GYN surgery complication Flashcards
Mesh erosion incidence
5-19% in all cases?
retropubic sling: 1.4%
Transobuturator sling: 2.2%
Rectovaginal fistula repair
- timing
- preop prep
- abx at surgery
- layers to reapproximate
Dentate line defines high or low fistula
Timing: at time of damage or 3-4 months after (wait for inflammation/infection to settle)
Preop: Abx if infection present. Liquid diet 24-48 hrs prior. Bowel prep - Golytely 1 L/hr till clear effluent beginning 24-48hrs prior. Max 4 hrs of golytely.
Surgery: Abx - 2g cefoxitin or 1g cefotetan
3 Layers
1. rectal submucosa - interrupted 3-0 or 4-0 vicryl
2. muscularis - 2-0 vicryl (removes tension from first suture line)
3. vaginal mucosa
also repair the puborectalis muscle
suture material
tension bearing = 2-0 vicryl
non-tension bearing = 3-0 vicryl or smaller
Watery vaginal discharge following TLH ddx (4)
ddx includes
- vesico-vaginal
- uretero-vaginal
- urinoma drainage from ureteral injury
- incomplete closure of vaginal apex
Urovaginal fistula - describe tampon dye test
Dual tampon dye test
– tampon in vagina
– PO pyridium (makes urine orange)
– instill methylene blue dye with saline into bladder
Vesicovaginal (bladder into vagina) = blue
Ureterovaginal (ureter into vagina) = orange
Urovaginal fistula diagnostic tests in general
tampon dye test
cystoscopy - identifies bladder vagina fistula visually
retrograde pyelography - tells you if ureters are intact and not leaking (ureteral integrity)
IVP - less useful for finding urethral integrity test, can miss a urethral leakage next to trigone with a small leak
Vesico-vaginal fistula management
Conservative
- foley for 4-6 weeks
- or 12 weeks if 6 is not enough
Surgical
3 layer closure - first excise fistulous tract, then mobilize and reapproximate the bladder submucosa, bladder muscularis, vaginal mucosa
Latzko technique (fistula < 1.5 cm) - don’t dissect fistula. just close the vagina with partial colpocleisis. may shorten vagina.
Uretero-vaginal fistula management
have to have cysto and CT urogram to identify where fistula is and exclude bladder injury
Lower ureter: ureteral catheter stenting, 30% healed at 3-4 weeks
– if failed spontaneous healing, then ureteroneocystotomy with CT urogram 2-3 weeks postop
High ureter: percutaneous nephrostomy for renal decompression, thne ureteral reimplantagion at 12w post op, then CT urogram 2-3 weeks postop
Bladder injury - intraoperative cystotomy
- Risk factors
Discuss pros and cons of routine cystoscopy at time of hysterectomy
RF:
- previous pelvic surgery
- inflammatory disease
- distortion of local anatomy
- operator experience
Bladder injury - how to repair depends on location relative to…?
how to close bladder - sutures and layers
how long does foley cath stay in
abx? yes or no
- location relative to trigone
- ureteral assessment/stenting by cystoscopy
- closure in 2-3 layers:
— mucosa/submucosa - 3-0 vicryl running
— muscularis - 3-0 vicryl interrupted
— bladder serosa - 2-0 vicryl interrupted
Check for leaks/cystoscopy
Foley catheter stays for 3-7 days (or 5-14 days) followed by voiding trial or voiding cystourethrogram to confirm injury has healed
no antibiotics indicated
Ureteral injury
- rate
- most common sites are…? there are 4
Rate by route
abd hyst - 0.1 - 1.7%
vag hyst - 0 - 0.1%
only 1/3 of injuries are identified intraop
most common sites
vaginal cuff repair
near uterosacral ligament
IP ligament
ligation of the cardinal ligaments/uterine arteries
How to evaluate ureteral injury
3 main considerations
- duration of injury
- distance from ureterovesical junction
- can repair without tension?
For injury >5 cm from uretero-vesical junction, what is the management? No tension
direct end to end reanastomosis
spatulate the ureteral ends
use 4-6 interrupted sutures of 4-0 vicryl
ureteral stenets and foley catheter for 10 days
For injury <5 cm from uterovesical junction, what is the management? No tension
Bladder reimplantation
Ureteral injury with tension? Management options
Call expert!
- psoas hitch
- boari flap
- contra-lateral ureto-ureterostomy (rare)
Bowel injury considerations
Size of injury
Type of injury (thermal or sharp)
Location (small intestinal, terminal ileum, large colon)
Vascular supply
Existence of fecal contamination
Which direction to close bowel injury and why
Always close the injury PERPENDICULAR to long axis of bowel
- this avoids narrowing the lumen (shorten long axis versus width)
Bowel or bladder injury…Closure in two layers - what two layers and what sutures
Mucosal/submucosal layer
and
Muscaularis/serosa reinforcing layer
Use interrupted or continuous
Multiple sutures are okay
Nerve injuries
- prevalence
- most common reason why
2% of pelvic surgery
usually from patient position or retraction
Type of nerve injuries
Transection
Entrapment
Compression/stretching
Numbness above incision in triangle shape pointing towards umbilicus
what kind of nerve injury of which nerve? and how?
Likely from dissection of the anterior rectus sheath which can injure terminal sensory fibers during a transverse abdominal incision
nerves: iliohypogastric and ilioinguinal
usually resolved in 6 monthsS
Sharp burning lancinating pain, radiates from incision to suprapubic area, labia or thigh. paresthesia over the area. Relief with local anesthetic.
what kind of nerve injury of which nerve? and how?
entrapment of nerve from sutures at the lateral poles of transverse fascial incision during transverse abdominal incision
nerves: iliohypogastric and ilioinguinal
Sensory deficit of the anterior/medial thigh
Motor weakness of hip flexion and knee extension
what kind of nerve injury of which nerve? and how?
compression of nerve against pelvic sidewall with very deep or lateral placement of retractor blades. also with excessive hip adduction with vaginal surgery
nerve: femoral
usually resolves spontaneously
Perineal, mons and vulvar pain which worsens when seated.
what nerve and what kind of injury during what surgery?
pudendal nerve S2-4
entrapment or injury during SSLF or pelvic reconstructive surgery
motor symptoms - weakness of knee flexion and dorsiflexion of foot
sensory symptoms - plantar foot involved
what nerve, how?
sciatic nerve
extensive external rotation of hip and incomplete flexion of the knee from candy cane stirrups during vaginal surgery
