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 intrauteri