Textbook Of Gynecology. Dc Dutta’s

Chapter 35. Endoscopic Surgery in Gynecology (Syn: Minimally invasive surgery, Minimal access surgery)

The range of surgical procedures in gynecology, performed with the use of either a laparoscope or a hysteroscope is designated as endoscopic surgery. With very fast technological advancement, as much as 80 percent of gynecological operations can be performed endoscopically.

HistoryFirst description of endoscopy is recorded by Phillip Bozzini in 1805. He used a simple tube and candle light to visualize the interior of the urethra. Pantaleoni of Ireland first used a cystoscope in 1869 as an hysteroscope to diagnose a case of irregular vaginal bleeding. Jacobaeus of Sweden in 1910 first introduced a cystoscope in the peritoneal cavity and coined the term laparoscopy. In 1938, Veress first reported the spring loaded needle for creating pneumothorax in patients with tuberculosis. In 1947, Raoul Palmer of France introduced the use of gaseous distension of the peritoneal cavity using gas and the lithotomy (Trendelenburg) position. Landmark progress of the use of “Coldlight” and fiberoptics were made by Fourestier and others. In 1967 Steptoe of England first published the monograph “Laparoscopy in Gynaecology” in english language. Kurt Semm of Germany is credited for his advanced operative laparoscopic procedures (myomectomy) in the 1970s. First laparoscopic hysterectomy was reported by Reich et. al in 1989.

Advantages of Laparoscopic Surgery

♦ Rapid postoperative recovery.

♦ Less postoperative pain and reduced need of postoperative analgesia.

♦ Shorter hospital stay and reduced concomitant cost

♦ Quicker resumption of day-to-day activity

♦ Less adhesion formation

♦ Minimal abdominal scars (cosmetic value)

♦ Reduced blood loss

♦ No large incisions

♦ Less risk of incisional hernia

♦ Increased patient’s satisfaction.

Fig. 35.1: Laparoscopic view of a normal pelvis showing uterus tubes, ovaries, round ligament (Rt), uterosacral ligments and the pouch of Douglas (Courtesy: Prof. Alka Kriplani, Dept. Ob-Gyn., AIIMS, New Delhi)

Disadvantages

Disadvantages are mainly related to case selection and experience of the surgeon:

• Operation time—may be longer

• Risk of iatrogenic complications (see p. 619)

• High initial expenditure

• Surgeon needs specialized training and expertise

• Long learning curve

• Instruments and equipments are sophisticated

• Complications are specific to laparoscopy and may be fatal.

BASIC INSTRUMENTS AND ELECTROSURGICAL UNITS FOR LAPAROSCOPIC SURGERY (FIG. 35.2)

♦ Telescope—Caliber varies from 4-12 mm with rod lens system. Angle of view may be either straight forward (0°) or fore oblique (30°).

♦ Veress needle—It is used for creating pneumoperitoneum by carbon dioxide. It is spring loaded to prevent visceral injury. The blunt tip point springs out when it enters the peritoneal cavity.

♦ Trocar and cannula—is inserted through the abdominal wall following pneumoperitoneum. The trocar is removed and the telescope is introduced through the cannula (sleeve). Disposable trocar and veress needles are available.

♦ Light source—High intensity light (xenon or halogen source) beam (cold light) is transmitted to the telescope for excellent visualization. Fiber optic cables are used to transmit the cold light from source to the telescope.

♦ Imaging system includes: Laparoscope, light source, fiber optic cord, camera unit and monitors.

♦ Camera unit includes: Camera head, cable and camera control. The camera head is attached to the eye piece of the laparoscope. The image resolution depends on the number of pixels (2,50,000 - 3,80,000) on the chip. High definition digital camera uses resolution up to 1,100 lines to produce more vivid picture.

• Monitor: High resolution color monitors with 700 lines provide optimal picture visualization.

• Insufflator: The rate of gas flow rate (L/min) and intra-abdominal pressure (mm of Hg) are displayed on the insufflator. It is used to create controlled pneumoperitoneum as there is some amount of gas (CO2) leak through the different ports. Either low flow rate (0.5-1 L/min) or high flow rate is used depending on the need.

Accessory Instruments (Fig. 35.3)

♦ Scissors of different sizes and designs are used for dissection and to cut tissue.

♦ Grasping forceps of different designs with are used to hold tissues.

Fig. 35.3: Ancillary instruments: A. Scissors; B. Bowel grasper; C. Myoma screw; D. Bioplar coagulating forceps; E. Grasping forceps (alligator jaws); F. Grasper (Babcock); G. Dissecting and grasping forceps.

Fig. 35.2: Laparoscopic instruments: (A) Telescope (B) Trocar and cannula (C) Veress needle

♦ Probes Blunt probe is used for manipulation of visceras (e.g. intestines and ovaries) to visualize other structures.

♦ Aspirator and irrigator Blunt and sharp aspirators are used for aspiration of fluid from the peritoneal cavity or ovarian cysts. Irrigation is done for washing the peritoneal cavity with normal saline at the end of a surgical procedure.

♦ Morcellator is needed when a large piece of tissue (myoma) is morcellated into small pieces so as to be removed through the laparoscopic sleeve.

♦ Uterine manipulator is used for adequate visualization of the uterus and adnexae during operation.

♦ L-hook for cutting tissues using monopolar energy.

♦ Myoma screw—for myomectomy (laparoscopic modification (Fig. 35.3C).

♦ Specimen retrieval bag.

HEMOSTASIS DURING LAPAROSCOPIC SURGERY

Perfect hemostasis is mandatory at the end of any endoscopic surgery.

Electrocoagulation: Electrosurgical units are used for cutting and coagulation of biological tissues. Cutting mode provides uninterrupted low voltage to vaporize tissues (100oC). Lateral thermal spread is minimal. Coagulation mode creates peak voltage three times higher than of cutting made. It causes rapid tissue desication and carbonization. In blended mode cutting and coagulation currents are combined creating alternate high and low voltage current.

Monopolar Electrosurgery: The current (electrons) is pushed from the generator through the active electrode to the contact tissue. The current returns back to generator through the neutral electrode after it has passed through the patient.

It is important to check the return electrode is in good contact with the patient. It should be broad enough to reduce the current density far below the level of tissue burning.

Depending upon the size of the electrodes (current density) and voltage used, unwanted burns may be produced due to stray current flow.

Bipolar Electrosurgery: Here the current flows from the generator between the two jaws of the forceps or scissors, holding the target tissue (Fig. 35.6). There is no need for ground plate. Bipolar energy is very effective for hemstasis. It works by conducting electrical current with high power density that is confined between the jaws of the forceps. It has limited lateral thermal spread, low contact temperature and high compressive effects. Damage to tissue is more precise compared to unipolar mode.

Laser Coagulation (see p. 123): Lasers used in gynecological surgery are CO2, KTP-532 and Nd: YAG lasers. For effective cutting, vaporization and coagulation of tissue, power density is an important factor. The depth of tissue penetration depends on the type of laser used, e.g. for CO2 (most commonly used) 0.1 mm, KTP-532— 0.4-0.8 mm and Nd: YAG is 0.6-4.2 mm (see p. 123).

LigaSure is a bipolar electrosurgical device used to cut, vaporize, coagulate and seal blood vessels. It delivers electrical energy as high current and low voltage output. The problem of sticking and charring to tissues are less. Lateral thermal spread is also less. It seals blood vessels, up to 7 mm in size.

Enseal Vessel Fusion is a bipolar system that deliver a locally regulated current. Tissue temperature remains within 120oC as there is generation of resistance in the plastic jaws of the instrument. The device has a mechanical blade that can be advanced gradually to desiccate and cut tissue bundles.

Harmonic scalpel: It is an ultrasound energy source to break hydrogen bonds in tissues. It uses vibration at the rate of 55,000 cycles per second. Hormonic Ace (Ethicon) has minimal lateral thermal injury. This is effective in cutting or coaptation (sealing) of vessels upto 4 mm diameter. There is no risk of electrical injury.

Mechanical Clips and Staples: Titanium clips and staples are used for hemostasis by securing blood vessels. Disposable stapling cartridge with a selfcontained knife blade (Endo GIA 30) is used for laparoscopic hysterectomy producing quick cut and hemostasis.

Sutures and Ligature: Like an open surgery sutures can be used to ligate blood vessels and to secure vascular pedicles. Different methods of suturing and knot tying are used: (a) intra-corporeal knot tying,

(b) extra-corporeal knot tying or (c) endoloops pretied ligature (Roeder loops).

INDICATIONS OF LAPAROSCOPIC SURGERY

Advances in electrosurgical units, optics, technology, instrumentation and video imaging have widened the area of endoscopic surgery day-by-day. The laparoscopic surgical procedures are graded according to the extent of surgery and also to the competence of the surgeon. They are labelled as follows:

A. Diagnostic laparoscopy (see p. 121)

B. Therapeutic (operative) laparoscopy

■ Minor procedures

♦ Tubal sterilization (see p. 496, Fig. 35.8).

♦ Adhesiolysis (without bowel involvement) (Fig. 35.7)

♦ Aspiration of simple ovarian cysts.

♦ Ovarian biopsy.

Fig. 35.4: Laparoscopic linear salpingostomy for unrputered tubal ectopic pregnancy—(a) Linear incision on the antimesenteric border (b) Gestation sac is removed (C) Incision margins left unsutured. Left: Operation and Right: Schematic

■ Moderate procedures (Fig. 35.4)

Ectopic pregnancy:

♦ Salpingostomy—(Fig. 35.4)

♦ Segmental resection

♦ Salpingectomy

♦ Salpingo-oophorectomy

Endometriosis: Ablation by diathermy or laser.

Ovary

♦ Diathermy for PCOS (Fig. 35.6)

♦ Drainage of endometriomas

♦ Ovarian cystectomy

♦ Salpingo-ovariolysis (Fig. 35.7).

Uterus

♦ Myomectomy

♦ Laparoscopic assisted vaginal hysterectomy (LAVH)

♦ Adhesiolysis - including bowel involvement (Fig. 35.7)

■ Extensive procedures

♦ Major endometriosis

♦ Myomectomy

♦ Retroperitoneal lymphadenectomy

♦ Hysterectomy

♦ Urinary incontinence

♦ Sacrocolpopexy.

Contraindications (Table 35.1)

One should be familiar with the contraindications to maximize the patient safety and minimize the procedure related morbidity.

OPERATIVE PROCEDURES FOR LAPAROSCOPY

Preoperative screening is essential and contraindications are excluded (see Table 35.1). Informed consent is taken and it should include the permission for open surgery if necessity arises. General anesthesia is generally preferred. There is significant hemodynamic changes during laparoscopy due to—(a) raised intra-abdominal pressure (CO2 insufflation), (b) head-down position, (c) lung compression due to pneumoperitoneum and bradycardia due to vagal stimulation (visceral manipulation). Cardiac output may fall by 10-30 percent. Procedures like sterilization could be performed under local anesthesia. The operating table should have the facilities for rotating at different angles. Low lithotomy position of the patient with buttocks protruding slightly from the edge of the table is used.

SURGICAL TECHNIQUES

♦ Patient positioning

♦ Production of pneumoperitoneum

♦ Introduction of trocar and cannula

♦ Introduction of laparoscope

♦ Creation of accessory ports

♦ Surgical procedures to carry out

♦ Deflation of the peritoneal gas

♦ Closure of the parietal wound (ports).

Position of patientThe patient is placed in lithotomy position. The buttocks are at the edge or slightly over the table’s edge. Sterrups should have ample padding to support the lower leg. Head end of the patient is lowered (Trendelenburg 15-30°) after insertion of the primary trocar. This is done to displace the bowel out of the pelvis. For good view and hand-eye coordination, both for the surgeon and the assistants, the video monitor is placed at the foot end of the table. The electrosurgical unit and the suction irrigator should be placed behind the surgeon or assistant. The bladder is emptied by a Foley’s catheter. Pelvic examination is done methodically. An uterine manipulator is introduced through the cervical canal for manipulation to visualize the tubes and uterus at a later step.

Pneumoperitoneum: A small skin incision (1.25 cm) is made just below the umbilicus. The veress needle is introduced through the incision with 45° angulation into the peritoneal cavity. The abdomen is inflated with about 1L-4L of gas (carbon dioxide). But for diagnostic purposes nitrous oxide or room air or oxygen can be used. Symmetrical distension of abdomen with loss of liver dullness is suggestive of proper pneumoperitoneum. Volume of gas varies from 1L-4L depending upon the patient. But in any case intra-abdominal pressure should not exceed 20 mm Hg. The flow rate of the gas is about one liter per minute with a pressure not exceeding 20 mm Hg. Otherwise this interferes with diaphragmatic excursion and venous return due to caval obstruction.

Correct placement of veress needle is verified by:

(a) Hanging drop method—a small amount of sterile saline is placed on the top of the veress needle. The saline drops in the peritoneal cavity while there is negative intra-peritoneal pressure.

(b) Syringe barrel test—a 10 mL syringe with normal saline is attached to the veress needle. Aspiration is done to rule out blood or bowel contents. The saline is then pushed down and aspiration is again done. If the needle placement is correct, the fluid cannot be withdrawn as it goes in the peritoneal cavity.

(c) Intra-abdominal pressure is low (<10 mm Hg) on correct placement and there is free flow of gas.

(d) Obliteration of liver dullness (on percussion).

Other possible sites of veress needle insertion:

(a) Left subcostal margin [3 cm below in midclavicular line-Palmer’s point]. Stomach must be decompressed and splenomegaly to be ruled out. (b) Transvaginal—through the pouch of Douglas.

Laparoscopic Insufflator

Operative laparoscopic procedures needs high flow. Automatic sensors of the insufflator shut off gas flow when the intra-abdominal pressure reaches 15 to 20 mm Hg.

Port Entry (Fig. 35.5): Peritoneal cavity is entered through three main sites: (i) At the umbilicus (most common). (ii) Suprapubic (2-4 cm above). (iii) Palmer’s point (midclavicular line) on the left. In obese patients the needle is inserted more vertically.

Introduction of Trocar and Cannula

The abdominal wall is elevated and the trocar with cannula is inserted through the same incision. The angle of insertion is similar to that of the veress needle, directing towards the hollow of the sacrum. There is escape of gas when the trocar is within the peritoneal cavity. The trocar is removed and the laparoscope is then introduced. Open laparoscopy was introduced (Hasson-1971) to reduce the risk of blind insertion of the veress needles and trocars.

Fig. 35.5: Port Entry: A. Primary port- Umbilical port. B1 and B2. Accessory ports—Lateral ports one on each side 3-4 cm medial to anterior superior iliac spine but lateral to inferior epigastric artery. C. Palmer's point. D. Suprapubic port

Peritoneal cavity is opened through a small incision (1 cm) at the umbilicus pneumoperitoneum is done through a special cannula inserted in the incision. The laparoscope is then introduced.

Secondary trocar insertion is needed for both the diagnostic and operative procedures (see Fig. 35.5). Sites selected are either on the flank (3-4 cm lateral to the medial umbilical ligament) or lateral to the lateral margin of rectus abdominis muscle or on the suprapubic region. This is done under direct vision with illumination to avoid trauma to abdominal organs and the inferior epigastric vessels.

Laparoscopic procedures of tissue dissection:

(i) Blunt dissection. (ii) Sharp dissection (using scissors). For control of bleeding, bipolar diathermy is used for hemostasis. (iii) Aquadissection with hydraulic pressure is used to create tissue planes. (iv) Electrodissection using unipolar or bipolar diathermy for dissection and coagulation. (v) Laser dissection (see p. 123). (vi) Harmonic scalpel.

Methods of hemostasis (see p. 613).

Removal of specimens: Large volume of tissues after laparoscope could be removed by any of these methods: (i) Morcellation. (ii) By enlarging any of the suprapubic trocar incision site. (iii) Through the colpotomy incision. The specimen is put in a EndoCatch bag and is taken out without spilling.

Examination of the Pelvis

After introduction of the laparoscope, a systematic inspection of the pelvic and abdominal organs is done. The patient is put to Trendelenburg position for proper visualization of the pelvic organs.

Fig. 35.6: Surgical treatment of PCOS by drilling

Visualization: Diagnostic procedures may be performed with direct optical visualization. Operative procedures are carried out with video camera (Fig. 35.12).

OPERATIVE LAPAROSCOPY

■ Tubal sterilization with single puncture technique: The various operative techniques of laparoscopic procedures are beyond the scope of the book. As the laparoscopic sterilization is commonly done, this procedure is described in p. 496 (Fig. 35.6).

■ Total laparoscopic Hysterectomy (TLH)

Uterus is freed of all its attachment laparoscopically. The uterus is removed either vaginally or abdominally following morcellation. Vagina is closed with sutures laparoscopically (details see below).

■ Laparoscopic Assisted Vaginal Hysterectomy (LAVH): See below

Benefits of laparoscopy prior to vaginal hysterectomy are: (i) Diagnosis of any other pelvic pathology. (ii) Adhesiolysis or excision of endometriosis. (iii) Adnexae is freed laparoscopically. (iv) Dissection of bladder from uterus. (v) Desiccation and transection of uterine artery (vi) Entire uterus may be freed from its attachments.

Fig. 35.7: Laparoscopic adhesiolysis (salpingolysis and overiolysis)

PROCEDURE OF LAPAROSCOPIC HYSTERECTOMY

Three or four puncture sites are made. One 10 mm umbilical port is used for the laparoscope, connected to the video camera. Three other secondary ports are made, each of 5 mm size (see p. 612). Two of them are placed on the ipsilateral side and the third on the opposite side. These are placed lateral to the inferior epigastric artery or in the mid-line above the bladder. The left lower puncture is the major portal for operative manipulation. The right is used for retraction with atraumatic grasping forceps.

Bipolar coagulation or Harmonic Scalpel are used to transect pelvic ligaments and to achieve hemostasis. Bipolar coagulation desiccates the blood vessels. Scissors are used to transect the pedicles following coagulation. The round ligament, infundibulopelvic ligament are similarly coagulated and transected. Sutures, staples or clips can also be used. The leaves of the broad ligament are opened up with the scissors. The peritoneum of the vesicouterine pouch is dissected with the scissors. Hydrodissection may be used to develop the space.

• LAVH, the laparoscopic procedure is stopped at this point. The rest of the operation is completed vaginally. Uterine vessel ligation is done from below. This is exactly the same as that of vaginal hysterectomy (see p. 220).

• Total Laparoscopic Hysterectomy (TLH)

Dissection is continued to expose the uterine vessels. After careful identification of the uterine vessels and the ureter, the uterine vessels are desiccated using bipolar diathermy and then cut. Harmonic Scalpel use causes coagulation and cutting simultaneously.

Uterus is then freed from the rest of attachment. The cardinal ligaments on each side are divided. Colpotomy device and vaginal occluding device (Colpotomizer system) help to detect the site of colpotomy and maintain pneumoperitoneum simultaneously. Wet laparotomy sponge may be placed in the vagina for this purpose. Vagina is transected using monopolar energy or by harmonic. Bipolar cautery is used for hemostasis. The specimen is removed (see above). Vaginal vault is closed. Extra corporeal sutures may be used.

After completion of the procedure, laparoscope is used to check the pelvis for hemostasis. Peritoneal cavity is irrigated with Ringer’s lactate solution and suctioned until clear fluid is obtained. Bleeding vessels are coagulated. 500 mL of Ringer’s solution are left in the peritoneal cavity. The laparoscopic instruments are then removed and the pneumoperitoneum is deflated. The trocar incisions (ports) are closed.

Postoperative Care

General postoperative care is similar to any other major gynecological surgery. Care specific to laparoscopic hysterectomy are:

(a) Prophylactic antibiotics are used in a case of hysterectomy (p. 584)

(b) Laparoscopic ports should be kept clean and dry for next 7-10 days.

(c) Diet may be started by next 12 hours.

(d) Discharge: Patient may be discharged by next 48-72 hours.

(e) Daytoday physical activity may be started by 10-12 days time.

(f) Intercourse should be avoided for next 6 weeks.

Fig. 35.8: Laparoscopic view showing tubal sterilization with silastic (Fallope) rings

Fig. 35.9: Laparoscopic myometomy. Myoma screw (Fig. 35.3C) is used for traction of the myoma (Courtesy: Dr. Parul Kodtawala, Ahmedabad)

COMPLICATIONS OF LAPAROSCOPY

Complications are grouped into: (i) specific to laparoscopy itself, (ii) due to anesthesia, (iii) common to any surgical procedures.

■ Complications due to laparoscopy itself:

(1) Extraperitoneal insufflation

(a) Surgical emphysema

(b) Omental emphysema

(c) Cardiac arrhythmia

(2) Injury to blood vessels—mesenteric, omental, injury to major pelvic or abdominal artery or vein. Inferior epigastric vessels may be injured during insertion of accessory trocars.

(3) Injury to bowel—with veress needle or trocar especially when there is adhesions.

(4) Injury to organs like bowel, bladder or ureter. Damage may be mechanical during dissection or thermal by electrical or laser energy.

(5) Electrosurgical complications—causing thermal injury (electrode burns, insulation defects).

(6) Gas (carbon dioxide) embolism—resulting in hypotension, cardiac arrhythmia.

■ Anesthetic complications peculiar to laparoscopy are:

(1) Hypoventilation (pneumoperitoneum and Trendelenburg position lead to basal lung compression and reduced diaphragmatic excursion).

(2) Hypercarbia and metabolic acidosis (when CO2 is used for pneumoperitoneum).

(3) Basal lung atelectasis.

(4) Others—esophageal intubation, aspiration and cardiac arrest.

■ Complications common to any surgical procedure

(1) Hemorrhage (2) Infection

(3) Wound dehiscence (4) Port site hernia.

Death rate in diagnostic laparoscopy is about 5/100,000 procedures. With experience, the fatality is markedly reduced to even zero. Causes of death are cardiac arrest, gas embolism and consequences of intestinal injury.

ROBOTICS: Robotic surgical system allow the surgeon to operate from a distant station. Two robotic arms filled with instruments works inside patient’s abdomen. These arms have 360° range of movement. It has the advantage of increased dexterity, minimum fatigue, tremors or incidental hand movement. It is expensive and needs training.

HYSTEROSCOPY

Hysteroscopy is a procedure that allows direct visualization inside the uterus (Fig. 35.10). It can be used for diagnostic as well as therapeutic purposes (Fig. 35.12).

Basic Instruments and Electrosurgical Units for Hysteroscopic Surgery (Fig. 35.11)

TelescopeRigid telescopes are commonly used. The telescope may be either straight on (forward view) (0°) or fore oblique view 30°, 70° or 90°.

Flexible telescopesThe tip of the hysteroscope can bend up to 110°. It has the advantage of easy uterine entry through the angle between cervix and uterus. It helps easy aligning the catheter for tubal cannulation (Fig. 35.10).

Microhysteroscope acts as a high powered microscope by switching the lens to 150X. Light contact with the mucous membrane is needed.

Telescope sheathA sheath is required to introduce the telescope. Sheath used for diagnostic purposes are smaller (5 mm) than that for operative sheath (710 mm). Operative instruments are introduced through the sheath. Operative hysteroscopy needs separate inflow and outflow sheaths. The inflow sheath carries the distension medium to the tip of the telescope, from where it is withdrawn via the outer sheath. This helps to maintain the clear view.

Distending mediaThe uterine cavity is distended with a media to separate the uterine walls and to have a panoramic view. The media used could be either a gas or a liquid.

Carbon dioxide (CO2)—is commonly used for diagnostic purposes. It is soluble in blood and is safe.

Hysteroflator provides gas flow rate of maximum 100 mL per minute and a maximum pressure of 100 mm Hg.

Liquid media is used for operative procedures.

Normal saline can be used but not suitable for monopolar electrosurgery. Constant flow is to be maintained to flush the operative area.

Glycine 1.5 percent is used in many centers for excellent visualization. It is hypoosmolar. Resectoscope (monopolar electrosurgery) can be used as it does not conduct electricity. Fluid can be pressurized via a roller pump or by a pressure infusion bag cuff system with a maximum flow rate of 100 mL/ min and maximum pressure of 100 mm Hg.

Mannitol (5%) and Glycine (2.2%) are Iso- osmolar, so can be used safely. They can be used with electrosurgical devices also.

While using liquid distension media, volume of fluid instilled, volume of return fluid and the fluid deficit must be calculated. Significant fluid deficit (Saline 1.5-2L) warns the surgeon to discontinue the procedure. Glycine: A fluid deficit of > 500 ml, may cause hyponatremia and hypo-osmolar state.

A fluid deficit of (> 500 ml is alarming to prevent hyponatraemia and hypo-osmolality. Deficit of > IL, require measurement of serum electrolytes and diuretic (frusemide) therapy.

A pressure of about 50-70 mm Hg is required for adequate distention of the uterine cavity. This pressure should not exceed the mean arterial pressure to avoid extravasation.

Accessary instruments are: scissors, forceps, grasping forceps (Fig 35.3) Monopolar and bipolar electrodes (a ball, needle or cutting loop) are used for operative hysteroscopy. Image-recorder—recorded images are useful as teaching aids to the trainees. They can also be used as an evidence (in defense) for medicolegal purpose.

CameraThe hysteroscopic image is visualized on the monitor with the help of a camera. The camera used for laparoscopy can also be used. The monitor is checked before hand for visualization of appropriate image. A high resolution camera and color monitor is required for both the surgeon and the assistants.

Light sourceXenon or mercury halide can provide high intensity light sources for excellent illumination.

Fig. 35.12: Hysteroscopic procedures in progress

Anesthesia and Procedures

Diagnostic procedures—are carried out as an outpatient under paracervical block with 1 percent xylocaine (10-15 mL). Initial steps are same as in dilatation and curettage p. 585. Telescope inserted within the diagnostic sheath, is gradually inserted through the cervical canal while the light is on. The distension media is flushed through the sheath. Uterine cavity is evaluated throughly with a closer view at fundus, lateral, anterior, posterior walls and the tubal ostia. Endocervical canal is seen while withdrawing the hysteroscope from the uterus.

Operative procedures—are carried out under general anesthesia or regional anesthesia (spinal or epidural).

INDICATIONS OF DIAGNOSTIC HYSTEROSCOPY

(a) Abnormal uterine bleeding:

♦ Menorrhagia (Fig. 35.13).

♦ Postmenopausal bleeding (see p. 559).

Fig. 35.13: Hysteroscopic view of a submucous fibroid

(b) Infertility—when associated with abnormal hysterosalpingogram (filling defect, synechiae).

(c) Mfillerian anomalies like arcuate, subseptate, septate, bicornate uterus or uterus didelphys can be diagnosed with hysteroscopy. The procedure is combined with laparoscopy for confirmation.

(d) Recurrent miscarriage: Intrauterine pathology such as fibroids, polyps, Asherman’s syndrome (see Fig. 37.73) can be diagnosed and treated.

(e) Misplaced IUD (see Fig. 29.6).

(f) Chronic pelvic pain due to obstructive uterine anomaly, fibroids, bicornuate uterus may be diagnosed. Laparoscopy is done to exclude other pelvic pathologies.

(g) Transformation zone (p. 322) could be visualized with colpomicrohysteroscopy.

(h) Hemangioma and arterio venous malformation— diagnosis.

INDICATIONS OF OPERATIVE HYSTEROSCOPY

(a) Polypectomy and myomectomy.

(b) Lysis of intrauterine adhesions (synechiolysis).

(c) Endometrial ablation (laser or roller ball) for patients suffering from DUB (see p. 195).

(d) Endometrial resection—where endometrium is excised using a resectoscope (Fig. 14.4) for patients with DUB (p. 195).

(e) Metroplasty (resection of uterine septum) Fig. 35.14.

(f) Removal of foreign body or IUD, when the thread is missing.

(g) Biopsy of suspected endometrium under direct vision.

(h) Tubal cannulation—under hysteroscopic guidance can release any proximal tubal obstruction (due to mucos plugs or spasm). A special catheter is passed through the tubal ostium up to the interstitial part of the tube.

(i) Sterilization—by destroying the interstitial portion of the tubes using Nd:YAG laser or electrocoagulation or for insertion of Essure (p. 501).

(j) Laser coagulation of endometrial hemangioma and arteriovenous malformation in cases with unresponsive bleeding.

Pretreatment Evaluation and Protocol

► It should preferably be done in the postmenstrual phase with normal sized uterus.

► Should be preceded by diagnostic hysteroscopy.

► Pretreatment with danazol, GnRH analogue or progestogen for 4-6 weeks to make the endometrium thin prior to endometrial ablation/resection.

LEVELS OF HYSTEROSCOPIC PROCEDURES (RCOG 1994)

■ Level 1. (Diagnostic procedures)

♦ Diagnostic hysteroscopy plus target biopsy.

♦ Removal of simple polyp.

♦ Removal of IUCD.

■ Level 2. (Minor operative procedures)

♦ Fallopian tube cannulation (proximal)

♦ Minor Asherman’s syndrome

♦ Removal of pedunculated fibroid or large polyp.

■ Level 3. (Complex operative procedures)

♦ Resection of uterine septum

♦ Major Asherman’s Syndrome

♦ Transcervical resenction of endometrium (TCRE)

♦ Resection of submucous leiomyoma

CONTRAINDICATIONS OF HYSTEROSCOPY

Pelvic infection: Hysteroscopy can cause spread of infection. The distension media flowing through the tube spreads the infection in the peritoneal cavity.

Pregnancy: However, hysteroscopy can be done to remove an IUCD when the threads are missing.

• Cervical cancer: Trauma to the friable cervix can cause excessive bleeding.

• Cardiopulmonary disorders are at higher risk of anesthesia as hysteroscopy carries its own risk of gas embolism, fluid overload and pulmonary oedema (see p. 619).

• Cervical stenosis: Can cause cervical trauma. PGE2 gel inserted 2 hours before surgery, softens the cervix and help easy dilatation.

OPERATIVE HYSTEROSCOPY

Transcervical resection of endometrium (TCRE) or laser ablation of endometrium (LAE) is done as an alternative to hysterectomy for dysfunctional uterine bleeding.

Principle of this operation is to destroy the endometrium up to a depth of 3-5 mm. There would be no further regeneration of endometrium as the basal layer of endometrium as well as the basal and spiral arterioles are destroyed.

Procedure: Endometrial resection is done from cornu to cornu (fundus) and all the walls. Ablation is not needed below the level of the internal os. TCRE or LAE is completed by about 30 minuts time and patient can go home on the same day.

Total resection or ablation of endometrium should result in amenorrhea. Selection of the patient is very important. Presence of pelvic pain is a contraindication. Before TCRE or LAE endometrium is suppressed using danazol or GnRH analogue for 4-6 weeks (see p. 534). Therapeutic response following TCRE or LAE has been observed in 80-85 percent of cases (see p. 196).

HYSTEROSCOPIC MYOMECTOMY

It is done for submucous myomas as an alternative to hysterectomy or laparotomic myomectomy for a patient with intractable symptoms.

Indications: (i) Infertility (ii) Menorrhagia.

Surgical technique: Preoperative GnRH agonist therapy is used (p. 525). Resectoscope is normally used for myoma resection. Electro surgical working element with 90° cutting loop (Fig. 35.11) is usually used to shave off any submucous leiomyoma (Fig. 19.8). Myometrium is desiccated through contact coagulation for 30-40 seconds to control bleeding. Bleeding can also be controlled using roller ball coagulation. Uterine tamponade with the inflated bulb of a Folley Catheter is also effective.

Common complications are: Uterine perforation and hemorrhage (see below).

COMPLICATIONS OF HYSTEROSCOPY

Complications may arise from any of these following:

♦ Peroperative ♦ Late

• Peroperative Complications

(A) Distension media:

♦ Fluid overload.

♦ Pulmonary edema, cerebral edema.

♦ Hyponatraemia.

♦ Neurological symptoms.

♦ Ammonia toxicity due to excess glycine absorption.

♦ Embolism (CO2).

(B) Operative procedures

♦ Uterine perforation.

♦ Hemorrhage—intraoperative or postoperative.

♦ Injury to intra-abdominal organs.

(c) Electrosurgical—Thermal injury to intraabdominal organs due to laser or electricity.

(d) OthersInfection, anesthetic complications and treatment failure.

• Late Complications

1. Abnormal uterine bleeding due to failure of TCRE especially in the young age group.

2. Hematometro and pyometers—may occur due to infection after hysteroscopic surgery with cervical stenosis. Ablation near internal os level should not be done.

3. Pregnancy—may occur following TCRE (rare).

KEY POINTS

Endoscopy is the procedure to visualize the interior of a viscus or space with the use of a telescope. In gynecology as much as 80 percent of operations can be performed endoscopically with the use of either a laparoscope or a hysteroscope.

During laparoscopy, the magnification of the object depends upon the distance of the laparoscope from the object. With 'Storz' it is nearly 10 times when working distance is 3 mm and is 1 when the distance is 30 mm.

Laparoscopic surgery could be diagnostic (see p. 121) or therapeutic (see p. 617). Before any procedure is undertaken, contraindications must be carefully excluded (Table 35.1). Informed consent should include the permission for open surgery if necessity arises.

Hemostasis during laparoscopic surgery can be achieved using electrocoagulation (monopolar/bipolar), laser coagulation, ligatures, sutures(extracorporeal/intra-corporeal), enseal, harmonic scalpel or by stapler and clips. (p. 613)

Thermal damage caused by electrosurgery or laser depends on the degree of' heat applied to the tissues. Tissue damage with heat is as follows: 45°C = Tissue death; 70°C = Coagulation; > 90°C = Desiccation;

> 100°C = Vaporization; > 200°C = Carbonization (charring).

Laparoscopic tubal sterilization is the commonest surgical procedure. In LAVH the uterine arteries are clamped and secured through vaginal route. In TLH (p. 617) entire procedure is done laparoscopically.

Complications of laparoscopy may be due to the procedure itself or due to anesthesia (see p. 619).

Hysteroscopy is superior to HSG . The distending media commonly used in hysteroscopy is normal saline or glycine (1.5 %).

The contraindications (see p. 622) of hysteroscopy are pelvic infection, pregnancy and active uterine bleeding. Complications include fluid overload, pulmonary edema, and injury to genital or abdominal organs or electrosurgical injuries (see p. 623).

Hysteroscopic surgery should be done in the postmenstrual phase. Pretreatment with danazol or GnRH analogue for 4-6 weeks facilitate endometrial ablation or resection.



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