This document discusses ureteric injuries that can occur during gynecological surgeries. It notes that the most common site of injury is near the pelvic brim at the infundibulopelvic ligament. The most common type of injury is obstruction and the most common cause is attempts to obtain hemostasis. It provides details on the anatomy of the ureter and risk factors for injury. Preventive strategies discussed include preoperative imaging, adequate exposure during surgery, and avoiding blind clamping of vessels near the ureter. Treatment depends on the severity, location, and timing of diagnosis of the injury. Options include conservative management, delayed repair, or immediate reoperation.
Ureters are retroperitoneal structues which run anterior to psoas muscle and cross lateral to medial.4sites are prone where ureter can be injured and its management
Ureteric injury in Gyenec Surgery, Serious complication of gynecologic surgery
Significant morbidity and long-term sequelae
Uncommon in benign gynecologic surgery
Vaginal hysterectomy has the lowest rate of ureteral injury
Laparoscopic hysterectomy has the highestThe ureters are the muscular ,thick walled narrow tubes(Right and Left)
Each measures 25-30 cm in length and extends from renal pelvis to its entry in the bladder.The ureter are located retroperitonealy and run from the renal pelvic to urinary bladder.
First part –Enter the pelvis by crossing the common iliac vessel from lateral to medial aspect at their bifurcation just medial to ovarian vessel and run downwards along with greater sciatic notch & reaches ischial spine.
Ureters are retroperitoneal structues which run anterior to psoas muscle and cross lateral to medial.4sites are prone where ureter can be injured and its management
Ureteric injury in Gyenec Surgery, Serious complication of gynecologic surgery
Significant morbidity and long-term sequelae
Uncommon in benign gynecologic surgery
Vaginal hysterectomy has the lowest rate of ureteral injury
Laparoscopic hysterectomy has the highestThe ureters are the muscular ,thick walled narrow tubes(Right and Left)
Each measures 25-30 cm in length and extends from renal pelvis to its entry in the bladder.The ureter are located retroperitonealy and run from the renal pelvic to urinary bladder.
First part –Enter the pelvis by crossing the common iliac vessel from lateral to medial aspect at their bifurcation just medial to ovarian vessel and run downwards along with greater sciatic notch & reaches ischial spine.
Classification & conservative surgeries for prolapseIndraneel Jadhav
Stage 0
no prolapse
- Aa,Ba,Ap,Bp are all at -3
- C or D between tvl and < tvl -2
Stage I
most distal portion > 1cm above level of hymen
Stage II
<1cm proximal to or distal to the plane of hymen
Stage III
>1cm below the plane of the hymen
Stage IV
complete eversion, distal portion at least (tvl -2 cm)
Prevention of Ureteral Injury 2014 - En'wezohDerick En'Wezoh
Author: Derick En'Wezoh
This presentation describes the anatomy of the ureter, risk factors for ureteral injury, and key points from the literature relating to injury of the ureters.
Urinary Tract Fistulas -(VVF) Etiology, Diagnosis, ManagementVikas V
Urinary Tract Fistulas - Etiology, Diagnosis, Management
Surgical and Relevant Anatomy, Classification, eitiology, VVF in Detail, Examination and Diagnosis, Management of VVF - Both Conservative And Surgical Management - Steps of Surgical Management, Post operative Management.
In this introductory remark at workshop on vaginal hysterectomy where Dr Shirish Seth was operating faculty.
I spoke “lets promote and propagate vaginal hysterectomy which is an indigenous surgery in line with PM Modi’s mission of MAKE IN INDIA.
Vaginal hysterectomy is like Aam admi surgery which is in the best interest of patients and has best scientific evidences in its favour."
Let us not be driven by glamour,gadgets and gimmicks."
Laparoscopy in gynaecology presented by drs igbodike emeka philip and dr rotimiigbodikeobgyn
This slide will be helpful if the presentation revolves around laparoscopy in gynaecological practice. Kindly like , clip and share the slide. it is free!
Classification & conservative surgeries for prolapseIndraneel Jadhav
Stage 0
no prolapse
- Aa,Ba,Ap,Bp are all at -3
- C or D between tvl and < tvl -2
Stage I
most distal portion > 1cm above level of hymen
Stage II
<1cm proximal to or distal to the plane of hymen
Stage III
>1cm below the plane of the hymen
Stage IV
complete eversion, distal portion at least (tvl -2 cm)
Prevention of Ureteral Injury 2014 - En'wezohDerick En'Wezoh
Author: Derick En'Wezoh
This presentation describes the anatomy of the ureter, risk factors for ureteral injury, and key points from the literature relating to injury of the ureters.
Urinary Tract Fistulas -(VVF) Etiology, Diagnosis, ManagementVikas V
Urinary Tract Fistulas - Etiology, Diagnosis, Management
Surgical and Relevant Anatomy, Classification, eitiology, VVF in Detail, Examination and Diagnosis, Management of VVF - Both Conservative And Surgical Management - Steps of Surgical Management, Post operative Management.
In this introductory remark at workshop on vaginal hysterectomy where Dr Shirish Seth was operating faculty.
I spoke “lets promote and propagate vaginal hysterectomy which is an indigenous surgery in line with PM Modi’s mission of MAKE IN INDIA.
Vaginal hysterectomy is like Aam admi surgery which is in the best interest of patients and has best scientific evidences in its favour."
Let us not be driven by glamour,gadgets and gimmicks."
Laparoscopy in gynaecology presented by drs igbodike emeka philip and dr rotimiigbodikeobgyn
This slide will be helpful if the presentation revolves around laparoscopy in gynaecological practice. Kindly like , clip and share the slide. it is free!
Maternal birth canal injury following child birth process are quite common and significant to maternal morbidity and even to death. Also, a second most frequent cause of PPH.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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2. incidence
• 75 % of the ureteric injuries occur during
gynaecological surgeries
• Incidence is .3 to .4 %
• Most common procedure :total abdominal
hysterectomy(.5 to 1%)
• Vaginal hysterectomy(.1%)
• Gynae-oncosurgery(30%)
3. Interesting facts……
• Most common site:-pelvic brim near the
infundibulopelvic ligament
• Most common type of injury:-obstruction
• Most common activity leading to injury:attempts to obtain haemostasis
• Most common time of diagonosis:-none
• Most common long term sequele:-none
11. Common sites of injury
• Lateral pelvic sidewall above the uterosacral
ligament
• Dorsal to infundibulopelvic ligament near or at
the pelvic brim
• Cardinal ligament
• Tunnel of Wertheim
• Intramural portion of the ureter
12.
13. Anatomical risk factors
• Ureter……..
1.Has close attachment to peritoneum
2.Has variable course
3.Not easily seen or palpated.
16. Types of injuries
• Intraoperative
1. Crushing(misapplication of a clamp)
2.Ligation(with a suture)
3.Angulation(with secondary obstruction)
4.Ischaemia(stripping,laser,electrocoagulation)
5.Transection(partial or complete)
6.Resection
22. General preventive strategies
• Preoperative measures
1.Intravenous urogram
2.Ultrasound scan
Identify ureteric dilatation and disclose anatomic
variations
3.Preop stenting in case of anatomic distortion
23. • Intraoperative measures
1.Appropriate operative approach
2.Adequate exposure
3.Avoid blind clamping of blood vessals
4.Mobilise bladder away from the operative site
5.Stay outside the vascular sheath
6.Zone of thermal injury
7.Dissection should preferably be done under direct
visualisation
24. • surgeon is to constantly
and equivocally know
where the ureter is all
times
25.
26.
27.
28.
29. Specific preventive measures
• Laparoscopy associated injuries
.3 to .4 % of all the cases
More likely result of thermal injury
More likely to be diagonosed 2 to 5 days after the
surgery
Most commonly during laparoscopic hysterectomy
---when uterine vessals are stapled or electrocoagulated
---infundibulopelvic ligament is transected
Extreme caution when using cautery or laser near or
over the ureter
30. • Complex adnexectomy
Between pelvic brim to tunnel of werthiem
Ureter is commonly injured
Injuries can be avoided using retroperitoneum
approach…..advantages:
1.Access the pelvic vessals for haemostasis
2.Adhesion and pathology free space to operate
If an adnexal mass is adherant to the medial half of the
broad ligament or pelvic peritoneum overlying the
ureter ,the ureter can be safely dissected laterally from
the peritoneum
31. • Abdominal hysterectomy
From where ureter enters tunnel under uterine artery ,lateral to the
uterosacral ligaments,until ureter terminates in the bladder
High risk of injury
-LUS fibroid or cervical fibroid,protruding into broad ligament
-bleeding from pedicals ,esp at the vaginal corners
Myomectomy of a broad ligament fibroid should be preferred by
incision adjacent to the ureter and cervix,staying within the
myometrial capsule
Bleeding from pedicles or vaginal angle should be controlled by a
“superficial”3-0 sutures
Intrafascial hysterectomy,by creating a plane within the
myometrium of LUS and cervix after ligating uterine artery vessels
Fearful of injury:-21 gauge butterfly needle technique.
32. • Caesarean hysterectomy
Supracervical hysterectomy
Hysterotomy incision can be extended
caudally towards the cervix-allow tactile as
well as visual guidance
33. • Vaginal hysterectomy
Uncommon because traction on the cervix
pulls the uterus farther from the ureter
Culdoplasty places the ureter at risk
Maneuvres:1.Palpatory ureteral identification
2.Placinng an allis clamp on the vaginal cuff in
the area of uterosacral ligament
34. • Bladder neck suspension
During retropubic repair
How can injury occur/
-vigorous dissection of space of retzius and
periurethral tissues
-high elevation of burch colposuspension suture
-paravaginal defect repair in combination with
burch procedure
-excessive lateral mobilisation of the bladder brings
ureter into thhhe operative field
35. • Pelvic organ prolapse
relatively common
due to :
1. Direct ligation
2. Kinking as redundant tissues are plicated
Cystoscopy with iv indigo carmine can be
routinely performed.
36. • Radical pelvic surgery
Intentional ureteral surgery:
1.MD Anderson type IV radical hysterectomy
2. Total or anterior pelvic exenteration
3.Resection of a fixed pelvic sidewall mass
Accidental:
1.MD Andersons type 3 radical hysterectomy
2.Radical vaginal trachelectomyfor women with FIGO
stage 1A1 to 1B1 cervical cancer
30 %risk of ureteral dysfunction following therapuetic
radiation therapy.
37.
38.
39.
40.
41.
42.
43.
44. Aim of management
• Preservation of renal function
• Anatomical continuity
• Decision depends upon:1.Time of detection
2.Extent of injury
3.Site of injury
4.General condition of the patient
45. Conservative?
• Obstruction without intraperitoneal or
retroperitoneal leakage
• No major degree of obstruction
• Obstruction is not the result of a permanent
agent
• Small ureteral leak in the setting of prior pelvic
radiation
• For patient waiting for definite repair
46. When to operate?
• If diagonosed immediate post op:-reoperation
within 24 to 48 hrs
• If diagonosed later:-delayed repair
47. General guidelines for the Mx of
ureteral injuries identified at the time
of surgery
• Ureteral ligation:Deligation,assessment of the viability,stent placement
• Partial transection:Primary repair over a ureteric stent
• Total transection: Uncomplicated upper third and middle third:Ureteroureterostomy over ureteral stent
Complicated upper third and middle third:Ureteroileal interposition
Lower third:Ureteroneocystostomy with psoas hitch over ureteral stent
• Thermal injury:Resection with Mx as per a transection
48.
49. Ureteral ligation
Angulation or kinking is much more common if sutures are within
the paraurethral tissues or partially placed through the ureter
First management approach:-PCN
Contrast is injected to see if even a small trickle of dyr gets past the
obstruction;if yes,a thin guidewire is passed down th ureter past
the obstruction;if successful,larger catheters are passed over
it;finally a double J stent left in place for 6 to 8 weeks till the
sutures causing obstruction have dissolved
If obstruction is too tight to be stented or ureter is partially or
completely ligated:-surgical ureterolysis
If the concerned segment is
viable:stent(ureterostomy,cystoscopy,cystostomy)
if dead:-resect
50. Partial transection
Repair is easiest and fastest(ureterotomy has
already occurred)
A stent is placed up and down through the
ureterotomy
A small hole:-stent is not necessary
Excessive suture placement is avoided
Healing is usually rapid and complete
A closed suction drain is placed at the base of the
repair
51.
52. Note……..
Be sure that ureteroureterostomy is
completely tension free
During spatulation be sure that vessals
running in the ureteral sheath are not
transected
Spatulation if done on opposing sides
,ensures a complete water tight seal