Optimizing Surgical Outcomes: Intra-Op considerations

This is a pediatric focused summary of the AUA white paper: Optimizing outcomes in urologic surgery — Intraoperative considerations.

Surgical “Time-Out”

The first section of the White paper talks about checklists, which have been shown to reduce mortality and morbidity by improving communication among the surgical team.

 

Surgical Site Infections (SSI)

Following are some recommendations from the American Collegue of Surgeons and the Surgical Infection Society SSI guidelines.

For the surgical prep, the guidelines recommend an alcohol-containing preparation — chlorhexidine or iodine — except for high fire risk or exposed mucosa.

If alcohol-containing preparation cannot be used, they recommend chlorhexidine over iodine.

With regard to antibiotic prophylaxis, the guideline recommends starting the antibiotic before the incision. There is no evidence that continuation of antibiotic prophylaxis beyond incision closure offers any benefit — with a couple non-pediatric urologic exceptions. They recommend stopping all prophylaxis after incision closure which is a departure from earlier guidelines that recommended stopping antibiotics within 24 hrs. Quinolones and Vancomycin need to be administered slowly and thus should be started 1-2 hrs before incision. It is safe to use cephalosporins in patients with reported penicillin allergies.

Something I never heard before is the guideline recommendation to use of triclosan antibacterial suture (i.e. PDS Plus) to close abdominal incisions.

Some recommendations are specific for colorectal cases: changing gloves for closure, new instruments for closure, using a wound-vac instead of staples for closing the wound, and mechanical plus oral antibiotic prep. With regards to pediatric urology, that could apply during bladder reconstruction and colocystoplasty. The guidelines point out that the literature has come full circle back to recommending a combination of mechanical and oral antibiotic preparation for elective colorectal cases.

There is no evidence that early showering –12 hrs after surgery — increases the risk of infection.

MRSA bundles are used to prevent MRSA related SSIs and consists of screening, decolonization, contact precautions in the hospital, and vancomycin-containing antibiotic prophylaxis.

Regarding clothing, the guidelines recommend that scrubs not be worn outside the hospital and that a lab coat is used after a case when talking to the family — mostly out of professionalism.

The White Papers recommends clipping rather than shaving non-scrotal hair and to do it right before surgery. However, for scrotal skin, clipping may cause greater damage to scrotal skin than shaving without preventing SSI.

Fire prevention

With the exception of buccal mucosa harvesting, fire risk is low during pediatric urologic surgery. The White papers recommend 3 things: allow adequate time for alcohol-containing preps to dry (if scrotal hair was prepped with alcohol-containing prep, it can take an hour to dry so don’t use); reholster the cautery in between uses, and watch for light sources when not been used.

Radiation exposure

I found a few things useful here. Although rare in paediatrics, PCNL access aided endoscopically can decrease fluoroscopy time. Having the surgeon control the pedal also decreases radiation time by decreasing communication problems between the surgeon and the tech. For ureteroscopy, imaging might not be necessary at all.

Protecting the surgeon from radiation is also important. Besides the lead apron and thyroid shield,  lead glasses/gloves, dosimeters, and optimization of dose/distance/settings are things that can minimize radiation risk to the surgeon.  The best way to minimize radiation risk is to minimize radiation time.

Optimizing intraoperative physiology

The White paper recommends avoiding an intraoperative blood transfusion if possible given their immunosuppressant effects, which could result in a decrease recurrent-free survival and cancer-specific mortality for some solid organ tumours. Preoperative iron, erythropoietin, normovolemic hemodilution, and use of cell saver are some strategies to decrease the need for transfusion.

Other tidbits

There is evidence to suggest an improved operative time, shorter learning curve, decrease pain and infections with dedicated non-physician operating room teams.

To improve ergonomics, the recommended height of the OR table (height of area being operated upon) is 5 cm under the surgeon’s elbow. Head should be kept straight avoiding this:

Laparoscopic table height should be lower — pubic bone height –to maintain the surgeon’s elbows flexed at 90-120 degrees. Monitors should be aligned with the target organ. The top of the laparoscopic monitor should be at the level of the eyes to promote a “gaze down” approach which has proven benefits. The optimal distance from the head of the surgeon to the monitor is 3-4 feet. The white paper has some very illustrative figures and pictures exemplifying good and bad posture.  Lastly, warm-ups and micro-breaks can be used to prevent muscular injuries.

 

 

Conclusion

The White Paper reviewed is long. Above is a distillation of the information I found most useful to pediatric urologists.

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