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Hiraishi H, Kitahara Y, Kobayashi M, Hasegawa Y, Tsukui Y, Miida M, Nakao K, Ikeda S, Hirakawa T, Iwase A. Factors related to clearance of the small pelvic cavity during gynecologic laparoscopic surgery. J Obstet Gynaecol Res 2024; 50:1392-1397. [PMID: 38804513 DOI: 10.1111/jog.15978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
AIM To identify factors influencing the Trendelenburg angle required during laparoscopic gynecological surgery. METHODS Patients who underwent laparoscopic surgery at a single university hospital between May 1, 2019, and March 31, 2021 were enrolled. Data were extracted from the medical records, while magnetic resonance imaging scans and all laparoscopic surgery videos were retrospectively reviewed to assess the presence of the small intestine in the pelvic cavity as well as the adhesions at each site. Groups with and without the small intestine in the pelvic cavity, and those requiring a Trendelenburg angle above or below 13° were compared. RESULTS In total, 219 patients were examined. The Trendelenburg angle was significantly higher (p = 0.004), while a significant increase in ovarian adhesions was observed (p = 0.033; odds ratio [OR], 2.30; 95% confidence interval [CI], 1.05-5.01) in the group without the presence of the small intestine in the pelvic cavity. Furthermore, the group requiring a Trendelenburg angle of ≥13° had significantly thicker subcutaneous fat (p = 0.044) and more ileal adhesions (p = 0.040, OR, 1.82; 95% CI, 1.03-3.23) than the group with an angle of <13°. CONCLUSION Cases of ileal adhesions or thick subcutaneous fat are more likely to require a Trendelenburg angle of ≥13°. Therefore, Trendelenburg complications should be considered in this group. In addition, ovarian adhesions make it more difficult to exclude the small intestine from the small pelvic cavity, and may be associated with endometriosis.
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Affiliation(s)
- Hikaru Hiraishi
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yoshikazu Kitahara
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Mio Kobayashi
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yuko Hasegawa
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yumiko Tsukui
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Miki Miida
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kohshiro Nakao
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Sadatomo Ikeda
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takashi Hirakawa
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Akira Iwase
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Kellegrew J, Hicks A, Gill L, Chemmanam I, Mountjoy R. Diagnostic and Therapeutic Ilioinguinal and Iliohypogastric Nerve Blocks: A Case Report. A A Pract 2024; 18:e01740. [PMID: 38259135 DOI: 10.1213/xaa.0000000000001740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
We present a case report of a consult for a gynecologic patient who presented with unrelenting postsurgical pain and previously underwent laparoscopic surgery. Given the pain distribution, we hypothesized the patient had an ilioinguinal or iliohypogastric nerve entrapment injury. We performed a diagnostic and therapeutic ilioinguinal and iliohypogastric nerve block, alleviating the patient's pain. The patient returned to the operating room to release a fascial stitch, permanently relieving the pain. This is a reminder that anesthesiologists can use regional anesthesia for both diagnosis and treatment.
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Affiliation(s)
- Jay Kellegrew
- From the Department of Anesthesiology & Perioperative Medicine, Maine Medical Center, Portland, Maine
| | - Anne Hicks
- From the Department of Anesthesiology & Perioperative Medicine, Maine Medical Center, Portland, Maine
- Spectrum Healthcare Partners, South Portland, Maine
| | - Lydia Gill
- Department of Obstetrics & Gynecology, Maine Medical Center, Portland, Maine
| | - Isaac Chemmanam
- From the Department of Anesthesiology & Perioperative Medicine, Maine Medical Center, Portland, Maine
- Spectrum Healthcare Partners, South Portland, Maine
| | - Ryan Mountjoy
- From the Department of Anesthesiology & Perioperative Medicine, Maine Medical Center, Portland, Maine
- Spectrum Healthcare Partners, South Portland, Maine
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Indraccolo U, Losavio E, Carone M. Applying graph theory to improve the quality of scientific evidence from textual information: Neural injuries after gynaecologic pelvic surgery for genital prolapse and urinary incontinence. Neurourol Urodyn 2023; 42:669-679. [PMID: 36648454 DOI: 10.1002/nau.25133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/07/2022] [Accepted: 01/06/2023] [Indexed: 01/18/2023]
Abstract
AIMS To provide the overall rate for all types of neurologic iatrogenic injuries during urogynaecologic surgery from textual data. METHODS Systematic research focused on complications of gynaecologic surgery and neurologic injuries in abstracts. Keywords concerning complications (cluster A), unspecific; neurologic issues (cluster B); surgery (generic words) (cluster C); specific gynaecologic operations (cluster D); and specific gynaecologic operations for pelvic organ prolapse and urinary incontinence (cluster E) were extracted. Associations among clusters of keywords were assessed by using multiple runs of text-mining software Semantic Brand Score (SBS, https://semanticbrandscore.com/#primary). Association scores were converted into probabilities. The rate of neurologic complications in urogynaecologic surgery was calculated ("a priori" probability) by applying Bayes' theorem. Textual estimates of neurological injuries in urogynaecologic surgery are 0.035554 (95% confidence intervals 0.019607-0.0515001; no quantitative data were found). To test if the probability calculated on textual information was the same as quantitative data reports ("a posteriori" probability), the rate of neurologic complication of all gynaecologic surgery was calculated using a meta-analytics approach and was compared with the textual analysis value. RESULTS The rate of neurologic complications in gynaecologic surgery after meta-analytic data synthesis has been 0.016489 (95% confidence intervals 0.012163-0.022320), which is equal to the textual estimate (0.016889, 95% confidence intervals 0.019607-0.051501). Therefore, 0.035554 is a reliable likelihood to observe a neurologic complication in urogynaecologic surgery. CONCLUSION Iatrogenic nerve injuries in urogynaecologic surgery are higher than whole gynaecologic surgery. Text-mining software SBS and probability conversion can provide reliable answers from overall scholars' opinions on unsolved clinical questions when better evidence is lacking.
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Affiliation(s)
- Ugo Indraccolo
- Maternal-Infantile Department, "Alto Chiascio" Hospital of Gubbio-Gualdo Tadino, Complex Operative Unit of Obstetrics and Gynecology, ASL 1 Umbria, Perugia, PG, Italy
| | - Ernesto Losavio
- IRCCS di Bari, Istituti Clinici Scientifici Maugeri, SPA SB, Pavia, Italy
| | - Mauro Carone
- IRCCS di Bari, Istituti Clinici Scientifici Maugeri, SPA SB, Pavia, Italy
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Factors Associated With Peripheral Nerve Injury After Pelvic Laparoscopy: The Importance of Surgical Positioning. THE JOURNAL OF NURSING RESEARCH : JNR 2023; 31:e259. [PMID: 36692838 DOI: 10.1097/jnr.0000000000000530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Nerve damage after abdominal and pelvic surgery is rare but potentially serious. The incidence of peripheral nerve injury is difficult to assess, and rates of between 0.02% and 21% have been cited in the literature. Signs and symptoms of this type of injury may appear immediately after surgery or a few days later. PURPOSE This study was developed to assess the rate of peripheral nerve injury after pelvic laparoscopy and to identify associated risk factors. METHODS A pilot prospective cohort study was conducted between March 2018 and April 2019 on 101 patients with a 1-month follow-up using two semistructured clinical interviews. We carried out a descriptive analysis followed by univariable and multivariable logistic regression analyses. RESULTS Thirteen patients were found to have peripheral nerve injuries, representing a rate of 12.9%. Overall, 14 injuries (five severe and nine mild) were detected. One patient had two mild injuries. In this study, the risk of injury was found to increase 1.77-fold (OR = 1.77, 95% CI [1.13, 2.76], p = .007) for each hour the patient was in the Trendelenburg position. CONCLUSIONS/IMPLICATIONS FOR PRACTICE The longer the patient is in the Trendelenburg position, the greater the risk of peripheral nerve damage. Patients aged 60 years or less also face a higher risk of nerve injury.
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Bjøro B, Ballestad I, Rustøen T, Fosmark MH, Bentsen SB. Positioning patients for robotic-assisted surgery: A qualitative study of operating room nurses' experiences. Nurs Open 2023; 10:469-478. [PMID: 36631733 PMCID: PMC9834175 DOI: 10.1002/nop2.1312] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 12/21/2021] [Accepted: 07/29/2022] [Indexed: 01/16/2023] Open
Abstract
AIM One of the challenges of robotic-assisted surgery is related to positioning of the patient on the operating table. Technological developments place increased demands on operating room nurses' competence to prevent positioning injuries and ensuring care quality. Therefore, the aim of the present study was to describe operating room nurses' experiences when positioning the patients for robotic-assisted surgery. DESIGN A descriptive qualitative design. METHODS Seven operating room nurses with experience in robotic-assisted surgery were included at a university hospital. Data were obtained through individual interviews and analysed using qualitative content analysis. The Consolidated Criteria for Reporting Qualitative research COREQ checklist was used. RESULTS We identified three categories, (a) patient positioning is challenging during robotic-assisted surgery, (b) operating room nurses take responsibility for patient positioning during robotic-assisted surgery, but teamwork is important and (c) operating room nurses aim to achieve safe patient positioning during robotic-assisted surgery.
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Affiliation(s)
- Benedikte Bjøro
- Department of Operating Services, Division of Emergencies and Critical CareOslo University HospitalOsloNorway
- Department of Nursing Science, Faculty of Medicine, Institute of Health and SocietyUniversity of OsloOsloNorway
| | - Ingvild Ballestad
- Department of Health and Caring SciencesWestern Norway University of Applied SciencesBergenNorway
| | - Tone Rustøen
- Department of Nursing Science, Faculty of Medicine, Institute of Health and SocietyUniversity of OsloOsloNorway
- Department of Research and Development, Division of Emergencies and Critical CareOslo University HospitalOsloNorway
| | - Monica Hetlesæther Fosmark
- Faculty of Health SciencesUniversity of StavangerStavangerNorway
- Operating DepartmentHelse Stavanger HFStavangerNorway
| | - Signe Berit Bentsen
- Department of Operating Services, Division of Emergencies and Critical CareOslo University HospitalOsloNorway
- Department of Health and Caring SciencesWestern Norway University of Applied SciencesBergenNorway
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Evaluation and Management of Common Intraoperative and Postoperative Complications in Gynecologic Endoscopy. Obstet Gynecol Clin North Am 2022; 49:355-368. [DOI: 10.1016/j.ogc.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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7
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Zampieri N. Commentary on: 15-Year varicocelectomy outcomes in pediatric age: Beware of genitofemoral nerve injury. J Pediatr Urol 2021; 17:874-875. [PMID: 34583901 DOI: 10.1016/j.jpurol.2021.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Nicola Zampieri
- Woman and Child Hospital, Azienda Ospedaliera Universitaria Integrata, Department of Surgery, Dentistry, Paediatrics and Gynaecology, Paediatric Fertility Lab, University of Verona, Piazzale, A.Stefani 1, Verona, Italy.
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Hay AK, McDougall A, Hinstridge P, Rajakuldendran S, Yoong W. Prolonged brachial plexus neuropathy: a rare complication following protracted endometriosis surgery in Lloyd-Davies position. BMJ Case Rep 2021; 14:e243408. [PMID: 34844958 PMCID: PMC8634370 DOI: 10.1136/bcr-2021-243408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/04/2022] Open
Abstract
Brachial plexus injury is a rare but potentially serious complication of laparoscopic surgery. Loss of motor and/or sensory innervation can have a significant impact on the patient's quality of life following otherwise successful surgery. A 38-year-old underwent elective laparoscopic management of severe endometriosis during which she was placed in steep head-down tilt Lloyd-Davies position for a prolonged period. On awakening from anaesthesia, the patient had no sensation or movement of her dominant right arm. A total plexus brachialis injury was suspected. As advised by a neurologist, an MRI brachial plexus, nerve conduction study and electromyography were requested. She was managed conservatively and made a gradual recovery with a degree of residual musculocutaneous nerve neuropathy. The incidence of brachial plexus injury following laparoscopy is unknown but the brachial plexus is particularly susceptible to injury as a result of patient positioning and prolonged operative time. Patient positioning in relation to applied clinical anatomy is explored and risk reduction strategies described.
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Affiliation(s)
- Anna Katrina Hay
- Obstetrics and Gynaecology, North Middlesex University Hospital NHS Trust, London, UK
| | - Anna McDougall
- Obstetrics and Gynaecology, North Middlesex University Hospital NHS Trust, London, UK
| | - Peter Hinstridge
- Obstetrics and Gynaecology, North Middlesex University Hospital NHS Trust, London, UK
| | | | - Wai Yoong
- Obstetrics and Gynaecology, North Middlesex University Hospital NHS Trust, London, UK
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Watrowski R, Kostov S, Alkatout I. Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review. Wideochir Inne Tech Maloinwazyjne 2021; 16:501-525. [PMID: 34691301 PMCID: PMC8512506 DOI: 10.5114/wiitm.2021.108800] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/30/2021] [Indexed: 11/26/2022] Open
Abstract
Almost all gynecological and general-surgical operations are - or can be - performed laparoscopically. In comparison to an abdominal approach, the minimally invasive access offers several advantages; however, laparoscopy (both conventional and robotic-assisted) can be associated with a number of approach-specific complications. Although the majority of them are related to the laparoscopic entry, adverse events may also occur due to the presence of pneumoperitoneum or the use of laparoscopic instruments. Unfortunately, a high proportion of complications (especially affecting the bowel and ureter) remain unrecognized during surgery. This narrative review provides comprehensive up-to-date information about definitions, classifications, risk factors and incidence of surgical complications in conventional and robotic-assisted laparoscopy, with a special focus on gynecology. The topic is discussed from various perspectives, e.g. in the context of stage of surgery, injured organs, involved instruments, and in relation to malpractice claims.
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Affiliation(s)
- Rafał Watrowski
- St. Josefskrankenhaus, Teaching Hospital of the University of Freiburg, Freiburg, Germany
| | - Stoyan Kostov
- Department of Gynecology, Medical University Varna, Varna, Bulgaria
| | - Ibrahim Alkatout
- Department of Gynecology and Obstetrics, Kiel School of Gynecological Endoscopy, University Hospitals Schleswig-Holstein, Kiel, Germany
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Postoperative Lower Extremity Neuropathy With Boot Stirrups Compared With Candy Cane Stirrups. Obstet Gynecol 2021; 137:916-923. [PMID: 33831927 DOI: 10.1097/aog.0000000000004353] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/28/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess whether candy cane stirrup use is associated with an increased risk of lower extremity peripheral neuropathy compared with boot stirrups in women undergoing surgery requiring dorsal lithotomy positioning. METHODS This retrospective cohort study (June 2008-August 2015) included patients who underwent gynecologic surgery for benign indication lasting 60 minutes or longer in the lithotomy position. Patients with preexisting neurologic disease were excluded. Stirrup type, demographics, medical history, surgical factors, and relevant outcomes were collected from the medical record. Postoperative neuropathy was identified in clinical diagnoses or in physician documentation through the 6-week postoperative visit. Patient characteristics and outcomes were compared using Student's t test, χ2 test, or Fisher exact test. Logistic regression analysis was used to adjust for other clinical characteristics associated with the outcome at P≤.1. RESULTS The study included 2,449 patients, 1,838 (75.1%) with boot and 611 (24.9%) with candy cane stirrups. Women positioned in boot stirrups were younger (mean age 45.6 years [SD 13.5] vs 55.9 [SD 15.7] years; P<.001), heavier (mean body mass index [BMI] 31.5 [SD 8.7] vs 29.6 [SD 7.0]; P<.001), more likely to smoke (n=396 [21.5%] vs n=105 [17.2%]; P=.021), and had longer surgical duration (mean 176.5 minutes [SD 90.0] vs 145.3 [SD 63.9] minutes; P<.001), respectively. Diabetes (8.3%) did not differ between the groups (P=.122. Neuropathy occurred less often in the boot cohort (n=29, 1.6%, 95% CI 1.1-2.3%) than in the candy cane cohort (n=21, 3.4%, 95% CI 2.1-5.2%) (P=.008). After adjusting for age, BMI, smoking, anesthesia type and surgical time, only candy cane stirrup type (adjusted odds ratio [aOR] 2.87, 95% CI 1.59-5.19) and surgical time (per hour) (aOR 1.40, 95% CI 1.20-1.63) were independently associated with postoperative neuropathy. CONCLUSION Candy cane stirrups are associated with a significantly increased risk of lower extremity postoperative neuropathy compared with boot stirrups for women undergoing gynecologic surgery for benign indication.
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Yavuz A, Ethemoglu FB, Olpak M, Nessar G. Trendelenburg Position-Induced Brachial Plexus Injury Following Laparoscopic Rectal Cancer Surgery. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02335-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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12
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Araque Cancar JC, Lázaro Rosado S, Del Palacio Salgado M, Morales Palacios MT. [Ischiofemoral impingement syndrome: Report of an unusual case]. Rehabilitacion (Madr) 2021; 56:159-163. [PMID: 33712287 DOI: 10.1016/j.rh.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 11/17/2022]
Abstract
Ischiofemoral impingement syndrome is usually underdiagnosed; this syndrome forms part of the differential diagnoses to be included in hip pain. It was initially described with surgical procedures but, with the passage of time, various medical entities have been described, as well as techniques and postures that can aggravate this syndrome, which can even be associated with neurological involvement. Current treatment is initially conservative, consisting of rest, analgesia, cold and progressive exercises aimed at the lumber and gluteal muscles and lower extremities but there is no established standard of care.
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Affiliation(s)
- J C Araque Cancar
- Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España.
| | - S Lázaro Rosado
- Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
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Lower Extremity Nerve Injury in Childbirth: AWHONN Practice Brief Number 11. J Obstet Gynecol Neonatal Nurs 2020; 49:622-624. [PMID: 33092945 DOI: 10.1016/j.jogn.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Lower Extremity Nerve Injury in Childbirth: AWHONN Practice Brief Number 11. Nurs Womens Health 2020; 24:470-472. [PMID: 33093000 DOI: 10.1016/j.nwh.2020.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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15
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Gupta A, Meriwether K, Tuller M, Sekula M, Gaskins J, Stewart JR, Hobson D, Cardenas-Trowers O, Francis S. Candy Cane Compared With Boot Stirrups in Vaginal Surgery: A Randomized Controlled Trial. Obstet Gynecol 2020; 136:333-341. [PMID: 32649498 DOI: 10.1097/aog.0000000000003954] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate differences in physical function at 6 weeks after vaginal surgery among women positioned in candy cane and boot stirrups. METHODS We conducted a single-masked, randomized controlled trial of women undergoing vaginal surgery with either candy cane or boot stirrup use. The primary outcome was a change in the PROMIS (Patient-Reported Outcomes Measurement Information System) physical function short form-20a from baseline to 6 weeks after surgery. To achieve 80% power to detect a moderate Cohen effect (d=0.5), we required 64 participants in each group. RESULTS From March 2018 to October 2019, 141 women were randomized, and 138 women (72 in the candy cane group and 66 in the boot stirrup group) were included in the final analysis. There were no baseline differences in participant characteristics including age, body mass index, comorbidities, or preoperative history of joint replacements. There were no between-group differences in surgery type, duration of surgery, estimated blood loss, or adverse events at 6 weeks postoperation. Participants in the candy cane group demonstrated worse physical function at 6 weeks compares with the improvement seen in those in the boot stirrup group; this was significantly different between groups (-1.9±7.9 candy cane vs 1.9±7.0 boot, P<.01). CONCLUSION Women undergoing vaginal surgery positioned in boot stirrups have significantly better physical function at 6 weeks after surgery when compared with women positioned in candy cane stirrups. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT03446950.
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Affiliation(s)
- Ankita Gupta
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, and the Department of Obstetrics & Gynecology, University of Louisville School of Medicine, and the Department of Bioinformatics & Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, Kentucky; the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics & Gynecology, University of New Mexico, Albuquerque, New Mexico; and the Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, Michigan
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Pelvic Neuroanatomy: An Overview of Commonly Encountered Pelvic Nerves in Gynecologic Surgery. J Minim Invasive Gynecol 2020; 28:178. [PMID: 32540500 DOI: 10.1016/j.jmig.2020.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/27/2020] [Accepted: 06/08/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE This video tutorial identifies key anatomic landmarks useful in identifying the path of the most commonly encountered pelvic nerves in benign gynecologic surgery. DESIGN This is a narrated overview of commonly encountered pelvic nerves during benign gynecology, their origin, sensory, and motor function, as well as sequelae related to injury. SETTING The unintended injury of pelvic neural connections can be a complication of any pelvic surgery, however, surgery for malignancy or endometriosis may increase the likelihood of encountering these nerves. The majority of focus surrounding surgical nerve injury, however, relates to patient positioning [1]. Injury to the pelvic nerves can lead to lifelong sexual, bladder, and defecatory dysfunction [2]. INTERVENTIONS We review the Genitofemoral, Lateral Femoral Cutaneous, Ilioinguinal, Obturator, Superior and Inferior Hypogastric nerves, Pelvic Splanchnic nerves, and the Sacral nerves. Surgical illustrations are used (Fig. 1) alongside real-time narrated video to help viewers recognize the normal course of commonly encountered pelvic nerves at the time of gynecologic surgery (Figs2-3). CONCLUSION The surgical management of complex pelvic disease can unfortunately carry significant patient morbidity [3]. The neural pathways traveling through the pelvis via the hypogastric nerves are responsible for proprioception, vaginal lubrication, and proper functioning or the urethral and anal sphincters [4]. Sparing these nerves during pelvic surgery, and especially when anatomic planes are distorted by pelvic disease, requires surgical expertise and an immense understanding of pelvic neuroanatomy [4,5]. Preservation of the pelvic neural pathways is necessary to deliver the best patient outcomes while minimizing unwanted surgical complications. This video tutorial also highlights the origin of these nerves, their anatomic location, procedures in which these nerves may be encountered, and what sequelae occur from their unintended injury.
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Greaves E, Rosser M, Saunders PTK. Endometriosis-Associated Pain - Do Preclinical Rodent Models Provide a Good Platform for Translation? ADVANCES IN ANATOMY, EMBRYOLOGY, AND CELL BIOLOGY 2020; 232:25-55. [PMID: 33278006 DOI: 10.1007/978-3-030-51856-1_3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pelvic pain is a common symptom of endometriosis. Our understanding of its etiology remains incomplete and medical management is limited by poor translation from preclinical models to clinical trials. In this review, we briefly consider the evidence, or lack thereof, that different subtypes of lesion, extra-uterine bleeding, and neuropathic pathways add to the complex and heterogeneous pain experience of women with the condition. We summarize the studies in rodent models of endometriosis that have used behavioral endpoints (evoked and non-evoked) to explore mechanisms of endometriosis-associated pain. Lesion innervation, activation of nerves by pronociceptive molecules released by immune cells, and a role for estrogen in modulating hyperalgesia are key endometriosis-associated pain mechanisms replicated in preclinical rodent models. The presence of ectopic (full thickness uterus or endometrial) tissue may be associated with changes in the spinal cord and brain, which appear to model changes reported in patients. While preclinical models using rats and mice have yielded insights that appear relevant to mechanisms responsible for the development of endometriosis-associated pain, they are limited in scope. Specifically, most studies are based on models that only resulted in the formation of superficial lesions and use induced (evoked) behavioral 'pain' tests. We suggest that translation for patient benefit will be improved by new approaches including models of ovarian and deep infiltrating disease and measurement of spontaneous pain behaviors. Future studies must also capitalize on new advances in the wider field of pain medicine to identify more effective treatments for endometriosis-associated pain.
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Affiliation(s)
- Erin Greaves
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK.
| | - Matthew Rosser
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Philippa T K Saunders
- Centre for Inflammation Research, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
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Bjøro B, Mykkeltveit I, Rustøen T, Candas Altinbas B, Røise O, Bentsen SB. Intraoperative peripheral nerve injury related to lithotomy positioning with steep Trendelenburg in patients undergoing robotic-assisted laparoscopic surgery - A systematic review. J Adv Nurs 2019; 76:490-503. [PMID: 31736124 DOI: 10.1111/jan.14271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/08/2019] [Accepted: 11/05/2019] [Indexed: 12/22/2022]
Abstract
AIMS To examine the incidence of intraoperative peripheral nerve injury, symptoms, risk factors, functions, and quality of life in patients undergoing robotic-assisted laparoscopic surgery to lithotomy positioning with steep Trendelenburg. DESIGN A systematic review. DATA SOURCES The Cochrane Library catalogue, PubMed, EMBASE, CINHAL and SveMed + databases were searched from January 2000 - February 2019. REVIEW METHODS Titles and abstracts were screened for inclusion. Full-text assessments of each paper were conducted by two reviewers. The quality of the included papers was assessed using the Mixed Methods Appraisal Tool. Descriptive statistics and thematic analysis were used to synthesize the data. RESULTS Eleven quantitative studies were included with three themes: (a) incidence of intraoperative peripheral nerve injury; (b) upper extremity intraoperative peripheral nerve injury related to steep Trendelenburg positioning; and (c) lower extremity intraoperative peripheral nerve injury related to lithotomy positioning. The overall incidence of intraoperative peripheral nerve injury in robotic-assisted laparoscopic urologic, gynaecologic and colorectal surgery was 0.16%-10.0% and the symptoms appeared immediately after surgical procedures. Risk factors for intraoperative peripheral injury were prolonged operative time, high American Society of Anesthesiologists scores, comorbidities and high body mass index. CONCLUSION Intraoperative peripheral nerve injuries are rare, but occasionally serious when related to lithotomy positioning with steep Trendelenburg. Operating room nurses have a responsibility both for positioning patients and for being familiar with the technological developments that will influence the preoperative handling of patients. IMPACT This systematic review emphasizes the need for operating room nurses together with surgical team to have knowledge about mechanisms for injury, positioning, anatomy/physiology, and evaluation of risk factors to ensure that patients are not exposed for intraoperative peripheral nerve injuries. Increased robotic-assisted laparoscopic surgery necessitates further research examining the incidence of intraoperative peripheral nerve injury related to positioning and how these affect patients' function and the quality of life.
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Affiliation(s)
- Benedikte Bjøro
- Department of Operating Services, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Ida Mykkeltveit
- Faculty of Health Science, University of Stavanger, Stavanger, Norway
| | - Tone Rustøen
- Department of Nursing Science, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway.,Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Bahar Candas Altinbas
- Department of Surgical Disease Nursing, Faculty of Health Science, Karadeniz Technical University, Trabzon, Turkey
| | - Olav Røise
- Division of Orthopedics Surgery, Faculty of health Sciences, Oslo University Hospital, SHARE-Center for Resilience in Healthcare, University of Stavanger, Stavanger, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Signe Berit Bentsen
- Department of Operating Services, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.,Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
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A Practical Guide to the Clinical Evaluation of Endometriosis-Associated Pelvic Pain. J Minim Invasive Gynecol 2019; 27:270-279. [PMID: 31669551 DOI: 10.1016/j.jmig.2019.10.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 10/15/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
Abstract
Endometriosis-associated pain (EAP) has a significant impact on the quality of life of those affected and their families. Recognizing that endometriosis is a chronic condition associated with an impairment in function and negative social impact, there is a shift toward reducing diagnostic delays and initiating timely management. This article provides a comprehensive and practical approach to the clinical diagnosis of EAP, which can subsequently facilitate prompt and directed treatment. The key components of the history, physical examination, and high-quality imaging to evaluate suspected EAP and related pain conditions are presented. Currently, biomarkers have limited utility in the diagnosis of endometriosis, but research in this area continues; development of a reliable noninvasive test for endometriosis may further improve early identification of this condition.
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Prospective randomized controlled trial comparing cephalad migration in robotic gynecologic surgery using egg-crate foam versus the Pink Pad®. J Robot Surg 2019; 14:343-347. [DOI: 10.1007/s11701-019-00990-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
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22
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Aisu Y, Hori T, Kato S, Ando Y, Yasukawa D, Kimura Y, Takamatsu Y, Kitano T, Kadokawa Y. Brachial plexus paralysis after thoracoscopic esophagectomy for esophageal cancer in the prone position: A thought-provoking case report of an unexpected complication. Int J Surg Case Rep 2019; 55:11-14. [PMID: 30654315 PMCID: PMC6348979 DOI: 10.1016/j.ijscr.2018.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 12/11/2018] [Indexed: 11/10/2022] Open
Abstract
This is the first case of brachial plexus injury during thoracoscopic esophagectomy in the prone position. This paralysis is due to excessive abduction and external rotation associated with the intraoperative position. To avoid intraoperative brachial plexus injury in the prone position, thoughtful orientation of the head and right arm in a less loaded position is important.
Introduction During prone esophagectomy, placement of a port in the third intercostal space for upper mediastinal dissection requires adequate axillary expansion. To facilitate this, the right arm is elevated cranially and simultaneously turned outward. Brachial plexus paralysis associated with esophagectomy in the prone position has not been documented. Presentation of case A 58-year-old man diagnosed with middle intrathoracic esophageal cancer was referred to our department. Thoracoscopic esophagectomy in the prone position was performed following neoadjuvant chemotherapy. After surgery, he complained of difficulty moving his right arm. Physical examination revealed perceptual dysfunction and movement disorder in the territory of cervical spinal nerve 6. Magnetic resonance imaging indicated the injury in the right posterior cord of the brachial plexus at the costoclavicular space. Therefore, we diagnosed the patient with right brachial plexus injury caused by the intraoperative position. The postoperative course was uneventful other than the brachial plexus paralysis, and he was discharged on postoperative day 23. He underwent continuous rehabilitation as an outpatient, and the right brachial plexus paralysis had completely disappeared by 2 months after surgery. Discussion This is the first case of brachial plexus injury during thoracoscopic esophagectomy in the prone position. In prone esophagectomy, managing the patient’s position, especially the head and arm positions, is so important to avoid brachial plexus injury due to intraoperative positioning. Conclusion The clinicians should consider managing the patient’s position with anatomical familiarity to avoid brachial plexus injury due to intraoperative positioning.
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Affiliation(s)
- Yuki Aisu
- Department of Gastrointestinal Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan.
| | - Tomohide Hori
- Department of Gastrointestinal Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan.
| | - Shigeru Kato
- Department of Gastrointestinal Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan.
| | - Yasuhisa Ando
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa Prefecture, 761-0793, Japan.
| | - Daiki Yasukawa
- Department of Gastrointestinal Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan.
| | - Yusuke Kimura
- Department of Gastrointestinal Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan.
| | - Yuichi Takamatsu
- Department of Gastrointestinal Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan.
| | - Taku Kitano
- Department of Gastrointestinal Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan.
| | - Yoshio Kadokawa
- Department of Gastrointestinal Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan.
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Das D, Propst K, Wechter ME, Kho RM. Evaluation of Positioning Devices for Optimization of Outcomes in Laparoscopic and Robotic-Assisted Gynecologic Surgery. J Minim Invasive Gynecol 2018; 26:244-252.e1. [PMID: 30176363 DOI: 10.1016/j.jmig.2018.08.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/16/2018] [Accepted: 08/24/2018] [Indexed: 01/20/2023]
Abstract
In this review, we evaluate techniques, devices, and equipment for patient positioning and their effect on patient outcomes, such as cephalad slide and neuropathy, in laparoscopic and robotic-assisted gynecologic surgery. We conducted a systematic review by searching MEDLINE, Embase, and Cochrane Library for relevant articles published over a 15-year period. Study selection, data extraction, and quality assessment were performed by 2 reviewers independently. Seven articles, including 3 randomized controlled trials and 4 case series, were included in our analysis. Four studies evaluated cephalad patient slide. In 2 randomized controlled trials (n = 103), the mean slide with various devices (i.e., memory foam, bean bag with shoulder braces, egg crate, and gel pad) ranged from 1.07 ± 1.93 cm to 4.5 ± 4.0 cm. The use of a bean bag with shoulder supports/braces was associated with minimal slide, with a median slide of 0 cm (range, 0-2 cm) in a retrospective series and with mean slide of 1.07 ± 1.93 cm in a randomized controlled trial (vs memory foam). No conclusive effect of body mass index on slide could be identified. Five studies evaluating the incidence of neuropathy found an overall incidence of 0.16% and no differences among slide-preventing devices. The minimal slide described across studies supports the conclusion that any of the currently used devices and techniques for safe patient positioning are within reason. The low overall incidence of neuropathy is also reassuring. Best evidence recommendations cannot be made for a specific device or technique; our findings suggest the importance of strict adherence to the basic tenets of safe patient positioning to minimize slide and prevent nerve injury.
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Affiliation(s)
- Deepanjana Das
- From the Department of Obstetrics and Gynecology Cleveland Clinic, Cleveland, Ohio.
| | - Katie Propst
- From the Department of Obstetrics and Gynecology Cleveland Clinic, Cleveland, Ohio
| | | | - Rosanne M Kho
- From the Department of Obstetrics and Gynecology Cleveland Clinic, Cleveland, Ohio
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Defining and mitigating the challenges of an older and obese population in minimally invasive gynecologic cancer surgery. Gynecol Oncol 2018; 148:601-608. [DOI: 10.1016/j.ygyno.2017.12.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 12/13/2017] [Accepted: 12/16/2017] [Indexed: 12/11/2022]
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Woodfin KO, Johnson C, Parker R, Mikach C, Johnson M, McMullan SP. Use of a Novel Memory Aid to Educate Perioperative Team Members on Proper Patient Positioning Technique. AORN J 2018; 107:325-332. [PMID: 29486082 DOI: 10.1002/aorn.12075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Interdisciplinary collaboration is key to safe surgical positioning. Although the surgical procedure dictates the patient's position, surgeons, anesthesia care providers, intraoperative nurses, and ancillary staff members must work together to achieve the goal of safe positioning. Correct patient positioning includes the provision of adequate access to the surgical site for the surgeon and surgical assistants. Surgical positions may put the patient at risk of injury. Understanding human anatomy, including the nerves commonly affected by each surgical position, can help the surgical team prevent accidental and irreversible patient injury. A lack of knowledge of proper positioning practices can result in serious patient injury, such as permanent paralysis, blindness, tissue necrosis, burns, bone fracture, and even death. This article reviews surgical positioning and introduces a learning module that involves the use of mnemonics as memory aids for perioperative team members who are learning proper positioning techniques.
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