Gynecology

Fibroids are non-cancerous (benign) growths of the muscle wall of the uterus. They are probably responsible for more unnecessary gynecologic surgery than any other condition. Every year a staggering 600,000 American women have a hysterectomy. And about 30 percent of those hysterectomies, 180,000 in all, are performed because of fibroids. For many years gynecologists have surgically removed these growths, often because of fear of the problems they might cause in the future. And those problems are often overstated.

Approximately 750,000 hysterectomies are performed annually in the United States, with a mortality rate of about 12 per 10,000 operations.1 Costs to consumers and insurers have been estimated at approximately $1.7 billion per year.2 Thus, alternative procedures that are safer and less invasive, preserve the uterus, and cost less are increasingly in demand. In recent years, several such techniques have been introduced.

Laparoscopic myomectomy (LM) is a minimally invasive surgical procedure for the removal of uterine myomas. It was first described in the late 1970s by Semm. Subsequently, equipment has been developed to enhance the procedure. LM requires advanced laparoscopic skill and expertise in suturing and tissue removal. Laparoscopic assisted myomectomy (LAM), a procedure that combines operative laparoscopy and minilaparotomy, was described by Nezhat et al in 1994.

Rectovaginal fistula (RVF) is an epithelium-lined communication between the rectum and vagina. Most RVFs are acquired, the most common cause being obstetric trauma. Most of the high RVFs are repaired by conventional open surgery. Laparoscopic repair of RVF is rare and so far only one report is available in the literature.

A Randomised Controlled Trial to Assess the Efficacy of Laparoscopic Uterosacral Nerve Ablation (LUNA) in the Treatment of Chronic Pelvic Pain: The trial protocol [ISRCTN41196151]The LUNA Trial Collaboration

Fallopian tube prolapse as a complication of abdominal hysterectomy is a rare occurrence. A case with fallopian tube prolapse was managed by a combined vaginal and laparoscopic approach and description of the operative technique is presented.

Exploratory laparoscopy is often used in women with chronic pelvic and abdominal pain, but negative findings are often reported. This article describes how better physical exams and diagnosis can often eliminate an unnecessary surgery.

Submucous and intracavitary myomas can often be removed through the cervix using an instrument called a resectoscope. The resectoscope is a special type of hysteroscope with a built in wire loop that uses high-frequency electrical energy to cut or coagulate tissue. It was developed for surgery of the bladder and the male prostate over fifty years ago to allow surgery inside an organ without having to make an incision, and has made hysteroscopic myomectomy possible.

Fibroids that are attached to the outside of the uterus by a stalk (pedunculated myomas) are the easiest to remove laparoscopically. Many subserous myomas (close to the outer surface) can also be removed through the laparoscope.

Uterine fibroid embolization represents a fundamentally new approach to the treatment of fibroids. Embolization is a minimally invasive means of blocking the arteries that supply blood to the fibroids. It is a procedure that uses angiographic techniques (similar to those used in heart catheterization) to place a catheter into the uterine arteries. Small particles are injected into the arteries, which results in the blockage of the arteries feeding the fibroids. This technique is essentially the same as that used to control bleeding that occurs after birth or pelvic fracture, or bleeding caused by malignant tumors.

Fibroids are non-cancerous (benign) growths of the muscle wall of the uterus. They are probably responsible for more unnecessary gynecologic surgery than any other condition. It is a staggering number, but about 600,000 American women have a hysterectomy every year. And about 30% of those hysterectomies, 180,000 in all, are performed because of fibroids. For many years these growths have been surgically removed, often because of fear of the problems they might cause in the future. And, those problems are often overstated. While approximately 30% of all women will have fibroids during their lifetimes, the vast majority of these women will never have symptoms and will never require treatment. And, for the rare patient that does have problems, there are a number of sound and effective options available. Hysterectomy should be the solution of last resort.

In some situations surgery may be recommended by your physician. Although many people around the world walk into hospitals each day to face an operation, very few of us can do it without at least some fear. It is always a step that requires a great deal of thought and consideration since it involves some discomfort, some risk, and some disruption of one's life.

Over the past decade, a technique has been developed that can reduce or stop your periods without a hysterectomy. This surgery can be done in women who have flooding either with or without fibroid tumors. Dr. Dott was one of the surgeons who introduced this minimally invasive procedure in Atlanta. He has performed this procedure many times and is certified by the Accreditation Council for Gynecological Endoscopy in Advanced Hysteroscopic Surgery. He has taught this procedure in training institutions both in the United States and Russia.

Laparoscopy, looking inside the abdomen through a tube placed through a small incision, is a procedure commonly used by gynecologists to diagnose and treat a number of medical conditions. Since the early 1900's when rudimentary laparoscopes were used to visualize, but not treat, abdominal diseases, advancements in this technique have led to the ability to perform complex surgical procedures through a few small incisions, rather than the larger incisions used in the past.

Laparoscopy is a form of minimally invasive surgery. The surgeon inserts a tiny telescope (laparascope) though a small incision at the umbilicus (belly-button). The laparoscope allows the surgeon to visualize the pelvic organs on a video monitor. Several additional smaller incisions are made in the abdomen for the surgeon to place specially designed surgical instruments, which help the surgeon carry out the same procedure as in open surgery.

Many gynecologists will remove laparoscopically ovaries/ovarian cysts and treat ectopic pregnancies as well as endometriosis. Hysterectomies, bladder suspension surgeries and pelvic floor repair can also be treated by laparoscopy but these procedures are more advanced and may require additional training.

Hysteroscopy is a form of minimally invasive surgery. The surgeon inserts a tiny telescope (hysteroscope) through the cervix into the uterus. The hysteroscope allows the surgeon to visualize the inside of the uterine cavity on a video monitor. The uterine cavity is then inspected for any abnormality. The surgeon examines the shape of the uterus, the lining of the uterus and looks for any evidence of intrauterine pathology (fibroids or polyps). The surgeon also attempts to visualize the openings to the fallopian tubes (tubal ostia).

Questions on Laparoscopy & Hysteroscopy

More than half of the 600,000 hysterectomies performed in the 1900s involved bilateral salpingo-oophorectomy, and it has been estimated that many of those were performed solely to reduce the risk for ovarian cancer. While there has been increased knowledge in the risk in women with familial history, a knowledge gap still exists for other women, which could lead them down the path of potentially unnecessary surgery

In Part 3, the speakers address the question: Is there a place for robot-assisted laparoscopy? They also discuss the benefits that should not be ignored and what role robot-assisted laparoscopy might play in clinical practice in the future.

In Part 2, the authors discuss how robotic laparoscopic hysterectomy compares with traditional laparoscopic hysterectomy. They also explore the clinical implications of one treatment versus the other.

Optical coherence tomography (OCT), a new imaging technology that allows noninvasive cross-sectional imaging, has high sensitivity for diagnosing cervical cancer, but low specificity, according to a study published in the March issue of Lasers in Surgery and Medicine.

Cementless modular total hip arthroplasty together with subtrochanteric osteotomy appears to be a satisfactory treatment for patients with prior Crowe Group-IV dysplasia of the hip, according to research published in the March 16 issue of The Journal of Bone & Joint Surgery.

To prevent over-distention of the bladder, clinicians rely on indwelling catheters for several days. However, little is know about the ideal length of time for catheter use. Although short-term catheterization can reduce hospital stays and urinary tract infections, it can also lead to increased postoperative voiding problems such as obstructive voiding and large residual volumes; these in turn can result in urinary tract infections and bladder dysfunction.

Performing surgeries laparoscopically offers patients faster recovery, decreased blood loss and transfusion rates, and less postoperative pain, but laparoscopic procedures in gynecologic oncology can be very challenging and requires significant technical expertise and experience. It is believed that the integration of robotics into these surgeries might offer a significant advantage in the learning curve, thus allowing more surgeons to offer this procedure to their patients. . . but is this an effective and safe alternative?