Gynecological laparoscopy is an alternative to open surgery
In order to perform open abdominal surgeries, surgeon makes a cut which is large enough to have adequate visibility, access to the abdominal organs and allow the use of hand-held surgical instruments. Depending on the size of the patient and the type of operation, the cut may be 6 to 12 inches in length. There is a significant amount of discomfort associated with these cuts .They have more blood loss,prolonged hospitalstay, and longer recovery time post-surgery. These traditional techniques have long been used and taught to generations of surgeons, they are widely available.
Laparoscopic surgery refers to a technique where the surgeon makes several small cuts about half an inch in size, instead of a single large incision. For major surgeries, 3-4 cuts are needed. Small tubes are placed through these cuts and into the abdomen. Carbon dioxide gas is used to fill the abdomen so that the surgeon has room to work. With this, the surgeon uses a camera (which can be single chip,3 chip, High definition and 3 D cameras) attached to a thin metal telescope ( laparoscope) to watch a magnified view of the abdomen on monitors. Special instruments are passed through the trocars to take the place of the surgeon’s hands and traditional surgical instruments.
Large fibroids laparoscopic removal is possible
Now a day’s lot of women suffering from menstrual disorders like heavy and prolonged bleeding, painful Periods are found to have large fibroids in uterus, most of them would not know of large size until they develop symptoms of bowel and bladder disturbance. Earlier such women had to undergo open surgery involving large cut on the lower abdomen either to remove fibroid (Myomectomy) or remove uterus (Hysterectomy) depending upon their age and fertility status.
A 46 Year old housewife in Bangalore was diagnosed to have fibroids in 2004, but she was reluctant to Undergo treatment. (Which was due to bad experience for treatment of rheumatoid arthritis and Diabetes)). She was seen in Koramangala Beams Hospital laparoscopic surgery centre, OPD for Swelling in the umbilicus (Large umbilical hernia). She gave a history of heavy and prolonged bleeding during cycles for long duration. On evaluation she was found to have a large uterus (about 7-8 months Pregnant uterus size and umbilical hernia). She was anaemic with about 6g Hemoglobin (Normal 12-14) and was also found to be diabetic. Uterus of 2.58 kg weight was removed by laparoscopic method using specialequipment’s to control bleeding and to extract the large uterus piecemeal through small holes and hernia repair was done.
Advantages of laparoscopy over open surgery
Small incision- less pain and short recovery time, wounds heal quickly. There is less scarring with bettercosmesis.
The pain is less. So less administration of pain medication.
Reduced bleeding and need of blood transfusion is negligible.
2-3 days stay in the hospital after surgery. Few are discharged on the same day. This enables the patient to return to normal routine life quickly.
There is reduced chance of infections & contaminations.
Dermoid cyst ovary
Dermoid cyst ovary- Bizarre type of thick walled cyst typically contains a variety of tissues including hair, teeth, bone, thyroid, nail etc develops in the ovary, usually nonmalignant. These growths are common in a woman during reproductive years. They can cause torsion, infection, rupture, andcancer. A dermoid cyst develops from a totipotential germ cell (a primary oocyte) that is retained within the egg sac (ovary) which can mature to all types of cells and form hair, bone, neural tissue etc. They grow from few cm to as big as 15 cm. The large majority (about 98%) of these tumors are benign, the remaining fraction (about 2%) becomes cancerous (malignant).
Symptoms of dermoid cyst
Most of them do not have any symptoms, symptoms include
- Abdominal pain with radiation to legs
Abnormal vaginal bleeding.
Difficulties in urinating if the cyst puts pressure on the bladder.
If it undergoes torsion severe pain abdomen with nausea and vomiting
Diagnosis of dermoid ovarian cyst
As most cysts are asymptomatic they are diagnosed when patient has routine health check or Ultrasound for some other problem.
Treatment for ovarian dermoid cyst
Depends on size, symptoms and age of the patient.Very rarely if the cyst has grown very huge they come with emergency with torsion of ovary
Cystectomy- removal of cyst wall only preserving ovary for future fertility.
Oophorectomy- if cyst is huge, if suspicious of cancer, and completed family
Endometriosis is a disorder in which cells that normally lines the inside the uterus the endometrium grows outside your uterus.It is common in reproductive age 25-35 years. It most commonly involves ovaries, fallopian tubes and the tissue lining your pelvis. Sometimes endometrial tissue may spread beyond pelvic organs.
When endometriosis involves the ovaries, cysts called endometriomas or chocolate cyst because it is chocolate color. When it forms in the uterine musculature it is called adenomyosis, when it forms on previous scar called scar endometriosis.
Symptoms of endometriosis
Common signs and symptoms of endometriosis may include:
- Painful periods (dysmenorrhea).
- Pain with sex
- Pain with bowel movements or urination
- Excessive bleeding especially in adenomyosis
- Infertility- 30-40 % will have difficulty in conception
- Other symptoms.You may also experience fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.
Although the exact cause of endometriosis is not certain, many possibilities are suspected
Several factors place you at greater risk of developing endometriosis, such as:
- Never giving birth ( Nulliparous)
- Period at an early age
- Menopause at an older age
- Short menstrual cycles ex- less than 27 days
- Having higher levels of estrogen in your body or a greater lifetime exposure to estrogen
- Low body mass index- thin tall ladies
- Alcohol consumption
- Family history (mother, aunt or sister) with endometriosis
- Any medical condition that prevents the normal passage of menstrual flow out of the body
- Uterine abnormalities
Recommendation is conservative approaches first, opting for surgery as a last resort. Treatment options are with medications or surgery depend on the severity of your signs and symptoms and weather planning for conception. Options are
If patients are young and planning for conception, surgery to remove as much endometriosis may increase your chances of success done with laparoscopy (keyhole surgery)
Assisted reproductive technologies
Assisted reproductive technologies, if conservative surgery doesn’t work.
In severe cases of endometriosis with severe symptoms who has already completed the family, failed other methods of treatment, surgery to remove the uterus as well as both ovaries is the best treatment.
Because the cause of endometriosis is poorly understood, there are no known ways to prevent its development.
Recurrence rate varies with the severity endometriosis, methods of surgery, skills of the surgeons who performed the surgery, weather post-operative suppressive therapy given or not to eliminate residual endometriotic cells. The most recent studies have shown that endometriosis recurs at a rate of 20% to 40% within five years following conservative surgery.
A Hysterectomy is a surgical procedure to remove a womens uterus (womb)
Why hysterectomy is done
- Uterine Fibroids.
- Pelvic support problems(Prolapse)
- Abnormal uterine bleeding.
- Chronic pelvic pain.
- Gynecologic cancer.
Total hysterectomy- The whole uterus along with the cervix is removed
Subtotal/supra cervical/partial hysterectomy-Only the uterus is removed leaving the cervix, which can be performed abdominally (Open) or laparoscopically.
Radical hysterectomy- It is done for the cancer, where the whole uterus, cervix, tubes, ovaries, surrounding tissues of uterus, cervix and upper part of the vagina is removed.
Surgical technique for the hysterectomy Surgeons use different approaches for hysterectomy. The hysterectomy technique will partly determine healing time and the kind of scar.
There are two approaches to surgery – a traditional or open surgery and surgery using a minimally invasive procedure
Abdominal hysterectomy -is an open surgery. It generally requires a large cut on the abdomen 6-10 inch, which requires long hospital stay and recovery time.
Laparoscopic hysterectomy involves a few small (about half inch long) cuts in your abdomen. A laparoscope (Long instrument with attached camera and light)inserted through one of these cuts allows the surgeon to see the pelvic organs. Other surgical instruments are used to perform the surgery through separate small incisions.
A robot-assisted laparoscopic hysterectomy is performed with the help of a robotic machine controlled by the surgeon.
In a vaginal hysterectomy, the uterus is removed through the vagina. There is no abdominal incision. Not all women are able to have a vaginal hysterectomy. For example, women who have adhesions from previous surgery or who have a very large uterus may not be able to have this type of surgery.
Hysterectomy recovery time
It takes two to three weeks for laparoscopic hysterectomy and four to six weeks for abdominal hysterectomy. Compared with abdominal hysterectomy, laparoscopic hysterectomy results in less pain, has a lower risk of infection, and requires a shorter hospital stay. You may be able to return to your normal activities sooner.
- Fever and infection
- Heavy bleeding during or after surgery after a hysterectomy, you’ll experience some vaginal bleeding and discharge. This will beless discharge than during a period, but it may last up to six weeks. If you experience heavyvaginal bleeding, start passing blood clots, or have a strong-smelling discharge.
- Injury to the urinary tract or nearby organs more common in those with multiple previous open surgeries
- Blood clots in the leg that can travel to the lungs
- Breathing or heart problems you may be at greater risk of problems related to anesthesia.
- Complications rate is same either we do laparoscopy or open surgery.
LAPAROSCOPY FOR INFERTILITY
Laparoscopic surgery to help in diagnosing a cause for infertility. Usually, it’s performed only after other infertility testing has been completed and initial treatment methods for infertility has failed.
Female infertility – accounts for 35-40 per cent of all fertility problems, probable causes can be
Ovulatory cause-Any condition (usually hormonal) that prevents the release of a mature egg from an ovary. Common one is polycystic ovaries-Patients whose ovaries contain many small cysts, have hormone imbalances and do not ovulate regularly. Laparoscopy helps to puncture ovarian cysts.
Endometriosis- Condition, in which endometrial tissue (the uterine lining that sheds with each monthly period) grows outside the uterus, is a major cause of infertility in women .Laparoscopy helps for removal of ovarian cysts and endometriomas with reconstruction of the ovary to a fully functional state.
Female tubal blockage- Blocked or damaged fallopian tubes prevent eggs from getting to the uterus and sperm from getting to the egg. Leading cause is pelvic infection. Laparoscopy helps to evaluate the tubes for patency and ovaries and also removal of scar tissue around the tubes and ovaries and opening blocked tubes (tuboplasty).
Ovarian cyst is a fluid filled sac, surrounded by a very thin wall, within an ovary. Most (about95%) are harmless and occurs during the reproductive years at any age.
Ovarian cyst size varies from small 2-3 cm like almond to big as watermelon
Types of ovarian cysts
Functional cysts– most common and form the part of normal menstrual type and short lived examples are follicular cyst and corpus luteal cyst
Complex ovarian cyst (Pathological cysts) – these are cysts that grow in the ovaries, they may be harmless (benign) or cancerous (Malignant) examples are Dermoid cyst, endometriotic cyst, cystadenomas.
Malignant cyst (cancerous)
Ovarian cyst causes
- Hormonal problems. These are usually functional cysts and disappear without treatment. They may be caused by hormonal problems or by drugs used to help you ovulate.
- Endometriosis.This condition causes uterine endometrial cells to grow outside your uterus. They can grow in the ovary to form cyst
- Severe pelvic infections.Infections can spread to the ovaries and fallopian tubes and cause cysts to form
- Pregnancy.An ovarian cyst normally develops in early pregnancy to help support the pregnancy until the placenta forms. Sometimes, the cyst stays on the ovary until later in the pregnancy andmay need removal.
- History of previous cyst in the ovary
Ovarian cyst symptoms
- Ovarian cyst pain can be mild to severe in the lower abdomen
- Fullness in the abdomen
- Pain during or after menstrual periods
- Irregular periods and Infertility
- Urinary or Bowel disturbance
Diagnosis of ovarian cysts
Ovarian cysts are usually diagnosed by either ultrasound or CT scan
Blood test- blood tests like CA 125 will be elevated in certain types of ovarian cancer
Ovarian cyst treatment-
Ovarian cyst treatment depends on the type of the cyst, age of the patient, she has completed her family or not, size of the cyst and symptoms.
- Observation– this is recommended, especially if the cysts are simple, small and if she in reproductive age, repeat scans are done to assess further.
Ovarian cyst removal
- 2. Laparoscopic ovarian cystectomy– (key hole surgery)-In this cysts can be removed through small incision. Even large cysts can also be removed by this depending on the type of the cyst. In most of the case they can go on the same day. This type of the surgery does not usually affect a women fertility and recovery time is much faster.
- Open surgery– This is more serious operation and may be recommended if the cyst is cancerous. A longer cut is made giving the surgeon better access to the cyst. Cysts are removed and sent to the lab.
An ovarian cyst often causes no problems, but sometimes it can lead to complications.
- Ovarian cyst torsion: The stem of an ovary can become twisted if the cyst is growing big especially in dermoid and cystadenomas. It can block the blood supply to the cyst and cause severe abdomen pain, vomiting, sometime if left alone without intervention it can cause ovarian tissue death.
- Ovarian cyst Burst (Ovarian cyst rupture): Cyst can rarely rupture because of vigorous activity and sex causing severe pain and internal bleeding.
- Cancer: In rare cases, a cyst may be an early form of ovarian cancer.
Ovarian cysts during pregnancy.
Ovarian cysts occasionally develops during pregnancy. In most cases, they are simple cyst and does not need intervention. Surgery may be indicated if there is torsion, rupture, if suspicious ofmalignancy or if the size of the cyst is likely to present problems with the pregnancy.
Can Surgery Be Performed On Pregnant Women
As the risks of surgery and undergoing anesthesia are higher for pregnant women, surgery is only usually performed when the cyst has grown huge which is causing symptoms like pain, for torsion or if any suspicious of malignancy. The procedure is carried out by laparoscopy and ideally should be done in the second trimester of pregnancy.
Fibroid in uterus
Fibroids in the uterus are non-cancerous growth from muscle layer of the uterus, affecting 30-40 % of women of 30-50 year age group. It is one of the commonest cause of hysterectomy under 50 years.
There is no specific risk factors that promote formation of fibroids have been identified, but it has shown to some extent its growth depends on estrogen. They have shown increasing size in reproductive age, during pregnancy and usually regress following menopause. Risk has shown high in those who is never pregnant, family history of fibroids and In African population
Most of fibroids do not cause symptoms.
Heavy and prolonged bleeding during periods.
Abdominal heaviness, back pain and abdomen pain, abdomen can get enlarged if its big.
Pressure symptoms like constipation, frequency of urination and Difficulty in emptying
Fibroids can cause difficult in conception, miscarriage, and abnormal position of the baby, obstruction during the delivery requiring cesarean and bleeding during and after delivery.
Uterine fibroids are usually found during a routine pelvic exam. If you have symptoms of uterine fibroids, doctor will recommend the following tests.
Ultrasound.To diagnose the fibroid, location, size and number.
If routine ultrasound doesn’t provide enough information, your doctor may order other imaging studies, such as:
- Magnetic resonance imaging (MRI).This imaging test can show the size and location of fibroids, identify different types of tumors, malignant changes and help determine appropriate treatment options.
- Hysterosonography,also called a saline infusion sonogram, uses sterile saline to expand the uterine cavity helps to diagnose submucosal fibroids ( Fibroids protruding in the uterine cavity)
- Hysterosalpingography, uses a dye to highlight the uterine cavity and fallopian tubes helps to diagnose submucosal fibroid and fallopian tube patency
- Small, lighted camera called a hysteroscope passed through your birth passage into your uterus to examine the walls of your uterus and the openings of your fallopian tubes.
If your fibroids are not bothering you, you do not need to do anything about them. Your doctor will check them during your regular visits to see if they are increasing or remaining same size, only 10-20% of them need treatment.
Many women with uterine fibroids experience no signs or symptoms, or only mildly annoying signs and symptoms that they can live with. If that’s the case for you, watchful waiting could be the best option.
Medications for uterine fibroid targets hormones that regulates your menstrual cycles, they dont eliminate the fibroids, they shrink it temporally helps to postpone the surgery.
MRI guides focused ultrasound Non Invasive high energy ultrasound waves given after localizing the fibroid.
Embolization of fibroids-Particle are injected in to the arteries supplying uterus cutting the blood supply of the fibroid resulting in shrinkage of fibroids, shrinkage of fibroids is slow and may take up to 3 months
Surgical- Surgical removal of fibroids or uterus is the definitive treatment options for fibroids.
Minimally invasive procedures (laparoscopy)
In order to perform open surgeries, surgeon make cut large enough to have adequate visibility, depending on the type of surgery 6-12 inch length. There will be more discomfort associated with these cuts, needs more hospitalization and blood loss , long recovery post-surgery.
In Laparoscopic surgery where surgeon makes small 3-4 cuts about half an inch instead of large cut. Small tubes are placed through these cuts and carbon dioxide is used fill the abdomen so surgeon will have more room to operate. Surgeon uses camera (recently even we have High definition and 3D cameras) to have magnified view, and other special instruments are passed through tubes to operate.
Laparoscopic myomectomy- Laparoscopic myomectomy in young patients who wants to conserve uterus for future fertility. In myomectomy surgeon removes fibroid leaving uterus in place.
Morcellation a process of breaking fibroids into smaller pieces and taking out fibroid from abdomen if the fibroid has cancerous changes may increase the risk of spreading cancer, there are several ways to reduce that risk, such as evaluating risk factors before surgery, newer technique of morcellating the fibroid in a bag.
Hysteroscopic myomectomy- This is an option in case if fibroids are inside the uterine cavity, camera is passed from birth passage to uterine cavity and fibroids are removed.
Laparoscopic hysterectomy- removal of uterus who have completed the family who doesnt want to conserve the uterus.
Many of the patients seek alternative treatments, such as specific dietary recommendations, magnet therapy, black cohosh, herbal preparations or homeopathy. So far, there’s no scientific evidence to support the effectiveness of these techniques.
Although many research are going to know the causes of fibroid tumors, no scientific evidence is available on how to prevent them, because the cause of fibroids is poorly understood, there are no known ways to prevent its development, but only a small percentage of these tumors require treatment. But, by making healthy lifestyle choices, like maintaining a normal weight and eating fruits and vegetables, you may be able to decrease your fibroid risk.