Surgery/ Procedures

Question 1

When we consider vertical midline incision in CS:

Answer 1

● The incision-to-delivery time is critical
● A transverse incision may not provide adequate exposure
● The patient has a bleeding diathesis and thus is at increased risk of subcutaneous or
subfascial hematoma formation

Question 2

risk of miscarriage following amniocentesis is

Answer 2

‏around 1%.

Question 3

Indications for classical cesarean section:
(Can rupture before labor so repeat classical CS done at 36-37 wks)

Answer 3

1. Cervical Cancer (absolute)
2. Dense adhesions btw bladder and lower uterine segment
3. Post mortem CS
4. Impacted shoulder (transverse lie) of large fetus
5. Very small fetus with breech
6. Major degree of placenta previa with placenta attached to anterior uterine wall
7. Very preterm CS (power segment not formed yet)
8. Previous classical CS

Question 4

Abx prophylaxis before CS

Answer 4

ACOG:
single pre-op dose of 1(if <80)/ 2 gm(if >80kg) IV injection cefazolin <30 min prior

Or 3 doses 8 hourly for high risk cases or suspected infection

Long procedure greater than 2 drug half-lives (>4 hours for cefazolin from time of dose)
Administer additional intraoperative dose of the same antibiotic
Excessive blood loss >1,500 ml
Administer additional intraoperative dose of the same antibiotic

Allergy (anaphylaxis, angioedema, respiratory distress, or urticaria)
900 mg clindamycin and 5 mg/kg aminoglycoside

Question 5

….. forceps can be used for delivering fetal head during CS

Answer 5

Wrigley’s forceps / Barton forceps

Question 6

In deep impacted head of fetus, shoulders are delivered first and head last. This is called ………. technique

Answer 6

Patwardhan

Question 7

……. forceps/ …….. forceps can be used for delivering fetal head during CS

Answer 7

Wrigley’s / Barton

Question 8

Upper uterine segment incision increases the chances of uterine rupture by

Answer 8

4-9 %

Question 9

Lower uterine segment incision increase the chance of uterine rupture by

Answer 9

0.2 - 1.5 %

Question 10

Recurrence rate of uterine rupture in classical CS is

Answer 10

32 %

Question 11

Short interpregnancy interval increases risk for uterine rupture and other major morbidities …fold to …..fold in VBAC candidates.

Answer 11

twofold to threefold

Oxytocin use in previous scar can increase uterine rupture 2-3 folds as well

Question 12

Glycine vs. NS media in hysteroscopy

Answer 12

If monopolar current, which require non-electrolyte distending media such as glycine and sorbitol, hypotonic so that excessive absorption can cause a number of complications including hyponatremia, a variable degree of hypo-osmolality.

Isotonic electrolyte-containing solutions (NS and RL) cannot be used with monopolar energy because this leads to activation of ions that disperse the electric current and reduce the power density. Hence the heat generated in tissues is insufficient to destroy or have a tissue effect

Question 13

Absorbable sutures are:

Answer 13

Plain and Chromic Catgut,Polyglactin,Polyglyconate,Polyglycolic Acid,Polydiaxone,Polyglycaprone.

Surgically used suture material polydioxanone (PDS) undergoes hydrolysis and complete absorption.

Vicrylisa delayedabsorbable synthetic suture material and is aCo-Polymer of glycolide and lectide.

Question 14

Non-absorbable sutures are:

Answer 14

Silk,Linen,Surgical Steel,Polyester,Polybutester,Polypropylene.

Question 15

Best suture for friable tissues that oozes and easily bleed (e.g. after 2nd layer of uterus or friable vagina during suturing episiotomy)

Answer 15

Monocril 2-0 reverse cutting needle

Question 16

Packing Techniques

Answer 16

parachute pack or umbrella pack, to be useful as a last-ditch effort to control persistent venous bleeding from the pelvic floor muscles after pelvic exenteration.

Question 17

Diagnostic conization is indicated in the following situations:

Answer 17

• Finding epithelial cell abnormalities,(HSIL) or(LSIL) in the absence of gross or colposcopic lesions of the cervix
  -Unsatisfactory colposcopy, defined as the examiner’s inability to view the entire transformation zone, including the squamocolumnar junction, in women with epithelial cell abnormalities
  -Uncertainty regarding the presence or absence of microinvasion or invasion following the diagnosis of CIN by directed biopsy
  -Finding CIN or microinvasive cancer during endocervical curettage
  -Cytologic or histologic evidence of premalignant or malignant glandular epithelium
  -Cytologic diagnosis inconsistent with histologic diagnosis based on directed biopsy findings

Question 18

Abdominal Drain complications

Answer 18

drain site sepsis,
bleeding from abdominal wall vessels,
kinking and knotting of drains, which may require operative removal,
incisional hernia which may, in turn, result in intestinal obstruction and small bowel incarceration,
erosion of adjacent structures and fistula formation.

Question 19

The blades that can be used for Conization

Answer 19

Beaver blade
Blade no. 11

Question 20

Intraoperative pulmonary function may be challenged during laparoscopy. How?

Answer 20

First, the diaphragm is displaced upward by intraabdominal pressure from the pneumoperitoneum. This can be accentuated by organs also being pushed cephalad against the diaphragm during Trendlenburg positioning. Moreover, insuffulation pressures stiffen the diaphragm and chest wall. Together, these alterations lead to higher required airway pressures to achieve adequate mechanical ventilation. Also, as the diaphragm moves up, lung volume and functional residual capacity are diminished, which in turn reduces the reserve volume for oxygenation. Moreover, this lung volume decline favors a tendency for alveolar collapse, leading to atelectasis. This can create ventilation and perfusion mismatching and an increased alveolar-arterial oxygen gradient. In sum, all of these factors favor poorer oxygenation.

Question 21

Urinary output commonly is diminished during laparoscopy how?

Answer 21

This may result from lowered cardiac output, decreased splanchnic blood flow, direct renal parenchymal compression, or release of renin, aldosterone, or antidiuretic hormone. Together, these lessen renal blood flow, reduce glomerular filtration rate, and diminish urine output. Importantly, renal function typically returns to normal following pneumoperitoneum decompression (Demyttenaere, 2007).

Question 22

Consent for myomectomy risks and complications include

Answer 22

significant bleeding and need for transfusion. Larger tumors, intramural location, and greater myoma number increase this risk. Infrequently, uncontrolled hemorrhage or extensive myometrial injury during tumor removal may force hysterectomy. Fortunately, conversion rates to hysterectomy during myomectomy are low and range from 0 to 2 percent (Iverson, 1996; LaMone, 1993; Sawin, 2000). Postoperatively, the risk of pelvic adhesion formation is significant. Also, leiomyomas can recur with time, and rates after 5 years approximate 60 percent.

Question 23

Molar pregnancy suction and evacuation procedure steps

Answer 23

At the beginning of the evacuation, the cervix is dilated to admit a 10-to 12-mm plastic suction curette. As aspiration of molar tissues ensues, intravenous oxytocin is given. At our hospital, 20 units of synthetic oxytocin are mixed with 1 L of crystalloid and infused at rates to achieve uterine contraction. If available, intraoperative sonographic guidance is preferred to help reduce the risk of uterine perforation and assist in confirming complete evacuation. Finally, a thorough, gentle curettage is performed. Following curettage, because of the possibility of partial mole and its attendant fetal tissue, Rh immune globulin is given to nonsensitized Rh D-negative women.

Question 24

TLH vs. LH vs. LAVH

Answer 24

Laparoscopically assisted vaginal hysterectomy (LAVH): laparoscopic dissection down to, but not including, uterine artery transection • Laparoscopic hysterectomy (LH): laparoscopic dissection, including uterine artery transection, but completion of hysterectomy vaginally • Total laparoscopic hysterectomy (TLH): complete laparoscopic excision of the uterus

Question 25

Poor candidates for a vaginal approach hysteroectomy include

Answer 25

patients with minimal uterine descent, extensive abdominal or pelvic adhesions, a large uterus not amenable to tissue manipulation or extraction methods, adnexal pathology, and a restricted vaginal vault or contracted pelvis. Patients with these findings are generally considered for TAH or TLH (Schindlbeck, 2008).

Question 26

Note about Harmonic scalpel

Answer 26

The Harmonic scalpel is selected for its ability to cut with minimal smoke plume and little surrounding thermal tissue damage. Notably, it only is used to seal vessels up to 5 mm.

Question 27

UAE vs. GnRH agonists prior to myomectomy

Answer 27

GnRH Agonists. In addition to preoperative control of abnormal uterine bleeding, these agents significandy shrink uterine volume after several months of use (Benagiano, 1996; Friedman, 1991). Decreased uterine size following treatment may allow a less invasive surgical procedure. For example, myomectomy may be completed through a smaller laparotomy incision or by laparoscopy or hysteroscopy (Lethaby, 2002; Mencaglia, 1993). These agents also diminish leiomyoma vascularity and uterine blood flow (Matta, 1988; Reinsch, 1994). The use of preoperative GnRH agonists, however, may also have disadvantages. Within leiomyomas, GnRH agonists can incite hyaline or hydropic degeneration, which may obliterate the pseudocapsule connective tissue interface between the tumor and the myometrium. Such obliterated cleavage planes may lead to tedious and lengthy tumor enucleation (Deligdisch, 1997). Moreover, rates of leiomyoma recurrence in women treated with GnRH agonists prior to myomectomy are higher (Fedele, 1990; Vercellini, 2003). Leiomyomas treated with these agents may shrink in volume and be missed during surgical removal. Uterine artery embolization (UAE) on the morning of surgery can help limit blood loss. And unlike GnRH agonist use, UAE allows tissue planes to be preserved. Disadvantages of UAE include risks for subsequent pregnancy complications, collateral ovarian infarction, and formation of uterine synechiae. Thus, preoperative UAE may best be limited to patients with large uteri in whom excessive blood loss is a concern.

Question 28

metastatic GTN is highly vascular and prone to severe hemorrhage either spontaneously or during biopsy. Heavy menstrual bleeding is a frequent presenting symptom. The most common sites of spread are

Answer 28

the lungs (80 percent), vagina (30 percent), pelvis (20 percent), liver (10 percent), and brain (10 percent)

Question 29

the risk of GTN persistence after hysterectomy remains approximately – to – percent.

Answer 29

20 to 30 percent, and these patients should be monitored postoperatively.

Question 30

Chemotherapy for Low-Risk GTN

Answer 30

• Single-agent methotrexate (MTX} is the most common treatment, and complete response rates range from 67 to 84 percent.
• Dactinomycin is less frequently used for the primary treatment of low-risk disease due to toxicity concerns, but it has superior efficacy as a single agent (Alazzam, 2016; Yarandi, 2008). MTX-resistant GTN often responds to pulse dactinomycin, with a success rate of71 to 74 percent (Li, 2018; O>vens, 2006). Patients initially treated with pulse dactinomycin who develop resistant GTN may still be successfully treated with the 5-day course of dactinomycin (Kobom, 2002).

Question 31

Methotrexate regimens used for low risk GTN

Answer 31

the current standard regimen is an 8 days alternating regimen of intramuscular (IM) MTX at a dose of 1 mg/kg on treatment days 1, 3, 5, and 7, and folinic acid, 15 mg taken orally on days 2, 4, 6, and 8. Treatment is repeated every 2 weeks.(Taylor, 2013a) . Alternatively, a daily dose is given intravenously (IV) or IM for 5 days and this series is repeated every 2 weeks. MTX dosing is 0.4 mg/kg/day (National comprehensive Cancer Network, 2018). All of these regimens are continued until B-hCG levels are undetectable, and then two or three additional weekly doses are given (Lybol, 2012).

Question 32

Chemotherapy for High-Risk GTN

Answer 32

Etoposide, methotrexate, and dactinotmycin (actinomycin D), alternating with .cyclophosphamide and vincristine (oncovin) (EMA/CO) chemotherapy is a well-tolerated and highly effective regimen for high-risk GTN. It is considered the preferred treatment for most high-risk disease.
Secondary treatment usually involves platinum-based chemotherapy combined with possible surgical excision of resistant disease (Alazzam, 2016).
by replacing the cyclophosphamide and vincristine component with etoposide and cisplatin (EMNEP). EMNEP is an effective option in patients resistant to EMA/CO, but paclitaxel (T axol) plus cisplatin alternating with paclitaxel plus etoposide (TPffE) has comparable efficacy and appears less toxic (Patel, 2010; Wang, 2008). Bleomycin, etoposide, and cisplatin (BEP) is another potentially effective regimen (Alazzam, 2016; Essel, 2017; Lurain, 2005). Pembrolizumab, described in Chapter 27 (p. 601), also has achieved responses (Ghorani, 2017).

Question 33

Risks associated with chemotherapy in high risk GTN

Answer 33

• High-risk patients with a large disease burden are at risk for early death with standard EMA/CO due to tumor lysis-related hemorrhage and clinical deterioration. In these selected circumstances, “induction low-dose etoposide-cisplatin” appears to reduce the mortality risk tenfold (Alifrangis, 2013).
• Etoposide-based combination chemotherapy has been associated with an increased risk of leukemia, colon cancer, melanoma, and breast cancer up to 25 years after treatment for GTN. An ovetall50-percent excess risk was observed (Rustin, 1996).

Question 34

Posttreatment Surveillance and Monitoring of patients with low/high-risk GTN consists of

Answer 34

weekly B-hCG measurements until the level is undetectable for 3 consecutive weeks. This is followed by monthly titers until the level is undetectable for 12 months. Patients with high-risk disease are followed for 24 months due to the greater risk of late relapse. Patients are encouraged to use effective contraception,

Question 35

Quiescent Gestational Trophoblastic Disease

Answer 35

Patients with persistent mild elevations (usually less than 50 miU/mL) of true 13-hCG may have a dormant premalignant condition if no tumor is identified by physical examination or imaging studies (Khanlian, 2003). In this instance, phantom 13-hCG, described next, should be conclusively excluded as a possibility. The low 13-hCG titers may persist for months or years before disappearing. Chemotherapy and surgery usually have no effect. Hormonal contraception may be helpful in lowering titers to an undetectable level, but patients are closely monitored since metastatic GTN may eventually develop (Khanlian, 2003; Kohorn, 2002; Palmieri, 2007).

Question 36

How to differentiate btw phantom vs. True B-hcg

Answer 36

First, a urine pregnancy test can be performed. With phantom B-hCG, the heterophilic antibodies are not filtered or renally excreted. Thus, these test-altering antibodies will be absent from the urine, and urine testing will show true negative results for B-hCG. Importantly, to conclusively exclude trophoblastic disease by this method, the index serum B-hCG level must be significantly higher than the detection threshold of the urine test. Second, performing serial dilutions of the serum sample leads to a proportional decline in the B-hCG level if B-hCG is truly present. However, phantom B-hCG measurements will be unchanged by dilution. In addition, if phantom B-hCG is suspected, some specialized laboratories may be able to block the heterophilic antibodies. Last, heterophilic antibodies will cause interference with one assay, but they may bind poorly to another assay’s antibodies. Thus, switching B-hCG assay kits to one by a different manufacturer may accurately demonstrate the absence of true B-hCG (Cole, 1998; Olsen, 2001; Rotmensch, 2000).

Question 37

Type I hysterectomy is also known as

Answer 37

an extrafascial hysterectomy or simple hysterectomy. It removes the uterus and cervix but does not require excision of the parametrium or paracolpium. It is appropriately selected for benign gynecologic pathology, preinvasive cervical disease, and stage IA1 cervical cancer.

Question 38

Type II hysterectomy is also known as

Answer 38

modified radical hysterectomy. With it, the cervix, proximal vagina, and parametrial and paracervical tissues are removed. This hysterectomy is well suited for tumors in patients with stage IAl cervical cancer who have positive margins following conization and have insufficient cervix to repeat conization. This hysterectomy is also appropriate for patients with stage IAl cervical cancer with LVSI. Some institutions perform type II hysterectomies in women with stage IA2 tumors and smaller stage IB tumors with good outcomes (Landoni, 2001)

Question 39

Type Ill hysterectomy, also known as

Answer 39

radical hysterectomy, requires greater resection of the parametria. Its goal is to remove microscopic disease that has extended into the parametrium and paracolpium, and around the uterosacral ligaments. This procedure is performed for stage IA2, stage 182, stage llA1; for some stage 1 83 lesions; and for patients with relative contraindications to radiation. These contraindications include diabetes, pelvic inflammatory disease, hypertension, collagen disease, inflammatory bowel disease, or adnexal masses.

Question 40

Cervical cancer Stage I B lesions are defined as

Answer 40

those extending past the limits of microinvasion yet still confined to the cervix. This stage is now subcategorized as IB 1 if tumors measwe <2 em or as I B2 if they measure >2 cm but < 4 cm. Last, I B3 describes lesions measuring >4 em

Question 41

Stage IB to llA cervical cancers do not extend into the parametria and thus can be managed with

Answer 41

either surgery or chemoradiation.

Question 42

Systematic lymphadenectomy can lead to complications such as

Answer 42

lymphocyst and lymphedema.

Question 43

In meta analysis sentind node in cervical cancer detection rate was – percent and sensitivity was – percent.

Answer 43

sentind node detection rate was 89 percent and sensitivity was 90 percent. Smaller tumor si2:.e ( <2 cm) and early-stage disease were associated with the highest sensitivity and detection rate (Kadkhodayan, 2015). Sentind lymph node biopsy can be considered for women with tumors <2 cm and is now included in the National Comprehensive Cancer Guiddines.

Question 44

Primary Trocar Entry four basic techniques

Answer 44

These include Veress needle insertion, direct trocar insertion, optical-access insertion, or open entry methods.

Question 45

The technique of risk-reducing adnexectomy (RRS) in women with a high-risk hereditary mutation.

Answer 45

the IP is divided 2 cm past the ovary and the fallopian tube is transected at the uterine conu.

Question 46

General safety rules for monopolar diathermy apply

Answer 46

avoiding indirect thermal damage, pedicle effect, avoid coupling, checking for faulty insulation.

Question 47

What is the alternative that can be used for stenosis cervix pre-op if misoprostol is not given or contraindicated

Answer 47

intracervical injection of dilute vasopressin or dilute lidocaine plus epinephrine solutions can diminish the force required for cervial dilation (Phillip., 1997).

Question 48

Pratt vs. Hanks dilator

Answer 48

Pratt dilators have a long, tapered tip that makes dilation easier and less traumatic but may perforate the smaller uterus. Hanks dilators have a stop at 8 cm, the depth of most adult uteri, to minimize the risk of perforation.

Question 49

Why Is Management of Diabetes Important in the Surgical Setting?

Answer 49

abnormal glucose balance is a risk factor for postoperative sepsis, endothelial dysfunction, cerebral ischemia, and impaired wound healing. In addition, the stress response may also cause other diabetic pathologies including diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar syndrome (HHS) during surgery or postoperatively.

Question 50

The bundle identifies four domains important to infection prevention:

Answer 50

readiness, recognition and prevention, response, and reporting and systems learning (Pellegrini, 2017).

Question 51

The incidence of ureteral injury during gynecologic surgery is commonly cited as

Answer 51

1% to 2%

Question 52

In normal adults, the ureter is between – and – cm in length from the renal pelvis to the trigone of the bladder. By convention, the pelvic brim divides the ureter into the abdominal and pelvic segments; each of these components is approximately – to – cm in length.

Answer 52

In normal adults, the ureter is between 25 and 30 cm in length from the renal pelvis to the trigone of the bladder. By convention, the pelvic brim divides the ureter into the abdominal and pelvic segments; each of these components is approximately 12 to 15 cm in length.

Question 53

the ureter is approximately – cm lateral to the cervix, where it enters the paracervical tissues. The ureter passes through this paracervical tissue, often referred to as “the tunnel” of the cardinal ligament/anterior bladder pillar (also referred to as —————). Once through this tunnel, the ureter travels medially and anteriorly over the vaginal fornix to enter the trigone of the bladder.

Answer 53

the ureter is approximately 1.5 cm lateral to the cervix, where it enters the paracervical tissues. The ureter passes through this paracervical tissue, often referred to as “the tunnel” of the cardinal ligament/anterior bladder pillar (also referred to as the web or the tunnel of Wertheim). Once through this tunnel, the ureter travels medially and anteriorly over the vaginal fornix to enter the trigone of the bladder.

Question 54

Bladder injury in surgery is often suggested by

Answer 54

observing blood in the urine, or in the case of laparoscopic surgery, air entering the urine collection bag. Direct observation of urine extravasation into the abdomen or vagina with bladder distention confirms bladder injury. Cystoscopy can also help identify bladder injury. In addition to identifying fluid extravasation from the bladder, it is also important to identify any visible suture material in the bladder, such as from vaginal cuff closure.

Question 55

The risk of injury to the ureter during hysterectomy can be minimized

Answer 55

by careful dissection of the bladder off the cervix, by traction on the uterus during the placement of clamps, and by clamping the uterine artery immediately along the cervix (rather than more laterally). At the conclusion of hysterectomy, the surgeon should be particularly vigilant when addressing bleeding from pedicles, especially at the vaginal angles. Bleeding from the pedicles or vaginal angle should be controlled by a “superficial” 3-0 suture so as not to incorporate the ureter.

Question 56

N.B.

Answer 56

If ureteral injury is suspected, visualizing peristalsis is inadequate to exclude occlusion or extravasation. Ureteral integrity can be confirmed during intra-abdominal surgery by observing urine efflux from the ureteral orifices cystoscopically. Intravenous administration of a coloring agent (such as indigo carmine, fluorescein, or methylene blue) may assist this process. In vaginal surgery, direct visualization of the at-risk ureteral segments is seldom possible.administration of a coloring agent (such as indigo carmine, fluorescein, or methylene blue) may assist this process.

Question 57

Complications related to stent placement (including

Answer 57

ureteral perforation, stent malposition, extravasation, hematuria, and stricture are rare.

Question 58

Common manifestations of urinoma include

Answer 58

fever, unexplained leukocytosis, peritonitis, or vaginal fluid leakage (e.g., through the healing cuff). Hematuria may also be seen. Rarely, urinoma may present as a palpable pelvic or abdominal mass. It should be noted that changes in serum creatinine are not a reliable indicator of ureteral injury. Postoperative elevations in serum creatinine should prompt further investigation, but normal values do not adequately exclude ureteral injury.

Question 59

Most common site of ureteral injury:

Answer 59

At the ligation of the cardinal ligament and uterine vessels

Question 60

Most common procedure associated with ureteric injury:

Answer 60

Simple abdominal hysterectomy

Question 61

Most common type of ureteric injury:

Answer 61

Obstruction

Question 62

Most common “activity” leading to ureteric injury:

Answer 62

Attempts to obtain hemostasis

Question 63

General Guidelines for Management of Ureteral Injuries Identified at Time of Surgery in case of Ureteral ligation:

Answer 63

Delegation, assessment of viability, stent placement

Question 64

General Guidelines for Management of Ureteral Injuries Identified at Time of Surgery in case of Partial transaction:

Answer 64

Primary repair over ureteral stent

Question 65

General Guidelines for Management of Ureteral Injuries Identified at Time of Surgery in case of Total transection (the level of injury should guide the method of repair):

Answer 65

-Uncomplicated upper and middle thirds: Ureteroureterostomy over ureteral stent
-Complicated upper and middle thirds: Ureteroileal interposition
-Lower third: Ureteroneocystostomy with psoas hitch over ureteral stent
-Thermal injury: Resection with management as per a transection

Question 66

The main mechanisms of the postoperative ileus pathophysiology are

Answer 66

fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch, and inflammation.

Question 67

Anatomic factors influencing the route of hysterectomy include

Answer 67

the size, shape, and lateral extent of the uterus; uterine support; suspected pelvic adhesion; the angle of the pubic arch; and the extent of pathology. Medical disorders potentially exacerbated by increased intra-abdominal pressure due to insufflation or steep Trendelenburg position may also affect the decision. The abdominal route is sometimes more appropriate when orthopedic conditions restrict or prevent the patient from assuming the lithotomy position.

Question 68

TAH steps

Answer 68

The uterus is placed on traction with curved Kelly clamps at the cornua. The round ligament may be divided with an electrosurgical blade or may be sucured with 0-gauge delayed-absorbable suture. Once the round ligament is divided, the broad ligament beneath it separates into thin anterior and posterior leaves. The anterior leaf of the broad ligament is placed on traction and is sharply dissected to the vesicoucerine fold. The posterior leaf of the broad ligament is then placed on traction and sharply dissected along the pelvic sidewall parallel to the infundibulopelvic (IP) ligament. retroperitoneal space is bluntly dissected in the area lateral to the IP ligament until the external iliac artery is palpated just medial co the psoas major muscle. The index and middle fingers are placed on either side of the artery, and the areolar connective tissue is bluntly finger dissected toward the patient’s head using a backward “walking” motion. To permit further cephalad inspection, the medial portion of the broad ligament’s posterior leaf is elevated. This permits direct identification of the common iliac artery bifurcation and origins of the external and internal iliac arteries. Here, the ureter crosses over the bifurcation or over the proximal portion of the external iliac artery. After laterla dissection of ureter To free the ureter’s medial surface, tips of a Mixter right-angle clamp are opened and closed parallel to the ureter to develop. an avascular space between it and its medial peritoneal attachment. Through this space, clamp tips are then passed beneath the ureter to grasp a quarter-inch-wide Penrose drain.

Question 69

What is Name of this instrument ?

Answer 69

Tischler biopsy forceps or a Kevorkian curette

Question 70

Name of this instrument

Answer 70

pennington grasping forceps

Question 71

Rate if urinary bladder/ ureteral/ bowel injuries

Answer 71

The bladder laceration rate approximates 2 injuries per 1000 cesarean deliveries, whereas that for ureteral trauma nears 0.3 events per 1000 cases (Güngördük, 2010; Oliphant, 2014). Bowel is damaged in about 1 in 1000 cesarean deliveries (Silver, 2006).

Question 72

What is the preparation that Obstetrician– gynecologists should take for bleeding, as with any patient who undergoes colposcopy with biopsies ?

Answer 72

by having scopettes, with available silver nitrate, ferric subsulfate, and equipment for suturing.

Question 73

What is the management for Girls with recurrent UTIs and labial agglutination?

Answer 73

Girls with recurrent UTIs and labial agglutination should undergo the recommended evaluation for children with recurrent UTIs who do not have labial agglutination. Lichen sclerosus and genital trauma should be considered in the differential diagnosis.

Question 74

absolute contraindications to a vaginal hysterectomy

Answer 74

Extrauterine disease, including adnexal pathology, severe endometriosis with adhesions, and an enlarged uterus may preclude a vaginal approach. However, with appropriate patient selection, an enlarged uterus can be morcellated, bisected, or cored out.