Objectives. GI surgery for the Gynecologist

Transcription

1 GI surgery for the Gynecologist Samar Nahas, MD, MPH, FRCSC, FMIGS Division director. Gynecologic Oncology, MIS. Assistant professor UCR Objectives Show dissection of the left sidewall natural adhesion Review incidental appendectomy, lysis of adhesion Show oversaw of bowel, repair of colotomy Review Same day discharge: what is required?

2 Lysis of adhesion When and why? Do we need to do it? In our way of performing the assigned surgery Patient with chronic pelvic and abdominal pain S. Review for large number of articles including 3 RCT Potentially effective Gerner- Rasmussen J. The efficacy of adhesiolysis on chronic abdominal pain: a systematic review. Langenbecks Arch Surg ;400(5): Lysis of adhesion Do it safe Sharp dissection Small bites, mm X mm technique Gentle handling of the tissue A- traumatic instruments

3 Natural left pelvic side wall adhesion In our way

4 In our way/ Pelvic Pain

5 GI injury GI injury basically a hole that needs to be closed Know there is a hole Where the hole is Close it, easy!!

6 GI injury diagnosis Intra operative is a KEY Post operative Significant morbidity and mortality from Strategies for prevention and intra- operative diagnosis Anatomy!! Safe entry will drop the risk by > 50% Sharp dissection with dense adhesion using mm by mm technique, gentle handling of the bowel Delineate the rectum using rectal probe Check: Bubble test, run the bowl

7 Strategies for prevention and intra- operative diagnosis Small bowel: Run the bowel/inspection Large bowel: Inspect/ delineate Bubble test MB/Iodine test Prevention: Avoid blunt dissection, awareness

8 Bowel Laceration Repair Less than ½ the circumference Repair in 2 layer closure with imbricating layer perpendicular to the direction of the bowel, regardless of orientation of the laceration, Consider using delayed absorbable monofilament, delayed absorbable braided suture, barbed suture* Greater than ½ the circumference General surgery consultation for resection/re- anastomosis Never bad to call for help *Chamsy D, Lee T. The use of barbed suture for bladder and bowel repair. JMIG. 2015;22(4): Bowel Thermal Injury: Burns Mark the AREA immediately!! General surgery consultation Never bad to call for help

9 Suturing perpendicular to the axis of the bowel Intra- operative diagnosis Antibiotics, Flagyl with full thickness inj Rarely will need an ostomy or drain Patients do well

10 Bubble test, Dye test

11 GI surgery in gynecologic oncology Ileostomy/colostomy for advance cancer or fistula 1 Safe, effective, improved patient s outcome. 2 S.S shorter OR time, LOS, less complication LAR 1 Young MT. Laparoscopic Versus Open Loop Ileostomy Reversal: Is there an Advantage to a Minimally Invasive Approach? World J Surg ;39(11): A. Rather, Cleveland clinic FL, SS02 colorectal session SAGES.

12 Why include appendectomy? If treating pelvic pain and see endometriosis: improves dysmenorrhea, non- menstrual pelvic pain, dyspareunia, dyschezia, quality of life. Roman JD. JMIG % appy pathology: endometriosis 13%, peri- appendicitis/serositis in 16%, carcinoid tumour 3%. Wie, Aust N Z J Ob Gyn 2008 Why include appendectomy? If treating pelvic pain, and see no endometriosis: appendectomy reduces post-op pain. Pandza H, Med Arh 2008 When appendix appears normal, pathology in 9%, including 3 carcinoids. O'Hanlan Jsls 2007.

13 Appendectomy " 1959: Incidental in C Sections. " 1962: Incidental in ectopic pregnancies. " 1967: Incidental in abdominal, vaginal hysterectomies. " 1968: Essential for ovary cancer staging. " 1973: Incidental in post- partum sterilizations. " 1977: Suggested prophylaxis in Gyn/OB procedures. Waters O&G an elective appendectomy should be performed with abdominal and pelvic surgery whenever the opportunity is presented " " 1970: Laparoscopic assisted therapeutic appy. " 1990: Total laparoscopic therapeutic appy. Gotz, Surg Endosc " 1991: Laparoscopic incidental appy series of 100 cases. Nezhat, AJOG. any risk associated with elective appendectomy as reported here is minimal and outweighed by the benefits of eliminating future emergency appendectomy, simplifying future differential diagnosis of pelvic pain and removing unsuspected abnormality found in the appendix.

14 O Hanlan & O Holleran, JSLS, 2007

15 821 TLH stratified by incidental appendectomy No increased complications. In cases with appendectomy, similar OT, EBL, LOS. Path: 5%. Includes 1% (3) carcinoids. (2 required ileoascending resection for nodes) Conclude: Safe - do it! O Hanlan et al, JMIG, 2007 Incidental appendectomy O Hanlan 2016; 1105 TLH with app compared to 821 TLH. 10% pathology in normal looking appendix No increase in complication

16 Laparoscopic Appendectomy Lift appendix, identify base and window. Incise through meso- appendix, with 1 cm mesentery, to window. Ligate base with Endoloop. Incise at 5mm, and deliver using a no- touch technique, using ring forcep on open appy tip through vagina, or trochar, or pouch. If see enteric material, suction first, then irrigate.

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21 drawn Starve Same day discharge SDD Reduce risk of hospital acquired infection Patient will have at least 1:1 care compare to hospital 1:4-1:5 nurse to patient care. Patient in her own bed, bathroom, comfort.

22 SDD Vaginal hysterectomy Started as few pilot studies in the late 1980 s Many small studies for vaginal hysterectomy showed that its safe and feasible The important key is proper counseling, good selection criteria, patient agreement, communication Moore J. RN, 1986 Powers TW et al, Am j obstet gyn 1993 Stovall TG et al, 1992 Bran. Spellman, Aorn journal 1995 SDD Laparoscopic hysterectomy Large retrospective observational study (ACS- NSQIP) > 250 US hospital, 8846 lapx hysterectomy 3564 SDD (40%), trend overtime toward SDD. Lower over all morbidity, complication, DVT ACS- NSQIP: American college of surgeons national surgical quality improvement program Khavanin N et al, JMIG 2013

23 SDD Laparoscopic hysterectomy Khavanin N et al, JMIG 2013 SDD Laparoscopic hysterectomy Similar trend and safety was concluded by a large data review 128,634 lapx hyst cases SDD increased from 11.3% in 2000 to 46% in Schiavone MB et al, AJOG, 2012

24 SDD Laparoscopic hysterectomy Schiavone MB et al, AJOG, 2012 SDD Laparoscopic hysterectomy + Staging for gynecological malignancies Gien, 303 mixed malignancy cases, SDD 48.5%, 4.8 % readmission 6.9% convert to laparotomy 5 more retrospective studies with similar results Gien LT et al, gyn onc 2011

25 Successful SDD Surgeons agreeing to try it!! Discussion with chairman, Anasthesia, and PACU nurses. Pre- op patient selection and counseling. Handout and FU. Discuss expectation and pain control (prescription prior to surgery) Successful SDD Proper counseling Patient selection: Age <75 Within an hour from the hospital, Transportation Support at home at least first 24 h Agreeing for SSD Start with healthier and younger patient, then expand the selection criteria to your comfort level.

26 Successful SDD PACU discharge criteria: Fully awake, ambulating Tolerating CF Void before discharge Good pain control, limited nausea if any. Stable VS, and good O2 saturation

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29 Summary Lysis of adhesion only if in your way or the only finding with chronic pelvic pain GI injury IO recognition is the key Elective appendectomy in gyn surgery SDD is safe and effective, and cost effective.