Mr Ashwini K Trehan MBBS, DRCOG, FRCOG, FRCS (Edin)

Consultant Minimal Access Gynaecologist

(with special interest in Endometriosis and Keyhole Surgery)

MR TREHAN'S INNOVATIVE PROCEDURES AND SERVICES

Below are some techniques and procedures which Mr. Trehan suggested, innovated and implemented in order to improve the quality of life for patients suffering with chronic pelvic pain and improve their experience of surgery.

Innovative Surgical Treatment of Endometriosis

Total Peritoneal Excision - Pouch of Douglas, Utero Sacral Ligament and Ovarian Fossa - Management of Endometriosis

In order to improve the outcome and safety, reduce the recurrence rate and preserve the organs especially the ovaries, he has recommended some modifications to the excision technique. For more information on the technique he has innovated, click here to view the presentation which Mr Trehan presented at the International Conferences (San Francisco, 2004 & London 2005). This presentation also shows Mr Trehan's outcome results of Radical Excision of Endometriosis

An abstract which Mr. Trehan has presented on this technique:
 

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.

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Innovative surgical technique to prevent ovarian adhesions and reduce pelvic pain

Temporary Ovarian Suspension

The ovaries are the most common organ which forms adhesions in the pelvis (ie. they stick to the pelvis wall) resulting in chronic pelvic pain, dyspareunia (painful sexual intercourse) and infertility.  In order to prevent the formation of these ovarian adhesions, he has innovated this technique which is widely used.

An abstract which Mr. Trehan has presented on this technique:
 

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.

To read Mr. Trehan's paper on this technique, click here.

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Innovative surgical treatment for chronic pelvic pain and dyspareunia (painful sexual intercourse) for women who have had a hysterectomy in the past.

Laparoscopic Posthysterectomy Vaginal Vault Excision

Inspite of having had a hysterectomy, there are many women who continue to suffer with chronic pelvic pain and dyspareunia (painful sexual intercourse) due to problems related to the internal hysterectomy scar wound in the vagina.  In this technique, the old hysterectomy scar wound of the vagina is removed and restitched.  This helps with the aforementioned symptoms.

An abstract which Mr. Trehan has presented on this technique:
 

10th World Congress on Endometriosis, Melbourne, Australia - 11 -14 March 2008
British Society for Gynaecological Endoscopy Annual Scientific Meeting - London, 7-8 May 2009

INTRODUCTION: Chronic pelvic pain and dyspareunia following hysterectomy is well known entity. Excision of vaginal vault for dyspareunia is underreported. On literature search we found only two case series in the English literature of vaginal vault excision1,2.


MATERIALS/METHOD: This is a case series of 22 patients with post hysterectomy dyspareunia and chronic pelvic pain who had vaginal vault (apex) excision in Dewsbury and District Hospital, UK between 2003 and 2007. The case notes were reviewed retrospectively. All patients were examined to confirm vault tenderness. Once bladder and bowel were mobilized from the vaginal apex and ureters identified, full thickness vaginal vault was excised along with scar tissues or any cyst. The vaginal cuff was closed laparoscopically. All patients had pain score checked before and after 6 months. Quality of life and sexual health questionnaire were sent in Aug 2007 to all patients.


RESULTS: The mean age of the patients was 40.5 years (range - 35years to 56years). The interval between hysterectomy and this operation was 1 to 22 years. All women had vaginal vault tenderness on examination. There was no intraoperative or post-operative complication except one who had bladder perforation with verres needle. All patients were discharged after overnight stay. The histology of the excised vault tissue confirmed pathology in 19 (86.4%). These were fibrous tissue (6), endometriotic cyst (4), neuroma (3), fibroma (1), inclusion cyst (3), chronic inflammation (2).

The mean theatre occupancy for the operation was 219 minutes for excision of vaginal vault with additional procedures like radical excision of endometriosis, excision of peritoneal scar, adhesiolysis, ovarian cystectomy, oophorectomy, temporary ovarian suspension, excision of hydrosalpinx, cystoscopy etc..

Quality of life and sexual health questionnaire received from 16 (73%) women. 12(75%) confirmed improvement in dyspareunia and other symptoms, 2(12.5%) were sexually not active but had improvement of other symptoms, 1(6.25%) had superficial dyspareunia due to dryness ( had previous removal of both ovaries) but had improvement of other symptoms, only 1(6.25%) reported no improvement. 15 (94%) will recommend it to their friends with similar symptoms. The longest interval between vaginal vault excision and assessment of improvement in dyspareunia was 4 years.

The detailed statistical analysis of the results on SPSS will be presented at congress.

CONCLUSIONS: Excision of vaginal vault is a safe and an effective option for posthysterectomy dyspareunia and chronic pelvic pain. It provides an opportunity to detect and surgically excise previously undiagnosed endometriosis and other pathology.


REFERENCES:

1. Sharp HT, Dodson MK, Langer KM, Doucette RC, Nortan PA. The role of vaginal apex excision in the management of persistent posthysterectomy dyspareunia. Am J Obstet Gynecol. 2000 Dec;183(6):1385-8; discussion 1388-9.
2. Lamvu G, Robinson B, Zolnoun D, Steege JF. Vaginal apex resection: a treatment option for vaginal apex pain. Obstet Gynecol. 2004 Dec; 104(6):1340-6.
 

To read Mr. Trehan's paper on this technique, click here.

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Innovative Service - Overnight hospital stay service following major/complex gynaecological operations

Mr Trehan has shown a unique new direction to the future of major/complex gynaecological surgery by proving that almost all non-cancerous gynaecological surgery can be undertaken via keyhole means. He strongly believes that there is very little need for the traditional and widely used choice of open surgery where a large cut is given to the patient’s stomach.

Mr Trehan has pioneered, developed, introduced and is running effectively the UK’s only one of its kind “Overnight hospital stay service following major benign gynaecological surgery”.
An article which Mr. Trehan has written about this service:
 

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.