Short bio-data Dr.Pragnesh ShahFOGSI’S Endoscopy Committee Chairperson.West Zone co-ordinator, Indian Association Of Gynaecological Endoscopists (IAGE ).Practicing Gynaec. Endoscopic Surgeon in Ahmedabad.FOGSI recognized Advanced Endoscopic Training center in Ahmedabad.Presented many presentations at International (AAGL), National (FOGSI).Keen interest in teaching & transferring Endoscopic skill to fellow Gynecologists.KEEN TO ESTABLISH STRATEGIES FOR ENDOSCOPIC ACCREDITATION INITIATIVES & Setting standards in Gyn. Endoscopy Training & practices IN INDIA .

Setting of Hysteroscopy Unit :Fertility Enhancement &

Laparoscopy

Dr.Pragnesh Shah (M.D.,FICOG)FOGSI Endoscopy Committee Chairperson

Ahmedabadwww.laparoscopyexpert.com

Email : pragnesh@laparoscopyexpert.com

Why hysteroscopy Unit ?Setting Standards in Hysteroscopy

Practices

How many Laparoscopies are carried out without hysteroscopy while doing Endoscopy for Infertility patient ?

IVF experts are doing only hysteroscopy ?.....Laparoscopy ?….

Should we include Hysteroscopy training compulsory in Gyn. Endoscopy training program ?

How many Medical Collages are equipped with Hysteroscopy unit today in India ?

No. of level-I / II / III Hysteroscopic surgeries done today……

How can we make hysteroscopy safe ?• We should understand the potential hazards of

the procedure and equipments involved• The complication rate in diagnostic The complication rate in diagnostic

hysteroscopy is low and was estimated by hysteroscopy is low and was estimated by Lindemann (1989) to be 0.012% . Lindemann (1989) to be 0.012% .

• Complications from operative hysteroscopy are Complications from operative hysteroscopy are more common and potentially more serious.more common and potentially more serious.

UNIVERSAL CONCERN FOR SAFETY :ACOG GUIDELINES ON PATIENT SAFETYON ERROR MANAGEMENT : LESSONS FROM AVIATION :

BMJ 200; 320The impact of aviation based team work training on

attitudes of health care personnel : J Am Coll Surg 2004; 199My copilot is a nurse : using crew resource management training in commercial aviation J AORN 2006; 83Reinvigorating safety in Office based Gynaecology : JMIG 2010 DEC

Setting of Hysteroscopy Unit

Proper Hysteroscopic training with hands on practices on Hystero trainer.

Changing attitude : All Infertility Endoscopy evaluation must be combined with Hysteroscopy & Laparoscopy.

Selection of cases and anticipating complications in difficult/complicated cases from the basis of our skill/experience.

Strict Pre-op evaluation & preparations.Safe OR Infrastructure & Check lists & protocols (SOPs).Intra operative monitoring protocols, Mock drills.Post-operative care.EMR & Video recording of all cases and Auditing of

cases.

HYSTEROSCOPIC TRAININGDiagnostic Hysteroscopy

Operative Hysteroscopy

T.C.R.E.Sub mucus Fibroid Resection

Selection of cases and anticipating Complications in difficult/complicated cases from the basis of

our experience

5th to 10th Day of Menstrual cycle; Thin EndometriumCondition of cervix : Small :

Good dilator set with 5 mm difference.Pre-op Misopristol.Office Hysteroscopes : 2mm,2.9 mm, 1.9 mm etc.

Sev Asherman's syndrome : Skill level & USG guidance

Multiple fibroids : Expert TVUSG for fibroid mappingMisplaced IUCD : Expert TVUSG with Cu-t locationTCRE : Good counseling with lap TL

Strict Pre-op evaluation & preparations.

LMP : TIMING THE SURGERY IN EARLY PROLIFERATIVE PHASE

Presence of infection. Check for pre-op Infection/period ?Tubal Cannulation set for PTB.Check all hysteroscopy instruments before anesthesia is

given.Safe Lithotomy position.Avoidance of air embolism during hysteroscopy / TUR set.Pre-op S.Na+ : 135 mEq/lit.Calculation of Fluid deficit to dedicated one OT staff.

PRE-OPERATIVE CHECKLISTS :FOR OT STAFF AND THEIR ACTIVITIES :

INSTRUMENT TROLLEY, FUMIGATION, STERILISATION

CHECKLIST FOR SURGEONS REGARDING INSTRUMENT CHECKS

CHECKLIST FOR ANAESTHETISTSCheck List for

Hysteroscopic photos & Findings.

SAFE MONITORING :Check List

BOYLES TROLLEY with Circle absorber.DEFIBRILLATORSMULTIPARAMONITOR : T, P, R, NIBP, ECG,EtCO2END TIDAL CO2 MONITORSINTRAOP SPIROMETRYPOST OP RECOVERY ROOM CONCEPT WITH

STAFF trained for managing semiconscious patients

Safe OR Infra structureOperation Theatre.O.T.TableSafe lithotomy positionPlacing of safe Cautery padHysteroscopy instrumentsLaparoscopy instrumentsVideo Monitors for Hysteroscopic & Laparoscopic

surgeryDistention media gadgets PREVENTION OF INSTRUMENT FAILURE & Back up.Safe Monitoring & MOCK DRILLS Post op wards for High risk patient

Office Hysteroscopy

INSTRUMENTSHYSTERPSCOPE

4 m.m.& 30’,Rigid

Suction/Irrigation cannulaIrrigation-5 m.m.Sucti.+Irriga.= 6mmOperating Sheath=

7mmResectoscope = 10mm

Operating Sheath- 6 F.

Resectoscope

CHECKLIST FOR SURGEONS REGARDING INSTRUMENT CHECKS

Hysteroscopes : 2mm, 2.9 mm, 1.9 mm, 4mm 7 30’ Hysteroscope

Diagnostic sheathsOperative sheaths : Bettochi sheathTubing's with Luer lock at end to prevent fluid leakage.Uterine distention & Fluid delivery system.1 lit pints of Normal saline/Ringer lactate3 lit. pints of 1.5 % Glycine100 ml pint of 3% Normal saline5F. Tubal Cannulation set, Scissor, grasperResectoscope with loop/Kolin’s knife & Monopolar cableTUR Set

CHECKLIST FOR SURGEONS REGARDING INSTRUMENT CHECKS

Understanding different hysteroscopic set up

Check their fittings Placement Video

monitorsPosition of the

patient : Edge of the table

PREVENTION OF INSTRUMENT FAILURE :USE STANDARD INSTRUMENTS . KEEP

THEM WELL MAINTAINEDPROPER SOURCE OF ELECTRICITY : UPS ,

STABILIZERS , INVERTERS, GENERATORSPROPER EARTHING : POTENTIAL

DIFFERENCE OF LESS THAN 3 VOLTS BETWEEN EARTH AND NEUTRAL

SPARE BULBS, FUSES, CONSUMMABLESSTANDBY EQUIPMENTSSTANDBY SERVICE PERSONNELS

MOCK DRILLS :Periodic mock drills should be performed in

the theatre to assess skills, response, co-ordination, communication and skills amongst the team members to handle various types of emergencies

Create training manuals for the entire staff : Basic life support, Advanced Cardiac life support

3. THE DISTENSION 3. THE DISTENSION MEDIAMEDIA• Complications produced by Complications produced by the distension media are the distension media are specific to hysteroscopic specific to hysteroscopic surgery. surgery. • It is essential that all the It is essential that all the operating room staff should operating room staff should know the side effects of the know the side effects of the distension mediadistension media..

Carbon dioxide.Carbon dioxide.

• Cardiac arrhythmiaCardiac arrhythmia may occur may occur with diagnostic hysteroscopy with diagnostic hysteroscopy with CO2with CO2

• The The hysteroflatorhysteroflator delivers CO2 delivers CO2

at a rate 100ml per minute at a rate 100ml per minute whereas the whereas the laparoflatorlaparoflator can can deliver 1-20 liters per minutedeliver 1-20 liters per minute..

Carbon dioxide:Carbon dioxide:•A A laparoflatorlaparoflator should NEVER should NEVER be used for hysteroscopy. be used for hysteroscopy.

• It is rare for CÓIt is rare for CÓ22 to produce to produce any side effects if gas any side effects if gas embolism of less than 400ml embolism of less than 400ml occurs.occurs.

Intra operative monitoring protocols.Anesthesia, Intubation, Pulse Oxymetry & EtCo2Fluid balance/deficitDuration of Hysteroscopic Surgery.Disturbance/Noise on Monitor while

electrocautery is onBleeding during surgeryVigilant watch on Multipara monitoring for early

detection of TUR Syndrome by Experienced Anesthetist.

In complicated case we must know when to stop hysteroscopic surgery with appearance of early signs of TUR Syndrome.

Sev. Asherman’s syndromeHysteroscop

ic Surgery

Under USG guidance

Energy Source for Resection:

MonopolarCommonly used. Glycine has to be used as distension media.

Energy Source for Resection: Bipolar

Relatively Safe. Expensive. Saline can be used.

Other Newer sources : Laser , Plasma Kinetic systems

Prevention of Fluid Prevention of Fluid OverloadOverload1.1. Using appropriate distension media and Using appropriate distension media and

delivery systems delivery systems 2.2. Keeping operating times to a minimum Keeping operating times to a minimum 3.3. Avoiding entering the vascular channels Avoiding entering the vascular channels 4.4. Keeping fluid pressures below 80mmHg. Keeping fluid pressures below 80mmHg.

Or Mean Arterial Pressure.Or Mean Arterial Pressure.5.5. Meticulous accountancy of fluid balance.Meticulous accountancy of fluid balance.

6.6. The procedure must be abandoned if the The procedure must be abandoned if the deficit rises to 1.5 liters or there is deficit rises to 1.5 liters or there is

evidence of venous congestion..evidence of venous congestion..

FLUID DELIVERY SYSTEMS :GRAVITY ASSISTED :POSITIVE PRESSURE BAGS : BP CUFF, MEDEX BAG.

SIMPLE, ECONOMICAL, WIDELY USED.NEEDS A VIGILANT STAFF TO PREVENT AIR

EMBOLISM, FLUID OVERLOAD, OVERDISTENSION OF UTERINE CAVITY

FREQUENT COLLAPSE OF CAVITY WHILE CHANGING BOTTLES

DIFFICULT TO MAINTAIN INFLOW-OUTFLOW CHART

FLUID DELIVERY SYSTEMS :

Instruments for delivery of distention medium

Distention

Pressure Cuff: A pressure bag with

pressure meter. The pressure has to be maintained manually. Ideally a pressure of 150-200mmhg is utilized.

Hysteromat: A motorized unit that

automatically controls a constant flow of fluid entering the cavity. Its easy to calculate the input of NS with this equipment. Ideally a pressure of 80mmhg is utilized.

FACTORS CAUSING FLUID ABSORPTION :The intrauterine pressure. The mean arterial blood pressure. The patency of the outflow channel of the

hysteroscope. The depth of penetration of the uterine

instruments. Baggish MS (1989) Distending media for panoramic hysteroscopy. In Baggish MS, Bardot J, Valle RF (eds)Diagnostic and Operative Hysteroscopy. pp. 89-101. Chicago: Year Book Medical Publishers Inc.

AUTOMATED FLUID DELIVERY SYSTEMS :

GOOD EQUIPMENT TO MAINTAIN THE INTRAUTERINE PRESSURE TO A PRESET LEVEL.

80 MMHG USUALLYMAINTAINS OPTIMUM INTRAUTERINE CAVITYREDUCES THE CHANCES OF SPILLAGE INTO

POUCH OF DOUGLAS,REDUCES CHANCES OF FLUID OVERLOAD,

(Input & output can be documented)SURGEON GETS MORE OPERATING TIME,

PEACEFULLYE.g. Hysteromat, Endomat

AUTOMATED FLUID DELIVERY SYSTEMS :

FLUID OVERLOAD INITIAL FLUID OVERLOAD INITIAL SYMPTOMS:SYMPTOMS:

1.1. Nausea and vertigo, confusion and Nausea and vertigo, confusion and disorientation. disorientation. ( CONSCIOUS PATIENT)( CONSCIOUS PATIENT)

2.2. Transient hypertension & bradycardia Transient hypertension & bradycardia followed by hypotension & followed by hypotension & tachycardia tachycardia (may be the only sign in (may be the only sign in patients of general anesthesia)patients of general anesthesia)

HENCE THE ROLE OF GOOD MONITORING HENCE THE ROLE OF GOOD MONITORING EQUIPMENTS..EQUIPMENTS..

FLUID OVERLOAD BY FLUID OVERLOAD BY GLYCINE :GLYCINE :Glycine overload may produce elevated Glycine overload may produce elevated

blood ammonium levels leading to blood ammonium levels leading to encephalopathy and death.encephalopathy and death.

Hyponatraemia can lead to cerebral Hyponatraemia can lead to cerebral edema edema

OT PERSONNEL SHOULD BE TRAINED TO OT PERSONNEL SHOULD BE TRAINED TO BE ALERT FOR THE VARIOUS SYMPTOMS BE ALERT FOR THE VARIOUS SYMPTOMS AND SIGNSAND SIGNS

NEW METHOD TO IDENTIFY FLUID NEW METHOD TO IDENTIFY FLUID

OVERLOAD OVERLOAD ::ETHANOL TAGGED MANNITOL / SORBITOL : for knowing exact fluid absorption in the circulation by analysing the Expiratory Breath Ethanol level .

COMPLICATIONS OF THE COMPLICATIONS OF THE SURGERY:SURGERY:• Uterine perforation and hemorrhage. . • Delayed complications : infection, Delayed complications : infection,

discharge and adhesion discharge and adhesion formation.formation.

Complex perforationComplex perforation:: • Scissors may cause when Scissors may cause when dividing adhesions in cases of dividing adhesions in cases of extensive intrauterine extensive intrauterine synechaie. [Asherman's synechaie. [Asherman's syndromesyndrome. ]. ]• Hysteroscopy in such cases Hysteroscopy in such cases should always be done under should always be done under laparoscopic guidance laparoscopic guidance to to recognize impending or recognize impending or occult perforation.occult perforation.

Uterine Perforation:Uterine Perforation:• Incidence : 0.8% (Hill et al, 1992). Incidence : 0.8% (Hill et al, 1992). • British Mistletoe study 0.6% (Maresh 1996). British Mistletoe study 0.6% (Maresh 1996).

Simple perforation:Simple perforation: • Simple perforation may be made Simple perforation may be made

with a cervical dilator or with the with a cervical dilator or with the hysteroscope. hysteroscope. • Perforation with the hysteroscope Perforation with the hysteroscope

should be avoided by always should be avoided by always introducing the telescope under introducing the telescope under direct visual control.direct visual control. • FOR TORTUOUS OR STENOTIC

CERVIX : THINNER ZERO DEG SCOPE MAY BE USED.• Misoprostol tab 400mg might help

Complex perforation:Complex perforation: • Complex perforation Complex perforation

may be made with :may be made with :

1.1. MechanicalMechanical

2.2. Electrical Electrical

3.3. Laser instrumentsLaser instruments

• Complex perforation caused Complex perforation caused by electrosurgical by electrosurgical instruments or laser may be instruments or laser may be associated with thermal associated with thermal injury to adjacent structures injury to adjacent structures including bowel or large including bowel or large vessels.vessels.

Complex perforation: Complex perforation:

PREVENTION OF SURGICAL MISADVENTURES :

KNOW YOUR LIMITS.MULTIPLE SITTINGS FOR DIFFICULT CASESDO NOT CAUSE HARM TO THE PATIENTMAINTAIN THE SKILL BY PROPER TRAININGKEEP A MENTORTAKE HELP FROM COLLEAGUESSPEND TIME ON HYSTEROTRAINER FOR BOTH

SURGEON AND ASSISTANTS esp if the case load factor is low { Even Sachin Tendulkar does net practice to this

day }

Auditing of our complication& Learning from some ones else’s complication

HOWEVER GOOD THE CAR WITH ITS SAFETY FEATURES AND HOWEVER GOOD THE ROAD, THE DRIVER STILL HAS TO DRIVE CAREFULLY TO COMPLETE THE JOURNEY SAFELY.

THANK YOU