Diagnostic laparoscopy for infertile patients as a training program

Diagnostic laparoscopy for infertile patients as a training program

Int. J. Gymecol. O&et., 1982,20: 19-22 International Federation of Gynaecology & Obstetrics DIAGNOSTIC LAPAROSCOPY FOR INFERTILE PATIENTS AS A TRAINI...

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Int. J. Gymecol. O&et., 1982,20: 19-22 International Federation of Gynaecology & Obstetrics

DIAGNOSTIC LAPAROSCOPY FOR INFERTILE PATIENTS AS A TRAINING PROGRAM

G.I. SEROUR and FL HEFNAWI Department

of Obstetrics and Gynecology, Al-Azhm University, Cairo, Egypt

(Received January 28th, 1981) (Accepted February 27th, 1981)

Abstract Serour GI, Hefmwi FI: (Dept of Obstetrics and Gynecology, Al-Azhar University, Cairo, Egypt). Diagnostic laparoscopy for infertile

patients as a training program. Int J Gynaecol Obstet 20: 19-22, I982 During a 3-year period, 2650 cases of diaglaparoscopy were performed on nostic selected infertility patients in a training program on gynecologic laparoscopy at hospitals in Egypt, the Sudan and Saudi Arabia. All cases were attended by the senior author. Most of the procedures were performed by physicians who either had never performed the procedure or had not had significant experience with it. This report presents the laparoscopic findings, complications and problems encoutered. It shows that with emphasis on equipment care and handling, careful patient selection and observation of simple precautions during and after the operation, the procedure can be safely included in the training program of residents in obstetrics and gynecology.

Key words: Diagnostic laparoscopy; Infertility; Endoscopy unit; Training centers Introduction Since the 1960s laparoscopy has become a useful and relatively safe procedure. However, results from several annual surveys of members of the American Association of Gynecol002-7292/82/0000-0000/$02.75 0 1982 International Federation of Gynaecology & Obstetrics

ogical Laparoscopists (AAGL) demonstrated unequivocally that gynecologic laparoscopy is a complex art that requires much versatility and skill in the use of optics, light sources, electric current, gas pressure, cameras and array of rapidly changing and improving instruments 151. The working party of the confidentional enquiry into gynecological laparoscopy conducted by the Royal College of Obstetricians and Gynecologists concluded that the risk rate of the procedure is low and probably compares favorably with other diagnostic and operative procedures [ 1I. They recommended that training centers should be properly organized to perform an adequate number of laparoscopies each year so that sufficient teaching is available to all in training. Materials and methods An endoscopy unit supervised by the authors established at Al-Azhar was University Teaching Hospitals in 1976. To date, 70 doctors, including residents, members of the University staff, local and visiting consultants from Africa and Asia who either had never performed the procedure or had not had significant experience with it, received training in this unit. The training program described in this report included gynecologic laparoscopy procedures performed at the Al-Azhar University Teaching Hospitals, affiliated hospitals and at 21 other hospitals in Egypt, the Sudan and Saudi Arabia. In t J Gynaecol Obstet 20

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Serour and Hefnnwi

The period of laparoscopy training was either five clinical practice training sessions per week or eight sessions per month. The training always began with instructions on the equipment: its handling, cleaning, maintenance, sterilization, equipment-associated complications and dealing with minor defects that may arise. This was followed by a demonstration of the laparoscopy technique on a few cases, with the patients under general and local anesthesia. The doctor-intraining was the first assistant in these initial few cases. The doctor-in-training then performed 10-l 5 procedures of diagnostic laparoscopy (with the patients under general and local anesthesia) under the direct supervision and assistance of the senior author. The doctor-in-training was not allowed to perform operative laparoscopy until he satisfied the senior author of his ability to handle and use the equipment safely and of his familiarity with the procedure. Some of those who received training in the unit were field visited by the senior author in their institutions for additional on-site training. During the period June 1976 to June 1979, 2650 procedures of diagnostic laparoscopy were performed. All cases were attended by the senior author who either performed the procedure himself (1200 patients, 45.28%) or directly assisted in and supervised the operation (1450 patients, 54.72%). Laparoscopy was performed as a primary method of investigation, after clinical examination and semen analysis, in 886 patients. These included cases of long-term infertility, late marriage and when pelvic pathology, such as pelvic endometriosis or ovarian or uterine agenesis, were suspected on a clinical basis. Laparoscopy was performed as a last-line of investigation in 1764 patients. These included cases of unexplained infertility when simple methods of investigation other revealed no abnormality or when hysterosalpingograms were suggestive of tubal or cardiorespiratory pelvic disease. Gross Int J Gynaecol Obstet 20

embarrassment, abdominal mass, umbilical incisional hernia, multiple lower and abdominal explorations, generalized peritonitis and hemoperitoneum were considered absolute contraindications to the procedure. A single previous lower abdominal scar or a small umbilical hernia was considered a relative contraindication. Of the total, 1950 procedures (73.58%) were performed with the patient under general anesthesia and 700 (26.42%) were performed with the patient under local anesthesia. With local anesthesia, premeditation on the operating table with an intravenous injection of 50 mg of meperidine hydrochloride and 10 mg of diazepam was used. Paracervical block was produced by injecting 7 ml of 0.5% lignoCaine on each side of the cervix at the 3-and g-o’clock sites. The subumbilical area was infiltrated with 10 ml 0.5% lignocaine. Catheterization of the bladder was performed in all cases. The intraperitoneal placement of the pneumoperitoneum needle was checked by the saline test, the pressure manometer reading and symmetrical distension of the abdomen. Gas was allowed to flow to obtain an adequate pneumoperitoneum. The gas used was CO* in most cases; nitrous oxide was used occasionally. The patient was placed in an approximately 20” Trendelenburg position before the trocar and cannula were introduced downwards and backwards. After completion of the procedure, the pneumoperitoneum was carefully emptied. The scope was reintroduced, and the cannula was removed under vision. The wound was closed with subcuticular absorbable stitches. If there were no problems, the patient was discharged from the hospital on the same day. Results Table I shows the causes of infertility in the 2650 patients. Table II shows the complications encountered. The ten cases of bleeding included seven cases of bleeding from the abdominal wound and three cases of bleeding from the ovaries during manipula-

Dkagnosticlaparoscopy training Table I.

Laparoscopic findings in 2650 infertile patients.

Laparoscopic findings

No.of cases

%

Ovarian factor Cystic changes of the ovary Cystic ovaries Ovarian agenesis Premature menopause Ovarian tumor

855 391 370 61 24 9

32.26

Tubal factor

670

25.28

Table III. visits.

Equipment

Hosp. No.

Damaged equipment

(1) (2) (3)

(4) (5)

567

21.39

Uterine factor Fibroid uterus Bicomuate uterus Hypoplastic uterus Mullerian duct agenesis

275 200 12 34 29

10.37

PeIvic tuberculosis

134

5.05

(7)

R/V/F

103

3.88

(81

PeIvic endometriosis

29

1.09

No pathologic findings

10

0.37

Broad ligament tumor

4

0.15

Ectopic pregnancy

3

0.11

(61

tion with the forceps. These ten patients required hospitalization and observation overnight. Laparotomy was not necessary in any of these patients. Of the 2 1 field-visited hospitals, there were six hospitals (28.57%) in which the author Compkations

encountered

of laparoscopy in 2650 diagnostic

Complication

No. of cases

Frequency/ 1000 cases

Surgical emphysema Bleeding Perforation of uterus Iatrogenic cyst Inadequate visualization Severe bradycardia Wound infection Postoperative discomfort

15 10 3 9 3 2 5 25

5.66 3.77 1.13 3.39 1.13 0.75 1.88 9.43

Scope Scope Scope Cautery forceps Trocar and cannula Power box Scope Trocar and cannuIa Ring applicator Uterine canmda Ring applicator Gas pressure. gauge Verres needle Trocar and cannula Scope Trocar and cannula Scope

in 21 field

Extent of damage Major

Massive pehric inflammatory disease

Table II. cases.

problems

21

Minor

+ + + + + + + + + + + + + + + + +

faced major equipment problems that required replacement of the damaged part of the equipment. In five hospitals (23.80%), the author encountered minor equipment problems; the damaged part was mended without the need for replacement. Table III shows the equipment problems encountered in the 21 field visits. Both major and minor damage to the equipment was caused by improper handling. Discussion The laparoscopic findings and the complications encountered in these 2650 cases of diagnostic laparoscopy are discussed in another publication [Serour GI and Hefnawi, unpublished]. The discussion in this paper will be restricted to diagnostic laparoscopy as a training program. Three factors had contributed to the relatively slow rate of acceptability of laparoscopy, namely: (a) the cost of the equipment; (b) its frequent breakdown; and (c) the serious and occasionally fatal complications reported in the literature that are peculiar to laparoscopy [2,3]. It has In t J Gynaecol Obstet 20

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become apparent that laparoscopy is being performed by physicians not fully aware of the specific risks inherent in the technique and of the precaution necessary to ensure safety [ 4,6]. The fact that most of the procedures in this large series were performed by doctors-in-training, with very few resulting complications, none of which were serious, clearly shows that when doctors receive their supervised training in a center offering experience in an adequate number of laparoscopies, the serious complications can be avoided and the minor complications can be minimized. A I-2day field visit conducted by the person providing the training to the candidates after they return to their institutions is beneficial. The purpose of the field visit is to assist the physician in setting up his own endoscopic unit by installing the equipment, orienting the nursing staff and supervising the candidate’s first few surgical cases. In five out of the six hospitals (83.33%) where the author faced major equipment problems, the equipment had been uncrated and used by the candidate on his own before the field visit was conducted [ 7,8]. It would appear that when such a system of training is followed, the complications of the procedure will be reduced to a significant extent, the equipment will remain in a good

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shape for a long period of time and the expense of the equipment will be seen as minimal when compared to the service it provides. References Chamberlain GV: Review of Gynecologic Laparoscopy. In Recent Advances in Obstetrics and Gynecology (ed J Stallworthy, G Boume), p 195. Churchill Livingstone, 1979. Loffer FD, Pent D: Indications, contraindication and complications of laparoscopy. Obstet Gynecol Surv 30: 407, 1975. Palmer P: Safety in laparoscopy. J Reprod Med 13: 1, 1974. Phillips J, Keith D, Hulks J, Hulks B, Deith L: Gynecologic laparoscopy in 1975. J Reprod Med Z6: 105, 1976. Phillips JM: Complications in laparoscopy. Int J Gynaecol Obstet. 15: (2), 1977. Rioux JE, Yuzpe AA: Know the generator. Contemp Obstet Gynecol6: 15,1975. Serour GI, Proceeding of the JHPIEGO regional Consultants Meeting. Tunisia January 21-23, 1980, in press. Serour GI: in Proceeding of the JHPIEGO Conference on Surgical Equipment for educational Programs in Reproductive Health. Key Biscayne Florida September 16-18, 1979, in press. Address for reprints: GamaI I. serour IntemationaI Islamic Center Research P.O. Box 1176 Cairo, Egypt

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