Practical Training and Research in Gynecologic Endoscopy
Current status of gynaecologic endoscopy
and experience with training in South America
L. Devoto and A. Fuentes
Institute for maternal and child research
Department of Obstetrics and Gynaecology
School of Medicine, University of Chile, Santiago
Introduction
Background
Laparoscopy was first introduced to South America during the 1970s. Several international agencies such as United States Agency for International Development (USAID) and Johns Hopkins University Program for International Education in Reproductive Health (JHPIEGO) funded training programmes to train physicians in the public sector and to increase the capability of newly created endoscopic fertility centres. The goal was to provide an ambulatory laparoscopic tubal sterilization service.
The development of these programmes was orientated towards demographic control. At that time, very few fertility centres in the region used laparoscopy for gynaecological diagnosis or minor surgical procedures. It was not until the next decade that a number of young gynaecologists trained in the field of Reproductive Medicine in Europe or USA under the sponsorship of the Human Reproduction Programme of WHO, Ford or Rockefeller Foundations returned to their home countries and employed these endoscopic techniques for diagnostic, therapeutic or research purposes. The majority of these physicians were able to perform endoscopic techniques in the field of human reproduction, particularly in fertility promoting surgery.
Hysteroscopy became an increasingly popular procedure in South America in the late 1980s. The European gynaecologists, especially the French and Italians, played a important role in the introduction of this technique to the region.
The other major contribution to endoscopy was the introduction of video-endoscopy in the late 1980s, promoting a sudden increase in the number of procedures performed by laparoscopy and hysteroscopy. The development of more advanced surgery such as ovarian cystectomy, the treatment of ectopic pregnancy, hysterectomy, endometrial ablation and resection of polyps has stimulated greater interest in endoscopy among gynaecologists.
During the 1970s and 80s gynaecological endoscopy in South America was in carried out in both the public and academic sector. However due to resource constraints and the limited number of trained personnel, endoscopy has moved rapidly into the private sector in the 1990s.
Indications for Gynaecological Endoscopy in South America
The following list represents the most popular endoscopic procedures.
- Diagnostic Laparoscopy and/or Hysteroscopy:
- Evaluation of female infertility
- Chronic pelvic pain
- Pelvic inflammatory disease
- Evaluation of uterine bleeding
- Surgical Laparoscopy or Hysteroscopy
- Female sterilization.
- Diathermy to endometriosis or laparoscopic management of endometrioma
- Adhesiolysis
- Tubal pregnancy
- Management of benign ovarian cysts
- Resection of submucous myomas
- Asherman’s syndrome
- Removal of endometrial polyps
- Endometrial ablation
Hysterectomy, pelvic lymphadenectomy, pre-sacral neurectomy and laparoscopic surgery for incontinence are performed in a limited number of Institutions in South America.
Current training opportunities in Gynaecological Endoscopy
The availability of training in gynaecological endoscopy is a limiting factor in South America. Diagnostic endoscopic procedures are part of the residency training programme in a limited number of centres. Operative laparoscopy or hysteroscopy are only part of the fellowship training programme in human reproduction. Few academic institutions in the region have an accreditation programme for this type of surgery. The cost and the maintenance of equipment can be too high for many public or academic health institutions in South America. This, together with the difficulty in obtaining supplies and replacements, represent a limiting factor in the development of endoscopy.
Role of the Endoscopic Industry
The endoscopic industry has played a major role in the introduction of the new endoscopic procedures. Several postgraduate courses in South America have been sponsored by different endoscopic companies but limited funds have been invested in practical and research training activity in the region.
Accreditation
Several countries in the region have a number of skilled endoscopic surgeons but there is a lack of criteria for accreditation of centres in South America in. There is an urgent need to develop guidelines for the accreditation of centres. These criteria should take into consideration the viability of a qualified core faculty, core facilities, the duration of training, the evaluation of the trainee and medico-legal responsibility of the trainee, institution and supervisor.
Gynaecological Societies, Ministry of Health or Academic Institutions in collaboration with the World Health Organization should promote guidelines for accreditation of endoscopic centres and individuals since industry is stimulating general obstetricians and gynaecologists in the private sector to adopt these techniques as standard procedures in gynaecological practice.
Conclusion
It is accepted that the development of endoscopic surgery represents a major advance in reproductive surgery. However progress must not be limited to a few skilled surgeons and the advantages of such techniques in efficiency and safety must be made available to all patients. In order to reach this goal there is an urgent need o change both undergraduate and postgraduate education in gynaecological endoscopy. The public, academic and private sectors must be stimulated to establish postgraduate Research and Training Programmes in this field and provide guidelines for accreditation of centres or individuals. This is important to avoid unnecessary injuries to the patients by unskilled surgeons who could jeopardize the acceptance of this new access to surgical exploration of the pelvis.
Acknowledgements
The authors are grateful to Dr. Irene Furman PhD, Dr. Cristian Miranda and Dr. Emilio Fernandez for their comments regarding the present status of the Research and Training Programme in the region.