Gynecology

To interpret the literature describing the results of surgery for endometriosis, a clear understanding of the evolution and limitations of the various techniques is necessary. Up to the end of the 1970’s, minimal and mild endometriosis was destroyed endoscopically by heat application (endothermia) and by unipolar or bipolar coagulation. Treatment of more severe endometriotic disease was mostly radical by hysterectomy, often leaving some rectovaginal endometriosis which has not been fully recognised before 1989.

Endometriosis can infiltrate the surrounding tissues resulting in an important sclerotic, and inflammatory reaction which can translate clinically in nodularity, bowel stenosis and ureteral obstruction. The most severe forms such as rectovaginal endometriosis and endometriosis invading the rectum or the sigmoid have been known since the beginning of this century. These conditions, however, are relatively rare with an estimated prevalence of less than 1%.

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.

Welcome to this, my first column for OBGYN.net. My hope is that my monthly articles will entertain, question and stimulate you in all areas of OBGYN. I am a general obstetrician and gynecologist working in North London, United Kingdom with particular interests in endoscopic surgery and urogynaecology. I am also an award winning medical journalist. Over the coming months I hope to share my experiences and thoughts with you, challenge our beliefs and contribute to the ongoing debate that shapes improvements in clinical care. I welcome your feedback.

Most patients with endometriosis do not have intestinal (GI) involvement. Among the difficult cases of endometriosis I see from around the world, only 27% have GI involvement. Since over 1900 patients with endometriosis have undergone surgery at St. Charles, that means I’ve operated on over 500 patients with GI involvement. The symptoms of GI involvement depend on the severity and location of the disease. The severity of disease depends on the depth of invasion into the bowel wall.

If we consider how the management of our patient's medical problems has changed throughout the years, it is easy to despair at the well-meaning intentions of our predecessors. Though we still cannot be complacent about many of the current treatment options for patients, a new era of evidence based practice as opposed to the intuitive based practice of former times has evolved. Evidence based practice is not a panacea, but it can provide us with an insight into the advantages and disadvantages of existing therapies, and expose their weaknesses thus encouraging further research.

Objective: To study the findings obtained by diagnostic laparoscopy in gynaecological problems in order to re-assess the role of laparoscopy in the diagnosis of gynaecological problems during the study period.

60 obese infertile women (BMI >30) and 60 non-obese infertile women (BMI

Objectives: To compare the efficiency of laparoscopic treatment versus conventional abdominal surgery in the treatment of ectopic pregnancy (EP) and to review the clinical presentation, evaluate methods of diagnosis, and identifying the risk factors.

Acute on-set of Hematometra and Hematosalpinx in a non-communicating Rudimentary Horn of an Unicornuate Uterus: Laparoscopic Management

A preliminary examination under anaesthesia should be performed, the results of pre-operative investigations should be checked to confirm the indications and limitations of the proposed procedure. The retroperitoneal lomboaortic lymphadenectomy achieved via a left internal iliac approach (Dargent et al, 2ooo). The left side is chosen for this approach because most of the lymphnodes are found in the left paraortic region (Michel et al,1998) and because it is also possible to dissect on the right side via this approach (Dargent et al, 2000).If the preoperative work-up reveals right side adenopathy, a similar approach on the right is entirely possible.

Following the first studies carried on by S. Gordts, the technique of Fertiloscopy has been developed, starting in 1997, by A.Watrelot at the "Centre Lyonnais de recherche et d'étude de la stérilité (CRES®)". Fertiloscopy is a new minimally invasive methods for the exploration of the posterior cul-de-sac which allows a complete work out of the mechanical factors of female infertility.

Hysterectomy is the most frequently performed surgery in women. The difference in life time risk between countries probably reflect the mainly the attitude of the surgeon and the available techniques.

Total laparoscopic hysterectomy (TLH) has for me since 1996 completely replaced all abdominal hysterectomies, except when the uterus is bigger than 1 kilo. A series of larger uteri have been operated (my biggest was 1850 grams) but when a uterus is larger than 1 kilo it is preferable to discuss the surgery in detail with the patient beforehand.

Both types of surgery are complimentary. Each has specific advantages and indications. It is an advantage to have and to be able to use both.

Pelvic floor disorders: Cystocoele, Rectocoele - Enterocoele, Descensus Uteri, Incontinence

Endometriosis is still poorly understood despite a high and still increasing publication rate of over 500 articles a year, i.e. 455 426, 448, 504 and 534 in the last 5 years respectively. It is considered to be one of the most important causes of pelvic pain and of infertility. The exact prevalence is not known since a laparoscopy is required to make the diagnosis and since the recognition varies with the training and the interest of the laparoscopist. Moreover the pathophysiology is poorly understood, which makes it difficult to formulate and test simple hypotheses.

Dr. Dubuisson stated that there is is a great demand from patients for minimally invasive surgery and it is important that the surgeon apply certain conditions to the selection of patients for successful treatment of leiomyomas by laparoscopy. Dr. Dubuisson said that the indications for a safe laparoscopic myomectomy include the following:

Laparoscopic hysterectomy is indeed promising, but it is not yet within the capability of most gynecologists. Further refinement in the technique is needed before it is ready for general endorsement.

When performing operative laparoscopy and using bipolar current to achieve hemostasis or desiccate vessels, there are a couple of simple techniques that can make the task easier for the surgeon. The first trick alleviates the frustration when one is attempting to desiccate either vessels or tissue with a bipolar instrument, and the instrument keeps sticking to the tissue and the char. Inevitably then when the surgeon attempts to remove the instrument or pull it from contact with the tissue, the seal is broken and the vessel or tissue begins bleeding again.

Mackendrodt performed the first colonic resection for sigmoid endometriosis in 1909. Research has revealed that approximately 10 percent of menstruating women have endometriosis and up to 34 percent may have intestinal involvement.

Laparoscopy has been steadily replacing laparotomy because the abdomen does not have to be opened up, resulting in faster recovery and reduction of complications. In laparoscopy, only three small incisions are made for the entry of a small camera and other instruments. Thus, the operation that is taking place inside the abdomen/pelvis can be viewed on a video screen placed next to the operating table.

The word Laparoscopy simply means visual examination of the abdomen by means of a laparoscope. Laparoscopy (often called "belly button surgery", endoscopy, or key hole surgery) is a surgical technique involving small incisions in the abdomen through which major surgical procedures can be performed. One of the incisions is made in the umbilicus ("belly button").

For pelvic floor repair we use the following principles.1. Site specific repair i.e. repair of the defect only. 2. Restrictive use of a mesh i.e. when necessary only. A mesh by definition carries a little risk of complications such as infection, of mesh erosion and more complicated subsequent surgery when necessary. 3. The use of a mesh when the vaginal wall is opened should be avoided.

Laparoscopy is now an option for many gynecological conditions. This overview discusses specific laparoscopic procedures and the conditions they treat.