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OB Gyn Oral Boards Topics > Columbus: complications of laparoscopy and hysteroscopy > Flashcards

Columbus: complications of laparoscopy and hysteroscopy Flashcards

0
Q

What is the rate of uterine perforation at hysteroscopy?

When does this typically occur?

A

1%

During sounding, dilation or initial insertion of the scope

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1
Q

What is the single greatest factor leading to injury and liability?

A

Ignoring contraindications

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2
Q

When does uterine perforation require surgical exploration?

A

Lateral perforation or perforation with an active electrode

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3
Q

What factors increase the risk of CO2 embolism at laparoscopy?

A 
Length of surgery
Obesity
Cardiopulmonary disease
Patient position
Amount of dissection
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4
Q

When does air embolism usually occur during laparoscopy?

A

At insufflation

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5
Q

What steps should be taken when trocar injury to the large bowel is recognized?

A
  1. Leave the laparoscope in place to prevent spread of bacteria
  2. Begin broad-spectrum antibiotics
  3. Anesthesiologist to place an NG/OG tube
  4. consuly general surgery.
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6
Q

What complications can occur during laparoscopy during insufflation?

A 
Failed pneumoperitoneum
Pneumoperitonium-Induced Pneumothorax
Subcutaneous emphysema
Extra peritoneal insufflation
Pneumo-Mediastinum
CO2 embolism
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7
Q

What are some strategies for failed pneumoperitoneum?

A

Left upper quadrant insertion
Open laparoscopic port placement
Ninth intercostal space insertion
Laparotomy

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8
Q

How does CO2 embolism present?

A 
Decreased oxygen saturation and expired CO2
Bradycardia, arrhythmia, and widened QRS
Bilateral mydriasis
Pulmonary interstitial edema
Cyanosis
Hypotension
Acidosis
Cardiovascular collapse and death
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9
Q

How is CO2 embolism treated?

A

Immediate release of pneumoperitoneum
Left side down in Trendelenburg forces gas into base of right ventricle
100% oxygen and anticholinergics
Place central line
Consult cardiologist to aspirate air bubble from right heart

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10
Q

How is CO2 embolism prevented?

A

Continuous end-tidal CO2 monitoring
Maintenance of intra-abdominal pressure within predetermined limits
Rarely invasive cardiac monitoring

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11
Q

What steps are done prior to surgery to reduce stomach perforation?

Bladder perforation?

A

Minimal bagging and NG/OG tube.

Indwelling Foley catheter or preoperative emptying.

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12
Q

What patients require consideration of alternative entry site for laparoscopy?

A

Large pelvic mass, pregnancy, or previous surgery.

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13
Q

How is ureteral injury best diagnosed?

What is the most common clinical finding in patients with ureteral transaction?

A

Intravenous pyelogram

Elevated WBC

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14
Q

How is left upper quadrant insertion performed? What needs to be considered?

A

Palmers point
Entry at midclavicular line or lateral
Empty the stomach with NG or OG tube
Evaluate for hepatosplenomegaly

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15
Q

When do patients usually present with ureteral injury?

What are the most common signs of ureteral injury?

A

48 to 72 hours

Elevated WBC, fever, peritonitis. Hematuria and flank pain are present infrequently.

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16
Q

How is major vascular injury managed laparoscopy?

A

Leave the Veress or trocar in place to help mark the site of injury
Perform immediate laparotomy with midline incision
Stabilize hemodynamic parameters
Consult vascular surgery

17
Q

How is ureteral injury repaired?

A

Reimplantation into the bladder
Anastomosis of the damage ureter
Transureteral ureterostomy

18
Q

How is inferior epigastric vessel perforation managed?

A

Pressure, vasopressin, Foley balloon, or suture

19
Q

How should brisk intraoperative bleeding be managed?

A 
Hydrolavage
Mechanically coapt the bleeder
Revisit anatomy
Mobilize vasculature if necessary
Desiccate
Hydro lavage and reassess
20
Q

What are risk factors for adhesion formation?

A 
Ischemia
Infection
Necrosis
Hemorrhage
Foreign body
Abrasion
Surgery
21
Q

What steps can be performed to improve the safety of hysteroscopy?

A

Void prior to surgery or Foley catheter
Examination under anesthesia or preoperative imaging
Careful dilation and uterine sounding

22
Q

How can adhesions be prevented?

A

Incise rather than excise

Avoid crushing and desiccation

23
Q

What are contraindications to hysteroscopy?

A

PID or acute vaginitis
Profuse uterine bleeding
Pregnancy

24
Q

What is the number one cause of postmenopausal bleeding?

In what other clinical settings may this be seen?

A

Endometrial atrophy

OCP or progestin use

25
Q

What are complications of endometrial ablation?

A 
Urine perforation
Hemorrhage
Fluid overload
Infection
Thermal injury to viscera
Anesthesia related
26
Q

What are signs of uterine perforation?

A

Depth of passage of uterine sound or dilator is greater than apparent uterine size
Very rapid flow of liquid distention media
Direct visualization
Any hemorrhage before the beginning of the surgical procedure is suggestive

27
Q

What are risk factors for uterine perforation?

A 
Postpartum
Postmenopausal
Retroverted uterus
Prior LEEP or cone biopsy
Uterine cancer
Marked cervical stenosis
28
Q

How should uterine perforation be managed?

A

Perforation usually does not require repair.
Stop the surgery
Give antibiotics
Observe patient

Lateral perforation or with active electrode must have laparoscopic evaluation

29
Q

What steps can be taken to avoid uterine perforation?

A

Pretreat with misoprostol for patients at high risk
Careful EUA
Laparoscopic or ultrasound guidance

30
Q

What electrical system is used with glycine and sorbitol distention medias?

What complications are associated with its use?

A

Monopolar

Fluid overload, hyponatremia, hypo-osmolality leading to pulmonary and cerebral edema

31
Q

How can intraoperative hemorrhage during hysteroscopy be managed?

What should be considered postoperatively?

A

Electrocautery
Uterine balloon with 15 to 30 mL for three hours

Consider coagulopathy evaluation

32
Q

What is the risk of using CO2 as the distention media for diagnostic hysteroscopy?

A

CO2 venous embolism

33
Q

Why is dextran 70 high viscosity fluid no longer used?

A

Associated with anaphylaxis, clotting disturbances, ARDS

34
Q

What is the advantage of mannitol 5% over glycine or sorbitol?

A

Mannitol acts as its own diuretic and may cause hyponatremia but not hypo-osmolality.

35
Q

How much would sodium be expected to drop if 1000 milliliters of glycine were absorbed?
2300?
2700?

A

8 mEq
16
25

36
Q

How can fluid overload be prevented?

A

Strict I/O’s
Stop case at 1.5 L of nonelectrolyte fluid or 2.5 L of saline
For nonelectrolyte fluids check electrolytes at 750 mL deficit

37
Q

How does fluid overload and hyponatremia present?

How is it treated?

A

Headache, nausea and vomiting, confusion, and lethargy. If severe can cause seizure, coma, cardiovascular collapse and death
Symptoms usually start at 130 to 125 mEq of sodium
Treated with water restriction, loop diuretic, and close observation.

38
Q

What is the risk of rapid correction of hyponatremia?

A

Central Pontine mylinolysis

39
Q

How is correction of hyponatremia calculated?

And how is the 3% saline administered?

A

Volume of TBW x (125 - current sodium) = total sodium needed

TBW = 0.6 x weight in kg

3% saline has 513 mEq per liter

Replace at 1 to 2 mEq per hour

40
Q

What laboratory value is used to diagnose severe hyponatremia?

How does it present?

What is the major risk of the delayed diagnosis and treatment?

How is this treated?

A

Sodium less than or equal 125 mEq

CNS symptoms such as muscle twitching or weakness convulsions or altered mental status

Risk of brainstem herniation from cerebral edema

Treated with 3% saline

41
Q

What other steps could be considered for anticipated difficult hysteroscopic resections such as large or multiple fibroids?

A

Pretreatment with GnRH agonist
Two-stage procedure
Intraoperative use of vasopressin or oxytocin

OB Gyn Oral Boards Topics (82 decks)

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