Broken Play Laparoscopy -- What to do when there's no findings?

MESA, Ariz., July 2, 2018 /PRNewswire/ -- Any surgeon who has done enough laparoscopy has been there. In the office it seemed like the patient had all the classic signs of endometriosis. She had a family history of endometriosis, the pain was worse during intercourse, worse during her period, there might have an even been a little hemorrhagic cyst that looked "oh-so-close" to an endometrioma on ultrasound. But you got the scope in and her abdomen is cleaner than a self-reported surgical complication list. Other than just waking up the patient and explaining the pain must not be from gynecologic causes, what do you do? In football we have a scenario very much like this – we call it a "Broken Play." Basically the quarterback gets the ball and whatever was supposed to happen that play, be it a handoff or pass suddenly cannot happen. It could be because of unexpected coverage, or it may be the running back tripped or the receiver ran the wrong route. Whatever the reason, the quarterback ends up with the ball in a collapsing pocket, wondering if there's any way he can make something good happen out of the horrible turn of events that have unfolded for him. I've heard many ideas about what to do in this scenario, so I'll cover a few of them in detail.

"Almost" Incidental Appendectomy

We all know that appendix is going to look a little infected. Does that mean it deserves to go? Do you even have privileges to remove it at this hospital (or surgery center?) The nurse thinks that there's a general surgeon a few operating rooms over, or in the cafeteria, or living just "5 minutes away." Generally, suspicion of acute appendicitis is considered an emergency that does not require advanced consent. While I agree the temptation may be strong, I recommend not to perform the incidental appendectomy unless you really feel there are compelling signs of inflammation. Proactively, however, I do recommend discussing the appendectomy with all patients who have primarily right sided pelvic pain before surgery, although I can't say I always remember to do it. It really should be something to think about consenting the patient for whenever you are going in for right sided pelvic pain without a clear cause. I recommend going so far as to asking the patient ahead of time "if I don't find anything, would you want your appendix removed? "

"Desperation" Ovarian Cystectomy

As gynecologic surgeons we are sometimes put in a real dilemma as to whether or not to remove a normal appearing ovary that really seems like the cause of the pain. If you're like me, it really takes a high threshold to remove an otherwise normal appearing ovary, just because it is assumed to be the unproven cause of the patient's pain. Cystectomy, on the other hand, backed by clinical suspicion, can appear as a seemingly free move in the uncomfortable case of a laparoscopy devoid of findings. We can always find a small follicle that could be the cause of the pain, right? With less than a third of ovarian tissue being required to maintain hormonal support, one could also ask the question of why you would not try to fix the patient's pain with a generous ovarian cystectomy?

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