common ob/gyn injuries howard t. sharp md vice chair and professor dept. of obstetrics and...

Common OB/Gyn Injuries

Howard T. Sharp MDVice Chair and Professor

Dept. of Obstetrics and Gynecology

Case 1

• 2 week post op check from C-Section• Pain at right groin, just outside corner of

incision• Give it 1 month.• At 6 weeks, minimal improvement

The Pfannenstiel Incision as a Source of Chronic Pain

(Loos et al, Obstet Gynecol, April 2008)

• 866 patients with Pfannenstiel incisions• 2 year follow-up (questionnaire) Level III• 33% experienced CPP at incision (26% ITT)• 7% had moderate to severe pain• Nerve entrapment 53% (17/32 examined)• Avoid lateral extension (rectus sheath) / delay in

treatment

Ilioinguinal and Iliohyopogastric Nerves

Case 2

• 2 week post op check from TLH• Pain at right groin, just outside corner of right

trocar incision• Give it 1 month.• At 6 weeks, minimal improvement

Trocars and anterior abdominal wall nerves(Rahn Am J Obstet Gynecol 2010)

Nerve Mean distance from ASIS in cm (range)

MedialInferior

Ilioinguinal nerve 2.5 (1.1-5.1) 2.4 (0-5.3)

Iliohypogastric nerve 2.5 (0-4.6) 2.0 (0-4.6)

Author’s conclusions: Risk is minimized when the trocar is placed superior to the ASIS.

Incidence: 5% of laparoscopies (Shin, JMIG 2012)

Nerves and vessels of the anterior abdominal wall.(Rahn AJOG 2010)

Case 3

• Patient s/p TVH wakes up with right foot drop.• Candy cane stirrups were used.

Sciatic Nerve

• L4 through S3 nerve roots (stretch)

• 2 divisions

– Tibial

– Common peroneal (compression)

• Anterior to the piriformis muscle, passes through greater sciatic foramen to posterior thigh until it divides

Sciatic Nerve: Tibial Branch

• Posterior leg

• Motor to plantar flexors

• Intrinsic foot flexors

• Sensory to plantar surface and toes

Sciatic Nerve: Common Peroneal

• Anterior to fibular head

• Motor to dorsiflexors and evertors of foot.

• Sensation to lateral leg and dorsum of foot.

Sciatic Nerve Injury Risks(Mechanism: Stretch, compression)

• Lithotomy position

• Excessive hip flexion

• Straightening of the knee

• Pulling on lat leg (2nd stage labor) – peroneal branch

• Sudden blood loss requiring large mattress sutures placed in deep lateral pelvis.

• Beware the “leaning assistant.”

Recommendations

• Avoid excessive hip flexion

• Make sure there is adequate bending at the knee

• Avoid excessive external rotation

• Risky patients:

– Tall patients – external rotation

– Short patients – inadequate flexion at the knee

Case 4

• Patient s/p C-Section for twins wakes up with right foot drop.

• No stirrups were used.• How did this happen?

Intraoperative positioning during cesarean as a cause of sciatic neuropathy.

Roy et al, Obstet Gynecol. 2002;99:652-3.

• C-Section under spinal for twins.

• Right hip roll placed at 30 degrees.

• Left foot drop recovered by 6 weeks post partum

• Right buttock elevation during cesarean caused a compression sciatic neuropathy.

• Decreasing the duration of left lateral position may reduce the risk of this uncommon complication.

Case 5

• Patient weighing 105 undergoes TAH

• Quadriceps are paralyzed

• Knee can not be extended

• Loss of sensation over

– Medial and anterior thigh

– Medial side of lower leg

– Medial side of foot

Femoral Nerve

• L2, L3, and L4 nerve roots

• Pierces psoas, emerges between iliacus and psoas, courses under inguinal ligament

• Motor supplies hip flexors and leg extensors

Femoral Neuropathy

Femoral Neuropathy Risks(Mechanism: Compression)

• Self-retaining retractors – (vasa nervorum)

• Transverse or Pfannenstiel incisions

• Thin body habitus

• Excessive hip flexion

• Long OR times - laparoscopy

Case 6

• Patient undergoes LAVH

• Allen type stirrups were used.

• Quadriceps are paralyzed

• Knee can not be extended

• Loss of sensation over

– Medial and anterior thigh

– Medial side of lower leg

– Medial side of foot

Case 7

• 60 year old undergoes TLH• Surgical time is 65 minutes.• BMI is 30• She has a few varicose veins.• Otherwise healthy.• Pneumatic compression devices used.

POD 1

• Dies from massive PE

Why So Disastrous?

• Up to 14% of patients undergoing gynecologic

surgery for benign conditions develop VTE.

(Walsh J Obstet Gynocol Br Commonw 1974)

• Most deaths occur within 30 minutes of event.

• Pulmonary embolism often not suspected (70-

80% of cases post mortem).

Thromboprophylaxis □Yes □ No

• Email orders for DVT in indicated cases• VTE at 90 days

– 4.9% in intervention group– 8.2% in control group

• PE reduced by 60%• DVT reduced by 53%(Kucher et al. NEJM 2005)

The Mechanism of Death

• DVT is most common source of PE

• PE is usually a result of an asymptomatic thrombus being released into pulmonary circulation

• If large enough, PE leads to cardiogenic shock, followed by circulatory collapse and death

“Why are we stuck in 1975?” Clarke-Pearson Obstet Gynecol 2011

• 40% of patients receive no VTE prophylaxis• Assume :

– 3% DVT rate – 0.5% fatal PE (without prophylaxis)

• 292,307 untreated women– 8,769 DVTs– 1,461 Fatal Pes

• Assume: 60% reduction (appropriate prophylaxis)– 5,261 DVTs prevented!– 876 fatal PEs prevented!

2012 CHEST Guidelines

• Focused on risk stratification balancing:– Patient’s VTE risk (Roger’s / Caprini scores)– Patient’s bleeding risk from therapy

• 3 major divisions: medical patients, orthopedic patients, other surgical patients

• “Consider these options as a guide in the decision making to individual circumstances”

VTE RiskGould et al, CHEST 2012

Risk Level % Risk / Bleeding Assessment Caprini Score

1. Very low VTE risk <0.5%0

2. Low VTE risk 1.5%1-2

3. Moderate VTE risk 3% / Low bleeding risk 3-4

4. Moderate VTE risk 3% / High bleeding risk 3-4

5. High VTE risk 6% / Low bleeding risk >5

6. High VTE risk 6% / High bleeding risk >5

Caprini ScoreEach factor represents 1 point:

Age 41 to 60 years Minor surgery planned History of prior major surgery (<1month) Varicose veins History of inflammatory bowel disease Swollen legs (current) Obesity (BMI>25kg/m2) Acute myocardial infarction Congestive heart failure (<1month) Sepsis (<1month) Serious lung disease including pneumonia (<1month) Abnormal pulmonary function (chronic obstructive pulmonary disease) Medical patient currently on bed rest Other risk factors (specify)

Caprini ScoreEach factor represents 2 points:

Age 60 to 74 years Arthroscopic surgery Malignancy (present or previous) Major surgery (>45minutes) Laparoscopic surgery (>45minutes) Patient confined to bed (>72hours) Immobilizing plaster cast (<1month) Central venous access catheter


Age>75years History of DVT/PEFamily history of thrombosis* Positive Factor V Leiden Positive prothrombin 20210A Elevated serum homocysteine Positive lupus anticoagulantElevated anticardiolipin antibodies Heparin-induced thrombocytopenia Other congenital or acquired thrombophilia


Elective major lower extremity arthroplasty

Hip, pelvis, or leg fracture (<1month)

Stroke (<1month)

Multiple trauma (<1month)

Acute spinal cord injury (paralysis) (<1month)

Case 7

• 60 year old undergoes TLH• Surgical time is 65 minutes.• BMI is 30• She has a few varicose veins.• Otherwise healthy.• Pneumatic compression devices used.



1.Very low VTE risk <0.5%0

No Pharmacologic or mechanical prophylaxis










Mechanical prophylaxsis - IPCs










- LMWH, LDUFH, or IPCs










IPCs



Prophylaxis: Moderate-Risk

• LDU Heparin 5,000 U BID (1A / 1C)

– or

• LMW Heparin Q Day (1A / 1C)

– or

• Intermittent Pneumatic Compression (1B / 1C)

IPCs

• Should be used for at least 18 hours daily• Some machines record compliance• Average adherence rate is 53%• Full adherence rate is 19%








LMWH or LDUFH with IPCs

If cancer add 4 weeks of LMWH (50-75% risk reduction)


Prophylaxis: High-Risk Patients

• LDU Heparin 5,000 U TID (1A) or

• LMW Heparin Q Day (1A)or

• IPC (1A)• May consider:

– IPC plus Pharmacologic Prophylaxis (1C)









IPCs alone until bleeding risk is diminished, then LMWH or LDUFH

Unfractionated Heparin• Highly effective against DVT prophylaxis

(based upon over 25 controlled trials)

• 5,000 U - 2 hours prior to surgery or 6 hours after surgery.

– Less bleeding if given post op with no additional risk (Hansen, Acta OGS 2008)

• Use every 8 to 12 hours until discharge

• Some studies show higher transfusion rates

LMWH Dosing

• Given 2 hours prior to surgery, or 6 hours after surgery, then daily for 7 – 10 days

• May be less bleeding 12 hours prior.

• Enoxaparin 40 mg

• Dalteparin 2,500 U (moderate-risk)

– 5,000U (high-risk)

Case 8

• While performing a TVH, you notice a gush of yellow fluid.

• OR• During a TAH or TLH you visualize the rubber

of a Foley catheter.

Cystotomy Pearls

• Finish the dissection before repairing the cystotomy.

• Repair in 2 layers, particularly if in dependent portion of the bladder.

• Perform cystoscopy or open the bladder and visualize ureteral patency while in OR.

• Keep a Foley catheter in place for 3 to 10 days post op.

Cystotomy Repair

Case 9

• POD 3 s/p laparoscopic adhesiolysis patient presents to ER with abdominal distension, shock.

• CT shows air in abdomen significant peritoneal fluid

I worry when…

• I press a button and nothing happens to tissue.

Electrosurgery

Generator Output

Conclusions

• Pay attention to patient positioning• Know where vulnerable nerves are at risk.• Use cut and coag modes appropriately• Take advantage of thromboprophylaxis.

common ob/gyn injuries howard t. sharp md vice chair and professor dept. of obstetrics and...

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