MIS Flashcards
Percentage of ureteral injuries during gyne procedures?
it is estimated that 52–82% of iatrogenic injuries occur during gynecologic surgery [Lee et al. 1988; Dowling et al. 1986; St Lezin and Stoller, 1991].
What are the clinical risk factors for ureteral injury during hysterectomy ?
include a large uterus, endometriosis, pelvic organ prolapse, and prior pelvic surgery [Vakili et al. 2005; Dandolu et al. 2003].
Where is The most common sight of ureteral injury?
is near the ureterosacral ligaments [Grainger et al. 1990].
low anterior resection (LAR) and abdominal perineal resection (APR), are responsible for 9% of all ureteral injuries [St Lezin and Stoller, 1991].
APR or LAR are complicated by an iatrogenic ureteral injury in 0.3–5% of cases [Coburn, 1996].
Possible sites to insert viress needle
1) peri-umbilical
2) palmar point
3) cul-de-sac
4) trans-uterine
5) btw 9th and 10th intercostal space
Iatrogenic ureteric injury is a well-recognised complication of radical hysterectomy occurring in —-% of cases.
Iatrogenic ureteric injury is a well-recognised complication of radical hysterectomy occurring in 5–30% of cases.
During entry of the insufflation needle or the first trocar in laparoscopy The most commonly injured major vessels are
the distal aorta and the right common iliac artery (RCIA)
Laparoscopy using a pneumoperitoneum is contraindicated in very few clinical conditions, but these include
acute glaucoma, retinal detachment, increased intracranial pressure, and some types of ventriculoperitoneal shunts. Thus, laparoscopy is appropriate for many, although modifications are warranted for certain clinical situations.
brachial plexus injury complicates — percent of gynecologic laparoscopic procedures
brachial plexus injury complicates 0.16 percent of gynecologic laparoscopic procedures
Due to a 60-percent increased incidence during the past few decades, now the most common variant and account for 40 to 50 percent of all malignant ovarian germ cell tumors
Immature teratoma
Immature teratomas contain a disorderly mixture of mature and Immature tissues derived from the three germ cell layers-ectoderm, mesoderm, and endoderm. Of the Immature elements, Immature —– Is the most common.
Immature neuroeplthellum Is the most common.
What are Laparoscopic accommodations in pregnancy , pressure used, techniques … etc
limiting insuffiation pressures to 10 to 15 mm Hg, maintaining end-tidal C02 levels between 32 and 34 mm Hg, moving trocar placement appropriately cephalad to avoid puncture of the gravid uterus, and limiting uterine manipulation, routine use of perioperative prophylactic tocolytics is not recommended in these cases. However, pre-and postoperative fetal heart rate assessment and contraction monitoring for more advanced gestations are typically implemented.
The organ most frequently injured during laparoscopy is
bowel
rates of 0.6 and 1.6 per 1000 cases are reported (Chapron, 1999; Harkki-Siren, 1997)
Major vascular injury associated with laparoscopy rate
Puncture rates are cited as 0.09 to 5 per 1000 cases, and the terminal aorta, inferior vena cava, and iliac vessels, particularly the right common iliac artery, may be injured (Bergqvist, 1987; Catarci, 2001; Nordcstgaard, 1995). Uncommonly, air embolism from gas insufllation following vessel puncture may occur.
if the inferior epigastric artery is injured, several simple techniques can control hemorrhage.
First, bipolar electrosurgical coagulation of the bleeding site may suffice. If unsuccessful, a 14F Foley catheter can be threaded through the cannula of the wounding trocar or through the defect created by this trocar. The Foley balloon then is inflated and pulled upward to create direct pressure against the posterior surface of the anterior abdominal wall. At the skin surface, a Kelly clamp is placed perpendicular across the Foley catheter and paralld to the skin to hold the balloon firmly in place. The balloon and catheter can be removed approximately 12 hours later. Alternatively, sutures can be placed that traverse the skin, abdominal wall, and peritoneum; arch under the bleeding vessel; and exit the abdomen to directly ligate the vessel. Similarly, the Carter-Thomason tool can be used to ligate both ends of this vessel.
Rate of Trocar-Site Metastasis or hernia
1% ( Mets more frequent with ovarian cancer)
Contrindications to septoplasty include
pregnancy and active pelvic infection, and these should be excluded.
What is the major vascular structure most likely to be injured at the time of laparoscopic umbilical trocar placement ?
The distal aorta and right common iliac artery
Which vessel is at risk of injury during laparoscopic lateral trocar placement?
Inferior epigastric artery
cardiovascular and pulmonary physiologic changes in laparoscopy
(1) absorption across the peritoneum and into circulation of CO2 lead to systemic C02 accumulation and hypercarbia. In turn, hypercarbia produces sympathetic stimulation that raises systemic and pulmonary vascular resistance and elevates blood pressure. If not cleared by compensatory ventilation, acidemia develops followed by direct myocardial contractility depression and decreased cardiac output, it can lead to tachycardia and arrhythmia.
(2) elevated intraabdominal pressure created by the pneumoperitoneum, Less commonly, bradycardia can stem from vagal stimulation. This may follow pelvic organ manipulation, cervical stretching during uterine manipulator placement, or peritoneal stretching during pneumoperitoneum creation. This raised pressure as well decreases flow in the inferior vena cava, causes blood pooling in the legs, and raises venous resistance. In sum, venous return to the heart is decreased, and thereby cardiac output is lowered. Increased intraabdominal pressure can also directly lower splanchnic blood flow.
(3) head-down Trendelenburg positioning pushes organs cephalad against the diaphragm moves it up more, lung volume and functional residual capacity are diminished, which in turn reduces the reserve volume for oxygenation. Moreover, this lung volume decline favors a tendency for alveolar collapse, leading to atelectasis. This can create ventilation and perfusion mismatching and an increased alveolar-arterial oxygen gradient.
Laparoscopic entry-related injuries can be classified into two main groups:
type 1 injuries, which include damage by the Veress needle or trocar to normally located blood vessels and bowel,
type 2 injuries, which include damage by the Veress needle or trocar to bowel adherent to the abdominal wall.
Laparoscopic Umbilical Entry techniques
Closed Entry / Veress Needle or trochar Entry Open entry (Hasson technique)
the most sensitive measurement of correct intraperitoneal Veress needle placement
The initial pressure
An initial intraabdominal pressure of 8 mm Hg or below always indicates correct placement of the Veress needle
The Palmer point is located at
3 em below the left costal margin in the midclaviculat line.
inferior epigastric vessels were – cm from the midline at the level of the ASIS and were always lateral to the rectus abdominis muscle at a level – cm superior to the pubic symphysis.
inferior epigastric vessels were 3.7 cm from the midline at the level of the ASIS and were always lateral to the rectus abdominis muscle at a level 2 cm superior to the pubic symphysis.
