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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
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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
RADICAL EXCISION
Absolute indications Ureteric obstruction Bowel obstruction
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OTHER INDICATION
Fertility Menstrual Pain Pain on Sex Bowel Pain Bladder Pain
WHAT IS REQUIRED FOR THE CENTRE
• A dedicated consultant led endometriosis service run within a specialist outpatient clinic.
• Workload
• Supporting Surgeon
• Other supporting clinicians
• Data collection
• Endometriosis Specialist Nurse
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WHAT DO CENTRES OFFER
•Correct preparation •Correct pre-operative counselling •Correct surgeon •Correct post-operative care •Prevents wastage of resources
BETTER PATIENT OUTCOME
CONTINUUM OF CARE INCLUDES MULTIDISCIPLINARY SERVICE
Patient
Gynaecologists
Pain Management
Colorectal surgeons
Nurse specialists
Urologists
Assessment Unit
PATIENT
INJURY
Bladder Bowel injury Ureteric injury
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INJURY
Cut Heat Damage Devascularisation Break down due to infection
Energy Sources
Haemostasis Cutting
Ideal Energy Sources
No electrical spread
No heat spread
Totally haemostatic Ability to coagulate and cut
Separately and together
Ability to grasp and dissect
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Suturing Bipolar Impedence feedback bipolar
Haemostasis alone
Scissors
Cutting alone
Non Electrical Energy Sources
Laser
Vibrating energy sources
• Rotational • Linear • Linear with Bipolar
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THUNDERBEAT
DIAGNOSING BLADDER INJURY
Air in Catheter Bag Instill Blue in Bladder Cystogram post-operatively Urinary Leakage due to Fistula at 5 to 10 days
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Bladder
Failure to diagnose
Becomes generally unwell when catheter removed Excessive fluid in the drain Low grade pyrexia Ileus Delayed leak may present as a fistula
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Ureter
URETERIC DISSECTION
URETER REPAIR
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Failure to diagnose
Detection rate may be as low as 10% May result from delayed necrosis May result in a fistula
Failure to diagnose
May result in long term renal damage Stenosis of the ureter Other symptoms due to urine in abdomen Nephrostomy and repair when well
Ureter
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OBSTRUCTION
Bowel Injury
Cut Heat Damage Devascularisation Break down due to infection
Bowel Injury
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D
Deliberate opening
Failure to diagnose
Becomes rapidly unwell 5 days for diathermy injury Delayed leak may present as a fistula
What Should the Primary Treatment for Stress Urinary Incontinence be
in 2014 ? Has the Mid-Urethral Tape Seen its Day?
TVT
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Open retropubic colposuspension
Laparoscopic retropubic colposuspension
Suburethral sling procedures:
• Retropubic
• Obturator
• Mini sling
Rectus facial sling
Bladder neck needle suspension
Vaginal anterior repair (anterior colporrhaphy)
Periurethral injection
Artificial sphincter
TREATMENT OF STRESS INCONTINENCE
Ward & Hilton BMJ 2002;325:67 Prospective multicentre randomised trial of tension-free vaginal tape and colposuspension as primary treatment for stress incontinence
Hilton P. Br J Obstet Gynaecol 2002; 109: 1081-1088 Trials of surgery for stress incontinence thoughts on the "Humpty Dumpty principle."
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Sparc, Monarc Bioarc
Polypropylene woven as a monofilament tape
Above down
Obturator out / in
Above down
Can use any material
TVT OBTURATOR
The tape is a knitted polypropylene polymer (multifilament TYPE III) It can be used vaginally or abdominally.
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Uretex® Self-Anchoring Urethral
Support System
PelviLace™ BioUrethral
Support System
Polypropylene mesh with Macroporous knit Vaginal / Suprapubic and Obturator
Porcine dermis
Porcine small bowel mucosa
The polypropylene mesh is anchored between two columns of silicone and is inserted with a needle that can be used transvaginally or suprapubically.
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TVT SECURE
Mesh Type •Polypropylene
•Monofilament •Multifilament •Microporous •Macroporous •Stiffness •Elasticity
•Porcine skin •Porcine Small bowel
Insertion •Vaginal Insertion •Suprapubic insertion •Obturator Out/In •Obturator In/Out
Size of needles
VARIABLES
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BURCH LAP COLPO
Sutures Mesh Glue
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
UTERINE SUSPENSION USING SACRAL PROMONTARY
SUTURE SUSPENSION
Maher CF, Carey MP, Murray CJ. Laparoscopic suture hysteropexy for uterine prolapse. Obstet Gynecol 2001; 97(6):1010-1014.
43 women FU 6-32 mths. 79% success 2 ureteric kinking. 1 laparotomy
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BJOG. 2010 Jan;117(1):62-8.
Laparoscopic hysteropexy: the initial results of a uterine suspension procedure for uterovaginal prolapse.
Price N, Slack A, Jackson SR.
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Different stages of life
Different requirements
MAIN ROLE AT PRESENT
•Nulliparous women
•Between pregnancy
•Elderly
•Surgically unfit
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CHOOSING WHICH OPERATION
PREFERRED CHOICE FOR TREATMENT OF UTERINE
PROLAPSE
LAPAROSCOPIC HYSTEROPEXY
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MOVING BEYOND HYSTERECTOMY AS A CONCEPT
It maybe that standard
teaching in the surgical
approach to uterovaginal
prolapse is turned on its
head, and uterine
preservation becomes the
preferred choice, in terms
of efficacy and morbidity
CONCLUSION
• Consider uterine conservation
• Vaginal mesh repair is dangerous
• Laparoscopic surgery is superior but requires training
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ACCEPTING CHANGE
