腹腔镜子宫切除术中的伦理问题【视频+英文讲义】

Ethical issues in Laparoscopic Hysterectomy

The hysterectomy is the surgical removal from the uterus, usually performed by a gynecologist. Hysterectomy means removing the body, fundus, and cervix of the uterus; known as complete or partial removal of the uterine body while leaving the cervix intact; also called supracervical. It is the most commonly performed gynecological surgical treatment. In 2003, over 600,000 hysterectomies were performed in the usa alone, of which over 90% were performed for benign ailments

Hysterectomy is conducted for a wide range of benign and malignant conditions, such as fibroids, menorrhagia and pelvic pain, and gynaecological malignancies. 30 percent of women includes a possibility of undergoing hysterectomy in her own lifetime. Conventionally abdominal hysterectomy is done with the open approach. However, many patients assume that the modern laparoscopic hysterectomy is better than the conventional approach. Laparoscopic surgical centres are mushrooming in most of the bigger cities. This article presents ethical considerations active in the decision-making procedure for choosing from the minimal access surgical possibilities of hysterectomy.

Indications for laparoscopic hysterectomy

In private practice, the commonest indication for laparoscopic hysterectomy is dysfunctional uterine bleeding. Most often the patients are young and therefore are advised this procedure without undergoing full medical or hormonal treatment. One should remember that the laparoscopic route is difficultl for severe pelvic adhesions, very large uterine fibroids and adnexal masses. Moreover, only in Type V laparoscopic hysterectomy may be the uterus removed entirely with the abdominal route. Vaginal surgery completes the procedure in Types I to IV. When the patient is multiparous, laxity of pelvic supports provides easy manoeuverability to the vaginal surgeon even just in the existence of significant uterine enlargement. In fact, many cases of laparoscopic hysterectomies would have been easily operated vaginally anyway.

Laparoscopic hysterectomy is definitely an innovation within the gynaecologists armamentarium. It is a minimal access procedure that allows patients to recover faster and with less pain than does exactly the same procedure performed with the conventional open approach. The web is flooded with home elevators this procedure and every literate patient requiring a hysterectomy opts with this form of treatment. What this means is the operating surgeon too the individual should be aware of the potential ethical issues involved.

Protracted learning curve

The time taken for that procedure is significantly longer for laparoscopic hysterectomy when compared with abdominal hysterectomy. In a single study, within the initial training period, the mean duration was 150 minutes for that laparoscopic hysterectomy group while abdominal hysterectomy averaged 98 minutes. Unlike laparoscopic cholecystectomy or appendicectomy, laparoscopic hysterectomy has a slightly longer learning curve during which the chance of complications is relatively higher than open abdominal hysterectomy. This really is seldom acknowledged by practising consultants who has started their carrier in laparoscopic surgery.

Informed consent

Informed consent is a valuable part associated with a surgical treatment. The patient must be up to date regarding the rationale, the intended benefits, the alternatives, the potential risks and cost implications. The rate of major complication for laparoscopic surgery is twice what it is for abdominal approaches. For every 20 women undergoing laparoscopic hysterectomy, one will experience a complication additional to those probably be felt by women undergoing abdominal hysterectomy. Urinary tract damage, particularly ureteric injury, remains the major concern with regards to the laparoscopic approach. Inside a number hysterectomies, the incidence of urinary tract injuries was highest with the laparoscopic approach (2.2 percent) and lowest with the vaginal hysterectomy at 0.04 percent. The complications related to trocar entry and CO2 pneumoperitoneum are only at the specific to the laparoscopic route and is technique related.

The patient should be warned about the chance of converting the procedure to laparotomy. In the initial many years of a laparoscopic surgeons practice, as much as 25 per cent of laparoscopic procedures might have to be converted to a laparotomy. This boosts the length of operative hours, postoperative morbidity and, finally, the cost.

You will find very few Indian studies published regarding the safety of laparoscopic hysterectomy. In a retrospective study of 60 patients who had undergone laparoscopic assisted vaginal hysterectomy (LAVH), complications occurred in 13 percent and conversion to laparotomy in five per cent of patients. The primary indications for LAVH in this series were uterine enlargement, limited vaginal access, lack of uterine descent, need for concomitant adnexectomy, suspicion of adhesions, endometriosis along with a clear-cut indication for going through the remainder of abdomen. In such cases, a simple vaginal hysterectomy might have increased operative risks for example haemorrhage and bladder and ureteric injuries and a conventional surgeon would have preferred open abdominal hysterectomy. However, vaginal hysterectomy is advantageous compared to abdominal hysterectomy when it comes to morbidity, hospital stay, cost and resumption to work. It was therefore suggested that in appropriately selected cases a LAVH will be preferable to either an abdominal hysterectomy or perhaps a vaginal hysterectomy alone.

Ethical regulations for innovative surgical procedures:

In a survey of ethical regulation outcome stated that government regulations for that safety of human subjects of innovative surgery wouldn't be appropriate. The survey concluded that the current system of definitions, ethical guidelines, and voluntary professional guidelines to safeguard patients from unwittingly becoming experimental subjects inside a new procedure may be inadequate to meet the process of surgical innovation. Hence, there's a need to bring innovative surgery under regulation, depending on medical ethics, common law, and sound social policy. This should protect patients while allowing progress inside the surgical field.

Cost analysis, training and credentialing

At the moment, postgraduate learning India is limited to conventional surgeries and diagnostic laparoscopies in certain premier institutions. There is no degree or diploma programme in operative laparoscopy. Gynaecologists usually learn the technique by undergoing very short training programmes which involve substantially high fees; this may not include on the job surgical training but training on mannequins or virtual simulators. The cost of a laparoscopic surgical setup is extremely high. Many gynaecologists don't consider ethical guidelines when recruiting patients for laparoscopic hysterectomy within their exercise. Another concern is that surgeons may possibly reuse disposable accessories to lessen costs.

All gynaecologists planning to perform laparoscopic hysterectomies must have experience in basic laparoscopic procedures such as ovarian cystectomies, fulguration of endometriotic implants, adhesiolyis and ectopic pregnancies. Additional training in a hands-on, approved didactic and realistic course should subsequently be completed, and actual surgical procedures on patients observed. The initial three to five cases should be carefully supervised by another surgeon fully credentialed and experienced in laparoscopic hysterectomy. Early and effective accreditation is crucial to maintaining a higher level of patient treatment and minimising adverse surgical results.

Conclusion

This specific brief article illustrates the significance of negotiating rational and acceptable choices with fully informed patients. Many patients assume how the more contemporary laparoscopic techniques are intrinsically preferable to standard approaches. The machine of family medicine seems to be appropriate in the Indian context only at that juncture. In western countries, family physicians take part in several layers of the decision. They begin the process of informing patients and helping them work out the perfect surgical options. They are also called on after the surgical consultation to interpret the information conveyed through the surgeon and assist the patient to create the very best decision for her. Family physicians should be familiar with the outcomes of their own referral surgeons. The supposed and optimal benefits of laparoscopic hysterectomy is possible in trained, skilled hands in clearly indicated cases.