ENDOSCOPY IN OBSTETRIC & GYNAECOLOGY

OUTLINE

• DEFINITION• SUB-TYPES• INDICATIONS• RELATIVE BENEFITS• CONTRAINDICATIONS• COMPLICATIONS• MEDICAL LITIGATION & ENDOSCOPY

DEFINITION

• Examination of the interior of a canal, cavity or hollow viscus by means of a special instrument, called an endoscope.

SUBTYPES OF ENDOSCOPY

• Endoscopy can be either open or closed.• Open endoscopy entails such procedures as

colposcopy.• Hysteroscopy & laparoscopy are two most

widely used closed endoscopy procedures in obs/gyn. Culdoscopy is also a form closed endoscopy but is rarely used.

HYSETEROSCOPY

• Hysteroscopy can be performed for diagnostic or operative(therapeutic) purposes.

1. DIAGNOSTIC HYSTEROSCOPYHysteroscopy has become a basic investigation in modern gynaecology practice and has essentially replaced the time honoured D&C.It can be done as an outpatient procedure.

Indications For Diagnostic Hysteroscopy

• Abnormal menstruation(age>40yrs or not responsive to treatment for those <40yrs);

• Intermenstrual bleeding despite normal cervical smear;• Postcoital bleeding despite normal cervical smear;• Postmenopausal bleeding(persistent or endometrial thickness>4mm);• Abnormal pelvic ultrasound findings(eg endometrial polyps,submucosal

fibroids);• Others(relative indications): -subfertility; -recurrent miscarriages; -Asherman’s syndrome; -congenital uterine anomaly; -lost intrauterine contraceptive device.

Contraindications to Diagnostic Hysteroscopy

• Pelvic infection;• Pregnancy;• Cervical cancer;• Heavy uterine bleeding.

RELATIVE BENEFITS

• It’s the gold standard for assessment of the uterine cavity;

• Even OPD hysteroscopy has been shown to have a success rate of well over 90%;

• Pick-up rate of pathology depends on the indication, but about 40-50% of women with menstrual symptoms will have positive findings, chiefly fibroids & polyps.

2)OPERATIVE HYSTEROSCOPY• Operative hysteroscopy has a number of indications, & it’s

the treatment of choice for polypectomy,myomectomy for intracavitary or submucous fibroids,adhesiolysis & metroplasty.

• Pretreatment to thin the endometrium and make it less fluffy greatly facilitates the surgery. The choice is between using GnRH analogues, donazol, a progestogen or the combined pill, usually for atleast 6weeks prior to surgery. The alternative is to time the operation to just after menstruation, which can be difficult.

INDICATIONS FOR OPERATIVE HYSTEROSCOPY

• Proximal fallopian tube cannulation;• Asherman’s syndrome;• Removal of pedunculated fibriod;• Division/resection of uterine septum;• Resection of submucous fibroid(type 1&2);

COMPLICATIONS OF HYSTEROSCOPY

-It’s a safe procedure & complications are uncommon.

-The most frequently seen problem is pain when negotiating the cervix or distending the uterine cavity, & a vaso-vagal reaction to cervical dilatation.

-Uterine perforation should not happen if it’s introduced under direct vision unless there’s extreme cervical stenosis.

-Infection

LAPAROSCOPY• This refers to examination of the contents of the

abdominopelvic cavity with a laparoscope passed through the abdominal wall.

• The peritoneal cavity is first inflated with CO2 gas (insuflation) to achieve pneumoperitoneum, and the laparoscope passed through a small incision in the abdominal wall. A second incision is usually required to provide surgical access to the area of interest. An elaborate armamentarium of surgical instruments has been developed to perform incision, drainage, excision, cautery, ligation, suturing, and other procedures with the laparoscope.

CATEGORIES OF LAPAROSCOPY

• As with hysteroscopy, laparoscopy can also be diagnostic or operative.

a) DIAGNOSTIC LAPAROSCOPY• Usually done as an inpatient procedure under

GA, unlike diagnostic hysteroscopy which can be done as an OPD procedure.

• The main indication for diagnostic laparoscopy is the investigation of pelvic pain & subfertility.

b) OPERATIVE LAPARASCOPY

• Most procedures done by laparatomy can also be done laparoscopically provided there is no large pelvic mass or extensive malignancy.

• However, laparoscopy is not always the best option & the decision about the route of surgery depends more on the particular skills of the gynaecologist, the presence of contraindications, & the relative risks of complications.

Indications For Laparoscopy (in obs/gyn)

• Acute or chronic pelvic pain;• Ectopic pregnancy• Pelvic inflammatory disease(including TB);• Endometriosis;• Adnexal torsion;• Subfertility;• Congenital pelvic abnormality;• Abnormal pelvic scan;• Unexplained pelvic mass;• Staging for ovarian malignancy.

Contraindications to Laparoscopy(Absolute & Relative)• Mechanical or paralytic bowel obstruction;• Generalised peritonitis;• Diaphragmatic hernia;• Major intraperitoneal haemorrhage (shock);• Severe cardio-respiratory disease;• Massive obesity;• Inflammatory bowel disease;• Large abdominal mass;• Advanced pregnancy;• Multiple abdominal incisions;• Irreducible external hernia.

Complications of Laparoscopy

• It’s a safe procedure with published complication rates of as low as 2-4/1000 procedures;

• Most complications occur during the set-up phase of the procedure when the abdomen is being instrumented;

• These include:I. Vascular injuryII. Injury to bowel & other abdomino-pelvic viscera.III. Bladder injuryIV. Gas embolism (can lead to death)

MEDICAL LITIGATION & ENDOSCOPY

• There is a common misconception among people that ‘keyhole’ surgery converts a ‘major’ surgical procedure into a ‘minor’ one, & not only is the cosmetic result better & recovery faster, but the risks are also lessened.

• The reality is that it is only the size of the incision which is different; it’s not surprising therefore that if there is a problem, patients often assume there has been negligence.

• As a result, endoscopic surgery has become one of the major areas of medical litigation in gynaecology.

• Patients have to be provided with sufficient information on which to base their decision to undergo a procedure. They have to warned about the relative risks of laparoscopy compared with the conventional surgery.

LAPAROSCOPY vs LAPAROTOMY

LAPAROSCOPY• Less postoperative

discomfort• Shorter hospitalisation• Faster return to normal

activities• Procedures are often more

complex & hence take longer• Operative time is less

predictable• More expensive

LAPAROTOMY• More postoperative

discomfort• Longer hospitalisation• Longer return to normal

activities• Less complex & hence take

shorter time• Operative time is relatively

easier to predict• Cheaper