Quick & Dirty MUST KNOWS Flashcards
Describe the course of the ureter
Total length ~ 30 cm (15 in abdomen, 15 in pelvis)
Commences at renal pelvis
Descends over psoas muscle (lateral to medial)
Enters pelvic brim at the bifurcation of the common iliac vessels
Descends along side wall posterior to ovarian fossa
Crosses under the cardinal ligament/under uterine artery
Goes anteromedial and inserts in the bladder
Cystotomy Repair
Assess location relative to trigone
Need for ureteral stents? Consult Urology
Bladder dome injury:
- Close mucosa/submucosa with 3-0 vicryl running
- Close musclaris with 3-0 vicryl interrupted
- Close bladder serosa with 2-0 vicryl interrupted
- Cystoscopy/Bladder instillation to check for leaks
- Replace foley catheter, leave in p lace 3-7 days
- Voiding trial on Day #7
- If large injury- do voiding cystourethrogram (or if foley removed prior to day 7)
NO ANTIBIOTICS NEEDED
Most commons sites of ureteral injuries?
- Clamping IP ligament
- Clamping uterine artery
- Near uterosacral ligament
- Closing vaginal cuff
Recommend MTX regimen for ectopic pregnancy?
Single dose Regimen
50 mg/m2 BSA single dose
Obtain Hcg on D#4 and D#7 and assess for 15% decrease
If less than 15% decrease administer second dose
Follow Hcg titer to negative
No folate-containing vitamins or NSAIDs
EFFECTIVE BIRTH CONTROL!
Theraputic dosing for lovenox?
1 mg/kg BID
What types of things are considered in the caprini score?
Age
Route of surgery (open vs. lsc)
BMI
Hx of DVT/thrombophilia
OCPs/HRT use
Reversal for Heparin?
Protamine Sulfate
Goal PTT with Heparin?
PTT 1.5 -2.5 x normal
Heparin MOA and dosing
Cofactor for antithrombin
Increases inhibition of thrombin and Factor Xa
150 u/kg loading dose > 20 u/kg/hr maintenance
Change to warfarin or SubQ 8-10k units BID
What is the Wells score?
Clinical assessment for pulmonary emoblism
What patient would be a candidate for SCDs and perioperative anticcoagulation?
Caprini score 3-4
Always use SCDs then could consider LDUH or LMWH if average risk of bleeding
(If high, then just use SCDs)
Management of Caprini score > 5?
SCDs
Extended anticoagulation after surgery
LMWH 28 days
If high risk of bleeding, wait to start until bleeding risk is lower
How does the Caprini score stratify risk?
Low = 1.5% VTE risk
Moderate risk = 3% risk
High risk = 6% risk
What types of things are considered in the caprini score?
Age
Route of surgery (open vs. lsc)
BMI
Hx of DVT/thrombophilia
OCPs/HRT use
Describe the route of the ureter
Total length ~ 30 cm (15 in abdomen, 15 in pelvis)
Commences at renal pelvis
Descends over psoas muscle (lateral to medial)
Enters pelvic brim at the bifurcation of the common iliac vessels
Descends along side wall posterior to ovarian fossa
Crosses under the cardinal ligament/under uterine artery
Goes anteromedial and inserts in the bladder
Considerations when repairing a cystotomy?
- Location relative to trigone
- Ureteral assessment
- Closure in 2 or 3 layers
- Check for leaks/cysto
- Foley catheter 3-7 days
- Voiding trial or voiding cystourethrogram
Layers of closure for the bladder
Mucosa/submucosa = 3-0 vicryl running
Muscularis = 3-0 vicryl interrupted
Bladder Serosa = 2-0 vicryl interrupted
Most common sites ureteral injury?
- Clamping IP ligament
- Clamping uterine artery
- Near uterosacral ligament
- Closing vaginal cuff
Repair of ureteral injury > 5 cm above UVJ
Direct end-end reanastomosis
(uretero-ureterostomy)
- Spatulate the ureteral ends
- 4-6 interrupted sutures of 4-0 vicryl
- Ureteral stents + foley catheter x 10 days
Repair of ureteral injury < 5 cm above the UVJ
Bladder re-implantation
(Uretero-neocystotomy)
What to do if there is too much tension to do an end-end re anastomosis or bladder re-implantation?
Psoas Hitch - pulling the bladder to the ureter by attaching it to the psoas muscle
Boari Flap - essentially the same thing, using the bladder to form a longer tube to connect to the ureter
Basics of bowel injury
Always close the injury perpendicular to the long axis of the bowel
If laceration is parallel to long axis = do end to end closure
If laceration is perpendicular to long axis to side to side closure
Additional antibiotics needed for a bowel injury?
Small bowel - no additional if pt received her pre op abs
Large bowel - YES, add dose of Flagyl
*No post op dietary restrictions necessary
*Do NOT need routine NG tube placement
How to avoid nerve injuries during surgery?
- Avoid hyperextension and flexion when positioning
- Use padding to minimize compression
- Avoid lateral extension of transverse incisions beyond the border of the rectus muscle
- Retractors should not compress the psoas muscles
- Identify the obturator nerve when performing extensive dissection in the obturator fossa
Why do you use robotics?
- Extensive robotic training in residency
- Experienced assistant is not available (work with NP with 2 years of OR experience, similar to intern level skills)
- Better visualization, able to operate at lower insufflation levels to help with pain
- Better fine motor control with articulated instruments
- Able to use minimally invasive approach for more complex cases (fibroids/endometriosis)
- Better detection of endometriosis lesions
Compared to TAH:
- Similar OR time
- Less blood loss
- Lower complication rate
- Shorter hospital stay
Risk of pre-menopausal oophorectomy?
- Increase is CVD
- Increase in Stroke
- Cognitive impairment
- Dementia
- Parkinson’s disease
- Glucoma
- CKD
- Osteoporosis
- Increase all cause mortality
- Increase sexual dysfunction
Medical management of acute heavy bleeding?
- Conjugated IV estrogen 25 mg Q6h for 24h
- High dose (35 mcg) COC TID for 7 days
- Medroxyprogesterone 20 mg TID for 7 days
- TXA 1,300 mg TID for 5 days
