• What is diagnostic hysteroscopy?

Diagnostic hysteroscopy is used to diagnose problems of the uterus. Diagnostic hysteroscopy is also used to confirm results of other tests, such as hysterosalpingography (HSG). HSG is an X-ray dye test used to check the uterus and fallopian tubes. Diagnostic hysteroscopy can many times be done in an office setting.

Additionally, hysteroscopy can be used with other procedures, such as laparoscopy, or before procedures such as dilation and curettage (D&C). In laparoscopy, your doctor will insert an endoscope (a slender tube fitted with a fiber optic camera) into your abdomen to view the outside of your uterus, ovaries and fallopian tubes. The endoscope is inserted through an incision made through or below your navel.


• What is operative hysteroscopy?

Operative hysteroscopy is used to correct an abnormal condition that has been detected during a diagnostic hysteroscopy. If an abnormal condition was detected during the diagnostic hysteroscopy, an operative hysteroscopy can often be performed at the same time, avoiding the need for a second surgery. During operative hysteroscopy, small instruments used to correct the condition are inserted through the hysteroscopy.

• When is operative hysteroscopy used?

Your doctor may perform hysteroscopy to correct the following uterine conditions:

  • Polyps and fibroids —Hysteroscopy is used to remove these non-cancerous growths found in the uterus.

  • Adhesions —Also known as Asherman’s Syndrome, uterine adhesions are bands of scar tissue that can form in the uterus and may lead to changes in menstrual flow as well as infertility. Hysteroscopy can help your doctor locate and remove the adhesions.

  • Septums— Hysteroscopy can help determine whether you have a uterine septum, a malformation of the uterus that is present from birth.

  • Abnormal bleeding— Hysteroscopy can help identify the cause of heavy or lengthy menstrual flow, as well as bleeding between periods or after menopause. Endometrial ablation is one procedure in which the hysteroscope, along with other instruments, is used to destroy the uterine lining in order to treat some causes of heavy bleeding.



• What are the benefits of hysteroscopy?

Compared with other, more invasive procedures, hysteroscopy may provide the following advantages:
  • Shorter hospital stay

  • Shorter recovery time

  • Less pain medication needed after surgery

  • Avoidance of hysterectomy

  • Possible avoidance of "open" abdominal surgery


• How safe is hysteroscopy?http://www.gynecologistkolkata.net/cimage30/110622pic20.jpg

Hysteroscopy is a relatively safe procedure. However, as with any type of surgery, complications are possible. With hysteroscopy, complications occur in less than 1 percent of cases and can include:

  • Risks associated with anesthesia

  • Infection

  • Heavy bleeding

  • Injury to the cervix, uterus, bowel or bladder

  • Intrauterine scarring

  • Reaction to the substance used to expand the uterus


• When should the procedure be performed?

Your doctor may recommend scheduling the hysteroscopy for the first week after your menstrual period. This timing will provide the doctor with the best view of the inside of your uterus. Hysteroscopy is also performed to determine the cause of unexplained bleeding or spotting in postmenopausal women.


• What type of anesthesia is used for hysteroscopy?

Anesthesia for hysteroscopy may be local, regional, or general:

  • Local anesthesia --the numbing of only a part of the body for a short time

  • Regional anesthesia --the numbing of a larger portion of the body for a few hours

  • General anesthesia --the numbing of the entire body for the entire time of the surgery

The type of anesthesia used is determined by where the hysteroscopy is to be performed (hospital or doctor’s office) and whether other procedures will be done at the same time. If you are having general anesthesia, you will be told not to eat or drink for a certain amount of time before the hysteroscopy.


• How is hysteroscopy performed?http://www.gynecologistkolkata.net/cimage30/110622pic35.jpg

Prior to the procedure, your doctor may prescribe a sedative to help you relax. You will then be prepared for anesthesia. The procedure itself takes place in the following order:

  • The doctor will dilate (widen) your cervix to allow the hysteroscope to be inserted.

  • The hysteroscope is inserted through your vagina and cervix into the uterus.

  • Carbon dioxide gas or a liquid solution is then inserted into the uterus, through the hysteroscope, to expand it and to clear away any blood or mucus.

  • Next, a light shone through the hysteroscope allows your doctor to see your uterus and the openings of the fallopian tubes into the uterine cavity.

  • Finally, if surgery needs to be performed, small instruments are inserted into the uterus through the hysteroscope.

The time it takes to perform hysteroscopy can range from less than 5 minutes to more than an hour. The length of the procedure depends on whether it is diagnostic or operative and whether an additional procedure, such as laparoscopy, is done at the same time. In general, however, diagnostic hysteroscopy takes less time than operative.


• What can I expect after the procedure?

If regional or general anesthesia is used during your procedure, you may have to be observed for several hours before going home. After the procedure, you may have some cramping or slight vaginal bleeding for one to two days. In addition, you may feel shoulder pain if gas was used during your hysteroscopy. It is also not unusual to feel somewhat faint or sick. However, if you experience any of the following symptoms, be sure to contact your doctor:

  • Fever

  • Severe abdominal pain

  • Heavy vaginal bleeding or discharge


• Will I have to stay in the hospital overnight?

Hysteroscopy is considered minor surgery and usually does not require an overnight stay in the hospital. However, in certain circumstances, such as if your doctor is concerned about your reaction to anesthesia, an overnight stay may be required.


Why does one require laparoscopy?

Laparoscopy is an important diagnostic tool in the evaluation of an infertile patient. An inspection through the laparoscope gives us a general impression of the state of the pelvis and enables us to find the cause of infertility. Also, the tubal patency can be checked by injecting a blue dye into the uterus, through a thin tube inserted through the cervix (mouth of the uterus), and seeing it spill out though the tubes. In addition the laparoscope can also be used to safely carry out operative procedures, which enhance fertility.


Commonly done procedures by laparoscopy

  • Assessment of tubal patency by chromopertubation

  • Adhesiolysis to clear tubes, ovaries and uterus and restore normal anatomy of pelvis

  • Laparoscopic Ovarian drilling in PCOS

  • Cyst removal from ovaries

  • Laparoscopic Endometriotic cyst drainage and fulgurating all endometriotic deposits in the cyst

  • Clearance of endometriosis including fulguration of all possible deposits in pelvis

  • Obtaining biopsies to confirm diagnosis if in doubt from ovaries, tube or deposits in the pelvis

  • Opening of the distal end of tubes

  • Removal of ectopic pregnancy

  • Removal of fibroids protruding on the surface of the uterus

  • Clipping or removal of tubes before IVF in case of gross hydrosalpinx

  • Controlling hysteroscopic septum resection or hysteroscopic adhesiolysis by direct visualization by laparoscope simultaneously, to prevent injury to uterus or any other surrounding structures

  • Confirming successful cornual cauterization to achieve tubal patency by seeing spillage of dye from the outer end of the tube.

Advantages of laparoscopy over open surgery

  • Smaller and cosmetically better scars

  • Reduced pain after surgery

  • Shorter stay in the hospital

  • Less chances of wound infection

  • Faster recovery and resumption of normal activity

Complications of laparoscopy

  • Inability to perform the procedure due to technical problems or extreme obesity

  • Intended laparotomy (open surgery) in the best interest of the patient whenever required

  • Injury to internal organs and blood vessels


Hysteroscopy

Hysteroscopy is an operative procedure performed under general anesthesia where a telescope is introduced into the uterus through the vagina to visualize the inside of the uterus.

Why does one require hysteroscopy?
Hysteroscopy is done to visualize the inside of the uterus to make sure that there are no pathologies, which could cause infertility and which if present, can be corrected simultaneously by operative hysteroscopy to improve fertility.

Hysteroscopy can treat following conditions:http://www.gynecologistkolkata.net/cimage30/110622pic18.jpg

  • Visualization of cavity of uterus and site specific targeted biopsies whenever necessary

  • Removal of endometrial polyps

  • Removal of sub- mucous fibroids

  • Clearance of adhesions in the cavity of the uterus

  • Excision of uterine septum

  • Removal of foreign bodies or old products of conception or embedded intra uterine contraceptive devices

  • Cornual catherizationto open up the tubes

  • Insertion of ESSURE for proximal tubal occlusion


Complications Of Hysteroscopy

  • Inability to perform the procedure due to technical problems

  • Poor visualization due to thickened endometrial/ poor distension

  • Difficult cervical dilation due to fibrosis/ cervical ridge

  • Uterine perforation

 Q1. What is the approximate time taken for surgery?
Ans. About 30 minutes to 1 hour depending upon nature of the surgery.

Q2.Will I need to take complete bed rest?
Ans. No, You can get up from bed and start moving about as early as 2 hours after surgery unless advised otherwise by your consultant. You can start walking, climbing stairs and can resume all basic activities on the very same day, 4-6 hours after surgery.

Q3. How soon can I start eating after the surgery?
Ans. Approximately 3 hours after surgery (initially liquids followed by soft diet), normal diet is allowed next day onwards.

Q4. When can I bathe after Laparoscopy?
Ans. You can bathe the day after the surgery. In case the dressing becomes wet, you can even take it off and then apply some aftershave lotion or spirit and put a band-aid on it.

Q5. Will I have any pain after surgery?
Ans. Slight pain and distension of abdomen along with shoulder pain are common after surgery. This is because, gas is filled into the abdomen to visualize the inside during surgery. However, this settles within 24 hours. You can take a pain killer whenever required. A slight pain at the stitch line may continue even up to 7 days, which is normal.

Q6. Can I have vaginal bleeding after surgery?
Ans. There may be some bleeding for a few days after hysteroscopy, which subsides on its own.

Q7. When can I get back to work?
Ans. Usually one to two days of low activity after surgery should suffice. However, follow the concerned doctor’s advice.

Q8. Will I require general anesthesia & overnight stay in the hospital?
Ans. Procedures using laparoscopy are routinely performed under general anesthesia as day care cases, without the need for an overnight stay in hospital. However, prolonged laparoscopic procedures may require one or more days as an in-patient, depending on the exact nature of the procedure.

Myomectomy (my-o-MEK-tuh-mee) is a surgical procedure to remove uterine fibroids — also called leiomyomas (lie-o-my-O-muhs). These are common noncancerous growths that appear in the uterus, usually during childbearing years, but they can occur at any age.

The surgeon's goal during myomectomy is to take out symptom-causing fibroids and reconstruct the uterus. Unlike hysterectomy, which removes your entire uterus, myomectomy removes only the fibroids and leaves your uterus intact.

Women who undergo myomectomy report improvement in fibroid symptoms, including heavy menstrual bleeding and pelvic pressure.



Why it's done?

Your doctor might recommend myomectomy for fibroids causing symptoms that are troublesome or interfere with your normal activities. If you need surgery, reasons to choose a myomectomy instead of a hysterectomy for uterine fibroids include:

  • You plan to bear children

  • Your doctor suspects uterine fibroids might be interfering with your fertility

  • You want to keep your uterus

Here's what you can do to prepare:

  • Gather information. Before surgery, get all the information you need to feel confident about your decision to have a myomectomy. Ask your doctor and surgeon questions.http://www.gynecologistkolkata.net/cimage30/110622pic27.jpg

  • Follow instructions about food and medications. You'll need to stop eating or drinking anything in the hours before your surgery — follow your doctor's recommendations on the specific number of hours. If you're on medications, ask your doctor if you should change your usual medication routine in the days before surgery. Tell your doctor about any over-the-counter medications, vitamins or other dietary supplements that you're taking.

  • Discuss the type of anesthesia and pain medication you may receive. Abdominal, laparoscopic and robotic myomectomies are performed under general anesthesia, which means you're asleep during the surgery. Hysteroscopic myomectomy is performed under general anesthesia or spinal anesthesia, where medication is injected into your spinal canal to numb the nerves in the lower half of your body. Ask about pain medication and how it will likely be given.

  • Arrange for help. Your facility may require that you have someone accompany you on the day of surgery. Make sure you have someone lined up to help with transportation and to be supportive.

  • Plan for a hospital stay if necessary. Whether you stay in the hospital for just part of the day or overnight depends on the type of procedure you have. Abdominal (open) myomectomy usually requires a hospital stay of two to three days. In most cases, laparoscopic or robotic myomectomy only requires an overnight stay. Hysteroscopic myomectomy is often done with no overnight hospital stay.




What you can expect?

Depending on the size, number and location of your fibroids, your surgeon may choose one of three surgical approaches to myomectomy.

Abdominal myomectomy
In abdominal myomectomy (laparotomy), your surgeon makes an open abdominal incision to access your uterus and remove fibroids. Your surgeon enters the pelvic cavity through one of two incisions:

  • A horizontal bikini-line incision that runs about an inch (about 2.5 centimeters) above your pubic bone. This incision follows your natural skin lines, so it usually results in a thinner scar and causes less pain than a vertical incision does. It may be only 3 to 4 inches (8 to 10 centimeters), but may be much longer.  Because it limits the surgeon's access to your pelvic cavity, a bikini-line incision may not be appropriate if you have a large fibroid.

  • A vertical incision that starts in the middle of your abdomen and extends from just below your navel to just above your pubic bone. This gives your surgeon greater access to your uterus than a horizontal incision does and it reduces bleeding. It's rarely used, unless your uterus is so big that it extends up past your navel.

http://www.gynecologistkolkata.net/cimage30/110622pic28.jpg

Laparoscopic or robotic myomectomy

In laparoscopic or robotic myomectomy, minimally invasive procedures, your surgeon accesses and removes fibroids through several small abdominal incisions.

During laparoscopic myomectomy, your surgeon makes a small incision in or near your bellybutton. Then he or she inserts a laparoscope — a narrow tube fitted with a camera — into your abdomen. Your surgeon performs the surgery with instruments inserted through other small incisions in your abdominal wall. During robotic myomectomy, instruments are inserted through similar small incisions, and the surgeon controls movement of instruments from a separate console.

The fibroid is cut into smaller pieces and removed through these small incisions in the abdominal wall or, rarely, through an incision in your vagina (colpotomy).

Laparoscopic and robotic surgery use smaller incisions than a laparotomy does. This means you may have less pain, lose less blood and return to normal activities more quickly than with a laparotomy. Uterine size and fibroid number and location are factors in determining when laparoscopic surgery is appropriate.



Hysteroscopic myomectomy

To treat fibroids that bulge significantly into your uterine cavity (submucosal fibroids), your surgeon may suggest a hysteroscopic myomectomy. Your surgeon accesses and removes fibroids using instruments inserted through your vagina and cervix into your uterus.
Your surgeon inserts a small, lighted instrument — called a resectoscope because it cuts (resects) tissue using electricity or a laser beam — through your vagina and cervix and into your uterus. A clear liquid, usually a sterile salt solution, is inserted into your uterus to expand your uterine cavity and allow examination of the uterine walls. Using the resectoscope, your surgeon then shaves pieces from the fibroid until it aligns with the surface of your uterine cavity. The removed tissue washes out with the clear liquid that's used to expand your uterus during the procedure.
Rarely, surgeons also use a laparoscope inserted through a small incision in your abdomen to view the pelvic organs and monitor the outside of the uterus during a complicated hysteroscopic myomectomy.



When you go home?


At discharge from the hospital, your doctor prescribes oral pain medication, tells you how to care for yourself, and discusses restrictions on your diet and activities.
You may have to avoid certain activities, such as driving, lifting heavy objects, climbing stairs or exercising vigorously until you recover. Also, your doctor may advise that you not use tampons or have sexual intercourse during recovery. You can expect some vaginal spotting or staining for a few days up to six weeks, depending on the type of procedure you've had.

*Abdominal myomectomy recovery typically takes four to six weeks.
*Laparoscopic or robotic myomectomy recovery typically takes two to three weeks.
*Hysteroscopic myomectomy recovery typically takes less than a week.

Results:

Outcomes from myomectomy may include:

  • Symptom relief. After myomectomy surgery, most women experience relief of bothersome signs and symptoms, such as excessive menstrual bleeding and pelvic pain and pressure.

Fertility improvement. Removing submucosal fibroids by hysteroscopic myomectomy can improve fertility and pregnancy outcomes. Many factors can impact fertility, but often, women who plan a pregnancy after myomectomy conceive within one year of having the surgery. After a myomectomy, wait three months before attempting conception to allow the uterus enough healing time. Although more studies are needed, the effect of abdominal, laparoscopic or robotic myomectomy on fertility appears to be about the same — more limited than if your fibroids can be removed by hysteroscopic myomectomy.
 

 
 
 
 
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