Evidence-Based Gynecologic Surgery Best Practices: The AHRQ Safety Program

SUMMARY:

The AHRQ, American College of Surgeons and Armstrong Institute at Johns Hopkins have developed a safety program to assess and help incorporate evidence-based practices into surgical care. An evidence review of gynecologic surgery was conducted, supporting the protocol elements in the AHRQ Safety Program that include the following best practices

Preoperative

Patient Education

  • ‘Potential’ association between preoperative patient education and improved outcomes (low level evidence)

Immediate Preoperative

Bowel Prep

  • Minimally invasive gyn surgery
    • Oral mechanical bowel prep should be abandoned (strong level evidence)
  • When bowel prep is desired (patients at high risk such as colorectal resection)
    • Based on colorectal surgery evidence, oral mechanical bowel prep alone is not effective
    • Use one of the following regimens (moderate level evidence)
      • Oral mechanical bowel prep and oral antibiotic
      • Oral antibiotic alone
    • Note: The review states “Data from non-randomized studies suggest that bowel preparation may be omitted within a well-developed ERP (enhanced recovery pathways) that incorporates a SSI reduction bundle even when bowel resection is anticipated”

Intraoperative

Drains

  • Routine nasogastric tube
    • Associated patient discomfort with no known benefit (high level evidence)
  • Routine peritoneal drains
    • Prophylactic use is not beneficial following lympadenectomy for gyn surgery
    • Avoid unless there is a rectal anastomosis within 6 cm of the anal verge and no diversion or patient at high risk for pelvic collections (moderate level evidence)

Postoperative

Early Mobilization

  • Beneficial – avoid prolonged bedrest (moderate level evidence)

Early Alimentation

  • Early oral feeding is safe (high level of evidence)
    • Well tolerated
    • Shorter hospital length of stay
    • Initiate as early as 4 hours following gyn surgery with or without bowel resection

Early Urinary Bladder Catheter Removal

  • Use catheters for <24 hours (moderate level evidence)
    • However, it is appropriate to consider fall risk and necessity of urine output monitoring for some patients
  • Uncomplicated surgeries
    • Removal at 6 hours balances rates of infection vs retention
  • Complicated surgeries (e.g., urogynecologic or gynecologic oncology procedures)
    • Morning after may be more appropriate

Prevention of Ileus and accelerate return of bowel function

  • Standardized use of postoperative laxatives
    • Recommended for gyn surgery (low level evidence)
    • Examples: Senna with docusate | Docusate | Magnesium oxide or magnesium hydroxide | Bisacodyl
  • Chewing gum
    • Recommended for gyn surgery (high level of evidence)
  • Alvimopan (novel peripheral μ-opioid antagonist)
    • May not be beneficial in benign gyn surgery
    • May decrease ileus in ovarian cancer surgery and can be considered for use in patients undergoing bowel resection (moderate level evidence)

Early IV Fluid discontinuation

  • Discontinue maintenance IV fluids within 12 to 24 hours following surgery, especially with early fluid and solid intake (low level of evidence)
    • Urine output as low as 20 mL/hour
      • Recognize as normal perioperative stress response
      • Intervention not required

KEY POINTS:

Other Evidence-Based Perioperative Interventions

  • Surgical site infection bundles (see ‘Related ObG Topics’ below)
    • Use of surgical site infection bundles should be considered (high level evidence)
  • Glucose management
    • Perioperative glucose goal: ≤ 180 mg/dL (10.0 mmol/L) (high level evidence)

Venous Thromboembolism (VTE) Prophylaxis

  • Preoperative
    • Intermittent pneumatic compression alone for (moderate level evidence)
      • Minimally invasive surgery for any indication or
      • Laparotomy for benign disease
    • Add preoperative pharmacologic prophylaxis for patients undergoing laparotomy for gynecologic malignancies
      • Weak level evidence from observational studies but consideration given to high rate of VTE in this population
      • Supported by multiple societies
    • Postoperative
      • Use mechanical prophylaxis for the duration of hospitalization in all gynecologic surgical patients and mechanical and/or pharmacologic prophylaxis for gynecologic oncology surgical patients (high level of evidence)
      • Gyn oncology: Extend VTE chemoprophylaxis for 4 weeks following surgery
        • Supported by multiple guidelines, but further research required on long-term benefits

Learn More – Primary Sources:

Surgical Technical Evidence Review for Gynecologic Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery Related Website link