TOG - Nerve injuries in gynae surgery

Question 1

How frequent are nerve injuries in gynae surgery?

Answer 1

1.1 - 1.9%

Question 2

What are the main conributors to nerve injuries in gynae surgery?

Answer 2

Patient mal-positioning
Improper incision sites
Self-retaining retractors

Question 3

What are the 3 types of nerve injury?

Answer 3

Neuropraxia - nerve compression - wks/months
Axonotmesis - Axon damage - months recovery
Neurotmesis - Axon and Schwann damage - needs reparative sx

Question 4

Which nerves are liable to injury if a transverse incision extends beyond the lateral inferior rectus muscle?

Answer 4

Lateral cutaneous branches of iliohypogastric and ilioinguinal nerves
Chronic pain in 7% if entrapped

Question 5

What is the origin and course of the femoral nerve?

Answer 5

L2-4
Lateral border psoas
Beneath inguinal ligament to thigh
11% gynae neuropathy - compression from retractor, positioning

Question 6

What position will increase femoral nerve compression injury?

Answer 6

Hyper-flexion, abduction, external rotation of the hip

Question 7

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?

Answer 7

Femoral

Question 8

What is the origin and course of the iliohypogastric and ilioinguinal nerves?

Answer 8

T12-L1
Lateral psoas
Along quadratus lumborum
Through external oblique aponeurosis/inguinal ring
3.7% injury following Pfannenstiel; also midurethral tapes

Question 9

Sharp burning pain from Pfannenstiel to mons pubis, labia, thigh
Parasthesia gluteal and hypogastric region
Pain relief following LA injection
Which nerve is injured?

Answer 9

Iliohypogastric

Question 10

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?

Answer 10

Ilioinguinal

Question 11

What is the origin and course of the genitofemoral nerve?

Answer 11

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

Question 12

Parasthesia mons pubis, femoral triangle, labia majora.

Which nerve is injured?

Answer 12

Genitofemoral

Question 13

What is the origin and course of the lateral cutaneous nerve of the thigh?

Answer 13

L2-3
Lateral psoas
Anterior to iliacus
Lateral end inguinal ligament into thigh

Question 14

Parasthesia to anterior/Postero-lateral thigh
(Meralgia parasthetica)
Which nerve is injured?

Answer 14

Lateral cutaneous nerve of the thigh

Question 15

Parasthesia medial thigh
Unable to adduct
Which nerve is injured?

Answer 15

Obturator L2-4

Question 16

Foot drop
Parasthesia lateral calf, dorsum of foot
Which nerve is injured?

Answer 16

Common peroneal (sciatic)

Question 17

Cavus deformity of foot
Parasthesia plantar foot, toes
Which nerve is injured?

Answer 17

Tibial (sciatic)

Question 18

What is the origin/course of the obturator nerve?

Answer 18

L2-4
Passes pelvic brim in front of sacroiliac joint
Behind common iliac vessels
Into thigh via obturator foramen
Damage: retroperitoneal surgery, TOT

Question 19

What is the origin/course of the sciatic nerve?

Answer 19

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

Question 20

What is the origin/course of the pudendal nerve?

Answer 20

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

Question 21

Gluteal, perineal and vulval pain, worse in seated position. Which nerve is damaged?

Answer 21

Pudendal

Question 22

How long postop should an EMG be performed?

Answer 22

> 3-4/52; denervation from muscle is often delayed