MIS

Question 1

Percentage of ureteral injuries during gyne procedures?

Answer 1

it is estimated that 52–82% of iatrogenic injuries occur during gynecologic surgery [Lee et al. 1988; Dowling et al. 1986; St Lezin and Stoller, 1991].

Question 2

What are the clinical risk factors for ureteral injury during hysterectomy ?

Answer 2

include a large uterus, endometriosis, pelvic organ prolapse, and prior pelvic surgery [Vakili et al. 2005; Dandolu et al. 2003].

Question 3

Where is The most common sight of ureteral injury?

Answer 3

is near the ureterosacral ligaments [Grainger et al. 1990].

low anterior resection (LAR) and abdominal perineal resection (APR), are responsible for 9% of all ureteral injuries [St Lezin and Stoller, 1991].
APR or LAR are complicated by an iatrogenic ureteral injury in 0.3–5% of cases [Coburn, 1996].

Question 4

Possible sites to insert viress needle

Answer 4

1) peri-umbilical
2) palmar point
3) cul-de-sac
4) trans-uterine
5) btw 9th and 10th intercostal space

Question 5

Iatrogenic ureteric injury is a well-recognised complication of radical hysterectomy occurring in —-% of cases.

Answer 5

Iatrogenic ureteric injury is a well-recognised complication of radical hysterectomy occurring in 5–30% of cases.

Question 6

During entry of the insufflation needle or the first trocar in laparoscopy The most commonly injured major vessels are

Answer 6

the distal aorta and the right common iliac artery (RCIA)

Question 7

Laparoscopy using a pneumoperitoneum is contraindicated in very few clinical conditions, but these include

Answer 7

acute glaucoma, retinal detachment, increased intracranial pressure, and some types of ventriculoperitoneal shunts. Thus, laparoscopy is appropriate for many, although modifications are warranted for certain clinical situations.

Question 8

brachial plexus injury complicates — percent of gynecologic laparoscopic procedures

Answer 8

brachial plexus injury complicates 0.16 percent of gynecologic laparoscopic procedures

Question 9

Due to a 60-percent increased incidence during the past few decades, now the most common variant and account for 40 to 50 percent of all malignant ovarian germ cell tumors

Answer 9

Immature teratoma

Question 10

Immature teratomas contain a disorderly mixture of mature and Immature tissues derived from the three germ cell layers-ectoderm, mesoderm, and endoderm. Of the Immature elements, Immature —– Is the most common.

Answer 10

Immature neuroeplthellum Is the most common.

Question 11

What are Laparoscopic accommodations in pregnancy , pressure used, techniques … etc

Answer 11

limiting insuffiation pressures to 10 to 15 mm Hg, maintaining end-tidal C02 levels between 32 and 34 mm Hg, moving trocar placement appropriately cephalad to avoid puncture of the gravid uterus, and limiting uterine manipulation, routine use of perioperative prophylactic tocolytics is not recommended in these cases. However, pre-and postoperative fetal heart rate assessment and contraction monitoring for more advanced gestations are typically implemented.

Question 12

The organ most frequently injured during laparoscopy is

Answer 12

bowel

rates of 0.6 and 1.6 per 1000 cases are reported (Chapron, 1999; Harkki-Siren, 1997)

Question 13

Major vascular injury associated with laparoscopy rate

Answer 13

Puncture rates are cited as 0.09 to 5 per 1000 cases, and the terminal aorta, inferior vena cava, and iliac vessels, particularly the right common iliac artery, may be injured (Bergqvist, 1987; Catarci, 2001; Nordcstgaard, 1995). Uncommonly, air embolism from gas insufllation following vessel puncture may occur.

Question 14

if the inferior epigastric artery is injured, several simple techniques can control hemorrhage.

Answer 14

First, bipolar electrosurgical coagulation of the bleeding site may suffice. If unsuccessful, a 14F Foley catheter can be threaded through the cannula of the wounding trocar or through the defect created by this trocar. The Foley balloon then is inflated and pulled upward to create direct pressure against the posterior surface of the anterior abdominal wall. At the skin surface, a Kelly clamp is placed perpendicular across the Foley catheter and paralld to the skin to hold the balloon firmly in place. The balloon and catheter can be removed approximately 12 hours later. Alternatively, sutures can be placed that traverse the skin, abdominal wall, and peritoneum; arch under the bleeding vessel; and exit the abdomen to directly ligate the vessel. Similarly, the Carter-Thomason tool can be used to ligate both ends of this vessel.

Question 15

Rate of Trocar-Site Metastasis or hernia

Answer 15

1% ( Mets more frequent with ovarian cancer)

Question 16

Contrindications to septoplasty include

Answer 16

pregnancy and active pelvic infection, and these should be excluded.

Question 17

What is the major vascular structure most likely to be injured at the time of laparoscopic umbilical trocar placement ?

Answer 17

The distal aorta and right common iliac artery

Question 18

Which vessel is at risk of injury during laparoscopic lateral trocar placement?

Answer 18

Inferior epigastric artery

Question 19

cardiovascular and pulmonary physiologic changes in laparoscopy

Answer 19

(1) absorption across the peritoneum and into circulation of CO2 lead to systemic C02 accumulation and hypercarbia. In turn, hypercarbia produces sympathetic stimulation that raises systemic and pulmonary vascular resistance and elevates blood pressure. If not cleared by compensatory ventilation, acidemia develops followed by direct myocardial contractility depression and decreased cardiac output, it can lead to tachycardia and arrhythmia.
(2) elevated intraabdominal pressure created by the pneumoperitoneum, Less commonly, bradycardia can stem from vagal stimulation. This may follow pelvic organ manipulation, cervical stretching during uterine manipulator placement, or peritoneal stretching during pneumoperitoneum creation. This raised pressure as well decreases flow in the inferior vena cava, causes blood pooling in the legs, and raises venous resistance. In sum, venous return to the heart is decreased, and thereby cardiac output is lowered. Increased intraabdominal pressure can also directly lower splanchnic blood flow.
(3) head-down Trendelenburg positioning pushes organs cephalad against the diaphragm moves it up more, lung volume and functional residual capacity are diminished, which in turn reduces the reserve volume for oxygenation. Moreover, this lung volume decline favors a tendency for alveolar collapse, leading to atelectasis. This can create ventilation and perfusion mismatching and an increased alveolar-arterial oxygen gradient.

Question 20

Laparoscopic entry-related injuries can be classified into two main groups:

Answer 20

type 1 injuries, which include damage by the Veress needle or trocar to normally located blood vessels and bowel,
type 2 injuries, which include damage by the Veress needle or trocar to bowel adherent to the abdominal wall.

Question 21

Laparoscopic Umbilical Entry techniques

Answer 21

Closed Entry / Veress Needle or trochar Entry
Open entry (Hasson technique)

Question 22

the most sensitive measurement of correct intraperitoneal Veress needle placement

Answer 22

The initial pressure

An initial intraabdominal pressure of 8 mm Hg or below always indicates correct placement of the Veress needle

Question 23

The Palmer point is located at

Answer 23

3 em below the left costal margin in the midclaviculat line.

Question 24

inferior epigastric vessels were – cm from the midline at the level of the ASIS and were always lateral to the rectus abdominis muscle at a level – cm superior to the pubic symphysis.

Answer 24

inferior epigastric vessels were 3.7 cm from the midline at the level of the ASIS and were always lateral to the rectus abdominis muscle at a level 2 cm superior to the pubic symphysis.

Question 25

How to minimize the risk of ilioinguinal and iliohypogastric nerve and inferior epigastric artery injury during placing the accessory ports in laparoscopy?

Answer 25

Most injuries to these nerves and to the inferior epigastric vessels can be averted by placing the accessory ports superior to the ASIS and >6 cm from the abdomen’s midline (Rahn, 2010).

Question 26

Complications rates for women undergoing hysteroscopy are low and cited at < 1 to 3 percent and that’s includes:

Answer 26

fulse cervical pathway creation, uterine perforation, cervical laceration, hemorrhage, and postoperative endometritis. Gas venous embolism and excessive intravascular fluid absorption

Question 27

Treatment of fluid media induced hyponatremia in hysteroscopy

Answer 27

immediate limitation of fluid intake and stimulation of diuresis with furosemide (Lasix), 20 to 40 mg given intravenously. Correction of hyponatremia is achieved with 3-percent sodium chloride, administered at a rate of 0.5 to 2 mUkglh. Acute neurologic symptoms andl or nausea and vomiting constitute a true medical emergency. Alternatively, 3-percent saline can instead be given in a 100 mL infusion over 30 minutes and repeated an additional two times if needed (Nagler, 2014; Verbalis, 2013). The goal of therapy is to reach a serum sodium level of 135 mEq/L within 24 hours. Rapid correction or overcorrection is avoided to prevent additional cerebral effects.

Question 28

Uterine perforation during hysteroscopy risk factors include

Answer 28

cervical stenosis, postmenopausal status, prior cervical or intrauterine surgery, and retroverted uterus.

Question 29

The incidence of uterine perforation in hysteroscopy is reported to be – percent

Answer 29

The incidence of uterine perforation in hysteroscopy is reported to be 1.4 percent

Question 30

Air embolism in hysteroscopy can lead to rapid cardiovascular collapse. Signs and symptoms include

Answer 30

chest pain, dyspnea, and hypotension. Anesthesia staff may note decreased end~tidal C02 levels, oxygen desaturation, dysrhythmias, or a “mill wheel” murmur (Groenman, 2008).

Question 31

Surgeons can minimize the risk of gas embolism by

Answer 31

avoiding Trendelenburg positioning of the patient during hysteroscopy, ensuring that air bubbles are purged from all tubing prior to introduction of the hysteroscope into the uterus, maintaining intrauterine pressures < 1 00 mm Hg, minimizing the effort needed to dilate the cervix, avoiding deep myometrial resec~ tions, and limiting multiple removals and reinsertions of the hysteroscope in and out of the uterine cavity.

Question 32

The overall risk of serious complications is —/1,000 women in laparoscopic surgery

Answer 32

The overall risk of serious complications is 2/1,000 women (include damage to the bowel, bladder, ureter and major blood vessels which may need laparotomy to repair the damage). However, 15% of the bowel injuries are not recognized at the time of surgery and may present later.

Question 33

Rate conversion to open laparotomy in laparoscopy in large series of hysterectomy for benign disease

Answer 33

Approximate 5%

Question 34

The organ most frequently injured during laparoscopy is …., what is the rate ?

Answer 34

Bowel, 0.6 -1.6 per 1000 cases

Question 35

in those with suspected abdominal adhesive disease, several preventative steps can help avoid bowel injury. These include:

Answer 35

(1) an alternative site for primary trocar entry, for example in the left hypochondrium (Palmer point), rather than at the umbilicus; (2) introduction ofa microlaparoscope to scout for adhesions; and (3) preopera- tive sonography using the visceral slide test to exclude bowel adhered to the anterior abdominal wall.

Question 36

Which hysterectomy approach poses the greatest risk to the ureters?
a. Vaginal hysterectomy
b. Abdominal hysterectomy
c. Laparoscopic hysterectomy
d. No difference in approaches

Answer 36

Laparoscopic hysterectomy

Question 37

A ter undergoing hysteroscopic resection o a broad- based leiomyoma, patients are encouraged to delay conception attempts or what length o time?

Answer 37

Three menstrual cycles

Question 38

Patients undergoing endometrial ablation or a bleed- ing abnormality should not be guaranteed amenorrhea as a treatment goal. In general, which o the ollowing rangeso amenorrhearatesisexpected?

Answer 38

15-35%

Question 39

What intra-abdominal pressure should be achieved to safely insert the primary trocar?

Answer 39

An intra-abdominal pressure of 20–25 mmHg should be used for gas insufflation before inserting the primary trocar. Grade B

Question 40

What specific measures are required for laparoscopic surgery in the very thin woman?

Answer 40

The Hasson technique or insertion at Palmer’s point is recommended for the primary entry in very thin women. Grade C

Question 41

What should the intra-abdominal pressure be set at for insertion of the secondary ports?

Answer 41

Secondary ports must be inserted under direct vision perpendicular to the skin, whilst maintaining the pneumo- peritoneum at 20–25 mmHg. Grade C

Question 42

What specific measures are required for laparoscopic surgery in the obese woman? Preferred entry technique?

Answer 42

The open (Hasson) technique or entry at Palmer’s point is recommended for the primary entry in morbidly obese women. If the Veress needle approach is used, particular care must be taken to ensure that the incision is made right at the base of the umbilicus and the needle inserted vertically into the peritoneum. Grade C