Sinai Health Systems

Is there a new trend in Gynecology that you would like to shed light on in this particular edition?

The American Association of Gynecologic Laparoscopists (AAGL) has released five statements, which need to be informed to the patients by the practicing gynecologist. As per the first statement, we refrain from performing open surgeries for non-malignant diseases when they can be performed laparoscopically, vaginal, or using a robot to reduce the complications and costs. The second statement advises against performing routine removal of ovaries in women before menopause if they are getting a hysterectomy with low risk for ovarian cancer since this procedure is associated with higher rates of coronary heart diseases and cardiovascular health in the age group of fewer than 50 years. In contrast, approximately one percent of women who have their uterus removed with the ovaries intact develop cancer.

The third statement says that prophylactic antibiotics are not indicated in lower-risk laparoscopic procedures. If a patient has their tubes removed due to surgical sterilization, there is no indication to give antibiotics. The American College of Obstetrics and Gynecology recommends giving antibiotics in only two scenarios. When a woman is undergoing a vaginal or abdominal hysterectomy, she should receive a single dose of antimicrobial prophylaxis. However, she should not receive antibiotics when undergoing diagnostic laparoscopy or exploratory laparotomy. A simple explanation for this is the overuse of antibiotics can create antibiotic resistance.

According to the fourth statement, physicians should avoid removing endometrial polyps without any direct visualization until the hysteroscopic guidance is available and can be safely performed. That is because removing the polyps without direct visualization is associated with low sensitivity, and there is a negative predictive value of success compared to a hysteroscopy.

The fifth and final statement is to avoid opioid misuse in patients with chronic pelvic pain after gynecologic surgery. Good care and pain control can be provided, even without an opioid prescription. The first method would be education using the FDA and CDC guidelines. The second way for medication is having first-hand knowledge of the risk factors associated with opioid misuse. For the final method, our obstetrics and gynecology department has had an award-winning ‘Enhanced Recovery After Surgery(ERAS) protocol’ since 2018, which is virtually narcotics-free. In one year, our hospital has saved $4.8 million by reducing the length of stay for C-section patients from three days to two days. By implementing the ERAS protocol our use of opiods has reduced over 75%.

These five statements should be mentioned to the patient undergoing surgery, so the care they receive, is evidence-based, free of harm, and truly necessary.

What impact do you expect from these five statements from AAGL in the larger medical space?

Patients undergoing surgery in renowned institutions either get a top-notch robotic surgery or an open surgery via Midline. In my practice, about 99 percent of my surgeries are minimally invasive. It is hard to believe that open surgeries are being performed on patients with no previous record of surgeries in their abdomen or pelvis.

The eradication of opioid misuse is also on the horizon, followed by the enhancement of outcomes for the affected patients. With the protocols followed correctly, patients can go home on the same day on the ERAS protocol and without a prescription for narcotics.