Causes (Four T’s):
Hello from Addison and Lundy.
ACOG Practice bulletin: # 171
PTL or TPTL: Preterm <37wks, cervical change
Evaluation:
SSE first: Collect GC/CT cultures, FFN (no gel, blood or semen), GBS, eval for rupture if needed
SVE:
Cervical change–can dilation or effacement changes
FFN: Fetal fibronectin
If tPTL:
PPROM: Preterm <37wks, Ruptured membranes
SSE: Confirm rupture with Pooling, nitrazine ferning. Collect GC/CT and GBS.
If PPROM: Delivery at 34wks or at diagnosis if chorio or 34+wks
What approach: Abdominal, laparoscopic, vaginal or combination
Taking or leaving the tubes and ovaries?
Tubes: What benefit do they provide? Risk?
Ovaries: What benefit do ovaries provide? What about after menopause? Still have benefit for bones and cardiovascular health. 65yr old cut-off
If it’s laparoscopic–listen to the LSC podcast for more details on the approach
Let’s talk about important steps:
Review anatomy– you’ll be able to see well!
Pimped- Youtube Channel videos for laparoscopic anatomy
What case are you doing and why?
Review common indications, steps to procedure and potential risks/complications
Saying hi to the patient first
Being helpful setting up — yellowfins or stirrups for lithotomy
Scrubbing in — ask to grab your gown/gloves for the scrub, open carefully or get help if unsure
Abx: If entering uterus or vagina ie hyst
Prep: infection prevention with chloraprep or something
EtOH based, needs to evaporate before draping or risk fire!
Vaginal prep — betadine or chlorhexidine
Then everyone scrubs
Let resident/attending drape unless asked.
You may be asked to help with foley/manipulator
Uterine manipulators: Many sizes/shapes/types
Vagina is dirty– can’t go from vagina to abdomen
Abdomen:
Entry: Typically in umbilicus or just above. Can use Palmer’s Point if needed.
Direct visualization with Hassan
Visiport
Veres needle
Insufflate with CO2
Port placement: Typically middle ⅓ of distance between ASIS and umbilicus. Avoid obvious superficial vessels and inferior epigastric –watch from below
Common procedures:
Closing ports: Close fascia on ports >5mm due to increased risk of hernia
Post-op checks: Many LSC cases are same-day, meaning patients go home
-Nausea/vomiting, eating/drinking, voiding, passing flatus, ambulating
-UOP, BPs,
Hypertension in Pregnancy — One large spectrum
Mild range: 140/90
Severe range 160/110
CHTN → SIPE
gHTN → Pre-E
BP meds: Methyldopa, labetalol, hydralazine, nifedipine
Severe features:
HELLP
Hemolysis, Elevated Liver (enzymes), Low Platelets
Eclampsia — Seizures
Why?
Scheduled: Repeat cesarean, hx of uterine surgery, abnormal placentation (placenta previa, vasa previa, accrete, etc) malpresentation (not cephalic), multiple gestation
In labor: arrest of dilation, arrest of descent, nonreassuring fetal heart tones, elective
Anatomy: Layers of anterior abdominal wall: skin, subcutaneous tissue, superficial fascia (Campers, scarpa’s), external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, preperitoneal adipose and areolar tissue, and peritoneum. Nerves, blood vessels, and lymphatics are present throughout.
Now you’re at the uterus — or should be. Clear the surgical field, take down adhesions, bladder flap if needed.
Hysterotomy — lower uterine segment, lateral uterine vessels to avoid
Delivery baby — delay cord clamp, placenta
Likely lots of bleeding — same atony meds as vaginal delivery
Clean inside of uterus to remove all membranes etc.
Possibly exteriorize uterus to see better — depends on scaring
How can you be helpful — visualization! Bladder blade back in, suction or clean with lap between when surgeon placing sutures.
Two layers to hysterotomy if they might ever want to labor again or if needed for hemostasis.
Clean up the abdomen–irrigation vs moist laps vs suction
Now to close:
Peritoneium — either way, close or not– no evidence either way
Muscle– don’t close, evidence that closing it can cause hematoma
Fascia–Close!
Closing Fascia:
Nerves at the lateral edges of the fascial incision are ilioingiunal, iliohypogastric
Subcutaneous fat — if >2cm depth, close to reduce risk of seroma/hematoma/infection
Skin closure — stables, suture, absorbable stables
