SESSION II: Treatment considerations
Melanie Marin, MD - Preventing Complications
Advancing the Science and Surgery of Endometriosis
Monday and Tuesday, April 18-19, 2016
The Union Club, New York
Good morning and thank you for having me. I spoke last year and I am pleased to be invited back again this year and to see some old friends and old faces.
I was asked to talk about preventing complications during surgery for endometriosis. When I first got the topic my eyes glazed over a little bit as I thought about the innumerable lectures over the past few years with the Swiss cheese model of medical and surgical complications and then I thought a little bit more about what I think is important to remember and review in terms of preventing complications during laparoscopic surgery.
This is the unit insignia from the 18th Field Artillery Brigade of America “Sweat Saves Blood”. This is probably true in most activities of life but especially true with high risk activities like surgery. Sweat saves blood; preparation, planning and practice save blood.
How do we prevent complications during laparoscopic surgery? Especially with surgery like laparoscopy that requires a high level of skill and practice – preparation, planning and practice. We talked a little bit yesterday about training our surgeons. This is no longer a simple mentor/student relationship like surgical training had been since the inception of surgery until very recently in time.
The learning curve for advanced laparoscopic surgical skills is long and steep, and especially for robotic surgery now too. As we discussed yesterday there are many surgeons performing sub-optimal surgery for endometriosis because they have not climbed the steep slope. Things are changing. When I started residency and finished residency there were no fellowships for minimally invasive surgery. Residency training is now monitored and studied differently. Surgical simulators, and these are just some examples, I am not trying to promote any particular simulators, surgical simulators are becoming the norm and rightly so. Studies show that medical students, residents and even experienced surgeons do better and make fewer mistakes when warmed up and practiced. Prior to simulators we older surgeons knew that we would visualize, mentally practice our difficult surgeries in order to be ready. Studies in musicians and athletes who are also performing highly technical skills demonstrate that pre-performance mental practice improves actual performance. Now we have the surgical simulators to allow surgeons to practice in advance if they want to, to allow us to train our residents and our fellows to decrease their surgical time and decrease surgical errors once they do start operating.
The relatively new fellowships in minimally invasive surgery further standardized training for these difficult skills. I think that is an important thing to remember and something I tell my residents all the time is standardization reduces complications, reproducible training, reproducible techniques, surgical moves that are taught, learned and performed in the same way time and time again reduces the possibility of errors.
Systems reduce errors. We learned this from the field of aviation and have begun applying it to surgery over the past decade or so. The Joint Commission set core measures for surgical care improvement over a decade ago. These measures covered steps for preventing infection including standardization of pre-operative antibiotics, proper hair removal, maintenance of normal thermia during surgery. Each of these measures decreases the likelihood that the patient will experience a post-operative complication of infection.
Standardized operating room protocols reduce surgical complications. We have the standard ones that the OR requires now, check lists, correct patient, correct surgery. Are there any anticipated problems, are they any anticipated needs for blood, special supplies or special instruments? All of these checklists can avert complications by turning potential emergencies into planned for contingencies. Again, systems reduce errors. Systematic patient positioning and operating room preparation helps to prevent errors. I try to tell my residents that as well, always put the Foley in the same place, always prep the same way, always put your instruments on the same side and always have your nurse and your technician be in the same place. These things reduce the possibility of chaos when emergencies do occur.
Systematic patient positioning has been the standard since I started laparoscopy to help prevent nerve injuries. We have used bean bags, foam padding and shoulder braces to support our patients when they are in steep Trendelenburg, all to keep the patient stable without compressing any pressure points and causing neuropathies. Again, at the risk of sounding like a salesperson, at Mt. Sinai we eliminated using shoulder braces because even with the shoulder braces, especially in heavy patients in steep Trendelenburg you can get some brachial plexus injuries and shoulder injuries. We started using the Pigazzi Pink Pad with a chest strap and it is easy and quick. The patient sinks into the foam and no longer slides up the table. We can do steep lithotomy. There is no shoulder damage at all and she does not move so we are not stuck where we cannot get to manipulating the vaginal instruments.
Good surgical technique and an awareness of the potential damage each technique can cause allows us to mitigate the risk of surgery and decrease possible complications. We already know, we all know, in this room that the laparoscopic approach allows for magnification to better see what we are doing, to cause less tissue damage, fewer adhesions post-operatively, to do the extremely difficult and meticulous dissections that are needed to completely excise endometriosis. We also know that the most dangerous portion of laparoscopy is the initial trocar insertion. There have been many reviews in examining insertions: should you insufflate and then insert the trocar, should you do a direct trocar insertion, should you do an open laparoscopy?
The most important thing to take away from this is, again, systems reduce errors. Each one of these is a safe and valid way of entry and the best way to avoid injury is for the surgeon to use the entry that he or she feels most comfortable with and to use it routinely unless there are specific contraindications in a particular patient.
Studies have noted that there is up to ten-fold reduction in the complication rate when a consistent operating format is used. This is the most important thing that we can take away from this and that we can teach our residents and fellows, do it systematically, the same way every time. It is not important what instrument you use, it is not important which method you prefer, what is important is that each surgeon chooses a method or set of instruments that is comfortable for him or her, use the same instruments and follow the same steps every time you operate. Consistency alone will decrease your complication rate.
Once in the abdominal cavity meticulous surgical technique decreases complications. When I trained, again, there were no fellowships in minimally invasive surgery. I was privileged to finish my residency and apprentice with one of the greatest laparoscopic surgeons in my opinion, Dr. Harry Reich. Like Dr. Seckin mentioned yesterday, Dr. Reich taught me to use cold scissors to cut tissue, to avoid heat, not to spread or cook the tissue as Dr. Seckin was saying yesterday but to cut precisely. If heat is used a high voltage cutting current to avoid damaging the surrounding tissue, we used microbipolar cautery under lactated ringers so always underwater to avoid tissue spread and to be able to see what we were doing more clearly. Precise moves, minimal tissue handling and complete excision of all inflammatory endometriosis decreased post-operative inflammation and post-operative pain.
That brings me to the point about laparoscopy. One of the down sides as Dr. Seckin mentioned today is the drying of the carbon dioxide gas used to distend the abdomen. The dry gas creates peritoneal stress and releases inflammatory mediators like C reactive protein, interleukin 6 and other lymphokines and cytokines. All that inflammatory damage can increase post-operative pain and increase the likelihood of post-operative adhesions, especially in our endometriosis patients whose peritoneum is already damaged with extensive inflammation it is important to minimize further damage from surgery. Keeping the abdominal cavity warm and humidified can help. Copious amounts of warmed irrigation fluid can relieve some of this chemical stress and Dr. Reich taught me this 20 years ago. We always operated with copious amounts of warmed fluid. We were always looking under water and we always left warmed fluid in the abdomen when we finished to reduce the damage of the residual carbon dioxide gas, to reduce the peritoneal irritation and inflammation that result in in referred shoulder pain.
This kind of meticulous attention to surgical detail and to eliminating possible sources of peritoneal irritation and inflammation decreases the likelihood of post-operative complications caused by post-operative pain. Uncontrolled post-operative pain can cause urinary retention and the need for prolonged or repeated catheterization. Patients in pain do not walk as soon as they might unless they are at higher risk for venous embolism. Patients in pain splint when they are breathing, they do not stand up straight when they are walking around and so they are at higher risk for pulmonary complications. Controlling post-operative pain by minimizing tissue damage at surgery is key to avoiding many of these complications.
Especially for our endometriosis patients, post-operative pain relief starts prior to surgery. Our patients are often anxious, they have been in pain a long time, they are often on narcotics and pain medications already so they are going to be less responsive to the narcotics we give them afterwards. Start pre-operatively. Use anxiolytics if needed. Start with pre-operative IV Tylenol. Give oral gabapentin the day before surgery. Start with scopolamine patches if your patient has a tendency for nausea or vomiting. Intravenous ketorolac prior to waking the patient decreases both the inflammation and pain. All of these medications help control post-operative pain and decrease the likelihood of post-operative complications.
And of course our patients with chronic pelvic pain who have been using narcotics regularly might need an increased dosing of narcotics in the immediate post-operative period. If you have an experienced anesthesiologist they know this but sometimes we do not so sometimes we need to direct the amounts of narcotics that are being given.
My favorite diagram, for women with endometriosis and chronic pelvic pain the most devastating complication is persistent, progressive disease due to failure to diagnose. We have heard the numbers but I think it is worth repeating. Seventy percent of women with chronic pelvic pain have endometriosis. Still, most of them suffer for seven years or longer before they are diagnosed and treated. Chronic pain creates long term maladaptive changes in the central nervous system, in the peripheral nervous system and in the muscular system that are difficult to treat and reverse, even when the initial insult the endometriosis has been completely excised.
In my opinion this failure to diagnose is the most devastating complication of all. Pondering the possibility of endometriosis is the first step to avoiding the terrible complications resulting from years of chronic pain. Perhaps an important point here; if you are a surgeon and you operate you will have complications so make sure you are looking while you are operating. A complication that is recognized and repaired during surgery really ends up not being a complication. If you look at what you are doing and of you are not sure, investigate again. Find the complication and repair it during surgery. Your patients will thank you.
Of course the best way to avoid complications is if your patient does not need surgery do not operate on her. Not everyone with pelvic pain needs surgery for endometriosis. Surgery is inherently a risky business. Even in the best of hands complications can occur. A good pre-operative evaluation is imperative. I do not agree with some of my colleagues that a good pelvic exam and rectal exam are unnecessary. I am solidly with Dr. Reich on this. I think a good rectal exam in a patient with chronic pain is the best way to evaluate pelvic endometriosis and decide if surgery is needed. Even in women with mild disease they feel it when you touch it and they feel it when you are done touching it. The patient who is sitting on the table afterwards going like this she has endometriosis I think almost 100 percent of the time. I ask them if they are still feeling the reverberations of my exam when they are sitting up. If they are, they are going to the operating room.
On the other hand there are plenty of patients with endometriosis who have pelvic pain not caused by their endometriosis. I had a 40-year-old patient with two children who came to me after she had surgery elsewhere. She initially presented with left-sided pelvic pain, dysmenorrhea and dyspareunia. She had surgery in 2011 and came to me for continued treatment of her endometriosis afterwards. She had been on the continuous pill since then with no pain, no dyspareunia, no periods, no nothing. A year ago she came in complaining that her endometriosis was back. Her left ovary and back hurt, the pain went down her left leg and it felt like something was attacking her rectum. She reported that it felt just like her endometriosis pain before she had surgery in 2011. Now I listened to that carefully. If a patient tells me her endometriosis pain is back she is usually right. She wanted a laparoscopic hysterectomy and a left salpingo-oophorectomy but when I talked to her a little further she still was not having any periods. She was still having regular sex with her husband and was not having any pain. I did a rectovaginal exam. She had a small, smooth uterus, no tenderness, no nodularity, no tenderness in the cul-de-sac and the uterosacral ligaments were smooth and non-tender. I did not think she had endometriosis back. We sent her for an MRI of her back and she had severe spinal stenosis with nerve compression. When I questioned her further she had numbness and tingling down her left leg. She went to the neurologist and the orthopedic surgeon and had surgery on her back followed by physical therapy with no pain. She still has no periods, no dyspareunia and now no pain after the spinal stenosis surgery.
I love to do surgery. I like to do it on the right people and laparoscopic surgery on this patient could have caused severe complications. Modified dorsal lithotomy is not a good position for spinal stenosis and for lumbar disc injury. And that I figured out just from her rectal exam combined with her story.
While we do not want to hesitate to perform diagnostic and therapeutic surgery for a patient who warrants it we want to be very careful and not operate on the wrong patient.
To prevent complications make sure you are well trained and experienced in the surgery you intend to do. Listen to your patient. Do a systematic evaluation of her symptoms and exam. Make sure she needs the surgery. Plan the surgery in your mind. Adhere to the standardized operating room protocols. Adhere to meticulous surgical technique. Use appropriate pre-op and post-op medications to minimize inflammation and pain. Save your patient from the devastating complications of chronic pain by early diagnosis and treatment.
I just want to comment that the Society of Laparoendoscopic Surgeons has an open access internet textbook that is actually very interesting, “Prevention and Management of Laparoendoscopic Complications—Third Edition”. You can also buy an interactive one for your iPad if you want to.
So first, do no harm. Second, sweat saves blood. And third, early diagnosis of endometriosis saves blood, sweat and tears. Thank you.