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287: A New Method for Local Anesthesia by Hysteroscope
S104
Journal of Minimally Invasive Gynecology, Vol 14, No 6, November/December Supplement 2007
285
Design: Three case series, with follow-up at one, three and six months. Setting: One academic tertiary care medical center and one nonprofit community hospital. Patients: Forty women with pelvic pain and/or menorrhagia secondary to uterine fibroids who desired a minimally invasive treatment. Intervention: Transvaginal Doppler-guided uterine artery occlusion (D-UAO). Measurements and Main Results: At six months, the average reduction in the dominant fibroid size was 30%-35% as measured by MRI, while the average reduction in uterine size was 20%. Among patients with excessive menstrual bleeding, patients experienced a 35%-40% reduction in menstrual blood loss, associated with a 35% minimum average reduction in Ruta scores, a subjective quality of life instrument. There were no reports of amenorrhea, and the majority of subjects did not report adverse events. Five subjects experienced a total of six hydronephrosis events. In the first three patients, the hydronephrosis resolved spontaneously. The remaining three events occurred in two patients. One patient had complete resolution after unilateral ureteral stenting. The other patient had hydronephrosis that spontaneously resolved, followed by contralateral hydronephrosis that was alleviated with unilateral stenting followed by endoureterotomy. Immediately after the recognition of unresolved hydronephrosis in two patients, a mitigation strategy was put into place. No hydronephrosis has occurred in the three patients subsequently treated. Based on these initial pilot study results, two large prospective multicenter trials in the US and EU are in progress, one of which will serve as the Pivotal Registration Study for this device. Conclusion: Transvaginal D-UAO appears to be a promising minimally invasive technique for the treatment of fibroid-associated symptoms.
The Isobaric Laparoscopic Myomectomy (ILM) With Lucini’s Laparotenser: 748 Consecutive Cases 1 Vignali M, 2Melgrati L, 2Franzoni G, 2Capobianco F, 2 Stepanyan M, 3Busacca M. 1Milano, Italy; 2Casa di Cura S. Pio X, Milan, Italy; 3University of Milan, Milan, Italy Study Objective: Laparoscopic myomectomy has been found to be as effective as traditional surgery in removing fibroids with all the benefits of minimal invasive surgery. Nevertheless increased operative time, excessive bleeding and surgical skill in suturing affect the choice of this surgical approach. The Isobaric Laparoscopic Myomectomy (ILM) achieves an intraperitoneal working trunk-conic chamber through a subcutaneous abdominal wall lifter, allowing the use of conventional surgical instruments introduced through small (2 cm) abdominal incisions. Design: Retrospective analysis of 748 consecutive cases of ILM from 1997 to 2006. Setting: Private practice setting. Patients: Seven hundred forty-eight women (Mean age 37.3 yrs; range 22-48 yrs) with symptomatic uterine fibroids. Intervention: Seven hundred forty-eight Isobaric laparoscopic myomectomies (ILM) with Lucini’s laparotenser. Measurements and Main Results: Patients were contacted by phone. The mean follow-up was 24 (range, 6-60) months. A total of 2095 myomas were removed, of which 42% intramural, 58% subserosal. Mean size of myomas was 71 (range 1-20) mm. Four-hundred and seventy-one (63%) patients had singleton myoma whereas 277 (37%) had more than one. Mean operative time was 76 (range 20-280) min. Mean blood loss was 114,6 (range 40-800) mL. Mean hospital stay was 2,9 (range 2-15) days. Conversions to laparotomy occurred in two patients (0.3%), one for excessive bleeding and one for a retroperitoneal hematoma. Perioperative complications rate was quite low (2.4%) and included 15 cases of postoperative fever (⬎38° C), two subcutaneous hematomas and one Richter’s hernia at the right port site. Of 180 infertile patients 127 (70,5%) achieve a pregnancy. Conclusion: ILM with Lucini’s laparotenser represents a safe and reproducible procedure in the surgical management of symptomatic intramural and subserosal myomas, coupling all the benefits of the laparoscopic and conventional surgery without any of their disadvantages. 286 Transvaginal Doppler-guided Uterine Artery Occlusion for the Management of Leiomyomata Uteri: Initial Pilot Study Results Vilos GA. University of Western Ontario, London, Ontario, Canada Study Objective: To evaluate the preliminary effectiveness and safety of a minimally invasive technique, temporary occlusion of the uterine arteries, a procedure administered by a gynecologic surgeon to reduce fibroid-associated symptoms.
287 A New Method for Local Anesthesia by Hysteroscope Vleugels MPH. Riverland Hospital Tiel, Malden, Netherlands Study Objective: Development of a new needle system to apply local anaesthesia in the fundal area of the uterus to extend the possibility of performing hysteroscopic procedures in the Out patient department. Local anaesthesia clockwise the cervix creates analgesia in the cervical channel and the lower part of the cavity. However, the innervation of the upper part of the uterus is supplied by nerves coming alongside the infundibulum pelvicum. Application of heat, cryo coagulation or deep trauma will be experienced as painfull due to the stretch or pressure receptors in the muscle layers or the innervation of the serosa. Application of local anaesthesia in this area is difficult due to the parallax between the optic and the straight needle as well as dangerous by the risk for perforation due to the lack of vision on the tip of the needle.
Oral Presentations Design: Description of the needle system and demonstration of its use in practice. Setting: Out patient department and daycare center in a regional training hospital. Intervention: Several cases of fibroid vaporisation and polypectomy with local anaesthesia will be presented on video. Measurements and Main Results: Local anaesthesia can be given in the fundal area under and around pathology without the mentioned problems, i.e. lack of vision on the tip of the needle and without the risk of perforating deeply the wall of the uterus due to the construction of the needle tip. Conclusion: The special WING needle fits in the working channel of the small hysteroscopes and can easily be followed during the manipulation. This feature and the special designed tip to prevent deep placement prevents the risk of perforation and facilitates the application of local anaesthesia around and under the pathology. 288 Force Reflecting Instruments (FROI): The Future Becomes Reality? Vleugels MPH. Riverland Hospital Tiel, Malden, Netherlands Study Objective: Description of the development of endoscopic instruments with force feed back which actual can be used in practice. Design: Description of instruments and the preliminary in virtro use will be discussed. Setting: The instruments has been developed by the cooperation of EFI Ltd (EndoscopicForceInstruments, Maastricht Nederlands), TNO (Technical national Institute Delft Netherlands) and the author. Measurements and Main Results: A new laparoscopic instrument concept has been developed which uses an integrated optical fiber to measure forces at the tip. This information is used to give accurate haptic feed back to the surgeon using small electromotors integrated in the handle. With this instrument the risk of complications can be reduced because the surgeon feels the tissue manipulation forces. Also the learning curve for laparoscopic operations could be shortened. Moreover the measured tissue impedances during operations can be used to feed virtual reality training computers. Conclusion: With this instrument which can be used in daily practice the surgeon can improve safety and outcome of endoscopic operations. 289 Laparoscopic Training in Residency and Practice Patterns in Recent Ob-Gyn Graduates Wai CY, Gala R, Congleton MJ. University of Texas Southwestern Medical Center, Dallas, Texas Study Objective: To evaluate the gynecologic laparoscopic surgical experience during residency and in graduates within five years after training.
S105 Design: Questionnaire evaluating volume, types, and proportions of gynecologic laparoscopy performed in practice and during residency, laparoscopic surgery preferences, self-perceived skill, beliefs on optimal methods in laparoscopic training and skill maintenance after residency. Setting: Academic and community-based OB-GYN residency programs. Patients: Graduates of Dallas, Texas OB-GYN residency programs (2000-2005). Intervention: Questionnaire. Measurements and Main Results: Responded - 69/150 (53%). The majority were within 3 years of graduation (46/65). The most frequent procedure in practice was tubal ligation, ovarian cystectomy, followed by variants of laparoscopic hysterectomy. Laparoscopic myomectomy was rare, with only 9 respondents performing 1-5 /yr. This trend mirrored residency experience (most frequent: tubal ligation; least: myomectomy). Although the majority reported longer operating time for the same procedure laparoscopically when compared to open, 32/67, a substantial number reported equal operating time, 27/67. Though 65/66 reported adequate laparoscopy training during residency and 63/69 (91%) rated their skill as ‘average’ or ‘above average’, 61/66 felt additional training was needed. Surgical volume was the most important cited factor to improved residency training in laparoscopy. Mean number of cases required to achieve laparoscopic competence was felt to be 12-19. The most selected method to maintaining laparoscopic skills after residency was “day conferences” (46/69) and the least popular was fellowship training (6/69). However, 22 would pursue a gynecological laparoscopy fellowship, given the opportunity. Conclusion: Although the majority of recent OB-GYN graduates believe they have received sufficient training in laparoscopy ⬍50% of their current surgical load is performed laparoscopically. Many feel additional training is necessary but not through fellowship training. Increasing laparoscopic surgical load for residents may help increase the amount of laparoscopy performed in private practice. 290 Inital Experience of Laparoscopic-assisted Staging Surgery in Treating Early Stage Endometrial Cancer Wang IT. Taipei, Taiwan Study Objective: The aim of this study was to evaluate the feasibility of laparoscopy in the management of early stage endometrial cancer. Design: Reviewed analysis of 56 cases of endometrial cancer received laparoscopic assisted staging surgery (LASS) by laparoscopy. Setting: University-affiliated teaching hospital. Patients: Fifty-six patients including 7 cases of stage II and 49 cases of stage I recorded from January 1999 to May 2007. Intervention: Laparoscopic peritoneal washing, hysterec-
Journal of Minimally Invasive Gynecology, Vol 14, No 6, November/December Supplement 2007
285
Design: Three case series, with follow-up at one, three and six months. Setting: One academic tertiary care medical center and one nonprofit community hospital. Patients: Forty women with pelvic pain and/or menorrhagia secondary to uterine fibroids who desired a minimally invasive treatment. Intervention: Transvaginal Doppler-guided uterine artery occlusion (D-UAO). Measurements and Main Results: At six months, the average reduction in the dominant fibroid size was 30%-35% as measured by MRI, while the average reduction in uterine size was 20%. Among patients with excessive menstrual bleeding, patients experienced a 35%-40% reduction in menstrual blood loss, associated with a 35% minimum average reduction in Ruta scores, a subjective quality of life instrument. There were no reports of amenorrhea, and the majority of subjects did not report adverse events. Five subjects experienced a total of six hydronephrosis events. In the first three patients, the hydronephrosis resolved spontaneously. The remaining three events occurred in two patients. One patient had complete resolution after unilateral ureteral stenting. The other patient had hydronephrosis that spontaneously resolved, followed by contralateral hydronephrosis that was alleviated with unilateral stenting followed by endoureterotomy. Immediately after the recognition of unresolved hydronephrosis in two patients, a mitigation strategy was put into place. No hydronephrosis has occurred in the three patients subsequently treated. Based on these initial pilot study results, two large prospective multicenter trials in the US and EU are in progress, one of which will serve as the Pivotal Registration Study for this device. Conclusion: Transvaginal D-UAO appears to be a promising minimally invasive technique for the treatment of fibroid-associated symptoms.
The Isobaric Laparoscopic Myomectomy (ILM) With Lucini’s Laparotenser: 748 Consecutive Cases 1 Vignali M, 2Melgrati L, 2Franzoni G, 2Capobianco F, 2 Stepanyan M, 3Busacca M. 1Milano, Italy; 2Casa di Cura S. Pio X, Milan, Italy; 3University of Milan, Milan, Italy Study Objective: Laparoscopic myomectomy has been found to be as effective as traditional surgery in removing fibroids with all the benefits of minimal invasive surgery. Nevertheless increased operative time, excessive bleeding and surgical skill in suturing affect the choice of this surgical approach. The Isobaric Laparoscopic Myomectomy (ILM) achieves an intraperitoneal working trunk-conic chamber through a subcutaneous abdominal wall lifter, allowing the use of conventional surgical instruments introduced through small (2 cm) abdominal incisions. Design: Retrospective analysis of 748 consecutive cases of ILM from 1997 to 2006. Setting: Private practice setting. Patients: Seven hundred forty-eight women (Mean age 37.3 yrs; range 22-48 yrs) with symptomatic uterine fibroids. Intervention: Seven hundred forty-eight Isobaric laparoscopic myomectomies (ILM) with Lucini’s laparotenser. Measurements and Main Results: Patients were contacted by phone. The mean follow-up was 24 (range, 6-60) months. A total of 2095 myomas were removed, of which 42% intramural, 58% subserosal. Mean size of myomas was 71 (range 1-20) mm. Four-hundred and seventy-one (63%) patients had singleton myoma whereas 277 (37%) had more than one. Mean operative time was 76 (range 20-280) min. Mean blood loss was 114,6 (range 40-800) mL. Mean hospital stay was 2,9 (range 2-15) days. Conversions to laparotomy occurred in two patients (0.3%), one for excessive bleeding and one for a retroperitoneal hematoma. Perioperative complications rate was quite low (2.4%) and included 15 cases of postoperative fever (⬎38° C), two subcutaneous hematomas and one Richter’s hernia at the right port site. Of 180 infertile patients 127 (70,5%) achieve a pregnancy. Conclusion: ILM with Lucini’s laparotenser represents a safe and reproducible procedure in the surgical management of symptomatic intramural and subserosal myomas, coupling all the benefits of the laparoscopic and conventional surgery without any of their disadvantages. 286 Transvaginal Doppler-guided Uterine Artery Occlusion for the Management of Leiomyomata Uteri: Initial Pilot Study Results Vilos GA. University of Western Ontario, London, Ontario, Canada Study Objective: To evaluate the preliminary effectiveness and safety of a minimally invasive technique, temporary occlusion of the uterine arteries, a procedure administered by a gynecologic surgeon to reduce fibroid-associated symptoms.
287 A New Method for Local Anesthesia by Hysteroscope Vleugels MPH. Riverland Hospital Tiel, Malden, Netherlands Study Objective: Development of a new needle system to apply local anaesthesia in the fundal area of the uterus to extend the possibility of performing hysteroscopic procedures in the Out patient department. Local anaesthesia clockwise the cervix creates analgesia in the cervical channel and the lower part of the cavity. However, the innervation of the upper part of the uterus is supplied by nerves coming alongside the infundibulum pelvicum. Application of heat, cryo coagulation or deep trauma will be experienced as painfull due to the stretch or pressure receptors in the muscle layers or the innervation of the serosa. Application of local anaesthesia in this area is difficult due to the parallax between the optic and the straight needle as well as dangerous by the risk for perforation due to the lack of vision on the tip of the needle.
Oral Presentations Design: Description of the needle system and demonstration of its use in practice. Setting: Out patient department and daycare center in a regional training hospital. Intervention: Several cases of fibroid vaporisation and polypectomy with local anaesthesia will be presented on video. Measurements and Main Results: Local anaesthesia can be given in the fundal area under and around pathology without the mentioned problems, i.e. lack of vision on the tip of the needle and without the risk of perforating deeply the wall of the uterus due to the construction of the needle tip. Conclusion: The special WING needle fits in the working channel of the small hysteroscopes and can easily be followed during the manipulation. This feature and the special designed tip to prevent deep placement prevents the risk of perforation and facilitates the application of local anaesthesia around and under the pathology. 288 Force Reflecting Instruments (FROI): The Future Becomes Reality? Vleugels MPH. Riverland Hospital Tiel, Malden, Netherlands Study Objective: Description of the development of endoscopic instruments with force feed back which actual can be used in practice. Design: Description of instruments and the preliminary in virtro use will be discussed. Setting: The instruments has been developed by the cooperation of EFI Ltd (EndoscopicForceInstruments, Maastricht Nederlands), TNO (Technical national Institute Delft Netherlands) and the author. Measurements and Main Results: A new laparoscopic instrument concept has been developed which uses an integrated optical fiber to measure forces at the tip. This information is used to give accurate haptic feed back to the surgeon using small electromotors integrated in the handle. With this instrument the risk of complications can be reduced because the surgeon feels the tissue manipulation forces. Also the learning curve for laparoscopic operations could be shortened. Moreover the measured tissue impedances during operations can be used to feed virtual reality training computers. Conclusion: With this instrument which can be used in daily practice the surgeon can improve safety and outcome of endoscopic operations. 289 Laparoscopic Training in Residency and Practice Patterns in Recent Ob-Gyn Graduates Wai CY, Gala R, Congleton MJ. University of Texas Southwestern Medical Center, Dallas, Texas Study Objective: To evaluate the gynecologic laparoscopic surgical experience during residency and in graduates within five years after training.
S105 Design: Questionnaire evaluating volume, types, and proportions of gynecologic laparoscopy performed in practice and during residency, laparoscopic surgery preferences, self-perceived skill, beliefs on optimal methods in laparoscopic training and skill maintenance after residency. Setting: Academic and community-based OB-GYN residency programs. Patients: Graduates of Dallas, Texas OB-GYN residency programs (2000-2005). Intervention: Questionnaire. Measurements and Main Results: Responded - 69/150 (53%). The majority were within 3 years of graduation (46/65). The most frequent procedure in practice was tubal ligation, ovarian cystectomy, followed by variants of laparoscopic hysterectomy. Laparoscopic myomectomy was rare, with only 9 respondents performing 1-5 /yr. This trend mirrored residency experience (most frequent: tubal ligation; least: myomectomy). Although the majority reported longer operating time for the same procedure laparoscopically when compared to open, 32/67, a substantial number reported equal operating time, 27/67. Though 65/66 reported adequate laparoscopy training during residency and 63/69 (91%) rated their skill as ‘average’ or ‘above average’, 61/66 felt additional training was needed. Surgical volume was the most important cited factor to improved residency training in laparoscopy. Mean number of cases required to achieve laparoscopic competence was felt to be 12-19. The most selected method to maintaining laparoscopic skills after residency was “day conferences” (46/69) and the least popular was fellowship training (6/69). However, 22 would pursue a gynecological laparoscopy fellowship, given the opportunity. Conclusion: Although the majority of recent OB-GYN graduates believe they have received sufficient training in laparoscopy ⬍50% of their current surgical load is performed laparoscopically. Many feel additional training is necessary but not through fellowship training. Increasing laparoscopic surgical load for residents may help increase the amount of laparoscopy performed in private practice. 290 Inital Experience of Laparoscopic-assisted Staging Surgery in Treating Early Stage Endometrial Cancer Wang IT. Taipei, Taiwan Study Objective: The aim of this study was to evaluate the feasibility of laparoscopy in the management of early stage endometrial cancer. Design: Reviewed analysis of 56 cases of endometrial cancer received laparoscopic assisted staging surgery (LASS) by laparoscopy. Setting: University-affiliated teaching hospital. Patients: Fifty-six patients including 7 cases of stage II and 49 cases of stage I recorded from January 1999 to May 2007. Intervention: Laparoscopic peritoneal washing, hysterec-