Laparoscopy or key-hole surgery is a type of minimally-invasive surgery which uses a telescope to view the internal organs in the pelvis. The image is magnified to give a very good view, and very small incisions (5mm-1cm) is used to perform the operation using long, slender instruments. The procedure is done whilst under general anaesthetic.
What can laparoscopy be used for?
Laparoscopy can be used to diagnose and treat many conditions. In gynaecology, some of the procedures done via laparoscopy include:
- Ectopic pregnancy
- Ovarian cysts
- Treatment of infections
- Division of adhesions
What are the advantages of laparoscopic surgery?
Compared to open surgery (laparotomy), laparoscopic surgery has a number of benefits including smaller incisions and therefore less scarring, quicker recovery time, less pain, less time spent in hospital, and faster return to work and previous activity.
What are the complications of laparoscopic surgery?
As with all surgery, there are risks involved in laparoscopic procedures, and I will discuss these in more detail with each individual. It is often not practical to mention every possible risk of a surgery but in general, some of these risks include:
- General anaesthetic risk: such as breathing problems, heart problems, blood clots
- Infection: of the wound or internal structures
- Bleeding: internally or at wound
- Hernia: at the umbilicus where the camera is inserted. This may require further surgery
- Laparotomy: there is always a small risk that a laparoscopic procedure needs to be converted to an open abdominal procedure (laparotomy). This may be due to patient factors such as finding something unexpected or in the case of a life-threatening complication
- Damage to other organs or structures: specifically the bladder, bowel, ureters or blood vessels. These injuries may be diagnosed during the procedure or sometime afterwards. Although the risk is very small, if this happens it can mean return to theatre, involvement of other specialists (Urologist, General surgeons) and further operations such as the need for an ileostomy or colostomy, or a urinary catheter for a prolonged period.
What usually happens after the surgery?
Depending on what was done during the surgery, you may go home on the same day or be admitted to hospital for 1-3 days usually. You may have a urinary catheter in place which will be removed once walking (commonly this happens on the day or day-after surgery). The small incisions will have dissolvable stitches or dissolvable glue on them.
You may experience some soreness, vaginal bleeding (typically only spotting) for a few weeks and some shoulder-tip pain.
I will discuss when you can return to normal activities such as exercise, work and intercourse depending on your surgery.
A hysteroscope is a long slender camera that is inserted through the vagina into the uterus. In a hysteroscopic procedure, a fluid is used to dilate the uterus and the camera magnifies the picture, allowing the surgeon to see a high-resolution image on a screen. There are no cuts to the skin or vagina.
What is hysteroscopy used for?
Hysteroscopy can be used to make a diagnosis of why you may be experiencing symptoms (diagnostic hysteroscopy) or be used to treat pathology (operative hysteroscopy).
During this procedure, it is possible to perform minimally-invasive surgery such as excision of polyps or fibroids, correction of uterine abnormalities or division of adhesions (e.g. to treat infertility or recurrent miscarriage) as well perform contraceptive techniques (such as insertion of Mirena or Essure). A biopsy can be taken and at the same time, dilatation and curettage can be performed (D&C) for example to rule out cancer.
What can I expect from the surgery?
Hysteroscopic procedures are day-surgery procedures and overnight stay in hospital is usually not necessary. A general anaesthetic or light sedation is usually used.
After the procedure you may experience vaginal blood loss like a period that should settle over the next few days. Usually no analgesia or simple analgesia like paracetamol and non-steroidal anti- inflammatory medication is what is required afternwards. Other post-operative instructions will be given on the day.
What are the risks involved?
As with all surgery, there are risks that will be discussed with you prior to the procedure. Hysteroscopies are usually well-tolerated. Some risks may include:
- General anaesthetic risk e.g. heart and lung problems
- Perforation of the uterus: rare complication that can occur where an inadvertent hole is made in the wall of the uterus. This complication may become apparent during or sometime after the procedure. Depending on the type of surgery and where this occurs in the uterus, a further surgery may be required to ensure there is no damage to nearby structures (such as bladder, bowel or blood vessels) and to repair this.
After this procedure, I will usually see you in a couple of weeks to ensure good post-operative recovery (bulk-billed).
What is endometriosis?
Around 10% of women suffer from endometriosis, where the lining of the uterus deposits in other areas of the body, mainly in the pelvis such as on the ovaries and along the lining of the pelvic organs. Symptoms of endometriosis can vary from having no symptoms at all, to severe and debilitating pain which affects daily activities, work and intimate relationships. Endometriosis is not cancerous but can lead to chronic pain, infertility and inability to carry out normal activities.
Why does endometriosis occur?
There are many theories as to why endometriosis occurs but none have been completely proven. It is likely a combination of genetics and the effect on individuals that leads to symptoms. Not everyone with endometriosis even knows they have it. Rarely, there are problems with a woman’s anatomy that can cause endometriosis to worsen.
Does everyone need surgery?
Not everyone with endometriosis needs surgery however the earlier it is diagnosed, the more we can try to prevent the complications that could arise from this disease. Surgery is particularly useful to diagnose and remove endometriosis. It can be very useful if you have ovarian cysts (endometrioma or chocolate cysts) related to endometriosis, if your pain is severe, if you have tried other options without success, or if you are having difficulty with getting pregnant. Therefore, if you are experiencing pelvic pain, painful periods, pain with intercourse or urination/bowel motions, or difficulty getting pregnant, it is important to see your GP and discuss the possibility of endometriosis.
What are the management options?
Management can be as simple as using medications such as anti-inflammatories, analgesia or hormonal methods (such as the pill or Mirena IUD). Often surgery is via laparoscopic removal of the disease and evidence shows that removal of endometriosis by an experienced surgeon can lead to decreased pain, improved fertility and a reduction in recurrence of endometriosis.
It is important to manage endometriosis in a holistic manner, addressing all the issues that are involved in this complex disease. Therefore we may discuss a combination of treatments and possibly utilise other specialists (e.g. pain specialists) if necessary. Similarly if fertility is an issue, we would aim to treat endometriosis as part of the fertility process with or without additional treatments such as IVF.
What does surgery involve?
The best way to remove endometriosis is via key-hole surgery (laparoscopy) by a doctor who has experience in endometriosis surgery. This will ensure that endometriosis is not missed and that all disease is removed whilst preserving normal function of the pelvic organs. Sometimes, severe endometriosis requires complex surgery with a specialised team in addition to an experienced gynaecologist, such as urologists and bowel surgeons.
Laparoscopic surgery (compared to open surgery) is associated with less pain, scarring, quicker recovery and return to work. This is especially beneficial when trying to get pregnant and not wanting to prolong the fertility process. Recovery time and duration in hospital will depend on severity of the disease and complexity of the surgery. In most cases, hospital stay is one day with full recovery in a few weeks.
If you think you have endometriosis or this has been confirmed previously, I will initially take a thorough history and examine you and review all your scans. Sometimes I may order a specialised ultrasound or do an ultrasound in my rooms. We will then discuss all your management options and together, we can tailor an individualised management plan to treat your main symptoms and/or complications such as infertility.
Removal Of Fibroids and Polyps
What are Fibroids?
Fibroids (also known as myomas) are growths from the muscle of the uterus. They are not cancerous and are very common with nearly half of all women in their 40’s having a fibroid. Fibroids can grow inside or outside of the uterus and most women don’t even know they have them. The cause of fibroids is not completely known and it likely a combination of genetic factors, reproductive factors and hormones which cause them to grow. Occasionally fibroids can cause complications such as miscarriages, pain, heavy menstrual bleeding and pressure symptoms. Whilst fibroids are not cancerous and not thought to become cancerous, there are rare growths of the uterine muscle that are cancerous (leiomyosarcoma). These cancerous growths tend to grow very rapidly and have certain radiological features on imaging such as MRI. Reassuringly, the incidence of these cancerous tumours is only around 0.2% of all uterine growths.
What are the non-surgical options for treatments for Fibroids?
Fibroids don’t need to be removed unless they are causing symptoms or interfering with fertility. Depending on factors such as age, size of fibroids, type of fibroid, symptoms and fertility status, treatment needs to be individualised and may include:
- Medication: such as anti-inflammatory drugs and tranexamic acid to help reduce the bleeding
- Hormonal treatments: various hormonal treatments such as the pill, intra-uterine device, progesterone may be suitable to decrease the bleeding and/or stop further growth. Gonadotrophin-releasing hormone (GnRH) in the form of an injection or nasal spray may be prescribed to decrease the size of the fibroid prior to surgery or as a short-term measure (as this had many side-effects and shouldn’t be used long term)
- Uterine artery embolization: in this technique, radiologists will occlude one of the main blood vessels that supply the fibroids – the uterine artery. This is not always an option for instance if pregnancy is desired in the future
- MR-guided Focused ultrasound: radiologists use ultrasounds directed at the fibroids to reduce the size. This technique is suitable for certain types, sizes and number of fibroids. The effect on future pregnancies is unknown therefore it may not be an option if pregnancy is desired.
What are the surgical treatments for fibroids?
Surgery may be appropriate if:
- Medication isn’t helping
- Large fibroids
- Heavy bleeding causing anaemia
- Pressure symptoms
- Fertility issues
Types of Surgery:
- Removal of fibroids (myomectomy) may be done via an abdominal cut, key-hole surgery (laparoscopy) or through a small instrument and camera inserted through the vagina and uterus (hysteroscopy)
- The type of surgery would depend on the nature of the problem, symptoms, age, size, general health and reproductive factors
- Hysterectomy: removal of the uterus may be an option if the fibroid is complicated (large, multiple) and childbearing is complete
What are polyps?
Polyps are small growths of the inner lining of the uterus. They are very common and most women may not realise they have them. Sometimes they can cause heavy periods, bleeding in-between periods or difficulty with falling pregnant. These growths are usually benign (non-cancerous) however there is a small chance, depending on risk factors, age and features of the polyp that a percentage of these can be cancerous. I would discuss the risk of this for each individual during a consultation, but generally once found, these polyps are removed to rule out cancer, relieve symptoms or improve fertility.
How are polyps removed?
Polyps are removed via hysteroscopy. A thin camera is placed into the uterus through the vagina whilst under general anaesthetic. The polyp is removed and sent to be tested to rule out cancer. This procedure can be done as a day procedure and recovery is usually only a day.
What is a Hysterectomy?
A hysterectomy is the surgical removal of the uterus, cervix and fallopian tubes. Sometimes the ovaries are also removed. Hysterectomy are common gynaecological procedure that may be done for various conditions. Each year around 30 000 women have this procedure.
Why do I need a Hysterectomy?
There are many reasons why I would discuss a hysterectomy as an option for treatment. A few of these include:
- Abnormal menstrual bleeding: for example, heavy bleeding which hasn’t responded to first-line management options such as medication, hormonal treatments
- Fibroids: if causing symptoms or growing rapidly where other treatment are not effective or suitable
- Adenomyosis: this is where the lining of the uterus infiltrates the muscle layer of the uterus. This condition can lead to painful periods and is related to endometriosis. Sometimes adenomyosis and endometriosis don’t respond to initial treatments and a hysterectomy may be an option
- Precancerous lesions of the uterus or cervix: such as endometrial hyperplasia or persistent abnormal pap smears
- Uterine prolapse: sometimes a hysterectomy is helpful for uterine prolapse
What about my ovaries and hormone levels?
Current recommendations are to preserve normal looking ovaries in women up to the age of 65yrs. when performing surgery if there is no increased risk of cancer for that individual. This is because there is thought to be some benefit from the small amounts of hormones still secreted by the ovary even after menopause. Prior to menopause if the ovaries are removed, a woman usually has to take hormone-replacement until the age of 50 years. Therefore, for anyone over the age of 65yrs, I would usually remove the ovaries routinely if performing a hysterectomy. For anyone under this age, I would recommend removing the only if there was a risk of ovarian cancer (e.g. strong family history or abnormal looking ovary), if there was disease of the ovary or there was a problem due to the hormones secreted by the ovary.
How will the hysterectomy be performed?
There are a few different ways that a hysterectomy can be performed and this needs to be individualised to suit the presenting problem, patient factors (e.g. size of the uterus, previous vaginal deliveries, previous surgery, health of the patient). If we decide on a hysterectomy, then I will discuss in detail which surgery would most suit you depending on all these factors and together we will decide on the best way to perform the surgery.
- Vaginal hysterectomy: this surgery is performed through a cut in the vagina so there are no abdominal scars. It is most suitable for women who have some degree of prolapse and have had previous vaginal deliveries. It is usually not possible to remove ovaries or to do this surgery if there is other pelvic pathology which needs treating (e.g. endometriosis). Usual hospital stay is 1-2 nights.
- Abdominal hysterectomy: also known as an open hysterectomy is when a cut is made on the abdomen (laparotomy) to get the uterus out. This cut can be horizontal along the bikini line or vertical from the belly-button to the pubic symphysis. The direction of the cut and size will depend on the size of the uterus and other patient factors. Hospital stay is usually 3-4 nights and full recovery takes around 6 weeks.
- Laparoscopic hysterectomy: also referred to as a TLH, is where the hysterectomy is performed through key-hole surgery through the abdomen and the uterus removed from the vagina.
Why do a laparoscopic hysterectomy?
This type of hysterectomy usually replaces what traditionally would have been done via a laparotomy (abdominal hysterectomy). It is less invasive, has a quicker recovery time (hospital stay is around 2 days with return to usual activities in about 3-4 weeks), and less scarring.
Compared to a vaginal hysterectomy, this technique allows an excellent view of the pelvis and its organs and therefore simultaneous diagnosis and treatment of other pathology e.g. any cysts of the ovary, any endometriosis. It also allows safe removal of the ovaries and tubes.
In this procedure, a thin camera is placed through a small cut in the bellybutton with 3 other small cuts (5mm) made to insert the instruments. The camera allows close-up and magnified viewing of the surgical field.
Is it safe?
As a laparoscopic surgeon, the risks of this type of surgery is similar to the risks of an open abdominal hysterectomy. As with most surgeries the risks include anaesthetic risks, bleeding and damage to nearby structures. I will discuss all the risks in detail with you prior to any decision regarding a surgery as some of these risks are specific to individuals.