Fellowship in Laparoscopic Surgery and Infertility

Dare to be Different”

In the last 22 years that I have been in private practice, I have dedicated my professional life to laparoscopic surgery and infertility. I started my laparoscopic surgery training after spending 2 months with Prof Song and Dr. Lee Chyi Long at the Chang Gung Memorial Hospital in 1994. After that I gradually honed my skills by visiting laparoscopic surgeons in di erent parts of the world, watching them operate and at times assisting them. I am indeed grateful to these doctors who have unselfishly shared their knowledge and skills with me.

The uptake of laparoscopic surgery in Malaysia is disappointing. One of the reasons is because in Malaysia there are not many teachers in this field.

Over the years, many Malaysian OBGYN specialists have requested to watch and assist me when I perform laparoscopic surgeries. Foreign gynaecologists have also spent weeks learning these skills under my guidance. However, I felt that these short training stints were insu cient and a longer training

programme would benefit young gynaecologists who are keen to learn both laparoscopic surgery skills and infertility management. I felt this training could also be done outside a teaching University Hospital. Therefore, in 2013, I decided to be di erent. My years of acquiring advanced skills and knowledge as a laparoscopic surgeon, allowed me to try something that had never been done before — to start a Fellowship in Laparoscopic Surgery and Infertility, in a private hospital in Malaysia.

I had many doubts about starting this programme:
1.Would a private hospital allow me to start this Fellowship?
2.Would the Ministry of Health recognize my programme?
3.Would any gynaecologist be interested in the training I intend to o er? 4.Would I have enough cases in laparoscopic surgery and infertility
to train gynaecologists?
5.Would my private patients agree to be seen by other specialists?

My journey started with me first talking to the chairman of the board of directors of Mahkota Medical Centre, Dr Gan See Khem, who was courageous enough to give me her blessing to start the programme. Unfortunately, the credentialling and privileging committee of the Mahkota Medical Centre wanted all Fellows to have a postgraduate degree exceeding 3 years. I wrote to the Ministry of Health for approval and got a reply which was equivocal: neither an approval nor a disapproval of the programme.

With this in hand, I advertised the Fellowship in the newsletter of Obstetrical and Gynaecological Society of Malaysia and the Malaysian Medical Association. My first Fellow was Dr. Thinakaran Malappan, a gynaecologist from Ipoh who spent 3 months with me. I was as apprehensive as he was in starting this programme. My second Fellow was Dr. Agilan Arjunan, who trained under me for 1 year. I have included a copy of their experience, training under me. I currently have my third Fellow, Dr. Senthil Muthuraman who has been with me since February 2016.

I have learnt a lot after starting this Fellowship. Although, it is impossible to be perfect in patient management, having a Fellow keeps me on my toes. As my Fellows are always watching me, my management must be evidence

based. A young mind will question everything so I learn and improve myself everyday. Of course, I teach whatever I know to my Fellows hoping that their stint with me will be beneficial to increasing their skills and knowledge.

On the whole, I have enjoyed this challenge of having Fellows in my practice. I think all doctors have something to teach and something to learn from other doctors. The teaching of young doctors should not be confined to just government and teaching hospitals. The Health Ministry should recognize and accept willing and qualified private practitioners to train these young doctors, as well. Teaching may not be every private practitioner’s cup of tea but I am sure, if given the opportunity, many will want to do so.

Selva

MY FELLOWSHIP EXPERIENCE

My fellowship with Dr.Sevellaraja was from March to June 2014. I had come upon his fellowship o er in the March issue of Berita MMA in 2013. It was only the following year in March that I had managed to secure my unrecorded leave from KKM and the coverage needed from my hospital to join Dr.Sevellaraja in Mahkota Medical Centre, Melaka. I was fortunate to be chosen as his 1st fellow.

Dr.Selva ,as he is fondly called ,is well known in the O&G fraternity as an advanced Gyane-laparoscopic surgeon and a Reproductive Medicine

subspecialist. With that in mind , I went in assuming that the training was just limited to work related to Laparoscopy and Infertility but what I finally learnt and experienced was much more and beyond that.

A typical day usually starts at 8am where we would do ward rounds together and cases seen in the ward would be discussed briefly. If it was not an operating day, we would then proceed to the clinic after a short breakfast at the Doctor’s lounge. In the clinic, I would be sitting in with him in the consultation room during the entire session. Despite it being his private run clinic ,we would still discuss about the case in terms of the relevant history, investigations and the management options for the patient where ever possible. The patients in turn were very accommodative. I was fortunate that I was able to see a good mix of patients which were not only infertility and laparoscopic related but also many obstetric and general gynaecologic cases as well. The clinic will usually run till 530pm with a short lunch break(1–2pm) in between.

The operating days were usually 2 days per week. We would have at least 4–5 cases per day which all were mostly laparoscopic cases.(Eg: Total Laparoscopic Hysterectomy, Lap Myomectomy, Lap Cystectomy, etc). I had not only the opportunity to assist him in the cases but also was given the opportunity for some hands on as well including laparoscopic suturing in live patients which I’m sure will not be o ered elsewhere in other training courses either locally or overseas. As he has more than 20 years experience , I learnt many important techniques just by assisting (as a 1st Assistant) and observing how he perform his surgeries and most importantly he wasn’t reluctant to share his tips and tricks on certain laparoscopic techniques. He was very patient and took pains to ensure that I had gained the maximum benefit with each and every case that was posted on each operating day. He also provided me a laparoscopic endotrainer with suturing instruments and models for me to train in my spare time. As he is also known for his popular Laparoscopic workshops that he organizes on a regular basis, I also had the opportunity to be involved in the organization of his first 3D Laparoscopic workshop in May 2014 that was held at Mahkota Medical Centre.

As it was a Infertility fellowship as well, Dr.Selva ensured that I was not neglected in this aspect as well. He provided me with the necessary reading material (textbooks, journals,etc) and I was exposed to many infertility patients that attended his clinic. I was involved right from the beginning in their management plans and was also involved in their subsequent follow ups including initiation of di erent stimulation protocols , follicular tracking scans, oocyte retrievals and embryo transfers for patients seeking IVF/ICSI. I

was given the opportunity to visit the IVF lab in Mahkota Medical Centre and was given detail explanations regarding all the procedures done there(ISCI/IVF, Seminal analysis,etc) by their experienced Embryologist. In terms of hands on, I was given the opportunity to perform Oocyte retrievals for a few cases and also a case for embryo transfer. On certain clinic days, we also make it a point to go through previous infertility case notes and discuss relevant matters regarding that particular case.(Eg: why a particular stimulation protocol was chosen , their follow up plan and if their IVF treatment has failed, what measures would be taken di erently at their next treatment cycle.)

The additional benefits that I was fortunate enough to experience was the opportunity to see how a private O&G practice was run. As he is a very meticulous person and with his vast experience in private practice, he gave me his views on how to set up a simple clinic in terms of sta ng and basic equipments needed. He shared with me his insights on how he manages his record keeping and clinic information( eg: patients case files , Ultrasound Images, Operative notes, laboratory and HPE results)which are all stored systematically using a computer software which makes them easily traceable whenever needed. As all his surgical procedures are recorded, he also taught me on video editing techniques using computer software and how a DVD can be prepared and given to patients for their reference!

I have been to a few laparoscopic workshops and courses within and out of the country and I must say the training I had with Dr.Selva was THE best and MOST BENEFECIAL for me. I would strongly recommend this fellowship to others who have a strong interest in learning laparoscopy and infertility. I feel that KKM could perhaps incorporate Dr.Selva’s fellowship as a part of the Reproductive Training subspeciality programme or make it as a recognised accredited training programme for Gynaecologists interested in Minimally Invasive Surgery(MIS).

In conclusion, my 3 months with Dr.Selva was definitely worth the time and sacrifice. I had gained much more that I had ever intended. I’m more confident now in performing laparoscopic surgeries including laparoscopic hysterectomies and managing Infertility patients. I’m also very fortunate, in that, at the end of the training, I did not only gain a mentor but also a very good friend. My only regret was that my fellowship was for only 3 months and not longer.

Fellowship In IVF & Laparoscopic Surgery : What I have lost…

As doctors, many of us realise that our ‘true’ learning of the art of medicine begin the day we graduated. The 5 years spent in medical school was just a preparation of core knowledge. Our career paths varies after graduation and for many, we seek to go to ‘graduate school’ or simply known as specialty or sub-specialty trainings. Then,the hard cold facts of reality hits upon us. What is o ered in these ‘ graduate schools’ may not be actually what we want to do. Are we at the end of a road? Do we just choose the path that is o ered to us and go forward?

As the saying goes, ‘Ask and it will be given , seek and you will find, knock and it will be opened’. With this in mind, you will most likely find the path you are looking for. That’s what happened to me.

In 2013, I came across an advertisement in the OGSM Bulletin about a Fellowship Programme In IVF & Laparoscopic Surgery by Dr.S.Selva from Mahkota Medical Centre Melaka. Yes, you are right, it’s a programme o ered by a private practitioner. This program is first of its kind in Malaysia and I was a bit worried and skeptical. It’s not from Ministry of Health and am I going to learn anything? Will I be just wasting my time there as the program is not recognised by the ministry?

In the midst of wrestling with my conscious and subconscious mind about what to do, I remembered a segment from the movie Polar Express . In this movie the train conductor will tell the child, “ You know something about trains, it’s not about where the train is going ,it’s about deciding to get on.”

I applied to join the programme and decided to get on the train.

I started in August 2014 after another ‘passenger’ had completed his journey .

My first day was very stressful, though I tried my best not to show it! Moving from a busy government hospital to a clinic set up, I tried to get acclimatised. Someone told me that Dr.Selva runs a ‘one-man general hospital’, and I have to agree with it.

There were many varieties of patients in his clinic. We see patients right from adolescent girls, infertility, obstetrics till general gynaecology and menopausal women. You name the condition, and most likely we have seen them.

I was able to observe and participate in the care of infertility couples. I learned to manage male, female and unexplained infertility. These are the major causes of infertility that we see in our daily practice. Another skill that I learned is to perform o ce hysteroscopy. I begin to appreciate the usefulness of o ce hysteroscopy as a valuable tool to diagnose intra-uterine pathology that may adversely a ect the outcome of ART treatment.

Dr. Selva did not treat me as just an ‘observer’ in his clinic. I was involved in the decision-making and discussion about nearly every infertile couples that walked through his clinic. This directly involved me with the care of the couples. In fact, we worked as a team where one of us will see the couples throughout their treatment cycle, including oocyte collection and embryo transfers.

Dr.Selva has a great passion for laparoscopic surgery. We see many patient seeking help for gynaecological problems such as ovarian cyst/endometriosis, fibroid and pelvic pain every single day. If your aim is to become a endoscopic gynaecologist , this is where you will see it all.

I have to admit that i have learned common pathologies in gynaecology and clinical skills needed to manage them in greater details than i have ever learned before.

My learning was never confined to the clinic alone. Our operating list is on every Wednesday and Friday. This is where the real action is! This is where I saw 3D laparoscopy done. In fact , this is the birth place of 3D laparoscopy in Malaysia. Immediately I began to realise the advantages of 3D laparoscopy. The depth perception is fantastic. This makes my training in laparoscopy much more fun and a lot more easier. I have gone through the pain of learning to suture using my self-made endotrainer. For those beginners , they know what i’m talking about! 3D laparoscopy made it so much more easier to suture. You got to do it, to believe it..

The operating room is the place where we have our regular dose of adrenalin surge. In the past 1 year I spent there , I have learned to operate a case as simple as an ovarian cyst and as advanced as hysterectomy and endometriosis, laparoscopically.

Am I going to loose my skills in performing an open surgery? It depends on how you look at it. If you are geared to improve your laparoscopic skills, then you will have nothing to complain about. We still do caesarean sections and laparotomies for very di cult cases or whenever the cases are deemed not suitable for laparoscopy.

As a human being , we always want to be surrounded by people with whom we are comfortable with. That is true for work place surroundings too. I had this same worry when I first stepped into Mahkota Medical Centre. The first day I was there , I realised my worries were uncalled for. Dr.Selva and his sta s were welcoming. I never felt the burden of a big career shift that I had made. I had my personal space and nurses to assist me , as if it was my own clinic! I am very much in gratitude to the sta s Soo Yin , Julai, Nora , Aida and Mag, and of course Dr.Selva for making my past 1 year a pleasant journey.

Looking back at the past 1 year of my life , I cannot ignore the fact that I have ‘changed’. The fellowship programme not only taught me about IVF and

Laparoscopic Surgery but also about attitude and self development. We all know that education is life long, but how many of us actually understood this? Throughout my fellowship , I have learned how to maximise my time , how to use technology to support my learning ( I have become an Apple-user for good!) and most importantly able to discover my passion for my life long learning . I have also learned to always aim to do a good job , everything else will follow .

So, what I have lost? Maybe a little of my ego and time away from my family . What I have gained is priceless and i know its just the beginning…

2 Comments

  1. mrs Esther Christian nyeche says:

    please I need u to help me Dr. I ha
    ve watched ur video and I like it so I need u to help me get rid of my cyst they said is extra overian please how do I reach u

  2. mrs Esther Christian nyeche says:

    please Dr.I need your help please I have just one ovary left and on DAT one I have the cysts please I have previously been operated on my right ovary of ectopic and d right tube destroy so am left with d left and am having a large cyst on it growing up to a year now and is 7mm x8mm thou I don’t know how large it is but I need your help on how to shrink or treat it without surgery cos am scared if going for surgery might affect the only ovary I have left pleas advice me

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