aicog kavita
TRANSCRIPT
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OFFICE DAY CARE
THERAPEUTIC
PROCEDURES
DR KAVITA PRIYA MD
CENTRAL HOSPITALDHANBAD
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In-Office Procedures
Office procedures are surgical
procedures which may be
performed in a clinic oroutpatient setting.
In-Office Procedures allow the
patient to resume her normalactivities the next day.
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DAY CARE ONE END
OF THE SPECTRUM
OF SHORT STAY SURGERYSHORT STAY
SURGERY
24-72 HOURSADMISSION TO
DISCHARGE
INTERVALDAY CAREPROCEDURESPATIENT ISDISCHARGEDWITHIN A DAY
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DAY CARESURGERY
Nicoll1 observed that the results
(of Surgery) obtained in the
outpatient department at a tithe(tenth) of the cost are equally
good as those following
inpatient surgery.
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OFFICE DAY CARE
PROS & CONSCONS1) NEEDS SPECIALIZED TRAINING
2) MINIMALLY INVASIVE EQIPMENT
3) CUTTING EDGE TECHNOLOGY
4) HEAVY INITIAL OUTLAY5) RISKY IN LOW RESOURCE SETUP
6) INADEQUATE SURVEILLANCE
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CONS7) Need for a responsible person to
oversee the day care patient at home
for 24-48 hours.
8) Surgery restricted to experienced
seniors; less opportunity for juniors
9) Extra work for the GP in postop
period; patients often ring up for
advice or t/t.
10) Less cost-effective when the unit
deals with less complex cases on a
day basis.
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PROS Less disruption of patients personal lives Minimal invasion
Reduced pain
Minimal anaesthesia
Early recovery in home with family Less nosocomial infections
Reduced in-patient waiting lists
Increased availability of busy hospital beds
Reduced costs
Financially lucrative for doctor
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WHAT PATIENTS WANT.
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I DONT
WANT TO
STAND IN
LINE
ANYMORE!
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CUT
COSTS
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MONEY MATTERS
WHY IS DAY CARE SURGERY COSTEFFECTIVE?
LESS STAFF NEEDED AT NIGHT,WEEKENDS, PUBLIC HOLIDAYS
SPARES INPATIENT BEDS
CANCELLATIONS LESS
MANY MORE PATIENTS CAN BETREATED THAN IN INPATIENTSETUP
SHIFT DUTIES NOT NEEDED
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MONEY MATTERS
- AND HOW!! USA SAVING OF 15-30% UK SAVING OF 40%
INDIA COST OF PATIENTOCCUPYING BED IN GOVT.HOSPITAL RS.800-900 PER DAY,RS1000 PER DAY IN HIGHERCENTRES LIKE PGIMERCHANDIGARH
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OFFICE HYSTEROSCOPYOffice procedure
Smallerendoscopes(3-5 mmOD) used.
Atraumatic introduction.
No previous cervical dilatation.
Little or noanesthesia needed.Earlier office hysteroscopy was onlydiagnostic.
Now newer endoscopes (4 to5 mmOD) permit continuous flow of a lowviscosity fluid via a small, built-inchannel.
Allow minoroperative procedures asoffice rocedures .
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OFFICE HYSTEROSCOPE
OPERATIVE
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7MM OD operative
hysteroscopes can be used for
office procedures.Their channels permit
manipulation of sturdy, rigid,
and semirigid operating
instruments.
Cervical dilatation withMisoprost/Laminaria / Hegar
Paracervical block/ Regional A
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OPERATIVE HYSTEROSCOPE
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THERAPEUTIC OFFICE
HYSTEROSCOPY1)Treatment of abnormal uterinebleeding2)Sterilization (Essure method)
3)Removal of fibroids & endometrialpolyps
4)Removal of leiomyomas
5)Removal of adhesions caused byinfections or past surgeries
6)Removal of lost IUCD
7) Resection of intrauterine septum
E d t i l l ith t i l l t t
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Endometrial polyp with atypical vessel structure
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Intrauterine Leiomyoma
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Adenocarcinoma of the endometrium with an
irregular surface with necrosis and dilated
tortuous vessels
EUROPEAN SOCIETY FOR
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EUROPEAN SOCIETY FOR
GYNAECOLOGIC ENDOSCOPY
ESGE CLASSIFICATION I THIN FILMY ADHESION EASILY
RUPTURED BY HYSTEROSCOPY
SHEATH ALONE, CORNUA NORMAL II SINGULAR DENSE ADHESION
NOT SO RUPTURED, BOTH TUBAL
OSTIA CAN BE VISUALISED III OCCLUDING ADHESIONS ONLY
IN REGION OF INTERNAL OS,
UPPER UTERINE CAVITY NORMAL
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ESGE CLASSIFICATIONIV MULTIPLE DENSE ADHESIONS
CONNECTING SEPARATE AREAS OF UTER.CAVITY, ONE TUBAL OSTIUM BLOCKED
V EXTENSIVE DENSE ADHESIONS WITH
UTERINE CAVITY PARTIALLY OCCLUDED,
BOTH OSTIA PARTIALLY BLOCKED
Va EXTENSIVE ENDOMETRIAL SCARRING
& FIBROSIS + GRADE I OR II ADHESIONS,
& AMENORRHOEA/OLIGOMENORRHOEAVb EXTENSIVE ENDOMETRIAL SCARRING
& FIBROSIS + GRADE I OR II ADHESIONS &
AMENORRHOEA
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FRAGILE GRADE I IUAs (ESGE CLASSIFICATION)
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GradeIII IntraUterine Adhesions(ESGE classification)
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Grade III IUAs (ESGE classification)
S
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Submucous myoma without intramural
extension (type 0, ESGE classification
ESGE CLASSIFICATION OF
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ESGE CLASSIFICATION OF
SUBMUCOUS MYOMAS
DEGREE OFINTRAMURALEXTENSION
TYPE 0NONE
TYPE I50%
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MGMT. OF MYOMA
Submucous myomas withoutor with only limitedintramural extension shouldbe treated withendoresection as soon as thediagnosis has been made, aswith increasing size,endoresection will becomemore difficult
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IUD LOST &
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A fragmented Dalkon shield IUDpartially embedded in the uterine wall.
Copper-7 IUD within the uterinecavity;
its filament is in the uterine fundus.
Biopsyforceps grasping a
Dalkon shield for removal.
IUD in the Uterine
Cavity Found at
Hysteroscopy
IUD - LOST &
FOUND !!!
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CONTROL OF
INTRAUTERINE ENDOSURGERY
The results of intrauterine
endosurgery should always beevaluated with a2 or 3 months after the procedure :
1)To assess endometrial healing2)To exclude residual pathology
3)To remove adhesions, if present.
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CONTRAINDICATIONS
ID
REGNANCY
ROFUSE BLEEDING
REVIOUS INFECTION
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OFFICE PROCEDURESINSERTION & REMOVAL OF
IUCDs & HORMONE DELIVERY
SYSTEMS
LEVONORGESTREL RELEASING
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LEVONORGESTREL RELEASING
INTRAUTERINE SYSTEM
MIRENA
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IMPLANON
INSERTION & REMOVAL
Inserting Implanon Removing Implanon
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ETONORGESTREL
IMPLANONA preloaded applicator is used to insert it in theupper part of the arm in the groove between thebiceps and the triceps under local anaesthetic.
INSERTION TIME 1 minute. REMOVAL 3minImmediate contraceptive efficacy .
Inserted on a) Day 1-5 of cycle
b) Day 1 of pill free interval if on pillspreviously
c) Day 21-28 after childbirth or laterwith condom protection for 7 days
Removed under LA through a small incision
Etonogestrel levels drop almost immediately onremoval.
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LEEP
The loop electrosurgical excision procedure(LEEP) uses a thin, low-voltageelectrified wire loop to cut out abnormaltissue in the cervix
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LEEP LEEP LOOPELECTROSURGICAL EXCISION ADVANTAGE PERFORMED ASA SIMULTANEOUSLY DIAGNOSTIC& THERAPEUTIC OPERATION FOR
CIN DURING OUTPATIENT VISIT ELECTROEXCISION
SMALL WIRE LOOP (0.5MM)HIGH POWER (35-55 WATTS)WATER-LADEN TISSUE CUT BYSTEAM ENVELOPE FORMED ATWIRE LOOP TISSUE INTERFACE
LEEP
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LEEP ELECTROFULGURATION
HAEMOSTASIS ACHIEVED BYELECTROCAUTERY
BALL ELECTRODE (5MM)
LOW POWER (50 W)
THERMAL DAMAGE
DISADVANTAGES OF LEEP
PRETERM BIRTH, PROM, LBW
INFECTION, HAEMORRHAGE, CERVICALSTENOSIS
FAILURE RATE 8%-39%, OVERALLRECURRENCE RATE 27.5% (LIVASY ET AL)
OFFICE DAYCARE WITH
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OFFICE DAYCARE WITH
STATE OF ART FACILITIES
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