For the past three decades, gynecologists have been utilizing the hysteroscope in the office to diagnose a variety of conditions that can be responsible for symptoms such as abnormal uterine bleeding, recurrent miscarriage, infertility, and post menopausal bleeding. The most common lesions found during diagnostic office hysteroscopy include cervical and uterine polyps, submucous myomata, uterine septae, intrauterine adhesions, endometrial hyperplasia and endometrial cancer.
Video of Hysteroscopic Polypectomy
It is advantageous to perform surgery in the least invasive way possible while still getting optimal results. Although I usually prefer to do surgery through a laparoscope rather than through a larger incision, I have felt limited by the lack of wrist-like movements of the instruments. I felt that deeper myomas (that couldn’t be removed by a hysteroscope) were better removed through a regular incision.
The most important requirement for successful hysteroscopy is satisfactory distension of the uterus. While many different media have been used, recent advances in equipment have greatly simplified the use of saline for diagnostic and simple operative hysteroscopy that does not require the use of electrosurgical instruments.
It is usually quite simple to find the cause of abnormal menstrual bleeding, although occasionally the cause may not be found. Since abnormal uterine bleeding can be caused by disorders of the uterus, hormone imbalance (usually not ovulating), and pregnancy, it is helpful to look at each area separately. When I see someone for abnormal bleeding, I ask the following questions.
There are many ways to treat cervical dysplasia (CIN). Factors influencing the choice of treatment for cervical dysplasia include the extent and severity of the dysplasia, the age of the woman, and whether or not she has any other gynecological problems. Often the experience of the physician or other clinician, and the availability of equipment are also major factors. The following are the most common methods of treating cervical dysplasia:
Dr. Paul Indman: “Jordan, this is a momentous occasion. It’s hard to believe there’s talk of your retirement and, of course, I don’t believe that you’re really retiring.”Dr. Jordan Phillips: “Well, it’s a change of activity. I will retire as of December 31, 2000 from the Board of Trustees. I anticipate continuing some of my other activities; I’m the Managing Editor of the Journal of the AAGL, and I plan to continue that and other things.”Dr. Paul Indman: “I’m sure you’ll be just as involved as ever.”Dr. Jordan Phillips: “Not on a day-by-day basis.”Dr. Paul Indman: “You’ve been characterized as a visionary by everyone who has spoke and certainly I think you are. Today we saw a presentation on space medicine doing laparoscopy in zero gravity. What do you see as the future of endoscopic surgery?”Dr. Jordan Phillips: “Number one, I think endoscopic surgery has proven that it’s a very important part of the armamentarium for surgery. I see that through the last several years the use of endoscopy has gone from just being a diagnostic tool and a sterilizing tool to being a full operating tool. So now we can do full surgeries using the endoscope but it requires one other major ingredient and that’s the skill of the surgeon so you must have a very competent surgeon doing complicated endoscopic procedures.”Dr. Paul Indman: “What is the AAGL doing to improve the skill of surgeons?”Dr. Jordan Phillips: “We continue to do many things. Not only do we have the annual meeting but we also have regional meetings, we have workshops, and we put on live cadaveric surgical anatomy programs. We’re doing a whole series of things besides publishing the Journal with all the recent articles, putting out News Scope, which is a news article, and having bulletins put out. AAGL has been very busy.”Dr. Paul Indman: “I think the AAGL has been responsible for improving the skill of surgeons around the world and certainly it’s probably the number one influence that I’ve seen. What are some of your wildest dreams that we’ll be doing in twenty-five years?”Dr. Jordan Phillips: “It’s come even faster than that and that is the majority of surgeries performed will be actually done through an endoscope. They’ll be very few operations performed in a routine gynecological practice that’s being done by open surgery. Open surgery doing a full open incision is almost obsolete and there are some departments in the world today where 90% of all gynecologic operations are done through an endoscope.”Dr. Paul Indman: “What do you see as the biggest resistance to that in our country?”Dr. Jordan Phillips: “The biggest resistance that we have is the case that we have to continue to train people and to make them better surgeons and smoother; safe surgeons I guess is the best term to use.”Dr. Paul Indman: “One of the problems I hear constantly with surgeons is that insurance companies are reimbursing less and less, they may essentially reimburse for a half an hours worth of work and the surgeons say - I can do this in a half an hour if I make a giant incision but it will take me three or four hours through a laparoscope, I can’t afford to do that. How can we get around that?”Dr. Jordan Phillips: “They’ve been able to prove that by using a laparoscope it’s less cost because they use less equipment, the patient doesn’t stay in the hospital as long, and most endoscopic operations are done in a short stay. That is they go in in the morning and they have the operation then go home in the afternoon so they don’t even stay overnight so the expenses will change because of the decreased hospital costs.”Dr. Paul Indman: “The total cost though but still the surgeon has such a major disincentive for doing that and I’m wondering how we can change that?”Dr. Jordan Phillips: “We tried to educate the insurance companies that we’re actually saving the insurance company money on their hospital bills and frankly we are. We have tried and we’ve convinced some of the insurance companies to actually have part compensation. If you do a hysterectomy through a laparoscope or do a hysterectomy through an open incision or vaginal they should have equal compensation, whichever method or approach you use.”Dr. Paul Indman: “Let’s get back to you, Jordan, because this is obviously a very important meeting. This is your last meeting where I guess your Chairing the Board.”Dr. Jordan Phillips: “That’s correct.”Dr. Paul Indman: “What do you think you will be doing next, personally?”Dr. Jordan Phillips: “Oh, we’re quite busy. My wife and I have a project in China called Medical Books for China International where we collect unwanted medical books that we send to China. We’ve now completed 60 shipments of 20 tons in each shipment so we’ve sent over 1,000 tons of medical books, journals, audio tapes, and video tapes to China that have been distributed to over 1,000 medical libraries. This takes a lot of organization, and it’s all handled through our own office. We’ve become the focal point for many institutions, many book dealers, and many book distributors to actually have them send their surplus books to us. Now it adds up to actually over 3 million books in all specialties not only in eye, ear, nose, throat, cardiology, chest, GI, GU, orthopedics, all specialties including nursing, veterinary medicine, basic science, medical law, and all of the various paramedical activities in books. So we’ve actually filled the shelves of many libraries in China, which were empty when we started.”Dr. Paul Indman: “So you’ll be working on that a lot?”Dr. Jordan Phillips: “Not a lot, we have it well organized. We have a staff that does it but it does require attention that we go to China. The Chinese distribute the books, we don’t distribute the books, and we’re planning for next June to have a World Congress in China on medical libraryship on the technical aspects of doing a medical library. There’s a lot to it where it’s changed with the use of computers and all the various new modalities that are available, and we’re going to introduce this to China. All of the Chinese major medical schools, and there are 127 medical schools in China, will come to this meeting. My wife, Mary Zoe Phillips, is actually Secretary General of this entire meeting. We did one ten years ago but now it’s ten years later.”Dr. Paul Indman: “What other visions for the future do you have, Jordan?”Dr. Jordan Phillips: “What other visions for myself?”Dr. Paul Indman: “For yourself and AAGL.”Dr. Jordan Phillips: “The AAGL will continue; it will continue its impact, continue its growth, and continue to be innovative. When you have these very dynamic young people who are push, push, push, I think that this is what’s going to happen. I have complete faith in the future.”Dr. Paul Indman: “You certainly need to be congratulated on such a wonderful organization and it’s a true family.” Dr. Jordan Phillips: “Yes, it really is a family and that’s what we started. In fact, we started right from the beginning and I didn’t call them board dinners, I called them family dinners and that’s just what it is. We got involved with the people, their children, their wives, and families and many other things. I can tell you one of the greatest joys I’ve had has been writing letters of recommendation for some of our people to become advanced in their academic activity. To write letters to become professors or associate professors, it’s a joy for me to do that.”Dr. Paul Indman: “The AAGL has been a family to me, thank you so much, Jordan.”Dr. Jordan Phillips: “You’re welcome, Paul Indman, it’s been a pleasure to see you. Thank you.”
Excess absorption of liquid distending media is one of the most frequent complications of operative hysteroscopy. Although most women recover uneventfully, we are seeing cases of permanent morbidity or death resulting from this complications.
Currently there are two ways to treat endometriosis – hormonal therapy and surgery. Depending on the patient’s expectations and the extent of the disease, we may prescribe hormonal therapy, surgery, a combination of surgery and hormonal therapy, or occasionally a just “wait and see” approach.
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.
OBGYN.net Conference CoverageFrom the 34th Annual Meeting - Chicago, Illinois - November 2005
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.
Isolated unilateral torsion of a fallopian tube is an infrequent but significant cause of acute lower abdominal pain in a female of reproductive age. We present a literature review and a case of a 41 yrs old lady who presented with sudden onset right sided lower abdominal pain radiating to right thigh. Clinical examination revealed tenderness in right lower abdomen and tender right adnexal mass was noted on vaginal examination.
A rare case of the inguinal endometriosis was reported with immunohistochemical analysis. A 28-year-old woman had a thumb-sized tumor in the right groin for two years with a gradual increase in size and pain. An operation revealed an elastic hard tumor with an unclear margin and adhesion to the uterine round ligament. The histology showed irregular proliferation of the endometrial glands and stroma.
The usefulness of hysterosalpingography (HSG) as routine investigation in the fertility work-up prior to laparoscopy and dye had been assessed in a randomized controlled trial. Recruiting subjects to the study was more difficult than anticipated. The objective of this study was to explore possible reasons for non-participation in the trial.
Intracytoplasmic sperm injection (ICSI) is a component of infertility treatment often employed when conventional in vitro fertilization is unlikely to be successful. Despite good clinical results with ICSI, the procedure is typically associated with degeneration of a significant percentage (approximately 10%) of the treated oocytes. The cause of this degeneration remains unclear. Speculation that damage caused by oocyte compression during the injection procedure may be responsible has led to the development of a novel technique known as laser-assisted ICSI.
Comparison of Human Uterine Cervical Electrical Impedance Measurements Derived Using Two Tetrapolar Probes of Different Sizes
Tubal sterilization is the method of family planning most commonly used. The existence of the post-tubal-ligation syndrome of menstrual abnormalities has been the subject of debate for decades.
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.
It is usually quite simple to find the cause of abnormal menstrual bleeding, although occasionally the cause may not be found. Since abnormal uterine bleeding can be caused by disorders of the uterus, hormone imbalance (usually not ovulating), and pregnancy, it is helpful to look at each area separately.
"Fibroids" or "uterine myomas (short for leiomyoma)", affect 30% of women. The terms "fibroid" and "myoma" are used interchangeably. Most fibroids do not cause symptoms, and do not require treatment.
Hysteroscopy uses a hysteroscope, which is a thin telescope that is inserted through the cervix into the uterus. Modern hysteroscopes are so thin that they can fit through the cervix with minimal or no dilation.
Myomectomy is the only surgical treatment of myomas that preserves fertility. The safety of pregnancy after uterine artery embolization has not been established, and pregnancy is impossible after hysterectomy. The average reduction in volume of fibroids after a UAE is 50%, where fibroids that have removed are completely gone.
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.