TOG - Nerve injuries in gynae surgery Flashcards
How frequent are nerve injuries in gynae surgery?
1.1 - 1.9%
What are the main conributors to nerve injuries in gynae surgery?
Patient mal-positioning
Improper incision sites
Self-retaining retractors
What are the 3 types of nerve injury?
Neuropraxia - nerve compression - wks/months
Axonotmesis - Axon damage - months recovery
Neurotmesis - Axon and Schwann damage - needs reparative sx
Which nerves are liable to injury if a transverse incision extends beyond the lateral inferior rectus muscle?
Lateral cutaneous branches of iliohypogastric and ilioinguinal nerves
Chronic pain in 7% if entrapped
What is the origin and course of the femoral nerve?
L2-4
Lateral border psoas
Beneath inguinal ligament to thigh
11% gynae neuropathy - compression from retractor, positioning
What position will increase femoral nerve compression injury?
Hyper-flexion, abduction, external rotation of the hip
Weak hip flexion and adduction and knee extension
(Can’t walk up stairs)
No knee jerk reflex
Parasthesia - anterior/middle thigh, medial calf
Which nerve is injured?
Femoral
What is the origin and course of the iliohypogastric and ilioinguinal nerves?
T12-L1
Lateral psoas
Along quadratus lumborum
Through external oblique aponeurosis/inguinal ring
3.7% injury following Pfannenstiel; also midurethral tapes
Sharp burning pain from Pfannenstiel to mons pubis, labia, thigh
Parasthesia gluteal and hypogastric region
Pain relief following LA injection
Which nerve is injured?
Iliohypogastric
Sharp burning pain from Pfannenstiel to mons pubis, labia, thigh
Parasthesia groin, inner thigh, labia majora
Pain relief following LA injection
Which nerve is injured?
Ilioinguinal
What is the origin and course of the genitofemoral nerve?
L1-2 Anterior psoas Lateral to external iliac vessels Genital branch - deep inguinal ring Femoral branch - femoral sheath
Injury - side wall surgery, ext iliac nodes
Parasthesia mons pubis, femoral triangle, labia majora.
Which nerve is injured?
Genitofemoral
What is the origin and course of the lateral cutaneous nerve of the thigh?
L2-3
Lateral psoas
Anterior to iliacus
Lateral end inguinal ligament into thigh
Parasthesia to anterior/Postero-lateral thigh
(Meralgia parasthetica)
Which nerve is injured?
Lateral cutaneous nerve of the thigh
Parasthesia medial thigh
Unable to adduct
Which nerve is injured?
Obturator L2-4
Foot drop
Parasthesia lateral calf, dorsum of foot
Which nerve is injured?
Common peroneal (sciatic)
Cavus deformity of foot
Parasthesia plantar foot, toes
Which nerve is injured?
Tibial (sciatic)
What is the origin/course of the obturator nerve?
L2-4 Passes pelvic brim in front of sacroiliac joint Behind common iliac vessels Into thigh via obturator foramen Damage: retroperitoneal surgery, TOT
What is the origin/course of the sciatic nerve?
L4-S3
Below piriformis
Midway between posterior superior iliac spine and ischial tuberosity
Then ischial tuberosity and greater trochanter
Midthigh splits to tibial and common peroneal (lateral fibular neck)
Injury: malposition, hyperflexion of thighs; CP in lithotomy
What is the origin/course of the pudendal nerve?
S2-4
Greater sciatic foramen below piriformis
Behind lateral 1/3 sacrospinous ligament and ischial spine
Reenters through lesser sciatic foramen to pudendal (Alcock’s) canal
Injury: SSF
Gluteal, perineal and vulval pain, worse in seated position. Which nerve is damaged?
Pudendal
How long postop should an EMG be performed?
> 3-4/52; denervation from muscle is often delayed
