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Virtual reality hysteroscopy
August 1996, Vol. 3, No. 4 Supplement
The Journal of the American Association of Gynecologic Laparoscopists
genitourinary tract damage, and less formation of granulation tissues on the vaginal cuff associated with persistent leukorrhea and postcoital bleeding occurred with TLH, probably because more precise surgery can be done under direct vision. We believe TLH can be performed more safely and quickly than LH by an experienced surgeon. A potential advantage of TLH is less postoperative infection due to less vaginal manipulation. Other advantages are the lengthening of the vagina, less postoperative prolapse of the vagina, and less enterocele development because of more precise ',anatomic restoration of the pelvic structures under direct visualization. Since detailed pelvic structures can be visualized, excised, and restored, TLH has all the possible benefits of subtotal hysterectomy, if any, due to the maximum preservation of supporting structures (cardinal, uterosacral ligaments) and nerve plexus, thus making subtotal hysterectomy obsolete. Further studies and long-term follow-up are required.
Total Laparoscopic Intrafascial Hysterectomy PI Lee. Jeil Women's Hospital, Seoul, Korea.
Bladder and ureteral injuries are associated with several types of hysterectomies performed laparoscopically. Subtotal hysterectomy is said to cause fewer complications and provide better pelvic support by preserving the uterosacral and cardinal ligaments, but there axe also arguments against it. A new technique, total laparoscopic intrafascial hysterectomy (TLIH) has all the benefits of total and subtotal hysterectomies, but fewer complications. Conventionally, uterosacral liganaents are cut at or just below their junction with the cervix, and the remaining vagina and cardinal ligaments are cut at the same level. With TLIH, using a uterine manipulator and colpotomizer, the incision is made at a much higher level. The cervix is circumcised whilLepreserving the entire uterosacral and cardinal ligaments and full length of the vagina, except in cases of raalignancy or severe pelvic endometriosis. The ureter is mobilized farther from the cervix. A longer vagina and excellent pelvic support can be achieved with maximum preservation of the vagina and pelvic supporting structures. A modified McCall culdoplasty and reinforcement of the cardinal ligaments are done, and the vaginal cuff is closed with everted mattress sutures either vertically or transversely. Less granulation tissue is formed on the vaginal vault and postoperative leukorrhea or postcoital vaginal bleeding is
$25
reduced. Moschcowitz culdoplasty or high McCall culdoplasty can be done at the same time to correct or prevent an enterocele or prolapsed vagina.
Teaching Surgical Hysteroscopy with a Computer Y Lefebvre, J Cote, L Lefebvre. Department of Obstetrics and Gynecology, University of Maisonneuve Hospital, University of Montreal, Quebec, Canada.
Using a hysteroscope can be simulated on a computer. It will improve physician training by measuring basic knowledge and abilities, allow different interventions and anatomic variations, minimize the trauma of surgical intervention, and reduce operative casualties. An integrated questionnaire covers instrumentation, fluid infusion, power source, indications and preparation for endometrial ablation, surgical techniques, and complications to evaluate the user's knowledge. The operation simulation then proceeds. In the endometrial cavity, by virtual simulation, the operating field should appear in real time to allow physicians to adapt the trajectory of the instruments. The computer is an IBM PC compatible. We use a modified joystick with optical encoders to know the instrument position. The simulation can be repeated as desired. An evaluation system is integrated in the software to keep the user informed on the amount of burn area(s) that have been completed. This prototype model is available.
Review of 208 Medicolegal Cases over 20 Years CJ Levinson. Stanford University, Menlo Park, CA.
A review of the 208 medicolegal cases sent to me from 1975 to 1995 showed that problems were related to one of the following: indication for surgery, consent, anesthesia, vascular injury, bowel injury, urologic injury, nerve injury, abandonment, and unwanted pregnancies. The cases were categorized as reviewed only, progress with no further action, deposition, settled, and to trial. Approximately 50% of cases did not go to trial.
Virtual Reality Hysteroscopy ]S Levy. Jefferson Medical College, Philadelphia, PA.
New interactive computer technologies are having a significant influence on medical education, training, and practice. The newest innovation in computer technology, virtual reality, allows an individual to be
Selected Scientific Abstracts
One Hundred Twenty-four Laparoscopic-Assisted Vaginal Hysterectomies
immersed in a dynamic computer-generated, threedimensional environment and can provide realistic simulations of surgical procedures. A new virtual reality hysteroscope passes through a sensing device that synchronizes movements with a three-dimensional model of a uterus. Force feedback is incorporated into this model, so the user actually experiences the collision of an instrument against the uterine wall or the sensation of the resistance or drag of a resectoscope as it cuts through a myoma in a virtual environment. A variety of intrauterine pathologies and procedures are simulated, including hyperplasia, cancer, resection of a uterine septum, polyp, or myoma, and endometrial ablation. This technology will be incorporated into comprehensive training programs that will objectively assess hand-eye coordination and procedural skills. It is possible that by incorporating virtual reality into hysteroscopic training programs, a decrease in the learning curve and the number of complications presently associated with the procedures may be realized. Prospective studies are required to assess these potential benefits.
WM Liu. Department of Obstetrics and Gynecology, Veterans General Hospital, Taipei, National Yang-Ming University, Taipei, Taiwan.
Laparoscopic-assisted vaginal hysterectomy (LAVH) is not yet widely practiced in Taiwan, but interest in this operation is increasing as our knowledge of operative laparoscopy expands. From October 1994 to December 1995, 124 LAVHs were performed. The endoscopic stapler divides tissues and achieves hemostasis quite easily, but its cost is a disadvantage. Kleppinger bipolar forceps for hemostasis and scissors for division are less expensive for the average hospital. Ureteral injury is a crucial issue in LAVH, and is linked to various stages of the operation. Identifying the ureter before the operation and dissecting it after division of the infundibulopelvic ligament are essential to avoid ureteral injury.
Long-Term Resultsof LaparoscopicButch Urethropexy RW Lobel, GD Davis. Division of Urogynecology, Evanston Hospital, Northwestern University Medical School, Evanston, IL.
Five Hundred Twenty-two Resectoscopic Myomectomies
We evaluated the long-term efficacy of laparoscopic Burch urethropexy performed in 35 consecutive women (average age 45.5 yrs, average weight 67.7 kg, average parity 2.3) between May 1992 and July 1994. Preoperative evaluations included cotton swab testing, urinalysis, dynamic urethrocystoscopy, and multichannel urodynamic testing. All subjects had genuine stress incontinence and a positive cotton swab test. Urethropexy was performed with curved needie suturing in 7 women, straight needle suturing in 5, and Stamey needle suturing in 23. Outcome variables were operative time, concomitant surgery, suture needle, length of hospital stay, need for catheterization, and subjective success. Women were divided into groups based on surgical success. Wilcoxon twosample, Z2, and Fisher's exact tests were used to determine which variables were significantly associated with surgical success. Twenty-five women (71.4%) had concomitant pelvic surgery at the time of urethropexy. Average time of surgery was 190 minutes, length of stay 1 day, and length of time for catheterization 5 days.
BL Lin, N Ozawa, N Miyamoto. Department of Obstetrics and Gynecology, Kawasaki Municipal Hospital, Kawasaki, Japan.
Between January 1985 and March 1996, 522 women with submucous myomas underwent resectoscopic myomectomy. Fifty-two were treated with subsequent endometrial ablation. To ensure easy and complete resection of sessile or large submucous myomata, the two-resectoscope method was used. To increase safety, the procedure was monitored by simultaneous ultrasound, and in 1995 Lin's myoma forceps was produced to facilitate the procedure. The average specimen weight was 23.9 g (505 patients). The largest intrauterine myoma was 148 g and the largest myoma delivery was 210 g. The average operating time was 34.2 minutes (517 patients). No uterine perforation occurred. No laparotomy was necessary during or after the operation. Almost all of the women experienced improvement of their symptoms.
$26
The Journal of the American Association of Gynecologic Laparoscopists
genitourinary tract damage, and less formation of granulation tissues on the vaginal cuff associated with persistent leukorrhea and postcoital bleeding occurred with TLH, probably because more precise surgery can be done under direct vision. We believe TLH can be performed more safely and quickly than LH by an experienced surgeon. A potential advantage of TLH is less postoperative infection due to less vaginal manipulation. Other advantages are the lengthening of the vagina, less postoperative prolapse of the vagina, and less enterocele development because of more precise ',anatomic restoration of the pelvic structures under direct visualization. Since detailed pelvic structures can be visualized, excised, and restored, TLH has all the possible benefits of subtotal hysterectomy, if any, due to the maximum preservation of supporting structures (cardinal, uterosacral ligaments) and nerve plexus, thus making subtotal hysterectomy obsolete. Further studies and long-term follow-up are required.
Total Laparoscopic Intrafascial Hysterectomy PI Lee. Jeil Women's Hospital, Seoul, Korea.
Bladder and ureteral injuries are associated with several types of hysterectomies performed laparoscopically. Subtotal hysterectomy is said to cause fewer complications and provide better pelvic support by preserving the uterosacral and cardinal ligaments, but there axe also arguments against it. A new technique, total laparoscopic intrafascial hysterectomy (TLIH) has all the benefits of total and subtotal hysterectomies, but fewer complications. Conventionally, uterosacral liganaents are cut at or just below their junction with the cervix, and the remaining vagina and cardinal ligaments are cut at the same level. With TLIH, using a uterine manipulator and colpotomizer, the incision is made at a much higher level. The cervix is circumcised whilLepreserving the entire uterosacral and cardinal ligaments and full length of the vagina, except in cases of raalignancy or severe pelvic endometriosis. The ureter is mobilized farther from the cervix. A longer vagina and excellent pelvic support can be achieved with maximum preservation of the vagina and pelvic supporting structures. A modified McCall culdoplasty and reinforcement of the cardinal ligaments are done, and the vaginal cuff is closed with everted mattress sutures either vertically or transversely. Less granulation tissue is formed on the vaginal vault and postoperative leukorrhea or postcoital vaginal bleeding is
$25
reduced. Moschcowitz culdoplasty or high McCall culdoplasty can be done at the same time to correct or prevent an enterocele or prolapsed vagina.
Teaching Surgical Hysteroscopy with a Computer Y Lefebvre, J Cote, L Lefebvre. Department of Obstetrics and Gynecology, University of Maisonneuve Hospital, University of Montreal, Quebec, Canada.
Using a hysteroscope can be simulated on a computer. It will improve physician training by measuring basic knowledge and abilities, allow different interventions and anatomic variations, minimize the trauma of surgical intervention, and reduce operative casualties. An integrated questionnaire covers instrumentation, fluid infusion, power source, indications and preparation for endometrial ablation, surgical techniques, and complications to evaluate the user's knowledge. The operation simulation then proceeds. In the endometrial cavity, by virtual simulation, the operating field should appear in real time to allow physicians to adapt the trajectory of the instruments. The computer is an IBM PC compatible. We use a modified joystick with optical encoders to know the instrument position. The simulation can be repeated as desired. An evaluation system is integrated in the software to keep the user informed on the amount of burn area(s) that have been completed. This prototype model is available.
Review of 208 Medicolegal Cases over 20 Years CJ Levinson. Stanford University, Menlo Park, CA.
A review of the 208 medicolegal cases sent to me from 1975 to 1995 showed that problems were related to one of the following: indication for surgery, consent, anesthesia, vascular injury, bowel injury, urologic injury, nerve injury, abandonment, and unwanted pregnancies. The cases were categorized as reviewed only, progress with no further action, deposition, settled, and to trial. Approximately 50% of cases did not go to trial.
Virtual Reality Hysteroscopy ]S Levy. Jefferson Medical College, Philadelphia, PA.
New interactive computer technologies are having a significant influence on medical education, training, and practice. The newest innovation in computer technology, virtual reality, allows an individual to be
Selected Scientific Abstracts
One Hundred Twenty-four Laparoscopic-Assisted Vaginal Hysterectomies
immersed in a dynamic computer-generated, threedimensional environment and can provide realistic simulations of surgical procedures. A new virtual reality hysteroscope passes through a sensing device that synchronizes movements with a three-dimensional model of a uterus. Force feedback is incorporated into this model, so the user actually experiences the collision of an instrument against the uterine wall or the sensation of the resistance or drag of a resectoscope as it cuts through a myoma in a virtual environment. A variety of intrauterine pathologies and procedures are simulated, including hyperplasia, cancer, resection of a uterine septum, polyp, or myoma, and endometrial ablation. This technology will be incorporated into comprehensive training programs that will objectively assess hand-eye coordination and procedural skills. It is possible that by incorporating virtual reality into hysteroscopic training programs, a decrease in the learning curve and the number of complications presently associated with the procedures may be realized. Prospective studies are required to assess these potential benefits.
WM Liu. Department of Obstetrics and Gynecology, Veterans General Hospital, Taipei, National Yang-Ming University, Taipei, Taiwan.
Laparoscopic-assisted vaginal hysterectomy (LAVH) is not yet widely practiced in Taiwan, but interest in this operation is increasing as our knowledge of operative laparoscopy expands. From October 1994 to December 1995, 124 LAVHs were performed. The endoscopic stapler divides tissues and achieves hemostasis quite easily, but its cost is a disadvantage. Kleppinger bipolar forceps for hemostasis and scissors for division are less expensive for the average hospital. Ureteral injury is a crucial issue in LAVH, and is linked to various stages of the operation. Identifying the ureter before the operation and dissecting it after division of the infundibulopelvic ligament are essential to avoid ureteral injury.
Long-Term Resultsof LaparoscopicButch Urethropexy RW Lobel, GD Davis. Division of Urogynecology, Evanston Hospital, Northwestern University Medical School, Evanston, IL.
Five Hundred Twenty-two Resectoscopic Myomectomies
We evaluated the long-term efficacy of laparoscopic Burch urethropexy performed in 35 consecutive women (average age 45.5 yrs, average weight 67.7 kg, average parity 2.3) between May 1992 and July 1994. Preoperative evaluations included cotton swab testing, urinalysis, dynamic urethrocystoscopy, and multichannel urodynamic testing. All subjects had genuine stress incontinence and a positive cotton swab test. Urethropexy was performed with curved needie suturing in 7 women, straight needle suturing in 5, and Stamey needle suturing in 23. Outcome variables were operative time, concomitant surgery, suture needle, length of hospital stay, need for catheterization, and subjective success. Women were divided into groups based on surgical success. Wilcoxon twosample, Z2, and Fisher's exact tests were used to determine which variables were significantly associated with surgical success. Twenty-five women (71.4%) had concomitant pelvic surgery at the time of urethropexy. Average time of surgery was 190 minutes, length of stay 1 day, and length of time for catheterization 5 days.
BL Lin, N Ozawa, N Miyamoto. Department of Obstetrics and Gynecology, Kawasaki Municipal Hospital, Kawasaki, Japan.
Between January 1985 and March 1996, 522 women with submucous myomas underwent resectoscopic myomectomy. Fifty-two were treated with subsequent endometrial ablation. To ensure easy and complete resection of sessile or large submucous myomata, the two-resectoscope method was used. To increase safety, the procedure was monitored by simultaneous ultrasound, and in 1995 Lin's myoma forceps was produced to facilitate the procedure. The average specimen weight was 23.9 g (505 patients). The largest intrauterine myoma was 148 g and the largest myoma delivery was 210 g. The average operating time was 34.2 minutes (517 patients). No uterine perforation occurred. No laparotomy was necessary during or after the operation. Almost all of the women experienced improvement of their symptoms.
$26