Principles of surgery

PART II
Specific Considerations

CHAPTER 41
Gynecology

BASIC SCIENCE QUESTIONS

1. The round ligament leaves the abdomen through the internal inguinal ring to attach to the mons pubis. Its proximal origin is

A. The broad ligament

B. The uterosacral ligament

C. The uterine cervical junction

D. The cornu of the uterus

Answer: D

Emanating from the uterine cornu and traveling through the inguinal canal are the round ligaments, eventually attaching to the subcutaneous tissue of the mons pubis. (See Schwartz 9th ed., p 1479, andFig. 41-1.)

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FIG. 41-1. Internal pelvic anatomy, from above.

2. Which of the following physiologic changes occurs during pregnancy?

A. Increased systemic vascular resistance

B. Decreased minute ventilation

C. Decreased gastric motility

D. Decreased fibrinogen

Answer: C

Table 41-1 summarizes the physiologic changes due to pregnancy. Gastric motility is decreased. Systemic vascular resistance, minute ventilation, and fibrinogen are all increased. (See Schwartz 9th ed., p 1487.)

TABLE 41-1 Physiologic changes due to pregnancy


Cardiovascular changes

Increased cardiac output

Increased blood volume

Decreased systemic vascular resistance

Decreased venous return from lower extremities

Respiratory changes

Increased minute ventilation

Decreased functional residual capacity

GI changes

Decreased gastric motility

Delayed gastric emptying

Coagulation changes

Increased clotting factors (II, V, VII, VIII, IX, X, and XII)

Increased fibrinogen

Increased risk for venous thromboembolism

Renal changes

Increased renal plasma flow and glomerular filtration rate

Ureteral dilation

Initial increased bladder capacity


Source: Adapted with permission from Gabbe S, Niebyl J, Simpson J: Obstetrics: Normal and Problem Pregnancies, 4th ed. Philadelphia: Churchill Livingstone, 2001, Chap. 19, p 608. Copyright © Elsevier.

CLINICAL QUESTIONS

1. Which of the following groups of women should receive an annual cervical cytologic examination (Pap smear)?

A. Starting at age 18, regardless ofn onset of intercourse, and yearly thereafter

B. Starting after 5 years of onset of sexual intercourse and yearly thereafter

C. Starting after first sexual intercourse at any age

D. All women starting after 3 years of onset of sexual intercourse or by age 21 and until 30 years of age

Answer: D

The present guidelines for cervical cytology recommend annual evaluation for all sexually active women up to the age of 30 years old. After age 30, cervical cytology may be extended to every 2 to 3 years if cytology has remained negative and/or testing for human papillomavirus (HPV) high-risk types has been negative. This can be achieved with either liquid techniques or the older smear technique, recognizing that the accepted approach is moving to liquid techniques as they allow for reflex testing of HPV high-risk subtypes as appropriate. (See Schwartz 9th ed., p 1481.)

2. The most common cause of vaginitis is

A. Human papillomavirus

B. Anaerobic bacteria

C. Candida albicans

D. Trichomonas vaginalis

Answer: B

BV (bacterial vaginitis) is the most common cause of vaginal discharge, accounting for 50% of cases. It results from reduction in concentration of the normally dominant lactobacilli and increase in concentration of anaerobic organisms like Gardnerella vaginalisMycoplasma hominisBacteroides spp, and others. Diagnosis is made by microscopy and involves recognition of clue cells, which are epithelial cells studded with adherent bacteria causing their margins to be obliterated. The discharge typically produces a fishy odor upon addition of KOH (amine or Whiff test).

Candida and trichomonas are also common causes of vaginitis. HPV is associated with cervical aplasia and does not cause vaginitis. (See Schwartz 9th ed., p 1484, and Table 41-2.)

TABLE 41-2 Features of common causes of vaginitis

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3. A patient presents with a single genital ulcer. Of the following, the most likely cause is:

A. Herpes

B. Chancroid

C. Lymphgranuloma venereum

D. Granuloma inguinale

Answer: C

Lymphogranuloma venereum usually presents with a single ulcer. Herpes and chancroid most commonly have multiple lesions. Granuloma inguinale is variable in its presentation. The other infection that commonly presents with a single ulcer (chancre) is the primary stage of syphilis. (See Schwartz 9th ed., p 1485.)

4. With no treatment, what percent of patients with primary syphilis eventually progresses to tertiary disease?

A. 10%

B. 30%

C. 50%

D. 70%

Answer: B

The primary stage [of syphilis] is marked by the appearance of a single ulcer (chancre). The chancre usually is firm, round, painless, may be accompanied by regional adenopathy, and develops at the site of entry of the bacterium. It lasts 3 to 6 weeks, and it heals without treatment. However, without treatment, the primary infection progresses to secondary syphilis and eventually to tertiary disease in 30% of cases, after a variable latent phase that usually lasts for years. During pregnancy, syphilis can be transmitted to the fetus and may result in the varied manifestations of congenital syphilis syndrome, which may results in fetal hydrops and intrauterine fetal demise. The diagnosis of syphilis is typically made by examination and serologic testing. Nonspecific nontreponemal tests such as rapid plasma reagin and Venereal Disease Research Laboratories are used for screening, and specific treponemal tests such as fluorescent-labeled treponema antibody absorption and microhemagglutination assay for antibodies to T. pallidum are used for confirmation. (See Schwartz 9th ed., p 1485.)

5. Appropriate antibiotic treatment for chancroid is

A. Penicillin

B. Acyclovir

C. Azithromycin

D. Doxycycline

Answer: C

There are four antibiotics that can be used to treat chancroid (see Table 41-3): azithromycin, ceftriaxone, ciprofloxacin, and erythromycin.

Chancroid is a contagious sexually transmitted ulcerative disease of the vulva caused by Haemophilus ducreyi, small gram-negative rods that exhibit parallel alignment on Gram’s staining (“school of fish”). After a short incubation period, the patient usually develops multiple painful soft ulcers on the vulva, mainly on the labia majora and, less commonly, on the labia minora or involving the perineal area. The chancroid ulcer has ragged, irregular borders and a base that bleeds easily and is covered with grayish exudates. Approximately half the patients will develop painful inguinal lymphadenitis within 2 weeks of an untreated infection, which may undergo liquefaction and presents as buboes. These may rupture and discharge pus. Diagnosis is made by Gram’s stain and, less commonly, by culture. (See Schwartz 9th ed., p 1485.)

TABLE 41-3 Clinical features of genital ulcer syndromes

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6. A 32-year-old woman presents with a swollen, red, tender 3-cm mass in the posterior aspect of the right labia majora at the vaginal orifice. In addition to antibiotics, the appropriate treatment for this lesion is

A. Observation

B. Aspiration and cytologic evaluation

C. Resection of the mass

D. Incision, drainage, and pWord catheter

Answer: D

Bartholin’s glands (great vestibular glands) are located at the vaginal orifice at the 4 and 8 o’clock positions and they are rarely palpable in normal patients. They are lined with cuboidal epithelium and secrete mucoid material to keep the vulva moist. Their ducts are lined with transitional epithelium and their obstruction secondary to inflammation may lead to the development of a Bartholin’s cyst or abscess. Bartholin’s cysts range in size from 1 to 3 cm, and are detected on examination or recognized by the patient. They occasionally result in discomfort and dyspareunia and require treatment. Cysts and ducts can become infected and form abscesses. Infections are often polymicrobial; however, sexually transmitted Neisseria gonorrhea and C. trachomatis are sometimes implicated. Abscesses usually present as acutely inflamed, exquisitely tender masses. Treatment consists of incision and drainage and placement of a Word catheter, a small catheter with a balloon tip, for 2 to 3 weeks to allow for formation and epithelialization of a new duct. Appropriate antibiotic therapy should be instituted and modified based upon culture results. Recurrent cysts or abscesses are usually marsupialized, but on occasion necessitate excision of the whole gland. Marsupialization is done by incising the cyst or abscess wall and securing its lining to the skin edges with interrupted sutures. Cysts or abscesses that fail to resolve after drainage and those occurring in patients >40 years of age should be biopsied to exclude malignancy. (See Schwartz 9th ed., p 1485.)

7. A young female presents with fever, nausea and vomiting, abdominal pain, and a pelvic mass. While in the ED she was given IV fluids and started on IV antibiotics. However, within an hour of presentation she rapidly progressed to septic shock. She was taken to surgery where a ruptured tubo-ovarian abscess was identified. In addition to appropriate antibiotic therapy, the surgical treatment of choice in this unstable patient is

A. Washout with planned re-exploration in 24-48 hours

B. Pelvic drainage

C. Resection of the involved Fallopian tube

D. Total abdominal hysterectomy and bilateral salpingooophorectomy

Answer: D

Surgical intervention becomes necessary if medical therapy of a tubo-ovarian abscess fails or if the abscess ruptures. Rupture of a tubo-ovarian abscess is a surgical emergency with a high mortality rate if not recognized and managed promptly. In addition to management of the septic shock state, total abdominal hysterectomy and bilateral salpingooophorectomy is the procedure of choice; however, conservative surgery must be considered in young patients desiring of future fertility. The abdomen should be explored for meta-static abscesses, and special attention must be paid to bowel, bladder, and ureteral safety due to the friability of the infected tissue and the adhesions commonly encountered at the time of surgery. Placement of an intraperitoneal drain and mass closure of the peritoneum, muscle, and fascia with delayed-absorbable or permanent sutures is advised. (See Schwartz 9th ed., p 1486.)

8. In a nulliparous young female with contraindications to methotrexate therapy, a nonruptured ectopic pregnancy should be treated by

A. Observation if the patient is hemodynamically stable and the Hb is >12 gm/dL

B. Removal of the products of conception by milking to distal end of the Fallopian tube

C. Antimesenteric salpingotomy and removal of products of conception

D. Unilateral salpingectomy

Answer: C

Early ectopic pregnancies can be managed with methotrexate. Advanced ectopic pregnancy or a patient with unstable vital signs is managed by laparoscopy or laparotomy. Linear salpingostomy along the antimesenteric border and removal of the products of conception is a reasonable option unless the oviduct has already ruptured and a large hemoperitoneum already exists, in which case removal of the tube should be performed. (See Schwartz 9th ed., p 1487.)

9. The material most commonly used for a urethral sling (for urinary incontinence) is

A. Wire mesh bands

B. Prolene suture in doublets

C. Gortex mesh bands

D. Autograft rectus fascia or allograft fascia lata.

Answer: D

A variety of organic and synthetic graft materials have been used to construct suburethral slings. Synthetic materials fell out of favor after a high incidence of postoperative urinary retention and urethral damage were found to be associated with their use. Currently, the most commonly used sling materials include autografts of rectus fascia and processed cadaveric allografts (fascia lata).

The procedure is performed by a combined abdominovaginal approach, using a small transverse suprapubic skin incision. The space of Retzius is entered using a blunt clamp or closed heavy Mayo scissors to penetrate the perineal membrane along the inferior aspect of the descending pubic ramus. A Bozeman clamp or long-angled ligature carrier is used to perforate the rectus fascia two fingerbreadths superior to the pubic bone just medial to the pubic tubercle, and the instrument is guided along the back of the pubic bone through the space of Retzius and into the vaginal incision to retrieve one arm of the sling. After bringing up the other side of the sling, and confirming the absence of urinary tract injury, the sling arms are tied.

Cure rates range from 75 to 95% for the many different types of sling procedures. Slings are associated with higher complication rates than most other incontinence procedures, most frequently involving voiding dysfunction, urinary retention, new-onset urge incontinence, and foreign-body erosion. (See Schwartz 9th ed., p 1490.)

10. Paget’s disease of the vulva is associated with

A. Invasive adenocarcinoma

B. Papillary carcinoma of the thyroid

C. Retroperitoneal fibrosis

D. Melanoma

Answer: A

Paget’s disease of the vulva is an intraepithelial disease of unknown etiology that affects mostly white postmenopausal women in their sixth decade of life. It causes chronic vulvar itching and is sometimes associated with an underlying invasive vulvar adenocarcinoma or invasive cancers of the breast, cervix, or GI tract. Grossly, the lesion is variable but usually confluent, raised, erythematous to violet, and waxy in appearance. Biopsy is required for diagnosis; the disease is intraepithelial and characterized by Paget’s cells with large pale cytoplasm. Treatment is assessment for other potential concurrent adenocarcinomas and then surgical removal by wide local resection of the involved area with a 2-cm margin. Free margins are difficult to obtain because the disease usually extends beyond the clinically visible area. Intraoperative frozen section of the margins can be done to ensure complete resection. Unfortunately, Paget’s vulvar lesions have a high likelihood of recurrence even after securing negative resection margins. (See Schwartz 9th ed., p 1491.)

11. Up to what percentage of cervical cancer in the United States could be prevented if girls were vaccinated against HPV prior to infection?

A. 10%

B. 30%

C. 50%

D. 70%

Answer: D

The oncogenes of high-risk HPV are both initiating and promoting for cervical cancer. Other correlates with disease include concurrent active HIV infection with immunosuppression, smoking, and probably other genetic factors. It is anticipated that early vaccination, before infection, will function as primary prevention for cervical cancer. It is expected to reduce both the risk and frequency of high-grade CIN, but also translate to marked reduction in actual invasive cancer, requiring 20 to 40 years to see full impact. However, not all high-risk HPV subtypes are covered in the two vaccines available in 2009. Thus, vaccination will likely prevent approximately 70% of cancers in the United States, depending on regional area distribution of oncogenic subtypes. Vaccines are approved for girls ages 9 to 26, but are recommended preferentially for the younger girls as there was a stronger immunologic response seen. (See Schwartz 9th ed., p 1494.)

12. At the time of laparoscopic cholecystectomy, extensive endometriosis is noted in the pelvis. The patient denies pelvic pain and has completed her family with no desire for future pregnancies. The best treatment is

A. Follow clinically; no treatment is indicated

B. Oral contraceptive pills (OCPs)

C. Danazole

D. Ablation of the lesions with electrocautery

Answer: A

Endometriosis is the finding of ectopic endometrial glands and stroma outside the uterus. It a common condition affecting 10% of the general population, and it is an incidental finding at the time of laparoscopy in >20% of asymptomatic women. It is especially prevalent in patients suffering from chronic pelvic pain (80%) and infertility (20 to 50%).

Expectant management is appropriate in asymptomatic patients. Those with mild symptoms can be managed successfully with cyclic or continuous OCPs combined with the as- needed use of analgesics such as NSAIDs. Moderate symptoms are treated with medroxyprogesterone acetate 10 to 20 mg orally daily or 150 mg IM injection every 3 months. Its use should be limited to 2 years or less because of its negative effects on bone density. Severe symptoms are treated with either danazol or gonadotropin-releasing hormone (GnRH) agonists to induce medical pseudomenopause. Danazol has been largely abandoned secondary to its marked androgenic side effects, such as acne and hirsutism. GnRH agonists act by suppressing the release of gonadotropins (luteinizing and follicle-stimulating hormones) from the pituitary gland and are available in injections or nasal spray preparations.

Conservative surgical therapy [for symptomatic patients] is a popular option because it can be done at the time of the diagnostic laparoscopy and usually involves lysis of adhesions, ablation of endometriotic implants using carbon dioxide laser or electrocautery, and/or resection of deep endometriotic implants. (See Schwartz 9th ed., p 1497.)

13. Which of the following is a contraindication to uterine artery embolization for treatment of a symptomatic leiomyoma?

A. Solitary lesion 6 cm in diameter

B. Plans for future pregnancies

C. Submucosal location

D. Intramural location

Answer: B

Management options of leiomyomas are tailored to the individual patient, depending on her age and desire for fertility and the size, location, and symptoms of the myomas. Conservative management options include OCPs, medroxyprogesterone acetate, GnRH agonists, uterine artery embolization, and myomectomy. Uterine artery embolization is contraindicated in patients planning future pregnancy and frequently results in acute degeneration of myomas requiring hospitalization for pain control. Myomectomy is indicated in patients with infertility and those who wish to preserve their reproductive capabilities and can be done by laparoscopy, hysteroscopy, or laparotomy. (See Schwartz 9th ed., p 1498, and Fig. 41-2.)

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FIG. 41-2. Types of uterine myomas.

14. A 38-year-old patient with a family history of colon and endometrial cancer in multiple first- and second -degree relatives is diagnosed with endometrial cancer herself. She should be offered:

A. MRI of the brain

B. Colonoscopy and genetic testing

C. Bone marrow biopsy

D. Ultrasound of the thyroid

Answer: B

Hereditary nonpolyposis coli cancer, a cancer family syndrome, also known as Lynch II syndrome, is an autosomal dominant inherited predisposition to develop colorectal carcinoma and other extracolonic cancers, predominantly including tumors of the uterus and ovaries, with rare but defined inclusion of breast cancer. The risk of colorectal carcinoma is as high as 75% by age 75 years old. Affected female patients have a 40% and 10% lifetime risk of developing uterine and ovarian cancers, respectively. Surveillance has not been proven to identify disease in early stage for these patients but is (informally) recommended and should include annual cervical cytology, mammography, transvaginal ultrasound (TVUS), CA measurements, and an endometrial biopsy. (See Schwartz 9th ed., p 1499.)

15. The average distance from the umbilicus to the aorta in a woman of normal weight is

A. 6 cm

B. 9 cm

C. 12 cm

D. 15 cm

Answer: A

The aorta is only approximately 6 cm from the umbilicus. The distance is even less if the abdominal wall is compressed towards the spine. This is critically important to recognize when placing Varess needles for induction of laparoscopic pneumoperitoneum. (See Schwartz 9th ed., p 1506, and Fig. 41-3).

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FIG. 41-3. Changes in the anterior abdominal wall anatomy with weight.

16. Which of the following is considered a risk factor for epithelial ovarian cancer?

A. Pregnancy

B. Tubal ligation

C. OCP use for >5 years

D. Endometriosis

Answer: D

Patients with endometriosis are at increased risk for epithelial ovarian cancer. Pregnancy, tubal ligation, and oral contraceptive (OCP) use for >5 years decrease the risk of developing epithelial ovarian cancer.

Ovarian endometriosis can mimic ovarian/tubal cancer symptoms and also can be associated with an increase in CA 125. It has been associated with an increased risk of malignant ovarian disease of endometrioid and clear-cell histology with reported relative risks in the range of 1.4. (See Schwartz 9th ed., p 1508, and Table 41-4.)

TABLE 41-4 Risk and protective factors for epithelial ovarian and fallopian tube cancers

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17. Which of the following is one of the variables included in the ovarian cancer symptom index?

A. Constipation

B. Dysuria

C. Early satiety

D. Menstrual irregularity

Answer: C

Common symptoms for either benign or malignant ovarian tumors include pelvic discomfort, cramping, pain, fullness, headache, backache, and others. These are all symptoms that can be attributed to a variety of pathology from infection to pregnancy to irritable bowel syndrome to cancer. Recent work has identified an ovarian cancer symptom index (Table 41-5), now adopted/supported by the Ovarian Cancer National Alliance, the Gynecologic Cancer Foundation, the Society of Gynecologic Oncologists, and the American Cancer Society. It is based on a 2007 publication by Goff and colleagues, and describes symptoms of bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms of urgency or frequency. These are symptoms that women with ovarian cancer report as newly developed and persistent, or representing a distinct change from their personal norm. The consensus statement says that if the symptom(s) persist for more than a few weeks, the woman should seek medical care. This medical attention should include an evaluation specifically targeted for identification of gynecologic malignancy. (See Schwartz 9th ed., p 1508.)

TABLE 41-5 Ovarian cancer symptom index (2007) and ACOG guidelines for patient referral to gynecologic oncology

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18. At the time of laparoscopic appendectomy in a 26-year-old nulliparous female, an isolated 4-cm right ovarian mass was identified. A right salpingo-oophorectomy was performed. The abdominal and pelvic surveys were negative and the contralateral ovary was normal. Pathologic examination revealed a mucinous borderline tumor confined to the ovary. The most appropriate management is

A. Clinical follow- up

B. Contralateral oophorectomy

C. Total abdominal hysterectomy

D. Total abdominal hysterectomy + chemotherapy

Answer: A

LMP [low malignant potential] tumor, also known as borderline tumor, is histologically different from true malignancy. It is seen in the ovary with case reports of occurrences in fallopian tubes and accounts for approximately 15% of ovarian neoplasms. The World Health Organization defines LMP tumors as characterized by epithelial proliferation greater than seen in benign tumors and lack of destructive (ovarian) stromal invasion. This entity has an earlier median age of onset, up to two decades earlier than epithelial malignant tumors. Presentation is predominantly stage I and II, and histology includes all subtypes identified for frank malignancy: papillary serous, mucinous, clear-cell, endometrioid, and transitional or Brenner tumor. Surgical intervention is the recommendation of choice. Stages I and II LMP tumors have a 10-year survival of nearly 100%. (See Schwartz 9th ed., p 1509.)