GYN- Surgery Flashcards
Caprini scores and corresponding treatmetns
Score 1-2: mechanical ppx
Moderate, score 3-4: pharmacologic or mechanical ppx, if high risk for bleeding then mechanical ppx
High: score >5: pharmacologic plus mechanical. if high risk for bleeding, mechanical until bleeding risk diminishes, then add pharmacologic
High risk + Cancer: > 5: pharm + mechanical + extended duration post discharge. If high risk for bleeding, then mechanical until bleeding risk decreases, then add pharm
High risk and LDUH/LMWH contraindicated: fondaparinux or mechanical or both
MOA of fondaparinux
Dose for dvt
indirect factor Xa inhibitor. equivalent efficacy to LMWH, for people with hx of HIIT
5-10 mg based on weight ( 5 mg of <50 kg, 7.5 mg qd if 50-100 kg, and 10 mg qd if >100 kg)
when to stop/start LMWH with regional anesthesia
stop ppx dosing 12h before catheter placement or removal. Don;t restart for at least 4 hours after catheter removal
when to start/stop LDUH w/ regional anesthesia
can be administered 4-6h before catheter placement or removal
can restart ppx dosing right after catheter removal. can also be given with catheter in situ. ppx dosing not associated with increased risk of hematoma
what is high d dimer level
500
heparin MOA
loading dose for DVT/PE
maintenance dose
prevention
complications
MOA: co factor for antithrombin . increases inhibition of thrombin and factor Xa
Loading: DVT- 100 u/kg; PE-150u/kg
maintenance: 15-25 u/kg/hr. convert to warfarin or LMWH (if preg) when stable. Warfarin 5 mg qd then INR goal 1.5-2.5x normal
prevention: 5000u BID, TID in pts with gyn cancer
PE-8-10k units BID
complicatons: osteoporosis, alopecia, thrombocytopenia
reversal agent for LDUH
protamine sulfate
when to redose abx
1) obese- give 3g ancef if >120kg
2) lengthy procedure- give additional dose if 4 hours or more from last dose
3) excessive blood loss (>1500 cc)
GYN surgeries you would give abx for (6)
1) Hysterectomy - ancef
2) uterine evacuation- doxycycline 200 mg before (within one hour)
3) colporrhaphy - ancef
4) vaginal sling placement- cefazolin
5) laparotomy without entry into bowel or vagina (can consider ancef)
6) chromotubation/HSG: doxy 100 BID x5d if hx of PID or find abnormal tubes
treatment for dilated fallopian tubes
seen on HSG
doxycycline 100 mg BID for 5 days
alternative treatment if allergic to PCN
if NOT anaphylaxis, urticaria (hives) or bronchospasm or SJS, toxic epidermal necrolysis- can give them ancef
-immediate hypersensitivity (IgE mediated), occurs within 1 hour
-delayed hypersensitivity, occurs days later (pruritic rash, urticarial) use of ancef is generally acceptable
if either of those- clinda 900 mg q6h OR flagyl 500 mg
PLUS gentamicin 5 mg/kg OR aztreonam 2g
what to give patients with MRSA
single preoperative IV dose of vacomycin (15 mg/kg) up to 2h before incision
how to repair bladder injury
assess location with respect to trigone
close in three layers if possible
1) non locking continuous 3-0 Vicryl through mucosa and submucosa
2) interrupted 3-0 vicryl to muscularis layer
3) interrupted 2-0 vicryl to paravesical fascia layer
backfill bladder with die (sterile milk, indigo carmine)
leave catheter for 3-7 days, no antibiotics
ureteral injury
>5 cm above UVJ
ureteroureterostomy (end to end anastomosis)
spatulate ends
4-6 interrupted sutures of 4-0 chromic through full thickness of cut edge
drain
ureteric stents and bladder cath x10 days
ureteral injury
<5 cm above UVJ
ureteroneocystotomy
consider psoas hitch or boari flap if unrepairable without tension
transureteroureterostomy (implant ureter into contralateral ureter)
always consider nephrostomy
Bowel injury and repair
small bowel lac parallel to long axis of bowel
closure end to end (avoid narrowing of lumen)
Mucosa/submucosa in single layer with interrupted 3-0 vicryl
muscularis/serosa with 3-0 non absorbable suture (silk or vicryl)
can do interrupted or continuous
small bowel laceration at right angle to long axis of bowel
closure now side to side
if small bowel injury occurred and pt got preop antibiotics, don’t need additional abx
pfannensteil
Joel Cohen
Cherney
Maylard
midline
pfanny: separation of sheath from rectus, hernia uncommon
Joel cohen- minimze sharp dissection leading to quick entry. more cephalad than pfanny. straight line.
cherney- excise rectus tendon from pubis, can damage inf epigastrics, good exposure of lower abd, bleeding hematoma inc risk
maylard- transection of rectus muscle with ligation of inferior epigastric vessels. No separation of sheath from rectus. inc bleeding hematoma. good visualization of lower abd
midline: quick entry, good exposure, less blood loss, less nerve injury, easy to extend, inc risk of dehisence
Bipolar instrument with hysteroscopy
What fluid medium?
Normal saline
+ electrolytes
isotonic
Don’t get hyponatremia, get volume overload and right sided heart failure, pulmonary edema and death
treat fluid overload with IV lasix (20-40 mg)
Monopolar instrument with hysteroscopy
What fluid medium
No electrolytes
Hypotonic (1.5 glycine and 3% sorbitol)
isotonic solutions (5% mannitol)
what happens when you absorb hypotonic electrolyte free fluids
1.5% glycin and 3% sorbitol
hypoosmolality, hyponatremia, cerebral edema, hypotonic encephalopathy, permanent neuro injury, heart failure, pulm edema, and death
5% mannitol is less likely to cause hypoosmolality, can lead to hyponatremia
how to treat symptomatic hyponatremia
infusion of 3% sodium chloride (0.5-2 ml/kg/hr)
how to treat asymptomatic hyponatremia
fluid restriction
careful monitoring of urine output
what are the two clicks with veress needle
how much pressure to inflate abdomen
rectus sheath and then peritoneum
25-30 mm hg
who should get preop EKG
HTN
DM
smoking
family hx of CAD
wells clinical criteria and scores
> or equal to 4: PE likely; <4: PE unlikely
clinical sx of DVT- 3 points
other dx less likely: 3 points
heart rate >100: 1.5 points
immobilization: 1.5 points
previous DVT/PE: 1.5 points
hemoptysis: 1 point
malignancy 1 point
what do you do if you have elevated wells score
get d dimer
if d dimer is <500. PE exlcuded
if d dimer is >500 : CTPA aka ct angio with contrast
cannot get d dimer if pregnant or post op (will be elevated)
if PE is likely - go straight to CT angio
treatment dose of lovenox for PE
1.5 mg/kg sc daily for 5-10 days, at three days then warfarin
or 1 mg/kg BID
therapeutic monitoring for heparin and lovenox
heparin: aPTT 1.5-2.5X
lovenox: anti factor xa activity 0.6-1.0 units/mL, test 4 hours after dose
diff between below and above arcuate line
inferior epigastric vessels enter rectus sheath at arcuate line and vascularize the rectus muscle
above arcuate line: rectus muscle is in between oblique externus and oblique internus/transversus
below arcuate line: fascia is above rectus muscle (externus, internus and transversus)
blood supply of ovary
R ovarian vein: IVC, L: L renal vein
arterial: both come from ovary
anterior branches of hypogastric artery (internal iliac)
OUUMII
obturator
umbilical artery
uterine
middle rectal
inferior gluteal
internal pudendal
posterior branches of internal iliac
iliolumbar
lateral sacral
superior gluteal
anatomy of the ureter
commences at renal pelvis and descends over psoas muscle from lateral to medial
enters pelvic brim at bifurcation of common iliac vessels
abdominal ureter (above) is 15 cm long
pelvic ureter (below) is 15 cm long
descends along side wall posterior to ovarian fossa
crosses under cardinal
crosses under uterine
goes anteriomedial and inserts in bladder
intaoperative cystotomy
close to trigone: stent so you dont kink ureters. Dont have to worry if at dome not close to trigone
close in 2-3 layers
mucosa/submocsa: 3-0 vicryl running
muscularis: 3-0 vicryl interrupted
bladder serosa: 2-0 vicryl interrupted
check for leaks /cystoscopy
foley cath for 3-7 days, voiding trial
antibiotics not indicated
ureteral injury MC sites
clamping IP ligament
when clamping uterine artery
near uterosacral ligament
closing vaginal cuff
occurs where the ureter passes
antibiotics for colon injury?
if she had preop antibiotics, just need to add metronidazole
small bowel, don’t need additional antibiotics if she had pre op ancef
post op fever differential
wind: 1-2 days, pneumonia, bowel obstruction, ileus
water: 2-5d, UTI
wound: 3-5 days, surgical site infection
walk 7-10d; DVT
wonder drugs: drug allergies, drug reaction
fever on two occasions 4 hours a part AFTER the first 24 hours post op (first 24h usually cytokine release)
abdominal appendectomy steps
dissect the meso appendix
ligate appendiceal vessels
clamp and cut base of appendix
purse string suture around base
invert (embed) the stump prior to closing purse string
lsc appendectomy steps
isolate the meso appendix
cauterize and divide it with 5 mm ultrasonic shear
skeletonize the base of the appendix
staple across the base
excise the appendix
inspect stump for hemostasis
remove specimen in a bag
suction and irrigate
how would you diagnose a bowel injury
ileus: abdominal xray
bowel injury: CT abdomen and pelvis with oral contrast and IV contrast – pos if oral contrast does not reach lower GI tract, extravasation of bowel contrast into peritoneal cavity, bowel wall defects, bowel wall thickening, pneumoperitoneum
don’t use barium as contrast agent- can cause peritonitis and death
Percent of people that get reop after hysterectomy for another surgery for ovaries
3-7 (less than 10) percent if done for benign reasons
Close to 30% if done for endometriosis
positives and negatives of cystoscopy after hysterectomy
decreased rates of delayed urologic injuries, increase rate of intraoperative bladder injury detection, can fix it there
increased cost ($83) per hysterectomy, extra time, another procedure
may have false positive findings in up to 2% of cases
how to diagnose delayed bladder injuries
CT urogram
routine imaging may reveal evidence of urinary ascites
peritoneal fluid creatinine levels will be elevated in comparison to serum values
bladder injury: pinpoint full thickness or serosal injury only
expectant management, routine fu
non trigonal, less than 1 cm bladder injury
primary repair or expectant management
urinary cath decompression for 1 week
non trigonal, more than 1 cm bladder injury
primary repair. 1-2 layers, plus or minus closed suction drain
initial layer: running non locked incorporating bladder mucosa and muscularis (3-0 vicryl)
second layer: running or interrupted suture including bladder serosa in imbricating fashion
after repair: retrofill bladder with at least 300 cc of saline with or without methylene blue
can also consider cystoscopy
urinary cath decompression x1-2 weeks with or without cystogram
no abx needed
trigonal, complicated, necrotic, infected injury
consult urology
repair
possible stenting or reimplantation
closed suction drain
urinary cath decompression, possible stenting, CT urogram
small superficial sharp or thermal small bowel injuries to the serosa
oversewn interrupted fashion with 3-0 vicryl in cross sectional plane. Generally do not require resection
partial thickness seromuscular defects that do not penetrate through to the mucosa
interrupted 2-0 or 3-0 vicryl
single layer adequate in most cases
full thickness small bowel injury smaller than 1 cm
closed in 1 or two layers in similar manner to partial thickness injuries
first layer interrupted
second layer imbricating
full thickness bowel injury larger than 1 cm
primary repair or resection and re anastomosis
CLD until return of bowel function
large, delayed, necrotic, grossly infected, complicated bowel injury
resection and re anastomosis plus or minus diverting proximal ostomy
CLD until return of bowel function
external ilial artery
IDF (i am down to F)
inferior epigastric
deep circumflex
femoral
course of the inferior epigastric artery
comes from external iliac artery
traverses deep to rectus towards umbilicus in a window 4-8 cm from the midline
typically lies 3.7 cm from midline at level of ASIS
forms anastomosis from superior epigastric arteries, which are continuation from internal thoracic artery
how to perform TVH
1) place two teanculum on the cervix
2) inject the cervix with dilute vasopressin
3. Circumferential incision with scalpel with 10 blade. stay above pubovesical fascia anteriorly and the perirectal fascia posteriorly. Dissect the bladder off the anterior lower uterine segment
4. grab the posterior vagina and pull tissue posteriorly. Use curved mayo tips to make a large cut to enter the peritoneum. Stretch the peritoneum
5. take curved haney clamps and place them across the uterosacral ligament. Cut with curved mayo. Haney stitch around the clamp and tie. repeat on contralateral side.
6. lift the anterior vagina and use metzenbaum scissors to displace the bladder. Enter the peritoneum anteriorly
7. sequential bites up the side of the uterus either via clamp and tie technique or bipolar
9. transect the utero ovarian ligament, broad, and tube
Abdominal hysterectomy steps
-pfannensteil incision
-enter abdomen, exteriorize uterus
-grasp uterus at cornua with pean clamps
-round ligaments suture ligated with 0-vicryl, incise with bovie
-open anterior and posterior leaves of broad ligament with bovie. Create bladder flap
-find avascular space beneath uterovarian ligament. Pierce bluntly with bovie. Then doubly clamp, incise and suture ligate with 0-vicryl followed by free ligature of 0 vicryl.
-skeletonize uterine vessels
-doubly clamp, incise, and suture ligate with 0 vicryl.
-repeat same procedure on the other side
-serially clamp, incise and suture ligate with 0 vicryl cardinal and uterosacral ligaments on both sides
-amputate at the level of the vaginal cuff. Angles of the cuff sutures with 0-vicryl heaney sutures. Remainder of cuff closed with figure o 8 sutures
Lsc hysterectomy steps
-abdominal survey, identify ureters
-grasp round ligament and coag and cut with ligasure. Carrier incision down the anterior leaf of broad ligament to create bladder flap. The tube placed on stretch and transected from mesosalpinx in the avascular plane
-grasp utero ovarian pedicle and dissect with bipolar and then cut
-incise posterior leaf of broad ligament to lateralize the ureters
-skeletonize uterine vessels , grasp and desiccate with bipolar.
-Do this same procedure on the opposite side as well.
-then cut the uterine vessels on both sided
-make the colpotomy along v-care cup
-remove uterus and cervix through colpotomy
-close with running 2-0 v lock
-check all pedicles under low pressure
-check ureters again
Ileus vs obstruction
Ileus- distention, 48-72h post op, no bowel sounds, peripheral gas in colon and air in rectum on and X-ray, treat with NGT, NPO, IV fluids, correct electrolytes
Obstruction- cramping, 5-7d post op, high pitch vowel sounds, central gas in small intestine with air fluid levels on X-ray, no air in rectum. Treat with NGT, NPO, IVFluids, correct electrolytes, and surgery if conservative unsuccessful
Example of
Direct Xa inhibitor
Direct thrombin inhibitor
DOACs
Who can and cannot get them
Xa- rivaroxaban (xarelto) and apixaban (eliquis)
Thrombin- dabigatran (Pradaxa)
DOAC-Oral, fixed dose, no lab monitoring. Avoid with renal impairment. Contraindicated if preg and breastfeeding
half life of
gut suture
vicryl
PDS
Permanent
gut- completely dissolves in 3-4 weeks
vicryl- half life is 2w, dissolves in 5-6w
PDS: half life is 3 weeks, dissolves 10-12w
permanent: absorbed over months to years, half life is 2 mo
injuries arising from transverse incision (pfannensteil or cherney)
- dissection: of the ant rectus sheath may injure terminal sensory fibers of iliohypogastric and ilioinguinal nerve. small triangular area of numbness above incision, apex towards umbilicus. resolves within 6 mo
- entrapment of iliohypogastric and ilioinguinal nerves from sutures at the lateral poles from normal scarring/healing process can cause- sharp burning pain from incision to suprapubic area, labia or thigh, paresthesias over these areas, pain relief with infiltration of local anesthetic. sx can occur soon after surgery or months to years later
femoral nerve injury
deep pelvic surgery, usually abdominal hyst
compression of femoral nerve against pelvic sidewall with deep lateral placement of retractor blades during pelvic surgery
can also occur from excessive hip abduction during vaginal surgeries
motor sx: weakness of hip flexion and knee extension
Pudendal nerve
S2,3,4
risk of entrapment or injury during sacrospinous ligament fixation or pelvic reconstruction procedures
sx: perineal/mons and vulvar pain, worsens when seated
pain responds to nerve blocks, surgical decompression is preferred
sciatic nerve
injuries from using candy cane stirrups in vaginal surgery (caused by external rotation of hip and incomplete flexion at knee)
motor: weakness of knee flexion and dorsiflexion of foot
sensory: plantar foot
peroneal nerve
arise from allen supportin legs/footrests in vaginal surgery
caused by pressure of leg rest on upper lateral tibial area during surgery
produces foot drop, resolves spontaneously in 3-6 months
also paresthesias and/or sensory loss over dorsum of foot and lateral shin
obturator nerve
L2,3,4
uncommon
paravaginal repair, radical PLND, TOT
cant adduct thigh
numbness of inner thigh
how to repair ureteral injury
1) reimplant into bladder
2) end to end reanaastomosis
-ID site of injury and determine nature
-free ureter and excise any injured tissue or suture
-pass ureteral stent through urethra out through small bladder base incision, into ureter and thence to the kidney
-split the ureteral end to enlarge the lumen
-two sutures of 4-0 vicryl placed on each side of the end of the ureter, then placed through the submucosa and muscularis of bladder (inside to outside) on tying- the ureteral end is drawn into the bladder
-reinforce with suture reaaproximation of bladder muscularis over the lower ureter
-ureteral stent in place for 10-14d
-IVP performed at that time and again 8-12 weeks post op to assess for stricture
if injury > 5 cm from UVJ, end to end reanastomosis of ureter
how do you run the bowel
Open the patient and repair the injury- not comfortable running the bowel lsc
start at ligament of Trietz (retroperitoneal connection between duodenum and ileum) , examine all surfaces of small bowel (jejunum and ileum), it is about 6-7 meters long
connection of small bowel to large bowel is ileocecal valve
go up ascending colon, then transverse colon, then descending colon to sigmoid colon and rectum
how to diagnose delayed ureteral injuries
contrast CT of abdomen and pelvis
if not definitive, then cystoscopy with retrograde pyelography
what do you do if you have a thermal injury to the ureter
immediate ureteral stenting
urology consultation intraop
primary repair as soon as stenting is accomplished
Look at other sites and make sure no more injuries
Types of transfusion reactions
1) simple febrile: AB reaction to leukocytes, antipyretics
2) Allergic reaction: allergy to plasma proteins in product- antihistamine therapy
3) anaphylactic reaction: IVF, bronchodilators, epinephrine IM 0.3-0.5 cc of 1:1000 dilution, every 10-15 min
4) hemolytic reaction: recipients antibodies induce hemolysis of donor RBCs in product . ABO incompatibility. AKI, DIC.
5) Trali: recipents neutrophils activated against transfused product - resp distress
treat and SEND THE BLOOD BACK
Septic pelvic thrombophlebitis
Persistent fever for 3-5 days despite antibiotics and no abscess
Palpable cord like mass
Can potentially see congested vessels on CT scans
Diagnosis of exclusion
Continue antibiotics
Lovenox 1mg/kg bid, discontinue 48 hours after fever resolution or 6 weeks. Get heme on board, Not well determined duration of treatment. 6 weeks if thrombosis. Dc antibiotics when improving
