ABSTRACT
Decision-making in surgery is one of the great unspoken challenges, an important but markedly challenging skill that takes a lifetime to master. The choice not to operate generally proves a significantly harder conclusion than opting for intervention. Our paper explores the influences which affect a clinician's decision to operate or not. The challenging situation where patient and clinician disagree on proposed management is also explored. Implications on management are discussed, with constructive communication techniques offered, including the recent COVID-19 pandemic.
ABSTRACT
Clinicians have learnt valuable lessons throughout the COV-SARS-2 pandemic, many of which have produced solutions that we aim to continue to implement within the foreseeable future. Optimising patients' surgical pathways to reduce the length of stay and complications is an area of particular importance, both for maximal utilisation of available resources and for reduction of the exposure of inpatient and elective patients to an increased risk of infection within healthcare facilities. The aim of this review was to investigate the possible implications of using low-pressure laparoscopic gynaecological surgery versus standard- or high-pressure pneumoperitoneum surgeries. The primary outcome was postoperative pain, with secondary outcomes including duration of surgery, length of inpatient stay and rate of complications. MEDLINE, Embase and Cochrane CENTRAL were searched from inception to December 2020. We searched for published randomised control trials comparing low-pressure laparoscopic surgery (≤8 mmHg) to at least one additional standardised pneumoperitoneum pressure (≥12 mmHg and/or ≥15 mmHg). A total of 203 studies were reviewed, five of which were included in this analysis. Studies comparing low-pressure laparoscopic surgery against gasless abdominal cavities were excluded. The meta-analysis of the results was pooled and calculated within RevMan 5.0 software (Cochrane, London, England). Studies using a visual analogue scale (1-10) to compare low versus standard pneumoperitoneum pressures did not display a significant diminution of postoperative pain at ≤ 6 or 24 hours: -0.30 [95% CI -0.63, 0.03] and -0.66 [95% CI -1.35, 0.02], respectively. Studies additionally demonstrated worse visualisation of the surgical field within the low-pressure group (risk ratio 10.31; 95% CI, 1.29-82.38 I2 = 0%). Studies measuring postoperative pain using a numerical rating scale displayed significant pain reduction at all hours measured (p ≤ 0.01). The rate of intraoperative complications was 1% for all groups measured. Cumulative analysis of the duration of surgery did not differ significantly between groups (p = 0.99). The pandemic has revealed new issues that must be addressed by clinicians to promote the safety of patients and the efficiency of inpatient stay. This review has paved the way for new possibilities and innovative approaches to address the issue of optimising patient surgical pathways; however, at present, we cannot give a firm justification for the use of low-pressure gynaecological laparoscopy. Reasons for this include the minimal reduction in pain scores between low, standard and high pneumoperitoneum pressures, leading to a mixture of statistically significant results, as well as a reduction in the visualisation of the surgical field and the small population sizes in the reviewed papers. Additional research is required to further explore the potential clinical benefits of gynaecological laparoscopy to ensure its effective ambulatory use within mainstream surgical operations.