Re: Ob: staples at C/S
From: D. Ashley Hill (dahmd@cfl.rr.com)
Sun Jul 30 21:53:01 2006
After I sent my post I recall a couple of times where junior residents
tagged the apex suture and the tip of the hemostat poked into the
ovarian vein, causing both bloodletting and subsequent attending
remorse.
Ashley
At Sun, 30 Jul 2006, Joe wrote:
>
>Ashley: ref tagging of the incision. Always thought that a waste of time
>and effort . Maybe some used for traction. Joe C
>
>D. Ashley Hill wrote:
>> It's fascinating to see the variation in techniques from listmembers.
>>
>> Dr. Potur, why lock the peritoneum? I was taught that locking is for
>> hemostasis., and the peritoneum rarely bleeds. Although I was trained
>> to lock the uterine incision, I stopped doing this about 10 years ago
>> since I suspect it causes tissue necrosis. Since we're on this subject,
>> can anyone offer a coherent explanation for "tagging" the lateral
>> uterine (apex) sutures with hemostats while sewing an exteriorized
>> uterus? Thanks,
>>
>> Ashley
>>
>> At Sun, 30 Jul 2006, =?UTF-8?Q?Bülent_Potur?= wrote:
>>
>>>Dear Doctor Siegel,
>>>I am pleased that my message got a citation. :)
>>>I think we are discussing the closure of the skin, not a whole procedure.
>>>Personally I have been closing all the skins with 00 prolene subcuticular
>>>stitch for the last 5 years. So not one patient had to request me courtously
>>>to do it this way. And believe me, it is a see one do one and teach one
>>>experience. About patient hospitalization: Legally we have to keep them one
>>>week in the hospital after birth or cesarean. The c/s patients usually quit
>>>the hospital on the second or at most third post operative day by signing
>>>their file. They do not have to come back to the hospital for removal of
>>>their sutures. At a village health hearth a nurse cuts one end the suture
>>>and pulls it out from the other end, the whole suture, in all in one step in
>>>a second or two on the seventh postoperative day. It does not ache.
>>>
>>>For listmates who may have noticed my old messages I must confess that I
>>>changed what I said there after I started to use Joel Cohen Incision and
>>>Misgav Ladach Technique. I must also mention Dr. Joane's remarks and last
>>>years trend and recommendations to close parietal peritoneum.
>>>What I do now: Uterus corners no 2 chromic, 1 layer No1 vicryl without
>>>locking, viceral peritoneum 00 continuous locking, parietal peritoneum 00
>>>chromic continous locking, fascia no2 vicryl continuous, skin 00
>>>subcuticular prolene continuous. That's all.
>>>So: Uterus is closed one layer without locking, recti muscles are not
>>>approximated, subcutaneum is not sutured. After Misgav Ladach I do not
>>>remember ever putting a knot for a subcutaneous bleeder. An I never use
>>>cautery in a C/S operation.
>>>Why I started to leave the skin to the nurses ? Well I observed them and I
>>>saw that they do it perfectly well. And they want to do it. If they complain
>>>I may restart any time.
>>>
>>>Bulent Potur MD Obgyn
>>>Kirikkale TURKEY
>>>
>>>2006/7/29, Garry E. Siegel, M.D. <garrys@mindspring.com>:
>>>
>>>>an).
>>>>
>>>>>And no, you wouldn't argue with a "professional" about his job, e.g. the
>>>>>ood
>>>>>was prepared. So does that make you feel like more of a "server" than a
>>>>>"professional?" It should.
>>>>>
>>>>>And therein lies one of the major problems with medicine today. Patient
>>>>
>>>>and
>>>>
>>>>>ge
>>>>>of "client."
>>>>>
>>>>>Joe P.
>>>>
>>>>I explain my experience to patients and they typically understand. I to
>>>>have had my midwives comment on this and have had to explain my way out
>>>>of situations because they have told patients that I do it because it is
>>>>faster. That is true, but not the reason I do it. Bottom line is there
>>>>is no difference in the ultimate outcome so you do what you are most
>>>>comfortable doing, as the surgeon. Can you imagine the cardiovascular
>>>>surgeons response to somebody telling them how to close a chest... Lynn
>>>>
>>>>Bingo, and thanks. I am the patient's (not the husband, thank you
>>>>Bradley method) physician, not their waiter. I have a greater calling
>>>>and responsibility than the waiter, or the plumber, with no disrespect
>>>>to those fine individuals. Obviously, there must be something out there
>>>>in the circles in which these patients travel, and I bet that the time
>>>>factor ("the DOCTOR is in a hurry") may be some part of it.
>>>>
>>>>Dr. Potur's comment regarding courtesy is important, but I contend
>>>>that, at the end of the day, a courteous request to do that which you
>>>>don't think proper (i.e. I want you to use stitches, even though that's
>>>>not what you're good at) is simply foolhardy and so inappropriate.
>>>>
>>>>Yesterday, I did two sections for patients of our CNMs, both of whom
>>>>asked for stitches, and both of whom got staples.
>>>>
>>>>The first, a failed VBAC, when asked why she wanted stitches, said:
>>>>
>>>>"Because staples are so impersonal."
>>>>
>>>>That was a new one.
>>>>
>>>>Garry
>>>>
>>>>That said, I wish that the tile man and the plumber would get finished
>>>>in our bathroom!
>>>>
>>>>--
>>>>Garry E. Siegel, M.D.
>>>>Private Practice
>>>>Roswell, GA
>>>>
>> --
>> D. Ashley Hill, MD
>> Associate Director
>> Department of Obstetrics and Gynecology
>> Florida Hospital Family Practice Residency
>> Medical Director, Loch Haven Ob/Gyn Group
>> Division Director, Dept. of Ob/Gyn, Florida Hospital Orlando
>> Orlando, Florida
>>
--
D. Ashley Hill, MD
Associate Director
Department of Obstetrics and Gynecology
Florida Hospital Family Practice Residency
Medical Director, Loch Haven Ob/Gyn Group
Division Director, Dept. of Ob/Gyn, Florida Hospital Orlando
Orlando, Florida
