Infection Prevention and Gynecologic Surgery

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Shout out to Taylor DeGiulio for today’s episode idea! We’re doing a pretty close reading of ACOG PB 195 if you want to follow along!

SSI represents the most common complication after GYN surgery, however definitions of this may surprise you. The National Surgical Quality Improvement Program (NSQIP) divides SSI up into three broad categories, with their definitions below:

  1. Superficial incisional: occurs within 30 days of surgery, involving only skin or subcutaneous tissue.

  2. Deep incisional: occurs within 30 days of surgery without an implant, or within 1 year of surgery with an implant, and involves deep soft tissues (rectus muscle, fascia).

  3. Organ space: occurs within 30 days of surgery without an implant, or within 1 year of surgery with an implant, and involves any other area manipulated during operative procedure (i.e., osteomyelitis if bone, endometritis or vaginal cuff for GYN, etc.)

  • In addition to satisfying these time and location definitions, an SSI also must have one of the following characteristics present:

    • Purulent drainage from the area of infection.

    • Spontaneous dehiscence or deliberate opening of a wound by the surgeon, with organisms subsequently obtained from an aseptically collected culture; or not cultured, but the patient displays signs/symptoms) of infection (i.e., fever, localized pain or tenderness, redness, etc.).

    • Abscess or other evidence of infection noted on examination.

    • Diagnosis of infection made by surgeon or attending physician.

In GYN surgery, our threats for infection lie primarily from vaginal organisms or skin organisms; however we may also come into contact with fecal content or enteric contents as well. Thinking about the organisms we’re helping to bolster defense against will help in selecting a preventive antibiotic. Thinking about the wound class is a simple way to characterize this:

ACOG PB 195

ACOG also recommends a number of perioperative considerations/techniques to reduce SSI:

  1. Treat remote infections - this one seems pretty obvious. If there’s an infection going on, like a skin infection or a UTI, it’s likely best to postpone surgery in favor of treating the infection!

  2. Do not shave the incision site - Preoperative shaving by patients themselves has actually been shown to be likely harmful, increasing the risk of infection by introducing a nidus for infection remote from surgery. If hair needs to be clipped, it should be done immediately pre-op with electric clippers.

  3. Prevent preop hyperglycemia - blood glucose should be targeted to < 200 mg/dL for both non-diabetic and diabetic patients before proceeding with surgery. Performing a preoperative random blood sugar prior to major surgery is a practice our hospital has implemented to identify diabetes in our patients, and to prevent SSI.

  4. Advise patients to shower or bathe with full body soap on at least the night before surgery -We found it fairly surprising that no particular soap is recommended over another. Many offices offer patients a chlorhexidine soap for use the night before surgery. The soap significantly reduces risk of cellulitis versus no bathing.

  5. Use alcohol-based preop skin prep, unless contraindicated - chlorhexidine-alcohol combinations have been proven in RCTs and meta-analyses to be superior to povidine-iodine for preoperative skin preparation. For mucosal sites such as the vagina, where high alcohol concentrations should not be used due to irritation risk, povidine-iodine or chlorexidine soap solutions should be used.

  6. Maintain appropriate aseptic technique - Of course, right? But in addition, our surgical technique does matter! Effective hemostasis while preserving vital blood supply, maintaining normothermia and reducing operative time, gentle tissue handling, avoiding inadvertent injuries, using drains when appropriate, and eradicating dead space can all help to reduce risk of SSI.

  7. Minimize OR traffic - safety bundles that have included components to reduce opening of OR doors during cases have been shown to reduce SSI.

  8. For hysterectomy, consider preop screening for bacterial vaginosis - prior to routine use of antibiotic prophylaxis for hysterectomy, use of metronidazole pre-op in patients who screened positive for BV reduced SSI. These studies haven’t been repeated with systematic antibiotic prophylaxis, but given the data, ACOG does state that screening is reasonable at the preop visit.

Alright, now time for the antibiotics! We dive deeper in the podcast, but PB 195 will give you the quick version here in the tables:

ACOG PB 195

ACOG PB 195

The Evidence-Based Cesarean Section

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Today we go through the steps of cesarean delivery from an evidence basis. We hope this helps everyone from the new interns starting up in just a few weeks to senior residents thinking more about their technique and teaching. The essential article on this from AJOG in 2013 can be found here. However, there have been a number of other articles and talks since, including one regularly given at the ACOG Annual Meeting (check out the 2017 edition by Dr. Strand here), that you all may be aware of and that we encourage you to check out.

One of the more challenging things to relay in the podcast is incisional technique, particularly comparing the traditional Pfannenstiel technique to newer techniques such as Joel-Cohen or Misgav-Ladach. We summarize the differences in those techniques here:

(C) CREOGs Over Coffee (2019)

What’s the difference in these skin incisions?

  • Pfannenstiel: traditionally taught as a curved incision made two finger breadths above the symphysis pubis, with the mid portion of the incision generally within the superior-most aspect of the pubic hair.

  • Joel-Cohen: a straight incision made 3cm below the imaginary line that connects the ASIS on either side. Ultimately this is slightly higher than the Pfannenstiel.

  • Maylard: curved incision made 5-8 cm obove the pubic symphysis. The rectus fascia and muscle are cut transversely, and the inferior epigastric arteries must be ligated.

  • Cherney: using the same skin incision as a Pfannenstiel, but then blunt dissection is used to identify the rectus muscle tendons at their insertion to the public symphysis. They are cut 1-2 cm above their insertion point. On closure, the muscles should be reattached to the anterior rectus sheath, as reattaching to the pubic symphysis may serve as a nidus for osteomyelitis.

Uterovaginal Prolapse

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Today we sit down with Dr. Julia Shinnick, one of our co-residents at Brown University and future FPMRS specialist, to talk through prolapse!

The POP-Q tool from AUGS is a helpful web-based tool (also with iPhone/iPad apps!) that can help you understand prolapse, as well as illustrate prolapse to patients in your practice.

One common quiz question are the levels of support. These are:

  • Level I consists of the cardinal and uterosacral ligaments, and suspends the vaginal apex. Uterosacral/cardinal ligament complex, which suspends the uterus and upper vagina to the sacrum and lateral pelvic side wall. In a magnetic resonance imaging (MRI) study of asymptomatic women, the uterosacral ligaments were found to originate on the cervix in 33 percent, cervix and vagina in 63 percent, and vagina alone in 4 percent. Loss of level 1 support contributes to the prolapse of the uterus and/or vaginal apex.

  • Level II consists of the paravaginal attachments, are what create the H shape of the vagina. The anterior vaginal wall is suspended laterally to the arcus tendineus fascia pelvis (ATFP) or “white line,” which is a thickened condensation of fascia overlying the iliococcygeus muscle. The anterior Level II supports suspend the mid-portion of the anterior vaginal wall creating the anterior lateral vaginal sulci. Detachment of these lateral supports can lead to paravaginal defects and prolapse of the anterior vaginal wall. There are also more posterior lateral supports at Level II. The distal half of the posterior vaginal wall fuses with the aponeurosis of the levator ani muscle from the perineal body along a line referred to as the arcus tendineus rectovaginalis. It converges with the ATFP at a point approximately midway between the pubic symphysis and the ischial spine. Along the proximal half of the vagina, the anterior and posterior vaginal walls are both supported laterally to the ATFP. 

  • Level III consists of the perineal body and includes interlacing muscle fibers of the bulbospongiosus, transverse perinei, and external anal sphincter.  Loss of level 3 support can result in a distal rectocele or perineal descent.  

Remember — the treatments are generally conservative with pelvic floor PT; devices, such as pessaries; or surgeries.

Perioperative Care and Optimization for GYN Patients

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Today we’re featuring a special guest on the Podcast! Dr. Lauren Stewart is a current PGY-6 in Female Pelvic Medicine and Reconstructive Surgery here at Brown / Women and Infants. Lauren has special interest in perioperative care strategies in GYN, and has published a two-part series on the subject in “Topics in Obstetrics and Gynecology.”

It is a venti episode - a bit longer, but chock full of useful information!

While we can’t share Lauren’s articles directly due to paywall restrictions, you can find them here if your institution has a subscription: Part 1 and Part 2.

At the beginning of this episode, we discuss a number of systems you can utilize for preoperative evaluation of risk for patients, each with their own sets of pros and cons:
American Society of Anesthesiology (ASA) Physical Status Classification
Revised Cardiac Risk Index (RCRI)
American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator

In addition, ACOG does have some publications that can aide with your perioperative management:
-PB 195 - Preventing Infection after GYN Surgery
-CO 750 - Enhanced Recovery After Surgery (ERAS)
-PB 084 - Prevention of DVT/PE

The Caprini score we talk about in the podcast is a common tool for deciding on perioperative mechanical vs. pharmacological DVT prophylaxis, and is the scale recommended in the 2012 CHEST guidelines for VTE prophylaxis in non-orthopedic surgical patients. MD Calc has an excellent appraisal of the evidence as well as an interactive Caprini calculator for your use.

The Caprini score for VTE prevention in surgical patients

For antibiotic prophylaxis, this table from PB 195 is very handy review for CREOGs:

ACOG PB 195 - for further review of evidence, see full text.