Surgical Skills and Postoperative Care Flashcards
A 35 year old woman undergoes extensive laparoscopic surgery in the lithotomy position. She presents after 3 days with unresolved weakness of right hip extension and right knee flexion. There is associated sensory impairment below the right knee. Damage to which nerve is the most likely cause?
a. Femoral
b. Ilio-inguinal
c. Lateral cutaneous nerve of the thigh
d. Obturator
e. Sciatic
E - Sciatic
A 65 year old had a hysterectomy for endometrial cancer. She recovered well but complained of dribbling urine 2 days later and was given a course of antibiotics for a presumed UTI. On review at 4 weeks she complains of continued urinary incontinence. She has no dysuria, no sensation of urgency, needs to wear a pad at night and intermittently voids good volumes of urine with normal flow. Urinalysis is negative. What is the most likely diagnosis?
a. Fistula
b. Occult, underlying stress incontinence
c. Overactive bladder syndrome
d. Overflow incontinence
e. Urinary tract infection
A - Fistula
In the developed world, the vast majority of urinary tract fistulae occur following hysterectomy and caesarean section. This is usually due to a failure to dissect the bladder from of the cervix and upper vaginal. Leakage starting in the immediate post-operative period suggests direct damage. Leakage 1-2 weeks later suggests avascular necrosis.
A woman has been recommended to undergo hysterectomy and bilateral salpingo-oophorectomy for benign disease. You discuss the risks and benefits of an open versus a laparoscopic procedure. What sort of injury is more common at laparoscopic hysterectomy compared with an open procedure?
a. Bowel
b. Nerve
c. Ovary
d. Urinary tract
e. Vascular
D - Urinary Tract
Laparoscopic surgery involves risk to bowel, urinary tract and major blood vessels. These risks are higher in women who are obese or significantly underweight however the risks of laparotomy are significantly higher in the morbidly obese. Urinary tract injury and vaginal cuff dehiscence are more common in the laparoscopic approach with an odds ratio of 2.61 for urinary tract injury.
A 55 year old woman is due to come in for a total abdominal hysterectomy and bilateral-salpingoophorectomy for a large mucinous ovarian cyst. She takes sequential HRT for menopausal symptoms. What is the approximate overall risk of serious complications from abdominal hysterectomy?
a. 1 operation in every 100
b. 2 operations in every 100
c. 3 operations in every 100
d. 4 operations in every 100
e. 5 operations in every 100
D - 4 operations in every 100
The overall risk of serious complications from abdominal hysterectomy is approximately 4 operations in every 100 (common)
A 48 year old woman presents one week after a total abdominal hysterectomy. She has persistent weakness of hip flexion and paraesthesia over the anterior and medial aspects of her left thigh. Damage to which nerve is the most likely cause?
a. Femoral
b. Gemito-femoral
c. Ilioinguinal
d. Lateral cutaneous nerve of the thigh
e. Obturator
A - Femoral
Gynaecological surgery, especially abdominal hysterectomy is the most common cause of iatrogenic femoral nerve injury and injury to the femoral nerve is the most common nerve injury in gynaecological practice.
A 36 year old woman undergoes laparoscopic resection of deep infiltrating endometriosis. You advise her regarding the risk of injury to her ureters during the surgery and the fact that this may be either a direct or a thermal injury related to electrocautery. If she does receive a thermal injury, when would you expect her to present?
a. 1-2 days post-surgery
b. 5-7 days post-surgery
c. 10-14 days post-surgery
d. 3-4 weeks post-surgery
e. 5-6 weeks post-surgery
C - 10-14 days post-surgery
Thermal injuries to the ureter may result in delayed necrosis and/or fistula formation that will typically present clinically 10-14 days post-operatively.
You see a 48 year old woman opting for a hysterectomy for management of her heavy menstrual bleeding. While obtaining her consent for the operation you explain that the risk of haemorrhage requiring transfusion is a ‘common’ procedural risk. What is the numerical ratio for a complication when it is quoted as ‘common’?
a. 1/1 to 1/10
b. 1/10 to 1/100
c. 1/100 to 1/1000
d. 1/1000 to 1 in 10,000
e. Less than 1 in 10,000
B – 1/10 – 1/100
A 68 year woman with post-menopausal bleeding is attending for a diagnostic hysteroscopy under general anaesthetic. You discuss the complications with her. What is the incidence of serious complications during hysteroscopy?
a. 1 in 50
b. 1 in 100
c. 1 in 500
d. 1 in 1000
e. 1 in 5000
C – 1 in 500
Uterine perforation is uncommon but a small post-menopausal uterus is an independent risk factor, especially where it cervical os is stenosed.
A 40 year old woman presents with severe pelvic pain. She has had a myomectomy in the past through a vertical midline incision to the level of the umbilicus. To investigate her pain she undergoes a diagnostic laparoscopy using the Palmer’s point of entry. Where is Palmer’s point?
a. 3cm below the left costal margin in the midaxillary line
b. 3cm below the left costal margin in the midclavicular line
c. 3cm below the right costal margin in the midaxillary line
d. 3cm below the right costal margin in the midclavicular line
e. 3cm below the xiphisternum in the midline
B – 3cm below the left costal margin in the mid-clavicular line
Palmer’s point should be used where there is a high suspicion of adhesions. Adhesions are found in up to 50% following a midline laparotomy but rarely in the LUQ. If there are two failed attempts at umbilical insufflation then utilising Palmer’s point or the open Hasson technique should be utilised
A 23 year old woman undergoes laparoscopic cystectomy of a right endometrioma, densely adherent to the pelvic side wall. She is discharged home soon after the surgery but presents 36 hours later with right-flank pain. Which investigation would you arrange to confirm and locate any ureteric injury?
a. CT IV urogram
b. MRI
c. Renogram
d. Transurethral cystoscopy and stenting
e. Ultrasound
A – CT IV urogram
Endometriosis increases the risk of injury to the urinary tract. An acute injury usually presents within 48 hours with diffuse abdominal pain, distension and ileus. The chemical peritonitis has more subtle symptoms when compared with peritonitis secondary to faeces or infection. A contrast CT will usually demonstrate uro-peritoneum and may show direct evidence of the injury. MRI is useful in late presentations where a fistula is suspected.
A 55 year old woman is seen in the pre-assessment clinic. She is due to undergo full staging surgery for ovarian cancer as recommended by the MDT. Her only current medications are thyroxine and clopidogrel. If the benefits of stopping clopidogrel outweigh the risks, how long should clopidogrel be stopped prior to surgery?
a. 1 day
b. 3 days
c. 5 days
d. 7 days
e. 14 days
D - 7 days
A 25 year old woman develops a wound infection after a straightforward elective subtotal hysterectomy. What is the single most likely causative organism?
a. E. Coli
b. H. Influenzae
c. MRSA
d. Staph. Aureus
e. Strep. Milleri
D – Staph. Aureus
All wounds are colonised with bacteria. This does not mean all wounds will become infected – if there is an infection it is likely to be from skin flora which has colonised the wound; thus Staph. Aureus is the most likely culprit.
A 37 year old woman is undergoing a diagnostic laparoscopy for investigation of pelvic pain. Following insertion of the primary trocar through the umbilical port, you find bowel adherent to the anterior abdominal wall in the midline. You are worried that bowel may be adherent under the umbilicus. What is the recommended course of action?
a. Continue with the procedure as Palmer’s test was normal
b. Convert to laparotomy
c. Remove port and reinsert at Palmer’s point
d. Seek surgical advice
e. Visualise the primary trocar from a secondary port site
E – Visualise the primary trocar from a secondary port site
If there are adhesions within the abdomen it is advisable to check the umbilical port by inspecting it through a – preferably 5mm – secondary port. If damage has occurred, then surgical advice should be sought.
A group of trainees are preparing a tutorial session on laparoscopic hysterectomy. They plan to review the risks of urinary tract damage associated with laparoscopic hysterectomy in order to provide inform about the risks and diagnosis of urinary tract injury. What important information as part of the tutorial needs to be included?
a. Damage to the ureter at the vesico-ureteric junction is the most common ureteric injury
b. MRI is suboptimal to diagnose vesico-vaginal fistula because of poor tissue contrast in that area.
c. The most common site of bladder injury is the midline above the inter-utreteric bar
d. Thermal injuries present within 72 hours with uroperitoneum or vesico vaginal fistula
e. Traumatic bladder injury is prevented by catheterisation
C – The most common site of bladder injury is the midline about the inter-ureteric bar
An ST3 is asked to review a previously fit woman. She is 6 hours post-operative following a laparoscopic hysterectomy. She looks pale and confused and agitated. Her pulse is 120bpm, respiratory rate 40 breaths per minute and blood pressure 60/40mmHg. She has a urine output of 5ml/hour. Her weight is 70kg. Approximately what percentage of her blood volume has she lost?
a. 10-15%
b. 20-25%
c. 30-35%
d. 40-45%
e. 50-55%
C – 30-35%
A patient is reviewed on the ward round on day 1 following a total abdominal hysterectomy. She complains of right-sided weakness adducting and flexing her hip and of altered sensation over the anterior-medial thigh and calf. On examination, the knee jerk reflex is absent on the affected side. Injury to which nerve is most likely to be responsible for these findings?
a. Obturator
b. Femoral
c. Ilioinguinal
d. Sciatic
e. Genitofemoral
B - Femoral
