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Laparoscopy and laparoscopic surgery
REVIEW
Laparoscopy and laparoscopic surgery
Alex Swanton MD MRCOG Consultant Gynaecologist, Royal Berkshire Hospital, Reading, UK. Conflicts of interest: none declared.
most hysterectomies are performed for benign conditions, the choice of route almost entirely depends upon the surgeon’s skill and experience. Avoiding a laparotomy in the appropriately chosen patient is without doubt beneficial. The 2009 Cochrane review has looked at the evidence for which route is best for performing hysterectomy. The conclusions were that the vaginal route is best. In patients whom the vaginal route is not possible, laparoscopic hysterectomy has benefits over the abdominal route. The benefits of laparoscopic hysterectomy versus abdominal hysterectomy were lower intra-operative blood loss (mean difference (MD) 45.3 ml, 95% CI 17.9e72.7 ml) and a smaller drop in haemoglobin level (WMD 0.55 g/L, 95% CI 0.28e0.82 g/L), shorter duration of hospital stay (MD 2.0 days, 95% CI 1.9e2.2 days), speedier return to normal activities (MD 13.6 days, 95% CI 11.8e15.4 days), fewer wound or abdominal wall infections (OR 0.31, 95% CI 0.12e0.77), fewer unspecified infections or febrile episodes OR 0.67, 95% CI 0.51e0.88), at the cost of longer operating time (MD 11.8 minutes, 95% CI 8.6e14.9 minutes) and more urinary tract (bladder or ureter) injuries (OR 2.41, 95% CI 1.21e4.82). There was no significant difference in the following long-term complications: fistula formation and urinary dysfunction. There was no benefit in performing a total laparoscopic hysterectomy over a laparoscopically assisted vaginal hysterectomy. In those patients where a vaginal hysterectomy is contraindicated or not technically possible, the default should therefore be to use a laparoscopic approach. The first hysterectomy using only laparoscopic techniques was performed in 1988 by Harry Reich. Other milestones are shown in Table 1. Total laparoscopic hysterectomy can be a technically difficult procedure to perform. A number of alternative laparoscopic techniques to perform all or some of the hysterectomy have therefore been introduced to simplify the procedure, but retain the major advantages of the approach, i.e. avoidance of a laparotomy wound. Laparoscopic sub-total hysterectomy is becoming an increasingly common procedure and some units have reported success in performing it as a day case. A recent Cochrane review has shown that sub-total hysterectomy is not superior to total hysterectomy in terms of sexual, urinary or bowel function. The advantages of this approach have been well documented, but the laparoscopic route has been little used by general gynaecologists to date. Although it has been possible to reduce the laparotomy rate for hysterectomy to 10% in some units, there is evidence from the UK (Table 2) and the USA that more than 70% of all hysterectomies are still being performed by laparotomy. More recently robot-assisted laparoscopic hysterectomy has emerged as a new technique to perform hysterectomy. Instead of directly moving the instruments, the surgeon uses a robotic device to control them. There is currently no evidence that this technique is superior to the laparoscopic/vaginal routes for benign conditions. Further research will be needed to determine any advantage.
Nicolas Vulliemoz MD is Subspecialist in Reproductive Medicine and Surgery at the Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women’s Centre, The John Radcliffe Hospital, Oxford, UK. Conflicts of interest: none declared.
Myomectomy Uterine fibroids are responsible for a wide variety of symptoms, including menorrhagia, pain/pressure symptoms, urinary tract symptoms and have been implicated in subfertility. The
Alex Swanton Nicolas Vulliemoz
Abstract Today, laparoscopy is an alternative technique for carrying out many operations that have traditionally required an open approach. The benefits of minimal access surgery have been well recorded, including lower postoperative morbidity, shorter duration of hospital stay and a shorter return to work. Advances in technology, specifically in fibre optics and video imaging, have made the relatively recent rapid progress in laparoscopic surgery possible. Operative laparoscopy, however, requires a high degree of technical skill and training. The use of small instruments and imaging systems that provide magnification allow for the high degree of precision that can be achieved with laparoscopic surgery. This is often difficult to obtain by a conventional laparotomy, as magnification is not available and the surgeon’s hands and large instruments often obscure the operative field. It is this precision that has lead to advances in the treatment of conditions such as endometriosis, adhesions and in the field of reproductive surgery. It is unfortunate however that in reality very few major gynaecological procedures are performed laparoscopically. They are technically difficult and require the surgeon to master a whole new set of surgical skills and in effect to return to the bottom of the surgical learning curve. A wide range of simple laparoscopic procedures needs to be mastered to develop the hand eye coordination required to perform complex tasks. These procedures need to be performed on a regular basis to maintain skills and only when these skills can be regularly performed accurately can complex surgical tasks be carried out. As a result of this, most established gynaecologists have very little time and resources to be able to retrain in what is essentially a new surgical field, although most experts throughout the country agree that the vast majority of gynaecological surgery could safely and efficiently be performed laparoscopically.
Keywords laparoscopic surgery; laparoscopy; minimal access surgery
Current practice Hysterectomy Hysterectomy remains one of the most common gynaecological inpatient procedures. About 60,000 hysterectomies are performed every year in the UK and over 600,000 in the US. Since
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ability to palpate the uterine tissue, detecting smaller fibroids. It may also be more difficult to approximate myometrial and serosal tissues, leading to poor healing of the uterine wall potentially leading to complications in future pregnancies. A recent survey of UK gynaecologists revealed that just over 10% performed laparoscopic myomectomies as part of their normal practice.
Milestones in hysterectomy First vaginal hysterectomy First abdominal hysterectomy Cautery to cervical stump Definition of sub-total technique Low transverse incision Myomectomy Total hysterectomy Dominance of total hysterectomy Endometrial ablation Laparoscopic hysterectomy Intra-uterine levonorgestrel
Langenbeck (1810) Clay (1843) Keith (1880) Kelly (1896) Pfannenstiel (1900) Bonney (1920) Richardson (1929) (1940s and 50s) de Cherney, Hamou (1980s) Reich (1988) Nilsson (1977)
Ectopic pregnancy (Figure 2) It is now accepted that minimal access surgery provides the best and most efficient method of treating ectopic pregnancies (RCOG Grade A recommendation). However, gynaecologists in the UK have been slow to establish laparoscopic management of ectopic pregnancies as standard practice. A recent audit on the management of ectopic pregnancy in a Scottish teaching hospital showed that only 62% of cases were managed laparoscopically compared with over 90% in France. This disappointingly low rate in the UK is most likely to be the result of a lack of training among junior staff. Hospitals have addressed this issue by: Identifying experienced surgeons willing to be available to train and supervise juniors. Establishing emergency gynaecological clinics with vaginal ultrasound and serum beta human chorionic gonadotrophin measurements. Where these measures have been taken, the result is that the vast majority of ectopic pregnancies can be managed laparoscopically during normal working hours with senior input readily available.
Table 1
management of fibroids depends on the patient’s symptoms and the location of the fibroid in the uterus (Figure 1). Asymptomatic patients can be managed conservatively and those in whom fertility is not an issue can be managed medically or by hysterectomy. Where fertility needs to be conserved, myomectomy is the treatment of choice. Submucus fibroids can normally be resected hysteroscopically but intramural and subserosal fibroids require an abdominal approach. Laparoscopic myomectomy has been demonstrated as a feasible procedure in a number of observational studies. The large spectrum of fibroid size and location, difficulty with morcellation and removal, and the technical requirements of suturing make the procedure difficult to perform. These difficulties also complicate clinical outcome based evaluation. A 2009 meta-analysis of 6 randomized trials has looked at the outcomes between laparoscopic and open myomectomy. Laparoscopic myomectomy was associated with significantly lower haemoglobin drop and blood loss, higher rate of patients fully recovered at day 15, lower pain but at a cost of longer operation time. There was no difference in the rate of major complication (defined as life-threatening perioperative condition, risks of major functional sequelae or events resulting in temporary inability to return to normal working life for at least 3 months or major additional surgical procedure during the same or a second anaesthesia). There was also no difference in the recurrence and pregnancy rates between the two groups. On the other hand it may not be possible to remove multiple fibroids through the same incision and the surgeon looses the
Laparoscopic surgery for pelvic organ prolapse The traditional approach to treating pelvic organ prolapse has been to correct it vaginally, using vaginal hysterectomy and repairs of cystocele, rectocele, enterocoele and the vaginal vault. These procedures have few complications and are relatively easy to perform, however they have a relatively high recurrence rate, with the risk of having to have repeat surgery reported to be as high as 29%. To overcome the problem of recurrence, synthetic, nonabsorbable meshes have been developed that allow the surgeon to reinforce weak tissues and repair fascial defects. Meshes have been used to repair prolapse via both the abdominal and vaginal route, and recently specifically shaped meshes with needle systems for placing them have been developed to repair anterior, posterior and vaginal vault prolapse. Reported short term recurrence rates are much less than with conventional surgery (<4%). A major issue with the use of synthetic meshes in the repair of prolapse is mesh erosion. This has been reported to be as high as 12% in vaginal procedures and can be difficult to manage. Recent concerns have led to withdrawal of some transvaginal meshes from the market following FDA review in the USA. If the repair is carried out laparoscopically without opening the vaginal vault, the erosion rate can be reduced to 1e2%. The laparoscopic route also has the additional benefit of not shortening or narrowing the vagina. Procedures that are used commonly include laparoscopic sacrocolpopexy with or without sub-total hysterectomy and laparoscopic paravaginal repairs.
RCOG UK hysterectomy audit All hysterectomy operations in UK between October 1994 and September 1995 in 343 hospitals C 36 000 hysterectomy procedures C 3% laparoscopic C 20% vaginal Table 2
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a
b
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a Diagram of uterine fibroid positions; b a fundal uterine fibroid; c an MRI of uterine fibroids. Figure 1
Laparoscopic surgery for endometriosis
endometriotic cysts and deep nodular lesions. Laparoscopy and biopsy remain the gold standard for diagnosis; however, the skill of the surgeon is crucial to achieving an accurate diagnosis. The surgeon who does not perform laparoscopic surgery routinely will certainly diagnose typical endometriotic lesions, but risks missing a substantial amount of subtle disease. The laparoscopic surgeon should therefore adhere to a systematic approach and meticulous method of evaluating the pelvis to ensure complete diagnosis of endometriosis. The laparoscope affords the surgeon the capability of altering the field of view, depending upon the proximity of the laparoscope to the tissue (Figure 3aec). The definitive treatment of endometriosis for both pelvic pain and fertility is through laparoscopic excision or vaporization of the endometriotic tissue. For fertility, this was demonstrated through the Canadian Collaborative Group in Endometriosis who carried out a randomized controlled trial to determine whether laparoscopic surgery enhanced pregnancy rates in infertile
The diagnosis of endometriosis is based on the presence of endometrial-like tissue outside the uterine cavity. Clinically, three entities can be distinguished: peritoneal implants,
Figure 2 Tubal pregnancy.
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a
b
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a Endometriosis on utero-sacral ligament; b bilateral ovarian endometriosis with pelvic adhesions; c endometriosis on diaphragm. Figure 3
women with minimal or mild endometriosis. They concluded that laparoscopic resection or ablation of minimal and mild endometriosis enhances pregnancy rates in infertile women (cumulative probabilities, 30.7% in the treated group and 17.7% in the untreated group). Clinically, the most difficult form of endometriosis to diagnose and treat is deep infiltrating disease. Koninckx described three types of lesion (Figure 4), as follows: Type 1: large lesion in the peritoneal cavity, infiltrating conically with deeper parts becoming progressively smaller. It has been suggested that this type of endometriosis is caused by infiltration. Type 2: the main feature in this type of lesion is that the bowel is retracted over the lesion, the latter becoming situated in the rectovaginal septum, although not really infiltrating it. Type 3: the deepest and most severe lesions. They are spherically shaped, situated deep in the rectovaginal septum, and are often only visible as a small typical lesion at laparoscopy. This lesion is often more palpable than visible, originates from the rectovaginal septum tissue, and consists essentially of smooth muscle with active glandular epithelium and scanty stroma. Laparoscopic excision of this severe form of endometriosis requires significant skill. It is essential that the patient’s bowel is appropriately prepared before the operation as there is a significant possibility that the rectum will have to be opened to excise the disease completely. It is therefore likely that this degree of skill will only exist in a small number of centres nationally. These centres should therefore be identified to allow regional and national referral. In line with Clinical Governance, centres
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undertaking this highly skilled surgery should produce figures to demonstrate the numbers of cases being performed, along with their success and complication rates.
Laparoscopic surgery and infertility management The success rates, based upon clinical pregnancies, of assisted reproductive technologies (ART) have improved over the last 10 years. Operative endoscopy has also, however, made significant advances, thereby ensuring its place in the ongoing management of infertility. ART bypasses pelvic pathology to attempt to obtain a pregnancy. Surgical approaches, however, improve natural fertility by correcting pathological conditions, for example endometriosis and adhesions. By correcting them, the patient improves their fertility and also potentially improves other related symptoms such as pain. After surgery, couples can have unlimited attempts to conceive naturally without being subject to the risk of multiple pregnancies and ovarian hyperstimulation, stress and cost associated with ART.
Laparoscopic surgery in gynaecological oncology Over the last decade, laparoscopic surgery has become an acceptable alternative for the treatment of women with early stage endometrial carcinoma. Several studies have attested to the feasibility and safety of laparoscopic surgery among select groups of women with endometrial carcinoma, not only for hysterectomy but also for lymphadenectomy when indicated. A 2012 review from Nezhat et al. has looked at surgical management of early stage endometrial cancer from 1950 to 2011 and compared the abdominal versus laparoscopic route. Patients who were
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type 1
type 2
type 3
Types of deep infiltrating lesions. Figure 4
treated laparoscopically had less blood loss, fewer complications, a shorter length of stay but longer operating room times. There was no difference in the number of lymph nodes removed. More importantly there was also no difference in recurrence or survival. The conclusion is that laparoscopy should be the standard of care for surgical management of early stage endometrial cancer. Early stage cervical cancer is usually treated with radical hysterectomy which is classically performed openly. Laparoscopic radical hysterectomy has been described 1992 but the development of minimal-invasive technique for cervical cancer has remained very slow. Small observational studies have suggested a potential benefit in terms of perioperative morbidities. There is currently no long-term data available. Robot-assisted laparoscopic procedures for gynaecologic malignancies has emerged as a new treatment option but robust data confirming safety, benefit and cost-effectiveness remain to be published.
difference in major morbidity between the two groups. Minor morbidity was significantly less in the laparoscopy group (odds ratio 1.89); 95% confidence intervals (CI 1.38, 2.59), and the duration of operation was about 5 minutes shorter in the laparoscopy group (MD 5.34; 95% CI 4.52, 6.16). Litigation following laparoscopic sterilization may result due to a complication of the procedure or, more often, as a result of failure of the technique. Although we all almost universally advise patients of the risk of failure of the procedure and the potential complications of the operation, such a disclaimer does not prevent legal action because the surgeon owes a duty of care to the patient, and inappropriate or unacceptable surgery will therefore result in litigation. Appropriate preoperative planning, correct patient selection and the use of suitably skilled surgeons carrying out or supervising the procedure should decrease the litigation following this and other laparoscopic procedures. Table 3 lists the major complications that arise with operative laparoscopies. The majority arise because of: Difficulties obtaining a pneumoperitoneum. Bleeding, usually as a result of accessory trocars. Problems with ectopic pregnancies. Most complications of minimal access surgery can be avoided with good technique. Where patients are known to be at risk, they must be fully informed of all complications, and the operation should be carried out by a senior, appropriately trained surgeon. A 9-year survey of seven French laparoscopic centres, including 29,966 diagnostic and operative laparoscopies, showed similar results to those in Table 1. As might be expected, this survey found that the complication rate correlated significantly with the complexity of the procedure (P < 0.0001), with one out of four of the complications not being diagnosed during surgery. This survey also showed that increased experience of the surgeons had three consequences: a statistically significant
Litigation and laparoscopic surgery As the volume of laparoscopic procedures increases, so does the number of actions for negligence against the surgeon. Complications following laparoscopic surgery may arise from poor technique, poor judgement, inadequate instrumentation or misadventure. Most complications have occurred during operative laparoscopic procedures (rate 17.9/1000). However, as more diagnostic laparoscopic procedures (complication rate 2.7/1000) and sterilization procedures (complication rate 4.5/1000) are carried out, it is these simple procedures that tend to account for most of the overall litigation. A Cochrane database comparison of laparoscopic sterilization compared with mini-laparotomy concluded that there was no
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or supra-pubic insertion with or without visualization with a laparoscope. Surgeons carrying out laparoscopic surgery should familiarize themselves with these different methods so that the most appropriate can be used as necessary. The loss or partial loss of the pneumoperitoneum during surgery can result in an increased risk of complications. Restricting the operator’s view of the surgical field can result in an inability to secure haemostasis or repair trauma to the bowel which is now closer to the end of the laparoscope. This loss of pneumoperitoneum may be the result of defective equipment (e.g. leaking trocar valves) or due to the continuous suction necessary to remove blood/smoke from the pelvis. The development of high flow insufflators capable of insufflating up to 30 l/min has helped greatly and proved to be essential for certain procedures, especially those involving the use of lasers where continuous smoke extraction is necessary.
Major complication per 1000 operative laparoscopies By instrument Verres needle Large trocar Accessory trocar Electrocautery Laser Pneumoperitoneum By site of injury Vessel/bleeding Bowel Genitourinary Nerve Uterine perforation Other indicators Death Hospitalization Hospital readmission Persistent beta-hCG titres Infection Febrile
2.7 2.4e2.7 2.5e6.0 0.5e2.8 1.2 7.4 2.6e11.0 0.6e2.0 0.6e1.6 6.1 3.7 0.05e0.3 472 h 4.2e27.0 3.1e5.0 63.2e144.0 1.4e6.5 2.0
Injury to bowel when creating pneumoperitoneum or during insertion of trocar Inadvertent injury to the bowel on insertion of the Veress needle or trocar should be avoided in patients without a history of previous surgery. Obese patients, thin patients and those who have had previous abdominal surgery are most at risk. Bowel injury by the Veress needle is usually insignificant and closes spontaneously, but unrecognized injury with a trocar can lead to faecal peritonitis and potential death. Confirmation of peritoneal entry by the Veress needle can be obtained by a number of tests. The syringe test is the most popular; this involves attaching a 10-ml syringe filled with saline to the Veress needle, and injecting 5 ml into the peritoneal cavity. The syringe plunger is then withdrawn. No aspirate should be obtained if the needle is in the correct place as the fluid will have dispersed between loops of bowel. If the needle lies in the abdominal wall, clear fluid will be obtained, but if the aspirate is stained red or brown, perforation of the bowel or a blood vessel has probably occurred.
Table 3
decrease in the number of bowel injuries (P <0.0003); a significant decrease in the number of conversions to laparotomy (P < 0.01); and a change in the way that complications were managed, with more being managed by laparoscopy (P < 0.0001). Recommendations from a medical defence perspective for minimizing risk include the following: Advising the patient of the risks and benefits of laparoscopic procedures and discuss alternatives, including conventional surgery. Discuss the risk of failure with laparoscopic sterilization and record this in the notes. Careful post-operative monitoring and prompt investigation of suspected sepsis. Make sure patients know what signs of post-operative complications to look out for and what steps to take following discharge from the hospital. Adequate training and supervision before carrying out laparoscopic surgery independently. Only delegate procedures to those with an appropriate level of skill.
Vascular injuries Whereas some gastrointestinal injuries at laparoscopy may be unavoidable, the majority of injuries to the great vessels of the abdomen and pelvis should be avoidable. The usual sites of trauma to the large vessels are the terminal aorta near its bifurcation and the common iliac arteries. The vena cava and the iliac veins may also be lacerated and may be more difficult to repair. In thin women, the distance between the umbilicus and the aortic bifurcation may be less than 3 cm, and the umbilicus is directly over the bifurcation in 53% of women. The Veress needle and the trocar should be inserted with the patient in a flat position and not in the Trendelenburg position, since this displaces the umbilicus upwards, brings the common iliac vessels closer to the horizontal plane, and decreases the distance between the umbilicus and the aortic bifurcation. Injury to the inferior epigastric vessels is the most common vascular injury at operative laparoscopy. Inferior epigastric vessels are adjacent to the umbilical ligament and beneath the lateral margin of the rectus muscle. The inferior epigastric vessels can be seen through the laparoscope intra-abdominally.
Difficulties with obtaining and maintaining a pneumoperitoneum Difficulties in establishing a satisfactory pneumoperitoneum can occur, particularly in obese patients. Superficial introduction of the needle can lead to extraperitoneal insufflation and emphysema, which can dissect the peritoneum from the posterior rectus sheath and limit entry into the peritoneal cavity. If the standard umbilical entry fails because of the patient’s obesity, or the approach is inappropriate because of previous abdominal surgery or the presence of a large pelvic mass (including pregnancy), alternative techniques can be used. These include open laparoscopy, passage of the needle through the posterior cul-desac or the uterine fundus, introduction in the left upper quadrant
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Placement of trocars lateral to these regions will minimize the risk of injury.
They must attend an approved course and be observed and declared competent by a preceptor. These skills should be acquired during all gynaecological training programmes. Level 2 is Intermediate-level Endoscopy (previously classified as Level 3). This level is concerned with intermediate-level procedures in laparoscopic surgery involving the tubes, ovaries, mild peritoneal endometriosis and laparoscopic-assisted hysterectomies. Demonstration of competence in these areas is not compulsory, but it is expected that all who undertake this type of minimal access surgery can demonstrate that they have been appropriately trained in the procedures they undertake, and have attended an appropriate course and have been accredited competent by an approved RCOG preceptor. These techniques require additional skills above those acquired in routine training, and are best achieved as a special-interest module in an appropriate surgical centre as part of the training programme. Special skills modules in laparoscopic and hysteroscopic surgery have just been introduced by the RCOG to allow trainees to undergo a formalized training in laparoscopic surgery to a level that is the equivalent of the Level 2 certification. Level 3 is set as Advanced-level Endoscopy (previously classified as Level 4), that will encompass a number of different areas such as oncology, urogynaecology, reproductive medicine and pelvic dysfunction. Due to the expertise needed in each area, it has been suggested that it would be ‘both inappropriate and impractical to expect any individual to become competent in all areas’. There is, as yet, no agreed mechanism for training and accreditation in any of these advanced endoscopic procedures. Each of these groups requires complex surgical, particularly laparoscopic, skills that need considerable time to acquire. Specialist training in endoscopic surgery now takes place in the form of Advanced Training Skills Modules (ATSM) through the RCOG in association with the British Society of Gynaecological Endoscopy (BSGE). The intermediate laparoscopy skills ATSM (achievable in 1 year) and the advanced laparoscopy skills ATSM (achievable in 2 years) are available. Registration and completion of these modules depend on availability and opportunity of an approved preceptor which can vary depending on the Deanery. Alternative options include undertaking a specialized fellowship post (in the UK or abroad) either as time out of programme (OOPE) or after completion of specialist training. In addition to this it is also possible to undertake an MSc in endoscopic surgery. As at other levels of training, RCOG-approved preceptors and courses should be identified. The numbers requiring such specialized training would be small and should perhaps be provided on a national basis. Training should be from within a given subspecialty, but with help, where appropriate, from other specialities.
Training Training in general obstetrics and gynaecology has changed significantly over the past 10 years. With the introduction of the Calman training system, and more recently the European Working Time Directive, trainees have made significant gains in quality of life, but have also lost some important aspects of training. Working hours have been reduced and training is now structured and includes a specific appraisal programme. In order to comply with the European Working Time Directive, which forms part of health and safety law, working patterns have had to be changed, with most trainees working a ‘shift’ pattern rather than the old ‘on-call’ system. These changes have lead to a reduction in the time available for training as conflicts inevitably arise between service provision and training. Trainees have also lost the close working relationships they once had with individual consultants as the NHS service has become increasingly consultant based as opposed to consultant led. Training in laparoscopic surgery varies considerably across the UK. Twenty years ago, most consultant gynaecologists could perform practically all operations in gynaecology. Today, however, with the increase in minimal access surgery, a significant proportion of senior gynaecologists have limited experience in this area. This results in an inability to ‘train’ their juniors in these procedures. In 1994, the Royal College of Obstetricians and Gynaecologists (RCOG) published the report from its Working Party on ‘Training in Gynaecological Endoscopic Surgery’. The report was produced partly because endoscopic surgery was becoming an increasingly important component of gynaecological surgery, and partly because of surgical complications resulting from these procedures. The Working Party felt that training in endoscopic surgery would begin with conventional open surgery, and then subsequently proceed to laparoscopic surgical techniques. If trainees did not demonstrate an aptitude, they should not progress. The award of a certificate of completion of specialized training (CCST) at the end of 5 years of general training would include a statement that competence up to a certain level in endoscopic surgery had been achieved. In 1994, the various laparoscopic and hysteroscopic procedures were divided into four levels, with the skills required for Levels 1 and 2 being assessed at the place of work by the MRCOG trainer as an integral part of the formative and summative assessment for the membership examination. The acquisition of skills for Level 3 and 4 procedures was not necessarily a prerequisite for the membership examination or CCST. Those who wished to attain the necessary skills would be expected to attend RCOG-recognized advanced courses, obtain expert supervision by a preceptor recognized by the RCOG, and be involved in compulsory audit. The classification then changed with the introduction of three levels of competence. Level 1 is Basic-level Endoscopy (previously classified as Levels 1 and 2). This is concerned with basic diagnostic and elementary operative hysteroscopic and laparoscopic techniques. Every candidate for the MRCOG examination must demonstrate knowledge and practical competence in procedures at this level.
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Laparoscopic training: virtual reality as an option for the future? Recent studies investigating the effectiveness of computer-based virtual training models have been encouraging. These experimental settings show a high-quality surgeonecomputer interface and might be useful in assessing the laparoscopic skills of a surgeon. Another development that is closely related to this virtual technique is the use of microsurgical robots in laparoscopy,
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Royal College of Obstetrics and Gynaecology. Hysterectomy audit. UK, 1995. Sutton C, Diamond M, eds. Endoscopic surgery for gynaecologists. London: W.B. Saunders Company, 2000. Sutton C, Philips K. RCOG green-top guideline 49. Preventing entry related gynaecological laparoscopic injuries, May 2008. Tulandi T, ed. Atlas of laparoscopic and hysteroscopic techniques for gynecologists. 2nd edn. London: W.B. Saunders Company, 1999.
although because of the limited availability and high costs involved, this application remains experimental.
Conclusion Over the past 20 years, technology has allowed minimal access surgery to progress at a rapid rate. The development of superior light sources and microchip video cameras has resulted in superior imaging of the operative field, allowing ever-increasing precision, far greater than could be expected at open surgery. Current work on the use of three-dimensional technology, integrated minimal access theatre suites, new methods of suturing and new generations of lasers will continue to advance the field. However, the major challenge facing laparoscopic surgery is training. Unlike the general gynaecologist of 20 years ago, current gynaecologists would not and should not be expected to be able to undertake most gynaecological operations. The establishment of an approved national training programme with a small number of audited, specialized centres to which the most complex cases are referred will hopefully be established soon. Through training and audit, the confidence and experience both inside the profession and within the public will grow, resulting in the minimal access approach as the preferred option of choice.A
TRAINING INFORMATION British Society for Gynaecological Endoscopy. http://www.bsge.org.uk. Royal College of Obstetricians & Gynaecologists. http://www.rcog.org.uk, http://www.rcog.org.uk/curriculum-module/atsm-benigngynaecologicalsurgery-laparoscopy.
Practice points Benefits C Less post-operative morbidity, shorter hospital stay and quicker return to work C Magnification allows for greater surgical precision C Most procedures that are carried out through a laparotomy can now be performed by laparoscopy
FURTHER READING Asch R, Studd J. In: Nezhat CR, Nezhat F, Nezhat CH, eds. Progress in reproductive medicine. New York: Parthenon Publishing, 1996. Claims analyses. MDU J January 2009; 25: 18e20. Cofman RS, Diamond MP, De Cherney A. Complications of laparoscopy and hysteroscopy. Oxford: Blackwell Scientific Publications, 1993. Kononickx PD. Deeply infiltrating endometriosis. In: Brosens I, Donnez J, eds. Endometriosis: research and management. New York: Parthenon Publishing, 1994; 437e446. Royal College of Obstetrician and Gynaecology. MAS training subcommittee recommendations. Arch Gynecol Obstet March 2011; 283: 509e12.
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Problems C Operative laparoscopy, however, requires a higher degree of technical training and skill C A lack of skill or training can result in increasing medico legal claims Solutions C Structured RCOG/BSGE training programme for advanced laparoscopic skills C Development of regional centres for more advanced surgical cases
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Laparoscopy and laparoscopic surgery
Alex Swanton MD MRCOG Consultant Gynaecologist, Royal Berkshire Hospital, Reading, UK. Conflicts of interest: none declared.
most hysterectomies are performed for benign conditions, the choice of route almost entirely depends upon the surgeon’s skill and experience. Avoiding a laparotomy in the appropriately chosen patient is without doubt beneficial. The 2009 Cochrane review has looked at the evidence for which route is best for performing hysterectomy. The conclusions were that the vaginal route is best. In patients whom the vaginal route is not possible, laparoscopic hysterectomy has benefits over the abdominal route. The benefits of laparoscopic hysterectomy versus abdominal hysterectomy were lower intra-operative blood loss (mean difference (MD) 45.3 ml, 95% CI 17.9e72.7 ml) and a smaller drop in haemoglobin level (WMD 0.55 g/L, 95% CI 0.28e0.82 g/L), shorter duration of hospital stay (MD 2.0 days, 95% CI 1.9e2.2 days), speedier return to normal activities (MD 13.6 days, 95% CI 11.8e15.4 days), fewer wound or abdominal wall infections (OR 0.31, 95% CI 0.12e0.77), fewer unspecified infections or febrile episodes OR 0.67, 95% CI 0.51e0.88), at the cost of longer operating time (MD 11.8 minutes, 95% CI 8.6e14.9 minutes) and more urinary tract (bladder or ureter) injuries (OR 2.41, 95% CI 1.21e4.82). There was no significant difference in the following long-term complications: fistula formation and urinary dysfunction. There was no benefit in performing a total laparoscopic hysterectomy over a laparoscopically assisted vaginal hysterectomy. In those patients where a vaginal hysterectomy is contraindicated or not technically possible, the default should therefore be to use a laparoscopic approach. The first hysterectomy using only laparoscopic techniques was performed in 1988 by Harry Reich. Other milestones are shown in Table 1. Total laparoscopic hysterectomy can be a technically difficult procedure to perform. A number of alternative laparoscopic techniques to perform all or some of the hysterectomy have therefore been introduced to simplify the procedure, but retain the major advantages of the approach, i.e. avoidance of a laparotomy wound. Laparoscopic sub-total hysterectomy is becoming an increasingly common procedure and some units have reported success in performing it as a day case. A recent Cochrane review has shown that sub-total hysterectomy is not superior to total hysterectomy in terms of sexual, urinary or bowel function. The advantages of this approach have been well documented, but the laparoscopic route has been little used by general gynaecologists to date. Although it has been possible to reduce the laparotomy rate for hysterectomy to 10% in some units, there is evidence from the UK (Table 2) and the USA that more than 70% of all hysterectomies are still being performed by laparotomy. More recently robot-assisted laparoscopic hysterectomy has emerged as a new technique to perform hysterectomy. Instead of directly moving the instruments, the surgeon uses a robotic device to control them. There is currently no evidence that this technique is superior to the laparoscopic/vaginal routes for benign conditions. Further research will be needed to determine any advantage.
Nicolas Vulliemoz MD is Subspecialist in Reproductive Medicine and Surgery at the Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women’s Centre, The John Radcliffe Hospital, Oxford, UK. Conflicts of interest: none declared.
Myomectomy Uterine fibroids are responsible for a wide variety of symptoms, including menorrhagia, pain/pressure symptoms, urinary tract symptoms and have been implicated in subfertility. The
Alex Swanton Nicolas Vulliemoz
Abstract Today, laparoscopy is an alternative technique for carrying out many operations that have traditionally required an open approach. The benefits of minimal access surgery have been well recorded, including lower postoperative morbidity, shorter duration of hospital stay and a shorter return to work. Advances in technology, specifically in fibre optics and video imaging, have made the relatively recent rapid progress in laparoscopic surgery possible. Operative laparoscopy, however, requires a high degree of technical skill and training. The use of small instruments and imaging systems that provide magnification allow for the high degree of precision that can be achieved with laparoscopic surgery. This is often difficult to obtain by a conventional laparotomy, as magnification is not available and the surgeon’s hands and large instruments often obscure the operative field. It is this precision that has lead to advances in the treatment of conditions such as endometriosis, adhesions and in the field of reproductive surgery. It is unfortunate however that in reality very few major gynaecological procedures are performed laparoscopically. They are technically difficult and require the surgeon to master a whole new set of surgical skills and in effect to return to the bottom of the surgical learning curve. A wide range of simple laparoscopic procedures needs to be mastered to develop the hand eye coordination required to perform complex tasks. These procedures need to be performed on a regular basis to maintain skills and only when these skills can be regularly performed accurately can complex surgical tasks be carried out. As a result of this, most established gynaecologists have very little time and resources to be able to retrain in what is essentially a new surgical field, although most experts throughout the country agree that the vast majority of gynaecological surgery could safely and efficiently be performed laparoscopically.
Keywords laparoscopic surgery; laparoscopy; minimal access surgery
Current practice Hysterectomy Hysterectomy remains one of the most common gynaecological inpatient procedures. About 60,000 hysterectomies are performed every year in the UK and over 600,000 in the US. Since
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ability to palpate the uterine tissue, detecting smaller fibroids. It may also be more difficult to approximate myometrial and serosal tissues, leading to poor healing of the uterine wall potentially leading to complications in future pregnancies. A recent survey of UK gynaecologists revealed that just over 10% performed laparoscopic myomectomies as part of their normal practice.
Milestones in hysterectomy First vaginal hysterectomy First abdominal hysterectomy Cautery to cervical stump Definition of sub-total technique Low transverse incision Myomectomy Total hysterectomy Dominance of total hysterectomy Endometrial ablation Laparoscopic hysterectomy Intra-uterine levonorgestrel
Langenbeck (1810) Clay (1843) Keith (1880) Kelly (1896) Pfannenstiel (1900) Bonney (1920) Richardson (1929) (1940s and 50s) de Cherney, Hamou (1980s) Reich (1988) Nilsson (1977)
Ectopic pregnancy (Figure 2) It is now accepted that minimal access surgery provides the best and most efficient method of treating ectopic pregnancies (RCOG Grade A recommendation). However, gynaecologists in the UK have been slow to establish laparoscopic management of ectopic pregnancies as standard practice. A recent audit on the management of ectopic pregnancy in a Scottish teaching hospital showed that only 62% of cases were managed laparoscopically compared with over 90% in France. This disappointingly low rate in the UK is most likely to be the result of a lack of training among junior staff. Hospitals have addressed this issue by: Identifying experienced surgeons willing to be available to train and supervise juniors. Establishing emergency gynaecological clinics with vaginal ultrasound and serum beta human chorionic gonadotrophin measurements. Where these measures have been taken, the result is that the vast majority of ectopic pregnancies can be managed laparoscopically during normal working hours with senior input readily available.
Table 1
management of fibroids depends on the patient’s symptoms and the location of the fibroid in the uterus (Figure 1). Asymptomatic patients can be managed conservatively and those in whom fertility is not an issue can be managed medically or by hysterectomy. Where fertility needs to be conserved, myomectomy is the treatment of choice. Submucus fibroids can normally be resected hysteroscopically but intramural and subserosal fibroids require an abdominal approach. Laparoscopic myomectomy has been demonstrated as a feasible procedure in a number of observational studies. The large spectrum of fibroid size and location, difficulty with morcellation and removal, and the technical requirements of suturing make the procedure difficult to perform. These difficulties also complicate clinical outcome based evaluation. A 2009 meta-analysis of 6 randomized trials has looked at the outcomes between laparoscopic and open myomectomy. Laparoscopic myomectomy was associated with significantly lower haemoglobin drop and blood loss, higher rate of patients fully recovered at day 15, lower pain but at a cost of longer operation time. There was no difference in the rate of major complication (defined as life-threatening perioperative condition, risks of major functional sequelae or events resulting in temporary inability to return to normal working life for at least 3 months or major additional surgical procedure during the same or a second anaesthesia). There was also no difference in the recurrence and pregnancy rates between the two groups. On the other hand it may not be possible to remove multiple fibroids through the same incision and the surgeon looses the
Laparoscopic surgery for pelvic organ prolapse The traditional approach to treating pelvic organ prolapse has been to correct it vaginally, using vaginal hysterectomy and repairs of cystocele, rectocele, enterocoele and the vaginal vault. These procedures have few complications and are relatively easy to perform, however they have a relatively high recurrence rate, with the risk of having to have repeat surgery reported to be as high as 29%. To overcome the problem of recurrence, synthetic, nonabsorbable meshes have been developed that allow the surgeon to reinforce weak tissues and repair fascial defects. Meshes have been used to repair prolapse via both the abdominal and vaginal route, and recently specifically shaped meshes with needle systems for placing them have been developed to repair anterior, posterior and vaginal vault prolapse. Reported short term recurrence rates are much less than with conventional surgery (<4%). A major issue with the use of synthetic meshes in the repair of prolapse is mesh erosion. This has been reported to be as high as 12% in vaginal procedures and can be difficult to manage. Recent concerns have led to withdrawal of some transvaginal meshes from the market following FDA review in the USA. If the repair is carried out laparoscopically without opening the vaginal vault, the erosion rate can be reduced to 1e2%. The laparoscopic route also has the additional benefit of not shortening or narrowing the vagina. Procedures that are used commonly include laparoscopic sacrocolpopexy with or without sub-total hysterectomy and laparoscopic paravaginal repairs.
RCOG UK hysterectomy audit All hysterectomy operations in UK between October 1994 and September 1995 in 343 hospitals C 36 000 hysterectomy procedures C 3% laparoscopic C 20% vaginal Table 2
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a
b
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a Diagram of uterine fibroid positions; b a fundal uterine fibroid; c an MRI of uterine fibroids. Figure 1
Laparoscopic surgery for endometriosis
endometriotic cysts and deep nodular lesions. Laparoscopy and biopsy remain the gold standard for diagnosis; however, the skill of the surgeon is crucial to achieving an accurate diagnosis. The surgeon who does not perform laparoscopic surgery routinely will certainly diagnose typical endometriotic lesions, but risks missing a substantial amount of subtle disease. The laparoscopic surgeon should therefore adhere to a systematic approach and meticulous method of evaluating the pelvis to ensure complete diagnosis of endometriosis. The laparoscope affords the surgeon the capability of altering the field of view, depending upon the proximity of the laparoscope to the tissue (Figure 3aec). The definitive treatment of endometriosis for both pelvic pain and fertility is through laparoscopic excision or vaporization of the endometriotic tissue. For fertility, this was demonstrated through the Canadian Collaborative Group in Endometriosis who carried out a randomized controlled trial to determine whether laparoscopic surgery enhanced pregnancy rates in infertile
The diagnosis of endometriosis is based on the presence of endometrial-like tissue outside the uterine cavity. Clinically, three entities can be distinguished: peritoneal implants,
Figure 2 Tubal pregnancy.
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a
b
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a Endometriosis on utero-sacral ligament; b bilateral ovarian endometriosis with pelvic adhesions; c endometriosis on diaphragm. Figure 3
women with minimal or mild endometriosis. They concluded that laparoscopic resection or ablation of minimal and mild endometriosis enhances pregnancy rates in infertile women (cumulative probabilities, 30.7% in the treated group and 17.7% in the untreated group). Clinically, the most difficult form of endometriosis to diagnose and treat is deep infiltrating disease. Koninckx described three types of lesion (Figure 4), as follows: Type 1: large lesion in the peritoneal cavity, infiltrating conically with deeper parts becoming progressively smaller. It has been suggested that this type of endometriosis is caused by infiltration. Type 2: the main feature in this type of lesion is that the bowel is retracted over the lesion, the latter becoming situated in the rectovaginal septum, although not really infiltrating it. Type 3: the deepest and most severe lesions. They are spherically shaped, situated deep in the rectovaginal septum, and are often only visible as a small typical lesion at laparoscopy. This lesion is often more palpable than visible, originates from the rectovaginal septum tissue, and consists essentially of smooth muscle with active glandular epithelium and scanty stroma. Laparoscopic excision of this severe form of endometriosis requires significant skill. It is essential that the patient’s bowel is appropriately prepared before the operation as there is a significant possibility that the rectum will have to be opened to excise the disease completely. It is therefore likely that this degree of skill will only exist in a small number of centres nationally. These centres should therefore be identified to allow regional and national referral. In line with Clinical Governance, centres
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undertaking this highly skilled surgery should produce figures to demonstrate the numbers of cases being performed, along with their success and complication rates.
Laparoscopic surgery and infertility management The success rates, based upon clinical pregnancies, of assisted reproductive technologies (ART) have improved over the last 10 years. Operative endoscopy has also, however, made significant advances, thereby ensuring its place in the ongoing management of infertility. ART bypasses pelvic pathology to attempt to obtain a pregnancy. Surgical approaches, however, improve natural fertility by correcting pathological conditions, for example endometriosis and adhesions. By correcting them, the patient improves their fertility and also potentially improves other related symptoms such as pain. After surgery, couples can have unlimited attempts to conceive naturally without being subject to the risk of multiple pregnancies and ovarian hyperstimulation, stress and cost associated with ART.
Laparoscopic surgery in gynaecological oncology Over the last decade, laparoscopic surgery has become an acceptable alternative for the treatment of women with early stage endometrial carcinoma. Several studies have attested to the feasibility and safety of laparoscopic surgery among select groups of women with endometrial carcinoma, not only for hysterectomy but also for lymphadenectomy when indicated. A 2012 review from Nezhat et al. has looked at surgical management of early stage endometrial cancer from 1950 to 2011 and compared the abdominal versus laparoscopic route. Patients who were
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type 1
type 2
type 3
Types of deep infiltrating lesions. Figure 4
treated laparoscopically had less blood loss, fewer complications, a shorter length of stay but longer operating room times. There was no difference in the number of lymph nodes removed. More importantly there was also no difference in recurrence or survival. The conclusion is that laparoscopy should be the standard of care for surgical management of early stage endometrial cancer. Early stage cervical cancer is usually treated with radical hysterectomy which is classically performed openly. Laparoscopic radical hysterectomy has been described 1992 but the development of minimal-invasive technique for cervical cancer has remained very slow. Small observational studies have suggested a potential benefit in terms of perioperative morbidities. There is currently no long-term data available. Robot-assisted laparoscopic procedures for gynaecologic malignancies has emerged as a new treatment option but robust data confirming safety, benefit and cost-effectiveness remain to be published.
difference in major morbidity between the two groups. Minor morbidity was significantly less in the laparoscopy group (odds ratio 1.89); 95% confidence intervals (CI 1.38, 2.59), and the duration of operation was about 5 minutes shorter in the laparoscopy group (MD 5.34; 95% CI 4.52, 6.16). Litigation following laparoscopic sterilization may result due to a complication of the procedure or, more often, as a result of failure of the technique. Although we all almost universally advise patients of the risk of failure of the procedure and the potential complications of the operation, such a disclaimer does not prevent legal action because the surgeon owes a duty of care to the patient, and inappropriate or unacceptable surgery will therefore result in litigation. Appropriate preoperative planning, correct patient selection and the use of suitably skilled surgeons carrying out or supervising the procedure should decrease the litigation following this and other laparoscopic procedures. Table 3 lists the major complications that arise with operative laparoscopies. The majority arise because of: Difficulties obtaining a pneumoperitoneum. Bleeding, usually as a result of accessory trocars. Problems with ectopic pregnancies. Most complications of minimal access surgery can be avoided with good technique. Where patients are known to be at risk, they must be fully informed of all complications, and the operation should be carried out by a senior, appropriately trained surgeon. A 9-year survey of seven French laparoscopic centres, including 29,966 diagnostic and operative laparoscopies, showed similar results to those in Table 1. As might be expected, this survey found that the complication rate correlated significantly with the complexity of the procedure (P < 0.0001), with one out of four of the complications not being diagnosed during surgery. This survey also showed that increased experience of the surgeons had three consequences: a statistically significant
Litigation and laparoscopic surgery As the volume of laparoscopic procedures increases, so does the number of actions for negligence against the surgeon. Complications following laparoscopic surgery may arise from poor technique, poor judgement, inadequate instrumentation or misadventure. Most complications have occurred during operative laparoscopic procedures (rate 17.9/1000). However, as more diagnostic laparoscopic procedures (complication rate 2.7/1000) and sterilization procedures (complication rate 4.5/1000) are carried out, it is these simple procedures that tend to account for most of the overall litigation. A Cochrane database comparison of laparoscopic sterilization compared with mini-laparotomy concluded that there was no
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or supra-pubic insertion with or without visualization with a laparoscope. Surgeons carrying out laparoscopic surgery should familiarize themselves with these different methods so that the most appropriate can be used as necessary. The loss or partial loss of the pneumoperitoneum during surgery can result in an increased risk of complications. Restricting the operator’s view of the surgical field can result in an inability to secure haemostasis or repair trauma to the bowel which is now closer to the end of the laparoscope. This loss of pneumoperitoneum may be the result of defective equipment (e.g. leaking trocar valves) or due to the continuous suction necessary to remove blood/smoke from the pelvis. The development of high flow insufflators capable of insufflating up to 30 l/min has helped greatly and proved to be essential for certain procedures, especially those involving the use of lasers where continuous smoke extraction is necessary.
Major complication per 1000 operative laparoscopies By instrument Verres needle Large trocar Accessory trocar Electrocautery Laser Pneumoperitoneum By site of injury Vessel/bleeding Bowel Genitourinary Nerve Uterine perforation Other indicators Death Hospitalization Hospital readmission Persistent beta-hCG titres Infection Febrile
2.7 2.4e2.7 2.5e6.0 0.5e2.8 1.2 7.4 2.6e11.0 0.6e2.0 0.6e1.6 6.1 3.7 0.05e0.3 472 h 4.2e27.0 3.1e5.0 63.2e144.0 1.4e6.5 2.0
Injury to bowel when creating pneumoperitoneum or during insertion of trocar Inadvertent injury to the bowel on insertion of the Veress needle or trocar should be avoided in patients without a history of previous surgery. Obese patients, thin patients and those who have had previous abdominal surgery are most at risk. Bowel injury by the Veress needle is usually insignificant and closes spontaneously, but unrecognized injury with a trocar can lead to faecal peritonitis and potential death. Confirmation of peritoneal entry by the Veress needle can be obtained by a number of tests. The syringe test is the most popular; this involves attaching a 10-ml syringe filled with saline to the Veress needle, and injecting 5 ml into the peritoneal cavity. The syringe plunger is then withdrawn. No aspirate should be obtained if the needle is in the correct place as the fluid will have dispersed between loops of bowel. If the needle lies in the abdominal wall, clear fluid will be obtained, but if the aspirate is stained red or brown, perforation of the bowel or a blood vessel has probably occurred.
Table 3
decrease in the number of bowel injuries (P <0.0003); a significant decrease in the number of conversions to laparotomy (P < 0.01); and a change in the way that complications were managed, with more being managed by laparoscopy (P < 0.0001). Recommendations from a medical defence perspective for minimizing risk include the following: Advising the patient of the risks and benefits of laparoscopic procedures and discuss alternatives, including conventional surgery. Discuss the risk of failure with laparoscopic sterilization and record this in the notes. Careful post-operative monitoring and prompt investigation of suspected sepsis. Make sure patients know what signs of post-operative complications to look out for and what steps to take following discharge from the hospital. Adequate training and supervision before carrying out laparoscopic surgery independently. Only delegate procedures to those with an appropriate level of skill.
Vascular injuries Whereas some gastrointestinal injuries at laparoscopy may be unavoidable, the majority of injuries to the great vessels of the abdomen and pelvis should be avoidable. The usual sites of trauma to the large vessels are the terminal aorta near its bifurcation and the common iliac arteries. The vena cava and the iliac veins may also be lacerated and may be more difficult to repair. In thin women, the distance between the umbilicus and the aortic bifurcation may be less than 3 cm, and the umbilicus is directly over the bifurcation in 53% of women. The Veress needle and the trocar should be inserted with the patient in a flat position and not in the Trendelenburg position, since this displaces the umbilicus upwards, brings the common iliac vessels closer to the horizontal plane, and decreases the distance between the umbilicus and the aortic bifurcation. Injury to the inferior epigastric vessels is the most common vascular injury at operative laparoscopy. Inferior epigastric vessels are adjacent to the umbilical ligament and beneath the lateral margin of the rectus muscle. The inferior epigastric vessels can be seen through the laparoscope intra-abdominally.
Difficulties with obtaining and maintaining a pneumoperitoneum Difficulties in establishing a satisfactory pneumoperitoneum can occur, particularly in obese patients. Superficial introduction of the needle can lead to extraperitoneal insufflation and emphysema, which can dissect the peritoneum from the posterior rectus sheath and limit entry into the peritoneal cavity. If the standard umbilical entry fails because of the patient’s obesity, or the approach is inappropriate because of previous abdominal surgery or the presence of a large pelvic mass (including pregnancy), alternative techniques can be used. These include open laparoscopy, passage of the needle through the posterior cul-desac or the uterine fundus, introduction in the left upper quadrant
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Placement of trocars lateral to these regions will minimize the risk of injury.
They must attend an approved course and be observed and declared competent by a preceptor. These skills should be acquired during all gynaecological training programmes. Level 2 is Intermediate-level Endoscopy (previously classified as Level 3). This level is concerned with intermediate-level procedures in laparoscopic surgery involving the tubes, ovaries, mild peritoneal endometriosis and laparoscopic-assisted hysterectomies. Demonstration of competence in these areas is not compulsory, but it is expected that all who undertake this type of minimal access surgery can demonstrate that they have been appropriately trained in the procedures they undertake, and have attended an appropriate course and have been accredited competent by an approved RCOG preceptor. These techniques require additional skills above those acquired in routine training, and are best achieved as a special-interest module in an appropriate surgical centre as part of the training programme. Special skills modules in laparoscopic and hysteroscopic surgery have just been introduced by the RCOG to allow trainees to undergo a formalized training in laparoscopic surgery to a level that is the equivalent of the Level 2 certification. Level 3 is set as Advanced-level Endoscopy (previously classified as Level 4), that will encompass a number of different areas such as oncology, urogynaecology, reproductive medicine and pelvic dysfunction. Due to the expertise needed in each area, it has been suggested that it would be ‘both inappropriate and impractical to expect any individual to become competent in all areas’. There is, as yet, no agreed mechanism for training and accreditation in any of these advanced endoscopic procedures. Each of these groups requires complex surgical, particularly laparoscopic, skills that need considerable time to acquire. Specialist training in endoscopic surgery now takes place in the form of Advanced Training Skills Modules (ATSM) through the RCOG in association with the British Society of Gynaecological Endoscopy (BSGE). The intermediate laparoscopy skills ATSM (achievable in 1 year) and the advanced laparoscopy skills ATSM (achievable in 2 years) are available. Registration and completion of these modules depend on availability and opportunity of an approved preceptor which can vary depending on the Deanery. Alternative options include undertaking a specialized fellowship post (in the UK or abroad) either as time out of programme (OOPE) or after completion of specialist training. In addition to this it is also possible to undertake an MSc in endoscopic surgery. As at other levels of training, RCOG-approved preceptors and courses should be identified. The numbers requiring such specialized training would be small and should perhaps be provided on a national basis. Training should be from within a given subspecialty, but with help, where appropriate, from other specialities.
Training Training in general obstetrics and gynaecology has changed significantly over the past 10 years. With the introduction of the Calman training system, and more recently the European Working Time Directive, trainees have made significant gains in quality of life, but have also lost some important aspects of training. Working hours have been reduced and training is now structured and includes a specific appraisal programme. In order to comply with the European Working Time Directive, which forms part of health and safety law, working patterns have had to be changed, with most trainees working a ‘shift’ pattern rather than the old ‘on-call’ system. These changes have lead to a reduction in the time available for training as conflicts inevitably arise between service provision and training. Trainees have also lost the close working relationships they once had with individual consultants as the NHS service has become increasingly consultant based as opposed to consultant led. Training in laparoscopic surgery varies considerably across the UK. Twenty years ago, most consultant gynaecologists could perform practically all operations in gynaecology. Today, however, with the increase in minimal access surgery, a significant proportion of senior gynaecologists have limited experience in this area. This results in an inability to ‘train’ their juniors in these procedures. In 1994, the Royal College of Obstetricians and Gynaecologists (RCOG) published the report from its Working Party on ‘Training in Gynaecological Endoscopic Surgery’. The report was produced partly because endoscopic surgery was becoming an increasingly important component of gynaecological surgery, and partly because of surgical complications resulting from these procedures. The Working Party felt that training in endoscopic surgery would begin with conventional open surgery, and then subsequently proceed to laparoscopic surgical techniques. If trainees did not demonstrate an aptitude, they should not progress. The award of a certificate of completion of specialized training (CCST) at the end of 5 years of general training would include a statement that competence up to a certain level in endoscopic surgery had been achieved. In 1994, the various laparoscopic and hysteroscopic procedures were divided into four levels, with the skills required for Levels 1 and 2 being assessed at the place of work by the MRCOG trainer as an integral part of the formative and summative assessment for the membership examination. The acquisition of skills for Level 3 and 4 procedures was not necessarily a prerequisite for the membership examination or CCST. Those who wished to attain the necessary skills would be expected to attend RCOG-recognized advanced courses, obtain expert supervision by a preceptor recognized by the RCOG, and be involved in compulsory audit. The classification then changed with the introduction of three levels of competence. Level 1 is Basic-level Endoscopy (previously classified as Levels 1 and 2). This is concerned with basic diagnostic and elementary operative hysteroscopic and laparoscopic techniques. Every candidate for the MRCOG examination must demonstrate knowledge and practical competence in procedures at this level.
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Laparoscopic training: virtual reality as an option for the future? Recent studies investigating the effectiveness of computer-based virtual training models have been encouraging. These experimental settings show a high-quality surgeonecomputer interface and might be useful in assessing the laparoscopic skills of a surgeon. Another development that is closely related to this virtual technique is the use of microsurgical robots in laparoscopy,
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Royal College of Obstetrics and Gynaecology. Hysterectomy audit. UK, 1995. Sutton C, Diamond M, eds. Endoscopic surgery for gynaecologists. London: W.B. Saunders Company, 2000. Sutton C, Philips K. RCOG green-top guideline 49. Preventing entry related gynaecological laparoscopic injuries, May 2008. Tulandi T, ed. Atlas of laparoscopic and hysteroscopic techniques for gynecologists. 2nd edn. London: W.B. Saunders Company, 1999.
although because of the limited availability and high costs involved, this application remains experimental.
Conclusion Over the past 20 years, technology has allowed minimal access surgery to progress at a rapid rate. The development of superior light sources and microchip video cameras has resulted in superior imaging of the operative field, allowing ever-increasing precision, far greater than could be expected at open surgery. Current work on the use of three-dimensional technology, integrated minimal access theatre suites, new methods of suturing and new generations of lasers will continue to advance the field. However, the major challenge facing laparoscopic surgery is training. Unlike the general gynaecologist of 20 years ago, current gynaecologists would not and should not be expected to be able to undertake most gynaecological operations. The establishment of an approved national training programme with a small number of audited, specialized centres to which the most complex cases are referred will hopefully be established soon. Through training and audit, the confidence and experience both inside the profession and within the public will grow, resulting in the minimal access approach as the preferred option of choice.A
TRAINING INFORMATION British Society for Gynaecological Endoscopy. http://www.bsge.org.uk. Royal College of Obstetricians & Gynaecologists. http://www.rcog.org.uk, http://www.rcog.org.uk/curriculum-module/atsm-benigngynaecologicalsurgery-laparoscopy.
Practice points Benefits C Less post-operative morbidity, shorter hospital stay and quicker return to work C Magnification allows for greater surgical precision C Most procedures that are carried out through a laparotomy can now be performed by laparoscopy
FURTHER READING Asch R, Studd J. In: Nezhat CR, Nezhat F, Nezhat CH, eds. Progress in reproductive medicine. New York: Parthenon Publishing, 1996. Claims analyses. MDU J January 2009; 25: 18e20. Cofman RS, Diamond MP, De Cherney A. Complications of laparoscopy and hysteroscopy. Oxford: Blackwell Scientific Publications, 1993. Kononickx PD. Deeply infiltrating endometriosis. In: Brosens I, Donnez J, eds. Endometriosis: research and management. New York: Parthenon Publishing, 1994; 437e446. Royal College of Obstetrician and Gynaecology. MAS training subcommittee recommendations. Arch Gynecol Obstet March 2011; 283: 509e12.
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Problems C Operative laparoscopy, however, requires a higher degree of technical training and skill C A lack of skill or training can result in increasing medico legal claims Solutions C Structured RCOG/BSGE training programme for advanced laparoscopic skills C Development of regional centres for more advanced surgical cases
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