Gynecologic anatomy and surgery Flashcards
Lymph nodes draining the various parts of the female reproductive system
Bony pelvis
External female genitalia
Pelvic floor muscles
Basic female reproductive anatomy
Uterus and associated ligaments
Arteries surrounding and supplying female reproductive organs
Ovarian veins
Arteries supplying uterus
Path of the ovarian and uterine arteries
Inferior epigastric artery
Locations of ectopic pregnancy
Ligaments of the uterus
Which uterine ligaments are true and which are false?
Triangles of doom and pain
Location of triangles of doom and pain on laporoscopy
The ovarian vein and artery are located within the ___
The ovarian vein and artery are located within the suspensory ligament of the ovary
Segments of the fallopian tube
In which segment of the fallopian tube is fertilization most likely to occur?
The ampulla
Anastamotic connection between the uterine, vaginal, and ovarian arteries
The uterine vein and artery are located within. . .
. . . the cardinal ligament
“Water under the bridge” in regards to female pelvic anatomy
The cardinal ligament, containing the uterine artery, crosses over the ureter.
So, the ureter (water) is beneath the cardinal ligament (bridge)
___ is at risk of injury during ligation of the uterine vessels for hysterectomy.
The ureter is at risk of injury during ligation of the uterine vessels for hysterectomy.
Anterior view of uterus and broad ligament
Sections of the broad ligament
Fornix
Ligaments connected to the uterus
- Utero-ovarian ligament medially
- Suspensory ligament laterally (contains blood supply)
- Mesovarium posteriorly
Nervous supply of internal vs external hemorrhoids
Internal hemorrhoids (above the dentate line) are innervated by autonomic fibers from the inferior hypogastric plexus. As such, they do not cause the same type of acute pain that external hemorrhoids do.
External hemorrhoids (below the dentate line) are innervated by somatic fibers from the pudendal nerve.
Identify the major structures on this ovarian histology
The __ artery branches off of the internal iliac and supplies much of the anterior internal pelvis, terminating at ___.
The __ artery branches off of the internal iliac and supplies much of the posterior internal pelvis, terminating at ___.
The obturator artery branches off of the internal iliac and supplies much of the anterior internal pelvis, terminating at the obturator membrane.
The pudendal artery branches off of the internal iliac and supplies much of the posterior internal pelvis, terminating at the perineum.
The ovarian arteries are branches of the. . .
. . . aorta
They have a long path down the peritoneal cavity to the ovaries.
This is important from a vascular standpoint as the ovarian arteries also anastamose with the uterine arteries, creating an anastamotic pathway between the internal iliac and the aorta.
Branches of the internal iliac artery
Location of the cardinal ligament
Location of the uterosacral ligament
Location of the round ligament
Location of the pubocervical fascia
The remnant of the umbilical vein in adult humans is the ___.
The remnant of the umbilical arteries in adult humans are the ___.
The remnant of the umbilical vein in adult humans is the ligamentum teres.
The remnant of the umbilical arteries in adult humans are the medial umbilical ligaments.
In female anatomy, the vaginal artery replaces the ___ artery.
In female anatomy, the vaginal artery replaces the inferior vesicular artery.
As such, women only have a superior vesicular artery.
The anterior trunk of the internal iliac supplies mostly ___.
The posterior trunk of the internal iliac supplies mostly ___.
The anterior trunk of the internal iliac supplies mostly pelvic visceral organs.
The posterior trunk of the internal iliac supplies mostly posterior muscles (iliacus, psoas major, quadratus lumborum)
After giving off several branches, the anterior trunk of the internal iliac artery continues as the. . .
. . . internal pudendal artery, which passes through the greater sciatic foramen AND lesser sciatic foramen to arrive at the perineum and external genitalia.
The __ muscle is in a constant state of contraction
The levator ani muscle is in a constant state of contraction
It has to be in order to support the pelvic contents. It is the major portion of the pelvic diaphragm, along with the coccygeus.
Risk factors for pelvic floor insufficiency
- Multiparity
- Large babies
- Chronic elevated intraabdominal pressure (weight lifting, coughing)
What is the structure you are most worried about nicking during hysterectomy?
The ureter!!!!
Especially if the patient has had previous abdominal surgeries, including C section. This can cause changes that move the ureter even closer to the site of dissection in hysterectomy.
Since there is so much variability in the branching of pelvic vasculature, an artery can only be truly identified once. . .
. . . it is traced to the organ that it supplies
___ must be avoided during port placement for laporoscopy, especially for procedures like tubal ligation
The inferior epigastric artery must be avoided during port placement for laporoscopy, especially for procedures like tubal ligation
Pudendal nerve block
Often necessary in obstetrics, especially when there is no time for a spinal block
Find the ischial spine and position the needle 1 cm inferiorly and medially. Aspirate to ensure that you are not injecting into the pudendal artery or inferior gluteal artery, which are in close approximation. Once you have confirmed this, inject lidocaine here.
Nerves innervating the superficial female genitalia
What is the single most common location for an ectopic pregnancy?
The ampulla of the fallopian tube
What exactly is twisting in ovarian torsion?
The ovary itself is sort of twisting, causing its medial and lateral ligaments to cross one another.
The lateral suspensory ligament of the ovary (containing the ovarian artery and vein) crosses the utero-ovarian ligament, and the utero-ovarian ligament squishes the artey and vein, causing ischemia.
Ligaments of the bladder
- Medial umbilical ligament: Unpaired. From the apex of the bladder to the umbilicus
- Lateral ligament of the bladder: From the inferolateral aspect of the bladder to the parietal pelvic fascia
- Pubovesicular ligament: From the bladder neck/upper urethra to the posterior pubis
- Vesicouterine ligament: From the fundus of the bladder to the supravaginal portion of the uterine cervix
Path of the uterine round ligament
The vaginal artery is contained within the ___.
The uterine artery is contained within the ___.
Sandwiched between them is the ___.
The vaginal artery is contained within the paracervical fascia.
The uterine artery is contained within the parametrial fascia.
Sandwiched between them is the ureter.
The blood vessels enter the uterus at approximately the level of the. . .
. . . internal cervical os
Corpus luteum turns into ___ after it involutes.
Corpus luteum turns into corpus albicans after it involutes.
Why is it thought that smoking is associated with infertility?
It is thought that it is largely related to ciliary dyskinesia in the fallopian tube (basically what happens in the bronchi too!)
Why does the round ligament insert on the labia majora?
Because it is the analogous structure to the spermatic cord in males!
The round ligament contains ___
The round ligament contains Sampson’s artery
Generally speaking, anterior perineal structures are more ___ than posterior perineal structures
Generally speaking, anterior perineal structures are more fixed than posterior perineal structures
The ureter, for example, can hardly move. But he rectum has a large range of motion.
This is another reason why it is better to delivery infants with the head flexed and facing posteriorly.
The __ ligaments define the pouch of Douglas
The uterosacral ligaments define the pouch of Douglas
The gut paristalses. The ureter ___.
The gut paristalses. The ureter vermiculates.
Why is uterine dextrorotation a risk factor for pyelonephritis in third trimester women, but not uterine levorotation?
Ureteral dilation is more pronounced on the right side because of dextrorotation of the uterus, whereas the left ureter is more protected from compression by the gas filled sigmoid colon
Endometrial ablation
- Endometrial tissue is destroyed through one of many possible methods
- Indicated for women who have menorrhagia unrelated to other uterine condition
- Contraindicated in individuals with endometrial hyperplasia or malignancy
- Preceded by hysteroscopy to assess anatomy and initiation of contraception
- Fewer complications than hysterectomy, but will of course produce infertility
Prophylaxis in GYN surgery
Usually done preoperatively with cefazolin (for almost all indications where it is requited)
Cefazolin must be re-dosed intraoperatively if >1300 mL of blood is lost or if the surgery is longer than 4 hours
Ways to diagnose ectopic pregnancy
- Visualization
- 48 hour interval beta hCG with interval increase less than 50%
- beta hCG over 2000 but below 300,000 with no intrauterine pregnancy seen on imaging
Heterotopic pregnancy
Coexisting intrauterine and ectopic pregnancies
Treatment for ruptured ectopic pregnancy
Salpingectomy of the ruptured tube.
Concurrent hysterectomy and/or salpingo-oophorectomy are contraindicated in this case since this is an emergency surgery, even if the patient does not desire future fertility. They may be scheduled later a an outpatient.
Ovarian remnant syndrome
May occur following bilateral oophorectomy
Left-behind ovarian tissue in the pelvic cavity can grow, form cysts or hemorrhage, producing chronic pelvic pain.
Nerve entrapment syndromes following pelvic surgery
- Iliohypogastric: Provides sensation to the groin and pubis.
- Ilioinguinal: Provides sensation to the groin, labia, pubic symphysis, and upper-inner thigh
Single best sign that chronic pelvic pain may be cured by hysterectomy
Focal tenderness confined to the uterus
The majority of cases of ovarian torsion during pregnancy occur. . .
. . . at 14 weeks gestation OR postpartum
Distinguishing ovarian torsion and appendicitis
Both can produce colicky RLQ abdominal pain, nausea, and vomiting
However, appendicitis often has other accompanying symptoms, such as fever, leokocytosis, and anorexia.
Forms of abdominal pain with increased incidence in the first trimester of pregnancy
- Cholecystitis
- Ectopic pregnancy
- Ruptured corpus luteum (Lower abdomen, sometimes unilateral, acute onset sharp pain often with syncope)
Presentation of appendicitis in pregnancy
Pain is localized superiorly and laterally to McBurney’s point, since the appendix is pushed in this direction by the gravid uterus.
Sometimes appendicitis will thus present as right flank pain in a pregnant patient.
Biliary colic in pregnancy
Often treated with low-fat diet and expectant management if signs of cholecystitis (fever, leukocytosis) are not present.
However, if fever or leukocytosis are present, surgery is often the treatment of choice.
Pain of degenerating fibroid
Generally felt very focally over the area of the degenerating fibroid.
FIbroids often degenerate during pregnancy since their rapid estrogen-driven growth outpaces their ability to create an adequate blood supply.
The first sign of hypovolemia
Reduced urine output!
This happens before tachycardia or hypotension.
Workup for PE in pregnancy: V/Q scan, or angiography?
Angiography.
V/Q exposes to more radiation, and iodinated coctrast is NOT contraindicated in pregnancy
Following a PE during pregnancy, . . .
. . . prophylactic heparin is used for the remainder of the pregnancy up until 6 weeks post-partum
Epigastric abdominal pain following delivery in a patient with preeclampsia with severe features should make you think. . .
. . . hepatic rupture or hepatic hematoma
MAP > ___ is necessary for vital organ perfusion.
MAP > ___ is necessary for brain perfusion.
MAP > 65 mmHg is necessary for vital organ perfusion.
MAP > 47 mmHg is necessary for brain perfusion.
Common peroneal nerve injury
- Common nerve injury during obstetrical procedures
- Characterized by high stepping gate, weakness of foot eversion, weakness of dorsiflexion, and decreased sensation on sole of foot and anterolateral leg
Presentation of ureteral injury following pelvic surgery
Often presents ~7-10 days following surgery, but can present within just a day or two. Clinical picture is often nearly identical to pyelonephritis, but in the context of very recent pelvic or abdominal surgery.
The most common location of injury is at the level of the cardinal ligament. Any disease which disrupts normal pelvic anatomy is a risk factor (endometriosis, cancer, peritoneal tuberculosis, PID, etc etc etc)
Diagnose w/ intravenous pyelograp (IVP) or contrast CT of the abdomen and pelvis.
Next steps include antibiotic administration and cystoscopy to attempt retrograde stent passage.
Three main types of wound complication
- Superficial separation
- Dishiscence (Separation of part of the surgical incision, but with an intact peritoneum)
- Evisceration (Disruption of all layers of the incision with omentum or bowel protruding through the incision)
Presentation of post-surgical fascial disruption
Presents with profuse drainage (usually serosanguinous) from the incision site 5 to 14 days after surgery.
Often accompanied by signs of surgical site infection (erythema, swelling around incision, fever, leukocytosis).
What is the most common etiology for surgical incision site fascial disruption?
Suture tearing through fascia
This happens more frequently than the suture being poorly tied/loose and coming apart.
Confirming a diagnosis of Asherman’s syndrome and treating Asherman’s syndrome
Hysterosalpingogram OR saline sonography
Then treat w/ operative hysteroscopy (insertion of IUD or pediatric Foley at this time helps prevent reformation of adhesions)
Turner’s patients have ___ instead of ovaries
“Gonad streaks”
Treatment of endometriosis-associated infertility is. . .
. . . surgical
Medical therapy will not improve fertility in these patients
Radical trachelectomy
Removal of cervix and upper vagina while leaving the uterus
Preserves fertility while removing the cervix in women with stage I cervical cancer
