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Didactic: Reducing Errors and Optimizing Surgical Quality:

Oncology Pearls for the Gynecologist

PROGRAM CHAIR

Amanda Nickles Fader, MD

David M. Boruta, MDNoah A. Goldman, MD

William M. Burke, MDEdward J. Tanner, MD

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 3 Value‐Based Care in Gynecologic Surgery: Why Minimally Invasive Surgery Matters A. Fader ......................................................................................................................................................... 4 Optimal Positioning and Laparoscopic Access in the Morbidly Obese, Pregnant or Surgically Complex Patients: Cases and Discussion E.J. Tanner ................................................................................................................................................... 13 Advanced Pelvic Anatomy: The Retroperitoneum, Ureters and Challenging Bladder W.M. Burke ................................................................................................................................................. 20 Step‐by‐Step TLH: Avoiding the Pitfalls D.M. Boruta ................................................................................................................................................. 26 Avoiding Bladder and Ureteral Injuries…and How to Manage Injuries Should They Occur N.A. Goldman .............................................................................................................................................. 31 Small Bowel and Rectal Injuries: Avoidance and Surgical Pearls for Intestinal Repair W.M. Burke ................................................................................................................................................. 36 Minimizing Trocar and Vascular Injuries D.M. Boruta ................................................................................................................................................. 40 Principles in Preventable Harm and Patient Safety: Reducing Surgical Site Infection, DVT and Readmissions A. Fader ....................................................................................................................................................... 47 Cultural and Linguistics Competency ......................................................................................................... 52

ONC-‐708 Didactic: Reducing Errors and Optimizing Surgical Quality:

Oncology Pearls for the Gynecologist

Presented in cooperation with the AAGL Special Interest Group on Oncology

Amanda Nickles Fader, Chair

Faculty: David M. Boruta, William M. Burke, Noah A. Goldman, Edward J. Tanner Morbidity and mortality in patients undergoing surgical procedures may, in most cases, be preventable. These “preventable” issues range from individual errors in surgical technique and perioperative decision making to system errors in the operating room or hospital. As gynecologic surgical patients become more complex and the current health care climate mandates that medical errors are kept to a minimum, it will become increasingly important for the minimally invasive gynecologic surgeon to understand these issues and to adopt best practices and advanced techniques to optimize quality and safety. Principles for avoiding preventable harm and optimizing patient safety and quality in minimally invasive gynecology surgery are the focus of the course. Pelvic anatomy, advanced surgical technique, management of complex surgical patients and avoidance of complications will be emphasized. Participants will be taught best practices in patient safety and quality in minimally invasive gynecology surgery so they may decide what strategies they may wish to incorporate into their practices. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Formulate an evidence-‐based critical appraisal of laparoscopic abdominal access techniques; 2) discuss abdominal techniques in special populations: the obese, pregnant or surgically complex patient; 3) identify and restore pelvic anatomy reliably in challenging situations; 4) review tips and tricks to avoid laparoscopic complications and review their management; and 5) discuss principles in surgical quality, surgical site infection and patient safety as they apply to the MIS gynecologic patient.

Course Outline 7:00 Welcome, Introductions and Course Overview A. Fader

7:05 Value-‐Based Care in Gynecologic Surgery: Why Minimally Invasive Surgery Matters A. Fader

7:30 Optimal Positioning and Laparoscopic Access in the Morbidly Obese, Pregnant or Surgically Complex Patients: Cases and Discussion E.J. Tanner

7:55 Advanced Pelvic Anatomy: The Retroperitoneum, Ureters and Challenging Bladder W.M. Burke

8:20 Step-‐by-‐Step TLH: Avoiding the Pitfalls D.M. Boruta

8:45 Questions & Answers All Faculty

8:55 Break

9:10 Avoiding Bladder and Ureteral Injuries…and How to Manage Injuries Should They Occur N.A. Goldman

9:35 Small Bowel and Rectal Injuries: Avoidance and Surgical Pearls for Intestinal Repair W.M. Burke

10:00 Minimizing Trocar and Vascular Injuries D.M. Boruta

10:25 Principles in Preventable Harm and Patient Safety: Reducing Surgical Site Infection, DVT and Readmissions A. Fader

10:50 Questions & Answers All Faculty 1

11:00 Adjourn

2

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Erica Dun* Frank D. Loffer, Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: Intuitive Royalty: CooperSurgical Sarah L. Cohen* Jon I. Einarsson* Stuart Hart Consultant: Covidien Speakers Bureau: Boston Scientific, Covidien Kimberly A. Kho Contracted/Research: Applied Medical Other: Pivotal Protocol Advisor: Actamax Matthew T. Siedhoff Other: Payment for Training Sales Representatives: Teleflex M. Jonathon Solnik Consultant: Z Microsystems Other: Faculty for PACE Surgical Courses: Covidien FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). David M. Boruta* William M. Burke* Amanda Nickles Fader* Noah A. Goldman* Edward J. Tanner* Asterisk (*) denotes no financial relationships to disclose.

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1

Value-Based Care in Gynecologic Surgery: Why Minimally Invasive

Surgery MattersAmanda Nickles Fader, MDAssociate Professor and Director, The Kelly Gynecologic Oncology ServiceJohns Hopkins Hospital

Disclosures

• I have no financial relationship to disclose

October 15, 2015 2

Talk Objectives

• Define value-based care in gynecologic surgery and how quality, safety and service interact in the value equation.

• Review the implications of a “pay for performance” model of care.

• Discuss why prioritizing minimally invasive gynecologic surgery is critical to reducing perioperative morbidity and improving the quality of surgical care

October 15, 2015 3

• I am not an expert in quality or safety

• GYN surgeon interested in how I can innovate and improve my own practice to offer the best care for my patients and in developing best practices

• I won’t likely tell you anything today that you don’t already know

October 15, 2015 4

What is the Scope of the Problem?

• 50,000-98,000 Americans die annually in hospitals as a result of medical errors

• $37 billion from adverse events

• $17 billion from preventable harm

• More die from medical errors than highway accidents or all gynecologic cancer deaths combined

October 15, 2015 5

The Problem: High Cost…But is there More Quality?

• Disproportionate increase in health care costs without showing improvement

• Regulatory organizations and purchasers of surgical care demanding comparative documentation of surgical quality and outcomes

• Support for implementing performance-based standards derived from two risk-adjusted national surgical quality improvement programs (NSQIP)

October 15, 2015 6

4

Surgical Quality: Incentives vs Penalties

– NSQIP, SCIP and other programs have documented substantial decreases in perioperative morbidity and mortality with quality improvement initiatives

– Dramatic improvements in patient outcomes and corresponding decreases in health care costs have led to recommendation of "pay-for-performance" models for surgical disciplines

– Quality incentive payments will be offset by reduced reimbursement for substandard performances

October 15, 2015 7

At a Crossroads…

October 15, 2015 8

The Problem Continued…

• For specialties that have not developed specific performance metrics, the implications are substantial

• Gynecologic surgical community has an exigent need to develop standards and methods to assess quality within our discipline that are specialty specific, equitable and risk adjusted

October 15, 2015 9

Standardization and Transparency are Key

Standardization and transparent tracking of specific measures improves outcomes and allows for meaningful change

• Six Sigma

• Lean

• SCIP

• NSQIP

• CQIOctober 15, 2015 10

Value-Based Care

• A critical component of understanding value is measurement.

• How can we know what works unless we measure our results and track them over time?

• Any patient considering a procedure should be able to know from their physician what it will cost and what her results will be, with firm data.

• Without that data, patients lack the tools to make informed choices. October 15, 2015 11

The Value Equation

Value = Quality/Cost

October 15, 2015 12

5

How is Value Defined?

• It depends on the perspective…

– Physician

– Patient/Relatives

– Hospital

– Payor/Insurance Company

October 15, 2015 13

What Does This Mean…

• To patients? – The expectation of safe, appropriate, and

effective care with enduring results, at reasonable cost.

• To physicians? – Employing evidence-based medicine and

proven treatments and techniques that take into account the patients’ wishes and preferences

October 15, 2015 14

The “Consumer Reports” of Health Care

How is Value Defined?

• Outcome—the end result or final product

• Safety—freedom from harm, danger or injury

• Service—the process of helping or doing work for someone

October 15, 2015 15

Metrics

• Outcome—– Transfusion, length of stay, unexpected return to the

OR, readmission, costs of care

• Safety—– Freedom from harm, danger or injury

– Avoidance of ”never events”

• Service—– Patient satisfation, call-to-appointment, door-to-OR

16

Factors Impacting Surgical Outcomes

• Endogenous patient factors– Obesity, diabetes, tobacco use etc.

– Underlying path, ie, cancer, endometriosis

• Surgical complexity

• Surgeon competence, experience and volume

• Institutional resourcesOctober 15, 2015 17

Some changes are already in play:

• Out-of-pocket costs for patients are increasing, access to information via internetmotivating patients to become more discriminating

• Surgery will shift from low-volume to high-volume physicians who have demonstrated excellent outcomes – Otherwise known as “value-based purchasing,”

based on a model from Harvard Business SchoolOctober 15, 2015 18

6

What Will Gynecology Surgeons Be Measured On?

• Patient satisfaction

• Patient quality of life

• Morbidity and mortality

• Cost

October 15, 2015 19

The Affordable Care Act

October 15, 2015 20

• How do we pull this all together and consider:– Patient value

perceptions/goals

– Hospital financial goals

– Third-party payor goals

– Surgeon preferences and goals

• Quality

• Patient Satisfaction

• Costs

• Value

Modify What is Truly Modifiable

• Best prophylactic practices to reduce preventable harm

• Optimize patient’s health

• Adherence to surgical principles

• Consider pre-emptive interventions

• Improve your surgical technique

October 15, 2015 21

Minimally Invasive Surgery

• Why does it matter?

• Optimizes all aspects of the value equation!

October 15, 2015 22

AAGL Position Statement

October 15, 2015 23

“It is the position of the AAGL that most hysterectomies for benign disease should be performed either vaginally or laparoscopically and that continued efforts should be takento facilitate these approaches.”

“ Surgeons without the requisitetraining and skills required for the safe performance of VH or LH should enlist the aid of colleagues who do or should refer patients requiring hysterectomy to such individuals for their surgical care.”

ACOG and SGS Position Statements

October 15, 2015 24

• “Given advantages that VH and LH offer to women, their families, their employers, and the health care system in general, it seems desirable to optimize their application in women requiring hysterectomy because of benign uterine conditions”

• “Abdominal hysterectomy should be reserved for the minority of women for whom a vaginal or laparoscopic approach is not appropriate”

7

Vaginal Hysterectomy: The Gold Standard

Vaginal hysterectomy versus abdominal hysterectomy• Quicker return to normal activities (mean

difference [MD] 9.5 days)

• Fewer febrile episodes or unspecified infections (odds ratio [OR] 0.42)

• Shorter duration of hospital stay (MD 1.1 days)

October 15, 2015 25

Niebower et al, Cochrane Database Review, 2009

1

Two Meta-Analyses: RCTS in Lsc versus Abdominal Hysterectomy

• Quicker return to normal activities (median 13.6 days)

• Lower intraoperative blood loss (median 45 cc)

• Smaller drop in hemoglobin (median 0.55 g/dL)

• Shorter hospital stay (median 2.0 days)

• Fewer wound or abdominal wall infections (OR 0.31)

• Increased risk of urinary tract (bladder or ureter) injuries (OR 2.41)

• Longer operation time (median 20.3 minutes)

October 15, 2015 26

Neiboer et al, Cochrane Database Syst Rev. 2009

October 15, 2015 27

Walker et al, J Clin Oncol, 2012

• Short term QoL scores and >grade 2 complications favor Lsc arm

Randomized trials in endometrial cancer: GOG LAP2

RCT Comparing Two Chemotherapy Treatments

• Drug A—– Easy to administer

standard regimen

– Side effect profile—higher risk of cardiac toxicity, DVT/PE, stroke and neutropenic fever/sepsis

– Has to be administered inpatient

– Higher rate of readmission

• Drug B—– More challenging to

administer

– Excellent side effect profile (no cardiac toxicity, low risk of DVT, stroke, fever)

– Quality of life improved

– Improved survival

– Similar or lower costs

– OutpatientOctober 15, 2015 28

How do we solve the problem of OPEN Hysterectomy?

• Women's health organizations recommend avoiding laparotomy, and advise abdominal hysterectomy (AH) only when the vaginal or laparoscopic route is not possible or ruled out

• We may ask ourselves….why does practice tend to go against this consensus?

• Why are many hysterectomies still performed by laparotomy when the majority of cholecystectomies, appys etc are performed laparoscopically?

October 15, 2015 29

It’s Complicated…

• Training background

• Patient characteristics and preferences

• Surgeon volume, competence and preferences

• Reimbursement rates-CMS October 15, 2015 30

8

1 Johns Hopkins, 5/29/2015

9

HCUP/NIS Database

• Laparoscopic hysterectomy for benign disease completely under utilized in U.S. (13%!)

• Complications significanlty higher in laparotomy arm compared to laparoscopic (4.95% vs. 6.97%, p=0.001)

31

Makary et a, BMJ, 2014October 15, 2015 32

• Quality measures in endometrial cancer care:

• Endometrial cancer patients with Stage I-III disease (node positive, adnexal) should be surgically managed via minimally invasive surgery

SGO and American College of Surgeons Commission on Cancer

Association of Variables with Receipt of MIS Hysterectomy

October 15, 2015 33

Hospital volume Variable OR 95% CI

Race White 1.0

Black 0.45 0.39, 0.51

Hispanic 0.77 0.67, 0.88

Hospital VolumeLow 1 ref

Medium 1.96 1.45, 2.64

High 2.74 1.77, 4.23

Comorbidities Elixhauser score

0.83 0.81, 0.85

Payor Status Medicaid 0.67 0.58, 0.79

Self-pay 0.75 0.61, 0.93

HCUP-NIS Database Study: Endometrial Cancer MIS vs LAP

Outcome of Interest n OR 95% CI

Any complication 5,257 2.13 1.94, 2.33

Surgical complication 4,132 1.97 1.77, 2.20

Surgical site infection 367 4.91 3.29, 7.34

Pneumonia 460 1.95 1.48, 2.56

VTE 446 3.15 2.28, 4.36Sepsis** 168 2.98 1.82, 4.89

October 15, 2015 34

Adjustsed COSTS: HCUP-NIS Study

October 15, 2015 35

• Open Hysterectomy: $403,716,204 {95% CI: $362,389,042 - $445,043,366}

• Laparoscopic Hysterectomy: $104,016,815 {95% CI: $87,068,877 -

$120,964,753}

Hopkins Pilot Program

• Trends in minimally invasive hysterectomy

• Reducing the burden of perioperative complications and costs

October 15, 2015 36

10

Hopkins Pilot Program in MIS Utilization

October 15, 2015 37

• Hired 7 surgeons in last 2 years with extensive fellowship training in MIS

• Increased opportunities for surgical training to improve MIS skills (formal robotics training, cadaver course work)

• Prioritize MIS at peer-review preop conferences

• Quarterly review of data and outcomes

Pilot Program in MIS: GOALS

October 15, 2015 38

• 90% or higher MIS hysterectomy rate

– Vaginal, Laparoscopic Robotic

• <2% SSI/UTI rates

• <2% readmission rates

Pilot Program in MIS: Goals

• Develop departmental policies regarding appropriateness for VH, LH, RA-LH and AH– 16 week size uterus or smaller

– No absolute contraindications to laparoscopy

– Similar to standards for labor induction, patients must meet certain criteria and policies enforced

October 15, 2015 39

JHH MIS GYN Utilization: Hysterectomy

October 15, 2015 40

p<0.001

MIS Effort Initiated in 2012

91%

Hopkins Gynecology MIS Hysterectomy 2012-2015

• SSI reduced by 67% (p<0.001)

• Readmissions reduced by 32% (p=0.04)

October 15, 2015 41

Possible Institutional Solutions

• Not enough hysterectomies for all GYNs to be high volume surgeons (defined as n=~24/year or two hysterectomies/month)

• Designate 2-3 individuals in each practice to perform all hysterectomies– Incentivize referral to high volume surgeons

• “Teach the teachers” program at Hopkins—lower volume surgeons have opportunity to operate with higher volume surgeons

October 15, 2015 42

11

Teamwork, Vigilance and Persistence = Success!

• Critical to the success

• Education– Each team member held accountable to

their discipline/specialty

• Develop patient satisfaction survey

• Identified potential hurdles; have patience– Culture change is hard

– Timeline October 15, 2015 43

United Health Care

• United Health Restricts Use of Non-vaginal Hysterectomies

• April 6, 2015—Requires Prior Authorization for any Hysterectomy not Performed Vaginally

• ACOG "has identified the preferred method for hysterectomies to be vaginal.”

October 15, 2015 44

What Can We Do?

• Think creatively to contain costs.– A good book on this subject is Unaccountable: What

Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, by Marty Makary, MD.

• Track our own outcomes.– Easier with electronic medical records.

• Challenge preconceived notions and beliefs.– We have many in surgery.

– No lifting after hysterectomy, no sex or pool time after hysterectomy,

October 15, 2015 45

What Can We Do?

•Participate in efforts to define and improve quality of care.

•Get a seat at every table…– to participate in data definitions, acquisition, and

dissemination to inform our daily clinical decisions

October 15, 2015 46

What Can We Do?

• If we do not have a seat at the table, then we will be on the menu!

October 15, 2015 47

Thank you!

• [email protected]

October 15, 2015 48

12

Optimal Positioning and Laparoscopic Access in the Morbidly

Obese, Pregnant or Surgically Complex Patients:

Cases and Discussion

Edward Tanner, M.D.

Johns Hopkins University

I have no financial relationships to disclose.

• Review appropriate laparoscopic positioning to avoid injury

• Formulate an evidence‐based critical appraisal of laparoscopic abdominal access techniques

• Discuss abdominal techniques in special populations: the obese, pregnant or surgically complex patient

Case 1

• 42 y.o. with 5 cm complex left adnexal mass

• PMH: morbid obesity (BMI 54), DM

• Surgery: C‐section x 2, umbilical hernia repair

Obesity: The New Normal

• By 2030, 50% of U.S. adults will be obese1

• Even now, we are accepting this as our new national identity

• ~60% of gyn surgery patients are overweight2

Anthropormorphics Are Critical• BMI does not tell the whole story!

• Central adiposity and pannus: how does it lay when pt supine?

• Waist‐hip ratio critical– WHR >0.85 in women correlates with

degree of central adiposity

– “Apple” versus “pear shape”

• Apples far more challenging and more prevalent

• Associated with metabolic syndrome, Type 2 DM, HTN3

13

#1: Ensure operating table has a weight capacity that will accommodate morbidly obese patients and also has optimal intraoperative maneuverability

Tips for Laparoscopy in Obese Women

#2: Use an anti‐skid positioning device for alllaparoscopic cases

– Ensure bean bag, gel pad, or egg crate is positioned properly for patient comfort and to prevent patient slippage


• Anti‐skid egg crate associated with minimal slip (1.3 cm) during laparoscopic/robotic procedures4

• No shoulder bracing prevent brachial plexus injury


#3: Ensure buttocks is slightly beyond end of the bed

#4: Tuck both arms every time!

– Pad/support all pressure points, wrap hands/fingers

– Use sleds or arm extenders

#5: Always position the patient yourself! – Low lithotomy

– Thighs parallel to the floor, knees flexed at no more than 60 degrees, knee in line with contralateral shoulder


Patient Positioning: Arms


• Positioning more critical than ever:

– Higher risk of pressure sores and neuropathies in obese

– Consider Ultrafin stirrups for lithotomy

– Corporeal padding

– Padding of fingers, wrists, elbows and shoulders and knees/calves


14

Tips for Safe Laparoscopy in Obese Women

Patient Positioning: Legs, Feet and Hips

Tips for Safe Laparoscopy in Obese Women

1. Place 2 narrow foam pads over chest, being sure to cover the triceps completely

2. Re‐secure with wide tape twice

3. Avoid letting tape touch skin

Patient Positioning: Chest

#6: Consider Open Hasson or Left Upper Quadrant (Palmer’s Point) Entry Incisions

Tips for Laparoscopy in Obese WomenClosed versus Open Entry

• Meta‐analysis of any prospective or retrospective reports of major injuries during laparoscopic entry38

• Included any study reporting both the rate of injury and number of patients evaluated

Technique # of Series# of

Procedures

Major Vascular Injuries

% Vascular Injuries

MajorVisceral Injuries

% VisceralInjuries

Open 11 22,465 0 0 11 0.049

Closed 22 760,890 336 0.044 515 0.067

Larobina M, et al. 2007.


You never know…


You never know…


15

Veress Needle: No Role in Obese Women

45

Image Ref #5• Increased risk of preperitoneal insufflation• Increased risk of injury due to anatomic distortion• Problems are magnified by use of Veress needle


Ref #6

Surgical Access: Open Hassan Technique

Consider supraumbilical entry in morbidly obese OR…


• LUQ technique most optimal?

• Palmer’s point

• 2‐5 mm long optical trocar

• DO NOT elevate the abdominal wall excessively

Surgical Access: LUQ Approach


LUQ Entry Video


LUQ Entry: Safest Option in Obese Patients

Author McDanald7 Granada9 Peijnenburg9

# patients 267 136367

BMI > 35: 78%

Injuries3 liver injuries

(minor)0 0

Failed insufflation

4 (1.5%) 2 (1.5%) 4 (1.1%)

Tips for Laparoscopy in Obese Women Tips for Laparoscopy in Obese Women

Additional Trocar Placement

• Pannus anatomic landmarks distorted

• Position additional trocars more laterally and superiorly (above pannus)

• Initially increase the insufflation pressure to 20 mmHg to allow a greater distance for trocar placement

• Then reduce the pressure to 10-15 mmHg to prevent CO2 retention and decreased chest wall compliance

• Consider balloon tip trocars to prevent trocar slipping

16


Conclusions

• MIS feasible/beneficial in morbidly obese women if co‐morbidities optimized

• Consider critical patient safety issues in OR including proper planning and positioning

• Consider Hasson or LUQ approach to abdominal access

• Lateralize and elevate additional trocars

Case 2

• 22 y.o. with 5 cm complex left adnexal mass

• PMH: none

• Surgery: C‐section x 2

Laparoscopy in Pregnancy

• ~1 in 500 to 1 in 635 women will require non‐obstetrical abdominal surgery during their pregnancies10‐11

• The most common non‐obstetrical surgical emergencies complicating pregnancy are acute appendicitis, cholecystitis, and intestinal obstruction10

• For GYN, ovarian cysts, mass, torsion, and abdominal pain of unknown origin are the most common reasons

• The incidence of adnexal masses in pregnancy is estimated between 1‐4%12‐13


When to Operate?

• Potential malignancy14

• Torsion or severe pain15‐23

• Adversely impact the pregnancy

• Obstruct labor

• Persist into the 2nd trimester and• >10cm in size• Symptomatic


Advantages Over Laparotomy

• Less postoperative pain24‐26

• Less postoperative ileus24‐26

• Decreased fetal respiratory depression27‐30

• Lower risk of wound complications28,31‐32

• Diminished postoperative maternal hypoventilation26,32

• Shorter hospital stays24‐26

• Decreased risk of thromboembolic events

• Improved visualization reduced uterine irritability by decreasing the need for uterine manipulation33‐34

• Faster return to work24‐26

Tips for Laparoscopy in Pregnancy

Positioning

• Left lateral decubitus position35‐37

– Lying flat can cardiac output by 30%

– 15°tilt is appropriate

17


Where To Begin?

• Adjust the initial access according to the fundal height

• Palmer’s point or LUQ entry

• Supraumbilical entry also OK

Tips Laparoscopy in Pregnancy

Placing Other Trocars

• Place accessory trocars under direct visualization with enough lateral room to work

• Keep pressures ≤ 15mmHgbut use the least amount necessary for visualization

• Increased repercussions of insufflation with CO2 during pregnancy

• Gasless laparoscopy?


Accessing Your Anatomic Target

• Ovary usually sitting on uterus but can be stuck in the cul de sac

• Adjust trocar placement based on initial assessment place one trocar at a time based on anatomic distortion

• Often requires asymmetric trocar placement


Conclusions

• Laparoscopy is safe in pregnancy

• Left lateral tilt

• Hasson or direct entry

• Supraumbilical or Palmer’s point

• Lowest pressure necessary for insufflation

Case 3

• 50 y.o. with menorrhagia requiring multiple transfusions

• PMH: colon cancer, ventral hernia

• Surgery: rectal resection, ventral hernia repair with mesh, endometrial ablation

Laparoscopy in the Hostile Abdomen

“Hit’em Where They Ain’t”

18

Laparoscopy in the Hostile Abdomen

• Hasson technique is preferred technique especially if there is concern for LUQ adhesions

• Avoid entering hernia sac to avoid bowel injury

• Careful lysis of adhesions

• Take your time! patients with prior surgery/hernia likely benefit most from laparoscopic approach

• May require extra trocars just for lysis of adhesions

Conclusions

• Be prepared

• Be flexible may need to adjust

• Familiarize yourself with all entry options

• Practice on easy cases for when you need special techniques

THANK YOU!

1. Finkelstein A, et al. Obesity and severe obesity forecasts through 2030. Am J Prev Med 2012; 42(6): 563‐70.

2. Mahdi H, et al. The impact of obesity on the 30‐day morbidity and mortality after surgery for endometrial cancer. J Minim Invasive Gynecol 2015; 22(1): 94‐102.

3. Mokdad A, et al. The continuing epidemics of obesity and diabetes in the United States. JAMA 2001; 286(10): 1195‐200.

4. Klauschie J, et al. Use of Anti‐Skid Material and Patient‐Positioning To Prevent Patient Shifting during Robotic‐Assisted Gynecologic Procedures. J Minim Invasive Gynecol 2010; 17(4): 504‐7.

5. Baggish M. How to avoid major vessel injury during gynecologic laparoscopy. OBG Management 2012; 24(8).

6. Hurd WH, et al. The Relationship of the Umbilicus to the Aortic Bifurcation: Implications for Laparoscopic Technique. Obstet Gynecol 1992; 80(1): 48‐51.

7. McDanald D, et al. Left upper quadrant entry during gynecologic laparoscopy. Surg Laparosc EndoscPercutan Tech. 2005; 15(6): 325–7.

8. Granata M, et al. Are we underutilizing Palmer’s point entry in gynecologic laparoscopy? Fertil Steril 2010; 94(7): 2716‐9.

9. Peijnenburg E, et al. Laparoscopic abdominal access using a modified left upper quadrant technique in morbidly obese women undergoing gynecologic surgery. AAGL 2015 Global Congress (abstract).

10. Kammerer WS. Nonobstetric surgery during pregnancy. The Medical Clinics of North America 1979; 63: 1157‐1164.

11. Kort B, et al. The effect of nonobstetric operation during pregnancy. Surg Gynecol Obstet 1993; 177: 371‐6.

12. Schmeler KM, et al. Adnexal masses in pregnancy: surgery compared with observation. Obstet Gynecol2005; 105: 1098‐1103.

13. Struyk AP, Treffers PE. Ovarian tumors in pregnancy. Acta Obstet Gynecol Scand 1984; 63: 421‐4.

14. Lee GS, et al. Elective versus conservative management of ovarian tumors in pregnancy. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecologyand Obstetrics 2004; 85(3): 250‐4.

15. Nichols DH, Julian PJ. Torsion of the adnexa. Clin Obstet Gynecol 1985; 28: 375‐80.

16. Mage G, et al. Laparoscopic management of adnexal torsion. A review of 35 cases. J Reprod Med 1989; 34: 520‐4.

17. Garzarelli S, Mazzuca N. One laparoscopic puncture for treatment of ovarian cysts with adnexal torsion in early pregnancy. A report of two cases. J Reprod Med 1994; 39: 985‐6.

18. Morice P, et al. Laparoscopy for adnexal torsion in pregnant women. J Reprod Med 1997; 42: 435‐9.

19. Abu‐Musa A, et al. Laparoscopic unwinding and cystectomy of twisted dermoid cyst during second trimester of pregnancy. J Am Assoc Gynecol Laparosc 2001; 8: 456‐60.

20. Bassil S, et al. Successful laparoscopic management of adnexal torsion during week 25 of a twin pregnancy. Hum Reprod 1999; 14: 855‐7.

21. Argenta PA, et al. Torsion of the uterine adnexa. Pathologic correlations and current management trends. J Reprod Med 2000; 45: 831‐6.

22. Tarraza HM, Moore RD. Gynecologic causes of the acute abdomen and the acute abdomen in pregnancy. Surg Clin North Am 1997; 77: 1371‐94.

23. Oelsner G, et al. Long‐term follow‐up of the twisted ischemic adnexa managed by detorsion. Fertil Steril1993; 60:976‐9.

24. Fatum M, Rojansky N. Laparoscopic surgery during pregnancy. Obstet Gynecol Surg, 2001; 56: 50‐9.

25. Oelsner G, Stockheim D, Soriano D, et al. Pregnancy outcome after laparoscopy or laparotomy in pregnancy. J Amer Assoc of Gynecologic Laparoscopists, 2003; 10:200‐4.

26. Curet MJ, Allen D, Josloff RK, et al. Laparoscopy during pregnancy. Arch Surg, 1996; 131: 546‐50.

27. Stepp K, Falcone T. Laparoscopy in the second trimester of pregnancy. Obstetrics and gynecology clinics of North America, 2004; 31:485‐496, vii

28. Pucci RO, Seed RW. (1991) Case report of laparoscopic cholecystectomy in the third trimester of pregnancy. Am J Obstet Gynecol, 1991; 165: 401‐2.

29. Weber AM, Bloom GP, Allan TR, Curry SL. Laparoscopic cholecystectomy during pregnancy. ObstetGynecol, 1991; 78: 958‐9.

30. Williams JK, Rosemurgy AS, Albrink MH, et al. Laparoscopic cholecystectomy in pregnancy. A case report. J Reprod Med, 1995; 40: 243‐5.

31. Arvidsson D, Gerdin E. Laparoscopic cholecystectomy during pregnancy. Surg Laparosc Endosc, 1991; 1:193‐4.

32. Costantino GN, Vincent GJ, Mukalian GG, Kliefoth WL, Jr. Laparoscopic cholecystectomy in pregnancy. J Laparoendosc Surg, 1994; 4:161‐4.

33. Soriano D, Yefet Y, Seidman DS, et al. Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy. Fertil Steril, 1999; 71: 955‐60.

34. Curet MJ. Special problems in laparoscopic surgery. Previous abdominal surgery, obesity, and pregnancy. Surg Clin North Am, 2000; 80:1093‐1110.

35. Elkayam UGN. (1982) Cardiovascular physiology of pregnancy. Alan R Liss, New York.

36. Clark SL, Cotton DB, Pivarnik JM, et al. Position change and central hemodynamic profile during normal third‐trimester pregnancy and post partum. Am J Obstet Gynecol 1991; 164:883‐7.

37. Gordon MC. (2002) Maternal Physiology in Pregnancy. In: Gabbe SG, J.R. Niebyl, J.L. Simpson (ed) Obstetrics: Normal and Problem Pregnancies, Churchill Livingstone, Philadelphia, pp 63‐91.

38. Larobina M, Nottle P. Complete evidence regarding major vascular injuries during laparoscopic access. Surg Laparosc Endosc Percutan Tech 2005; 15(3): 119‐23.

19

Advanced Pelvic Anatomy: The Retroperitoneum, Ureters and Challenging

Bladder

William M. Burke, M.D.

Associate Professor

Columbia University Medical Center

New York, New York

Disclosures

• I have no financial relationships to disclose

Objectives

1. Review work-up and evaluation of patients with difficult pelvic pathology

2. Discuss the proper surgical set-up important for completing safe and successful surgical procedures on patients with difficult pelvic pathology

3. Demonstrate how to surgically approach the difficult female pelvis

Be Prepared: Get to Know Your Patient

• Take a careful and detailed patient history• Duration of disease

• Medical management success and

• Pain medication use and abuse

• Medical co-morbidities

• PRIOR SURGICAL PROCEDURES!• How many?

• What did the surgeons encounter….Read the operative reports

Careful Physical Exam

• Assess body habitus carefully….do not get fooled by BMI• Pay attention to the waist-to-hip ratio

• Note all prior surgical incisions and start planning your route of entry

• Assess uterine size and mobility

• Note any palpable adnexal masses

• Pay careful attention to utero-sacral thickening and rectovaginal nodularity

BMI: 38.6

Obesity classification II

WHR < 0.85

Laparoscopy feasible.

BMI: 37.6

Obesity classification II

WHR > 0.85

Laparoscopic Challenge.

20

Imaging Studies

• Pelvic ultrasound

• Pelvic MRI

• Cystoscopy with suspected bladder lesions

• Colonoscopy with suspected rectosigmoid involvement

MRI Demonstrating Deep Pelvic Endometriosis

Preoperative Preparation

• Prepare your patient for the complications that may arise during surgery for advanced endometriosis.

• Type and screen

• Antibiotics if appropriate for the procedure

• Bowel preparation

• Consideration of ureteral stent placement

Operative Approach

• Conventional laparoscopy

• Robotic assisted laparoscopy

• Hand-assisted laparoscopy

• Laparotomy

Surgical Preparation

• Proper positioning• Plan on needing steep trendelenberg• Plan for a potentially long case

• Gastric decompression

• Three-way foley catheter

• Rectal delineator/Manipulator

• Uterine manipulator with vaginal delineator

• Ureteral stent placement if necessary

Final Proper Positioning

21

Uterine Manipulation

Start with the umbilical port placement.

Use spinal needles as finders to guide proper placement of the remaining trocars

Adjust for the pannus when trying to place your trocars based on the usual anatomic landmarks.

Think about placing the ports more laterally as this will often give you more exposure and decrease the torque on the ports.

Trocar Placement

Robotic Port Placement Attacking the Pelvis: Advantages of Anatomical Safe Havens

Retroperitoneal Access

• Divide the round ligament

• Open the pelvic side wall lateral and parallel to the infundibulopelvic ligment

• Enter over the the ureteral fold

• Open the para-rectal space

Pelvic Sidewall Entry

22

Opening Over the Ureteral Fold

Retroperitoneal Access with Endometriosis

Beware

• The external iliac vessels are in closer proximity then you may realize

• The ureters are often not where they are supposed to be

• The rectosigmoid may take some unpredictable turns.

Keep Moving

Opening the Pelvic Sidewall Altered Anatomy

Bladder Endometriosis

• Don’t be afraid of filling the bladder.

• Don’t be afraid of resecting portions of the bladder if necessary

• Don’t forget to remind your patients they may require prolonged catheterization

23

Resection of Bladder Endometrosis

Bladder Closure

Rectovaginal Endometriosis

• Take advantage of the uterine manipulator

• Take advantage of a rectal delineator

• Do not hesitate to check for rectosigmoid injury. Please retro fill the colon with air or blue dye to look for perforations

• Always be prepared for potential rectosigmoid resection

Opening the Rectovaginal Space

Opening Rectovaginal Space With Endometriosis

Resection of Rectovaginal Nodule After Hysterectomy

24

Resection of Rectovaginal Endometriosis

Completion of Rectovaginal Resection

Citations

25

Step-by-Step TLH: Avoiding the Pitfalls

David M. Boruta

Massachusetts General Hospital


Describe the basic steps involved in performance of laparoscopic hysterectomy

Discuss potential pitfalls associated with laparoscopic hysterectomy

Describe strategies for avoidance of common pitfalls associated with laparoscopic hysterectomy

TLH: basic steps

• Patient and MD positioning

• Uterine manipulator placement and use

• Abdominal access

• Pelvic exposure

• Retroperitoneal access

• Ureteral identification and mobilization

TLH: basic steps

• Isolation / transection of ovarian vasculature

– or utero‐ovarian ligament / FT

• Development of bladder flap

• Isolation / transection of uterine vasculature

• Colpotomy incision

• Vaginal cuff closure

TLH: pitfalls

• Injuries

– Vascular

– Gastrointestinal

– Genitourinary

– Neurologic

– Healing defects

• Conversion to laparotomy

26

Patient and MD positioning

• Avoid neurologic injury

– to patient

– to MD

• Optimize access / exposure

VIDEO/PHOTOS to be inserted

• Arms tucked at side

• Immobilization

• Buttock at base

• Padding and angles in general

• MD ergonomics

Uterine manipulator placement and use

• Critical to success and safety of case

• Variety of products

• Ensure it is done right up‐front

• Frequently check status of manipulator

• Options when placement fails


• Demonstrate proper and improper placement

• Utility of colpotomy cup

• Discuss implication of no cup

Abdominal access

• Laparoscopic incisions are stab wounds

• Optimal location, size, and number of ports


• Demonstrate port herniation

• Demonstrate potential poor ergonomics of port location

27

Pelvic exposure

• Restore normal anatomy

• Ensure separation from innocent bystander tissues


• Demonstrate novel retraction of bowel

• Demonstrate flexible‐tip or angled scope utility

Retroperitoneal access

• Key to safe pelvic surgery

• Safe entry locations

• Development of pelvic spaces


• Demonstrate alternate locations of retroperitoneal access

Ureteral identification and mobilization

• Retroperitoneal identification

• Constant vigilance

• Utility of mobilization


• Demonstrate ureteral identification

• Show close calls

28

Isolation / transection of ovarian vasculature

• Ensure separation from ureter

• Tips for hemostatic transection

• Incorporate vascular broad ligament tissues

• What if the pedicle slips / bleeds


• Demonstrate technique for hemostatic transection

• Demonstrate proper margin for BSO

• What to do if the pedicle slips and bleeds

Development of bladder flap

• Be flexible in where incision is initiated

• Avoid central scar

• Utilize colpotomy cup

• Baby bites until it’s easy

• Stay out of vascular / fatty tissue


• Demonstrate bladder flap from side near uterine vasculature

• Demonstrate incorrect plane of dissection

Isolation / transection of uterine vasculature

• Well skeletonized pedicles are hemostatic

• Anticipate bleeding

• Stay above the cup

• Consider bilateral seal prior to transection

• Lateralize pedicle

• Know how to access the uterine vessels at their origin


• Demonstrate approach to uterine transection

• Discuss unsafe approach to bleeding uterine vasculature

29

Colpotomy incision

• Ensure cup is pressed up firmly

• Cut on top of the cup

• Be aware of surrounding tissue when using energy

• Maintain pneumoperitoneum


• Demonstrate challenging colpotomy incision

Vaginal cuff closure

• Multiple approaches and techniques

• Avoid sutures through bladder or near ureters

• Avoid stabbing the uterine vessels

• Ensure substantial tissue bites

• Check closure with vaginal exam


• Demonstrate techniques for closure of cuff and discuss potential perils

Conclusions

30

Avoiding Bladder and Ureteral Injuries…and How to Manage

Injuries Should They Occur

Noah A. Goldman, MDSubspecialty Director, Gynecologic Oncology

The Valley HospitalParamus, NJ

Disclosures

I have no financial relationships to disclose

Objectives• Identify the anatomic structures in the pelvis

• Explain how to dissect the avascular spaces to identify the ureter

• Discuss the procedures used to avoid and identify genitourinary injuries

• Discuss the procedures used to repair genitourinary injuries

Genitourinary Injuries

• Genitourinary injuries are most common injuries during hysterectomy

• Ureteral injuries are one of the most serious complications in gynecology

• Most injuries are unrecognized

• increased morbidity

• ureterovaginal fistula

• loss of renal function

Rate of Bladder Injury

Abdominal Hysterectomy

Vaginal Hysterectomy

Laparoscopic Hysterectomy

Donnez, O et al.(2009)1 0.73% 0.44% 0.31%

Brummer, T et al.(2011)2 0.9% 0.6% 1%

Adelman et al.(2014)3 — — 0.05% - 0.66%

1. BJOG 2009; 116:4922. Hum Reprod 2011; 26:17413. JMIG 2014; 21:558

Rate of Ureteral Injury

Abdominal Hysterectomy

Vaginal Hysterectomy

Laparoscopic Hysterectomy

Donnez, O et al.(2009)

— 0.33% 0.25%

Brummer, T et al.(2011)

0.3% 0.04% 0.3%

Adelman et al.(2014)

— — 0.02-0.4%

1. BJOG 2009; 116:4922. Hum Reprod 2011; 26:17413. JMIG 2014; 21:558

31

Anatomy

• Pelvic ureter is 13 cm - 15 cm

• Enters pelvis by crossing common iliac bifurcation

• Passes under the uterine artery ~1.5 cm - 2 cm from internal os

Pelvic Anatomy

Types of Ureteral Injuries• Transection

Scissor

Linear stapler

Vascular Sealing Device (VSD)

• Kinking

• Thermal

Electrocautery

Laser

Location of Injuries

Sequelae from Genitourinary Injury1

• Vesicovaginal Fistula = 3.4%

• Ureterovaginal Fistula = 2.4%

• Require Ureteral Stent = 11.8%

• Require > 1 surgery = 19.7%

1. JMIG 2014; 21:558

Risk Factors • Previous C-section

OR (cystotomy) = 3.38 - 7.501

>3 C-sections = 20% cystotomy rate2

• Previous laparotomy

OR (cystotomy) = 4.691

• Endometriosis

• Adhesive disease

• Fibroids

• Low volume surgeons

• VSDs

1. JMIG 2014; 21:558 2. Wang, L et al. JMIG 2010; 17:186

32

Risk Factors• VSDs (Trivedi et al. 2009; 1:83)

~900 TLH performed at a single institution

evaluated GU injury before acquiring VSD and after

• 390 cases before VSD = 0 genitourinary injuries

• 502 cases after VSD = 4 ureter / 2 bladder injuries

CONCLUSION:

Surgeons may have overconfidence during initial use

Excitement Euphoria Overconfidence Troubles Solutions

Bladder Dissection

Bladder dissection (prev. C/S) Ureter (retroperitoneal approach)

Ureter (transperitoneal approach) Prevention

• Primary Prevention

• Secondary Prevention (IntraOp)

• Tertiary Prevention (PostOp)

33

Primary Prevention

DON’T DO IT!!!

Primary Prevention

• Know anatomy

• Address patient-specific risk factors

• Proper exposure

• Proper technique

Recognition of Injury1

• Overall Rate = 51.1% - 87.4%

• Bladder Injury = 45.2% - 85.4%

• Ureteral Injury = 3.7% - 12%

1. JMIG 2014; 21:558

Secondary Prevention

• Assess for injury intraoperatively

• Bladder

Air in Foley bag

Methylene Blue retrograde

Cystoscopy

• Ureter

Cystoscopy (+/- stent)

IV Indigo Carmine

Retrograde pyelogram

Cystoscopy?• Vakili et al. (Am J OB Gyn 2005; 192:1599)

• 471 patients (TAH/VH/TLH)

• Intraop recognition (before cysto)

Bladder = 53%

Ureter = 12.5%

• 96% of injuries were recognized with cysto

• 6 ureteral injuries in TAH had ureteral peristalsis

Cystoscopy?• Ibeanu et al. (Obstet Gynecol 2009; 113:6)

• 839 patients

• Intraop recognition (before cysto)

Bladder = 37.5%

Ureter = 6.7%

• 97% of injuries were recognized with cysto

• 21 cases had sluggish/absent efflux with no injury

• Transection (40%) and Kinking (40%) at the level of the uterine artery

34

Cystoscopy?

• AAGL Statement (JMIG 2012)

“…surgeons and institutions should consider routine implementation of cystoscopy at the time of TLH.”

• Decreased morbidity and improved outcome

• 80% - 90% 0f ureteral injuries were detected

Stent, Or Not To Stent….?


Stent No Stent

ELAP0.62%(2/322)

0.1%(2/2016)

LSC0

(0/147)0

(0/586)

Retrospective1

3071 patients


Stent No Stent

LSC 1.2% 1.09%

Prospective/Randomized2

3141 patients

1. Urology 1998; 52:10042. Int Urogyn Pelvic Floor Dysfunct 2009; 20:689

Tertiary Prevention

• Symptoms

Abdominal pain/distention

Oliguria

• Labs

serum Cr bump = 0.8 mg/dl

• Testing

CT urogram

Retrograde pyelogram

Repair

• Most bladder injuries can be repaired laparoscopically.

• Ureteral injuries depend on location

• within 5 cm of UVJ = ureteroneocystotomy

• below pelvic brim = ureteroneocystotomy with psoas hitch or Boari flap

• above pelvic brim = uretero-ureterostomy or diversion

35

Small Bowel and Rectal Injuries: Avoidance and Surgical Pearls

for Intestinal Repair

William M. Burke, MD

Associate Professor

Division of Gynecologic Oncology

Columbia University Medical Center

Disclosure

I have .no financial relationships to disclose

Objectives

Discuss the incidence of small bowel and rectal injuries at the time of laparoscopy.

Identify ways of avoiding bowel complications at the time of laparoscopy.

Discuss different techniques for managing bowel injuries at the time of laparoscopy.

Incidence

Bowel injuries at the time of laparoscopy are typically rare

Incidence 1/769 (0.13%)

Range 1/3333 to 1/256 (0.03% to 0.39%)

Why do we care?

Bowel injury is associated with high morbidity and mortality rates.

Delayed diagnosis of bowel injury at the time of laparoscopy is associated with a mortality rate as high as 21%. (6,7 from Green article review)

Laparoscopic bowel injury is a significant cause of litigation in the United States.

Incidence of Bowel Injury by Procedure

Laparoscopic Hyst (benign) 0.39%

Laparoscopic Hyst (malignant) 0.41%

Laparoscopic myomectomy 0.03%

Diagnostic procedures 0.07%

36

Location of Bowel Injuries

Small intestine 46.9%

Large intestine 29.9%

Rectum 18%

Stomach 6%

Cause of Bowel Injury

Veress needle, trocar 54.9%

Electrosurgery or laser 28.7%

Surgical dissection or LOA 11.5%

Other (Clips, suction, etc) 0.3%

Delay in Diagnosis

Delayed diagnosis 41%

Median time to diagnosis 3 days

Range in time to diagnosis 1 to 13 days

Presenting Signs and Symptoms

Peritonitis

Abdominal pain

Fever

Abdominal distention

Mortality

Typically occurs with delayed diagnosis 1/125 (0.8%)

In large analysis there were no deaths reported with intra-operatively recognized bowel injury

Entry Techniques

Veress Needle

Direct Trocar Entry

Hasson Open Entry

Optical Trocar Entry

37

Open vs Closed Technique

Most studies comparing visceral injury to open and closed techniques show no difference in injury rate. Open technique may lead to less cases of delayed

diagnosis for those bowel injuries related to entry

Most global professional surgical societies endorse that the preferred technique should be the surgeons preference.

Avoiding Laparoscopic Bowel Injury

Detailed surgical history and careful physical exam noting all abdominal incisions

Choose entry technique that you are most comfortable with

Prepare for multiple entry possibilities

Ensure proper positioning and instrumentation

Avoiding Laparoscopic Bowel Injury

Take the time to run the entire small intestine and inspect the entire colon if you suspect injury at entry or at anytime during operative dissection.

Keep operative instruments in your sight at all times

This includes replacement at the time of both laparoscopic and robotic surgery

Limit the use of electrosurgery, especially when completing and extensive lysis of adhesions.

In instances of significant pelvic adhesive disease or endometriosis using a rectal delineator is imperative.

Suspected Rectal Injury

Keep a high index of suspicion with difficult dissections

Utilize proctoscopy or colonoscopy and insufflation underwater to look for air leaks

Rectal installation of dilute methylene blue in saline may aid in detecting rectal injuries as well

Fixing Injuries

Enterotomy (less than 1 cm)

Laparoscopic repair with multiple layer closer using delayed absorbable suture and/or silk

Laparoscopic linear stapler

Enterotomy (greater than 1 cm)

Small bowel resection with functional end-to-end anastomosis utilizing flexible wound retractor and mini-laparotomy.

Fixing Injuries

Rectal Injuries

Size does not matter

Location does matter

Clinical situation does matter

Primary, multiple layer closure

Primary, multiple layer closure with diverting ileostomy

38

Fixing Injuries

Always consider a minimally invasive repair if technically feasible

Do not hesitate to convert to laparotomy if necessary

Do not hesitate to call for help if you need it

References

Llarena N, Shah A, Milad M. Bowel Injury in Gynecologic Laparoscopy. Obstetrics and Gynecology. 2015; 125: 1407-1417.

Cuss A, Bhatt M, Abbott J. Coming to Terms With the Fact That the Evidence for Laparoscopic Entry Is as Good as It Gets. JMIG. 2014; 22: 332-341.

Philips P, Amaral J. Abdominal Access Complications in Laparoscopic Surgery. J Am Coll Surg. 2000; 192: 525-536.

Van der Voort M, Hijnsdijk E, Gouma DJ. Bowel Injury as a complication of laparoscopy. British Journal of Surgery. 2004; 91: 1253-1258

39

Minimizing Trocar and Vascular Injuries

David M. Boruta

Massachusetts General Hospital


– Describe techniques and approaches to minimize risk and significance of trocar and vascular injuries during laparoscopy

– Discuss risks and benefits associated with abdominal access techniques

– Describe a rational approach to prevention and management of vascular complications

Trocar injuries

• Immediate

– Penetration of viscus

• Bowel

• Bladder

• Blood vessel

• Delayed

– Hernia

– Nerve entrapment

Minimize trocar injuries

• Access technique

– Closed

• Veress needle

• Optical trocar entry

• Direct trocar entry

– Open

• Incision location

Access technique: data• Many inconclusive, underpowered studies

• Cochrane Collaboration review1

– 28 RCTs with 4680 individuals

– Closed versus open technique

– Veress needle versus direct trocar entry

– No advantage of any single technique in terms of preventing major vascular or visceral complications

– but no study adequately powered to detect an advantage

40

Closed versus open technique Closed versus open technique

Closed versus open technique So why not just do open?• Advantage

– Likely less (extreme) vascular injuries

– If you have a viscus injury, you’ll probably know it

– Less failed entries

• Disadvantage

– Time consuming?

– Hernia risk?

– Cosmesis?

– Lack of training

• Video of open incision Mind closed to open

• Veress vs. direct

• Use of optical guidance

41

Closed technique Closed technique

• Video of closed techniques for access Veress vs. direct trocar

• Omental injury, extraperitoneal insufflation, and failed entry more likely with Veress

• 828,204 patients necessary to show a reduction in bowel‐injury rate from 0.3% to 0.2%

• No standardization of operative technique

• Question applicability to general population as several studies excluded previous abdominal surgery and obesity

Closed techniques: elevate? • Video of not lifting

42

Incision location

• Umbilical

• Palmer’s point

• Elsewhere

• Video of adhesions at open scope

• Video of RUQ entry Cautionary case #1

• 63 y/o with advanced stage EOC. s/p 3 cycles of NACT with good response based on CA‐125 (2249 to 25).

– PMH: BMI 42, HTN, COPD, h/o CAD and MI, seizure disorder

– PSH: TAH/USO via vertical midline open incision

– Plan for laparoscopy, possible debulking

Event timeline• 1534: Left upper quadrant access with direct trocar placement using optical

guidance. Single pass without difficulty. Dense omental adhesions to anterior abdominal wall present. Additional ports placed. Adhesiolysis progressed.

• 1550: ? Non‐functioning BP cuff.

• 1600: Anesthesia requests surgical pause due to difficulty measuring BP. No “relevant” bleeding noted on laparoscopy. Arms repositioned.

• 1608: Pneumoperitoneum released. Additional venous access and A‐line initiated.

• 1617: Pneumoperitoneum reestablished. No bleeding noted.

• 1624: CPR initiated due to cardiopulmonary arrest.

– 1651: Exlap. Hemoperitoneum identified. Pressure placed over aorta. Trauma Surgery service called emergently.

– 1712: Trauma MDs arrive. Source of hemorrhage identified in mesentery and controlled. “Lemon size” hematoma near SMA branch‐point.

– 1805: Patient packed open and brought to ICU. Intubated, on pressors, acute kidney injury, pH as low as 6.9. Resuscitated aggressively.

– 0000: Ongoing bleeding. Exlap in ICU by Trauma MDs. “Copious” blood and new transverse mesocolon hematoma. Additional suture ligation for control.

– 0200: Procedure done, repacked in ICU.

– 0830: Discussion with healthcare POA to transition to comfort‐care.

– 0953: Patient declared dead.

43

Quality assurance evaluation

– Gyn

• Patient selection and procedure

• Access location and technique

• Delay to recognize bleeding

– Anesthesia

• Monitoring

• Algorithm dependent upon surgeon findings

• USN

Cautionary case #2

• 55 y/o with stage IIIC EOC who s/p 3 cycles of NACT with response based upon CA-125 and repeat CT.

– PMH: BMI 37– PSH: CS x3, LS cholecystectomy– Plan for laparoscopy, possible debulking

Event timeline

• 0836: Procedure start. Periumbilical incision with direct trocar placement using optical guidance. Some concern regarding entry. Additional ports placed. Blood in cul-de-sac. Punctures at mesentery.

• 0850: Conversion to laparotomy. Massive hemoperitoneum.

• Immediate steps

– Vascular surgery emergent consult

– Anesthesia access, resuscitation, call for blood

– Pressure over vena cava

– Vascular MD identifies and repairs lacerated mesenteric vessels

• After stabilization and repair

– Omentectomy and BSO for optimal interval debulking

– EBL 2500

– Uneventful recovery with discharge home on POD #5

– Resumed chemotherapy POD #24

Vascular complications

• Prepare and plan for a vascular complication

– with every patient

– with every case

– anticipate high‐risk portions of the case, but be vigilant for surprise

Preoperative concerns• Patient specific

– overall fitness

• 28 y/o marathon runner vs. 78 y/o obese vasculopath

– hematologic concerns

• anemia, anticoagulation therapy, antibodies

– target organ specific

• mass size, mobility, attachments

– cultural concerns

• acceptability of blood products

44

Preoperative considerations

• Case specific

– relative risk for vascular complication

• tubal ligation vs. paraaortic lymphadenectomy

• know your case, know the anatomy


• Case specific

– equipment

– open on field

– immediately available

– available at all?


• Operative environment

– vascular access

• number and caliber IV

• arm positioning

– blood product availability

• type and screen vs. type and cross

– consultant availability

– outpatient surgicenter vs. hospital

Intraoperative considerations

• Prevention of vascular complications

– Gentle tissue handling

– Dissection between natural tissue planes

– Pedicle exposure and isolation

– Skeletonize

– Minimum pedicle tension

– Right tool for the job

– Use the tool as it was meant to be used

Intraoperative considerations

• Think one step ahead

• If bleeding were to occur…

– how can I make the environment safer

– do I have the tools, assistance, team available

Immediate management• Stop bleeding with pressure if possible

• Pause to:• think

• communicate– Anesthesia / nursing / assistant

• understand resources/call for help

• resuscitation

• necessary equipment

• plan before further action

45

• Video of bleeding When to open and when to call for help

Patient safety

Minimally invasiveapproach

• Video of well‐handled bleeding

• 1. Ahmad G, O’Flynn H, Duffy JMN, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD006583. DOI: 10.1002/14651858.CD006583.pub3.

46

Principles in Preventable Harm and Patient Safety: Reducing Surgical Site Infection, DVT

and Readmissions

Amanda Nickles Fader MD

Disclosure

• I have no financial relationships to disclose

Objective

• Discuss principles in preventable harm and patient safety: Reducing surgical site infection, DVT and readmissions

Preventable Harm

• 230 million surgeries/yr worldwideMore common than births (36 million/yr)

• 25% inpatient surgeries followed by complication7 million disabling complications/yr

• 50% of all hospital adverse events linked to surgeryAt least 50% of adverse surgical events are avoidable

• 1 out of every 20 surgical patients will be readmitted within 30 days of discharge

2009: based on Medicare claims data

2015: based on ACS National Surgical Quality Improvement Program data

American College of SurgeonsNational Surgical Quality Improvement Program

• First nationally validated, risk‐adjusted, outcomes‐basedprogram to measure the quality of surgical care

• Hospitals participating in ACS NSQIP significantly improvesurgical outcomes over time

• Hospitals collect standardized and audited clinical data on patient demographics, preoperative risk factors, labdata, operative variables & postoperative complications

• 30 day follow‐up for postoperative outcomes

47

Difference in Observed

vs Expected Ratio

Time Across the Program in Years

Hospitals Participating in ACS NSQIP SignificantlyImprove Surgical Outcomes Over Time

Cohen ME et al. Ann Surg, Feb 2015

At present, Maryland is the only state exempt from this;Maryland follows an all‐payer‐rate setting system.

Thirty‐Day Readmission Rates, Length of Stay, & Daysfrom Discharge to Readmission Following Hysterectomy

Most Common Reasons for Unplanned Readmission After Hysterectomy

Factors Associated with Unplanned Readmission

ASA ClassAscites

Disseminated CancerBleeding DisorderRenal FailureSteroid Use

Weight Loss >10%Inpatient Complication Including VTE

Discharge to Location Other Than HomeTeaching InstitutionHigh Volume Center

Total study patients = 460

Readmission after Cytoreduction for Ovarian Cancer

Clark RM et al. Gynecol Oncol, 2013

48

Readmission after Robotic Surgery for Endometrial Cancer

*Fever (31.3%)

Vaginal drainage (25%)Gastrointestinal (12.5%)

Cardiopulmonary (9.4%): PEBleeding (18.8%)

17% reoperation rate:vaginal cuff separation

port site hernia

Hospital Costs for Readmission

Total cost of all readmissions is greater than that of index admissions

Jennings AJ et al. AJOG, 2015

Laparoscopic Hysterectomy Readmission Score

1 PointDiabetesCOPD

Disseminated CancerChronic Steroid UseBleeding Disorder

Length of Surgery > 2hrs

2 PointsAny Postoperative

Complication Prior to DC

Readmission Rates According to Score

1 = 2.4%2 = 3.3%3 = 5.8%4 = 9.5%

8890 patients; 3% 30‐day readmission rate

Validation Set

1‐2 = 2.8%3‐4 = 9.6%

Normogram to Predict Readmission in General Surgery Patients

The Comprehensive Unit‐Based Safety Program Impact of a Surgical Inpatient Unit Based CUSP on the Climate of Safety and Teamwork at JHH

TC = teamwork climate, SC = safety climate, M = moraleSR = stress recognition, WC = working conditionsPM/PUM = perceptions of management/unit management

(Safety Attitudes Questionnaire)

Timmel J et al. Jt Comm J Qual Patient Saf, 2010.

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Impact of a Surgical Inpatient Unit Based CUSP on Surgical Site Infection at JHH

Wick EC et al. J Am Coll Surg, 2012

The Effect of Enhanced Recovery after Surgery Protocol on Morbidity After Surgery for Ovarian Cancer

Marx C et al. Acta Obstet Gynecol Scand, 2006

(‐) (+) ERAS

JHH ERAS Protocol for Ovarian Cancer Debulking

• Intensified preoperative counseling• Interventions to reduce surgical site infection• Use of regional anesthesia &

non‐narcotic pain medications• Restriction of intravenous fluids• Early enteral feeding and mobilization• Multidisciplinary discharge planning• Strict adherence to VTE prophylaxis guidelines

X

X

X

Moderate‐VTE‐risk patients(Caprini score of 3‐4) IPC or LMWH

Low‐VTE‐risk patients(~1.5%; Caprini score of 1‐2) IPC

Use of VTE Prophylaxis Following MIS for Gynecologic Malignancies

Rate of symptomatic VTE 0.5%

X

X

X

Moderate‐VTE‐risk patients(Caprini score of 3‐4) IPC or LMWH

Low‐VTE‐risk patients(~1.5%; Caprini score of 1‐2) IPC

50

Nick AM et al. Green Journal, 2010

Identifying Higher Risk Subgroups Conclusions

• Readmission rate 3‐12% following hysterectomy• Postoperative readmissions are directly related to

surgical complications:‐ SSI & ileus/obstruction following cytoreduction for OC‐ Fever, vaginal drainage & GI sequelae following roboticsurgery for endometrial cancer; 17% reoperation rate

• Strategies to reduce readmissions:1) participation in NSQIP2) tools for identifying and targeting high risk

populations for readmission 3) implementation of CUSPs and ERAS pathways4) possibly refine VTE prophylaxis guidelines

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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

52

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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