View
5
Download
0
Category
Preview:
Citation preview
SPA in Gynaecology
Päivi Pakarinen MD PhDHelsinki University Central HospitalDepartment of Obstetrics and GynecologyFinlandpaivi.pakarinen@hus.fi
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
Päivi Pakarinen SPA in gynaecology
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
Päivi Pakarinen SPA in gynaecology
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
Päivi Pakarinen SPA in gynaecology
WHY LESS?• Faster recovery• Less pain• Wounds less
– Infections– Bleeding– Hernias– Cosmetic result
Päivi Pakarinen SPA in gynaecology
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.
Päivi Pakarinen SPA in gynaecology
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
Päivi Pakarinen SPA in gynaecology
Ports
DaVinci® Surgical System docked to robotic trocars in GelPort® at umbilicus.
Covidien multi-channel SILS™ port.
Uni-X image
Päivi Pakarinen SPA in gynaecology
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
Päivi Pakarinen SPA in gynaecology
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.
Päivi Pakarinen SPA in gynaecology
QuickTime™ jaTIFF (LZW) pakkauksen purkuohjelma
tarvitaan elokuvan katselemiseen.
QuickTime™ jaTIFF (LZW) pakkauksen purkuohjelma
tarvitaan elokuvan katselemiseen.
FERT STER 2010
Päivi Pakarinen SPA in gynaecology
• 89% no conversions• blood loss 0-75ml• Postoper pain VAS 3-5• Recovery without problems• Cosmetic outcome excellent
Päivi Pakarinen SPA in gynaecology
• Soul Korea• 52 SPA-TLH• 105 TLH• Retrospektiivinen tapaus-verrokkitutkimus
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
Päivi Pakarinen SPA in gynaecology
Postoperative pain
QuickTime™ and a decompressor
are needed to see this picture.
Päivi Pakarinen SPA in gynaecology
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.
Päivi Pakarinen SPA in gynaecology
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
Päivi Pakarinen SPA in gynaecology
HYKS patients
• 4 patients– 4 Adnexectomy
• Profylactic– Ovarian cyst
• Benign 14 cm– Hysterectomy
• PM bleeding
Päivi Pakarinen SPA in gynaecology
Laparoendoscopic Single-Site Surgery Consortium for Assessment and Researc
LESSCAR /USA
Päivi Pakarinen SPA in gynaecology
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
Päivi Pakarinen SPA in gynaecology
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)
Päivi Pakarinen SPA in gynaecology
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
Päivi Pakarinen SPA in gynaecology
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
Päivi Pakarinen SPA in gynaecology
SPA in gynecologic surgery 28.5.2010 HYKS Helsinki
Dr Francisco Carmona, Barcelona
Päivi Pakarinen SPA in gynaecology
SPA in gynecologic surgery 28.5.2010Live surgery/ profylactic ophorectomy
Recommended