Welcome to the November issue of The Surgeons’ Lounge. This issue features Martin Newman, MD, from the Department of Plastic Surgery, who is head of Clinical Research at Cleveland Clinic Florida, Weston, and Michel C. Samson, MD, from the Department of Plastic Surgery, Cleveland Clinic Florida, Weston. Drs. Newman and Samson reply to a question related to recommended analgesia care following reconstructive thoracic surgery after tumor extirpation.
Check out the answer to the Surgeon’s Challenge—how did you do?
We conclude this issue with The EuroAsian Corner, in which David Hazzan, MD, discusses totally laparoscopic right hemicolectomy with transvaginal specimen extraction.
I hope all our U.S. readers went out and voted earlier this month!
As always, we greatly value our readers’ opinions and encourage all feedback.
From Pedro Vieira, MD
New Jersey Medical School, University of Medicine and Dentistry of New Jersey, University Hospital General Surgery Program
We are planning to perform a thoracic surgery with reconstruction following tumor extirpation. The patient is an otherwise healthy 75-year-old woman with a recurrent, locally invasive subscapular spindle cell tumor. It is likely that the resection will include several segments of posterior ribs at or around the T4 level. My plan for reconstruction includes placement of a prosthetic mesh with muscle flap coverage. Considering the level of postoperative pain that can be expected in such cases, as well as our plans for reconstruction, can you provide a recommendation for postoperative analgesia?
This is an excellent question.
Thoracic wounds and subsequent reconstructions such as the one you anticipate are often associated with substantial postoperative pain. Often the intensity of pain following thoracic surgery and reconstruction is greater than that seen with wounds of the abdomen, cranium or extremities. Broadly speaking, I look at the options for postoperative pain control as generally falling into one of two classes: centrally acting agents such as narcotics, and agents that act locally. Narcotics and other centrally acting analgesics are a well-established option for postoperative pain control. The pharmacokinetics of these medications are well understood. Similarly, the negative side-effect profiles of these medications are familiar to, and in many cases dreaded by, surgeons, nurses and experienced patients. Although not all centrally acting agents have an identical profile, naturally occurring and synthetic opioids generally tend to make patients sluggish. Since pulmonary, toilet, and ambulation factors play such vital roles in the recovery process of thoracic patients, I would recommend using these agents sparingly during the postoperative phase. I would not eliminate them completely, but instead use them as an adjunct in my armamentarium. The level of the surgery also concerns me. Although I have significant respect for epidural blocks and catheters in their ability to reduce postoperative pain and narcotic consumption, the high thoracic location of the tumor precludes the use of epidural anesthesia. Agents that act locally have taken a greater role in my practice in recent years. The advent of devices with implantable indwelling catheters designed to direct the slow but constant administration of long-acting local anesthetics has made a difference in my practice. For the past eight to 10 years, these tools have played an ever-increasing role in my management of postoperative analgesia. Personally, I have noted a decreased need for narcotics and a faster recovery in my patients. Other surgeons also have noted the benefits of these devices, and the literature has become replete with manuscripts that cite their advantages. However, despite the many benefits associated with use of indwelling catheters that deliver local anesthetics, there are drawbacks. One drawback is the theoretical increase in the risk for infection associated with indwelling catheters. Although the increase is theoretical, I try to limit the number of foreign bodies in surgical reconstruction sites. Prosthetics, such as in the case you present, are sometimes necessary as are closed suction drains. However, the addition of an indwelling catheter to this mix concerns me and may dissuade me from placing yet another foreign body in an already crowded surgical field. In addition, cost is a drawback. These “pumps” can be expensive. In an economic climate such as the current one, the cost of these devices is evaluated not only as an out-of-pocket expense, but also as the “time to fill” the device.
Luckily, there are other options. Recently, a pharmaceutical company specializing in slow-release drug delivery liposomes has made available a slow-release bupivacaine formulation. According to the manufacturer, the medication can be injected into the surgical incision. Slow release of the bupivacaine is said to last 72 hours. If this product delivers as promised, it will be a significant and desirable advance for patients: Not only will we be able to reap the maximum anesthetic benefits associated with local agents, but also will be able to avoid the theoretical risks and costs associated with indwelling catheter infusion pumps.
I agree with Dr. Newman, and I can share an anecdotal experience. Recently, I had a case similar to the one you are describing, in which I had the opportunity to use the slow-release liposomal formulation of bupivacaine. Similar to the case that Dr. Vieira is describing, in my recent case, ablation incorporated several posterior rib segments involved with the neoplastic process. The defect was reconstructed with a synthetic mesh that I covered with a latissimus dorsi muscle flap. I injected the liposomal bupivacaine directly into the muscle and ribs surrounding the defect and the reconstruction. As is my practice in these cases, I left closed suction drains, which I brought out remotely from the incision but I did not use indwelling catheters designed to deliver local anesthetic.
In retrospect, I found the postoperative pain control remarkable. On rounds during Postoperative day (POD) 1, I found the patient sitting up in a chair eating breakfast and smiling. She reported her pain as being minimal and controlled with acetaminophen. She ambulated well on that day and throughout the subsequent days. On POD 4, it was obvious to me that the beneficial effects of the liposomal bupivacaine were decreasing. She began, for the first time, to complain about postoperative pain and began asking for PRN hydrocodone. This seemed to manage her pain well. She continued to participate in respiratory therapy and to ambulate throughout her hospitalization. She eventually was discharged and is doing well. This case illustrates one positive experience I had with the liposomal formulation of bupivacaine. However, I have used this medication several times since, for patients undergoing reconstructive procedures as well as patients undergoing cosmetic procedures. I have continued to have good experiences with it. I believe slow-release liposomal bupivacaine represents the next phase in providing patients with the postoperative analgesia they desire and deserve.
Disclosures: Drs. Newman and Samson serve as consultants to Pacira Pharmaceuticals, Inc. Dr. Newman is a consultant for LifeCell Corporation.
By David Hazzan, MD
Laparoscopic surgery is a well-established alternative to open surgery for the treatment of patients with benign and malignant right-sided colon pathologies. Early concerns about the oncologic outcomes of laparoscopy have been addressed by trials reporting equivalent oncologic outcomes between the two approaches. Despite the very good results obtained by advances in laparoscopic surgery, an abdominal wall incision has been necessary to retrieve the specimen and in some cases to perform the anastomosis, either by a midline, Pfannenstiel or muscle-splitting incision. The larger the abdominal incision, the greater the risk for wound-related morbidity, such as incisional hernias and wound infection.1 To eliminate the need for a counter-incision for extraction and anastomosis construction, transvaginal extraction has been described for left and right laparoscopies, as well as total colectomies (Figures 1-5). The vagina has been used to access the abdominal cavity since 1910, and since then it has been widely used for the extraction of surgical specimens such as the gallbladder, kidney and spleen.2
In 1996, Redwine et al3 reported the first series of transvaginal colon removals in five women with endometriosis of the sigmoid colon.4 Since then, a few case series and case reports have been published describing different techniques for right-sided colon pathologies. In order to perform the procedure, advanced laparoscopic surgical skills are needed; transection of the specimen and anastomosis should be done intracorporeally.
In 2010, Park et al5 reported a case series of 14 patients with right-sided colon adenocarcinoma. His group used four 5 mm trocars and one 11 mm trocar for the camera. A 12 mm trocar was placed through the posterior vagina and a 60 mm endoscopic stapler device was introduced through it in order to create a functional end-to-end anastomosis in an antiperistaltic fashion. After placement of the specimen into a retrieval bag, the vaginal colpotomy was enlarged to 3 to 4 cm long and the specimen was removed. Finally, the posterior colpotomy was closed transvaginally with absorbable sutures. In the same year, McKenzie6 reported his experience in four patients with right colon adenocarcinoma. We recently summarized our institutional experience of 11 patients with malignancy of the right colon. All patients underwent a formal oncologic laparoscopic right hemicolectomy with isoperistaltic side-to-side end functional intracorporeal anastomosis, followed by transvaginal extraction of the resected specimen.
None of the cases required an open conversion, but in one patient the planned transvaginal retrieval of the specimen was aborted because of severe carbon dioxide retention and an inability to tolerate the steep Trendelenburg position necessary to perform the posterior colpotomy. The median operating time was 128 minutes (range, 102-154 minutes). The median number of harvested lymph nodes was 16.8 (range, 12-26). There was no perioperative mortality or major morbidity, except one case of postoperative rectal bleeding that was conservatively managed. No patient experienced complications directly associated with the transvaginal approach, and the median hospital stay was five days (range, four to eight days). Despite a small number of case series and the lack of randomized studies, I think that totally laparoscopic, right hemicolectomy with intracorporeal anastomosis and transvaginal retrieval of the specimen is a feasible and safe alternative for selected patients with right-sided colon cancer. A careful review of gynecologic history and preoperative consultation is required when selecting appropriate female patients. In general, transvaginal access is not recommended for patients who have vaginal narrowing, are virgins, have a history of endometriosis or are planning a pregnancy. The described procedure may be applicable to small tumors and early colon cancer, and serve as a bridge between conventional laparoscopic surgery and incision-free surgery. More studies with long-term follow-up are necessary to establish the role of this technique in the treatment of right-colon benign and malignant diseases.
(from October 2012 issue)
(Co-collaborator: Adam Bauermeister, MD, PGY1, Cleveland Clinic Florida, Weston)
A 49-year-old man underwent laparoscopic longitudinal gastrectomy (sleeve) for morbid obesity (body mass index [BMI]: 40 kg/m2). On postoperative day (POD) 1, the patient is recovering well and complaining only of mild abdominal tenderness. Upper gastrointestinal evaluation with Gastrograffin demonstrates no obstruction or leak, and duplex ultrasonography of the lower extremities indicate no deep vein thrombosis. The patient has mild hypotension and normal labs (complete blood cell count [CBC] and comprehensive metabolic panel [CMP]). The patient is advanced to a Phase I diet and a Foley catheter is discontinued. On POD 2, the patient is tolerating a diet, the hypotension has resolved, but he comments that he has unusual mild to moderate right buttock pain. On examination, the buttock is without erythema, induration or signs of infection. The rectal exam is normal; the urine output is adequate; and labs (CBC and CMP) are still within normal limits. What workup and further management should be performed at this stage of the patient’s hospital course?
This male patient recently underwent laparoscopic longitudinal gastrectomy for morbid obesity. On POD 2, the patient was recovering well and tolerating his Phase II diet. He complained of mild right buttock pain and stated that it felt as if he had pulled a muscle. The right buttock was tender on examination with no erythema or signs of infection. Due to a concern about a possible deep vein thrombosis (DVT), a duplex ultrasonography of the gluteal region was performed and was found to be negative. Serum creatinine phosphokinase (CPK) and myoglobin levels were ordered. CPK and myoglobin labs were significantly elevated (CPK: 3,536 IU/L; myoglobin: 57 μg/L). These symptoms and lab findings led to the diagnosis of rhabdomyolysis (RML). RML is an increasingly recognized and potentially fatal complication in morbidly obese patients who undergo long-duration surgeries.
RML occurs from injury to the skeletal muscle. Subsequent release of myoglobin into the bloodstream can result in serious complications such as acute renal failure, disseminated intravascular coagulation (DIC) and local compartment syndrome.1 RML is believed to occur due to pressure injury to muscle during prolonged procedures. Risk factors include prolonged surgery time, nonphysiologic positioning (supine or lithotomy positions), inadequate padding and inadequate intraoperative hydration.2 Symptoms most commonly include numbness or pain in gluteal, lumbar or lower extremity muscles and/or oliguria.3 RML is diagnosed by elevated CPK levels with a value five times greater than normal (>1,050 IU/L).4 The presence of myoglobinuria, found on examination or from lab reports, is an important supporting factor for the diagnosis of RML. Treatment of RML includes IV hydration, diuresis, alkalinization and correction of electrolyte abnormalities. Treatment for subsequent renal failure, DIC or compartment syndrome includes dialysis, treatment of coagulopathy and decompression.
Attention to postoperative complaints of pain, weakness, neuropathy, dark urine or oliguria should alert clinicians to the possibility of RML. Particularly, one should have increased suspicion in morbidly obese patients, who have a higher risk for developing this complication due to their excess weight.2 Diagnosis by serial serum CPK levels and aggressive therapy, started early, are recommended to prevent the potentially fatal complications of RML.