Minimally Invasive Treatment for Infertility in Rural Areas [video]

Video Transcript

(Dr. J. Gnanaraj MS., Mch (UROLOGY), FARSI, FICS, FIAGES, Director Medical Services in SEESHA Karunya Community Hospital)

Today we are going to talk about the Minimally Invasive Technique that is available for treatment to infertility in rural areas. Infertility is not an uncommon condition. One out of seven couples who are married are infertile. Before the year of diagnostic laparoscopies evaluation of infertility is very difficult, because X rays like hysterosalpingogram was very inaccurate and it is not acceptable to many patients to have a big laparotomy for evaluation. Without diagnostic laparoscopy it is difficult to diagnostic condition like Pelvic inflammatory disease (PID), Adhesions, Endometriosis etc., with certainty. Again conditions like Asherman’s syndrome very difficult to diagnose without the Minimally Invasive Techniques.

Today we will show you the various Minimally Invasive Technique that are possible in rural areas, this is the Ureterorenoscope that are used generally in Urology. We can use this to have a look at the fallopian tube with URS. We place the patient in lithotomic position and dilate the cervix then we use the scope to visualize the opening of the fallopian tube and what we can do is with methylene blue we can use the path finder to flush the any additions or any block is which are there in fallopian tube. This has been very successful. If that doesn’t work then what we do is we use a 0.025 inch guide wire and train open out any other blocks which were there in the fallopian tube.

These are again instruments which are normally available with the any Urologist.

We can use the Resectoscope to resects the septum in the Asherman’s syndrome or small Fibroid which may present inside the uterus which is cause the infertility.

If it is a difficult to pass the Resectoscope even the ordinary Cystoscope along with the Bugbee Electrodes kept could be used for vaporizing or cauterizing these small defects.

This is a part of the Lift apparatus that are used for diagnostic laparoscopies. The advantage is that each place has a different type of a operating table and it is difficult to use the standardized lifts. So what we have done is to make an arrangement where to size could be altered so that it kept into any other Operating Table. We also have a special “V” shape screw which makes it to hold on to the table very tightly. The most important procedure that we do is the diagnostic laparoscopy for infertility we go through the small incision in the umbilicus.

We lift the umbilicus with the two towel clips like this and make an incision starting from the middle of the umbilicus.

We use these special “S” shape retractors to retract and make a small incision just below the umbilicus on the retractor just enough to aloe a index finger so what we do is this we put a index finger and sweep all around umbilicus to make sure that there is no addition there is no bowel or intestine between the abdominal wall and the apparatus. Then what we do is use this special apparatus which we were designed to pass into the small incision like this and lift the interior abdominal wall. Once again we pass the finger to make sure there is no intestine between the abdominal wall and the device. We can also confirm it by using the Telescope, so once this is done the abdominal wall you lifted held that position. Once abdominal wall is lifted this is the portion that is use for keeping it in position.

It has a ball and socket joint which allows a lot of movement and also there are just two levers which can be used to keep the lift and whichever position that is desirable and locking is very simple just use of these two levers and the abdominal wall can be further lifted if necessary.

Once in position the patient is placed in steep lithotomic position, so that intestine moves away from the area of interest.

This is developed as a wound protector, we can use this as an umbilical port, we can just pass it inside and this would keep it open and there is no soiling of the instruments with blood when pass the instrument.

During the surgery these are the common instrument that we used.

This is the Atraumatic Grasper we use to move the intestines away from the area of interest. Sometimes it is useful to put a uterine manipulator so that the uterus also could be moved in whichever direction if necessary.

This is the hook which can be used for releasing additions and if necessary we can use either the vessel sealing equipment or Harmonic (Shear) equipment to release additions which are really common and contributing infertility.

However the most common instrument that we used is the puncture needle, we used for puncturing the ovary in polycystic ovarian disease. We use a grasper like this which obviously cannot be used during conventional laparoscopic surgery. To hold the ovaries up and then we make a multiple punctures.

In Mizoram during the last one year we found that almost 40 to 45% of the patient on view we had operated at conceived during the last year.

When we doing a procedure especially single incision surgeries vessel sealing equipment like this is very handy, we can remove the ovary and cyst or half the ovaries whatever if necessary without causing damage to other tissues using the vessel sealing. Although these are made by Valley lab it has possible to connect them to many others locally produced generators like the Allens generator that we have.

We have been doing these procedures for the last two decades. We started them in very remote hospital in Assam and we found that almost 18% of the patients whom we treated conceived, then we started working with the Gynecologist specializing in infertility work, and this improvement from 18% it went up to 30 to 40%, because it should combined along with the medical treatment and these surgical procedures.

And these very patient friendly because the scars are very small. Once a umbilical scar healed its hardly visible and very difficult for people to make out that the even had a surgery. So the patient acceptance is very good. Unlike the traditional laparoscopic surgery where single incision require a much bigger incision. The size of the incision necessary only 1 or 2 cms, and which strives further with the healing.

So we will not have much problem with the wound infection, the infection rate has been less than 6% in many other studies. And again working in rural areas generally the infection rate is much less.

Hence this is the very useful procedure and big advantage is that possible to do them under spinal anesthesia. Few of the things needs to be remember is that because we are giving spinal it takes the little time to the medicine to get fixed. So we need to be wait for about 15 to 20 minutes after giving the Spinal anesthesia to have a steep lithotomy position and then again because we are using single incision, it is important to do whatever we do under vision so that there is no damage to the intestine, omentum, or any other structure without our knowledge.

And before closing it is good to inspect the entire abdominal cavity for look for injuries, any other pathologies which might be there. And recently what we have been doing is we are comparing the leaving Methylene blue or Saline solution that we use for chromopertubation, because we found that that is less post-operative addition and the chance of conceiving is more.

Conclusion: In conclusion is the very simple procedure which anybody can do and is possible even in very remote areas because it is carried under spinal anesthesia and the sturdy equipment make it very less expensive and the use of traditional open instrument make it easy to learn.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.
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