Rethinking pharmacological venous thromboembolism prophylaxis in minimally invasive gynaecological procedures

Although VTE risk in minor gynaecological procedures is low, a systematic approach to prophylaxis is necessary

Venous thromboembolism (VTE) is a rare but highly morbid risk of surgery that is largely preventable with appropriate prophylaxis.1,2 Methods of VTE prophylaxis range from conservative options with early ambulation, to mechanical compression devices used during and after surgery, to pharmacological prophylaxis with unfractionated or low molecular weight heparin. The current National Health and Medical Research Council guidelines, endorsed by the Royal Australian and New Zealand College of Gynaecologists, recommend the use of pharmacological prophylaxis for all gynaecological operations.1 However, this fails to acknowledge the difference in VTE risk in major versus minimally invasive surgeries. Indeed, the widely recognised international guidelines published by the American College of Obstetricians and Gynecologists and the American College of Chest Physicians incorporate both procedural (eg, mode of incision) and patient factors in the assessment of VTE risk.3,4 These guidelines encourage early ambulation or mechanical prophylaxis alone for very low and low risk patients, respectively, which largely includes those undergoing minimally invasive gynaecological procedures (with no additional risk factors).3,4 Further, a 2018 systematic review highlighted the very low risk of VTE in minimally invasive gynaecological surgeries, including laparoscopic and vaginal procedures, compared with open procedures. The review concluded that there is unlikely to be any additional benefit of pharmacological prophylaxis compared with mechanical prophylaxis alone in low risk patients.5 This is particularly relevant given the increased risk of haemorrhage associated with pharmacological VTE prophylaxis.6 Consequently, a 2020 Australian Commission on Safety and Quality in Health Care report acknowledged that there is no consensus among evidence‐based guidelines regarding the preferred method of VTE assessment, and clinicians and institutions should refer to the evidence‐based VTE risk assessment tool of their choosing.7 We sought to evaluate the risk of VTE in minimally invasive gynaecological procedures and determine the need for pharmacological prophylaxis in addition to mechanical prophylaxis.