OFFICE DAY CARE THERAPEUTIC PROCEDURES IN GYNAECOLOGY A ONE YEAR STUDY

DR KAVITA PRIYA MD CENTRAL HOSPITAL DHANBAD

MARCH 2011FEBRUARY 2012

TIME FRAMEWORK

In-Office Procedures
Office procedures are surgical procedures which may be performed in a clinic or outpatient setting. In-Office Procedures allow the patient to resume her normal activities the next day. General Anaesthesia is not used
Cochrane Library 2009

The term day surgery, or ambulatory surgery, refers to the practice of admitting into hospital on the day of surgery carefullyselected and prepared patients for a planned, non-emergency surgical procedure and their discharge within hours of that surgery

DAY CARE SURGERY

DAY CARE SURGERY

The father of day care surgery was James Nicoll, a Glasgow surgeon who performed almost 9000 outpatient operations on children in the early 19th century.

DAY CARE ONE END OF THE SPECTRUM OF SHORT STAY SURGERY

SHORT STAY SURGERY

DAY CARE PROCEDURES PATIENT IS DISCHARGED WITHIN A DAY

ADMISSION TO DISCHARGE INTERVAL

24 - 72 HOURS

OFFICE THERAPEUTICS
DAY CARE SURGERY

CONS 1) NEEDS SPECIALIZED TRAINING 2)MINIMALLY INVASIVE EQUIPMENT 3) CUTTING EDGE TECHNOLOGY

OFFICE DAY CARE

4) HEAVY INITIAL OUTLAY 5) RISKY IN LOW RESOURCE SETUP 6) INADEQUATE SURVEILLANCE

7) Need for a responsible person to oversee the day care patient at home for 24-48 hours. FALLBACK 8) Surgery restricted to experienced seniors; less opportunity for juniors.

9) Extra work for the busy GP whose patients keep ringing in the postop period 10) Less cost effective when the unit deals with less complex cases on a BUSY GP day basis

PROS
1)Minimal invasion 2)Reduced pain 3)Less disruption of patients personal lives 4)Minimal anaesthesia 5)Early recovery in home with family

 6) Less nosocomial infections

7) Reduced in-patient waiting lists

8) Increased availability of busy hospital beds

9) Reduced costs

10) Financially lucrative for doctor

WHAT PATIENTS WANT.

I WANT TO GO

HOME !!!

I WANT TO GO

HOME !!!

I DONT WANT TO STAND IN LINE ANYMORE!

HOW TO CUT COSTS ???

MINIMAL ANESTHESIA

ZERO PAIN

WHAT DOCTORS WANT

UP TO DATE OFFICE/HOSPITAL

TECH KNOWHOW

MONEY

OFFICE DAY CARE IS USER FRIENDLY PATIENT FRIENDLY

OFFICE DAY CARE THERAPEUTIC PROCEDURES FORM A HEALTH CARE DELIVERY MODULE WHICH SUITS PATIENT & DOCTOR ALIKE

DAY CARE SURGERY IS

MONEY MATTERS

COST EFFECTIVE
CANCELLED

Spares inpatient beds

Less staff
No waiting More output

MONEY MATTERS - AND HOW!!

USA SAVING OF 15-30% UK SAVING OF 40% INDIA COST OF PATIENT OCCUPYING BED IN CENTRAL & GOVT. HOSPITALS IS RS.800-900 PER DAY, RS1000 PER DAY IN HIGHER CENTRES LIKE PGIMER CHANDIGARH

OFFICE DAY CARE GYNAECOLOGY

THERAPEUTIC PROCEDURES
MARCH 2011 FEBRUARY 2012

OFFICE DAYCARE GYNAE IN MY SET-UP

1)Treatment of abnormal uterine bleeding 2)Sterilization 3)Removal of endometrial polyps 4)Removal of submucous leiomyomas 5)Removal of adhesions caused by infections or past surgeries 6)Insertion & Removal of IUCD 7)Cervical Biopsy

D&C

MYOMA

DUB

POC

OFFICE HYSTEROSCOPE OPERATIVE

OFFICE HYSTEROSCOPY
1) Direct Visualization
2) Directed biopsy

DILATATION & CURETTAGE

Blind Procedure

60% <Cavity curetted 38% <1/4 cavity 3) 98% sensitive in DUB 65% - 89% sensitive endometrial ca 4) 90% sensitive in May completely miss a submucous submucous myoma or myoma, endometrial polyp endometrial polyp

OFFICE HYSTEROSCOPY
Office procedure Smaller endoscopes(3-5 mmOD) used Atraumatic introduction. No previous cervical dilatation. Little or no anesthesia needed.

OFFICE HYSTEROSCOPY

Earlier it was only diagnostic. Now newer endoscopes (4 - 5 mm OD) permit continuous flow of a low viscosity fluid via a small, built-in channel. Allow minor operative procedures as office procedures

7MM OD operative hysteroscopes can be used for office procedures. Their channels permit manipulation of sturdy, rigid, and semirigid operating instruments. Cervical dilatation with Misoprost/Laminaria / Hegar Paracervical block/ Regional A

OPERATIVE HYSTEROSCOPE - WHAT A SCOPE !

ENDOMETRIAL ABLATION
Endometrial ablation techniques are recommended for menorrhagic symptoms which have not resolved with pharmacological intervention (NICE GUIDELINES 2007)

ENDOMETRIAL ABLATION
OFFICE T/T FOR DUB LASER THERMAL ABLATION THERMAL ENDOMETRIAL ABLATION 1) NORMAL SALINE (HOT FREE FLUID) 2) BALLOON FILLED SALINE AT 85*C 3) RADIOFREQUENCY ELECTRICITY USING RESECTOSCOPE FREEZING MICROWAVE

HTA
This device circulates heated saline which burns the lining of the uterus. This will stop or significantly decrease HMB. 94% of patients reported improvement.

BALLOON ABLATION
Thermachoice III balloon is filled with heated fluid to destroy the uterine lining.

NOVASURE

 In Novasure a mesh is put into the cavity and the lining is destroyed by applying electrical energy to the mesh. The PRE NOVASURE heat will damage the adjacent endometrium. 87% successful in treating HMB
POST NOVASURE

OFFICE HYSTEROSCOPY - POLYPECTOMY

Endometrial polyp with atypical vessel structure

OFFICE HYSTEROSCOPY USED IN T/T OF STAGE 1A ENDOMETRIAL CA

Adenocarcinoma of the endometrium with an irregular surface with necrosis and dilated

tortuous vessels

ADHESIOLYSIS
EUROPEAN SOCIETY FOR GYNAECOLOGIC ENDOSCOPY ESGE ADVOCATES HYSTEROSCOPIC ADHESIOLYSIS IN

STAGE 1 ADHESIONS

THIN FILMY ADHESIONS EASILY RUPTURED BY HYSTEROSCOPY SHEATH ALONE, CORNUA NORMAL UPPER UTERINE CAVITY NORMAL

OFFICE HYSTEROSCOPY ADHESIOLYSIS IN ESGE STAGE 1 ADHESIONS

FRAGILE GRADE I IUAs (ESGE CLASSIFICATION)

ESGE CLASSIFICATION OF SUBMUCOUS MYOMAS

DEGREE OF INTRAMURAL EXTENSION

TYPE 0 NONE

TYPE I <50%

TYPE II >50%

OFFICE HYSTEROSCOPY - MYOMECTOMY

Submucous myoma without intramural extension (type 0, ESGE classification

MGMT. OF MYOMA
Submucous myomas without or with only limited intramural extension should be treated with endoresection as soon as the diagnosis has been made, as with increasing size, endoresection will become more difficult

OFFICE DAYCARE GYNAE MARCH 2011 TO FEBRUARY 2012

D&C POLYPECTOMY HYSTEROSCOPIC ADHESIOLYSIS * HYSTEROSCOPIC ABLATION * HYSTEROSCOPIC POLYPECTOMY * HYSTEROSCOPIC* RESECTION MYOMA

108 5 2 4

1
2

*workshop

LAPAROSCOPIC STERILIZATION A DAY CARE PROCEDURE

728 lap ligations in BCCL CAMPS & CHD in March 2011 Feb 2012

ESSURE PROCEDURE - TUBAL STERILIZATION OF TOMORROW

ESSURE PERMANENT STERILIZATION
WORLDS 1st ESSURE ON NOV 4, 2002 PERFORMED IN OFFICE SETTING NO ANAESTHESIA NO INCISION 10-15 MINUTES

ESSURE

SEP 26, 2009 !!! India's First Essure Insertion by an Indo-Israeli Team on an Indian patient

ESSURE

Optimal device positioning when 3-8 coils of the device are visible within the uterine cavity at hysteroscopy

SIMILARLY THE LEFT TUBE IS OCCLUDED BY AN ESSURE COIL

IUD - LOST & FOUND !!!

A fragmented IUD partially embedded in the uterine wall. Copper-7 IUD with filament is in the uterine fundus.

IUD in the Uterine Cavity Found at Hysteroscopy

Removal of embedded Copper T

CONTROL OF INTRAUTERINE ENDOSURGERY The results of intrauterine endosurgery should always be evaluated with a 2 or 3 months after the procedure : 1)To assess endometrial healing 2)To exclude residual pathology 3)To remove adhesions, if present.

CONTRAINDICATIONS

ID REGNANCY ROFUSE BLEEDING REVIOUS INFECTION

OFFICE PROCEDURES

CU T 380

MULTILOAD 375

MIRENA

LEVONORGESTREL RELEASING INTRAUTERINE SYSTEM MIRENA

CONTRACEPTIVE TREATS HMB/MENORRHAGIA USED WITH ERT TO PROTECT AGAINST ENDOMETRIAL HYPERPLASIA INSERTED ON a) DAY 1-7 b)JUST AFTER 1st TRIMESTER ABORTION C) 6-12 WKS POSTPARTUM

20ug / day

IUCDs MARCH 2011 FEB 2012

COPPER T 380A 128 MULTILOAD 375 17 MULTILOAD 250 3 MIRENA 2 REMOVAL OF IUD 20 HYSTEROSCOPIC 1 REMOVAL

LEEP

The loop electrosurgical excision procedure (LEEP) uses a thin, low-voltage electrified wire loop to cut out abnormal tissue in the cervix

 LEEP

LEEP

EXCISION ADVANTAGE SIMULTANEOUSLY DIAGNOSTIC & THERAPEUTIC OPERATION FOR CIN DURING OUTPATIENT VISIT

LOOP ELECTROSURGICAL

ELECTROEXCISION

SMALL WIRE LOOP (0.5MM) HIGH POWER (35-55 WATTS) WATER-LADEN TISSUE CUT BY STEAM ENVELOPE FORMED AT WIRE LOOP TISSUE INTERFACE

 ELECTROFULGURATION

LEEP

HAEMOSTASIS ACHIEVED BY ELECTROCAUTERY BALL ELECTRODE (5MM) LOW POWER (50 W) THERMAL DAMAGE FAILURE RATE 8%-39% OVERALL RECURRENCE RATE 27.5% (LIVASY ET AL) 3 CASES OF LEEP IN WORKSHOP ON CIN 47 CASES OF CERVICAL WEDGE BIOPSY ALL PATIENTS DISCHARGED WITHIN 24 HOURS

OFFICE DAYCARE SURGERY WITH STATE OF THE ART FACILITIES