Hysteroscopy Hysteroscopy is a surgical technique by which the internal cavity of the uterus can be visually inspected by inserting a hysteroscope (a thin fiber optics lens that is 3-5mm in diameter with a built in light source) through the cervical os (the opening of the vagina into the uterine cavity). Fluid is introduced simultaneously through an accessory port of the hysteroscope and permitted to flow out another port. The control of the fluid (hydrostatic) pressure serves to help expand the walls of the uterus and thus facilitate the visualization of the uterine cavity. Flow of the fluid in and out of the cavity also ensures clarity of view by continuously flushing out obscuring blood, particles, and/or debris.
Hysteroscopy can be coupled with specialized surgical instruments small enough to fit through additional small accessory ports of the scope, thus allowing the surgeon to biopsy, destroy or remove lesions such as polyps or fibroids from the uterine cavity.
Because of the relatively non-invasive nature of the procedure, the patient can undergo the procedure in the doctor’s office with minimal post operative pain, blood loss and a rapid post operative recovery. As previously stated, the instrument is introduced through the cervical os, which is an existing orifice in the uterus, and therefore no incisions in the uterine and or abdominal wall are required during the procedure.
Hysteroscopy can be also utilized to perform in-office permanent sterilization:
With Adiana™ procedure by Hologic®, and Essure™ procedure by Conceptus®, a slender flexible instrument is introduced through the operative port of the hysteroscope that has been placed in the uterine cavity of the patient. The opening of the fallopian tubes in the uterine cavity are identified, and small devices are inserted into the opening of the each fallopian tube in the uterine cavity. Following delivery of the miniscule devices, the hysteroscope and instruments are removed and the devices are left in place. The devices cause closure of the fallopian tubes over the course of 90 days. These procedure are extremely safe, and are performed in the comfort of the doctors office under mild analgesia. No cutting or removal of tissue is needed. A test to confirm the closure of the fallopian tubes is performed 90 days after application of the devices.
Endometrial Ablation Endometrial ablation is a procedure utilized to treat and resolve abnormal uterine bleeding (excessive in amount, duration or frequency) that can occur as a consequence of hormonal imbalance, and/or perimenopause.
Abnormal bleeding can also be caused or aggravated by other problems such as fibroids, endometrial polyps and/or malignancies of the uterus. It is therefore imperative for the patient to have an appropriate workup to rule out these possibilities. This workup may include an endometrial biopsy (sampling of the inner lining of the uterus) and/or a visual (hysteroscopic) examination of the uterine cavity. Menstrual periods are the consequence of the monthly regeneration and shedding of the endometrial lining of the uterus in a cyclic fashion.
The purpose of the ablation is to destroy the endometrium. The end result of destroying the endometrium is that the uterus loses the ability to regenerate and shed this lining on a monthly basis. As a result, the patient’s menstrual periods become scant, sometimes disappearing altogether. Because of the targeted nature of the procedure, only the endometrium is affected, and therefore the body of the uterus and other reproductive organs (i.e. ovaries) are spared and remain functioning in their normal manner.
It is a good alternative for a woman with excessive or irregular menses with bleeding that has not been effectively controlled by medications such as oral contraceptive pills. Sometimes the patient has had previous dilatation & curettage (D&C) procedures that have had short acting or temporary effect, and are seeking a more permanent therapy. Most important, endometrial ablation offers an effective treatment modality to eliminate excessive and/or irregular bleeding for the long term (current data show >85 % absence of periods rate for greater than 5 years), without having to recur to more serious surgical procedures, such as a hysterectomy.
The procedure is performed under mild anesthesia at a hospital on an outpatient basis, or in the comfort of the doctor’s office. The total duration of the procedure including the examination of the uterine cavity is approximately 15 minutes. The patient is released the same day, and post-operative discomfort is limited to mild to moderate uterine cramps that are effectively managed at home with pain medications such as Ibuprofen.
There are different protocols or techniques for performing the ablation, but they are all equally safe and effective. The doctor may recommend a particular procedure based on the size and shape of your uterine cavity.
Novasure™ endometrial ablation by Hologic® utilizes radio waves energy for the treatment of the endometrium. A hysteroscopic evaluation of the uterine cavity is performed. The device is then inserted through the endocervical canal and a small mesh-like array is deployed. Upon deployment, the mesh-like array is allowed to come in close contact with the endometrial surface of the uterine cavity, and radio wave energy is transmitted through the mesh. The endometrium is treated for up to 90 seconds, and after completion of the treatment, the array is folded and removed from the uterine cavity. A quick hysteroscopic evaluation of the cavity is again performed in order to verify proper treatment.
It is important to note that since the intended purpose of the procedure is to destroy the endometrium, it is not recommended for women who desire future fertility. This procedure will most likely seriously impair the ability to conceive and carry a pregnancy. By the same token, the procedures are not intended as a mode of contraception. We routinely recommend that patients continue to use some form of contraception, or undergo a permanent sterilization procedure prior to having an endometrial ablation.
Laparoscopy and Robotic Assisted Laparoscopy Similar in concept to a hysteroscopy, this technique involves the direct visualization of abdominal and pelvic organs via the introduction of a small fiber optic lens 5-10 mm in size (with a built in light source) into the abdominal cavity. Entry to the abdominal cavity is achieved by making a small incision at the level of the umbilicus (navel), inserting a multipurpose access port, and passing the fiber optic lens through the port into the abdomen. In contrast to hysteroscopy where fluid is used to expand the uterine walls, in laparoscopy, nitrogen gas is used to expand the abdominal walls, and therefore obtain good visualization of the abdominal and pelvic organs.
Additional access ports may be placed in strategic places along the abdominal wall in order to facilitate the passage of multiple specialized surgical instruments. The net effect is to permit the surgeon to perform intra-abdominal/pelvic surgery without the need of a large surgical incision. Again, post operative pain is substantially decreased and post operative recovery time is minimized. Many patients are discharge home from the hospital the same day of the procedure.
Procedures traditionally performed through large abdominal incisions are now routinely handled through laparoscopic interventions. Examples of these procedures are diagnostic procedures, destruction and/or excision of endometriosis lesions, hysterectomies (removal of the uterus), myometomies (removal of uterine fibroids), surgeries for urinary incontinence, removal or drainage of ovarian cysts, removal of ovaries and/or fallopian tubes, bilateral tubal ligation and evacuation of ectopic (tubal) pregnancies. A specialized form of laparoscopy called Single Incision Laparoscopic Surgery or SILS is designed for those individuals that desire the aesthetic benefits of having their entire laparoscopic surgery done through a single small (generally an umbilical) incision.
The use of robotic assisted laparoscopic surgery plays an important role in complex laparoscopic cases. The daVinci™ robotic platform manufactured by Intuitive Surgery® enables the laparoscopic surgeon to see the operative field in a 3-D enhanced fashion, and allows magnification of the operative field up to 10 fold. In addition, the surgeon controlled robotic arms allow the laparoscopic surgeon to perform complex surgical maneuvers with great precision and ease not previously available in traditional laparoscopic surgery. As a result, complex cases that would have required a large abdominal incision, can now be performed with greater ease in a laparoscopic fashion. The robotic assisted laparoscopic surgery has the same benefits as traditional laparoscopic surgery in terms of significant reduction of post operative pain, and decreased post operative recovery time.
Currently, our robotic cases are done exclusively at Silver Cross Hospital in New Lenox, Illinois.