Endoscopy in Contemporary Gynaecology

Introduction

 


Endoscopic surgery is probably the most significant advancement in surgical practice. It is being increasing favoured over the abdominal approach because of its well recognized advantages: minimal trauma, superb visualization, low incidence of complications, reduction of adhesions1, shorter hospital stay, rapid recovery and good cosmetic result. With the advances in technology, laparoscopic surgery is rapidly and progressively replacing conventional surgery except for the most difficult cases. Endoscopy has many applications in modern gynaecology and the list is growing every year.

These can be hysteroscopic, laparoscopic, and cystoscopic. Commonly performed procedures can be diagnostic, operative or second-look. Furthermore aggressive treatment of endometriosis often requires multidisciplinary input in diagnostic procto-sigmoidoscopy. Fertiloscopy, or hydro-endoscopic pelvic examination via a vaginal approach, was pioneered in France as a diagnostic tool for subfertility. Falloposcopy is another micro-laparoscopic examination of the fallopian tubes. For the purpose of this review, focus will be placed on laparoscopy hysteroscopy and cystoscopy.

Diagnostic Laparoscopy
Diagnostic laparoscopy remains an invaluable tool for assessing patients with chronic pelvic pain, infertility, adhesions and endometriosis, and an adjunct in grading of gynaecological cancers. Superb visualization of the peritoneal cavity not only aids in diagnosis, but allows for an accurate assessment of the extent/severity of these conditions. Peritoneal washings, tissue biopsies and lymph node sampling are other indications

Operative Laparoscopy
Over the last few decades however, an increasing number of gynaecologic pathologies are being managed laparoscopically as a result of new technologies which allow for safe delivery of energy to tissues such as monopolar and bipolar electric currents, lasers, ultrasonics (Harmonic scalpel) and microwaves (endometrial ablation), coupled with advances in surgical equipment and video-monitoring.

The laparoscopic approach is now the preferred method for the treatment of adnexal pathology such as ovarian cysts, ectopic pregnancies and inflammatory masses2. A recommendation by the Royal College of Obstetricians and Gynaecologists based on level 1a evidence is that the laparoscopic approach to the surgical management of ectopic pregnancy in the haemodynamically stable patient is preferable to the open approach3. The laparoscopic approach however is contraindicated in patients with massive haemoperitoneum.

Most patients with ovarian cysts can be managed laparoscopically. Large cysts can first be aspirated followed by stripping of the cyst wall to minimise the risk of recurrence. In the case of endometriomas where it may be difficult to strip the wall of the cyst capsule, it may be ablated following puncture and drainage of the cyst contents. For the removal of dermoid cysts, the use of specially designed pouches or special containers for specimen removal prevents spillage of the cyst contents into the peritoneal cavity.

Laparoscopy for ovarian masses is contraindicated however, if there is a suspicion of malignancy. The use of high-resolution ultrasonography with colour Doppler and vaginal transducer4 coupled with risk factors such as patient’s age, symptoms and Ca-125 levels enables the Gynaecologist to select the cases appropriate for management by the laparoscopic approach.

Endoscopy has secured a firm place in the management of patients with infertility. Laparoscopy can be used not only for assessing tubal patency but to detect and treat coexisting pathologies such as adhesions and endometriosis. For patients with distal tubal blockage, pregnancy rates following laparoscopic adhesiolysis and tuboplasty has been shown to be comparable to laparotomy and microsurgical techniques5. Laparoscopic ovarian drilling is proven to be effective in inducing ovulation in patients with clomiphene resistant polycystic ovarian syndrome, although there remains great variation in the recommended number of burns to the ovary and whether it should be performed on one or both ovaries. Periovarian adhesions is a potential complication following this procedure.

Endoscopy in urogynaecology
Cystoscopy has numerous applications in gynaecology

a) Assessment of urological injury.
Due to the close anatomical relationship, it is not surprising that over 70% of injuries to the urinary tract occur following gynaecological procedures. In cases of suspected bladder injury, cystoscopy can be useful to identify the site and extent of bladder injury. Bladder injury is estimated to occur in 4.4 – 71% of cases following insertion of tension -free vaginal tapes.6 Cystoscopy is therefore routinely performed during TVT procedures looking for possible injury and for the presence of intravesical mesh which, if it goes unnoticed may cause pain, bleeding, infection and irritative bladder symptoms.

Cystoscopy is also useful following any procedure (such as colposuspension, difficult hysterectomies with severe endometriosis or distortion of normal anatomy etc) which has an increased risk of injury (ligation/kinking) to the ureters. Direct visualization of the ureteric orifices and passage of urine into the bladder confirms patency.

b) Cystoscopy as a diagnostic tool
Cystoscopy is useful in the investigation of patients with haematuria, recurrent urinary tract infections and in those with irritative bladder symptoms (urgency, frequency, nocturia) in the absence of detrusor instability and can identify tumours, calculi, diverticulae and typical mucosal appearances seen in inflammatory conditions such as interstitial cystitis.

c) Cystoscopy as an adjunt to staging of cancers
Cystoscopy is used in the clinical staging of advanced (clinically or based on CT/MRI imaging) cervical carcinoma. Bladder mucosal involvement can be confirmed by cystoscopic biopsy.7

Laparoscopic surgery has also extended to the management of pelvic floor disorders. Laparoscopic sacrocolpopexy is commonly performed in patients with vault prolapse. Various procedures which result in shortening of the supporting ligaments of the uterus are particularly useful in young patients wanting to preserve their reproductive function.

Laparoscopic gynaecological oncology
There is now a wider acceptance of the laparoscopic approach in many areas of gynaecological oncology, particularly with cervical and endometrial cancers. Laparotomy has traditionally been the surgical treatment of choice. An increasing number of total hysterectomy, assisted vaginal hysterectomy, assisted surgical staging and pelvic lymphadenectomy are now being performed laparoscopically. For patients with endometrial carcinoma, the reported rates of survival and recurrence are comparable for both the laparoscopic and open approach8.

Hysteroscopy
Diagnostic
Direct visual examination of the uterine cavity has virtually replaced blind methods. Hysteroscopy has proven to be invaluable in assessing patients with abnormal uterine bleeding, postmenopausal bleeding, infertility and recurrent pregnancy loss. Not only does it allow the accurate detection of intrauterine pathology, but enables exact location of the pathology and determination of its intracavitary extent.

Operative
The development of hysteroscopes with operating channels and instruments such as scissors,biopsy forceps, snares and electrosurgical operating devices such as ball and loop electrodes allow many operative procedures to be performed hysteroscopically. For patients with intrauterine pathologies such as uterine septa, synechiae, polyps and fibroids, the hysteroscopic approach is preferable as the integrity of the myometrium is preserved. Hysteroscopic resection remains the most suitable surgical treatment option for submucous fibroids.

Female sterilisation can also be performed hysteroscopically with the use of various mechanical occlusive devices or plugs (e.g Essure). It is gaining widespread interest as it can be performed on patients in whom laparoscopy is contraindicated. The main advantage of this procedure however is that it avoids the risks associated with laparoscopic sterilization and allows women a quicker return to normal activities9.

Endometrial destruction is an effective treatment option for uterine bleeding. This can be achieved by resection or ablation and is a suitable alternative to hysterectomy. Development of newer devices such as Novasure allow endometrial ablation to be performed as an outpatient procedure, making it an even more attractive option to patients. Increased uptake of endometrial ablation has resulted in fewer women undergoing hysterectomy. For those women having hysterectomy, laparoscopy can facilitate the vaginal approach, particularly if bilateral oophorectomy is being undertaken at the same time. Total laparoscopic hysterectomy is also a feasible option, although the total operating time is somewhat longer.

Complications from endoscopy
Although endoscopy has revolutionized modern gynaecologic surgery, it is not without risks. A retrospective survey of 29,966 laparoscopic procedures by French gynaecologists Chapron et al10 reported an overall major complication rate of 4.64 / 1000. These were limited to vascular, bowel and bladder only and were noted to be proportional to the extent and complexity of the procedures: (0.84/1000 for minor, 4.3/1000 for major and 17.5/1000 for advanced procedures). Complications may arise during the laparoscopic entry or during the procedure itself (Table 1). The major risks with laparoscopic surgery include injury to bowel and major blood vessels. These and how to prevent and manage them are summarised in Table 2.

Table 1: Laparoscopic entry techniques

Types of laparoscopic entry Comments
Closed abdominal entry with insufflation

  • Veress needle entry
  • Palmer’s point entry
  • Direct trochar introduction
Favoured by majority of gynaecologists Palmer’s variation advised for patients with suspected peritoneal adhesion or history of laparotomic midline scars. Direct introduction of the trochar is not popular and may be difficult to defend medico-legally
Vaginal vault entry The Fertiloscope is introduced through the vaginal vault and uses saline or Hartmann’s as distension medium
Open entry

  • Hasson’s technique
The routine use of Hasson’s entry technique is popular with general surgeons. It is claimed, but not proven that this technique reduces entry injuries. (12). Majority of gynaecologists use this technique for patients with suspected severe peritoneal adhesion. Some use it routinely.
Gasless Laparoscopy

  • With mechanical peritoneal distension
Increasingly popular in diagnostic gynaecologic oncology, where it is believed to reduce tumour seeding associated with pneumoperitoneum.

Table 2: Common complications of endoscopic surgery and management options.

Complications from Endoscopic surgery Management
Anaesthetic

  • Hypercapnia and acidosis; Carbon dioxide embolus
  • Gastric content aspiration
Rare complication, unexplained or sudden hypotension, arrhythmias, raised end tidal CO2, mill-wheel murmur; Reduce or evacuate CO2 quickly, head-down, left-lateral position, central venous line to aspirate gas from heartBest management is prevention.: Ensure pre-operative empty stomach, speedy insertion of cuffed endotracheal tube; Surgeon to reduce insufflation pressure during operation
Operative injuries

  • Uterine, bowel or vascular entry injuries:
  • Diathermy injuries
    • Active electrode injuries
    • Diverted current injuries e.g. alternate site burn; insulation failure, direct coupling, capacitative coupling,
    • Urological complications
High index of suspicion, good surgical technique, palpate the bifurcation in very slim women and consider open entry technique and those with history suggestive of peritoneal adhesions. Consider the Palmer’s entry technique in those with a midline abdominal scar.Surgeon to directly control electrode activation, keep all instrument in direct view during operating, remove or withdraw all instruments into sheath when cleaning laparoscopic lens.

Most modern diathermy machines now eliminate alternative site burns, by triggering an alarm. Ensure all instruments are well maintained. Examine each instrument before use. Avoid contact of electrode casing with tissue; Do not cross instruments. Avoid hybrid cannula systems in operative laparoscopy. Use bipolar diathermy; avoid monopolar diathermy as much as possible.

Empty bladder, visualise or catheterise ureters, avoid monopolar diathermy for pelvic side wall surgery.

Post-operative

  • Reactionary and secondary haemorrhage; delayed bowel perforation, infection, death
Patients must be told pre-operatively; and given relevant printed information, to report any deterioration after discharge home. Early intervention can minimise damage and prevent catastrophes. In clean wounds, infection rate is not modified by peri-operative antibiotics. However, in clean-contaminated or dirty wounds, antibiotic cover is mandatory.
Complications of hysteroscopy and cystoscopy

  • Uterine perforation, haemorrhage, bladder and bowel injuries
  • Fluid -related complications
  • Infection
High index of suspicion, good surgical technique, perform laparoscopy if uterine or bladder perforation suspected; laparotomy may be required to deal with bowel and urological injuriesDuring hysteroscopy, excessive absorption of non-electrolyte fluid may cause potentially fatal hyponatraemia, pulmonary and brain oedema, and encephalopathy. This is referred to as TURP-like syndrome and can be prevented by close monitoring of fluid balance; and not exceeding a deficit of about 1000mL Unfinished surgery can always be rescheduled.

Antibiotic prophylaxis is frequently advised for ablative surgery or following division of Asherman’s synaeche.

Rising litigations rate in endoscopic surgery
With the expansion of endoscopic surgery, litigation claims have increased. Most of the litigation that arise result from improper prevention, inadequate recognition and delayed intervention11. To minimise these and risks to patients the following steps are essential.

  1. Patients must be involved in the decision-making process, i.e. informed consent is mandatory when considering patients for laparoscopic surgery. They must be made to understand the risks of the procedure taking into account their individual risk factors such as obesity and previous abdominal surgeries.
  2. Surgeons should adhere to general surgical principles, but make necessary adjustments as the need arises, e.g. alternative entry points in patients with risk of adhesions from previous midline incisions.
  3. Surgeons must be vigilant, so that complications when they arise may be recognized early and prompt management instituted. As a general rule, patients get better by the day after endoscopic surgery. Any deviation from this rule must rouse suspicion and be investigated
  4. The importance of careful documentation can not be over emphasised. The use of photographic, video or DVD recording is controversial. For example, a poorly recorded photo of laparoscopic sterilisation, which does not show enough detail of tubal identification or Filshie clip placement, can be a medico-legal liability. For this reasons, some gynaecologists do not routinely use photographic records.

The progress made by endoscopic surgeons over the last few years means that a greater number of complications can be managed laparoscopically, thereby reducing the number of conversions to laparotomy. Investment in training is essential to produce surgeons highly skilled in laparoscopic surgery. It is fundamental that this is combined with complete training in classical surgery to allow surgeons to manage complex procedures, conversions or injuries.

Conclusion
Endoscopic surgery has a firmly established role in contemporary gynaecological practice. Ensuring that the right procedure is performed by the right method, on the right patient at the right time by the right person means that patients will benefit from receiving high quality service whilst minimizing potential risks.

References

  1. Postoperative adhesion formation: evaluation at early second-look laparoscopy. Operative Laparoscopy Study Group Feril Steril 1991; 55: 700 -704
  2. Minimally Invasive Surgery in Gynaecologic Practice. L.V. Adamyan. International Journal of Gynaecology and Obstetrics 82 (2003) 347 -355
  3. Clinical Green Top Guidelines – The Management of Tubal Pregnancy. nMay 2004. RCOG
  4. Sonographic accuracy in the diagnosis of ovarian masses. Benacerraf et al. Journal of Reproductive Medicine
  5. Treatment and causes of female infertility. Chapron C et al. Lancet 344: 333 – 334
  6. The tension-free vaginal tape reviewed : an evidence based review from inception to current status. Atherton MJ, Stanton SL BJOG 2005; 112: 534 – 46
  7. The usefulness of cystoscopy in the staging of cervical cancer Liang CC et al Gynecol Oncol 2000. 76: 200 – 3
  8. Laparoscopic management of early endometrial cancer: current status. Zdenek Holub Gynecol Surg (2006) 3: 245 – 252
  9. Advances in hysteroscopic sterilization Andrew Baxter The Obstetrician and Gynaecologist Vol 8 No. 2 2006; 103 – 106
  10. Surgical complications of diagnostic and operative gynaecological laparoscopy: a series of 29 966 cases Chapron C et al Human Reproduction .vol 13 no.4 867 -872
  11. Complications and litigation in gynaecologic endoscopy Harry Rein Current opinion in Obstetrics and Gynaecology. 2001, 13: 425 -429
  12. Towards evidence-based laparoscopic entry techniques: clinical problems and dilemmas.Garry R Gynecol Endosc 8 (6): 315 – 326
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