GYN surgery complication

Question 1

Mesh erosion incidence

Answer 1

5-19% in all cases?
retropubic sling: 1.4%
Transobuturator sling: 2.2%

Question 2

Rectovaginal fistula repair
- timing
- preop prep
- abx at surgery
- layers to reapproximate

Answer 2

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

Question 3

Watery vaginal discharge following TLH ddx (4)

Answer 3

ddx includes
- vesico-vaginal
- uretero-vaginal
- urinoma drainage from ureteral injury
- incomplete closure of vaginal apex

Question 4

Urovaginal fistula - describe tampon dye test

Answer 4

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

Question 5

Urovaginal fistula diagnostic tests in general

Answer 5

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

Question 6

Vesico-vaginal fistula management

Answer 6

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.

Question 7

Uretero-vaginal fistula management

Answer 7

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

Question 8

Bladder injury - intraoperative cystotomy
- Risk factors

Discuss pros and cons of routine cystoscopy at time of hysterectomy

Answer 8

RF:
- previous pelvic surgery
- inflammatory disease
- distortion of local anatomy
- operator experience

Question 9

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

Answer 9

• 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

Question 10

Ureteral injury
- rate
- most common sites are…? there are 4

Answer 10

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

Question 11

How to evaluate ureteral injury
3 main considerations

Answer 11

1. duration of injury
2. distance from ureterovesical junction
3. can repair without tension?

Question 12

For injury >5 cm from uretero-vesical junction, what is the management? No tension

Answer 12

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

Question 13

For injury <5 cm from uterovesical junction, what is the management? No tension

Answer 13

Bladder reimplantation

Question 14

Ureteral injury with tension? Management options

Answer 14

Call expert!
- psoas hitch
- boari flap
- contra-lateral ureto-ureterostomy (rare)

Question 15

Bowel injury considerations

Answer 15

Size of injury
Type of injury (thermal or sharp)
Location (small intestinal, terminal ileum, large colon)
Vascular supply
Existence of fecal contamination

Question 16

Which direction to close bowel injury and why

Answer 16

Always close the injury PERPENDICULAR to long axis of bowel
- this avoids narrowing the lumen (shorten long axis versus width)

Question 17

Bowel or bladder injury…Closure in two layers - what two layers and what sutures

Answer 17

Mucosal/submucosal layer
and
Muscaularis/serosa reinforcing layer

Use interrupted or continuous
Multiple sutures are okay

Question 18

Nerve injuries
- prevalence
- most common reason why

Answer 18

2% of pelvic surgery
usually from patient position or retraction

Question 19

Type of nerve injuries

Answer 19

Transection

Entrapment

Compression/stretching

Question 20

Numbness above incision in triangle shape pointing towards umbilicus
what kind of nerve injury of which nerve? and how?

Answer 20

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

Question 21

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?

Answer 21

entrapment of nerve from sutures at the lateral poles of transverse fascial incision during transverse abdominal incision
nerves: iliohypogastric and ilioinguinal

Question 22

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?

Answer 22

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

Question 23

Perineal, mons and vulvar pain which worsens when seated.
what nerve and what kind of injury during what surgery?

Answer 23

pudendal nerve S2-4
entrapment or injury during SSLF or pelvic reconstructive surgery

Question 24

motor symptoms - weakness of knee flexion and dorsiflexion of foot
sensory symptoms - plantar foot involved
what nerve, how?

Answer 24

sciatic nerve
extensive external rotation of hip and incomplete flexion of the knee from candy cane stirrups during vaginal surgery

Question 25

foot drop, paresthesia/sensory loss over dorsum of foot and lateral shin
what nerve, how, resolution?

Answer 25

peroneal nerve (lateral tibial surface)
from allen stirrups, too much pressure on the upper tibia laterally
resolves within 3-6 months

Question 26

inability to adduct thigh, numbness of inner thigh

Answer 26

obturator nerve L2-4
uncommon, but can happen during radialcl pelvic surgery for malignancy, TOT urethropexy

PT is effective generally