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Re: GYN: fibroids/future fertilityFrom: John Robertson M.D. (john.robertson@obgyn.net)Fri Feb 27 15:01:04 1998
At Fri, 27 Feb 1998, Betty Rommel, MD, PhD wrote: > >At Thu, 26 Feb 1998, Garry E. Siegel, M.D. wrote: >> >>Today, she had an irregular fibroid uterus at exam under anesthesia, a >>large (3 or 4 cm) fibroid that filled most of the uterine cavity at >>hysteroscopy, and several large intramural and subserosal fibroids from >>2 to 5 cm distorting the uterus. She had one spot of endo over the >>right ureter on the sidewall, and gelatinous goop reminiscent of old PID >>hanging from both ovaries, which were otherwise ok (no endo). There was >>minimal adhesive disease between the ovaries and the ovarian fossae, >>easily broken up with flipping the ovaries, and one tube easily filled >>and spilled (the right), and the left was occluded distally with >>clubbing. Incidentally, I could see only the left tubal ostium by >>hysteroscope. >> >>So, she needs an open myomectomy, I think, and a goop cleanup at the >>same time, as she wishes pregnancy this summer. What should I do, if >>anything, with the clubbed tube? >> >Why did you waste her time and yours with a diagnostic laparoscopy if >you didn't plan on fixing anything at the time? > >If I were your patient I'd be pretty upset to be told that I have >fibroids, adhsesions, a clubbed tube and endo and that nothing was done >about it. Let's assume you had a surgical complication and the patient >died - in essence, she died for nothing. Maybe surgical procedures >should be done with a little more consideration for treating the >problems that are present. > >-- >Betty Rommel, MD, PhD > Betty, I don't know how it works for Garry, but for me a diagnostic laparoscopic procedure, and a therapeutic open procedure are 2 completely different things. For starters the consent for surgery is different, and converting a procedure into an open case for therapeutic (as apposed to life saving) reasons may well not be part of the consent. A lot of these patients would be very upset to wake up and find they are going to be in hospital for 5 days and off work for 6 weeks as apposed to home in the afternoon and back to work in a few days. A diagnostic procedure is just that, done for diagnosis. It is unlikely that Garry knew exactly what he was going to see before he went in, and as his post suggests, the findings need to be considered prior to planning definitive surgery. Maybe the patient will say "thanks but no thanks" and walk away. Maybe she doesn't want the increased risk of bleeding that the surgery (as proposed by Garry) would entail (increased above the diagnonstic procedure. I'm sure Gary had a talk with this patient prior to the procedure, and the options for management were discussed.
-- J.G.M.Robertson MD, 109-9181 Main St. Chilliwack, B.C. V2P 4M9 (604) 793-9988 e-mail john.robertson@obgyn.net Who is wise and understanding among you? Let him show it by his good life, by deeds done in the humility that comes from wisdom. James 3 vs 13, NIV
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