Joshua Klein, DO Department of Surgery, Trauma & Acute Care Surgeon, Westchester Medical Center, Division of Trauma & Acute Care Surgery, New York Medical College, Valhalla, NY, USA Iatrogenic ureteral injury is a potential complication of surgery, and management depends on the location of the injury. Gynecologic, colorectal, and vascular pelvic surgery have been shown to have higher rates of iatrogenic injury compared to other surgical procedures. The distal ureter is the most common site of injury, and the treatment depends on which part of the ureter is injured. Distal ureteral injury is best managed by debridement of the ureter and re‐implantation (correct choice C). An anterior or posterior location on the dome of the bladder is the preferred site of the ureteroneocystostomy as lateral re‐implantation is prone to kinking of the ureter leading to a partial or complete outflow obstruction. A vesico‐psoas hitch can be performed in conjunction with the ureteroneocystostomy if there is a large defect in the distal ureter that would result in tension on the anastomosis. Nephrostomy tube placement may be used in conjunction with repair but it by itself would not be sufficient (choice A). Upper and mid‐ureteral injuries can be managed with ureteral debridement and primary ureteroureterostomy (choice B). Ureteral repairs should be performed in conjunction with stenting and indwelling urinary catheter drainage. Antibiotics and drainage alone would also not be a viable alternative (choice D). Ureteral ligation may be a last ditch damage control option, but a nephrostomy tube would be required. Also in a damage control scenario, externalization of the ureter with an internal drain is also an option. Answer: C Burks F, Santucci R. Management of iatrogenic ureteral injury. Therapeutic Advances in Urology. 2014; 6(3):115–24. Sharp HT, Adelman MR. Prevention, recognition, and management of Urologic Injuries during gynecologic surgery. Obstetrics & Gynecology. 2016; 127(6):1085–96 Endometriosis is characterized by the presence of endometrial tissue outside of the uterine cavity. Endometriosis affects 10–15% of all women of reproductive age and 70% of women with chronic pelvic pain. Ultrasound and magnetic resonance imaging have low sensitivity and specificity for deep infiltrating endometriosis, and there are no serum markers to aid in diagnosis. Laparoscopy is the gold standard for the diagnosis, and surgical biopsies allow for histological confirmation. Management involves surgical debulking and hormonal treatment to suppress recurrence and progression. Ectopic pregnancy should be suspected in patients with B‐HCG greater than 1500 mIU/mL and a transvaginal ultrasound not showing an intrauterine gestational sac (choice A). Ovarian torsion is characterized by acute pelvic pain and caused when the ovary and its vascular pedicle twists on its suspensory ligament (choice D). Ultrasound will show an enlarged ovary with absence of Doppler flow. Adenomyosis is a benign gynecologic condition in which there is the presence of ectopic endometrial glands and stroma within the myometrium of the uterus (choice E). Hemorrhagic cysts are formed after ovulation with spontaneous bleeding into a corpus luteum cyst. There would not be endometrial glands present in hemorrhagic cysts (Choice C). Answer: B Parasar P, Ozcan P, Terry K. Endometriosis: Epidemiology, diagnosis, and clinical management. Current Obstetrics and Gynecology Reports. 2017; 6(1):34–41 Protopapas A, Grimbizis G. Adenomyosis: disease, uterine aging process leading to symptoms, or both. Facts, Views and Vision in OBGYN. 2020; 12(2):91–104. REBOA is a minimally invasive procedure in which a balloon occlusion catheter is introduced into the aorta through a percutaneous groin puncture in the femoral artery (choice A). REBOA can be a temporary measure that serves as a bridge to definitive control of hemorrhage. In order to facilitate proper balloon placement, the aorta is divided into three functional zones; Zone I, which extends from the left subclavian artery to the celiac trunk; Zone II, which lies between the celiac truck and renal artery; Zone III, which is comprised of the infra‐renal aorta. Zone II is not a recommended balloon inflation zone due to risk of dissection and/or perforation of visceral and renal vessels (choice B). Total aortic occlusion is not without potential risks to other organ systems. Animal studies have shown that occlusion time greater than 40 minutes can result in irreversible organ injury and death; therefore, balloon deflation should occur as soon as life‐threatening bleeding has been controlled (choice D). Prolonged ischemia followed by reperfusion can result in multisystem organ failure, limb ischemia, and myonecrosis. While prophylactic lower extremity fasciotomies are not recommended, comprehensive neurovascular exams along with the patient’s overall physiologic status should guide post‐REBOA procedures (choice E). Studies have shown that prophylactic use of REBOA deployed to Zone III under fluoroscopy or x‐ray during elective c‐sections for patients with morbidly adherent placenta, resulted in lower overall blood loss and fewer blood transfusions as compared to c‐sections performed without REBOA. In patients with morbidly adherent placenta, REBOA may serve as an adjunct to minimize blood loss intraoperatively. Placenta previa is classified by the degree of encroachment upon the internal cervical os. In total placenta previa, the cervical os is completely covered by the placenta. In partial placenta previa, the cervical os is partly covered by the placenta. Invasive placentas are classified according to the degree of myometrial invasion. In placenta accreta, the abnormally adherent placental villi are attached directly into the myometrium, but do not invade it. In a placenta increta, the villi invade the myometrium. When the placental villi penetrate through the myometrium, reaching the serosal surface of the uterus, then a placenta percreta is present. Answer: C Source: From Robert, J.N., et. al, Resuscitative endovascular balloon occlusion of the aorta with a low profile, wire free device: A game changer?, Trauma Case Reports, Vol. 7, 2017, 11–14, with permission. Manzano‐Nunez R, Vidarte M. Resuscitative endovascular balloon occlusion of the aorta deployed by acute care surgeons in patients with morbidly adherent placenta: a feasible solution for two lives in peril. World Journal of Emergency Surgery. 2018; 13:44. Ribeiro M, Feng C, Nguyen A. The complications associated with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). World Journal of Emergency Surgery. 2018; 13:20. Pelvic inflammatory disease (PID) is caused by an ascending infection from the cervix that is frequently related to an untreated sexually transmitted infection. The primary pathogens include Neisseria gonorrhoeae and Chlamydia trachomatis, although other cervical microbes including Mycoplasma genitalium, and Peptostreptococcus species have been implicated as well. Risk factors for development of PID include multiple sexual partners, previous history of PID, intrauterine device implantation, and tubal ligation. Patients typically present with lower abdominal or pelvic pain, vaginal discharge, dyspareunia, cervical motion tenderness, and vaginal bleeding. Ultrasound and computed tomography have a low sensitivity for PID diagnosis; therefore, early treatment should be started based on clinical suspicion (choice A). Initial treatment will depend upon the patient’s physiologic status, with indications for hospitalization including pregnancy, failed outpatient treatment, and severe clinical illness or signs of sepsis. Removal of an intrauterine device is only recommended in cases of PID, which show no clinical improvement in the first 48–72 hours when treated with antibiotics (choice B). A patient with suspected PID should be treated with either intravenous cefotetan or cefoxitin plus doxycycline. In patients with cephalosporin or tetracycline allergies, clindamycin plus gentamicin is an appropriate substitution. Outpatient treatment with intramuscular ceftriaxone and oral doxycycline should be reserved for those patients with mild disease (choice D) but this patient has hypotension and septic shock. Tubo‐ovarian abscess is a complication of PID in which an abscess forms involving the tubes and ovaries (choice E). Initial management consists of antibiotics; however, uncontrolled infection may require percutaneous drainage or surgical intervention. Answer: C Centers for Disease Control and Prevention. Pelvic Inflammatory Disease. 2015 Sexually Transmitted Diseases Treatment Guidelines. Cdc.gov/std/tg2015/pid.htm. Fitz‐Hugh‐Curtis syndrome is a chronic manifestation of pelvic inflammatory disease (PID). Spread of PID is hypothesized to occur in three ways: (1) ascending infection from the cervix or vagina travel to the endometrium, through the fallopian tubes, and into the peritoneal cavity; (2) lymphatic spread; (3) hematogenous spread. Diagnosis can be made via laparoscopy or laparotomy by direct visualization. The classic “Violin string” adhesions can be visualized on the hepatic capsule. Treatment consists of antibiotics covering Chlamydia trachomatis, Neisseria gonorrhea, and gram‐negative organisms. Abscesses visualized during laparoscopy can be surgically drained. Endometriosis is the presence of endometrial tissue outside of the uterine cavity and laparoscopy will identify bluish or red spots on the peritoneal surface (choice C). Diverticula can either be “false” diverticula in which the mucosa and submucosa herniate through a defect in the muscularis layer, or “true” diverticula, which involves outpouching of all layers of the intestinal wall (choice A). Causes of intraperitoneal fluid are multifactorial and not specifically related to PID (choice E). Ovarian cysts can range from physiologically normal to an ovarian malignancy. Risk factors for development of ovarian cysts include infertility treatment, pregnancy, hypothyroidism, and tobacco use. PID is not a risk factor for ovarian cyst development (choice B). Answers: D Das B, Ronda J, Trent M. Pelvic inflammatory disease: improving awareness, prevention, and treatment. Infection and Drug Resistance. 2016; 9:191–97. Khine H, Wren SB, Rotenberg O. Fitz‐hugh‐curtis syndrome in adolescent females: a diagnostic dilemma. Pediatric Emergency Care. 2019; 35(7):121–23. Adnexal torsion may involve twisting of the ovary alone, ovary and fallopian tube together, or the fallopian tube alone. Ovarian torsion occurs when the ovary folds over the adnexal ligaments compromising the blood flow from the ovarian and uterine arteries. Any ovarian mass will predispose an individual to torsion. In adults, a cyst is typically the precipitant mass that may lead to the torsion. Other conditions and masses leading to torsion include ovarian cysts and tumors, corpus luteum cysts, tubal pregnancies, and hemo/hydrosalpinx. Torsion is more likely to occur on the right than the left as the right‐sided ureteral ovarian ligament is longer. Some authors speculate that the presence of the sigmoid colon reduces space of the left pelvis and decreases the likelihood of left‐sided torsion. Presentation is variable, ranging from lower abdominal pain in early stages to overt sepsis once the ovary undergoes necrosis. Patients present with sudden onset of intense unilateral pelvic pain, which may radiate to the lumbar area. The pain episodes may be intermittent if the adnexal structures spontaneously torsed and detorsed. Ultrasound is typically used for diagnosis; however, it is specific but not sensitive for adnexal torsion. Ultrasound findings, which may be suggestive of adnexal torsion, includes the absence of flow to the affected side and asymmetry of the ovaries. Treatment consists of surgical detorsion and observation of the ovary for viability as the first step (choice B). If the ovary appears necrotic, management should include salpingo‐oophorectomy (choice C). If after detorsion, the cause of torsion is secondary to an ovarian cyst, cystectomy can be performed if benign appearing; if there are concerns for malignancy or if the woman is postmenopausal, salpingo‐oophorectomy should be performed. Bilateral oophorectomy would not be recommended as there is no indication to remove the contralateral ovary as torsion on one side does not predict torsion on the other (choice D). Hysterectomy would obviously not be indicated in this case (choice E). Answer: B
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Gynecologic Surgery
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