Donna Wyant


A 39 year-old woman presented with urinary frequency and pelvic pressure. On pelvic examination, a large pelvic mass was felt adjacent to the uterus, deep in the pelvis. MRI showed a 12 cm subserosal fibroid adjacent to the right side of the uterus (see figure LS 2012). The patient requested a laparoscopic myomectomy.


Incisions were made in the umbilicus, in the right lower quadrant superior and medial to the iliac crest, midway between the right lower quadrant incision and in the left lower quadrant. The fibroid was seen in the right broad ligament (figure: broad ligament a) and the ureter was identified on the right pelvic sidewall down to the level of the uterine artery where it appeared to course lateral to the fibroid.

The round ligament was severed near the uterus and a vertical incision was made in the peritoneum medial to the fibroid and away from the pelvic sidewall (figure: broad ligament b).

The dissection was carried down into the pelvis using traction to enucleate the fibroid. As the fibroid was separated from the peritoneum, the ureter was unexpectedly found on the inferior and medial side of the peritoneal incision (figure: broad ligament c, arrow).


Figure c: Broad Ligament, arrow
Careful dissection continued until the fibroid was removed and placed near the cecum. The peritoneal defect can be seen in figure: broad ligament d.

Interrupted sutures were placed to close the defect. A small hydrosalpinx was incidentally found in the right fallopian tube and the tube was removed. Morcellation was performed and the procedure was completed. Estimated blood loss was 50 ml. The patient was discharged home the same day and she made an uneventful recovery.

Articles

A 39 year-old woman presented with urinary frequency and pelvic pressure. On pelvic examination, a large pelvic mass was felt adjacent to the uterus, deep in the pelvis. MRI showed a 12 cm subserosal fibroid adjacent to the right side of the uterus.

Case Study: Broad Ligament Fibroid with Ureteral Dissection: Laparoscopic Myomectomy

Laparoscopic surgery offers unique advantages over abdominal surgery. It allows the physician to illuminate and magnify the surgery site, while viewing the procedure on a large monitor.  This gives a degree of detail that is simply not possible with a laparotomy.  Close proximity and detail are important for safe manipulation of the laparoscopic instruments; however this close view also has disadvantages.  The brain thinks it knows what it sees, but that is when surgery can take a serious turn.

Dr. William Parker explains that if we understand the limitations of the human brain we can learn to navigate through difficult surgical situations and possibly avoid serious complications in the operating room.

•	Visual perception and processing errors: Once the brain has imprinted an image, it is difficult to see beyond that image.  What the brain has perceived is not necessarily what is actually there.  If the information was incorrect based on a quick impression, contrary information may be ignored and you may not see a potential problem. 
 •	Loss of haptic perception:Identification and differentiation are difficult in the surgical world. The brain relies on many senses to process information.  Limiting sensory input in any regard, i.e. the sense of touch, can have a negative impact on one’s interpretation the information available.  This narrowed input can result in surgical misjudgments.  
 •	Poor performance under stress: In stressful situations, our instinct is to allow the fight or flight response to take over but during surgery the physician must remain focused, calm and deliberate in his responses.   This takes extensive practice and experience; role playing stressful situations in the OR can aide in developing controlled responses.
 •	Lack of situational awareness: The need to be aware of the entire surgical field at all times is crucial in laparoscopic surgery because the laparoscope can limit peripheral vision, making spatial orientation more difficult.   Situational awareness is achieved by pulling back the scope, locating anatomical structures and realigning one’s sense of location.  Situational awareness requires active involvement and planning.

“Research demonstrates that focusing on one’s mistakes is the best way to improve performance.  Errors in surgery will happen; we are human.  The emphasis should not be on punishment but on training, communication, and teamwork” states Dr. Parker.  Simulations of unexpected complications are an excellent and safe way to redirect the brain not to simply react in an emergency but to stop and think first.

Dr Parker states, “Research has also shown that fail safe procedures in the OR such as checklists also minimize errors.” Check lists or time-out’s allow the surgical team to make sure everyone is on the same page by verifying important information that would normally be assumed.  What surgery is being performed, what is the site, what is the medical history, patient’s name, etc. are discussed.   While these things are assumed in surgery it is easy to forget to go over these important steps.

Fail safe procedures also enhance a teamwork approach in the OR by:

• Opening the lines of communication between the surgical staff.   A team approach offers several sets of eyes focused on the same patient and monitors.  Each view has a unique vantage point and what one may not see, another may and can indicate a potential problem.
• Allowing everyone to understand the meaning of and level of each person’s concern by using the same terminology, which allows for the team to communicate using the same language with the same meaning.
• Encourages mutual respect and a team approach in the OR where each person’s concerns are addressed.

According to Dr. Parker, learning and experience must continue well beyond the residency years with an accumulation of training, simulated practice, and actual surgery.   Attention should be specifically directed towards the pelvic anatomy, managing surgical emergencies, surgical techniques, an understanding of the limitations of the human brain, as well as teamwork in the OR.

:
Parker WH. Understanding errors during laparoscopic surgery. Obstet Gynecol Clin North Am. 2010 Sep;37(3):437-49.

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Dr Parker is a Gynecologist in Santa Monica, California, in private practice. He is also the former chair at Saint John's Hospital and Health Center, Department of Obstetrics and Gynecology and past president of the American Association of Gynecologic Laparoscopists. Dr. Parker is a frequent lecturer and teacher of advanced surgical techniques both in the United States and abroad. He is extensively published, and has expertise in advanced laparoscopic surgery and advanced hysteroscopic surgery.

Laparoscopic surgery offers unique advantages over abdominal surgery but there are some disadvantages.  What can be done to improve your surgical skills?

Understanding the Limitations of the Human Brain, Laparoscopic Surgery and Patient Safety

This is Donna Wyant from OBGYN.net and I am here today with Dr. Bill Parker. Dr Parker is a Gynecologist in Santa Monica, California, in private practice. He is also the former chair at Saint John's Hospital and Health Center, Department of Obstetrics and Gynecology. Dr. Parker is a frequent lecturer and teacher of advanced surgical techniques both in the United States and abroad. He is extensively published, and has expertise in advanced laparoscopic surgery and advanced hysteroscopic surgery.

We are here to talk about patient safety in the operating room. The operating room is the most common place for medical errors to occur in the hospital setting. Complications from errors can include surgical site infections,
anesthesia related incidents, surgical errors and even death but research has shown that this can be significantly reduced. Dr. Parker, if many of these errors could be avoided, what should be done to improve patient safety in the operating room?

WHO surgical safety checklist and implementation manual

A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population

The operating room is the most common place for medical errors to occur in the hospital setting. Here, Dr. Bill Parker, a gynecologist in Santa Monica, Calif., discusses improving patient safety.

Operating Room Patient Safety

Despite the effectiveness and safety of long term reversible contraception, (LTRC), women continue to favor using short term reversible contraception (STRC).  This tendency for user dependent, short term contraception was brought to light when Kathy L. Schulman, of Outcomes Research Solutions Inc. in Bolton, Mass., and her colleagues evaluated data from the National Survey of Family Growth in 2002 and 2006 to 2008.

In her research, Ms. Schulman noted that while majority of women at risk for unintended pregnancy are using birth control, they rely more heavily on the forms that require a higher level of user dependency and accuracy.  “These types of contraception are highly user dependent, where as the user must consistently and accurately apply the birth control method to avoid pregnancy.   This is especially true of young, nulliparous woman, who are at risk of unintended pregnancy, “states Ms. Schulman.  “Typical use, first year, failure rates for the three most common methods of birth control (pill, male condom, withdrawal) range from a low of 8.7% for the pill to a high of 18.4% for withdrawal.  In contrast, the less user dependent, longer acting methods of birth control have first year, typical use failure rates that range from a low of 0.1% for the IUD Mirena and 1.0% for the Copper T IUD to a high of 6.7% for the 3 month injectable.“

Contraceptive use by age and parity varies greatly.  The research shows that Long Acting Permanent methods (LAP) (46.5% vs. 3.9%) and Long Acting Reversible methods (8.9% vs. 4.3%) are more commonly used in parous women who tend to be older (34.4 years vs. 25.2 years) and married (65.9% vs. 25.5%).  (Figure 2)  While Short Acting Hormonal Methods (STH) (17.1% vs. 51.0%) and Short Acting Barrier Methods (STB) (12.8% vs. 21.4%) are favored more prevalently by nulliparious women, with the highest use by the 25 to 29 year old group.  (Figure 3) 
 



Distribution of Current Contraceptive Method by Age Group, Parous Women Only


Distribution of Current Contraceptive Method by Age Group, NulliParous Women Only



“The focus of education has been on the task of preventing pregnancy and how to use the method correctly but a new way of looking at education should be a shift towards the methods that are less user dependent.”  This shift of use could ultimately reduce the unintended pregnancy rate.

Ms. Schulman states, “Healthcare providers should note, when discussing the use of contraceptive and the options available, to take into consideration the patient, the degree of user dependency and the likely success rate.  Contraception that requires a higher rate of accurate and consistent user action is at a greater risk of failure.   Long term reversible contraception that is less user dependent should be discussed as a safe and reliable treatment option.  This is especially true with young, nulliparous women who are at risk of pregnancy. “

:Contraceptive Use Patterns: Reversible, Permanent, Long and Short Acting Methods of Contraception K. L. Schulman, H. J. Cabral, A. Prezioso, J. Pocoski, L. A. Costa, A. W. Law Outcomes Research Solutions, Inc., Bolton, MA; Department of Biostatistics, Boston University School of Public Health, Quincy, MA; Health Economics and Outcomes Research, Bayer Healthcare Pharmaceuticals, Wayne, NJ

Research presented at the ASRM's meeting shows that women at risk of unintended pregnancy are using some form of contraception. However there is a tendency for user dependent, short term contraception which has a higher failure rate than long term reversible contraception.

Donna Wyant

Articles

Case Study: Broad Ligament Fibroid with Ureteral Dissection: Laparoscopic Myomectomy

Understanding the Limitations of the Human Brain, Laparoscopic Surgery and Patient Safety

Operating Room Patient Safety

Contraceptive Use Patterns: It’s Time to Shift Our Thinking