OFFICE DAY CARE THERAPEUTIC PROCEDURES

DR KAVITA PRIYA MD CENTRAL HOSPITAL DHANBAD

In-Office Procedures
Office procedures are surgical procedures which may be performed in a clinic or outpatient setting. In-Office Procedures allow the patient to resume her normal activities the next day.

DAY CARE ONE END OF THE SPECTRUM OF SHORT STAY SURGERY

SHORT STAY SURGERY 24-72 HOURS ADMISSION TO DISCHARGE INTERVAL

DAY CARE PROCEDURES PATIENT IS DISCHARGED WITHIN A DAY

DAY CARE SURGERY

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.

CONS 1) NEEDS SPECIALIZED TRAINING 2) MINIMALLY INVASIVE EQIPMENT 3) CUTTING EDGE TECHNOLOGY 4) HEAVY INITIAL OUTLAY 5) RISKY IN LOW RESOURCE SETUP 6) INADEQUATE SURVEILLANCE

OFFICE DAY CARE PROS & CONS

CONS
7) 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.

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

WHAT PATIENTS WANT.

I DONT WANT TO STAND IN LINE ANYMORE!

CUT COSTS

MONEY MATTERS
WHY IS DAY CARE SURGERY COST EFFECTIVE? LESS STAFF NEEDED AT NIGHT, WEEKENDS, PUBLIC HOLIDAYS SPARES INPATIENT BEDS CANCELLATIONS LESS MANY MORE PATIENTS CAN BE TREATED THAN IN INPATIENT SETUP SHIFT DUTIES NOT NEEDED

MONEY MATTERS - AND HOW!!

USA SAVING OF 15-30% UK SAVING OF 40% INDIA COST OF PATIENT OCCUPYING BED IN GOVT. HOSPITAL RS.800-900 PER DAY, RS1000 PER DAY IN HIGHER CENTRES LIKE PGIMER CHANDIGARH

OFFICE HYSTEROSCOPY
Office procedure Smaller endoscopes(3-5 mmOD) used. Atraumatic introduction. No previous cervical dilatation. Little or no anesthesia needed. Earlier office hysteroscopy was only diagnostic. Now newer endoscopes (4 to5 mm OD) permit continuous flow of a low viscosity fluid via a small, built-in channel. Allow minor operative procedures as office procedures .

OFFICE HYSTEROSCOPE OPERATIVE

7MM OD operative hysteroscopes can be used for office procedures. Their channels permit manipulation of sturdy, rigid, and semirigid operating instruments. Cervical dilatation with Misoprost/Laminaria / Hegar Paracervical block/ Regional A

OPERATIVE HYSTEROSCOPE

THERAPEUTIC OFFICE HYSTEROSCOPY

1)Treatment of abnormal uterine bleeding 2)Sterilization (Essure method) 3)Removal of fibroids & endometrial polyps 4)Removal of leiomyomas 5)Removal of adhesions caused by infections or past surgeries 6)Removal of lost IUCD 7) Resection of intrauterine septum

Endometrial polyp with atypical vessel structure

Intrauterine Leiomyoma

Adenocarcinoma of the endometrium with an irregular surface with necrosis and dilated

tortuous vessels

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

ESGE CLASSIFICATION

IV 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/OLIGOMENORRHOEA Vb EXTENSIVE ENDOMETRIAL SCARRING & FIBROSIS + GRADE I OR II ADHESIONS & AMENORRHOEA

FRAGILE GRADE I IUAs (ESGE CLASSIFICATION)

GradeIII IntraUterine Adhesions (ESGE classification)

Grade III IUAs (ESGE classification)

Submucous myoma without intramural extension (type 0, ESGE classification

ESGE CLASSIFICATION OF SUBMUCOUS MYOMAS

DEGREE OF INTRAMURAL EXTENSION

TYPE 0 NONE

TYPE I <50%

TYPE II >50%

MGMT. OF MYOMA
Submucous myomas without or with only limited intramural extension should be treated with endoresection as soon as the diagnosis has been made, as with increasing size, endoresection will become more difficult

IUD - LOST & FOUND !!!

A fragmented Dalkon shield IUD partially embedded in the uterine wall.

IUD in the Uterine Cavity Found at Hysteroscopy

Copper-7 IUD within the uterine cavity; its filament is in the uterine fundus.

Biopsy forceps grasping a Dalkon shield for removal.

CONTROL OF INTRAUTERINE ENDOSURGERY The results of intrauterine endosurgery should always be evaluated with a 2 or 3 months after the procedure : 1)To assess endometrial healing 2)To exclude residual pathology 3)To remove adhesions, if present.

CONTRAINDICATIONS

ID REGNANCY ROFUSE BLEEDING REVIOUS INFECTION

OFFICE PROCEDURES
INSERTION & REMOVAL OF IUCDs & HORMONE DELIVERY SYSTEMS

LEVONORGESTREL RELEASING INTRAUTERINE SYSTEM MIRENA

IMPLANON INSERTION & REMOVAL

Inserting Implanon

Removing Implanon

ETONORGESTREL IMPLANON
A preloaded applicator is used to insert it in the upper part of the arm in the groove between the biceps and the triceps under local anaesthetic. INSERTION TIME 1 minute. REMOVAL 3min Immediate contraceptive efficacy . Inserted on a) Day 1-5 of cycle b) Day 1 of pill free interval if on pills previously c) Day 21-28 after childbirth or later with condom protection for 7 days Removed under LA through a small incision Etonogestrel levels drop almost immediately on removal.

LEEP

The loop electrosurgical excision procedure (LEEP) uses a thin, low-voltage electrified wire loop to cut out abnormal tissue in the cervix

 LEEP ELECTROSURGICAL EXCISION ADVANTAGE PERFORMED AS A SIMULTANEOUSLY DIAGNOSTIC & THERAPEUTIC OPERATION FOR CIN DURING OUTPATIENT VISIT ELECTROEXCISION SMALL WIRE LOOP (0.5MM) HIGH POWER (35-55 WATTS) WATER-LADEN TISSUE CUT BY STEAM ENVELOPE FORMED AT WIRE LOOP TISSUE INTERFACE

LEEP LOOP

LEEP
ELECTROFULGURATION
HAEMOSTASIS ACHIEVED BY ELECTROCAUTERY BALL ELECTRODE (5MM) LOW POWER (50 W) THERMAL DAMAGE DISADVANTAGES OF LEEP PRETERM BIRTH, PROM, LBW INFECTION, HAEMORRHAGE, CERVICAL STENOSIS FAILURE RATE 8%-39%, OVERALL RECURRENCE RATE 27.5% (LIVASY ET AL)

OFFICE DAYCARE WITH STATE OF ART FACILITIES