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RANZCOG -Gynaecology 2024 > Surgery > Flashcards

Surgery Flashcards

1
Q

Discuss adhesions
-Incidence
-Causes (2)
-Pathophysiology
-Consequences (4)

A
  1. Incidence - 60-90% of patients who undergo gynae surgery
  2. Causes
    -Previous surgery - 75%
    -Infection / inflammation - 25%
  3. Pathophysiology
    -Adhesions are caused by aberrant healing process
    -Following disruption of peritoneum fibrin is deposited with 3 hrs
    -New mesothelioma cells aggregate and re-epithelialise peritonium in 5-7 dyas
    -If fibrin deposits don’t undergo satisfactory fibrinolysis then infiltration with fibroblasts occur and structures remain.
  4. Consequences
    -Bowel obstruction
    -Infertility
    -Pelvic pain
    -Increased operative difficulty in subsequent procedures
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2
Q

Discuss methods to avoid adhesions
-Surgical technique (3 categories)
-Adhesion barriers
-Solid bariers (3)
-Liquid barriers (2)
-Pharmacological methods (3)

A
  1. Surgical techniques
    Minimise trauma to tissue
    -Meticulous haemostasis
    -Minimise devascularisation
    -Careful dissection to tissue planes
    Avoid forgien bodies or irritants
    -avoid latex gloves
    -Use fine non-reactive sutures
    Route of surgery
    -Laparoscopy is less invasive
  2. Solid adhesion barriers
    -Interceed - oxidised regenerated cellulose
    -Seprafilm
    -ePTFE - nonabsorbable, sutured into place
    (Poor evidence for all solid barriers in reducing adhesions)
  3. Liquid adhesion barriers
    -Adept - Icodextrin 4%. High quality evidence reduces adhesions. No difference in clinical outcomes (fertility, pain, bowel obstruction)
    -Spraygel - polyethylene glycol
  4. Pharmacological methods
    -No impact on adhesion formation
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3
Q

Discuss bladder injuries
-Incidence
-When most likely to occur (2)
-Risk factors for bladder injury (9)
-How to prevent bladder injury (3)

A
  1. Incidence
    -0.3% CS
    -0.5 - 25% of gynaecological operations
    -50% unrecognised at time of procedure
  2. Time most likely to occur
    Port placement
    -Place second port under direct visualisation
    -Avoid Veres entry supra-pubically
    -Deflate bladder
    Dissection of bladder of cervix, usually in the midline -
  3. Risk factors
    -Inexperienced surgeon
    -Type of surgery - increased in LAVH
    -Complexity of surgery
    -Distorted anatomy (endometriosis, large pelvic mass)
    -Previous surgery, CS
    -Neoplasm
    -Obesity
    -Previous radiotherapy
    -Extensive bladder dissection
  4. Avoiding bladder injury
    -Empty bladder
    -Meticulous dissection of bladder
    -Maintain high index of suspicion
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4
Q

Discuss recognising and investigating for bladder injury
-Prevention principles (3)
-Regnoition intraoperatively (5)
-Recognition post-operatively (6)
-Investigations (6)

A
  1. Principles of prevention
    -Know anatomy
    -Safe electrocautery
    -Meticulous technique
  2. Recognition intra-operatively
    -Obvious cystotomy, urine leakage, CO2 or haematuria in catheter bag, intraoperative cystoscopy undertaken.
  3. Recognition post-operatively
    -Failing to recover as expected, oligouria, suprapubic pain, haematuria, PV urine leakage, chemical peritonitis.
    -Usually noted within 48hrs of injury but can be upto 10-14 days with thermal injury (uroperitoneum / fistula)
  4. Investigations
    -Increased serum creatinine - increased absorption by peritonum
    -CT urogram to see uroperitonieum or injury
    -Retrograde cystography - confirms diagnosis
    -Cystoscopy - helps to determine management approach
    -Methylene blue into bladder to look for PV leakage (fistula)
    -MRI to look for fistula
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5
Q

Discuss the management of bladder injury
1. Principles of repair (3)
2. Repairing injury in dome
3. Repairing injury at trigone / ureter

A
  1. Principles of repair
    Consider radiologist, urologist assistance
    Consider size of injury
    - <2mm consider expectant management
    - 2mm - 1cm consider expectant or surgical management
    - >1cm repair
    Consider location of injury
    -If dome can repair
    -If Trigone or ureter get help from urologist
  2. Repairing injury at bladder dome
    -Repair in 2 layers with continuous absorbable 2.0/3.0 vicryl suture
    -Mucosa
    - muscularis + Serosal layer
    -In posterior bladder wall injuries interpose omentum to minimise fistulation
    -Check integrity of repair with methylene blue to check water tight
    -Under take cystoscope at time of repair
    -Keep bladder decompressed - IDC for 14/7
    -Perform cystogram prior to removal. If leakage keep IDC for further week then repeat
    -Cover with antibiotics
  3. Repairing trigone
    -Assess patency of ureter
    -Consider if obstruction to ureter by suture and consider removing
    -Call urologist for help
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6
Q

Discuss pre-operative evaulation and management for intra-operative blood loss
-Management of antiplatelets (2)
-Management of anticoagulants - things to consider (1)
-Warfarin (low and high thrombotic risk)
-Thrombin inhibitors and FActor Xa inhibitors (low and high bleeding risk)

A
  1. Antiplatelets
    Aspirin - can usually be continued. Stop 7 days pre-op
    Clopidogrel - can usually be continued. Stop 7 days pre-op
  2. Anticoagulants
    -Need to consider clotting vs bleeding risk
    -High clotting risk AF HEaret valves, recent VTE
    -High bleeding risk any major op >45mins
  3. Warfarin
    Low thrombotic risk - stop 4-5D pre-op. Operate if INR <=1.5
    High thrombotic risk - stop 4-5D pre-op. Once INR <=2.0 cover with LMWH then operate 24hrs post stopping LMWH.
    Restart warfarin at maintenance dose night of surgery
  4. Thrombin inhibitors (Dabiagatran / Rivaroxiban)
    -Low bleeding risk - Stop 2 days pre-op. Restart 24hrs post op
    -High bleeding risk - Stop 3 days pre-op. Restart 48hrs post op
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7
Q

Discuss managment of intra-operative haemorrhage
-General principles (7)
-Surgical haemostasis (7)
-Topical haemostasis
- types (2)
-Risks (3)
-Benefits (4)

A

1.General principles
-Avoid hypothermia
-Avoid excess venous pressure at surgical site
-Consider deliberate hypotension
-Involve anaesthetics
-Intravascular resus with IVF
-TXA
-Blood products if Hb <80 or clinically appropriate
2. Surgical haemostasis
-Pressure
-Monopolar diathermy if vessle <2mm
-Advance bipolar if vessle <7mm
-Vessle ligation if vessle >7mm
-Proximal vessle ligation
-Consider conversion to open for access
-Consider vascular input
3. Topical heamostatic agents
Active
- contains fibrin or thrombin to trigger coagulation cascade - Floseal
-Removed by fibrinolysis
Mechanical
-Contains collagen, cellulose or gelatin as framework for platelet activation - surgicel
-Removed by absorption
Risks: excess material may cause granulation, may complicate radiological and clinical diagnosis of abscess/granuloma/tumours, may increase adhesion formation
Benefits: Improved haemostasis in venous ooze, absorped in 2-5weeks, has bacteriostatic effect, pilable

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8
Q

Discuss management of bowel injury
-Grade of injury (5)
-Management depending on grade
-Antibiotics
-Post operative considerations (1)
-Suture type

A
  1. Grade of injury and management
    -Grade 1 - partial thickness without devascularisation - repair in 1-2 layers
    -Grade II - <50% of circumference - debride edges and repair with 2 layers longitudinally
    -Grade III - >50% of circumference - debride edges and repair in 2 layers longitudinally
    -Grade IV - Transection - resection and anastomosis
    -Grade V - devascularised - resection and anastamosis
  2. Management of serosal damage - oversew with continuous 3.0 PDS to bury raw edges
  3. Pre-operative antibiotics usually sufficient. If not given then broad specturm
  4. Post op diet - no restrictions
  5. Suture type
    3-0 PDS
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9
Q

Discuss the complications of hysterectomy
1. Serious complications and incidence (8)
2. Frequent complications (4)

A
  1. Serious complications overall 4:100
    -Requiring blood transfusion 23/1000
    -Major bleeding 5:1000
    -Return to OT - 7:1000
    -Urological injury - 7:1000
    -VTE 4:1000
    -Pelvic abscess/infection 2:1000
    -Bowel injury - 0.4/1000
    -Death 1:4000 (0.25:1000) - Mostly VTE or MI
  2. Frequent complications
    -Urinary sx - Increased frequency, UTI
    -Minor bleeding/bruising
    -Wound concerns (dehiscence, delayed healing, herniation)
    -keloid formation
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10
Q

Describe vaginal hysterectomy
-Indications
-Contra-indications
-Complication rate
-Advantages (6)
-Disadvantages (2)

A
  1. Indication
    -Benign indications only - HMB, Prolapse
  2. Contra-indications
    -Adnexal pathology, malignancy
    -Adhesions, enlarged uterus, long vagina, narrow pubic arch,
  3. Complication rate - 23%
  4. Advantages:
    -Least post-OP pain
    -Quicker recovery
    -Shorter hosptial stay
    -Fewer post op infections
    -Can perform concurrent continence surgery.
    -Supported as route of choice by ACOG and Cochrane review
  5. Disadvantages
    -Reduced ability to manage pelvic pathology
    -Salpingectomy not routinely performed
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11
Q

Describe the steps of a vaginal hysterectomy (12)

A
  1. Grasp cervix with valsallum / Alice
  2. Infiltrate with LA to fornicies
  3. Circumfrential incision around cervix
  4. Dissect vaginal epithelium off fascia to level of fornicies
  5. Divid cervicovesicular ligaments and reflect bladder anteriorly
  6. Enter peritoneum posteriorly in POD and use sims to retract rectum
  7. Clamp, cut and tie cardinal ligaments
  8. Clamp, cut and tie uterine vessles
  9. Clamp and ligate broad ligament, round ligament, ovarian ligament and fallopian tube (in one or two bites)
  10. Remove uterus and cervix
  11. Incorperate uterosacral ligaments into closure of posterior peritonuem and lateral edges angles of vaginal vault
  12. Close vaginal vault using continuous suture
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12
Q

Describe abdominal hysterectomy
-Indications (4)
-Contra-indications
-Complication rate
-Advantages (4)
-Disadvantages (3)

A
  1. Indications
    -Uterus >12/40, Hx of PID/Endo?multiple CS, Malignancy, Minimal uterine decent, narrow pubic arch, long vagina
  2. Contra-indications - Nil
  3. Complication rate 17%
  4. Advantages
    -Visualisation and tactile examination of pelvic / abdominal organs
    -Concurrent management of pelvic pathology
    -Easy clearence of bowel with wet sponges
    -Easier adhesiolysis
  5. Disadvantages
    -Most Post OP pain
    -Longest hosptial stay
    -Reduced QoL and sexual function
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13
Q

Describe the steps of abdominal hysterectomy (14)

A
  1. Entry as per laparotomy
  2. Gain access with bowel packing and retractor
  3. Straight tissue forceps over round ligament and fallopian tube
  4. Clamp round ligament with curved tissue forceps at mid point and incise
  5. Bluntly create hole in broad ligament with finger
  6. Further clamp either to tube and ovarian ligament (medial to ovary) or to IP ligament if BSO
  7. Incise anterior leaf of broiad ligament down to uterovesicular peritoneum and reflect bladder down
  8. Place Kocher at R angles to uterus at midpoint and incise medially then ligate pedicle sercuring uterine artery
  9. Clamp and ligate paracervical tissue
  10. Incise anterior and posterior fornix
  11. Clamp and ligate uterosacral ligaments
  12. Perform colpotomy
  13. Close vaginal vault in two layers incorperating uterosacral ligaments into angles
  14. Close abdomen
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14
Q

Discuss laparoscopic hysterectomy
-Indications
-Contra-indications
-Complication rate
-Advantages (6)
-Disadvantages (3)

A
  1. Indications - minimal uterine decent, long narrow vagina
  2. Contra-indications - medical contra-indication to laparoscopy, likelihood of severe adhesions
  3. Complication rate 19%
  4. Advantages
    -Can evaluate other pelvic pathology
    -Can perform other adnexal procedures
    -Shorter hospital stay
    -Less post-OP pain
    -Less wound infection
    -Better QoL
    -Early return to activities
  5. Disadvantages
    -Longest operating time
    -Most urinary tract injuries
    -More severe bleeding
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15
Q

Describe the steps for Laparoscopic hysterectomy (9)

A
  1. Insert uterine manipulator - grasp cervix, sound uterus, dilate cerix, insert rumi slide and sercure cup to cervix
  2. Enter abdomen laproscopically
  3. Perform salpingectomy
  4. Ligate gonadal pedicle IP or ovarian ligament depending on ovarian conservation or not
  5. Divide round ligament and incise anterior leaf of broad ligament towards the UV fold to reflect bladder
  6. Skeletonise and divide uterine vessles
  7. Perform colpotomy using counter traction with uterine manipulator to advance cuff superior to ureters. Remove uterus.
  8. Close vault in two layers incorperating uterosacral ligaments
  9. Check haemostasis
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16
Q

Discuss total vs subtotal hysterectomy
-disadvantages of subtotal hysterectomy (2)
-Difference in outcomes (7)
-Preference

A
  1. Disadvantges
    -Ongoing cervical screening required
    -Risk of cyclical bleeding
  2. Difference in outcomes
    -NO difference for urinary/bowel/sexual function/surgical recovery/readmission rate/transfusion rate/POP/urinary incontinence
  3. Preference is total hysterectomy always. May not be possible due to mechanical or technical difficulties
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17
Q

Discuss management of adnexa at hysterectomy for benign pathology
-Benefits of oopherectomy (2)
-Risks of oopherectomy (6)
-Benefits of salpingectomy (1)
-Risk of salpingectomy (1)

A
  1. Benefits of oopherectomy - reduced risk of breast cancer if <45, reduced risk of ovarian cancer
  2. Risks of oopherectomy - Increased all cause mortality if <65yr, Increased CHD, osteoporosis, hip fractures, depression and anxiety, cognitive dysfunction, more severe vasomotor sx, sexual dysfuction if premenopausal
  3. Benefits of salpingectomy - Reduces risk of high grade serous ovarian/fallopian/peritoneal cancer
  4. Risks of salpinectomy - none
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18
Q

Discuss the RANZCOG recommendations and evidence for management of adnexa at hysterectomy
-RANZCOG recommendations (3)
-Evidence from Ovarian conservation study
-Evidence from Nurses health study

A
  1. RANZCOG recommendations
    -If women are <50 and considering oopherectomy counsel regarding: increased mortality at older age with oopherectomy and reduction in ovarian cancer and deaths with their removal.
    -In women >50 considering oopherectomy counsel regarding reduction in ovarian cancer and death from ovarian cancer but no change in survival benefit.
    -Discuss the benefits of BS with hysterectomy including reduced ovarian cancer dx (no studies report reduced risk of death). No increased risk of complications
  2. Evidence from ovarian conservation study
    -BSO at 50-54 8.5% excess mortality at 80yrs
    -BSO at 55-59 3.9% excess mortality at 80yrs
    -No age shows clear benefit of oopherectomy for survival
    -BSO associated with increased all cause mortality, CHD, lung cancer
    -BSO associated with reduced breast cancer and ovarian cancer
  3. Evidence Nurses study
    -BSO associated with decreased breast and ovarian cancer
    -BSO associated with increased risk of CHD and all cause mortality
    -BSO not associated with decreased survival if after 55yrs
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19
Q

Discuss surgical site infections
-Definition
-Risk factors (7)

A
  1. Definition: infection related to an operative procedure near or at the surgical incision within 30 days or 90 days if prosthetic material implanted
  2. Risk factors
    -Smoking
    -Older age
    -Obesity
    -Diabetes
    -Immunosupression
    -Malnutrition
    -Open surgery > laparoscopic
    -Emergency > elective
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20
Q

Discuss prevention measures for surgical site infection
-Pre-operative measures for the patient (4)
-Measures at the theatre level (4)
-Measures for patient prep (4)

A
  1. Pre-operative measures for patient
    -Optimise nutrition
    -Use minimal route for operation
    -Encourage smoking cessation even if just on morning of operation
    -Bowel prep - only if possibility of bowel injury
  2. Measures at OT level
    -Limit number of people in OT can through OT
    -Have filtration systems
    -Have OT cleans between cases and deep terminal clean
    -Have sterile instruments and storage of instruments
  3. Patient preparation
    -Clip rather than shave at surgical site
    -Skin preparation - chlorhex better in horizontal stripes
    -Vaginal prep - chlorhex better than Iodine (bacteriocidal not static)
    -Shower prep with chlorhex - decreases skin flora but dosen’t impact SSI
    -MRSA declonisation not required unless ortho op
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21
Q

Discuss prophylactic antibiotic use in surgical site infections
-Type
-TIming
-Efficacy
-Repeat dosing during surgery

A
  1. Type of antibiotic
    -Should be active against skin flora.
    -Cefazolin most widely studied
  2. Timing - should be 30-60 mins before knife to skin for cefazolin to have max penetration at skin
  3. Efficacy - Reduces SSI by 50%
  4. Consider repeat dosing if:
    -Operation >4hrs
    -Blood loss >1.5L
    -Don’t forget to consider dose adjustment with renal impairment
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22
Q

Discuss surgical techniques to decrease risk of surgical site infection
-On entrance (2)
-Intraoperatively (4)
-Wound closure (6)
-Specific to CS (4)

A
  1. On entrance
    -No difference in SSI between scalpel adn electrosurgery but aim to reduce tissue necrosis to decrease SSI
    -Avoid repeated strokes at incision
  2. Intra-operatively
    -Avoid tissue drying out
    -Ensure haemostasis
    -Avoid exessive tension/traction on tissues
    -Wound retractiors (Alexis) reduce SSI by keeping wound edges protected and moist
  3. Wound closure
    -Ensure haemostasis
    -Close wounds without tension
    -Close campers fascia if >2cm of fate
    -Don’t leave dead tissue
    -Aim for monofilament
    -Staples less likely to obscure wound drainage but uincreased risk of wound separation
  4. For CS
    -Avoid MROP
    -No optimal method for closing sheath
    -Close fat layer
    -No evidence fresh blade or change in gloves or irrigation of wound improves SSI rates
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23
Q

Describe the following:
-Current
-Resistance
-Voltage
-Power
-Frequency
-Joules law of thermodynamics
-DC current
-AC current

A
  1. Current: the rate of flow of electorons through a conductor (amps)
  2. Resistance: The opposition of the flow of current (Ohms)
  3. Voltage: The force required to move a unit of charge from one point to another (Volts)
  4. Power: Energy produced Watts
  5. Frequency: Number of cycles of positive and negative alternation pf current per second (hertz)
  6. Joules law of thermo dynamics: Heat created is proportional to the current, the tissue resistance and the duration of time of application (Heat = current squared x reistance x time)
  7. DC current: elctrons flow in same direction
  8. AC current flow of electrons change direction periodically
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24
Q

Discuss the effect of heat on tissues at different temperatures
-45 degrees
-70 degrees
-90 degrees
-100 degrees
-200 degrees

A
  1. 45 degrees causes protien denaturation and tisssue damage which may be irreversible
  2. 70 degrees: causes boiling of intracellular fluid, cell shrinkage and linkage of adjacent cells - coagulation
  3. 90 degrees: Desiccation of tissue
  4. 100 degrees: vaporisation of bubbling of tissue
  5. 200 degrees: Char formation or carbonisation of tissue
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25
Q

Describe coagulation in terms of:
-frequency and voltage
-Temperature
-Impact to tissue
-Sites of use
-Thermal spread

A
  1. Uses low frequency interupted wave form adn high voltage 5000V
  2. Temperature is slow to rise in tissue due to intermittent heat delivery
  3. Results in cell dehydration and shrinkage, protien denaturation, welding of adjacent cells
  4. Use for highly vascular areas for haemostasis adn high resistance tissue - Fat
  5. Has increased thermal spread compared to cut
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26
Q

Describe cutting in terms of:
-Frequency and voltage
-Temperature
-Impact to tissue
-Site of use
-Thermal spread

A
  1. Uses high frequency continous wave form and low voltage 1000V
  2. Has radip temperature ris
  3. Causes rapid heating of intracellular fluid and cell rupture
  4. Use when close to important structures
  5. Has narrow thermal spread cf coagulation
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27
Q

Discuss the following in terms of:
temperature, mode to achieve, contact with tissue, effect on tissue
-Dessication
-Vaporisation
-Fulguration

A
  1. Dessication
    -90 degrees
    -Achieved on cut or coag
    -Direct contact with tissue
    -Dehydration and shrinkage of cells and protien denturation and welding of tissue
  2. Vaporisation
    -100 degrees
    -Cutting more
    -Non-contact
    -Rapid brief increase in temperature converting intracellular fluid to stream rupturing cells
  3. Fulguration
    -200degrees
    -Coag mode
    -Non-contact
    -Breakdown on tissue into anatomical components with charring over large area
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28
Q

Discuss monopolar
-Circuit
-Advantages (7)
-Disadvantages (7)

A

Monopolar is a single active electrode in contact with the tissue.
The circuit is complete by passage of curent through the path of least resistance to a base plate
Advantages:
-Reaily available
-Cheap
-Range of configurations
-Versatile
-Range of variables
-Wide range of tissue effects
-Popular
Disadvantages:
Risk of capcitive coupling/current leakage
-Improper application
-Lateral spread
-Smoke plume
-Poor vessle sealing - 1mm max
-Delayed presentation of thermal injury
-Electrical current passes through patient

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29
Q

What are the considerations for applying a base plate for monopolar - (8)

A
  1. Full contact with electrode surface
  2. Site free of soiling or surface residue
  3. Avoid boney protrusions
  4. Avoid scar tissue
  5. Avoid implants
  6. Shave heavy hair growth
  7. Position close to operating table
  8. Be accessible under drapes
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30
Q

Discuss bipolar
-Circuit
-Advantages (6)
-Disadvantges (4)

A
  1. Bipolar current flows from one electrode to another and not through the body of the patient
  2. Advanatages
    -Almost zero chance of alternative pathway burns
    -Low power requirement
    -Readily available
    -Inexpensive
    -Good vessles sealing 5-7mm
    -Can do dessication and coagulation
  3. Disadvantages
    -Limited dissection capability
    -Risk of lateral thermal spread
    -Need for additional technology for transection
    -No audio feedback on completion so increase slateral spread
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31
Q

Discuss thermal spread in terms of electrosurgical injury
-defintion
-Extend of spread with different modalities

A
  1. Thermal spread is damage to tissues in the area surrounding the intended tissue
  2. Extent of spread by modality
    -In traditional bipolar ranges 2-22mm
    -Harmonic scalpel - 0.3mm
    -Ligasure 4.5mm
    -Adavanced bipolar systmes have much less thermal spread
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32
Q

Discuss direct coupling
-Defintion
-Causes of direct coupling (3)

A
  1. Defintion: direct electrical burns
  2. Causes
    -Accidental activation of the electrode while touching a nontarget tissue
    -Acidental activation of the electrode while touching another metal instrument in the abdomen that is touching a non-target tissue
    -Insulation failure due to micro leaks allowing passage of coagulation wave form
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33
Q

Discuss capacitive coupling
-Cause
-Ways to avoid (2)

A
  1. Occurs when hybrid metal ports with plastic collars are used. Current from the electrode passes onto the metal port and cannot be dissipated and so arcs into tissu or onto another istrument
  2. Ways to avoid
    -Use all metal ports
    -Use all plastic ports
34
Q

Describe methods to reduce electorsurgical complications
1. Equipment (5)
2. Settings (2)
3. Technique (6)

A
  1. Equipment
    -Inspect insulation - usually fails at tip. Seen with sparking
    -Ensure correct placemnt of base plate and sercure connections
    -Store unused electrodes in sheath or quiver
    -Consider using second generation or ultrasonic devices
    -Avoid hybrid port devices with metal and plastic components
  2. Settings
    -Use lowest power setting
    -Use lowest voltage wave form (cut)
  3. Technique
    -Keep instruments in view
    -Avoid touching two metal instruments while one is charged
    -Use brief intermittent activation
    -Use cut for monopolar
    -Only activate diathermy once in contact with the tissue
    -Never allow assistant to use pedals for you
35
Q

What are the properties that regulate thermal effect (5)

A
  1. Current (power output)
  2. Modulation level - manipulation of pulse combination to achieve pure cut, blend or pure coag
  3. Shape of the electrode - thin pointed electrode gives high energy - cutting effect. Large surface area electrode spreads energy = coag effect
  4. Condition of the electrode. Presence of escar increases resistance and give non-uniform untidy thermal effect
  5. Tissue proerties - different tissues have different resistance
36
Q

Discuss advanced bipolar devices
-Principle of system
-Types (3)
-Advantages (5)
-Disadvantages (6)

A
  1. All ultilise impedance controls whereby energy is delivered according to tissue impedance. Combines use of pressure to oppose vessles and bipolar diathermy to cause collagen and elastin to seal.
  2. Types
    -Ligasure
    -Enseal
    -Gyrus plasma kinesis
  3. Advantages
    -Audio signals when device recognises tissue impedance when vessle is sealed
    -Impedance based feedback allows lowest efective power to be used
    -Seals vessels up to 7mm in diameter
    -No curent passes through patient
    -Can be used as a grasper and has inbuilt transection method resulting in less instrument traffic and more efficent surgery
  4. Disadvantages
    -Single use
    -Expensive
    -Requires specialised electrosurgery unit
    -Limited dissection ability
    -Risk of lateral thermal injury - but less than classic bipolar
    -Eschar formation possible causing greater impedance adn less effective tissue heating
37
Q

Discuss ultrasonic devices used for electrosurgery
-Principles of device
-Types
-Advantages (9)
-Disadvantages (5)

A
  1. High frequency vibration at the active blade of the device allows for cut and coagulation.
  2. Harmonic
  3. Advantages:
    -Can seal up to 7mm vessles
    -Vessels are sealed at alower teperature
    -Less plume is generated
    -Can cut and coag with same instrument
    -No current passes through patient
    -No electrical source so can use if pace maker
    -Less thermal spread
    -Less char and eschar formation
    -Decreased surgical instrument traffic
  4. Disadvantages:
    -Tip of device can remain hot so can cause tissue damage
    -Unable to use as grasper
    -Expensive
    -Takes longer to achieve haemostasis
    -Steeper learning curve
38
Q

What are the contraindications for laparoscopy (6)

A
  1. Haemodynamic shock
  2. Severe cardiorespiratory disease
  3. Severe obseity
  4. Previous midline laparotomy
  5. Severe intra-abdominal adhesions
  6. Multiple intraabdominal surgeries
39
Q

Discuss the complcations of laparoscopy
-Overall serious complication risk
-Overall complication risk
-Serious complications (10)
-Frequent complication risk (4)

A
  1. Serous complication risk 2:1000
  2. Any comlication risk 3-8:1000
  3. Serious complications
    -Bleeding from abdo wall vessles - 3:1000
    -Bleeding from retroperitoneal vessles 0.9:1000
    -Damage to bowel 1-4:1000
    -Damage to urological system 0.3:1000
    -Failure to gain entry
    -Damage to nerves
    -Revert to open 3.3:1000
    -Hernia 2:1000
    -VTE <1:1000
    -Death 3-8:100,000
  4. Frequent complication
    -Infection
    -Bruising
    -Shoulder tip pain
    -Wound gaping
40
Q

Discuss the risk factors for compications with laparoscopic surgery (6)

A
  1. Obese - recommended hasan or palmers point entry
  2. Very thin - recommend hasan or palmers point entry
  3. Previous abdominal surgery
    -Midline 50% chance umbillical adhesions
    -Horizontal incision - 25% chance umbillical adhesions
    -Any previous surgery - 15% chance umbillical adhesions
  4. Intra abdominal adhesions arising from:
    -PID, endometriosis, Crohns,
  5. Surgical indication - large pelvic or abdominal mass
  6. Pre-existing condition
41
Q

Discuss laparoscopic entry
-Incision size (3)
-Locations (3)
-Types (3)
-Comparative complications of entry types (2)

A
  1. Incision size
    -5mm port 8mm incision
    -10mm port 16mm incision
    -12mm port 19mm incision
  2. Locations
    -Umbillical - most common
    Fusion of facial layers, devoid of subcutaneous fat, relatively avscular
    -Palmers point
    3cm below L costal margin, mid clavicular line
    Needs NGT to decompress stomach
    Consider if adhesiosn, umbillical mesh, hernia, large pelvic mass, pregnant
    Contraindicated in previous splenic or gastric surgery, hepatosplenomegaly, portal HTN, gastric/pancreatic mass
    -9th intercostal space in anterior axillary line
  3. Types of entry
    Open entry - Hassan and modified hassan
    Closed entry - Veres and direct optical entry
  4. Comparative complications
    Increased rate of failed entry with Veres vs optical
    Same rates of visceral injury with open and closed techniques
    Increased vascular injury in closed technique 1:20,000 open vs 1:2000 closed
42
Q

Describe the steps for Veres entry (13 steps) (RANZCOG guideline)

A
  1. 5mm skin incision from base of umbilicus caudally
  2. Check veres needle
  3. Elevate abdominal wall with non dominant hand
  4. Grip veres needle in pen grip 3cm from tip and apply with constant pressure perpendicularly
  5. Await pop of abdominal fascia then second pop of parietal peritoneium
  6. Undertake placement tests - hanging drop, aspiration
  7. Check pressure - should be <8mmHg - most sensitive measure that in correct place
  8. Commence low flow insufflation - 1-3L/min
  9. Increase to high flow to achieve pressure of 20mmHg
  10. Remove Veres needle
  11. Place port in incision site in constant pressure and twisting motion
  12. Once placement confirmed drop pressure to 15mmhg
  13. If 3 x failed attempts opt for Palmers point or Hassan entry or seek senior help
43
Q

Describe steps of optical entry - 8 steps

A
  1. Do not infiltrate with local anaesthetic
  2. Vertical skin incision from base of umbillicus cordially
  3. Elevate abdominal wall
  4. Place 0 degree scope into transperant port
  5. Place port into incision and apply perpendicular downward pressure and twisting motion
  6. Visualise layers as port progresses - anterior sheath then posterior sheath and parietal peritoneum
  7. Once entered abdominal cavity change angle to 45 degrees and advance 2cm
  8. Take out trocar with laparoscope an dcommence low flow to confirm location
44
Q

Describe step of Hassan entry (12 steps)

A
  1. Place little woods on edges of umbillicus and evert
  2. Infiltrate with local anaesthetic
  3. Vertical incision from umbillical base caudally
  4. Graps umbilical stalk with little woods
  5. Dissect subcutaneous fat from stalk and advance down stalk untill fascia is reached
  6. Incise fascia until small amount of preperitoneal fat is seen
  7. Place purse string stay suterue with J need’e
  8. Enter peritoneum and check internal abdominal wall for adhesions in sweeping motion
  9. Place blunt end of trocar through incision
  10. Conmmence low flow insufflation
  11. Check location and secure port with stay suture
  12. Increase to high flow
45
Q

Discuss the pros and cons of:
1. Veress entry (4 pro’s, 2 cons)
2. Direct optical entry (3 pro’s 3 cons)
3. Hassan entry (4 pros, 3 cons)

A
  1. Veress Pro’s
    -Equivalent risk of visceral injury
    -Fast entry into peritoneal cavity
    -Reduced risk of access site hernia
    -Pneumoperitoneum prior to trocar
    Veress Con’s
    -Increase vascular injury
    -Increased failed entry
  2. Direct optical entry pro’s
    -Equivalent risk of visceral injury
    -Quicker than Hassan
    -Less failed entry
    Cons
    -Pneumoperitoneum not achieved prior to port placement
    -More force required for entry
    -More vascular injury
  3. Hassan Pro’s
    -Equivalent risk of visceral injury
    -Less vascular injury
    -Avoids sharp instruments following initial incision
    -Allows direct visualisation of entry before insufflation
    Cons
    -Takes time
    -Must always close sheath
    -More adhesion formation
46
Q

Discuss placement of lateral ports (3 points)

A
  1. Avoid inferior epigastric arteries (medial to insertion of round ligament into inguinal canal)
  2. Place first 2cm medial and 1 cm superior to ASIS. Aim for fat pad lateral to lateral umbillical fold
  3. Place second lateral port 1/3 along arc between ASIS to umbillicus
47
Q

When should the fascial layer be closed with laparoscopic port sites (3)

A
  1. Hassan entry
  2. Midline port >10mm
  3. Lateral port >7mm (Be careful to avoid entrapment of ilioinguinal iliohypogastric nerves)
48
Q

Discuss the contra-indications of hysteroscopy (5)

A
  1. Viable IUP
  2. Active pelvic infection - including herpes
  3. Known cervical or uterine cancer
  4. Excessive uterine bleeding
  5. Occasionally medical comorbidities
49
Q

Discuss types of scope for hysteroscopy and their size (3)

A
  1. Office hysteroscope 2.7mm
  2. Rigid endoscop 4mm usually
  3. Resectoscopy with additional sheaths for operative hysteroscopy - 7-9mm
50
Q

Discuss isotonic distension media for hysteroscopy
-Examples
-Properties
-Able to support use of electrical current and type
-Pros (2)
-Cons (2)

A
  1. Normal saline, Ringers lactate
  2. Isotonic
  3. Bipolar
  4. Advantages:
    -No risk of hyponatremia
    -Can be used with bipolar, morecllators, laser, mechanical tissue removal
  5. Disadvantages
    -Risk of fluid over load with large volumes
    -Can’t use monopolar
51
Q

Discuss hypotonic distension media in hysteroscopy
-Examples
-Properties
-Able to support which type of electrical current
-Advantages
-Disadvantages

A
  1. 1.5% glycerine, 3% Sorbitol, 5% Mannitol
  2. Hypotonic
  3. Monopolar
  4. Can be used with monopolar
  5. Can lead to hyponatremia
52
Q

Discuss CO2 as a distension media for hysteroscopy
-Type of electrical current supported
-Advantages
-Disadvantages

A
  1. Electricity not recommended due to thermal risk
  2. Advantages
    -Clear field of view
    -Perception of maximal angle of view
    -Rapidly absorbed
    -Long history of safety
  3. Disadvantages
    -Gas bubbles may interfer with visualisation
    -Inappropriate for operative hysteroscopy due to thermal risk
    -Risk of CO2 embolism
    -Non-uniform uterine distension
    -Poor view with bleeding
53
Q

Discuss complications of hysteroscopy (9)

A
  1. Overall serious complication risk is 2:1000
  2. Vasovagal with cervical shock
  3. Perforation of false passage
  4. Failure to traverse cervical canal
  5. Failure to obtain diagnostic sample
  6. Damage to surrounding structures
  7. Haemorrhage
  8. Infection
  9. Fluid overload
54
Q

Discuss methods to avoid failure to transverse cervical canal during hysteroscopy (7)

A
  1. Pre operative misoprostol
  2. Serial Hegar dilitation
  3. Pre-operative USS/Exam to know uterine lie
  4. Treat vaginal atropy to allow better vaginal access
  5. Straighten cervix with traction on cervix with velcellum
  6. Consider USS guided entry
  7. Intracervical injection of vassopressin
55
Q

Discuss fluid overload in hysteroscopy
-Definition for isotonic and hypotonic distension media
-Incidence
-Factors that predispose to systemic fluid absorption - 9
-Presentation (3)
-Management

A
  1. Defintion
    -Fluid deficit >2500mL if isotonic
    -Fluid deficit >1000mL if hypotonic
  2. <5%
  3. Factors that predisopse to fluid absorption
    -High intrauterine pressure (higher than MAP). Usually >75mmHg
    -Low MAP seen with elderly and CVD
    -Duration of surgery
    -Large uterine cavity with increase surface area
    -Depth of myometrial penetration - exposes vessles for absorption
    -Type of distension media - hypo-osmolar absorbed more readily by osmosis
    -Cardiovascula and renal disease - reduced ability to manage fluid shifts
    -GA - increases fluid overload risk
    -Large diameter resectoscope
  4. Presentation
    -SOB, Peripheral oedema, Sx of hyponatremia
  5. Management
    -Fluid restrict
    -Loop diuretics
    -Strict fluid balance
    -Monitor serum electrolytes
56
Q

Dicuss nerve injury during surgery
-Incidence (3)
-Symptoms (4)
-Causes of injury (3)
-Types of injury and time to recovery
-Risk factors (3)

A
  1. Incidence
    -2% following pelvic surgery
    -Most commonly secondary to poor positioning not direct injury
    -7% of women have chronic pain after pfannensteil incision
  2. Symptoms
    -Pain, weakness, paresthesia, loss of sensation
  3. Causes of injury
    -Transection - more common from transverse incision, trochar insertion, thermal injury
    -Ligation - entrapement
    -Stretch or compression - patient positioning, retractors, haematoma
  4. Types of nerve injury
    -Neuropraxia - weeks to months
    -Axonotmesis - asxonal damage - several months
    -Neurotmesis - transection. Poor prognosis
  5. Risk factors
    -Thin body habitus
    -Narrow pelvis
    -Prolonged surgery
    -Use of self retractors
    -Long procedure >4hrs abdo, >2 hrs vaginal
57
Q

Discuss neuroma formation
-Cause
-Symptoms
-Management (3)

A
  1. Cause
    -Entrapemnt, trasection, trauma
  2. Persistent pain and burning at incision, sensory changes in area of nerve distribution
  3. Management
    -NSAIDS, Local anasethtic, excision
58
Q

What nerves are commonly impacted by nerve injury during pelvic surgery (7 nerves)
-Nerve
-Mechanism of injury
-Presentation

A
  1. Illoinguinal and illiohypogastric
    -Suture entrapment at lateral boarders of pfannenstiel
    -Senosry changes to groin and uper thigh
  2. Genitofemoral
    -During pelvic sidewall surgery
    -Sensory changes to mons, labia and fem triangle
  3. Lateral cutaneous nerve of thigh
    -Compression against sidewall or poor positioning
    -Sensory anterior and lateral thigh
  4. Femoral - 11% of all gynae nerve injuries
    -Compression against side wall or poor positioning
    -Sensory to ant and lat thigh. Hip flexion and adduction
  5. Obturator
    -Retroperitoneal dissection, TOT, endo surgery
    -Sensory upper medial thigh, Motor hip adductors
  6. Common peroneal
    -Compression at fibular neck in lithotomy
    -Sensory - lateral calf and dorum of foot, Motor dorsiflexion and foot eversion
  7. Pudendal
    -Entrapemtn during SSF
    -Sensory to clitoris, labia and perinium. Motor the external anal and urethral sphincter
59
Q

Discuss prevention of nerve injury during pelvic surgery (6)

A
  1. Avoid malpositioning
    -Minimal hyperflexion of legs, abduction and external rotation at hip
  2. Use gel pads to avoid compression
  3. Avoid prolonged lithotomy >4hrs
  4. Avoid lateral incisions > boarders of rectus muscles
  5. Avoid retractor compression
    -use short blades
    -Use packs between blades and abdo wall
    -Avoid self retainers where possible
  6. Visualise obturator nerve during pelvic wall dissection
60
Q

Discuss management of nerve injury in pelvic surgery (7)

A
  1. Most spontaneously resolve
  2. Get correct dx with detailed neuro exam
  3. EMG 3-4 weeks post injury
  4. Ref to neuroloist
  5. Nuropathic analgesia - TCA, GABA antagonistis
  6. Physio
  7. Micosurgery repair
61
Q

Discuss outpatient hysteroscopy
-Scope and sheath size. TYpe of scope
-Analgesia
-Cervical preparation
-Cervical diltation

A
  1. Scope type - rigid better images and less failure. Flexi scope less pain
    Scope size 2.7mm with 3.5mm sheath
  2. Analgesia - NSAIDS. Avoid opiates
    -Routine use of paracervical block not indicated but consider if - cervical dilitation, PM women, larger hysteroscopy >5mm
  3. Cervical preperation not required - doesn’t reduce pain, trauma or failure rates
  4. Cervical dilation
    -Routine dilitation not required - increase cx shock, uterine truma
62
Q

Discuss synthetic sutures
-Mode of absorption
-Examples (2)
-Advantages (2)
-Disadvantages (3)

A
  1. Mode of absorption - Hydrolysis
  2. Eamples: Polyglactin, Polydioxanone
  3. Advantages
    -Stonger
    -Less inflammatory reaction
  4. Disadvantages
    -Expensive
    -More difficult to handle
    -Encapsulation can result in expulsion by the body
63
Q

Discuss natural sutures
-Mode of absorption
-Examples (1)
-Advantages (3)
-Disadvantages (4)

A
  1. Enzymatic degredation with phagocytosis
  2. Cat gut
  3. Advantages
    -Cheap
    -Good handling and knotting
    -Avoids Forgien body
  4. Disadvantages
    -Weaker - strength 5 days lasts 3 weeks
    -Can cause tissue reaction and inflammation
    -Local tissue necrosis can cause pain
    -Rapid absorption can result in wound failure
64
Q

Discuss absorbable monofilament sutures
-Types (2)
-Tensile strength
-Absorption time
-Advantages (4)
-Disadvantages (5)

A
  1. Types and properties
    Monocryl (Poliglecarpone)
    -Tensile strength lost within 3-4 weeks.
    -Completely absorbed by 3-4 months
    PDS (Polydiaxanone)
    -Minimal absorption by 90 days. Total absorption 6 months
  2. Advanatges
    -Less tissue reaction
    -Less tissue trauma
    -Fluids unable to travel along suture
    -Provide temporary wound support until healing undertaken
  3. Disadvantages
    -Suture memory - difficult handling
    -End knots require burial
    -Stiffer suture
    -Poor knot sercurity
    -Offers shorter mechanical support
65
Q

Discuss non-absorbable monofilaments
-Types
-Properties of each
-Advanatges (4)
-Disadvantages (6)

A
  1. Prolene (Polypropelene)
    -Gradually encapsulated by fibrous conective tissue
  2. Ethilon
    -Gradually encapsulated by fibrous conective tissue
    -Loss of strength at rate of 15-20% per year
  3. Advantages
    -Less tissue reaction
    -Less tissue trauma
    -Fluid unable to travel along the suture
    -Offers longer mechanical support
  4. Disadvantages
    -Suture memory
    -End of knots need to be buried
    -Stiffer suture
    -Poor knot sercurity
    -Forgien body left in situ
    -Suture removal can be costly, inconvenient to remove
    -Risk of tissue extrusion
66
Q

Discuss braided absorbable sutures
-Types
-Properties of each
-Advantages
-Disadvantages

A
  1. Types
    Vicryl Rapide (Polyglactin)
    -Tensile strength lost within 10-14 days
    -Absorbed by 6 weeks
    Vicryl (Polyglactin)
    -Minimal absorption until 40 days
    -Complete absorption by 70 days
  2. Advantages
    -Greater tensile strenth and flexibility
    -Easy to handle
    -Good knot sercurity
    -Provides temporary wound support until healing
  3. Disadvantages
    -More tissue reaction
    -Can harbour bacteria
    -Capillary action by wicking fluid
    -Tissue trauma
    -Offers shorter mechanical support
67
Q

Discuss braided non-absorbable sutures
-Type and properties
-Advantages
-Disadvantages

A
  1. Mersilene (polyester). Gradual encapsulation by fibrosis
  2. Advantages
    -Flexible and no memory
    -Easy to handle
    -Good knot sercurity
    -Offers long mechanical strength
  3. Disadvantages
    -Harbours bacteria
    -Wicks fluid (capillary action)
    -Tissue truama
    -Can cause tissue reaction
    -Forgien body
    -Costly and inconvienent to remove
    -Risk of tissue extrusion
68
Q

Discuss suture needles
-Types and properties
-Tip types
-When to use each

A
  1. Types and proerties
    -Round bodied - seperates tissue fibres, tissue closes tightly around suture
    -Cutting
  2. Tip types
    -Cutting edge, blunt taper point, taper point, blunt
  3. When to use:
    Round bodied - use on soft tissue and for transfixing or ligating arteries
    -Includes blunt taperpoint and blunt
    Cutting - use on skin and tough dense tissue
    -Includes tapercut, cutting and reverse cutting
69
Q

What are the main sites of ureteric injury

A
  1. Left uterer is more commonly damaged compared to right. Closer to cervix and displaced up secondary tot he sigmoid colon
  2. Crossing the pelvic brim*
  3. At ligation of the infundibulopelvic ligament - common
  4. Ligation of the uterine arteries*
  5. Securing the vaginal vault angles
  6. Ligating paracervical tissue at the cardinal ligaments - common
  7. Dissection into the lateral pelvic side walls esp at level of uterosacral ligaments
  8. Dissection of bladder off the uterus
70
Q

What are the rates of ureteric injury
-Overall
-Laparoscopically
-Abdominal hysterectomy
-Vaginal hysterectomy
-Radiacal hysterectomy
-Peripartum hysterectomy
-Risk factors for ureteric injury (7)

A
  1. Overall 0.2 -1%
  2. <1-2% laparoscopic
  3. 0.3-2% Abdominal hysterectomy
  4. 0.02-0.5% Vaginal hysterectomy
  5. 0.2-0.6 radiacal hysterectomy
  6. 1.7% peripartum hysterectomy
  7. Risk factors
    -Enlarged uterus esp broad ligament fibroids
    -Pelvic radiation
    -Radical hysterectomy
    -Intraoperative haemorrhage
    -Endometriosis
    -Neoplasm
    -Distortion of anatomy (Adhesions, previous surgery)
71
Q

What are the mechanism of injury for ureteric injury
-Most common type
-When most commonly occurs
-Types of injury (7)

A
  1. Most common type - obstructive
  2. Occurs most commonly when haemostsis is being attempted
  3. Types of injury
    -Ligation
    -Kinking / angulation
    -Incision
    -Transection
    -Thermal injury
    -Crush injury
    -Ischaemic injury
72
Q

What measures can be taken to avoid ureteric injury (9)

A
  1. Know anatomy and expose pelvic structures
  2. MRI if concerned for difficult surgery or ureteric involvement
  3. Meticulous surgical technique
  4. Identify ureter and course from pelvic brim and maintain knowledge of this through operation
  5. Look for vermiculation
  6. Consider transillumination with ureteroscopy
  7. Consider ureterolysis - to mobilise and identify
  8. Consider stenting
  9. Dissect baller well off uterus to bring ureters inferiorly
  10. Avoid operating blindly in areas of bleeding
  11. Undertake short applications of diathermy near ureter
73
Q

How can ureteric injury be recognised
1. Intraoperatively
2. Post operatively
-Symptoms
-Examination
-Investigations

A
  1. Reconition intra-operatively
    -Spillage of urine when performing uterolysis
    -Bulge retroperitonially
    -Lack of jets on cystoscopy or blue dye
    -Lack of peristalsis
    -Leak of IV indigo carmin / methylene blue into retroperitoneal space
    -haematuria
  2. Recognition post-operatively
    Symptoms
    -Flank/groin pain
    -Fever
    -Prolonged ileus
    Examination:
    -Flank tenderness
    -Abdominal mass - haematoma, inflammation, infection, uroma
    Investigations:
    -Rising creatinine - obstruction or reabsorption by peritonium
    -Intraventous pyelogram
74
Q

Discuss the management of ureteric injury
-General prinicples (2)
-Surgical principles for repair (7)

A
  1. General prinicples
    -Call urologist for help
    -Commence IVABx
  2. Surgical principles of repair
    -Laproscopic repair best
    -Adequately debride ureter to avoid shortening
    -Careful dissection to avoid devascularisation
    -Aim for water tight tension free anastamosis
    -Use intermittent absorbale sutures
    -Ensure drainage with stents, IDC
    -Consider omental flap
75
Q

Discuss repair of transected ureter
Complete transection
-In upper and middle third
-In lower third
Partial transection

A
  1. Upper and middle third
    -Place stent
    -Perform end to end uretero-ureterostomy
    -Remove stent in 4-6 weeks and IVP to chec patience
  2. Lower third (within 6cm of UV junction
    -Ureteroneocystostomy with psoas hitch to enable reimplantion into bladder without tension
  3. Partial transection
    -Place stent and repair in small interupted absorbable sutures
76
Q

Discuss management options depending on type of ureteric injury (5)

A
  1. Conservative managment - minor crush, needle injuries
  2. Stenting - crush or ligature injuries causing obstruction or small thermal injuries
  3. Suture and stent - lacceration injuries
  4. Excision of affected area and re-anastomosis - deep thermal injury
  5. Re-anastomosis - transection
77
Q

Discuss morcellation
-Definition
-Risks of power morcellation (3)
-How can the risks of morcellation be reduced (6)

A
  1. Defintion
    -the division of larger specimen into smaller fragments to allow their removal from the peritoneal cavity via small incisions
  2. Risks
    -Patient injury to surounding structures
    -Dissemination of fragments through out the peritoneal cavity resulting in seeding, poorer outcomes, need for adjuvant therapy
    -Impact the atomical relationships of the tissue and impact lab diagnosis.
  3. Risk reducing strategies
    -Do NOT undertake is any suspicion of malignancy or pre-malignancy and do USS and smear to make sure.
    -Maintain tip in view all the time
    -Maintain control of the specimen all the time
    -Feed the speciment into the morcellator in a controlled manner
    -Minimise spillage of fragments
    -Retrive all macroscopic fragments post morcellation
78
Q

Discuss recommendations for prophylactic Abx in CS (RANZCOG)
-When to give
-Issues with timing
-Abx type
-Dose

A
  1. When to give
    Traditionally given after cord clamping to:
    -Avoid fetal exposure
    -Avoid masking early fetal sepsis
    -Avoid maternal anaphylaxis impacting fetus
    Now given 30mins before knife to skin
    -50% decrease in skin infx and endometritis
  2. Abx type
    -Narrow spectrum abx effective against gram +/- and some anti-anaerobic activity
    -Suggest first gen cephalosorin
    -If allergic consider clindamycin 600mg IV + Gent 2mg/kg IV
  3. Dose
    -2g IV
    -3g IV if wt >120kg
    -Consider redosing if procedure >3hrs
79
Q

Discuss recommended antibiotics for the following procedures (RANZCOG)
-Operative vaginal delivery
-MROP
-Cerclage
-3rd and 4th degree tears
-Insertion of IUD
-Diagnostic lap
-Hysteroscopy
-HSG
-LLETZ
-Major abdominal, laparoscopic or vaginal procedures
-Surgical termination

A
  1. Operative vaginal delivery - 1.2g stat Augmentin
  2. MROP - No evidence. Case by case
  3. Cerclage - no evidence. Case by case
  4. 3rd and 4th degree tears - no evidence. Case by case
  5. IUD insertion - not required unless RF
  6. Diagnostic lap - not required
  7. Hysteroscopy - not required
  8. HSG - not required unless Hx of PID
  9. LLETZ - not required
  10. Major procedures
    - Cefazolin 2g IV + Metronidazole500mg IV prior to surgical incision
    -If penecillin allergic consider clindamycin 600mg IV + Gent 2mg/kg IV
  11. Surgical termination
    -Consider where STI not investigated
    -Doxy 400mg prior to procedure or Metronidazole 2g prior to procedure + 1g PO Azythromycin
80
Q

Discuss the eValuate study
-Aim
-Methods
-Primary outcomes
-Results

A
  1. Aim
    -To compare TAH vs TLH
    -To compare TLH vs VH
  2. Methods
    -2 x multicentre RCT
    -FU 1 yr
  3. Outcomes
    -Major complications rate; haemorrhage requiring tx, bowel / bladder / ureter injury, PE, wound dehiscence, unintended laparotomy
    -Minor complications
  4. Results
    -n in abdo tiral ~900
    -n in VH trial ~500
    -TLH >TAH major complications. 11 vs 2% (SS) NNH 20
    -TLH vs TAH - less pain and better QoL at 6/52
    -TLH vs VH - no SS in major complications but under powered
    -TLH took longest time compared with TAH and VH
    -No difference in minor complications for any comparison

RANZCOG -Gynaecology 2024 (11 decks)

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