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 Endometriosis
A wide range of procedures come under the title of endometriosis surgery. The common objectives are to relieve chronic pain while preserving natural fertility. Occasionally the solitary goal of surgery is to improve access for IVF, particularly when the fallopian tubes are absent and when the bowel is stuck to the ovaries.
Surgery for endometriosis is really about restoring anatomy and function to near normal. These procedures involve carefully excising endometriosis deposits from the pelvic walls, bladder, bowel, vagina, tubes and ovaries. When there are cysts (endometriomas) within the ovary, they must also be carefully removed, while preserving as much normal ovarian tissue (reserve) as possible.
When important organs such as the bowel, bladder and ureter are involved, very specific techniques are required to safely remove these nodules. During surgery, nerve pain is very often reduced or stopped completely once the cause of compression by endometriosis is identified and removed.
Very often patients with poor capacity bladder pre-operatively find that surgery to relieve the bladder pressure, while also releasing compression of the pelvic (autonomic) nerves, allows them to return to normal function. Occasionally there is a slight delay in bladder function, but this is easily managed in the day or so after surgery with the assistance of a urinary catheter.
In patients seeking to conceive within two to twelve months of surgery, dye testing to prove that the fallopian tubes are open is often undertaken. This is a simple, reassuring test that adds little to the overall time of surgery.
Most patients will have a temporary pain pump as well as a drain tube to relieve gas pressure from the laparoscopy. The distinct advantage of excisional surgery is that it allows the entire ‘root’ of endometriosis tissue to be removed.
Hysteroscopy / D&C / Examination under anaesthetic
This means, literally, to look into the uterus. It is often completed at the commencement of surgery to establish that the uterine cavity is normal and that there are no endometriotic nodules growing in the vagina, cervix or uterus. The uterine cavity is measured (using a probe called a ‘sound’), particularly if a IUD is to be installed at the conclusion of surgery.
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.
This is a simple plastic device that releases a very low dose of a progesterone IUD for up to five years.
The effect is:
- relief of uterine cramping pain (adenomyosis)
- reversible contraception
- reduction in period volume (menorrhagia or dysfunctional bleeding).
Total laparoscopic hysterectomy (TLH)
Hysterectomy is occasionally indicated in women with a completed family who are troubled with intractable pain secondary to adenomyosis, or when there are large uterine fibroids that cannot be simply removed. Hysterectomy is also undertaken for various gynaecological cancers, but this requires a separate discussion with a gynae-oncologist.
The preferred and proven safest technique is total laparoscopic hysterectomy (TLH). 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 can be done with preservation of normally functioning ovaries so that menopause does not occur. In patients where the bowel is attached to the uterus by endometriosis, a combined procedure with a colorectal surgeon can be undertaken so that all abnormal tissue is removed, including a small segment of bowel if indicated.
A hysterectomy procedure involves removing the uterine body and the attached cervix; it is strongly advisable to remove the fallopian tubes at the same time. There is increasing evidence that the fallopian tubes are the origin of so-called STIC lesions (serous tubal intraepithelial carcinoma), which are a precursor to developing ovarian cancer.
TLH is a very advanced surgical technique, particularly when removing endometriosis or a limited bowel resection is involved as part of a larger planned procedure. The operating time is between one and a half and five hours, depending on associated pathology. The details of surgery will be discussed in detail by A/Prof. Cooper with each patient. The average in hospital stay is two nights only, a car may be driven within a week, and return to full work (non-manual) will be two to three weeks.
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.
Bowel resection for patients with deep infiltrating rectal endometriosis
In patients with ultrasound, MRI or laparoscopically proven endometriosis, a bowel resection may be required. Patients may experience chronic and increasing bowel pain leading up to their periods, they may have cyclical changes in bowel habit, or the bowel may be stuck across the lower pelvis preventing safe access to future planned IVF.
Combined colorectal/gynaecological bowel surgery is always undertaken in conjunction with a colorectal surgeon.
Over the last 20 years, A/Prof. Cooper has been involved in over 1700 bowel resection procedures, all with deep infiltrating endometriosis.
The average in-hospital stay is three to five days. In patients with a completed family, where there is a known risk of the bowel attaching to an adenomyotic uterus, removing the uterus (TLH) may be undertaken simultaneously with appropriate consent.
Bowel function returns within two to four days of surgery, initially sporadic, but by three to four months bowel actions have completely returned to normal. The early bowel actions can be blood stained but this settles within the first week or so. There are many factors to consider regarding surgical removal of rectal endometriosis, and these will be discussed with each patient in the planning stages with both surgeons well before an anticipated procedure. It is the aim of every such surgery to maintain as much bowel as possible and if a lesser surgery will produce the desired outcome, this procedure will be undertaken preferentially.
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 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.
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.