Practical training and research in gynecologic endoscopy for developing countries
D.M. Walker and A. Campana
Geneva WHO Collaborating Centre for Research in Human Reproduction
This text provides practical guidelines for general gynecologists in developing countries where exposure to advanced gynecologic endoscopy may be limited. The authors are international experts and innovators in the field and present an up to date overview of endoscopic techniques. The goal is that the practitioner review this text and determine independently which procedures have potential advantages in their particular setting. This book provides the information to identify the instruments and skills necessary to perform a particular operation and identifies the risks and complications of each procedure. The reader may then be able to estimate the overall benefits gained by providing a particular endoscopic technique. Also important, this text aims to point out those areas in gynecologic endoscopic surgery where research is lacking, in hopes of motivating potential investigators. To appreciate the technological explosion that has occurred in gynecologic endoscopy over the past 20 years a brief history of endoscopy is in order.
The first "endoscopy" was performed in 1901 using a Nitze cystoscope on a dog. Shortly after this milestone, Jacobaeus in 1911, reported abdominal and thoracic endoscopy on humans. In 1938, the first major technical advance occurred with the development of the Veress needle for insufflation. Additional instrumental developments followed with the invention of automatic insufflators, lighting systems, video systems, and computer chips.
As the technology advanced, gynecologists became the early pioneers and innovators of endoscopic surgery. These individuals were responsible for introducing laparoscopic surgery, with a wide range of applications for the general gynecologist. Five to ten years ago, gynecologic laparoscopy was used only for the diagnosis of pelvic pathology or tubal sterilization. With the development of specialized instruments and the use of video camera systems, not to mention the innovative thinking of some prominent gynecologists, laparoscopic surgery has become a primary therapeutic mode for many gynecologic problems.
As mentioned above, laparoscopy was initially used primarily for diagnosis in cases of chronic pelvic pain, pelvic masses, or for the suspicion of an ectopic pregnancy. The first surgical intervention to be performed by laparoscope was tubal sterilization, by either coagulation, rings, or clips. Work by Dr. Hulka, established operative laparoscopy as a safe and effective technique. Laparoscopic sterilization was not only safe and effective but it also allowed for sterilization to be performed on an outpatient basis with local anesthesia. These advances made this procedure particularly attractive in developing countries. Soon others recognized the benefits of laparoscopic surgery, namely, decreased length of hospitalization, and decreased surgical morbidity. And so began the explosion in new laparoscopic techniques.
Infertility surgeons quickly recognized the potential applications of endoscopic surgery in their specialty. They began introducing laparoscopy in cases of infertility; to assess tubal patency, adhesion formation, and to guide decisions prior to major surgical interventions. Shortly, it was recognized that endoscopy was an ideal means for lysing adhesions and fulgurating endometriosis. The CO2, Argon and KTP lasers were introduced to the endoscopic operating room for these purposes.
Infertility specialists also recognized the advantages to their patients that by avoiding a laparotomy they avoided inevitable scarring and adhesion formation. Women with early-unruptured ectopic pregnancies benefited from the early improvements in laparoscopic surgical instruments, which made it possible to perform laparoscopic salpingectomy or salpingotomy.
Others soon joined in the efforts to make endoscopic surgery more widely practiced and accepted. The American Association of Gynecologic Laparoscopists was founded in 1971. Since then, advances have been rapid, aided in part by the acceptance and innovations of general surgeons using endoscopy for procedures where it was once contraindicated.
Salpingostomy for the treatment of infertility caused by tubal blockage was developed simultaneously with ovarian cystectomy for the treatment of benign ovarian cysts; both are becoming widely accepted. Endoscopic ovarian cystectomy once considered taboo by most gynecologists, is now accepted practice under specific conditions.
Today, major gynecologic procedures are making their way into endoscopy suites throughout the world. Procedures such as myomectomy, oophorectomy and hysterectomy, until recently were only possible by laparotomy. Now endoscopy may be a reasonable alternative. In many cases, endoscopic procedures are performed on an outpatient basis with discharge the same day or shortly after. Thanks to the technical advancements made by both gynecologists and general surgeons these procedures in skilled hands are being performed safely and effectively. Both gynecologic oncologists and urogynecologists are finding appropriate and beneficial applications for endoscopic surgery. For example, laparoscopic pelvic lymphadenectomy, unheard of only a few years ago, is slowly becoming accepted as an alternative technique for lymph node sampling. For the treatment of stress urinary incontinence, it is not unreasonable to consider an endoscopic Burch procedure.
As endoscopic surgery advanced, other innovative gynecologists turned to hysteroscopy. Operative hysteroscopy has enjoyed a parallel technologic explosion. This technique, once used only to visualize the intrauterine cavity has become a primary route to perform intrauterine surgery. Illustrating the pervasiveness of this technique, hysteroscopy is now a widely accepted adjuvant to endometrial curettage, one of the most commonly performed gynecologic procedures. A simple endometrial curettage is infrequently performed today without also performing a diagnostic hysteroscopy. This change in practice is supported by research showing that addition of hysteroscopy to endometrial curettage has increased our ability to diagnose intrauterine pathology.
Today, , hysteroscopic techniques go far beyond simple diagnosis. Potential applications of operative hysteroscopy include directed biopsy for visible intrauterine lesions, lysis of synechiae, location and retrieval of intrauterine devices, resection of uterine septa or submucous myomata, and endometrial ablation.
Although detailed endoscopic and hysteroscopic procedures, both basic and more advanced, are presented in this text, It is important to remember that these techniques require the skill and expertise of an advanced laparoscopist and should only be practiced after adequate training and credentialing.
The chapter on credentialing and continuing education provides accepted guidelines for the gynecologic endoscopist.
This book is not intended as a complete surgical text. Its value is its potential use in the developing world where the opportunities to practice operative laparoscopic and hysteroscopic techniques are limited. The status of laparoscopic surgery in various parts of the developing world, China, Africa, Eastern Europe, South America, is presented to provide an overview of endoscopic surgery in the world today. The procedures described are clearly not expected to be performed in all settings. Each technique may, or may not, be applicable in a particular country. However, an up to date presentation of the potential uses of gynecologic endoscopy and hysteroscopy will provide a basis to help make operative decisions and realize operative possibilities.
Furthermore, there is no worldwide acceptance of the actual advantage of endoscopic procedures over standard surgical approaches. The only procedure that has been adequately studies is laparoscopic female sterilization, where the advantages in terms of operative time, recovery, complications and cost have been affirmed.
Research in this field is sorely lacking. For example, no consensus exists as to the advantage of laparoscopic hysterectomy over vaginal hysterectomy, although a few studies have been done looking at cost, complications, and operative time. However, for the great majority of the procedures presented, there is no clear evidence that an endoscopic approach is superior to a standard approach. Most endoscopists believe there exist clear advantages in terms of operative time, morbidity, reduced surgical trauma, and decreased hospitalization and recovery time. Yet, proof is lacking and we can only promote widespread use of these techniques over standard surgical procedures after reliable studies have confirmed their utility.
This issue is particularly pertinent in developing countries with limited resources where investing in laparoscopic instruments, video cameras, irrigation and light systems, may be viewed as a frivolous luxury. However, it is also in these countries where post-operative infection, hospitalization, and prolonged recovery times have the greatest relative cost. One can argue that investment in this high tech system may be beneficial once proof of the advantages is available. This will only occur if well conducted studies are performed in various economic and social settings to determine the specific benefits of endoscopic surgery. This text opens the doors to prospective researchers, identifying these unanswered questions.
- Stellato. TA. History of laparoscopic surgery. Surgical Clinics of North America. Vol. 72, Number 5, Oct. 1992.