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MRCOG PART 2 SBAs and EMQs

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EMQ1476
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ASSAY 366

ASSAY 366 Posted by mariam M.

Advatages of hysteroscopic sterilization include that it is non incisional method ,avoids abdominal entery,can be done as an office procedure so more cost and time effective  and avoids general anesthesia as it can be done without anaesthesia or with minimal sedation and also less post operative pain with quick return to work and normal activities never the less it can be done in women with extensive pelvic adhesions and also in women who have comorbidites that preclude laparoscopy or laparotomy    the most important is that it is an effective procedure 95-99%   success rate and also less anxiety  it avoids visceral injury   and contain no hormones                                                                                                   however unlike laparoscopic sterilization which conveys immediate reliability ,hyseroscopic sterilization is amulti step process in which the hysteroscopic sterilization procedure is followed by confirmatory hyserosalpingogram performed at least three months after the initial procedure  to prove bilateral occlusion before women can relay on this method of contraception  and there is high risk of unilateral tubal occlusion there is risk of perforation to the uterus and risk of intraoperative bleeding risk of assending infections and 5%experienced failed placement and require another procedure  alsa it needs technical skills  it is also an irreversable procedure unlike laproscopic sterilization in which reversibility is 50-90%                                                                                                                                                                              B appropriate counseling shoud be done prior to surgery there is increased risk in obese women or unde weight and those with previous mid line incisions peritonitis or inflammatory bowel disease  the surgeons should have appropriate training supervision and experience and are familiar with the equipment and should ensure that nursing staff and surgical assistants are appropriately trained for the role they will undertake during the procedure  .The primary incision shoud be vertical from the base of the umbilicus iit shoud not be so deeply to enter the peritoneal cavity  the veress needle shoud be sharp ,with agood and tested spring action Adisposable needle is recommended ,as it will fulfil these criteria.  The operating table should behorizontal (not in the Trendelenburg tilt) at the start of the procedure. The

abdomen should be palpated to check for any masses and for the position of the aorta before insertion

of the Veress needle.The lower abdominal wall should be stabilised in such a way that the Veress needle can be inserted at

right angles to the skin and should be pushed in just sufficiently to penetrate  the fascia and the

peritoneum. Two audible clicks are usually heard as these layers are penetrated.Excessive lateral movement of the needle should be avoided, as this may convert a small needlepoint injury in the wall of the bowel or vessel into a more complex tear. An intra-abdominal pressure of 2025 mmHg should be used for gas insufflation before inserting theprimary trocar.The distension pressure should be reduced to 1215 mmHg once the insertion of the trocars is complete.

This gives adequate distension for operative laparoscopy and allows the anaesthetist to ventilate thepatient safely and effectively. The primary trocar should be inserted in a controlled manner at 90 degrees to the skin, through theincision at the thinnest part of the abdominal wall, in the base of the umbilicus. Insertion should be

stopped immediately the trocar is inside the abdominal cavity.Once the laparoscope has been introduced through the primary cannula, it should be rotated through

360 degrees to check visually for any adherent bowel. If this is present, it should be closely inspectedfor any evidence of haemorrhage, damage or retroperitoneal haematoma.

If there is concern that the bowel may be adherent under the umbilicus, the primary trocar site shouldbe visualised from a secondary port site, preferably with a 5-mm laparoscope.On completion of the procedure, the laparoscope should be used to check that there has not been athrough-and-through injury of bowel adherent under the umbilicus by visual control during removal. When the Hasson open laparoscopic entry is employed, confirmation that the peritoneum has beenopened should be made by visualising bowel or omentum before inserting the blunt tipped cannula Direct trocar insertion is an acceptable alternative trocar insertion method Palmers point is the preferred alternative trocar insertion site, except in cases of previous surgery inthis area or splenomegaly. Secondary ports must be inserted under direct vision perpendicular to the skin, while maintaining the pneumoperitoneum at 2025 mmHg. During insertion of secondary ports, the inferior epigastric vessels should be visualised

laparoscopically to ensure the entry point is away from the vessels.During insertion of secondary ports, once the tip of the trocar has pierced the peritoneum it should be

angled towards the anterior pelvis under careful visual control until the sharp tip has been removed.Secondary ports must be removed under direct vision to ensure that any haemorrhage can be observed and treated, if present. The open (Hasson) technique or entry at Palmers point are recommended for the primary entry in

women with morbid obesity. If the Veress needle approach is used, particular care must be taken to ensure that the incision is made right at the base of the umbilicus and the needle inserted vertically into the peritoneum. The Hasson technique or insertion at Palmers point is recommended for the primary entry in women who are very thin.