HYSTEROSCOPIC SURGERIES

Hysteroscope is an instrument which can be inserted into the uterus through the opening of the uterus called cervix which can be seen through the vagina. The instrument is connected to a camera and all the abnormalities inside the uterus can be seen on the screen of the monitor to which the camera is connected. The uterine cavity is distended with a fluid while the instrument is inside the uterus, so the problems in the uterus can be seen.

Hospital stay and aftereffects for the patients: The patient can be admitted on the same day and discharged on the same day if they wish. There is no wound on the abdomen, as the instrument is inserted through the vagina. In the days following the procedure, in some patients, there may be a watery discharge from the vagina till the tissues in the body heal.

Indications: Patients with heavy bleeding, recurrent abortions, infertility with blocked tubes, may benefit from this procedures. Hysteroscopic tubal cannulation: In some infertile patients the fallopian tubes necessary for the passage of the egg and the ovum is blocked near their entry into the uterus. These types of blocks called cornual blocks can sometimes be removed by passing a tube through the uterus negotiating through the block and into the fallopian tube

Hysteroscopic myomectomy: Sometimes fibroids protrude into the cavity of the uterus causing heavy bleeding. In such cases if their size is less than 5cm, they can be removed through the hysteroscope using electric current. There is no scar on the abdomen and no incision need be made into the muscle of the uterus. The patient goes home the next day absolutely painfree

Hysteroscopic septal resection, adhesiolysis,etc: Some patients abort repetitively and when an X-ray is taken they are found to have some structural abnormality like a fibrous wall in the centre(Septum) , some adhesions between the walls of the uterus or some abnormality in the shape of the uterus. These can be corrected through the hysteroscope after which the patient has excellent prospects of carrying the pregnancy to term.

INTRAUTERINE INSEMINATION

Intrauterine insemination involves the placement of motile sperms in the cavity of the uterus to enhance fertility. In normal fertile couples, semen is deposited in the vagina. Only a few sperms find their way in to the uterus in the normal course of events as many of them perish on their way up into the uterus traversing the sticky mucus in the mouth of the uterus, cervix, the opening of the uterus, etc. Intrauterine insemination increases the number of good motile sperms that reach the uterus, as good motile sperms are deposited directly inside the uterus.

Indications: This procedure can be done only for patients with patent tubes.

•  Patients with intractable infertility where all other measures of treatment have failed.
•  Patients with unexplained infertility
•  Wives of men with low sperm count and
•  Women who have some disease of the cervix

Involvement for the patient: IUI is usually done in cycles where ovulation is enhanced using oral and injectable drugs to make sure that the woman produces a lot of ova which can stay ready for the sperms. The woman has to undergo ultrasound examination every alternate days from day 10-11 to find out when her follicles have reached the appropriate size. Usually when the follicle has reached 18mm, an injection is given to induce ovulation. Intra uterine insemination is done 36 hours later after confirming ovulation on ultrasonography.

As the procedure involves repeated visits to the hospital , it may place a lot of mental strain on the patient and should be done only when all other doors seem to be really closed. It should be the choice of therapy before going in for the more costly treatment of IVF-ET or ICSI. Procedure: Semen is collected by masturbation. There is a separate room for semen collection where the couple can be together if need be at the time of collection. Semen is mixed with some media (medical fluids) and centrifuged. The supernatant sticky portions of the semen are removed and the sperm pellet is left behind. A little (about 0.5ml) of medium is layered over the sperms and it is incubated. The more active sperms swim up in the medium and these are collected in a tube and placed into the uterus. A swim down method is used in some cases. In IUI, the dead and ineffective sperms and a lot of useless debri are discarded and only the active and useful sperms are deposited in the uterus. These can reach the ovum faster as they have to travel much less.
Result: The couple can expect a pregnancy rate of 15-25% depending on the indication for which the procedure is done.

LAPAROSCOPIC ADHESIOLYSIS FOR CHRONIC PELVIC PAIN

Continuous low grade pain is a very common condition found in middle aged women. Quite often it is due to some low grade infection which can be cured when treated meticulously. In some cases of chronic pelvic pain(Defined as persistent pain of more than 6 months duration), laparoscopy may be useful in evaluating and curing the disease

How laparoscopy can be useful:

•  Sometimes pelvic infection leaves scars around the uterus and ovaries leading to pain. Release of painful adhesions through the laparoscope could give relief.
•  Severe pain during periods not cured with medicines could be treated by a procedure called uterosacral nerve vaporization.
•  In patients with a disease called endometriosis, laparoscopy helps in diagnosing the condition. Resection of endometriosis from all surfaces, specially the rectovaginal septal space could give relief
•  Sometimes pelvic pain is due to dilated veins near the uterus. These veins extend to the side of the ovary and sometimes may go upto the upper abdomen. This is called pelvic venous congestion. Proper diagnosis can be made only from laparoscopy. The other definitive mode of diagnosis of this condition, viz; venography is not done for this condition routinely in India. After diagnosis proper medications could be given for cure. If not properly diagnosed, many a time the woman may be subjected to hysterectomy and this would not cure the disease and the woman would end up undergoing a major surgery without getting cure for her illness.
•  Sometimes no abnormality is found on doing a laparoscopy and in these instances it is my practice to show them the videocassette of the procedure, and then the patients are ready to accept the pain or control it with simple analgesics as they have the happy knowledge that nothing serious is wrong with them.
•  In some patients who have undergone major surgery like LSCS or hysterectomy the intestines may be adherent to the abdominal structures and may cause colicky pain when food passes through the adherent segment. Laparoscopic release of these adhesions may give symptom relief. The author has done about 10 cases of severe intestinal adhesions with good relief for the patients

What it involves for the Patient: Usually the patient is admitted the previous day, and an extensive bowel enema given. She is asked to be on oral fluids from the previous day. In case of minor adhesiolysis, she is allowed to go home the next day. But if extensive intestinal adhesions, the patient is observed for 4-5 days to make sure the intestines are working properly. Before surgery these patients are also warned about the possibility of intestinal injury which might lead to opening of the abdomen for bowel repair.

LAPAROSCOPIC MYOMECTOMY

The uterus sometimes developers noncancerous tumours in them called fibroids. When single, they can be removed successfully through the laparoscope allowing for early discharge. The procedure of removing fibroids with the laparoscope is called laparoscopic myomectomy. The procedure is done through 3 or 4 tiny holes in the abdomen, with the help of the laparoscope. The edges of the wound have to be sutured endoscopically. There are many studies in medical literature which have shown scientifically that even in multiple fibroids, laparoscopy is better than laparotomy. However, in the author’s opinion, Laparoscopic myomectomy is best reserved for single or at the most 2 or three superficially located fibroids. Patients are worried that the fibroids may recur. Since the body has an inclination to produce fibroids, the possibility of recurrence cannot be ruled out. However, in young women with regular menstruation, preserving the uterus is worthwhile.

LAPAROSCOPIC OVARIAN CYSTECTOMY

The ovaries may sometimes develop membraneous bags in them filled either with blood or sometimes, a colourless fluid which sometimes requires surgery for correction. These cysts can be removed laparoscopically . A number of unmarried girls who had cysts of this kind (some of them even extending above the umbilicus) have undergone ovarian cystectomy/salpingoophorectomy in this unit. For such patients it is a boon not to have a scar on the abdomen, besides avoiding the stigma of prolonged hospital stay in a gynaecology unit.

The magnification offered by the video camera also allows for a more meticulous surgery. When such cysts occur in an older woman, after meticulously ruling out cancer, using blood tests and colour doppler ultrasound, it is possible to remove them laparoscopically. These procedures have also been done in patients with history of multiple surgeries done in the past. When such patients under go open procedures many surgeons often remove the uterus also fearing that if it needs removal in future, it may lead to another traumatic surgery for the patient. This is not really necessary. When removing the ovaries laparoscopically, this fear is less and the surgeon removes only the diseased part, viz: the ovary. Thus laparoscopic surgery in these cases also allows for a less morbid surgical procedure.

The patient can be admitted on the same day and discharged the next day or the day after. Patients who have extensive bowel adhesions, may need longer stay, as they may not tolerate full diet immediately after surgery.

LAPAROSCOPIC SURGERY FOR FERTILITY ENHANCEMENT

Laparoscopy essentially means the visualization of the abdominal organs through a scope. Laparoscope is a tubular instrument introduced into the abdomen through a 1cm opening near the umbilicus. A CCD camera is attached to the outer end of the laparoscope. The uterus, ovary and the rest of the pelvic and abdominal organs can be visualized through the scope and viewed on a television monitor. Instruments passed through two tiny 5mm holes lower down in the abdomen can rectify any defects in the visualized organs. It is usually combined with hysteroscopy. Hysteroscopy visualizes the interior of the uterus and any polyps or adhesions can be removed.

Indications in the infertile woman: Laparoscopy as a primary modality for diagnosis of the infertile woman is no more practiced. Laparoscopy may be resorted to in the following situations. Laparoscopic drilling of ovaries:In women who fail to ovulate because of a condition called polycystic ovarian syndrome, if oral medications fail to achieve ovulation, laparoscopic drilling of the ovaries may be done. In polycystic ovaries, the ovaries are fully of tiny follicles with fluid in it. A few of these fluid filled follicles are punctured using an instrument introduced through the laparoscope. This causes reduced levels of hormones called androgens and subsequently there is restoration of normal ovulation. In the adjacent picture, the white organ is the ovary. the few brown spots seen on it are made by the electrocautery.

What to expect after this procedure: Will my PCOD be totally cured? In 82% of patients, ovulation can be expected. In 63% , conception can be expected either spontaneously or after treatment with medications to which they were previously resistant. It is cheaper compared to treatment with hormone injections. The effect may last longer. The rate of miscarriage in PCOD patients who conceive with laparoscopic drilling is slightly lower than that of women with PCOD who conceive with medical treatment. For those who respond to laparoscopic drilling, but relapse into an ovulation, a repeat procedure has been shown to be effective. This procedure is particularly useful for slim women with PCOD.

Tubal block: If a woman fails to conceive inspite of medical treatment, it may be prudent to check and see if the fallopian tubes are patent. This can be achieved by injecting fluid into the uterus through a cannula introduced through the vagina. The fluid traverses the uterus , the fallopian tubes and then comes into the abdomen through the opening of the tubes called the fimbrial end. The fimbrial ends are visualized on the laparoscopy monitor. Any blocks near the fimbrial end or any adhesions near any part of the tube can be removed through laparoscopic instruments. If there is a block near the uterie end of the tube it can be rectified through hysteroscopic cannulation.

Endometriosis: In some women, there may be severe abdominal cramps near the time of menstrual periods. This could be due to a disease called endometriosis. On examination of the vagina, the doctor may find some nodularities in the vagina. Endometriosis could cause infertility in many ways and the best way to correct it is through the laparoscope. Laparoscopic correction of endometriosis yields very high pregnancy rates. Adhesions between the uterus and ovaries could cause infertility and these could be corrected through the laparoscope. In the adjacent picture, there are adhesions between the ovary (The white organ) and the uterus (the pink organ) caused by endometriosis. The release of the adhesions with an instrument has resulted in some amount of bleeding, seen in the picture.

What it involves for the patient: The procedure is usually done under General anaesthesia. The patient’s basic blood investigations are done and she is given a laxative the previous night. Patients staying in the same district as the hospital are admitted on the same day of the surgery. The patient has to be nil by mouth on the day of the procedure. After the procedure she is kept in the recovery room for about 3-4 hours and then taken to her room. Usually the patient is discharged on the next day in our centre.

PAINLESS HYSTERECTOMY

Hysterectomy is traditionally performed through the abdominal route when the uterus is not prolapsed. This involves pain at the incision site. The majority of patients find it painful to turn over, walk, etc on the second post-operative day. The patient has to be hospitalised for 5-9 days and has to take rest from heavy jobs for a period of 3 months at least. There is a small risk of wound infection, incisional hernia, etc. If the hysterectomy is done without opening the abdomen, chance of wound infection in the abdomen or incisional hernia is not there. If hysterectomy is done with the assistance of a laparoscope , or entirely through the vagina, there are no major incisions on the abdomen, After this type of hysterectomy, the patient has no pain and is very comfortable while bending, turning over, walking, etc from the second day itself.

The patients normally go home on the 3rd post-operative day and are even allowed to travel by bus . They can resume normal duties within 7-10 days of surgery. In laparoscopic assisted hysterectomy, 3-4 tiny holes are made in the abdomen. Long slender instruments are inserted through these holes. The images of the uterus are transferred to a monitor outside the body. The surgeon looks at these images and operates on the uterus, using long slender instruments. The uterus is finally removed through the vagina.

At Sun Medical and Research Centre (Unit of Trichur Heart Foundation) in normal course of events, the rough cost of Laparoscopic assisted vaginal hysterectomy may be just around Rs.30,000.totally for patients taking single room for stay.

Experience : Dr.Shobhana Mohandas has been doing such surgeries for the past sixteen years, and almost in almost 95% of cases coming for hysterectomy, there has been no need to open the abdomen. . Uterus weighing upto 1kilogram have also been removed vaginally. Patients who have undergone 2 or 3 caesarian sections before have also undergone this procedure successfully.

THERMAL ABLATION

Dr.Shobhana Mohandas MD.DGO.FICOG (Dip.Ensoscopy ) Women nearing menopause quite often have excessive uterine bleeding. When there is no obvious structural abnormality in the uterus or ovaries to account for this, it is called dysfunctional uterine bleeding. Normally, it is amenable to medical therapy. When the bleeding becomes intractable or the patient gets fed up of medications, in the past, the only recourse was hysterectomy,or removal of the uterus. Of late many alternative treatment modalities have come up for treatment of intractable uterine bleeding. One of them is endometrial ablation. Endometrium can be ablated using hot solutions. This is called Thermal ablation. I have been doing Thermal ablation in my unit for the past1 7 years using ordinary urinary catheters . The urinary catheter with a bulb at one end is inserted into the uterine cavity and the bulb inflated using boiling hot water. The cost of therapy is considerably reduced by not using the company made thermal ablators.

What it involves for the patient: The procedure is done usually under local anaesthesia and intramuscular sedation. Patients who request anaesthesia are given general anaesthesia. By and large all women who have undergone the procedure under local anaesthesia have not expressed dissatisfaction at not being given general anaesthesia. The procedure is done on a day care basis. It takes about 45 minutes by the method I do. Patients complain of uterine cramps after the procedure, which can be controlled with medications. They normally go home by evening. Follow up: I used to contact the patients over telephone every 6 months and have ascertained that 80% of patients are satisfied with the procedure. Some of them have no periods(Amenorrhoea), decreased periods (Oligomenorrhoea) or normal periods following the procedure.

TRIGGER POINT INJECTIONS FOR CHRONIC PELVIC PAIN

Some patients who have undergone previous abdominal surgery or have had pelvic infection in the past get a nagging pain in the abdomen near about the scar or site of infection. They normally don’t get relief with pain killers. Pain tends to come on with movements of the abdomen. After ruling out active infections, these patients have been found to be relieved by injecting a mixture of local anaesthetic, hydrocortisone and distilled water in the painful points. The pain relief is permanent.

TUBAL MICROSURGERY

Sometimes after a woman has undergone sterilization by tubectomy she may either lose her children or want to remarry and have children by her new husband. In such instances it is possible to recanalise the tubes by way of tubal microsurgery. This recanalisation is possible with microsurgery. Small tiny instruments are used and under magnification, the blocked ends of the tubes are cut and the cut ends recanalised making the tube patent again. Tubal microsurgery is also possible for women who have blocked tubes as a cause of infertility.

ULTRA SOUND SCANNER

This is a Scanner machine working on ultra sound principle, which is mostly useful in Gynecology, Obstetrics, General Surgery, Urology and Gastro- enterology.
Computerised Pulmonary Function Test System
This equipment gives the correct picture of function and defects in the functioning of the lungs.

COMPUTERISED LABORATORIES

All clinical lab tests can be done here including, Bio Chemistry and Hematology, Microbiology and is equipped with VITROS-250 (Bio chemistry analyser-dry chemistry method), MINIVIDAS (Hormone analyser-ELFA method), ROCHE-OMNI-C (Blood gas and electrolyte analyser), BACT/ALERT -3D (For culturing blood and body fluids), VITEK 2 COMPACT (For identification and sensitivity of micro organisms), Auto Analysers, Elisa Readers, blood cell counters, Computerised Acid base gas analyser and electrolyte analyser. The latter equipments are unique and accurate for management of critical care and this is the only institution which have these facilities in this part Kerala

DIGITAL CATH LAB SYSTEM

There are two of the sophisticated equipments which is used for diagnosis and treatment of Heart diseases. The detailed study of the Chambers, valves, Coronary arteries and blood flow details of the heart are visualised with this equipment. As a treatment device, this equipment is used for Balloon Angioplasty for removing obstruction and dilating heart valves and occluded Coronary arteries - A procedure to avoid surgeries in suitable cases

Two numbers Digital Cath Labs

•  Siemens SIMENS Artis Zee 14 with DSA system
•  Siemens COROSKOP

WHOLE BODY C T SCAN

This is one of the latest generations C. T. Scan from GE, and is highly sophisticated and can do studies of whole body-bone as well as soft tissues with excellent clarity and diagnostic accuracy.

COLOUR DOPPLER ECHO CARDIOGRAM

This is the latest in this series and first in Kerala. In addition to the ordinary Echo Cardiogram studies which mainly show the muscles and valves of the Heart and its movements, the Doppler gives Blood flows details also. With the Colour Doppler, in addition to the above mentioned facilities the actual directions and quantities of the blood flow can be mapped, thereby in many cases the costly Cardiac, Catheterization can be avoided. This machine is equipped to do all these tests under stress also