Surgery Flashcards

1
Q

What are 5 surgical methods to reduce adhesion formation in Gynae surgery?

A
Laparoscopic approach - less trauma
Gentle tissue handling
meticulous haemoastasis
precise application of electrosurgery
minimise revascularisation
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2
Q

What are the causes of adhesions in patients?

A
Previous surgery (75%) 
Infection/inflammation (25%)
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3
Q

What is the pathophysiology of adhesion formation?

A

Disruption of peritoneum
Deposition of fibrin within 3 hrs
Infiltration of leukocytes and cytokines
Recruitment of new mesothelial cells which re-epithelialise the entire surface by 5-7 days

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4
Q

List 4 complications of adhesions

A

Pelvic pain
Bowel obstruction
Sub fertility
Operative complications -increased operation time and risk

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5
Q

aside from surgical techniques to reduce adhesion risk what other methods can be used?

A

Remove nidus for infection
Irrigation
Avoid latex gloves
Fine, non reactive sutures

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6
Q

What is the incidence of bladder injury?

A

0.3% at caesarean
1% at gynaecological procedures
note - 50% unrecognised at time of procedure

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7
Q

when is bladder most at risk during operating?

A

Port placement during laparoscopic surgery

Dissection away from bladder during CS

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8
Q

list 4 factors that influence risk of bladder injury

A

Surgical experience (surgeon)
Type of surgery e.g. LAVH
Complexity of surgery
Distorted anatomy (e.g. endometriosis, cancer, adhesions etc)

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9
Q

How to recognise a bladder injury intra-operatively

A

Check catheter bag for CO2 and or haematuria
Consider that injury might be retroperitoneal - into the space of Retzius, so only infiltrate 200-300ml methylene blue
Perform intra-op cystoscopy

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10
Q

How to recognise a bladder injury post operatively?

A
  • failing to recover as expected
  • suprapubic pain, haematuria, PV urine leakage, oliguria
  • chemical peritonitis
  • usually presents within 48 hours unless injury is thermal
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11
Q

When do thermal injuries to the bladder present?

A

10-14 days post op

Present with uroperitoneum or fistula

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12
Q

How would you investigate for bladder injury (post op)

A

Creatinine - increased due to the reasbsorption of urine creatinine through the peritoneum
CT urogram
Retrograde cyst-graphy
MRI to diagnose Vesico-vaginal fistula

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13
Q

What are the principles of bladder repair intra-op?

A

Notify anaesthetist and theater staff
request appropriate equipment e.g. cystoscope
Identify extent of injury:
- back fill bladder with saline or methylene blue
- if <2mm manage expectantly
- if 2-1cm consider expectant vs surgical management
- If >1cm repair
If dome only - proceed with repair
If trigone involved - call Urology

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14
Q

How do you repair the dome of the bladder?

A
Repair in 2 layers with 3/0 vicryl
- mucosa and detrusor layer
- serosal layer
Check integrity of the repair
- backfill the bladder with methylene blue to check is watertight
Keep bladder decompressed 
- IDC for 14 days
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15
Q

What is the rationale for keeping the bladder decompressed (with IDC in) following repair?

A

The epithelial layer heals in 3-4 days

original integrity is obtained by day 21

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16
Q

What are the principles of trigone repair?

A

Assess patency of ureter
- administer 5mL of indigo carmine IV
- Observe for dye stain from both orifices
- if no dye observed in retroperitoneal or intra-abdominal space you can proceed with dome repair
Consider removing suture if this is cause of issue
Call urologist to help
ureteric stents may be required

17
Q

Following bladder injury what are 3 post operative management options?

A
  • consider cystoscopy to determine extent
  • IDC for 2/52
  • cover with 1/52 of antibiotics