Gynaec Endoscopic Surgery“By all for all”

Dr. Raju R SahetyaMD., DGO., DFP., FCPS., FICOG.,

Obstetrician & GynaecologistExpert

Infertility, Endoscopy & Prenatal Genetic Diagnosiswww.pushpaahospital.com, drrajusahetya@gmail.com

HonoraryBSES Hospital, Hiranandani Hospital, Mumbadevi Hospital

Vice PresidentIndian Society for Prenatal Diagnosis and Therapy

Member Managing CouncilMumbai Obstetrics & Gynecological Society

Association of Fellow Gynecologist

INTRODUCTION

Minimal access surgery has revolutionised the field of gynaecological surgery and

changed the way pelvic surgery was practised

This came about with the realisation that the minimal access approach, in trained hands,

allowed for a much more elegant form of surgery with reduced trauma

to the abdominal wall and pelvic tissue.

Cradle of Endoscopy

The laparoscopic approach had its infancy in gynaecology

in the middle of the twentieth century,

firstly with diagnostic laparoscopy and

later with

simple tubal sterilisation procedures.

Historical Perspective

Prior to 1980, traditional gynaecological

surgery remained

unchanged for over 60 yrs.

In the 1970s, Kurt Semm from Kiel pioneered operative laparoscopy into the

mainstream gynaecology.

The 1980s saw the introduction of the CO2 laparoscopic laser.

Historical Perspective

• In 1988, Harry Reich performed the world’s first laparoscopic hysterectomy.

• By early 1990s, the availability of

surgical aids such as quality

cameras, ports, staples and electrocautery

had facilitated the progression of laparoscopic surgery

Benefits of Laparoscopic Surgery

Very small incisions

in healthy tissue and muscle.

Generally, incisions are 3 to 4 , half to 1 cm,

shorter than the

6 to 8 inches with “open surgery”.

As a result

less pain, shorter hospital stay, fewer adhesions, shorter recovery time and

smaller scars.

Incisions at Laparoscopic Surgery

Assessment of the impact

The ability to translate the potential benefits of minimal access surgery into actual

results in patients

depends, in part, on how widely the technique has been adopted.

It is also an indicator of the maturity of our

development in this area.

DISCUSSION

The benefits of minimal access surgery are evident provided

the practitioners are trained in the technique.

Some applications, particularly those which can be easily performed by a generalist

have found immediate impact,

whilst others, such as the more advanced procedures which require additional training

and special skills, have had a much lower short term impact.

ectopic pregnancy

The treatment of ectopic pregnancy was one of

the earliest applications of the

laparoscopic surgery.

It was first described in the 1970s but the technique really matured in the 1980s.

It is a relatively simple procedure and is generally one of the first conditions that a gynaecologist

beginning his or her experience

in laparoscopic surgery will deal with.

ovarian cystsFraught with controversy in the early 1990s owing to

the concern that patients with ovarian cancer may

be inadvertently missed or mismanaged.

However, this problem can be minimised when

careful pre-operative evaluation & selection of patients, Tumor marker, Colour Doppler, CT / MRI

combined with a disciplined and thorough intra-operative evaluation of the cyst and peritoneal

cavity.

ovarian cysts…contn..

The take-up rate was not as rapid as that for treatment of ectopic pregnancies.

consultants who were not trained in the technique were still uncomfortable with

large cysts~ dermoids

Myomectomy and hysterectomy

The impact of the minimal access approach was obviously more limited as these are

level three procedures.

This also means that only gynaecologists

who have undergone additional advanced training

were accredited to perform these procedures

To ensure that the outcome of these procedures were good and complication rates were kept low.

Myomectomy and hysterectomy…

A recent prospective randomised study comparing between laparoscopic myomectomy and

abdominal myomectomy suggested that the obstetric outcome should be similar.

Notwithstanding the slow take-up rate,

Laparoscopic myomectomy and hysteroscopic resection of submucous fibroids were able to

reduce the percentage of laparotomy performed for the procedure.

Laparoscopic Myomectomy

Other procedures

laparoscopic resection of advanced endometriosis,

Laparoscopic Burch colposuspension, and

laparoscopic tubal reanastomosis.

Impact of Endoscopy surgery

Enthusiasts were also advocating the laparoscopic approach for

early stage cervical and endometrial cancer

such as laparoscopic Lymph-adenectomy & radical hysterectomy.

Overall rate of complications in the 27 selected randomized controlled trials.

Chapron C et al. Hum. Reprod. 2002;17:1334-1342

© European Society of Human Reproduction and Embryology

Traditional Gynaec is made to believeEndoscopic Surgery is…

• Difficult and require extra courage

• Training is not easy and is extensive

• Set up is expensive or ever demanding

• Hand eye coordination is not simple

• Not easy to assist and participate

Kept Distant from Training and Adapting Endo-surgery

Myths by senior traditional Gynaec Surgeons Lap/Hystero training is long / difficult /

young.In actual fact

Does not require extra ordinary courage

Juniors, average Gynaecologist pick up Endoscopy &50% of them become good even without being

Exceptionally good conventional surgeon.

An average traditional Onco-Surgeon performs Laparoscopic Radical Surgery and have became experts in spite of

initial few complications

Late Dr. S.K.Bhansali got trained and performed Laparoscopic cholecystectomy at 70 years plus of age.

Myth by traditional Gynaecologist

that Lap / Hystero setup is expensive

In actual fact

Cost of up-gradation of the set up,

That surely appreciates with time

Where there is a Will there is a Way

A successful endo-surgeon sooner or later

gains much more fame and revenue

Training and Team Work

The Make-up of 21st Century Training

• Tomorrow’s gynaecologists will be trained and assessed over a

variety of surgical skills covering

energy sources, suturing skills and

other techniques for haemostasis, and

of course overall ability.

The Make-up of 21st Century Training

It is imperative that this generation is trained to perform

elegant anatomical surgery rather than the unanatomical feel safe approach of the past.

The make-up of our

twenty-first century trainees

will have enormous effect on

the future of gynaecological surgery.

Conclusion

The minimal access approach demands that the gynaecologists be trained in an

entirely different, though not difficult discipline from open surgery

The hand-eye co-ordination is very different, and the margin for error is

far smaller than in traditional open surgery.

ConclusionThe challenge for the future will be to have

adequate provision for structured training within the gynaecology residency

programme to equip the new generation of gynaecologists with the skills to perform

these procedures well and safely,

So as to confer the benefit of minimal access surgery to the broadest possible spectrum

of people who need surgery.

" Don't be afraid of being slow in new progress, be scared of standing still &

not starting at all”

Its all about the Mind Set and Training

So my dear friends

Set your mind and get advanced training

To make possible

Gynaec Endoscopic Surgery“By all for all”

Thank You