General points 3

Question 1

Main structural support to the uterus

Answer 1

Central perineal tendon

Question 2

Local anaesthetic toxicity treatment

Answer 2

Stop injecting the anaesthetic agent
High flow 100% oxygen via face mask
Cardiovascular monitoring
Administer lipid emulsion (Intralipid 20%) at 1.5ml/Kg over 1 minute as a bolus
Consider lipid emulsion infusion, at 0.25ml/ Kg/ minute
If toxicity due to prilocaine then administer methylene blue

Question 3

Lignocaine

Answer 3

3mg/kg

7mg/kg if with adrenaline

Question 4

Bupivicane

Answer 4

2mg/kg (with or without adrenaline)

Question 5

Prilocaine

Answer 5

6mg/kg

9mg/kg (with adrenaline)

Question 6

Milroy’s disease

Answer 6

Present from birth and is due to failure of the lymphatic vessels to develop

Question 7

Lymphoedema causes

Answer 7

Primary

• Congenital < 1 year: sporadic, Milroy’s disease
• Onset 1-35 years: sporadic, Meige’s disease
• > 35 years: Tarda

Secondary

• Bacterial/fungal/parasitic infection (filariasis)
• Lymphatic malignancy
• Radiotherapy to lymph nodes
• Surgical resection of lymph nodes
• DVT
• Thrombophlebitis

Question 8

Lymphoedema surgery

Answer 8

Indications for surgery

• Marked disability or deformity from limb swelling
• Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure
• Lymphocutaneous fistulae and megalymphatics

Procedures

• Homans operation -Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.
• Charles operation - All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.
• Lymphovenous anastamosis - Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.

Question 9

Immediate or urgent surgery in patients taking warfarin

Answer 9

1. Stop warfarin
2. Vitamin K (reversal within 4-24 hours)
   - IV takes 4-6h to work (at least 5mg)
   - Oral can take 24 hours to be clinically effective
3. Fresh frozen plasma
   Used less commonly now as 1st line warfarin reversal
   -30ml/kg-1
   -Need to give at least 1L fluid in 70kg person (therefore not appropriate in fluid overload)
   -Need blood group
   -Only use if human prothrombin complex is not available
4. Human Prothrombin Complex (reversal within 1 hour)
   - Bereplex 50 u/kg
   - Rapid action but factor 6 short half life, therefore give with vitamin K

Question 10

Diaphragm disease

Answer 10

Lumen of the small bowel is divided into short compartments by circular membranes of mucosa and sub-mucosa; these membranes have a pinhole lumen leading to frequent bouts of intestinal obstruction
Rare and associated with prolonged or long-term usage of NSAIDs
More common in the elderly
Treated by surgical resection as the condition typically results in SBO