opportunities and benefits of ultrasound technique in … · 2020. 5. 28. · ultrasound in...

Krankenhaus Sachsenhausen Akademisches Lehrkrankenhausder Johann Wolfgang Goethe-Universität Frankfurt am Main

Ultrasound in gynecological laparoscopic surgeryBari (Italy) June 4-7 2008

Krankenhaus Sachsenhausen

Frankfurt am MainAkademisches Lehrkrankenhaus derJohann Wolfgang Goethe-Universität

Frankfurt am Main

Department ofGynecology and Obstetrics

Center forMinimal Access Surgery

ISGE CongresBari, Italy 7 - 4 june 2008

Opportunities and benefits of ultrasound technique in gynecological laparoscopic surgery

(hysterectomy, myomectomy and endometriosis)

Philipp-Andreas Hessler



Greetings from Frankfurt (Germany)



2000 – 2008 statistics

8000 interventional laparoscopies1300 total laparoscopic hysterectomies (TLH)400 subtotal laparoscopic hysterectomies (SLH)2700 laparoscopic myomectomies140 laparoscopic lymphonodectomies

severe endometriosis, surgery of adnexa

… and all this was done with ultrasound technique !

*)*) we are minimal access surgery …



19 77108 178181

30521 44

43 7676 96 115

42

26

8 0

50

100

150

200

250

300

350

20002001

20022003

20042005

20062007

2008*ABD VAG LAVH SLH TLH

Surgical access for hysterectomy 2000-2008 (n=1869)

*)

*)

*) expected 2008



Advantages and disadvantages of ultrasound techniques

Advantages: - Multifunktional instrument (cutting, cavitationand coagulation)

- precise dissection- small necrosis zones- no secondary lesions (cautery)

Disadvantages: - high costs (single use)- long learning curve- relatively „slow“- disappointing coagulation of big vessels



The 2 (3) effects of ultrasound dissection

Power (Level 5)Dissection speedTension of tissueSharp side

Cutting Coagulation

Power (Level 3)Dissection speedTension of tissueFlat side

SuperficialCoagulation

with thetip



Ultrasound vs. HF

HF energy

Ultrasound energy



Bipolar, BiClamp + Ultracision (1)

classical bipolar dissection

broad zone of necrosis

change of instrument




Peritoneal dissection - bladder

dissection uterine vessels

dissection of the bladder

adhesions (no collateral damages)



Ultrasound tecnique for laparoscopic myomectomy (1)

monopolar dissection bipolar dissection ultrasound dissection



Ultrasound tecnique for laparoscopic myomectomy (2)



Laparoscopic total hysterectomy operating techniques

We must be aware of the fact that:Total laproscopic hysterectomy is impossible

to perform withoutmodern dissection techniques

(i.e. preparation and coagulation)!

So what is the best operating technique ?bipolar, ultrasound ?



Laparoscopic total hysterectomy study design (1)

(excluding cancer or prolaps surgery)

578284

20 56

TLH (Total Laparoscopic Hysterectomy)

SLH (Subtotal Laparoscopic Hystrectomy)

ABD (Abdominal Hysterectomy)

VAG (Vaginal Hysterectomy)

December 2005 to May 2008

944 hysterectomies

Laparoscopic Hysterectomiesn = 862 (578 TLH and 284 SLH)




(excluding cancer or prolaps surgery)

6%2%

30%

62%

TLH (Total Laparoscopic Hysterectomy)

SLH (Subtotal Laparoscopic Hystrectomy)

ABD (Abdominal Hysterectomy)

VAG (Vaginal Hysterectomy)


944 hysterectomies

Laparoscopic Hysterectomies92% (TLH and SLH)




• only simple hysterectomies (if appropriate with monolateral or bilateral surgery on adnexa e.g. ovarian cyst or adnectomy), but independent of uterus size

• preoperative, but if appropriate also initially intraoperative exclusion of hysterectomies with complicating subsidiary interventions (adhesion site, severe endometriosis, large tumours of adnexa etc.)

• following a study-independent acclimatization period, all operations were performed with one set of instruments by one and the same surgeonin as uninterrupted a sequence as possible

• if it became apparent in the course of a test series that a procedure or instrument was disadvantageous to the course of the operation, the series was discontinued on ethical grounds




1. Preparation: following preoperative diagnostic hysteroscopy (obligatory at our hospital) and once positioning, disinfecting and sterile draping are complete, this phase comprises:ingresswith the Veress needle, safety checks, positioning of the 4 trocars (10 mm subumbilical, 5 mm suprasymphysial, median and bilateral), visualization of the site possibly with smaller adhesiolyses around the caeca or adnexa and preparation of the instruments for the hysterectomy itself.

2. Hysterectomy: period between detaching the adnexa from the uterus or from the infundibu-lum pelvicum and detaching the portio from the vagina.

3. Extraction: the following procedures were used depending on uterus size: simple vaginal extraction (102/172=58.2 %), hemisection, morcellation or myoma nucleation (33/172=19.2 %) or the use of 15 mm or 20 mm morcellators (37/172 = 21.6 %)

4. Suturing of the vaginal fundus: provide the stump of the vagina with a continuous suture using PDS 0 and subsequent central peritonealization of the central wound area above the vaginal fundus.

5. Finishing up: irrigate the abdominal cavity, check that intestine and ureters are undamaged, position a 15 Robinson drain in the pouch of Douglas, retract the instruments under observation and drain the pneumoperitoneum, intracutaneous skin closure and dressings.

= Total operating time: made up of all the above-mentioned individual steps together.




252

338 included instudy

Studyn = 338 (58%)


578 total laparoscopichysterectomies



Laparoscopic total hysterectomy Results

No significant differences:

Age (years): 47,4 29 – 90

Hospitalisation (days): 4,6 2 – 20

Uterus weight (g) 290 34 – 2450

Hemoglobine loss - 0,7 -5,6 - +2,7



Laparoscopic total hysterectomy Patients age

60,755,4

58,8

26,2

0

10

20

30

40

50

60

70

Abdominalhysterectomy

without adnexa

Abdominalhysterectomy with

adnexa

Vaginalhysterectomy

Laparoscopic totalhysterectomy

< 20 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 > 69

55,4%60,7%

55,5%

48,1%

0%10%20%

30%40%50%60%70%

80%90%

100%


without adnexa


adnexa

Vaginalhysterectomy

Total laparoscopichysterectomy

< 20 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 > 69

Hessen 2006 Abdominal hysterectomy without adnexa n = 2010(QS OP Gyn) Abdominal hysterectomy with adnexa n = 1121

Vaginal hysterectomy n = 2730

KH Sachsenhausen Total laparoscopic hysterectomy n = 330TLH study (with or without adnexa)11/2005 bis 5/2008



20,010,5

51,7

86,5

0,010,020,0

30,040,050,060,070,0

80,090,0

100,0


without adnexa


adnexa

Vaginalhysterectomy


< 30 30 - 59 60 - 89 90 - 120 > 120

86,5%

51,7%

10,5%20,0%

0%

20%

40%

60%

80%

100%


without adnexa


adnexa

Vaginalhysterectomy


< 30 30 - 59 60 - 89 90 - 120 > 120

Laparoscopic total hysterectomy Duration of surgery






Laparoscopic total hysterectomy days of hospitalisation

61,556,3

47,3

4,9

0,010,020,0

30,040,050,060,070,0

80,090,0

100,0


without adnexa


adnexa

Vaginalhysterectomy


0 - 6 7 - 10 11 - 13 14 - 20 > 20

94,3%

46,1%

7,6%12,3%0%

10%20%

30%40%50%60%70%

80%90%

100%


without adnexa


adnexa

Vaginalhysterectomy


0 - 6 7 - 10 11 - 13 14 - 20 > 20






Laparoscopic total hysterectomy n = 330 techniques

UC 1 SonoSurg BiClamp BiSect Bipolar UC 2 UC +BiClamp

n = 60 60 34 11 7 60 98

Overall surgery 45 45 47 45 45 38 36time (min) 25-105 28-72 30-75 35-80 37-66 25-116 22-72

- Preparation 6 6 7 6 7 6 5- Hysterectomy 18 18 19 19 18 15 14- Extraction 5 5 3 4 4 4 4- Suture 10 10 11 10 10 8 8- Finishing up 6 6 6 6 5 5 5

- Preparation 14% 14% 15% 14% 15% 15% 15%- Hysterectomy 39% 41% 41% 42% 40% 40% 38%- Extraction 10% 11% 7% 8% 9% 11% 11%- Suture 23% 21% 24% 23% 24% 20% 21%- Finishing up 14% 13% 13% 12% 12% 14% 15 %

UC = Ultracision



Laparoscopic total hysterectomy duration surgery %

39 41 41 42 40 40 38

23 21 24 23 24 20 21

14 1415 14 15

15 15

14 1313 12 12 14 15

10 11 7 8 9 11 11

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

UC 1 SonoSurg BiClamp BiSect Bipolar UC 2 UC+Biclamp

Hysterectomy Suture Preparation Finishing up Extraction



Laparoscopic total hysterectomy duration surgery (min)

18 18 19 19 18 15 14

10 10 11 10 108 8

6 67 6 7

6 5

6 66

6 5

55

5 53 4 4

44

0

10

20

30

40

50

UC 1 SonoSurg BiClamp BiSect Bipolar UC 2 UC+Biclamp

Hysterectomy Suture Preparation Finishing up Extraction



Laparoscopic total hysterectomy uterus weight

2 : 1

0200400600800

10001200140016001800200022002400

0

10

20

30

40

50

60

70

80

90

100

Uterusgewicht OP-Zeit Hysterektomie-Zeit Extraktion

gramm min.Total operating time / uterus weightmean first 50: 278 grammmean last 50: 278 gramm

n = 330range 34 – 2450 gramm



Laparoscopic total hysterectomy learning curve

2 : 1

0

20

40

60

80

100

Total operating time Hysterectomy PreparationSuturing Extraction Finishing up

Total operating time:mean first 50: 48 min.mean last 50: 34 min.

n = 330range 22 – 116 min

min.



Advantages and disadvantages of ultrasound techniques

Advantages: - Cutting + coagulation with a single instrument- precise dissection- small necrosis zones- no secondary lesions (cautery)

Disadvantages: - high costs (single use)- long learning curve- „slow“ handling- disappointing coagulation of big vessels



Thank you for your

attention !

opportunities and benefits of ultrasound technique in … · 2020. 5. 28. · ultrasound in...

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