AICOG KAVITA

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    OFFICE DAY CARE

    THERAPEUTIC

    PROCEDURES

    DR KAVITA PRIYA MD

    CENTRAL HOSPITALDHANBAD

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    In-Office Procedures

    Office procedures are surgical

    procedures which may be

    performed in a clinic oroutpatient setting.

    In-Office Procedures allow the

    patient to resume her normalactivities the next day.

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    DAY CARE ONE END

    OF THE SPECTRUM

    OF SHORT STAY SURGERYSHORT STAY

    SURGERY

    24-72 HOURSADMISSION TO

    DISCHARGE

    INTERVALDAY CAREPROCEDURESPATIENT ISDISCHARGEDWITHIN A DAY

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    http://images2.layoutsparks.com/1/147822/rainbow-spectrum-sky-horizon.jpg
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    DAY CARESURGERY

    Nicoll1 observed that the results

    (of Surgery) obtained in the

    outpatient department at a tithe(tenth) of the cost are equally

    good as those following

    inpatient surgery.

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    OFFICE DAY CARE

    PROS & CONSCONS1) NEEDS SPECIALIZED TRAINING

    2) MINIMALLY INVASIVE EQIPMENT

    3) CUTTING EDGE TECHNOLOGY

    4) HEAVY INITIAL OUTLAY5) RISKY IN LOW RESOURCE SETUP

    6) INADEQUATE SURVEILLANCE

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    CONS7) Need for a responsible person to

    oversee the day care patient at home

    for 24-48 hours.

    8) Surgery restricted to experienced

    seniors; less opportunity for juniors

    9) Extra work for the GP in postop

    period; patients often ring up for

    advice or t/t.

    10) Less cost-effective when the unit

    deals with less complex cases on a

    day basis.

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    PROS Less disruption of patients personal lives Minimal invasion

    Reduced pain

    Minimal anaesthesia

    Early recovery in home with family Less nosocomial infections

    Reduced in-patient waiting lists

    Increased availability of busy hospital beds

    Reduced costs

    Financially lucrative for doctor

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    WHAT PATIENTS WANT.

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    I DONT

    WANT TO

    STAND IN

    LINE

    ANYMORE!

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    CUT

    COSTS

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    MONEY MATTERS

    WHY IS DAY CARE SURGERY COSTEFFECTIVE?

    LESS STAFF NEEDED AT NIGHT,WEEKENDS, PUBLIC HOLIDAYS

    SPARES INPATIENT BEDS

    CANCELLATIONS LESS

    MANY MORE PATIENTS CAN BETREATED THAN IN INPATIENTSETUP

    SHIFT DUTIES NOT NEEDED

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    MONEY MATTERS

    - AND HOW!! USA SAVING OF 15-30% UK SAVING OF 40%

    INDIA COST OF PATIENTOCCUPYING BED IN GOVT.HOSPITAL RS.800-900 PER DAY,RS1000 PER DAY IN HIGHERCENTRES LIKE PGIMERCHANDIGARH

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    OFFICE HYSTEROSCOPYOffice procedure

    Smallerendoscopes(3-5 mmOD) used.

    Atraumatic introduction.

    No previous cervical dilatation.

    Little or noanesthesia needed.Earlier office hysteroscopy was onlydiagnostic.

    Now newer endoscopes (4 to5 mmOD) permit continuous flow of a lowviscosity fluid via a small, built-inchannel.

    Allow minoroperative procedures asoffice rocedures .

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    OFFICE HYSTEROSCOPE

    OPERATIVE

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    7MM OD operative

    hysteroscopes can be used for

    office procedures.Their channels permit

    manipulation of sturdy, rigid,

    and semirigid operating

    instruments.

    Cervical dilatation withMisoprost/Laminaria / Hegar

    Paracervical block/ Regional A

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    OPERATIVE HYSTEROSCOPE

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    THERAPEUTIC OFFICE

    HYSTEROSCOPY1)Treatment of abnormal uterinebleeding2)Sterilization (Essure method)

    3)Removal of fibroids & endometrialpolyps

    4)Removal of leiomyomas

    5)Removal of adhesions caused byinfections or past surgeries

    6)Removal of lost IUCD

    7) Resection of intrauterine septum

    E d t i l l ith t i l l t t

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    Endometrial polyp with atypical vessel structure

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    Intrauterine Leiomyoma

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    Adenocarcinoma of the endometrium with an

    irregular surface with necrosis and dilated

    tortuous vessels

    EUROPEAN SOCIETY FOR

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    EUROPEAN SOCIETY FOR

    GYNAECOLOGIC ENDOSCOPY

    ESGE CLASSIFICATION I THIN FILMY ADHESION EASILY

    RUPTURED BY HYSTEROSCOPY

    SHEATH ALONE, CORNUA NORMAL II SINGULAR DENSE ADHESION

    NOT SO RUPTURED, BOTH TUBAL

    OSTIA CAN BE VISUALISED III OCCLUDING ADHESIONS ONLY

    IN REGION OF INTERNAL OS,

    UPPER UTERINE CAVITY NORMAL

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    ESGE CLASSIFICATIONIV MULTIPLE DENSE ADHESIONS

    CONNECTING SEPARATE AREAS OF UTER.CAVITY, ONE TUBAL OSTIUM BLOCKED

    V EXTENSIVE DENSE ADHESIONS WITH

    UTERINE CAVITY PARTIALLY OCCLUDED,

    BOTH OSTIA PARTIALLY BLOCKED

    Va EXTENSIVE ENDOMETRIAL SCARRING

    & FIBROSIS + GRADE I OR II ADHESIONS,

    & AMENORRHOEA/OLIGOMENORRHOEAVb EXTENSIVE ENDOMETRIAL SCARRING

    & FIBROSIS + GRADE I OR II ADHESIONS &

    AMENORRHOEA

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    FRAGILE GRADE I IUAs (ESGE CLASSIFICATION)

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    GradeIII IntraUterine Adhesions(ESGE classification)

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    Grade III IUAs (ESGE classification)

    S

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    Submucous myoma without intramural

    extension (type 0, ESGE classification

    ESGE CLASSIFICATION OF

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    ESGE CLASSIFICATION OF

    SUBMUCOUS MYOMAS

    DEGREE OFINTRAMURALEXTENSION

    TYPE 0NONE

    TYPE I50%

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    MGMT. OF MYOMA

    Submucous myomas withoutor with only limitedintramural extension shouldbe treated withendoresection as soon as thediagnosis has been made, aswith increasing size,endoresection will becomemore difficult

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    IUD LOST &

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    A fragmented Dalkon shield IUDpartially embedded in the uterine wall.

    Copper-7 IUD within the uterinecavity;

    its filament is in the uterine fundus.

    Biopsyforceps grasping a

    Dalkon shield for removal.

    IUD in the Uterine

    Cavity Found at

    Hysteroscopy

    IUD - LOST &

    FOUND !!!

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    CONTROL OF

    INTRAUTERINE ENDOSURGERY

    The results of intrauterine

    endosurgery should always beevaluated with a2 or 3 months after the procedure :

    1)To assess endometrial healing2)To exclude residual pathology

    3)To remove adhesions, if present.

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    CONTRAINDICATIONS

    ID

    REGNANCY

    ROFUSE BLEEDING

    REVIOUS INFECTION

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    OFFICE PROCEDURESINSERTION & REMOVAL OF

    IUCDs & HORMONE DELIVERY

    SYSTEMS

    LEVONORGESTREL RELEASING

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    LEVONORGESTREL RELEASING

    INTRAUTERINE SYSTEM

    MIRENA

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    IMPLANON

    INSERTION & REMOVAL

    Inserting Implanon Removing Implanon

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    ETONORGESTREL

    IMPLANONA preloaded applicator is used to insert it in theupper part of the arm in the groove between thebiceps and the triceps under local anaesthetic.

    INSERTION TIME 1 minute. REMOVAL 3minImmediate contraceptive efficacy .

    Inserted on a) Day 1-5 of cycle

    b) Day 1 of pill free interval if on pillspreviously

    c) Day 21-28 after childbirth or laterwith condom protection for 7 days

    Removed under LA through a small incision

    Etonogestrel levels drop almost immediately onremoval.

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    LEEP

    The loop electrosurgical excision procedure(LEEP) uses a thin, low-voltageelectrified wire loop to cut out abnormaltissue in the cervix

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    LEEP LEEP LOOPELECTROSURGICAL EXCISION ADVANTAGE PERFORMED ASA SIMULTANEOUSLY DIAGNOSTIC& THERAPEUTIC OPERATION FOR

    CIN DURING OUTPATIENT VISIT ELECTROEXCISION

    SMALL WIRE LOOP (0.5MM)HIGH POWER (35-55 WATTS)WATER-LADEN TISSUE CUT BYSTEAM ENVELOPE FORMED ATWIRE LOOP TISSUE INTERFACE

    LEEP

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    LEEP ELECTROFULGURATION

    HAEMOSTASIS ACHIEVED BYELECTROCAUTERY

    BALL ELECTRODE (5MM)

    LOW POWER (50 W)

    THERMAL DAMAGE

    DISADVANTAGES OF LEEP

    PRETERM BIRTH, PROM, LBW

    INFECTION, HAEMORRHAGE, CERVICALSTENOSIS

    FAILURE RATE 8%-39%, OVERALLRECURRENCE RATE 27.5% (LIVASY ET AL)

    OFFICE DAYCARE WITH

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    OFFICE DAYCARE WITH

    STATE OF ART FACILITIES

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