TREATMENTS

Laparoscopy (key hole surgery) is an operation using small cuts in your tummy to look at your abdominal and pelvic organs and to perform surgeries. Laparoscopy is a thin camera attached to a light source to visualise abdominal and pelvic organs clearly. Camera is connected to a screen to display real time video image of the organs and surgery. Usually it involves 3 small key holes in your tummy. There will be a 5 or 10mm cut (around ¼ or ½ an inch) in the belly button and 2 more, even smaller 5mm (around ¼ of an inch) cuts in your lower tummy.

Camera will be passed through the belly button incision and small operative instruments are then passed through the other 2 small holes to perform surgery.

Indications:

Laparoscopy can be performed for diagnostic or therapeutic purposes.

Diagnostic Laparoscopy:

1. Pelvic pain: There are several reasons for pelvic pain. Some of them are due to gynaecological causes. Some of the gynaecology causes are diagnosed by ultrasound scan including ovarian cyst, ectopic pregnancy, etc. However, some conditions need laparoscopy to diagnose. This includes endometriosis and scar tissue (adhesion) and pelvic infection.

2. Fertility: Laparoscopy helps in the confirmation of fallopian tube patency for fertility patients. Dye can be injected through the neck of the womb to confirm this.
Sometimes wemay not find any cause for your pelvic pain in laparoscopy. This will help usto reassure you that there is unlikely to be a gynaecology cause for your pelvic pain.

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Therapeutic Laparoscopy:

There are several minor and major gynaecological procedures that can be performed via laparoscopy. The list is ever increasing due to advanced skills and new technology / instruments. Some of them are,
1. Ectopic pregnancy treatment
2. Ovarian cyst removal
3. Tubal block surgery
4. Endometriosis surgery
5. Scar tissue (adhesions) removal
6. Fibroid surgery
7. Hysterectomy (removal of womb)
8. Removal of ovaries / fallopian tubes
9. Sterilisation

Advantages of Laparoscopy:

1. Early recovery from surgery
2. Early return to work and normal routine
3. Less post-operative pain
4. Less scar tissue formation
5. Better cosmetic appearance with small scar

Risks associated with Laparoscopy:

As with any surgery, laparoscopy also carries risk. Risks include pain and bruising at the site of incision, Pain in the pelvis, infection of the wound or urine, anaesthetic risks, sickness and vomiting due to anaesthesia, transient shoulder tip pain, blood clots in the leg, injury to viscera (bowel, bladder, ureter), bleeding and blood transfusion, opening up the tummy to complete the surgery. Some surgeries carry higher risks than others. Some patients have higher risk due to associated conditions including high BMI, previous multiple tummy surgeries. Mr Vathanan will have a detailed discussion about the risks associated with your surgery before you make any informed decision.

Further information:

1. https://www.nhs.uk/conditions/laparoscopy/
2.https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/recovering-well/laparoscopy.pdf

Hysteroscopy is a telescopic examination of the uterine cavity (womb cavity). It can be done under local or general anaesthesia depending on the nature of the treatment.

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Procedure:

Telescope in introduced through the vagina and neck of the womb in to uterine cavity. Therefore, it does not involve any cuts in your tummy. Saline in used to distend uterus. Telescope is connected to a screen to display real time video image of the uterine cavity and surgery.
Hysteroscopy is usually a day procedure and you will be discharged home on the same day after the procedure. If you have had general anaesthesia for the procedure, we advise you not to drive any vehicle and machinery for 24 hours as anaesthetics effects may last up to 24 hours. You need someone to pick you up after surgery.

Indications:

Hysteroscopy can be used for diagnostic and/or therapeutic purposes. Hysteroscopy is used for the diagnosis and treatment of abnormal uterine bleeding, heavy periods, fibroids, uterine polyps, removal of uterine septum, removal of impacted coil, removal of any foreign bodies or scar tissue (Asherman’s syndrome).

Duration of the surgery:

This depends on the type of surgery. Diagnostic hysteroscopy usually takes around 15 minutes to complete. Operative hysteroscopy can take up to an hour depending on the nature of the surgery

Risks with hysteroscopy:

As with any surgery, hysteroscopy also has risks. This includes bleeding during or after surgery, infection of the womb, anaesthetic complications such as nausea and vomiting, allergic reactions, blood clots in the leg and making a hole (perforation of the uterus) in the uterus. If a uterine perforation is suspected, a laparoscopic examination of the abdomen and pelvis may be necessary to rule out any organ damage. However, this is very rare.

Further information:

1. https://www.nhs.uk/conditions/hysteroscopy/

Hysterectomy involves removal of womb and neck of the womb (cervix). Neck of the womb can be left behind in certain conditions after a detailed discussion about its advantages and disadvantages. Hysterectomy sometimes combined with removal of ovaries and fallopian tubes. This depends on the reason for hysterectomy. Sometimes you will be offered removal of ovaries and fallopian tubes at the time of hysterectomy based on your age and other risk factors for any future risk for ovarian and fallopian tube diseases. Hysterectomy is a major operation and should only be performed once other conservative, medical and less invasive treatments are failed.

Indication:

Hysterectomy is done for several reasons, including heavy periods, fibroid uterus, premalignant or malignant conditions of the uterus, ovary or fallopian tubes.
After hysterectomy, your periods will stop and you will not be able to have children. If you had total hysterectomy (removal of womb and neck of the womb), you do not need cervical smear tests as cervix is also removed.

Removal of womb can be done via opening the abdomen (tummy) or through the vagina.
Different routes for hysterectomy depend on several factors including size of the uterus, any previous surgeries, nature of your condition, any associated prolapse of the womb, etc. You may or may not be suitable for a particular approach. Mr Vathanan will discuss this in detail when discussing hysterectomy option with you.

1. LaparoscopicHysterectomy: Removal of womb via 3 small key holes in your tummy. There will be a 10mm (around ½ an inch) cut in the belly button and 2 more, even smaller 5mm (around ¼ of an inch) cuts in your lower tummy, both sides.
Camera will be passed through the belly button incision and connected to a monitor to view inside your pelvis clearly. Small instruments are then passed through the other 2 small holes to disconnect womb from all its connections. Womb will then be removed through a cut in the vagina which is not visible outside. All sutures are dissolvable and you do not need any suture removal. Surgery takes around 2 hours and usually you will be discharged home on the 1st or 2nd day after surgery depending on your recovery. Laparoscopic approach has several advantages. It is done through 3 small incisions and scars are barely visible once healed. Therefore, it is more cosmetically appealing. Recovery is faster than tummy approach and most ladies go home and start their normal routine very early. As the cuts are smaller, post-operative pain is less.

Further information:

https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/recovering-well/laparoscopic-hysterectomy.pdf

2. Abdominal Hysterectomy: Surgery is done via an incision (cut) in the tummy. Incision can be a bikini incision (just above the bikini hair line) of around 10cm length. Some ladies need up down incision (from belly button to bikini hair line). Incision site mainly depends on the size of the uterus. Bikini incision is cosmetically appealing and heals faster with less risk for hernia and less post-operative pain than up and down incision. You will be discharged home on day 2 or 3 after surgery depending on recovery.

Further information:

https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/recovering-well/abdominal-hysterectomy.pdf

3. Vaginal Hysterectomy: You will not have any cut in your tummy. Womb is removed via a cut in the vagina, therefore it is cosmetically more appealing than other routes of hysterectomy. Vaginal hysterectomy is done only if you have a prolapse womb. You will be discharged home on day 2 or 3 after surgery depending on your recovery.

Further information:

1. https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/recovering-well/vaginal-hysterectomy.pdf

2. https://www.nhs.uk/conditions/hysterectomy/

Each woman has 2 ovaries that release egg every month for fertilisation and release female hormones in response to stimulation from brain. As you can see, ovaries play a major role in reproduction. Reproduction is not possible without at least 1 ovary, except having donor egg for fertilisation.

Ovaries can be removed via key hole surgery. You will only have 3 small cuts in your tummy (as in laparoscopy).

Indications:

One or both ovaries are removed for several reasons. It is done for cysts with malignant potential, symptomatic cysts or to reduce the risk for future ovarian cancer in high risk ladies.

Ovaries secrete female hormones. On removal of both ovaries, you will not produce female hormones anymore and you will enter in to menopause, if you are not already. You will develop menopausal symptoms. If you experience any post-menopausal symptoms, you may need hormonal treatment (HRT). Mr Vathananwill discuss this when he offers removal of both ovaries surgery. As removal of both ovaries stops all female hormones, your period will also stop after the surgery if you have both ovaries removed. If you have only 1 ovary removed, you will not usually experience any menopausal symptoms and you will continue to have regular periods. Hormones from 1 ovary is usually enough for reproduction and you can have children even after removal of 1 ovary.

Each woman has 2 fallopian tubes. Function of fallopian tube is to transfer fertilised embryo in to uterus for implantation. You need at least 1 functioning fallopian tube to transfer embryo. Therefore, fertilisation is still possible with 1 functioning tube. If you lose both tubes, fertilisation is not possible, except via in vitro fertilisation (IVF).

Indications:

Fallopian tube removal surgery (salpingectomy) is done for several reasons. Most common reason is to remove tubal ectopic pregnancy in which pregnancy is implanted and growing in the tube which is life threating if it ruptures. Other reasons include collection of water (hydrosalpinx), blood (haematosalpinx) or pus (pyosalpinx) in the tube. Sometimes damaged tubes are removed before IVF treatment to improve its success.

Procedure:

Surgery is done via laparoscopy (key hole surgery). You will have 3 small cuts in the tummy (see laparoscopy section for details) and one or both tubes are removed. Operation will take around 45 to 60 minutes and you will be discharged on the following day. Recovery will be early and most of the ladies will be doing their daily routine within a week or two.

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Fibroids can be removed via key hole (laparoscopy) or hysteroscopy or by opening the tummy. Mode of surgery is determined by the size and location of the fibroids. Larger, multiple fibroids need opening the tummy to remove all of them. If they grow within the cavity of the womb, they can be removed via hysteroscopy without any cut or scars in your tummy. Whatever the approach for surgery, it is difficult to remove all small, microscopic fibroids in the uterus. These small fibroids may grow up to become big fibroids later. So, myomectomy surgery is not a permanent cure for your fibroids even though we remove all fibroids during surgery, especially if you have had multiple fibroids. Some women need hysterectomy as a permanent cure for fibroids. Hysterectomy is usually offered after menopause or once you have completed your family or if there is any suspicion of premalignancy or malignancy within the fibroids.

1. Hysteroscopic surgery (minimal access):This approach is useful for sub mucous fibroids (when fibroid is grown within the cavity of the womb). This is usually a day surgery and you will be able to go home on the same day. Surgery will be under general anaesthesia and duration of surgery depends on the size and number of fibroids. Usually it takes around 25 to 30 minutes. Surgery involvesinserting a telescope in to your womb through vagina. Uterine cavity is distended with normal saline. Small instrument with a cutting tip is introduced via a small channel in the telescope and fibroid is cut in to small pieces and removed. Risks include bleeding, infection of the womb / pelvis, peroration of the womb (making a hole in the womb) and injury to bowel or bladder, fluid overload and blood clots in the leg. Complications are rare when surgery is performed by experienced surgeon.

2. Laparoscopic surgery (Key hole):Small and few fibroids can be removed via key hole surgery with 3 small cuts in your tummy. Surgery will be done under general anaesthesia. Durations of surgery depends on size and number of fibroids and experience of the surgeon. Usually you will be staying for 2 to 3 nights after surgery. Recovery takes up to 4 to 6 weeks, even though you will do your daily routine within a week or two. Risks includes as that for laparoscopy surgery ( see laparoscopy section). Fibroids are very vascular (high blood flow). Therefore, bleeding is particularly a risk. We will use different methods and techniques to reduce bleeding. In spite of this there is a risk of blood transfusion if the bleeding is heavy.

3. Open surgery:Larger and multiple fibroids are dealt with opening your tummy. It could be either bikini cut or up and down cut. The incision (tummy cut) depends on the size of the fibroids. Sometimes, we use medications to reduce the size of fibroids before surgery to have the surgery via bikini cut which is cosmetically appealing.Generalanaesthesiawill be used for surgery. All the fibroids are removed and will be sent for biopsy. You will be staying in the hospital for 2 to 3 nights depending on your recovery.

Risks includegeneral anaesthesia risks, bleeding, blood transfusion, pelvic infection, injury to surrounding structures (bowel, bladder), blood clots in the legs. As with any surgery, risks and complications are less when surgery is performed by experienced surgeon.

Ovarian cyst removal is usually done via key hole. But this depends on the size and nature of the cyst. Larger cysts can be deflated in a bag before extracting them via the small key hole. If there is any suspicion of malignancy, open surgery is preferred especially for larger cysts to remove the cyst intact without any spillage of contents in to the abdomen.
Most of the patients will be discharged on the same day, occasionally you may have to stay overnight.

Surgery for endometriosis depends on the extent and nature of organ involvement along with symptoms. Management also depends on the reproductive needs of the woman. Surgery is performed via key hole under general anaesthesia. Duration of surgery depends on the extent of the disease. Principle of endometriosis surgery involves removing all visible endometriosis and scar tissues that are formed as a result of endometriosis. This results in restoration of normal anatomy and function.

Superficial endometriosis:

This involves excision of all visible endometriotic deposits safely without damaging any organs. Sometimes we use laser / diathermy / Helica beam to destroy any superficial endometriosis.

Ovarian Endometrioma:

This is endometriotic cyst in the ovary. This is also called chocolate cyst of the ovary. Surgery involves excision of ovarian cyst and stripping off the cyst wall completely as otherwise recurrences are common. We use energy (Helica /Laser / diathermy) to destroy any remaining deposits in the ovary

Adhesiolysis (Removal of scar tissue):

This involves removal of all scar tissues in the pelvis to restore normal anatomy and to relieve pain. Scar tissues may involve abdominal and pelvic organs including bowel, bladder, uterus, fallopian tubes and ovaries. There is risk of injury to these organs, depending on the extent of organ involvement with scar tissue. Those who are trying to conceive will need complete removal of tubal and ovarian adhesions to improve fertility.

It is difficult to remove all endometriotic deposits, especially the deep infiltrating ones completely by surgery alone. Therefore, you may need varying lengths of medical treatment after the surgery. This depends on the extent of the disease, your symptoms and reproductive wishes. Mr Vathanan will discuss this in detail during consultation as the type of surgery and medical management differs from patient to patient.

Surgery depends on the type of prolapse.Mr Vathanan recommends you should continue your pelvic floor exercises regularly before and after surgery.

1. Bladder prolapse (Cystocele): Surgery involves reducing the prolapsed bladder and keep it reduced by supportive sutures. Surgery is performed under general or spinal anaesthesia. Surgery duration is around 40 to 45 minutes. You will be staying overnight for recovery. Complications are rare and include anaesthetic risks, bleeding, pelvic / urine infection, and injury to bladder.
2. Rectal prolapse (Rectocele): Surgery involves reducing the prolapsed rectum and keep it reduced by supportive sutures. Surgery is performed under general or spinal anaesthesia. Surgery duration is around 40 to 45 minutes. You will be staying overnight for recovery. Complications are rare and include anaesthetic risks, bleeding, pelvic / urine infection, and injury to bowel.
3. Uterine prolapse: Surgery involves vaginal hysterectomy. As the hysterectomy is performed vaginally, you will not have any cuts in your tummy. Surgery is performed under general or spinal anaesthesia. Surgery duration is around 40 to 50 minutes. You will be staying 2 to 3 nights in the hospital. Complications include anaesthetic risks, bleeding, pelvic / urine infection, and injury to bowel / bladder.

Further information:

https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/recovering-well/vaginal-hysterectomy.pdf

This is a surgery for cervical weakness (incompetence of neck of womb). Cervical weakness can give rise to miscarriages, especially late miscarriages.

Indication:

1. Short cervix with previous late miscarriage
2. Short cervix due to previous surgeries to cervix
3. Previous history of late miscarriage when the reason was likely be due to cervical incompetence
Procedure: Surgery can be done under general or spinal anaesthesia. You will be awake but do not feel any pain during surgery if you choose to have spinal anaesthesia. Surgery involves inserting a tape like suture around your cervix. This will be tightened around the cervix in order to close and support the neck of the womb (cervix). This helps to prevent premature opening of the cervix before labour. Surgery will take around 15 – 20 minutes. You will be staying overnight after surgery. You will be prescribed with medications on your discharge. Mr Vathanan will review you regularly after surgery to ensure stitch is in place and working. This involves ultrasound scanning.

Removal of stitch: Stitch will be removed around 37 weeks. This can be done in labour ward without any anaesthesia. If you are due to have caesarean section for any reason, then your stitch will be removed at the time of surgery.

Risks with cervical cerclage: Cervical cerclage is done to prevent pre term delivery. However, on rare occasions stitch can go through the water bag membrane and break the water. This can lead to pre term labour or infection of the womb. Risk is higher when stitch is inserted with already opened cervix with bulging membrane. Risk of this happening is very rare when you have elective cerclage by an experienced surgeon.

Further information:

https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-cervical-stitch.pdf

It is a procedure whereby lining of the womb of ablated (destroyed) with high temperature energy to treat heavy periods. This is a day procedure, so you will go home on the same day. It can be done under general or local anaesthesia.

Success Rate:

Around 90 % of ladies will be satisfied after the procedure due to reduce or no periods. Around half of them will have their periods completely stopped and the rest will have significantly reduced period. Around 10% of the ladies will continue to have heavy periods even after this procedure.

Contraindication:

1. Abnormally shaped uterus / very large or very small uterine cavity
2. Those who wish to have more children. Endometrial ablation reduces your fertility and pregnancy is dangerous after ablation. You should continue to use effective contraception to avoid pregnancy

Procedure:

It will be performed under general anaesthesia. Initially a hysteroscopy (telescope examination of the womb) is performed and biopsy from the lining of the womb is taken (if not performed already). An ablation devise is introduced through your vagina and neck of the womb in to the endometrial cavity (womb cavity). This devise destroys the lining of the womb with electrical energy. You will be discharged home on the same day.

Risks:

Risks are rare, but as in any surgery, there are risks. It includes risk of infection of the womb/ pelvis, risk of damage to the cervix (womb neck), womb or part of the bowel or bladder (if womb injury makes a hole in it). You may experience vaginal bleeding like a light period and period type abdominal cramps for few days. Risks are rare and far less than the risk of having hysterectomy

Further information:

1. https://www.acog.org/-/media/ForPatients/faq134.pdf?dmc=1&ts=20190213T0011379142
2. https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/recovering-well/endometrial-ablation.pdf