Diagnosis
& Repair of 3rd & 4th degree
San Paulo
26 de April 2018
Local: Hotel Pullman – Rua das Olimpíadas,
205 - Vila Olímpia, São Paulo – SP
Horário: 15:00 as 19:00 - Mezzanino
Hands-on Workshop
www.perineum.net
Chairpersons
Mr Abdul H
Sultan, MB.ChB, MD, FRCOG
Consultant Obstetrician & Urogynaecologist
Miss Ranee
Thakar, MB.BS, MD, FRCOG
Consultant
Obstetrician & Urogynaecologist
Croydon
University Hospital
Croydon,
Surrey, UK
Email: abdulsultan@nhs.net
ranee.thakar@nhs.net
Obstetric anal sphincter injuries (OASIS)
HANDS ON WORKSHOP
Program (subject to change)
15- 00 Introduction Abdul
Sultan
15-15 Applied
Anatomy & Physiology Ranee
Thakar
15-45 Endoanal
ultrasound Ranee
Thakar
16- 00 Diagnosis
of OASIS Abdul
Sultan
16- 30 Video
on diagnosis
17-00 Coffee
17-30 Repair
Techniques Abdul
Sultan
18-00 Video
diagnosis & repair Abdul
Sultan
Video repair - pig sphincters Ranee Thakar
18-30h Hands-on repair on
pig sphincters
19-00h Close
Applied anatomy and physiology of the
perineum and anorectum
Ranee Thakar/
Abdul Sultan
Anatomy
of the anorectum (Fig 1)
The anorectum is the most distal part of
the gastrointestinal tract and consists of two parts: the anal canal and
rectum. The anal canal measures about 3.5 cms (2.5 cm anteriorly in female) and
lies below the anorectal junction formed by the puborectalis muscle. The
striated external anal sphincter (EAS) is made up of three parts (subcutaneous,
superficial and deep) and is inseparable from the puborectalis dorsally. The
internal anal sphincter (IAS) is a thickened continuation of the circular
smooth muscle of the rectum. It is separated from the EAS by the conjoint
longitudinal coat which is a continuation of the longitudinal smooth muscle of
the rectum.
EAS:
- Striated muscle in a state of
tonic contraction
- Innervated by the Pudendal
nerve
- Up to 30% of resting pressure.
- Most of the squeeze pressure.
- Contraction maintained for
< 2 minutes
- Reflex contraction with sudden
increase in intra-abdominal pressure
- Relaxes during straining
- Damage results in urge faecal incontinence
-
IAS:
·
Smooth muscle
·
Autonomic control
·
Contributes up to 70% of
resting pressure
·
Damage results in passive
soiling and flatus incontinence
·
Figure 1: Anatomy of the anal sphincter
Episiotomy & 2nd
degree tears
Introduction
Ø 85%
women who have a vaginal birth sustain some form of perineal trauma
Ø Approximately
350,000 women per year in the UK need sutures for perineal injury after
spontaneous vaginal delivery
Ø The
morbidity associated with perineal injury and repair is a major health problem
worldwide
Indications for episiotomy
Ø Minimise multiple & extensive tears
Ø Thick & inelastic perineum
Ø Forceps delivery
Ø Expedite delivery
Ø Suspected fetal distress
Ø Shoulder dystocia
Ø Breech
Benefits
of midline episiotomy
Ø Decreased blood loss
Ø Easier to recognise OASIS
Ø Easier to repair
Ø Better anatomical result
Ø Reduced pain
Ø Decreased risk of infection
Ø Decreased dyspareunia
Disadvantage
of midline episiotomy
Ø OASIS
Episiotomy
Andrews V et al BJOG 2004, Andrews V et al Birth
2006
Ø 254 primips
Ø No midwife and only 13 (22%) doctors performed a
truly mediolateral episiotomy (between 40 to 60 degrees from the midline)
Ø Episiotomies angled closer to the midline
significantly associated with OASIS (26 vs 37 degrees)
Episiotomy
Eogan et al BJOG 2006
Ø Case-control study (54 versus 46 controls)
Ø Mean angle of episiotomy smaller
Ø (30% versus 38% p<0.001)
Ø 50% risk reduction for every 6°from midline
Ø The relationship of
episiotomy angle with risk of OASIS was sig (p<0.001)
Angle of episiotomy before and after repair
Kalis V et al 2008 (IJGO)
Ø 50
women undergoing first delivery
Ø Mediolateral
episiotomy during crowning at 40 degrees away from midline
Ø Angle
of scar measured after delivery = 22.5 degrees
Ø Should
aim for 60 degrees at crowning
email:info@medinvent.net
Episiotomy & 2nd degree tears
Suture
Materials
Dexon vsVicryl Kettle
C, Dowswell T, Ismail K 2010
Ø Cochrane systematic review of 9 RCT’s (n = 4017)
Ø Absorbable synthetic materials (Dexon and Vicryl)
versus catgut
¯
Perineal pain
¯
¯
Analgesic use
¯
Dehiscence wounds
¯
Resuturing
Vicryl Rapide vs Vicryl Suture
Material
Ø 5
RCT (n = 2349 women)
Ø Similar
rates of short and long-term pain
Ø Fewer
women in the rapidly absorbing suture group reported the need for pain relief
at 10 days
Ø More
women in the standard suture material group required suture removal
Suture material
Ø Standard
polyglactin 910 (Vicryl)- not totally absorbed from the wound until 60–90 days.
Ø Rapid
absorption polyglactin 910 (Vicryl Rapide)- completely absorbed from the tissue
by 42 days
Evidence based practice
Repair Techniques
Kettle C, Dowswell T, Ismail K 2012
Ø Cochrane systematic review - 16 RCT’s (n = 8184)
found that continuous stitches compared to interrupted is associated with : -
Ø Less short term pain at 10 days
Ø Reduction in analgesia use
Ø Reduction in suture removal
Ø No significant difference in dyspareunia
Ø Reduction in pain is even greater if continuous
technique used for all layers compared to only skin
Technique of repair
Prior to commencing the repair
Ø Check
extent of perineal trauma – perform per vaginal and per rectal examination
Ø Check
equipment - suture pack, materials
Ø If
needed ensure that appropriate supervision/support is available prior to
commencing the repair
Ø Ensure
that the wound is adequately anaesthetised (10-20mls Lignocaine 1%) - don’t
inject local through the skin
Step 1 - suturing the vagina
Ø Identify
the apex of the vaginal wound
Ø Close
the vaginal trauma with a loose continuous stitch
Ø Continue
to suture the vagina until the hymenal remnants are reached and re-approximated
Ø At
the fourchette insert the needle through the skin to emerge in the centre of
the perineal trauma
Step 2 - suturing the muscle layer
Ø Check
the depth of the trauma - it may be necessary to insert two layers of sutures
Ø Continue
to close the perineal muscle with a continuous non-locking stitch - taking care
not to leave any dead space
Step 3 - suturing the perineal skin
Ø At
the inferior end of the wound bring needle out under the skin surface
Ø The
stitches are placed below the skin surface in the subcutaneous layer - thus
avoiding the profusion of nerve endings
Ø Continue
taking bites of tissue from each side of the wound until the hymenal remnants
are reached
Ø Secure
the finished repair with a loop knot tied in the vagina
Finally
Ø Check
the finished repair is anatomically correct
Ø No
bleeding
Ø PV
- insert two fingers
Ø PR
Ø Check
swabs & instruments
Ø Complete
documentation
Conclusion
Ø It
is imperative that women receive high quality evidenced based care wherever
childbirth takes place
Ø Practices
that reduce the adverse effects of perineal trauma and make vaginal birth more
desirable are to be encouraged
Ø Improved
perineal care may decrease the escalating interest in caesarean section as an
alternative mode of delivery
Diagnosis of
obstetric anal sphincter injuries (OASIS)
Abdul H Sultan
·
Until the advent of anal ultrasound, the
development of anal incontinence was attributed largely to pelvic neuropathy.
·
However prospective studies before and after
childbirth have shown that up to one third of women sustain anal sphincter
damage that is not recognised at delivery (Sultan AH et al 1993).
·
Andrews et al (2006) performed a study in which
241 women having their first vaginal delivery had their perineum re-examined by
an experienced research fellow and endoanal ultrasound was performed
immediately after delivery and repeated 7 weeks postpartum. When OASIS were
identified by the research fellow, the injuries were confirmed and repaired by
the duty registrar or consultant. The prevalence of clinically diagnosed OASIS
increased from 11% to 25% (n=59). Every clinically diagnosed injury was
identified by postpartum endoanal ultrasound. At 7 weeks no de novo
defects were identified by ultrasound. This study concluded that most if not
all sphincter defects that have previously been designated as “occult” injuries
were in fact injuries that should have been recognisable at delivery. It was alarming to find that 87% and 27% of
OASIS were not identified by midwives and doctors respectively. Although it is
likely that some of these would have been detected at the time of suturing the
tear, it is of concern that clinical recognition of OASIS is suboptimal.
·
This finding is not
unique as Groom and Patterson found that
the rate of third degree tears rose to 15% when all “2nd degree
tears” were re-examined by a second experienced person.
·
It has been shown
that only 16% of doctors and 39% of midwives feel that they were trained
adequately to identify OASIS (Sultan et al 1995).
·
On the other hand it
is possible that the sphincter tear had been recognised but classified as a
second-degree tear. A questionnaire sent to all UK consultants (Fernando et al
2002) and trainees (Sultan et al 1995) confirmed that up to 40% are still
classifying partial and even complete disruption of the sphincter as a second
degree. The reason for this confusion is partly due to previous teachings (Sultan
& Thakar 2002) and therefore for the sake of clarification and consistency
Sultan (1999) proposed a comprehensive classification that is now
accepted by RCOG (Greentop guideline 2007), NICE (NICE.org.uk) and the
International Consultation on Incontinence (Norton et al 2002) (Fig 2):
Fig 2: Classification
of OASIS (Sultan 2007 Springer)
OASIS – Classification (See
Fig 2)
Sultan
AH, Clinical Risk 1999; RCOG GreenTop Guidelines 2001; ICI 2002; NICE 2007;
ACOG 2014
1st
degree = vaginal epithelium
2nd
degree = perineal muscles
3rd
degree = anal sphincter
3a = <50% external sphincter
thickness
3b = > 50% external
sphincter thickness
3c = internal sphincter
torn
4th
degree = 3rd degree +
anal epithelium torn
Repair techniques of obstetric anal sphincter injuries (OASIS)
Abdul
Sultan
Anal
incontinence after primary repair of OASIS Sultan AH,Thakar R 2007
35 studies in the last 25
years
• Anal incontinence mean
39% (range 15 to 61%)
• Faecal incontinence mean
14% (range 2-29%)
Internal sphincter defects Mahony
R et al 2007
·500 consecutive OASIS
·Persistent
IAS defect independently associated with severe anal incontinence. OR 5.1 (95%
CI = 1.5 – 22.9)
Fecal incontinence after vaginal
delivery Fenner DE et al AJOG 2003
·
831
primips completed bowel questionnaire 6 months after delivery
·
20%
sustained OASIS
·
30% OASIS vs 20% of
controls had poor bowel control.
·
Symptoms 10x higher
in 4th degree tears
Immediate –vs- delayed repair Nordenstam J et al 2008
Ø RCT of 161 women
Ø Team of 3 obstetricians and 3 colorectal
surgeons
Ø At 12 months 40% reported any anal
incontinence (17% flatus > 1 per week)
Ø No difference in outcome between
immediate and delayed (8 to 12 hours) repair
No justification in delaying
repair until the next day.
Delayed and
early secondary anal sphincter repair
Soerensen MM et al 2008
Ø 21 female patients and 21 controls
Ø Delayed primary repair (<72 hours postpartum)
Ø Early secondary repair (<14 days postpartum)
Ø Repaired by 2 senior obstetricians
Ø Mean follow up of 4 years
Ø No post-op complications and none needed
colostomy
Ø No significant difference in QoL with 19
controls
25% vs 5% of controls had
faecal incontinence
Anal canal length & good outcome Hool GR et al DCR 1998
Ø Secondary overlap sphincter
repair (n=51)
Ø Mean follow-up = 16 months
Ø Post-operative anal canal
length best predicted continence
Secondary anal sphincter repair Engel AF et al 1994; Malouf AJ et al 2000
Ø
Prospective
study (n= 55) of overlap repair.
Ø
80%
success at 18 months
Ø
50%
at 5 years (n=46)
Ø But one third had more than one
repair
overlap vs end-to-end
primary repair Sultan AH et al 1999
Ø
Anal
incontinence: reduced from 42% to 8% (flatus)
Ø
External
sphincter defects: reduced from 85% to 15%
Ø Technique or operator? randomised
study needed
End-to-end vs overlap RCT Fernando R et al 2004
Ø 64 randomised
Ø At one year compared to the end-to-end repair,
significantly fewer women with overlap EAS repair suffered faecal incontinence
Ø 9 of 15 who had 3c/4th degree tear had FU scans
Ø All
9 had intact IAS.
End-to-end
vs Overlap Rygh AB and Korner H
2010
Ø 119
primips 3b tear
Ø Primary
outcome = solid stool leakage at least once per week
Ø No
significant difference
End-to-end vs overlap RCT Farrell SA et al 2012
Ø 3
year follow-up
Ø No
significant difference
Methods
of repair for OASIS
Fernando R et al 2013 (Cochrane Review)
6
RCTs of EAS overlap –vs- end-to-end
Conclusions
Ø Overlap
appears to be
associated with lower risks of developing urgency and anal incontinence
symptoms.
Ø At 36 months there was no difference in flatus or
faecal incontinence between the two techniques.
Ø However, since this evidence is based on only two
small trials, more research evidence is needed in order to confirm or refute
these findings
Is the overlap repair more robust over time???
Suture materials (www.perineum.net)
Ø Do NOT use figure-of-eight
sutures for the mucosa or muscles
Ø Anal Mucosa - Single interrupted or non
locking continuous Vicryl 3-0
Ø Internal Anal Sphincter - Mattress end-to-end PDS 3-0
Ø External Anal Sphincter -
Mattress/Overlap PDS 3-0
Suture material Williams et al 2006
Ø 112 women – 4x4 randomised study
Ø No difference in suture related morbidity between Vicryl
and PDS
–
But 70% were 3a
tears and only 54% 12 month follow-up
Operating Theatre
Ø Sterile environment
Ø Good lighting, exposure
and assistance
Ø Appropriate
instrument tray, sutures
Ø Anaesthesia –
spinal, epidural, General
Antibiotic prophylaxis for
OASIS Duggal N et al 2008
ØProspective placebo controlled RCT (n=147)
ØSingle IV dose of cephalosporin
ØPerineal wound infection 8% vs 24% in placebo
Forceps vs Vacuum Eason
and Thakar 20074
FF
t 
h
degree tears ¯ 12 to
< 1 per year
Other Interventions to reduce OASIS Laine K et al 2008
Ø Third and 4th degree tears 4.03% to 1.17%
Ø 4th degree tears 12 to < 1 per year
OASIS repair - recommended practice Sultan AH, Thakar R 2007
Ø
Experienced
obstetrician
Ø
Repair
in operating theatre
Ø
Regional
or general anaesthesia
Ø
IV antibiotics +/- oral for 3 days
Ø
EAS
®
End-to-end for all 3a
®
End-to-end or overlap for full thickness and full length 3b
Ø
IAS
® End–to-end
mattress
Ø
Monofilament
sutures (PDS) for the sphincter (Vicryl
2-0 can also be used)
Ø
Rectal
examination before and after repair
Ø
Foleys
catheter for 12 hours
Ø
Lactulose
15mls bd for 7 to 10 days
Ø Clinic Follow up in 2 to 3 months
Also refer to RCOG Green-top guideline
2015
Fig 3 External sphincter defect (between
arrows) on 3d endoanal ultrasound
Management of
OASIS after subsequent pregnancy
Abdul Sultan
Mode of delivery after OASIS
Caesarean section or Vaginal
delivery?
Recurrence risks with
previous OASIS Peleg D et al 1999
·
Primips,
ceph, term, 3o/4o (n=704); Incidence = 19% (midline
episiotomy)
·
Recurrence
rate = 12% vs 7 % if no previous OASIS (P=0.001)
Previous OASIS - is
recurrence predictable? Harkin
R et al 2003
·
Mediolateral
episiotomy
·
2 of
45 (4.4%) in subsequent vaginal
deliveries developed a repeat OASIS
Previous OASIS Poen AC et al 1998
· 43 of 110 women studied
·
Anal
incontinence 56% -v- 34% in women with no subsequent delivery. (RR = 1.6, CI =
1.1-2.5)
Previous OASIS Sangalli MR et al 2000
· 177 women 13 years FU
· Faecal
Incontinence in 114 subsequent deliveries (3o tears = 2.5% ; 4o tears
= 26.5%
Can OASIS be prevented ? Can only minimise the risk of OASIS
· Episiotomy
·
Restrictive
vs Liberal
·
Mediolateral
vs Midline
· Instrumental delivery - forceps vs vacuum
·
Perineal support Laine K et al 2012; Hals E et al 2010
Performing mediolateral episiotomy Andrews et al 2004;
Andrews et al 2006
·
254 primips, 41% mediolateral episiotomy
·
No midwife and only 13 (22%) doctors performed a
truly mediolateral episiotomy (between 40 to 60 degrees from the midline)
·
Episiotomies angled closer to the midline
significantly associated with OASIS (26 vs 37 degrees)
Episiotomy Eogan et al 2006
·
50% risk reduction of third degree tears for every 6°away
from midline
Management of subsequent pregnancy after OASIS Scheer I et al 2009
Ø 56 deliveries 2002 –2006
Ø 38 (70%) vaginal deliveries
Ø No significant deterioration in:
–
bowel or bladder symptoms
–
quality of life
–
resting and squeeze pressures
Ø
No significant new scan defects
Treatment of anal incontinence
Conservative
management: Biofeedback
Norton
1999, BJS
Ø
67% cure and improvement
Ø
Most successful in urge incontinence
Ø
Improvement even if structural damage
Management of anal incontinence
Ø Antidiarrhoeal agents
Ø e.g. Loperamide (Imodium),
Codeine, diphenoxylate (Lomotil)
Ø Reduces intestinal
transit
Ø Increases rectal compliance
& resting pressure of IAS
Ø Codeine causes drowsiness
and dependence
Anterior anal sphincter repair
Engel AF et al 1994, Malouf et al 2000
Ø Prospective study (n=55) of
overlap repair.
Ø Successful outcome at 15
months in 80%.
Ø 5 year follow-up = 50%
success
Dynamic Graciloplasty
Ø Multicentre trial
Ø 139 patients
Ø 60% success and improved QoL
Ø 74% complication
Ø 40% reoperation
Dynamic Graciloplasty
Ø Complications
Ø Technical problems with
muscle wrap and stimulation
Ø Infection
Ø Anorectal dysfunction
Sacral
nerve modulation
Altomare DF et al 2009
Ø
52 patients with fecal incontinence
Ø
Minimum of 5y FU
Ø
Wexner score ¯ from 15±4 to 5±5 (P<0.001)
Ø
Significant improvement in QoL
Ø
Minor complications 13%
Injectable biomaterials
Ø Collagen
Ø PTQ implants
Ø Carbon coated Zirconium
oxide beads
Ø Polyacrylamide hydrogel
Ø Small case series show
variable short term
Ø
Efficacy
For pictures,
DVD, bibliography
and suggested reading
2009. XII, 196 p. 82 illus., 32 in color. Softcover
▶
ISBN 978-1-84800-996-7
- Every woman who has a vaginal
delivery has a 3rd or 4th degree tear until proved
otherwise
- A 3rd or 4th
degree tear (as well as an isolated buttonhole tear of the rectum) cannot
be excluded without a rectal examination
- Therefore a careful digital
rectal examination with good exposure, adequate lighting and analgesia is
mandatory.
- There is Level 1a evidence that second degree tears
and episiotomies should be repaired using the continuous technique of
repair for all three layers with Vicryl Rapide
- Restoration of normal
sphincter length best predicts continence and therefore the full length of
the torn sphincter must be repaired
- The torn internal sphincter
should be identified and repaired separately using an end- to-end repair
technique
- Partially torn external
sphincter tears must be repaired using the end-to-end technique.
- Full thickness and full length
external sphincter tears can be repaired by either the overlap or
end-to-end technique. However the superiority of the overlap repair has
only been demonstrated in one study where all repairs were conducted by
only two operators. The Cochrane review does not recommend one technique
over the other.
- The anal mucosa and anal
sphincter muscles must not be repaired using figure-of- eight sutures as
they can cause ischaemia and necrosis of tissue
- The best chance of successful
repair of OASIS is at the time of delivery; secondary sphincter repair
(especially of the internal sphincter) is comparatively poor
- In terms of subsequent pregnancy management:
- Compare like with like ie. the worst scenarios of CS
and VD
- Risks following
CS is not just for one CS but cumulative with each subsequent CS
- The risk of recurrence of OASIS is about 7%
- Outcome of vaginal delivery after OASIS is good in
selected patients
OBS - FIGURAS E SLIDES ORIGINAIS SÓ DISPONÍVEIS PARA OS INSCRITOS
===========================================================
WORKSHOP – USO DE PESSÁRIOS EM UROGINECOLOGIA
VII JORNADA INTERNACIONAL DE UROGINECOLOGIA DA FMUSP
26 de abril de 2018 das 8:00 às 12:00h
Organização
Dra.
Thais Villela Peterson (FMUSP)
Dra.
Cássia Raquel Teatin Juliato (UNICAMP)
Dra.
Marilene Monteiro (UFMG)
Dr. José
Ananias Vasconcelos Neto (UFC)
Avenida
Dr. Enéas de Carvalho Aguiar, 255, 10º andar -
Cerqueira César, Cidade de São Paulo, Estado de São Paulo, Cep 05403-000
Programa
|
Parte
Teórica
|
|
8:00-8:20
|
Tipos
de pessários, indicações e contra-indicações
Cássia Raquel Teatin Juliato
|
|
8:20-8:40
|
Como
escolher o modelo e o tamanho adequado
Cássia Raquel Teatin Juliato
|
|
8:40-9:00
|
Cuidados
pós inserção e seguimento
Thaís Villela Peterson/Marilene Monteiro
|
|
9:00-9:20
|
Complicações
do uso de pessários e indicadores prognósticos
José Ananias Vasconcelos Neto
|
|
9:20-9:40
|
Q&A
|
|
9:40-10:00
|
Coffee
break
|
|
Parte
Prática
|
|
10:00-10:30
|
Grupo
1
|
Colocação de pessários em modelos de
pelve (Dra. Cássia)
|
|
|
Grupo
2
|
Vídeo (Dr. Ananias)
|
|
|
Grupo
3
|
Colocação de pessários internos (Dra.
Thais)
|
|
|
Grupo
4
|
Colocação de pessários externos (Dra.
Marilene)
|
|
|
|
|
|
10:30-11:00
|
Grupo
1
|
Vídeo (Dr. Ananias)
|
|
|
Grupo
2
|
Colocação de pessários em modelos de
pelve (Dra. Cássia)
|
|
|
Grupo
3
|
Colocação de pessários externos (Dra.
Marilene)
|
|
|
Grupo
4
|
Colocação de pessários internos (Dra.
Thais)
|
|
|
|
|
|
11:00-11:30
|
Grupo
1
|
Colocação de pessários internos (Dra.
Thais)
|
|
|
Grupo
2
|
Colocação de pessários externos (Dra.
Marilene)
|
|
|
Grupo
3
|
Vídeo (Dr. Ananias)
|
|
|
Grupo
4
|
Colocação de pessários em modelos de
pelve (Dra. Cássia)
|
|
|
|
|
|
11:30-12:00
|
Grupo
1
|
Colocação de pessários externos (Dra.
Marilene)
|
|
|
Grupo
2
|
Colocação de pessários internos (Dra.
Thais)
|
|
|
Grupo
3
|
Colocação de pessários em modelos de
pelve (Dra. Cássia)
|
|
|
Grupo
4
|
Vídeo (Dr. Ananias)
|
==============================================================
WORKSHOP “ SUTURA LAPAROSCOPICA” VII JORNADA
INTERNACIONAL DE UROGINECOLOGIA DA DISCIPLINA DE GINECOLOGIA DA FMUSP
Local: KARL STORZ ENDOSKOPE – SÃO PAULO – BRASIL
Rua Joaquim
Floriano, 413 - 20º. andar
Data: 26 de
Abril de 2018.
Training Supervisor: Armando Romeo
Turma l
8:30hs
– Teórica
·
Introdução da Técnica de Sutura e seus princípios pedagógicos; M.ROSIM
·
Técnica de Suturas Intra e Extra Corpórea;
·
Classificação dos Nós e Sequências Bloqueadoras;
·
Romeo’s Gladiador Rule;
·
Teoria do Ponto Perfeito;
·
Eixos e Angulos de Sutura;
·
Modelos de Suturas e Exercícios de Treinamento.
09:30
– Coffee break
10:00hs
– Treinamento Prático de Suturas
·
Técnicas de Anodamento, nós mão manual;
·
Técnicas de Posicionamento da Agulha e Orientação;
·
Mão direita - Trocar Direito – Regra Gladiador – movimento sentido horário;
·
Mão direita - Trocar Direito – Regra Gladiador – movimento sentido
anti-horário;
·
Mão direita - Trocar Central – Sentido horário e anti-horário – Posição
Suprapúbica;
·
Treinamento Prático PONTOS;
·
Passos simples;
·
Pontos Fáceis.
12:30hs
– Encerramento
Turma
ll
13:30hs
– Teórica
·
Introdução da Técnica de Sutura e seus princípios pedagógicos ; C.ROCHA
·
Técnica de Suturas Intra e Extra Corpórea;
·
Classificação dos Nós e Sequências Bloqueadoras;
·
Romeo’s Gladiador Rule;
·
Teoria do Ponto Perfeito;
·
Eixos e Ângulos de Sutura;
·
Modelos de Suturas e Exercícios de Treinamento.
14:30
– Coffee break
15:00hs
– Treinamento Prático de Suturas
·
Técnicas de Anodamento, nós mão manual;
·
Técnicas de Posicionamento da Agulha e Orientação;
·
Mão direita - Trocar Direito – Regra Gladiador – movimento sentido horário;
·
Mão direita - Trocar Direito – Regra Gladiador – movimento sentido
anti-horário;
·
Mão direita - Trocar Central – Sentido horário e anti-horário – Posição
Suprapúbica.
·
Treinamento Prático PONTOS;
·
Passos simples;
·
Pontos Fáceis.
17:30hs
– Encerramento
===========================================================
Workshop: Fraxx a Nova Tecnologia - Alta Frequência
Fracionada Microablativa (AFFMA) e Pulsada para Estética e Rejuvenescimento
Íntimo, com Melhora Funcional
Dia 26 de Abril de 2018
Hotel Pullman Vila Olímpia
Rua Olimpíadas , 203
08:30 – 12:00
Horário:
9h às 12 – com 15 minutos de intervalo (tolerância de 5
minutos para assentarem**)
Coordenadora:
Dra. Priscila Katsumi Matsuoka
8h30 – 10h30
Palestrante: Dr. Celso L. Borrelli
Programação Teórica: Duração de 2h
1h30
30 minutos para debates
10h30 – 10h45
Intervalo de 15 minutos
10h45 – 12h00
Programação Prática: Duração de 1h15
Uso do sistema FRAXX em simuladores
com tecido animal e aberto a dúvidas.
Temas:
1. Princípios
Biofísicos da Alta Frequência Fracionada Microablativa (AFFMA);
2. Evidências
dos efeitos da Energia Fracionada Microablativa;
3. Aplicação
da AFFMA no TGI – Estimulando Neocolagenese/ Neoelastogenese e
Neovascularização;
3.1
Vagina – Periuretral;
3.2
Vulva;
4. Literatura
com evidências sobre o tema.
Monitores:
Dr. Celso L. Borrelli
Uriel Binembaum
Margot Rohwedder
Nilton Rocha
Bruna Moraes
=============================================================
Programa do WS da Urodinâmica:
Alacer
Local: Hotel Pullman – Rua das Olimpíadas, 205 -
Vila Olímpia, São Paulo – SP - Mezzanino
Horário: 08:00 as 12:00
8:00-8:10 - Introdução (Dra
Simone Brandao e Dr. Rogerio Fraga)
8:10-8:30 - Fisiologia
Urinária - Dr. Rogerio Fraga
8:30-8:50 - Boas Praticas em
Urodinâmica - Dra Simone Brandao
8:50-9:00 – Perguntas
9:00-9:20 – Intervalo
9:20-12:00 - Discussão de
casos clínicos e traçados de Urodinamica
=========================================
WORKSHOP LASER DE CO2
LOCAL: LBT Rua Itajobi, 54 – Pacaembu- São Paulo/SP
26.04.2018
MANHÃ
|
8:00 -8:20 Aspectos físicos , modo de ação do laser
de CO2
Engº Martin Sabado
|
|
8:20-8:40 Laser
CO2 e sua aplicabilidade em uroginecologia
Dra. Lucília
Carvalho
|
|
8:40-9:00 Laser
de CO2 na atrofia vulvovaginal
Dra. Elsa Gay
|
|
9:00-9:40 Procedimentos
cirúrgicos e estética genital
Dr. Gabriel Femopase
|
|
9:40-10:00 O papel do ginecologista na saúde sexual
Dra. Elsa Gay e Dra
Lucília Carvalho
|
|
10:00-10:30 Coffee Break
|
|
10:30-12:00 Demonstração prática
|
- Aplicação
do laser de CO2 para tratamento da Incontinência Urinária
Dra. Lucília
Carvalho
-Aplicação do
Laser de CO2 para tratamento da Atrofia Genital
Dra. Elsa Gay
- Aplicação
do laser de CO2 para Vulvoplastia
Dr. Gabriel
Femopase
============================================================
WORKSHOP FISIOTERAPIA - Aguardando programa dos responsáveis.
nota do editor / Dr. Homero Guidi
