Episode 9.13 The Surgical Maze: Trocars, Cuff Closure, Visceral Slide, and More
Surgical techniques in gynecology vary widely between surgeons, creating both excitement and frustration for residents trying to learn the “right way” to perform procedures. Howard and guest host Maddie White discuss this and more:
• Trocar placement during laparoscopy requires careful consideration of patient factors and potential adhesions
• Elevating the abdomen during trocar placement remains standard practice, though definitive evidence on its necessity would require studies of over 100,000 patients
• Surgeons should understand power analysis to recognize when studies are underpowered to detect meaningful differences in rare complications
• Visceral slide technique using ultrasound can identify adhesions and determine the safest entry point for laparoscopic surgery
• Palmer’s point may no longer be the safest entry point for many patients given the prevalence of bariatric surgeries
• Jain’s point (lateral to the umbilicus) may now be statistically safer for many patients with complex surgical histories
• Vaginal cuff dehiscence rates are 6-10 times higher with laparoscopic/robotic hysterectomy compared to vaginal approaches
• The higher dehiscence rate stems from using energy devices for colpotomy rather than cold scalpel techniques
• Barbed sutures simplify cuff closure but don’t reduce dehiscence rates compared to standard suturing techniques
• Surgery consists of “a thousand little things done well” – mastering these micro-skills distinguishes excellent surgeons
00:00:00 Surgical Techniques: Excited and Frustrated
00:08:00 Elevation During Trocar Placement
00:17:00 Evidence and Power Analysis
00:21:35 Visceral Slide Technique
00:35:10 Alternative Trocar Entry Points
00:40:10 Cuff Closure and Dehiscence Risk
00:51:45 Laparoscopic vs Vaginal Colpotomies
01:03:00 First Accredited OB-GYN Residency Program
Links Discussed
Is it necessary to lift the abdominal wall when preparing a pneumoperitoneum? A randomized study
Comparison of different suture techniques for laparoscopic vaginal cuff closure
Transcript
Announcer: 0:01
Welcome to Thinking About OB-GYN. Today’s episode features Howard Harrell and Maddie White discussing trocar placement, cuff closure and more.
Maddie: 0:15
Howard.
Howard: 0:16
Maddie.
Maddie: 0:18
What are we thinking about on today’s episode?
Howard: 0:21
Well, we’re going to talk about some surgical techniques, some options, some complications, some stuff like that. So, if our listeners will remember, maddie’s, our resident ninja, or maybe ninja resident, I’m not sure, but one of those things. But we like to talk about things that residents get maybe excited about and excited to learn but also frustrated at the same time, and excited to learn but also frustrated at the same time. And one of those things is all of the variety of different approaches and little different nuanced things that people do with some of our surgical procedures.
Maddie: 0:52
Yeah, I think that’s a very good way to describe it excited and frustrated at the same time. Everybody seems to do every procedure in a slightly different way, and I think, as a learner, we’d like to kind of standardize everything so that we can learn the right way to do something. But in reality we see it done lots of different ways with lots of variety. It gets very frustrating. Sometimes we don’t know necessarily which way is right or wrong, or if it makes a difference on how you do something, or when some approaches should be preferred over others, and we also feel that we don’t have enough time to do the research or the reading to figure those things out.
Howard: 1:26
Yeah, exactly, also the right way right. There may not be a right way for everything and I guess that’s some of the nuance we’ll talk about or a right way for every patient every time. I think, though, the nature of resident education is that, ultimately well, you do what you’re told to do, and you end up just memorizing what each attending likes, but I think that’s a good thing too, because you learn a variety and a repertoire that can come in handy with different scenarios and in different patient populations. Again, some of the variety is appropriate in some patient populations, maybe not in every one, and the more you see, the more experience you have with. That, I think, is a good thing.
Howard: 2:06
Now, I think, when we discuss some of the things today that you know, you’re going to hear my right way, correct way of doing something, and I’ll give you my reasons for it. And I try to be evidence-based and thoughtful. But the truth is, for many of these surgical sort of questions, there just aren’t adequate randomized controlled trials to tell us what the right way is or the correct way to do this. It’s certainly applicable for multiple surgeons and multiple patient types.
Maddie: 2:33
Yeah, and I think there’s so much variation in techniques and skills as well. I think it’s become very evident that a good surgeon can sometimes use inferior techniques and still have great outcomes, and so even when you see clinical trials or surgical techniques, the best variable is just going to be the skill of the surgeon. And then there’s so much variation in the pathology and the anatomy of individual patients that it becomes really hard to conduct a randomized control trial to find out which way is better, because you’ve got all these different kinds of people in your study.
Howard: 3:04
Yeah, and just emphasize that again, the most important variable in any surgical study is the surgeon, and I think people really don’t appreciate how true that is.
Howard: 3:14
Ultimately, people are good at what they’re good at, though, even barring for surgical talent. So it could be that I may do something, and maybe it’s not the very most evidence-based way of doing it, but I’ve done it a thousand times and so I’m very good at that thing, and I would actually have worse outcomes if I switched to some new technique that I wasn’t comfortable with and hadn’t done a thousand times. That you demonstrated to me was better in some trial. So that makes the science behind surgical techniques very difficult. So that makes the science behind surgical techniques very difficult. Now, before you start asking me questions, let me give you two pieces of just surgical philosophy. The first one is that if you see two or more surgeons do a procedure in very different ways, but they both have reasonably good outcomes, similar outcomes it’s likely that the way they do it doesn’t matter, and you may not be able to prove ever that one way is necessarily better than another although one might have an advantage in a large enough sample size.
Howard: 4:11
So you do get into this rarefied thing of a complication that happens once every five or 10,000 cases. How do you see the difference? And is that noise or data in a trial? Now we shouldn’t ignore those rare outcomes that might occur like that. So if we can show that one technique is associated with a bad outcome but yes, it’s only every, say, thousand cases well, that probably is never noticeable, doesn’t mean anything for some individual surgeon’s career. It’s probably imperceptible to them.
Howard: 4:40
But that’s where scientific evidence comes in. But when you see dogmatic personalities argue that their way is the best way, maybe because they’ve never had a negative outcome, and then the next person argues that the exact opposite technique is the best way, the truth is probably both are wrong and neither technique’s really important, at least not in that dogmatic way. Now the second philosophy point is that surgery is a thousand little things done. Well, I personally believe that a surgeon should spend a lot of time breaking down every little step of a surgical procedure and thinking about how to improve it or if it’s being done optimally. Is there a better way, a more efficient way, a better tool?
Howard: 5:22
you know what different needle for the suture, like all the smallest details and to me that’s the difference between a great surgeon and an average surgeon or good surgeon and a bad surgeon is the attention to detail, even the smallest little details. I think residents get frustrated sometimes by what feels like micromanaging those very small details. Sometimes that seems like nitpicking, the annoying little. You’re just trying to get the big broad brush strokes right and somebody’s worried about some fine strokes. That can be frustrating and a surgeon can annoy a resident. They can have good intentions and good reasons. They can be right about this fine brush stroke, this little detail that they would like to see you do better.
Howard: 6:06
But at the same time the devil’s in the details and I would encourage people to break down every procedure in that way and as many micro steps as possible, not be frustrated by that sort of that just part of the learning curve where you’re overwhelmed by all of these details, but pay attention to them and try to make sure that you’re developing all these little micro steps and micro skills as optimally as you can. The good news is most of these things cross over to multiple surgical procedures. So once you’ve mastered these things, then everything gets better. All of your surgery gets better, but we can talk about that in detail sometime, some other time. But take something that you think has 10 steps and break it down into a hundred and then break it down into 200 and learn what all those steps are.
Maddie: 6:52
Yes, I agree, definitely feels like micromanaging sometimes. But I also can understand that when you’re in the OR you have to learn things at the smallest level and all the smallest details to just understand even the most basic things. And so, especially things like entering, which we’ll talk about later I think I would rather someone give me every small micromanaging tip, because it’s the scariest part of the case sometimes. But anyways, back in episode 7.5, you and Antonia talked about the history of laparoscopy and mostly about the initial laparoscopic port placement. So I don’t think we need to go over all of those details again.
Maddie: 7:28
But the summary is that for most patients an optical trocar entry close to the base of the umbilicus is probably the best initial way of entering the abdomen as opposed to a cut-down method like the Hassan technique or the varus needle. And you all talked about the complication rates of the various methods and the history of how that developed. So we don’t need to talk about all that again. But I do have just a couple of questions about that initial laparoscopic trocar placement. My first question is does it really matter if you elevate the abdomen as you’re placing the trocar?
Howard: 7:59
Yeah. So this is a great question. This is one of those details that may be trivial, may be super important, and I think it shows you’re really breaking this down into all those little steps. And I think it also illustrates the difficulty in our surgical literature, because once you get into this level of detail in each of these little steps, the next thing is you’re going to be frustrated perhaps by the trials that are available, the data that’s available, the heterogeneity of that data and the lack of appropriate trials to give really great answers.
Howard: 8:32
So now this idea, of course, of elevating the abdomen. One of the problems is that elevation of the abdominal wall with the umbilical trochlea placement has just been taken for granted, so that it’s usually going to be bundled. When you look in clinical trials into a study that looks at the various methods of inserting a trocar, it’s just going to. That’s just part of doing it right, so it’s going to just be there. It’s almost always done. So if I’m going to claim that direct optical entry into the umbilicus with a trocar, an optical trocar is safe in some respect, some aspect that’s the way I’m advocating it should be done, compared to other methods of entry, like you mentioned, the Hassan or Veris or something like that, then I need to insert that trocar in the way that it’s been inserted in all of the trials, or almost all of the trials that’s looked at that technique that I’m basing that opinion on the data that you mentioned back in that episode about complication rates. Well, the studies that come from that everybody who was inserting those trocars was elevating the abdominal wall. So if I’m going to take credit for that data or claim that data as part of that technique, I have to do it the way they did it, right.
Howard: 9:41
If I change the technique in some meaningful way, like not elevating the abdominal wall, for example, then I need an adequately powered study to show that that doesn’t change the rates of visceral or vascular injury that I’m worried about, that I’m claiming benefit from, or that it doesn’t change the rate of successful entry, for example, which is a very important metric. So it certainly could be the case that a large randomized trial might find that elevation of the abdominal wall makes no difference. But to answer that question I would need a large, a very large randomized, controlled trial of direct entry with and without elevation of the abdominal wall, or that was the only variable, that was the only thing that was different, and that trial would have to be sufficiently powered to find a statistically significant difference in relatively rare complications like bowel perforation. Bowel perforations occur at a rate of about one per 2,000 laparoscopies with direct optical entry technique, and that number comes from studies where elevation of the abdominal wall was almost certainly used routinely. So now if you want to see that not elevating the abdominal wall makes you know no difference or something, then you have to ask the question of how many patients would have to be in a randomized trial to answer that question. And if you do some back of the envelope power analysis calculations, you’ll find that you need at least 100,000 patients enrolled in a randomized controlled trial to answer the question of whether elevation makes a difference or not.
Howard: 11:10
So this is going to be one of those questions that we just don’t have a good evidence-based answer for, and you’re reliant on the large data sets, which are almost all retrospective, which already exist and which will come out in the future, but they’ll be almost always retrospective, with a lot of heterogeneous complications. But you have to rely on those large data sets that incorporate the technique of abdominal wall elevation into them. You can’t tease that part out and just assume it makes no difference. So my expert opinion would be that if you want to stop elevating the abdominal wall, you should probably prove it first with some large data set that it doesn’t matter, and maybe that over time will come about in a retrospective data set or something like that.
Howard: 11:52
Now, what happens in real life is that some small paper gets published, some small data set, and somebody has published their series of a few hundred or something like that entries without elevating the abdominal wall, and they didn’t have a bowel injury or they didn’t have a vascular injury, and so then it’s claimed that it makes no difference in the rate of injury. And that’s why you have to think about the power analysis and how many patients you need to have enrolled in your study to actually find a difference, if there was one. This is a mental model that people need to build out, because you see this all the time, where some study says that X makes a difference or something like that, and the very first thing that you should think about is this study sufficiently powered to answer the question being asked? I don’t care if they found a difference or didn’t find a difference. You’ve got to reconcile that, and so this will help protect you against underpowered studies, if you think in these terms.
Maddie: 12:44
And what did those small studies show? And does it matter if it’s in the umbilicus versus Palmer’s point, for example? And before you answer that, I’ll just remind us all that a power analysis would be based upon the baseline event rate. So in this it would be the baseline risk of bowel injury, which you said was one in 2000,. And then some assumed event rate for the new technique. So based upon some preliminary study, you might assume that your technique was 50% better, let’s say, or you might also assume that a minimum difference of 10% would be clinically important. Either way, you need to know what the new event rate that would be important is and then you can conduct a power analysis to determine how many patients you would need to enroll to answer the question.
Howard: 13:26
Yeah, if you wanted to find a difference, you could also do a non-inferiority study. So if you just want to show that it doesn’t make a difference whether you do it or not, that it leads to the same outcomes, then the assumptions are a little bit different for a non-inferiority study and sometimes it’s pragmatically easier to do a non-inferiority study. The back of the envelope math for that would still be about 32,000 patients per group, so still about 64,000 patients total enrolled just for a non-inferiority study. So still a huge study, even to show that there’s not a difference in the two techniques.
Howard: 14:01
And one of the things about that that you have to think about is what is the negative of elevating the abdominal wall? Do we really need to commit massive amounts of energy to do a study with 64,000 patients in it to show that I don’t need to elevate it? So usually a study like that’s only going to be done. I get the intellectual question of does it matter? But don’t do things without evidence. But no one’s going to commit the financial resources to proving that it doesn’t need to be done, just for that pragmatic reason.
Maddie: 14:32
Yeah, so I guess what we’re saying is there’s probably not any studies.
Howard: 14:36
Yeah, none that should add anything to this conversation. There was a trial that we’ll put a link to it, that that randomized 150 patients, 150 patients to various needle insertion, with and without abdominal wall lifting, and they found that lifting required in their study, more attempts at intraperitoneal placement of the needle than not lifting, which honestly makes some sense. You’re potentially bundling the tissue up and making it longer, but they didn’t have any injuries in either group. But again, we just learned that you would need close to 100,000 patients to see a difference in visceral or vascular injury and the findings of decreased rates of intraperitoneal placement with lifting doesn’t apply to the optical entry technique that we’re discussing anyway and, frankly, may be a false positive finding in such a small study in that case too, or something. That’s just technique different for the individual surgeons.
Howard: 15:29
So there’s a lot of this kind of stuff that happens where some little study is done, somebody has a pet peeve and they just think that, oh, those people that do that are stupid and they do a study with their patients that year, so they get 150 patients in it or something and that slightly slight modification of their preferred way, and then it’s assumed that since lifting might lead to lower success with the varus needle and no difference in injury. Big asterisk on no difference in injury, right? Because they didn’t prove that at all. Then they advocate for that and then they apply it to a completely different technique like optical entry, which one of the benefits of optical entry is. It mostly solves the problem of inadequate laparoscopy, of not getting into the perineal cavity that’s associated with the varus needle.
Maddie: 16:14
Right, so they shouldn’t be able to make any claims about injury rates with only 150 patients.
Howard: 16:20
That’s right. They can put the sentence in their paper, and this is where it’s misleading. They can put the sentence in the paper that they didn’t have injuries in either group. But if they were doing their due diligence, if they were trying to be fair, they’d also say this study was underpowered to detect any differences in this outcome, and that’s why we need to talk about the power analysis. If you don’t understand that, then you might make the mistake of assuming that small studies like this can be used to draw conclusions that should direct your care, and it should not. That’s what I’m saying. These studies of that nature don’t add anything to this conversation.
Howard: 17:04
About is confusing where the trocar is placed in the different techniques there, and inferring that what might be good at one place on the abdominal wall, say umbilicus, versus Palmer’s, is good for another. So you asked about other entry points, like Palmer’s point, and there may be no benefit of lifting the abdominal wall at Palmer’s point. Sure, that could be true, but we’re talking specifically about the most evidence-based placement for most patients, most types of patients, which is direct entry at the umbilicus. The umbilicus, by the way, if you look at a cross-section of the abdominal wall, is the thinnest point. It’s where there’s less body fat, both above and below preperitoneal and abdominal wall body fat and it narrows out there.
Howard: 17:46
And the closer you are to the base of the umbilicus the better. Even in very obese patients that point narrows down and that’s the whole benefit of that is requiring less effort and more likely to have successful abdominal entry through the thinnest point and in other words, not below the umbilicus where it all of a sudden thickens back out, particularly if you’re at an angle and not above the umbilicus but in the umbilicus In fact, alternate entry points are where a lot of this confusion, I think, even stems from. So the truth is today and get ready, folks, I have a ton of very good friends and other people who Palmer’s Point. That’s where they go all the time because it’s a fad. It’s a fad, I think, mostly driven by G1 oncologists in the era of da Vinci, and we can talk about that. But Palmer’s Point is outdated. It’s not even probably what you should be doing for the cases you’re worried about adhesions, all right.
Howard: 18:44
Now, palmer’s Point is typically two to three centimeters below the left subcostal margin in the midclavicular line, and this was promoted by Raoul Palmer, who was one of the pioneers of early laparoscopic technique, particularly combined with CO2 insufflation, and he had noted that in cadavers and specimens that were analyzed that that point was the anatomic area likely to have the least amount of adhesions. But of course this was work largely done at a time when gastric bypass and other sort of stomach surgeries like that were less common. Most people if they were going to have adhesions they came from these large midline incisions which were very common back in the day.
Howard: 19:25
Everybody got stem to stern for everything, even C-sections, or they’d had previous appendectomies for appendicitis on the right side or maybe pelvic inflammatory disease which encompassed bilateral pelvis or maybe gallbladder disease on the right upper part, or maybe they had a cesarean and that cesarean likely used a vertical incision back in the day or something like that, and so all of these adhesions tended to be on the midline pelvis and the right side of the body, and so going up on the left, away from all that made a lot, and so a lot of patients have had stomach surgeries or other issues that are individual to them, and it’s likely no longer true that Palmer’s point is the site that’s statistically likely to have the least amount of adhesions. This is probably that this point today, with our understanding, would be what we now call Jane’s point.
Maddie: 20:21
Okay, what’s Jane’s point and how are you spelling Jane? Is that J-A-I-N?
Howard: 20:27
J-A-I-N. Yeah, okay, yeah, the Jane Point is named for Newton and Vandana Jane.
Maddie: 20:33
Fancy Wait a minute. So is this a new eponym?
Howard: 20:37
Well, it’s not new, but it may be new to some of the listeners. But yeah, it’s been around for a few years. But yes, it’s an eponym.
Maddie: 20:43
And are either of those people female?
Howard: 20:46
Well, actually both are female.
Maddie: 20:49
Okay, so we have discovered another female eponym, so tell us more about the Jane point.
Howard: 20:55
Yeah, okay. Well, this point is at the level of the umbilicus, but it’s about 10 to 13 centimeters lateral to the umbilicus. Another way of thinking about it is if you draw a line that’s about two and a half centimeters medial to the anterior superior iliac spine and we’ll put a picture of this on the Instagram and then go straight up to the level of the umbilicus.
Howard: 21:18
That’s Jane’s point. So this is lower and more lateral than Palmer’s point and completely different than the other non-umbilical, non-Palmer’s point which is sometimes used, particularly in the age of robotics, which is the Lee-Huang point.
Maddie: 21:34
Okay, you just dropped another point on me. What’s that one?
Howard: 21:37
Okay, so this is another one of those points. We can put that on a picture too. That’s sometimes favored by the gynecologists, and it comes from Taiwanese gynecologic oncologists who pioneered this and that’s two people’s names combined, li and Huang and what they really wanted was a better way to get periaortic lymph node dissection accomplished, and they realized that when you started in the umbilicus, it didn’t provide the best field of view if you were specifically setting out to do periordic lymph node dissection. So they described this back in the nineties.
Maddie: 22:12
Okay, and were either of them women?
Howard: 22:15
No, no, they were both men, the well dried up again yeah.
Maddie: 22:18
All right, well then you can just tell us where it is. But then let’s go back to the Jane point.
Howard: 22:23
There we go. Okay, well, it’s in the midline of the upper abdomen between the xiphoid process and the umbilicus. So if people are doing robotics with the sort of typical W or M distribution of ports that run along the costal margin with da Vinci, you’re probably doing this point. It may not be your initial point but it could be, for For them it was. It avoids the abdominal adhesions and most of the midline stuff because it’s above it.
Howard: 22:52
You know that stuff’s usually below the umbilicus and it’s easier to insert and it requires less force than when you insert it in palmar’s point because it’s in the midline and so it’s not going through muscles and just in that thinning area. And then it gives that expanded operative view for larger pelvic pathology. Or again, like you need to do nodes or maybe you’re doing a fixation to the sacral promontory or something like that and you need to be just higher than the umbilicus to have a good field of view. So for these guys it was about this requires less force than palmers, which can be a benefit, because sometimes the force required to get in is what causes deeper penetrating injuries to vascular structures for example. But it was really not about preventing injuries or it being safer. It was about having an expanded field of view.
Howard: 23:42
And this point has become very popular again along geooncologists and then happened to be peaking at a time when robotics was coming out and so we. Well, it was sold first and adopted first in GYN a lot of times by oncologists who needed a larger field of view, maybe for masses or those parahedral lymph no dissections, and then some people also still because it provides. They like it because it provides a central view rather than the kind of if your camera is still in palmers off to the side, it feels a little distorted sometimes. People like it for that too, but you do have to think about it being essentially on top of the aorta when you put it in, and you definitely need to decompress the stomach with palmers and with the Lee-Hong point. So again, this wasn’t developed to minimize injury per se but to make surgery easier and improve the field of view.
Maddie: 24:31
Okay. Well, take us back to Jane’s point now.
Howard: 24:33
Okay, well, I brought up the Jane point because today that’s likely to be the point, should be the point with the least adhesions statistically on an average patient patient in the modern world where a lot of people have had bypass stomach, bypass surgery and things like that.
Howard: 24:50
And the Janes has collected thousands of patients in their case series in India and they used in their situation they used a varus needle and they didn’t lift the abdominal wall. So that’s why I brought this up. So my point was only that sometimes the technique that they describe for their insertion, where they just put it in this very safe point without lifting the abdominal wall, well, that’s maybe the best evidence that there’s no value in lifting the abdominal wall. But again, they pre-insufflated with the varus needle. So they just gently put the varus needle in the safest place in the abdomen, didn’t lift, pre-insufflated, and then they put their trocars in which the whole idea of pre-insufflation is that you’re lifting the abdominal wall, you’re just doing it with gas, right? So we shouldn’t conflate what the Janes’ did and the fact that they didn’t lift the abdominal wall there. And in an underpowered study they had thousands but not 100,000. We shouldn’t conflate that with the claim that well, okay, there’s no value in lifting if I put a direct optical entry into the umbilicus. That was my point about all that.
Maddie: 25:57
Well, what about for the Li Huang port?
Howard: 25:59
Yeah well, they first described their port really before optical entry, this direct optical entry. We had direct entry for a long time, but not optical direct entry, and there’s a difference. Imagine just putting a big 10 millimeter stainless steel sharp trocar just in the abdomen blindly. That’s not what we’re doing, but that was a thing for a long time, and so they also use the varus needle, and in their original paper, with 188 patients, they still had two significant mental vascular injuries, and they had a colon injury that they had to repair.
Howard: 26:33
So, if you think about it, if anything, you might expect that that point of entry or primary entry, likely has more complications associated with it, and I can’t imagine putting a variceal there and not thinking about some elevation, if I could, or some angulation. Particularly, you think about a patient with a large liver. It’s pretty easy to stick trocars and varus needles in livers when you’re doing that upper entry point, and a lot of patients might have. They’ve got cirrhosis or something else, and so you got to be very mindful of that anatomy. But the reality, though, is it’s hard to elevate that with that particular position, and it’s hard to elevate with the palmers, and so I think that’s also why people don’t tend to do it Like how do you elevate the abdomen in a way that matters up there? So that gets us back to the umbilicus, or Jane’s point.
Maddie: 27:21
Yeah, okay. So I think the lesson is don’t take evidence from one technique and apply it to another, and don’t change your practice from what is the accepted norm, based on underpowered studies that don’t have enough patients in them to actually see the expected outcomes that you’re concerned about.
Howard: 27:37
Right. But confirmation bias people love to. I do a thing, the way I do a thing, and then, oh look, there’s a paper with 150 patients in it that says the way I do that thing works. Ha, I’m evidence-based. People love evidence when it agrees with their little pet theory and they hate evidence when it disagrees with them. And they tend to discount even large, very good studies. Well, they had this problem, whatever. But then some little tiny paper in the Micronesian Journal of Gynecologic Oncology showed blank and they ran with it. So you have to be careful about this selective interpretation.
Howard: 28:10
The other thing I’ll mention again before we move on about all this is that I’ve used all of these points at different times for different patients and the truth is each patient is different and you should be a little thoughtful about what surgeries your patients had.
Howard: 28:25
And today in particular, you should be thinking about using ultrasound and the visceral slide technique to map where those adhesions are and pick the safest point. You’ve got some choices and use the umbilicus if it’s safe and if not, evaluate them at Palmer’s and evaluate them at Jane’s and see what’s the safest point and also what visceral organs are underneath there, especially if you’re thinking about the Li-Huang point. But mapping of adhesions of visceral slide is what’s going to help you be safe. And more and more when I do that, I do end up using Jane’s point if I can’t use the umbilicus, and that’s where I’ve placed most of my non-umbilical trochars the most in recent years, at least based upon not necessarily because that was my go-to or anything, but based upon their surgical history lots of patients with gastric bypass surgery and things like that and based upon my ultrasound telling me where the adhesions are.
Maddie: 29:18
Okay. So where did the idea come from that everybody should have every first trocarp placed at Palmer’s point or something other than the umbilicus?
Howard: 29:27
Well, it’s certainly not evidence-based, but I do think again it involved. The gynecologic oncologist wanted a bigger view of the abdomen for some of the things that they’re doing, whether that’s again periordinary glyphosate dissection or just a big mass, a big uterus, a big ovary, just a bigger fill to the pelvis getting up to an obentectomy, things like that. So this is a view that’s not necessary for most simple laparoscopic hysterectomies or most of the things that a benign gynecologist is doing, or a tubal or something like that, or treatment of ovarian cysts or things like that. So that was happening at the same time that da Vinci, that intuitive, was coming around teaching people how to use the robot for hysterectomies, and in a rather rigorous way. This is how you do it Go watch this guy who’s done it and he puts five ports up here and we need this so the arms don’t bang against each other, right. So they developed these port placements. That was for their benefit, for the robot’s benefit.
Howard: 30:25
That didn’t lead to the arms touching each other during surgery, and so in the early days of da Vinci, the most popular way of doing this was with that five port placement up along the costal margin, one of which would be a Palmer’s.
Howard: 30:40
So there are lots of different ways that people do this and it’s evolved over time, but it often involves putting that first port with the camera port either in Lihong or in Palmer’s Point.
Howard: 30:52
So I think a lot of folks out in practice now grew up at this point, grew up with DaVinci telling them where to put their ports, not based upon science or anything like that, but based upon a way that made the technology of their robots, particularly the early implementations of the technology, work best, and they’ve had a huge influence on how people do this. And then also the gynecologic oncologists are usually the people who are looked up to the most as surgeons in OB-GYN residency programs and they have a different reason, maybe the same, because they’re using their robot, but maybe also because they want this bigger field of view when they’re doing their surgeries. And so then somehow all that transformed into everybody should get Palmer’s point every time for the first, for the first port, even if you’re just doing regular laparoscopy, because it’s safer, obviously. That’s why we do it that way, right, and not based upon any scientific evidence.
Maddie: 31:49
OK, well, that’s the word robot out of your mouth way too many times for me to count, so let’s move on.
Howard: 31:54
Okay, well, I know it feels like we didn’t talk about a whole lot just for the last 30 minutes or whatever, but we did get into some weeds and there’s a lot to learn from the. I think the thought process that really was started back in that episode you mentioned in season seven, where Antonia and I talked about the initial laparoscopic entry, and then continues with this conversation and what we’re going to find as we continue to talk about more and more different surgical techniques and this in future episodes like this one is that very often there just isn’t a clear-cut scientific answer to many of these questions because of the complexity of doing randomized trials to answer questions like this. So if you are frustrated by how vague everything seems to be and it seems like we’re just back on relying upon expert opinion, that’s going to be a theme when you talk about surgical technique, and it’s also why we lack standardization in surgical techniques, which again frustrates residents who have to learn 10 different ways to do one thing. But, just like we discussed with cesarean technique in a prior episode, there is value in us trying to adopt a standard approach, because that’s what ultimately will lead to the ability to do large-scale studies. If you’ve put 15 gynecologic surgeons in a room, you’d probably get 15 different techniques on initial laparoscopic trocar injury Little.
Howard: 33:10
Is the bed angled or not? Do I lift the abdomen or not? Do I use this port or not? What kind of trocar do I use? Do I use varus or not? Do I do cut down or not? It’s pretty easy to get a bunch of variety, but there is a thought process that could lead to standardizing that technique and then you get a bunch of people who have done it that same way for enough time that they’re all competent in it and then you change one thing or two things at a time or something like that in a large population. In over a year or two you can actually start to develop significant evidence that informs the best technique. But as it is now almost everything in a lot of these things like surgical techniques, stuff is published is not worthwhile and a lot of these things like surgical techniques, if it’s published is not worthwhile.
Maddie: 33:50
Yeah, so you guys discussed cesarean technique in episode 8.7, and we should talk about that in detail again sometime, maybe in a later episode. But I do have some more questions for you related to gun procedures. First, one thing that you brought up, but I unfortunately have never seen, is something called visceral slide for deciding where to place stroke cars when people have the potential for extensive adhesions. So can you walk us through how you do that?
Howard: 34:13
Sure Well, we mentioned visceral slide technique in prior episodes, when every issue has come up about either obtaining safe access to the abdominal wall for the stroke car or obtaining access at the time of vaginal hysterectomy, when you make your posterior colpotomy. So in both cases, the issue of adhesions is paramount to having safe entry. So the visceral slide technique is an ultrasound-based method for determining whether adhesions are present in either of these locations, and this has been around for a long time, but I think it’s never caught on to the degree it probably should have, because the people who lead the thoughts about this stuff are general surgeons and they don’t have an ultrasound machine in their office. They don’t use them routinely and they don’t have one readily available to do a point-of-care ultrasound when their patient’s sitting there on the exam table, and even among most OBGYNs who have ultrasound in their office, they’re not routinely using it.
Howard: 35:07
They have a machine that they schedule appointments with their ultrasonographer and they’re practically speaking, they’re not going to have a bedside machine that they pull over and say, okay, let’s look at these adhesions. It’s just not how their workflow works and their ultrasonographer may not know how to do that. But if you’re worried about abdominal adhesions and where you should be placing your first trocar, then this technique can help you understand safe access points. So let’s say you have a patient with a prior vertical laparotomy or some other intra-abdominal surgeries or infectious processes or something like that, that you’re worried, some risk factor for adhesions? Well, and that could be a history of diverticular disease or pelvic inflammatory disease, really anything. Then you place the ultrasound on the abdominal wall and zoom in deeper so that you’re essentially seeing the thickness of the abdominal wall through about half of your field of view, and then you can note the fascia and you can see the peritoneal lining on the inside of the abdominal wall. And then you have the patient slowly valsalva and reduce it repeatedly. Just take a deep breath and what you should see is free movement of the viscera along the abdominal wall at the point you’re ultrasounding. So you can note a point that you’re watching on the abdominal wall, on the peritoneum or the fascia, which is ideally the place where you want to put the trocar. So put this over the umbilicus or put it over Jane’s point or Palmer’s point or whatever you want to do, and then if you want to put a measurement up on the screen of two centimeters and then watch the viscera as the patient takes that deep breath, and if it travels at least two centimeters from the point you’ve noted, you should be good. Now, different studies over the years have tried to identify the optimal length of slide and the truth is it’s probably something less than two centimeters. But I think if you see two centimeters of slide, you should feel very comfortable using a trocar at that point. And some people have looked at one centimeter and other numbers. But just when you’re starting out with this two centimeters, In a world in which more and more people have had stomach surgeries or gastric bypass type bariatric surgeries, this is really where we should be at.
Howard: 37:10
Let me first look at the umbilicus and if it appears that I can enter there and I don’t have a need to have that bigger field of vision I don’t need I’m doing a tubal or something or just a laparoscopic hysterectomy then I’ll use that point if it’s free, and if it’s not, then I’ll check Jane’s point and Palmer’s point and look at those different points, thinking about the individual patient and what field of view I need, and in some cases you’ll find that the safest spot is actually on the right side of the abdomen, particularly if they’ve had gastric or stomach surgeries and this would just be the mirror image of Jane’s point. And again you can put it over there and take a look, make sure their liver margin’s not too low, things like that. And so think about the surgeries they’ve had and think about the field of view you need, and then you can map those adhesions.
Maddie: 37:53
Okay, and you said before that you do this when you’re looking for obliterated cul-de-sacs as well at the time of vaginal hysterectomy. So can you tell us how you do that?
Howard: 38:02
So really the same thing, except you’re going to test for slide along the posterior wall of the uterus and you can also do this with the anterior wall of the uterus. If you’re worried about adhesions from cesarean to the anterior abdominal wall. Now this is best done with the vaginal probe. In most patients and many times you can do this simply by pushing the vaginal probe gently into the posterior cul-de-sac and just moving the uterus a couple of centimeters and seeing that the viscera is unattached. But you can also just get a view of the uterus and again have the patient valsalva in the same way and look for that slide both on the back and the front although in most cases it’s the back that we’re worried about from endometriosis or prior PID or whatever it is. If they’ve had cesareans, look at the front. No-transcript anyway.
Howard: 39:34
And a lot of very good vaginal surgeons don’t quite get past 60 or 70 percent vaginal hysterectomy because they’re thinking in those terms. They’re worried about adhesions when they see the individual patient and so they just they do the case laparoscopically for 25, 30, 35% of their patients. So in some cases of course that’s still more than appropriate if you suspect advanced endometriosis or things like that. But in many cases we’re just doing a second procedure or a unnecessary laparoscopic procedure on a patient out of fear of adhesions that we can easily identify preoperative.
Maddie: 40:07
Okay, well, that’s all very helpful. While we’re on the topic of surgery, I think another good thing to talk about would be laparoscopic or robotic cuff closure. So I feel like we’ve all seemed to go to the way of barbed suture for the cuff and closing it in a running fashion. Is there any data that you’ve read on barbed suture versus non-barbed? And then, on that note, is there any data that, despite doing a case laparoscopically or robotically, that an argument can be made to still close from the vagina for better support and cuff outcomes?
Howard: 40:36
Yeah, Another really interesting question and one of the things that you see at the meetings and in different programs people sit around and argue about or talk about their favorite way of doing this and the other, and, of course, a lot of what we’re talking about in questions like this is going to be related to the influence of industry on the choices that our surgeons are making and how we do surgery and with which tools we do that surgery. So one of the biggest selling points of people if you’re honest about it for the robotic platform for hysterectomy is the ease with which you can tie knots and suture the cuff. There are a lot of very good laparoscopic hysterectomists who still struggled with just sewing the cuff. It takes longer, it’s a bit embarrassing because you think you’re hot stuff, but then you really slow down and everybody’s bored with you struggling to sew and that sort of thing, and the robot just makes that so much easier.
Howard: 41:31
Now, I think people aren’t always going to be quite so honest to admit this, but I think if you get your friendly robotic hysterectomist, you get them a couple of glasses of wine, a couple of beers at night. Get them a little tipsy. Then they may confess the point to you that this is why they use the robot primarily. I’ve had this experience with more than one such person and I’ll confess the point that the robot absolutely does make knot tying much and suturing much easier, particularly if you don’t do a lot of it.
Maddie: 41:58
Okay, so what I’m hearing is that you’re pro-robot.
Howard: 42:00
now Well, it doesn’t make me pro-robot, but it’s true, right, it’s true, and I think a lot of people they use a robot and they see that ergonomically, they feel a little bit better.
Howard: 42:11
It makes things like the tying knots feel better, things like that, and so in some cases the robot just feels better for them and better for the surgeon. And then, unfortunately, they also then claim that the robot’s better for the patient, when what we’re really talking about is it’s better for the surgeon’s affect and frustration level sometimes with things like that. But in a world where, particularly even pre-robot, in a world where tying knots laparoscopically was a real frustration point for a lot of people is a real frustration for a lot of people, along comes barbed sutures. These were actually patented way back in 1964 by a general surgeon named John Alcamo and they first found a clinical application when an orthopedic surgeon named AR McKenzie used them for tendon repairs. And these original sutures were unidirectional, not bidirectional, so you had to double back at the end until it was secure, and secure that last spot by doubling back. But then of course, we got now the bidirectional sutures about 20 years ago, and the quill that was the quill knotless tissue closing device back in 2004. And now of course, we have several products on the market.
Howard: 43:20
So if you’re doing laparoscopic hysterectomies in 2010, let’s say it’s not that hard to to run down the upper pedicles with your energy-sealing device and not that hard to dissect the bladder down, and by that point we had plenty of uterine manipulators with colpotomy rings on them, which made it a fairly simple thing to make your anterior and posterior colpotomies with your energy-sealing device. None of that stuff is hard. None of it takes much time seven minutes and a lot of people didn’t even need the fancy manipulators. They would just use a sponge stick or something like that. But those products leveled the playing field for folks who struggled with the colpotomy step and that’s what took us away from doing supra cervical hysterectomies. That had been the fad in the early mid 2000s for a while. And then they got easier and gynecologists tried to learn all these steps of a laparoscopic hysterectomy. And then it got easier and gynecologists tried to learn all these steps of laparoscopic hysterectomy. And then you got to the cuff closure and they struggled.
Maddie: 44:18
Yeah, and both sewing laparoscopically and tying knots laparoscopically is definitely one of the hardest thing, I’d say gynecologists do, unless you’re doing a lot of it, in which case obviously you’re well-practiced, but that’s definitely not a skill that we’re using every day in gynecology.
Howard: 44:34
Yeah, exactly. And so hardliners like me would say well, you need to get in your little sim lab, get your little Ethicon kit at home and you need to practice and you should know how to do these things. But the reality is that for the average gynecologic surgeon out there who’s only doing one or two hysterectomies a month maybe five if they’re busy, that sort of thing they’re never going to get really great at laparoscopic sewing unless they have a natural knack for it or something. And so closing the cuff is going to take them in many cases as long or longer than the whole hysterectomy did, which is frustrating. So that’s where you might be tempted to just go down and close it vaginally if you’re frustrated in that way.
Maddie: 45:15
Okay, so that’s the second part of my question, which was would it just be better to close it vaginally in all of these cases?
Howard: 45:21
Yeah, well, it might be quicker, but not necessarily better, to close it vaginally, I think. Let me answer the question and then I want to talk about the different ways that you could do this, because I think this is confusing too to people. So the other thing that everyone was learning about back at this time was they were struggling initially with laparoscopic hysterectomy, with the rate of vaginal cuff dehiscence, and it was higher with endoscopic hysterectomy laparoscopic primarily back then than it had been with other routes of hysterectomy, including abdominal hysterectomy and certainly vaginal hysterectomy. And there were several factors in this, including just the size of bites being taken, because folks were looking at these smaller bites but they were magnified by the laparoscope, so they thought they were taking an adequate bite and we had to teach people to take a bigger bite. But studies haven’t shown that when you close the cuff vaginally at the time of laparoscopic or robotic hysterectomy that there is a lower rate of vaginal cuff dehiscence.
Howard: 46:18
Now it might be quicker, like I said, especially if you’re so slow up there, if you just go down, pull the uterus out, put a couple of alloses on it, retract her in and just close it vaginally. And also, hey, maybe you have a bunch of vaginal repairs to do. So you need to go down there anyway. So the transition to go down and have that prepared as an operative field and reposition the patient a little bit and whatever, is worth the time. But it’s not going to necessarily be safer. And you also have this weird thing that happens where you have to reposition the patient and you’ve got a primarily laparoscopic surgeon trying to do vaginal stuff now and you’re sending them down to act like they’re a vaginal surgeon for a minute. So studies haven’t shown that it’s much benefit to routinely go down and do that.
Maddie: 47:03
Okay, so I thought that the rate of cuff dehiscence was lower with vaginal hysterectomy than with laparoscopic or robotic hysterectomy.
Howard: 47:10
Yeah right, yeah, so I didn’t make that point. Yeah, so it is. It’s about, I think, between six and 10 times lower, and the difference there is probably how good your laparoscopic surgeon is. As laparoscopic surgeons improve their bite size and things like that, they got it better, but it’s still.
Howard: 47:28
In one meta-analysis I saw recently I think the relative risk was 6.2 for cuff dehiscence for endoscopic hysterectomy compared to vaginal hysterectomy, and the difference is it’s because at the time of vaginal hysterectomy the colpotomies are being made with a cold scalpel and at the time of endoscopic hysterectomy they’re being made with an energy source. So the tissue and the limiting factor of endoscopic hysterectomy they’re being made with an energy source. So the tissue and the limiting factor of endoscopic hysterectomy in that sense is that you’re devitalizing the tissue with the energy source, and so that’s just a natural limitation of the endoscopic approach. Now I can train you again to take bigger bites and do all that stuff, but you’re still not going to overcome the fact that I can take bigger bites vaginally too, right. You’re still not going to overcome the fact that I can take bigger bites vaginally too right. You’re still not going to overcome the fact that you have devitalized the tissue with an energy source, and it’s also why you shouldn’t use the bovie at the time of vaginal hysterectomy to make your colpotomy, because the bovie will devitalize the tissue probably worse than a lot of the ways we’re doing this. People do it different ways and some people even use a bovie, but it’s certainly going to devitalize the tissue when you do that vaginally, and that’s what I wanted to talk just for a second about.
Howard: 48:41
I find this useful sometimes to think about the Gary and Reich classification of hysterectomies. I don’t know if I talked about that in my vaginal hysterectomy book, but maybe I should put it in the second edition, but I think it’s useful to think about this. And again, this is where we need to be clear about, when we talk about and quote studies, what we’re talking about and the different things. So they described nine types of hysterectomy. So type one was a diagnostic laparoscopy and then you go down and do a vag test, which sounds crazy and I have done this a few times in my life, but it’s exactly what we just mentioned about visceral slide. I’m afraid she’s got an alliterated cul-de-sac. I’m not sure what I’m looking at and I don’t want to go down there and blindly cut into the posterior colpotomy without first rolling it out. So you stick a camera in the belly, you look and see the pelvis is clean. A lot of times I don’t even put a trocar in.
Howard: 49:34
I just put the camera in, put her in T-Berg, take a look, see that the pelvis is clean down there. And then I just take it out, glue it up, go down to the bottom and do the vag hiss. That’s a type one. Type two is where you just do a vag hiss and then you do a laparoscopic after your hysterectomy. You do your hysterectomy and any vaginal repairs you want to do, and then you go up and you do a laparoscopic vaginal vault suspension which again sounds what, but it actually makes a lot of sense for a lot of people.
Howard: 49:57
Intraperitoneal, high uterus sacral colpopexy is difficult for most OBGYNs to do. They never learned how to do it perhaps, but it’s pretty easy to do laparoscopically. And or sometimes you try to do your intraperitoneal colpopexy and the ligaments just are hard to identify or there’s adhesions or something like that, and so you just do all your stuff and then go up top, put three ports in and do the high uterociclic colpopexy laparoscopically or whatever vaginal valve suspension you want to do. All right, that’s type two. Type three is a laparoscopic assistive vaginal hysterectomy. Now here’s what’s confusing about this issue. The original laparoscopic assisted vaginal hysterectomies were just like the upper pedicles. In fact, gary and Reich distinguish the LAVH, where you just say an upper pedicle, from a type 4, which they call laparoscopic hysterectomy, where you actually ligate the uterine arteries. Now, for me, most of the time if I do an LAVH, I don’t want to have to open up two energy sources, and of course I use an energy source with hysterectomy vaginally, so I’ll just go down and get the uterines with that. So I’m really my LAVH is really a type four, harry and Reich, and then I’ll go down. But in both cases, in the type three and the type four, you’re not making the colpotomies, and the type 4, you’re not making the colpotomies laparoscopically. So you’re going down to the vagina and you’re using a scalpel and you’re making these colpotomies and they’re not devascularized, and then you should get the same rate of vaginal cuff dehiscence that we see with vaginal hysterectomy.
Howard: 51:28
Now then type 5 was a total laparoscopic hysterectomy, which they defined, I think, originally as you made the colpotomies up top and you closed the cuff. They didn’t account for this idea that some people would make the colpotomies up top and then go down to the bottom and close the cuff, which is the question that we’re just asking now. But they were also wonderful surgeons laparoscopically, and they had no problem sewing with archaic equipment by today’s standards. So that wasn’t part of their thought process is that you’d go down to the bottom and do it. But now, when you get up to type five, that means that you have made the colpotomies with an energy source. There’s no other way to do it besides that, and so, whether you sew up there or sew down there, you’ve now accepted a higher rate of cuff dehiscence.
Howard: 52:18
Type six was just a supra cervical hysterectomy, again very popular in the mid 2000s. I’ve done plenty of trachelectomies for people who had these surgeries done. That came back with, I think, anyone recently and came back with problems with their cervix. Type 7 was a laparoscopic hysterectomy with a lymphadenectomy, so we’re getting into oncology world. Type 8 was a lymphadenectomy plus an omentectomy and type 9 was a radical laparoscopic hysterectomy. Okay, but the difference is and what I want you to focus on is how the colpotomies are made. Are they made with a cold knife or are they made with an energy source? That’s the difference.
Maddie: 52:55
Okay, and so, to reiterate, you would have to do everything but the colpotomies laparoscopically and then go down to the bottom to complete the case of adjelon, to make a difference on the rate of cuff dehiscence.
Howard: 53:07
So that would be the argument for, in those cases that require some laparoscopic views, that would be the argument for a laparoscopic, a type three or type four class hysterectomy, where you’re making the colpotomies at the bottom. It’s also going to be cheaper because you’re not using the expensive uterine manipulator that has the colpotomizer rings on it. You don’t need to spend money on that. You don’t need any manipulator. Usually I don’t even put a sponge stick in and it’s going to be quicker and you’re going to save OR time if you do it that way. But yes, that will lead to a lower rate of cuff dehiscence and reoperation associated with cuff dehiscence and ER visits and angst and all the other things. Now, though, if you go back to 2010 or so, in the midst of all this sea of frustration, where people are trying to just do it all laparoscopically they weren’t vaginal surgeons anyway, and a lot of the early adopters there weren’t vaginal hysterectomists saying, oh, I want to learn how to do a laparoscopic hysterectomy. There’s some of them out there. I don’t associate with them, no joking, but they were abdominal hysterectomies 20 years ago were done abdominally. Like it’s unconscionable today, but it’s true.
Howard: 54:18
And so back in the early 2000s 2010, people were learning. The abdominal hysterectomists were trying to learn how to be minimally invasive and do laparoscopic. And they had this struggle and they weren’t keen on doing laparoscopic assisted vaginal hysterectomies. They weren this struggle and they weren’t keen on doing laparoscopic assisted vaginal hysterectomies. They weren’t vaginal surgeons. If they were vaginal surgeons they probably wouldn’t be having this problem. And so then comes Barb’s suture, and it was like manna from heaven.
Howard: 54:41
So you’ve already made your colpotomies with an energy source endoscopically and then you’re not going to gain anything in terms of outcomes and cuff dehiscence by going to the bottom and closing vaginally, so you might as well make your laparoscopic closure as quick as possible, and the impediment to that is how slow you are at sewing and tying knots laparoscopically, and so barb sutures step into the room here, and it’s a great way of speeding up that last step, and studies have shown that the cuff dehiscence rate is no better or no worse than with regular suture. The price of the barbed suture is low enough that most surgeons are going to make up for the cost of how expensive it is by how much time they’re saving in the operating room, and so it makes sense for laparoscopic hysterectomists who are not good at sewing laparoscopically or tying knots to use barbed suture.
Maddie: 55:30
But then people transition to the robot because of the ease with which they could sew and tie knots. But use the barb suture anyway, right, yeah, Well, something like that, right?
Howard: 55:38
So then the robot is the other solution, the more expensive solution to your frustration, and they transition to the robot for lots of factors, most of which are not based in outcomes and or cost effectiveness certainly not in cost effectiveness, but this transition’s happened and general surgery’s been going through the same issue, where the science says, for example, that most gallbladders and appendixes and most of the hernia repairs and things like that should be done laparoscopically. But they’re just all getting done with a robot, because that’s the world we live in and that’s where we’re at with hysterectomy, and so people who were doing laparoscopic hysterectomy and were fine with it are converting to robotics right Now. It’s still just true that your hysterectomy should be done vaginally if possible, and if not, then perhaps laparoscopically or as a laparoscopic-assisted vaginal hysterectomy.
Howard: 56:25
And if that’s not possible, then robotics should be the rarest use case. That should be the rarest use case. That should be the. Or maybe abdominal should be the rarest use case. But robotics should be third in line, no more than third in line. But all of a sudden it’s become the most common, and that’s industry and all those things, and we’re driving up costs and all that. And then we’re going to drive it up even more by throwing a barbed suture in it, which takes away the robot’s selling point of hey, this makes it easy to sew.
Howard: 56:51
But that’s why it’s important to understand that barb sutures don’t decrease the rate of vaginal cuff dehiscence. So I think that what gets thrown into the marketing is that it actually is associated with a lower rate of cuff dehiscence, and there are some ways of making that argument that are temporal. So remember, we had a tenfold higher rate, compared to vaginal hysterectomy, of cuff dehiscence in the 2010 era than before, and then, around the same time that barb sutures start to come into play, but also surgeons are going to their conferences and learning to take bigger bites and all that stuff, the rate went down to sixfold. So you need a randomized trial to show that, and so we just don’t see a difference in cuff dehiscence, but it’s probably sold that way, and so if you don’t realize that the cuff dehiscence rate isn’t lower, then you may be using barbed sutures because you think it improves the patient outcome and it doesn’t.
Howard: 57:38
I’ll put a link to a 2025 article that has some data to support my statements. Again, with all of these surgery articles, it’s always tough because you have people doing what they’re good at and not doing what they’re not good at, and then comparing it to them having to do something that they’re not good at, and so it’s difficult to interpret. But in this case, the variable that you need to always keep in mind is how the colpotomies were made whether they use an energy device or whether they use the scalpel and whether the tissue then was devitalized.
Howard: 58:07
This is also why you shouldn’t use as said again, you shouldn’t use a bovie when you do your copotomy to vaginal hysterectomy, and in some of the vaginal hysterectomy studies you need to tease that out specifically, did the surgeon use a bovie? Because there are some vaginal hysterectomy studies with a higher rate of cuff dehiscence and you’ve got to understand how they did it.
Maddie: 58:28
Yeah, there’s so many potential things to talk about in surgery no-transcript and you have to be really careful when you’re reading and applying the outcomes of those studies if you don’t realize some of the little things like the lifting of the abdomen or how they made their colpotomy or things like that, when it comes to applying their results to your own practice.
Howard: 59:17
Right, and that gets back to the thousand little things done. Well, we could have a discussion about hysterectomy, let’s say, and the benefits of different routes of hysterectomy and the limitations, and go through the thousand things. I know we’ve talked about hysterectomy before. In the next episode, antonia and I are going to talk about a new study published this year from Sweden that deals with the best route of hysterectomy and what they’re seeing happen in Sweden. But yeah, we could talk about a lot of these surgical things in the future episodes.
Maddie: 59:45
Okay. Well, let me guess I’m going to go with. It says vaginal is the best.
Howard: 59:49
The Swedish article.
Howard: 59:49
Yeah Well, tune in to the next episode for the answer.
Howard: 59:52
But when you say vaginal hysterectomy or you say robotic or laparoscopic hysterectomy, in a big study like that, a retrospective study, there’s a huge amount of variety. You might have a robotic hysterectomy done through a single umbilical port and the next one might have five ports on the abdomen. Same for laparoscopic hysterectomy. For a laparoscopic hysterectomy you might have someone who uses the bovie to make colpotomies at the time of vaginal hysterectomy rather than the knife, and throw in all the almost endless amounts of variation with every procedural step, with every different route and the wide variety of skills and just abilities and experiences that different surgeons bring to the case, and then throw all that into a big matrix that compounds with different patients and their different patient pathologies and in the end, if you’ve seen one hysterectomy or you’ve seen one cesarean, you’ve seen one hysterectomy and one cesarean. So that’s where I like to direct your focus, on the idea that surgeries are really a thousand little things done well and that we should be working on standardizing these techniques so that we can do better science.
Maddie: 1:00:55
Right, and some of those thousand little things are seemingly some of the inconsequential things that we talked about today, like where you put your first trocar, how you decide where the best place is in a particular patient. But then you could add to that what type of trocar you use. Do you lift the abdomen or not? Do you use the varus needle Before you insert the trocar? Is the bed going to be positioned flat or in Trendelenburg when you insert the trocar? Is the bed going to be positioned flat or in Trendelenburg when you insert it?
Howard: 1:01:13
Yeah, all sorts of things. So now take that type of thinking and go into even more detail. How big is your skin incision? Is it five millimeters or six millimeters? Do you make it up and down? Do you make it side to side? Is that an angle? How deep is the incision that you make with your scalpel? Really like? These are the levels of detail to think about. You have to think about all these levels of detail and answer the questions as best you can and pay attention to these subtle little things.
Howard: 1:01:40
Each of these things do consequentially add up to higher or lower net morbidity and mortality, and for many of them there are best answers.
Howard: 1:01:49
For most of them, we don’t have incredibly satisfying answers from randomized controlled trials though. So no one’s going to do a randomized controlled trial about whether you should make your skin incision four millimeters or five or six millimeters for a five millimeter trocar, and that’s where we do rely on expert opinion and experience, because one of those answers is better if we don’t have an RTC to show it, and it’s just. Are you paying attention to that detail, to that level of detail? The skin drags.
Howard: 1:02:16
Obviously People understand what I’m saying. The skin will drag on a four millimeter, and you’ll struggle and have more difficulty, and so you’ve got to make your incision big enough that you don’t have any skin drag. But we don’t need a trial to say that. One of the things I always did when I was a resident was take every surgery or procedure, everything and try to make a list of as many of these little decision points as possible and as much detail as I could think of, and then force myself to look for evidence and think about the pros and cons of the choices that were there.
Maddie: 1:02:45
Yes, and naturally you taught me to do that, so I’ve been trying In fact, I’ve been creating something that we may have something to help residents out with in the future. You will, of course, be proofreading it for me, but it’s a great intellectual exercise. And then, of course, you have to go out and find the answers for yourself sometimes.
Howard: 1:03:02
And I think that’s what we’re doing today on this episode is showing the process about how to think about these answers. So it’s a tough thing, okay. Well, speaking of residents, do you know we have to do a history segment. Do you know when the first OB-GYN residency was started in the United States?
Maddie: 1:03:17
I do not.
Howard: 1:03:22
Well, this it may be a bit of a trick question because it depends on how you define a residency program, but the first accredited four-year residency program was at the Sisters Charity Hospital in Buffalo, new York, and this was accredited in 1947. But that doesn’t necessarily mean that there weren’t training programs obviously prior to 1947. The modern idea of residency programs really starts at Johns Hopkins in America, but it was based upon what the Germans in particular and Europeans in general had already been doing.
Howard: 1:03:46
Many of the early Hopkins faculty had trained in Germany for a year or two or three in different subjects, and then they came back to the United States.
Howard: 1:03:55
Howard Kelly founded the Department of Gynecology at Hopkins in 1889 and started training people under him in a resident type manner, and in 1899, williams of Williams Obstetrics was the first professor hired by Howard Kelly for that role in the new Department of Obstetrics at Hopkins, and they also had formal training programs.
Howard: 1:04:16
But they weren’t externally accredited by some organization and many of the graduates from those programs went around and started founding other programs to train like they had been trained, and this was happening at Hopkins and other fields too, in medicine and surgery pathology. So the ACGME, that organization that does accreditation today, wasn’t actually established until 1981. Prior to that there was a liaison committee for graduate medical education that had been founded in 1972. And prior to that the AMA worked with the various specialty boards, like ABOG for OBGYN, to try to develop standards for training that would be acceptable to that board, to grant board certification, and so the American Board of Obstetrical Gynecology was founded in 1927, but of course it took another 20 years for it to have impact and influence enough, so that the first modern type residency program that met ABOG’s thoughts of what a program should have was at the Sisters Charity Hospital in Buffalo.
Maddie: 1:05:15
Okay, well, did you do your research and see if there were any women in that first class at the residency program?
Howard: 1:05:22
I didn’t. I’ll see if I can figure that out Interesting.
Maddie: 1:05:25
Well, you have something to read tonight then, all right.
Howard: 1:05:28
Okay, well, antonio and I will be back in a couple of weeks and we’ll have something interesting.
Maddie: 1:05:35
Okay, bye-bye.
