Cystorrhaphy, suture of bladder wound, injury or rupture; complicated

Synonyms
Suture of bladder rupture complicated by previous surgery
Suture of wound, injury, or rupture of bladder
Suture of bladder injury complicated by congenital defect
CYSTORRHAPHY SUTR BLDR WND INJ/RPT COMPLICATED
Suture of bladder injury
Suture of bladder rupture complicated by congenital defect
Suture of bladder rupture
Suture of bladder injury complicated by previous surgery
ID

http://purl.bioontology.org/ontology/CPT/51865

altLabel

Suture of bladder rupture complicated by previous surgery

Suture of wound, injury, or rupture of bladder
Suture of bladder injury complicated by congenital defect
CYSTORRHAPHY SUTR BLDR WND INJ/RPT COMPLICATED
Suture of bladder injury
Suture of bladder rupture complicated by congenital defect
Suture of bladder rupture
Suture of bladder injury complicated by previous surgery

CPT LEVEL

CC

CPTDTK CONCEPT ID

1008302

cui

C0372384
C3867815
C3522855
C3867816
C3514622
C3522854
C3867817
C3867818

Date created

Pre-1990

Inverse of SIB
notation

Cystorrhaphy, suture of bladder wound, injury or rupture; simple

51865

prefLabel

Cystorrhaphy, suture of bladder wound, injury or rupture; complicated

REPORTABLE

tui

T061

subClassOf

Cystorrhaphy, suture of bladder wound, injury or rupture

Postpartum Hemorrhage in Emergency Medicine

Author: Maame Yaa A B Yiadom, MD, MPH; Chief Editor: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM,
FACHE more...

Overview

Presentation
DDx
Workup
Treatment
Medication
Updated: Nov 07, 2015

Practice Essentials

Background
Pathophysiology
Frequency
Prognosis
Patient Education
Show All
References

Practice Essentials
Defining postpartum hemorrhage (PPH) has historically been difficult. Waiting for a patient to meet PPH criteria,
particularly in resource-poor settings or in cases of sudden hemorrhage, may delay appropriate intervention.
Any bleeding that has the potential to result in hemodynamic instability, if left untreated, should be considered
PPH and managed accordingly. PPH can be divided into 2 types: early (< 24 hours after delivery) and late (24
hours to 6 weeks after delivery). Most cases of PPH (>99%) are early.

Signs and symptoms

The clinical history should begin with consideration of signs and symptoms that are most crucial in managing
potential circulatory collapse, identifying the cause of PPH, and selecting therapies, as follows.
Severity of bleeding:

Is the placenta delivered?

What has been the duration of the third stage of labor?
How long has the bleeding been heavy?
Was initial postdelivery bleeding light, medium, or heavy?
Are symptoms of hypovolemia present?
In delayed PPH, what is the bleeding pattern since delivery?
Intervention guides:

Is there a history of transfusion or transfusion reaction? What was the reason for transfusion?
Past medical history
Allergies
Predisposing factors and potential etiology:

History of PPH
Gravity, parity, length of most recent pregnancy, history of multiple gestations
Number of fetuses for the most recent pregnancy
Pregnancy complications
Spontaneous versus manual delivery of the placenta
Vaginal delivery versus cesarean delivery, current and past
Cesarean delivery Planned in advance, decided on after a failed vaginal delivery attempt, or
performed on an emergency basis
Other uterine surgeries
Personal or family history of bleeding disorder

Medications
Vaginal penetration since delivery
Signs or symptoms of infection
Other information helpful for continued management
Time and location of delivery, and any assistant(s) involved
Location and provider of prenatal care
Health of infant at delivery and any complications or concerns before, during, or after delivery
Past surgical history
The physical examination should focus on determining the cause of the bleeding. Important organ systems to
assess include the following:

Pulmonary (pulmonary edema)

Cardiovascular (heart murmur, tachycardia, strength of peripheral pulses)
Neurologic (mental status changes from hypovolemia)
Specifically, examination should include the following:

Abdominal examination
Perineal examination
Speculum examination of the cervix and vagina
Bimanual examination
Placental examination
See Presentation for more detail.

Diagnosis
Laboratory studies that may be helpful include the following:

Complete blood count (CBC) with hemoglobin and hematocrit

Coagulation studies
Electrolytes
Blood urea nitrogen (BUN) and creatinine
Type and crossmatch
Liver function tests (LFTs), amylase, lipase
Lactate
Imaging studies to be considered include the following:

Ultrasonography This is a fast and helpful modality for imaging pelvic structures and should be the
first-line study for pelvic pathology

Computed tomography (CT) This may be a helpful follow-up study when ultrasonography is not
diagnostic and may also be the first-line study when a pelvic hematoma or abscess is suspected

Magnetic resonance imaging (MRI) This study can help determine whether a fluid collection
(hematoma or abscess) is intrauterine or extrauterine when ultrasonography or CT does not; it can also help
to distinguish a placenta accreta from simple retained products of conception
See Workup for more detail.

Management
Prehospital care includes the following:

Primary survey of the mother (vital signs, ABCs)

Immediate interventions as appropriate Gentle massage of the uterine fundus; fluid resuscitation with
crystalloids; packing of any visible perineal lacerations; oxytocin

Minimal measure necessary on scene to stabilize the mother and baby for transport and further care
Emergency department care includes the following:

History and physical examination according to acute life support algorithms

Immediate OB/GYN consultation

Primary survey (ABCs)
Laboratory studies (including blood cultures if the patient is febrile or the vaginal blood/discharge is
malodorous)

Secondary survey Focused physical examination; bedside ultrasonography (FAST)

Interventions to address specific presentations as appropriate Uterine atony; uterine rupture; trauma;
retained placental tissue; uterine inversion; thrombosis
Immediate consultation with an OB/GYN is vital. If no OB/GYN is available, a general surgeon should be
consulted. Direct contact with the blood bank is essential for assuring timely arrival of any blood products
ordered.

Hysteroscopy

Author: John C Petrozza, MD; Chief Editor: Michel E Rivlin, MD more...

Overview
Workup
Treatment
Updated: Dec 30, 2015

Background

History of the Procedure

Indications
Relevant Anatomy
Contraindications
Show All
Tables
References

Background
Hysteroscopy is the process of viewing and operating in the endometrial cavity from a transcervical approach.
The basic hysteroscope is a long, narrow telescope connected to a light source to illuminate the area to be
visualized. With a patient in the lithotomy position, the cervix is visualized by placing a speculum in the vagina.
The distal end of the telescope is passed into a dilated cervical canal, and, under direct visualization, the
instrument is advanced into the uterine cavity. A camera is commonly attached to the proximal end of the
hysteroscope to broadcast the image onto a large video screen. Other common modifications are inflow and
outflow tracts included in the shaft of the telescope for fluids. Media, such as sodium chloride solution, can be
pumped through a hysteroscope to distend the endometrial cavity, enabling visualization and operation in an
enlarged area.
Hysteroscopy is a minimally invasive intervention that can be used to diagnose and treat many intrauterine and
endocervical problems. Hysteroscopic polypectomy, myomectomy, and endometrial ablation are just a few of
the commonly performed procedures. Given their safety and efficacy, diagnostic and operative hysteroscopy
have become standards in gynecologic practice.

Equipment
Hysteroscopes
The telescope consists of 3 parts: the eyepiece, the barrel, and the objective lens. The focal length and angle
of the distal tip of the instrument are important for visualization (as are the fiberoptics of the light source).

Angle options include 0, 12, 15, 25, 30, and 70. A 0 hysteroscope provides a panoramic view, whereas
an angled one might improve the view of the ostia in an abnormally shaped cavity.
Hysteroscopes are available in different styles, including rigid and flexible (used most commonly in clinical
settings) hysteroscopes, contact hysteroscopes, and microcolpohysteroscopes. The diameter of each
instrument varies and is an important consideration. The requirement of a sheath for input-outflow of distention
media increases the size of the hysteroscope.
Rigid hysteroscopes
Rigid hysteroscopes are the most commonly used instruments. Their wide range of diameters allows for inoffice and complex operating-room procedures. Of the narrow options (3-5 mm in diameter), the 4-mm scope
offers the sharpest and clearest view. It accommodates surgical instruments but is small enough to require
minimal cervical dilation. In addition, patients tolerate this instrument well with only paracervical block
anesthesia.
Rigid scopes larger than 5 mm in diameter (commonly 8-10 mm) require increased cervical dilation for
insertion. Therefore, they are most frequently used in the operating room with intravenous (IV) sedation
or general anesthesia. Large instruments include an outer sheath to introduce and remove media and to
provide ports to accommodate large and varied surgical instruments.
Flexible hysteroscopes
The flexible hysteroscope is most commonly used for office hysteroscopy. It is notable for its flexibility, with a tip
that deflects over a range of 120-160. Its most appropriate use is to accommodate the irregularly shaped
uterus and to navigate around intrauterine lesions. It is also used for diagnostic and operative procedures.
During insertion, the flexible contour accommodates to the cervix more easily than does a rigid scope of a
similarly small diameter. The view was initially described as having a ground-glass quality, which was markedly
less desirable than the view obtained with rigid scopes.[1] New, digitally enhanced scopes now offer similar
image quality to a rigid hysteroscope lens.
Light source
Each hysteroscope is attached to an internal or external light source for illumination at the distal tip. Energy
sources include tungsten, metal halide, and xenon. A xenon light source with a liquid cable is considered the
superior option.[2, 3]
Surgical instruments
Surgical instruments are available in both rigid and flexible forms to be inserted through the operating channels
of the scopes. Examples of surgical instruments and their uses are listed below:

Scissors - To incise a septum, excise a polyp, or lyse synechiae

Biopsy forceps - To perform directed biopsy for pathologic review
Grasping instruments - To remove foreign bodies
Roller ball, barrel, or ellipsoid - To perform endometrial ablation and/or desiccation (This instrument is
used with a resectoscope.)
Loop electrode - To resect a fibroid or polyp or endometrium (This instrument is used with a
resectoscope.)
Scalpel - To cut or coagulate tissue, with high power density at its tip (This instrument is used with a
resectoscope.)
Vaporizing electrodes To destroy endometrial polyps, fibroids, intrauterine adhesions, and septa; also
used for endometrial ablation (This instrument is used with a resectoscope.)
Morcellator To cut and remove endometrial polyps or fibroids
Improvements in hysteroscope design have improved the effectiveness of the inflow-outflow channels and of
specific operating instruments. For example, the Chip E-Vac System (Richard Wolf Medical Instruments
Corporation, Vernon Hill, Ill) incorporates a suction channel and a pump to aid in removing chips of tissue
during resection. This feature improves visibility and may decrease time otherwise spent emptying the pieces
from the endometrial cavity.

Another instrument in the forefront is a hysteroscopic morcellator (Smith & Nephew, Inc, Andover, Mass), which
may reduce myomectomy and polypectomy time by morcellating and removing tissue in 1 movement under
direct visualization. It requires cervical dilation to 9 mm. A new hysteroscopic morcellating system called
MyoSure (Interlace Medical, Inc, Framingham, Mass) is reported to work just as well, removing submucosal
fibroids up to 3 cm in diameter, with a unit that only requires cervical dilation to 6 mm. This smaller diameter
suggests it may be used in an office setting.

Energy sources and uses

Monopolar and bipolar electricity, as well as laser energy, all have uses in hysteroscopy.
Monopolar cautery
The resectoscope is a specialized instrument often used with a monopolar, double-armed electrode and a
trigger device for use in hypotonic, nonconductive media, such as glycine. It cuts and coagulates tissue by
means of contact desiccation with resistive heating.[4] The depth of thermal damage is based on several factors:
endometrial thickness; speed, pressure, and duration of contact during motion; and power setting. [5, 4]
A thin electrode can cut tissue, whereas one with a large surface area, such as a ball or barrel, is best suited
for coagulation.[6]
Bipolar cautery
The VersaPoint system (Gynecare, Inc, Somerville, NJ), uses bipolar circuitry for electrosurgery, which can be
performed in isotonic conductive media. This system includes a spring tip for hemostatic vaporization of large
areas, a ball tip for precise vaporization, and a twizzle tip for hemostatic resection and morcellation of tissue.
There is also a cutting loop similar to traditional resectoscopy.[4]
Bipolar resectoscopes have been designed by both Karl Storz (Tuttlingen, Germany) and Richard Wolf Medical
Instruments Corporation (Vernon Hill, Ill). The latter has developed the Princess (Petite Resectoscope Including
E-Line and S-Line Systems), a 7 mm resectoscope the smallest bipolar resectoscope available. In addition,
the Chip E-Vac System (Richard Wolf Medical Instruments Corporation, Vernon Hill, Ill) can be used with
bipolar and monopolar energy.
Laser techniques
Several fiberoptic lasers are available for gynecologic use, including potassium-titanyl-phosphate (KTP), argon,
and Nd:YAG lasers. They all have different wavelengths, though the KTP and argon lasers have similar
properties.

Media
The use of media is critical for panoramic inspection of the uterine cavity. The medium opens the potential
space of the otherwise narrow uterine cavity. Intrauterine pressures needed to adequately view the
endometrium are proportional to the muscle tone and thickness of the uterus. The refractive index of each
medium affects magnification and visualization of the endometrium.
Gases
Carbon dioxide (CO2) is rapidly absorbed and easily cleared from the body by respiration. The refractory index
of CO2 is 1.0, which allows for excellent clarity and widens the field of view at low magnification. The gas easily
flows through narrow channels in small-diameter scopes, making it useful for office-based diagnostic
hysteroscopy. However, this method offers no way to clear blood from the scope.
With CO2, a hysteroscopic insufflator is required to regulate flow and limit maximal intrauterine pressure. (Note
that laparoscopic insufflators are not safe.) A flow rate to 40-60 mL/min at a maximum pressure of 100 mm Hg
is generally accepted as safe. Pressures and rates higher than this can result in cardiac arrhythmias,
embolism, and arrest.[2]
Fluids

The advantage of fluid over gas is the symmetric distention of the uterus with fluid and its effective ability to
flush blood, mucus, bubbles, and small tissue fragments out of the visual field. Both low-viscosity and highviscosity fluid media can be used for distention. A pressure of 75 mm Hg is usually adequate for uterine
distention; rarely is more than 100 mm Hg required, and pressures higher than this can increase the risk of
intravasation of medium.[7]
Various delivery systems are designed to suit the many media used for uterine distention and to accurately
record volumes of inflow and outflow. This recording is important because fluid can leave the uterus by means
of intended efflux systems, cervical or tubal leakage, or intravasation. Preventing excess absorption of
hypotonic fluids is essential for patient safety. The simplest delivery system is a syringe that most often is used
with high-viscosity Dextran 70. Hanging, gravity-fed containers to deliver low-viscosity fluids can be raised or
compressed with a cuff; however, these can be unreliable in estimating intrauterine pressures. Pumps are
available to monitor pressure and volume for low-viscosity media. Media then usually flows into the uterine
cavity through an inner sheath around the hysteroscope. A perforated outer sheath is used for collection or
efflux of media. This design creates laminar flow, which keeps the visual field clear.[1]
As noted above, new, sophisticated efflux mechanisms have been designed to improve the clearance of both
blood and particulate matter from the operating space. Closed systems actively return fluid to a pump reservoir,
whereas open systems allow free flow of the medium out the cervix into a collection bag for volume monitoring.
0.9% sodium chloride solution and lactated Ringer solution
Normal sodium chloride solution and lactated ringer solution are isotonic, conductive, low-viscosity fluids that
can be used for diagnostic hysteroscopy and for limited operative procedures. Surgical procedures using
mechanical, laser, monopolar (only with the ERA sleeve or Opera Star systems), and bipolar energy
(VersaPoint system) are safe (see Surgical instruments and Energy sources and uses above).
Two major disadvantages associated with these solutions include (1) their miscibility with blood, which
obscures visibility with bleeding, leading to the need for increased volumes to clear the operative field, and (2)
their excellent conductivity, which precludes procedures that use standard monopolar electrosurgery.
5% Mannitol, 3% sorbitol, and 1.5% glycine
The hypotonic, nonconductive, low-viscosity fluids 5% mannitol, 3% sorbitol, and 1.5% glycine improve
visualization when bleeding occurs. They can be used in diagnostic as well as operative hysteroscopy. (Note
that 5% mannitol can be used only with monopolar operative procedures.)
All impose a risk of volume overload and hyponatremia from intravascular absorption (particularly > 2 L).
Therefore, careful fluid monitoring is required during their use. When intravasation of 5% mannitol occurs, it
stays in the extracellular compartment; treatment of this condition is discontinuing the procedure and
administering diuretics.[7] 3% sorbitol is broken down into fructose and glucose and therefore has an added risk
of hyperglycemia when absorbed in excess. Use 1.5% glycine with caution in patients with impaired hepatic
function because glycine is metabolized to ammonia.
Dextran 70
The only high-viscosity medium available, Dextran 70 (Hyskon; Pharmacia Laboratories, Piscataway, NJ) is a
nonelectrolytic, nonconductive fluid that can be used in all types of procedures. It is immiscible with blood and
minimally leaks through the cervix and tubes, allowing for excellent visibility during surgical procedures.
Like the other nonelectrolytic fluids, however, prevent absorption of more than 500 mL to avoid fluid overload.
With each 100 mL of Dextran 70 absorbed, the intravascular volume increases by 800 mL. [7, 8] Allergic reactions
and anaphylaxis, fluid overload, disseminated intravascular coagulopathy, and destruction of instruments are
adverse effects of this medium.