AAGL 2004 LSH Symposium
Q & A Session: LSH: The Emerging Trend in Hysterectomy
with Tom Lyons, MD and
panel
Listen to Q & A in RealMedia or
Windows Media
| Q: What do you use for post-op pain especially on patients that leave about two to three hours after surgery? And the second question is: you only use a camera port and two other ports, is that it, three ports total? |
Thomas Lyons, MD: I use a four ports total in a normal size uterus. In this large uterus I used six, but in a normal size uterus I use four ports. There will be one at the umbilicus, two well lateral superior ischial spines, and one midline. That midline port is a ten/eleven, or ten mm port, and that is where I put my morcellator through; through that lower midline port. That is my style of doing this. The main thing I think we should try to do is you put the ports where you need to put them to get the job done. You do not put the ports in the same place every time just because you put them there yesterday. If you have a different job today, you put the ports where you need them, to get it done. That arrangement has helped me get it done.
I will answer the question on pain relief and then we will ask the rest of panel because each one of them have the same situation as I do, because our patients go home very rapidly also.
| Q: What do you use for post-op pain especially on patients that leave about two to three hours after surgery? |
Thomas Lyons, MD: On average our patients in the facility will get one perineural injection, in my case it is Demerol Phenergan if the patient is not allergic. That is the average number of perineural injections. Post-op in the operating room as they are leaving, they get 30 mg of Toradol, either IV or IM. We switch them to Vicodin and/or Toradol, or some other non-steroidal, as soon as they are able to take things by mouth. They are given a prescription at their pre-operative visit for Vicodin. For post-op they are told that they can take Advil, Aleve, whatever else first, to try that. If that does not work they will proceed to the Vicodin because they can add it to that. We have not done an official study but our patients tell us that they rarely use the Vicodin. And we do inject the ports.
Seth Kivnick, MD: We give the patients Vicodin and Motrin to go home with. And some of the doctors give the patients Compazine also. We use a 15 mm trocar in the umbilicus and then two 5's laterally at the level of the umbilicus, and we can do most cases with those three trocars. And the 15 mm incision, because we put it right through the umbilicus, is the best one cosmetically. It is almost invisible in two weeks.
Steven Bush, MD: We use the same. We give 30 of Toradol in the OR once we are finished, and then Advil, Vicodin or Darvocet when they go home.
Deborah Wilson, MD: Most of my patients actually do spend the night and we have Demerol Phenergan ordered, we have Percocet ordered. We give them Vicodin to go home with, but most of them end up not using it. They just use Ibuprofen. I personally have had a laparoscopic supracervical hysterectomy. I got one shot of Demerol in the recovery room and never had anything that I would qualify as pain afterwards.
Malcolm Munroe, MD: Ours get some IV Toradol before they leave the OR. They get Mepivocaine in all the incisions with ½ percent with adrenalin, and they go home with Ibuprofen and Vicodin. I cannot tell you how much they utilize the Vicodin, it varies.
Thomas Lyons, MD: By the way, my recommendation is do not use a PCA. You use a PCA, the patient is never going to get up. Do not use a PCA, they are not leaving. Put them on PCA and they are with you. Nurses are not going to visit with them either.
| Q: I have a general question for the panel. There seems to be a variety of lengths of stay, you know, two hours, eight hours, 23 hours. I was just wondering what maybe the different criteria was for that? |
Thomas Lyons, MD: Our criteria is basically that I tell the patient, and our patients are told, that they can stay overnight if they want to. In other words that is available to them. And I tell them that they can leave when they want to leave. They have to meet the criteria in the recovery room, which means they have stable vital signs, whatever else, taking PO. Usually up and voiding, although we have had a few that have said, “Hey I don't need to pee, I want to go.” But generally speaking, it is once they meet criterion and they say, “Hey I want out of here”. Now admittedly they are prepped for this, and again, the patient's expectation makes a lot of difference as to what they are going to do. A lot of our patients go home around the traffic. We have patients that don't go home between 3:00 and 7:00. They will go home before 3:00 and they will go home after 7:00, but between 3:00 and 7:00 they are not going to go home because of traffic.
Seth Kivnick, MD: Yes, our criteria are basically if the patient can ambulate, urinate, drink liquids and take pain pills then she can go home. We try to encourage all patients to go home the same day unless there are other complicating medical conditions. The most common reason for keeping the patient overnight is that the patient does not want to go home. If their friends have stayed overnight, if their mother had a hysterectomy and stayed over night, they generally want to stay.
Deborah Wilson, MD: My patients usually stay the night. We give them the option of going home but most of them elect to spend the night.
Malcolm Munroe, MD: We are the same as Tom.
| Q: Are there any data looking at the best way to fulgurate or obliterate the endocervix so that there is less cyclical bleeding? Any data? |
Thomas Lyons, MD: The best evidence is that it does not make any difference. In other words, the fulguration in the cervical canal, as far as we know, does not make any difference. Certainly, if you are doing fundectomies you are going to have a higher rate of bleeding. The problem that we have, and there was a paper that was just read in an earlier meeting, which was basically the J. Cooper Ward paper, they looked at their cyclical “bleeding episodes” after supracervical in Huston, and they had 17 percent. What they asked the patient for six months after the surgery, was, “Do you every have cyclic bleeding?” I asked the guy if he asked the patient if they knew what cyclic bleeding was, and they did not. In other word if you asked a patient if they had any bleeding, which is what one of my fellows did with a group of our patients, they got a four percent positive. If you have bleeding on a monthly basis that persists, it is much less than one percent. I think the key is, go down low enough, and based upon what you are hearing from the panel you are going to be better off. The ablation of the endocervical canal was a technique that Kilkoo recommended back when they did their cases in the 1950's, and it was to decrease the incidence of dysplastic changes in the cervical canal. But it had nothing to do with cyclical bleeding.
| Q: I personally use the Gyrus knife to cauterize both of the IP ligaments and the uterine arteries before I cut them. Do you guys do it once, twice, three times, four times, or what? |
Thomas Lyons, MD: I do them till they are cooked. Basically I think you look at the feedback you are getting from your machines. One of the things I look at is the bubbling because since this is a desiccation process, when you see the tissue stop bubbling, that means it is dry, it means it is desiccated. You should be okay with that. I think everybody up here, from what I've seen, said that on the uterine arteries they are going to hit those several times. The upper pedicles, I think a couple of times is plenty in most cases. The upper pedicles are much easier to isolate. The problem with the uterine vessels is that they are coiled and you are really not sure where the vasculature is running in all cases. It is one of the reasons why I think the harmonic scalpel is inappropriate on the uterine vessels. It is perfectly fine on other vasculature pedicles but the LCS device is an inappropriate tool to use on the uterine vasculature. Otherwise it is a great tool. I have used it many times, but I do not take it on the uterines.
| Q: How long did it take you to endear yourself to the pathologists when they got these specimens initially? |
Thomas Lyons, MD: Well, they got them for a while and one of my pathologists called me and said, “What is this pit-bull surgery that you are sending us?” But, in point of fact, they also sent their people that work for them, that needed hysterectomies; they sent them to us because they knew they were getting them back on Monday. So, they did not hesitate to do that either! Seriously, that is true. I got virtually the whole pathology department. Their uteruses are all up there courtesy of me.
| Q: What do you do with a patient with a pacemaker? |
Thomas Lyons, MD: That should not be any
problem with bipolar, electrosurgery. It certainly could be with monopolar, in
theory, but it is a direct current.
Malcolm Munroe, MD: I think bipolar is
probably not an issue.
Seth Kivnick, MD: I had such a patient and
cardiology put a special kind of magnet over her pacemaker during the case, and
then reset it afterwards.
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