Intraoperative methadone for day-case gynaecological laparoscopy: A double-blind, randomised controlled trial

Optimal pain relief in day-case surgery is imperative to patient comfort and timely discharge from hospital. Short-acting opioids are commonly used for analgesia in modern anaesthesia, allowing rapid recovery after surgery. Plasma concentration fluctuations from repeated dosing of short-acting opioids can cause patients to oscillate between analgesia with potential adverse effects, and inadequate analgesia requiring rescue dosing. Methadone's unique pharmacology may offer effective and sustained analgesia with less opioid consumption, potentially reducing adverse effects. Using a double-blind, randomised controlled trial, we compared post-anaesthesia care unit opioid consumption between day-case gynaecological laparoscopy patients who received either intravenous methadone (10 mg), or short-acting opioids intraoperatively. The primary outcome was post-anaesthesia care unit opioid consumption in oral morphine equivalents. Secondary outcomes included total opioid consumption, discharge opioid consumption, pain scores (0-10) until discharge, adverse effects (respiratory depression, postoperative nausea and vomiting, excess sedation), and rate of admission. Seventy patients were randomly assigned. Patients who received methadone consumed on average 9.44 mg fewer oral morphine equivalents in the post-anaesthesia care unit than the short-acting group (18.02 mg vs 27.46 mg, respectively, 95% confidence interval 0.003 to 18.88, P = 0.050) and experienced lower postoperative pain scores at every time point, although absolute differences were small. There was no evidence of lower hospital or discharge opioid consumption. No significant differences between the methadone and short-acting groups in other outcomes were identified: respiratory depression 41.2% versus 31.4%, Padjusted >0.99; postoperative nausea and vomiting 29.4% versus 42.9%, Padjusted >0.99; overnight admission 17.7% versus 11.4%, Padjusted >0.99; excess sedation 8.82% versus 8.57%, Padjusted >0.99. This study provides evidence that, although modestly, methadone can reduce post-anaesthesia care unit opioid consumption and postoperative pain scores after day-case gynaecological laparoscopy. There were no significant differences in any secondary outcomes.

Malignant mesothelioma of the peritoneum mimicking primary peritonitis carcinomatosis

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Effect of a pre-emptive 2-hour session of high-flow nasal oxygen on postoperative oxygenation after major gynaecologic surgery: a randomised clinical trial

BACKGROUND

We aimed at determining whether a 2-h session of high-flow nasal oxygen (HFNO) immediately after extubation improves oxygen exchange after major gynaecological surgery in the Trendelenburg position in adult female patients.

METHODS

In this single-centre, open-label, randomised trial, patients who underwent major gynaecological surgery were randomised to HFNO or conventional oxygen treatment with a Venturi mask. The primary outcome was the Pao2/FiO2 ratio after 2 h of treatment. Secondary outcomes included lung ultrasound score, diaphragm thickening fraction, dyspnoea, ventilatory frequency, Paco2, the percentage of patients with impaired gas exchange (Pao2/FiO2 ≤40 kPa) after 2 h of treatment, and postoperative pulmonary complications at 30 days.

RESULTS

A total of 83 patients were included (42 in the HFNO group and 41 in the conventional treatment group). After 2 h of treatment, median (inter-quartile range) Pao2/FiO2 was 52.9 (47.9-65.2) kPa in the HFNO group and 45.7 (36.4 -55.9) kPa in the conventional treatment group (mean difference 8.7 kPa [95% CI: 3.4 to 13.9], P=0.003). The lung ultrasound score was lower in the HFNO group than in the conventional treatment group (9 [6-10] vs 12 [10-14], P<0.001), mostly because of the difference of the score in dorsal areas (7 [6-8] vs 10 [9-10], P<0.001). The percentage of patients with impaired gas exchange was lower in the HFNO group than in the conventional treatment group (5% vs 37%, P<0.001). All other secondary outcomes were not different between groups.

CONCLUSIONS

In patients who underwent major gynaecological surgery, a pre-emptive 2-h session of HFNO after extubation improved postoperative oxygen exchange and reduced atelectasis compared with a conventional oxygen treatment strategy.

CLINICAL TRIAL REGISTRATION

NCT04566419.

Ventilation strategy during urological and gynaecological robotic-assisted surgery: a narrative review

Robotic-assisted surgery has improved the precision and accuracy of surgical movements with subsequent improved outcomes. However, it requires steep Trendelenburg positioning combined with pneumoperitoneum that negatively affects respiratory mechanics and increases the risk of postoperative respiratory complications. This narrative review summarises the state of the art in ventilatory management of these patients in terms of levels of positive end-expiratory pressure (PEEP), tidal volume, recruitment manoeuvres, and ventilation modes during both urological and gynaecological robotic-assisted surgery. A review of the literature was conducted using PubMed/MEDLINE; after completing abstract and full-text review, 31 articles were included. Although different levels of PEEP were often evaluated within a protective ventilation strategy, including higher levels of PEEP, lower tidal volume, and recruitment manoeuvres vs a conventional ventilation strategy, we conclude that the best PEEP in terms of lung mechanics, gas exchange, and ventilation distribution has not been defined, but moderate PEEP levels (4-8 cm H2O) could be associated with better outcomes than lower or highest levels. Recruitment manoeuvres improved intraoperative arterial oxygenation, end-expiratory lung volume and the distribution of ventilation to dependent (dorsal) lung regions. Pressure-controlled compared with volume-controlled ventilation showed lower peak airway pressures with both higher compliance and higher carbon dioxide clearance. We propose directions to optimise ventilatory management during robotic surgery in light of the current evidence.

Clinical Alarms in a Gynaecological Surgical Unit: A Retrospective Data Analysis

Alarm fatigue refers to the desensitisation of medical staff to patient monitor clinical alarms, which may lead to slower response time or total ignorance of alarms and thereby affects patient safety. The reasons behind alarm fatigue are complex; the main contributing factors include the high number of alarms and the poor positive predictive value of alarms. The study was performed in the Surgery and Anaesthesia Unit of the Women's Hospital, Helsinki, by collecting data from patient monitoring device clinical alarms and patient characteristics from surgical operations. We descriptively analysed the data and statistically analysed the differences in alarm types between weekdays and weekends, using chi-squared, for a total of eight monitors with 562 patients. The most common operational procedure was caesarean section, of which 149 were performed (15.7%). Statistically significant differences existed in alarm types and procedures between weekdays and weekends. The number of alarms produced was 11.7 per patient. In total, 4698 (71.5%) alarms were technical and 1873 (28.5%) were physiological. The most common physiological alarm type was low pulse oximetry, with a total of 437 (23.3%). Of all the alarms, the number of alarms either acknowledged or silenced was 1234 (18.8%). A notable phenomenon in the study unit was alarm fatigue. Greater customisation of patient monitors for different settings is needed to reduce the number of alarms that do not have clinical significance.

A Comparative Study of Palonosetron with Ondansetron for Prophylaxis of Postoperative Nausea and Vomiting (PONV) Following Laparoscopic Gynaecological Surgeries

Background

Incidence of postoperative nausea and vomiting (PONV) in susceptible patients can be unacceptably high (70-80% reported incidence). This study was designed to evaluate the effect of palonosetron and ondansetron in preventing PONV in high-risk patients undergoing gynaecological laparoscopic surgery.

Methodology

In this randomised, controlled, double-blind trial, nonsmoking females 18-70 years and weighing 40-90 kg, scheduled for elective laparoscopic gynaecological surgeries, were enrolled into the ondansetron (Group A, n=65) or palonosetron (Group B, n=65) group. Palonosetron (1 mcg/kg 4) or ondansetron (0.1 mg/kg 4) were administered just before induction. Postoperatively, incidence of nausea, vomiting, PONV (scored on a scale of 0-3), need for rescue antiemetic, complete response, patient satisfaction, and adverse effects were evaluated for up to 48 h following surgery.

Results

The overall PONV scores and postoperative nausea score during 0-2 h and 24-48 h were comparable, but PONV scores (P=0.023) and postoperative nausea scores (P=0.010) during 2-24 h were significantly lesser in Group B compared to Group A. There was no statistically significant difference in the postoperative vomiting score or retching during 0-48 h. The amount of first-line rescue antiemetic used during 2-24 h was significantly higher in Group A (56%) than in Group B (31%) (P=0.012; P<0.05). Complete response to the drug during 2-24 h was significantly higher (P=0.023) in Group B (63%) compared to Group A (40%), whereas response was comparable during 0-2 h and 24-48 h. Both groups had comparable incidences of adverse effects and patient satisfaction scores.

Conclusion

Palonosetron has superior antinausea effect, less need of rescue antiemetics, and lesser incidence of total PONV in comparison to ondansetron during 2-24 h and comparable effect to ondansetron during the 0-2 h and 24-48 h postoperative periods in high-risk patients undergoing gynaecological laparoscopic surgery.

Gynaecological management of women with inherited bleeding disorders

Women with inherited bleeding disorders (IBDs) may present to healthcare professionals in a variety of ways and commonly will be encountered by either haematology or gynaecology services. Heavy menstrual bleeding is very often the first manifestation of an IBD. There is a wide variation in severity of bleeding for women with IBD and diagnosis and subsequent management of their condition requires multidisciplinary specialised care which is tailored to the individual and includes excellent cross-specialty communication between gynaecology and haematology teams. This guideline is intended for both haematologists and gynaecologists who are involved in the diagnosis and management of women with bleeding disorders. It sets out recommendations about how to investigate heavy menstrual bleeding (HMB), the commonest presentation for women with IBD to hospital services, to guide physicians about how to diagnose an IBD and covers the management of women with known IBD and HMB. The second section sets out recommendations for patients known to have IBD and covers management of patients with IBD in the setting of gynaecological surgery and management for all other non-surgical gynaecological situations.

Meta-analysis for the evaluation of perioperative enhanced recovery after gynaecological surgery

OBJECTIVES

To systematically evaluate the effectiveness and safety of enhanced recovery after surgery (ERAS) in gynaecological surgery and provide a scientific basis for its clinical promotion and application in the Chinese population.

MATERIAL AND METHODS

Systematic retrieval from CNKI, Wanfang, VIP database and other Chinese literature databases. Studies on ERAS application with a randomised controlled trial in gynaecological surgery were included in the present report. Outcome indicators: hospitalisation time, postoperative ambulation time, postoperative feeding time, postoperative exhaust time, postoperative defecation time, operation time, postoperative blood loss, postoperative morbidity, patient satisfaction, hospitalisation expenses, etc. The meta-analysis was performed using the Revman 5.3 software.

RESULTS

A total of 24 studies were included in the analysis. The results showed that, compared with the traditional group, the ERAS group had a lower hospitalisation time (SMD = -1.67, 95% CI = -2.03 ~ -1.30, p < 0.0001), postoperative ambulation time (SMD = -4.16, 95% CI = -5.12 ~ -3.20, p < 0.0001), postoperative feeding time (SMD = -7.36, 95% CI = -9.67 ~ -5.05, p < 0.0001), postoperative exhaust time (SMD = -2.59, 95% CI = -3.15 ~ -2.03, p < 0.0001), postoperative defecation time (SMD = -2.23, 95% CI = -2.88 ~ -1.57, p < 0.0001), postoperative morbidity (OR = 0.22, 95% CI = 0.15 ~ 0.31, p < 0.0001) and hospitalisation expenses (SMD = -0.53, 95% CI = -0.78 ~ -0.28, p < 0.0001). The patient satisfaction was significantly improved (odds ratio = 8.11, 95% CI = 4.96 ~ 13.24, p < 0.0001), and there were no significant differences in intraoperative blood loss and operation time between the two groups.

CONCLUSIONS

The application of the ERAS protocol in gynaecological surgery significantly improves the effectiveness and safety of the procedure. Thus, it can be promoted and applied in clinical practice in China.

Practice changes in Italian Gynaecologic Units during the COVID-19 pandemic: a survey study

The impact of Coronavirus disease 2019 pandemic on Italian Gynaecological Units practice and the compliance and satisfaction with available guidelines/recommendations is unknown. Therefore, a survey was conducted among all Italian Gynaecological Units Directors in April 2020. The response rate was 90% (135/150). 77.8% of centres performed surgery only for oncologic or not deferrable pathologies, and 9.6% was closed. 68.7% of directors were at least moderately satisfied by published guidelines/recommendations, but 94.8% of respondents identified limitations, mainly (83%) the absent definition of benign non-deferrable pathology. Responders considered as non-deferrable severe endometriosis (69.6%), endometriosis with organ failure/dysfunction (74.1%), and unresponsive symptomatic fibroids (89.6%). Despite guidelines/recommendations, respondents treated ovarian (77%) and endometrial (71.6%) cancer as usual. Only a minority of respondents reduced the laparoscopic approach (11.2%) and adopted all recommended surgical precautions (9.6%). Compliance with available guidelines/recommendations appears incomplete. Reconsidering guidelines/recommendations regarding oncological cases and specify non-deferrable benign pathologies would improve guidelines/recommendations compliance.Impact statementWhat is already known on this subject? The SARS-CoV-2 pandemic has profoundly influenced medical routine practice worldwide. Surgery units have been forced to reduce or even completely restrict their activity to re-allocate human resources. Many major international gynaecological societies have released statements and guidelines, providing various recommendations to guide practice changes. However, the impact of the SARS-CoV-2 pandemic on Italian Gynaecological Units practice and the compliance and satisfaction with available guidelines/recommendations is unknown.What do the results of this study add? Study results provide evidence showing how the SARS-CoV-2 pandemic has changed surgical activity in the Italian Gynaecological Units. Most centres reduced surgical activity, limiting surgery only for oncologic or not deferrable pathologies. Moreover, our research shows the level of compliance and satisfaction with available guidelines/recommendations and where they need to be improved. Most directors were at least moderately satisfied but identified different limitations. Guidelines/recommendations do not provide enough details, such as the absent definition of benign non-deferrable pathologies.What are the implications of these findings for clinical practice and/or further research? The limited compliance with available guidelines/recommendations and identified limitations suggest reconsidering guidelines/recommendations focussing on identified gaps. Provide more details, such as specifying non-deferrable benign pathologies, would improve guidelines/recommendations compliance.

Endometriosis and other causes of pelvic pain in perspective

Assuming we know the perfect management for endometriosis or pelvic pain is folly, but we should be celebrating our successes, not abandoning everything that we currently know.

Are we better off using multiple endometriosis classifications in imaging and surgery than settle for one universal less than perfect protocol? Review of staging systems in ultrasound, magnetic resonance and surgery

There are multiple classifications in imaging and surgery of endometriosis and in this article, we offer a review of the main evaluation systems. The International Deep Endometriosis Analysis group consensus is the leading document for ultrasound assessment, while magnetic resonance imaging is guided by the European Society for Urogenital Radiology recommendations on technical protocol. In surgery, the revised American Society for Reproductive Medicine classification is the oldest system, ideally combined with newer classifications, such as Enzian or Endometriosis Fertility Index. Recently, The World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonisation Project introduced detailed proforma for clinical and intraoperative findings. There is still no universal consensus, so the initial emphasis should be on the uniform reporting of the disease extent until research clarifies more the correlations between extent, symptoms and progression in order to develop a reliable staging system.Impact StatementWhat is already known on this subject? There have been several reviews of surgical classifications, comparing their scope and practical use, while in the imaging the attempts for literature review has been scarce.What do the results of this study add? This is the first up to date review offering detailed analysis of the main classification systems across the three main areas involved in endometriosis care - ultrasound, MRI and surgery. The mutual awareness of the radiological classifications for surgeons and vice versa is crucial in an efficient multidisciplinary communication and patient care. On these comparisons we were able to demonstrate the lack of consensus in description of the extent of the disease and even further lack of prognostic features (with the exemption of one surgical system).What are the implications of these findings for clinical practice and/or further research? Future attempts of scientific societies should focus on defining uniform nomenclature for extent description. In the second step the staging classification should encompass prognostic value (risk of disease and symptoms recurrence).

From complication to litigation: The importance of non-technical skills in the management of complications

Complications do occur in daily clinical life and can sometimes lead to litigation, which adversely affect the entire health care system, leading to a loss of confidence in medical providers, an increase in defensive medical practice and high professional indemnity insurance costs. Some complications are inevitable but can be minimised by completing a structured training programme. The likelihood of litigation can be reduced when adequate and clear information is given to the patient preoperatively. Non-technical skills are essential in complication management and crucial if confronted with litigation. Checklists and documentation of medication and surgical steps should be routine in all surgeries. Awareness of the complexity of the planned operation, theatre set-up and equipment are important in preventing complications. Mental preparation of surgeons is of the utmost importance in order to be able to confront any problem. When complications occur, remaining calm, calling for assistance, effective team leadership and harmony in the team are important in managing the situation. Good and effective communication with the patient and relatives, offering explanations, apologies and timely intervention without delays reduce the risk of litigation and strengthen any defence in court.

Ureteric Injury During Gynaecological Surgery - Lessons from 20 Cases in Canada

BACKGROUND

Ureteric injury is a complication of gynaecological surgery that can cause significant morbidity for the patient and is a leading cause of litigation in many countries.

OBJECTIVES

To determine patient characteristics, peri-operative circumstances and clinical and legal outcomes of ureteral injuries associated with gynaecological surgery.

PATIENTS AND METHODS

This is a retrospective review of 20 cases of ureteric injury during benign gynaecological surgery.

MAIN OUTCOME MEASURES

All cases were assessed for the following variables-patient characteristics, indications for surgery, injury, postoperative symptoms and presentation, and clinical and legal outcomes.

RESULTS

Risk factors associated with ureteric injury included obesity, previous laparotomic pelvic surgery, pelvic adhesions, large pelvic masses and intra-operative bleeding. 70% (14/20) of ureteral injuries were diagnosed after discharge. 50% (10/20) of patients had a complicated post-operative course and 45% (9/20) of cases resulted in unfavourable legal outcomes (settlement or lost at trial) for the surgeon. The conduct of surgery and the failure to act in a timely fashion postoperatively were the most frequent reasons for adverse clinical and unfavourable litigation outcomes for the surgeon.

CONCLUSIONS

Intra-operative surgical consultation and ureteral identification should be considered if there is concern for ureteral involvement in the surgical field. Ureteric injury may not constitute negligence if it is demonstrated that the surgeon provided reasonable care that would be expected during the peri-operative phases.

WHAT IS NEW

This review identifies patient characteristics and peri-operative variables that correlate with poor clinical and legal outcomes after ureteric injury.

Does Cost Influence the Choice of Disposable Versus Reusable Instruments? Mailed Survey of Obstetrician/Gynaecologists

OBJECTIVE

A "cost-awareness" campaign was undertaken at a tertiary hospital from 2015 to 2016 to raise awareness about costs of disposable versus reusable instruments in laparoscopic procedures. We undertook a before and after survey of obstetrician/gynecologists (Ob/Gyns) to find out if the campaign had affected their attitudes about choosing disposable versus less expensive reusable instruments.

METHODS

In 2015 (before the cost-awareness campaign) and 2017 (after the cost-awareness campaign), all full-time university-associated Ob/Gyns were mailed a cover letter, questionnaire, and coffee card ($5) with a postage-paid return envelope. Responses (with unique identification) from Ob/Gyns who perform laparoscopic procedures were entered into a password-protected REDCap database on a secure server. All statistical analyses were performed using SAS software version 9.4 (SAS Institute Inc, Cary, NC) (Canadian Task Force Classification II-3).

RESULTS

A total of 35 of 42 eligible Ob/Gyns (85%) with a median 10 years in practice completed questionnaires before and after the intervention. The majority had undertaken minimally invasive surgery training, mainly during residency (80%) and conferences (71%). Before the intervention, the three most important qualities influencing their decision to use a particular instrument were safety (66%), effectiveness (57%), and personal experience (49%). After the intervention, the three most important qualities were effectiveness (57%), safety (57%), and ease of use (46%). Device cost was ranked sixth (26%) before and seventh (17%) after the intervention. The majority (57%) of participants did not change their choice of disposable or reusable instruments, or they would make the choice according to the specific procedure.

CONCLUSION

Given the current economy, operative costs are constantly under review. Knowledge about Ob/Gyns' attitudes provides information to design more effective awareness campaigns to encourage use of less costly instruments. To change practice, a campaign increasing Ob/Gyns' exposure to less expensive but safe and effective instruments may help to increase uptake and potentially lead to cost reduction. Cost awareness alone is unlikely to change practice.

Postoperative pain and neuropathy after caesarean operation featuring blunt or sharp opening of the fascia: a randomised, parallel group, double-blind study

The purpose of this study was to compare postoperative pain and neuropathy after primary caesarean sections with either blunt or sharp fascial expansions. A total of 123 women undergoing primary caesarean sections were included in the study. The sharp group had 61 patients, and the blunt group had 62. In the sharp group, the fascia was incised sharply and extended using scissors. In blunt group, the fascia was bluntly opened by lateral finger-pulling. The primary outcome was postoperative pain. The long-term chronic pain scores were significantly lower in the blunt group during mobilisation (p = .012 and p = .022). Neuropathy was significantly more prevalent in the sharp group at both 1 and 3 months postoperatively (p = .043 and p = .016, respectively). The odds ratio (OR) and 95%CI for postoperative neuropathy at 1 and 3 months were as follows; OR 3.71, 95%CI 0.97-14.24 and OR 5.67, 95%CI 1.18-27.08, respectively. The OR for postoperative pain after 3 months was 3.26 (95%CI 1.09-9.73). The prevelance of postsurgical neuropathy and chronic pain at 3 months were significantly lower in the blunt group. Blunt fascial opening reduces the complication rate of postoperative pain and neuropathy after caesarean sections. Impact statement What is already known on this subject? The anatomic relationship of the abdominal fascia and the anterior abdominal wall nerves is a known fact. The fascia during caesarean sections can be opened by either a sharp or blunt extension. Data on the isolated impact of different fascial incisions on postoperative pain is limited. What do the results of this study add? The postoperative pain scores on the incision area are lower in the bluntly opened group compared to the sharp fascial incision group. By extending the fascia bluntly, a decrease in trauma and damage to nerves was observed. What are the implications of these findings for clinical practice and/or future research? The lateral extension of the fascia during caesarean sections must be done cautiously to prevent temporary damage to nerves and vessels. The blunt opening of the fascia by lateral finger pulling might be a preferred method over the sharp approach that uses scissors. We included only primary caesarean cases, however, comparisons of blunt and sharp fascial incisions in patients with more than one abdominal surgery should be explored in future studies.

Non-indicated use of prophylactic antibiotics in gynaecological surgery at an academic tertiary medical centre

Surgical site infections (SSI) are the most common surgical complication. Perioperative antibiotics can reduce SSI when used properly. Despite guidelines from The American College of Obstetrics and Gynecology, non-indicated antibiotic use is widespread which exposes women to unnecessary risks. This study represents a quality improvement analysis assessing surgeon compliance with established guidelines regarding antibiotic use in gynaecological surgery. This is a single centre, retrospective study examining gynaecological procedures over two years. Cases were identified using Current Procedure Terminology codes. Perioperative antibiotics were used contrary to published guidelines in 199 of 1046 cases. Three variables were independently associated with inappropriate administration of perioperative antibiotics: entrance into abdominal cavity, higher EBL, and longer procedures. Impact statement Overuse of antibiotics has unintended consequences including allergic sequelae, extended length of hospital stay, increased healthcare costs, and the formation of antibiotic-resistant organisms. Antibiotic stewardship programmes have been shown to reduce the number of resistant pathogens, decrease incidence of Clostridium difficile colitis, and decrease length of hospital stay without increasing infection rates. Further outcomes-based research is needed regarding the use of antibiotic stewardship programmes in gynaecological surgery.

Effect of epidural clonidine on characteristics of spinal anaesthesia in patients undergoing gynaecological surgeries: A clinical study

Background and Aims:

Combined spinal–epidural (CSE) anaesthesia is being increasingly used for effective post-operative analgesia. This study was designed to evaluate the effect of epidural clonidine on characteristics of spinal anaesthesia for gynaecological surgeries.

Methods:

This was a prospective randomised, double-blind, controlled study involving sixty patients belonging to American Society of Anesthesiologists Physical Status I and II who underwent gynaecological surgeries were randomly divided into clonidine (C) group and saline (S) group of thirty each. All patients received CSE anaesthesia. Ten minutes before subarachnoid block (SAB), Group C received clonidine 150 μg diluted to 5 ml in normal saline (NS) and Group S received NS epidurally. Hyperbaric bupivacaine (15 mg) was administered intrathecally for both groups after epidural injection. Sensory and motor block characteristics, analgesia, sedation and haemodynamics were observed. Statistical analysis was performed using appropriate tests.

Results:

Epidural clonidine produced faster onset (37.83 ± 8.58 s in Group C compared to 50.33 ± 8.80 s in Group S, P = 0.001) and prolonged duration of sensory block (241.17±18.65 minutes in group C compared to 150.33±19.16 minutes in group S, P = 0.001). Time for two segment regression of sensory block was193.67 ± 19.82 min in Group C and 109.33 ± 18.56 min Group S (P < 0.001). The duration of analgesia was 299.00 ± 43.38 min in Group C and 152.50 ± 21.04 min in Group S (P < 0.001). Haemodynamics and sedation scores were comparable between two groups.

Conclusion:

Administration of clonidine epidurally, 10 min before SAB, caused early onset and prolonged duration of motor blockade and analgesia, without any significant post-operative complication.

Standardised Registration of Surgical Complications in Laparoscopic-Gynaecological Therapeutic Procedures Using the Clavien-Dindo Classification

Introduction: The registration of complications represents an important component in the evaluation of surgical therapeutic procedures. The aim of the present study was to examine the frequency of occurrence as well as the severity of surgical complications after laparoscopic-gynaecological operations in a standardised manner using the Clavien-Dindo system. Material and Methods: Altogether 7438 treatment courses after laparoscopic-gynaecological interventions by 9 working groups were evaluated. Covariates recorded were the technical complexity of the operation, type of study cohort, study size, data acquisition as well as study centre. Target variables recorded were the surgical morbidity rate, subdivided into mild (Clavien-Dindo grade I-II) and severe complications (Clavien-Dindo grade III-V). In addition, a binary logistic regression analysis for the mentioned covariates and the occurrence of surgical complication was carried out. Results: 946 complications were recorded (overall complication rate: 13 %). These included 664 mild complications (8.9 %) and 305 severe complications (4.1 %). A correlation was found between the covariates technical complexity (relative risk [rR] 1.37; p < 0.01), study size (rR: 0.35; p < 0.01) and study centre (rR 0.19; p < 0.01) and the occurrence of surgical complications. Conclusion: By means of a standardised registration of complications using the Clavien-Dindo classification it appears to be possible to limit the methodologically caused underestimation of surgical morbidity in the retrospective evaluation of gynaecological-endoscopic therapeutic procedures. Factors decisively influencing the surgical morbidity of gynaecological-laparoscopic therapeutic procedures are the respective operative experience of the treating facility as well as the technical complexity of the intervention.

A personalised eHealth programme reduces the duration until return to work after gynaecological surgery: results of a multicentre randomised trial

OBJECTIVE

To evaluate the effectiveness of an eHealth intervention on recovery and return to work, after gynaecological surgery.

DESIGN

Randomised multicentre trial that ran from March 2010 until September 2011.

SETTING

Secondary care in seven general and university hospitals in The Netherlands.

POPULATION

A cohort of 215 women (aged 18-65 years) who had a hysterectomy and/or laparoscopic adnexal surgery for a benign indication.

METHODS

The women were randomly assigned to the intervention group (n = 110) or the control group (n = 105). The intervention group received an eHealth programme that provided personalised tailor-made pre- and postoperative instructions on the resumption of daily activities, including work, and tools to improve self-empowerment and to identify recovery problems. The control group was provided with access to a control website.

MAIN OUTCOME MEASURES

The primary outcome was the duration of sick leave until a full sustainable return to work. Secondary outcome measures were quality of life, general recovery, and pain intensity.

RESULTS

In intention-to-treat analysis the eHealth intervention was effective on time to return to work (hazard ratio 1.43; 95% confidence interval 1.003-2.040; P = 0.048). The median duration of sick leave until a full sustainable return to work was 39 days (interquartile range 20-67 days) in the intervention group and 48 days (interquartile range 21-69 days) in the control group. After 26 weeks pain intensity was lower (visual analogue scale, cumulative odds ratio 1.84; 95% confidence interval 1.04-3.25; P = 0.035) and quality of life was higher (Rand-36 health survey, between-group difference 30, 95% confidence interval 4-57; P = 0.024) in the intervention group, compared with the control group.

CONCLUSIONS

The use of the eHealth intervention by women after gynaecological surgery results in a faster return to work, with a higher quality of life and less pain.

Gynaecological laparoscopic surgery: eight years experience in the Yaoundé Gynaeco-Obstetric and Paediatric Hospital, Cameroon

This is a retrospective analysis of eight years of gynaecological laparoscopic surgery in a resource-limited setting. All gynaecological patients managed by laparoscopy at the Yaoundé Gynaeco-Obstetric and Paediatric Hospital from 1 January 2004 to 30 November 2011 were included. Amongst the 9194 gynaecological surgeries performed during the study period, 6.9% (633) were done by laparoscopy. Most of the women underwent an operative laparoscopy (568/592; 95.9%). The most common indication was infertility (415/592; 70.1%). Diagnostic laparoscopies were mostly indicated for chronic pelvic pain (18/24; 75%). The most common surgical finding was tubo-peritoneal adhesions (412/592; 69.6%). A total of 35 patients (35/592; 5.9%) had at least one complication. The mean duration of hospitalization was 3.4 ±1.8 days. The general uptake of gynaecological laparoscopic surgery is low in our setting. The laparoscopic complication rate of 5.9% is encouraging.

The bionomic approach to patient safety and its application in gynaecological surgery

In the past 2 decades, a gradual shift has taken place from the 'person approach' to patient safety (in which the individual clinician at the sharp end is blamed for any accident) to a 'systems approach' (in which causation of accidents is attributed to loopholes in the organisational defences). Increasingly, however, concern has been expressed that the systems approach risks absolving individuals from responsibility for patient safety, and a balance between the systems and person approaches has been sought. In this paper, resolution of the tension between the person and the systems approaches is advocated through the use of a paradigm that places more emphasis on the relationships between the individual at the sharp end and other components of the system. This paradigm, which is adapted from ecosystems, has been labelled the 'bionomic approach'. A bionomic approach to patient safety incorporates principles and concepts of human ecology and applies them to the healthcare system, situating the individual as an intrinsic component of the system rather than an adjunct. It builds on the notion that 'people create safety' and on the recognition that, in some clinical areas, particularly surgery, the individual is the primary defence against patient safety incidents. Skills required for 'error wisdom' are described, and the principles of the bionomic approach are applied to gynaecological surgery, using an illustrative case study.

Effectiveness of a multidisciplinary care program on recovery and return to work of patients after gynaecological surgery; design of a randomized controlled trial

BACKGROUND

Return to work after gynaecological surgery takes much longer than expected, irrespective of the level of invasiveness. In order to empower patients in recovery and return to work, a multidisciplinary care program consisting of an e-health intervention and integrated care management including participatory workplace intervention was developed.

METHODS/DESIGN

We designed a randomized controlled trial to assess the effect of the multidisciplinary care program on full sustainable return to work in patients after gynaecological surgery, compared to usual clinical care. Two hundred twelve women (18-65 years old) undergoing hysterectomy and/or laparoscopic adnexal surgery on benign indication in one of the 7 participating (university) hospitals in the Netherlands are expected to take part in this study at baseline. The primary outcome measure is sick leave duration until full sustainable return to work and is measured by a monthly calendar of sickness absence during 26 weeks after surgery. Secondary outcome measures are the effect of the care program on general recovery, quality of life, pain intensity and complications, and are assessed using questionnaires at baseline, 2, 6, 12 and 26 weeks after surgery.

DISCUSSION

The discrepancy between expected physical recovery and actual return to work after gynaecological surgery contributes to the relevance of this study. There is strong evidence that long periods of sick leave can result in work disability, poorer general health and increased risk of mental health problems. We expect that this multidisciplinary care program will improve peri-operative care, contribute to a faster return to work of patients after gynaecological surgery and, as a consequence, will reduce societal costs considerably.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR2087.

Delayed recognition of bilateral ureteral injury after gyneacological surgery

BACKGROUND

Iatrogenic bilateral ureteric injury is a rare complication of pelvic surgery, which if not recognised immediately results in significant morbidity and even mortality

OBJECTIVE

To describe the presentation, aetiology and treatment of iatrogenic bilateral ureteric injuries recognised late following gynaecological surgery.

METHODS

The case notes of 14 consecutive cases of bilateral ureteric injury managed between October 2000 and January 2007 were studied.

RESULTS

Thirteen cases resulted from abdominal hysterectomy and one from vaginal repair of vesicovaginal fistula. Excessive bleeding with difficult haemostasis was the predominant predisposing factor. The indication for referral included oliguria, anuria, and urinary ascites or azotaemia. The time interval between the original surgery and the recognition of the injury ranged between 1 and 92 days. Patients in whom deterioration in renal function was ascribed to obstructive uropathy from bilateral ligation (postrenal renal failure) were referred much earlier than those in whom a diagnosis of prerenal renal failure was made (mean of 2 vs. 10 days). Five patients (36%) required dialyses before repair. All the repairs were done at open surgery. Thirteen survived with no loss of kidney. One patient died of overwhelming sepsis.

CONCLUSIONS

Late recognition and referral of bilateral ureteric injury was associated with serious complications. Post operative deterioration in a patient's renal function following pelvic surgery should be assumed to be due to ureteric obstruction until proven otherwise. Such patients should be promptly referred to centres with the facility for further investigation and management. Early open repair for these injuries is advocated.