Surgery Flashcards

Question

Evidence around removal of ovaries for benign disease

Answer 1

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

Answer 2

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

Answer 3

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

Answer 4

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

Answer 5

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

Answer 6

Relatively common: ~20% Majority treated with Abs alone Indications for drainage: - Sepsis - Persistent symptoms - e.g. pain - Large size

Answer 7

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

Answer 8

Ligation of the ovarian vessels Ligation of the uterine vessels (most common) Closure of the angles of the vaginal cuff

Answer 9

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

Answer 10

Positively identifying ureters during operation Dissecting down bladder Cystoscopy to check for ureteric jets at end of procedure Consideration of ureteric stenting

Answer 11

Suture removed and inspection of ureter should occur Check cystoscopy and ureteric stenting Consider indigo carmine

Answer 12

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

Answer 13

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

Answer 14

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)

Answer 15

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

Answer 16

1. Give antibiotics 2. Call colorectal surgeons for assistance. 3. 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 4. Extensive washout

Answer 17

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

Answer 18

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?

Answer 19

Up to 50% following midline laparotomy Up to 23% following low transverse incision No previous surgery - 0.68% Previous laparoscopy 1.6%

Answer 20

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

Answer 21

``` 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

Answer 22

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

Answer 23

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

Answer 24

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

Answer 25

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

Answer 26

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)

Answer 27

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

Answer 28

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

Answer 29

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

Answer 30

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

Answer 31

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 ```

Answer 32

>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

Answer 33

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

Answer 34

Gas (CO2) Low viscosity fluids - Conductive - saline (commonly used) - Non-conductive - dextrose, glycine

Answer 35

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

Answer 36

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

Answer 37

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

Answer 38

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

Answer 39

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)

Answer 40

``` 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

Answer 41

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

Answer 42

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

Answer 43

``` Renal Gonadal Internal iliac Uterine Vesical ```