GYN Trocar injuries - Forum

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John Dissector

GYN Trocar injuries - Ärzteforum

Post#1 »

I've just returned from the Southeastern Surgical Congress in Atlanta and during the PG course one of the sections was about treatment of GYN trocar injuries. According to those in attendence this seems to be a considerable problem. We have not observed this to be true in our institution. I'm not sure if our guys are good, lucky, or both, but they do not seem to be having the problems that others have observed.

I'm just curious to poll the members on if they have seen an increase or even a prevalence of bowel or vascular injuries with the GYN service, either those recognized at the time or those manifested by fistulas, etc. I think the main point was that gyn surgeons don't handel the complications, but dump them on the general surgeons, and many present were venting their frustrations

Also, many attendees noted that many GYN surgeons enter the abdomen with a trocar **BEFORE** CO2 insuflation...does anyone know what their justification is for doing this? NOTE: I certainly do not mean to bash the gyn's, but I'm simply curious.


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Surgeon

Re: GYN Trocar injuries - Ärzteforum

Post#2 »

Many injuries occur not from trocars, but from multiple insertions of the Veress needle. There is literature support for simply inserting the trocar before insufflation. I will do this in a patient with no previous abdominal surgeries where I can get a good "handful" of abdominal wall to elevate. It is fast and easy. Anybody who believes that the pneumoperitoneum protects the bowel and vessels from injury is naive. It only allows you to probe the underside of the abdominal wall with the needle to check for adhesions.

Marcel

Re: GYN Trocar injuries - Ärzteforum

Post#3 »

Unfortunately, as you know, most Gen/Surgs learned laparoscopic techniques at the foot(ugh) of the pelvic pirates. Some have adopted the technique, popularised by some Gyn's as you say, ....blind trocar entry without Verres needle insufflation beforehand. All of the General Surgeons in my country are currently paying off a malpractice settlement where a blind entry/lap chole was carried out on a thin young 30-ish mother with lacerations to iliac arteries and veins, resuscitated but left vegetative. This is in my opinion, and was in the opinion of our learned Canadian judges, malpractise. What is the effing hurry? Can't one wait a couple of minutes for a pneumoperitioneum with a Verres? Can't one wait a couple of minutes for a Hasson cutdown? I think these types of injuries only happen when the surgeon is impatient, perceptually pressed for time, or simply stupid, arrogant and dangerous.

Marcel

Re: GYN Trocar injuries - Ärzteforum

Post#4 »

Let's dispense with Catholicism for your next response. I believe there have been studies where it has been shown that a handful of abdominal flab doesn't appreciably elevate the peritoneum from the surface of the OR table. When I used to use the Verres needle, we elevated the umbo with a towel clip. I believe that if the puncture is made at the umbo, it is possible that you will be elevating the peritoneum. If you are confident that no added risk is imparted to the patient by blind uninsufflated trocar entry into the belly, the Canadian Medical Protective Association will be happy to hear from you, and pay you a hefty sum for your wisdom, and I will be a lot happier with a smaller malpractice premium to pay in the years ahead, if you can successfully overturn this judment in appeal.

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Lady Surgeon

Re: GYN Trocar injuries - Ärzteforum

Post#5 »

I think (and have some evidence from participating in the OB-GYN list) that the real problem is inadequate surgical training in the OB-GYN residencies. At best, they get 2 years (the other 2 years is spent in OB) surgical training. Even worse, the older GYNs did a weekend course (I know so did we all with lap choles, but the average general surgeon is a far better technician and has many more hours in training and in practice doing surgery, so I think we general surgeons learned more easily) in lap gynecology and think they are experts because after all, they have been doing laparoscopy for years (but actually only simple lap tubals which are not technically challenging). They also tend to be arrogant and unwilling to learn from or collaborate with general surgeons (after all in their opinion, they have far longer laparoscopy experience than the late comers (general surgeons)--therefore they don't think general surgeons have anything to teach them.

Add to all this, an oversupply of GYNs--this leads them to do cases they shouldn't with inadequate training to maintain their practices and their incomes.

As far as the direct entry method (actually I first heard of this about 2010, so it is not new), their journal articles show that this is no less safe than Verress needle methods and actually in their hands is not much less safe than open entry methods. Anyhow, direct entry is a standard acceptable technique for the gynecologists, although, at the Oct ACS GYN sessions, they stated that it is hard to legally defend any injuries that occur with this method, because it is too easy for the plaintiff's lawyers to find experts that feel direct entry is less safe than the other entry methods.

As far as GYN trocar injuries, I am not seeing them, but at the moment, I am doing the vast majority of the lap gyn work--our gyn is not getting the cases. He did manage to injure the small bowel, though, on a postpartum tubal and had to call a general surgeon to fix it. Other problems he has had within the past 2 years include: 25% incidence of bladder entries at hysterectomy, C-section almost bled to death from mesenteric vascular bleeding (would not listen to the Recovery Room and ICU nurses when they told them patient had a problem because she was hypotensive), injured spleen just palpating left upper quadrant on ovarian borderline potential tumor. He often has needed help from Urology or general surgery to fix these problems.

At one of the former hospitals I worked at, our GYN has 3 consecutive colon injuries with prolonged post-op stays---I think he injured them taking down adhesions, probably bluntly--this was in the early days of lap hysters.

In spite of all the criticism above, I have learned a lot on the OB-GYN Forum. There are some excellent well-trained well-educated GYN surgeons who are willing to share their knowledge and answer my questions. Interestingly, one (Bernard Christalli from France) is double boarded in general surgery and gynecology but does mostly OB-GYN.

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A Doctor

Re: GYN Trocar injuries - Ärzteforum

Post#6 »

I haven't noted any problem. When I have scrubbed with the GYN's they have also insufflated first prior to trocar insertion.

Kardashian surgeon

Re: GYN Trocar injuries - Ärzteforum

Post#7 »

I have been called to a GYN room many times over the last 15 years to attend liver injuries or bowel injuries (usually from Verres needle insertion), most of which I have been able to deal with laparoscopically much to the horror of the gynecologist. Some of these were even in the days when, like most surgeons, I didn't have laparoscopy privileges. More dramatically, about 6 months ago I was called to the OR as the anesthetist was waking a GYN's tubal sterilization patient (the gynecologist had left) because his patient was crashing big time. I opened her immediately and found, as I expected, an impressive tear in one of her iliac arteries. She survived (did well), and surprisingly didn't sue the gynecologist. Which is the really amazing part of the story.

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Treatment guru

Re: GYN Trocar injuries - Ärzteforum

Post#8 »

I have been asked to repair more trochar injuries to bowel made by Gyn surgeons than all 4 of the general surgeons in my hospital have ever experienced. I don't have any hard data for Er, but it is my feeling that Gyn surgeons are much more bold and less aware of adhesion risks than general surgeons when they place trochars. I'm also impressed with the frequency of trochar site hernias in gyn patients compared to ours (general surgeons) Our Gyn surgeons never suture trochar sites.

Wired

Re: GYN Trocar injuries - Ärzteforum

Post#9 »

Interesting. I have used (probably mentioned this before) the small Bard Marlex plug and patch for trocar site hernias. They worked quite well.

Re the trocar bowel injuries: One of the rules of general surgery (as I learned it) is if you can't fix it, don't injure it. Obviously, if the GYNs are going to cause trocar injuries (any kind), they should be able to fix them.

In all fairness, though, I learned the trocar site closure method I use for the deeper more difficult closures from a GYN. This is the large pick-ups (preferrably Bonneys) under the fascia pulling up (more as a retractor than a pick-up) and an S retractor retracting above this.

Jorjo

Re: GYN Trocar injuries - Ärzteforum

Post#10 »

That's the same principle used by our group but using the PdB.You can find the reference of the PdB for laparotomy closing procedure in J Am Coll Surg.

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