Your SlideShare is downloading. ×
0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Hysteroscopy 0
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Hysteroscopy 0

726

Published on

Published in: Health & Medicine
1 Comment
1 Like
Statistics
Notes
  • Quite interesting presentation, congratulations!
    http://www.medicaldebtsconsolidation.com
    http://www.medicaldebtsconsolidation.com/category/medical-debt-consolidation/
    http://www.medicaldebtsconsolidation.com/category/medical-debt-relief/
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total Views
726
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
0
Comments
1
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • Transcript

    • 1. Office Hysteroscopy part II procedures MPH Vleugels Riverland hospital Tiel
    • 2. Hysteroscopic procedures in the office <ul><li>diagnostic procedures </li></ul><ul><li>minor surgical procedures </li></ul><ul><ul><ul><li>conventional instruments </li></ul></ul></ul><ul><ul><ul><li>Versapoint ® </li></ul></ul></ul><ul><li>Essure ® sterilisation </li></ul>
    • 3. Hysteroscopic procedures in the office <ul><ul><ul><li>Versapoint ® </li></ul></ul></ul>
    • 4. “ how long does the procedure take…???? Hysteroscopic procedures in the office
    • 5. Versapoint: CLINICAL RESULTS ANAESTHESIA totaL general local none polyps 95 24 41 30 fibroids 51 14 23 14 septa 8 8 -- -- synechia 7 6 -- 1 others 2 -- 1 1 total 163 51 65 46 M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office
    • 6. Versapoint: fibroid size / operation time M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office
    • 7. Type intramural extension 0 none I <50% II >50% Submuceus Myoma: Classification
    • 8. Versapoint:fibroids comparison general/local anaesthesia none/local general number: 37 14 type 0 19 (51%) 5 (36%) type I 16 (43%) 7 (50%) type II 2 (6%) 2 (14%) M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office
    • 9. Versapoint: polyp size / operation time M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office
    • 10. Versapoint: Conclusions for the office <ul><li>small </li></ul><ul><li>bipolar electrode: coagulation </li></ul><ul><li>cutting vaporisation </li></ul><ul><li>active in normal saline </li></ul><ul><li>fits in 5mm scope </li></ul><ul><li>learningcurve 3-5 procedures for diagn. scopist </li></ul><ul><li>safe as long as the principles of hysteroscopy are respected </li></ul>Vleugels MPH gyn endoscopy 2002
    • 11. Versapoint: results knowing the specific characteristics = small electrodes, ACCEPTABLE OPERATION TIME 30-45 MIN ???? FIBROID <2CM POLYP <2CM HOW MUCH OF THE PATHOLOGY CAN BE OPERATED WITH THIS ELECTRODE ON THE OFFICE? Hysteroscopic procedures in the office
    • 12. Retrospective analysis 2yrs surgery; 92% of all FIBROIDS TYPE 0 OR TYPE I 47% of all FIBROIDS TYPE 0 84% of all FIBROIDS SMALLER THAN 3 CM 95% of all POLYPS SMALLER THAN 4 CM 70 - 80% can be operated in the office Hysteroscopic procedures in the office How much pathology can be operated in the office?
    • 13. operation settings on OPD <ul><li>continous flow hysteroscope 4.2or 4.9 mm </li></ul><ul><li>control in/outflow = resorption normal saline </li></ul><ul><li>cutting (polyps) = Versapoint twizzle electrode </li></ul><ul><li>vaporizing (fibroid) = Versapoint spring electrode </li></ul><ul><li>start always presettings VC 1 with small electrodes </li></ul><ul><li>and decrease to VC2 or VC 3 when touching the wall </li></ul><ul><li>most important setting = well communicating nurse </li></ul>
    • 14. Versapoint on the OPD Trics for removal polyps <ul><li>Use twizzle </li></ul><ul><li>cut into pieces </li></ul><ul><li>present to pathologist!! </li></ul><ul><li>Do not vaporize </li></ul>
    • 15. Versapoint on the OPD &quot;painting like an artist&quot; Trics for removal fibroid
    • 16. <ul><li>PREMEDICATION: </li></ul><ul><li>diclofenac supp 2-3 x 100 mg </li></ul><ul><li>paracetamol 1 x 1000 mg </li></ul><ul><li>(diazepam 1 x 10 mg) </li></ul><ul><li>IF NECESSARY: </li></ul><ul><li>paracervical block lidocain 0.5% + epinephrine 1/200.000 </li></ul><ul><li>MANDATORY IS A GOOD SOCIAL INTELLIGENT NURSE </li></ul><ul><li>and doctor!!! </li></ul>Versapoint: Analgesia on OPD
    • 17. Office Based Hysteroscopic Surgery with a Bipolar Electrosurgery System in Normal saline VERSAPOINT
    • 18. Take home messages………...
    • 19. <ul><li>Surgery L.A./non anaesthesia: </li></ul><ul><li>informed consent/good communication </li></ul><ul><li>criterium of speculum examination ( cutner,erian gyn.endo 1996) </li></ul><ul><li>POLYPS < 3 CM </li></ul><ul><li>FIBROIDS < 2 CM type 0 and I </li></ul><ul><li>SYNECHIAE CLASSICATION WAMSTEKER < III </li></ul>patient selection for bipolar hysteroscopic surgery in the office Hysteroscopic procedures in the office
    • 20. <ul><li>Surgery general anaesthesia/spinal: </li></ul><ul><li>patients after cervical surgery </li></ul><ul><li>POLYPS > 3 CM </li></ul><ul><li>FIBROIDS  2 CM type 0 and I </li></ul><ul><li>FIBROIDS type II </li></ul><ul><li>SYNECHIAE CLASSICATION WAMSTEKER  III </li></ul><ul><li>SEPTUM </li></ul>patient selection for bipolar hysteroscopic surgery not in the office Hysteroscopic procedures in the office
    • 21. Hysteroscopic procedures in the office <ul><li>Essure ® sterilisation </li></ul>
    • 22. Hysteroscopic procedures in the office <ul><li>A new method of female hysteroscopic sterilisation </li></ul><ul><li>Marketed and sold by Conceptus, Inc. </li></ul><ul><li>Approved by FDA on Nov. 4 th , 2002 </li></ul>Essure ® sterilisation
    • 23. Hysteroscopic procedures in the office Essure procedure= Bettocchi vaginal approach
    • 24. Hysteroscopic procedures in the office
    • 25. Hysteroscopic procedures in the office Ideal Placement Spanning the Uterotubal Junction (UTJ) With Deployed Micro-insert Visible in the Uterine Cavity UTJ 3-8 expanded outer coils visible in uterine cavity Hysteroscopic Image 2 4 3 1 4 expanded outer coils Last coil not expanded Uterus Cervix
    • 26. The dutch appraoch
    • 27. Hysteroscopic procedures in the office Can this procedure done on the OPD without any anaesthesia? which method? * procedure time? * pain experience? * placement failure rate * patient satisfaction? ** control after 3 months? *** * Study A n=173; ** study B n=273 *** study C n=160; all studies submitted
    • 28. Flowchart essure sterilisation Intake informed consent gyn examin ultrasound data recording Planning < CD 10 Premedication procedure OPDepartm. Data recording pain score list Ultrasound TVS HSG 1-2-5 followup T=0 T=12wks T=12 wks Hysteroscopic procedures in the office
    • 29. Dutch protocol <ul><li>Planning procedure < 10 e cycle day </li></ul><ul><ul><ul><li>In case of spontaneous cycle or OAC; no difference!! </li></ul></ul></ul><ul><ul><ul><li>No need to remove the IUD unless a difficult procedure </li></ul></ul></ul><ul><li>Premedication </li></ul><ul><ul><ul><li>Diclofenac 100mg sup at their wake up </li></ul></ul></ul><ul><ul><ul><li>Diclofenac 100mg sup+1000mg paracetamol orally leaving home </li></ul></ul></ul><ul><li>Good breakfast/lunch!! Partner present </li></ul>Hysteroscopic procedures in the office
    • 30. Essure on the OPD; method without anaesthesia <ul><li>“ Bettocchi”approach=no speculum, no tenaculum, no local anaesthesia, no sedation </li></ul><ul><li>Dilatation warm Normal saline 0.9%, low pressure, minimal slow movements </li></ul>* Study A n=173 accepted Hysteroscopic procedures in the office
    • 31. Evaluation of pain (Visual Analoque Score; 0-10 ): average 2,5 ±2,5 (0-8) median 2,0 two patients got local anaesthesia ; 2/900 Average amongst nulli; 5.2! Dutch experience; Results 2 first clinics Hysteroscopic procedures in the office
    • 32. Hysteroscopic procedures in the office Dutch experience; First 273 patients procedure time introduction of scope till removal
    • 33. Averaged Procedure time related to parity; Multiparae; 10.3 minutes Nulliparae; 15.3 minutes Procedure time related to placement failure rate; Succes placement; 9.8 minutes Failure placement; 24!! minutes Hysteroscopic procedures in the office procedure time Multicenter data netherlands n=1021 21 clinics in 2005
    • 34. Crude failure rate; 7.4% True failure rate=after exclusion Asherman 5.3% Failure rate related to parity (trainings clinic n=297 2002-2004) failure rate nulliparae 32% failure rate multiparae 5.1% Failure rate Multicenter data netherlands n=1021 21 clinics in 2005 Hysteroscopic procedures in the office
    • 35. How do we control the effect? X ray to see whether the device is in abdomen? In the uterus? HSG to prove occlusion of the tubes?? Hysteroscopic procedures in the office
    • 36. Hysteroscopic procedures in the office Control after 3 months by transvaginal ultrasound!!!
    • 37. No X-Ray No- HSG HSG HSG X- Ray A B c Predictive value of US?? Hysteroscopic procedures in the office
    • 38. Hysteroscopic procedures in the office Diagnostic value of Transvaginal Ultrasound Sensitivity: 50% Specifity: 94.6% Pos. predictive value: 99.3 (95% CI: 98.0% - 100.6%) Neg. predictive value: 11% (95% CI:6.0% - 16.0%) Veersema S, Vleugels MPH: fert ster. Dec 2005
    • 39. Hysteroscopic procedures in the office <ul><li>X HSG only required: </li></ul><ul><li>in unsatisfactory placements </li></ul><ul><li>after difficult procedures </li></ul><ul><li>Pelvic X-ray only required: </li></ul><ul><li>missing device by ultrasound </li></ul>13 th Annual Congress of the ESGE, Cagliari, Sardinia In all other cases an ultrasound is sufficient
    • 40. The dutch experience Patients leave straight after Treatment for work or other activities
    • 41. Hysteroscopic procedures in the office <ul><li>It takes twelve weeks for the tubes to be completely occluded. </li></ul><ul><li>Patient must stay on alternative contraception for the twelve weeks </li></ul>After the Procedure
    • 42. <ul><li>Conditions </li></ul><ul><li>good (diagnostic ) hysteroscopist </li></ul><ul><li> operating without local anaesthesia; </li></ul><ul><ul><ul><ul><ul><li>BETTER OUTCOME THAN LOCAL/GENERAL; Ubeda, Lopez, Dhanaut studies </li></ul></ul></ul></ul></ul><ul><li> create appropiate conditions </li></ul><ul><ul><ul><ul><ul><li>i.e. social intelligent doctor,nurse </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>i.e. nice surrounding, quiet, music! </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>i.e. work quickly,fluently </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>i.e. good breakfast </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>i.e. extra monitor for patient </li></ul></ul></ul></ul></ul>Hysteroscopic procedures in the office
    • 43. <ul><li>take home message </li></ul><ul><li>Essure has been developed to be used without anaesthesia /without IV sedation in out pat clinic/center,…. </li></ul><ul><li>Using the correct instruments on the proper way after training of the whole team = doctor and assistent,…. </li></ul><ul><li>Respecting the limits of the patient=she is guiding you, then.. </li></ul><ul><li>Control can be done by ultrasound unless a correct protocol has been followed </li></ul><ul><li>Efficacy, safety and satisfaction of patient and the team will be high </li></ul>Hysteroscopic procedures in the office
    • 44. Placement failures: 14 (8%) partial Syndrome of Asherman 5 tubal spasme 2 failure of Essure device ( former type) 1 unknown 4 pre-existant obstruction tubes 2 all 14 patients got laparoscopic sterilisation The dutch experience <ul><li>Thank you, for your attention </li></ul><ul><li>In case you need more information… </li></ul><ul><li>Training for Essure protocol…. </li></ul><ul><ul><ul><li>[email_address] </li></ul></ul></ul>
    • 45. Hysteroscopic procedures in the office
    • 46.  

    ×