surgery Flashcards
VH
EUA to assess mobility size and descent of the uterus
IDC
Grasp cx
Circumferentially infiltrate local anaesthetic with adrenaline and incise cervico vaginal junction
Reflect the vaginal mucosa
Reflect the bladder superiorly and retract
Perform anterior and posterior colpotomy.
Perform three pedicle hysterectomy approach
clamp cut and tie bilaterally
Uterosacrals
Uterine vessels
uteroovarian pedicle
Deliver specimen
Assess access for salpingectomy
Check for haemostasis at all pedicles
Oppose bilateral uterosacral ligaments and secure to vault for suspension
Closure of the vaginal vault continuous locked suture
Vaginal pack
internal artery ligation
call for help open the side wall identify the ureter sweep medial identify the external iliac trace back to bifurcation and identify the internal iliac. Trace down and identify the posterior branch. separate vein suture ligate anterior branch check femoral pulses
List branches of internal iliac
Iliolumbar Lateral sacral Gluteal superior and inferior Pudendal Inferior vesical Middle rectal Vaginal Obturator Uterine and umbilical
Burch
pfannenstiel or laparoscopically
access the retzuis space without entering the peritoneal cavity
Place non dominant hand in the vagina to elevate bladder neck
dissect off periurethral fatty tissue to expose paravaginal fascia
Place 2-4 permanent sutures bilaterally through the full thickness of paravaginal fascia and attach to the iliopectineal ligament
Check haemostasis
TVT
in and out catheter to empty bladder
2 stab incision either side of the midline over the pubic symphesis
LA with adrenaline infiltrated with a spinal need to hydrodissect
inferiorly
LA with adrenaline to anterior vaginal mucosa
incision 1 cm below the urethral meatus in the midline
LA to hydrodissect the tract to urogential diaphragm bilaterally
metzumbamns scissors to create a tunnel
use a dilator to deviate bladder neck
Use TVT introducer to insert tape bilaterally
Adjust tape to ensure it is placed flat and is tension free
perform
Cystoscopy to exclude perforation
remove plastic cover
cut tape flush to skin and glue incisions closed
Suture vaginal incision and
Place IDC
laparoscopy set up
Thromoboprophylaxis
GA and Lloyd Davis
Prep and drape
Gentle bimanual +/- uterine manipulator
Laparoscopic entry technique
Establish pneumoperitoneum prior to primary trochar in Veress entry
Camera in and 360 degree view looking for injury
Insert further ports with a pressure of 20mmHg, then drop pressure to 14mmHg
Reverse trendelenberg
Systematic inspection of all structures
If removing something: grasp and move away from structures
Check haemostasis
Remove ports under direct vision
Expel gas
Close sheath if needed and skin with subcuticular suture
Post-op: document, debrief, DVT prophylaxis, arrange F/U
Le Forte colpocleisis
lithotomy
prep drape
Grasp cx
rectangles on anterior and posterior wall are marked out 2 cm distal to the cervix
Injection saline and adrenaline for hydrodilation and sharply dissect off the vaginal wall mucosa
Fascia anteriorly and posteriorly are plicated,
Edges of the anterior and posterior vaginal mucosa are sutured in successive rows to invert the cervix and the vagina
Aggressive perineorrhaphy
Cystoscopy to ensure patency and rule out bladder injury
Word catheter
WORD CATHETER
The Word catheter is a balloon that is placed in the Bartholin gland after I&D to allow continued drainage and reepithelialisation of a tract for future drainage.
INDICATIONS Bartholins abscess
CONTRAINDICATIONS The stem of the Word catheter is latex, and thus use of this device is contraindicated in patients with latex allergy.
PREPROCEDURE EVALUATION AND PREPARATION — confirm that a vulvar mass is a Bartholin abscess, rather than another vulvar mass.
Informed consent is obtained
PROCEDURE
●sterile prep and drape
●Inject 1 to 3 mL of local anaesthetic to infiltrate the site planned for the stab incision. (At or behind the hymnal ring)
●Hold the cyst or abscess wall with small forceps to maintain traction and prevent collapse of the cyst wall after puncture.
●Incise the cyst or abscess with a 5 mm stab incision, 1.5 cm deep, in the introitus at or behind the hymnal ring to prevent vulvar scarring.( If the incision is too large, the catheter will fall out.)
●Drain the cyst or abscess contents completely by breaking up loculations with the hemostat. Culture abscess contents with a culture swab and send for microbiologic identification.
●Place the Word catheter through the incision, as deep as possible. Make sure the catheter is in the duct cavity. Holding onto the cyst wall with forceps helps to prevent creation of a false passage separate from the cavity.
●Inflate the balloon of the Word catheter with 2 to 3 mL of saline or water injected into the catheter hub with a needle and syringe.
●Tuck the end of the Word catheter into the vagina to minimize discomfort
●Empiric broad spectrum antibiotics may be given if patient is at risk of complicated infection.
COMPLICATIONS AND OUTCOME — bleeding, infection, and scarring leading to dyspareunia or distortion of anatomy. Recurrence rates (2-15%)
FOLLOW-UP
Wear a pad to absorb discharge.
maintain pelvic rest
Use sitz baths and mild analgesics to treat pain, if present during the first postoperative day or two.
To come back if pain bleeding increases
The catheter is left in place for at least four weeks to promote formation of an epithelialized tract for permanent drainage of glandular secretions. Epithelialization may occur as soon as three weeks.
If persistent discomfort despite analgesics, remove 0.5 to 1 mL of fluid from the balloon.
When the tract appears well-epithelialized, remove the catheter by deflating the balloon in the office.
If the catheter falls out, determine further treatment based on examination results
If recurrent cysts then repeat word catheter, marsupialization or excision
how to manage a
? Vault haematoma
Vaginal cuff cellulitis ?
?Vault dehiscence
IVL, G&H, FBC, UEC, LFTs, Coags, CRP
Vaginal examination- speculum and bimanual
USS pelvis
NBM
Resuscitate if unwell/unstable with fluid/blood
Give IV antibiotics and TXA
If bleeding heavily place pack in vagina
Consider surgical drainage or interventional drainage if remains unwell
Vaginal cuff cellulitis
IVL, G&H, FBC, UEC, LFTs, Coags, CRP
Vaginal examination- speculum and bimanual
CT abdo/pelvis
NBM
Resuscitate if unwell/unstable with fluid/blood
Give IV antibiotics
Consider surgical drainage or interventional drainage if remains unwell
Vault dehiscence This is a surgical emergency IVL and bloods (G&H, FBC, UEC, LFTs, lactate, coags) NBM Broad spectrum IV antibiotics Examine the eviscerated bowel for injury, reduce, pack the vagina with warm moist packs Insert IDC Proceed to theatre Consider laparotomy vs laparoscopy Run the bowel Irrigate +/- debride the cuff Suture the cuff closed with PDS Consider drain Post-op: 3/12 no intercourse, avoid heavy lifting, debrief/document
Total colpocleisis
Consent: bleeding, pain, infection, haematoma, organ damage, fistula, no further sexual intercourse
WHO time out
Position in lithotomy with yellow fins
IV Abx pre-op
IDC
Infiltrate under vaginal mucosa with large volume local with adrenaline (eg 40mls 0.25 Marcaine with adrenaline)
Make circumferential incision around the base of the prolapse and longitudinal incisions to the most distal point of the prolapse
Dissect the mucosa away from the underlying fascia using sharp and blunt dissection and remove the mucosa in sections
Starting at the most distal point of the prolapse place circumferential purse-string sutures with a delayed absorbable suture (such as 1 Vicryl) until the prolapse has been completely reduced
Colpoperinorrhaphy is then performed to shorten the genital hiatus
Make a crescent shaped incision at the posterior fourchette and use a combination of sharp and blunt dissection laterally to reveal the inferior attachments bilaterally of the levator ani
Use a delayed absorbable suture (such as 1 Vicryl) to bring the levator ani attachments together in the midline, closing the posterior fourchette with interrupted sutures. Close the overlying skin using an absorbable suture (such as 2/0 Vicryl Rapide) with interrupted sutures
Check the colour of the urine and perform a PR examination.
Post-op: TROC, thromboprophylaxis, follow up 6-8 weeks
TAH
Risks: Anaesthetic risks, Bleeding and need for transfusion, infection, injury to internal organs notably bowel, bladder, ureter, or ovary (if intending to retain these), fistula, need for subtotal procedure, vault collection, VTE, wound complications such as dehiscence, hernia, or abnormal scar formation, vault prolapse.
Pre-operative workup: Anaesthetic review, ECG and CXR where applicable
FBC, Group and screen, HCG
Review of previous surgeries, uterine size to determine appropriate incision
Procedure:
Introductions WHO check list
Anaesthetic Allergies Anticoag plan
hcg no metal wear valid G+H
Position: Supine. EUA and insertion of IDUC with sterile technique. Prep and drape.
Pfannelstiel skin incision with entry through subcuticular fat, rectus sheath, dissection of sheath off muscles superiorly toward umbilicus and inferiorly toward pubic symphysis to optimise access. Peritoneal entry. [washings if indicated]. Gentle examination of pelvic organs to assess size, mobility, and adnexae. Bowel packed away, self-retaining retractor placed.
Kocher clamps to grasp uterus incorporating utero-ovarian and round ligaments. Round ligament opened and secured with vicryl. Retroperitoneal space gently opened and ureter definitively identified. Anterior peritoneum gently opened with fine scissors exposing UV fold. Bladder reflected inferiorly to below cervix using gentle sharp and blunt dissection.
Posterior peritoneum gently opened below the utero-ovarian ligament.
Uterine arteries identified, heavy curved clamps (Maingot) applied with care to avoid ureter, cut and secured with vicryl.
Cardinal ligaments identified, heavy clamps applied, cut and secured with vicryl.
Vault opened anteriorly, curved clamps applied to cervico-vaginal junction incorporating vaginal angles, and uterus removed. Vaginal angles secured with vicryl, incorporating uterosacral ligaments for support. Vault closure with vicryl. Ureters checked again, pelvis irrigated and all pedicles checked for haemostasis.
Packs and retractor removed, abdomen closed in layers.
May place vaginal swab.
Post operative cares:
Eat and drink as tolerated
Monitor PV loss (pack out mane if placed)
Clexane thromboprophylaxis
IDUC out once mobile
FBC if clinically indicated
Home when mobile, able to PU and manage pain independently
Histology follow up 1-2 weeks and contact with result
Outpatient follow up 6 weeks
