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Endometriosis surgery: Women can expect years-long benefits
LAS VEGAS – according to a survey study from the University of Pittsburgh.
The work was likely the first to assess long-term outcomes after laparoscopic endometriosis excision with a disease-specific questionnaire, the Endometriosis Health Profile-30 (EHP-30). The findings should reassure both surgeons and patients. “I really feel these results can help us as endometriosis providers” to counsel women, said lead investigator Nicole M. Donnellan, MD, a gynecologic surgeon at the University of Pittsburgh.
Surgery “offers lasting improvement in all quality of life domains ... measured by the EHP-30”: pain; control/powerlessness; emotional well-being; social support; and self-image, with supplemental questions about work, sexual function, and other matters. Because “definitive surgery was not associated with improved outcomes when compared with fertility-sparing surgery ... fertility preservation should continue to be offered as first-line surgery for treatment of symptomatic disease,” Dr. Donnellan and her team concluded at a meeting sponsored by AAGL.
Surgery is the gold standard for endometriosis, but there just hasn’t been much data on long-term outcomes until now, especially with a potent questionnaire like the EHP-30. The gap left surgeons in the lurch on what to tell women how they’ll do, especially because results from previous, shorter, and less-rigorous studies have been mixed. The Pittsburgh results mean that competent surgeons can breathe easier and be confident in telling women what to expect.
The team administered EHP-30 to 61 women before surgery and at 4 weeks postoperatively; 45 patients (74%) had fertility-sparing excisions, 7 (11%) had hysterectomy with adnexa preservation, and 9 (15%) had hysterectomy with bilateral salpingo-oophorectomy. The women were contacted again in 2017 to fill out the survey anywhere from 3 to 7 years after their operation; 45 women agreed, a response rate of 74%.
There was a definitive, statistically significant reduction in scores across all five domains of the survey, both at 4 weeks and out to 7 years, and the improvements did not vary by endometriosis stage or the type of surgery women had.
The overall score – a combination of the five domains – fell from a preoperative median of 50 points out of a possible 100, with 100 being the worst possible score, to a median of about 20 points 4 weeks after surgery, and a median of about 10 points at long-term follow-up. Pain scores fell about the same amount; the greatest improvements were on questions that focused on sense of control and empowerment.
At long-term follow-up, overall scores improved a median of 43 points in women with American Society for Reproductive Medicine stage 1 endometriosis and 28 points among women with stage 4 disease (P = .705). Although the differences were not statistically significant, women with stage 1 disease generally reported the greatest improvements, except on the control and empowerment scale, where women reported the same improvement across all four stages, about 50 points out of 100.
Long-term score improvements were pretty much identical among women who had fertility-sparing surgery and those who had hysterectomies, with, for instance, both groups reporting about a 33-point improvement in pain scores. The two groups separated out only on emotional well-being scores, a 38-point improvement in the hysterectomy group versus 21 points, but the difference was not statistically significant (P = .525).
The long-term results remained the same when eight women who had subsequent gynecologic surgery were excluded.
In the end, the take home is that “all of these women improved,” Dr. Donnellan said.
The investigators didn’t report any disclosures.
SOURCE: Donnellan NM et al. 2018 AAGL Global Congress, Abstract 82.
LAS VEGAS – according to a survey study from the University of Pittsburgh.
The work was likely the first to assess long-term outcomes after laparoscopic endometriosis excision with a disease-specific questionnaire, the Endometriosis Health Profile-30 (EHP-30). The findings should reassure both surgeons and patients. “I really feel these results can help us as endometriosis providers” to counsel women, said lead investigator Nicole M. Donnellan, MD, a gynecologic surgeon at the University of Pittsburgh.
Surgery “offers lasting improvement in all quality of life domains ... measured by the EHP-30”: pain; control/powerlessness; emotional well-being; social support; and self-image, with supplemental questions about work, sexual function, and other matters. Because “definitive surgery was not associated with improved outcomes when compared with fertility-sparing surgery ... fertility preservation should continue to be offered as first-line surgery for treatment of symptomatic disease,” Dr. Donnellan and her team concluded at a meeting sponsored by AAGL.
Surgery is the gold standard for endometriosis, but there just hasn’t been much data on long-term outcomes until now, especially with a potent questionnaire like the EHP-30. The gap left surgeons in the lurch on what to tell women how they’ll do, especially because results from previous, shorter, and less-rigorous studies have been mixed. The Pittsburgh results mean that competent surgeons can breathe easier and be confident in telling women what to expect.
The team administered EHP-30 to 61 women before surgery and at 4 weeks postoperatively; 45 patients (74%) had fertility-sparing excisions, 7 (11%) had hysterectomy with adnexa preservation, and 9 (15%) had hysterectomy with bilateral salpingo-oophorectomy. The women were contacted again in 2017 to fill out the survey anywhere from 3 to 7 years after their operation; 45 women agreed, a response rate of 74%.
There was a definitive, statistically significant reduction in scores across all five domains of the survey, both at 4 weeks and out to 7 years, and the improvements did not vary by endometriosis stage or the type of surgery women had.
The overall score – a combination of the five domains – fell from a preoperative median of 50 points out of a possible 100, with 100 being the worst possible score, to a median of about 20 points 4 weeks after surgery, and a median of about 10 points at long-term follow-up. Pain scores fell about the same amount; the greatest improvements were on questions that focused on sense of control and empowerment.
At long-term follow-up, overall scores improved a median of 43 points in women with American Society for Reproductive Medicine stage 1 endometriosis and 28 points among women with stage 4 disease (P = .705). Although the differences were not statistically significant, women with stage 1 disease generally reported the greatest improvements, except on the control and empowerment scale, where women reported the same improvement across all four stages, about 50 points out of 100.
Long-term score improvements were pretty much identical among women who had fertility-sparing surgery and those who had hysterectomies, with, for instance, both groups reporting about a 33-point improvement in pain scores. The two groups separated out only on emotional well-being scores, a 38-point improvement in the hysterectomy group versus 21 points, but the difference was not statistically significant (P = .525).
The long-term results remained the same when eight women who had subsequent gynecologic surgery were excluded.
In the end, the take home is that “all of these women improved,” Dr. Donnellan said.
The investigators didn’t report any disclosures.
SOURCE: Donnellan NM et al. 2018 AAGL Global Congress, Abstract 82.
LAS VEGAS – according to a survey study from the University of Pittsburgh.
The work was likely the first to assess long-term outcomes after laparoscopic endometriosis excision with a disease-specific questionnaire, the Endometriosis Health Profile-30 (EHP-30). The findings should reassure both surgeons and patients. “I really feel these results can help us as endometriosis providers” to counsel women, said lead investigator Nicole M. Donnellan, MD, a gynecologic surgeon at the University of Pittsburgh.
Surgery “offers lasting improvement in all quality of life domains ... measured by the EHP-30”: pain; control/powerlessness; emotional well-being; social support; and self-image, with supplemental questions about work, sexual function, and other matters. Because “definitive surgery was not associated with improved outcomes when compared with fertility-sparing surgery ... fertility preservation should continue to be offered as first-line surgery for treatment of symptomatic disease,” Dr. Donnellan and her team concluded at a meeting sponsored by AAGL.
Surgery is the gold standard for endometriosis, but there just hasn’t been much data on long-term outcomes until now, especially with a potent questionnaire like the EHP-30. The gap left surgeons in the lurch on what to tell women how they’ll do, especially because results from previous, shorter, and less-rigorous studies have been mixed. The Pittsburgh results mean that competent surgeons can breathe easier and be confident in telling women what to expect.
The team administered EHP-30 to 61 women before surgery and at 4 weeks postoperatively; 45 patients (74%) had fertility-sparing excisions, 7 (11%) had hysterectomy with adnexa preservation, and 9 (15%) had hysterectomy with bilateral salpingo-oophorectomy. The women were contacted again in 2017 to fill out the survey anywhere from 3 to 7 years after their operation; 45 women agreed, a response rate of 74%.
There was a definitive, statistically significant reduction in scores across all five domains of the survey, both at 4 weeks and out to 7 years, and the improvements did not vary by endometriosis stage or the type of surgery women had.
The overall score – a combination of the five domains – fell from a preoperative median of 50 points out of a possible 100, with 100 being the worst possible score, to a median of about 20 points 4 weeks after surgery, and a median of about 10 points at long-term follow-up. Pain scores fell about the same amount; the greatest improvements were on questions that focused on sense of control and empowerment.
At long-term follow-up, overall scores improved a median of 43 points in women with American Society for Reproductive Medicine stage 1 endometriosis and 28 points among women with stage 4 disease (P = .705). Although the differences were not statistically significant, women with stage 1 disease generally reported the greatest improvements, except on the control and empowerment scale, where women reported the same improvement across all four stages, about 50 points out of 100.
Long-term score improvements were pretty much identical among women who had fertility-sparing surgery and those who had hysterectomies, with, for instance, both groups reporting about a 33-point improvement in pain scores. The two groups separated out only on emotional well-being scores, a 38-point improvement in the hysterectomy group versus 21 points, but the difference was not statistically significant (P = .525).
The long-term results remained the same when eight women who had subsequent gynecologic surgery were excluded.
In the end, the take home is that “all of these women improved,” Dr. Donnellan said.
The investigators didn’t report any disclosures.
SOURCE: Donnellan NM et al. 2018 AAGL Global Congress, Abstract 82.
REPORTING FROM THE AAGL GLOBAL CONGRESS
Key clinical point: Endometriosis excision improves quality of life for at least 7 years, even when women have conservative, fertility-sparing surgery.
Major finding: The overall score on the Endometriosis Health Profile-30 fell from a preoperative median of 50 points out of a possible 100, with 100 being the worst possible score, to a median of about 20 points 4 weeks after surgery, and a median of about 10 points at the 7-year follow-up.
Study details: A review of 61 cases
Disclosures: The investigators didn’t report any disclosures.
Source: Donnellan NM et al. 2018 AAGL Global Congress, Abstract 82.
Miscarriage after myomectomy depends on fibroid number, uterine incisions
LAS VEGAS – according to a review of 252 cases at Northwestern University, Chicago.
Surgeons feel terrible when a woman loses a pregnancy after fibroid treatment, and wonder if they “caused it, or if it was just a bad uterus or a bad initial pathology,” said lead investigator Laura M. Glaser, MD, an ob.gyn. in private practice in Lake Forest, Ill.
Her study, which was presented at a meeting sponsored by AAGL, suggests that miscarriage occurs mostly from complex pathology, as indicated by the number of fibroids and the degree of uterine cutting needed to remove them. The team reviewed outcomes among women who conceived after treatment; 28 had robotic-assisted myomectomies; 208 had open, abdominal myomectomies; and 16 had uterine fibroid embolization (UFE). Miscarriage was defined as pregnancy loss before 24 weeks.
After the researchers adjusted for age, body mass index, and parity, there were no statistically significant differences in miscarriage rates among the three groups (31% after UFE, 29% after robotic myomectomy, and 22% after abdominal myomectomy).
Open cases had the largest dominant fibroid at a mean of 8.5 cm, the most fibroids removed at 4.5, and the highest rate of cavity entry, 42%. Even so, at 22%, open cases were the least likely to miscarry.
Uterine size, specimen weight, time from procedure to pregnancy, and fibroid location didn’t seem to matter otherwise. The only risk factors that reached statistical significance were among women who had myomectomies; an increasing number of uterine cuts (odds ratio, 1.558; P = .004) and fibroids removed (OR, 1.11; P = .033) increased the odds of miscarriage.
More than 40% of women in the UFE group had previous fibroid surgery, versus 5% among women who had myomectomies. UFE women also were far more likely to have had a previous birth (50% versus 17%), but less likely to have subserosal fibroids (13% versus 33%), and their dominant fibroid was a few centimeters smaller.
Subjects were in their mid-30s, on average, with a mean body mass index of about 28 kg/m2. Just over 40% of the women who had myomectomies were white, versus 19% of women who had UFE.
There was no outside funding for the work, and the investigators didn’t have any disclosures.
SOURCE: Glaser LM et al. 2018 AAGL Global Congress, Abstract 160
LAS VEGAS – according to a review of 252 cases at Northwestern University, Chicago.
Surgeons feel terrible when a woman loses a pregnancy after fibroid treatment, and wonder if they “caused it, or if it was just a bad uterus or a bad initial pathology,” said lead investigator Laura M. Glaser, MD, an ob.gyn. in private practice in Lake Forest, Ill.
Her study, which was presented at a meeting sponsored by AAGL, suggests that miscarriage occurs mostly from complex pathology, as indicated by the number of fibroids and the degree of uterine cutting needed to remove them. The team reviewed outcomes among women who conceived after treatment; 28 had robotic-assisted myomectomies; 208 had open, abdominal myomectomies; and 16 had uterine fibroid embolization (UFE). Miscarriage was defined as pregnancy loss before 24 weeks.
After the researchers adjusted for age, body mass index, and parity, there were no statistically significant differences in miscarriage rates among the three groups (31% after UFE, 29% after robotic myomectomy, and 22% after abdominal myomectomy).
Open cases had the largest dominant fibroid at a mean of 8.5 cm, the most fibroids removed at 4.5, and the highest rate of cavity entry, 42%. Even so, at 22%, open cases were the least likely to miscarry.
Uterine size, specimen weight, time from procedure to pregnancy, and fibroid location didn’t seem to matter otherwise. The only risk factors that reached statistical significance were among women who had myomectomies; an increasing number of uterine cuts (odds ratio, 1.558; P = .004) and fibroids removed (OR, 1.11; P = .033) increased the odds of miscarriage.
More than 40% of women in the UFE group had previous fibroid surgery, versus 5% among women who had myomectomies. UFE women also were far more likely to have had a previous birth (50% versus 17%), but less likely to have subserosal fibroids (13% versus 33%), and their dominant fibroid was a few centimeters smaller.
Subjects were in their mid-30s, on average, with a mean body mass index of about 28 kg/m2. Just over 40% of the women who had myomectomies were white, versus 19% of women who had UFE.
There was no outside funding for the work, and the investigators didn’t have any disclosures.
SOURCE: Glaser LM et al. 2018 AAGL Global Congress, Abstract 160
LAS VEGAS – according to a review of 252 cases at Northwestern University, Chicago.
Surgeons feel terrible when a woman loses a pregnancy after fibroid treatment, and wonder if they “caused it, or if it was just a bad uterus or a bad initial pathology,” said lead investigator Laura M. Glaser, MD, an ob.gyn. in private practice in Lake Forest, Ill.
Her study, which was presented at a meeting sponsored by AAGL, suggests that miscarriage occurs mostly from complex pathology, as indicated by the number of fibroids and the degree of uterine cutting needed to remove them. The team reviewed outcomes among women who conceived after treatment; 28 had robotic-assisted myomectomies; 208 had open, abdominal myomectomies; and 16 had uterine fibroid embolization (UFE). Miscarriage was defined as pregnancy loss before 24 weeks.
After the researchers adjusted for age, body mass index, and parity, there were no statistically significant differences in miscarriage rates among the three groups (31% after UFE, 29% after robotic myomectomy, and 22% after abdominal myomectomy).
Open cases had the largest dominant fibroid at a mean of 8.5 cm, the most fibroids removed at 4.5, and the highest rate of cavity entry, 42%. Even so, at 22%, open cases were the least likely to miscarry.
Uterine size, specimen weight, time from procedure to pregnancy, and fibroid location didn’t seem to matter otherwise. The only risk factors that reached statistical significance were among women who had myomectomies; an increasing number of uterine cuts (odds ratio, 1.558; P = .004) and fibroids removed (OR, 1.11; P = .033) increased the odds of miscarriage.
More than 40% of women in the UFE group had previous fibroid surgery, versus 5% among women who had myomectomies. UFE women also were far more likely to have had a previous birth (50% versus 17%), but less likely to have subserosal fibroids (13% versus 33%), and their dominant fibroid was a few centimeters smaller.
Subjects were in their mid-30s, on average, with a mean body mass index of about 28 kg/m2. Just over 40% of the women who had myomectomies were white, versus 19% of women who had UFE.
There was no outside funding for the work, and the investigators didn’t have any disclosures.
SOURCE: Glaser LM et al. 2018 AAGL Global Congress, Abstract 160
REPORTING FROM AAGL GLOBAL CONGRESS
Key clinical point: The number of uterine incisions and fibroids removed increase the risk of miscarriage after fibroid treatment, not the type of procedure.
Major finding: After adjusting for age, body mass index, and parity, there were no statistically significant differences in miscarriage rates between the three groups (31% after uterine fibroid embolization; 29% after robotic myomectomy, and 22% after open abdominal myomectomy).
Study details: Review of 252 cases
Disclosures: There was no outside funding for the work, and the investigators didn’t have any disclosures.
Source: Glaser LM et al. 2018 AAGL Global Congress, Abstract 160
Uterine volume, fibroid diameter predict robotic myomectomy duration
LAS VEGAS – It would be nice if surgeons could know beforehand how long robotic laparoscopic myomectomies will take, according to Peter Movilla, MD, a minimally invasive gynecologic surgery fellow at Newton (Mass.) Wellesley Hospital.
Best guesses are sometimes wrong, and it’s not uncommon for robotic cases to go longer than expected, especially when they have to be converted to an open approach.
Among other problems, going long backs up operating room (OR)scheduling and makes families impatient. Also, if it was known beforehand that a robotic case might take 5 hours, patients could be offered a quicker open procedure, especially if they are not good candidates for prolonged pneumoperitoneum.
After a case went past 6 hours at the University of California, San Francisco (UCSF), when Dr. Movilla was an ob.gyn. resident, he wanted to find a better way.
“I saw that we were not the best at guessing how long these surgeries were going to take, and thought maybe we could make prediction a little better by [incorporating] preoperative factors” in a structured way. “I wanted to create something that would give us an answer of how long it will take,” he said at a meeting sponsored by AAGL.
So he and his colleagues reviewed 126 robot-assisted laparoscopic myomectomies at UCSF. The mean operative time from skin incision to closure was 213 minutes, mean specimen weight 264.4 g, mean dominant fibroid diameter 8.5 cm, and mean number of fibroids removed 2.5. Four cases (3%) were converted to open laparotomy.
The team divided the cases by how long they took; 20% were under 3 hours, 70% took 3-5 hours; and 10% went over 5 hours. “Five hours is a long time to be in the OR,” especially when a case could have been done open, Dr. Movilla said.
Length of surgery correlated with 7 of the 21 preoperative factors considered on multivariate logistic regression. Cases tended to be longer in younger women and in women with diabetes, and when surgeons had less experience. There was a trend toward longer cases with higher body mass indices, but it was not statistically significant.
Having three or more fibroids on preoperative imaging and a larger number of fibroids over 3 cm were predictive of operations longer than 3 hours. However, the strongest predictors of long cases were uterine volume and the diameter of the largest fibroid, a mean of 532.4 cm3 and 8.8 cm, respectively, in cases over 5 hours. Posterior and intramural fibroids also increased operative time, but, again, the trends were not statistically significant.
The team put it all together in a risk calculator they tested against their subjects’ actual surgery times. The model tended to underestimate very short and very long cases at either end of the curve, but overall the fit was “not too bad,” and the more cases that are added to the model, the more accurate it will get, Dr. Movilla said.
There was no external funding for the work, and Dr. Movilla had no disclosures.
SOURCE: Movilla P et al. 2018 AAGL Global Congress, Abstract 69.
LAS VEGAS – It would be nice if surgeons could know beforehand how long robotic laparoscopic myomectomies will take, according to Peter Movilla, MD, a minimally invasive gynecologic surgery fellow at Newton (Mass.) Wellesley Hospital.
Best guesses are sometimes wrong, and it’s not uncommon for robotic cases to go longer than expected, especially when they have to be converted to an open approach.
Among other problems, going long backs up operating room (OR)scheduling and makes families impatient. Also, if it was known beforehand that a robotic case might take 5 hours, patients could be offered a quicker open procedure, especially if they are not good candidates for prolonged pneumoperitoneum.
After a case went past 6 hours at the University of California, San Francisco (UCSF), when Dr. Movilla was an ob.gyn. resident, he wanted to find a better way.
“I saw that we were not the best at guessing how long these surgeries were going to take, and thought maybe we could make prediction a little better by [incorporating] preoperative factors” in a structured way. “I wanted to create something that would give us an answer of how long it will take,” he said at a meeting sponsored by AAGL.
So he and his colleagues reviewed 126 robot-assisted laparoscopic myomectomies at UCSF. The mean operative time from skin incision to closure was 213 minutes, mean specimen weight 264.4 g, mean dominant fibroid diameter 8.5 cm, and mean number of fibroids removed 2.5. Four cases (3%) were converted to open laparotomy.
The team divided the cases by how long they took; 20% were under 3 hours, 70% took 3-5 hours; and 10% went over 5 hours. “Five hours is a long time to be in the OR,” especially when a case could have been done open, Dr. Movilla said.
Length of surgery correlated with 7 of the 21 preoperative factors considered on multivariate logistic regression. Cases tended to be longer in younger women and in women with diabetes, and when surgeons had less experience. There was a trend toward longer cases with higher body mass indices, but it was not statistically significant.
Having three or more fibroids on preoperative imaging and a larger number of fibroids over 3 cm were predictive of operations longer than 3 hours. However, the strongest predictors of long cases were uterine volume and the diameter of the largest fibroid, a mean of 532.4 cm3 and 8.8 cm, respectively, in cases over 5 hours. Posterior and intramural fibroids also increased operative time, but, again, the trends were not statistically significant.
The team put it all together in a risk calculator they tested against their subjects’ actual surgery times. The model tended to underestimate very short and very long cases at either end of the curve, but overall the fit was “not too bad,” and the more cases that are added to the model, the more accurate it will get, Dr. Movilla said.
There was no external funding for the work, and Dr. Movilla had no disclosures.
SOURCE: Movilla P et al. 2018 AAGL Global Congress, Abstract 69.
LAS VEGAS – It would be nice if surgeons could know beforehand how long robotic laparoscopic myomectomies will take, according to Peter Movilla, MD, a minimally invasive gynecologic surgery fellow at Newton (Mass.) Wellesley Hospital.
Best guesses are sometimes wrong, and it’s not uncommon for robotic cases to go longer than expected, especially when they have to be converted to an open approach.
Among other problems, going long backs up operating room (OR)scheduling and makes families impatient. Also, if it was known beforehand that a robotic case might take 5 hours, patients could be offered a quicker open procedure, especially if they are not good candidates for prolonged pneumoperitoneum.
After a case went past 6 hours at the University of California, San Francisco (UCSF), when Dr. Movilla was an ob.gyn. resident, he wanted to find a better way.
“I saw that we were not the best at guessing how long these surgeries were going to take, and thought maybe we could make prediction a little better by [incorporating] preoperative factors” in a structured way. “I wanted to create something that would give us an answer of how long it will take,” he said at a meeting sponsored by AAGL.
So he and his colleagues reviewed 126 robot-assisted laparoscopic myomectomies at UCSF. The mean operative time from skin incision to closure was 213 minutes, mean specimen weight 264.4 g, mean dominant fibroid diameter 8.5 cm, and mean number of fibroids removed 2.5. Four cases (3%) were converted to open laparotomy.
The team divided the cases by how long they took; 20% were under 3 hours, 70% took 3-5 hours; and 10% went over 5 hours. “Five hours is a long time to be in the OR,” especially when a case could have been done open, Dr. Movilla said.
Length of surgery correlated with 7 of the 21 preoperative factors considered on multivariate logistic regression. Cases tended to be longer in younger women and in women with diabetes, and when surgeons had less experience. There was a trend toward longer cases with higher body mass indices, but it was not statistically significant.
Having three or more fibroids on preoperative imaging and a larger number of fibroids over 3 cm were predictive of operations longer than 3 hours. However, the strongest predictors of long cases were uterine volume and the diameter of the largest fibroid, a mean of 532.4 cm3 and 8.8 cm, respectively, in cases over 5 hours. Posterior and intramural fibroids also increased operative time, but, again, the trends were not statistically significant.
The team put it all together in a risk calculator they tested against their subjects’ actual surgery times. The model tended to underestimate very short and very long cases at either end of the curve, but overall the fit was “not too bad,” and the more cases that are added to the model, the more accurate it will get, Dr. Movilla said.
There was no external funding for the work, and Dr. Movilla had no disclosures.
SOURCE: Movilla P et al. 2018 AAGL Global Congress, Abstract 69.
REPORTING FROM AAGL GLOBAL CONGRESS
Key clinical point: A calculator is in the works to predict exactly how long robotic myomectomies will take.
Major finding: a mean of 532.4 cm3 and 8.8 cm, respectively, in cases over 5 hours.
Study details: Review of 126 cases.
Disclosures: There was no external funding, and Dr. Movilla had no disclosures.
Source: Movilla P et al. 2018 AAGL Global Congress, Abstract 69.
Gynecologic surgery insufflation pressure: Less is more
LAS VEGAS – performed at a single center by the same surgeon, said researchers at New York University (NYU) Medical Center.
Each incremental drop in abdominal insufflation pressure “improved intraoperative and postoperative clinical outcomes” with “faster postoperative recovery times, decreased immediate postoperative pain, and improved intraoperative respiratory parameters, without increasing duration of surgery or blood loss,” said investigator Christine Foley, MD, formerly at NYU, and now a minimally-invasive gynecologic surgery fellow at the University of Pittsburgh.
An abdominal insufflation pressure of 10 mm Hg or less was the sweet spot, she said at the meeting sponsored by AAGL.
The general surgery literature recommends operating at the lowest possible abdominal insufflation pressure to reduce postoperative pain, and that recommendation has been incorporated into enhanced recovery after surgery (ERAS) protocols. Gynecologic surgeons have not routinely followed suit, she noted. “Surgeons should consider operating at lower insufflation pressures to improve patient outcomes and PACU [postanesthesia care unit] utilization. Further research is warranted to determine if lower pressures ... should be included in ERAS protocols” for gynecologic surgery.
There’s not much in the way of data on insufflation pressures in robotic gynecologic surgery. What has been published suggests, as in general surgery, less postop pain, but at the cost of impaired visualization and greater blood loss. At the moment, robotic cases are often done at insufflation pressures above 12 mm Hg.
To get a better grasp of the issue, Dr. Foley and her team reviewed 196 hysterectomies, 275 myomectomies, and 127 endometriosis surgeries at NYU, all performed robotically by the same surgeon for benign indications. Ninety-nine cases were at 15 mm Hg; 100 at 12 mm Hg; 99 at 10 mm Hg, and 300 at 8 mm Hg.
The study did not address why the surgeon opted for different pressures in different cases. The body mass index was a mean of 27 kg/m2, and patient age was about 40 years, in all four pressure groups. There were trends for higher pressures with hysterectomies and lower pressures for endometriosis, but also considerable crossover, with more than 40% of the hysterectomies performed at 8 mm Hg, and almost 10% of the endometriosis cases done at 15 mm Hg.
Across the board, patients did better at lower pressures. Each drop in insufflation pressure correlated with a significant decrease in the initial pain score in the PACU (5.9 out of 10 points at 15 mm Hg, 5.4 at 12 mm Hg, 4.4 at 10 mm Hg, and 3.8 at 8 mm Hg, P less than .0001); lower pressures also correlated with shorter PACU stays (449 minutes, 467 minutes, 351 minutes, and 317 minutes, P less than .0001).
Surgery duration was a mean of 70 minutes across all four groups. Estimated blood loss was 114 mL at 15 mm Hg, 97.4 mL at 12 mm Hg, 127 mL 10 mm Hg, and 78.4 mL at 8 mm HG; the differences were not statistically significant. Maximum PACU pain levels favored lower pressures, and lower pressures correlated with significantly lower peak inspiratory pressures and tidal volumes.
The results argue for operating at the lowest possible pressure, Dr. Foley said, but she and her team did not address how their outcomes might have been influenced by the type of surgery the women had.
There was no external funding for the study. Dr. Foley had no relevant financial disclosures.
SOURCE: Foley C et al. 2018 AAGL Global Congress, Abstract 23.
LAS VEGAS – performed at a single center by the same surgeon, said researchers at New York University (NYU) Medical Center.
Each incremental drop in abdominal insufflation pressure “improved intraoperative and postoperative clinical outcomes” with “faster postoperative recovery times, decreased immediate postoperative pain, and improved intraoperative respiratory parameters, without increasing duration of surgery or blood loss,” said investigator Christine Foley, MD, formerly at NYU, and now a minimally-invasive gynecologic surgery fellow at the University of Pittsburgh.
An abdominal insufflation pressure of 10 mm Hg or less was the sweet spot, she said at the meeting sponsored by AAGL.
The general surgery literature recommends operating at the lowest possible abdominal insufflation pressure to reduce postoperative pain, and that recommendation has been incorporated into enhanced recovery after surgery (ERAS) protocols. Gynecologic surgeons have not routinely followed suit, she noted. “Surgeons should consider operating at lower insufflation pressures to improve patient outcomes and PACU [postanesthesia care unit] utilization. Further research is warranted to determine if lower pressures ... should be included in ERAS protocols” for gynecologic surgery.
There’s not much in the way of data on insufflation pressures in robotic gynecologic surgery. What has been published suggests, as in general surgery, less postop pain, but at the cost of impaired visualization and greater blood loss. At the moment, robotic cases are often done at insufflation pressures above 12 mm Hg.
To get a better grasp of the issue, Dr. Foley and her team reviewed 196 hysterectomies, 275 myomectomies, and 127 endometriosis surgeries at NYU, all performed robotically by the same surgeon for benign indications. Ninety-nine cases were at 15 mm Hg; 100 at 12 mm Hg; 99 at 10 mm Hg, and 300 at 8 mm Hg.
The study did not address why the surgeon opted for different pressures in different cases. The body mass index was a mean of 27 kg/m2, and patient age was about 40 years, in all four pressure groups. There were trends for higher pressures with hysterectomies and lower pressures for endometriosis, but also considerable crossover, with more than 40% of the hysterectomies performed at 8 mm Hg, and almost 10% of the endometriosis cases done at 15 mm Hg.
Across the board, patients did better at lower pressures. Each drop in insufflation pressure correlated with a significant decrease in the initial pain score in the PACU (5.9 out of 10 points at 15 mm Hg, 5.4 at 12 mm Hg, 4.4 at 10 mm Hg, and 3.8 at 8 mm Hg, P less than .0001); lower pressures also correlated with shorter PACU stays (449 minutes, 467 minutes, 351 minutes, and 317 minutes, P less than .0001).
Surgery duration was a mean of 70 minutes across all four groups. Estimated blood loss was 114 mL at 15 mm Hg, 97.4 mL at 12 mm Hg, 127 mL 10 mm Hg, and 78.4 mL at 8 mm HG; the differences were not statistically significant. Maximum PACU pain levels favored lower pressures, and lower pressures correlated with significantly lower peak inspiratory pressures and tidal volumes.
The results argue for operating at the lowest possible pressure, Dr. Foley said, but she and her team did not address how their outcomes might have been influenced by the type of surgery the women had.
There was no external funding for the study. Dr. Foley had no relevant financial disclosures.
SOURCE: Foley C et al. 2018 AAGL Global Congress, Abstract 23.
LAS VEGAS – performed at a single center by the same surgeon, said researchers at New York University (NYU) Medical Center.
Each incremental drop in abdominal insufflation pressure “improved intraoperative and postoperative clinical outcomes” with “faster postoperative recovery times, decreased immediate postoperative pain, and improved intraoperative respiratory parameters, without increasing duration of surgery or blood loss,” said investigator Christine Foley, MD, formerly at NYU, and now a minimally-invasive gynecologic surgery fellow at the University of Pittsburgh.
An abdominal insufflation pressure of 10 mm Hg or less was the sweet spot, she said at the meeting sponsored by AAGL.
The general surgery literature recommends operating at the lowest possible abdominal insufflation pressure to reduce postoperative pain, and that recommendation has been incorporated into enhanced recovery after surgery (ERAS) protocols. Gynecologic surgeons have not routinely followed suit, she noted. “Surgeons should consider operating at lower insufflation pressures to improve patient outcomes and PACU [postanesthesia care unit] utilization. Further research is warranted to determine if lower pressures ... should be included in ERAS protocols” for gynecologic surgery.
There’s not much in the way of data on insufflation pressures in robotic gynecologic surgery. What has been published suggests, as in general surgery, less postop pain, but at the cost of impaired visualization and greater blood loss. At the moment, robotic cases are often done at insufflation pressures above 12 mm Hg.
To get a better grasp of the issue, Dr. Foley and her team reviewed 196 hysterectomies, 275 myomectomies, and 127 endometriosis surgeries at NYU, all performed robotically by the same surgeon for benign indications. Ninety-nine cases were at 15 mm Hg; 100 at 12 mm Hg; 99 at 10 mm Hg, and 300 at 8 mm Hg.
The study did not address why the surgeon opted for different pressures in different cases. The body mass index was a mean of 27 kg/m2, and patient age was about 40 years, in all four pressure groups. There were trends for higher pressures with hysterectomies and lower pressures for endometriosis, but also considerable crossover, with more than 40% of the hysterectomies performed at 8 mm Hg, and almost 10% of the endometriosis cases done at 15 mm Hg.
Across the board, patients did better at lower pressures. Each drop in insufflation pressure correlated with a significant decrease in the initial pain score in the PACU (5.9 out of 10 points at 15 mm Hg, 5.4 at 12 mm Hg, 4.4 at 10 mm Hg, and 3.8 at 8 mm Hg, P less than .0001); lower pressures also correlated with shorter PACU stays (449 minutes, 467 minutes, 351 minutes, and 317 minutes, P less than .0001).
Surgery duration was a mean of 70 minutes across all four groups. Estimated blood loss was 114 mL at 15 mm Hg, 97.4 mL at 12 mm Hg, 127 mL 10 mm Hg, and 78.4 mL at 8 mm HG; the differences were not statistically significant. Maximum PACU pain levels favored lower pressures, and lower pressures correlated with significantly lower peak inspiratory pressures and tidal volumes.
The results argue for operating at the lowest possible pressure, Dr. Foley said, but she and her team did not address how their outcomes might have been influenced by the type of surgery the women had.
There was no external funding for the study. Dr. Foley had no relevant financial disclosures.
SOURCE: Foley C et al. 2018 AAGL Global Congress, Abstract 23.
REPORTING FROM AAGL GLOBAL CONGRESS
Key clinical point: Lower insufflation pressures were associated with improved patient outcomes and reduced PACU use.
Major finding: There was a significant decrease in initial postop pain score with each incremental drop in insufflation pressure (5.9 out of 10 points at 15 mm Hg, 5.4 at 12 mm Hg; 4.4 at 10 mm Hg, and 3.8 at 8 mm Hg, P less than .0001).
Study details: Review of 598 robotic gynecologic procedures done at New York University by the same surgeon.
Disclosures: There was no external funding for the study. The presenter did not have any relevant financial disclosures.
Source: Foley C et al. 2018 AAGL Global Congress, Abstract 23.
Don’t push women into preterm delivery after myomectomy
LAS VEGAS –
The American College of Obstetricians and Gynecologists lists prior myomectomy as a medically-indicated reason for delivery before 39 weeks. The advice reflects a traditional concern that uterine scars will rupture during labor, with potentially devastating consequences for both mother and infant.
Reviews have put the risk at less than 1%, so ob.gyns. have shied away from ACOG’s blanket advice and now use uterine-cavity entry during myomectomy as their talisman for deciding whether or not to offer women vaginal delivery. The assumption is that uterine entry makes rupture more likely, but there’s not much evidence to support that idea, and it’s become clear in recent years that women who have a significant full-thickness insult to uterine integrity – a prior C-section – can usually deliver vaginally with no problem. In short, the uterus seems to have a remarkable ability to heal itself.
Even so, there are still ob.gyns. who pressure women into having premature babies if they’ve had a fibroid removed even without cavity entry. Barring additional indications, that doesn’t happen anymore at Northwestern University, said lead investigator Nathan King, MD, an ob.gyn. resident at the university.
The Northwestern team wanted to clear the fog. What they found adds to “literature that demonstrates the overall low risk of undergoing VTOL [vaginal trial of labor] after a prior myomectomy. We hope providers will feel more comfortable talking to their patients about delivery [options] and the success of VTOL after myomectomy,” Dr. King said at a meeting sponsored by AAGL.*
He and his team analyzed pregnancy outcomes in 112 women who had a live birth after non–cavity-entering myomectomies. Forty-nine women (44%) were allowed to undergo VTOL; 63 others had C-sections, most at term.
Thirty-two VTOL women (65%) had vaginal deliveries, a success rate similar to that of labor after C-section. There was just one uterine rupture in the VTOL group, for an incidence of 2%, which also was comparable to the rupture risk after a low-transverse C-section.
The rupture was discovered after spontaneous vaginal delivery, and an addressed by laparotomy. Both mother and infant were fine.
Adverse events were less likely in the VTOL group, regardless if they ultimately delivered vaginally or by C-section. The lower adverse event rate was driven by fewer postpartum hemorrhages (odds ratio, 0.441, 95% confidence interval, 0.2002-0.9722, P = .042).
There were no demographic difference between women who were allowed to undergo VTOL and those who were not. For most, it was their first delivery.
Women who had their uterine cavities entered during myomectomy weren’t allowed to undergo VTOL at Northwestern, and were not included in the analysis. Also, the study did not include women who became pregnant after myomectomy, but did not have a live delivery. The incidence of uterine rupture among them, if any, was not reported.
There was no external funding for the work, and Dr. King didn’t have any disclosures.
SOURCE: King N et al. 2018 AAGL Global Congress, Abstract 162.
*Correction, 12/11/2018: An earlier version of this story misstated the name of the meeting sponsor. It is AAGL.
LAS VEGAS –
The American College of Obstetricians and Gynecologists lists prior myomectomy as a medically-indicated reason for delivery before 39 weeks. The advice reflects a traditional concern that uterine scars will rupture during labor, with potentially devastating consequences for both mother and infant.
Reviews have put the risk at less than 1%, so ob.gyns. have shied away from ACOG’s blanket advice and now use uterine-cavity entry during myomectomy as their talisman for deciding whether or not to offer women vaginal delivery. The assumption is that uterine entry makes rupture more likely, but there’s not much evidence to support that idea, and it’s become clear in recent years that women who have a significant full-thickness insult to uterine integrity – a prior C-section – can usually deliver vaginally with no problem. In short, the uterus seems to have a remarkable ability to heal itself.
Even so, there are still ob.gyns. who pressure women into having premature babies if they’ve had a fibroid removed even without cavity entry. Barring additional indications, that doesn’t happen anymore at Northwestern University, said lead investigator Nathan King, MD, an ob.gyn. resident at the university.
The Northwestern team wanted to clear the fog. What they found adds to “literature that demonstrates the overall low risk of undergoing VTOL [vaginal trial of labor] after a prior myomectomy. We hope providers will feel more comfortable talking to their patients about delivery [options] and the success of VTOL after myomectomy,” Dr. King said at a meeting sponsored by AAGL.*
He and his team analyzed pregnancy outcomes in 112 women who had a live birth after non–cavity-entering myomectomies. Forty-nine women (44%) were allowed to undergo VTOL; 63 others had C-sections, most at term.
Thirty-two VTOL women (65%) had vaginal deliveries, a success rate similar to that of labor after C-section. There was just one uterine rupture in the VTOL group, for an incidence of 2%, which also was comparable to the rupture risk after a low-transverse C-section.
The rupture was discovered after spontaneous vaginal delivery, and an addressed by laparotomy. Both mother and infant were fine.
Adverse events were less likely in the VTOL group, regardless if they ultimately delivered vaginally or by C-section. The lower adverse event rate was driven by fewer postpartum hemorrhages (odds ratio, 0.441, 95% confidence interval, 0.2002-0.9722, P = .042).
There were no demographic difference between women who were allowed to undergo VTOL and those who were not. For most, it was their first delivery.
Women who had their uterine cavities entered during myomectomy weren’t allowed to undergo VTOL at Northwestern, and were not included in the analysis. Also, the study did not include women who became pregnant after myomectomy, but did not have a live delivery. The incidence of uterine rupture among them, if any, was not reported.
There was no external funding for the work, and Dr. King didn’t have any disclosures.
SOURCE: King N et al. 2018 AAGL Global Congress, Abstract 162.
*Correction, 12/11/2018: An earlier version of this story misstated the name of the meeting sponsor. It is AAGL.
LAS VEGAS –
The American College of Obstetricians and Gynecologists lists prior myomectomy as a medically-indicated reason for delivery before 39 weeks. The advice reflects a traditional concern that uterine scars will rupture during labor, with potentially devastating consequences for both mother and infant.
Reviews have put the risk at less than 1%, so ob.gyns. have shied away from ACOG’s blanket advice and now use uterine-cavity entry during myomectomy as their talisman for deciding whether or not to offer women vaginal delivery. The assumption is that uterine entry makes rupture more likely, but there’s not much evidence to support that idea, and it’s become clear in recent years that women who have a significant full-thickness insult to uterine integrity – a prior C-section – can usually deliver vaginally with no problem. In short, the uterus seems to have a remarkable ability to heal itself.
Even so, there are still ob.gyns. who pressure women into having premature babies if they’ve had a fibroid removed even without cavity entry. Barring additional indications, that doesn’t happen anymore at Northwestern University, said lead investigator Nathan King, MD, an ob.gyn. resident at the university.
The Northwestern team wanted to clear the fog. What they found adds to “literature that demonstrates the overall low risk of undergoing VTOL [vaginal trial of labor] after a prior myomectomy. We hope providers will feel more comfortable talking to their patients about delivery [options] and the success of VTOL after myomectomy,” Dr. King said at a meeting sponsored by AAGL.*
He and his team analyzed pregnancy outcomes in 112 women who had a live birth after non–cavity-entering myomectomies. Forty-nine women (44%) were allowed to undergo VTOL; 63 others had C-sections, most at term.
Thirty-two VTOL women (65%) had vaginal deliveries, a success rate similar to that of labor after C-section. There was just one uterine rupture in the VTOL group, for an incidence of 2%, which also was comparable to the rupture risk after a low-transverse C-section.
The rupture was discovered after spontaneous vaginal delivery, and an addressed by laparotomy. Both mother and infant were fine.
Adverse events were less likely in the VTOL group, regardless if they ultimately delivered vaginally or by C-section. The lower adverse event rate was driven by fewer postpartum hemorrhages (odds ratio, 0.441, 95% confidence interval, 0.2002-0.9722, P = .042).
There were no demographic difference between women who were allowed to undergo VTOL and those who were not. For most, it was their first delivery.
Women who had their uterine cavities entered during myomectomy weren’t allowed to undergo VTOL at Northwestern, and were not included in the analysis. Also, the study did not include women who became pregnant after myomectomy, but did not have a live delivery. The incidence of uterine rupture among them, if any, was not reported.
There was no external funding for the work, and Dr. King didn’t have any disclosures.
SOURCE: King N et al. 2018 AAGL Global Congress, Abstract 162.
*Correction, 12/11/2018: An earlier version of this story misstated the name of the meeting sponsor. It is AAGL.
REPORTING FROM AAGL GLOBAL CONGRESS
Key clinical point: Vaginal trial of labor is safe after myomectomy, at least if the uterine cavity wasn’t entered.
Major finding: Sixty-five percent of women who didn’t have their uterine cavities entered had vaginal deliveries, a success rate similar to labor after C-section.
Study details: Review of 102 pregnancies with live births after myomectomy at Northwestern University, Chicago
Disclosures: There was no external funding, and the lead investigator didn’t have any disclosures.
Source: King N et al. 2018 AAGL Global Congress, Abstract 162.
Cervical bupivacaine blocks pain after laparoscopic hysterectomy
LAS VEGAS – according to a small trial at the University of Tennessee, Chattanooga.
Twenty-one women were randomized to 0.5% bupivacaine, 5 mL injected into the cervix at the 3 o’clock position, and 5 mL injected into at the 9 o’clock position to a depth of 3 cm, after anesthesia induction but before insertion of the uterine manipulator. A control group of 20 women received 5 mL of 0.9% saline injected into the same positions. Surgeons were blinded to the randomization.
A stopwatch was started at extubation, and the women were asked to rate their pain on a 10-point visual analogue scale exactly at 30 and 60 minutes.
The bupivacaine group had less pain at both 30 minutes (3.2 versus 5.7 points, P = .01) and 60 minutes (2.3 versus 5.9 points, P less than .001); 71% of women in the bupivacaine group had an average score of 4 or less, indicating adequate pain control, versus just 25% in the control arm (P = .003)
“This is something we should be considering” routinely for laparoscopic hysterectomy, an audience member said after hearing the presentation at a meeting sponsored by AAGL.
Another audience member was concerned about urinary retention, but there was no increase in the treatment arm, said lead investigator Steven Radtke, MD, a former ob.gyn. surgery fellow at the university, but now at Texas Tech University, El Paso.
There have been many prior attempts to reduce pain after laparoscopic hysterectomy, such as infiltrating port sites with local anesthetic, but the results have been marginal at best, and almost all of them have focused on the abdominal wall as the source of pain.
The investigators thought that pain was more related to perimetrium dissection, colpotomy, and other parts of the operation. There also have been good studies showing that agents injected into the cervix infuse throughout the area. The team decided to try bupivacaine because it’s inexpensive and has a good duration of action, about 8 hours.
There were no significant demographic or intraoperative differences between the groups. On average, women were in their mid-40s, with a body mass index of about 31 kg/m2. The operations took about 2 hours, and were for benign indications, such as fibroids. Oophorectomy was the only concomitant procedure allowed.
The investigators are interested in repeating their investigation with liposomal bupivacaine (Exparel), which has a duration of action past 24 hours. It’s much more expensive, but the strong trial results justify the cost, Dr. Radtke said.
There was no external funding, and Dr. Radtke didn’t have any disclosures.
SOURCE: Radtke S et al. 2018 AAGL Global Congress, Abstract 130.
LAS VEGAS – according to a small trial at the University of Tennessee, Chattanooga.
Twenty-one women were randomized to 0.5% bupivacaine, 5 mL injected into the cervix at the 3 o’clock position, and 5 mL injected into at the 9 o’clock position to a depth of 3 cm, after anesthesia induction but before insertion of the uterine manipulator. A control group of 20 women received 5 mL of 0.9% saline injected into the same positions. Surgeons were blinded to the randomization.
A stopwatch was started at extubation, and the women were asked to rate their pain on a 10-point visual analogue scale exactly at 30 and 60 minutes.
The bupivacaine group had less pain at both 30 minutes (3.2 versus 5.7 points, P = .01) and 60 minutes (2.3 versus 5.9 points, P less than .001); 71% of women in the bupivacaine group had an average score of 4 or less, indicating adequate pain control, versus just 25% in the control arm (P = .003)
“This is something we should be considering” routinely for laparoscopic hysterectomy, an audience member said after hearing the presentation at a meeting sponsored by AAGL.
Another audience member was concerned about urinary retention, but there was no increase in the treatment arm, said lead investigator Steven Radtke, MD, a former ob.gyn. surgery fellow at the university, but now at Texas Tech University, El Paso.
There have been many prior attempts to reduce pain after laparoscopic hysterectomy, such as infiltrating port sites with local anesthetic, but the results have been marginal at best, and almost all of them have focused on the abdominal wall as the source of pain.
The investigators thought that pain was more related to perimetrium dissection, colpotomy, and other parts of the operation. There also have been good studies showing that agents injected into the cervix infuse throughout the area. The team decided to try bupivacaine because it’s inexpensive and has a good duration of action, about 8 hours.
There were no significant demographic or intraoperative differences between the groups. On average, women were in their mid-40s, with a body mass index of about 31 kg/m2. The operations took about 2 hours, and were for benign indications, such as fibroids. Oophorectomy was the only concomitant procedure allowed.
The investigators are interested in repeating their investigation with liposomal bupivacaine (Exparel), which has a duration of action past 24 hours. It’s much more expensive, but the strong trial results justify the cost, Dr. Radtke said.
There was no external funding, and Dr. Radtke didn’t have any disclosures.
SOURCE: Radtke S et al. 2018 AAGL Global Congress, Abstract 130.
LAS VEGAS – according to a small trial at the University of Tennessee, Chattanooga.
Twenty-one women were randomized to 0.5% bupivacaine, 5 mL injected into the cervix at the 3 o’clock position, and 5 mL injected into at the 9 o’clock position to a depth of 3 cm, after anesthesia induction but before insertion of the uterine manipulator. A control group of 20 women received 5 mL of 0.9% saline injected into the same positions. Surgeons were blinded to the randomization.
A stopwatch was started at extubation, and the women were asked to rate their pain on a 10-point visual analogue scale exactly at 30 and 60 minutes.
The bupivacaine group had less pain at both 30 minutes (3.2 versus 5.7 points, P = .01) and 60 minutes (2.3 versus 5.9 points, P less than .001); 71% of women in the bupivacaine group had an average score of 4 or less, indicating adequate pain control, versus just 25% in the control arm (P = .003)
“This is something we should be considering” routinely for laparoscopic hysterectomy, an audience member said after hearing the presentation at a meeting sponsored by AAGL.
Another audience member was concerned about urinary retention, but there was no increase in the treatment arm, said lead investigator Steven Radtke, MD, a former ob.gyn. surgery fellow at the university, but now at Texas Tech University, El Paso.
There have been many prior attempts to reduce pain after laparoscopic hysterectomy, such as infiltrating port sites with local anesthetic, but the results have been marginal at best, and almost all of them have focused on the abdominal wall as the source of pain.
The investigators thought that pain was more related to perimetrium dissection, colpotomy, and other parts of the operation. There also have been good studies showing that agents injected into the cervix infuse throughout the area. The team decided to try bupivacaine because it’s inexpensive and has a good duration of action, about 8 hours.
There were no significant demographic or intraoperative differences between the groups. On average, women were in their mid-40s, with a body mass index of about 31 kg/m2. The operations took about 2 hours, and were for benign indications, such as fibroids. Oophorectomy was the only concomitant procedure allowed.
The investigators are interested in repeating their investigation with liposomal bupivacaine (Exparel), which has a duration of action past 24 hours. It’s much more expensive, but the strong trial results justify the cost, Dr. Radtke said.
There was no external funding, and Dr. Radtke didn’t have any disclosures.
SOURCE: Radtke S et al. 2018 AAGL Global Congress, Abstract 130.
REPORTING FROM AAGL GLOBAL CONGRESS
Key clinical point: Postoperative pain can be significantly reduced by injecting the cervix with bupivacaine prior to laparoscopic hysterectomy.
Major finding: The bupivacaine group had less pain at both 30 minutes (3.2 versus 5.7 points, P = .01) and 60 minutes (2.3 versus 5.9 points, P less than .001).
Study details: In a randomized study, 21 women received bupivacaine anesthesia and 20 control women were injected with saline.
Disclosures: There was no external funding, and Dr. Radtke didn’t have any disclosures.
Source: Radtke S et al. 2018 AAGL Global Congress, Abstract 130.
Cold packs help reduce pain after laparoscopic hysterectomy
LAS VEGAS – Patients like cold packs for pain control after laparoscopic hysterectomy, according to a small trial from Cleveland Clinic Florida (Weston).
Cold packs have been shown to reduce pain in other types of surgery, so investigators at the clinic wanted to try them out for the procedure, said study lead Pamela Frazzini Padilla, MD, an ob.gyn. at the clinic.
Twenty-eight women were randomized to get packs right after surgery, and told to use them – before turning to oxycodone tabs – every 6 hours for 72 hours – and then as needed. Twenty-eight other women were randomized to the control group. Surgery was for benign indications, most often uterine bleeding secondary to fibroids. Besides the cold packs, there were no differences between the groups in analgesia protocols.
The differences in pain control, assessed on a 10-point scale over the phone, weren’t statistically significant, but they di move in the right direction. At 24 hours, women who were cold pack users reported a median pain score of 4, versus 4.5 among controls. At 72 hours, they reported a median score of 2, versus 2.5 in the control group.
At 2 weeks postoperatively, women who were cold pack users had used a mean of 4 oxycodone pills, versus 7 among the controls, which translated into a mean of 13 IV morphine equivalents versus 24 in favor of cold packs (P = .143).
While not significantly different, overall numbers of opioid tabs consumed and morphine equivalents “demonstrated lower use in the study group,” Dr. Frazzini Padilla noted at the meeting sponsored by AAGL.
Also, 89% of women said that cold packs helped reduce their pain, and 92% said they’d use them again after an operation. “In a day when everything is driven by patient satisfaction, patients’ perception of their recovery” is important. Because cold packs are cheap, harmless, and seemed to help with patient perceptions, “we do recommend that people use” them. “It’s just another added measure that we give” at Cleveland Clinic Florida, she said.
The study team also found that 86% of the women in the trial used 10 or fewer oxycodone tabs after surgery. Across the country, women are prescribed about 25 tabs after a laparoscopic hysterectomy; the study suggests it’s overkill, as an audience member noted, especially given the current climate.
The two arms of the study were well balanced. The mean age was 46 years, and mean body mass index 30.4 kg/m2.
There was no outside funding, and the investigators didn’t have any disclosures.
aotto@mdedge.com
SOURCE: Frazzini Padilla P et al. 2018 AAGL Global Congress, Abstract 21.
LAS VEGAS – Patients like cold packs for pain control after laparoscopic hysterectomy, according to a small trial from Cleveland Clinic Florida (Weston).
Cold packs have been shown to reduce pain in other types of surgery, so investigators at the clinic wanted to try them out for the procedure, said study lead Pamela Frazzini Padilla, MD, an ob.gyn. at the clinic.
Twenty-eight women were randomized to get packs right after surgery, and told to use them – before turning to oxycodone tabs – every 6 hours for 72 hours – and then as needed. Twenty-eight other women were randomized to the control group. Surgery was for benign indications, most often uterine bleeding secondary to fibroids. Besides the cold packs, there were no differences between the groups in analgesia protocols.
The differences in pain control, assessed on a 10-point scale over the phone, weren’t statistically significant, but they di move in the right direction. At 24 hours, women who were cold pack users reported a median pain score of 4, versus 4.5 among controls. At 72 hours, they reported a median score of 2, versus 2.5 in the control group.
At 2 weeks postoperatively, women who were cold pack users had used a mean of 4 oxycodone pills, versus 7 among the controls, which translated into a mean of 13 IV morphine equivalents versus 24 in favor of cold packs (P = .143).
While not significantly different, overall numbers of opioid tabs consumed and morphine equivalents “demonstrated lower use in the study group,” Dr. Frazzini Padilla noted at the meeting sponsored by AAGL.
Also, 89% of women said that cold packs helped reduce their pain, and 92% said they’d use them again after an operation. “In a day when everything is driven by patient satisfaction, patients’ perception of their recovery” is important. Because cold packs are cheap, harmless, and seemed to help with patient perceptions, “we do recommend that people use” them. “It’s just another added measure that we give” at Cleveland Clinic Florida, she said.
The study team also found that 86% of the women in the trial used 10 or fewer oxycodone tabs after surgery. Across the country, women are prescribed about 25 tabs after a laparoscopic hysterectomy; the study suggests it’s overkill, as an audience member noted, especially given the current climate.
The two arms of the study were well balanced. The mean age was 46 years, and mean body mass index 30.4 kg/m2.
There was no outside funding, and the investigators didn’t have any disclosures.
aotto@mdedge.com
SOURCE: Frazzini Padilla P et al. 2018 AAGL Global Congress, Abstract 21.
LAS VEGAS – Patients like cold packs for pain control after laparoscopic hysterectomy, according to a small trial from Cleveland Clinic Florida (Weston).
Cold packs have been shown to reduce pain in other types of surgery, so investigators at the clinic wanted to try them out for the procedure, said study lead Pamela Frazzini Padilla, MD, an ob.gyn. at the clinic.
Twenty-eight women were randomized to get packs right after surgery, and told to use them – before turning to oxycodone tabs – every 6 hours for 72 hours – and then as needed. Twenty-eight other women were randomized to the control group. Surgery was for benign indications, most often uterine bleeding secondary to fibroids. Besides the cold packs, there were no differences between the groups in analgesia protocols.
The differences in pain control, assessed on a 10-point scale over the phone, weren’t statistically significant, but they di move in the right direction. At 24 hours, women who were cold pack users reported a median pain score of 4, versus 4.5 among controls. At 72 hours, they reported a median score of 2, versus 2.5 in the control group.
At 2 weeks postoperatively, women who were cold pack users had used a mean of 4 oxycodone pills, versus 7 among the controls, which translated into a mean of 13 IV morphine equivalents versus 24 in favor of cold packs (P = .143).
While not significantly different, overall numbers of opioid tabs consumed and morphine equivalents “demonstrated lower use in the study group,” Dr. Frazzini Padilla noted at the meeting sponsored by AAGL.
Also, 89% of women said that cold packs helped reduce their pain, and 92% said they’d use them again after an operation. “In a day when everything is driven by patient satisfaction, patients’ perception of their recovery” is important. Because cold packs are cheap, harmless, and seemed to help with patient perceptions, “we do recommend that people use” them. “It’s just another added measure that we give” at Cleveland Clinic Florida, she said.
The study team also found that 86% of the women in the trial used 10 or fewer oxycodone tabs after surgery. Across the country, women are prescribed about 25 tabs after a laparoscopic hysterectomy; the study suggests it’s overkill, as an audience member noted, especially given the current climate.
The two arms of the study were well balanced. The mean age was 46 years, and mean body mass index 30.4 kg/m2.
There was no outside funding, and the investigators didn’t have any disclosures.
aotto@mdedge.com
SOURCE: Frazzini Padilla P et al. 2018 AAGL Global Congress, Abstract 21.
REPORTING FROM AAGL GLOBAL CONGRESS
Key clinical point:
Major finding: Cold pack women at 2 weeks used a mean of 4 oxycodone pills, versus 7 among the controls, which translated into a mean of 13 IV morphine equivalents versus 24 in favor of cold packs (P = 0.143)
Study details: A study of 28 women using cold packs and 28 controls.
Disclosures: There was no outside funding, and the investigators didn’t have any disclosures.
Source: Frazzini Padilla P et al. 2018 AAGL Global Congress, Abstract 21.
Laparoscope doubles as cystoscope in robotic hysterectomy
LAS VEGAS – to check for injuries, according to a review from St. Joseph’s University Medical Center, in Paterson, N.J.
Postoperative urinary tract infections (UTIs) are the big worry with using the same scope, but they really weren’t a problem at St. Joe’s; in a study of 45 women, there was just one UTI, confirmed by culture, at the 2-week postoperative visit, yielding a rate (2.2%) that is actually better the 5%-10% reported for stand-alone cystoscopy, said lead investigator and ob.gyn. resident Nikki Amirlatifi, MD.
“This is a safe alternative to traditional cystoscopy. We had no problems with visualization, and it doesn’t increase the rate of UTIs. Of course, it’s not only cost saving but time saving, as well,” she said.
The cases all were routine, however. For tougher ones, “where we need a more in-depth look at the bladder, we would [still] do cystoscopy,” she said at the meeting sponsored by AAGL.
There’s some debate about routine cystoscopy during laparoscopic hysterectomy, but Dr. Amirlatifi noted that it’s been reported to detect up to 89% of ureter injuries and up to 95% of bladder injuries. Using the same scope for both procedures makes it easier.
After the uterus was taken out, the bladder was backfilled with 180 mL of sterile water, then the Foley catheter was pulled. The previously used 5 mm laparoscope, which had been used for abdominal entry at 0 degrees, was introduced into the bladder. Efflux from both ureteral orifices was visualized, then the catheter reinserted until the end of surgery.
The women were an average of 44 years old, with an average body mass index of 32 kg/m2. Abnormal uterine bleeding, pelvic pain, and fibroids were the main indications for surgery. No ureteral or bladder injuries were detected.
Everyone was questioned about UTI symptoms and gave a clean-catch urine sample at the first postoperative visit. Cultures were performed on the seven women who reported symptoms or had white cells in their sample, and they were treated empirically with antibiotics. Only one culture grew out despite a high prevalence of UTI risk factors, including diabetes (13%), obesity (42%), and smoking (11%).
All the women had preoperative antibiotics and phenazopyridine. Most went home on the day of surgery.
There was no outside funding for the work, and the investigators didn’t have any relevant financial disclosures.
SOURCE: J Minim. Invasive Gynecol. 2018 Nov-Dec;25[7]:S46-47.
LAS VEGAS – to check for injuries, according to a review from St. Joseph’s University Medical Center, in Paterson, N.J.
Postoperative urinary tract infections (UTIs) are the big worry with using the same scope, but they really weren’t a problem at St. Joe’s; in a study of 45 women, there was just one UTI, confirmed by culture, at the 2-week postoperative visit, yielding a rate (2.2%) that is actually better the 5%-10% reported for stand-alone cystoscopy, said lead investigator and ob.gyn. resident Nikki Amirlatifi, MD.
“This is a safe alternative to traditional cystoscopy. We had no problems with visualization, and it doesn’t increase the rate of UTIs. Of course, it’s not only cost saving but time saving, as well,” she said.
The cases all were routine, however. For tougher ones, “where we need a more in-depth look at the bladder, we would [still] do cystoscopy,” she said at the meeting sponsored by AAGL.
There’s some debate about routine cystoscopy during laparoscopic hysterectomy, but Dr. Amirlatifi noted that it’s been reported to detect up to 89% of ureter injuries and up to 95% of bladder injuries. Using the same scope for both procedures makes it easier.
After the uterus was taken out, the bladder was backfilled with 180 mL of sterile water, then the Foley catheter was pulled. The previously used 5 mm laparoscope, which had been used for abdominal entry at 0 degrees, was introduced into the bladder. Efflux from both ureteral orifices was visualized, then the catheter reinserted until the end of surgery.
The women were an average of 44 years old, with an average body mass index of 32 kg/m2. Abnormal uterine bleeding, pelvic pain, and fibroids were the main indications for surgery. No ureteral or bladder injuries were detected.
Everyone was questioned about UTI symptoms and gave a clean-catch urine sample at the first postoperative visit. Cultures were performed on the seven women who reported symptoms or had white cells in their sample, and they were treated empirically with antibiotics. Only one culture grew out despite a high prevalence of UTI risk factors, including diabetes (13%), obesity (42%), and smoking (11%).
All the women had preoperative antibiotics and phenazopyridine. Most went home on the day of surgery.
There was no outside funding for the work, and the investigators didn’t have any relevant financial disclosures.
SOURCE: J Minim. Invasive Gynecol. 2018 Nov-Dec;25[7]:S46-47.
LAS VEGAS – to check for injuries, according to a review from St. Joseph’s University Medical Center, in Paterson, N.J.
Postoperative urinary tract infections (UTIs) are the big worry with using the same scope, but they really weren’t a problem at St. Joe’s; in a study of 45 women, there was just one UTI, confirmed by culture, at the 2-week postoperative visit, yielding a rate (2.2%) that is actually better the 5%-10% reported for stand-alone cystoscopy, said lead investigator and ob.gyn. resident Nikki Amirlatifi, MD.
“This is a safe alternative to traditional cystoscopy. We had no problems with visualization, and it doesn’t increase the rate of UTIs. Of course, it’s not only cost saving but time saving, as well,” she said.
The cases all were routine, however. For tougher ones, “where we need a more in-depth look at the bladder, we would [still] do cystoscopy,” she said at the meeting sponsored by AAGL.
There’s some debate about routine cystoscopy during laparoscopic hysterectomy, but Dr. Amirlatifi noted that it’s been reported to detect up to 89% of ureter injuries and up to 95% of bladder injuries. Using the same scope for both procedures makes it easier.
After the uterus was taken out, the bladder was backfilled with 180 mL of sterile water, then the Foley catheter was pulled. The previously used 5 mm laparoscope, which had been used for abdominal entry at 0 degrees, was introduced into the bladder. Efflux from both ureteral orifices was visualized, then the catheter reinserted until the end of surgery.
The women were an average of 44 years old, with an average body mass index of 32 kg/m2. Abnormal uterine bleeding, pelvic pain, and fibroids were the main indications for surgery. No ureteral or bladder injuries were detected.
Everyone was questioned about UTI symptoms and gave a clean-catch urine sample at the first postoperative visit. Cultures were performed on the seven women who reported symptoms or had white cells in their sample, and they were treated empirically with antibiotics. Only one culture grew out despite a high prevalence of UTI risk factors, including diabetes (13%), obesity (42%), and smoking (11%).
All the women had preoperative antibiotics and phenazopyridine. Most went home on the day of surgery.
There was no outside funding for the work, and the investigators didn’t have any relevant financial disclosures.
SOURCE: J Minim. Invasive Gynecol. 2018 Nov-Dec;25[7]:S46-47.
REPORTING FROM AAGL GLOBAL CONGRESS
Key clinical point: It is just as safe to look inside the bladder with the laparoscope after robotic hysterectomy in routine cases as to use a separate cystoscopy setup.
Major finding: Only 2.2% of women had a UTI, and there were no ureteral or bladder injuries detected using the laparoscope.
Study details: This was a prospective study of 45 women who underwent robotic hysterectomy whose bladder was inspected with the laparoscope at the end of surgery.
Disclosures: There was no outside funding for the work, and the investigators didn’t have any relevant financial disclosures.
Laparoscopic hysterectomy with obliterated cul-de-sac needs specialist care
LAS VEGAS – When stage IV endometriosis with obliterated posterior cul-de-sac is discovered during laparoscopic hysterectomy, or suspected beforehand, women should be referred to a minimally invasive gynecologic surgery specialist because the procedure will be much more difficult, investigators said at the meeting sponsored by AAGL.
They reviewed 333 laparoscopic hysterectomies where endometriosis was discovered in the operating room. The disease is known to increase the complexity of hysterectomy; the investigators wanted to quantify the risk by endometriosis severity. Among their subjects, 237 women (71%) had stage I, II, or III endometriosis; 96 (29%) had stage IV disease, including 55 women (57%) with obliterated posterior cul-de-sacs.
Surgery was longer among stage IV cases (137 vs. 116 minutes), and there was greater blood loss; 66% of stage IV women required laparoscopic-modified radical hysterectomy versus about a quarter of women with stage I-III endometriosis.
A total of 93% required modified radical hysterectomies versus 29% of stage IV women with intact cul-de-sacs. Additional procedures were far more likely in this population, including salpingectomy, ureterolysis, enterolysis, cystoscopy, ureteral stenting, proctoscopy, bowel oversew, and anterior resection anastomosis. The differences all were statistically significant.
Among stage IV cases, mean operating time was longer in obliterated cul-de-sac cases (159 vs. 108 minutes), with higher blood loss, 100 mL versus 50 mL.
“Patients with obliterated cul-de-sacs identified intraoperatively should be referred to minimally invasive gynecologic surgeons because of the ... extra training required to safely perform [laparoscopic hysterectomy] with limited morbidity,” said lead investigator Alexandra Melnyk, MD, a University of Pittsburgh ob.gyn resident.
There was no industry funding and the investigators reported no disclosures.
SOURCE: Melnyk A et al. 2018 AAGL Global Congress, Abstract 81.
LAS VEGAS – When stage IV endometriosis with obliterated posterior cul-de-sac is discovered during laparoscopic hysterectomy, or suspected beforehand, women should be referred to a minimally invasive gynecologic surgery specialist because the procedure will be much more difficult, investigators said at the meeting sponsored by AAGL.
They reviewed 333 laparoscopic hysterectomies where endometriosis was discovered in the operating room. The disease is known to increase the complexity of hysterectomy; the investigators wanted to quantify the risk by endometriosis severity. Among their subjects, 237 women (71%) had stage I, II, or III endometriosis; 96 (29%) had stage IV disease, including 55 women (57%) with obliterated posterior cul-de-sacs.
Surgery was longer among stage IV cases (137 vs. 116 minutes), and there was greater blood loss; 66% of stage IV women required laparoscopic-modified radical hysterectomy versus about a quarter of women with stage I-III endometriosis.
A total of 93% required modified radical hysterectomies versus 29% of stage IV women with intact cul-de-sacs. Additional procedures were far more likely in this population, including salpingectomy, ureterolysis, enterolysis, cystoscopy, ureteral stenting, proctoscopy, bowel oversew, and anterior resection anastomosis. The differences all were statistically significant.
Among stage IV cases, mean operating time was longer in obliterated cul-de-sac cases (159 vs. 108 minutes), with higher blood loss, 100 mL versus 50 mL.
“Patients with obliterated cul-de-sacs identified intraoperatively should be referred to minimally invasive gynecologic surgeons because of the ... extra training required to safely perform [laparoscopic hysterectomy] with limited morbidity,” said lead investigator Alexandra Melnyk, MD, a University of Pittsburgh ob.gyn resident.
There was no industry funding and the investigators reported no disclosures.
SOURCE: Melnyk A et al. 2018 AAGL Global Congress, Abstract 81.
LAS VEGAS – When stage IV endometriosis with obliterated posterior cul-de-sac is discovered during laparoscopic hysterectomy, or suspected beforehand, women should be referred to a minimally invasive gynecologic surgery specialist because the procedure will be much more difficult, investigators said at the meeting sponsored by AAGL.
They reviewed 333 laparoscopic hysterectomies where endometriosis was discovered in the operating room. The disease is known to increase the complexity of hysterectomy; the investigators wanted to quantify the risk by endometriosis severity. Among their subjects, 237 women (71%) had stage I, II, or III endometriosis; 96 (29%) had stage IV disease, including 55 women (57%) with obliterated posterior cul-de-sacs.
Surgery was longer among stage IV cases (137 vs. 116 minutes), and there was greater blood loss; 66% of stage IV women required laparoscopic-modified radical hysterectomy versus about a quarter of women with stage I-III endometriosis.
A total of 93% required modified radical hysterectomies versus 29% of stage IV women with intact cul-de-sacs. Additional procedures were far more likely in this population, including salpingectomy, ureterolysis, enterolysis, cystoscopy, ureteral stenting, proctoscopy, bowel oversew, and anterior resection anastomosis. The differences all were statistically significant.
Among stage IV cases, mean operating time was longer in obliterated cul-de-sac cases (159 vs. 108 minutes), with higher blood loss, 100 mL versus 50 mL.
“Patients with obliterated cul-de-sacs identified intraoperatively should be referred to minimally invasive gynecologic surgeons because of the ... extra training required to safely perform [laparoscopic hysterectomy] with limited morbidity,” said lead investigator Alexandra Melnyk, MD, a University of Pittsburgh ob.gyn resident.
There was no industry funding and the investigators reported no disclosures.
SOURCE: Melnyk A et al. 2018 AAGL Global Congress, Abstract 81.
REPORTING FROM THE AAGL GLOBAL CONGRESS
Tegaderm eliminates corneal abrasions in robotic gynecologic surgery
LAS VEGAS – There hasn’t been a single corneal abrasion in 860 cases of gynecologic robotic surgery at the University of Texas, Austin, since surgeons and anesthesiologists there started sealing women’s eyes shut with a thick layer of ointment and Tegaderm, instead of the usual small squeeze of ointment and tape, according to Michael T. Breen, MD, a gynecologic surgeon at the university.
“Go back to your hospital, meet with your anesthesiologists, and see what you’re doing to protect your patients’ eyes,” Dr. Breen said at the meeting, sponsored by the American Association of Gynecologic Laparoscopists.
Slathered eyes and Tegaderm are now standard practice at the university. Before the switch was made, there were six corneal abrasions in 231 cases over 6 months. Two of those patients stayed longer in the hospital than they would have otherwise. The changes have eliminated the problem.
The impetus for the switch was a 42-year-old woman who had a robotic hysterectomy. The surgery went fine, but then Dr. Breen had to rush back to the recovery room. The woman was screaming in pain, not from her surgery, but from her left eye.
Corneal abrasions are a well-known risk of surgery because anesthesia decreases tear production and dries the eyes. Robotic gynecologic surgery increases the risk even more, because patients are under longer than with other approaches, and the steep Trendelenburg increases intraocular pressure and eye edema, especially with excess IV fluid.
And “believe it or not, having a pulse oximeter on the dominant hand [also] increases your risk of ocular injury,” Dr. Breen said. Sometimes, patients wake up, go to rub their eyes, and drag the device across their cornea, he said.
The screaming patient – who recovered without permanent damage – prompted Dr. Breen and his colleagues to turn to the literature for solutions. “One was a fully occlusive eye dressing, more than the tape we’ve all been accustomed to, with thick eye ointment application and Tegaderm applying positive pressure to the eye,” he said.
Dr. Breen showed his audience a slide of the setup. “It looks a little unorthodox, but this is how every one of our robotic patients now have their eyes protected. Thick gel which is then covered with a positive pressure Tegaderm,” he said.
, and placing the pulse ox on the nondominant hand. The team already had been decreasing IV fluids as part of their enhanced recovery after surgery protocol, and bringing patients out of steep Trendelenburg as soon as possible.
With the changes, “the rate of corneal abrasions decreased from 2.6% to 0% – and has stayed there,” Dr. Breen said.
There’ve been no allergic reactions to Tegaderm and no eyelid problems. “What we have seen with the simple taping is that, when it comes off, so does some of the eyelid, particularly with geriatric patients. We have not seen that with Tegaderm,” he said.
“Some people use goggles to protect the eyes, and we thought initially that the camera was hitting the face, so we used the Mayo stand to protect it from the camera,” but that didn’t turn out to be the problem, he said. “Goggles actually may make things worse.”
The project had no industry funding, and Dr. Breen had no relevant disclosures.
aotto@mdedge.com
SOURCE: Breen MT et al. 2018 AAGL Global Congress, Abstract 16.
LAS VEGAS – There hasn’t been a single corneal abrasion in 860 cases of gynecologic robotic surgery at the University of Texas, Austin, since surgeons and anesthesiologists there started sealing women’s eyes shut with a thick layer of ointment and Tegaderm, instead of the usual small squeeze of ointment and tape, according to Michael T. Breen, MD, a gynecologic surgeon at the university.
“Go back to your hospital, meet with your anesthesiologists, and see what you’re doing to protect your patients’ eyes,” Dr. Breen said at the meeting, sponsored by the American Association of Gynecologic Laparoscopists.
Slathered eyes and Tegaderm are now standard practice at the university. Before the switch was made, there were six corneal abrasions in 231 cases over 6 months. Two of those patients stayed longer in the hospital than they would have otherwise. The changes have eliminated the problem.
The impetus for the switch was a 42-year-old woman who had a robotic hysterectomy. The surgery went fine, but then Dr. Breen had to rush back to the recovery room. The woman was screaming in pain, not from her surgery, but from her left eye.
Corneal abrasions are a well-known risk of surgery because anesthesia decreases tear production and dries the eyes. Robotic gynecologic surgery increases the risk even more, because patients are under longer than with other approaches, and the steep Trendelenburg increases intraocular pressure and eye edema, especially with excess IV fluid.
And “believe it or not, having a pulse oximeter on the dominant hand [also] increases your risk of ocular injury,” Dr. Breen said. Sometimes, patients wake up, go to rub their eyes, and drag the device across their cornea, he said.
The screaming patient – who recovered without permanent damage – prompted Dr. Breen and his colleagues to turn to the literature for solutions. “One was a fully occlusive eye dressing, more than the tape we’ve all been accustomed to, with thick eye ointment application and Tegaderm applying positive pressure to the eye,” he said.
Dr. Breen showed his audience a slide of the setup. “It looks a little unorthodox, but this is how every one of our robotic patients now have their eyes protected. Thick gel which is then covered with a positive pressure Tegaderm,” he said.
, and placing the pulse ox on the nondominant hand. The team already had been decreasing IV fluids as part of their enhanced recovery after surgery protocol, and bringing patients out of steep Trendelenburg as soon as possible.
With the changes, “the rate of corneal abrasions decreased from 2.6% to 0% – and has stayed there,” Dr. Breen said.
There’ve been no allergic reactions to Tegaderm and no eyelid problems. “What we have seen with the simple taping is that, when it comes off, so does some of the eyelid, particularly with geriatric patients. We have not seen that with Tegaderm,” he said.
“Some people use goggles to protect the eyes, and we thought initially that the camera was hitting the face, so we used the Mayo stand to protect it from the camera,” but that didn’t turn out to be the problem, he said. “Goggles actually may make things worse.”
The project had no industry funding, and Dr. Breen had no relevant disclosures.
aotto@mdedge.com
SOURCE: Breen MT et al. 2018 AAGL Global Congress, Abstract 16.
LAS VEGAS – There hasn’t been a single corneal abrasion in 860 cases of gynecologic robotic surgery at the University of Texas, Austin, since surgeons and anesthesiologists there started sealing women’s eyes shut with a thick layer of ointment and Tegaderm, instead of the usual small squeeze of ointment and tape, according to Michael T. Breen, MD, a gynecologic surgeon at the university.
“Go back to your hospital, meet with your anesthesiologists, and see what you’re doing to protect your patients’ eyes,” Dr. Breen said at the meeting, sponsored by the American Association of Gynecologic Laparoscopists.
Slathered eyes and Tegaderm are now standard practice at the university. Before the switch was made, there were six corneal abrasions in 231 cases over 6 months. Two of those patients stayed longer in the hospital than they would have otherwise. The changes have eliminated the problem.
The impetus for the switch was a 42-year-old woman who had a robotic hysterectomy. The surgery went fine, but then Dr. Breen had to rush back to the recovery room. The woman was screaming in pain, not from her surgery, but from her left eye.
Corneal abrasions are a well-known risk of surgery because anesthesia decreases tear production and dries the eyes. Robotic gynecologic surgery increases the risk even more, because patients are under longer than with other approaches, and the steep Trendelenburg increases intraocular pressure and eye edema, especially with excess IV fluid.
And “believe it or not, having a pulse oximeter on the dominant hand [also] increases your risk of ocular injury,” Dr. Breen said. Sometimes, patients wake up, go to rub their eyes, and drag the device across their cornea, he said.
The screaming patient – who recovered without permanent damage – prompted Dr. Breen and his colleagues to turn to the literature for solutions. “One was a fully occlusive eye dressing, more than the tape we’ve all been accustomed to, with thick eye ointment application and Tegaderm applying positive pressure to the eye,” he said.
Dr. Breen showed his audience a slide of the setup. “It looks a little unorthodox, but this is how every one of our robotic patients now have their eyes protected. Thick gel which is then covered with a positive pressure Tegaderm,” he said.
, and placing the pulse ox on the nondominant hand. The team already had been decreasing IV fluids as part of their enhanced recovery after surgery protocol, and bringing patients out of steep Trendelenburg as soon as possible.
With the changes, “the rate of corneal abrasions decreased from 2.6% to 0% – and has stayed there,” Dr. Breen said.
There’ve been no allergic reactions to Tegaderm and no eyelid problems. “What we have seen with the simple taping is that, when it comes off, so does some of the eyelid, particularly with geriatric patients. We have not seen that with Tegaderm,” he said.
“Some people use goggles to protect the eyes, and we thought initially that the camera was hitting the face, so we used the Mayo stand to protect it from the camera,” but that didn’t turn out to be the problem, he said. “Goggles actually may make things worse.”
The project had no industry funding, and Dr. Breen had no relevant disclosures.
aotto@mdedge.com
SOURCE: Breen MT et al. 2018 AAGL Global Congress, Abstract 16.
REPORTING FROM THE AAGL GLOBAL CONGRESS
Key clinical point: “The rate of corneal abrasions decreased from 2.6% to 0% – and has stayed there.”
Major finding: Of the 860 cases of gynecologic robotic surgery at the University of Texas, Austin, there has not been a single case of corneal abrasion since the switch.
Study details: Quality improvement project at the university.
Disclosures: The project had no industry funding, and Dr. Breen had no relevant disclosures.
Source: Breen MT et al. 2018 AAGL Global Congress, Abstract 16.