1. Common OB/Gyn Injuries Howard T. Sharp MD Vice Chair and Professor Dept. of Obstetrics and Gynecology

2. Case 1 2 week post op check from C-Section Pain at right groin, just outside corner of incision Give it 1 month. At 6 weeks, minimal improvement

3. The Pfannenstiel Incision as a Source of Chronic Pain (Loos et al, Obstet Gynecol, April 2008) 866 patients with Pfannenstiel incisions 2 year follow-up (questionnaire) Level III 33% experienced CPP at incision (26% ITT) 7% had moderate to severe pain Nerve entrapment 53% (17/32 examined) Avoid lateral extension (rectus sheath) / delay in treatment

4. Ilioinguinal and Iliohyopogastric Nerves

5. Case 2 2 week post op check from TLH Pain at right groin, just outside corner of right trocar incision Give it 1 month. At 6 weeks, minimal improvement

6. Trocars and anterior abdominal wall nerves (Rahn Am J Obstet Gynecol 2010) NerveMean distance from ASIS in cm (range) MedialInferior Ilioinguinal nerve 2.5 (1.1-5.1) 2.4 (0-5.3) Iliohypogastric nerve2.5 (0-4.6) 2.0 (0-4.6) Author’s conclusions: Risk is minimized when the trocar is placed superior to the ASIS. Incidence: 5% of laparoscopies (Shin, JMIG 2012)

7. Nerves and vessels of the anterior abdominal wall.(Rahn AJOG 2010)

8. Case 3 Patient s/p TVH wakes up with right foot drop. Candy cane stirrups were used.

9. Sciatic Nerve L4 through S3 nerve roots (stretch) 2 divisions – Tibial – Common peroneal (compression) Anterior to the piriformis muscle, passes through greater sciatic foramen to posterior thigh until it divides

10. Sciatic Nerve: Tibial Branch Posterior leg Motor to plantar flexors Intrinsic foot flexors Sensory to plantar surface and toes

11. Sciatic Nerve: Common Peroneal Anterior to fibular head Motor to dorsiflexors and evertors of foot. Sensation to lateral leg and dorsum of foot.

12. Sciatic Nerve Injury Risks (Mechanism: Stretch, compression) Lithotomy position Excessive hip flexion Straightening of the knee Pulling on lat leg (2 nd stage labor) – peroneal branch Sudden blood loss requiring large mattress sutures placed in deep lateral pelvis. Beware the “leaning assistant.”

13. Recommendations Avoid excessive hip flexion Make sure there is adequate bending at the knee Avoid excessive external rotation Risky patients: – Tall patients – external rotation – Short patients – inadequate flexion at the knee

14. Case 4 Patient s/p C-Section for twins wakes up with right foot drop. No stirrups were used. How did this happen?

15. Intraoperative positioning during cesarean as a cause of sciatic neuropathy. Roy et al, Obstet Gynecol. 2002;99:652-3. C-Section under spinal for twins. Right hip roll placed at 30 degrees. Left foot drop recovered by 6 weeks post partum Right buttock elevation during cesarean caused a compression sciatic neuropathy. Decreasing the duration of left lateral position may reduce the risk of this uncommon complication.

16. Case 5 Patient weighing 105 undergoes TAH Quadriceps are paralyzed Knee can not be extended Loss of sensation over – Medial and anterior thigh – Medial side of lower leg – Medial side of foot

17. Femoral Nerve L2, L3, and L4 nerve roots Pierces psoas, emerges between iliacus and psoas, courses under inguinal ligament Motor supplies hip flexors and leg extensors

18. Femoral Neuropathy

19. Femoral Neuropathy Risks (Mechanism: Compression) Self-retaining retractors – (vasa nervorum) Transverse or Pfannenstiel incisions Thin body habitus Excessive hip flexion Long OR times - laparoscopy

20. Case 6 Patient undergoes LAVH Allen type stirrups were used. Quadriceps are paralyzed Knee can not be extended Loss of sensation over – Medial and anterior thigh – Medial side of lower leg – Medial side of foot

21. Case 7 60 year old undergoes TLH Surgical time is 65 minutes. BMI is 30 She has a few varicose veins. Otherwise healthy. Pneumatic compression devices used.

22. POD 1 Dies from massive PE

23. Why So Disastrous? Up to 14% of patients undergoing gynecologic surgery for benign conditions develop VTE. (Walsh J Obstet Gynocol Br Commonw 1974) Most deaths occur within 30 minutes of event. Pulmonary embolism often not suspected (70- 80% of cases post mortem).

24. Thromboprophylaxis □ Yes □ No Email orders for DVT in indicated cases VTE at 90 days – 4.9% in intervention group – 8.2% in control group PE reduced by 60% DVT reduced by 53% (Kucher et al. NEJM 2005)

25. The Mechanism of Death DVT is most common source of PE PE is usually a result of an asymptomatic thrombus being released into pulmonary circulation If large enough, PE leads to cardiogenic shock, followed by circulatory collapse and death

26. “Why are we stuck in 1975?” Clarke-Pearson Obstet Gynecol 2011 40% of patients receive no VTE prophylaxis Assume : – 3% DVT rate – 0.5% fatal PE (without prophylaxis) 292,307 untreated women – 8,769 DVTs – 1,461 Fatal Pes Assume: 60% reduction (appropriate prophylaxis) – 5,261 DVTs prevented! – 876 fatal PEs prevented!

27. 2012 CHEST Guidelines Focused on risk stratification balancing: – Patient’s VTE risk (Roger’s / Caprini scores) – Patient’s bleeding risk from therapy 3 major divisions: medical patients, orthopedic patients, other surgical patients “Consider these options as a guide in the decision making to individual circumstances”

28. VTE Risk Gould et al, CHEST 2012 Risk Level % Risk / Bleeding Assessment Caprini Score 1. Very low VTE risk <0.5%0 2. Low VTE risk 1.5%1-2 3. Moderate VTE risk 3% / Low bleeding risk3-4 4. Moderate VTE risk 3% / High bleeding risk3-4 5. High VTE risk 6% / Low bleeding risk>5 6. High VTE risk 6% / High bleeding risk>5

29. Caprini Score Each factor represents 1 point: Age 41 to 60 years Minor surgery planned History of prior major surgery (<1month) Varicose veins History of inflammatory bowel disease Swollen legs (current) Obesity (BMI>25kg/m2) Acute myocardial infarction Congestive heart failure (<1month) Sepsis (<1month) Serious lung disease including pneumonia (<1month) Abnormal pulmonary function (chronic obstructive pulmonary disease) Medical patient currently on bed rest Other risk factors (specify)

30. Caprini Score Each factor represents 2 points: Age 60 to 74 years Arthroscopic surgery Malignancy (present or previous) Major surgery (>45minutes) Laparoscopic surgery (>45minutes) Patient confined to bed (>72hours) Immobilizing plaster cast (<1month) Central venous access catheter

31. Caprini Score Each factor represents 3 points: Age>75years History of DVT/PE Family history of thrombosis* Positive Factor V Leiden Positive prothrombin 20210A Elevated serum homocysteine Positive lupus anticoagulant Elevated anticardiolipin antibodies Heparin-induced thrombocytopenia Other congenital or acquired thrombophilia

32. Caprini Score Each factor represents 5 points: Elective major lower extremity arthroplasty Hip, pelvis, or leg fracture (<1month) Stroke (<1month) Multiple trauma (<1month) Acute spinal cord injury (paralysis) (<1month)

33. Case 7 60 year old undergoes TLH Surgical time is 65 minutes. BMI is 30 She has a few varicose veins. Otherwise healthy. Pneumatic compression devices used.

34. VTE Risk Gould et al, CHEST 2012 Risk Level % Risk / Bleeding Assessment Caprini Score 1.Very low VTE risk <0.5%0 No Pharmacologic or mechanical prophylaxis 2. Low VTE risk 1.5%1-2 3. Moderate VTE risk 3% / Low bleeding risk3-4 4. Moderate VTE risk 3% / High bleeding risk3-4 5. High VTE risk 6% / Low bleeding risk>5 6. High VTE risk 6% / High bleeding risk>5

35. VTE Risk Gould et al, CHEST 2012 Risk Level % Risk / Bleeding Assessment Caprini Score 1. Very low VTE risk <0.5%0 2. Low VTE risk 1.5%1-2 Mechanical prophylaxsis - IPCs 3. Moderate VTE risk 3% / Low bleeding risk3-4 4. Moderate VTE risk 3% / High bleeding risk3-4 5. High VTE risk 6% / Low bleeding risk>5 6. High VTE risk 6% / High bleeding risk>5

36. VTE Risk Gould et al, CHEST 2012 Risk Level % Risk / Bleeding Assessment Caprini Score 1. Very low VTE risk <0.5%0 2. Low VTE risk 1.5%1-2 3. Moderate VTE risk 3% / Low bleeding risk3-4 - LMWH, LDUFH, or IPCs 4. Moderate VTE risk 3% / High bleeding risk3-4 5. High VTE risk 6% / Low bleeding risk>5 6. High VTE risk 6% / High bleeding risk>5

37. VTE Risk Gould et al, CHEST 2012 Risk Level % Risk / Bleeding Assessment Caprini Score 1. Very low VTE risk <0.5%0 2. Low VTE risk 1.5%1-2 3. Moderate VTE risk 3% / Low bleeding risk3-4 4. Moderate VTE risk 3% / High bleeding risk3-4 IPCs 5. High VTE risk 6% / Low bleeding risk>5 6. High VTE risk 6% / High bleeding risk>5

38. Prophylaxis: Moderate-Risk LDU Heparin 5,000 U BID (1A / 1C) – or LMW Heparin Q Day (1A / 1C) – or Intermittent Pneumatic Compression (1B / 1C)

39. IPCs Should be used for at least 18 hours daily Some machines record compliance Average adherence rate is 53% Full adherence rate is 19%

40. VTE Risk Gould et al, CHEST 2012 Risk Level % Risk / Bleeding Assessment Caprini Score 1. Very low VTE risk <0.5%0 2. Low VTE risk 1.5%1-2 3. Moderate VTE risk 3% / Low bleeding risk3-4 4. Moderate VTE risk 3% / High bleeding risk3-4 5. High VTE risk 6% / Low bleeding risk>5 LMWH or LDUFH with IPCs If cancer add 4 weeks of LMWH (50-75% risk reduction) 6. High VTE risk 6% / High bleeding risk>5

41. Prophylaxis: High-Risk Patients LDU Heparin 5,000 U TID (1A) or LMW Heparin Q Day (1A) or IPC (1A) May consider: – IPC plus Pharmacologic Prophylaxis (1C)

42. VTE Risk Gould et al, CHEST 2012 Risk Level % Risk / Bleeding Assessment Caprini Score 1. Very low VTE risk <0.5%0 2. Low VTE risk 1.5%1-2 3. Moderate VTE risk 3% / Low bleeding risk3-4 4. Moderate VTE risk 3% / High bleeding risk3-4 5. High VTE risk 6% / Low bleeding risk>5 6. High VTE risk 6% / High bleeding risk>5 IPCs alone until bleeding risk is diminished, then LMWH or LDUFH

43. Unfractionated Heparin Highly effective against DVT prophylaxis (based upon over 25 controlled trials) 5,000 U - 2 hours prior to surgery or 6 hours after surgery. – Less bleeding if given post op with no additional risk (Hansen, Acta OGS 2008) Use every 8 to 12 hours until discharge Some studies show higher transfusion rates

44. LMWH Dosing Given 2 hours prior to surgery, or 6 hours after surgery, then daily for 7 – 10 days May be less bleeding 12 hours prior. Enoxaparin 40 mg Dalteparin 2,500 U (moderate-risk) – 5,000U (high-risk)

45. Case 8 While performing a TVH, you notice a gush of yellow fluid. OR During a TAH or TLH you visualize the rubber of a Foley catheter.

46. Cystotomy Pearls Finish the dissection before repairing the cystotomy. Repair in 2 layers, particularly if in dependent portion of the bladder. Perform cystoscopy or open the bladder and visualize ureteral patency while in OR. Keep a Foley catheter in place for 3 to 10 days post op.

47. Cystotomy Repair

48. Case 9 POD 3 s/p laparoscopic adhesiolysis patient presents to ER with abdominal distension, shock. CT shows air in abdomen significant peritoneal fluid

49. I worry when… I press a button and nothing happens to tissue.

50. Electrosurgery Generator Output

51. Conclusions Pay attention to patient positioning Know where vulnerable nerves are at risk. Use cut and coag modes appropriately Take advantage of thromboprophylaxis.