Three Thousand Cases of Office Hysteroscopy: See and Treat an Indian Experience.

STUDY OBJECTIVE: Assessment of feasibility of office hysteroscopy in Indian setting. DESIGN: Retrospective study design. SETTING: Tertiary care centre: Galaxy care Hospital, Pune, India. PATIENTS: Three thousand consecutive women undergoing office hysteroscopy between 2012 and May 2018. INTERVENTIONS: Office hysteroscopy 2200 cases (2012-2017) with Bettocchi 2.9 scope and Hamou endomat. Eight hundred cases (2017-2018) with Bettocchi 1.9 scope and EASI. Normal saline was used as distension medium. With Hamou endomat, settings have drip rate of 200 ml/min with irrigation pressure of 75 mmHg and suction bar 0.15. With EASI, settings were for Bettocchi 4 (1.9 mm) and Bettocchi 5 (2.9 mm) scope with 45 mmHg. Hysteroscopies were carried out by an experienced operator trained in office hysteroscopy. All hysteroscopies were done in early proliferative phase (4th-11th day). MAIN OUTCOME MEASURES: Success, failure and complication rates. RESULTS: Hysteroscopies were successfully performed in nearly 98.66% of cases with 4 patients requiring a two-step procedure due to > 3 cm pathology. One thousand eight hundred eight (62.2%) were diagnostic hysteroscopies, while operative hysteroscopies were performed in one thousand one hundred twenty (37.8%). One patient (1/3000) had a vasovagal attack. CONCLUSIONS: In outpatient setting, counselling the patient for office hysteroscopy played an important role to overcome pain and anxiety, in addition to low pressure, continuous flow irrigation and vaginoscopic approach. Traditional resectoscopic surgeries should be reserved for challenging cases (i.e. endometrial ablation) or for certain pathologies (myomas > 2.0 cm, broad-base, large-size polyps). Recent advances in technique and instrumentation facilitate this approach and might encourage greater adoption by the gynaecology community. With the right approach, technique and setup, office hysteroscopy is feasible with favourable outcomes.

Indian experience of robotics in gynecology.

AIMS: To study the role of robotics in various gynaecological cases, benign and malignant. MATERIALS AND METHODS: A total number of 80 cases have been analyzed. Operative time, estimated blood loss, hospital stay, complications, conversion rates have been retrospectively studied in all cases. Nodal yield, vaginal margin and paracervical clearance have been studied in all malignant cases. This investigation was conducted at a single minimal access surgery institute. RESULTS: Of total 80 cases, 29 were benign and 51 were malignant cases. In benign cases, total robotic hysterectomies were 24, 2 cases of tubotuboplasty, 1 case of endometriotic cyst excision, 1 case of metroplasty and 1 case of rectovaginal fistula. In 51 cases, 37 of radical hysterectomy, 9 exenterations and 6 were parametrectomy. In benign cases, mean operative time was 80 min, estimated blood loss was 20 ml, mean hospital stay was for 1 day, no major complications and no conversions. In malignant cases, mean operative time was 122 min, estimated blood loss was 50-100ml, 2 cases of ureteric fistulas and no conversions, nodal yield was 30, vaginal margin was 2.5-3.8 cm and para cervical clearance was 3-3.5 cm. CONCLUSIONS: Ours is the largest series of robotic surgery in gynecological procedures in India. Benign and malignant cases were addressed robotically showing the feasibility.

Understanding the pelvic anatomy.

The pelvic anatomy is constant, with few variations. It has a distinct appearance when observed using the 2-dimensional laparoscope. Thus it is important to master the laparoscopic anatomy and use this knowledge to perform better surgery. The laparoscope offers better vision in a narrow space and thus helps better understanding of the anatomy than what can be seen during open surgery. The objectives of this video are to enable the observer to become familiar with the surgical anatomy, to apply anatomical knowledge to develop fine surgical skills, and to address the myths of open surgical anatomy. The lucid graphics, images, and commentary will enable easy understanding of the pelvic anatomy.

Laparoscopic transvesical approach for vesicovaginal fistula repair.

STUDY OBJECTIVE: To access the technical feasibility of performing laparoscopic repair of vesicovaginal fistula. MATERIAL AND METHODS: We attempted a laparoscopic repair of vesicovaginal fistula in five women with a history of urinary leakage via the vagina after vaginal hysterectomy. Five pelvic ports were used. The surgical procedure was performed using the same principles as for open surgery, i.e., separation of the vaginal wall from the bladder wall, repair of the fistula, and interposition of the omentum. RESULTS: There was early recovery of the patients in terms of continence, with less chance of recurrence. Results were comparable to those with the vaginal approach. CONCLUSION: The use of minimally invasive surgery for vesicovaginal fistula repair helps to ease the suturing deep in the pelvis, and the magnification facilitates good identification of tissues planes and thus better mobilization of the vaginal and bladder walls and decreases postoperative morbidity.

Robotic oncological surgery: our initial experience of 164 cases.

Minimal access surgery is an accepted modality for benign surgery. Despite the advantages of laparoscopy, its acceptance in oncology is slow. Robotic surgery is an emerging field with rapid acceptance because of the 3-dimensional image, dexterity of instruments and autonomy of camera control. We report here our experience of using the Da Vinci robot for various oncological procedures. We performed 164 oncological surgeries from November 2009 to June 2011. The surgeries performed included thoracic, colorectal, hepatobiliary, gynaecological and urological system. We could complete 163 cases robotically. We share our initial experience of robotic surgery in oncology with comparison with other series.

Preservation of autonomic nerves in laparoscopic total radical hysterectomy.

OBJECTIVES: The aim of this study was to evaluate the feasibility, complications, margin status, and functional outcome (on urinary and sexual functions) of nerve-sparing radical hysterectomy (NSRH) performed laparoscopically. METHODS: Patients with cervical carcinoma of stage Ia2 and Ib1 underwent laparoscopic NSRH along with pelvic lymphadenectomy. We performed the technique in simple comprehensible steps with anatomic delineation of the autonomic nerves and selective cutting of the uterine and cervical branches. RESULTS: Laparoscopic NSRH was feasible in 85.7% of patients. Mean operative time was 160 minutes and all 7 patients had clear surgical margins. There were no complications and no blood transfusions were required. The median hospital stay was 3 days. The median return time for normal bladder function was 2 days and none of them required catheterization beyond 2 weeks. The mean residual urine volume was <50 mL. Urodynamic studies performed at 3 weeks after the operation showed no impairment of maximum flow rate (maximal flow rate: 20 ± 2 mL). The postoperative results of sexual dysfunction were inconclusive. CONCLUSION: Understanding this technique and the knowledge of laparoscopic anatomy of pelvic autonomic nerves is important in both benign and malignant pelvic surgeries. These preliminary results indicate that nerve sparing is easier done laparoscopically and its results are comparable to that of conventional laparoscopic radical hysterectomy in terms of lateral margin status and lymph node yield. Whether quality of life can be benefited by L-NRSH technique and its long-term oncological sequelae need further evaluation.

Robotic radical hysterectomy: applying principles of the laparoscopic Pune technique.

Minimal access surgery is an accepted treatment modality in cervical cancer. Despite the advantages of laparoscopy, the surgical technique of laparoscopic radical hysterectomy is not very commonly performed. Robotic surgery is an emerging field with rapid acceptance because of the 3-dimensional image, dexterity of instruments and autonomy of camera control. We report here our technique of performing robotic radical hysterectomy using the Da Vinci surgical system. Twenty patients with cervical cancer stage 1a1-1b2 underwent robotic radical hysterectomy since December 2009. The median duration of surgery was 122 min, and the average blood loss was 100 ml. Postoperative ureteric fistulas occurred in two patients and were managed by ureteric stenting. The median lymph node retrieval was 30 nodes (range 18-38). We compared our robotic results with our published data on laparoscopic radical hysterectomy (Pune technique). We were able to complete all 20 cases robotically with minimal morbidity, and could duplicate our laparoscopic steps in robotic radical hysterectomy.

Laparoscopic total radical hysterectomy by the Pune technique: our experience of 248 cases.

STUDY OBJECTIVE: To describe our experience and technique of total laparoscopic radical hysterectomy with pelvic lymphadenectomy, which is the largest single- institution study. DESIGN: Retrospective, nonrandomized study (Canadian Task Force classification II-2). SETTING: Private hospital. PATIENTS: Two hundred forty-eight patients with International Federation of Gynecology and Obstetrics stage IA2 (n = 32) and IB1 (n = 216) of cancer of the cervix. INTERVENTION: Total laparoscopic type III radical hysterectomy with bilateral pelvic lymphadenectomy was done. Simple repetitive steps were used to perform this surgery and develop an easily replicable technique. Harmonic Shears, bipolar coagulation, and vascular clips were used. Resection of the cardinal and uterosacral ligaments was performed with LigaSure (LigaSure Vessel Sealing System; Valleylab, Tyco Healthcare, Boulder, CO) or the Harmonic Shears (Ethicon Endo-Surgery, Inc., Cincinnati, OH). Pelvic lymph node dissection was done. MEASUREMENTS AND MAIN RESULTS: Histopathologically, there were 183 (73%) cases of squamous carcinoma, 52 (20%) adenocarcinomas, and 13 (5%) adenosquamous carcinomas. Four patients needing anterior exenteration because of bladder involvement were excluded from data analyses. The operation was performed entirely by laparoscopy in all patients and by the same surgical team. The patients' median age was 61 years. The median operative time was 92 minutes (range 65-120 minutes). The median number of resected pelvic nodes was 18. The median blood loss was 165 mL. The median length of stay was 3 days. All 15 intraoperative complications were tackled laparoscopically. No patients were converted to the open technique. There were no deaths in our series. Seventeen patients had complications within 2 months of surgery. Seven patients had recurrences after a median follow-up of 36 months. CONCLUSION: Our technique of total laparoscopic radical hysterectomy, developed over 248 cases, can be performed safely. It is an easily replicable technique. This procedure reduces the morbidity associated with abdominal radical hysterectomy. All of the complications can also be tackled laparoscopically, which does not further add to the morbidity.