Patient Checklist for gynecologic surgery
Is the indication for surgery correct
- how certain is the diagnosis - what it the margin of error ?
- did I get information about alternative interventions or therapies
Is the surgeon ok for this intervention
- Has my surgeon the skills to do this intervention ?
- What are his personal results and what is his experience for this intervention?
- Did I get information about alternative surgical techniques, as is required for informed consent eg laparoscopy instead of laparotomy ?
- did I get information about his personal complications?
- did I inform which intervention I do NOT want eg ovariectomy ?
Is the environment OK ?
- who is going to assist : what is the team ? Difficult and demanding surgery as deep endometriosis requires a good team, not a first year registrar
- Who is going to do the daily follow-up ?
Is the preoperative planning ok ?
- This is much more difficult for the patient to judge : for deep endometriosis this comprises the decisions not to do and tto avoid a bowel resection ?
- Video-registration is a strong indication that the surgeon feels confident.
- and will you get a copy of the video
Multi-disciplinarity versus the ‘Pelvic Surgeon’
Multi-disciplinarity is fashion since it brings knowledge and skills of different disciplines together. False multi-disciplinarity 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 around 1990 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 multi-disciplinarity. - see our letter to the editor
Difficulty of gynecologic laparoscopic surgery
Basic training 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 hysterectomy is 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 lymfadenectomy for cancer .
- Level 3 is advanced laparoscopic surgery When the anatomy is strongly alterated 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 balanced. This is the surgery of deep endometriosis and debulking for disseminated 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-aortic lymfadenectomy
Endoscopic surgery has been a revolution
Surgery is not a competition to be the best : safety comes first The only aim of clubs as “the one kilo club (Chicago 1996) and the the “Pelvic Surgeon” is
- to indicate the direction we have to go
- and to provide a forum where difficulties and solutions can be discussed between experts
The physics of CO2 laser surgery and of electro-surgery are depicted on the right. The minimal tissue damage and the haemostatic capacity of the laser will probably result in less adhesions if used well. The main indications of CO2 laser surgery are excision and/or vaporisation of superficial pelvic endometriosis. CO2 laser however is not suited for dissection surgery : this means that the surgeon should be skilled in both laser and in electro-surgery.