Five Things Patients and Providers Should Question

Avoid laparotomy for the management of non-malignant disease when surgery is indicated and a minimally invasive approach such as 1 hysteroscopy, vaginal laparoscopy or robotic-assisted surgery is feasible and appropriate. Selection of a minimally invasive approach should be tailored to patient selection, surgeon ability, and equipment availability. The surgeon should take into consideration how the procedure may be performed cost-effectively with the fewest complications and refer to subspecialists to provide optimal outcomes.

Do not perform routine oophorectomy in premenopausal women undergoing hysterectomy for non-malignant indications who are at 2 low risk for ovarian cancer. Outside of high-risk populations, the association of oophorectomy with increased mortality in the general population has substantial implications, particularly as it relates to higher rates of coronary heart disease and cardiovascular death. The long-term risks associated with salpingo-oophorectomy are most pronounced in women who are younger than 45–50 years of age but ovarian conservation until age 65 is of benefit.

Do not routinely administer prophylactic antibiotics in low-risk laparoscopic procedures. The use of prophylactic antibiotics in women undergoing gynecologic surgery is often inconsistent with published guidelines. Although the appropriate 3 use of antibiotic prophylaxis for hysterectomy is indicated, prophylactic antibiotics are increasingly being administered to women who are less likely to receive benefit, such as diagnostic and operative laparoscopic procedures other than hysterectomy, including cystoscopy, hysteroscopy, intrauterine device insertion, endometrial biopsy, oocyte retrieval, D&C for non-pregnancy indications, and cervical tissue biopsy, including LEEP or endocervical curettage. The potential results are significant resource use and facilitation of antimicrobial resistance.

Avoid removal of endometrial polyps without direct visualization when hysteroscopic guidance is available and can be safely performed. 4 Endometrial polyps are a common gynecologic disease. Though conservative management may be appropriate in some patients, hysteroscopic polypectomy is the mainstay of treatment. Removal without the aid of direct visualization should be avoided due to its low sensitivity and negative predictive value of successful removal compared to hysteroscopic polypectomy.

Avoid opioid misuse without compromising care through education, responsible opioid prescribing and advocacy. 5 Patients have a right to appropriate assessment and management of pain; however, opioid misuse has become a public health crisis. It is essential that providers become familiar with published FDA and CDC plans and guidelines. Providers must also educate and screen for risk factors for opioid misuse and follow patients on chronic opioid therapy for any signs of misuse.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physicians.

Released November 15, 2017; Updated October 11, 2019 How This List Was Created As an international leader in the advancement of minimally invasive surgery, AAGL relies on its society members and board to determine the various needs and best practices to promote safe, higher quality care to patients. The list of things to question provided to the Choosing Widely campaign was submitted to the AAGL Board, who developed a subcommittee dedicated to analyzing the recommended interventions. The subcommittee of expert surgeons in the field of minimally invasive surgery recommended and developed a more effective use of health care resources, along with safe techniques to practice. The submitted list was reviewed and approved by the AAGL Board.

Sources Gala R et al. Systematic Review of Robotic Surgery in Gynecology: Robotic Techniques Compared with Laparoscopy and Laparotomy, J Minim Invasive Gynecol. 1 2014 May-Jun;21(3):353-61. ACOG Committee Opinion: Choosing the Route of Hysterectomy for Benign Disease, Number 701, June 2017

Evans EC et al. Salpingo-oophorectomy at the time of Benign Hysterectomy. Obstet Gynecol 2016;128:476-485. 2 Parker WH et al. Long-term Mortality Associated with Oophorectomy versus Ovarian Conservation in the Nurses’ Health Study, Obstet Gynecol 2013;121(4):709-716.

Wright J et al. Use of Guideline Based Antibiotic Prophylaxis in Women Undergoing Gynecologic Surgery, Obstet Gynecol 2013; 122:1145-1153. 3 ACOG Practice Bulletin: Antibiotic Prophylaxis for Gynecologic Procedures, Number 104 May 2009 (Reaffirmed 2016)

AAGL Practice Report: Practice Guidelines for the Diagnosis and Management of Endometrial Polyps. Journal of Minimally Invasive Gynecology, Vol 19, No 1, January/ February 2012. 4 Bettocchi et al. Diagnostic Inadequacy of Dilatation & Curettage, Fertil Steril 2001;75:803-805. Svirsky R et al. Can We Rely on Blind Endometrial Biopsy for Detection of Focal Intrauterine Pathology?, Am J Obstet Gynecol 2008;199:115.e1-115.e3

Phillips DM. JCAHO pain management standards are unveiled. JAMA 2000;284:428-429. 5 Dowell, T.M. Haegerich, R. Chou, CDC guideline for prescribing opioids for chronic pain - United States, 2016, MMWR Recomm. Rep. 65 (1) (2016)

About the ABIM Foundation About the AAGL

The mission of the ABIM Foundation is to advance Established in 1971, AAGL was the first medical professionalism to improve the health organization of its kind dedicated to care system. We achieve this by collaborating with gynecologic endoscopic surgery. Still today, physicians and physician leaders, medical trainees, AAGL remains the largest international, health care delivery systems, payers, policymakers, professional society in minimally invasive consumer organizations and patients to foster a shared gynecology. With over 7,000 members, understanding of professionalism and how they can AAGL is recognized worldwide for leading adopt the tenets of professionalism in practice. the field through education, communication and research. AAGL works with some of the world’s finest gynecologic surgeons to promote quality health care To learn more about the ABIM Foundation, visit www.abimfoundation.org. for women by advancing minimally invasive gynecologic practices through clinical practice, research, innovation and dialogue.

For more information or to see other lists of Five Things Patients and Providers Should Question, visit www.choosingwisely.org.