ISGE January 2005 Volume 12

Editor: Togas Tulandi, MD ISGE Secretariat Dr. Bruno van Herendael Italilei, 62, 2000 Antwerp, Belgium, tel 00 32 3 2133750 / fax 00 32 3 2720797 info@isge.be Inside this Issue: Editor's Corner President's Message Laparoscopic Microsurgery: Evolution and Future Letter from the Chairman of the Conference Committee ISGE London 2005 Editor's Corner Togas Tulandi, MD Innovative Technologies Advances in technologies have allowed conduct of many procedures by laparoscopy and hysteroscopy. These are the essence of our specialty. Most new technologies foster improved performance. In business term, they are called sustaining technologies. In fact, most technological advances in an industry are sustaining in nature. Occasionally, disruptive technologies emerge. They offer different values proposition than had been available previously. One example of disruptive technology is laparoscopic hysterectomy. Harry Reich described the technique over a decade ago. Although not in a short term, compared to laparotomy it provides simpler, cheaper, and more convenient surgery. It progresses faster than market demand. Initially, it was available in small markets remote from the mainstream. It is disruptive as it subsequently became fully performance-competitive within the mainstream market against established hysterectomy by laparotomy. Today, we cannot imagine of not performing hysterectomy by laparoscopy. I look forward to more disruptive innovations in gynecologic endoscopy. Our Annual Congress in 2005 and 2006 will be in London, United Kingdom and in Buenos Aries respectively. Ellis Downes and Ricardo Sainz have put together exciting programs. Please save these important dates in your agenda. Currently, the society is looking for bids for 2008 and 2009. In this issue of ISGE NEWS, we are enclosing a bid letter from John Newton, Chairman of the Conference Committee. I welcome Tommaso Falcone and Nutan Jain as members of our editorial board. Togas Tulandi MD Editor President’s Message Jacques Donnez, MD Dear Members, First, I would like to extend my best wishes to you for 2005. May it prove as successful and productive as 2004. Our activities last year included the Annual Congress in Malaysia and the satellite endometriosis meeting in Cape Town, South Africa. The congress was attended by many of our members from Asia and Australia who shared their experiences with those from America, Europe and Africa. The endometriosis meeting was equally successful in Cape Town, one the most beautiful cities in the world. Thank to the organizers, Dr. Chong and Dr. Van der Wat and their organizing committee for their excellent organization. Last year, the Executive Committee of ISGE appointed a new Administrative Director, Dr Bruno Van Herendael, who subsequently set up a new secretariat in Belgium. Our ExCo meets every 4 months and engages in various activities related to our society including the prospect of creating a Federation of Gynecologic Endoscopy. I look forward to seeing you at our Annual Congress in London this spring. Sincerely, J. Donnez President ISGE Laparoscopic Microsurgery: Evolution and Future Dr Nutan Jain Laparoscopic microsurgery is a new and evolving field. It promises to be the wave of future. Benefits of traditional microsurgery, with the help of operating microscope, have been fully accepted, and, are the gold standard. The advent of microsurgical techniques for infertility began with Swolin who proposed the use of magnification and delicate instrumentation for adhesiolysis and neosalpingostomy. Gomel and Winston separately reported on their first series of microsurgical reversals techniques. The researchers began exploring the feasibility of performing true microsurgery through the laparoscope in 1990. The first laparoscopic microsurgical tubal anastomosis was performed in February 1992 using 7-0 and 8-0 nylon with microlaryngoscopic graspers and a modified needle holder. The adaptations and early instrumentation have modified immensely since then. Microsurgery employs two strategies: microsurgical technique and microsuturing. Microsurgical technique is a delicate surgical style that emphasizes the use of fine atraumatic instrumentation, magnification for accurate dissection and reconstruction, intermittent irrigation to avoid desiccation and tissue drying, achieve pinpoint hemostasis, and a precise energy source. The goal is to remove abnormal pathology with as little damage as possible to adjacent normal tissue to encourage better healing and less adhesion formation. Microsuturing involves the use of 6-0 to 10-0 microsutures. Before the advent of laparoscopic approaches, microsurgery was performed via laparotomy. With no alternative access route, the inherent disadvantages of the technique could not be improved upon. Compared to laparoscopy, laparotomy is associated with more adhesion formation. Furthermore, the operating microscope could only be directed vertically downward at the pelvic organs and could not access structures that were deep and beneath organs such as ovaries, tubes, or uterus. Therefore, mobilization frequently had to be performed macroscopically until it was possible to elevate the adnexa for actual microsurgery. Another disadvantage of the operating microscope was limited depth of field and the small field of view. With the development of laparoscopy, the varied angle of approach of the telescope allowed multiple angles of view as well as the ability to look underneath organs. The closed environment and the use of only patient positing and pneumoperitoneum to obtain exposure without retractors or packing are probably responsible for the reduction in de novo adhesion formation. The advantages of laparoscopic or minimal access surgery in terms of patient comfort and recovery are well documented and are additive to the previously mentioned therapeutic advantages. A magnification of 25 to 40 times is essential to identify healthy mucosa and muscularis before anastomosis can be performed. For microsuturing, a magnification at 10 to 15 times is adequate. With use of a three-chip camera available with zoom capability, magnification up to 40 times is achievable. To enhance contrast, some companies have come out with built-in digital enhancement in their cameras or as an add-on unit. Magnification requires a corresponding highresolution monitor to be used. This is achieved by using cameras and monitors capable of 800 lines of resolutions. An 8-0 suture 45 mm in diameter is easily seen using such a video system. Micro instrumentation has allowed laparoscopic microsuturing with precision and ease. It allows two-handed laparoscopic skills for intracorporeal knotting. Extracorporeal techniques for 7-0 and 8-0 sutures are impractical and crude and cause "cutting through" or disruption of tissue. The pool of patients suitable for reproductive surgery is continually decreased with better patient selection. The increasing use of in vitro fertilization is further reducing this pool. The remaining candidates for surgery require the best efforts of the skilled reproductive surgeon. Newer techniques for laparoscopic reversal of sterilization have emerged. The use of a single stitch with or without glue or by macrosuturing has not yielded pregnancy rates comparable with those achieved in open microsurgery. Laparoscopic suturing by using three or four titanium macrostaples to approximate tubal ends over a stent and the use of robotically assisted suturing for microsurgical anastomosis have been reported. The hope to reduce operator time may be hypothetical, and there has not been a direct comparison with laparoscopic microsuturing. The results of large retrospective studies comparing laparoscopy and laparotomy for the management of distal tubal disease seem to be comparable. Laparoscopic microsurgical eversion using 6/0 suture may yield an improved pregnancy rate. Indications for operative laparoscopy will expand as technical feasibility continues to improve by both technological advances and increased surgical dexterity. With the attainment of advanced laparoscopic skills achieved through experience with laparoscopic microsurgery, laparoscopists can transfer this technique into other applications, both within and beyond gynecology. Treatment of diseases such as salpingitis isthmica nodosa and other cornual blocks can now be attempted. It has been possible to perform ureter microdissection and anastomosis, myomectomy repair, and bowel repair using the techniques described herein. Repair of myometrial bed after myoma enucleation is done by repair utilizing three-layer closure. This gives anatomically gratifying results and added strength to the repair to endure stresses of future pregnancy and labor. Laparoscopic management of complications by using microsurgical principles is on the rise. The pelvic ureter can be accurately dissected to the bladder using microsurgical techniques with safety. Peri-ureteral endometriosis is common in cases of deep uterosacral and cul-de-sac endometriosis. Inadvertent ureter injury, which can occur commonly during radical excision of endometriosis, can be readily repaired. It has been possible to perform ureteral anastomosis without difficulty. The literature is full of reports of microsurgical dissection and ureteric repair. Bladder endometriosis can be excised with ureter stents in place to protect the trigone and ureteric orifice. A magnification by the laparoscope provides accuracy. The bladder is repaired using 3/0 Monocryl continuously in two layers using single suture, Small bowel injuries can be closed using 3/0 PDS with a BV1 needle. Repair of the large bowel injuries is practically feasible. The ability to repair by laparoscopy allows confidence in the radical excision of infiltrating endometriosis and extensive enterolysis. It appears that laparoscopic microsurgical tubal repair is applicable for all tubal diseases. We should teach this technique to others. The learning curve is steep, and the technique may not be attainable by all surgeons despite their best efforts. I hope that in the future, reproductive surgeons will become experts in laparoscopic microsurgery and suturing. I specially like this adage. "Today’s empowerment and progress in the use of endoscopic microsuturing will pave the way for tomorrow’s progress". Letter from the Chairman of the Conference Committee Dear Member of ISGE, We are always interested in receiving bid proposals to host Regional Meetings, which are specifically designed to meet the needs of a given country or region, and a bid application to host the Congress, which we hold every year. The Regional Meetings are held in September or October, and last three days. The Congress is held late March or early April, and also lasts for three days. The enclosed bid letter, for those of you who are interested, should be completed and sent to me before 1st March, 2005. The vacancies are: 2008 - A Regional Meeting in Zone A (the Americas) or Zone C (the Far East and Australasia) 2009 - The Congress is due to be held in Zone 1 (the Americas) and bids would be gratefully received. Regional Meetings can be held in the other 2 zones – Zone B (Europe, Middle East and Africa) and Zone C (the Far East and Australasia) I look forward to hearing from you. Yours sincerely, Professor John Newton ~~printer-friendly forms~~ ISGE Congress & Membership Information ISGE Membership Application ISGE Conference Application (Bid Letter) ISGE LONDON 2005 Preparations for the ISGE’s Annual Congress in London are now well underway. The Congress whose theme is ‘Endoscopy for All: Pushing back the Frontiers’ is in an advanced state of planning. The British Society of Gynaecological Endoscopy is excited and honoured to be hosting such a prestigious event. The 4-day of the Congress will be held at London’s Hilton Metropole Hotel situated in Paddington. As a trademark of our endoscopic meetings, the talks will be educating and entertaining. We will have lectures and advices on ‘data capture’, ‘avoiding medico-legal problems’ and ‘introducing innovation’. In addition, we have asked leading endoscopic surgeons to describe unusual cases and challenges that they have experienced. We are particularly delighted that Professor Mettler will deliver the ISGE’s inaugural Kurt Semm Memorial Lecture at the Congress opening ceremony. We have allocated plenty of space for free-communication for all ISGE members to share their work. We are particularly interested in early work so members can share their ideas. We are also hosting a number of National Endoscopic Societies who are holding sessions during the meeting. As is traditional we are hosting Pre-Congress workshops for more detailed discussion and focussed education. These are on the areas of ‘Endometriosis’, ‘Laparoscopic Urogynaecology’ and ‘Hysteroscopic surgery’. These are being held at the Royal College of Obstetrics and Gynaecology in Regents Park, London. We have a complimentary mix of social events to allow us to meet old and new friends including a gala dinner at the world famous Madame Tussauds waxwork museum. Further details about the Congress and registration details can be found at our conference website: www.isge2005.org We very much look forward to welcoming you in London in April 2005! Ellis Downes On behalf of the Local Organising Committee