GYN Flashcards
What are some clinical risk factors for DVT?
Age > 40
Surgery for malignancy
Prolonged surgery (> 30-45 mins)
Obesity
Delayed POP ambulation
Medical disease (DM, heart failure, COPD, prior DVT)
What are the steps to assess a bladder injury repair?
- Location of injury in relation to the trigone
- Proceed gently - friable bladder mucosa
- Close in 2-3 layers
- Submucosa + mucosa
- Muscularis +/- paravesical fascia - Consider sterile milk to test integrity
- Cystoscopy to assess trigone and closure
- Foley for 7d
How would you repair a ureteral injury > 5cm from the UVJ?
Uretero-ureteterostomy (End to end anastomosis)
- Spatulate ends
- 4-6 interrupted sutures of 4-0 chromic through full thickness of cut edge
- Make sure no tension
- Consider placing a drain (not in contact w suture)
- Stent the ureters and cath the bladder x 10d
How would you repair a ureteral injury < 5cm from the UVJ?
Ureteroneocystotomy (re-implant into the bladder)
- Must be off tension
- Consider Psoas Hitch, Baori flap, or mobilizing bladder
Transureteroureterostomy (implant to contralateral ureter)
Always place a drain to avoid urinoma
What can you do if a primary ureteral repair of an injury cannot be performed?
Percutaneous nephrostomy
What are the steps of repairing a bowel injury?
- Run the bowel first to identify other areas of injury
- Close to to avoid narrowing of the lumen of the bowel
- Side to side if lac is perpendicular to long axis
- End to end if lack is parallel to long axis - Use 3-0 vicryl to close mucosa/muscularis in single layer interrupted
- Use 3-0 non absorbable for muscualris/serosa
What are some different abdominal incisions?
Pfannenstiel
Joel-Cohen
Cherney
Maylard
What characterizes a Pfannenstiel incision?
2cm above the pubic symphysis
Separate rectus from sheath
What characterizes a Joel-Cohen incision?
5cm above the pubic symphysis
Blunt dissection
Associated with less fever, pain, blood loss, op time
What characterizes a Cherney incision?
Separate the rectus tendon from the pubic symphysis to visualize the space of Retzius
What characterizes a Maylard incision?
Transect the rectus muscle with ligation of the inferior epigastrics. No separation of rectus from sheath.
What characterizes a mass closure?
Incorporating the subcutaneous tissue, rectus, rectus sheath, fascia, and peritoneum in one bite
What characterizes a Smead-Jones mass closure?
Vertical mattress mass closure with double loop, then,
incorporate medical edge of sheath in a single loop
What are some factors necessitating mass closure?
Age, obesity, poor nutrition, steroids, radiotherapy, chemotherapy, any chronic condition leading to weak tissue
Suture material: Plain gut
- natural vs synthetic
- absorption time
- breakdown mechanism
Plain gut
- Natural
- 7d
- Inflammation
Suture material: Chromic gut
- natural vs synthetic
- absorption time
- breakdown mechanism
Chromic
- Natural
- 14d
- Inflammation
Suture material: Vicryl
- natural vs synthetic
- absorption time
- breakdown mechanism
Vicryl
- Synthetic
- Loses 50% tensile strength at 21d
- Hydrolysis
Suture material: Dexon
- natural vs synthetic
- absorption time
- breakdown mechanism
Dexon
- Synthetic
- Loses 50% of tensile strength at 30d
- Hydrolysis
Suture material: PDS/Maxon
- natural vs synthetic
- absorption time
- breakdown mechanism
PDS/Maxon
- Synthetic monofilament
- Loses 50% of tensile strength at 60d
- Hydrolysis
Suture material: Silk
- natural vs synthetic
- absorption time
- breakdown mechanism
Silk
- Natural braided
- Permanent
Suture material: Nylon
- natural vs synthetic
- absorption time
- breakdown mechanism
Nylon
- Synthetic monofilament
- Permanent
What are the 5Ws of post op fever?
Wind: bowel obstruction, ileus, PNA
Water: UTI
Wound: Infection
Walking : DVT
Wonder drugs: Drug allergies
(Wonder breasts: mastitis)
What is the time frame this cause of POP fever: PNA/GI?
1-3d POP
What is the time frame this cause of POP fever: DVT?
3-7d
What is the time frame this cause of POP fever: UTI?
4-7d
What is stage 0 POP?
No prolapse
What is stage 1 POP?
Greater than 1cm above the hymen
What is stage 2 POP?
Between 1cm above the hymen and 1cm below the hymen
What is stage 3 POP?
More than 1cm below the hymen but no further than 2cm less than total vaginal length
What is stage 4 POP?
Complete procidentia
What is a Halban’s culdoplasty for enterocele prevention?
Vertical sutures incorporating uterosacrals, performed abdominally
What is a Moskowitz culdoplasty for enterocele prevention?
Pursestring sutures incorporating uterosacrals, performed abdominally
What is a McCall’s culdoplasty for enterocele prevention (and prophylaxis for vault prolapse)?
Plicate the uterosacral ligaments in the midline, performed vaginally
What are three surgical treatments of vaginal vault prolapse?
- Abdominal sacrocolpopexy
- Sacrospinous ligament fixation
- Uterosacral ligament fixation
What are the 5 compartments to check for prolapse?
- Anterior (cystocele)
- Posterior (rectocele)
- Uterus/apex (apical)
- Posterior cul de sac (enterocele)
- Vaginal outlet (perineal body)
What are 3 risk factors for recurrent prolapse?
- Age < 60
- BMI > 26
- Stage 3 or 4 prolapse
What is the minimum evaluation of urinary incontinence?
- History
- Physical
- UA
- Assessment of stress incontinence
- Assessment of urethral mobility
- Measure PVR
What are 3 classes of medications for UUI?
- Antimuscarinics: Oxybutinin
- Beta adrenergics: Mirabegron
- Botox
How do antimuscarinics work for UUI?
Block parasympathetic M2/M3 receptors to inhibit involuntary detrusor contractions
Side effects: dry mouth and eyes, constipation
How do beta adrenergics work for UUI?
Relax detrusor muscle to increase bladder capacity
Side effects: no worse than placebo
Contraindicated with severe HTN, renal disease, liver disease
How does botox work for UUI?
Paralyses/relaxes bladder to increase capacity
Side effects: UTI, urinary retention
What is a treatment for refractory UUI?
Sacral neuromodulation
What are surgical treatment options for SUI?
Urethral bulking
Slings
Suspensions
What are some complications of sling procedures?
UTI
Surgical site bleeding, Retzius hematoma
Placement of sling or suture in bladder
Mesh erosion
Urinary retention
Unmasking of urge incontinence
Fistula if using mesh
What are the treatment options for mesh erosion?
- Pelvic rest for 6-8w, vaginal estrogen
- Excision of mesh in office
- Excision of mesh in OR with repair+cysto
What are the three levels of wound failure?
- Superficial separation
- Fascial dehiscence
- Evisceration
What factors are associated with regret for tubal sterilzation?
Age < 30yo
Recent decision < 6mo ago
Unstable marriage or single
Unhealthy children
Unhealthy neonate (low Apgars, premature, FGR, etc)
What are some disadvantages of robotic surgery?
Longer operative time
More surgical incisions
Extensive learning curve
Medical cost
What are some advantages of robotic surgery?
3D vision
Improved fine motor control and articulation
Potentially decreased blood loss
Minimally invasive approach to otherwise open cases
What are some risk factors for surgical site infection?
Obesity BMI > 30
Nutritional status
SubQ > 3cm
Smoking
Immunosuppression
Perioperative hyperglycemia
Co-existant infection at remote body site
Vaginal colonziation
MRSA status
What are the steps of an appendectomy?
- Dissect mesosalpinx
- Ligate appendix vessels
- Clamp and cut base of appendix
- Purse string suture around base
- Embed the stump prior to closing purse string
What are some complications of UAE?
Pain and degeneration of fibroids
Myometritis
Bacteriemia
Uterine artery perforation/hemorrhage
Loss of ovarian function
What qualities on US increase risk of adnexal mass malignancy?
Size > 10cm
Hetergeneous components
Intramural nodule
Papillary excrescences
Septatations
Increased doppler flow
Free fluid
What non-malignancy conditions can cause elevated Ca 125?
Endometriomas
PID
Inflammatory states (SLE/IBD)
Non gyn malignancy
Pregnancy
What is partner treatment for gonorrhea?
800mg cefixime (+100mg doxy bid if chlamydia status unk)
