Robotic surgery led to injury
Dr. Baggish fails to describe the most important variable in preventing major vessel injury: Do not do the wrong procedure! The complications described in the opening case could have been avoided if the surgeon had performed a simple open laparoscopy or mini-laparotomy. How can anybody justify the risks and cost of a robotic approach in a woman with a body mass index of 25 kg/m2?
I am ashamed of colleagues who jump onto the new-technology bandwagon to improve their learning curve or for marketing reasons.
Pablo Pinzon, MD
Oklahoma City, Oklahoma
Dr. Baggish responds Sharp trocars enhance control
Dr. Mann makes a good point. Direction and angle are critical variables in avoiding major vessel injury—but control of the trocar thrust is also an important part of the safety equation. Many of the aortic and iliac injuries I have studied are through-and-through injuries in which the trocar passed through the anterior abdominal wall, peritoneal cavity, and posterior wall, stopped only by the backbone.
Generally speaking, sharp disposable trocars require significantly less force to insert and provide better control for entry, provided the surgeon employs counter-traction and uses the thumb, index finger, and center finger to insert the trocar in the fashion of throwing a dart.1 This approach is safer than the twisting and pushing forces required with optical trocars and dull reusable instruments.
Dr. Pinzon makes a good point. The case I presented did not require a robot—that was the surgeon’s choice. And the decision to insert a trocar several centimeters above the umbilicus in the midline was not one I would have made. The gynecologist also used an 11-inch trocar—a dangerous device, particularly when it is thrust at the wrong angle of entry. However, the great vessel injury in this case had nothing to do with the robot, as the injury occurred before a robot could be deployed.
“DOES MEDIOLATERAL EPISIOTOMY REDUCE THE RISK OF ANAL SPHINCTER INJURY IN OPERATIVE VAGINAL DELIVERY?”
ERROL R. NORWITZ, MD, PHD (EXAMINING THE EVIDENCE; AUGUST 2012)
Is proper episiotomy repair a waning art?
The study that Dr. Norwitz reviewed failed to consider blood loss, postpartum healing, and subsequent dyspareunia when comparing midline and mediolateral episiotomies.1 It also would be of interest to assess long-term outcomes after proper repair of third- and fourth-degree episiotomies.
I believe that declining experience in operative delivery is behind many lasting problems. Is it possible that knowledge of proper repair of third- and fourth-degree episiotomies is being lost, thereby changing these statistics?
L.J. Leeds, MD
“NEW DATA: HIV-INFECTED WOMEN DO NOT HAVE AN ELEVATED RISK OF CERVICAL CANCER”
JANELLE YATES (AUGUST 2012)
Study sheds new light on a long-held misconception
The data highlighted in this article come from an excellent study that has shed more light on the long-held misconception that HIV-infected women have a higher risk of cervical dysplasia and, perhaps, cervical cancer.1 We need multicenter and multinational studies of this kind to settle this issue once and for all. The outcome would be of great significance in terms of reducing health-care costs and unnecessary interventions that many HIV-infected women undergo as a result of frequent Pap testing.
Christopher Enakpene, MD
Brooklyn, New York
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