Procedures

Question 1

Palmer’s point

Indications
Procedure

Answer 1

Indications:
Umbilical adhesions or hernia
Midline laparotomy
Concerns about significant pelvic adhesions
Fundus above umbilicus

Palpate liver and spleen - exclude splenomegaly
NG tube to empty stomach
Mark point - Left midclavicular line 3cm below costal margin
Verres entry - 3 pops, safety check with pressures <8mmHg, saline drop

Question 2

General preparation

Answer 2

Consent
Pregnancy test
Anaesthetic
WHO time out
Position - LLoyd-Davies
EUA
IV ABx - usually cefazolin +/- metronidazole
Clean - abdomen and vagina
Drape - surgical field
Manipulation
Mark surgical incision

Question 3

Course of the ureter

Answer 3

Renal pelvis
Descends medial to psoas major
Cross external/internal iliac bifurcation at pelvic brim
Descends posterior-medial to IP ligament
Medial leaf of broad ligament
Underneath uterine artery at level of internal os
Through ureteric tunnel in cardinal ligament
Enters bladder posteriorly
Runs obliquely until at trigone

Question 4

Branches of internal illiac artery

Answer 4

Posterior division:
Illiolumbar
Lateral sacral
Superior gluteal

Anterior division:
Internal pudendal
Middle rectal
Vaginal
Umbilical -> superior vesical
Obturator
Uterine
Inferior gluteal
Inferior vesical

Question 5

Mirena insertion

Answer 5

Review indication
Pregnancy test
Written consent
PO Analgesia prior
Gather equipment, adequate lighting and lithotomy position, chaperone
Bimanaul examination - assess uterine axis
Speculum into vagina
Chlorhexidine prep to cervix
Valsellum to anterior cervical lip
Sound to fundus and document uterine length
Dilate with Hegar dilators if cannot pass sound through
Insert Mirena device to length of sound measurement, reach fundus withdraw back to deploy arms, move back to fundus and deploy whole device
Trim strings to 3cm
Remove valsellum, haemostasis on cervix with silver nitrate or Monsel’s
Provide card with insertion and date for change
Return advice - increasing pain, bleeding, abnormal discharge, febrile symptoms
Advise to check strings monthly, see GP if strings not seen and use alternate contraception until reviewed
Document
Assess symptom response 3-6months

Question 6

TAH

Answer 6

Pre-op:
* Hb/Fe optimisation
* Valid G&H
* Consider cell saver
* Imaging - USS or MRI
* Surgical consent - pain, bleeding, infection, injury to bladder, bowel, vessels, nerves, ureters, DVT/PE, hernia, vault dehiscence or prolapse, need for further treatment
Consider alternatives depending on indication - OCP, Mirena, embolisation, ablation
* Ensure -ve hCG

Intra-op:
* WHO surgical time out
* Anaesthetic - GA +/- regional
* EUA
* IV ABx
* Clean and drape
* IDUC
* Pfannenstiel or midline skin incision
* Entry into layers of amdominal wall
* Peritoneal entry
* Check anatomy - access, other pathology, suitability to complete
* Pack bowels, insert self retaining retractor
* Idnetify ureters and their paths on pelvic sidewall
* Roberts on round ligaments, elevate out of pelvis
* Ligate round ligaments - cut and clamp
* Open anterior fold of broad ligament and dissect to level of UV fold
* Cut bladder flap by dissecting away UV fold just below reflection
* Gently push bladder inferiorly from cervix
* Open posterior leaf of broad ligament
* (Clamp IP ligament if taking ovaries otherwise clamp utero-ovarian ligament)
* Skeletonize uterine vessels - denude excessive connective tissue
* Clamp uterine vessels - flush with uterus, second clamp above and third above that to stop back bleeding
* Cut vessels and secure with suture and repeat on other side (securing twice on lateral side)
* Clamp cardinal ligament taking care of ureter at this point. Cut and secure with suture
* Secure uterosacrals, clamp and cut
* Palpate cervix, check position to vagina and clamp across vagina
* Remove specimen
* Secure vaginal vault angles and close
* McCall culdoplasty to bring uterosacrals together
* Check for haemostasis - saline test
* Remove packs, confirm counts correct
* Close rectus sheath, scarpers then skin

Post op:
* Document
* ERAS
* VTE prophylaxis
* Send specimen to pathology

Question 7

How do you manage a suspected ureteric injury after casarean?

Answer 7

Fluid from wound collected – creat level checked → elevated IVP (or CT w contrast)– left ureter transected just below pelvic brim, right ureter intact Management Urology Repair with Boari flap (lower third reimplant +/- hitch; middle third Boari flap, upper third end to end anastomosis over stent) Debrief

Question 8

Steps to a myomectomy

Answer 8

Pre-op:
GnRH analogue
Hb/Fe optimisation
Valid G&H
Consider cell saver
Imaging - USS or MRI
Surgical consent incl risk hysterectomy, pregnancy implications
Ensure -ve hCG

Intra-op:
WHO surgical time out
Anaesthetic - GA +/- regional
EUA
IV ABx
Clean and drape
IDUC
Pfannenstiel or midline skin incision
Peritoneal entry
Obtain access - packing and retractors
Anatomy check
(Foleys catheter uterin torniquet)
Vasopressin into fibroid
Incision over serosa
Myomectomy screw into fibroid to shell out, diathermy to vessels
Avoid cavity breach if possible (can inject methylene blue into uterine cavity prior)
Keep specimen intact if possible
Suture uterus with vicryl in 2 or 3 layers
Haemostasis check - TXA, haemostatic agents if needed
Consider pelvic drain
Abdomen and skin closure
Dressing

Post op:
Document
ERAS
VTE prophylaxis
Send specimen to pathology
Counsel re pregnancy - conception interval, need for CS and avoid labour

Question 9

Hysteroscopic submucosal fibroid resection

Answer 9

Pre-op:
* Imaging
* Hb, G&H
* Consent - bleeding, infection, perforation, injury to pelvic organs, fluid overload, ashermann’s, incomplete resection, recurrence, treatment failure, need for further treatment, hysterectomy
* Ensure -ve hCG

Intra-op:
GA
Prep and drape in lithotomy
Speculum into vagina, valsellum to anterior cervix
Hysteroscopy with hydrodilation, confirm views and document photos - NB can ditor appearance as hysteroscopic pressures cause regression
Dilate to hagar 7
Resection - Myosure, diathermy, endoloop if pedunculated
Haemostasis - TXA, uterine foleys balloon

Question 10

Hysteroscopy

Answer 10

Pre-op:
* Consent - bleeding, infection, perforation, injury to bladder/bowel/vessels/ureters, need for laparoscopy or laparotomy, unable to complete, need for further treatment
* Ensure -ve hCG

Intra-op:
* Anaesthetic (if applicable)
* WHO time out
* Prep and drape in lithotomy
* Not routine for ABx
* EUA
* Check hysteroscope is connected, camera and light on, white balance and focussed
* Speculum into vagina, valsellum to anterior cervix and put on tension
* Advance hysteroscope and distend with hydrodilation via saline until cavity reached
* Confirm views of both ostia and document photos
* If sampling: Dilate, curette all four walls and send sample away
* Instruments off, haemostasis check

Post-op:
* Document
* Debrief
* VTE prophylaxis
* Contact with results
* Return advice - bleeding, pain, abnormal discharge, feeling uwell

Question 11

Transvaginal cervical cerclage - McDonald technique

Answer 11

Pre-op:
* Consent - bleeding, infection, injury to cervix, bladder and bowel, rupture of membranes 2% if elective, failure
* Exclude infection, major fetal anomaly
* FHR auscultation

Intra-op:
Spinal
Lithtomy
Prep and drape
ABx not routine unless emergency
Pass metal catehter into bladder to delineate bladder margin
Suture (Nylon or Mercilene tape) as high as possible into cervix as a purse-string at 12 to 10 o’clock, 8 to 6 o’clock, 6 to 4 o’clock and 2 to 12 o’clock
Pull suture so os is tight and tie knot

Post-op:
Document where knot tied
FHR auscultation
Tocolysis
Follow up in ANC wiht return advice
Removal 36weeks or if SROM, in labour prior

Question 12

FGM deinfibulation

Answer 12

Pre-op
* Consent - bleeding, infection, scarring, anatomy not completely restored, illegal to reinfibulate
* Use diagrams to explain plan
* In pregnancy - do any time, best in 2nd trim due to planning
* Utilise cultural supports and translators

Intra-op
* LA into area
* May need IDUC
* Place fingers underneath skin fold (protecting fetal head if intrapartum) and incise cranially until level of urethral meatus exposed, do not go into clitoral body
* Oversew edges with 3/0 vicryl for haemostasis

Post-op
* Document
* Debrief and counselling - reinforce illegal to reinfibulate
* Expect higher menstrual and urinary flow

Question 13

Vaginal hysterectomy

Answer 13

Pre-op
* Consent - bleeding, infection, injury to bladder, bowels, ureter, nerves, vessels, fistula, vault dehiscence, VTE, vault prolapse
* Optimise co-morbidities
* Ensure -ve hCG

Intra-op
* GA
* WHO time-out
* Prep and drape in lithotomy
* IV ABx - cefazolin and metronidazole
* IDUC
* Speculum into posterior vagina, clamp on anterior cervical lip
* Create circumferential incision around cervix at top of vagina
* Dissect bladder away anteriorly
* Create posterior colpotomy through pararectal space and anterior colpotomy through UV fold
* Peform a sweep with fingers to check for adhesions
* Clamp, ligate and tie uterosacral ligaments bilaterally- tag with artery clamps
* Skeletonise uterine vessels
* Ligate uterine vessels
* Dissect up broad ligament to utero-ovarin ligament, clamp, ligate and tie off
* Finish off at round ligaments
* Retrieve specimen through vault
* Tie uterosacrals together and inc;ude vault to this - McCall Culdoplasty
* Secure vault angles, close vault with interrupted sutures using 0 vicryl

Post-op
* Document
* Debrief
* VTE prophylaxis
* IDUC out
* Follow up 6weeks unless concerns prior

Question 14

Sacrospinous fixation

Answer 14

Pre-op
* Consent - pain (buttock), bleeding, infection, injury to bladder, bowel, pudendal vessels and nerves, VTE, failure, unmasking/worsening of anterior prolapse and stress urinary incontinence, sexual dysfunction
* Ensure -ve hCG

Intra-op
* GA or spinal
* WHO time-out
* Clean and drape in lithotomy
* IDUC
* IV ABx - cefazolin
* LA for hydrodissection in postior vagina
* Incise in midline of posterior wall
* Blunt dissection with finger through R lateral pararectal space until ischial spine and sacrospinous ligament felt
* Load Capio needle with permanent sututre
* Deploy needle 2cm medial to R ischial spine along sacrospinous ligament
* Pass suture end though vaginal apex or cervix and clamp
* Repeat suture a second time
* Tie sutures off and trim under direct vision
* Close vaginal defect with running 2/0 vicryl continuously
* Insert vaginal pack
* PR at end

Post-op
* Document
* Debrief patient
* IDUC and pack out following day
* VTE prophylaxis
* Laxatives/stool softeners
* Post op follow up 6weeks unless concerns prior
* Discharge home with return advice

Question 15

EUA for cervical cancer

Answer 15

Pre-op:
* Consent - examination, cystoscopy, flexi sigmoidoscopy, consideration of concurrent intracavity rod insertion

Intra-op:
* GA or spinal
* WHO time-out
* IV ABx?
* Clean and drape in lithotomy
* Speculum + biopsy
* Bimanual - assessing vagina and which 1/3 involved. Rectovaginal examination to assess parametria involvement
* Cystoscopy +/- biopsies
* Flexible sigmoidoscopy +/- biopsies
* Palpate groin and supraclavicular lymph nodes and right upper quadrant for distant metastases.

Post-op:
* Document
* Debrief
* VTE prophylaxis
* Discuss treatment plan in MDM

Question 16

Vaginal radical trachelectomy

Answer 16

Pre-op:
* Consent - Risks = infection, bleeding, VTE, injury to bladder, bowel, vessels, nerves, ureters, urinary dysfunction, vagnal discharge, altered sexual function, lymphoedema, lymphocyst, vulval swelling, cervical stenosis, spont PTB, need for CS delivery, need for further treatment. Benefit = fertility preservation.
* Ensure appropriate stage
* Alternatives discussed depending on stage - TAH + BS, Radical hysterectomy, RTX
* Ensure -ve hCG

Intra-op:
* GA or spinal
* WHO time-out
* IV ABx?
* Clean and drape in lithotomy
* Grasp vaginal mucosa 1-2cm from cervix with straight clamps. Inject dilute adrenaline solution.
* Make a circumferential incision around the vaginal mucosa
* Grasp anterior and posterior edges of vaginal mucosa/cervix. Enter posterior cul-de-sac.
* Paracolpos excised, pararectal space entered, uterosacral ligaments divided and tied.
* Enter vesicouterine space anteriorly and dissect out paravesical spaces.
* Localise and mobilise the ureters by dissecting bladder pillars off the cardinal ligament. Mark ureters for ongoing identification
* Descending branch of uterine artery is identified, secured and transected
* Cervix transected approximately 1cm BELOW the internal cervical os
* Prophylactic Shirodkar cerclage placed with Mersilene tape or monofilament at the level of the isthmus
* Rubber catheter is inserted into the new uterine outlet to keep it patent
* Vaginal mucosa reapproximated to new ectocervix

Post-op:
* Document
* VTE prophylaxis
* IDUC
* Reveiw in clinic in 3weeks to remove cervical catheter
* Pregnancy management - high risk, planned CS

Removal of the upper third of the vagina and cervix with uterine preservation for fertility purposes.

Question 17

Pelvic lymph node dissection

For cervical cancer

Answer 17

Laparoscopy entry - via preferred method
Additional ports placed under direct vision. Pelvic side wall carefully dissected out. Obturator, external and internal iliac nodes are removed to the level of the lower common iliac vessels. Frozen section analysis. If negative, proceed to radical vaginal trachelectomy.

Question 18

Cone biopsy

Answer 18

Pre-op:
* Review indication - ACIS
* Consent - bleeding, infection, injury to adjacent structures, incomplete excision or finding of ca - need for further treatment, cervical stenosis - difficulty sampling in future, obstetric risks - infertility if stenosed, PPROM, 2nd trimester loss and sPTB, cervical dystocia needing CS. Will need cervical surveillance.
* Ensure -ve hCG

Intra-op:
* GA or spinal
* WHO time-out
* IV ABx?
* Lithotomy position
* Colposcopy first - assess TZ,
* Clean and drape
* Ensure good access - speculum for retraction
* Infiltrate LA with adrenaline into cervix at 2, 4, 8,10 o’clock
* Suture or Ellis clamp at 12 and 6 o’clock for traction and orientation
* Cold knife cone circumferentially around TZ
* Hold specimen on tension and excise down to desired depth, directing knife towards endocervical canal
* Excise specimen with knife or Mayo scissors
* Mark specimen with suture at 12 o’clock
* Take endocervical curettings with curette to level of internal os
* Haemostasis - diathermy base, Monsell’s, sutures at 3 and 9 o’clock

Post-op:
* Document
* VTE prophylaxis
* Avoid inserting anything into vagina for 4weeks
* Expect cramping, light PV bleeding, discharge from Monsell’s
* Return advice if increasing pain, heavy bleeding, malodorous discharge, fevers or unwell
* Follow up with histopathology

Question 19

Risk reducing BSO for BRCA

Answer 19

Pre-op:
* Consent - bleeding, infection, injury to surrounding structures, DVTE/PE, anasthetic risks, convert to open, 5% occult malignancy, 3% primary peritoneal ca, need for further treatment, surgical menopause
* Prefer family to be complete first
* Ensure -ve hCG

Intra-op:
* GA
* WHO time-out
* Clean and drape in lithotomy
* Empty bladder with in/out catheter
* Insert uterine manipulator
* Laparoscopic entry at umbilicus via preferred technique
* Place 5mm accessory ports under direct vision
* Diagnostic laparoscopy - survey peritoneal surfaces
* Pelvic washings
* Identify anatomy - see ureters vermiculate, look to pelvic brim if cannot identify
* Electrosurgical device - Ligasure - open pelvic sidewall lateral to IP ligament, isolate IP vessels with urter in view, salpingectomy along tubal mesosalpinx border, resect at cornu.
* Retrieve specimens separatly in specimen bag
* Haemostasis check - pressures reduce to 8mmHg, washout if needed
* Ports out under direct vision
* Close sheath if ports >/= 10mm
* Close skin
* Remove uterine manipulator
* Send specimens to laboratory separately for SEE-FIM protocol, ensure history provided on lab form

Post-op:
* Document
* Debrief - intra-op findings
* VTE prophylaxis
* Follow up with results
* Longer term return advice re new signs of malignancy as only risk reducing e.g. increasing pain, abdominal, distention, nausea, loss of appetite, unintentional weightloss

Question 20

Staging procedure for ovarian cancer

Answer 20

Pre-op:
* Optimise co-morbidities
* Ensure appropriate surgical team present, have urology and colorectal on standby if needed
* Consent - bleeding, infection, injury to bladder, bowel, ureters, vessels, nerves, DVTE/PE, anasthetic risks, surgical menopause
* Ensure valid G&H
* Review imaging to understand anticipated extent of disease
* Ensure -ve hCG

Intra-op:
* GA
* WHO time-out
* Clean and drape in supine
* IDUC
* Cefazolin
* Midline laparotomy
* Enter through sheath with diathermy, and then sharply into peritoneal cavity
* Inspect all peritoneal surfaces in a systematic manner - pelvis, omentum, bowel, appendix, liver, diaphragm
* Take peritoneal washings
* TAH + BSO, infracolic omentectomy
* Resect until no residual disease present (if not confirmed malignant take biopsies of any abnormal areas)
* Lymph nodes - retroperitoneal, para-aortic
* Send specimens to histopathology
* Insert a drain if needed
* Wound catheters if using
* Mass closure of sheath with loop PDS
* Staples for skin

Post-op:
* Document
* Debrief patient and supports
* ERAS (depending on if bowel resected)
* VTE prophylaxis - TEDS, SCDS, clexane
* Hb, electrolytes mane
* Fluid balance monitoring
* Dietician input
* Monitor for ileus
* Make a plan for outpatient follow up with results
* Ensure med onc referral for adjuvant chemotherapy and genetics (if not done) for BRCA testing
* Ongoing surveillance

Question 21

LLETZ procedure

Answer 21

Pre-op:
* Assess if appropriate for LA or GA
* Counsel - bleeding, infection, injury to bladder/bowel/vessels/vagina, incomplete excision, need for further treatment, obstetric impacts (cervical insufficiency -2nd trim loss, sPTB, PPROM)
* Ensure -ve hCG

Intra-op: (office)
* Lithotomy
* Speculum into vagina and cervix visualised
* Colposcopic assessment
* Cervical block 2,4,8, 10 o’clock LA with adrenaline
* Determine diathermy loop size
* Check diathermy settings
* Map out pass first
* Activate before engaging with tissue, cut, enter posteriorly to desired depth (8mm), continuous movement until point of exit
* Orientate specimen with suture at 12 o’clock
* Rollerball diathermy coagulation to crater
* Monsell’s and pressure

Post-op:
* Document
* Follow up with results
* If complete - test of cure with cyrtology and HrHPV test 6 and 18months
* Nothing inside vagina for 3weeks, return advice re bleeding and infection

Question 22

OASI

Answer 22

Pre-op:
* Choose optimal location to repair - in room or OT
* Assess EBL
* Consent - bleeding, infection, VTE incontinence (higher if not repaired), scarring, dyspareunia

Intra-op:
* Anaesthetic
* WHO time out
* Clean and drape
* PR and confirm tear extent, assess for other tearing, perform EUA first if needing to
* 4th degree - grasp edges of rectl mucosa with Elis clamps, repair with 4/0 vicryl rapide interrupted with knot intraluminal
* 3C - grasp edges of IAS with Elis clamps, continuously close defect with 3/0 PDS in end to end
* 3A/B - dissect out edges of EAS, grasp for retracted sections, feel PR and put on tension to assess if EAS is grasped. End-to-end or overlapping if 3B, end-to-end if 3A. 3/0 PDS in horizontal mattress suture
* PR - ensure no sutures in rectum (unless 4th degree) and adequate sphincter bulk
* Use 2/0 vicryl to bury PDS and oppose overlying tissue
* Use 2/0 vicryl to re-approximate superficial transverse perineii and bulbocavernosus
* Secure vaginal apex with 2/0 vicryl rapide, close vagina continuosly until reach hymenal remnant, secure knot, take suture underneath tissues and close superficial tissue or perineum, continuous subcuticular suturing of skin

Post-op:
* Document
* Debrief
* Antibiotics 5days
* Stool softeners
* Physiotherapy - PFM exercises
* ACC forms
* VTE prophylaxis
* Breastfeeding support
* Contraception
* Review at 6weeks or earlier if faecal incontinence or other concerns
* Consultation in future pregnancy - risk of recurrence, mode of delivery

Question 23

Chorionic villus sampling

Answer 23

Pre-op:
* Review placental location
* Review Rh status
* Consent - pain, bleeding, infection, injury to bowel, miscarriage 0.7%, transverse limb reduction if <10weeks, placental mosaicism 1%, maternal contamination, Rh sensitisation, procedure failure

Intra-op:
* Visualise FHR
* TA USS guidance to locate site at placenta
* Prep maternal abdomen
* LA into site under USS guidance
* Pass CVS needle into placenta under USS guidance
* Attach syringe, aspirate sample required
* Remove needle
* Dress site
* Visualise FHR at end

Post-op:
* Document
* Send results for required tests
* Anti-D if Rh -ve
* Return advice re preterm labour
* Follow up with results

Question 24

Anterior vaginal wall repair

Answer 24

Pre-op:
* Examine for other prolapse findings
* Consider any urinary incontinence
* Ovestin cream for 4weeks
* Consent - pain, bleeding, infection, injury to bladder, recurrence, unmasking urinary incontinence, dyspareunia, VTE
* Ensure -ve hCG

Inta-op:
* Anaesthetic
* WHO time out
* Clean and drape in lithotomy
* EUA
* IDUC
* Place Kocher on superior aspect of prolapse and inferior aspect at least 2cm from urethral meatus
* Use LA with adrenaline dilute in NaCl to hydrodissect along prolapse margin
* Sharply incise in midline between kochers
* Grasp vaginal mucosa edges wiuth Allis, use Macinode scissors to dissect vaginal mucosa off fascia and form a plane
* Use gauze against fingertip and bluntly dissect prolapse back off vaginal wall until completely reduced
* Use 3/0 PDS to repair paravaginal fascial defect, plicate fascial edges, start distal and move proximal until prolapse is reduced
* Conservatively trim excess vaginal mucosa
* Repair vaginal incision with 2/0 vicryl
* Insert vgainal pack with ovestin

Post-op:
* Document
* Debrief
* VTE prophylaxis
* Remove pack (and IDUC) after 6hours
* Avoid heavy lifting, intercourse for 6weeks
* Return advice re bleeding, infection, abnormal discharge, feeling unwell

Question 25

Posterior vaginal wall repair

Answer 25

Pre-op:
* Examine for other prolapse findings
* Ovestin cream for 4weeks
* Consent - pain, bleeding, infection, injury to bowel/rectum, recurrence, dyspareunia, VTE
* Ensure -ve hCG

Inta-op:
* Anaesthetic
* WHO time out
* Clean and drape in lithotomy
* EUA including PR to identify if rectocoele, enterocoele
* IDUC
* Place Kocher on superior aspect of prolapse and lateral aspects of vaginal introitus
* Use LA with adrenaline dilute in NaCl to hydrodissect along prolapse margin
* Make a diamond incision with a scalpel at posterior fourchette, dissect off excess tissue
* Sharply incise in midline along prolapse until reach kocher at distal margin
* Grasp vaginal mucosa edges with Allis, use Macinode scissors to dissect vaginal mucosa off fascia and form a plane
* Use gauze against fingertip and bluntly dissect prolapse back off vaginal wall until completely reduced
* Use 3/0 PDS to repair rectovaginal fascial defect, plicate fascial edges, start distal and move proximal until prolapse is reduced
* Conservatively trim excess vaginal mucosa
* Perform concurrent perineorraphy - plicate perineal fascia to midline with interrupted sutures
* Repair vaginal incision with 2/0 vicryl
* PR at end to ensure no sutures
* Insert vgainal pack with ovestin

Post-op:
* Document
* Debrief
* VTE prophylaxis
* Stool softeners
* Remove pack (and IDUC) after 6hours
* Avoid heavy lifting, intercourse for 6weeks
* Return advice re bleeding, infection, abnormal discharge, feeling unwell

Question 26

Burch colposuspension

Answer 26

Pre-op:
* Ensure appropriate indication - stress urinary incontinence
* Consider alternatives - Retropubic sling (mesh or autologous), perirethral bulking
* Consent - bleeding, infection, injury to bladder/bowel/vessels/ureters/nerves, convert to open, VTE, recurrence or non effect, urinary retention
* Teach self catheterisation
* Ensure -ve hCG

Intra-op:
* GA
* WHO time out
* IVABx
* Prep and drape
* IDUC
* Gain laparoscopic entry via preferred technique
* Retrofill bladder to delineate edges
* Space of retzius is opened to expose bladder neck
* Dissect to expose Cooper’s ligament
* Using permanent (or semipermanent) sutures attach paravaginal fascia (2cm lateral to bladder neck) to Cooper’s ligament along superior pubic rami
* Tie sutures but leave tension-free
* Close peritoneum
* Cystoscopy to exclude injury
* Close port sites

Post-op:
* Document
* Debrief
* TROC
* VTE prophylaxis
* Follow-up
* Return advice - bleeding, signs of infection, urinary retention

Question 27

Diagnostic laparoscopy

Answer 27

Pre-op:
* Consent - pain, bleeding, infection injury to bladder/bowel/vessels/nerves/ureters, VTE, hernia, inability to complete, need for further treatment, non positive findings
* Counsel and make a plan for positive and negative finidngs
* Ensure hCG negative

intra-op:
* GA
* WHO time out
* Some surgeons MAY give IVABx
* Clean and drape in lithotomy
* Empty bladder - in/out, IDUC if longer
* EUA
* Bottom end - speculum into vagina, valsellum to anterior cervix, insert manipulator
* Change gloves then come to the top
* Check camera and light on, white balanced, focussed
* Preferred method of entry - I use direct optical entry, back up of Hassan if not successful
* Evert umbilicus to base
* 10mm skin incision at umbilicus
* DIrect optical entry to visualise sheath layers and into peritoneum, remove trochas, connect gas and insufflate
* 360degree sweep of abdomen
* Insert accessory ports - usually 5mm under direct vision after transilluminating skin
* Trendleneberg position, sweep bowel away and perform diagnostic laparoscopy - visualising pelvis as a clockface, check ovarian fossae, POD, UV fold
* Biopsy any areas of concern
* Drop pressures to 8mmHg for haemostasis check
*

Question 28

Pessary fitting

Answer 28

Pre-insertion:
* Establish main symptom concerns and goals of treatment
* Assess desire for intercourse, ability to self manage, ability to use ovestin cream

Insertion (with chaperone and consent)
* Examination, POP-Q, health of vagina, exclude ulceration
* Decide which pessary is most suitable
* Insert ovestin
* Warm pessary
* Part labia and squeeze pessary to insert past introitus
* Fit so sits behind pubic symphysis

Post-insertion
* Ensure feels comfortable, able to mobilise, squat without falling out, feeling uncomfortable
* Ensure can empty bladder
* Trial self removal and reinsertion if relevant
* Written information
* Return advice
* Mak follow up for 3months time to asserss progress, effect, health of vagina

Question 29

Sacrocolpopexy

Answer 29

Pre-op:
* Ensure appropriate indication
* Review alternatives
* Consent - pain, bleeding, infection, osteomyelitis, injury to surrounding structures, VTE, mesh erosion, recurrence, need for further treatment, anaesthetic risks

Intra-op:
* GA
* WHO sign in, time out
* IVABx
* Clean and drape
* IDUC
* Access - open pfannenstiel or laparoscopic
* Grasp vaginal cuff, dissect off surrounding bladder and bowel
* Dissect peritoneum off sacral promontory
* Attach suture to ‘Y’ shaped mesh, secure to vaginal cuff (anterior and posteriorly) and secure tail to sacral promontory ligament
* Pull sutures on tension until prolapse reduction achieved
* Overlay peritoneum to sacral mesh so not exposed
* Haemostasis check
* Wound closure

Post-op:
* Document
* Debrief
* IDUC removal
* VTE prophylaxis
* 6week review to assess symptoms
* Return advice re post op complications and mesh exposure

Question 30

Colpocleisis (no uterus)

Answer 30

Pre-op:
* Ensure alternatives considered
* Consent - pain, bleeding, infection, injury to bladder/bowel, recurrence, vaginal obliteration - unable to have penetrative intercourse, regret

Intra-op:
* Anaesthetic - GA, spinal, LA
* WHO sign in, time out
* IVABx
* EUA
* IDUC
* Mark rectangular border on vaginal epithelium and incise around using scalpel or diathermy
* Grasp edges with Allis clamp, dissect off vaginal epithelium with Macindoe scissors
* Suture at apex on both sides
* Pass foleys catheter around apex so keeps patent channel
* Imbricate vaginal muscularis with 0 vicryl until prolapse reduced and longitudinal septum remains

Post-op:
* Document
* Debrief
* VTE prophylaxis
* Review 6weeks

Question 31

TVT

Answer 31

Pre-op:
* Review to ensure appropriate indication of stress urinary inctoninence
* Urodynamics
* Consent - bleeding, infection, injury to bladder 10%/bowel/vessels/nerves, urinary retention and need to self catheterise, VTE, mesh erosion, non resolution or recurrence
* Teach self catehterisation if needed
* Exclude UTI

Intra-op:
* Anasthetic
* WHO sign in, time out
* IVABx
* Clean and drape - vagina and lower abdomen
* IDUC
* Mark suprapubic exit points 2cm either side of the midline, just above pubic symphysis
* LA infiltration to suprapubic points, overlying urethra and bilaterally
* Make skin incisions with scalpel
* Grasp vagina above urethra and make 2cm long incision along urethra starting 1cm below meatus
* Use scissors to sharply dissect bilaterally to inferior pubic rami
* Inspect TVT mesh and trochars prior to use
* Place guidewire into IDUC and retract urethra and bladder to opposite side
* Insert TVT trochar through dissected area either side of urethra, hug pubic symphysis as enter space of retzius, exit at premarked points on skin
* Leave trochar in and perform cystscopy to exclude bladder perforation
* Remove trochar if satisfied and repeat on opposite side
* Adjust tension with small hegar dilator between mesh and urethra
* Remove plastic sheath, trim mesh edges
* Close skin and vagina

Post-op:
* Document
* Debrief
* VTE prophylaxis
* IDUC removal, formal trial of void
* Return advice re bladder emtpying and written info and equipment for self catheterisation if needed
* Review in 6weeks

Question 32

You perform a TVT and diagnose a bladder perforation of the trochar at cystoscopy check. How do you proceed?

Answer 32

Announce complication to the room
Seek assistance from urology if not able to repair yourself or have other concerns
Give further ABx prophylaxis
Leave trochar in whilst inspect for any other areas of injury, paying close attention to ureteric jets
Make a decision about need for repair of defect and safety of continuing procedure - most small perforations (<2cm) can be managed conservatively and do not need repair
If need to repair - convert to open or laparoscopic procedure to repair bladder injury, suture in 2 layers with vicryl or monocryl to achieve watertight closure (second layer imbricating)
If not repairing - remove trochar, reinsert along different plane and re-check with cystoscopy

Post-operative:
Open disclosure
Leave the IDUC in situ for 7-14days
Perform cystogram prior to removal
Log as complication and review in audit meeting

Question 33

B-Lynch suture

Answer 33

Prior:
* Confirm uterus empty
* Use as adjunct to other measures for control of severe atony

During:
* Re-enter uterine incision, make a hysterotomy along lower segment if has had NVB
* Use large needle - CTX-1 with 1/ vicryl
* Pass inferior to incision and exit superior to incision 3cm medial to edge of uterus
* Take suture over op of the uterus
* Enter cavity posteriorly at the same level as hysterotomy
* Exit cavity back out posteriorly at the same level as hysterotomy on other side
* Take suture back over the top of the fundus
* Pass suture superior to hysterotomy and exit inferiorly
* Manually compress uterus down and pull suture tightly
* Tie the suture ends anteriorly