Week 15 Handout Flipped Classrooms: Hysterectomy

Question 1

What is a hysterectomy?

Answer 1

Surgical removal of the uterus, performed for abnormal bleeding, fibroids, endometriosis, cancer, or emergencies like uterine rupture and placenta accreta.

Question 2

What are the surgical approaches for a hysterectomy?

Answer 2

Vaginal, Laparoscopic, Robotic-Assisted Laparoscopic, Open Abdominal (TAH).

Question 3

What are the preoperative preparations for a hysterectomy?

Answer 3

Labs: HCG, CBC, Coags, TEG; Large-bore IVs or central line; Foley and/or OG tube; Optimize volume; Early recognition through monitoring.

Question 4

What should be monitored preoperatively for a hysterectomy?

Answer 4

O2, CO2, ECG, BP, fluid status, quantification of blood loss.

Question 5

What consent should be discussed if reproductive organs are removed during a hysterectomy?

Answer 5

Sterilization consent.

Question 6

What is the highest complication risk during peritoneal access?

Answer 6

Insertion of instruments in peritoneal access has the highest complication risk, with over 50% complications occurring during laparoscopic procedures at the beginning of surgery.

Question 7

What are the risks associated with major vascular injuries during blind abdomen entry?

Answer 7

Major vascular injuries are infrequent but have high mortality rates, occurring 5 times more often during blind abdomen entry.

Question 8

How can injury to the bowel or bladder be prevented during surgery?

Answer 8

Injury to the bowel or bladder can be prevented by using pre-operative OG/Foley to decompress viscera and performing cystoscopy at the end to assess.

Question 9

What should be monitored for frank or occult bleeding during surgery?

Answer 9

Monitor hemodynamics, ETCO2, and be prepared for open conversion and transfusion.

Question 10

What are the hemodynamic effects of CO₂ insufflation?

Answer 10

CO₂ insufflation can cause early increases in BP and HR due to preload from splanchnic squeeze, followed by vagal stimulation leading to decreased venous return and hypotension.

Question 11

What are the effects of intraperitoneal CO₂ absorption?

Answer 11

Intraperitoneal CO₂ absorption can lead to hypercarbia and acidosis, requiring ventilator adjustments or cessation of insufflation for severe effects.

Question 12

What should be done to confirm ETT placement during hypoxia?

Answer 12

Confirm ETT placement, provide 100% O₂, release pneumoperitoneum, and ensure a neutral position.

Question 13

What are the key physiologic changes from CO₂ insufflation?

Answer 13

Key changes include increased intra-abdominal pressure, decreased venous return, increased vagal tone, increased CO₂ absorption, decreased pulmonary compliance, and potential for arrhythmias and hypoxemia.

Question 14

What is the first treatment strategy for the effects of CO₂ insufflation?

Answer 14

Volume resuscitation through bolus IV fluids to support preload is the first treatment strategy.

Question 15

How can insufflation pressure be reduced during surgery?

Answer 15

Request the surgeon to lower CO₂ pressure from 15 mmHg to 10–12 mmHg, and abort insufflation if unresponsive to interventions.

Question 16

What positioning adjustments can optimize visualization and hemodynamics?

Answer 16

Use Trendelenburg or Reverse Trendelenburg positioning, and return to neutral if pressure impairs perfusion or ventilation.

Question 17

What anesthetic management strategies should be employed during CO₂ insufflation?

Answer 17

Deepen anesthesia, hyperventilate for hypercarbia, and monitor ETCO₂, PIP, and hemodynamics.

Question 18

When should insufflation be aborted during surgery?

Answer 18

Abort insufflation and convert to an open procedure if hypotension persists, resuming only after stabilization.

Question 19

What is intraoperative hemorrhage?

Answer 19

Massive hemorrhage during surgery, especially in placenta removal, uterine atony, or pelvic vessel dissection.

Question 20

What are the causes of massive hemorrhage in obstetric cases?

Answer 20

1. Vascular engorgement of the gravid uterus 2. Distorted anatomy & adhesions from prior surgeries 3. Abnormal placentation

Question 21

What are the clinical effects of intraoperative hemorrhage?

Answer 21

1. Hemodynamic instability (hypotension, shock, cardiac arrest) 2. Coagulopathy & DIC 3. Airway edema/Respiratory Failure 4. Bladder or ureter injury 5. Increased morbidity & mortality

Question 22

How much higher is the maternal death rate in obstetric hysterectomy compared to non-obstetric?

Answer 22

25 times higher.

Question 23

What preparations should be made for intraoperative hemorrhage?

Answer 23

2 large-bore IVs, A-line, MTP activation, vasopressors, warmed fluids, prepare for conversion to GA.

Question 24

What is CO₂ gas embolism?

Answer 24

CO₂ enters the venous system during laparoscopy, causing RV outflow obstruction.

Question 25

What is the most sensitive diagnostic for detecting gas emboli in the heart?

Answer 25

TEE (Transesophageal Echocardiography) ## Footnote Appears as a white-out of the right heart chambers.

Question 26

What are the symptoms of CO₂ gas embolism?

Answer 26

Sudden decrease in ETCO2, hypotension, tachycardia, hypoxemia, arrhythmias, cyanosis, and a 'mill wheel' murmur.

Question 27

What is the treatment for CO₂ gas embolism?

Answer 27

Stop insufflation, hyperventilate with 100% O₂, place in Trendelenburg + left lateral decubitus, give IVF bolus, ACLS if arrest occurs.

Question 28

What is the goal of fluid management during surgery?

Answer 28

Maintain euvolemia and avoid overload.

Question 29

What are the risks of the lithotomy position?

Answer 29

Peroneal nerve injury, reduced CO and FRC, higher risk of nerve damage with BMI <20, surgery >4 hours, diabetic/smoker.

Question 30

What are the risks associated with steep Trendelenburg position?

Answer 30

Facial/airway edema, ETT migration, corneal abrasion, difficult extubation, reduced pulmonary compliance.

Question 31

What is the standard anesthetic technique for laparoscopic/robotic surgery?

Answer 31

General Anesthesia (GA) is the standard of care.

Question 32

Why is General Anesthesia required for laparoscopic/robotic procedures?

Answer 32

Due to CO₂ pneumoperitoneum, steep Trendelenburg position, and the need for controlled ventilation.

Question 33

What is preferred for airway management during General Anesthesia?

Answer 33

Endotracheal tube (ETT) is preferred over laryngeal mask airway (LMA).

Question 34

When is General Anesthesia preferred for open abdominal hysterectomy?

Answer 34

It is preferred in unstable patients for better control during hemorrhage, airway protection, and major fluid shifts.

Question 35

When is neuraxial anesthesia appropriate?

Answer 35

Only for stable elective open abdominal cases.

Question 36

What is the incidence of PONV in laparoscopy?

Answer 36

Up to 72%.

Question 37

What should be monitored during surgery?

Answer 37

Bleeding, airway edema, ETT displacement, ocular complications, gas embolism.

Question 38

What are key takeaways regarding insufflation effects?

Answer 38

Insufflation effects can mimic hypovolemia; treat with positioning, volume, and pressure adjustments.

Question 39

Student Question:What patient position is most commonly used to improve pelvic exposure during a laparoscopic hysterectomy? A. Prone B. Lithotomy only C. Reverse Trendelenburg D. Steep Trendelenburg

Answer 39

Answer: D. Steep Trendelenburg Rationale: The steep Trendelenburg position shifts abdominal contents cephalad, enhancing pelvic visualization for laparoscopic/robotic cases (Barash et al., 2017, p. 3168).

Question 40

Student Question: In the lithotomy position, which nerve is at highest risk of compression injury? A. Sciatic B. Femoral C. Peroneal D. Obturator

Answer 40

Answer: C. Peroneal Rationale: The common peroneal nerve, which wraps around the fibular head, is most vulnerable in lithotomy stirrups, especially if surgery exceeds four hours (Chestnut et al., 2019, p. 819).

Question 41

Student Question: Which anesthesia technique is required for a robotic‑assisted or laparoscopic hysterectomy? A. Spinal anesthesia alone B. Epidural anesthesia alone C. General anesthesia D. Local anesthesia

Answer 41

Answer: C. General anesthesia Rationale: Laparoscopic and robotic‑assisted hysterectomies necessitate pneumoperitoneum and steep Trendelenburg, which require controlled ventilation and airway protection only achievable under general anesthesia (Chestnut et al., 2019, p. 917).

Question 42

Student Question: During CO₂ pneumoperitoneum creation for a laparoscopic hysterectomy, which hemodynamic change is most directly attributable to the increased intra‑abdominal pressure? A. Increased venous return B. Decreased systemic vascular resistance C. Increased stroke volume D. Decreased preload

Answer 42

Answer: D. Decreased preload Rationale: Elevated intra‑abdominal pressure compresses the inferior vena cava, reducing venous return to the heart (preload), which can decrease stroke volume and cardiac output if uncorrected (Barash et al., 2017, pp. 3163–3164).

Question 43

Student Question: Which preoperative test is essential to rule out pregnancy before an elective hysterectomy? A. Serum β‑hCG B. Coagulation profile (PT/PTT) C. Urinalysis D. Liver function tests

Answer 43

Answer: A. Serum β‑hCG Rationale: β‑hCG is used specifically to detect pregnancy and must be obtained before any elective pelvic surgery to avoid operating on an unsuspected pregnancy (Chestnut et al., 2019, p. 916).

Question 44

Student Question: After creating pneumoperitoneum and placing the patient in steep Trendelenburg, what should be reconfirmed immediately? A. Intravenous line patency B. Endotracheal tube depth C. Sterile field integrity D. Foley catheter position

Answer 44

Answer: B. Endotracheal tube depth Rationale: Insufflation plus head‑down tilt shifts the diaphragm and can advance the ETT tip, risking endobronchial intubation, so tube depth must be rechecked (Barash et al., 2017, p. 3168).