Blog Previous Gynaecological Oncology Events: The Nottingham Total Laparoscopic Hysterectomy Masterclass courses: A very successful 15th Masterclass course on total laparoscopic (keyhole) hysterectomy with a group of very enthusiastic consultants from various hospitals. Below is my email of encouragement to the delegates who attended the course. "Dear all, I hope you all enjoyed your time in Nottingham recently at the Masterclass course and that you gained something from it. As usual, it was fun for me throughout and even more fun to interact with colleagues who are willing to take on the challenge of learning new skills. I salute you all. I also hope you enjoyed the mixture of cases during the live-operating session. Even though the 3rd case on the list turned out to be very challenging, I think it was good that you saw that too. Personally, I would have preferred that it was slightly more straightforward. However, as we all know, it is always difficult to predict potential surgical outcome. Unfortunately, the last case had to be cancelled. The patient that was cancelled was very understanding. I spoke to her earlier today and will now be doing her surgery first thing in 3 days and she is very delighted that I could bring her back so quickly. Regarding the 3 operated cases: I saw all of them this morning. You will be happy to hear that they were all (even the last case that was so tricky and difficult) already up and about, eating and drinking. They all had normal post op-hb. No further requirement for opiates but just regular NDSAIDs and paracetamol. The first 2 cases went home this morning (less than 24 hours following surgery). I decided to keep the last patient for another night even though she was keen to go home this evening. So, she will be discharged home tomorrow (within 48hrs of surgery). Overall, very good post operative outcome. Sorry that I could not personally say goodbye to all of you as I was seriously pre-occupied with the third case. For those who were not there to the end, I was eventually able to retrieve the uterus vaginally in the endo-bag without any intra-abdominal spillage. She had calcified fibroid, hence the extreme difficulty extracting it vaginally. She sustained a minor vaginal tear which was sutured, otherwise no other problem. Although there was no bladder injury, I have decided to keep her catheter in place for one-week just as a precaution. This is my usual practice whenever I have difficulty extracting the uterus vaginally. I guess, the other thing I could have done would have been to remove the uterus via a lower abdo transverse incision. I was however very keen to avoid this because of her very high BMI, as this may negatively impact her post operative recovery period with increased risk of wound dehiscence and infection. Suffice to say that I have had to do this on one previous occasion on a very slim patient and she went home after 2 days. Moving forward, I hope you are all encouraged to do TLH cases and suture the vault laparoscopically. Laparoscopic vault closure is really very easy especially with the v-loc suture. I would advice that you go to your local skills centre at least twice a week for a minimum of 1-hour session and practice laparoscopic suturing and knot tying. As I indicated during the Masterclass, please do feel free to contact me for any advice on tips/tricks and any difficulties you might have. The earlier you do cases of TLHs soon after the course, the better. So, please do not leave it too late before you do your first or more cases, if you are already doing them. Do let me know when you have done your TLH cases and succeeds in closing the vaginal vault laparoscopically. Don't hesitate to consult with your local Covidien representative for help and support if required. Also, feel free to contact me should you wish to visit me to observe procedures. Some of my videos are on youtube (google search- *youtube videos by Jafaru Abu*). I will continue to add some more as I deem fit, including difficult cases. My very best wishes to you all for the future." Guess what? Already preparing for the 16th Masterclass from 7-8 September 2015. This course is already fully subscribed. Very exciting times indeed. The 15th Nottingham Total Laparoscopic Hysterectomy Masterclass Course for Consultant Gynaecologists 23-24 July 2015 I am looking forward to the next TLH Masterclass course. An opportunity to interract with other gynaecology consultants from across the country who are enthusiastic about taking their laparoscopic (key-hole operation) to another level. I have been running this course now for almost 8 years. Together with my team of faculty members (gynaecologists, anaesthetists and theatre nursing staff), we are hopeful to run another very successful 2-day hands-on training course for consultants for the benefits of their patients. It is always wonderful to see these consultants make excellent progress with their laparoscopic skills after attending the course. Overall, well over 90% of consultants who attend the course do eventually progress to performing most of their hysterectomies entirely laparoscopic. This has significant impact on patients recovery and wellbeing. It is a win-win situation for all - patients, their relatives, place of work and of course the hospital. The two-day course comprises of lectures, hands-on cadaver lab operating and live operating by faculty members. There is usually an opportunity for mentorship training for consultant following full attendance at the course. Consultants are also awarded CME points by the Royal College of Obstetricians and Gynaecologists (RCOG) following successfull completion of the course. The 19th International Meeting of The European Society of Gynecological Oncology (ESGO), 24-27 Oct 2015, NICE, FRANCE As usual, this promises to be another exciting ESGO meeting. I have attended all the ESGO meetings over the last 10 years and none has ever failed to live up to the very high expectations. A fantastic opportunity for learning, presentations and interractions with other members from across the globe. Innovations in the management of gynaecological cancers as well as all the latest research studies are discussed extensively. As a gynaecological cancer surgeon, I have always found these meetings invaluable in keeping my knowledge up to date and also an opportunity to see what others are doing that could potentially be of benefit to my patients. I am hoping to sort out my registration soon and get the "early-bird" rate. The link below will take you directly to the conference website. Happy viewing! http://esgo2015.esgo.org/ The British Gynaecological Cancer Society - https://bgcs.org.uk I have just returned from this annual meeting held in Newcastle, UK from 9-10 July. For the first time the meeting was held in conjuction with the the Turkish Gynaecological Cancer Society. The meeting was packed full of surgical updates in gynaecological cancers. Ovarian cancer Endometrial (womb) cancer Cervical (neck of the womb) cancer Vulvar cancer Ovarian Cancer: There is no doubt that in the United Kingdom, we are still playing catch up, when it comes to surgical debulking for advanced stage ovarian cancer, compared to our European and North American colleagues. The British gynaecological oncologists have long been known for been very conservative with surgical radicality in advanced stages of ovarian cancer. There are properly randomised trials which have long showed that complete tumour debulking which involves extensive surgery (total hysterectomy, removal of both tubes and ovaries, total omentectomy, liver mobilisation with peritoneal resection, systematic retroperitoneal lymphadenectomy, (+/- splenectomy, +/- bowel resection, +/- distal pancreatectomy, +/- resection of tumour from the liver), are associated with better overall survival. The UK survival from ovarian cancer is poor compared to the other rich European nations (such as Germany, Belgium, Finland, France), North America, Canada and Australia. This is not just due to late ovarian cancer presentation. A recent article in the Lancet found out that patients in Australia and Canada do not present any earlier to their specialists than UK patients. Chemotherapy is more or less universal. The only difference is in the extent of surgical debulking. At the recent BGCS conference, it was confirmed from various studies that on average, the UK gynaeclogical oncologist spends 2 hours, (compared to an average of 4 hours by our colleagues in the rest of Europe and North America) in performing advanced ovarian cancer surgery. This cannot be right if every effort is made to resect all macroscopically obvious tumour at the time of surgery. Luckily, this shortcoming is now be recognised nationwide and many gynaecological cancer surgeons are now getting additional training to be able to carry out the appropriate surgical debulking for advanced stages of ovarian cancer. Where needed, other surgical specialties, such as colorectal and hepatobilliary surgeons, are now been increasingly involved. This will eventually benefit our patients and translate into a better overall survival comparable to those in Europe, USA, Canada and Australia. Patients should be empowered to ask questions about the treatment they are receiving. The hospital managers should also provide the resources and time that is required to accomplish this goal. A surgical operating list should not just be about "Quantity" but "Quality". For additional information, please read my information leaflet on ovarian cancer on the main website menu under "operations". Endometrial Cancer: The surgical uterine cancer care pathway (SUCCP) on uterine cancer management is a comprehensive plan (please refer to my main website, under the menu - Expertise). Every woman with a diagnosis of uterine (womb) cancer should have at least an MRI scan of the pelvis and abdomen except of course if they have a very high BMI. I have carried out key-hole hysterectomy on women with BMI as high as 75+ where this is virtually infeasible and you just have to rely only on pre-operative chest X-ray and pelvic ultrasound scan staging. Apart from this scenario, pre-operative MRI staging is vitally important for all endometrial cancer staging - depth of myometrial invasion and the status of the pelvic lymph nodes. This is irrespective of the the histological (cellular) type. For those with type 2 endometrial cancer (serous and clear cell type) and the carcinosarcomas, CT staging of the chest, abdomen and pelvis should also be done. Where resources are been rationalised and the decision is been made to perform only one imaging modality for staging, then, a CT scan of the chest, abdomen and pelvis only should be done. On the other hand, if it is the low grade (Type 1 endometrial cancer - grades 1 and 2), and the MRI suggests less than 50% myometrial invasion with no enlarged pelvic lymph nodes (low risk), such patients can be spared pelvic lymphadenectomy as there is no evidence of benefit. However, if the MRI suggests more than 50% myometrial invasion or enlarged pelvic lymph nodes, such patients should have pelvic lymph nodes dissection for proper staging. Remarkably, at the recent BGCS meeting, I heard of some cases that were presumed to be early stage, low grade endometrial cancer that recurred either at the vaginal vault or the pelvic sidewalls. This further justifies the proper staging of intermediate risk endometrial cancer so that appropriate adjuvant treatment (radiotherapy +/- chemotherapy) may be adminstered after surgery to help reduce the risk of recurrence. Women ought to be properly informed by their clinicians and the options extensively discussed. ESGO: I have just sorted out my registration for the Meeting in Nice, France. Yes, I did get the "early-bird" discounted rate which was "nice". Yet to sort out my accommodation and hopefully will be doing this over the next few weeks. ESGO 19 NICE, FRANCE I attended the conference as planned. Arrived in Nice on the 23rd October 2015, day prior to the conference and was there for the 4 days. As expected, the meeting was well attended with nearly 3,000 delegates. It was another opportunity to interact with colleagues not only from Europe, but from across the globe. The surgical aspect of the meeting was amazing with video sessions, surgical reasearch updates, etc. Ovarian cancer management was a major focus during the meeting with emphasis on surgical debulking. There is no longer any doubt that the aim of surgery in advanced stages of ovarian cancer should now be complete resection of all tumours whether during upfront or delayed surgery after neoadjuvant chemotherapy. As much as possible, upfront surgery followed by chemotherapy should be the standard of care. However, in some cases, thorough pre-operative evaluation may indicate a high probability for suboptimal surgical resection if primary debulking surgery is performed. In such cases, patients should have primary chemotherapy with 3 cycles before an attempt is made for complete surgical resection of any visible cancer. I was particularly impressed with the study by the Dutch group looking at the impact of retroperitoneal lymph nodes staging and adjuvant chemotherapy on the survival outcome of early stage ovarian cancer. The study further emphasises the fact that all patients who have presumed early stage ovarian cancer should be comprehensively staged by retroperitoneal lymph nodes dissection - pelvic and para-aortic lymphadenectomy. Although this was a retospective study and therefore had its limitations, it was however a very large retospective cohort study of over 3,500 patients and cannot be completely ignored. Irrespective of the histological type, lymph nodes removal was associated with improved overall survival. Giving adjuvant chemotherapy to comprehensively staged patients with early stage ovarian cancer, irrespective of the histological type, did not improve the overall survival. On the other hand, giving chemotherapy to patients who did not have retoperitoneal lymph nodes dissection did not compensate for incomplete surgical staging. To avoid a second operation, patients with presumed early stages of ovarian cancer should undergo frozen section histology to decide intra-operatively whether or not to perform pelvic/para-aortic lymph nodes dissection. I know that frozen section histology is not 100% reliable. However, it will help to differentiate between frankly invasive and borderline tumours on one hand and the benign tumours on the other hand. This way, one is able to exclude the benign histological cases. With experience, pathologists who routinely carry out frozen section histology, do get better with time and eventually able to reliably distinguish between borderline and invasive tumours. There is no survival advantage from doing lymph nodes dissection in borderline ovarian tumours and these patients can be spared the additional procedure. The Next Nottingham TLH Masterclass Preparing for the next TLH Masterclass course in Nottingham from 24-25th July 2017. Expecting at least 6 consultant gynaecologists. Will also be running a new course later in the year on Total Laparoscopic Radical Hysterectomy. Hoping to keep you up dated.