apage symposium · 2020-01-30 · •adnexal masses (not suspicious) ... genesis of the guidance...
TRANSCRIPT
Sponsored by
AAGLAdvancing Minimally Invasive Gynecology Worldwide
APAGE Symposium
PROGRAM Co-CHAIRS
Prof. Chyi-Long Lee & Prof. Mitsuru Shiota
Prashant Mangeshikar, MD Hsuan Su, MD
Table of Contents
Course Description ........................................................................................................................................ 1 Transvaginal Natural‐Orifice Transluminal Endoscopic Surgery (NOTES) in Adnexal Procedures C. Lee, H.Su ................................................................................................................................................... 2 Demystifying the Total Laparoscopic Hysterectomy P. Mangeshikar ............................................................................................................................................. 9 Cultural and Linguistics Competency ......................................................................................................... 13
APAGE Symposium
Professor Chyi-Long Lee and Professor Mitsuru Shiota, Co-Chairs
Faculty: Dr. Preshant Mangeshikar, Dr. Hsuan Su
Course Description Natural orifice transluminal endoscopic surgery (NOTES) uses the natural orifices of human body (ex, mouth, anus, etc.) as port of laparoscopy to achieve a “scarless” abdominal surgery. Though the techniques of transcolonic or transesophageal accesses have also been developed, the transvaginal access is the most frequently used and suitable for gynecologists. The first course, Transvaginal NOTES in Adnexal Procedures, provides its technical details and feasibility evaluation. Hysterectomy is one of the most commonly performed surgical procedures. Total laparoscopic hysterectomy (TLH) is characterized by performing all the procedures and disconnecting the uterus from pelvic floor with solely abdomen approach. The second course, Demystifying the Total Laparoscopic Hysterectomy, provides the technical details, points out the key principle of operative safety, and offers the tips and tricks of achieving a successful TLH.
Learning Objectives At the conclusion of this course, the participant will be able to: 1) Illustrate the techniques of both procedures; 2) recognize the advantages and limitations of both procedures; and 3) select appropriate patients to perform the procedures.
Course Outline 1:10 Welcome, Introductions and Course Overview M.Shiota, C. Lee 1:15 Transvaginal Natural-Orifice Transluminal Endoscopic Surgery (NOTES) in
Adnexal Procedures C. Lee, H.Su 1:40 Demystifying the Total Laparoscopic Hysterectomy P. Mangeshikar 2:05 Questions & Answers All Faculty 2:10 Adjourn
1
Transvaginal Natural-Orifice Transluminal Endoscopic Surgery (NOTES) i Ad l P d
Hsuan Su M.D.Division of Gynecologic Endoscopy, Department of Obstetrics and
GynecologyChang Gung Memorial Hospital, Linkou, Taiwan
(NOTES) in Adnexal Procedures
No financial relationships to discloseto disclose
• To explain the retinal of NOTES procedure in gynecologic minimal invasive surgery
• Share the experience of Chang Gung Memorial hospitalMemorial hospital
Surgical procedure
NOTESWhat is NOTES
Natural-Orifice TransluminalEndoscopic Surgery
2
What is NOTES
In Gynecology…Endoscopic surgery through Vagina
First NOTES like procedure
Culdocopy: Von Ott D. 1902
orz
Decker A Culdoscopy; its diagnostic value in pelvic disease
Culdoscopy
Diagnostic & Operative procedure
Decker A. Culdoscopy; its diagnostic value in pelvic disease. JAMA. 1949;140:378–885
Paldi E, Timor-Tritsch I, Abramovici H, Peretz BA. Operativeculdoscopy.Br J Obstet Gynaecol. 1975;82:318–320
Restricted visualization
Culdoscopy -Criticized
Limited operative capabilities
Risk of infection
Transvaginalhydrolaparoscopy
Darai E, Dessolle L, Lecuru F, Soriano D. Transvaginal hydrolaparoscopycompared with laparoscopy for the evaluation of infertile women:
a prospective comparative blind study. Hum Reprod. 2000;15:2379–2382.
Fertility evaluation
3
Vaginal approach
Common skill for gynecologists
Limitation for gynecological procedures
- Too deep to identify the target - Too close to proceed the procedure
Uterus
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2007 culdoscopy
Hydrosalpinx, salpingectomy2 cases
Hsuan Su
Uterus
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2007 culdoscopy
Limitation
Poor visual distance
Hsuan Su Port unstable
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2010 Vaginal glove port
Kim TJ, et al. Single-port access laparoscopic adnexalsurgery. J Minim Invasive Gynecol. 2009;16:612–615
CGMH
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2010 Vaginal glove port
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2010 Vaginal glove port
Karl Storz 0 or 30 degreeg
5 mm or 10 mm telescope
4
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
Single incision laparoscopic surgery, SILS
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
Vaginal endoscopic surgery, VES
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2010 Vaginal endoscopic surgery, VES
May 2010 First NOTES hysterectomy
Aug 2010 First NOTES tubal sterilization
Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES): Feasibility of an innovative approachSu H. et al Taiwan J Obstet Gynecol. 2012 Jun;51(2):217-21
-
Transvaginal natural-orifice transluminal endoscopic surgery (NOTES) in adnexal proceduresLee CL, et alJ Minim Invasive Gynecol. 2012 Jul-Aug;19(4):509-13. Epub 2012 Mar 16.
-
Uterus
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2010 Vaginal endoscopic surgery, VES
Hsuan Su
Vagina
Uterus
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2010 Vaginal endoscopic surgery, VES
Wound retractorWound retractor
Hsuan Su
Uterus
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2010 Vaginal endoscopic surgery, VES
Wound retractorWound retractor
Hsuan Su
5
Uterus
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2010 Vaginal endoscopic surgery, VES
Wound retractorWound retractor
Hsuan Su
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
The result is ….
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
Create an adequate visual distance, and made vaginal surgery a reality
Bigger port diameter. Let triangulation become possible
Rigid scope and instruments.
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTESChang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2010 transvaginal endoscopic surgeryFirst case tubal ligation
Uterus Uterus
beforeAfter
Ovary OvaryTube
Tube
6
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2010 transvaginal endoscopic surgery
Right endometrioma, before
Right Left
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2010 transvaginal endoscopic surgery
Right endometrioma, after
Right Left
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
2010 transvaginal endoscopic surgery
Video of NOTES cystectomy
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
Advantage
Following embryologic anatomy
Less pain
Faster recover
Scarless
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
Limitation
Can not inspect whole pelvis, endometriosis ?
Loss of triangulation
Instruments limitation
Anatomy re-establish
7
Chang Gung Memorial Hospital, Linkou, Taiwan
Experience of NOTES
Indication of NOTES adnexal surgery
Teratoma
Tubal sterilization
Ectopic pregnancy
Benign adnexal neoplasm
Endometriosis ?
NOTES adnexal surgery
Several months later
NOTES adnexal surgery NOTES adnexal surgery
Transvaginal endoscopic surgery for adnexal procedures is an alternative method with a well patient selection
Conclusion
Surgical outcome should be evaluated
The limitation of the procedure should be explored
1. Von Ott D. Die Beleuchtung der Bauchhohle (Ventroskopie) als Methode bei Vaginaler Coeliotomie. AblGynakol. 1902;231:817–823
2. Decker A. Culdoscopy; its diagnostic value in pelvic disease. JAMA. 1949;140:378–885
3. Paldi E, Timor‐Tritsch I, Abramovici H, Peretz BA. Operative culdoscopy.Br J Obstet Gynaecol. 1975;82:318–320
4. Darai E, Dessolle L, Lecuru F, Soriano D. Transvaginal hydrolaparoscopy compared with laparoscopy for the evaluation of infertile women: a prospective comparative blind study. Hum Reprod. 2000;15:2379–2382
5. Kim TJ, et al. Single‐port access laparoscopic adnexal surgery. J Minim Invasive Gynecol. 2009;16:612–615
6. Su H. et al Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES): Feasibility of an innovative approach Taiwan J Obstet Gynecol. 2012 Jun;51(2):217‐21
7. Lee CL, et al J Transvaginal natural‐orifice transluminal endoscopic surgery (NOTES) in adnexal procedures Minim Invasive Gynecol. 2012 Jul‐Aug;19(4):509‐13. Epub 2012 Mar 16.
8. Lee CL, Huang KG, Jain S, Wang CJ, Yen CF, Soong YK. A new portal for gynecologic laparoscopy.J Am AssocGynecol Laparosc. 2001 Feb;8(1):147‐50.
9. Ahn KH, Song JY, Kim SH, Lee KW, Kim T. Transvaginal single‐port natural orifice transluminal endoscopic surgery for benign uterine adnexal pathologies J Minim Invasive Gynecol. 2012 Sep;19(5):631‐5. Epub 2012 Jul 3.
8
Demystifying the Total Laparoscopic Hysterectomy
Prashant Mangeshikar Mumbai INDIA
AAGL 41st Global Congress of Minimally Invasive Gynecology, Las Vegas, November 2012
Understanding the Difficult TLH
• Difficult Vaginal Access
• Low mobility of the Uterus
• Severe Endometriosis
• Adnexal masses (not suspicious)
• Adhesions (from previous laparotomy)
• Large Size uteri
The Difficult TLH
Knowledge of Anatomy
Knowledge of Instrumentation
Knowledge of Technique
Knowledge of Difficulties
Knowledge of possible Complications
Knowledge of Limits
Trocar CannulaShort Self RetainingV l Sili d “ t f i dl ”
Trocar CannulaShort Self RetainingV l Sili d “ t f i dl ”
Total Laparoscopic HysterectomyInstrumentation
Total Laparoscopic HysterectomyInstrumentation
Valve: Silicon and “suture friendly”ScissorsUltrasonic EnergyESU: Monopolar and BipolarGrasping ForcepsMangeshikar Knot Pusher
Koh Needle Holders: Right and Left versions
Valve: Silicon and “suture friendly”ScissorsUltrasonic EnergyESU: Monopolar and BipolarGrasping ForcepsMangeshikar Knot Pusher
Koh Needle Holders: Right and Left versions
The Difficult TLH made Easy
Technique easily reproducible
Reusable Instruments
Energy Sources
Suturing Skills
Total Laparoscopic HysterectomyInstrumentation
• EndoTIP: Safe Visual Abdominal Entry of Primary Portal
• Uterine Manipulation: Mangeshikar Uterine Mobilizar
• Telescope:
• 0 and 30 degree Laparoscope
• Bariatric Telescope: Extra 10 cm long
9
TLH for the Large Uterus
Approach: Primary Portal
Lee Huang Point
The Difficult TLH made EasyVisual Abdominal Entry: EndoTIP Cannula
High Pressure Entry: Pneumoperitoneal Pressure @ 20 mms. Hg. or more
TLH for the Large UterusTLH for the Large Uterus
Accessory Portals: Number: 3 or 4
Koh Point: Rt. & Lt
5 mms. self retaining Hunt Reich Cannulas with Silicon valves
TLH for the Large Uterus
Approach: 10 mms. Telescope
Degree: 0 and 30
Longer Length: Bariatric
Total Laparoscopic HysterectomyTotal Laparoscopic Hysterectomy
VisualisationVisualisation
ExposureExposure AccessAccess
Uterine ManipulationUterine Manipulation
10
MANGESHIKAR UTERINE MOBILIZAR
Mobilize the uterus in multi directions
Present the Vaginal FornicesPresent the Vaginal Fornices
Maintain Pneumoperitoneum
TLH for the Large UterusMangeshikar Uterine Mobilizar
Vaginal Delineating Tube
•Medical Grade Polypropylene Tube OD 30 ~ 40 mm•Lifts Vagina Upwards•Displaces Ureter, Bladder and Rectum outside surgical fie•Uterine vessels well delineated against the rim
The Difficult TLH made EasyEnergy Sources
M l E P C t 80WMonopolar Energy: Pure Cut 80W
Bipolar Energy: 40 W
Reusable RoBi (Robust Bipolar) Forceps
Harmonic Scalpel
The Difficult TLH
Is Robotic Hysterectomy the Answer?y y
Robots are for the Handicapped!!! Charles Koh
11
The Difficult TLH
•Does LSK have LIMITS ?
•The Surgeon himself!
•Remember:
•The MAGIC is in the MAGICIAN
•and
• NOT in the WAND
Faculty Disclosure
No Financial Relationships to Disclose
Video
NO ROBOT WAS USED DURING THIS SURGERY
NO QUILLS AND NO BARBS USED
ONLY SURGICAL SKILLS AND DEXTERITY
12
CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as
the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians
(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which
recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).
California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws
identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org
Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from
discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national
origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the
program, the importance of the services, and the resources available to the recipient, including the mix of oral
and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.
Executive Order 13166,”Improving Access to Services for Persons with Limited English
Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,
including those which provide federal financial assistance, to examine the services they provide, identify any
need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.
Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every
California state agency which either provides information to, or has contact with, the public to provide bilingual
interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.
~
If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.
A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.
US Population
Language Spoken at Home
English
Spanish
AsianOther
Indo-Euro
California
Language Spoken at Home
Spanish
English
OtherAsianIndo-Euro
19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%
13