SPA in Gynaecology - Gynekologisen Kirurgian Seuragks.fi/wp-content/uploads/2012/03/Single-site-surgery-24...Päivi Pakarinen SPA in gynaecology 1. Theoretical aspects: a. Difference

SPA in Gynaecology

Päivi Pakarinen MD PhDHelsinki University Central HospitalDepartment of Obstetrics and [email protected]

Päivi Pakarinen SPA in gynaecology

Development of gynecologic surgery : hysterectomy 1

• SORANUS of Ephesus 2nd century AD– First hysterectomy for

prolapse??, gangrenous uterus • 18th CENTURE

» Mortality rate 90%• SEMMELWEIS 1818-1865 • LISTER 1827-1912

» Antiseptic techniques reduced morbidity and mortality

• SIMPSON London, England» 1847 chloroform anesthesia


Development 2

• PÈAN 1830-1898» Instrumentation

• PORRO Milan, Italy» 1876: First hysterectomy on gravid uterus

• SCHAUTA and his student WERTHEIMVienna, Austria» 1898: First radical hysterectomy» for cancer of the uterus

• PALMER Paris, France» 1940s: Introduction oflaparoscopy

http://www.google.fi/imgres?imgurl=http://upload.wikimedia.org/wikipedia/commons/c/ce/Pean.jpg&imgrefurl=http://commons.wikimedia.org/wiki/File:Pean.jpg&usg=__g0aztqe3aaxGeNwoa6yRiDau4J4=&h=412&w=750&sz=57&hl=fi&start=1&zoom=1&tbnid=GIe97lAK6zsfWM:&tbnh=77&tbnw=141&prev=/images%3Fq%3DPEAN%26hl%3Dfi%26gbv%3D2%26tbs%3Disch:1&itbs=1


Development 3

• SEMM Kiel, Germany– 1970s/1980s: Marked advance with

operative laparoscopy (pelviscopy) • REICH Pennsylvania-USA

– 1989: First laparoscopic-assisted vaginal hysterectomy

• SEMM Kiel, Germany– 7 Sept.1991: First C*I*S*H*

(Classic Intrafascial S.E.M.M. Hysterec-tomy)

• Robotic assisted hysterectomy 2000s• Single port laparoscopic hysterectomy 2000s


WHY LESS?• Faster recovery• Less pain• Wounds less

– Infections– Bleeding– Hernias– Cosmetic result


Techical challenges

• Triangulation---> Single port• Flexible scopes• Instrumentation development

– Cross handed instruments– Articulated instruments

• Robotic assistance QuickTim e™ and aMotion JPEG OpenDML decom pressor

are needed to see this picture.


Single port LaparoscopySynonyms

• Single Port Access -surgery SP• Laparo Endoscopic Single-Site -surgery LESS• Single Incision Laparoscopic Surgery SILS• One Port Umbilical Surgery OPUS • Single Port Incisionless conventional Equipment-utilizing Surgery SPICES• Natural Orifice Transumbilical Surgery NOTUS• Embryonic Natural Orifice Transumbilical Surgery E-NOTES


Ports

DaVinci® Surgical System docked to robotic trocars in GelPort® at umbilicus.

Covidien multi-channel SILS™ port.

Uni-X image


Tri- and Quadport


E-NOTES procedures

•Tubal ligation 1969 Wheeless•Total hysterectomy BSO 1991 Pelosi•Supracervical hysterectomy BSO 1992 Pelosi •Appendectomy 1992 Pelosi •Cholecystectomy 1997 Navarra •Ovarian cystectomy 2001 Kosumi •Salpingectomy for ectopic pregnancy 2005 Ghezzi•Lap-assisted ventriculoperitoneal shunt 2006 Goitein •Meckel's diverticulectomy 2007 Cobellis

David Canes et al Urol 2008


Gynecologists adapted early

• C.R. Wheeless, A rapid, inexpensive, and effective method of surgical sterilization by laparoscopy, J. Reprod. Med. 5 (1969), p. 255

• Pelosi MA, Pelosi MAIII Laparoscopic supracervical hysterectomy using a single umbilical puncture (minilaparoscopy). J Reprod Med (1992) 37:777:784

• Ghezzi F, Cromi A, Fasola M, Bolis P. One-trocar salpingectomy for the treatment of tubal pregnancy: a 'marionette-like' technique. BJOG (2005); 112: 1417-9.


SPA procedures



QuickTime™ jaTIFF (LZW) pakkauksen purkuohjelma

tarvitaan elokuvan katselemiseen.

QuickTime™ jaTIFF (LZW) pakkauksen purkuohjelma

tarvitaan elokuvan katselemiseen.

FERT STER 2010


• 89% no conversions• blood loss 0-75ml• Postoper pain VAS 3-5• Recovery without problems• Cosmetic outcome excellent


• Soul Korea• 52 SPA-TLH• 105 TLH• Retrospektiivinen tapaus-verrokkitutkimus

QuickTime™ and a decompressor





Patients


SPA-TLH vs TLH


Postoperative pain




Juntendo University of Medicine, Tokyo, Japan 2010

• Center for laparoscopic gynecologic surgery

• 2 port technique is used on daily basis

• Hysterectomy is not a trend in Japan

• Myomektomy

– 1000 myomectomies/ year

• Umbilical port as done in SPAQuickTim e™ ja

p akkauks en p urkuohjelm atarvitaa n eloku van katse lem iseen.


Modification with 2 port

• 13 cases– Ectopic pregnancy– Myoma– Ovarian cysts

• OP Time 40-146 min• BL 5-303 ml• No Conversions

Kikuchi et al 2009 J Min Inv Oncol


HYKS patients

• 4 patients– 4 Adnexectomy

• Profylactic– Ovarian cyst

• Benign 14 cm– Hysterectomy

• PM bleeding



Laparoendoscopic Single-Site Surgery Consortium for Assessment and Researc

LESSCAR /USA


LESSCAR training


Training for laparoendoscopic single-site surgery (LESS)Training for laparoendoscopic single-site surgery (LESS)Enrico Mattana Müllera, Leandro Totti Cavazzolaa, , , João Vicente Machado Grossia, Mirandolino Batista Marianob, Cláudio Moralesb and Maurício Brunb

a Department of Surgery, Universidade Luterana do Brazil, Canoas, RS, Brazilb Universidade de Passo Fundo, Passo Fundo, RS, Brazil

Int J Surgery 2010


1. Theoretical aspects:a. Difference between single-incision and

single-port proceduresb. Equipment and surgical instrumentation needed

for LESSc. Definition of the target organ and incision sited. Differences between the technique employed in the

main surgeries using LESS and that employed in conventional laparoscopy

e. Need for appropriate transoperative planningf. Conversion plan in the case of complicationsg. Difficulty, and sometimes impossibility,

of centering the clamps on the screenh. Surgical wound complications – theoretical possibility that a larger incision may increase the risk of infection and incisional hernia.

Muller et al 2009

Training for laparoendoscopic single-site surgery (LESS)


2. Practical aspects:a. Use of simulators;b. Extensive training on animal models, after achieving proficiency in simulators;c. Team training on instrument handling;d. Training on restricted movements;e. Use of flexible instrumentation;f. Work with experienced surgeons in LESS as

a camera assistant before performing any procedure of this nature;g. In the first LESS procedures, to be accompanied by

a surgeon experienced in the method;h. Always work with a team largely familiar with the method.

Muller et al 2009


Additionally, it is essential to emphasize that:

1. Laparoscopic surgeons, with a complete and experienced surgical team

2. The operation must focus on the primary procedure, thus minimizing the risk of unexpected injuries, especially due to the lower range of movement allowed by this technique

3. In LESS “the great is enemy of the good” (the camera assistant is affected by instrumentation collision and vision is often peripheral, but, if vision is considered safe, it is allowed in LESS)

4. There must be a safety plan prior to surgery, including conversion to laparoscopic surgery or even to open surgery in the case of complications

5. LESS should be gradually implemented in medical residency programs Muller et al 2009


SPA in gynecologic surgery 28.5.2010 HYKS Helsinki

Dr Francisco Carmona, Barcelona


SPA in gynecologic surgery 28.5.2010Live surgery/ profylactic ophorectomy


Take home message

• New method – Technically demanding– Training– Advanced instrumentation in OR

• New way of thinking– Operate without scars– Patient satisfaction and body image

SPA in Gynaecology - Gynekologisen Kirurgian Seuragks.fi/wp-content/uploads/2012/03/Single-site-surgery-24...Päivi Pakarinen SPA in gynaecology 1. Theoretical aspects: a. Difference

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