Gyn Surgery complications

Question 1

What are most common causes of nerve injury during pelvic surgery?

Answer 1

1. Transection from incision, tracer insertion or thermal injury
2. Entrapment: ligation for bleeding control, pelvic reconstruction
3. 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

Question 2

Describe injury w/ iliohypogastric or ilioinguinal nerve?

Answer 2

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

Question 3

Describe injury w/ femoral nerve?

Answer 3

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

Question 4

Describe injury w/ pudendal nerve (S2-4)?

Answer 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

Question 5

Describe injury w/ sciatic nerve?

Answer 5

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.

Question 6

Describe injury w/ perineal nerve?

Answer 6

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

Question 7

Describe injury w/ obturator nerve (L2-4)?

Answer 7

UNCOMMON
- paravaginal repair (TOT sling)

• inability to adduct thigh, numbness of inner thigh
• PT will help

Question 8

What are risk factors for cystotomy?

Answer 8

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

Question 9

How do you perform a cystotomy repair?

Answer 9

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.

Question 10

How would you manage bladder injury that appeared superficial?

Answer 10

• 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.

if you cauterize bladder, resect area with 1cm margin and repair in 2 layers

Question 11

What are most common sites of ureteral injury?

Answer 11

1. crossing of ovarian vessels in IP
2. crossing of uterine vessels
3. level of cadrinal/uterosacral ligaments
4. adjacent to vaginal apex closure and uterosacral ligament plication sutures.

Question 12

How do you avoid ureteral injury?

Answer 12

• 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!!

Why do you do cysto for all cases: advantage of detecting ureteral injury at time of surgery to decrease morbidity.

Question 13

How do you recognize delayed ureteral injury? How do patients present?

Answer 13

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.

Question 14

What is location of ureter?

Answer 14

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

Question 15

How do you manage ureteral injury?

Answer 15

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.

Question 16

What is septic pelvic thrombophlebitis?

Answer 16

can occur 2/2 pelvic vein endomthelial damage, venous stasis, hyper coagulability
- usually postpartum after CD on r side
- ddx of eclusion
- if F>5d of Abx and no abscess
- ANTIBIOTICS: broad spectrum (Unasyn - amp-sulbactam or gent+clinda) x 1 week.

• Tx=continue abx and start anticoagulation (heparin)
• presumed diagnosis if fever resolves within 48hr of starting heparin. continue for 48hr if no confirmed thrombosis. If confirmed, continue for 2-6w

Question 17

What are steps of appendectomy?

Answer 17

LSC
- isolate meso-appendix.
- cauterize/divide with 5mm ultrasonic shears
- skeletonize to base of appendix. staple across base, excise it.
- inspect stump for hemostasi
- remove specimen in bag. suction and irrigate.

OPEN
- dissect emo-appendix and ligate vessels
- clamp/cut base of appendix
- purse string suture around base.

Question 18

What is VTE?

Answer 18

Virchow’s Triad
- hyper coagulable state
- stasis
- endothelial damage.

• thrombophilias occur in 50% cases
  Factor V leiden 5% thrombosis risk
  Prothrombin G
  Protein C and S
  Antithrombin (greatest thrombosis risk of 30-50%!)
  Antiphospholipid syndrome ~5%

multiple mutations can occur in protein C,S, factor V Leiden carriers

Question 19

What are inherited and acquired thrombophilias?

Answer 19

Inherited: Factor V leiden (ddx=factor V mutation)

Acquired: Antiphospholipid syndrome (ddx=lupus anticoagulant, anti-cardiolipin, anti-b2 glycoprotein)

Either:
- Antithrombin (ddx=antithrombin level)
- protein C,S (ddx=activity level)

Question 20

What is Caprini score?
What gives you 1,2,3, and 5 points?

Answer 20

assess risk of VTE, good for preoperative period

+1: age 41-60, minor surgery, BMI >25, OCP, HRT, SERM use, pregnancy, acute MI

+2: age 61-74, LSC or open surgery >45 min, arthroscopic surgery, malignancy

+3: age >75, hx VTE, any thrombophilia, HIT

+5: stroke <1 month, hip/pelvis/leg fracture

Question 21

What are recommended thromboprophylaxis by VTE level?

Answer 21

Low risk: Caprini score 1-2 - mechanical ppx

Mod risk: score 3-4 - mechanical or pharmacologic

High: score >5 : pharmacologic + mechanical

• can start pharmaco-prophylaxis 2-12 hrs pre-operatively.

Question 22

What is a risk factor for major bleeding during surgery?

Answer 22

active bleeding
acute stroke
complex surgery
comcomitant use of anticoagulants, antiplatlet
known untreated bleeding disorder
LP, epidural or spinal anesthesia
malignancy
severe renal/hepatic failure
thrombocytopenia
uncontrolled HTN

Question 23

What is fondaparinux?

Answer 23

indirect factor Xa inhibitor
- used if UFH/LMWH contraindicatedW

Question 24

What is a DOAC?
What is peri-op management?

Answer 24

• direct oral anticoagulant agents
  rapid onset/rate of clearance
• equivalent to LMWH

Direct factor Xa inhibitors: rivaroxaban (Xarelto) or apixaban (Eliquis)

Direct thrombin inhibitors (dabigatran)

Low/mod risk: stop 1 day prior to surgery, resume 24hrs post procedure.

High risk: stop 2 day prior, resume 2 day post surgery.

Question 25

when is estrogen-containing contraception contraindicated?

Answer 25

• major surgery with anticipated prolonged immobilization
• discontinue 4-6w prior to procedure
• if expect pt to be ambulatory post-op, DO NOT DISCONTINUE.

Question 26

What are recs for UFH and LMWH prophylaxis with surgery?

Answer 26

UFH: no incr risk hematoma w/ neuraxial. administer 4-6hrs before catheter placement/removal.
- can give prophylactic dose w/ catheter in-situ or immediately after removal.
- if no epidural, can give 6-8hrs post procedure

LMWH: administer 12hrs before catheter placement/removal.
- hold for 4 hrs after removal.
- if no epidural, can give within 24hrs surgery if hemostasis.

Question 27

What is a DVT?
What are risk factors?

Answer 27

RF: age>40, malignancy, prolonged surgery (>30min), obesity, delayed post-op ambulation, medical dx (DM, HF, COPD, prior DVT)

Differential: DVT, fluid retention 2/2 fluid overload, nephrotic syndrome

sx: warm, swollen calf >3cm difference in calf circumference, tender

• Homans: sign: tenderness in popliteal area when foot actively dorsiflexed. not super reliable.

Treatment: if 1st, 3 months.

Question 28

What is clinical presentation and workup of PE?
What is differential diagnosis?

Answer 28

Dyspnea, chest pain, tachypnea, hemoptysis, tachycardia

Differential: MI, PNA, asthma, fluid overload, CHF, intra-abdominal bleeding

Workup: apply modified Wells (ask if PE likely or unlikely!)
- if PE unlikely, get D-dimer. if elevated -> CTPA (pulmonary angiography)
- if PE likely, do CTPA

Question 29

What is treatment of PE?

Answer 29

Medical:
- LMWH, fondaparinux, UFH, Doacs
-heparin=cofactor for antithrombin, inhibits thrombin and factor Xa
- loading dose: 100units/kg for DVT, 150 units/kg for PE
- complications: osteoporosis, alopecia, and thrombycytopenia.

1. IV heparin (establish PTT at 1.5-2.5x normal, then initiate warfarin same day. rapid onset
   — good for severe renal failure, hemodynamically unstable, extensive clot burden
2. LMWH (requires renal dosing): 1mg/kg BID or 1.5mg/kg daily. start warfarin same day or after. PTT/PT normal. longer half life, lower risk major bleeding. no reversal agent.
   - good for poor oral intake or pregnancy.
3. DOACs: oral, fixed dose. Factor Xa or direct thrombin inhibitors. no lab monitoring, avoid with renal impairment. cannot use in pregnancy/breastfeeding.
4. Fondaparinux SubQ: alternative to lovenox if history of HIT. Dose 5, 7.5 or 10mg depending on weight.

Question 30

What are types of ureteral repairs for injury?

Answer 30

> 5cm above UVJ=ureteroureterostomy (end-to-end anastomosis)
- interrupted sutures of 4-0 chromic through full thickness of cut edge.
- use drain
- ureteral stents + foley x 10d

<5cm above UVJ=ureteroneocystotomy (implant ureter directly into bladder)
- if can’t do without tension, consider Psoas hitch or Boari flap.

• consider nephrostomy if unable to perform primary ureteral repair!

Question 31

How do you repair bowel injury?

Answer 31

run the bowel prior to any repair to identify exact site of injury from Ligament of Treitz to Ileocecal valeve.
- repair perpendicular to intestinal axis to prevent stricture. Repair mucosa and muscular with 4-0 vicryl. repair serosa with 3-0 silk as second layer

• small bowel laceration parallel to long axis of bowel: closure end-to-end. close mucosa/muscularis in single layer with interrupted 3-0 and muscularis/serosa with 3-0 non-absorbable.
• small bowel laceration at right angle to long axis of bowel: side-to-side closure.
• AVOID luminal narrowing.

Question 32

How do you inject lidocaine?
What is max dose of lidocaine?

Answer 32

Inject at cervico-vaginal junction at 4 and 8 o’clock. Avoid cervical branches of uterine artery at 3 and 9 so avoid that. Drawback before injecting to make sure not in vessel.

WITHOUT epi? 4-5 mg/kg or 30cc
WITH EPI: 7mg/kg or 50cc

Question 33

How do you manage bladder perforation w/ sling?

Answer 33

can cause direct injury to bladder or urethra
- if suspected, need circumferential cysto.
- If see perforation, remove sheath/trocar and empty bladder. Then replace trochar hugging posterior surface of pubic bone. repeat cysto. If no further injury, continue procedure.

Question 34

What is differential diagnosis and workup for post-op fever after TAH?

Answer 34

• intraperitoneal hemorrhage or hematoma
• retroperitoneal hemorrhage of hematoma
• vaginal cuff cellulitis
• occult dehiscence or impending evisceration
• acute ureteral obstruction
• cystitis, pyelonephritis
• bowel perforation, bowel ischemic injury
• cystotomy w/ urine drainage causing urinoma
• pneumonia
• retained foreign body

Management: vitals, monitor UOP and pain, PE, CBC w/ diff, CMP, amylase/lipase, UA/UCx, imaging. SERIAL PHYSICAL EXAMS.

Question 35

What is differential for vaginal bleeding/discharge post-hyst?

Answer 35

• retained suture
• granulation tissue (tx=silver nitrate or vaginal estrogen if post-menopausal)
• entrapment of intra-peritoneal tissue (fallopian tube/bowel)
• traumatic bleeding (coitus, tampon)
• retained vaginal sponge

Question 36

What is C. diff colitis?
Workup and treatment?

Answer 36

consider if N/V or diarrhea post surgery.

workup: exam w/ rectal exam and stool occult blood test.
- assess for WBC >15K and serum Cr >1.5 (suggests severe CDI).
- fulminant colitis if hypotension or shock, ileus or megacolon.

tx=oral fidaxomicin or vancomycin for 10d

Question 37

What is differential for 4 months post ex lap with new abdominal pain/cramping?

Answer 37

Acute GI illness (viral gastroenteritis, food poisoning)
Post-op adhesions w/ partial SBO
Incisional hernia w/ bowel incarceration (hernias occur in 3% benign surgery and 5% gyn onc)
Cholecystitis

• examine margins of fascial defect (may have multiple distinct defects like Swiss cheese)
• ask pt to valsalva to detect hernia, need supine and standing positions.
• if need testing (obese), CT.

If hernia <1cm, primary repair. larger needs mesh

Question 38

What is management of a delayed ureteral injury?

Answer 38

CTAP w/ contrast. If not definitive, cysto + retrograde pyelography.

If incomplete injury: retrograde ureteral scenting.
- IF complete transection: formal repair within 7d
- If >7d post injury, retrograde imaging + stent. OR percutaneous nephrostomy then repair at 3mo.

Question 39

How would you repair bowel injury to serous, small and large bowel?

Answer 39

Serosa: examine w/ laparoscope. close w/ interrupted absorbable suture incorporating sears and outer muscular.

Small bowel:
- small defect: continuous or interrupted 3-0 silk.
- full thickness: 2 layer closure.
- large defect: stapling device or resection + re-anastomosis.

Large bowel
- risk of stricture LOWER bc lumen larger.
- irrigate abdomen after repair.

If abx pre-op, no additional abx needed. If no abx given, need broad-spectrum abx.

Question 40

How do you manage retroperitoneal bleeding?

Answer 40

avoid opening. retroperitoneal is an enclosed space so natural limitation on bleeding process. if open -> unenclosed and uncontrollable hemorrhage.

IF OPEN RETROPERITONEAL SPACE:
- call in specialists: vascular surgeon, gyn onc, notify blood bank, institute massive transfusion protocol.
- primary concern=ureteral injury during exploration
- expanding hematoma from pedicle expands into pelvic sidewall on LATERAL aspect of ureter.
- do cysto before closing abdomen, if ureter compromised, release sutures sequentially beginning at most inferior placement site. consider stents.

Question 41

What is Veress needle injury?

Answer 41

• can affect viscera (small bowel/colon/bladder/uterus)
• vasculature (IVC, aorta, iliac vessels)
• retroperitoneal blood vessels
• need proper pt positioning (AP diameter of peritoneal cavity is 8-10cm in slender pt). avoid clamps or towel clips to elevate bc misdirects needle.

IF INJURY:
- notify all OR staff, prep for ex lap
- immediate ex lap if confirmed bowel injury, vascular injury, intraperitoneal bleeding w/o identifiable vessel injury
- lsc management if mental injury, retroperitoneal hematoma not-expanding, injury to bladder (need foley) or uterus.

Question 42

What is a step for identifying lost lap during surgery?

Answer 42

Xray of entire operative field.
- if not in Xray (2-dimensional space identification only), do fluoroscopy w/ C-arm to perform 3-D assessment and localization.

Question 43

What is differential for oliguria after TAH?

Answer 43

• obstructed or misplaced foley
• volume depletion from dehydration or inadequate resuscitation
• intraperitoneal or retroperitoneal hemorrhage
• obstructed ureter 2/2 suture entrapment, ligation in a pedicle, surgical division or kinking
• intra-op cystotomy w/ urine drainage intra peritoneal
• acute renal dz like RTA

Workup:
- replace foley
- assess I/O
- IVF bolus (500cc)
- BMP, Nephro consult prn

Question 44

When to transfuse post-op?

Answer 44

Assess vitals, intra-peritoneal bleeding, Hct/hgb.
- consider at Hgb 7-8 g/dL. Give 1u pRBC and check post-transfusion Hgb (as early as 15min post)

• consider transfusion at 8-10 if symptomatic anemia, ongoing bleeding or conditions who can’t tolerate anemia (CVD, pulmonary dz, immunocompromised, therapeutic anticoagulation).

can have febrile non-hemolytic transfusion reaction (aka simple febrile): self-limited, occurs in 1%. give antipyretic.

Question 45

What is management of diabetes in peri-op period?
What are post-op risks?

Answer 45

Risk of peri-op complications, infection, CV morbidity/mortality.

Pre-op: H&P for end organ dz (retinopathy, nephropathy, coronary dz, peripheral vascular, HTN).
- CBC, CMP, a1c, glucose
- EKG, CXR
- pulmonary and cards clearance

Post-op risks:
- healing complications (wound infxn, breakdown)
- hematoma/seroma/wound collections
- fascial dehiscence
- ileus/SBO
- thrombotic
- cardiovascular events

Do surgery 1st thing in AM. hold insulin, use iV insulin at 1u/hr. check BG q1-2hrs. continue insulin until pt starts eating.

Question 46

What is peri-op management of Coumadin?

Answer 46

• withhold for 5d prior to surgery to let iNR normalize. If stop less than 5d prior, check INR (goal < 1.5. If higher, give oral Vitamin K and recheck INR next day).
• bridge if high risk VTE. start SQH 5K 3d prior to surgery, hold 5 hrs prior to surgery.
• can also use Lovenox (start 3 day pre-op), anti Xa 0.1-0.3
• resume Coumadin by 24hrs post-op. takes 5-10d to achieve full anticoagulant so need bridging agent if high risk.

Question 47

What are risk factors for VTE?

Answer 47

recent surgery
recent immobilization
prior VTE
obesity
LE trauma
malignancy
hormone use
pregnancy/postpartum
heart failure
thrombophilia
APLS

• need pre-op VTE risk assessment w/ Caprini score for all patients!!

Question 48

What are reversal agents for heparin and warfarin?

Answer 48

Heparin: protamine sulfate 50mg IV

Coumadin/warfarin: Vit K PO/IM/IV.

Question 49

What is evaluation of post-op pelvic abscess?

Answer 49

Differential: SSI, vaginal cuff or pelvic cellulitis, infected uroma, infected hematoma, septic pelvic thrombophlebitis, pelvic abscess, necrotizing fasciitis, pyelonephritis, bowel perf, PNA.

Eval: CBC, CMP, amylase/lipase, vaginal cultures, GC/CT, UA/UCx, BCx
- imaging w/ CTAP, renal US, CXR
- Tx: surgical re-exploration, need type and cross.
- empiric abx for aerobes and anaerobes: Zosyn (piperacillin/tazobactam) or CTX + flagyl or clinda. if PCN allergic: aztreonam + clinda.
- continue IVF until afebrile for 48hr, then PO for 14d (flagyl + Bactrim or augmentin).

Question 50

What is surgical management of post-op pelvic abscess?

Answer 50

• Midline vertical incision. Get Cultures, drain abscess, excise necrotic tissue
• irrigate pelvis copiously w/ 2-3L
• inspect for additional collections. find origin of abscess (ruptured appendicitis’s diverticulitis, Meckel’s diverticulum)
• place drain if lots of inflammation.
• close fascia w/ delayed absorbable (PDS - lasts 12wks), do NOT close subQ. Close skin.

Question 51

What is differential diagnosis for serosanguinous drainage from laparotomy incision?

Answer 51

Wound seroma- limited to subcutaneous tissues
Wound hematoma
Fascial and peritoneal dehiscence w/ impending evisceration
Fistula of ureter or bladder.

RF: obesity, diabetes, choice of suture material.

Management: palpate incision, probe drainage tract. culture any fluid. apply wet-to-dry dressings for secondary healing. don’t need abx if no cellulitis.

Question 52

How would you manage alcoholic patient peri-operatively?

Answer 52

RISKS:
- hepatic disease affects metabolism of anesthesia, pain meds, hemostasis.
- nutritional deficiency affects healing (SSI)
- post-op withdrawal
- cardiovascular events (CVA, MI)
- injury from falls/trauma
- polysubstance abuse.

PRE-OP
- alcohol/drug hx
- CBC, CMP, coags, EKG, CXR
- cardiac clearance, psych consult, tox screen

PERI-OP:
- benzos to prevent withdrawal: valium or lorazepam day of and post-op.

• to prevent stress-induced Wernicke-Korsakoff: daily thiamine 100mg PO/IV and multivitamin infusion

Question 53

Where could you have bleeding from TAVH post-op? From bottom to top

Answer 53

Vaginal apex/cuff, uterosacral/cardinal ligaments, uterine artery pedicle, IP pedicle

If cant see bleeding on exam, go to OR. look vaginally and then LSC if necessary. On lSC, if not coming from IP or uterine, fix from below.

If bleeding from r uterosacral ligament pedicle, use figure-of-eight stitch. Clamp pedicle and draw it towards midline to separate from pelvic sidewall where ureter is before stitch!

Question 54

What to do to intra-operatively and post-operatively to decrease risk of cuff dehiscence?

Answer 54

INTRAOP: Avoid cautery with colpotomy, full-thickness closure, adequate margins with bites 1cm.

Post-operatively: pelvic rest for 6 wks, bowel regimen

Question 55

What are causes of fistulas?

Answer 55

pelvic surgery, vaginal delivery, perineal lacerations, radiation, trauma, cancer, infection, IBD.

How to differentiate prolapsed fallopian tube vs fistula: watery vaginal dyscharge and dyspareunia. Vesicovaginal fistula: PAINLESS vaginal discharge.

Question 56

How do you manage an expanding broad ligament hematoma?

Answer 56

pressure. Then can try ligating uterine-ovarian ligation bc likely cause of bleeding. Pack and pray.
- call vascular surgery or gyn onc. hyst or if stable, call IR for embolization.