Surgery Flashcards
Nerve injury at hysterectomy
Pfannenstiel incision
- can transect the iliohypogastric or ilioinguinal nerves
- 7% will experience symptoms - most will resolve after 6/12
- can cause neuroma - need to either reimplant the nerve or remove scar tissue
Retraction at hysterectomy can damage the:
- Femoral nerve as it emerges from the psoas muscle
- Genitofemoral nerve (lies of the belly of the psoas muscle, sensory perineum and upper thigh)
- Lateral cutaneous nerve (lies on the belly of the posts muscle, numbness and pain radiate down thigh towards knee)
Nerves that can become entrapped in reconstructive pelvic surgery
Sacrospinous fixation
- pudendal nerve when sutures placed in the arcus tendinus
uterosacral ligament suspension
- S1-4
Lithotomy nerve injuries
Common perineal nerve
How electricity is utilised in electrosurgery
Alternating current from wall outlets has a frequency of around 50 - 60 hertz
Low frequency currents have a stimulating effect on nerve and muscle cells
With high frequency alternating currents (>200 kHz) - doesn’t stimulate –> insensitivity to the stimulus develops
- Therefore, all electrosurgical instruments in the operating theatre must operate at a base frequency of greater than 300 kHz
Describe cutting waveform
Wave shape is a simple continuous sinusoidal form
Low voltage
Produces heat rapidly therefore vaporising or cutting the tissue
Describe coagulation waveform
Modulated current - the sinusoidal waveform is non-continuous
6%:94% modulated waveform
Pulses of current flow alternate with periods of no-flow –> heating effect
High voltage
Result in a deeper heating and thus a greater coagulation effect - intracellular water is removed and remaining proteins become sticky as the heat produces a collagen chain reaction
What is monopolar
Small active electrode produces heat at operative site in surgeon’s hand –> high current density and tissue effects occur through heating
Return electrode has a larger area, therefore very low current density so very little tissue heating
The smaller the electrode the higher the current concentration and greater the effect regardless of power setting
Electricity returns to generator by passing through patient then dispersed by return electrode on patient’s skin
Place on a well vascularised muscle mass avoiding areas of vascular insufficiency, irregular body contours or bony prominences
Monopolar - pros and cons
Advantages:
- Can be used on a small area / tissue
- Same electrode for cutting and coagulating
- Relatively inexpensive
- Readily available
- New isolated systems - current division cannot occur and there is no possibility of alternative site burns
Disadvantages:
- Can interfere with pacemaker function
- Energy preferentially dissipates via vascular pathways, therefore even if small serosal burn evident, may be much larger area of underlying devascularisation
- Arcing can occur with metal instruments
- Superficial burns if used for cutting with spirit based skin preparation
- Diathermy burns under indifferent return pad if improperly applied
what is bipolar
Primary (active) and return (passive) electrodes are the two blades
Electrically insulated from each other
Current passes between the two electrodes and produces a relatively localised area of heating of tissue between the blades
Clinical effect usually only of coagulation
No electrode pad required
Bipolar - pros and cons
Advantages:
- less spread of current
- Greater accuracy
- Greater safety
- Less tissue damage
- Relatively inexpensive
- Readily available
Disadvantages:
- Can interfere with pacemaker function
- Arching can occur with metal instruments
- Heated tissue can come into contact with other tissue, e.g. bowel, and inflict thermal damage
- Low power so not useful for cutting
Desiccation
At higher temp, both dehydration and protein denaturation occur –> desiccation
Tissue that is completely desiccated has very high resistance and does not conduct electrical current
Cut or coag
Contact
Vaporization
High heat vaporises tissue immediately adjacent to the tip of the electrode
Since the cells “explode”, no char is produced
Cut
Non-contact
Fulguration
Electrode held a bit further away that with vaporisation
Electrical current jumps or arcs between the tip and the nearby tissue –> char
Used to control bleeding over a wide area
- Useful to control diffuse bleeding over
Coag
Non-contact
Injuries from electrosurgery
Alternative site burn - Current finds an alternate way out of the body. If exit point is small enough, current is concentrated –> burn
Pad site burns - If contact is poor and the surface area of the pad is small enough
Direct coupling - Contact between active electrode and another conducting instrument, e.g. metal instrument. If tissue not firmly attached to body anymore, then don’t use diathermy on it
Capacitative coupling - Occurs when electric current is transferred from one conductor (active electrode) through intact insulation into adjacent conductive materials with direct contact
Insulation failure - Rate is higher in reusable instruments. s
Direct thermal spread
Smoke plume - Contains potentially toxic substances, can also transmit viruses
Current diversion - electrical energy finds the path of least resistance in monopolar energy
- As tissue is further diathermised, it becomes desiccated and its impedence increases
- If diathermy continues, power may flow preferentially to adjacent non-desiccated tissue by arcing
Thermal spread between devices
Harmonic scalpel 0-3mm
10mm Ligasure 1.8mm
5mm Ligasure 4.5mm
Traditional bipolar 2-22mm
Monopolar 50mm
Advanced bipolar devices
Use radiofrequency bipolar energy with an impedence-based feedback loop that modifies the bipolar energy delivered
- Fuses collagen and elastin within the vessel walls
A mechanical blade is needed to cut the tissue after coagulation
Thermal spread to adjacent tissues is approx 2mm
Advanced bipolar devices
- Ligasure
Pros and cons
ADVANTAGES
Excellent haemostasis is achieved, sealing vessels up to 7 mm
Reduced risk of tissue charring and tissue adherence - reduced risk of lateral thermal damage
Audio signal to alert endpoint reached
Tips of instruments remain relatively cool
Tissue spread of 2-3mm
Use lower temperatures (70-95)
DISADVANTAGES Expensive Bulky jaws, inferior dissector Smoke produced which can obscure view Single use
Ultrasonic devices
Convert electrical energy into ultra high frequency mechanical energy (oscillating blade)
Harmonic scalpel
- The vibrating blade oscillates longitudinally at 55,000 vibrations per second
- Heat generated through friction causes protein denaturation and coagulum formation providing haemostasis whilst simultaneously cutting through vaporisation and cavitation
- Inactive upper arm holds tissue in apposition
Ultrasonic dissection does not generate temperatures above 80 degrees, minimising the distance of thermal spread
PRos and cons of Harmonic
Advantages
- These instruments are great dissectors, quick cutters
- Very precise control of cutting and haemostasis without producing smoke or charring
- Less lateral thermal spread
Disadvantages
- Cost
- Limited lifespan of the ultrasound tip, therefore disposable
- More limited coagulation, slower coagulation
- Seals vessels up to 5mm
- May retain heat in the blade after activation, therefore don’t use as a grasper
Hybrid devices
E.g. Thunderbeat
Integrates both ultrasonically generated frictional heat energy and advanced bipolar energy in one instrument
- Ultrasonic tech rapidly cuts and precisely dissects tissue
- Advanced bipolar tech provides reliable vessel sealing
Can seal and cut vessels up to 7mm
Disadvantages
- Expensive
- Lack of good quality evidence on safety efficacy
Surgical strategies to prevent adhesions
Reduce tissue handling
Diligent haemostasis
Reduce drying of tissue
Frequent irrigation or only use wet packs
Limit use of sutures
Avoid foreign bodies
Use starch and latex free gloves at laparotomy
Adhesion prevention at laparoscopy
Barrier agents
- Cochrane review - No evidence for barrier agents (gels, hydroflotation) for reducing pain or infertility (reduce adhesions)
Ringer-lactate saline or icodextrin (Adept) solution
- Separate pelvic structures during early stages of healing.
- Mixed results: some evidence that reduces recurrent adhesion formation but no good evidence to show prevention of primary adhesions
No evidence of support corticosteroid use
- May impair healing
Cochrane 2015 - surgical approach to hysterectomy for benign gynaecological disease
VH appears to be superior to LH and AH - a/w faster return to normal activities
If VH not possible, LH has some advantages over AH - more rapid recovery, fewer febrile episodes, fewer wound or abdominal wall infections
- However longer operating time
LH no benefits over VH - longer operating time, TLH had more urinary tract injuries
No evidence that robotic-assisted hysterectomy is of benefit
Removal of the tubes at hysterectomy
consider after discussion with patient
Growing evidence that high-grade serous tumours of ovary and peritoneal surface epithelium originate in the fallopian tubes
Removal does not appear to increase surgical complications or impact ovarian function
No population based data to quantify the risk-benefit profile
Evidence around removal of ovaries for benign disease
Postmenopausal ovaries are physiologically active, continue to produce oestradiol (at low levels) and testosterone
Modelling study, 2005 - “women <65y clearly benefit from ovarian conservation, and at no age is there a clear benefit from prophylactic oophorectomy”
Nurses’ Health Study
- Median f/u 24y
- Bilateral oophorectomy at time of hysterectomy for benign disease a/w:
○ Decreased risk of breast and ovarian cancer
○ Increased risk of all-cause mortality, and fatal and non-fatal CHD
- At no age was oophorectomy a/w increased survival
- Oophorectomy not associated with decreased survival in women >55y
Evidence around removal of ovaries for benign disease
Postmenopausal ovaries are physiologically active, continue to produce oestradiol (at low levels) and testosterone
Modelling study, 2005 - “women <65y clearly benefit from ovarian conservation, and at no age is there a clear benefit from prophylactic oophorectomy”
Nurses’ Health Study
- Median f/u 24y
- Bilateral oophorectomy at time of hysterectomy for benign disease a/w:
○ Decreased risk of breast and ovarian cancer
○ Increased risk of all-cause mortality, and fatal and non-fatal CHD
- At no age was oophorectomy a/w increased survival
- Oophorectomy not associated with decreased survival in women >55y
Abdominal hysterectomy
- steps
Uterus elevated with clamps applied across the proximal fallopian tube, round ligament and ovarian ligament on each side
Clamp placed at the midpoint of the round ligament
Round ligament is cut, opening the broad ligament
- Develop avascular plane
Posterior leaf incised further, parallel and lateral to the ovarian vessels
Anterior leaf opened towards the point of the bladder reflection on the anterior uterine surface
Blunt dissection into the loose areolar tissue between the leaves of the broad ligament will lead to the common iliac artery bifurcation as it crosses the pelvic brim
- Identify ureter as it runs over the bifurcation
Make ovarian / IP pedicle (depending on ovarian conservation or not), ensuring ureter well clear
- double clamp and tie to secure haemostasis
Round ligament is sutured
Separate bladder from the cervix
- Bladder dissection takes ureters and bladder away from surgical field
Skeletalise uterine vessels
Hysterectomy clamp applied to cervix
- Cut and ligate uterine pedicle
Bladder and rectum are dissected further caudally if necessary, to the level of the vagina
Additional pedicle may be required
- Medial to the previous suture
Final pedicle includes the uterosacral ligaments, cardinal ligaments and vaginal angles
Vagina closed with continuous locking suture
Check haemostasis at pedicles and vault
- Pelvis can be filled with warmed water - the blood haemolyses and is visible as a red ‘jet’ of blood
locations of ureteric injury and how they would occur during a vaginal hysterectomy
Closing the vaginal vault
- Distortion of anatomy could disrupt the path of the ureter
- The ureter could get ligated when closing the vault
- Unable to visualise the path of the ureter as with laparoscopic or abdominal approach
When clamping, dividing or tying the pedicle containing the uterine vessels
- Ureter may be either divided or caught in tie at this pedicle
- If UV fold not well mobilised then ureters will be pulled down into field
Disseminated intravsacular coagulation
Procoagulant factors released into the circulation, stimulating the coagulation cascade
Increased production and consumption of coagulation factors, and vast consumption of factors and platelets –> further bleeding
Process of fibrinolysis is stimulated and release of fibrinogen degradation products interfere with the production of firm fibrin clots, which causes more bleeding
FDPs further interfere with cardiac function and aggravate both haemorrhage and shock
DIC diagnosis:
- Raised FDPs, fibrin soluble complexes
- Decreased fibrinogen, platelets
- Prolongation of clotting times
Treatment:
- Treat underlying cause
- FFP - contains most coagulation factors, low in fibrinogen
- Cryoprecipitate - contains more anti thrombin III and fibrinogen
Vault haematoma
Relatively common: ~20%
Majority treated with Abs alone
Indications for drainage:
- Sepsis
- Persistent symptoms - e.g. pain
- Large size
Most common sites of injury to ureter
At the pelvic brim, as it crosses lateral to medial, and anterior to the bifurcation of the common iliac arteries
- At this point the ureter runs just medial to the ovarian vessels
Ureters descend into the pelvis within a peritoneal sheath attached to the medial leaf of the uterine broad ligament and the lateral pelvic side wall
Just inferior to the internal cervical os, the ureter passes under the uterine arteries in the cardinal ligament through a tunnel of areolar tissue to the anterolateral surface of the cervix
The ureters then pass close to the anterolateral fornix of the vagina and enter the posterior aspect of the bladder
Steps in a hysterectomy that the ureter is most likely to be injury
Ligation of the ovarian vessels
Ligation of the uterine vessels (most common)
Closure of the angles of the vaginal cuff
Types of injuries to ureter
Direct trauma
- ligated
- crushed
Direct or indirect damage to the ureteric blood supply can cause avascular necrosis –> fistula formation
- Avascular necrosis presents in the first day
- Fistula day 7-10 post-op
Kinked
Preventing ureteric injuries:
Positively identifying ureters during operation
Dissecting down bladder
Cystoscopy to check for ureteric jets at end of procedure
Consideration of ureteric stenting
If ligation or kinking of the ureter with the suture
Suture removed and inspection of ureter should occur
Check cystoscopy and ureteric stenting
Consider indigo carmine
Injury to lower ureter:
Transection injuries will be repaired by:
if the ureteral injury is approximately 3-4cm proximal to the uterovesical junction a primary anastomosis is performed
if the injury is within 2cm from the uterovesical junction primary repair is difficult so a reimplant is used.
Psoas hitch completed if above repairs cannot be performed without tension
- Bladder is mobilised and then anchored to the psoas tendon with non-absorbable stitches
- Ureter is then reimplanted without tension
Injury to middle ureter:
7% of injuries occur in middle third of ureter
Boari flap:
- Bladder mobilised and 4cm flap created on anterior surface of bladder.
- Flap is sutured to psoas tendon and ureter implanted into it
Steps of fixing a bladder injury:
Identify the location and extent of the injury
- if suspicion of damage to the trigone - request urology attendance to help identify the extent of injury and carry out the necessary repair
- Indigo carmine dye may need to be given to ensure the ureters are unaffected
Injury isolated to the bladder dome
- repair in 2 layers using an absorbable suture (Vicryl)
- If in doubt, or gynaecologist not suitable qualified, request urology attendance.
Check the integrity of the repair by backfilling the bladder with methylene blue
- ensures that there are no other bladder injuries
IDC to remain in for a minimum of 7 days
- allows the suture line to heal without the bladder being distended and threatening its integrity
Cystourethrogram or CT cystogram prior to TROC to ensure that the bladder has healed
Ensure that appropriate reports are made to the hospital’s adverse outcome monitoring systems and organise appropriate after-care (e.g. referral to ACC for treatment injury in New Zealand)
Bowel injury
Incidence 0.3-0.8%
Majority minor lacerations
Majority (~75%) involve small bowel
Injuries that are recognised at the time of damage are associated with good outcomes
Increased risk:
- Abdominal adhesions from previous surgery (10-20 fold)
- Malignancy
- Sepsis, PID (2-fold)
- Pelvic radiotherapy
If suspect, do contrast CT
Most common site of large bowel injury - sigmoid and rectum
Management of bowel injury
- Give antibiotics
- Call colorectal surgeons for assistance.
- Serosal abrasions do not need to be repaired but if the muscularis or mucosa is involved these should be repaired.
Small bowel injury
- Interrupted 3.0 PDS
- Single layer closure is adequate
- Suture lines should be perpendicular to the long axis of the bowel to prevent narrowing of the lumen
- Large defects can be closed with stapling device, resection or reanastamoses
Colonic injury
- Repair similar to above.
- If larger injury may need resection and reanastamoses
- If extensive injury may need diverting colostomy
- Extensive washout
Outcomes of subtotal hysterectomy
2-7% risk of persistent cyclical bleeding
2% risk of cervical prolapse
1% risk of cervical cancer
No difference between subtotal and total abdominal hysterectomy in terms of quality of life, constipation, prolapse, satisfaction with sex life, pelvic pain, vaginal bleeding, complication rates
Pros and cons of laparoscopic surgery
Advantages of laparoscopic surgery
For society / healthcare providers: - Shorter hospital stay - Faster recovery - Quicker return to work For the surgeon: - Better visualisation of organs - Easier tissue approximation For the patient: - Small incisions, reduced pain - Quicker mobilisation - Lower infection rates
Disadvantages of laparoscopic surgery
Increased operation time?
Increased complication rate?
Previous surgery and rate of adhesions at the umbilicus
Up to 50% following midline laparotomy
Up to 23% following low transverse incision
No previous surgery - 0.68%
Previous laparoscopy 1.6%
Risks of serious complications for laparsocopy
RANZCOG - overall complication rate with gynae laparoscopy is 3-8/1000 women
Rate of all complications <1%
- Rate of major complications <0.5%
- Approx double for complex operations
50% of injuries happen at entry
Risks particular to laparoscopic surgery
- Nerve injury - Respiratory compromise - Facial oedema - Gas embolism - Port site metastasis
Pneumoperitoneum
- Chemical effects of CO2
- CO2 benefits
Chemical effects of CO2 (acidosis) - Impaired myocardial contractility - Myocardial irritability - Pulmonary HTN - Systemic vasodilation Mechanical effects - Pressure related, especially with pressures >10-15mmHg
CO2 benefits
- Chemically and physiologically insert - Low diffusion across the peritoneal membrane - Low solubility in body tissues - High solubility in blood - Non-toxic - Non-combustible - Colourless and odourless - Readily available - Inexpensive - Less likely to cause trouble if there is an embolism
CO2 is absorbed in peritoneal fluid as carbonic acid, diffuses across peritoneal membrane and dissolves in tissues and blood as carbonic acid leading to acidosis
- Acidosis can be partially correct by anaesthetic hyperventilation
Physiological changes of laparoscopy
Haemodynamic changes
- Arterial pressure increases
- CO falls by 10-30%
- Systemic and pulmonary vascular resistance increases
- HR is unchanged
- Vagal stimulation –> bradycardia and bradyarrhythmias may be provoked by mechanical distension of the peritoneum or manipulation of pelvic organs
Trendelenberg –> increased pressure on diaphragm –> reduced cardiac preload
Ventilatory changes
- Reduced pulmonary compliance by 30-50%
- Raised resistance and ventilation-perfusion mismatch
- Decreased lung volumes
Pneumoperitoneum –> 50% reduction in GFR and UO
Inferior epigastric artery
Arises from external iliac artery, immediately above the inguinal ligament
Ascends along the medial margin of the internal inguinal ring, pierces the transversalis fascia, and ascends behind the rectus abdominis
Landmark - obliterated umbilical artery is medial to the inferior epigastric
If injure vessel, put Foley catheter in and clamp it
Superficial vessels of the anterior abdominal wall
superficial circumflex iliac artery
- branch of femoral
- passes below inguinal ligament and then laterally towards ASIS
superficial epigastric artery
- branch of femoral
- crosses over inguinal ligament and travels superiorly
Cochrane 2019 - laparoscopic entry techniques
Overall evidence insufficient to support the use of one entry technique over another
Advantage of direct trocar entry over Veress - reduced incidence of failed entry
Tests to confirm for Veress entry placement
Saline test = Palmers test
- Withdraw to see if any fluid, pus, blood, faeces are aspirated
- Flush saline to ensure no blockage, should be no resistance
- Repeat aspiration
- Disconnect syringe and watch if fluid level within the needle drops
Initial insufflation pressure should be relatively low (<8mmHg) and gas should be flowing freely
- Highest sensitivity and specificity for correct placement
- If high BMI or LUQ entry, pressure might be 2mmHg higher (caution is >12)
Palmer’s entry
Left midclavicular line, 3cm below the costal margin
LUQ - adhesions rarely form
- May be inappropriate if previous entry in this area or splenomegaly (percuss over area prior)
NG tube first
Veress or optical trocar for primary port insertion
- 5mm port and scope
There will be 3 “clicks” on entering the abdomen
- External and internal oblique aponeuroses
- Peritoneum
Port closure
Any non-midline port >7mm and any midline port >10mm requires formal deep sheath closure to avoid the occurrence of port site hernia
Ports >10mm have a 1-2% risk of post-op incisional hernia unless sheath is closed
Lateral port sites are at greatest risk of hernia formation
Options for specimen retrieval
Retrieval bag
Posterior colpotomy
- Up to 8cm specimens can be retrieved intact via the vagina without having to enlarge port site incisions
Morcellator
- Defined as the division of a large specimen into smaller fragments to permit removal from the peritoneal cavity
Pros and cons for transverse incision
Pro
Excellent exposure of the pelvis Lower risk of dehiscence and herniation Less pain Best cosmetic result with primary wound healing Reduced recovery time
Con
Greater blood loss
More prone to haematoma formation
Nerve injury can result in paraesthesia of the overlying skin
Pros and cons of Vertical midline
Pro
Avoids all major blood vessels, nerves, muscles
Only cut rectus sheath
Useful for massive intra-abdominal bleeding
Adequate exposure
Mandatory for full staging laparotomy in cases of ovarian malignancy
Performed rapidly
Simple closure
Minimal risk of haemorrhage
Can be easily extended around and above the umbilicus
Con
Increased wound dehiscence Increased hernia formation Delayed healing Aesthetic concerns Increase umbilical adhesions
Abdominal myomectomy outcomes
> 80% improvement in AUB
Uncertain if improves spontaneous fertility if >41y
Very low conversion rate to hysterectomy (<1%)
Comparable surgical morbidity to hysterectomy (organ damage, transfusion, adhesion formation)
Re-treatment rates:
- 20% over 5y depending on age and how close to menopause
to reduce blood loss at myomectomy
Moderate evidence for
- vasopressin
- misoprostol
GnRH
- Reduced fibroid size may enable a laparoscopic approach to myomectomy or hysterectomy
- Permits abdominal procedures through a smaller incision
- Reduces blood loss
- Concern about loss of defined fibroid capsule with pre-op GnRH analogue use
Distension media for hysteroscopy
Gas (CO2)
Low viscosity fluids
- Conductive - saline (commonly used)
- Non-conductive - dextrose, glycine
Hyponatraemia fluid overload
- hysteroscopy
Presents as confusion, collapse, seizure, coma
Occurs when intrauterine distending fluid (glycine, saline) transmigrates through the uterus and enters the circulatory system
- Glycine is hypotonic relative to blood, 1-1.5L of glycine entering the circulatory system can cause significant hyponatraemia
- Normal saline is isotonic to blood, 2L can enter circulatory system without causing significant dilutional hyponatraemia
Need strict real-time fluid balance
hysteroscopy techniques for cervical stenosis
Pre-op misoprostol
Cochrane 2015 - pre-op ripening of the cervix before operative hysteroscopy is more effective than placebo or no treatment, associated with fewer intra-op complications such as lacerations and false tracks
- less likely to need mechanical dilatation
Side effects: pre-op pain, vaginal bleeding
Saline hydrodilation for entry
Betocchi scope (small)
Consider USS guidance
General anaesthetic - Optimal positioning and muscles / patient relaxed
Contraindications to ablation
Active pelvic infection
Any non-lower segment uterine scar
Previous ablation
Wanting fertility
Malignancy or hyperplasia
Submucosal fibroids that prevent ablation device from contacting endometrium
Extremes of uterine length – greater than 10cm or less than 4cm
Novasure procedure
Endometrial biopsy to exclude hyperplasia or cancer
Hysteroscopy immediately prior to ensure:
- Sounding or dilation has not caused a perforation or false passage
- No significant intrauterine pathology
- Assessment of cavity length and cervical length
Novasure uses bipolar impendence technology to ablate endometrium
Cavity integrity is then assessed using carbon dioxide – this will fail if there has been a perforation during hysteroscopy
Delivers electrical current to a triangular metallic mesh electrode to vaporise the endometrium
Second generation compared to first generation endometrial ablation
Second generation
- Non-resectoscopic (not performed under vision)
- Only ablation endometrium
- Easier to learn and perform
- Lower rates of serious complications
- Shorter operating and theatre time
- Fewer perioperative adverse effects
First generation
- Transcervical resection of the endometrium (TCRE)
- Hysteroscopic rollerball ablation
Require experienced operators
Complications dependent on:
- Operator experience (e.g. uterine perforation)
- Method (e.g. dilutional hyponatraemia if using glycine uterine distension in monopolar diathermy)
Short term risks of endometrial ablation
Pain Haemorrhage Perforation - Rare - If occurs before energy used, management is usually just observation
Thermal injury to surrounding structures
- Will need laparoscopy or laparotomy to check for injury if perforation occurs during heating phase
- Safety checks with NovaSure to prevent this
- More common if distorted cavity or thinned myometrium
Death
- Related to undiagnosed thermal injury to bowel
- Very rare but cases have been reported
Infection post-procedure, <1%
- Warn patients will have abnormal discharge for up to 1 month afterwards
Fluid overload - 0.06%
Device failure
Cervical laceration
long term risks of endometrial ablation
Failure of procedure
- 10% will notice no change
- Cannot repeat ablation if previous, as changes in myometrial impedence so increased risk of perforation / thermal injury
Need for hysterectomy in 20%
Dangerous to get pregnant after procedure
- Increased risk of ectopic, miscarriage, IUGR, accreta, uterine rupture
Hematometra
Cyclical pain
Difficulty with endometrial sampling in future
Functional status
ECOG / GOG / WHO performance status
0 Fully active
Able to carry on all pre-disease performance without restriction
1 Restriction in physically strenuous activity, but ambulatory and able to carry out work of a light or sedentary nature, e.g. light house work, office work
2 Ambulatory and capable of all self care but unable to carry out any work activities, up and about >50% of waking hours
3 Capable of only limited self care, confined to bed or chair >50% of waking hours
4 Completely disabled, cannot carry out any self care, totally confined to chair or bed
5 Dead
From which vessels does the ureter derive its arterial blood supply
Renal Gonadal Internal iliac Uterine Vesical
