This presentation is about setting up Gynecological endoscopy services: the components, the challenges and finally achieving and sustaining excellence.

1. Setting up Gynec Endoscopy
services

2. Thanks!
 Organizing committee: AMASICON 2013
 Dr. Asha Baxi
 Dr Sunita Chouhan

3. Outline: the
A,B,C,D,E…
 Approach
 Basic components
 Challenges
 Development
 Excellence

4. Contemplation: John Wild
Contemplation before surgery, by Joe Wilder

5. Surgeons:
the modern day priests
“We are the modern day priests – we prepare, we
change to our holy garments, we bring patients to
another world, and we change them.”
Dr. Simpson, Your Doctors Orders.

6. So…
 Surgeons: Modern day Priests
 Operating rooms: Modern day temples
 Patients : Our Gods
 Surgery: Prayer

7. Setting up of surgical services is thus akin to
making a temple, with careful consideration, faith,
hard work and tireless effort. Hoping that amidst
the multitude of units, it still finds its place,
providing healing and solace to people and
providing a haven of safety to their troubled bodies
and souls.

8. Gynec Endoscopic
procedures
 Level 1: Diagnostic laparoscopy, tubal ligations
 Level 2: Salpingectomy, adhesiolysis, cautery of
minor endometriosis, myolysis, ovarian drilling
 Level 3: oophorectomy, salpingostomy, surgery
for pedunculated fibroids, moderate
endometriosis
 Level 4: Hysterectomy, Myomectomy, ovarian
cystectomy(>8 cm), severe endometriosis

9. Hysteroscopy
 Diagnostic
 Operative: septum resection, polypectomy,
myoma resection, foreign body removal,
cannulation, TCRE

10.  Hysteroscopic procedures: office
 Almost all laparoscopic surgeries except TL done
in OR.
 Hysteroscopic procedures: Different OR setup,
skill set, instrumentation, anesthetic
considerations

11. COMPONENTS

12. INFRASTRUCTURE
Setting up Gynecological endoscopy services

13. Setting up: infrastructure
STARS
 Start up
 Turnaround
 Accelerated growth
 Realignment
 Sustaining success

14. Time and Money

15. Operating room
Ancillary areas
Instruments
Equipment
Misc: disposables,
drugs
INFRASTRUCTURE

16. Temples
 Mandala
 Lead from temporal world to eternal: progression
from worldly to Divine
 Innermost sanctum: Garbhagriha

17. Temple plan
Sanctum

18. Operating rooms
 Unsterile to sterile
 Sterile lobby 1, sterile lobby 2
 Operating room: ultrasterile area

19. 4
Sanctum

20. Modular Operating Rooms
mod·u·lar (adj)
.1. Of, relating to, or based on a module or modulus.
2. Designed with standardized units or dimensions, as
for easy assembly and repair or flexible arrangement
and use: modular furniture; modular homes.

21. Components
 Prefabricated GI/SS panel shell
 Hermetically sealing sliding doors
 Laminar air flow
 Pendants
 Workstations
 Others: scrub, surgeon control panel

27. Operating room
Ancillary areas
Instruments
Equipment
Misc: disposables, drugs
INFRASTRUCTURE

28. One way!
 One way changing room
 One way flow of supplies into the OR and one way
flow of soiled good outside the OR
 Shared corridor for patients and staff
 Sterile supplies delivered in OR from CSSD :separate
corridor
 Two designs: Double loaded corridor with
substerile rooms and perimeter corridor with
clean core

30. Perimeter corridor
with clean core

31. Double loaded
corridor design

32. Recovery area
 Accessible from theatre and outside
 1.5 spaces per OR
 Space per trolley/bed 9 sq. meters
 O2, suction, power, lighting
 Communication lines
 Scrub, nursing station

33. Operating room
Ancillary areas
Instruments
Equipment
Misc: disposables, drugs
INFRASTRUCTURE

34. Equipment
 Camera
 Telescope
 Monitor
 Light source
 Insufflator
 Irrigation/suction system
 Electrosurgical generator
 Recording and archiving

35. Camera
 Single chip: all three primary colors sensed by a
single chip
 Three chip: three sensors for red, green and blue
SD camera: A 4:3 aspect ratio, 640 by 480 horizontal
and vertical lines.
HD camera: The HD format provides a 16:9 aspect ratio,
1280 by 720 horizontal and vertical lines. The 1080 HD
standard also offers a 16:9 aspect ratio, but 1920 by
1080 horizontal and vertical lines-seven times the SD
resolution at 480 lines.

36. Telescope
 6 to 18 rod lens system telescopes are available
 0 to 120 degree telescopes are available
 1.5 mm to 15 mm of telescopes are available

37. Light source
 Halogen
 Xenon
 LED

38. Insufflator
 Steps down the pressure
 Manual /electronic
 Heated

39. Others
 Suction irrigation systems
 Electrosurgical generators
 Recording and archiving

40. Instruments
 Hand instruments
 Specific: morcellator, endomat

41. What is ideal ?1
What is feasible ?2
What is viable?3

43. Justifying the costs
 Sharing with other subspecialities
 Developing a high throughput unit
 Shared facility between different gynec
endoscopic surgeons

44. MANPOWER
Setting up Gynecological endoscopy services

45. The trinity

46.  Anesthetist: Father
 Surgeon: son
 Nurse: holy ghost!
“He acts as Comforter, one who intercedes, or supports or acts as an
advocate, particularly in times of trial. He acts to convince
unredeemed persons both of the sinfulness of their actions and
thoughts, and of their moral standing as sinners before God”

47.  Theatre: Camera person, assistant: two, scrub
nurse, floor nurse
 Recovery staff
 Support staff

48. PATHWAYS
Setting up Gynecological endoscopy services

49. “The best cars with the smartest drivers cant reach
anywhere if there isn’t a road”

50. Clinical pathway: Multidisciplinary management tool
based on evidence-based practice for a specific
group of patients with a predictable clinical course,
in which the different tasks (interventions) by the
professionals involved in the patient care are
defined, optimized and sequenced either by hour
(ED), day (acute care) or visit (homecare).
Outcomes are tied to specific interventions.

51. Integrated clinical
pathway
An ICP aims to have...
 the right people
 doing the right things
 in the right order
 at the right time
 in the right place
 with the right outcome
 all with attention to the patient experience

52. Pathways
 Patient admission and preoperative workup
 Discharge pathway
 Dealing with readmissions
 Thromboprophylaxis
 Infection control

53. CHALLENGES
Setting up Gynecological endoscopy services

54. Challenges
 Infrastructure: maintenance and repair
 Manpower: training, attrition, motivation
 Pathways: non conformities, non compliance
“ The real challenge is to keep growing, keep moving, slowly at
times, but always forward”

55. DEVELOPMENT
Setting up Gynecological endoscopy services

56. AIM
 Safe
 Sustainable
 System driven
 Successful
Gynecological endoscopy unit

57. EXCELLENCE
Setting up Gynecological endoscopy services

59. Key performance
indicators
 In-patient workload
 Out-patient workload
 Cancellation rates on day of surgery
 Day of surgery add-on rates
 Start time accuracy – first case of the day
 Start time accuracy – subsequent cases
 Estimated case duration
 Turnover time in-patient

60.  Turnover time out-patient
 Total case time in-patient
 Total case time out-patient
 Room utilization: 7:30 a.m.-3:15 p.m.
 Surgeon satisfaction
 Employee satisfaction
 Cost per case (labor)
 Cost per case (materials)
 Cost per case (total)
 Gross revenue per case

61. “Excellence is never an accident. It is always
the result of high intention, sincere effort, and
intelligent execution; it represents the wise
choice of many alternatives - choice, not
chance, determines your destiny.”

62. “Magic lies in the magician, not in the wand”

63. The future OR
(Sandberg et al, anesthesiology,2005)

64. A,B,C,D,E…
 Approach: akin to constructing a temple
 Basic components: infrastructure, manpower,
pathways
 Challenges
 Development
 Excellence: ongoing process

65. THANK YOU!