What data show about bowel preps
The literature provides conflicting messages about the effectiveness of mechanical bowel preparation in averting additional complications when bowel injury occurs. Nichols and colleagues surveyed 808 active board-certified colorectal surgeons in the United States and Canada in 1995.11 All of the 471 (58%) surgeons who responded reported using some form of mechanical bowel preparation for their elective and emergency colorectal procedures.
Zmora and associates described the difficulty of designing a multicenter study to evaluate the role of mechanical bowel preparation in patient outcome.10 Of the many variables that warrant consideration, surgical technique was the single most important factor influencing surgical outcome.
In a review of evidence supporting the need for prophylactic mechanical bowel preparation prior to elective colorectal surgery, Guenaga and colleagues concluded that this practice is unsupported by the data.12
Bottom line. Given these data, the gynecologist wanting to practice evidence-based medicine should base his or her recommendations about bowel preparation on the preferences of the general or colorectal surgeon who will be called if a bowel injury occurs.
Don’t forget the team
After preparing the patient, prepare your support team—the operating room (OR) and anesthesia staffs. The OR staff should ensure that extra sutures, instruments, and retractors are unopened, in the room, and available in case conversion is necessary. Inform the anesthesia staff of your anticipated surgical time and potential pitfalls. Let them know you will need maximum Trendelenburg position for pelvic exposure, but remain flexible if the patient has trouble with oxygenation and ventilation. Making your anesthesiologist aware of your willingness to work together will benefit both you and your patient immensely.
Preparation continues in the OR
Appropriate patient positioning is key to successful completion of difficult laparoscopic cases. Position the patient’s buttocks several inches beyond the table break to facilitate maximal uterine manipulation, which may be needed for completion of the colpotomy.
Place the patient in the dorsal lithotomy position using Allen stirrups, with the knees flexed at a 90° angle. Keep the knees level with the hips and the hips extended neutrally.
Arm position is important to maximize room for the surgeon alongside the OR table. Space is limited when the patient’s arms are positioned on arm boards. Tucking the arms at the patient’s sides, with the antecubital fossa anterior and the palm cupping the hip, improves the surgical field and secures the patient to the OR table (FIGURE 1). Protect the elbows and hands with cushions.
Place sequential compression devices (on the calf or foot) for the duration of the procedure to minimize the risk of blood stasis and clots that sometimes develop in the legs with prolonged surgical times. Many complex laparoscopic cases last longer than 2 hours.
FIGURE 1 Positioning the patient
Tuck the arms at the patient’s sides, with the antecubital fossa anterior and the palm cupping the hip, to improve the surgical field.
Maximum Trendelenburg position is a must
This positioning is essential for successful anatomic exposure in complex laparoscopic surgical cases. If the patient is positioned securely, maximum Trendelenburg position does not increase the risk of the patient sliding off the OR table, nor does it affect oxygenation in most morbidly obese patients. Rather, it allows the intestines to drop out of the pelvis into the upper abdomen, facilitating visualization and decreasing the risk of bowel injury.
Anesthesia staffers often limit the degree of Trendelenburg position unless the surgeon insists otherwise. Alternating patient position between maximum Trendelenburg for optimal surgical exposure and a less steep angle when patient oxygenation requires it allows the gynecologic surgeon and anesthesiologist to work together in the patient’s best interest.
Video monitor placement is key
It helps determine how efficiently you operate. Use of a single central monitor requires both the surgeon and assistant to turn their heads acutely during prolonged procedures, accelerating their fatigue and potentially increasing the risk of injury. Using two monitors—each placed to allow the surgeon and assistant to maintain neutral head position—minimizes fatigue and its attendant risks.
Entering the abdomen
Abdominal entry poses theoretical obstacles when the patient has a large uterus, but all types of entry remain safe as long as laparoscopic surgical principles are followed scrupulously. We have successfully used traditional Veress needle entry, open laparoscopic entry, and left upper quadrant entry.
Is entry above the umbilicus helpful?
Anecdotal reports suggest a midline port above the umbilicus when the uterus extends above the umbilicus, but we do not alter standard port placement in these cases. By tenting the abdominal wall at the umbilicus, we create adequate distance to achieve pneumoperitoneum and space for directed trocar entry to avoid injury to the uterus. The conventional umbilical primary port allows use of standard-length instruments. The cephalad uterine blood supply (infundibulopelvic ligament vessels or utero-ovarian ligament vessels) remains at or below the level of the umbilicus in almost all of these patients.