Is Gynecologic Endoscopy Past History.2

8/9/2019 Is Gynecologic Endoscopy Past History.2

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What is Minimally Invasive Surgery ?

Minimally Invasive Surgery (MIS) is a new kind of surgery

which gets more and more common nowadays. Another

well-known expression is 'endoscopic surgery'. With this

method, a surgical operation is performed by the help of: a small endoscopic camera. several long, thin, rigid instruments.

through natural body openings or small artificial incisions ('keyholesurgery').


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Minimally Invasive Surgery:

Becoming the Standard of Care

Laparoscopy is currently the preferred

surgical modality for a variety of

procedures like:

95% of cholecystectomies

90% of fundoplications

70% of ectopic

pregnancies 50% of benign ovarian

cysts


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Minimally Invasive Surgery:

Becoming the Standard of Care

Better Visualization

Able to visualize/evaluate all abdominal structures

Pelvis: Adnexa, Posterior Cul-de-Sac, Uterus

Upper abdomen: Liver, Stomach, Bowel

Complete evaluation of adnexal pathology


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Early Physician Assumptions

When one looked into the

surgical future of gynecology,most felt they would look

through an endoscope

Franklin D. Loffer, M.D


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Early Assumptions


The Gynecologic Endoscopists

everything will be done through the

scope

The Public - everything will be donewith a laser


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Indications for Surgery Have

Been Reduced

Better understanding of disease

process Better medical therapies

Economic considerations

Patient sophistication



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1805 Bozzini Urethroscopy

1865 Desormeaux Cystoscopy

1869 Pantaleoni Hysteroscopy

1894 Fritsch (not Asherman in1948)

Uterine Synechiae

1910 Jacobaeus Laparoscopy

1937 Bardenheuer (not Goldrath in1981)

Endometrial ablation

1940 Power & Barnes (not Loffer in1974)

Tubal coag

Endoscopy Just Turned

200 Years Old Is It Time For It To RIP?


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Medical Progress Frequently

Follows Technical Advances

1880 - Edison Incandescent light

1943 - Fourestiere Fiber optic light

1953 - Hopkins Rod lens



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Adoption of Endoscopy by

Specialty

Urologist 20th century

Gastroenterologist 1930sGynecologist late 1960s

General Surgeons late 1980s

Other Specialties 1990s



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At First Gynecologic Endoscopy

Was A Diagnostic Tool

Endometriosis

Ovarian cysts

Ectopic pregnancies

Endometrial polyp Submucosal myoma

Franklin D. Loffer, M.D.


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Early Modern Gynecologic

EndoscopyLaparoscopy - circa 1960s

Diagnostic

Tubal sterilization

Lysis of adhesions

Coagulation endometriosis

Hysteroscopy circa 1970s

Diagnostic

Tubal sterilization


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Advancing Modern Gynecologic

Endoscopy

Future Trends in Gynecologic Surgery

Laparoscopy - circa 1970s

Ectopic pregnancy Ovarian cystectomy

Salpingoopherectomy

Hysteroscopy circa 1980s

Septum

Adhesions


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Current Gynecologic

EndoscopyLaparoscopy - circa 1990

LAVH / TAH

Bladder suspension Pelvic floor reconstruction

Node dissection

Hysteroscopy circa 1990

Endometrial ablation/resection

Submucosal fibroid resection


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Challenges to Surgical

Endoscopy Hysteroscope vs LAVH in AUB

Global vs hysteroscopic EA

Vaginal hysterectomy vs LAVH UBT vs endometrial ablation

UAE / UAO / Ultrasound vs myomectomy

Sonohysterography vs hysteroscopy Transvaginal hydrolaparoscopy vs

diagnostic laparoscopy


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Gynecologic Surgery Before

Modern Endoscopy Was:

Hysterectomy

Oophorectomy

Pelvic repair vag & MMK

Tube sterilization & ectopic

D & C

Congenital anomalies



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Where does Endoscopy stand now ?


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What Has Happened to the

Hysterectomy? AUBAUB Endometriosis / Pelvic painEndometriosis / Pelvic pain

MyomasMyomas CIN - Leep

- Immunization?

Prolapse - Vaginal approach

Cancer - Still 10 approach


Will

discuss

later


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What Has Happened With the

Ovary?

Cystectomy - laparoscopy

Oophorectomy - laparoscopy



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What Has Happened With

Pelvic Repair and Incontinence?

Laparoscopic Burch

Slings

Meshes

Radio frequency



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the Fallopian Tubes?

Sterilization - Laparoscopic

- Hysteroscopic - IUD

Ectopics - Laparoscopic approach

- Medical approach



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What Has Happened With The

D&C?*

Hysteroscopy Sonohysteroscopy


*The D&C Has Died RIP Franklin D. Loffer

Presented at the AAGL 3rd World Congress on Hysteroscopy

Miami Florida 1987


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Infertility?

PID - Laparoscopy

Tubal factor - IVF

Synechiae - Hysteroscopy



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Congenital Anomalies?

Septum - Hysteroscopy

Uterine Horn - Laparoscopy

Vaginal agenesis - Laparoscopy


Wh t H H d With th


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What Has Happened With the

Management of Abnormal

Uterine Bleeding?

Endometrial ablation - Nd:yag

- Resectoscope

Progesterone - IUD

Submucosal myoma - Hysteroscopy



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Management of Endometriosis /

Pelvic Pain?

GnRH agonists - current

SPRMs - future LUNAS - not effective

Presacral neurectomy - rare

Other - IC



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Management of Myomas? UAE - Radiology UAO - Laparoscopic

- Vaginal Myolysis - Laparoscopic

- Focused ultrasound

Medical - Asoprisnil Resection - Hysteroscopic



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Obese patients

Ideal Robotic Case



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Obese

Case requiring extensivesuturing

- sacrocolpopexy

Ideal Robotic Case



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Obese patients

Extensive suturing

Complex gynecologic procedure

- invasive endometriosis

Ideal Robotic Case



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Obese patients

Extensive suturing

Complex gynecologic procedure

Complex oncologic procedure

- Aortic lymphadenectomy

Ideal Robotic CaseIdeal Robotic Case



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Compared to laparotomy there isdecreased:

- EBL- LOS

- Post-op transfusions

- Number of major post-opcomplications

pared

Giles, Magrina, Magtibay, Presented WAGO (June 2007)

Robotic Hysterectomy in theRobotic Hysterectomy in the

Treatment of Uterine CancerTreatment of Uterine Cancer


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Gynecologic Endoscopy

So where do we stand?



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Gynecologic Endoscopy

Trends


Increasing Decreasing NC

Ovary pelvic floor / incont Hyst

Ca Dx AUB Tube

Cong Anomal Endo / pain Dx

Myoma

Infertility


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Role of New Technology in Minimally

Invasive Gynecologic Surgery:

Robots, 3-D Vision, Simulators

Role of New Technology in Minimally

Invasive Gynecologic Surgery:

Robots, 3-D Vision, Simulators

Camran Nezhat, MD, FACOG,FACS.

www.nezhat.org

Camran Nezhat, MD, FACOG,FACS.

www.nezhat.org


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Its offspring is called

Minimally Invasive Gynecology



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Minimally Invasive Surgery: What

are the Limiting Factors?

Surgeons must progress beyond the traditionaltechniques of cutting and sewing . ,to a future in

which minimal access to the abdominal cavity areonly the beginning.

How can we overcome surgeon and equipmentlimitations?

Pappas, Jacobs, NEJM 2004

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Is Gynecologic Endoscopy Past History.2