Hello I am Dr. Swati Naik and welcome for Emcure AICOG tv live from Bhubaneswar with TheRightDoctors.com. I am pleased to have with me Dr. Vidhya Bhat. She is a Director at Radhakrishna Multispecality Hospital an IVF Center at Bangalore. She is also Endoscopist surgeon, and IVF specialist. Thank you very much for joining us on Emcure AICOG tv Madam. Thank you so much. Its pleased to see you after exactly one year. We interviewed you on the same topic last year. I think we’ll have newer techniques being discussed on this endoscopy in women’s health, which is our day to day practice now so would you like to tell us about what are the current practices for endoscopy in obstetrics and gynecology. See there was one era when we spoke about only open surgeries. Now this is the era of minimally invasive surgery. Almost all the surgeries in gynecology can be done by endoscopy. Except a few cancers of ovarian cancer and then advanced endometrium and cervical cancers. We can do everything by endoscopy of course robotics is there which is more precise, but endoscopy is no less because in our country we have the best endoscopic surgeons available because of our.., I think the techniques we use and we are used to managing things in low resource setting so I think ours is the only country where even well of person and a poor patient can afford endoscopic surgeries. Now with the advancement of all the equipments and the techniques we are able to do endoscopic surgeries very well you know blood less. There was one stage when endoscopic surgeries if the patient started bleeding they would convert to open, but those days are gone because we can tackle it endoscopically with our newer energy sources and a special dissection techniques and suturing. Suturing is another level 4 of endoscopic surgeries, where we can just take a stitch fast and our endoscopic surgeons are so good that it is as quick as the open surgeries so we are able to give this same amount of care or the same amount of precise surgical technique endoscopically as we used to give in open surgery. Open surgery right, absolutely so we can say that in today in 2018, we are very well equipped with the different techniques, different tools that are being available for the skilled laparoscopic surgery. Madam how do you prepare a patient for an endoscopic surgery or laparoscopic surgery not only on the patient profile, but financially. Are there any constraint that the patient comes to you with. See we do have different categories of patients coming. I know it is expensive our equipments everything is expensive, but still we can give our patients the best endoscopic I mean.., experience and surgical outcome to these people. One is of course by using newer gadgets, but if you do not have the gadgets because everybody can’t. A low resource setting cannot have the gadget or endoscopic surgeon who is being running to places one hospital will have all the newer gadgets, but the other low resource setting may not have the gadgets, but here we are able to give this same amount of good surgical technique with proper dissection and also the suturing techniques now when I say proper dissection, initially there was time when we used to use bipolar cautery when the other equipments were not there and we used to perform the hysterectomy, which would take a longer time, but now with the good surgical techniques and then lateral pelvic wall dissections we go and ligate uterine artery at its origin. Now this uterine artery at its origin can be either done with bipolar or one can take a stitch or just coagulate and cut. Of course the newer gadgets like a smart electrodes can be used here, but if that is not available we can do this and in large fibroid when we ligate the uterine artery the main blood source, the bleeding automatically comes down and then we can go ahead and do the surgery and one more hitch which has come now is the morcellation and for those things a morcellator because of its controversy people are trying to do vaginal morcellation and if at all there is a doubt when we can always open so these are newer things or the controversial things which have taken a proper path now so that there is no confusion for the doctors to do it in a proper channel so these some new things and then of course preparation of the patient we always tell them the advantage of endoscopic surgeries and then prepare a preoperative workup, see whenever we do endoscopic surgeries it is general anesthesia so in general anesthesia there are certain amounts of risk and suppose the patient is above 50 years, some previous cardiac event then we have to do a proper workup for the patient that is an ECG, echo everything has to be done and it is always ideal because these elective cases we are not doing as an emergency to keep the patient’s hemoglobin at least 10 or 11 so that we do not land up with disasters and blood transfusions later and then finally after the proper workup, the technique of the surgeon and the setup. One thing it is not one person doing it is the proper OT setup with a proper assistance. I mean everybody is unit here. The anesthetist , the assistant towards the camera it is teamwork so a proper team has be there and then the surgical technique if the person is not very well surgically equipped in the sense the technically if the person is not or the surgeon not up to the mark. It is always easy to call another person and then do the surgeries, because the safety of the patient becomes the priority. So I think in terms of patient preparation it goes hand in hand like the way we prepare the patient for open surgery, so right from its blood profile and having an hemoglobin at least 10 so is there is any role of iron or to be precise a parenteral iron that is to be used before and after the laparoscopic surgery. Now preparation of the patient as I said is very important. Suppose the patient’s hemoglobin is less now this is not an emergency, but we can always prepare the patient and to give parenteral I mean.., the oral iron and prepare the patient takes a long time so we prefer giving parenteral iron. We will have to wait for 6 weeks for an oral iron, if the rising in the hemoglobin. Right. Yeah right so this is within weeks we can improve so we give parenteral iron and bring the hemoglobin up to 10 or 11. Suppose there is loss we have a proper hemoglobin to the patient and due to some problem the patient loses blood. It is a huge fibroid and then any amount of care cannot control the bleeding though we take stitches some amount of blood is already lost and then postoperatively we find that the patient has less hemoglobin in such cases I think if it is below 8 we may think of blood transfusions, but if it is 8 and above we give parenteral iron sometimes if he is a well built patient even the hemoglobin falls to 7 also we have given parenteral iron and improved the patient and then of course once it reaches 9, 9.8 then given them oral iron therapy and we have send the patient. Madam with the availability of various parenteral iron preparations what has been your experience and which one you recommend or use very often. I always prefer using iron sucrose for pregnant ladies and of course Ferric carboxymaltose?. Yeah the Ferric carboxymaltose for., Yeah that’s a latest iron preparation, which is the most stable iron complex Yeah. it is one of my favorite product because;
I have been giving it to patients and even not only my preop and postop patients. Suppose the pregnant lady postoperatively has…, I mean post delivery and postpartum period she has less hemoglobin for her also we have given this preparation. Absolutely, so this is latest entrant in the parenteral iron preparations which is the most stable iron complex can be given in a very high dose, single dose and with least chances of adverse drug reaction so I think postoperatively when you have to monitor the patient 24-48 hours Yeah. and over and above if you have some parenteral iron going to give you an allergic reaction and a risk so your night is all the more fire ;
Correct yeah. Dr. Swati Naik so I think you can definitely rely on a preparation like Ferric Carboxymaltose which has really being a very good new advancement in parenteral iron. Probably I would call it boon only. Boon only yeah.. For mother and women. Madam any key message that you would like to give to the fellow obstetricians and gynecologist who have assembled here all across the country on this topic like is there a message how to do in a best possible way the endoscopy for your patient with a minimal risk. See first thing is proper workup any endoscopy case we should have a proper workup there is no shortcut. You know. We should have an ultrasound, we should do a proper workup of preanesthetic check up everything is mandatory, second important thing is the setup if the setup is not good or if the surgical skill level is not good always called somebody, okay, always call for help, there is no ego problems at all. Patient safety should be priority so call for help and once you have a very good set up and well prepared patient then endoscopic surgery is very easy in the sense it is a joy to perform that and the outcome is excellent to the patient as all of us know it is scar less, I mean with small scars and patient can get up and walk around cosmetically acceptable and postoperative period the recovery period also is very less so the patient can get back to work and the amount of antibiotics everything comes down so I feel first thing is we should all do endoscopic surgeries and learn the proper technique though the learning curve is more. I feel everybody should take up a proper path and learn endoscopic surgery. Thank you so much madam. Just a last question.. Moring who ask more and more, but a last question for budding young gynecologist are there any good centers in India where.., we are talking about the skill & the training which wiould come only from the best institutes, so do you recommend any training institute for endoscopy in India or outside India I think I will be selfish if I say it is my center only, but there are very good centers across India. I have been trained in India Okay Because I have never gone abroad for an endoscopic training. The best endoscopic training is available in our country. I think the advance surgeons we have, top surgeons like Dr. Hafez, Dr. Sajay Patel and all. They give excellent training. Madam your center also you could tell them like what is the number of student that you take in a year. At a time I take ICOG fellows for 6 months, then I have Rajiv Gandhi fellowship for one and half years then the 3 months training also I have. so how do the students approach you…, you could just tell them on this video. Website they can approach, they have my number. They have to just get into website Radhakrishna Hospital or even Vidhya Bhat or they can just send a mail. [email protected] Thank you so much madam I think young gynecologist . and obstetricians are definitely looking forward for this admissions at your center. Thank you so much. Thanks for joining us on Emcure AICOG tv.