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Setting of Hysteroscopy unit

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Dr.Pragnesh Shah is Gynaecological Endoscopic surgeon from Ahmedabad,Gujarat,India and having keen interest in Gynaecological Endoscopic Training. He is having experience of most of the difficult and …

Dr.Pragnesh Shah is Gynaecological Endoscopic surgeon from Ahmedabad,Gujarat,India and having keen interest in Gynaecological Endoscopic Training. He is having experience of most of the difficult and complicated laparoscopic and hysteroscopic surgeries with world class infra structure in Ahmedabad.
He has given Gynaecological Endoscopic Training to many Gynaecologists and surgeons of the world.

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  • 1. Short bio-data Dr.Pragnesh Shah
    • FOGSI’S Endoscopy Committee Chairperson.
    • West Zone co-ordinator, Indian Association Of Gynaecological Endoscopists (IAGE ).
    • Practicing Gynaec. Endoscopic Surgeon in Ahmedabad.
    • FOGSI recognized Advanced Endoscopic Training center in Ahmedabad.
    • Presented many presentations at International (AAGL), National (FOGSI).
    • Keen interest in teaching & transferring Endoscopic skill to fellow Gynecologists.
    • KEEN TO ESTABLISH STRATEGIES FOR ENDOSCOPIC ACCREDITATION INITIATIVES & Setting standards in Gyn. Endoscopy Training & practices IN INDIA .
  • 2. Setting of Hysteroscopy Unit : Fertility Enhancement & Laparoscopy Dr.Pragnesh Shah (M.D.,FICOG) FOGSI Endoscopy Committee Chairperson Ahmedabad www.laparoscopyexpert.com Email : [email_address]
  • 3. Why hysteroscopy Unit ? Setting Standards in Hysteroscopy Practices
    • How many Laparoscopies are carried out without hysteroscopy while doing Endoscopy for Infertility patient ?
    • IVF experts are doing only hysteroscopy ?.....Laparoscopy ?….
    • Should we include Hysteroscopy training compulsory in Gyn. Endoscopy training program ?
    • How many Medical Collages are equipped with Hysteroscopy unit today in India ?
    • No. of level-I / II / III Hysteroscopic surgeries done today……
  • 4. How can we make hysteroscopy safe ?
    • We should understand the potential hazards of the procedure and equipments involved
    • The complication rate in diagnostic hysteroscopy is low and was estimated by Lindemann (1989) to be 0.012% .
    • Complications from operative hysteroscopy are more common and potentially more serious.
  • 5. UNIVERSAL CONCERN FOR SAFETY :
    • ACOG GUIDELINES ON PATIENT SAFETY
    • ON ERROR MANAGEMENT : LESSONS FROM AVIATION : BMJ 200; 320
    • The impact of aviation based team work training on attitudes of health care personnel :
    • J Am Coll Surg 2004; 199
    • My copilot is a nurse : using crew
    • resource management training in
    • commercial aviation
    • J AORN 2006; 83
    • Reinvigorating safety in Office based
    • Gynaecology : JMIG 2010 DEC
  • 6. Setting of Hysteroscopy Unit
    • Proper Hysteroscopic training with hands on practices on Hystero trainer.
    • Changing attitude : All Infertility Endoscopy evaluation must be combined with Hysteroscopy & Laparoscopy.
    • Selection of cases and anticipating complications in difficult/complicated cases from the basis of our skill/experience.
    • Strict Pre-op evaluation & preparations.
    • Safe OR Infrastructure & Check lists & protocols (SOPs).
    • Intra operative monitoring protocols, Mock drills.
    • Post-operative care.
    • EMR & Video recording of all cases and Auditing of cases.
  • 7. HYSTEROSCOPIC TRAINING
    • Diagnostic Hysteroscopy
    • Operative Hysteroscopy
    • T.C.R.E.
    • Sub mucus Fibroid Resection
  • 8. Selection of cases and anticipating Complications in difficult/complicated cases from the basis of our experience
    • 5 th to 10 th Day of Menstrual cycle; Thin Endometrium
    • Condition of cervix : Small :
      • Good dilator set with 5 mm difference.
      • Pre-op Misopristol.
      • Office Hysteroscopes : 2mm,2.9 mm, 1.9 mm etc.
    • Sev Asherman's syndrome : Skill level & USG guidance
    • Multiple fibroids : Expert TVUSG for fibroid mapping
    • Misplaced IUCD : Expert TVUSG with Cu-t location
    • TCRE : Good counseling with lap TL
  • 9. Strict Pre-op evaluation & preparations.
    • LMP : TIMING THE SURGERY IN EARLY PROLIFERATIVE PHASE
    • Presence of infection. Check for pre-op Infection/period ?
    • Tubal Cannulation set for PTB.
    • Check all hysteroscopy instruments before anesthesia is given.
    • Safe Lithotomy position.
    • Avoidance of air embolism during hysteroscopy / TUR set.
    • Pre-op S.Na+ : 135 mEq/lit.
    • Calculation of Fluid deficit to dedicated one OT staff.
  • 10. PRE-OPERATIVE CHECKLISTS :
    • FOR OT STAFF AND THEIR ACTIVITIES : INSTRUMENT TROLLEY, FUMIGATION, STERILISATION
    • CHECKLIST FOR SURGEONS REGARDING INSTRUMENT CHECKS
    • CHECKLIST FOR ANAESTHETISTS
    • Check List for
      • Hysteroscopic photos &
      • Findings.
  • 11. SAFE MONITORING :Check List
    • BOYLES TROLLEY with Circle absorber.
    • DEFIBRILLATORS
    • MULTIPARAMONITOR : T, P, R, NIBP, ECG,EtCO2
    • END TIDAL CO2 MONITORS
    • INTRAOP SPIROMETRY
    • POST OP RECOVERY ROOM CONCEPT WITH STAFF trained for managing semiconscious patients
  • 12. Safe OR Infra structure
    • Operation Theatre.
    • O.T.Table
    • Safe lithotomy position
    • Placing of safe Cautery pad
    • Hysteroscopy instruments
    • Laparoscopy instruments
    • Video Monitors for Hysteroscopic & Laparoscopic surgery
    • Distention media gadgets
    • PREVENTION OF INSTRUMENT FAILURE & Back up.
    • Safe Monitoring & MOCK DRILLS
    • Post op wards for High risk patient
  • 13. Office Hysteroscopy
  • 14. INSTRUMENTS
    • HYSTERPSCOPE
      • 4 m.m.& 30’,Rigid
    • Suction/Irrigation cannula
      • Irrigation-5 m.m.
      • Sucti.+Irriga.= 6mm
      • Operating Sheath= 7mm
      • Resectoscope = 10mm
    • Operating Sheath- 6 F.
    • Resectoscope
  • 15. CHECKLIST FOR SURGEONS REGARDING INSTRUMENT CHECKS
    • Hysteroscopes : 2mm, 2.9 mm, 1.9 mm, 4mm 7 30’ Hysteroscope
    • Diagnostic sheaths
    • Operative sheaths : Bettochi sheath
    • Tubing's with Luer lock at end to prevent fluid leakage.
    • Uterine distention & Fluid delivery system.
    • 1 lit pints of Normal saline/Ringer lactate
    • 3 lit. pints of 1.5 % Glycine
    • 100 ml pint of 3% Normal saline
    • 5F. Tubal Cannulation set, Scissor, grasper
    • Resectoscope with loop/Kolin’s knife & Monopolar cable
    • TUR Set
  • 16. CHECKLIST FOR SURGEONS REGARDING INSTRUMENT CHECKS
    • Understanding different hysteroscopic set up
    • Check their fittings
    • Placement Video monitors
    • Position of the patient : Edge of the table
  • 17. PREVENTION OF INSTRUMENT FAILURE :
    • USE STANDARD INSTRUMENTS . KEEP THEM WELL MAINTAINED
    • PROPER SOURCE OF ELECTRICITY : UPS , STABILIZERS , INVERTERS, GENERATORS
    • PROPER EARTHING : POTENTIAL DIFFERENCE OF LESS THAN 3 VOLTS BETWEEN EARTH AND NEUTRAL
    • SPARE BULBS, FUSES, CONSUMMABLES
    • STANDBY EQUIPMENTS
    • STANDBY SERVICE PERSONNELS
  • 18. MOCK DRILLS :
    • Periodic mock drills should be performed in the theatre to assess skills, response, co-ordination, communication and skills amongst the team members to handle various types of emergencies
    • Create training manuals for the entire staff : Basic life support, Advanced Cardiac life support
  • 19. 3. THE DISTENSION MEDIA
    • Complications produced by the distension media are specific to hysteroscopic surgery.
    • It is essential that all the operating room staff should know the side effects of the distension media .
  • 20. Carbon dioxide.
    • Cardiac arrhythmia may occur with diagnostic hysteroscopy with CO2
    • The hysteroflator delivers CO2 at a rate 100ml per minute whereas the laparoflator can deliver 1-20 liters per minute .
  • 21. Carbon dioxide:
    • A laparoflator should NEVER be used for hysteroscopy.
    • It is rare for CÓ 2 to produce any side effects if gas embolism of less than 400ml occurs.
  • 22. Intra operative monitoring protocols .
    • Anesthesia, Intubation, Pulse Oxymetry & EtCo2
    • Fluid balance/deficit
    • Duration of Hysteroscopic Surgery.
    • Disturbance/Noise on Monitor while electrocautery is on
    • Bleeding during surgery
    • Vigilant watch on Multipara monitoring for early detection of TUR Syndrome by Experienced Anesthetist.
    • In complicated case we must know when to stop hysteroscopic surgery with appearance of early signs of TUR Syndrome.
  • 23. Sev. Asherman’s syndrome
    • Hysteroscopic
    • Surgery
    • Under USG
    • guidance
  • 24. Energy Source for Resection:
    • Monopolar
    • Commonly used. Glycine has to be used as distension media.
  • 25. Energy Source for Resection :
    • Bipolar
    • Relatively Safe.
    • Expensive.
    • Saline can be used.
    • Other Newer sources : Laser , Plasma Kinetic systems
  • 26. Prevention of Fluid Overload
    • Using appropriate distension media and delivery systems
    • Keeping operating times to a minimum
    • Avoiding entering the vascular channels
    • Keeping fluid pressures below 80mmHg. Or Mean Arterial Pressure.
    • Meticulous accountancy of fluid balance.
    • The procedure must be abandoned if the deficit rises to 1.5 liters or there is evidence of venous congestion..
  • 27. FLUID DELIVERY SYSTEMS :
    • GRAVITY ASSISTED :
    • POSITIVE PRESSURE BAGS : BP CUFF, MEDEX BAG.
    • SIMPLE, ECONOMICAL, WIDELY USED.
    • NEEDS A VIGILANT STAFF TO PREVENT AIR EMBOLISM, FLUID OVERLOAD, OVERDISTENSION OF UTERINE CAVITY
    • FREQUENT COLLAPSE OF CAVITY WHILE CHANGING BOTTLES
    • DIFFICULT TO MAINTAIN INFLOW-OUTFLOW CHART
  • 28. FLUID DELIVERY SYSTEMS :
  • 29. Instruments for delivery of distention medium
    • Distention
    • Pressure Cuff:
    • A pressure bag with pressure meter. The pressure has to be maintained manually. Ideally a pressure of 150-200mmhg is utilized.
    • Hysteromat:
    • A motorized unit that automatically controls a constant flow of fluid entering the cavity. Its easy to calculate the input of NS with this equipment. Ideally a pressure of 80mmhg is utilized.
  • 30. FACTORS CAUSING FLUID ABSORPTION :
    • The intrauterine pressure.
    • The mean arterial blood pressure.
    • The patency of the outflow channel of the hysteroscope.
    • The depth of penetration of the uterine instruments. Baggish MS (1989) Distending media for panoramic hysteroscopy. In Baggish MS, Bardot J, Valle RF (eds) Diagnostic and Operative Hysteroscopy . pp. 89-101. Chicago: Year Book Medical Publishers Inc.
  • 31. AUTOMATED FLUID DELIVERY SYSTEMS :
    • GOOD EQUIPMENT TO MAINTAIN THE INTRAUTERINE PRESSURE TO A PRESET LEVEL.
    • 80 MMHG USUALLY
    • MAINTAINS OPTIMUM INTRAUTERINE CAVITY
    • REDUCES THE CHANCES OF SPILLAGE INTO POUCH OF DOUGLAS,
    • REDUCES CHANCES OF FLUID OVERLOAD, (Input & output can be documented)
    • SURGEON GETS MORE OPERATING TIME, PEACEFULLY
    • E.g. Hysteromat, Endomat
  • 32. AUTOMATED FLUID DELIVERY SYSTEMS :
  • 33. FLUID OVERLOAD INITIAL SYMPTOMS:
    • Nausea and vertigo, confusion and disorientation. ( CONSCIOUS PATIENT)
    • Transient hypertension & bradycardia followed by hypotension & tachycardia (may be the only sign in patients of general anesthesia)
    • HENCE THE ROLE OF GOOD MONITORING EQUIPMENTS..
  • 34. FLUID OVERLOAD BY GLYCINE :
    • Glycine overload may produce elevated blood ammonium levels leading to encephalopathy and death.
    • Hyponatraemia can lead to cerebral edema
    • OT PERSONNEL SHOULD BE TRAINED TO BE ALERT FOR THE VARIOUS SYMPTOMS AND SIGNS
  • 35. NEW METHOD TO IDENTIFY FLUID OVERLOAD :
    • ETHANOL TAGGED MANNITOL / SORBITOL : for knowing exact fluid absorption in the circulation by analysing the Expiratory Breath Ethanol level .
  • 36. COMPLICATIONS OF THE SURGERY:
    • Uterine perforation and hemorrhage .
    • Delayed complications : infection, discharge and adhesion formation.
  • 37. Complex perforation :
    • Scissors may cause when dividing adhesions in cases of extensive intrauterine synechaie. [Asherman's syndrome . ]
    • Hysteroscopy in such cases should always be done under laparoscopic guidance to recognize impending or occult perforation.
  • 38. Uterine Perforation:
    • Incidence : 0.8% (Hill et al, 1992).
    • British Mistletoe study 0.6% (Maresh 1996).
  • 39. Simple perforation:
    • Simple perforation may be made with a cervical dilator or with the hysteroscope.
    • Perforation with the hysteroscope should be avoided by always introducing the telescope under direct visual control.
    • FOR TORTUOUS OR STENOTIC CERVIX : THINNER ZERO DEG SCOPE MAY BE USED.
    • Misoprostol tab 400mg might help
  • 40. Complex perforation:
    • Complex perforation may be made with :
    • Mechanical
    • Electrical
    • Laser instruments
  • 41.
    • Complex perforation caused by electrosurgical instruments or laser may be associated with thermal injury to adjacent structures including bowel or large vessels.
    Complex perforation:
  • 42. PREVENTION OF SURGICAL MISADVENTURES :
    • KNOW YOUR LIMITS.
    • MULTIPLE SITTINGS FOR DIFFICULT CASES
    • DO NOT CAUSE HARM TO THE PATIENT
    • MAINTAIN THE SKILL BY PROPER TRAINING
    • KEEP A MENTOR
    • TAKE HELP FROM COLLEAGUES
    • SPEND TIME ON HYSTEROTRAINER FOR BOTH SURGEON AND ASSISTANTS
    • esp if the case load factor is low
    • { Even Sachin Tendulkar does net practice to this day }
  • 43.
    • Auditing of our complication & Learning from some ones else’s complication
    • HOWEVER GOOD THE CAR WITH ITS SAFETY FEATURES AND HOWEVER GOOD THE ROAD, THE DRIVER STILL HAS TO DRIVE CAREFULLY TO COMPLETE THE JOURNEY SAFELY.
  • 44. THANK YOU Visit : www.laparoscopyexpert.com

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