book of yueng Flashcards
what do we want to avoid when putting in lap ports?
deep and superficial epigastrics
what is the origin of the superficial epigastric
femoral
what is the origin of the deep epigastric?
external iliac
how do you avoid the superficial epigastric
transillumination
in what layer is the deep epigastric?
rectus abdominus fascia
how do you avoid the deep epigastric
stay lateral to the rectus abdominus fascia (or lateral to the insertion of the round ligament at the inguinal canal)
what is endometriosis
ectopic endometrial glands and stroma
how do you diagnose endometriosis?
with a biopsy that shows endometrial glands and stroma
what does endometriosis look like
gun powder lesions
how do you find the ureter
at the pelvic brim (above the bifurcation of the common iliac into the internal and external iliacs–this is NOT water under the bridge)
where is the water under the bridge
where the ureter crosses under the uterine artery
how can you tell that it is a ureter
vermiculation
where can you find the uterine artery
at the level of the cervical os
what do you call the uterine artery traveling up the uterus?
ascending branch of the uterine artery
why is the ascending uterine artery tortous
so that it can expand with the uterus
triangle of doom
round ligament and medial umbilical fold (houses epigastric)
where does the round ligament attach
the round ligament goes into the deep ring of the inguinal canal
what artery is in the round ligament
Samson’s artery (branch of uterine artery)
does prevelance of endometriosis go up or down with obesity
prevelance of endometriosis goes down with obesity and most pts with endometriosis are normal weight
what type of estrogen comes from fat
esterone *made by aromatase*
what is the substrate for aromatase to make to estrone in fat?
androstendione
what is the substrate for aromatase to make estrodial
testosterone
does estrogen cause endo
no
is endo found in the uterus
no, it’s ectopic
why remove the uterus in endo cases?
to remove the suspected source of the endometriosis
why do we sometimes remove ovaries in endo cases?\ why remove the fallopian tubes
endometriosis can be estrogen responsive tubes can be a source of ovarian cancer
what ligament suspends the ovary?
IP ligament (infundibulopelvic)
which ligament attaches the ovaries to the uterus
uterine -ovarian ligament
what can damage the ureters (4 things)
ligation thermal injury kinking ischemia **kinking is most common**
what is most common cause of damage to ureters
kinking
when does kinking of the ureters usually occur
at the closing of the vaginal cuff
during cysto, what does a ureteral jet tell us
the ureter is patent (but not necessarily undamaged)
How do you evaluate for ureter damage intra operatively
cysto visual jets at UO
what dyes can you give patients to look for ureter damage?
methylene blue (can rarely causes methemoglobinemia) indigo carmine (national shortage) fluoresceine
what can you do if one of the ureters is not patent?
give IVF bolus release vaginal cuff call urology
what can you do post operatively to evaluate ureters
IV pyelogram(gold standard, not commonly done) CT scan (lets you look at nearby structures)
what is first line tx for endo pelvic pain
NSAIDs because there’s up regulated prostaglandin release due to the endo lesions
what does endometriosis look like on US
ground glass
what is primary dysmenorrhea?
pain from uterus contraction
what tx for primary dysmenorrhea
NSAIDs bc pain is thought to be due to prostaglandins
what is secondary dysmenorrhea
pain from a pathology and not just uterine contractions. e.g. fibroids, infection, endometriosis
what does a simple cyst look like on US
small black circle
what is a complex cyst
anything that isnt a simple cyst or small black circle on US
what are possible characteristics of complex cysts
irregular borders hyperechoic (calcifications…think dermoid cyst) multiloculated air fluid levels
can you diagnose endometriosis on US
no dx requires biopsy/pathology. you can only say that US raises suspicion
when you poke a cyst and chocolate comes out, does that mean it is an endometrionoma
nope, have to have pathology. could be a hemorrhagic cyst.
what is one way to tell the difference between hemorrhagic cyst and endometrionoma?
you can do serial US. the hemorrhagic cyst will usually resolve over time
what is the most dangerous part of laproscopy
insertion of first port because you have to do it blindly
what is the omentum
policeman of the abdomen bc it can wall off infections
ovaries are supplied directly by _____
aorta
right ovary, right kidney, right adrenal gland drain to ——
directly to vena cava
left ovary, left kidney, left adrenal gland drain to…
renal vein first before vena cava
external iliac artery passes through….and becomes….
external iliac artery passes through inguinal ligament and becomes femoral artery
in primary amenorrhea, you can see the girl has secondary sex characteristic so her endocrine axis is intact and US shows her anatomy is intact. What could be causing primary amenorrhea
pregnancy weight loss/athlete triad/stress imperforate hymen
in primary amenorrhea, you can see the girl has secondary sex characteristic so her endocrine axis is intact and US shows she doesnt have a uterus. What could be causing primary amenorrhea
mullerian agenesis
androgen insensitivity syndrome
you can tell the difference between these two by looking at testosterone level and karyotype
in primary amenorrhea, you can see the girl lacks secondary sex characteristic so her endocrine axis is not intact and US shows she does have a uterus. What could be causing primary amenorrhea?
Kallmans (hypothalamus -no mass! no GnRH)
craniopharyngeoma (anterior pituitary-mass)
Turners
In Kallmans and craniopharyngeoma, you make zero LH, FSH . get MRI to distinguish
in Turner’s, tons of LH and FSH trying to turn on nonfunctional ovaries. Karyotype and transvaginal US
primary amenorrhea and no sense of smell
Kallmans
primary amenorrhea, intact endocrine system, missing top 1/3 of vagina, uterus, tubes
mullerian agenesis
(mullerian ducts –> upper 1/3 of vagina, uterus, tubes)
Turner’s syndrome
secondary sex characteristics?
anatomy?
Turner: streak ovaries, has vagina, vulva, uterus, tubes
estrogen progesterone low –> can’t develop secondary sex characteristics. Elevated LH, FSH bc no neg feedback
*give estrogen and progesteron, **GET ECHO! (most commonly coarctation of aorta, bicuspid aortic valve)
definition of secondary amenorrhea
3-6 months or missed 3 periods
first steps in secondary amenorrhea workup
pregnancy test, TSH, prolactin level
all negative: progesterone challenge, if positive–> not ovulating, probably PCOS
if neg, estrogen/progesterone test. If no bleeding, ashermans or ablation of endometrium. If yes bleeding, then endometrium is fine it’s the axis thats messed up. Get FSH, LH, and FSH:LH ratio. If these high, it’s an ovary prob
retrograde theory of endometriosis
Retrograde Menstruation. Retrograde menstruation theory is the oldest principle explaining the aetiology of endometriosis. This theory proposes that endometriosis occurs due to the retrograde flow of sloughed endometrial cells/debris via the fallopian tubes into the pelvic cavity during menstruation
doesnt explain why premenstral, postmeno females get endometriosis
endo’s evil twin
interstitial cystitis
pelvic pain, bladder irritability, frequency, dysparunia
medial umbilical ligament
remnant of fetal umbilical arteries
median umbilical ligament
remnant of fetal urachus
posterior pedicle of internal iliac
becomes three vessles
iliolumbar
lateral sacral
superior gluteal
(I love sex)
in hysterectomy, clamp and cauterize round ligament (samson’s arter), then dissect anterior leaf of broad ligament in order to….. and then the posterior leaf of broad ligament in order to…
dissect anterior leaf of broad ligament to dissect off bladder and then the posterior leaf to avoid ureters
why remove fallopian tubes during hysterectomy
bc ovarian cancer can originate in the fallopian tubes especially the fimbriae
what is primary infertility
nulliparious woman, trying for a year , not on contraception, + “random coitus”
what is primary amenorrhea
pt has never had menses
what is secondary amenorrhea
pt used to have menses but has missed 3 cycles/6months
what are causes of secondary amenorrhea
PCOS
asherman’s
pregnancy
thyroid problems
prolactinemia
menopause, ovarian failure, ovarian insenstivity (Savage)
what vessles in IP ligament
ovarian vessles
treatment for endometriosis
nsaids
OCPs
progesterone analogs (medroxyprogesterone, levongesterol)
danazol (steroid) (stops LH, FSH peaks)
gonadotropin releasing hormone modulators (decreases estrogen)
surgery
