OR complications Flashcards
RF for nerve injury
BMI <20 kg/m^2
long OR time
robotic surgery
emergency surgery
smoking
systemic dz
name 4 nerve injuries in from pfanny or cherney incision
ilioinguinal
lateral cutaneous femoral
anterior cutaneous iliohypogastric nerve
genitofemoral nerve
what nerve do you think was trapped in your take back?
anterior cutaneous branches of subcostal nerve
injury to the lateral cutaneous femoral will lead to what effect?
paresthesia and pain in anterior and lateral thigh down to the knee
sensory only
high lithotomy, candy canes
injury to the genitofemoral will lead to what effect?
upper medial thigh, labia
sensory only
injury to the common peroneal will lead to what effect?
foot drop
decreased sensation to the ankle and foot
is the sciatic nerve sensory or motor?
mostly sensory and pain.
can have motor with SEVERE injury
injury to the femoral nerve will lead to what effect?
decreased knee extension, thigh abduction, and hip external rotation
cannot go from sitting to standing
falling with ambulation
What dorsal lithotomy positing mistakes can lead to obturator nerve injury?
too much hip abduction
kneess too far apart
injury to the obturator nerve will lead to what effect?
adductor muscle weakness
medial thigh pain
describe the course of the pudendal nerve.
s2-4 nerve roots, exits pelvis through greater sciatic foramen, re-enters through the less sciatic foramen to enter the pudendal canal
your TVT patient comes back with a hematoma, what are the possible vessels that were injured?
paravescial venous plexus
inferior epigastric
obturator artery
external iliac
describe the steps of a martius flap.
-make a longitudinal incision over the medial apsect of the labia majora
-isolate the bright yellow, fibrofatty pad with care to maintain the superior and inferior blood supply
-then secure the blood supply at the end that is intended for mobilization.
-tunnel the flap through the lateral vaginal side wall
-secure the flap into place
rate of gluteal pain after SSLF?
what nerves are involved in this
> 50%
S3 nerve roots
sciatic
pudendal
inferior gluteal
sacral plexus
nerve to the levator ani
Post op patient has an abscess, how so you manage?
> 2cm- IV abx, consider drainage
7cm you must drain it
not improving on IV abx
What is the risk of explant of SNM device after placement?
2%
Your SSLF patient wakes up with gluteal pain.
What’s your plan?
assess severity of the pain, radiating down the leg. Can they walk?
if mild, gabapentin, PT
if severe, release the stitch, can try trigger point injections
rate of dyspareunia after posterior colporrhaphy.
9-20% due to trapping of perineal nerves
there is a ureteral injury during your hyst. how do you decide on a ureteoneocystomy and a ureteroureterostomy?
distance from the UVJ
if <2cm, neocystomy
if >2cm ureteroureterostomy
describe the steps of a ureteroureterostomy.
excise damaged tissue
spatulate both ends
attach them using small absorbable suture leave a stent for 6 weeks.
Describe the steps of a ureteoneocystomy.
-make a flap at the dome
-make a partial thickness dissection into the flap
-trim devitalized tissue from the ureter
-then attach the ureter to the flap.
When to do a Psoas hitch vs Baori Flap?
psaos if tension free implantation is not possible
baori if you need 6-8 cm of mobilization
steps of psoas hitch.
-4 cm incision in the dose of the bladder
-attach the dome to the psoas muscle using PDS
- trim and spatulate the ureter and tunnel the ureter into the mobilized dome and secure it
-close the dome
steps of baori flap
-mobilize the bladder as much as possible, transecting the urachus and securing the umbilical vessels.
-make a rectangular flap in the dome
-place stay sutures to attach the flap to the psoas tendon using PDS
-trim the ureter and tunnel it submusocally and attach it to the flap
-close the full length of the flap using 5-0 monocryl
steps of cystotomy repair
-isolate the cystotomy
-trim devitalized tissue
-stent prn if near the trigone
-mucosal closure- absorbable sutures
-muscularis closure-absorbale suture
-flap if needed
-back fill to ensure water tight closure.
describe the steps of a primary repair of a rectal injury.
What size injury is reasonable for a primary repair?
If the injury was large, how long would the patient need a colostomy for?
3 layer closure
mucosa, muscularis, and serosa with delayed absorbable suture
<1cm
3-6 motnhs
small bowel injury
<1 cm, how do you repair it?
Assess the bowel to look for any other injury
1 layer of absorbable suture perpendicular to the longitudinal axis of the bowel
small bowel injury
> 1 cm or complex, how do you repair it?
consult for reanastamosis
What are the superior and inferior blood supply for the martius flap?
superior- external pudendal
inferior-internal pudendal
Patient with RVF undergoes repair, but it breaks down. What is her chance of successful with repeat repair?
80-85%
RF for VVF
OR > 5hrs
uterine size >250g
concurrent ureteral injury
smoking
DM
immunosuppression
OB trauma
radiation
Your SSLF patient has gluteal pain. What findings would make you want to return to the OR immediately beside pain?
-numbness, weakness
-motor deficit
one ureter is not spilling after your procedure. What do you do?
-consider unilateral renal anomaly
-give furosemide 20mg IV
-flourescein 0.25 mg IV
- level the patient
- remove potential obstructive retractors or insufflation
- cut sutures
- consult urology
-retrograde pyelogram and double J stent
What is the weigert meyer rule?
upper ureter drains inferomedially,
while the lower ureter drains superolaterally
what percentage of renal anomalies are associated with mullerian anomalies?
40%
What is the embryologic failure that causes an ectopic ureter?
failure or delay in separation of the ureteric bud from the mesonephric duct
DDx of UI in a teenager.
OAB
spina bifida
fistula
diverticulum
IC
ectopic ureter
tumor
MRi is not available for a patient who you suspect has a urinary tract anomaly.
What’s an alternative option?
renal sono with VCUG
Young adult cannot have penetrative intercourse.
What’s your DDx?
-vaginal agenesis
-fusion defect/septum
-vaginal mass
-hymenal defect
-scar tissue
A sling patient presents with obstruction. You do a pelvic ultrasound. What shape will the sling be to demonstrate obstruction?
C shaped
What is the VLPP to Dx ISD?
<60 cm H20
What percentage of OAB patients have DO on UDS?
30%
one ureter is not spilling after your vaginal hysterectomy USLS. You pass a wire without shooting a retrograde pyelogram. How could this give you false reassurance?
without a retrograde pyelogram, the wire could be passing into the abdomen instead of in the ureter.
post op patient can’t plantar flex.
What nerve is injured?
tibial
post-op Posterior colporrhaphy patient with rectal pain.
perineal branches of pudendal nerve
Name 2 ways to injure sacral nerve roots
SCP
USLS
What is the corona mortis vessel?
anastomosis between inferior epigatric and obturator
risk of nerve pain after SSLF
12%
Optimal
risk of nerve pain after USLS
7%
OPTIMAL
