OBGS): Past, Present, and Future: Part I

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Gynecology SURGICAL TECHNOLOGY INTERNATIONAL Volume 35 Office-Based Gynecologic Surgery (OBGS): Past, Present, and Future: Part I

MORRIS WORTMAN , MD, FACOG CLINICAL ASSOCIATE PROFESSOR OF GYNECOLOGY UNIVERSITY OF ROCHESTER MEDICAL CENTER DIRECTOR CENTER FOR MENSTRUAL DISORDERS ROCHESTER , N EW YORK

KATHRYN CARROLL , BS, RN CLINICAL RESEARCH COORDINATOR CENTER FOR MENSTRUAL DISORDERS ROCHESTER , N EW YORK

ABSTRACT he gynecologist’s office was, historically speaking, the original setting for surgical practice. In 1809, Ephraim McDowell performed the first ovariotomy and removed a 22.5-pound tumor from Jane Craw - Tford in his Danville, Kentucky office—decades before the development of anesthesia or the aseptic tech - nique. Three developments—introduction of surgical anesthesia, improved operative techniques, and the evolution of the medical-economic environment—shaped surgical practice for over two centuries. The latter part of the 20th century also brought two dramatic changes that affected gynecologic practice. The first included social changes which created a demand for legalized abortion and elective sterilization. The second was a cascade of technological growth and innovations that created the field of minimally invasive gynecologic surgery (MIGS), allowing many procedures to be transferred from the hospital to the outpatient setting and then to the office. With the increasing demand for patient-centered care, effective operating room utilization, and the efficient use of physicians’ time, many gynecologic procedures are now being performed in an office-based setting. But, at least three important obstacles remain: the need for widespread accreditation, the availability of teaching in an office-based environment, and meeting the ethical obligation for adequate analgesia and sedation in an office environment.

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Office-Based Gynecologic Surgery (OBGS): Past, Present, and Future: Part I WORTMAN/CARROLL

INTRODUCTION ment for practice in most hospitals. gynecologic procedures to be trans - World War II produced a sea change ferred to the office-based surgical in the practice of medicine and surgery , (OBS ) setting as well . Soon, laparoscop - Gynecologic surgery did not originate while stimulating the dramatic expan - ic sterilization, diagnostic hysteroscopy, within the prestigious chambers of a hos - sion of the 20 th -century hospital system the treatment of vulvar cysts, and loop pital operating room; instead it began in and motivating the modern infrastruc - electrosurgical excision procedures the remote confines of an early 19 th cen - ture of health insurance. The post-war (LEEPs) were being reported in an tury physician’s office, in central Ken - years witnessed numerous technological office setting—but only by a limited tucky, where a bold and original achievements in medicine and surgery group of pioneering physicians. idea —removing a life-threatening along with a rapidly growing and well- The last 30 years have seen three intraabdominal tumor—came to insured population that soon exceeded major changes that are now motivating fruition . For most of the 19 th century, as the capacity of hospital beds and operat - many gynecologic procedures to move to operative techniques and anesthesia were ing rooms. The response to these short - the OBS setting. First, the technological developing , gynecologic surgery was ages spurred the development of achievements of the last three decades increasingly performed in an office or outpatient surgery centers beginning in have resulted in the unprecedented ease home setting. However, in the latter part the 1960s. With the advent of Medicare and safety of many commonly performed of that century , during the decades fol - and Medicaid programs in 1965 3 the gynecologi c procedures —diagnostic lowing the Civil War , enormous strides federal government adopted a central and operative hysteroscopy , as well as were made in surgery, anesthesia, aseptic role in financing the costs of American endometrial ablation —in an OBS set - techniques, and formalized nursing train - heathcare . ting. Second, the increased growth and ing that would affect the future of our The 1970s also witnessed another complexity of hospital systems has specialty. important social change—the legaliza - imposed many new insurance and The turn of 20 th century brought tion of abortion services in the United administrative barriers to the delivery many demographic and social changes to States .4 The management of a large of care to patients . Third, the major America . Simultaneously, a revolution in influx of elective pregnancy termina - healthcare payers, in an effort to reduce surgery and anesthesia, the development tions, requiring discretion and privacy, the cost of inpatient and outpatient of diagnostic and laboratory services, was ill-suited to the hospital or emerg - operating room services, have provided along with the modernization of medical ing outpatient department and stimulat - strong financial incentives for physicians education witnessed the hospital emerge ed the early growth of office-based to perform procedures in an OBS set - as a modern institution of healing and gynecologic surgery (OBGS) . A handful ting. In 2006 , The Medicare resource- teaching. In the years just prior to World of physicians soon recognized that the based relative value scale (RBRVS) War II, both the American Board of skills learned in this setting—gentle tis - dramatically increased the reimburse - Obstetrics and Gynecology 1 as well as sue handling, the use of local anesthesia, ment for endometrial ablation and hys - the American Board of Anesthesiologists 2 and intravenous sedation—along with teroscopic sterilization performed in an were founded and the imprimatur of the support of a well-trained nursing office-based setting .5 As recently as these specialty boards became a require - and administrative staff allowed other 2017, the Centers for Medicare and Medicaid Services (CMS) instituted a 237% increase in relative value units for diagnostic hysteroscopy with endome - trial sampling .6 The relocation of many gynecologic procedures , from the hospital and out - patient setting to the office , comes at a time when gynecologists struggle for improved reimbursement and better utilization of their time while seeking reduced administrative barriers to more patient-centered care . Patients are motivated by the inherent cost sav - ings of OBGS and the individualized care available in the already-familiar office environment removed from the complexities of an increasingly corpo - rate hospital structure .7 This article will trace the history of gynecologic surgery as it moves from its original setting—the early 19 th century physician’s office —to the increasingly sophisticated but complex environment of the late 20 th century hospital . We will Figure 1. Ether Dome (Courtesy of Massachusetts General Hospital Archives). examine how the advances in surgery and anesthesia and the changing medical

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Gynecology SURGICAL TECHNOLOGY INTERNATIONAL Volume 35 economic environment have inter - known Edinburgh obstetrician, experi - definitely ascertained” and noted that twined and influenced the growth of mented with the inhaled vapors on him - chloroform was used in 72.2%, ether in OBGS. After examining the present -day self and two of his friends at a dinner 14.7% , and a mixture in 9.1% of cases. status of OBGS , we will also identify party on November 4, 1847. Chloro - Chloroform was likely the preferred the obstacles to OBGS practice and how form “and its effects were rapidly agent since it was non-flammable and best to overcome them. demonstrated by the three seekers after was associated with a quicker induction, truth falling out of their chairs and lying greater potency , and more rapid return unconscious under the table .” 13 With no to consciousness .20 Although various EvolEuVtOioLUnT IoONf AOFn eANstEhSeTHsiEaSIA unpleasant after-effects , Simpson adopt - inhalation devices were available at the ed chloroform as an obstetrical anes - time, most anesthetics were delivered thetic agent and introduced it to the by pouring the agent onto a handker - Anesthesia was arguably America’s world in a paper delivered before the chief, towel, napkin, sponge, lint , or first important contribution to medical Medico-Chirurgical Society of Edin - special cone .21 The merciful relief that practice. Josiah Trent, in celebrating the burgh. Simpson withstood withering anesthesia afforded the victims of the centenary of anesthesia, described sur - professional and religious criticism in Civil War was best expressed by Con - gical practice prior to 1846 as follows: mid-19 th -century England and was federate Army General “Stonewall” “The patients were few in number, for opposed by those who suggested “God Jackson after being wounded during the the fear of pain was a deterrent equally has ordained that women should suffer Battle of Chancellorsville. Dr. Hunter as strong as the fear of possible acci - during childbirth .” 14 After being sum - McGuire informed General Jackson that dents or of fatal errors by the surgeon; moned by Queen Victoria in 1848 to he would be administering chloroform many preferred to die rather than attend the birth of her sixth child, in order to amputate the general’s left endure the exquisite agony which was Simpson’s participation was strongly arm two inches below the shoulder. in store for them .” 8 opposed by Her Majesty’s medical After administering the agent McGuire The first surgical procedure to be attendants who were concerned with reported that as General Jackson’s pain performed with anesthesia is generally the safety of chloroform administra - and suffering was mitigated, he credited to Crawford Long, who , in tion .15 But , in 1853, at the behest of exclaimed, “What an infinite blessing,” 1842 , employed sulfuric ether to excise Prince Albert, Dr. John Snow—a Lon - and then continued to repeat the word a tumor from the neck of his friend, don physician known for his meticulous “blessing” until he became insensible .22 James Venables. Mr. Venables, after study of ether anesthesia —was sum - Despite the increased acceptance and inhaling ether from a towel , had not moned to administer chloroform during use of anesthesia for the remainder of believed the tumor had been removed the birth of Leopold, Victoria’s eighth the 19 th century , “anaesthetists were low until Long had showed it to him .9 The child .16 The Queen reportedly inhaled in the medical hierarchy” and had not account of this achievement remained chloroform for 53 minutes 17,18 from a yet developed the professional organiza - unpublished until 1849 and was later handkerchief and later wrote in her tions for teaching and disseminating described by Nuland as “America’s journal “Dr. Snow gave that blessed information through courses, journals, greatest gift to the art of healing .” 10 The chloroform and the effect was soothing, meetings , and societies .23 The emer - popularization of ether-anesthesia is quieting and delightful beyond mea - gence of anesthesiology as a medical credited to William T. G. Morton, and sure .” 19 specialty would await the early part of John Collins Warrens, who on October The development of anesthesia the 20 th century with the establishment 16, 1846 excised a tumor of the jaw foundered at first in the United States, of the American Society of Anes - from Mr. Edward Gilbert Abbott in a but the Civil War (1861 –1865) cement - thetists —the forerunner of the Ameri - “public” event at the Massachusetts Gen - ed its place in American medical prac - can Society of Anesthesiologists eral Hospital (Fig . 1). 11 Ether was tice. Much of the data relating to the (ASA) —in 1935 .24 The American administered through a newly con - use of anesthesia during the Civil War Board of Anesthesiology was founded in structed inhalation apparatus and the came from the landmark publication, 1938 as a division of the American technique soon gained world-wide the Medical and Surgical History of the Board of Surgery, and board certifica - notoriety. Oliver Wendell Holmes, the War of the Rebellion (MSHWR) —a tion soon followed .25 The public recog - venerated 19 th century physician and 6,000-page analysis of all aspects of nition of anesthesia was affirmed as a writer , declared that “the fierce extrem - medical and surgical care involving both specialty when it was advertised as the ity of suffering has been steeped in the Union and Confederate forces .20 The “hit show in the Medicine and Public waters of forgetfulness, and the deepest chapter entitled “Anesthetics” is an Health Building” of the New York furrow in the knotted brow of agony has analysis of 80,000 instances in which World’s Fair in 1939 .26 been smoothed forever .” 12 It was anesthetic agents were employed in the World War II brought an accelerated Holmes who suggested to Morton the treatment of over 320,000 Union growth in medical and surgical technol - name “anesthesia,” —a term that had troops. Albin 21 estimates that the com - ogy and resulted in the development of been used by Plato to denote the bined Union and the Confederate blo od banking, the treatment of infec - absence of feeling. armies utilized a total of 130,000 anes - tious diseases, and an extraordinary The search for other anesthetic thetic agents during the course of the investment in public and private hospi - agents soon followed. Among those Civil War —employing them in a quar - tals. The war also stimulated the under consideration was chloroform, a ter of all surgical procedures. The growth of medical insurers whose colorless volatile liquid discovered in MSHWR focused on 8,900 cases of reimbursement policies in the post- 1831. James Young Simpson, a well- “major operations in which agents were WWII era favored hospital-based care.

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In the set ting of a well-insured popula - ner of the modern surgery center. The being the first ovari otomist.” tion, with an abundance of surgeons and two believed that quality measures , Despite McDowell’s pioneering hospital beds , operative outcomes including proper patient evaluation and genius , gynecologic surgery was gener - improved and there was an unprece - proper equipment , were more impor - ally unknown and unpracticed through dented need for anesthesiologists .27,28 tant than whether or not the surgical most of remainder of the 19 th century. By the 1960s, however, many com - procedure occurred in a hospital or out - Dr. Thomas Cullen, professor of gyne - munities experienced a deficiency in patient setting. Cohen and Dillon cology at the Johns Hopkins Medical hospital beds. Purvis Martin noted “a reported excellent outcomes with a low School , recalled gynecologic practice at severe shortage of hospital beds in the hospital transfer rate and demonstrated the end of the 19 th century as follows: San Diego community during the 2 a significant savings to patients and decades following World War II .” 29 In insurance companies. By the late 1970s , Now and then he would operate this setting , gynecologists began per - it was estimated that 20 –40% of all sur - in a private house repairing a per - forming selected procedures , such as gical procedures performed in an aver - ineum or cervix. The operator dilation and curettage, in an office- age community hospital could be would go to the patient’s home based setting , and sodium thiopental accomplished just as safely in an ambu - the day before, pick out the room was administered by either an associate latory or outpatient surgery setting .31 he deemed most suitable, have it gynecologist or a “roving anesthesiolo - The role of the modern outpatient cleared out and cleaned, and the gist.” In fact, Martin noted “we felt rela - surgery center continues today as the next day he and two or three of tively secure in using this agent for primary setting for low-risk and mini - his colleagues would repair to the minor surgery on normal risk patients.” mally invasive surgical procedures . patient’s home… The operator This all changed when medical liability would go to the kitchen, pick out insurance carriers, based on their expe - a suitable pan, place his instru - rience in other communities, required EvEoVlOuLtUiToIOnN o OfF G GyYNnEeCcOoLlOoGgICi cS USRuGrEgReY ry ments in this and set them on the the discontinuation of this practice and stove to boil. Meanwhile the assis - denied coverage to gynecologists .29 In tants would be scrubbing up and a the setting of increasing demand for The first surgical observatory and relatively untrained man would hospital services and a shortage of oper - amphitheater in the United States was put the patient to sleep... ating room facilities , the outpatient constructed in 1804 at Pennsylvania Gynecological operations were in surgery center was conceived. Hospital 32 at a time when surgical light - large measure limited to removal In 1962 , two anesthesiologists, ing was provided by the mid-day sun of labial growths, perineal David Cohen and John Dillon , sought to and sterile techniques were not yet repairs, repair or amputation of improve hospital bed utilization at the practiced. Despite these prestigious sur - the cervix, curetting of the uterus UCLA Medical Center .30 Cohen and roundings, the first intraabdominal for cancer, curetting of the uterus Dillon established an outpatient surgery surgery was performed under consider - for retained membranes, and the program that is considered the forerun - ably more humble environs. removal of large non-adherent In December 1809 , Dr. Ephraim ovarian cysts… Little or no McDowell (Fig . 2) was called to the attempt was made to remove pus home of Jane Todd Crawford in Green tubes. Fibroids were left alone County, Kentucky to evaluate what was and no one would venture to thought to be a pregnancy that had “far remove the uterus for cancer of exceeded the usual period .” 33 After the cervix or body .35 learning of her ovarian growth , Mrs. Todd agreed to travel on horseback The evolution of gynecology as a some 60 miles back to Danville, “resting specialty would await the development her tumor on the horn of the saddle” 34 ; of hospitals, diagnostic testing, and whereupon , McDowell removed a advances in both anesthesia and antisep - 22.5-pound ovarian neoplasm on sis. Even after Lister’s announcement in Christmas morning of 1809. Given that 1867 , an antiseptic technique was only the procedure was performed without slowly incorporated into established anesthesia , and that Jane Crawford American surgical practice. Boiled rub - made a complete and uncomplicated ber gloves were first used by William recovery , one can fairly state that she Halsted in 1890 and , by 1895 , dry heat deserves as much credit as he for the and steam had largely replaced Lister’s beginning of modern surgery. McDow - carbolic acid for the sterilization of ell published a description of his proce - instruments and dressings .1 dure , performed in his home office By 1897 , improvements in surgical (Fig . 3), in 1817 , and included two technique led to an increased use of additional cases .33 Schachner 34 noted hysterectomy. That year, Thomas Addis that had McDowell “lived under the Emmet, the profession’s elder states - overpowering shadow of a famous uni - man, even criticized the use of “promis - versity, it is safe to say that he would cuous hysterectomy ” at the 22 nd Annual Figure 2. Ephraim McDowell. never have had [the] distinction of Meeting of the American Gynecological

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Gynecology SURGICAL TECHNOLOGY INTERNATIONAL Volume 35

Society. Dr. Emmet cautioned that “Now that the operation of hysterecto - my has been so perfected, it stands as a terror to me, for I am often tempted to do it when I would not think of it if the result of the operation was not so suc - cessful . The danger of the procedure is the least obstacle to our progress today, for its execution has become too easy .” 1 The 20 th century would see profound advances in the new unified specialty of obstetrics and gynecology as medical education, surgical technique, pharma - cology , and anesthesiology advanced. The American Board of Obstetrics and Gynecology administered their first examinations to 79 applicants in May 1931 .1 By the 1970s , gynecologic oncology, maternal and fetal medicine , and reproductive endocrinology were Figure 3. Professor George Kasson Knapp’s painting of “The First Ovariotomy.” all recognized as subspecialties. The lat - ter part of the 20 th century also brought a panoply of social and technological unleashed a religious and political tor - abortion. The demonstrated safety and change to women’s healthcare. In addi - rent that continues to this day. As a discretion of pregnancy termination tion, this era would stimulate changes in result of the need for medical discre - services caused a major shift in practice the distribution of gynecological surgi - tion, patient privacy, and the already as services were increasingly brought cal practice in the United States that proven safety of first -trimester abortion into the outpatient and OBS setting. affects us to this very day, including the under local anesthesia, pregnancy ter - The 1970s and 80s also witnessed a development of office -based gynecolog - mination services were increasingly per - rapid technological growth in our spe - ic surgery. formed in a dedicated outpatient facility cialty —the addition of laparoscopy into In 1958 , a major technical innovation or an OBS setting. The safety of office- gynecologic practice. Advancements in was introduced by two Shanghai obste - based first trimester abortion was sup - laparoscopic light sources and techniques tricians —Drs. Yuantai Wu and ported by Peterson et al .40 who coincided with a growing demand for Xianzhen Wu—that would influence observed that general anesthesia carried surgical sterilization, which was now abortion services worldwide. The a two- to four-fold increased risk of suitable for the newly created outpa - method of vacuum aspiration, first pub - death related to elective first-trimester tient and ambulatory surgery centers. lished in the Chinese Journal of Obstet - rics and Gynaecology ,36,37 was soon adopted by physicians in the Soviet Union, Hungary, Bulgaria, Yugoslavia , and Czechoslovakia. By the mid-1960s , vacuum aspiration was introduced in both England and in the United States and concerned individuals throughout the world re-evaluated abortion prac - tice through the lens of improved safety and expediency .36 The 1960s and 1970s witnessed a state-by-state shift in laws regulating abortion practice in the United States. As a result of the 1973 United States Supreme Court decision in Roe v. Wade , elective abortion became the most com - monly performed gynecologic proce - dure in the US. By 1990 , over 1.4 million abortions were performed annually .38 Until there was a demand for a large number of elective pregnancy terminations, the vast majority of gyne - cologic surgery was performed in a hos - pital-setting under general, spinal , or Figure 4. Hassan cannula for open laparoscopy shown with single puncture laparoscope used for steriliza - epidural anesthesia .39 The Roe decision tion.

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Office-Based Gynecologic Surgery (OBGS): Past, Present, and Future: Part I WORTMAN/CARROLL

(Fig . 8) have been performed in office- based settings .49,50 There are numerous factors that cur - rently favor the expansion of OBGS , including the development of equip - ment specifically designed for office- use, a favorable economic environment for gynecologists and patients, and the administrative ease of scheduling—all improving office efficiency . Additional - ly, the advantages of working with a consistent team of nurses and support staff is likely to provide better outcomes in a more welcoming and patient-cen - tered environment. Both the American College of Obstetrics and Gynecology (ACOG) 51 and the American Society of Anesthesiologists (ASA) 52 have devel - oped essential guidelines to assure the safety of OBS and continue to represent Figure 5. Office-based configuration of laparoscopy and hysteroscopy, in 1986, at Dr. Wortman’s office. important efforts on behalf of both pro - fessional societies to embrace and enhance continuing quality improve - Concomitantly, several physicians strong advocate for surgical sterilization ment. became interested in the possibility of in an OBS setting under local anesthe - performing laparoscopic sterilization sia .46 under local anesthesia in an outpatient The last two decades of the 20 th cen - THE MEDICAL-ECONOMIC ENVIRONMENT: 41-43 The Medical-Economic Envi - setting . In 1977 , Penfield reported a tury witnessed many developments in ronTmHEe nEVtO: LTUhTIeO NE vOoF lHuOtSiPoInTA LoSf AHNoD spi - series of 1200 laparoscopic sterilizations gynecologic surgery including the tals and HHeEaALlTtHh IINnSsUuRrAaNnCcE e under local anesthesia in two free- acceptance of outpatient and free-stand - standing surgical units in Syracuse, New ing surgical centers, as well as office 44 York . Because of the possible risk of surgical suites (Fig . 5) for an increasing The earliest US hospitals traced their major blood vessel injuries inherent to number of gynecologic procedures . origins to 7 th century British almshous - sharp-trocar laparoscopy, Penfield Soon, techniques which had once been es—Christian-based charitable institu - insisted that procedures performed performed exclusively in hospital oper - tions which provided care for the under local anesthesia be carried out ating rooms, such as laparoscopy, mini - widows, orphans, sick, and destitute of with the availability of an operating laparotomy, hysteroscopy , and LEEP 47,48 their community. Almshouses func - room and anesthesia services. However, procedures , were increasingly tioned as a combination guest-home, with the development of the Hassan migrating into these alternative sites. In st religious house , and infirmary , and they cannula (a blunt instrument that elimi - the early part of the 21 century , were often referred to as “Maison nated the use of both the Verres needle endometrial ablation, endomyometrial Dieu,” “Bede-house,” and “God’s and sharp trocars; Fig. 4), also known as resection (Fig . 6) , hysteroscopic 45 House ,” as well as the more familiar “open laparoscopy ,” Penfield became a polypectomy (Fig . 7), and myomectomy “Hospital,” and “Almshouse .” 53 While serving the chronically ill, deprived, destitute , and disabled, their therapeu - tic value was often questioned —at least one New York almshouse was charac - terized as “a public receptacle for poor invalids undeserving the name hospital .” 54 In 1736 , both the New York City Almshouse and the New Orleans Hospital of Saint John were founded and became the forerunners of Bellevue and Charity Hospital respectively .55 While providing a generalized welfare system for society’s underclass, the 18 th and early 19 th century almshouses were characterized by their squalid and over - crowded conditions and poor staffing that often required inmates to care for one another in such matters as nursing, Figure 6. Office-based endomyometrial resection (EMR). washing , and ironing, as well as the

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Gynecology SURGICAL TECHNOLOGY INTERNATIONAL Volume 35 cleaning of rooms .56 In many cases , these early almshouses may have served more as a deterrent to poverty and pub - lic assistance than an institution of heal - ing. The almshouse began its metamor - phosis into the modern hospital by shift - ing its focus to caring for those that were capable of rehabilitation and could be returned to contribute to society. Benjamin Franklin criticized charitable institutions as causing the poor to be “less provident.” He reasoned that giving mankind “a dependence on anything for support…besides industry and frugality during youth and health, tends to flatter our natural indolence, to encourage idleness and prodigality, and thereby promote and increase poverty, the very evil it was intended to cure: thus multi - plying beggars instead of diminishing them .” 57 In 1751 , the Pennsylvania assembly passed an act creating the first Figure 7. Office-based hysteroscopic polypectomy. Anglo-American hospital, modeled after the British “voluntary hospital,” in order to save and restore “useful and respect for both the medical profession into a business organization redesigned laborious” poor people to the communi - and hospitals as they embraced a new to be more attractive, safer , and accept - ty .57 Benjamin Franklin, Dr. Thomas era of therapeutic optimism. able to a broader swathe of society. By Bond , and a coterie of Quaker mer - The post -war era also ushered in the sending the incurably ill, and the chants and other physicians also recog - Second Industrial Revolution and “wicked and undeserving” to almshous - nized hospitals as a vehicle for caused the migration of large numbers es, while directing those with conta - expanding medical education. Formal - of working people into urban centers. gious illnesses to “pesthouses ,” the ized instruction at the hospital followed , The new city dwellers—removed from hospital’s mission was transformed to and , in 1765 , the colonies’ first medical their family structure and living in one of curing acute illness .56 The exclu - school at the College of Philadelphia apartments—required a different set - sion of undesirable cases also served to was established. The Pennsylvania Hos - ting for the management of acute illness combat the widespread public percep - pital remained the only general hospital and surgery. The social and scientific tion that hospitals functioned as a house in the 13 colonies until the Revolution - changes of the late 19 th century spurred of death. ary War . Other “voluntary” hospitals— the evolution of the hospital from a Late 19 th century doctors—aware of financed by donations rather than “well of sorrow and charity” to “a work - the need to persuade the public of the taxes —soon followed, including the place for the production of health .” 56 hospital’s new role—understood that New York Hospital in 1771 and the The hospital —once a benevolent insti - adopting an organizational structure Massachusetts General Hospital in tution for the chronically ill —evolved could be an indispensable vehicle for 1821 .56 Still, in the early nineteenth century , most Americans gave birth, endured illnesses , and even underwent “kitchen surgery” at home. Prior to the 1860s , a physician might be content to spend an entire career without visiting a hospital ward, but the Civil War transformed nearly all aspects of medicine, surgery , and the institution of the hospital. By 1865, the last year of the war, the Union had built over 130,000 beds and treated over a million soldiers .58 The war stimulated both sur - gical innovation and the use of anesthe - sia—each facilitating the other. The adoption of antiseptic and aseptic tech - niques, along with greater attention to adequate ventilation in the late 19 th cen - tury , enhanced an already increasing Figure 8. Office-based hysteroscopic myomectomy.

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Office-Based Gynecologic Surgery (OBGS): Past, Present, and Future: Part I WORTMAN/CARROLL

a b Figure 9a, b. Small diameter hysteroscope (Endosee) Courtesy of Cooper Surgical. medical education and a means to inter - late 19 th century hospital would eventu - from three to 432 , and , with it , there connect physicians, surgeons, anes - ally depend on the adoption of the for - was a profound rise in the prestige of thetists , and paid support staff. But the malized training for professional nurses; the nursing profession .56,60 wholesale renovation of the almshouse a notion not initially embraced by physi - The close of the 19 th century also and early hospitals into institutions of cians. Prior to the Civil War , nursing witnessed the geometric growth of health would require substantial capital was considered a menial occupation intraabdominal surgery. Between 1889 investment and the involvement of the taken up by women of lower socioeco - and 1892 , William and Charles Mayo business community. As a result, physi - nomic classes. Formalized nursing began had performed only 54 abdominal oper - cians, in search of greater legitimacy, in 1861, when the Woman’s Hospital of ations—a number that grew to 612 in formed alliances with wealthy and influ - Philadelphia was incorporated and began 1900 and 2,157 by 1905. 56 As surgical ential donors seeking to enhance their the training of professional nurses. The technology improved in the early 20 th personal reputations with the public. In first course lasted six months and pro - century , it expanded to include the tho - some cases, doctors —aware of the need duced a single graduate in 1865, but the rax as well as the nervous and cardio - for the imprimatur of the hospital school did not flourish until after the vascular systems. This growth gradually structure —even volunteered their ser - Civil War. The war demonstrated that moved surgery from the home - or vices and provided medicine at their intelligent, disciplined student nurses office-based setting to the hospital. own expense .59 Community leaders— performed a superior and cost-effective Between the onset of the Civil War and bankers, lawyers, judges, clergy, mer - service and the profession eventually the turn of the 20 th century, hospitals chants , and industrialists—were also won public and hospital administrative evolved from institutions concerned aware of the benefit of lending their support .60 With the growing emphasis with the care of the poor and chronical - support toward the establishment of on cleanliness, orderliness , and the asep - ly ill to centers that provided the orga - facilities in their own communities. tic technique, professional training nizational and support structure for These leaders, in turn, became the schools—modeled after the Nightingale scien tific research, education , and tech - future managers and trustees of the School in London —were soon estab - nological advancement that was tailored newly formed institutions 56 and bene - lished in New York, New Haven , and to the management of the acutely ill. As fitted from the networks of influence. Boston. Between 1873 and 1900 , the a result, the number of US hospitals The organizational structure of the number of nursing schools increased increased from 178 in 1872 to more

Figure 10. Self-contained global endometrial ablation systems. Figure 11. Small diameter resectoscope.

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Gynecology SURGICAL TECHNOLOGY INTERNATIONAL Volume 35 than 4000 in 1910 .61 of General Paul Hawley, the post -WWII 2009 alone. Unfortunately, the office The technological advancements of VA established a policy of affiliating the still remains a relatively unregulated the increasingly complex 20 th century new hospitals with medical schools, environment, with only a fraction of hospital came at a financial cost; one establishing policies that would attract states 74 requiring formal accreditation; a that was increasingly borne by the con - new doctors and encourage the VA hos - situation that has been described as sumer. The onset of the Great Depres - pital-based research program. The Hill- medicine’s “wild west .” 75 As of 2012 , sion exposed the vulnerability of the Burton Act—signed into law by only 28 states had any guidelines or reg - new healthcare system as hospital beds President Truman in 1946 —provided ulations pertaining to office-based facili - became vacant. In this setting , the con - funds for the construction and expan - ties , and the vast majority lack cept of medical insurance emerged. The sion of community hospitals for a rapid - accreditation by one of the three major archetype for today’s insurance plans ly expanding and demilitarizing accrediting agencies .74 were developed at Baylor University population. By 1975 , Hill-Burton had Medical Center in 1929 62 in a plan that been responsible for the construction of 69 DISCUSSION was offered to the local teacher’s union. nearly one-third of US hospitals . Discussion By 1939 , the Baylor experiment evolved The post -war years also caused a re - into the first Blue Cross plans and evaluation of the government’s role in enlisted some three million people. But , providing healthcare to Americans. The development of gynecologic health insurance was still relatively Many European countries had already surgery, anesthesia , and the modern uncommon before World War II ,63 as adopted some form of national health hospital system have , for nearly two most Americans could ill-afford the insurance —a system that was rejected centuries , evolved and benefitted from premiums. However, in 1942, the in the United States. However, in 1965, what has been an interdependent rela - National War Labor Board instituted President Lyndon Johnson signed an tionship—each of these pillars enabling wage and price controls to minimize amendment to the Social Security Act the growth and development of the inflation and war costs. In a setting of which provided medical care for the other. The social, technological , and severe labor shortages , companies elderly and poor—Medicare and Med - economic changes of the past 50 years unable to offer higher wages , could icaid respectively .70 The dramatic rise of have witnessed the migration of surgery attract much needed workers by offer - healthcare costs in the years that fol - from the hospital to the ambulatory set - ing healthcare insurance instead. To lowed caused Medicare to amend its fee ting , and , more recently , into the office. encourage the trend, the federal gov - structure in 1983 with the implementa - Today’s gynecologist has the benefit of ernment ruled that monies paid for tion of the prospective payment system small-diameter hysteroscopes (Fig . 9) , employees’ health benefits would not be for Medicare patients based on diagnos - self-contained global endometrial abla - taxed. The result was a surge in the tic-related groups (DRGs). The pro - tion systems (Fig . 10), and even minia - number of Americans with health insur - found changes in the economic ture resectoscopes (Fig . 11) and ance between 1940 and 1955 , which incentives for hospitals made ambulato - morcellators that were unknown to pre - skyrocketed from 10 to 60% 63 as labor ry surgery profitable, which , together vious generations. Recently, the change unions became major consumers of with newer anesthetic and minimally in the reimbursement structure 5,6 has health insurance. invasive techniques , promoted a rapid provided an additional impetus for diag - World War II and its aftermath growth of ambulatory surgery. The nostic and operative hysteroscopies as brought astonishing growth in medical number of procedures being performed well as endometrial ablation in an technology. The recently industrialized in ambulatory surgery centers (ASCs) office-based setting. Apart from the production of penicillin played a major increased from 380,000 in 1983 to 31.5 economic incentives, the gynecologist role in treating countless wounded fol - million in 1996 .71 benefits from the greater ease of sched - lowing the D-day landings .64 The imme - The price tag of healthcare has seen a uling procedures , the consistency of diate post-war era saw the introduction dramatic increase in the United nursing personnel , and the improved of the intensive care unit ,65 the expand - States —the cost as a percentage of efficiency afforded by the office struc - ed use of ventilators ,66 and even the gross domestic product (GDP ) ture. The benefits to patients include development of chemotherapy for sev - increased from 5% in 1960 to 17.9 % in convenience, privacy, reduced cost , and eral cancers such as leukemia .67 All of 2017 .72 The economic stress forced greater personal attention in an already these scientific achievements under - many hospitals to the brink of closure, 73 familiar environment . But , three signifi - scored the increasingly important role increasing the financial burden to the cant problems persist in OBGS. of the hospital and demand for its ser - existing ASC infrastructure , insurers, The first is a lack of accreditation vices. Although the federal, state , and physicians , and patients . The forces of standards around the country. Only a local governments had provided limited cost-containment and technological small fraction of states require accredi - support to hospitals in the early 20 th innovations that permitted a shift in tation by one of the three major agen - century , they would play an increasingly surgery from the hospital to ambulatory cies .75 Although ACOG published vital role in the development of the hos - settings are now encouraging the trans - guidelines for OBGS in 2010 ,51 these pital system in the post-war era. fer of relatively low -risk and non-inva - lack the force of a legal standard and , in Two important hospital construction sive procedures to the office setting . most cases , formal accreditation initiatives were adopted following According to Urman et al ., 74 medical remains voluntary. WWII—the expansion of the Veterans practitioners in private offices per - A second issue in instituting OBGS Administration (VA) program 68 and the formed 10– 12% of ambulatory proce - relates to the lack of training. Most resi - Hill-Burton Act. 69 Under the direction dures with an estimated 12 million in dency training programs allow for the

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Office-Based Gynecologic Surgery (OBGS): Past, Present, and Future: Part I WORTMAN/CARROLL mastery of hysteroscopy, polypectomy, intraoperative events such as cervical dures performed with the adjuvant use endometrial ablation , and a wide variety stenosis, vasovagal reactions , and unan - of intravenous sedation. In 2012 , one of of gynecologic procedures under gener - ticipated pain. There are few studies that the authors (MW) published a series of al anesthesia. But , as these procedures critically analyze the acceptability of 414 operative hysteroscopies 86 including are transferred to an office-based set - these techniques for patients. In the endomyometrial resection, myomec - ting , there is often a lack of skilled and author’s experience, exceeding 50,000 tomies, polypectomies, division of uter - experienced supervision. This can be an office-based procedures, a substantial ine septae and lysis of adhesions under important obstacle to OBGS as proce - number of patients require some form moderate sedation with a completion dures under local anesthesia or minimal of intravenous sedation or monitored rate of 99% —the one case that was not or moderate sedation are often highly anesthesia care to undergo commonly - completed was unrelated to pain con - modified compared to their hospital performed gynecologic procedures in a trol. counterparts. manner that is humane and considerate The third issue for gynecologists per - and achieves a desirable outcome. forming OBGS is that, unlike other spe - Bradley and Wildrich 81 reported that , ConclusioCnOs NCLUSION cialties, gynecologists have not embraced even in the most experienced hands, the use of sedation and analgesia proto - 12.4% of patients considered perfor - cols for office practice. While plastic sur - mance of a vaginoscopic technique with - In the next of this two-part series , we geons, dermatologists, urologists, and out paracervical block (PCB) and a will review the current state of office- gastroenterologists have adapted to the small-diameter flexible hysteroscope , based technology and examine the office-based environment by providing a “barely tolerable ,” while another 3.6% author’s nearly 40 -year experience in range of anesthetic regimens—including considered it “intolerable ,” precluding performing simple and complex gyneco - local, intravenous sedation , and moni - completion of the procedure. Readman logic procedures in the OBS setting. We tored anesthesia care —gynecologists and Maher 82 demonstrated that diagnos - will examine the organizational struc - have lagged far behind. In 1990 , tic hysteroscopy without supplemental ture of an office-based surgery center, Herman 76 reported a prospective study analgesia or sedation was intolerable in the initial and recurrent training of of 212 consecutive unselected patients 10% of subjects , while Lau et al .83 com - office staff, and, more recently, the undergoing office-based colonoscopy and pared the use of 2% lignocaine with incorporation of mobile anesthesia ser - noted that while 82% of patients normal saline in women undergoing vices as well as the importance of required no analgesia or sedation , the hysteroscopy and biopsy and concluded accreditation to professional staff, remaining 18% found it essential for the that PCB failed to attenuate the pain patients , and the public. It is the author’s completion of their procedure. In 2007 , associated with hysteroscopy and noted firm belief that , as gynecologists whose Rubin et al .77 reported the results of that the injection itself is painful and goal is to offer thoughtful and compas - 3,733 subjects undergoing colonoscopy associated with some risk. One might sionate care to women , we can and and compared physician -administered reasonably conclude that PCB anesthesia should do better. Moreover, we must conscious sedation (midazolam and fen - may, at best , be ineffective, and , at gain and maintain public trust to assure tanyl) to anesthesiologist-supervised worst , may be associated with increased patients that office-based surgery offers propofol, noting that both methods were pain attributable to the injection itself .83 not only the advantages of expedience over 96% successful. In 2008 , the Amer - In recent years, with the advent of and economic incentives but that it does ican Society for Gastrointestinal self-contained and non-resectoscopic so without compromising care. Endoscopy published guidelines for seda - endometrial ablation techniques , many Our ethical responsibilities for pro - tion and anesthesia in GI endoscopy 78 so-called “global endometrial ablation” viding patient safety and comfort in an providing important principles for the procedures have migrated to the office office setting are affirmed in the ACOG administration of these agents in an as well. A study by Clark 84 found that Executive Summary for the Presidential office-based setting . Similarly, urologists 34% of women undergoing radiofre - Task Force on Patient Safety in the have long recognized the importance of quency ablation—the most common Office Setting ,52 which states that “the providing the option of intravenous pro - variety used in the United States — type and level of anesthesia should be cedural sedation for cystoscopy -79 and “would have preferred general anesthe - dictated by the procedure with input sonographically -guided prostate biopsy .80 sia in hindsight.” Wallage et al .85 studied based on patient preference. The deci - Yet , the literature for OBGS provides lit - 191 women who were randomized to sion regarding the type of anesthesia tle guidance in offering the option of undergo microwave endometrial abla - should not be altered based on limita - intravenous sedation for patients who, tion under general or local anesthesia. tion of equipment or personnel in the because of anxiety or the need for pain The authors noted that only 69% of eli - office setting; rather, it should be based control, require it. gible women would even consider treat - on patient need in relation to the While office-based surgery offers ment under local anesthesia. Of those planned procedure.” STI clear advantages to properly -trained that began their treatment under local gynecologists , most OBGS procedures anesthesia , 9% were unable to complete appear to rely heavily on proper patient their procedures without conversion to AuthAoUrTsH’ ODRiSs’c DlIoSsCuLOrSeUs RES selection, the use of local anesthetics, general anesthesia. Although numerous and orally -administered non-opioid women can tolerate many of the mini - analgesics and sedative hypnotics. The mally invasive office-based gynecologic Dr. Wortman is a consultant for limitations of such an approach are obvi - procedures , it is clear that many would OCON Healthcare, Ltd . Ms. Carroll ous given the frequency of unexpected prefer the option of having their proce - has no conflicts of interest to disclose.

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