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EVIDENCE BASED MEDICINE AND SURGERY EVIDENCE BASED MEDICINE

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									 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: jtsaltas@ozemail.com.au
                                          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: ayazdani@ivps.net          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: michael@mjwcooper.com.au
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: michael@mjwcooper.com.au
                                                                                                                      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.
                                                 kingstona@sesahs.nsw.gov.au
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:karunaagarwal@hotmail.com
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: bradles01@hotmail.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: ayazdani@ivps.net            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: nickbee@optushome.com.au
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 drtamsh@aol.com

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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