Surgery Flashcards
Common sites of ureteric injury
Left> right
Ligation of IP ligament
- ureters enter the pelvis lateral to the IP first, then runs medial and inferior to the ovarian vessels
Ligation of uterine artery
- ureter runs under the uterine artery in the medial leaf of the broad ligament
Securing vaginal vault angles
Ligating paracervical tissue
- the ureter perforates the cardinal ligament to run in the tunnel of Wertheim (1.5cm lateral at the level of the interval cervical os)
Dissection in the lateral pelvic side walls
- particularly just above the uterosacrals
Dissection of the bladder off the uterus
- bladder dome injury
Intra- op recognition of ureteric injury
Dissect out ureter
Perform cystoscopy
Give IV indigo carmine to look for retroperitoneal leakage of blue dye
Consider intra- op pyelogram
Repairing ureteric injury by complete transection
Upper and middle third:
- place stent with end- to- end uretero- ureterostomy
- remove stent in 4-6 weeks + IV pyelogram to confirm patency
Lower third (within 6cm of UV junction):
- reimplantation of ureter into the bladder
Ureteric injury by ligation, repair
Attempt to put JJ stent for 6-8 weeks until sutures responsible for obstruction have dissolved
If too tight to pass JJ stent, for nephrostomy until definitive surgery
Principles of bladder injury repair recognised intra- op
Notify anaesthetist + OT staff
Request appropriate equipment irme cystoscope
MDT- call urology +/- radiology
Identify extent of injury- back fill the bladder with methylene blue/ normal saline
- if <2mm- manage expectantly
- 2mm- 1cm- expectant vs surgical
- if >1cm- repair
If trigone/ ureters suspected to be involved- urology needs to be called
Dome injury:
- repair in 2 layers with absorbable sutures
- check integrity of repair
- keep bladder decompressed to allow healing- IDC for 14 days
- cystogram prior to removal. If leakage noted, leave IDC in for 1 more week then repeat
If trigone/ ureteric injury:
- as above, urology for help
Always cover with 1 week of PO Abx
What’s the rate of complications during laparoscopy
Serious: 2: 1000 or 0.002%
Overall: 3-8: 1000 or 0.003- 0.008%
Describe Palmers point entry
NG tube to decompress stomach prior
Palpate there’s no hepatosplenomegaly
Make sure pt is flat/ no tilt
Check veress needle sharpness and spring action
Make a 5mm skin incision 3cm below the left sub costal margin at the mid- clavicular line
insert verress needle while holding 3cm from the tip, applying continuous pressure perpendicular to skin- wait for 2 pops
Safety check- opening pressure should be < 8 mmHg, aspiration check (not poo or blood) and/ or saline drop test
Commence insufflation at low flow rate 1-3L/min then increase to high flow to achieve IAP of 20-25 mmHg for port placement
- remove veress needle and insert 5mm port under direct vision
- once placement is visually confirmed, reduce pressure to 15mmHg
Landmark for inferior epigastric artery
Emerges just medial to entry of round ligament into the inguinal canal
The lateral umbilical fold is the peritoneal covering of the IE vessels
Effect of heat on tissues
45 degrees C- tissue damage that may be irreversible
70C- coagulation or blanching of tissues
90C- desiccation/ drying of tissues
100C- vaporisation or bubbling
200C- carbonisation or charring
Compare dessication, vaporisation and fulguration
Dessication
- 90 degrees
- cutting or coag mode
- direct contact with tissue ie no sparking
- dehydration and shrinkage of cells, protein denaturation, welding of tissue
Vaporisation
- 100 degrees
- cutting mode (low voltage, unmodulated current)
- non- contact
- rapid brief increase in temp, converting intracelular fluid to steam, rupturing cell. No char
Fulguration
- 200 degrees
- coag mode- high voltage, modulated current
- non- contact/ sparking
- breakdown of tissue into anatomic components and charring over a large area
Types of electrosurgical injuries
Thermal spread
- hot structure sitting next to another so transfer of heat
Direct coupling/ direct burn
- accidental activation of the electrode while touching non- target tissue or while touching another metal instrument that is touching non- target tissue
Capacitive coupling
- occurs with hybrid metal ports
- current from electrode passes to the metal and cannot be readily dissipated into the patient therefore arcs to another instrument or tissue
Insulation failure
- micro leaks in insulation allowing passage of coag waveform
Diathermy pad failure
- pad incorrectly attached resulting in incomplete circuit resulting in current seeking alternative path of least resistance ie through ECG wires
Plume
- smoke plume may contain toxic substances and could transmit viruses
