Advanced Endoscopic Surgery

Advantages of laparoscopic or Minimal Invasive Surgery

From greek : scopy .. endo.. = look inside. In the abdomen : laparoscopy ; in the uterus : hysteroscopy.

Endoscopic surgery has important advantages over open surgery. Postoperative pain is less and recovery and hospitalisation and absence from work are faster. This has been proven today for most gynecologic interventions such as hysterectomy, pelvic floor surgery, fertility surgery, cancer surgery and endometriosis surgery.
In addition incisions can be within bikini limits (easier with a laser since incisions can be placed lower).

What is advanced endoscopic surgery ? Levels III surgery

Laparoscopic and hysteroscopic surgery need a special and additional training after laparotomy training.
Basic training in gynaecology permits simple surgery as ovariectomy and cystectomy .
Level 1 permits a total laparoscopic hysterectomy (TLH) up to 500-800 grams. During the learning curve often a laparoscopic assisted hysterectomyis performed (LAVH).
Level 2 means dissection and suturing together with a more advanced knowledge of anatomy. This is required for pelvic floor surgery the promontofixation and lymadenectomy for cancer .
Level 3 is advanced laparoscopic surgery When the anatomy is stronlyalterated and when other organs as bowels, bladder and ureter are involved more and additional experience is necessary. In addition during surgery the risk and the advantages of a complete excision of endometriosis have to be balaced. This is the surgery of deep endometriosis and debulking for dissiminated ovarian cancer .

Other surgery that that should be situated at this level is surgery that is rare and that thus obviously not too many surgeons can have a lot of experience . These are hysterectomy for a uterus of more than1 kilo, the laparoscopic Wertheim for cervical cancer and the laparoscopic para-ortic lymfadenectomy

How to choose a surgeon ?

1. Sufficient technical skills for the planned intervention. This means that a surgeon should not operate above his level.
2. Sufficient knowledge and experience of the pathology. It should be clear that for the combination of advanced surgery and rare diseases such as deep endometriosis or Wertheims only few surgeons will have the required expertise.

3. Judge the surgical team. Who is going to assist ? Who is responsible for the follow-up. Difficult and demanding surgery as deep endometriosis requires a good team, agood surgeon only is not sufficient.

4. Honest Information. Of the indication and the method : Hysterectomy is the example : whereas many of us performed their last laparotomic hysterectomy more than 10 years ago, even today in the USA only 20% areperformed by laparoscopy. Of the personal exprience, results and whether videoregistration is performed.

Multidisciplinarity versus the ‘Pelvic Surgeon’

Multidisciplinarity is fashion

Real multidisciplinarity brings knowledge and skills of different disciplines together.

False multidisciplinarity occurs when the gynaecologist hides his inadequate training, and asks a surgeon to help (as a technician). This occurs increasingly frequently. It remembers me the pioneering years when together with abdominal surgery (Prof Penninckx) I performed the first series of laparoscopic cholecystectomies bringing together the technique of endoscopy (PK) and the knowledge of open cholecystectomy. This was useful to develop the technique but this is not multidisciplinarity.

Endoscopic surgery has been a revolution in gynaecology

Endoscopic surgery started around 1986 after the introduction of lightweight camera’s. In Belgium Prof Koninckx was a pioneer performing the the first interventions for endometriosis, the first series of cholecystectomies (with prof Penninckx), the first series of pneumothorax (with Prof Lerut). Drssa Ussia was a pioneer in Italy performing the first laparosopic hysterectomies.
During the early ninties development of technique was very fast and progressively we shifted all open surgery to laparoscopy. Sinds 1996 I not do any longer a laparotomy, except rare exceptions such as hysterectomy for more than 2 kilo uterus. This resulted in 1996 in the foundation of the “1 kilo club” , a platform for advancing laparoscopic surgery.
During the following years we learned how to master complications laparoscopically resulting in the virtual 0 conversion rate during surgery and the introduction of the ‘early repeat laparoscopy’ in endometriosis surgery.
More recently we introduced quality control through continuous registration.
But the revolution is not over Endoscopic surgery is much more difficult than we – the pioneers- thought 10 years ago and the introduction in gynaecology is slow. There are only fewthe endoscopists of level III who have mastered endoscopic bowel surgery and ureter and bladder surgery. We therefore advocated ‘pelvic surgery’ as a subdiscipline in gynaecology.

Why has CO2 laser surgery not yet beern introduced everywhere

Prof Koninckx developed the first high flow insufflator and specific trocars, later marketed by Storz. This is essential for lasersurgery and also otherwise when surgery becomes difficult.
This explains why laser surgery has been developed predominantly in Leuven for endometriosis and that this surgery was subsequently introduced in Oxford and Rome. Laserchirurgy of endometriosis is faster, better with less adhesions.

Already in 1991 we patented the uterine rotator for hysterectomy but it took a long time to get this manipulator available.

Hysteroscopy

Hysteroscopy has been developed in parallel with laparoscopy, mainly though technical innovation such as smaller diameter scopes, bipolar instruments and safety monitoring.
Today we mainly have as groups
the diagnostic hysteroscopy in the outpatient office.
the operative hysteroscopy for polyps, intra-uterine myoma and endometrial ablation
recently some of these procedures can be done under local anaestheisa