LAPAROSCOPY AND HYSTEROSCOPY
Complications of laparoscopy
Laparoscopy is a surgical procedure and
as all surgical procedures it has complications. Complications of laparoscopy
are more frequent in inexperienced hands. Complications arise either during
insertion of the ports (trocars) through which the instruments are introduced or
while performing the surgery itself. Great vessel or bowel injuries may occur
while insertion of the trocars and the telescope. During the surgery, bowel,
bladder, ureter or vascular injuries may occur. Some of these complications may
require conversion to open surgery for repair. Another complication of
laparoscopy is conversion to open surgery due to technical impossibility of the
planned laparoscopic procedure. This is usually done in the same session. When
unexpected cancer is diagnosed during laparoscopy, it may be necessary to stop
the operation, wake the patient and get consent for more radical surgery
requiring the removal of the uterus and the ovaries.
Complications of hysteroscopy
Laceration of the cervix may occur
during dilatation prior to insertion of the hysteroscope. The uterus may be
perforated during dilatation or during the surgical procedure itself. If the
uterus is perforated the operation should be stopped and repeated in a
subsequent session. If electrical energy is used for bleeding or surgery, it may
cause bowel injury. Injuries of the bladder and ureter are encountered very
rarely.
LAPAROSCOPIC PROCEDURES
Laparoscopic procedures may be diagnostic or operative. Diagnostic laparoscopy is undertaken in a patient with no positive history or physical findings. Operative laparoscopy is performed when there is a pathology that necessitates intervention. Diagnostic laparoscopy Popularity of diagnostic laparoscopy has decreased over the years and has become a relatively rarely performed operation. Diagnostic laparoscopy is performed to determine the cause of infertility in a woman who has no abnormality in her medical history or physical examination. In a woman without secondary dysmenorrhea, dyspareunia, history of sexually transmitted disease (gonorrhea, chlamydial infection, etc.), previous pelvic surgery (cytectomy, myomectomy or ectopic pregnancy, etc.) or intrauterine device use, and has a normal physical exam with a normal hysterosalpingogram, laparoscopy is not expected to yield a significant problem. Mild endometriosis, mild intraabdominal adhesions or tubal obstruction may be diagnosed in these cases. It is extremely rare to see obstructed tubes at the time of laparoscopy in a woman with a normal hysterosalpingogram, and whenever this is encountered it is thought to be due to tubal spasm. Whether the treatment of mild endometriosis diagnosed during laparosocopy improves infertility is debatable. The treatment should be the same as for unexplained infertility in these patients. Hydrolaparoscopy is another procedure that may be regarded as diagnostic laparoscopy. It does not require general anesthesia. Sterile saline is infused to the abdominal cavity through a needle inserted from the vagina. Ovaries, tubes, uterus and pelvic peritoneum are examined. Like normal diagnostic laparoscopy, hydrolaparoscopy also provides limited information and does not change the management so its indications are also controversial.
Operative
laparoscopy
Operative laparoscopy is performed to
treat a previously diagnosed condition or to remove a diseased organ.
Laparoscopic
procedures to increase fertility (fertility promoting laparoscopic surgery)
Adhesiolysis, salpingostomy and
fimbrioplasty
Previous pelvic infections and pelvic
surgery usually cause adhesions that impair the relationship between the tubes
and the ovaries. When the adhesions are filmy and if it is technically feasible
to release them laparoscopic adhesiolysis may be beneficial. Following
restoration of the normal anatomic relation between the tubes and the ovaries,
pregnancy rates between 30 to 60% have been reported depending on the age of the
woman and the presence of other causes for infertility. When the adhesions are
dense, reformation rate following adhesiolysis is high, hence the pregnancy
rates are low. Obstructed tubes may be opened by laparoscopy. Especially when
the tubes are obstructed at the distal ends (on the fimbrial tip) -namely
hydrosalpinges- they may be opened by a procedure called salpingostomy.
Reocclusion rates vary between 30 to 100% depending on tubal wall thickness,
tubal mucosal injury and the presence of surrounding adhesions. Pregnancy rates
vary between 10 to 70% depending upon the severity of the adhesions. When
creating a new opening to the tubes is impossible, they must be removed so that
the pregnancy rate in a subsequent in vitro fertilization treatment (IVF) is not
impaired. Leaving the obstructed tubes particularly hydrosalpinx in place
decrease pregnancy rates when IVF is performed
Laparoscopic
endometriosis surgery
Endometriosis is one of the most
frequent indications for operative laparoscopy. Endometriosis is caused by
implantation and growth of endometrial cells outside of the uterus. It is most
frequently localized on the peritoneum (inner lining of the abdominal cavity)
and the ovaries. Additionally it may develop between the uterus and the distal
portion of the bowel and cause considerable pain. In advanced stages of the
disease uterus, ovaries, tubes, and the bowel may adhere to form a mass and
cause pelvic pain and/or infertility. In the early stages of the disease there
are small lesions on the peritoneum that resemble gunpowder spots. These lesions
may be cauterized or vaporized by laser during laparoscopy.
In more advanced stages, cysts called
endometriomas form in the ovaries. Laparoscopic removal of endometriomas
increases the chances of a spontaneous conception. Preservation of ovarian
reserve during laparoscopic surgery is paramount. Injury to normal ovarian
tissue may occur during stripping the cyst wall that may decrease ovarian
reserve. Both endometriosis per say and surgery to treat endometriosis may
inevitably decrease ovarian reserve, so especially in women with recurrent
endometriomas, there’s a trend towards directly proceeding to IVF instead of
surgery. But if the major concern is pain, then there’s no other choice than
surgery. Approximately 50% of infertile couples achieve a pregnancy in the first
6 months following surgery. IVF is necessary for couples who have still not
conceived one year after surgery.
Laparoscopic removal of deep
endometriosis located between the bowel and the uterus is possible. Removal of
the lesions usually alleviates the pain. Surgical treatment of deep
endometriosis takes time and requires an experienced surgeon.
It has to be kept in mind that
endometriosis is a disease with risk of recurrence. Especially in the
premenopausal period the risk of recurrence is approximately 50%. For this
reason, we offer IVF to women failing to achieve a spontaneous pregnancy in a 6
months period following complete surgical removal of all endometriotic lesions.
Intra uterine insemination is not offered in this context due to low pregnancy
rates.
Laparoscopic
surgery for cysts
Although endometriomas are the most
common cystic lesions that are treated by laparoscopy, persistent simple cysts
and dermoid cysts are also amenable to this form of treatment. Endometriomas
were mentioned previously so in this section I will discuss simple cysts and
dermoids.
Dermoid
cysts
Dermoid cysts contain all tissue types
present in the human body. Fat, hair, teeth, neural or muscular tissue may be
present in dermoid cysts. They are usually formed during intrauterine life with
sequestration of these tissues in the ovaries. It is not known why they continue
growing in the postnatal life. They most frequently cause a complication named
“ovarian torsion”. This is turning of the ovary with its neighboring tube around
its axis impeding blood flow. If timely laparoscopic intervention is not
performed, eventually necrosis starts in the ovary and the tube, necessitating
their excision. Dermoid cysts may need to be removed if they exceed 3 to 4
centimeters in size. They are quite easily removed with laparoscopy. In 15% of
the cases the contralateral ovary may be also involved necessitating careful
intraoperative evaluation. There’s 1% chance that dermoids may have malignant
components. Malignant dermoids contain immature neural tissue.
Paraovarian cysts
These are congenital remnants adjacent
to the ovary. Very rarely they bear malignant potential. They must be excised if
they grow big. Laparosocpic removal is an easy procedure.
Cystadenomas
These tumors grow in the ovary and bear
malignant potential. A cystadenoma is suspected when cystic and solid components
are seen together in an ovarian cyst. Cyst excision is necessary for a
definitive diagnosis. Cystadenomas are most frequently serous or mucinous
nature. They are easily excised with laparoscopy. Removal of the ovary is a
better choice for women approaching or in menopause. Ovary may be preserved in
younger women but the cyst must be examined for malignancy during operation
(frozen section).
Laparoscopic
surgery for fibroids
A substantial proportion of fibroids can
be removed with laparoscopy. Indications for myomectomy are as follows:
Size: Fibroids over 6 centimeters in
diameter as well as rapidly enlarging fibroids should generally be removed
surgically.
Bleeding: Fibroids do not cause bleeding
unless they protrude to or exert pressure on the inner layer (endometrium) of
the uterus. Surgery is recommended regardless of size for fibroids that protrude
into endometrium and cause bleeding. The surgical method of choice in these
patients is hysteroscopic myomectomy. Fibroids are removed through the cervix
and vagina.
Symptoms of pressure: When fibroids are
located between the ligaments supporting the uterus, they may occlude the ureter
(tube connecting kidney and bladder). Such a fibroid must be removed. Fibroids
growing in the anterior wall of the uterus may exert pressure on the bladder,
while fibroids growing in the posterior wall may exert pressure on the rectum.
Infertility: Fibroids usually do not
cause infertility. But if previous examinations fail to detect another cause for
infertility then fibroids may be removed. It is generally recommended that
fibroids larger than 5 centimeters should be removed. Any fibroid protruding
into endometrial cavity in an infertile woman must be removed, regardless of
size and the presence of other complaints.
Laparoscopic removal is preferred for
fibroids smaller than 8 centimeters, or when number of fibroids larger than 3
centimeters is less than 3, or the fibroids are not deeply buried in the uterine
tissue. Pregnancy should be avoided for 3 month following laparoscopic
myomectomy. Adhesion formation following laparoscopic myomectomy is less
frequent compared to open surgery. Laparoscopic myomectomy takes between 1 to 3
hours depending on the localization and the size of fibroids. Patients usually
need to stay one night in the hospital after the operation.
Laparoscopic
removal of the uterus (hysterectomy)
It is possible to remove the uterus
laparoscopically. In cases of uterine descensus vaginal hysterectomy is the
preferred method. Laparoscopic hysterectomy is an alternative to classical
abdominal hysterectomy, a descended uterus should not be removed
laparoscopically. Laparoscopic hysterectomy is a successful operation in
experienced hands, and has all advantages of laparoscopy. In laparoscopic
assisted vaginal hysterectomy (LAVH) the uterus is partly released with
laparoscopy and is taken out through the vagina. This operation is feasible in
women who had previous vaginal deliveries. If the woman has not delivered
vaginally and the uterus is big a laparosopic total hysterectomy mAy be
necessary. In this setting the uterus is completely released by laparoscopy.
It may be removed from the vagina or through the abdomen by morcellation.
Patients are usually discharged from the hospital in 1 to 2 days. Complications
of laparoscopic hysterectomy include conversion to open surgery due to technical
difficulties or complications, bleeding, and injury to the blood vessels, ureter
or bowel.
Office hysteroscopy
Hysteroscopy performed in the office
without anesthesia is called office hysteroscopy. Fine instruments not requiring
dilatation of the cervix for introduction into the womb are used. Office
hysteroscopy was used for mainly diagnostic procedures in the past but today it
became possible to cure many uterine diseases with office hysteroscopy. Office
hysteroscopy is most commonly used for evaluation of abnormal uterine bleeding,
infertility and intrauterine adhesions. Small fibroids and polyps can be removed
with office hysteroscopy. Congenital intrauterine septa can be cut or lost
intrauterine devices can be removed with office hysteroscopy.
Office hysteroscopy is done under mild
sedation without using vaginal speculum or dilating or grasping the cervix. Mild
cramps may be felt during introduction of the office hysteroscope to the womb.
Sterile saline is instilled into the uterine cavity and the cavity is inspected
on the screen.
Office hysteroscopy is extremely useful
for evaluation of abnormal bleeding both before and after menopause. Polyps,
fibroids or tumors in the womb are easily seen with the hysteroscope. Some of
them may be removed with the office hysteroscope. But some require wider
hysteroscopic resection or other surgical interventions under general
anesthesia.
Hysteroscopy is very useful for
evaluation of infertility. Adhesions or masses in the womb can cause infertility
and a substantial proportion of these problems can be treated with hysteroscopy.
Confirmation of a normal uterine cavity, especially in women who do not have a
prior hysterosalpyngogram, is important before commencement of IVF procedures.
Hysteroscopy is more important for women with prior IVF failures. There are
several studies demonstrating uterine abnormalities in more than 50% of women
with 2 or more prior IVF failures. Endometritis, adhesions, polyps and deep
septa are the most common abnormalities encountered in these women. Treatment of
these abnormalities may restore IVF pregnancy rates to normal levels in these
poor prognosis women.