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58 Cards in this Set

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what do you legally have to get before any procedure that explains risks, benefits, and alternatives.
informed consent
If someone refuses treatment, what must you do?
write down and sign that they refused treatment or preventative measures
What are the current recommendations for pre-op evaluation?
H&P, pregnancy test (<60yo), hematocrit, creatinine, and DEPENDING ON SITUATION: CBC (pulmonary fxn tests for evaluation of dyspnea/COPD); ECG (women>55 or risk), CXR,
What pre-op imaging studies help with evaluation?
IUP (intravenous pyelogram) - however, doesn't decrease risk of ureteral injury; CT; MRI; US (help evaluation suspicious pelvic mass and detect areas suggestive of metastatic disease)
what is a coincidental appendectomy?
going ahead and taking out an appendix so no else would have to do it later (while your in there...)
What pre-op measures should you do to prevent post-operative problems?
give antibiotics prophylactically and in elderly patients do an in-patient bowel prep to prevent dehydration
Name some important risk and factors concerning surgery on elderly women.
They have an increased risk for MI, PE, CVA, DVT, pneumonia, infection, and sepsis. Operability is based on health status not age; ALL ABOUT IMPROVING QUALITY OF LIFE.
what measures should you take to ensure hemo stability?
stop herbals, aspirin, anticoagulants; get blood type and screen;
Who medically clears the patient?
all her doctors (doesn't mean surgery is going to go perfectly); STOP SMOKING (8wks prior and post)!(extra: plastic surgeon will not operate on people that smoke - vasoconstriction; delay healing)
Can hypertensives take their medication before surgery?
YES!, stop diurectics 48hrs prior
Why are bowel preps done prior to surgery?
preventative: less injury to bowel if empty and not in the way, limits fecal spillage and lessens risk of infection (complication of bowel prep: dehydration)
Who is at high risk for thromboembolism?
women >40; cancer patients; procedures lasting>30min; pregnant women; legs in stirrups (static blood); women on HRT and OC (stop 6wks prior to surgery)
What is involved in the pre-op cardiac assessment?
check for any caridac risks; SBE (subacute bacterial endocarditis) prophylaxis with pts with cardiac abnormalities (do echo if murmur present)
List the pulmonary risk factors that put a pt at risk for pulmonary complications.
upper abdominal surgery; last >3hrs; poor general health; COPD; smoker; general anesthesia; emergency surgery; PaCO2>45mmHg; current URI, abnormal CXR; age >70
What is the difference in cone-knife biopsy and conization procedures?
cold cone knife biopsy - you actually remove a cone shaped piece of the transformation zone and endocervical canal to diagnose cervical cancer; conization is taking a piece - its a more generally procedure (not in the shape of a cone)
Name excisional treatments.
use: 1)scalpel, 2)Laser, 3)Electrosurgery/Diathermy (LEEP- Loop Electrosurgical Excision Procedure and LLETZ -Large Loop excision of the Transformation Zone = both are same thing) - advantage of LLETZ/LEEP= tissue can be sent for examination unlike laser where they are destroyed
What are ablative procedures and name the disadvatages.
cryo-laser; good alternative to conization, but there is no specimen left to look at - it is ablated; purely therapeutic, not for diagnosis
what is the goal of a cervical conization procedure?
to remove the entire transformation zone
Why don't you remove low grade HPV?
high incidence of stenosis with conization procedures and low incidence of advancing
If you have to do a LEEP during pregnancy, what do you do to prevent miscarriage?
do a cervical cerlage procedure - place a stich in the cervix to reduce pregnancy loss
Why are D&C (dilation and curettage) done?
diagnostic (sampling endometrium, endometrial hyperplasia, insufficient tissue on biopsy, cervical stenosis preventing biopsy, concomitantly wih hysteroscopy/laparoscopy)
List the therapeutic indications of D&C.
treatment of incomplete, inevitable, missed, septic, and induced abortion; tx of molar pregnancy; manage DUB
What are the contraindications to D&C?
viable, desired intrauterine pregn.; bleeding diathesis; acute vaginal, cervical, or pelvic infection; cervical cancer obstructing the cervical canal
List the complications of D&C.
anesthesia related, hemorrhage, uterine perforation, infection, Asherman's Syndrome, Trophoblast embolization
What is the most common immediate complication of a D&C?
uterine perforation
Explain the minimally invasive hysteroscopy.
under general anesthesia: insert a tiny telescope into the uterus and inspect the uterus and tubal ostia for any abnormalities; can use a solution to distend the cavity for better visual
What are the benefits of hysteroscopy?
quick recovery, minimal post-op pain; no wound to get infected
Name some contra-indications for a hysteroscopy.
systemic health problems, esp. cardio-pulm; pelvic infection; excessive bleeding; cervical cancer; pregnancy (exception: IUD removal)
Name some reasons a hysteroscopy would fail?
if done in the office: too much pain or stenosis of cervix - can't dilate well; OR: too much bleeding, can't see; may perforate
Name the technique used in women with DUB that prevents the lining from growing back.
endometrial ablation called resectoscope - used with hysteroscopy
Who is a good candidate for ablation?
women with abnormal uterine bleeding who have completed child bearing - 1st do an endometrial biopsy to R/O hyperplasia/cancer and any other intrauterine pathologies
When is hysteroscopy with resectoscope (ablation) not recommended?
large cavity (>12cm), hyperplasia/cancer; submucosal fibroid/polyp, severe dysmenorrhea
Name the instrument. Telescope through umbilical port to visualize pelvic organs on a video monitor.
Laparoscopy
Describe how laparoscopy is done.
use general anesthesia, inflate the abdomen with CO2, trocar is placed through an incision that allows the use of different instruments needed; there are 3 incisions made that allow for different instruments: midline and laterally in the lower abdomen with trocar through umbilicus
Who should not have a laparoscopic surgery?
people with health problems (cardio, pulm); people with hx of multiple abdominal surgeries (too many adhesions causing limited access)
Name the most common performed gynecologic procedure.
hysterectomy - 90% are for a benign cause and abdominal route is the most common
Name some medical and surgical alternatives to hysterectomy.
Hormonal Tx: progestins for hyperplasia; GnRH analogs (for painful endometriosis); Pain Control; Conization; Endometrial Ablation; D&C, Hysteroscopy; Abdominal Myomectomy
What are the main indications for doing a hysterectomy?
Leiomyomata, Pelvic Pain, Pelvic Relaxation, Abnormal Uterine Bleeding, malignant or pre-malignant disease
What are the concerns of the patient when having a hysterectomy?
problems with: 1) sexual fxn (research shows no change); 2)Pelvic Organ prolapse; 3) incontinence/constipation; 4)Cyclic Vaginal Bleeding; 5) must have PAPs afterwards
What are the concerns for the doctor when doing hysterectomies?
length of surgery/hospital stay is longer; amount of blood loss/transfusion rate; few complications/ureteral injury; routine screening post-op
Name the 4 routes of hysterectomies.
abdominal, vaginal, LAVH (laparoscopic assisted vaginal hysterectomy), and Total Laparoscopic hysterectomy.
what is the difference in a total vs subtotal hysterectomy?
total = cervix plus uterus; subtotal= supracervical (uterus only)
According to the ACOG, what is the safest route of doing a hysterectomy?
vaginal
Compare a vaginal vs. abdominal hysterectomy?
Vaginal= shorter hospital stay, speedier recovery, fewer infections or fevers
Compare laparoscopic hysterectomy vs. abdominal hyst.
Lap= less blood loss, shorter hospital stay, speedier recovery, fewer wound infections, longer operating time, more UTIs
compare lap vs. vaginal hysterectomy.
similar outcomes, Lap= takes longer in OR
If surgery is for a benign case, always try and ____ salvage the ovaries.
salvage
Name the indications for oophorectomy.
benign ovarian neoplasms; prophylactic oophorectomy; adnexal torsion with necrosis; ovarian malignancy; TOA unresponsive to antibiotics; definitive treatment for endometriosis
What is the difference in laparotomy vs. laparoscopy?
opening up the abdomen vs. three small incisions and using a scope; laparoscopy - newer and better
If you find a malignancy, what must you do immediately.
get a frozen section done right then; if malignant do an open surgical procedure for staging; have a gyn-onco on standby
When doing laparoscopic surgery, what tools can you use to remove tissue.
loop, bipolar electrocautery, stapling device, and harmonic scalpel
Name the possible complications with ovarian surgery.
bleeding, injury to bowel/bladder, ureteral injury, ovarian remnant syndrome, spillage of malignant cells
Why should you not aspirate ovarian cysts?
no tissue for pathology, not reliable for exclusion of malignancy, high rate of recurrence
name the term that describes moving the ovary from its normal position to preserve its fxn and get it out of harms way.
oophoropexy
What are some disadvantages of oophorectomy, esp. in a younger woman.
early menopause (hot flashes, vaginal atrophy); osteoporosis, increase in LDL, decrease in libido
What measures do you take to prevent surgical sites infections?
maintain sterile techniques, attention to hemostasis, sharp dessection, minimal tissue destruction, prophylactic ABX,
What measures do you take post-operatively to reduce risks of complications.
DVT prophylaxis/Heparin, compression stockings, pulmonary spirometry, early ambulation