Gynecologic surgery can be very tricky and it’s not uncommon for patients to sustain injury to their upper and lower extremities. While the latter has a higher rate of occurrence, most of these injuries are transient in nature, and they soon get resolved by themselves. Unfortunately, in a few rare cases, the injuries don’t heal and lead to long-time problems.
Types of Gynecological Nerve Injuries
Nerve injuries during gynecologic surgery can be divided into three separate categories, viz. axonotmesis, neurotmesis, and neuropraxia. Axonotmesis occurs due to the severe decompression of axons, and this takes a long time to heal. On the other hand, neuropraxia takes place owing to nerve demyelination at the area of injury from compression and gets resolved within a few weeks to some months. Neurotmesis occurs due to total transaction and is related to poor prognosis minus reparative surgical procedures.
How It Works
Gynecologic surgery takes place vaginally through minimally invasive surgery or laparotomy. Robotic or laproscopic assistance is a must during the process. Each of these surgical processes carries with it a certain type of risk and may cause nerve injury. Stretch and compression injuries usually occur due to the improper or prolonged positioning of the patient, and the placement of the retractor. The occurrence of transaction injuries is rarer. Entrapment injuries, on the other hand, are related to lower loss of functions but the amount of pain sustained is a lot higher.
Below you’ll find a list of things to keep in mind while performing gynecologic surgery to avoid nerve damage.
Tips and Tricks
When the neurosurgeon tucks a patient’s arm to conduct minimally invasive surgery, suitable padding needs to be placed near the wrist and the elbow. Moreover, the arm must be placed in a “thumbs-up” position. The shoulder blocks need to be placed across the patient’s acromioclavicular joint. At the time that a laproscopy is being performed, it is important that the surgeon use the shortest blade to enable sufficient visualization. They need to check the blades at the time of the procedure to make sure additional pressure isn’t applied on the psoas muscle. The pressure exerted on the lateral blades needs to be released at regular intervals in the middle of the procedure. The stirrups must be placed at the same height and it needs to be ensured that the leg remains in line with the contralateral shoulder of the patient. The surgeon should be careful to ensure that the lateral fibula doesn’t touch the stirrup and the padding is placed properly between the stirrup and the fibular head.
Care should be taken to prevent the low transverse incision from extending past the lateral margin of the rectus muscle. Moreover, the facial closure suture should not be more than 1.5 cm from the fascial incision’s lateral edge to prevent catching the nerve in the suture. The surgeon should be extra careful in identifying and sparing the nerve at the time of external iliac node removal or retroperitoneal dissection.
It’s common for nerve injuries to take place during gynecologic surgery, and these are often a major reason behind morbidity in the patient. Though they’re sometimes unavoidable and are a part of the surgical procedure, injury can often be prevented by paying suitable attention and checking the position in which the patient is placed and the use of the retractor. Thus, it’s important for gynecologists to be aware of the risks and have in-depth knowledge about the anatomy. However, if any injury does occur, the surgeon should assure the patient that no damage has occurred and a full recovery is possible.