CHRISTINA KRUSE – Visiting Ullevål Universitetssykehus, Oslo - 2009
As a part of my expert education in treatment of endometriosis, I visited the Department of Obstetrics and Gynecology (Kvinneklinikken) at Ullevål University Hospital in Oslo for 3 months.
This department has a large endoscopy section, headed by Doctor Anton Langebrekke, who has a long experience in advanced endometriosis surgery, and patients with severe endometriosis are referred from all parts of Norway for treatment.
I spent four days a week at the operating rooms and participated in a lot of endometriosis surgery, including excision of infiltrating endometriosis, rectosigmoid resection and treatment of extensive pelvic adhesions. Between the endometriosis operations, I had the opportunity of watching other kinds of advanced laparoscopic surgery, including cancer surgery and myomectomies. Laparoscopic surgery is widely used in this department and is the standard procedure in hysterectomies: Even uteri with large fibroids are removed by laparoscopy, and the training of young doctors includes supravaginal laparoscopic hysterectomy. The equipment for laparoscopic surgery is excellent, and new instruments and techniques are frequently tested.
Once a week I joined Doctor Anton Langebrekke at his outpatient clinic and learned about the departments' principles for preoperative investigation and postoperative medical treatment of patients with endometriosis.
Overall, this was an interesting and inspiring visit, and I thank the NFOG board for the financial support, which made it possible.
Christina Kruse
Dept of Obstetrics and Gynecology
Skejby University Hospital
Denmark
ULLA B. KNUDSEN - Malmø University Hospital, University of Lund
Gynaecological ultrasound scanning.
In the application 2 purposes were mentioned:
1) To see real experts in gynaecological ultrasound scan at work, to gather experience books/courses can not give.
2) Discuss education in gynaecological ultrasound in the Nordic countries.
To obtain this I applied to visit the ultrasound clinic in Malmø and in Stockholm.
In May 2006 I went to visit the Ultrasound clinic at the Malmø University Hospital, University of Lund. Both Professor Lil Valentine and Doctor Povilas Sladkevicius were extremely positive towards demonstrating the ultrasound techniques and teaching me all the extra finesses that can support/underline the right result of the examination. All different techniques (3D, 4D, Doppler, video, water scan (HSU), biopsies from the endometrium) were used routinely when pathology was found, but the interaction of the probe and hands, and asking the patient to help by different procedures gave much respect for the skill.
The ultrasound clinic examined women with obstetrics and gynaecological problems. The specialists in the Gynaecological-Obstetric department did the initial scanning, but ask for second opinion when special cases were found.
The days flew as I saw many interesting cases of gynaecological ultrasound scans. Some tumours were examined prior to the operation, and we guessed whether the tumour was of benign or malignant potential. The next day the result of the operation was proclaimed even though the pathologic results took a bit longer.
When the pathologist’s description of the tumour arrived, it was compared to the ultrasound description, so one could learn what the components were. We could all learn from this feedback on our scans.
In between patients I was “examined” in rare, interesting cases, displayed on the screen.
The ultrasound scan machines and the IT in connection with them are enviable. The machines were some of the best on the marked! Every thing is categorised so pictures/cases can be found when research is done. More machines were in reserve, so nobody had to wait due to lack of scanners!
The objects was not measured when the patient was present, but measured on the screen after the examination, giving more time to look carefully at each picture, and summarize it all. Furthermore, the pictures were fantastic for showing to colleagues for discussion, and getting a well-measured, standardised description.
Once every second week an Ultrasound-conference was held, where cases were demonstrated for the staff at the Gynaecological-obstetric department, and a good discussion took place.
“Barnmorska´s” (midwifes) did nearly all the ultrasounds screening in week 19 and 32 of gestation, whereas amniocentesis, which was the most common invasive procedure for prenatal screening based on age above 35 years, was done by the two ultrasound doctors. Nuchal translucency thickness (Nakkefoldscanning) is under consideration in Sweden, and Prof. Lil Valentin is participating in this workgroup.
Two afternoons every week were planned for research patients/women. Several projects were running, and the positive attitude both among the doctors and the other staff towards the importance of this was inspiring!
They used “glideslim” when doing TVU in stead of ordinary gel, which they used at the abdomen. They had found that some women got itching after TVU. I guess we have never asked the Danish women if they have had a problem after scanning?!
Education. No set education has started yet in Sweden, but it is on its way. In Malmø young doctors get experience from “the acute clinic” and “the bleeding day-clinic”, where they either show the doctors at the ultrasound clinic the pictures or scan along with them, and discuss the clinical implications of it.
By the end of the week we have discussed arranging a joint ultrasound course in gynaecology for gynaecologist from the Nordic countries in 2007. Exchange visits can give new impressions of our speciality and very fruitful discussions and interrelationships – you should try it!
Ulla B. Knudsen
Senior Hospital Physician, Ph.D.
Dept. of Gynecol. & Obstet.
Odense University Hospital
Odense, Denmark
TAPIO VÄYRYNEN – St. Göran, Stockholm
Doctor Tapio Väyrynen visited our gynaecological unit for two weeks at the end of January this year. Dr. Väyrynen is already a very experienced vaginal surgeon and he didn’t come here for improving his surgical skills but rather to study our unique concept of fast track surgery. Basically this concept means that patients who are operated upon because of incontinence or prolapse will receive local anaesthesia, will be mobilized within hours and will be able to be discharged either the day of the operation or the day after. Doctor Väyrynen participated in our daily operative procedures Monday to Thursday. Our weekly production amounts to around 4-5 hysterectomies (majority vaginal), 10-12 incontinence procedures and 10-12 prolapse repairs. Dr. Väyrynen was introduced to newly developed methods for repairing cystoceles and vaginal vault prolapses. I myself and the whole staff greatly enjoyed having Dr. Väyrynen with us – for his skills and for his good humour.
Folke Flam
Dept. of Gynecology
S:t Goran Hospital
S 112 81 Stockholm
Sweden
folke.flam@gynekologkliniken.se
Dr Tapio Väyrynen visited the Department of Gynaecology of St Görans Hospital, Stockholm, from Jan 22 to Jan 30, 2005. The visit was supported by the NFOG Visitor Program. The aim of his visit was to look at the processes of an effective day surgery unit as well as new operative techniques especially for prolaps and incontinence surgery. The visit has proven to be very beneficial to our clinic. Tapio Väyrynen has carried out in practice new concepts for streamlining preoperative measures of day surgery. He also has started prolapse operations under local anaesthesia. Collection of pictures and video clips taken during the visit are used for training. The aim of the visit is fulfilled exceptionally well.
On behalf of our clinic I will thank NFOG for making the visit of Tapio Väyrynen to St Görans Hospital possible. Without doubt the Nordic cooperation is greatly enhanced by the Visitor Program.
Juhani Toivonen
Chief, Department of Obstetrics and Gynecology
HUCH, Jorvi Hospital
Turuntie 150
FIN- 02740 Espoo
Finland
BIRTHE ANDERSEN + PIA DENULLY - Joensuu and Hyvinkaa
We organised two days demonstrations of laparoscopic hysterectomies. All operated cases were complicated ones with big myomatous uteruses. I operated and the visitors assisted. The cases went well; we even had one complication (a bladder lesion) which was prepared laparoscopically. Between the cases organisational aspects were discussed. Unfortunately our OR facilities were under reconstruction during the time of visit, so we only had a possibility operate in on theatre. From my point of view the visit was successful and I strongly recommend continuing with this kind of activities.
Hyvinkää 18.3.2005
Minna Kauko, MD, PhD
Head of the dept. of obst . et gyn
Hyvinkää Hospital
The purpose of the visits was to study the concept of laparoscopic hysterectomies that consultant gynaecologist Minna Kauko had build up during the time she was head of department at the gynaecological/obstetrical department in Joensuu and after that visit Dr Kauko in her present working position at the gynaecological/obstetrical department at the hospital in Hyvinkaa. Our expectations were that we would gather information, tools, and ideas that we could implement in our own department at the County hospital of Roskilde.
The visit to Joensuu was arranged with dr. Jaana Fraser, who is the laparoscopic expert in Joensuu after dr. Minna Kauko has left the department. The department in Joensuu is considerably smaller than the department we belong to, but the operation ward is functioning quite effectively with the same number of operations every day in each operating room as we have. According to their statistics more than 65% of all hysterectomies are performed laparoscopic operations, in our department only 25% of hysterectomies are performed laparoscopically. It turned out that the hysterectomies are performed via the laparoscopic route even in case of very enlarged uteri and it was demonstrated to us, how you could remove large intraligamentary fibroids in the same way. All doctors at Joensuu specialising in Ob/Gyn are competent to use the laparoscopic technique, which makes the planning easier and enables the department to perform so many hysterectomies laparoscopically.
After a couple of interesting days in Joensuu we visited Hyvinkaa. Unfortunately both the department and the operation ward were being reconstructed but we did see dr. Minna Kauko perform 4 complicated hysterectomies only with the help of her nurse. At one of the hysterectomies there was an accidental bladder lesion. This lesion was of course repaired through the laparoscope. Dr. Minna Kauko informed us that no hysterectomy is planned to be performed abdominally until it has been discussed with her and accepted. All specialist doctors (Ob/Gyn) are trained or training in the laparoscopic technique. As we are responsible for the laparoscopic surgery at the department of Ob/Gyn in our own department at the County Hostile of Roskilde and perform 4 hysterectomies each week laparoscopically it was inspiring to see and experience how other departments handle this technique. It was also very interesting to watch and participate in the removal of bigger uteri through the laparoscope, the size of the uteri exceeding what we would choose to operate laparoscopically.
We hereby wish to thank the NFOG visitor program for the financial support to our trip.
Dr. Birthe Andersen
Dr. Pia de Nully
Department of Ob/Gyn
County Hospital of Roskilde
DK 4000 Roskilde
Denmark
The two most operating laparoscopic surgeons of the department of Obstetrics and Gynecology, County Hospital of Roskilde, Denmark went to Finland to study how it is organized in departments where 65% of all hysterectomies are performed laparoscopically. Dr. Birthe Andersen and dr. Pia de Nully came back reporting admiration for the skills they had seen in a group of doctors all training to master the laparoscopic technique. In Denmark the attitude towards advanced laparoscopic gynaecological surgery is more often to keep it on few hands, thus creating very specialized doctors. They were also impressed by the attitude, always to consider the laparoscopic way making the abdominal route the exception. They experienced doctors doing a very good job, working with instruments and equipment that were not as technically advanced as the equipment they are used to using in the department of Obstetrics and Gynaecology, County Hospital of Roskilde. They saw working conditions that were not ideal, such as no assistant doctors and very inconvenient working position. They were impressed with the skills and engagement in the assisting nurses.
In short they came back with inspiration and ideas as how to expand the indications of laparoscopic surgery “at home”, but they also experienced the satisfaction of feeling very fortunate of their own ways of working, seeing conditions that were not worth copying. Thus the visits fulfilled the expectations, seeing, learning and comparing, sharing experience and ideas in a specialized field of Obstetrics and Gynaecology.
I am sure that this visit will benefit the department of Obstetrics and Gynecology, County Hospital of Roskilde and on behalf of the department would like to thank NFOG for making it possible. We do think that also dr. Jaana Fraser, who is the laparoscopic expert in Joensuu after dr. Minna Kauko has left should give her report of the visit.
Roskilde Feb. 19 2005
Charlotte Wilken-Jensen
JON IVAR EINARSSON – St. Göran, Stockholm
Doctor Jon Ivar Einarsson honored our gynecological unit with a two week visit in April of this year. I knew from his CV that he - despite his young age - was very experienced. Thus we also learnt a great deal from him. Doctor Einarsson participated in our daily operative procedures Monday to Thursday. Our focus is on vaginal surgeries and he was able to assist and in some instances operate himself. Our weekly production amounts to around 4-5 hysterectomies (majority vaginal), 10-12 incontinence procedures and 10-12 prolapse repairs. The two latter procedures are performed in local anesthesia in a fast track setting meaning that the majority of the patients leave the ward the day of the operation. I do not think we had anything to teach Dr. Einarsson from the technical point of view but hopefully he brought back with him the courage and confidence to perform more procedures in local anesthesia.
Folke Flam
Dept. of Gynecology
S:t Goran Hospital
S 112 81 Stockholm
Sweden
This is a brief report on my stay in Sweden that was made available by a generous grant from your organization. I visited with Dr. Folke Flam and his colleagues at Gynekologkliniken, which is located at St. Gorans Hospital in Stockholm. The clinic is run by Steffan Lundberg and Folke Flam as a private facility and specializes in prolapse and incontinence surgery, most of which is performed under local analgesia. This was a very productive time for me and I came away with a great deal of valuable lessons. Dr. Flam and his colleagues were extremely hospitable and allowed me to perform several incontinence surgeries and I also had the opportunity to observe and assist in several other procedures. The center is one of a few in Scandinavia that has begun using contemporary mesh technology, and I was fortunate enough to be exposed to that as well. In addition, I learned many ‘tricks of the trade’, both when it comes to clinical matters and also in administrative tasks, skills that have been developed over the years by the faculty at Gynekologkliniken. I have already laid plans to implement some of those tricks into my practice. Overall this was time well spent and I am very grateful to the board of NFOG to have made this experience possible.
Jon Ivar Einarsson MD MPH
Landspitali-University Hospital
Department of Obstetrics and Gynecology
Hringbraut 101 Reykavik
Iceland
Tel +354 856 0077
HANNE MOHAPELOA - Haukeland Sykehus, Bergen
I am a specialist in Gynaecology and Obstetrics since 2001, sub-specializing in foetal medicine at the department of Gynaecology and Obstetrics at Aalborg Hospital, Aarhus University, and during my studies, courses and meetings I have been privileged to meet Professor Torvid Kiserud, and hear about his research, and thereby learn about the normal blood flow in the foetus and the changes due to foetal stress as in the case of anaemia, placental insufficiency etc. in order to use this information to give the best treatment to the foetus and the mother. Professor Torvid Kiserud is one of the leading researchers on venous and arterial Doppler flow in the foetus, especially on the Ductus Venosus and Foramen Ovale, and I am much honoured to be accepted as a NFOG-visitor to study at his clinic and laboratory. I am also thankful that the department of Gynaecology and Obstetrics, Aalborg University Hospital, supported my plans and agreed to pay my normal salary for the two weeks of visit, and to NFOG, who agreed to pay my expenses in the NFOG-visitor program.
The aims for the visit were as follows:
I was welcomed by professor Kiserud and introduced to the staff of the Department of Gynaecology and Obstetrics, many of whom I already knew from earlier meetings and courses in obstetric ultrasound, and from at short vacancy in 2003.
Dept. of Gynaecology and Obstetrics (Kvinneklinikken) has 5000 births/year, and is a tertiary reference hospital for the western region of Norway. The department accepts deliveries from 24 weeks of gestation, and with most complications, and the ultrasound clinic evaluates pregnancies suspected of malformations, growth retardation and previous pregnancy problems. Furthermore, the ultrasound clinic has ongoing research especially on the blood flow in the foetus and placenta, primarily using Doppler ultrasound.
I was given the opportunity to do ultrasound examinations on several of the pregnant women in the ward suspected of growth retardation, pre-eklampsia or HELLP, or malformations, and monochoriotic-diamniotic twins, suspected of twin to twin transfusion syndrome, and some of the patients I was able to see several times to follow the development of their condition.Luckily I was able to use an ultrasound machine identical to the one I use at home in Aalborg, minimizing the technical problems of the examination, and allowing me to focus on optimizing my skills on identifying the vessels and obtaining the Doppler flow profiles needed to evaluate the foetus. Prof. Kiserud evaluated the patients with me, instructing me how to do the exams and to recognise the different flow profiles, and to use the changes in Doppler flow in the foetus to evaluate the wellbeing of the foetus. I got training in obtaining and evaluating Doppler flow in the umbilical artery, the uterine arteries, the middle cerebral artery, the Ductus Venosus and the umbilical vein, and learned how the flow profiles on the pulmonal veins and the veins and arteries of the liver and the guts could be obtained and evaluated. As a bonus I saw how Professor Kiserud evaluated foetuses suspected of malformations, including evaluations of the foetal hearth, and I saw him do a chorion villus biopsy, transcervically, in contrast to the guided transabdominal routine in Aalborg and in Denmark in general. I saw how two of the younger researchers Cathrine Ebbing and Joerg Kessler were examining the flow in the foetal gut and liver during their ongoing research. I attended the defence for the Medical Doctorate of Svein Magne Skulstad on “Umbilical vein constriction at the abdominal wall. An ultrasound study in low risk pregnancies”, an interesting study related to my interest in Doppler Ultrasound. During my visit Professor Kiserud showed me how to measure the venous flow at the umbilical ring, and how stricture at this point may affect the foetus may lead to foetal demise in severe cases.
I enjoyed the discussions with the doctors, especially during lunch break, exploring the different views on subjects such as screening for Downs syndrome using Nuchal Translucency, vaginal delivery of breech presentation, and caesarean section in general.
I appreciate the way I was accepted by the doctors, midwives, secretaries and the staff in general, doing their outmost to make my visit successful and pleasant. I enjoyed a cosy evening with the “Danes in exile” Hanne Wielandt and Jeppe Bohm, and an Ethiopian dinner with Torvid Kiserud.
I stayed at Haukeland Hotel, a hotel situated inside the hospital area, accommodating patients and relatives, living far from Bergen, and the facilities were suitable for my needs.
All in all the above mentioned aims of my visit were fully fulfilled, and I would really describe my visit as a success, both socially and in terms of expanding my skills.
I only have one complaint: In Bergen it is always raining!
Hanne Mohapeloa MD
Specialist in gynaecology and obstetrics.
Dept. of Gynaecology and Obstetrics
Aalborg Hospital, Aarhus University.
Postbox 561
9200 Aalborg, Denmark
Vasiliki Tsaknakis, Rigshospitalet, København
Jag auskulterade under en månad på Rikshospitalet i Köpenhamn .
Jag var tillsammans med Dr Christian Ottosen på operation och
assisterade vid canceroperationer.
Fick vara med vid alla sorters gynekologiska canceroperationer,
inklusive trachelectomier och laparaskopiska lymfkörtelutrymningar.
Var med vid fullständig peritonealectomier vid mucinösa cancrar ,
tarmresektioner och uppläggande av stomier mm.
Lärde mig oerhört mycket som jag sedan har haft stor nytta av i
samband med diverse operationer på KK i Halmstad.
Med vänlig hälsning
Vasiliki Tsaknakis
2004