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Big myoma

Dear prof. Koninckx, I have a uterine fibroid and one part has passed through cervix into vagina, but the larger part is still in the uterus. I have no pain, no temperature, I can walk and behave as usual. Ultrasound showed that a fibroid is 11 cm big.   MRI  showed 19 cm. For the last two months I have a huge yellow, brown vaginal disharge, and doctors said it is necrotizing. I really wish to do a laparoscopic surgery, since I’m 40 and I haven’t give birth, so I just want to preserve the uterus. In attachment I sent  an Ultrasound pictures, and I can send you MRI image, too. *********************************************************** Dear Mrs The diagnosis is not clear to me A fibroid passing the cervix will give the discharge you have - such a fibroid is rarely bigger than 5-6 cm and generally a pedunculated intracavitary fibroid which can be removed vaginally - if the fibroid is avascular and necrotisising the risk of an infection of this mass becomes real. This is not without risk and will need urgent surgery, probably hysterectomy My guess is that the large 11 or 19 cm fibroid is 1 or more other fibroids.Our approach would be - let us confirm the diagnosis by clinical exam/ultrasound and proceed to surgery - I hope we first can remove the intracavitary fibroid  vaginally/by hysteroscopy - then a laparoscopy should be performed and decisions taken : what I anticipate is first clip the uterine arteries to prevent too much blood loss if a 10 cm fibroid : can probably be taken care off by laparosopy if a 19...

How does a digital operating room improve quality of surgery ?

“Digital Operating Room” is used to suggest better surgery through a better surgical environment. In a recent article we discussed this in detail . –The basic “Digital operating room” integrates 1 operating room. This generally indicates that in 1 operating room endoscopic images can be shown to the surgeon on any screen in that room (routing and switching). In addition images from previous exams such as X-rays, or the patient file can be displayed for review by the surgeon. For the surgeon it is useful if more information is easily available. In addition most digital operating rooms offer the possibility of recording operating images, and of broadcasting surgery. The latter however, generally need dedicated assistance for conferencing. The underlying technology is similar to a television studio where a technician chooses which image of the several camera’s will be shown to the public. Since a (video) cable needs to connect every source and every screen with the broadband switch, this results in a bunch of cables and a rather static configuration with little intelligence. Indeed a new device or screen will need a new cable set of cables. - The advanced digital operating room integrates the hospital . Similar to the intranet of most hospitals, which connects every computer, printer etc with the computer room, the advanced digital operating room will use an internet platform to connect all devices from 1 or all operating rooms using the IT network of the hospital. The advantages and the differences from the older solution are obvious. Since many signals can be transported over 1 internet cable, this system needs only 1 cable instead...

Problem with informed consent for laparoscopic hysterectomy

A laparoscopic hysterectomy should always be preferred unless the uterus is more than 1 kgr. A bigger uterus can be operated by laparoscopy but this is technically more difficult. The biggest we operated was 1850 gram (in Oxford) There is a serious problem concerning informed consent for hysterectomy. Informed consent should inform the patient also about all alternative treatments, including those not performed by the gynecologist. Yet the incidence of total laparoscopic hysterectomies (TLH) is less than 10% in Belgium and in most counties of this world. Subtotal laparoscopic hysterectomy (SLH) is performed in less than 5%. Even if LAVH (laparoscopic assisted vaginal hysterectomy ) is considered a laparoscopic hysterectomy the incidence is less than 25%. Why is a laparoscopic hysterectomy better ? The advantages of a TLH for the patient are less pain, less scar, faster recovery and less adhesions. Without disadvantages. It is clear that the complication rate of a TLH is comparable or less provided the surgeon is an experienced laparoscopist. If accidents occur videoregistration is useful. Without videoregistration the technique might be blamed. Conversions ( start by laparoscopy and end by laparotomy) are extremely rare. Personally we never did a conversion. If more than 5% conversions occur , as often indicated in the literature, there must be a problem of indication and or skills of the surgeons. Again videoregistration is necessary to prove this. TLH cause less adhesions. Adhesions decrease further if the duration of surgery is short and associated with little bleeding. ” a better surgeon causes less adhesions” Training thus becomes a problem knowing that during training duration of surgery easily exceeds 3...

Robotic surgery in gynaecology and endometriosis

The discussion on robotic assisted surgery is continuing . Following our opinion statement on www.endometriosis.org John F Dulemba posted in World Endometriosis Research Foundation 7 January 07:43 PEOPLE. THE ROBOT IS JUST LAPAROSCOPY!!!!!!!!!!!!! PLEASE WATCH THIS MINUTE VIDEO….TO THE VERY END. YOU WILL SEE HOW PRECISE THE INSTRUMENTS CAN BE, AND I DO NOT THINK ANY STANDARD LAPAROSCOPISTS CAN BE AS PRECISE AS THE DOCTOR IN THIS VIDE!!!!!! When I wrote the comment below, the video has been withdrawn Nice video but misleading - obviously for specific movements a robot is superior to the human. Therefore I do expect that a robotic tubal reanastomosis will be superior to standard laparoscopy and come close to classic microsurgery. Unfortunately however , to the best of my knowledge, this superiority has never been demonstrated. No attemps were made even to demonstrate this in animal models. So doubt persists whether there is some uncertainty about outcome of such a trial. Failure indeed would killing a major indication - except tubal reanastomosis I doubt that superiority can be proven for any other gynaecological intervention (since it probably does not exist) - in addition robotic surgery can be potentially dangerous when performed by surgeons without sufficient training in laparoscopic surgery. (see blog http://www.gynsurgery.org/hysterectomy-myomectomy/robotic-surgery-is-not-superior-and-potentially-dangerous/) - finally, in this period of economic crisis, it is unclear who is willing to carry the associated huge cost : the surgeon ? the hospital ? (for marketing reasons) the patient ? (I doubt any patient is willing to pay today if correctly informed) I anyway want to stress my interest in robotic surgery as can be found in de development...

Small bowel herniation in trocar sites and early repeat laparoscopy

Small bowel herniation in trocar sites and early repeat laparoscopy RCTs have not been performed, nor will be performed , in order to document the incidence and the prevention of small bowel herniation in trocar sites. Indeed it is a rare complication and for obvious ethical reasons trials will not be performed. The evidence therefore can only be circumstantial.   We would try to summarise as follows our attitude. 1. The risk of small bowel herniation is believed to depend  on trocar diameter and on the surgical lesion caused by trocar insertion. 2. Unfortunately I am not aware of evidence that the risk of small bowel herniation is decreased by the use of conical trocars instead  of sharp triangular trocars or by the use of  the Termanian trocar. This could be expected given a smaller trauma as demonstrated years ago by Malcom Munro. 3. For the first intra publical trocar the risk seems so low that most of us will not suture the fascia. A plausible explanation could be that the insertion  is generally slightly oblique and that hte insertion thus closes by a flap valve mechanism.  For this reasons,  we only close the fascia of the first trocar insertion when either the patient is extremely thin or afther the incision has been enlarged for specimen retrieval. 4. For the secondary trocars which are inserted perpendicularly (in order to permit eventual backloading of sutures)  we do not close the fascia for 5 mm ports but always close them when 10mm or larger ports were used. 5. The biggest clinical challenge, however, is the diagnosis of a small bowel herniation since symptomatology is insidious.  For this reason, we advocate an early repeat laparoscopy whenever a patient does not improve...

Surgical mistakes and surgical quality

Surgical mistakes and surgical quality. Recently, surgical mistakes have been highlighted in the Belgian press because of surgical instruments left behind in the abdomen of patients. Fortunately this occurs very rarely. However, it has been said that more people die every year because of surgical mistakes than by car accidents Google ‘surgical mistakes’ and the problem and the stakeholders become clear. This however is only the tip of the iceberg. The most frequent problem indeed in surgery is patients providing “informed consent” based upon incomplete information and lack of information concerning surgical quality (ie. the surgeon’s experience and complication rates). For most patients it is not very clear which quality of surgical care will be given, and this care varies from the best available to the minimum practice, which is the medico legal standard. This can be highlighted by the observation that it takes between 10 and 20 years or longer before innovation is introduced; the slow introduction of laparoscopic surgery is an example of this – it is only today, 30 years after its introduction, that laparoscopy is more or less accepted as the standard of care when performing a hysterectomy, removing fibroids, and treating endometriosis This website principal aim therefore is providing information for the patient which is considered essential for obtaining informed consent . Surgical quality often is suboptimal There is no official/formal quality control for individual surgical intervention . National statistics only reveal complications. But without evidence of the entire surgical procedure it is very hard to demonstrate the underlying mistake, which may have caused the complication. For this reason we published in 2009 the...

Shiny Trinket

Shiny trinkets are shiny.