Milo L. Hibbert

Credentialing residents for intraoperative cystoscopy

Objective To determine whether incorporation of routine intraoperative cystoscopy for evaluation of potential urinary tract injury into gynecologic residency training provides sufficient experience to justify hospital credentials after graduation. Methods We developed a curriculum to train residents in intraoperative cystoscopic evaluation of potential lower urinary tract injury. Cystoscopy was performed when indicated with hysterectomy and routinely in conjunction with pelvic reconstruction. Faculty members evaluated conceptual and technical proficiency by oral examination and direct observation in the operating room. Once the resident demonstrated a thorough understanding and proficiency in performing intraoperative cystoscopy, a competency certification document was issued by the Program Director. This certification was transmitted to the postresidency hospital credentials committee to justify granting privileges. Results Since 1994 over 400 transurethral cystoscopic evaluations have been done in conjunction with major gynecologic abdominal and vaginal surgeries, and since 1997 an additional 50 transvesical microcystoscopies have been done in selected abdominal cases. Twenty-five residency graduates have been certified as fully trained in intraoperative diagnostic cystoscopy. All these graduates have been granted intraoperative cystoscopy privileges at their subsequent hospital practice. Conclusion Incorporation of cystoscopic urinary tract evaluation into routine gynecologic surgical training is good medical practice and provided a mechanism whereby obstetrics and gynecology residents could obtain intraoperative cystoscopy hospital privileges after graduation.

A microlaparoscopic technique for Pomeroy tubal ligation

Objective To evaluate the efficacy of performing Pomeroy tubal ligation using microlaparoscopic techniques. Methods Thirty-eight consecutive women desiring permanent sterilization underwent laparoscopic Pomeroy tubal ligation using small (2 or 5 mm) transumbilical laparoscopes and secondary midline sites (5 mm and 14 gauge). The procedures were performed under general anesthesia (n = 28) or local anesthesia with conscious sedation (n = 10). Results The mean operative time ± standard deviation (SD) in minutes was 33.0 ± 10.3. The mean recovery time ± SD in minutes was 104.3 ± 41.6. There were no operative complications, and no cases required conversion from the microlaparoscopic technique to a traditional method. Conclusion The results of this study indicate that the Pomeroy tubal ligation may be performed using microlaparoscopic techniques. Furthermore, in selected cases, this technique can be performed under local anesthesia in an outpatient setting.

Micro-hydrovaginoscopy in examining children.

Background The gynecologic evaluation of children is challenging and requires mastery of special examination techniques. Technique Small-diameter endoscopic trocar sleeves and endoscopes (2 or 3 mm) were used in conjunction with hydrodistention with normal saline, to view atraumatically the entire vagina and cervix. Experience During the past 3 years we have used micro-hydrovaginoscopy (2-mm trocar sleeve and endoscope, with hydrodistention) for vaginal examination of young girls and in selected cases of young adolescents and virginal adults in whom traditional speculum examination proved difficult or impossible. This technique was effective for (1) confirming diagnosis of cribriform hymen and facilitated hymenotomy; (2) diagnosis of vaginal discharge unresponsive to medical treatment caused by an intravaginal foreign body (color crayon), which was removed under direct endoscopic view; (3) suspected müllerian agenesis and persistent vaginal discharge confirming absence of the cervix and ruling out foreign body in the urogenital portion of the vagina; and (4) a vulvar straddle injury and urinary retention in which vaginal laceration and hematoma were excluded. Conclusion Micro-hydrovaginoscopy is simple, minimally invasive, and effective for vaginal examination in prepubertal girls. It permits precise and complete diagnosis, directs and assists treatment, and has potential for well-tolerated office use in cooperative patients.

Gender reassignment surgery and the gynecological patient

With the increasing number of open transsexuals in the population and the advances in reconstructive surgical techniques, gender reassignment surgery has been increasing since the 1960s. Secondary to the increase in patients undergoing gender reassignment surgery, the practicing gynecologist is more likely to encounter a transsexual patient. A 49-year-old, nulligravid, white female presented to the gynecology clinic for her annual gynecological exam. Her past surgical history was significant for male to female gender reassignment surgery in 1991. Her hormonal medications included levothyroxine and estrogen. She described a strong family history of breast cancer for which she was being followed in our institutional Breast Watch Clinic. On physical examination, findings were notable for surgically constructed female external genitalia and a neovagina. The rectal exam was normal and failed to demonstrate any prostate pathology. It is important for the experienced gynecologist to be familiar with transsexualism, the reconstructive surgery involved, the surgical complications, and gender identity support groups and clinics available to these patients. Transsexuals should be treated to the extent possible like other female gynecological patients, while care is taken not to overlook underlying or preexisting medical conditions, including conditions unique to the prior and new genders.

Microlaparoscopic tubal ligation under local anesthesia

Local anesthesia to perform laparoscopic tubal ligation is of increased interest due to potential safety and cost benefits. We performed tubal ligation using microlaparoscopic techniques with local anesthesia and continuous intravenous sedation in 16 women desiring sterilization. Operating and recovery times and patient satisfaction were recorded and compared with values for 30 similar women undergoing microlaparoscopic tubal ligation under general anesthesia. Mean +/- SD operating and recovery times for local and general anesthesia were 29.3+/- 8.1 versus 33.6 +/- 11.1 minutes, and 83.9 +/- 59.4 versus 114.5 +/- 69.8 minutes, respectively. Patient satisfaction was high. The potential for cost savings when performed in an outpatient or clinic setting is significant.