Minimally Invasive Surgery in Gynaecology
Minimally Invasive Surgery in Gynaecology includes the use of Normal Orifice Transluminal Endoscopic Surgery (NOTES) i.e. the vagina, minimal access surgery as in Laparoscopy as well as operating through the vagina, ultrasound guided, telescospic/microscopic assisted or straight naked eye vision with minimal interferences.
Minimally Invasive Endoscopy Surgery is using a high performance digital video camera connected to a small telescope, the surgeon places it through the naval (laparoscopy) into the abdomen or through the cervix into the uterine cavity (hysteroscopy). A variety of very small instruments, no larger than a quarter inch in diameter, are then employed to complete the procedure. All the while, the surgeon has a crystal clear view of the procedure as it is projected on a monitor screen set throughout the treatment room. In colposcopy, the cervix and the vagina are directly exposed and magnified from examination. As for the ultrasound guided procedures, the view can be seen on the monitor screen and the transvaginal sonographic needle-guided aspiration observed.
Minimally invasive gynecologic surgery eliminates the severe pain, prolonged recovery, and scarring associated with the large abdominal incision (laparotomy) typically used to perform operations for benign gynaecologic conditions. Normally completed as a same-day surgery, minimally invasive procedures produce smaller incisions, which dramatically accelerate all aspects of recovery, reduce the need for pain medications, leave no scars or very small scars that are cosmetically pleasing, and reduce the chance of scar tissue formation.
Women who undergo minimally invasive surgery typically report a quick return to normal activity and well-being. For certain conditions, minimally invasive surgical procedures can be performed safely and comfortably in an office setting.
- Abnormal uterine bleeding
- Asherman's syndrome (Intrauterine adhesions)
- Ectopic pregnancy
- Endometrial polyps
- Imperforate hymen
- Tight/Wide vagina
- Ovarian cysts
- Pelvic pain
- Dyspareunia (painful sexual intercourse)
- Pelvic adhesions
- Infertility/checking patency of fallopian tubes
- Post - menopausal bleeding
- Post - ablation syndrome
- Stenotic uterine cervix ("stenotic os")
- Uterine anomalies (uterine septum)
- Vaginal anomalies (vaginal septum)
- Vulval itching/Vulval lesions
- Abnormal Pap smear
- HPV Infection
Laparoscopy is a surgical procedure that has been used widely in medicine over 30 years. The faster recovery time, the minimizing of pain, hospitalization and the better aesthetic result are some of the advantages which made laparoscopy very popular among patients and surgeons. Also some technical parameters such as the magnification offered by the endoscope during the procedure and the small risk of complications resulted to the wide use of laparoscopic surgery in gynecology. Laparoscopy has gained a leading role and appears to be the gold standard method for a quiet wide range of gynecologic procedures such as tubal ligation, removal of ovarian cyst or adnexa, treatment of ectopic pregnancy, hemorrhagic rupture of a cyst, exploration of chronic pelvic pain, sterility, treatment of endometriosis, removal of fibroids, hysterectomy, and lately for treatment of pelvic organ prolapse, urinary incontinence and even in gynecologic cancers. Despite the advantages of laparoscopic procedures, they do not come without risk and complications for the patient. As with laparotomy there is always danger for deep vein thrombosis, inflammation and creation of adhesions. It should be noted though that compared to laparotomy there is a higher risk of injury to the major blood vessels positioned in the pelvis and the urinary system, and that is why patients considered to be subjected to laparoscopy should be carefully chosen.
Thorough preoperative evaluation of the patient, combining ultrasonography with the measurement of tumor markers, may greatly improve the accuracy of diagnosis of malignancy. Moreover, laparoscopy is, in the first place, used as a diagnostic tool whereby the pelvis and the abdominal cavity are thoroughly evaluated.
Indications for Laparoscopy
- Diagnostic laparoscopy
- Laparoscopic total hysterectomy (leaving the ovaries inside)
- Laparoscopic myomectomy - removal of fibroids
- Laparoscopic supracervical (subtotal) hysterectomy
- Endometriosis resection (removal)
- Ovarian cystectomy - removal of a cyst in the ovary
- Laparoscopic ovarian drilling
- Tubal occlusion
- Adhesiolysis (Separation of adhesions)
A hysteroscopy is a test to examine the inside walls of the uterus.
This test is able to detect scar tissue, polyps, fibroids, and any uterine abnormality such as a septate uterus, that may prevent an embryo from implanting properly. Having an abnormality in the uterus can also reduce the chances for pregnancy.
The procedure :
The hysteroscopy is usually done in the office and takes about 30 minutes. A speculum is inserted into the vagina (like when having a Pap smear). A local anesthetic (paracervical block) is given, and then a tiny telescope with a camera is placed through the cervix into the uterine cavity. Sterile salt water is instilled into the uterus so that the walls can be seen. The TV monitor connected allows to visualize the inside of the cavity. We have the latest in office hysteroscopy equipment, including a 3.9 mm hysteroscope which results in significantly less discomfort.
Although some women feel some cramping, especially when the sterile salt water is instilled. Women with blocked fallopian tubes may feel more uncomfortable. Even though we are using the smallest hysteroscope available. We do recommend that one hour before the procedure you take 2-3 pills of regular ibuprofen or Diclofenac suppositories to help prevent or reduce cramps during the procedure.
Apart from this discomfort, occasionally vaginal spotting or bleeding may occur. This can be managed accordingly.
Indications for office hysteroscopy
A. Evaluation of abnormal uterine bleeding
- Premenopausal ovulatory bleeding
- Premenopausal anovulatory bleeding that fails medical therapy
- Post-menopausal bleeding
B. Infertility evaluation
- Routine infertility
- Pre-IVF evaluation
- Abnormal hysterosalpingogram
- Recurrent miscarriage
- History of Asherman's syndrome
C. Location of intrauterine devices and foreign bodies
D. Preoperative evaluation
- Grade 0, I, II submucous myomata
- Asherman's syndrome
- Septate uterus
- Evaluation of endometrial hyperplasia and carcinoma
E. Minor surgical procedures
- Endometrial polypectomy
- Tubal recanalization
- Tubal occlusion
A colposcopy is an examination which is recommended after a positive or abnormal Pap smear result or HPV infection, also if it was found that the cervix has cervical erosion or a lesion apparent to the naked eye and causing symptoms.
Colposcopy is a simple, 10- to 15-minute procedure that is painless and performed in our office. The position for the examination is like taking the Pap cervical smear. An acetic acid (such as common table vinegar) and 10% Lugol’s iodine is placed on the cervix.
The colposcope which is a mobile electric microscope that is positioned approximately 30 cm from the vagina to view the cervix.
During this procedure, the areas of the cervix where light does not pass through the abnormal cervical changes are seen as white areas with mosaic pattern, the whiter the area, the worse the cervical abnormality/dysplasia. Abnormal vascular (blood vessel) changes are also apparent through the colposcope. Typically, the worse that the vascular changes are, the worse the abnormality/dysplasia.
When the entire abnormal area is viewed through the colposcope, a tissue sample or biopsy is taken from the whitest abnormal areas and sent to the laboratory for further evaluation. The abnormal areas can be ablated/removed. It is important to appreciate that if the abnormality is NOT TREATED, there is a chance of this to turn into full cancer in time. The treatment can be done by the following procedures :
- Cone Biopsy
- Microwave Diathermy
SEXUAL ENHANCEMENT, VAGINOPLASTY & BOTOX
Sexual vaginal pleasure is important for both partners just as much, but women sometimes experience unease or discomfort in that sensitive area and around the external genitalia or the outside down below, which makes the sexual pleasure deficient! This can be as a result of previous childbirth which makes the vagina rather wide, or formation of cysts or lesions around the vulva or the vagina or even being tight or have a rigid vaginal entrance or hymen, to the degree that sexual intercourse becomes unpleasant or even painful and cannot be accomplished. These can be dealt with professionally, skilfully and effectively accordingly by the following procedures :
Labioplasty - labial reconstruction, refashioning and reshaping.
Non-surgical, non-invasive injection of botox or collagen and other material which improves sexual vaginal pleasure and restores the original vaginal function.
Hymenotomy for imperforated or rigid hymen.
Vaginoplasty - when indicated proper vaginal reconstruction to tighten or widen the vagina to ease sexual intercourse.
Excision of cysts or lesions when found.
ULTRASOUND GUIDED OVARIAN CYSTS
Ovarian cysts formation is a common occurence in women of child bearing age. These cysts if left untreated can cause complications, like torsion, rupture, or haemorrhage within the cyst. It is now possible with minimally invasive technique to aspirate these cysts through the vagina, guided with 3D/4D vaginal ultrasound probe with very little or no discomfort at all.