8 ABSTRACTS EVIDENCE BASED MEDICINE, GUIDELINES AND TRIALS Dr David Molloy Queensland Gynaecological Endosurgery Group, 225 Wickham Tce, Brisbane 4000 The aims of Evidence Based Medicine are to improve patient care based on principles and treatments that have been proven to be correct, preferably by prospective randomised control trials rather than simply relying on conventional wisdom, experience and clinical judgement. Evidence Based Medicine therefore has the potential to impact on: 1. Modes of practice. Evidence Based Medicine may provide pathways for clinical decision making and subsequent patient treatment. 2. The establishment of treatment protocols, particularly in institutions. 3. The establishment of medico-legal risk, negligence and the determination of reasonable and appropriate care. 4. The provision of services within hospitals or communities maybe based on EBM. If a particular treatment or operation has been shown not to work it may not be made available. Treatments, which have been expressly shown to be efficacious, may be fast tracked into service or more quickly funded. 5. The availability of private and private sector funding. However, it is time to review the appropriateness of Evidence Based Medicine. There are many actual and potential problems with Evidence Based Medicine which include: 1. The knowledge base in medicine is extensive and exhaustive. There is a large body of knowledge which is both factually and intuitively correct. 2. The collection of Cochrane level 1 or 2 evidence using predominantly prospective randomised controlled trials is arduous, expensive and exacting. It has been estimated that fewer than 20% of patients who present to a specialist during an ordinary working day would have a clinical problem in which the results of a prospective randomised control trial would direct the clinical management. 3. Cochrane level reviews consistently show that much of the data relating to specific medical issues is usually level 3 or level 4 data. Often only one or two prospective randomised controlled trials will have been performed. However errors occur in these trials. Frequently second and third trials which confirm the outcomes are not present. Sometimes also the results of reputable prospective trials are conflicting. 4. Various institutions and funding bodies are now starting to insist that an Evidence Based Medicine procedure be followed prior to the introduction or the maintenance of specific forms of treatment. Many Cochrane Review Boards have a lack of front line clinicians. It is also possible that these review panels have excellent expertise in terms of data analysis and the ability to review information but may have a weakened clinical understanding as to the practice of medicine 5. The absence of evidence supporting a particular treatment may be used as an argument that that treatment is either unnecessary or wrong.. It is important that reviewers report a historical absence of information in that context and do not fill a void with their own equally unproven beliefs of prejudices. 6. The establishment of protocols and guidelines across broad treatment areas using EBM as its intellectual base may lack flexibility and clinical applicability. Protocols and guidelines are at their strongest when they extensively cover a very small area. 7. Trials, reviews and subsequent guidelines become rapidly outdated. They are difficult to replace due to the extensive cost and workshopping that is needed to modify them. EBM has a useful place to place in medicine and surgery but its limitations need to be recognised. EVIDENCE BASED MEDICINE AND SURGERY Ray Garry It is now becoming a recognized standard of good practice that new surgical procedures like new drugs are carefully and formally assessed before being available for widespread use. History is littered with examples of surgical procedures that are supported by the wise and the good to be subsequently shown to be ineffective or downright harmful. To avoid such disasters it is essential to compare the new procedure with appropriate measures directly against the existing gold standard technique. Although correct evaluation is essential it is also extremely difficult. Patients need to trust their surgeon and believe that he is doing the best possible operation for them. It does little for the surgeon patient relationship to be told that the doctor is testing out two procedures because he does not know which is best. It is even less helpful to that relationship to be aware that it is a computer and not the surgeon who will select the therapy to be given. All surgeons must inevitably be biased towards particular operations. That is why they recommend them. Evidence based medicine and particularly randomized clinical trials are there to avoid or at least reduce to a minimum the bias in a trial. Just as they are more difficult to undertake it is therefore more important that we all become used to EBM. I should like to illustrate the problems and potential solutions to conducting an surgical RCT by illustrating with some of the problems and solutions we encountered during the Evaluate hysterectomy Trial. As this is probably the largest RCT ever performed in gynaecological surgery I can assure you that we came up against almost every problem that you might expect and some that you may not. We will cover issues of trial design and the vital issue of sample size. Almost invariably we choose a sample size that is about the size of population we expect to have available in the time we think we can spare for the study. Before we performed the Evaluate study 11 other RCT’s were performed comparing LH with TAH. Each of these studies made specific statements that there results confirmed that both procedures were safe. The size of the studies varied from 40 to 200 patients and the total number of patients in all the studies was 695. In order to detect a difference of the magnitude we could expect we calculated that we would need 450 patients per trial arm using an 80% power and a two-sided type 1 error of 5%. ie if the purpose of the study was to determine if the new method of hysterectomy was as safe as its predecessor, none of the studies were remotely powered to detect this. From that point of view they were a complete waste of time and the conclusions of safety drawn were invalid. Sadly this is the case for most trials. Obviously other data with greater magnitudes of differences can still be analysed from these trials but this example is intended to point out the need to match the size of the trial to the order of magnitude of difference we expect from the procedures. The message is clear. Carefully drawn up trials are essential but the techniques of trial design and execution are important and like all statistics garbage in is garbage out. 10 ABSTRACTS PELVIC SIDE WALL AND URINARY TRACT ENDOMETRIOSIS Alan Lam Centre for Advanced Reproductive Endosurgery, North Shore Private Hospital , University of Sydney In the assessment and treatment of pelvic side wall and 4. Energy sources urinary tract endometriosis, it is important to have a clear » Electro-surgery knowledge of: » Ultrasonic: harmonic scalpel, LCS 1. Anatomy » Lasers: CO2, NdYAG, KTP » Pelvis 5. Principles of » Pelvic side wall » Tissue dissection » Ureter » Surgical planes 2. Depth of endometriosis » Team work: oncologist, urologist, colo- » Superficial rectal, vascular surgeons » Intermediate This presentation will cover these issues, illustrate » Deep anatomical landmarks, demonstrate principles and 3. Surgical approaches methods of surgical treatment, and presents the » Laparoscopy Australian multi-centre study on urinary tract » Laparotomy endometrirosis. EXTRAPELVIC ENDOMETRIOSIS AND ADJUVANT THERAPIES Dr G D Reid Director of Gynaecological Endoscopy, Liverpool Hospital, Liverpool NSW; Lecturer in Gynaecology, University of New South Wales, Randwick, NSW I was asked to prepare a lecture on extrapelvic endometriosis I will present a case of progressive postmenopausal and to sequence this with potential adjuvant therapies for endometriosis that raises the issue of aberrant aromatase endometriosis in general. activity in, at least, some endometriotic cases8. Consideration of For this review, pelvic endometriosis is defined as disease aromatase inhibitors as potential therapeutic agents will be involving the surface of the uterus, the surface or internal discussed. structure of the ovary, the fallopian tubes or local pelvic I will close with a summary of other potential adjuvant therapies peritoneum. Extrapelvic endometriosis refers to disease found undergoing evaluation in the world at present. elsewhere, including the gastrointestinal tract, urinary tract, pulmonary system, central nervous system and the skin or subcutaneous tissue. 1. Olive DL, Schwartz LB: Endometriosis. N Engl J Med I concur with David Olive1 that the literature on endometriosis in 328:1759, 1993 general is both inadequate and confusing. The literature on 2. Jubanyik KJ, Comite F: Extrapelvic Endometriosis. extrapelvic disease is even worse2, so our local experience is Obstet Gynecol Clin North America: 24(2) 411-440, probably as useful as any other available data3-7. 1997. I will present data on the incidence, diagnosis and management of extrapelvic endometriosis, including gastrointestinal, urinary 3. Kaloo PD, Reid GD: The Acute Presentation and tract, thoracic, hepatic and abdominal wall or cutaneous Surgical Management of Intestinal Endometriosis to disease. General Surgeons over a 13-year period. (Submitted for publication). The primary aim of this presentation is to increase awareness of rare but nevertheless real presentations of endometriosis for 4. Kaloo PD, Reid GD, Wong F: Caesarean section scar which diagnosis is often significantly delayed. Cases of endometriosis: two cases of recurrent disease and a extrapelvic disease are regarded as curiosities, but occur more literature review. Aust NZ J Obstet Gynaecol 42(2): 149- frequently than often thought. They sometimes provide insight 151, 2002 into the pathophysiology of the disease, and are occasionally 5. Nada W, Parker J, Wong F, Cooper M, Reid G: associated with high-risk clinical circumstances. Compromised Laparoscopic Excision of Endocervicosis of the Urinary renal function, diaphragmatic invasion, hepatic involvement and Bladder. JAAGL: 7(1): 135-137, 2000 pre-malignant change need timely diagnosis and expert 6. Cooper MJW, Russell, P, Gallagher PJ: Diaphragmatic management. Endometriosis. Med J Aust. 172: 142-143, 1999. The secondary aim is to use certain extrapelvic cases to explore 7. Reid GD, Cooper MJW, Kowalski D, Gallagher PJ: potential adjuvant therapies. This has been a hugely neglected Hepatic Endometriosis (In preparation) area of clinical research. Recurrence following surgical 8. Zeitoun KM, Bulun SE: Aromatase: a key molecule in “debulking” of endometriotic disease remains a major problem. the pathophysiology of endometriosis and a Some clues to effective adjuvant therapies may arise from study therapeutic target. Fertil Steril 72(6): 961-969, 1999. of extrapelvic disease. 11 ABSTRACTS THE ROLE AND TECHNIQUES OF HYSTERECTOMY IN THE MANAGEMENT OF ENDOMETRIOSIS Ray Garry It is now well recognized that endometriosis produces a number However, in the remaining 20% of patients, RLEE proves of different types of pain and other symptoms which can ineffective. In such cases combining repeat RLEE with collectively be called the endometriosis-symptom-complex concomitant hysterectomy often seems to be more effective. On (ESC). The role of hysterectomy in relieving these various histological examination of the specimens we have observed the consequences of endometriosis is a paradoxical one. presence of intra-uterine adenomyosis co-existing with extra- The most common and often most severe aspect of the ESC is uterine endometriosis. Two distinct types of adenomyosis have dysmenorrhoea. Removal of the uterus often relieves this aspect been defined. The typical diffuse type in which multiple deposits of ESC and most patients will experience some improvement in of glands and stroma are found scattered through the endometriosis related pain after hysterectomy. Endometriosis is myometrium but lying principly just beneath the endometrium- however characterized by the presence of endometrial glands myometrial junction and a variant in which there is a single and stroma outside the uterus. Hysterectomy will seldom wedge-like focus apparently invading the myometrium from the remove these extra-uterine deposits and consequently patients outer serosal surface. Such lesions are almost invariably found will frequently continue to suffer from other elements of ESC in continuity with extensive adenomyotic-like lesions in the cul such as non-menstrual pelvic pain, dysparunia and dyschesia. de sac. Planes of dissection cannot be found between the two Severe symptoms progress and we have seen many cases in lesions and they appear to be a single entity. We are currently whom bowel or ureteric obstruction occur after hysterectomy. investigating ways of detecting such lesion pre-operatively. It Hysterectomy alone is an inadequate and irrational surgical would seem rational that hysterectomy should be combined treatment for endometriosis. with the primary therapy when patients have extensive co- In contrast laparoscopic excision of all extra-uterine existing extra-uterine and intra-uterine disease. endometriosis has been shown by us and others (1-4) to In conclusion it would seem that both RLEE and Hysterectomy produces prolonged relief of most elements of the symptom may have indications in the primary surgical treatment of complex in about 80% of cases. Such radical laparoscopic advanced endometriosis. More accurate pre-operative diagnosis excision of endometriosis (RLEE) seems a more rational may enable us to predict the cases in which such combined approach to the primary surgical management of endometriosis. treatment may be most therapeutically beneficial. THE ROLE OF FIBROHYSTEROSCOPY IN THE ASSESSMENT OF ABNORMAL UTERINE BLEEDING René Marty For the evaluation of abnormal uterine bleeding (AUB) the use of needing a biopsy. This saves two successive procedures, time, the fibrohysteroscope XP 3mm (FHS) is essential before or after money and discomfort for the patient. the menopause. We have conducted a French national survey on During the same session, Office FHS provides a visual the use of diagnostic FHS “AAGL Meeting, November 2001”: for diagnostic, allows to confirm it by histology and permits to 13 219 procedures reported the indication was AUB (39% of all perform mino operative procedures such as polypectomy. the indications). To conclude, one must keep in mind that for ovulatory or For the imaging the choice is mainly between saline instillation anovulatory AUB patients, as well as for the women under TAM sonography (SIS) versus FHS. All the other processes are less or HRT, the histologic evaluation remains the gold standard of reliable. any assessment. As well as THS, SIS allows a screening evaluation of the endometrial cavity and reveals the true location of any intra uterine pathology. But we prefer FHS versus SIS because it allows: » to observe the real color of the full surface of the endometrium » to detect a focal area of abnormal vascular pattern » to perform simultaneously a targeted endometrial biopsy under direct visual control » to take a specimen in a specific area where it exists an alteration of the general color of the endometrial lining. FHS is a quicker procedure than SIS, does not require a tenaculum and avoids the prescreening by SIS to target patients AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 12 ABSTRACTS ADIANA: A NEW METHOD FOR FEMALE STERILIZATION – RESULTS OF A PILOT STUDY. T. Vancaillie; J. Garza-Leal Royal Hospital for Women, Sydney, Australia; Hospital Universitario, Monterrey, Mexico Objective: the Adiana method consists of the combination Results: Nineteen treated tubes are so far available for of thermal destruction of the endosalpinx with analysis. HSG shows occlusion in all of them. insertion of a matrix to encourage colonization Using rSG at 50mmHg pressure all tubes are by fibroblasts leading to occlusion. A pilot study again closed. At 100mmHg, 17 tubes sustained in humans was designed to evaluate the the pressure for 60+ seconds, one for 27 seconds feasibility, safety and efficacy of the proposed and another for 57 seconds. Histology shows method. tissue ingrowth within the matrix with minimal Methods: 30 women of reproductive age, scheduled to chronic inflammamtory reaction. undergo hysterectomy for benign conditions are Conclusion: This pilot study shows that combining thermal being recruited. A hysterosalpingography (HSG) destruction of the endosalpinx with insertion of a is performed to establish patency of the oviducts. biocompatible matrix leads to occlusion of the The Adiana procedure is performed by oviduct. hysteroscopy. Twelve weeks later, the HSG is repeated followed by hysterectomy. The specimen is then submitted to retrograde salpingography (rSG) and the cornual regions are examined by histologic serial sections. MEDICO-LEGAL IMPLICATIONS OF STERILISATION FAILURES Dr Sara Bird United Medical Protection In numerical terms sterilisation failure accounts for about Filshie clip issues and medico-legal implications of some 12% of UNITED’s O&G claims, Australia wide. These are newer sterilisation procedures will be discussed. Risk potentially expensive cases to settle. They may well become management strategies designed to avoid claims in this area more so, if a test case currently before the High Court of practice will be outlined. extends compensation entitlements to allow the cost of child rearing through until adulthood. ENTEROCOELE AND VAULT PROLAPSE Alan Lam Centre for Advanced Reproductive Endosurgery, North Shore Private Hospital, University of Sydney In this presentation, the author will discuss: 8. Surgical techniques and results 1. Normal pelvic floor and vaginal anatomy » Sacrospinous: ipsilateral, bilateral 2. Aetiology » Laparoscopic L.A.M. pelvic floor repair 3. Mechanism » Laparoscopic mesh sacrocolpopexy 4. Clinical presentation of enterocoele and vault prolapse 9. Potential complications of enterocoele and vault formation reconstruction 5. Assessment » Anterior compartment defects: midline, » Pre-operative paravaginal » Physical examination » Urinary stress incontinence » Imaging: Ultrasound, radiological, MRI » Urinary tract injury » Urodynamics » Bowel complications » Ano-rectal physiological assessment » Suture or mesh erosion and infection » Intra-operative » Bleeding: pelvic side wall, vault, presacral 6. Management principles 10. Conclusions and recommendations 7. Surgical approaches » Vaginal » Laparoscopic » Laparotomy 13 ABSTRACTS ANTERIOR ENTEROCELE: A SURGICAL DILEMMA H.P. Dietz, T.G. Vancaillie Royal Hospital for Women and King George V Memorial Hospital, Sydney Anterior enterocele or a large posterior cystocele would incur a high risk of bleeding, ureteric injury and represent a particularly vexing problem for the subsequent mesh complications in an area crucial to incontinence and prolapse surgeon. The lower anterior upper and lower urinary tract function. The addition of an vaginal wall can be immobilized well via retropubic anterior extension to a standard vault suspension procedures, and the posterior vaginal wall to the vaginal procedure is assumed to resolve this problem. However, it apex may be reliably reconstructed via a vault suspension may be very difficult if not impossible to cover the whole procedure such as a sacrospinous colpopexy or a defect without compromising ureteric function. laparoscopic or abdominal sacrocolpopexy. However, Nature, i.e., anatomy, imposes limits on reconstructive there remains an area between the apex and the trigone pelvic floor surgery, and those limits are nowhere as which is very difficult to reach surgically. As an isolated apparent as in the treatment of anterior enterocele. This clinical problem, it is seen most frequently in women after particular problem has, in the opinion of the authors, not retropubic surgery and/ or after sacrospinous colpopexy yet found a satisfactory solution. and other vault suspension procedures which leave the anterior upper vagina unsupported. On the one hand, potential support structures such as Cooper’s ligament, the arcus tendineus fasciae pelvis, the sacral promontory and the sacrospinous ligament are all too distant from this area to provide effective support. On the other hand, any attempt at using mesh in this area BURCH COLPOSUSPENSION: DOES A LAPAROSCOPIC APPROACH DECREASE POSTOPERATIVE SYMPTOMS OF BLADDER OVERACTIVITY? H.P. Dietz Royal Hospital for Women and King George V Memorial Hospital, Sydney The symptoms of urgency, frequency, nocturia and urge distortion due to the procedure is said to be causative, incontinence are commonly encountered after either 1.) via some degree of obstruction, 2.) via stretching colposuspension and similar procedures which elevate of presumed stretch receptors in the vagina, or 3.) via and immobilise the bladder neck to cure genuine stress deformation of the trigone or overelevation of the bladder incontinence (GSI). The likelihood of such symptoms after neck. Another potential factor is the interaction of Burch colposuspension ranges from 5% to over 50 % and subsequent cystocele recurrence, uterine prolapse, appears to increase over time. Irritative symptoms also enterocele or rectocele with the bladder neck. occur after laparoscopic procedures such as It has been hypothesized that laparoscopic procedures colposuspensions and urethropexies and also after fascial may be associated with a lower incidence of postoperative and synthetic slings. symptoms of bladder irritability, possibly due to reduced Several theories have been advanced to explain dissection and postoperative inflammation and/ or less exacerbated or de novo detrusor instability with the distortion of the bladder neck. Own data will be presented symptoms of urgency, frequency, nocturia and urge comparing open Burch colposuspension to laparoscopic incontinence after the operative therapy of GSI. Ageing of colposuspension and laparoscopic urethropexy. It tissues and decreasing oestradiol levels have been appears that at least some forms of laparoscopic bladder blamed as has the impairment of bladder innervation due neck surgery may be associated with a decreased to surgical dissection, urethral denervation and incidence of postoperative bladder irritability. intercurrent hysterectomy. Most commonly mechanical AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 14 ABSTRACTS MESH IN GYNAECOLOGY Christopher Maher Mater & Royal Women’s Urogynaecology, Brisbane, QLD Despite an improved understanding of pelvic anatomy and slings (TVT6, IVS) and in the vaginal approach to recurrent advances in surgical techniques the long-term success rate of prolapse7. Increasingly, new complications are being reported8- pelvic reconstructive surgery is variable. 10. This presentation will review the management of these Failure of surgery can usually be related to complications, possible indications for and alternatives to the » Poor surgical technique: use of mesh in Gynaecology. inappropriate procedure, dissection, suture type or placement, infection. 1. Moir JC. The gauze-hammock operation. J Obstet » Patient factors: Gynecol Br Common 1968;75(1)1-9 chronically raised intra-abdominal pressure, intrinsic 2. Usher FC. The repair of incisional and inguinal weakness of tissue or impaired healing. hernias.Surg Gynecol Obstet 1970;131:525-530. 3. Maher CF, Carey MP, Dwyer PL, Moran P. Pubovaginal or Our forefathers recognized that mesh might have a role in vicryl mesh rectus fascia sling in intrinsic sphincter improving the outcome of reconstructive pelvic surgery. In 1968 deficiency. Int Urogynecol J 2001;12(2)111-6. Moir used Mersilene mesh in the placement of the Aldridge 4. Weber AM, Walters MD, Piedmonye MR, Ballard LA. sling1 and Usher described mesh in the repair of ventral wall Anterior colporrhaphy: a randomized trial of three hernia2. surgical techniques. Am J Obstet Gynecol 2001;185:1299-304. Meshes can be absorbable (Vicryl, Dexon), permanent (Marlex, 5. Benson TJ, Lucente V, McClellan E. Vaginal versus Prolene, Atrium, Teflon, Gortex) or more recently a combination abdominal reconstructive surgery for the treatment of of both (Vypro). Absorbable meshes have not improved the pelvic support defects: A prospective randomized study outcome of slings3 or cystocele repair4. A large array of with long-term outcome evaluation. Am J Obstet permanent meshes are currently used in Gynaecology in the Gynecol 1996;175: 1418-22. repair of incisional hernia, recurrent prolapse and in continence 6. Ward KL, Hilton P. A randomized trial of surgery. The ideal mesh is one that is both chemically and colposuspension and tension-free vaginal tape for primary genuine stress incontinence- 2 yr follow-up. Int physically inert, non-carcinogenic, mechanically strong, easily Urogynaecology J 2001; 12: abstract 173. fabricated and strong. While meshes can improve the intrinsic 7. Julian TM. The efficacy of marlex mesh in the repair of strength of the tissue being repaired the problems of infection, severe, recurrent vaginal prolapse of the anterior mid- rejection and erosion into surrounding organs remains vaginal wall. Am J Obstet Gynecol 1996;175:1472-5. substantial. All of these properties will vary with the porosity, 8. Patsner B. Mesh erosion into the bladder after flexibility, stiffness, interstices between filaments and whether a abdominal sacral colpopexy. Obstet Gynecol 2000;95:1029 monofilament or multifilament mesh is chosen. During this 9. Madjar S, Tchetgen MB, Van Antwerp A, et al. Urethral presentation we will review these important structural features erosion of tension-free vaginal tape. Urology of the different meshes. 2002;59(4):601. While the popularity of the traditional mesh slings has 10. Haferkamp A,Steiner G, Muller SC et al. Urethral diminished mesh continues to be used successfully in the erosion of tension-free vaginal tape. J Urol abdominal sacral colpopexy5 and more recently in mid-urethral 2002;167:250. PATHOPHYSIOLOGY & PHARMACOLOGY OF PAIN Milton Cohen St Vincent's Campus, Sydney Pain, especially when persistent or chronic, is now appreciated nociception and treating the pain itself, rather than necessarily as a biopsychosocial phenomenon, with a somatic dimension seeking and treating disease. The main modality of treatment (determined neurophysiologically) interacting with affective, here is pharmacotherapy , with an increasing number of options. cognitive and behavioural dimensions (determined The second key concept is the recognition of distress, to which psychosocially). There are two key concepts in developing a nociception may be but one of a number of contributors, the rational approach to the assessment and management of others reflecting changes in the life of the person as influenced persistent pain. Firstly is the phenomenon of plasticity, that is, by personal beliefs, community attitudes and societal structures. the capacity of noxious stimuli over time to sensitise central Expectations determined by prior experience and consequences nervous system pathways with resulting spontaneous pain and determined by the social environment are powerful modulators increased reactivity to innocuous stimuli. This concept of central of distress, as may be altered mood, change of role, lowered self- sensitisation of nociception may be relevant in patients with esteem, financial difficulty, inability to pursue preferred repeated episodes of painful pelvic disease. Recognition of recreational activities, altered relationships and loss of sleep. possible visceral hyperalgesia has important implications for Cognitive-behavioural techniques of therapy are as important as management, including seeking to modify mechanisms of pharmacotherapy in addressing this dimension of pain. 15 ABSTRACTS LAPAROSCOPIC SURGERY IN PREGNANCY – WHEN, HOW AND WHY? Dr. Nesrin Varol The rising tide of laparoscopic procedures in pregnancy without allowing for the disease process itself. owes much to the gynaecological surgeon’s appreciation Compared to that in the first trimester, laparoscopy in the of its key advantages compared with laparotomy. Potential presence of enlarged uterus of second trimester of pregnancy advantages of laparoscopic surgery in pregnancy include is technically more challenging. However, the second trimester decreased fetal depression due to lessened postoperative is generally the safest time to perform surgery. narcotic requirements, lower risks of wound complications Laparoscopy in pregnancy should be performed at the and diminished postoperative maternal hypoventilation. lowest possible insufflation pressure. The surgeon should Additional benefits may include more rapid maternal let uterine size determine the method for abdominal recovery. Two studies suggest there is no difference in access and must have mustered laparoscopic techniques fetal outcome for patients with singleton pregnancies before performing the procedure in pregnancy. Pregnant undergoing laparoscopy or laparotomy. The incidence of patients with complications that necessitate surgery surgery in pregnancy ranges from 0.5% to 2.0%. The should not be part of a laparoscopic learning curve. laparoscopic procedures most commonly reported during Current data demonstrate that laparoscopy can be pregnancy are cholecystectomies, followed by adnexal performed safely during pregnancy, especially before 20 surgery and appendectomy. Review of data of animal and weeks’ gestation. Given that surgical complications in human studies acknowledges an increased incidence of pregnancy are fairly rare, however, only an enormous poor outcomes after surgical intervention during multicenter study could conceivably generate enough pregnancy. It is mere conjecture to assign blame for all cases to reach statistical power adequate for a valid “poor outcomes” to a solitary event such as surgery, prospective study. BOWEL DAMAGE IN LAPAROSCOPIC SURGERY Associate Professor Michael Solomon Department of Colorectal Surgery, RPAH & University of Sydney Bowel damage during laparoscopic gynaecological cause, can localise and change clinical signs and thus surgery is fortunately uncommon with an incidence of delay diagnosis. Operative gynaecological laparocopy and 0.18-0.65 percent of procedures. A third of injuries occur in particular hysterectomy has the highest incidence of from the primary trochar and only a third are noted at the bowel damage. Prevention by case selection is often a time of initial surgery. Morbidity and mortality is greatly poor indicator, however familiarity with instruments and increased with the latter delayed diagnostic group but is close observance of primary trochar may be of some help minimal in those where the damage is detected initially. but the low incidence of complications fortunately Bowel perforation can occur immediately, in a few days prevents good data (RCT). Awareness of the possibility of when the bowel returns or be delayed for 1-2 weeks in delayed bowel complications when nonspecific clinical partial thickness burns. Monopolar diathermy gives the symptoms develop and early intervention may minimise greatest width of burns. Adhesions can be a precipitating the morbidity and mortality of this rare complication. WHAT TO DO WHEN FACED WITH UNEXPECTED CANCERS? Prof. Tom Jobling The majority of cancers encountered by the Use of risk of malignancy indices does help avoid the gynaecological endoscopist will be adnexal malignancies unexpected, but some patients will still slip through the net. or secondary cancers from the GTI or breast. Strategies for management to avoid compromising In pre-menopausal women the pre-operative evaluation patients’ outcomes , and achieving an accurate diagnosis, using conventional ultrasound and tumour markers, is not as as well as a case report, will be presented. straight forward in post menopausal women. AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 17 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 3A 1330-1340 Session 3A 1340-1350 None of the patients had any problems. No hemodynamic Non-disposable Safer Primary Trocar difference was noted using the Laparoscopic Entry. Is it about monitoring outlined below. Careful monitoring is necessary for the early Instrument Insulation pressure? detection of untoward physiological Failure in the Tertiary J. Tsaltas1, A. Meads2, J. Mezzatesta2, changes. Standard monitoring S. Nicolson2. included electrocardiography, blood Institution pressure, pulse oximetry, Anusch Yazdani1, Brad Armstrong1, The majority of laparoscopic capnography and airways pressure. Hanna Krause2 complications occur in the initial The patients were all ASA1. Mater Mothers’ Hospital1, Royal Women’s phase of the laparoscopy. This is Hospital1, Brisbane at the time of Veress needle and Conclusion trocar insertion. The vast majority This technique is now used Objective (2/3) of major vascular injuries routinely for all ASA1 patients. We To determine the prevalence of occur at the time of inserting the recommend that this technique be laparoscopic insulation failure in a umbilical trocar. adopted almost universally where tertiary institution Articles in the literature have Veress needle and closed trocar recommended an intraabdominal insertion is used. Methodology pressure of 25mmHg prior to SWOT assessment of the electrical inserting the umbilical trocar. This insulation integrity of all technique seemed a very safe Gynaecologist laparoscopic instruments in a option and the authors felt it Anaesthetist number of tertiary institutions appropriate to evaluate this Jim Tsaltas technique in an Australian Head of Unit Results environment. The technique Endosurgical Unit Up to 50% of non-disposable appears safer as it increased the Monash Medical Centre laparoscopic instruments were distance between the anterior c/o found to contain breaches in abdominal wall and the 19 Simpson Street East Melbourne 3002 electrical insulation, affecting up retroperitoneal structures. Ph: (03) 9416 1172 to 100% of all advanced We performed 1150 consecutive Fax:(03) 9416 4274 gynaecological operative trays. Email: email@example.com laparoscopies between the period The defects were visible in less 1 January 2000 to 31 December than 20% of cases. The type of 2001. This technique was used for instrument, location and both diagnostic and operative predictability of the breach are laparoscopies. The procedures discussed and illustrated. were performed at 3 hospitals. Monash Medical Centre, Cliveden Dr Anusch Yazdani Hill Private Hospital & Mt Waverley Department of Gynaecology Private Hospital. Mater Mothers’ Hospital The Veress needle was inserted Raymond Tce and insufflation was commenced South Brisbane QLD 4101 Mobile 0408 133368 at 2 l/min and intraabdominal e-mail: firstname.lastname@example.org pressures of 25 mmHg were established prior to the insertion of the primary trocar. Once all the trocars had inserted the pressure was reduced to 15mmHg. AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 18 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 3A 1350-1400 Session 3A 1400-1410 Contact: A novel method for the Respiratory symptoms M Cooper 187 Macquarie St, Sydney 2000 detection of bowel as an indicator of Tel: 61 2 9233 3546 Fax: 61 2 9232 8270 damage at laparoscopy undiagnosed bowel Email: email@example.com MJW Cooper perforation following King George V Hospital, Clinical Senior Lecturer Sydney University. laparoscopic surgery: B Cornell. Ambri Pty Ltd, Chatswood. An observation. MJW Cooper Objective King George V Hospital, Clinical Senior To establish a method of Lecturer Sydney University. determining if bowel injury had GD Reid occurred as a result of the use of a Liverpool Hospital, NSW. Verres needle or primary trocar. PD Kaloo University of New South Wales. Methods Objectives A novel trocar is currently being To outline eight cases of undiagnosed developed which will act to trap bowel perforation in which the bowel contents if perforation respiratory symptoms of dyspnoea occurs. After removal of the trocar and tachypnoea manifested from the abdominal cavity the end themselves as an integral part of the is washed and the contents clinical presentation. extracted. Additionally tests will be performed on existing trocars Methods and the material left on the end Retrospective case report. will be washed into a tube for Results assessment. The contents are A most notable feature of the cases, then analysed ex-vivo using the which has not been widely Ambri system for the presence of recognised, is the presence of bacteroides (large bowel) and respiratory signs i.e. dyspnoea and antigenic glycoproteins from the tachypnoea. Several of these patients mucosal lining of the small bowel. had the diagnosis of bowel perforation delayed because of the Results presence of what were felt to be Initial results will be presented at clinical features within the chest. the meeting. Diagnoses of pneumonia and embolism were considered with Conclusion several patients undergoing lung A method of detection of bowel scans and chest X rays. damage is proposed. Large scale studies will be required to Conclusions determine if this method has Respiratory symptoms may be a part of the varied presentation of practical clinical significance. undiagnosed bowel perforation and as such should be seen as a potential Contact: warning ‘sign’. M Cooper 187 Macquarie St, Sydney 2000 Tel: 61 2 9233 3546 Fax: 61 2 9232 8270 Email: firstname.lastname@example.org 19 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 3A 1410-1420 Conclusions safety precautions should be The major complication rate of incorporated routinely to decrease A prospective multi- 8.8/1000 is satisfactory or avoid these risks. These include centre study of major considering the complexity of real time fluid balance monitoring, surgery involved and the case selection, and establishment complications subsequent symptomatic relief of a departmental protocol for experienced during that is obtainable. management based on serum sodium levels. excisional laparoscopic surgery for Session 3A 1420-1430 endometriosis Istre O, Bjoennes J, Naess R et al. PD Kaloo Hyponatraemia and Postoperative cerebral oedema after Liverpool Hospital. Operative transcervical resection and uterine irrigation with 1.5% glycine. Lancet MJW Cooper King George V Hospital, NSW. Hysteroscopy. 1994; 344: 1187-1189. Garry R, Hasham R, Kokri MS et al. The GD Reid Evolution, effect of pressure on fluid absorption Liverpool Hospital, NSW. DJ Kowalski Identification and during endometrial ablation. J Gynecol Surg 1992; 8: 1-10. Liverpool Hospital, NSW. Management Fraser CL, Arieff AI. Epidemiology, Vince Lamaro pathophysiology and management of Objectives Harneck Rai hyponatremic encephalopathy. Am J Med To clarify the rate of major intra- St Vincent’s Hospital Campus, 1997; 102: 67-77. operative and post-operative Darlinghurst, Sydney, Australia Kumar S, Berl T. Sodium. Electrolyte quintet. Lancet 1998; 352: 220-228. complications experienced in excisional laparoscopic surgery for Arieff AI. Management of hyponatraemia. Objectives British journal of Medicine 1993; 307: stage 1-4 disease. To define the setting in which 305-308. hysteroscopy exposes the patient Arieff AI, Ayus JC. Endometrial ablation Methods to the risk of hyponatraemia. To complicated by fatal hyponatraemic A prospective observational study outline the management of encephalopathy. JAMA 1993; 270: 1230- was undertaken of all consecutive hyponatraemia. To discuss the 1232. subjects undergoing laparoscopic ways in which the risk of excisional surgery for minimal to developing hyponatraemia may be severe endometriosis. All subjects prevented. were operated on by two specialist gynaecological endoscopists in the Methods Public and Private hospital sectors. Case review and literature review. Results Results 790 subjects were recruited over a The evolution of a case of 3-year period. Seven major hyponatraemia is identified. complications were experienced; Current recommendations for four bowel injuries, one management and avoidance of cystotomy, one ureteric hyponatraemia are presented. transection, and one major Conclusions vascular injury. All visceral or vascular injuries were diagnosed Hyponatraemia during operative prior to completion of the surgery. hysteroscopic surgery can be No significant long-term sequelae associated with great morbidity were experienced. and the risk of mortality. Various AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 20 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 3A 1430-1440 Session 3A 1440-1450 quality of life, sexual activity and procedural satisfaction and Microwave A double blind acceptability. A pictorial blood loss endometrial ablation: randomised controlled assessment chart was completed pre-op and 6-months post-op. All a preliminary trial comparing the patients received a single dose of evaluation of 60 Cavaterm™ GnRH analogue one month pre- operatively and kept blinded to patients endometrial ablation the procedure performed until Peter J Maher system with the after the 6-month assessment. Melbourne Nd:YAG laser for the Main outcome measures Endometrial ablation has been treatment of The primary outcome measure available in Australia since 1989. was amenorrhoea rate. Secondary dysfunctional uterine It is a viable alternative to outcomes were effect on blood hysterectomy for patients bleeding. loss, quality of life, sexual activity, suffering from dysfunctional Jed Hawe, Jason Abbott, David patient satisfaction and procedure bleeding with reported success Hunter, Graham Phillips, Ray Garry acceptability. rates between 80-90%. Results Unfortunately the uptake of this Objective procedure, although popular in the Seventy-two women were To compare the effectiveness of early 90’s,has declined over the last randomised. Amenorrhoea rates the Cavaterm thermal balloon few years. The main reason, in the at 12 months in the Cavaterm and endometrial ablation system with author’s opinion, is the failure rate in ELA groups were 29% vs. 39% the Nd-YAG laser for the treatment inexperienced hands. It is (p=0.286), with combined of dysfunctional uterine bleeding. recognised as a procedure with a a m e n o r r h o e a a n d long learning curve. Design hypomenorrhoea rates of 81% vs. 73% respectively. At 12 months With this in mind industry has Double blind randomised repeat surgery rates were higher endeavoured to introduce simple controlled trial. in the ELA group (15% vs. 12%, systems which can offer p=0.395). Cavaterm was an Setting successful outcomes without the acceptable procedure and 93% of long learning curve. There are Minimal access gynaecological surgery unit in a district general patients satisfied or very satisfied many such systems available in at 12 months (95% ELA). Twelve the marketplace today. hospital. months after treatment, Cavaterm One of the newer systems is the Population was associated with a statistically microwave endometrial system (MEA). 72 women with dysfunctional significant increase from baseline The results of the first 60 cases uterine bleeding requesting in SF12 physical score (mean performed by the author will be conservative surgical difference –6.1 [95%CI -9.7, -2.4] presented with follow-up ranging management of their condition. p=0.001) and mental health score from 2-15 months. The early (mean difference –5.6 [95%CI success rate of the procedure is Methods –9.9, -1.3] p=0.001). Patients own better than that reported for Women with a normal endometrial assessment of health (EuroQol electro-surgical endometrial biopsy and normal uterine cavity thermometer) was also ablation. Discussion will include were randomly allocated to one of significantly improved from warnings about so-called “simple” the two treatment arms. Patients baseline (mean difference –7.6 systems. completed pre-op, 6- and 12 [95%CI –13.9, -1.3] p=0.02). month post-op questionnaire Concerning sexual activity, there assessing menstrual symptoms, was a trend towards increased 21 F R E E C OM MU N I C AT I O N A B ST R AC TS pleasure and habit but the Diagnostic laparoscopy is a safe symptom duration of 167 days (SD changes did not reach statistical accurate procedure, performed as 87). Four had positive pre- significance. There were no major a day procedure allowing definitive operative ultrasound, but these complications in either group. therapy if necessary. findings were confirmed in only 2 cases(2 dermoids). 26 (74.5%) of Conclusions Objective the women had positive The Cavaterm thermal balloon The objective of our study was to laparoscopic findings, 20 (57%) endometrial ablation system describe the symptoms, signs and had endometriosis, 4 (had pelvic compares favourably with the intra-operative findings in a group adhesions and 2 had benign Nd:YAG laser when used for the of adolescent women undergoing teratomas) . The remaining 9 treatment of dysfunctional uterine diagnostic laparoscopy for acute (25.5%) had no abnormalities bleeding. It results in a significant and chronic pelvic pain. seen. reduction in menstrual blood loss and comparable amenorrhoea Study Design rates, patient satisfaction, A retrospective case note review improvement in patient quality of was performed focussing on life, and therefore can be adolescent women undergoing a considered as an alternative diagnostic laparoscopy for pelvic treatment for women with pain at our institution between dysfunctional uterine bleeding. Jan1 1996 and Jan1 2001. Acute pain was generally classified as pain present for three months or Session 3A 1450-1500 less, chronic pain being classified as being present for over 3 months Laparoscopy in the . adolescent female Results patient A total of 75 women between the a.g.e.s. of 12 and 18 years had a R.O’Sullivan, M.Wynn-Williams, diagnostic laparoscopy performed. A.Lam, G.Cario, M.Carlton Sydney Womens Endosurgery Centre, Their mean age was 16.25 years St.George Hospital and UNSW (SD 1.6) and had an overall symptom duration of 7.4 days (SD Introduction 78). Forty of these presented acutely, with a mean symptom Pelvic pain is a common duration of 4 days (SD 5 days). presenting complaint in Ultrasound findings were present adolescent females attending in 26 (65%) of women in this gynaecological services. In many group, which correlated in all cases an underlying cause can be cases, including 2 cases of found. Pain can be categorised as obstructed Müllerian tract acute or chronic, the division abnormalities. A further 6 (15%) usually arbitrary but generally had active endometriotic lesions defined as pain present for less or discovered at laparoscopy, 4 had greater than 3 months acute pelvic inflammatory disease, respectively. The younger patient the remainder (6) having no will often have delayed diagnostic abnormalities seen at laparoscopy. procedures in the belief that the pain will remit in this group. The 35 adolescent women with chronic pelvic pain had a mean AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 22 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 3B 1330-1340 Royal Hospital for Women registrars. Some candidates were Randwick NSW from rural centres. The subjects Hysteroscopic 93826548 completed 10 laparoscopic tasks. email@example.com Training, “the Nine of the tasks were designed to Abbott J test manual dexterity, hand-eye butternut pumpkin Deputy Director coordination and instrument model” Department of Endo-Gynaecology handling. One task tested Royal Hospital for Women theoretical knowledge of Kingston A, Abbott J, Vancaillie T.G. Barker St, Randwick, electrosurgery in the form of 4 Sydney 2034 Operative hysteroscopy involves written short-answer questions. significant hand eye coordination, Vancaillie TG Candidates were marked on each utilizing energy sources, video Director task based on their precision and Department of Endo-Gynaecology speed. A pass or fail was awarded imaging and the safe control of the Royal Hospital for Women for each task and an overall distending medium .We have found Barker St, Randwick, through a series of workshops that ‘personal best’ score aggregated. Sydney 2034 the butternut pumpkin is a useful A pass was only awarded if the inanimate model to practise skills task was completed satisfactorily needed to perform safe operative Session 3B 1340-1350 in its entirety. Candidates’ heart hysteroscopy. rate measurements were taken at five-minute intervals for twenty Utilising this model, the An educational model minutes prior to the test and at the gynaecologist is able to mimic for an objective start and end of each task. Each simple grasping and cutting skills; perform parallel procedures such assessment of candidate at the end of the assessment filled out a feedback as a simulated adhesiolysis and operative questionnaire. perform simulated electrosurgery including resection of the laparoscopic skill Results endometrium and rollerball Scott Pearce,1 Zorana Mayooran,2 Jim The task with the highest pass ablation. This model allows for Tsaltas,1 Luk Rombauts,2 T. Ian H. Brown,2 Anthony S. Lawrence,1 Kym rate (81.25%) was recorded for realistic electrosurgery simulation setting up the endoscopic ‘stack’. Fraser,2 David L. Healy 2 within appropriate distention No candidates passed an 1Monash Medical Centre, Clayton, media, and demonstrates intracorporeal knot tying task or Victoria. vaporisation and carbonisation 2Monash University, Clayton, Victoria. the written task on electosurgery. effectively and safely. Most candidates who failed a task The butternut pumpkin is cheap, Objectives did so because of time constraints. relatively easy to set up and allows No correlation was found between This prospective study aims to the gynaecologist to practise a candidates ‘personal best’ and develop an objective educational electrosurgery safely whilst the years of operative model to assess the skill level of developing hand-eye coordination laparoscopic practise. There was laparoscopic surgeons using a skills. Video excerpts will be shown no correlation between heart rate pelvi-trainer. of the “operative view” within the measurements and the pass rate cavity of the pumpkin, as well an Methods of candidates. Some equipment overview of the set up used during assessment was not Sixteen doctors practising requirements. currently being used by some of gynaecology were tested on the Monash University gynaecological the candidates. laparoscopic pelvi-trainer. Eight Conclusion Kingston A Clinical Nurse Consultant Endo- candidates were FRANZCOG It is possible to objectively Gynaecology consultants and 8 were accredited evaluate basic operative Department of Endo-Gynaecology 23 F R E E C OM MU N I C AT I O N A B ST R AC TS laparoscopic skills with well experience of trainees in New The data were derived from a structured tasks and marking South Wales. Their perception of retrospective chart review from of criteria. Feedback from the the teaching skills of their trainers all admissions 1999 to 2001 candidates indicates that the was also assessed. Fourteen assessment model was questions were asked, and Results representative of what is expected trainees were advised to refer to 74% of the 96 cases identified in to be able to be performed in their training assessment records this time frame were managed gynaecological laparoscopy. for providing information. laparoscopically. There was no This paper will focus on the significant difference in the trainee’s perception of adequacy operating time between Session 3B 1350-1400 of training. Findings from a consultants and training literature search on issues relating registrars. 50% of the Endoscopic training to endoscopic surgical training will laparoscopic cases listed a also be presented. consultant as the primary experience of surgeon. In contrast, only 15% of obstetrics and laparotomies listed a consultant as the primary surgeon. The gynaecology trainees Dr Karuna Raja conversion rate to laparotomy was Fellow in pelvic surgery in NSW Liverpool Hospital almost 10%, the majority of which Dr Karuna Raja Sydney NSW (85%) which listed a training Fellow in pelvic surgery Ph: 02 9828 3000 registrar as the primary surgeon. Liverpool Hospital, Sydney NSW Mobile: 0402805241 Email:firstname.lastname@example.org The popularity of endoscopic Dr Brad Armstrong surgery has lead to the Department of Obstetrics and introduction of many new surgical Session 3B 1400-1410 Gynaecology procedures. Despite this there is a Mater Mothers’ Hospital general lack of formalised training Management of Raymond Tce South Brisbane QLD 4101 and accreditation for endoscopic Ectopic Pregnancy in Mobile 0438185641 techniques in Australia. Training opportunity is dependent upon a Tertiary Hospital: e-mail: email@example.com both the availability of Does the Surgeon’s experienced trainers, and training time. There is a real concern Level of Training among trainees about limited Influence the opportunity for endoscopic Laparotomy Rate? training, especially in peripheral hospitals. Brad Armstrong, Anusch Yazdani Mater Mothers’ Hospital, Brisbane (all Various systems have been authors) developed to improve trainee skills, such as surgical animal Objective laboratories and videoscopic simulator training. Structured To determine the of influence the training programs have been level of experience and degree of widely accepted overseas. supervision on laparotomy rates for ectopic pregnancies in a Against this background, a tertiary institution questionnaire was designed to evaluate the endoscopic surgical Methodology AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 24 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 3B 1410-1420 Setting media training tools. Further Centre for Advanced Reproductive evaluation and longer term follow- Development of an Endosurgery (CARE), North Shore up will be required to validate the Integrated Advanced Private Hospital in collaboration effectiveness of the CARE with Northern Clinical Skills program. Training Program for School and The Mater Hospitals, Training and University of Sydney. Evaluation of Minimal Methods Session 3B 1420-1430 Access Pelvic Surgery To develop the CARE program, the Objective Evaluation author caries out a world-wide A Lam, A Yazdani, M Wynn-Williams, K literature search of the teaching of a new Advanced Karthigasu, A Kwok, , H Torode, R Ford and learning of surgical skills as Integrated Minimal Background well as a review of the national Access Training training courses. The program is Major developments in divided into two advanced Program instrumentation, equipment and courses, each with a clearly Anusch Yazdani, Alan Lam, Krishnan advances in surgical skills have defined training syllabus. Each Karthigasu, Robert Ford, Michael revolutionised gynaecological course incorporates clinical skills Wynn Williams, Ray O’Sullivan surgery in the last decade. It is Centre for Advanced Reproductive and animal laboratories, live now well accepted that most Endosurgery (all authors) surgery, interactive tutorials, pelvic pathology can be managed multi-media training tools. Over a by Minimal Access surgery (MAS) period of twelve months, the Objective with the same level of confidence program has developed To evaluate the efficacy of a new and safety as at “open” surgery. standardised skill acquisition and Australian minimal access surgery The well-publicised benefits of validation programs, targeted training program. MAS are, however, only achievable performance goals, and objective when the surgeon has attained a Methodology skills and knowledge evaluation. satisfactory level of technical Prospective evaluation of competence and knowledge to Results participants of the Advanced offer patients the most The CARE program has been well Integrated Minimal Access appropriate surgical option. received by local as well as Training Program of the Centre for The uptake of MAS in gynaecology overseas fellows and registrars. Advanced has been slow. Access to an The program is recognised by the Reproductive Endosurgery, based appropriate training program, RANZCOG for CME as well as on theoretical knowledge and leaving a busy practice, Practice Improvement composite scoring of knowledge maximising the benefits for the Accreditation. A pool of data is and skills in dry and wet labs at time spent, ongoing training, being collected to evaluate the the beginning and conclusion of revision and advice have been effectiveness of the CARE program the course. some of the major obstacles to and to allow valid comparison of MAS training. the skills and knowledge between Results participants. 36 participants were evaluated Objective between February 2001 and To describe the development, Conclusion February 2002. Less than 20% of acceptance and uptake of the The uptake of MAS can be participants were able to complete CARE Advanced Integrated improved by an integrated training basic open and laparoscopic Training Program in MAS at the program with standardised skill surgical tasks. On completion of Northern Clinical School. labs, live surgery demonstration the course, all participants were and interactive tutorial and multi- 25 F R E E C OM MU N I C AT I O N A B ST R AC TS able to successfully complete lumen to span the uterotubal in relation to both trainee and these tasks. Data are presented on junction under paracervical block preceptor. the efficacy of the dry and wet or minimal sedation (Kerin, The overall failure of bilateral labs, stratified for participant age Carignan and Cher, ANZJOG, 2001; placement was 29/205 (14%). and experience. Outcome and 41; 4; 364). Over a three 3 month These failures were analysed for uptake data are presented. period a local benign tissue avoidable factors, such as poor ingrowth from the adjacent tube hysteroscopic or Essure™ into the device causes its technique, and unavoidable Dr Anusch Yazdani occlusion (Valle, Carignan and Department of Gynaecology factors such as tubal obstruction Wright, Fertil. Steril, 2001; 76; 5; or stenosis, during the learning Mater Mothers’ Hospital Raymond Tce 974). As of March 2002 there have curve. The avoidable factors South Brisbane QLD 4101 been 9700 women months’ accounted for 8% of cases and the Mobile 0408 133368 exposure to intercourse without a non avoidable factors for 6% of e-mail: firstname.lastname@example.org pregnancy to date. cases of failed bilateral placement. Methodology Session 3B 1430-1440 In 2001, Australia became the first Conclusions country to use the Essure™ device The learning curve is somewhat Essure™ in clinical practice. It was steep and peer preceptorship Hysteroscopic considered important that supervision considered most gynaecologists undertake a effective. Once the learning curve Sterilization: The formal training programme under is mastered, the 8% avoidable First Clinical preceptorship supervision in order factor should be potentially to master the Essure™ placement eliminated. There is now evolving Evaluation under technique. A series of training evidence that the bilateral Preceptorship courses as outlined in a training placement rate is consistently manual were presented as a series Training Conditions of 6 integrated modules in power above 90% after a gynaecologist has completed 15-20 Essure™ point format, a pelvitrainer device procedures. This preceptorship John F Kerin1, David Rosen2, Lynne placement session and a live case experience has provided valuable Rogerson3, Geoffrey Reid4 demonstration by one of the insight into the various challenges 1Essure™ Training and Research Centre, preceptors, Kerin, Rosen or Reid. presented to a gynaecologist Ashford Hospital, Ashford and performing a delicate operative Reproductive Medicine Unit, University of Results Adelaide, 2St. George Hospital, Kogarah, hysteroscopic procedure, often for Kerin preceptored 26 the first time in an awake woman, NSW, 3St. James University Hospital, gynaecologists in 108 procedures, Leeds, UK, 4Liverpool Hospital, Sydney, where gentleness of technique, NSW. Rosen 13 in 43 procedures and time and motion efficiency and Reid 20 in 54 procedures. During communication skills become 2001, 59 gynaecologists essential ingredients for success. Introduction performed a total of 205 Essure™ As a result a skill set of “20 Steps The safety and effectiveness of procedures, with an average of 3.5 Essure™ (Conceptus Inc., San to Successful Essure™ first time procedures per Placement” has been devised. Carlos, California, USA) as a new gynaecologist. The bilateral hysteroscopic method for placement under preceptorship permanent birth control has been supervision for Kerin was 94/108 under investigation in multicentre (88%), Rosen 36/43 (89%) and Phase II and Pivotal clinical trials Reid 46/54 (85%), demonstrating since 1998. These micro inserts a consistently high first procedure are placed into the proximal tubal success rate of bilateral placement AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 26 31 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 3B 1440-1450 » Intrauterine grooved segment in different diameters, with Uterovaginal Elevator marking acting as depth guage. Nicholas Biswas » Silastic/Santoprene cup with specific durometer and Objectives thickness ( Disposable) A new uterovaginal elevator is » Open end of the cup, of described, which is simple, different diameters, acting as effective, easy to manipulate the vaginal vault elevator. Fig 3 Biswas Uterovaginal Elevator™ uterus and also simultaneously » Open end is bevelled inwards elevate the vaginal vault, while to direct tip of the knife keeping tight air seal during total inwards to protect any damage Contact Details: laparoscopic hysterectomy. to ureters. Nicholas Biswas FRANZCOG, FRCOG Instrument » Configuration of the cup will Phone 61 2 9686 0686 Instrument is made of different maintain pneumoperitoneum Mobile 0410 568 880 segments and made of non at all times . Email: email@example.com disposable segment of surgical » Uterus can be manipulated at Suite 8, Level 3, stainless steel, and disposable all times. The Hills Private Hospital segment of Silastic/santoprene . » Sleeve at the tip of cup to 499, Windsor Road, Baulkham Following is the diagram of the prevent slippage of the cup Hills 2153 PO Box 247, Baulkham Hills instrument and functions of backwards during effort to NSW 1755 different segments: elevate vaginal vault. » Smooth segment with extension if more depth is Session 3B 1450-1500 required. » Base of the handle can double A most unusual as a sizer. foreign body removed 12 months following laparoscopic surgery. Greg Cario This video demonstrates removal intact of a large foreign body used by the surgeon to remove a 10 cm benign ovarian tumour at the time of total laparoscopic hysterectomy, 12 months earlier. Despite the large size of this foreign body it was not seen at the completion of the procedure when Fig. 1 Demonstrating different parts the pelvis was checked and of the Instrument. photographed and port closure up » Tip is flat dome prevents to the level of the umbilicus was perforation through uterine performed. There were no fundus. postoperative symptoms until Fig 2 Position of the Elevator during weeks before the surgery. This Laparoscopic Hysterectomy video is one not to miss. 27 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 4A 1530-1540 Areas covered by the paper performed. Some show a include: significant increase in Medical and Surgical » the relationship between morbidity1,2, as well as longer Innovation: An intellectual property and operating time3,4 and increased patents; conversion rate to Introduction to laparotomy 2,4,5,6,7. Others show » the requirements for a valid Protecting Inventive patent; no increase in morbidity3,8,9. Efforts » the patentability of surgical Objectives Rob Silberstein and medical inventions; and To compare laparoscopically » a brief overview of the patent assisted vaginal hysterectomy Inventors in surgical and medical (LAVH) for endometrial cancer in process in Australia. spheres are looking to laws of obese and non-obese women. intellectual property (IP) to It is critical that surgeons, provide them with protection for physicians and medical Methods their inventive efforts. One form of researchers are aware of the ways Data on all women who had a IP particularly pertinent to medical in which IP, and in particular LAVH for endometrial cancer developments relates to obtaining patents, can assist in the between January 1994 and March patent protection for such protection of their ideas. 2002 were extracted from the developments. Patents provide a Gynaecological Oncology mechanism through which DataBase in our Unit. All data was inventors can protect their Session 4A 1540-1550 collected prospectively. Women development; and may provide a with a BMI > 30 were compared to lever to assist inventors in Laparoscopically women with a BMI < 30. The obtaining financial remuneration following outcome measures were Assisted Vaginal for time, effort and money assessed: operating time, intra- expended throughout the stages Hysterectomy for operative blood loss, intra- of invention, development and Endometrial Cancer in operative and post-operative commercialisation. complications, conversion to Obese Women laparotomy and length of hospital There are several important issues relating to obtaining patents with Michele Batey, Alan Ferrier stay. which inventors and soon-to-be- Results inventors should be familiarised. Background Some of these issues should form Obesity is a growing problem in There are a total of 100 women in part of an inventive surgeon’s, our community. This, in addition the series of whom 42 had a LAVH physician’s and medical to the fact that obesity is a risk alone, 52 had a LAVH and pelvic researcher’s general knowledge factor for endometrial cancer, lymph node dissection, 5 had a since disregarding them could means that a significant number of LAVH, pelvic lymph node potentially result in irrevocable women requiring surgery for dissection and omentectomy, and loss of opportunity to be granted endometrial cancer are obese. It is 1 had a LAVH and omentectomy. patent protection for their well known that obesity increases 26 patients were classified as invention. the risk of morbidity in open obese (BMI>30) while the abdominal surgery. The remaining 74 had a BMI less than This paper has been written with relationship between obesity and 30. Multiple regression analysis surgical and medical inventors in morbidity in laparoscopic surgery was performed and the results will mind. It broadly sets out some of is more uncertain. Although none be presented. the more basic and introductory aspects of the patenting process, are specific to hysterectomy, a with an emphasis on a few of the number of studies on laparoscopic need-to-know issues. surgery and obesity have been AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 28 F R E E C OM MU N I C AT I O N A B ST R AC TS References Session 4A 1550-1600 was shorter in the laparoscopic 1. Jamieson DJ et al. Complications group (3.8days compared to of interval laparoscopic tubal Ten Year Review of 6.3days in both vaginal and open sterilization: findings from the groups). The lowest rate of major United States Collaborative Hysterectomy: Why Review of Sterilization. complications was in the vaginal Obstetrics and Gynecology isn’t there wider group (3.7%). The major 96(6):997-1002, Dec 2000. acceptance of complication rates were 13.3% 2. Delaitre B. et al. Laparoscopic and 9.4% in open and Splenectomy for Haematological Laparoscopic laparoscopic groups respectively. Diseases. Study of 275 cases. Hysterectomy? Infectious morbidity was lowest in Annales de Chirurgie 125(6):522- the laparoscopic group. 9, Jul 2000. JR Cook, RT O’Shea 3. Unger SW, Scott JS, Unger HM, Flinders Endogynaecology, Flinders Conclusion Edelman DS. Laparoscopic University and Flinders Medical Centre As previously demonstrated, approach to gallstones in the morbidly obese patient. Surgical vaginal hysterectomy is the safest Objective Endoscopy 5(3):116-7, 1991. route for hysterectomy1. To compare outcomes for open, Laparoscopic hysterectomy was 4. Jacobs SC. et al. Laparoscopic Nephrectomy in the markedly vaginal and laparoscopic designed as a substitute to open obese living renal donor. Urology hysterectomy based on ten years hysterectomy2. Detractors of 56(6):926-9, 2000 Dec 20. in a University Teaching Hospital. minimally invasive surgery point to 5. Hildebrandt U, Kreissler-Haag D, increased complication rates. As Lindemann W. Laparoscopy Methods demonstrated in this series, the assisted colorectal resections: Retrospective review of case complication rate for laparoscopic morbidity, conversions, outcomes history notes of all hysterectomies of a decade. Zentralblatt fur hysterectomy is, in fact, lower than performed from 1 January 1992 to with open hysterectomy. As the Chirurgie. 126(4):323-32, 2000 Apr. 31 December 2001. Data extracted medico-legal climate escalates and included indication, age, weight, Registrar exposure in this area is 6. Eltabbakh GH, Piver MS, Hempling RE, Recio FO. parity, operating time, estimated clearly inadequate, debate must Laparoscopic Surgery in obese blood loss, primary operator, centre on improved training if women. Obstetrics & major and minor complications1, laparoscopic surgery is to advance. Gynecology. 94(5 Pt 1):704-8, length of hospitalisation. 1999 Nov. 7. Schwandner O, Schiedeck TH, Results References: Bruch H. The role of conversion A total of 1367 hysterectomies 1. Dicker RC, Greenspan JR, Strauss LT, in laparoscopic colorectal et al. Complications of abdominal were performed in this time surgery: Do predictive factors and vaginal hysterectomy among exist? Surgical Endoscopy. period. 50% were performed by women of reproductive age in the 13(2):151-6, 1999 Feb. the open route, 29.8% by the United States. Am. J. O&G 8. Collet D, Edye M, Magne E, vaginal route and 20.2% were 1992;144:841-848. Perissat J. Laparoscopic performed laparoscopically. 2. Reich H, McGlynn F, Sekel L. Total cholecystectomy in the obese 26.8% of laparoscopic laparoscopic hysterectomy. patient. Surgical Endoscopy. hysterectomies were performed Gynae. Endoscopy, 1993;2:59-63. 6(4):186-8, 1992. by a Registrar compared to 48% 9. Singh KB, Huddleston HT, Nandy and 43% respectively in open and I. Laparoscopic tubal sterilization vaginal groups. Laparoscopic Affiliations: in obese women: experience from a teaching institution. Southern hysterectomies took an average of J.R.Cook, Fellow in Medical Journal. 89(1):56-9, 130.7mins whilst open and vaginal Endogynaecology 1996. procedures lasted an average of R.T.O’Shea, Consultant Gynaecologist 80.8mins and 89.6mins respectively. Average hospital stay 29 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 4A 1600-1610 Conclusions Three patients (4%) had When compared with other undergone previous anterior A prospective multi- laparoscopic entry techniques, vaginal colporrhaphy. centre study of direct entry is a safe, cheap, Thirteen (18%) patients effective and under-utilised underwent a concomitant laparoscopic modality for entering the operation – 10 posterior complications related peritoneal cavity in ‘low-risk’ colporrhaphy, 1 laparoscopic subjects. hysterectomy, 1 laparoscopic to the ‘direct’ entry hysteropexy and 1 sacrospinous technique. colpopexy. Session 4A 1610-1620 PD Kaloo, Liverpool Hospital. Five cases (6.8%) of bladder MJW Cooper, King George V Hospital, perforation occurred. NSW. A long-term follow-up No major intraoperative or GD Reid, Liverpool Hospital, NSW. DJ Kowalski, Liverpool Hospital, NSW. of laparoscopic Burch postoperative complications colposuspension. occurred. Fourteen (19%) patients Objectives developed a postoperative urinary Scott Pearce1, Kenneth Leong1, Anna tract infection. Median duration of to prospectively evaluate the Rosamilia1, Geoffrey Edwards1. 1Monash Medical Centre, Melbourne, urinary catheterization was 3 major complication profile of the Victoria. days. Median hospital stay was 3 ‘Direct’ entry technique at time of days (range 2 – 9 days). diagnostic or operative laparoscopy. Background Eighty six percent of patients had Urinary stress incontinence is a no stress incontinence at the 6 Methods common and often debilitating week follow up. Over a period of 3 years, 1838 condition affecting women. Our Of 45 patients telephoned for follow consecutive subjects were objective is to assess long-term cure up, the long-term subjective stress recruited from the practice of two rates, complications and patient incontinence cure rate was 81%. experienced gynaecological satisfaction with laparoscopic Burch Twenty one percent of women endoscopists. Complications colposuspension. complained of urge incontinence. directly related to the entry One patient complained of recurrent technique that occurred intra- Methods urinary infections (3 or more per operatively, either immediately or A retrospective patient history year). When asked to grade up to 2 weeks post-operatively record review of 73 consecutive satisfaction with overall bladder were recorded prospectively. women who underwent function on a linear scale between 1 Complications were considered laparoscopic Burch and 10, the median score was 8.5 events that significantly prolonged colposuspension at Monash (interquartile range 5 - 10). or altered the planned procedure, Medical Centre between 1995 and delayed discharge or led to a 2000 was performed. Forty five Of the telephoned patients, two prolongation of the subjects (62%) of this group could be (2.7%) had undergone further convalescence. contacted by telephone interview incontinence surgery and three to assess subjective cure rates, (4%) prolapse surgery – 2 Results complications and patient posterior colporrhaphy and one Only one major injury occurred. An satisfaction. anterior colporrhaphy. injury to large bowel occurred with Conclusions immediate diagnosis and Results laparoscopic management with no The median patient age was 51 Long-term subjective cure rates long-term sequelae. years and median follow up 28 are satisfactory. Few major months (range 10 – 60 months). complications were reported. Overall patient satisfaction was AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 30 F R E E C OM MU N I C AT I O N A B ST R AC TS high with poor satisfaction often Tripolar diathermy, and the Ligasure being associated with the Atlas. The purpose of the study was presence of urgency or urge to address the issue of cost because incontinence, even if subjectively of the high cost of disposables stress incontinence was cured. inherent in the use of staples. Results Session 4A 1620-1630 There were 2 bladder injuries, 1 ureteric injury, 2 bowel injuries, 9 Laparoscopic Assisted cases were converted to open for haemostasis and 8 patients Vaginal require blood transfusions of all Hysterectomies, the LAVH performed. Review of Tweed Heads Length of surgery (LAVH alone) in minutes were 88±26 for endoGIA Experience With (n=190), Diathermy 114±34 (n= 4), Respect to Outcome, tripolar 117±65 (n=5) and Ligasure Atlas 87±20 (n=10). The average Complications, length of stay in hospital was Techniques, Time and 3.3±2.9 days. Cost. Conclusion Our complication rates are Dr Sim Hom Tam*, comparable to the literatures. The Dr P Henderson#, Dr C Margin# differences in time of operation *Registrar Liverpool Hospital, #Gynaecologist Tweed Heads & John has a considerable bearing on the Flynn Hospitals theatre costs of the procedure and bearing this in mind it is calculated Background that considerable cost savings (Au$ 600 per case) are achievable LAVH is gaining popularity as the through the use of the Ligasure alternative to abdominal Atlas in our service with similar hysterectomy. Various methods outcomes. are decribed to performed and cost remain a major hindering factor. *Contact Objective Dr Sim Hom Tam (02)9828 5676 or To review the outcome and reduce 0414 255717, the cost of LAVH in our service. Email firstname.lastname@example.org Technique A retrospective analysis of 287 LAVH’s was undertaken to compare the outcome, (complication, time in theatre, length of stay) and theatre costs of the same procedure by the same personnels utilising the modalities endoGIA, Diathermy, 31 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 8A 1330-1340 of total laparoscopic hysterectomy. The decision to proceed with TLH is helped by the various The use of dual Methods instruments at different steps energy sources for The records of all patients along the operation up to vault undergoing laparoscopic closure. Manipulation of the large laparoscopic hysterectomy in which bipolar uterus, isolation of the uterine hysterectomy diathermy (Aesculap Adtec arteries, precise vaginal vault Bipolar) combined with LSC or delineation and vault suturing will M Wynn-Williams, Ray O’Sullivan, Harmonic scalpel (JJM) was used be demonstrated on video. A Lam were reviewed. The operative Centre for Advanced Reproductive Endosurgery technique is described combined North Shore Private Hospital with video demonstration Session 8A 1350-1400 Results Background Use of a Hands Free Since March 2000, there were 114 A single energy source is generally women undergoing laparoscopic Uterine Manipulator used and recommended in laparoscopic hysterectomy for hysterectomy in which the and Vaginal Funnel as Aesculap Adtec bipolpar safety reason. This is either in the diathermy was used in conjunction an aid to Total form of electrocautery, ultrasonic with the LSC or harmonic scalpel. Laparoscopic or laser energy. This may be The indications for surgery, the combined with the use of suturing anaesthetic time, EBM, pathology Hysterectomy. and extracorporeal or results, perioperative L.D. Brett and P. Maouris intracorporeal knot tying for complications are presented. Gynaecology Clinical Care Unit, King ligation of ovarian and uterine Edward Memorial Hospital for Women, pedicles. Conclusion Perth Western Australia. The use of electrocautery, The combined use of LCS and Appropriate uterine manipulation particularly in unipolar mode, is Bipolar diathermy is safe and and dileneation of vaginal fornices associated with potential increases the efficiency of remain an essential part of complications. Bipolar current, on laparoscopic hysterectomy. performing total laparoscopic the other hand, while an excellent hysterectomy. To date, most of the coagulation tool, is not an effective systems available necessitate a cutting instrument. The ultrasonic Session 8A 1340-1350 second assistant to perform the energy, delivered via a harmonic manipulation. The system scalpel or laparoscopic Total Laparoscopic presented allows full uterine coagulating shear, is an excellent and safe tissue dissector, Hysterectomy (TLH) - movement by the surgeon with an intrauterine cannula and teflon particularly in the division of the instruments to help vaginal funnel. This system round, broad, utero-sacral the average simplifies the delineation of the ligaments, parametrium and the vaginal fornices, uterine vessels vaginal vault. gynaecologist tackle and ureters without the use of a Objective the large uterus. second assistant. The facilitation Dr Jiwan Steven Singh of bladder disection, colpotomy To describe, demonstrate and and vaginal vault closure will be discuss the concurrent use of A video of cases to demonstrate demonstrated. Bipolar Diathermy and ultrasonic manipulation of the large uterus energy (laparoscopic coagulating and new instruments to facilitate shear or harmonic scalpel) to safe TLH. increase the safety and efficiency AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 32 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 8A 1400-1410 Variation of technique: Session 8A 1410-1420 One case, one side uterine vessels Large uterine fibroid stapled vaginally, A Decade of masses removed - inadequate access from above Laparoscopically endoscopically by because of lateral fibroid. Assisted Vaginal total laparoscopic Mean Range Hysterectomy Vs Total hysterectomy and Specimen weight: 560g (285- 1,000g). Laparoscopic trans-abdominal Operating time: 185 mins (135-280 Hysterectomy morcellation: 22 mins). RT O’Shea, JR Cook, Seman EI, Verco consecutive cases Post-operative stay: 2 days (1-3 CJ, Lombardi E. days). Flinders Endogynaecology, Flinders since 1997. University and Flinders Medical Centre Roger A. McMaster-Fay, Complications: No injuries or re- Dept O & G, University of Sydney, operations; Objective Nepean Hospitals, Penrith. No transfusions or post-op. Hb < To compare the outcomes between 85; LAVH and TLH based on a 10 year Since late 1997, 22 consecutive cases of large uterine fibroid X 1 readmission for 24 hours, no experience at Flinders masses have been removed totally treatment; Endogynaecology, Flinders endoscopically using the one X 2 infections treated with oral University and Flinders Medical technique. antibiotics; Centre Technique X 1 hypertensive episode post-op. Methods 1. Vaginal mobilization of bladder + partial visual field loss ? cause. Retrospective analysis of case (Koninckx technique 1992), records for all women undergoing Summary laparoscopic hysterectomy at -simple uterine elevator (Wolf ) Here is a safe technique for Flinders Endogynaecology over the applied; removing large uterine fibroid ten year period 1 January 1992 to 2. Staples (EndoGIA) trans- masses totally endoscopically. 31 December 2001. Data extracted abdominally for all vascular included age, weight, indication, pedicles, surgeon, operating time, 1 McMaster-Fay R. (1997) -via umbilical port for uterine Gynaecological Endoscopy estimated blood loss, vessels (McMaster-Fay1 ); 6(Supp): 59. complications and length of 3. Morcellation (WISAP) trans- hospital stay. The most common abdominally via 15mm port indications were heavy menstrual (left); bleeding (37.3%), fibroids (22.8%) and prolapse (8.8%). There were 4. Uterus cut off vagina with Roger A. McMaster-Fay, Dept O & G, University of Sydney, 424 TLH procedures performed laparoscopic scissors, and 382 LAVH procedures. Nepean Hospitals, Penrith. -moist vaginal pack to maintain PO Box 82, Emu Plains, NSW Comparisons were then made pneuoperitoneum, 2750, Australia. between LAVH and TLH. -uterine stump delivered Results vaginally; The average age was 47.2years 5. Vagina closed laparoscopically (range 18-86), average weight (EndoStitch), 75.5kg (range 39-135) and average -suction drain in pelvis. parity 2.3 (range 0-11). TLH was, on 33 F R E E C OM MU N I C AT I O N A B ST R AC TS average, performed in less time Session 8A 1420-1430 pulmonary emboli declined from than LAVH (122mins Vs 132mins) 0.2% to zero. The rate of infectious and was associated with less morbidity declined from 18% to average blood loss (137mL Vs Total Abdominal 14.4%. Hospital stay likewise 261mL). The major complication Hysterectomy: still a declined from an average of rate for TLH was 5.4% and for 7.5days to 5.5days. LAVH 8.4%. This included a higher viable option? rate of excessive blood loss, JR Cook, RT O’Shea, S Kennedy- Conclusions transfusion, bladder injury, bowel Andrews There has been a definite trend Flinders Endogynaecology, Flinders towards a lower rate of open injury, conversion to open and University and Flinders Medical Centre return to theatre for bleeding in hysterectomies in the last 12 years the LAVH group. Women in the TLH which has co-incided with the group spent an average of 3.4days Objective introduction of laparoscopic (range 1-14) in hospital compared To present current Australian hysterectomy. Almost universal to an average of 4.8days (range 1- statistics for Total Abdominal use of prophylactic antibiotics and 13) for the LAVH group. hysterectomy based on a 12 year heparin has resulted in a decrease experience in a University in the rate of pulmonary emboli Conclusion Teaching Hospital and infectious morbidity. These As demonstrated previously1, TLH results are consistent with other remains a superior option for Methods published results for open laparoscopic removal of the Retrospective analysis of case hysterectomy.2,3 The open uterus. records for all women undergoing approach remains a safe route of References abdominal hysterectomy over the hysterectomy and certainly a 1. O’Shea RT, Gordon SJ, Seman EI, twelve year period 1 January 1990 viable option for gynaecologists Verco CJ. Total laparoscopic tube to 31 December 2001. Data without laparoscopic skills. Hysterectomy: a safer option? extracted included age, weight, Gynae. Endoscopy indication, antibiotic usage, References: 2000;9(5):285-291 heparin usage, operating time, 1. Dicker RC, Greenspan JR, Strauss estimated blood loss, LT, et al. Complications of complications and length of abdominal and vaginal hospital stay. Major complications hysterectomy among women of reproductive age in the United Affiliations: were defined as estimated blood States. Am. J. O&G 1992;144:841- R.T.O’Shea, loss in excess of 1000mL, 848. Consultant Gynaecologist transfusion, visceral injury, return 2. Chryssikopoulos A, Loghis C. J.R.Cook, to theatre for bleeding and Indications and Results of Total Fellow in Endogynaecology pulmonary embolus.1 Hysterectomy. Int. Surg. 1986; E.I.Seman, Consultant Gynaecologist Comparisons were made between 71:188-194. C.J.Verco, the periods 1990 – 1994 and 1995 3. Varol N, Healey M, Tang P, et al. Consultant Obstetrician and – 2002. Ten-Year Review of hysterectomy Gynaecologist morbidity and mortality: can we E.Lombardi, Results change direction? ANZJO&G Consultant Obstetrician and 2001;41(3):295-302. The percentage of open Gynaecologist hysterectomies performed over this time period declined Affiliations: dramatically from 68% (562) to J.R.Cook, 39.7%(373). There was a non- Fellow in Endogynaecology significant decline in the rate of R.T.O’Shea, major complications from 11.2% to Consultant Gynaecologist 10.8%. There was a zero rate of S.Kennedy-Andrews, ureteric injury. The incidence of Consultant Obstetrician and Gynaecologist AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 34 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 8A 1430-1440 5.3% to 2.6%.The transfusion rate Session 8B 1330-1340 dropped from 2.6% to zero. There was a zero rate of ureteric and Laparoscopic mesh Vaginal Hysterectomy bowel injury over the twelve year sacrocolpopexy for remains the safest period. The length of hospitalisation declined from an recurrent vault Method for average of 8.5days to prolapse. Hysterectomy 5.3days.There was a non- Dr. Gregory M. Cario, JR Cook, RT O’Shea, significant decline in the rate of Sydney Women’s Endosurgery Centre S Kennedy-Andrews, infectious morbidity (27.5% to Flinders Endogynaecology, Flinders 25.8%). This has co-incided with There is a lifetime risk of 11% of University and Flinders Medical Centre. wider use of prophylactic undergoing an operation for pelvic antibiotics. The rate of thrombo- floor prolapse with about 30% Objective embolic events dropped from requiring multiple operations. To present current Australian 0.4% to zero and this Vault prolapse post hysterectomy statistics for vaginal hysterectomy corresponded with greater use of has been reported in up to 43% of based on a 12 year experience in a prophylactic heparin post- patients. Sacrocolpopexy has University Teaching Hospital operatively. been found to be an effective procedure for repair of vault Methods Conclusions prolapse with success rates Retrospective analysis of case A decline in the rate of vaginal ranging from 84%- 98% but records for all women undergoing hysterectomy was observed over traditionally this requires a vaginal hysterectomy over the the past 12 years in our institution. laparotomy, which limits its use. In twelve year period 1 January 1990 This has co-incided with the the age of minimally invasive to 31 December 2001. Malignancy introduction of laparoscopic surgery, we present in video and obstetric emergencies were hysterectomy. This is despite format, our surgical technique for excluded. Data extracted included evidence of low major and minor laparoscopic sacrocolpopexy age, weight, indication, surgeon, complications rates for vaginal using mesh. This can be antibiotic usage, heparin usage, hysterectomy.1,2 performed safely and efficiently operating time, estimated blood with operating times comparable loss, uterine weight, complications References: to open surgery, once curved and length of hospital stay. The 1. Dicker RC, Greenspan JR, Strauss LT, needle suturing has been most common indications overall et al. Complications of abdominal mastered. The identification of site were prolapse (82.1%) and heavy and vaginal hysterectomy among specific pelvic floor defects and women of reproductive age in the menstrual bleeding mesh length, tension and position United States. Am. J. O&G (10%).Comparisons were made 1992;144:841-848. is vital particularly to avoid between the periods 1990 – 1994 2. Garry R, et al. EVALUATE (in press). anterior enterocele. and 1995 – 2002. Results The overall average age was 60.8years (range 25-90) and Affiliations: average weight was 67.8kg (range J.R.Cook, Fellow in Endogynaecology 40-118). Over the last 12 years R.T.O’Shea, there has been a decline in the rate Consultant Gynaecologist of vaginal hysterectomy (32% S.Kennedy-Andrews, down to 26.9%). The major Consultant Obstetrician and complication rate declined from Gynaecologist 35 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 8B 1340-1350 there was 1 DVT, 1 pelvic infection, The approach to restoration of 1 urinary infection and 2 cases of vaginal vault prolapse with Initial experience significant back pain. Median associated anterior and posterior with laparoscopic hospital stay was 2 days (range 1- defects can be achieved using the 9 days). At 6 weeks, 2 patients had patients native tissue and pelvic floor repair symptomatic prolapse and 2 attachment to uterosacral Scott Pearce, Anthony Lawrence, asymptomatic prolapse. Of the 17 ligaments. This gives a durable Anna Rosamilia, Jim Tsaltas. patients seen at 6 months, 4 and anatomic result without the Endosurgery unit patients had prolapse present, 2 use of synthetic grafts. Monash Medical Centre and Monash asymptomatic. University, Melbourne. Furthermore, intraoperative assessment of presumed defect, Conclusions proposed support structure and Laparoscopic prolapse repair is a Objective realtime anatomical correction low morbidity procedure. The To evaluate perioperative allow safe and accurate defect initial operating time learning morbidity and surgical outcome in reconstruction. curve is reduced as proficiency patients following laparoscopic with laparoscopic suturing The objective is to present the pelvic floor repair. improves. Initial surgical outcome technique and anatomical is satisfactory. Long-term principals of defect identification Methods and repair, and to discuss the outcomes will be awaited. The case notes of thirty-eight Laparoscopic pelvic floor repair current literature in support of this consecutive patients who had a cannot adequately correct a technique. laparoscopic pelvic floor repair midline cystocoele, low rectocoele were reviewed. The procedures or perineal deficiency. These » Shull BL. Bachofen C. Coates KW. were performed at a Melbourne defects can be repaired vaginally Kuehl TJ. A transvaginal approach tertiary teaching hospital or at 2 at the same time as the to repair of apical and other private hospitals by 6 surgeons. laparoscopic procedure. associated sites of pelvic organ The main outcomes measured prolapse with uterosacral were perioperative complications ligaments. American Journal of Obstetrics & Gynecology. and surgical outcomes. Session 8B 1350-1400 183(6):1365-73; 2000 Dec. Results » Barber MD. Visco AG. Weidner AC. Median age was 50 years. Eight Intraoperative Amundsen CL. Bump RC. Bilateral uterosacral ligament vaginal (21%) patients had previously had assessment and vault suspension with site- a vaginal repair and 1 (2.6%) a reconstructive surgery specific endopelvic fascia defect Burch colposuspension. Nine repair for treatment of pelvic (23%) patients had a single for correction of vault organ prolapse. American Journal of Obstetrics & Gynecology. laparoscopic procedure whilst 29 prolapse associated 183(6):1402-10; 2000 Dec. (76%) underwent multiple procedures. Median operating with enterocele, » Carter JE. Winter M. Mendehlsohn S. Saye W. Richardson AC. Vaginal time for all procedures was 155 rectocele or cystocele, vault suspension and enterocele minutes (range 47-235 mins). repair by Richardson-Saye Fourteen (36%) patients utilizing fascial laparoscopic technique: underwent a concurrent vaginal reattachment to description of training technique and results. Journal of the Society operation and 2 required uterosacral ligaments. of Laparoendoscopic Surgeons. laparoscopic division of 5(1):29-36, 2001 Jan-Mar. adhesions. One bladder wall V Lamaro suture occurred at a Burch Department of Gynaecology, St Vincent’s Campus, Sydney colposuspension. Postoperatively AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 36 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 8B 1400-1410 electrocautery. The treated skin, Session 8B 1410-1420 buried beneath the pubocervical The use of ablated fascia with interrupted plicated Prolapse vaginal skin in the sutures, is meant to act as a skin graft to add support and strength symptomatology and repair of central impact on life and Operative details are recorded, cystocele including perioperative quality of life complications. The women are M Wynn-Williams, Ray O’Sullivan, assessment of women A Lam followed up at 6 weeks, 6 months Centre for Advanced Reproductive then a year. with genital prolapse, Endosurgery North Shore Private Hospital Results pre and post The technique was simple to laparoscopic pelvic Background perform. There was no increase in floor repair- a Central cystocele, caused by operating time. There was no attenuation or tear in the intraoperative or immediate prospective study pubocervical fascia, has postoperative complication. Krishnan Karthigasu, Anusch classically been repaired by Follow-up time ranges from 6 Yazdani, Alan Lam, Greg Cario, Mark weeks to 12 months. Four women Carlton midline plication of the developed inclusion cysts in the Sydney Women’s Endosurgery Centre pubocervical fascia with Centre for Advanced Reproductive absorbable sutures. This is anterior vaginal wall at 8 months Endosurgery associated with a high a from the time of surgery. Two have recurrence rate (15-30%) and required surgical excision, and Genital prolapse is a common potential denervation of the two remain asymptomatic. condition and usually women bladder base. (Anterior present in later life for treatment. Conclusion colporrhaphy has been associated In the twenty first century women with post-operative urge urinary With a 9% inclusion cyst rate, are living longer and healthier and symptoms, believed to be further assessment of this surgical are expecting that many of the secondary to trigonal technique is required. A trial conditions that is not life denervation.)i. comparing traditional anterior threatening, but inconvenience life repair with the ablated skin graft are effectively treated. Objective technique, with long term follow Unfortunately with prolapse, the To report our experience in the use up is planned. treatments that have been of ablated vaginal skin in the available in the past are repair of central cystocele i Stanton ,Hilton, Norton, Cardozo notoriously ineffective and are Clinical and urodynamics effects of anterior coloporrhaphy and associated with a number of Methods complications. vaginal hysterectomy for 43 women underwent repair of prolapse with and without Over the past decade there has central cystocele either as a incontinence. BJOG May 1982 89; been an emergence of primary or secondary procedure 459-463 laparoscopic gynaecological over a period of twelve months operations, including laparoscopic from May 2001 as part of their treatment of genital prolapse. The pelvic reconstructive operation. presumed advantages of the The technique involves a diamond laparoscopic route are improved shaped skin incision over the base visualisation leading to better of the central cystocoele. The assessment of the pelvic floor incised skin, instead of being anatomy and defects, better excised, is fulgurated with ability to access the defects and 37 F R E E C OM MU N I C AT I O N A B ST R AC TS repair them, better identification of Session 8B 1420-1430 above do not apply in young vital structures and avoid them nulliparous women, this variation and faster recovery time and return The case for a is likely to be at least partly to normal activity. congenital contribution congenital. When the same group However there is relatively little of patients was stratified for to female pelvic organ ethnicity, women of Asian data to assess the effectiveness of the laparoscopic route of prolapse and stress background could be shown to treatment. In fact there is little have significantly less descent of incontinence the anterior and posterior data overall assessing the impact of genital prolapse on a woman’s H.P. Dietz compartments (p = 0.03 and 0.04 Royal Hospital for Women and King antepartum and p= 0.01 and 0.02 life and quality of life issues pre George V Hospital postpartum). and post surgical repair of genital Sydney, Australia prolapse. These issues are the Once a phenotype is sufficiently well most important in terms of the Genuine Stress Incontinence (GSI) defined and a congenital and patient, as regardless of the and Female Pelvic Organ Prolapse possibly genetic contribution surgery performed, the woman will (FPOP) are both multifactorial in suspected, molecular genetic be satisfied if the symptomatology nature, with pregnancy, childbirth, techniques are required for further she presents with is cured and she obesity, constipation and asthma investigation. This paper will discuss can resume the activities she mentioned as predisposing the rationale for doing so, outline desires with a minimal risk of conditions. However, there is possible approaches and present adverse complications. All evidence that congenital factors first results of a target gene approach surgeons should be aware of these also play a role. First- degree focusing on one of the most symptoms and their degree of family history carries a relative risk promising connective tissue genes, impact of the patient’s life before of 2.4 to 3.2. Furthermore, FPOP in Collagen 3A1. embarking on surgical repair. young women is familial in 30%, Our units have commenced a and seems to occur similarly in prospective questionnaire survey identical twins. Ethnic back- assessing the symptoms of ground seems to influence the risk prolapse and degree of impact of of developing FPOP and GSI, and a the prolapse of the woman’s life, racial difference has recently been plus quality of life assessment confirmed for bladder neck using validated questionnaires on mobility. women undergoing laparoscopic Two recent observations treatment of genital prolapse. strengthen the theory that The study was commenced in congenital factors contribute to January 2001 and as of December the development of GSI and FPOP. 2001 80 patients have been In a study conducted on 200 enrolled prospectively with 20 nulliparous pregnant women, all reaching the 6 month follow up indices of pelvic fascial support mark. This talk will discuss the varied widely: for position of the interim prolapse symptomatology bladder neck on Valsalva from 34.4 impact on life and quality of life mm above to 16 mm below the results of this ongoing study into symphysis, for Cervical position laparoscopic treatment of genital from 87 mm above the symphysis prolapse. to 21 mm below, and for the rectal ampulla from 58 mm above to 30 mm below the symphysis. Since virtually all risk factors described AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 38 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 8B 1430-1440 hysterectomies. Forty-two (13.8%) Session 8C 1340-1350 procedures were converted to Laparoscopy in the open surgery because of A two year experience elderly patient pathology (35 cases) and of the role of complications (vascular and bowel R.O’Sullivan, M.Wynn-Williams, complications and technical laparoscopic vaginal A.Lam, G.Cario, M.Carlton Sydney Womens Endosurgery Centre, problems) (7 cases). vault suspension St.George Hospital and UNSW The mean in-patient stay was 3.4 (lyons,liu) days (SD 2.1). Anaesthetic Introduction complications occurred in 2 cases Elvis I Seman, JR Cook, RT O’Shea Flinders Endogynaecology As the mean population age with intra-operative complications advances, an increasing demand on occurring in 5 (1.6%). The post- operative course was complicated Objective healthcare resources will come from the over 60 years age group. With in a total of 10 (3.2%) cases. Two To assess the technical ease, improved anaesthetic and surgical patients developed venous efficacy and safety of the techniques there is less associated thrombo-embolism, 1 had Laparoscopic Vaginal Vault morbidity in these age groups. pneumonia diagnosed, 2 had Suspension, as described by urinary tract infections ,2 had Lyons and Liu1, and define its role Objective urinary retention and 3 had post- in the treatment of genital We aimed to review the morbidity op ileus. Two patients (0.65%) prolapse. and mortality rates associated with died following their surgery, a 75 Method laparoscopy in a group of female year old had a pulmonary embolus patients over 65 years old at our and the other, a 69 year old A prospective review of 60 institution over a 2 year period. developed peritonitis following a patients from April 2000 to April bowel perforation secondary to 2002.Cure is defined in terms of Study design ischaemia and ileus. restoration of anatomical A retrospective review of the structure and function. Pre- Overall there was a 0.65% clinical data set collected by our operatively, prolapse was mortality rate with a 7.2% institution was undertaken. All qualified into an attachment or complication rate, both figures laparoscopic procedures fascial defect at Delancey level I, II exceeding the quoted rates in the performed on female patients by or III.2 Each case was then literature by a factor of 2. the gynaecological and surgical quantified by POPQ system of services between January 2000 The overall complication rate for prolapse assessment. Each and Dec 2001 were included. all laparoscopies was 3.2%, patient underwent Laparoscopic however, it rose to 5.2% for VVS in isolation or in combination Results operative laparoscopy compared with other laparovaginal pelvic A total of 304 patients were with 1.2% for diagnostic floor repair procedures. eligible for inclusion. The patients laparoscopy (p <0.001, Fisher’s Postoperative assessment had a mean age of 69.3 years (SD exact test). involved POPQ staging at 6 weeks 7.1), with 106( 34.8%) of the and then six monthly. patients having their laparoscopies performed by the Results gynaecological services . A variety Average operating times for VVS in of procedures were performed, isolation and in combined including diagnostic procedures were 70 mins (range laparoscopies, laparoscopic 30-90) and 141min (range 30 – cholecystectomies, ovarian and 240) respectively. The total rate of adnexal surgery, colectomies and major complications was 6.7% (four cases) and minor 39 F R E E C OM MU N I C AT I O N A B ST R AC TS complications 27%. The mean Session 8C 1350-1400 (Valsalva). There were no duration of hospital stay was 4.6 consistent relationships between days (range 1-18). After follow-up Does TVT location symptoms (incl. voiding at 2 years, there were seven matter ? dysfunction) and tape position anatomic failures – objective and mobility except between success 88% at 2 years (mean H.P. Dietz, L. Mouritsen#, G. Ellis*, stress incontinence and lower P.D. Wilson* follow up 10 months). This tape position on Valsalva (-0.75 Royal Hospital for Women, Sydney, procedure is technically the Australia, #Glostrup Hospital, (StD 0.68) in women with SI vs. - simplest of all laparoscopic pelvic Copenhagen, Denmark and *Dunedin 0.35 (StD 0.69) in those without, floor procedures. School of Medicine, University of Otago, p= 0.003) when all assessments Dunedin, New Zealand were considered. This relationship Conclusion however did not reach significance Laparoscopic VVS is a technically Aims when only one assessment per simple, effective, safe and widely patient was evaluated. The TVT appears to enjoy applicable procedure for Delancey widespread popularity for the Conclusion Level I support failure. With the surgical treatment of Genuine current availability of training The position and mobility of the Stress Incontinence, providing courses facilitating the translation TVT varies markedly even with an good cure rates in a wide range of of open into laparoscopic suturing operative technique that clinical situations. This study was skills, it ought to become a supposedly follows the standard designed to investigate tape general gynaecological procedure. recommendations. This may be position and mobility after TVT References explained by varying degrees of and correlate this data with 1. Liu CY (ed.): Laparoscopic dissection and the preoperative symptoms of incontinence, Hysterectomy and Pelvic Floor degree of anterior vaginal wall frequency, nocturia and voiding Reconstruction. Massachusetts, prolapse. However, variations in Blackwell Science, 1996. dysfunction. placement have relatively little 2. DeLancey JOL. Anatomic aspects Methods effect on symptoms, This confirms of vaginal eversion after the clinical impression that the hysterectomy. Am. J. O&G. 141 patients who had undergone a TVT were seen yearly over four TVT has a wide margin of 166:1717-24, 1992. years, resulting in 245 functional safety and efficacy. assessments. A standardized symptom questionnaire was filled in, with special emphasis on Affiliations: E.I.Seman, voiding. The TVT is echogenic and Consultant Gynaecologist easily identified on translabial J.R.Cook, ultrasound in the midline dorsal to Fellow in Endogynaecology the urethra. Images were taken at R.T.O’Shea, rest and on Valsalva and the Consultant Gynaecologist position of the superior tape margin determined relative to the inferoposterior symphyseal margin. Results Tape placement varied from 30 mm above to 10 mm below (at rest) and between 12 mm above to 23 mm below the symphysis AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 40 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 8C 1400-1410 laparoscopy with suspected or improvement was also statistically confirmed endometriosis had to different between these groups: A double-blind be present. Women were median improvement 0% (Inter randomised, placebo randomized to one of two groups Quartile Range (IQR) 0-13) vs. prior to surgery; Group 1 had a median improvement 30% (IQR 0- controlled trial planning laparoscopy at time 0, 50) p<.017. Following second evaluating followed by excisional surgery at surgery, 83% of women in group time 6 months and final one reported an improvement in laparoscopic surgery assessment at 12 months. Group 2 symptoms and 60% of women in for endometriosis had excisional surgery at time 0, a group 2 reported an improvement second look laparoscopy at time 6 in symptoms. As part of the related pain months and final assessment at 12 protocol, 16/20 women in group 2 Jason Abbott, Jed Hawe, David months. Women were blinded to had further disease excised at the Hunter, Graham Phillips, Ray Garry. their allocation group until the 12 time of their second look Department of Endo-Gyanecology, Royal month follow up assessment. All laparoscopy. At the end of the Hospital for Women, Sydney Australia data was collected by follow up period 79% of women in questionnaire administered by a group 1 and 100% of women in Objective blinded research nurse. Surgery group 2 reported that their To assess the effects in pain and for both procedures involved 4 symptoms had been improved. quality of life following incision sites, abdominal drain, Twelve women were trying to laparoscopic surgical excision of catheter and patient-controlled conceive during the follow up endometriosis in women with analgesia device in the post- period. There were six women who pelvic pain. operative period. Patients were conceived overall. Three of these excluded from the study if they did were in Group one and conception Design not have histologically confirmed only occurred after their second A double-blind, randomised, disease. (true) surgery. Three women in placebo-controlled trial Group two became pregnant after Main Outcome Measures their first (true) surgery. No Setting Overall response to surgery and women became pregnant A minimal access gynaecological overall symptom reduction; pain following placebo surgery. unit within a district general scores for dysmenorrhea, non- hospital in North-East England cyclic pelvic pain, dyspareunia and Conclusion dyschesia as assessed by visual There is a clear relationship Population analogue score. Pregnancy was a between excision of 54 women with pelvic pain and secondary outcome measure. endometriosis and improvements clinical features suggestive of in overall pain symptoms. There Endometriosis Results appears to be a benefit in Following randomisation, 7 performing second look Methods women were withdrawn following laparoscopy. There appears to be a Women who had pelvic pain such laparoscopy as there was no benefit to women wishing to as dysmenorrhea, non-cyclic histologic confirmation of conceive following excision of pelvic pain, dyspareunia or endometriosis. 6 women withdrew endometriosis. dyschesia were considered form prior to surgery and two became inclusion in the study. In addition, pregnant prior to surgery. This left clinical findings suggestive of 39 women available for analysis. invasive pelvic disease, In group 1, 22% reported an ultrasound or other radiologic improvement after their first features suggestive of surgery compared to 73% in Group endometriosis or previous 2 (p<0.01). The degree of 41 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 8C 1410-1420 Session 8C 1420-1430 average of 8.5 postoperative days. Follow up ranged from 3-16 Laparoscopic Assisted Endometriosis of the months. Medical suppression was Low Anterior urinary tract: An used in 8% of cases. 3 women underwent further surgery. Resection for Australian Conclusions treatment of severe collaborative study Urinary tract endometriosis occur in Recto-Sigmoid A Lam, FRANZCOG., A Yazdani, 1-45 of all cases. Many women have FRANZCOG., MC Cooper, FRANZCOG., Endometriosis G Reid, FRANZCOG., PJ Maher, concomitant pelvic, ovarian, bowel FRANZCOG., G Cario, FRANZCOG,. J disease. Diagnosis is often delayed M Wynn-Williams, A Lam, Ray Tsaltas, FRANZCOG., M Wynn- with serious consequences. There O’Sullivan, Margaret Schnitzler Williams, MRANZCOG., R O’Sullivan, are no randomized trials to guide Centre for Advanced Reproductive MRCOG. management. A multidisciplinary Endosurgery approach is required. Surgery is North Shore Private Hospital Objective indicated in the presence of ureteric To study the prevalence, obstruction, severe pelvic fibrosis, Objective presentations, management and deep nodules. Medical therapy To discuss a multidisciplinary outcome of urinary tract requires careful follow-up. approach to the management of endometriosis. severe recto-sigmoid endometriosis. Design & Setting Retrospective review of all cases Patient of urinary tract endometriosis 43 yr old nulliparous woman managed at tertiary referral cyclical rectal bleeding, pelvic centres in Australia. OUTCOMES: pain, abdominal distension and A total of 26 cases were collected. altered bowel habit. Mean age = 36.8 (range 26-53). Parity = 61.5% nulliparous. 69% Methods had had multiple previous surgery. A case presentation and video of a Presenting complaints included laparoscopic assisted anterior pelvic /abdominal pain 92%, resection for severe endometriosis dysuria 34%, cyclical of the recto-sigmoid. dysuria/stranguria 17%, urgency 13%, haematuria 8%, pelvic mass Conclusion 4%. Preoperative investigations In the hands of a multidisciplinary included ultrasound 39%, team, laparoscopic assisted cystoscopy 43%, IVP 13%, CT 8%. anterior resection can be safely Operative findings showed performed with rapid patient bladder lesions 86%, ureteric recovery. lesions 22%, concomitant pelvic disease 52%, concomitant bowel disease 26%. Procedures performed included laparotomy 26%, laparoscopic partial cystectomy 56%, laparoscopic nephrectomy 4%, ureteric stents 34%. IDC was used for and AUSTRALIAN GYNAECOLOGICAL ENDOSCOPY SOCIETY XIIth ANNUAL SCIENTIFIC MEETING 42 F R E E C OM MU N I C AT I O N A B ST R AC TS Session 8C 1430-1440 route are improved visualisation of the anatomy of the pelvic defect, Sexual function of improved ability to repair the site- women with genital specific defects without anatomical distortion and hence prolapse, pre and post less impairment of body function, laparoscopic pelvic including sexual function. Also improved visualisation of vital floor repair - a structures and thus avoiding prospective study injury. Plus a rapid recovery and return to normal activities, vital in Krishnan Karthigasu, Anusch Yazdani, Alan Lam, Greg Cario, Mark the elderly woman. Carlton However, despite these advances, Sydney Women’s Endosurgery Centre there has been very little data to Centre for Advanced Reproductive prove the advantages of Endosurgery laparoscopic surgery to the Genital prolapse had been known previous surgery. Our units since the time of Hippocrates, yet commenced a prospective since that time there has been no questionnaire survey in 2001 of all effective treatment for the women undergoing laparoscopic condition. Over 200 different treatment of genital prolapse surgical techniques have been assessing bowel and urinary used to treat genital prolapse all function, prolapse falling in and out of favour over symptomatology, sexual function, time due to ineffectiveness or side and quality of life. effects associated with the In this presentation I discuss the procedures. sexual function of women In recent times sexual function of presenting for laparoscopic women, particularly post surgical treatment of genital menopausal women, has gained prolapse and the effect of the greater public exposure as women laparoscopic route of treatment on are living longer and healthier and subsequent sexual function at 6 desire the full range of function as months post operatively. From Jan a younger women, including 2001 to Dec 2001 80 patients were sexual function. It has been found enrolled in the study with 20 than much of the surgery in the reaching the 6 month mark at past did indeed impair the sexual November 2001. function of the woman and now The interim results of the study are women demand an improved to be presented and discussed. treatment for prolapse without the impairment of body function. In the last decade there has been an emergence of laparoscopic gynaecological surgery, including the area of pelvic reconstructive surgery. The theoretical advantages of the laparoscopic
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