30/06/2014 1 Gynaecological Surgery Mr Alfred Cutner, Consultant Gynaecologist, University College Hospital, London Laparoscopic surgery techniques Common complications of laparoscopic surgery Intra-operative injuries: perforation, failure to diagnose and treat TVT tapes Uterine prolapse WHAT IS LAPAROSCOPIC SURGERY?
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30/06/2014
1
Gynaecological Surgery
Mr Alfred Cutner, Consultant Gynaecologist, University College Hospital, London
Laparoscopic surgery techniques
Common complications of laparoscopic surgery
Intra-operative injuries: perforation, failure to
diagnose and treat
TVT tapes
Uterine prolapse
WHAT IS
LAPAROSCOPIC
SURGERY?
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Open Surgery Through Small Holes
LAPAROSCOPIC SURGERY
ENHANCED VISION
LEARNING CURVE
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SURGICAL SKILLS
Infrastructure
Equipment potential
Finances
Surgeons
Support staff
Patient pressure
NEED TO CONSIDER
Surgical skills
Surgical environment
Patient expectation
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NEED TO PREVENT
TEAM
EQUIPMENT FIT FOR PURPOSE
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Ceiling hung monitors Correct number Correct position Wire free floor Piped CO2 Green light Surgeon control Light Gas Laparoscope light
Image storage Video storage Video transmission
Ergonomics
The study of designing equipment and devices that fit the human body, its movements, and its cognitive abilities
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Cognitive Effects
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Cutner A, Stavroulis A, Zolfaghari N. Risk assessment of the ergonomic aspects of laparoscopic theatre. Gynecol Surg. May 2013. 10 (2) 99-102
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Risk rating
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Stavroulis A, Cutner A, Liao L-M. Staff perceptions of the effects of an integrated laparoscopic theatre environment on teamwork. Gynecol Surg. Aug 2013. 10 (3) 177-180
Results
all staff IT- median (IQR) for all
three groups together
NIT - median (IQR) for all
three groups together
Satisfaction/Preference
overall 9 (8,10) 5 (3,6)
Overall efficiency/Theatre
efficiency 9 (8,10) 5 (3,6)
Positive theatre team
behaviour/ Teamwork 9 (7,10) 5 (5,7)
Stress level 2 (1,2) 7 (6,8)
Please rate the following features according to how important you feel they are
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Patient Choice
• State of the art theatres
• Latest technology
• Skilled theatre teams
• Advanced minimal access surgery
• Low complication rates
SURGICAL SKILLS
NEW TRAINING PATHWAY
How to train surgeons in advanced laparoscopic surgery?
Lab based Animal based Observation Preceptorship
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TRAINING METHODS
Animal models Cadaveric models
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“Big day Hoskins, the training wheels come off”
CORRECT SKILLS
Operate with 2 hands Dissection techniques Ability to control Haemostasis Ability to suture Ability to tie knots: Intra-corporeal Extra-corporeal
Knots
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DA VINCI® SURGICAL SYSTEM
New surgical skills
Different set up
Different Equipment
CHANGE TO ROBOTICS
Research Project
Saves Money
A complication that you feel will be resolved
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12 X 2 8 X 3 48mm
11 X 2 5 X 2 32mm
11 mm
11 mm 12 mm
12 mm
8 mm
8 mm
8 mm
CHANGE TO ROBOTICS
More holes Bigger holes
CHANGE TO ROBOTICS
Takes Longer
CHANGE TO ROBOTICS
Costs More
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ENDOMETRIOSIS
Different levels of complexity
Potential risks
Demonstrates decision making process
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ENDOMETRIOTIC CYST
Uterosacral ligaments
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DECISION MAKING
Risk Benefit
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INCREASED RISK
Too Thin Too Fat Previous surgery Midline greater than transverse Multiple surgery is greater risk Previous infection Previous complication at pelvic / abdominal surgery Major surgery Adhesions Large Abdominal Mass Congenital Anomaly
CONGENITAL ANOMALIES
LUT anomalies
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EXCISE BOWEL ENDOMETRIOSIS
Duepree et al, 2002
51 Patients
26 serosal excision
18 bowel resection
5 disc resection
10.3% complication rate
4 converted to laparotomy
3 readmitted within 30 days
7 required TAH or BSO
Bowel Shave Disc
Resection
RECTOVAGINAL DISEASE
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Recto-vaginal dissection
NO YES
30
20
10
0
PASSED
FAILED TOV
Bladder function
EXCISE BOWEL ENDOMETRIOSIS
Functional Risks
Bowel storage problems Williamson et al, Dis Colon Rectum:1995 3 month: 53% some leakage and urgency 1 year: 29% some leakage and urgency
IS ADVANCED LAPAROSCOPIC
SURGERY ACCEPTABLE COMPARED
TO OPEN SURGERY
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COUNSELLING
Discuss whether the proposed surgery is likely to cure Discuss Risks Need to include what may be done as part of operation What may be done regards a complication Time to reflect where risks are great Understand the implications of inadequate surgery
Women who are considering having surgery for stress incontinence should be given full information about the advantages and drawbacks of the options available.
Open Burch X 1 Lap colpo X 10 Sling X 30 Injection X 10
COUNSEL ALL METHODS AVAILABLE
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LAP Colpo
•Level 1+ evidence no difference
•Needs skills to be learnt
•Implication for resources
NO TRAINING PROGRAM
NO ACCREDITATION
NO RE-ACCREDITATION
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IS LAPAROSCOPIC SAME AS OPEN ?
Dean, N.M., et al., Laparoscopic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev, 2006
10 trials to compare laparoscopic with open colposuspension. Results were difficult to compare due to the large variation in lengths of follow-up, outcome measures and definitions used.
Subjective cure rates within 18 month follow-up
open group 58 to 96%
laparoscopic group 62 to 100%
no significant difference was found between 18 months and five years of follow-up
The risk of developing voiding dysfunction or de novo detrusor overactivity was similar in both groups as were the results of various Quol
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Laparoscopic group significantly fewer postoperative complications (Comparison 01.07; RR 0.74, 95% CI 0.58 to 0.96 lower estimated blood losses shorter duration of catheterisation
Laparoscopic versus open colposuspension - results of a prospective randomised study
Kitchener et al,BJOG:2006
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BURCH Mid Urethral Tape
COLPOSUSPENSION TVT
VOID DIFF YES YES
DO YES YES
PROLAPSE YES NO
EROSION NO YES
SUCCESS 80% 80%
MORBIDITY VARIABLE LOW
LONG TERM DATA YES YES
COLPOSUSPENSION vs TVT
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Eight studies comparing the laparoscopic
colposuspension with the TVT type sling
procedures were reviewed in the Cochrane Review
No significant difference in subjective cure rates
by 18 month follow-up.
Even at longer term follow-up (four to eight years
the TVT was found to have similar results to the
laparoscopic colposuspension.
E
I
THER
TVT COLPO
Cystocoele
Other intra-abdominal surgery
Young
Fit
Slim
No prolapse
Previous surgery
Obese
Elderly
Medically unfit
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E
I
THER
TVT COLPO
As TVT easier to do with apparent less morbidity
E
I
THER
TVT COLPO
Anxieties over mesh
UTERINE PROLAPSE
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PROLAPSE
DISPLACEMENT OF AN ORGAN FROM ITS NORMAL CONFINES
APICAL
EFFECTS OF SURGERY ON DIFFERENT COMPARTMENTS
ANT POST
VAULT PROLAPSE
POST HYSTERECTOMY • 11.6% if performed for prolapse
• 1.8% if performed for another reason
Marchionni M et al. Journal of Reproductive Medicine 1999;44: 679-684. True incidence of vaginal vault prolapse: Thirteen years of experience.
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VAULT SUPPORT
VAGINAL MESH KITS
IS IDENTICAL SUPPORT REQUIRED FOR ALL?
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Anatomy vs Function
AIMS OF TREATMENT
RESTORE ANATOMY MAINTAIN FUNCTION Bladder Bowel Sexual ENABLE FUTURE TREATMENT
LEGAL ACTION
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FDA
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MESH REPAIR
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How else can we avoid the vault recurrence?
• Why remove the uterus at all?
• Rather than being a cause of the prolapse, the uterus may be regarded as an innocent bystander, descending as a result of failure of apical support mechanisms