Nurse Endometriosis

Nurse Hysteroscopists

Live Surgery

Nurse Hysteroscopists

Nurse Endometriosis

Nurse Hysteroscopists

Nurse Endometriosis

Nurse Endometriosis

Nurse Hysteroscopists

Nurse Hysteroscopists

Nurse Endometriosis

Nurse Hysteroscopists

Methoxyflurane (Penthrox 99.9% 3mL) is a well-established self-administered inhalational analgesia for the emergency relief of moderate to severe pain in conscious adult patients. We performed a single centre retrospective patient evaluation study to evaluate the efficacy of Penthrox within the ambulatory gynaecology setting (June 2022-July 2023). Included participants completed a post-procedure symptom questionnaire, with visual analogue pain scores recorded. Results -In total, n=219 ambulatory procedures were included; n=179 hysteroscopic, 5 MVA and 35 ‘other’. Indications during hysteroscopy included patient anxiety, previous discomfort and discomfort during this index procedure. Overall, 9 (4.1%) procedures were not completed, with cervical stenosis, patient request and loss of hysteroscopic view reasons indicated. Pain score sub-analysis according to hysteroscopic procedure was as follows; endometrial biopsy (EB)(n=59; 33.3%; median pain score (PS)=3 [95% CI 1-3]), EB+intrauterine system insertion (IUS) (n=30; 16.8%; PS=3[1-3]), myomectomy (Myosure/Bigatti)+/-IUS (n=5; 0.6%, PS=2[0-5]), polypectomy (Myosure/Bigatti) ) +/-IUS (n=41; 22.9%, PS=3[2-5]) and polypectomy ‘other method’) +/-IUS (n=19; 10.6%, PS=4[3-6]). The median pain score for MVA was (n=5; 0.6%, PS=2[0-7]). No significant difference in pain score was measured between diagnostic (n=63; PS=3[2-4]) and interventional (n=70; PS=4[2-4]) hysteroscopy procedures (p>0.05). Conclusion- Penthrox appears an effective analgesic for diagnostic and operative hysteroscopy procedures. Further prospective, comparative data, including overall patient satisfaction assessment, is required. The potential value for women requiring early pregnancy complication management is also important.

Nurse Endometriosis

Introduction: Robotic assisted laparoscopic (RAL) surgery is increasingly used to assist in gynaecological procedures world-wide. RAL in gynaecology has predominantly been used for gynaecological malignancies but the use of the robot has been now increasing for cases of endometriosis and other subspecialties such as urogynaecology. Methods: We reviewed the cases of RAL in Benign gynaecology, Endometriosis and Urogynaecology performed at our hospitals from October 2021 to December 2023. Patient demographics, surgical data, operation timings, conversion rates, complication rates and readmission rates were analysed. Results: 148 robotic assisted benign gynaecological procedures were carried out by 3 consultants. 45% Benign Gynaecology cases; 42% Endomteriosis cases and 13% Urogynaecology cases. Colposuspension (32%); Sacrocolpopexy (26%) and Iliopectineal suspension (26%) were the three most commonly performed RAL urogynaecological procedures Average EBL for TRH+/- BS/BSO was 161ml; for adnexal surgery was 128ml; Resection of endometriosis was 50ml and for urogynaecological procedures was 90ml. The average inpatient stay was 1.72 nights. Conversion to laparotomy was done in 3 cases (1.6%) Intraoperative complications encountered in 4 cases (2.7%) 6 cases were readmitted (4.1%) Conclusion: As one of the first UK trusts performing RAL in urogynaecology, our trail blazing centre has shown that RAL is feasible and safe, and has positive outcomes in urogynaecology as well as in complex Endometriosis surgery. Quicker operating and recovery times and reduced blood loss have been advantageous. We aim to facilitate daycase procedures in Urogynaecology. Dual consoles will allow second operators for concurrent multi-disciplinary operating in complex endometriosis cases.

Nurse Hysteroscopists

NICE guidelines on management of menopause in 2015 and 2019 suggested that for healthy symptomatic women, benefits of HRT outweigh the risks. HRT remains the most effective treatment for menopausal symptoms. After years of reticence, the demand for HRT is exponential. Consequently, bleeding on HRT is increasingly reported. We suspect that it burdens the gynaecological cancer pathway. We audited the referrals for “Bleeding on HRT “and the impact on gynaecology outpatient services. Methods We compared referrals to target gynaecology clinics over April and October in 2019, 2021 and 2023. The clinic lists were obtained from our electronic record system (EPIC). The referrals for ‘Bleeding on HRT’ were analysed specifically looking at ultrasound scan findings, and further investigation/histology results. Results A total of 779 referrals were reviewed. The number of referrals for ‘Bleeding on HRT’ increased from 12.6% in 2019-2021 to 20.7% in 2023. This was statistically significant (z=2.92. p=0.003). The endometrial thickness (ET) measured on transvaginal ultrasound was less than 4.5mm in 75% of women. A total of 29 patients underwent an endometrial biopsy. Histology results were benign in 93% of cases. No case of malignancy was found. Conclusion We demonstrate a significant increase in referrals for bleeding on HRT. In most women the endometrium was thin and no further investigation were indicated. However, the 2ww consultations capacity was impacted. We believe patients could be managed in primary care with a risk-factor based approach, change of the progestogenic part of HRT and if persistent symptoms a community ultrasound.

Nurse Endometriosis

Endometriosis surgery can be one of the most complex operations surgeons perform, requiring a multidisciplinary (MDT) approach between colorectal, urology, fertility, radiology and other disciplines to optimise surgical planning prior to surgery. Methods We reviewed 300 cases of complex endometriosis over a two-year period which have gone through robust multidisciplinary discussion to finalise plan for surgical management. All MDT outcomes were analysed to measure the accuracy of surgical decisions. Surgical decisions were divided into two major categories: Gynaecology-team only surgery or joint surgery with another team (colorectal, or urology). Further analysis of joint cases with urology was also performed. Results Radiological interpretation of MRI imaging and MDT discussions led to decisions for endometriosis surgeries to be carried out by an experienced endometriosis surgeon or in a joint setting with colorectal surgery. The decision for joint surgery was based on involvement of rectal muscularis, bowel lumen narrowing, multiple bowel lesions or additional risk factors such as inflammatory bowel disease. Surgical planning decisions were accurate in 138 out of 150 cases, indicating 92% accuracy of correctly identifying surgical complexity. In the remaining 10 cases, disease was found to be less or more than described by the MRI which led to emergency intra-operative review by colorectal surgeons. Two cases were converted to two-stage surgery and returned for joint surgeries at a later date. Conclusion MDT has a central role in the surgical planning of complex endometriosis cases. There is no place for routine staging laparoscopies in the modern management of complex endometriosis.

Nurse Hysteroscopists

Introduction Atypical endometrial hyperplasia (AEH) is associated with risk of coexistence of undiagnosed endometrial cancer or progression to cancer. Women who decline hysterectomy should be offered Levonorgestrel IUS or high dose oral progesterone with timely endometrial biopsy surveillance based on RCOG’s recommendations. Objective and Methods This a retrospective study conducted to explore how COVID-19 pandemic affected the endometrial biopsy surveillance in women with AEH who opted for conservative management. Data was collected from hospital electronic records of patients diagnosed with AEH on histology, using a standardised proforma. Results We identified 279 patients with histology diagnosis of AEH, gathered from 01/01/2020 to 31/10/2022, excluding 5 deceased patients secondary to other medical causes. Out of 108 patients who chose conservative management, only 37% (n=40) had endometrial biopsy in 3-6 months as surveillance. 11% of patients (n=12) did not attend their scheduled appointments. 46% (n=50) had delayed endometrial biopsy surveillance, due to administrative issues, pandemic related disruption of clinical activity and inadequate patient tracking across different Gynaecological subspecialties. Out of 26 patients who achieved the defined disease regression for AEH, only 42% (n=11) had 6-12 monthly endometrial biopsy surveillance as follow-up. Conclusion Significant delay in endometrial biopsy surveillance in women with AEH was demonstrated during COVID pandemic. Despite the delays, there was no disease progression, affirming the safety and efficacy of conservative management with Levonorgestrel IUS or high dose oral progesterone in AEH. A Benign Gynaecology MDT was established to coordinate the follow-up for patients with AEH and facilitate the discussions of complex cases.

Nurse Endometriosis

Introduction Endometriosis affects 190 million women worldwide, yet there are no accurate non-invasive diagnostic tests contributing to the average 8-year diagnostic delay. EnBi1 has been identified as a candidate urine biomarker and this study aims to assess its diagnostic accuracy. Methods Patients with symptoms of endometriosis undergoing elective laparoscopy were recruited into this prospective observational study. Patients were allocated into deep (DE), superficial (SE) or no endometriosis groups (SC) by a BSGE-accredited endometriosis surgeon. Healthy volunteers (HV) were carefully screened and recruited. Urinary EnBi1 expression was determined by ELISA (Abbexa) and normalised to specific gravity. Results 190 participant samples were analysed: 152 women with endometriosis, 19 symptomatic controls and 19 healthy volunteers. Mean age of participants was 33 (range 19-49) and BMI 27 (range 16-44). There was no difference between groups for age (p=0.15) or BMI (p=0.07). EnBi1 was detectable in every sample with a mean level of 13.8 ng/ml (range 0.25-54.22). The highest urinary EnBi1 levels were seen in HV, with significantly lower levels in women with endometriosis compared to controls (KW p=0.008). In participants not taking hormonal contraception EnBi1 levels are significantly lower in participants with DE compared to SE (MW p=0.02), SC (MW p=0.05) and HV (MW p Conclusion EnBi1 is detectable in the urine of reproductive age women and is a promising marker of deep endometriosis. Recruitment is ongoing to investigate its clinical utility together with its association with menstrual cycle and hormonal medications.

FC Videos

Background: Parasitic fibroids are a rare occurrence reported at 0.12% when a fibroid nodule acquires its major blood supply from adjacent structures and surviving on the new blood supply. In further studies, prevalence was found to be 0.9 and 1.2 %, primarily attributed to iatrogenic factors related to the growing use of morcellation without a containment bag in laparoscopic surgeries for uterine fibroids.(1) Method: We present a video record for a 41-year-old patient undergoing laparoscopic hysterectomy for heavy menstrual bleeding following failed conservative and surgical management. She had a previous laparoscopic myomectomy 5 years ago and had been often complaining of pinching pain in her lower chest on breathing for the past 2 years. An incidental finding of multiple small parasitic fibroids in the pelvis region, notably in the Pouch of Douglas and a larger subdiaphragmatic fibroid forming an adhesion band with the liver capsule. This video illustrates a secure laparoscopic technique for: 1-Excision of the fibroids in the Pouch of Douglas. 2- Adhesiolysis around the subdiaphragmatic fibroid and its excision and retrieval. Discussion: This case emphasizes the risks associated with morcellation of fibroids without a containment bag, showcasing the potential for parasitic fibroid implantation in the abdominal cavity, leading to diverse symptoms based on its location. Despite these risk, laparoscopic management is a safe approach. Conclusion The presented video demonstrates a secure laparoscopic methodology for excising both pelvic and subdiaphragmatic parasitic fibroids. The findings propose this approach for adoption by gynaecology surgeons. Referrence: Cucinella G,Granese R, Calagna G, et al. Parasitic myomas after laparoscopic surgery: an emergency complication in the use of morcellator? Description of four cases. Fertil Steril. 2011;96(2) e90-96.

Training

Endometriosis 1

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Aims: Demonstrate the excision of endometriosis with significant lateral and posterior infiltration, affecting the right lumbosacral plexus, ureter and anterior division of the internal iliac vessels. Background: Nerve endometriosis is rare (0.1%) but can have a significant effect on quality of life. Symptoms and signs include cyclical/non-cyclical pain with associated sensory symptom with dermatomal distribution and/or motor weakness. Surgical management involves neurolysis of one or more nerves. This requires careful dissection and skeletonization of these structures with the intention to normalise the anatomy. Patient/Interventions: The patient was a 37-year-old P2 with cyclical gluteal pain and sciatica. MRI had revealed significant lateral infiltration up to the right obturator internus with the disease enveloping the anterior division of the internal iliac vessels and lumbosacral plexus. At robotic-assisted laparoscopy, following hysterectomy, extended colpotomy for vaginal endometriosis and shave of rectal endometriosis, a medial and lateral approach was taken to delineate the nodule. The nodule had enveloped the entirety of the anterior division of the internal iliac, which had to be ligated to remove the disease. Careful and cautious dissection is demonstrated to circumnavigate the nodule and finally excise it entirely from the lumbosacral plexus. The video also highlights the management of a vascular injury. Conclusion/Discussion: Endometriosis has an innate capacity to infiltrate surrounding structures; displayed to a severe extent in this case. Careful planning and discussion is paramount. Multidisplinary surgery offers procedural flexibility and facilitates appropriate decision making in cases such as this.

FC Videos

Laparoscopic Transabdominal Cerclage (TAC) is becoming increasingly in demand by patients in the UK. Despite this there are only a few centres that routinely offer this service. We offer this service at the Birmingham Women's hospital, currently being practiced by a single surgeon in the unit. TAC is a preferred option for women with previously failed vaginal cervical sutures, previous midterm pregnancy losses and women with trachelectomy or cervical surgeries. It can be very technically challenging and an advanced laparoscopic surgical skill set is required. We present a video tutorial showing a step by step guide on how to perform a laparoscopic TAC discussing key steps and anatomical landmarks. We discuss the risks involved with the procedure as well as management with pregnancy complications once the TAC is placed. There is a need for laparoscopic surgeons within their units to develop these skills so this service can be offered nationwide without geographical restrictions.

Endometriosis 1

FC Videos

Broad ligament fibroid is a challenging entity in hysterectomy whatever is the mode of the procedure. It does impose technical difficulty particularly with regard of the relationship of the fibroid to the pelvic sidewall structures including the ureter. This is a case of 55 year nulliparous woman who required a hysterectomy for persistent dyskaryosis smear despite having three LLETZ procedure including a recent one. She had 16 week multi fibroid uterus with recurrent left iliac fossa pain. CT investigation for this pain confirmed big fibroid uterus but other concerns. Past history was otherwise not remarkable. She was consented for vNOTES. hysterectomy and BSO. The hysterectomy started with successful application of the Alexis retractor and Gelpoint platform and pneumoperitoneum of 8mm Hg. Voyant energy devise was used and it was sufficient. The laparoscopic phase of the procedure indicated difficulty on the left side due to broad ligament fibroid. It was feasible to open the sidewall and visualise the ureter before fully sealing and dividing the uterine attachments and the IP ligaments. The laparoscopy element took 45 min and there was no need for morcellating or contained retrieval. Total procedure duration was 90 minutes and final check cystoscopy was normal. Patient made an efficient recovery and discharged home next day with minimal pain scores. Further follow up indicated full healing and resolution of the dyskaryosis on the vault smear. Conclusion; the case demonstrated feasibility of advanced concept of navigating the pelvic sidewall in vNOTES a difficult unexpected anatomical findings. This also demonstrated the advantage of having or acquiring advanced minimal access skills in performing vNOTES on more complex cases.

Sponsored by Karl Storz

Training

FC Videos

Blood loss leading to transfusion at the time of hysterectomy can be around 3%1 . It is even higher when hysterectomy is performed for fibroids, adenomyosis and endometriosis. Uterine artery closure at origin is associated with significantly reduced blood loss without higher complication rates1 . The common practise is to perform closure of uterine artery at uterine level with advanced bipolar device. Exposure of retroperitoneum is commonly performed for cancer and endometriosis surgery, infrequently for benign surgeries. Surgeons performing it on a routine basis are comfortable and more confident in retroperitoneal dissection with exposure of uterine artery. Uterine artery is a branch of anterior division of the internal iliac artery. It runs inferomedially into the broad ligament. Umbilical artery which is also a branch of anterior division of internal iliac artery is a surgical landmark to identify uterine and superior vesical artery. In this video we demonstrate simple and reproducible technique to close uterine artery at origin. 1. Uccella S, Garzon S, Lanzo G, Gallina D, Bosco M, Porcari I, Gueli-Alletti S, Cianci S, Franchi M, Zorzato PC. Uterine artery closure at the origin vs at the uterus level in total laparoscopic hysterectomy: A randomized controlled trial. Acta Obstet Gynecol Scand. 2021 Oct;100(10):1840-1848. doi: 10.1111/aogs.14238. Epub 2021 Aug 15. PMID: 34396512

FC Videos

Indocyanine green (ICG) is a type of fluorescent dye which, under specific near infrared fluorophores, emits a green fluorescence during laparoscopy. Historically used primarily to identify sentinel lymph nodes during gynae-oncology surgery, its use is becoming increasingly popular in many “benign’ gynaecological surgeries and for some it has become a routine adjunct to many surgical procedures. In this video we detail its many uses in gynaecology, highlighting potential surgical benefits including: Ureteric identification - injecting dilute ICG via ureteric catheters to aid ureteric visualisation. This can be helpful in simple cases to aid ureteric visualisation and complex cases aiding retroperitoneal dissection and ureterolysis. Identification of the endometrial cavity during myomectomy - use of ICG instilled into the uterine cavity allows better identification of the endometrial cavity, careful dissection during myomectomy and reduces inadvertent cavity breaches. Demarcating bladder and assessing for injury - helpful adjunct to identify bladder margins to aid difficult dissections in cases of multiple caesarean sections. Fallopian tube dye test - using ICG as an alternative to methylene blue allows the dye test to be done at the beginning of the procedure without the concerns for unwanted blue staining of the pelvis and avoids false negatives due to tubal spasm.

Imaging

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Hysteroscopy

RIGS

RIGS

RIGS

Imaging

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RIGS

Hysteroscopy

RIGS

RIGS

Hysteroscopy

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Background In 2023, the UK’s first NHS robotic gynaecology High Intensity Theatre (HIT) weekend was successfully carried out at a high-volume tertiary gynaecology unit in London in a bid to tackle excessive local waiting lists following the Covid19 pandemic. Aim To share the key experiences of the pre-operative preparation; intra-operative execution and post operative care phases that facilitated the successful completion of the UK’s first NHS robotic gynaecology HIT weekend. Methods 4 HIT surgical lists were conducted in 2 parallel operating theatres over a span of 2 days running from 0800-2000. Results All 24 cases were successfully completed without complication. Surgical procedures were classified as 8% simple; 79% moderate and 13% complex including excision of endometriosis, hysterectomy and salpingo-oophorectomies High theatre team efficiency was demonstrated with average length of procedure of 69 mins (51-81); average time between patients of 17 minutes (4-42) and 68% of theatre time used for operating. 42% of patients were discharged on the same day and 75% within 24 hours. The key elements to the success included rigorous pre-operative planning for case selection and patient counselling , optimisation of theatre team efficiency and utilisation of enhanced recovery protocols. Conclusions The High intensity theatre (HIT) operating model can be successfully implemented to reduce gynaecology waiting lists in the NHS by careful preoperative planning, optimised teamwork and enhanced recovery protocols.

RIGS

Imaging

Faster

Background: The exact etiology and pathophysiology of endometriosis are not well understood. Numerous environmental and lifestyle risk factors have been identified including a lower body mass index (BMI). We have further examined this relationship including lifetime body shape, figure descriptors and physical activity. Methods: 402 consecutive patients age 18-49 attending their first laparoscopy for symptoms suspicious of endometriosis were prospectively recruited. BMI was calculated and participants completed the ‘Personal information and lifestyle’ section of the WERF EPQ-S. Results: BMI was significantly different between cases and controls (24.7kg/m2 vs. 27.2kg/m2, p=30kg/m2 gave odds ratios of 0.61 (95% CI 0.37-0.98, p=0.044) and 0.34 (0.19-57, p=25kg/m2. Slimmer body shape in teens and 20s gave odds ratios of 0.77 (0.64-0.93, p=0.008) and 0.75 (0.62-0.92, p=0.006) respectively, including in those with BMI>25kg/m2 at the time of surgery. The figure descriptor “Pear” correlated most strongly with endometriosis (OR 3.5 (1.15-10.6, p=0.027). Change in body shape or figure over preceding decade did not correlate with endometriosis at any age. Level of physical activity was independent of BMI (p=0.328) and did not correlate with a diagnosis of endometriosis (p=0.434). BMI did not correlate with site or severity of endometriosis (ovarian endometrioma p=0.102, invasive endometriosis p=0.369) Conclusion: A lower BMI was strongly associated with a diagnosis but not severity of endometriosis. Slimmer body shape at adolescence and early 20s was associated with endometriosis even in those who were overweight at the time of surgery. This suggests an early adolescent association between adiposity and endometriosis etiology that warrants further exploration.

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Introduction: Reduced operative exposure in recent years has led to the development of laparoscopic simulation programmes within gynaecology training. This enables attainment of crucial psychomotor skills and dexterity required for laparoscopic surgery. Transferable skill development ensures trainees are prepared for “real-time” operating1. Methods: Trainees were provided with box simulators and access to the EoSIM programme. A five-question survey was then submitted to all trainees. Equal percentage (33%) of trainees responded within Core (ST1-2) / Intermediate (ST 3-5) / Advanced training (ST6-7). Multiple responses were permitted on questions. Results: 100% of trainees did not complete the EoSIM training programme. 40% didn’t sign up, 7% felt was not useful, 7 % attributed it to lack of consultant support, 27% stated it was lack of dedicated faculty, 20% related it to lack of operating opportunities, 46% correlated it to rota commitments, 13% had technical issues and 40% had no free time. Other responses included exam preparation and heavy workload. Conclusion: Feedback is a critical motivator for learning and improvement. Other than rota commitments and technical problems, the lack of dedicated simulation faculty, consultant support and absence of an on-site simulation laboratory may be the real crux of disengagement1. The quality of the transferable skills obtained are reliant on the quality of the exercises. Improving psychomotor and perception skills in a safe, simulated environment will prepare trainees for real-time operating, yet 7% of trainees failed to recognise this. An important aspect of the EoSim programme was self-directed learning, yet in this instance 100% of trainees failed to utilise the opportunity. 1. 'Perfect practice make perfect': The role of laparoscopic simulation in modern gynaecology training. Bryant-Smith A, Rymer J, Holland T. 2019

Uterine Surgery

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Robotic Surgery

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Uterine Surgery

Robotic Surgery