Peri-op Mx Flashcards
Pre-op planning
Scenario 1 - previous peritonitis
Scenario 2- previous midline
Scenario 3 - risk reduction surgery for genetic mutation (e.g. Lynch)
FHx + mutation
- risks of unknown ca - spill/upstage
- MDT rv of case - advice
- MDI ?GONC opinion
- Pelvic washing
Previous surgery
- risks of bowel adhesion/injury
- MDT rv of case - advice
- MDI - gyn/gen surg/anaesthetic
- PP vs Hasson
- PP - mark/NGT/midclav/2 FB subcost
JW peri-op mx
- risk of anemia/recovery
Pre-op
- all products acceptable
- products if condition deteriorate
- check for coagulopathy
- optimize anemia pre-op
Peri-op
- cell-saver
- min phlebotomy peri-op
- consider anti-fibrinolytic
- concern re: postop bleed - RTT
Peri-op mx on bkg of VTE Hx
- risk of bleeding on anticoag
- risk of VTE without anticoag
- MDI - gyn/haem
- ? cessation/bridging/recommence
- calf-compressors intra-op
- meticulous hemostasis intra-op
- avoid antifibrinolytic intra-op
- LWMH post-op/mobilization
- +/- recommence regular anticoag
Postop DVT mx
Scenario 1 - post D&C for MC
- FBE/UEC/LFT/CRP/Coag/LL USS +/- ECG
- LL USS -‘ve w chest sx -> CXR-CTPA/VQ
- LL USS -‘ve w/o chest sx - rpt LL USS
- risk of DVT = PE/T2RF/Cardiac
- MDI - gynae/haem
- empirical LMWH (wt/renal dependent)
- LMWH education pro/cons
- monitor sx & F/U plan
+/- thrombophilia screen
mx of unexpected malignancy at laparoscopy for benign surgery
Scenario 1 - 33yo, diagnostic lap FI of non-specific abdominal pain & irregular menstrual sx -> extensive primary peritoneal ca with abdominal mets
Scenario 2 - 50yo, diagnostic lap washout of TOA 12cm, large torted ovary/necrotic tube, suspicious, not consented for USO
Intra-op
- risk of no mx - delay in rx
- inform team of finding
- pause, take photos
- GONC opinion +/- assistance
- rv consent +/- contact NOK +/- proceed
- pelvic washings +/- bx +/- staging
- urgent specimen to path
Post-op
- debrief team/pt
- VTE prophylaxis
- GONC MDT ref/opinion
- organize urgent Ix
- follow-up plan
mx of ureteric injury intra-op or postop
- ureter transection - TAH
- ureter kinking - apical/vault suspend
- ureter thermal/transect - lap endo
- ureter transection - CS/hyst - clear fluid draining from abdo wound
Intra-op identification
- inform team
- pause surgery/ensure hemostasis
- contact urologist for assistance
- finish primary surgery
- IDC & fluid balance
- direct inspection of ureter
- IV meth blue or indigo carmine ?leak
- cystoscopy - UO jets ?absent/sluggish
- +/- intra-abdo drain (fluid creatinine)
- postop care MDI - Gyn/Urology
- Debrief/Document - cx/mx/fu plan
- MDM/audit
Postop identification
- Ix - FBE/CRP/UEC/CT-IVP
- Risk of sepsis/renal failure
- MDI - Gyn/Uro/Radiology
- stent vs nephro vs re-implant
- Debrief/Document - cx/mx/fu plan
- MDM/audit
Mx of bladder injury intra-op
- bladder injury at TVT insertion
- bladder injury at hysterectomy
Intra-op
- inform team
- pause surgery/ensure hemostasis
- assess extent - trigone vs dome
- call Urology for assistance
- whilst waiting, complete primary op
- 2-layer closure absorbable sutures
- methylene blue leak test
+/- cystoscopy (efflux)
+/- stent if suspect trigonal injury
- leave IDC in-situ
Postop
- Debrief/Document - cx/mx/risk of VVF
- IDC 10 days till cystogram +/- TOV
- MDM/Audit
Mx of vascular injury intra-op in general
Minor
- pressure
- coag vs ligate vs hemostatic agent
- irrigation
- hemostasis
- survey surrounding tissue for injury
- reduce intra-abdo pressure
+/- intra-abdominal drain
Major
- risk - life threatening
- inform OT team
- activate emergency response
- MDI - resus/stabilization/def mx
- fluid resus + activate MTP
- Trendlenburg + midline laparotomy
- pressure+/-packing +/- Txa
- await vascular team to arrive
- ICU postop
- Debrief/Document/F/U
- MDM/Audit
Mx of excessive bleeding during STOP/HDC
Scenario 1 - during STOP
Scenario 2 - during STOP ? perf
Scenario 3 - FDIU 18/40 due to parvo induced anaemia -> hydrops - D&E performed - noticed perf intra-op
Scenario 4 - HDC for ix of PMB
DDx
- uterine perforation
- cervical tear
- uterine atony
Mx
Intra-op
- Alert team
- Stop procedure
- Call for help
- MDI - simul resus/stabilization
- Identify source of bleeding
- Bimanual +/- Oxytocin
- Fluid resus +/- MTP
- IDC/IV Abx
- Laparoscopy +/- repair +/-
- Assess other organs
Postop
- Admission for observation 24/24
- debrief/document - cx/mx/f/u
- MDM & audit
- future preg imp
+/- rebook procedure (e.g. if ix for PMB but didn’t get a curette sample)
Mx of inferior epigastric artery injury intra-op
Identification & repair
- risk of hematoma/infection
- inform team
- pause surgery
- apply pressure
- call for help - senior support
- tamponade w foley cath 14F till help
- likely need percut suture w endoclose
+/- open surgery to ligate +/- embolize
Post repair
- reduce intra-abdominal pressure
- confirm hemostasis
- port removal under vision
- debrief/document
- MDM & audit
Mx of bowel injury intra-op
Intra-op identification
- inform team
- pause surgery/ensure hemostasis
- call for help - CR
- leave trocar in place
- mid-line lap below site of injury
- antibiotics
- wait for help
Mx of postop bowel cx
Scenario 1 - incarcerated bowel
Scenario 2 - burst abdomen
- risk sepsis/ischemia/BO
- emergency
- call for help - gyn/gen surg
- MDI - simult resus/stabilise/rx
- NBM/IVC - FBE/UEC/LFT/G&S
- IVT/IV Abx/Consent/RTT
- EUA +/- debride +/- repair
- Debrief/Document - cx/mx/F/U
- M&M/Audit
Mx of postop ileus
Scenario 1 - post TOA w/o
DDx
- bowel handling
- hemoperitoneum
- intra-abdo collection - blood/urine/pus
- intra-abdo infection
Ix
- FBE/UEC/LFT/CRP
- AXR
Mx
- risks - dehydrate/malnutrition/BO
- MDI - gyn/gen surg/nursing
- NBM/IVC/IVT +/- NGT
- Mobilize/Gum/Glycerin suppository
- VTE prophylaxis
- Monitor blds/axr/clinical improv
- Upgrade of diet accordingly
Mx of postop vaginal discharge
Scenario 1 - post hysterectomy
DDx
- vault hematoma
- vault infection
- vault dehiscence
- risks - dehiscence/evisceration
- FBE/UEC/CRP/G&S/CTAP
- MDI - gyna/ID
- Admission
- IDC/IVT/IV ABx
- monitor clinical/biochem
+/- RTT - Debrief/Document
- M&M/Audit
Mx of postop abdominal pain
Scenario 1 - accumulation of abdominal fluid 1 day postop
Scenario 2 - post lap
Scenario 3 - severe endo, lap excision, p/w abdo pain/N&V/distension
DDx
- Intra-abdominal bleed
- Bowel perforation
- Collection - blood/urine
- Infection - UTI/gastro
- FBE/UEC/LFT/CRP/Coag/BC/G&S
- G&S +/- X-match PRBC/MSU
- CTAP or CT-KUB
- risks … sepsis/life threatening
- emergency
- simult resus/stabilize/ix
- MDI - Gyn/Gen Surg/Urology
- NBM/IVC - above
- IDC/IVT/IV ABx (broad spec)
- +/- RTT +/- other intervention
- Debrief/Document
- M&M/Audit
