One of the limitations of minimal access surgery is difficulty in retrieval of tissue. Previously, surgeons were reluctant to perform many of the advanced surgical procedure due to this difficult procedure.
This document provides guidelines for laparoscopic entry techniques. It discusses positioning the patient and various methods for primary and secondary port entry. The preferred primary entry is through the umbilicus using a closed Veress needle technique. Guidelines are provided for Veress needle insertion including abdominal pressure, saline testing, and insufflation. Alternatives like Palmer's point or open Hasson technique should be considered if umbilical entry fails or is risky due to adhesions. Secondary ports should be inserted under direct vision at specific locations and angles to avoid injury.
This document provides information on operative hysteroscopy, including therapeutic indications, instruments used, specific procedures, complications, and techniques. Some key points:
- Operative hysteroscopy is used to treat conditions like uterine septum, synechiae, polyps, and myomas. Instruments include a resectoscope, cutting loops, and electrodes.
- Specific procedures discussed include hysteroscopic metroplasty for septate uterus, adhesiolysis for synechiae, transcervical resection of submucous myomas, and endometrial ablation.
- Complications can be perioperative like bleeding, perforation, or fluid absorption syndrome, or postoperative like adhesions or
Georg Kelling performed the first laparoscopy procedure on a dog in 1901 in Dresden, Germany. Hans Christian Jacobaeus performed the first laparoscopy on a human in Sweden. In 1977, Patrick Steptoe performed the first diagnostic laparoscopy and the first IVF baby was conceived using laparoscopy to collect eggs. Raul Palmer published on modern diagnostic laparoscopy in France in 1947. Kurt Semm, known as the "mad scientist," pioneered the use of the cold light source, gas insufflator, laparoscopic suturing, and the first laparoscopic appendectomy in 1981 in Kiel, Germany. Laparoscopic surgery complications like bowel or bladder injuries may
Safety measures in operative hysteroscopyOsama Warda
Â
Operative hysteroscopy has a low complication rate of around 0.22% according to a large multicenter study. The most common complications are uterine perforation, fluid overload, hemorrhage, and bladder or bowel injury. Several safety measures can help minimize risks, including proper patient selection, an experienced surgeon, good instrumentation, clear visualization, and concurrent laparoscopy or ultrasound guidance when needed. Careful management of distending media is also important to prevent fluid overload issues.
This document provides information on operative hysteroscopy, including prerequisites, contraindications, instrumentation, anaesthesia, distension media, indications, and techniques for various procedures like endometrial ablation, uterine septum resection, myomectomy, and adhesiolysis. It discusses the advantages and disadvantages of hysteroscopic morcellators. Complications of hysteroscopic myomectomy and post-operative care are also outlined. Various classifications for submucous fibroids and intrauterine adhesions are presented.
Diagnosis and classification of tubal factor infertilitySanjay Makwana
Â
This document discusses tubal factor infertility (TFI), including causes such as damage from injury or pelvic inflammatory disease. It evaluates various diagnostic tests for TFI like hysterosalpingography (HSG), laparoscopy, and chlamydial antibody testing. Treatment options discussed include expectant management, antibiotics, tubal surgery like cannulation or anastomosis, and IVF. The evidence for different approaches is limited, with no randomized controlled trials directly comparing treatments. The conclusion is that IVF is generally the best treatment for older patients or more severe TFI, while surgery may be considered for milder cases or proximal tubal obstruction.
The document discusses peripartum hysterectomy, including its definition, history, incidence and trends, risk factors, types, indications, complications, and techniques. A key point is that a sequence of conservative measures should be attempted before hysterectomy to control uterine hemorrhage, as indecisiveness can lead to fatal excessive bleeding. The "Triple-P procedure" is also summarized as a three-step conservative approach involving obstetric, anesthesia and interventional radiology teams to prevent hemorrhage and need for hysterectomy in high-risk cases.
This document provides guidelines for laparoscopic entry techniques. It discusses positioning the patient and various methods for primary and secondary port entry. The preferred primary entry is through the umbilicus using a closed Veress needle technique. Guidelines are provided for Veress needle insertion including abdominal pressure, saline testing, and insufflation. Alternatives like Palmer's point or open Hasson technique should be considered if umbilical entry fails or is risky due to adhesions. Secondary ports should be inserted under direct vision at specific locations and angles to avoid injury.
This document provides information on operative hysteroscopy, including therapeutic indications, instruments used, specific procedures, complications, and techniques. Some key points:
- Operative hysteroscopy is used to treat conditions like uterine septum, synechiae, polyps, and myomas. Instruments include a resectoscope, cutting loops, and electrodes.
- Specific procedures discussed include hysteroscopic metroplasty for septate uterus, adhesiolysis for synechiae, transcervical resection of submucous myomas, and endometrial ablation.
- Complications can be perioperative like bleeding, perforation, or fluid absorption syndrome, or postoperative like adhesions or
Georg Kelling performed the first laparoscopy procedure on a dog in 1901 in Dresden, Germany. Hans Christian Jacobaeus performed the first laparoscopy on a human in Sweden. In 1977, Patrick Steptoe performed the first diagnostic laparoscopy and the first IVF baby was conceived using laparoscopy to collect eggs. Raul Palmer published on modern diagnostic laparoscopy in France in 1947. Kurt Semm, known as the "mad scientist," pioneered the use of the cold light source, gas insufflator, laparoscopic suturing, and the first laparoscopic appendectomy in 1981 in Kiel, Germany. Laparoscopic surgery complications like bowel or bladder injuries may
Safety measures in operative hysteroscopyOsama Warda
Â
Operative hysteroscopy has a low complication rate of around 0.22% according to a large multicenter study. The most common complications are uterine perforation, fluid overload, hemorrhage, and bladder or bowel injury. Several safety measures can help minimize risks, including proper patient selection, an experienced surgeon, good instrumentation, clear visualization, and concurrent laparoscopy or ultrasound guidance when needed. Careful management of distending media is also important to prevent fluid overload issues.
This document provides information on operative hysteroscopy, including prerequisites, contraindications, instrumentation, anaesthesia, distension media, indications, and techniques for various procedures like endometrial ablation, uterine septum resection, myomectomy, and adhesiolysis. It discusses the advantages and disadvantages of hysteroscopic morcellators. Complications of hysteroscopic myomectomy and post-operative care are also outlined. Various classifications for submucous fibroids and intrauterine adhesions are presented.
Diagnosis and classification of tubal factor infertilitySanjay Makwana
Â
This document discusses tubal factor infertility (TFI), including causes such as damage from injury or pelvic inflammatory disease. It evaluates various diagnostic tests for TFI like hysterosalpingography (HSG), laparoscopy, and chlamydial antibody testing. Treatment options discussed include expectant management, antibiotics, tubal surgery like cannulation or anastomosis, and IVF. The evidence for different approaches is limited, with no randomized controlled trials directly comparing treatments. The conclusion is that IVF is generally the best treatment for older patients or more severe TFI, while surgery may be considered for milder cases or proximal tubal obstruction.
The document discusses peripartum hysterectomy, including its definition, history, incidence and trends, risk factors, types, indications, complications, and techniques. A key point is that a sequence of conservative measures should be attempted before hysterectomy to control uterine hemorrhage, as indecisiveness can lead to fatal excessive bleeding. The "Triple-P procedure" is also summarized as a three-step conservative approach involving obstetric, anesthesia and interventional radiology teams to prevent hemorrhage and need for hysterectomy in high-risk cases.
1. The document discusses various methods for evaluating tubal patency in infertile patients, including hysterosalpingography (HSG), laparoscopy, and tests like Chlamydia antibody testing.
2. HSG is the most common screening test but has limitations like radiation exposure and false positives. Findings on HSG like mucosal rugae can provide prognostic information.
3. Laparoscopy allows direct visualization but is more invasive. It remains the gold standard for diagnosing conditions like endometriosis.
4. For treatment, IVF is now often preferred over surgery for moderate to severe tubal damage, while laparoscopic surgery may be considered for milder issues
This document provides information about hysteroscopy, including:
- A hysteroscope is an endoscope used to visualize the uterine cavity and perform procedures.
- It describes the historical development of hysteroscopy from the 19th century to modern techniques.
- The types of hysteroscopes and instrumentation used are outlined, including distention media, electrodes, sheaths, and cameras.
- The document discusses the procedures, indications, contraindications and complications of diagnostic and operative hysteroscopy.
History of radical hysterectomy for cancer cervixSakshi Mundra
Â
The document provides a history of radical hysterectomy for cervical cancer treatment over 2500 years. It discusses key pioneers and developments including Hippocrates attempting trachelectomy in 460-370 BC, Wilhelm Freund developing the first standardized radical hysterectomy technique in 1878, and Ernst Wertheim performing the first full radical abdominal hysterectomy in 1898. The modern radical hysterectomy was developed in the late 19th/early 20th century by surgeons including John Clark, Joseph Meigs, and Hidekazu Okabayashi. Classification systems for radical hysterectomy procedures including the Piver-Rutledge-Smith and Querleu and Morrow systems are also summarized.
Laparoscopy is a minimally invasive surgical technique that allows visualization of the abdominal organs through small incisions. It has many applications in gynecological endoscopy including diagnostic laparoscopy to investigate causes of infertility, ovarian cysts, ectopic pregnancy, and endometriosis. Key steps in the laparoscopy procedure are pneumoperitoneum creation, trocar insertion, visualization of organs, and completion with gas evacuation. It provides diagnostic and therapeutic benefits over laparotomy with less pain and faster recovery.
Tubal factor and fertility by Dr.GayathiriMorris Jawahar
Â
This document discusses tubal factor infertility, which is caused by diseases, obstructions, damage or other factors that impede the passage of eggs through the fallopian tubes. Common causes include pelvic inflammatory disease, endometriosis, ectopic pregnancy and previous tubal surgery or ligation. Diagnostic tests include hysterosalpingogram, sonohysterography and laparoscopy. Treatment depends on the location and severity of the blockage, and may include tubal surgery such as recanalization or salpingostomy, or IVF for more severe cases or sterilization reversals. Management of hydrosalpinges often involves drainage, salpingectomy or proximal tubal occlusion prior to IVF
Complications of hysteroscopy can be classified as those related to distention media, mechanical issues, electrocautery, anesthesia, or late effects. Distention media like glycine can be absorbed systemically during the procedure and cause electrolyte disturbances. Mechanical complications include cervical laceration and uterine perforation. Electrocautery risks include injury to intraperitoneal structures if the uterus is perforated. Positioning patients in lithotomy can potentially lead to compartment syndrome or neurologic injuries over time. Preventing complications involves using the lowest effective pressures, detecting fluid deficits, and avoiding overzealous electrocautery.
Cervical insufficiency, also known as cervical incompetence, is a condition where the cervix is unable to retain a pregnancy at term due to a functional or structural defect. It is characterized by painless dilatation of the cervix resulting in premature rupture of membranes and delivery, usually occurring in the second or third trimester. Cervical cerclage procedures aim to surgically suture the cervix closed to prevent premature opening. There are several techniques for cervical cerclage placement depending on the location and indication, including McDonald, Shirodkar, emergency/rescue cerclages, and pessary or balloon alternatives. Cerclage procedures can be done through the vagina or abdomen depending
1. Shirodkar's sling surgery is a conservative surgical procedure for uterine prolapse that involves attaching a tape to the cervix and passing it through the broad ligaments and behind the sigmoid colon to attach to the sacral promontory, creating a hammock of support.
2. It was developed by Dr. V.N. Shirodkar in the 1960s as one of several sling procedures established in India to address high rates of uterine prolapse among young, anemic women after childbirth.
3. The procedure involves making an abdominal incision, attaching a tape to the cervix, passing it through the broad ligaments and retroperitoneum on each side
This document discusses hysteroscopic procedures, including their history, indications, equipment, techniques, complications, and conclusions. Hysteroscopes allow physicians to examine and treat the inside of the uterus using small cameras and surgical tools inserted through the cervix. The document outlines the various diagnostic and therapeutic indications for hysteroscopy. It also details the counseling, anesthesia, positioning, equipment, distending media, procedures, and potential complications involved. In conclusion, the author states that hysteroscopy is a valuable technique for gynecological surgeons, providing minimally invasive options through the uterus's natural pathway.
The document discusses the use of hysteroscopy in evaluating and treating infertility. It provides evidence-based guidelines on when hysteroscopy is recommended and not recommended in infertility workup. It also reviews evidence on techniques for diagnostic and operative hysteroscopy, including indications, preparation, distension media, findings, and treatment of various intrauterine issues like polyps, fibroids, adhesions that may cause infertility. Complications are also discussed.
1) Laparoscopic entry is the most dangerous part of the procedure and complications are often entry-related. Safe entry techniques aim to minimize injury to organs and blood vessels.
2) Common entry methods include closed access using a Veress needle or direct trocar entry without pneumoperitoneum, and open access using the Hasson technique. Secondary trocars should be inserted under direct vision to avoid epigastric vessels.
3) Factors like patient body habitus, previous scarring, and failed attempts can increase risks. The Veress needle should have a sharp tip and good spring action. High intra-abdominal pressure may improve safety during primary trocar insertion.
In this introductory remark at workshop on vaginal hysterectomy where Dr Shirish Seth was operating faculty.
I spoke “lets promote and propagate vaginal hysterectomy which is an indigenous surgery in line with PM Modi’s mission of MAKE IN INDIA.
Vaginal hysterectomy is like Aam admi surgery which is in the best interest of patients and has best scientific evidences in its favour."
Let us not be driven by glamour,gadgets and gimmicks."
This document provides information on setting up a hysteroscopy unit, including the key components, equipment, and considerations. It discusses:
1. The essential components for intracavitary vision including video cameras, cold light sources, light cables, endoscopes, and video monitors for imaging and data archiving.
2. Options for intracavitary distension including non-electrolyte and electrolyte liquid solutions, as well as methods for supplying the distension media.
3. Hysteroscopes and resectoscopes suitable for diagnostic and operative procedures, along with mechanical instruments and bipolar electrosurgical tools.
4. Considerations for ambulatory and operating room settings
This document discusses ureteric injury as a complication of gynecologic surgery. It covers the incidence, risk factors, applied anatomy of the pelvic ureter, common sites of injury, prevention strategies, and management approaches. Ureteric injury can occur in 0.03-6% of hysterectomies, with laparoscopic hysterectomy having the highest risk. The pelvic ureter has variable anatomy and is susceptible to injury at sites like the pelvic brim. Prevention focuses on proper identification and dissection of the ureter during surgery. Management depends on the severity and timing of injury but may involve stenting, urinary diversion, or ureteral reimplantation
Laparoscopy in gynaecology presented by drs igbodike emeka philip and dr rotimiigbodikeobgyn
Â
This slide will be helpful if the presentation revolves around laparoscopy in gynaecological practice. Kindly like , clip and share the slide. it is free!
Hysteroscopy can be used both diagnostically and therapeutically for a variety of gynecological issues. It allows visualization of the uterine cavity using a camera. Diagnostically, it is useful for evaluating abnormalities seen on ultrasound or HSG such as polyps, fibroids, or synechiae. Therapeutically, it can be used to remove polyps, type 0 or 1 fibroids, and divide uterine septa. It is also used to treat intrauterine adhesions and perform endometrial ablation for abnormal uterine bleeding. Hysteroscopy has advantages over blind procedures as it allows for direct visualization and targeted treatment of observed issues.
PREGNANCY OF UNKNOWN LOCATION DR. SHARDA JAIN DR. JYOTI AGARWAL DR. JYOTI BH...Lifecare Centre
Â
PREGNANCY OF UNKNOWN LOCATION DR. SHARDA JAIN DR. JYOTI AGARWAL DR. JYOTI BHASKAR
WHY THIS PPT ??
One of our of patient’s was discharged home with presumed COMPLETE miscarriage.
Subsequently returned with pain abdomen , bleeding & ruptured EP
…We thought of reviewing
PRENANCY OF UNKNOWN LOCATION
Laparoscopic cholecystectomy is the gold standard for the treatment of gallstone disease. The operation is routinely performed using four or three ports of entry into the abdomen. At laparoscopy hospital, we frequently perform cholecystectomy by two-port method using modified extracorporeal knot.
This document discusses peritoneal adhesions and laparoscopic adhesiolysis. It begins by introducing peritoneal adhesions as a common cause of bowel obstruction, pelvic pain, and infertility. Adhesions form following abdominal or pelvic surgery as a normal response to peritoneal injury, but can cause morbidity. Laparoscopic adhesiolysis offers advantages over open surgery such as less pain, reduced hernia risk, and shorter recovery. The document then discusses the technique of laparoscopic adhesiolysis in detail, including port placement, dissection methods, and measures to prevent readhesion. Key aspects of pathogenesis and preventing adhesion formation are also reviewed.
1. The document discusses various methods for evaluating tubal patency in infertile patients, including hysterosalpingography (HSG), laparoscopy, and tests like Chlamydia antibody testing.
2. HSG is the most common screening test but has limitations like radiation exposure and false positives. Findings on HSG like mucosal rugae can provide prognostic information.
3. Laparoscopy allows direct visualization but is more invasive. It remains the gold standard for diagnosing conditions like endometriosis.
4. For treatment, IVF is now often preferred over surgery for moderate to severe tubal damage, while laparoscopic surgery may be considered for milder issues
This document provides information about hysteroscopy, including:
- A hysteroscope is an endoscope used to visualize the uterine cavity and perform procedures.
- It describes the historical development of hysteroscopy from the 19th century to modern techniques.
- The types of hysteroscopes and instrumentation used are outlined, including distention media, electrodes, sheaths, and cameras.
- The document discusses the procedures, indications, contraindications and complications of diagnostic and operative hysteroscopy.
History of radical hysterectomy for cancer cervixSakshi Mundra
Â
The document provides a history of radical hysterectomy for cervical cancer treatment over 2500 years. It discusses key pioneers and developments including Hippocrates attempting trachelectomy in 460-370 BC, Wilhelm Freund developing the first standardized radical hysterectomy technique in 1878, and Ernst Wertheim performing the first full radical abdominal hysterectomy in 1898. The modern radical hysterectomy was developed in the late 19th/early 20th century by surgeons including John Clark, Joseph Meigs, and Hidekazu Okabayashi. Classification systems for radical hysterectomy procedures including the Piver-Rutledge-Smith and Querleu and Morrow systems are also summarized.
Laparoscopy is a minimally invasive surgical technique that allows visualization of the abdominal organs through small incisions. It has many applications in gynecological endoscopy including diagnostic laparoscopy to investigate causes of infertility, ovarian cysts, ectopic pregnancy, and endometriosis. Key steps in the laparoscopy procedure are pneumoperitoneum creation, trocar insertion, visualization of organs, and completion with gas evacuation. It provides diagnostic and therapeutic benefits over laparotomy with less pain and faster recovery.
Tubal factor and fertility by Dr.GayathiriMorris Jawahar
Â
This document discusses tubal factor infertility, which is caused by diseases, obstructions, damage or other factors that impede the passage of eggs through the fallopian tubes. Common causes include pelvic inflammatory disease, endometriosis, ectopic pregnancy and previous tubal surgery or ligation. Diagnostic tests include hysterosalpingogram, sonohysterography and laparoscopy. Treatment depends on the location and severity of the blockage, and may include tubal surgery such as recanalization or salpingostomy, or IVF for more severe cases or sterilization reversals. Management of hydrosalpinges often involves drainage, salpingectomy or proximal tubal occlusion prior to IVF
Complications of hysteroscopy can be classified as those related to distention media, mechanical issues, electrocautery, anesthesia, or late effects. Distention media like glycine can be absorbed systemically during the procedure and cause electrolyte disturbances. Mechanical complications include cervical laceration and uterine perforation. Electrocautery risks include injury to intraperitoneal structures if the uterus is perforated. Positioning patients in lithotomy can potentially lead to compartment syndrome or neurologic injuries over time. Preventing complications involves using the lowest effective pressures, detecting fluid deficits, and avoiding overzealous electrocautery.
Cervical insufficiency, also known as cervical incompetence, is a condition where the cervix is unable to retain a pregnancy at term due to a functional or structural defect. It is characterized by painless dilatation of the cervix resulting in premature rupture of membranes and delivery, usually occurring in the second or third trimester. Cervical cerclage procedures aim to surgically suture the cervix closed to prevent premature opening. There are several techniques for cervical cerclage placement depending on the location and indication, including McDonald, Shirodkar, emergency/rescue cerclages, and pessary or balloon alternatives. Cerclage procedures can be done through the vagina or abdomen depending
1. Shirodkar's sling surgery is a conservative surgical procedure for uterine prolapse that involves attaching a tape to the cervix and passing it through the broad ligaments and behind the sigmoid colon to attach to the sacral promontory, creating a hammock of support.
2. It was developed by Dr. V.N. Shirodkar in the 1960s as one of several sling procedures established in India to address high rates of uterine prolapse among young, anemic women after childbirth.
3. The procedure involves making an abdominal incision, attaching a tape to the cervix, passing it through the broad ligaments and retroperitoneum on each side
This document discusses hysteroscopic procedures, including their history, indications, equipment, techniques, complications, and conclusions. Hysteroscopes allow physicians to examine and treat the inside of the uterus using small cameras and surgical tools inserted through the cervix. The document outlines the various diagnostic and therapeutic indications for hysteroscopy. It also details the counseling, anesthesia, positioning, equipment, distending media, procedures, and potential complications involved. In conclusion, the author states that hysteroscopy is a valuable technique for gynecological surgeons, providing minimally invasive options through the uterus's natural pathway.
The document discusses the use of hysteroscopy in evaluating and treating infertility. It provides evidence-based guidelines on when hysteroscopy is recommended and not recommended in infertility workup. It also reviews evidence on techniques for diagnostic and operative hysteroscopy, including indications, preparation, distension media, findings, and treatment of various intrauterine issues like polyps, fibroids, adhesions that may cause infertility. Complications are also discussed.
1) Laparoscopic entry is the most dangerous part of the procedure and complications are often entry-related. Safe entry techniques aim to minimize injury to organs and blood vessels.
2) Common entry methods include closed access using a Veress needle or direct trocar entry without pneumoperitoneum, and open access using the Hasson technique. Secondary trocars should be inserted under direct vision to avoid epigastric vessels.
3) Factors like patient body habitus, previous scarring, and failed attempts can increase risks. The Veress needle should have a sharp tip and good spring action. High intra-abdominal pressure may improve safety during primary trocar insertion.
In this introductory remark at workshop on vaginal hysterectomy where Dr Shirish Seth was operating faculty.
I spoke “lets promote and propagate vaginal hysterectomy which is an indigenous surgery in line with PM Modi’s mission of MAKE IN INDIA.
Vaginal hysterectomy is like Aam admi surgery which is in the best interest of patients and has best scientific evidences in its favour."
Let us not be driven by glamour,gadgets and gimmicks."
This document provides information on setting up a hysteroscopy unit, including the key components, equipment, and considerations. It discusses:
1. The essential components for intracavitary vision including video cameras, cold light sources, light cables, endoscopes, and video monitors for imaging and data archiving.
2. Options for intracavitary distension including non-electrolyte and electrolyte liquid solutions, as well as methods for supplying the distension media.
3. Hysteroscopes and resectoscopes suitable for diagnostic and operative procedures, along with mechanical instruments and bipolar electrosurgical tools.
4. Considerations for ambulatory and operating room settings
This document discusses ureteric injury as a complication of gynecologic surgery. It covers the incidence, risk factors, applied anatomy of the pelvic ureter, common sites of injury, prevention strategies, and management approaches. Ureteric injury can occur in 0.03-6% of hysterectomies, with laparoscopic hysterectomy having the highest risk. The pelvic ureter has variable anatomy and is susceptible to injury at sites like the pelvic brim. Prevention focuses on proper identification and dissection of the ureter during surgery. Management depends on the severity and timing of injury but may involve stenting, urinary diversion, or ureteral reimplantation
Laparoscopy in gynaecology presented by drs igbodike emeka philip and dr rotimiigbodikeobgyn
Â
This slide will be helpful if the presentation revolves around laparoscopy in gynaecological practice. Kindly like , clip and share the slide. it is free!
Hysteroscopy can be used both diagnostically and therapeutically for a variety of gynecological issues. It allows visualization of the uterine cavity using a camera. Diagnostically, it is useful for evaluating abnormalities seen on ultrasound or HSG such as polyps, fibroids, or synechiae. Therapeutically, it can be used to remove polyps, type 0 or 1 fibroids, and divide uterine septa. It is also used to treat intrauterine adhesions and perform endometrial ablation for abnormal uterine bleeding. Hysteroscopy has advantages over blind procedures as it allows for direct visualization and targeted treatment of observed issues.
PREGNANCY OF UNKNOWN LOCATION DR. SHARDA JAIN DR. JYOTI AGARWAL DR. JYOTI BH...Lifecare Centre
Â
PREGNANCY OF UNKNOWN LOCATION DR. SHARDA JAIN DR. JYOTI AGARWAL DR. JYOTI BHASKAR
WHY THIS PPT ??
One of our of patient’s was discharged home with presumed COMPLETE miscarriage.
Subsequently returned with pain abdomen , bleeding & ruptured EP
…We thought of reviewing
PRENANCY OF UNKNOWN LOCATION
Laparoscopic cholecystectomy is the gold standard for the treatment of gallstone disease. The operation is routinely performed using four or three ports of entry into the abdomen. At laparoscopy hospital, we frequently perform cholecystectomy by two-port method using modified extracorporeal knot.
This document discusses peritoneal adhesions and laparoscopic adhesiolysis. It begins by introducing peritoneal adhesions as a common cause of bowel obstruction, pelvic pain, and infertility. Adhesions form following abdominal or pelvic surgery as a normal response to peritoneal injury, but can cause morbidity. Laparoscopic adhesiolysis offers advantages over open surgery such as less pain, reduced hernia risk, and shorter recovery. The document then discusses the technique of laparoscopic adhesiolysis in detail, including port placement, dissection methods, and measures to prevent readhesion. Key aspects of pathogenesis and preventing adhesion formation are also reviewed.
The Obstetric Gynaecologis - 2013 - Stavroulis - Methods for specimen remov...Amer Raza
Â
This document discusses different methods for removing specimens from the peritoneal cavity after laparoscopic excision. It describes using mini laparotomy, transumbilical or ancillary port-site incisions, or posterior colpotomy. Recently, using morcellators and endoscopic bags to remove specimens laparoscopically has grown in popularity. The size, whether cystic or solid, and risk of malignancy influence the retrieval method. There is a risk of spillage, especially with suspected early malignancy, so this must be considered during excision and retrieval. In the future, natural orifice transluminal endoscopy may be an operative and retrieval route.
Minimal access surgery (MAS) a new surgical and
interventional approach, was called by different name and
one of the popular is minimally invasive surgery. However,
unique complications are associated with gaining access
to the abdomen for laparoscopic surgery. The technique
of first entry inside the human body with telescope and
instruments is called access technique. The hallmark of the
new approaches is the reduction in the trauma of access.
The technique for access to the peritoneal cavity, choice of
access technique, placement locations, and port placement
is very important in MAS. Technique of access is different for
different minimal access surgical procedures. Thoracoscopy,
retroperitoneoscopy, axilloscopy, and arthroscopy all have
different ways of access. In this chapter, we will discuss
various abdominal access techniques.
It is important to know that approximately 20% of
laparoscopic complications are caused at the time of initial
access. Developing access skill is one of the important
achievements for the surgeon practicing MAS. First entry or
access in laparoscopy is of two types: (1) closed access and
(2) open access.
World's Most Popular Hands-On Laparoscopic Training Instituteraja766604
Â
World Laparoscopy Hospital is a well-known and highly respected international training center for laparoscopic surgery. It offers a comprehensive laparoscopic surgery training course for general surgeons, gynecologists, and urologists. The training program is designed to provide both basic and advanced theoretical and practical experience to the candidates.
The laparoscopic surgery training course at World Laparoscopy Hospital is completely candidate-centered, with an emphasis on practical laparoscopic surgical problems encountered while operating on patients. The training takes place within an ultramodern laparoscopic HD wet operating room, followed by live exposure of live laparoscopic surgery in the operation theater with expert consultants.
The laparoscopic training program is affiliated with a Government-recognized university, and upon completion of the course, candidates receive a Laparoscopic Fellowship and Diploma Certificate issued by a UGC recognized university and the World Association of Laparoscopic Surgeons.
https://www.laparoscopyhospital.com/SERV01.HTM
Minimal access surgery (MAS) a new surgical and interventional approach, was called by different name and one of the popular is minimally invasive surgery. However,unique complications are associated.
Challenges & controversies in robotic myomectomyApollo Hospitals
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Robotic surgery for gynecology is being performed since 2005. For myomectomy, it is a better technology since suturing of myoma bed is better with lower incidence of scar rupture. However, the morcellation for the myoma retrieval has to be done carefully in a bag, and pre-operative investigation should be done to exclude occult leiomyosarcoma.
Laparoscopic sterilization was the first popular minimal access surgical procedure ever performed. Laparoscopic sterilization is very straightforward procedure. Worldwide laparoscopic sterilization is now the most commonly applied method for family planning
Management of reproductive tract anomalies1drmcbansal
Â
This document discusses the management of reproductive tract anomalies. It describes various treatment options for disorders of Mullerian agenesis including surgical removal of uterine bulbs. It also discusses the psychological preparation of patients, diagnostic testing, classification of vaginoplasty methods (surgical and nonsurgical), and details the Abbe-Wharton-McIndoe skin graft operation technique for creating a neovagina.
The Obstetric Gynaecologis - 2019 - Moustafa - Issues around vaginal vault ...Amer Raza
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This document discusses issues related to vaginal vault closure after hysterectomy. It describes different techniques for closing the vaginal vault during abdominal, vaginal, and laparoscopic hysterectomy, including the use of different suture materials and patterns. Potential complications after hysterectomy are also reviewed, such as vaginal vault dehiscence, vault prolapse, and vault hematoma. The document compares techniques for minimizing these risks and supporting the vaginal vault.
This document discusses techniques for performing a difficult vaginal hysterectomy. It identifies 5 keys to success: 1) ensuring adequate surgical experience, 2) obtaining adequate exposure through proper retraction and lighting, 3) entering the anterior cul-de-sac first to avoid bladder injury, 4) gaining uterine mobility through ligating supporting structures if needed, and 5) using proper morcellation techniques once the uterus is detached. The document emphasizes the importance of surgical experience and proper technique to overcome challenges and perform vaginal hysterectomy even in more difficult cases.
Laparoscopic ovarian surgery can be used to manage most ovarian abnormalities. Key steps in laparoscopic ovarian cystectomy include aspirating cyst contents, stripping the cyst capsule from the ovarian cortex, and extracting the capsule. It is important to avoid injury to nearby structures like the ureter and completely remove the cyst to evaluate for early carcinoma. Outcomes are better when the ovary can be preserved through cystectomy rather than full oophorectomy. Teratomas require especially careful removal of all contents to prevent chemical peritonitis.
This document discusses ventral incisional hernia repair and compares the sublay retromuscular technique using lightweight Vypro mesh versus heavier Prolene mesh. It provides background on incisional hernias, risk factors, techniques for open repair including suture repair, inlay, onlay, and sublay/retromuscular approaches. The study aims to evaluate the challenge of the sublay technique with new technical points to reduce recurrence and compare results of Vypro versus Prolene mesh in postoperative complications, chronic pain, and recurrence rates.
This study evaluated the experiences and outcomes of 150 patients who underwent single incision laparoscopic cholecystectomy (SILC) between 2009-2011. Two different techniques were used for the single incision procedure. The median operative time was 29 minutes. Patients were discharged after a median hospital stay of 1.33 days. Five patients developed superficial wound infections. Port site hernias developed in 5 patients within 6 months of surgery. No other major complications occurred. The study concluded that SILC is a safe procedure that can be performed successfully with conventional laparoscopic instruments and may provide advantages of reduced postoperative pain and improved cosmetic outcomes compared to traditional laparoscopic cholecystectomy.
Episiotomy slideshare by dr alka mukherjee & dr apurva mukherjee msalka mukherjee
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Normal birth can cause tears to the vagina and the surrounding tissue, usually as the baby's head is born, and sometimes these tears extend to the rectum. These are repaired surgically, but take time to heal. To avoid these severe tears, it is recommended making a surgical cut to the perineum with scissors or scalpel to prevent severe tearing and facilitate the birth. This intervention, known as an episiotomy, is used as a routine care policy during births in some countries. Both a tear and an episiotomy need sutures, and can result in severe pain, bleeding, infection, pain with sex, and can contribute to long term urinary incontinence.
Episiotomies—incisions made between the vagina and anus during childbirth—have long been a topic of debate among clinicians, researchers and advocates. Outdated clinical guidelines previously recommended the routine use of episiotomy to avoid natural vaginal tearing. Over the past two decades, a growing body of literature and increased advocacy efforts have led to a general consensus that episiotomy should not be conducted as a standard practice. Nevertheless, in many parts of the world, the majority of women still undergo episiotomy during childbirth.
In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma.
Robotic hysterectomy: A review of indications, technique, outcome, and compli...Apollo Hospitals
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Hysterectomy is the second most common surgery performed on women after cesarean section. The advantages of minimally invasive hysterectomy such as reduced hospitalization, quick recovery with more rapid return to normal activities, and less postoperative morbidity are well known. Although most guidelines recommend that minimally invasive hysterectomy should be the standard of care, the gynecologists have been slow in adopting minimally invasive laparoscopic techniques to perform this operation. Since its approval in 2005 for gynecological surgeries, robot-assisted hysterectomy has been found to be feasible and safe both in benign and malignant indications. This significant difference is mainly due to ergonomics, endowrist movements of instruments, and stereoscopic three-dimensional magnified vision. The specific indications for hysterectomy where the robotic technology can benefit women are the ones with adhesions such as severe endometriosis, large uterus with large or multiple fibroids, early carcinoma cervix, and/or endometrial carcinoma. However the main benefit of this procedure was seen in the reduction of open surgery including conversions during laparoscopic hysterectomies. In the long run, we need to critically examine the long-term benefits and appropriate indications for robot-assisted hysterectomy especially in benign conditions, thus reducing the incidence of open surgery in gynecology. This review describes the operative procedure of robotic hysterectomy in eight steps.
The document provides information about rectal prolapse including its definition, types, classification, causes, clinical features, pathogenesis, differential diagnosis, complications and treatment. It discusses partial (mucosal) prolapse and complete (full thickness) prolapse. For treatment, it describes both medical management and surgical procedures for rectal prolapse including perineal procedures like Delorme's procedure and Altemeier's procedure as well as abdominal procedures like Wells operation and Ripstein sling operation. It also lists several homeopathic medicines commonly indicated in the treatment of rectal prolapse such as Podophyllum, Aesculus, Sulphur, Ferrum metallicum, Ruta, Ignatia, Muriaticum
Spigelian Hernia: A Rare Hernia With Peculiar Anatomy. (Case Report And Revie...KETAN VAGHOLKAR
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Background: Spigelian hernia best described as
spontaneous lateral ventral hernia is an extremely rare type of
hernia. The anatomical peculiarities and diagnostic challenges
need to be understood in order to surgically mange this hernia.
Introduction: Spigelian hernia occurs through a defect in the
spigelian fascia typically lying in the spigelian zone.
Case report: A case of a large incarcerated spigelian hernia
is presented to highlight the diagnostic and anatomical
peculiarities of this hernia.
Discussion: The anatomical basis of this hernia along with
clinical presentation, diagnostic modalities and treatment
options is discussed.
Conclusion: Clinical suspicion confirmed by imaging is
necessary for diagnosis. Surgery is the mainstay of treatment.
This document discusses laparoscopic colonic surgery. It provides an overview of different types of laparoscopic colon surgery techniques including standard laparoscopic surgery, laparoscopic-assisted surgery, and hand-assisted laparoscopic surgery. It also discusses indications for laparoscopic colonic resection including colon cancer. Guidelines are provided for performing laparoscopic colonic resection while maintaining oncologic principles.
Ureteral injury is one of the most serious complications of gynecologic surgery. Ureteral injury during laparoscopic surgery has become more common as a result of the increased number of laparoscopic hysterectomies and retroperitoneal procedures that are being performed.
On July 11, 2000, the Food and Drug Administration (FDA) approved the first completely robotic surgery device, the da Vinci surgical system from Intuitive Surgical (Mountain View, CA).
Since the advent of laparoscopic surgery in the 1980s, laparoscopic surgery has been popularized by surgeons throughout the world. However, routine laparoscopic surgery has been slow to catch the pregnant patient.
The esophageal hiatus is an elliptical opening in the diaphragmatic muscular portion. The crura of diaphragm originate from the anterior surface of the first four lumbar vertebrae on the right and L2–L3 on the left to insert anteriorly into the transverse ligament of the central portion of diaphragm.
The document discusses trocar site herniation (TSH), a complication of minimal access surgery where abdominal contents protrude through incisions made for laparoscopic ports. TSH requires emergency repair and can lead to bowel complications if left untreated. The literature recommends preventative measures like fascial closure of port sites ≥10 mm to prevent TSH. Additional risk factors include port location, obesity, extensive port manipulation, and poor port closure technique. Proper closure of fascial defects at port sites is emphasized as the most important preventative factor against TSH. Various port closure instruments and techniques are described, including the use of a Veress needle which allows port closure to be performed internally under vision. Meticulous port closure can
When widespread use of laparoscopy and thoracoscopy in adult patients occurred in the first part of the 1990s, it did not transfer into widespread application in the pediatric population for a number of reasons.
The indications and preparation for laparoscopic liver surgery remain the same as in open hepatic surgery. Visualization is excellent with the laparoscope, and the addition of laparoscopic ultrasound has been shown to help intraoperative plans in 66% of cases when compared to laparoscopic exploration alone.
Gastroesophageal reflux disease (GERD) is defined as the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus. It is a condition which develops when the reflux of stomach contents causes troublesome symptoms and complications.
It is well-known that laparoscopy is the consequence of advances made in the field of medical engineering. Each surgical specialty has different requirement of instruments. Laparoscopy was initially criticized owing to the cost of specialized instruments and possible complications due to these sharp long instruments.
Laparoscopic hysterectomy is a minimally invasive surgical procedure to remove the uterus through small incisions in the abdomen using laparoscopic instruments and visualization. There are several types of laparoscopic hysterectomy depending on the extent of the procedure and whether it is assisted vaginally. Key advantages over traditional abdominal hysterectomy include less postoperative pain, shorter hospital stay, and faster recovery time. Important anatomical structures like the ureters must be carefully identified and protected during the procedure.
Dissection is defined as the separation of tissues with hemostasis. It consists of a sensory visual and tactile component, an access component involving tissue manipulation, and instrument maneuverability.
Laparoscopic exploration of the common bile duct (CBD) is performed either for the diagnosis or the treatment of CBD stones. CBD stones demonstrated by laparoscopic intraoperative cholangiography (IOC) or laparoscopic ultrasonography (LUS) are extracted either through the cystic duct or through choledochotomy.
Laparoscopic colon resections are being performed with increasing frequency all over the world. However, the use of minimal access surgery in colorectal surgery has lagged behind its application in other surgical fields.
Appendicitis was first recognized as a disease entity in the 16th century and was called perityphlitis. McBurney first described its clinical findings in 1889.
Laparoscopic surgery has undergone rapid development in recent years. Laparoscopic cholecystectomy was first performed in 1985. Since the introduction of laparoscopic cholecystectomy into general practice in 1990, it has rapidly become the dominant procedure for gallbladder surgery.
The future laparoscopic technology includes threedimensional virtual reality and expands the scanning rate from 525 lines of resolution to 1,000 or 1,200 lines per frame and the quality of picture would be twice better than existing system.
Storyboard on Acne-Innovative Learning-M. pharm. (2nd sem.) CosmeticsMuskanShingari
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Acne is a common skin condition that occurs when hair follicles become clogged with oil and dead skin cells. It typically manifests as pimples, blackheads, or whiteheads, often on the face, chest, shoulders, or back. Acne can range from mild to severe and may cause emotional distress and scarring in some cases.
**Causes:**
1. **Excess Oil Production:** Hormonal changes during adolescence or certain times in adulthood can increase sebum (oil) production, leading to clogged pores.
2. **Clogged Pores:** When dead skin cells and oil block hair follicles, bacteria (usually Propionibacterium acnes) can thrive, causing inflammation and acne lesions.
3. **Hormonal Factors:** Fluctuations in hormone levels, such as during puberty, menstrual cycles, pregnancy, or certain medical conditions, can contribute to acne.
4. **Genetics:** A family history of acne can increase the likelihood of developing the condition.
**Types of Acne:**
- **Whiteheads:** Closed plugged pores.
- **Blackheads:** Open plugged pores with a dark surface.
- **Papules:** Small red, tender bumps.
- **Pustules:** Pimples with pus at their tips.
- **Nodules:** Large, solid, painful lumps beneath the surface.
- **Cysts:** Painful, pus-filled lumps beneath the surface that can cause scarring.
**Treatment:**
Treatment depends on the severity and type of acne but may include:
- **Topical Treatments:** Such as benzoyl peroxide, salicylic acid, or retinoids to reduce bacteria and unclog pores.
- **Oral Medications:** Antibiotics or oral contraceptives for hormonal acne.
- **Procedures:** Such as chemical peels, extraction of comedones, or light therapy for more severe cases.
**Prevention and Management:**
- **Cleanse:** Regularly wash skin with a gentle cleanser.
- **Moisturize:** Use non-comedogenic moisturizers to keep skin hydrated without clogging pores.
- **Avoid Irritants:** Such as harsh cosmetics or excessive scrubbing.
- **Sun Protection:** Use sunscreen to prevent exacerbation of acne scars and inflammation.
Acne treatment can take time, and consistency in skincare routines and treatments is crucial. Consulting a dermatologist can help tailor a treatment plan that suits individual needs and reduces the risk of scarring or long-term skin damage.
Spontaneous Bacterial Peritonitis - Pathogenesis , Clinical Features & Manage...Jim Jacob Roy
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In this presentation , SBP ( spontaneous bacterial peritonitis ) , which is a common complication in patients with cirrhosis and ascites is described in detail.
The reference for this presentation is Sleisenger and Fordtran's Gastrointestinal and Liver Disease Textbook ( 11th edition ).
Congestive Heart failure is caused by low cardiac output and high sympathetic discharge. Diuretics reduce preload, ACE inhibitors lower afterload, beta blockers reduce sympathetic activity, and digitalis has inotropic effects. Newer medications target vasodilation and myosin activation to improve heart efficiency while lowering energy requirements. Combination therapy, following an assessment of cardiac function and volume status, is the most effective strategy to heart failure care.
Storyboard on Skin- Innovative Learning (M-pharm) 2nd sem. (Cosmetics)MuskanShingari
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Skin is the largest organ of the human body, serving crucial functions that include protection, sensation, regulation, and synthesis. Structurally, it consists of three main layers: the epidermis, dermis, and hypodermis (subcutaneous layer).
1. **Epidermis**: The outermost layer primarily composed of epithelial cells called keratinocytes. It provides a protective barrier against environmental factors, pathogens, and UV radiation.
2. **Dermis**: Located beneath the epidermis, the dermis contains connective tissue, blood vessels, hair follicles, and sweat glands. It plays a vital role in supporting and nourishing the epidermis, regulating body temperature, and housing sensory receptors for touch, pressure, temperature, and pain.
3. **Hypodermis**: Also known as the subcutaneous layer, it consists of fat and connective tissue that anchors the skin to underlying structures like muscles and bones. It provides insulation, cushioning, and energy storage.
Skin performs essential functions such as regulating body temperature through sweat production and blood flow control, synthesizing vitamin D when exposed to sunlight, and serving as a sensory interface with the external environment.
Maintaining skin health is crucial for overall well-being, involving proper hygiene, hydration, protection from sun exposure, and avoiding harmful substances. Skin conditions and diseases range from minor irritations to chronic disorders, emphasizing the importance of regular care and medical attention when needed.
- Video recording of this lecture in English language: https://youtu.be/RvdYsTzgQq8
- Video recording of this lecture in Arabic language: https://youtu.be/ECILGWtgZko
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
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Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
CLASSIFICATION OF H1 ANTIHISTAMINICS-
FIRST GENERATION ANTIHISTAMINICS-
1)HIGHLY SEDATIVE-DIPHENHYDRAMINE,DIMENHYDRINATE,PROMETHAZINE,HYDROXYZINE 2)MODERATELY SEDATIVE- PHENARIMINE,CYPROHEPTADINE, MECLIZINE,CINNARIZINE
3)MILD SEDATIVE-CHLORPHENIRAMINE,DEXCHLORPHENIRAMINE
TRIPROLIDINE,CLEMASTINE
SECOND GENERATION ANTIHISTAMINICS-FEXOFENADINE,
LORATADINE,DESLORATADINE,CETIRIZINE,LEVOCETIRIZINE,
AZELASTINE,MIZOLASTINE,EBASTINE,RUPATADINE. Mechanism of action of 2nd generation antihistaminics-
These drugs competitively antagonize actions of
histamine at the H1 receptors.
Pharmacological actions-
Antagonism of histamine-The H1 antagonists effectively block histamine induced bronchoconstriction, contraction of intestinal and other smooth muscle and triple response especially wheal, flare and itch. Constriction of larger blood vessel by histamine is also antagonized.
2) Antiallergic actions-Many manifestations of immediate hypersensitivity (type I reactions)are suppressed. Urticaria, itching and angioedema are well controlled.3) CNS action-The older antihistamines produce variable degree of CNS depression.But in case of 2nd gen antihistaminics there is less CNS depressant property as these cross BBB to significantly lesser extent.
4) Anticholinergic action- many H1 blockers
in addition antagonize muscarinic actions of ACh. BUT IN 2ND gen histaminics there is Higher H1 selectivitiy : no anticholinergic side effects
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)GeorgeKieling1
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Home
Organization
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
About AOMA: The Academy of Oriental Medicine at Austin offers a masters-level graduate program in acupuncture and Oriental medicine, preparing its students for careers as skilled, professional practitioners. AOMA is known for its internationally recognized faculty, award-winning student clinical internship program, and herbal medicine program. Since its founding in 1993, AOMA has grown rapidly in size and reputation, drawing students from around the nation and faculty from around the world. AOMA also conducts more than 20,000 patient visits annually in its student and professional clinics. AOMA collaborates with Western healthcare institutions including the Seton Family of Hospitals, and gives back to the community through partnerships with nonprofit organizations and by providing free and reduced price treatments to people who cannot afford them. The Academy of Oriental Medicine at Austin is located at 2700 West Anderson Lane. AOMA also serves patients and retail customers at its south Austin location, 4701 West Gate Blvd. For more information see www.aoma.edu or call 512-492-303434.
1. INTRODUCTION
One of the limitations of minimal access surgery is difficulty
in retrieval of tissue. Previously, surgeons were reluctant
to perform many of the advanced surgical procedure due
to this difficult procedure. New techniques for removing
tissue have helped increase the number and types of
laparoscopic surgeries that can be done laparoscopically.
Recently, the Food and Drug Administration (FDA)
recommends that surgeon should use tissue containment
systems when using laparoscopic power morcellators,
and that they ensure the laparoscopic power morcellator
and tissue containment system are compatible. Legally,
marketed laparoscopic power morcellation containment
systems are intended to isolate and contain tissue that
is considered benign. Based on testing and clinical data,
use of a containment system confines morcellated tissue
within the containment system.
Safe removal of tissue is an important consideration
in laparoscopic surgery and applies to all specimens
irrespective of whether they are thought to be benign or
malignant. The importance of wound protection is shown by
considering laparoscopic cholecystectomy for symptomatic
gallstone disease. Most of the gallbladders at the time of
retrieval can be squeezed out through an unprotected
port wound. At the time of extraction exit wound must be
of sufficient size, and wound protection should be used to
ensure that there is no contact between the specimen and
the abdominal wall during removal. We all know that the
incidence of unsuspected gallbladder cancer is between
0.5 and 1% and there are reported cases of port site tumor
nodules because of implantation of tumor cells after
extraction of the gallbladder through an unprotected wound.
Tissue reduction enables extraction through small
wounds but can be used only for benign specimens.
Tissue reduction can be carried out by various techniques,
including mechanical fragmentation and morcellation. It
should be done inside a rip-proof bag whenever possible.
This is essential for laparoscopic splenectomy to prevent
implantation of splenic fragments on the serosal surfaces,
which leads to splenosis (Fig. 1).
Fig. 1: Appendix hidden within cannula.
Tissue RetrievalTechnique
Most commonly the resected tissue should be hidden
under port and then everything should come together with
port. This technique is used for most of the small size organs
such as appendix, gallbladder, small ovarian cyst, ectopic
pregnancy, salpingectomy, small oophorectomy, etc.
ENDOBAGS
In some cases, the tissue to be removed is first encased in
a specimen retrieval bag. These tissue retrieval bags are
available in market and can be prepared by surgeon himself
at the time of laparoscopic surgery (Fig. 2A).
For infected tissue and in case of suspected carcinoma,
tissue retrieval bag should be used. Many sizes of disposable
tissue retrieval bags are available and hard rims of these
retrieval bags are easy to negotiate inside the abdominal
cavity (Figs. 2B to D).
One can easily make the retrieval bag by tying and cutting
the fingers of sterilized gloves. If the gloves used for the
retrieval of tissue, it should be used carefully. It should not
puncture while removing from the abdominal cavity (Fig. 3).
The glove is kept stretched while one assistant will tie it in
the middle (Figs. 4A and B).
Prof. Dr. R. K. Mishra
2. 158 SECTION 1: Essentials of Laparoscopy
C D
A B
Figs. 2A to D: Disposable endobags.
Fig. 3: Endobags.
A B
Figs. 4A and B: Making endobag with glove.
3. 159
CHAPTER 11: Tissue Retrieval Technique
Fig. 5: Glove endobag.
Fig. 6: Way of introducing endobag.
Fig. 7: Using glove endobag.
Keeping it stretched will create a good dumbbell after
knotting and so there is no chance of slipping of knot inside
the abdominal cavity (Fig. 5).
The latex material used to manufacture gloves sometimes,
react with human tissue and it can create a problem if the
glove is punctured and a piece of latex is left inside human
body. Most commonly this torn piece of gloves can be missed
in the layers of abdominal wall (Fig. 6).
At the time of introduction of glove endobag, it should
be held by its cut end and kept stretched over the shaft of
grasper to decrease its thickness (Fig. 7).
The polythene covering of Ryle’s tube can also be used as
inexpensive readymade retrieval bag. This is sterilized and
open at one end (Figs. 8A and B).
These polythene bags can be used as excellent retrieval
pouch if used carefully. The polythene bag has one demerit
that sometime the edges are difficult to find out because it
is transparent and secondly because it is thin and does not
have elastic property like gloves so it slips easily after once
held by grasper (Figs. 9A to E).
Drawback of this self-made retrieval bag is that they do
not have hard rim so it is difficult to manipulate inside the
abdominal cavity.
These bags can be introduced inside the abdominal
cavity through 10 mm ports. In special circumstances if there
is difficulty is found, it can be introduced directly through
the port wound after withdrawing the cannula.
Once the retrieval bag is inside, it should be positioned in
free abdominal space and the rim of bag should be stabilized
with nondominant hand and dominant hand should be
used to put the specimen inside. Once the bag is inside the
abdominal cavity both the edges of the retrieval bag should
be lifted to displace the specimen into the base of the bag
(Figs. 10A and B). Condom can also be used for retrieving
tissue. Lubricated condom should be avoided because it can
cause tissue reaction.
To take the specimen out, surgeon should hide the mouth
of retrieval bag inside the cannula by pulling it and then the
cannula together with the neck of bag is pulled outside the
abdominal cavity.
Once the neck of the bag is out, its opening is stretched
by the help of assistant. Ovum forceps can be introduced
inside to morcellate the tissue manually if there is difficulty
in pulling the bag out (Fig. 11).
COLPOTOMY
For large size gynecological tissue, colpotomy route is good
for retrieval. Colpotomy can be done laparoscopically
with the help of heal of hook. Counter pushing by other
instruments is effective. Sponge over sponge-holding forceps
is inserted in posterior vaginal fornix by one assistant and
surgeon cuts the vaginal fascia between both the uterosacral
ligaments with the heel of hook (Fig. 12).
4. 160 SECTION 1: Essentials of Laparoscopy
B
A
Figs. 8A and B: Polypropylene endobag.
C
A B
D E
Figs. 9A to E: Introduction of tissue in endobag.
A B
Figs. 10A and B: Neck of endobag pulled outside the abdominal wall.
5. 161
CHAPTER 11: Tissue Retrieval Technique
Fig. 11: Morcellation of tissue through endobag. Figs. 12: Colpotomy.
Fig. 13: Electrical morcellator. Fig. 14: Different type of morcellator.
HAND-ASSISTED LAPAROSCOPIC SURGERY
Hand-assisted technique was initially started keeping inside
ease of tissue retrievals, wherein the surgeon uses his or
her hand, inserted through the initial incision, to aid in the
exploration, isolation, and removal of tissue.
Hand-assisted technique offers distinct advantages,
the superior visualization afforded by the laparoscope and
a tactile component that is important in many aspects of
surgery and has allowed surgeons to apply a less invasive
approach to surgeries that previously could not have been
done laparoscopically.
Hand-assisted laparoscopy can also serve as a bridge
between open surgery and straight laparoscopy, making it
easier for surgeons to practice and learn the skills necessary
for performing laparoscopic procedures.
MORCELLATOR
Use of morcellator is another way which facilitates grinding
of solid tissue and then these can be taken out without
any difficulty. Recently many companies have launched
battery-operated morcellator. The morcellator is important
instrument for tissue retrieval in myomectomy and
splenectomy (Fig. 13).
One of the early concerns about laparoscopic procedures
in cancer patient was that they caused port site metastases,
i.e., the appearance of recurrent tumor tissue at the site of
trocarentry(Fig.14).Useoflaparoscopicpowermorcellators
allow for minimally invasive surgical procedures, which,
when compared to open abdominal surgery, typically
reduce the risk of infection, and shorten the postoperative
recovery period. However, when used in myomectomy
or hysterectomy procedures, there is an increased risk of
spreading unsuspected cancer and benign tissue within
the abdomen and pelvis. The risk of unsuspected cancer
increases with age, particularly in women over 50 years of
age.
Cancer surgery, however, poses some unique challenges
that make the application of laparoscopic surgery in
oncology more problematic. It is critically important in
6. 162 SECTION 1: Essentials of Laparoscopy
Fig. 15: Power morcellation of tissue. Fig. 16: Morcellation of tissue.
cancer that whole organs should be removed intact (en
bloc) so that pathologists can properly examine them and
measure and document the depths and margins of tumor
invasion. A second concern for surgical oncologists is cell
transfer or cell spillage. Diseased tissue must be removed
without contaminating adjacent tissues and structures with
cancer cells. Because of these concerns, tissue morcellation,
a technique commonly used in noncancer laparoscopic
surgery in which the tissue is divided into pieces so that it
can be removed more easily should not be used for oncologic
procedures. All the 10 mm or >10 mm defects should be
closed properly to prevent any future possibility of hernia
(Figs. 15 and 16).
The suture passer should be used to pass the thread and
then it should be tied externally.
Especially, designed port closure instruments are also
available commercially.
If port is suddenly taken out, the chance of port site
hernia and adhesion is much higher. It is a good practice to
insert some blunt instrument while removing the last port
out, to prevent entrapment of omentum or bowel content.
After closing the rectus sheath, the skin can be closed by
intradermal, skin stapler or by any of the surgical skin glues
available.
FDA Warnings about Power
Morcellation (Fig. 15)
When laparoscopic power morcellators are used for
myomectomy or hysterectomy in women with presumed
uterine fibroids that are actually uterine sarcomas, the
surgical procedure poses a risk of spreading cancerous
tissue beyond the uterus, worsening a woman’s chance of
long-term survival. In April 2014, the FDA issued a statement
discouraging use of laparoscopic power morcellation
in hysterectomy for uterine fibroids; this was followed
by a warning in November 2014 against use of uterine
power morcellation because of risk for dissemination of
malignant tissue. In response, many hospitals banned power
morcellation. The FDA currently estimates that a hidden
uterine sarcoma may be present in approximately 1 in 225
to 1 in 580 women undergoing surgery for uterine fibroids
based on recent publications. The FDA also estimates that
a leiomyosarcoma may be present in approximately 1 in
495 to 1 in 1,100 women undergoing surgery for uterine
fibroids based on recent studies. Prior to 2014, the clinical
community estimated uterine sarcomas to be present much
less frequently, in as few as 1 in 10,000 women undergoing
surgery for uterine fibroids.
Several studies show that using a laparoscopic power
morcellator during gynecologic surgery in women with
hidden uterine sarcomas is associated with lowering their
chances of long-term survival without cancer. While these
studies have limitations, women who have had fibroid
surgery with a laparoscopic power morcellator later found
to have a hidden uterine sarcoma, have lower disease-free
survival, when compared to women who were treated with
manualmorcellationorwithoutmorcellation.MorSafe®
isan
innovative single-use disposable device intended to be used
as a receptacle for benign tissue mass during gynecological
procedures such as laparoscopic myomectomy or
laparoscopic hysterectomy. The device has unique features
to allow for quick deployment, insufflation, morcellation,
and spill-proof withdrawal of the bag.
MorSafe®
Tissue Isolator
MorSafe®
, with its unique two port design, offers the surgeon
superior visibility during the surgery compared to a single
port approach (Figs. 17A and B). Designed to fit and take
the shape of the abdomen, it has been constructed utilizing
a special tear-resistant material to prevent leakage. It also
contains a special ring in the bag opening to allow the
surgeon ultimate control of the bag opening and easy access
to the interior of the bag during surgery.
7. 163
CHAPTER 11: Tissue Retrieval Technique
Figs. 17A and B: MorSafe®
tissue isolator.
A B
BIBLIOGRAPHY
1. Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences
in the treatment of early-stage lung cancer. N Engl J Med.
1999;341:1198-205.
2. Ballesta-Lopez C, Bastida-Vila X, Catarci M, Mato R, Ruggiero
R. Laparoscopic Billroth II distal subtotal gastrectomy with
gastric stump suspension for gastric malignancies. Am J Surg.
1996;171:289-92.
3. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital
volume on operative mortality for major cancer surgery. JAMA.
1998;280:1747-51.
4. Bouvy ND, Marquet RL, Jeekel H, Bonjer HJ. Impact of gas
(less) laparoscopy and laparotomy on peritoneal tumor
growth and abdominal wall metastases. Ann Surg. 1996;224:
694-701.
5. Callery MP, Strasberg SM, Doherty GM, Soper NJ, Norton
JA. Staging laparoscopy with laparoscopic ultrasonography:
optimizing resectability in hepatobiliary and pancreatic
malignancy. J Am Coll Surg. 1997;185:33-9.
6. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method
of classifying prognostic comorbidity in longitudinal studies:
development and validation. J Chron Dis. 1987;40:373-83.
7. Chew DK, Borromeo JR, Kimmelstiel FM. Peritoneal mucinous
carcinomatosis after laparoscopic-assisted anterior resection
for early rectal cancer: report of a case. Dis Colon Rectum.
1999;42:424-6.
8. Cox DR. Regression models and life-tables. J R Statist Soc
(Ser B). 1972;34:187-220.
9. Cubiella J, Castells A, Fondevila C, Sans M, Sabater L,
Navarro S, et al. Prognostic factors in nonresectable
pancreatic adenocarcinoma: a rationale to design therapeutic
trials. Am J Gastroenterol. 1999;94:1271-8.
10. DeMeester TR, Wang CI, Wernly JA, Pellegrini CA, Little AG,
Klementschitsch P, et al. Technique, indications, and clinical use
of 24-hour esophageal pH monitoring. J Thorac Cardiovasc Surg.
1980;79:656-70.
11. Dieter RA Jr, Kuzycz GB. Complications and contraindications of
thoracoscopy. Int Surg. 1997;82:232-9.
12. Dorrance HR, Oien K, O’Dwyer PJ. Effects of laparoscopy on
intraperitoneal tumor growth and distant metastases in an
animal model. Surgery. 1999;126:35-40.
13. Drouard F, Delamarre J, Capron JP. Cutaneous seeding of
gallbladder cancer after laparoscopic cholecystectomy. N Engl J
Med. 1991;325:316.
14. Eadie LH, Seifalian AM, Davidson BR. Telemedicine in surgery. Br
J Surg. 2003;90:647-58.
15. Fleshman JW, Nelson H, Peters WR, Kim HC, Larach S, Boorse
RR, et al. Early results of laparoscopic surgery for colorectal
cancer: retrospective analysis of 372 patients treated by Clinical
Outcomes of Surgical Therapy (COST) Study Group. Dis Colon
Rectum. 1996;39:S53-8.
16. Forde KA, Hulten L. Laparoscopy in colorectal surgery. Surg
Endosc. 1996;10:1039-40.
17. Forster R, Storck M, Schafer JR, Honig E, Lang G, Liewald F.
Thoracoscopy versus thoracotomy: a prospective comparison of
trauma and quality of life. Langenbecks Arch Surg. 2002;387:32-6.
18. Freedman LS. Tables of the number of patients required in clinical
trials using the logrank test. Stat Med. 1982;1:121-9.
19. Geer RJ, Brennan MF. Prognostic indicators for survival
after resection of pancreatic adenocarcinoma. Am J Surg.
1993;165:68-72.
20. Giulianotti PC, Coratti A, Angelini M, Sbrana F, Cecconi S,
Balestracci T, et al. Robotics in general surgery: personal
experience in a large community hospital. Arch Surg.
2003;138:777-84.
21. Jacobi CA, Sabat R, Bohm B, Zieren HU, Volk HD, Müller JM.
Pneumoperitoneum with carbon dioxide stimulates growth of
malignant colonic cells. Surgery. 1997;121:72-8.
22. Jacobi CA, Wildbrett P, Volk T, Muller JM. Influence of different
gases and intraperitoneal instillation of antiadherent or cytotoxic
agents on peritoneal tumor cell growth and implantation with
laparoscopic surgery in a rat model. Surg Endosc. 1999;13:1021-5.
23. Jones DB, Guo LW, Reinhard MK, Soper NJ, Philpott GW, Connett
J, et al. Impact of pneumoperitoneum on trocar site implantation
of colon cancer in hamster model. Dis Colon Rectum.
1995;38:1182-8.
24. Kalbfleisch JD, Prentice RL. The Statistical Analysis of Failure
Time Data. New York, NY: John Wiley and Sons; 1980.
25. Kaplan EL, Meier P. Nonparametric estimation from incomplete
observations. Am Stat Assoc. 1958;53:457-81.
26. Kumar A, Kumar S, Aggarwal S, Khilnani GC. Thoracoscopy:
the preferred approach for the resection of selected posterior
mediastinal tumors. J Laparoendosc Adv Surg Tech A.
2002;12:345-53.
27. Lacy AM, Garcia-Valdecasas JC, Pique JM, Delgado S, Campo E,
Bordas JM, et al. Short-term outcome analysis of a randomized
study comparing laparoscopic vs open colectomy for colon
cancer. Surg Endosc. 1995;9:1101-5.
8. 164 SECTION 1: Essentials of Laparoscopy
28. Mack MJ. Video-assisted thoracoscopy thymectomy for
myasthenia gravis. Chest Surg Clin N Am. 2001;1:389-05.
29. Masaoka A, Yamakawa Y, Niwa H, Fukai I, Kondo S, Kobayashi M,
et al. Extended thymectomy for myasthenia gravis patients: a
20-year review. Ann Thorac Surg. 1996;62:853-9.
30. Melfi FM, Menconi GF, Mariani AM, Angeletti CA. Early
experience with robotic technology for thoracoscopic surgery.
Eur J Cardiothorac Surg. 2002;21:864-8.
31. Milsom JW, Bohm B, Hammerhofer KA, Fazio V, Steiger E,
Elson P. A prospective, randomized trial comparing laparoscopic
versus conventional techniques in colorectal cancer surgery: a
preliminary report. J Am Coll Surg. 1998;187:46-54.
32. Morgan JA, Ginsburg ME, Sonett JR, Morales DL,
Kohmoto T, Gorenstein LA, et al. Advanced thoracoscopic
procedures are facilitated by computer-aided robotic technology.
Eur J Cardiothorac Surg. 2003;23:883-7.
33. Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N.
Pulmonary function, postoperative pain, and serum cytokine
level after lobectomy: a comparison of VATS and conventional
procedure. Ann Thorac Surg. 2001;72:362-5.
34. Nifong LW, Chu VF, Bailey BM, Maziarz DM, Sorrell VL, Holbert D,
et al. Robotic mitral valve repair: experience with the da Vinci
system. Ann Thorac Surg. 2003;75:438-42.
35. Onnasch JF, Schneider F, Falk V, Mierzwa M, Bucerius J, Mohr FW.
Five years of less invasive mitral valve surgery: from experimental
to routine approach. Heart Surg Forum. 2002;5:132-5.
36. Onoda N, Ishikawa T, Yamada N, Okamura T, Tahara H, Inaba M,
et al. Radioisotope-navigated video-assisted thoracoscopic
operation for ectopic mediastinal parathyroid. Surgery. 2002;
132:17-9.
37. Potosky AL, Riley GF, Lubitz JD, Mentnech RM, Kessler LG.
Potential for cancer related health services research using a linked
Medicare-tumor registry database. Med Care. 1993;31:732-48.
38. Poulin EC, Mamazza J, Schlachta CM, Gregoire R, Roy N.
Laparoscopic resection does not adversely affect early
survival curves in patients undergoing surgery for colorectal
adenocarcinoma. Ann Surg. 1999;229:487-92.
39. Ramshaw BJ. Laparoscopic surgery for cancer patients. CA Cancer
J Clin. 1997;47:327-50.
40. Romano PS, Mark DJ. Bias in the coding of hospital discharge
data and its implications for quality assessment. Med Care.
1994;32:81-90.
41. Roviaro GC, Varoli F, Vergani C, Maciocco M. State of the
art in thoracoscopic surgery: a personal experience of 2000
videothoracoscopic procedures and an overview of the literature.
Surg Endosc. 2002;16:881-92.
42. Schmid T. Editorial to: main topics: robotic surgery. Eur Surg.
2002;34:155-7.
43. Schurr MO, Arezzo A, Buess GF. Robotics and systems technology
for advanced endoscopic procedures: experiences in general
surgery. Eur J Cardiothorac Surg. 1999;16(2):S97-105.
44. SEER Cancer Statistics Review, 1973–1997. Bethesda, MD:
National Cancer Institute; 2000.
45. Sener SF, Fremgen A, Menck HR, Winchester DP. Pancreatic
cancer: a report of treatment and survival trends for 100,313
patients diagnosed from 1985–1995, using the National Cancer
Database. J Am Coll Surg. 1990;189:1-7.
46. Soper NJ, Brunt LM, Kerbl K. Medical progress: laparoscopic
general surgery. N Engl J Med. 1994;330:409-19.
47. Takiguchi S, Matsuura N, Hamada Y, Taniguchi E, Sekimoto M,
Tsujinaka M, et al. Influence of CO2 pneumoperitoneum during
laparoscopic surgery on cancer cell growth. Surg Endosc.
2000;14:41-4.
48. TewariA,PeabodyJ,SarleR,BalakrishnanG,HemalA,Shrivastava
A, et al. Technique of da Vinci robot-assisted anatomic radical
prostatectomy. Urology. 2002;60:569-72.
49. Volz J, Koster S, Schaeff B, Paolucci V. Laparoscopic surgery: the
effects of insufflations gas on tumor-induced lethality in nude
mice. Am J Obstet Gynecol. 1998;178:793-5.
50. Wetscher GJ, Glaser K, Wieschemeyer T, Gadenstaetter M,
Prommegger R, Profanter C. Tailored antireflux surgery for
gastroesophageal reflux disease: effectiveness and risk of
postoperative dysphagia. World J Surg. 1997;21:605-10.
51. Wexner SD, Cohen SM. Port site metastases after laparoscopic
colorectal surgery for cure of malignancy. Br J Surg. 1995;82:295-8.
52. Whelan RL, Allendorf JD, Gutt CN, Jacobi CA, Mutter D,
Dorrance HR, et al. General oncologic effects of the laparoscopic
surgical approach. 1997 Frankfurt International Meeting of
Animal Laparoscopic Researchers. Surg Endosc. 1998;12:1092-5.
53. Whelan RL, Lee SW. Review of investigations regarding the
etiology of port site tumor recurrence. J Laparoendosc Adv Surg
Tech A. 1999;9:1-16.
54. Bouvy ND, Giuffrida MC, Tseng LN, Steyerberg EW,
Marquet RL, Jeekel H, et al. Effects of carbon dioxide pneumo-
peritoneum, air pneumoperitoneum, and gasless laparo-
scopy on body weight and tumor growth. Arch Surg. 1998;133:
652-6.
55. WittichP,MarquetRL,KazemierG,BonjerHJ.Port-sitemetastases
after CO2 laparoscopy. Is aerosolization of tumor cells a pivotal
factor? Surg Endosc. 2000;14:189-92.
56. Wykypiel H, Wetscher GJ, Klaus A, Schmid T, Gadenstaetter M,
Bodner J, et al. Robot-assisted laparoscopic partial posterior
fundoplication with the DaVinci system: initial experiences and
technical aspects. Langenbecks Arch Surg. 2003;387:411-6.
57. Yim AP. Thoracoscopic thymectomy: which side to approach?
Ann Thorac Surg. 1997;64:584-5.