The Benefits of Microlaparoscopy

Dr. Hugo Verhoeven:  “I’m Hugo Verhoeven from the Center for Reproductive Medicine in Dusseldorf, Germany.  I’m a member of the Editorial Board of the OBGYN.net, and I’m reporting from the 9^th Annual meeting of the Society of Laparoendoscopic Surgeons in Orlando, Florida.  It is a great honor for me to have the chance to interview today Dr. Radha Syed from Staten Island University in New York.  Dr. Syed is Chairman of the GYN Endoscopy Committee at the Staten Island University Hospital, Staten Island, New York and she is the President of the Richmond Obstetric and Gynecology Associates also in Staten Island, New York.  Radha, thank you very much for giving me the pleasure to do this interview with you.  We’ve known each other for quite a long time and we are both convinced that our patients are requesting more and more minimal invasive surgical procedures.  The topic we’re going to discuss today is the importance of micro-endoscopy for our patients and we’re especially going to talk about the value of micro-laparoscopy and micro-hysteroscopy.  First, let’s go back a little bit in the past.  What is new about micro-hysteroscopy and micro-laparoscopy?  What are we exactly talking about?”

Dr. Radha Syed:  “Hugo, I’d like to thank you for the honor of the interview.  I’m very honored that you have chosen me as part of this interviewing process.  Firstly, I’d like to say that I have been doing macro-laparoscopy, as I call it, which is the traditional laparoscopy with a traditional laparoscope, which is usually 10-12 mm in size.  From 1995 there has been on the market micro-laparoscopes which measured anywhere from 1-1.9 mm and now for better view there’s the 3 mm scope in the micro-laparoscopy setups.  I am  using the 1.9 mm scope, which has been manufactured initially by the Imagyn Company, which was bought over by the U.S. Surgical Company, and they have marketed it as a gold mini-laparoscope.  Initially, the Imagyn Company also came up with the micro-hysteroscope to view the internal cavity of the uterus and this has been traditionally done with a  2.7-5 mm scopes and now  a  1.6mm scope. With the exterior sheath, which allows the fluid irrigation inside the uterine cavity,  and additionally acts as an operative channel , the micro-hysteroscope measures  about 3.6 mm.  The advantage of this is, it is well tolerated by the patient, and postoperatively they have less pain and complications.  The reason for that is that there is less suturing involved and because there’s less cutting and less suturing, the complications as a result of any incision in the body, namely hernia and infection, are all significantly reduced.  Additionally, the recovery and time to return to work as well as postoperative pain are reduced . In many areas in the United States and Canada they’re using the micro-laparoscope without general anesthesia and they’re able to allow the patients to visualize their own internal cavities. This allows them to have more understanding of what is happening inside the body  and the reason for the pain .  This is called “conscious pain mapping”. Moreover, with a micro-hysteroscope which is used to view the uterine cavity for the most common complaint amongst women, which is abnormal uterine bleeding, one is able to visualize the intrauterine cavity without pain because it’s a very, very tiny scope .This is done easily in the office without anesthesia.  With the video magnification, we are  able to visualize polyps or small fibroids or other conditions which may be quite amenable to treatment right within the office.  That prevents the patient from taking off from work, having to undergo the risks of anesthesia, and also the expense of going into the hospital.  With all this,  the patient is quite comfortable in viewing her condition and is able to cooperate with the procedure to boot!”

Dr. Hugo Verhoeven:  “You’ve now given us a very nice overview.  Let’s go a little bit more in detail first to the micro-laparoscopy.  It is our experience that there is practically no procedure thinkable that would not be possible to be performed by a laparoscope except maybe only a C-section but all the rest are technically possible with traditional or standard laparoscopic techniques.  I guess there are some restrictions for doing all those procedures with a micro-laparoscopes.  Could you give us some criteria of exclusion . What surgical procedures you cannot do with the micro-laparoscope that you could be able to perform with the traditional laparoscopes?”

Dr. Radha Syed:  “Hugo, that’s an excellent question and it’s something which is just evolving as more and more people not only in the gynecological specialty but also in surgery and urology are turning to.  The most important factor is,  because it’s a very tiny scope,  there are problems with optics and, therefore, the light diffusion into the cavity .Visualization and visual acuity are both restricted and this brings to point something that we need to develop and that is, skill and dexterity, which are very important. Therefore, there is a learning curve with the use of this particular scope and also there’s a problem with the fact that many specialties are not used to immediately converting to a micro-laparoscope.  As you know, general surgeons adopted laparoscopy quite late in the picture, only from 1990. So, for them to turn from open laparotomy to macro-laparoscopy, which is a 10 mm scope and now to a 2 mm scope is very difficult.  Many times they have problems with visualization but I do know that even gynecologists have the same problem and there are people who are slowly converting.  For example, in general surgery cholecystectomy, which is traditionally being performed now in the United States almost exclusively laparoscopically,  is being performed with a micro-laparoscope, also appendectomy and other smaller procedures like incisional hernia but major procedures are still a problem .  Similarly, in gynecology there’s a problem in doing many  prolonged surgeries because it can be very fatiguing to the eye .  For example, there are people who are doing hysterectomies with micro-laparoscopy and almost the entire process is being done that way.  Many sophisticated procedures like tubal surgery or tubal anastomosis which is pretty fatiguing to the eye using very tiny needles is also being performed by surgeons like Charles Koh in Milwaukee but I don’t think it’s possible for the general gynecologists because it requires a lot of training and the training also involves getting expensive equipment.  Storz has produced an exceptional video magnification and exceptional optics in micro-laparoscopy of 3 mm size and also instrumentation, which are optimal to perform these sophisticated procedures.  There are limitations but I think there is a tremendous move in the medical field to satisfy patient demands for minimally invasive surgery.”

Dr. Hugo Verhoeven:  “This is a very important thing that the patients are requesting minimal invasive procedures and then it cannot bed acceptable for the doctor that he has a lack of training or is not ready to do the financial investment for doing this procedure.  As long as the patient wants a certain procedure, they will go where it’s offered.  So could you confirm that there is no need to use the macro-laparoscopes anymore especially in gynecology and in infertility and that you can do practically all procedures with the micro instruments on the condition that you are well trained and that you are ready to do the investment, is that correct?”

Dr. Radha Syed:  “I think you’re 90% correct, Hugo.  However, there are problems with adaptation of certain technology, for instance, laser technology.  Laser technology is not yet adaptable to a smaller scope; they still need to have a larger scope to allow these lasers to be used.  Additionally, there is other instrumentation, which are required which need to be developed to accommodate smaller instrumentation. For example, there’s no effective bipolar cautery with the 2 mm instrumentation, maybe 3 mm is just coming up at some time. There are also other procedures, for example, which need removal of large masses that cannot be done with a smaller scope like large fibroids, large pelvic masses, and also treatment of malignant conditions that we still need to properly remove lymph nodes through larger portals to prevent portside implants of cancer. Procedures with dense adhesions where we can get into problems without proper overview of the entire abdomen still require a larger scope with better optics.  I think clarity of the area of surgery is still most important.  If you’re not able to see the anatomy properly, you’re unlikely to prevent complications in procedures.”

Dr. Hugo Verhoeven:  “The definition micro is very relative because it could be that what we are calling micro today is macro in 5 five years from now, as we’ll have at that time even smaller devices and even smaller instruments and much better optics and light sources . It is certainly a tendency to always go for smaller and smaller and smaller instruments.  Finally, we should talk a little bit on hysteroscopy because I have the impression that hysteroscopy is neglected especially in Europe.  In my own experience maybe only 1% or 2% of the doctors who are evaluating, for instance, their infertile patients or their patients who are bleeding think about the possibility of hysteroscopy.  In the field of infertility, doctors do not perform an evaluation of the uterine cavity.  If the patient is bleeding, the routine is still to do a D&C but not to look inside and to see what is actually happening into the uterine cavity.  Why is that?  Hysteroscopy is an easy technique and it’s not difficult to learn, why aren’t that many doctors interested in doing this technique?”

Dr. Radha Syed:  “Hugo, you’re totally right.  It’s a neglected field to investigate this very small cavity, called uterus, which gives so many problems to so many millions of women all over the world.  Unfortunately, a D&C or dilatation and curettage of the uterine cavity has found a tremendous place in the field of gynecology, and it’s very difficult to shake that place.  But people are reluctant to do hysteroscopy primarily because of the cervix.  he cervix is painful and difficult to dilate.  When you dilate the cervix, patients  feel dizzy or faint.  Syncope is also one of the problems which forces us to do procedures under anesthesia.  With the dilatation of the cervix, there is often bleeding -and that immediately clouds the vision of the uterine cavity. Overcoming this very small 4 cm passage to the uterine cavity has been a big problem, not only mentally for obstetricians and gynecologists all over the world but also physically. As we come towards micro-hysteroscopy I think that we have really conquered that area very nicely and with more and more people getting trained, one day we will have the ideal conditions to investigate the cavity for the uterine bleeding.”

Dr. Hugo Verhoeven:  “Is it also possible to do major surgical procedures through a micro-hysteroscope?  I’m thinking about ablation of the endometrium, the resection of big myomas, or the resection of a septum - is it also possible with micro-hysteroscopy techniques?”

Dr. Radha Syed:  “Micro-hysteroscopy has leant itself very elegantly to many procedures.  I don’t think we can go to large myomas because it will take too much time.  Up to 2 cm myomas can be easily vaporized using bipolar cautery, which has been produced by a company called Gynecare. They have a product called VersaPoint : a bipolar cautery which vaporizes small lesions effectively.  Temporarily, it has been removed from the market but we hope to get it back in the next few months.  It’s also possible to do endometrial ablation with the same technique of using VersaPoint, however, it will take too long. Therefore, you must resort to macro-hysteroscopy which is between 4.7-8 mm in size .

Dr. Hugo Verhoeven:  “My final question, what is your vision for the future?  What do you expect to be revolutionized in the next few years in the field of endoscopy?”

Dr. Radha Syed:  “I think the revolution has already begun.  I feel miniaturization of endoscopes is happening in all the companies driven by the patient market and patient demands.  Many scopes are coming up with removal of the rod lens and putting the camera right at the tip of the scope. Olympus has already improved the optics tremendously with this technology and removed all the refractive errors which are produced by keeping the camera at the head of the lens.  With this, the next step is that of  miniaturization of those scopes and to improve light diffusion  inside the cavity.  As better visualization takes place and clarity of vision improves, many procedures are made  easier.  I definitely feel that the process of miniaturization of these instruments will enable us to move surgery from the hospital into an outpatient or office setting.”

Dr. Hugo Verhoeven:  “Radha, thank you very much for this interview.  I think it will be very interesting for our listeners.  Again, thank you very much.”