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Gyn Surgery Flashcards

(68 cards)

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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
What suture is used for Pomeroy tubal ligation
Rapidly absorbable e.g. catgut or plain
26
Absorbable suture types
``` Catgut/Chromic Plain Vicryl monocryl (monofilament) PDS (monofilament) ```
27
Non-absorbable suture
Silk Nylon (monofilament) Prolene (monofilament) Ethibond
28
What kind of hernias can be closed without mesh?
Small, 3cm or less
29
What kind of hernias can be closed laparoscopically?
10cm or less incisional hernias
30
What are risk factors for hernias?
Obesity, diabetes, malignancy, smoking, hx prior laparotomy, wound infection, wound dehiscence, immunosuppressants/steroids
31
What is the definition of superficial incisional infection?
skin and subQ tissue 1) pus OR 2) pain/tenderness/erythema AND surgical opening of incision OR 3) organism cultured
32
What are not surgical site infections?
``` Cellulitis alone (without pus) Stitch abscess ```
33
What is the definition of deep incisional SSI
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
What is the risk of infection in a clean-contaminated case?
3.94% (e.g. hysterectomy)
35
What is the risk of infection in a clean case?
1.7%
36
What is the risk of infection in a contaminated case?
4.75%
37
What is the risk of infection in a dirty/infected case?
5.1%
38
What is the risk of SSI for a c-section?
incision infection 2-7% | endometritis 2-16%
39
What is the rate of cuff dehiscence after TLH? | After robotic hyst?
1-4% 3% for robotic (but this literature is also from as people are learning how to do MIH)
40
What is the mean time to cuff dehiscence?
7 weeks for TLH | 13 weeks for TAH
41
What are risk factors for cuff dehiscence?
``` laparoscopic/robotic hyst increased electrocautery/coagulation increased age # vaginal surgeries vaginal atrophy any poor wound healing post-op infection/hematoma ```
42
What factors can reduce risk of cuff dehiscence?
bidirectional barbed suture | intracorporeal vaginal closure
43
What is the preferred approach to repair a vaginal cuff dehiscence?
None preferred over others, depends on patient, visualization, and surgeon
44
Differences in laparoscopic vs robotic hyst outcomes
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
Robotic myomectomy vs laparoscopic
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
How many surgeries does it take to be efficient in the robot?
20-30 | improvements seen up to first 100 surgeries
47
What is Surgicel? How long does it last?
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
What is Surgifoam or Gelfoam?
Absorbs blood/fluid matrix for clot formation and mechanical barrier Available as sponge or powder Lasts 4-6 weeks requires intact coagulation cascade
49
What is Floseal or Surgiflo?
``` 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
What is Monsel's solution
ferric subsulfate 20% | coagulates leading to tissue necrosis, enhancing thrombus formation and hemostasis
51
What is silver nitrate?
A caustic agent
52
What is an isthmocele?
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
Risk factors for isthmocele?
Multiple c-sections | c-section in active labor
54
How may isthmoceles present?
abnormal uterine bleeding (bleeding after menses) | most asymptomatic
55
What are risks of isthmoceles?
Placenta previa Invasive placentation Uterine rupture (NOT related to scar thickness) C-section scar ectopic pregnancy
56
How do you diagnose isthmocele?
TVUS Could also use saline infused sonography or HSG MRI Hysteroscopy
57
How are isthmoceles repaired?
Laparoscopic (excise serosal defect and repair over endometrial defect) or hysteroscopic (remove endometrium and endmetrial scar tissue) and/or both
58
What is the correlation between frozen pathology and final pathology for leiomyoma vs leiomyosarcoma?
~50%
59
Risk of failure of Filshie clips?
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
Course of the ureter
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
Inferior epigastric artery
arises from external iliac travels 4-8cm from midline anastamosis to superior epigastric arteries (continuation from internal thoracic)
62
Abbe-McIndoe procedure
Dissection of space bw rectum and bladder; placement of stent covered with skin graft into space Vaginoplasty
63
Williams vaginoplasty
Horseshoe shaped incision along perineum, labial majora used to create puch Used second-line in setting of scaring
64
Davydov procedure
3 stage vaginoplasty Dissection of rectovesicular space Abdominal mobilization of peritoneum Attachment of peritoneum to introitus
65
Sigmoid vaginoplasty
Sigmoid colon resection pulled down to introitus to create neovagina (and closed to create blind pouch)
66
What is an absolute contraindication to use of cell saver?
Blood mixed with sterile water | sterile water or alcohol results in red cell destruction > end-organ damage
67
Relative contraindications to cell saver
``` Malignancy Sickle cell disease/trait Intra-op infection Amniotic fluid Bowel contents Clotting agents ```
68
Layers of the bladder
``` Transitional epithelium Lamina propria Submucosa Muscularis (detrusor) Adventitia (serosa) ```

Gynecology (3 decks)

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