APAGE Symposium · 2020-01-30 · •Adnexal masses (not suspicious) ... genesis of the Guidance...

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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


Experience of NOTES

2007 culdoscopy

Limitation

Poor visual distance

Hsuan Su Port unstable


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


Experience of NOTES



Experience of NOTES


Karl Storz 0 or 30 degreeg

5 mm or 10 mm telescope

4


Experience of NOTES

Single incision laparoscopic surgery, SILS


Experience of NOTES

Vaginal endoscopic surgery, VES


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


Experience of NOTES


Hsuan Su

Vagina

Uterus


Experience of NOTES


Wound retractorWound retractor

Hsuan Su

Uterus


Experience of NOTES



Hsuan Su

5

Uterus


Experience of NOTES



Hsuan Su


Experience of NOTES


Experience of NOTES

The result is ….


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.


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


Experience of NOTES

2010 transvaginal endoscopic surgery

Right endometrioma, before

Right Left


Experience of NOTES


Right endometrioma, after

Right Left


Experience of NOTES


Video of NOTES cystectomy


Experience of NOTES

Advantage

Following embryologic anatomy

Less pain

Faster recover

Scarless


Experience of NOTES

Limitation

Can not inspect whole pelvis, endometriosis ?

Loss of triangulation

Instruments limitation

Anatomy re-establish

7


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


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


• 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

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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APAGE Symposium · 2020-01-30 · •Adnexal masses (not suspicious) ... genesis of the Guidance...

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