APPRECIATE THE PAST

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The history of the Division of Gynecologic Endoscopy, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital began when Prof. Dr. Prapan Areemitr (1969), Head of Department, introduced endoscopy to the department by using a scope inserted through an incision at the navel to examine the pelvic cavity. Later, Prof. Dr. Suporn Koetsawang (1970) used endoscopy for examination and sterilization of patients in the family planning division. Asst. Prof. Dr. Apsorn Amatayakul (1974) used a cystoscope to examine the bladder to help diagnose the stage of cervical cancer invasion. Around the same time, Clinical Prof. Emeritus Dr. Prapas Bhiralert introduced the culdoscope to examine female pelvic organs and perform sterilization through the cul-de-sac in the vagina (Natural Orifice Transluminal Endoscopic Surgery). In 1975, Asst. Prof. Dr. Kovit Pimolpan was appointed head of the Division of Gynecologic Endoscopy. He continued the work of Prof. Dr. Prapan and Prof. Dr. Suporn. In 1976, Assoc. Prof. Dr. Chaiyos Assawajinadawat (Teerapakawong) was appointed as a faculty member in the division. In 1977, Prof. Dr. Pongsakdi Chaisilwattana was appointed as a faculty member in the division. All faculty members worked together to develop and modernize the division continuously. I must express my deep gratitude and remember the kindness of all the professors.

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Laparoscope

The instrument shown here is the first laparoscope we received from the JHPIEGO project (Johns Hopkins Program for International Education in Gynecology and Obstetrics 1973), which was funded by the United States Agency for International Development (USAID). This laparoscope consists of a scope with an extension side tube eyepiece and an operating channel for inserting instruments such as a grasper with monopolar electric coagulation for diagnosis and surgery like sterilization.

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Pneumoperitoneum

In the early days, room air from the operating room was used, squeezed through a rubber bag covered with a mesh to prevent over-inflation. The surgeon had to use their hand to feel the tension and pressure in the rubber bag to avoid injecting too much air too quickly into the abdominal cavity. At that time, there was no gauge to measure intra-abdominal pressure like today. Room air was blown through an air filter into the patient's abdominal cavity. The assistant had to observe the abdominal pressure along with the inflation of the air bag to allow the doctor to perform the laparoscopy conveniently and safely.

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Self -Training Process

For training in using the scope and performing procedures in the abdominal cavity, we did not have a pelvic trainer box like today. I used a shoe box, punched a hole to represent the navel, then borrowed a scope from the operating room to practice during non-office hours. I used it to practice accuracy in targeting and performing procedures skillfully, and trained on animal models like pigs and rabbits before operating on real patients.

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Diagnostic laparoscopy and Tubal Sterilization via laparoscopy assisted

When performing laparoscopy and sterilization surgery on patients, the doctor performed laparoscopy and tubal sterilization by injecting local anesthesia at the navel along with injecting valium and pethidine. The patient would be drowsy and not feel much pain. The doctor performed surgery by making an incision at the navel, inserting a trocar & sleeve, and inserting the scope into the navel carefully and quickly. Diagnosis and treatment were performed as quickly as possible according to the available instruments. For sterilization, a monopolar grasper was used to cauterize the fallopian tube until it swelled and made a popping sound, then pulled apart. The severed ends of the tube were then cauterized to ensure there was no opening of the fallopian tube and to stop any bleeding. This method ensured there would be no re-anastomosis of the uterine tube. Therefore, this sterilization method caused more extensive damage to the fallopian tube tissue than traditional tubal ligation. This made it more difficult to reconnect the fallopian tube to restore its patency compared to sterilization by tubal ligation.

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Uterine Manipulator

The Siriraj Model uterine manipulator was designed by Prof. Dr. Suporn Koetsawang and manufactured by a factory in Thailand. The uterine manipulator consists of two rods that, when closed together, form a straight line with a diameter of about 5 mm, which can fit perfectly through the cervical os. It has a ring to prevent inserting the uterine manipulator beyond the length of the uterine cavity to prevent perforating the uterus. It has a handle and a pin to slide the two rods inside the uterine cavity near the fundus to spread apart and support the uterus to prevent it from slipping out. When the surgery is finished, the pin is twisted to close the two rods together into a straight line and can be easily removed. It is still available in the TGMET CENTRE museum. It was effective, held well to the uterine cavity without slipping easily and did not cause excessive trauma to the uterine cavity.

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New Instrumentation

Later we received additional modern equipment that was more convenient and safer, including a pneumoperitoneum insufflator with pressure gauge and volume meter for the gas injected into the abdominal cavity. At this time we used carbon dioxide gas instead of room air.

 

Imaging Record

For recording images inside the patient's abdomen, we did not have a video recorder. We used a regular Olympus camera loaded with Kodak Chrome slide film attached to the eyepiece of the laparoscope and took still photos. When the film was finished, it was developed into slides for use in teaching.

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At the end of 1992 

The Division of Gynecologic Endoscopy received a new set of laparoscopic surgical instruments with a camera but no monitor. We connected the camera to a home television to perform surgery. The TV had many obstacles. Besides the image not being very clear, when using the monopolar hook to cauterize tissue with electricity, the image on the screen would disappear and be replaced by electrical waves. This caused us to have to pause briefly and check the area we cauterized to ensure it was on target and effective. Therefore, before using monopolar instruments, we had to aim carefully and keep our hands steady and accurate before stepping on the pedal to cauterize, because when stepping on the pedal there would be interference on the TV screen and we would no longer see the image of the instruments and tissue. We began to develop to the next level - instead of just using the laparoscope for diagnosis and sterilization or simple procedures like cystectomy as mentioned earlier, we started performing surgical procedures on the ovaries, fallopian tubes, removing uterine fibroids and hysterectomies in patients with uncomplicated diseases. Before being approved to perform such surgeries laparoscopically, there were many obstacles from many senior faculty members who disagreed with performing major surgery through small incisions via laparoscopy. Many gave the adage "Big surgeon, Big incision". So I could only perform surgery in a limited scope. Therefore, I could only perform laparoscopic surgery on patients under my own responsibility.

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In 1993,

We received support from Olympus Thailand to borrow equipment when we had surgical cases. This made surgery more convenient, easier and much more effective than before. We also collaborated to organize the first laparoscopic gynecologic conference and workshop with hands-on porcine model training. There were 4 stations in total. About 60 obstetrician-gynecologists applied for the training. 16 doctors trained on the hands-on porcine model, 4 per station. We conducted laparoscopic workshops with Olympus 3 times a year for about 1 year. Later this company had problems with the parent company in Japan so they stopped supporting us. In 2000, STORZ GMBS came to support and collaborate with us, with Professor Dr. Dr. H.R. Tinneberg and Madam Dr.hc.mult. Sybill Storz coming to help set it up. So we started organizing Endoscopic Workshops again, 4 times a year.

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In 1995,

Our team consisting of Asst. Prof. Dr. Kovit Pimolpan, Prof. Dr. Jesada Intraphuvasak, Assoc. Prof. Dr. Pongsakdi Chaisilwattana (team leader), and Dr. Pranom (first fellowship trainee from Obstetrics & Gynecology, Khon Kaen University) successfully performed first case of Radical Hysterectomy and pelvic lymphadenectomy in a patient with stage I cervical cancer. The patient was able to urinate on her own on day 3 after surgery and return home to rest on day 4 after surgery. The total time in the operating room was 16 hours, with actual surgical time of about 7 hours. The remaining time was spent dealing with obstacles from instruments and cauterization.

In the same year, I was invited by ELSA (Endoscopic and Laparoscopic Surgeons of Asia) to attend an academic conference on laparoscopic surgery with surgeons at Dusit Thani Hotel, Cha-am, Chonburi. At the conference I met and got to know Dr. Somchai Kovitcharoenkul, an obstetrician-gynecologist from Bangkok Christian Hospital.

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Genesis of TSGE

When I returned to Siriraj, I consulted with Asst. Prof. Dr. Kovit Pimolpan (Head of the Division of Gynecologic Endoscopy), Asst. Prof. Dr. Jongrak Nipawong and Prof. Dr. Jesada Intraphuvasak that we should establish a central organization like ELSA to be a center for gathering gynecologic endoscopic surgeons together, for the benefit of meeting and exchanging knowledge and skills between Thai doctors and between Thai and international doctors. All the professors who thought about it together, including Dr. Somchai Kovitcharoenkul, agreed. In February 1996, I called and sent letters to contact faculty doctors who were interested in gynecologic endoscopic surgery at various universities to come meet together.

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Dr. Somchai Kovitcharoenkul and Dr. Sunanta Sinpermsukskul from Bangkok Christian Hospital, Asst. Prof. Dr. Jamnong Utawichai from Chiang Mai University, Asst. Prof. Dr. Kanok Seejorn from Khon Kaen University, Dr. Haturn Thinthara from Prince of Songkla University, Dr. Wirat Wisawasukmongkol from Chulalongkorn University, Dr. Chatchai Srisombut from Ramathibodi Hospital, Mahidol University, Dr. Theerasak Thamrongteerakul from Phra Mongkutklao Hospital, Dr. Mongkol Chantapakul from Chareonkrungpracharak Hospital, and Dr. Narumol Charakorn from Hua Chiew Hospital met on the holidays at the JI Clinic, CTI Tower, 8th floor of Prof. Dr. Jesada Intraphuvasak. We met several times. The important matters were determining the name of the society, establishing a committee, and jointly drafting the constitution and regulations of the society.

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The committee organized the official launch of the Thai Society of Gynecologic Endoscopy (TSGE) on May 26, 1996 at the Royal Hotel, Ratchadamnoen Road. The meeting resolved to appoint me as the first president of the society. But I declined and asked Dr. Wirat to invite Prof. Emeritus Khunying Dr. Kobchitt Limpaphayom from Chulalongkorn University to be the first president of the society, with the reason that she was a WHO Consultant and one of the first three people to perform patient sterilization using the scope received from JHPIEGO (The Johns Hopkins Program for International Education in Gynecology and Obstetrics. (Prof. Emeritus Khunying Dr. Kobchitt Limpaphayom, Prof. Dr. Kamhaeng Chaturachinda, Prof. Dr. Suporn Koetsawang)). She was well-known among senior international gynecologists. When she became president, she would be able to use her personal connections to lead the society to the international level faster, without having to start from scratch, because I had very little connection network with senior foreign doctors.

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When Prof. Emeritus Khunying Dr. Kobchitt graciously accepted to be the first president to help the society, we clearly saw that she introduced the society to become known to international endoscopic surgery societies quickly, such as ISGE (International Society of Gynecologic Endoscopy).

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Genesis of TGMET center

On August 1, 2000, the Thai-German Multidisciplinary Endoscopic Training Center, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital was established. It received initial funding and support in various aspects from the Dean, Professor Emeritus Dr. Chanika Tuchinda, received support from the Head of the Department of Obstetrics and Gynecology, Clinical Professor Dr. Somchai Nueangton, and assistance from Germany both in medical academics with help from Professor Dr. Dr. h.c. H.R. Tinneberg, who currently holds the position of Professor, Head of the Department of Obstetrics and Gynecology at Giessen University, located in Giessen, Germany, and he has also been appointed as a Visiting Professor of Mahidol University. In addition, we received support in teaching equipment and surgical instruments from Dr. h.c. mult. Sybill Storz of STORZ Company, Germany. Later this center was developed into the International Thai-German Multidisciplinary Endoscopic Training Center for South East Asia.

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TSGE & ISGE

In 2002, the society was entrusted by ISGE (International Society of Gynecologic Endoscopy) to organize the 6th Regional Meeting of ISGE & Annual Scientific meeting of TSGE on Nov. 12-15, 2002 (Glorious Mission of Endoscopy Beyond TheYear 2002). The society organized the conference at Shangri-La Hotel Bangkok, Thailand. This first international conference of the society had about 350 Thai and foreign doctors and speakers attending. It made TSGE known at the international level. It was considered a great success and a great honor for the society.

 

Genesis of APAGE

In 2003, the society attended the ISGE conference in London, England. Professor Dr. Chyi-Long Lee and the TAMIG (Taiwan Association for Minimally Invasive Gynecology) team invited me to a meeting in a small meeting room at RCOG (Royal College of Obstetricians & Gynecologists) to jointly establish APAGE (Asia Pacific Association for Gynecologic Endoscopic Surgeons and Minimal Invasive Surgery).

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TSGE-APAGE-RTCOG Workshop

On Wednesday, August 1, 2007 will be the opening day of the newly developed Thai-German Multidisciplinary Endoscopic Training Center and the opening of the TSGE-APAGE-RTCOG International Gynecologic Endoscopic Surgery Training Workshop. The center received the royal grace of Her Royal Highness Princess Maha Chakri Sirindhorn to preside over the opening ceremony of the training and open the said training center. This brought immense joy and gratitude for the royal grace to the committee and trainees beyond measure.

 

TGMET centre under The Royal Patronage of HRH Princess Maha Chakri Sirindhorn

Later on Friday, March 4, 2011, the center received royal grace from Her Royal Highness Princess Maha Chakri Sirindhorn again by taking the Thai-German Multidisciplinary Endoscopic Training Center under royal patronage. This brought immense joy and gratitude for the royal grace to the committee and trainees beyond measure.

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The Thai-German Multidisciplinary Endoscopic Training Center under The Royal Patronage of HRH Princess Maha Chakri Sirindhorn,Thai Society of Gynecologic Endoscopy, and Royal Thai College of Obstetricians and Gynecologists, and international societies such as APAGE have jointly organized international academic conferences together continuously.

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EMBRACE THE FUTURE

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For the future of laparoscopic surgery, especially advancements in technology and minimally invasive surgery, we must pay close attention and keep up to date. This will allow us to develop surgical techniques and treat patients with excellent results, both for patients and medical professionals, with the most cost-effective investment. Artificial intelligence in medicine has advanced rapidly, accompanied by increasing costs. Medical investments are continuously rising. Thailand is almost 100% a user country, purchasing tools for use. It is necessary to learn about the tools, how to use them, maintain them, and understand the benefits for patients and the medical field. By thoroughly studying and understanding the advancements in tools and collaborating with engineers and scientists from other fields, we can help develop technology and innovations, especially in artificial intelligence. This could transform Thailand from a user to a producer in the future.

 

Rapid developments we will encounter include:

​Endoscopic visualization systems, lenses, and image recording: When combined with artificial intelligence, these will produce clear, precise, and real-time images similar to satellite and spacecraft cameras. Particularly, 3D cameras will see significant development, allowing doctors to see images similar to or better than exploratory laparotomy.

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Surgical instruments and tools will become much smaller but stronger, more precise, and durable. They will be suitable for surgery in narrow and hard-to-reach areas, utilizing high-end computer chips to help doctors perform surgeries conveniently and accurately, with clear magnified images and excellent results. This will reduce complications and allow patients to recover quickly.

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Robotic Assistance will be developed significantly, enhancing surgical precision with real-time image analysis. This will be especially useful in areas where surgery is difficult, such as regions with thick and extensive adhesions or lesions attached to important organs, helping doctors plan and make more accurate surgical decisions.

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Nanotechnology: In the future, Microscopic Robot systems will assist doctors in targeted procedures, focusing on surgery at the cellular level without invading surrounding organs.

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Therapeutic Advancement: Future developments will include extremely minimally invasive surgery and tissue removal techniques, such as Super Laser Beam Technology, Ultrasound, tissue resolving and advanced tissue repairing procedures. These will greatly improve surgical outcomes, with patients experiencing little to no pain, better results, and faster recovery.

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Surgical scars may be minimal or non-existent (Scarless Surgery), such as Natural Orifice Transluminal Endoscopic Surgery (NOTES). This method not only eliminates visible scars but also reduces pain and speeds up recovery.

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Surgery for infertility treatment (Fertility Preservation and Reproductive Surgery) will improve outcomes, especially for conditions like Deep Infiltrating Endometriosis (DIE) and Preservation of Ovarian Function.

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Telemedicine and Remote Surgery will be beneficial for operating on patients in different locations, allowing experts to help solve difficult problems encountered during surgery to ensure patients receive the best treatment. It will also be used for teaching and learning from experts in different institutions, which will become easier and faster in the future with the development of ultra-high-speed internet systems.

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Education and Training for laparoscopic surgeons: Teaching laparoscopic surgery on animal models or cadavers will become more difficult and expensive. This will lead to a greater reliance on Simulation Technology and Virtual Reality, which are becoming more advanced but also more expensive, for teaching and developing doctors' skills.

 

All of these developments require high budgets and high potential for maintenance and development. To save costs and aim for excellence, Thailand should have a central space called the High-End International Multidisciplinary Endoscopic Training Center (HIMET center). This center would bring together laparoscopic surgery experts from Thailand and internationally, veterinarians, scientists, engineers, and other relevant personnel for teaching, patient treatment, development, research, and academic and innovation exchange at national and international levels. This will help our beloved Thailand develop towards excellence in laparoscopic surgery. 

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