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MRCOG PART 2 SBAs and EMQs

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EMQ1476
SBA2074
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Answer to the new SAQ

Answer to the new SAQ Posted by ALi S.

Advantages of Hysteroscopic sterilisation are many ;as it can be done as an outpatient procedure under local anaesethetic and/or sedation compared to laparscopic procedure which is usually  done under general anaesthesia as day case procedure. The procedure also give a chance to visualise endometrial cavity for any abnormalities like submucous fibroids and polyps. Major avdantage that hysterroscopic sterilisation is considered as very good alternative to patient with high BMI or very low BMI when risk of viscral damage deemed high so hysteroscopic sterilisation will avoid viscral damage in these patients.Also it carries higher sucess rate 97-99% and less failure rate rate 3.1 per 1000 compared to 1:200 in lapraoscopic sterilisation.

Disadvantage of the procedure are less compared to laparscopic procedure , mainly pain during the procedure ,sometimes vasovagal attack,increse risk of of ascending infection and PID if STI not screened or antibiotic prophylaxis were not given.Missing the oppurtunity to visualise the pelvic cavity for any pathology like endometriosis ,ovarian cysts.other important disadvantage is the need for 3 months of contraception following the procedure until ubal blockage confirmed by HSG in contrary to laparposcopic sterilisation when contraception is only needed until next period.Hysteroscopic sterlisation also carries risk of uterine perforation and expulsion or migration of the device as well as it necessiate special training and expertise. .

In oreder to minimise the risk of viscral damage during laparoscopic preocdures , steps will start from good patient selection as patients with  morbid obesity and previous mid line abdominal scars and/or bowel surgery all posses increased risk of bowel perforation. insertion of veresse needle should be intraumblical and while the patient in supine flat position and intraabdoimnail pressure following needle insertion <10 mmHg  before commencing Co2 insufflation. pneumoperitoneum created up to pressure 20-25mmHg to ensure safety during trocars insertion . all secondary troars should be placed under direct visualisation to avoid risk of injury to epigastric vessels or any viscral damage.Inspection of whole peritoneal cavity once lapracoscopy introduced .In cases of difficulties anticipated with Veresse needle insertion alternative options like insertion at Palmer point or open laparoscopy 'Hasson technique' are good options. in addition to that careful use of diathermy and usage of bipolar diathermy to minimise risk opf thermal bowel injury and if any viscral injury anticipated or suspected during the procedure; less manipulation is required until  help requested from general surgeon.Patient counseling regarding the benefits and risk are mandatory before obtaining the consent which should also include the  need of any extra procedure to rectify any damge.