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Essay 366

Essay 366 Posted by Farrukh G.

 

A healthy 35 year old mother of 5 children has been referred to the gynaecology clinic because she wishes to be sterilised. (a) Discuss the advantages and disadvantages of hysteroscopic sterilisation as compared to laparoscopic sterilisation [10 marks]. (b) Discuss the steps that can be taken to minimise the risk of visceral injury in women undergoing laparoscopic sterilisation [10 marks].

Answer 366 Posted by Shivamalar  V.

(a) The advantages of hysteroscopic ligation are , it is quick procedure, done under direct camera guidance and can be performed in outptient setting. It does not involve abdominal scar and efficay rate is upto 96-99%. The sterilisation clip is snuggly fit into fallopian tube and carries low risk of dropping out. It allows ficrous formation surrounding it over time and block the tube for sperm passage renders fertilisation. It carries lower risk of visceral organ injury compared to laparoscopic sterilisation. It also does not require highly specialised surgeon to perform. It is cheaperthan laparoscopic ligation.But it carries risk of pain, bleeding immediately or during insertion, clip drop out and expulsion, and clip not properly placed at the desired place.It requires patient to be on another compliant method of contraception for at least 3 months after procedure and they need to undergo hysterosalpingogram evaluation to ensure the tub eis completely blocked before can solely reliable on this method..Hysteroscopy procedure also carries risk of pelvic inflammatory disease with ascending infection.And this procedure is almost irreversile once it is done compared to laparoscopic sterilisation which is reversible.

 

(b) Ideal patient selection is important factor. Patient who had previos abdominal surgery particularly midline scar are high risk to have adhesion and hence visceral organ injury therefore should be counselled for diffrent metod of contraception. Procedure should be done by skilled surgeona nd trainees should perform under supervsion by consultant.Equipments should be checked and ensure they are functioning well before surgery. Adequately trained assistant and scrub nurse would be present during surgery. Patient should be in supine position before and during port insertion. If adhesion is suspected at umbilicus, first port shoudl be inserted in alternate site and most commonly this woul be palmar's point where usually lesser adhesion present unless patient had previous surgery like splenectomy.For obese patient and very thin patient, Hasson's method should be used, and throcar should be introduced only once the peritoneal cavity is visible. If veress needle inserted, 2 click sound should be heard before inserting throcar as this indicates the 2 fascias hasve been penetrated. this should be tested with saline injection to ensure lower pressure in the peritoneal cavity and the introducing pressure should be <10mmHg.The assessory port should be introduced under direct camera vision and once the port has been though the peritoneum, it shoul dbe directed towards the anterior pelvic wall. The intraperitoneal pressure should be maintained at 20-25mmHg until all port are introduced as this increase the distance or the visceral organ from parietal peritoneum. Subsequently patietn can be placed in trendelenburg;s postiion to move bowel away from operative field which is the pelvic region in this case. At this point the pressure can be reduced to 12-15mmHg. In dwelling catheter should be inserted to drain the bladder throughout the entire surgery.

Dharani Posted by DHarani C.

 

A)

The advantages of hysteroscopic sterilization include that the procedure can be undertaken as an out patient procedure which saves theatre time where as laparoscopic sterilization is carried out as day case procedure.  Can be undertaken under local anesthesia and avoids complications associated with general anaesthesia  while majority of laparoscopic sterilizations are performed under general anaesthesia. Patient can return to her normal routine quickly compared to laparoscopic sterilization. Viseral and vascular injury associated with laparoscopic procedures and their consequences such as laparatomy are avoided with hysterscopic sterilization. The shoulder tip pain due to pneumoperitoneum and abdominal discomfort observed during laparoscopic procedures are not expected in hysteroscopic sterilization. 

 

Pelvic anatomy can not be evaluated during hysteroscopic sterilization procedure while it can be studied in detail during laparoscopic sterilization which is a disadvantage of this procedure.

Reversal is not possible with hysteroscopic sterilization while the possibility of reversal is around 50-90% with laparoscopic procedure.

Vaginal bleeding for about a week in the post operative period is common in hysteroscopic sterilization which is uncommon in case of lap sterilization.

Additional procedures such as x-ray, USG or hysterosalpingogram are necessary to ensure the correct placement of the devices where as correct placement of clips can be confirmed during laparoscopic sterilization.

Woman should follow alternative contraception till 12 weeks which is time for the development of fibrous tissue for occlusion of tubes, while contraception is required only till the next menses for laparoscopic sterilization. The disposable devices used for hysteroscopic sterilization are expensive. The pregnancy prevention at 1 year is about 98.9% and this procedure lacks long term data unlike laparoscopic sterilization . Skills of hysteroscopic sterilization are still lacking among surgeons unlike laparoscopic procedures performed by comparatively more number of surgeons with appropriate skills. Only short term data are available regarding safety and efficacy of hysteroscopic sterilization compared to  laparoscopic sterilization which has been evaluated better and  long  term data are available. 

B) Laparoscopy is associated with a risk of visceral injury in 0.4 per 1000 cases . Visceral injury leads to infection, peritonitis, prolonged hospital stay, increased morbidity. There is also increased cost to the NHS in the form of litigation and repeat surgery.

Appropriate patient selection is of value. Preoperative identification of high risk cases such as previous abdominal surgery, documented adhesions, obesity, inflammatory bowel disease.

 Adequate training and supervision is essential to minimize visceral injury. The training should include operative technique as well as use of energy sources like laser and diathermy. 

Prior emptying of bladder by catheterisation minimizes bladder injury. The operating table should be horizontal (not in the Trendelenburg tilt) at the start of the procedure. Examination under anaesthesia is carried out to exclude abdominopelvic masses and for the identification of position of aorta. 

The primary incision should be vertical from the base of the umbilicus and care should be taken not to incise so deeply as to enter the peritoneal cavity. Insertion of verees needle should be at right angles to the skin

The Veress needle should be sharp, with a good and tested spring action. A disposable needle is recommended, as it will fulfil these criteria.

Appropriate way of insertion of verees needle is essential to lessen the risk of visceral injury.The lower abdominal wall should be stabilised in such a way that the Veress needle can be inserted at right angles to the skin and should be pushed with two audible clicks  to penetrate the fascia and the peritoneum.  

Excessive lateral movement of the needle should be avoided, as this may convert a small needlepoint injury in the wall of the bowel into a more complex tear. 

Choosing alternate points of entry is required in case of previous abdominal surgery or with morbid obesity. The preferred point of entry is 3 cm below the left costal margin in the mid clavicular line( Palmer's point). Open technique of Hassan may avoid major vascular injury but the risk of bowel injury is not excluded.

Adequate pneumoperitoneum is important to minimize visceral injury. An intra-abdominal pressure of 20–25 mmHg is essential for inserting the primary trocar. Once the laparoscope has been introduced through the primary cannula, it should be rotated through 360 degrees to check visually for any adherent bowel.

 

Secondary ports should be inserted under direct vision while maintaining the pneumoperitoneum at 20-25 mm of Hg. Instruments, should be inserted and removed under direct vision. 

Early identification is important in management of visceral injury with multidisciplinary care by involving appropriate specialist. Laparotomy is required to repair the damage. 

 

Posted by huaida A.

 

Hysteroscopic sterelisation uses either ESSURE or ADIANA, devices can be done as an office procedure  

this will offset it,s cost.

It needs no anathesia,also has high efficacy ,  up to 99.75% success rate,

Has high satisfaction rate,as it is permenant and need no abdominal incision.

The patient need to use acontraceptive for 3 months ,(the period required  for the fibrosis to build up  arround the device  , so completely occluding the tube.

 

there is risk of fainting attack during application, risk of not iserting the device in the correct place,and  risk of perforation these are more common with the old device ESSURE.

Failure of the the technique inspite rare  may result in ectopic pregnancy.

Hystersalpingogram should done 3 months later to confirm the complete occlusion of the tubes  

This may increase the risk of pelvic inflamatory disease ,and patient discomfort,

the procedure is not suitable  for those with distorted uterine cavity ,in those whose tubes cannot be visualised and for those  who are sensetive to the devices material or to the dye used in hysterosalpingogram.

on the other hand laproscopic sterilisation   result in immediete  tubal occlusion  that necessiate no further confirmatory test

The contraception may used  up  to the next  period only after laproscopic steralisation

How  ever it need general anathesia, with abdominal incision ,with risk of viseral and vasular injury of arround 1-3/1000

also it carries the risk of laprotomy ,

Has failture rate of 1/200 , and if failed  there is increased risk of ectopic pregnancy.

B/

Proper training and supervision  is the gold standard in decreasing the associated risk.

Examination of the pateint under anathesia and defining the  the place of the aorta and detection of any abdominal masses is of paramount importance,

uses of end guarded trochar  and true directioning of the trochar during insertion helps in  avoiding damage to the viscera

paying additional attention to an adherent bowel to exclude it,s injury

Uses of palmar point in cases of previous surgery and adhesions 

intra-abdominal pressure of 20-25mmhg help in good visulisation of the intaperitoneal cavity

inserion of second pore canulae should be under direct vision to avoid hypogastric vessel injury

 removal of any canula should be under direct  vision 

 

 

 

Posted by Nabila A.

Hysteroscopic  steriliation is less invasive as compared to laproscopic procedure .it is done under local anaesthesia or intravenous sedation which avoids the use of general anaesthesia being commonly used for laproscopic sterilization and its potential complications .It is done as an outpatient procedure whereas laproscopy is daycare procedureIt is safe  with low rate of complications.Total occlusion of the tubes  successfully obtained in 91-97% of cases.Occlusion of the tubes is to be confirmed byHSG, x ray or ultrasound at 3 months,0.2-3% of the tubes are found to be still patent  at 3 months which will be confirmed  to be occluded at 6 months HSG. Patient  satisfaction  is found in 94% cases.Majority of the patients find periopertive pain almost nonexistent.

Overall pregnancy rate is 0.16%

 Improper placement  of microinserts is found in 0.4% ,perforation of tubal lumen or uterus is found  in 1-2.6%.Failure rate is 3/1000  with hystroscopic  insertion .Other potiential  adverse effects are infection, spotting/vaginal bleeding /abdominal pain /asymptomatic migration  or expulsion,  vasovagal syncope    .Effective contraception needs to be used till tubal occlusion is confirmed  which is done by HSG at 3 months and a small proportion which does nt show complete occlusion will have to be followed till 6 months.

Laprosco pic sterilization is done as day care procedure under general anaesthesia.local anaesthesia is an alternative .Risks of laproscopic entry should be explained  …incidence of bowel injury is 0.4/1000 and that of vascular injury 0.2%.these risks will be increased in both the obese as well as thin,also with previous abdominal surgery which increase the risk of adhesions(  50% in case of midline abdominal incision and 23% with transverse incision) Also the risk of hernia formation at the entry site..Failure rate is 1 in 200.Effective contraception is to be used  till the procedure and till the next period.It is reversible although the rates after reversal  31-92% with 1-7% risk of ectopic pregnancy depending on the method used for tubal ligation . Risk of laparotomy is 1.4-3/1000 with a risk of death of 1/12000.

Abdomen should be inspected for scars ,palpated for any masses and aorta.

To minimize the risk of visceral injury,careful  entry technique is required .Position of the patient should be horizontal rather than trendelenberg. The incision should be in the base the umbilicus not below itand peritoneal cavity should not be opened..Veress needle should be sharp ,spring tested.After penetration of peritoneal cavity ,it should not be moved laterally as it will extend the tear if any .Primary tr ocar  should be inserted at 90 deg. after careful positioning of the abdominal skin.when the laproscpe  is inserted   should be rotated all around 360 deg. to identify any vascular or visceral injury on the inside of abdominal  wall.In case of previous abdominal surgery  wher there I srisk of adhesions  open technique can be used  although there is no evidence of safety.Entry can be proceeded at Palmers point in case of previous surgery or in obese  which is not feasible in case of spenomegaly   .If required  trocar insertion can be done after confirmation of absence of adhesions after viewing the cavity through a secondary port(5mm hystroscope).the insufflations pressure should be 25mm hg  before trocar insertion  and then reduced  to 12-15 mmhg .Withdrawl of the trocar should be under direct vision to avoid injury as well as to recognize any .

 

Answer to Essay 366 Posted by preetiba rani V.

a)  Sterilization procedures are done in couples who are sure that they have completed their family with no intention for further child bearing.

Hysteroscopic sterilization can be done as a daycase or as an office procedure as this procedure can be carried out by administering local anaesthesia or intravenous sedation.  This is in contrast with laparoscopic sterilization where it is done under general anaesthesia with it's accompanying complications

The placement of intrafallopian implants causes fibrosis and occlusion of the tubes.  However this procedure needs an additional contraception for up to 3 months until an imaging (such as x-ray, ultrasound and hysterosalphingography) is done to ensure the occlusion of the tubes. In this case, laparoscopic sterilization has an advantage because it is immediately effective and no additional contraception is required.

The pregnancy prevention rate after 1 year of hysteroscopic procedure is almost 98% comparing to failure rate of 0.5% in laparoscopic sterilization procedure.

Hysteroscopic sterilization is generally more acceptable to patients as this can be done as an office procedure where no abdominal incisions need to be performed as in the case of laparoscopic sterilization

Hysteroscopic sterilization is however associated with the risk of uterine perforations, fallopian tube lumen perforations, device migration and expulsion, vasovagal reaction and pelvic pain.  These complications however is unlikely to be seen following a laparoscopic sterilization where complication regarding visceral injury is common

 

b)  Careful selection of patients for laparoscopic sterilization procedures is essential to identify the patients who are at risk of having visceral injury such as those patients who had a history complicated pelvic surgery.  It is also important to ensure that the surgeon performing the procedure is well trained and is familiar with the equipments in the operating theatre.  The operating theatre table must be in a horizontal position.  Before an incision is made the abdomen must be palpated for any masses and aortic pulsation to avoid injury. 

Using an alternative entry point such as Palmer's point is useful when dense adhesion is expected at the umbilical region due to previous surgeries.  The direction of entry should be in a controlled manner with 90 degrees to the skin.  The entry is stopped immediately upon entering the abdominal cavity.  Once entered the camera should be rotated 360 degrees to check for any adherent bowel.  Subsequent trochars and ports should be inserted under direct visualization.  After completion of the procedure the trochars have to be removed under direct visualization.

 

ANSWER 366 Posted by mariam M.

Advatages of hysteroscopic sterilization include that it is non incisional method ,avoids abdominal entery,can be done as an office procedure so more cost and time effective  and avoids general anesthesia as it can be done without anaesthesia or with minimal sedation and also less post operative pain with quick return to work and normal activities never the less it can be done in women with extensive pelvic adhesions and also in women who have comorbidites that preclude laparoscopy or laparotomy    the most important is that it is an effective procedure 95-99%   success rate and also less anxiety  it avoids visceral injury   and contain no hormones                                                                                                   however unlike laparoscopic sterilization which conveys immediate reliability ,hyseroscopic sterilization is amulti step process in which the hysteroscopic sterilization procedure is followed by confirmatory hyserosalpingogram performed at least three months after the initial procedure  to prove bilateral occlusion before women can relay on this method of contraception  and there is high risk of unilateral tubal occlusion there is risk of perforation to the uterus and risk of intraoperative bleeding risk of assending infections and 5%experienced failed placement and require another procedure  alsa it needs technical skills  it is also an irreversable procedure unlike laproscopic sterilization in which reversibility is 50-90%                                                                                                                                                                              B appropriate counseling shoud be done prior to surgery there is increased risk in obese women or unde weight and those with previous mid line incisions peritonitis or inflammatory bowel disease  the surgeons should have appropriate training supervision and experience and are familiar with the equipment and should ensure that nursing staff and surgical assistants are appropriately trained for the role they will undertake during the procedure  .The primary incision shoud be vertical from the base of the umbilicus iit shoud not be so deeply to enter the peritoneal cavity  the veress needle shoud be sharp ,with agood and tested spring action Adisposable needle is recommended ,as it will fulfil these criteria.  The operating table should behorizontal (not in the Trendelenburg tilt) at the start of the procedure. The

abdomen should be palpated to check for any masses and for the position of the aorta before insertion

of the Veress needle.The lower abdominal wall should be stabilised in such a way that the Veress needle can be inserted at

right angles to the skin and should be pushed in just sufficiently to penetrate  the fascia and the

peritoneum. Two audible clicks are usually heard as these layers are penetrated.Excessive lateral movement of the needle should be avoided, as this may convert a small needlepoint injury in the wall of the bowel or vessel into a more complex tear. An intra-abdominal pressure of 2025 mmHg should be used for gas insufflation before inserting theprimary trocar.The distension pressure should be reduced to 1215 mmHg once the insertion of the trocars is complete.

This gives adequate distension for operative laparoscopy and allows the anaesthetist to ventilate thepatient safely and effectively. The primary trocar should be inserted in a controlled manner at 90 degrees to the skin, through theincision at the thinnest part of the abdominal wall, in the base of the umbilicus. Insertion should be

stopped immediately the trocar is inside the abdominal cavity.Once the laparoscope has been introduced through the primary cannula, it should be rotated through

360 degrees to check visually for any adherent bowel. If this is present, it should be closely inspectedfor any evidence of haemorrhage, damage or retroperitoneal haematoma.

If there is concern that the bowel may be adherent under the umbilicus, the primary trocar site shouldbe visualised from a secondary port site, preferably with a 5-mm laparoscope.On completion of the procedure, the laparoscope should be used to check that there has not been athrough-and-through injury of bowel adherent under the umbilicus by visual control during removal. When the Hasson open laparoscopic entry is employed, confirmation that the peritoneum has beenopened should be made by visualising bowel or omentum before inserting the blunt tipped cannula Direct trocar insertion is an acceptable alternative trocar insertion method Palmers point is the preferred alternative trocar insertion site, except in cases of previous surgery inthis area or splenomegaly. Secondary ports must be inserted under direct vision perpendicular to the skin, while maintaining the pneumoperitoneum at 2025 mmHg. During insertion of secondary ports, the inferior epigastric vessels should be visualised

laparoscopically to ensure the entry point is away from the vessels.During insertion of secondary ports, once the tip of the trocar has pierced the peritoneum it should be

angled towards the anterior pelvis under careful visual control until the sharp tip has been removed.Secondary ports must be removed under direct vision to ensure that any haemorrhage can be observed and treated, if present. The open (Hasson) technique or entry at Palmers point are recommended for the primary entry in

women with morbid obesity. If the Veress needle approach is used, particular care must be taken to ensure that the incision is made right at the base of the umbilicus and the needle inserted vertically into the peritoneum. The Hasson technique or insertion at Palmers point is recommended for the primary entry in women who are very thin.

 

 

Posted by Ghida R.

A- hysteroscopic sterilisation is by inserting an implant in the cornual end of the Fallopian tube causing its blockage. It is a minimally invasive procedure that is done through the neck of the womb, and is done as a day case procedure with minimally discomfort post procedure and minimal or no interruption from work. However its insertion is associated with risk of rupture of oviducts and subsequently injury of intraabdominal organs e.g bowel and risk of bleeding if there is puncture of major vessels. its reversiblity is possible, but cannot guarantee tubal patency and normal tubal function.

As regard laparoscopic sterilization it is also a minimally invasive procedure that is done through keyhole incisions in the belly, it involve visualisation of the oviducts and putting a metal clip (Filshie Clips) in order to obstruct the oviducts. It also is a day case procedure associated with a 1% pain at the site of incisions that is managed by pain medications, it has a 3in 1000 risk of bowel or vessel injury, and a 1 in 12000 risk of death.The procedure has a failure rate of 1 in 200, and thefailure can be due to a pregnancy that was already in the tube at the time of the procedure, that's why patient should be on effective contraception till the next period. there is also early failure associated with displacement of the clip and late failures due to recanalisation of the tube. Reversibilty is possible but patient cannot be assured it is 100% and patient should be sure about her decision.

B- steps that can be done to decrease risk of visceral injury are first correct position of the patient at insertion of primary trocar. The patient should be in supine position to minimize injury of the Aorta upon vertical entry to the abdomen. The bladder should be emptied before abdominal entry to avoid its injury by the suprapubic trocar. Entry to the abdomen is usually at the umbilicus, but in obese or very thin patients the palmer point can be used (left hypochondrium).Closed method by using verres needle  and open method (Hasson technique) can be either use as there is no advantage in matter of safety or avoidance of visceral injury. Verres needle should be inserted perpendicular to the skin. the correct placement of the needle should be checked by aspirating through an empty syringe, blood or fecal matter indicate vessel or bowel injury. intrabdominal pressure should be low <8mmHg, high pressures indicated either obstruction of tip of verres needle, or incorrect entry to the peritoneal cavity. Care should also be taken not to move the needle as this may extend a puncture injury. the intraabdominal pressure should be raised till 20mmHg to allow for safe entry of the primary trocar as this will further displace the abdominal wall from underlying organs. After insertion of the primary trocar the pressure is decreased till 16mmHg, and careful inspection of the abdomen and pelvis is done. At the end of procedure, the sites of trocar incision should be checked after removal of the secondary trocars, and the camera should be removed only after removal of the primary trocar to check for presence of through and through bowel injury.

Posted by fadi A.

A)  The advanteges of hysteroscopic method sterilization that it can be done as office procedure in day surgery under local anesthesia and women can avoid complication of general anesthesia.but compaire to laparoscopic method it require 12 weeks for fibrosis formation for complite tubal     block and need additional contraception.After the procedure women should performed hysterosalpingography to insure that procedure is successful.During hysteroscopy she may fill some discomfort or allergy reaction on device ,procedure may be difficult if cervix is stanosed or there is distortion of uterine cavity.Thre some study wich show that hsteroscopic occlusion of tube has some protection  from ovarian cancer.   

B)The safety of laparoscopic entery  depend on appropriate selection of patients who are at risk for complication (obese, underweight women, previous inflammatory bovel process and abdominal surgery) , careful taining and supervision of staff ,safe entery of primary trocar and careful visualisation of  intra-abdominal structures.

The trainees should    be familiar with Veress needle (women in horizontal position ,lifting abdomen, observation of gas pressure ) Hasson technique - open technique to entery in abdomen and use of Palmer point in patient with suspected adhisions.

Answer to 366 Posted by ALi S.
Hysteroscopic sterilisation is considered as a safe procedure as it can be done under local anaesthesia and/or sedation so avoiding risks relating to general anaesthesia during laparoscopic sterilisation. It can be done on outpatient basis saving cost of hospital admission and possible overnight stay in laparoscopic procedure. It also gives the opportunity to visualise the uterine cavity for undiagnosed pathology like sub mucous fibroids and polyps.but the major advantage of the hysteroscopic procedure versus the laparoscopic procedure is avoidance of visceral and vascular damage encountered during veresse needle and/or taro car insertion at laparoscopy especially in obese and very thin patients with previous abdominal scars. It has high success rate 97-99% and less failure rate of 3.1per 1000 compared to 1per 200 in laparoscopic sterilisation. Hysteroscopic sterilisation had some disadvantages like pain during insertion and vasovagal reaction in contrary to laparoscopic procedure which is usually under general anaesthetic. Inability to visualise the pelvic cavity for any adnexal pathology and endometriosis.need for 3months of contraception until tubal blockage confirmed by HSG in contrary to short period of contraception until the next period in laparoscopic clip sterilisation.other possible disadvantages include uterine perforation and ascending pelvic infection if STI not screened beforehand or if no prophylactic antibiotic were given as well as risk of expulsion and peritoneal migration of the device. The first step to minimise the risk of visceral damage start with patient selection when BMI, and previous midline laparotoies as well as previous bowel surgery are considered risk factors for visceral damage during the laparoscopic sterilisation and necessitate experienced laparoscopist and or alternative abdominal entry techniques. Patient should lie flat during needle and trocar insertion completed and ensure that bladder is empty. ,Veresse needle insertion intraumblical rather than subumblical as it's the shortest distance to peritoneal cavity. Other entry methods like Palmer point entry or open laparoscopy or Hasson technique can be used in obese patients and with patients with midline scars and previous bowel surgery., intraabdominal pressure after Veresse needle insertion should be <10mmHg to ensure intraabdominal placement. Pneumoperitoneium created by co2insufflation to pressure 25mmHg until all trocar insertion has been completed . Insertion of secondary trocars should be under direct visualisation to avoid injury to epigastric vessels and/or visceral damage . Once laparoscopy had been inserted visualisation of the peritoneal cavity and trocar insertion sites for diagnosis of any possible visceral damage and bleeding. If damage is suspected manipulation should stopped and perforating instrument kept in place until help achieved from surgeons. Avoid excessive cautrisation especially with monopolar diathermy to minimise risk do thermal bowel injury. At any time all instrument should be visualised until completion of the procedure. At the end of terilisation removal of the instruments and trocars should be under direct vision to avoid loop of intestine or momentum to be dragged to port site .All informations regarding visual damage risk and need for additional procedure should be discussed during consent process as well as debriefing the when complication arises.
Answer 366 Posted by Anagha W.

 

Hysteroscopic sterilisation involves hysteroscopic placement of microinserts in both fallopian tubes. This induces fibrotic changes in the tubes, causing tubal blockade, thus inhibiting sperms entering the tubes and fertilising ova. Commonly used device for this purpose is Essure. Laparoscopic sterilisation is usually performed using rings, Filshie clips or Hulka clips and less often diathermy for tubal occusion. It requires admission and administration of general anaesthesia. Hysteroscopic sterilisation can be performed as an office procedure under local anaesthetic or intravenous sedation. Since no incision is required, the recovery is quicker than by laparoscopic approach. Efficacy is better than that of laparoscopic procedure, with lesser failure rate.  It is cheaper than laparoscopic sterilisation. It is also associated with lower incidence of visceral injury including bowel, bladder and blood vessels, which is about 3 per 1000 laparoscopic sterilisations.

Since it is a fairly new method, expertise is not widely available, while laparoscopic sterilisation is a commonly performed procedure worldwide. Complications like tubal rupture, uterine perforation, microimplant migration or expulsion, though not common can occur.  Laparoscopic sterilisation does not require any confirmatory tests for its correct application, however hysteroscopic sterilisation requires confirmation 3 months after the procedure which can be done by X-ray or an Ultrasound Scan followed by a Hysterosalpingography (HSG) or HSG alone.

Reversal of tubal occlusion is less likely to succeed in case of hysteroscopic sterilisation as compared to that of laparoscopic approach.

 

Certain measures can be taken preoperatively to reduce the incidence of visceral injury at laparoscopic sterilisation. Primarily the operator should have the necessary expertise, experience and should be familiar with the equipment. The staff should also be appropriately trained with clearly distinguished roles with respect to the surgery. Previous history of abdominal surgery, peritonitis, bowel infection, abdominal sepsis should raise a suspicion of possible intraperitoneal adhesions.

 

Urinary bladder should be emptied at the beginning of the surgery to avoid bladder injury. Intraoperatively, highest chance of visceral injury is during the blind insertion of veress needle. Once veress needle is inserted the insufflation pressure should be checked or palmer's test or normal saline test should be performed to confirm the veress needle is in the peritoneal cavity. Alternative technique like open laparoscopy or Hasson's technique can be used when bowel adhesions are anticipated. Although it may not reduce the incidence of bowel injury, it is associated with early recognition of injury, that is, at laparoscopy. It may also reduce the incidence of injury to major blood vessels. Veress needle can also be inserted at palmer's point, that is 2 cm below subcostal margin in the left midclavicular line. The umbilical site can be examined for any adhesions through a telescope inserted at the palmer's point and umbilical trocar can be inserted inder direct vision. Intraabdominal pressure should be kept at 22-25 mm Hg; this allows adequate splinting of all viscera for safe insertion of all trocars and avoids visceral injury. Once all trocars are inserted the pressure can be reduced to 12-15 mm Hg. Tips of trocars should be inspected for any bowel contents. All instruments should be inserted under direct vision. Tips of instruments in the abdominal cavity must be kept under direct vision to avoid injury outside the field of vision, which might be difficult to locate. If bowel/bladder/ureteric/blood vessel injury is suspected, immediate corrective measure should be taken and appropriate expert should be called in for help. Defects should be sutured either by a surgeon or gynaecologist trained at laparoscopic suturing. Laparotomy might be appropriate to allow examination of loops of bowel for suspected injury. Ureteric stenting would be required for ureteric injury and suprapubic catheter for bladder injury. 

Essay 366 Posted by sujata B.

 

a)Hysteroscopic sterilization involves the insertion of microinserts (metal springs) into the cornual end of the fallopian tube via a hysteroscope. The advantages are that it can be an O.P.D procedure with no requirement of anaesthesia, non surgical ( no incision) , unlike as in laparoscopy , where it is a surgical procedure under general anaesthesia and requires in –patient care . This method is safe in patients with heart disease and obesity, which are risk factors for a laparoscopic method of sterilization.

The disadvantages are that a hysteroscopic sterilization takes three months for its full blocking effect of the tube and another method of contraception should be used till then. It is contraindicated in utrene anomalies like the unicornuate uterus. The microinsert can get expelled in 2-3 % of cases and in 1% it can perforate the tube when a laparotomy would be required. A second procedure may be required in some cases and confirmation will have to be done with a HSG after 3 months.

b) Minimising visceral injury in laparoscopic sterilization would begin from a proper history to note any previous surgeries, to aid us in anticipating bowel additions to the abdominal wall. Although we should anticipate bowel additions to the abdominal wall even in those without surgery.Safe insertion of the primary trocar is the most important step. In suspected adhesions at the umbilicus, insertion of the trocar can be done via the palmar port. The safe entry of the Veress needle should be done after the intra abdominal pressure is raised upto 20-25 ml of mercury. Installation of 2-3 ml saline through a syringe into the Verres to ensure free flow should be done. Lateral movements of Verres should be avoided. Insertion should be done when the patient is lying flat. Subsequently the primary troca is inserted. Once inside, a 360 degrees turn is done to visualize bowel additions. A 5 mm scope is inserted in the secondary port to visualize and release adhesions near the primary port. After the surgery the laparoscope is removed through direct vision to look for any through and through bowel injury.

Post operative assessment regarding distention and bowel sounds and passing of flatus  needs to be done. The advice on discharge should include importance of reporting back in case of vomiting and bloated feeling with non passage of flatus as bowel injuries are often recognized later.

Laparoscopic surgeries should be carried out by operators with the skill, knowledge and training to avoid complications. 

answer 366 Posted by shazard S.

Essay 366

(A) 

Regarding advantages of hysteroscopic sterilisation. Hysteroscopic sterilisation and laparoscpic sterilisation are both safe and effective methods of sterilisation. The one year failure rate of hysteroscopic sterilisation is 1%. The lifetime failure rate of laparoscopic sterilisation is 1/200. Hysteroscopy is done as an out patient procedure under local anesthesia and avoids the risks associated with general anesthesia. Laparoscopic sterilisation is often done under general anaesthesia and therefore entails risk of general anaesthesia. Convalescence with hysteroscopic sterilisation is faster than with laparoscopic sterilisation. Complications of hysteroscopic sterilisation include expulsion or migration of the microinsert, pelvic pain, tubal perforation, vaginal spotting, PID, vaso- vagal syncope, painful insertion and failure. Laparoscopic sterilisation entails the risk of visceral injury. Risk of bladder injury is 0.6/1000, bowel injury is 0.4/1000 and vascular injury is 0.2/1000. Risk of laparoscopic sterilisation related death is 1/12000, 39% of which is due to anaesthetic complications. Minor morbidity includes post operative nausea and shoulder tip pain. These risks are avoided with hysterosocopic sterilisation and may be better for those at risk with laparoscopy (obese, very thin patients, those with prior abdominal surgery or those with inflammatory bowel disease). Hysteroscopy allows visualisation of the endometrial cavity. Laporoscopy allows visualisation of the pelvic organs. Regarding disadvantages of hysteroscopic sterilisation. Additional contraception is recommended for at least 3 months. Further imaging is required 3 months after the procedure.  Tubal occlusion is confirmed by HSG or correct placement of microinserts confirmed by ultrasound or pelvic X-ray. Laparoscopic sterilisation requires additional contraception only until the next period and requires no other investigation. Hysteroscopic sterilisation is a relatively new technique. Long term data is not yet available. Operator skills are still on the learning curve. Laparoscopy being an established technique has been well studied. Long term data regarding outcomes are available and operator skill is often considerable. Data regarding reversal of laparoscopic sterilisation indicates success in 30-90%. This data is not yet available for hysteroscopic sterilisation. Supplement counselling with written information.

 

(B)

Reduce the risk of visceral injury by identifying at risk patients pre-operatively. These are morbidly obese, very thin, patients with previous abdominal surgery and those with large abdominal masses. An appropriately skilled surgeon should perform the procedure. Equipment should be tested and functional. Catheterising the patient’s urinary bladder keeps it out of the surgical field. The patient should lie flat. Palpate the abdomen noting any masses and the position of the patient’s aorta. Regarding primary entry into the abdomen use Hasson’s open technique or Palmer’s point (3cm below left inferior costal margin along the mid-clavicular line) for those at high risk for visceral injury. Use palmer’s point if 2 failed attempts at entry through umbilicus.  Avoid palmer’s point in those with prior splenectomy or splenomegally. With the closed technique the primary incision is vertical and made through the base of the umbilicus. The Veress needle is inserted at 90 degrees to the skin. Stop entry immediately after the second click is heard. This indicates entry through the parietal peritoneum. Perform the pressure/flow test to confirm entrance into the abdominal cavity. Free CO2 flow at 8mmhg indicates correct position. Avoid lateral movement of the needle. This prevents conversion of a needle point injury into a tear. Insufflation of the abdomen to a pressure of 20-25mmHg maximises the distance between viscera and the anterior abdominal wall. This reduces the risk of injury from primary and secondary port insertion. Insert the primary trochar at 90 degrees to the umbilicus with a pneumoperitoneum at 20-25mmHg stopping immediately after the parietal peritoneum is pierced. Using the laparoscope through the primary port perform a 360 degree view of the abdominal cavity noting any bowel adherent to the abdiominal wall. Observe closely bowel that is adherent to the umbilicus for  injury. Insert secondary ports, under direct vision, at 90 degrees to the skin with a pneumo-peritoneum of 20-25mmHg stopping immediately after the parietal peritoneum is pierced. Visualise with the laparoscope the inferior epigasric vessels during entry and avoid them. After entry achieved angle the trochar anteriorly toward the pelvis. In very obese patients enter secondary ports well lateral to the lateral boder of the rectus sheath taking care not to injure the vessels of the pelvic side wall. After secondary ports entered reduce insufflations pressure to 10-15 mmHg. Regarding removal of ports. Remove secondary ports under direct vision. Note bleeding at port sites and ensure haemostasis. Remove the laparoscope from the primary port site while looking for bowel that may have had through-and-through injury from primary port insertion. Close deep fascial layers if a non-midline port >7mm or midline port >10mm is used. This prevents port site hernias.

 

Posted by FAUZIA  T.

Hysteroscopic sterilisation is an outpatient procedure, requires local anaesthesia or intravenos sedation.it requires additional form of contraception till imaging shows satisfactory placement of microinsert initially by Xray and ultrasound and later by HSG at 3 months as compared to laparoscopy in which contraception is required only till the next menstrual cycle. There is no risk of general anaesthesia. With laparoscopy there is  a risk of visceral injury, bladder injury and vascular injury. there is an increased risk with laparoscopy in patients who are obese. very thin, those who had peritonitis, inflammatory bowel disease or with midline incision.

Hysteroscopic sterilisation can lead to infection, perforation, expulsion or migration , pelvic pain or vaso vagal reaction. also it cannot be used in woman with distorted uterine cavity or stenosed cervix.

Risk of visceral injury can be minimised by appropriate selection of patient, for woman who are morbidly obese or underweight, open technique (hasson) is better than closed method.woman who had peritonitis, inflammatory bowel disease or with midline incision, primary trocar should be inserted from the palamer's point.The surgeon should have the knowledge, experience and skills.the staff should be fully trained. the abdomen should be palpated before the laparoscopy to feel for any masses and the position of the aorta. the veress needle should be tested for double spring action. The skin sould be stabilised at the veress needle should be inserted at 90 degree to the skin. the table should be in horizontal position.the laparoscope should be rotated at 360 degree to see for any damage, haemorrhage or haematoma.In woman who had inflammatory bowel disease, the laparoscope should be inserted at the secondary port to see if there is  any adhesions. secondary port should be removed under direct vision.

 

 

Answer to essay 366 Posted by Jyoti B.
Hysteroscopic sterilisation is a relatively newer method of permanent contraception which is still under evaluation.In this method though the hysteroscope inserts are inserted in the Fallopian tube which fibrose in about 3 months which cause the tube to be blocked,this it doesn't have an immediate effect as laproscopic sterilisation and it needs to be confirmed by hysterosalpingography.Complications include vasovagal syncope, uterine perforation, migration of the inserts,increased risk of ectopic pregnancy.However when compared to laproscopic sterilisation, it is an outpatient procedure that can be done under local anaesthesia or Intravenous sedation and doesn't require general anaesthesia and hence avoids its compliacations.there are no surgical incision on abdomen and risk of visceral injury is reduced.The operating time is less and has a quicker recovery.According to studies failure rate is about 3 in 1000 vs in laproscopic sterilisation is 1 in 200,hence making it more cost effective and safer option than laproscopic sterilisation. B) To minimise visceral injury during laproscopy, firs of all we should identify the patients who are at a higher risk like those with previous abdominal surgeries especially previous midline midline laprotomies, perotonitis, inflammatory bowel disease, very obese or very thin patients.The surgeon undertaking the procedure should be well qualified for the procedure or should be supervised by a senior.Although there have been no stastical difference in visceral injury by either of the open or the closed entry technique,in high risk women an open Hanson technique of entery or insertion at palmers point(3cm below left sub costal line)may be undertaken as a primary entry. During initially entery by a verris needle the spring action of the needle should be check prior to procedure, the operating table should be horizontal and direction of the entery should be perpendicular to be abdomen at the base of the umbilicus.With two failed attempts it should be converted to an oppen technique.During the entery of the trocar the abdominal pressure should be kept at 20-25mm hg,which after entery may be reduced to 10-12mm hg,same holds for entry of secondary ports if required.Entry direction should be perpendicular,once entered should be directed towards the pelvis.Once entered the scope should be rotated by 360degres to check for bowel injury.also taking ou the scope should be under vision.
answer Posted by Yingjian C.

a)

Advantages of hysteroscopic sterilisation compared to laparoscopic are hysteroscopic sterilisation is less painful than laparoscopy; can be done as a day surgery case; may have higher patient acceptability compared to laparoscopy; can be done under local or regional or general anesthesia compared to laparoscopic sterilisation which is done under regional or general anesthesia. Hysteroscopic sterilisation can be done for patients not suitable for laparoscopy such as obese patients, history of extensive intraabdominal adhesions or complicated laparotomies and those who cannot tolerate gas insufflation such as those with respiratory or cardiovascular compromise or those with large abdominal hernias. Hysteroscopic sterilisation may also have quicker operating time and faster recovery than laparoscopic ligation; is more suitable for centres with no expertise/equipment/facilities for laparoscopic surgery and may be less expensive than laparoscopy. Hysteroscopic sterilisation also avoids risks of laparoscopy such as pneumoperitoneum, subcutaneous emphysema, visceral injury and failure of laparoscopic entry and conversion to laparotomy.

 

Disadvantages of hysteroscopic sterilisation are that it requires expertise/equipment/ facilities for hysteroscopy, risks of hysteroscopy such as uterine perforation and visceral injury, bleeding, infection, failure of entry thru cervix, fluid overload, poor visualisation and abandoning operation. It may also be less acceptable for patients who are nulliparous and more difficult in patients with previous extensive cervical surgery compared to laparoscopy.

 

b)

To minimise risk of visceral injury, preoperatively I would assess patient’s history for suitable patient selection for laparoscopy noting any previous laparotomies, difficulties in surgery, history of intraoperative adhesions, endometriosis, severe pelvic inflammatory disease, patient’s body mass index or abdominal hernias.

Operatively, if patient has above risk factors in history, I would use palmer’s point for entry or open Hasson method instead of veress needle entry if using umbilical site for entry. On inserting camera port, I would use slow controlled movements; if using Veress needle entry, I should hear 2 clicks on entry, opening gas pressure should be <8mmHg. Ancillary ports must be inserted under vision with controlled slow entry and gas insufflated to 20mmHg at time of insertion. On identifying tubes, care taken on manipulating bowels away from exposure to prevent accidental injury, patient can be put on tredenlenberg position for easier exposure. Care also taken when ligating tubes to prevent ligation of round ligaments or ovarian vessels. Postoperation, ports must be removed under visualisation, gas from pneumperitoneum slowly released, camera port slowly removed without catching any bowel and care taken on closing skin not to dig the needle too deeply to prevent catching any underlying bowel in thin patients.  

 

SG Posted by gouthaman S.

Hysteroscopic  sterilisation is  associated  with  less  anaesthetic  complications

as compared to laparoscopic method as it is done under local anaesthesia or iv

 sedation .Laparoscopic sterilisation is done under GA.In  hysteroscopic

sterilisation there  is  no need for making cuts in the abdomen.Bowel,blood

vessel injury  are  less common than laparoscopic method.In  studies  very  few

  ectopic  pregnancies  are  reported  with  hysteroscopy,so  if  failure  occurs

less chance  of  ectopic  pregnancy  than  laparoscopy.Hysteroscopy  is

  preferred  if  previous surgery,bowel pathology, obesity  due  to  decreased

 risk of visceral injury and adhesions.There is no risk of wound infection,

shoulder tip pain,hernia formation associated  with laparoscopy.

The  disadvantage of  hysteroscopy is it is irreversible.Contraception  has to be

 used atleast for 3 months till is proved that the tubes are blocked. Second 

procedure HSG is required for this.Laparoscopy  requires contraception till

 procedure or next cycle only.The  risk of uterine perforation,improper coil

placement  are with hysteroscopy.Since  new procedure requires skills and

training. Data  and studies are limited for hysteroscopic

sterilisation.Postoperatively  majority have pain compared to

laparoscopy and vaginal  bleeding.Hysteroscopy is 96-98% successful.Failure rate of laparoscopy is 1 in 200.

 

B}Preoperative assessment including obesity,previous surgeries,bowel

 pathology,underweight  should  be  made  prior to surgery for proper

 planning.Adequate  skillsof the operator, assistants proper knowledge of

equipments are necessary.Optimisation of trocar and canula insertion is the most effective way of reducing entry

related injury.Patient position should be horizontal without tilt.Verees needle should be sharp,good spring

action ,disposable.Abdomen is palpated before incision for masses and position of aorta.Incision should be made

from the base of the umbilicus and verees is inserted to right angles to minimise injury.Lateral movements are

restricted as it will convert needle point tear to complex tear of the bowel and vessel.Pressure is kept at 20 to25

mmHG for splinting action till primary and secondary trocar insertions and reduced to 10-12mmhg later.Trocars are

inserted at right angles.After insertion telescope is rotated through 360 to visualise adherent bowel,injury and if

needed visualised via secondary ports.Removal of ports is done under direct vision to identify injuries.Secondary ports

are inserted after visualising epigastric arteries.Two failed techniques,obesity,underweight,previous surgeries Hassons

orPalmer point entry is used.Newer techniques if available radially expanding trocars, endotip can be used for better

visualisation .

  

Essay 366 hysteroscopic sterlisation Posted by MONA V.
A). Hysteroscopic sterilization is a relatively new technique but there is adequate evidence for safety and efficacy. Main advantage as compared tp laparoscopic sterilization is outpatient procedure done under local anesthesia or intravenous sedation so avoids complication of anaesthesia. It avoids cut on abdomen as it involves hysteroscopic insertion of implants into Fallopian tubes. It is preferable in obese patients, those with previous surgery as it avoids risk of visceral injury associated with lap sterlisation. It avoids frequent risk of laparoscopy like wound infection gaping bruising and shoulder pain. It has. 97-99% success rate compared with failure rate of 1 in200 for lap sterlisation . Disadvantage is that additional contraception is needed for 3 months till tubal occlusion is confirmed by x ray, ultrasound or hsg (hysterosalpingogram). In lap sterlistion additional contraction needed only til next period . Due to hysteroscopy used there can be serious ,rare risk like uterine perforation ,fluid overload . There can be fallopian tube tears, pelvic pain, infection vasovagal attack and device misplacement . It is an irreversible technique unlike lap sterilization which has a variable reversal rate. B). Laparoscopy associated visceral injury can be prevented by careful patient selection noting BMI , previous surgery , inflammatory bowel disease. Surgeon and team performing procedure should have adequate skill ,supervision and be familiar with instruments. Operating table should be horizontal with no tilt till trocar placement. Closed veress needle technique is safe and needle should be sharp with good tested spring action.. Before entry abdomen mass aorta position checked, . Veress needle inserted at right angles after stabilizing lower abdomen by incision at base of umbilicus and pushed to pierce fascia and peritoneum by noting two clicks . Avoid excess lateral movement of needle or needle point injury made into large bowel tear. Two failed attempts with veress , extremes of weight , previous surgery should prompt has son's open technique or Palmer point entry. Primary trocar placement done at 20-25 mmhg abdominal pressure. Secondary port insertion is done under direct vision with trocar tip towards anterior pelvis after entry. Removal of port done under vision.
Essay 366 Posted by MONA V.
A).   Hysteroscopic  sterilization is a relatively new technique but there is adequate evidence for safety and efficacy. Main advantage as compared tp laparoscopic sterilization is outpatient procedure done under local anesthesia or intravenous sedation so avoids complication of anaesthesia. It avoids cut on abdomen as it involves hysteroscopic insertion of implants into Fallopian tubes. It is preferable in obese patients, those with previous surgery as it avoids risk of visceral injury associated with lap sterlisation.  It avoids frequent risk of laparoscopy like wound infection gaping bruising and shoulder pain. It has. 97-99% success rate compared with failure rate of 1 in200 for lap sterlisation . Disadvantage is that additional contraception is needed for 3 months till tubal occlusion is confirmed by x ray, ultrasound or hsg (hysterosalpingogram). In lap sterlistion additional contraction needed only til next period . Due to hysteroscopy used there can be serious ,rare risk like uterine perforation ,fluid overload . There can be fallopian tube tears, pelvic pain, infection vasovagal attack and device misplacement . It is an irreversible technique unlike lap sterilization which has a variable reversal rate. B).    Laparoscopy associated visceral injury can be prevented by careful patient selection noting BMI , previous surgery , inflammatory bowel disease. Surgeon and team performing procedure should have adequate skill ,supervision and be familiar with instruments. Operating table should be horizontal with no tilt till trocar placement.  Closed veress needle technique is safe and needle should be sharp with good  tested spring action.. Before entry abdomen mass aorta position checked, .  Veress needle inserted at right angles after stabilizing lower abdomen by incision at base of umbilicus and pushed to pierce fascia and peritoneum by noting two clicks . Avoid excess lateral movement of needle or needle point injury made into large bowel tear.  Two failed attempts with veress , extremes of weight , previous surgery should prompt has son's open technique or Palmer point entry.  Primary trocar placement done at  20-25 mmhg abdominal pressure. Secondary port insertion is done under direct vision with trocar tip towards  anterior pelvis after entry.  Removal of port done under vision..
Answer to essay no 366 Posted by uzma sultana M.

.A] Hysteroscopic sterlization is a out patient procedure   called  ASSURE    which is done by a trained health care personal   under para cervical block anaesthesia or   local anaesthesia   , is applied to the ecto cervix   ,where as laproscopic sterlization is done in a day case procedure usually under general anaesthesia  , but can also be done under local anaesthesia   . Before proceeding to both the procedures counselling, detailing and risk  associated with these procedure is discussed  and information leaflet is provided and   consent is taken.   In both the procedure   screen for clamydia infection and give prophylactic antibiotic ,   In hysteroscopic sterlization a flexible scope of diameter 2.7- 3 mm is passed through the cervix  with   saline as a distending medium ,  a rigid scope can  also be used   but in flexible scope the risk of vasovagal shock and pain is less  , a gel foam is plugged in the fallopian tubes.  it takes about 3 months to fibrous inside the tubes   till then the patient should use effective contraception for 3 months   Pain is less in this procedure,   if patient wishes she can take NSAID to prevent post procedure pain   but this is not much helpful ,   it doesnt need consious sedation.   does not need to prepare the cervix before the procedure,   The benifits are it is out patient procedure,   short time,   quick recovery,   no need for General anaesthesia,   less expensive.    The disadvantages are it is still under evaluation   the succes rate and failure rate   are not known   , it is done in limited places   , the succes of recanulation is not known  , there is risk of   cervical damage on forced entry   in stenosed cervix,   damage to the cornuea, and bleeding, when  plugging the tubes    . there is risk of  introducing intrauterine  infection .    IN laproscopic sterlization there is risk   of damaging the bowel,   bladder, and the   vessels at the time of   entry in the abdomen , risk of exposure     to General anaesthesia  , haemoperitonium, and shoulder tip pain after the procedure,   and port herniation.   advantages are it is day case procedure ,  with quick recovery  , less post operative pain and   contraception to be used till next menstrual period and   reversal is succesful.       

    B]   Laproscopic procedure is a day case procedure  usually  done  under General anaesthesia   .The risks can be minimised first by selecting the patients,    if patient is very obese BMI >40  and thin BMI less than 19   and patients who had previous abominal surgeries are avoided ,    A trained surgeon  has to do the procedure in a fully equiped theatre, and trained staff,    information has to be given verbally and information leaflet provided.   Consent should involve if procedure is failed will proceed with minilaporotomy    .Before proceeding the patient is made to lay supine , on the table which is horizontal not the trendelburg position ,   abdomen is palpated for masses and abdominal aorta located  , there are 3 or more  procedures for entry   closed or,  open called HASSONS entry  and alternative entry   ,a vertical incision is put at the base of the umbilicus   and veeres disposable needle is introduced  at 90 degree to the skin    with a good spring action,   the needle is avoided lateral displacement to avoid damage to the vessels and bowels    then, the trocar and cannula is introduced with a doubble click  sound  . once inside the abdomen the abdomen is inflated with co2 GAS at a intra abdominal pressure of 20-25 mm hg then   the scope is introduced and rotated 360 degrees  to see if any bowel adherent to anterior abdominal wall  .THE abdominal pressure is reduced to 10-12 mm hg  and  IF any injury to the viscera or vessels Is suspected   a mini scope of 5mm diameter  is introduced through another port and confirmed, and repaired immediately  .   IN case of high risk patients such as history of PID,Inflamatory bowel disease, Endometriosis, obese patients a entry at Palmers point is selected .   It is 3 cms below the left coastal margin in the mid clavicular line .  This point is free of adhesions unless spleenectomy is done  , At this point care must be taken not to damage inferior epigastric artery   . After the procedure the skin is sutured to prevent port herniation.                                                                           

Posted by Lola B.

The advantages of hysterecospic sterilization will be that it averts the need to perform a laparoscopy for the patient. A laparoscopic surgery has higher risks of bleeding, infection, injury to organs like blood vessels, bladder, bowel and ureter. Hysteroscopic sterilization can also be done under RA -- which is safer and carries less risks than a GA, for which a laparoscopic sterilizaion is needed. A hysteroscopic sterilization enables us to survey the endometrial cavity at the same time, noting any fibroids and polyps and performing any therapeutic treatment at the same time. It is also cheaper.

The disadvantages are that there is a a higher failure rate. Its is also more techically difficult, requiring trained personnel to carry it out. The ostia may not be able to be visualised in the proceure due to submucous fibroids or an abnormally shaped cavity., thus procedure will not be possible. There is a need to wait for 1-2 months for fibroisis to occur -- It is not immediately effective. Additional contraception has to be used in the meantime. Reversal of sterilization is more difficult. And there is not benefit of being able to survery intraabdominal and pelvic organs like in a laparoscopic procedure. 

b) Entry can be done byt he veress needle of the Hassan's method, depending on fhte skill and comfort level of the operator. Ensure a well trained and experiecned surgeon carries out the surgery. If using the veress needle method, the abdomne must be level witht he ground. 2 Clincks must be distinctly heard upon insertion of the veress needle. Testing for entry intot eh abdominal cavtiy is done by air aspiration of water instillation facing no resistance, and noting the pressure to be <10mmHg. 

If the open method is used, the recturs sheath must be visualised, incised and entry intot he abdominal cavity must be directly visulised. The veress needle must be stabilised and horizontal movements avoided, to avoid converting a pinpoint injury in the bowel into a horizontal sheer injury. 

The entral trocar is inserted witht he intraabdominal pressure at 20-25mmHG and patient level with the ground. Upon placing the camera, to do a survey of bowels and surrounding organs to bensure no injury is caused upon entry. Secondary ports are inserted at 20-25mmHg insufflation with the patient level and ports perpendicular to the skin. Upon the trocar entering the cavity, it is directed anteriorly and toweards to pevis. 

Care is taken to avoid the inferior epigastric vessels by visualising them within the camera. If the patient is obese, the secondary ports are placed lateral to the rectus muscle. 

If there is suspicioun of periumbilical adhesions (in the presence of previous caesareans or surgeries), a palmar's point entry is taken with a 5mm camera, to survey the periumbilical area, and entry is taken under direct laparoscopic vision. 

Alwasy keep instruments in full view withint he camera's vision. Especially when activating energy sources, the instruments must always be visualised. Ports are removed under full visualsation, making sure to look for any blood vessel injury that may be tamponaded by the port placemnets. In obese or very thin patients, the opn method of entry is encouraged.

sterisation Posted by shraddha G.

 

A)     Hysteroscopic sterilisation is a quick and an outpatient procedure, performed under local anaesthesia or intravenous sedation while laparoscopic sterilisation often requires general anaesthesia with endotracheal intubation or regional anaesthesia. Hysteroscopy precludes the entry into the peritoneal cavity and thus injury to major viscera, blood vessels. Post-operative chest discomfort and shoulder pain due to abdominal distension in laparoscopy; is not present with hysteroscopic sterilization. Thus hysteroscopy offer  the benefits of economical and safe, early convalescence and overall less invasive as compared to the laparoscopic sterilization. But hysteroscopic  sterilization, still in budding stage is technically difficult, limited to the theatres of surgeons, skilled in hysteroscopy, thus requirement of expertise is its limitation. It involves placement of “Essure” which is a nickel microinsert into bilateral fallopian tubes under hysteroscopic vision. Scarring around the microcoils and occlusion of the tubes take around 3 months , so one has to use additional form of contraception till the imaging by X-ray/USG/HSG confirms the occlusion. Thus the candidates who are not willing for the follow-up are not suitable candidates for hysteroscopic sterilisation while sterilisation by laparoscopy requires no additional imaging and is effective immediately.

Pelvic infection, post-op pelvic pain, bleeding are other disadvantages  of hysteroscopic sterilisation. Device migration, expulsion, uterine perforation, tubal lumen perforation are other problems associated with hysteroscopic sterilisation. Vasovagal syncope is most frequent complication associated with hysteroscopy, not so with lap- sterilisation.  Success of hysteroscopic sterilisation is in 96-97% cases. Failure rate & ectopic pregnancy rates are higher with hysteroscopy compared to laparoscopic sterilisation. Persistence of pain may require subsequent procedure to remove the microinserts  and nickel allergy may be there, which is rare with silicon(inert) rings used in lap-sterilisation. Reversal of sterilisation has lower success rate in hysteroscopy as compared to lap- sterilisation using clips.

B)      Proper positioning of patient, supine position ( not Trendelenberg) while placement of trocars is the crucial step to prevent injury to major viscera. Closed technique of entry is associated  with approximate 0.4/1000 bowel injury as compared to open (Hasson’s) entry which leads to 0.6/1000 cases of bowel injury. Insufflation pressure of 25 mmHg before placement of trocars provide 5.6 cm depth below umbilicus and thus visceral injury can be minimised. Entry through palmer’s point or open technique to enter in case of previous laparotomy, peritonitis or inflammatory bowel disease is safe.Double puncture technique is more  safe compared to single puncture technique. Entry into the abdomen via secondary trocar should be made under direct vision after confirming the position of inferior epigastric arteries or with single puncture technique, try to enter at the most lateral margin  of rectus sheath. Hold the fallopian tube with microforceps at right angle at isthmus, 2-3 cm from the cornua. Because holding the fallopian tube with a tilt may transect it and may also cause injury to intestinal loop. Minimal use of cautery again prevents major viscera injury and donot perform bipolar electrocoagulation as method of sterilization, as it often leads to unrecognised bowel injury. Take out the instruments, cautery and  trocars from the peritoneal cavity under direct vision so as to prevent as well as timely identify injury to bladder, bowel or abdominal wall. 

Shivamalar Posted by PAUL A.

 

(a) The advantages of hysteroscopic ligation are , it is quick procedure, done under direct camera guidance is lap steri not done under direct camera guidance? and can be performed in outptient setting (1) . It does not involve abdominal scar and efficay rate is upto 96-99% what does this mean?. The sterilisation clip do you use clips? is snuggly fit into fallopian tube and carries low risk of dropping out. It allows ficrous formation surrounding it over time and block the tube for sperm passage renders fertilisation.? meaning It carries lower risk of visceral organ injury compared to laparoscopic sterilization (1). It also does not require highly specialised surgeon to perform.Does it not? How many of these has your F2 done? It is cheaperthan laparoscopic ligation more cost-effective.But it carries risk of pain, bleeding immediately or during insertion does lap steri not have risk of bleeding or pain?, clip drop out and expulsion, and clip not properly placed at the desired place. It requires patient to be on another compliant method of contraception for at least 3 months after procedure and they need to undergo hysterosalpingogram evaluation to ensure the tub eis completely blocked before can solely reliable on this method.Is this an advantage? .Hysteroscopy procedure also carries risk of pelvic inflammatory disease with ascending infection is this an advantage? .And this procedure is almost irreversile once it is done compared to laparoscopic sterilisation which is reversible is it? Is this what you tell women who require lap steri?? When a patient asks you: what are the advantages and disadvantages? You answer: the advantages are a, b, c, d…x, y, z – do you expect the patient to decide for on their own that a, b, c are advantages but x, y, z are disadvantages without you saying so?.

 

(b) Ideal patient selection is important factor. Patient who had previos abdominal surgery particularly midline scar are high risk to have adhesion and hence visceral organ injury therefore should be counselled for diffrent metod of contraception. Procedure should be done by skilled surgeona nd trainees should perform under supervsion by consultant (1) .Equipments should be checked and ensure they are functioning well before surgery. Adequately trained assistant and scrub nurse would be present during surgery. Patient should be in supine position before and during port insertion. If adhesion is suspected at umbilicus, first port shoudl be inserted in alternate site and most commonly this woul be palmar's point where usually lesser adhesion present unless patient had previous surgery like splenectomy.For obese patient and very thin patient, Hasson's method should be used ? evidence that thisis better, and throcar should be introduced only once the peritoneal cavity is visible. If veress needle inserted, 2 click sound should be heard before inserting throcar as this indicates the 2 fascias hasve been penetrated (1). this should be tested with saline injection to ensure lower pressure in the peritoneal cavity not a useful test and the introducing pressure should be <10mmHg.The assessory port should be introduced under direct camera vision (1) and once the port has been though the peritoneum, it shoul dbe directed towards the anterior pelvic wall. The intraperitoneal pressure should be maintained at 20-25mmHg (1) until all port are introduced as this increase the distance or the visceral organ from parietal peritoneum. Subsequently patietn can be placed in trendelenburg;s postiion to move bowel away from operative field which is the pelvic region in this case. At this point the pressure can be reduced to 12-15mmHg. In dwelling catheter should be inserted to drain the bladder throughout the entire surgery no, in-out cath would do.

Dharani Posted by PAUL A.

 

A)

The advantages of hysteroscopic sterilization include that the procedure can be undertaken as an out patient procedure which saves theatre time where as laparoscopic sterilization is carried out as day case procedure (1).  Can be undertaken under local anesthesia and avoids complications associated with general anaesthesia (1)  while majority of laparoscopic sterilizations are performed under general anaesthesia. Patient can return to her normal routine quickly compared to laparoscopic sterilization (1). Viseral and vascular injury associated with laparoscopic procedures and their consequences such as laparatomy are avoided with hysterscopic sterilization (1). The shoulder tip pain due to pneumoperitoneum and abdominal discomfort observed during laparoscopic procedures are not expected in hysteroscopic sterilization. 

 

Pelvic anatomy can not be evaluated during hysteroscopic sterilization procedure while it can be studied in detail during laparoscopic sterilization which is a disadvantage of this procedure.

Reversal is not possible with hysteroscopic sterilization while the possibility of reversal is around 50-90% with laparoscopic procedure. Is it? Do you tell women requesting steri this? Are you aware of any reports of attempts at reversing hysteroscopic sterilization?

Vaginal bleeding for about a week in the post operative period is common in hysteroscopic sterilization which is uncommon in case of lap sterilization.

Additional procedures such as x-ray, USG or hysterosalpingogram advantage or disadvantage? are necessary to ensure the correct placement of the devices where as correct placement of clips can be confirmed during laparoscopic sterilization.

Woman should follow alternative contraception till 12 weeks which is time for the development of fibrous tissue for occlusion of tubes, while contraception is required only till the next menses for laparoscopic sterilization advantage or disadvantage?. The disposable devices used for hysteroscopic sterilization are expensive is the laparoscope / light source / theatre cheap?. The pregnancy prevention at 1 year is about 98.9% is this an advantage or a disadvantage? and this procedure lacks long term data unlike laparoscopic sterilization . Skills of hysteroscopic sterilization are still lacking among surgeons unlike laparoscopic procedures performed by comparatively more number of surgeons with appropriate skills is this an advantage or disadvantage?. Only short term data are available regarding safety and efficacy of hysteroscopic sterilization compared to  laparoscopic sterilization which has been evaluated better and  long  term data are available. You were asked for advantages and disadvantages. Your first paragraph begins: the advantages… The word disadvantages does not appear anywhere in your answer. You expect the examiner to decide at which point you are writing about disadvantages and give you marks??

 

B) Laparoscopy is associated with a risk of visceral injury in 0.4 per 1000 cases . Visceral injury leads to infection, peritonitis, prolonged hospital stay, increased morbidity. There is also increased cost to the NHS in the form of litigation and repeat surgery. Not necessary – does not answer the question

Appropriate patient selection is of value. Preoperative identification of high risk cases such as previous abdominal surgery, documented adhesions, obesity, inflammatory bowel disease.

 Adequate training and supervision (1) is essential to minimize visceral injury. The training should include operative technique as well as use of energy sources like laser and diathermy. 

Prior emptying of bladder by catheterisation minimizes bladder injury. The operating table should be horizontal (not in the Trendelenburg tilt) at the start of the procedure.Examination under anaesthesia is carried out to exclude abdominopelvic masses and for the identification of position of aorta (1)

The primary incision should be vertical from the base of the umbilicus and care should be taken not to incise so deeply as to enter the peritoneal cavity. Insertion of verees needle should be at right angles to the skin

The Veress needle should be sharp, with a good and tested spring action. A disposable needle is recommended, as it will fulfil these criteria (1).

Appropriate way of insertion of verees needle is essential to lessen the risk of visceral injury.The lower abdominal wall should be stabilised in such a way that the Veress needle can be inserted at right angles to the skin and should be pushed with two audible clicks  to penetrate the fascia and the peritoneum.  

Excessive lateral movement of the needle should be avoided, as this may convert a small needlepoint injury in the wall of the bowel into a more complex tear. 

Choosing alternate points of entry is required in case of previous abdominal surgery or with morbid obesity. The preferred point of entry is 3 cm below the left costal margin in the mid clavicular line( Palmer's point). Open technique of Hassan may avoid major vascular injury but the risk of bowel injury is not excluded.

Adequate pneumoperitoneum is important to minimize visceral injury. An intra-abdominal pressure of 20–25 mmHg is essential for inserting the primary trocar (1). Once the laparoscope has been introduced through the primary cannula, it should be rotated through 360 degrees to check visually for any adherent bowel (1).

 

Secondary ports should be inserted under direct vision (1)while maintaining the pneumoperitoneum at 20-25 mm of Hg. Instruments, should be inserted and removed under direct vision (1)

Early identification is important in management of visceral injury with multidisciplinary care by involving appropriate specialist. Laparotomy is required to repair the damage.

Huaida Posted by PAUL A.

 

Hysteroscopic sterelisation uses either ESSURE or ADIANA, devices can be done as an office procedure  

this will offset it,s cost. So does it cost nothing?

It needs no anathesia,also has high efficacy ,  up to 99.75% success rate, ? meaning? Successful operation or pregnancy prevention?

Has high satisfaction rate,as it is permenant and need no abdominal incision. These are three different issues

The patient need to use acontraceptive for 3 months ,(the period required  for the fibrosis to build up  arround the device  , so completely occluding the tube. Is this an advantage or disadvantage? You want the examiner to decide and give you marks?

 

there is risk of fainting attack during application, risk of not iserting the device in the correct place,and  risk of perforation these are more common with the old device ESSURE. Advantage or disadvantage?

Failure of the the technique inspite rare  may result in ectopic pregnancy.

Hystersalpingogram should done 3 months later to confirm the complete occlusion of the tubes  advantage or disadvantage?

This may increase the risk of pelvic inflamatory disease ,and patient discomfort,

the procedure is not suitable  for those with distorted uterine cavity ,in those whose tubes cannot be visualised and for those  who are sensetive to the devices material or to the dye used in hysterosalpingogram.

on the other hand laproscopic sterilisation   result in immediete  tubal occlusion  that necessiate no further confirmatory test

The contraception may used  up  to the next  period only after laproscopic steralisation

How  ever it need general anathesia, with abdominal incision ,with risk of viseral and vasular injury of arround 1-3/1000

also it carries the risk of laprotomy ,

Has failture rate of 1/200 , and if failed  there is increased risk of ectopic pregnancy.

 

You were asked: discuss the advantages and disadvantages. You cannot answer this question without using the words advantages and disadvantages (or synonyms) and expect to earn any marks!!! If a patient asked you this question in clinic, you cannot just talk to her without signposting advantages and disadvantages.

B/

Proper training and supervision (1)is the gold standard ? meaning in decreasing the associated risk.

Examination of the pateint under anathesia and defining the  the place of the aorta and detection of any abdominal masses is of paramount importance (1),

uses of end guarded trochar  and true directioning ? meaning of the trochar during insertion helps in  avoiding damage to the viscera

paying additional attention to an adherent bowel to exclude it,s injury what does additional attention mean? What will you do?

Uses of palmar point in cases of previous surgery and adhesions 

intra-abdominal pressure of 20-25mmhg help in good visulisation of the intaperitoneal cavity this is not the reason for raising the pressure to this level

inserion of second porepoor English – secondary port canulae should be under direct vision to avoid hypogastric vessel injury this does not avoid injury to the vessel unless you trans-illuminate and identify the vessel. Direct vision minimizes injury to the viscera

 removal of any canula should be under direct  vision (1)

Nabila Posted by PAUL A.

 

Hysteroscopic  steriliation is less invasive as compared to laproscopic procedure .it is done under local anaesthesia or intravenous sedation which avoids the use of general anaesthesia being commonly used for laproscopic sterilization and its potential complications advantage or disadvantage? .It is done as an outpatient procedure whereas laproscopy is daycare procedureIt is safe  with low rate of complications advantage or disadvantage? .Total occlusion of the tubes  successfully obtained in 91-97% of cases advantage or disadvantage? .Occlusion of the tubes is to be confirmed byHSG, x ray or ultrasound at 3 months,0.2-3% of the tubes are found to be still patent  at 3 months which will be confirmed  to be occluded at 6 months HSG advantage or disadvantage?. Patient  satisfaction  is found in 94% cases.Majority of the patients find periopertive pain almost nonexistent.

Overall pregnancy rate is 0.16% advantage or disadvantage?

 Improper placement  of microinserts is found in 0.4% ,perforation of tubal lumen or uterus is found  in 1-2.6%.Failure rate is 3/1000  with hystroscopic  insertion .Other potiential  adverse effects are infection, spotting/vaginal bleeding /abdominal pain /asymptomatic migration  or expulsion,  vasovagal syncope    .Effective contraception needs to be used till tubal occlusion is confirmed  which is done by HSG at 3 months and a small proportion which does nt show complete occlusion will have to be followed till 6 months.

Laprosco pic sterilization is done as day care procedure under general anaesthesia.local anaesthesia is an alternative .Risks of laproscopic entry should be explained  …incidence of bowel injury is 0.4/1000 and that of vascular injury 0.2%.these risks will be increased in both the obese as well as thin,also with previous abdominal surgery which increase the risk of adhesions(  50% in case of midline abdominal incision and 23% with transverse incision) Also the risk of hernia formation at the entry site..Failure rate is 1 in 200.Effective contraception is to be used  till the procedure and till the next period.It is reversible although the rates after reversal  31-92% with 1-7% risk of ectopic pregnancy depending on the method used for tubal ligation . Risk of laparotomy is 1.4-3/1000 with a risk of death of 1/12000.

Abdomen should be inspected for scars ,palpated for any masses and aorta.You were asked: discuss the advantages and disadvantages. You cannot answer this question without using the words advantages and disadvantages (or synonyms). If a patient asked you this question in clinic, you cannot just talk to her without signposting advantages and disadvantages.

 

To minimize the risk of visceral injury,careful  entry technique is required .Position of the patient should be horizontal rather than trendelenberg. The incision should be in the base the umbilicus not below itand peritoneal cavity should not be opened..Veress needle should be sharp ,spring tested.After penetration of peritoneal cavity ,it should not be moved laterally as it will extend the tear if any (1).Primary tr ocar  should be inserted at 90 deg to what?. after careful positioning of the abdominal skin ? meaning .when the laproscpe  is inserted   should be rotated all around 360 deg. to identify any vascular or visceral injury on the inside of abdominal  wall (1).In case of previous abdominal surgery  wher there I srisk of adhesions  open technique can be used  although there is no evidence of safety.Entry can be proceeded at Palmers point in case of previous surgery or in obese  which is not feasible in case of spenomegaly  ? meaning.If required  trocar insertion can be done after confirmation of absence of adhesions after viewing the cavity through a secondary port(5mm hystroscope).the insufflations pressure should be 25mm hg  before trocar insertion (1)  and then reduced  to 12-15 mmhg .Withdrawl of the trocar should be under direct vision (1) to avoid injury as well as to recognize any .

Preetiba Posted by PAUL A.

 

a)  Sterilization procedures are done in couples who are sure that they have completed their family with no intention for further child bearing.

Hysteroscopic sterilization can be done as a daycase or as an office procedure as this procedure can be carried out by administering local anaesthesia or intravenous sedation.  This is in contrast with laparoscopic sterilization where it is done under general anaesthesia with it's accompanying complications advantage or disadvantage?

The placement of intrafallopian implants causes fibrosis and occlusion of the tubes.  However this procedure needs an additional contraception for up to 3 months until an imaging (such as x-ray, ultrasound and hysterosalphingography) is done to ensure the occlusion of the tubes advantage or disadvantage?. In this case, laparoscopic sterilization has an advantage because it is immediately effective and no additional contraception is required is it not?.

The pregnancy prevention rate after 1 year of hysteroscopic procedure is almost 98% comparing to failure rate of 0.5% in laparoscopic sterilization procedure. Is this an advantage or disadvantage or are you just trying to confuse the examiner / patient? Are you saying that a pregnancy prevention rate of 98% is better than a failure rate of 0.5% (pregnancy prevention rate of 99.5%)?

Hysteroscopic sterilization is generally more acceptable to patients as this can be done as an office procedure where no abdominal incisions need to be performed as in the case of laparoscopic sterilization

Hysteroscopic sterilization is however associated with the risk of uterine perforations, fallopian tube lumen perforations, device migration and expulsion, vasovagal reaction and pelvic pain.  These complications however is unlikely to be seen following a laparoscopic sterilization where complication regarding visceral injury is common the advantages of hysteroscopic sterilization are a…b…c. The disadvantages of hyst steri are c..d..e. Nothing else will do.

 

b)  Careful selection of patients for laparoscopic sterilization procedures is essential to identify the patients who are at risk of having visceral injury such as those patients who had a history complicated pelvic surgery.  It is also important to ensure that the surgeon performing the procedure is well trained and is familiar with the equipments in the operating theatre ? supervision.  The operating theatre table must be in a horizontal position.  Before an incision is made the abdomen must be palpated for any masses and aortic pulsation to avoid injury empty bladder

Using an alternative entry point such as Palmer's point is useful when dense adhesion is expected at the umbilical region due to previous surgeries.  The direction of entry should be in a controlled manner with 90 degrees to the skin.  The entry is stopped immediately upon entering the abdominal cavity how do you know you have entered the abdominal cavity?.  Once entered the camera should be rotated 360 degrees to check for any adherent bowel (1).  Subsequent trochars and ports should be inserted under direct visualization (1).  After completion of the procedure the trochars have to be removed under direct visualization (1).

Huda Posted by PAUL A.

 

Advatages of hysteroscopic sterilization include that it is non incisional method ,avoids abdominal entery,can be done as an office procedure so more cost and time effective  and avoids general anesthesia as it can be done without anaesthesia or with minimal sedation and also less post operative pain with quick return to work and normal activities never the less it can be done in women with extensive pelvic adhesions and also in women who have comorbidites that preclude laparoscopy or laparotomy    the most important is that it is an effective procedure 95-99%   success rate and also less anxiety  it avoids visceral injury   and contain nothis is a single sentence listing several facts with no context. Hormones however unlike laparoscopic sterilization which conveys immediate reliability ,hyseroscopic sterilization is amulti step process in which the hysteroscopic sterilization procedure is followed by confirmatory hyserosalpingogram performed at least three months after the initial procedure  to prove bilateral occlusion before women can relay on this method of contraception (1) and there is high risk is there? of unilateral tubal occlusion there is risk of perforation to the uterus and risk of intraoperative bleeding risk of assending infections and 5%experienced failed placement and require another procedure  alsa it needs technical skills  it is also an irreversable procedure unlike laproscopic sterilization in which reversibility is 50-90% so you tell women requesting lap steri that it is reversible?                                                                                                                                                                               Bappropriate counseling shoud be done prior to surgery there is increased risk in obese women or unde weight and those with previous mid line incisions peritonitis or inflammatory bowel disease  the surgeons should have appropriate training supervision (1) and experience and are familiar with the equipment and should ensure that nursing staff and surgical assistants are appropriately trained for the role they will undertake during the procedure   this is a long sentence covering several issues. What did you write in your answer plan that translated into this sentence? Every point in your answer plan should be 1-2 sentences in your essay. You have covered counseling, training, equipment in a single sentence.The primary incision shoud be vertical from the base of the umbilicus iit shoud not be so deeply to enter the peritoneal cavity  the veress needle shoud be sharp ,with agood and tested spring action Adisposable needle is recommended ,as it will fulfil these criteria.  The operating table should behorizontal (not in the Trendelenburg tilt) at the start of the procedure. The

abdomen should be palpated to check for any masses and for the position of the aorta before insertion

of the Veress needle empty bladder.The lower abdominal wall should be stabilised in such a way that the Veress needle can be inserted at

right angles to the skin (1)and should be pushed in just sufficiently to penetrate  the fascia and the

peritoneum. Two audible clicks are usually heard as these layers are penetrated.Excessive lateral movement of the needle should be avoided, as this may convert a small needlepoint injury in the wall of the bowel or vessel into a more complex tear. An intra-abdominal pressure of 20–25 mmHg (1)should be used for gas insufflation before inserting theprimary trocar.The distension pressure should be reduced to 12–15 mmHg once the insertion of the trocars is complete.

This gives adequate distension for operative laparoscopy and allows the anaesthetist to ventilate thepatient safely and effectively. The primary trocar should be inserted in a controlled manner at 90 degrees to the skin, through theincision at the thinnest part of the abdominal wall, in the base of the umbilicus. Insertion should be

stopped immediately the trocar is inside the abdominal cavity.Once the laparoscope has been introduced through the primary cannula, it should be rotated through

360 degrees to check visually for any adherent bowel(1). If this is present, it should be closely inspectedfor any evidence of haemorrhage, damage or retroperitoneal haematoma.

If there is concern that the bowel may be adherent under the umbilicus, the primary trocar site shouldbe visualised from a secondary port site, preferably with a 5-mm laparoscope.On completion of the procedure, the laparoscope should be used to check that there has not been athrough-and-through injury of bowel adherent under the umbilicus by visual control during removal. When the Hasson open laparoscopic entry is employed, confirmation that the peritoneum has beenopened should be made by visualising bowel or omentum before inserting the blunt tipped cannula Direct trocar insertion is an acceptable alternative trocar insertion method Palmer’s point is the preferred alternative trocar insertion site, except in cases of previous surgery inthis area or splenomegaly. Secondary ports must be inserted under direct vision (1)perpendicular to the skin, while maintaining the pneumoperitoneum at 20–25 mmHg. During insertion of secondary ports, the inferior epigastric vessels should be visualized (1)

laparoscopically to ensure the entry point is away from the vessels.During insertion of secondary ports, once the tip of the trocar has pierced the peritoneum it should be

angled towards the anterior pelvis under careful visual control until the sharp tip has been removed.Secondary ports must be removed under direct vision (1)to ensure that any haemorrhage can be observed and treated, if present. The open (Hasson) technique or entry at Palmer’s point are recommended for the primary entry in

women with morbid obesity. If the Veress needle approach is used, why are you discussing this here when you discussed use of Verres needle earlier? particular care must be taken to ensure that the incision is made right at the base of the umbilicus and the needle inserted vertically into the peritoneum. The Hasson technique or insertion at Palmer’s point is recommended for the primary entry in women who are very thin. There is a marked difference between your answer to part (a) and your answer to part (b). The language is completely different and the quality of the sentences is so different that one would have to conclude that the contents of (b) were simply copied from the guidelines / notes or a previous answer. This does not help you in the exam.

Ghida Posted by PAUL A.

 

A- hysteroscopic sterilisation is by inserting an implant in the cornual end of the Fallopian tube causing its blockage. It is a minimally invasive procedure that is done through the neck of the womb, and is done as a day case procedure not day case with minimally discomfort post procedure and minimal or no interruption from work is this an advantage or disadvantage?. However its insertion is associated with risk of rupture of oviducts and subsequently injury of intraabdominal organs e.g bowel and risk of bleeding if there is puncture of major vessels is this an advantage or disadvantage when compared to lap steri?. its reversiblity is possible, but cannot guarantee tubal patency and normal tubal function can you guarantee this for lap steri?.

As regard laparoscopic sterilizationyou were not asked about lap steri. You were asked about advantages and disadvantages of hyst steri compared to lap steri it is also a minimally invasive procedure that is done through keyhole incisions in the belly, it involve visualisation of the oviducts and putting a metal clip (Filshie Clips) in order to obstruct the oviducts. It also is a day case both are day case so where is the advantage or disadvantage? procedure associated with a 1% pain only 1% of patients with a surgical incision have pain?? at the site of incisions that is managed by pain medications, it has a 3in 1000 risk of bowel or vessel injury, and a 1 in 12000 risk of death advantage or disadvantage?.The procedure has a failure rate of 1 in 200 advantage or disadvantage?, and thefailure can be due to a pregnancy that was already in the tube at the time of the procedure, that's why patient should be on effective contraception till the next period. there is also early failure associated with displacement of the clip and late failures due to recanalisation of the tube. Reversibilty is possible but patient cannot be assured it is 100% and patient should be sure about her decision.

B- steps that can be done to decrease risk of visceral injury are first correct position of the patient at insertion of primary trocar. The patient should be in supine position to minimize injury of the Aorta upon vertical entry to the abdomen. The bladder should be emptied before abdominal entry to avoid its injury by the suprapubic trocar abdominal masses. Entry to the abdomen is usually at the umbilicus, but in obese or very thin patients the palmer point can be used (left hypochondrium).Closed method by using verres needle  and open method (Hasson technique) can be either use as there is no advantage in matter of safety or avoidance of visceral injury. Verres needle should be inserted perpendicular to the skin how?. the correct placement of the needle should be checked by aspirating through an empty syringe not recommended – poor test, blood or fecal matter indicate vessel or bowel injury. intrabdominal pressure should be low <8mmHg, (1) with free flow high pressures indicated either obstruction of tip of verres needle, or incorrect entry to the peritoneal cavity. Care should also be taken not to move the needle as this may extend a puncture injury. the intraabdominal pressure should be raised till 20mmHg (1) to allow for safe entry of the primary trocar as this will further displace the abdominal wall from underlying organs. After insertion of the primary trocar the pressure is decreased till 16mmHg, and careful inspection of the abdomen and pelvis is done. At the end of procedure, the sites of trocar incision should be checked after removal of the secondary trocars ? meaning, and the camera should be removed only after removal of the primary trocar to check for presence of through and through bowel injury (1) direct vision.

Fadi Posted by PAUL A.

 

A)  The advanteges of hysteroscopic method sterilization that it can be done as office procedure (1) in day surgery under local anesthesia and women can avoid complication of general anesthesia (1).but compaire to laparoscopic method it require 12 weeks for fibrosis formation for complite tubal     block and need additional contraception do you not need contraception after lap steri?.After the procedure women should performed hysterosalpingography to insure that procedure is successful ? advantage or disadvantage?.During hysteroscopy she may fill some discomfort or allergy reaction on device ,procedure may be difficult if cervix is stanosed or there is distortion of uterine cavity.Thre some study wich show that hsteroscopic occlusion of tube has some protection  from ovarian cancer ? disadvantage??.   

B)The safety of laparoscopic entery  depend on appropriate selection of patients who are at risk for complication (obese, underweight women, previous inflammatory bovel process and abdominal surgery) , careful taining and supervision of staff ,safe entery of primary trocar and careful visualisation of  intra-abdominal structures.

The trainees should    be familiar with Veress needle (women in horizontal position ,lifting abdomen, observation of gas pressure ) Hasson technique - open technique to entery in abdomen and use of Palmer point in patient with suspected adhisions. There are 10 marks and you have written about 1/5th of an A4 page. Your answer is not detailed enough to earn any marks. See answers above

Ali Posted by PAUL A.

Hysteroscopic sterilisation is considered as a safe procedure as it can be done under local anaesthesia and/or sedation so avoiding risks relating to general anaesthesia (1) during laparoscopic sterilisation. It can be done on outpatient (1)  basis saving cost of hospital admission and possible overnight stay in laparoscopic procedure. It also gives the opportunity to visualise the uterine cavity for undiagnosed pathology like sub mucous fibroids and polyps what will you do about it? Do another operation in an asymptomatic woman?.but the major advantage of the hysteroscopic procedure versus the laparoscopic procedure is avoidance (1) reduced risk of visceral and vascular damage encountered during veresse needle and/or taro car insertion at laparoscopy especially in obese and very thin patients with previous abdominal scars. It has high success rate 97-99% and less failure rate of 3.1per 1000 is this per year or over life-time? compared to 1per 200 is this per year or over a life-time? in laparoscopic sterilisation. Hysteroscopic sterilisation had some disadvantages like pain during insertion and vasovagal reaction in contrary to laparoscopic procedure which is usually under general anaesthetic so general anaesthesia is now advantageous when you said the opposite above. Inability to visualise the pelvic cavity for any adnexal pathology and endometriosis.need for 3months of contraception until tubal blockage confirmed by HSG in contrary to short period of contraception until the next period in laparoscopic clip sterilization (1).other possible disadvantages include uterine perforation and ascending pelvic infection if STI not screened beforehand or if no prophylactic antibiotic were given as well as risk of expulsion and peritoneal migration of the device. The first step to minimise the risk of visceral damage start with patient selection when BMI, and previous midline laparotoies as well as previous bowel surgery are considered risk factors for visceral damage during the laparoscopic sterilisation and necessitate experienced laparoscopist and or alternative abdominal entry techniques. Patient should lie flat during needle and trocar insertion completed and ensure that bladder is empty. ,Veresse needle insertion intraumblical rather than subumblical as it's the shortest distance to peritoneal cavity. Other entry methods like Palmer point entry or open laparoscopy or Hasson technique can be used in obese patients and with patients with midline scars and previous bowel surgery., intraabdominal pressure after Veresse needle insertion should be <10mmHg to ensure intraabdominal placement. Pneumoperitoneium created by co2insufflation to pressure 25mmHg until all trocar insertion has been completed . Insertion of secondary trocars should be under direct visualisation to avoid injury to epigastric vessels and/or visceral damage . Once laparoscopy had been inserted visualisation of the peritoneal cavity and trocar insertion sites for diagnosis of any possible visceral damage and bleeding. If damage is suspected manipulation should stopped and perforating instrument kept in place until help achieved from surgeons. Avoid excessive cautrisation especially with monopolar diathermy to minimise risk do thermal bowel injury. At any time all instrument should be visualised until completion of the procedure. At the end of terilisation removal of the instruments and trocars should be under direct vision to avoid loop of intestine or momentum to be dragged to port site .All informations regarding visual damage risk and need for additional procedure should be discussed during consent process as well as debriefing the when complication arises. Where is part (b)?

Anagha Posted by PAUL A.

 

Hysteroscopic sterilisation involves hysteroscopic placement of microinserts in both fallopian tubes. This induces fibrotic changes in the tubes, causing tubal blockade, thus inhibiting sperms entering the tubes and fertilising ova. Commonly used device for this purpose is Essure. Laparoscopic sterilisation is usually performed using rings, Filshie clips or Hulka clips and less often diathermy should not be used for tubal occusion. It requires admission and administration of general anaesthesia advantage or disadvantage?. Hysteroscopic sterilisation can be performed as an office procedure under local anaesthetic or intravenous sedation. Since no incision is required, the recovery is quicker than by laparoscopic approach. Efficacy is better than that of laparoscopic procedure, with lesser failure rate.? evidence  It is cheaper than laparoscopic sterilisation. Cost is not most relevant – cost-effectiveness is. It is also associated with lower incidence of visceral injury including bowel, bladder and blood vessels, which is about 3 per 1000 laparoscopic sterilisations.

Since it is a fairly new method, expertise is not widely available, while laparoscopic sterilisation is a commonly performed procedure worldwide. Complications like tubal rupture, uterine perforation, microimplant migration or expulsion, though not common can occur.  Laparoscopic sterilisation does not require any confirmatory tests for its correct application, however hysteroscopic sterilisation requires confirmation 3 months after the procedure which can be done by X-ray or an Ultrasound Scan followed by a Hysterosalpingography (HSG) or HSG alone.

Reversal of tubal occlusion is less likely to succeed in case of hysteroscopic sterilisation as compared to that of laparoscopic approach. ? evidence? If you were a patient reading this about hyst steri and lap steri, will you know what the advantages of hyst steri were over lap steri and what the disadvantages were?

 

Certain measures can be taken preoperatively to reduce the incidence of visceral injury at laparoscopic sterilisation. Primarily the operator should have the necessary expertise, experience and should be familiar with the equipment ? trainees?. The staff should also be appropriately trained with clearly distinguished roles with respect to the surgery. Previous history of abdominal surgery, peritonitis, bowel infection, abdominal sepsis should raise a suspicion of possible intraperitoneal adhesions.

 

Urinary bladder should be emptied at the beginning of the surgery to avoid bladder injury ? abdominal masses. Intraoperatively, highest chance of visceral injury is during the blind insertion of veress needle. Once veress needle is inserted how? the insufflation pressure should be checked what should it be? or palmer's test poor test and not recommended or normal saline test should be performed to confirm the veress needle is in the peritoneal cavity. Alternative technique like open laparoscopy or Hasson's technique can be used when bowel adhesions are anticipated. Although it may not reduce the incidence of bowel injury, it is associated with early recognition of injury, that is, at laparoscopy. It may also reduce the incidence of injury to major blood vessels. Veress needle can also be inserted at palmer's point, that is 2 cm below subcostal margin in the left midclavicular line. The umbilical site can be examined for any adhesions through a telescope inserted at the palmer's point and umbilical trocar can be inserted inder direct vision. Intraabdominal pressure should be kept at 22-25 mm Hg(1); this allows adequate splinting of all viscera for safe insertion of all trocars and avoids visceral injury. Once all trocars are inserted the pressure can be reduced to 12-15 mm Hg. Tips of trocars should be inspected for any bowel contents. All instruments should be inserted under direct vision (1). Tips of instruments in the abdominal cavity must be kept under direct vision to avoid injury outside the field of vision, which might be difficult to locate. If bowel/bladder/ureteric/blood vessel injury is suspected, immediate corrective measure should be taken and appropriate expert should be called in for help. Defects should be sutured either by a surgeon or gynaecologist trained at laparoscopic suturing. Laparotomy might be appropriate to allow examination of loops of bowel for suspected injury. Ureteric stenting would be required for ureteric injury and suprapubic catheter for bladder injury. 

Sujata Posted by PAUL A.

 

a)Hysteroscopic sterilization involves the insertion of microinserts (metal springs) into the cornual end of the fallopian tube via a hysteroscope. The advantages are that it can be an O.P.D procedure with no requirement of anaesthesia no anaesthesia whatsoever?, non surgical is it a medical method? ( no incision) , unlike as in laparoscopy , where it is a surgical procedure under general anaesthesia and requires in –patient care . This method is safe in patients with heart disease and obesity, which are risk factors for a laparoscopic method of sterilization.

The disadvantages are that a hysteroscopic sterilization takes three months for its full blocking effect of the tube and another method of contraception should be used till then (1). It is contraindicated in utrene anomalies like the unicornuate uterus. The microinsert can get expelled in 2-3 % of cases and in 1% it can perforate the tube when a laparotomy would be required (1). A second procedure may be required in some cases and confirmation will have to be done with a HSG after 3 months.

b) Minimising visceral injury in laparoscopic sterilization would begin from a proper history to note any previous surgeries, to aid us in anticipating bowel additions to the abdominal wall. Although we should anticipate bowel additions to the abdominal wall even in those without surgery.Safe insertion of the primary trocar is the most important step. In suspected adhesions at the umbilicus, insertion of the trocar can be done via the palmar port. The safe entry of the Veress needle should be done after the intra abdominal pressure is raised upto 20-25 ml of mercury how do you raise intra-abdominal pressure BEFORE inserting the Veress needle?. Installation of 2-3 ml saline through a syringe into the Verres to ensure free flow should be done not recommended. Lateral movements of Verres should be avoided. Insertion should be done how? when the patient is lying flat. Subsequently the primary troca is inserted how?. Once inside, a 360 degrees turn is done to visualize bowel additions. A 5 mm scope is inserted in the secondary port to visualize and release adhesions near the primary port.Why is this necessary? After the surgery the laparoscope is removed what about secondary ports/ instruments? through direct vision to look for any through and through bowel injury.

Post operative assessment regarding distention and bowel sounds and passing of flatus  needs to be done do you do this before you discharge women who have had a lap steri?. The advice on discharge should include importance of reporting back in case of vomiting and bloated feeling with non passage of flatus as bowel injuries are often recognized later.

Laparoscopic surgeries should be carried out by operators with the skill, knowledge and training to avoid complications. ? supervision

Answer to essay 366 Posted by Pulkit N.

A) Hysteroscopic sterilisation is a new technique of inserting metal implants into the fallopian tubes, via hysteroscope , which expands and ultimately cause fibrosis. Advantages of hysteroscopic sterilisation is that it is done under Local anaesthesia or Intravenous sedation, requires shorter operating time, well accepted and comfortable to majority of woman with less requirement of intra and postoperative analgesia. In woman with medical comorbidites like cardiac diseases or severe obstructive pulmonary diseases or in morbidy obesity or women with previous multiple surgeries, Hysteroscopic sterilisation can be preffered over laparoscopic approach because no need of GA, and abdominal cavity is not entered.  Disadvantages of hysteroscopic sterilisation is that it relatively new technique with few surgeons performing it. May need refferal to other hospital. If a surgeon decides to do this , local hospital authorities need to be informed . The successful fibrosis of tubes have to be  assessed at a later stage (3 months) by Hysterosalpingogram directly or iniatally by x-ray/ ultrasound and later confirmed by hysterosalpingogram. Woman needs to take contraceptive precautions till then. Reversal of this procedure is not possible.  Risks of hysteroscopic sterilisation are perforation of uterus or trauma to cervix.

Laparoscopic sterilisation is time tested ,safe ,effective and commonly done. Women need contraception in only that menstural cycle. As abdominal cavity is entered , other intraabdominal pathologies can be noted.

Disadvantages are that it is usually done under GA ( can be done in LA), Carries small risk of major (3/1000) morbidity of damage to bowel , bladder or blood vessel ,incisional hernia development and need for conversion to laparotomy. Minor risks involve bruising of skin and shoulder tip pain  .

Faliure rate of both the procedures are same.

 

B)  Proper case selection is must. Detailed history and bimanual examination should always be done before  deciding and again rechecked by operating surgeon. Trainee registrars should perform operation under supervision .    History of multiple abdominal surgeries or morbid obesity have higher chances of visceral injuries and conversion to laparotomy. These cases should be done by a senior experienced surgeon in a hospital setting with facilities for immediate laparotomy.  Abdomen should be palpated by the surgeon to check for any palpable mass and splenomegaly. Tone of abdominal wall assessed. An incision in the deepest part of umblicus is made. Before insertion, verress needle should be checked for spring action (preferably disposable used) . Veress needle is inserted at right angle to skin after stabilising the abdominal wall. Two audible clicks shoud be heard . Once in, side to side movement of needle should be avoided to prevent any injury ocurred from becoming big. Free flow of saline seen. Pressure inside abdominal cavity should be < 8 mmHg. During gas insufflation, gradual rise of pressure in relation to total gas infused and flow rate is noted. For primary trocar insertion, 20-25 mmHg pressure is required to avoid excessive force on trocar for insertion. The length of trocar inserted shoud be under control. With telescope, First the whole abdominal cavity shoud be examined with particular attention to the area of Verress needle blind entry to look for any bowel injury. Secondray trocar insertion done under vision , in 20-25 mmHg pressure, away from inferior epigastric artery. Insertion to be directed away from pelvis. Clips or rings applied only after confirming fallopian tubes by visualisng the fimbriae. In previous  surgery or morbid obesity caes, insertion via Palmer's point should be done, after palpating for spleen because less chances of adhesions at this area. Direction should be right angled . Removal of secondary trocars is to be done under vision to avoid any bowel loop suction and also look for any bleeding fron trocar site. If through and through bowel injury is suspected , a 5mm telescope via an accessary port visualises the primary trocar length. Primary trocar should also be removed slowly by first sliding canula over the telescope , and withdrawing telescope last so that bowel does enter the incision pathway and cause adhesions or obstruction.  Verress needle insertion shold be avoided at other sites like suprapubic area bec high chances of bladder or uterus injury. 

Answer -366 essay Posted by Liza S.

By liza

(A)Both methods of sterilization are the Principle methods of contraceptions used world wide.

The advantages of hysteroscopic sterilzation that it is a trascervical approach and a office procedure performed with or without local anesthesia and sedation ,and the total procedure time is 35 minutes,not carrying any operative risk incidents such as bowel bladder and vessel injuries.Safely can be used in obese ladies and abdominal scarring presence and medical morbidities like heart and pulmonary diseases.Well tolerated procedure with high success rate more than 99%.Highly cost effective.

Disadvantages-it is a irreversible permanent method of sterilization.Extra contraceptive cover required for the first three months. HSG mostly used to confirm tubal blockage.Reports of device breakage , uterine perforation and distal placement of the device are the main disadvantages.

Laparascopic sterilization --Advantages -It is a abdominal approach performed as a outpatient procedure under local anesthesia,well tolerated procedure with high success rate (effectiveness of 99.7% 5yr).Disadvantage-it is a irreversible permanant method ofsterilization ,life time failurer rate is 1 in 200 and the possibility of a future pregnancy occuring in the fallopian tube is there if failurer occur.Not a suitable procedure in Patients with co-morbidies like cardiopulmonary disease,obese ladies or history of multiple surgeries with a risk of increased complications.Injury to bowel,bladder or blood vessels are serious but infrequent risk 3 in every 1000 proceduresand may need extra procedures which become necessary during the procedure like laparatomy and repair of damage bowel and bladder or blood vessels.

(B)Surgeon intending to perform laproscopic surgery shouldhave appropriate training,supervision and experience.The surgeon also ensure that nursing staff and surgical assistants are appropriately trained for the roles they will undertake during the procedure.Empty the bladder to clear the field.Abdomen should be palpated to check for any masses and for the position of the aorta before insertion of the veress needle.Primary incision for laparascopy should be vertical from the base of the umblicus(not in the skin below the umblicus),unless with previous midline incision other site like palmer point of entry can be used.Care shouldbe taken not to incise so deeply as to enter the peritoneal cavity.The veress needle shouldbe shrap with a good and tested spring action.A disposible veress needle shouldbe used directed perpendicular to the skin, and patient should be horizontal on the table.Excessive lateral movement of the needle should be avioded, as this may convert a small needle point injury in the wall of the bowel or vessel into a more complex tear.An intra-abdominal pressure of 20-25mmHg should be used for gas insufflation before inserting the primary trocar.The primary trocar should be inserted in a controlled manner at 90 degree to the skin.Once the laproscope has been introduced viathe primary cannula it should be rotated through 360 degree to check visuallyfor any adherent bowel ,if thisis present ,it should be closely inspected foe any evidence of haemorrhage,damage or retropertitonial haematoma.Secondary port should be inserted under direct vision whilemaintaing the pneumoperitoneum at 20-25mmHg.During insertion of the secondary port the inferior epigastric vessels shouldbe visualized laproscopically to ensure the entry is away from the vessels .Under direct vision the instrument should be inserted or removed and clips placed under direct vision.Secondary port should beremoved under direct vision and laproscope used to check that there has not been a through-and-through injury to bowel if adherent under the umblicus and to ensure that any haemorrhage can be observed and treated if present ,Documentation of appropriate counsulling should be done. 

 

Shazard Posted by PAUL A.

Essay 366

(A) 

Regarding advantages of hysteroscopic sterilisation. Hysteroscopic sterilisation and laparoscpic sterilisation are both safe and effective methods of sterilisation. The one year failure rate of hysteroscopic sterilisation is 1%. The lifetime failure rate of laparoscopic sterilisation is 1/200 is this an advantage or a disadvantage? Is a 1 year failure rate of 1% greater or lower than a life-time failure rate of 1/200? Do you expect the woman to be able to compare figures presented to her as 1% and 1/200?. Hysteroscopy is done as an out patient procedure under local anesthesia and avoids the risks associated with general anesthesia (1) . Laparoscopic sterilisation is often done under general anaesthesia and therefore entails risk of general anaesthesia. Convalescence with hysteroscopic sterilisation is faster (1) recovery than with laparoscopic sterilisation. Complications of hysteroscopic sterilisation include expulsion or migration of the microinsert, pelvic pain, tubal perforation, vaginal spotting, PID, vaso- vagal syncope, painful insertion and failure are these advantages?. Laparoscopic sterilisation entails the risk of visceral injury. Risk of bladder injury is 0.6/1000, bowel injury is 0.4/1000 and vascular injury is 0.2/1000. Risk of laparoscopic sterilisation related death is 1/12000, 39% of which is due to anaesthetic complications. Minor morbidity includes post operative nausea and shoulder tip pain. These risks are avoided (1) with hysterosocopic sterilisation and may be better for those at risk with laparoscopy (obese, very thin patients, those with prior abdominal surgery or those with inflammatory bowel disease). Hysteroscopy allows visualisation of the endometrial cavity so is this an advantage or a disadvantage?. Laporoscopy allows visualisation of the pelvic organs is this an advantage or a disadvantage? Is the woman better-off having her uterine cavity examined or her abdominal cavity?. Regarding disadvantages of hysteroscopic sterilisation. Additional contraception is recommended for at least 3 months. Further imaging is required 3 months after the procedure (1).  Tubal occlusion is confirmed by HSG or correct placement of microinserts confirmed by ultrasound or pelvic X-ray. Laparoscopic sterilisation requires additional contraception only until the next period and requires no other investigation. Hysteroscopic sterilisation is a relatively new technique. Long term data is not yet available (1). Operator skills are still on the learning curve. Laparoscopy being an established technique has been well studied ? so every one doing lap steri is skilled and everyone doing hyst steri is still on a learning curve?. Long term data regarding outcomes are available and operator skill is often considerable. Data regarding reversal of laparoscopic sterilisation indicates success in 30-90%. This data is not yet available for hysteroscopic sterilization so if reversibility of sterilization is supposed to be an advantage of that method, how do you know that reversal will not be more successful for hyst steri?. Supplement counselling with written information.

 

(B)

Reduce the risk of visceral injury by identifying at risk patients pre-operatively. These are morbidly obese, very thin, patients with previous abdominal surgery and those with large abdominal masses. An appropriately skilled surgeon should perform the procedure ? trainees. Equipment should be tested and functional. Catheterising the patient’s urinary bladder keeps it out of the surgical field. The patient should lie flat. Palpate the abdomen noting any masses and the position of the patient’s aorta (1). Regarding primary entry into the abdomen use Hasson’s open technique or Palmer’s point (3cm below left inferior costal margin along the mid-clavicular line) for those at high risk for visceral injury. Use palmer’s point if 2 failed attempts at entry through umbilicus.  Avoid palmer’s point in those with prior splenectomy or splenomegally. With the closed technique the primary incision is vertical and made through the base of the umbilicus. The Veress needle is inserted at 90 degrees to the skin. Stop entry immediately after the second click is heard (1). This indicates entry through the parietal peritoneum. Perform the pressure/flow test to confirm entrance into the abdominal cavity. Free CO2 flow at 8mmhg indicates correct position (1). Avoid lateral movement of the needle. This prevents conversion of a needle point injury into a tear. Insufflation of the abdomen to a pressure of 20-25mmHg (1) maximises the distance between viscera and the anterior abdominal wall. This reduces the risk of injury from primary and secondary port insertion. Insert the primary trochar at 90 degrees to the umbilicus with a pneumoperitoneum at 20-25mmHg stopping immediately after the parietal peritoneum is pierced. Using the laparoscope through the primary port perform a 360 degree view of the abdominal cavity noting any bowel adherent to the abdiominal wall. Observe closely bowel that is adherent to the umbilicus for  injury. Insert secondary ports, under direct vision (1), at 90 degrees to the skin with a pneumo-peritoneum of 20-25mmHg stopping immediately after the parietal peritoneum is pierced. Visualise with the laparoscope the inferior epigasric vessels (1) during entry and avoid them. After entry achieved angle the trochar anteriorly toward the pelvis.What is the point of doing this AFTER you have already entered the peritoneal cavity? In very obese patients enter secondary ports well lateral to the lateral boder of the rectus sheath does the rectus sheath have a lateral border? taking care not to injure the vessels of the pelvic side wall. After secondary ports entered reduce insufflations pressure to 10-15 mmHg. Regarding removal of ports. Remove secondary ports under direct vision (1). Note bleeding at port sites and ensure haemostasis. Remove the laparoscope from the primary port site while looking for bowel that may have had through-and-through injury from primary port insertion. Close deep fascial layers if a non-midline port >7mm or midline port >10mm is used. This prevents port site hernias.

FAUZIA Posted by PAUL A.

Hysteroscopic sterilisation is an outpatient procedure, requires local anaesthesia or intravenos sedation advantage or disadvantage? I say advantage.it requires additional form of contraception till imaging shows satisfactory placement of microinsert initially by Xray and ultrasound and later by HSG at 3 months as compared to laparoscopy in which contraception is required only till the next menstrual cycle advantage or disadvantage – I say disadvantage. There is no risk of general anaesthesia ? disadvantage?. With laparoscopy there is  a risk of visceral injury, bladder injury and vascular injury. there is an increased risk with laparoscopy in patients who are obese. very thin, those who had peritonitis, inflammatory bowel disease or with midline incision.

Hysteroscopic sterilisation can lead to infection, perforation, expulsion or migration ? advantage or disadvantage?, pelvic pain or vaso vagal reaction. also it cannot be used in woman with distorted uterine cavity or stenosed cervix. The examiner will not help you by deciding what is an advantage / disadvantage and then award marks

Risk of visceral injury can be minimised by appropriate selection of patient, for woman who are morbidly obese or underweight, open technique (hasson) is better than closed method.woman who had peritonitis, inflammatory bowel disease or with midline incision, primary trocar should be inserted from the palamer's point.The surgeon should have the knowledge, experience and skills.the staff should be fully trained. the abdomen should be palpated before the laparoscopy to feel for any masses and the position of the aorta ? empty bladder. the veress needle should be tested for double spring action. The skin sould be stabilised at the veress needle should be inserted at 90 degree to the skin. the table should be in horizontal position.the laparoscope should be rotated at 360 degree how do you get laparoscope in?to see for any damage, haemorrhage or haematoma.In woman who had inflammatory bowel disease, the laparoscope should be inserted at the secondary port to see if there is  any adhesions. secondary port should be removed under direct vision.

See answer above

Jyoti Posted by PAUL A.

Hysteroscopic sterilisation is a relatively newer method of permanent contraception which is still under evaluation.In this method though the hysteroscope inserts are inserted in the Fallopian tube which fibrose in about 3 months which cause the tube to be blocked,this it doesn't have an immediate effect as laproscopic sterilisation and it needs to be confirmed by hysterosalpingography is this an advantage or a disadvantage?.Complications include vasovagal syncope, uterine perforation, migration of the inserts,increased risk of ectopic pregnancy compared to what? Is this an advantage or a disadvantage?.However when compared to laproscopic sterilisation, it is an outpatient procedure that can be done under local anaesthesia or Intravenous sedation and doesn't require general anaesthesia and hence avoids its compliacations.there are no surgical incision on abdomen and risk of visceral injury is reduced.The operating time is less and has a quicker recovery.According to studies failure rate is about 3 in 1000 so 1 in 333 – is this per year or per life-time? vs in laproscopic sterilisation is 1 in 200 is this per year or per life time? How then do you conclude that one is more effective than the other?,hence making it more cost effective and safer option than laproscopic sterilisation. You have not indicated what is an advantage and what is a disadvantage. B) To minimise visceral injury during laproscopy, firs of all we should identify the patients who are at a higher risk like those with previous abdominal surgeries especially previous midline midline laprotomies, perotonitis, inflammatory bowel disease, very obese or very thin patients.The surgeon undertaking the procedure should be well qualified for the procedure or should be supervised by a senior(1).Although there have been no stastical difference in visceral injury by either of the open or the closed entry technique,in high risk women an open Hanson technique of entery or insertion at palmers point(3cm below left sub costal line)may be undertaken as a primary entry. During initially entery by a verris needle the spring action of the needle should be check prior to procedure, the operating table should be horizontal and direction of the entery should be perpendicular to be abdomen at the base of the umbilicus.With two failed attempts it should be converted to an oppen technique.During the entery of the trocar the abdominal pressure should be kept at 20-25mm hg (1),which after entery may be reduced to 10-12mm hg,same holds for entry of secondary ports if required are they required for lap steri?.Entry direction should be perpendicular,once entered should be directed towards the pelvis.Once entered the scope should be rotated by 360degres to check for bowel injury.also taking ou the scope should be under vision (1) see answer by Shazard above.

Yingjian Posted by PAUL A.

a)

Advantages of hysteroscopic sterilisation compared to laparoscopic are hysteroscopic sterilisation is less painful than laparoscopy; can be done as a day surgery case; may have higher patient acceptability compared to laparoscopy; can be done under local or regional or general anesthesia compared to laparoscopic sterilisation which is done under regional or general anesthesia.This is simply a list with no discussion Hysteroscopic sterilisation can be done for patients not suitable for laparoscopy such as obese patients, history of extensive intraabdominal adhesions or complicated laparotomies and those who cannot tolerate gas insufflation such as those with respiratory or cardiovascular compromise or those with large abdominal hernias. Hysteroscopic sterilisation may also have quicker operating time and faster recovery (1) than laparoscopic ligation; is more suitable for centres with no expertise/equipment/facilities for laparoscopic surgery and may be less expensive than laparoscopycost-effective. Hysteroscopic sterilisation also avoids risks of laparoscopy such as pneumoperitoneum, subcutaneous emphysema, visceral injury and failure of laparoscopic entry and conversion to laparotomy (1).

 

Disadvantages of hysteroscopic sterilisation are that it requires expertise/equipment/ facilities for hysteroscopy what about the expertise / equipment / facilities needed for laparoscopy?, risks of hysteroscopy such as uterine perforation and visceral injury, bleeding, infection, failure of entry thru cervix, fluid overload, poor visualisation and abandoning operation. It may also be less acceptable for patients who are nulliparous you said it was more acceptable above and more difficult in patients with previous extensive cervical surgery compared to laparoscopy.

 

b)

To minimise risk of visceral injury, preoperatively I would assess patient’s history for suitable patient selection for laparoscopy noting any previous laparotomies, difficulties in surgery, history of intraoperative adhesions, endometriosis, severe pelvic inflammatory disease, patient’s body mass index or abdominal hernias.

Operatively, if patient has above risk factors in history, I would use palmer’s point for entry or open Hasson method instead of veress needle entry if using umbilical site for entry. On inserting camera port, I would use slow controlled movements; if using Veress needle entry, I should hear 2 clicks on entry, opening gas pressure should be <8mmHg free flow. Ancillary ports must be inserted under vision with controlled slow entry and gas insufflated to 20mmHg at time of insertion (1). On identifying tubes, care taken on manipulating bowels away from exposure to prevent accidental injury, patient can be put on tredenlenberg position for easier exposure. Care also taken when ligating tubes to prevent ligation of round ligaments or ovarian vessels. Postoperation, ports must be removed under visualization (1), gas from pneumperitoneum slowly released, camera port slowly removed without catching any bowel and care taken on closing skin not to dig the needle too deeply to prevent catching any underlying bowel in thin patients.  See answer by Shazard above

SG Posted by PAUL A.

Hysteroscopic  sterilisation is  associated  with  less  anaesthetic  complications (1)

as compared to laparoscopic method as it is done under local anaesthesia or iv

 sedation .Laparoscopic sterilisation is done under GA.In  hysteroscopic

sterilisation there  is  no need for making cuts in the abdomen.Bowel,blood

vessel injury  are  less common than laparoscopic method (1).In  studies  very  few

  ectopic  pregnancies  are  reported  with  hysteroscopy,so  if  failure  occurs

less chance  of  ectopic  pregnancy  than  laparoscopy.Hysteroscopy  is

  preferred  if  previous surgery,bowel pathology, obesity  due  to  decreased

 risk of visceral injury and adhesions.There is no risk of wound infection,

shoulder tip pain,hernia formation associated  with laparoscopy.

The  disadvantage of  hysteroscopy is it is irreversible is lap steri reversible?.Contraception  has to be

 used atleast for 3 months till is proved that the tubes are blocked. Second 

procedure HSG is required for this(1).Laparoscopy  requires contraception till

 procedure or next cycle only.The  risk of uterine perforation,improper coil

placement  are with hysteroscopy(1).Since  new procedure requires skills and

training does lap steri not require skill and training?. Long-term Data  and studies are limited for hysteroscopic

sterilisation.Postoperatively  majority have pain compared to

laparoscopy ? evidence and vaginal  bleeding.Hysteroscopy is 96-98% successful.Failure rate of laparoscopy is 1 in 200. is this a disadvantage? So you are saying failure rate is higher than for lap steri?

 

B}Preoperative assessment including obesity,previous surgeries,bowel

 pathology,underweight  should  be  made  prior to surgery for proper

 planning.Adequate  skillsof the operator, assistants proper knowledge of

equipments are necessary.Optimisation of trocar and canula insertion ? meaning – what is optimum? is the most effective way of reducing entry

related injury.Patient position should be horizontal without tilt.Verees needle should be sharp,good spring

action ,disposable.Abdomen is palpated before incision for masses and position of aorta ? empty bladder.Incision should be made

from the base of the umbilicus and verees is inserted to right angles to minimise injury.Lateral movements are

restricted as it will convert needle point tear to complex tear of the bowel and vessel.Pressure is kept at 20 to25

mmHG (1) for splinting action till primary and secondary trocar insertions and reduced to 10-12mmhg later.Trocars are

inserted at right angles.After insertion telescope is rotated through 360 to visualise adherent bowel (1),injury and if

needed visualised via secondary ports.Removal of ports is done under direct vision (1) to identify injuries.Secondary ports

are inserted after visualising inferior epigastric arteries.Two failed techniques,obesity,underweight,previous surgeries Hassons

orPalmer point entry is used.Newer techniques if available radially expanding trocars, endotip can be used for better

visualisation .see answer by Shazard above

MONA Posted by PAUL A.

A). Hysteroscopic sterilization is a relatively new technique but there is adequate evidence for safety and efficacy. Main advantage as compared tp laparoscopic sterilization is outpatient procedure done under local anesthesia or intravenous sedation so avoids complication of anaesthesia (1). It avoids cut on abdomen as it involves hysteroscopic insertion of implants into Fallopian tubes. It is preferable in obese patients, those with previous surgery as it avoids risk of visceral injury (1) associated with lap sterlisation. It avoids frequent risk of laparoscopy like wound infection gaping bruising and shoulder pain. It has. 97-99% success rate compared with failure rate of 1 in200 for lap sterlisation is this an advantage? That is the problem when you quote incompatible figures – the success rate for lap steri will be 99.5% - is this lower than 97-99%? If you make this mistake, how do you expect the patient to get the sums right?. Disadvantage is that additional contraception is needed for 3 months till tubal occlusion is confirmed by x ray, ultrasound or hsg (hysterosalpingogram) (1). In lap sterlistion additional contraction needed only til next period . Due to hysteroscopy used there can be serious ,rare risk like uterine perforation ,fluid overload . There can be fallopian tube tears, pelvic pain, infection vasovagal attack and device misplacement (1). It is an irreversible technique unlike lap sterilization which has a variable reversal rate.Is lap steri reversible? B). Laparoscopy associated visceral injury can be prevented by careful patient selection noting BMI , previous surgery , inflammatory bowel disease. Surgeon and team performing procedure should have adequate skill ,supervision (1) and be familiar with instruments. Operating table should be horizontal with no tilt till trocar placement. Closed veress needle technique is safe and needle should be sharp with good tested spring action.. Before entry abdomen mass aorta position checked ? empty bladder, . Veress needle inserted at right angles after stabilizing lower abdomen by incision at base of umbilicus and pushed to pierce fascia and peritoneum by noting two clicks (1). Avoid excess lateral movement of needle or needle point injury made into large bowel tear. Two failed attempts with veress , extremes of weight , previous surgery should prompt has son's open technique or Palmer point entry. Primary trocar placement done at 20-25 mmhg abdominal pressure(1). Secondary port insertion is done under direct vision (1) with trocar tip towards anterior pelvis after entry. Removal of port done under vision (1).

Uzma Posted by PAUL A.

A] Hysteroscopic sterlization is a out patient procedure   called  ASSURE ??? it is called hysteroscopic sterilisation   which is done by a trained health care personal   under para cervical block anaesthesia or   local anaesthesia   , is applied to the ecto cervix   ,where as laproscopic sterlization is done in a day case procedure usually under general anaesthesia  , but can also be done under local anaesthesia   ? advantage or disadvantage?. Before proceeding to both the procedures counselling, detailing and risk  associated with these procedure is discussed  and information leaflet is provided and   consent is takenHow does this answer the question??  In both the procedure   screen for clamydia infection and give prophylactic antibiotic ,   In hysteroscopic sterlization a flexible scope of diameter 2.7- 3 mm is passed through the cervix  with   saline as a distending medium ,  a rigid scope can  also be used   but in flexible scope the risk of vasovagal shock and pain is less  , a gel foam is plugged in the fallopian tubes.  it takes about 3 months to fibrous inside the tubes   till then the patient should use effective contraception for 3 months   Pain is less in this procedure,   if patient wishes she can take NSAID to prevent post procedure pain   but this is not much helpful ,   it doesnt need consious sedation.   does not need to prepare the cervix before the procedure,   The benifits this is nearly what you were asked about. If the examiner asked you for advantages, why tell them about benefits? are it is out patient procedure,   short time,   quick recovery,   no need for General anaesthesia,   less expensive.    This is just a list with no discussionThe disadvantages are it is still under evaluation   the succes rate and failure rate   are not known   , it is done in limited places   , the succes of recanulation is not known  , there is risk of   cervical damage on forced entry   in stenosed cervix,   damage to the cornuea, and bleeding, when  plugging the tubes    . there is risk of  introducing intrauterine  infection this is just a list with no discussion.    IN laproscopic sterlization there is risk   of damaging the bowel,   bladder, and the   vessels at the time of   entry in the abdomen , risk of exposure     to General anaesthesia  , haemoperitonium, and shoulder tip pain after the procedure,   and port herniation.   advantages are it is day case procedure ,  with quick recovery  , less post operative pain and   contraception to be used till next menstrual period and   reversal is succesful.      You were not asked about the disadvantages of lap steri

    B]   Laproscopic procedure is a day case procedure  usually  done  under General anaesthesia   .The risks can be minimised first by selecting the patients,    if patient is very obese BMI >40  and thin BMI less than 19   and patients who had previous abominal surgeries are avoided ,    A trained surgeon  has to do the procedure in a fully equiped theatre, and trained staff,    information has to be given verbally and information leaflet provided.How does this reduce risk of injury?   Consent should involve if procedure is failed will proceed with minilaporotomy    .Before proceeding the patient is made to lay supine , on the table which is horizontal not the trendelburg position ,   abdomen is palpated for masses and abdominal aorta located empty bladder , there are 3 or more  procedures for entry   closed or,  open called HASSONS entry  and alternative entry   ,a vertical incision is put at the base of the umbilicus   and veeres disposable needle is introduced  at 90 degree to the skin    with a good spring action,   the needle is avoided lateral displacement to avoid damage to the vessels and bowels  ? meaning  then, the trocar and cannula is introduced with a doubble click  sound  do you get a double click when you insert the trocar?. once inside the abdomen the abdomen is inflated with co2 GAS at a intra abdominal pressure of 20-25 mm hg then   the scope is introduced and rotated 360 degrees  to see if any bowel adherent to anterior abdominal wall  (1).THE abdominal pressure is reduced to 10-12 mm hg  and  IF any injury to the viscera or vessels Is suspected   a mini scope of 5mm diameter  is introduced through another port and confirmed, and repaired immediately  .   IN case of high risk patients such as history of PID,Inflamatory bowel disease, Endometriosis, obese patients a entry at Palmers point is selected .   It is 3 cms below the left coastal margin in the mid clavicular line .  This point is free of adhesions unless spleenectomy is done  , At this point care must be taken not to damage inferior epigastric artery  at Palmer’s point?? . After the procedure the skin is sutured to prevent port herniation.  See answer by Shazard above                    

Lola Posted by PAUL A.

A)     Hysteroscopic sterilisation is a quick and an outpatient procedure, performed under local anaesthesia or intravenous sedation while laparoscopic sterilisation often requires general anaesthesia with endotracheal intubation or regional anaesthesia would you do lap steri under regional anaesthesia?. Hysteroscopy precludes the entry into the peritoneal cavity and thus injury to major viscera, blood vessels (1). Post-operative chest discomfort and shoulder pain due to abdominal distension in laparoscopy; is not present with hysteroscopic sterilization. Thus hysteroscopy offer  the benefits of economical and safe, early convalescence (1) and overall less invasive as compared to the laparoscopic sterilization. But hysteroscopic  sterilization, still in budding stage is technically difficult ? evidence if it is being done as an office procedure, limited to the theatres of surgeons, skilled in hysteroscopy, thus requirement of expertise is its limitation does laparoscopy not require expertise?. It involves placement of “Essure” which is a nickel microinsert into bilateral fallopian tubes under hysteroscopic vision. Scarring around the microcoils and occlusion of the tubes take around 3 months , so one has to use additional form of contraception till the imaging by X-ray/USG/HSG confirms the occlusion (1). Thus the candidates who are not willing for the follow-up are not suitable candidates for hysteroscopic sterilisation while sterilisation by laparoscopy requires no additional imaging and is effective immediately.

Pelvic infection, post-op pelvic pain, bleeding are other disadvantages where in this essay did you start writing about disadvantages? of hysteroscopic sterilisation. Device migration, expulsion, uterine perforation, tubal lumen perforation are other problems associated with hysteroscopic sterilization (1). Vasovagal syncope is most frequent complication associated with hysteroscopy, not so with lap- sterilisation.  Success of hysteroscopic sterilisation is in 96-97% cases. Failure rate & ectopic pregnancy rates are higher with hysteroscopy compared to laparoscopic sterilization are they?. Persistence of pain may require subsequent procedure to remove the microinserts  and nickel allergy may be there, which is rare with silicon(inert) rings used in lap-sterilisation. Reversal of sterilisation has lower success rate in hysteroscopy as compared to lap- sterilisation using clips.? evidence

B)      Proper positioning of patient, supine position ( not Trendelenberg) while placement of trocars is the crucial step to prevent injury to major viscera what do you do before inserting the trocar?. Closed technique of entry is associated  with approximate 0.4/1000 bowel injury as compared to open (Hasson’s) entry which leads to 0.6/1000 cases of bowel injury. Insufflation pressure of 25 mmHg (1) before placement of trocars provide 5.6 cm depth below umbilicus and thus visceral injury can be minimised. Entry through palmer’s point or open technique to enter in case of previous laparotomy, peritonitis or inflammatory bowel disease is safe.Double puncture technique what is this? is more  safe compared to single puncture technique. Entry into the abdomen via secondary trocar should be made under direct vision (1) after confirming the position of inferior epigastric arteries how? or with single puncture technique, try to enter at the most lateral margin  of rectus sheath does the rectus sheath have a lateral margin? When you do CS and divide the rectus sheath do you see a lateral margin?. Hold the fallopian tube with microforceps at right angle at isthmus, 2-3 cm from the cornua.Why is this necessary?  Because holding the fallopian tube with a tilt may transect it and may also cause injury to intestinal loop. Minimal use of cautery why should you use any cautery?? again prevents major viscera injury and donot perform bipolar electrocoagulation as method of sterilization, as it often leads to unrecognised bowel injury.Often? Do you often get bowel injury when you do lap hysterectomy? (-1)  Take out the instruments,cautery and  trocars from the peritoneal cavity under direct vision(1)  so as to prevent as well as timely identify injury to bladder, bowel or abdominal wall.

Posted by Lola B.

 

Dear Dr Paul, 

Am afraid you might have marked the wrong answer to my name. Here's a repost of my answer. Appreciate it if you can mark it thank you!

 

Lola

 

The advantages of hysterecospic sterilization will be that it averts the need to perform a laparoscopy for the patient. A laparoscopic surgery has higher risks of bleeding, infection, injury to organs like blood vessels, bladder, bowel and ureter. Hysteroscopic sterilization can also be done under RA -- which is safer and carries less risks than a GA, for which a laparoscopic sterilizaion is needed. A hysteroscopic sterilization enables us to survey the endometrial cavity at the same time, noting any fibroids and polyps and performing any therapeutic treatment at the same time. It is also cheaper.

The disadvantages are that there is a a higher failure rate. Its is also more techically difficult, requiring trained personnel to carry it out. The ostia may not be able to be visualised in the proceure due to submucous fibroids or an abnormally shaped cavity., thus procedure will not be possible. There is a need to wait for 1-2 months for fibroisis to occur -- It is not immediately effective. Additional contraception has to be used in the meantime. Reversal of sterilization is more difficult. And there is not benefit of being able to survery intraabdominal and pelvic organs like in a laparoscopic procedure. 

b) Entry can be done byt he veress needle of the Hassan's method, depending on fhte skill and comfort level of the operator. Ensure a well trained and experiecned surgeon carries out the surgery. If using the veress needle method, the abdomne must be level witht he ground. 2 Clincks must be distinctly heard upon insertion of the veress needle. Testing for entry intot eh abdominal cavtiy is done by air aspiration of water instillation facing no resistance, and noting the pressure to be <10mmHg. 

If the open method is used, the recturs sheath must be visualised, incised and entry intot he abdominal cavity must be directly visulised. The veress needle must be stabilised and horizontal movements avoided, to avoid converting a pinpoint injury in the bowel into a horizontal sheer injury. 

The entral trocar is inserted witht he intraabdominal pressure at 20-25mmHG and patient level with the ground. Upon placing the camera, to do a survey of bowels and surrounding organs to bensure no injury is caused upon entry. Secondary ports are inserted at 20-25mmHg insufflation with the patient level and ports perpendicular to the skin. Upon the trocar entering the cavity, it is directed anteriorly and toweards to pevis. 

Care is taken to avoid the inferior epigastric vessels by visualising them within the camera. If the patient is obese, the secondary ports are placed lateral to the rectus muscle. 

If there is suspicioun of periumbilical adhesions (in the presence of previous caesareans or surgeries), a palmar's point entry is taken with a 5mm camera, to survey the periumbilical area, and entry is taken under direct laparoscopic vision. 

Alwasy keep instruments in full view withint he camera's vision. Especially when activating energy sources, the instruments must always be visualised. Ports are removed under full visualsation, making sure to look for any blood vessel injury that may be tamponaded by the port placemnets. In obese or very thin patients, the opn method of entry is encouraged.

assay 366 Posted by huaida A.

Hello

pls sir we need the ideal answer

thanks

Pulkit Posted by PAUL A.

A) Hysteroscopic sterilisation is a new technique of inserting metal implants into the fallopian tubes, via hysteroscope , which expands and ultimately cause fibrosis. Advantages of hysteroscopic sterilisation is that it is done under Local anaesthesia or Intravenous sedation (1), requires shorter operating time, well accepted and comfortable to majority of woman with less requirement of intra and postoperative analgesia. In woman with medical comorbidites like cardiac diseases or severe obstructive pulmonary diseases or in morbidy obesity or women with previous multiple surgeries, Hysteroscopic sterilisation can be preffered over laparoscopic approach because no need of GA, and abdominal cavity is not entered how is this beneficial?.  Disadvantages of hysteroscopic sterilisation is that it relatively new technique with few surgeons performing it. May need refferal to other hospital. If a surgeon decides to do this , local hospital authorities need to be informed which authorities and why?. The successful fibrosis of tubes have to be  assessed at a later stage (3 months) by Hysterosalpingogram directly or iniatally by x-ray/ ultrasound and later confirmed by hysterosalpingogram if you do x-ray or ultrasound, why do you have to do HSG as well?. Woman needs to take contraceptive precautions till then (1). Reversal of this procedure is not possible why is this a disadvantage?.  Risks of hysteroscopic sterilisation are perforation of uterus or trauma to cervix.

Laparoscopic sterilisation is time tested ,safe ,effective and commonly done. Women need contraception in only that menstural cycle. As abdominal cavity is entered , other intraabdominal pathologies can be noted.

Disadvantages are that it is usually done under GA ( can be done in LA), Carries small risk of major (3/1000) morbidity of damage to bowel , bladder or blood vessel ,incisional hernia development and need for conversion to laparotomy. Minor risks involve bruising of skin and shoulder tip pain  .

Faliure rate of both the procedures are same.

 You were not asked about advantages / disadvantages of lap steri

B)  Proper case selection is must. Detailed history and bimanual examination should always be done before  deciding and again rechecked by operating surgeon. Trainee registrars should perform operation under supervision .    History of multiple abdominal surgeries or morbid obesity have higher chances of visceral injuries and conversion to laparotomy. These cases should be done by a senior experienced surgeon in a hospital setting with facilities for immediate laparotomy so where should straight-forward cases be done?.  Abdomen should be palpated by the surgeon to check for any palpable mass and splenomegaly empty bladder. Tone of abdominal wall assessed how does this help you?. An incision in the deepest part of umblicus is made. Before insertion, verress needle should be checked for spring action (preferably disposable used) . Veress needle is inserted at right angle to skin after stabilising the abdominal wall. Two audible clicks shoud be heard(1). Once in, side to side movement of needle should be avoided to prevent any injury ocurred from becoming big. Free flow of saline seen where?. Pressure inside abdominal cavity should be < 8 mmHg and free flow of gas. During gas insufflation, gradual rise of pressure in relation to total gas infused and flow rate is noted. For primary trocar insertion, 20-25 mmHg pressure is required to avoid excessive force on trocar for insertion. How does pressure stop you using excessive force? The length of trocar inserted shoud be under control ? meaning. With telescope, First the whole abdominal cavity shoud be examined with particular attention to the area of Verress needle blind entry to look for any bowel injury (1). Secondray trocar insertion done under vision (1), in 20-25 mmHg pressure, away from inferior epigastric arteryhow do you identify them?. Insertion to be directed away from pelvis to where?. Clips or rings applied only after confirming fallopian tubes by visualisng the fimbriae. In previous  surgery or morbid obesity caes, insertion via Palmer's point should be done, after palpating for spleen because less chances of adhesions at this area. Direction should be right angled . Removal of secondary trocars is to be done under vision (1) to avoid any bowel loop suction and also look for any bleeding fron trocar site. If through and through bowel injury is suspected , a 5mm telescope via an accessary port visualises the primary trocar length. Primary trocar should also be removed slowly by first sliding canula over the telescope , and withdrawing telescope last so that bowel does enter the incision pathway and cause adhesions or obstruction.  Verress needle insertion shold be avoided at other sites like suprapubic area bec high chances of bladder or uterus injury.

Liza Posted by PAUL A.

(A)Both methods of sterilization are the Principle methods of contraceptions used world wide ? meaning.

Theadvantages of hysteroscopic sterilzation that it is a trascervical approach and a office procedure performed with or without local anesthesia and sedation ,and the total procedure time is 35 minutes how long does it take to do a lap steri?,not carrying any operative risk I suspect you will list some operative risks later in your answer incidents such as bowel bladder and vessel injuries.Safely can be used in obese ladies and abdominal scarring presence and medical morbidities like heart and pulmonary diseases.Well tolerated procedure with high success rate more than 99%.Highly cost effective (1).

Disadvantages-it is a irreversible permanent method of sterilization is lap steri reversible?.Extra contraceptive cover required for the first three months. HSG mostly used to confirm tubal blockage(1).Reports of device breakage , uterine perforation and distal placement of the device are the main disadvantages.

Laparascopic sterilization --Advantages -It is a abdominal approach performed as a outpatient procedure under local anesthesia,well tolerated procedure with high success rate (effectiveness of 99.7% 5yr).Disadvantage-it is a irreversible permanant method ofsterilization ,life time failurer rate is 1 in 200 and the possibility of a future pregnancy occuring in the fallopian tube is there if failurer occur.Not a suitable procedure in Patients with co-morbidies like cardiopulmonary disease,obese ladies or history of multiple surgeries with a risk of increased complications.Injury to bowel,bladder or blood vessels are serious but infrequent risk 3 in every 1000 proceduresand may need extra procedures which become necessary during the procedure like laparatomy and repair of damage bowel and bladder or blood vessels. Did the question ask you for advantahes and disadvantages of lap steri?

(B)Surgeon intending to perform laproscopic surgery shouldhave appropriate training,supervision and experience (1).The surgeon also ensure that nursing staff and surgical assistants are appropriately trained for the roles they will undertake during the procedure.Empty the bladder to clear the field.Abdomen should be palpated to check for any masses and for the position of the aorta before insertion of the veress needl (1).Primary incision for laparascopy should be vertical from the base of the umblicus(not in the skin below the umblicus),unless with previous midline incision other site like palmer point of entry can be used.Care shouldbe taken not to incise so deeply as to enter the peritoneal cavity.The veress needle shouldbe shrap with a good and tested spring action.A disposible veress needle shouldbe used directed perpendicular to the skin, and patient should be horizontal on the table (1).Excessive lateral movement of the needle should be avioded, as this may convert a small needle point injury in the wall of the bowel or vessel into a more complex tear.An intra-abdominal pressure of 20-25mmHg should be used for gas insufflation before inserting the primary trocar (1).The primary trocar should be inserted in a controlled manner at 90 degree to the skin.Once the laproscope has been introduced viathe primary cannula it should be rotated through 360 degree (1) to check visuallyfor any adherent bowel ,if thisis present ,it should be closely inspected foe any evidence of haemorrhage,damage or retropertitonial haematoma.Secondary port should be inserted under direct vision(1) whilemaintaing the pneumoperitoneum at 20-25mmHg.During insertion of the secondary port the inferior epigastric vessels shouldbe visualized laproscopically how do you do this? to ensure the entry is away from the vessels .Under direct vision the instrument should be inserted or removed and clips placed under direct vision (1).Secondary port should beremoved under direct vision and laproscope used to check that there has not been a through-and-through injury to bowel if adherent under the umblicus and to ensure that any haemorrhage can be observed and treated if present (1),Documentation of appropriate counsulling should be done. 

 

Lola Posted by PAUL A.

Dear Dr Paul, 

Am afraid you might have marked the wrong answer to my name. Here's a repost of my answer. Appreciate it if you can mark it thank you! Sorry we assigned a different member’s answer to you in error.

 

Lola

 

The advantages of hysterecospic sterilization will be that it averts the need to perform a laparoscopy for the patient avoiding laparoscopy is not necessarily an advantage. A laparoscopic surgery has higher risks of bleeding, infection, injury to organs like blood vessels, bladder, bowel and ureter(1). Hysteroscopic sterilization can also be done under RA -- which is safer and carries less risks than a GA have you ever done lap steri under RA?, for which a laparoscopic sterilizaion is needed. A hysteroscopic sterilization enables us to survey the endometrial cavity at the same time, noting any fibroids and polyps and performing any therapeutic treatment at the same time why is this an advantage? You will be doing an operation in an asymptomatic woman . It is also cheaper cost-effectiveness not just cost.

The disadvantages are that there is a a higher failure rate does it? What is it?. Its is also more techically difficult, requiring trained personnel to carry it out does lap steri not require training?. The ostia may not be able to be visualised in the proceure due to submucous fibroids or an abnormally shaped cavity., thus procedure will not be possible. There is a need to wait for 1-2 months for fibroisis to occur is it 1 month or 2 months? 3 months-- It is not immediately effective. Additional contraception has to be used in the meantime. Reversal of sterilization is more difficult evidence. And there is not benefit of being able to survery intraabdominal and pelvic organs like in a laparoscopic procedure. 

b) Entry can be done byt he veress needle of the Hassan's method, depending on fhte skill and comfort level of the operatorwhat do the RCOG guidelines recommend?. Ensure a well trained and experiecned surgeon carries out the surgery ? trainees. If using the veress needle method, the abdomne must be level witht he ground.? meaning2 Clincks must be distinctly heard upon insertion of the veress needle spring action…. Testing for entry intot eh abdominal cavtiy is done by air aspiration of water instillation facing no resistance,? meaningand noting the pressure to be <10mmHg. 

If the open method is used, the recturs sheath must be visualised, incised and entry intot he abdominal cavity must be directly visulised. The veress needle must be stabilised and horizontal movements avoided why are you using Veress needle in open technique?, to avoid converting a pinpoint injury in the bowel into a horizontal sheer injury. 

The entral trocar is inserted witht he intraabdominal pressure at 20-25mmHG and patient level with the ground (1) horizontal or supine. Upon placing the camera, to do a survey of bowels and surrounding organs to bensure no injury is caused upon entry (1). Secondary ports are inserted at 20-25mmHg insufflation with the patient level and ports perpendicular to the skin direct vision. Upon the trocar entering the cavity, it is directed anteriorly and toweards to pevis. 

Care is taken to avoid the inferior epigastric vessels by visualising them within the camera ? how do you do this?. If the patient is obese, the secondary ports are placed lateral to the rectus muscle. 

If there is suspicioun of periumbilical adhesions (in the presence of previous caesareans or surgeries), a palmar's point entry is taken with a 5mm camera, to survey the periumbilical area, and entry is taken under direct laparoscopic vision. 

Alwasy keep instruments in full view withint he camera's vision. Especially when activating energy sources which energy sources do you use for lap steri?, the instruments must always be visualised. Ports are removed under full visualsation (1), making sure to look for any blood vessel injury that may be tamponaded by the port placemnets. In obese or very thin patients, the opn method of entry is encouraged.

 

Answer Posted by PAUL A.

A good answer should include

(a)

Advantages

·         Location – can be undertaken as office procedure with women typically discharged within 2 hours (1 mark)

·         Anaesthetic – avoids the use of general anaesthesia (1 mark)

·         Surgical risks - lower risk of visceral injury compared to laparoscopic sterilization. No surgical incisions (1 mark)

·         Efficacy – similar success rates / failure rates to laparoscopic sterilization (1 mark)

·         Recovery – women may return to normal activities on the same day (1 mark)

·         Cost-effective compared to laparoscopic sterilization (1 mark)

Disadvantages

·         Not immediately effective. Additional contraception needed for at least 3 months (1 mark)

·         Further testing required to confirm placement of device including X-ray, ultrasound scan or HSG (1 mark)

·         Failure to insert device reported in 1-15% of cases, leaving the woman un-sterilised (1 mark)

·         Risk of device expulsion and migration (1 mark)

·         Long-term safety and cumulative effectiveness data not available (1 mark)

(b)

Minimising risk of visceral injury at laparoscopic sterilization

·         Undertake prior assessment for abdominal masses, position of aorta. Empty bladder (1 mark)

 

·         Use closed Verres needle technique as may be associated with lower risk of visceral injury unless there is a previous mid-line incision (1 mark)

 

·         Know appropriate technique for inserting Verres needle including tested spring action (1 mark)

 

·         Check for correct placement by obtaining low pressure (<8 mmHg) and free flowing gas (1 mark)

 

·         Raise intra-abdominal pressure to 20-25mmHg before inserting primary trocar. Know appropriate technique (1 mark)

 

·         Inspecting for adherent bowel on first inserting the laparoscope through the primary cannula (1 mark)

 

·         Trans-illuminate the inferior epigastric vessels in order to avoid injury during insertion of the secondary port (1 mark)

 

·         Insert secondary port under direct vision with abdominal pressure at 20-25mmHg (1 mark)

 

·         Instruments should be inserted / removed and clips placed under direct vision (1 mark)

 

·         Secondary port should be removed under direct vision and the laparoscope used to check that there has not been a through-and-through injury to bowel adherent under the umbilicus (1 mark)

 

·         Know the importance of appropriate training and supervision (1 mark)