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Anna and louise > Surgery > Flashcards

Surgery Flashcards

1
Q

Nerve injury at hysterectomy

A

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)
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2
Q

Nerves that can become entrapped in reconstructive pelvic surgery

A

Sacrospinous fixation
- pudendal nerve when sutures placed in the arcus tendinus

uterosacral ligament suspension
- S1-4

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3
Q

Lithotomy nerve injuries

A

Common perineal nerve

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4
Q

How electricity is utilised in electrosurgery

A

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

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5
Q

Describe cutting waveform

A

Wave shape is a simple continuous sinusoidal form

Low voltage

Produces heat rapidly therefore vaporising or cutting the tissue

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6
Q

Describe coagulation waveform

A

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

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7
Q

What is monopolar

A

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

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8
Q

Monopolar - pros and cons

A

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
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9
Q

what is bipolar

A

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

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10
Q

Bipolar - pros and cons

A

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
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11
Q

Desiccation

A

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

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12
Q

Vaporization

A

High heat vaporises tissue immediately adjacent to the tip of the electrode
Since the cells “explode”, no char is produced

Cut

Non-contact

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13
Q

Fulguration

A

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

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14
Q

Injuries from electrosurgery

A

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
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15
Q

Thermal spread between devices

A

Harmonic scalpel 0-3mm

10mm Ligasure 1.8mm

5mm Ligasure 4.5mm

Traditional bipolar 2-22mm

Monopolar 50mm

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16
Q

Advanced bipolar devices

A

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

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17
Q

Advanced bipolar devices
- Ligasure

Pros and cons

A

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
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18
Q

Ultrasonic devices

A

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

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19
Q

PRos and cons of Harmonic

A

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
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20
Q

Hybrid devices

E.g. Thunderbeat

A

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
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21
Q

Surgical strategies to prevent adhesions

A

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

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22
Q

Adhesion prevention at laparoscopy

A

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

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23
Q

Cochrane 2015 - surgical approach to hysterectomy for benign gynaecological disease

A

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

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24
Q

Removal of the tubes at hysterectomy

A

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

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25
Q

Evidence around removal of ovaries for benign disease

A

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

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26
Q

Evidence around removal of ovaries for benign disease

A

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

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27
Q

Abdominal hysterectomy

- steps

A

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

28
Q

locations of ureteric injury and how they would occur during a vaginal hysterectomy

A

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
29
Q

Disseminated intravsacular coagulation

A

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
30
Q

Vault haematoma

A

Relatively common: ~20%
Majority treated with Abs alone

Indications for drainage:

  • Sepsis
  • Persistent symptoms - e.g. pain
  • Large size
31
Q

Most common sites of injury to ureter

A

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

32
Q

Steps in a hysterectomy that the ureter is most likely to be injury

A

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

33
Q

Types of injuries to ureter

A

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

34
Q

Preventing ureteric injuries:

A

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

35
Q

If ligation or kinking of the ureter with the suture

A

Suture removed and inspection of ureter should occur

Check cystoscopy and ureteric stenting

Consider indigo carmine

36
Q

Injury to lower ureter:

A

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
37
Q

Injury to middle ureter:

A

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
38
Q

Steps of fixing a bladder injury:

A

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)

39
Q

Bowel injury

A

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

40
Q

Management of bowel injury

A
  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
  1. Extensive washout
41
Q

Outcomes of subtotal hysterectomy

A

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

42
Q

Pros and cons of laparoscopic surgery

A

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?

43
Q

Previous surgery and rate of adhesions at the umbilicus

A

Up to 50% following midline laparotomy
Up to 23% following low transverse incision

No previous surgery - 0.68%
Previous laparoscopy 1.6%

44
Q

Risks of serious complications for laparsocopy

A

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
45
Q

Pneumoperitoneum

  • Chemical effects of CO2
  • CO2 benefits
A 
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

46
Q

Physiological changes of laparoscopy

A

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

47
Q

Inferior epigastric artery

A

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

48
Q

Superficial vessels of the anterior abdominal wall

A

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
49
Q

Cochrane 2019 - laparoscopic entry techniques

A

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

50
Q

Tests to confirm for Veress entry placement

A

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)
51
Q

Palmer’s entry

A

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
52
Q

Port closure

A

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

53
Q

Options for specimen retrieval

A

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

54
Q

Pros and cons for transverse incision

A

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

55
Q

Pros and cons of Vertical midline

A

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
56
Q

Abdominal myomectomy outcomes

A

> 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

57
Q

to reduce blood loss at myomectomy

A

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
58
Q

Distension media for hysteroscopy

A

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

59
Q

Hyponatraemia fluid overload

- hysteroscopy

A

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

60
Q

hysteroscopy techniques for cervical stenosis

A

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

61
Q

Contraindications to ablation

A

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

62
Q

Novasure procedure

A

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

63
Q

Second generation compared to first generation endometrial ablation

A

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)

64
Q

Short term risks of endometrial ablation

A 
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

65
Q

long term risks of endometrial ablation

A

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

66
Q

Functional status

ECOG / GOG / WHO performance status

A

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

67
Q

From which vessels does the ureter derive its arterial blood supply

A 
Renal 
Gonadal
Internal iliac
Uterine
Vesical

Anna and louise (28 decks)

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