endoscopic surgery by all for all
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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
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