CHICAGO — Global endometrial ablation can be performed easily and safely in the office as long as physicians are adequately prepared and strictly adhere to protocols, Dr. Ted Anderson said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).
Dr. Anderson and his associates developed a protocol incorporating guidelines for office-based procedures from the American College of Surgeons, American Society of Anesthesiologists (ASA), personal or published accounts, and professional liability insurance providers.
Some of its primary considerations are:
▸ Strict adherence to the indications and contraindications for each technique.
▸ Thorough diagnostic evaluation. Imaging and sampling should be done in advance to avoid surprises and to determine the thickness of the myometrium, a frequently overlooked aspect.
“Doing these procedures in the office is not the place for an atypical patient or an atypical uterus,” he said. “You want a straightforward procedure, don't take risks, and keep in mind that doing this procedure in your office is not just simply changing the place that you're doing it. It's a mentality that you're changing as well. You need to be absolutely comfortable before you move to the office.”
▸ Careful patient selection. Consider American Society of Anesthesiologists class I or II patients only. Avoid patients with comorbid conditions such as asthma, anxiety, obesity, or heart disease which might decompensate in the office.
▸ Consider psychosocial issues. Look for clues during the biopsy for how well the patient might tolerate an in-office procedure. Make sure she has realistic expectations of the procedure and its outcomes.
▸ Anesthesia considerations. Start with full sedation in the operating room (OR) and slowly lessen the anesthesia over time as you become confident in your technique. Operate at this reduced level of anesthesia in the OR before moving the procedure to your office.
“Ultimately, how you may modify the exact nature of the anesthesia will be dictated by your comfort level and the technology you use,” said Dr. Anderson of Vanderbilt University Medical Center, Nashville.
▸ Ergonomic considerations. Reduce the instrumentation in the OR to exactly what you will have available in your office. Ultimately, you want to be performing the procedure in the operating room exactly the way you plan to do it in the office.
▸ Use oral NSAIDs and intravenous ketorolac (Toradol) 30 mg up to an hour before the procedure, and paracervical blocks in all patients.
▸ Patient monitoring. If you're going to use conscious sedation, have someone present with advanced cardiac life support certification or someone who is a certified registered nurse anesthetist. Resuscitation and stabilization equipment should be readily available in the event that the patient decompensates and needs to be stabilized or moved to another facility.
▸ Physician preparation. Have absolute comfort with the technology and technique, and your ability to perform that technique. Written protocols should be in place that detail how and what you are going to do. Regulatory agencies and professional liability carriers will demand them.
The protocol, “Office-based Endometrial Ablation: paradigm for the future,” is available free of charge from CME Outfitters of Rockville, Md., 240–243–1300, www.cmeoutfitters.com