Gynaecology

Endometriosis

The endometrium is the lining of the womb, and changes in hormone levels during the menstrual cycle cause first its thickening, then its shedding at the time of a period. Endometriosis occurs when cells similar to those lining the womb are found at sites outside the womb, commonly behind the womb or on the ovaries. Endometriotic tissue also responds to cyclical changes in hormone levels associated with the menstrual cycle. Cyclical bleeding from the deposits occurs, leading to pain, scarring and if the ovaries are involved, cysts can occur.

It has been estimated that endometriosis is present in 10 to 25% of women presenting with gynaecological symptoms in the UK.

The most common symptoms are pelvic pain, often starting before the period, pain with deep penetration at intercourse, and less commonly pain on passing urine or opening the bowel, worse or only at the time of the period.

There appears to be little relationship between the severity of symptoms and the severity of the disease. Treatment can be medical or surgical, or a combination of the two. Surgical treatment consists of cauterising or removing endometriotic deposits. This is done using keyhole (laparoscopic) surgery, usually as a day case procedure. Medical treatment usually starts with simple pain killers, and then hormonal treatments to stop ovulation and thereby prevent the cyclical changes in hormone levels causing menstruation, such as the contraceptive pill, progestogens, and the Mirena IUS.

For more information, or to arrange a consultation, contact Mr Chilcott.

Laparoscopy

Laparoscopy is one of the most common procedures used for both diagnosing and treating gynaecological problems.

This procedure involves having a general anaesthetic. Whilst under anaesthetic, a needle is inserted into the abdomen, via the navel. This enables carbon dioxide gas to be passed into the abdominal cavity to lift the wall of the abdomen away from the organs eg bowel, bladder and blood vessels. A 1cm long cut is made in the navel. Through this the laparoscope is passed. This is a cylindrical instrument 1cm in diameter, with a light and camera attached. A clear view can be obtained of the abdominal and pelvic organs. A small probe is then inserted through the abdominal wall through a second small cut, which can be used to move the pelvic organs slightly, to enable a better view. Abnormalities of the pelvic organs can then be seen.

As well as being a diagnostic procedure as above, many operative procedures can be carried out laparoscopically. This involves 1 or 2 additional 5 to 10mm long cuts being made in the lower abdomen to allow the passage of other instruments. Examples of procedures which can often be performed laparoscopically include sterilisation, treatment of ectopic pregnancies, ovarian cysts, endometriosis, adhesions (scar tissue), removal of ovaries and hysterectomy.

The advantages of laparoscopy over an open operation (laparotomy) include a much quicker recovery and reduced post operative problems.

Risks of laparoscopy

Serious complications are rare. The most important risks are of injury to bowel, bladder, blood vessels or other organs. The chances of this are around 2 per 1000 cases.

After the operation

You can expect your abdomen to feel bruised and your navel tender. Sometimes discomfort is felt in the shoulders. This is from some of the carbon dioxide gas left behind – most is removed. You may feel nauseous after the anaesthetic. Most women go home on the day of the laparoscopy, and feel back to normal in a few days. Worsening of pain, worsening nausea/vomiting, development of a high fever or significant bleeding from a wound site are symptoms which may indicate a complication and you should contact Mr Chilcott via the Portland Hospital if they occur.

For more information, or to arrange a consultation, contact Mr Chilcott.

Hysteroscopy

This procedure, enables visualisation of the inside of the womb, via a hysteroscope. This is a narrow cylindrical instrument which is passed through the vagina and cervix, into the cavity of the uterus. In some cases this is done with the patient awake, on other occasions a general anaesthetic may be used. The view is improved by distending the womb with some clear fluid or gas. Abnormalities in the womb cavity can be seen and a biopsy of the lining is often taken.

Operative hysteroscopy may involve removal of polyps, fibroids, or the womb lining, or cutting of adhesions or congenital abnormalities such as uterine septae.

Risks of hysteroscopy

Complications are rare. Infections of the womb lining can occasionally occur. The most significant complication is making a small hole (perforation) in the wall of the uterus. This usually heals without any specific treatment. If this occurs, a laparoscopy may be required.

After a hysteroscopy

Minor vaginal bleeding or discharge, and period type pains, may occur for several days. Sex should be avoided until this stops.

For more information, or to arrange a consultation, contact Mr Chilcott.

Laparoscopic Hysterectomy

A conventional hysterectomy involves removing the uterus (womb) through an abdominal incision or through the vagina. The cervix may be removed along with the uterus (total hysterectomy) or it can be left in situ (subtotal or supracervical hysterectomy).

A laparoscopic hysterectomy is carried out using key-hole or laparoscopic surgery, where much smaller incisions are made in the abdomen to access and detach the uterus and sometimes the fallopian tubes and ovaries. Different terms are used to describe the procedure (laparoscopic hysterectomy (LH), total laparoscopic hysterectomy (TLH) and laparoscopic assisted vaginal hysterectomy (LAVH)), depending on the extent of surgery carried out via the laparoscope. Removal of the fallopian tubes and ovaries is known as salpingo-oophorectomy.

A laparoscopic procedure results in a much quicker recovery from the operation, and minimal scarring of the skin.

Summary of procedure

Laparoscopic hysterectomy is done whilst you are asleep under general anaesthesia. A manipulator is placed in the uterus via the vagina and a laparoscope is introduced through a small incision in the umbilicus. A urinary catheter is inserted to drain urine from the bladder. This will usually be removed on the morning after your operation. Two further small incisions are made in the lower abdomen, to provide access for additional surgical instruments. The remainder of the procedure varies according to the amount of surgery performed laparoscopically.

A haemostatic cutting device such as monopolar or bipolar diathermy scissors, stapling gun or harmonic scalpel is used to detach the uterus from surrounding and supporting structures including ligaments and blood vessels. The uterus is then removed through the vagina, or may be cut into small pieces, and removed through one of the abdominal ports.

Why do I need a hysterectomy?

Hysterectomy is performed for a wide range of conditions, including uterine malignancy, and benign conditions, such as fibroids, heavy periods and pelvic pain, that have not responded to medical treatment. Depending on the indication for the hysterectomy and your age, removal or conservation of the tubes and ovaries and hormone replacement therapy will be discussed with you.

What are the alternatives?

The alternative to this surgery is to decide not to have surgery and the implications of deciding not to have surgery will be discussed with you. Other forms of treatment available for your particular condition (such as heavy periods) would have been discussed with you by Mr Chilcott. Laparoscopic hysterectomy may not be suitable for all women. It may then be appropriate to consider an abdominal or vaginal hysterectomy.

What are the benefits of laparoscopic surgery?

The potential advantages are less pain and a shorter recovery time. As only small cuts need to be made, the scars following laparoscopy are much smaller. Most women are able to leave hospital the day after surgery and return to work after four weeks.

Before the operation

You must have nothing to eat or drink for six hours before the operation (even if you are at home). Unless you have been told not to take your regular medication, continue to take them as usual but take them with as small amount of water as possible.

After the operation

When you wake up from your operation you will be in the recovery room and you will stay there for approximately 20-30 minutes before you are taken back to the ward by one of the nurses. Initially you may feel drowsy and nauseous but this is normal and it will soon pass. You will bleed slightly from your vagina after the procedure and your nurse will monitor this. You may also experience some pain in your abdomen, neck and shoulders. This is due to your abdomen being inflated with carbon dioxide, which can collect beneath your diaphragm causing a feeling of discomfort in your shoulders. You will have been prescribed regular pain killers by the anaesthesist. However, please ask your nurse for some more painkillers if you require them. Usually following surgery you will be able to drink fluids when you are ready and have breakfast the next morning. You will usually be able to go home the next day after your surgery, depending on your condition afterwards.

Going home

Long-term effects of treatment

If you do not experience any complications during the operation there should be no adverse long-term effects. However, if you had your ovaries removed you might experience menopausal symptoms such as hot flushes, night sweats and low mood. You should discuss with your doctor regarding hormone replacement therapy.

If you would like further information, or to arrange an appointment, contact Mr Chilcott.