Gynae surgery and anatomy Flashcards
Obese lady day 6 post hysterectomy. She was febrile and placed on IV antibiotics. On day 3 the wound began to discharge large amount of a clear fluid. Your management will be:
a - change antibiotics
b - perform erect and supine abdominal Xray
c - return to operating theatre
c - return to operating theatre
Working diagnosis is sheath dehiscence
What effect does an electrical waveform have if it is high-current, low-voltage and elevates the tissue temperature rapidly (>100 degrees celcius) to produce vaporisation?
a. Cutting
b. Fulguration
c. Coagulation
d. Dessication
e. Blend
a - Cutting
O
Fulguration
- Low voltage
- Electrical current jumps or arcs between the tip and the nearby tissue –> char
- Used to control bleeding over a wide area
- Coag, Non-contact
Dessication
- At higher temp, both dehydration and protein denaturation occur –> desiccation
- Cut or coag, contact
Coagulation
- high voltage
The proven benefits of subtotal hysterectomy include:
A - reduced hospital stay B - better sexual function C - reduced risk of vault prolapse D - all of the above E - none of the above
E - none of the above
Milford
Less surgical time, lower risk of ureteric injury
A 30 yo with TAH for intraepithelial Ca of the cervix. Flushed, temp 39 C, PR 140/min, RR 24, clear chest. Most likely diagnosis?
A - PE B - Pelvic sepsis secondary to bacteroides fragilis C - Beta Strep D - Pelvic vein thrombosis E - Reaction to blood
B - Pelvic sepsis secondary to bacteroides fragilis
bacteroides fragilis
- normal microbe of human colon
Milford answer - B
*CHECK as other answer says C
You are performing an endocervical curettage, which of the following is true?
A - dilate the internal os, perform the endocervical curettage, then uterine curettage
B - dilate the internal os, perform the uterine curettage, then perform endocervical curettage
C - perform endocervical curettage, dilate internal os, then perform uterine curettage
D - perform uterine curettage, dilate the internal os ,then perform endocervical curettage
C - perform endocervical curettage, dilate internal os, then perform uterine curettage
When is the least sensible time to remove a 45 yo woman’s ovaries?
A - during operation for a fibroid uterus with a family history of ovarian cancer
B - during operation for endometriosis with bowel involvement
B - during operation for endometriosis with bowel involvement
- Lower risk of re-operation if removal at time of surgery for endometriosis
- FHx depends on if BRCA or not
During a TAH for severe endometriosis a 1cm longitudinal laceration is made in the sigmoid colon. Your management would be:
A - anterior resection B - hemicolectomy C - repair defect in colon D - repair defect and form transverse loop colostomy E - repair defect and form caecostomy
C - repair defect in colon
Anterior resection - involves sigmoid and part of rectum
Up To Date - for discrete large bowel injuries, colostomy is rarely needed
The most likely place of damage and haemorrhage in suction D&C?
a - anterior laceration of corpus
b - posterior laceration of corpus
c - lateral laceration of corpus
d - cervical laceration
d - cervical laceration
ND YAG laser hysteroscopy. Which medium?
A - CO2 B - Glycine C - Dextrose D - Sorbitol E - N Saline
E - N Saline
Consensus from previous and Baggish & Karram
If using coag / current, need to use glycine as distension medium as non-conducting
Operative hysteroscopy – when are you most likely to perforate?
A - dividing septum
B - submucous fibroid resection
C - rollerball
A - dividing septum
TeLindes
Milford
Ten days after a vag hyst a patient developed a watery vaginal discharge. IVP demonstrated a uretero-vaginal fistula 3cm above the ureterovesical junction. What is the appropriate treatment?
A - uretero-ureteral reanastamosis B - reimplantation of the ureter C - perform a Boari flap D - end to end reanastomosis E - insertion of a suprapubic catheter and await spontaneous closure
B - reimplantation of the ureter
UTD says only reimplant if 2cm from VUJ
RCOG article says reimplant if =5cm
Advantages of hysteroscopic scissors which slip over scope but in sheath.
A - cost
B - flexible distance between scope and scissors
C - heavier more robust rigid scissors possible
D - scissors only take up 1/4 of view
D - scissors only take up 1/4 of view
*Milford says C (TeLindes)
The best management of the ovarian capsule to prevent adhesions after excision of a small ovarian endometrioma once haemostasis achieved and ovarian cortex edges are approximated?
A - closure with running 4-0 chromic sutures
B - microsurgical closure with interrupted 6-0 Dexon sutures
C - microsurgical closure with running 6-0 Dexon sutures
D - closure with surgical glue
E - leaving it to heal
E - leaving it to heal
O
At end of TAH there is fluid in pelvis which looks like urine. What do you do?
A- sterile milk into bladder B - dissect out ureters C - ask anaesthetist to give IV indigo carmine D - redivac drain and close E - IDC x 10 days and close
C - ask anaesthetist to give IV indigo carmine
Milford
The main cause of mortality from tubal ligation?
a. Vascular injuries
b. Perforation of abdominal viscus
c. General anaesthetic
d. Air embolism
e. Infection
c. General anaesthetic
The patient had a radical hysterectomy and in the immediate post-operative period has difficulty walking and the next day she has paraesthesia over her left thigh as well as an absent patella jerk. Which of the following nerves would be appropriate?
A - obturator
B - femoral
C - internal pudendal
D - sciatic
B - femoral
Difficult hysterectomy with endometriosis, significant blood loss of 2 litres throughout the procedure. At the end of the procedure is noted to have a haemostatic suture too close to what you thought was the ureter. Your next options are:
A - do nothing but closely observe in the next couple of days
B - remove the suture
C - IV indigo carmine and watch the dye through the ureter
D - Do a cystotomy at the operation and pass some catheters up the bladder to make sure the ureter is patent
C - IV indigo carmine and watch the dye through the ureter
All are bad options
Would prefer cystoscopy rather than cystotomy
A patient undergoes difficult vaginal hysterectomy, with post operative fever. On day 5 she develops a watery brown vaginal discharge. The MOST APPROPRIATE next step in management is
a. Return to theatre for EUA
b. IV pyelogram
c. CT abdomen and pelvis
d. Vaginal packing
e. Intravenous antibiotics
e. Intravenous antibiotics
Milford answer says B
*Need to consider fistula
Which one of the following is a branch of the posterior division of the internal iliac artery
a. Uterine artery
b. Lateral sacral artery
c. Obturator artery
d. Middle rectal artery
b. Lateral sacral artery
Iliolumbar Lateral sacral Superior gluteal Inferior gluteal Internal pudendal Middle rectal Obturator Uterine Vaginal/inferior vesical Umbilical remnant/ superior vesical
In Australia, the MOST COMMON cause of vesicovaginal fistula is
a. Anterior colporrhaphy
b. Radiation
c. Vaginal hysterectomy
d. Abdominal hysterectomy
e. Obstetric trauma
d. Abdominal hysterectomy
O
Which artery should be ligated in order to remove the omentum?
a. Middle colic artery
b. Gastroepiploic arteries
c. Middle sacral artery
e. Epigastric artery
b. Gastroepiploic arteries
O
Right and left gastroepiploic (a.k.a. gastromental arteries)
Branches of coeliac trunk
A 44yo woman is having a TLH. During surgery a 3cm hole was found in the bladder. The CORRECT MANAGEMENT is:
a. Repair laceration with ethibond in 2 layers and insert SPC for 5 days
b. Repair laceration with Vicryl in 2 layers and insert IDUC for 7 days
c. Repair laceration with PDS in 2 layers and insert IDUC for 2 days then perform lateral cystogram prior to removal
d. Repair laceration in 2 layers with PDS and omental patch, IDUC for 10 days.
b. Repair laceration with Vicryl in 2 layers and insert IDUC for 7 days\
O
The photobiologic basis for the CO2 laser is tissue absorption of CO2 laser energy by
a. Mitochondria
b. Cell membrane
c. Intracellular water
d. Intracellular protein
c. Intracellular water
O
CO2 laser energy is highly absorbed by water, and because water is the primary component of most biologic tissue, CO2 laser energy is highly absorbed by most tissues. Causes rapid heating of intracellular water, boiling, gasesous expansion and cell destruction
A slim 55yo woman has had an abdominal hysterectomy for complex atypical endometrial hyperplasia. The operative procedure is technically easy, exposure is good with the aid of a self-retaining retractor and operating time is 65 minutes. On the first post-operative day she complains of weakness and inability to weight bear on the left leg. There is numbness and reduced sensation over the anterior left thigh, the patella reflex is absent. The injury described is usually associated with:
a. Pressure from a haematoma surrounding the nerve
b. Stress from Trendelenburg position
c. Pressure of the retractors on the psoas muscle and underlying nerve
d. Pressure from the restraining strap across the patients thighs
e. Pressure from a haematoma on the lateral pelvic wall
c. Pressure of the retractors on the psoas muscle and underlying nerve
O
This is femoral nerve palsy
Retraction at hysterectomy can damage the:
- femoral nerve as it emerges from the psoas muscle
- genitofemoral nerve (lies of the belly of the psoas muscle, sensory perineum and upper thigh)
- lateral cutaneous nerve (lies on the belly of the posts muscle, numbness and pain radiate down thigh towards knee)
Upon inserting your main umbilical trochar during a diagnostic laparoscopy and prior to inserting the laparoscope, you notice that there is faecal matter in the tip of the trochar. Should the surgeon
a. Remove the cannula, discontinue the operation, give antibiotics and wait and see?
b. Remove the cannula and perform laparotomy to find and repair the damaged bowel
c. Leave the cannula where it is, perform laparotomy using a low transverse incision
d. Leave the cannula where it is, perform laparotomy using a midline incision
e. Insert the telescope through a new puncture and attempt repair of the bowel using new laparoscopic techniques for suturing
d. Leave the cannula where it is, perform laparotomy using a midline incision
O
