Types of Procedures

Types of Minimally Invasive GYN Surgery Procedures

Myomectomy

Myomectomy is the removal of fibroids from the wall of the uterus. A fibroid is a benign (non-cancerous) smooth muscle tumor, usually in the uterus.

A myomectomy is done to relieve problems caused by fibroids without having to perform a hysterectomy (removal of the uterus). These problems include:

Pelvic pain
Back pain
Pressure on the bladder
Abnormal uterine bleeding (often leading to anemia)
Difficulty becoming pregnant
Discomfort during sexual intercourse

MIS for Fibroid Removal

There are different ways of removing fibroid tumors from the uterus. Surgical options include open (traditional) approach or laparoscopic (minimally invasive) surgery. If you are a candidate for minimally invasive surgery, here is what you can expect during the procedure:

A small incision is made in the navel, and a laparoscope is inserted into the uterus. A laparoscope is a specialized endoscope, which is a fiber optic tube attached to a viewing device. This is used to examine the abdomen.

Two or three additional small incisions are made in the abdomen. Special laparoscopic tools are inserted through these incisions. Using the laparoscope, the surgeon finds each fibroid and surgically removes it. In some cases, Pitressin, a drug that causes the blood supply to stop for up to 20 minutes, is first injected into the fibroid. This reduces bleeding when the fibroid is removed. After the fibroids are removed, special care is taken to stitch each layer of tissue in the uterus. This prevents blood clots, excessive bleeding, and infection. The tools are removed and the incision is closed with stitches or clamps.

Hysteroscopic Myomectomy

Some fibroids may even be accessible vaginally with no abdominal incision through a procedure called hysteroscopic myomectomy.

Uterine Fibroid Embolization

Uterine fibroid embolization (UFE) is a non-surgical procedure to treat uterine fibroids. The procedure is performed while the patient is conscious but sedated, and typically requires an overnight hospital stay. The physician makes a small incision (usually in the groin area) and inserts a thin, flexible tube. Tiny pellets are injected through the tube into the arteries that feed the fibroids. The pellets block the vessels supplying blood to the fibroids, cutting off their blood supply and causing them to shrink and die. While this procedure does preserve the uterus, it is not recommended for women who wish to get pregnant.

Removal of the Uterus (Hysterectomy)

Hysterectomy is the surgical term for removal of the uterus. This procedure, which can be done through the abdomen or the vagina, is performed to treat a variety of conditions such as:

Fibroids
Endometriosis
Uterine prolapse – a benign condition in which the uterus moves from its usual place down into the vagina
Chronic pelvic pain
Heavy menstrual bleeding
Chronic pelvic inflammatory disease

Surgeons may recommend a partial hysterectomy (removal of the uterus) or a total hysterectomy (removal of the uterus and the cervix).

Depending on the condition, there are alternatives to hysterectomy. Other options may include non-surgical (medical) approaches and less invasive procedures, such as endometrial ablation, which is a procedure without incisions that can be performed as day surgery. You should explore your options and ask many questions before having a hysterectomy.

If your physician recommends a hysterectomy as your best treatment option, ask if you are a candidate for vaginal or laparoscopic hysterectomy. A vaginal hysterectomy involves no abdominal incisions, and a laparoscopic hysterectomy is performed with very small incisions.

Treatment for Endometriosis

Normally, endometrial tissue is found only inside the uterus. The uterus is the reproductive organ where a fetus develops. Hormones cause the tissue to form there, preparing the body for a fertilized egg. If you do not become pregnant, the tissue leaves the body during menstruation.

In endometriosis, endometrial-like tissue is found outside the uterus – on organs in the abdomen or pelvis, for example. In these places, the tissue still responds to hormones. It swells, breaks down, and bleeds. But it is unable to leave when you menstruate. Surrounding tissue becomes inflamed. There is often scarring.

Symptoms range from mild to severe. You may have many large growths with little pain. Or, you may have small areas with intense pain. Symptoms include:

Cramping and pelvic pain (especially just before and during menstrual bleeding)
Pain during sex
Low back pain
Pain during bowel movements or urination
Infertility

There are several treatments for endometriosis: pain medication, hormonal therapy, and surgery, including minimally invasive GYN surgery. If you have severe symptoms or you want to get pregnant, physicians may be able to remove endometrial growths, often with laparoscopic surgery. At the time of laparoscopic exploration, the gynecologist can cut (excise) or destroy (ablate) the endometrial lesions that exist for "conservative" surgery to spare the uterus.

Unfortunately the only way to potentially cure endometriosis is with a hysterectomy - with or without removal of the fallopian tubes and ovaries. This option is reserved for women who are done with childbearing or who suffer with debilitating pain. Extensive, widespread endometriosis may require removal of both tubes and ovaries at the time of the hysterectomy.

Traditionally a hysterectomy required a large abdominal incision and a long recovery time. Now with surgical advances, surgeons can make the diagnosis by inserting a camera into the abdomen, through a 5 mm to 1 cm puncture, to see the extent of the disease, and make an appropriate surgical plan. This plan may include proceeding with the hysterectomy while still being able to send the patient home the same or next day. The recovery time is one-third to one-quarter what it used to be, and most patients are back to their regular activities as quickly as two weeks.

Minimally invasive surgery with a tiny camera allows surgeons to see angles and views of the deep pelvis and upper abdomen that you cannot always see with the human eye through a large incision. The technique also allows magnification of small lesions that may otherwise have been missed with the human eye. The benefit of a magnifying lens, along with the benefit of using a camera to view all corners of the pelvic and abdominal cavity, translates into a more accurate assessment and effective treatment plan.

Treatment for Abnormally Heavy Menstrual Bleeding

Abnormal bleeding between menstrual periods and heavy uterine bleeding can be a symptom of several different (and potentially serious) conditions – from uterine cancer and endometriosis to fibroids. Based on your diagnosis, there are several different choices to consider in consultation with your physician.

Hormonal medications can be used to decrease the amount of menstrual bleeding and/or reduce the number of days a woman has her period. There is also a hormone-containing IUD, or intrauterine device, that reduces bleeding by about 90 percent and can even stop periods entirely in some women.

Endometrial ablation is a surgical alternative to hysterectomy (removal of the uterus) to treat abnormal and heavy bleeding. Endometrial ablation is a procedure without incisions that can be performed as day surgery. More than 90 percent of patients who undergo this procedure have reported satisfaction with it, and 40 percent no longer have periods. However, endometrial ablation is not recommended for women who want to have children.

Hysterectomy may be the best treatment choice for some women with debilitating bleeding or a serious diagnosis such as cancer. Discuss the risks and benefits with your doctor, and if you choose a hysterectomy, ask if you are a candidate for a vaginal (without any incisions) or a laparoscopic (using very small incisions) minimally invasive approach.

Permanent Birth Control

For a woman who does not want any more children, there are two different minimally invasive and permanent approaches for sterilization. The traditional method of permanent surgical sterilization, also known as tubal ligation, consists of making one or two small abdominal incisions and either blocking or removing part of the fallopian tubes.

A newer approach, which involves no general anesthesia and no abdominal incisions, is hysteroscopic sterilization. During the procedure, the physician uses a camera attached to a narrow instrument (called a hysteroscope) that is inserted through the vaginal opening into the womb (uterus) to access the fallopian tubes. With the help of the camera, the physician threads coils into the tubes. Over time, scar tissue forms around the implants and effectively blocks the fallopian tubes.

It takes about three months for the small coils to form a natural barrier to block sperm from reaching the egg. You will need a follow-up X-ray to be sure both tubes are fully blocked before you can rely on this method for birth control.

Hysteroscopic sterilization does not protect against sexually transmitted diseases (STD), so it is important to use appropriate measures. Also, patients with nickel or contrast-dye allergies are not candidates for this procedure. And most importantly, because it is a permanent procedure, women should be absolutely certain that they do not want to get pregnant in the future.

Treatment for Ovarian Cysts

An ovarian cyst is a fluid-filled sac in the ovary. During the menstrual cycle, it is normal for the ovaries to make cysts. The largest of these normal cysts is usually less than an inch (2.5 cm). If you take birth control pills, then you usually do not form cysts larger than this size. Most cysts are small and benign (non-cancerous). But larger cysts can cause pain and other problems. When there is sudden and severe pain due to a cyst, it may because of:

Bleeding – blood irritates the surrounding tissue and causes pain
Torsion – the cyst twists around, disrupting blood flow to the ovary

Treatment for ovarian cysts depends on your age, menstrual status, the size and type of the cysts, and the severity of your symptoms (typically pelvic pain and menstrual bleeding). Your physician may recommend pelvic laparoscopy to remove a cyst that:

Grows larger or reaches a size greater than two inches
Has some solid material in it, or other features
Causes persistent or worsening symptoms
Lasts longer than two or three menstrual cycles
Disrupts blood flow

If the cyst is not cancerous, it can often be removed using minimally invasive techniques. However, in some cases, your whole ovary may need to be removed. If the cyst is cancerous, you may have both ovaries and uterus removed, typically with an open surgical procedure.

Treatment for Pelvic Pain

Pelvic pain is located between the belly button and hips. Pain that lasts for six months or more is called chronic pelvic pain. In women, chronic pelvic pain can be caused by a wide variety of gynecological (and non-GYN) conditions, such as endometriosis, pelvic inflammatory disease, fibroids, pain when ovulating, pain during menstrual period, cysts and/or ectopic pregnancy.

Treatment varies depending upon the condition causing the pain. Many conditions, such a fibroids and endometriosis, can be treated with minimally invasive surgery to relieve pain symptoms. Other treatment options include medication, complementary therapies (such as acupuncture, biofeedback), interventional approaches (like nerve blocks), psychological counseling, and traditional (open) surgery.

Talk with your doctor about the best treatment for you, based on your diagnosis.

Treatment for Ectopic Pregnancy

An ectopic pregnancy is a pregnancy that grows in a location other than the lining of the uterus. Most ectopic pregnancies (95 percent) occur within a fallopian tube. Rare locations include on the cervix, in the abdomen, or on an ovary. An ectopic pregnancy cannot survive because only the uterus can support the growth of a fetus and its placenta. If an ectopic pregnancy bursts a fallopian tube, it is a medical emergency that threatens the life of the mother due to hemorrhage in the abdomen.

Emergency surgery is needed if:

The ectopic pregnancy is judged to be too large for medical treatment or if the patient has other conditions, which would prevent the use of methotrexate, such as a history of kidney or liver disease. Methotrexate is a form of chemotherapy to prevent further growth of the ectopic pregnancy and avoid surgery.
The fallopian tube has burst or ruptured, usually with bleeding into the abdominal cavity.

This surgery can be done either with minimally invasive technique, through a laparoscope, or with an open abdominal incision. During the surgery, the pregnancy will be removed. If possible, the doctor will repair your fallopian tube. In some severe cases, the fallopian tube may need to be completely removed.