10: LAPAROSCOPIC COMPLICATIONS Flashcards
1
Q
Management of ureteral ligation injury
A
Remove suture
Assess viability
Place stent
2
Q
Management of ureteral angulation injury
A
Remove suture
Assess viability
Place stent
3
Q
Management of upper 1/3 ureteral transection injury
A
Ureteroureterostomy over stent
4
Q
Management of lower 1/3 ureteral transection injury
A
Ureteroneocystostomy with psoas hitch over stent
This ensures tension-free repair
In general - if injury is within 6cm of ureterovesicle junction, a ureteroneocystotomy should be performed
5
Q
Management of upper 1/3 ureteral resection injury
A
Ureteroureterostomy over stent
6
Q
Management of lower 1/3 ureteral resection injury
A
Ureteroneocystostomy with psoas hitch over stent
This ensures tension-free repair
In general - if injury is within 6cm of ureterovesicle junction, a ureteroneocystotomy should be performed
7
Q
Management of upper 1/3 ureteral crush injury
A
Resection and ureteroureterostomy over stent
8
Q
Management of lower 1/3 ureteral crush injury
A
Resection and ureteroneocystostomy with psoas hitch over stent
This ensures tension-free repair
In general - if injury is within 6cm of ureterovesicle junction, a ureteroneocystotomy should be performed
9
Q
Management of upper 1/3 ureteral ischemia injury
A
Resection and ureteroureterostomy over stent
10
Q
Management of lower 1/3 ureteral ischemia injury
A
Resection and ureteroneocystostomy with psoas hitch over stent
This ensures tension-free repair
In general - if injury is within 6cm of ureterovesicle junction, a ureteroneocystotomy should be performed
11
Q
Universal cystoscopy has increased intraoperative identification of ureteral injury from ___% to ___%
A
38% to 53%
12
Q
___% of ureteral injury is delayed, which increases morbidity
A
62%
13
Q
Post-operative ureteral injury symptoms
A
Unilateral cramping
Flank pain
Ascites
Retroperitoneal fluid collection
14
Q
Post-operative ureteral injury signs
A
Creatinine elevation (0.8mg/dL if unilateral)
Fever of unknown origin
Ascites
Retroperitoneal fluid collection
15
Q
Incidence of major vascular injury with LSC
A
1/10,000
16
Q
___% of major vascular injury with LSC that occurs at time of initial entry, ___% are not identified
A
> 50%
~25%
17
Q
If major vascular injury on LSC occurs, mortality rate is ___% with delayed diagnosis
A
33%
18
Q
Management of expanding retroperitoneal hematoma
A
Communicate
Direct pressure
Emergent vascular surgery consult
MLV laparotomy
AVOID CLAMPS/ELECTROSURGERY, OR OPENING RETROPERITONEUM (may increase size of vessel injury and lead to increased blood loss)
19
Q
Management of non-expanding retroperitoneal hematoma
A
Observe (pressure from pneumoperitoneum may tamponade hematoma, therefore pressure should be decreased and re-evaluate)
Inspect rest of anatomy for other sites of injury
Communicate
Proceed with surgery as planned if hemostatic and non-expanding
Re-evaluate
20
Q
Incidence of secondary port injuries
A
Up to 2%
21
Q
Management of injury to inferior epigastrics
A
Foley catheter through trochar and pull back for tamponade
Electrosurgery
Suture ligation (can use fascial closure device)
CONVERSION TO LAPAROTOMY SHOULD NOT BE FIRST STEP
22
Q
Incidence of GI injury during LSC
A
0.03-0.18%
23
Q
When do 50% of GI injuries occur during LSC
A
At time of LSC entry
24
Q
Most common part of GI system injured in LSC
A
Small bowel
25
Intraoperative recognition of bowel injury
Immediately examine prior to putting patient in Trendelenberg
Can tag area of concern with interrupted suture if needed
If injury noted, consider other abx for anaerobic bacteria
Run rest of bowel to ensure no other injuries
26
Small bowel injury management <2mm
Expectant
27
Small bowel injury management >/=2mm
Primary repair - perpendicular to the long axis of the bowel to avoid stricture/narrowing of lumen
28
American Association for the Surgery of Trauma (AAST) Grade 1 and management
Contusion or hematoma without devascularization, partial-thickness laceration
Primary repair in one or two layers; Transverse closure
29
American Association for the Surgery of Trauma (AAST) Grade 2 and management
Small laceration (<50% circumference)
Primary repair in one or two layers; Transverse closure
30
American Association for the Surgery of Trauma (AAST) Grade 3 and management
Large laceration (>/=50% of circumference)
Primary repair in one or two layers; Transverse closure
31
American Association for the Surgery of Trauma (AAST) Grade 4 and management
Transection
Resection and reanastamosis
32
American Association for the Surgery of Trauma (AAST) Grade 5 and management
Transection with tissue loss; Devascularized segment
Resection and reanastamosis
33
How to assess for small bowel injury
Run bowel from ileocecal junction (where appendix should be) to ligament of Treitz (duodenojejunal flexure)
34
Most common site of large bowel injury
Rectosigmoid colon
35
Describe air bubble test
To assess for large bowel injury
Inject air in rectum with sigmoid colon occluded proximally
Fill pelvis with fluid
Air in fluid will show site of injury for repair
36
Methylene blue enema for large bowel injury
Inject methylene blue in rectum with sigmoid colon occluded proximally
Dye will spill if injury, can identify site of injury
37
Rigid sigmoidoscopy for large bowel injury
Sigmoidoscope and obturator placed in rectum > remove obturator > insufflate air > when bowel lumen is seen, advance scope under direct visualization and inspect bowel
Remove air, then retract sigmoidoscope
38
Risk of perforation with rigid sigmoidoscopy
<0.1%
39
Floor of trigone
Detrussor muscle
40
Superior aspect of trigone
Ureteral orifices
41
Incidence of urinary tract injuries in GYN surgery
0.33%
42
Which approach is associated with highest rate of ureteral injury in GYN surgery
LSC
43
Incidence of bladder injury in GYN surgery
0.8%
44
Incidence of bladder injury in GYN surgery
0.3%
45
Location of most injuries in bladder
Posterior wall (location where bladder flap is created)
46
Recommendation if injury is close to ureteral orifices?
Consider placement of stents to minimize kinking
47
Recommendation if electrosurgery injury to bladder
Should excise edges to ensure well-vascularized edges present
48
Management if injury to bladder dome <1cm
Can do expectant management
Maintain indwelling catheter
49
Management if injury to bladder dome >1cm
Repair in two layers
Second layer incorporates muscularis, serosa, and parietal peritoneum layer
Maintain indwelling catheter
50
Presentation of unrecognized bladder injury
Vaginal drainage
Ileus
Oliguria
Ascites
Pain
Long-term: Fistula
51
General initial management of asystole/bradycardia in LSC
Stop insufflation
Deflate peritoneal cavity
Stop all meds contributing to myocardial depression
Administer 100% O2
Administer anti-cholinergic
Assess for cause
After r/o gas embolism, take patient out of Trendelenberg
Chest compressions if indicated
52
Incidence of gas embolism
0.0014%
52
Mortality of gas embolism
28.5%
53
Mechanism of gas embolism LSC
Veress inserted into vein or parenchymal organ
54
Signs of gas embolism
Decreased end-tidal CO2 > Hypotension > Cyanosis > Increased JVP > High arterial CO2 > Millwheel murmur
55
Management of gas embolism LSC
D/c insufflation
Stop all meds that cause myocardial depression
Hyperventilate with 100% O2
Maintain trendelenberg to maximize blood flow to brain and assist in central line placement
56
Incidence of SubQ/Pre-Peritoneal Emphysema
0.3-2.34%
57
Up to ___% of LSC patients have grossly undetectable subQ emphysema on post-op imaging
77%
58
Mechanism of SubQ/Pre-Peritoneal Emphysema
Pre-peritoneal insufflation
59
SubQ/Pre-Peritoneal Emphysema associated with ___ surgical duration and ___ intraabdominal pressures
>3hr surgeries
>15mmHg
60
Signs of SubQ/Pre-Peritoneal Emphysema
Skin crepitus
Hypercarbia (increased end-tidal CO2)
Cardiac arrhythmias
HTN
61
Management of SubQ/Pre-Peritoneal Emphysema
Usually expectant
Increasing O2 administration and ventilation rates can assist with evacuation of CO2
62
Incidence of pneumomediastinum/ pneumothorax
0.03% in LSC, though seen on CXR in up to 20% of patients
63
Mechanism of pneumomediastinum/ pneumothorax
Diaphragm defect (congenital or iatrogenic)
Ascending pre-peritoneal gas
64
Signs of pneumomediastinum
Emphysema in neck, face, or chest
65
Signs of tension pneumothorax
Cyanosis, engorged neck veins, increased airway pressure
66
Management of pneumomediastinum/ pneumothorax
Remain intubated until emphysema reduces
Pneumothorax - 100% O2, thoracostomy tube
67
Incidence of hypoxia/hypercapnia
0.002-0.003%
68
Mechanism of hypoxia/hypercapnia
Aspiration
CO2 absorption
69
Signs of hypoxia/hypercapnia
Hypoxia
High airway pressures
Bronchospasm
Gastric contents found in esophagus
70
Management of hypoxia/hypercapnia
Increase O2 concentration
Bronchodilators
PEEP
Decreased intraabdominal pressure
71
Incidence of vagal reaction
27%
72
Incidence of cardiac arrest
0.002-0.003%
73
Mechanism of vagal reaction
Distention of peritoneum or viscera causing vagal nerve irritation
74
Signs of vagal reaction
Bradycardia
Asystole
Hypotension
75
Management of vagal reaction
Deflate abdomen
Anti-cholinergic agent
76
Mechanism of diminished cardiac preload
Significant compression of vena cava (ex: gravid uterus, large uterus or adnexal mass, intraperitoneal pressure >40mmHg)
77
Signs of diminished cardiac preload
Bradycardia
Asystole
Hypotension
78
Management of diminished cardiac preload
L lateral tilt if uterus
Intraperitoneal pressure <15mmHg
79
Patient mortality rates if major vascular injury with LSC
9-17%
80
Definition of massive transfusion protocol
Administration of at least 10U pRBC within 24hr
81
Recommended ratio for massive transfusion protocol
1:1:1 pRBC/FFP/plt to prevent hemodilution and restore normal coag function
82
Presentation (in days) of intestinal perforation
24-48hr
83
Presentation (in days) of thermal bowel injuries, as well as mechanism
4-10 days
Causes a coagulation necrosis > weakening of the bowel wall > delayed lumen perforation
84
Recommended imaging for suspected bowel perf
CTAP IV + PO contrast
85
Management of bowel perforation
Bowel resection and re-anastamosis (margin of a few cm to include any area that may undergo delayed necrosis)
86
Mortality rate of bowel perf
20-50%
87
Sensitivity and specificity of CTAP w/ PO contrast for bowel injury
Sensitivity: 90%
Specificity: 98%
88
Post-op complications after bowel perf repair
Bowel obstruction
Bowel leak at repair site
Wound dehiscence
Repeat laparotomy
Parenteral nutrition if bowel function does not return quickly
Remote infection (ex: pneumonia)
Sepsis
ICU admission
89
Incidence of vesicovaginal fistula after hysterectomy
0.02%
90
Incidence of ureterovaginal and ureterosigmoid fistula after hysterectomy
0.02%
91
Presentation of fistula after hysterectomy
Urine/feces from vagina (often constant, worse with valsalva/standing)
Unexplained fever
Hematuria
Flank/vaginal/suprapubic pain
Abnormal urinary stream
Recurrent cystitis/pyelonephritis if present for long periods of time
92
Body fluid creatinine level if fistula
Elevated (typically in excess of 10mg/dL - this is typical of urine)
93
Dye test for fistula
Phenazopyridine PO, backfill bladder with NS stained with methylene blue
Orange tampon: Ureterovaginal fistula
Blue tampon: Vesicovaginal fistula
94
Imaging to identify entirety of renal collecting system?
IV contrast urography
95
Imaging for fistula
Cystourethroscopy
96
Non-surgical management for:
Vesicovaginal fistula
Ureterovaginal fistula
If small fistula that is identified early, prior to epithelialization of fistulous tract
VV: Foley cather
UV: Urinary stent for 4-8w
97
Timing of surgical repair for fistula
If healthy, repair immediately (within 48hr of initial surgery)
If delay in diagnosis, delay for 3-6mo because of inflammation
98
Definition of ileus
Mechanical dysfunction of GI tract (can involve stomach, small bowel, or large bowel)
Disruption of anterograde peristalsis
99
When does post-op stomach and small bowel normal activity resume?
Within 8hrs
100
When does post-op large bowel normal activity resume?
48-72hr post-op
101
Milestones showing normal return to bowel function
Tolerating normal diet, then flatus (occurs over several days)
102
RFs for ileus
Dehydration
Intestinal manipulation
General anesthetic
Narcotics
Immobility
Surgical complications (Ex: unrecognized injury, hematoma, abscess, peritonitis)
Electrolyte abnormalities
Diabetes
Chronic laxative use
103
Symptoms of ileus
N/V
Worsening pain
Absent flatus
Abdominal distention
Tympanic
Hypoactive bowel sounds
104
What to do if ileus >3-5 days
KUB to make sure there is not a mechanical SBO
105
Ileus on imaging
Intermittent air throughout GI tract, including large intestine and rectum
106
SBO on imaging
Proximal loops of small bowel with distention and air; No gas in colon
107
Treatment of ileus
Usually resolves with conservative management
Bowel rest - strict NPO
IV hydration
Electrolyte repletion
Physical activity (avoid)
Avoid narcotics
ERAS protocol (decreases rates of ileus and NG tube placement)
Chewing gum, coffee
108
Mechanism of port-site hernia
Longer the hernia is there, longer it is not able to be reduced - intestines become edematous, eventually resulting in constriction of mesentery and bowel hypoxia (higher risk for bowel perforation and necrosis)
109
Incidence of port-site hernia
0.21-3.2%
110
Risk of hernia at tissue-extraction site
7%
111
Estimated incidence of vagina cuff dehiscence
0.14-4.1%
112
Incidence of evisceration
0.032-1.2%
113
Mean time to presentation for vaginal cuff dehiscence
6.1w-1.6% following hysterectomy
114
Risk of vaginal cuff dehiscence per hyst route
TAH - 23%
TVH / LAVH - 26%
TLH - 58%
Other pelvic surgery - 5%
115
Precipitating event for vaginal cuff dehiscence
~70% spontaneous
8-48% after intercourse
16-30% occur after defecation or valsava
116
Most common symptom of vaginal cuff dehiscence
Pain (58-100%)
117
Second most common symptom of vaginal cuff dehiscence
Vaginal bleeding or watery discharge
118
% of vaginal cuff dehiscence that have evisceration
~70%
119
% vaginal cuff dehiscence that are asymptomatic
>50%
120
RFs for vaginal cuff dehiscence
Older age
Vaginal atrophy
Extensive pelvic or vaginal surgical hx
Poor wound healing (ex: malignancy, chronic steroid use, malnutrition, radiation therapy)
Valsalva
Infection
Hematoma
121
Prevention of vaginal cuff dehiscence
Cuff closure with monofilament suture
Minimal electrosurgery
Full thickness closure (include pubocervical fascia, mucosa, uterosacrals)
Vaginal estrogen if post-menopausal
122
Which repair approach to vaginal cuff dehiscence is superior?
NONE!
If evisceration present, cannot heal by secondary intention
123
How to repair vaginal cuff
Sharply debride edges until bleeding is achieved
Reapproximate with delayed monofilament suture
124
% risk of repeat dehiscence
4%
125
Indications for transvaginal repair of vaginal cuff dehiscence
Medically stable
No peritonitis
No bowel injury
126
Incidence of neurologic injury with LSC
1-2%
127
Most common nerve injury LSC
Lumbosacral or brachial plexus
128
Origin of femoral nerve
L2-L4
129
Pathway of femoral nerve
Passes inferolaterally through psoas, exits pelvis beneath inguinal ligament
130
Mechanism of femoral injury
COMPRESSION INJURY
Retractors
Hyperflexion
131
Femoral nerve injury symptoms
M: Hip flexion, knee extension, loss of patellar reflexes
S: Anterior/medial thigh and leg
132
Origin iliohypogastric/ilioinguinal nerves
T12-L1
133
Pathway of iliohypogastric/ilioinguinal nerves
Run laterally thorough psoas mm and diagonally along QL
134
Mechanism of iliohypogastric/ilioinguinal nerve injury
ENTRAPMENT OR COMPRESSION:
During lateral port placement or fascial closure
PLACE TROCHARS ABOVE ASIS
135
Iliohypogastric/ilioinguinal nerve injury symptoms
IH: Numbness over hypogastric and gluteal
II: Numbness over groin, inner thigh, labia majora
136
Origin genitofemoral nerve
L1-L2
137
Pathway genitofemoral nerve
Traverses anterior psoas, lies lateral to external iliac vessels
138
Mechanism of genitofemoral nerve injury
STRETCH, TRANSECTION, OR ENTRAPMENT INJURY:
During pelvic sidewall dissection, pelvic LND
139
Genitofemoral nerve injury symptoms
S: Numbness along mons pubis, labia majora, femoral triangle
140
Origin obturator nerve
L2-L4
141
Pathway obturator nerve
Passes over pelvic brim, behind common iliac vessels, enters thigh in obturator foramen
142
Mechanism of obturator nerve injury
STRETCH, TRANSECTION, OR ENTRAPMENT INJURY:
During pelvic sidewall dissection, pelvic LND, transobturator sling placement, paravaginal defect repair
143
Obturator nerve injury symptoms
M: Hip adduction
S: Numbness along upper medial thigh
144
Sciatic nerve origin
L4-S3
145
Pathway of sciatic nerve
Emerges from pelvis under piriformis > travels lateral and inferior through gluteal region
146
Mechanism of sciatic nerve injury
STRETCH INJURY:
Mainly from improper patient positioning
147
Sciatic nerve injury symptoms
M: Hip extension, knee flexion
S: Numbness along posterior thigh and leg
148
Origin common peroneal nerve
Sciatic nerve (L4-S3)
149
Pathway of common peroneal nerve
Mid thigh - passes over fibular head
150
Mechanism of common peroneal nerve injury
COMPRESSION INJURY:
During improper patient positioning
151
Common peroneal nerve injury symptoms
M: Dorsiflexion/foot drop
S: Numbness along lateral leg and dorsum of foot
152
Origin of pudendal nerve
S2-S4
153
Pathway of pudendal nerve
Exits pelvis through greater sciatic foramen, travels in close proximity to ischial spine, enters pelvis again through lesser sciatic foramen
154
Mechanism of pudendal nerve injury
ENTRAPMENT INJURY:
During sacrospinous ligament fixation
155
Pudendal nerve injury symptoms
Post-operative gluteal, perineal, vulvar pain that worsens with sitting
156
Origin of brachial plexus
C5-T1
157
Pathway of brachial plexus
Lies within posterior triangle of neck
158
Mechanism of brachial plexus nerve injury
STRETCH INJURY:
Improper patient positioning
Hyperabduction of arm, shoulder depression with shoulder blocks during trendelenberg
159
Brachial plexus nerve injury symptoms
M: Depends on portion involved, loss of ability to use small mm of hand, medial rotation and pronation of hand
S: Sensory loss to hands and fingers
