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.

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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.

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

Coverage of the 37th Annual Global Congress on Minimally Invasive Gynecology

A Gynecologist's Second Opinion

Click             here for Audio/Video Version

   Good morning, I’m Barbara Nesbitt, I’m the editor of OBGYN.net and  we’re here this morning at the AAGL and I have the pleasure of being  with a good friend and editorial advisory board member of OBGYN, Dr.  William Parker.
 
 

  Dr. Parker is in  private practice in Santa Monica and he has his second book out, which  is The Incontinence Solution:  Answers for Women of All Ages.  His first  book that we have on the website which is . . .
 
 

   The Gynecologist’s Second Opinion.
 
 

  And this morning  we’re going to talk about incontinence and the all age part and this  book is written, as both of them are, for patients.  Good morning, Dr.  Parker.
 
 

   Good morning,  Barbara, thanks for having me.  We felt there was a real need for a book  about incontinence that, if you go to the bookstore which I often do,  my wife and I do on Saturday nights often, there are no books for women  talking about incontinence and we felt there was a real need to explain  the problems, explain the solutions, to women that had incontinence  problems, so we decided to write a book about it.
 
 

  All right.  For  those out there when, the subtitle is For All Ages.  I don’t think, I  think most women my age think that incontinence is probably something  that would come as you age, after menopause.  Explain to the audience  why it is also a young woman’s problem.
 
 

   It is  extremely common in young women; it’s a really interesting issue.  Any  woman that’s had a child has the risk, vaginal delivery, has the risk of  having incontinence and many women don’t talk about it.  They don’t  talk about it to their best friends, their husbands, partners, they  certainly don’t tell their doctors and interestingly, doctors don’t  often ask about it because they’re not very well trained to deal with  the problems, at least historically.  But young women have this problem,  women who are teenagers sometimes even have this problem and don’t  discuss it, but certainly women who’ve had a vaginal delivery, it’s not  uncommon and there are many, many non-surgical solutions to these  problems.  Another thing we found is that women don’t want to talk to  their doctors about it because they think they’re going to have to have  an operation and they don’t want an operation and I understand that, but  70% of women with incontinence can be treated without any surgery.
 
 

  Tell us a couple of things that you would suggest to them first before you ever do surgery for them to try.
 
 

   Well, the  simplest things are, there are Kegel exercises, which many women have  heard about, but many women do them improperly, they actually contract  the wrong muscles and there are simple ways now that we can sense what  muscles you are contracting and teach you how to contract the proper  muscles to strengthen the muscles under the bladder and that works  extremely well, it usually takes two or three visits, we have a nurse  practitioner who teaches people how to do that and it’s called  biofeedback and it’s very simple, fifteen minutes at a time, two or  three times, once a week for three weeks and that seems to work for the  majority. 
 
 There are new medications that are now available that work extremely  well for certain problems.  Simple things like women who have to get up  six or seven times a night to urinate and if they stop drinking liquids  after dinner, especially alcohol, caffeine, things like that, that they  can decrease their need to get up in the middle of the night and it’s  simply something simple just like a lifestyle change can make a big  difference. 
 
 There are certain foods, spicy food, citrus, caffeine, alcohol, that  irritate the bladder lining and they can feel the urge to go kind of  frequently so sometimes dietary changes.  But when we talk to patients,  we go through a complete history and physical exam, see if we can  identify the problem and then deal with the simplest thing first.
 
 

  Okay.  Now say  they try all those things or say on examination you see that there is a  problem and it needs to have a surgical procedure done.  What are some  of those options and, say, what would be the simplest and . . .
 
 

   Yeah, the nice  thing now is that this field, in the last five years, has exploded in  terms of research and we’re seeing now new procedures that are invented,  the simplest and newest one is TVT and spark procedures that can be  done through a small incision in the vagina as an outpatient, go home  the same day without a catheter, virtually no pain, the incisions are  about this big and the success rate is 90% success rate after five  years, which is comparable to every other procedure that’s ever been  invented through big incisions.  So there’s a lot of new things  happening in this area surgically.
 
 

  So if I’m correct,  in this book, it will explain things, signs to look for, identify them  and hopefully help women to say, ‘I could get this corrected.’
 
 

   Yes.  There’s a  chapter on what’s normal, and there are chapters about incontinence,  what that means, the different kinds of incontinence, there’s a chapter  about how you get incontinence in terms of childbirth, some of the risk  factors, forceps deliveries for long labor, pushing for four or five  hours, really large babies, babies that have turned the wrong way and  those are things that could be discussed with the obstetrician even  before you have to say, hey, if this happens, I’d rather have a caesarean section.  Now most people don’t want a caesarean section, but  most people don’t want to have incontinence when they’re 70, 60, 70 or  later.
 
 

  Okay now, obviously, I’m not having a baby but say I . . .
 
 

  That would be, I  would make a lot of money.  Say I were to have a child, could, if I was  to say I had forceps delivery, would I then be able to start some of the  things you talked about like Kegels to hopefully not or prevent a  problem?
 
 

   We think that  that is probably likely but nobody has proved that it does make a  difference.  So we’re not sure that that works or not.
 
 

  Okay.  Well, we’re  going to have the book on the website and as in your other book, we’ll  have some chapters here and there that they, you can read and I read the  book, I think it’s written very well.
 
 

   Well, my wife  is an English teacher so we wrote it together and she doesn’t understand  the science and she’s a good writer and she helped and so it’s very  easy to read and . . .
 
 

  It is easy and so is your other book.
 
 

   That’s what we tried to do, thank you very much.
 
 

OBGYN.net Conference CoverageFrom the 31st Annual Meeting of the American Association of Gynecological Laparoscopists (AAGL)