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GYN Flashcards

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1
Q

What are some clinical risk factors for DVT?

A

Age > 40
Surgery for malignancy
Prolonged surgery (> 30-45 mins)
Obesity
Delayed POP ambulation
Medical disease (DM, heart failure, COPD, prior DVT)

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2
Q

What are the steps to assess a bladder injury repair?

A
  1. Location of injury in relation to the trigone
  2. Proceed gently - friable bladder mucosa
  3. Close in 2-3 layers
    - Submucosa + mucosa
    - Muscularis +/- paravesical fascia
  4. Consider sterile milk to test integrity
  5. Cystoscopy to assess trigone and closure
  6. Foley for 7d
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3
Q

How would you repair a ureteral injury > 5cm from the UVJ?

A

Uretero-ureteterostomy (End to end anastomosis)
- Spatulate ends
- 4-6 interrupted sutures of 4-0 chromic through full thickness of cut edge
- Make sure no tension
- Consider placing a drain (not in contact w suture)
- Stent the ureters and cath the bladder x 10d

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4
Q

How would you repair a ureteral injury < 5cm from the UVJ?

A

Ureteroneocystotomy (re-implant into the bladder)
- Must be off tension
- Consider Psoas Hitch, Baori flap, or mobilizing bladder

Transureteroureterostomy (implant to contralateral ureter)

Always place a drain to avoid urinoma

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5
Q

What can you do if a primary ureteral repair of an injury cannot be performed?

A

Percutaneous nephrostomy

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6
Q

What are the steps of repairing a bowel injury?

A
  1. Run the bowel first to identify other areas of injury
  2. Close to to avoid narrowing of the lumen of the bowel
    - Side to side if lac is perpendicular to long axis
    - End to end if lack is parallel to long axis
  3. Use 3-0 vicryl to close mucosa/muscularis in single layer interrupted
  4. Use 3-0 non absorbable for muscualris/serosa
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7
Q

What are some different abdominal incisions?

A

Pfannenstiel
Joel-Cohen
Cherney
Maylard

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8
Q

What characterizes a Pfannenstiel incision?

A

2cm above the pubic symphysis
Separate rectus from sheath

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9
Q

What characterizes a Joel-Cohen incision?

A

5cm above the pubic symphysis
Blunt dissection
Associated with less fever, pain, blood loss, op time

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10
Q

What characterizes a Cherney incision?

A

Separate the rectus tendon from the pubic symphysis to visualize the space of Retzius

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11
Q

What characterizes a Maylard incision?

A

Transect the rectus muscle with ligation of the inferior epigastrics. No separation of rectus from sheath.

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12
Q

What characterizes a mass closure?

A

Incorporating the subcutaneous tissue, rectus, rectus sheath, fascia, and peritoneum in one bite

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13
Q

What characterizes a Smead-Jones mass closure?

A

Vertical mattress mass closure with double loop, then,
incorporate medical edge of sheath in a single loop

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14
Q

What are some factors necessitating mass closure?

A

Age, obesity, poor nutrition, steroids, radiotherapy, chemotherapy, any chronic condition leading to weak tissue

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15
Q

Suture material: Plain gut
- natural vs synthetic
- absorption time
- breakdown mechanism

A

Plain gut
- Natural
- 7d
- Inflammation

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16
Q

Suture material: Chromic gut
- natural vs synthetic
- absorption time
- breakdown mechanism

A

Chromic
- Natural
- 14d
- Inflammation

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17
Q

Suture material: Vicryl
- natural vs synthetic
- absorption time
- breakdown mechanism

A

Vicryl
- Synthetic
- Loses 50% tensile strength at 21d
- Hydrolysis

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18
Q

Suture material: Dexon
- natural vs synthetic
- absorption time
- breakdown mechanism

A

Dexon
- Synthetic
- Loses 50% of tensile strength at 30d
- Hydrolysis

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19
Q

Suture material: PDS/Maxon
- natural vs synthetic
- absorption time
- breakdown mechanism

A

PDS/Maxon
- Synthetic monofilament
- Loses 50% of tensile strength at 60d
- Hydrolysis

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20
Q

Suture material: Silk
- natural vs synthetic
- absorption time
- breakdown mechanism

A

Silk
- Natural braided
- Permanent

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21
Q

Suture material: Nylon
- natural vs synthetic
- absorption time
- breakdown mechanism

A

Nylon
- Synthetic monofilament
- Permanent

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22
Q

What are the 5Ws of post op fever?

A

Wind: bowel obstruction, ileus, PNA
Water: UTI
Wound: Infection
Walking : DVT
Wonder drugs: Drug allergies
(Wonder breasts: mastitis)

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23
Q

What is the time frame this cause of POP fever: PNA/GI?

24
Q

What is the time frame this cause of POP fever: DVT?

25
What is the time frame this cause of POP fever: UTI?
4-7d
26
What is stage 0 POP?
No prolapse
27
What is stage 1 POP?
Greater than 1cm above the hymen
28
What is stage 2 POP?
Between 1cm above the hymen and 1cm below the hymen
29
What is stage 3 POP?
More than 1cm below the hymen but no further than 2cm less than total vaginal length
30
What is stage 4 POP?
Complete procidentia
31
What is a Halban's culdoplasty for enterocele prevention?
Vertical sutures incorporating uterosacrals, performed abdominally
32
What is a Moskowitz culdoplasty for enterocele prevention?
Pursestring sutures incorporating uterosacrals, performed abdominally
33
What is a McCall's culdoplasty for enterocele prevention (and prophylaxis for vault prolapse)?
Plicate the uterosacral ligaments in the midline, performed vaginally
34
What are three surgical treatments of vaginal vault prolapse?
1. Abdominal sacrocolpopexy 2. Sacrospinous ligament fixation 3. Uterosacral ligament fixation
35
What are the 5 compartments to check for prolapse?
1. Anterior (cystocele) 2. Posterior (rectocele) 3. Uterus/apex (apical) 4. Posterior cul de sac (enterocele) 5. Vaginal outlet (perineal body)
36
What are 3 risk factors for recurrent prolapse?
1. Age < 60 2. BMI > 26 3. Stage 3 or 4 prolapse
37
What is the minimum evaluation of urinary incontinence?
1. History 2. Physical 3. UA 4. Assessment of stress incontinence 5. Assessment of urethral mobility 6. Measure PVR
38
What are 3 classes of medications for UUI?
1. Antimuscarinics: Oxybutinin 2. Beta adrenergics: Mirabegron 3. Botox
39
How do antimuscarinics work for UUI?
Block parasympathetic M2/M3 receptors to inhibit involuntary detrusor contractions Side effects: dry mouth and eyes, constipation
40
How do beta adrenergics work for UUI?
Relax detrusor muscle to increase bladder capacity Side effects: no worse than placebo Contraindicated with severe HTN, renal disease, liver disease
41
How does botox work for UUI?
Paralyses/relaxes bladder to increase capacity Side effects: UTI, urinary retention
42
What is a treatment for refractory UUI?
Sacral neuromodulation
43
What are surgical treatment options for SUI?
Urethral bulking Slings Suspensions
44
What are some complications of sling procedures?
UTI Surgical site bleeding, Retzius hematoma Placement of sling or suture in bladder Mesh erosion Urinary retention Unmasking of urge incontinence Fistula if using mesh
45
What are the treatment options for mesh erosion?
1. Pelvic rest for 6-8w, vaginal estrogen 2. Excision of mesh in office 3. Excision of mesh in OR with repair+cysto
46
What are the three levels of wound failure?
1. Superficial separation 2. Fascial dehiscence 3. Evisceration
47
What factors are associated with regret for tubal sterilzation?
Age < 30yo Recent decision < 6mo ago Unstable marriage or single Unhealthy children Unhealthy neonate (low Apgars, premature, FGR, etc)
48
What are some disadvantages of robotic surgery?
Longer operative time More surgical incisions Extensive learning curve Medical cost
49
What are some advantages of robotic surgery?
3D vision Improved fine motor control and articulation Potentially decreased blood loss Minimally invasive approach to otherwise open cases
50
What are some risk factors for surgical site infection?
Obesity BMI > 30 Nutritional status SubQ > 3cm Smoking Immunosuppression Perioperative hyperglycemia Co-existant infection at remote body site Vaginal colonziation MRSA status
51
What are the steps of an appendectomy?
1. Dissect mesosalpinx 2. Ligate appendix vessels 3. Clamp and cut base of appendix 4. Purse string suture around base 5. Embed the stump prior to closing purse string
52
What are some complications of UAE?
Pain and degeneration of fibroids Myometritis Bacteriemia Uterine artery perforation/hemorrhage Loss of ovarian function
53
What qualities on US increase risk of adnexal mass malignancy?
Size > 10cm Hetergeneous components Intramural nodule Papillary excrescences Septatations Increased doppler flow Free fluid
54
What non-malignancy conditions can cause elevated Ca 125?
Endometriomas PID Inflammatory states (SLE/IBD) Non gyn malignancy Pregnancy
55
What is partner treatment for gonorrhea?
800mg cefixime (+100mg doxy bid if chlamydia status unk)

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