Amy Garcia, M.D. – Clinical Assistant Professor of OB/GYN New Mexico Health Science Center, Director of Hysteroscopic Services Center for Women’s Surgery, Albuquerque, New Mexico, USA
Prof. Attilio Di Spiezio Sardo – Professor of OB/GYN at the University of Naples Federico, Chief of the Hysteroscopic Unit of OBGYN, University of Naples Federico II, Naples Italy Good day everyone on behalf of Carl stores endoscopy. Welcome to another educational event for gynecology. It is my pleasure to moderate today's E masterclass webinar titled histories, coptic polyp ectomy. My name is Dr arti Cial Carey Sing. I'm a fellowship trained minimally invasive gynecologic surgeon who recently joined Carl Stores as their medical director. I have the honor to introduce today's webinar speakers. Dr amy Garcia and Professor Attilio DSPs. So Sardo dr amy Garcia attended the University of New Mexico School of Medicine and completed her residency in obstetrics and gynecology in Chicago. She completed an A A. G. L. Fellowship in minimally invasive gynecologic surgery at the University of Illinois in Chicago and currently performs advanced laparoscopic and history topic procedures and a surgical based private practice. In New Mexico. Dr Garcia actively participates in resident education as a clinical assistant professor in the department of obstetrics and gynecology at the New Mexico Health Sciences Center in Albuquerque. New Mexico. She is a past board member of the H. L. A. Current member of the advisory board. While actively serving on several committees. She has served as chair of postgraduate courses and hands on labs for the global congress of the HDL and american college of Obstetrics and gynecology and has participated as faculty and numerous a A. G. L. And a card courses in minimally invasive gynecology. She serves as an ad hoc reviewer for the journal of minimally invasive gynecology and as a dedicated innovator and leader in our society for advancing pelvic health care and office history copy Professor Attilio DSPs Asado is a full professor of Obstetrics and gynecology at the University of Federico. Two in Naples. Italy. He serves as a member of the teaching staff and as the coordinator for minimally invasive and robotic surgical instrumentation for the institution. Since 2016, professor disputes Luzardo has been recognized at the university for being a master and historic topic surgery and is the head of the diagnostic and operative hysteria Skopje outpatient department. In the past decade, he has held multiple leadership positions within the university and well respected international medical societies, participate in over 150 national international clinical educational programs and contributed to our medical literature with around 200 publications, although his curriculum vitae is written in italian and it took me time to decipher it. His 50 pages of accomplishments are very translatable to understand how his outstanding achievements make him a leader in our gynecology community. It has truly been a great pleasure and privilege to work alongside Dr Garcia and professor dispute. So Sardo and gynecology and hysteria Skopje. Welcome dr Garcia and professor. Thank you for your time and expertise today. Thank you. Before we get thank you. Um before we get started with our program, I have a few housekeeping comments, please use the Q. And a chat box to submit any questions you have for our speakers. We will do Q. And a question and answer sessions. After each presentation. Today's program is being recorded and a link will be provided to you within two weeks after today's presentation and will also be on Carl's sources. Network one gynecology site. Lastly as a disclaimer the content in this presentation is provided for general educational purposes. Only this presentation does not constitute a representation that any products, techniques or procedures described would necessarily be appropriate or recommended for any particular patient. The decision to utilize or implement any of the medical opinions, techniques and or procedures presented in this program is up to the sole discretion and clinical judgment of each healthcare professional. A healthcare professional must always refer to product labels and instructions for use, including the instructions for cleaning and sterilization if applicable before using any product. Thank you in advance for your attention. We will now begin our webinar with Professor DiSpirito Sorrento's presentation on clinical indications. Professor the mic is yours. Yes, thank you, arty. So thanks for the wonderful introduction that you did for me and my close friend and colleague Emmy. So and then congratulations for pronouncing my surname in the correct way. So you deserve an award for that. Thank you very much. I thank car starts for arranging these educational events. And also I have to admit that car stores has always supported my activity since the beginning and it continues to do and thanks once more for all the support first before starting with the proper presentation. It's important that me and Demi knows about the expectation that you have on this webinar. So if you can please answer to this question, it would be nice. So in order to better arrange our speech today. So 100% of both of you wants to receive tips N tricks and I have to tell you that if I was an attendee of this educational webinar I would have answered the same. I have to admit that when artie and on Poland that I want to thank once more for all the support that both of them gave to me and amy to arrange this educational event. I was a little bit surprised that we were arranging our webinar on polyps and polyps. Ectomy. Such an old fashioned topic. But I immediately realized that This topic is still very actual in 2021 because if you look at this light We are not far away at the moment in 2021, from the conclusion of professors caught in 1953 that state that remedial polyp was an enigma as far as frequency bleeding potential and the possibility of malignant transformation are concerned. And we are probably in 2021 in the same situation of nearly 70 years ago. I don't want to waste time to define the polyp because everyone knows what a polyp is. This is one of the most common and used definition of the polyp but I want to reflect, I want that you reflect on the fact that not all the polyps are the same from mr logical point of view. And this is important because for example, the functional polyp and observed a polyp can be treated by hormonal treatment or anti inflammatory drugs. While a dynamometer, cirrhosis, paper, plastic or cystic polyp needs surgical therapy. If we want to remove this lesion from the carriage, the problem is that you want to know some tips and tricks About polyp ectomy and I'm sure that amy and at the end myself will give you some tips n tricks. But the problem is that we should understand and we should say to our patients, if this polyp have to be treated or not, this is the um Miletic dilemma that we still have in 2021. And the question should be the same. So why should I perform a polyp ectomy? The answer can be even easy if we want to resolve problems associated to this pathology or mostly in postmenopausal age. If we want to exclude malignancy and rule out the possibility that the lesion can create problems to the life of our lady. But the problem is that we should understand if really the symptoms that we think associated to polyps are really associated to this pathology. What literature says is that polyp can cause abnormal uterine bleeding and infertility. Look at these lights, 68% of both women reproductive age and in postmenopausal age when they have a polyp they have a symptomatic polyp in terms of abnormal vaginal bleeding. So most polyps are symptomatic and we know the classification that Malcolm muro and this group did a few years ago recognized that polyp is one of the cost of abnormal uterine bleeding of the lady. The problem is that we should understand that some polyp can regress spontaneously, that some polyps are completely as symptomatic and that when we propose polyp ectomy as the main treatment is telescopic polyp ectomy is the main treatment resolve the problems of bleeding of the lady with polyps. We don't have very high level scientific evidence to support this treatment. But you know that sometimes this is the problem of of some issues that are so evident then that too plain randomized trial to support our convention is very difficult. However, polyps cause bleeding bleeding can be resolved by stereoscopic polyp ectomy. But when we try to understand if the symptoms of abnormal uterine bleeding are really associated to polyp, one of the symptom is most significantly associated with the presence of polyp and this the inter menstrual bleeding. This is the reason why if the lady has every menstrual bleeding and you remove the polyp, probably the lady will continue to have heavy menstrual bleeding. If the lady has some spotting some inter menstrual bleeding in between the menstrual period, then you remove the polyp probably you will result that one 100%. But these symptoms that can affect the life of our women even more complicated is the second issue infertility. There are many, many papers showing that polyp can affect the spontaneous and post IVF fertility of our lady. And you know that many protective mechanism have been postulated that the basis of this relationship, polyp and infertility. The problem is that we know that polyp can be in different locations in the uterine cavity. We don't know why, but polyps are more commonly present in the posterior wall of the uterus. But the polyps that are more frequently associated with infertility are the polyp in the uterus. Coachable junction. And this can be very evident because they can create a sort of blockage of the opening of the tube. The problem is that we should say to our patients, if I remove the polyp, I can improve your pregnancy outcome. And you see that. Unfortunately there is a dramatic lack of well designed study. We have only one randomized study showing that the famous parents medina trial that if you remove a polyp And you say to the couple, please have free sexual intercourse. Is or do an intra uterine insemination in the next six months. You can double the chance of pregnancy from 29% to 64%. But we have only one randomized trial that can support the effectiveness of extras coptic polyp ectomy to improve reproductive outcome. But just to consider how difficulties to analyze the available evidence in literature to Cochrane review. One of these 2014 says that for example, that the parents is not so good to support the use of polyp ectomy to improve pregnancy outcome of Our Lady. The same paper has been considered by the authors of these other Cochrane review. Reaching opposite conclusions that the paper is very good and the stereoscopic removal of endometrial polyps should be advocated in order to increase the clinical pregnancy rate of our couple. So that's why my first messages, that paper should always be read with very careful attention. And sometimes some others can reach different conclusions, even if based on a single randomized trial. And the same trial was also included in my meta analysis. Reaching the same conclusion, if you remove the polyp you can improve the pregnancy outcome. Another question should be. But the sides of the polyp, the number of the polyp is important. Apparently according to this study. No, it doesn't matter if the polyp is bigger or smaller than one centimeter or if there is a single or multiple polyp. And even in this other study, you can see that the location in the cavity, the sites of the polyp and the number of polyps are not statistically significantly associated with a better or worse outcomes when we remove the polyp. So we can say that every polyp in the cavity independently. If it's big a small uh wherever it is located in the cavity should be removed in order to improve the pregnancy outcome. And much important is that if you remove the polyp in the world cup in the diagnostic work up of a couple undergoing IVF, you can see that you can save a lot of money. It even if you remove the polyp in the inpatient setting rather than in outpatient office setting in both settings. However, you can save a lot of money because polyp ectomy can not only improve the pregnancy outcome after IVF but can also reduce the need for unneeded IVF. Because as we have seen in the paper of paris medina, if you remove the polyp, the couple can get pregnant spontaneously few weeks after the procedures. So take in mind this concept and last issue that we should analyze is the risk of malignancy. If we analyze all the paper in literature, we see that less than 5% of polyp malignancy inside the polyp. And if we also consider pre malignancy inside the polyp we can reach 7%. 1 trial says 13%. But however the risk of having malignancy in Nepal quite small. The problem is that we should analyze and we should identify which polyps are risk of malignancy. First of all the risks a risk of having a malignant polyp when the lady is older, you see that in perimenopausal and postmenopausal age. The risk of having a malignant polyp is much higher. And other studies have found that the high weight of the patient, the age over 50 for and even the size of polyp. So bigger than two cm, there is a higher risk of malignancy. Our clinical risk factors for having a malignancy in a polyp that's why my suggestion is that even when you do a diagnosis of a polyp don't just limit yourself to say endometrial polyp. It's important that you identify the number, the location that you have to describe the shape of the politics. It's regular, irregular if there are necrotic areas white ish area on the polyp, the sites of the policy because all these factors can help the doctors to understand if this polyp needs to be removed or not removed. The problem is that when we look at the polyp, unfortunately we can only describe some a typical aspect of the polyp. For example, the risk of having a malignancy is higher when the polyps and irregular surface and when we have an a typical vascular ization, what does it mean a typical vascular ization that there is a disagreement between the main vascular access, the main political of the polyp and the direction of the growth of the lesion. This means that the vascular ization is a typical and of course if you have this vascular ization, the risk of having a typical polyp is higher and once more if the polyp is greater than half of the uterine cavity. In other words more than two centimeters. And if there are whitish area on the surface of the polyp, which means necrosis on the polyp. So these polyps are more likely to be a typical and so better to remove this polyp. But you see that if we only limit is stereoscopic visualization of the polyp specificity is very high but sensitivity. So the capacity of identifying the malignant polyp is very low. That's why it's important to remove the polyp and to send to the pathology and another small differentiation that you have to do. But it's very important. Something is the malignant polyp that is a benign polyp. And inside this polyp there is an a typical area in this polyp, something different from polyp oid cancer when you have a polyp in the cavity. But you have no evidence of benign tissue in polyp but it's all malignant. So it's cancer that has a polyp oid pattern of growth. And this is important because if people ask you which is the percentage of the endometrial carcinoma based on the polyp. Look at this trial, you can see that malignant polyps are nearly one third of the endometrial carcinoma. Stage one. A and what is interesting if that if you have a malignancy in the polyp most of the time you can have a nest a type very aggressive like sarah's esta type. And so even if the lesion is located into a polyp. So probably this lesion is more aggressive than the other endometrial uh esta type. But according to this single trial, however, they did not find that there were there was very difference between malignant polyp and polyp oid carcinoma in terms of stage sites and type of the polyp. But what was interesting was that into the polyp with malignancy there were both precursor of type one, estrogen dependent and type two no estrogen dependent dental media carcinoma. And so one of the unmet question that we have at the moment is why polyp that is an apple estrogenic lesion. So is characterized by more less dependent instrument esta type like type two endometrial carcinoma. So we have an endometrial polyp in which we know that hyper estrogen can cause polyp. But The estrogen independent type two carcinoma is more frequently located into a malignant polyp. So this is a question at that moment, we cannot give a definitive answer. So just to give a quick summary when you have the suspicious in a postman, a possibility that the polyp can be malignant. So many authors have published very difficult as you can see in these lights algorithm to decide if you remove or not the polyp based on the weight on the sides of the leash in the age of the patient. I would you give you a very clear message if you have a lady in perimenopausal postmenopausal each. And there is a polyp and the patient has also symptoms related to this polyp. Like symptomatic vaginal bleeding. Please remove this polyp because this polyp is a higher risk of having a malignancy into the polyp itself, thank you very much. And I give it the toll the speech to charity for some quick question and answer. Yeah. So thank you so much Attilio for that excellent presentation and background. One question that came through is what is your pre operative work up? If a woman comes in with symptoms, do you go straight to a hysteria skopje or are you performing any form of ultrasound or saline infused? Sona hissed a gram. Absolutely, we don't want to give the message that extra Skopje is the first line investigation for uterine pathology. So ultra sonography. Well done of course is the primary prime line investigation in case of lady with bleeding or lady when probably the symptoms are very suggestive of an Endo cava Torrey pathology. You do sonography. And if you find thickened endometrium or uh Sana graphic appearance of a polyp. Then I move straight away to a quick and easy offices microscopy in order to confirm the sauna graphic diagnosis and if possible. But emi will tell you about we try in office setting straight away remove the polyp in to do diagnosis and possibly treatment of delusion itself. Thank you. And on that note I would like to invite dr Garcia to demonstrate her polyp ectomy techniques and procedures of videos. Good morning. Thank you Arthuis uh and carl Stewart so much for this opportunity. And Attilio. Always a pleasure my friend to be with you uh teaching and thank you for that. Great Uh really segue into what I will address, which is a little bit of now that you've made of technique of polytech to me now that you've made the decision that the polyp you have found or polyps need to be removed. Um I'm going to talk about a few ways to do that. And really the objective of of what I am about to present is mostly making sure that you can understand the physics of the history scope which make polyp ectomy feasible and the lens specifically in creating the visual field in order to do that and understanding how to use operative instruments with the history scope. That's right. So it's about mastering the history topic field of view. What you're looking at will determine how you bring instruments into the field. So it's it's not only understanding the lens position but understanding that if you're operating with a 12 degree or 30 degree in gold lens that your instrument um approaches the uterine pathology very very differently than if you have a zero degree lens. And keeping the lens instrument relationship will maximize your ability to remove these polyps efficiently with minimal movement, especially in the office with a weight patients regarding the field of view. When we look at a zero degree lens. Our field of view is limited and no matter how many times we rotate about that access we will not change our visual field. So in order to see any lateral components of the uterine cavity, we have to angle that history scope significantly in order to see for example the fungus fully or the cornelia. When we added an angle to the lens that's called the forward oblique angle and our operative history scopes are better suited for operative instruments. When we've got an angled lens, the orientation of the lens will always be opposite to the light post. If you find this fixed position of the light post, you'll know which direction your lens looks because it will always look opposite to wherever that light post is attached. And this becomes very important in understanding not only our visual field but as we bring operative instruments into our field. This is what we see because the lens is looking um asymmetrically we see an asymmetrical visual field. So with the lens looking down, we see the majority of our visual field is below the horizontal plane. If we rotate our light post up that rotates our lens angle in an upward direction and now our visual field is asymmetrically um looking at more of our visual field in the upper uh component of our visual field. Why is this important to understand? It's important um especially when accessing the uterine cavity. If we are used to using a zero degree lens, our brain wants to create what we see here in the left panel. If your history scope happens to have a forward oblique angle, the you'll have to angle the the history scope significantly to recreate what your mind is trying to do. However, that will cause significant trauma. The ideal here is to understand how your visual field is created so that you can bring your history scope parallel to the endo cervical canal and minimize trauma. When we put this all together, then we see that this is the indo cervical canal. We have an asymmetrical visual field. We see interior early light post is down or lens angle up and we are parallel to the industry vertical canal. I want to talk a little bit about this circle down here. This is a marker on the lens itself. This is called a radical. If we look at the radical up close the they come in various shapes in general. What you will find is that the radical is in the position that corresponds to the attachment of the light post. So if I rotate the light post, this radical will rotate about my visual field. If I'm ever in a scenario where I don't see landmarks like being inside the the cervical canal, I know which way I'm looking simply by looking at my visual field, I don't have to look down at my history scope to find my light cord. I just look for the radical. If the radical is at 6:00 PMclock corresponds to the light post that's indicative of the light post being opposite to my visual field. The visual field, therefore is opposite the radical. Here's the scenario where I have no other landmarks. The radical is at 6:00. I'm looking up and I can stay oriented now. What happens when we bring an instrument into our visual field? This upper panel is an example of what happens when we use a tissue removal device. Those generally are using a zero degree lens. The first thing that happens is that in order to see the pathology you have to extend it uh your instrument a little bit further away from the tip of your history scope. So your instrument will be extended further into the endometrial cavity. You will be a little bit further from your pathology in order to get a significant amount of the pathology in your visual field to operate on that pathology versus when we have a four oblique lens, we can operate closer because the pathology we see more of it as it's closer to the camera. Again, the light post looking opposite the operative instrument with a forward forward oblique history scope will always always be uh huh Where the lens is looking. If the light post is looking up, I know where my instrument will be seen because the lens will always be looking at my operative instrument and this is just a function of the mechanical way that the lenses uh the history scope is created, The operative report is always below the lens so that as you extend your instrument into the visual field, you will always be looking at your lens. And because of that here, we can see that I can operate closer to my history scope which can sometimes create a little bit of added safety as well as see more of the uterine pathology as I'm operating. So let's talk about this and how it relates then to approaching the pathology within the uterine cavity. Here is an anterior lesion. The ideal access to the attachment point of this lesion is to bring my instrument perpendicular to the attachment, which in a sense is parallel to the uterine wall, perpendicular to the attachment means that I am maximizing the surface area of any instrument I have to the base. And it makes for a more efficient removal or grasping of that pathology. I know where my instrument will enter my visual field because I have a radical. So when you look in this I'm not sure if you can see my My cursor, but if you see down at 5:00, that is the position of the radical. I know that my instrument will enter my visual field opposite to the radical here in the last panel you see that as I bring the instrument in. This is simply rotated. If I just flipped the handle over, then this instrument will be exactly parallel with that orange line, so I can plan where I place my instrument based on my radical in my visual field. Remember also that the instrument will move as one with my history scope. And that does take a little bit getting used to. But it's one tool within the uterine cavity and the instrument is merely an extension of my tool which is the history scope. Looking at this again. The radical here in this panel is at 3:00. The pathology is a left lateral attachment. What I would like to do is to bring my instrument parallel to the uterine wall and perpendicular to that point of attachment. If I keep my lens oriented in this angle, I don't have the best approach to coming perpendicular and a more efficient use of my instrument uh and minimizing movement within the endometrial cavity. What I would like to do then is rotate my lens. The radical is moving in conjunction is just an indicator of where that light post is attached. I take my light post. The radical and light posts are now at 4:00. My instrument is moving within that visual field and now with the radical at seven o'clock, My instrument comes in at this one or two o'clock position and now I have parallel access parallel to the uterine wall and perpendicular to this attachment makes me more efficient. One other component about visual field is to understand that you have a camera head attached to your your history scope. This first panel shows the light post up with the lens angle looking down and seeing the majority of the visual field below the horizontal plane. The camera head is in an upright position or in an anterior post area orientation. If I get distracted and I'm not paying attention and suddenly my camera had rotates. Essentially what happens is my visual field will change. This is what I should be saying because the uterus hasn't moved. The only thing that's happened here is my camera head is rotated and yet visually this is what I will see on my monitor. So if I'm not careful, I can easily get disoriented, especially if I have no other landmarks to show me where I am inside the uterine cavity. These are some of the instruments that we use. Um They are semi rigid. They are single action or double action. The double action will basically have both arms of the device open. These tend to be our grasshoppers and grabbing instruments. It allows that double action allows that instrument to open further versus the single action where just one arm opens and the other is stationary. These tend to be the scissors to allow a more powerful fulcrum for cutting. Let me go back. These are these are my go. Two's a sharp set of scissors are appointed. Rather they should always be sharp. They're more efficient if they're sharp. Um I use a tin acura. Um This instrument right next to it with the spike was developed by dr disappears and you can tell you about it but it really helps penetrate into into thick tissue like a small my Oma. Or a dense polyp to pull that polyp out a blunt set of scissors. And then a regular grasshopper. And that's kind of my my go to instruments now that you've made the decision to remove a polyp. Um One must keep in mind several things about the polyp that you see in order to make a plan on how to remove it. The first will be the type of attachment padang related polyp will always be easier than one with a cecil attachment. It just relates to how much cutting or you know separation that you'll need to do with that policy. The location of the polyp, lateral and anterior are far easier to remove. Then either a fungal attachment or a posterior attachment. If the polyp is large, a posterior attachment can be very very difficult. Um or at least more difficult. This size. Is it small? Is it big if it's big? Is it too big to get out the five millimeter endo cervical canal? And will you have to do something different? Is it dense? Is it cystic? Is it soft? Is it pliable again? Do you have to do something different to get it out the the indo cervical canal? And then how many are there? How long will you be there? Uh In the procedure all of this you need to take into account especially again in the office environment with an awake patient. The first type of polyp ectomy is with the grasshopper. And this is the easiest form of polytech. To me this is ideal when you have a polyp that has a nice production weighted base. The idea is to use what I've just presented which is to use your instrument. Uh Two come at a perpendicular approach to the base of the attachment that's keeping your history scope parallel to the uterine wall, grasping at the base. And this is a small maneuver. Small movement. It's literally just rotating the the entire history history scope slightly with a small slight word extension with your instrument. And essentially what you're doing is separating then with this momentum. The polyp from the attachment. Here is one example. You can see that my radical is moving. It's at about 2:00 on the right, It's now down at 5:00. I am trying to get this instrument parallel to the uterine wall and perpendicular to the base. So my radical is down grasping a small motion forward and a slight rotation of the history scope. And now I have this ready grasped in the ah along the long axis of the polyp which makes it easier to pull through the indo cervical canal. Here is another polytech to me with a grasshopper. This is a post menopausal patient who's had a bleeding endometrial polyp. You don't always, you're not always able to fully get it at the base. But here what I can do is the same technique grab at the base, perpendicular extended to the uterine cavity slightly remove that, and I can always go back with the grasshopper or scissors to remove any Paula that's still attached to the uterine wall. This is um a carcinoma. This technique is the same technique as you would do with a directed biopsy, opening the grasshopper at the attachment, grasping, pushing slightly forward and then there is my pathology to remove. So whether it is a simple grasshopper polyp ectomy or directed biopsy, the technique is the same. Very importantly, what you you want to do in this scenario is once you've got pathology within your grasp, er go ahead and turn off your inflow ports. Um Sometimes the grasp is tenuous or the tissue very very fragile and you don't want to lose that biopsy specimen because your inflow is running uh and pushes the specimen off your grasshopper. This is showing an anterior attachment. Getting back to the images that I've showed you. This is a post menopausal patient with benign polyps adenocarcinoma, a trophic endometrium with catastrophic bleeding. A number of different pathologies. The radical is down at 5:00. I know exactly where my instrument enters the visual field. I'm coming perpendicular to the base. I don't have a lot of inflow here because this is a very fragile tissue essentially. This is a tissue biopsy a directed biopsy. But the technique is the same whether for biopsy or for polytech to me, I'm going to leave this attached so I don't have to change this fragile piece of tissue around the cavity pressed down into the tissue. Um let there be some substance and the grasshopper turn off my inflow ports and now I've got a nice tissue piece for evaluation. What if the polyp is fundamental? Things changed a little bit in terms of how you use your instruments instead of approaching the attachment from a perpendicular standpoint, you end up using the very tips of your instrument, which is why having a set of blood scissors is really important. It gets very difficult not to um put the tips of a sharp or appointed a set of scissors into the endometrium. So you want to use a blunt tip scissors and you end up using just the very tips. You also want to open your device or closed. But either way whether it's open or closed, use it to literally push down on the polyp. It exposes the attachment of the polyp and it makes it easier for you to see where to cut next. Sometimes just pushing the polyp is enough to get it to separate from the uterine wall. So that technique of of pushing can be used whether it is a lateral anterior fondle or posterior attachment simply with the the funnel attachment. You're more reliant on that particular technique using the scissors to cut and then repeating the motion of cut, push cut, push if you push with the instrument closed, it will not be as efficient as if you push. That's like pushing with a finger or pushing with your hand on the side versus opening the scissor and pushing with the hand open tends to be a little bit more efficient. This is again a post menopausal patient. This problem has been there for a long time. She's a trophic, there's been some bleeding. It's a somewhat dense glandular polyp and it has taken on the form of the cornu on each side. So you know that this has been there for a long time approaching. Just with the tips, exposing the attachment separating, pushing down as you and it gets a little wildly when you only push with a finger versus a hand. So as you cut and push and cut and push, you will begin then to further the separation, expose what needs to be cut all while trying to to really be very mindful of not pushing forward into the endometrium. I said before and I'll say it again. As you see in these videos, I can always go back and and trim sometimes the pathology is just in your way and you just want to get the majority off and if you need to go back, you can always go back, use the scissor. Use a grasshopper to take any part or component of the polyp that remains that you think is important to remove. And so this is the funnel technique here. The intra uterine fluid pressure is helping push this polyp out. I do want to try to grab it along the long axis if I can. And this tin accurate is a nice instrument when there's some significant density to the polyp. If I try to use this tin acura lamanna software polyp, I just can't, I just can't use it to get the polyp but it pulls right through the tissue. So any polyp that has some density. It's really nice. Now, what about a posterior polyp? This does become a bit challenging, especially if that polyp is bigger. This is the same patient that that you've continued to to see. This is a large benign polyp, somewhat cecil attachment on the posterior wall. What I've just told you in terms of technique you would say, well I want my instrument to come in perpendicular to the base So my radical needs to be at the two oclock position. However, I'm going to break that rule because what happens is that that might work for the few first few millimeters of separation. But as we work our way under this polyp, it gets very difficult to see because the polyp basically blocks our visual field. So we need to do something a little bit different which is have our radical actually down so that we are looking up and our instrument is coming um in a in a downward angle and not uh not fully parallel and perpendicular to the attachment is otherwise at an acute angle and perpendicular to the attachment. What it means is that we um see our our operative field a little bit more at the inferior aspect of our visual fields. The technique will be the same which is to cut and lift and cut and lift and fully expose what we need to cut. And I can better demonstrate this for you just from the video. It's important that this is the angle of approach. If I am angled to acutely, what will happen is that my tips will start to um to engage too much with the endometrium and I'll find that I'm removing a significant amount of the endometrium. And so I want to try to at least keep a shallow approach or only use the tips and make sure that I don't dig into or gouge the endometrium again, here's the patient that we've seen. I'm going to start off by looking down and allowing my my scissors to be parallel. It doesn't work for very long. And now I've rotated my visual field so I am looking up but with the same technique that I've talked about before, I can use just the tips to cut and lift and cut and lift, trying very hard to to stay out of that endometrium taking just the polyp. Now what happened? This is not a lateral polyp, this is posterior. And what's happened is an example of if I'm not watching my camera head and my camera head rotates all of a sudden. Now I can get very disoriented and um I'm doing okay still. But you can see that that that was not a lateral polyp that was posterior. Here. I'm using the 10 acura. Um because this is a very dense polyp compressing the tissue and then having to gauge whether or not I made an accurate assessment of. Can I get this polyp out My window, cervical canal, which is at least 5.4 mm because that's what size my operative history scope is. If the polyp is pliable if it has um the ability to conform to the industrial canal. And sometimes I am lucky and it's better to be lucky than good. And sometimes not. Sometimes I just can't get it through. I'm gonna have to do something else to get that polyp to come through Now. What about polyp size? So my estimation of looking at that polyp maybe very very different than the actual size. And that's because I'm using a history scope, which magnifies my visual field ideally I would have known or suspected that there was an endometrial polyp within the endometrial cavity based on an ultrasound exam and measurements from the ultrasound to give me an idea of what I'm dealing with, combined with my visual field. If I don't have that, then I need to estimate the polyp size and how will I do that best. Well, these are my surgical instruments and I've measured these instruments might inaccurate would open fully is a centimeter. I can literally open the jaw fully and march that instrument as I'm looking at the polyp marching across my visual field and across the length of that polyp to get a very good estimation of polyp size. My grasshopper is eight and my two scissors are five a piece. So you can do this with your own instruments because this is the same polyp here. Because I've got to get this big polyp out this small indo cervical canal. What are the techniques to do that is to transect the polyp. And what that means is to fully cut pieces of this polyp away from uh away from itself. With the last transaction cut being the cut that separates the polyp completely. It is much more difficult to try to transact the polyp. It is if it's floating inside the uterine cavity, it's very very difficult. So, fully transacting pieces off importantly here, you want to make sure that the pieces that you are transacting will still be small enough to remove through the indo cervix. You don't want to necessarily just cut this at at site number two and have two pieces that are both still too big to remove. This is an example of transaction. I want to thank Attilio for this video. This is using um an instrument. That is a beautiful instrument. It's a bipolar needle. Um And he will also show you some more of this technique. Um And this is a story of bipolar needle. This is a reusable needle. And so what we see here is using the electric energy source to transact that first. And now you can go and separate from the base, creating two pieces that will each on their own fit through the endo cervical canal. And this is a way to be very efficient and make sure that you get your entire pathology. It's a beautiful technique he's using here small bursts of energy staying off the endometrium and making this feasible to then go back and grab the pieces that he wants. And presumably Attilio to um can always go back and clean up the base with a grasshopper or electro surgery or a scissor. This is another of Vasilios videos. Um A small polyp here with a scissor technique, you can see that he's rotated to have his scissor perpendicular to the base. Sometimes if I have a lot of polyps, I will let them stay within the endometrial cavity while I'm working and then take them all out together here. Attilio took this one out and then we'll proceed with using the bipolar needle and trendsetting fully. The pieces of this polyp here. You're going to see that he leaves the pieces inside until he has separated them completely And then put in a grasping instrument and then take them out at the end. This is the instrument With its 10 accurate with the spike Attilio. You can tell us what what this is called when you come back on and thank you for those videos. The other option is to maybe not necessarily transact fully. But what if we can segment into the polyp before we separate it from? Oh, the uterine wall? What will happen is if I grab this polyp along the long axis as I bring it into the cervical canal. If I twist and rotate this polyp, then because it's been segmented, will elongate to a much thinner ah sighs and I can then easily get this polyp out and this is an example of that. Um I do have a lot of postmenopausal bleeding patients in my in my practice this is a benign polyp that's been has a hemorrhagic tip. I am essentially making an incision into the polyp. You can see here if if the scissors aren't sharp, You end up nine tissues are better to have a sharp set of scissors. I've made one incision. I'm going to come from a different angle and now I will move to separate this polyp from the base. This essentially is a posterior attachment and you can see that I am looking up my radical is down. My instrument is coming at a slight uh a slight angle. Using just the tips pushing up. This is the technique that I showed you before. This is a nice instrument. Now if I close on this too tightly, those claws will essentially transect the polyp so it's just enough to get a nice grasp, rotate that polyp as it comes out and then I can get the entire polyp to come out easily. This is what I call it, the technique and um I learned this from Attilio while watching him operate and I like it. So I'm going to show it to you. This is with a large pathology that you can actually utilize the history scope by pulling the pathology into the cervical canal alongside the history scope and then using that pressure within the cervical canal from the history scope on the pathology to give that that added traction on on the tissue to pull that tissue out. This is an uh an anterior CSS style, fairly dense uh a trophic cystic polyp I'm using now appointed scissor because it's cystic and because it's a little bit dense tissue. Um and because its interior, I'm less likely to to poke the tips into the patient and more than the removal here, I'm I'm going to get to um taking it out of the uterine cavity. So here I'm going to use the 10 accurate because it's cystic. These tend to be filled with little pockets of mucus. Getting a nice bite along the long axis. Pulling the tissue toward the history scope, which is right, you're gonna see me pull it into the history scope here and I'm angling that tissue and I'm telling you what I'm doing. It's hard to to see that I'm actually doing it but using the history scope uh to drag that pathology out and now I can get a nice piece of tissue going back cleaning up as I need to remove the rest of the endometrium polyps. And that is where I will leave you. Attilio now is going to show you some of his techniques that he has with different instruments and um artie I can answer questions and if there's none happy to answer anything at the end. Thank you amy. Um We just have a couple of questions and there's quite a few actually in the chat as well, but I think those are gonna be best answered when both you and until you are on for the live Q. And A. At the end of the presentation. Um One thing I always love about your presentations, amy is that you focus so much on ergonomics and I think setting yourself up to be to have a successful outcome in surgery is very important. Um a couple of tricks are you sitting standing, how do you orient? How do you keep the camera oriented so that you don't have to lose focus on that while you're operating in this small field. Um Thanks Dorothy for that and I am sitting all of the things the videos that I've showed you in all these techniques I use with awake patients in my office. Um and it's easier for me in the office environment to sit if I'm doing a reset disk opic procedure in the operating room, I tend to stand those are a little bit more dynamic. Uh and I'm moving a little bit more but in this in this scenario where the patient is in the in the office I sit on rolly stool. Um I do have boots strips. Um something if you don't have boots trip so you need to support the knees to be able to give you enough room between the patient's legs. Great thank you. And there are quite a few questions but I think what we'll do is go ahead and invite professor dispute so Sardo to demonstrate his polyp ectomy procedural techniques and videos and then we'll rejoin all of us for Q. And A. Okay. So thank you very much Artie. Honestly I'm I was really astonished by probably was more than for a weapon that was a magistrate lecture that Emmy did about to me. And even for people like me that are supposed expert was very nice to see really how she standard died. All the things as Artie said before about ergonomics, visual field, position of the hands on the history scope, it's very very important. So if you wanted to know some tips and tricks I think that uh Emma lessons was full of tips and tricks even for people who are expert because sometimes in extra Skopje we do some movements that are immediate are natural but we don't reflect that probably we could modify our ergonomics in order to make our works easier and more effective. So thanks hemi for your talk. So my talk will be even quicker than expected because most of the tips and tricks at least for the technique. With miniaturized instruments have been perfectly elucidated by Emmy. When we speak about polyp ectomy probably is the technique most versatile in terms of instruments technique. I didn't know that I had a technique but thanks Sammy. But these are just tips and tricks modification of standard techniques because keep in mind that if you are able to remove polyps In your clinical practice you are able to do nearly 60, of your operative procedures. Because polyp is the most common pathology that you are faced with in your clinical activity. It apparently very easy. I would say stupid lesion. But most of the time you will face with this lesion. So it's important that you know how to treat in a safe and effective way. Uh Of course when I did with the support of car stores this uh book about the technique for all the and the lavatory pathology that can be removed. We have decided to divide the technique in technique that you can do in ambulatory setting, office setting and technique that you do in your parenting room. So it means that most of the time you it requires cervical dilatation and the use of an aesthetic. So regarding the technique with five french miniaturized instruments. Just to emphasize concepts already given by any. It's important as you have seen in any video that when you grasp the base of deletion of the polyp in a perpendicular way. With medical, you have to push rather than to pull towards you. In this way you are going to remove the pentacle or from the base of delusion. Any already stated that the possibility of having reusable electrodes makes your cutting more effective and more even quicker because of course, rather than using the scissors that everyone knows that most of the time, mostly if you use for many, many times they do not cut properly so you can waste time more than saving time. But of course from economical reason if you have the possibility to use sisters as first line instruments, go ahead with scissors. Otherwise you have the possibility of reusable electrodes that are fantastic as amy showed before because you can cut the leash in in several pieces. You see when you have a big polyp assessable polyps. So with the base very broad. It's important that you have to cut the polyp in several pieces in these cases I try to do first and your example cut. But generally the standard techniques should be to go from the free margin of the polyp towards the base of the lesion. When you cut the polyp with bipolar electrodes, it's always important that you see the white ceramic insulator that is placed in between the active electrodes and rhetoric electrodes that are placed in line. So uh when we have decided to apply the philosophy of the sea entreaty spectroscopy in our clinical activity, we understood that with new bipolar electrodes was very, very nice to cut the leash in the most time consuming part of the procedure. And sometimes the most frustrating part of the procedure is the removal of fragment from the cavity. That's why we decided to develop with car store some more robust instrument as this uh modified in a column that we called, who was the inventor of the original telecyl. Um and this my surname. So combined just because we we modified and we make more robust even with this pin in between the two arms of the 10 A. Column. And mostly when you have big fragment or feb Roddick fragments of polyps or even if you have uh small pieces of the myeloma that have a very hard consistency. This fragment. This uh this robust instruments can help you to remove big fragment from the uterine cavity for polyps just to anticipate question, there is no cut off in terms of sites does not mean that all the polyps can be removed with miniaturized instruments. But when you go into the cavity, you have to do an estimation of the sites of the polyp as Emmy stated before. But you have to understand since the beginning, how much time do I need to remove the polyp According to the sites of the polyp? The instruments that I have and my experience, AM I able to remove the polyp in less than 15:20 minutes. If the question the answer is yes, go ahead. Otherwise is not to blame to schedule the patient for another type of treatment in inpatient setting or with mild sedation. But the cut off is not the sites But the time 1520 minutes is the maximum that, according to my experience we should not overpass because even the most compliant patient after this cut off time starts to complain about the procedures Because probably 20 minutes is the maximum to tolerate a procedure without any kind of analgesia or anesthesia. Just to be complete. We have to know that there are some colleagues and friends like Sir Joksimovic for example that use a lot of the laser. The technique is the same of bipolar adequate but you have these other possibility to cut the lesion using laser. But I think that the main innovation that we had not only for polyp actually but for many outpatient procedures in the last I would say five years is the advent of a purely bipolar uh mineral sector scope because since the beginning we use this device, we understood that it was very easy because of course reading them doing the movement with bipolar electrodes, five french bipolar electrodes that are not very immediate With the 15 French mineral sector scope. You can use the same economic movements that you normally do in your inpatient setting. When you use the standard sized resect a scope and having bipolar technology a robust Uh this possible loop that allows you a perfect and efficient cut with a real minimal production of bubble if you combine with out a con 403rd vision third version. So you can remove even big large polyp multiple polyps that probably You should have scheduled for inpatient treatment. You can remove in office or outpatient setting without any problems. And you see that before I show you a video of a 2.5 cm cecil posterior polyp. I removed this polyp with bipolar instrument electrodes in three minutes. In six minutes. Now same type of polyp, 2.5 cm cecil broad based polyp in three minutes. It means it means that I could reduce of 50% of the time of our surgery. And because we said before that time is the main limiting factor. So 15 french salary sector scope has allowed to enlarge the indication for our outpatient procedure. Of course you have the possibility even to choose different loops that you have because this device can fit several loops. Some loops are not electrified. They have been developed for the cold loop. Myomectomy but sometimes for example, I use even to perform blunt additional analysis in the cervical canal. Because without using any kind of electricity, just mechanical movement, you can break the cervical edition, you can go into the uterine cavity. Then you can use the standard sides cutting loop just to remove to do the slicing of the polyp. The technique is identical to the technique that you are used to perform in your operating room with the standard sized resect a scope. The slicing technique is done by progressive movement of the loop over the lesion, starting always from the free margin of the lesion, progressively moving towards the beast. And then you can use this other rake loop not electrified to remove the fragment from the uterine cavity. Take in mind that you can use even your loop to remove the fragments. But because it is this possible, we don't want to waste many loops to perform a single procedures. And then you can have also the equatorial loop. If you have a fund a lesion or if you want to refine the base of a polyp without going too deep into the Miami atrium. So keep in mind that this mineral sector scope can fit many different loops. And so you can a large indication of your procedures. Uh of course we have to consider that uh when you have big lesion inside the Cavity, probably the possibility of having 15 French mineral sectors. Or has allowed even to reduce the number of procedures that we perform in our operating room because in the past when we had 2.53 centimeters three centimeters of polyp in the uterine cavity, we knew that with standard instrumentation. We could not Do the procedures in less than 50 20 15 minutes. And so we scheduled the patient for operating room. Now that you have this instrument that is 15 french, which means five millimeters. And when an instrument is five millimeter big, it means that you can put this instrument into the uterine cavity without any kind of cervical dilatation. And as you can see in these and other videos, I go in and out from the uterine cavity, always with the gyroscopic approach because I don't need any cervical dilatation. I don't have any vaginal instrumentation as speculum or vassal um to grasp the cervix and you can also perform some biopsies. Some long strips of biopsy if you want to have also specimen from the healthy endometrium. Keep in mind I forgot to present. But there is a paper who has shown that when you have a polyp and even if the polyp is benign, if you do some target random biopsy in the cavity, there is a percentage of cases is about 10% in which you can find some a typical area in normally appearing like uh endometrium area. So since I read this article generally when I do polyp ectomy, I also prefer to do some random biopsy on the endometrium which appears normal. One of the problems that you can have with the mineral sector scope is the removal of the chips. We have two techniques. One is the standard techniques that you use even with your standard sized, resect a scope so to grasp the chip and to go very slowly in the cervical canal. So this is the standard technique that we use. And this technique is useful mostly when you want to remove specifically one ship of the polyp. For example, in a typical area of the polyp that you don't like and you want to send for specific histological examination. And there is the second technique. The video was. My fault is absent. So is Jabba to will explain its voice. You just put yourself with the tip of your respective scope in the cervical canal. And because you have the outflow channel of the resect a scope open and connected with the suction, the suction flow of your endowment machine. Of course all the fragments that are small enough will be go out come out from the uterine cavity without even the need to grasp with the cutting loop. So you put your extra scope in the ethnic area and you will see the toll. The fragment will come out by themselves from the uterine cavity. But another innovation in the stereoscopic field. So this is the beauty of Extra Skopje many different possibility was the advent of tissue removal device because there was a guy very clever like marc Anthony Manuel who understood that? One of the main limiting factor we said before his time. How can we save time if we can cut and aspirate the lesion in the same time? That's why the tissue removal device came in the market. And so immediately we understood that it was easy to save time. No use of electro surgery. Less risk of addition, low risk of preparation because you put the device inside it, cut and aspirate simultaneously. So you don't have to go in and out as I showed you before an enemy. The same when we use miniaturized instruments or when we use the mineral sector scope. However we have to cut and then to remove the fragments. So we go in and out from the uterine cavity With a tissue in world device. You don't use any kind of electro surgery. In this case. For example, I'm using what we call the Mini Bugatti. So because it's a smaller sites in comparison with the original one, it is nine and 19 French sites. And you see that it's very, very easy. The beauty of this surgery is lays in the fact that it's very boring at the end because the surgeon as no, it is not required any specific surgical skill. Of course you have to know how to go into the uterine cavity. You have to understand the problem of the visual field. But rather than using electra surgical loops, you just put the tip of your shaver next to deletion and the device will do the job by itself. And so you can do in a few seconds I would say even less than one minute the removal of big lesion from the uterine cavity. When we understood in the past we in the recent years that the shiver offers you the possibility even to perform a cleaning of all the uterine cavity. Because sometimes when you have a broad based polyp in the cavity but you have also a thick endometrium most of the time it's very difficult to perform a proper polytech to me to identify the base of the polyp. So in this case personally I convert my procedures to the tissue removal device. So I first remove the polyp in a few seconds. And if I want to perform a proper sampling of all the uterine cavity I do the visual D. N. C. And I hope that in the next month we will publish together with my friend Pablo casado from Italy. Our experience with using the tissue removal device in doing the visual D. N. C. For the fertility sparing treatment of endometrial carcinoma in young women desiring pregnancy because the shaver and generally all the tissue removed device allows you to remove all the endometrium which covers the uterine cavity without going deep into the my ah material. And because this lady wants of course to preserve their fertility, the possibility of modulate the depth of reception with resect a scope is a little bit challenging. If you are not expert having the shaver or a tissue removal device, you can remove all the paper, plastic or not plastic tissue from the uterine cavity and to clean the cavity before putting a coil releasing levonorgestrel to maximize your surgery. Of course. Just to conclude there are some polyps that are some patients that they cannot tolerate the outpatient approach. They want anesthesia. They don't want to have the procedures performing outpatient settings. So in this case you bring the patients to the operating room. If you have to delay the certain tricks you can use your telescope so you know that you do always in retrograde movement, moving from the fungus towards the base towards the cervical canal, progressively moving from the free margin of the lesion until the base of the lesion, paying attention not to go too deep into the wall of the uterine cavity. And even if you have big large multiple polyp in your parting room, the tissue removal device, the Bugatti shiver once more represents a good option. Look for example, this case there is an enormous polyp starting from the fungal area and then arriving up to the external uterine Austria. Um The beauty of the devices that even if you don't know where you have to start, you go on the free margin you stay there. It's important that you put always the blade of the instrument in contact with the lesion and then the device that the job by itself and the politics. That whatever instruments you are going to use. Five french mineral sector scope, standard sized resect a scope. However, it would last 2025 minutes when you have enormous polyp with the shaver so you can remove in a few minutes a big lesion that otherwise would have required much time. I think that all the techniques have been expanded by me and Emmy I want just to do but it's just for free this book. So it's just for educational proposed I received support from stores to updated my first manual honest Roszke copy and all the techniques. All the tricks that we have, we have stated today, me and Emmy for polyps. But even for other pathology can be found on this book. It is free downloadable from car stores website. So please if you are a fan of Extra Skopje, some tips, n tricks can be found there and you can enjoy this wonderful technique. So thank you very much once more and I'm ready for questions. Thank you Attilio. Excellent presentations from both of you. Uh quite a few questions. And so I'm going to go ahead and um ask them from the chat. If you have any more questions, please put them in now so we can address them before the end of the session um from dr Mark Rosen Attilio. I think this is addressed to you. If size and number of polyps makes no difference in effect on fertility. Could it be the reason that the polyp develops in the actual case? Did the polyp develop? So if if the size and number of polyps makes no difference on effective fertility. Could it be the that the reason that the polyp develops is the actual cause. Sorry I may have misstated it. Okay so what literature says is that number sites location of pipe was not affect the reproductive outcome in. Or we can say it in other words, all polyps seems to affect fertility with no difference in sides number and location of the polyp into the uterine cavity. So what I think is that probably the polyp is not only a problem of the volumetric uh use of the volume of the uterine cavity by the polyp itself. But probably the mechanism is more complex. Probably it can modify endometrial receptivity problem. Possibly it can modify the endometrial environment in terms of cytokine integral. So probably the mechanisms more complex. So um there is no reason why you have to live a polyp of 0.5 cm and removing one of two cm if fertility issue is fertility is the main issue of this patient. So personally when I found the polyp and the lady wants to have a pregnancy. I always say why not removing the polyp mostly if you are able to remove with a quick and easy see and treat procedures. Right. And I'm you know of course you're in the cavity. So if there's any surrounding pathology you are able to address that at the same time as well. Um This question is from dr Frederick vireo or rubio. Excuse me if I mispronounced your name, uh If you knew ahead of time that the patient had endometrial cancer, would you still perform endometrial resection or purely endometrial biopsy or polyp ectomy? If the politest it appears as malignant, of course you have to. The main aim is that you have to send to to pathology pathologists enough tissue to do appropriate diagnosis. Uh Sometimes I get upset with my trainees or with other colleagues that they said very very small fragment of N a medium to the pathologies with five french instruments and without any clinical reports of the lady. And of course even the pathology needs to be trained to analyze very small specimen of endometrium. Uh personally, if I'm able to do many biopsies with five french instruments is my priority. My gold standard now that I have the mineral sector scope. I sometimes prefer to do a large ship with the mineral sector scope. And sometimes I also mostly when you have a focal carcinoma. I can also do a cut into the Miami atrium in order to have also an evaluation of the myeloma tral invasion of the endometrial carcinoma. Mostly if this lady wants to preserve her fertility and she would ask for a conservative fertility sparing treatment of her carcinoma and mineral sector scope has a great great advantages in case of endometrial carcinoma which spread beyond the the internal uterine costume in the cervix. Because we know that in order to do a proper diagnosis of stage two economical carcinoma, we need a specimen which is representative even of this trauma of the cervical canal. And with grasping caesar's you cannot do with the mineral sector scope. You can do a cut into the cervical trauma. And so the pathologist will appreciate you so much in order to do a proper diagnosis of invasion of the cervical of the cervical canal. Can I can I answer that from a postmenopausal bleeding perspective, it's a little bit different. Attilio does quite a bit of the infertility work. Um What what um he said is really important about the tissue sample size and I have checked with my pathologists to make sure that they basically use a small basket that they used to capture the tissue and then prepare it to make sure that they are able to actually appropriately process um the tissue from from my grasp. Er um And that being said, I do make a point in these post menopausal patients too. Um If I'm not going to remove the whole lesion. Certainly um make sure that I'm getting an adequate sample. There are times when I actually know that the polyp is not normal, but I'm sometimes wrong and I will get the pathology back and it's not cancer. It is a benign polyp. And so if there are circumstances where I suspect that it is abnormal and I just don't know those might be situations, I just take my time and remove the whole polyp in the event that it it is benign. Then I've I've done everything that that that patient needs. And I don't have to go back if I had only taken a piece. Excellent thoughts from both of you. Thank you. We have two questions from dr renaud jean. Uh First question is how do you tackle the bloody field when you are doing operative hysteria? Skopje Amy, would you like to start? Um Sure. So um in two ways, you know, it's really being very mindful of your intra uterine pressure with an awake patient. And there's certainly a balance between what you're able to do in terms of the patient comfort um and also fluid intra visitation. But making sure that your understanding um your your history, scope the inflow, the outflow um and allowing uh the, you know the pressure just to be able to clean your visual field um between the inflow and the outflow. Sometimes you actually need to turn the outflow down a little bit to give yourself more intra uterine pressure to stop the small bleeding that you see from these polyps vessels. Sometimes it's just too much. Um And I also have a bipolar instrument which is phenomenal um You know, it's it's way more efficient to use in a set of scissors and that the electrode is reusable. Is it just makes it that much more cost effective as well. But having a little bit of electro surgery can allow you to really spot um desiccated tissue, stop the bleeding and that allows you to help clear your visual field. Attilio, do you have any thoughts to add that? There is nothing to add? Probably just this concept that in East Ra Skopje you never have to use coagulate mode or whatever instruments you are using. So just to be clear, the the blue pedal should not be used unless you have some small bleeding vessels into the uterine cavity. It can happen for example when you remove a polyp or that my oma more than a polyp. So or when you do metra plasticity or when you do an ablation sometimes. So you can do pinpoint coagulation. So you just put the tip of your electrodes or your loop just in contact because of course for coagulation mode, you need the contact with the bleeding vessels but not because you are scared about the bleeding, but just because in the spectroscopy, if you have even a small bleeding vessels, you can have some problems of visual field even if you have a proper continuous flow history scope. You are using the best available pumps on the market but even a small bleeding vessels can create a reddish visual field. So it's important that you sometimes as Emmy suggested you close the outflow you increase for a while. The introduction pressure, you go closer to the blade feeding vessels. You identify very bleeding and you pimp you coagulate with a very delicate movement just putting the electors for a few seconds on the bleeding vessels and you uh stop immediately. Uh this problem into the uterine cavity. Thank you. Dr shen has a second question. Not in particular to polyps but still would appreciate your expertise. Any tips to remove embedded intra uterine device in Miami atrium embedded intra uterine device. Yes a few years ago I published a video article. I think it's still very actual very nice on Jamie Big showing the technique for the embedded I. I. U. D. Generally. There are many tips and tricks. It's important that you know how deep is the I. U. D. Into the uterine wall first of all. So you need a good sonography or good. Um Right that exclude that you have a preparation full thickness with one of the arm of the I. O. D. And then it's important that you have to follow all the length of the arm of the device. If it's if it's one of the arm embedded into Miami Truman with careful attention, meticulous attention I would say with sisters or even with the I. U. D. Or with the electrodes you can just make free the arm. So removing all the tissue that is around the the arm and you have to use even contra traction. Sometimes in some moment of your surgery with your grasping forceps in order to try to remove the device. Of course sometimes you need a little bit of sedation because the patient can have pain. Keep in mind that sensory all innovation in the uterus is in the biometric. Um So whatever you are working in the bio medium of course you can cause pain to the patient. But sometimes pain can also help you if you do with the patient awake to understand if you are going in the correct direction or if you are really creating a perforation with your instruments trying to resolve the situation. However if you look at this video article I think it can be nice and because some tips and tricks are emphasized. No thank you. Uh I know amy you have a hard stop right now and um until you if you could stay on we could help answer some more of the audience questions. But amy would you like to provide any more information on any tips or techniques for the embedded internet advice or any more thoughts, concluding thoughts on Phillip ectomy. No no I think I'm Attilio article is nice. Um I I like bipolar um I can I can inject, I've got an anesthetic needle that allows me to put the anesthetic into the geometry. Um If I if I feel it's important. But the bipolar is a great instrument for me to be able to um you know in size just around the usually the arm that needs to come out. Um But Attila's article is is great and thank you so much for the opportunity. Um I am happy to have stored share my email. If anybody has questions they want to to reach out to me offline would be happy to do so. And again, thank you to carl Stewart's and my uh my friend and colleague Attilio. Always a pleasure. Thank you amy. Thank you have a wonderful day and really appreciate your time today. Thank you. Thank you Attilio, thank you for staying on. I this is to your point, a simple topic but yet really very extensive as there's it's very common and there's so many different pathologies and methodologies. RT in Italy. There are seven deaths in the last 15 years. No, probably more than 15, years. Seven deaths for operative Extra Skopje and all of them were for politics. To me and you get everyone could say why polytech to my, to me. More challenging mental capacity ablation and all the different difficult procedures because politifact um is something that even the young doctors, even the doctor with no expertise start from polytech to me and most of the deaths were related to the fact that the doctor perforated uterus was in the abdomen and he didn't realize that it was in the abdomen and it started to resect iliac artery bowel ureter. And that song, that's why it's important that you understand that we are speaking about uterine surgery is not less complicated than abdominal laparoscopic surgery. You need to know some rules. And even if you are, if you are facing with very easy lesion as polyp. Sometimes the even these easy procedures can hide some dangers that you have to recognize. Absolutely well spoken. Um Dr Mark Rosen wanted to ask if it is a monopoly over needle equivalent or just as good um to a bipolar needle except for needing to change the medium. Of course, yep. The bipolar needle is the evolution of the monopoly er needle honestly, probably artie you know better than me. I don't know if stores still has on the market. The monopoly er needle for Extra Skopje. Because honestly, to be honest, I don't see any great reason to support to continue to support the use of monopolize her. I can understand if you tell me that many other companies have disposable electrodes. And so the costs are an issue. But now, for example, if we speak about the same company starts, they have reusable bipolar electrodes. So rather than putting the plate on the lady that you have to change even the liquid distension medium because normally with the agnostic with Solin. So there is so you should change even the bag. Why you don't have any advantage in using monopolize her. Then if you tell me that this is the only possibility that you have your institution. You have the monopoly. You want to use. The technique is the same. But of course you have to change the distension medium. You have to put the plate so the returnable electrodes on the leg of your lady. And of course you have also to consider if you perform the procedures with the patient awake that little bit more of thermal dispersion it can happen. And it caused pain to the patient. Thank you dr Andreas focus asked. How do you remove the chips from the vagina without a speculum or any other instrument Then Honestly if some vaginas. If some uh piece of tissue are instilling vagina, I just put a note at the end of the procedure over my fingers. So I put the goods over my finger in the vagina. And you will see that the goats will collect most of the tissue are in the vagina. Of course we are speaking if we are doing the procedure with the patient awake in office setting and we have to minimize the discomfort. We emphasize the genus coptic approach. Miniaturized instruments. It's a pity if at the end of the procedure you put the speculum you put the forceps and so you waste all the sacrifices that you did before. On the other end. If the patient is in the operating room, she's under local regional anesthesia or under G. A. Of course if you have a lot of chips of my oma into the vagina. You stop for a while. The surgery, you can put the speculum and you can remove with your spoon forceps all the fragmenting vagina but sometimes by simply pushing with your fingers in the vagina. So you can see that the water comes out with all the fragments. And we have a bag below the buttocks of the lady which collects all the tissue at the end of the surgical procedures. Of course, all these problems you will not have with the tissue removal device because all the fragments will be collected straight away in a small bag that is connected to the outflow channel of the of the pump connected to the device and so you can collect all the tissue without need to uh to go in the vagina or below the patients uh etcetera etcetera. We have a comment and a question, Professor Attilio sir. I am Dr Tariq from Bangladesh. It's great to see you here sir. My question regarding what is the best histories Ka pik tissue removal device. Yeah, I think personally, but I can tell you what I think the best way to answer is just to show my experience. I tried probably all the devices and I can tell you that the tissue removal device from Medtronic from a logic from stores they are. I would say if you compare the same sites of the blade comparable in terms of efficiency of the cut. What I personally have in my institution is the tissue removal device, the five and six millimeter from Medtronic and the 6.3 millimeter from stores. But you know why? Because they are the only ones that at the moment allows me to go into the uterine cavity without any kind of cervical dietitian. I personally don't like the tissue removal device for inpatient setting. If I schedule the patient for inpatient setting, a parting room, I used the resect a scope because our delusions that I could not remove in my outpatient setting. If I used the device in the outpatient setting, I want a device that allows me to avoid cervical dilatation and of course from 6.3 to 5 it's perfect bigger than this. I cannot use in my office setting. I hope that this is a very honest answer expected. So, giving an answer to your question actually as a follow up, what about the aspect that it's reusable versus the disposable blades. Do you see any decrease in sharpness? This is this is another issue. The shaver is reusable. The blade associated with Medtronic Logic devices are disposable. So the issue, the cost issue is something that I'm sure that in Bangladesh are different from in Italy are different from the United States and probably in United States like in Italy are different from region to region. So if the cost of course reusable, if it's possible, they should always be preferred to disposable. But it also depends in the way in which you can perform sterilization of the instruments in your institution. I know that in many countries many hospital the reusable cannot be used because they don't have the possibility to sterilize in a short time. But of course on the other end if you use all this possible, the cost will jump a lot. And so you have to I think that many factors have to be considered what I can tell you that wherever tissue removal device you are going to choose. I tried all of them they are comparable then the ideal instrument does not exist but exist. The ideal instruments for yourself and your setup. I have all the setup in my institution of stocks. So it's also important that you have a good tissue removal device that works and that can fit with the machine that you have for water distention control because otherwise you can do a mess if you have a tissue removal device of a company, the irrigation machine from another company. And sometimes even if they say that they are compatible, they are not. And so you think that the device does not work. But the problem is that you cannot have enough intra uterine pressure or suction pressure to aspirate all the fragments. That's why it's very important that you consider all the setup that you have in your institution. You cannot just choose one instrument. Yeah. And one of the arguments by using disposable though is that you always will have a sharp blade. What has been your experience with the reusable and the sharpness or does it dull after a certain number of cases? Reusable does not mean that it is forever. It is something that people also to understand reusable. If you do 20 procedures with the Shaver per day, of course you have to change after a while the the blade. So people have to understand and even the hospital administrators have to understand that it's not like the camera and the optic that are reusable and they last for years. Even the blade of reusable shiver so they are not forever. So, but I can tell you that a large amount of procedures can be done. Then personally I have my technicians from stores. They are very skillful in Naples in the south of Italy. They sometimes they can also clean with some specific products the blade of the of the shaver making. So longer the life of the device itself. Great thank you. And the way we should clean and in which you sterilize the instrumentation is very important personally. We use only chemical sterilization because personally we think that in autoclave the amy life of the instruments is shorter. Not only the optic but even all the other instruments. Thank you. We have one last participant who has many questions. Who has a few questions And it comes from not from the one and only dr linda Bradley? Um So linda writes, How often do you recommend? Hi linda? How often do you recommend marina? You d to decrease risk of recurrence or abnormal bleeding? Especially in overweight women. Very pertinent questions. So I think that Mirena or however the old the intra uterine device releasing a higher amount of Levonorgestrel 52 mg. I always personally put this kind of the device to prevent recurrence in overweight lady with deacon endometrium hyper plastic risk. Of course don't I always say to my lady that if I remove the polyp and I don't do anything in three months, the lady come back to you with the same problems because there is an apple estrogenic state and you can only resolve by putting a coil or giving if the lady does not love the coil progesterone gin in a cyclic way or even in a continuous way to reduce the recurrence. So when there is a risk of recurrence, mostly if the lady has some risk factor for uh endometrial carcinoma, like diabetes hypertension, elevated body mass index. In this situation, Mirena would be a great option to avoid recurrence and mostly to avoid the risk of development of hyperplasia? Even with Ethiopia? Her next question is if fertility is desired. Do you perform a post operative history ross copy to look for adhesive disease. To to look for adhesive disease adhesions. Additionally, of course, I suppose that this question is not related to polyp because if there is a procedure that is not a dis eugenic. If you use of course the the proper technique you don't do to resect the polyp 1.5 cm below the base of the Polyp Blah Blah Blah. So polyp ectomy honestly is the procedures that I don't check the cavity after. I don't put any kind of anti addictive strategy. If the question is also referred to procedure who are more estrogenic like myomectomy of myeloma with intramural component or multiple mastectomy on opposing walls or when I do metra plasticky for shaped T shaped uterus or for accepted uterus. This kind of procedures are always always followed by an office follow up extra Skopje's just to check that everything is fine in case of metra plastic just to refine little bit the fungal area if it needed. But even for the risk of additions because if editions are there it is likely that they will be not very severe and just with the tip of your history scope or in a very with mechanical instruments you can remove these additions and of course if the lady have a strong desire of pregnancy. This follow up is more these ladies really mandatory for according to my opinion? Uh Dr Bradley's last question, how do you distended the endometrium the central cavity? You've been correct? Yeah, personally. But I used the end math machine. The old machine personally was even better than the new uh endo mat probably because I used for a long time but I could modulate the intra uterine pressure in a better way than with the new one. At the moment we have the endometrium machine. Uh and um we have also the select when we use the shiver in the in our outpatient setting. So uh this is I don't use anymore the pressure bag for example, neither in your parenting room or nor in the outpatient setting. But I prefer an electronically controlled irrigation and suction device which can at least try to maintain a new uniform and constant pressure during the procedures. But even in this case you have to know that it is different according to the instruments that you are going to use. That's why for example, Beto key always thought trainees that they have to start the examination with Pataki history scope already with the grasping inside the operating channel. Because the operating channel of the history scope is part of the inflow channel of the history scope itself. And so of course if you put later the instruments, you have a drop of the uterine pressure in the cavity. And when you have modification of the intra uterine pressure, it means uterine contractions. And if there are uterine contraction, it means pain of the patients and lower visibility in the cavity because of course you have not a good distention of the uterine world and it's very difficult to do any kind of diagnosis or operative procedures. Wonderful questions and answers. Thank you so much. And um to conclude I would really like to thank our experts Dr Amy Garcia and Professor Attilio di piazza Sardo for their time and expertise. Today delivering an outstanding educational webinar and history topic polyp ectomy. Thank you to all the participants for your attention questions and most importantly your dedication to women's health care. This concludes our history topic webinar E Masterclass series. For 2021. Please visit the Carl Stores Network One website. To view any sessions you have missed or would like to review again. I wish you all a wonderful weekend, a safe and enjoyable holiday season and a happy new Year. Thank you.