[Reparative surgery of urologic complications of gynecologic surgery].
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Female↗
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[Eclecticism and humanization in gynecologic surgery].
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General Surgery↗
Topical diclofenac patch for postoperative wound pain in laparoscopic gynecologic surgery: a randomized study.
STUDY OBJECTIVE: To compare pain management of standard analgesic and standard analgesic plus diclofenac transdermal patch in patients who undergo laparoscopic gynecologic surgery. DESIGN: Randomized prospective study (Canadian Task Force classification I). SETTING: University hospital. PATIENTS: One hundred twenty patients requiring laparoscopic surgery for gynecologic benign diseases. INTERVENTIONS: Patients were divided into two groups, one medicated with a diclofenac patch (diclofenac group) and the other medicated with standard skin medication (placebo; control group) at all incisional areas at the end of the operation. MEASUREMENTS AND MAIN RESULTS: The principal measures of outcome were pain intensity at 6, 12, and 24 hours after surgery and consumption of analgesics. The two treatment groups were comparable with respect to demographic and intraoperative characteristics. No significant difference was observed between the two groups in mean pain intensity at 6 hours after surgery. Mean pain intensity at 12 and 24 hours, respectively, after surgery was significantly lower in the diclofenac group (3.7 +/- 1.3 and 2.0 +/- 0.6) than that observed in the control group (5.7 +/- 1.9 and 4.6 +/- 0.5) (p value, respectively, .002 and <.001). Twenty-one patients (35.0%) in the diclofenac group required analgesics in the first 36 hours after the operation versus 43 patients (71.7%) in the control group (p <.001). Hospital discharge was significantly more rapid in the diclofenac group (28 +/- 5 hours vs 39 +/- 3 hours; p = .031). CONCLUSION: Diclofenac transdermal administration seems a valid help to standard analgesic treatment in postoperative pain control and could also help reduce the period of hospitalization of patients who undergo laparoscopic benign gynecologic surgery.
Administration, Topical↗
P6 acupressure may relieve nausea and vomiting after gynecological surgery: an effectiveness study in 410 women.
PURPOSE: To investigate the effect of sensory stimulation of the P6 point on postoperative nausea and vomiting (PONV) after gynecological surgery in the everyday clinical setting (effectiveness study). METHODS: Four hundred and ten women undergoing general anesthesia for elective gynecological surgery were included in a prospective, consecutive, randomized, multicentre, placebo-controlled, double-blind clinical trial with a reference group. One group was given bilateral P6 acupressure (n = 135), a second group similar pressure on bilateral non-acupressure points (n = 139), and a third group (n = 136) served as reference group. Nausea (scale 0-6), vomiting, pain, and satisfaction with the treatment were recorded. Primary outcome was complete response, i.e., no nausea, vomiting or rescue medication for 24 hr. Results were analyzed by applying logistic regression with indicators of treatments, type of operation and risk score for PONV as explanatory variables. RESULTS: Complete response was more frequent in the P6 acupressure group than in the reference group (P = 0.0194) Conversely, the incidence of PONV was 46% in the reference group, 38% after pressure on a non-acupoint and 33% after P6 acupressure. The decrease from 46% to 33% was statistically significant. When considering vaginal cases separately, the decrease in PONV was from 36% to 20% (P = 0.0168). The corresponding decrease from 59% to 55% in the laparoscopic surgery group was not statistically significant. CONCLUSION: P6 acupressure is a non-invasive method that may have a place as prophylactic antiemetic therapy during gynecological surgery.
Acupuncture Therapy↗
Managing anemia in gynecologic surgery with postoperative administration of recombinant human epoetins.
OBJECTIVE: To investigate whether postoperative administration of erythropoietin can safely augment in the rapid restoration of hemoglobin (Hgb) values following major gynecologic surgery. METHODS: Thirty-three women were enrolled. They had all undergone gynecologic surgery due to malignant or non-malignant reasons. Because of chronic blood loss, many of these patients were iron depleted. Examinations of hematology, serum chemistry and urinalysis values were obtained. Subcutaneous administration of r-HuEPO, in a dosage of 40,000 IU was initiated on the first postoperative day. One additional injection of 40,000 IU was given on the fourth day after surgery. Contemporarily the patients received orally a polysaccharide-iron complex. RESULTS: During the early postoperative period three patients that were transfused due to severe anemia and one more that was lost in follow-up were excluded from the study analysis. The remaining 29 patients showed a considerable rise in Hgb counts that reached a median value of 1.9 g/dl within a 20-day period. CONCLUSION: The postoperative administration of r-HuEPO in gynecologic surgery in patients where autologous blood transfusions can be avoided is challenging, since it can guarantee an uneventful postoperative period with rapid resuscitation without posing the patient to the well-established risks of transfusions.
Adult↗
[Usefulness of the combined transfusion of autologous blood as pre-deposited and preoperatively diluted in gynecological surgery].
To eliminate the risks involved in homologous blood transfusion in gynecological surgery, we studied the effect of the combined transfusion of autologous blood as predeposited and preoperatively diluted. Thirty-nine cases were operated on and studied. In 27 cases, a total of 695 ml/person of autoblood was taken during the 15 preoperative days. In 39 cases, an average of 1,038 ml/person of autoblood was collected at the beginning of surgery. In 37 out of 39 cases, we were able to avoid homologous blood transfusion. In the remaining two cases with homologous blood transfusion, although more than 3,000 ml of operative blood loss was observed, only about 700 ml of homologous blood was needed. We did not find any serious side effect with autoblood transfusion. These results demonstrate the usefulness of the combined transfusion of autologous blood as predeposited and preoperatively diluted in gynecological surgery.
Adult↗
Addition of 0.1% bupivacaine to buprenorphine and droperidol in patient-controlled epidural analgesia improved postoperative pain scores on coughing after gynecological surgery.
STUDY OBJECTIVE: To compare the analgesic efficacy of additional 0.1% bupivacaine to patient-controlled epidural analgesia (PCEA) using buprenorphine and droperidol after gynecological surgery. DESIGN: Randomized, double-blinded study. SETTING: Operating theater and general ward at Jichi Medical School Hospital. PATIENTS: Thirty patients with American Society of Anesthesiologists physical status I and II scheduled for gynecological surgery. INTERVENTIONS: Patients received combined general and epidural anesthesia for surgery and epidural analgesia for postoperative analgesia. Patients were assigned to receive PCEA with or without 0.1% bupivacaine. Group 1 (n = 15) received buprenorphine 20 microg and droperidol 0.1 mg diluted with saline, and group 2 (n = 15) received bupivacaine 2 mg, buprenorphine 20 microg, and droperidol 0.1 mg diluted with saline (0.1% bupivacaine solution) in a bolus dose of the PCEA, respectively. No background epidural infusion was used. MEASUREMENTS: Visual analog pain scale (VAPS) scores at rest and on coughing, and cumulative frequency of self-administrated analgesic solution in PCEA were recorded at 24 and 48 hours postoperatively. MAIN RESULTS: There were no significant differences noted between the groups in VAPS scores at rest or in cumulative volumes of PCEA solution in 24 or 48 hours postoperatively. Median VAPS scores on coughing in group 2 were significantly lower than those values in group 1 at 24 hours (36 vs 65 mm, P < .001) and 48 hours (32 vs 54 mm, P = .036) postoperatively. CONCLUSIONS: Addition of 0.1% bupivacaine to PCEA using buprenorphine and droperidol provides better analgesia on coughing after gynecological surgery.
Adult↗
Disability and litigation from urinary tract injuries at benign gynecologic surgery in Canada.
OBJECTIVES: To estimate the prevalence of urinary tract injury and the relative risk of litigation from an injury for benign gynecologic surgery in Canada and to analyze a subset of cases of litigation, determining independent risk factors that predicted medical and legal outcomes. METHODS: The prevalence of urinary tract injury and the relative risks of litigation from an injury were determined from the national hospital discharge abstract and the national physician malpractice databases. Multiple logistic regression was performed on a subset of litigation cases. RESULTS: The prevalence of urinary tract injury at benign gynecologic surgery was low (0.33%). If a patient sustained a urinary tract injury, there was a high relative risk of litigation (relative risk 91, 95% confidence interval [CI] 55-158). Patients had a higher chance of major disability after urinary tract injury from hysterectomy for abnormal uterine bleeding (odds ratio [OR] 6.16, 95% CI 1.13-39.01, P = .04), but a lower chance of this being a permanent disability (OR 0.23, 95% CI 0.05-0.96, P = .05). Permanent disability was more likely after an obstructed ureter compared with other types of urinary tract injuries (OR 4.54, 95% CI 1.55-14.88, P = .008). Only 18% of the injuries were recognized intraoperatively. An acute bladder injury was more likely to be recognized intraoperatively than other types of injury (OR 14.98, 95% CI 3.89-57.74, P < .001). No obstructed ureters or urinary tract fistulae were recognized intraoperatively. CONCLUSION: Urinary tract injuries are an uncommon but significant complication from benign gynecologic surgery. Such injuries are associated a high relative risk of litigation.
Adnexa Uteri↗
Laparoscopy in gynecologic surgery.
Laparoscopy has been utilized in gynecologic surgery for over 20 years. With the introduction of video monitoring and the development of new endoscopic instruments, the role of laparoscopy has greatly expanded. Laparoscopy is an invaluable tool in the management of the cancer patient. Current use focuses primarily on the diagnosis and staging of intraabdominal and pelvic malignancies. However laparoscopy is also utilized as an adjunct to therapeutic resection and palliation. The following is a brief discussion of the role of laparoscopy in the management of gynecologic cancer.
Adult↗
Antimicrobial prophylaxis in laparoscopic gynecologic surgery: a prospective randomized study comparing amoxicillin-clavulanic acid with cefazolin.
Numerous studies have been published in recent years about antimicrobial prophylaxis in gynecologic surgery, but the optimal drug and schedule for the different surgical procedures is still a matter of debate. The aim of the present study was to compare two ultra-short term antimicrobial prophylaxis regimens (amoxicillin-clavulanic acid and cefazolin) in preventing infections following laparoscopic gynecologic operations. Three hundred sixty women hospitalized for a laparoscopic gynecologic surgery procedure were included in the study between January 1999, and December 2001. Patients were randomly allocated to receive amoxicillin-clavulanic acid (2.2 g) [Group A] or cefazolin (2 g) [Group B] as a single dose 30 minutes before surgery. Each patient was assessed daily until discharge to evidence febrile status and the presence of infections at the operative site, urinary tract and respiratory tract. In the amoxicillin-clavulanic acid (Group A) and cefazolin (Group B) groups, overall 164 and 172 patients, respectively, were evaluable for prophylactic efficacy at hospital discharge. Infectious complications were infrequent in both groups with febrile morbidity occurring in only one patient (0.6%) in the amoxicillin-clavulanic group. No sign of infections at the surgical site, urinary tract and respiratory tract was observed in either group. No death due to sepsis was recorded. It is concluded that ultra-short term prophylaxis with both amoxicillin-clavulanic acid and cefazolin is safe and effective in elective laparoscopic gynecologic surgery.
Adolescent↗
Effects of intraperitoneal 6% dextran 70 on serum immunoglobulin levels, peripheral cell populations, and lymphocyte subpopulations in women undergoing gynecologic surgery.
Twelve women underwent elective major gynecologic surgery for benign, non-pregnancy-related conditions. No perioperative or postoperative "anti-adhesion" adjuvants were used. Serum immunoglobulin levels (IgG, IgM, IgA) and peripheral cell counts, including lymphocyte subpopulations, were measured in each patient during the immediate preoperative and postoperative periods as well as 5 to 8 weeks later. These results were compared to a treatment population of 16 women who underwent similar surgery and received 150 ml 6% dextran 70 intraperitoneally at the conclusion of the procedure. There was a decrease in the level of all serum immunoglobulins measured in the immediate postoperative period in both groups (not statistically different). At 5 to 8 weeks postoperatively there was a greater level of IgM in the control population than in the dextran-treated group (P = 0.03). Alterations in the peripheral cell counts, including lymphocyte subpopulations, were similar in the two groups. The use of intraperitoneal 6% dextran 70 did not result in postoperative alterations in the human immune system different from those induced by the surgical procedure itself.
Adult↗
Use of ketorolac and fentanyl during outpatient gynecologic surgery.
In healthy outpatients undergoing minor gynecologic surgery, the analgesic efficacy of ketorolac was compared to fentanyl and to a combination of the two analgesics. One hundred and nine patients were randomly selected to receive fentanyl 50-100 micrograms, ketorolac 30-60 mg, or a combination of fentanyl 50-100 micrograms and ketorolac 30-60 mg, intravenously (IV). Anesthesia was induced with midazolam 2 mg IV and propofol 1 mg/kg, IV, and maintained with propofol, 50-160 micrograms.kg-1.min-1, IV, and nitrous oxide 67% in oxygen via a face mask. Intraoperative anesthetic conditions, recovery times, and postoperative pain and side effects were evaluated. In the ketorolac group, 75% of patients required supplemental fentanyl intraoperatively (mean dose +/- SD, 47 +/- 54 micrograms), compared to only 19% (13 +/- 30 micrograms) and 18% (6 +/- 15 micrograms) of patients in the fentanyl and combination groups, respectively. In the ketorolac group, 74% of patients moved in response to surgical stimulation compared to only 16% and 19% of patients in the fentanyl and combination groups, respectively. Although there were no significant differences in intraoperative mean arterial pressure, heart rate, and oxygen saturation of hemoglobin values among the three treatment groups, the ketorolac group manifested significantly more rapid respiratory rates throughout the procedure compared with the fentanyl and combination groups. Recovery times, postoperative side effects, and pain scores, as well as postoperative analgesic and antiemetic requirements, were similar in all three treatment groups. However, the ketorolac group reported significantly higher pain scores in the early postoperative period.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Comparison of ramosetron and granisetron for preventing postoperative nausea and vomiting after gynecologic surgery.
UNLABELLED: In a prospective, randomized, double-blinded study, we evaluated the efficacy of granisetron and ramosetron for preventing postoperative nausea and vomiting (PONV) in major gynecologic surgery. One hundred twenty patients, ASA physical status I or II, aged 23-65 yr, received i.v. granisetron 2.5 mg or ramosetron 0.3 mg (n = 60 each) at the end of surgery. A standard general anesthetic technique and postoperative analgesia were used. The incidence of a complete response, defined as no PONV and no need for another rescue medication, 0-3 h after anesthesia was 87% with granisetron and 90% with ramosetron; the corresponding incidence 3-24 h after anesthesia was 85% and 90%; the corresponding incidence 24-48 h after anesthesia was 70% and 92% (P < 0.05). No clinically serious adverse events due to the drugs were observed in any of the groups. In conclusion, prophylactic therapy with ramosetron is more effective than granisetron for the longterm prevention of PONV after major gynecologic surgery. IMPLICATIONS: We compared the efficacy of granisetron and ramosetron for preventing postoperative nausea and vomiting in major gynecologic surgery. Prophylactic therapy with ramosetron was more effective than granisetron for preventing postoperative nausea and vomiting 24-48 h after anesthesia.
Adult↗
Value of urinary prophylaxis with methenamine in gynecologic surgery.
BACKGROUND: There is a high risk of postoperative bacteriuria and urinary tract infection after gynecologic surgery. Postoperative asymptomatic bacteriuria often disappears without treatment, but 15-20% of patients still require treatment for postoperative urinary tract infection. This study was carried out to assess the value of prophylactic treatment with methenamine hippurate after routine gynecologic surgery. METHODS: This was a prospective, randomized, double-blind, placebo-controlled clinical trial comprising 145 patients undergoing routine gynecologic laparotomy or vaginal plastic surgery using a Foley catheter for 24 h. Antibiotics were not used. Subjects received 1 g Hiprex or placebo twice daily for 5 days. Urine was cultured preoperatively, at catheter removal, and 2 days later. Patients with positive cultures were not given antibiotics unless they were symptomatic. The follow-up period was 1 month. STATISTICS: The chi-square test, Fisher exact test, and t-test were used with level of significance at 0.05, and odds ratios with 95% confidence intervals were calculated. RESULTS: Asymptomatic bacteriuria was diagnosed in 36 cases (50.0%) in the placebo group and 22 cases (30.1%) in the methenamine group (p = 0.02). Urinary tract infection was diagnosed in 10 cases (13.9%) in the placebo group and two cases (2.7%) in the methenamine group (p = 0.03). There were few adverse events. CONCLUSIONS: Prophylactic treatment with methenamine hippurate significantly reduces the incidence of postoperative bacteriuria and urinary tract infection.
Administration, Oral↗
A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery.
OBJECTIVE: The objective was to determine whether, when compared with traditional dietary advancement, early oral intake following major gynecologic surgery leads to a reduction in the length of hospitalization. METHODS: Patients undergoing major abdominal gynecologic surgery were invited to participate in this study. After informed consent was obtained, they were randomized to one of two groups. The control group (group 1) was treated traditionally. Oral intake was initiated only after documentation of bowel function, which was defined by two of the following three criteria: (1) bowel sounds; (2) flatus or bowel movement; and (3) subjective hunger. Those assigned to the study group (group 2) were given a clear liquid diet on postoperative day 1. Once 500 cc was tolerated, a regular diet was given. Patients were evaluated on a daily basis for bowel sounds, flatus, bowel movement, hunger, nausea, vomiting, and need for nasogastric tube decompression. The groups were compared with regard to length of hospital stay, length of postoperative ileus, and incidence of adverse effects including nausea, vomiting, and postoperative complications. Statistical analyses were performed with the Student t and chi 2 tests. RESULTS: The demographic characteristics of the control (N = 47) and study groups (N = 49) were similar, with no significant differences in underlying medical conditions, prior abdominal surgery, or diagnosis of a malignancy. The groups did not vary statistically in the number of subjects who required postoperative antiemetics or postoperative biscodyl suppository. There was a statistically significant reduction in the length of hospitalization for those patients on the early feeding regimen. The average length of stay for group 1 was 4.02 days +/- 0.30 (SEM), while that for group 2 was 3.12 days +/- 0.16 (P = 0.008). While there was a significantly higher incidence of emesis in the study population, this was not associated with any untoward outcome, and this group actually tolerated a solid diet nearly one full day earlier (2.72 days +/- 0.14 vs 1.88 days +/- 0.14, P < 0.0001). CONCLUSIONS: Early postoperative oral intake results in a decreased length of hospitalization and is well tolerated when compared with traditional dietary management in patients undergoing abdominal surgery on a university gynecologic oncology service.
Enteral Nutrition↗
Warming intravenous fluids reduces perioperative hypothermia in women undergoing ambulatory gynecological surgery.
UNLABELLED: We evaluated whether warming i.v. fluids resulted in less hypothermia (core temperature < 35.5 degrees C) compared with room-temperature fluids. Thirty-eight adult outpatients undergoing elective gynecological surgery of > 30 min were randomized to two groups: fluid warming at 42 degrees C or control (room temperature fluids at approximately 21 degrees C). All patients received general anesthesia with isoflurane, tracheal intubation, standard operating room blankets and surgical drapes, and passive humidification of inspired gases. Tympanic membrane (core) temperatures were measured at baseline and at 15-min intervals after induction. The incidence of shivering and postoperative requirement for meperidine and/or radiant heat were evaluated. Core temperatures were lower in the control compared with the warm fluid group at the end of surgery (35.6 +/- 0.1 degrees C vs 36.2 +/- 0.1 degrees C; P < 0.05). More patients had final core temperature < 35.5 degrees C in the control compared with the warm fluid group (35% vs 0%; P < 0.05). There were no differences in time to discharge from the postanesthesia care unit or the incidence of shivering between the groups. We conclude that fluid warming, in conjunction with standard heat conservation measures, was effective in maintaining normothermia during outpatient gynecological surgery; however, there was no improvement in patient outcome. IMPLICATIONS: Women who received i.v. fluid at body temperature had significantly higher core temperatures during and after outpatient gynecological surgery compared with women who received i.v. fluids at the temperature of the operating room.
Adult↗
Ureteric trauma in gynecologic surgery.
Nearly all gynecological procedures have been reported to cause ureteric injury, with an incidence of 0.4%-2.5% for non-malignant conditions. The incidence is rising as more ambitious operations are undertaken laparoscopically. Risk factors for ureteric injury include cancer, hemorrhage, endometriosis, adhesions and an enlarged uterus. Types of injury include ligation, crush, laceration, avulsion, stretch and devascularization. The diagnosis may be obvious intraoperatively, but postoperative presentation with loin pain, pyrexia, fistula or non-specific signs is more common. A significant number are asymptomatic. Early diagnosis is vital, and urological investigation should be considered in any patient who is not recovering as expected. Injuries recognized intraoperatively should be repaired during the same operation. Delayed recognized injuries are being managed conservatively with increasing success in selected cases. Early operative repair achieves good results unless the injury is severe. Litigation is less likely if the diagnosis is prompt, repair is successful and the patient is treated with consideration.
Female↗
Laparoscopic robotic gynecologic surgery.
The first gynecologic procedure performed with a robot was a tubal anastomosis. This was performed in 1998 with the Zeus robot. Over the past several years other gynecologic procedures have been performed with other robots. Current robotic technology may not be universally applicable to many gynecologists' clinical practice. The field of surgical robotics is evolving at an ever increasing pace, however, and gynecologists need to participate in its development.
Female↗