Morcellation

In this post I wish to share with all my blog readers,few pictures depicting a procedure called MORCELLATION.

Ligaments being cut using harmonic

470 gms fibroid

Endometriotic gelationous lesions over the uterosacral ligament

Morcellator grasping the fibroid

Morcellation in progress

A Morcellated piece of the same 470 gms fibroid

What do you do with the uterus? Do you melt it inside with laser?It is such a big uterus how will you remove it out from a 1 cm cuts and so on ............?My patients have so many questions to ask and are very worried when they are opting for a TLH for big fibroids,When this instrument morcellator wasn't available I would do the TLH and then blindly chop the pieces from vaginal end and take it out.With the availability of morcellator the TLH of huge size fibroids has become easy and much less time consuming and it is all done under vision. The big uterus and fibroid is shredded into pieces like 'pasta' and then removed out from one of the 1 cms skin cut.
The same instrument is used for laparoscopic myomectomy where one intends to just remove the fibroid and save the uterus for the purpose of future reproduction.

Atrophic Endometrium

Atrophic endometrium

At times very thinned out endometrium rather than thick endometrium is the cause of heavy  vaginal bleed as the exposed blood vessels start bleeding.Progesterone isn't successful in such cases and one might need a mixed estrogen and progesterone pill.

Thanks and congratsDr Vinita Salvi and Aishwarya Rai Bachchan

Now as the excitement regarding delivery of Ashwarya Rai Bachchan is settling down I would like to first of all congratulate her and secondly thanks her.
She has broken the stereotype of a well decked up celebrity entering the hospital.All planned.Elective caesarean and baby is out!!" Too posh to push"!!She tried a normal delivery at 38 years of age and managed it.Ladies who love to follow her please take a few cue from her this action as well.
I have rich words of appreciation for her obstetrician who handled such a high profile delivery nicely and didn't succumb to the usual pressure  of VIP syndrome which very frequently leads to a caesarean section to prevent any medicolegal problem.I am sure she must be a very competent doctor.



Dr Vinita Salvi

 As a team,Very good Performance!!I respect the Prof for handling a delivery the way it should be rather than going in the merits of patients profile.
And Media when gives credit to Aishwarya  for her normal should also write a few lines about her doctor who gave her the option,took care of her and led to a safe and happy outcome.As I wrote in one of my blogs Normal delivery these days is not just about the doctor being patient but also is about knowing one's subject well,being competent in one's work and having the confidence that she can handle the pressures of normal delivery which needs much closer monitoring than a planned caesarean section.

Bleeding Heavily???

Thickened Endometrium at the level of internal OS

Thickened endometrium which in biopsy turned out to be cancerous

Endometrial Polyp

same Polyp from a different angle

Removal of the same Polyp using recetoscope

Thickened endometrium which in biopsy suggested simple hyperplasia

It is a common problem when you notice that your periods have become heavy or Irregular.Now this post is for Ladies above 40 years of age.If you have any such irregularity with your periods like a heavy or irregular bleeding it should be taken seriously.majority of the time it is just a hormonal imbalance which corrects of it's own but at times it can be problems like Polyp,Thickened inner lining of the womb,also called Endometrial hyperplasia(which can have pre cancerous potential),fibroids and in very small percentage endometrial cancer itself,which has a very good prognosis if detected early.Thus it is important not to ignore your problem.Your Gynaecologist might suggest you Hysteroscopy and biopsy of the inner lining of the womb.Go for it if suggested.It is a small minimally invasive procedure done under anaesthesia with a very quick recovery time and one can come back home the same day.A stitch in time saves nine............

For further details visit http://www.gynelaparoscopy.co.in/

Advanced laparoscopy in gynaecology

Using harmonic to cut the round ligament

Opening of anterior fold of peritoneum

same as above

Ligation of uterine artery

A clearly visible uterine artery

Uterine artery ligated on the other side

Opening the vagina

White coloured colpotmizer visualized



Hysterectomy over with the colpotimzre seen very clearly lifting the diseased uterus

 There have been immense advancements in performing laparoscopic surgeries in recent past.It no longer is a domain of a few selected blue eyed laparoscopist and in India we have many good laparoscopic gynaecologist performing much complicated gynaecology surgeries with great ease and deftness.Following are the pictures from a Total Laparoscopic Hysterectomy for fibroids uterus  performed by me which finished in 35 minutes.
For more details visit http://www.gynelaparoscopy.co.in/

Twin Pregnancy.......... a challenge

So last week we went ahead with a selective reduction of the anencephalic foetus at 12 weeks.The patient stood the procedure well and just awaiting the next scan to see how things go.

Fundal Pressure during delivery

There are three possible ways of delivery

• Normal delivery
• Vaginal delivery ( Instrumental delivery including ventouse and forceps)
• Caesarean section

Normal delivery without any intervention is the best one if one can achieve it.I am now rather tired of mentioning this very obvious fact again and again on by blog.I wish not to mention it but after conducting a vaginal delivery I feel as I am the odd one out in our current scenario.
Why am I writing this post? I am agitated at the ignorance of our health care professionals including gynaecologists,paediatricians and neonatologist and nurses in Indian setting who think that caesarean is a safer and better option for the baby.I am not saying that 100% of the healthcare givers feel that way but majority of them do.
A ventouse or forceps delivery is looked with horror.I am ashamed to write as I know my blog is read by a much wider group than just Indians,that in India including the best of set ups gynaecologists,nurses  as well as paediatricians consider something which is condemned in civilized work  as a safer option of delivery rather than a safely conducted instrumental delivery.Pushing the ladies uterus hard to deliver the baby in order in avoid the assisted delivery is considered safe.They forget that this fundal pressure can lead to rupture of uterus,spleen,liver and ribs of the pregnant lady and in long run can lead to uterine prolapse
.Agreed it requires no technique ,just brute force,but how does that make it safe? NEXT TIME YOU FIND YOUR OBSTETRICIAN OR HER ASSISTANT PUSHING YOUR UTERUS DOWN STOP THEM!!!!!!!!!!!!It can lead to grave injury to you.(there are two conditions where uterine pressure is justified .One is at the time of delivering the baby out at the time of a caesarean delivery and another one when there is shoulder dystocia).
If any of you wish to correct me regarding this fundal pressure thing................please feel free to leave a feedback with evidence regarding the same.
And caesarean at the drop of the hat might be right thing to avoid a medicolegal process from a gynaecologists point of view but what about the various risks of future  that the Lady is left with,like Placenta praveia,accreta,adhesions,infertility.

Laparoscopy in treating Infertility

Infertility is an ever increasing problem due to various reasons which I have tried to analyse in past to best of my understanding and have shared with you.
In my current post I would share with you pictures of some of the laparoscopic procedures which can be done with great ease to enhance fertility.As if done by as a laparoscopic procedure there is minimal discomfort and the patient is fit to be discharged the same day and can return to day to day activities from next day on wards.
Here follows pictures of laparoscopic opening of blocked fallopian tube and Ovarian drilling done performed for Polycystic Ovaries

Blocked Fallopian tube

Polycystic Ovary

Blocked Fallopian tube being opened

Spillage of Dye from open tube

Polycystic Ovary

Ovarian drilling in progress

Bilateral Ovarian drilling with spillage of dye from both sided fallopian tube following tubal opening surgery

For further details visit www.gynelaparoscopy.co.in

Surgical treatment of tubal ectopic pregnancy

Ruptured left tubal Pregnancy



Bleeding stopped following removal of the affected tube





Right tubal patency checked with mythlene blue 

For further reading please visit http://www.gynelaparoscopy.co.in/

Twins Pregnancy ......a challenge

I have written about twins in past as well,but there are so many variants of twins and its complicationsit keeps on intriguing me.
Now the latest one is a Lady who had a diamniotic and diachorionic twin (i.e separate Kitchen and separate living room which means separate Placenta and separate sacs),At 12 weeks we discovered that one of the twins has anencephaly i.e absence of front of brain tissue.The other twin is is perfectly alright.Situation would have been worse with monoamniotic monochorionic twins,but thank God for big mercies.Now wondering how to manage her.KCl can be injected in the heart of the abnormal twin which will kill the foetus inside the womb and probably body will absorb it.It has a 5% miscarriage rate.Other option is to manage her without any intervention and then she runs the risk of having increased amniotic fluid around the abnormal baby and thus has 25% risk of Preterm delivery.At the time of delivery this abnormal baby will come live though won't survive for long due to absenceof the brain tissue.
Have again consulted the foetal medicine specialist and they are of the opinion of selective reduction.Will keep you guys posted as we come out of this rather tricky situation. 

Intrauterine detection of Autism

Recently a lady visited me for a preconceptional visit.Unfortunately her first child has autism and she wished to know if in her second pregnancy anything could be done preconceptionally to prevent it,diagnose it and ultimately if it had any genetic origin.
As a gynaecologist we don't deal with Autism so frequently and I counselled her as per my MBBS level knowledge of the condition which was mostly correct but that made me read more about it,just in case there are other such parents who might be having similar questions.
Autism is usually diagnosed by altered behaviour,communication and socialization developing before 36 months of age.
The reason for Autism isn't very clear yet and it can be multi factorial like exposure to chemicals (teratogens),Intra uterine or extrauterine Infections like Cytomegalovirus,Rubella and Toxoplasma and of course complex involvement of genes have also been associated.
Till date scientists have not been able to pick any specific genes and thus intrauterine detection of autism is thus not possible at this point of time.It has been stated that those who have an affected child the chances of second child also having the condition increases.If there are multiple members of the same family with such disorder the risk certainly increases many fold.

It has also been found that in identical twins the chances of both the twins having Autism is much higher again supporting the genetic basis but unfortunately where we stand , We can't detect it inside the uterus and need to wait till baby is delivered.
At the moment I have referred her to the Foetal medicine specialist.If the Foetalmedicine experts adds anything new I shall be updating this post.

Welcome back

It has been ages since I communicated with you dear friends.I knew I was certainly missing something but wasn't sure what it was till I realized that we haven't communicated since well over a month.
So my Nirvana Country residence cum clinic started seeping badly and lock stock and barrel,I had to move almost overnight to my current 71 Arjun Marg ,DLF phase 1 residence.it is quite a convenient little centrally located place.I have almost settled down,though it wasn't as easy as in between I myself underwent some surgical procedure.
Like any other month October was as busy work wise.I was actually proud of myself that I could juggle between my shifting and Surgery and taking care of my patients as well.I know a lot of my patients are  very eagerly waiting for my clinic to restart.There is good news on that front as well.From tomorrow the construction of the chamber will start and within a few days I should be ready.
Let me start with my professional laurels first and then I will talk about my not so boastful results.In Gurgaon Deliveries are the bread and butter of an average gynaecologist .A laparoscopic hysterectomy or any any major operation is not so very common because of the young population of gurgaon.So last month I managed to have 3 VBAC ( Vaginal birth after caesarean section)Many ventouse deliveries.Hmmm.....here I wish to tell that there is difference between indian and caucascian ladies.Indian ladies also want normal delivery but they are not keen to bear any pain and thus comes epidural.then they are not keen to push and exet and I have become the proverbial 'Ventouse woman'.Some good gynaecology surgeriesTotal Laparoscopic surgeries and few Urogynaecology procedures.
There were some downsides as well.Wished to go to himacal pradesh for a medical camp for the under privileged but couldn't due to family commitments Didn't feel good about it at all.And then One of 'my babies' developed HIE without any warning signs in a totally low risk pregnancy.I feel bad for the parents.Tried to self audit myself if I could have done any thing myself differently and couldn't find an answer.The baby has been discharged but I hope in long term his milestones remain alright.I once wrote tat I need the courage to write when things don't go right.And I think now I am there where I can accept that not all was well.Not that I could have helped but then God could have been more kind on this very nice couple.We doctors do come across with outcomes which we don't like for our patients and it is always good to self audit one self.This case will be audited later by a team of gynaecologists later and I hope they are able to see something which I possiblyly missed.
Last year this time it was a super massive Post partum haemorrhage and this time HIE.My festivity is mixed with self analysis since last 2 years around Diwali time.
Festivity at home.At hospital this time we doctors weren't much enthusiastic.Don't know why?Recession :-)))!!Played poker at Diwali and won some money too.may be Lady Luck will be on my side this year.
One more aspect which depresses me is that now with a very busy working schedule I hardly get time to study and for the real academics!!That has started making me feel hollow.Think need to take a  month long break to just update my theory.
And yes I need a secretary for my new clinic.
My biggest woe.......I am not able to take out my Hindi MBBS certificate from Magadh University since past 3 months despite paying a hefty bribe of 10 Kfor just duplicate of my own certificate which I lost (Sorry Anna Hazare Uncle) but that is how ourcountry still functions.the clerks need more money.
I shall be more regular in Nov though I don't yet have a broadband as though both Airtel as well as BSNL installed the telephoneline they goofed up with the broadband and it is my Samsung mobile and data card taking the brunt.And it is already more than 45 days.