Office procedures

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Chapter 7 Office procedures

Eric Swisher, Christinne Canela, and Patrice M. Weiss

Introduction

Recent trends in health-care delivery have dramatically increased the frequency of office based surgical procedures. Office procedures have quickly become more accessible and prevalent as technology, physician comfort, and reimbursement have reinforced this paradigm shift. Surgical procedures such as dilation and curettage, hysteroscopy, loop electrosurgical excision procedures, and global endometrial ablation are particularly well suited to an office setting provided the surgeon’s skill set and patient selection are considered. Patient preference, medical history, pain tolerance, anatomy and anxiety among other factors must be evaluated in selecting patients for surgical management in the office. For some patients, the office may provide a more comfortable and less intimidating setting while limiting cost and reducing exposure to hospital acquired infections. Time management, logistics, and administrative burdens may also be more favorable both for patients and providers in the office versus a hospital surgical suite. Despite the migration of some procedures out of a more formal surgical setting, attention to quality of care, physician competency, and patient safety remains paramount and must be equivalent irrespective of the chosen setting.[1]

Several aspects of safe surgical care are universal irrespective of the facility in which such care is delivered. Although not historically implemented in the office environment, credentialing and privileging of providers for surgical procedures should be part of a culture of safety in offices providing invasive care.[1] Although the office setting may allow for less paperwork, a detailed patient history and physical including attention to allergies, medications, bleeding dyscrasias, and surgical risk factors are still required preparations.[1] Informed consent is a universal standard and must not be approached more casually for office based surgical procedures. Consent is a process and requires more than a signed form to ensure the patient is fully prepared for the proposed surgery. The surgeon must ensure that patients are aware of and agree with the procedure, its possible complications, the anticipated level of discomfort, the potential for aborting in medias res, and the option for choosing a hospital or surgery center instead of the office. Though the tenets of care are similar, a patient planning for surgery in the office must understand the limitations and nuances of office care. Ambulatory Care National Patient Safety Goals (NPSG) established by the Joint Commission provides an excellent framework for surgical safety in the office setting. Fundamental elements of the NPSG are patient identification, attention to medication safety, patient history and documentation, a preoperative verification process, and the intraoperative time out.[2] Perioperative patient identification and confirmation of surgical plans should follow well established operating room protocols and practices. A reliable mechanism for specimen management and result tracking must be in place. Checklists are very useful adjuncts to safe patient care, verification of preparation, and compliance with office procedures.[1]

D&C/Hysteroscopy

Hysteroscopy is an outpatient surgical procedure particularly amenable to safe and convenient delivery in the office setting. Such procedures may offer prompt diagnostic, and in some cases, therapeutic benefits such as the identification and removal of endometrial polyps. Patients suspected to have submucosal myomas would typically be less ideal candidates for office surgery unless resection was not intended. Office hysteroscopy also provides the option of transcervical tubal sterilization procedures – currently the Essure®. Dilation and curettage (D&C) for missed abortion is also easily provided in the office. In many practices, office based D&C offers the additional benefit of readily available sonography for guidance of the cannula or curette, which avoids perforation and ensures complete evacuation or lesion retrieval. Global endometrial ablation by several methods lends itself to satisfactory delivery in the office. The authors prefer to pair hysteroscopy with all office endometrial ablations, which may add some degree of safety to the “blind” methods for the global endometrial ablation commonly in use. A sample medication algorithm for hysteroscopy and similar procedures is listed in Table 7-1. A typical equipment list for such procedures follows in Table 7-2.

Table 7-1 Sample medication algorithm
  • PM preop: Cytotec 100 mcg–200 mcg (4–5 PM)

  • 1 hour preop:

Hydrocodone or oxycodone 1–2 tablets PO

Promethazine 25 mg PO or ondansetron 8 mg PO

Ketorolac 60 mg IM

  • Postop:

Ibuprofen or another NSAID

Hydrocodone or oxycodone prn

Table 7-2 Typical equipment list
  • Hysteroscope camera and monitor and fluid/tubing

  • Paracervical block (2 × 10 cc 1% lidocaine)

  • D&C tray (speculum, ring forceps, tenaculum, dilators, curette)

  • Drape

  • Sterile gown and sterile gloves

  • Betadine or hibiclens

  • Large Q-tips

  • 4 × 4 sponges

  • Specimen cup and fixative

  • Endometrial sampling device (curette)

  • Global endometrial ablation equipment if ablation planned

Careful patient selection is prudent, and while postmenopausal and nulliparous patients may be safely evaluated by hysteroscopy in the office, a severely stenotic cervix or highly anxious patient should give the surgeon pause in the planning process. If the patient does not want her case in the office, the surgeon does not want her case in the office. Likewise, morbidly obese patients may be better served with a hospital procedure if medical complications are a concern or hyperflexion of the thighs is required to adequately access the cervix. Patients with cardiac or pulmonary disease and those with a complicated medical history should be carefully considered before offering surgical procedures in the office setting.

In the absence of plans for sedation, patients are not generally nil per os (NPO) and intravenous access is typically optional in most clinical situations. However, patients may be managed with more or less aggressive anesthesia protocols on an individual basis. In these authors’ experience, the “awake” patient may provide some degree of protection against the risk of perforation versus the patient under heavy sedation or general anesthesia where the surgeon’s tactile sense may be the only preventive measure. Pulse oximetry is an excellent monitoring device for instantaneous patient assessment throughout the surgical process. Some offices may utilize an anesthesia provider for sedation, thus making for a more outpatient surgery center experience. This approach is beyond the perspective of this chapter and does require a more rigorous medical screening process and more conservative perioperative management (NPO, IV access, supervised recovery).

Preoperative cervical ripening with misoprostol 12–24 hours prior to transcervical surgery often facilitates or eliminates the cervical dilation portion of the procedure. Patients are dosed with analgesics 30–60 minutes preoperatively. Oral oxycodone or hydrocodone, oral promethazine or ondansetron, and IM ketorolac in our practice are typical, although protocols vary considerably. Anxiolytics may be beneficial in some cases with use tailored to the individual patient. As with any surgical procedure, a time out is completed and the patient’s antiseptic preparation will vary by surgeon preference. We use betadine or chlorhexidine to cleanse the cervix and vagina for hysteroscopy or D&C with drapes limited to either side of the vulva. Some providers may opt to include antiseptic cleansing of the vulva and thighs followed by a more formal draping process, but infection rates are low with either approach. In fact, the rates of infection are so low that many surgeons do not administer prophylactic antibiotics as a routine for office hysteroscopy.[3] Oral doxycycline or clindamycin may be administered if prophylaxis is desired. A cervical or paracervical block is a useful adjuvant, typically using 10 cc–15 cc of 1% xylocaine. While the block is evolving, the previously inspected and assembled surgical instruments are readied for use.

Office dilation and curettage can be very useful for both expedient management and patient convenience. As noted earlier, preoperative cervical ripening with misoprostol the day prior to surgery eases the cervical dilation portion of the procedure. In the case of a missed abortion, this ripening may cause undesirable cramping and bleeding. As previously mentioned, patients’ may be dosed with analgesics 30–60 minutes preoperatively. Oral oxycodone or hydrocodone, oral promethazine or zofran, and IM ketorolac are commonly utilized. Anxiolytics may useful depending upon the patient. The D&C is performed in the usual manner following placement of a paracervical block using 10 cc–15 cc 1% xylocaine. The cervix is secured with a single tooth tenaculum and the os (opening) is dilated if necessary to accommodate a sharp currette or suction cannula. A 6 mm–7 mm suction cannula directed by sonography provides a safe and effective means of accomplishing surgical evacuation of most incomplete or missed abortions while minimizing risk of perforation or retained gestational tissue. Sharp curettage may be similarly utilized though often with greater patient discomfort. Several passes may be required, but the advantage of ultrasound guidance for the procedure is verification of complete evacuation without excessive endometrial trauma or risk of perforation. Perioperative hemorrhage is uncommon, but may be effectively treated with fluid resuscitation and 0.2 mg IM methylergonovine or 400 mcg–800 mcg misoprostol rectally. Intrauterine balloon via Foley or Bakri device may be an effective management of hemorrhage in extreme cases.

For simple diagnostic hysteroscopy, premedication and preparation are completed as previously detailed, and the hysteroscope is readied for insertion by priming the irrigation fluid though the tubing and completing a white balance for the camera. A single tooth tenaculum is placed on the anterior or posterior ectocervix. The cervix is then gently dilated to accommodate the hysteroscope as necessary. Preoperative misoprostol ripening may obviate the need for cervical dilation, especially in the parous patient. In fact, some patients may require use of the tenaculum to buckle the cervix around the hysteroscope to adequately seal the scope for uterine distension. The hysteroscope is advanced into the endometrial cavity under direct and hysteroscopic visualization. The findings may be documented by photography or by videography. Once the procedure is accomplished and the hysteroscope withdrawn, endocervical and endometrial tissue samples for histology may be obtained as clinically indicated. A repeat hysteroscopy may be performed following curettage to confirm adequate sampling of the endometrium or sampling of a particular lesion targeted for the procedure. Upon completion, the tenaculum and speculum are withdrawn and the patient is gradually returned to a supine and then sitting position.

Endometrial ablation

A global endometrial ablation in the office follows a similar preparation and implementation as described for hysteroscopy. If well screened for tolerance, motivation, and medical risk factors, the office ablation can be a very satisfying approach for clinician and patient. Preparing patients emotionally for the experience is critical. Once the patient has been dosed with preoperative narcotic, antiemetic, and NSAID as detailed earlier, the procedure is initiated with visualization of the cervix and paracervical block placement. The cervix is dilated to accommodate the hysteroscope if a cavity assessment was planned prior to the ablation. A preablation and postablation hysteroscopy is helpful in our opinion to evaluate the anatomy, confirm the trajectory for safe entry into the endometrial cavity, verify cavity dimensions, and to confirm a thorough ablative result upon completion. Endometrial sampling is accomplished if not previously performed. The ablation is then completed with the surgeon’s preferred device (balloon, radiofrequency, cryoablation). Due to the potential for vagal hypotension and bradycardia, continuous pulse oximetry is a prudent choice during such a procedure. Such patients may require intramuscular atropine in severe cases.

Hysteroscopic sterilization

Essure and Adiana for tubal sterilization were developed with the expectation of in-office placement for most patients desiring this contraceptive approach. The Adiana is no longer marketed or available, but the Essure is a very effective and well-tolerated office sterilization procedure. It is so well tolerated that in our experience, some may only require a paracervical block in patients motivated to avoid all other perioperative medications for personal reasons. It is a safe and viable option for women who have completed childbearing. Advantages include the ability to safely perform the procedure in the office setting with minimal or no anesthesia, avoidance of intra-abdominal entry, and the avoidance of incisions. Appropriate patient selection and counseling is mandatory prior to the procedure (Table 7-3). Complications of Essure placement include tubal perforation (1%–3% in the Essure clinical trials), improper coil placement (intraperitoneal placement in 0.5%–3% and other improper placements in 0.5%) and expulsion of the occlusion device (in 0.4%–2.2%). A retrospective study of 4, 306 office-based Essure placements demonstrated its efficacy and safety with 98.5% of patients having successful bilateral coil placement and a low overall complication rate of 2.7%, the most common of which was vasovagal syncope.[4, 5] Patients should be counseled on the possibility that bilateral coil placement may not be achievable for each patient, therefore, contingency plans should be reviewed in the event that bilateral placement is not achieved. Known contraindications to the procedure should also be identified prior to the procedure (Table 7-4).[6]