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Gynecology > Gyn Surgery > Flashcards

Gyn Surgery Flashcards

1
Q

What is the complication rate in benign gyn surgery?

A

3.7%

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2
Q

Definition of major postoperative complications

A

Death, vascular event (MI, stroke), renal failure, infectious (pna, sepsis), respiratory (mechanical ventilation, intubation), wound dehiscence, intra-abdominal infection, deep site infection, VTE (DVT or PE)

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3
Q

What are predictors of 30-day morbidity after surgery?

A 
Age >80
Dependent functional status
Diabetes
Morbid obesity
Bleeding disorder
Current smoking
Emergency surgery
Operative time
Unintentional weight loss
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4
Q

Rate of vascular injury in laparoscopic entry?

A

0.1 to 6 per 1000

Most commonly omental or mesenteric

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5
Q

Rate of bowel injury in laparoscopic entry?

A

1.8/1000 or appx 0.03-0.18%, higher in hysterectomy than sterilization
30-55% occur during entry

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6
Q

What is the advantage of open entry?

A

Fewer cases of failed entry compared to closed (veress or direct)

Lower risk of major vascular complications compared to closed (Veress) technique

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7
Q

Advantage of direct entry?

A

Lower rates of failed entry compared to Veress

Less extraperitoneal insufflation

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8
Q

What part of bowel is most likely to be injured in laparoscopic surgery?

A

Small bowel

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9
Q

What percent of bowel injuries go unrecognized?

A

41%

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10
Q

What percent of laparoscopic bowel injuries are electrosurgical?

A

29%

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11
Q

Why are electrothermal injuries more damaging?

A

Coagulative necrosis that occurs subsequently over hours-days

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12
Q

How are superficial serosal bowel injuries managed?

A

Purse string closure or oversewn in two layers

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13
Q

How are electrosurgical bowel injuries managed?

A

Assume full thickness injury. Requires a segmental resection, 4-5cm around the area of blanching.

If 2+ bowel injuries, significant bowel spillage, or multiple transfusions, segmental resection and colostomy

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14
Q

When oversewing a bowel injury, what direction do you sew?

A

Longitudinally, so as not to risk a stricture or decrease the lumen of the bowel

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15
Q

How do you manage non-thermal bowel injuries involving >50% of the bowel circumference?

A

bowel resection. if <50%, can oversew.

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16
Q

Acute compartment syndrome risk factors

A

obesity, prolonged operative time, aggressive fluid resuscitation, lithotomy

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17
Q

Earliest sign of acute compartment syndrome

A

Passive stretch

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18
Q

T12-L1 give off which nerves? what are injury symptoms?

A

ilioinguinal and iliohypogastric nerves

- parasthesia of lower abdomen and mons

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19
Q

L1-L2 give off which nerves? what are injury symptoms?

A

genitofemoral - parasthesia of labia and upper thigh

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20
Q

L2-L4 give off which nerves? what are injury symptoms?

A

obturator and femoral nerve

  • obturator numbness of inner thigh and weakened adduction
  • femoral - anterior and posterior thigh numbness
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21
Q

L5-S2 give off which nerves?

A

inferior gluteal
superior gluteal
common peroneal

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22
Q

S2-S4 give off which nerves?

A

Pudendal

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23
Q

Air embolism - what position do you put the patient in?

A

Trendelenberg

Left lateral decubitus

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24
Q

What suture is used for a McDonald cerclage

A

Non-absorbable, large suture

e.g. 1-Prolene

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25
Q

What suture is used for Pomeroy tubal ligation

A

Rapidly absorbable e.g. catgut or plain

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26
Q

Absorbable suture types

A 
Catgut/Chromic
Plain
Vicryl
monocryl (monofilament)
PDS (monofilament)
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27
Q

Non-absorbable suture

A

Silk
Nylon (monofilament)
Prolene (monofilament)
Ethibond

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28
Q

What kind of hernias can be closed without mesh?

A

Small, 3cm or less

29
Q

What kind of hernias can be closed laparoscopically?

A

10cm or less incisional hernias

30
Q

What are risk factors for hernias?

A

Obesity, diabetes, malignancy, smoking, hx prior laparotomy, wound infection, wound dehiscence, immunosuppressants/steroids

31
Q

What is the definition of superficial incisional infection?

A

skin and subQ tissue

1) pus OR
2) pain/tenderness/erythema AND surgical opening of incision OR
3) organism cultured

32
Q

What are not surgical site infections?

A 
Cellulitis alone (without pus)
Stitch abscess
33
Q

What is the definition of deep incisional SSI

A

Deep tissues (fascia or muscle)
1+ of following:
- pus
- spontaneously dehisced or opened incision + fever/tenderness/pain
- e/o infection on imaging, path, gross anatomical test

34
Q

What is the risk of infection in a clean-contaminated case?

A

3.94% (e.g. hysterectomy)

35
Q

What is the risk of infection in a clean case?

A

1.7%

36
Q

What is the risk of infection in a contaminated case?

A

4.75%

37
Q

What is the risk of infection in a dirty/infected case?

A

5.1%

38
Q

What is the risk of SSI for a c-section?

A

incision infection 2-7%

endometritis 2-16%

39
Q

What is the rate of cuff dehiscence after TLH?

After robotic hyst?

A

1-4%
3% for robotic

(but this literature is also from as people are learning how to do MIH)

40
Q

What is the mean time to cuff dehiscence?

A

7 weeks for TLH

13 weeks for TAH

41
Q

What are risk factors for cuff dehiscence?

A 
laparoscopic/robotic hyst
increased electrocautery/coagulation
increased age
# vaginal surgeries
vaginal atrophy
any poor wound healing
post-op infection/hematoma
42
Q

What factors can reduce risk of cuff dehiscence?

A

bidirectional barbed suture

intracorporeal vaginal closure

43
Q

What is the preferred approach to repair a vaginal cuff dehiscence?

A

None preferred over others, depends on patient, visualization, and surgeon

44
Q

Differences in laparoscopic vs robotic hyst outcomes

A

no differences were found in perioperative outcomes, including blood loss, length of stay, type or number of complications, postoperative pain levels, analgesic use, or recovery time

45
Q

Robotic myomectomy vs laparoscopic

A

robotic = longer operative time
however
decreased blood loss, rates of transfusion, and length of hospital stays compared to laparoscopic
also decreased risk of conversion to open

46
Q

How many surgeries does it take to be efficient in the robot?

A

20-30

improvements seen up to first 100 surgeries

47
Q

What is Surgicel? How long does it last?

A

Oxidized regenerated cellulose
powder or mesh
Provides scaffold for platelet aggregation and clot formation; activates extrinsic coagulation cascade
1-2 weeks

CANNOT use with topical thrombin due to low pH of surgicel

48
Q

What is Surgifoam or Gelfoam?

A

Absorbs blood/fluid
matrix for clot formation
and mechanical barrier

Available as sponge or powder

Lasts 4-6 weeks
requires intact coagulation cascade

49
Q

What is Floseal or Surgiflo?

A 
Topical thrombin (converts fibrinogen to fibrin) and gelatin granules
Lasts 4-6 weeks
Biologic agent - does not need intact coagulation cascade but does need fibrinogen
cannot use with surgicel - intactivates due to low pH
50
Q

What is Monsel’s solution

A

ferric subsulfate 20%

coagulates leading to tissue necrosis, enhancing thrombus formation and hemostasis

51
Q

What is silver nitrate?

A

A caustic agent

52
Q

What is an isthmocele?

A

Cesarean scar defect with myometrial discontinuity in the anterior uterine wall, at least 1-2mm
Often filled with endometrium and/or endometrial fluid collection

53
Q

Risk factors for isthmocele?

A

Multiple c-sections

c-section in active labor

54
Q

How may isthmoceles present?

A

abnormal uterine bleeding (bleeding after menses)

most asymptomatic

55
Q

What are risks of isthmoceles?

A

Placenta previa
Invasive placentation
Uterine rupture (NOT related to scar thickness)
C-section scar ectopic pregnancy

56
Q

How do you diagnose isthmocele?

A

TVUS
Could also use saline infused sonography or HSG
MRI
Hysteroscopy

57
Q

How are isthmoceles repaired?

A

Laparoscopic (excise serosal defect and repair over endometrial defect) or hysteroscopic (remove endometrium and endmetrial scar tissue) and/or both

58
Q

What is the correlation between frozen pathology and final pathology for leiomyoma vs leiomyosarcoma?

A

~50%

59
Q

Risk of failure of Filshie clips?

A

CREST STUDY: 36.5 pregnancies /1000 procedures in Filshie clips (3.6%) including interval procedures

RCT of postpartum women, 700 women clip vs salpingectomy, 1.7% pregnancy rate in clip group vs 0.4% rate in salpingectomy group

60
Q

Course of the ureter

A

Renal pelvis
Descend along anterior surface of psoas major in the retroperitoneum
Cross pelvic brim
Cross bifurcation of common iliac arteries into internal/external iliac
Run down lateral pelvic walls, medial to the branches of the internal iliac, in the medial leaf of the broad ligament
Crosses under the uterine arteries 1-2cm

61
Q

Inferior epigastric artery

A

arises from external iliac
travels 4-8cm from midline
anastamosis to superior epigastric arteries (continuation from internal thoracic)

62
Q

Abbe-McIndoe procedure

A

Dissection of space bw rectum and bladder; placement of stent covered with skin graft into space

Vaginoplasty

63
Q

Williams vaginoplasty

A

Horseshoe shaped incision along perineum, labial majora used to create puch
Used second-line in setting of scaring

64
Q

Davydov procedure

A

3 stage vaginoplasty
Dissection of rectovesicular space
Abdominal mobilization of peritoneum
Attachment of peritoneum to introitus

65
Q

Sigmoid vaginoplasty

A

Sigmoid colon resection pulled down to introitus to create neovagina (and closed to create blind pouch)

66
Q

What is an absolute contraindication to use of cell saver?

A

Blood mixed with sterile water

sterile water or alcohol results in red cell destruction > end-organ damage

67
Q

Relative contraindications to cell saver

A 
Malignancy
Sickle cell disease/trait
Intra-op infection
Amniotic fluid
Bowel contents
Clotting agents
68
Q

Layers of the bladder

A 
Transitional epithelium
Lamina propria
Submucosa
Muscularis (detrusor)
Adventitia (serosa)

Gynecology (3 decks)

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