Surgery

Question 1

What % of complications in laparoscopy occur at entry ?
what are they?
What is the overall complication rate

Answer 1

50%
vascular and bowel are more common then urinary
Minor complications - intraperitoneal insufflation and failed entry
3-8/1000

Question 2

how to prepare for a laparoscopy

Answer 2

Patient flat
prepped
draped
empty bladder
note the clinical landmarks note the umbilicus is a variable position

Question 3

How do you make a veress entry

Answer 3

1) Ensure all equipment avaliable before starting
2) prep drape empty bladder check landmarks
3) check veress needle sharpness and spring
4) intraumbilical incision with an 11 or 15 blade from the centre of the umbilicus caudally
5) tap should be open
6) Split the abdominal wall with the non dominant hand
- one can elevate the skin (this does not change the risk of bowel injury but may decrease the risk to retroperitoneal structures)
7) Hold the veress needle a few cm from the needle tip
8) using continuous pressure the needle is inserted into the base of the umbilicus where there is the least distance to be transversed perpendicularly
9) there may be a single or dual loss of resistance or pop
10) only the tip needs to be inserted to commence and assess pressures

Question 4

How do you check you veress needle placement

Answer 4

Do NOT do the swinging needle test - do not feel for the freedom of the tip it may compound injury

The aspiration and saline drop test has moderate sensitivity and specificity only

The test with the highest sensitivity and specificity is immediate gas pressures and 5 successive pressures less then 8 has the best correlation with correct placement

Question 5

What happens if you fail 3 attempts at insufflation

Answer 5

Seek assistance from a snr colleague
Choose an alternative site placements such as LUQ
Cease the procedure completely

Question 6

What pressures are you aiming for

What flow do you want it on

Answer 6

commence low flow rates of 1-3L/min
Initial pressures should be less then or equal to 8
If palmers point or high BMI ok to accept pressures to 10, caution if pressures are over 12 as that maybe a preperitoneal placement
Intraabdominal pressures is the most important factor in reducing placement of the primary trochar (time or volume not accurate)
Aiming for 20-25mmHg is best - ensure this is discussed with the anaesthetist
Confirm position once primary trochar is placed - reduce the pressures to 12-15mmHg

Question 7

What is the consequence of not reducing your pressures from the 20-25mmHg

Answer 7

Ventilatory compromise

Surgical emphysema

Question 8

How do you insert the primary trochar

Answer 8

operating table comfortable height
Obturator held in the dominant hand, with the index finger down the shaft to prevent deep displacement
Pressure perpendicular to the skin using constant pressure or twisting
once the tip is in the peritoneal cavity then angling down to the pelvis
Release the pressures once the camera is in
The obturator is then removed and the scope placed and ensure the cannular is correctly positioned
360 degree sweep to look for injury
Then trendelenburg

Question 9

What does RANZCOG say about driving after a surgery

Answer 9

Check insurance status to ensure no policy exclusions
Need to not be using sedating analgesia
need to work the controls, look over their shoulder, be able to emergency break
may take 2-6 weeks
Recovery is variable

Question 10

Why give antibiotics before skin incision at a LSCS?

What is the baby concern?

Answer 10

For a caesarean : strong evidence that antibiotics given prior to skin
incision reduce the risk of post-operative endometritis and surgical site infection by approximately 50%.

1) exposure of the fetus to antibiotics could mask newborn positive bacterial culture results;
2) fetal antibiotic exposure could lead to an increase in colonization or infection with antibiotic-resistant
organisms
3) to avoid the risk of severe fetal compromise in the rare event of maternal anaphylaxis.

Question 11

What is RANZCOG s protocol for antibiotic administration before a LSCS

Answer 11

• Antibiotic prophylaxis should be given for all caesarean sections.
• Antibiotics administered prior to skin incision will minimise the risk of post-operative infectious
morbidity, but:
o It may still be appropriate to administer post-delivery in patients who have a significant history of anaphylaxis to other antibiotics or uncertain drug allergy;
o Consideration should be given to how the fetus could be delivered expeditiously in the rare event of maternal anaphylaxis.
• Surgical data suggests that for antimicrobial prophylaxis to be effective ideally it should be administered at least 30 minutes before caesarean section, to ensure a bactericidal concentration is reached by the time of incision. For example, at the time of IV cannulation.
• Narrow-spectrum antibiotics that are effective against gram-positive and gram-negative bacteria
with some anaerobic bacteria are the most appropriate choice.
• 1g intravenous cefazolin is an appropriate antibiotic choice, with an increased dose (2g) indicated
for obese women (>100kg).
• For women with a significant allergy to β-lactam antibiotics, such as cephalosporins and penicillins, clindamycin with gentamicin is a reasonable alternative.

Question 12

Types of nerve injury

Answer 12

• transection -Neuroma is formed at the transected site - LAP / groin pain / burning / sensory impairment
• thermal injury,
• entrapment from ligation - pain and loss of function
• Compression of stretching of the nerve
• Compartment syndrome - Pain disproportionate to findings on exam, weakness, hypesthesia of the foot or leg, reduced pedal pulses - this is a surgical emergency

Question 13

What is the path of the femoral nerve + how is it injured?

Answer 13

The usual mechanism is compression of the femoral nerve against the pelvic sidewall as the nerve emerges from the border of the psoas muscle before exiting the pelvis at the inguinal ligament.

Deep pelvic surgery, particularly abdominal hysterectomy, is the most common setting for femoral neuropathy
Compression is caused by very deep or lateral placement of the retractor blades during pelvic surgery 7.5% of laparotomies

However, hyperflexion of the thigh can cause kinking of the nerve under the inguinal ligament, resulting in femoral neuropathy and stretching of the nerve by hip abduction and external rotation.

Question 14

What are the risk factors for femoral nerve injury

Answer 14

Risk factors:
Wide Pfannenstiel or Maylard incision
●Thin subcutaneous fat layer (body mass index ≤20 kg/m2)
●Operating time over four hours
●Poorly developed rectus muscles
●Narrow pelvis
●Use of self-retaining retractors, especially those associated with extreme lateral traction

Question 15

How do femoral nerve injuries present

Answer 15

both sensory and motor impairment and is manifested by anesthesia of the anterior and medial thigh and weakness in the quadriceps and iliopsoas muscles.
Most femoral neuropathies resolve spontaneously. If they do not, significant disability may occur since the resulting weakness of hip flexion and knee extension impedes the patient’s ability to climb stairs

Question 16

When and how are the ilioinguinal nerve and iliohypogastric nerve injured?

Answer 16

Iliohypogastric or ilioinguinal nerve injury may be caused by entrapment by sutures at the lateral poles of transverse fascial incisions for laparotomy, laparoscopic or open hernia surgery, direct trauma, or formation of a neuroma during the normal scarring/healingprocess. The ilioinguinal nerve seems to be at greatest risk; the iliohypogastric seems to be involved less often but is often associated with ilioinguinal symptoms.

Question 17

How does injury to the ilioinguinal nerve and iliohypogastric nerve present?

Answer 17

Sharp, burning, lancinating pain radiating from the incision to the suprapubic area, labia/scrotum, or thigh
●Paresthesia over these areas
●Pain relief after infiltration with a local anesthetic

Question 18

When and how are the genitofemoral nerve and lateral femoral cutaenous nerve at risk?

Answer 18

genitofemoral and lateral femoral cutaneous nerves lie on the belly of the psoas muscle, lateral to the external iliac vessels. They are at risk of compression from retractor blades, which should be elevated away from this area to protect the nerves, and at risk of transection during dissection of the external iliac lymph nodes, mobilization of the iliac vessels, or removal of a large pelvic mass adherent to the pelvic sidewall.

Question 19

What is the presentation of injury of the genitofemoral nerve and the lateral cutenous nerve of the thigh ?

Answer 19

njury to the genitofemoral nerve causes anesthesia or paresthesia of the labia/scrotum and upper medial thigh without motor deficits.

Injury to the lateral femoral cutaneous nerve results in paresthesias and pain that radiate down the anterior and posterior-lateral aspect of the thigh toward the knee (as in meralgia paresthetica)

Question 20

What is the path of the obturator nerve?

Answer 20

The obturator nerve arises from L2,3,4
The fibers then unite posterior to the psoas muscle and pass inferiorly over the sacrum or pelvic brim to the obturator canal. The obturator nerve then bifurcates into anterior and posterior divisions. Both divisions innervate the thigh adductor muscles; the anterior division provides sensory input from the hip joint and anterior medial thigh and the posterior division from the knee.

Question 21

When is the obturator nerve injured?

How does it present?

Answer 21

The obturator nerve may be injured with passage of a trocar through this area (eg, for placement of a transobturator tape or passage of a vascular graft), or during pelvic lymph node dissection in the obturator fossa. During dissection of the obturator fossa, the obturator nerve should be identified. Procedures associated with obturator nerve injury include excision of endometriosis, paravaginal defect repair with dissection in the space of Retzius, and obturator bypass

If unilateral obturator nerve injury occurs, numbness of the inner thigh and minor ambulatory problems will be noted due to weakened adduction of the thigh.

Question 22

What is the path of the pudendal nerve?

Answer 22

The pudendal nerve arises from the S2,3,4, exits the pelvis through the greater sciatic foramen, then re-enters the pelvis via the lesser sciatic foramen to enter the pudendal canal (Alcock’s canal), a fascial sheath on the medial aspect of the obturator internus muscle. The nerve passes behind the lateral third of the sacrospinous ligament and posterior to the ischial spine, which is also the attachment for the arcus tendineus fasciae pelvis.

Question 23

How does a pudendal nerve injury present ?

Answer 23

Symptoms include perineal and vulvar/scrotal pain, which worsens in the seated position. The diagnosis is made clinically;
Pain in the area innervated by the pudendal nerve (ie, ipsilateral clitoris/penis, distalurethra, labia/scrotum, perineum, and anus), the patient is not awakened by pain, no sensory loss on clinical examination (sensory deficits are suggestive of a sacral nerve root lesion), resolution of pain with administration of pudendal nerve block

Question 24

What injuries S1-4 nerve roots?

how does it present?

Answer 24

uterosacral ligament suspension procedures identified seven women (3.8 percent) who manifested such symptoms within 24 hours of their surgical procedure

neuropathic symptoms, which include postoperative sharp buttock pain and numbness that radiates down the center of the posterior thigh to the popliteal fossa.

Question 25

What is the nervi erigentes?

Answer 25

arise from the ventral rami of S2-S4 and provide parasympathetic innervation to the hindgut. - can be injured in pelvic surgery and disrupts parasympathetic activity leaking to rectal and urinary incontinence

Question 26

Foot drop post laparoscopy

Answer 26

peroneal injury - The most common site of injury of the common fibular nerve is just below the knee, where the nerve wraps around the lateral aspect of the fibula, immediately before dividing into its deep and superficial branches

Question 27

Risk of pfannensteil with nerve injury

Answer 27

7% chronic pain after a pfannensteil - iliohypogastric or ilioinguinal nerves
Dissection of the anterior rectus sheath, as required for the Pfannenstiel or Cherney incision, may injure terminal sensory nerve fibers of the anterior cutaneous branches of the iliohypogastric and ilioinguinal nerves and perforating branches of the epigastric vessels
Paresthesia often temporary
A transverse incision that extends beyond the lateral margin of the inferior rectus abdominis muscle fibers may injure the lateral cutaneous branches of the iliohypogastric and ilioinguinal nerves.

Question 28

How to prevent patient nerve injury in lithotomy

Answer 28

Patient positioning
•	Ensure pre op baseline documented 
•	Surgeons responsibility
•	Padding under heels and arms 
•	Take care with artificial or arthritic joints 
•	Tucking arms keeps them safe 
Lithotomy position 

●There should be minimal abduction and external hip rotation.
●The hips, lateral fibulas, posterior thighs, and heels should be padded.
●The hips and knees should be moderately flexed and securely supported.
●The weight of the lower extremities should be directed toward the soles of the feet.
●Knee stirrups should be adjusted so that tissue is not folded over metal and the stirrup edges do not cut into the calf (eg, peroneal nerve), posterior thigh, or low on the Achilles tendon.
Take care with movements once prepped and draped and after each movement reassess position safety
Avoid prolonged lithotomy (over 4 hours)

Arms
• Do not extend more then 90 degrees
• Shoulder restraints should sit over the AC Joints
Avoid extreme Trendelenburg position

Question 29

How to reduce nerve injury in a transverse incision

Answer 29

●Use of a midline longitudinal incision is less likely to disturb abdominal nerves than a transverse incision.
●A short transverse incision placed within the borders of the rectus muscles and 3 cm above the symphysis pubis results in minimal loss of neural function. If it is necessary to extend the incision, curving it cephalad, rather than continuing in a straight line, may help avoid injuring the iliohypogastric and ilioinguinal nerves

●Avoiding use of cautery on the perforating branches of vessels helps to avoid injury to the terminal sensory nerve fibers, which typically run alongside these vessels. Severe nerve injuries have also resulted from extensive use of cautery on the posterior lateral pelvic side wall.

Question 30

How to use retractors to reduce nerve injury

Answer 30

• Take care so lateral retractors don’t compress the psoas
• Shortest blade that effectively retracts
• Consider packs between the retractor and the abdominal wall
• Avoid extended transverse incisions
• Relieve self retaining retractors

Question 31

How to treat nerve injury

Answer 31

• Generally conservative management
• If absorbable suture - will dissolve and the nerve will recover
• stretch injuries will resolve
• Unless repair is immediate functional recovery of sensory nerves is poor
• Medications including tricyclics, anticonvulsants, GABA antagonists SSRIs, SNRIs
• Physio

Question 32

Surgical site infections

Pre op prevention and how to manage risk

Answer 32

Patient discussion: (NICE)
Risks of infection
Tell the patient what the risks of infection, or plan for reducing the risk and what to do if they are noted
Tell they patient if they are getting ABs
Pre op showering

Decolonisation - Consider nasal mupirocin in combination with a chlorhexidine body wash before procedures in which Staphylococcus aureus
along with local protocols

Use clippers not razors to remove hair

There should be specific theatre clothing, no nail polish, or hand jewelry

Antibiotic prophylaxis depending on the surgery

Question 33

Intraoperative phase of reducing wound infection

Answer 33

Hand decontamination
sterile drapes, gowns, gloves
Aseptic skin preparation
Diathermy increases the risk of surgical site infection
Maintain patient homeostasis
- maintain oxygenation, perfusion, temperature,
Do not use wound irregation or intracavity lavage

Question 34

Post op management for reduce wound infection

Answer 34

use an aseptic no touch technique for changing or removing surgical wound dressings
Use sterile saline within 48 hours of surgery
After 48 hours patients can shower and ok for tap water for wound cleaning after 48 hours

Question 35

Surgical wound classification

What is 
clean
clean - contaminated
Contaminated
Dirty or infected

Answer 35

Clean: an incision in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary or genitourinary tracts are not entered.

Clean-contaminated: an incision through which the respiratory, alimentary, or genitourinary tract is entered under controlled conditions but with no contamination encountered.

Contaminated: an incision undertaken during an operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than 12 to 24 hours old also fall into this category.

Dirty or infected: an incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered (for example, emergency surgery for faecal peritonitis), and for traumatic wounds if treatment is delayed, there is faecal contamination, or devitalised tissue is present

Question 36

Surgical risks

How to explain how common something is

Very common
Common
Uncommon
Rare
Very rare

Answer 36

Very common
1/1 - 1/10
A person in the family

Common
1/10 to 1/100
a person in the street

Uncommon
1/100- 1/1000
a person in the village

Rare
1/1000 - 1/10 000
A person in a small town

Very rare
less then 1/10 000
a person in a large town

Question 37

What are the goals of ERAS?

Answer 37

The goal is to  
Reduce hospital stay 
Can reduce from 8 – 5 days  
Reduce cost 
Decrease perioperative opioid requirements

Question 38

What practices does ERAS discourage

Answer 38

Discourage 
Mechanical bowel prep 
Routine NG tubes 
Surgical drains 
Caloric restriction 
Routine IV opiate 
Over vigorous IV hydration

Question 39

What are the 3 main components of ERAS?

Answer 39

early feeding
Optimize pre op nutritional status
Carbohydrate loading is recommended the morning of surgery to prepare the body for the stress of surgery and minimize insulin resistance
early feeding (regular diet before 4-6 hours post op) resulted in shorter hospital stay and improved patient satisfaction – may be associated with increased n and v that responds to antiemetics. ERAS does not increase the incidence of ilieus

opioid‐sparing multimodal pain management
Prior to induction of anesthesia, it is recommended that patients be given acetaminophen, celecoxib, and gabapentin
Infiltration of the wound with local anesthetic significantly reduces the need for opioids immediately after surgery
Patients should be provided with acetaminophen, ibuprofen, or ketorolac, and given limited doses of oral opioid if needed

euvolemia
Fluid overload - peripheral and small bowel edema, pulmonary congestion, and electrolyte abnormalities, and increases postoperative pain

Fluid depletion - decrease cardiac output and thus oxygen delivery to tissues, delaying healing and causing end organ dysfunction.
Replacing insensible losses, maintaining perfusion and blood pressure, allowing permissive oliguria (20 mL/h), and limiting boluses to 250 mL all factor into a reasonable approach to volume administration for patients undergoing gynecologic surgery