Transvaginal HydroLaparoscopy

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Dr. Mark Perloe: “One of the exciting things that I’ve seen at the meeting is transvaginal hydrolaparoscopy but some of the physicians are saying that this is nothing more than recycling culdoscopy. Dr. Mark Surrey is here, and I wonder if you could comment on this new procedure and why you think it’s a major advance.”

Dr. Mark Surrey: “That’s a good point, there are some differences. Culdoscopy was abandoned a number of years ago because of the difficulty in initially positioning the patient in the knee-chest position as well as the difficulty in visualizing the pelvic structures utilizing gas insufflation compared to the view that one was able to obtain through the umbilicus by conventional laparoscopy. The differences now with the technique that’s been called transvaginal hydrolaparoscopy are as follows - firstly, the patient is in the modified dorsal lithotomy position, and is, therefore, not uncomfortable without general anesthesia. Secondly, the view is through a small incision that is utilized to the total diameter of 2.5 - 2.7 mm. It’s inserted through a Veress style needle and is performed largely without anesthesia. The visualization because of the improved optics is very good and is done without CO2 gas but rather with saline or Ringer’s lactate, a fluid insufflation media. This enables the surgeon to, firstly, view the reproductive organs in a more natural environment posteriorally without manipulating the fallopian tube and the ovary. One is able to appreciate, I think, the relationship between the distal tube and the ovary which is the critical area for ovum pick-up in fertility patients, probably as good if not better by this technique as one can by traditional laparoscopy involving general anesthesia, CO2 insufflation, and accessory trocars inserted for instrumentation necessary to manipulate the ovary and fallopian tube. So the essential advantages as we see it right now are firstly, it’s a minimally invasive procedure that does not require a general anesthetic. Secondly, it enables a very clear visualization of the part of the reproductive system that is most significant and most predictive in regard to a woman’s fertility, and thirdly, it does so without the use of CO2 gas but rather a warmed saline solution.”

Dr. Mark Perloe: “The obvious application is for patients who are undergoing an infertility evaluation. Do you find that the ability to perform this in the office will allow an earlier evaluation of the tubal status and enhance your ability to develop an appropriate treatment plan?”

Dr. Mark Surrey: “Yes, we do. That’s been shown to be the case over the past year since it’s been utilized in some of the centers in Western Europe. In this country, I think, it’s even got a broader application from the perspective of the time, as well as the money that it may save. For example, our controlled ovarian stimulation involving the use of gonadotropins is a relatively expensive proposition to undergo. In our practice, a full 30%-40% of our patients with unexplained infertility will probably have some pathologic condition such as endometriosis or adhesions that will make the patient infertile despite the utilization of these medications. So I think, it’s to the patient’s advantage and to the physician’s advantage to be able to have a procedure like this, whereby before taking expensive medications, one can assess the ability of the tubo-ovarian hiatus to function properly so that we’re at least assured that it’s possible for the medical treatment to be effective.”

Dr. Mark Perloe: “I think that brings up a good point, you mentioned the diagnosis of endometriosis and despite the Endo-Can study last year, there’s still some controversy about the role of treatment in minimal endometriosis patients in regards to their fertility status. How would you approach the patient who you’re dealing with in an infertility situation and you find minimal endometriosis? At this point, are you recommending a traditional laparoscopy and treatment or do you think this opens the possibility then for a comparative trial where you have the diagnosis but you’re not capable of treating, and you’re randomized to surgical treatment or ovulation induction treatment? What’s your approach now?”

Dr. Mark Surrey: “First of all, the individual treatment is dependent upon the circumstances. The most important of which, in our view, is the patient’s age in so much as that in the older patient with a diagnosis of endometriosis, we might suggest and opt for the patient to proceed directly to an assisted reproductive procedure such as in vitro fertilization as being the quickest path potentially to a conception. With younger patients, it depends upon the stage of the disease and whether or not there’s any associated significant pelvic pain. The initial therapy for the younger patient without pain might either be no therapy at all or a trial of controlled ovarian stimulation with a less expensive medication such as clomiphene citrate or another option would be if there is associated pain, suppression with either an agonist, Danazol, or even a continuous form of oral contraceptive followed by a trial at attempting to conceive again. In the older patient, one might be more aggressive. If the patient has pain, one might be more aggressive surgically. If the patient doesn’t have pain and is only concerned with her fertility, as I mentioned, one might consider going directly to in vitro fertilization. So I do think that it enables you to change or at least have an informed patient from the perspective of what their diagnosis is, what their options are, and tailor the patient’s treatment to the individual based upon an informed consent that you can then give the patient with the patient’s options. From the perspective of the information that this enables us to derive, you’re absolutely correct. If we can assess this part of the body in a inexpensive minimally invasive way then it enables us to do a number of different things including assess our treatment of diseases like endometriosis and do what we call second-look laparoscopies to evaluate the effectiveness of either surgery or medical therapy for diseases like endometriosis.”

Dr. Mark Perloe: “What other applications do you see for this new technology?”

Dr. Mark Surrey: “One of the things that we’ve done is introduce it to our cancer center where they’re considering a trial for women at risk for ovarian cancer in routine yearly evaluations of the surface of the ovary. I don’t know what this is going to show us but that’s a potential application.”

Dr. Mark Perloe: “Dr. Surrey, this is exciting new technology, where do you see the future of this in your practice and for gynecology in general?”

Dr. Mark Surrey: “In our practice, as well as for people in general, I think, the future is going to be able to unfold by having some people who are technically skilled at doing this and are trained to do this. I’ll have to underline that because as simple as this procedure is, it does require adequate training. To do this in an office environment as opposed to a hospital environment which will make access then to this part of the abdominal cavity an office procedure and make it much less expensive and much more accessible to a significantly larger percentage of patients.”

Dr. Mark Perloe: “One of the problems now in an office environment is getting supply costs and equipment costs covered. Do you see this requiring special negotiation with insurance companies or how do you see the economics of the individual physician being able to afford the new equipment?”

Dr. Mark Surrey: “Even if you’re not able to obtain a facility fee for this, the equipment is non-disposable, relatively inexpensive, and one endoscope can be utilized in the same sitting for both a transvaginal hydrolaparoscopy and hysteroscopy, and the cost of the saline is fairly nominal. So what your talking about is the cost of a TV video monitor, a light source, a camera, and the endoscope which if you amortize it out over probably two dozen cases the average clinician would be able to afford it without any insurance reimbursement.”

Dr. Mark Perloe: “Certainly saving the time of not having to schedule cases in a hospital, perform H&P’s, and wait for your room to be ready in the OR is going to be a major time and money saving for us.”

Dr. Mark Surrey: “It will, and I think technically down the line it will evolve into a larger diameter piece of equipment perhaps containing an operating channel where right now the diagnostic nature of the procedure might be expanded into some therapeutic applications.”

Dr. Mark Perloe: “We’re at the annual meeting of the American Association of Gynecologic Laparoscopy and recent press reports have brought to fore a tragic accident that involved the use of some new technology. I’m wondering if you can speak to the fact that we do have all this new technology, and it’s hard for the practicing physician to adapt this and take steps to adapt it in their practices. Could you speak to physicians how we can make sure that when the new technology is out there, we’re taking the appropriate steps to provide for the safety of our patients?”

Dr. Mark Surrey: “It’s a continual problem that in this country is monitored on a local basis, meaning your local hospital establishes criteria and standard of care from the perspective of who is allowed to do a new procedure. This includes what training an individual surgeon has before he or she can do a new procedure, and what type of proctoring he or she needs before doing a new procedure. As a medical community, I think, we simply have to recognize the fact that the operating surgeon or the attending physician is, in fact, responsible for the health and the safety of his or her patient and must use the best judgement they have in providing for this. We can only, I think, on a national level continue to do as we have intended to do at this meeting which is attempt to bring to the forefront and to physicians new equipment, new instrumentation, as well as attempt to provide venues for training and utilization of this new equipment. As to how the individual surgeon or the individual hospitals sees fit to regulate the utilization of new equipment is something that is usually regulated on a local level.”

Dr. Mark Perloe: “The media reports would have the public believe that the physician’s education is coming primarily from equipment representatives. Do you see this as the case?”

Dr. Mark Surrey: “I don’t know the details of this particular instance that has apparently brought this to one’s attention but I think, in general, that’s not the case. I think that instrument company representatives are clearly meant to be salespeople, and that’s what they should remain.”