Contemporary OB/GYN readers speak up about exploratory laparotomy, the cesarean epidemic, and the difficulty to re-enter ob.
I appreciate this article regarding the differential diagnosis of pelvic pain. [“Unusual cause of pelvic pain,” March 2016 Contemporary OB/GYN] However, I do take significant exception regarding management. Why would anyone go straight to an exploratory laparotomy on a young, healthy, nulliparous patient? The obvious choice would be diagnostic laparoscopy.
In this situation the fibroids could easily be amputated with laparoscopic instruments, and the pathology removed through a small minilaparotomy or (if God willing its return) a morcellator. I understand the need for resident experience in open cases, but in this case the patient was definitely harmed with a big incision. Since a retractor and packing the intestine obviously occurred, the risk of adhesions, pain, and infertility are compounded on top of the surgical removal of the fibroids. If you don’t start laparoscopically, no case can be done laparoscopically. There are few cases, in my opinion, that warrant primary laparotomy in our day and age.
Richard Chudacoff, MD
Las Vegas, Nevada
Thank you for your comment. The decision to proceed with an open approach in the case presented was based on physical exam as the fibroid was quite large and the surgeon did not feel the surgery could safely be accomplished laparoscopically. I agree wholeheartedly that, if technically possible and safe for the patient, minimally invasive methods should be used first. The decision to make a laparotomy was not made for any reason other than it was deemed to be the safest option for the patient, which should always be the basis for choosing a surgical approach. I commend you on your passion for advocating for minimally invasive surgery for patients when possible as it does avoid the complications you cited.
Kate C Arnold, MD
NEXT: 'When in doubt, deliver the baby'
[Regarding “Cesarean epidemic: Are we too quick to cut?,” April 2016 Contemporary OB/GYN] Consider the disincentives of the medicolegal system. There are many more lawsuits for failure to perform cesarean than for “unnecessary” cesareans. Any complication associated with instrumental delivery is judged harshly. “Zero birth trauma” expectations judge harshly even the slightest signs of birth trauma. Some personnel on L & D units seem against active management of labor. A side issue, but all the alarms on labor units (HCFA driven) can increase the stress on a large unit-IV, epidural pump, bp monitor, pulse ox, fetal monitor, buzzer to enter unit, phones, etc. When in doubt … deliver the baby.
Bob Stockburger, DO, FACOG
NEXT: Re-entering ob after time away
I believe I have a possible solution to ob/gyn burnout: one that I am a part of-re-entry into ob! [“Why are ob/gyns burning out?” March 2016 Contemporary OB/GYN]
I stopped practicing ob in 2008 precisely for a typical burnout reason. I practiced in a small community with call every other to Q3 nights and had 4 small children. I switched to practicing balance. During this time, I was able to hone my laparoscopic surgical skills and have a regular schedule. However, now my children are older (in college and high school), I have been investigating what it would take to “re-enter ob.”
There is a dearth of knowledge regarding this topic and no standards. There is one program in Phoenix, Arizona that has a 3-month fellowship-like program that is costly and not convenient for a community physician to attend. To obtain hospital ob privileges, one has to show a minimum number of deliveries within the past 2 years. How is one to get that experience without investing time and $10,000 to $20,000? What can be done to help draw more physicians like me, who are ready to get back into the unpredictable but fulfilling career of ob? It would help the shortage problem.
Also, I believe my “sabbatical” from ob will make me a better clinician. I’ve gained experience, insight, and maturity and no longer have the tug of small children to attend to.
Fortunately, I have found a group that is willing to invest in me and I am very excited about this future opportunity to switch gears and get back into obstetrics. I am taking a CME course in high-risk ob, performing standardized fetal heart rate tracing tests, and am working with a hospital’s ob department to see what kind of extra proctoring is needed. I will be moving this summer to a new city and state.
It hasn’t been easy finding this opportunity. There is a need all over the country for obs, but little interest in helping facilitate a re-entry candidate.
Susan Gorman, MD