Surgery Flashcards
What are 5 surgical methods to reduce adhesion formation in Gynae surgery?
Laparoscopic approach - less trauma Gentle tissue handling meticulous haemoastasis precise application of electrosurgery minimise revascularisation
What are the causes of adhesions in patients?
Previous surgery (75%) Infection/inflammation (25%)
What is the pathophysiology of adhesion formation?
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
List 4 complications of adhesions
Pelvic pain
Bowel obstruction
Sub fertility
Operative complications -increased operation time and risk
aside from surgical techniques to reduce adhesion risk what other methods can be used?
Remove nidus for infection
Irrigation
Avoid latex gloves
Fine, non reactive sutures
What is the incidence of bladder injury?
0.3% at caesarean
1% at gynaecological procedures
note - 50% unrecognised at time of procedure
when is bladder most at risk during operating?
Port placement during laparoscopic surgery
Dissection away from bladder during CS
list 4 factors that influence risk of bladder injury
Surgical experience (surgeon)
Type of surgery e.g. LAVH
Complexity of surgery
Distorted anatomy (e.g. endometriosis, cancer, adhesions etc)
How to recognise a bladder injury intra-operatively
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
How to recognise a bladder injury post operatively?
- failing to recover as expected
- suprapubic pain, haematuria, PV urine leakage, oliguria
- chemical peritonitis
- usually presents within 48 hours unless injury is thermal
When do thermal injuries to the bladder present?
10-14 days post op
Present with uroperitoneum or fistula
How would you investigate for bladder injury (post op)
Creatinine - increased due to the reasbsorption of urine creatinine through the peritoneum
CT urogram
Retrograde cyst-graphy
MRI to diagnose Vesico-vaginal fistula
What are the principles of bladder repair intra-op?
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
How do you repair the dome of the bladder?
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
What is the rationale for keeping the bladder decompressed (with IDC in) following repair?
The epithelial layer heals in 3-4 days
original integrity is obtained by day 21