Urinary Tract Injuries, Incisions and Nerve Injuries

1. A 48-year-old woman undergoes laparoscopic hysterectomy and bilateral salpingo-oophorectomy, pelvic lymphadenectomy and peritoneal washings for grade 3 endometrial cancer. It was a difficult operation due to extensive adhesions. Her abdominal drain is straw-coloured fluid and is 500 mL on day 2. She is clinically stable. Her haemoglobin (HB) is 9 gm% and serum creatinine is 75. Drain fluid creatinine is reported as 90.
Which of the following is not a sign or symptom of urinary tract injury in her case?

2. A 31-year-old para 1 undergoes radical vaginal trachelectomy and laparoscopic bilateral lymph node dissection for early cervical cancer. She presents with paraesthesia over the mons pubis, labia majora and the femoral triangle.
Her symptoms are most likely caused by injury to which of the following?

3. The Smead–Jones closure is a mass closure technique of the anterior abdominal wall using a far–far, near–near approach. The closure is performed using a delayed absorbable suture to include all the abdominal wall structures on the far–far portion and only the anterior fascia on the near–near portion. T is allows good healing without intervening fat or muscle.
Which of the following best describes the rate of fascial dehiscence with running mass closure of the abdomen?

4. Suture materials have different physical properties. Which of the following is the property by which a suture is capable of supporting acute angulation without breaking or opposing excessive resistance?

5. Polydioxanone (PDS) is synthetic, absorbable mono lament surgical suture material. It is particularly useful when a combination of an absorbable suture and extended wound support is desirable.
Which of the following best describes the breaking strength retention (tensile strength) of 3-0 PDS at 6 weeks?

6. A 36-year-old primigravida has an emergency caesarean section for failure to progress following a long period of augmentation and delivers a 4.8 kg baby. Despite various uterotonics, the uterus remains hypotonic and there is bleeding. The haemorrhage stops temporarily with compression. A decision to perform a B-Lynch suture is performed. A suture on a large needle is requested.
Which would be the best suture material to use?

7. A 30-year-old patient is diagnosed with Stage IB cervical cancer. She wishes to retain her fertility and undergoes trachelectomy with laparoscopic pelvic lymphadenectomy.
Figure courtesy of Mr Anish Bali, Consultant Gynaecologist/Oncologist Surgeon, Derby Teaching Hospitals NHS Foundation Trust, with permission

The structure marked in Figure 213 is accidentally cut, which results in:

8. A 46-year-old woman had total abdominal hysterectomy for heavy menstrual bleed- ing due to a multiple fibroid uterus. Postoperatively, she had extreme difficulty in climbing the stairs. There is also some paraesthesia over the anterior and medial thigh as well as the medial aspect of the calf.
Which nerve has been injured during the operation?

9. A 45-year-old woman underwent a total abdominal hysterectomy for heavy menstrual bleeding. In the postoperative period she develops weakness of hip flexion and adduction and is unable to extend the knee. On examination the knee jerk reflex is lost and there is altered sensation over the medial aspect of thigh and calf.
What nerve is most likely to have been damaged?

10. A 28-year-old woman had a caesarean section for failure to progress. She visits her general practitioner four months postpartum with paraesthesia and sharp burning pains radiating from the incision site to the left labia and thigh.
Which nerve is most likely to have been involved?

11. A 38-year-old woman has undergone a difficult laparoscopically assisted vaginal hysterectomy, with blood loss of 600 mL. Forty-eight hours after surgery, she complains of flank pain and has abdominal distension with generalized abdominal tenderness. She has oliguria and she is apyrexial. Bowel sounds are present but scanty. Investigations have revealed haemoglobin 10.8 g/L (normal 11.5–16.5), white cell count 8.3 × 109/L (normal 4–11) and creatinine 342 μmol/L (normal 27–88).
What is the most likely diagnosis?

12. A 70-year-old woman had a sacrospinous fixation one week ago. She was readmitted complaining of severe right buttock and perineal pain, which is aggravated in the seating position.
What is the most likely nerve involvement?

13. A 45-year-old woman is due to have a transobturator tape procedure for stress urinary incontinence. You counsel her about the risks of the procedure, including the risk of obturator nerve injury.
What motor findings would be consistent with obturator nerve injury?

14. A woman had a difficult abdominal hysterectomy for a fibroid uterus. The transverse suprapubic incision needed to be extended laterally on both sides to facilitate the surgery. Postoperatively she developed sharp, burning pain and paraesthesia over her mons pubis, labia and the lateral aspect of her thigh. On examination, no motor weakness is found.
Which nerve is affected?

15. During a vaginal repair, the assisting junior doctor asks about the different suture materials used. At that point, you are using polyglactin (Vicryl). You explain it is absorbable.
How long does it take to be absorbed?

16. A 34-year-old woman had a total abdominal hysterectomy for chronic menorrhagia following unsuccessful endometrial ablation. Postoperatively, she complains of weakness of the left leg, along with paraesthesia over the anterior and medial thigh.
What is the most likely injury causing her symptoms?

17. A 52 year old woman had laparoscopic assisted vaginal hysterectomy. She sustained a bladder injury during the procedure that was repaired laparoscopically. The approximate incidence of fistula formation is:

18. A 54 year old sustained bladder injury during laparoscopic assisted vaginal hysterectomy. She had the catheter for 2 weeks. Prior to removal of the catheter she needs:

19. A 65 year old lady is having debulking surgery for ovarian cancer. Excision of external iliac nodes was carried out. 2 months later, she presented with paraesthesia over mons pubis and labia.
Which nerve injury did she sustain during the surgery?

20. Hat proportion of ureteric injuries are recognised intraoperatively during laparoscopic surgery?

21. Which nerve is particularly susceptible to damage when self-retaining retractors are used in gynaecological surgery?

22. A patient is seen 2 weeks after a laparoscopic hysterectomy. An intraoperative bladder injury was noted and repaired laparoscopically by the urologist. A catheter has been left in situ for 2 weeks. A retrograde cystogram subsequently reports a leak from the bladder. The woman is clinically well.
What is the most appropriate management?