|
|
|
Endoscopic Surgery In Gynaecology
DR. S. Kalaichandran, MBBS, MD, FRCSC,FSOGC (Canada), FRCOG
Lecturer University
of Ottawa Physicians
recognized the value of inspecting body cavities
for almost
200 years.
In 1807
Bozzini described
a vase
like instrument
with a
candle for
illumination. Physicians of
old were hampered by poor
illumination and lens
systems. Endoscopy
made a quantum
leap with
the introduction
of the
cold light
and Hopkins
lens system
in 1952.
Endoscopy remained
a diagnostic
tool until
recently. Advances
in Anaesthesia, development of
safe intracavity
lasers and electro surgery
and introduction
of well-designed endoscopic instruments
over the last 15-20 years have made
endoscopic surgery
as a
real alternative
to traditional
surgery in
all surgical
specialties. Endoscopic
surgery is
minimally invasive
surgery and
results in
shorter hospital
stay and
recovery, greater
patient comfort
and greatly enhanced
productivity for patient and
community. Safe endoscopic
surgery requires
a well trained surgeon
, expert assistants
and satisfactory
equipment. In a community
hospital particularly when the administration do not buy into the philosophy of minimally invasive surgery and the community not
sophisticated enough to demand it as their right, lack of equipment is a
frustrating reality. Gynaecological endoscopic surgeon performs laparoscopic and hysteroscopic surgeries. (A) Hysteroscopic surgery: The
uterus is
a muscular organ
where the
anterior and
posterior walls
are in
contact. The
cavity is
not an
actual space
but a potential space.
In order
to inspect
the cavity
or to
do surgery in
the uterine cavity
one has
to distend
it with
gas or
fluid. This
is done
through the
hysteroscope inserted
through the cervix,
the natural
opening. Carbon dioxide
and normal
saline are
used for
diagnostic hysteroscopy
and glycine
is used
for operative
hysteroscopy. Mechanical
and electro-surgical instruments
and laser
can be used through
the hysteroscope. The hysteroscope is a most useful diagnostic tool in the investigation for infertility and also abnormal vaginal bleeding, particularly peri and post menopausal bleeding. The most frequent hysteroscopic surgeries are removal of polyps, fibroids and ‘lost’ IUD, division of intra uterine septum and adhesions, canulation of the fallopian tubes to open it or to help during tubal surgery including laparoscopic reanastamosis and endometrial ablation ( as an alternative to hysterectomy). (B) Laparoscopic surgery: The peritoneal cavity is also a potential space. The cavity is in negative pressure. In order to inspect the pelvic and abdominal organs or to do surgery the cavity is distended with carbon dioxide. The pressure required here is a lot lower than that for hysteroscopy. There are no natural openings into the peritoneal cavity and carbon dioxide is usually introduced through the umbilicus. The laparoscope is also introduced through this port. Various other ports are also placed for the introduction of various instruments and lasers for operative laparoscopy. The instruments are removed and the carbon dioxide released and the ports closed at the end of the procedure. The laparoscope
is used as a diagnostic tool in the investigation of abdominal/ pelvic pain and
infertility. Operative laparoscopic
procedures include treatment of ectopic pregnancy, tubal surgery including
anastamosis, ovarian cystectomy, oophorectomy, myomectomy, hysterectomy,
ventrosuspension, uterine nerve ablation (for dysmenorrhoea), colposuspension
(for urinary incontinence) and ablation of endometriotic lesions.
The following
are video clips of gynaecological endoscopic procedures edited for brevity: 1.
VIDEO LAPAROSCOPIC UTERINE SUSPENSION Four out of
five women will have their uterus tilted forward (anteverted) and the fifth will
have it tilted backward (retroverted). This
is a normal variation and NOT abnormal. This was not realised until about 20 years ago and major
surgery was performed to correct this ‘
abnormality’. Occasionally,
retroverted uterus may be associated with painful menses, pain during sexual
intercourse or subfertility. It is possible to antevert the uterus with the
video laparoscope as an out patient procedure.
The patient is
given general anaesthesia, video laparoscope inserted through the umbilicus, and
the abdominal cavity distended with carbon dioxide. The round ligaments are
grasped and brought out side the abdominal wall through the two small incisions
made above the groin, one on either side. The round ligaments are shortened by
plication before returning it back into the abdominal cavity and securing it to
the strong facia covering the abdominal muscles. The gas is released and the
skin incisions closed with adhesive tape. In the video, you see the uterus, fallopian tubes with Falope rings (used for sterilization), round ligaments, small and large bowel with appendix, Liver and spleen. 2.VIDEO
LAPAROSCOPIC OVARIAN CYSTECTOMY Video
laparoscopy as before. The ovarian cyst opened using the laparoscopic scissors.
Cyst wall is removed. Bleeding is stopped by electro surgery and
peritoneal cavity cleansed with irrigation and suction.
Evacuation of gas and closure as before.
An Oophorocystectmoy was performed to remove this Dermoid Cyst, which was twelve cm in size. After placing it in an endo bag, the laparoscopic incision had to be extended to extract the dermoid cyst. 3. VIDEO LAPAROSCOPIC MYOMECTOMY (Video Courtesy of Mr. A. Magos FRCOG, London, UK) Video laparoscopy as before.
Incision on uterus. Fibroid exposed and grasped. Haemostasis by electro surgery.
Two fibroids removed in endo bag. Uterine incision repaired by endo suturing.
Peritoneal cleansing and closure as before.
Copyright © 1999 [Dr. Kalaichandran]. All rights reserved.
|
