Evidence-Based GYN Surgery

Check out: https://www.ajog.org/article/S0002-9378(18)30583-0/fulltext

Remember the evidence-based C-section? Turns out, there is also good evidence for gyn surgery practices!

Preoperative - Includes things that are part of the ERAS protocol

1. Patient Education 

   • Two randomized control trials 

   • There was some potential association between preoperative patient education and improved outcomes (low level evidence) —> perhaps some decrease in length of stay and pain.

2. Bowel Prep

   • Minimally invasive gyn surgery:

     • Strong evidence that oral mechanical bowel prep should not be used.

   • In those with high risk of colorectal resection:

     • Based on colorectal surgery evidence, oral mechanical bowel prep alone is not effective 

     • Use of one of the following regimens can be considered: (moderate level evidence) 

       • Oral bowel prep AND oral antibiotic 

       • Oral antibiotic alone

3. Surgical site infection bundles - high level of evidence

   • High level of evidence - use of surgical site infection bundles should be considered! 

     • Listen back to our episode on “Infection Prevention and Gynecologic Surgery”: https://creogsovercoffee.com/notes/2019/10/13/infection-prevention-and-gynecologic-surgery

     • Sometimes, it’s not always just a single thing, but the whole bundle!

4. Glucose management 

   • Goal of <180 mg/dL (high level of evidence) 

5. Diet

   • Reduce fasting - may ingest solids until 6 hours prior to anesthesia induction and clear liquids until 2 hours prior to induction 

     • High level of evidence 

   • Carbohydrate loading - routine carbohydrate loading is recommended (moderate level of evidence) 

     • May ingest 2-3 hours up to induction of anesthesia - can include things like apple juice, ensure clear, etc. 

6. Pre-anesthesia medication 

   • Pain:

     • Combination of acetaminophen, COX-2 inhibitor (celecoxib, for example), and/or gabapentin - level of evidence is high!

   • Nausea:

     • Scopolamine, midazolam, or gabapentin (high level of evidence) 

7. VTE prophylaxis - moderate evidence 

   • Overall low rates of VTE in general, but preoperative intermittent pneumatic compression alone for patients undergoing MIS or laparotomy for benign disease

   • Weak evidence from observational studies supports adding preoperative pharmacologic prophylaxis for patients undergoing laparotomy for gynecologic malignancies  

Intra-operative 

1. Drains 

   • Routine NG tube - associated with patient discomfort and no known benefit (high level of evidence) - from the ERAS Society 

   • Routine peritoneal drains - not recommended routinely in gyn or onc surgery including cases with lymphadenectomy or bowel surgery

     • 2017 Cochrane Database showed drainage was not associated with reduced rates of lymphocyst formation. However, use of surgical drains increased rates of symptomatic lymphocyst formation when the pelvic peritoneum was left open 

     • Overall, moderate evidence  

2. Antibiotic prophylaxis

   • Given within 1 hour prior to incision per CDC and ACOG; redose prophylactic antibiotics for long procedures (ie. Ancef 3-4 hours after incision)

     • Level of evidence is high

3. Skin prep

   1. Ideally use 2% chlorhexidine and 70% isopropyl alcohol solution (high level of evidence) 

4. Blood transfusion (for hemoglobin 6-10) and fluids to maintain intraoperative euvolemia

5. Maintain normothermia 

6. Pain management - liposomal bupivicaine for laparotomy cases (moderate)  

Postoperative

1. Early mobilization - moderate level of evidence 

   • Has been shown to be beneficial and to avoid prolonged bedrest; basically meaning out off bed and mobilizing within 24 hours of surgery 

     • Reduces PEs and VTEs, also may protect against muscle atrophy and deconditioning 

2. Early alimentation 

   • Postoperative feeding - within 24 hours of surgery (can be as early as 4 hours after surgery with or without bowel resection) 

   • Two systematic reviews and 1 meta-analysis - early feeding is safe, well-tolerated and results in earlier return of bowel function and shorter LOS 

3. Early urinary bladder catheter removal (mod level evidence) 

   • Catheter use for < 24 hours, but appropriate to consider fall risk and necessity of urine output monitoring 

   • Uncomplicated surgeries: consider removal at 6 hours to balance rate of infection vs retention 

   • Complicated: morning after may be more appropriate (ie. urogyn or gyn onc cases) 

4. Prevention of ileus and accelerate return of bowel function

   • Use of postop laxatives (recommended for gyn surg, low level of evidence) 

     • Docusate sodium (Colace): more about its lack of utility here.

   • Chewing gum (high level of evidence) 

   • Alvimopan (novel peripheral u-opioid antagonist) - may not be beneficial in benign gyn 

     • However, may decrease ileus in ovarian cancer surgery and can be considered for use in patients undergoing bowel resection  

5. Early IV fluid discontinuation 

   • Discontinue maintenance IV fluids within 12-24 hours following surgery, especially with early PO intake (low level of evidence) 

     • Urine output as low as 20 mL/hour

       • Can be normal post op stress response 

       • Intervention not required 

6. Postoperative VTE: 

   • Mechanical prophylaxis for duration of hospitalization in all gyn surg patients 

   • Mechanical and/or pharmacologic prophy for gyn onc surgical patients (high level of evidence) 

     • Additionally, for oncology cases with laparotomy, should extend VTE prophylaxis for 4 weeks following surgery