Module 7 - Surgical Procedures Flashcards
You are consenting a patient prior to laparoscopic resection of extensive endometriosis. What is the most common major complication of gynaecological laparoscopic surgery?
Injury of the urinary tract (includes bladder and ureters) is the most common major complication of gynaecological laparoscopic surgery
What are the risks of overall serious complication in laparoscopy?
2 in 1,000
What is the risk of bowel injury during laparoscopy?
0.4 in 1,000
What is the risk of vascular injury during laparoscopy?
0.2 in 1,000
What is the risk of death during laparoscopy?
5 in 100,000
What two risks of surgery are more common with laparoscopic hysteretcomy vs open hysterectomy?
1) Urinary tract injury
2) Vaginal cuff dehiscence
What is the overall risk of serious complications from TAH?
4 in 100 (common)
What proportion of women will require a hysterectomy after UAE?
3%
What proportion of women will be asymptomatic or have improved symptoms at 1 year after UAE?
80-90%
What proportion of women with UAE will require a second intervention by 5 years?
1/3
<40 - 20%
> 40 - 10%
What are the adverse pregnancy outcomes following UAE?
Higher rates of:
- CS
- PPH
- 1st trimester miscarriage
What are the absolute contraindications to UAE? (5 points)
1) Recent or current pelvic infection
2) Pregnancy
3) Refusal to accept hysterectomy if required
4) Asymptomatic fibroids
5) Uncertain diagnosis
When do complications for UAE typically occur?
After 30 days
What is associated with sulphur granules?
Actinomycosis
What is the most common ureteric injury during gynae laparoscopic surgery?
Complete transection (60%)
What is the risk of ureteric injury during laparoscopy?
<1 - 2%
What proportion of ureteric injuries are diagnosed intra-operatively during laparoscopy?
30%
What proportion of bladder injuries are diagnosed intra-operatively during laparoscopy?
50%
What is the risk of ureteric injury during laparoscopy where there is deep-infiltrating endometriosis with hydronephrosis?
20%
What is the most common site for bladder injury during surgery?
In the midline above the inter-ureteric bar
As you dissect the bladder from the cervix
What are the most common sites for ureteric injury during surgery?
Lower 1/3 injuries make up 50% of injuries
Pelvic brim
Lateral to cervix/uterine vessels at cardinal ligament
What are the overall risk of serious complication with abdominal hysterectomy?
4 in 100
What is the risk of haemorrhage requiring blood transfusion in abdominal hysterectomy procedures?
23 in 1,000
What is the risk of urinary tract injury in abdominal hysterectomy procedures?
7 in 1,000
0.7%
What is the risk of ureteric injury during laparoscopy?
<1 - 2%
What percentage of women who have had a subtotal hysterectomy will have persistent cyclical bleeding?
5%
For patients taking warfarin, when do you stop it prior to a surgical procedure?
5 days prior to surgery regardless of their risk of intra-operative bleeding
If a woman is taking Warfarin and is due to have an elective gynae procedure when should Warfarin be stopped, and in which circumstance would she need anti-coagulation bridging with LMWH?
1) Stop Warfarin 5 days prior to operation
2) For women at HIGH RISK of VTE - give bridging therapy with TREATMENT DOSE LMWH. Stop LMWH 24 HOURS prior to operation
Which patients are regarding as High-risk for VTE and thus would need LMWH bridging when stopping Warfarin prior to surgery?
1) VTE within the last 3 months (have a target INR of 3.5)
2) Stroke or TIA in the last 3 months
3) Mechanical heart valve
4) Previous stroke or TIA with 3 or more of:
- Congestive heart failure
- HTN
- Age >75
- Diabetes
Which gynaecological procedures are regarded as posing a major bleeding risk?
All day case and inpatient surgeries
A patient is booked to have an open myomectomy for large uterine fibroids. She is taking Aspirin because of her history of previous stroke. When should her Aspirin be stopped prior to surgery?
You do not stop it.
If on Aspirin monotherapy you can continue Aspirin for all Gynae procedures
A patient is due to have an open myomectomy for large uterine fibroids. She is on Aspirin and Clopidogrel dual therapy due to a recent ACS 4 months ago. When should her medications be stopped prior to surgery?
If a patient had a recent ACS or coronary artery stenting within the last 6 months then avoid surgery if possible.
If unable to delay surgery (and <6 months):
Low-bleeding risk - Continue Aspirin + Clopidogrel
High-bleeding risk - Continue Aspirin. Stop Clopidogrel 7 days before
A woman taking Warfarin is 9 weeks pregnant with a suspected tubal ectopic pregnancy. She has consented to a laparoscopic salpginectomy. She last took Warfarin 3 hours ago. How long should the operation be postponed for?
Aim to post-pone for 6-8 hours after last dose in emergency gynae operations. Then give 5mg VITAMIN K i.v. (Phytomenadione) to decrease the INR
If surgery can’t be delayed then give 25-50 IU/kg Four factor Prothrombin complex concentrate and then check the INR
When do you stop Warfarin for a patient planned to have a low-bleeding risk gynaecological operation?
1) Stop 5 days before operation
2) Check INR day before op
- if INR >1.5 - give Vitamin K i.v.
3) Check INR day of op
If high VTE risk - bridge with treatment dose LMWH
When do you re-start Warfarin for a patient planned to have a low-bleeding risk gynaecological operation?
1) Re-start Warfarin 12-24 hours after operation
2) Start LMWH 24 hours after operation - continue until INR within therapeutic range
When do you stop Warfarin for a patient planned to have a high-bleeding risk gynaecological operation?
1) Stop 5 days before operation
2) Check INR day before op
- if INR >1.5 - give Vitamin K i.v.
3) Check INR day of op
If high VTE risk - bridge with treatment dose LMWH
When do you re-start Warfarin for a patient planned to have a high-bleeding risk gynaecological operation?
1) Re-start Warfarin when bleeding risk is minimised
2) Start LMWH 48 hours after op
When do you stop Apixaban, Rivaroxaban and Edoxaban for a patient planned to have a low-bleeding risk gynaecological operation?
1) CrCl >30 - stop 24 hours before op
2) CrCl <30 - stop 48 hours before op
When do you re-start Apixaban, Rivaroxaban and Edoxaban for a patient planned to have a low-bleeding risk gynaecological operation?
Re-start 6-12 hours after op
When do you stop Apixaban, Rivaroxaban and Edoxaban for a patient planned to have a high-bleeding risk gynaecological operation?
1) CrCl >30 - stop 48 hours before op
2) CrCl <30 - stop 72 hours before op
When do you re-start Apixaban, Rivaroxaban and Edoxaban for a patient planned to have a high-bleeding risk gynaecological operation?
Re-start 48 hours after op
If high VTE risk then give prophylactic dose of anticoagulation before restarting at full therapeutic dose
