1' What percentage of women require surgery during pregnancy

1

• 1. What percentage of women require surgery
  during pregnancy?
• A. 2
• B. 5
• C. 10
• D. 15
• E. 20

A 0.2 to 2.2 of pregnant women require surgery
during pregnancy.
2

• 2. The most common surgical complication of
  pregnancy is
• Cholecystitis
• Appendicitis
• Small bowel obstruction
• Perforated Duodenal Ulcer

• B Appendicitis
• Most common surgical complication of pregnancy
• Incidence similar to non-pregnant population
• Fetal mortality low when diagnosed and treated
  early.
• Mortality rates rise with peritonitis and sepsis

3

• 3. The most common operation during the first
  trimester is
• A. Laparoscopy to r/o ectopic pregnancy
• B. Appendectomy
• C. Cholecystectomy
• D. Repair Incarcerated Hernia

• A Surgery during Pregnancy (Swedish Study)
• 25 were abdominal operations
• Diagnostic laparoscopy to r/o ectopic gestation
  was most common 1st trimester procedure
• Appendectomy most common procedure in second
  trimester

4

• 4. Delaying Surgery for acute cholecystitis
  increases perinatal morbidity.
• True
• False

True Biliary Disease is second most common
general surgery condition encountered in pregnant
women. 1/2000 to 1/4000 pregnancies. Pregnancy
increases risk of gallstones (high progesterone
inhibits smooth muscle activity). Studies show
that delaying surgery for acute cholecystitis has
increased perinatal morbidity. Laparoscopy safe
and effective in this population.
5

• 5. The most common cause of intestinal
  obstruction during pregnancy is the enlarged
  uterus displacing/compressing the bowel
• True
• False

• False
• Incidence similar to general population(1/3000
  deliveries)
• Adhesive disease vs hernia most common cause
• Prior abdominal or pelvic surgery

6

• 6. The most frequent complication of PEG tube
  placement is
• Fistulous tract formation
• Peristomal infections
• Peritonitis
• Ileus
• Bleeding

7

• 7. Which of the following is an absolute
  contraindication for PEG placement?
• Previous gastric surgery
• Coagulopathy
• Morbid obesity
• Inability to transilluminate
• Neoplastic disease of the gastric wall

• D. Absolute contraindications
• all those which are for upper GI endoscopy,
• inability to transilluminate the abd wall and
  appose the ant gastric wall

8

• 8. PEGs placed under fluoro have a higher
  complication rate than those placed
  endoscopically.
• True
• False

False Equal rates have been reported.
9

• 9. Which of the following is false?
• If there are concerns about location of PEG tube,
  a gastrograffin study should be ordered
• Pneumoperitoneum can be seen in as many as 56 of
  cases and can persist for up to 4-5 wks
• Hydrogen peroxide is appropriate for PEG site
  care
• We should wait 3-4 hrs before beginning TFs post
  PEG placement

C Peroxide is NOT appropriate. PEG site care
mild soapH2O, not hydrogen peroxide (irritates
skin and ? risk of stomal leaks) drain sponges
over, not under, ext bumper topical silver
nitrate for excessive granulation tissue
antibiotics if infection adequate preop skin
sterilization
10

• 10. Buried Bumper Syndrome is
• Insertion of the internal bumper into the colon
• Insertion of the internal bumper into the SB
• Growth of granulation tissue around the external
  bumper
• Growth of gastric tissue over the internal bumper

D. Buried bumper is partial or complete growth
of gastric mucosa over the internal bolster. It
presents as peritubal leakage, infection,
immobile catheter, and/or abdominal pain.
11

• 11. The most common location of the defect in
  congenital diaphragmatic hernia is
• Septum transversum
• Foramen of Morgagni
• Esophageal hiatus
• Posterolateral Foramen of Bochdalek
• Foramen of Monroe

D The vast majority of congenital diaphragmatic
hernias occur as the result of failure of
mesenchymal primordial to grow into the
posterolateral pleuroperitoneal fold to complete
the muscular elements of the diaphragm. This
allows egress of gut into the left pleural space,
undermining pulmonary development and maturation.
Most defects can be closed primarily, however
the larger variety may have no muscle at the
posterior rim and require patch repair. Both
artificial and biologic materials have been used
with mixed success and a rate of recurrence that
varies between 5 and 40.
12

• 12. The primary cause of death in infants with
  congenital diaphragmatic hernia is
• Persistent fetal circulation
• Pulmonary hypoplasia
• Necrosis of incarcerated gut
• Sepsis
• Prematurity

B. The space occupying effect of the abdominal
contents herniated into the left pleural space is
felt to be the major impediment to development
and maturation of the ipsilateral lung. If the
effect is significant enough, bilateral
hypoplasia undermines pulmonary function from
birth.
13

• 13. Timing of surgical repair of congenital
  diaphragmatic hernia is
• Considered an emergency and performed immediately
  after birth, regardless of pulmonary status
• Occurs only after a successful ECMO run
• Appropriate when oxygenation has been optimized
• Required within 24 hours of birth
• Only necessary if there is evidence of gut
  necrosis

C The primary determinant of survival is
adequate oxygenation. If this can not be
achieved, survival is not likely regardless of
surgical repair of the hernia. Some centers
actually perform repair with the baby on ECMO
(and anti-coagulated). Most prefer the patient
be off ECMO and the coagulopathy reversed.
Despite the volume of incarcerated abdominal
contents, strangulation is uncommon.
14

• 14. Gut injury associated with gastroschisis is
• Permanent and usually results in short gut
• Results from exposure to amniotic fluid and/or
  ischemia from mesenteric compression
• Commonly complicated by necrotizing enterocolitis
• Routinely associated with intestinal atresia
• Always precludes immediate primary closure

B Fortunately, most babies recover from the
injury that results from exposure to amniotic
fluid and which can become catastrophic if the
cincture effect of the defect causes mesenteric
ischemia. The best way to enhance recovery is to
return the gut to the peritoneal cavity. The
decision to close primarily is based on right of
domain, intra-abdominal pressure, and
confirmation of adequate perfusion. If these can
not be confirmed, silo placement is the safest
and best option.
15

• 15. Babies recovering from gastroschisis should
  be fed
• As soon as possible by gavage
• No sooner than 21 days post repair
• Only when return of peristalsis is determined
• When NG output is less than 50 cc/day
• Elemental diets that do not contain
  polysaccharides.

C There is no absolute indicator that guarantees
the baby can be safely fed. Likewise, there is
no difference in trajectory of gut recovery
between primary closure and silo use. When there
is evidence of return of peristalsis, the baby
can begin slowly increasing feeds of full
strength formula. It is not unusual for the
dyskenesia associated with the gut injury to
cause occasional distention and feeding
intolerance. Decompression, patience and gentle
persistence will almost always result in
achievement of full feeding.