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Endoscopy

Gynec endoscopy implies both hysteroscopy and laparoscopy. Hysteroscopy is visualization of the internal cavity of the uterus, the tubal openings and the endometrial lining. Through a Hyteroscope we can visualize and also correct any abnormalities like a uterine polyp, a fibroid projecting into the cavity, any growth which projects into the cavity, blocked openings of the fallopian tube, and correct any intrauterine septum or adhesions. Laparoscopy is used to visualize and operate on any of the abdominal organs like liver, gall bladder, and in women with infertility, the uterus, fallopian tube and ovaries. A Gynecologist who is trained to perform Gynaecolgical endoscopic surgery both for the purpose of diagnosis of a problem and also to surgically correct it is a Gynec endoscopic surgeon.

Dr. Sudha Tandan

Laparoscopy surgery involves performing the surgery by making very small punctures on the abdomen instead of the traditional big incision. This involves the use of highly technical equipments like telescopes, camera, light source, medical monitors, electrosurgical equipments and electronic CO2 insufflators. The entire procedure can be recorded on a video cassette or a CD. Clipping of the important steps of the surgery can be stored on a computer and a print of the same can be given to the patient. In laparoscopy, as there only small punctures on the abdomen and not big cuts, the advantages to the patient are very little pain in the postoperative period, faster mobilization, faster recovery and resumption of work, almost within 10-15 days after major surgery, early oral intake of fluids within 12-24 hours after surgery, discharge within 24-48 hours after surgery and better cosmetic appeal.
It is indicated in women with:

Infertility.
Chronic lower abdominal/pelvic pain.
Painful periods.

Laparoscopy is now a standard form of surgical treatment in the infertile women who have the following problems:

Ectopic pregnancy.
Endometriosis.
Fibroid.
Adhesions/Tubal blocks.
Polycystic ovarian disease.
Ovarian cysts.




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Diagnostic Laparoscopy

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As the name suggests, the word 'diagnostic laparoscopy' means, use of laparoscope to see, and diagnose the cause of a problem like infertility, chronic abdominal pain or painful periods. The uterus is a muscular organ present in the centre. The surface of the uterus is smooth. The two fallopian tubes on their medial ends are attached to the uterus on either side. The other end is called the fimbrial end is free and appear like the petals of a flower. The fallopian tube is 10 cms long. The inner cavity of the uterus is in connection with the inner lumen of the fallopian tube. Hence on diagnostic laparoscopy, when the fallopian tubes are open, a sterile coloured fluid (usually sterile methylene blue) when injected through the cervix, is seen flowing out from the fimbrial end of the fallopian tube.

The ovaries are almond shaped white coloured structure, also attached to the uterus. The surface is irregular, which suggests that the woman is ovulating regularly. The space behind the uterus and which is in between the uterus in front and the rectum behind is called the Pouch of Douglas. It is normally free of adhesions. Diagnostic hysteroscopy can be done under local anesthesia but when it is combined with a diagnostic laparoscopy, general anesthesia is used. Operative hysteroscopy is done either under local, spinal or general anesthesia. Office hysteroscopy is a procedure which is performed using a flexible hysteroscope of less than 2mm diameter. This is not painful and it can be done as an outpatient procedure without any anesthesia or under local anesthesia.

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Hysteroscopy Service

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Hysteroscopy is visualization of the cavity of the uterus, the lining of the uterus and the openings of the fallopian tubes, Normally the cavity of the uterus is collapsed. But for hysteroscopy, the cavity is distended with sterile solution. Diagnostic and operative hysteroscopy is indicated in

Infertility:
  • To open the cornual openings
  • To cut intrauterine adhesions
  • To cut the intrauterine septum
  • To visualize the uterine cavity before Embryo Transfer
  • To resect of the submucous fibroid
  • To excise intrauterine polyp
  • In women with postmenopausal bleeding
  • In women with excessive bleeding

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Laparoscopy Services

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Laparoscopy is a procedure which is performed under full general anesthesia. In laparoscopy, a long needle is inserted in the abdominal cavity through a very small cut below the naval, carbon dioxide is passed through this needle to distend the abdominal cavity, and next the laparoscope is inserted through the same opening. Cold light is transmitted through a fiber optic cable attached to the laparoscope, this helps in visualizing the organs. The picture got is transmitted to the TV monitor through a camera attached to the telescope. The organs are handled by means of other long instruments which go through smaller punctures. Hence during a laparoscopy a woman will have 2–4 puncture marks on the skin of the abdomen. General anesthesia is the safest anesthesia for laparoscopy.

The pain with laparoscopy procedure is very minimal as it is performed through very small punctures on the skin, and not through a big cut on the abdomen. After a laparoscopy procedure, the woman is mobilized within a 10-12 hours and can be discharged within 1-2 days. At home, there is no need of complete bed rest. She could move around. She can start her normal activities, and even resume her work within 10-15 days after the operation.

In laparoscopy, the abdomen is just punctured with very small incisions and not cut as in traditional surgery, the advantages to the patient are very little pain in the post operative period, faster mobilization, faster recovery and resumption of work, almost within 10-15 days after major surgery, early oral intake of fluids within 12-24 hours after surgery, discharge within 24-48 hours after surgery, better cosmetic appeal as there are no big scars on the abdomen.
It is indicated in women with:

Infertility.
Chronic lower abdominal/pelvic pain.
Painful periods.

It is now a standard form of surgical treatment in the infertile women who have the following problems-Ectopic pregnancy.

Endometriosis.
Fibroid.
Adhesions/Tubal blocks.
Polycystic ovarian disease.
Ovarian cysts.

Surgeries like hysterectomy, some cancer surgeries and surgery for stress urinary incontinence are also being routinely and successfully performed laparoscopically.

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Tubal Pathology

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  • Tubal pathology is the cause of infertility in about 20-25% of the women.
  • When an organ is stuck to an abnormal location, it is said to be adherent. Adhesions can cause symptoms like pain. Adhesions in the pelvis are caused by previous infections, previous surgery or because of endometriosis. These are an important cause of pelvic pain and infertility. In pelvic adhesions, the tube and ovary are stuck; their normal anatomical relations are altered. The adhesions need to be cut without causing any damage to the structures. Laparoscopy is an excellent way to diagnose and correct the adhesions. Laparoscopic scissors and energy sources are used to correct the adhesions between the tube and ovary. The patency of the tube is tested. If the tubes are open, we wait for a natural conception. If the tubes are severely affected, then surgical correction will not help the woman to conceive. IVF/ICSI is the treatment option for these women.
  • Tuberculoisis is very rampant infection that affects all classes of people in our country. Genital Tuberculosis damages the tubes, the lumen gets blocked at various points and the tubes are almost nonfunctional. It could cause intrauterine adhesions which need to corrected hysteroscopically. IVF/ICSI is the only options of treatment for these women.

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PCOS Drilling

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Polycystic ovarian syndrome is a syndrome which affects 10-15 % of the women. These women are generally obese, have menstrual irregularities, are infertile, have excessive facial hair and have acne. Their ovaries have a typical picture on sonography. It is seen that the women with PCOS have increased levels of Androgens i.e. the male hormone due to an increase in the Luteinizing Hormone (LH). Infertility in an affected woman is very effectively treated with fertility enhancing drugs like Citrate, , Metformin, and hormone injections like Human Menopausal Gonadotropins, Follicle Stimulating Hormone and Recombinant FSH that help in the maturation and release of the egg from the ovary. The fertility enhancing drugs are also called Ovulation inducing drugs. When the woman is on these drugs her follicular response is judged by performing serial ultrasonographies which monitors the maturation and release of the egg from the ovary. Apart from these ovulation inducing drugs, reduction of weight remarkably improves both the ovulatory and consequently the pregnancy rates.

Laparoscopic drilling of the polycystic ovaries is an option which benefits an affected woman who does not respond to ovulation inducing drugs. In laparoscopic ovarian drilling, both the ovaries are drilled with an energy source and about 4-6 punctures are made. The ovary is immediately cooled with a sterile Ringer solution. Laparoscopy also has an advantage that the fallopian tubes can be tested at the at the same sitting. Also any associated pathology like a tubal block can be corrected at the same sitting.

Laparoscopic ovarian drilling has many advantages. About 30-40% of the women will conceive naturally after this procedure. The follicular response to ovarian stimulation with drugs also improves. The dose of hormonal injections required is less. The abortion rate and the rate of hyperstimulation with hormonal injections is also less.

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Fibroids

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Uterine fibroids are benign (i.e. non cancerous) growths arising from the uterus. A fibroid can cause infertility when it is very large i.e. > 5cms in diameter, it protrudes in the endometrial canal, or it causes a mechanical obstruction of the fallopian tube or the cervical canal. There are no medicines to cause a permanent cure of fibroid. However, GnRH analogues either in the form of daily or monthly injections or nasal spray are used in the treatment of fibroids. This treatment can be useful to decrease the size of the fibroids before they can be operated upon. This treatment is used for a period of 4-6 months and the size of the fibroid decreases by 30-60%. Majority of the cases of fibroid need surgical treatment either laparoscopically or by the traditional cut on the abdomen. Fibroids situated in the cavity of the uterus are best operated upon through the Hysteroscopy.

Depending on the skill of the laparoscopic surgeon, Fibroids of all sizes can be operated laparoscopically. Fibroids are very vascular tumors and could bleed a lot during surgery. There are various techniques that can be used to decrease the blood loss during surgery. An incision is made on the bulge on the uterus where the fibroid is located. The fibroid is separated or dissected out. The defect on the uterus is sutured or closed laparoscopically. The fibroid is then taken out of the abdomen by cutting it into strips with the help of a morcellator. We have operated on fibroids of 12-15 cms at our setup. The pregnancy rates either natural or with treatment improves after a fibroid surgery.

Hysteroscopy is useful to operate on fibroids that protrude into the cavity of uterus. The fibroid is cut into small strips with the help of energy source passed through resectoscope. The uterus is distended with a non–ionic fluid like while doing the resection of the submucous fibroid.

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