1. 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, drrajusahetya@gmail.com
Honorary
BSES 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
2. 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.
3. 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.
4. 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.
5. 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
6. 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.
9. 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.
10. 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.
11. 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.
12.
13. ovarian cysts
Fraught 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.
14. 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
15.
16. 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.
17. 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.
20. Other procedures
laparoscopic resection of advanced
endometriosis,
Laparoscopic Burch colposuspension, and
laparoscopic tubal reanastomosis.
21.
22. 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.
24. 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 participate
Kept Distant from Training and Adapting
Endo-surgery
25. 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.
26. 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
29. 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.
30. 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.
31. 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.
32. 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.
33. " Don't be afraid of being
slow in new progress, be
scared of standing still &
not starting at all”
34. 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
