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AGES Focus Meeting14 & 15October 2011& ComplexitiesPan Pacific PerthWestern AustraliaGynaecological ConundrumsInternational Guest SpeakerProfessor Ellis DownesUnited KingdomProgram& AbstractsMajor Sponsor of AGESPlatinum Sponsor of AGES

AGES Focus Meeting14 & 15 October 2011Gynaecological Conundrums& ComplexitiesCONTENTSSponsors and ExhibitorsPR&CRM and CPD PointsInside CoverInside CoverOrganisation & Faculty 2Conference CommitteeAGES Board MembersAGES SecretariatFacultyMembership of AGESWelcome 3Program 4Day 1 - Friday 14 October 4Day 2 - Saturday 15 October 6Program Abstracts 7Day 1 - Friday 14 October 7Day 2 - Saturday 15 October 11Free Communications Abstracts 19Free Communications 1 19Free Communications 2 24Conference Information& ConditionsFuture AGES ConferencesInside Back CoverBack Cover1

WelcomeDear Colleagues,Welcome to the 2011 AGES Focus Meeting – GynaecologicConundrums and Complexities.Over the next two days here in Perth we will look at commongynaecologic problems, complexities and complications andhow to manage them.The program you see assembled here highlights national andlocal experts, subspecialists (and even non gynaecologists!)The key topics include obesity and surgery, early pregnancyissues, surgical teaching and peri-operative risk management.A highlight will be the session on complications - simplesurgical tips on how to get out of trouble from commoncomplications. There will also be interactive sessions onsurgical anatomy and reproductive medicine, as well as freecommunications sessions.We are delighted to welcome our international guestspeaker Professor Ellis Downes from Middlesex University.Professor Downes is an honorary senior lecturer at UniversityCollege Hospital and Board member of both the British andInternational Societies of Gynaecologic Endoscopy. He isalso an Editor of the British Journal of Obstetrics andGynaecology and a member of the Editorial Board ofGynaecological Surgery.The broad scope of the meeting will provide an excellentopportunity for gynaecologists and obstetricians as well astrainees in O&G to further their knowledge.Bell TowerWe hope you enjoy your stay here in Perth.Stuart SalfingerConference ChairmanDirector AGESJim TsaltasAGES President3

AGES Focus Meeting14 & 15 October 2011Gynaecological Conundrums& ComplexitiesDAY 1Friday 14 OctoberPan Pacific PerthGolden Ballroom0730-0800 Conference Registration0800-0805 Conference Opening and WelcomeJ Tsaltas, S SalfingerSESSION 10805-1000 Obesity and SurgerySponsored by StrykerChairs: J Tsaltas, S Salfinger0805-0830 Anaesthetic approach to the obese patientN McDonnell0830-0850 Surgery for obesity. Normal size me.H Chandraratna0850-0910 Obesity and fertility A Yazdani0910-0925 Obesity and cancers: can laparoscopicgastric bands be used to treatendometrial cancers?J J Tan0925-0945 Obesity and gynaecologic surgeryA McCartney0945-1000 Discussion1000-1030 Morning Tea and Trade ExhibitionSESSION 21030-1230 Surgical AnatomySponsored by Johnson & Johnson MedicalChairs: M McEvoy, K JansenSESSION 31330-1440 Free Communications 1Golden BallroomChairs: M McEvoy, K Karthigasu1330-1340 A minimal access surgical approach tocornual ectopic pregnancyLarmour L, Najjar H, Shashan T, Tsaltas J1340-1350 The role of the gynaecological oncologist in atertiary hospitalActon J, Salfinger S1350-1400 Tuberculous peritonitis mimicking advancedovarian malignancy - an emerging clinicalconundrum Menon A, Thottungal A, Leung Y,Dickinson JE1400-1410 Retrospective review to assess thecorrelation of small nerve fibres at uterinecurettage to laparoscopic findings ofendometriosis Ma T, Leslie C, Stewart C,McElhinney B1410-1420 Tubal choriocarcinoma - a case report andliterature review Roy A, Marry J, Chan F1420-1430 Identifying factors associated withhaemorrhage at hysterectomyBurnet S1030-1100 Plenary LectureBailey & Love -a short history of surgeryE Downes1430-1440 Update on surgical treatment for infertilewomen with endometriosisTsaltas J, Myers C, Druitt M41100-1120 Anatomy of endometriosisK Karthigasu1120-1140 Abnormal anatomy in gynaecologic cancer:the cerebral checklist for surgery or thecrumpled paperY Leung1140-1200 The anatomy of prolapse J P Daborn1200-1230 Discussion1230-1330 Lunch and Trade Exhibition1330-1440 Free Communications 2Goldsworthy RoomChairs: R Hart, Y Leung1330-1340 Persistent abdominal ectopic pregnancyafter cornual rupture and expulsionSmith CJ, Morris AR, Lyons SD1340-1350 Initial Australian experience with MyoSure:a novel mechanical hysteroscopic tissueremoval systemLaw K, Abbott J

1350-1400 Gut on the floor: vaginal eviscerationArachchi A, Davidson A-J , Vasudevan A,Maung H, Sanasuriya C1400-1410 The early pregnancy assessment service card:a suggestion from a retrospective audit of anEPAS unit Budden A, Salim S, Abbott J1410-1420 A novel cause of ureteric obstruction! Longterm deposition of foreign bodies into thevaginaAmir M, Talmor A , Pearce S, Myers C, Tsaltas J1420-1430 Pregnancies with donor eggs afteradnexal clearances for severe recurrentendometriosis: two cases and a discussion ofthe issues Druitt M, Tsaltas J, Yazdani A1430-1440 Questions1440-1510 Afternoon Tea and Trade ExhibitionSESSION 41510-1700 Peri-Operative Risk ManagementSponsored by Karl Storz EndoscopyChairs: K Karthigasu, R Hart1510-1545 Pre-operative workup and assessmentN McDonnell1545-1610 Anticoagulation N Staples1610-1625 WHO Checklist - the UK experience ingynaecological surgeryE Downes1625-1700 Peri-operative blood management S TowlerPerth MintMosmans Restaurant1900 for 1930 Gala DinnerMosmans Restaurant Perth15 Johnson Parade, Mosman Park WA 6012P +61 8 9383 3388Complimentary coach transfers provided.Please assemble in the foyer of the Pan PacificPerth by 18305

AGES Focus Meeting14 & 15 October 2011DAY 2Saturday 15 OctoberPan Pacific PerthGolden BallroomSESSION 50800-1000 Surgical EducationSponsored by StrykerChairs: A Yazdani, K Jansen0800-0810 Teaching techniques B McElhinney0810-0825 Teaching endoscopy – the current modelJ Tsaltas0825-0845 Surgical training in obstetrics andgynaecology: College requirements andhow to meet themJ Abbott0845-0900 Surgical training: the trainee perspectiveJ Acton0900-0920 Tools to assist teaching Y Leung0920-0940 Does using medical devices make usbetter or worse surgeons? E Downes0940-1000 Discussion1000-1030 Morning Tea and Trade ExhibitionSESSION 61030-1230 Complications – Simple Tips for (Common?)ProblemsSponsored by Johnson & Johnson MedicalChairs: J Tsaltas, Y Leung1030-1100 Plenary LectureReducing complications in laparoscopicsurgeryE Downes1100-1125 Bowel damage and laparoscopicmanagementH ChandraratnaSESSION 71330-1500 Early Pregnancy IssuesSponsored by Karl Storz EndoscopyChairs: A Yazdani, J Abbott1330-1345 Ectopic pregnancy – cornual, cervical,scar – imagingK Milward1345-1410 Ectopic pregnancy – management at thedifferent sitesB McElhinney1410-1425 Management of ovarian torsion in pregnancyM McEvoy1425-1445 Cancer in pregnancy S Salfinger1445-1500 Discussion1500-1530 Afternoon Tea and Trade ExhibitionSESSION 81530-1700 Reproductive Medicine Interactive ForumSponsored by StrykerChairs: H MerkurIntroduction and presentation of evidencefor each scenarioFacilitator R HartPanel A Yazdani, J Tsaltas, J Abbott, G Thompson1. Uterine septa2. Submucosal fibroids3. PCO ovaries: to drill or not?4. Endometriosis1700-1710 Close and Award J Tsaltas, S Salfinger61125-1140 Repairing damage to the inferior epigastricarteryH Merkur1140-1200 Approach to major vascular injuryVascular Surgeon1200-1215 Liver, spleen, the diaphragm and other funJ T Tan1215-1230 Discussion1230-1330 Lunch and Trade Exhibition

Gynaecological Conundrums& ComplexitiesProgram AbstractsFriday 14 OctoberSession 1 / 0805-0830Anaesthetic approach to the obese patientMcDonnell NThe obese patient presents the anaesthetist with a numberof challenges and a detailed pre-operative assessment isessential secondary to the higher incidence of co-morbiddiseases such as diabetes, hypertension, ischaemic heartdisease and obstructive sleep apnoea. The pre-operative visitis also essential to review potentially significant technicalissues that may impact on the performance of anaesthesiaso that appropriate planning and discussion with the patientcan be made. The major technical difficulties that may beencountered include the placement of intravenous access,whether non invasive blood pressure monitoring will bepossible and whether there are any potential airway issues.The placement of intravenous access can be made moredifficult in obese patients. Ultrasound guidance may berequired and care is needed to ensure that intravenous accessis not compromised intra-operatively. Conventional monitoringin terms of ECG and pulse oximetry should not cause anyproblems, but non invasive blood pressure monitoring can beunreliable even when appropriate sized cuffs are used. For thisreason invasive arterial access is often utilized.Often of most concern for the anaesthetist is the ability tosecure the airway in the obese patient. In settings wherethe airway is predicted to be particularly difficult this mayrequire an awake intubation technique. The presence of thesurgeon is often appreciated in case the rapid performance ofa surgical airway is required. Obese patients have a decreasedfunctional residual capacity, the primary store of oxygen in thebody, hence in conjunction with an increased oxygen demandassociated with obesity these patients may desaturaterapidly post induction. To increase the time available for theanaesthetist a head up position is preferred, as this increasesthe FRC and hence oxygen reserves.Optimal positioning of the patient on the operating table isalso essential to decrease airway related complications. A‘ramped’ technique is recommended, such that the sternalnotch is in line with the external auditory meatus. When thisposition is utilized the intubation success has been reported tobe between 97-99% in obese patients. It is also important thatpositioning takes into account the higher risk of nerve injuriessecondary to compression.Adequate ventilation of obese patients can be more difficultsecondary to changes in compliance associated with theincreased weight of the chest wall and abdomen. This canresult in higher mean and peak airway pressures, which inconjunction with a pneumoperitoneum and trendelenburgpositioning may significantly compromise ventilation. For thisreason lower insufflation pressures and avoiding extreme headdown positioning may be required.The post-operative management of the obese patient canbe complex. The frequent occurrence of obstructive sleepapnoea means the avoidance of long acting opioids such asmorphine is advised. Higher levels of care may be requiredand hence planned admission to a high dependency unit orintensive care unit should be arranged. Obesity is a significantfactor for venous thromboembolism and hence multimodalpreventative measures should be employed wheneverpossible. These include attention to general measures suchas early mobilization and hydration, mechanical methods (eggraduated compressions stockings or intermittent pneumaticcompression devices that are appropriately fitted) andpharmacological techniques.AUTHOR AFFILIATION: Dr Nolan McDonnell; Staff Specialist,Department of Anaesthesia and Pain Medicine, King EdwardMemorial Hospital for Women in Perth, Western Australia,Australia.Session 1 / 0830-0850Surgery for obesity. Normal size meChandraratna HWith an epidemic of morbid obesity amongst us, the incidenceof obesity associated diseases is quickly rising. Non-surgicaloptions have a mere 3% long term effectiveness and nowmore people are turning to surgery. The different proceduresavailable offer different advantages and disadvantages and alldoctors need to understand them and how they can be bestintegrated into practice. This talk will cover a brief history ofweight loss surgery and what the different options are and adiscussion on the best choice for your practice.AUTHOR AFFILIATION: Dr Harsha Chandraratna; St John of GodHospital, Subiaco, Western Australia, Australia.Session 1 / 0910-0925Obesity and cancers: Can laparoscopicgastric bands be used to treat endometrialcancers?Tan J JAustralia is today ranked as one of the fattest nations in thedeveloped world. The prevalence of obesity in Australia hasmore than doubled in the past 20 years.7

AGES Focus Meeting14 & 15 October 2011Program AbstractsFriday 14 OctoberCancers of the colon, breast (postmenopausal), endometrium,kidney, and esophagus are associated with obesity. Somestudies have also reported links between obesity and cancersof the gallbladder, ovaries, and pancreas. 1 Obese women are up to four times more likely to developendometrial cancer and at a younger age. Detection andinvestigations are more difficult, whilst surgical treatment ofendometrial cancer in the obese patient highlights the benefitsof laparoscopic and/or robotic hysterectomy over a vaginal/open approach.Does obesity reduction after primary treatment of obesityrelated malignancies reduce risk of recurrences and influenceprognosis? Sparse data will be reviewed, and further studiesare required to evaluate the use of weight loss surgery in thesetting “treating” obesity related cancers.REFERENCE:1. Vainio H, Bianchini F. IARC handbooks of cancer prevention.Volume 6: Weight control and physical activity. Lyon, France: IARCPress, 2002.AUTHOR AFFILIATION: Dr Jason J. S. Tan; King EdwardMemorial Hospital, Western Australia, Australia.Session 1 / 0925-0945Obesity and gynaecologic surgeryMcCartney AThe September 2003 Bulletin 8 from AIHW it was reportedthat 20% of women were obese, that is they had a Body MassIndex of 30 or greater. In a classification based on abdominalcircumference of 88cm or more some 28% of women werefound to be abdominally obese. This group of women providespecial challenges for the gynaecologic surgeon.Peri-operative management of the co-morbidities that areassociated with obesity such as diabetes, cardiovasculardisease and the risk of thrombo-embolic phenomena mayinvolve assessment delays, deferment or even cancellation ofplanned surgery.Intra-operatively, obesity often results in difficulties in establishingintravenous and intra-arterial access lines as well as increaseddifficulty with intubation. Special operating tables, leg stirrupsand anaesthetic machines may be necessary. Stabilisation devicessuch as antislip mattresses and bean bags become important toreduce patient movement with the demands of head down tilt toimprove pelvic access. The application of laparoscopic and robotictechniques to obese patients has resulted in a marked reductionon post-operative morbidity particularly as it relates to woundcomplications as compared to open surgery.AUTHOR AFFILIATION: Professor Anthony McCartney; St Johnof God Hospital, Subiaco, Western Australia, Australia.Session 2 / 1030-1100Bailey and Love – A short history ofsurgeryDownes EBailey and Love – a short history of surgery is one ofthe world’s most popular surgical text books that was firstpublished in 1932. It was put together by two young surgeons,Hamilton Bailey and Robert McNeill Love. Robert McNeill Loveis the maternal grandfather of Ellis Downes.This cultural lecture will outline a history of Bailey and Loveand detail the remarkable story of a textbook that manysurgeons worldwide use in their postgraduate training.AUTHOR AFFILIATION: Professor Ellis Downes; ConsultantObstetrician and Gynaecologist, The Wellington Hospital, StJohn’s Wood, London, United Kingdom.Session 2 / 1100-1120Anatomy of endometriosisKarthigasu KEndometriosis is a progressive disease characterised byinflammation, fibrosis and adhesion formation within thepelvis and to distant sites. These processes lead to significantanatomical distortion, which can contribute to the symptomsof pain, infertility, bowel and bladder symptoms. Some ofthe best anatomical descriptions of endometriosis are by theoriginal proponents of the disease Sampson and Cullen in the1920’s and these descriptions still hold true today despite ouradvances in the laparoscopic technology.In this talk we have a brief look at the historical part ofendometriosis anatomy by Cullen and Sampson. Then a look atthe laparoscopic anatomical abnormalities with endometriosisas seen by the laparoscope as it applies to laparoscopicsurgical management of the disease. Finally, a review ofsome of the new staging systems of endometriosis, whichare dependent on the degree of anatomically abnormalityproduced by the disease.REFERENCES:1. Archives of surgery 1920, Cullen,T2. Archives of Surgery 1921, Sampson, J3. Adamson GD, Pasta DJ. Endometriosis fertility index: the new,validated endometriosis staging system Fertil Steril. 20108

Gynaecological Conundrums& ComplexitiesProgram AbstractsFriday 14 OctoberOct;94(5):1609-15.4. [Tuttlies F, Keckstein J, Ulrich U, Possover M, Schweppe KW,Wustlich M, Buchweitz O, Greb R, Kandolf O, Mangold R, MasettiW, Neis K, Rauter G, Reeka N, Richter O, Schindler AE, Sillem M,Terruhn V, Tinneberg HR. ENZIAN-score, a classification of deepinfiltrating endometriosis].Zentralbl Gynakol. 2005 Oct;127(5):275-8[Article in German]5. Miller, C et al , AAGL 2011 Endometriosis ClassificationAUTHOR AFFILIATION: Associate Professor Krish Karthigasu;Head of Gynaecologic Endoscopy, King Edward MemorialHospital, Subiaco, Western Australia, Australia. ClinicalAssociate Professor, University of Western Australia, Perth,Western Australia, Australia.Session 2 / 1120-1140Abnormal anatomy in gynaecologiccancer: The cerebral checklist for surgeryor the crumpled paperLeung YThis is a practical presentation on managing the abnormalanatomy drawn from my personal experience as a trainee andthen as a surgical teacher. I share my thought processes andpractical tips when operating with abnormal anatomy. It is apresentation on how to approach the Abnormality and bring itto Anatomy.Too often as a trainee, the focus is on the outcome – ‘I wantto do a hysterectomy’. Not enough attention is paid to theprocesses, the steps required to complete a hysterectomy suchas, How do I consistently open the pelvic side wall safely? Howdo I consistently identify the ureters?Give priority to the processes, and the desired outcome willgenerally follow.Give priority to the outcome but the processes are flawed, theoutcome will generally be flawed.Be prepared to ask yourself the critical question: When I amstruggling with the procedure, what can I do to make it easier?The content of this presentation will hopefully benefit both thetrainees and the experts in the audience. The tips are just asapplicable in the straightforward cases.AUTHOR AFFILIATION: Professor Yee Leung; Professorof Gynaecology, School of Women’s and Infants’ Health,University of Western Australia. Head of Department, WesternAustralian Gynaecologic Cancer Service, Director SurgicalEducation, King Edward Memorial Hospital for Women, Subiaco,Western Australia, Australia.Session 2 / 1140-1200The anatomy of prolapseDaborn J PThis lecture will present the pelvic anatomy relevant toprolapse surgery. In particular, it will review the various pelvicsupports for each anatomical compartment, the correlationof anatomy and the POP-Q, the evolution of vaginal mesh kitprocedures and new research in pubovisceralis injury. Specificanatomy of the sacrospinous ligament and the retropubis willbe used to identify structures that can be potentially injured inprolapse surgery.AUTHOR AFFILIATION: Dr J. Philip Daborn; Urogynaecologist,King Edward Memorial Hospital, Subiaco, Western Australia,Australia. University of Western Australia, Perth, WesternAustralia, Australia.Session 4 / 1510-1545Pre-operative workup and assessmentMcDonnell N‘Can you please assess this patient’s fitness for surgery?’and ‘She will be fine with the operation but the anaestheticmay kill her’. These two statements, the former a relativelycommon occurrence and the later now thankfully quite rare,demonstrate a number of misconceptions about the preoperativeworkup process by the anaesthetist. With modernmonitoring and improvements in the drugs available to theanaesthetist, it is unusual for surgery to be declined purely onanaesthetic indications and death secondary to anaesthesiaitself is thankfully very rare.For the anaesthetist, the aims of the pre-operative assessmentare to ensure that the patient is in the optimal condition forthe procedure being performed, to organize any additionalinvestigations that may assist with risk stratification for thepatient and to discuss with the patient the potential optionsavailable for anaesthesia and the risks associated with theseoptions. It is a vital component of comprehensive clinical careand when performed properly it decreases the incidence ofday of surgery cancellations as well as decreasing morbidityand mortality. In addition it improves the overall patientexperience and helps to relieve patient anxiety.The optimization of patients pre-operatively can involve anumber of different medical conditions and organ systems.A key decision making step is the urgency of the plannedsurgical intervention, as this impacts the degree of preoperativeoptimization that can occur. If the surgery is trulyurgent, ie an acutely unwell patient, then the optimization9

AGES Focus Meeting14 & 15 October 2011Program AbstractsFriday 14 Octoberis limited by the time available and seeks to correct criticalderangements of organ function. If the degree of urgency isless, but speed is still important (eg curative cancer surgery),then a limited degree of optimization is usually possible(eg the correction of abnormal heart rates and rhythms,optimization of cardiac failure, treatment of unstable angina).If the surgery is purely elective and not time critical thenfull optimization should take place according to establishedguidelines.AUTHOR AFFILIATION: Professor Ellis Downes; ConsultantObstetrician and Gynaecologist, The Wellington Hospital, StJohn’s Wood, London, United Kingdom.Of the organ systems that most commonly requireoptimization, diseases of the cardiovascular systempredominate. The two key decisions making steps, assumingthe surgery is not urgent, is whether the surgery itself isconsidered intermediate or high risk and the functionalcapacity of the patient. Higher risk procedures are thoseassociated with intra-thoracic or intra-abdominal procedures,large fluid shifts and prolonged procedures, especially inpatients aged over 70 and with a history of coronary arterydisease.Functional capacity is especially important as it provides anindication of the underlying cardiac reserve. Patients with agood functional capacity, even with high risk surgery, are lesslikely to need detailed investigation. In contrast, patients withdramatically limited functional capacity may not stress theirheart enough to reveal underlying disease and hence needspecialized tests to determine whether any underlying, criticalcardiac disease is present.AUTHOR AFFILIATION: Dr Nolan McDonnell; Staff Specialist,Department of Anaesthesia and Pain Medicine, King EdwardMemorial Hospital for Women in Perth, Western Australia,Australia.Session 4 / 1610-1625WHO Checklist – The UK experience ingynaeclogical surgeryDownes EThe World Health Organisation Checklist for safer surgery isdesigned to reduce complications caused by poor teamwork,inadequate preparation and human error by carefully checkinganaesthetic, nursing, equipment and procedural requirementsare in place before anaesthsia starts.The lecture will discuss the development of the checklist,experience with its implementation and give examples ofpotential difficulties for individual surgeons and institutions toconsider. Checklists are only as good as the team using them,some team-members may be negative towards their use andstrategies to encourage their uptake will be considered.10

Gynaecological Conundrums& ComplexitiesProgram AbstractsSaturday 15 OctoberSession 5 / 0800-0810Teaching techniquesMcElhinney BOBJECTIVE: The purpose of this study was threefold: (a) toassess the impact of different approaches to training on aphysical simulator with regard to improving psychomotor skillsrequired for laparoscopic surgery (b) to establish if these skillsare retained over time in surgically naïve candidates and, (c) tocompare independent and proctored methods of teaching.DESIGN: Prospective randomised controlled trial.SAMPLE: One hundred fourth year medical students wererandomised into one of three groups. One group was assignedto ‘massed’ or continuous training (150 minutes) on a videobox trainer (VT), a second group assigned to ‘distributed’training (30 mins on five consecutive days) and a third groupacted as a control group. The control group did not practice.Each group was further sub-divided into ‘proctored’ and‘independent’ sub-groups. Ten experienced laparoscopicsurgeons performed the drills and were given a time/performance score.INTERVENTIONS: Laparoscopic box trainer performance timeswere measured for four validated drills on three separateoccasions. The first timing was a baseline time performedbefore commencement of the study (t1), the second timingwas performed within a day of practice (t2) and the finaltiming was performed four weeks (+/-1 week) later (t3). Inaddition, a score was awarded for technical performancebased on the global rating scale (1-best; 5-worst); low markawarded for good performance to correlate with low timescore.MAIN OUTCOME MEASURE: The main outcome measurewas to establish the benefit of the different types of trainingby documentation of the time required to perform fourstandardised drills. The secondary outcome measure wastechnical performance; this was assessed and graded on a5-point rating scale in accordance with the global rating scale.The final outcome measure was retention of newly acquiredskills over a period of time.A regression or logit model of a time or performance scoreused the baseline (t1) time or score. A mixed model of thetwo later times (t2 & t3) or performance scores used the timeor score and a variable for the sequence of the measurementcalled ‘period’RESULTS: Both training groups performed significantly betterthan the control group in most of the tasks. Furthermore, the‘distributed’ group had some advantage over the ‘massed’group in more tasks and reduced the number of studentshaving a time/performance score less than the lowestsurgeons 25% score at four weeks. ‘Distributed’ training asa single variable with baseline and period is significant atdecreasing the time it takes to perform a drill. Student scoresimproved with each subsequent timing. It would appear thatstudents do just as well whether or not they receive individualtuition. Surprisingly, no associations were found for gender,age, handedness, acuity, video game familiarity or interestin surgery. There was no statistically significant difference inperformance score between the two training groups when‘massed’ or ‘distributed’ without the control group wasanalysed. However the ‘distributed’ group had fewer studentsin the last test ‘period’ (t3) below the failure criteria of thebottom surgical measure.CONCLUSIONS: Video box trainers appear to improve thetechnical skills of medical students. Proctored instructiondoes not appear to benefit the trainee. Improvement persistsover time (retention test at four weeks). ‘Distributed’ trainingimproved time and performance in more tasks and resulted infewer students having the lowest scores at the final timing.AUTHOR AFFILIATION: Dr Bernadette McElhinney; King EdwardMemorial Hospital, Subiaco, Western Australia, Australia.Session 5 / 0810-0825Teaching endoscopy - The current modelTsaltas JEducation in laparoscopic surgery remains a challengenationally and internationally. I have been asked to discuss thecurrent status of laparoscopic surgical education. I can say thatI am sure it is broad and varied in both scope and application.In this presentation I will outline the evolution of laparoscopicsurgical education and training in our institution, its currentstatus and then discuss future directions.Our training position probably mirrors how many units haveevolved in Australia; each has distinct features which reflectlocal hospital and state requirements. In our institutionwhen laparoscopic surgery started to develop a profile andenormous interest around the world the department made adecision to develop a dedicated Endosurgery unit. Initially itwas overseen by the Reproductive Biology unit. This was in1991. At this early stage one consultant was sent to ClermontFerrand to learn the appropriate skill set for the laparoscopicmanagement of Ectopics and Ovarian cystectomy. This wasthen applied on his return. A second consultant was thenappointed to the department and all laparoscopic surgeryother than oncology was done by the two Endosurgeryconsultants. At this stage the RBU fellow attended and assistedon the one Endosurgery list per week and all ectopics in hours11

AGES Focus Meeting14 & 15 October 2011Program AbstractsSaturday 15 Octoberand after hours with one endosurgey consultant. The RBUfellow is still responsible for the supervision of all ectopicsin consultation with consultant staff as required. Surgery isperformed laparoscopically as is necessary and appropriate forectopics by the most junior O & G registrar present in theatreunder supervision. This is vital as part of early laparoscopictraining and education.The department in the mid 1990s appointed its first fellowin laparoscopic surgery. At this stage the unit operated incollaboration with the pelvic floor surgeons and oncologistsand expertise and knowledge was shared. The merging of skillsets and operative requirements allowed the rapid expansionof Endosurgery into all gynaecological surgical subsets. Thefellow and the registrars were exposed to this importantcollaboration. This surgical and research collaborationcontinues today amongst the consultants and moreimportantly amongst the fellows in endosurgery, oncology andurogynaecology.In the Endosurgery department the number of consultantshas expanded to 6 over all three major campuses of SouthernHealth. Accreditation is a vital part of these appointments.As we now have six consultants we are now able to train2 fellows. The fellows training occurs both in the publicand private sector. Training involves both a traditionalapprenticeship model and also dry lab skill acquisition.Research and presentation both nationally at AGES andinternationally are a vital part of the position. The consultantsand fellows are also responsible for teaching other registrarslevel 3 AGES/RANZCOG surgical procedures.Once every 12 – 18 months a live animal lab is conducted forthe fellows and General SRs specifically aimed at complicationmanagement. Industry is a vital partner in this area and wewould not be able to do these labs without their support.I am proud to know that all out fellows have leading educationroles both at a national and international level.Certainly many other programs in Australia have evolved inthis manner and due to AGES consultants from all over thecountry involved in laparoscopic education have a forum tomeet, discuss and advance training. In fact these discussions(many of them informal) at AGES have led to adaptations ofvarious education tools from one department to another.FUTURE DIRECTIONS: In the future there will be some changesin laparoscopic surgical skill acquisition and formal education.The formats that were developed over the past 20 yearswill not be the only tools available for training. The classicapprenticeship model will still form the cornerstone but with agreater focus on simulation training – incorporating computersimulation, classic dry and wet lab pelvitrainer simulationand animal labs. A national theoretical curriculum is required.As more fellows are trained there will be many consultantsreturning to their departments and being able to teach bothregistrars and other consultants Endosurgery skills.AUTHOR AFFILIATION: Dr Jim Tsaltas; Head of GynaecologicalEndoscopy Monash Medical Centre and Southern Health,Victoria, Australia. President AGES.Session 5 / 0825-0845Surgical training in obstetrics andgynaecology: College requirements andhow to meet themAbbott JThere is increasing concern from trainees that the currentCollege training program does not meet surgical requirementsnecessary to be a competent gynaecological surgeon at thecompletion of training. Surgical requirements include a basicsurgical skills program undertaken in first year that has beenanalysed and demonstrates only a marginal retention ofknowledge and skills 5 years into the training program (Kochet al ANZJOG 2011). Completion of advanced gynaecologicalskills requirements include competence at difficult openhysterectomy, prolapse repair, Level III laparoscopy and theoption of advanced hysteroscopic procedures. Using theMedicare database, it may be unrealistic to expect all traineesto become and maintain competence for some procedureswith the following annual cases reported and paired with thenumber of procedures/fellow/year that may be expected:Procedure Number/year Number/yearMedicare* Fellow**A+/-P repair 12400 7.75Difficult hysterectomy 1800 1.1Complex laparoscopy 13300 8.3Lap hyst variant 4500 3Abdominal hysterectomy 3300 2Any operative hysteroscopy 3300 2*Medicare database www.medicare.gov.au June 2010-2011** based on Fellows database www.ranzcog.edu.auFurther information indicates that most Fellows are generalists,with 90% practicing both obstetrics and gynaecology andof these, 90% perform operative gynaecology. These datasuggest that the above numbers will not be increasedmarkedly by subspecialisation or operative restrictions.What then remains is the capacity to recognize one’s ownlimitations and to consider the issues of credentialing andperformance of complex surgical procedures safely. Necessaryin this discussion is the capacity to offer concrete alternativesto the satisfactory completion of surgical skills.12

Gynaecological Conundrums& ComplexitiesProgram AbstractsSaturday 15 OctoberThis may include:1. Expansion of the current skills training programs (RANZCOG/AGES) to include repetition and re-assessment at intervals2. Limitation of surgical skills training to a smaller number oftrainees (streaming/ATM’s)3. Restriction of item numbers to those who havedemonstrated competence in surgical performance4. Restructuring remuneration to make it more attractive torefer patients onto surgical colleagues5. Formal mentorship in surgical skills advancement for newFellowsIt is apparent that a combination of the above may developand it is the palatability of any ‘restrictions’, ‘control’, oradministrative capacity that will shape final surgical skillsprograming. Ultimately the teaching, performance andrecognition of surgical skills to the greatest advantage of ourpatients are necessary.AUTHOR AFFILIATION: Associate Professor Jason Abbott; RoyalHospital for Women, Randwick, New South Wales, Australia.Session 5 / 0845-0900Surgical training: the trainee perspectiveActon JIn 2009 a Survey of Surgical Skills of RANZCOG trainees waspublished in the ANZJOG. This study looked at the proceduresthat trainees performed, how confident and competent theywere at performing them throughout their training and howthey felt about their surgical training. Disturbingly, the finalyear trainees did not feel competent to perform severaloperations independently. These included classical caesareansection, B-Lynch suture, abdominal hysterectomy, level 3laparoscopy or vaginal hysterectomy and vaginal repairs. Thelevel six trainees were also not competent or confident todeal with any surgical complications. Teaching was felt to bereasonable with obstetrics, abdominal and vaginal surgery, butpoor in laparoscopic and surgical complications.There are several issues identified by the current trainees.Overall, there is a definite decrease in the number of surgicalcases such as abdominal hysterectomy, exacerbated bydecreased working hours and increased trainee numbers.There is also felt to be a large variation in the rotationsand surgical experience of each individual trainee. Whenexamining the rotations and surgical numbers of the currentsecond years, their vastly different experience is evident.There is the belief that service obstetrics is a real determiningfactor in job allocation, rather than previous surgical exposureto ensure equal and adequate training amongst all. Evenwithin obstetrics there are difficulties noted, particularly withinprocedure training such as elective caesarean sections. Theexposure to difficult caesareans is also limited.The solution for these issues is not simple. There needs tobe steps taken by both the college and training sites, as wellas the registrars themselves. The college must examine ifadequate surgical training can occur with the current numbersand if not must not increase these further. The possibility of asurgical stream within our training must be discussed further,as it may be the only way to provide adequate training.Registrars themselves must also make changes to improvetheir training. We must know our anatomy and our operationsteps; we cannot expect to operate on a patient if we don’tknow their history or how to do the case they are about tohave. We must be assertive and to tell our seniors that wewant to be involved and prove that we should be rewardedwith the experience. Trainees must use their own time toimprove their skills through courses and private assisting.AUTHOR AFFILIATION: Dr Jade Acton; King Edward MemorialHospital, Subiaco, Western Australia, Australia.Session 5 / 0900-0920Tools to assist teachingLeung YMany factors now conspire against an ITP trainee obtainingsufficient surgical experience during their training time. Theseinclude increasing number of trainees, rostering for safehours, changing gynaecologic management, access to the OR,experience and attitudes of the surgical teachers.New RANZCOG consultants and trainees were surveyed in2008. (Obermair et al. Survey of surgical skills of RANZCOGtrainees. ANZJOG 2009; 49: 84–92) Findings include advancedtrainees lacked confidence in a range of surgical proceduresand identified weakness in the teaching experience of trainers.Similar findings were found in a survey of United StatesSurgical residents. Findings included worry that they willnot feel confident performing procedures independentlywas reported by 1185 (27.5%; 95% CI, 26.2%-28.8%), while2681 (63.8%; 95% CI, 62.4%-65.3%) reported that they mustcomplete specialty training to be competitive. (Yeo et al.Attitudes, Training Experiences, and Professional Expectationsof US General Surgery Residents: A National Survey. JAMA.2009;302(12):1301-1308)This presentation provides the results of a pilot study of anencounter tool aimed at the upskilling of the teachers. By13

AGES Focus Meeting14 & 15 October 2011Program AbstractsSaturday 15 Octoberupskilling the teachers, the next generation of trainees maybe better placed at the conclusion of their training to managesurgical problems. The pilot also examines the applicability ofthis tool for trainees in enhancing their surgical experience.AUTHOR AFFILIATION: Professor Yee Leung; Professorof Gynaecology, School of Women’s and Infants’ Health,University of Western Australia. Head of Department, WesternAustralian Gynaecologic Cancer Service, Director SurgicalEducation, King Edward Memorial Hospital for Women, Subiaco,Western Australia, Australia.Session 5 / 0920-0940Does using medical devices make us betteror worse surgeons?Downes EThis challenging lecture will examine the relationship betweenthe medical device industry and surgeons. In the UnitedKingdom more money is now spent on medical devices thanpharmaceuticals.This lecture will cover the regulations which allow medicaldevices to be used, it will highlight the occasional lack ofclinical research (in regard of efficacy) and challenges surgeonsmust address before medical devices are used in theirroutine practice. Patients must be treated as individuals anda thorough assessment made to determine the appropriatepattern of care suitable for them. The conflict between deviceindustry sales teams and “trainers” will also be addressed.‘Me too’ devices are being rapidly introduced into ourspeciality such as sub-urethral tapes and meshes to treatutero-vaginal prolapse. This lecture will give examples ofpotential complications relating to these meshes whichare being increasingly recognised. (ED is the Gynaecologyrepresentative on the Government ‘Committee of Safety forDevices’ (CSD) at the Medicines and Healthcare RegulatoryAgency (MHRA); he is speaking in a personal capacity)AUTHOR AFFILIATION: Professor Ellis Downes; ConsultantObstetrician and Gynaecologist, The Wellington Hospital, StJohn’s Wood, London, United Kingdom.Session 6 / 1030-1100Reducing complications in laparoscopicsurgeryDownes ESurgery is becoming increasingly safe due to advancesin surgical training, instrumentation and hopefully a ‘noblame’ clinical governance culture to encourage reporting ofcomplications with a view to minimising their re-occurrencethrough experiential learning. With well trained surgeonsworking in an established multidisciplinary surgical team,with a good volume of surgical cases, the complication rateis becoming extremely low. Complications are a surgical factof life, and as the complication rate continues to fall, we maysoon reach a rate which can’t be further lowered. Identifyingthe “true” complication rate rather than the “published”complication rate remains a challenge due to wide-spreadunder-reporting.This lecture will try to identify complications that arepotentially avoidable which may further reduce thecomplication rate. However, there will always be a degreeof complications in laparoscopic surgery which may beunavoidable for which patient counselling during the consentprocedure is essential to minimise patient dis-satisfaction andmedico-legal difficulties.AUTHOR AFFILIATION: Professor Ellis Downes; ConsultantObstetrician and Gynaecologist, The Wellington Hospital, StJohn’s Wood, London, United Kingdom.Session 6 / 1125-1140Repairing damage to the inferiorepigastric arteryMerkur HDamage to the inferior epigastric artery (IEA) is a seriouscomplication of laparoscopic surgery. Prevention is obviouslya key strategy and a number of authors have described theanatomy of the IEA and its tributaries 1,2,3 . The IEA has a varietyof origins, but to the practising gynaecologist the main areaof injury can occur in both iliac fossa regions of the anteriorabdominal wall. The incidence of IEA injury ranges from 0.2-2% of laparoscopies.Avoidance of injury to the IEA has been addressed by Saber etal (2004)1 and they suggested that anywhere from the xiphoidto the symphysis pubis, if you stayed inside 4 cm from themidline, or outside 8 cm, this would decrease the likelihood ofvascular trauma.14

Gynaecological Conundrums& ComplexitiesProgram AbstractsSaturday 15 OctoberEpstein et al (2004)2 used a proportional technique and foundthat the main stem of the IEA will be avoided if trocars areinserted more than two-thirds of the way along a horizontalline between the midline and a sagittal plane running throughthe ASIS.Using CT scanning + contrast and colour Doppler U/Stechniques to track the course of the IEA, Sriprasad et al(2006)3 suggested the safest port placement was along ahorizontal line at the ASIS, more than 6 cm from the midline.Port strategies for safe entry and avoidance of the IEA rely onaccurate knowledge of anatomy, vision of the vessels belowthe arcuate line, good instrumentation and of course luck!Whilst you may miss the main trunk of the IEA, its tributariescan still be hit and cause considerable damage.Rescue procedures to repair damage to the IEA includesuturing the vessel laparoscopically, bipolar diathermy, ballooncatheter techniques and tamponade, interventional radiologyand embolisation, and open surgery.REFERENCES:1. Saber A et al. Annals of Surgery 2004; 239 (2): 182 - 1852. Epstein J et al. Clinical Anatomy 2004; 17: 400 - 4083. Sriprasad S et al. J of Endourology 2006; 20 (7): 498 - 503AUTHOR AFFILIATION: Dr Harry Merkur; MBBS (Syd) FRCOGFRANZCOG, A/Prof O&G University Western Sydney, HonSecretary AGES, VMO SWAHS (Sydney West Area HealthService), VMO Norwest Private, Westmead Private, DirectorSWAPS (Sydney West Advanced Pelvic Surgery Unit),Blacktown, New South Wales, Australia.Session 6 / 1200-1215Liver, spleen, the diaphragm and other funTan J TPractical pointers to management of intra-operative challengesencountered in the upper abdomen will be explored, withvideo examples.AUTHOR AFFILIATION: Dr Jeremy T. H. Tan; Department ofGeneral Surgery, Sir Charles Gairdner Hospital, Nedlands,Western Australia, Australia.Session 7 / 1330-1345Ectopic pregnancy – cornual, cervical,scar – imagingMilward KClose to 99% of ectopic pregnancies occur within theFallopian tubes. Ectopics in other sites can cause diagnosticconfusion leading to delay in diagnosis with consequentincrease in morbidity. Of particular concern are caesarean scarpregnancies, which appear to have been rising in frequencydramatically in recent years. With improving ultrasoundtechnologies and attention to detail, diagnosis should still bepossible soon presentation with symptoms.AUTHOR AFFILIATION: Dr Kristy Milward; Sessional Consultant,Diagnostic Imaging, King Edward Memorial Hospital, Subiaco,Western Australia, Australia.Session 7 / 1345-1410Ectopic pregnancy – management at thedifferent sitesMcElhinney BClinical manifestations of ectopic pregnancy typically appearsix to eight weeks after the last normal menstrual period. Theclassic symptoms of ectopic pregnancy are abdominal pain,amenorrhea and vaginal bleeding. The diagnosis of ectopicpregnancy should be considered in patients in the reproductiveage group complaining of these symptoms, especially in thosewho have risk factors. Over 90 percent of ectopic pregnanciesare located in the fallopian tube, while the remainder implantin locations such as the cervix, ovary, abdomen and caesareanscar. Diagnosis of ectopic pregnancy is based on a combinationof quantitative ßhCG and high resolution TVUS. These testsenable early diagnosis of the ectopic pregnancy, before tubalrupture, and at times an option for medical management.While surgical approaches are the mainstay of treatment,advances in early diagnosis allows medical management inselected individuals. The dose of Methotrexate (MTX) used totreat ectopic pregnancy (50 mg/m2 or 1 mg/kg) is relativelylow. Failure to diagnose ectopic pregnancy before tubal rupturelimits the treatment options and increases maternal morbidityand mortality.MANAGEMENT AT DIFFERENT SITES: These types ofpregnancies are uncommon, and sites include cervical,ovarian, rudimentary uterine horn, abdominal cavity andcaesarean scar.• Cervical pregnancy is estimated to occur in 1 percent ofectopic pregnancies15

AGES Focus Meeting14 & 15 October 2011Program AbstractsSaturday 15 October16• Ovarian pregnancy occurs in 1 to 3 percent of ectopicpregnancies• Interstitial pregnancy accounts for up to 1 to 3 percent ofectopic pregnancies• Abdominal pregnancy accounts for up to 1.4 percent ofectopic pregnancies• Intramural pregnancy refers to pregnancy implanted withinthe myometrium of the uterus and is extremely rareThe most common symptom of CERVICAL PREGNANCY isvaginal bleeding, which is often profuse and painless. Patientswho are haemodynamically stable can be treated medicallyusing multidose MTX therapy with intraamniotic and/orintrafetal injection of local potassium chloride (KCL) whenfetal cardiac activity is present. This treatment is successfulin at least 80 percent of cases. Diagnosis and treatment earlyin pregnancy are important to avoid significant bleeding andhysterectomy.Sonographic diagnosis of an OVARIAN PREGNANCY is difficultand it is typically made at the time of surgery. Thesepregnancies are usually treated by surgical excision of theinvolved organs although MTX treatment has been successfulin case reports.An INTERSTITIAL PREGNANCY can be difficult to distinguishon ultrasound from an intrauterine pregnancy that iseccentrically positioned but it usually appears as a gestationalswelling lateral to the insertion of the round ligament. If thepatient is stable and a suitable candidate, treatment can bewith MTX therapy initially, resorting to surgical therapy if thereis any deterioration in clinical status. Surgical therapy includeshysterectomy for unwanted fertility. A residual mass withpersistent vascularity on ultrasound has been reported despitecomplete hCG resolution; close follow-up in patients treatedmedically is advised. In those with increasing abdominal pain,early surgical intervention should be considered. After medicaltreatment of an interstitial pregnancy, there is an unknown riskof uterine rupture in a future pregnancy.Because of the variable location in the abdomen, ABDOMINALPREGNANCY is associated with a wide range of signs andsymptoms including abdominal pain, vaginal bleeding andpregnancy-related symptoms. Abdominal pregnancies shouldbe interrupted at the time of diagnosis because of the pooroutcome. If diagnosed at an early gestational age (firsttrimester), operative laparoscopy is an option. As the diagnosisis usually made later in pregnancy, medical treatment has notbeen used with much success. If the diagnosis is made late inpregnancy, a viable infant may be delivered via laparotomy.Symptoms of a CAESAREAN SCAR PREGNANCY are similarto tubal ectopic pregnancy, and include vaginal bleeding andabdominal pain. An enlarged mass in the region of the scaris detected by USS. Features include presence of trophoblastbetween the bladder and the anterior uterine wall, emptyuterus and absence of myometrium between the gestationalsac and the bladder. Treatment should be tailored to theindividual patient; fertility desire, gestational age and clinicalstatus of the patient need to be considered. Options includedilatation and curettage (not advisable), removal of the ectopicpregnancy via laparotomy or laparoscopy, hysteroscopicexcision, local injection of KCL into the sac under USS guidanceif the pregnancy has not ruptured, and local or systemicmethotrexate administration. Rupture can result in significantbleeding so these patients need to be monitored closely ifundergoing medical therapy.HETEROTOPIC PREGNANCY: Although the incidence is low,it is increased in patients undergoing ART; the extrauterinepregnancy is usually in the fallopian tube. Difficulty indiagnosis arises because serial hCG concentrations are notinterpretable in the presence of both a viable intrauterine andectopic pregnancy. On ultrasound examination, the diagnosis issuggested by visualization of both an ectopic and intrauterinepregnancy or the presence of echogenic fluid in the POD in thepresence of an intrauterine pregnancy. Surgery (laparoscopicsalpingectomy) is the standard treatment since the intrauterinepregnancy is a contraindication to medical therapy.AUTHOR AFFILIATION: Dr Bernadette McElhinney; King EdwardMemorial Hospital, Subiaco, Western Australia, Australia.Session 7 / 1410-1425Management of ovarian torsion inpregnancyMcEvoy MConsidering ovarian torsion is essential for all obstetricians,gynaecologists, emergency physicians, general practitionersand midwives involved in the care of pregnant women withabdominal pain.The most difficult aspect of ovarian torsion in pregnancy ismaking the diagnosis as acute antenatal abdominal pain isa frequent occurrence with an extensive gynaecological andnon-gynaecological differential diagnosis.Diagnosis is based primarily on a history of sudden, transientand remitting severe abdominal pain accompanied by vomitingand nausea. Torsion occurs more frequently in early rather thanlate pregnancy with an incidence of the order of 1 in 5000.The most frequent pathology is benign teratoma. Torsion of anormal ovary is exceptional but torsion of a normal fallopiantube with or without the ovary is more frequent.

Gynaecological Conundrums& ComplexitiesProgram AbstractsSaturday 15 OctoberExamination usually reveals an adnexal mass on bimanualexamination. Bedside vaginal and abdominal ultrasound andformal ultrasound are the prime methods for confirmation ofthe diagnosis. However solid ovarian masses can be confusedfor bowel and missed by ultrasound. Likewise Doppler flowmay either over or under diagnose torsion of the ovary. Acombination of ultrasound with magnetic resonance imagingmay improve diagnostic acumen and is particularly useful forthe diagnosis of appendicitis, ilea or volvulus, common bileduct stones, pancreatitis and diverticulitis. CT scanning mayalso be a useful adjunct.Once a diagnosis of ovarian torsion has been made, urgentsurgical intervention should occur. The use of laparoscopy inpregnancy, even in the second and third trimester, has beenshown to be safe. An open approach can always be used ifrequired.Options for surgical intervention include inspection todetermine ovarian necrosis and perfusion followed by adecision to either untwist the torsion or remove the torsion.Ovarian ligamentopexy may also be considered to prevent the15 % which recur.AUTHOR AFFILIATION: Dr Michael McEvoy; Senior VisitingGynaecologist, Womens & Childrens Hospital, North Adelaide,South Australia, Australia.0.01%. Increased pick up of masses with more frequent, betterquality ultrasound. Tumour markers are generally unreliable.Conservative surgery during early pregnancy is possible.Chemotherapy may be instituted depending on the trimesterwhile achieving fetal maturity to delay definitive surgery tilldelivery at fetal viability.Endometrial carcinoma – Very uncommon during pregnancy.Presence usually results in infertility. If pre-existing diseaseis treated conservatively then progression may occur duringpregnancy.AUTHOR AFFILIATION: Dr Stuart Salfinger MBBS, FRANZCOG,CGO. Certified Gynaecologic Oncologist, Western Australia,Gynaecologic Cancer Service - KEMH & SJOG Hospitals, ClinicalSenior Lecturer, School of Women’s and Infants Health -University of Western Australia, Perth, Western Australia,Australia.Session 7 / 1425-1445Cancer in pregnancySalfinger SCancer in pregnancy presents a complex clinical dilemma thatrequires consideration of the disease, maternal factors andfetal factors in its management. Treatment is best managed ina multidisciplinary team scenario.Cervical cancer – 1-3% of cases are diagnosed in pregnancy.Diagnostic delay can be an issue. Generally slowly progressivedisease may allow delays in treatment to allow fetal viabilityhowever interruption of pregnancy may be required tooptimize maternal outcomes. Treatment options include earlyexcisional treatment for early invasive lesions. Treatmentof more advanced early pregnancy lesions usually involveseither radical surgery or chemo-radiation, which will interruptthe pregnancy. In later pregnancy non-standard options mayinclude neo-adjuvant chemotherapy to ‘buy time’ whiledelaying standard treatment till fetal maturity and deliverywhen definitive treatment can be instituted.Ovarian carcinoma – lifetime risk of ovarian carcinoma 1.7%,chance of complex ovarian mass during pregnancy 0.2-2.0%,risk of ovarian carcinoma during pregnancy during pregnancy17

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Gynaecological Conundrums& ComplexitiesFree Communications 1Friday 14 OctoberFree Communications 1 / 1330-1340A minimal access surgical approach tocornual ectopic pregnancyLarmour L, Najjar H, Shashan T, Tsaltas JAIM: To demonstrate a minimal access surgical techniquefor the management of cornual ectopic pregnancy, a rare(accounting for 2-4% of all ectopic pregnancies, or 1 in 2 500to 5 000 live births ) but potentially life threatening condition.METHODS: We present a case report with video footage of theminimal access surgery.RESULTS: A woman with a ectopic pregnancy thoughtto be tubal from ultrasonographic imaging was takenfor laparoscopic excision of the pregnancy. On operativeexploration the pregnancy was found to have a cornualcomponent. To facilitate surgical management of the ectopicpregnancy adrenaline was injected into the myometriumsurrounding the pregnancy prior to myometrial incision anddebulking of the ectopic pregnancy. Following debulking ofthe cornual component of the pregnancy salpingectomy wasperformed. Postoperative recovery was uncomplicated andthe patient had a rapid decline in serum hcg values. She had ashort inpatient stay in hospital.CONCLUSION: We have demonstrated that laparoscopicresection of a cornual ectopic pregnancy can be a safe andeffective method for management of this rare condition.REFERENCE:1. Damario, M. A., Rock J.A., 2008, Ectopic Pregnancy, in Rock, J.A.,Jones III, H.W., Te Linde’s Operative Gynecology, (10th edition),Philadelphia, Lippincott WIllian & Wilkins, p 816AUTHOR AFFILIATION: L. Larmour, H. Najjar, T. Shashan, J.Tsaltas; Monash Medical Centre, Clayton, Victoria, Australia.Free Communications 1 / 1340-1340The role of the gynaecological oncologistin a tertiary hospitalActon J, Salfinger SINTRODUCTION: Whilst the prime role of a gynaecologicaloncologist is the comprehensive management of womenwith a gynaecologic cancer, increasingly their surgical skillsare often utilised for general gynaecological and obstetricsurgery. Within tertiary centres there is increasing provisionof support, for both emergency cases and booked complicatedcases. The recent National Gynaecologic Cancer Centre’sDelivery and Resource Framework found that the number ofwomen across Australia currently requiring complex surgeryby gynaecological oncologists for benign conditions that couldbe treated by gynaecologists with more advanced surgicalskills is unclear and that this must be further investigated forworkforce planning. This study aims to investigate and definethe growing role of the gynaecological oncologist withinobstetrics and gynaecology and ascertain how it can be bestutilised.METHOD: A retrospective study was conducted, involvingall non gynaecological oncology unit cases from 2006-2010that required the presence of a gynaecological oncologistin theatre. The preoperative diagnosis, surgical procedures,reason for requiring assistance, complications, outcomes andwhether the cases were booked or emergency were noted.RESULTS: A wide variety of surgical situations that required theinvolvement of a gynaecological oncologist were identified.These ranged from complications such as bowel injuries andhaemorrhage, to gynaecological surgeries in complicatedpatients, and obstetric procedure in high-risk women such asplacenta acreta and intra-operative diagnosis of unexpectedmalignancy. The results included both emergency and bookedprocedures.CONCLUSION: The role of the gynaecological oncologistwithin a tertiary centre is expanding to include the provisionof support to general gynaecologist and obstetricians. Thereis increasing utilisation of these services whereby theirassistance in pre-arranged prior to the surgery, howeveremergency cases requiring assistance is not uncommon.Discussing possible high risk or complicated cases with thegynaecological oncology team prior to operation can improveoutcomes.AUTHOR AFFILIATION: J. Acton, S. Salfinger; King EdwardMemorial Hospital, Subiaco, Western Australia, Australia.Free Communications 1 / 1350-1400Tuberculous peritonitis mimickingadvanced ovarian malignancy - anemerging clinical conundrumMenon A, Thottungal A, Leung Y, Dickinson JEBACKGROUND: Tuberculosis continues to be endemic inthe developing world and has shown a resurgence in theWestern countries. Tuberculous peritonitis is rare, but hasincreased in incidence over the past decade, accounting for3.3% of cases of extrapulmonary TB. In female patients theclinical presentation and findings of ‘wet type’ of tuberculousperitonitis can mimic advanced ovarian cancer and thediagnosis is often made at laparotomy.19

AGES Focus Meeting14 & 15 October 201120Free Communications 1Friday 14 OctoberWe present two cases of tuberculous peritonitis who hadpresented with non specific abdominal symptoms, massiveascites and elevation of CA-125.CASE1: 48 yr old immigrant woman from China was referredwith a diagnosis of advanced ovarian cancer following CTand ultrasound. A repeat ultrasound showed a right ovariancyst with no sinister features, extensive ascites and pleuraleffusions. She underwent laparotomy with a provisionaldiagnosis of advanced ovarian cancer. Histology showednecrotising granulomatous reaction and culture grewMycobacterium tuberculosis.CASE2: 79 year old woman, an immigrant from Vietnam, wasreferred from another hospital for further investigation ofgross ascites. An ultrasound examination showed free fluid inthe pelvic cavity and a normal left ovary. Her CT scan and PETscan showed findings consistent with advanced malignancy.Laparotomy findings were consistent with granulomatousperitonitis. The histology and microbiology resultsconfirmed TB.DISCUSSION: The sonographic appearance of tuberculousperitonitis consists of ascites with debris, membranesand delicate floating septations. Although there are nofeatures alone or in combination that are pathognomonicof tuberculosis, these ultrasound features especially in thepresence of an adnexal mass /pelvic mass with low echogeniccontent is highly suggestive of tuberculous peritonitis withfemale genital tract tuberculosis. During laparotomy frozensections are necessary to differentiate TB and malignancywhich reveals chronic granulomatous reaction with orwithout caseating necrosis and acid fast bacilli on ZN stain.Mycobacterium culture is the gold standard for diagnosingTB despite its long incubation period. In contrast, PCR testingestablishes the diagnosis in 24-48hours. However in casesof extrapulmonary TB the sensitivity of PCR may be greatlyreduced due to very low bacterial load.CONCLUSION: A high index of suspicion of tuberculousperitonitis to be maintained in patients presenting withascites and nonspecific clinical symptoms and signs. Testingfor tuberculosis should be considered pre-operatively. Frozensection to be done intra-operatively to avoid unnecessaryextensive surgery and delay in anti-tuberculous treatment. Thehigh risk group include immigrants from developing countries,patients with HIV and immunosuppression.AUTHOR AFFILIATION: A. Menon, A. Thottungal, Y. Leung, J.E. Dickinson; Department of Obstetrics & Gynaecology, KingEdward Memorial Hospital, Perth, Western Australia, Australia.Free Communications 1 / 1400-1410Retrospective review to assess thecorrelation of small nerve fibres atuterine curettage to laparoscopic findingsof endometriosisMa T, Leslie C, Stewart C, McElhinney BINTRODUCTION: ‘Gold standard’ diagnosis of endometriosisis currently by laparoscopy and biopsy. This results in delayeddiagnosis and is invasive with potential iatrogenic injury,expensive and operator dependent 1)The presence of small nerve fibres at endometrial samplingby uterine curettage may be a possible indirect test forendometriosis (n=99, specificity of 83% and a sensitivity of98%) 2 .This study was performed to see if these findings could bereplicated at King Edward Memorial Hospital.METHOD: Ethics approval was obtained (Reg No: 2290 -06/10).Theatre records were searched for all cases where alaparoscopy and hysteroscopy, dilation and curettagewere performed on the same day from 2006-2009. Thesepatients were then checked with pathology records to isolatewhich patients had laparoscopically confirmed diagnosis ofendometriosis. 25 patients were eligible for inclusion.Controls were patients who underwent the same proceduresduring the same time period but were negative forendometriosis. 20 controls were used.Patients had their clinical notes and operation reportsreviewed. Specimens were reviewed by a pathologist blindedto the clinical findings.RESULTS: 1 control did not have sufficient material forassessment and was excluded. 6 patients (3 cases and 3controls) were equivocal for the presence of small nerve fibresand treated as negative. Presence of small nerve fibres wasfound to have a sensitivity of 28% (7/25), specificity of 68%(13/19), positive predictive value of 50% (7/14) and negativepredictive value of 40% (12/30).DISCUSSION: This study was unable to replicate the findingsof Al Jefout et al., though the study design is significantlydifferent.The results of this study suggest that endometrial curreting forsmall nerve fibres is a poor diagnostic test for endometriosis ina routine clinical setting.The search for an ideal diagnostic test for endometriosisremains.

Gynaecological Conundrums& ComplexitiesFree Communications 1Friday 14 OctoberREFERENCES:1. R Schenken. Pathogenesis, clinical features, and diagnosis ofendometriosis. Uptodate. Ver 18.3. 2010.2. Al-Jefout M, Dezarnaulds G, Cooper M, Tokushige N, Luscombe GM,Markham R, Fraser IS. Diagnosis of endometriosis by detectionof nerve fibres in an endometrial biopsy: a double blind study.Human Reproduction. 24(12):3019-3024. 2009.AUTHOR AFFILIATION: T. Ma a , C. Leslie b , C. Stewart c , B.McElhinney d ; a. Obstetrics and Gynaecology Registrar, KingEdward Memorial Hospital, Perth, Western Australia, Australia.b. Pathology Registrar, King Edward Memorial Hospital, Perth,Western Australia, Australia. c. Pathology Consultant, KingEdward Memorial Hospital, Perth, Western Australia, Australia.d. Obstetrics and Gynaecology Consultant, King EdwardMemorial Hospital, Perth, Western Australia, Australia.Free Communications 1 / 1410-1420Tubal choriocarcinoma - A case report andliterature reviewRoy A, Marry J, Chan FBACKGROUND: Few cases of Tubal choriocarcinoma havebeen reported. We present 2 such cases of right tubalchoriocarcinoma in SSWAHS in last 2 decades.CASE: First case illustrates a 48 yr. old woman presentingwith 12 weeks of amenorrhea and abdominal pain in the year2007. TV USS showed complex right adnexal mass. B- HCGwas 26000IU. Overall clinical picture was highly suspicious ofEctopic pregnancy. She subsequently had laparoscopic rightsalpingectomy and ligation of the left tube. Histopathologyconfirmed right hemosalpinx with choriocarcinoma. Furtherinvestigations showed no evidence of metastasis. She received3 cycles of Chemotherapy. Her follow up B-HCG level fell tonormal within 3 months.Second case is of a lady of age 32 presenting with s/s ofectopic pregnancy in the year 1994 with Beta HCG of 27700.On laparoscopy- right tubal abortion was diagnosed with intacttube and the histopathology confirmed choriocarcinoma.CONCLUSION: This case stresses the important role ofhistopathologic examination in all tubal pregnancies toavoid missing this rare but a dreadful entity. Moreover, closefollow-up of human chorionic gonadotropin levels is requiredwhenever a GTD is suspected.TUBAL CHORIOCARCINOMA – CASE REPORTSCASE ONE (YEAR 2007) A 48 yr. old woman presented toher GP with pelvic pain and amenorrhoea of 12 wks in earlyApril 2007. She had several years of menstrual irregularityand was unaware that she could conceive and believed shewas postmenopausal. She had 20 yr old daughter born byNVD and 2 miscarriages of 4-6 wk sizes, several yrs ago. Herpast medical and surgical history included 2 laproscopies forsecondary infertility, cholecystectomy, obesity, hypertensionand left total knee replacement surgery. She was a chronicsmoker and was up-to-date with pap smears. She had familyhistory of bowel cancer. Her blood gp was A+.Her LMP was 1/2/2007 and urine pregnancy test camepositive, further confirmed by serum beta HCG of 6716(2ndApril). Her 1st USS (10th April) failed to identify pregnancyand the 2nd USS (24th April) showed a small hypo echoic areain right adnexa (? ectopic pregnancy, ? ovarian mass) withvery vascular right ovary and bulky uterus with multiple smalluterine fibroids. The quantitative beta HCG was high with levelof 26000. She was referred to Campbeltown ED.On presentation to Hospital, she had minimal low abdominalpain with nil PV bleeding. On examination, her abdomen wassoft and nontender and bimanual examination revealed normalsized anteverted uterus, nil adenexal mass or tenderness, nilcervical excitation. Her serum HCG was 27828 on 25/4/11.A possibility of ectopic pregnancy or HCG producing ovariantumour was raised. She was consented for laparoscopicsalpingectomy +/- oophorectomy and ligation of left tube onpatient request. Laparoscopy revealed 4 cm right tubal pregnancywith normal right ovary and 2 cm left ovarian cyst. She hadright salpingectomy, left tubal ligation and D&C on 26/4/11. Herpostoperative period was uncomplicated and was dischargedhome on day 2 with f/up plan in 2 weeks in Gynae clinic.The histopathology report was right hemosalpinx withchoriocarcinoma and gestational alteration of endometrium.The slides were sent to Dr Peter Russell, RPAH for secondopinion and that confirmed choriocarcinoma of right tube.The patient was referred to the Gynaecological Oncologyat Liverpool Hospital for further management. The ChestX-ray was normal and CT Abdomen and pelvis showednil metastasis. F/up Beta HCG dropped to 402 by 7th May2007. The case was discussed at MDT and decision to startchemotherapy with EMACO was taken. The chemotherapywas started on 1/6/2007 and her HCG normalised by 2ndcycle. She in total received 3 cycles of EMACO with nil adverseeffects. She was finally discharged from gynaecologicaloncology clinic in July 2008 after 1 yr of normal HCG f/up.CASE TWO (YEAR 1997) A 32 yr. woman, G4P3 presentedto Campbeltown on 18/2/1997 with abdominal pain, PV21

AGES Focus Meeting14 & 15 October 2011Free Communications 1Friday 14 Octoberbleeding. Serum Beta HCG was 27700 on 13th Feb 1997. Adiagnostic laparoscopy was planned with suspicion of ectopicpregnancy. Laparoscopy has to be converted to minilaprotomyon 14/2/11. Intra-operative finding was right tubal abortionadherent to broad ligament and right ovary, right tube wasintact, 300mls blood in POD, normal left tube and ovary. Theevacuation of right ectopic was done with minimal intraoperativebleeding. Postoperative recovery was uneventfuland she was discharged home on 18/2/11 with f/up planin gynae clinic in 3 wks. The Beta HCG on 15/2/97, prior todischarge was 4550.She was a healthy woman and had 3 kids with nil miscarriageor TOP. Her youngest child was 2 yr old and her Blood groupwas A positive.The patient delivered a healthy baby 2 yrs later.DISCUSSION: Choriocarcinoma is a highly malignant tumourof the villous trophoblast which lacks placental villi andmolar vesicle. This is a necrotic and haemorrhagic tumour.1st described by MARCHAND in 1895, it has been primarilyreported in individual cases with exception of small seriesfrom the New England GTD Register which reported 6 primarytubal choriocarcinoma in 2100 cases over 25 yrs 9 .Incidence-It may complicate any pregnancy with a risk ofoccurrence of 1 / 160 000 in normal pregnancy, 1 / 15 386in case of abortion, 1 / 5333 in case of ectopic pregnancyand 1/40 if hydatidiform mole 2, 4 . Gestational choriocarcinomaoccurs in approximately 4/100,000 pregnancies in Australia 1 .Primary gestational choriocarcinoma of the fallopian tube iseven rarer with unknown incidence.Age-tubal choriocarcinoma can develop in all women duringtheir reproductive years, but especially beyond 40 years giventhe increasing incidence of molar pregnancySite-The location of the right tubal choriocarcinoma seems5, 6, 7, 8much more frequent22

Gynaecological Conundrums& ComplexitiesFree Communications 1Friday 14 OctoberParity-choriocarcinoma always occurs in a woman who hadat least one pregnancy carried to term or not, with a latency2, 3, 4, 7period ranging from two months to 15 yearsChemotherapy-Given the rarity of the condition, there are noguidelines for the use of adjuvant chemotherapyCONCLUSION: Tubal choriocarcinoma is rare but has dreadfulprognosis without treatment. Our case is interesting becauseit points to the indispensability of histological examination incase of management of the ectopic pregnancy. The diagnosisof choriocarcinoma should be considered in all tubal ectopicpregnancies with an abnormal elevation of Beta HCG andsalpingectomy should be performed. The CT scan is currentlythe gold standard for staging. Using the FIGO score, bringsthe standard treatment of choriocarcinoma and improves theprognosis of patientsACKNOWLEDGEMENTS: The author would like to acknowledgeDr Santos for his valuable contribution.COMPETING INTERESTS: None declared.REFERENCES:1. Altieri A, Franceschi S, Ferlay J, Smith J, La Vecchia C. Epidemiologyand aetiology of gestational trophoblastic diseases. Lancet Oncol2003; 4: 670-6782. Vuong PN, Guillet JL, Houissa-Vuong S, Lhomme C, Proust A,Cristalli B. Pathology of gestational trophoblastic tumors. GynecolObstet Fertil 2000; 28: (12) 913-926.3. Golfier F Raudrant D Frappart L, Guastalla JP, Trillet-Lenoir V,Mathian B, et al. The hydatidiform moles and trophoblastic tumors:management practice. CNGOF. Updates Obstet Gynecol 2003; XXVII:53-99.4. Phan TH, Nguyen TN, Phan VQ. A clinical trial is diagnostic scoringsystem of choriocarcinoma and invasive mole in Vietnam. J ObstetGynaecol 1995; 21: (3) 257-262.5. Body G, Tariel D, Y Bach, EH Metman, Fetissof F, Lansac J. Tubalchoriocarcinoma: a case report. J Gynecol Obstet Biol Reprod(Paris) 1985; 14: (6) 735-740.6. Soulier A, Chasseray JE, Riquet M, Bellamy J, Aurousseau R. Tubalchoriocarcinoma. A case report. J Chir (Paris) 1982, 119: (4) 267-270.7. Chan DP, Wong WP. Ectopic gestational choriocarcinoma. Report ofTwo boxes. Obstet Gynecol 1970; 35: (5) 730-733.8. Patton GW, Goldstein DP. Gestational choriocarcinoma Of The tubeand ovary. Surg Gynecol Obstet 1973; 137: (4) 608-612.9. Muto MG, Large JM, Bezkowitz RSAUTHOR AFFILIATION: A. Roy, J. Marry, F. Chan; LiverpoolHealth Services, New South Wales, Australia.Free Communication 1 / 1420-1430Identifying factors associated withhaemorrhage at hysterectomyBurnet SOBJECTIVE: A retrospective review of data collected over an11 year period where a hysterectomy was performed, and thepatient suffered a perioperative complication of haemorrhage(defined as > 500mls blood loss).The aim was to identify patient or surgeon variables that maybe associated with intra-operative haemorrhage. Also themost common site of haemorrhage was recorded.METHODS: The SWAPS database was searched and notesreviewed where a hysterectomy was performed withhaemorrhage of >500mls. Patient and surgeon factors wereanalysed and compared with a control group.The patient factors of age, BMI, associated surgery, sizeof uterus, presence of adhesions or endometriosis wereanalysed, as well as surgeon factors of years in practice, yearsperforming hysterectomies, percentage of total workloadbeing in gynaecology.The results of this study will help in predicting factorsassociated with increased risk of haemorrhage athysterectomy, as well as common sites of hemorrhage.AUTHOR AFFILIATION: S. Burnet; Sydney West AdvancedPelvic Surgery Unit, Blacktown Hospital, Blacktown, New SouthWales, Australia.Free Communications 1 / 1430-1440Update on surgical treatment for infertilewomen with endometriosisTsaltas J, Myers C, Druitt MDespite the interest and research that is going intoendometriosis, it is still a poorly understood condition.Endometriosis is known to be associated with infertilityhowever there is a very incomplete understanding of howsignificant its impact is and, more particularly, how best totreat infertility in the setting of endometriosis.We have done a review of the literature and analysis of all thesignificant trials relating to surgical treatment of endometriosisfor infertility.The literature relating to treatment for infertility in minimal/mild endometriosis is relatively simple. There have been2 major trials and these have been reviewed as part of aCochrane review 1 . They findings of the meta analysis are that23

AGES Focus Meeting14 & 15 October 2011Free Communications 2Friday 14 October24surgery for these women improves fertility.The evidence for surgical treatment in infertile women withmore severe endometriosis is much more confusing. Thereare a number of small trials looking at different surgicaltechniques. Some of these are well conducted using controlgroups. Others are large retrospective reviews of a singleperson or a single institution’s cases. We reviewed theliterature to ascertain if any particular surgical treatmentoptions have the support of good evidence. The studieswere assessed with the GRADE system and then overallrecommendations for found.The findings of the literature review and with ourrecommendations will be presented.REFERENCES:1. Jacobson TZ, Duffy JMN, Barlow D, Farquhar C, Koninckx PR,Olive D. Laparoscopic surgery for subfertility associated withendometriosis. Cochrane Database of Systematic Reviews 2010,Issue 1. Art. No.: CD001398. DOI: 10.1002/14651858.CD001398.pub2AUTHOR AFFILIATION: J. Tsaltas, C. Myers, M. Druitt; MonashMedical Centre, Clayton, Victoria, Australia.Free Communications 2 / 1330-1340Persistent abdominal ectopic pregnancyafter cornual rupture and expulsionSmith CJ, Morris AR, Lyons SDCASE REPORT: A 36 year old nulliparous woman presented tothe emergency department with severe right iliac fossa pain inthe setting of a positive BhCG. She had previously undergonea laparoscopic myomectomy for a right broad ligament fibroid,at which a concurrent right salpingo-oophorectomy wasperformed.Emergency laparoscopy revealed a large haemoperitoneum;adhesiolysis of omental adhesions to the uterus confirmed theruptured right cornua as the site of haemorrhage. Laparoscopicwedge resection was performed with restoration of anatomywith extra-corporeal sutures. Intra-operative histopathologicevaluation confirmed trophoblast including features consistentwith an implantation site but no definite products ofconception. Despite systematic inspection of the peritonealcavity, no gestational sac was observed.Post-operative recovery was excellent, however, the gradualdecline in BhCG level plateaued after three weeks and thenbegan to rise. A pelvic ultrasound found no intrauterinegestational sac, although a small spherical mass was identifiedsuperior to, and separate from, the right uterine fundus.Secondary laparoscopy confirmed an abdominal ectopicpregnancy suspended between an omental adhesion and thebladder peritoneum. The right cornua remained intact. Thepregnancy was excised and confirmed on histopathology.Biopsies of abnormal peritoneum within the pelvis confirmeddisseminated trophoblast.BhCG levels initially decreased and then plateaued again. Dualdose methotrexate treatment was necessary for restoration ofnon-pregnant BhCG levels.DISCUSSION: The optimal approach for the management ofabdominal ectopic pregnancy diagnosed at early gestationis thought to be via operative laparoscopy as it providesminimally invasive, endoscopic treatment of a potentiallylife threatening condition¹. There is little evidence to supportthe use of primary methotrexate in the treatment of thiscondition². We present an unusual case of a persistentabdominal pregnancy after cornual rupture and presumedexpulsion, which required both surgical and medicalmanagement for successful resolution.REFERENCES:1. Gerli S, Rossetti D, Baiocchi G, Clerici G, Unfer V, Di Renzo GC.Early ultrasonographic diagnosis and laparoscopic treatmentof abdominal pregnancy. Eur J Obstet Gynecol Reprod Biol.2004;113(1):103.2. Zinger M, Rosenfeld D. Failed treatment of abdominal pregnancywith methotrexate. A case report. J Reprod Med. 2001;46(4):392.AUTHOR AFFILIATION: C. J. Smith, A. R. Morris, S. D. Lyons:Department of Obstetrics and Gynaecology, Royal North ShoreHospital, St Leonards, New South Wales, Australia.Free Communications 2 / 1340-1350Initial Australian experience withMyoSure: a novel mechanical hysteroscopictissue removal systemLaw K, Abbott JINTRODUCTION: MyoSure (Hologic, Inc., Bedford MA, USA)is a novel hysteroscopic mechanical tissue removal systemthat enables fast and safe removal of intracavitary fibroidsand polyps, with the potential to be used in the office-basedsetting.METHODS: Video presentation of a single-operator initial caseseries.RESULTS: We present a case series of six women treated withthe MyoSure system, including a 5cm intracavitary polyp, anendocervical fibroid, and a 4cm type 1 fundal submucosalfibroid. All procedures were performed under general

Gynaecological Conundrums& ComplexitiesFree Communications 2Friday 14 Octoberanaesthesia in the operating theatre. The 5cm intracavitarypolyp was completely removed using the MyoSure systemin 3 minutes. The removal of the 4cm submucous fibroidwas terminated when the fluid deficit reached 2L of normalsaline. Approximately 50% of the fibroid was removed. Inall of the cases in this series, there were no intra-operativecomplications, and histological examination showed nomalignancy.DISCUSSION: Conventional hysteroscopic removal ofintracavitary polyps and fibroids is performed with amonopolar electrosurgical loop introduced via a 10mmresectoscope, using a nonconducting distension medium e.g.1.5% glycine. Various resectoscopic systems that allow theuse of physiological distension fluid (e.g. 0.9% NaCl) havebeen described, and the MyoSure system is the most recentlyintroduced system which incorporates a 6.25mm hysteroscopeand a mechanical tissue removal device that simultaneouslycuts and removes tissue. However, even though the fluid lostis isotonic, clinicians should not be lured into a false sense ofsecurity, as there is still a risk of hypervolaemia.Our initial experience with MyoSure is promising, with goodintra-operative results. One advantage is the shorter proceduretime compared to conventional hysteroscopic resection, andfibroids up to 3cm can be removed in less than 10 minutes.The ability to cut and remove tissue at the same time resultsin better vision and improved efficiency and safety, minimisingthe need to take out and reinsert the hysteroscope duringsurgery and thereby reducing the potential for cervicaltrauma and perforation. The tissues removed are collectedin a “tissue trap”, allowing histological examination of allremoved tissues with no thermal artefact. The small diameterof the hysteroscope means that minimal cervical dilatation isrequired, and the system may be suitable to be used officebasedsetting in selected patients.CONCLUSION: The MyoSure is an alternative new option forminimally invasive management of intracavitary fibroids andpolyps, but randomised, comparative studies with prospectivedata collection regarding complications are recommended.AUTHOR AFFILIATION: K. Law, J. Abbott; Royal Hospital forWomen, Barker Street, Randwick, New South Wales, Australia.Free Communications 2 / 1350-1400Gut on the floor: vaginal eviscerationArachchi A, Davidson A-J , Vasudevan A, Maung H, Sanasuriya CA 77 year old female presented to the emergency departmentafter noticing a mass that came out of her vagina. She wasstraining to defecate and suddenly noticed loops of bowelprolapsing through her vagina. She had previously had aTension-free Vaginal Tape or Trans-Vaginal Tape (TVT) nineyears earlier for stress incontinence and was on morphine forchronic back pain, associated with multiple myeloma, whichcaused her to strain on defecation. On examination therewas vaginal evisceration of multiple loops of small bowel.The patient had an emergency midline laparotomy. The smallbowel loops were reduced bi-manually without any smallbowel resection.. Small piece of semi degraded tape fromthe TVT was found at the site of vaginal wall perforationsuggesting the tape had eroded in to the posterior fornix ofthe vagina leading to the evisceration. The vaginal defectwas closed and an inlay layer of Surgisis (biological mesh)mesh was used to support the pelvic floor. The patient’s postoperativerecovery was complicated by a large myocardialinfarction and she unfortunately passed away 4 weeks afterthe surgery.Vaginal evisceration of the small bowel is rare 1 . Presentationsinclude pelvic pain, vaginal bleeding and a protruding mass 2 .It is more common in postmenopausal women and mostcommonly occurs in patients who have had previous vaginalsurgery but may occur spontaneously 2 . It represents a surgicalemergency.REFERENCES:1. V. Giridhar, P. B. Kumar, K. Natarajan & P. Hegde. : VaginalEvisceration Following Anterior Pelvic Exenteration. The InternetJournal of Oncology. 2010 Volume 7 Number 12. Yaakovian MD, Hamad GG, Guido RS. Laparoscopic managementof vaginal evisceration: case report and review of the literature. JMinim Invasive Gynecol. 2008 Jan-Feb;15(1):119-21AUTHOR AFFILIATION: A. Arachchi 1 , A-J. Davidson 1 , A.Vasudevan 2 , H. Maung 1 , C. Sanasuriya 3 ; 1. Monash University,Clayton, Victoria, Australia. 2. Newcastle University, New SouthWales, Australia. 3. Melbourne University, Parkville, Melbourne,Victoria, Australia.25

AGES Focus Meeting14 & 15 October 2011Free Communications 2Friday 14 OctoberFree Communications 2 / 1400-1410The early pregnancy assessment servicecard: a suggestion from a retrospectiveaudit of an EPAS unitBudden A, Salim S, Abbott JBACKGROUND: Miscarriage affects approximately 55,000Australian couples annually with many women initiallyattending primary care providers rather than specialistservices. In response to this most obstetric hospitals offer anEarly Pregnancy Assessment Service to manage and supportthese women and their families.AIM: To assess the adequacy of our EPAS unit with respectto the DOH auditable standards and suggest a change inmanagement for future patients.METHOD: Auditable information was collected in a databaseand included:• Appropriate use of anti-D prophylaxis• Appropriate screening for genital tract infection• Appropriate use of serial investigations (BhCG,Progesterone)• Uptake rates for expectant and surgical interventions• Complications of management• How many visits are required to reach definitive diagnosis• Are our current documentation methods appropriate toaddress the aboveA retrospective analysis of EPAS consultations was conductedand information used to develop the EPAS card for future use.RESULTS: 597 patient consultations were reviewed of which362 (60.2%) were new presentations. Documentation wasvariable and potential for omissions and inefficient carewere noted, often largely due to the variety of sources thatinformation was initiated (GP, Accident and Emergency) anda lack of single, patient-held information card. An example ofthis is the 15.8% of women with no rhesus status documentprior to referral and almost none adequately documented timefrom bleeding to anti-D. The use of laboratory investigationssuch as BHCG, serum progesterone, and appropriatescreening for genital tract infection were also difficult totrack. Importantly, there was poor documentation of thefinal outcome with concerns that patients may be attendingother health care facilities, and as such complications ofinterventions could be under reported. In response to thisaudit, an EPAS card has been drafted – akin to the antenatalcard – with patient-held information that is transferable andeasily identifiable. This card will be assessed with the aboveauditable information as to improving patient care throughthis system.CONCLUSION: An Early Pregnancy Assessment Service Cardhas been drafted to help with adequate documentation andauditing of the service. This card will serve as the new referralletter and it is hoped it will guide primary practitioners inappropriate investigations and referral, as well as providing aneasier method of audit and follow up of patients that attendthe service.AUTHOR AFFILIATION: A. Budden 1 , S. Salim 2 , J. Abbott 1,2 ; 1.Royal Hospital for Women, Randwick, Sydney, Australia. 2.University of New South Wales, Sydney, Australia.Free Communications 2 / 1410-1420A novel cause of ureteric obstruction!Long term deposition of foreign bodiesinto the vaginaAmir M, Talmor A , Pearce S, Myers C, Tsaltas JA case report of an elderly schizophrenic patient with aprotracted history of inserting foreign bodies into her vagina.The patient was treated with a total abdominal hysterectomyfollowing vaginal evacuation of over one kg of tightlycompacted matter.The consequence of this ingrained behavioural trait wasurinary incontinence caused by two vesico-vaginal fistulae,stretched urethra and bladder, and left ureteric obstructionresulting in renal dysfunction.Following surgical intervention, the patients renal functionimproved; she declined any further intervention to repair thefistulae.As far as we know this is the first case report of long standing,foreign bodies within the vagina acting in the same way as apelvic space occupying lesion; causing ureteric obstruction.AUTHOR AFFILIATION: M. Amir, A. Talmor, S. Pearce, C.Myers, J. Tsaltas; Monash Medical Centre, Clayton, Victoria,Australia.26

Gynaecological Conundrums& ComplexitiesFree Communications 2Friday 14 OctoberFree Communication 2 / 1420-1430Pregnancies with donor eggs afteradnexal clearances for severe recurrentendometriosis: two cases and a discussionof the issuesDruitt M, Tsaltas J, Yazdani ATwo women required repeated surgery for recurrent severeendometriosis including bowel resections. Pain and quality oflife eventually necessitated bilateral salpingo oophorectomyand removal of all visible endometriosis. IVF with donor eggsfrom younger sisters followed.Issues with assisted conception, risks in pregnancy andmanagement of them will be discussed with reference to theliterature.AUTHOR AFFILIATION: M. Druitt 1 , J. Tsaltas 1 , A. Yazdani 2 ; 1.Monash Medical Centre, Clayton, Victoria, Australia. 2. RoyalBrisbane & Women’s Hospital, Herston, Queensland, Australia.GYN 37-1 a5-quer-australia-04-2009:GYN37-a5landscape-aus 06.04.2009 11:57 Seite 1ROTOCUT TM G1 –The New Morcellator GenerationExtremely simple handling combinedwith maximum powerGYN 37.1/E/6/07/AKARL STORZ GmbH & Co. KG, Mittelstraße 8, D-78532 Tuttlingen/Germany, Phone: +49 (0)7461 708-0, Fax: +49 (0)7461 708-105, E-Mail: info@karlstorz.deKARL STORZ Endoscopy Australia Pty. Ltd., 15 Orion Road, Lane Cove NSW 2066, Phone +61 (0)2 94906700, Fax +61 (0)2 94200695, karlstorz@karlstorz.com.auwww.karlstorz.com27

AGES Focus Meeting14 & 15 October 2011Gynaecological Conundrums& Complexities28

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Thisinsurance is to be purchased in your country of origin.Pricing policy:It is impossible to predict increases to cost elements such asgovernment taxes and other service provider tariffs. In the event ofsuch fluctuations or increases affecting the price of the Conference,we reserve the right to adjust our prices as may be necessary atany time up to and including the first date of the Conference, eventhough the balance payment may have been made.If we are forced to change your booking or any part of it for anyreason beyond our control – for instance, if an airline changes itsschedule – we reserve the right to vary your itinerary and will giveyou, or cause to be given to you, prompt notice thereof.Conference Costs do not include: Insurance, telephone calls,laundry, food and beverage except as itemised in the brochure, anditems of a personal nature.Travel and Accommodation:The Conference Organisers are not themselves carriers orhoteliers nor do we own aircraft, hotels, or coaches. The flights,coach journeys, other travel and hotel accommodation hereinare provided by reputable carriers and hoteliers on their ownconditions. It is important to note, therefore, that all bookings withthe Conference Organisers are subject to terms and conditionsand limitations of liability imposed by hoteliers and other serviceproviders whose services we utilise, some of which limit or excludeliability in respect of death, personal injury, delay and loss ordamage to baggage.Our responsibility:The Conference Organisers cannot accept any liability of whatevernature for the acts, omissions or default, whether negligent orotherwise of those airlines, coach operators, shipping companies,hoteliers, or other persons providing services in connection withthe Conference pursuant to a contract between themselves andyourself (which may be evidenced in writing by the issue of aticket, voucher, coupon or the like) and over whom we have nodirect and exclusive control.The Conference Organisers do not accept any liability in contractor in tort (actionable wrong) for any injury, damage, loss, delay,additional expense or inconvenience caused directly or indirectlyby force majeure or other events which are beyond our control,or which are not preventable by reasonable diligence on our partincluding but not limited to war, civil disturbance, fire, floods,unusually severe weather, acts of God, act of government or anyauthorities, accidents to or failure of machinery or equipment orindustrial action (whether or not involving our employees and eventhough such action may be settled by acceding to the demands ofa labour group). Please note that add prices quoted are subject tochange without notice.Privacy:Collection, maintenance and disclosure of certain personalinformation are governed by Australian legislation. Please notethat your details may be disclosed to the parties mentioned in thisbrochure and your details may be included in the list of delegates.Entry to Australia:All participants from countries outside Australia are responsible forcomplying with Australian visa and entry requirements and re-entrypermits to their own countries. Letters to support visa applicationswill be sent upon request, but only after receipt of registration formsand fees.Conference Badges:Official name badges must be worn or produced on demand atall times during the Conference to obtain entry to all Conferencesessions and to social functions. Proof of identity will be requiredfor the issue of replacement badges.The Conference Organisers:References to ‘the Conference Organisers’ in the above ConferenceInformation and Conditions mean Australasian GynaecologicalEndoscopy and Surgery Society Limited ACN 075 573 367 and MicheleBender Pty Limited ACN 003 402 328 trading as Conference Connection,and if the context requires, each of them severally.

AGES Focus Meeting14 & 15 October 2011Gynaecological ConundrumsFUTURE AGES MEETINGS& ComplexitiesAGES Pelvic Floor Symposium &Workshop XIII 2012Vaginal and Pelvic Surgery:the Art and the ControversiesAGES XXII ANNUAL SCIENTIFIC MEETINGin association with12 th APAGE Annual CongressMinimally Invasive Gynaecology:Idealism, Scepticism and RealityCrown Conference CentreMELBOURNE16 & 17 MARCH 2012AGES FOCUS MEETING 2012in association withNASOGThe Perfect Mix of Medicine &Politics - Getting the Right Blendfor Your PracticeMARRIOTT RESORT AND SPASURFERS PARADISE16 & 17 NOVEMBER 2012SAVETHESEDATESSYDNEY HiltonSYDNEY31 MAY - 2 JUNE 201224 & 25AUGUST2012SYDNEY CLINICAL SKILLS &SIMULATION CENTRERoyal North Shore HospitalSt Leonards NSWTraineeWorkshop VIII4