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Gynae Pre-Op Care, Procedures and Operations - Coggle Diagram

- - - - Oral anti-hyperglycaemic agents
      - Insulin
    - - Fasting - operation timing
      - Enhanced recover with good glycaemic control
      - Glycaemic control must be taken into account perioperatively
  - - - Stress dose for pts on long term steroid therapy for difficiancy
  - - - Consider discontinuing VTE risk
  - - - Antiplatelets
      - Anticoagulants
    - - Bleeding risk
    - - Aspirin Monotherapy
        
        Can be continued safely for gynae procedures
      - DAPT - Aspirin and clopidogrel
        
        When possibel postphone surgery for more than 6 months
        
        If delay not possible discuss with Haem
      - Clopidogrel
        
        Hold for 5-7days - no antidote
- - - - Minor procedure
        
        None
      - Intermediate
        
        ECG if CVD / DM / Renal
        Renal profile if risk of AKI
      - Major
        
        FBC
        Renal profile
        Liver profiel
        ECG if >65 or risk factors
    - - Minor
        
        ECG if GA
        Renal profile if AKI risk
      - Intermediate
        
        FBC
        Coag
        Renal
        Liver
        ECG / ECHO
        Lung fx test if relevant
      - Major
        
        FBC
        Coag
        Renal
        Liver
        ECG / ECHO / Lung fx if relevant
- - - - Infx
      - Failure
        
        Failure of contraception
        
        Failure of insersion
        
        Expulsion
      - Local structures
        
        Uterine perforation
      - Irregular bleeding
      - Pelvic pain
      - Higher rate of ectopic if conception does not occure
  - - - Assess normality of pelvis
      - Size, shape, position, mobility of uterus
    - - Speculum
      - Sponge forceps
      - Gauze
      - Antiseptic solution
      - Vulsellum / Tenaculum
      - LA - consider
      - Dental needle / Syringe or Instillagel
      - Uterine sound (for sizing)
      - Mirena coil
      - Scissors
    - - https://www.youtube.com/watch?v=aVZoH0Pda-4
  - - - Pain varies greatly
      - Many have non
        Strong period like cramps for 102 days
      - Use simple analgesia
    - - Copper coil (IUD) is Effective immediately
      - LNG-IUS i fittest of first day of cycle is effective immediately
        At any other time advise use of contraceptive method for 7days
    - - May occur following insertion
      - May be spotting
      - Copper IUD my increase flow and length
      - LNG-IUS not unsual to have irregular and unpredictable bleeding for first 3-6 months
        Rarely heavy, settles with time
        May have light / infrequent periods / no period after
    - - Check 6 weeks after insertion
      - Monthly checks after 1st period finishes
    - - Could be risk of pregnancy if:
        
        Unusual cramps
        
        Cannot find threads
        
        Threads feel unusually long
      - Use contraception and have a check-up
    - - Symptoms
        
        Persistent / worsening lower abdominal pain
        
        Abnormal vaginal discharge
        
        Fever
        
        Feeling unwell
        
        Pain during sex
    - - Seek review if period missed with copper coil - may be pregnant
- - - - Pain
      - Subfertility
      - Pregnancy of unknown location - ectopic
    - - Ovarian cystectomy
      - Oophorectomy
      - Torsion
      - Tubal ligation
      - Salpingectomy
      - Ectopic pregnancy
      - Patency
      - Hysterectomy
  - - - Method
        
        Umbilical / infra-umbilican incision
        
        Identify base of umbilical ligament
        
        Incise base of umbilical ligament - - opening to peritoneal cavity
        
        Insert balloon port - inflate balloon to secure port in site incision
    - - Minimising Entry Related Risks
        
        Sharp needle, disposable with good tested spring action
        
        Horizontal operating tbale
        
        Palpate for masses/ aorta / aneurysyms
        
        1cm incision in skin in umbilicus
        
        Stabilise abdominal wall, insert veress at right agles to the skin
        
        Two audible clicks as layers penetrated - then STOP
        
        Avoid excessive lateral movement - needle injury of bowel / vessels
        
        Test correct placement - low opening Co2 insufflation pressures (<8mmHg)
        
        Inset primary trocar at 90 degrees to skin through thinnest part of abdominal wall
        
        Stop insertion immediately when inside peritoneal cavity
        
        360 sweep of abdomen
        
        Pick site of secondary trocars under direct vision avoiding inferior epigastric, bowel adherences, masses
        
        Remove porst under direct vision, reducing pressure to assess for bleeding
      - Insufflation Pressure
        
        Insertion of primary trocar
        
        20-35mmHg
        
        Benefits of this pressure
        
        Increased adbominal distension increases depth
        
        Completion of trocars insertion
        
        12-15mmHg
        
        Benefits
        
        Reduced splinting - bleeding noted intraoperatively
        
        Appropraite for anaethetist - pressure on the diaphragm
    - - No statistical difference in risk
      - Know both - do what you know - tailor to pt risks
      - Consider - virtually no major vessel injuries with Hasson
- - - - Larger massess
      - Pt GA risk factors
      - Malignancies
    - - Laparoscopic / robotic
      - Enhanced recovery / malignancies
    - - Prolapse
      - Pt GA risk factors - Spinal anaethetic can be used
  - - - Overall risk of serious complications is 4/100
      - Damage to bladder / ureter and / or disturbance to bladder function 7/1000 - uncommon
      - Damage to bowel 4/10,000
      - Haemorrhage requiring transfusion 23/1000 - common
      - Return to theatre bc bleeding / wound dehiscence etc 7/1000 - uncommon
      - Pelvic abcess / infection 2/1000 - uncommon
      - VTE / PE 4/1000 - uncommon
      - Death within 6 weeks 32/100,000 - rare
    - - Bladder / ureter damage
      - Bowel damage
      - Haemorrage requiring transfusion
      - Pelvic abcess / infx
      - VTE / PE
      - Death
    - - Wound infection, pain, bruising
      - Delayed wound healing or keloid formation
      - Numbness, tingling, burning sensation around sca
      - Frequency of micturition
      - UTI
      - Ovarian failure
    - - Blood transfusion
      - Repair to bladder, bowel, major blood vessel
      - Oophorectomy for unsuspected disease
  - - - Cervix grasped and circumferential incision made
        
        Bladder reflected off uterus anteriorly and Peritoneal space entered and
        
        Posteriorly rectovaginal space / POD opened
        
        Uterosacral / Cardinals Uterine Artery/Vein Broad L. /Ovarian L. / Round Ligaments
        
        Vaginal mucosa closure
      - Ovaries and tubes may or may not be
        removed at vaginal hysterectomy
        – do not assume they haif a woman has had a vaginal hysterectomyve been removed
        ( or indeed any hysterectomy!)
    - - Serious Risks
        
        Bladder / UT damage : 2/1000 - uncommon
        
        Bowel damage : 5/1000 - uncommon
        
        Bleeding requiring transfusion 2/100 - common
        
        New / continuing bladder dysfunction - variable related to underlying problem
        
        Pelvic abcess 3/1000 - uncommon
        
        Failure to achieve results, recurrence of prolapse - common
        
        VTE common, PE uncommon
        
        Death in 6 wks 37/100,000
      - Frequent Risks
        
        UTI, retention, frequency
        
        Vaginal bleeding
        
        Post op pain and / or pain with sex
        
        Wound infection
        
        5.
      - Risk of Additional Procedures
        
        Transfusion 2/100
        
        Repair of bladder / bowel damage
        
        Laparotomy and conversion to abdominal approapch