Problems that occur with a woman's reproductive organs sometimes cannot be found by a physical examination alone. Laboratory tests, Ultrasound, X- Rays may still leave some uncertainty. Frequently, problems that cannot be discovered by routine investigations can be discovered by laparoscopy or hysteroscopy, two procedures which provide a direct look at the pelvic organs. Laparoscopy and hysteroscopy can be used for both diagnostic (looking only) and operative (looking and treating) purposes. Diagnostic laparoscopy may be recommended to look at the outside of the uterus, fallopian tubes, ovaries, and internal pelvic area, Diagnostic hysteroscopy is used to look inside the uterus. If an abnormal condition is detected during the diagnostic procedure, operative laparoscopy or hysteroscopy can often be performed to correct it at the same time, avoiding the need for second surgery.
Laparoscopy can help gynaecologists diagnose many problems including endometriosis, uterine fibroids and other structural abnormalities, ovarian cysts, adhesions, ectopic pregnancy, tubal disease, and genital tuberculosis. Many infertile patients require laparoscopy for a complete evaluation. Generally, the procedure is performed after the basic infertility tests, although the presence of pain, history of past infection or an abnormal ultrasound may signal a need to perform diagnostic laparoscopy sooner in the evaluation. Laparoscopy is usually performed as an outpatient basis, under general anaesthesia, and with minimal discomfort.
After anaesthesia, a needle is inserted through the navel, and the abdomen is filled with carbon dioxide gas. As the gas enters the abdomen, it creates a space inside by pushing the abdominal wall and the bowel away from the organs in the pelvic area allowing a view of the reproductive organs. Next, a long thin telescope (laparoscope) is inserted through the insertion in the navel. It is connected to a tiny camera which sends images to a television monitor. While looking at the monitor, the surgeon can see the uterus, fallopian tubes, ovaries, and nearby structures. A small probe is inserted through another incision in order to move the pelvic organs into clear view Additionally, a blue solution is injected through the cervix to determine if the fallopian tubes are open. If no abnormalities are noted at this time, one or nvo stitches close the incisions. The incisions are closed using an adhesive dressing, If defects or abnormalities are discovered, one can proceed to operative laparoscopy.
Many infertility disorders can be safely treated through the laparoscope at the same sitting. Operating instruments like graspers, biopsy forceps, scissors, coagulators, electrosurgical or laser instruments, needle holders and suture materials are inserted through two or three incisions in the area above the pubis. Operative procedures include adhesiolysis, treatment of blocked tubes, fulguration of endometriosis, removal of chocolate cysts, treatment of ovarian cysts, PCOD drilling, removal of diseased ovaries, removal of uterine fibroids, and treatment of ectopic pregnancy. Operations for female sterilization, hysterectomy, urinary incontinence and genital prolapse can also be performed laparoscopically.
Hysteroscopy is an important tool in the study of infertility, recurrent miscarriage, or abnormal uterine bleeding. Diagnostic hysteroscopy is used to examine the inside of the uterus, also known as the uterine cavity (figure 3) and is helpful in diagnosing abnormal uterine conditions such as polyps, internal fibroids, scarring, and developmental abnormalities. A hysterosalpingogram (an x ray of the uterus and fallopian tubes) may be performed before a diagnostic hysteroscopy. Diagnostic hysteroscopy is usually conducted on an outpatient basis with either general or local anesthesia. For infertility evaluation the hysteroscopy and laparoscopy are combined together usually soon after menstruation because the uterine cavity is more easily evaluated and there is no risk of interrupting a pregnancy.
After dilating the cervix (mouth of the uterus) with a series of dilators, a narrow telescope (hysteroscope) is passed through the cervix into the uterine cavity. Special clear solutions are then injected into the uterus through the hysteroscope sheath. This distends the uterine cavity, clears blood and mucus, and allows the gynaecologist to directly view the internal structure of the uterus.
A wider hysteroscope allow operating instruments such as scissors, biopsy forceps, graspers, electrosurgical or laser instruments to be introduced into the uterine cavity through a channel in the operative hysteroscope. Fibroids, polyps, adhesions can be removed from inside the uterus. Congenital abnormalities, such as uterine septum, can also be corrected through the hysteroscope. After surgical repair, a Foley catheter or intrauterine device may be placed inside the uterus to prevent the uterine walls from fusing together. Antibiotics and/or hormonal medication may also be prescribed after uterine surgery to prevent infection and stimulate healing of the endometrium (uterine lining).
Serious complications of diagnostic and operative laparoscopy are rare. Allergic reactions and anaesthesia complications rarely occur. The major risk is damage to the bowel, bladder, ureters, major blood vessels, or other organs, which would require immediate laparotomy to repair the injury. Injury can also occur during the insertion of various instruments through the abdominal wall or during operative treatment. Certain conditions may increase the risk of serious complications. These include previous abdominal surgery, presence of bowel or pelvic adhesions, severe endometriosis, obesity or excessive thinness. In experienced hands the risk of injury is 2-3 per 1000 procedures. The risk of death during laparoscopy is 1-2 per 100000 procedures, is less than the risk of death during pregnancy. Complications of hysteroscopy are rare and seldom serious. Perforation of the uterus (hole in the uterus) is the most common complication, but the hole usually heals on its own. Some complications related to the liquids used to distend the uterus include fluid overload, pulmonary edema (fluid in the lungs), blood clotting problems, and severe allergic reactions. Complications related to the surgical procedure include damage to intra-abdominal organs and hemorrhage. Severe or life threatening complications, however, are very uncommon.
After Laparoscopy / Hysteroscopy, the patient is allowed to rest for 2 - 4 hours to recover from the anesthesia. She is allowed liquids after 4 hours and soft diet in the evening. After the operation, the patient may feel some discomfort:
Most of these minor complaints are gone in a day or two after surgery.
The procedure is done under local or general anaesthesia. A tiny telescope is inserted into the uterus to observe the cavity. It allows viewing of the inner lining of the uterus (endometrium), shape, size, and diagnose intrauterine problems such as adhesions, septum, polyps or fibroids. If an abnormal condition is detected during the diagnostic procedure, operative hysteroscopy can often be performed to correct it at the same time, avoiding the need for second surgery.
A Polyp is a benign growth from the endometrium, It causes menstrual irregularities, heavy bleeding or infertility. It can be removed by cutting the stalk with scissors or shaved into pieces using an electric instrument called the resectoscope which is introduced into the uterus through the cervix.
Adhesions are fibrous or vascular strands that cause the uterine walls to stick to each other. In severe cases the cavity can be completely obliterated. They cause scanty menstruation, amenorrhoea (absent menses), recurrent miscarriage or infertility. Removal of the adhesions is called adhesiolysis. They can be cut using scissors or electric current through an operative hysteroscope.
Fibroids projecting in the uterine cavity (sub-mucous myomas) can cause heavy menses, pain, dysmenorrhoea, recurrent miscarriage or infertility, They can be removed using the resectoscope by shaving the myomas into small pieces and removing them through the cervix.
Alterations in the size, shape and capacity of the uterus can occur due to congenital (uterine septum, T-shaped, hypoplastic uterus) or acquired (previous infection, previous surgery) conditions. Metroplasty is a procedure where using operative techniques the uterus is restored to its normal size, shape or capacity.
Tubal blocks can be due to mucous plugs, debris or thin membranes covering the tubal ostia. A fine catheter can be guided through the hysteroscope to open these blocks.
Foreign Body Removal
Misplaced or broken IUCD's or fetal bones from previous abortions can be retained in the uterine cavity. They can cause irregular bleeding or infertility. A forceps or grasper can be used to remove these objects using an operative hysteroscope.
The procedure is done under general anaesthesia. A thin telescope is inserted through the umbilicus (belly button) to look at the outside of the uterus, fallopian tubes, ovaries, and internal pelvic area. If an abnormal condition is detected during the diagnostic procedure, operative laparoscopy can often be performed to correct it at the same time, avoiding the need for second surgery.
Adhesions are fibrous or vascular strands that stick pelvic organs like uterus, tubes, ovaries and bowel. They result from previous infection or surgery. Although in most cases, adhesions are innocuous, they can cause pain, dyspareunia and infertility. Removal of the adhesions is called adhesiolysis. They can be cut using scissors, electric current or laser.
A polycystic ovary is a condition in which the ovaries are bulky due to multiple (8 20) tiny follicles in the ovary, diagnosed by ultrasonography. They suffer from infrequent menses, irregular menses, obesity, hirsuitism (excessive facial and body hair), and infertility. In patients wishing to conceive, when medical treatment fails, laparoscopic drilling of ovaries is performed. A needle is used to drill multiple holes on the ovarian surface using high frequency current. The procedure leads to fall in hormone levels, normalization of menses and improved fertility.
Cysts in the ovary could be due to hormonal imbalance or tumor process. Majority of them are benign (non-malignant). In young women wishing to preserve fertility, the cysts can be treated laparoscopically by performing cystectomy (removal of the cyst lining). The normal ovarian tissue is preserved. The lining is put in a endobag and removed from the abdomen.
Ovarian cysts or tumors which involve the entire ovary or when they occur in elderly women (fertility preservation not required), are treated by oophorectomy (removal of the entire ovary).
Laparoscopy is ideally suitable for endometrisis surgery as diagnosis, staging of the disease and treatment can be performed in a single setting. It causes pelvic pain, menstrual pain, painful intercourse or infertility. The surgery can be fertility preserving/ enhancing in younger women who wish to conceive or preserve fertility or radical in older women who do not wish to conceive. Read Endometriosis - treatment options
Fibroids are common tumors in the reproductive age group, occurring in 20 - 25% of women. Although they are asymptomatic in most women, they may cause pain, heavy menstruation, pressure symptoms, infertility or recurrent miscarriage. In symptomatic patients removal of the fibroids (myomectomy) can be performed laparoscopically. The surgery involves removal of the fibroid from the uterus, reconstruction (suturing the defect) and removal of the fibroid from the abdomen by morcellation (reducing the fibroid into small chunks using a special instrument).
Pregnancy occurring in any site other than in the uterus is called Ectopic. The commonest site for ectopic pregnancy is the fallopian tube. Tubal ectopic pregnancy can cause pain, and internal bleeding following tubal rupture leading to shock or even death. If diagnosed early, it can be treated by laparoscopy. Salpingotomy (incision of the tube to remove the pregnancy) or Salpingectomy (removal of the tube) can be performed.
Removal of the fallopian tube (Salpingectomy) may be required when it is diseased due to infection or a cause of pelvic pain.
Removal of the fallopian tube and the ovary may be required when they are diseased due to infection or tumor.
Removal of the appendix
Repair of Genital Prolapse
The pelvic organs can be displaced from its normal position due to injury during delivery or weakening of pelvic supports due to ageing or menopause. Genital prolapse can cause backache, discomfort, urinary and bowel symptoms. Pelvic reconstruction can be performed to repose these organs to their normal position.
Removal of the uterus may be required in patients suffering from menorrhagia (hea\.y menstruation), adenomyosis, fibroids, genital infection, malignancy or prolapse. Read Understanding Hysterectomy. Previously, diagnosing and treating gynecological problems required major surgery and many days of hospitalization. However, laparoscopy and hysteroscopy allows correction of these problems on an outpatient basis. The procedures decrease patient discomfort, significantly reduce recovery time and has minimal risks.