Minimizing Surgical Complications

Howard T. Sharp, MDProfessor and Vice Chair for Clinical Affairs

Department of Obstetrics & GynecologyUniversity of Utah School of Medicine

Learning Objectives

• Review 4 difficult complications• Discuss prevention / risk reduction

– Electrosurgical injury– Nerve injury– Thromboembolic events– Ureteral injury

1994 - 1995

• Optical access trocar through aorta– Baltimore– Death

• Optical access trocar through pregnant uterus – cholecystectomy– University of Utah– Fetal death at 23 weeks

The MAUDE Database

Source: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm

Optical Access TrocarsSharp HT et al, Obstet Gynecol 2002

MAUDE DB37 major vessel injuries

18 bowel injuries3 liver lacerations

4 deaths

WORLD LITERATURE2 major vessel injuries

Endometrial AblationGurtcheff SE, Sharp HT, Obstet Gynecol 2003

MAUDE DBComplications: 85

Thermal bowel injury: 8Emergent lap: 12

Death: 1

WORLD LITERATUREHemorrhage: 2

PID: 1Endometritis: 20Vaginal burns: 2

Hierarchy of Study Design

Descriptive Studies

COHORTTROHOC

RCT

Hierarchy of Study Design

Descriptive Studies

COHORTTROHOC

RCT

MAUDE

Case 1:• You get called

to L&D for this

Noted after C-Section - RUQ

2 burns, 17 cm apart

Surgical energy-based device injuries & fatalities reported to

the FDAOverbey et al, J Am Coll Surg 2015

• 3553 Injuries• 178 deaths

Cut vs. Coag• Coagulating current poses a greater potential for

damage because of higher voltage requirements

I worry when….

…And nothing happens

Stray Energy – High Voltage

Insulation Failure

Recommendations

• Use cut mode– (low voltage)

• Use cold scissors• Test monopolar

instruments– (Biomed)

• Avoid inadvertent touching– (situational awareness)

Thromboprophylaxis“Why are we stuck in 1975?”

Clarke-Pearson Obstet Gynecol 2011

“Why are we stuck in 1975?”Clarke-Pearson Obstet Gynecol 2011

• 40% of patients receive no VTE prophylaxis• Assume :

– 3% DVT rate – 0.5% fatal PE (without prophylaxis)

• 292,307 untreated women– 8,769 DVTs– 1,461 Fatal Pes

• Assume: 60% reduction (appropriate prophylaxis)– 5,261 DVTs prevented!– 876 fatal PEs prevented!

Caprini DVT Risk App

Caprini App

VTE RiskGould et al, CHEST 2012

Risk Level % Risk / Bleeding Assessment Caprini Score

1. Very low VTE risk <0.5% 02. Low VTE risk 1.5% 1-23. Moderate VTE risk 3% / Low bleeding risk 3-44. Moderate VTE risk 3% / High bleeding risk 3-45. High VTE risk 6% / Low bleeding risk >56. High VTE risk 6% / High bleeding risk >5IPCs alone until bleeding risk is diminished, then LMWH or LDUFH

Recommendations• Use UF heparin, or LMWH with or without IPCs

• Consider the risk of bleeding with pharmacologic therapy.

• Consider the use of a risk assessment tool.

• Certain risk factors may require combined therapy.

• Consider giving LMWH 12 hours before surgery.

Case 2• Patient weighing 105 undergoes TAH

• Quadriceps are paralyzed

• Knee can not be extended

• Loss of sensation over

– Medial and anterior thigh

– Medial side of lower leg

– Medial side of foot

Femoral Neuropathy

Nerves and vessels of the anterior abdominal wall.(Rahn AJOG 2010)

Trocars and anterior abdominal wall nerves(Rahn Am J Obstet Gynecol 2010)

Nerve Mean distance from ASIS in cm (range)Medial Inferior

Ilioinguinal nerve 2.5 (1.1-5.1) 2.4 (0-5.3)Iliohypogastric nerve 2.5 (0-4.6) 2.0 (0-4.6)

Author’s conclusions: Risk is minimized when the trocar is placed superior to the ASIS.

Incidence: 5% of laparoscopies (Shin, JMIG 2012)

The Pfannenstiel Incision as a Source of Chronic Pain

(Loos et al, Obstet Gynecol, April 2008)

• 866 patients with Pfannenstiel incisions• 2 year follow-up (questionnaire) Level III• 33% experienced CPP at incision (26% ITT)• 7% had moderate to severe pain• Nerve entrapment 53% (17/32 examined)• Avoid lateral extension (rectus sheath) / delay in

treatment

Recommendations

• Position high lithotomy – with no > 90° flexion at hip– 45° abduction

• Use “Allen type” stirrups if anatomy if problematic– Tall / short patients

• Feel for psoas muscles with self retaining retractors– Thin patients at risk

Recommendations

• THUMBS UP to prevent ulnar nerve injury

• Go above the ASIS and 2 cm medial with laparoscopic trocars.

Ureteral InjurySharp HT, Adelman MR - Prevention, recognition, and

management of urologic injuries during gynecologic surgery Obstet Gynecol 2016

• Intraoperative identification is NOT always possible.

• Intraoperative identification is preferable.

• Early recognition decreased subsequent morbidity

Types of Ureteral Injuries

• Devasularization• Kinking• Ligation• Transection• Thermal injury

Ureteral Injury

• Incidence– TAH 0.3%– TVH 0.04%– TLH 0.3%

• VVF / UVF Incidence (if ureteral injury)• 3.4% / 2.4%

Ureteral Injury

• Gynecologic surgery carries inherent risk to ureteral injury (proximity, visualization)

• Risks:– Endometriosis– C-Section– Low-volume surgeons (<10 hyst / yr)– Tobacco use

Avoiding Ureteral Injury• Look for ureters early to get a trajectory• Mobilize the bladder• Skeletonize the uterine arteries• Ureterolysis / ureteral stenting• Myomectomy

Recognition

• Routine cystoscopy for “at risk” procedures

• Sodium fluorescein (25 mg of 10% soln)

• Ureteral stenting

Take Away

• Think prevention– Use more cut mode– Consider Caprini score– Meticulous positioning

• Know risks and anticipate / recognize• Dictate accurately and timely