Gynecologic Surgery Continues to Evolve

The movement of gynecology cases to same-day surgical spaces is being driven by physicians who want to perform procedures on carefully selected patients in comfortable and safe environments, according to gynecologist James A. Gohar, MD. He’s the owner of Viva Eve, a specialty women’s outpatient surgery practice in Manhattan where he performs office-based surgery.

Dr. Gohar and his partners realized women’s health is often fragmented and not well organized, requiring patients to visit different specialists in several offices during multiple clinic visits. “We thought this provided a great opportunity to set our practice apart through personalized, integrated and high-tech care,” he says.

His team wants to avoid being the jack of all trades and the master of none. “It’s important to have a carefully curated group of services,” says Dr. Gohar. “That requires listening to the science and investing in technology that is connected to enhancing the patient experience and improving clinical outcomes.”

Dr. Gohar and his colleagues perform a wide range of procedures in the office-based setting, including many forms of hysteroscopy and colposcopy, uterine polyp removal and the treatment of Bartholin’s cysts, abscesses and fibroids. He says, “Our guiding principle is to perform minimally invasive procedures that have as little impact on the body as possible by using the right approach for the right patient.”

Hysterectomy is among the most common procedures performed in the U.S., although 20% are in fact unnecessary, according to Dr. Gohar. “That’s a huge percentage if you consider hundreds of thousands are done each year,” he says. “We will of course perform them if there is a real medical indication to do so, but we try to leave it as a last resort as opposed to a first treatment option.”

Scripps Health in San Diego is one of the few programs in the country that performs most hysterectomies on an outpatient basis, according to Bruce Kahn, MD, director of the Scripps Fellowship in Minimally Invasive Gynecologic Surgery. Dr. Kahn performs hysterectomies laparoscopically and with robotic assistance, although he prefers the latter approach because of the 3D visualization and increased maneuverability of instrumentation the technology affords.

Still, according to Dr. Kahn, there’s not a significant difference in being able to perform hysterectomies on an outpatient basis based on surgical technique alone. “We have a dedicated care team that works together to implement enhanced recovery after surgery (ERAS) protocols,” he says. “They’re an integral part of what we do.”

Dr. Kahn says 80% of his patients don’t require narcotics to recover in relative comfort. They receive a combination of the anti-inflammatory celecoxib and acetaminophen before surgery. Anesthesia providers place TAP blocks at the end of procedures to decrease abdominal wall pain and extend analgesic effects beyond discharge. Patients are given discharge instructions to take ibuprofen and acetaminophen — at no more than 4 grams a day — at regular intervals for three days post-op, regardless of the level of discomfort they’re experiencing instead of waiting to treat breakthrough pain.

ERAS protocols have gained momentum in recent years and continue to be adopted in a growing number of service lines. Lisa Chao, MD, an assistant professor of obstetrics and gynecology at UT Southwestern Medical Center in Dallas, says minimally invasive surgical techniques improve the outcomes of gynecologic surgery, especially when they’re combined with ERAS protocols such as opioid-sparing pain control, body temperature management and the monitoring of fluid levels during surgery. “The ERAS concept has been implemented in many surgical subspecialties with positive outcomes. Its application to minimally invasive gynecologic surgery is no different and has been shown to provide high-quality clinical care for patients,” says Dr. Chao, who co-authored a recent review about the benefits of ERAS protocols in the journal Obstetrics and Gynecology Clinics of North America.

“The implementation of ERAS programs in minimally invasive gynecologic surgery results in substantial improvements in clinical outcomes with higher rates of same-day discharge, reduction in postoperative nausea and vomiting, improved patient satisfaction and decreased opioid consumption without an increase in complications, readmissions or healthcare costs,” she adds.

Scripps La Jolla is planning to open a new surgery center in the next couple of years in which a robotic platform will be housed, signaling the health system’s expectation of significant future growth in robotic-assisted gynecologic surgery. Dr. Kahn points out that several companies are developing robotic platforms and says increased competition in the marketplace will make the technology more affordable and accessible to outpatient facilities. 

Dr. Kahn believes moving hysterectomies to the outpatient setting is currently regionalized and based on the willingness of surgeons, care teams and the facilities at which they work to add the cases. He says doing so requires a dedicated team of providers who perform a high volume of cases in order to build successful processes and employ continuous quality improvement practices. 

Dr. Gohar believes this is an exciting time in gynecology during which a lot of evolution is taking place. “The past couple of years have been challenging during the pandemic, but that’s also what’s forced some acceleration in outpatient care,” he says. “There are several factors that have created a more competitive landscape in which patients want more from their physicians and a better overall care experience.” OSM