1
Q
Close all port sites ___mm or greater
A
12
2
Q
risk factors for trocar site hernia (6)
A
trocar size/type
port > 10 mm
blading vs dilating
tissue extraction site
medical comorbidities (obesity, age, infection)
surgical factors: trocar placement extenssive traction
3
Q
Injuries to what nerves in the anterior abdominal wall can cause searing nerve pain in lower abdomen and groin that radiates to the vulva
A
iliohypogastric
ilioinguinal
4
Q
Trocars should be placed above the ____ to avoid injury to the iliohypogastric and ilioinguinal nerves
A
anterior superior iliac spine
5
Q
inferior epigastric artery originates from the ___
A
external iliac
6
Q
Inferior epigastric artery is located medial to the ____ ligament and lateral to the ____ ligament
A
round ligament
medial umbilical
7
Q
to avoid injury, lateral ports should be placed within ___ cm of the midline or more than ___ cm from the midline
A
4
8
8
Q
In low BMI patients, insert the veress at ___ degree angle for entry
average BMI: ___ degrees
obese pt : ___
A
30
45
90
9
Q
Palmers point is __ cm below the left costal margin and within the midclavicular line
A
3
10
Q
contraindications to palmer point entry
A
hepatospenomegaly
history of splenic surgery
11
Q
location of subxiphoid entry:
A
3 cm below xiphoid process
12
Q
contraindication to subxiphoid entry
A
hepatosplenomegaly
13
Q
What suture gauge should be used in the following tissue:
fascia
vaginal cuff
bowel
skin
A
fascia: 0 or 1
vaginal cuff: 0 or 2-0
bowel: 2-0
skin: 4-0
14
Q
suture length for extracorporeal suturing
A
at least 70 cm
15
Q
Which tissue types are better for cutting, reverse cutting, and taper needles tips
A
cutting and reverse cutting: tougher tissue like skin
taper: soft tissue, like bowel, bladder and vaginal cuff
16
Q
list the 3 FDA approved barrier methods to reduce adhesion formation
A
oxidized regenerated ceullulose
icodextran 4% solution
modified hyaluronate carboxymethylcellulose
17
Q
local anesthesia signs of neurologic toxicity include ______ numbness
_______ taste
mental status and visual changes
muscle ______
seizures
respiratory depression
A
perioral numbness
metalic taste
muscle twitching
18
Q
what is the maximum mg/kg dose of the follow w/o and w epi
2% lidocaine
1.5% mepivicaine
0.5% ropivacaine
0.25% bupivicaine
A
lidocaine: 4.5, 7
mepivicaine: 5, 7
ropivacaine: 3, 3.5
bupivicaine: 2.5, 3
19
Q
what is the incidence of perforation during diagnostic vs operative hysteroscopy
A
diagnostic: <1%
operative: ~1 %
20
Q
what are the most common areas for uterine perforation
A
fundal region
posterior and anterior walls
21
Q
Expectant management of uterine perforation is acceptable when all of the following are true: (5)
A
VSS
blunt instrument
no electrosurgical energy
fundal location
no vascular or visceral injury concerns
22
Q
Vasopressin has what effects on systemic venous return and mean arterial pressure.
A
vasocontriction –> increased venous return and increased mean arterial pressure
23
Q
how can vassopressin cause cardiac arrest
A
vasoconstriction –> hyperension –> bradycardia –. cardiac arrest
24
Q
what concentration of vasopressin should be used when injecting the cervix
A
0.1-0.2 U/mL, 5 units in 100 mL of NS
25
How many units of vasopressin should be injected to the cervix at a time
< 5 U
26
where is vasopressin injected prior to hysteroscopy
stroma of ectocervix
27
list the electrolyte poor distention fluids that can be used with monopolar energy
1.5% glycine
3% sorbitol
5% mannitol
28
List the electrolyte rich/containing fluids (isotonic) that are used with bipolar energy
normal saline
lactate ringer
29
____ dissection should be used for thin filmy adhesions
blunt
30
_____ dissection should be used for dense avascular adhesions or near the organs (ie bowel)
sharp (cold)
31
what are the indications for surgical management of ectopic precnancy
hemodynamic instability
ruptured ectopic
failed medical treatment
32
when should salpingostomy be considered (rather than salpingectomy) for treatment of ectopic pregnancy
future fertility desired and contralateral tube is damaged
33
What is the rate of retained trophoblastic tissue when salpingostomy is performed for ectopic pregnancy
20% (consider administering methotrexate as well. trend beta HCG postop )
34
risk factors of ovarian torsion (5)
reproductive age
ovarian mass >5 cm
pregnancy
ovulation induction
prior torsion
35
A complication of laparoscopic myomectomy is hemorrhage with transfusion rate being ____%
28
36
Name 3 medications that can decrease risk of hemorrhage during myomectomy
misoprostol
vasopressin
GnRH agonist
37
Rate of hysterectomy due to hemorrhage during myomectomy is ___%
4%
38
running or interrupted sutures during a myomectomy have lower risk of developing adhesions
running
39
rate of ureter injury in pelvic surgery
0.3-1.5%
40
where is ureteral injury most likely to occur during gynecologic surgeries
vaginal cuff (71%)
pelvic brim (29%)
41
what are the medial and lateral borders of the paravesical space (avascular area where the ureter can be identified retroperitoneally)
medial border = ureter
lateral border = internal iliac artery
42
when is operative management recommended for endometrioma
enlarging
symptomatic
optimize fertility
43
recurrence rate after draining an endometrioma
80-100%
44
endometrial biopsy: specificity, sensitivity
specificity: 96-99%
sensitivity: 83%
45
what are the types of ablation (3)
radiofrequency electricity
freezing
heated fluid
46
Describe type 0, I and II fibroids
0: entirely within the endometrial cavity
I: <50% mymoetrial extension
II: >50% myometrial extension
47
ligation ureter injury management
deligation (remove the stitch)
assess viability
stent placement
48
angulation ureter injury managment
de-angulation
assess viability
stent placement
49
management of transection or resection of ureter :
upper and middle third of the ureter vs lower 3rd (within 5 cm of UVJ)
upper and middle third: ureteroureterostomy over stent (reconnect the ureter)
lower third: ureteroneocystostomy with psoas hitch over stent (divert the ureter to a stoma through the skin)
50
management of crush or ischemic injury of ureter :
upper and middle third of the ureter vs lower 3rd (within 5 cm of UVJ)
upper and middle third: ureteroureterostomy over stent (reconnect the ureter)
lower third: ureteroneocystostomy with psoas hitch over stent (divert the ureter to a stoma through the skin)
51
postoperative symptoms of unrecognized ureter injury (4)
unilateral cramping
flank pain
ileus
watery vaginal discharge
52
what findings are associated with unrecognized ureteral injury (4)
elevated creatinine
fever
ascites
retroperitoneal fluid collection
53
what imaging can diagnose unrecognized ureteral injury
renal ultrasound: can show hydronephrosis or hydroureter
CT abd and pelvis with IV contrast
(renal ultrasound is preferred in pts w elevated Cr, to avoid contrast)
54
Management of retroperitoneal vascular injury/expanding retroperitoneal hematoma
communicate surgical emergency
direct pressure
emergent vascular surgery consult
vertical midline laparotomy
MTP
55
Management of small bowel injury <2 mm vs 2 mm or greater
<2 mm: expectant
2 mm or greater: primary repair perpendicular to the axis of the bowel to prevent stricture
56
define AAST grade of bowel injuries grade I through V
I: contusion or hematoma, partial thickness laceration
II: small laceration < 50 % of the circumference
III: large laceration > 50 % of circumference
IV: transection
V: transection with tissue loss, devascularized segment
57
how are AAST grade I-V bowel injuries repaired
grade I - III: primary repair in 1 or 2 layers, transverse closure
grade IV and V: resection and reanastomosis
58
most common area of injury to the large bowel in laparoscopic surgery
rectosigmoid colon
59
how to assess for large bowel injury (3)
air bubble test, methylene blue enema, rigid sigmoidoscopy
60
how to assess for small bowel injury during laparoscopic surgery
running the bowel
61
If incidental cystotomy occurs due to _____ injury, edges of the cystotomy should be excised before repair
thermal
62
describe incidental cystotomy repair
two layer repair w absorbable suture
1st layer: bladder mucosa
2nd layer: imbrication of the bladder muscularis and serosa
backfill the bladder and maintain indwelling catheter
63
when is expectant management of cystotomy acceptable
bladder dome injury < 1 cm
64
what is the mechanism of gas embolism in laparoscopy
veress inserted into vein or parenchymal organ
65
what are signs of gas embolism during laparoscopy
decreased end tidal CO2 volume
hypotension
cyanosis
66
management of gas embolism during laparoscopy
discontinue insufflation
hyperventilation with 100% FiO2
Trendelenberg position to increase cerebral perfusion
67
subcutaneous or preperitoneal emphysema signs
skin crepitus
hypercarbia
cardiac arrhythmias
68
subcutaneous or preperitoneal emphysema management
increase ventilation rate
69
pneumomediastinum or pneumothorax mechanism in laparaoscopy
diaphragm defect
ascending preperitoneal gas
70
signs of pneumomediastinum or pneumothorax
emphysema in neck, face, or chest
cyanosis
increased airway pressure
71
treatment of pneumomediastinum or pneumothorax in laparoscopy
remain intubated until swelling decreases
if pneumothorax, administer 100% FiO2 and place chest tube
72
mechanism of hypoxia or hypercapnia during laparoscopy
aspiration or excessive CO2 absorption
73
signs of hypoxia or hypercapnia during laparoscopy
hypoxia
high airway pressure
gastric contents in esophagus
74
management of hypoxia or hypercapnia during laparoscopy
increased O2
bronchodilators
PEEP
decreased intra abdominal pressure
75
mechanism of vagal reaction during laparoscopy
vagal nerve irritation
76
signs of vagal reaction during laparoscopy
bradycardia
asystole
hypotension
77
management of vasal reaction during laparoscopy
deflate abdomen and administer anticholinergic agent
78
what is the mechanism of diminished cardiac preload during laparoscopy
significant compression of inferior vena cava
79
what are signs of diminished cardiac preload
bradycardia
asystole
hypotension
80
management of diminished cardiac preload during laparoscopy
left lateral tilt if due to mass effect
pneumoperitoneum < 15 mm Hg
81
initial management of asystole and bradycardia during laparoscopy
stop insufflation and deflate peritoneal cavity
stop medications contributing to myocardial depression
administer 100% oxygen
administer anticholinergic agent
assess for cause and take out of trandelenburg position if air embolism ruled out
chest compressions
82
what is the definition of massive transfusion and what products are administered in what ratio
10 units of blood products in a 24 hour period
1:1:1 of pRBC, FFP, PLT
83
when do intestinal thermal injuries present? ____ days postop
4-10
84
what imaging should be ordered when intestinal thermal injury is suspected
CT with IV and PO contrast
85
presentation of fistula after hysterectomy: ____ days postop
10-20 days
86
describe the dye test to diagnose fistula
administer phenazopyridine and back fill the bladder with methylene blue
blue tampon = vesicovaginal tampon
orange tampon= ureterovaginal fistula
87
how does testing the creatinine of vaginal fluid help determine if fistula is present
if creatinine > serum level (greater than 10) then likely urine
88
how are small fistulas treated nonsurgically
urinary diversion:
foley for vesicovaginal
ureteral stent for ureterovaginal fistula
89
When should fistulas after hysterectomy be repaired
if tissue healthy, can repair immediately within 48H
if delay diagnosis or inflammation, repair delayed 3-6 months
90
should fistulas be repaired transvaginal or transabdominal
transvaginal: lower portion of bladder
transabdominal: higher portion of bladder, multiple or ureteral repair
91
normal postop function returns to small bowel and stomach in _____ hours and large intestines in _____
8H
24-48H
92
ileus vs small bowel obstruction on abdominal XR
both will show intermittent air throughout GI tract and air fluid levels
small bowel obstruction will not show gas in colon
93
how long after hysterectomy does vaginal cuff dehiscence typically occur
6.1 w - 1.6 yrs
94
list in order the most to least incidence of cuff dehiscence: TAH, TLH, TVH
TLH > TVH > TAH
95
when can transvaginal repair of vaginal cuff dehiscence be completed
medically stability
no peritonitis
no bowel injury
96
how should vaginal cuff dehiscence be repaired in the case of prolapsed bowel with vascular compromise or traumatized bowel
laparotomy or laparoscopy
97
common cause of intraoperative femoral nerve injury
compression injury ie self retaining retractors, hyper flexion patient positioning
98
symptom of femoral nerve injury
hip flexion, knee extension, patellar reflex
sensory to anterior and medial thigh
99
ilioinguinal/iliohypogastric nerve injury most often occur how
entrapment or transection during lateral port placement or fascia closure (avoid this by placing above the ASIS
100
what is the sensory innervation of ilioinguinal/iliohypogastric nerve
sensation of inner thigh, labia majora, gluteal region, hypogastric region
101
common cause of injury of genitofemoral nerve
stretch or transection injury during pelvic sidewall or pelvic lymph n ode dissection
102
sensory innervation of genitofemoral nerve
mons pubis, labia majora, femoral triangle
103
common causes of injury to the obturator nerve
stretch, tansection, or entrapment during pelvic sidewall dissection
104
motor and sensory innervation of obturator nerve
hip adduction
sensory: upper medial thigh
105
common cause of sciatic nerve injury
stretch injury due to improper patient positioning
106
sciatic nerve innervation
hip extension, knee flexion
sensory: posterior thigh and leg
107
common cause of injury to common peroneal nerve
improper patient positioning
108
common cause of pudendal nerve injury
entrapment injury ie sacrospinous ligament fixation
109
innervation of common peroneal nerve
dorsiflexion (injury = footdrop)
sensory: lateral leg, dorsum foot
110
What is the initial evaluation for someone with suspected fluid overload for a patient following hysteroscopy
CMP/BMP
CXR
EKG
strict fluid balance measurements
multidisciplinary involvement
111
How is fluid overload managemed for pts with serum sodium > 120
fluid restriction
loop diuretic
112
how is fluid overload managemed for patients with sodium <120
3% hypertonic NaCl
serial metabolic profile
supplemental oxygen
foley
ICU/anesthesia management
113
what are the disadvantages of laparoscopy vs laparotomy
increased operative time
increased risk of ureter injury
increased risk of vaginal cuff dehiscence
114
list 4 ultrasound findings that are associated with malignancy when assessing an adnexal mass
size > 10 cm
irregular shape
free fluid or ascites
thick walled septations
115
adnexal masses in post menopausal patients ___ benign, ____ are malignant (fraction)
2/3 benign
1/3 malignant
116
how are adnexal masses managed based on sized (in the absence of symptoms, elevated tumor markers, or changes in size)
1-3 cm: no follow up
3-5 cm: repeat US in 3-6 mo
5-10 cm: surveillance or surgery
> 10 cm: surgery
117
when should a patient with adnexal mass be referred to gyn onc (4)
postmenopausal and CA 125 > 35
pre menopausal with CA 125 > 200
imaging concerning for malignancy
elevated risk assessment score
118
How should diabetic patient's metormin and insulin be managed peri-operatively
hold metformin and short acting insulin
administer 50% of long acting insulin
*also schedule as first start case
*goal blood sugars postop < 180
119
explain management of maintenance steroids, preoperative hydrocortisone, and postoperative hydrocortisone for patients with rheumatologic diseases in minor, moderate, and major surgeries
continue maintenance steroids in all surgeries
Major: preop: 100 mg IV. postop: 50 mg IV q8h for 24 hr then taper to maintenance
Moderate: preop: 50 mg IV. postop: 25 mg PO q8h for 24 hr then resume maintenance steroid
120
what are the borders of the paravesical space
lateral: medial umbilical ligament
medial: bladder
caudad: uterine artery
121
what are the borders of the retropubic space
(space of retzius)
anterior: pubic symphysis
lateral: pubic rami and obturator internus
posterior: bladder and endopelvic fascia
122
what are the borders of the presacral space
what lies within the space
lateral: common iliac vessels and ureters
anterior: rectum
posterior: sacrum
sacral artery and left common iliac vein
123
ureter travels on the medial leaf of broad ligament, passes within 1 cm lateral to ______ ligaments and then travels into cardinal ligaments _____the uterine vessels. _______ lateral to the cervix near internal os
1 cm lateral to uterosacral ligaments
under uterine vessels
1.5-2 cm lateral to cervix
124
Apical suspension with the ______ /______ ligament complex suspend upper vagina and uterus. Compromise leads to uterine or vaginal prolapse
uterosacral/cardinal ligament complex
125
lower pelvic support of the pelvic floor includes the ___ and ____ muscles. defects cause rectal prolapse and anal incontinence
perineal body
levator ani muscles
126
what provides lateral support to the pelvic floor. Compromise leads to anterior or posterior vaginal wall prolapse
arcus tendineus fascia pelvis
pubocervical and rectovaginal fascia
127
follicular cyst vs corpus luteal cyst
follicular cyst: thin walled, fluid filled. on US: unilocular, thin walled and anechoic
corpus luteal cyst: thick walled and yellow. On US: internal echos, central lucency and thickened walls
128
what is the risk of recurrence after aspiration of a functional cyst
30% risk of recurrence
129
what angle scope are best for visualizing the following:
urethra
posterior wall
anterior and lateral wall
urethra: 0 degree
posterior wall: 30
anterior and lateral: 70
130
define direct coupling vs capacitive coupling
direct: active electrode comes in contact w metal object
capacitive: currents affect non-targeted tissues
131
what phase of menstrual cycles offers the best visualization in hysteroscopy
early proliferative phase
132
_____ = voltage/resistance
current
133
_____ = voltage X current
power
134
bipolar and monopolar energy use constant polarity circuit or alternating polarity circuit
alternating polarity circuit (no net electron flow, just bidirectional electron movement back and forth)
135
describe monopolar vs bipolar in terms of active electrodes and grounding pads
mono: active electrode and a grounding pad (more dispersion through patient)
bipolar: active electrodes
136
cut or coag? :
low voltage waveform, continuous
cut
137
cut or coag? :
high voltage waveform, intermittent with gaps in flow
coag
138
cell vaporization occurs at how many degrees celcius
100
139
instant cell death ( desiccation, protein coagulation) occurs at what degree celsius
60-95
140
describe the technique to cause vaporization
cut and noncontact with tissue
141
describe the technique to cause fulguration
coag and non contact
142
describe technique to cause dessication
contact with the tissue and cut
143
When should desiccation (cut) vs fulguration (coag) be used for coagulation
dessication (cut) : larger vessels, deep hemostasis
fulguration (coag): small vessels ie oozing capillaries, superficial hemostasis
144
what is the lateral thermal spread for bipolar devices
1-3 mm
145
bipolar devices are approved to seal vessels up to ___ mm
7
146
radiofrequency electrosurgical injury typically presents ____ days postop
4 - 10
147
what is the most common iatrogenic nerve injury in gynecologic surgery
femoral nerve
148
lateral femoral cutaneous nerve innervation
proximal, lateral aspect of thigh
149
what nerves are at risk of injury from excessive hip flexion, abduction, and external rotatoin
femoral, lateral femoral cutaneous nerve, sciatic, obturator
150
what nerve is at risk of injury from direct pressure on lateral aspect of knee and prolonged knee flexion
common peroneal nerve
151
common peroneal nerve innervation
sensation to lateral and anterior aspect of leg, dorsiflexion
152
intraabdominal pressure : < _____ mm Hg
10
153
what is the most accurate test to tell you've successfully placed verress needle intraabdominally
pressure < 10 mm Hg
154
frequency of umbilical adhesions with the following prior surgeries:
-laparoscopy
-low transverse incision
-vertical midline incision
laparoscopy: 1.6%
low transverse incision: 19.8%
vertical midline incision: 51.7%
155
EMIGs
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