Daniel Tsin, MD

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  Hi, today we are at the Olympus at the AAGL and with me is Dr Karen  Abbott from San Carlos, California.  Dr Abbott is a well-known  laparoscopist and has extensive experience in the procedures that are  limited to smaller portals than 10mm and removing the risk of  development of the larger scars, that is a tendency in our field.  What  would you like to tell me about this little fabulous medical device?
 
 

 Well, the 5mm  device is outstanding because not only do you get the light, but you  also get the object of the 10mm with half the weight or less, so not  only do you get excellent visibility and small scars, but your assistant  surgeon doesn’t whine so much because it’s not so heavy over long  cases.
 
 

  I have heard this device is not only light but also has a couple of features.  Would you like to explain?
 
 

 Sure, there’s an  automatic light balance, there’s an automatic focus and then there’s a  zoom, so you can have a great time with this thing and it’s wonderful  when you come to editing because you can do both close-ups and overview  pictures.
 
 

  So actually you zoom in and zoom out just with the press of the button, rather than the older method.
 
 

 Oh, I know, you had to sit there fiddling with the dial.
 
 

  That’s very nice.  But probably I would say there’s something that sets  you apart, it’s how many procedures, what kinds of procedures you can  do just with 5mm rather than the 10mm?
 
 

 Actually, you can  do any procedure using the 5mm that you can with the 10mm because you  get as much light and as excellent optics with this as you do a 10mm, in  fact, probably better.  And you can get into places a 10mm could never  get because it’s so small, so it’s wonderful for work in the cul-de-sac  or over in the ovarian process because you can get right up under the  tube or ovaries and be able to work with direct contact.  It’s fabulous.
 
 

 The light’s  excellent.  The only time we’ve had problems is when we’re dealing with  uteruses in excess of 1,000 grams, then if you do a lot of morcellation,  you have a lot of dark surfaces that would lose light but, in general,  for most of our endometriosis cases, our uterus suspensions and our  myomectomies, as well as our supracervical hysterectomies, this is the instrument of choice for me.
 
 

  Will the use of 5mm instruments prolong in any way the length of the procedure?
 
 

 No, in fact, I  think it shortens it, because what you have is so thin, you have, you  can use this scope in any port, so if I am doing endometriosis surgery  using 5mm ports elsewhere, I can move it to any port and not have to  step up to a 10mm or larger port.  Now when I’m doing hysterectomies, I  tend to use larger ports because I use a morcellator exponentially, but  we use a 10mm, 11mm InnerDyne system for that, but with a 5mm, this way,  if I have something up high or valid adhesions up under the liver, then  I can temper to any port I want.  Very effective.
 
 

  Of course, so that means you can use the 5mm no limit at all right into the umbilicus.
 
 

  And you can have the option to look at the diaphragmatic area from either lateral or the view gives you another option.
 
 

 Yeah.  That gives you a lot of flexibility.
 
 

  Well, I think that obviously proves what we, as laparoscopists, tend to  believe; that the smaller the incision, the less aggressive we are in  surgery the less scarring and this will take us from 10mm to 5mm.
 
 

 Oh, we have, and  the patients feel incredibly well because pain is incision-related and  you make the smaller incision and you pre-inject it and you’re using a  5mm, they basically even have trouble finding their incision by the time  they come back for their post-op visit.  It’s very, very effective.
 
 

  Dr Abbott, you mentioned that in your experience in thousands of cases,  you used a 5mm very successfully.  Would you like to give us a sort of  shopping list of what you have done with this?
 
 

Oh, yes, I do a  lot of endometriosis excision surgeries using the YAG laser, contact  YAG.  I do a lot of supracervical hysterectomies and consequently uterus  suspensions.  I’m a clinical investigator with Inlet on new suspension procedures for both prolapse and retroflection,  and I did an AAGL telesurgery last year, did a laparoscopic biolectomy using this scope, as a matter of fact.
 
 

  Well, obviously, what we can see is that we always wanted a laparoscopy  to move to the largest to the smallest instrument and obviously you  make big in-roads moving this way.  I hope that most of our people in  laparoscopy follow your step and I myself agree with you 100%, I think  that we’ve got to 5mm, maybe the next thing will be 3mm.
 
 

  And I’m sure you have already the first step will be from 10mm to 5mm  and I think that I’m waiting to see you with your next telesurgery  talking about 3mm.  I agree with you from 10mm to 5mm, from 5mm to 3mm, I  think that this is the way that we should go.
 
 

  Well, I’m glad we talked today about the 5mm would be available for  possible procedures and I think that it is the right way to go.  So  we’re very grateful to have the opportunity to talk to you.
 
 

  Is there anything you’d like to tell us?
 
 

  No.  I’m having a great meeting.  It was a pleasure meeting you.
 
 

  It was very nice to be here at the Olympus booth and I hope to see you very soon again at the next AAGL.
 
 

Articles

OBGYN.net Conference CoverageFrom the 31st Annual Meeting of the American Association of Gynecological Laparoscopists (AAGL)

Operating Room Use of the 5mm Olympus Endoeye

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From the 34th Annual Meeting - Chicago, Illinois - November 2005

ISGE 2006, Buenos Aires Video

 Hi, I am Dr. Paul Indman. We are at the  AAGL meeting, World Congress of Minimally Invasive Gynecologic Surgery in  Chicago and we are fortunate to have with us Dr. Daniel Tsin, who is Director of  Minimally Invasive Surgical Services at Mount Sinai Hospital at Queens. Dr. Tsin,  you have a special interest in the small retractors used in mini-laparotomies.  As a gynecologic surgeon, I have been thinking about using those, but what is  the advantage of that over a traditional metal retractor?
 
 

 I think that mini-laparotomy has been used by us for  many years and tubal ligation is the typical one, but the advantage of the  elastic retractor is that it is soft, provides an operative field which is  approximately 30% larger than provided by the traditional metal retractors and  you have an unobstructed view since metal retractors are not blocking your  field. In soft tissue, especially in a mini-laparotomy, when we use the metal  retractors, they have a tendency to slip and can produce visceral damage and  waste time to apply and re-apply the retractor. So the elastic retractor is like  a renewal or rejuvenation of the old-fashioned mini-laparotomy with which we are  so familiar from many years ago.
 
 

 I have seen people define mini-laparotomy as an incision  of any size following a laparoscopy so they do not have to admit defeat. What  kinds of incisions are you talking about?
 
 

 Well, I think that, essentially, I would say  mini-laparotomy is an incision that is too small to fit your hand. If you can  put your hand inside the abdomen, it is not a mini-laparotomy anymore. So I  would say anything from 5 cm and less should be in the concept of  mini-laparotomy.
 
 

 So what is this hand-assisted laparoscopy? How does that  compare?
 
 

 Hand-assisted laparoscopy is substantially more because  I do not know what size hand, mine is more than 5 cm, so hand-assisted  laparoscopy is an entirely different approach. It appears to be like  mini-laparotomy in the sense that you have this incision to help you and aid you  with the surgery, but when we talk about mini-laparotomy, we are talking about  substantially smaller incisions.
 
 

 What types of procedures will you do through these  smaller incisions? Would you do a 10 cm myoma through a 2 cm incision?
 
 

 Definitely. We have been doing myomectomies,  hysterectomies, we have been doing supracervical hysterectomies, we have been  doing oophorectomies, I think I mentioned that twice, we have been doing  sacropexy with this procedure, so essentially we can do practically every  procedure as quickly as you get the proper learning curve. It is substantially  faster for people with experience than the laparoscopy learning curve.
 
 

 What is the largest size uterus you would do a  hysterectomy on with this incision?
 
 

 I have done hysterectomies in approximately where the  uterus is a two finger breadth above the umbilicus.
 
 

 Two finger breadths above the umbilicus. How large is  the incision?
 
 

 Suprapubic. I usually use Pfannenstiel or a colpotomy-type  of incision to do this approach.
 
 

 How do you get a uterus that large through? How do you  get to the vessels to see what you are doing?
 
 

 Essentially, we use morcellation, which is surgical  morcellation, and we know the pathology, there is a uterine myoma and we use a  tenaculum with an injection of vasopressin to give you the points of interest,  in some cases it could be the round ligament, and I will do a manual dissection,  a manual investigation, by manual I mean fingers only, through the area of the  infundibulopelvic in one way and then we gradually work our way through.
 
 

 Okay. So typically when we do a hysterectomy, we will,  let us say, take the utero-ovarian ligaments or the infundibulopelvic and work  our way down and then you have the uterines. So are you just ligating the  uterines first? How do you expose the uterines if you still have the broad  ligaments intact?
 
 

 The ideal situation is to deliver the whole uterus out.  This has happened in uteri up to 12 week size. When you are talking about a  situation of a uterus of the magnitude which I mentioned to you which is almost  above the umbilicus, you have to just cut out part of the uterus, making a  reduction to allow this exposure.
 
 

 Well, that is very interesting. I would like to thank  you once more, Dr Tsin, from the AAGL meeting in Chicago. Thank you.
 
 

Daniel Tsin, MD

Articles

Operating Room Use of the 5mm Olympus Endoeye

Operating Room Use of the 5mm Olympus Endoeye Video

ISGE 2006, Buenos Aires Video

Mini lap with elastic retractors in the treatment of fibroids