Mn Wasson

Randomized controlled trial of postoperative belladonna and opium rectal suppositories in vaginal surgery

BACKGROUND: After vaginal surgery, oral and parenteral narcotics are used commonly for pain relief, and their use may exacerbate the incidence of sedation, nausea, and vomiting, which ultimately delays convalescence. Previous studies have demonstrated that rectal analgesia after surgery results in lower pain scores and less intravenous morphine consumption. Belladonna and opium rectal suppositories may be used to relieve pain and minimize side effects; however, their efficacy has not been confirmed. OBJECTIVE: We aimed to evaluate the use of belladonna and opium suppositories for pain reduction in vaginal surgery. MATERIALS AND METHODS: A prospective, randomized, double‐blind, placebo‐controlled trial that used belladonna and opium suppositories after inpatient or outpatient vaginal surgery was conducted. Vaginal surgery was defined as (1) vaginal hysterectomy with uterosacral ligament suspension or (2) posthysterectomy prolapse repair that included uterosacral ligament suspension and/or colporrhaphy. Belladonna and opium 16A (16.2/60 mg) or placebo suppositories were administered rectally immediately after surgery and every 8 hours for a total of 3 doses. Patient‐reported pain data were collected with the use of a visual analog scale (at 2, 4, 12, and 20 hours postoperatively. Opiate use was measured and converted into parenteral morphine equivalents. The primary outcome was pain, and secondary outcomes included pain medication, antiemetic medication, and a quality of recovery questionnaire. Adverse effects were surveyed at 24 hours and 7 days. Concomitant procedures for urinary incontinence or pelvic organ prolapse did not preclude enrollment. RESULTS: Ninety women were randomly assigned consecutively at a single institution under the care of a fellowship‐trained surgeon group. Demographics did not differ among the groups with mean age of 55 years, procedure time of 97 minutes, and prolapse at 51%. Postoperative pain scores were equivalent among both groups at each time interval. The belladonna and opium group used a mean of 57 mg morphine compared with 66 mg for placebo (P=.43) in 24 hours. Patient satisfaction with recovery was similar (P=.59). Antiemetic and ketorolac use were comparable among groups. Subgroup analyses of patients with prolapse and patients <50 years old did not reveal differences in pain scores. The use of belladonna and opium suppositories was uncomplicated, and adverse effects, which included constipation and urinary retention, were similar among groups. CONCLUSION: Belladonna and opium suppositories are safe for use after vaginal surgery. Belladonna and opium suppositories did not reveal lower pain or substantially lower narcotic use. Further investigation may be warranted to identify a population that may benefit optimally from belladonna and opium use.

Prognostic Factors for Morcellation During Vaginal Hysterectomy

OBJECTIVE: To determine prognostic factors associated with cold-knife morcellation during vaginal hysterectomy. METHODS: We conducted a retrospective cohort study evaluating all consecutive patients undergoing a vaginal hysterectomy between January 1, 2009, and August 31, 2014. The primary outcome was the utilization of uncontained vaginal morcellation performed using cold-knife wedge resection at the time of vaginal hysterectomy. Secondary outcomes included perioperative data. Significant factors were included in a multivariate logistic regression model to the binary variable vaginal morcellation at the time of vaginal hysterectomy. RESULTS: A total of 743 women met study inclusion criteria and underwent vaginal hysterectomy with intact uterine removal (n=383) or with uterine morcellation (n=360) with and without other vaginal procedures. A nonparametric Wilcoxon-rank-sum test and &khgr;2 test were used to compare the cohorts of patients with and without morcellation. Characteristics associated with significantly increased likelihood of morcellation included younger age, non-Caucasian race, American Society of Anesthesiologists class 1 or 2, lower parity, lower number of prior vaginal deliveries, absence of prolapse, presence of leiomyoma, and an enlarged uterus. A multivariate logistic model utilizing factors most likely associated with morcellation revealed lack of prolapse (adjusted odds ratio [OR] 3.87, P<.001), leiomyoma (adjusted OR 2.77, P=.035), and larger uterine weight (adjusted OR 7.25, P<.001) increased the likelihood of morcellation. Prior vaginal delivery was associated with a decreased likelihood of morcellation (adjusted OR 0.79, P=.005). CONCLUSION: Vaginal hysterectomy with morcellation is associated with the following factors: absence of prior vaginal delivery, absence of prolapse, presence of leiomyoma, and a uterus larger than normal size.

Screening Women at High Risk for Cervical Cancer: Special Groups of Women Who Require More Frequent Screening

&NA; The updated cervical cancer screening guidelines recommend that women at average risk who have negative screening results undergo cervical cytological testing every 3 to 5 years. These recommendations do not pertain to women at high risk for cervical cancer. This article reviews recommendations for cervical cancer screening in women at high risk.

Robotic-Assisted Total Hysterectomy: Hysterectomy Techniques in the Normal-Sized and Small Uterus

The introduction of robotic technology has dramatically altered the surgical approach to hysterectomy. Following introduction of the robotic surgical system, there has been a dramatic decrease in the proportion of hysterectomies being performed via laparotomy. Furthermore, a continually growing number of hysterectomies are being performed via laparoscopy both with and without the assistance of robotic technology [1]. In order to safely and efficiently perform a robotic hysterectomy on a normal-sized or small uterus, a surgeon must be methodical in the techniques employed.

Patient Positioning and Trocar Placement for Robotic Procedures

Sound knowledge and application of correct patient positioning and port placement for gynecologic robotic procedures allow surgeries to be completed efficiently and safely. Most commonly, gynecologic procedures require Trendelenburg and dorsal lithotomy positioning. Incorrect placement of patients into this position can result in serious effects, including nerve injuries. Robotic port placement most commonly requires the use of a conventional “M” configuration directed at the target pathology. When ports are not placed optimally, target anatomy and pathology can be more challenging to access. This results in great frustration and oftentimes prolonged surgical times. Understanding of the key steps in patient positioning and port placement is essential for all novice and master gynecologic robotic surgeons.

Feasibility of Oophorectomy at the Time of Vaginal Hysterectomy in Patients with Pelvic Organ Prolapse

STUDY OBJECTIVE To determine the feasibility of oophorectomy at the time of vaginal hysterectomy in patients with pelvic organ prolapse and to define prognostic factors and perioperative morbidity associated with the procedure. DESIGN A retrospective cohort study (Canadian Task Force classification II-2). SETTING An academic medical center. PATIENTS All women who underwent total vaginal hysterectomy for the treatment of pelvic organ prolapse over 5 years were considered for inclusion in the study. INTERVENTIONS Total vaginal hysterectomy and concomitant pelvic organ prolapse repair with or without oophorectomy. MEASUREMENTS AND MAIN RESULTS A total of 289 women underwent total vaginal hysterectomy with pelvic organ prolapse repair. Vaginal oophorectomy was attempted in 179 patients (61.9%). The procedure was successful in 150 patients (83.8%; 95% confidence interval [CI], 77.6%-88.9%). High ovarian location was the most commonly cited reason for the inability to perform a planned unilateral/bilateral oophorectomy (n = 24, 82.7%). Attempting oophorectomy vaginally was associated with an increased duration of surgery by 7.3 minutes (p = .03), an increased change in hemoglobin by 0.2 g/dL (p = .02), and a higher rate of readmission (7.3% vs 1.8%, p = .04). Multiple logistic regression showed that increasing age (odds ratio = 1.12; 95% CI, 1.05-1.20; p <.001) and body mass index (odds ratio = 1.17; 95% CI, 1.07-1.27; p<.001) were associated with an increased risk of vaginal oophorectomy failure. On univariate analysis, race (p = .64), parity (p = .39), uterine weight (p = .91), need for uterine morcellation (p=.21), presence of endometriosis (p=.66), prior cesarean section (p=.63), prior laparoscopy (p=.37), and prior open abdominal/pelvic surgery (p = .28) did not impact the likelihood of successfully performing oophorectomy. CONCLUSION In patients with pelvic organ prolapse, a planned oophorectomy at the time of vaginal hysterectomy can be successfully performed in the majority of cases. Greater age and body mass index are associated with an increased likelihood of failure.

Robotic Excision of Diaphragm Metastases With Liver Involvement

Interventions: Robotic aproach with colon segmentectomy, ureterolysis, nerve sparing, oophoroplasty, ressection of the retrocervical mantle shape endometriosis and vaginal fornix shaving. Measurements & Main Results: This took about 170 minutes, with a estimated blood loss around 60ml, and patient was discharged from hospital on the fourth day after surgery. After 90 days from surgery, she is symptom free, with normal bowel and bladder functions and referred for IVF. Conclusion: The radicality may be associated with decreased surgical morbidity when new technologies are applied, especially when presented with multifocal intestinal endometriosis and retrocervical mantle shape endometriosis.