Module 7 - Surgical Procedures

Question 1

You are consenting a patient prior to laparoscopic resection of extensive endometriosis. What is the most common major complication of gynaecological laparoscopic surgery?

Answer 1

Injury of the urinary tract (includes bladder and ureters) is the most common major complication of gynaecological laparoscopic surgery

Question 2

What are the risks of overall serious complication in laparoscopy?

Answer 2

2 in 1,000

Question 3

What is the risk of bowel injury during laparoscopy?

Answer 3

0.4 in 1,000

Question 4

What is the risk of vascular injury during laparoscopy?

Answer 4

0.2 in 1,000

Question 5

What is the risk of death during laparoscopy?

Answer 5

5 in 100,000

Question 6

What two risks of surgery are more common with laparoscopic hysteretcomy vs open hysterectomy?

Answer 6

1) Urinary tract injury
2) Vaginal cuff dehiscence

Question 7

What is the overall risk of serious complications from TAH?

Answer 7

4 in 100 (common)

Question 8

What proportion of women will require a hysterectomy after UAE?

Answer 8

3%

Question 9

What proportion of women will be asymptomatic or have improved symptoms at 1 year after UAE?

Answer 9

80-90%

Question 10

What proportion of women with UAE will require a second intervention by 5 years?

Answer 10

1/3

<40 - 20%

> 40 - 10%

Question 11

What are the adverse pregnancy outcomes following UAE?

Answer 11

Higher rates of:
- CS
- PPH
- 1st trimester miscarriage

Question 12

What are the absolute contraindications to UAE? (5 points)

Answer 12

1) Recent or current pelvic infection
2) Pregnancy
3) Refusal to accept hysterectomy if required
4) Asymptomatic fibroids
5) Uncertain diagnosis

Question 13

When do complications for UAE typically occur?

Answer 13

After 30 days

Question 14

What is associated with sulphur granules?

Answer 14

Actinomycosis

Question 15

What is the most common ureteric injury during gynae laparoscopic surgery?

Answer 15

Complete transection (60%)

Question 16

What is the risk of ureteric injury during laparoscopy?

Answer 16

<1 - 2%

Question 17

What proportion of ureteric injuries are diagnosed intra-operatively during laparoscopy?

Answer 17

30%

Question 18

What proportion of bladder injuries are diagnosed intra-operatively during laparoscopy?

Answer 18

50%

Question 19

What is the risk of ureteric injury during laparoscopy where there is deep-infiltrating endometriosis with hydronephrosis?

Answer 19

20%

Question 20

What is the most common site for bladder injury during surgery?

Answer 20

In the midline above the inter-ureteric bar
As you dissect the bladder from the cervix

Question 21

What are the most common sites for ureteric injury during surgery?

Answer 21

Lower 1/3 injuries make up 50% of injuries

Pelvic brim
Lateral to cervix/uterine vessels at cardinal ligament

Question 22

What are the overall risk of serious complication with abdominal hysterectomy?

Answer 22

4 in 100

Question 23

What is the risk of haemorrhage requiring blood transfusion in abdominal hysterectomy procedures?

Answer 23

23 in 1,000

Question 24

What is the risk of urinary tract injury in abdominal hysterectomy procedures?

Answer 24

7 in 1,000
0.7%

Question 25

What is the risk of ureteric injury during laparoscopy?

Answer 25

<1 - 2%

Question 26

What percentage of women who have had a subtotal hysterectomy will have persistent cyclical bleeding?

Answer 26

5%

Question 27

For patients taking warfarin, when do you stop it prior to a surgical procedure?

Answer 27

5 days prior to surgery regardless of their risk of intra-operative bleeding

Question 28

If a woman is taking Warfarin and is due to have an elective gynae procedure when should Warfarin be stopped, and in which circumstance would she need anti-coagulation bridging with LMWH?

Answer 28

1) Stop Warfarin 5 days prior to operation 2) For women at HIGH RISK of VTE - give bridging therapy with TREATMENT DOSE LMWH. Stop LMWH 24 HOURS prior to operation

Question 29

Which patients are regarding as High-risk for VTE and thus would need LMWH bridging when stopping Warfarin prior to surgery?

Answer 29

1) VTE within the last 3 months (have a target INR of 3.5) 2) Stroke or TIA in the last 3 months 3) Mechanical heart valve 4) Previous stroke or TIA with 3 or more of: - Congestive heart failure - HTN - Age >75 - Diabetes

Question 30

Which gynaecological procedures are regarded as posing a major bleeding risk?

Answer 30

All day case and inpatient surgeries

Question 31

A patient is booked to have an open myomectomy for large uterine fibroids. She is taking Aspirin because of her history of previous stroke. When should her Aspirin be stopped prior to surgery?

Answer 31

You do not stop it. If on Aspirin monotherapy you can continue Aspirin for all Gynae procedures

Question 32

A patient is due to have an open myomectomy for large uterine fibroids. She is on Aspirin and Clopidogrel dual therapy due to a recent ACS 4 months ago. When should her medications be stopped prior to surgery?

Answer 32

If a patient had a recent ACS or coronary artery stenting within the last 6 months then avoid surgery if possible. If unable to delay surgery (and <6 months): Low-bleeding risk - Continue Aspirin + Clopidogrel High-bleeding risk - Continue Aspirin. Stop Clopidogrel 7 days before

Question 33

A woman taking Warfarin is 9 weeks pregnant with a suspected tubal ectopic pregnancy. She has consented to a laparoscopic salpginectomy. She last took Warfarin 3 hours ago. How long should the operation be postponed for?

Answer 33

Aim to post-pone for 6-8 hours after last dose in emergency gynae operations. Then give 5mg VITAMIN K i.v. (Phytomenadione) to decrease the INR If surgery can't be delayed then give 25-50 IU/kg Four factor Prothrombin complex concentrate and then check the INR

Question 34

When do you stop Warfarin for a patient planned to have a low-bleeding risk gynaecological operation?

Answer 34

1) Stop 5 days before operation 2) Check INR day before op - if INR >1.5 - give Vitamin K i.v. 3) Check INR day of op If high VTE risk - bridge with treatment dose LMWH

Question 35

When do you re-start Warfarin for a patient planned to have a low-bleeding risk gynaecological operation?

Answer 35

1) Re-start Warfarin 12-24 hours after operation 2) Start LMWH 24 hours after operation - continue until INR within therapeutic range

Question 36

When do you stop Warfarin for a patient planned to have a high-bleeding risk gynaecological operation?

Answer 36

1) Stop 5 days before operation 2) Check INR day before op - if INR >1.5 - give Vitamin K i.v. 3) Check INR day of op If high VTE risk - bridge with treatment dose LMWH

Question 37

When do you re-start Warfarin for a patient planned to have a high-bleeding risk gynaecological operation?

Answer 37

1) Re-start Warfarin when bleeding risk is minimised 2) Start LMWH 48 hours after op

Question 38

When do you stop Apixaban, Rivaroxaban and Edoxaban for a patient planned to have a low-bleeding risk gynaecological operation?

Answer 38

1) CrCl >30 - stop 24 hours before op 2) CrCl <30 - stop 48 hours before op

Question 39

When do you re-start Apixaban, Rivaroxaban and Edoxaban for a patient planned to have a low-bleeding risk gynaecological operation?

Answer 39

Re-start 6-12 hours after op

Question 40

When do you stop Apixaban, Rivaroxaban and Edoxaban for a patient planned to have a high-bleeding risk gynaecological operation?

Answer 40

1) CrCl >30 - stop 48 hours before op 2) CrCl <30 - stop 72 hours before op

Question 41

When do you re-start Apixaban, Rivaroxaban and Edoxaban for a patient planned to have a high-bleeding risk gynaecological operation?

Answer 41

Re-start 48 hours after op If high VTE risk then give prophylactic dose of anticoagulation before restarting at full therapeutic dose