Survey
* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
Download 1b-Schimp-Surgical Complications
Document related concepts
Transcript
3/31/2016 Surgical Complications Veronica L. Schimp, D.O. Chief Gynecologic Oncology April 2016 Objectives • To understand when it is appropriate to use surgical intervention • To understand how to identify organ damage at the time of surgery • To understand how to manage intra-operative complications 1 3/31/2016 Billroth, MD 1879 “A person may have learned a good deal and still be a bad doctor who earns no trust from patients. The way to deal with patients is to win their confidence, listen to them (patients are more eager to talk than to listen) and help them, console them, get them to understand serous matters: none of this can be read in books. A student can learn it only through intimate contact with his teacher, whom he will unconsciously imitate…The patient longs for the doctor’s visit; his thoughts and feelings circle around that event. The doctor may do whatever is necessary with speed and precision – but he should never give the impression of being in a hurry, or of having other things on his mind…” General Principles of Surgical Technique REMEMBER THE URETER REMEMBER THE URETER • • • • • • • • Do NOT clamp BLINDLY • Cut only as deep as you can see • Cutting peritoneum and areolar tissue is safe • Work where exposure is good • Avoid haste and fatigue • Do not get ahead of yourself Know the anatomy Restore the anatomy Obtain adequate exposure Develop avascular planes Isolate vascular Pedicles Control the blood supply Use finesse NOT Force The shortest cancer survival is an OPERATIVE DEATH!! Morrow’s Gynecologic Cancer Surgery, 2nd Ed. 2013 2 3/31/2016 Know Your Anatomy Abdominal Wall Anatomy 3 3/31/2016 Abdominal Wall Nerves Omentum • • • • Derivative of Dorsal mesentery of stomach Covered by mesothelium Arises greater curvature of stomach Ligaments • Gastrocolic • Gastrophrenic • Gastrosplenic 4 3/31/2016 Omentum • Blood supply • Derived from gastroepiploic arcade • Anastamosis of left and right gastroepiploic arteries • Left off splenic off Celiac trunk • Right off gastroduodenal off Common Hepatic off Celiac Lesser Omentum • From lesser curvature of stomach • Gastrohepatic ligament (free edge) • Contains common bile duct, hepatic artery and portal vein • Also contains Left gastric artery and nerves to stomach 5 3/31/2016 Arterial Supply to Abdomen • Inferior Phrenic Arteries • Celiac Artery (3 branches) • Splenic Artery • L gastroepiploic arteries • Short gastric arteries • Common Hepatic Artery • Proper hepatic • R gastroduodenal • R gastroepiploic • Left Gastric Artery Arterial Supply to Abdomen • Superior Mesenteric Artery (7 branches) • • • • • • • Pancreaticoduodenal Artery Middle Colic Artery Right Colic Artery Ileocolic Artery Jejunal Arteries Ileal Arteries Marginal Artery of Drummond • Gives rise to the vasa recta (straight vessels) that enter the bowel wall 6 3/31/2016 Arterial Supply to Abdomen • • • • Renal Arteries Ovarian Arteries Lumbar Arteries (5 pairs) Inferior Mesenteric Artery (at about L3) • Left Colic Artery ascending and descending • Sigmoid Arteries • Superior Rectal Artery Veins • Portal Vein • SMV • Splenic Vein • IMV • Drains into Splenic Vein • Left Ovarian Vein • Drains into left renal vein • Right Ovarian Vein • Drains into IVC 7 3/31/2016 Blood Supply to Ureter Innervation of Ureter 8 3/31/2016 9 3/31/2016 Know Your Anatomy Arterial Supply to the Pelvis • Common Iliac Arteries • External Iliac artery leg and abdominal wall • Inferior epigastric artery • Femoral Artery (after inguinal ligament) • Superficial external pudendal • Superficial circumflex iliac • Superficial epigastric • Deep external pudendal 10 3/31/2016 Arterial Supply to the Pelvis • Internal Iliac Arteries (2 divisions) • Posterior division (4 branches) • • • • Iliolumbar Superior lateral sacral Inferior lateral sacral Superior gluteal • Anterior division (9 branches) • • • • • • • • • Umbilical Superior Vesicle (Uterine and Vaginal may arise from here) Uterine Vaginal Obturator Inferior Vesicle Middle Rectal Internal pudendal (inferior rectal, perineal branches) Inferior gluteal (runs through Alcock’s canal) • Middle Sacral Artery Venous Drainage • Flows mainly to the caval system via the internal iliac veins • Superior rectum normally drains into the hepatic portal system, although superior rectal veins anastomose with the middle and inferior rectal veins, the tributaries of the int iliac veins 11 3/31/2016 Neurovascular Relationships of Pelvis • Obturator Nerve along obturator internus muscle • Note relationship b/w inferior gluteal artery and Pudendal Nerve 12 3/31/2016 Somatic Nerve Plexus of Pelvis Autonomic Nerves of Pelvis 13 3/31/2016 Femoral Nerve Injury • Is a retractor related injury • Can also be due to positioning and too much hip extension Obturator Nerve Injury • • • • A – perineal nerve B – inferior cluneal nerve C – obturator nerve D – genitofemoral and ilioinguinal nerves • Lymph node dissection common site of injury • Alcock’s canal pain syndrome 14 3/31/2016 Peroneal Nerve Injury • Positioning Injury in stirrups • Foot Drop Nerves to Know • Iliinguinal (L1)—Sensory Only • Branch of L1 joins inguinal canal and supplies labia majora and skin of the mons • Iliohypogastric (L1)—Sensory Only • Superior to Ilioinguinal Nerve and lateral to psoas muscle • Genitofemoral (L1-2) –Sensory Only • Runs along ant psoas and genital br runs with round ligament • Femoral branch emerges under inguinal ligament with the external iliac and supplies skin over femoral triangle • Lateral Femoral Cutaneous (L2-3) –Sensory Only • Skin to lateral thigh • Lateral border of psoas along iliacus under inguinal ligament medial to AIS • Posterior Femoral Cutaneous (S1-3) – Sensory Only • Female pudendum lateral to ischial tuberosity and lateral labia 15 3/31/2016 Nerves to Know • Pudendal (S2-4)—Motor • Through greater sciatic foramen around ischial spine and back into pelvis through lesser sciatic foramen then through Alcock's canal with nerve and vein • Three branches • Inferior rectal nerve—anus and perirectal skin • Perineal nerve—small muscles of superficial and deep perineal spaces and labia • Dorsal nerve of the clitoris • Obturator (L2-4) –Motor (predom), Sensory medial thigh • From inferiomedialpsoas and traverses obturator canal • Adductor longus, brevis, magnus, gracilis and pectineus muscle • Repair 8-0 monofilament epineurium • Femoral (L2-4) –Motor, Sensory • Lateral psoas to lateral femoral cutaneous, on top inguinal • Adductor magnus and pectineus • Cutaneous—innervates skin lower 2/3 anterior and medial thigh • Anterior • Medial • Injury likely from self retaining retractors at psoas and round ligament junction • Numbness anteromedial thigh • Sciatic (L4-S3) – Motor, Sensory • Exits pelvis through greater sciatic foramen Pudendal Nerve & Vessels • Sensory and motor nerve of the perineum • Course and distribution in the perineum is parallel the pudendal artery and veins that connect with the internal iliac vessels • Arises from S2-S4 • Vessels from anterior division of the internal iliac artery • Leave the pelvis through the greater sciatic foramen by hooking around the ischial spine and sacrospinous ligament to enter the pudendal (Alcock’s) canal through the lesser sciatic foramen. 16 3/31/2016 Somatic Nerves of Pelvis Nerve Origin Distribution Sciatic L4, L5, S1-3 Articular branches to hip & muscular br to flexors knee in thigh & all mu leg & foot Superior Gluteal L4, L5, S1 Gluteus maximus & minimus muscles Nerve to quadratus femoris (& inf. Gemellus) L4, L5, S1 Quadratus femoris & inf gemellus m. Inferior gluteal L5, S1, S2 Gluteus maximus Nerve to obturator internus (& sup. Gemellus) L5, S1, S2 Obturator internus & sup. Gemellus m Nerve to piriformis S1, S2 Piriformis m Post cutaneous nerve thigh S2, S3 Cutaneous br to buttock & upper medial/post surfaces thigh Perforating cutaneous S2, S3 Cutaneous br to medial buttock Pudendal S2-S4 Sensory to genitalia; muscular br to perineal m, ext urethral & anal sphincters Pelvic splanchnic S2-S4 Pelvic viscera via inferior hypogastric & pelvic plexuses Nerves to levator ani & coccygeus S3, S4 Levator ani & coccygeus m Surgical Complications 17 3/31/2016 OMG—Hole in Artery! • Pressure • Umbilical tape or vascular clamps • Puncture wound • Close with interrupted 6-0 prolene • Larger wounds (>1cm) • Call vascular surgery OMG—I hit a VEIN! • Pressure • Slide finger little by little • If adequately mobilized use satinsky clamps or bulldog clamps • Allis clamps • 6-0 prolene running suture • Pack 18 3/31/2016 Internal Iliac Vein • Turn with allis clamp or rotate with sponge wrapped around • Clip or suture (6-0 prolene) Vena Cava • NO Clips • Interrupted 6-0 prolene • Larger than 1 cm • CALL Vascular 19 3/31/2016 Cardinal Ligament/Parametrial Tissue • If specific bleeder not identified • Suture general area 2-0 vicryl • Cautious of sciatic nerve which is inferior to this area Presacral Veins • • • • • Stay above Waldeyer’s fascia to avoid injury Pressure Thumbtack Bone wax Suture 2-0 or 3-0 prolene 20 3/31/2016 Obturator Vein • Figure of Eight • 6-0 prolene Large Bowel Injury • Colotomy repair • • • • May be done in unprepped bowel and no vascular compromise If >1 liter blood loss &/or shock than primary closure is allowed Trim edges of perforation with metzenbaums Close transversely with single layer interrupted 3-0 silk or vicryl on SH needle • 5-7% anastamotic abscess reported • Can usually be drained percutaneously 21 3/31/2016 Large Bowel Injury • Colotomy repair • Distal Sigmoid colon and rectum • If injury involves the mesentery and there is question of bowel viability: • Divide with GIA • End-colonic colostomy • Call General surgery • Repair 6-8 weeks later Small Bowel Injury • Coagulation injury • Spread can be visual up to 1 cm and non-visual up to 2-3 cm • Resect the damaged area • Don’t have to open in a laparoscopic case, call general surgery • Perforation • Oversew cephalad to caudad • Devitalized bowel • Need to resect 22 3/31/2016 Intra-operative Urinary Tract Injuries • Most are crushing or laceration of ureter • Remove clamp/ligature immediately • Mobilize ureter from surrounding tissue & inspect • If ureter appears viable and no extravasation of Indigo Carmine: • Site of injury can be stented • Lacerations without vascular compromise • Close primarily with 4-0 prolene over stent Intra-operative Urinary Tract Injuries • Severe crushing injury— likely requires resection • Below pelvic brim ureteroneocystotomy (Psoas hitch or Boari flap) • Above pelvic brim primary anastamosis 23 3/31/2016 Ureteral injury/repair Avoid the transureteroureterostomy—high infection and renal failure rates Cutaneous Pyelostomy PCN Transureteraoureterostomy Internal stenting Boari flap Uretrero reconstruction with ielum Ureteroureterosstomy Psoas Hitch Ureteroneocystostomy Ureteroureterostomy Post-operative Ureteral Injury • Intra-abdominal leakage • FIX IMMEDIATELY • No intra-abdominal leakage • Try stenting or PCN tubes • Wait 6-8 weeks and then repair • Stenting or foley drainage with heal most small fistulas 24 3/31/2016 Intra-operative Bladder Injury • Dome of bladder most common • First layer • 3-0 vicryl • Reapproximate vesical mucosa • Running • Second layer • Imbricate muscular portion • 3-0 vicryl • Continuous or interrupted • Foley drainage • If high in dome, 3-4 days or until UA neg for microscopic blood • If low in bladder, 10-14 days • Trigone injuries • Call Urology • Need stents • Repair is similar to repair of vesicovaginal fistula repair Post-Splenectomy 25
