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Home > Quality assurance > Audit > Gynaecological Endoscopic Surgery 2002; 1997
Territory Wide Audit in Gynaecological Endoscopic Surgery (2002)


The Hong Kong College of Obstetricians and Gynaecologists conducted the first territory-wide audit on gynaecological endoscopic surgery in 1997. All hospitals providing in-patient gynaecoloigcal care in Hong Kong participated in that audit exercise. A simple audit form was designed for both laparoscopic and hysteroscopic surgery to capture information on the qualification of the surgeon and assistant, the operative diagnoses and procedures, the surgical time and complications. At that time, 18 hospitals provided data on laparoscopic surgery and 14 on hysteroscopic surgery. A total of 2200 laparoscopic surgeries and 199 hysteroscopic surgeries were audited. This represented about 80% of the laparoscopic and 60% the hysteroscopic surgery performed in the territory in 1997.

Five years after the first audit, the College repeated the same audit with some modification in conjunction with the Hong Kong Gynaecological Endoscopy Society (HKGES). This time, all gynaecological laparoscopy and hysteroscopy, including diagnostic procedures, were included to give a more comprehensive information on the practice and safety of gynaecological endoscopy in Hong Kong. In addition to that, as initiated by the HKGES, a comprehensive audit on laparoscopic hysterectomy was carried out at the same time. A web-based database program was developed to allow online data entry, anywhere and anytime, and continuous audit in endoscopic surgery is now possible. In the current exercise, 22 hospitals provided data on laparoscopy and hysteroscopy, and the data covered about 85% of all laparoscopies and 98% of all hysteroscoies performed in the territory in 2002. Compared to 1997, the number of operative laparoscopies performed in the whole of Hong Kong doubled while that of operative hysteroscopies increased by 5 folds.

Laparoscopic Surgery

Compared to 1997, the total number of laparoscopic procedures audited increased from 2200 to 6065. The significant increase was not just because of the inclusion of Level 1 procedures (diagnostic and sterilization procedures) in this exercise, but related to the general increase in the performance of laparoscopic surgery in the territory. Over these 5 years period, the total number of operative laparoscopies performed in the whole of Hong Kong has doubled.

The total number of Level 1 procedures was 1634, accounting for about 28% of all the laparoscopies performed in 2002; about 30% were diagnostic procedures and 70% were for tubal sterilization/occlusion. The operation was mainly performed by doctors with MBBS (37.2%) and MRCOG (28.7%); about half were assisted by specialists. About 70% of the procedures were performed by doctors without accreditation in gynaecological laparoscopy, of which 28% were assisted by nurses. The application of rings was the most commonly used method for laparoscopic sterilization, accounting for 66% of cases and clips were used in 34%.

Similar to 1997, operative laparoscopy was mainly performed for the removal of adnexal mass (about 50%), followed by removal of ectopic pregnancy (14.5%), removal of uterus 11.8% and enucleation of fibroid (4.6%). Level 5 procedures were still uncommonly performed. Overall, 60% of the procedures were performed by specialists, 25% by doctors with MRCOG and 15% by pre-MRCOG doctors. Over 50% of the surgeons were not accredited by the College, 27% were accredited with intermediate level and 20% advanced level.

There was a significant change in the practice of primary trocar entry. There was a significant increase in the use of the open technique and the incidence increased from 0.4% to 30%. The use of closed method reduced from 85% to 65% and that of visual-guided trocar reduced from 15% to 5%. Electrosurgery remained the most commonly used energy source.

Conversion was required in 2.0% of all laparoscopies and 1.8% of operative laparoscopies, compared to 5.7% in 1997. Surgical difficulty remained the main reason for conversion, of which dense adhesions accounted for over 70% of the cases.

The overall complication rate of all laparoscopies was 2.7% with major complication occurred in 0.7% and minor complication in 2.0%. For operative laparoscopies, the complication rate was 5%, compared to 8% in 1997. Laparoscopic hysterectomy was associated with the highest complication rate of 12.6%, compared with other procedures.

Hysteroscopic Surgery

Compared to 1997, the total number of hysteroscopic procedures audited increased from 199 to 8652. Although about 85% of the cases were diagnostic procedure, there was a 5 fold increase in the total number of operative hysteroscopies performed in the whole of Hong Kong since 1997.

For diagnostic hysteroscopy, three quarters of the procedures were performed as day procedure and about 60% were performed under no anaesthesia or analgesia. Cervical priming was not used in 95% of cases. Normal saline was the distending medium used in 60% and carbon dioxide in 40%. The procedure was performed by specialists in 45%, doctors with MRCOG in 32% and pre-MRCOG doctors in 23%. Failure rate was 1% and the overall complication rate was 1.3%.

For operative hysteroscopy, resection of polyp accounted for 60% of the procedures, compared to 40% in 1997. Although the incidence of resection of fibroid remained unchanged (24%), that of endometrial ablation/resection reduced from 41.2% to 18.3%. Glycine was the distending medium used in about 60%, compared to 90% in 1997. This was because of the increased use of normal saline in up to 36% (7% in 1997), probably related to the introduction of the bipolar operating system. Endometrial preparation was carried out in 21% of all operative hysteroscopies and 45% of those undergoing endometrial ablation/resection. Cervical priming was also not routinely practiced and carried out in only 10%. About 65% of the procedures were performed specialists, 20% by doctors with MRCOG and 20% by pre-MRCOG doctors. The overall complication rate was 2.8% which was significantly lower than the 8.5% in 1997. Excessive fluid absorption (> 1.5 L) was the most common complication and occurred in 1.1% (3.0% in 1997). Resection of fibroid was associated with the highest complication rate of 6.4% compared with other procedures.

Working Group on Territory-wide Audit on Gynaecological Endoscopic Surgery 2002

Dr YUEN Pong Mo (Chairman)
Dr CHAN WT Joseph
Dr LO SF Leslie
Dr PUN Ting Chung
Dr PANG Chung Pui

Members of Gynaecological Endoscopic Surgery Subcommittee 2002

Dr CHAN WT Joseph (Chairman)
Dr CHIN KH Robert
Dr HO Lau Cheung
Dr LI FH Dominic
Dr LO SF Leslie
Dr PANG Chung Pui
Dr PUN Ting Chung
Dr SIU KS Catherine
Dr SO WK William
Dr YUEN Pong Mo

Hospital Coordinators

Dr NG Pui Shan (Alice Ho Miu Ling Nethersole Hospital)
Dr LEE Eric (Canossa Hospital)
Dr MO Siu Chee (Caritas Medical Centre)
Dr LIU Yuk Kuen (Evangel Hospital)
Dr TSAI Albert (Hong Kong Adventist Hospital)
Dr LEE Eric (Hong Kong Central Hospital)
Dr SUM Tak Keung (Hong Kong Baptist Hospital)
Dr CHAN Joseph (Hong Kong Sanatorium & Hospital Ltd)
Dr WONG Kin Sun (Kwong Wah Hospital)
Sister LEE Bernie (Maltida Hospital)
Dr NG Pui Shan (North District Hospital)
Dr WONG Kin Sun (Our Lady of Maryknoll Hospital)
Dr WONG Wilfred (Pamela Youde Nethersole Eastern Hospital)
Dr NG Pui Shan (Prince of Wales Hospital)
Dr MO Siu Chee (Princess Margaret Hospital)
Dr CHAN Chung Sum (Queen Elizabeth Hospital)
Dr LAU Chung Ting (Queen Mary Hospital)
Dr CHUNG Ka Leung (St Paul's Hospital)
Dr WONG Shu Pong (St Teresa's Hospital)
Dr SO Kon Ping (Tsuen Wan Adventist Hospital)
Dr PANG Chung Pui (Tuen Mun Hospital)
Dr YU Kai Man (Union Hospital)
Dr MOK Chung Wai (United Christian Hospital)