Preoperative medications
How should you counsel a preoperative patient using NSAIDs?
Stop 7 days prior to surgery
Name 2 risks of opioid use
Postoperative nausea and vomiting
Impairement in bowel function
Delayed mobilization
Increased pulmonary morbidity
What is the origin of the inferior epigastric artery?
External Iliac artery
An immediate postoperative patient goes to the pacu after laparoscopic cystectomy. Intraoperatively surgeon used one port at the umbilicus and two in the lower quadrants. Procedure was uncomplicated. You are called to the bedside to evaluate the patient due to worsening pain and mild hypotension. On examination you find an expanding hematoma at the lower quadrant port lateral to the rectus sheath with bleeding through her lateral port dressing? What is the diagnosis and what is your management?
Diagnosis: Inferior Epigastric Artery Injury
Management: unstable--> back to the OR for open surgical repair
During laparoscopic entry at the umbilicus, for class 3 obese patient what angle should entry performed?
90 degrees
How should you counsel a preoperative patient using statins?
What is the concern about utilization or lack of utilization perioperatively?
Continue in the perioperative period.
This medication decreases the risk of cardiac morbidity.
What is the antibiotic and dose for a patient who is undergoing a vaginal sling placement for stress urinary incontinence who weighs 115 kg?
2g Cefazolin
What is the blood supply to the bladder?
Internal illiac artery (superior vesicle artery)
On veress entry for a laparoscopic salpingectomy you perform your water drop test and aspirate blood, you remove your syringe and blood vigorously flows out of the veress and the patient becomes severely hypotensive what is your next step?
1. Leave the veress in
2. Notify anesthesia and OR staff
3. Call for blood (can consider massive transfusion)
4. Consult vascular surgery
5. Perform exploratory laparotomy
During laparoscopic surgery when placing a suprapubic port what should be in the patient prior to placing the port?
Bladder decompression with foley catheter
How should you counsel a preoperative patient using Metformin?
Hold Metformin the morning for surgery
A 75 year old female with obesity and history of pulmonary embolism undergoing laparoscopic hysterectomy presents for preoperative visit. She is not currently on chronic anticoagulation. Her caprini score is 9. What are her risks factors for VTE after surgery and what do you recommend to prevent VTE in the perioperative period?
Risk factors:
- age 75 (3+ points)
- obesity (BMI > 25 is 1+ points)
- pulmonary embolism (3+ points)
- surgery > 45 minutes ( 2+ points)
Recommend pneumatic compression devices and low dose heparin or LMWH at time of surgery with 30 day postop duration for chemoprophylaxis
What are the four areas that the ureter can be injured in gynecologic surgery?
1. Infundibulopelvic ligament
2. Uterine arteries
3. Uterosacral ligament
4. Vaginal cuff closure
While performing an excision of endometriosis an accidental enterotomy is made with the monopolar scissors. What antibiotics should you give for repair?
Metronidazole 500mg IV
True or false can you transiluminate the inferior epigastric vessels?
False you can only illuminate superficial vessels
How should you counsel a preoperative patient using ACE Inhibitors and Angiotensin II receptor blockers?
What is the concern with utilization or lack of utilization of this medication in the perioperative period?
Individualized decision to continue or discontinue, although usually held morning of surgery. Usually continued if utilized for HF or poorly controlled hypertension.
Restart within 48 hours of surgery
Perioperative hypotension
What is the usual threshold for postponing elective surgical intervention due to anemia?
Name 2 risks of undergoing surgery while anemic?
10
Increase morbidity and mortality
Higher blood transfusion rate
Increased risk of infection
Slower wound healing
Prolonged hospitalization
What is the length of the ureter
Name the parts?
Which part is more likely injured in gynecologic surgery?
25 cm
Proximal (abdominal/upper ureter)
Distal ureter (pelvic/lower ureter)
Intramural ureter
During laparoscopic hysterectomy a 5 mm port is placed into the bladder how do you manage this?
Small direct trocar injury < 10 mm in the dome of the bladder --> bladder decompression for 7-10 days.
What size port should you close the fascia with and describe how you would close the fascia?
10 mm port or greater.
Can closure with carter thompson device, market closure devices or in an open fashion.
How should you counsel a preoperative patient utilizing Metoprolol?
What class of medication is this
What is the concern with utilization or lack of utilization of this medication in the perioperative period?
Continue during the perioperative period and throughout hospital stay
Beta blocker
In patient with cardiac disease, beta blockers have been reported to reduce cardiac morbidity and MI in the postoperative period
What is the threshold for postponing elective surgical intervention for Diabetes?
Name 2 risks of diabetics undergoing surgical intervention?
A1c approximately 8%
Infection
Delayed wound healing
Higher risk of MI
Acute kidney failure
Increased 30 day mortality
What is the blood supply origin of the distal ureter?
Internal illiac artery branches (superior and inferior vesicle artery)
What is the difference between a boari flap verus a posas hitch?
Usually either is used when too much tension on repair.
Psoas hitch: usually during a lower ureteral injury repair the bladder is mobilized and anchored to the psoas tendon
Boari flap: usually during middle ureteral injury repair the bladder is tubularized in order for the distal ureter to be implanted into the bladder
During hysterectomy name 2 ways to avoid injury to the ureter?
Utilizing a uterine manipulator
Identification of ureter