into detail reading about here, but I've left it here for your reference and interest if you'd like to have a look through your slide later, postoperatively, as you'd expect with any surgery. Early mobilization is encouraged to prevent clots. Pain relief is given fluids to maintain optimum fluid balance and to aid healing and to prevent surgical wounds. Re opening. You would avoid any activities that would increase intra aimal pressure, like heavy lifting and prevent constipation with a good fluid intake and high fiber diet, complications can arise again as with any surgery. And this is usually patch from damage to surrounding structures like the bladder, the ureters and um the rectum if this was a posterior vaginal wall repair for a rectocele or the surgery, um may just have not worked collapsed. Surgery usually improves sexual function and would alleviate pain experienced during intercourse. But surgery can lead to vaginal tissue scarring and changes in vaginal anatomy, which could unfortunately just worsen the pain. So I hope at least some of what I've said has stuck cos now we're going to see Missus Thompson. But before we do, I do have to warn you again that you're about to see some images that you're not used to. So if you're feeling sick, it's ok to just stick this one out. So that let's head into theater. So we're all scrubbed in eager to observe. Mrs Thompson is under general anesthesia. And as a consultant, your gynecologist is performing the incision onto the anterior vaginal wall. She clocks you and says, so I've just started a vers incision down the vaginal epithelium. As the consultant dissects the epithelium, you notice a smooth glistening tissue underneath. She asks, taking into consideration that Missus Thompson has a cystocele, what tissue have I just exposed. And at this point, there should be some polls popping up and answers coming in and I'll just wait, I'm sorry, you're just going to have to read out what the most popular answer is, that's fine. No problem. I think people are just thinking at the moment I'll give it another. Oh, it was looking close. Oh, no, actually, yeah, that's good. That's what I like. I'll wait for one more. Let's get it to 10. Oh, people are hesitant. Oh, there we go. Oh, it's a tie between which ones I need to know between subepithelial, vaginal tissue and pubocervical. Oh, someone's just voted pubocervical fascia is the winner. That's ok. I'm going to talk about the both of them anyway. So this is fine. I'm I'm glad this was the outcome. So the correct answer is pubocervical fascia. So I'll just imagine that you all chose that. So the consultant not in approval and you feel validated. You can't wait to tell your mum about this. Excellent. It's the weakening of the pubocervical fascia that leads to bladder prolapse and the urinary incontinence. Therefore, this is the area we want to target for a native repair. But I'm sorry if we had chosen the subepithelial vaginal tissue, which I will talk about because it relates to something that's somewhat of a hot topic in gynecology at the moment. So this is the plane that you'd operate in if you were putting in a mesh. Now, because of complications associated with a mesh, it's no longer recommended by the NHS. And the UK is one of the few countries that just don't do mesh implants anymore because for a pelvic floor repair, a large area of as much as needed. And if it's in the wrong place, you can be exposed to say the vagina, the bladder or the rectum and it's gonna damage those structures and put them at increased risk of infection. And that's why we don't offer it anymore. Oh, great. I love it all the time. So this might also be quite difficult. The consultant continues to dissect the vaginal epithelium away from the pubis of fascia bilaterally. Which part of the underlying pelvic anatomy do you dissect up to? So just think about those pelvic bones. This one is quite difficult as well. I'll just wait for one or two more responses. How is it looking? Is it close? There's uh a winner emerging. Um So it seems like pubic synthesis is the consensus? Brilliant. OK. Good. Is that everyone voted, not everyone but a decent number? OK. OK. So I can understand why I would choose pic Sims. And I'm sorry, this is a bit of a mean question and my case just has a lot of mean questions because last time, my tutorial work that was a bit too easy. I really wanted to test you guys. But the registrar stares at you in disbelief. The pubic synthesis is in the same axis as a vaginal opening, the width of the dissection wouldn't be nearly enough. So if we recall back to how the pubic bones um is aligned obviously, as he says, the pubic synthesis is just in line with the vaginal opening. So you would be dissecting up the way, but you wouldn't be, be dissecting laterally enough to give you enough tissue to work with. If that makes any sense. Alternatively, if he had chosen the superior pubic M I, this is the superior pro pubic ami. The overlying anatomy would essentially be, you'd be somewhere up in the suprapubic region of the abdomen, which is just a bit too much tissue to work with. And therefore, the correct answer would be the inferior pubic amide because you want to dissect laterally towards the um towards the inner thigh. This will give us this will give you enough space and tissue to close the vaginal mucosa but also limits the risk of trapping underlying tissue. It just depends on how much tissue dissected. Um um So you have a lot to work with, but you also don't want to dissect too much. Another difficult one. So the consultant begins to approximate the pubic of fascia while she's busy with the sutures. The be asks if Missus Thompson had a hysterectomy, what are the ligaments you would consider suturing to the vaginal cuff to prevent a post hysterectomy, vault collapse? I'll give you a hint what would be weakened if there was a vault relapse? And this one is just a free text answer. So you can just write them down. Someone said, Cardinal. Yeah. Yeah. Are there any more mister Steven. Not yet. I'll do it. Well, Carpine is one of them. I don't know if you guys can remember the other one. It's fine if you can't, I'll tell you in a minute and, oh, small set. The Masti lis. Not sure how you pronounce that. Ma I think that's the other word for, um, or could be getting this wrong. I'm so sorry. I think that's the other word. Cardinal ligaments. I'm not sure if you guys know James not, I think. Yeah. Yeah, that's, yeah, that's right. That's good. So yeah, you're right. It is the card ligaments, but also the uterosacral ligaments. So I know we haven't gone through hysterectomy yet and it's a bit of a mean question. But in a hysterectomy, the cardinal and uterosacral ligaments might be ligated. And if they're not reattached, that can lead to BT prolapse because if you remember at all from the previous lives, it's the cardinal and uterus sacral ligaments that provide the most support to the uterus cervix and vaginal cuff. Thank you for offering some answers guide. So, following approximation, oxide and the excess vaginal epithelium is trimmed by a quarter. The consultant then begins to approximate the vaginal wall. And as the operation comes to the close, the anesthetist appears over at you from her phosphor puzzle. Not that I'm doubting the consultant skills, but she's been operating in some pretty important structures, what investigation might we do to check their function if we were worried we might have damaged them again. A free answer. It's find you can't remember the name of the investigation, maybe because, um, you can write down what structure you would consider investigating and we can go on from there. Someone said urinary bladder, urinary bladder. Is that what you? Yeah, that's it. Yeah. So the bladder is what we would want to investigate because obviously with the Cystocele, it's a prolapsed bladder and if you're suturing, um and incising right above it, then of course, there is a chance that you might nick it. Um So we would investigate that with something called uh a cystoscope. So that's just a camera that you insert in into the bladder. So you can have a look inside and find where the surgeon might have injured the bladder. And this can be done during surgery when the patient is still on the. So that's a pelvic floor repair done. Missus Thompson is sent into recovery and just to summarize everything that we've covered. Um So we've talked about the most common indication for a pelvic floor repair, which is a pelvic organ prolapse. We've gone through the risk factors, namely anything that raises intraabdominal pressure, um clinical features and for the most part, prolapses are uh asymptomatic and the management is down to patient preference and how much the prolapse bothers them. We've covered pelvic floor anatomy, placing a good deal of emphasis on fascia and ligaments. And we've also talked about the pre peri and post opposite considerations for anterior vaginal wall repair. It's important to know that while pelvic floor repair has a good success rate, it may not always fix the problems that the patient is struggling with. And so with that, you look at the theater list and you see a hysterectomy next. So what do you do? You hit the books and you study up on hysterectomies? Cool. Um Shall we give people a couple of minutes? Um, just for a bit of a break and then I'll crack on with hysterectomy. Um, ok, cool. So, hi, Ron, my name is Jane. Um, and I'm gonna be talking to you our last case, which is Hysterectomy and that is the removal of the uterus. Um So I'm gonna be carrying a bit of the anatomy that would be relevant for a hysterectomy and then speak to you a bit about the stats involved in a hysterectomy and then go to a patient case. Um So first up a bit of anatomy. Um So, um, as you know, the uterus has got different parts to it. Um So the top of the uterus which has already been mentioned is called a fundus. Uh And then you've got the horn of the uterus on each side, which is called a Corno. And then you've got the body of the uterus and then the cervix, which is the lower part of the uterus which uh connects the uterus to the vagina and, and then just again, a bit of a recap in terms of where the uterus sits in the pelvis. Um so they have your uterus um and then anterior to that, you've got your bladder and between the bladder and the anterior surface of uterus, you've got um a full of periton called the vesical uterine um pouch. And then posterior to your uterus, you've got your rectum and again, between your rectum and the posterior wall of your uterus, you've got um another form of peritoneum called the pouch of Douglas and or the rectal uterine pouch. Um And then just later to your uterus, you've got your tubes or um and some ligaments, which I'll go into a bit more details in the next few slides. Uh and then superior to your uterus, you've got your broad ligament um and intestines above that as well. Uh And then just inferior to your uterus, you've got your cervix and your vagina. So, as mentioned, um we've got quite a few ligaments that help to support the uterus and helps to maintain its position um in the pelvis. Um So, the first one that I'm gonna talk about is the broad ligament. This is a double four peritoneum um that causes the uterus and pro uh help maintains its position in the pelvis, as mentioned. And then you've got um so this broad ligament attaches the uterus to the pelvic side wall. Uh And then the next ligament is the round ligament here. So you've got one on each side and that attaches the uterus um and then it enters the inguinal canal and eventually attaches to the labial mera. Um And then the next ligament here is the ovarian ligament. As you can see, it connects the ovaries to the uterus and it also contains uh the ovarian artery and vein. Um And then moving on from that, we've got the suspensory ligament of ovary or another name for it is the infundibular pelvic ligament. This is not to be confused with the oan ligament. So as you can see the oran ligament uh connects the ovaries to the uterus, whereas the suspensory ligament of the orry comes away from the uh from the ovary, sorry. And that attaches to the pelvic side wall. And then the last two ligaments have been mentioned in the second case earlier. So the, the, that's the cardinal ligament. Uh So it comes off from the cervix and the left fornix of the vagina and attaches to the pelvic sidewall. Um and then it also contains uh the uterine artery and vein. And then the last ligament mentioned is the uterus sacral ligament. And as the name suggests, it um attaches from the uterus to the sacrum. So those are all the important ligands to know for a hysterectomy moving on from that we've got blood supply to the uterus. And so the main blood supply and as obvious that it sounds uh to the uterus is the uterine artery and this is a bunch of um artery coming off from the internal I an artery. And to be precise, it's the anterior division of it. Um And as you can see in this diagram, the uterine artery then um kind of travels just below the broad ligament. Um and then uh it goes ascends up the lateral wall of the uterus. Um and then it also anastomose with the ovarian artery. And then if you follow the uterine uh uterine artery down, you can see that it gives off the vagina artery. And then in terms of blood, um kind of drainage of blood from the uterus. And so it the blood drains to the uterine vein and then eventually ends up in the, into the iliac vein. Um and one c kind of clinical relevant and anatomy and teaching point, I'd like to highlight here is um about the ureter. So, and the ureter actually kind of travels quite closely with the uterine artery. As you can see in this diagram here, it is approximately one cm to about 1.5 cm away from the uterine artery. And so in a hysterectomy is quite important for the surgeon to make sure that they can identify the ureter. And they usually try and feel for the urethra as well to make sure that when they are cutting the ligaments and clamping the uterine artery, they are not clamping and cuffing the ureter and by accident. Ok. So that's the anatomy out of the way. Um And then in terms of Hysterectomy, uh there are a few common indications for it um and listed on the slides here. Um But one thing I'd like to highlight is that um for most of these um indications, so things like fibroids, heavy menstrual bleeding, prolapse, endometriosis, p infection and chronic pelvic pain. A hysterectomy is not kind of your go to first line management option. You usually go for conservative or me management before you consider hysterectomy. But for things like a gyne malignancy or pre pre malignancy, then um usually a hysterectomy would be kind of your first line management. And, and then in terms of the actual process of like hysterectomy. Um So, in terms of pre op, I'm not really gonna speak into much detail about this cause it's pretty much a standard pre-op um assessment that you do uh as mentioned in the previous two cases. Um And then in terms of the operation itself, uh the patient would usually be put under general anesthesia. Um And then they'll lie in something called a lithotomy position and which is quite a common position to be in, in for any kind of gyne uh procedures. And then I'm just gonna run through kind of the steps involved in a hysterectomy just to, so that to help uh you guys kind of follow through with the case later on So what happens in theater is that once the patient has been put under a general anesthesia, the surgeon will perform a vagina examination and just to confirm the pathology and also to confirm the position of the uterus and, and then they'll cut open and the abdomen and then uh they will kind of use forceps to elevate the uterus so that it's easier for them to work around uh the ligaments and the artery and things like that. And then they'll kind of cut through the different ligaments starting with the round ligament, followed by the suspect ligament of the ovary and, and then they'll move away because the bladder is quite close to the uterus as you already know, and they'll move the bladder away from the uterus and, and then continue cutting um the uterine vel and then the re remaining ligaments. So your blood ligament, your card card ligament and also your uterus sacra ligament. Uh And then depending on whether it's a subtotal hysterectomy where the cervix is um preserved or a total hysterectomy where the cervix, cervix is also removed. So, depending on which type of hysterectomy, it is, uh you either separate the cervix from the uterus and take the uterus out or you separate the cervix from the vagina and take the uterus and the cervix out and then moving on to your POSTOP again, it's pretty much just standard POSTOP kind of um things that you look out for. And so I'm not really gonna talk into too much detail and the slides are there for you to refer back to later on, moving on to complications. Again, you can divide this into short term and long term complications. Common kind of short term complications for a hysterectomy would be risk of infection, risk of clot and risk of bleeding and risk of damage to surrounding structures. And for hysterectomy, it commonly be a bladder, the urethra or the bowel and just pain after the surgery, uh, around the site of incision. And then in terms of long term complications, um, you can get a prolapse so you can get, um, either your bladder or your, uh, bladder or the top of your vagina prolapsing down. Um, or you can get urinary incontinence either because of the bladder prolapse or because, uh, there's been damage to the pelvic nerve during the operation. Ok. So now we're gonna move on to the last bit, which is talking to a patient case. So we've got a patient here. Uh, Miss Adams who is a 36 year old lady presenting with very heavy periods and she's complaining that she's tired all the time and sometimes she's, she's got pelvic pain and constipation as well. Um, she first started her period at the age of 11. She's ever since then. She's, she's always had a regular cycle and she bleeds has, has a period for seven days. Um, every 28 days and her last menstrual period was a week ago. Uh she's never been pregnant before, no kids of her own. Uh And other than that, there's nothing really significant in her history. Um So after you take a history from a patient and you done to go on to perform some examination. So the first one you do is the abdominal examination and on examination, uh you can feel a mass in her pelvis and then you go on to do a vagina and a bal examination. And when you do this, you can feel that her uterus is actually enlarged, a bit irregular, a bit firm, but it's not tender. So you go on to do some investigations and so you do a urine pregnancy test which comes back negative. So, you know, she's not pregnant for sure. And then you do some regular bloods as well. And and there's nothing significant except for a low hemoglobin level, which kind of would be consistent with her history of heavy periods and feeling tired all the time. And most importantly, you do a transvaginal ultrasound and this shows a fibroid in her uterus. So um just a bit about fibroids, fibroids are kind of benign, smooth muscle growth and in the uterus. And as you can see in the picture here, there are different types of fibroids. So you can have fibroids growing within the myometrium and that's called intramural and fibroid or you can get a fibroid growing just below the perimetrium. That's the subserosal fibroid or a fibroid growing just below the endometrium. That's a submucosal fibroid. And then you've got a fibroid green on a stock and that's called pedunculated fibroid. And we, we don't really know what causes uh fibroids, but it's quite commonly seen in women in kind of their later year of reproductive years. So that's kind of between the age of 3050 it's thought to develop and grow and respond to estrogen. So kind of postmenopausal, you don't really, the fibroids tend to string or you don't really tend to see fibroids in a woman uh after menopause. Ok. So continue on with our case. And so what we know so far is that MS Adams has been diagnosed with a uterine fibroid and as I mentioned quite early on and you won't really opt for hysterectomy before trialing medications. So MS Adams has tried uh nsaids to help with the pain, a Mirena coid to help with the bleeding and the pain. And she's also tried growth hormone receptor ago agonist to try and shrink the fibroid and reduce the symptoms. But none of these uh medications have worked and actually her symptoms are getting worse and it's really affecting her day to day life. So what would be the most appropriate management plan? Well, because this is the case on hysterectomy. The next step would be a hysterectomy for MS Adams. And yeah, again, just to summarize you know, she's tried mega treatments which has not worked and symptoms getting worse and she doesn't plan to have a like have to start a family. So actually hysterectomy would, in this case would be a win-win situation for both Miss Adams and her, the medical team. Well, surgical team looking after her. So, and now Miss Adams have been wheeled into theater and you follow her into theater, you say hi to the surgical team and the consultant then walks up to you and ask what position should Miss Adams be lying in for a hysterectomy. So it seems like most people are going for a uh which is the correct answer. So, yeah, picture A is a lithotomy position. So that's when the patient is lying on your back with your legs kind of flex out like this. Um And it's again, quite a common position. U use in Gynae procedures. Um And then I'll speak briefly about the other option. So, option B, that's when the patient is lying on their side and this is a bit more common for surgery on the to and, and then option C is when the patient is lying flat with the operating hip to the up. And this would be common for upper abdominal surgery that's to help to kind of move other structures out of the way to uh increase your ac access to the upper abdominal area. Uh But yeah, you usually won't be in this position. For a pelvic surgery or lower abdominal surgery. Ok. So now before the procedure start the crap me again, let you know that you might see things that you've not seen before and it's fine to be feeling a bit faint and if you do feel free to just step out and that's completely fine. So now, MS Adam is prepped for surgery. Uh, the consultant makes a midline incision and then elevates the uterus, um and then starts looking for ligaments to cut. And the consultant then looks at you and ask which ligament is usually the first ligament to be cut in a hysterectomy. It seems like most people is going for round ligaments. So, yeah, the round ligament is the correct answer, well done. Um So you usually go for the round ligament first um and then just cut that first before you move on to cutting the next ligament, um which is actually the infundibular pelvic ligament or um another name for it su um ligament of the ovary. And and then uh in terms of the third option, uterus sacral ligament, just if you think about it in terms of anatomy, this wouldn't be the right answer just because it's u the uterus sacral ligament is kind of a bit more lower down and compared to the round ligament and the infundibular pelvic ligament. So, yeah, it would make sense to cut the round ligament and the infundibular pelvic ligament first before you go on to cut the uterus sacral ligament. OK? And then the consultant then moves on. And so now we've cut the round ligament and the infundibular ligament. And as she does that, she turns and look at you again and ask what structure should be identified and palpated for to avoid damage to this structure. When you're cutting the ligaments cool. It seems like most people are going for the third option, the ureter. Um So, yeah, that is correct. That is the ureter. Um So again, as mentioned previously, the urethra uh runs quite closely to not only the uterine artery but also to the unfund pelvic ligament. And so when you're cutting this ligament, it's very important that you feel for the ureter before you cut the ligament and uh just to briefly speak through the other two options. So bowel, although this would be a possible complication and doing a hysterectomy and it's not as common as a ureter injury and also bowel injury tends to be a bit more common. Um, in patients who previously had abdominal surgery before and because of adhesion and things like that, it makes the bowel injury more likely. But in Miss Aams case, she's, uh this is the first time having an a abdominal surgery. So it's less likely that she's gonna sustain a bowel injury from, from it. Uh And then the peroneal nerve, uh this is incorrect because it's kind of in terms of anatomy. It, it's not really near the area where the surgeon would be operating on. Uh But you can get a perinal nerve injury from a hysterectomy due to positioning of the legs. Um But again, it's quite, it's not that common. Ok. So now the operation continues and the consultant then moves away the bladder and separates it from the uterus. And just when you thought the consultant would be done asking you questions, she asked which peritoneal for do I need to dissect to separate the bladder from the uterus? Cool most people have one for the vesical uterine pouch, uh which is the correct answer. Um So again, just to recap, this is a double full of the peritoneum between the anterior surface of the uterus and the bladder. Um Whereas the first option, the pouch of Douglas, that's not the name for the rectal uterine pouch, which is the full peritoneum between the posterior surface of the uterus and the rectum. Ok. So, after removing the bladder from the uterus, and the consultant then continues to cut the uterine vessels and the rema remaining ligaments like the broad ligament card, cardinal ligament, and also the uterus sacral ligament. Um And because MS Adams is going for a subtotal hysterectomy, uh the cervix is done separated from the uterus and then MS Adams uterus is then removed. Um And then the surgical team then starts closing up with the operation. So MS Adams is now off to recovery and you look at the, the list and realize that that was the last case for the day. And because you're such a teen like student, you decide that you should cons consolidate your learning instead. So I'm gonna pass it over to be great. So I hope you've got a wee bit of energy left after three intense cases, you've just got a few short empty Qs. Um So if you can go on to next time, please, Jane. Uh first M TQ, what is the most superficial layer of the uterus, myometrium, perimetrium or endometrium? And then next side p change which of these muscles is not part of the pelvic floor, the iliococcygeus puborectalis or Ischiocavernosus. And then final slide please. Jane, which ligament pulls the uterus in the anteverted and antiflex position. Is it the broad ligament, the infundibular pelvic ligament or the round ligament? Let's give you a me time for those. Great and next slide, please, Jane, right. So today, um we've covered three major surgery and anatomical areas of obstetrics and gynecology with Cesarean section, pelvic floor repair, and hysterectomy. Um And before we finish, I think we'll each give a quick summary of key takeaways from our operations. So, from Cesarean section, I think the key areas to remember are the layers of the abdominal wall from superficial to deep. So the skin campus fascia, scarps, fascia, rectus sheath, um rectus abdominis muscles, visceral peritoneum, and then the layers of the uterus from perimetrium, myometrium and endometrium and remembering uh not to damage the bladder as well and to make sure you um retract that out of the way. Kayla, do you want to share a quick summary point from pelvic floor rep just some key point. Is it the fascia and the ligaments, the weakness in the fascial ligaments that actually leads to a prolapse, not so much the muscles itself. So just keep in mind the pubic cervial fascia for a urethrocele and a cystocele and the rectovaginal fascia for a rectocele. And of course, the sacral ligaments and the card ligaments for a uterine or B prolapse. If you remember that you're good, it's kayla and last comments from you, Jane. Yeah. And uh in terms of hysterectomy, um I guess for anatomy, it's important to know where the uterus sits and the surrounding structures. Um and also the ligaments that support and maintain the position of the uterus in uh the pelvis, namely the broad ligament round ligament, uh oran ligament, um infundibular pelvic ligament, the card ligament and uterus sacral ligament. And, and yeah, if you know those two bits of the mas for a hysterectomy and you should be gone. Great. Thanks Jane. Um and just to highlight some further resources as well. A big one is complete anatomy and I'd highly recommend this for medical students. It's, you can download it as an application on your computer as well. Um And it allows you to in a 3d plane navigate the human body and it shows different layers as well. So you could shower from the skin or go down to muscle, just show connective tissue. And it allows you to hone in on particular body parts. And um using the search function, you can highlight um particular areas of the body such as the brachial plexus. And it will um show you um arrows too relevant and ask me there and also a couple of websites in a textbook we'd recommend as well. Um Just so we can go to the last side, Jane. Um, that's the end of this um, tutorial this evening. Thank you everyone for joining. Um, I'll just pop a feedback form into the chat, um, which will also be disseminated out afterwards and if you can complete that, we greatly appreciate it and you'll receive a certificate of attendance upon completion. Um We've also got some time to answer any questions as well. If anyone has questions, please do pop them in the chat. But otherwise thank you very much for coming. I can't see any, any questions in the chat. So I think we'll leave it there. Um The slides will also be available after this tutorial and the final slide include it includes our references as well. Yeah. Thank you again, everyone for coming.