ISGE VIDEOS

Tamer Seckin:  Hi, my name is Dr. Tamer Seckin from New York City.  I am starting an interview for the ISGE website on a continuing series of our video journal we just launched, and I am proud to have today Dr. Ornella from Rome.  I have just heard a wonderful presentation of her myomectomy experience together with other Italian groups, a big number of cases, and I would like to share her experience with the viewers.

 

Tamer Seckin:  I want to ask the first question, how long you have been performing the laparoscopic myomectomy?

 

Ornalla Sizzi:  We started laparoscopic myomectomy in 1991.  Of course, in 1991, myoma size was no more than 6 cm.  Now, myoma size can range between 1-20 cm, so we have improved.

 

Tamer Seckin:  Right now, at this point, how many myomectomies do you guys perform a week?

 

Ornalla Sizzi:  A week, you can say two or three.

 

Tamer Seckin:  Two or three.  Do you scrub together with your partner always or one of you scrub with a resident.

 

Ornella Sizzi:  Some times, we scrub with a resident.  Some times, we do the procedure together if we have multiple myomas since it would be a fairly long procedure.  But if we have just one or two myomas, we scrub with the assistant.

 

Tamer Seckin:  When you started myomectomy?  What is your, at this point of your experience, for years, now the learning curve obviously, I consider myomectomy is the hardest procedure in GYN Laparoscopic history, due to its size at times, we get challenged by, bleeding second thing, and possibly the fear of other issues with sarcoma or adenomyosis, some times getting into cavity.  But in your experience, what is your concern when you start a myomectomy?

 

Ornala Sizzi:  Okay.  Generally, when I see a patient with multiple myomas, in this case I know that the procedure would be long and I am not sure that the patient in one year’s time would not have again myomas.  So, sometimes, I have a personal feeling of an unuseful operation that is something that is really upsetting to me, she has now eight myomas, probably in two years’ time, they will have five more.  That is something and probably it has nothing to do with the procedure I am doing, but is a concern for the patient.

 

Tamer Seckin:  So, in other words you question yourself even though you believe you do the right thing at that time for the patient.  You remove whatever visible and feelable or picked up by sonogram.  You do your best and you know there will be two issues after that; one is there are small myomas you will still miss.  The second is there will be new fibroids coming.  I don’t think you should feel bad about it because if the patient knows that you are doing your best to either prevent hysterectomy or to help her to get pregnant.  So, my personal fear in a myomectomy is really it becomes an issue of how I will remove the specimen.  I am not the very promo proponent of morcellators from above, and I do feel that my colpotomy removals I have found experience and grow competent in it.  And the other thing is bleeding and I am also very afraid of assessing it due to something personal because of my experience.  Apparently, as I discussed with you before, your experience with the testing has never been any adverse effects or what you have heard from your friends and that big serious _.

 

Ornalla Sizzi:  No.  We didn’t have any problem with the _.  We use this very diligently because we use one in _.  So, in a way, it is very-very-very diligent.

 

Tamer Seckin:  How long does it last to keep the nonbleeding stage?

 

Ornalla Sizzi:  More or less 20 minutes.

 

Tamer Seckin:  And then every 20 minutes, you have to infiltrate it again?

 

Ornalla Sizzi:  But usually in 20 minutes, we have been able to remove the myoma in step precision.

 

Tamer Seckin:  I see.  I want to, for the sake our viewers from all around the globe, we believe in ISGE, we want to empower the individual surgeon from wherever they are.  Some of them new members, young residents, just finishing their program, going on to practice.  They will be starting these procedures.  What do you advise to new laparoscopists who are starting this ?.  What can they do to cut their learning time and what are the initial highlights?

 

Ornalla Sizzi:  I suppose myomectomy, you need to be able to suture.  If you can remove a uterus and not be able to suture, _ suturing.  In myomectomy, you must be able to suture.  So, in my opinion, before starting to do surgery of a live patient, you would need spend a lot of time on _.  In my opinion, you cannot use a patient as a _.  That is it.

 

Tamer Seckin:  So, suturing is a must?

 

Ornalla Sizzi:  Suturing is a must and the second thing you can start with smaller things and go on as soon as you will get more confidence about the procedure.

 

Tamer Seckin:  And the other thing probably, you would like to say bleeding control, being an expert on bleeding control.

 

Ornella Sizzi:  Okay.  We can use so much electrosurgery doing myomectomy because you will inject vasopressin usually into the myoma and usually you start to apply a suture, so in most of the cases, you do not have so much bleeding.  You must be careful, for instance some very _easy_ pedunculated myoma, some of the residents make the same mistake.  They inject vasopressin next to _.  In this case, you can have a massive bleeding while you are injecting vasopressin in pedunculated myoma.

So far, I don’t know if pedunculated myomas could be easier atleast for the beginning to use Endoloop and tied Endoloop.

 

Tamer Seckin:  And my final two questions.  The first is for patients, who are infertile and fail IVF and they come to you for myomectomy, what are the considerations on these patients that are different from hysterectomy alternative myomectomy?

 

Ornalla Sizzi:  If the patient comes from, okay if she has myoma?

 

Tamer Seckin:  Myoma, she has failed for IVF or they are referred to you for before even they have attempted IVF, they want their fibroids to be removed.  What in practical you make sure if the cavity is regular.  The general feeling many times that there are other fibroids that may not need to be removed.

 

Ornalla Sizzi:  Usually no, not all the myoma needs to be removed _ the outcome.  So usually, if the patient comes to me, the cavity is normal, the myoma is not so big, if she has a big myoma probably it could be better to remove it because you can have problem in the pregnancy.  As you know, I have a strange story.  Once I saw a patient, she came to me and she was already pregnant.  It was the first time I _, she had something like ten myomas and the size of these myomas were 5, 4, 8, 9 as the baby’s size.  I was really worried for her pregnancy, but the pregnancy went on and I used to call this baby, “baby _ “because in all the ultrasounds it was showing like this with all the myomas and she eventually had a cesarean section after an uneventful pregnancy.  Because she wanted another pregnancy, I removed the myomas before the second pregnancy.  During the second pregnancy, she had more problems than during the first.  She had the _ over the last month.  So,

 

Tamer Seckin:  There is always questions ……..

 

Ornalla Sizzi:  But it’s not a question……..

 

Tamer Seckin:  When you want to help, it may not be the same thing.

 

Ornalla Sizzi:  But anyway if the myoma is interruption to the cavity, I think it is good to remove it.

 

Tamer Seckin:  And final question, what are the instrumentation that you personally use for myomectomy,

 

Ornalla Sizzi:  Very basic instrumentation, because clinically, we don’t use disposables.  So, we have reusable trocar.  We have bipolar bayonet forceps.  We have a tenaculum to pull the myoma.  Of course, very good needle holder and morcellation system.

 

Tamer Seckin:  Thank you, Dr. Ornella Sizzi from Rome.

 

Ornalla Sizzi:  Okay thank you.