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Can visual access cannulas improve laparoscopic safety?
14
TUESDAY,
SS2.06.02 TEACHING CHINESE YOUTH ABOUT AIDS/STD/SAFER Yu Yue Jin, Shanghai second Medical University, Department Preventive Medicine, Shanghai, P. R. China
SEX of
We carried out an AIDS/STD/Safes sex peer education programme in Beijing and Shanghai, China from August 1998. This programme is based on the peer education model which is novel and lively, making it easily acceptable. The modules consist of basic scientific information, games, stories, slide shows, quizzes, miniplays, discussions and questions. The education content consisted of six modules, Module 1 on HIV/AIDS; Module 2 on sexually trammitted diseases; Module 3 on self-protection (safer sex); Module 4 on facing the challenge AIDS; Module 5 on self-esteem, confidence and responsibility; Module 6 on contraception. By now, this education programme has been carried out at 8 Universities, in Beijing and Shanghai. About 2000 students have received our peer education. After completion of all the six modules. We carried out spot evolution and questionnaire surveys. From the process evaluation and research after education, it is clear that all the students approved of and praised this peer group education.They thought this method was relevant to the lives of young people.It should be widely used for high school and universally students in sex education,and may even be applied to other educational subjects. Beyond the peer education at Universities, we also brought it to middle schools in Shanghai and we were warm welcomed. The programme was well received by the students, the school authorities. I think the peer education to youth about AIDS/STD/Safer sex is extremely successful, and could very easily be popularized.
EN2.02 IAPAROSCOPIC
SURGERY:
SAFE ENTRY
EN2.02.02 THE STEP SYSTEM (THE RADIALLY EXPANDING ACCESS SYSTEM) D. Dept. Of Ob/Gyn, Santa Barbara Associates, Santa Barbara, CA, United States Laparoscopy is inherently difficult, involving precise hand and eye coordination, two-dimensional imaging through the video screen, a diminished tactile sense, and the entry problems associated with a blind procedure. The true incidence of complications is hard to determine because the data comes from either malpractice cases, surveys, medical device reports or practitioners and very little, unfortunately, from prospective controlled studies. What appears clear, however, is that the access materials and methods in operative laparoscopy are the causes of the vast majority of complications. Vascular injuries, visceral injuries and hernias are all associated with this part of the procedure. In fact, the problems can be further isolated to accessing the intraabdominal space by the primary port. In a study of malpractice cases associated with cholecystectomy, 86% of the visceral injuries were caused by the trocar. In the case of malpractice concerning gynecological laparoscopy, it has been shown the primary port is the site of 50% of the major vascular injuries. The secondary port and Veress needle are each involved in 10% of the injuries and miscellaneous injuries account for the remaining 30% To date there has been no consensus to the correct way to enter the abdomen with either the Veress needle, trocar or other access device. This paper is intended to submit an argument for the use of the radially expanding access system. This system is itself first described followed by the data supporting its efficacy and finally a description of the clinical applications.
EN2.02.03 CAN VISUAL ACCESS CANNULAS IMPROVE LAPAROSCOPIC SAFETY? Artin M. Ternamian, Department of Obstetrics and Gynecology, St. Joseph’s Health Centre, University of Toronto, Canada Laparoscopic complications is a growing global concern, and absolute prevention of technical misadventure though medico-legally desirable as
SEPTEMBER
5
a standard of care, may be clinically unachievable, given our present day endoscopic knowledge, training and technology. It is accepted that about half of these injuries are access related. In order to improve laparoscopic access safety, tissue dynamics at port site was studied during application of conventional First Generation pushthrough trocars. Specific Performance Shaping Factors (PSFs) were identified that individually and collectively infers added risk to access cannula insertion and removal. Having determined system weaknesses of conventional Closed and Open laparoscopy, a new interactive visual port system is re-engineered and ergonomic access cannula designed. This Second Generation access system avoids the identified PSF’s, and allows error recovery before harm occurs. Surgeons can anticipate danger, avoid error or recognize mishap. It is anticipated that when uncontrolled axial penetration force is not applied at port site, sharp or pointed trocars are not required, and port creation is visual and interactive, the process becomes less dangerous. With the recent White House initiative to curb medical errors, Congress just passed legislation ordering the Agency for Health Care Policy and Research to design strategies to reduce medical mistakes. Our culture of “blaming the human” must change as it is increasingly evident that most serious laparoscopic access injuries are more a system problem and less of a surgeon or instrument issue.
EN2.02.04 GASLESS LAPAROSCOPY IN GYNECOLOGY HOW TO AVOID COMPLICATIONS DUE TO CARBONDIOXIDE INSUFFLATION? Daniel Institute for Gynaecologic Endoscopy, University Witten / Herdecke, Germany
of
Purpose: Pneuoperitoneum laparoscopy has some disadvantages, e.g. complications at the time of Veres or trocar entry as well as physiologic alterations and complications. To exclude complications due to carbondioxide insufflation and “blind” abdominal entry gasless laparoscopy is beeing used. Methods: 1039 gasless laparoscopic operative laparoscopic procedures, e.g. total laparoscopic hysterectomies, myomectomies, operations on ovarian tumors and severe endometriosis were performed during the period of 1990 2000, for the last five years only with reusable abdominal wall lifting systems which were developed by our Institute. Results: There was no complication at the time of abdominal entry and any complication related to carbondioxide insufflation. All surgeries could be performed with conventional surgical instruments. There were no side effects of carbon dioxide like an increase of arterial PO,, metabolic acidosis, hypercarbia or hypoxemia, an increase of the intra-abdominal pressure, a compression of the diaphragm, hypoventilation, compression of the vena cava with reduction of cardiac output, high central venous pressure and an increase of the peripheral resistance. There was no decrease of the body temperature and no decrease of the intra-abdominal temperature. Postoperative pain, especially shoulder pain and its intensity was beeing reduced significantly by gasless laparoscopy in comparison to carbondioxide. Conclusions: Gasless laparoscopy with reusable abdominal wall lift combines the advantages of laparoscopy (small incisions, short hospitalisation) and of laparotomy (conventional instruments and standard procedures) but excluding the disadvantages of both methods. Complications of gas laparoscopy due to blind punctures at the time of abdominal entry with the Veres needle or first trocar insertion like lesions of bowel or vessels could be eliminated.
FM2.08 MANAGEMENT
OF PREGNANCY
HYPERTENSION
FM2.08.01 MANAGEMENT OF PREGNANCY HYPERTENSION METHODS SCREENING K. University of Zimbabwe, Harare, Zimbabwe
OF
Hypertension in pregnancy complicates up to 10% of pregnancies and contributes significantly to both maternal and perinatal mortality and morbidity. Despite extensive research to elucidate origin of pre eclampsia there is currently no well validated prophylactic treatment; nor is there any effective method of identifying women at risk for pre eclampsia. At present therefore predicting the risk will identify women for more careful monitoring and may also identify population or women for research into its etiology and then possible prevention or treatment.
TUESDAY,
SS2.06.02 TEACHING CHINESE YOUTH ABOUT AIDS/STD/SAFER Yu Yue Jin, Shanghai second Medical University, Department Preventive Medicine, Shanghai, P. R. China
SEX of
We carried out an AIDS/STD/Safes sex peer education programme in Beijing and Shanghai, China from August 1998. This programme is based on the peer education model which is novel and lively, making it easily acceptable. The modules consist of basic scientific information, games, stories, slide shows, quizzes, miniplays, discussions and questions. The education content consisted of six modules, Module 1 on HIV/AIDS; Module 2 on sexually trammitted diseases; Module 3 on self-protection (safer sex); Module 4 on facing the challenge AIDS; Module 5 on self-esteem, confidence and responsibility; Module 6 on contraception. By now, this education programme has been carried out at 8 Universities, in Beijing and Shanghai. About 2000 students have received our peer education. After completion of all the six modules. We carried out spot evolution and questionnaire surveys. From the process evaluation and research after education, it is clear that all the students approved of and praised this peer group education.They thought this method was relevant to the lives of young people.It should be widely used for high school and universally students in sex education,and may even be applied to other educational subjects. Beyond the peer education at Universities, we also brought it to middle schools in Shanghai and we were warm welcomed. The programme was well received by the students, the school authorities. I think the peer education to youth about AIDS/STD/Safer sex is extremely successful, and could very easily be popularized.
EN2.02 IAPAROSCOPIC
SURGERY:
SAFE ENTRY
EN2.02.02 THE STEP SYSTEM (THE RADIALLY EXPANDING ACCESS SYSTEM) D. Dept. Of Ob/Gyn, Santa Barbara Associates, Santa Barbara, CA, United States Laparoscopy is inherently difficult, involving precise hand and eye coordination, two-dimensional imaging through the video screen, a diminished tactile sense, and the entry problems associated with a blind procedure. The true incidence of complications is hard to determine because the data comes from either malpractice cases, surveys, medical device reports or practitioners and very little, unfortunately, from prospective controlled studies. What appears clear, however, is that the access materials and methods in operative laparoscopy are the causes of the vast majority of complications. Vascular injuries, visceral injuries and hernias are all associated with this part of the procedure. In fact, the problems can be further isolated to accessing the intraabdominal space by the primary port. In a study of malpractice cases associated with cholecystectomy, 86% of the visceral injuries were caused by the trocar. In the case of malpractice concerning gynecological laparoscopy, it has been shown the primary port is the site of 50% of the major vascular injuries. The secondary port and Veress needle are each involved in 10% of the injuries and miscellaneous injuries account for the remaining 30% To date there has been no consensus to the correct way to enter the abdomen with either the Veress needle, trocar or other access device. This paper is intended to submit an argument for the use of the radially expanding access system. This system is itself first described followed by the data supporting its efficacy and finally a description of the clinical applications.
EN2.02.03 CAN VISUAL ACCESS CANNULAS IMPROVE LAPAROSCOPIC SAFETY? Artin M. Ternamian, Department of Obstetrics and Gynecology, St. Joseph’s Health Centre, University of Toronto, Canada Laparoscopic complications is a growing global concern, and absolute prevention of technical misadventure though medico-legally desirable as
SEPTEMBER
5
a standard of care, may be clinically unachievable, given our present day endoscopic knowledge, training and technology. It is accepted that about half of these injuries are access related. In order to improve laparoscopic access safety, tissue dynamics at port site was studied during application of conventional First Generation pushthrough trocars. Specific Performance Shaping Factors (PSFs) were identified that individually and collectively infers added risk to access cannula insertion and removal. Having determined system weaknesses of conventional Closed and Open laparoscopy, a new interactive visual port system is re-engineered and ergonomic access cannula designed. This Second Generation access system avoids the identified PSF’s, and allows error recovery before harm occurs. Surgeons can anticipate danger, avoid error or recognize mishap. It is anticipated that when uncontrolled axial penetration force is not applied at port site, sharp or pointed trocars are not required, and port creation is visual and interactive, the process becomes less dangerous. With the recent White House initiative to curb medical errors, Congress just passed legislation ordering the Agency for Health Care Policy and Research to design strategies to reduce medical mistakes. Our culture of “blaming the human” must change as it is increasingly evident that most serious laparoscopic access injuries are more a system problem and less of a surgeon or instrument issue.
EN2.02.04 GASLESS LAPAROSCOPY IN GYNECOLOGY HOW TO AVOID COMPLICATIONS DUE TO CARBONDIOXIDE INSUFFLATION? Daniel Institute for Gynaecologic Endoscopy, University Witten / Herdecke, Germany
of
Purpose: Pneuoperitoneum laparoscopy has some disadvantages, e.g. complications at the time of Veres or trocar entry as well as physiologic alterations and complications. To exclude complications due to carbondioxide insufflation and “blind” abdominal entry gasless laparoscopy is beeing used. Methods: 1039 gasless laparoscopic operative laparoscopic procedures, e.g. total laparoscopic hysterectomies, myomectomies, operations on ovarian tumors and severe endometriosis were performed during the period of 1990 2000, for the last five years only with reusable abdominal wall lifting systems which were developed by our Institute. Results: There was no complication at the time of abdominal entry and any complication related to carbondioxide insufflation. All surgeries could be performed with conventional surgical instruments. There were no side effects of carbon dioxide like an increase of arterial PO,, metabolic acidosis, hypercarbia or hypoxemia, an increase of the intra-abdominal pressure, a compression of the diaphragm, hypoventilation, compression of the vena cava with reduction of cardiac output, high central venous pressure and an increase of the peripheral resistance. There was no decrease of the body temperature and no decrease of the intra-abdominal temperature. Postoperative pain, especially shoulder pain and its intensity was beeing reduced significantly by gasless laparoscopy in comparison to carbondioxide. Conclusions: Gasless laparoscopy with reusable abdominal wall lift combines the advantages of laparoscopy (small incisions, short hospitalisation) and of laparotomy (conventional instruments and standard procedures) but excluding the disadvantages of both methods. Complications of gas laparoscopy due to blind punctures at the time of abdominal entry with the Veres needle or first trocar insertion like lesions of bowel or vessels could be eliminated.
FM2.08 MANAGEMENT
OF PREGNANCY
HYPERTENSION
FM2.08.01 MANAGEMENT OF PREGNANCY HYPERTENSION METHODS SCREENING K. University of Zimbabwe, Harare, Zimbabwe
OF
Hypertension in pregnancy complicates up to 10% of pregnancies and contributes significantly to both maternal and perinatal mortality and morbidity. Despite extensive research to elucidate origin of pre eclampsia there is currently no well validated prophylactic treatment; nor is there any effective method of identifying women at risk for pre eclampsia. At present therefore predicting the risk will identify women for more careful monitoring and may also identify population or women for research into its etiology and then possible prevention or treatment.