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1 Safety and training
1 Safety and training ALAN
G. GORDON
Hysteroscopy was first performed over 130 years ago but for many years its development was hindered by technical difficulties and limited indications. A relatively small number of clinicians have practised diagnostic hysteroscopy since the early 1970s but only in the last decade has it achieved general acceptance. Now in most centres, diagnostic hysteroscopy with endometrial biopsy has replaced dilatation and curettage in the investigation of dysfunctional uterine bleeding. This change in attitude has been influenced by the development of improved lens systems, fibreoptic light cables with safe proximal illumination, and effective uterine distention with gas or fluid using automatic flow systems. The majority of gynaecologists perform panoramic hysteroscopy in which the distended uterine cavity is observed through a telescope with a direct or oblique distal lens. Initially, orientation with the oblique lens may be difficult but, with practice, a better view can be obtained of the whole uterine cavity. The angle of the distal lens varies from 12 to 30 °. The addition of separate channels to accommodate accessory instruments allows operative procedures to be carried out using mechanical instruments, electrosurgery or laser. Microhysteroscopy and microcolpohysteroscopy are performed using a telescope which has been modified by the introduction of a system of magnifying lenses (Hamou, 1981). These allow both panoramic and microscopic vision with magnification up to × 150. This is a valuable adjunct to colposcopy and for examination of the structure of the endometrium but does not contribute significantly to the performance of endometrial ablation. A flexible hysteroscope can be directed to all parts of the uterine cavity and a more extensive examination may be possible. It incorporates a separate channel through which biopsy forceps or a laser fibre can be passed allowing directed biopsy and ablation to be performed. It is not suitable for endometrial electroresection. DIAGNOSTIC HYSTEROSCOPY Diagnostic hysteroscopy is usually a simple procedure. However, introduction of the hysteroscope may cause bleeding from the cervix or Baillibre' s Clinical Obstetrics and Gynaecology--
Vol. 9, No. 2, June 1995 ISBN 0-7020-1952-6
241 Copyright © 1995, by Bailli6re TindaU All rights of reproduction in any form reserved
242
a.G. GORDON
endometrium and failure to maintain adequate uterine distention may interfere with vision. Complications should be uncommon and are rarely serious. Lindemann (1986) carried out a postal survey of members of the European Society of Hysteroscopy and found there were no deaths and the incidence of complications such as cardiorespiratory accidents, anaesthetic reactions, allergies or uterine perforation was 0.012% in over 100000 cases. The surgeon should become proficient in diagnostic hysteroscopy before undertaking hysteroscopic surgery. Only by doing so will the skill be acquired to recognize all the uterine landmarks, appreciate the importance of uterine distention and be able to work in the uterine cavity. The surgeon must also learn to accommodate to the two-dimensional image offered by the telescope and then to operate from the video screen and become adept at orientation within this new environment. Hysteroscopy is indicated in any situation where visualization of the uterine cavity enhances diagnostic accuracy and helps to define therapy. The indications for diagnostic hysteroscopy include abnormal uterine bleeding, infertility and repeated pregnancy loss, misplaced intrauterine contraceptive devices and the staging of endometrial carcinoma. Although diagnostic hysteroscopy is a safe procedure, there are well defined contraindications to its use. These include upper or lower genital tract infection, cardiorespiratory disease, pregnancy and occult cervical malignancy. Uterine bleeding is no longer a contraindication because, with a continuous flow hysteroscope, the blood can be washed out, the intrauterine pressure of the distension fluid increased and a clear view obtained. TRAINING IN DIAGNOSTIC HYSTEROSCOPY
The trainee should learn to perform diagnostic hysteroscopy correctly under supervision. This training should be available during residency training programmes. Older surgeons who have not had this opportunity during their training should attend a basic course or visit an expert's operating room to gain experience under supervision. The trainee must first become familiar with the instruments and their assembly. Time spent learning to assemble the hysteroscope and to appreciate the extent and direction of the visual field will be amply repaid by the speed with which expertise increases. The advantages and disadvantages of the various distension media must be appreciated. While carbon dioxide has excellent optical properties, bleeding can obscure vision. Initially, many trainees find it easier to use a fluid medium with a narrow-bore continuous flow diagnostic hysteroscope. The basic skills can be learnt on an inert model or a hysterectomy specimen. The tubes of the excised uterus can be clamped, hysteroscopy performed and the uterus then opened to compare the lesion seen at hysteroscopy with the actual gross appearance. It is sometimes a chastening experience to compare the perceived pathology with the actual appearance of the opened uterus. The first attempt at diagnostic hysteroscopy is often a complete failure.
SAFETY AND TRAINING
243
The trainee may commence with enthusiasm only to become disillusioned and abandon the technique altogether. It is common in the early part of the learning curve to fail to obtain a clear view of the cavity. It should be remembered that the cervical canal must be negotiated gently, atraumatically and under direct vision to reach the uterine cavity without causing bleeding. The cavity itself is a small cleft in a thick muscle which must be distended before a panoramic view can be obtained. Diagnostic hysteroscopy should first be performed under general anaesthesia during a operating list in which there is time to practise on a suitable subject. The most favourable patient is a parous woman in the postmenstrual phase of her cycle and with a normal sized uterus. The number of diagnostic hysteroscopies that will need to be performed to achieve competence will vary depending on the trainee's ability. A number of problems may be encountered initially and much frustration and waste of time may be avoided by awareness of them. These include leaks in the distention system, gas bubbles, difficulty in accommodating to the angled lens and in negotiating the cervical canal. Attention to detail, avoidance of trauma, patience and practice will always be rewarded by a rapid increase in expertise and the ability to visualize the uterine cavity in nearly every case. Only when this degree of skill has been attained should the hysteroscopist progress from diagnostic to operative procedures.
HYSTEROSCOPIC SURGERY
The ability to operate through the accessory channels of the hysteroscope is a logical extension of diagnostic hysteroscopy. This exciting prospect has resulted in a sudden and rapid increase in the popularity of hysteroscopy. One unfortunate but natural side-effect of this has been that surgeons have been tempted to perform difficult surgery in an unaccustomed environment before they have achieved competence in diagnostic techniques. The daily routine of any practising gynaecologist should allow adequate opportunity to become proficient in diagnostic hysteroscopy. There can be no fixed rule for the number of diagnostic hysteroscopies which one should perform before progressing to hysteroscopic surgery because everyone's learning curve is different and in recent years the teaching of endoscopy has improved to such an extent that an arbitrary number is meaningless. Only the individual surgeon can assess when this progression can be made safely. Hysteroscopic surgery has distinct advantages o v e r hysterectomy for dysfunctional uterine bleeding. In general the patient will require a shorter stay in hospital and recovery will be quicker. It is unusual for a patient to remain in hospital more than 24 hours after hysteroscopic surgery and she should be fit to resume normal duties within a few days, significantly reducing both the cost of the operation and the postoperative period. Emotionally the women who has had endometrial resection rather than hysterectomy may feel better as she will avoid the psychological trauma that may be
244
A.G. GORDON
produced by removal of the uterus. Many women have a wish to retain their menstrual pattern as evidence of their femininity and resent the loss of their menstrual periods in their late thirties or early forties. They feel they have reached the menopause. In addition, conservative hysteroscopic surgery for submucous fibroids does not compromise the integrity of the uterus in a subsequent pregnancy. The development of expertise in hysteroscopic surgery involves the surgeon undergoing a change in attitude, acquiring the appropriate knowledge, undergoing formal training and then practising the new technique (Taylor and Gordon, 1993).
Changes in attitude The majority of gynaecologists have been primarily trained in abdominal or vaginal surgery and, possibly late in their careers, have developed an interest in laparoscopy and hysteroscopy. It may be difficult for senior surgeons to adapt to new techniques and to accept that new skills must be acquired. Indeed the more experienced they are in the old operations, the more difficult it may be for them to change to new ones. Their learning curve may be significantly longer than for a younger, more adaptable person. Residents in training should be taught hysteroscopy as a primary skill. The trainee must appreciate that the instruments are different from those used in conventional surgery. Working off a video screen should be adopted as soon as possible in the training period as in many cases it is difficult to work without it. In addition to learning to use the new instruments, the trainee must appreciate their capabilities, their risks and their limitations. Initially the staff in the operating room must accept that operations may take longer although, with experience, hysteroscopic surgery will take approximately the same or less time than conventional surgery. Most experienced hysteroscopic surgeons should be able to complete endometrial resection or ablation in about 15-30 minutes. The nursing staff must learn to use and maintain the new instruments in order to function as a team. This will be helped by the use of video cameras so that they can see the operation and, when necessary, assist in its performance.
Acquisition of knowledge The surgeon's knowledge must be reinforced by reading and attending conferences and courses where there is didactic teaching. Reading should include both basic textbooks and current specialist journals. The gynaecologist may obtain an overview of the possibilities of hysteroscopic surgery by attending conferences where hysteroscopy is discussed and, if possible, where live operations are relayed to the auditorium from the operating room. Video recordings make excellent teaching aids but they can be criticized because editing can make the operation look easier and better than it really is. Few surgeons will produce a recorded video containing the failures of their techniques as well as the successes.
SAFETY AND TRAINING
245
Conferences are organized in many countries throughout the world, either sponsored by institutions or by the instrument manufacturers to whom credit must be given for their interest in education and promoting safety in these techniques. National and international societies are now developing which seek to educate by means of endoscopy courses and to monitor the success of the procedures and the incidence of complications. Their meetings also provide a forum for discussion and allow the surgeon who wishes to learn operative hysteroscopy to listen and watch the expert at work. The preliminary acquisition of knowledge should be followed by in-house training when available or by attending a course.
Formal training Many hospitals are developing very successful in-house training programmes. A great deal of co-operation between the surgical and nursing staff is required. Usually a week should be allocated to a training session so that the didactic part of the course and laboratory practice, taught by experienced staff with the assistance of visiting experts, precede 3 or 4 full days of hands-on instruction in the operating room. Workshops for trainees from other hospitals should last at least 2 days and include lectures and discussion on the theory and practice of hysteroscopy. The groups should be small enough to allow all the participants to contribute to discussion and to have the opportunity for 'hands-on' training in the laboratory and operating room. Six trainees is probably the ideal number and, in order to obtain the maximum benefit from the workshop, they should already have some preliminary experience in diagnostic hysteroscopy and have attended at least one larger conference. Longer attachment to a training unit is desirable but not always practical because of financial constraints and the time involved. There may be inefficient use of time if the trainer has limited access to the operating room and so a week at a centre may only allow attendance at two or three operating sessions. Initial training can commence on inert models which consist of a plastic case with a replacable wax lining resembling the uterine cavity which can be excised by the resectoscope loop. Biological tissue can be provided by an excised bovine uterus or porcine bladder which are larger than the human uterus but provide a readily available substitute on which to practise the use of the instruments. Alternatively an excised human uterus can be used in vitro to gain experience before commencing hysteroscopic surgery. When the skills of diagnostic hysteroscopy have been mastered, progress may be made to operative hysteroscopy. Initially at a workshop or in-house training programme, the trainee may perform part of a resection or ablation under supervision using a video screen. After gaining initial but limited experience of the technique, further progress may be made by operating supervised by a trained colleague in-house or by attending a colleague's operating session and working on a one-to-one basis. The development of surgical skills will increase faster and with greater safety than if the learner were to work unsupervised. Alternatively the trainer may go to the trainee's
246
A.G. GORDON
hospital which has the advantage that all the operating room staff have the opportunity to learn from the visiting trainer. Practice
The final step in the training programme is practice. Many surgeons in their early learning period have continued their practical training by performing endometrial resection prior to hysterectomy with the abdomen open so that an assistant can watch for perforation or undue heat transmission. Others have used the laparoscope as a safety measure, to detect perforation and ensure that bowel was kept away from the uterus, until they were sufficiently competent to operate without these precautions. The surgeon must appreciate the importance of a clear view of the uterine cavity and must know to stop the operation if vision is compromised. Tragedies have resulted from inexperienced hysteroscopic surgeons failing to appreciate the significance of loss of vision when the uterine distention system has failed and continuing to use high frequency current or laser. This may produce the disastrous result of perforation of the of the uterus and damage to organs such as major vessels, ureter and bowel. As with any newly acquired skill, it is sensible to move from the simple to the complex. Ideally any advance in difficulty should be under supervision and that should always be the case with the training of junior surgeons. However, in most countries relatively few senior surgeons are trained in hysteroscopic surgery at present and it would be unrealistic to expect them to be supervised for more than their basic training period. Nevertheless, no surgeon should undertake advanced hysteroscopic surgery without proper training for to do so, and for the patient to suffer avoidable complications, could be construed as negligence. The mastery of the simple procedures will take time. If the learner feels that the time is of such duration that the techniques of major surgery learnt in a workshop have become rusty, a refresher course or several sessions spent working with an experienced colleague are recommended before embarking on more complex procedures unsupervised. CLASSIFICATION OF HYSTEROSCOPIC OPERATIONS Hysteroscopic surgery has been classified into minor, intermediate and advanced operations (Table 1). This classification has merit in that it gives some indication of the progression which surgeons in training should undertake. They should commence with simple procedures before attempting complicated ones and should recognize the degree of difficulty of each operation. Level 1 suggests the type of operation which any competent surgeon with experience in diagnostic hysteroscopy should be able to perform. These simple procedures will allow the surgeon to develop expertise and familiarization with working in the uterine cavity. With practice, these operations should be possible within a few weeks of commencing training. Progression to level 2 should be within the compass of
SAFETY AND TRAINING
247
most surgeons and can be learnt in-house during the residency training programme. Level 3 requires attendance at courses and supervision by a trainer during operating sessions.
Table 1. Classification of hysteroscopic operations. Level 1
Diagnostic hysteroscopy and target biopsy Removal of simple polyps Removal of intrauterine contraceptive devices
Level 2
Proximal fallopian tube cannulation Division of minor synechiae Removal of pedunculated fibroid
Level 3
Divisior~'resection of uterine septum Endometrial resection/ablation Resection of submucous/intramural fibroid Division of major synechiae Repeat endometrial resection/ablation
TRAINING OF OTHER OPERATING ROOM PERSONNEL
The importance of the training for other operating room personnel is well recognized. The development of new approaches to surgery has created new training needs for nurses, operating room assistants and anaesthetists, as well as surgeons. The nursing staff need to know how to care for the instruments which are delicate and expensive. Some of the narrow instruments are difficult to clean. Training in maintenance is essential to avoid cross-contamination. Nursing staff and operating room assistants also need to have a clear understanding of the safety considerations concerning uterine distension systems, the dangers of fluid overload and the use of electrosurgical and laser generators. They should also attend suitable courses which are often organized in parallel with the courses for surgeons and give them the opportunity to work on simulators as well as listen to lectures and watch operations. The anaesthetist also needs to be aware of the special needs of the patient undergoing endometrial ablation and the risks involved. Active participation by the anaesthetist in fluid accountancy and the early recognition of overload may be the difference between an uneventful operation and surgical tragedy. RECOGNITION OF LATE COMPLICATIONS The special needs of the patient and her attendants should be considered. Many, if not most, endometrial ablation procedures are performed on a day-care basis. While complications are uncommon after the patient leaves the day-care unit, it is vital that they be recognized and treated without delay. The patient should be given adequate information sheets prior to
248
A.G. GORDON
surgery so that she or her relatives know when to seek medical aid. There should also be good communication with the family doctor. It is probable that most family doctors have undergone their training before the advent of endoscopic surgery and they must be updated on current practice by helpful letters from the surgeon. FUTURE NEEDS
The Working Party of the Royal College of Obstetricians and Gynaecologists (RCOG) and the British Society for Gynaecological Endoscopy has made a number of recommendations for future training and practice in endoscopic surgery (RCOG, 1994). A departure in Britain from the time-honoured apprenticeship system of training and the introduction of credentialling is envisaged. Their recommendations will need to be reviewed when the majority of consultant gynaecologists are accomplished in endoscopic surgery. They suggest that the certification of gynaecological endoscopists should be supervised by appropriate regional advisors who, in turn, will be advised by the College. Certification will depend upon the opinion of the advisor on the trainee's competence rather than on the accomplishment of a given number of operations. They recognize the difference in individual learning curves and that some trainees may never reach a level of confidence in advanced surgery and should be appropriately advised about this. Each gynaecologist performing hysteroscopic surgery should first be competent in diagnostic procedures and, after credentialling, should produce evidence of continuing medical education. They should be encouraged to attend updating courses every 2 years. SUMMARY
Provided progress is made systematically, the surgeon never attempts to perform operations that are too difficult, and all the safety protocols are adhered to, hysteroscopic surgery should be within the capabilities of most gynaecologists. Failure to appreciate the risks and failure to undergo continuous training in the learning period will inevitably lead to complications which should otherwise be avoidable. Hysteroscopic surgery offers many advantages over conventional surgery and, like many other types of minimal access surgery, appears to be the surgery of the future. Endoscopic surgery will not supplant open surgery but will become another essential part of our practice which the patient will expect and, indeed, demand. There will be problems. Training programmes must be established to try to prevent complications which will be encountered if inadequately trained surgeons perform these new forms of surgery. There must be continuous education in existing methods and research into value and results of new techniques and instruments both for laser and electrosurgery.
SAFETY AND TRAINING
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It is possible that in the future new biophysical or pharmacological approaches may render laser and electrosurgery obsolete. Safer forms of physical energy, photosynthesis and new forms of hormone therapy are all undergoing trials with preliminary results which are encouraging. Whichever techniques eventually prove to be the most effective and safe, we must learn to use them because we owe to our patients the opportunity to benefit from them. REFERENCES Hamou JE (1981) Microhysteroscopy, A new procedure and its original applications in gyneco-
logy. Journal of Reproductive Medicine 26: 375. Lindemann H-J (1986) Complications ofhysteroscopy. Presented to the European Society of Hysteroscopy, Antwerp. Royal College of Obstetricians and Gynaecologists (1994) Report of the RCOG Working Party on Training in Endoscopic Surgery. London: RCOG Press. Taylor PJ & Gordon AG (1993) Practical Hysteroscopy, pp 103-106. Oxford: Blackwell.
G. GORDON
Hysteroscopy was first performed over 130 years ago but for many years its development was hindered by technical difficulties and limited indications. A relatively small number of clinicians have practised diagnostic hysteroscopy since the early 1970s but only in the last decade has it achieved general acceptance. Now in most centres, diagnostic hysteroscopy with endometrial biopsy has replaced dilatation and curettage in the investigation of dysfunctional uterine bleeding. This change in attitude has been influenced by the development of improved lens systems, fibreoptic light cables with safe proximal illumination, and effective uterine distention with gas or fluid using automatic flow systems. The majority of gynaecologists perform panoramic hysteroscopy in which the distended uterine cavity is observed through a telescope with a direct or oblique distal lens. Initially, orientation with the oblique lens may be difficult but, with practice, a better view can be obtained of the whole uterine cavity. The angle of the distal lens varies from 12 to 30 °. The addition of separate channels to accommodate accessory instruments allows operative procedures to be carried out using mechanical instruments, electrosurgery or laser. Microhysteroscopy and microcolpohysteroscopy are performed using a telescope which has been modified by the introduction of a system of magnifying lenses (Hamou, 1981). These allow both panoramic and microscopic vision with magnification up to × 150. This is a valuable adjunct to colposcopy and for examination of the structure of the endometrium but does not contribute significantly to the performance of endometrial ablation. A flexible hysteroscope can be directed to all parts of the uterine cavity and a more extensive examination may be possible. It incorporates a separate channel through which biopsy forceps or a laser fibre can be passed allowing directed biopsy and ablation to be performed. It is not suitable for endometrial electroresection. DIAGNOSTIC HYSTEROSCOPY Diagnostic hysteroscopy is usually a simple procedure. However, introduction of the hysteroscope may cause bleeding from the cervix or Baillibre' s Clinical Obstetrics and Gynaecology--
Vol. 9, No. 2, June 1995 ISBN 0-7020-1952-6
241 Copyright © 1995, by Bailli6re TindaU All rights of reproduction in any form reserved
242
a.G. GORDON
endometrium and failure to maintain adequate uterine distention may interfere with vision. Complications should be uncommon and are rarely serious. Lindemann (1986) carried out a postal survey of members of the European Society of Hysteroscopy and found there were no deaths and the incidence of complications such as cardiorespiratory accidents, anaesthetic reactions, allergies or uterine perforation was 0.012% in over 100000 cases. The surgeon should become proficient in diagnostic hysteroscopy before undertaking hysteroscopic surgery. Only by doing so will the skill be acquired to recognize all the uterine landmarks, appreciate the importance of uterine distention and be able to work in the uterine cavity. The surgeon must also learn to accommodate to the two-dimensional image offered by the telescope and then to operate from the video screen and become adept at orientation within this new environment. Hysteroscopy is indicated in any situation where visualization of the uterine cavity enhances diagnostic accuracy and helps to define therapy. The indications for diagnostic hysteroscopy include abnormal uterine bleeding, infertility and repeated pregnancy loss, misplaced intrauterine contraceptive devices and the staging of endometrial carcinoma. Although diagnostic hysteroscopy is a safe procedure, there are well defined contraindications to its use. These include upper or lower genital tract infection, cardiorespiratory disease, pregnancy and occult cervical malignancy. Uterine bleeding is no longer a contraindication because, with a continuous flow hysteroscope, the blood can be washed out, the intrauterine pressure of the distension fluid increased and a clear view obtained. TRAINING IN DIAGNOSTIC HYSTEROSCOPY
The trainee should learn to perform diagnostic hysteroscopy correctly under supervision. This training should be available during residency training programmes. Older surgeons who have not had this opportunity during their training should attend a basic course or visit an expert's operating room to gain experience under supervision. The trainee must first become familiar with the instruments and their assembly. Time spent learning to assemble the hysteroscope and to appreciate the extent and direction of the visual field will be amply repaid by the speed with which expertise increases. The advantages and disadvantages of the various distension media must be appreciated. While carbon dioxide has excellent optical properties, bleeding can obscure vision. Initially, many trainees find it easier to use a fluid medium with a narrow-bore continuous flow diagnostic hysteroscope. The basic skills can be learnt on an inert model or a hysterectomy specimen. The tubes of the excised uterus can be clamped, hysteroscopy performed and the uterus then opened to compare the lesion seen at hysteroscopy with the actual gross appearance. It is sometimes a chastening experience to compare the perceived pathology with the actual appearance of the opened uterus. The first attempt at diagnostic hysteroscopy is often a complete failure.
SAFETY AND TRAINING
243
The trainee may commence with enthusiasm only to become disillusioned and abandon the technique altogether. It is common in the early part of the learning curve to fail to obtain a clear view of the cavity. It should be remembered that the cervical canal must be negotiated gently, atraumatically and under direct vision to reach the uterine cavity without causing bleeding. The cavity itself is a small cleft in a thick muscle which must be distended before a panoramic view can be obtained. Diagnostic hysteroscopy should first be performed under general anaesthesia during a operating list in which there is time to practise on a suitable subject. The most favourable patient is a parous woman in the postmenstrual phase of her cycle and with a normal sized uterus. The number of diagnostic hysteroscopies that will need to be performed to achieve competence will vary depending on the trainee's ability. A number of problems may be encountered initially and much frustration and waste of time may be avoided by awareness of them. These include leaks in the distention system, gas bubbles, difficulty in accommodating to the angled lens and in negotiating the cervical canal. Attention to detail, avoidance of trauma, patience and practice will always be rewarded by a rapid increase in expertise and the ability to visualize the uterine cavity in nearly every case. Only when this degree of skill has been attained should the hysteroscopist progress from diagnostic to operative procedures.
HYSTEROSCOPIC SURGERY
The ability to operate through the accessory channels of the hysteroscope is a logical extension of diagnostic hysteroscopy. This exciting prospect has resulted in a sudden and rapid increase in the popularity of hysteroscopy. One unfortunate but natural side-effect of this has been that surgeons have been tempted to perform difficult surgery in an unaccustomed environment before they have achieved competence in diagnostic techniques. The daily routine of any practising gynaecologist should allow adequate opportunity to become proficient in diagnostic hysteroscopy. There can be no fixed rule for the number of diagnostic hysteroscopies which one should perform before progressing to hysteroscopic surgery because everyone's learning curve is different and in recent years the teaching of endoscopy has improved to such an extent that an arbitrary number is meaningless. Only the individual surgeon can assess when this progression can be made safely. Hysteroscopic surgery has distinct advantages o v e r hysterectomy for dysfunctional uterine bleeding. In general the patient will require a shorter stay in hospital and recovery will be quicker. It is unusual for a patient to remain in hospital more than 24 hours after hysteroscopic surgery and she should be fit to resume normal duties within a few days, significantly reducing both the cost of the operation and the postoperative period. Emotionally the women who has had endometrial resection rather than hysterectomy may feel better as she will avoid the psychological trauma that may be
244
A.G. GORDON
produced by removal of the uterus. Many women have a wish to retain their menstrual pattern as evidence of their femininity and resent the loss of their menstrual periods in their late thirties or early forties. They feel they have reached the menopause. In addition, conservative hysteroscopic surgery for submucous fibroids does not compromise the integrity of the uterus in a subsequent pregnancy. The development of expertise in hysteroscopic surgery involves the surgeon undergoing a change in attitude, acquiring the appropriate knowledge, undergoing formal training and then practising the new technique (Taylor and Gordon, 1993).
Changes in attitude The majority of gynaecologists have been primarily trained in abdominal or vaginal surgery and, possibly late in their careers, have developed an interest in laparoscopy and hysteroscopy. It may be difficult for senior surgeons to adapt to new techniques and to accept that new skills must be acquired. Indeed the more experienced they are in the old operations, the more difficult it may be for them to change to new ones. Their learning curve may be significantly longer than for a younger, more adaptable person. Residents in training should be taught hysteroscopy as a primary skill. The trainee must appreciate that the instruments are different from those used in conventional surgery. Working off a video screen should be adopted as soon as possible in the training period as in many cases it is difficult to work without it. In addition to learning to use the new instruments, the trainee must appreciate their capabilities, their risks and their limitations. Initially the staff in the operating room must accept that operations may take longer although, with experience, hysteroscopic surgery will take approximately the same or less time than conventional surgery. Most experienced hysteroscopic surgeons should be able to complete endometrial resection or ablation in about 15-30 minutes. The nursing staff must learn to use and maintain the new instruments in order to function as a team. This will be helped by the use of video cameras so that they can see the operation and, when necessary, assist in its performance.
Acquisition of knowledge The surgeon's knowledge must be reinforced by reading and attending conferences and courses where there is didactic teaching. Reading should include both basic textbooks and current specialist journals. The gynaecologist may obtain an overview of the possibilities of hysteroscopic surgery by attending conferences where hysteroscopy is discussed and, if possible, where live operations are relayed to the auditorium from the operating room. Video recordings make excellent teaching aids but they can be criticized because editing can make the operation look easier and better than it really is. Few surgeons will produce a recorded video containing the failures of their techniques as well as the successes.
SAFETY AND TRAINING
245
Conferences are organized in many countries throughout the world, either sponsored by institutions or by the instrument manufacturers to whom credit must be given for their interest in education and promoting safety in these techniques. National and international societies are now developing which seek to educate by means of endoscopy courses and to monitor the success of the procedures and the incidence of complications. Their meetings also provide a forum for discussion and allow the surgeon who wishes to learn operative hysteroscopy to listen and watch the expert at work. The preliminary acquisition of knowledge should be followed by in-house training when available or by attending a course.
Formal training Many hospitals are developing very successful in-house training programmes. A great deal of co-operation between the surgical and nursing staff is required. Usually a week should be allocated to a training session so that the didactic part of the course and laboratory practice, taught by experienced staff with the assistance of visiting experts, precede 3 or 4 full days of hands-on instruction in the operating room. Workshops for trainees from other hospitals should last at least 2 days and include lectures and discussion on the theory and practice of hysteroscopy. The groups should be small enough to allow all the participants to contribute to discussion and to have the opportunity for 'hands-on' training in the laboratory and operating room. Six trainees is probably the ideal number and, in order to obtain the maximum benefit from the workshop, they should already have some preliminary experience in diagnostic hysteroscopy and have attended at least one larger conference. Longer attachment to a training unit is desirable but not always practical because of financial constraints and the time involved. There may be inefficient use of time if the trainer has limited access to the operating room and so a week at a centre may only allow attendance at two or three operating sessions. Initial training can commence on inert models which consist of a plastic case with a replacable wax lining resembling the uterine cavity which can be excised by the resectoscope loop. Biological tissue can be provided by an excised bovine uterus or porcine bladder which are larger than the human uterus but provide a readily available substitute on which to practise the use of the instruments. Alternatively an excised human uterus can be used in vitro to gain experience before commencing hysteroscopic surgery. When the skills of diagnostic hysteroscopy have been mastered, progress may be made to operative hysteroscopy. Initially at a workshop or in-house training programme, the trainee may perform part of a resection or ablation under supervision using a video screen. After gaining initial but limited experience of the technique, further progress may be made by operating supervised by a trained colleague in-house or by attending a colleague's operating session and working on a one-to-one basis. The development of surgical skills will increase faster and with greater safety than if the learner were to work unsupervised. Alternatively the trainer may go to the trainee's
246
A.G. GORDON
hospital which has the advantage that all the operating room staff have the opportunity to learn from the visiting trainer. Practice
The final step in the training programme is practice. Many surgeons in their early learning period have continued their practical training by performing endometrial resection prior to hysterectomy with the abdomen open so that an assistant can watch for perforation or undue heat transmission. Others have used the laparoscope as a safety measure, to detect perforation and ensure that bowel was kept away from the uterus, until they were sufficiently competent to operate without these precautions. The surgeon must appreciate the importance of a clear view of the uterine cavity and must know to stop the operation if vision is compromised. Tragedies have resulted from inexperienced hysteroscopic surgeons failing to appreciate the significance of loss of vision when the uterine distention system has failed and continuing to use high frequency current or laser. This may produce the disastrous result of perforation of the of the uterus and damage to organs such as major vessels, ureter and bowel. As with any newly acquired skill, it is sensible to move from the simple to the complex. Ideally any advance in difficulty should be under supervision and that should always be the case with the training of junior surgeons. However, in most countries relatively few senior surgeons are trained in hysteroscopic surgery at present and it would be unrealistic to expect them to be supervised for more than their basic training period. Nevertheless, no surgeon should undertake advanced hysteroscopic surgery without proper training for to do so, and for the patient to suffer avoidable complications, could be construed as negligence. The mastery of the simple procedures will take time. If the learner feels that the time is of such duration that the techniques of major surgery learnt in a workshop have become rusty, a refresher course or several sessions spent working with an experienced colleague are recommended before embarking on more complex procedures unsupervised. CLASSIFICATION OF HYSTEROSCOPIC OPERATIONS Hysteroscopic surgery has been classified into minor, intermediate and advanced operations (Table 1). This classification has merit in that it gives some indication of the progression which surgeons in training should undertake. They should commence with simple procedures before attempting complicated ones and should recognize the degree of difficulty of each operation. Level 1 suggests the type of operation which any competent surgeon with experience in diagnostic hysteroscopy should be able to perform. These simple procedures will allow the surgeon to develop expertise and familiarization with working in the uterine cavity. With practice, these operations should be possible within a few weeks of commencing training. Progression to level 2 should be within the compass of
SAFETY AND TRAINING
247
most surgeons and can be learnt in-house during the residency training programme. Level 3 requires attendance at courses and supervision by a trainer during operating sessions.
Table 1. Classification of hysteroscopic operations. Level 1
Diagnostic hysteroscopy and target biopsy Removal of simple polyps Removal of intrauterine contraceptive devices
Level 2
Proximal fallopian tube cannulation Division of minor synechiae Removal of pedunculated fibroid
Level 3
Divisior~'resection of uterine septum Endometrial resection/ablation Resection of submucous/intramural fibroid Division of major synechiae Repeat endometrial resection/ablation
TRAINING OF OTHER OPERATING ROOM PERSONNEL
The importance of the training for other operating room personnel is well recognized. The development of new approaches to surgery has created new training needs for nurses, operating room assistants and anaesthetists, as well as surgeons. The nursing staff need to know how to care for the instruments which are delicate and expensive. Some of the narrow instruments are difficult to clean. Training in maintenance is essential to avoid cross-contamination. Nursing staff and operating room assistants also need to have a clear understanding of the safety considerations concerning uterine distension systems, the dangers of fluid overload and the use of electrosurgical and laser generators. They should also attend suitable courses which are often organized in parallel with the courses for surgeons and give them the opportunity to work on simulators as well as listen to lectures and watch operations. The anaesthetist also needs to be aware of the special needs of the patient undergoing endometrial ablation and the risks involved. Active participation by the anaesthetist in fluid accountancy and the early recognition of overload may be the difference between an uneventful operation and surgical tragedy. RECOGNITION OF LATE COMPLICATIONS The special needs of the patient and her attendants should be considered. Many, if not most, endometrial ablation procedures are performed on a day-care basis. While complications are uncommon after the patient leaves the day-care unit, it is vital that they be recognized and treated without delay. The patient should be given adequate information sheets prior to
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surgery so that she or her relatives know when to seek medical aid. There should also be good communication with the family doctor. It is probable that most family doctors have undergone their training before the advent of endoscopic surgery and they must be updated on current practice by helpful letters from the surgeon. FUTURE NEEDS
The Working Party of the Royal College of Obstetricians and Gynaecologists (RCOG) and the British Society for Gynaecological Endoscopy has made a number of recommendations for future training and practice in endoscopic surgery (RCOG, 1994). A departure in Britain from the time-honoured apprenticeship system of training and the introduction of credentialling is envisaged. Their recommendations will need to be reviewed when the majority of consultant gynaecologists are accomplished in endoscopic surgery. They suggest that the certification of gynaecological endoscopists should be supervised by appropriate regional advisors who, in turn, will be advised by the College. Certification will depend upon the opinion of the advisor on the trainee's competence rather than on the accomplishment of a given number of operations. They recognize the difference in individual learning curves and that some trainees may never reach a level of confidence in advanced surgery and should be appropriately advised about this. Each gynaecologist performing hysteroscopic surgery should first be competent in diagnostic procedures and, after credentialling, should produce evidence of continuing medical education. They should be encouraged to attend updating courses every 2 years. SUMMARY
Provided progress is made systematically, the surgeon never attempts to perform operations that are too difficult, and all the safety protocols are adhered to, hysteroscopic surgery should be within the capabilities of most gynaecologists. Failure to appreciate the risks and failure to undergo continuous training in the learning period will inevitably lead to complications which should otherwise be avoidable. Hysteroscopic surgery offers many advantages over conventional surgery and, like many other types of minimal access surgery, appears to be the surgery of the future. Endoscopic surgery will not supplant open surgery but will become another essential part of our practice which the patient will expect and, indeed, demand. There will be problems. Training programmes must be established to try to prevent complications which will be encountered if inadequately trained surgeons perform these new forms of surgery. There must be continuous education in existing methods and research into value and results of new techniques and instruments both for laser and electrosurgery.
SAFETY AND TRAINING
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It is possible that in the future new biophysical or pharmacological approaches may render laser and electrosurgery obsolete. Safer forms of physical energy, photosynthesis and new forms of hormone therapy are all undergoing trials with preliminary results which are encouraging. Whichever techniques eventually prove to be the most effective and safe, we must learn to use them because we owe to our patients the opportunity to benefit from them. REFERENCES Hamou JE (1981) Microhysteroscopy, A new procedure and its original applications in gyneco-
logy. Journal of Reproductive Medicine 26: 375. Lindemann H-J (1986) Complications ofhysteroscopy. Presented to the European Society of Hysteroscopy, Antwerp. Royal College of Obstetricians and Gynaecologists (1994) Report of the RCOG Working Party on Training in Endoscopic Surgery. London: RCOG Press. Taylor PJ & Gordon AG (1993) Practical Hysteroscopy, pp 103-106. Oxford: Blackwell.