Core Surgical Skills Flashcards
What is the overall rate of serious complications at gynaecological laparoscopy?
1 in 1,000 cases
Which complications must be explained for every woman having a gynaecolgical laparoscopy?
Damage to bladder, bowel and urinary tract, and incisional hernia
What is the evidence for open (Hasson’s) versus closed (Veress/Visiport) laparoscopic entry?
No significant safety advantage to either method on meta-analysis
What two points of technique are evidenced to improve successful Veress needle entry?
- Not elevating the abdominal wall
- Observe that the initial insufflation pressure is <8mmHg
What intra-abdominal pressures should be used during and after laparoscopic entry?
- Entry pressure of 20-25mmHg
- Operating pressure of 12-15mmHg
Where is Palmer’s point?
3cm below the left costal margin in the mid-clavicular line
What are the rules for the deep rectus sheath should be closed at a port site?
- Any non-midline port over 7mm should be closed
- Any midline port over 10mm should be closed
Why may saline be a better distension medium than CO2 at outpatient hysteroscopy?
- It is associated with fewer cases of vasovagal syncope
- Image quality is often better than with CO2
- Saline is required if using bipolar electrosurgery
What analgesia should be provided if grasping the cervix with a tenaculum is necessary at outpatient hysteroscopy?
Topical local anaesthetic
What is the evidence for cervical preparation with prostaglandins prior to outpatient hysteroscopy?
- No reduction in rate of cervical lacerations across a meta-analysis
- No reduction in failure rates across a meta-analysis
- Less pain during cervical dilatation for post-menopausal women who received Misoprostol prior to OPH
Which incision gives access to the space of Retzius, necessary for some urogynaecological surgery?
Cherney’s incision
Which pelvic side-wall artery can be more easily accessed with a Cherney incision?
The hypogastric artery
What is the major risk of the Maylard incision?
Lower extremity ischaemia due to inferior epigastric artery ligation
What can be a useful landmark to identify the midline during midline laparotomy?
The pyramidalis muscle
What structures can be damaged if a transverse incision is extended beyond the lateral edges of the rectus muscles?
The ilioinguinal and iliohypogastric nerves
What closure technique is favoured by the literature?
Mass closure technique using looped, delayed-absorbable suture (i.e. loop PDS), with a wound: suture length ratio of 1:4
Which closure technique can be described as far-far, near-near?
Smead-Jones
What is the relative risk of wound infection for morbidly obese patients?
7:1
Above what size laparoscopic port incision should deep sheath closure be done?
> 7mm for non-midline
10mm for midline
Approximately how many days does PDS take to be absorbed?
180-210 days
Approximately how many days does Vicryl take to be absorbed?
60-90
What is the incidence of neuropathy following gynaecological surgery?
1.1-1.9%
Why is regeneration of nerve function possible with axonotmesis?
Because the Schwann cell layer is not disrupted
Why might lateral thigh pain happen following Caesarean section?
Due to damage of the lateral cutaneous branches of the iliohypogastric and ilioinguinal nerves
What are the nerve roots of the femoral nerve?
L2-L4
What is the course of the femoral nerve?
Passes infero-laterally through the psoas muscle
Exits the pelvis beneath the inguinal ligament, lateral to the femoral vessels
What is the incidence of femoral nerve injury with abdominal hysterectomy?
11%
Weakness of hip flexion and adduction, and knee extension is suggestive of damage to which nerve?
The femoral nerve
Which nerve roots give rise to the ilioinguinal and iliohypogastric nerves?
T12-L1
What is the course of the ilioinguinal and iliohypogastric nerves?
Pass laterally through the head of the psoas muscle
Run diagonally along quadratus lumborum
What is the incidence of ilioinguinal or iliohypogastric nerve injury at Pfannenstiel incison?
3.7%
What is the diagnostic triad for ilioinguinal/iliohypogastric nerve entrapment syndrome?
- Sharp burning pain radiating from the incision site to the mons pubis, labia and thigh
- Paresthesia over the nerve distribution areas
- Pain relief following administration of local anaesthetic
What are the nerve roots of the genitofemoral nerve?
L1-L2
What is the course of the genitofemoral nerve?
Traverses the anterior surface of psoas
Lies lateral to the external iliac vessels
Genital branch enters the deep inguinal ring
Femoral branch passes deep to the inguinal ligament
What nerve is most likely to be injured during removal of external iliac lymph nodes
The genitofemoral nerve
What are the nerve roots of the lateral cutaneous nerve?
L2-L3
What is the course of the lateral cutaneous nerve?
Emerges from lateral border of psoas
Crosses iliac fossa anterior to iliacus
Enter the thigh posterior to the lateral end of the inguinal ligament
What are the nerve roots of the sciatic nerve?
L4-S3
What is the course of the sciatic nerve?
Emerges below the piriformis muscle
Lies midway between the posterior superior iliac spine and the ischial tuberosity
Which nerve winds forward around the neck of the fibula?
The common peroneal nerve
What motor impairment is caused by sciatic nerve injury?
Weakness of hip extension and knee flexion
What are the roots of the sciatic nerve?
Anterior branches of L2-L4
What is the course of the obturator nerve?
Roots converge behind Psoas muscle
Passes over pelvic brim in front of the sacroiliac joint
Passes behind common iliac vessels and through obturator foramen
During which surgeries is the obturator nerve most commonly injured?
Excision of endometriosis
Retroperitoneal surgery
How does obturator neuropathy present?
Sensory loss in upper medial thigh
Motor weakness in hip adductors
What are the nerve roots of the pudendal nerve?
S2-S4
What is the course of the pudendal nerve?
Exits the pelvis through the greater sciatic foramen
Runs behind the lateral third of the sacrospinous ligament and ischial spine
Re-enters the pelvis through the lesser sciatic foramen
During which surgery is the pudendal nerve most commonly injured?
Sacrospinous fixation
Whilst most postoperative neuropathies resolve spontaneously, how long does this typically take for sensory and motor neuropathies?
Sensory neuropathies typically within 5 days
Motor neuropathies up to 10 weeks
What is the gold standard way of placing self-retaining retractors to avoid nerve injury?
Cradle the rectus muscle without compressing the psoas muscle underneath
What is the procedure most commonly associated with uterine perforation?
TOP
What is the average incidence of uterine perforation at outpatient hysteroscopy?
0.002-1.7%
What is the incidence of uterine perforation with operative hysteroscopy?
1.6%
What is the rate of hysterectomy due to perforation at TOP?
7 per 100,000
What is the most common site of uterine perforation?
Anterior body of the uterus
What is the name of the tapered dilator used in some SMM sets and why is it used in preference to Hegar dilators?
Hawkins-Ambler dilators
Some papers suggest less force is needed for cervical dilatation than with Hegar dilator
What percentage of doctors leave O&G before completion of training?
30%
What is the name of the law which gives the inverted U shaped anxiety-performance curve?
Yerkes-Dodson law
