OBG MANAGEMENT and The Female Patient sponsored the 14th annual Pelvic Anatomy and Gynecologic Surgery Symposium (PAGS) December 8–10, 2011 at the Wynn Las Vegas, featuring respected senior faculty from the Cleveland Clinic, Mayo Clinic, Christ Hospital of Cincinnati, and other institutions. More than 300 physicians attended the 3-day program.
Course Directors Mickey M. Karram, MD, and Tommaso Falcone, MD, led off the symposium with back-to-back sessions on pelvic anatomy, and the program ended two days later with focused breakout sessions on surgical complications, endometriosis, robotic surgery, urodynamics, and cystourethroscopy.
“Patients want choices” when it comes to the surgical approach to their hysterectomy, said Tommaso Falcone, MD, Chairman of the Department of Gynecology at The Cleveland Clinic Foundation, Cleveland, Ohio, to open his talk this morning at The 2011 PAGS: Pelvic Anatomy and Gynecologic Surgery CME Symposium, in Las Vegas, on the myriad and complex variables that a surgeon must consider in arriving at a decision on an approach.
Dr. Falcone, who is also PAGS Course Co-Director, went on to note: “Evidence-based medicine doesn’t mean giving the patient one option—the one with the highest odds ratio in Cochrane Reviews. Rather, the decision reflect a partnership between doctor patient; you, the surgeon, must consider the emotional and perceptional impact of hysterectomy on the patient.”
Patient selection is a key first step in choosing an approach, Dr. Falcone told PAGS attendees.
“You have to exclude malignancy, or a pre-malignant state. You have to be sure that the patient’s expectations are realistic: Does she want a 100% guarantee of amenorrhea? Well, research has shown that 24% of patients had residual endometrium in the stump after laparoscopic hysterectomy. And, of course, she must be aware of the risk of prolapse postoperatively.”
Dr. Falcone examined several perioperative considerations across the various laparoscopic approaches, including prophylactic antibiotics and heparin to prevent venous thromboembolism (VTE).
“Initiate prophylactic antibiotics within 1 hour of making the incision. Use a first- or second-generation cephalosporin, and discontinue it within 24 hours,” Dr. Falcone advised.
“For VTE prophylaxis,” he recommended, “give unfractionated heparin, 5,000 units every 12 hours, or low-molecular-weight heparin (such as enoxaparin, 40 mg, or 2,500 units of dalteparin). Alternatively, apply a pneumatic compression device to the legs.”
And more on preventing VTE: “For patients older than 40 years and those younger than 40 who have a risk factor, such as obesity, give unfractionated heparin, 5,000 units every 8 hours, or low-molecular-weight heparin—5,000 units of dalteparin or a similar dose of enoxaparin (40 mg).”
Dr. Falcone concluded his comparison of the spectrum of approaches to lap hysterectomy with a look at the novel laparo-endoscopic single-site (LESS) technique hysterectomy, and its equipment, challenges, and success and complication rates. He offered “LESS Tips” that promote “ergonomics and efficiency”:
Expert Pearls for Managing a Ruptured Ovarian Cyst
“What should you do when your patient’s stage-1 malignant ovarian cyst ruptures during surgery?” asked Javier Magrina, MD, Professor of Obstetrics-Gynecology at the Mayo Clinic Scottsdale, Scottsdale, Ariz., of attendees today at 2011 PAGS: Pelvic Anatomy and Gynecologic Surgery CME Symposium, in Las Vegas. Dr. Magrina’s challenge to the audience of gyn surgeons came during his wide-ranging presentation, “Laparoscopic and Robotic Management of the Adnexal Mass.”
“And,” Dr. Magrina continued, “what’s the impact of such rupture, and your management of it, on subsequent treatment and on prognosis?”
“Here is what you can do when you’re faced with this problem,” Dr. Magrina explained. “Control spillage. Perform suction. Irrigate the pelvis with water—preferably, at 57ºF. Take cytology specimens at the end of surgery.”
“Then, irrigate the trocar sites with water—again, 57ºF is preferable.”
“Surgical staging should be performed, but if staging is going to be delayed longer than 6 weeks, chemotherapy should be started, unless the malignancy is Grade 1.”
Dr. Magrina also commented on management of ovarian cysts during pregnancy.
“Laparoscopy is safe in these patients, although you should wait until the second trimester to operate. As you consider intervening, however, keep in mind that the CA 125 level is elevated in pregnancy, and that fewer than 5% of cysts are malignant,” Dr. Magrina said.
Luncheon Symposium (non CME)
Synthetic Slings and Vaginal Mesh after the FDA Warning:
What's the Bottom Line?
PAGS attendees were given an overview of the ongoing FDA review of vaginal mesh kits by PAGS Course Director Mickey Karram, MD, Director of Urogynecology at The Christ Hospital, Cincinnati, Ohio. Dr Karram told the audience that between January 1, 2008 and December 31, 2010, the FDA received 2,8784 reports of complications associated with surgical mesh used to repair stress urinary incontinence or pelvic organ prolapse. Subsequently, in July 2011, the FDA issued an update to a previous Public Health Notification about the risk for adverse events with mesh for prolapse repair and recommended that physicians obtain specialized training for each mesh placement technique. As a result, sales of mesh kits have dropped precipitously.
Further, following the results of an extensive FDA review of the published data that questioned the efficacy of transvaginal surgical placement of mesh for pelvic organ prolapse repair, the FDA Medical Devices Advisory Committee convened in early September to discuss this issue with a panel of experts. Since then, vaginal mesh kits have been reclassified by the FDA from Class II to Class III devices, meaning that there is a greater potential for harm. As such, mesh kits will be required to undergo a premarket approval process (PMA) for new devices and additional post-market surveillance studies for existing devices.
Dr Karram told the PAGS audience that the FDA’s action will have a huge impact on their profession: affecting the way surgeons will be taught and trained, the informed consent process, medico-legal status, hospital credentialing, and third-party reimbursement. “Severe mesh complications are occurring,” said Dr Karram, “but are the majority of them technical or would they occur in the best of hands?” The bottom line, according to Dr Karram, is who should be ultimately responsible for training surgeons to utilize new devices or materials. Should it be the device manufacturer, the hospital, he medical organization that represents the surgeon, or a formal credentialing board along with certified, trained proctors with demonstrated competence with the device for prolapse. This will be a major issue moving forward.
In addition, Dr Matthew Barber, who is president of the American Urogynecologic Society, which has been working closely with the FDA on this matter, updated attendees on the Society’s most recent discussions with the FDA. One of the September Advisory Panel’s recommendations was that the devices should not be taken off the market, and Dr Barber informed them that the FDA has not yet made a decision yet on the fate of vaginal mesh kits. He did however say the expectation was that the FDA would follow all of the Panel’s recommendations. When asked when the FDA will announce their decision, Dr Barber said he didn’t.
View of Pelvic Anatomy Changes Through a Laparoscope
The anatomy of a woman’s pelvis has a distinct presentation and appearance when seen through the laparoscope, explained Tommaso Falcone, MD, of the Cleveland Clinic Foundation, to an audience of gyn surgeons today in the opening session at the 2011 PAGS: Pelvic Anatomy and Gynecologic Surgery CME Symposium in Las Vegas.
Knowing the “relationship of the vessels and nerves to potential entry sites for trocars” is therefore essential, Dr. Falcone, who is also PAGS Course Co-Director, emphasized. “Consider the bifurcation of the aorta—in thin patients, the bifurcation is located at the umbilicus. But that landmark is found more caudad with increasing weight of a patient.”
Dr. Falcone’s comprehensive anatomic “tour” also pinpointed the location of nerves in the abdomen in relation to common sites for inserting trocars. He offered the audience a target position for insertion of a trocar in the left upper-quadrant.
“In the left upper-quadrant, a trocar should be placed 2 cm below the subcostal margin of the midclavicular line,” Dr. Falcone advised, “There, you’ll know the distance to surrounding organs: 11 cm from the aorta, 12 cm from the spleen (unless there is splenomegaly), about 4.5 cm from the stomach, 4 cm from the liver, and just over 13 cm from the left kidney.”
PAGS Course Co-Director Mickey Karram, MD, Director of Urogynecology at The Christ Hospital in Cincinnati, Ohio, expanded on Dr. Falcone’s remarks with a further look at anatomic considerations in vaginal procedures—including a review of planes of dissection in the pelvis, how best for surgeons to safely obtain access to the sacrospinous ligament complex, and a “virtual dissection” of the obturator foramen.
The obturator foramen is “covered by a tough membrane that’s continuous with periosteum and tendinous attachments. The obturator canal—sometimes it’s called the fossa—is 2 to 3 cm long, and begins at the anterolateral opening of membrane. That canal is traversed by the obturator nerve, artery, and vein—vessels that all pass downward into the thigh.”
SUI Surgery: Which Sling, Which Patient?
The choice of urethral sling for treating stress urinary incontinence will vary—by patient and by surgeon’s expertise and preference, noted Mark Walters, MD, of the Cleveland Clinic Foundation, in a talk today at 2011 PAGS: Pelvic Anatomy and Gynecologic Surgery CME Symposium, in Las Vegas. Before comparing available slings, Dr. Walters offered the audience four key “green lights” for proceeding with surgery for SUI.
“First, you need to be sure you’ve made the correct diagnosis. Second, you should have attempted a trial of conservative therapy. You have to be sure your patient is an acceptable surgical candidate, and that she does not want to retain her fertility.”
Among Dr. Walters’ analyses of sling types was a useful in-depth look at the transobturator sling, and how it compares to other techniques.
“There are several reasons to consider a transobturator, or TOT, sling,” Dr. Walters noted. “The technique reproduces a woman’s natural suspension mechanism—much like a hammock. There is less risk of overcorrecting the patient’s problem—creating urgency or dysuria. The postop rate of voiding dysfunction is lower.”
“We’ve also found that, because the needles are generally passed safely, there may be no need for cystoscopy postop,” Dr. Walters said. “There is also less risk of vessel, bowel, and bladder injury.”
“Last, the technique is easy to learn.”
“Data suggest similar rates of continence, less postop voiding dysfunction and urgency, and fewer bladder perforations than what’s been seen with retropubic transvaginal tape, or TVT, slings,” Dr. Walters concluded during this part of his talk.
Hysteroscopy in the Office—for Managing AUB and Other Conditions
“Hysteroscopy is better than transvaginal ultrasonography for evaluating the uterine cavity,” declared Amy Garcia, MD, Director of the Center for Women’s Surgery I, New Mexico, in her presentation, “Office Hysteroscopic Evaluation and Management of Abnormal Uterine Bleeding,” today at 2011 PAGS: Pelvic Anatomy and Gynecologic Surgery CME Symposium, in Las Vegas.
“There are several advantages to hysteroscopy over other techniques,” Dr. Garcia continued, including direct visualization of the cavity, the opportunity to take directed biopsies, and the benefit of having histopathologic findings in hand.
“In-office hysteroscopy is valuable for evaluating abnormal uterine bleeding, menorrhagia, abnormal findings on a sonogram, an enlarged endometrial stripe, and suspected intracavitary pathology,” Dr. Garcia explained. “It’s also useful in the workup and treatment of infertility and for placing a contraceptive intrauterine device.”
“Hysteroscopy offers superior accuracy, sensitivity, and specificity compared to blind biopsy.”
“This is a 'see it and treat” tool,’” Dr. Garcia noted. “No cervical prepping is needed—dilation is usually unnecessary when you’re using a 3-mm flexible hysteroscope.” She also discussed issues surrounding cervical priming with misoprostol.
Dr. Garcia’s in-depth look at the logistics of in-office hysteroscopy covered the range of “essentials”: the necessary supplies and instruments; how to overcome barriers to patient and staff acceptance; documentation; reimbursement; and procedure room set-up.
“There are a number of in-office essentials if you are going to adapt this technique for the office,” Dr. Garcia noted. A few of numerous examples that she offered to the attendees: “The patient is kept awake; fluid pressure must be kept low; the speculum is removed once the scope is introduced; patient movement has to be minimized; and you must communicate continually with the patient.”
Note: Dr. Garcia is also Assistant Professor in the Division of Urogynecology, Department of Obstetrics and Gynecology, at the University of New Mexico in Albuquerque.
AUDIO : Dr.Mickey_Karram_audio.mp3