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AAGL listserv. Date: Sun, 28 Oct 2012 17:52:08 -0400 From: Joseph M Maurice
Subject: Question on surgical documentation and endometriosis treatment

A patient was scheduled for a diagnostic laparoscopy and diagnostic hysteroscopy. The patient was diagnosed with pelvic pain, and the preoperative diagnosis was endometriosis. A diagnostic laparoscopy was performed. An endoscopic port was placed in the infraumbilical area, and a second accessory port was placed midway between the endoscopic port and the symphysis pubis. Stage 4 endometriosis was diagnosed. No biopsies of the endometriotic implants were taken; no further laparoscopic procedures were performed.

During the hysteroscopic portion of the case, it was noted that the pictures from the laparoscopy did not process through the printing system and were lost.

My questions are as follows:
1. Would anyone repeat the laparoscopic portion of the procedure, re-take pictures to document endometriosis and have something to show the patient after surgery? Or, would you not repeat the procedure, notify the patient of your intra-operative findings and apologize for the technical disruption.
2. If you elected to repeat the laparoscopic portion of the procedure, how would your document the case in your operative report? Also, if you repeated the laparoscopy, how would you discuss this with the patient post-operatively?
3. When diagnosing endometriosis, do you routinely obtain specimens of the implants to confirm the diagnosis of endometriosis, if not, why?
4. Would anyone perform a staged procedure? Meaning, initially perform a diagnostic laparoscopy, make the diagnosis of endometriosis (either visually or histologically), and then have the patient return for a second procedure: resection/de-bulking of the endometriosis at a later date? Or, would you perform the diagnostic laparoscopy, make the diagnosis and immediately perform the operative laparoscopic portion of the procedure?

Answer

Two questions are raised , first documentation of surgery and endometriosis and 2nd surgery for endometriosis
1. Documentation with pictures can be useful to discuss with the patient or their GP/gynecologist the diagnosis and what is suggested that should be done. This however is based upon personal good-will and clinically not strictly necessary. For us this would not warrant a repeat laparoscopy.
2. Documentation with pictures only can be used for information of what was done during surgery. Only registration of the entire intervention however will permit to judge the quality of surgery performed and eventual complications. (cfr : JMIG : videoregistration should be mandatory as quality control http://www.gynsurgery.org/ols/pdf/080312_videoregistration.pdf )
3. Loss of documentation is another issue which is inherent to personal and simple registration systems. We therefore favor centralised registration with incorporation into the patient record as performed by the Nucleus system of eSaturnus NV(https://www.esaturnus.com). This system in addition automatically provides back-up and protection against loss of data while autheticating the video’s for medico-legal use.
4. Documentation and videoregistration cannot be discussed without addressing the issue of informed consent (see http://www.gynsurgery.org/hysterectomy-myomectomy/problem-with-informed-consent-for-laparoscopic-hysterectomy/ ) and of the contract made with the patient.
5. Surgery for endometriosis is a more straightforward problem. We always give the following advice. When the diagnosis is made during laparoscopy go ahead and do the surgery provided you have the skills, informed consent was obtained, and the necessary pre-op workup was done such as a bowel preparation for deep endometriosis. Otherwise plan another intervention, eventually by a team experienced and skilled to do this. Everybody can make mistakes, but these should be rare. Therefore we consider videoregistration important for medicolegal protection of this complication prone and difficult type of surgery. (for extensive discussion see http://www.gynsurgery.org/)

Prof em Philippe R. Koninckx and Drssa Anastasia Ussia
Gruppo Italo Belga of the European center for advanced endoscopic surgery.
pkoninckx@gmail.com anastasia.ussia@gmail.com

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