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Hysteroscopy
Hysteroscopy involves placing you under general anesthesia, dilating the cervix and inserting a rigid or flexible scope (camera) through the cervix into the uterine cavity. Various ways can be used to distend the cavity to enable the doctor to get a good view such as carbon dioxide, normal saline fluid, glycine, or hyscon. Specific operations can be performed from inside the uterus such as removal of endometrial polyps, fibroid removal, endometrial ablation, excision of uterine septum or adhesions, or unblocking fallopian tubes.
Options to not doing hysteroscopy depend upon your situation and the doctor will be able to discuss this with you.
The risks of hysteroscopy involve heavy bleeding. Bleeding may occur from cervical dilation, uterine perforation, and removal or resection of a uterine lesion. Uterine perforation may be self-limiting, but may require exploratory surgery to ensure other internal organs were not injured. Hysterectomy would be considered in the case of life-threatening bleeding, but this would only be a final option. Other risks include infection post-procedure, with the need for antibiotic therapy and intrauterine scarring following the procedure, especially if a polyp or fibroid were removed.
Uterine distension media such as glycine or Hyscon can, in rare situations, cause liver failure or platelet dysfunction, but careful monitoring of the volume used is the safest preventative technique. Carbon dioxide insufflation can cause shoulder pain from diaphragmatic irritation. Additionally, in very rare situations, acute air embolism can occur, which can be fatal.
Laparoscopy
This outpatient procedure involves placing a scope (camera) through an incision in the abdomen. Typically, this is in the lower part of the belly button, but advances have made the scope position variable as in gall bladder removal, hernia repair, and appendectomies. Gynecologic laparoscopy uses carbon dioxide gas to fill the abdomen to provide a good view. Other incisions can be made in the lower abdominal wall to insert operating instruments. The surgery may involve as many as five puncture sites on your abdomen, but one in the belly button, and two to three in the lower abdomen is typical. We prefer to do laparoscopy after your menstrual flow has ended when the blood flow to the area is minimal.
Risks include injury to internal organs such as the bowel, bladder, vessels, and female organs. This may require opening the abdomen to repair or remove the injured organ (see Laparotomy). Shoulder pain, some nausea and vomiting after the surgery is not uncommon and will go away in 24-36 hours.
Adhesions released through the laparoscope tend to recur less frequently than when done through an open incision. This procedure is also used during GIFT or ZIFT (see Treatments and Procedures) to place the gametes or pronuclear embryos in the fallopian tube.
Convalescence time after 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 enables you to convalesce and be ready for work on Monday.
Laparotomy
Laparotomy involves opening a patient's abdomen by a larger incision. This is truly major surgery. There are various incisions and locations used for various procedures. Laparotomy may be indicated if a particular procedure cannot be performed effectively by laparoscope. If possible, we prefer to attempt a Pfannensteil incision or smiley cut just above your pubic bone. This is the most cosmetically appealing incision and provides the greatest support to the abdomen.
In most circumstances you will be admitted to the hospital the day of the surgery and if you are able to eat the next day, you may go home to convalesce in your own bed. The hospital will attempt to contact you the day before surgery to inform you to be at the hospital two hours before surgery. You will eat nothing after midnight before the surgery.
Once home after the surgery, avoid climbing stairs, lifting anything, bending, or prolonged sitting. Apply heat to the abdominal incision. Do not take baths for 10 days but shower and then use a pad to dry the incision area. Move around for 5-10 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 its 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
Fibroids or myoma are commonly benign growths of uterine smooth muscle. They can appear in any location of the uterus. Depending upon their size, number, and location, they can cause uterine cramping and heavy, irregular bleeding. An alternative to hysterectomy in this case is removal of the fibroid, a procedure called "myomectomy". Contraindications would include vaginal bleeding with a low blood count or if they are shown to be cancerous. Rapid growth over a few months or during the menopausal period suggests that they may not be benign. Indications are to preserve the uterus and avoid hysterectomy.
Fibroids can be removed via a laparoscope, laparotomy, or hysteroscope. See the above sections on these procedures. If the uterine cavity is entered during the surgery, a distending balloon may be placed in the uterine space and will have a line exiting the vagina. In most situations, you will be able to eat and walk by the next day and are encouraged to convalesce at home.
Risks include bleeding, injury to internal organs, repair or removal of female organs, bladder, or bowel, and the formation of pelvic adhesions which may require further surgery. It will be 2 or 3 months before you can attempt pregnancy. After the surgery you will be on estrogen to build the lining and 12 to 14 days after the surgery, the balloon can be removed. You may need a hysterosalpingogram to evaluate the uterine shape and any residual scarring.
Metroplasty
Metroplasty involves surgical reshaping of the uterus and uterine cavity. Uterine septum and cavity unification are best done with operative hysteroscopy. Septums can be thin or thick and are associated with a higher rate of pregnancy losses, especially in the second trimester. Removal of the septum may be followed by placement of a distending balloon in the uterus to attempt to prevent or minimize intrauterine adhesions.
The risks are basically the same as those with hysteroscopy and myomectomy. In some severe cases, a procedure may require laparotomy in order to reshape the uterus such as unifying a two-horned or two-cavity uterus. A follow-up hysterosalpingogram is necessary to determine the success of the uterine reshaping.
Ovarian Diathermy
This outpatient procedure involves laparoscopy and some form of intentional injury to the ovarian surface. By lasering, burning, or coagulating the ovarian cortex and associated follicles, the polycystic ovary (PCO) patient has up to a 94% chance of spontaneous ovulation and a 75% chance of achieving pregnancy within one year. The results will vary depending upon the size of the patient, the smoking history, and the duration of unchecked polycystic ovaries. This surgical approach is associated with up to a 28% chance of ovarian adhesions post-operatively. An alternative to this is low-dose gonadotropin therapy for ovulation induction. Benefits of diathermy include immediate improvement of the abnormal hormonal profiles with frequent resumption of ovulation, lowered androgen levels, and elevated estradiol levels.
First posted: 10/26/96
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