Tutorial 22nd. August 2016

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22 August 2016.

75	EMQ. Kallmann’s syndrome
76	EMQ. Endometrial cancer & FIGO
77	EMQ. Epidural anaesthesia
78	SBA. Sutures and needles
79	EMQ. PALB gene

75.         EMQ. Kallmann’s syndrome.

Abbreviations.

Ks:         Kallmann’s syndrome

Scenario 1.                

Which of the following might be included in descriptions of Kallmann’s syndrome?

Option list.

A	hypogonadotrophic hypogonadism
B	hypogonadotrophic hypogonadism + anosmia
C	hypogonadotrophic hypogonadism + anosmia + colour-blindness
D	hypogonadotrophic hypogonadism due to uterine agenesis

Scenario 2.                

Lead in.

Which, if any, of the following are features of the Kallmann phenotype?

A	absent or minimal breast development
B	aortic stenosis
C	blue eyes
D	blue hair
E	hot flushes
F	short stature
G	tall stature
H	vaginal agenesis
I	none of the above

Scenario 3.                

How common is Kallmann’s syndrome and what is the female: male ratio?

A	1 in 1,000 and F:M ratio 1:1
B	1 in 5,000 and F:M ratio 1:1
C	1 in 10,000 and F:M ratio 1:4
D	1 in 50,000 and F:M ratio 1:4
E	1 in 100,000 and F:M ratio 1:8
F	1 in 250,000 and F:M ration 1:10

Scenario 4.                

What is the most common mode of inheritance of Ks?

Option list.

A	hypogonadotrophic hypogonadism
B	hypogonadotrophic hypogonadism + anosmia
C	hypogonadotrophic hypogonadism due to uterine agenesis
D	autosomal dominant
E	autosomal recessive
F	X-linked recessive
G	new mutation of the ANOS1 gene
H	the most common mode of inheritance is not known

Scenario 5.                

How is Kallmann’s syndrome diagnosed?

A	abdominal and pelvic ultrasound scan
B	cell-free fetal DNA
C	chromosome analysis
D	CT scan of hypothalamus / pituitary
E	MR scan of hypothalamus / pituitary
F	none of the above.

Scenario 6.                

How is Kallmann’s syndrome treated initially?

Which of the following statements are true?

Option list.

A	GnRH analogue depot
B	pulsatile GnRH therapy
C	combined oral contraceptive
D	counselling & education re gender re-assignment
E	depot progestogen
F	none of the above

Scenario 7.                

A woman was diagnosed with Kallmann’s syndrome at 16 and had successful initial treatment. She is now 25, married and wishes to have a pregnancy. She has had pre-pregnancy assessment and counselling. Which of the following can be considered?

A	GnRH analogue depot
B	induction of ovulation with clomiphene
C	gonadotrophin therapy
D	pulsatile GnRH therapy
E	none of the above

76.         EMQ. Endometrial cancer & FIGO.

Lead-in.

The following scenarios relate to endometrial cancer and the FIGO classification.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Option list.

Scenario 1.

A histology report on endometrial curetting is of 95% adenocarcinoma with 5% solid, non-squamous areas. What is the FIGO grade?

Scenario 2.

A histology report on endometrial curetting is of 90% adenocarcinoma with 10% solid, non-squamous areas. What is the FIGO grade?

Scenario 3.

A histology report on endometrial curetting is of 50% adenocarcinoma with 50% solid, non-squamous areas. What is the FIGO grade?

Scenario 4.

A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 5% myometrial invasion. What is the FIGO staging?

Answer.

Scenario 5.

A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 25% myometrial invasion. What is the FIGO staging?

Scenario 6.

A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 60% myometrial invasion. What is the FIGO staging?

Scenario 7

A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the uterus. There is no myometrial invasion, but there is extension to the endocervical endothelium. What is the FIGO staging?

Scenario 8

A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the uterus. There is no myometrial invasion, but there is extension to the stroma of the cervix. What is the FIGO staging?

Scenario 9

A woman undergoes surgery for carcinoma of the endometrium. Peritoneal washings are +ve but there is no other evidence of spread outside the uterus. There is no myometrial invasion. There is extension to the stroma of the cervix. What is the FIGO staging?

Scenario 10

A woman undergoes surgery for carcinoma of the endometrium. There is no evidence of extension outside the uterus. There is myometrial invasion through to and including the serosa. What is the FIGO staging?

Scenario 11

A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. There is no evidence of disease elsewhere. What is the FIGO staging?

Scenario 12

A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. Positive pelvic nodes are found, but no other lymphatic involvement. There is no distant spread. What is the FIGO staging?

Scenario 13

A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. The tumour involves the mucosa of the bladder. There is no lymphatic or distant spread. What is the FIGO staging?

77.         EMQ. Epidural anaesthesia.

Option list.

A.        True

B.         False

C.         ≥ 1 in 10

D.        1 in 10 to 1 in 100.

E.         1 in 100 to 1 in 1,000

F.         1 in 1,000 to 1 in 50,000

G.        1 in 50,000 to 1 in 100,000

H.        1 in 100,000 or less

I.           T₈ - T₁₂

J.          T₁₀ – L₁

K.         L₂ - L₈.

L.          L₈ - S₁

M.      S₁ – S₄

N.        S₂ – S₄

O.        S₃ – S₅

P.         10%

Q.        20%

R.         20 – 50%

S.         50 – 70%

T.     80 – 90%

U.     90 – 100%

V.     I have no idea, I don’t care and I am going to the pub to drown my sorrows!

W.   None of the above.

Scenario 1.

Which spinal level(s) conduct pain sensation from the uterus and cervix?

Scenario 2.

Which spinal level(s) conduct pain from the perineum?

Scenario 3.

Which spinal level(s) conduct pain from the left big toe and what does it signify?

Scenario 4.

Maternal pyrexia is a complication of epidural anaesthesia.

Scenario 5.

Spinal anaesthesia is effective more rapidly than epidural anaesthesia.

Scenario 6.

Adding an opioid to the local anaesthetic drug increased the potency of epidural anaesthesia.

Scenario 7

What is the rate of incomplete block with epidural anaesthesia?

Scenario 8

Epidural anaesthesia may worsen idiopathic intracranial hypertension.

Scenario 9

Epidural anaesthesia increases the risk of instrumental delivery.

Scenario 10

Epidural anaesthesia increases the Caesarean section rate.

Scenario 11

Epidural anaesthesia increases the length of labour.

Scenario 12.

Epidural anaesthesia is contraindicated for the woman with idiopathic intracranial hypertension who is in labour.

78.         EMQ.

Sutures and needles.

Abbreviations

Eas:          external anal sphincter

Ias:           internal anal sphincter

OASI:       obstetric anal sphincter injury

SSI:           surgical site infection

Question 1.

Lead-in

What is the incidence of significant infection of abdominal surgical wounds?

Option List

A.	≤ 1%
B.	≤ 3%
C.	≤ 5%
D.	≤ 7%
E.	≤ 10%

Question 2.

Lead-in

Which, if any, of the following statements are true in relation to SSIs?

Option List

A.	pre-operative showering with antiseptic reduces the rate
B.	pre-operative chemical depilation of the wound site halves the rate
C.	povidone-iodine preparations are superior to those with chlorhexidine
D.	alcohol based antiseptic preparations are superior to aqueous
E.	antiseptic solutions should be applied using sponge not swab

Question 3.

Lead-in

Why do alcohol-based solutions carry more risk and how can these risks be minimised?

There is no option list – write your thoughts and compare them with my answer.

Question 1.

Lead-in

Which of the following terms are used to categorise suture materials?

Option List

F.	natural
G.	synthetic
H.	monofilament
I.	coated
J.	none of the above

Question 4.

Which, if any, of the following are sources of catgut?

Option List

A.	cats
B.	cows
C.	kangaroos
D.	sheep
E.	whales

Question 5.

Lead-in

Which of the following is closest to being the ideal suture material?

Option list

A.	natural
B.	synthetic
C.	monofilament
D.	coated
E.	none of the above

Question 6.

Lead-in

What would be the key characteristics of the ideal suture?

There is no option list – write as many as you can dream up.

Question 7.

Lead-in

Which suture is recommended in GTG 29 for the repair of the anal mucosa in OASIs?

Option List

A.	2-0 polyglactin
B.	3-0 polyglactin
C.	2-0 PDS
D.	3-0 PDS
E.	none of the above

Question 8.

Lead-in

Which, if any, of the following suturing techniques are recommended in GTG 29 for the repair of the anal mucosa in OASIs?

Option List

A.	continuous suture
B.	figure of 8 suture
C.	interrupted sutures with the knot buried beneath the perineal muscles
D.	interrupted sutures with the knots in the anal canal
E.	submucosal suture like a subcuticular suture for skin

Question 9.

Lead-in

Which would be the most suitable suture for repair of the mesosalpinx during tubal re-anastomosis for reversal of sterilisation after tubal ligation?

Option List

A.	Vicryl 0 on a cutting needle
B.	Vicryl 2-0 on a cutting needle
C.	Vicryl 2-0 on a round-bodied needle
D.	Vicryl 3-0 on a cutting needle
E.	Vicryl 3-0 on a round-bodied needle

Question 10.

Lead-in

Which would be the most suitable suture for the tubal surgery necessary during tubal re-anastomosis for reversal of sterilisation after tubal ligation?

Option List

A.	Vicryl 3-0 on a cutting needle
B.	Vicryl 3-0 on a round-bodied needle
C.	Vicryl 5-0 on a cutting needle
D.	Vicryl 5-0 on a round-bodied needle
E.	Vicryl 7-0 on a cutting needle
F.	Vicryl 7-0 on a round-bodied needle

Question 11.

Lead-in

You are performing Caesarean section on a woman who has had 2 previous sections. The bladder is very adherent. You separate it from the lower segment using sharp dissection and taking great care. You notice a 1 cm. defect in the dome of the bladder. The ureteric openings are far from the damage. Which suture would you use for the repair, assuming that you have the training and expertise to perform it?

Option List

A.	Single-layer repair using interrupted sutures of 2-0 Vicryl
B.	Two-layer repair using interrupted sutures of 2-0 Vicryl
C.	Single-layer repair using interrupted sutures of 3-0 Vicryl
D.	Two-layer repair using interrupted sutures of 3-0 Vicryl
E.	None of the above

Question 12.

Lead-in

You are performing hysterectomy + bilateral salpingo-oophorectomy for menorrhagia and extensive endometriosis. After dissecting the right ovary free from adhesion  to the pelvic side-wall, you detect urine and note that the ureter has been cut. It is suitable for anastomosis.

Which of the following would you use for the repair, assuming that you have the training and expertise to perform it?

Option List

A.	Single-layer repair using interrupted sutures of 2-0 Vicryl
B.	Two-layer repair using interrupted sutures of 2-0 Vicryl + stent
C.	Single-layer repair using interrupted sutures of 3-0 Vicryl
D.	Two-layer repair using interrupted sutures of 3-0 Vicryl + stent
E.	None of the above

Question 13.

Lead-in

An obese, woman of 80 years has a laparotomy for debulking of an ovarian malignancy via a mid-line incision. Which of the following would be most suitable for closing the abdomen.

Option List

A.	0 Vicryl to muscle / fascia, 2-0 Vicryl to fat, interrupted 2-0 Vicryl to skin
B.	0 Vicryl to muscle / fascia, 2-0 Vicryl to fat, interrupted 2-0 Vicryl to skin + fat drain
C.	mass closure using 0 Vicryl, interrupted 2-0 Vicryl to skin
D.	mass closure using 1 Vicryl, interrupted 2-0 Vicryl to skin
E.	mass closure using 0 Prolene, interrupted 2-0 Vicryl to skin

Question 14.

Lead-in

You perform Caesarean section for a woman with a breech presentation. She had a mid-line lower abdominal scar resulting from a laparotomy some years before. She has requested that you use this scar and is aware of the slightly increased risk of dehiscence and hernia formation.

Which of the following best describes your decision re closing the abdomen.

Option List

A.	close each layer separately using 0 Vicryl, don’t close peritoneum
B.	mass closure using continuous 0 Prolene, peritoneum not closed
C.	mass closure using interrupted 0 Prolene, peritoneum not closed
D.	mass closure using continuous 0 Vicryl, peritoneum not closed
E.	mass closure using 0 Vicryl, peritoneum closed

Question 15.

Lead-in

You perform Caesarean section for a primigravida with a breech presentation. When you close the uterus, which of the following statements will govern the technique you use.

Option List

A.	the uterus should be exteriorised to maximise access
B.	the uterus should be explored digitally to exclude retained products, e.g. a succenturiate lobe of the placenta
C.	the uterus should be cleaned out with a swab to remove any debris
D.	double-layer closure is recommended
E.	closure of the pelvic peritoneum is recommended

Question 16.

Lead-in

A parous woman has a normal delivery, then a PPH. All conservative measures fail to arrest the bleeding and you decide to insert a uterine compression suture. Which of the following statements would apply to what you do.

Option List

A.	place and inflate an intrauterine balloon before inserting the suture to maximise the effect.
B.	exteriorise the uterus to reduce the risk of injury to bowel when placing sutures
C.	use 1 Vicryl or 1PDS
D.	use a curved needle of diameter at least 6 cm.
E.	none of the above

TOG CPD 16.1

Abdominal incisions and sutures in obstetrics and gynaecology

With respect to the risk of surgical site infection following abdominal incisions,

1.     it is reduced with preoperative antiseptic showering.

2.     it is reduced if the site is depilated preoperatively.

3.     it is increased approximately seven-fold by morbid obesity.

Which of the following is/are true about abdominal incisions?

4.     In a Pfannenstiel incision, the layers of the abdominal wall are cut transversely, including the rectus muscle.

5.     A Joel-Cohen incision is located slightly lower than a Pfannenstiel incision.

6.     The incidence of wound dehiscence is ↓ with paramedian compared with median incisions.

7.     A caesarean section through the Joel-Cohen incision carries less postoperative febrile morbidity when compared to that through a Pfannenstiel incision.

8.     A transverse incision is associated with reduced incidence of wound dehiscence compared with a vertical incision.

9.     With regard to skin incisions for laparoscopic surgery,. those that are more than 7 mm will need formal deep sheath closure.

Which of the following statements is/are true?

10.   The primary function of a suture is to maintain tissue approximation during healing.

11.   Wound infection rate is higher with braided compared with monofilament sutures.

12.   Non-absorbable sutures are associated with reduced incidence of wound dehiscence.

13.   PDS (polydiaxanone) is a braided suture with high tissue reaction.

14.   Polypropylene is a monofilament suture with least tissue reaction.

15.   Vicryl rapide is absorbed in 60–90 days.

With regard to use of staples for closure,

16.   the non-absorbable variety has the highest tensile strength of any wound closure device.

17.   contaminated wounds closed with staples have a lower incidence of infection compared with those closed with sutures.

18.   the absorbable varieties have a tissue half-life of 10 weeks.

With regard to electrosurgery,

19.   it is associated with poor wound healing when used to incise the skin.

20.   the use of a separate scalpel for superficial and deep incisions is recommended.

79.         SBA. PALB2 gene

Lead-in.

The following scenarios relate to PALB2 mutations

Scenario 1.  What does the acronym PALB2 mean?

Option list.        

         A.  Partner and localiser of BRCA2

         B.  Partial amyl-lipase bearer

         C. Pulmonary and liver beta-hydrogenase 2

         D.  Patently absurd language bashing

         E.  My second-best friend in secondary school

Scenario 2.  What kind of gene is PALB2?

Option list.

         A.  cytochrome P450 inducing gene

B.  DNA repair gene

         C.  RNA repair gene

         D.  maternal mitochondrial gene

Scenario 3.  Which female cancer is particularly linked to loss-of-function mutations in PALB2?

Option list.

         A.  breast cancer

         B.  cervical cancer

         C.  choriocarcinoma

         D.  endometrial cancer

         E.  ovarian cancer