Technological advances in equipment over the last decade have revolutionised the approach to traditional gynaecological problems requiring surgery. Some 80 to 90% of benign gynaecological conditions may now be managed by minimal access (small cut) techniques.
The avoidance of laparotomy now enables most women to be discharged in under 24 hours and return to normal activities within a week.
The benefits of endoscopic techniques have been widely reported. These include rapid patient recovery, decreased discomfort, less disfigurement, decreased adhesion formation and potential cost savings. The complication rate for operative laparoscopy at least, has been quoted at around 5 per 1000 cases.
Claims in the popular press of major complications associated with these techniques have often arisen as a result of poorly trained surgeons embarking on ambitious procedures early in their “learning curve”. Nevertheless, significant complications may still occur in expert hands. Most complications will be recognised intraoperatively, however, unrecognised complications, such as bowel injury, may present in the first week following discharge.
Diagnostic dilatation and curettage (scraping the inside of the uterus), when performed in a tertiary referral setting, must now be relegated to a position of historical interest. Diagnostic hysteroscopy, ideally done as an outpatient procedure, has been shown to have a substantially higher pick up rate and lower false negative rate, such that many American insurance companies will now not pay for diagnostic curettage. The hysteroscopic view allows accurate diagnosis of problems relating to menorrhagia (heavy bleeding), fibroids, infertility and uterine development anomalies.
Operative hysteroscopic procedures have become commonplace. Procedures for menorrhagia, dysfunctional uterine bleeding and infertility such as myomectomy, polypectomy, septum excision and endometrial ablation and resection may be performed as day cases, even under local sedation if required, although in Australia general anaesthesia is the norm. The initial enthusiasm for endometrial ablation has tempered with the realisation of high (at least 20%) reoperation rates and the numbers of cases performed in Australia are declining.
Diagnostic laparoscopy is now standard in all gynaecological units for a wide array of indications including pelvic pain, infertility, cysts and sterilisation. It is interesting to note that this modality is increasingly being used in surgical units to differentiate appendicitis from other causes of lower abdominal pain, especially in the group of women of reproductive age in whom appendicitis is notoriously difficult to diagnose.
Treatment of Ectopic Pregnancy
Already the “gold standard” for the treatment of ectopic pregnancy is laparoscopic removal of the tube (salpingectomy) or just the ectopic pregnancy (salpingotomy). Postoperative fertility and repeat ectopic rates are at least as good if not better than the open approach. A new problem occurring with the conservative approach is that of persistent ectopic pregnancy requiring further treatment. It has been estimated that this may occur in up to 5% of cases and is usually detected by persistently elevated HCG levels (pregnancy hormone). Currently the most common approach is repeat laparoscopic intervention although some units have utilised medical treatment such as methotrexate. It should be noted that a laparoscopic approach might not always be appropriate, particularly in cases of severe blood loss.
Tubal reconstructive surgery including adhesiolysis (dividing adhesions), salpingostomy (opening blocked tubes) and fimbrioplasty (surgery at the end of the tube) may all be performed via the laparoscope with results at least as good as laparotomy. Salpingoscopy and falloposcopy, whereby the tubal lumen may be visualised have recently been introduced and promise to aid in the grading of severity of tubal disease, thus influencing treatment and prognosis. Some suggest immediately recommending in vitro fertilisation if the tubes are badly damaged because of the low probability of successful pregnancy. Assisted conception techniques, although offering success rates of around 25%, remain time consuming, expensive and in some areas scarce. Operative laparoscopy as a “one off” procedure may thus be a viable alternative even for those patients with severe tubal disease.
It is now possible to perform tubal reversal with laparoscopic techniques as a day only procedure.
Treatment of Endometriosis
Treatment of Ovarian Cysts
Laparoscopy allows definitive treatment of most benign ovarian cysts. The limitations are malignancy, in which case most gynaecologists would recommend formal laparotomy, and size greater than 12 cm where laparoscopic treatment can become difficult. Utilising a various array of techniques it is possible to perform oophorectomy (removal of the ovary) or ovarian cystectomy (removal of just the cyst, leaving the ovary behind). Elaborate closing bag systems, into which the ovary or mass is placed after removal, have been developed to decrease or avoid spillage and assist in specimen retrieval.
It is possible to remove myomas (fibroids) with laparoscopic techniques. The defect in the uterus can be oversewn the same as at open surgery. The procedure is difficult as the size of the myoma increases and may not be possible above 12cm. Prior to surgery the myoma can be shrunk with various medications to ease the procedure. The problems of the surgery relate to the difficulty of removing all the myomas, blood loss and the potential for rupture of the scar if it is not repaired properly.
A significant degree of controversy has surrounded the concept of utilising the laparoscope to assist with hysterectomy. Most would agree the vaginal approach is the quickest and most comfortable for the patient. Despite this however, in Australia only some 30% of the 20,000 hysterectomies performed annually are accomplished in this fashion. The laparoscopic approach may be used to divide pedicles from above, avoiding a large incision and thus allowing the uterus to be removed from below.
This technique should not be used as an alternative to vaginal hysterectomy, but as a method to allow an abdominal hysterectomy to be converted to a vaginal hysterectomy, or to convert a difficult vaginal hysterectomy to an easy procedure. In experienced hands the requirement for abdominal hysterectomy has now dropped considerably. The major drawbacks to laparoscopic hysterectomy include the increased operating time which is often needed and the difficult learning curve to acquire the necessary skills.
It has been estimated that up to 60% of all women at some stage of their lives suffer from uncontrolled urinary loss when coughing, sneezing, laughing or exercising. Most women, because of embarrassment, do not like to talk about the problem, even to their doctor. There are different types of incontinence, although the most common is termed genuine urinary stress incontinence (GUSI). GUSI is more common after pregnancy and with increasing age.
There are a number of conservative methods of treating GUSI including pelvic floor exercises, pessaries and avoiding precipitating events. These approaches are often of great help but require dedicated perseverance and may be unsuccessful in severe cases, hence a number of surgical procedures have been developed.
The most established procedure for GUSI is the Burch colposuspension. It should be noted that no operation for GUSI is 100% successful. The Burch colposuspension is effective in about 80 to 90% of cases and early reports suggest this also holds true for the laparoscopic approach.