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Endoscopic Surgery in Gynaecology
Dr Glen Taylor




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Endoscopic Surgery in Gynaecology
Table of Contents
  • Endometrial Ablation - Resection
  • Ectopic pregnancy
  • Adnexal surgery
  • Hysterectomy (LAVH, laparoscopic assisted vaginal hysterectomy)
  • Colposuspension
    • The last five years have seen a consolidation and advancement of gynaecological Endoscopic surgery. I feel that it is timely that these techniques be reviewed with terminology verified.
    Typical portal sitesalign:right

    Endometrial Ablation - Resection

    This procedure has now found its niche and continues to be a popular alternative for women with unacceptable menstrual blood loss (quantity, length) or unacceptable withdrawal bleeds on hormonal replacement. I use the term "ablation" to refer to pure roller-ball coagulation and TCRE (trans-cervical resection of endometrium) to refer to resectoscope excision alone or in combination with roller-ball (usually).

    Patient selection is critical and permanent amenorrhoea is no longer emphasised (although this occurs in 50 per cent + of patients). If the woman would not accept a continuation of menstruation (albeit much reduced in volume and usually length and symptomatology), I don't think she is a candidate for ablation or resection. A much higher degree of permanent amenorrhoea is expected the closer to the menopause. The advantages clearly lie with its shortness and simplicity of surgical procedure - a day only stay and virtually pain free, and early return to usual activities.

    Ectopic pregnancy

    In Lismore I would estimate that more than 90 per cent of ectopic pregnancies are now dealt with by Endoscopic techniques. The minimal procedure is performed and includes:
    • Laparoscopic aspiration - tubal abortion or fimbrial ectopic,
    • Laparoscopic linear salpingostomy - products of conception removed, tube flushed, follow-up HCG levels? Methotrexate is being used in some centres,
    • Laparoscopic segmental tubal resection,
    • Laparoscopic salpingectomy,
    • Laparoscopic salpingo-oophorectomy,
    • Laparoscopic oophorectomy (ovarian ectopic).
    Most patients are discharged within 24-48 hours. At a recent meeting, figures were presented to show that there is a higher fertility rate/intra-uterine pregnancy rate in subsequent pregnancies with laparoscopic techniques.

    Adnexal surgery

    These include - adhesiolysis, ovarian cystectomy, oophorectomy, ovariectomy, correction of torsion and non-ectopic tubal surgery, e.g. hydro salpinx, drainage or resection. A high degree of clinical prediction of benign conditions is a pre-requisite. Cystic lesions are usually aspirated and debulked to be removed. Solid benign tumours can be removed piecemeal or through culdotomy (the Pouch of Douglas).

    Hysterectomy (LAVH, laparoscopic assisted vaginal hysterectomy)

    Increasingly popular. A definite alternative to abdominal hysterectomy (not a straightforward vaginal hysterectomy).

    The upper pedicle - broad ligament are taken laparoscopically with the utero-sacral ligaments and uterine arteries taken vaginally with the uterus being removed vaginally. A very large fibroid uterus can be debulked for removal vaginally. Can be combined with laparoscopic adnexal surgery e.g. ovariectomy or adhesiolysis. Definite improved post-operative course over abdominal hysterectomy.

    Colposuspension

    This involves replicating an open Burch procedure with laparoscopic techniques. Provides excellent anatomical definition. The advantages over the open Burch procedure are - no need for supra-pubic catheterisation and subsequent voiding retraining which usually takes four plus days. With the laparoscopic technique an indwelling catheter (Foleys) remains in situ for only 24 hours post-operatively. Patients are discharged 48 hours post surgery.

    There is no need for a Redivac drainage to the cave of Retzius. Recent studies have shown that the laparoscopic procedures maintains the high expected long term cure rate of genuine stress incontinence as does the open procedure (90 per cent).

    All the above minimally invasive surgical techniques in gynaecological Endoscopic procedures are now well established in Lismore and I look forward to their increased consolidation and future addition of techniques.

    Glenn Taylor
    Obstetrician and Gynaecologist

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