Surgery Flashcards
Risks of oil based contrast and HSG
o Granuloma formation
o Pulmonary/cerebral oil embolism
Causes of distal tubal disease
PID, surgery, endo
Post HSG pregnancy rates by instillation fluid
- Oil: 58% in 1 year
- Water: 38% in 1 year
Higher rates after oil: Mechanism: mechanical lavage of tubes, release of peritubal adhesions, stimulation of cilia of tubal mucosa, alteration of cervical mucous, bacteriostatic effect, reduction of inflammatory cells
Diagnostic accuracy of HSG
PPV 40%: True obstruction, when obstruction detected on HSG
NPV 95%: True patency, when patency detected on HSG
Sensitivity 70%: Test demonstrates obstruction when actually obstructed
Specificity 80%: Test demonstrates patency when actually patent
Most common surgical times to injure ureter
clamping of IP, clamping of uterine, near uterosacral, closing vagina cuff
Describe Hassan entry
- Sharply dissect down to fascia; incise the fascia until a small amount of preperitoneal fat is identified. Place stay sutures in the fascial edges
- Open the peritoneum sharply, sweep the underside of the abdominal wall with the index finger to clear omentum or bowel, and confirm the absence of adhesions in the region of the incision.
- Place a blunt-ended trocar (ie, Hasson) through the incision, and secure it with the stay sutures
- Attach the gas to the port and insufflate
Uterine tourniqet
- Palpate the broad ligament just above the level of the internal cervical os to identify a space that is free of vessels and the ureter.
- Make a 1 cm incision in this clear space bilaterally.
- Pass the tourniquet (eg, a Penrose drain) through the incisions with the ends protruding anteriorly.
- Pull the tourniquet tight and secure by securing the ends with a Kelley clamp. Take care to avoid enlarging the broad ligament incisions.
Endometrial abalation
Indication: Heavy menstrual bleeding with normal cavity and without desire for future fertility
Outcome: Normalization of menstrual flow (80%), not necessarily amenorrhea (40% with Novasure)
Need pre-op EMB (do NOT sample at time of ablation)
Fibroid recurrence risks
Single myoma -> 10% re-operation
Multiple myomas -> 25% re-operation
Transfundal myomectomy = classical cesarean section -> schedule C/S at 36w0d-37w6d
Femoral nerve injury
L2-L4
Injury: Blade of self-retain retractor in thin woman; exaggerated hip flexion in dorsal lithotomy
-Sensory: Anterior/medial leg and thigh
-Motor: Hip flexion and knee extension
Lateral peroneal
L4-S2
Injury: Lat displace/inadeq support of knee in stirrup
-Sensory: N/A
-Motor: Foot drop; foot inversion
Risks and presentation of intravasation on HSG
*Forms reticulated pattern
*Predisposing factors: tubal disease, recent uterine surgery, intrauterine synechiae, uterine anomalies, misplacement of tip, excessive injection pressure
*Inconsequential
Methylene Blue
For chromopertubation: use dilute solution 1:20
Minimize pressure during HSC?
-Typically use 75 mmHg
-Risks of higher pressures: extravasation of medium, rupture of non-compliant uterus
-Continually measure fluid deficit and provide alerts
-we use “manual technique”, nurse assigned to monitor input and output, pressure cuff/gravity for media flow, short surgical times
Signs and symptoms of fluid overload
- Volume overload: acute heart failure, pulmonary edema, dilutional anemia
- Electrolyte/plasma imbalance: hyponatremia, hypoosmolality, hyperammonemia, hyperglycemia, acidosis
- Neurologic sequelae: slurred speech, visual disturbances, hypersomnia, confusion, seizure, coma
Considerations for tubal surgery
o Age of patient
o Ovarian reserve
o Prior fertility
o Number of children desired
o Site and extent of tubal disease
o Presence of other infertility factors
o Experience of surgeon
o Success rates with IVF
o Patient preference/religion/culture
o Cost/insurance
Outcomes after tubal recannulation
Bilateral: relieved in 85% of tubes, 50% conceive, 33% reocclude
Vaginal dilation
o Dilation
First line treatment
* Up to 95% able to achieve functional success
* Success = ability to have sexual intercourse, vaginal acceptance of largest dilator without discomfort, vaginal length of 7 cm
Manual placement of graduated dilators on vaginal dimple and applying pressure for 30 min-2h/day
Insertion after warm bath can help
Pressure should be down and inward in line of normal vaginal axis
Pressure should cause mild discomfort, not pain
Time ranges from 4 months to several years
McIndoe Procedure
- Dissection of space between rectum and bladder
- Use of split-thickness skin graft
o Site: from buttocks or artificial skin
o Split-thickness = epidermis and portion of dermis, leaves behind hair follicles and sweat glands, can surface, used for larger defects
o Full thickness = epidermis+dermis
o Harvested using a dermatome, intermediate thickness - Transverse incision made at the vaginal dimple
- Space between rectum and bladder are dissected to the level of the peritoneum
- Skin graft is placed over a mold (foam rubber with condom covering), epidermal side in and sutured along its seam with 4-0 vicryl
- Meticulous hemostasis must be obtained
- Mold and skin graft are inserted
- Labia minora are secured around the stent to prevent expulsion
- Diligent use of vaginal dilation postoperatively
o Continuous for 6-9 weeks (removing to urinate/defecate)
o Night only for 6 months
o Prevents graft contracture - Success rate: 80-100%
- Complications
o Graft failure
o Post-op hematoma
o Rectal perforation
o Fistula formation
o Increased risk with prior vaginal or perineal surgery
Vecchieti Procedure
- Classically an abdominal procedure through Pfannenstiel incision
- Now performed by L/S approach
- Neovagina created by invagination using an acrylic “olive” placed against the vaginal dimple
- Olive is attached to a traction device resting on the abdomen by subperitoneal sutures placed with L/S
- Traction is applied to produce 1-1.5cm of invagination per day
- Takes 7-9 days total
- Active dilation is required
- Success: limited data but up to 98%
Time to pregnancy after septoplasty
2 months
Jones Metroplasty
- Wedge resection of the portion of the uterine fundus containing the septum
- Reconstruction begins at the lower portion of the cavity
- Anterior and posterior walls are closed in 3 layers
o Endometrium + small portion of myometrium, knot inside cavity
o Intermediate myometrium layer
o Final layer in continuous or interrupted contains myometrium and serosa imbricating the rough serosal edges - Blood loss reduction measures
o Penrose drain tourniquets
Broad ligament lateral to the uterine vessels
Infundibulopelvic ligaments, using the same hole in the broad ligament
Must stop arterial blood flow
o Vasopressin (up to 20 units diluted in 20mL of saline) injected into anterior and posterior walls of the uterus before incision - Delay in pregnancy for 4-6 months
Good prognostic factors for tubal reanastomosis
Younger age, strongest predictor
Postoperative tubal length >4-5cm
Site of anastomosis: Isthmic-isthmic reported to be better, data not great
Interval from sterilization to reversal inversely related to success
Type of sterilization: rings/clips > PP modified Parkland > Bipolar electrosurgery
When would you refer to gyn onc?
o Referral criteria for premenopausal women
Very elevated CA125
Ascites
Evidence of metastases
o Sonographic criteria
Solid component that isn’t hyperechoic, often nodular or papillary
Septations that are thick >2-3mm
Flow to solid component
Presence of ascites
Peritoneal masses, enlarged nodes, matted bowel
Incidence of endo with CPP
70%
Polyp recurrence risk
15%
Risk of tubal disease if Chlamydia antibody test is negative
<15% (NPV: 90%)
PPV/NPV of SIS for endometrial polyps/myoma/adhesions
> 90%
Risk of malignancy in an endometrial polyp postmenopausal
5%
Rate of uterine polyps
10% of reproductive aged population
Risk of ectopic pregnancy after tubal re-anastomosis
4-8%
Risk of ectopic pregnancy after IVF
1.4%
Risk of ectopic pregnancy after 1 prior ectopic
15%
Risk of ectopic pregnancy after 2 prior ectopics
25%
Incidence of ectopic pregnancy in general
1-2%
Proportion of people with ectopic pregnancy with no risk factors
50%
Unicornuate LBR
30%
Unicornuate PTD
44%
Unicornuate ectopic
4%
Unicornuate SAB
25%
Unicornuate second trimester loss
10%
Unicornuate IUFD
10%
Sensitivity of HSG for endometrial polyps or submucosal myoma
50%
PPV of HSG for endometrial polyps/myoma
40%
MRI accuracy of a septum
70%
Time to conceive after septum resection
1 month without cautery, 2 months with cautery
Time to conceive after myomectomy
3 months
Recurrence rate of ashermans
33% if moderate, 66% if severe
risk factors for endometrial polyps
age, premenopausal, obesity, tamoxifen
Improvement of fertility with polypectomy?
Yes
> 1 cm less likely to resolve
RCT showed 63% chance of pregnancy s/p PPY compared to 28%
Changes in glycodelin and receptivity
Association with endometritis
Unipolar
current passes between generator (instrument), ground plate, and back to generator
Ground plate covered with jelly and attached to patient
Lateral spread larger (2-3 cm)
Monopolar
2 insulated jaws carry current to and from generator
High frequency, low voltage (cutting current) to coagulate vessels
1-2 cm coagulation damage from point grasped
Seprafilm
modified sodium hyaluronic acid and carboxymethyl cellulose
lasts 7 days
FDA approved for laparotomy
Brittle
Dosing of TXA
1.3 g oral TID
10 mg/kg IV q 8 hrs
MOA: prevent fibrin degredation
