PAUL’S HOSPITAL

FELLOWSHIP IN GYNECOLOGICAL ENDOSCOPY

Background

Basic endoscopic training course was started in 1989 and advanced endoscopic training in 1994. More than 800 doctors have been trained since then.

This program was developed because of the recognition that most graduating residents in obstetrics and gynecology were not fully trained in operative endoscopic surgery. In addition, it was recognized that most of the advances in endoscopic surgery were being developed in the non-teaching hospitals.

Purposes of the Fellowship

	To provide an opportunity for gynecologists who have completed their PG to acquire additional skills in advanced endoscopy and reproductive surgery.
	To further research in endoscopic surgery.

Conduct of the Fellowship

	Course duration is for 1 year
	On satisfactory completion of one month training, course will be extended for 1 year.
	Course fee is one Lakh rupees.
	Single room accommodation will be provided in the hospital.
	Eligible for stipend of Rs 10,000 per month.

The fellow can work with the preceptor and other designated members of the training team in the operating room. The fellow should participate in the pre-operative, intra-operative and post-operative care of patients. The fellow may be assigned to other professionals to gain additional knowledge and experience in procedures and techniques. In addition, the fellow is required to participate in research in endoscopic surgery.

Documentation of the Fellowship

At the successful completion of the fellowship, each fellow will receive a certificate.

Application and Agreements of Preceptee for the Fellowship in Gynecologic Endoscopic Surgery

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General Information

Name

Date of Birth

Address			Tel No: (O):
			Tel No:(R):
			Fax No:
			F. Mail:

Name of Institution

Designation

Qualifications

Year	Degree	Institutions

Previous Endoscopy Training

Type of Endoscopy procedures presently doing

Facilities available at your centre

Date:
Place:			Signature

Download General Information

Professional References

Medicolegal cases- Information

Representations and Warranties

By applying for appointment as PRECEPTEE, I represent and warrant that:

	All information submitted by me in this application is true to the best of my knowledge and belief.
	I agree to practice my profession according to the professional and ethical standards of my specialty
	I have satisfactorily completed MD/DGO and have Indian Medical council Registration.

Educational program

The endoscopy fellowship program is a one-year program covering all aspects of endoscopy including hysteroscopy, laparoscopy, benign gynecology, pelvic support, and reproductive surgery as well as knowledge of endoscopic urology and general surgery as it relates to gynecology. A detailed description of training objectives in each area is given below.

Educational Objectives

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Anatomy

	1	Know the anatomic structures of the pelvis, including the bony structures, muscles, blood vessels, lymphatics, and nerves.
	2	Know the pelvic viscera, their anatomic relationships to one another, and to the other structures of the pelvis.
	3	Understand the embryology of the pelvic viscera.
	4	Know the layers, vascular supply, and nerve supply of the abdominal wall.
	5	Be familiar with the retroperitoneum and retroperitoneal spaces of the pelvis, including the prevesical space (Space of Retzius), the paravesical space, the vesicovaginal space, the rectovaginal space, the pararectal space, and the presacral space.
	6	Know the course of the ureter and the major vessels through the lower abdomen and pelvis.
	7	Know the structures of the pelvic floor and their relationship to structures visualized at laparoscopy.

Instrumentation

	1	Understand alternative video-cameras, light sources and insufflators available.
	2	Be familiar with instruments to access peritoneal cavity; veress needle, trocars.
	3	Know the principals behind various optical instruments, micro- and macrolaparoscopes.
	4	Be familiar with forceps for grasping, holding, manipulating, dissecting, and typing.
	5	Understand the use of needle holders, curved, straight, fine for microsuturing.
	6	Thoroughly understand the physics behind electrosurgical instrumentations; unipolar forceps, needles, probes.
	7	Be familiar with irrigators/aspirators, irrigating fluids.

Operative Laparoscopy

	1	Know the role of laparoscopy in the diagnosis and management of gynecologic disease.
	2	Understand the advantages and disadvantages of laparoscopic surgery in gynecology.
	3	Know the instruments that are utilized in laparoscopic access to the peritoneal cavity.
	4	Be aware of the various approaches to establish a pneumoperitoneum; i.e. entry sites.
	5	Be familiar with open and closed laparoscopy.
	6	Understand the disposable and reusable instruments.
	7	Understand the various power sources utilized in laparoscopic surgery.
	8	Know the anatomic landmarks of the anterior abdominal wall to safely introduce the principal and accessory trocars.
	9	Know the anatomic landmarks of the abdominal/pelvic cavity and its organs.
	10	Recognize normal versus abnormal anatomy, organs, and disease processes of the peritoneal space.

Operative Hysteroscopy

	1	Know the anatomy and physiology of the cervical canal and endometrial cavity.
	2	Understand the properties of the different fluid distension media, their complications, and their treatments.
	3	Be familiar with automated fluid management systems, fluid pumps, and other ancillary information used in lysteroscopy.
	4	Understand the principals of continuous flow hysteroscopic instrumentation.
	5	Know the indications, methods and complications associated with endometrial ablation.
	6	Know the indications, methods, and complications associated with hysteroscopic myomectomy.
	7	Know the indications, methods, and complications associated with lysis of intrauterine adhesions.
	8	Know the indications, methods, and complications associated with incision/excision of uterine septum.
	9	Know the indications, methods, and complications associated with hysteroscopic tubal cannulation.

Learning Objectives

Benign Gynecology

Ectopic pregnancy

	1	Describe the major risk factors to ectopic pregnancy.
	2	Describe the differential diagnosis of ectopic pregnancy.
	3	Perform and interpret the tests necessary to confirm the diagnosis including accurate performance of transvaginal ultrasound.
	4	Describe the indications, success and complications of medical management including prognosis for future pregnancy.
	5	Describe the indications, complications and success of endoscopic surgery including prognosis for future pregnancy.
	6	Perform laparoscopic salpingectomy, linear salpingostomy and partial salpingectomy.
	7	Describe the diagnosis and treatment options for nontubal ectopic pregnancy.
	8	Knowledge of endoscopic approach to nontubal ectopic pregnancy.

Recurrent pregnancy loss

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	1	Describe the causes of recurrent pregnancy loss and the diagnostic testing.
	2	Describe congenital uterine malformations and role in recurrent pregnancy loss.
	3	Describe surgical procedures to treat congenital uterine malformations.
	4	Perform uterine septum resection.
	5	Describe causes and diagnosis of Asherman’s syndrome.
	6	Perform hysteroscopic uterine lysis of synechiae.
	7	Describe the role of myomas in recurrent pregnancy loss and accurately counsel patients.
	8	Perform myomectomy - hysteroscopic, laparoscopic and abdominal.
	9	Understand the role of hydrosalpinx in recurrent pregnancy loss and treatment options.

Sterilization

	1	Describe the methods of tubal ligation, how to perform them, and the rates.
	2	Describe history of hysteroscopic sterilization.
	3	Perform tubal ligation.

Abnormal Uterine Bleeding

	1	Describe the causes of abnormal uterine bleeding and appropriate tests to establish an accurate diagnosis.
	2	Perform transvaginal sonography and hysterosonography.
	3	Perform office hysteroscopy.
	4	Treat abnormal uterine bleeding medically.
	5	Perform operative hysteroscopy and endometrial ablation.
	6	Describe types of endometrial ablation including risks and success.
	7	Describe pros and cons of abdominal hysterectomy, vaginal hysterectomy laparoscopic assisted vaginal hysterectomy,laparoscopic supracervical hysterectomy, laparoscopic assisted vaginal hysterectomy, laparoscopic supracervical hysterectomy,and total laparoscopic hysterectomy.
	8	Perform laparoscopic assisted vaginal hysterectomy, laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy.

Adnexal Masses

	1	Describe the differential diagnosis of adnexal masses and the appropriate testing to confirm the diagnosis.
	2	Perform transvaginal ultrasound with accurate interpretation to narrow differential diagnosis.
	3	Describe management options of functional vs. pathologic ovarian cyst.
	4	Describe ovarian cancer risks by age, ultrasound appearance and markers.
	5	Describe risks of laparoscopic approach to ovarian cancer.
	6	Perform laparoscopic ovarian cystectomy for benign adnexal path including endometrioma, dermoid cyst, fibroma, and paratubalcy
	7	Describe management options for tubo-ovarian abscess and role of laparoscopy.
	8	Perform laparoscopy for tubo-ovarian abscess.
	9	Describe appropriate evaluation and treatment for hydrosalpinx.
	10	Perform salpingectomy and neosalpingostomy.
	11	Describe the evaluation of adnexal masses in pregnancy. Describe optimal timing of surgery and the use of the laparoscopic approach in pregnancy.
	12	Perform laparoscopic surgery in pregnancy for evaluation and treatment of adnexal mass.

Uterine Myoma

	1	Describe differential diagnosis and evaluation of uterine masses.
	2	Describe indication for treatment of uterine masses.
	3	Describe role of uterine myoma in infertility and pregnancy.
	4	Describe treatment option for myomas including success and risks.
	5	Manage patients undergoing uterine artery embolization.
	6	Perform hysteroscopic resection of myoma.
	7	Perform laparoscopic myomectomy.
	8	Perform laparoscopic hysterectomy for uterine myoma.

Chronic Pelvic Pain

	1	Describe the causes of pelvic pain and the evaluation indicated to make an accurate diagnosis.
	2	Describe or perform the injection of an anesthetic to trigger point.
	3	Describe or perform laparoscopy under IV sedation with pain mapping.
	4	Describe or perform transvaginal hydrolaparoscopy.
	5	Describe treatment options and their success for chronic pelvic pain.

Endometriosis

	1	Describe pathogenesis theories and common symptoms of endometriosis.
	2	Describe common physical exam and ultrasound findings for endometriosis and the role of other testing.
	3	Describe medical management alternatives and their success in infertility pain management.
	4	Describe ASRM staging system and its limitations.
	5	Perform operative laparoscopy for all stages of endometriosis. Perform ablation of endometriosis and peritoneal resection of endometriosis.
	6	Perform ureterolysis and cul de sac dissection for ovarian fossa and cul de sac endometriosis.
	7	Perform ovarian cystectomy and/or ovarian ablation for endometrioma.
	8	Perform or describe treatment of endometriosis involving the bladder, ureter, colon, small bowel, or diaphragm.
	9	Perform or describe laparoscopic presacral neurectomy.

Reproductive Surgery

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	1	Know microsurgical principles as they apply to pelvic laparoscopic surgery.
	2	Be able to perform lysis of adhesions.
	3	Be prepared to laparoscopically treat endometriosis by ablation and excision.
	4	Be capable of performing a laparoscopic fimbrioplasty, neosalpingostomy, and neosalpingotomy.
	5	Be able to laparoscopically treat ectopic pregnancy.
	6	Be aware of laparoscopic techniques for tubal anastamosis.

Urogynecology

Stress Urinary Incontinence (SUI)

	1	Know the appropriate work-ups and proper diagnosis for various types of Stress Urinary Incontinence.
	2	Be familiar with Laparoscopic Burch Colposuspension for the treatment of Genuine Stress Urinary Incontinence (GSUI) due to loss of fibromuscular support of anterior vaginal wall and hypermobility of the urethra.
	3	Know the techniques for Endoscopic Periurethral Collagen Injection for GS secondary to Intrinsic Sphincteric Deficiency (ISD) with a well supported urethra.
	4	Laparoscopic Suburethral Sling Procedure for GSUI secondary to Intrinsic Sphincteric Deficiency (ISD) and hypermobile urethra or failed Periurethral Collagen Injection.

Endoscopic Pelvic Floor Reconstruction

	1	Be able to accomplish restoration of the integrity of fibromuscular vaginal tube by performing laparoscopic enterocele repair.
	2	Be prepared to achieve resuspension of the apex of the vagina to the level of ischial spine by using one of the various endoscopic techniques: uterosacral ligaments vaginal vault suspension, sacsospinous ligament vaginal vault suspension or sacro-colpopexy.
	3	Know how to perform correction of the cystocele and restoration of the support of the anterior vaginal wall by performing laparoscopic Paravaginal repair.
	4	Know how to perform correction of the rectocele by identifying and reattaching the rectovaginal septum to the perineal body and medial fascia of levator ani.

General Urology

	1	Be able to perform cystoscopy and ureteral stent placement.
	2	Be able to perform urodynamic testing.
	3	Be capable of performing a laparoscopic cystotomy repair.
	4	Be capable of performing a laparoscopic ureterolysis.
	5	Be able to perform a laparoscopic ureterotomy repair and ureteroureterostomy.

General Surgery

	1	Be able to perform laparoscopic appendectomy.
	2	Be able to perform laparoscopic enterolysis.
	3	Be able to describe and manage the complications of bowel surgery.

Complications

	1	Know the anatomic landmarks of the abdominal wall and of the pelvis that are important for laparoscopic access and endoscopic surgery.
	2	Understand safe trocar placement and insertion to reduce complications.
	3	Know potential complications associated with laparoscopic surgery.
	4	.Thoroughly understand the safe and effective use of power (electricity, laser,ultrasonic energy) instruments in the endoscopic surgery.
	5	Be familiar with surgical endoscopic techniques that facilitate exposure and reduce the incidence of complications.
	6	Know how to diagnose and manage endoscopic complications.

Medico-legal Issues

	1	.Understand the definition of medico legal cases.
	2	Be aware of procedures/situations which create increased risk for litigation.
	3	Know the meaning of and practice true informed consent.
	4	Develop excellent documentation/charting skills.
	5	Know the appropriate methods for decreasing the risk of litigation when complications occur.

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