.png){kind=small}
.png){kind=small}
BackTable / OBGYN / Podcast / Transcript #79
Podcast Transcript: Laparoscopy in Pregnancy: Key Considerations for Surgeons
with Dr. Craig Sobolewski
What surgical techniques and safety measures are important to consider when operating in a pregnant patient? In this episode of the BackTable OBGYN podcast, Dr. Craig Sobolewski, a minimally invasive GYN surgeon at Duke, speaks with host Dr. Mark Hoffman about the intricacies of laparoscopic surgery in pregnant patients. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Pregnancy & Progress: Overcoming Early Boundaries through Laparoscopic Research
(2) Common Surgeries & Surgical Indications for Pregnant Patients
(3) Advanced Laparoscopic Procedures and Techniques in Gynecology
(4) Adapting Laparoscopic Techniques for Pregnancy Physiology
(5) Pregnant vs Non-Pregnant: Navigating Surgical Approaches and Care
(6) Cerclage Procedures and Providing Supportive Patient Counseling
(7) Reflections, Lessons, and Final Thoughts
Listen While You Read
Stay Up To Date
Follow:
Subscribe:
Sign Up:
[Dr. Mark Hoffman]
All right, welcome back to another episode of BackTable OB-GYN. This is Mark Hoffman, your host, and I've got with me a good friend, as we often have on our show, Dr. Craig Sobolewski. Welcome to the show.
[Dr. Craig Sobolewski]
It's great to be here. I really appreciate the invitation, Mark.
[Dr. Mark Hoffman]
It's always a pleasure to get to catch up with you, a friend and mentor, and someone I always-- even though we have a lot of fun and hang out, I always feel like I learn stuff whenever we get to see each other. For our listeners, Dr. Sobolewski is a minimally invasive GYN surgeon at Duke. We still are friends. Kentucky beat Duke this year, so it makes it a little easier for me, but I think you guys have a better team.
[Dr. Craig Sobolewski]
We'll throw some crumbs every now and again.
[Dr. Mark Hoffman]
You've got to give us hope to come back the next time. Assistant professor of OB-GYN, and chief of the Division of Minimally Invasive GYN Surgery, and the Department of OB-GYN at Duke. Is that correct?
[Dr. Craig Sobolewski]
Yes, for almost 25 years now. 24 years, I guess, yes.
[Dr. Mark Hoffman]
Yes, right. You were the first MIG surgeon there, right? You came from Pennsylvania.
[Dr. Craig Sobolewski]
Yes, I'm old, Mark. I did not do a fellowship, although there were a few of those unaccredited one-year things, but I trained in the shadows of Harry Reich. I was up in Allentown, Pennsylvania, which is about an hour outside of Scranton, where Harry was, and a bunch of my attendings and faculty and mentors knew him personally. He would let anybody who wanted to come into the OR with him.
[Dr. Mark Hoffman]
Is that where his practice was?
[Dr. Craig Sobolewski]
Yes, it was. Yes, private practice up in Scranton, PA, in Wilkes-Barre, Scranton area. The faculty, Larry Glazerman, Mike Patriarco at my institution, got the itch and were early adopters. We were a small program and a ton of surgical experience. These were the days where industry was very interested in helping to facilitate the adoption. There were some training facilities that we used to get to go to one or two times every year and do pig labs, cadaver labs, that sort of thing. I grew up making stuff up as we went along, and grandfathered in, which I used to say now that I'm a grandfather, I guess I really am a grandfathered in.
[Dr. Mark Hoffman]
Yes, good. It's good to get some anecdotal evidence to go with the clinical evidence we see. You gave us a little bit of background. That's what we like to start our shows with, let our listeners learn about how you are. Then you went to Duke 25 years ago. They just picked up the phone and said, "Hey, we need somebody?" What was the story there?
[Dr. Craig Sobolewski]
Yes. I was a residency program director for several years at Lehigh, and realized early on that we needed to figure out ways to do laparoscopic training in safe ways that were motivational and fun. Created a lot of low-fidelity, hands-on training exercises that would culminate at the end of the year in a laparoscopic Olympics, where each class would compete against each other, full-on opening ceremony, the whole shebang, crowning of the victors at the end, that sort of thing. I used to take my kids' toys, I distinctly remember taking a Hercules figure or something, and they had to suture his leg down.
It was the Lilliputian ligature was the name of the exercise, and stuff like that.
Then some of the things we did, we actually monitored and did some pretty simple studies of intervention versus no intervention, and then presented a lot of it at CREOG APGO. My chair, Haywood Brown, here at Duke, when he came here, realized that there was a need, and he knew me through the program directorship, because he was a program director before he came here. That's how I got the phone call.
[Dr. Mark Hoffman]
How long? Because John Steege was at Duke, right, initially, before he went to the UNC?
[Dr. Craig Sobolewski]
Yes, before I got here, John was here. Who else was here? Cap Arthur Haney was here.
[Dr. Mark Hoffman]
He was my chair at the University of Chicago.
[Dr. Craig Sobolewski]
Yes. I knew that you were there.
[Dr. Mark Hoffman]
He retired as chair, and then became chair, so he's collecting two paychecks, I think.
[Dr. Craig Sobolewski]
Yes. He was leaving just as I was coming.
[Dr. Mark Hoffman]
I think your chair was my chair when I interviewed for residency there. I remember I had a really good meeting with him. He's a really amazing guy, Haywood. A really interesting guy. Good. You worked with a couple of good friends, too, especially Arleen, who trained me, is someone who I always like to give credit to whenever I have a chance, and she's one of the best. You've got a good group down there, lucky Fellows.
[Dr. Craig Sobolewski]
New fellowship, yes. Arleen Song is here, and Amy Broach from University of Pittsburgh. It's just our second year.
[Dr. Mark Hoffman]
Do you have a first and second-year fellow, or are you just doing one or the other?
[Dr. Craig Sobolewski]
We started with one, and then we just matched our first fellow. Our first fellow was an internal candidate outside of the match, and then we matched what we think is going to be a great fellow for next year. Then, after this year, we'll have one every year.
[Dr. Mark Hoffman]
That's great. It's a lot of work. You mentioned the one-year apprentices. Even when I was applying 15 years ago, there were 20, I think, programs, and 10 were 1-year.
[Dr. Craig Sobolewski]
It's remarkable what's happened, yes.
[Dr. Mark Hoffman]
As you know, my career took a little bit of a left turn, but it was the time where I was like, "Well--" I have a partner now, and we have enough of us doing this. We could probably think about a fellowship, but the requirements now to get a fellowship before was like, "Who wants to come work with me?" Now, it really is. It's a rigorous application process, and you and many others have done a ton of work to really build it up. It was like, "Oh, man, all this stuff I got to do to have a fellowship." Then I got to apply for my current position, and that blew that candle out for at least the time being. It is a lot of work, and it's a great program. You guys have an awesome, awesome, awesome group of faculty, for sure.
[Dr. Craig Sobolewski]
Yes, I feel very blessed, for sure. I know your institution feels blessed to have you in your new role there.
[Dr. Mark Hoffman]
They are extremely lucky, for sure.
[Dr. Craig Sobolewski]
[laughs] They are. Absolutely.
(1) Pregnancy & Progress: Overcoming Early Boundaries through Laparoscopic Research
[Dr. Mark Hoffman]
It's a fun time to be a part of. There's a lot happening where we are, so I'm excited. I know we had Jamal on recently talking a little bit about robotics specifically in pregnancy, but you had given a talk at AGL, and I was really excited to have you come chat with us about laparoscopy and pregnant patients and physiologic differences and those kinds of things. I wanted to hear a little bit about how you got interested in that, and where all that came out of.
[Dr. Craig Sobolewski]
Yes, thanks. I think it's something that we all needed to, at some point in our careers, whether we're a generalist or a specialist or subspecialist, have some experience with and have to think about. What's really been interesting over a long career is what at one point was pretty avant-garde is now considered routine, and that's just the evolution of life and certainly the evolution of medicine. I think that we really used to have to be very thoughtful about who were appropriate patients to consider this approach in and who were not.
Interestingly, when I came here in the early 2000s, general surgeon Steve Eubanks was the division director for the MIS portion of the general surgery department here at Duke. If you look at publications on the effects of pneumoperitoneum on pregnant fetuses, he did a lot of that work. Here at Duke, there's a big vivarium. He did pregnant use, so pregnant sheep studies, looking at the effects of pneumoperitoneum and safety. A lot of the groundbreaking research was laparotomy on a pregnant sheep, invasive monitoring of both mother and fetus, close the sheep back up, do pneumoperitoneum for an hour, monitor PO2, PCO2, uterine blood flow, those kinds of things.
Thankfully, to pioneers like him and others, we've learned a lot, and we know that done properly, it's incredibly safe. All of the standard advantages of laparoscopy that we talk to all of our patients about certainly pertain to pregnant patients, and in many ways are even more important, like lower risk for VTE, for example, things like that. Yes, it was pretty interesting to meet him and hear about the work that he was doing when I first got here.
[Dr. Mark Hoffman]
It's incredible to think about being a physician and scientist like that. Again, I know there's a lot of folks doing research out there, but so much about academic medicine these days. In many places, it's productivity. It's really, you have to decide clinical practice or focus on research. There's so many hours in the day, and to think about some of these guys that were doing, I'm sure he was a busy surgeon. Then in his spare time operating on sheep, it just seems--
Yes, it is. It is an amazing testament to the guys who were able to do these things so long ago, it wasn't that long ago, I guess, that allowed us to do these things that you said. You said we take it for granted. Oh, yes, well, obviously, laparoscopy is the right thing to do in these situations, but there were times-- I talked to Arnie about this. I heard all the stories in Michigan, and it was like malpractice, we'll call them peer review if you consider doing these crazy things. To be a pioneer, it takes guts.
[Dr. Craig Sobolewski]
Yes, definitely need some cowboys out there, for sure. He did that. I think at first, I was like, "Well, gosh, you're a general surgeon. Why are you interested in this?" The reality is the overwhelming majority of abdominal surgeries on pregnant patients are done for non-gynecologic indications. The majority of them are acute appendicitis or acute cholecystitis. In retrospect, it made perfect sense that he was interested in doing that research at that time, but it seemed a little bit unusual for a non-gynecologic, non-OB-GYN to be doing a lot of that work.
(2) Common Surgeries & Surgical Indications for Pregnant Patients
[Dr. Mark Hoffman]
No, it's important work, though. That's right. We think about-- I haven't done many surgeries on pregnant patients, so there's a few things we can get into in a little bit. As a resident managing pregnant patients who ultimately had surgical issues, it was almost never a gynecologic indication per se. What are the most common surgeries? You mentioned appendicitis, cholecystitis. Talk to us about-- I don't know what you know. I don't know if that's part of your talk or not, but thinking about how those present in patients that are pregnant and how differently they present. I know it can be a little trickier.
[Dr. Craig Sobolewski]
It wasn't much of it. It really wasn't part of the focus of the presentation, but I think that, and we should all know this as obstetricians, the classic teaching about appendicitis in pregnancy is that the location of the appendix obviously changes with the gravid uterus, and so the classic signs may not all be obvious. You might not have pain in McBurney's point. You might not have a positive psoas sign depending on the gestational age of the patient. Abdominal pain, weight count, think appendicitis.
[Dr. Mark Hoffman]
I know that I remember the patient from residency that we watched, and I was like, no one watched too long, it definitely looks a little different.
[Dr. Craig Sobolewski]
It's interesting now, because since COVID, they don't do that many appendectomies anymore. They all just get antibiotics and watched, or not all of them, obviously, but so many more than what I remember to be the case.
[Dr. Mark Hoffman]
No, they medically manage a lot of them. I feel like maybe the pendulum's starting to swing back a little bit because there's something they watch and maybe it didn't go great, and it's like, if it ruptures, it's a lot worse than [crosstalk].
[Dr. Craig Sobolewski]
You would think, wouldn't you?
[Dr. Mark Hoffman]
Yes. This is anecdotal from what I'm seeing, but it seems like maybe the pendulum's swinging the other way, but that's always how it works. Talk about the most common GYN indications, like why are we operating on pregnant patients?
[Dr. Craig Sobolewski]
The obvious, well, perhaps not obvious, but the most common indications from a gynecologic perspective, they're going to be symptomatic ovarian cysts and torsion. Most other gynecologic indications for at least elective surgical intervention are things that we would typically watch during pregnancy. Fibroids, endometriosis, the kinds of common, benign, surgically-treated gynecologic entities are not something that we're going to deal with during pregnancy and can safely wait until afterwards. Symptomatic cysts, and the key word there should be symptomatic, and then if there's any concern about torsion.
[Dr. Mark Hoffman]
Talk to me about symptomatic cysts. I think a lot of times we see them, and they're like, okay, they're there, but what are ones besides torsion that would make you consider surgery?
[Dr. Craig Sobolewski]
I think it would need to be a hard push. Patient is really significantly disabled by pain and discomfort. The cyst that's incidentally noted at the time of a dating ultrasound or that sort of thing should not be operated on. It might be appropriate to follow it, and if it's enlarging and still asymptomatic and has otherwise benign features, I think those are the ones that you sit on unless there's substantial worsening of the patient's quality of life. It still surprises me, but the classic data and teaching is that 5% of these could be malignant, which just seems so shocking to me. That seems like such a high number.
[Dr. Mark Hoffman]
5% of all cysts in pregnancy, or just in general?
[Dr. Craig Sobolewski]
Adnexal cysts in pregnancy.
[Dr. Mark Hoffman]
What makes them different in pregnancy? We think about-- simple cysts, are we including those, or complex, or is it just old hummers?
[Dr. Craig Sobolewski]
I can't answer the question, Mark. I think it's likely a combination of the fact that they are persistent, as opposed-- if you just look at the denominator, the denominators are going to be substantially different, all of the women who are not pregnant versus a subset of women who are. Of all of the cysts in non-pregnant patients, the majority of them are going to be functional or physiologic and go away, and so of those in pregnancy that persist over a smaller diameter, I think it just changes the percentage.
[Dr. Mark Hoffman]
Most cysts that we're seeing in non-pregnant patients are related to the cycle. Ovulatory, hemorrhagic cysts, all those things are things that result from processes that are-- we see in non-pregnant, cyclic patients, so that's interesting.
[Dr. Craig Sobolewski]
Yes.
[Dr. Mark Hoffman]
No, I like that. Okay, so we're eliminating–
[Dr. Craig Sobolewski]
Hey, that's just conjecture.
[Dr. Mark Hoffman]
Yes. Hey, listen–
[Dr. Craig Sobolewski]
It makes sense to me. [laughs]
[Dr. Mark Hoffman]
It's where research comes from. Oh, yes, I've solved a million problems in my brain. Don't worry. We don't need research.
[Dr. Craig Sobolewski]
That's right.
(3) Advanced Laparoscopic Procedures and Techniques in Gynecology
[Dr. Mark Hoffman]
It makes sense. It's got a pathologic or a physiologic plausible pathway. There's certain things we just don't know, but that makes sense.
[Dr. Craig Sobolewski] Those are the biggest gynecologic-- Although nowadays, as a laparoscopic surgeon, and I know there's a lot of presentations about this over the more recent years at meetings like AHL, are laparoscopically performed abdominal cerclage in pregnant and non-pregnant patients, but in pregnant patients, too.
[Dr. Mark Hoffman]
Are you doing a bunch of those?
[Dr. Craig Sobolewski]
I don't know. Define a bunch. We do–
[Dr. Mark Hoffman]
Even more than zero? [laughs]
[Dr. Craig Sobolewski]
Yes, more than zero is for sure. We have a prematurity prevention center here at Duke, and so patients from the surrounding catchment area come to us. One of the more common reasons that they're seen here in that clinic, there's a variety of things, obviously, but one of them is cervical incompetence. Ideally, those patients are seen in clinic when they're not pregnant, and then they get a nice, easy, simple laparoscopic abdominal cerclage if they've failed a previous vaginal attempt.
[Dr. Mark Hoffman]
That was Cap Haney's big thing. I don't know. I guess if he was doing those at Duke or not, but when he was at the University of Chicago, that was his-- he lined them up. That's all he really did. We've talked about this on the show a number of times, but the beautiful mini-laparotomy he would do. God, it was like 2 centimeters, and you'd see these incisions, you're like, "There's no way-
[Dr. Craig Sobolewski]
That's fascinating.
[Dr. Mark Hoffman]
-we're doing." He would do no bladder flap. We'd put a figure of eight in the fundus of the uterus, pull it up, and he'd have the blunt needle. He'd always scare a medical student, and–
[Dr. Craig Sobolewski]
Oh, and the Mersilene tape, blunt needle tape.
[Dr. Mark Hoffman]
Mersilene tape, tie down the knot with silk stitches, but it was get in, get out, get in, get out. We weren't throwing the cerclage stitch, but we were getting in, getting out with a mini-lap. It became one of the most valuable incisions, now that with more, especially with morcellation, love a good mini-lap. That was something that he-- I think he had developed at Duke, and when he came to Chicago, that was the big thing he did there. I wasn't sure if there was any carryover people he'd trained, or if he took it with him, or what.
[Dr. Craig Sobolewski]
Not that he trained, but Haywood Brown did abdominal cerclages. Dr. Brown is a maternal-fetal medicine, and he was the abdominal cerclage person. In fact, we do all of our cerclages, standard laparoscopic straight stick, but the very first one that I did, I did robotically, and Dr. Brown came into the OR-
[Dr. Mark Hoffman]
Oh, that's pretty cool.
[Dr. Craig Sobolewski]
-and sat in there, and was just harassing me the entire time while I was doing the procedure. That's probably why I don't do it robotically anymore. I just have PTSD from that experience. [laughs]
[Dr. Mark Hoffman]
Do you do a bladder flap or anything, or just feed it on uterines and tie it down?
[Dr. Craig Sobolewski]
Amy Broach really has spearheaded this in our division, and she has developed this pretty slick technique. I suspect that we do some things probably uniquely different than some other places. One is that we use just the cup, a colpotomy cup-- a colpotomizer cup. We just use the cup to delineate the apical vagina, the vaginal fornix. We take some ring forceps, put them on a colpotomy ring, the 4-centimeter one, the large one, and we just have somebody down below just pushing up on the vaginal apex. It really helps to make sure that we're putting the stitch at the true internal loss instead of just guessing.
[Dr. Mark Hoffman]
Oh, that's great. I use a curved baby needle driver on the cup. Gives you a little bit of an angle to push up, but yes, same idea. When I'm doing a trachelectomy or something, where they don't have a manipulator attached. Yes, it's a great technique.
[Dr. Craig Sobolewski]
Yes, we do that for the cerclages. Then she developed a technique where we actually make a fenestration in both the posterior and anterior leaf of the broad ligament. We put our needle driver below the round through that space to throw our stitches from posterior to anterior. The angle that you get from that is so nice. It's so perfectly aligned. We do it for all of them, but especially for the pregnant uterus, where sometimes trying to see that space or feel comfortable that you're putting your suture in the appropriate position, not having the visualization that you can get because you can't see there because the broad is intact. It's a little tricky, I think, probably to envision what we're talking about.
[Dr. Mark Hoffman]
You make a window in the broad so you can see through it?
[Dr. Craig Sobolewski]
Yes.
[Dr. Mark Hoffman]
Do you close it back up?
[Dr. Craig Sobolewski]
Yes, we do. Just a barbed suture. We do make a bladder flap, and we tie the knot down anteriorly. We don't suture it down like I used to back in the day, like you said that Dr. Haney did. Every time we throw the stitch, Amy always jokes that she gets another gray hair because in those pregnant patients, it is still, you got to hold your breath when you're doing it.
[Dr. Mark Hoffman]
Dr. Haney, I've never seen a man sweat like I saw somebody sweat when he would do those cases in the pregnant patients. He's like, "Turn the heat down."
[laughter]
(4) Adapting Laparoscopic Techniques for Pregnancy Physiology
[Dr. Mark Hoffman]
Not sure it was a sterile field the amount of sweating he was doing. No, those were the toughest ones, for sure. We weren't doing those through mini-laps. This is definitely a bigger incision for those cases. That's ones where I think going back to you're talking operating on pregnant patients, that's the ones where I think laparoscopy would provide a massive benefit compared to open. You're really seeing things in ways you just couldn't before.
[Dr. Craig Sobolewski]
No question. Yes. I couldn't agree more. Those are things we can if you'd like to get back to the physiology piece of things because, ideally, there is definitely a sweet spot when you're thinking about doing these operations in pregnancy. That early second trimester is really ideal because it's scary to be touching the uterus, that you can imagine something's kicking back at you when you're in there. What's important to remember about the gravid uterus is that as it gets bigger in the supine position, it's going to cause venous compression on the vena cava. One of the things that we do in that case and others is routinely, we'll tilt the table in a left lateral position. We'll have anesthesia airplane the table.
[Dr. Mark Hoffman]
Certain number of degrees are just enough.
[Dr. Craig Sobolewski]
Yes, 11 degrees. No, just enough.
[Dr. Mark Hoffman]
Now that everybody's iPhone-
[Dr. Craig Sobolewski]
Can do that, yes.
[Dr. Mark Hoffman]
-is a level, you can tell exactly how much.
[Dr. Craig Sobolewski]
Yes, just enough. As a former obstetrician many, many years ago, it was always tilt them to the left. I'll put a pillow under them so that they're tilted to the left, because it does. It gets the uterus a little bit more easily off of the vena cava. The same thing happens if you tilt them to the right. If we're putting the suture in on the right side of the patient, we'll tilt the patient to her left if we're doing-
[Dr. Mark Hoffman]
Oh, that's interesting.
[Dr. Craig Sobolewski]
-it on the other side, then we airplane the table the other way. Whatever you can do because-- The residents hear me say this all the time, there's only two things that you have to do to be a good surgeon. It's, you have to know anatomy, so you have to have the knowledge of anatomy and you have to have exposure. If you have one without the other, you are up the proverbial creek.
If you know what you need to see, but you can't figure out a way to see it, you can't progress the surgery forward. In these patients, there's a liver retractor that we use, which is a 5-millimeter long snake-like device that as you turn it, it shapes itself into almost like a curved metal triangle. It's got a big space in the center of it. We can put that underneath the uterus and scoop it up a little bit and still only have a small surface area that's in contact with the uterus. We'll use that liver retractor.
[Dr. Mark Hoffman]
Are you doing that for most of these cerclages?
[Dr. Craig Sobolewski]
Yes. I would use it. If I had a big dermoid or something, it was stuck down there posteriorly, and I was trying to get it elevated up out of the pelvis and I couldn't. I thought that'd be the first instrument I'd call for to nudge that uterus over a little bit, just to create a little bit more room or space if I had to.
[Dr. Mark Hoffman]
Is it disposable or, I guess [crosstalk]?
[Dr. Craig Sobolewski]
No, it's reusable.
[Dr. Mark Hoffman]
Is it?
[Dr. Craig Sobolewski]
Yes, it's reusable 5-millimeter liver retractor. I suspect they're in every OR.
[Dr. Mark Hoffman]
Oh, very cool.
[Dr. Craig Sobolewski]
There are those hemodynamic changes that are important to at least think about.
[Dr. Mark Hoffman]
Does the T-burg help with the fetus congestion, gravity, maybe giving you a little bit of a lift, or how does the Trendelenburg impact physiology and patient in pregnant patients?
[Dr. Craig Sobolewski]
Mostly the effects of Trendelenburg are negative, and it's on pulmonary function. Basically, it's going to decrease the respiratory compliance, decrease functional residual capacity, decrease overall pulmonary dead space. Just pregnancy itself, the diaphragm raises, but by the end of gestation, the diaphragm will elevate by about 4 centimeters. Already, there's less volume available in the chest, and that's just in the standard resting position. Then once you put them in Trendelenburg, now you've got a pressurized abdomen in T-burg, and that's going to further affect pulmonary compliance.
[Dr. Mark Hoffman]
I'm having Cryog flashbacks here. Yes, no, that's right, all these things. I knew once when I was providing obstetric care. That's interesting.
[Dr. Craig Sobolewski]
Yes. Physiology of pregnancy is really fascinating because the way that the body has to compensate for all of these things is really pretty interesting. The rib cage gets bigger. Even though the diaphragm goes up, the rib cage gets bigger. Your tidal volumes will go up, but because these other pulmonary functions decrease, patients will respond.
Essentially you get a respiratory alkalosis because of the physiology of pregnancy. The way that the pregnant patient compensates for that is by increased minute ventilation. I know you're a father. I know that you had a wife who's been pregnant, and by the end of their pregnancy, their minute ventilation is up there, man. They're huffing and puffing just so that they don't get too alkalotic.
[Dr. Mark Hoffman]
It's an incredible-- it is. I think a lot of us GYN surgeons, what's unique about us as surgeons, we didn't just train as surgeons. We trained as obstetricians as well. It's one of those things-- Most of residency is OB for a lot of us. Giving it up is something that-- you probably gave it up after a longer period of time than me, but I do remember what it's like. I just want GYN-only job. Then I did OB for a few years, and I remember my chair saying, "I think it's time for you to stop doing OB." I was like, "Oh, man." It felt like a bit of a loss, honestly.
[Dr. Craig Sobolewski]
Yes. Maybe.
[laughter]
[Dr. Mark Hoffman]
I got over it pretty quick.
[laughter]
[Dr. Mark Hoffman]
That's interesting. No, those are the kinds of things I would imagine that make you want to be a little bit more efficient in the OR. Having a plan, all those things, these are not great positions for pregnant patients to be in.
[Dr. Craig Sobolewski]
Yes. The work, honestly, falls all on our anesthesia colleagues because they're the ones that have to understand that physiology and make the appropriate changes in the vent settings in order to compensate for that. The pulmonary function part, we need to be good colleagues and make sure that we're operating on the lowest bias, so no more than 15 millimeters of mercury. If you can see as well as you need to at 12, that's probably going to make our anesthesia friends a little nicer when you're having a cup of coffee at the end of the case.
[Dr. Mark Hoffman]
Are you actively trying to minimize the pressure, or is it only if they're complaining across the drape?
[Dr. Craig Sobolewski]
We'll start at 15 to get in. It just depends. First of all, any entry technique that you're comfortable using is safe in pregnancy. You clearly need to understand that you might need to think of an alternate site. If you normally go in with a Veress at the umbo, you might want to reconsider that if your patient's 16 weeks pregnant or something like that. They've all been described in literature, they've all been demonstrated to be safe. Whether it's Veress, followed by a trocar, whether it's optical trocar without a Veress, whether it's openness on, they're all perfectly safe.
[Dr. Mark Hoffman]
What's your technique?
[Dr. Craig Sobolewski]
We'll universally go in left upper quadrant at Palmer's point. I typically go in Veress up there, followed by an optical trocar, but I don't know, depending on my mood, sometimes I'll just go direct optical. Then, we'll get in at 15 just to do our initial survey, and then we'll decrease it a bit. If we can still see sufficiently well, then we just stay there. I will say that for our pregnancy cerclages, we almost always just keep it at 15 just because the view is already so obscured by the size of the uterus because they're never early second trimester. They're always right around 14, 15 weeks, and that's a challenge.
I think it's not a bad idea to try to operate on. If your standard is 15, if you can get by with a little bit lower, that's probably in your patient's best interest, and certainly makes life a little bit easier for anesthesia.
[Dr. Mark Hoffman]
What are most of what you're operating on? Is it typically torsion, or is it more big cysts or is it a combo?
[Dr. Craig Sobolewski]
No, honestly, the majority of them are abdominal cerclages. If it's a torsion, it's likely going to be whoever's on call for us at Duke. If it's an emergent situation, our faculty, whatever, the subspecialty typically can handle that. Now, if it's something particularly unique about the patient, we may get called in, but most of the time those are just going to be handled by whichever providers on call at that particular site. If it's a little bit more elective, worsening pain, dermoid, not torsed, then those patients will get referred to us, and we'll take care of them expeditiously, but not emergently.
[Dr. Mark Hoffman]
Cystectomies with torsion or not when you're dealing with torsion?
[Dr. Craig Sobolewski]
I think as best we can, we should manage these patients in the way that's most appropriate whether they're pregnant or not. If we can safely perform a cystectomy, then I think that we should do that. I think that's just good medical care and good advice generally. I don't think I would criticize somebody who-- if it was a generalist and they were nervous and they didn't feel super comfortable and they decided to do an oophorectomy for a torsion, I think that that's fine. I think, in general, just because they're pregnant, we should not take shortcuts if we can avoid it.
(5) Pregnant vs Non-Pregnant: Navigating Surgical Approaches and Care
[Dr. Mark Hoffman]
Yes. Talk to me about energy in pregnant patients. Do you think much about that? Does it matter, or is it–
[Dr. Craig Sobolewski]
I don't think it should matter. I think you have to be careful to understand things like direct coupling and ways that if-- I like to operate in the near field. I like to have my laparoscope pretty close to whatever it is that I'm operating on. I think you just see better detail. If you are doing that and you forget that there's a big, huge uterus behind the tip of the laparoscope that you can't see, and you've got an energy instrument in there, if it's laying on the uterus or something, God forbid it.
I just feel like if you're going to use some energy, make sure you understand, as is always appropriate, what's nearby. Now you're going to have this big old mass there in the middle that you really don't want to burn if you can avoid it.
[Dr. Mark Hoffman] No reason to avoid monopolar, no reason to avoid anything specifically using harmonic or whatever. It's all good surgical technique-
[Dr. Craig Sobolewski] Yes.
[Dr. Mark Hoffman] -avoiding touching things you don't want to touch.
[Dr. Craig Sobolewski]
When I think about it, if I think about what's different about operating in a pregnant patient compared to a non-pregnant patient, I think there are some things that when you are making the decision to operate, whether any day of the week, you're in your clinic and you see a patient and you're making a decision to operate, and now you've made that decision, then you go through your list of what you do to plan for that procedure. All that's going to be the same in a pregnant patient, but there's going to be some things that might be a little bit different. Pregnancy is a hypercoagulable state. Do I need to do anything differently about my VTE prophylaxis? The answer is no, it really isn't.
Even though there are physiologic changes in terms of the coagulable factors, most of the increased PTE risk comes from venous stasis. I think being efficient in the OR, SCDs, if the patient-- if you have a scoring system that you use to determine VTE risk and that person scores at a level that would require perioperative heparin is safe in a pregnant patient. Whatever your VTE management is, it shouldn't change based on a pregnant patient. You're going through your order list. Do you have to prophylax them against infection differently? The answer there is no. You use standard guidelines for whatever antibiotic prophylaxis based on the procedure that you're doing.
When they're in the hospital in pre-op, there are some things you might do differently. At least we do. If it's a pre-viable pregnancy, we'll get fetal hearts by Doppler, and that's it. We'll do that both pre- and post-procedure. We don't do anything for tocolysis. There's no evidence to support routine tocolytics in any manner. If it's a viable pregnancy, they should have both electronic fetal heart monitoring as well as monitoring for contractions, both pre- and post-procedure. That's different. That's not going to be in your ERAS order set for whatever procedure you're doing.
Think about your trocar entry or your site of entry, how you're going to get in. Think about how you're going to position the patient throughout the operation. Make sure you have an anesthesiologist who's comfortable managing a patient during pregnancy. Post-operatively, other than fetal hearts, and based on gestational age, with whichever way you're going to do it, there's really no guidelines or need to manage those patients differently in the immediate post-operative timeframe.
[Dr. Mark Hoffman] Are you keeping them overnight? You're sending them home?
[Dr. Craig Sobolewski]
Yes, sending them home. There's no evidence to support this necessarily, but for our cerclages, we just document the deepest amniotic fluid pocket in pre-op and post-op. We do just a quick bedside ultrasound, look at fluid, and then we do a quick bedside ultrasound and look at fluid afterwards just because we're putting a needle that sometimes goes into the stroma of the uterus, just to document that we didn't rupture them so that if three or four days later, God forbid, they rupture, we know–
[Dr. Mark Hoffman]
You know that they ruptured three or four days later or not?
[Dr. Craig Sobolewski]
We know that it didn't happen as a consequence of the procedure that we did, yes.
[Dr. Mark Hoffman]
Cerclage loose enough that you can do a DNC?
[Dr. Craig Sobolewski]
Yes, that's the–
[Dr. Mark Hoffman]
Afterwards, that was something that we talked about.
[Dr. Craig Sobolewski]
I don't know how you ensure that that's the case. Part of our consent is that the patient might need a hysterotomy for an IUFD. Ideally, it would be nice if you could do that, but the flipside of this is, what's the purpose of the procedure? The purpose of the procedure is to retain the pregnancy. I haven't figured out a way to gauge the degree of constriction at the cervix. It's all done by eye and gestalt mostly. I will say it's part of the reason that we like doing these standard laparoscopic is just because you can get a little bit better tactile appreciation of how tight you're tying the knot. Although when I do robotics, I swear I can feel what I'm doing, but–
[Dr. Mark Hoffman]
You know your brain plays funny tricks on you, for sure. You push, it does seem like you can feel it.
[Dr. Craig Sobolewski]
Yes.
[Dr. Mark Hoffman]
When you're doing these on non-pregnant patients, are you making them a little looser or, again, just feel and see and–
[Dr. Craig Sobolewski]
You know what? On the non-pregnant patient, you have a manipulator in, so you know that you can at least-- that your cervix is at least dilated to the degree that your manipulator's there. That's probably-
[Dr. Mark Hoffman]
Like a seven, right?
[Dr. Craig Sobolewski]
-a seven or eight, yes. At least the first trimester miscarriages, you can manage that way for sure.
(6) Cerclage Procedures and Providing Supportive Patient Counseling
[Dr. Mark Hoffman]
How do you counsel patients on who needs a cerclage? I think, again, going back to all the times I heard Cap Haney talk about it, was how many second-trimester losses should somebody have to go through? To him, it was one, and that was a pretty controversial take at the time. I'm not as up-to-date on the conversation, which is why we get you on. How do you counsel patients? The second-trimester losses are traumatic. They're terrible. They're tough.
[Dr. Craig Sobolewski]
I will get my good friend and colleague, Dr. Wheeler, who runs the Prematurity Clinic, to come on and answer that question for you, because the simple answer is, when they tell us to do it, we do it. We're not involved with that counseling. When we see these patients, the decision's already been made, and then, our counseling is about risks. "I know that they've told you this is what you need, but this is the potential consequences of you having this operation. I want you to understand the potential."
[Dr. Mark Hoffman]
They're MFM?
[Dr. Craig Sobolewski]
Yes.
[Dr. Mark Hoffman]
Interesting.
[Dr. Craig Sobolewski]
I can't, without reviewing our data, swear by this, but the overwhelming majority of patients have had at least one vaginal cerclage that failed before.
[Dr. Mark Hoffman]
Oh, wow. Okay. Why is that? Again, I'm not up-to-date on what's out there. 10 years ago, last time I looked at it, they just weren't great vaginal cerclages. Honestly, around here, that's all they do. It's not anything that-- to your point, it's an MFM-driven program at times, or maybe REI. We don't have an REI group here. You got to go have a pretty significant volume of patients who need those, and I've never done one in my practice. It's not that anyone's asked me and I said I couldn't, it's not come through our OB programs at all.
[Dr. Craig Sobolewski]
At least my sense is that it's a factor of the fact that abdominal cerclages, the other terminology that was used to describe that procedure was a rescue cerclage. Typically, abdominal cerclages, because they were laparotomies, were reserved for patients in whom all other options had been tried and failed and exhausted. It was truly a rescue operation because it was such a potentially morbid procedure.
[Dr. Mark Hoffman]
These days, laparoscopically, I know you said you guys do a bladder flap. I've seen 50 of them in residency, and not one of them involved a bladder flap, and the numbers from his cases were pretty impressive. I know there's a lot of different ways to do that procedure, but I would say a lot of the ones I see are arguably less morbid than a vaginal cerclage.
[Dr. Craig Sobolewski]
No, I think so, too. I don't know. I don't know if they're less morbid, but maybe not necessarily more morbid-
[Dr. Mark Hoffman]
Not more.
[Dr. Craig Sobolewski]
-since we can do them minimally invasively. Again, I'm not involved with the counseling, so I don't-- I wish I had a better answer for you, Mark. Again, Amy does the majority-- Amy does all of the non-pregnant cerclages now, in fact. Like it or not, that's the way that she's settled into things here. I can't answer with certainty, but back when we first started doing these, my sense was that these were still patients that had had a loss after--
The majority of them were referred because whoever their OB was, they had, in a previous pregnancy, put in a vaginal cerclage, and they failed it. Then, now they're pregnant again, they get sent to Duke for MFM consult, and those are the patients that came to us because they had tried and failed a simpler procedure. That may not be the case anymore. Now that we've got an established program here, maybe the MFM folks are seeing patients, and it's just they've had a second trimester loss, and we are just getting them because they had a second trimester loss. I don't know the answer to that.
[Dr. Mark Hoffman]
I can see it both ways. The success rate for abdominal cerclage in terms of maintaining pregnancy till term is phenomenal. It's one of the most successful procedures that we do, right?
[Dr. Craig Sobolewski]
Yes, I really feel like that we are on the right path of making vaginal cerclage as a thing of the past. I'm just not familiar enough with what the obstetric algorithm is to decide-- to answer your question. To Cap Haney's point, I think that if you had one second trimester loss and there was no other explainable reason for it, why not? I will say what it does do is confines all those patients to a C-section, and–
[Dr. Mark Hoffman]
Yes, and I think if that's the worst outcome, and obviously there are other complications associated with it, but I think the possibility of a second was something that he talked about in terms of insurance companies, how many preterm deliveries, 23 weeks, NICU cost, does it take to pay for 20 cerclages for one, is far less than one long NICU stay, six-month NICU stay. Those are the kinds of things that-- it's not all just about money, but in terms of justifying it, I think, having a success rate that high in something, knowing that what you went through is so traumatic, is not something that I think a lot of people would agree to that.
I know that Dr. Haney's cases were coming from all over the country, all over the world. It was in the early days of message boards and stuff. We have some friends who've become internet-famous through their medical procedures. He was one that I think very early on, people found him and they all just flocked to him, and he did all sorts. We were doing three to five, one on a Saturday, one every week for year round. How many do you think you do in a month, or do you do in a year? You said most of yours are pregnant when you get.
[Dr. Craig Sobolewski]
No, most of ours are non-pregnant. I'd say probably 25% of them are pregnant.
[Dr. Mark Hoffman]
It's a lot.
[Dr. Craig Sobolewski]
I bet you we just do a dozen a year, maybe.
[Dr. Mark Hoffman]
Oh, total, okay.
[Dr. Craig Sobolewski]
Yes.
[Dr. Mark Hoffman]
That's part of it, too, is if we do-- if we start it and are we going to do one or two a year, people nearby doing a handful, is that better for them? Probably, not big on dabbling in general and surgery. I know we talk about that quite a bit here, just in general, but trying to find something that's really rare to do a lot is a challenge.
[Dr. Craig Sobolewski]
Yes. The non-pregnant ones, Mark, are not difficult for a skilled surgeon like yourself. You wish that that's all that you got. Those numbers, like I said, probably at least three-quarters of the ones that we do are in the non-pregnant patients. I think that if the pendulum is swinging to a point where that is the new standard of care treatment, which, like you said, probably ought to be, then there'll be a real need for people to be able to do those, even though second trimester losses, hopefully, are not that frequent. That would be the ideal scenario.
[Dr. Mark Hoffman]
It's something that you can-- our residents, so the whole residency program, not seeing it. There's other places where it's done a lot, but it's one of those things that, yes, it's important to have your options, but it's a good partnership with MFM and with MIGS. It's a surgery that I think it's got its place in our ward, for sure. Are you using Mersilene? What's the suture you're using for?
[Dr. Craig Sobolewski]
Yes, good old Mersilene. I don't know what else it's used for. What else is that stuff used for?
[Dr. Mark Hoffman]
Anything else? I don't know. Two-sided needle, or the needle on each end, or what's the–
[Dr. Craig Sobolewski]
Yes. We have a five in each of the lower quadrants, a five left.
[Dr. Mark Hoffman]
Yes, poor placement, that was my next question. Thank you.
[Dr. Craig Sobolewski]
Yes, a 5 on the right and the left, a 5 in the left upper quadrant, and, a 10 or a 12 at the umbo, and that's just big enough to force that ginormous Mersilene needle through there. Sometimes we have to bend it open just a little bit.
[Dr. Mark Hoffman]
I guess you could backload it, too, right?
[Dr. Craig Sobolewski]
You could.
[Dr. Mark Hoffman]
I do that for my cuff closures, for my CT1, to keep my all fives.
[Dr. Craig Sobolewski]
We just bring it up through the vagina. Then we just straighten it and bring it out. It'll fit through there. Like I said, we go posterior to anterior around both sides, cut the needle off, straighten it, pull it up through the five, and tie it down anteriorly.
[Dr. Mark Hoffman]
Closing fascia on a umbilicus in a pregnant patient, how are you doing that?
[Dr. Craig Sobolewski]
However you want to.
[Dr. Mark Hoffman]
Are you using Carter-Thomason like a pass-through needle? Just with the uterus being right there, just throwing–
[Dr. Craig Sobolewski]
Yes, if it was me, I would, depending on where the-- how close to the uterus is. I don't think I would feel super comfortable doing it that way. Amy is a product of McGee, and so at the umbo, she's always a open Hasson person, so our trocar there is-- The fascia's already been tagged at that site. That's a good question. Yes, I don't-- if you're going to do something like that, you better keep your eyes wide open, and be careful if you're going to use a Carter-Thomason or some other suture assist device there.
[Dr. Mark Hoffman]
That's why I asked. I was interested. I was like, "Yes, yes."
[Dr. Craig Sobolewski]
Are you familiar with this WECK-- the company WECK? They make a fascial closure device called EFx, Endo Fascial Closure. The X is supposed to be for closure. The WECK device is pretty slick. You slide it down through the incision. There's a way that you open it on the inside, and then your needle catches the suture, it self-loads the suture, but the part that opens is protective, so the needle can't go past this part that protects. You don't need another grasper or anything to help you because it–
[Dr. Mark Hoffman]
Do you use that, or is that just something you–
[Dr. Craig Sobolewski] It's available in our OR. I do use it. It's more expensive than the other options.
(7) Reflections, Lessons, and Final Thoughts
[Dr. Mark Hoffman]
Now, I oversee the surgical value analysis team, so it's going to be tough to get-- If I'm not letting other folks get their expensive toys in, I have to be really thoughtful about which toys I ask for.
[Dr. Craig Sobolewski]
You just have to negotiate very aggressively.
[Dr. Mark Hoffman]
Yes, what's the PCI on that one? What are we paying for compared to everybody else? It's amazing how much I've learned. It's been about a year now since I got this job, but my goodness, it is a lot.
[Dr. Craig Sobolewski]
Drinking from the fire hose still, or what?
[Dr. Mark Hoffman]
I thought I had it bad. We have a new chief operating officer for the entire system. He just started a little bit ago, and he's great, but the amount of stuff you learn. The first-- it's been 12 months, I feel like I'm just now figuring out who everybody is and what I'm doing and all these things. All those ideas that I had, the projects I was starting to-- It takes a lot. You think OB and GYN and primary care is a lot to learn, and you're like, "Wait, now it's hospital medicine and behavioral health and ER and lab and all these things that I got to--" it's been pretty darn fulfilling for me. It's been something that, until I did it, I didn't realize how much I liked it. I'll start my MBA in the fall, hopefully, and I don't want to go back. Not that I don't like what we do here, but I was lucky to get this opportunity and lucky to have such a great boss and team of people who are supporting all the learning that I'm doing, but it's pretty cool. I know a lot of my friends, when I told them, they're like, "Oh, sorry." No, no, no, it's pretty great. There's a handful who are like, "That sounds amazing." It takes all kinds.
[Dr. Craig Sobolewski]
Yes. Like I said at the start, they're lucky to have you. I know you well enough to know that you don't give up easily. Pete, you need someone like that to be a leader and to be able to push through initiatives that make sense, because there's going to be a lot of times where people are telling that you can't do something or that you shouldn't do something. As long as you have the wherewithal and understand that it is the right thing to do, especially the physicians at your institution, are going to need somebody like you to have that physician mindset and get the things done that need to get done.
[Dr. Mark Hoffman]
Nice of you to say.
[Dr. Craig Sobolewski]
Good for you.
[Dr. Mark Hoffman]
I'm surrounded by a lot of people who share my ideas and who want-- that's everything. We're all paddling the boat in the same direction. It's hard to work for people who want different things than you. It's hard to want to go back to work every day. That's been the luckiest part of it all, but mostly lucky to have you as a friend, mentor. Again, talk about drinking from the firehouse, what I learned from you, not just about GYN surgery, but all the coding and stuff. What a gift it was to get to work with you, meet you, and build a friendship with you. It was a pleasure to have you on. Always something to learn from you, and it's, again, mostly just a great excuse to catch up with a friend.
[Dr. Craig Sobolewski]
[laughs] Couldn't agree more, Mark. Thanks again for the invite, the opportunity. Congrats on this, too, buddy. This is really fantastic.
[Dr. Mark Hoffman]
No, thanks. Again, team, this is Aaron and the guys at BackTable that do all the heavy lifting, and Josh, who is our engineer here on the show today, that a lot of people working hard just so I get to come here and hang out with my buddies and catch up and talk about what we do every day, so I'm a lucky person in all the ways. You got to try to remember to be grateful on those long days. All right, man, look forward to catching up with you soon. Be well, and tell the rest of your team I said hey.
[Dr. Craig Sobolewski]
Will do. You too, Mark.
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2025, March 11). Ep. 79 – Laparoscopy in Pregnancy: Key Considerations for Surgeons [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Up Next
Articles
Vaginal vs Abdominal Cerclage: Sustaining Second Trimester Pregnancies
Improving Laparoscopic Surgery in Pregnancy: Patient Selection, Tools & Techniques
Topics
