Sponsored by
AAGLAdvancing Minimally Invasive Gynecology Worldwide
Didactic: Surgical Stepping-Stones: Essential Lessons Along the Path to Laparoscopic Excellence
PROGRAM CHAIR
David M. Boruta, MD
Ahmed N. Al-Niaimi, MD Douglas N. Brown, MD William M. Burke, MD
Professional Education Information Target Audience This educational activity is developed to meet the needs of surgical gynecologists in practice and in training, as well as other healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) 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 ...................................................................................................................................................... 2 Pelvic Retroperitoneal Spaces: Essential Anatomy for Advanced Gynecologic Laparoscopy D.M. Boruta ................................................................................................................................................... 3 Stab Wound versus Safe Incision: Recognizing and Minimizing the Risks of Initial Abdominal Access W.M. Burke ................................................................................................................................................. 10 The Urinary Tract and the Gynecologist: Avoiding a Predator‐Prey Relationship D.N. Brown ................................................................................................................................................. 16 Tools of the Trade: Rational Approach to Equipment Options for Complex Laparoscopy A.N. Al‐Niaimi ............................................................................................................................................. 23 Conversion Is a Dirty Word: Strategies to Minimize the Need for Laparotomy in Challenging Situations W.M. Burke ................................................................................................................................................ 29 Good Intention Causing Harm: Avoiding Oncologically Unsound Laparoscopic Surgery D.N. Brown ................................................................................................................................................. 35 Sooner Rather Than Later: Early Recognition and Management of Laparoscopic Complications A.N. Al‐Niaimi ............................................................................................................................................. 41 Cultural and Linguistics Competency ......................................................................................................... 45
ONC-706: Didactic: Surgical Stepping-Stones: Essential Lessons Along the Path
to Laparoscopic Excellence
Presented in affiliation with the Society of Gynecologic Oncology (SGO) and in cooperation with the AAGL Special Interest Group on Oncology
David M. Boruta, Chair
Faculty: Ahmed N. Al-Niaimi, Douglas N. Brown, William M. Burke This course provides a review of fundamental knowledge and skills essential to the safe, successful
completion of complex minimally invasive gynecologic procedures. Lectures will emphasize the necessity
of maintaining patient safety and oncologically sound surgical principles, while striving to minimize
morbidity with the use of minimally invasive surgical approaches. The importance of a thorough
understanding of pelvic anatomy as a key element of surgical excellence will be emphasized. A rational
approach to selecting surgical instrumentation, including robotic-assisted and traditional laparoscopic
equipment, will be discussed in regards to best facilitating completion of safe, effective minimally
invasive procedures. Advanced laparoscopic procedures in challenging patients with complex pathology
may be associated with serious complications. Surgical principles to aid in avoidance of these, as well as
instruction on their early recognition and management, will be emphasized. Video-based case
presentation will be used to demonstrate valuable lessons learned by this group of gynecologic
oncologists experienced in performing advanced laparoscopy. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Employ strategies to
reduce potential complications during complex laparoscopic procedures; 2) identify minimally invasive
surgical techniques that maintain patient safety and oncologic efficacy in addressing potentially
malignant pathology; and 3) recognize clinical signs and symptoms of serious postoperative
complications and plan for their management.
Course Outline 7:00 Welcome, Introductions and Course Overview D.M. Boruta
7:05 Pelvic Retroperitoneal Spaces: Essential Anatomy for Advanced Gynecologic Laparoscopy D.M. Boruta
7:30 Stab Wound versus Safe Incision: Recognizing and Minimizing the Risks of
Initial Abdominal Access W.M. Burke
7:55 The Urinary Tract and the Gynecologist: Avoiding a Predator-Prey Relationship D.N. Brown
8:20 Tools of the Trade: Rational Approach to Equipment Options for
Complex Laparoscopy A.N. Al-Niaimi
8:45 Questions & Answers All Faculty
8:55 Break
9:10 Conversion Is a Dirty Word: Strategies to Minimize the Need for Laparotomy
in Challenging Situations W.M. Burke
9:35 Good Intention Causing Harm: Avoiding Oncologically Unsound
Laparoscopic Surgery D.N. Brown
10:00 Sooner Rather Than Later: Early Recognition and Management of
Laparoscopic Complications A.N. Al-Niaimi
10:25 True Stories: Video Case Presentations That Taught Us Valuable Lessons All Faculty
10:50 Questions & Answers All Faculty
11:00 Adjourn 1
PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* R. Edward Betcher* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical David M. Boruta* Sarah L. Cohen Consultant: Olympus Erica Dun* Joseph (Jay) L. Hudgens Contracted Research: Gynesonics Frank D. Loffer, Medical Director, AAGL* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* Karen C. Wang* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Sawsan As-Sanie Consultant: Myriad Genetics Lab Jubilee Brown* Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Jon I. Einarsson* Suketu Mansuria Speakers Bureau: Covidien Andrew I. Sokol* Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Stock Ownership: Titan Medical Karen C. Wang* 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). Ahmed N. Al-Niaimi* David M. Boruta* Douglas N. Brown Consultant: Medtronic William Burke* Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.
2
Essential Anatomy for Advanced Gynecologic Laparoscopy
David M. Boruta
David M. Boruta
Disclosures
I have no financial relationships to disclose.
2
• Knowledge of anatomy is the foundation of surgery
– Critical to safety and success
• Pelvic anatomy is difficult to envision
– 3-dimensional
– Complex layering of structures
3
Key to surgical success
4
• Gynecologic
– Uterus, adnexa, vagina
• Urinary
– Bladder, ureters
• Gastrointestinal
– Sigmoid colon, rectum, cecum, appendix
5
Organ systems A beautiful pelvis…
6
3
• Abdominal wall layers
• Pelvic fascia
– Broad ligament (peritoneal drape)
– Cardinal ligament (cervix to obturator internus muscle)
– Uterosacral ligament (cervix to sacrum)
– etc… “endopelvic fascia”
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Connective tissues Abdominal wall
8
9 10
Vasculature
• Abdominal wall
– Inferior epigastric vessels
• Abdominal
– Aorta/IVC
– Mesenteric vessels
• Pelvic
– Iliac vessels and their tributaries
– Gonadal vessels
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Abdominal wall
12
4
Pelvis (left sagittal)
13
Left pelvic sidewall
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Nerves
• Abdominal wall
– Ilioinguinal
• Pelvic
– Obturator
– Genitofemoral
– Femoral
– Sacral plexus
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Abdominal wall
16
Pelvis
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Left pelvic sidewall
18
5
Ureteral pathway
• Pelvic brim
• Pelvic sidewall
• Relationship to uterine vasculature
– “water under the bridge”
• Ureterovesical junction
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Finding the ureter
20
Ureter and IP at the brim
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Ureteral danger zones
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Avascular spaces
23
The beautiful pelvis, again…
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6
The Saturday add-on case pelvis…
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Pelvic spaces schematic
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Prevesical space (Retzius)
• Utility:
– Access to paravaginal space
– Correction of paravaginal defects, Burch colposuspension
• Borders:
– Back of pubic bone and anterior bladder wall
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Prevesical space
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Vesicouterine (-vaginal) space
• Utility:
– Any hysterectomy, C-section
• Borders:
– Anterior: bladder
– Posterior: vagina / cervix
– Lateral: bladder pillars
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Vesicouterine/vaginal space
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7
Paravesical space
• Utility:
– Pelvic LND, radical hysterectomy or trachelectomy
• Borders:
– Anterior: pubic symphysis
– Posterior: cardinal ligament
– Lateral: external iliac vessels and obturator internus muscle
– Medial: bladder and superior vesicle artery
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Paravesical space (left side)
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Pararectal space
• Utility:
– Safeguard ureters, resection of pelvic peritoneum
• Borders:
– Anterior: cardinal ligament
– Posterior: sacrum
– Lateral: internal iliac vessels
– Medial: ureter
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Pararectal space (right side)
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Rectovaginal space
• Utility:
– Resection of endometriosis from pouch of Douglas
– Colorectal resection
• Boundaries:
– Anterior: vagina
– Posterior: rectum
– Lateral: uterosacral ligaments
35 36
8
Retrorectal (presacral) space
• Utility:
• Borders:
– Anterior: rectum
– Posterior: sacrum
– Lateral: internal iliac vessels
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Sagittal pelvis
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Left pelvis
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Left pelvis
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s/p radical hysterectomy/BPLND
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9
Stab Wound versus Safe Incision: Recognizing and Minimizing the Risks of Initial Abdominal Access
William M. Burke, MD
Associate ProfessorDivision of Gynecologic Oncology
Department of Obstetrics and GynecologyColumbia University College of Physicians and Surgeons
I have no financial relationships to disclose.
• At the end of this presentation, audience members will be able to:
– Review important anatomy related to peritoneal access
– describe techniques and approaches to minimize risk and significance of trocar injuries during laparoscopy
– discuss risks and benefits associated with abdominal access techniques
Trocar injuries
• Immediate
– Penetration of viscus
• Bowel
• Bladder
• Blood vessel
• Delayed
– Hernia
– Nerve entrapment
Anatomy
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Abdominal Wall Vasculature Nerves of the Anterior Abdominal Wall
Considerations
• Procedure
• Patient body habitus
• Prior surgical history
• Potential complications
Preparation for Trocar Placement
• Gastric decompression
– Should have been confirmed prior to insufflation
• Proper insufflation pressure achieved
• Ensure that the patient is flat and not in trendelenberg
• Grasp trocar to limit insertion distance
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
11
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
Mind closed to open
• Veress vs. direct
• Use of optical guidance
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Incision location
• Umbilical
• Palmer’s point
• Elsewhere
Closed technique
Closed technique Palmer’s Point
Palmer’s point is 2 cm below the intercostal margin in the midclavicular line
The insufflation needle is inserted at a steep 60 to 80 degree angle and slightly toward the midline
Keith Isaacson. Complications of Gynecologic Endoscopic Surgery
Left Upper Quadrant Entry
Left upper quadrantMidclavicular line beneath
left costal margin ( can insufflate between ribs 9 & 10)
Check for hepatosplenomegaly; Hx of surgery in LUQ
Decompress stomach
13
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
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15
The Urinary Tract and the Gynecologist:
Avoiding the Predator-Prey Relationship
Douglas N. Brown, MD, FACOG, FACSChief, Minimally Invasive Gynecologic Surgery
Director, Center for Minimally Invasive Gynecologic SurgeryMassachusetts General Hospital
Harvard Medical School
2
Consultant: Medtronic
Disclosure Slide
Objectives
Articulate the anatomical course of the ureter and corresponding blood supply
Identify common locations susceptible to ureteral injury during gynecologic surgery
Illustrate common procedures performed for ureteral repair
Anatomy
Ureters are retroperitoneal structures that run from the renal pelvis to the bladder
Approximately 25-30cm in length
Pelvic brim divides them into abdominal and pelvic segments
Can also be divided into upper, middle, and lower segments
Inferior border of the SI joint to the UV junction
Upper border to lower border of SI joint
Between the ureteropelvic junction to the upper border of
the SI joint
Anatomic course
The abdominal portion of the ureter lies on the anterior surface of the psoas muscle
Attached to the undersurface of the posterior parietal peritoneum
As it approaches the pelvis, it is crossed anteriorly by the ovarian vessels
16
Anatomic Course
Enter pelvis at the pelvic brim where they cross from lateral medial
Left ureter enters by crossing over the left common iliac artery
Right ureter enters the pelvis by crossing over the right external iliac artery
Ureter is medial to the branches of the anterior division of hypogastric artery
Anatomic Course
Ureters descend into pelvis within a peritoneal sheath (ureteric fold) attached to the MEDIAL LEAF of the broad ligament
Run along the pelvic sidewalls just ABOVE the internal iliac arteries
In NORMAL anatomy, the ureters run medially in the base of the broad ligament to pass UNDERthe uterine arteries approximately 1.5 cm lateral to the internal cervical os
Anatomic Course
Ureter passes through the areolar tissue of the tunnel of Wertheim
They then pass by the anterolateral fornix of the vagina and enter the bladder posteriorly, approximately 5-6 cm apart
They run obliquely through the bladder wall for 1.5 cm before terminating at the trigone
VIDEO NORMAL URETER
PATHWAY
Ureteral Blood Supply
Multiple vessels contribute to the blood supply of the ureter:
In the abdomen, the ureter receives blood supply from small arteries approaching it medially
In the pelvis, the ureter receives its blood supply from vessels approaching it laterally
Renal Artery
Gonadal Artery Common Iliac Artery
Aorta
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Key Points
Important to maintain integrity of the
adventitial sheath during dissection
Peritoneal incision to expose the ureter should be made:
Lateral to the ureter in the abdomen
Medial to the ureter in the pelvis
Ureteral Injury
Approximately 0.4% - 2% rate of injury during benign pelvic surgery
Possible increased risk of ureteral injury in laparoscopic hysterectomy vs. abdominal or vaginal hysterectomies
Packiam VT et al. Urology. 2016 Jul 5. pii: S0090-4295(16)30370-3
96K Hysterectomies: 302 injuries
AH: .18%, MIH: .48%, VH: .04%
Causes of Ureteral Injury
Intraoperative injury may result from:
Ligation
Crush
Laceration
Transection
Ischemia
Risk factors
Most ureteral injuries have no identifiable risk factors
Abnormal anatomy and architecture of the ureters are associated with increased injury
Gynecologic malignancy
Endometriosis/Pelvic adhesions
Enlarged uteri
Adnexal masses
Cervical/broad ligament fibroids
Intraoperative hemorrhage
Most Common Sites of Injury
1. Pelvic Brim
2. Over Iliac Arteries
3. Within the cardinal ligaments at level of internal os
4. Anterolateral fornix of the vagina
Methods to Avoid Injury
KNOW YOUR ANATOMY
18
Ureteral Stents ?????
Ureteral stents can serve 3 useful functions:
Make the ureters more prominent
Make the ureters more rigid: good AND bad
Should the ureter be inadvertently injured the injury is much more likely to be recognized intra-operatively
Prophylactic Ureteral Catheterization in Gyn Surgery
Chou MT, et al. Int Urogyn J Pelvic Floor Dysfunct. 2009
Randomized trial; 1996-2007
Of 3141 patients who underwent gynecologic surgery, ureteral injury occurred in 1.2% of patients with stents and 1.09% of patients not receiving stents (p=0.77)
No difference in ureteral injury between patients who did and did not undergo ureteral catheterization
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VIDEO LIGHTED STENTS
Universal Cystoscopy
Ibeanu OA, et al. Obstetrics and Gynecology. 2009
Prospective clinical trial: 839 hysterectomy cases
Diagnostic cystoscopy was performed on all patients after hysterectomy for benign disease
Universal intraoperative cystoscopy detected 97.4% of ureteral injuries
BUT: negative cystoscopy does not rule out ureteral injury
Universal Cystoscopy
Sandberg EM et al. Obstet Gynecol. 2012 Dec;120(6):1363-70.
Retrospective cohort study
1982 patients underwent hysterectomy
No ureteral injuries detected intra-operatively with or without cystoscopy
5 patients (0.25%) diagnosed postoperatively with ureteral injury
—All associated with MIS
Recommendations
Selective rather than universal cystoscopy
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“The venial sin is injury to the ureter; the mortal sin is
failure of recognition.”
Higgins, JAMA, 1967
Clinical Management of Ureteral Injury
Intra-operative Period
Post-operative Period
- Obvious injury
- Leakage of IV Dye
Minor Injury Major Injury
-Ureteral Stent via cystoscopy/cystotomy
-F/U IVP at 6 weeks, remove stent if normal
LOCATION
Upper Middle Distal
End to end anastamosis
Ureteral implantation
- Transient elevation in Cr
- CVA tenderness, fever, ileus
NephrostomyAutotransplantation
Lower Ureteral Repair
~90% of trauma to ureter occurs in the lower portion
Ureteroneocystostomy: Injury within 2 cm of UV junction
—1. Intravesical technique (Leadbetter-Politano)
—2. Extravesical technique (Lich-Gregoire)
Ureteroureterostomy: If injury is 3-4 cm proximal to UV junction
Psoas Hitch ureteral reimplantation
Technique:
Mobilize both sides of the defect ends
Trim and spatulate ends when good vasculature has been identified
One layer repair of sutures at 6, 12, 9 and 3 o’clock.
Done over a cystoscopicallyplaced double-J stent
Ureteroureteral anastomosis
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VIDEOs - LAPAROSCOPIC URETEROURETERAL
ANASTOMOSIS
Ureteroneocystotomy
Indication: Transection within 4-5 cm of ureterovesical junction
Technique:
Mobilize proximal portion of ureter
1cm transverse bladder incision superior and medial to the native orifice
Ureter is brought to posterior bladder incision
Ureteral stent is passed through the ureterovesical junction cystoscopically
Sutures are placed at 6, 12, 9, and 3 o’clock to approximate the ureter to the bladder
20
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VIDEO – LAPAROSCOPIC URETERONEOCYSTOTOMY
Ureteroneocystomy with Psoas Hitch
Middle Ureteral Repair
Approximately 7% of all ureteral injuries
Ureteroureterostomy
Boari Flap
Transureteroureterostomy
Upper Ureteral Injury
Includes 2% of ureteral injuries
• Autotransplantation
• Nephrostomy
• Nephrectomy
Key Points
KNOW YOUR ANATOMY
Ureteroneocystostomy: Injury within 2 cm of UV junction
Ureteroureterostomy: If injury is 3-4 cmproximal to UV junction
Most important factor: NO TENSION
Laparoscopic ureteral repair is a safe and feasible option when adequate skill level is available
References Park JH, Park JW, Song K, Jo MK. Ureteral Injury in Gynecologic Surgery: A 5 Year Review in A
Community Hospital. Korean J Urol; 53: 120-125
Piscitelli JT, Simel DL, Addison WA.Who should have intravenous pyelograms before hysterectomy for benign disease? Obstet Gynecol. 1987 Apr;69(4):541-5.
Chou MT, Wang CJ, Lien RC. Prophylactic Ureteral Catheterization in Gyn Surgery: A 12 yr Randomized Trial. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Jun; 20(6): 689-693
Schimpf M, Gottenger E, Wagner J.Universal ureteral Stent Placement at Hysterectomy to Identify Ureteral Injury: A Decision Analysis. BJOG 2008; 115:1151-1158
Manoucheri E, Cohen S, Sandberg E, Kibel A, Einarsson J. Ureteral Injury in Laparoscopic Gynecologic Surgery. Reviews in Obstetrics and Gynecology. 2012; 5(2): 106-111
Sandberg EM1, Cohen SL, Hurwitz S, Einarsson JI.Utility of cystoscopy during hysterectomy. Obstet Gynecol. 2012 Dec;120(6):1363-70. doi: http://10.1097/AOG.0b013e318272393b.
Chan J, Morrow J, Manetta A. Prevention of ureteral injuries in gynecologic surgery. Am J Obstet Gynecol. 2003; 188:273-1277
Han CM1, Tan HH, Kay N, Wang CJ, Su H, Yen CF Lee CL. Outcome of laparoscopic repair of ureteral injury: follow-up of twelve cases. J Minim Invasive Gynecol. 2012 Jan-Feb;19(1):68-75. doi: 10.1016/j.jmig.2011.09.011. Epub 2011 Nov 18.
Ibeanu OA, Chesson RR, Echols KT, Nieves M, Busangu F, Nolan TE. Urinary Tract Injury During Hysterectomy Based on Universal Cystoscopy. Obstetrics and Gynecology. 2009 Jan;113(1):6-10.
Packiam VT, Cohen AJ, Pariser JJ, Nottingham CU, Faris SF, Bales GT. The Impact of Minimally Invasive Surgery on Major Iatrogenic Ureteral Injury and Subsequent Ureteral Repair During Hysterectomy: A National Analysis of Risk Factors and Outcomes. Urology. 2016 Jul 5. pii: S0090-4295(16)30370-3. doi: 10.1016/j.urology.2016.06.041.
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Thank You
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22
Tools of the Trade: Rational Approach to Equipment
Options for Complex Laparoscopy
Ahmed AL‐Niaimi, MD, FACOD, FACS
Assistant professor Gynecologic Oncology
Department of OBGYN
University of Wisconsin,
Madison, Wisconsin , USA
Disclosure
• I have no financial relationships to disclose.
Objectives
• Discuss the available equipment for your laparoscopic surgery
• Use the learning process to better understand the pros and cons of each device
The followings are to be discussed
• Operative Table height and configuration
• Camera
• Energy
• Surgical stapes
• Fluorescent aided surgery
Operative Table height and configuration
• Table height :
• Table can be anywhere between 50‐70 cm above ground [5]
• Surgical field should be at the level of the surgeon’s ileac crest
Cameras
Rigid vs. flexibe• Rigid is easy to use• Is available in 0o, 30 o or 45 o
2D vs. 3 D • 3D is not superior other than producing an impressive visual effect.• It might improve operative time [1] [2] [3]• But induce surgeon’s eye strain
Study Author Year Pros Cons
RCT Hanna at al [1] 1998 Visually better Eye strain
RCT Sahu et al [3] 2014 Shorter operative time Not reported
RCT Curro at al [2] 2015 Shorter operative time Increase eyestrain
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Energy sources
• Electro‐cautary Surgery Unites
• Mono‐polar
• Bi‐polar ( ligasure®, enseal®)
• Ultrasound technology ( Harmonic ®)
• Argon Plasma Coagulation (Argon beam, APC)
Electro‐cautery. principles
• Electrosurgical units (ESU) • convert standard electrical frequencies from the wall outlet
• Tissue effect. • Desiccation:
• Direct contact Causes dehydration and protein denaturation.
• Vaporization: • No direct contact The high heat vaporizes tissue.
• Fulguration: • No direct contact, further away than in vaporization
Two modes of Electro‐cauteryCutting mode Coagulation mode
continuous (or unmodulated) Interrupted (or modulated)
low‐voltage Effect over large surface area
Effect over a small area Effect over large surface area
rapid tissue heating Tissue heating is slower
Results in vaporization Results in coagulation
Minimal thermal damage (1 mm) More thermal spread than cutting modeTissue dependent
Blending
Tissue resistance The ultrasound activated scalpel (UAS)Principles
• Transferring • mechanical energy to ultrasonic frequency(25Khz ‐ 55KHz)
• The vibration produces frictional heat
• UAS cuts tissues by a relatively sharp blade vibrating at 25Khz ‐55Khz over a distance of up 100µm.
• UAS= produces • lower max temperature
• slower increase in tissue temperature than the heat from electrocautery.
24
The ultrasound activated scalpel (UAS)
Advantages
• Minimal lateral thermal tissue damage (data)
• Minimal charring and desiccation• No electricity to or through the patient
• Greater precision near vital structures
• Minimal smoke for improved visibility in the surgical field
• Better than electro‐cautary ? (Data)
Disadvantages
•Expensive•Can’t seal more than 5‐7 mm vessels•Technology does not allow flexible instrument
Thermal spreadAt the tip [12]
Thermal spreadAt the tip
Thermal spreadAt the tip
Thermal spreadAt the tip
Thermal spreadAt the tip
25
Thermal spreadAdjacent to the tip
Thermal spread1 cm away from the tip
Comparing US vs Electro‐cautary (clinically) [13]
Ultrasound compared to Cautery
Operative time elective - 8 minutes (p<0.001)
emergency -17 minutes (p=0.004)
Complicated -15 minutes (p=0.03)
Bile leak OR = 0.27 (0.17-0.42. p< 0.001)
Cholecystectomy RCT.No data exists in any other surgeries
Argon Plasma Coagulation (APC)tissue effect and depth
• creates uniformly deep zones of • devitalization (1)
• coagulation (2)
• desiccation (3)
• even in large‐area applications, these are automatically limited to at most 3(4) mm
APC tissue effect and depth
• Set up:• Energy
• Gas flow
• Tissue effect depends on • Duration
• Power
• And probe distance
APC tissue effect and depth
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Energy sources summary
• Electro‐cautary Surgery Unites
• Mono‐polar
• Bi‐polar ( ligasure®, enseal®)
• Ultrasound technology ( Harmonic ®)
• Argon Plasma Coagulation (APC)
• Plasma jet
Cheapest / least precision
Expensive / more precision
bowel resection and anastomosis. Staples ‐‐history• Traditionally were performed using hand‐sewn suture techniques
• Automated surgical stapling devices permits [15] • comparable efficacy,
• greater simplicity, and
• perhaps increased speed
• Post WWII Scientific Research Institute for Experimental Apparatus and Instruments in Moscow.
Staples – principles• Most modern staplers bend into a B‐shape
Staples ‐‐ principles• Principles of bowel staples are:
• Device configurations • thickness of staples
• Staple line length
• Staple line form ( straight or curved)
• Tissue properties• Fluid content of the tissue / thickness
• Perfusion
• Device‐tissue interaction • Compression load
• Tension or tensile load
• Compression time
Staples ‐‐ principles• Principles of bowel staples are:
• Device configurations • thickness of staples
• Staple line length
• Staple line form ( straight or curved)
Fluorescent aided surgery Indocyanine green (ICG)‐enhanced fluorescent
• LN mapping
• Bowel perfusion mapping
27
Fluorescent aided surgery Indocyanine green (ICG)‐enhanced fluorescent
• LN mappingICG has a high overall detection rate, and bilateral mapping [7]
• Bowel perfusion mapping
Fluorescent aided surgery Indocyanine green (ICG)‐enhanced fluorescent
• Bowel perfusion mappingICG‐enhanced fluorescent angiography provides useful intraoperative information about the vascular perfusion during colorectal surgery and may lead to change the site of resection and/or anastomosis
Reference [1] Hanna GB, Shimi SM, Cuschieri A. Randomised study of influence of two‐dimensional versus three‐dimensional imaging on performance of laparoscopic cholecystectomy. Lancet. 1998;351:248‐51.
[2] Curro G, La Malfa G, Caizzone A, Rampulla V, Navarra G. Three‐Dimensional (3D) Versus Two‐Dimensional (2D) Laparoscopic Bariatric Surgery: a Single‐Surgeon Prospective Randomized Comparative Study. Obes Surg. 2015;25:2120‐4.
[3] Sahu D, Mathew MJ, Reddy PK. 3D Laparoscopy ‐ Help or Hype; Initial Experience of A Tertiary Health Centre. J Clin Diagn Res. 2014;8:NC01‐3.
[4] Berguer R, Gerber S, Kilpatrick G, Beckley D. An ergonomic comparison of in‐line vs pistol‐grip handle configuration in a laparoscopic grasper. Surg Endosc. 1998;12:805‐8.
[5] Berquer R, Smith WD, Davis S. An ergonomic study of the optimum operating table height for laparoscopic surgery. Surg Endosc. 2002;16:416‐21.
[6] Boni L, David G, Dionigi G, Rausei S, Cassinotti E, Fingerhut A. Indocyanine green‐enhanced fluorescence to assess bowel perfusion during laparoscopic colorectal resection. Surg Endosc. 2016;30:2736‐42.
[7] Buda A, Bussi B, Di Martino G, Di Lorenzo P, Palazzi S, Grassi T, et al. Sentinel Lymph Node Mapping With Near‐Infrared Fluorescent Imaging Using Indocyanine Green: A New Tool for Laparoscopic Platform in Patients With Endometrial and Cervical Cancer. J Minim Invasive Gynecol. 2016;23:265‐9.
[8] Comajuncosas J, Hermoso J, Jimeno J, Gris P, Orbeal R, Cruz A, et al. Effect of bag extraction to prevent wound infection on umbilical port site wound on elective laparoscopic cholecystectomy: a prospective randomised clinical trial. Surg Endosc. 2016.
[9] Cohen SL, Greenberg JA, Wang KC, Srouji SS, Gargiulo AR, Pozner CN, et al. Risk of leakage and tissue dissemination with various contained tissue extraction (CTE) techniques: an in vitro pilot study. J Minim Invasive Gynecol. 2014;21:935‐9.
[10] MiladMP, Milad EA. Laparoscopic morcellator‐related complications. J Minim Invasive Gynecol. 2014;21:486‐91.
[11] Hall T, Lee SI, Boruta DM, Goodman A. Medical Device Safety and Surgical Dissemination of Unrecognized Uterine Malignancy: Morcellation in Minimally Invasive Gynecologic Surgery. Oncologist. 2015;20:1274‐82.
[12] Sutton PA, Awad S, Perkins AC, Lobo DN. Comparison of lateral thermal spread using monopolar and bipolar diathermy, the Harmonic Scalpel and the Ligasure. Br J Surg. 2010;97:428‐33.
[13] Weiss RC, Comis RL. Chemotherapy in the treatment of non‐small cell lung cancer. Cancer Invest. 1986;4:343‐51.
[14] Go PM, Goodman GR, Bruhn EW, Hunter JG. The argon beam coagulator provides rapid hemostasis of experimental hepatic and splenic hemorrhage in anticoagulated dogs. J Trauma. 1991;31:1294‐300.
[15] Bristow RE. Surgery for Ovarian Cancer, Third Edition, 3rd Edition. 2015.
[16] Teeluckdharry B, Gilmour D, Flowerdew G. Urinary Tract Injury at Benign Gynecologic Surgery and the Role of Cystoscopy: A Systematic Review and Meta‐analysis. Obstet Gynecol. 2015;126:1161‐9.
[17] Visco AG, Taber KH, Weidner AC, Barber MD, Myers ER. Cost‐effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy. Obstet Gynecol. 2001;97:685‐92.
[18] Chou MT, Wang CJ, Lien RC. Prophylactic ureteral catheterization in gynecologic surgery: a 12‐year randomized trial in a community hospital. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20:689‐93.
Thank you
28
Conversion Is a Dirty Word: Strategies to Minimize the Need for
Laparotomy in Challenging Situations
William M. Burke, M.D.
Associate Professor
Division of Gynecologic Oncology
Department of Obstetrics and Gynecology
Columbia University College of Physicians and Surgeons
Disclosures
• I have no financial relationships to disclose
Objectives
At the conclusion of this activity the participant will be able to:
1. Use the learning process to better understand the work-up and evaluation of patients with difficult pelvic pathology
2. Cite the proper surgical set-up important for completing safe and successful surgical procedures on patients with difficult pelvic pathology
3. Evaluate 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 failure
• 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.
29
Work-up
• 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
30
Uterine Manipulation Robotic Port Placement
Attacking the Pelvis: Advantages of Anatomical Safe Havens
Take Advantage of 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 EntryRetroperitoneal Access
with Endometriosis
31
Opening Over the Ureteral Fold
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 MovingOpening the Pelvic
Sidewall Altered Anatomy
Bladder Endometriosis
• Don’t be afraid of filling the bladder.
• Vasopressin injection at disease sites may be useful
• Don’t be afraid of resecting portions of the bladder if necessary
• Don’t forget to remind your patients they may require prolonged catheterization
Resection of Bladder Endometrosis
32
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
Resection of Rectovaginal Endometriosis
33
Completion of Rectovaginal Resection
Evaluation Question
• Which of the following is not a method for evaluating for possible bladder injury during a difficult hysterectomy for extensive endometriosis?
1. Cystoscopy
2. Back filling the bladder with methylene blue
3. Urology consult
4. Intra-operative voiding cystogram
34
Good Intention Causing Harm: Avoiding Oncologically Unsound
Laparoscopic Surgery
Douglas N. Brown, MD, FACOG, FACSChief, Minimally Invasive Gynecologic Surgery
Director, Center for Minimally Invasive Gynecologic SurgeryMassachusetts General Hospital
Harvard Medical [email protected]
2
Consultant: Medtronic
Disclosure Slide
Objectives
Articulate the rational for the current controversy surrounding tissue extraction in gynecologic surgery
Identify safe alternatives to laparotomy in gynecologic surgery
Apply the knowledge learned to safely offer minimally invasive surgical options to patients undergoing gynecologic surgery
Two Principle Issues: Safe Tissue Extraction
Large adnexal mass
Large uterus
4
Pre-operative Evaluation – Adnexal Masses
History and Clinical Evaluation
(age, family history, symptoms)
Imaging (US, CT, MRI)
Tumor Markers (when indicated)
5
Pre-operative Evaluation – Adnexal Masses
6
ACOG Practice Bulletin No. 83, 2007
35
Ultrasound
ACOG Practice Bulletin No. 83, 2007
Overwhelmingly Benign: Unilocular Thin-walled sonolucent cysts Smooth, regular borders Less than 8 cm No ascities
Modesitt SC et al., Risk of malignancy in unilocular ovarian cystic tumorsless than 10 centimeters in diameter. Obstet Gynecol 2003;102:594–9
Modesitt et al. Prospective Study 2763 postmenopausal women Unilocular cysts up to 10 cm Serial US Q 6 months (total 6.5 yrs) No Cancers, 65% Spontaneous Regression
Ultrasound
Concerning findings: Bilaterality Solid component(s) Doppler flow to the solid component Thick septations (greater than 2 to 3 mm) Presence of ascites
Pre-operative Evaluation – Adnexal Masses
9
ACOG Practice Bulletin No. 83: Management of Adnexal Masses.
Obstetrics & Gynecology. 110(1):201-214, July 2007
Laparotomy Versus Laparoscopy
Laparotomy and laparoscopy have equal rates ofintraoperative cyst rupture
But…. laparoscopy results in significantlydecreased operative time, perioperative morbidity,length of hospital stay, and postoperative pain
Use clinical judgment based upon availableinformation
10
Laparoscopic Management
Surgical Technique
Careful peritoneal evaluation
Biopsy of suspicious areas
Peritoneal Washings
Intact removal vs. controlled aspiration
Frozen section
If malignant - surgical staging
(laparoscopy/laparotomy)12
Nezhat's Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy, Fourth Edition, Cambridge University Press, 2013.
36
Cyst Aspirator
13 14
VIDEO : LAPAROSCOPIC CYST ASPIRATION - CYSTECTOMY
15
VIDEO : LAPAROSCOPIC CYST ASPIRATION – OOPHORECTOMY
CONTAINED REMOVALMINI-LAP UMBILICUS
Two Principle Issues: Safe Tissue Extraction
Large adnexal mass
Large uterus
16
Uterine Surgical Technique Is Linked to Abnormal
Growths and Cancer Spread – NYT, Feb 6 2014
Doctors Eye Cancer Risk in Uterine
Procedure – WSJ, Dec 18 2013
Patient safety must be a priority in all aspects of care –Editorial in The Lancet Oncology, Feb 2014
Evaluating the Risks of Electric Uterine Morcellation – JAMA Feb 6, 2014
Where Is This All Heading?
Johnson & Johnson’s Ethicon Division Recalls Gynecare Morcellator
Highmark, Inc. will no longer pay for hysterectomy or myomectomy that involves the use of a power morcellator
Hospitals Banning the Use of Morcellators
Laparoscopic Morcellator Lawsuits
37
But…
Patients who undergo abdominal hysterectomy have THREE times the risk of mortality than those who undergo laparoscopic hysterectomy
Wiser et al. Gynecol Sur 2013;10:117-22
Leiomyosarcoma & Prognosis
LMS (presumably) confined to the uterus treated with total hysterectomy
Five-year disease specific survival: 66%
Unclear whether or not adjuvant therapy improves survival
Chemotherapy (e.g. docetaxel/gemcitabine and/or doxorubicin)
Radiation therapy
Leiomyosarcoma & Prognosis
Advanced Stage LMS
5-year disease specific survival: 29-45%
Small patient series suggest optimal cytoreduction improves survival
Unclear whether or not immediate adjuvant therapy improves survival beyond optimal cytoreduction, but docetaxel/gemcitabine generally used in recurrent disease with ORR 27-36%
LMS: Does the Primary Procedure Matter ?
Group A (n=21): TAH
Group B (n=18): tumor injury (e.g. exlap myomectomy, exlap SCH, LS hyst with morcellator knife, hysteroscopic myomectomy)
Following LMS diagnosis, all underwent TAH
End of study period:
Group A 38% DOD
Group B 63% DOD
Gao Z, Li L, Meng Y. PLoS ONE. 2016;11(2):e0148050. doi:10.1371/journal.pone.0148050.
Morcellation Nightmare
42 y/o woman, 3 months s/p LS myomectomy using mechanical morcellation
Mass had been followed without change for 8 years
Pathology: benign leiomyoma
Presents with multiple intraperitoneal masses and port entry site masses
Slide review of initial pathology: malignant spindle cell neoplasm
Poor performance status
Palliative care…died after one week Anupama et al, J Minim Invasive Gynecol, 18: 386-389, 2011
Not An Isolated Report…
56 consecutive stage I/II LMS (1989-2010)
25 with morcellation (18 LAVH, 5 mini-lap, 1 LScope Myom, 1 VH)
31 without morcellation
5-year DFS: 65% non-morcellation, 40% morcellation
5-year OS: 73% non-morcellation, 46% morcellation
Abdomino-pelvic dissemination as shown by peritoneal sarcomatosis or vaginal apex recurrence greater in morcellation group (44% vs. 13%, p=0.032)
Park et al., Gynecol Oncol, 122:255-259, 2011
38
SGO/AAGL/ACOG
Pre-operative Diagnosis and Evaluation Increasing Age >45, > 50, > 60
Menopausal Status
Treatments or Hereditary Conditions
Pelvic Radiation, Tamoxifen, Lynch Syndrome, Renal Cell Ca
Patient Counseling and Informed Consent Risk of Occult Malignancy –
SGO:1:000, AAGL: 1:500, FDA- 1:350
Dissemination, Worsening of Prognosis
Histologic Diagnosis and Staging Difficulty
MUST discuss alternatives
Problem Tissue Dissemination
Tissue Disruption ???
Possible Solution: Containment Safe
Reproducible
Effective
From a Surgical Standpoint
Obstet Gynecol. 2014 Sep;124(3):491-7
Objective: To describe a novel technique for contained power morcellation within an
artificial pneumoperitoneum at the time of specimen removal duringminimally invasive gynecologic procedures.
Methods: Over the study period of January 2014 to April 2014, 73 patients underwent
morcellation of the uterus or myomas within a contained pneumoperitoneumat the time of minimally invasive hysterectomy or myomectomy.
Procedures were performed at four study sites, and included multi-portlaparoscopy, single-site laparoscopy, multi-port robot-assisted laparoscopyor single-site robot-assisted laparoscopy.
Morcellation within Contained Pneumoperitoneum
Obstet Gynecol. 2014 Sep;124(3):491-7
Results: Surgical specimen morcellation within an insufflated isolation bag was
successfully employed in all cases.
The median operative time was 114 minutes (range 32, 380), medianestimated blood loss was 50 mL (10, 500) and the median specimen weightwas 257 grams (53,1481).
There were no complications related to the contained morcellationtechnique, nor was there apparent dissemination of tissue outside of theisolation bag.
Conclusion: Morcellation within a contained pneumoperitoneum is a feasible, safe and
low-cost technique.
Morcellation within Contained Pneumoperitoneum
Obstet Gynecol. 2014 Sep;124(3):491-7
Prospective Study Assessing the Safety, Feasibility, and Efficacy of Morcellation in a Containment System
Multi-Center Prospective Trial
Enrolling ~400 Patients Undergoing Laparoscopic or Robotic Myomectomy or Hysterectomy
Evaluating Bag Integrity, Spillage (Dye), Time, Complications
39
31
Contained Manual Tissue Extraction
Good Times!!! References Nezhat's Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy, Fourth Edition, Cambridge
University Press, 2013.
Modesitt SC et al., Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter. Obstet Gynecol 2003;102:594–9.
Wiser, A., Holcroft, C.A., Tulandi, T. et al. Abdominal versus laparoscopic hysterectomies for benign diseases: evaluation of morbidity and mortality among 465,798 cases. Gynecol Surg (2013) 10: 117. doi:10.1007/s10397-013-0781-9
ACOG Practice Bulletin No. 83: Management of Adnexal Masses. Obstetrics & Gynecology. 110(1):201-214, July 2007.
Gao Z, Li L, Meng Y. A Retrospective Analysis of the Impact of Myomectomy on Survival in Uterine Sarcoma. Robboy SJ, ed. PLoS ONE. 2016;11(2):e0148050. doi:10.1371/journal.pone.0148050.
Anupama R1, Ahmad SZ, Kuriakose S, Vijaykumar DK, Pavithran K, Seethalekshmy NV.Disseminated peritoneal leiomyosarcomas after laparoscopic "myomectomy" and morcellation. J Minim Invasive Gynecol. 2011 May-Jun;18(3):386-9. doi: 10.1016/j.jmig.2011.01.014.
Park JY1, Park SK, Kim DY, Kim JH, Kim YM, Kim YT, Nam JH.The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol. 2011 Aug;122(2):255-9. doi: 10.1016/j.ygyno.2011.04.021. Epub 2011 May 12.
Cohen, S.L., Einarsson, J.I., Wang, K.C. et al, Contained power morcellation within an insufflated isolation bag. Obstet Gynecol. 2014;124:491–497.
Cohen, Sarah L. et al. Contained tissue extraction using power morcellation: prospective evaluation of leakage parameters. American Journal of Obstetrics & Gynecology , Volume 214 , Issue 2 , 257.e1 - 257.e6.
Thank You
40
Sooner Rather Than Later: Early Recognition and
Management of Laparoscopic Complications
Ahmed AL‐Niaimi, MD, FACOD, FACS
Assistant professor Gynecologic Oncology
Department of OBGYN
University of Wisconsin,
Madison, Wisconsin , USA
Disclosure
• No conflict of interest and nothing to disclose
Objectives
• Recognize the possibilities of surgical complications and other organ injuries
• Discuss each organ’s : • Anatomy
• Types of injuries
• Recognition and intervention
The followings are to be discussed
• Urinary tract injuries
• Gastrointestinal tract injuries
• Vascular injuries
Ureter
• Anatomy course in the pelvis
Ureter
41
Ureter Injury
• How often?
• Urinary tract injury = 0.3‐1% of all hysts is associate with a urinary injury of some form[1]
• Ureter 0.3%
• Bladder 0.8%
Mechanisms of injury
Potential mechanisms of intraoperative ureteral injury include :
• Crushed with a gasper
• ligated
• Lacerated or transected • During sharp or blunt dissection
• Using an energy source
• Devascularization or denervation
Urinary injury risk factors
• Risks factors were 1. previous Caesarian section OR: 4.33, 95% (CI): 1.53‐12.30
2. Previous laparotomy OR: 4.69, 95% (CI): 1.59‐13.8
3. The rate of injury decreases with the surgeons' experience and reaches a plateau of 0.4% after 100 hysterectomies performed, Lafay etal [2]
• Another study showed that endometriosis can increase the ureteric injury up to 13.6%, Jung at al [3]
What are the principle of avoiding Ureteric injury ?• Prevent it by seeing the ureter and stay away, calcucate the thermal spread
• Recognize at the time of injury, can be difficult , but cystoscopy helps and is cost effective [4]
• Recognition early post op is as important Increasing creatinine
Abdominal distension
Hematuria
Back pain
Prevent the injury be finding the ureter
Gastrointestinal track injury
• It is one of the most devastating complications• Sepsis and abscess with re operate at best
• Death is another real outcome
• One of the hardest to immediately recognize as well
Gastrointestinal track injuryHow often? • It is very hard to know because of underreporting
• A review of gynecologic procedure: The reported Access‐related bowel injuries occurred in 4.4/10,000 procedures [6]
• Prospective data showed that bowel injury can occur up to 0.5% in laparoscopy surgery [7]
42
Gastrointestinal track injury. What are the risk factors? • Previous surgeries: Most important risk factor OR 4.1, 95%CI=1.5‐7.6
• Surgical volume :A review of a nationwide inpatient database
The overall rates for complications related to laparoscopic hysterectomy were similar for low‐volume versus for high‐volume surgeons (9.8 and 10.4 percent, respectively) [8]
Gastrointestinal track injury Modalities of injuries• Thermal
• Puncture injury (pneumo‐insuflation needle)
• Crush injury
• Other injuries to • Spleen
• Liver / biliary tree
Gastrointestinal track entry injury
• In a retrospective review of 29,966 gynecologic patients [9]:• Pneumoperitoneum needle = 33%
• Umbilical trocar ; 50%
• Placement of a secondary trocar: 17%
Gastrointestinal track Thermal injury (Types)
• Direct • Type of devise
• Power
• Time of exposure
• Coupling and capacity effect.
Mesenteric injury, not to be taken lightly Gastrointestinal track injury management
1. When in doubt always convert to laparotomy because may be there are multiple injuries. Run the bowel.
2. Treatment modalities are:• Saw the serosa,
• resect with anastomosis
• With or without diversion
3. Drains ( matter of case scenarios)
43
Fluorescent aided surgery Indocyanine green (ICG)‐enhanced fluorescent
• Bowel perfusion mappingICG‐enhanced fluorescent angiography provides useful intraoperative information about the vascular perfusion during colorectal surgery and may lead to change the site of resection and/or anastomosis
Vascular injury
• Locations and severity 1. Minor : Abdominal wall or Omental
1. Generally underreported
2. Recognition can be delayed if slow bleeding in the
2. Major: abdominal or pelvic vascular tree (0.1‐1%) [10]
• Severity 1. Minor bleeding has high morbidity (re‐operate) because of the late
diagnosis
2. Major bleeding otherwise is easily recognizable, but still high morbidity.
Vascular injury management
1. Minor bleeding observation vs. surgical
2. Major bleeding always surgical, mostly conversion to laparotomy (video)
Reference •
• [1] Teeluckdharry B, Gilmour D, Flowerdew G. Urinary Tract Injury at Benign Gynecologic Surgery and the Role of Cystoscopy: A Systematic Review and Meta‐analysis. Obstet Gynecol. 2015;126:1161‐9.
• [2] Lafay Pillet MC, Leonard F, Chopin N, Malaret JM, Borghese B, Foulot H, et al. Incidence and risk factors of bladder injuries during laparoscopic hysterectomy indicated for benign uterine pathologies: a 14.5 years experience in a continuous series of 1501 procedures. Hum Reprod. 2009;24:842‐9.
• [3] Jung SK, Huh CY. Ureteral injuries during classic intrafascial supracervical hysterectomy: an 11‐year experience in 1163 patients. J Minim Invasive Gynecol. 2008;15:440‐5.
• [4] Visco AG, Taber KH, Weidner AC, Barber MD, Myers ER. Cost‐effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy. Obstet Gynecol. 2001;97:685‐92.
• [5] Chou MT, Wang CJ, Lien RC. Prophylactic ureteral catheterization in gynecologic surgery: a 12‐year randomized trial in a community hospital. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20:689‐93.
• [6] Ahmad G, Gent D, Henderson D, O'Flynn H, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev. 2015;8:CD006583.
• [7] Mayol J, Garcia‐Aguilar J, Ortiz‐Oshiro E, De‐Diego Carmona JA, Fernandez‐Represa JA. Risks of the minimal access approach for laparoscopic surgery: multivariate analysis of morbidity related to umbilical trocar insertion. World J Surg. 1997;21:529‐33.
• [8] Wright JD, Hershman DL, Burke WM, Lu YS, Neugut AI, Lewin SN, et al. Influence of surgical volume on outcome for laparoscopic hysterectomy for endometrial cancer. Ann Surg Oncol. 2012;19:948‐58.
• [9] Chapron C, Querleu D, Bruhat MA, Madelenat P, Fernandez H, Pierre F, et al. Surgical complications of diagnostic and operative gynaecological laparoscopy: a series of 29,966 cases. Hum Reprod. 1998;13:867‐72.
• [10] Sandadi S, Johannigman JA, Wong VL, Blebea J, Altose MD, Hurd WW. Recognition and management of major vessel injury during laparoscopy. J Minim Invasive Gynecol. 2010;17:692‐702.
Thank you
44
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%
45
