Episode 8.7 One Layer or Two? Endometrium or Serosa? And Minimally Invasive Surgery
In this episode, we discuss the evidence behind one layer and two layer Cesarean closures with an emphasis on inclusion of the endometrium and the risk of cesarean scar ectopics and placenta accreta spectrum disorders. Plus, we define minimally invasive surgery and trace the origin of the term and it’s introduce a new concept: less invasive vs minimally invasive surgery.
00:00:02 Hysterotomy Closure Techniques in Cesarean Deliveries
00:14:46 Debunking Claims About Cesarean Techniques
00:27:20 Uterine Closure Techniques in Cesarean Deliveries
00:36:44 Defining Minimally Invasive Surgery
00:48:18 Advanced Techniques in Minimally Invasive Surgery
Links Discussed
Cesarean section as a risk factor for the development of adenomyosis uteri
Hysterotomy closure at cesarean: beyond the number of layers
Hysterotomy closure at cesarean, beyond the number of layers; a response
Gynecologic Laparoscopy and Hysteroscopy in a Day Clinic: Trends and Perspectives
Transcript
Announcer: 0:02
This is Thinking About OB-GYN with your hosts Antonia Roberts and Howard Herrell.
Howard: 0:18
Antonia.
Antonia: 0:18
Howard.
Howard: 0:19
What are we thinking about on today’s episode?
Antonia: 0:21
We’re going to get to some new articles and also a list of a question or two, but first, what’s the thing we do without evidence?
Howard: 0:27
How about deliberately avoiding the endometrium when we close the hysterotomy at the time of a cesarean?
Antonia: 0:33
Okay, sure, so this is something that different surgeons have had different thoughts about over the years, and more recently there’s been a move, at least in the literature, to promote not including the endometrium during closure of the uterus as a way, in theory, of preventing cesarean scar niches or placenta accreta spectrum disorders in future pregnancies.
Howard: 0:55
Yeah, exactly, and we could throw in as a part of this discussion whether to include the serosa in the closure as well. There’s some surgeons who are very dogmatic about not including the serosa. But if you do the most common one-layer closure approach, then you’re taking a full thickness bite of the serosa or the peritoneum on top and the myometrium, and usually you’re going to get most, if not all, the endometrium in that same bite. So the default right now is that both the endometrium and the serosa would normally be included in your closure.
Antonia: 1:24
Yeah, and that’s been a widespread default standard practice for quite a while now. But as cesarean rates have risen and uterine rupture and invasive placenta have been studied more over time, maybe their rates have increased as well. Then different theories have come out about the hysterotomy closure technique. Well then, different theories have come out about the hysterotomy closure technique and, alternatively to the default with the full thickness including all layers, you could do a one layer closure that deliberately leaves the suture bites above the endometrial junction but might still include the serosa, or you could exclude the serosa too. You could run these locked, you could run these unlocked, or you could exclude the serosa too. You could run these locked, you could run these unlocked. Or you could do one layer that incorporates the endometrium in the inner two thirds or three quarters of the myometrium and then do a second layer that gets the serosa, that’s imbricating, but then excludes the endometrium. It’s almost like you could keep thinking of new, different variations and combinations, and I’ve heard all of these and I’m sure there’s more.
Howard: 2:30
Yeah, and depending on how those bites are taken, you might be approximating or opposing the myometrium to the myometrium itself, or you might be folding it up so that the endometrium becomes approximated to the endometrium, with the myometrial edges turned upward and not in contact with each other.
Antonia: 2:46
Yeah, and that’s how we’re taught that skin should be closed, because the skin supposedly when the edges are upturned will actually heal with a better scar than if they’re just barely touching. Then they end up healing with a little bit more of a defect, but that’s not necessarily how muscle heals. So when the edges of the myometrium are turned upwards, the surgeon probably took bigger bites, especially where the bites on the inside cavity edge are farther apart than the bites on the outer serosal surface. And so you can imagine, if you’re really following the extreme arc of a needle, how this can happen, where you put it in through the serosa and your wrist is really turned and then it ends up coming a lot more lateral on the endometrial side. So that will have the effect of puckering the endometrial surfaces in to the incision rather than keeping them flat and smooth.
Howard: 3:42
Yeah. So even when you say a one layer closure, that’s full thickness. There’s potentially huge variation in what that means from surgeon to surgeon. I for one do take smaller bites and try to have the endometrial edges laying flat against each other so that the suture is traveling through the tissue and not circling more widely at some depth. This is why surgical techniques are so hard to study, because I think we’ve described I don’t know six or eight different ways already that you could close the myotomy at the time of cesarean. And especially in retrospective studies where people just gather op notes and see what did somebody do or not do, it would be very unclear from all of our operative notes exactly which of the techniques we just described were actually used in the surgery. So it can be very confusing.
Antonia: 4:26
Okay, let’s quickly talk about the serosa first. Hopefully that’ll be an easier one to just open and shut, so to speak. So why would someone not want to include this in their suture line?
Howard: 4:37
Yeah, hopefully this is the easier of the two issues.
Howard: 4:40
So the serosa, I think, should be included in the closure. I think the reason why folks didn’t include it in the past was because the older techniques that we’ve described 50, 100 years ago the serosa of the uterus was intended to be closed as a separate layer. So you would have to deliberately avoid grabbing that serosa in your bites of your uterine closure so that then you could leave those edges to be closed later in a second separate layer of suture. So for decades the technique really emphasized not grabbing it so that you could have it preserved to close. And then we went through this period of time, starting in the 1990s or so, where we learned that closing the serosa independently as a separate layer, wasn’t necessary and might, if anything, be associated with more scar tissue. So we stopped closing it as a separate layer. But then some people continue to be dogmatic about not including it in their uterine training because of how they had been trained before, and I think today people confuse like separate layer versus within the same closure.
Antonia: 5:42
So it was always supposed to be closed, and the issue was just whether to close it separately or to include it in the same layer, not to leave it open.
Howard: 5:53
Yeah, I think so.
Antonia: 5:54
Yeah, so the studies that were saying that separately closing it weren’t looking at the alternative of either leaving it totally open or of closing it in the single layer? They were just commenting on separately. You don’t need to have it in its own layer.
Howard: 6:09
Exactly so.
Howard: 6:10
If you don’t now, if you don’t grab it in every single bite, don’t worry, sometimes you can’t see it, there’s a lot of bleeding.
Howard: 6:15
You’re just trying to get things closed quickly and it turns out that you didn’t grab it the whole way, on the bottom especially.
Howard: 6:20
Okay, well, don’t worry about that.
Howard: 6:22
You probably have less bleeding and require less bovying and less figures of eight. If you do get it enclosed, this serosa layer is what tends to bleed, and so leaving it out of your bites and having to deal with those bleeders may increase your operative time and increase the amount of suture used, which increases the inflammatory burden and perhaps creates more adhesions, which may be the problem with closing as a separate layer, as you’re increasing your operative time and putting more nidus of inflammation in there with a separate layer of suture. But if you read all the old studies that led to us not closing the serosa, you’ll see that the reasoning behind it was exactly that that it caused longer operative times and caused more inflammatory burden. But including the serosa as part of your full layer closure does not increase your operative time it’s the same bite or the inflammatory burden because it’s the same piece of suture but it does lessen the amount of bleeding from the serosal edge, where a lot of folks will spend a lot of time bovying once they’ve done their closure.
Antonia: 7:16
So people maybe have just confused the reasoning here. I can see where maybe a younger physician who has never seen the serosa closed as just its own separate layer might interpret these papers. They’re reading that talk about non-closure of the peritoneum and the serosa as meaning don’t even include it at all. But that’s not what it means. But now, when people are reading it that way and they’re starting to practice that way, it’s an accident of understanding the intent of these studies.
Howard: 7:44
Yeah, I think so, and I think you just called me old too. But certainly when I was a resident, there were attendings who wanted this closed as a separate layer. I’ve done it plenty of times and that went away.
Antonia: 7:55
Okay, then now let’s talk about the endometrial layer.
Howard: 8:03
The origin of this and the fact that this different technique has existed for so long is actually still related, I think, to why we used to close the serosa as a separate layer.
Howard: 8:13
So in the early days of surgery, and of obstetric surgery too, we emphasized what some call a Halsteadian approach to our procedures approach to our procedures and this was based upon viewing surgery as just applied anatomy, where it was important to dissect every layer carefully and preserve them as independent structures and then close every layer back in a fully opposed way so that healing would occur correctly. And this is the opposite, if you will, of minimally invasive surgery that we practice today. And 40 years ago, the most common way a cesarean would have been performed would be in a way that sharply dissected and preserved every layer and then closed every layer that you could identify anatomically. So two-layer closures were there to make sure that the myometrium was apposed correctly, and then an imbricating layer would prevent the edges from turning upward and also allow drainage of any blood into the cavity rather than into the abdomen in the pre-antibiotic days, when they were really worried about seroma formation.
Antonia: 9:10
Yeah, we didn’t really talk about the second layer being imbricating, so that has yet another wrinkle into how many ways the myometrium can be closed.
Howard: 9:19
Yeah, we’re up to 12 or 14 or 16, 18 ways now. So yeah, then you would close the serosa on the uterus as a separate layer on top of that imbricating layer, and then close the peritoneum, the parietal peritoneum, as a separate layer, and then the rectus fascia and you would even try to close camper’s fascia as a separate layer, always with this emphasis of re-approximating each anatomic layer to the other appropriate anatomic layer. But then we learned that it just doesn’t matter and that if you just put the tissue together it heals. In fact it heals as well or better without all that suture in there. But there’s been resistance to this. Simplification, and adoption of what I would call minimally invasive techniques, not including the endometrium, has been a stronghold for older surgeons who believe that they do a better job of having myometrial apposition and at least not pulling endometrium into the bulk of the myometrial incision.
Antonia: 10:14
Okay, so besides this Halstedian idea, wasn’t this originally about preventing adenomyosis?
Howard: 10:22
Sure, yeah, and endometriosis perhaps, right. So the idea was that you could have endometrium growing into a pocket of the myometrium by the way, that would be pulled up in there and that this would lead to adenomyosis. And it’s definitely true that having a prior cesarean is a risk factor for adenomyosis and endometriosis. The question is whether the method of closing the myotomy makes a difference in the development of those conditions. Some people also think that you shouldn’t include the serosa with your original suture, because you would pull endometrial cells up through and implant them into the serosa and cause surface endometriosis on the uterus.
Howard: 11:00
So this stuff has never been borne out in the literature, though right. More recently our knowledge of placenta accreta spectrum disorder has changed and developed into the idea that almost all of these placenta accreta spectrum disorder pregnancies start actually as cesarean scar ectopic pregnancies or they grow into the cesarean scar niche, and that these niches can be identified now even in the first trimester, with ultrasound. And so there’s been a renewed interest by proponents of different closure techniques that maybe a particular technique would avoid the endometrium, like not including it, because this might be a way of preventing a niche and therefore preventing placenta accreta spectrum disorder, right and therefore preventing placenta accretive spectrum disorder Right.
Antonia: 11:45
So the trophoblasts invade in the early first trimester into this defective area of biometrium, which is the niche where the NIDABUX layer is absent.
Howard: 11:55
Right. So folks interested in this have made the assumption that these niches are due to basically to poor technique and poor re-approximation and apposition of this layer. So in 2021, there was a paper published that reviewed the cases over several decades of a single practice in New York City where the partners had traditionally used a technique that does not include the endometrium as part of their closure. And then they looked at these cesareans, which included 506 patients who had at least one subsequent cesarean or pregnancy after the first one, and they found no cases of placenta accreta in the surgeries that they had performed. Now they did exclude five patients who had placenta accreta spectrum disorder because the cesarean had not been performed by the primary author.
Howard: 12:40
I thought that was immediately interesting because it seems like the patient might still have had an endometrial sparing technique in the same practice, it seems. But it’s very convenient that all five cases of placenta accretive spectrum disorder in the practice were excluded from the population that they intended to study. But in any event, the authors of this paper, who are friends with Dr Timur Trish, who has done a lot of the important work on ultrasound diagnosis of cesarean scar pregnancies and apparently, I believe, holds the personal opinion that excluding the endometrium would prevent these pregnancies. So this author’s technique is a two-layer closure along with a bladder flap closure or separate serosal closure. In other words, the author’s technique is the same technique from the 1950s or 60s that we tended to abandon as evidence-based practice in the last 25 years or so.
Antonia: 13:26
The statistics in that paper and the claims are very interesting, but there’s no comparator group with any other type of closure technique and I don’t think they really commented on the technique of the five that were excluded with Placenta Acreta and also that sample size is still very small, especially considering what is the baseline incidence of Placenta accreta.
Antonia: 13:45
And also that sample size is still very small, especially considering what is the baseline incidence of placenta accreta. It’s not that interesting, frankly, that out of about 500 cesareans none of them got placenta accreta, or rather that technically 1% of them got it and were then excluded without a whole lot of exploration on that. The incidence of Acreta after one prior cesarean is less than a third of a percent. They also talked about the decreasing rate of placenta previa in patients with multiple cesareans. But that’s frankly irrelevant to the theory that’s being studied here, because your cesarean suturing technique cannot possibly affect where in the uterus a future baby decides to implant, because sometimes it just ends up being previa, that that’s not due to the prior scar there and also the study wasn’t appropriately powered to determine the true rates of placenta previa either. So that’s all kind of distracting from the fact that they’re not really showing anything here.
Howard: 14:46
Yeah, exactly, it’s a brag is what it is, but the authors really felt like they found something and at least one of the authors is relatively influential and well-known name and obstetrics. It’s basically just saying hey look, we did 500 cesareans the way I’ve done it my whole career, and nobody had placenta accretive spectrum disorder. So it must be because I’m such a great surgeon and I’ve done it the way I’ve always done it and all that, but it’s just not designed in any way to make any conclusion like that. There’s definitely been an increase in the last five years among the small group of people talking about placenta accretive spectrum disorder, though, who are claiming that these cases are essentially preventable by going back to a technique for cesarean section that we had previously abandoned as new evidence came along. That said it wasn’t beneficial.
Antonia: 15:39
They did have some interesting visuals, so at least the theory is very strong. But again the numbers aren’t really that convincing. Are there any other studies about this infusion?
Howard: 15:50
ultrasounds on 172 patients who had had a previous cesarean, and most of these were actually repeat cesareans. The patients had either used technique A, which was an endometrium-free double layer closure, like we just read about in the last paper, or technique B, which was either a single or double layer closure that included the endometrium. Then they used ultrasound saline infusion ultrasound to look for niches in these patients, and they concluded that niches were much more common when the second technique was used.
Antonia: 16:29
Okay, that’s interesting. Is there something wrong with this paper?
Howard: 16:33
For starters, it disagrees with what’s already known about the topic and I’ll put a link to a prior systematic review that at least concludes that there’s no difference in a one-layer or two-layer closure, where two-layered closure typically excludes the endometrium, on the rate of cesarean scar pregnancies or rupture. But beyond that, in the current study the sample size is just too small to make any conclusions at all. There was also a significant different time period in which the two groups were ultrasounded and the niches we know are present in up to 60 or 70% of post-saccharin uteruses within a certain time period if you ultrasound. But it changes over time. The incidence of the niches will change over time relative to when the surgery was done. So it’s just not a good study and it lacks appropriate controls, sufficient numbers, blinding, randomization and all the other things that would be necessary to draw a conclusion like this.
Antonia: 17:24
Okay and all the other things that would be necessary to draw a conclusion like this. Okay, and it seems like it also lacks any outcome data, because the real concern is not whether there’s a niche that you can see on ultrasound. It’s whether or not they get a cesarean scar, ectopic or urine rupture or a placenta accreta in their next pregnancy. And given that all of those are relatively rare events, it’s a mistake to assume that all niches or all defects are created equal. The timing and the stage of healing is likely very important in understanding which niches that you see on ultrasound are actually going to affect clinical outcomes.
Antonia: 17:58
I can still remember a case of a patient with a prominent cesarean scar defect on ultrasound who had it twice laparoscopically repaired with the help of a subspecialist because she wanted to get pregnant again. But after her second repair it was still very prominent on ultrasound. I think she had it checked six weeks post-op or something and basically she was told she couldn’t be guaranteed to have a safe pregnancy ever again and wasn’t recommended to get pregnant. You can guess what happened she got pregnant on her own and she carried to term and then she had a repeat C-section that I was scrubbed in for and lo and behold, there was no sign of any kind of defect at the time of her C-section. Everything was completely full thickness.
Antonia: 18:47
And it’s not like we can draw universal conclusions from this kind of a story and say niches never exist, defects never exist. But to have seen it so prominently and so persistently and then it wasn’t there at the end of a pregnancy taught me how irrelevant ultrasound can be in some cases. And again, it’s not wrong to try to repair a defect when you see it. But clearly there’s a whole lot of uncertainty here. So anyway, is there a better study on this issue than the one that you just mentioned, where they were looking at ultrasound niche measurements?
Howard: 19:23
Yeah, two things. I would say that we might be a bit ahead of our skis in terms of what we’re doing as a community with these niches, because, since we made the connection that niches are related to placenta accreta, we’re just fixing them without knowing whether or not that changes their rates of it. So there’s probably a lot of not quite evidence-based surgery occurring. We’re very much in a learning and exploratory phase, so I would be leery of people making relevant claims related to something we haven’t really studied yet and we’re looking for them now and so, when you might see these present in 60 or 70% of people, depending on the time you look, all of a sudden we’re opening up a whole bunch of people having second surgeries after the cesarean based upon an ultrasound finding, when we don’t even know if that second surgery does anything.
Howard: 20:11
Now for the most part, people are operating on niches that are present a while after a year two years after.
Howard: 20:17
That’s still a significant number of people if you look for them, and so we don’t know that these surgeries are helping.
Howard: 20:23
They might be hurting, right, because it’s just more surgery.
Howard: 20:29
The other thing I was going to say is remember that double layer closures and the way we were trying to describe.
Howard: 20:31
We’ll have to include a graphic of these on the Instagram. But the double layer closures also will make the tissue look differently as it’s healing, and it looks different in the weeks to months as it goes on, as the healing is happening, as the sutures dissolve, things like that, and so we know that it changes the ultrasound appearance in a way that is perhaps less favorable to see niches. So an ultrasound a year after surgery may look completely different than an ultrasound right after. And that’s what I was saying about that particular study is the timing differences in group A and group B were done in a way that the two layer closures would probably give a different appearance, and so that it’s not controlled correctly. Because he had single layer and double layer closures and things like that, you’d have to do everything the same except exclude that endometrium in one closure, and they didn’t do that and they didn’t ultrasound them at the same time, so I don’t think any conclusions can be drawn from that study.
Antonia: 21:26
That makes intuitive sense. We do already tell patients to try to wait a year or longer after their cesarean to get pregnant again for the fullest healing of their hysterotomy, and we’re not ultrasounding them six weeks later and then giving them a go ahead. If it’s a certain thickness, okay, nevermind, you can get pregnant now if you want, because your ultrasound looked so good. We might even be falsely reassured if we tried to do that, especially if there was a double layer closure and there’s still suture material present and it looked better than it actually is six weeks out.
Howard: 22:02
Yeah, exactly. So be leery of surrogate outcomes that you pick. And in this case, what the? What it looks like a few weeks or a month or two after delivery? We need data that shows that these surgeries or these niches or that the specific technique actually lead to placenta accreta, and I know I didn’t do a good job of explaining that. But if you can imagine a cross section of a closed uterus and you’ve put like a second imbricating layer in, now imagine what that does to the bottom, where it puckers it into the cavity, and the endometrium is gapped and if you excluded the endometrium and it gapped down, it would look one way.
Howard: 22:35
If you included it, it might still look a different way. Like the immediate post-op appearance of this is affected by how you do the suture and the technique you used.
Antonia: 22:44
Yeah, hopefully that clarifies it a bit better.
Howard: 22:46
We’ll put a picture on the Instagram.
Antonia: 22:48
Yeah, and so you have found a paper that is a little bit better, right.
Howard: 22:53
So there was a paper just in the September 2024 Gray Journal we’re still barely in September as time recording, but this will be October 1st, I think or 2nd, and this seems to be our best evidence about this issue so far. So this paper was published online before it was published in print and interestingly, that means that we already have some letters to the editor and responses about the paper before it was printed. It’s really interesting how this works nowadays and even though it’s just now officially being published this month. But this is a multi-center, double-blinded randomized control trial performed at 32 different hospitals in the Netherlands, where patients were assigned to receive either a single layer or a double layer closure of the uterine incision. This current paper is actually a three-year follow-up of a previous paper that was already published, and they included 2,292 patients in that study and the primary outcome was live birth rate.
Howard: 23:44
They also looked at secondary outcomes like need for fertility treatments, modes of delivery, gynecologic symptoms like abnormal bleeding, which we know niches are associated with, and obstetric complications, including the rate of niches and placenta accreta, spectrum disorders and then, of course, subsequent uterine ruptures in future pregnancies. In the two-layer closures they included the endometrium and the second layer included the serosa, while in the one-layer closure it was the surgeon’s choice whether they included the endometrium or not. Now remember, if there’s even going to be a theoretic benefit to not including the endometrium, then you should really be paying attention to how those tissue layers line up. You probably should be doing a two-layer closure in that case, so that you can prevent them from turning upwards and out from the cavity. So the only possible examples of endometrium non-closure in this study they don’t do that.
Antonia: 24:37
Interesting this is probably how many people are implementing this endometrium sparing technique now, because we have seen plenty of studies saying that the one layer closure is the most evidence-based approach and that alone can be hard enough change if someone was trained on two layers. I was trained on two layers and then switched, or at least attempted to switch subsequently. I still end up putting in extra sutures for bleeding and stuff. Sometimes it ends up feeling like a second layer anyway. But now we’re throwing in this endometrium sparing thing into this one layer closure technique, so it may be a little bit out of context. So we end up with people increasingly doing a one layer closure that excludes the endometrium, which is the thing that they’re featuring in this Netherlands study.
Howard: 25:27
Exactly and, I think, what most people are doing in practice.
Antonia: 25:30
So what did they find?
Howard: 25:32
For one thing, they found a lower rate of uterine rupture in the single-layer group compared to the double-layer group, though this wasn’t statistically significant, but the only cases of placenta accreta spectrum disorder that they found were in the single layer group. They also had three cases of cesarean scar pregnancy and they were in the single layer group. Overall there was no differences, though, in reproductive outcomes at three years and, to reiterate, only the single layer group had endometrium sparing patients. The other closures all include the double layer group and they did not have placenta accretive spectrum disorder pregnancies or cesarean scar pregnancies.
Antonia: 26:11
We can’t know for sure, I don’t think, whether those specific cases had their endometrium layer spared or closed.
Antonia: 26:20
That’s right, but they’re the only ones that possibly could have had that. So it just really makes you wonder. Now, what do people really think is going to happen if you leave a gap in the endometrium on purpose? Now that we’re seeing this play out clinically, it’s not too surprising if you think about it. I do wonder if the double layer closure could be more devascularizing perhaps, and that may lead to a higher risk of uterine rupture, even though that wasn’t statistically significant. But it sounds like the things that may lead to higher risk of uterine rupture are not necessarily the same things that lead to placenta accreta or to cesarean ectopics.
Howard: 27:01
Yeah, and it’s amazing how far we’ve come already right, and now we’re talking about why two layer closures might be associated with more risk of uterine rupture, when five years ago people were shouting at people for doing daring to do one layer closures on people who intended to have future pregnancies, and I actually think that that illustrates a bigger point about all of this is we are.
Howard: 27:20
If anybody’s having struggling following along with this conversation, it’s because we’re nitpicking over minutiae that in reality, just does not matter. This is all an illusion of control, I think, where people think that they are affecting how the body heals and the truth is they’re almost certainly not having any impact one way or the other, but they’re seeing noise in little, insufficient samples of studies and then trying to draw broad conclusions because they really want to have control over this. And they probably really don’t.
Antonia: 27:52
The overall conclusion in this paper is there’s no superiority of a double layer uterine closure over a single layer, which agrees with the original paper that was published with just nine months of follow-up, and they recommend that guidelines should not encourage a two-layer closure. But there’s certainly nothing in this study, which is the best study we have today, to suggest that including the endometrium and the cirrhosa have any negative effect on the development of placenta accreta spectrum.
Howard: 28:24
Yeah, exactly, and we are seeing that change in guidelines. By the way, we had a letter to the podcast and a couple of episodes ago, I think, about somebody upset that they weren’t doing two layer closures as standard of care. But right now the standard of care, I think, about somebody upset that they weren’t doing two-layer closures as a standard of care, but right now the standard of care, I think, is a one-layer closure based upon the most recent literature, and this study informed a lot of that when it was originally published. Now, of course, as I said about the letters to the editor, about this one, these letters were immediately fired off, which claimed that the only real conclusion that you can draw from this study is that a two-layer closure that includes the endometrium is not beneficial over a one-layer closure that may or may not include the endometrium, which I guess in a sense is true because that’s what the study design was. But now this is a case of shifting goalposts.
Howard: 29:10
Right cases of placenta accreta spectrum disorder and cesarean scar niches in this large study occurred in the group that contained the patients who, some of whom, had excluded the endometrium in the repair.
Howard: 29:22
At the same time, the closure that included the endometrium had none of the adverse consequences that the proponents of this theory are talking about.
Howard: 29:30
So you can’t have it both ways. You can’t say that it’s the exclusion of the endometrium that makes a difference and then shift and say it’s the exclusion of endometrium, it only works if it’s also a two-layer closure. The burden of proof is on those who are making these so far unsubstantiated claims to do a randomized controlled trial and not to ignore evidence from the largest and best data set that we have here to now, which simply shows that a two-layer closure has no benefit over a one-layer closure and that not including the endometrium, if anything, is associated with more placenta accreta spectrum disorders. I’ll also include the author’s response to this letter, in which we learned that about a third of the single-layer closures didn’t have included endometrium. I don’t think they put that in the original paper, but they included that in the response, and so why don’t we see a one third less rate of these problems in that group if inclusion of the endometrium is the seminal point here?
Antonia: 30:30
Yeah, exactly. You can imagine how, if you’re deliberately trying to take a bite that’s above the endometrium, you’ll end up being about a millimeter or two higher, so you’re likely going to be leaving the bottom part of the myometrium open as well, at least in some of your bites. So you think you’re leaving a smooth inner surface that way, but you’re just leaving niches instead.
Howard: 30:53
You’re just leaving niches instead. Yeah, that’s a good point. It could actually be that not including the endometrium leads to non-closure of the bottom part of the myometrium because of how difficult it is to distinguish those layers, especially in someone who’s been laboring, and that’s actually the cause, right?
Howard: 31:08
So the fact that you can change your perspective about it just a little bit from the point you just made and see how, in fact, it could make sense that the opposite is true shows why you can’t make decisions about how you do surgery or anything else based upon just theory or expert opinion. We have to rely upon the best data that we have, and this randomized controlled trial is the best data that we have available right now. It might change, and if five years from now something new comes along, let’s go with it, but right now it’s the best we have. And, in summary, this means that the most evidence-based way to close the uterus at this time, based upon current data, is to do a one-layer enclosure. One-layer closure which includes the serosa to prevent all that extra bleeding, and which takes relatively small bites so that the tissue is actually opposed correctly and don’t go out of your way to avoid the endometrium.
Antonia: 32:02
Yeah, so I mentioned that. I have switched to something more like this from how I was taught to do a two layer closure, the second layer being just an imbricating layer, the second layer being just an imbricating layer. But I do get stuck with doing my full thickness one layer closure with a running lock stitch and then still seeing, even with including the serosa. I still get enough serosa bleeding enough times. If it’s just on one spot down, I often will just end up running the rest of the length of that stitch back.
Antonia: 32:36
But it is a little bit of an old habit because that’s how I used to do it anyway and it’s just comfortable. But that’s how a lot of times I’ll just deal with that serosal bleeding. So I really can’t imagine purposefully leaving the serosa open and somehow not expecting to have the whole thing bleed, because I get enough bleeding just when I already close it. But I was also taught to take really big, one by one centimeter bites. So that’s another thing I’m working on switching my muscle memory to make them a little more, a little tighter, closer together, and at the cost of really splitting hairs on this topic even more. I will mention that I saw in some studies that not including the serosa, might also be associated with a higher rate of niches.
Howard: 33:22
Yeah, and I didn’t go into those claims because it’s not from great data, but yeah, there’s actually a suggestion that trying to avoid the serosa may be associated with an increased rate of niches. The serosa may be associated with an increased rate of niches. The theory here is probably that the edges turn up and out away from the cavity side more if you’re tucking it in with that serosal layer closure. I also say that I think less is more you need when you close. You don’t need to go way up on the uterus and serosa, you just need a few millimeters of uterine tissue and serosa. And yeah, you don’t need to skip a centimeter.
Howard: 33:59
And of course, the theory there again is that if you take bites that are too close together, that you’re going to devascularize and there’s people who have all sorts of ideas about locking versus non-locking for that purpose. But just include everything. Take a little bit smaller than centimeter bites, make sure they’re tight and locked and you should rarely have to throw a second suture or do any bovying. But then when you don’t do that, people have a hard time switching to one layer closures because it’s gosh, I’m always having to go back and redo it anyway. I’m just going to do a two layer closure. Half the reason why two layer closures have persisted is because of frustration you’re talking about.
Antonia: 34:34
Yeah, and if someone out there is trying to skip both the endometrium and the serosa for some reason and they’re only doing one layer, then I’m just imagining how are they even navigating around the top serosa and the bottom endometrium with their needle and still making sure all of the bites are equal and symmetrical? It almost seems like you’d need a really tightly curved needle like a UR6, and that would just be really awkward. I would not trust that closure and this specific method. I haven’t had any colleagues say yeah, this is how I do it. Now I haven’t seen it in action, but it really doesn’t seem worth all that hassle for what’s really a very questionable theoretic benefit or even just a misunderstanding of the studies. So include the cirrhosa.
Howard: 35:24
Yeah, the theme of this podcast overall is avoid theory and focus on evidence, and this month’s grade journal has the best evidence we have about how to close the uterine layer, the uterine incision, and so hopefully people will act accordingly. And we’ve had this whole bunch of theory. It actually makes my head spin, all the different theoretical ways that we’re talking about you could close it. We haven’t even talked about should you use vicryl or monocryl, should you do X, y and Z? And the truth is it probably doesn’t really matter for any of these outcomes, which is why we end up in clinical studies saying do the thing that actually is associated with less blood loss and is quicker. And that’s actually why one layer full thickness closure wins is because we just don’t have control over this.
Howard: 36:10
This isn’t microsurgery. We’re not doing tubal re-anastomosis. We’re putting tissue layers together that know how to heal themselves. We’re putting tissue layers together that know how to heal themselves and there’s not a lot we can do to screw it up, except do more tissue damage with more sutures and more bites and take longer and put more suture that needs to dissolve, which causes more inflammation, and not include vascular structures in there that are going to bleed.
Antonia: 36:28
I think somehow the thing we do without evidence segment became our whole episode today. It was timely because this was a new article in the September Gray Journal, so it works out to kill two birds with one stone. Okay, yeah, we did get some articles this way. Then let’s get to a listener question or two if we still have time.
Howard: 36:46
Sounds perfect.
Antonia: 36:47
Okay, this question comes from a resident. They write dear OB, could you talk about what minimally invasive surgery really is? It seems like in my program it’s just anything that’s done with a robot, but in many cases it seems like the robot is more invasive than some of trocar sites, than the same surgery done with traditional laparoscopy. What are your thoughts? Signed too many trocars in Tucson.
Howard: 37:23
This is a great question, honestly, and it meshes with what we were just talking about.
Antonia: 37:28
Yeah.
Howard: 37:29
Minimally invasive at a uterine incision is doing one layer if that’s all that’s necessary and using the least surgery in the least time, right. I agree that at many meetings and in many publications now minimally invasive gynecologic surgery is just a euphemism for robotic surgery. But yes, we do need to define what we actually mean by minimally invasive surgery and I would suggest that we need to think of surgical approaches on a spectrum of most invasive and then something that’s less invasive, and then there is a least or minimally invasive way of doing most things, and minimally invasive should always be reserved for that least invasive option, not other things that are just less invasive, and we need to make a distinction there. And we also have to think about what invasive means. It’s not just how many port sites you have, for example.
Antonia: 38:19
Yeah, since MIS has become a fellowship in OBGYN, as it is in general surgery as well, I think it does seem like it has morphed into advanced robotic training and that’s something distinctly different in many cases from the least invasive or minimally invasive surgical option. The earliest reference I can find in a PubMed search for the term minimally invasive gynecologic surgery was in a paper in 1990 in the Journal of the American Association of Gynecologic Laparoscopists, aagl, and they were talking about all the technological advances that had made so many procedures able to be done endoscopically and concluded that more than 80% of all procedures at that time could be performed endoscopically. They hoped that number would grow even higher and that included both hysteroscopic and laparoscopic surgeries, and they also concluded that most of those cases could be done on an outpatient, same day surgery basis.
Howard: 39:21
Yeah, and this was in a background time then, when most hysterectomies were still being done abdominally and even things like ectopic pregnancies and ovarian cysts were routinely handled with laparotomies. So the preset is that an invasive surgery is something with a large laparotomy and a minimally invasive surgery is something endoscopic. From the takeaway there, and of course, that makes sense, but really what the term minimally invasive surgery means is to make as few of, or as small of, incisions as possible to get the job done, but it also means doing the least amount to the patient. So if you don’t need to take the appendix out while you’re doing the hysterectomy, don’t do it, which is something that they did back then. Or if you don’t need to take down a bunch of incidental adhesions in order to do your surgery, don’t do it. Don’t do things that don’t have a good reason, which had been the trend and maybe still is in some places.
Antonia: 40:12
Yeah, you talked in your vaginal hysterectomy book about how people would routinely make vertical laparotomies 100 years ago and go through and find every possible little thing that seemed different to them and operated on it even, incidentally, even though a lot of it was just variation in normal anatomy. But the only real reason they were there was for the hysterectomy.
Howard: 40:35
Yeah, the exploratory laparotomy right, let’s find all the little things. So do the least that you need to do through as few of incisions and as small of incisions as you possibly can to get the job done. That’s the principle. It also extends to how you make those incisions. So, for example, with cesarean, if you don’t need to dissect the rectus sheath off the fascia in order to do the cesarean, don’t do it. It causes more pain and bleeding and other problems for the patient. So if you can expose the uterus with just a simple fascial incision and don’t need to do all that rectus sheath dissection, then skip it, and I know that I can on almost all of my cesareans. There’s a few repeats where you need to do some dissection to make the space, but there’s all sorts of steps like that are included, and I think our discussion about how to close the endometrium is an example of a least invasive way. And then there’s some more invasive ways.
Antonia: 41:27
Yeah, we talked about that a while ago on our cesarean technique episodes and I definitely still have trouble on repeats getting the muscles to just fill apart in the midline if they’re also scarred in the fascia, and I haven’t dissected them off the fascia so it might just be an arm strength issue.
Howard: 41:45
Again, it’s you do what you need to do it right. Whatever you need for the particular patient, do the least you can. I would argue that the whole process of dissecting those muscles off in the first place probably leads to more scarring. So when you go back for the repeat and you’re struggling, you’re going to have a harder time. If that was done before, so if people would just leave the rectus fascia alone, it probably won’t scar up against the muscle and you can pull it apart easily or have enough space on the repeats to say in the future, with all that, without all that extra dissection, yeah, that could very well be true.
Antonia: 42:16
I don’t know if that specifically has been rigorously studied anywhere that I could find, but there’s definitely less trauma and less inflammatory response if you’re not doing all that pulling and clipping and bovying between the rectus and the fascia, so then you’re giving it less reason to scar. So there is even a minimally invasive way of performing a cesarean, when you’re avoiding unnecessary dissection and, more specifically, you’re using blunt rather than sharp dissection or electrocautery whenever you can, which then will have the effect of doing less tissue damage, less thermal damage and less extensions.
Howard: 42:54
Yeah, that’s the difference really between a fan instill incision and the Joel Cohen or Ms Goff Loddick style incision. It’s not the skin incision. I see a lot of people get that wrong too, where they think that what’s a fan instill? It’s where it’s curvilinear and it’s two centimeters above the symphysis pubis aimed towards. No, it’s not. It’s not the difference in the straightness or the position, it’s in how you do the dissection. In a fan instill, yes, you have that curved incision classically, but you’re in deliberately dissecting the rectus sheath off the muscles and you’re opening the peritoneum in a surgical manner and all these things. You’re doing all the things that people are still doing. And people will say they’re doing a Joel Cohn incision but they’ll still dissect the rectus muscles off. It’s not the shape of the skin incision, it’s the method of blunt entry versus that sharp dissecting entry. That’s different. And as far as the evidence, it’s unfortunately all amalgamated in basically the misgothlotic literature where you have a Joel Cohn versus a fan and steel.
Howard: 43:50
But yeah, the patients showed less pain and less need for narcotics and all those sorts of things because you’re doing less to their bodies. So minimally invasive surgery is really a philosophy. Now you have to think about what’s the least invasive way to do any particular surgery. So let’s say that I need to laparoscopically remove someone’s fallopian tubes for sterilization. I currently do that with one five millimeter trocar in the umbilicus for the camera and just one additional 5mm trocar in the patient’s right lower quadrant because I operate left-handed laparoscopically. You can put on the other side if you’re right-handed, and then I remove the fallopian tubes with only those two ports.
Antonia: 44:28
Yeah, I saw you made a new video on YouTube showing your technique for that and I have to say I was doubtful on YouTube showing your technique for that and I have to say I was doubtful, like it seems like it would be very awkward, but then I did, I do it, I did it and it’s fine. It’s an easy thing for anyone to try. Just see what, where you can manipulate the tubes just with one port and then you can always put in your typical third port If you need it, if you need it.
Antonia: 44:55
If you need it, no problem there, but just try it without yeah.
Howard: 44:59
And if you follow the Instagram, you saw a link to that video a few weeks ago. But the point is that doing it with two five millimeter ports is less invasive than doing it with three, although I think that’s certainly how most people probably still do it. I also don’t place a catheter. I don’t drain the bladder. I have them pee before coming back to the operating room, so that’s less invasiveness. We’re not catheterizing in the urethra and therefore decreasing the risk of urinary tract infection and those things. And I don’t use a uterine manipulator or even a sponge stick, so that’s less invasive. We’re not having to prep the vagina. We’re not having to put them in stirrups. We’re not putting something instruments in their vagina or in their uterus. We’re not causing bleeding and discomfort and pain from manipulators. So all those things are examples of being as least invasive as you need to be. So I don’t know a way of making this particular surgery, which is one of the simplest things we do, any less invasive, so I think that that’s the minimally invasive way to do it.
Antonia: 45:58
This is probably where some people came out with trying to do the single site surgery, single umbilical port. So could that possibly be less invasive for a tubal?
Howard: 46:11
Right. So then you would have only one incision, but that incision is typically about 18 millimeters, maybe a little bit bigger, which creates a different and certainly increased risk of a future umbilical hernia. And so, even though there’s only one skin incision, it would be, I think, more invasive, with more pain and more risk and more time and more expenses. They’ll have suturing in their umbilicus and increased hernia risk. And I just think 10 millimeters total incision length versus 18 millimeters.
Howard: 46:40
So I actually don’t think of that as less invasive. There used to be a single channel operative port that was 10 millimeters and people would do sterilizations through just one umbilical port, but that was using just a monopolar cautery and of course we don’t do that anymore. So yeah, I don’t think the single incision thing is necessarily lace invasive.
Antonia: 47:00
Yeah, I’ve never done it. I have heard anecdotally that those incisions tend to be troublesome. When people come back post-op they still have issues with how it looks.
Howard: 47:11
You can bury that five millimeter port down in the base of the umbilicus and nobody ever sees it. It’s relatively innocuous once it heals and it’s harder to do. I did them when it came out and did several adnexal surgeries with single site surgery and just didn’t find it worth the effort.
Antonia: 47:27
Okay, how about if you did it vaginally through a posterior colpotomy with V notes?
Howard: 47:36
colpotomy with V notes. Okay, and we used to do salpingectomies before laparoscopy was invented through a salpingectomy. And the truth is, if you want to make a posterior colpotomy and then do a salpingectomy that way, you don’t need the V notes to do that with usually. But so, yeah, there’s no incisions on the skin but in exchange for that you’ve made a pretty large incision, comparatively speaking, in the posterior cul-de-sac of the vagina and you spent a lot more money and time to do so, with an arguably increased risk of injury to adjacent organs and things like that and a longer recovery time and a longer time to resume normal activities like intercourse. So overall, I would still argue that two 5mm incisions is less invasive and it’s certainly less expensive and quicker, and that’s going to be the answer for a lot of V notes things. You can do a lot of stuff with V notes a lot of adnexal surgeries and things like that, but for the time and cost and equipment, I don’t know why you’re just not putting a couple of incisions up on the belly.
Antonia: 48:30
Yeah, I feel like I agree with you. Went through V notes and then went through another course, just an advanced laparoscopy course, and I feel like that gave a whole lot more, just a lot more bang for the buck. I should say that a lot more freedom and yeah.
Howard: 48:48
That’s what I think about V notes and hysterectomy too. If you need V notes to do a hysterectomy and you’re going to do all of that laparoscopy through the vagina, golly, just do abdominal laparoscopy. It’s cheaper, it’s faster, better access, better exposure.
Antonia: 49:03
Yeah, I, yeah, I agree. But if you enter in the belly in a safe way without hitting the aorta or the IVC, there is still a very minimal risk of that. But then you can operate on people who have an obliterated cul-de-sac, and you cannot do that with V notes. Or if their cervix is just way up high and you’re really struggling, you can’t do that with V notes either.
Howard: 49:26
Yeah.
Antonia: 49:27
Yeah.
Howard: 49:28
It’s just faster. It’s faster If you’re good at it laparoscopically you’re going to be faster than if you’re good at it with V notes.
Antonia: 49:33
Yeah, speed of surgery has to factor into this at some point too, like we’re talking about, especially when you’re considering trade-offs less speed for more of whatever and one of the benefits of less invasive or minimally invasive surgery should be less risk, and risk is always increased when you’re significantly prolonging the operative time risks of, let’s say, thromboembolism or infection or nerve compression injury or any other number of anesthetic complications too.
Howard: 50:10
Exactly is minimally invasive. We could debate about, like we have been doing a little bit, based upon what values you have and what you think is more important, like length of incision, number of incision, those sorts of things For hysterectomy. The minimally invasive route of hysterectomy is, and will always be, vaginal hysterectomy. So I would argue that saying that laparoscopic or robotic hysterectomy is minimally invasive is actually incorrect. It’s less invasive, so we maybe need a new term for the robotics folks. It’s less invasive than an abdominal hysterectomy but frankly I don’t really know how. Know anybody that routinely does abdominal hysterectomies anymore in 2024.
Howard: 50:49
So we’re making comparisons to the 1990s here. So robotic hysterectomy or laparoscopic hysterectomy is less invasive only in comparison to abdominal hysterectomy, but it’s more invasive than vaginal hysterectomy. So the minimally invasive route of hysterectomy is vaginal hysterectomy. We should emphasize that in our use of terminology and our teaching of residents so that they understand that there’s a gradient of it and appreciate when one thing is actually less invasive than the other. And I think that distinguishing between the terms less invasive and minimally invasive to show that is important. And the letter writer is getting at that right Robotic hysterectomy if he’s talking about a hysterectomy or she’s talking about a hysterectomy is more invasive than the vaginal route.
Antonia: 51:28
Yeah, can you imagine if these MIGS fellowships actually emphasized vaginal hysterectomy?
Howard: 51:35
It would be wonderful but and something that people need a fellowship in, frankly right, but one thing that different tantrum but one thing is like if you’re graduating residency in the United States and you can’t do vaginal, a non-abdominal hysterectomy, a laparoscopic hysterectomy, something like that, I don’t think you got your money’s worth in your four-year residency. But a lot of people do need extra training and we don’t really have a great fellowship opportunity outside of urogyne for people to learn advanced vaginal hysterectomy techniques. But the problem with urogyne taking the burden of that is that they’re mostly doing patients with prolapse.
Howard: 52:12
And so they’re not getting at the hard cases that a different kind of fellowship or pathway could emphasize. For a lot of laparoscopic things that we do, I’ll say too, as I mentioned, there’s simply no reason to put in uterine manipulators or catheters, and that’s not just things for tubal ligations and salpingectomies, but also for most oophorectomies and diagnostic laparoscopies, and most of these usually only need one operative port, just like with the salpingectomy. Once you get past that point and realize that you can do it with only one, there’s a lot of things you can do. So I don’t routinely put patients who are having laparoscopies in stirrups, don’t drain the bladder, don’t prep the vagina, don’t put manipulators in unless there’s a specific reason why I need it. Like saying, doing a chromopertubation where I know I need that manipulator in order to do that.
Howard: 53:17
When a lot of residency programs it’s just routine, right, the intern gets to put the uterine manipulator on and what we’re doing? A tubal and so that, and more invasive, I routinely take out even large ovarian things nowadays with just one port. I recently have done a 15 and I think an 18 over the summer centimeter ovary, removing the ovary with only one operative port, and it wasn’t super hard. It wasn’t as hard as you might think it is. You put them in Trendelenburg gravity provides all of the exposure you need, and then you just run across it with your energy sealing device, and then the hardest part is learning how to get it out of there.
Antonia: 53:40
Okay, so you put your camera in, let’s say, the umbilicus, and then one trocar on the side that you’re operating with your vessel sealing device or whatever it is, and that’s how you separate the ovary or separate the mass, and then is that the same port. You take your tool out and then you put the bag in. How do you just with a bag?
Howard: 54:01
Yeah, so it’s actually a lot easier than you might think it is. It’s again one of the things. Just try it. So you put the bag in the abdomen through the same port. Now I might have a five millimeter in for the energy ceiling device, and then I’m in a habit of not using another trocar to put the bag in Cause, just cause I’m always thinking about saving money.
Howard: 54:18
But you need if it’s 15, if it’s 15 centimeters, you need a big bag, so that’s going to be a 10 or a 12. And so you can either put the port in there, if you want, or I just make the incision a little bit bigger and put it in without a port and then you open it up inside and then you use it as a scoop and you scoop it up and a cyst like that just falls right into it and then you take it out like you would, regardless, drain the cyst or take it out in pieces, whatever you need to do. So for most surgeries that I do today, I either do everything completely vaginally or I make just two five millimeter incisions on the abdomen and, like I said, that incision will be bigger if I have to use a large bag and the incision may need suture in it, obviously if you’re having to put a 12 or something in for a bag. But the goal is to use as few of incisions and as small of incisions as possible.
Antonia: 55:05
Yeah, it’s ironic to talk about a robotic hysterectomy as being minimally invasive when you have four or five eight millimeter incisions, compared to a vaginal hysterectomy with zero abdominal incisions or even a laparoscopic history hysterectomy that can easily be done with three five millimeter ports. The thing that nobody likes to admit about this is there are techniques out there to effectively dissect and suture using only straight stick laparoscopy or, of course, the vaginal approach, where you don’t need the extra wrist motion of the robot.
Howard: 55:41
You just have to learn the techniques yeah, I heard somebody recently called the robot the most expensive sewing machine ever made. Because that’s essentially what people like about it is the ability to do intracorporeal suturing with relative ease due to those articulations. But that’s just not usually necessary for other things and we may be making up a bunch of surgeries to do that. We don’t need to do that. The robot benefits like.
Howard: 56:07
We’ll talk later more about niche repairs or even stripping peritoneum for endometriosis and things like that. So we have to rank things as less invasive versus minimally invasive and then challenge what the least invasive thing is and continue to improve upon it. But this lazy comparison to open surgery is past. We’re at this point we’re comparing minimally invasive routes to minimally invasive routes, I think, and we’re beyond the goal of just avoiding laparotomies, and the robotics community has really benefited from this false comparison for a while. It would be silly for me, for example, to transition my vaginal hysterectomy patients to a more invasive robotic hysterectomy approach, like you said, with four or five incisions on the belly or even laparoscopic. If I can do it vaginally, I don’t even want to put three incisions on the belly.
Antonia: 56:50
But if the alternative is a big abdominal incision, then the robot is a good thing.
Howard: 56:57
Yeah, I suppose that’s the goal right. But the question then would be could you have done the same thing with straight stick laparoscopy instead of the robot? And the question isn’t is it more comfortable for the surgeon? That’s not the question. The question is did the patient have a better outcome? And have you demonstrated that with scientific evidence? And after you’ve decided on a way of doing the case in a minimally invasive way, then the next question becomes cost and these other equalizers. Maybe you don’t see a difference in outcome between laparoscopic and robotic, whatever case. But if the laparoscopic approach is equal and is less expensive, then you should do the laparoscopic approach. That paper you found from 1994, they already were doing 80% of their cases laparoscopically or hysteroscopically, and that was written before we even had these modern bipolar energy sealing devices and all the fancy kit and equipment that we have today. So the use case for a robot to reduce an abdominal laparotomy versus just straight stick laparoscopy with all the bells and whistles we have today should be rare and uncommon.
Antonia: 57:55
I’m sure we’ll get some hate mail about this one from some robot lovers, I’m sure but I think the bottom line is that you should reserve the term minimally invasive surgery for the method that is actually the very least invasive that you could do and otherwise describe what you’re doing as just less invasive or, I don’t know, moderately invasive, if you mean to compare what you’re doing only to better than a wide open incision.
Howard: 58:24
Yeah, I think that’s right. Minimally invasive does not equal robot, it does not equal endoscopy. It is how do you do the surgery in the least invasive way, and you should do the least amount of surgery necessary to accomplish the goal for the patient. We could get into a lot more examples and, like I said, maybe we should discuss endometriosis in the future. But I do think that we need to talk about the stripping of peritoneum when ablation is probably the appropriate way in most cases, and so you might be harming your patient. But it’s because you can do some of these more advanced techniques with some ease Doesn’t mean that you should do them. You have to let the literature guide you, and I know we’re planning to talk about endometriosis later this season, but it’s a big topic.
Antonia: 59:04
Yeah, yeah. There’s definitely a lot more to that than I don’t want to dive into it too much because we’re getting out of time. But assuming you do the full range of procedures that you could potentially offer a patient, then you should have a good sense of what are the complication rates and you really need to weigh all of those potential risks against their severity of disease and their potential to benefit from it when you’re offering, oh, let me do a full, deep excision and strip all the peritoneum, as opposed to let me just ablate or burn or maybe biopsy off a few endometriotic lesions. Maybe, if they’ve already had 15 laparoscopies with ablations, maybe they need something a little bit more definitive, some deep excision or something. But that shouldn’t be the universal standard of care for everyone, especially first time you’re getting in for a diagnostic laparoscopy and one powder burn lesion, for example.
Antonia: 1:00:04
And there may be other patients where actually doing a full laparotomy is the right thing and actually, in a way, the minimally invasive thing to do. For example, if they have a very large fibroid uterus and if you did an abdominal hysterectomy through a transverse incision smaller than a C-section incision, you could be done in less than an hour. But then you do a robotic hysterectomy instead. Five incisions several hours deep, trendelenburg Overall. The patient was probably way better off with that open incision. But if their uterus is small enough to fit through the vaginal colpotomy then you should absolutely learn the techniques to dissect it either vaginally or laparoscopically, so that you can just use that vaginal incision to remove the specimen and to do as much of the rest of the surgery as you can. Just use that vaginal incision to remove the specimen and to do as much of the rest of the surgery as you can. That’s minimally invasive surgery.
Howard: 1:00:58
And the time trade-off is a real thing. I will say that if you’re doing the 16th laparoscopy on somebody for endometriosis and they haven’t been benefiting, you might have the wrong diagnosis.
Antonia: 1:01:08
Yeah, and I think people.
Howard: 1:01:09
That’s the other thing we’ll talk about. Half the patients with endometriosis don’t have symptoms, and people get in this sunk in cost fallacy, where they keep assuming that they need to be more and more aggressive surgeries for a condition that’s probably not even their source of their pain. We’ll talk about that. They’re the best person in the world because they spent five or six hours operating on a patient with a da Vinci to save an incision no bigger than a cesarean incision. So I do think that we’ve gotten a little silly with some of this stuff, but the key there is with the large fibroid incision, though, is that many operators will still make a vertical laparotomy for a large fibroid uterus, and that’s unnecessary as well. In fact, I think that’s dogmatic teaching in a lot of residency programs. So even when you’re making a choice about the type of incision that you make for a case like that, there may be a less invasive way, and maybe we can talk sometimes about how to do a large uterus through a very small horizontal incision.
Antonia: 1:02:12
Yeah, so it’s a complicated formula about what is actually least invasive or minimally invasive that takes into account risks of the surgery itself, as well as the number and the size of incisions and the operating time, because being invasive doesn’t just mean how much you’ve cut on the belly.
Howard: 1:02:31
It means all these other things that we’ve talked about risks that we’re exposing the patient to organ injury, thromboembolism, risks of recurrence risks of needing future surgery and things like that, and we could make a list or debate for any given patient what the least or most minimally invasive method is. But the bottom line is that what’s called minimally invasive is just less invasive to what was happening in the 80s and 90s and in many cases we’ve maybe gone backwards with some of the training by putting more incisions on the belly, particularly with the robot, compared to what could be done with straight stick laparoscopy or even vaginal surgery.
Antonia: 1:03:07
Yeah, as long as you can get in vaginally.
Howard: 1:03:10
Yeah, yeah, and that’s going to be. Admittedly, people are going to have different approaches with that. So the goal for everybody should be to do vaginal surgery if they can and increase their learning curve there and then, if you can’t do be able to do a great straight stick laparoscopic hysterectomy and that’s fine. I really don’t take issue personally with the straight stick laparoscopists who do hysterectomies If they can put three, five millimeter incisions and do that way. That’s a less invasive way than the robot and it’s certainly a lot less cost.
Antonia: 1:03:40
Agreed. I think it’s time for us to wrap up the Thinking About OBGYN website. We’ll have links to the studies we talked about. Check that out. Check out our Instagram and we’ll be back in a couple weeks thanks for listening.
Announcer: 1:03:56
Find us online at thinkingaboutobgyn.com. Be sure to subscribe. Look for new episodes every two weeks.
