Insertion of devices at 90˚ to the umbilicus is not safe for overweight and obese women

“ANATOMY FOR THE LAPAROSCOPIC SURGEON”
EMAD MIKHAIL, MD; LAUREN SCOTT, MD; STUART HART, MD, MS (SURGICAL TECHNIQUE, APRIL 2014)

Insertion of devices at 90˚ to the umbilicus is not safe for overweight and obese women
I read with interest the article entitled “Anatomy for the laparoscopic surgeon” written by Mikhail and colleagues. Although I have no problem with most of this article, I strongly disagree with the recommendation to insert the Veress needle and/or entry trocar as pictured (FIGURE 3). The article states that a 90˚ angle for insertion of the aforesaid devices is safe and recommended for overweight and obese women. Unfortunately, this is not good advice.

The basis for the authors’ suggestion is an article by Hurd and colleagues,¹ who conducted a retrospective review of computed tomography (CT) in three groups of women based on body mass index. There were 15 women in the nonobese group, 10 in the overweight group, and 10 in the obese group. The researchers state that the umbilicus is caudal to the aortic bifurcation in the overweight and obese groups. Thus, “… a technique in which both the Veress cannula and the primary trocar are placed near 90˚ from the horizontal appears to be appropriate in obese women.”¹

Mikhail and colleagues’ recommendation has appeared in earlier publications, but I doubt the referenced source was actually read in its original form. In their results section, Hurd and colleagues states that three out of 10 women (33%) in both the overweight and obese groups had their umbilicus located at the same level as the aortic bifurcation.¹ The advice to insert needles or trocars at 90˚ angles is based on a total of seven women in each of the overweight and obese groups. This is a pitifully small number of cases to base an important clinical decision, which, if wrong, could lead to a catastrophic injury to the patient.

In addition, Hurd and colleagues omit that, if the aortic bifurcation is above the umbilicus in the seven women cited, and you as the surgeon, aim the Veress needle and trocar at a 90˚ angle, you will be directly over the left common iliac vein.

It is worth noting that the 1992 Hurd article was preceded by a similar study by Hurd and colleagues² in 1991 that was also based on imaging studies and small numbers—with a total of 19 in the over-73-kg group (nine in the overweight group and 10 in the obese group).

By contrast, when Dr. Narendran and I prospectively studied 101 women who underwent laparoscopy with pneumoperitoneum, we performed 654 measurements.³ Our data differed from Hurd and colleagues¹ in several areas but, most critically, we observed that static measurements are deceiving compared with kinetic actuality. Obese women were found to have great elasticity to their anterior abdominal wall, such that when a force (a trocar) is pushed inward, the static measured distance between the anterior abdominal wall and the posterior retroperitoneum diminished significantly. Holding the abdominal wall up with one’s hand did little to alter the aforesaid dynamic.

According to data that I have published about major-vessel injury during laparoscopic operations performed by gynecologists,^4,5 the patient most at risk for injury to the great vessels is the obese woman. Trocar entry at or about 90˚ is the major factor for injury. Venous injuries are worse than arterial injuries; in either case, mortality is about 20%. I am now preparing an updated version of the major vascular injury paper5 that will be based on 60 cases. Unfortunately, the same risk factors remain.

Insertion of needle and trocar devices at 90˚ to the umbilicus is not safe for overweight and obese women and, in fact, is akin to playing Russian roulette.

Michael Baggish, MD
Professor of Obstetrics and Gynecology, University of California–San Francisco; The Women’s Center, St. Helena Hospital, St. Helena, California

References

“THE AFFORDABLE CARE ACT AND CONTRACEPTION—IS IT COVERED OR NOT?”
LUCIA DIVENERE, MA (PRACTICE MANAGEMENT; MAY 2014)

Two key ACA contraceptive controversies
I read with interest this article written by Ms. DiVenere, MA, in the May issue of OBG Management. First let me say, I found it completely politically motivated and, as a result, misleading. I am board certified in both ObGyn and urogynecology and have been practicing for more than 20 years. I agree that contraception access is an essential component to women’s health; however, to this day, I have never witnessed women being denied access to reproductive services, including contraception. But access and complete coverage are two different concepts.

As a successful female surgeon, I find it insulting that my government feels that women cannot be responsible for their own reproductive health without their interference. I particularly take offense to the claim that if a nonprofit corporation does not offer contraceptive coverage based on religious grounds, the “outcome will have a profound affect on women’s health.” On what do you base this claim? Nonprofits like Hobby Lobby, which you used as an example, are not denying coverage of contraception to their employees. Most contraceptives will be covered under their plans. Only the abortifacients are excluded, which make up a small percentage of all contraceptive options.

Like Ms. DiVenere, I am a believer in the provider−patient relationship, but I am more fearful of my government interfering with that relationship (which I witness daily while providing care to my Medicare and Medicaid patients) than my employer (who ironically happens to be a catholic hospital system).

Renee Caputo, MD
Columbus, Ohio

Ms. DiVenere responds:
I very much appreciate Dr. Caputo’s points of view. She puts her finger on two key aspects of the contraceptive coverage controversy. First, are the contraceptives in question—levonorgestrel, ulipristal acetate, the copper IUD, and the levonorgestrel-releasing intrauterine system—abortifacients? Second, are out-of-pocket costs a barrier to contraceptive access?

The October 2014 issue of OBG Management contains an update on the Affordable Care Act (ACA).¹ In that update, I address the abortifacient issue based on ACOG’s medical and scientific findings. I note, among other things, that “although there is no scientific answer as to when life begins, ACOG and the medical community agree that pregnancy begins at implantation.”¹ This contrasts the argument put forth by Hobby Lobby attorneys that pregnancy begins at fertilization. If pregnancy begins at implantation, as ACOG and others contend, then the four contraceptives mentioned are not abortifacients.

The potential connection between access and “complete” coverage, I assume means “free” coverage, is also worthy of further exploration. In 2013, after the ACA mandate went into effect, 24 million more prescriptions for oral contraceptives (OCs) were filled with no copay than in 2012, resulting in $483 million in out-of-pocket savings for OCs. More important than any cost savings to individuals—and mindful that someone’s always picking up the tab—is the public health good of encouraging broader access to contraceptives, measured in fewer unplanned pregnancies, healthier pregnancies, and more.

It’s worth asking Dr. Caputo’s second question: Do deductibles and copays pose an access barrier and, if so, to what degree? Considerable testimony on this and other topics was offered to the Institute of Medicine during its consideration of which services should be included in the women’s preventive services package mandated to be offered without cost-sharing by plans offered on the exchanges. The Guttmacher Institute offered the following data:

Long-acting and permanent methods of birth control, including the IUD, implants, and sterilization, are most effective and cost-effective, but all can entail hundreds of dollars in up-front costs. Cost-sharing can pose a significant barrier to access to these most effective contraceptives.

References

“UPDATE ON OPERATIVE VAGINAL DELIVERY”
ERROL R. NORWITZ, MD, PhD (JUNE 2014)

Believes outlet forceps delivery is sometimes justified
While I found the article “Update on operative vaginal delivery” by Dr. Errol Norwitz very informative, I would like to inject what I hope is a little common sense into the warning to only attempt operative delivery with either forceps or vacuum, never both. 

My objection to this rule is that it ignores those situations where the vacuum is used for a vertex slightly above the perineum, when the head descends easily to the introitus, but, because of caput and molding, cannot be delivered because adequate vacuum cannot be maintained. I believe an outlet forceps delivery in this situation is more justified than a trip to the OR for cesarean delivery. An outlet forceps delivery can resolve the concern about the infant’s health faster than would a cesarean delivery.

E. Darryl Barnes, MD
Richmond, Virginia  

Dr. Norwitz responds:
I’d like to thank Dr. Barnes for his interest and his comments. The decision to perform a forceps delivery after a failed vacuum extraction should be taken with extreme caution. The literature is clear that such deliveries are associated with a high risk of birth injury. While it is true that, in select cases, such an approach may expedite delivery sooner than an emergency cesarean and, as such, could be seen as a reasonable option under the circumstances, this decision may prove difficult to defend should a birth injury result. Might I suggest that providers reach first for the forceps.

Share your thoughts on these letters or another article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“ANATOMY FOR THE LAPAROSCOPIC SURGEON”
EMAD MIKHAIL, MD; LAUREN SCOTT, MD; STUART HART, MD, MS (SURGICAL TECHNIQUE, APRIL 2014)

Insertion of devices at 90˚ to the umbilicus is not safe for overweight and obese women
I read with interest the article entitled “Anatomy for the laparoscopic surgeon” written by Mikhail and colleagues. Although I have no problem with most of this article, I strongly disagree with the recommendation to insert the Veress needle and/or entry trocar as pictured (FIGURE 3). The article states that a 90˚ angle for insertion of the aforesaid devices is safe and recommended for overweight and obese women. Unfortunately, this is not good advice.

The basis for the authors’ suggestion is an article by Hurd and colleagues,¹ who conducted a retrospective review of computed tomography (CT) in three groups of women based on body mass index. There were 15 women in the nonobese group, 10 in the overweight group, and 10 in the obese group. The researchers state that the umbilicus is caudal to the aortic bifurcation in the overweight and obese groups. Thus, “… a technique in which both the Veress cannula and the primary trocar are placed near 90˚ from the horizontal appears to be appropriate in obese women.”¹

Mikhail and colleagues’ recommendation has appeared in earlier publications, but I doubt the referenced source was actually read in its original form. In their results section, Hurd and colleagues states that three out of 10 women (33%) in both the overweight and obese groups had their umbilicus located at the same level as the aortic bifurcation.¹ The advice to insert needles or trocars at 90˚ angles is based on a total of seven women in each of the overweight and obese groups. This is a pitifully small number of cases to base an important clinical decision, which, if wrong, could lead to a catastrophic injury to the patient.

In addition, Hurd and colleagues omit that, if the aortic bifurcation is above the umbilicus in the seven women cited, and you as the surgeon, aim the Veress needle and trocar at a 90˚ angle, you will be directly over the left common iliac vein.

It is worth noting that the 1992 Hurd article was preceded by a similar study by Hurd and colleagues² in 1991 that was also based on imaging studies and small numbers—with a total of 19 in the over-73-kg group (nine in the overweight group and 10 in the obese group).

By contrast, when Dr. Narendran and I prospectively studied 101 women who underwent laparoscopy with pneumoperitoneum, we performed 654 measurements.³ Our data differed from Hurd and colleagues¹ in several areas but, most critically, we observed that static measurements are deceiving compared with kinetic actuality. Obese women were found to have great elasticity to their anterior abdominal wall, such that when a force (a trocar) is pushed inward, the static measured distance between the anterior abdominal wall and the posterior retroperitoneum diminished significantly. Holding the abdominal wall up with one’s hand did little to alter the aforesaid dynamic.

According to data that I have published about major-vessel injury during laparoscopic operations performed by gynecologists,^4,5 the patient most at risk for injury to the great vessels is the obese woman. Trocar entry at or about 90˚ is the major factor for injury. Venous injuries are worse than arterial injuries; in either case, mortality is about 20%. I am now preparing an updated version of the major vascular injury paper5 that will be based on 60 cases. Unfortunately, the same risk factors remain.

Insertion of needle and trocar devices at 90˚ to the umbilicus is not safe for overweight and obese women and, in fact, is akin to playing Russian roulette.

Michael Baggish, MD
Professor of Obstetrics and Gynecology, University of California–San Francisco; The Women’s Center, St. Helena Hospital, St. Helena, California

References

“THE AFFORDABLE CARE ACT AND CONTRACEPTION—IS IT COVERED OR NOT?”
LUCIA DIVENERE, MA (PRACTICE MANAGEMENT; MAY 2014)

Two key ACA contraceptive controversies
I read with interest this article written by Ms. DiVenere, MA, in the May issue of OBG Management. First let me say, I found it completely politically motivated and, as a result, misleading. I am board certified in both ObGyn and urogynecology and have been practicing for more than 20 years. I agree that contraception access is an essential component to women’s health; however, to this day, I have never witnessed women being denied access to reproductive services, including contraception. But access and complete coverage are two different concepts.

As a successful female surgeon, I find it insulting that my government feels that women cannot be responsible for their own reproductive health without their interference. I particularly take offense to the claim that if a nonprofit corporation does not offer contraceptive coverage based on religious grounds, the “outcome will have a profound affect on women’s health.” On what do you base this claim? Nonprofits like Hobby Lobby, which you used as an example, are not denying coverage of contraception to their employees. Most contraceptives will be covered under their plans. Only the abortifacients are excluded, which make up a small percentage of all contraceptive options.

Like Ms. DiVenere, I am a believer in the provider−patient relationship, but I am more fearful of my government interfering with that relationship (which I witness daily while providing care to my Medicare and Medicaid patients) than my employer (who ironically happens to be a catholic hospital system).

Renee Caputo, MD
Columbus, Ohio

Ms. DiVenere responds:
I very much appreciate Dr. Caputo’s points of view. She puts her finger on two key aspects of the contraceptive coverage controversy. First, are the contraceptives in question—levonorgestrel, ulipristal acetate, the copper IUD, and the levonorgestrel-releasing intrauterine system—abortifacients? Second, are out-of-pocket costs a barrier to contraceptive access?

The October 2014 issue of OBG Management contains an update on the Affordable Care Act (ACA).¹ In that update, I address the abortifacient issue based on ACOG’s medical and scientific findings. I note, among other things, that “although there is no scientific answer as to when life begins, ACOG and the medical community agree that pregnancy begins at implantation.”¹ This contrasts the argument put forth by Hobby Lobby attorneys that pregnancy begins at fertilization. If pregnancy begins at implantation, as ACOG and others contend, then the four contraceptives mentioned are not abortifacients.

The potential connection between access and “complete” coverage, I assume means “free” coverage, is also worthy of further exploration. In 2013, after the ACA mandate went into effect, 24 million more prescriptions for oral contraceptives (OCs) were filled with no copay than in 2012, resulting in $483 million in out-of-pocket savings for OCs. More important than any cost savings to individuals—and mindful that someone’s always picking up the tab—is the public health good of encouraging broader access to contraceptives, measured in fewer unplanned pregnancies, healthier pregnancies, and more.

It’s worth asking Dr. Caputo’s second question: Do deductibles and copays pose an access barrier and, if so, to what degree? Considerable testimony on this and other topics was offered to the Institute of Medicine during its consideration of which services should be included in the women’s preventive services package mandated to be offered without cost-sharing by plans offered on the exchanges. The Guttmacher Institute offered the following data:

Long-acting and permanent methods of birth control, including the IUD, implants, and sterilization, are most effective and cost-effective, but all can entail hundreds of dollars in up-front costs. Cost-sharing can pose a significant barrier to access to these most effective contraceptives.

References

“UPDATE ON OPERATIVE VAGINAL DELIVERY”
ERROL R. NORWITZ, MD, PhD (JUNE 2014)

Believes outlet forceps delivery is sometimes justified
While I found the article “Update on operative vaginal delivery” by Dr. Errol Norwitz very informative, I would like to inject what I hope is a little common sense into the warning to only attempt operative delivery with either forceps or vacuum, never both. 

My objection to this rule is that it ignores those situations where the vacuum is used for a vertex slightly above the perineum, when the head descends easily to the introitus, but, because of caput and molding, cannot be delivered because adequate vacuum cannot be maintained. I believe an outlet forceps delivery in this situation is more justified than a trip to the OR for cesarean delivery. An outlet forceps delivery can resolve the concern about the infant’s health faster than would a cesarean delivery.

E. Darryl Barnes, MD
Richmond, Virginia  

Dr. Norwitz responds:
I’d like to thank Dr. Barnes for his interest and his comments. The decision to perform a forceps delivery after a failed vacuum extraction should be taken with extreme caution. The literature is clear that such deliveries are associated with a high risk of birth injury. While it is true that, in select cases, such an approach may expedite delivery sooner than an emergency cesarean and, as such, could be seen as a reasonable option under the circumstances, this decision may prove difficult to defend should a birth injury result. Might I suggest that providers reach first for the forceps.

Share your thoughts on these letters or another article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“ANATOMY FOR THE LAPAROSCOPIC SURGEON”
EMAD MIKHAIL, MD; LAUREN SCOTT, MD; STUART HART, MD, MS (SURGICAL TECHNIQUE, APRIL 2014)

Insertion of devices at 90˚ to the umbilicus is not safe for overweight and obese women
I read with interest the article entitled “Anatomy for the laparoscopic surgeon” written by Mikhail and colleagues. Although I have no problem with most of this article, I strongly disagree with the recommendation to insert the Veress needle and/or entry trocar as pictured (FIGURE 3). The article states that a 90˚ angle for insertion of the aforesaid devices is safe and recommended for overweight and obese women. Unfortunately, this is not good advice.

The basis for the authors’ suggestion is an article by Hurd and colleagues,¹ who conducted a retrospective review of computed tomography (CT) in three groups of women based on body mass index. There were 15 women in the nonobese group, 10 in the overweight group, and 10 in the obese group. The researchers state that the umbilicus is caudal to the aortic bifurcation in the overweight and obese groups. Thus, “… a technique in which both the Veress cannula and the primary trocar are placed near 90˚ from the horizontal appears to be appropriate in obese women.”¹

Mikhail and colleagues’ recommendation has appeared in earlier publications, but I doubt the referenced source was actually read in its original form. In their results section, Hurd and colleagues states that three out of 10 women (33%) in both the overweight and obese groups had their umbilicus located at the same level as the aortic bifurcation.¹ The advice to insert needles or trocars at 90˚ angles is based on a total of seven women in each of the overweight and obese groups. This is a pitifully small number of cases to base an important clinical decision, which, if wrong, could lead to a catastrophic injury to the patient.

In addition, Hurd and colleagues omit that, if the aortic bifurcation is above the umbilicus in the seven women cited, and you as the surgeon, aim the Veress needle and trocar at a 90˚ angle, you will be directly over the left common iliac vein.

It is worth noting that the 1992 Hurd article was preceded by a similar study by Hurd and colleagues² in 1991 that was also based on imaging studies and small numbers—with a total of 19 in the over-73-kg group (nine in the overweight group and 10 in the obese group).

By contrast, when Dr. Narendran and I prospectively studied 101 women who underwent laparoscopy with pneumoperitoneum, we performed 654 measurements.³ Our data differed from Hurd and colleagues¹ in several areas but, most critically, we observed that static measurements are deceiving compared with kinetic actuality. Obese women were found to have great elasticity to their anterior abdominal wall, such that when a force (a trocar) is pushed inward, the static measured distance between the anterior abdominal wall and the posterior retroperitoneum diminished significantly. Holding the abdominal wall up with one’s hand did little to alter the aforesaid dynamic.

According to data that I have published about major-vessel injury during laparoscopic operations performed by gynecologists,^4,5 the patient most at risk for injury to the great vessels is the obese woman. Trocar entry at or about 90˚ is the major factor for injury. Venous injuries are worse than arterial injuries; in either case, mortality is about 20%. I am now preparing an updated version of the major vascular injury paper5 that will be based on 60 cases. Unfortunately, the same risk factors remain.

Insertion of needle and trocar devices at 90˚ to the umbilicus is not safe for overweight and obese women and, in fact, is akin to playing Russian roulette.

Michael Baggish, MD
Professor of Obstetrics and Gynecology, University of California–San Francisco; The Women’s Center, St. Helena Hospital, St. Helena, California

References

“THE AFFORDABLE CARE ACT AND CONTRACEPTION—IS IT COVERED OR NOT?”
LUCIA DIVENERE, MA (PRACTICE MANAGEMENT; MAY 2014)

Two key ACA contraceptive controversies
I read with interest this article written by Ms. DiVenere, MA, in the May issue of OBG Management. First let me say, I found it completely politically motivated and, as a result, misleading. I am board certified in both ObGyn and urogynecology and have been practicing for more than 20 years. I agree that contraception access is an essential component to women’s health; however, to this day, I have never witnessed women being denied access to reproductive services, including contraception. But access and complete coverage are two different concepts.

As a successful female surgeon, I find it insulting that my government feels that women cannot be responsible for their own reproductive health without their interference. I particularly take offense to the claim that if a nonprofit corporation does not offer contraceptive coverage based on religious grounds, the “outcome will have a profound affect on women’s health.” On what do you base this claim? Nonprofits like Hobby Lobby, which you used as an example, are not denying coverage of contraception to their employees. Most contraceptives will be covered under their plans. Only the abortifacients are excluded, which make up a small percentage of all contraceptive options.

Like Ms. DiVenere, I am a believer in the provider−patient relationship, but I am more fearful of my government interfering with that relationship (which I witness daily while providing care to my Medicare and Medicaid patients) than my employer (who ironically happens to be a catholic hospital system).

Renee Caputo, MD
Columbus, Ohio

Ms. DiVenere responds:
I very much appreciate Dr. Caputo’s points of view. She puts her finger on two key aspects of the contraceptive coverage controversy. First, are the contraceptives in question—levonorgestrel, ulipristal acetate, the copper IUD, and the levonorgestrel-releasing intrauterine system—abortifacients? Second, are out-of-pocket costs a barrier to contraceptive access?

The October 2014 issue of OBG Management contains an update on the Affordable Care Act (ACA).¹ In that update, I address the abortifacient issue based on ACOG’s medical and scientific findings. I note, among other things, that “although there is no scientific answer as to when life begins, ACOG and the medical community agree that pregnancy begins at implantation.”¹ This contrasts the argument put forth by Hobby Lobby attorneys that pregnancy begins at fertilization. If pregnancy begins at implantation, as ACOG and others contend, then the four contraceptives mentioned are not abortifacients.

The potential connection between access and “complete” coverage, I assume means “free” coverage, is also worthy of further exploration. In 2013, after the ACA mandate went into effect, 24 million more prescriptions for oral contraceptives (OCs) were filled with no copay than in 2012, resulting in $483 million in out-of-pocket savings for OCs. More important than any cost savings to individuals—and mindful that someone’s always picking up the tab—is the public health good of encouraging broader access to contraceptives, measured in fewer unplanned pregnancies, healthier pregnancies, and more.

It’s worth asking Dr. Caputo’s second question: Do deductibles and copays pose an access barrier and, if so, to what degree? Considerable testimony on this and other topics was offered to the Institute of Medicine during its consideration of which services should be included in the women’s preventive services package mandated to be offered without cost-sharing by plans offered on the exchanges. The Guttmacher Institute offered the following data:

Long-acting and permanent methods of birth control, including the IUD, implants, and sterilization, are most effective and cost-effective, but all can entail hundreds of dollars in up-front costs. Cost-sharing can pose a significant barrier to access to these most effective contraceptives.

References

“UPDATE ON OPERATIVE VAGINAL DELIVERY”
ERROL R. NORWITZ, MD, PhD (JUNE 2014)

Believes outlet forceps delivery is sometimes justified
While I found the article “Update on operative vaginal delivery” by Dr. Errol Norwitz very informative, I would like to inject what I hope is a little common sense into the warning to only attempt operative delivery with either forceps or vacuum, never both. 

My objection to this rule is that it ignores those situations where the vacuum is used for a vertex slightly above the perineum, when the head descends easily to the introitus, but, because of caput and molding, cannot be delivered because adequate vacuum cannot be maintained. I believe an outlet forceps delivery in this situation is more justified than a trip to the OR for cesarean delivery. An outlet forceps delivery can resolve the concern about the infant’s health faster than would a cesarean delivery.

E. Darryl Barnes, MD
Richmond, Virginia  

Dr. Norwitz responds:
I’d like to thank Dr. Barnes for his interest and his comments. The decision to perform a forceps delivery after a failed vacuum extraction should be taken with extreme caution. The literature is clear that such deliveries are associated with a high risk of birth injury. While it is true that, in select cases, such an approach may expedite delivery sooner than an emergency cesarean and, as such, could be seen as a reasonable option under the circumstances, this decision may prove difficult to defend should a birth injury result. Might I suggest that providers reach first for the forceps.

Share your thoughts on these letters or another article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.