Gyn Surgery complications Flashcards
What are most common causes of nerve injury during pelvic surgery?
- Transection from incision, tracer insertion or thermal injury
- Entrapment: ligation for bleeding control, pelvic reconstruction
- Compression/stretching: positioning, retractors, hematoma.
2% incidence of injury after pelvic injury - likely 2/2 patient position/retraction.
Prevention:
- proper pt positioning (Avoid hyperflexion/extension)
- use padding
- avoid lateral extension of transverse incisions beyond border of rectus muscles
Describe injury w/ iliohypogastric or ilioinguinal nerve?
2/2 dissection of anterior rectus health.
- numbness above incision (triangular area w/ apex towards umbilicus)
- sharp burning lancinating pain radiates to suprapubic area/labia/thigh
-parathesias
- pain relief w/ local anesthetic.
- resolves in 6 mo
- entrapment 2/2 sutures near transverse fascia
Describe injury w/ femoral nerve?
Deep pelvic surgery (Eg TAH)
- compression of nerve against pelvic sidewall 2/2 retractors or excessive hip abduction w/ vaginal surgery
- Risks: thin patient, wide pfannensteil/maylard incision, >4hrs surgery time, narrow pelvis, self-retaining retractors
- incidence 8%, 90% resolves spontaneously
Sx:
- sensory deficit of anterior/medial thigh
- motor sx w/ weakness of hip flexion and knee extension
Describe injury w/ pudendal nerve (S2-4)?
Risk of entrapment/injury during sacrospinous ligament fixation or pelvic reconstruction.
Sx:
- perineal/mons and vulvar pain. worse w/ sitting
- pain responds to nerve blocks
- surgical decompression=BEST
Describe injury w/ sciatic nerve?
2/2 use of candy-cane stirrups (external rotation of hips and incomplete flexion at knee)
- sx=weakness of knee flexion, foot dorsiflexion. sensory sx of plantar foot.
Describe injury w/ perineal nerve?
2/2 allen stirrupts
- pressure of leg on upper lateral tibial rea
- sx=foot drop (Resolves in 3-5 mo)
- paresthesias/sensory loss over foot/lateral shin
Describe injury w/ obturator nerve (L2-4)?
UNCOMMON
- paravaginal repair (TOT sling)
- inability to adduct thigh, numbness of inner thigh
- PT will help
What are risk factors for cystotomy?
0.5-1% pelvic surgery, 6x more common in abdominal vs vaginal.
- prior operation at peritoneal bladder reflection (i.e. CS)
- inflammatory disease (endometriosis)
- mass distorting local anatomy (fibroid)
- operator experience.
usually occurs ABOVE trigone and lower ureters. can cysto to assess proximity to trigone
- if trigone defect, call specialist bc risk of ureteral injury
How do you perform a cystotomy repair?
mark bladder wall margins, repair w/ interrupted suture in 2 -3 layers.
- bladder submucosa
- muscular layer
- bladder serosa
- if small (<1cm), can manage w/ maintaining foley for 5-7d, confirm closure w/ cystogram.
- check for leakage: backfill bladder w/ methylene blue or sterile milk.
- if concern for ureteral injury: IV fluorescein, then cysto so see bilateral ureteral jetting.
- indwelling catheter x 5-14d, no antibiotics. consider voiding cyst-gram before removing catheter.
How would you manage bladder injury that appeared superficial?
- confirm depth of injury with cysto
- if appears superficial, can oversew but more conservative is to excise area in full thickness nd repair in 2-3 layers w/ delayed absorbable suture. foley for 5d.
- full thickness injury, manage w/ full thickness resection w/ 1cm margins, 2-3 layer repair and foley.
What are most common sites of ureteral injury?
- crossing of ovarian vessels in IP
- crossing of uterine vessels
- level of cadrinal/uterosacral ligaments
- adjacent to vaginal apex closure and uterosacral ligament plication sutures.
How do you avoid ureteral injury?
- proper pt selection for hyst. adequate mobility of uterus
- maintain adequate exposure
- careful attention to clamp placement
- If incidental cystotomy, identify ureters (consider scenting) prior to closure.
- surgical experience!!
How do you recognize delayed ureteral injury? How do patients present?
present in first 2 weeks post-op
- sx can be subtle:
- anuria/oliguria
- hematuria
- flank pain
-fever
- GI sx (N/V, ileus, pain, distention)
- leakage of clear fluid from vagina or abdominal incision.
What is location of ureter?
Abdominal and pelvic segments. total length=30cm.
- Abdomen: runs along anterior surface of psoas muscle to level of pelvic brim.
PELVIS:
- enters pelvis at common iliac bifurcation and descents into posterior lateral pelvic sidewall.
- becomes more medial -> under uterine artery and then enters trigone
How do you manage ureteral injury?
Intra-op: cysto. If have kinking/ligation w/ suture, remove suture and cysto to verify function. If efflux absent/abnromal, consult Urogyn or urology. If urology not available, video/photo documentation of injury. place JP drain to prevent Intraperitoneal uromaa formation. transfer to another institution.
- identify injury site and determine type of injury (Entrapment, crush injury, transection, thermal)
- free ureter and excise injured tissue
- perform ureteroneocystotomy.
- pass stent through urethra, out through small bladder base incision and into end of ureter and kidney
- split ureteral end to enlarge lumen. sutures placed on end of ureter and then through bladder layers.
- leave stent in for 10-14d
- IVP performed after 2 weeks to assess for stricture.
Delayed:
- CTAP. If not definitive, cysto w/ retrograde pyelography. Do retrograde ureteral stenting.
- consider percutaneous nephrostomy and repair 3 months later.
