Mr Ashwini K Trehan MBBS, DRCOG, FRCOG, FRCS (Edin)
Consultant Minimal Access Gynaecologist
(with special interest in Endometriosis and Keyhole Surgery)
MR TREHAN'S ARTICLES
Below are some of the articles which Mr Trehan has written.
"Overnight hospital stay service following major gynaecological operations"
Enthusiastic About Day Surgery
Ref: Health Service Journal (HSJ)
26th September 2002, P 21
We note with interest the targeting of performing 75 percent of elective surgery as day cases and wonder what gynaecology can contribute to this ('Expanded day surgery key to waiting times', 22 August).
The basket of day cases in the specialty had not changed much in 20 years and with the development of outpatient hysteroscopy is actually getting smaller. There can be few diagnostic or sterilising laparoscopies not performed as day cases as our ability to manage post-operative pain and co-morbidity had developed.
Have we reached a Plateau? While the emphasis is on short cases with a short stay in the unit, the answer is probably yes. However, a redefinition of a day case to include '23-hour stay' in dedicated beds in or adjacent to the day treatment unit widens our scope considerably.
We feel that although the move to change minor cases to day, ambulatory or even office care has become inexorable, the shortening stay of more major cases has the potential to release much more resources.
We have performed nearly 600 major laparascopic and laparascopic-assisted procedures on women who have only stayed in hospital for one post-operative night and with no emergency re-admission for complications. This innovative service includes cases like hysterectomies, ovarian and tubal surgery, extensive adhesiolysis, excisional procedures for endometriosis and other benign gynaecological diseases for which patients traditionally stay for an average of five days in hospital. At present, these go through our inpatient ward, but would seem ideal for a 23-hour unit.
Apart from the availability of such units, the major limitation to immediate widespread adoption of these methods seems to be a lack of exposure of trainees in gynaecology to training in appropriate techniques.
We feel we have established beyond question both feasibility and safety of 'one-night stay' gynaecological major surgery and would encourage its wider adoption.
We urge the relevant authorities to provide suitable exposure and encouragement both for trainees and existing consultants so that gynaecology can make a quantum leap into the 21st century and the target of 75 percent day surgery is met.
A K Trehan
Minimal access consultant gynaecologist
Dewsbury and District Hospital
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Mr Trehan's Abstract - Keyhole Hysterectomy
Overnight Stay Hysterectomy - Successfully Established in 1st UK Hospital
Ref: Reviews in Gynaecological Practice
June 2003 (Volume 3, issue 1), Laproscopy O37
Overnight hospital stay following Laparoscopic-Assisted Hysterectomy has been successfully introduced at Dewsbury District Hospital, the first U.K. hospital to offer this service without compromising patient safety. By sensible selection of patients, following strict protocols, meticulous operative technique, rigorous audit, team work and personal involvement this service has proved very popular among our patients, is very safe and has cost-saving implications.
We have introduced the hysterectomy overnight stay gradually and cautiously. Initial average hospital stay for my patients was 2.14 days but has now come down to 1.09 days. 91% of our patients now leave hospital after overnight stay. Total of 117 patients have been discharged home after overnight hospital stay.
Our overall complication rate, none of which are major, for 265 consecutive hysterectomies undertaken until September 2000, is 4.5%. We had no major complications involving bladder, ureter, bowel or vascular injury. None of our patients who were discharged home after overnight stay were readmitted or suffered any ill consequences. The type and complexity of our cases were no different from previously published papers on LAVH. The data were analysed using SPSS (version 10).
Detailed protocol, selection of patients, surgery details, postoperative follow up and complications would be discussed.
A K Trehan
Minimal access consultant gynaecologist
Dewsbury and District Hospital
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Mr Trehan's Abstract - Surgical Treatment of Endometriosis
Total Peritoneal Excision - Pouch of Douglas, Utero Sacral Ligament and Ovarian Fossa - Management of Endometriosis
Ref: Reviews in Gynaecological Practice
June 2003 (Volume 3, issue 1), Infertility P14
Excision is considered most effective way of treating both superficial and deep seated endometriosis with reported cure rate 57-66% [Redwine 1 Wheeler 2].
Personal observation that recurrence of endometriosis is in the areas of leftover peritoneum adjacent to excised area suggests the hypothesis that cure rate could be improved by completely excising the peritoneum covering the Pouch of Douglas, utero-sacral ligaments and both ovarian fossa, including both diseased and normal looking tissue. It may be that the area of peritoneum between frank clinical lesions seen on laparoscopy already contain subclinical endometriosis at an inception stage or it may be that there is continuing susceptibility to metapastic changes or retrograde menstruation.
Based on these observations, I believe that a more complete excision of the peritoneum covering Pouch of Douglas, utero-sacral ligaments and ovarian fossa should be attempted. In addition to removing potential sites of recurrence, the more complete destruction of retroperitoneal nerves implicit in this technique should produce better symptomatic relief.
The early results of this modification are encouraging. Further randomised prospective trial of local and complete excision are necessary. I will demonstrate and discuss my personal experience of the technique.
A K Trehan
Minimal access consultant gynaecologist
Dewsbury and District Hospital
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Mr Trehan's Publications - one night stay hysterectomy and safety of keyhole hysterectomy
Hysterectomy: Towards an Overnight Stay
Ref: Gynaecological Endoscopy
4th August 2002 (Volume 11, number 4, p181-187)
Abstract
Objective To review the introduction of an overnight stay laparoscopically-assisted vaginal hysterectomy (LAVH) service in a district general hospital.
Design A retrospective study.
Setting Dewsbury District Hospital is a 478-bedded district general hospital with 14 gynaecological inpatient beds, serving a population of 165 000.
Data collection Included in the study were 265 consecutive patients who underwent LAVH, performed by one consultant between September 1995 and September 2000. These patients were unsuitable for vaginal hysterectomy according to conventional (British) criteria and in the past would be have been offered abdominal hysterectomy. The names of the patients were obtained from the hospital register. All operative notes were abstracted and data collected independently by junior medical staff working in the department.
Results Postoperative stay was analysed for consecutive groups of 50 patients. Initially the median postoperative stay was 2 nights but by the last cohort, nine out of ten patients were going home after only 1 night's postoperative stay. None of the patients were readmitted or suffered complications as a result of this policy. Among the patients, 4.5% suffered one or more complications (most were minor). No patient suffered visceral injury. Patients had full surgical recovery by 6 weeks after operation except for a few who developed granulation tissue which needed topical treatment.
Conclusion In experienced hands LAVH has few complications, and it is acceptable and safe to discharge patients home after an overnight hospital stay provided strict guidelines are followed.
A K Trehan
Minimal access consultant gynaecologist
Dewsbury and District Hospital
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Mr Trehan's Abstract - new surgical technique to Prevent Ovarian Adhesion and reduce Pelvic Pain
Temporary Ovarian Suspension
Ref: Reviews in Gynaecological Practice
June 2003 (Volume 3, issue 1), Adhesions V01
Pelvic pain may continue to reformation of adhesion between posterior surface of ovary and and ovarian fossa following division of adhesions and or excision / coagulation of endometriosis. Various methods of adhesion prevention such as Interceed, Intergel, Herparanized saline etc., have proved unsuccessful.
Temporary Ovarian Suspension is a simple technique of suspending the ovary, for a few days (5-7), to the anterior abdominal wall. This allows separation of the raw area on the ovary and the ovarian epithelisation has occurred. When the suture is removed the ovary falls back to its anatomical position.
Technique: Anterior abdominal wall is transilluminated with laparoscope to demonstrate any major blood vessels especially the inferior epigastric vessels. Junction of lateral 1/4 and medial 3/4, approximately one inch above the inguinal ligament is the site on the anterior abdominal wall is used for ovarian suspension. Non absorbable number 0 proline on straight needle is used. Needle is pushed into the abdominal cavity at the above mentioned site, it picks up the ovary and comes out of the abdominal wall at the same site. Thread is tied on the anterior abdominal wall adjusting appropriate tension, the stitch is covered with transparent dressing which is left in position until the day of the removal of the stitch.
I will demonstrate and discuss this simple technique of suspending the ovaries.
A K Trehan
Minimal access consultant gynaecologist
Dewsbury and District Hospital