Tamer Seckin: Hello, this is Dr. Tamer Seckin in Osaka, Japan for ISGE Meeting. I am very pleased to have Dr. Hugo Verhoeven for follow-up on his beautiful presentation on transvaginal endoscopy. Hugo, it is nice having you here.
Hugo C. Verhoeven: Thanks for having me.
Dr. Tamer Seckin: First time, I have heard about transvaginal endoscopy was obviously the use of culdoscopy was history, but then Hugo Verhoeven had a little video. I was excited to see that because I do believe in culdotomies, that part of the cul-de-sac, I think it’s an incredible advantageous gate to gynecologists, not more than maybe 4 mm in thickness even in most…
Hugo C. Verhoeven: 3.5 mm.
Tamer Seckin: Something like that. We have one lumina of the vagina, maybe a little _ peritoneal tissue, that is it and avascular gives a lot. It is very easy access and it gives us access to the most hidden, unknown structures in human body, ovary and the tube.
Hugo C. Verhoeven: Exactly.
Tamer Seckin: And here you are talking about it today. Tell us about it? How did you start learning about it, how did you master it, and where are we to go from what you have shown us?
Hugo C. Verhoeven: Yes. Okay. We started doing the transvaginal endoscopy techniques about 6-7 years ago, and the reason why we are interested in this technique was quite easy. We did, well I did with my team about 15,000 laparoscopies transumbilically in infertility patients. You know, I am doing only infertility work. Our group is very big and we try to do on our patients everything ourselves, that means we do not want to send the patients for _ to somebody else and for blood sampling somebody to another center and for endoscopy again we tried to have everything under one roof. That means we are doing all the endoscopies whether its hysteroscopy or laparoscopy, we did it ourselves. And of course, we wanted to make money with that, that means top quality, but with minimal cost. So if you would do all endoscopies always in the hospital, the cost for the hospital are so high that it makes no sense to do hysteroscopies, for instance, operative laparoscopies because the hospitals are charging us too much for that. So when we reviewed those 15,000 laparoscopies, we found out that only 20% of the patients had pathology at the moment of laparoscopy. So, in 80% of the patients out of 15,000, we found nothing. And while 10 years ago a laparoscopy was still a quite invasive surgery, not harmless at all, there were people dying just after diagnostic laparoscopy and it was expensive. So, we were thinking should we really do laparoscopy as a routine in all our infertility patients, only 20% of the patients we could find something and we must account to the injuries, with legal suits, and everything. So what we did is we said, well we are going to postpone the laparoscopy part, the timing of the laparoscopy, and in lot of patient we couldn’t do a laparoscopy at all. Second-look laparoscopies after endometriosis, we didn’t do them and of course, we switched like everybody to hysterosalpingogram, to hysterocontrastsonography, do sonography, but of course missing so important information, you know I am a pupil, student of Ivo Brosens, and Ivo Brosens said always that female infertility directly begins at the cervix and ends at the ovary. So, we have no information about the morphology of the tubal wall, about the mucosa, about the thickness of the tubal wall adhesions, malformations of the tubal, and of course, endometriosis. So for us, a hysterosalpingogram, a hysterocontrastsonography gave us not enough information. So we said, if we do an exploration of the female genital tract, we will do it perfectly so it is laparoscopy. But we were afraid, it was too expensive and would harm us. And then the group of Ivo Brosens, Stephen Gordts he said why do not we just put again a scope through the vagina. There, there is no bowel, there are no big vessels, so there is not that much what we think can happen. Oh said, of course all the gynecologists they are starting culdoscopy. Culdoscopy again and they will have bowel perforation, they will have peritonitis, they will have infection. And what we are doing now is completely different. We are doing minimal invasive surgery, respecting all the principles of microsurgery, minimal grasping, no manipulation, and in the office setup local anesthesia or conscious sedation and we are going with a _ device with a needle trocar system, so that the opening in the vagina is only 1 mm and over that needle, we have tied a _ device and then the trocar and the trocar itself is 3.5 mm, after taking it out you have a very small hole.
Tamer Seckin: There is nothing to stitch, nothing to stitch.
Hugo C. Verhoeven: Exactly.
Tamer Seckin: And no any discharge nor any postprocedure, sexual dysfunction, you know, these questions always pops out. I have as a surgeon, I am very impressed. The whole procedure, how long does it take?
Hugo C. Verhoeven: Well, in experienced hands, in an experienced hands like, I think…
Tamer Seckin: How long it was taking 5, 6 years ago, 7 years ago when you started, and how long is it taking now?
Hugo C. Verhoeven: Yes, at the beginning, it took me one hour and now 3 to 4 minutes.
Tamer Seckin: 3 to 4 minutes.
Hugo C. Verhoeven: Yes, I did it in India and in China, and it is really 25 cases in one afternoon, and if you are really good in it and you are alone, if you have visitors it takes me much longer.
Tamer Seckin: How do you, yeah…
Hugo C. Verhoeven: But, I can do it in 3 to 4 minutes.
Tamer Seckin: Do you put something inside the, I probably missed that, do you put something inside the uterus balloon catheter to do tubal perfusion probably and do you keep it in a horizontal position?
Hugo C. Verhoeven: Yes.
Tamer Seckin: When the patient lies flat or is Trendelenburg?
Hugo C. Verhoeven: Absolutely in the horizontal normal gynecological position because we need for distention, water. So, in Trendelenburg the water will go to the diaphragm and we would have no distention. So, the patient is awake. She is lying in a very horizontal position and we start always with hysteroscopy.
Tamer Seckin: I see.
Hugo C. Verhoeven: Hysteroscopy takes us 30 seconds.
Tamer Seckin: Do you use again anesthetic for cervix before hysteroscopy?
Hugo C. Verhoeven: No because most of the time the patient has a little bit _ so she is in a conscious sedation situation. Yeah, bu
t if we do it without any anesthesia in patients; in 90% of the patients, you can do hysteroscopy also without any anesthesia. So, the same optic is later on introduced into the cul-de-sac and after that we put a small catheter of course in the uterus for doing the _. In case that the uterus is retroverted, of course are not fixed, retroverted, we put also a probe into the uterus so that we can bring the uterus in an anteverted position at the moment of the insertion.
Tamer Seckin: For our readers, after these procedures, what percent of the patients got pregnant?
Hugo C. Verhoeven: Well, this has nothing to do with pregnant or not. This is here the question in how many of the patients we see the same thing as you are in transumbilical laparoscopy. So, if after transumbilical laparoscopy, 20% of the patients after coagulation of endometriosis will get pregnant, we will have the same amount through the vagina, but there is no alteration or no difference in the pregnancy rate whether you do it through the umbilicus or through the vagina. It is just another way, another window to the pelvis.
Tamer Seckin: And out of these you have performed a little over 2,000 cases now over the last seven years, right?
Hugo C. Verhoeven: Yes.
Tamer Seckin: And you have as many professional surgeons would accept some unexpected complications. You have told us you have 6 rectum or bowel situations and how are they generally recognized. You found yourself in bowel inside the rectum directly or there was tear, bleeding or…
Hugo C. Verhoeven: Well, that is a very, very important question. If you go through the umbilicus, most of the perforations of the bowel are not seen, because you do the perforation with a Veress needle or with an additional trocar and at the moment that you put the scope, you cannot see anymore than the perforations. This is different if you go transvaginally because you are going first with a needle into the bowel and after that dilated opening, you put immediately the optic. So, you are in the bowel and you see the bowel and you see the _ of the bowel.
Tamer Seckin: And what do you, if you find yourself there, you just pull up and watch the patient, expecting there was white counts on _ or you just scope.
Hugo C. Verhoeven: Well no of course we do a follow up of all the cases in the world, there are about 100 cases of rectal perforation, we are now convinced that if you are in the bowel, take out the optic, and close just the vaginal wall because you have always a hole between the vagina and the bowel. There is no hole between the bowel and the abdominal cavity, so there is no leakage so peritonitis is not possible. The only thing one could happen is that you have later on fistula formulation. So we close, we finish the procedure, we give antibiotics for 2-3 days, and we check the patients with sedimentation and white blood count and that is all and we had no casualties.
Tamer Seckin: Very nice and how many other centers are doing this in Europe or around the world, in Europe.
Hugo C. Verhoeven: Well, that is a difficult question, because sometimes you know like you, we are traveling quite a lot around the world and then you are having a lecture in Beijing in China, and there are then coming people to me and saying, it’s a very nice presentation, that we did already since three years also and we did 7,000 cases. So…
Tamer Seckin: Really?
Hugo C. Verhoeven: Oh yes. So a lot of people read about this and they developed their own instruments and they just started doing that and whether you are using the instruments from _ or copies or self-developed instruments, so I think there are only in Asia, at least 300-400 groups doing that and in an enormous amount. There is a group in South America, for one, originated by one of the colleagues who died a few weeks ago or few months ago, he did also 3000, so.
Tamer Seckin: _.
Hugo C. Verhoeven: Yes.
Tamer Seckin: I have written an editorial on the website.
Hugo C. Verhoeven: So I just want to mention the name, but the group known from _ also 3000. So, I thought I am the number one, well I maybe the number one in Germany, but in Asia, there are people who are doing it in 15 ORs parallelly. So there patients are coming in or in examination rooms, so people in India come in, they just clean their feet, they put their shirts up, and it’s done _ it’s a very easy procedure.
Tamer Seckin: This is I believe why we surgeons, you are from Europe, I am from USA, New York, I am so excited to be a part of outside of the USA because so many variety of procedures are done by so many talented physicians, surgeons, and we do learn from them, yet they do need our organized experience. I think Hugo over the years I know you. This has been a great presentation. It’s very nice to have you here. Thank you very much.
Hugo C. Verhoeven: Thank you.