ISGE June 2003 Volume 9 Issue 2

Editor: Togas Tulandi, MD
Editorial Board: Alan Alperstein, Michelle Nisolle, Robert O’Shea, Kazuo Satoh 

Inside this Issue:

• Editor’s Corner
• President's Message
• Vice-President's Message
• Laparoscopic hysterectomy for uterine myoma

Editor's Corner
Togas Tulandi, MD

Professional Etiquette
Suppose for instance, that last year, the chair of an organizing committee invites you to lecture at a meeting. You accept. You then assist this chair in organizing the program by inviting other speakers to the meeting. Two months before the meeting, the invitation for you to speak is withdrawn. You are told that this is due to the excessive number of outstanding speakers. You feel that a professional courtesy was simply forgotten. Your colleague, a medical professional, has largely implied that you are not one of the outstanding speakers. 

The following passage is excerpted from a non-medical organization. 

"Once an invitation has been issued to a player, it must not be withdrawn provided the player accepts the invitation by the reply date. If an event is cancelled or postponed, the organizers shall provide compensation." 

Etiquette is paramount in life. Both medical and non-medical organizations, and their officers should follow this professional courtesy. This will allow all of us to live in a harmonious relationship with each other. 

We look forward to seeing you at the ISGE Regional Meeting, on October 12-14, 2003 in Toulouse, France and at the 2004 ISGE Congress, April 8-11, 2004 in Kuala Lumpur, Malaysia. The theme of the Annual Congress is "Gynaecologic Endoscopy: Bringing the message home". 

You will notice that ISGE NEWS has a better appearance. This has been made possible by a donation from Storz Endoscopy. On behalf of the Society, I express my great appreciation to Ms. Sybill Storz and her staff. 

In this issue, you can read the messages from 500 words). We like to keep you up to date with the latest developments around the world.

Togas Tulandi MD
Editor

President’s Message
Jacques Donnez, MD

Dear Colleagues,

It is a privilege and a great honor for me to assume the presidency of the ISGE. This is my first message as President. I plan to communicate with you frequently, through this Newsletter and by electronic means. 

I am pleased to report that the Annual Congress in Cancun, which was organized and presided by Dr. Alberto Valero, proved to be a big success. In addition to faculty and invited speakers, there were 350 paying registered participants. It was impressive to note that almost all of the speakers in the program traveled to Cancun despite the prevailing economical and political adversities.

With this, my first message I wish to express my sincere thanks to all the speakers and Board members who were present at the Congress for their important contributions during the meeting and the pre-congress courses.

At the Board Meeting, Harry Reich was elected Vice-President. During same Board meeting it was also agreed that henceforth the Vice-President would assume the task of Chair of the Scientific Committee.

Ray Valle remains the Treasurer and Victor Gomel continues as Honorary Secretary. I wish to acknowledge their work and dedication during the course of the last two years and especially during the last year, which was a difficult and critical period of the Society.

I have asked Victor Gomel henceforth to function as executive Secretary. He will closely collaborate with Kees Wamsteker, Consultant of the ISGE, and Simone Wamsteker, during the next two years, the transitional period that will lead the Society to the acquisition of professional management.

My sincere thanks to the previous two past Presidents, Lip Kee Yap and Jack Sciarra. I look forward to their continuing contributions.

I would like to thank John Newton, chairman of the Congress-Coordination for his innovative suggestions for the forthcoming meetings in Kuala Lumpur, Cape Town, Osaka, Vancouver, Beijing, etc …

Many thanks to Togas Tulandi, Editor of the ISGE News. He has worked single-handedly to produce the News. We will ensure that he will have an active Editorial Board to provide him with the support that he deserves.

I strongly believe that the ISGE plays an important role internationally. We have a democratic and open structure. We serve every continent of the World. I recognize that we must strive to have greater commitment by the members of the Board, greater involvement by individual members
in the running of the Society; that we must improve the effectiveness of our Scientific Committee and its collaboration with the local Congress organizers.

Please mark in your calendars the following ISGE events:

• The next regional meeting in Toulouse, France, October 11-13, 2003, organized by Denis Querleu and devoted to gynecologic

• and endoscopy. The most eminent individuals working in this field will attend this meeting.
• The next Annual Congress will be in Kuala Lumpur, April 7-11, 2004. We are planning a very exciting program for this wonderful City.

Finally, do not hesitate to contact me with your ideas, suggestions and concerns. We, the President and Executive, are here to serve you the members, and improve the quality and efficiency of our Society.

With my best regards,
J. Donnez
President ISGE

Message from the Vice President &
Chair of Scientific Committee
Harry Reich, MD

Let's get it on! We have to spread laparoscopic surgery until it is the standard of care worldwide. After all, it has been shown that compared to laparotomy, laparoscopic surgery has many advantages including less adhesion formation.

I have been involved with laparoscopy since its beginnings in the United States. Initially, there were very few of us doing advanced surgery by laparoscopy. The first session on advanced laparoscopic surgery at a major meeting took place at the Annual Meeting of the American Association for Gynecologic Laparoscopists (AAGL) in 1985. This session changed the gynecologists’ perception on laparoscopy. Electrosurgery also plays an important role in laparoscopy. One of the masters of electrosurgery is Roger Odell. His presentation at the ISGE meeting in 1990 educated others and me about electrosurgery.

My learning curve was from 1975 to 1983. Ever since, 99% of all of my operations were done by laparoscopy. New techniques are always met with criticisms. This is reflected in the rejection of my manuscript on the technique of oophorectomy with bipolar coagulation. It appears that the editor of the journal felt that the technique was too dangerous for most surgeons to attempt.

I believe that most participants at our meetings want to learn procedures they can do in the future. Accordingly, I would like to provide this knowledge in our future meetings. Our meetings should be more procedure orientated. We will also give emotional and possibly legal support to laparoscopic surgeons who encounter complications. Let's teach, support our members, and spread the message that major abdominal incisions are rarely necessary.

Harry Reich

Laparoscopic hysterectomy for uterine myoma
Jean-Bernard Dubuisson, Sandrine Jacob, Arnaud Fauconnier,Valrie Courtois, Charles Chapron

The first laparoscopic hysterectomy was reported by Reich. Over the past ten years this technique has evolved considerably. Our preference is total laparoscopic hysterectomy, where all steps including suturing of the vaginal cuff are performed by laparoscopy. Otherwise, we perform LAVH (laparoscopically assisted vaginal hysterectomy) or supracervical hysterectomy. 

1) Laparoscopically assisted hysterectomy 

Here, the laparoscopic part can be diagnostic or operative.

Laparoscopy for diagnosis
The laparoscopic part is for diagnostic only. The purpose is to evaluate the feasibility of performing hysterectomy vaginally or by laparotomy. History and clinical examination do not provide information about the presence and extent of endometriosis and/or adhesions.

Operative Laparoscopy
There are two types of operative laparoscopy in conjunction with hysterectomy. It can be a preparatory procedure or an integral part of the hysterectomy operation.

2) Total laparoscopic hysterectomy
Total laparoscopic hysterectomy is an alternative to laparotomy or when it promises a less complicated operation than vaginal  hysterectomy. It is done when there is a need for adnexectomy, presence of endometriosis, and when vaginal access is impossible.

Operative techniqueLaparoscopic adnexectomy
The first and absolutely crucial step is to locate the ureter. Dissection of the ureter is required only in cases where it cannot be located beneath the peritoneum usually due to severe endometriosis related adhesions. In the presence of adhesions, they are first liberated. The adnexa is excised by coagulating and dividing the infundibulopelvic ligament, followed by the same procedure on the mesosalpinx until the uterus is reached.

Hysterectomy via laparoscopy:
The Fallopian tube is first coagulated and divided. A similar procedure is done on the round and ovarian ligaments. The peritoneal layers of the broad ligament are incised vertically, parallel to the plane of the uterus.

The next step is separating the bladder from the cervix. This is performed by incising the vesicouterine peritoneum and detaching it from the uterus until the anterior fornix is reached. Extra care is required if there is a past history of cesarean section. If detachment of the bladder is difficult, injury to the bladder should be ruled out. This is done by instilling 300 ml of methylene blue solution into the bladder and make sure that there is no leakage from the bladder.

The uterine vessels are coagulated by bipolar coagulation forceps introduced ipsilateraly. This gives a perpendicular approach to the rising portion of the uterine artery, along the uterus. Section of the uterine artery must proceed gradually, with additional coagulation if required.

The cardinal ligament is then coagulated and dissected until the lateral wall of the vagina is reached. The uterosacral ligaments are treated in the same fashion by pushing the uterus firmly upwards. This is to avoid injury to the ureter.

The last step is to open the vagina at the anterior fornix. It is facilitated by insertion a sponge inside the anterior vaginal fornix. Leakage of CO2 via the vagina can be prevented by a large intra-vaginal sponge, or an intrauterine manipulator.  Complete circular colpotomy can be performed
and the uterus is extracted vaginally.

Laparoscopic hysterectomy for uterine myoma
Jean-Bernard Dubuisson, Sandrine Jacob, Arnaud Fauconnier,Valrie Courtois, Charles Chapron (continued)

Vaginal phase of the hysterectomy
Closing of the vaginal opening can be done vaginally and a drain is left in place for 24 hours. Prior to completion of a laparoscopic hysterectomy,
the laparoscopic examination is repeated to ascertain that hemostasis is complete. 

3) Laparoscopic supracervical hysterectomy
This technique was first described by Donnez. Our indications are:

• very large uterus with multiple fibroids and a normal cervix, often in a nulliparous patient
• past history of cesarean section with severe bladder adhesions to the cervix
• patient’s desire to retain the cervix
• multiple submucosal myomas
• failure of endometrial ablation

Operative technique
The procedure is similar to that of total hysterectomy. The cervix is excised with a unipolar hook or scissors after coagulation and section of the uterine vessels. Bipolar coagulation is used to ensure hemostasis of the cervical stump. Sutures may be necessary when hemostasis is incomplete. Extraction of the tissue is performed using a morcellator or through a posterior colpotomy.

Complications

Urologic complication

• Bladder injury: It is not unique to laparoscopic procedure. The incidence is 1.3%. Certain elements in the surgical or medical past history (pelvic infections, endometriosis) are risk factors. Immediate repair can be done by laparoscopy.
• Vesico-vaginal fistula: There have been 5 cases reported in the literature. Their prevention depends on cautious coagulation at the vicinity of the bladder and meticulous suturing of the vaginal stump.
• Ureter complications: It may involve stenosis, direct injury or uretero-vaginal fistula. The incidence of these complications is between 0.3 and 0.7%. This type complication is often discovered late, and requiring reoperation by laparotomy. Distortion of the anatomy due to endometriosis is one of the risk factors. Identification and dissection of the ureter may prevent this complication.
• Minor urologic complications (urinary infection, hematuria, urine retention) can occur in 2 to 3% of cases. The most common is urinary tract infection. 
• Bowel complications Major bowel complications are rare (0.3 to 0.5%). It is also a complication that is not unique to laparoscopy. 
• Vascular complications Major vessel injuries mainly to deep epigastric vessels occur at a rate of between 0.4% and 0.6%.
• Hemorrhagic complications With laparoscopic hysterectomy, hemorrhage complications requiring transfusion occur in 1.6 to 2.6% of cases. This is less than non-laparoscopic approaches. 
• Infectious complications Most infections are due to urinary tract infections. The incidence is 3 to 5%.
• Thrombo-embolic complications These are rare (0.2%) and are not specific to laparoscopy.
• Neurologic complications These are related to positioning and mainly involved the popliteal sciatic nerve or brachial plexus. The incidence is 0.2%.