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GYN > Quick & Dirty MUST KNOWS > Flashcards

Quick & Dirty MUST KNOWS Flashcards

1
Q

Describe the course of the ureter

A

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

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2
Q

Cystotomy Repair

A

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

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3
Q

Most commons sites of ureteral injuries?

A
  • Clamping IP ligament
  • Clamping uterine artery
  • Near uterosacral ligament
  • Closing vaginal cuff
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4
Q

Recommend MTX regimen for ectopic pregnancy?

A

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!

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5
Q

Theraputic dosing for lovenox?

A

1 mg/kg BID

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6
Q

What types of things are considered in the caprini score?

A

Age
Route of surgery (open vs. lsc)
BMI
Hx of DVT/thrombophilia
OCPs/HRT use

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7
Q

Reversal for Heparin?

A

Protamine Sulfate

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8
Q

Goal PTT with Heparin?

A

PTT 1.5 -2.5 x normal

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9
Q

Heparin MOA and dosing

A

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

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10
Q

What is the Wells score?

A

Clinical assessment for pulmonary emoblism

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11
Q

What patient would be a candidate for SCDs and perioperative anticcoagulation?

A

Caprini score 3-4
Always use SCDs then could consider LDUH or LMWH if average risk of bleeding

(If high, then just use SCDs)

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12
Q

Management of Caprini score > 5?

A

SCDs
Extended anticoagulation after surgery
LMWH 28 days
If high risk of bleeding, wait to start until bleeding risk is lower

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13
Q

How does the Caprini score stratify risk?

A

Low = 1.5% VTE risk
Moderate risk = 3% risk
High risk = 6% risk

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14
Q

What types of things are considered in the caprini score?

A

Age
Route of surgery (open vs. lsc)
BMI
Hx of DVT/thrombophilia
OCPs/HRT use

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15
Q

Describe the route of the ureter

A

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

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16
Q

Considerations when repairing a cystotomy?

A
  • 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
17
Q

Layers of closure for the bladder

A

Mucosa/submucosa = 3-0 vicryl running
Muscularis = 3-0 vicryl interrupted
Bladder Serosa = 2-0 vicryl interrupted

18
Q

Most common sites ureteral injury?

A
  • Clamping IP ligament
  • Clamping uterine artery
  • Near uterosacral ligament
  • Closing vaginal cuff
19
Q

Repair of ureteral injury > 5 cm above UVJ

A

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
20
Q

Repair of ureteral injury < 5 cm above the UVJ

A

Bladder re-implantation
(Uretero-neocystotomy)

21
Q

What to do if there is too much tension to do an end-end re anastomosis or bladder re-implantation?

A

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

22
Q

Basics of bowel injury

A

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

23
Q

Additional antibiotics needed for a bowel injury?

A

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

24
Q

How to avoid nerve injuries during surgery?

A
  1. Avoid hyperextension and flexion when positioning
  2. Use padding to minimize compression
  3. Avoid lateral extension of transverse incisions beyond the border of the rectus muscle
  4. Retractors should not compress the psoas muscles
  5. Identify the obturator nerve when performing extensive dissection in the obturator fossa
25
Q

Why do you use robotics?

A
  • 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

26
Q

Risk of pre-menopausal oophorectomy?

A
  • Increase is CVD
  • Increase in Stroke
  • Cognitive impairment
  • Dementia
  • Parkinson’s disease
  • Glucoma
  • CKD
  • Osteoporosis
  • Increase all cause mortality
  • Increase sexual dysfunction
27
Q

Medical management of acute heavy bleeding?

A
  • 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

GYN (14 decks)

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