Emergency

Question 1

What is fascial dehisence?

Answer 1

When the abdominal wall pressure overcomes the tissue or suture strength or knot integrity leading to a breach in fascial continuity.

Question 2

What are the risks for fascial dehisence?

Answer 2

Patient factors:
- obese
- ascites
- male
- post operative cough
- smoker
- age
- malnutrition
- heavy lifting

Disease factors:
- infection
- emergency surgery

Technical factors:
- poor suturing execution
- the longer the incision the higher the risk
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Question 3

When would you refer a patient with incidental finding of ovarian cyst either intraoperatively or on imaging to gynaecology?

Answer 3

Risk factors for cancer e.g. red flags in history or family history or genetic increased risk e.g. known BRCA mutation

Risk of Malignancy Index score >250

Intraoperatively if ver y large >5cm, possible cause of symptoms resulting in the laparoscopy in first place, bilateral masses, solid appearing components, associated ascites or mets, multilocular appearance

In premenopausal women:CA125 does not need to be undertaken when the diagnosis of a simple ovarian cyst has been made ultrasonographically. The CA125 can be raised by anything that irritates the peritoneum, so in premenopause there are numerous benign triggers for an increase.
Lactate dehydrogenase, alphafetoprotein and hCG should be measured in all women under 40 due to the possibility of germ cell tumours.
Rescan a cyst in 6 weeks. If it is persistent then monitor with ultrasound an CA125 3-6 monthly and calculate RMI.
If persistent or over 5cm consider laparoscopic cystectomy or oophorectomy.

In post-menopausal women:
Low RMI (less than 25): follow up for 1 year with ultrasound and CA125 if less than 5cm.
Moderate RMI (25-250): bilateral oophorectomy and if malignancy found then staging is required (with completion surgery of hysterectomy, omentectomy +/- lymphadenectomy).
High RMI (over 250): referral for staging laparotomy