Surgery

Question 1

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

Answer 1

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

Question 2

What are the causes of adhesions in patients?

Answer 2

Previous surgery (75%) 
Infection/inflammation (25%)

Question 3

What is the pathophysiology of adhesion formation?

Answer 3

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

Question 4

List 4 complications of adhesions

Answer 4

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

Question 5

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

Answer 5

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

Question 6

What is the incidence of bladder injury?

Answer 6

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

Question 7

when is bladder most at risk during operating?

Answer 7

Port placement during laparoscopic surgery

Dissection away from bladder during CS

Question 8

list 4 factors that influence risk of bladder injury

Answer 8

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

Question 9

How to recognise a bladder injury intra-operatively

Answer 9

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

Question 10

How to recognise a bladder injury post operatively?

Answer 10

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

Question 11

When do thermal injuries to the bladder present?

Answer 11

10-14 days post op

Present with uroperitoneum or fistula

Question 12

How would you investigate for bladder injury (post op)

Answer 12

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

Question 13

What are the principles of bladder repair intra-op?

Answer 13

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

Question 14

How do you repair the dome of the bladder?

Answer 14

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

Question 15

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

Answer 15

The epithelial layer heals in 3-4 days

original integrity is obtained by day 21

Question 16

What are the principles of trigone repair?

Answer 16

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

Question 17

Following bladder injury what are 3 post operative management options?

Answer 17

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