DIFFERENT ENDOSCOPIC SURGERIES:
Introduction:
Gone are the days when open surgery was restored to for most procedures, necessitating long hospital stays and painful patient recovery. With its promise of improved outcomes, shorter recovery time and reduced cost, Endoscopic surgery has evolved into an accepted surgical discipline in most therapeutic areas. Minimally invasive surgery is revolutionizing the healthcare arena. Laparoscopy has come a long way over the years, owing to the increase in the applicability of laparoscopy and technological breakthrough in the equipments used.
Since Jacobaeus first reported visualizing the human peritoneal cavity with an optical instrument in 1910, contributions from various fields of science have had a significant impact on Gynecological surgery. With the availability of new instruments, videoscopic guidance, various energy source, more surgical techniques will most likely be accomplished through the laparoscope. There appears to be an important role for operative laparoscopy where the laparotomy was once required. The thousands of endoscopies that have been done to date provide us now with an understanding of the benefits, and also point out the weakness. The safety, efficacy, and cost-effectiveness of the uses for operative Endoscopy need to be established. There are clear advantages to operative Endoscopy with operative Endoscopy with respect to laparotomy. Pelvic Endoscopy can offer decreased hospital stay and recuperation period, less adhesion formation, substantial cost savings, and overall improved patient satisfaction.
Infertility is often a result of periadnexal adhesions. It has been suggested that laparoscopy may cause less peritoneal damage and therefore be preferable to laparotomy. Additionally, the magnification allows for better visualization of lesions, thus preventing excessive cauterization that may irritate the peritoneal surface & better dissection techniques.
In the litigious environment in which we currently practice medicine, a procedure that allows for improved documentation offers an advantage over the procedure that can only be described in a postoperative dictation. Endoscopy, with the use of video technology, provides the surgeon with photographic documentation of normal and abnormal pelvic anatomy, surgical technique & sharing various views during live Operative Endoscopic workshops from different faculties during surgery. Recording may help in credentialing the laparoscopic surgeons for different advanced Endoscopic surgeries. The process of determining what skills the gynecologist must possess prior to performing a difficult Endoscopic procedures.
UNDERSTANDING DIFFERENT GYNAEC. ENDOSCOPIC SURGERIES:
(1) Diagnostic Laparoscopy & Hysteroscopy for Infertility
Diagnostic Laparoscopy & Hysteroscopy is the commonest type of work up in the entire Infertility patient. Single puncture Laparoscopy was replaced by double puncture Laparoscopy in most of the centers of the world. We must record both Laparoscopy & Hysteroscopy for future important record in Infertility patient, for second opinion & for deciding future treatment protocol. Observing free spill with methylene blue from both fallopian tubes is not enough/complete work up during laparoscopy. We must see on both ovarian fosses after lifting the tubes for the possibilities of Endometriosis. We must see for Tuberculosis, Endometriosis & PID in all the cases. Hysteroscopy requires dilatation of the cervix and flushes both fallopian tubes with high pressure fluid helps in achieving very good fertility enhancing results following Endoscopy in infertility patients. Addressing all the infertility related lesions like PCOD, Endometriosis, Adhesiolysis, Fibroid etc. helps us in treating infertility patients in the same sitting.
(2) PCOD Drilling & Diagnostic Hysteroscopy
Patient present to us with Obesity, hirsutisium, irregular/delayed cycles, anovulation & Infertility. TVUSG shows peripherally placed multiple follicles with hyperthicosis of stroma & large ovaries. PCOD drilling is indicated in Clomiphen resistant PCOD, where weight reduction & metformin had been tried sufficiently (for six months) in the past. As compared to Gonadotrophin (pure FSH), PCOD drilling had following advantages : 60-70% Ovulation rate, 40-50% Pregnancy rate, reduced abortion & OHSS following drilling, reduced requirement of CC.HMG/FSH/hCG following drilling. Effect of drilling lasts for nine months. According to the size of ovary 4 to 8 punctures should be made on both ovaries. One must understand the difference between Cystic ovary & PCOD.
(3) Endometriosis- Bilateral Chocolate cyst
Dysmenorrohea, Dysparenunia & pelvic pain & Infertility are the presenting symptoms. Endometriosis is the commonest cause of Infertility during Laparoscopy. Pigmented & white fibrotic lesions are the two different varieties of lesions. Endometriosis is poorly detected during laparoscopy leads to more than 2-3 laparoscopy of infertility patient without result. Endometriosis needs to better address during laparoscopy, as residual diseases leads to recurrence & Infertility. Lot of awareness needs to be generated among Gynecologists for its identification during Laparoscopy, right treatment & documentation during surgery, proper post operative aggressive fertility treatment within nine months as it may reoccur after nine months & follow up. Most rewarding results were achieved following laparoscopic surgery with pregnancy rate from 50 to 70% in different series in mild, moderate to severe Endometriosis.Cystectomy should be preffered over simple drainage for preventing reoccurrence. But if we feel that cystotomy dissection is too difficult & likely to destroy many normal ovarian follicles, we should do drainage & bipolar fulguration of internal surface of chocolate cyst. Rectovaginal endometriosis is not touched most of the time during laparoscopy. We need to learn, identify the right cleavage & proper dissection of recto-vaginal nodule for her pain relief. With increased awareness will find out more & more incidences of Endometriosis during Diagnostic laparoscopy.
(4) Endometriosis – Rectovaginal diseases
Dysmenorrohea, Dysparenunia & pelvic pain & Infertility are the presenting symptoms... Endometriosis needs to better address during laparoscopy, as residual diseases leads to recurrence & Infertility. Lot of awareness needs to be generated among Gynecologists for its identification during Laparoscopy, right treatment & documentation during surgery, proper post operative aggressive fertility treatment within nine months as it may reoccur after nine months & follow up. Most rewarding results were achieved following laparoscopic surgery with pregnancy rate from 50 to 70% in different series in mild, moderate to severe Endometriosis. Dichasia means pain during defecation suggests involvement of rectal mucosa must be evaluated before operation for the possibility of extensive dissection, help of Gastro-intestinal Surgeon during operation may require to resect rectal involvement and repair of rectum at the same time laparoscopically or even Special Stapler for certain diseases. Rectovaginal endometriosis is not touched most of the time during laparoscopy. We need to learn, identify the right cleavage & proper dissection of recto-vaginal nodule for her pain relief. With increased awareness will find out more & more incidences of Endometriosis during Diagnostic laparoscopy.
(5) Ectopic Pregnancy
More than 90% cases of Ectopic pregnancy cases are now treated by Laparoscopy all over the world. Important pre-requisite for laparoscopic management is – Patient should be haemodynamically stable. Ruptured Ectopic should be treated by salpingectomy as in subsequent pregnancy chances of repeat Ectopic will be more. Goal should be diagnosing Ectopic pregnancy in its asymptomatic/ enraptured stage so we can offer medical treatment with Methotraxate or Salpingostomy or Tubal milking for preservation of affected tube. Copious irrigation is necessary to prevent post-operative adhesions. Recording the surgery helps another consultant for the decision of Salpingostomy/Salpingectomy during past surgery. Procedure takes hardly 30 minutes & patient can be discharged on the same day like Lap.T.L.
(6) Ovarian cyst
Ovarian cyst less than 5 cms are generally benign follicular cyst & Asymptomatic only and needs to be treated conservatively. They present to us for pain or as mass in abdomen or chance finding during USG. All ovarian cyst cases must be evaluated for benign & malignancy by clinical means, USG with color & power Doppler and tumor markers. In doubt frozen facility should be kept available during laparoscopy & patient is counseled for omentectomy & Para-aortic lymph node dissection if frozen shows positive malignancy. Cystectomy for simple cyst, para-ovarian cyst.
(7) Dremoid Cyst
Young patient (14-20 yrs) presents to us for pain or torsion and pain. Diagnosis suspected from USG findings. Dremoid Cystectomy can be tackled by various dissection techniques very easily with preserving normal ovarian tissue after Cystectomy. Dremoid cyst can be retrieved in Endobag without spillage or with minimal spillage through posterior pouch. In cases of post-hysterectomy bilateral salpingo-ophrectomy is done.
(8) Lap. Mymectomy (Fibroid)
Fibroid less than 5 cms may be asymptomatic, may not be required to be removed. Fibroid with Menorrhagia, dysmenorrohea, pressure symptoms, Infertility required to be removed. Expert TVUSG with Color Doppler should be done to exclude Adenomyosis.Patient must be counseled for the possibility of adenomyosis before fibroid surgery. Fibroid mapping should be done before surgery to access during them during surgery. Sub mucus fibroid is approached hysteroscopically. Video helps in conveying the quality of Mymectomy we have done, especially adequate laparoscopic suturing helps us about scar integrity and safety in next pregnancy after Mymectomy. Adequate homeostasis & copious irrigation with ringer lactate helps in preventing post-operative adhesions. This surgery requires lot of experience & expertise. Patient can be discharged on the same day.
(9) Hysteroscopic Sub mucus Fibroid Resection
Hysteroscopic resection of sub mucus fibroid is the gold standard treatment all over the world. One must evaluate its intra-cavitary & intramural portion before surgery –As more than 50% intramural fibroid may be required to be removed in 2-3 sessions or by simultaneously laparoscopically depending upon the size of the fibroid. We should be very careful during surgery, especially FLUID (1.5 GLYCINE) DEFICIT SOULD BE LESS THAN 1.5 LITER to prevent TUR syndrome. S.Na level be around 135 me/L and should be measured in high risk case repeatedly. Observing clear working space helps in avoiding perforation and damage to surrounding structures during resection. This surgery requires lot of experience & expertise.
(10) T.C.R.E (Loop Resection)
Trance cervical resection of Endometrium is one of the treatment for Menorrhagia (Excessive periods), where in uterus is preserved, which gives better quality of sexual function compared to Hystrectomised patient. Advantage over other global ablation technique (Thermal ablation technique) is that it can be done in cases with menoggnaghia with more than 15 mm endometrial thickness & tissue for HPE is available to rule out malignancy. Preoperative counseling about Tubal ligation operation (future pregnancy will be dangerous-placenta accrete & increate) and about operative results: Success rate is very high; Total amenorrhea in 70% of cases & Oligomenorrhea in 95% of cases. One must be very careful in identifying 1.5 liter Glycine fluid deficit to prevent problems of TUR (Hypo-natremia) Syndrome.
(11) Laparoscopic Tubal Reversal (Anastomosis)
In event of accidental death of child in family seeks for this operation. This surgery requires lot of experience & expertise. Three chip camera & very good set up like special Needle holders and instruments are must to achieve good results. Reversal of Laparoscopic Tubal Ligation gives better results compared to Abdominal Tubal Ligation operation. Patient can be discharged within 24 hours with excellent results.
(12) Laparoscopic Burch’s for S.U.I.
Patient presents to us for distressing symptom - passing of urine on coughing or straining/laughing/weight lifting. Pre-operative assessment should be done to understand hyper mobility of mid-urethra & U-V junction and Detrusal instability should be excluded before operation. Space of Retzius is dissected easily till both cooper’s ligament is seen well. Mid-urethra & U-V junction dissected after elevating from below by assistant. Non-absorbable suture stitch is taken from mid-urethra & from U-V junction to Cooper’s ligament. Preoperative counseling is necessary for entire procedure & possible post-operative results. Laparoscopic approach has advantage of treating posterior & mid compartment defects repair simultaneously. This surgery requires lot of experience & expertise. Burch’s procedure gives better result than Kelly’s plication & needle suspension procedures. Cystoscopy is necessary to rule out possible bladder injury. Patient can be offered TVT or TOT as optional treatment as it is very easy and effective.
(13) Laparoscopic T.O.Mass
Patient presents to us for pain in lower abdomen or mass felt in lower abdomen. TVUSG or USG shows T.O.Mass of different varieties. Preoperative assessment is necessary to counsel the patient well about the procedure & possible results.
(14) Laparoscopic Adhesiolysis
PID, Tuberculosis, Endometriosis & past surgeries are the commonest causes of adhesions around pelvic genital organs. Tubercles with intestinal adhesions & adhesions all over abdomen & around liver- one should suspect Abdominal Tuberculosis. Here we must give adequate AKT before attempting Adhesiolysis. Aim of Adhesiolysis during diagnostic laparoscopy is to establish tubo-ovarian relationship. Post laparotomy adhesions are found in 20-70% of cases following various Gynecological surgeries leading to subsequent abdominal wall adhesions & posy operative pain requiring laparoscopic Adhesiolysis. Fact may inspire all patients to ask primary surgeon for not offering initial Gynaec surgery by Laparoscopic approach. Adhesiolysis is the most rewarding surgery in pain relief.
(15) Laparoscopic Vaginoplasty
Patient’s parents visits to us when their daughter does not menstruate after the age of 15-17 years of age for her fertility concern before marriage. In patient with absent uterus is evaluated for associated renal malformations. As compared to usual method (skin graft from thigh) patient’s on peritoneum is utilized for Vaginoplasty. Vaginal space is dissected in usual way after putting Folly’s catheter in urethra and rectal probe in rectum. Laparoscopic light & pnumo helps during dissection. Peritoneum is cathched with artery forcep, opened from below under laparoscopic guidance and circumferentially mobilized down till we can take tension free stitch with labia minora. Then vagina is closed with mop to prevent leakage of pneumoperitoneum and at the level of pelvic brim purse string stitches are taken to close vaginal upper end with No-1 vicryl stitch & approximating with extra corporeal stitch. This technique gives two cms wide vagina & 8-10 cms long vagina and good quality of sexual function and patient discharged on the next day & with minimum requirement of postoperative care. This surgery requires lot of experience & expertise.
(16) Laparoscopic Vault (prolapse) Repair
Patient presents to us for something coming per vaginum after the removal of uterus being done in the past along with urinary problem or problem in passing stool now. These multiple pelvic defects are identified and Anterior or Mid or Posterior compartment defects repair are done systemically to prevent reoccurrence. This surgery requires lot of experience & expertise.
(17) Laparoscopic Hysterectomy (Prev.C.S/Adnexal)
Laparoscopic approach is especially helpful with previous abdominal adhesions, previous 1/2/3/.4 LSCS, with adnexal mass & for very large uterus, Endometriosis, PID. Total laparoscopic hysterectomy is going to become popular, as we have understood pelvic floor support better. Good Bipolar cautery performance is must during LH. We believe that we can do NDVH upto 12-14 wks size uterus easily, along with laparoscopic Macall’s culdoplasty- Both utero-sacral ligaments are attached with anterior & posterior vaginal vault with non absorbable suture material after NDVH is very easy procedure & ideal way of vault support. Total Laparoscopic Hysterectomy (TLH) gives better sexual quality after operation compared to other methods. Even removal of both ovaries is safer with Laparoscopic approach. Removal of ovaries must be discussed with patient to understand menopausal protocols in future. Chances of post operative vault prolapse are less with Laparoscopic hysterectomy compared to NDVH.
(18) Hysteroscopic Septum Excision
Patient with Bed Obstetric History i.e. with H/o abortion or premature deliveries with HSG showing septum indicates the diagnosis. Laparoscopy is must before Hysteroscopic septum excision to rule out the possibility of Bi-cornuate uterus (depression on the fundus will be found during laparoscopy). Its 100% rewarding surgery in cases with BOH. Colin’s knife is used for septum excision with using pure cutting cut & simultaneously seeing both cornual ends in both directions. Procedure should be stopped once myometrium is seen or till both cornual ends are seen simultaneously. Postoperative high dose of equine estrogen (0.625 mg Premerin tab - 10 tabs/day for 1-2 months) to prevent postoperative adhesions.
(19) Hysteroscopic Bone Removal (Secondary Infertility)
Patient present to us with Secondary Infertility or for scanty period. Most of the time H/o second trimester MTP is present and responsible for bones in the uterine wall. Diagnosis is suspected from H/o and TVUSG Findings. It’s very easy operation and gives very good results after Hysteroscopic removal.
(20) Hysteroscopic Adhesiolysis (Asherman’s Synd.)
Patient present to us with amenorrhea or scanty menstruation and infertility. Hysteroscopic Adhesiolysis is the gold standard treatment all over the world for Asherman’s syndrome. Post operative high dose estrogen (10 tabs-0.625 mg –daily for one to two months) is necessary to prevent re-adhesion & endometrial growth over raw area after Adhesiolysis. Goal is to achieve clear visualization of both cornual tubal openings & triangular cavity. Adhesiolysis is done with scissor. This surgery requires lot of experience & expertise. Results are most rewarding after operation.
(21) Hysteroscopic Tubal Cannulation (ProximalTubal block)
Patient present to us with Infertility. During investigation in the form HSG or laparoscopy found to have Bilateral Cornual Tubal block. This procedure is very easy in most rewarding. In 50 to 70 % cases atleast one tube can be opened easily with this procedure.
(22) Hysteroscopic Polyp Removal (Secondary Infertility)
Patient present to us with Infertility. During TVUSG polyp is found and removed very easily hysteroscopically. Results are very good after removal.
(23) Laparoscopic Tubal Ligation
Laparoscopic Tubal ligation was the simplest operation from very beginning. In government set up it was done under local anesthesia & sedation. In private set up it was always done under general anesthesia & intubation. Severe obesity & previous scars over the abdomen were considered to be relative contraindication for laparoscopic approach in the past. With advancement and better understanding the advantages of laparoscopic surgeries, now severe obesity & previous scars over the abdomen are the most common indications for laparoscopic approach, where in we can remove omental & intestinal adhesions with abdominal wall during laparoscopic Tubal ligation operation, which may help her from relief of occasional pain due to adhesions of previous scar. Palmer’s point is the choice of site for primary 10/5 mm port, in cases of previous scar over abdomen. Through Umblicus will be the choice of primary 10 mm port, in case of severe obesity. Recording also helps in conveying the quality of loop made during laparoscopy of both fallopian tubes. In young patient with children’s age less than/around 5 years, Laparoscopic T.L. has better success rate following tubal reversal compared to abdominal T.L. in event of death of her children in future.
(24) Hysteroscopic Cu-T/Kerman’s canula Removal
Patient present to us as misplaced CU-T i.e. Cu-T thread not seen on P/S examination with TVUSG or X-ray KUB suggest misplaced IUCD. Procedure is very easy hardly takes one minute.
(25) Laparoscopic Sling operation (prolapse)
Young patient presents to us with something coming out per vaginum with or without urinary complaint and she wants to preserve her child bearing function (preserve her uterus) and desires to treat prolapse. Here Polypropylene mesh is fixed from posterior side of cervix to sacral promontory laparoscopically through tunnel created medial to Rt. Uterosacral Ligament and under laparoscopic guidance. Results are very good. This surgery requires lot of experience & expertise. Results are most rewarding after operation.
