Hysterectomy Flashcards
What are the steps of a vaginal hysterectomy?
Dorsal lithotomy, general anesthesia, foley placement. self-retaining retractor for exposure.
●Cervix incision: colpotomy w/ circumferential incision w/ electrocautery.
●Entry into the peritoneal cavity–enter posterior cul-de-sac using mayo scissors. then enter anterior cul-de-sac (Dissect bladder off of LUS/cervix).
●Hysterectomy: sequential clamping, ligating and dividing of uterosacral ligament, cardinal ligament & uterine vessels, broad ligament, utero-ovarian pedicle.
●Adnexal surgery when indicated
●Apical support procedures when indicated (i.e. uterosacral ligament suspension).
●Closure of the vaginal cuff: absorbable suture such as 1-0 or 0 polyglactin braided suture
Cystoscopy: detect patent ureters.
How do you repair a 3rd and 4th degree laceration?
- Using 3-0 or 4-0 delayed absorbable sutures, anchor the suture distal to the apex of the laceration, being careful to embed the knot within the anorectal lumen.
- close rectal mucosa with 3-0 vicryl in running non-locked.
- IDENTIFY IAS and close with 2-0 vicryl interrupted.
- Suture the anorectal mucosa in a running, nonlocked fashion approximately 5 mm past the anal verge. Use the overlying rectovaginal fascia to perform a second layer closure over the repaired anorectal mucosa with another 3-0 or 4-0 delayed absorbable suture.
- Identify the internal anal sphincter. If torn, repair the internal anal sphincter with interrupted sutures in an end-to-end fashion using a 3-0 polyglactin or polydioxanone suture.
- Identify the external anal sphincter and grasp each end with an Allis clamp.
- Reapproximate the external anal sphincter with 2-0 polyglactin or 3-0 polyglactin or polydioxanone sutures using the appropriate technique based on the severity of the laceration.
- Partial external anal sphincter laceration: Use an end-to-end technique with interrupted sutures tied at the posterior, inferior, superior, and anterior areas of the muscle.
- Complete external anal sphincter laceration: Use an overlapping technique, dissecting approximately 1.5 cm of the torn ends from the surrounding tissue, overlapping about 1 cm of the ends, and suture together with full-thickness interrupted or mattress sutures.
- Bury the knots from the anal sphincter repair behind the superficial perineal muscles.
- Reapproximate the remaining tissue using the second-degree perineal laceration repair approach
What is a 3rd degree perineal laceration?
second-degree laceration with the involvement of the anal sphincter complex, which can be further classified into the following 3 subcategories:
A: Involvement of <50% of the external anal sphincter
B: Involvement of >50% of the external anal sphincter
C: External and internal anal sphincters are torn
Fourth Degree: Tearing of the anal sphincter complex and the rectal mucosa
What is the rate of post-cuff dehiscence?
<1%. For laparoscopic or robotic, its slightly higher. Lowest incidence for vaginal and open (0.25%).
What is the differential diagnosis for pain and discharge 6 weeks post-op from hyst?
Vaginal cuff dehiscence, cuff cellulitis, normal post-op changes, vaginitis, FISTULA
What are the risk factors for cuff dehiscence?
- Infection (BV, cuff cellulitis)
- surgical technique
- obesity, smoking, anemia, poor nutrition, DM
- prior pelvic surgery
- use of corticosteroids
- Incr abdominal pressure (chronic cough). - - placement of sutures
- use of monopolar cautery for colpotomy can devascularize tissue
How can you prevent cuff dehiscence?
pre-op abx, vaginal prep, post-op (treat DM, anemia, bowel regimen to avoid constipation and straining), avoiding intercourse, heavy lifting for 6-8 wks.
How do you manage cuff dehiscence?
Start from vaginal approach. If concern for injury to bowel, look laparoscopically (Unasyn and doxy). Importance to get visualization of entire cuff, debride tissue, reinforce the cuff with sutures and give broad-spectrum antibiotics (Ancef).
How do you evaluate for ileus?
Exam: abdominal exam, check for bowel sounds (ABSENT - ileus, high-pitched possible SBO)
- usually 2-3d post-op.
What diagnostic tests? CBC, Abdominal Xray (distended bowel, air in rectum)
What are ileus sx and how would you manage?
Pain, 48-72hr post-op, ABSENT bowel sounds, AXR w/ gas in colon, air in rectum. Tx=NGT, NPO, IVF, electrolyte repletion
diffuse discomfort or pain, hypoactive bowel sounds, gas throughout GI tract
Xray: Diffuse air in both small and large bowel
conservatively. Bowel rest, IVF, electrolyte repletion, possible NGT. Rule out SBO. Ileus will resolve!
- if bile in NGT: replace loss w/ IVF (NS or D5NS), monitor I/O, check electrolytes, consider TPN if prolonged use of NGT
If not improving in 48hr? Rule out surgical complication: abscess, hematoma, ureter injury causing urinoma.. Get CT scan.
What is an SBO and how would you manage?
Cramping, RECURRENT EMESIS. 5-7d post-op (vs 2-3d for ileus). High-pitched bowel sounds, AXR w/ gas in small intestine + air-fluid levels, NO air in rectum.
Tx=NGT, NPO, IVF + surgery (if conservative unsuccessful), electrolyte repletion.
adhesion-induced. Usually 5 day post surgery. Intermittent cramping, high-pitched bowel sounds
Xray: proximally dilated bowel loops w/ air fluid levels, distal bowel may be gasless.
Start conservative, NPO, IVF. encourage ambulation.
Partial may resolve w/ conservative. If conservative unsuccessful, need surgery.
How can you avoid complications with initial trocar/Verees needle insertion?
- Maintaining the patient horizontal when the umbilical trocar is inserted at a 45° angle
- Use towel clips around the umbilicus to tent the abdominal cavity when the Veress needle is inserted
- Use a controlled twisting motion and blunt tip trocar, directed toward the sacral hollow.
- Use LUQ mode of entry with Veress needle to avoid adhesions from prior laparoscopy
IMPORTANT
- feel for two “pops.” 1st= abdominal fascia, 2nd= parietal peritoneum.
- attach 10cc syringe and aspirate to confirm no blood or bowel contents
- Remove the syringe and drip saline into the open Veress needle hub. If saline flows freely without resistance, an intraperitoneal location is assumed
The Hasson trocar and sleeve has been shown to reduce vascular complications. However, there is no advantage to the Hasson in preventing bowel injury.
What are complications with laparoscopy in obese patients?
Obese patients can lead to uncontrolled efforts in entering the abdomen, leading to bowel or vascular injury. Also, it is very easy to insufflate the subcutaneous tissues in these patients.
The best way to avoid such complications is to enter the peritoneum at the base of the umbilicus which is the smallest distance between skin and abdomen.
What would you do if you aspirated bowel contents from the Veress needle upon insertion?
In general, Veress needle injuries to the bowel do not lead to further infection. The needle can simply be removed and reinserted at an alternative site. The patient should be watched for 48 hours. It would not be incorrect to also perform a laparotomy and run the bowel.
Upon inserting a lateral trocar into the patient, you notice a significant hematoma forming under the anterior peritoneum. what do you do?
Attempt direct bipolar coagulation
Tamponade with a foley catheter
Suture ligation
