Gynaec Endoscopic Surgery “By all for all” Dr. Raju R Sahetya MD., DGO., DFP., FCPS., FICOG., Obstetrician & Gynaecologist Expert Infertility, Endoscopy & Prenatal Genetic Diagnosis www.pushpaahospital.com, email@example.com HonoraryBSES Hospital, Hiranandani Hospital, Mumbadevi Hospital Vice President Indian Society for Prenatal Diagnosis and Therapy Member Managing Council Mumbai Obstetrics & Gynecological Society Association of Fellow Gynecologist
INTRODUCTIONMinimal access surgery has revolutionised the field of gynaecological surgery and changed the way pelvic surgery was practisedThis came about with the realisation that the minimal access approach, in trained hands, allowed for a much moreelegant form of surgery with reduced trauma to the abdominal wall and pelvic tissue.
Cradle of Endoscopy The laparoscopic approach had its infancy in gynaecologyin 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.
Assessment of the impactThe ability to translate the potential benefits of minimal access surgery into actual results in patientsdepends, 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 providedthe 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 hysterectomyThe impact of the minimal access approach was obviously more limited as these are level three procedures. This also means that only gynaecologistswho have undergone additional advanced training were accredited to perform these proceduresTo 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.
Traditional Gynaec is made to believe Endoscopic 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 participateKept Distant from Training and Adapting Endo-surgery
Myths by senior traditional Gynaec SurgeonsLap/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 Gynaecologistthat 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 WayA successful endo-surgeon sooner or later gains much more fame and revenue
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 andother techniques for haemostasis, and of course overall ability.
The Make-up of 21st Century Training It is imperative that this generation is trained to performelegant anatomical surgery rather than theunanatomical 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.
ConclusionThe minimal access approach demands that the gynaecologists be trained in an entirely different, though not difficult discipline from open surgeryThe hand-eye co-ordination is very different, and the margin for error isfar smaller than in traditional open surgery.
Conclusion The 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.
" Dont 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 friendsSet your mind and get advanced training To make possible Gynaec Endoscopic Surgery “By all for all” Thank You