Episode 11.3 Preventing Surgical Complications
We map a prevention-first approach to OBGYN surgical complications—from environmental fixes and technique to early detection, skilled repair, and honest recovery—so fewer patients are harmed and clinicians carry less hidden burden. Practical steps, board-level reasoning, and real cases bring it to life. Featuring Stuart Winkler.
• applying primordial to quaternary prevention to surgical harm
• avoiding unnecessary hysterectomy and favoring safer routes
• bladder repair tactics by size and location
• ureter injury recognition, stenting, and reimplant options
• bowel injury triage, Lembert technique, and resection thresholds
• four practical tips to prevent bowel injury
• vascular control from aorta to epigastrics and presacral bleeds
• preventing neuropathies with smarter positioning and retractors
• disclosure with HEAL and supporting clinicians with just culture
• key historical insights
0:00Framing Complications With Prevention
2:55Primordial To Quaternary: The Model
7:30Urologic Risks: Bladder First
16:20Trigone, Stents, And Calling For Help
23:45Ureter Injury Playbook
33:20Delayed Ureter Injuries And Management
38:05Small Bowel: From Serosa To Resection
46:30Colon Injuries: Repair Or Resect
52:40Four Tips To Prevent Bowel Injury
58:10Vascular Injury: Aorta To Epigastrics
Links Discussed
Evidence for Reverse Trendelenburg Position (DOI: 10.1016/j.jmig.2022.09.003)
Transcript
ANNOUNCER: 0:01
Welcome to Thinking About OBGYN. Today’s episode features Howard Herrell and Stuart Winkler discussing surgical complications.
STUART: 0:14
HOWARD:
Stuart? What are we thinking about on today’s episode?
HOWARD: 0:19
Well, we’re going to get back and talk about surgical complications. For our listeners, this is Stuart Winkler, our G one oncologist friend. And we had promised on one of the episodes you did last year to come back and talk about surgical complications. And I also mentioned to you that I wanted to think about these in terms of the prevention model that we discussed when we talked about cervical cancer. So it’s easy to focus on how to recognize and fix these complications, but almost always prevention is the way to go.
STUART: 0:46
All right. Well, that sounds great. We’ve got a lot to talk about, and there are a lot of potential complications to go over today.
HOWARD: 0:52
Yeah, well, let me review briefly this prevention model again. So primordial prevention is when we fix the environment to help reduce the risk of complications, in this case surgical complications. Primary prevention is preventing the event itself from happening. Secondary prevention is early detection and mitigation. Tertiary prevention would be managing the complication, and quaternary prevention would be preventing or mitigating the after effects of the complication.
STUART: 1:17
Yeah, I really like this approach that you present. I don’t think I’ve really heard anybody use this approach before, but I think it’s a really helpful model and framework to think about the complications as a whole. So maybe we should do a paper on this at some point if this podcast works out.
SPEAKER_00: 1:31
Yeah.
STUART: 1:31
But I do think it’s more than just a trick. Really applying this public health model to surgical complications can serve as a framework for reducing the total burden of surgical complications on the patient population. And I would actually add on the surgeon as well, as we’ll talk about. But maybe you should give an example for each of these levels that we’ve talked about with this prevention model, and we can talk through a specific complication. So why don’t we do a ureter injury at the time of hysterectomy?
HOWARD: 1:57
Okay, sure. Yeah, we can exhibit these this model. So ureter injury, so primordial prevention will probably that’ll probably be the same for a lot of these. So this is a bit of a thought exercise, but in this case, for primordial, we need to change the environment in which these things occur to make it a safer environment or less likely to occur. So I’ll give some thoughts. You can add anything you think of. One would just be making sure that your residents and fellows have an adequate number of cases before they operate on their own. In the same way, another primordial prevention might be working on hospital credentialing and quality review to identify maybe low volume surgeons or surgeons who do have higher complication rates and either decredentialing them if necessary or putting them through on an improvement pathway or mentoring them or something like that. Another environmental prevention might be creating a culture that doesn’t do hysterectomies unnecessarily when alternatives to hysterectomy are available, or reducing the exposure of the patient population, therefore, to the procedure. You can’t have a complication if you don’t do the hysterectomy. So I think of those as environmental primordial things. Another one might be emphasizing vaginal hysterectomy in our training culture, since it’s associated with a lower rate of ureter injury. But I think that primordial prevention is probably the hardest of these to think about, and in some ways the hardest one to implement, but it’s where systemic quality improvement comes into play the most.
STUART: 3:20
Yeah. Yeah, and those prevention steps are going to be the same probably for most of our complications, not just in the case of a ureter complication. Another one I was thinking about for primordial prevention is creating a culture in the operating room where everybody is free to speak up and point out things that don’t look right or any concerns they might have. I had an attending who used to close every timeout that she would do with the little phrase, if you see something, say something. So if you see something, say something. And a lot of surgeons have gotten themselves into trouble when they’ve gone down pathways in the OR, made decisions in the OR that they shouldn’t have. In those cases, sometimes there’s other people in the room who may not even be as trained as they are, but who see things where they’re that surgeon could do something different and could prevent that problem. So that sort of cultural or environmental change can help reduce the rates of complication. And as you mentioned, for low volume surgeons, this would be important, but we definitely know that high volume surgeons have fewer complications. And as another primordial prevention, we may start to see hospital systems and insurances prefer that patients go to higher volume surgeons where they know that the complication rates are lower.
HOWARD: 4:26
Yeah. Okay, so those are systematic things. We may not talk really much more about primordial prevention, but listeners can certainly send in ideas they have. Okay, well, back to this ureter. So then primary prevention would just be implementing good technique, maybe visualizing the ureter, dissecting or skeletonizing a tissue around the infinibular pelvic or the uterine vessels is necessary to ensure that the ureter is safe. And we can talk more about some of those things, but basically this primary prevention is just good surgical technique, technique that’s designed to reduce the rate of complications. And then secondary prevention would be early identification of the injury and mitigation or repair. So this might be recognizing a thermal injury to the ureter and placing a stent before you finish the case or using cystoscopy to identify the injury and mitigating the complication by early identification and early management. Okay, that’s what we’re going to talk about a lot today. Then tertiary prevention for this might be reimplanting the ureter into the bladder or over a stent for repair. And then the other difficult one here on the other end of primordial is this quaternary prevention, which would include things like transparent communication to reduce the burden of malpractice lawsuits, or mentoring to reduce the harms of second victim syndrome, or even just preventing over medicalization of the patient with narcotics to prevent substance abuse, like these downstream long-term effects of the complication is what quaternary prevention focuses on.
STUART: 5:50
Yeah, for sure. And you mentioned it initially when we were talking about the primordial prevention, but I would almost even like to foot stomp almost like a proto-primordial prevention would be just avoiding unnecessary surgery. Like you said, it may be other alternatives and that sort of thing. But the only way to present 100% of injuries is to prevent unnecessary surgery, at least for that patient. Obviously, the more you operate, the more complications you may have. I know this may be a little reminiscent of the lessons of like abstinence-only sex education, where the only way to prevent a pregnancy is abstinence. But I think it it’s true. And you taught me this as a med student. I’m how I’m really terrible at memorizing quotes, but one that I always remember is from Richard Tallend, which I think is at the beginning of one of the recent editions of his operative gynecology. And he says, What does it profit a woman if the operation is technically perfect and the procedure unnecessary or even harmful? So it doesn’t matter if you’re the best surgeon in the world if you are doing a procedure that doesn’t need to be done in the first case. And that’s really the best case scenario. I do remember from fellowship, one of the bowel injuries that I had was in a patient who was having a so-called risk-reducing BSO for a genetic mutation that actually had a very low baseline risk of ovarian cancer. But it was a patient who was nervous. It was one where the risk was maybe very slightly elevated. But this is a patient who had multiple abdominal surgeries, maybe because she was a nervous person and liked intervention. But I put a trocar into her transverse colon because of adhesions from multiple abdominal surgeries. And I thought about that a lot. And maybe with a little bit more persuasion and really truly evaluating the risks, I could have avoided that complication by avoiding the surgery in the first place.
HOWARD: 7:33
Yeah. This all works on a population health model. So again, this model we’re discussing, we look out and took at the total population of people and population health. And I often tell students that don’t think about the individual patient in front of you, but think about a thousand or ten thousand patients like them. And what would be the best course of action for all of those patients across a population? And that’s the quadruple aim and this sort of prevention model and things like that. They force us to think on that population level for reduction of, in this case, surgical complications. Yeah. Orientation is a good idea.
STUART: 8:05
And that’s why Yeah, I’m sorry to interrupt. But that and that’s why we don’t that’s why we don’t treat our family members, right? Or you’ve talked about like the Serena syndrome before, whatever, where people get special treatment because they’re special people, that sort of thing. That’s why we don’t do that because we make different decisions about an individual than we would maybe on a population level.
HOWARD: 8:23
So yeah. Okay, well, for part one then, we can discuss urologic injuries in a little bit more detail. And then part two, we’ll discuss gastrointestinal injuries, which we already opened up that door. Part three, we can discuss vascular and hemorrhagic injuries. Part four, we can discuss neuropathies, and then we’ll see if we have any time left. Of course, there’s infectious complications, but we may not get to that and we’ll do that later. So urologic injuries. Gynecologists are way too afraid of the bladder. Let’s start off with the bladder injury. I lectured some residents recently about vaginal hysterectomy, and I asked them by show of hands how many of them were afraid of the bladder, and virtually all of them raised their hands. The bladder is commonly injured at the dome with insertion of trochars or even when making a laparotomy, maybe even at the time of cesarean. And then it might be injured at the base during dissection of the bladder or during colpotomy creation at the time of hysterectomy, regardless of the route. And the location of injury matters quite a bit here. Also, size matters. So why don’t you walk us through the repair strategies for different locations and sizes of these injuries, and I’ll think about some prevention tips.
STUART: 9:25
Yeah, sure. Absolutely. So I’ll say at the outset that I don’t necessarily do all of the repairs that I’ll discuss today, but I do think it’s really important to know the approach. And honestly, there are some repairs that I’m credentialed to do, but I’ll still call in a consultant if they’re available. For me, this ultimately comes down to a question of complexity and just surgical volume, like we’ve talked about. So I might do two or three ureter reimplants a year because I have to. Maybe a urologist isn’t available. But if a urologist who does 20 or 30 a year is available, I’m gonna call that person and they’ll probably do a better job than I will. And this is gonna be different for every surgeon. And honestly, it can change throughout a surgeon’s career as well. Um, but back to the urologic injury we talked about. So, as you mentioned, there’s a lot of variations on bladder injury. Overall, the bladder dome is pretty forgiving. Remember that you can remove a superpubic catheter in clinic and the bladder defect just heals on its own. Obviously, that’s a defect in the dome. But for small defects in the dome, less than one centimeter, you could, in theory, just send these patients home with a foley and remove it in a week or so, unless the patients had radiation or infection. And in those cases, you wouldn’t even need to do avoiding cysto urethrogram. But in reality, I’m always, I almost always put a stitch or two in to get a water pipe watertight seal when I have any sort of bladder injury. But it’s important to know that you don’t have to do this, especially if you aren’t credentialed for bladder repair, you don’t have a urologist on hand. So we’ll talk a lot about mechanism of injury today, and I think that’s the other part that matters a lot. And it’s really important to know and respect a thermal injury. So if the bladder injury is a centimeter, but it was done with a thermal device like a ligosure or some other device, I would be much more likely to trim away some of the desiccated tissue and do traditional two-layer closure with an absorbable suture. And so this would be like 3-0 or 4-0 vicral for the, or you could use PDS for the inner mucosal layer, and then something a little thicker like 3-0 vicral or PDS for the muscular layer, and you can incorporate the cirrhosis in that as well. And if you’re doing a laparoscopic case and are more comfortable with barb suture, that actually is an option as well. I’ve used barb suture for repairs before.
HOWARD: 11:36
Yeah. If you have an injury like this, the case is already probably going a lot longer than your average case. And if you aren’t super skilled at laparoscopic knot tying, this might be a wonderful place for that slightly more expensive suture and you can save a lot of time. We talked about that recently, but but yeah, they you please don’t open them up just to do it because you’re not comfortable tying knots. Right, right.
STUART: 11:57
Yeah, I would uh I would just add to make sure that it’s an absorbable barb suture. There are permanent barb sutures, so you want it to be absorbable. And for any larger repair like this, I usually leave a drain in post-op and check post-op day one creatinine. There’s some variations in practice for this, of course. And then generally it’s recommended that you leave a foley in for 10 to 14 days and do avoiding cysto urethrogram to evaluate for a leak prior to removing the foley. So that’s a simple injury of the dome, both for smaller and larger injuries. Now, trigone injuries are a lot more complicated. So if it’s an errant stitch in the trigone, you’re probably okay to just remove the stitch. But a lot of urologists I work with would still recommend putting in stents for a few weeks. When I talk to them in the surgeon’s lounge, they’re they tell me the reason that they do that is because they weren’t in the OR when the injury occurred. So they don’t know exactly the mechanism, and probably it’s just out of an abundance of caution. Now, full thickness bladder injuries in the trigone or within one centimeter of the ureteral orifices, these should be repaired by an expert. This often involves working through an intentional anterior systotomy, so you have a more direct repair. And then with ureter injuries being so high with these trigone injuries, and also the ureter injuries being somewhat more difficult to diagnose, stents are almost always placed in these cases, just in any case of intertrigonal injury.
HOWARD: 13:18
Yeah. Another thing I was thinking about while you were talking is just the idea of having a skilled friend when you’re already frustrated that you’ve had a complication is just the most wonderful thing in the world.
STUART: 13:28
Yeah.
HOWARD: 13:29
So if you’re uncomfortable or you’re anxious about your decision making, ask for help. That being said, most simple bladder injuries, I would hope that most gynecologists are comfortable repairing. And then obviously around the trigone, I would encourage almost all of them to ask for help, anything involving the ureter, especially if you’re not a gine oncologist. Okay, well, primary prevention again, then is good technique, identification of the bladder. Obviously, things like having the bladder drain before you place a trocar or before you perform a laparotomy or a cesarean is going to minimize the risk and exposure of of the bladder to injury. Identifying the anatomy well during your dissections at the time of hysterectomy will reduce the risk of injury. So sometimes it’s necessary even to backfill the bladder or to use cystoscopy to transluminate the bladder at the time of hysterectomy if the boundaries aren’t obvious due to scar tissue or things like that. But that would all be primary prevention, I guess.
STUART: 14:19
Yeah, yeah. And those are great tricks. Yeah. And one of my favorite tricks, and I use this one all the time, it’s to manipulate the folio bulb while it’s in the bladder. I use this a lot when I’m making like a vertical midline laparotomy and I’m extending that peritoneal incision inferiorly, particularly in cancer cases or cases with a lot of adhesions where the bladder is distorted. I’ll reach my hand down into the pelvis and make sure that the foley is loose and pull that folibloom up and then up to the dome of the bladder, and then you can really delineate the dome and show where to extend those peritoneal incisions and this kind of lateral chevron pattern to get more exposure.
HOWARD: 14:57
Yeah. Okay, and we know that morbidity from bladder injuries is reduced by something like 70 to 90 percent if you interoperatively recognize the injury and fix it at the time. So this goes a long way as well to reducing the risk of a lawsuit. So this is a quaternary stuff and second victim syndrome and other complications of what would be an unrecognized injury. So secondary prevention, remember, is identifying the injury, so cystoscopy or using intravenous dye or backfilling the bladder with dye, or these are all things that can aid in secondary prevention by helping you detect this intraoperatively. And then you just talked to us about tertiary prevention. At this point, we’re repairing it and we’re doing it the right way, and we’re calling a friend if we need to. And so that’s also preventing complications of that repair by doing it the right way, like vesicovaginal fistula. That includes the follow-up, managing the catheter for up to two weeks if necessary. That’s a very debatable thing also around the water cooler, is how long you really need to leave these catheters in. And you already feel bad that you have a complication, and then you feel bad because you’re leaving the catheter in for 10 to 14 days, but don’t, because that’s way better in some of these cases than having to deal with a fistula and err on the side of caution with the catheter.
STUART: 16:11
Yeah, for sure. Yeah, I know there’s a lot of debate too about cystoscopy and whether to do selective versus routine cystoscopy at the time of a hysterectomy. I really think there are good arguments for both. I do think until your own complication rate, it makes sense to do them routinely, especially if you can do a cystoscopy cheaply and avoid the cystotubing and you just backfill the bladder through the foley or red rubber, and you can use a 30-degree laparoscope without the sheath. That’s a poor man’s cystoscopy. But you should certainly do a cystoscopy after a tough case where you have any suspicion at all. And also recognize that a cystoscopy can’t always detect a thermal bladder or ureter injury that can cause a delay complication.
HOWARD: 16:54
Right. When they come back to the ER on day four, don’t put too much credence in the fact that you had a normal cysto. Cysto is not perfect even for regular injuries, let alone thermal injuries. And yeah, I don’t use cysto fluid really at all anymore. I stopped during the shortage of IV fluids as a way of saving and just used to doing what you said. And I I certainly do systole every time there’s any kind of bladder repair or uriconicologic procedure or things like that. Anytime there’s unexpected blood loss, anytime I’m throwing an extra suture near the uterine because I didn’t have hemostasis, things like that. And certainly early in your learning curve, as you said, do them all the time. Okay, well, so you mentioned the ureter, let’s move on to the ureter. So as I said, I let in this first scenario, I’ve done a vaginal suspension procedure, and I look and I don’t see efflux from one or both of my ureters.
STUART: 17:45
Okay, yeah. So we’ll speak a little bit from experience here, but I would say first remember the patient’s history. I remember another case, this was from residency, where we watched for efflux for several minutes before remembering that the patient had a nephrectomy on that side. So I think it can happen to the best of us, but that’s it’s embarrassing, and you want to make sure you know the patient’s history. But presuming that the patient had two functioning kidneys at the beginning of the case, I would do a few things. So, first, I’d be concerned if the UOs are a little more approximated than usual. So some kind of anatomic distortion at the time of the cystoscopy, especially if there’s a bunching up of the interic ridge or the bar of Mercier. By the way, Hard, so Louis Auguste Mercier was neither a female nor a gynecologist, so I think we can move past that eponym if we need to.
HOWARD: 18:32
We don’t need that one then, right? Yeah.
STUART: 18:34
No. But but if I did a culdiplasty at the time of the hysterectomy, I might try releasing that stitch if there was some kind of anatomic distortion of the UOs. Or obviously if there’s a visible stitch, I would cut that out. But assuming normal anatomy, you can kind of go through this process of different things to try to get the UOs to jet. And some of this may be a little bit of voodoo, some of it has a little bit of evidence for it. One thing is you can flatten the patient out if she’s in T-berg, and actually you can even put the patient in a little bit of reverse T berg up to 20 degrees. And there’s some evidence that at least in pro cystoscopies that are prolonged, waiting for a UO to jet that can decrease the time. For open cases, I’ll massage the kidney, but in this case, we could maybe ask a nurse to massage the flank. I don’t know if that helps or not. I know the kidney massage helps, but I don’t know if the flank massage helps. But sometimes I do that just to buy time. There’s things you can help ask anesthesia to help with so they can give LASIKs. I don’t routinely use fluoresce, but fluorescine could be another option as well. I generally use sterile water for my cystos, and then that difference in the osmolarity of the water and the urine makes the stream more visible. But sometimes fluorescence can help, particularly if it’s an older patient, maybe with a maybe the patient is older and the anesthesiologist has restricted fluids because she was in Steep T burg for a case and has a history of heart failure or something like that. That may be more helpful to see. But if it’s been five or 10 minutes and I still don’t see a stream, that’s when I start to ask for things to maybe intervene a little bit. So I’ll ask for like a hydrophilic coated wire and I’ll switch out to an operative sheath for the cystoscope. If I can pass that wire easily into the ureter, it’s not completely reassuring, but it does mean it isn’t kinked. It could still be transected though. And so depending on my clinical suspicion at that point, I would get a C arm in the room, and then I’d see that glide wire. If it made it all the way up to the renal calyx, I’d be reassured. Obviously, if it’s flopping free in the abdomen, that’s also an answer.
HOWARD: 20:30
Yeah. Right. Well, and in the vignette that I mentioned specifically, a lot of times the fix is just going to come from releasing your cuff securing suture, uterosacral suture, sacroculpx suture, whatever it is, it may have angulated the ureter or a McCall or McDonald’s cold plasty suture. And you may have to open your cuff back up completely to identify those and release them. And I also say if you don’t do ureteroscopy, urology friends is a wonderful thing for cases like this. You can even see the bruising around the ureter after you’ve released a suture, maybe leave a stint if you see that and and see how with detail how angulated it is or if there’s an injury too. So phone a friend for ureteroscopy. Okay, well let’s change it a little bit. I feel like a board examiner here. So let’s say instead that you discovered that the ureter has been crushed by a suture. So I didn’t kink it, but I put a suture all the way around it.
STUART: 21:19
Yeah, so I’d remove the stitch and I’d assess the ureter. Maybe at that point would put a scope in to look, but I would make sure that you know you need to determine if there’s any proximal hydrourator or anything like that. But ultimately, if I was reassured by the blood supply, still probably the safest thing to do would be a stent for six to eight weeks. At least if you were my board examiner, that’s that’s what I’d say.
HOWARD: 21:43
Yeah. And I think it’s interesting too, of course, this depends on your approach. You’re more used to being able to maybe see this laparoscopically or robotically or and see if it vermiculates correctly. Whereas I could not see that from a vaginal case. And so ureteroscopy is probably going to be more likely for me. But for your end, you could probably see it laparoscopically or whatever. So but yeah, that I think stents the board answer there. Okay, well, you did a laparoscopic hysterectomy, and you feel very confident that the ureter received a thermal injury, but it still is intact.
STUART: 22:14
So because of this anastomotic plexus that invests the ureter circumferentially along its length and kind of the tissue around that, it’s actually tougher to devascularise the ureter than you think. They’re a little tougher than you think they are, especially in benign surgery where it isn’t stripped and completely exposed. But a full thickness thermal injury or even thermal injury of the wall can definitely lead to a ureter leak and stricture. And so in this case, I’d place a double J stent for a few weeks to help keep the ureter patent and keep pressure off the wall while it heals. If it was a complete thermal injury to the entire ureter, I that would be a situation where I would potentially call urologists come in to come in and do a section of that part in there or re-inastomosis with the spatulating the ureter over a stent. That’s a pretty rare situation.
HOWARD: 23:04
You mean like you Yeah, you put the ligature on it and burn it and then like, oh crap, and didn’t fire the knife.
STUART: 23:09
Yeah, exactly. You didn’t transect it, but you did basically an entire ligation of the ureter. That is one that’s gonna I don’t think a stent’s gonna do for that. I think you’d have to actually resect that portion of the ureter. And that’s but that’s something that’s a lot easier to do right there than to come back and do it. And it depending on where it is, we we’ll talk a little bit about transections, but depending on where it is, you would either do ureter in the cystotomy into the bladder, or you if it was higher up, you would potentially do a UU.
HOWARD: 23:33
Yeah. Well, let’s do that now. So I’m the board examiner in Dallas, Dr. Winkler. And now imagine that you’ve transected the ureter completely. So Oh, wait, but location again. So the common place is about a transection at the pelvic brim near the IP. That’s where oncologists tend to get it because of pelvic masses, and then discuss lower down near the uterine vessels where people like me tend to get it.
STUART: 23:54
Yeah. So you heard me stumbling about over the terminology because it could be a little bit confusing, but yeah. The big picture is what connects where. So for ureter transections in the pelvis, these can almost always be reimplanted into the bladder. So that would be a ureteroneocstostomy. If it’s within five centimeters or so of the bladder, this is pretty simple. It can usually be done directly or with something called a psoas hitch, which you basically can kind of stretch and attach the bladder to the psoas tendon or to the psoas muscle so that you don’t have uh as much tension on the bladder. Injuries up to the brim usually require a Bayori flap, which can actually span up to 15 centimeters. So that’s a especially in a younger patient who hasn’t had radiation with a compliant bladder, you can actually get pretty good length from this flap. You need a compliant bladder and you need a urologist for this one. And then for higher injuries and or patients who’ve had pelvic radiation that limits bladder compliance, that’s one where you would reconnect the cut ends of the ureter over a stent. So this is a uretero, uretero, ureterostomy, uretero uretostomy or UU, is what we call them. And so you would do that, and typically it’s over a stent using like 5-O monocryl interrupted sutures, and you spatulate the ends to help avoid stricture as much as you can, although there’s still a pretty high stricture rate with this. And so that’s with the kind of a single transection. If you have a double transection, which occasionally happens, it’s a bad day. You can’t do a UU at two different points along the ureter because of the way the anastomotic plexus works, the length of the ureter. So you just won’t you won’t you won’t have too much of a devasperization to be able to do that, especially if they’re close to each other. And in that that so that case you would need a nephrostomy tube. Really, all the high things outside of the pelvic brim, really kind of the upper third, you would in the in at the time of injury, most of those would be managed with a nephrostomy tube, and then later come back for something like an auto-transplantation of the kidney, or you can use the bowel as a conduit or something like that. But that’s usually not done at the time of injury.
HOWARD: 26:00
Well, let’s hope to never have that day you just described. Occasionally, especially as a benign gynecologist. But okay, well, last ureter injury then. So let’s imagine we did a hysterectomy last week, and the patients now showed up at the ER, and they’ve got flank pain and fever and an ileus, and CT, of course, shows a uranoma, and it looks like the left ureter is transected and leaking right into the abdomen.
STUART: 26:24
Yeah. So in this case, we just need to prioritize treatment of the infection, and then the repair is going to need to happen down the road. If there’s not an infection, sometimes you can do a repair at the time, but most urologists I talked to about this would repair this down the road after a nephrostomy tube. But this patient needs antibiotics, percutaneous drainage and a nephrostomy tube.
HOWARD: 26:46
Yeah, and for our residents, really easy stuff here. Urin in the abdomen causes ileas. And that patient would have a probably a fairly elevated creatinine because the urine’s being reabsorbed through the peritoneum and their serum creatinine is five or six, and their kidneys are working great. It’s just spilling all the urine into the abdomen. So Okay, well, part two. So all right, I’m doing a laparoscopic case, and I discovered a small bowel injury as I’m dissecting bowel off the ovary or uterus or something. So let’s fix a cirrhosal injury first, and then maybe a small full thickness injury, and then a larger one, something larger than 50% of the circumference is how we usually talk about that. Sounds good.
STUART: 27:25
So really a pure cirrhosal injury, you can just watch. It doesn’t need to be repaired, but you would need to inspect it really well. And if there’s any muscular involvement, I would repair that. And the way I would repair that is with a single layer Lumbert stitch. So a Lumbert stitch is an interrupted stitch that’s designed to invert the edges of the bowel wall. And so you start this stitch, I’m right-handed, so I’d start on the right side of the uh of the defect, about eight to ten millimeters lateral to the defect. I would go deep to get some of the submucosa in the bite. This is the strength layer of the bowel. And then the stitch actually comes out on the same side of the of the defect, about three to five millimeters from the edge. And then next you span the defect, and then you do the reverse. So the needle enters three to five millimeters from the opposite side and then comes out about eight to ten millimeters from the incision. So if you imagine the bowel and cross section, you kind of have these two U’s of suture on either side of the defect. So classically, this is done with a non-absorbable 3-0 silk, and you would actually wait to tie these down until you throw them all so that you don’t distort the placement of your stitches. But I also will use 3-0 vicral for this sometimes. You really want to make sure that a permanent suture doesn’t enter the kind of the hollow viscous of the bowel and you’re going a little bit blind, assuming that you don’t go through the mucosa. So a lot of us will just use a Vicral for this. Now, this Limbert stitch is bulky, it’s designed to invert. But if you do that and you if you repair it parallel with the bowel, that bowel wall will narrow. So this is why you should always repair these perpendicular to the direction of the bowel. So that’s what I would do for a partial thickness injury. For a full thickness injury that’s less than half of the circumference of the bowel, you can repair this in two layers. So a running absorbable mucosal stitch, like with a four-o vitral, and then limbert stitches for for the muscular layer and the submucosa with either three-o vitral or silk. Now, if the blood supply to the bowel is compromised or more than 50% of the circumference of the bowel, of the small bowel is involved, these patients usually need a resection and a reanastomosis.
HOWARD: 29:36
Okay. Well, how about the colon? Let’s say I’ve injured the colon with a trocar maybe during an or maybe I’ve injured it a small injury during an endometriosis case.
STUART: 29:47
Yeah. So one of the benefits of direct entry for trocar entry is that if you put the trocar on the colon, you can see the injury immediately and you can do a simple two-layered repair with a couple of stitches. So if you do that, if you see stool when you place the trocar, I would just stop and leave the trocar in place. If you take it out, first of all, you can the stool can get everywhere, and second of all, you can have potentially a difficult time finding that spot again. So I just leave the trocar in so you can see the injury, and then I would put another trocar in, about eight to ten centimeters lateral to that, or wherever you think a good spot would be. And then you can either sew that laparoscopically with two layers, similar to the small bowel with the mucosal layer and then the overlying muscular layer, or you can make a small incision and bring the lupa bowel out and repair it and then put it back in. You can irrigate and then I would cover her with antibiotics until the return of bowel function. Really depending on where it is. Colon, you usually can feed the patient the next day. There’s really not an issue with that. Some of the more proximal small bowel stuff, we tend to go a little bit slower with diet, but usually colon you can feed them the next day. And then if you’re a varus needle person and you stick the needle into the colon, you probably can just repair that with a simple stitch, would be all that you need for that.
HOWARD: 31:01
Okay, so that’s a smaller large bowel injury. But what about a large bowel injury?
STUART: 31:07
Yeah. So the colon’s blood supply is a little more finicky than the small bowel. I have a lower threshold to resect larger injuries, especially in watershed regions. So like the ileocecum, the splenic flexure, rectosigmoid. Anything larger than about a third of the circumference of the colon probably needs to be resected. And then colon resections can be more complex than small bowel resections because of the blood supply. There’s also can be a difference in bowel caliber as you move along the colon. Unless I’m doing something straightforward that I do more commonly, like a rectosigmoid resection in the pelvis, I usually call my colorectal colleagues to help with these.
HOWARD: 31:43
Yeah, some of the listeners are wondering why we’re talking about how to fix these right now. But I will say that on board exams and things like that, or even just having knowledge with your patients and understanding it, you should know at least the theory of what you’re doing here, even if practically speaking, you’ve called a surgeon in to help. And on and the board examiners will do that trick of, oh, consult surgery. Well, all the surgeons are gone. Well, consult whatever. Well, they’re none, they’re none here. There’s a golf tournament and they’re all gone. So be prepared to answer these questions for boards. For gynecologists, a lot of bowel injuries that they’ll encounter are at the time of that initial trocar placement during laparoscopy. So primary prevention ends up being a discussion of the best techniques for trocar placement and avoiding injury during that first initial trocar, which is where 50% of laparoscopic complications take place, and then using direct visualization for placement of all your subsequent trocars. And we had a discussion about the details of this in season 9, episode 13, and also season 7, episode 5. We also discussed using ultrasound to map adhesions prior to surgery to try to prevent trocar injuries. In fact, we discussed most aspects of trocar injuries in those two episodes, so I’ll refer listeners to go back and listen to those. Great episodes for residents. Secondary prevention again focuses on discovering the injury. So good practice would always be to survey where you place your initial trocar and look for any injuries. But the goal here, of course, is to avoid a delayed diagnosis three to four days later when she shows up in the emergency department with fever and acute abdomen. And then you discussed tertiary prevention just now, again, the repairs. Yeah, yeah.
STUART: 33:16
Okay, so I’m gonna throw you a little bit of a curveball. So I know the four tips thing is your thing, but I was just gonna see, would you mind if I present my four tips for preventing bowel injury?
HOWARD: 33:26
We love four tips for preventing bowel injury.
STUART: 33:29
All right, sounds good. All right. So first one is to dissect before you cut. So if you can see through it, you can cut through it. And many times injuries happen when a surgeon cuts into this dense forest of adhesions without really knowing the distal part of what they’re cutting. If you can’t see through it, try using blunt dissection to make the area smaller that you need to cut. In open surgery, you can use this pinching technique to thin out the area. Sometimes that can be helpful. In laparoscopic surgery, it’s helpful to make windows in the adhesions. And then also, like if you’re using something like a ligature, you can actually use that to watch the tissue as you clamp down on it. Don’t burn or cut, but watch it as you clamp down on it. Sometimes you can tell then the kind of character or texture of the tissue as you do that. The more you do these things, the better you get at them. But you want to make those windows before you cut. And then number two is when you’re not sure and you cut, always cut cold. So a cold injury is easier to repair than a thermal injury, as we’ve talked about. So a hot injury complicates things because of these thermal effects and the tissue desiccation. And so I think if you cut cold, a lot of times the repair can be a lot more straightforward if you do happen to get into the bowel. Number three is one of the best tricks I have. So this comes up sometimes with really bad endometriosis or sometimes with like TOAs. If you really cannot tell where the bowel is, this can be a good time to use a stapler. So as long as you know where the ureter is and if you know where it’s not in the staple line, even if there is a little bit of bowel in there, you’ve sealed off the bowel wall if you if you create that with a stapler. Now you could, depending on where it is, you could worry about a bowel stricture. And obviously, if you’re on the mesenteric side of the bowel, you need to be really careful because you can compromise blood supply. But in certain situations, it’s actually been really helpful for me. I remember as a new attending, I guess as a new oncology attending, maybe three years ago, I was doing a really bad left-sided TOA, and I could not, for the life of me, separate the sigmoid from the left ovary. And by the way, TOAs, as you guys probably know, can be some of the worst things that you have to deal with surgic surgically. But the stapler was really my friend that day because I was able to basically run a staple line down the edge of the ovary and I avoided a bowel injury because sometimes when you’re, especially with infection like that, you’re dissecting and just the tissue just falls apart in your hands and it can you can big really make a big mess. So it’s it is, I think it should be rarely used, but it can be a really nice lifesaver in some of those situations. And then finally, number four, you can consider checking the integrity of blood supply with IV endocine and green or ICG. The dose I usually ask for is about five milligrams. So that is two CCs of the 25 milligrams and 10 cc’s of sterile water, which is the standard mix that the nurse will have. And then you give it to the anesthesiologist and they give it IV. And you can see this with a near infrared imaging either on the robot or some laparoscopic systems. Or if it’s an open surgery, you can use a handheld device called a spy fi, and that’s you can see that up on a screen as well. So you ask the anesthesiologist to push it, and then within about five seconds, you’ll see the bowel turn green. And if there’s an area of vascular compromise, the bowel will not light up in that area. So I almost listed the bubble test as number four, but really this is that this is that test where you look at the recto sigmoid integrity by filling the pelvis with fluid and then including the proximal sigmoid, and you introduce air into the rectum to look for bubbles. And but that’s really good for a Frank perforation, but it doesn’t really do anything for thermal or ischemic injury. So the ICG trick I think is better for that.
HOWARD: 37:07
Alright, well, four tips and a bonus. So okay, well, let’s move on to vascular injuries. And again, I would point the listener to episodes seven, season seven and episode five for a discussion about preventing vascular injuries, certainly at the time of trochar injury. But the main principle is to angle your initial trochard about 45 degrees and away from obviously away from vessels, and a little bit less so in obese patients and forty-five degrees in in thinner patients, and keep it midline so that it’s directed away from the aorta and away from the iliacs. We have a complete discussion of that elsewhere, and we talked about a lot of things there, and we discussed the literature too about elevating the abdominal wall during the time of trocar placement as well as alternate port site placements and all those sorts of things. So that’s primary prevention. Secondary prevention is easier here because the patients are bleeding, and so it’s usually hard to miss a vascular injury with a trocar unless it’s retroperitoneal and then it’s tamponotid, but still the patient, even in that case, will usually become hemodynamically unstable pretty quickly, and so go look for the vascular injury if it’s not obvious. Okay, well, let’s get to tertiary prevention and have you fix some of these vessels. So we’re gonna do this like the boards again, so you can’t say just consult vascular, even though it’s what you want to do, or your friendly trauma surgeon, or whoever, they’re out doing something else. So we’re gonna just talk about how to fix it, even though in real life, please call your trauma surgeon, your vascular surgeon, your general surgeon, whoever you can as fast as possible.
STUART: 38:35
Yeah, for sure. In real life, never sweat alone, you’re right.
HOWARD: 38:38
So yeah.
STUART: 38:39
But yeah, everyone should know how to deal with these and really know the steps and you know what your consultant would do. I work at an outpatient surgery center where some of my OBGYN colleagues do laparoscopic tubules. And I mean, this is a surgery center that’s like mostly ophthalmology and orthopedic surgeons, like nobody, nobody in that building is gonna help you. And there’s no vascular backup. You have to transfer those patients to the hospital. And these injuries can happen at any time, at really any time you put a scope in a patient.
HOWARD: 39:06
Yeah, or it’s 3 a.m. at a community hospital like mine, and you’ll get a surgeon, but it’s gonna be 30 minutes. And that’s a long time with a vessel injury. Okay, let’s start big. Your first injury is a trocar injury right into the aorta.
STUART: 39:19
All right. So to quote one of our favorite books, The Technique and the Use of Surgical Tools by Anderson and Romff, one of their quotes in there is hysteria is not a useful adjunct for control of hemorrhage. And I love that quote. While it may go against every instinct, as the surgeon, you have to make remain calm in these situations. So we have a trucker injury to the aorta, assuming this is a full thickness injury. At this point, you need to recognize that you will almost certainly need to open the patient. There may be some extremely skilled laparoscopist with an extremely skilled assistant right there, who and a highly trained OR team who can maybe handle this laparoscopically, but for most of us, that’s not the time to test those skills. So you need to prepare the OR for an emergency laparotomy. The trochar at that when you put it in, the trochar is tamponotting the injury at this point, so you don’t want to remove it or manipulate it. And then remember that once you make the laparotomy, the bleeding is going to pick up quickly. You probably haven’t put insufflated the abdomen, but still, once you remove all that pressure, the bleeding is going to pick up quickly. And you need to get your thumb on the proximal aorta just as quickly as you can, really within seconds. So even if you don’t have a vascular surgeon immediately available, you might try to get one on the phone. Sometimes they can be helpful to talk you through things. But assuming you can’t do that, the next thing I would ask for is bulldog clamps. Now, again, you can use your hands and you can use your assistant’s hands, but if you do have these clamps, they can be helpful. They’re like little thin spring clamps, they’re like chip clips, and they can do a lot to help free up your hands while you’re doing the repair. But in the absence of that, you can use either direct pressure with your fingers or with a sponge stick. You can get a couple sponge sticks to get proximal and distal control on the aorta. So thankfully the aorta is a thick walled vessel, so usually you don’t have to worry as much about making the tear worse like you do with the iliac veins or the IVC. So you want to isolate your uh your tear as best you can. All of these are going to start with restore normal anatomy as best you can get good visualization. You want to sew in a dry field, and then you want to use 5-0 or 6-0 permanent monofilament suture. So polypropylene, most commonly known as proline. You do simple interrupted stitches for these, and you don’t want to tie these down too tight, just enough to equate the vessel. And you may have a little bit of leak even after you sew these down, and sometimes you can use some product on there, some prothromin product to help a little bit, but it’s obviously not going to help if it’s brisk arterial bleeding. If you’re lucky to have pledgets, which are these little kind of felt squares that that help distribute the tension of your stitch tied down, you can ask for pledgets, but even if you may not even have those. Just know that even if the repair isn’t perfect, vascular surgery actually can come back later and do an endovascular repair, but obviously you just want to save the patient’s life and stop the bleeding as best you can. And this is really damage control at this point. If you really can’t repair it and you need to transfer the patient to a vascular surgeon, you can leave those bulldog clamps on as long as it’s an infrarenal injury, which assume I would assume it would be. So just leaving those clamps on the aorta and transferring the patient open can be an option.
HOWARD: 42:30
It’s hopefully an infrarenal injury for gynecologists, but and I’ll also say something quite obvious, hopefully to all the listeners, but I have a surgeon friend who told me about a case where an injury not to the aorta, but to I think the iliac we’ll get to next had occurred, and they went ahead and opened with a transverse incision. Please make a vertical laparotomy with these injuries. This is no time to have a thought about the cosmetics of the abdomen. Okay, so so let’s get to a large venous injury to the IVC or maybe the common iliacs from a trophy, let’s say.
STUART: 43:05
Absolutely. So this is similar in some ways. I will say there’s probably a better chance that this can be addressed laparoscopically. And particularly for small injuries of the common iliac or even the IVC, I’m actually less likely to put stitches in these because of the thin wall, and you can really pull those stitches through. And really, it’s a lot easier to make this injury worse. The aorta is thick walled and generally you can always make things worse. But it’s it in this case, it’s a lot easier to make things worse because you can pull through the thin wall of the venous vessels. So the first goal, again, is to get proximal and distal control. Remember that the blood flow is flowing towards the heart and the veins, and so that’ll help you remember where to focus your pressure. If I’m trying to do this laparoscopically, I would put a ratec in as quick as I can and just tamp it on and then work on my game plan. Believe it or not, often these five to six millimeter defects can be plugged with a hemostatic foam matrix like flow. Followed by five minutes of direct pressure. This is actually surprisingly effective. I’ve done this a handful of times. For a larger defect, you can sew it, but the other thing you can do is you can elevate the edges of the defect if it’s open either with an Alice clamp or laparoscopically, you can use one of those laparoscopic Alice clamps. And you can use like a locking polymer clip, like a hemolock clip, to go across the defect. You’ll narrow the lumen a little bit, but that’s less of a concern for these. But you would go parallel to the vessel. I learned this technique actually in a pig lab, and I’ve actually been able to use it on a real patient. So it is another option as well. If you try the repair and you end up tearing the vessel and you’re really in a mess, remember that you can always ligate the vein. Now this will lead to significant lower extremity edema, but in an emergency, you just need to stop the bleeding. Obviously, you can’t do this with an arterial injury of the common or external iliac, or the patient will lose her leg, but for a venous injury, that would be a possibility as long as you have really good view of your arterial vessels and your ureter.
HOWARD: 45:08
All right. Yeah. Well, let’s move on to retroperitoneal hematomas, retroperitoneal vessel that’s bleeding. So let’s say it’s a retracted uterine artery, maybe even something near the internal iliac. And you can assume that you have laparoscopic access or you’ve got a robotic system available.
STUART: 45:23
Yeah. So kind of same. Always start with pressure. Add an extra port if you need to. I didn’t mention that with the previous one, but at that point I would have extra ports in. Place a RayTec and then open a suction irrigator if you don’t routinely open one on a case, which you probably shouldn’t. And then next, I would try to find the origin of the internal iliac artery as best I could. Remember the posterior branch of this comes off about a centimeter or so after the bifurcation of the external and internal. So if you can go a little distal to that, you can avoid compromising the blood supply to the glute. And this is particularly important, especially in older patients. So I would essentially at this point make sure I can see my ureter, and then I would make sure I could see my external iliac vessels. And then at that point, I would seal the internal iliac artery with a bipolar. Don’t cut it, but just seal it. And that should get your bleeding under control. You could also potentially use a hemoloc clip if you would, if you want to. Those can be helpful in these situations as well. There is actually another retroperitoneal bleed that’s scarier, and I think we have to have a lot of respect for, and that’s bleeding from the pre-sacral venous plexus. These are small vessels and they’re classically at risk during rectal surgery, but also your gynecologist can injure it at the time of sacrocopexes, and then some deep endometriosis surgeries can injure it as well, or you could even injure it with a trocar placement. This can actually be life-threatening bleeding because these vessels retract into the sacrum and they can be really difficult to access. Sometimes they need things like pelvic packing, where you leave a pack in for 24 to 48 hours and then take the patient back to the OR to remove the packing later. For focal bleeding, there’s some tricks too, like surgical thumbtacks or even bone wax that could be helpful. But that is very scary bleeding.
HOWARD: 47:10
And the surgical thumbtacks are not in most hospitals. So if you’re a person who routinely does these mesh augmented sacroculpoxies or something like that, sacrospinus fixations, I should say, you should probably have them available because we need one. So okay, I’ll give you an easier one. Let’s say you’ve just injured an omental vessel with trochar, that’s pretty common, or maybe the inferior epigastric vessel when you put your trochar in.
STUART: 47:33
Yeah. So you’re right. This is easier in many ways, but we still have to remember our advice to remain calm. I think a panic surgeon in any of these bleeding situations can definitely make things worse. For omental vessel injury, it really comes down to isolating that bleeder and just making sure that there’s no bowel in it. The bowel’s not compromised. If it’s the greater omentum, you really don’t need to worry about compromising the blood supply. You can just seal the bleeder, usually with bipolar. But for the lesser omentum, there is mesentery that lies below that that you need to make sure not to injure. And really the worst thing would be to get the middle colic artery, which could really devascularise the colon. So you need to be careful with that. And you could use some of those techniques we talked about, like with ICG or something like that, if you’re worried about the blood spite of the colon. Again, extra ports can be helpful. You can move your camera around to the accessory ports if you’re having trouble seeing the anatomy and seeing behind where that vessel injury is. So that’s what I would do for a mental injuries. And that probably applies to like the greater curvature of the stomach, too. For your epigastric, inferior epigastric vessels, you can see if you can ligate those with a deep stitch, or you can use a Carter Thompson sometimes, particularly in obese patients, maybe to get down there. Or there’s that everyone’s favorite, that folibulb trick, where you can thread a small foley down the trocar, replace it with a Kelly, and then inflate the balloon interabdominally and clamp the tube externally to provide pressure for a little while where you continue with the surgery.
HOWARD: 48:58
Okay.
STUART: 48:59
All right.
HOWARD: 49:00
Well, you’re doing great from your board exam, board examiner’s perspective, but now I’ve got to push you to your limits of knowledge, right?
SPEAKER_00: 49:06
Right, right.
HOWARD: 49:07
So here’s your curveball, because you’ve you got you’re getting all the questions right when you get curveballs like this. So people are placing more and more of these trocars at Palmer’s point. And let’s say you do that, but you injure the splenic vein.
STUART: 49:19
Yeah. This is a tough one because you might think you can just ligate the splenic vein and all is good, but you really can’t do that, or the spleen will get engorged with blood. So, really, in this case, the uh a a kind of full injury of the vein needs the spleen needs to come out. So when we think of the spleen, we also have to think of the pancreas, which breaks those one of the core cardinal laws of surgery of not messing with the pancreas. But you need to explore for an injury of the pancreatic tail. If you hit the splenic vein, you gotta think about that. So in that case, after doing a splenectomy, I’d probably leave a drain around the tail of the pancreas just to make sure we don’t have any sort of leak.
HOWARD: 49:57
Okay, well, you pass. We may go long, but let’s finish this for the sake of completeness. So let’s move on to neuropathies. Now let me review quickly what people call the lithotomy nerves. These are super high yield for residents and for their exams and board exams. The femoral nerve remembers L2 to L4, and you see this sometimes with the blades of deep retractors like the O’Connor or Sullivan, and the patient comes in with loss of a patellar reflex and weak hip flexion. And then the common perineal nerve, L4 to S2, injury from pressure on the fibular heads in the stirrups can cause this, and the symptom is foot drop. And then the obturator nerve, L2 to L4, you get injury during pelvic lymph adenectomy or aberrant placement of TOT slings, things like that. And so you get adductor, adductor weakness, and sensory loss on the medial thigh. So for primary prevention, the emphasis is going to be on checking patient positioning, positioning in the stirrups, make sure they’re padding and in a neutral position, rechecking this throughout the case, especially if it’s a long case. I’ll add another primordial prevention that we didn’t discuss earlier, which is just having quicker cases. These sorts of injuries are very often associated with cases that are longer than two hours. So a culture that does all the things we talked about before and focuses on efficiency and speed in surgery will necessarily produce fewer of these injuries because their cases are quicker. So I think I’m going to put that in the primordial pot. But let’s go through prevention for each of these nerve injuries that we sometimes see happen, including upper extremity nerves, which I don’t worry so much about as a vaginal surgeon, but for longer robotic and laparoscopic cases, which are becoming increasingly common, that can be an issue. So let’s talk about prevention for each type of nerve injury. And I’ll let you start with brachioplexus injury prevention since you’re doing these those kinds of cases.
STUART: 51:42
Yeah, for sure. Yeah, these longer robot cases and these patients who are in 30 degrees of T-berg, oftentimes they’re in my OR at least, or are very obese and having surgery for endometrial cancer. Traditionally, we would use shoulder braces to help keep the patient from sliding. But I really prefer to use alternatives like an egg crate from a mattress. I have used a beanbag before, gel pads, all those sort of things that create kind of a high drag coefficient to prevent sliding. If you do have to use shoulder braces, and occasionally we do, you want to place them over the acromioclavicular joint rather than either too close to the neck or too lateral. You can get some injuries as well with the armboards. So you want to make sure that the arms are never abducted greater than 90 degrees from the body to avoid stretch or compression injuries. This is why people like to commonly tuck the arms. And you know, that’s more of an issue with traditional laparoscopy where you’re standing next to the patient. But when you tuck the arms, you actually can get an ulnar nerve injury as well. So you want to make sure that the forearm is protected on the armboard or it’s wrapped in foam to prevent compression within the cubital tunnel and make sure that your IV wires and such aren’t causing compression. So lots of things to think about with the upper extremities.
HOWARD: 52:58
Okay, and then back to the lower extremity. So the femoral nerve injuries, as I said, are usually caused by retractors. So one thing you can do is use the shortest possible blade on any of the self-retaining retractors, the metal retractors, so that they accommodate the thickness of the abdominal wall, but not much else. And then you can place a rolled laparotomy sponge between the retractor and the wall to increase the space away from the psoas muscle. Basically, you don’t want the tip of the retractor on the psoas. And you could consider releasing the retractors intermittently, especially during longer cases. Or of course nowadays you could just use a disposable bladeless retractor like the Alexis O and there’s some other ones out there, which do away with this issue altogether, hopefully. The other place the femoral nerve gets injured is with candy cane stirrups. So I emphasize using a very high positioning of the leg with candy canes, which gets the leg out of the way, but also the point of it is that the hip is not hyperflexed beyond 80 or 90 degrees. This extreme abduction or external rotation of the thigh is what can lead to an injury. So you want your candy canes almost as high as they’ll mechanically go so that the foot is pulled as high as possible into the air, and you want it at the very edge of the bed to prevent the hyperextension at the hip. And then of course you may still need to pad the knees, particularly on obese patients, so that the knees aren’t touching the cane of the stirrup. With stirrups, people worry more about, I think, common perineal nerve. Injury to the common perineal nerve is the one I think most people think about and why they believe fundamentally that they should use Allen’s type or yellow fin stirrups whenever possible as compared to candy cane stirrups as an important part of preventing the injury to the common perineal nerve. But I think that they actually confuse this issue a little bit. The candy cane stirrups, as I said, are more associated with femoral nerve injuries, and the Allen’s type stirrups are more associated with common perineal nerve injuries. So gynecologists should not be avoiding candy cane stirrups. They just need to use them in a high position to avoid hyperextension of the hip and possible femoral nerve injuries, and then make sure that the knees are padded with whatever either type of stirrup if there’s contact at the knee. And make sure that they have in the yellow fin, Allen’s type stirrups, that they have some freedom to move and avoid compression on the knee leading to these injuries. And also try your stirrup in both positions you’re going to have it in. If you’re going to have your yellow fin in a low position as you’re doing perhaps a laparoscopic portion of the case, and then you plan on moving them up to a higher position when you do a vaginal portion of the case, before you prep or you should test them in both positions to make sure that you like the padding and the mobility of the knee and everything. But overall, candy cane stirrups, particularly for just straight vaginal surgery, which is my focus, is associated with less injuries when the patient’s positioned correctly. You also want to check the lower extremity position uh before surgery to make sure there’s no excessive flexion of the hip to avoid injury to the lateral femoral cutaneous nerve.
STUART: 55:50
Yeah, one other thing to think about too is the width of your transverse incisions. So you really want to keep them within the bounds of the rectus abdominis muscle to avoid injury to the iliohypogastric and the ilioinguinal nerves.
HOWARD: 56:04
Yeah. And also think about where you place your trocars during endoscopy and stay away from those two nerves. Patients with those nerve injuries may complain of sharp pain and burning sensation at the incision. And I think this probably happens more than we realize with these big wide cesarean incisions. I see some scary long phantills that are usually just unnecessary. But patients, though, they’ll get paresthesias also over the mons pubis or even the labia or inner thigh if you injure one of those nerves. So obviously, most of the emphasis on neuropathies is prevention. Management of nerve injuries is going to be dependent upon the type of the injury and the degree of disability that the patient might have, but obviously it’s rehabilitative in nature.
STUART: 56:44
Yeah. Well, we’ve talked about a lot today. I think maybe we should save infections for another day. What do you think?
HOWARD: 56:50
Yeah. Well, I think we’re already over. I do think here at the end we can hit another aspect of quaternary prevention that you and I’ve talked about before. So just to mention again, two important parts of this are disclosure, which lessens the risk of liability and the anger of the patients, and then the second victim syndrome.
STUART: 57:06
A lot of lawsuits are brought because the patients want answers about what happened. When they feel like the surgeon or the hospital is covering something up or they’re not being honest, then they see the plaintiff’s attorney as a venue and an avenue to gain answers for what they really want to know what to know what happened. So disclosure does reduce the risk of malprac malpractice lawsuits. There is a mnemonic that is helpful called heal H E A L. This stands for honesty, empathy, apology, and lessons learned.
HOWARD: 57:36
Yeah. Well, when there’s a complication, our instincts are to be evasive or distant and to never admit guilt. Or if there’s any lessons learned, it’s always secreted away in some internal review or a morbidity and mortality conference or some peer review process. But this heel approach replaces that traditional deny and defend approach. And it’s been shown to drop new claims by about a third and maybe even more importantly, cut the financial impact of those claims by almost half. And this work’s been done at the University of Michigan where they fully embrace this model. You can apologize and show empathy and honesty and let the family and patient know that you’re going to do you’re going to do whatever you can to avoid this happening again to somebody else, if possible. And you can do all that without directly admitting liability, but you counter the sense of deception that they might have with your honesty and the sense of being devalued with the empathy that you show. And apology and preventing recurrence lets patients and families know that there’s accountability and systematic improvements can be made so that other patients won’t be harmed.
STUART: 58:40
And that’s what we all want. Yeah, those are all good ways of carter prevention. And then, of course, we need to think about the harm to the healers with the second victim syndrome. And we don’t have to go into that too much today, but obviously we need more robust systems that focus on mentoring and fairness for healthcare providers that doesn’t penalize them, but actually encourages them to seek help and improve if necessary. This is called just culture, and that’s something that your hospital or hospital system should be pursuing in their peer review processes to minimize the second victim burden and create a receptive environment for quality improvement.
HOWARD: 59:15
Yeah. Well, I know we’ve probably gone over on time, but we can’t do an episode without at least some mention of something historical. So I’m trying to think of what do we do about the history of surgical complications. And there is this famous the 300% mortality legend about Robert Liston. Yeah. He was known as the night he’s a 19th century surgeon known as the fastest knife in the West. So before anesthesia, speed was the only way you could really get the case done without without a patient who’s willing to lay there in agonizing pain. So the people were known for their speed, particularly at amputation. So during one particularly frenetic leg amputation, Liston reportedly worked so quickly that he amputated the patient’s leg, but the patient later died of gangrene. He accidentally sliped off the fingers of his assistant, who also then later died of gangrene. I wonder if they have a common cause. And then he slashed the coattails of the distinguished spectator who was so terrified that he’d been that he’d been stabbed that he apparently dropped dead of a heart attack. Or they said he died of fright. So this is the only surgical procedure that we know of that has a 300% mortality rate.
STUART: 1:00:25
So we did talk about infections. Yeah, right. Yeah. Yeah. Don’t get gangrene.
HOWARD: 1:00:31
The other thing I’ll mention just briefly, and we can end, just as a history segment, was the idea of the morbidity and mortality conference is our cultural response to complications in surgical training and certainly in all forms of surgical training, including gynecology. And this is credited to a Harvard physician known as Ernest Codman, who suggested a hospital should track their patients to see if the treatment was successful. And if it wasn’t, why wasn’t it? And he Similvice, though, was kicked out of Massachusetts General Hospital for his persistence. But he developed these complication logs, which became the blueprint for modern quality improvement and the basis for how surgeons learn from their mistakes. So that’s our history bit. Okay. Well, we’ll see if this all fits into roughly an hour and we’ll worry about infections later.
STUART: 1:01:22
Sounds great. Thanks so much for having me on. I appreciate it.
HOWARD: 1:01:24
We’ll have you on again later, hopefully this season or this summer. All right. Sounds great.
ANNOUNCER: 1:01:30
Thanks for listening. Be sure to check out thinking about obgyn.com for more information and be sure to follow us on Instagram. We’ll be back in two weeks.
