Major Intraoperative Injuries During Hysterectomy: Prevention, Recognition and Management
2021; Mary Ann Liebert, Inc.; Volume: 37; Issue: 3 Linguagem: Inglês
10.1089/gyn.2021.0055
ISSN1557-7724
Autores Tópico(s)Abdominal Surgery and Complications
ResumoJournal of Gynecologic SurgeryVol. 37, No. 3 Guest Editorial: Special TopicFree AccessMajor Intraoperative Injuries During Hysterectomy: Prevention, Recognition and ManagementNadim Bou ZgheibNadim Bou ZgheibAddress correspondence to: Nadim Bou Zgheib, MD, Gynecologic Oncology Division, Marshall University School of Medicine, Huntington, WV 25701-3655, USA E-mail Address: nadim.bouzgheib@chhi.orghttps://orcid.org/0000-0001-6163-9009Gynecologic Oncology Division, Marshall University School of Medicine, Huntington, West Virginia, USA.Search for more papers by this authorPublished Online:31 May 2021https://doi.org/10.1089/gyn.2021.0055AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Allow me first to thank Dr. Mitchel Hoffman, the editor-in-chief of the Journal of Gynecologic Surgery, for inviting me to guest edit a special section on the topic “Major intraoperative injuries during hysterectomy.” To best shed light on this important topic, I solicited collaboration from highly experienced and exceptional gynecologic and pelvic surgeons. The importance of this topic extends beyond hysterectomy and is applicable in one way or another to most pelvic surgeries.Hysterectomy is the second most common surgery performed by gynecologists in the United States (after a cesarean section).1 The wide variety of indications for a hysterectomy requires gynecologic specialists and subspecialists with different training and levels of expertise. Vascular, gastrointestinal (GI), and genitourinary (GU) complications are some of the surgical problems that may complicate a hysterectomy given the confined anatomical space of the female pelvis. It is imperative for every gynecologic surgeon to identify and understand the different surgical complications that may arise during a hysterectomy as well as the ways to avoid and manage these potential complications.PreventionBarouhas et al. discuss the GI complications associated with hysterectomy and stress the importance of prevention. Avoiding complications or minimizing their occurrence starts in the preoperative setting with a thorough evaluation of the patient.Careful assessment of the patient's condition and consideration of the indication for her hysterectomy, along with a discussion of all possible alternatives, build a robust doctor–patient relationship and confidence on both parts as the surgical plan proceeds.During surgery, prevention starts with having a good surgical team, and the appropriate skill set for the route of hysterectomy chosen. During surgery, the surgeon carefully assesses each surgical step about to be taken.Some considerations for prevention of complications immediately before starting the hysterectomy and during the surgery include the patient's position on the operating room table, the respective height of the table relative to the surgeon, drainage of the bladder, and suctioning of the stomach before making an incision. When using the laparoscopic approach, it is important for the surgeon and the assistant to have their line of vision aligned with the uterus and the video monitor.2Historically, vaginal hysterectomy was the only minimally invasive approach available. As stated by Dr. Barouhas and Dr. Khalife, the vaginal approach is the safest, and yet this route is least commonly used.3 Many of the advantages of vaginal hysterectomy may be unrealized given that many gynecologic surgeons lack this skill set. Hence, surgeons should base their choice of the route of hysterectomy, whether minimally invasive or vaginal hysterectomy, on clinical factors and the surgeon's expertise.IdentificationRecognizing a surgical complication is sometimes difficult and requires vigilance and attention to detail. Although vascular surgical injuries are hard to miss, thermal or indirect mechanical GI or GU injuries may be difficult to identify. When confronted with a challenging hysterectomy where the abdomen and pelvis have lost the anatomical planes, the risk of GI or GU injury increases. When the surgeon suspects an injury, this must be followed by a very methodical and meticulous search to determine the presence and extent of injury. Dr. Khalife discusses routine cystoscopy performed after a hysterectomy and concludes that the value of such a diagnostic procedure is highest with low-volume surgeons. Cystoscopy allows for identification of a mechanical injury but lacks the evidence to support its value in identifying thermal injury. Running the bowel is sometimes difficult to accomplish laparoscopically but is important when bowel injury is suspected. When a bowel injury is identified, expertise is needed to determine the extent of the injury (serosal, seromuscular, or full thickness), and the necessary surgical repair. When an injury is identified during hysterectomy, the gynecologic surgeon must determine whether intraoperative consultation is warranted and completely brief the consultant on the findings and possible mechanisms of injury.ManagementOnce identified, management of a surgical complication should follow an organized plan directed by the surgeon. This begins with verbal communication with the operating room team. As discussed in Dr. Hoffman's article, vascular injury should activate an emergent sequence of steps to avoid a catastrophe. These steps should be rehearsed in a low-stress environment (dry rehearsal in the operating room, porcine laboratory) on a regular basis as such vascular complications are rare but potentially fatal.4 In their articles, Dr. Hoffman and Dr. Khalife cite the value of surgical volume, which is a surrogate measure for the surgeon's experience.5 For low-volume surgeons, having a mentor if available is arguably the most important resource when complications are encountered.After initial control of a vascular injury and identification of a GI or GU injury, the surgeon's expertise should dictate the need for intraoperative consultation. The surgeon must answer the question of how the complication should be best managed. For example, in the case of a GI or GU injury during a laparoscopic or robotic hysterectomy, a surgeon might have the expertise to repair such a complication by converting to a laparotomy but might have a surgeon in the same hospital who is able to appropriately manage this complication without conversion.“First do no harm” is the motto that surgeons abide by, but unfortunately complications can happen. It is imperative for gynecologic surgeons to acquire the skills not only to avoid complications but also to identify and manage them. Mentorship is the key for junior and low-volume surgeons to enhance their skill sets as they gain experience.Finally, I hope this issue's special topic section helps gynecologic surgeons to reflect on their own limitations, continue their journey with life-long learning, including attending surgical focused courses, develop or get involved in surgical protocols to mitigate complications, and finally know the resources available to them at their institutions.References1. Hodges KR, Davis BR, Swaim LS. Prevention and management of hysterectomy complications. Clin Obstet Gynecol 2014;57:43–57. Crossref, Medline, Google Scholar2. Han ES, Advincula AP. Safety in minimally invasive surgery. Obstet Gynecol Clin North Am 2019;46:389–398. Crossref, Medline, Google Scholar3. Sandberg EM, Twijnstra ARH, Driessen SRC, Jansen FW. Total laparoscopic hysterectomy versus vaginal hysterectomy: A systematic review and meta-analysis. J Minim Invasive Gynecol 2017;24:206.e22–217.e22. Crossref, Medline, Google Scholar4. Asfour V, Smythe E, Attia R. Vascular injury at laparoscopy: A guide to management. J Obstet Gynaecol 2018;38:598–606. Crossref, Medline, Google Scholar5. Bretschneider CE, Frazzini Padilla P, Das D, Jelovsek JE, Unger CA. The impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for the large uterus. Am J Obstet Gynecol 2018;219:490.e1–490.e8. Crossref, Medline, Google ScholarFiguresReferencesRelatedDetails Volume 37Issue 3Jun 2021 InformationCopyright 2021, Mary Ann Liebert, Inc., publishersTo cite this article:Nadim Bou Zgheib.Major Intraoperative Injuries During Hysterectomy: Prevention, Recognition and Management.Journal of Gynecologic Surgery.Jun 2021.188-189.http://doi.org/10.1089/gyn.2021.0055Published in Volume: 37 Issue 3: May 31, 2021Online Ahead of Print:May 13, 2021PDF download
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