Gynecologic Surgery and Operative Techniques
What this domain tests
Surgical questions test route selection, pelvic anatomy, prevention of complications, and recognition of postoperative injury.
Core rules
- Route. Hysterectomy route depends on uterine size, prolapse, prior surgery, and adnexal needs. Vaginal is preferred for prolapse; laparoscopic suits moderate uteri; abdominal for very large uteri or malignancy.
- Ureter. The ureter passes about 1.5–2 cm lateral to the cervix and crosses under the uterine artery - 'water under the bridge'. Identify it before clamping the pedicle; skeletonize the uterine artery in difficult cases.
- Blood supply. Uterine artery from the internal iliac; ovarian artery from the aorta. Collateral supply explains why bilateral uterine artery ligation may not control bleeding.
- Infection and VTE. Cefazolin 2 g within 60 minutes of incision, redosed intraoperatively; mechanical and pharmacologic VTE prophylaxis in oncology patients and those with risk factors.
- Laparoscopic entry. Open (Hasson) or Palmer's point in patients with prior surgery; check for trocar injury before insufflation.
- Postoperative complications. Ureteral injury presents with flank pain, ileus, rising creatinine, or watery vaginal discharge; CT urogram is the test. Nerve injuries: obturator (lymphadenectomy), femoral (self-retaining retractors), genitofemoral.
- ERAS. Avoid prolonged fasting, use multimodal analgesia, feed early, and mobilize.
Worked example
Two days after total laparoscopic hysterectomy a woman has flank pain, nausea, and creatinine 1.6 mg/dL. Suspect ureteral injury; obtain CT urogram and place a ureteral stent. Injury is most likely at the level of the uterine artery where the ureter was dissected.
Traps
Assuming normal intraoperative inspection excludes ureteral injury; omitting VTE prophylaxis in gynecologic oncology; missing a delayed bowel injury after electrosurgery; clamping the infundibulopelvic ligament without identifying the ureter.