Gyn Surgery Flashcards
What is the complication rate in benign gyn surgery?
3.7%
Definition of major postoperative complications
Death, vascular event (MI, stroke), renal failure, infectious (pna, sepsis), respiratory (mechanical ventilation, intubation), wound dehiscence, intra-abdominal infection, deep site infection, VTE (DVT or PE)
What are predictors of 30-day morbidity after surgery?
Age >80 Dependent functional status Diabetes Morbid obesity Bleeding disorder Current smoking Emergency surgery Operative time Unintentional weight loss
Rate of vascular injury in laparoscopic entry?
0.1 to 6 per 1000
Most commonly omental or mesenteric
Rate of bowel injury in laparoscopic entry?
1.8/1000 or appx 0.03-0.18%, higher in hysterectomy than sterilization
30-55% occur during entry
What is the advantage of open entry?
Fewer cases of failed entry compared to closed (veress or direct)
Lower risk of major vascular complications compared to closed (Veress) technique
Advantage of direct entry?
Lower rates of failed entry compared to Veress
Less extraperitoneal insufflation
What part of bowel is most likely to be injured in laparoscopic surgery?
Small bowel
What percent of bowel injuries go unrecognized?
41%
What percent of laparoscopic bowel injuries are electrosurgical?
29%
Why are electrothermal injuries more damaging?
Coagulative necrosis that occurs subsequently over hours-days
How are superficial serosal bowel injuries managed?
Purse string closure or oversewn in two layers
How are electrosurgical bowel injuries managed?
Assume full thickness injury. Requires a segmental resection, 4-5cm around the area of blanching.
If 2+ bowel injuries, significant bowel spillage, or multiple transfusions, segmental resection and colostomy
When oversewing a bowel injury, what direction do you sew?
Longitudinally, so as not to risk a stricture or decrease the lumen of the bowel
How do you manage non-thermal bowel injuries involving >50% of the bowel circumference?
bowel resection. if <50%, can oversew.
Acute compartment syndrome risk factors
obesity, prolonged operative time, aggressive fluid resuscitation, lithotomy
Earliest sign of acute compartment syndrome
Passive stretch
T12-L1 give off which nerves? what are injury symptoms?
ilioinguinal and iliohypogastric nerves
- parasthesia of lower abdomen and mons
L1-L2 give off which nerves? what are injury symptoms?
genitofemoral - parasthesia of labia and upper thigh
L2-L4 give off which nerves? what are injury symptoms?
obturator and femoral nerve
- obturator numbness of inner thigh and weakened adduction
- femoral - anterior and posterior thigh numbness
L5-S2 give off which nerves?
inferior gluteal
superior gluteal
common peroneal
S2-S4 give off which nerves?
Pudendal
Air embolism - what position do you put the patient in?
Trendelenberg
Left lateral decubitus
What suture is used for a McDonald cerclage
Non-absorbable, large suture
e.g. 1-Prolene
What suture is used for Pomeroy tubal ligation
Rapidly absorbable e.g. catgut or plain
Absorbable suture types
Catgut/Chromic Plain Vicryl monocryl (monofilament) PDS (monofilament)
Non-absorbable suture
Silk
Nylon (monofilament)
Prolene (monofilament)
Ethibond
What kind of hernias can be closed without mesh?
Small, 3cm or less
What kind of hernias can be closed laparoscopically?
10cm or less incisional hernias
What are risk factors for hernias?
Obesity, diabetes, malignancy, smoking, hx prior laparotomy, wound infection, wound dehiscence, immunosuppressants/steroids
What is the definition of superficial incisional infection?
skin and subQ tissue
1) pus OR
2) pain/tenderness/erythema AND surgical opening of incision OR
3) organism cultured
What are not surgical site infections?
Cellulitis alone (without pus) Stitch abscess
What is the definition of deep incisional SSI
Deep tissues (fascia or muscle)
1+ of following:
- pus
- spontaneously dehisced or opened incision + fever/tenderness/pain
- e/o infection on imaging, path, gross anatomical test
What is the risk of infection in a clean-contaminated case?
3.94% (e.g. hysterectomy)
What is the risk of infection in a clean case?
1.7%
What is the risk of infection in a contaminated case?
4.75%
What is the risk of infection in a dirty/infected case?
5.1%
What is the risk of SSI for a c-section?
incision infection 2-7%
endometritis 2-16%
What is the rate of cuff dehiscence after TLH?
After robotic hyst?
1-4%
3% for robotic
(but this literature is also from as people are learning how to do MIH)
What is the mean time to cuff dehiscence?
7 weeks for TLH
13 weeks for TAH
What are risk factors for cuff dehiscence?
laparoscopic/robotic hyst increased electrocautery/coagulation increased age # vaginal surgeries vaginal atrophy any poor wound healing post-op infection/hematoma
What factors can reduce risk of cuff dehiscence?
bidirectional barbed suture
intracorporeal vaginal closure
What is the preferred approach to repair a vaginal cuff dehiscence?
None preferred over others, depends on patient, visualization, and surgeon
Differences in laparoscopic vs robotic hyst outcomes
no differences were found in perioperative outcomes, including blood loss, length of stay, type or number of complications, postoperative pain levels, analgesic use, or recovery time
Robotic myomectomy vs laparoscopic
robotic = longer operative time
however
decreased blood loss, rates of transfusion, and length of hospital stays compared to laparoscopic
also decreased risk of conversion to open
How many surgeries does it take to be efficient in the robot?
20-30
improvements seen up to first 100 surgeries
What is Surgicel? How long does it last?
Oxidized regenerated cellulose
powder or mesh
Provides scaffold for platelet aggregation and clot formation; activates extrinsic coagulation cascade
1-2 weeks
CANNOT use with topical thrombin due to low pH of surgicel
What is Surgifoam or Gelfoam?
Absorbs blood/fluid
matrix for clot formation
and mechanical barrier
Available as sponge or powder
Lasts 4-6 weeks
requires intact coagulation cascade
What is Floseal or Surgiflo?
Topical thrombin (converts fibrinogen to fibrin) and gelatin granules Lasts 4-6 weeks Biologic agent - does not need intact coagulation cascade but does need fibrinogen cannot use with surgicel - intactivates due to low pH
What is Monsel’s solution
ferric subsulfate 20%
coagulates leading to tissue necrosis, enhancing thrombus formation and hemostasis
What is silver nitrate?
A caustic agent
What is an isthmocele?
Cesarean scar defect with myometrial discontinuity in the anterior uterine wall, at least 1-2mm
Often filled with endometrium and/or endometrial fluid collection
Risk factors for isthmocele?
Multiple c-sections
c-section in active labor
How may isthmoceles present?
abnormal uterine bleeding (bleeding after menses)
most asymptomatic
What are risks of isthmoceles?
Placenta previa
Invasive placentation
Uterine rupture (NOT related to scar thickness)
C-section scar ectopic pregnancy
How do you diagnose isthmocele?
TVUS
Could also use saline infused sonography or HSG
MRI
Hysteroscopy
How are isthmoceles repaired?
Laparoscopic (excise serosal defect and repair over endometrial defect) or hysteroscopic (remove endometrium and endmetrial scar tissue) and/or both
What is the correlation between frozen pathology and final pathology for leiomyoma vs leiomyosarcoma?
~50%
Risk of failure of Filshie clips?
CREST STUDY: 36.5 pregnancies /1000 procedures in Filshie clips (3.6%) including interval procedures
RCT of postpartum women, 700 women clip vs salpingectomy, 1.7% pregnancy rate in clip group vs 0.4% rate in salpingectomy group
Course of the ureter
Renal pelvis
Descend along anterior surface of psoas major in the retroperitoneum
Cross pelvic brim
Cross bifurcation of common iliac arteries into internal/external iliac
Run down lateral pelvic walls, medial to the branches of the internal iliac, in the medial leaf of the broad ligament
Crosses under the uterine arteries 1-2cm
Inferior epigastric artery
arises from external iliac
travels 4-8cm from midline
anastamosis to superior epigastric arteries (continuation from internal thoracic)
Abbe-McIndoe procedure
Dissection of space bw rectum and bladder; placement of stent covered with skin graft into space
Vaginoplasty
Williams vaginoplasty
Horseshoe shaped incision along perineum, labial majora used to create puch
Used second-line in setting of scaring
Davydov procedure
3 stage vaginoplasty
Dissection of rectovesicular space
Abdominal mobilization of peritoneum
Attachment of peritoneum to introitus
Sigmoid vaginoplasty
Sigmoid colon resection pulled down to introitus to create neovagina (and closed to create blind pouch)
What is an absolute contraindication to use of cell saver?
Blood mixed with sterile water
sterile water or alcohol results in red cell destruction > end-organ damage
Relative contraindications to cell saver
Malignancy Sickle cell disease/trait Intra-op infection Amniotic fluid Bowel contents Clotting agents
Layers of the bladder
Transitional epithelium Lamina propria Submucosa Muscularis (detrusor) Adventitia (serosa)
