Gynaecological minimal access laparoscopic & hysteroscopic surgeries have revolutionized the surgeries in gynaecology. It is available since more than 5 decades. Today, laparoscopy is one of the most common surgical procedures performed by gynaecologists. It is a surgical technique which is applied to urogynaecology, reproductive medicine, gynaecological oncology and all benign gynaecological surgery. It isn’t false everybody quoting, the days are here where we will not have to open women’s abdomen other than carrying out cesarean section. With improvement in optics and availability of HD and 3D camera, light source quality, improvements in hand instruments, newer and safe energy sources used for the surgeries together with robotic approach, these minimal access surgeries have significantly improved the prognosis of the patient as they are more accurately done for the disease treated in trained hands. Here the last two words are very important. With these advances it is possible for a remote surgeon to operate in India with the help of robotics. Improved surgical field visualization, superior ergonomics, instrument articulation, decreased tremor, and apparently shortened learning curve make robotic-assisted surgery potentially advantageous. In the morbidly obese patients who present a significant challenge for laparoscopic and open surgery, robotic surgery has the potential for decreased postoperative complications. Robotic surgery with its better ergonomics may reduce problem of surgeon fatigue. Robotic surgeries are costly as disposables used are recurrently expensive. Application of robotics in gynaecology are same as laparoscopy. In India & world over minimal access surgery training and fellowship programs are available for doctors to learn this technique of surgery. As a different hand eye coordination learning is required with available 2D vision without haptics, out of many who are trained only a few of them acquire the desired skill which is required to perform these type of surgeries. We do not have institutional check with this regard in our country before some doctor offers these surgeries. There is another important aspect, surgeon heavily is dependent on the available technology & the assistants. It is mandatory for the surgeon to remain updated and be using the latest available technology, as the advancement are made to make these surgeries safer for the patients. It isn’t false if I tell these surgeries are unsafe in absence of expert & the latest equipment’s available for patients safety.

In gynaecology,  hysteroscopic surgeries are performed to treat various intrauterine pathologies, this avoids need for hysterectomy and or treats many pathology or cavity malformations causing infertility. These days they are further safe as newer methods uses saline & bipolar energy. Various intrauterine pathologies which can cause infertility or abnormal uterine bleeding are polyps, fibroids, endometrial hyperplasia, septum, intrauterine adhesions, tubal blocks etc. are effectively treated by expert hysteroscopic surgeon. Hysteroscopic surgeon needs to learn more technical skill as he has to operate in limited space and smaller diameter optics. Hysteroscopic surgeries also require authentic electrosurgical generator or other mechanical instruments to treat intrauterine pathology.
Gynaecological laparoscopic surgeries have replaced abdominal surgeries completely, whether it is for benign, malignant pathology or they are fertility enhancing surgeries. In addition, the technology and range of minimal access surgery skills have expanded to the level of radical hysterectomy and pelvic and para aortic lymphadenectomy as a routine practice in many centers. With the advent in the entry techniques it is possible to insert trocars through the abdominal wall safely to enter peritoneal cavity without complications especially in cases of previous one or multiple open surgeries. In fact laparoscopic surgeries are more suited for patients with one or many previous laparotomies or history of repair of abdominal wall hernia. Magnification used helps in treating pathology precisely and the blood loss during surgery is less. Two common energy sources are used in gynaecological laparoscopic surgeries, Electrosurgery & high frequency ultrasound generators. Exceptional conditions may require conversion to laparotomy or primary laparotomy. It is proven laparoscopic surgeries can be performed safely with pregnancy up to 28 weeks for adnexal pathology or for surgical reasons. There are different laparoacopic surgical principles used. Here I would like to mention heterotrophic pregnancy which is more common with IVF offered. Laparoscopic surgery treats tubal pregnancy successfully & intrauterine pregnancy continues. In clinical practice although there is a big investment in term of equipments & instruments, increased recurrent expense, yet can be made affordable for all class of the patients. This should be done by an expert as a matter of practice as his expertise should benefit everyone. Laparoscopy and hysteroscopic surgeries and robotics are revolution in gynaecological surgery because of being more & safer and less invasive. Most importantly, the prognosis of the disease treated by both types of minimal access surgeries do not differ. The introduction of any new technology implies a learning curve experience which certainly applies to Laparoscopic & robotic surgery.
The important issues in establishing these type of surgical program are associated with organizational challenges, training, team building, and cost measured against benefit to the patient, surgeon, and institution. Inadequate basic and advance training obtained with acquiring less surgical skill has not enable many canters to perform skillful and advance laparoscopic surgeries or have more number of complications reported. General anaesthesia and patient monitoring are important during laparoscopic surgery. Newer techniques have evolved & with availability of newer inhalation & intravenous drugs along with better airway management methods, many at risk patients are suitable for laparoscopic surgeries now. Patient’s post-operative recovery is also faster. We should not forget at the end the patients benefit in terms of faster recovery, less complications as compare to open surgeries and early return to work in expert hands.

Isha Hospital shares large number of patients (unpublished data) who had been offered day care & day case surgeries since past 15 years. There a set protocol which is followed for such day care & day case surgeries in the hospital. This group of patients consisted of all infertility& gynaec surgeries & even radical surgeries. Isha Hospital has policy of 1 day discharge for insurance patients and for others, it is day case surgeries. The hospital record does not have patients coming in between before their scheduled date of follow up.

Laparoscopic Gynaecological Surgeries

TLH for various uterine benign pathologies with history of previous surgeries and associated medical disorders, Laparoscopic radical hysterectomy with lymphadenectomy, Ovarian cystectomy, Oopherectomy, Salpingoopherectomy, Ectopic pregnancy conservative salpingostomy, salpingectomy, Adhesinolysis for chronic pelvic pain, Omentectomy, Surgeries for Nulliparous & Multiparous prolapse & Vault prolapse using synthetic mesh.

Laparoscopic Fertility Enhancing Surgeries

LOD, Adhesinolysis, Salpingostomy, Salpingoneostomy, Salpingectomy for hydrosalpingx, Ovarian Endometrioma & Endometriotic lesion excision, Salpingoscopy for distal half of tube, Fimbrial dilation, Chromotubation, Myomectomy single or multiple fibroids, Adenomyomectomy, Hysteroscopic surgeries in Gynaecology & Infertility.

Hysteroscopic Surgeries in Gynaecology & Infertility

Hysteroscopic resection of fibroid , polyps, Hysteroscopicadhesinolysis in case of intrauterine adhesions & cervical adhesions, Tubal cannulation, Cornual dilation, Septal resection, Lateral meteroplasty, Removal of foreign body & missed IUD, Isthmocele treatment etc.

All laparoscopic GI & Urologic Surgeries Instruments & Equipment’s

Advance Karl Storz & J & J instruments and equipment for laparoscopic and hysteroscopic surgeries with HD & 3D camera and high resolution monitors.

Skilled Minimal Access SURGERIES in GYNECOLOGY done in 2014

At ISHA, following surgeries are conducted for Obstetrics & Gynaecology department:

  • Total Laparoscopic Hysterectomy
  • Op. Laparoscopy with TL reversal
  • TCRE for synechiae / polyp / menorrhagia
  • Oncosurgery up to Wertheim’s Hysterectomy are successfully done with help of gynaec-onco surgeon
  • Hysterectomy – Abdominal and Vaginal
  • Op. Laparoscopy with Myomectomy
  • Laparoscopic management of ectopic pregnancy
  • Minor operations – D & E, Os tightening, Embryo reduction, TL (Tubectomy), Mirena insertion etc.
  • Operative Laparoscopy

    LAVH – Laparoscopic assisted Vaginal Hysterectomy
    TLH Total Laparoscopic Hysterectomy

    Removal of the uterus can be done by two types-

    • LAVH – Both cornua are cauterized by the help of a laparoscope. Rest method is used of Vaginal Hysterectomy.
    • TLH – Uterus is removed totally by laparoscopy. Uterus is delivered through vagina.

    Myomectomy

    Uterine fibroid is one of the causes of menorrhagia. Even fibroids of bigger sizes can be removed by laparoscopy operation. Morcellator is used for big sized fibroids – it peels the fibroid and makes small pieces to bring out from port.

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    Ectopic Pregnancy

    Ectopic pregnancy means implantation, which occurs outside uterus. Generally tubal ectopic is seen, wherein products are removed from the tube, if it is not ruptured. Part of the tube or whole is removed in case of ruptured ectopic.

    Tubectomy (TL) –

    TL reversal

    This is a laparoscopic microsurgery where the tubes are recanalized. The old TL’s site is cut and healthy tissue – tubes are re-anastomosed using 6-0 prolene. The chances of success depend upon remaining length of healthy tube.

    TCRE

    Trans Cervical Resection of Endometrium – Resectoscope and loop is inserted in the uterine cavity through cervix, to remove the endometrium from its root. It is opted in case of menorrhagia, to avoid removal of uterus. Menstrual bleeding reduces to minimum or only spotting. 90% patients recover by this method. The benefit is no scar on abdomen.

    Suspension operation for prolapsed

    Prolepses of uterus also effects bladder and rectum. It is repaired by laparoscopy method.

    Stress Urinary Incontinence (S.U.I.)

    Urine incontinence is corrected by laparoscopy method.

  • Operative Laparoscopy For Fertility Management

    Adhesiolysis

    If uterus, fallopian tubes and ovaries are stuck with other organs, it can be separated by blunt / sharp dissection.

    Operation for endometriosis and endometrioma

    Growth of ectopic endometrial tissues outside the uterus is called endometriosis. This is a progressive disease. It is cauterized by cautery endometriosis, cyst wall is tried to be removed and if not possible it is also cauterized with bipolar cautery.

    Ovarian cyst removal

    Ovarian cyst wall is removed to prevent recurrence.

    PCO drilling

    A special needle is used for drilling on ovary, when pt. is suffering from polycystic ovarian disease. Tubal Patency – Patency of the tubes can be confirmed by injecting methylene blue dye through the cervical canal, and spill of the same through the fimbria being visualized through the laparoscope.

    Myomectomy

    Uterine fibroid, of even bigger size, can be removed by laparoscopy operation. Morcellator is used for big size fibroid – it peels the fibroid and makes small pieces to bring out from the port.

    Adenomyoma removal

    Adenomyoma is removed by laparoscopic myomectomy, but it is quite difficult because adenomyoma is encapsulated and dissected by sharp dissection.

    Salpingiolysis – Hydrosalpinx

    Inflammation of distal end of fallopian tubes is called hydrosalpinx. Debris is removed from the tube and is repaired.

  • Operative Hysteroscopy

    Septal resection

    Resectoscope is used to cut intrauterine septum.

    Lateral Metroplasty

    It is performed in ‘T’ shaped uterine cavity, which is the cause of infertility or abortion. Intrauterine walls are cut with resectoscope to get enough space.

    Adhesiolysis for Asherman’s Syndrome

    This condition usually is the result of curettage following pregnancy, resulting in intrauterine scarification. Adhesions may be partial or complete and can also occur following uterine surgery. These patients can present with amenorrhea, hypo menorrhea, dysmenorrhea, abortions. It is called Asherman‟s Syndrome. Adhesions are removed with the help of hysteroscopy.

    Polypectomy

    Intrauterine polyp can be removed.

    Submucous myomectomy

    Resectoscope is introduced through hysteroscopy and fibroid is peeled with the help of loop.

    Cornual Cannulation

    Cornua is the opening of fallopian tubes in uterine cavity. Malleable catheter is introduced through hysteroscopy in the blocked cornua to open it.

    Foreign body removal

    Sometimes remaining bones of the foetus from a previous abortion or displaced IUD is found in the uterine cavity. This foreign body is removed under guidance of hysteroscopy.

  • Technology

    The service is well-supported by the most modern operating instruments and state-of-the-art operation theaters. The equipment’s are kept updated with the advent of new technologies.