GinecoUSP

domingo, 1 de abril de 2018

VII JORNADA DE UROGINECO USP - PROGRAMA DOS WORKSHOPS

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

www.medinvet.net

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 “2^nd 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 = 3^rd 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 4^th 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/4^th 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

Labour Ward Protocol See website www.perineum.net

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, 3^o/4^o (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 (3^o tears = 2.5% ; 4^o 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

See Website: www.perineum.net

2009. XII, 196 p. 82 illus., 32 in color. Softcover

▶

ISBN 978-1-84800-996-7

Take Home Messages

Every woman who has a vaginal delivery has a 3^rd or 4^th degree tear until proved otherwise

A 3^rd or 4^th 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

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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)

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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

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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

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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

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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