Hello everyone. Today we are talking about the instruments used for dilatation and curettage. This is the closing part of the instruments that are generally used in obstetrics and gynecology, more specific in gynecology, in gynecology OPD in small procedures. I have mentioned dilatation and curettage, but it could be dilatation and evacuation, it could be endometrial biopsy also right and some OPD instruments.
this is for those undergraduates and post graduates for your table vivas where you need to pick up the instruments and speak about it okay now first of all what is the difference between dilatation and curatage and dilatation and evacuation that we need to know dilatation and curatage is a procedure in which it is a gynecology procedure where there is no pregnancy we want to just curate to scrap the uterine walls and take out the material either for histopathology or some other procedure like you want to see the menstrual phase but dilatation and evacuation the word evacuation means to take out products of conception there is something related to obstetrics so this is the difference dnc is gynecology dne is obstetrics okay so we'll start with the lecture on instruments first of all How do we perform this procedure? We perform it in a lithotomy position and we need to insert a speculum and catch hold of the cervix with a valsalum. So I am starting with valsalum, valsalum, valsalum okay.
It is a long forceps with grip where at the end you have three to four teeth to grasp the cervix well. and there is a curvature to fit into the curvature of the vagina. So, it grips the cervical lips to visualize the cervix. Vaginal hysterectomy, IUD insertions, OPD procedures, DNE, wherever you want to work on the cervix or through the cervix, you need to stabilize the cervix and hold it with the Valsalim. It has got long curved shanks with 3 to 4 teeth at the end, what we have already discussed.
This is a short video where you can see this is the curved thing and when we open there are teeth and it has got catches. Catch, cramp, crush. Now sims vaginal speculum. Sims vaginal speculum, this is your valselem, this is your double ended sims speculum, this is your single-sided speculum. All types of speculums are available.
Generally, we pick the speculum from the table with the anterior vaginal wall retractor because when you put a speculum, it retracts the posterior vaginal wall and for retracting the anterior vaginal wall, you need an anterior vaginal wall retractor. For that, we will be discussing about it. But whenever you pick the instrument from the table, make sure that you are picking a sim speculum with a retractor, not a lone sim speculum. So, it is a double bladed instrument. Mostly, you will find this is the most common variety.
where it could be used from both the ends. The width of both the ends is different for different sized vaginas. It retracts the posterior vaginal wall and used for examining vagina as well as cervix.
This is important because this is not a self-retaining speculum. You can adjust it and you can examine the vagina also and the cervix definitely. But alternative to this is a Cusco speculum about which I will be talking about in a short while. so this is how a sim speculum looks see the blade it is flat to put on the posterior vaginal wall sometimes you don't have the other blade so that even if the patient is not at the edge of the table you can do that this is a more closer look to a valsalum now this is a cusco speculum what is the difference between sim speculum and a cusco speculum it is a self-retaining speculum when you don't have an assistant and when you don't want to inspect the vagina you have to focus on the cervix also so what you do there are two blades and these are adjustable screws you can actually collapse the structure put it inside the vagina and then open it and then fix it with screws so the all the vaginal walls are retracted and you can see the cervix directly but definitely it is only for diagnostic purpose where you have to see only the cervix especially when you are taking a pap smear in your opd where there is no one to hold the speculum we are doing some iui procedures or you have to do some colposcopy will i you have to apply lugol sardine so just fix the cusco's there and then you can apply Lugol's iodine via visual inspection after acetic acid. So this is a self-retaining speculum used to visualize cervix and mainly for the OPD procedures.
You have to remind yourself these names because when you are speaking on a table you should be able to answer 1, 2, 3 procedures. Next is Hegar cervical dilator. Once you have visualized the cervix, you have catch hold of that cervix with a valselem, you need to dilate that cervix. Now these are the dilators.
These are long instruments, I mean long as such but short as compared to other dilators like Pratt dilators. Hegar dilator is relatively small, easier to handle because you can hold it in a pen holding position. It is a short dilator, round, tipped and curved. Very very important. The tips are round.
They are not pointed to create perforations. So whenever you are catching hold of your cervix with a Valsalum, you rest your three fingers on the perineum of the patient, catch hold of the dilator in a pen holding position and according to the curvature of the uterus, whether it is anti-flexed, retroflexed, this has got a curvature to match that flexion, right? and then you put it inside in a pen holding fashion. Normally the cervix is non-dilated. If you are conducting a DNE, that means the patient is pregnant due to some reason you have to remove the products of conception.
The dilatation is to be done plus 1 from the weeks of gestation. For example, you are conducting a DNE on 8 weeks pregnant woman, then you will dilate it till number 9, right? So these are for successive dilatation. Very very important terminology. You will not catch hold 8 number dilator and just put it inside.
It cannot be like that. It will create a perforation. There will be some trauma to the cervix.
So start from a low number 5, 5.5, 6 and then successively you keep on dilating, dilating and dilating. It is easier to use, less traumatic. It is held in a pen holding fashion. And it comes in various numbers. So according to your requirement, what size of uterus you are dealing with, dilate plus 1. A 10 week size uterus, dilate till 11. This is how it looks.
Curved structure, pen holding fashion, round tip, atraumatic. Now once you are through the cervix like external osseous open, internal osseous open and you are through the cervical canal. Now you have to put a suction cannula inside for evacuating.
This way you need to put a suction cannula. Now these suction cannulas come in reusable autoclavable forms from this or one time use, single use and throw away. So single use are generally of plastics or and reusable. They also come in different sizes.
So, if you are evacuating 8 week size uterus, you will dilate it till number 9, but you will put a cannula of number 8. So, the cannula size is always corresponding to the weeks of the gestation, but dilatation is plus 1 because we need a smooth movement of the cannula inside the uterus. So, it is used to suction out the uterine contents. See.
This way, this tip goes inside, it has got two holes and the material will come inside and that portion is attached to a suction tubing which goes to the suction machine. Now what is the, this is just out of the blue moon, that manual vacuum aspiration syringe is something. It is, it can be an OPD procedure which can be done with minimal anesthesia or sedation.
If you don't want to go for this suction cannulas and suction tubing a handy thing is available which is this a big syringe with cannulas. You can read 4 mm, 5 mm, 6 mm. So there are different size cannulas for different size uteri. Generally it is used to empty small uteri.
You attach it the cannula to this place and just do a syringing and pull out the contents. this is called as manual vacuum aspiration if you are not doing the conventional dne or suction evacuation so these are generally opd procedures for small size uterine it looks something like that the cannula is attached to the syringe the anterior lip is catch hold by a tenaculum or a valsalum and you just rotate it inside after creating a vacuum so that the minimal products of conception they come out ovum forceps once we have done the suction or sometimes you feel that something is stuck inside which is not coming out then we use a forceps which is known as ovum forceps ovum forceps is actually a misnomer we are not taking out any ovum but we call it as ovum because it tip looks like an egg that tip is like this it is hollow from inside so that the products can be catch hold and mind it there are no catches no catches because we don't want to disturb anything we don't want to traumatize anything so by in a closed fashion we enter inside the uterus we try to catch hold of things in a delicate fashion without traumatizing the uterus there is no catch so anything which is loosely lying inside the uterus will come out but anything which is tight and which is stuck somewhere will not come out so it is used to grasp hold and remove tissue from inside the uterus and it is delicately used Spoon shaped tip. The tip has spoons on both the sides and there are no catches.
So how you differentiate between this instrument and other instruments? An instrument with no catches is an ovum forceps. This way.
No catches. Easily you can open it. There is spoon on both the side. You go inside, fill the contents inside the spoon, close it and just come out of the uterus. Now once you are through, you feel that the contents have been taken out.
Now you have to be sure that whether the uterus is completely empty or not. So you want to scrap the uterine walls and feel the gritting sensation that yes, this wall is empty, this wall is empty. So we go inside with blunt and sharp curette.
But in this picture, what I want to emphasize is just look at the three things. These two things are curettes of different sizes. this is small tip this is broad tip but this third one is not accurate it is anterior vaginal wall retractor I have kept it here to make you people understand because on table many students get confused and they call it as curate because it looks like one but it is very thick broader very very broad and with serrations so that you can retract the anterior vaginal wall but the curate generally smooth and this edge could be blunt or sharp sometimes you feel that the uterine cavity is very soft you go for blunt scrapping or you can go for sharp scrapping according to your need so one end is blunt and the other is sharp it is used to scrap the uterine cavity generally removes POCs POCs means products of conception so you have done dilatation evacuation suction everything and you want to check out anything which is just stuck you just take it out or you are doing a blind endometrial biopsy you want to take a sample from the endometrium just scrap out the endometrium a little bit of piece and send it for histopathological examination anterior vaginal wall retractor this thing what i am talking about it is used along with sims speculum for proper visualization of the cervix so you put the sim speculum to retract the posterior vaginal wall and the anterior vaginal wall you retract from this thing See, this is retractor, so broad, so thick with serrations and this is curate, sleek with sharp and blunt ends. This one is even sleeker for smaller size uteri.
Just on table try and differentiate between these two structures. The last one I have kept just to finish off with the instruments, it is a uterine sound. It is generally not used in DNA procedures.
It may be used in prolapse, uterus, in vaginal hysterectomies. But how to identify it? It is a guitar shaped structure. This last thing looks like a guitar. This is a long stem like structure with markings.
Markings are of centimeters. So that you can, what do you mean by sound? Sound means going inside a tubular structure and seeing the length of it.
So measuring. It mainly measures the utero cervical length so once you are catching hold of the cervix you go inside slowly this has got a curvature here to match with the flexion of the uterus you go inside till the fundus and then you put a finger at the external loss so you can actually see what is the utero cervical length so if it is the utero cervical length it is your external loss your sound will go like this and then you can measure the total length Before insertion of any IUCD, you want to know at what level you want to stop or doing any surgery, you want to know what length you are dealing with. So, it is a guitar shaped instrument, curved at the end to mimic the uterine flexion, has markings of centimeters for measuring the length. It measures the distance between the external os and the uterine fundus.
This is important, not the internal os. because your finger does not go to the internal loss, external loss to the fundus, total utero cervical length. This is how it looks. Guitar shaped from down below and there are markings on it right.
from where you can see what is the actual length. With this I finish off the instruments. Thank you very much.