Hysteroscopy
Hysteroscopy is a procedure by which an instrument with a camera is inserted through the cervix and into the uterus to allow visualization of the uterine cavity. Done under general anesthesia, the cervix is dilated, the hysteroscope inserted, and the uterine cavity is distended with carbon dioxide, normal saline, glycine, or hyscon to enable the doctor to better visualize all areas. If an abnormality is found, surgical procedures can be performed to remove such things as endometrial polyps, uterine fibroids, uterine septum or adhesions. In addition an endometrial ablation can be performed and certain fallopian tube obstruction can be corrected.
The risks associated with hysteroscopy include heavy bleeding, infection, or uterine scarring. Bleeding may occur from dilation of the cervix, perforation of the uterus, or from the site of removal or resection of a uterine lesion. Uterine perforation can be self-limiting, but may also require exploratory surgery to ensure other internal organs were not injured. It is possible that a hysterectomy would be necessary in the rare case of life-threatening bleeding, but this would be done only as a last resort.
The fluid used to distend the uterus (glycine, Hyscon) can, in rare situations, cause liver failure or platelet dysfunction, but careful monitoring is used to prevent this from occurring. Carbon dioxide insufflation can cause shoulder pain after the procedure and in very rare cases can cause an acute air embolism to occur that can be fatal.
Laparoscopy
Laparoscopy is an outpatient procedure in which an instrument with a camera is placed into the abdomen through a small incision in the lower part of the belly button. (Advances in laparoscopic techniques have made placement of the incision variable when it is used for gall bladder removal, hernia repair, and appendectomies.) Gynecologic laparoscopy uses carbon dioxide gas to fill the abdomen that allows the physician to visualize the ovaries, fallopian tubes and uterus. Additional incisions (as many as 5) may be made in the lower abdomen to allow for the insertion operating instruments if they are needed.
The risks associates with laparoscopy include: injury to bowel, bladder, vessels, uterus, fallopian tubes or ovaries that may require additional surgery to repair or remove the injured organ (see Laparotomy). It is common to experience shoulder pain, nausea and possibly vomiting after the surgery is not uncommon, however these symptoms generally resolve within 24-36 hours.
If you have adhesions, they can by released through the laparoscope. This type of treatment tends to offer less chance of recurrence than when the procedure is done through an open incision.
Laparoscopy is also the procedure used with GIFT or ZIFT (see Treatments and Procedures) to place the gametes or pronuclear embryos into the fallopian tube.
Recovery for a laparoscopy is variable but most patients may return to work within 3 days from the surgery. Thursdays and Fridays are optimal for such surgery as the weekend allows you to rest and recover so you can be ready for work on Monday. (We prefer to do laparoscopy after your menstrual flow has ended, so blood flow to the area is minimal.)
Laparotomy
Laparotomy is a procedure that involves making a larger incision in the lower abdomen and may be indicated if a particular procedure cannot be performed effectively with a laparoscope. When possible, we use a Pfannensteil incision (bikini or “smile”) just above your pubic bone that is the most cosmetically appealing and provides the greatest support to the abdomen.
In preparation for surgery, you will be instructed not to eat or drink anything (including water) after midnight before surgery. In most circumstances you will be admitted to the hospital on the day of the surgery and will go home the following day to recover in your own bed. The hospital will attempt to contact you before surgery to advise you to be at the hospital two hours before your scheduled surgery time.
After the surgery, avoid heavy lifting, bending, sitting for prolonged periods of time and climbing stairs. Apply heat to the abdominal incision. Do not take baths for 10 days but shower and then us a pad to dry the incision area. Move around for 5 to 10 minutes every two hours while awake and advance your activity slowly. Stand or recline but avoid sitting as it strains the back and stretches the abdominal incision. You should avoid intercourse for 6 weeks or until the doctor says it’s OK.
Slight vaginal spotting is normal and some low back pain for up to two weeks following the surgery. Obtain medical advice if you experience shortness of breath or chest pain, excessive or prolonged bleeding, temperature greater than 100.6 degrees or pulse greater than 100.
Myomectomy
Fibroid tumors or uterine myomas are common growths/tumors of uterine muscle wall that can appear anywhere in the uterus. Depending on the size, number, and location of the fibroids, they can cause uterine cramping and heavy and/or irregular bleeding. There are several treatment options available for fibroids, including hysterectomy, myomectomy, and embolization. Myomectomy is a surgical approach that can be performed through laparoscopy, laparotomy, or hysteroscopy to remove the fibroids without removing the uterus. This procedure, however, may be contraindicated in cases where heavy vaginal bleeding has caused a low blood count (anemia) or if there is a high suspicion for cancer. While fibroids are rarely malignant/cancerous, if they grow rapidly over a few months or during the menopausal period it is possible that they are not be benign.
The risks of myomectomy include bleeding, injury to the bowel, bladder, ovaries, fallopian tubes, or ovaries leading to repair or removal of the injured organ, and formation of pelvic adhesions that could require surgery in the future.
In most situations, you will be able to go home the next day to recover if you are able to eat and walk without assistance. If the uterine cavity is entered during the surgery, a distending balloon may be placed inside the uterus that has a tube leading out of the vagina. In this case you will be placed estrogen for 12 to 14 days to build up the lining of the uterus before the balloon can be removed. It will be 2 or 3 months before you can attempt pregnancy and you may need a hysterosalpingogram to evaluate the uterine shape and the formation of any scarring.
Metroplasty
Metroplasty is a surgical procedure that reshapes the uterus and uterine cavity and is done to correct defects of the uterus that can contribute to pregnancy loss and/or infertility. These defects most commonly involve the presence of a uterine septum (wall) that separates the uterus into two cavities. Most of these defects can be corrected with operative hysteroscopy, however, some defects may require laparotomy. Removal of the septum may also necessitate the placement of a distending balloon in the uterus to help prevent or minimize intrauterine adhesions. (see above) In addition a follow-up hysterosalpingogram will be necessary to determine the success of the uterine reshaping.
The risks associated with metroplasty are basically the same as those with hysteroscopy and myomectomy: bleeding, injury to the bowel, bladder, ovaries, fallopian tubes, or ovaries leading to repair or removal of the injured organ, and formation of pelvic adhesions that could require surgery in the future.
Ovarian Diathermy
Ovarian diathermy is an outpatient procedure involving laparoscopy for the purpose of intentionally injuring the surface of the ovary using laser, cautery, or coagulation. For women with polycystic ovarian syndrome (PCO) this procedure can lead to a 94% chance of spontaneous ovulation with a 75% chance of achieving pregnancy within one year depending such things as weight, smoking history, and the time her ovaries functioned in a polycystic fashion. There is, however, up to a 28% chance of developing ovarian adhesions post operatively. An alternative treatment for polycystic ovaries is the use of low dose gonadotropin therapy to stimulate ovulation. The benefits of ovarian diathermy are immediate improvement of abnormal hormonal profiles, resumption of ovulation, lowered androgen levels, and elevated estradiol levels.
