Professional Documents
Culture Documents
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Exam tips
1. Answer what your are confident 1st, you can leave query question till
Post exam
you finish, dont leave any question without answering at the end of the
exam. Intend from now that you will help your
2.You should keep confident, smiling and calm colleagues who will apply for the next
3. Don't discuss questions between the 2 papers or read papers you have
studied a lot. exam
4. Answer the question as you answer for the 1st time don't be happy
that you solve it before. It is usually changed even with change in one
adverb gives another meaning.
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Disclosure
Legal requirements
• When the patient gives consent
• Sharing clinically relevant information with other • Notification of disease
staff to assist in the management of a patient.
– Statutory requirements:
• Disclosure without consent may be justified • HIV, gonorrhoea, syphilis, clostridium difficile
where failure to do so may expose the patient or
others to risk or death or serious harm (when a • Notification of deaths to the coroner
patient may be a victim of neglect or abuse) – Neonatal deaths including <24 weeks if signs
• Personal information may be disclosed in the of life, Post op deaths, unknown cause of
public interest death
• E.G. Where a disclosure may assist in the prevention • MBRRACE
or detection of a serious crime, abuse of children. – Continual audit of maternal deaths
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Caldicott Principles
Caldicott Guardian
• All NHS organisations and local authorities
which provide social services must have a
Caldicott Guardian
• A senior person should be nominated in each
NHS organisation, including the Department of
Health and associated agencies, to act as a
"guardian". The "guardian" should normally be
a senior health professional or be closely
supported by such a person.
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EMQ
Options
Patient Down syndrome with HMB affecting
A. non malficience
her quality of life accompanied by her
B.beneficience mother who agree to offer MIRENA to her
C. vieracy daughter .You discuss with patient about
D.paternalism MIRENA pros and cons.
E. autonomy
F.justice
G.others
• Which of the principles of the options best
describes the coming situation
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• B.beneficience
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SBA
• B
• D
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• b
• d
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• C
• E
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EMQ EMQ
• 2. Mrs DC is a 34 year old woman having an • 1. Mrs AB: G2 P1, previous C/S for FTP at 9cm. Booked with independent
elective C/S under spinal anaesthetic in her third midwife for home birth. Spontaneous labour at term. Good progress initially,
8cm 6 hours ago, after 4 hours midwife brought patient to labour ward. Pt
pregnancy. She had 2 previous sections and has declines ARM and EFM. Intermittent auscultation showed variable
an anterior placenta praevia. The baby is delivered decelerations. VE confirms still 8cm, the patient is adamant she doesn’t want
safely but the placenta is adherent and there is any intervention and declines C/S. [ G ]
considerable bleeding. She is uncomfortable so a • 2. Mrs DC is a 34 year old woman having an elective C/S under spinal
GA is done. Bleeding continues despite a anaesthetic in her third pregnancy. She had 2 previous sections and has an
hysterectomy and her Hb is 31g/l. She is a anterior placenta praevia. The baby is delivered safely but the placenta is
adherent and there is considerable bleeding. She is uncomfortable so a GA
Jehovah’s Witness and had signed an advance is done. Bleeding continues despite a hysterectomy and her Hb is 31g/l. She
directive stating no blood products. The situation is is a Jehovah’s Witness and had signed an advance directive stating no
becoming critical. [ ] blood products. The situation is becoming critical. [ G ]
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For each of the scenarios described choose the single most appropriate
statement concerning the obtaining of patient consent with respect to the
law in England. Each option may be used once, more than once, or not at • A couple are referred to the fertility service because the 24-
all. year-old male partner has developed testicular cancer that
A: Abandon operative procedure and reschedule
B: Defer the operative procedure will require orchidectomy followed by chemotherapy.
C: Fraser competence must be demonstrable before obtaining consent They wish to have his semen stored for artificial
D: Obtain legal advice on individuals who withhold consent for treatment
insemination of his wife if he were to become azoospermic
E: Obtain legal advice on interpretation on the Abortion Act 1967 in the future
F: Obtain legal advice on interpretation on the Human Fertilisation and Embryology
Act 1990 and the Code of Practice of Human Fertilisation and Embryology
Authority Act 2009
G: Obtain legal advice on interpretation on the Mental Capacity Act 2005
H: Parental consent must be obtained before proceeding
I: Paternal consent must be obtained before proceeding
J: Perform additional procedure without explicit consent to do so
K: Proceed without consent in order to save the fetus’ life
L: Proceed without consent in order to save the woman’s life written consent must be obtained.
M: Respect the rights of the putative father of the fetus to withhold consent
N: Respect the rights of the unborn fetus and proceed to delivery Royal College of Obstetricians and
O: Respect the rights of the woman to withhold consent for treatment Gynaecologists. Obtaining Valid Consent. Clinical
P: Specific consent is unnecessary Governance Advice 6. London: RCOG; 2015.
Q: Verbal consent alone is acceptable
R: Verbal consent8/30/17
with witness and case note documentation
ELBOHOTY 67 8/30/17 ELBOHOTY 68
S: Written consent must be obtained
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• A 13-year-old girl requires a hymenotomy to treat her • A 14-year-old girl attends the gynaecology clinic
cryptamenorrhoea requesting a termination of pregnancy. Her last period was
10 weeks ago. She does not want her parents to know
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Lead-in.
• A SpR1 has been asked to carry out an audit and 50 sets of
case-notes were given to him to go through them and extract
• Snowballing the necessary data on a Friday afternoon.
• He decided to take the notes home to extract the data.
• On the way home he stoped at his favourite supermarket.
• When he emergesd, his car has been stolen with the notes
inside.
• He reported the theft to the police.
•
S Tell all those who know about the incident to discuss it with no one else, particularly the patient
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• Question 2. • Question 3.
• What action will you take to deal with the • What action will you take in relation to the
SpR? patient whose notes are missing?
• The first thing is to establish the facts. It is an adverse event and could be
Question 1. serious, so it should go to the Risk Management team as an adverse event.
They will seek out the facts and do a root-cause analysis.
• It will probably turn out that the doctor did not know that there was a policy
• The SPR1 informs you (the Clinical Director), about not removing case-notes from the Trust.
on the Monday when he returns to work. • There is also the wider issue of education on the subject, which might be
appropriate for the induction process for new staff.
• What action will you take? • The notes may contain little information that would amount to a serious
breach of confidentiality – the patient might only have attended once and
• H. Report events to the Risk Management that to the A&E department with a minor injury. And absence of these notes
Team would have no adverse effect on any future treatment. But the opposite
could be true with the potential for leakage of highly confidential information.
• Important information may no be longer available if the woman needs
treatment - someone will have to use their imagination to find as much as
they can – e.g. from hospital computer records, GP records, lab or radiology
reports stored on departmental computers.
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A 19 year old woman is admitted to intensive care with a sever asthma attack after being
prescribed ulipristal acetate for emergency contraception. She was known to be a poorly
controlled asthmatic. The ST1 admits to you they didn’t check the contraindications for
this drug before prescribing it.
a) Arrange a tutorial for all the ST1s and ST2s a) Arrange a tutorial for all the ST1s and ST2s
b) Submit an incident report b) Submit an incident report
c) Debrief the ST1 with a written record
d) Inform the Royal College Tutor
c) Debrief the ST1 with a written record
e) Inform the Medical Director d) Inform the Royal College Tutor
e) Inform the Medical Director
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• Clinical effectiveness
• Information management
• Patient and public involvement
• Risk management
• Strategic8/30/17
leadership ELBOHOTY 105 8/30/17 ELBOHOTY 106
• Clinical audit
• Clinical effectiveness
• Guideline development
• Information management
• Risk management
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• The RCOG exam has two componenets written • The goal of formative assessment is to monitor
and OSCE, Which choice best describes each: student learning to provide ongoing feedback that can
be used by instructors to improve their teaching and
• by students to improve their learning. Summative
• Written OSCE assessment
• Formative Summative • The goal of summative assessment is to evaluate
student learning at the end of an instructional unit by
• Formative Formative comparing it against some standard or benchmark.
• Summative Formative
• Summative Summative
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• In your hospital it was decided to use FFN for all • When couple is married at the time of still
patients who present with risk of preterm labour. After birth of their child,legal duty of registration
6 months only you realized that the stock that was lies on whom
ordered has all finished. You want to know whether
you have underestimated the number of patients that • Mother
present to your hospital or what. What is your • Health care professional
management:
• Father
• -Clinical effectiveness
• Couple as a unit
• -Arrange meeting with unit managers –
• Run an audit • Anyone can register as per situation
• -Make a research
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• 119. DR looks in literature to see effect • The answer is: D. Systematic review
of MIRENA in HMB.
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• 120. DR conduct study among doctors • The answer is: B. Case control
to see effect of smoking and non
smoking in lung cancer.
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EMQ. Interpretation.
Which one of the following statements best
Options: describes a type I statistical (α error)?
A. Convincing evidence of benefit.
B. Convincing evidence of harm. A. Rejecting a null hypothesis when there is a
C. No benefit & no harm. difference
D. A trend for benefit with concern of harm.
E. Unethical study. Should be terminated. B. Rejecting a null hypothesis when there is no
F. Underpowered. Repeat study with n=10000.
G. Underpowered. Repeat study with n=20000. difference
H. Odds ratio can't be counted upon
I. Invalid results C. Rejecting the alternative hypothesis when there is
Lead in: A RCT study was carried to evaluate a new drug for the treatment of hypertension a difference
in pregnancy. 2 groups; study group of 1000 women on the new drug & a control group of
1000 women on methyl dopa. Both groups were matched for age & BMI. D. Accepting a null hypothesis when there is a
96. In a preliminary analysis in a 50 women in the study group, the BP of 23 women has
dropped but 13 of them developed drug induced hepatitis. difference
97. At final analysis, BP readings were not available for 40% of the control group & 25%
of the study group. Besides, despite being matched for age, the mean age for the 2
E.
B Accepting the alternative hypothesis when there is
groups came different [28 yrs for control & 34 for study group]. (P value was 0.01) a difference
H8/30/17 ELBOHOTY 133 8/30/17 ELBOHOTY 134
I
90. A study was carried out to compare between the outcome of breech [CS Vs
vaginal]. The women were randomized into planned CS arm & planned VD
arm.
analogue scale. What kind of data is this? Severe neonatal morbidity: 0.4%
*350 delivered by CS
Severe neonatal morbidity: 1.6% P= 0.002
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b
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Maternal
Mortality in the UK
2009-12
2006-08 2011-13 2012-14
1952-54
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• Maternal suicides have now been reclassified by the • The perinatal mortality rate 6 per 1,000 total births
– Unexplained
World Health Organisation as a direct cause of maternal
– Congenital malformation
death. The rate of maternal death by suicide remains – Prematurity
unchanged since 2003 and maternal suicides are now
• The extended perinatal mortality rate 7 per 1,000 total
the leading cause of direct maternal deaths occurring births
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within a year after the end of pregnancy.
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* maternal mortality
A.direct
B.indirect
C.coincidental
D.accidental
E.late
F.not maternal death
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Effects of
Surgery?
Surgical considerations
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Principles of closure
- closure of the fascia should be 1.5 cm
from the edge with the suture 1 cm
apart.
-interrupted sutures are considered with
evidence of infection
-Excessive tension on sutures leads to
tissue necrosis and eventual failure of
closure
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Needles
– Cutting
• Triangular tip with the apex forming a cutting
surface
• Used for tough tissue, such as skin (use of a
tapered needle with skin causes excess trauma
because of difficulty in penetration)
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Absorbable Nonabsorbabl
sutures e sutures
Natural Natural
Synthetic sutures Synthetic sutures
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Episiotomy Continous, Vicryl rapid No. 0 or 2-0; taper point needle, 35-mm
Anal mucosa Vicryl No. 3-0; Round-body taper-point needle, 26-mm
Continuous or interrupted PDS or Vicryl No. 2-0 or 3-0; Round-body taper-point needle, 26-mm
Anal sphincter
Uterine incision Continuous 2 layers; Vicryl No. 1; Round-body taper-point needle. 50-mm
• Transverse incision:
Vicryl or PDS No. 1 or 2; taper cut needle or reversed-cutting needle
Rectus sheath
• Longitudinal incision: (mass closure is recommended)
PDS or Prolene No. 1 or 2; taper cut needle or reversed-cutting needle
Peritoneum Recommended not to be closed (neither parietal or visceral)
B-Lynch haemostatic suture Monocryl No. 1; Round-body taper-point needle; size = 70 mm.
Urinary bladder repair Vicryl No. 2-0 or 3-0; Round-body taper-point needle
Ureteric repair Vicryl No. 3-0; Round-body taper-point needle
Small intestine repair Vicryl No. 3-0; Round-body taper-point needle
Prolene No. 2-0; reverse-cutting needle, or
Skin Closure
Vicryl rapid No. 2-0; reverse-cutting needle
8/30/17 ELBOHOTY 179 Uterosacral ligament 8/30/17 Vicryl No. 0 or 1 ELBOHOTY 180
Vaginal vault Vicryl No. 0 or 1 taper cut needle or reverse-cutting needle
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Properties of Electricity
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Alternate current
• Characterized high frequency (400 kHz to 3.3 Components of electrosurgery
MHz)
• At this frequency electrosurgical energy can • Current and voltage
pass through the patient with no risk of provided by generator
electrocution. • Circuit: passes
through patient
• Tissue provides
resistance and
produces heat
8/30/17 ELBOHOTY 185 8/30/17 ELBOHOTY 186
Types of electrosurgery
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Complication Cause
• Superficial burns from pooling of inflammable liquid, such as spirit-based skin
preparations.
• Wrongly placed patient plate electrode.
Burns
• Retained heat in the electrode touching skin.
• Poorly insulated diathermy lead.
• Inadvertent use.
Electrocution • Poorly insulated diathermy leads.
Diathermy in Gynaecology-
General Use
•Benign Cervical Lesions-
•CIN (LEETZ / LEEP)-
•Ovarian Drilling in PCOD-
•Endometriosis-
•Hysteroscopic surgery
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lithotomy
Surgical positions
Lithotomy position is defined as supine position of the body with the legs separated, flexed
and supported in raised stirrups.
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Trendelenburg (45 degree) Lloyd Davis (leg flexed 15 & head down 30)
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Laparoscopic entry
techniques
• The most effective way to, reduce complications of
laparoscopic entry is to optimise insertion of the
Intra umbilical
primary trocar and cannula.
entry Veress
needle (closed)
laparoscopic entry
• Alternative entry site (palmers point)
technique
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Verres needle
• It is used to inflate air to the peritoneal cavity
(pneumoperitoneum) through the umbilicus where there is the
thinnest abdominal wall.
• The Veress needle should be sharp, with a good and tested spring
action. A disposable needle is recommended, as it will fulfill these
criteria.
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Insuflator:
– Used to insufflate through the verres needle.
– Check gas entering at low pressure (<8mmHg)
– Set pressure cut off to at least 20-25mmHg
– Start at low flow (1L/min)
– After 0.5L flow rate can be increased
– An intra-abdominal pressure of 20–25 mmHg
should be used for gas insufflation before inserting
the primary trocar.
– The distension pressure should be reduced to 12–
15 mmHg once the insertion of the trocars is
complete and trendlenberg position is taken.
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Type 2 injury
Type 1 injury (low pressure
Alternative entry
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Wound closure:
qOnce the tip of the trocar has pierced Avoid hernia risk by closing rectus sheath:
the peritoneum it should be angled - Midline port sites > 10 mm
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serious complications
Major laparoscopic
q The overall risk of serious complications from diagnostic
laparoscopy, approximately 2-3 women in every 1 000: complications
– damage to bowel
– Bladder
– uterus
– major blood vessels
Urinary
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Bladder injury
Frequent risks • Prophylaxis
• The Royal College of Obstetricians and Gynaecologists advises
• are usually mild and self-limiting. that suprapubic insertion of the Veress needle should be
• Bruising avoided as it puts the dome of the bladder at risk of injury, and
carries a high failure rate.
• shoulder-tip pain • Similarly, insertion of secondary trocars should be performed
• wound gaping under direct view. Although not evidence-based, bladder
catheterisation prior to peritoneal insufflation and insertion of
• infection. trocars is recommended to avoid injury to a bladder distended
by urine.
• Insertion of an indwelling catheter in long procedures. Keeping
the bladder empty during surgery will protect it not only
because its decreased size will keep it out of the surgeon’s
8/30/17 ELBOHOTY 229
operating field,
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but also because an empty bladder cannot230
ELBOHOTY
be
penetrated as easily as a distended one.
Intraoperative recogenition
• an obvious cystotomy or visualisation of urine leakage.
• A suspicion of a not so obvious injury may be raised by noting
haematuria or a distended catheter bag because of gas leaking
• Most injuries occur during dissection of the bladder through the defect into the bag. Therefore, it is always worth
from the cervix and therefore the most common site is inspecting the catheter and its bag, near the end of a complex
in the midline, above the inter-ureteric bar. laparoscopic pelvic operation and before closure.
• Intraoperative cystoscopy and/or instillation of 200– 300 mls of
• Less often the bladder can be put at risk during coloured saline (such as methylene blue or indigo carmine) into the
insertion of the Veress needle or a trocar. bladder will identify the site and extent of the injury.
• laparoscopic-assisted vaginal hysterectomy (LAVH), • Care is advised when instillating coloured saline to look for an injury,
as this may not be seen leaking intra-abdominally in cases where the
appear to be associated with a higher frequency of
bladder injury opens to the retro-pubic space (space of Retzius)
bladder injury compared with others. • Such an injury may occur for example during a difficult suprapubic
trocar insertion (previous suprapubic incision) which is accomplished
by repeated attempts. In such a case, an initial unsuccessful attempt
to insert the trocar may injure the bladder dome in a retro-peritoneal
8/30/17 ELBOHOTY 231 8/30/17 ELBOHOTY 232
fashion.
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Postoperative
• suprapubic pain, haematuria, leakage of urine per vagina and oliguria.
• Most bladder injuries can be sutured in one or two layers using a 2-0 or 3-0
• Uroperitoneum can present with diffuse abdominal pain, distension and absorbable suture (such as polyglactin).
ileus. Characteristically, tenderness may be absent.The above symptoms
• A running non-locked repair with the sutures placed 0.5 to 1 cm apart and
and signs usually appear within the first 48 postoperative hours unless a
0.5 to 1 cm lateral to the cystotomy angles is suggested.
thermal injury has occurred.
• Alternatively, if extra-corporeal knotting is preferred, interrupted sutures can
• Thermal injuries may present after 10–14 days with uroperitoneum or
be used at 0.5 cm intervals, whereas a ‘figure of 8’ suture may be enough to
vesico-genital fistula.
close a small defect.
• Biochemistry investigations aid the diagnosis as serum creatinine levels will
• Injuries involving the trigone require additional attention. Repair should aim
be abnormally elevated due to reabsorption of urine creatinine through the
to avoid obstructing the ureters or the urethra. In such cases ureteral stents
peritoneal membrane.
must be inserted and the patency of the urethra and ureters confirmed
• A computed tomography (CT) scan with contrast may confirm the presence following repair.
of uroperitoneum and/or show direct evidence of an injury.
• A thermal injury to the bladder will require debridement before repair,
• Retrograde cystography will confirm the diagnosis and cystoscopy will whereas an injury that pierces the bladder through the space of Retzius
assess the injury and help decide whether conservative management is alone may be managed conservatively by an indwelling catheter for 2
appropriate, depending on the extent of the damage weeks.
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• laparoscopic procedures where a ureteric injury occurred in a • Ureteric stenting (including lighted stents) is useful
patient with severe endometriosis concluded that unconscious only in very select cases, where the pelvic anatomy is
acceleration of surgery, possibly caused by fatigue, contributed severely distorted and/or usual methods of ureter
to a judgement error that led to the injury. identification have failed
• the higher the body mass index the closer the ureter was found • adequate reflection of the bladder off the uterus and
to be to the cervix
the cervix during total laparoscopic hysterectomy will
move not only the bladder, but also the ureters away
from the uterine vessels and the cervix, thus reducing
the risk of injury.
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Types of uretric injuries • Only a third of such injuries are recognised intraoperatively therefore any
uncertainty about the integrity of the ureter should prompt intraoperative
investigation and involvement of a urologist.
• Angulation • Cystoscopy allows visualisation of the ureteric orifices and urine jets which
rules out obstruction, but does not exclude other types of injuries.
• Crush • Presence of blood or air suggests injury. Intravenous administration of indigo
carmine colours the urine blue within 5 to 10 minutes and will assist a
• Ligation cystoscopic assessment as well as potentially allow the surgeon to identify a
urine leak laparoscopically.
• Thermal • Stents inserted without resistance, under direct laparoscopic visualisation to
ensure they do not exit through a possible injury, can also rule out
• Laceration obstruction. Occasionally, insertion of a stent alone can be therapeutic if the
problem was angulation (kinking) of the ureter. Ureteroscopy may locate the
• Transection The most commonly reported approximate height and extent of injury.
• Resection
• Flank pain and flank tenderness, • thermal injury to the ureter may result to delayed necrosis
and/or fistula formation that will often present clinically between
haematuria, oliguria or watery vaginal loss 10 and 14 days postoperatively.
may be present within the first 48 hours of • Ultrasound and/or CT scans can evaluate hydronephrosis,
an acute injury. urinomas and abscesses, whereas a CT intravenous urogram
(CT IVU) will locate the injury.
• Uroperitoneum will present clinically with • The consequences of an unrecognised injury can vary from
the often misleading features discussed spontaneous healing to fistula and/or stricture formation with
above.. associated deterioration of the function of the affected kidney.
This may occasionally require nephrectomy.
• A urinoma may develop • Up to 25% of unrecognised ureteral injuries result in eventual
loss of the ipsilateral kidney.
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PRINCIPLES OF REPAIR
• 2-0 or 3-0 absorbable suture-polyglactin(vicryl)
• Thermal injury requires debridement
• Adequate but careful debridement to avoid shortening the ureter
(debridement may be needed to enable the use of the healthy ureter for re-
• Upper third-uretero ureterostomy,
anastomosis) • middle third-uretero urertosotomy or trans
• Adequate but careful dissection to avoid devascularisation
(dissection/mobilisation may be needed to lengthen the ureter for uretero uretrostomy
anastomosis)
• Anastomosis must be:
• Lower third-ureteroneocystomy with psoas
•
•
water-tight
tension-free
or boaris flap
•
• spatulated or fish-mouth
Anaesthetic problems
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Hysteroscopy
• Clinical negligence claims related to hysteroscopic procedures include
– complications related to uterine perforation
Injuries
– subsequent internal organ injury.
• The failure to recognise the complication is the commonest cause of
litigation.
• When there has been internal organ damage, such as bowel, patients may
remain asymptomatic for 2–10 days before the nature of the injury, often
thermal, becomes apparent.
• Factors that increase the risk of perforation include cervical stenosis, acute
anteversion or retroversion, lower-segment fibroids or intrauterine synechiae
and operator inexperience.
• Uterine injury without the use of an electrical source can usually be
managed by observation of signs of vaginal or intraperitoneal bleeding.
However, where an electrical source has been used, laparoscopy is advised
to rule out bowel injury.
• Fatal complications to which the clinician should be alert during
hysteroscopy include: fluid overload causing hyponatraemia and
subsequent respiratory arrest and seizures, air embolism leading to
collapse and death..
Bladder injury
• Most injuries occur from dissection of bladder
from cervix....mc site is midline..above
interuretric ridge
• Half bladder injuries remain unrecog intraop
• Uroperitoneum presents with abd distn, pain,
ileus but tenderness is ABSENT...usually
presents within 48 hrs after injury
• Thermal injuries present 10-14 days later
• Serum 8/30/17
creatinine raised
ELBOHOTY
as absorbed thru 251 8/30/17 ELBOHOTY 252
peritoneum
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hysteroscopy Prerequisites
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Vaginoscopy versus
conventional hysteroscopy
• Vaginoscopy reduces pain during
diagnostic rigid outpatient
hysteroscopy.
Types • Vaginoscopy should be the standard
technique for outpatient hysteroscopy
Preparation
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Medium Media
Advantagesused in hysteroscopy
Disadvantages
CO2 • Well-tolerated, convenient and
easy to use
• Most serious disadvantage is
that of gas embolism
Hysteroscopic sterilisation
• Visibility can be distorted in the
presence of bleeding The procedure involves placing a micro-insert, consisting of a
Shoulder tip pain
•
stainless steel inner coil with polyester fibres and a super-
Normal
saline
•
•
Low cost and readily available
Reduce vasovagal episodes
Improved image quality and allows
outpatient diagnostic hysteroscopy
elastic nitinol outer anchoring coil, into the intramyometrial
• Also used for operative to be completed more quickly portion of each fallopian tube
hysteroscopy in bipolar compared especially in the
electrosurgical operative presence of bleeding
hysteroscopy (e.g. Versapoint)
1.5% • Electrolyte-free and non- • Excessive absorption causes
glycine conductive hyponatremia.
• Used in monopolar • Severe overload can lead to
electrosurgical operative haemolysis, coma and death
hysteroscopy
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Feasability
• Successful bilateral placement of the Essure"
device is possible in 81–99% of cases.
• The average time taken toinsert the device in
both fallopian tubes varied from 10.0 to 13.8
minutes.
• Sterilisation was shown to be 99.83% effective
based on a 5-year clinical study.
• The newly released long- term follow-up of a
phase III study observed no pregnancy
8/30/17 ELBOHOTY 277 8/30/17 ELBOHOTY 278
following hysteroscopic sterilisation
•
Causes of faliure
• Non-compliance
• Misinterpretation of the hysterosalpingogram
• Luteal phase pregnancy
• Failure to use contraception
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• Chronic pelvic pain: 2.1–24% Device removal has to be considered where the pain does not
resolve with conservative measures of pain management. Women should be reassured initially and managed
conservatively as the pain will resolve in 50% of cases in 3 months.40 Where the device cannot be visualised
or removed by hysteroscopy, such cases need to be dealt with by laparoscope with or without intraoperative
fluoroscopy to identify the device. Salpingectomy was the most commonly performed technique for device
8/30/17 ELBOHOTY 281 8/30/17 ELBOHOTY 282
removal.
• 5–12% of women were noted to have heavy bleeding during the 5-year follow-up period.
Radiological follow-up
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72
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Complications
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presentation management
• Where excessive systemic absorption of fluid distension media
is suspected, strict fluid balance monitoring should be
• Surgeons should be cognisant of commenced, a urinary catheter inserted and serum electrolytes
cardiovascular and neurological symptoms measured. If the patient develops signs of cardiac failure or
associated with systemic absorption of pulmonary oedema a cardiac echocardiogram and chest X-ray
should be undertaken. [GPP]
fluid distension media complications to
• Asymptomatic hypervolemia with or without hyponatraemia
allow timely recognition and treatment. should be managed by fluid restriction with or without diuretics.
[GPP]
The management of symptomatic hypervolemic hyponatraemia
• requires multidisciplinary involvement including anaesthetists,
physicians and intensivists in a high dependency or intensive
care unit. Initial treatment with 3 % hypertonic sodium chloride
8/30/17 ELBOHOTY 295 infusion 8/30/17 ELBOHOTY 296
74
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Gas embolism
75
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76
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Cystoscopy
Indications
• visible and unexplained haematuria, either without urinary tract infection
(UTI) or that persists after successful treatment of UTI in people aged 45
years and over
• visible and unexplained haematuria with a raised white cell count on blood
test in people aged 60 years and over • The only true contraindication to
• dysuria with unexplained, non-visible haematuria in people aged 60 years cystoscopy is an untreated UTI, outlined in
and over
• recurrent UTI
the British Association of Urological
• bladder pain syndrome Surgeons (BAUS) guidelines
• voiding symptoms
• vesicovaginal or colovesical fistulae
• urethral stricture
• congenital genital tract anomalies.
• Cystoscopy is part of some operations, such as: mid-urethral slings and
colposuspension intravesical botox injections
staging of gynaecological cancers.
8/30/17 ELBOHOTY 307 8/30/17 ELBOHOTY 308
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Risks
• Common risks (greater than 1 in 10)
– mild burning or bleeding on passing urine for a short period after the
operation
– biopsy of abnormal areas in bladder
• Occasional risks (between 1 in 10 and 1 in 50)
– infection of the bladder requiring antibiotics Rare (less than 1
in 50)
– temporary insertion of a catheter
– delayed bleeding requiring removal of clots or further
surgery
• – injury to the urethra causing delayed scar formation
• very rarely,
– perforation of the bladder requiring a temporary catheter or open surgical
repair
8/30/17 ELBOHOTY 309 8/30/17 ELBOHOTY 310
78
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Genital trauma
Uterine perforation
Technique and suture
Site of injury Technique Suture Needle
79
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Incidence
80
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81
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Prevention Prevention
• Risk assessment
• Adequate preparation • Bi-manual examination correctly identifying
– Prostaglandins or misoprostol in premenopausal uterine size, position & attitude
women
– No benefit in postmenopausal
• Gradual cervical dilatation by ½ size dilators
• Option of medical TOP would reduce risk of • Experienced operator
perforation particularly in the 2nd trimester • Ultrasound guidance in experienced hands
• Accurate estimation of gestational age
• Correct equipment • Laparoscopic guidance (if an abdominal
– Use of tapered Hawkins-Ambler dilators require procedure is done at same time)
less force then the parallel-sided Hegar dilators that
are in common use in NHS units in UK
8/30/17 ELBOHOTY 327 8/30/17 ELBOHOTY 328
82
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83
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31. A postop MEOWS chart was given: 65 yrs, known type 2 diabetic on metformin,
PH of DVT. Undergone TAH + BSO for endometrial cancer at 12:00. You were
called at 17:00 as the nurse was concerned about her chart & the patient is
complaining of lower abdominal pain & breathlessness.
At 17:00 exact the vitals were: BP 110/70 [It was 90/60 at 16 ], T 37°C, pulse rate • e
110 beat/ minute, RR 20/ minute, O2 sat 100%, pain score 5, fully alert. Her
postop Hb is 104%.
What is the most likely underlying problem?
A. PE.
B. Pelvic sepsis.
C. DKA.
D. Opiate overdose.
E. Internal bleeding.
84
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33. What is the commonest vascular injury during "umbilical" primary trocar insertion?
A. Suprarenal aorta.
B. Inferior vena cava.
C. Inferior epigastric.
D. Left Common iliac artery
E. Internal ileac. • d
85
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• 34. A scenario of TAH for a large fibroid which was found in the broad ligament but they
asked: from the following, what best describes the course of the ureter?
–A. The ovarian vessels course posterior to the ureter.
• e
–B. The ureter courses above the uterine artery.
–C. 1/3PrdP of the ureter is in the abdomen.
–D. The ureter courses medial to the bifurcation of the common ileac.
–E. The ureter courses medial to the internal ileac.
86
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87
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A patient is seen on the second post operative day after a difficult abdominal hysterectomy
complicated by haemorrhage from the left uterine artery pedicle. Multiple sutures were
placed into this area to control bleeding. The patient now has fever, left back pain, left Single Best Answer
costovertebral angle tenderness and haematuria. An ultrasound examination shows that
fluid has accumulated in the left flank. A ureteral injury is diagnosed. Options:
If the injury had been recognized at the time of surgery, which of the following procedures
could have been recommended?
Options:
a) Percutaneous nephrosto9my
b) Placement of ureteral stent without anastomosis
a) Percutaneous nephrosto9my
b) Placement of ureteral stent without anastomosis c) Intraperitoneal drainage without anastomosis
c) Intraperitoneal drainage without anastomosis
d) Uretero-ureteral anastomosis
d) Uretero-ureteral anastomosis
e) Ureteral reimplantation into the bladder e) Ureteral reimplantation into the bladder
88
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A. Abandon procedure & plan future The surgeon has opened the young girl as
management acute appendicitis. The signed consent
B. Abandon procedure included laparoscopy + removal of the
C. B. Proceed as planned/consented for appendix ± laparotomy. The appendix was
C. Ask a collegue found normal but there was an uncomplicated
D. Meet with next of kin 3 cm cyst [y] on the Rt. ovary [x]. The surgeon
E. Remove X & Y decided to leave the appendix & called you for
F. Remove Y from X the cyst.
G. Take biopsy from Y & close
H. Remove
8/30/17 Y. ELBOHOTY 353 8/30/17 ELBOHOTY 354
I. Other options
89
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*Vascular injury
• Inferior epigastric artery is a branch of: A. Superior gluteal
• A. Ext. iliac
B. inferior gluteal
• B. Int. iliac
• C. Femoral
C. ovarian
• D. Int. thoracic D. uterine
• E. Popliteal E.internal pudendal
F. internal iliac
8/30/17 ELBOHOTY 357 8/30/17 ELBOHOTY 358
90
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91
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92
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93
8/30/17
94
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95
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• Patient with history of subfertility and PID • The answer is: A. acute appendicitis
present with Rt iliac fossa pain nausea and
vomiting .leucocytosis 19.000 CRP 20 US non
compressible mass 5cm in length and 10 mm
in diameter what is the diagnosis:
• A. Acute appendicitis
• B. Fallopian tube infection
• C. Pelvic abscess
• D. Ectopic pregnancy
•
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EMQ Options
• Azithromycin
• Cefazolin .
• Amoxaciline + clavuronic acid
• Ceftriaxone i/m then doxy & metro
• Clinda + metro.
• Ofloxacin + metro
• Cefazoline + gentamicin
• only one option of flucloxacillin [& it was i/v, qds]
• Many other options including benzyl penicillin,…..
8/30/17 ELBOHOTY 385
• No need
8/30/17
for Antibiotic
ELBOHOTY 386
1. A 55 year old woman is planned for TAH. She has A Coated vicryl ® Braided polyglactin Half circle, roundbodied 3-0
C
Coated vicryl ®
Coated vicryl ®
Braided polyglactin
Braided polyglactin
J needle, roundbodied, heavy
2. A 44 year old woman is planned for VH and is D Dermabond ® Topical skin adhesive None
breast with fever and examination revealed that K Prolene® Monofilament: polypropylene Curved double 6-0
5. Young, non pregnant, diagnosed with acute PID. N Steristrips ® Skin adhesive strips None
She is8/30/17
allergic to penicillin.
ELBOHOTY 387
O VIcrylRapide®
8/30/17
Braided polyglactin
ELBOHOTY
Tapercut, halfcircle 2-0
388
97
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1. After encountering a 3rd degree perineal tear, you identified both IAS & EAS,
you are about to suture them using overlap method.
2. You are about to close the sheath for a 72 years old woman after the oncology
consultant have finished the staging laparotomy for an advanced ovatrian
tumour . It was midline laparotomy and you intend to do mass closure of – EMQ. The most likely postop complication.
anterior Abdominal wall
–Options:
3. You are about to suture the episiotomy skin.
–A. Acute urine retention.
–B. Intraabdominal hemorrhage.
–C. Bladder injury.
–D. Ureteric injury.
–E. Bowel injury.
–F. ? Many others
–
8/30/17 ELBOHOTY 389 – 44. 8/30/17 ELBOHOTY 390
46. A woman was found to have a large fibroid. US showed a larg fibroid in the
upper part of the uterus. The cavity was distorted & not fully seen. The
woman opted for UAE.
47. During surgery for a large fibroid, a biopsy was taken from a degenerative part
8/30/17 ELBOHOTY 391 & showed8/30/17
deeply infiltrating leiomayosarcoma.
ELBOHOTY 392
98
8/30/17
99
8/30/17
What is the main advantage of robotic surgery over laparoscopic • The answer is better precision and
surgery? microsurgical dissection. Compared with
conventional laparoscopy, the robotic
system downscales movements to up to
Better precision and microsurgical dissection 10 times, which provides tremor filtration
Decreased hospital stay and allows for precise movements. A
stable camera with 3D vision further
Improved cosmesis assists such precision and microsurgical
dissection.
Less pain after surgery
• Nair R, Killicoat K, Ind TEJ. Robotic
Quicker recovery for the patient surgery in gynaecology. The Obstetrician
& Gynaecologist2016;18:223–31.
8/30/17 ELBOHOTY 399 8/30/17 ELBOHOTY 400
100
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101
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A 30-year-old woman presents 7 days after an emergency caesarean • POVT presents with abdominal pain, pyrexia,
section with abdominal pain and a fever of 37.7°C . This isassociated nausea, vomiting, malaise and ileus with the fever
with nausea, vomiting and mild abdominal distension. She is started persisting despite antibiotics. On deep palpation
on antibiotics and sent home but 3 days later she re-presents with there is typically a mass in the adnexa that
no improvements in her symptoms and features of paralytic ileus.
represents the thrombosed vein surrounded by an
She is examined and found to have a tube-like mass in her abdomen
on deep palpation. A request is made for an ultrasound scan of the inflammatory mass – this is found in approximately
abdomen and pelvis. What is the most likely cause of this woman's 50% of cases. Most cases present within 10 days
symptoms? postnatally and the palpated mass is typically
tube-like. Differential diagnoses include
Infected haematoma
appendicitis, peritonitis, adnexal torsion, tubo-
ovarian disease, infected haematoma and
Postpartum ovarian vein thrombosis (POVT) pyelonephritis.
Pyelonephritis • Dougan C, Phillips R, Harley I, Benson G,
Torted ovarian cyst Anbazhagan A. Postpartum ovarian vein
thrombosis. The Obstetrician & Gynaecologist
Tubo-ovarian abscess 2016; DOI: 10.1111/tog.12295
8/30/17 ELBOHOTY 405 8/30/17 ELBOHOTY 406
A 26-year-old woman was seen 7 days after a ventouse delivery for • The recommended management of POVT is a
maternal exhaustion in the second stage with a fever, nausea,
vomiting and abdominal pain. When examined she had a
combination of intravenous antibiotics and
temperature of 38°C, mild abdominal distension, an abdominal mass heparin. The antibiotics should be administered for
on deep palpation on the right adnexum and absent bowel sounds. 7−10 days and the recommendation is to continue
An ultrasound scan of the abdomen and pelvis showed features
consistent with an ovarian vein thrombosis. What treatment should with this until 48 hours after leukocytosis has
this patient be offered? resolved. A combination of piperacillin/tazobactam
or carbapenem plus clindamycin provides a broad
Intravenous antibiotics for 7Þ10 days and fully anticoagulated with
fragmin or unfractionated heparin and then continue with warfarin for 3Þ6
coverage in cases of suspected sepsis. The
months recommended anticoagulation should follow the
Intravenous antibiotics for 7Þ10 days and intravenous heparin standards in haematology as recommended,
followed by warfarin for 3Þ6 months which is 3−6 months.
Intravenous heparin followed by warfarin for 3Þ6 months
• Dougan C, Phillips R, Harley I, Benson G,
Intravenous heparin for 3Þ6 months Anbazhagan A. Postpartum ovarian vein
Intravenous heparin for 4Þ5 days followed by subcutaneous heparin thrombosis. The Obstetrician & Gynaecologist
for 3Þ6 months
2016; DOI: 10.1111/tog.12295.
8/30/17 ELBOHOTY 407 8/30/17 ELBOHOTY 408
102
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103
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104