MODULE 6:

GYNAECOLOGY SURGERY
PRESENTATION
DATE: 07/08/2020
1
LEARNING OUTCOME:
In the end of learning session we will be able
1. Describe the pathophysiology (disease progress) of:-
i. Cervical Cancer
ii. Ectopic Pregnancy.
2. Explain the indication & instrumentation of hysterectomy through
abdominal approach
3. Explain the indication & instrumentation of hysterectomy through
vaginal approach
4. Explain the indication & instrumentation of hysterectomy through
laparoscopic approach
2
 5. Able to identify the indication for
surgical treatment of ectopic
Learning pregnancy.
Outcome 6. Able to list out the equipment and
instrument for the open and close
method for the ectopic surgery.
Learning Outcome: In end of learning
session we will be able to
7. Explain the patient & procedure consideration for
hysterectomy surgery.
8. Describe the patient and procedure consideration of
ectopic surgery.
 MODULE 5
GYNAECOLOGY
SURGERY
PRESENTATION
Group 5
NURZURAIN,
ELLISA , BEATRICE , OLIFIA, THEN

5
 Pathophysiology (disease progress) of:

1. Cervical Cancer

2. Ectopic Pregnancy

6
CERVICAL CANCER

• Cancer of the female reproductive system – affecting

the cervix
• Most often is squamous cell carcinoma
• 99% is due to human papilloma virus (HPV) & Herpes

7
PATHOPHYSIOLOGY OF CERVICAL
CANCER

8
9
1. Sexual activity (High risk factor)
2. HPV exposure – there is more > 100 types of HPV (high
chance of Cervical CA are; type 16, 18, and 31)
3. Virus enters in the basal layer of cervix – where it is begin at
cervical transformation zone typically in the immature
squamous epithelium
4. It will damages the genetic material of the cells (when this
infection lingers around the body especially the cervix, it is
called chronic infection)
5. May lead to pre cancerous changes in women 10
6. Invasions of the squamous cells refers to – the proliferation of
transformed cells and the progressive increase in tumour size
eventually leads to a breach in the barriers between tissues,
leading to tumour extension into adjacent tissue

11
Staging of Cervical CA

12
Risk factor
 Sex at young age
 Multiple sexual partners
 Smoking
 Depressed immune system
 Family history
 Long term use of contraceptive pills
 Having sex with the person infected with HPV

13
Sign & symptoms
 Abnormal vaginal bleeding
 Bleeding or pain after sexual intercourse
 Bleeding after menopause
 Heavier & larger menstrual periods
 Unusual vaginal discharge
 Discomfort while urinating
 Pelvic pain
 Leg pain
 Weight loss
 Constant fatigue 14
1. PATHOPHYSIOLOGY OF ECTOPIC
PREGNANCY

15
16
17
INDICATION & INSTRUMENTATION OF
HYSTERECTOMY
PREPARED BY GROUP 4: ELVY
KAMARIAH
LEE MEE CHIH
LORITA
NURHASMIZAH 18
Indications and instrumentation of
hysterectomy
- Abdominal approach
• The uterus is
removed through
an abdominal
incision and
opening of the
peritoneal cavity.

19
Abdominal Hysterectomy
Total hysterectomy – removal of the uterus and cervix.
• Sub-total hysterectomy – removal of the body of the uterus only,
leaving the cervix behind.
• Total hysterectomy and bilateral salpingo-oophorectomy –
removal of the uterus, cervix, fallopian tubes and ovaries.
• Radical hysterectomy – removal of the uterus and cervix, the
parametrium, a vaginal cuff and part of or the whole of the
fallopian tubes.
• This procedure is carried out in selected cases of cervical cancer.
• The ovaries may be removed or may be left behind, depending on the
patient’s age.

20
Female reproductive Total, subtotal and
system radical hysterectomy.
• The ovaries, fallopian tubes,
uterus, cervix and vagina (vaginal
canal) make up the female
reproductive system.

21
Indications of hysterectomy
Gynecologic cancer.

Fibroids.

Endometriosis.

Uterine prolapse.

Abnormal vaginal bleeding.

Chronic pelvic pain.

22
An abdominal hysterectomy may be
recommended over other types of
hysterectomy if:

1) Large uterus.

2) Check other pelvic organs for signs of disease.

3) If surgeon feels it's in the best interest to have an

abdominal hysterectomy.
23
Advantage of abdominal
hysterectomy
• Improves the quality of life and psychological
outcome, live saving in patient with malignant
lesion or severe hemorrhage
• Prevents uterine cancer growths in uterus.
• Relieves abnormal uterine bleeding which is
painful and distressing

24
Instrumentation- Abdominal
Approach
• Major procedures tray
• Abdominal hysterectomy tray
• Self-retaining retractor
⮚O’Sullivan O’Connor with 3 blades
⮚Balfour

25
 Abdominal Hysterectomy Tray
Specific Instruments
1. Long straight / curved
Kocher/Ochsne
2. Heaney-Balentine Forceps
3. Long Babcocks
4. Curved Phaneuf
5. Long Allis
6. Heaney needle holders
7. Curved Jorgenson scissors
26
Abdominal Hysterectomy Tray
8. Tenaculum 9. Myomectomy 5-mm corkscrew
(WISAP)

27
 Hysterectomy (Vaginal Approach)
1) Definition:
▪ Removal of the uterus through a surgical incision made
within the vagina and With a vaginal hysterectomy, the scar
is not outwardly visible.
▪ Also called as Vaginal Hysterectomy.
▪ Usually preferred approach for benign conditions, not as an
emergent procedure.

28
 Hysterectomy (Vaginal Approach)
) Most Common Indications :
2

▪ Abnormal or dysfunctional uterine bleeding

▪ Dysmenorrhea and/or dyspareunia of presumed uterine
cause
▪ Complex endometrial hyperplasia
▪ Symptomatic leiomyoma
▪ Symptomatic pelvic organ prolapse
▪ Cervical intraepithelial Neoplasia or micro invasive carcinoma
of the cervix. 29
 Hysterectomy (Vaginal Approach)
3)Contra-indications:
▪ Malignancy
▪ Extremely enlarged uterus
▪ Dense pelvic adhesions

4) Characteristics that can make the vaginal

approach challenging :
▪ Nulliparity (the condition in a woman of never
having given birth)
▪ Increased BMI
▪ History of pelvic radiation
▪ Lack of uterine descent 30
 Hysterectomy (Vaginal Approach)
5) Advantages :
▪ Provide the best cosmetic result , no scar.
▪ Faster recovery and return to normal activity.
▪ Shorter hospital stay
▪ Lower morbidity
▪ Less pain
▪ Less use of resources
▪ Less hemorrhage
▪ Safer
31
 Hysterectomy (Vaginal Approach)
6) Disadvantages :
▪ Blood clots in the legs or lungs
▪ Infection
▪ Damage to surrounding organs
▪ Adverse reaction to anesthetic.

7) Surgical planning:
▪ Informed consent
32
 Hysterectomy (Vaginal Approach)
Preparation of patient and procedure
1) POSITION

2) BLADDER CATHETER INSERTION

3) SKIN PREPARATION
• Raytex gauzes in 4% Chlorohexidine + 4% Isopropyl alcohol
concentration 33
Hysterectomy (Vaginal Approach)
Preparation of patient and procedure
4) DRAPING
• Including legging drape
5) SET:
• Basic Gynae Set
• Hysterectomy Set
• Paracervical & submucosal injection: 1 or 2% Lidocaine with
1:200,000
epinephrine or a dilute solution of vasopressin (used to help
decrease operative blood loss)
34
Hysterectomy (Vaginal Approach)
Preparation of patient and procedure
• Blade : BP Handle size 3 with blade Size 10
6) Special Instrument
Tenaculum Russian tissue Mayo Curve Scissor
Forceps

Dissection of full-
Use for stabilization Used for atraumatic thickness vaginal
and traction of the tissue grasping during mucosa from the
cervix and to dissection. underlying connective
decrease the flexion tissues 35
of the uterus
Hysterectomy (Vaginal Approach)
Preparation of patient and procedure
Lahey Heaney Clamp Glenner Clamp Heaney-Simon
Forceps Vaginal Retractor

To retract vaginal
To deliver the To secure the Utero
walls for
uterus in vaginal sacral ligaments,
visualization.
hysterectomy incorporating the
posterior peritoneum

36
Hysterectomy (Vaginal Approach)
Preparation of patient and procedure
Thumb Forceps with Auvard Speculum Sims Speculum
serrated teeth

For grasping, Keep vagina open so To open the vaginal

compressing, surgeon's hands free walls for inspection.
holding or for other tasks.
manipulating tissue
37
Hysterectomy (Vaginal Approach)
Preparation of patient and procedure
1)Placement of Tenaculum on Cervix &
injection of Hemostatic Agent
2)Cervico-vaginal incision,
dissection ,advancement of bladder
3)Entry into posterior Cul-De-Sac
4)Utero sacral ligament
clamping, transection, suturing
5)Entry into anterior peritoneum and
placement of retractor
6)Clamping, transection and suturing
uterine artery & round ligament
7)Double clamping of utero-ovarian pedicle,
transection, suturing, assessment of ovaries
38 and tubes
8)Hemostatic suturing
INDICATION AND
INSTRUMENTS OF
HYSTERECTOMY
Laparoscopic Approach

39
Laparoscopic Hysterectomy Approach
Define
⮚ Excision of uterus by laparoscopic
approach with varying components of
transvaginal manipulation and / or
intraoperative maneuvers.

Types of Laparoscopic Hysterectomy

i. Laparoscopic Approach
ii. Laparoscopic –Assisted Vaginal Approach

40
 Laparoscopic Hysterectomy Approach
Specific Indication
• Moderate prolapse of uterus
• Fibroids (30%)
• Endometriosis
• Cancer of the uterus, cervix, or ovaries
• Vaginal bleeding
• Difficult vaginal exposure
• Narrow suprapubic arch
• Adhesions
• A narrow vaginal space in a nulliparous women
• Adnexal masses (lump in tissue of the adnexa of uterus)
41
Advantages of laparoscopic Hysterectomy

• Less post-operative scarring

• Reduced pain, Shorter recovery time
• Less time spent in hospital to recover
• Reduced hemorrhage
• Reduced risk of exposing internal organs to external
contaminants
• Quicker return to normal activities
• Reduced wound complications
42
 Laparoscopic Hysterectomy Approach
.
1) O+G Laparoscopic set
2) Vaginal hysterectomy set
3) Abdominal hysterectomy set (Standby)
4) Catheterization set

❖ Requires two- procedure table

i. Laparoscopic portion
ii. Vaginal portion

43
 Laparoscopic Hysterectomy
Approach
Laparoscopic Portion Table
1. Verres needle
2. Trocar (5mm, 10/11 mm, 12mm, or Hasson)
3. ESU cord
4. Fiber-optic laparoscope, O ̊, and cord
5. Camera head and light source
6. CO2 insufflation tubing
7. Electrocoagulating probe
8. Babcock forceps
9. Maryland forceps
10. Endoscopic suture

44
 Laparoscopic Hysterectomy
Approach
Electrosurgical suction-irrigation-
Laparoscopic Bipolar Instrument
dissector

Endoscopic suture

45
 Laparoscopic Hysterectomy Approach

Hulkaclip Endoclip

46
 Laparoscopic Hysterectomy Approach

Specimen retrieval bag Disposable automatic stapler (For

intraabdominal cuff closure)

47
Laparoscopic Hysterectomy Approach
Morcellator Hysterectomy
Uterine Manipulator

48
Laparoscopic Hysterectomy Layout

49
50
Indications &
Instrumentation of Surgery
for Ectopic Pregnancy
i. Abdominal Approach
ii. Laparoscopic Approach
GROUP 3

Chai Min Choo

Aslinah Abdul Rahman

Follerinc John @ Florence

Shanney Yong

Victoria Anak Nawang Gayet

Indications for • not a suitable candidate for
surgical treatment medical therapy
of ectopic
pregnancy include • Medical therapy failed.
the following:
• heterotopic pregnancy
• hemodynamically unstable
INDICATION AND
INSTRUMENTS
FOR ECTOPIC
PREGNANCY
(ABDOMEN
APPROACH)
 Electrosurgical
unit (ESU)
Blade 20 or 10
Major set To incise the
subcutaneous
To incise the
As a basic needs tissue and deeper
initial skin
for open surgery. structure.
opening.
To clamp and ligate
the blood vessels.
 Deavers Retractor Richardson Allis Tissue
Retractor Forcep
To retract the soft
tissues, muscles, and Used to hold back
Used to hold or
other structures deep tissue grasp heavy
should be pulled aside structures / tissue / fascia and
for exposure of the retraction of wound soft tissues.
intended surgical site edges.
 Suction (tubing
and sucker tip)- Curved Artery Straight Artery
pool and yaunker Forcep (6) Forcep (2)

To clear all the Artery forcep hemostats

fluids and bloods
from the surgical To clamp and occlude the blood
site. vessels.
 Babcock Needle Holders

To fit around a tubular Used to grasp and hold

structure such as fallopian curved surgical needles for
tube or to grasp the tissue closure and approximate
without injury. the tissues.
(LAPAROSCOPIC
APPROACH)
Laparoscopic Ectopic
Pregnancy
Equipment for Laparoscopic Ectopic Pregnancy

Electrosurgical unit
(ESU)
Laparoscopic
monitor system
( 2D or 3D systems)

Suction Apparatus
with canister CO2 insufflator
machine
Basic Instrument

◦ Laparoscopic Instrument set

◦ General instrument set
◦ Sterile Basin
◦ S/B appendix set / BTL set
Consumables
items
◦ IV Drip Set
◦ Suction tubing
◦ Blade 11
◦ Active electrode monopolar pencil
( Standby)
◦ 10cc syringe (LL) x 2
-for aspiration test ( veress needle)
to establish pneumoperitoneum
- for LA
Consumables items
• Small Dressing ( x3)
• Steri-strip dressing
• Endopouch ( specimen bag)
• Surgical Clip ( different size )
• 0.9% normal saline ( 500mls or
3L)
Suture
• Monocryl 3/0 or 4/0
• Vicrly J-needle 2/0
Special instrument for laparoscopic surgery

Hudson trocar/ disposable

Telescope 0 degree or 30 Trocar ( 10mm and 5mm)
Gas Tubing degree ( 10mm and 5mm)

Maryland /Babcock/ Ultrasonic System :

Veress neddle
Grasphing forceps/ curved Harmonic scapel/ Ligassure
scissor scapel
 Special instrument for laparoscopic
surgery

Monopolar L-hook electrode

Diathermy cable
Bipolar laparoscopic
forceps

Clip Applicator : He-mo-lok Camera Head Fiber optic Cable

Special instrument for laparoscopic
surgery

Laparoscopic suction irrigation

Laparoscopic Needle
Holder (Curved/ Straight)
 Layout instrument

For Opening basic instrument Laparoscopic instrument

 Group 2
Suhainiza binti Dahalan
Azanwati binti Hassan
Gracie anak Kadoi
Senorita anak Limping

Patient & Procedure

considerations for
Hysterectomy Surgery
 Introduction

Abdominal Vaginal
Approach Approach
- Excision of the - Excision of the
uterus through an uterus via vaginal
abdominal incision. approach

69
 Generally

“
1 Emotional preparation
2. Anticipation-physical exposure, potential loss
of sexual function, infertility problem or
Introduction
termination of pregnancy
3. Patient- express concerns, ask questions &
receive reassurance & support

70
 Patient & procedure consideration for
hysterectomy surgey
Patient consideration Procedure consideration
1. Prevent the wrong patient, 1. Prevent cross contamination
wrong surgery done, and ▸ Combined approach -skin prep-
wrong side or site separate set up
▸ Identify pt correctly ▸ Isolate contaminated
▸ two consent instrument
▸ Time out ▸ dressing

71
 Cont...

2. Reduce patient anxiety 2. Prevent the delay progress

▸ explanation in surgery
▸ Blood product
3. Maintain patient privacy ▸ 2 suction unit
▸ expose only immediate
area

72
 Cont...
4. Prevent injury to the nerves, 3. Prevent contamination back
joints, and skin integrity when table
positioning the patient ▸ vaginal approach
▸ Padding ▸ vast for surgeon/assistant

5. Prevent post-op lumbosacral 4. Determining total fluid loss

strain (Lithotomy ) replacement
▸ simultaneously ▸ accurately record
73 ▸ Weigh
 cont...

6. Prevent cardiovascular 5. Prevent retained FB for

disturbances such as rapid patient safety
alteration in return. Abdo approach
▸ Slowly lowered & raised ▸ 3 count
the leg ( Lithotomy) ▸ removal of transvaginal pack
▸ slowly return to supine
( Trendelenburg's)

74
 Cont...

7. Prevent impairment of 6. Prevent urinary retention

skin integrity during skin resulting from swollen tissues
preparation around the operative site
▸ Document ▸ Abd(Pre-op)
▸ Assess ▸ Selected pt- via cystoscopy
▸ Vaginal(post-op)

75
 Cont...

8. Prevent patient’s 7. Prevent a reflux of urine that

discomfort on the table and could lead to UTI
lose body heat ▸ below bed level
▸ Monitoring
▸ Bair hugger
▸ warm fluid irrigation
▸ Warm pack

76
GROUP 1
PATIENT & PROCEDURE CONSIDERATION FOR
ECTOPIC SURGERY.

1. CASSANDRA ANN PAULUS

2. NORHAFIZAH STOH
3. DK NORSYAFINAZ
4. MIKE HENG
Definition Ectopic Pregnancy

◦ A fertilized ovum implanted outside the uterine cavity.

◦ 95% involved fallopian tube (Tubal Pregnancy)
◦ But also can developed in uterine cervix , on ovary or
intraabdominally.

(Philip,2017)
GOAL OF ECTOPIC SURGERY

1. to control bleeding, if present, and to

remove the ectopic pregnancy.
2. preservation of fertility in those patients
desiring for more children.
Patient and procedure consideration.
1.Operation will be done either laparoscopic / laparotomy.

Laparascopic for
Laparatomy for ruptured
unruptured
◦ Laparoscopic method is ◦ Salpingectomy usually
superior to laparotomy done in ruptured ectopic
method
and complete family
◦ Laparoscopic method
◦ Salpingotomy done in
needs to be considered as
a first option in unruptured unruptured ectopic and
ectopic. in patient desire to
◦ Laparotomy is best in the conserve her fertility
case of life saving as well
as with inadequate facilities
2. Patient will be put under General Anesthesia

3. Position :

Laparascopic Laparatomy
 laparatomy
4. Skin prepped
Laparascopic

(Abdomen, perineum & (Abdomen)

vagina)
5. Catheterization
Must empty patient’s bladder and to monitor urine output (to
prevent injury during trocar port placement-Laparoscopic)

6. Instrument / Set
 Laparoscopic ( Laparoscopic set , Minor set , Laparoscopic
system, D&C set, Uterine manipulator if needed)
 Laparotomy ( Laparotomy set )
7. ESU : Monopolar / Bipolar
Harmonic scalpel if needed.

8. GXM :- Ensure availability of blood product (Ruptured

ectopic)

9. Suction apparatus :Ensure standby 2 functioning suction

machine
Incase hemorrhage occur.

10. Record irrigation fluid : used to assist in determining blood

loss & fluid replacement needed.
86
 Conclusion by group 4

With the knowledge learned by the perioperative nurse, various illnesses and

operating method in Gynaecology Surgery knowledge and treatment can be

done well in providing care to the patient until she recovers from the illness

and surgery experiences for both patient and nurses satisfaction.

87
 Medical Therapy for ectopic pregnancy was implemented
so nowadays it has replaced by surgical therapy.
Conclusion Thus, management of ectopic pregnancy is consider a
by group 3 emergency surgical treatment.

So as perioperative team, we should prepare appropriate

equipment and instrument for the open or close ectopic
surgery to minimize the time of patient’s anesthetize and
shorten the time for surgery to improve surgery
efficiency.
 Conclusion by group 2

As a peri-operative nurse it is a vital for taking care of

the pre, intra and post operative patient and procedure
consideration in patient undergo for the hysterectomy surgery
either via abdominal and vaginal approach in order to keep
patient safety because patient safety is our priority .

89
Conclusion by group 1

◦ Ectopic pregnancy is common treatable condition.

◦ Perioperative nurse must be responsible and
accountable to all occurring during procedure
including the management of personnel
equipment, supplies and environment during the
ectopic surgery procedure.
 ▸ Q & A: (Group 5)

“ The pathophysiology
(disease progress) of:-
i. Cervical Cancer
ii. Ectopic Pregnancy.

91
 QUESTION 1 (TRUE/FALSE)

What can be happen to patient that have ectopic pregnancy?

A. Bleeding
B. Fresh vaginal spotting
C. Sharp and stabbing pain on lower abdominal quadrants.
D. Nausea and vomitting

92
ANSWER QUESTION 1

◦ A =TRUE
◦ B= FALSE
◦ C=TRUE
◦ D=TRUE

93
QUESTION 2

Which of the following is true about phase of cervical cancer, based

on the cervical intraepithelial neoplasia (CIN) and classed according
to it severity :
A. CIN 1 : HPV introduction phase
B. CIN 2 : Mild to moderate
C. CIN 3 : Severe to carcinoma in situ
D. CIN 4 : Carcinoma in situ
94
 Answer is - C

A. CIN 1 : HPV introduction phase × (Mild)

B. CIN 2 : Mild to moderate × (Moderate)
C. CIN 3 : Severe to carcinoma in situ √
D. CIN 4 : Carcinoma in situ × (This stage is non-exist)

95
QUESTION 3

Following are predisposing factors that can cause to developing

ectopic pregnancy, except for...

A. Webbing (fibrous bands)

B. Salphingitis
C. Pelvic Inflammatory Disease (PID)
D. Human Papillomavirus (HPV)
96
Answer is D

A. Webbing (fibrous bands)

B. Salphingitis
C. Pelvic Inflammatory Disease (PID)
D. Human Papillomavirus (HPV) -causing cervical cancer

97
 “
▸ Q&A: GROUP 4
▸ INDICATION &
INSTRUMENTATION
OF
HYSTERECTOMY

98
Question 1
Hysterectomy surgery can be done through which
approach?
a. Abdominal approach (T)
b. Vaginal approach (T)
c. Laparoscopic approach (T)
d. Thoracic approach (F)
99
 Question 2
Which specific indication for abdominal hysterectomy approach?

i. Large uterus (T)

ii. Check for other pelvic organs disease (T)

iii. Surgeon feeling of best interest for patient. (T)

iv. Narrow suprapubic arch (T)

100
Question 3
Which specific instruments required for Vaginal hysterectomy?

i. Uterine manipulator (F)

ii. Heaney-Simon vaginal retractor (T)

iii. Lahey forceps (T)

iv. Morcellator (F)

101
 “
▸ Q&A: GROUP 3
▸ Indications & Instrumentation
of Surgery for Ectopic
Pregnancy
i. Abdominal Approach
ii. Laparoscopic Approach

102
1. Choose the true statement regarding to the indication Surgery of ectopic
pregnancy.
A. Surgery is chosen as a treatment if medication is failed.
Answer : (True)
B. Surgery immediately will be chosen if there is ruptured and bleeding is occurred.
Answer : (True)
C. The surgery is done to remove the ectopic pregnancy.
Answer :(True)
D. The procedure is depending on the amount of bleeding and
damage and whether the tube has ruptured.
Answer: (True)
2. Which of these instrument are not related during
abdominal approach of ectopic pregnancy surgery?

A.Artery forceps
B.Right angle forceps
C.Wrigley forceps
D.Needle holder
Answer : C
3. As a scrub nurse what is the instrument do you
prepare to immediate evacuation of blood or fluid to
enhance the visibility of pelvic organ and structures
during laparoscopy surgery.
A.L hook, monopolar cable and ESU machine
B.Suction, tube irrigation and suction apparatus.
C.A non traumatic forceps
D. A telescope of 10 mm with 0 degree
Answer : B
 “
▸ Q&A : GROUP 2
▸ Patient & Procedure
considerations for
Hysterectomy Surgery

106
Q1 For the combined vaginal &
abdominal approach the sterile setup
must be separated are use?
a. True b. False
A1 True
3 closure count are taken for TAH are
a. At closure of the uterus
b. At closure of peritoneum
c. At Closure of vaginal cuff
d. At closure of the skin
A2 F,T,T,T
Q3 What is the action to be
taken to prevent post op
lumbosacral strain in lithotomy
position
A3 Both of the pt. leg to be
lifted simultaneuosly when
putting the legs in the stirrup
“
▸ Q&A: GROUP 1
▸ PATIENT &
PROCEDURE
CONSIDERATION
FOR ECTOPIC
SURGERY.
QUESTION 1

◦ What is the position for laparotomy ectopic pregnancy ?

A.Prone
B.Lithotomy
C.Supine
D.Reverse Trendelenburg
 Question 2

From which part should do the skin prep for laparoscopic ectopic
pregnancy ?
A. Abdomen.
B. Nipple line
C. Umbilicus site
D. Abdomen, perineum & Vagina
 Question 3
What other instrument need to prepare for
laparoscopic ectopic pregnancy ?
A.LSCS set
B.General set
C.D&C set
D.Jug
 References

Goldman M.A ( 2020) E-book pocket guide to the operating room fourth
Edition
Page: 282, 283, 284,296,297,314,315

Phillips N.M, ( 2017), Operating room technique, Berry & Kohn’s 13th Edition
Page: 673, 674

Rothrock J.C, ( 2019) Care of the Patient in Surgery 16th Edition

Page: 436, 437
117