Minimizing Surgical Complications · Clarke-Pearson Obstet Gynecol 2011 • 40% of patients receive...
Transcript of Minimizing Surgical Complications · Clarke-Pearson Obstet Gynecol 2011 • 40% of patients receive...
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Minimizing Surgical Complications
Howard T. Sharp, MDProfessor and Vice Chair for Clinical Affairs
Department of Obstetrics & GynecologyUniversity of Utah School of Medicine
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Learning Objectives
• Review 4 difficult complications• Discuss prevention / risk reduction
– Electrosurgical injury– Nerve injury– Thromboembolic events– Ureteral injury
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1994 - 1995
• Optical access trocar through aorta– Baltimore– Death
• Optical access trocar through pregnant uterus – cholecystectomy– University of Utah– Fetal death at 23 weeks
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The MAUDE Database
Source: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm
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Optical Access TrocarsSharp HT et al, Obstet Gynecol 2002
MAUDE DB37 major vessel injuries
18 bowel injuries3 liver lacerations
4 deaths
WORLD LITERATURE2 major vessel injuries
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Endometrial AblationGurtcheff SE, Sharp HT, Obstet Gynecol 2003
MAUDE DBComplications: 85
Thermal bowel injury: 8Emergent lap: 12
Death: 1
WORLD LITERATUREHemorrhage: 2
PID: 1Endometritis: 20Vaginal burns: 2
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Hierarchy of Study Design
Descriptive Studies
COHORTTROHOC
RCT
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Hierarchy of Study Design
Descriptive Studies
COHORTTROHOC
RCT
MAUDE
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Case 1:• You get called
to L&D for this
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Noted after C-Section - RUQ
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2 burns, 17 cm apart
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Surgical energy-based device injuries & fatalities reported to
the FDAOverbey et al, J Am Coll Surg 2015
• 3553 Injuries• 178 deaths
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Cut vs. Coag• Coagulating current poses a greater potential for
damage because of higher voltage requirements
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I worry when….
…And nothing happens
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Stray Energy – High Voltage
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Insulation Failure
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Recommendations
• Use cut mode– (low voltage)
• Use cold scissors• Test monopolar
instruments– (Biomed)
• Avoid inadvertent touching– (situational awareness)
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Thromboprophylaxis“Why are we stuck in 1975?”
Clarke-Pearson Obstet Gynecol 2011
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“Why are we stuck in 1975?”Clarke-Pearson Obstet Gynecol 2011
• 40% of patients receive no VTE prophylaxis• Assume :
– 3% DVT rate – 0.5% fatal PE (without prophylaxis)
• 292,307 untreated women– 8,769 DVTs– 1,461 Fatal Pes
• Assume: 60% reduction (appropriate prophylaxis)– 5,261 DVTs prevented!– 876 fatal PEs prevented!
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Caprini DVT Risk App
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Caprini App
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VTE RiskGould et al, CHEST 2012
Risk Level % Risk / Bleeding Assessment Caprini Score
1. Very low VTE risk <0.5% 02. Low VTE risk 1.5% 1-23. Moderate VTE risk 3% / Low bleeding risk 3-44. Moderate VTE risk 3% / High bleeding risk 3-45. High VTE risk 6% / Low bleeding risk >56. High VTE risk 6% / High bleeding risk >5IPCs alone until bleeding risk is diminished, then LMWH or LDUFH
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Recommendations• Use UF heparin, or LMWH with or without IPCs
• Consider the risk of bleeding with pharmacologic therapy.
• Consider the use of a risk assessment tool.
• Certain risk factors may require combined therapy.
• Consider giving LMWH 12 hours before surgery.
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Case 2• Patient weighing 105 undergoes TAH
• Quadriceps are paralyzed
• Knee can not be extended
• Loss of sensation over
– Medial and anterior thigh
– Medial side of lower leg
– Medial side of foot
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Femoral Neuropathy
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Nerves and vessels of the anterior abdominal wall.(Rahn AJOG 2010)
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Trocars and anterior abdominal wall nerves(Rahn Am J Obstet Gynecol 2010)
Nerve Mean distance from ASIS in cm (range)Medial Inferior
Ilioinguinal nerve 2.5 (1.1-5.1) 2.4 (0-5.3)Iliohypogastric nerve 2.5 (0-4.6) 2.0 (0-4.6)
Author’s conclusions: Risk is minimized when the trocar is placed superior to the ASIS.
Incidence: 5% of laparoscopies (Shin, JMIG 2012)
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The Pfannenstiel Incision as a Source of Chronic Pain
(Loos et al, Obstet Gynecol, April 2008)
• 866 patients with Pfannenstiel incisions• 2 year follow-up (questionnaire) Level III• 33% experienced CPP at incision (26% ITT)• 7% had moderate to severe pain• Nerve entrapment 53% (17/32 examined)• Avoid lateral extension (rectus sheath) / delay in
treatment
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Recommendations
• Position high lithotomy – with no > 90° flexion at hip– 45° abduction
• Use “Allen type” stirrups if anatomy if problematic– Tall / short patients
• Feel for psoas muscles with self retaining retractors– Thin patients at risk
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Recommendations
• THUMBS UP to prevent ulnar nerve injury
• Go above the ASIS and 2 cm medial with laparoscopic trocars.
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Ureteral InjurySharp HT, Adelman MR - Prevention, recognition, and
management of urologic injuries during gynecologic surgery Obstet Gynecol 2016
• Intraoperative identification is NOT always possible.
• Intraoperative identification is preferable.
• Early recognition decreased subsequent morbidity
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Types of Ureteral Injuries
• Devasularization• Kinking• Ligation• Transection• Thermal injury
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Ureteral Injury
• Incidence– TAH 0.3%– TVH 0.04%– TLH 0.3%
• VVF / UVF Incidence (if ureteral injury)• 3.4% / 2.4%
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Ureteral Injury
• Gynecologic surgery carries inherent risk to ureteral injury (proximity, visualization)
• Risks:– Endometriosis– C-Section– Low-volume surgeons (<10 hyst / yr)– Tobacco use
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Avoiding Ureteral Injury• Look for ureters early to get a trajectory• Mobilize the bladder• Skeletonize the uterine arteries• Ureterolysis / ureteral stenting• Myomectomy
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Recognition
• Routine cystoscopy for “at risk” procedures
• Sodium fluorescein (25 mg of 10% soln)
• Ureteral stenting
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Take Away
• Think prevention– Use more cut mode– Consider Caprini score– Meticulous positioning
• Know risks and anticipate / recognize• Dictate accurately and timely