Pelvic pain, endometriosis and minimal-access surgery

Published on 09/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

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6 Pelvic pain, endometriosis and minimal-access surgery

Pelvic pain

Pelvic pain is a common reason for referral to a gynaecologist. The origin of the pain may be gynaecological, but non-gynaecological causes such as irritable bowel syndrome (IBS) and constipation can have similar clinical features, including exacerbations in the premenstrual period or during menses. Diagnosis depends on a detailed genitourinary and gastrointestinal as well as gynaecological history. Often no specific cause is identified.

Clinical features

Ectopic pregnancy is suggested by pain associated with dizziness, fainting, shoulder pain or collapse.

Ovarian cyst torsion presents with sudden onset of unilateral pain, which is colic-like or twisting and severe. Vomiting is usual and tachycardia, hypotension and pyrexia are found on examination. The pain may be intermittent if torsion is incomplete.

Ovarian cyst rupture presents with constant pain and signs of peritonism, but systemic features are less common.

A full gynaecological and obstetric history is important to make an accurate diagnosis. The diagnosis will often be made by paying particular attention to the nature, timing and associated features of the pain:

Management

Acute pelvic pain

Acute pelvic inflammatory disease

Suspected PID must be managed urgently, as described in Chapter 9. A low threshold for antibiotic treatment is important to minimize complications of tubo-ovarian abscess, chronic pain, subfertility or ectopic pregnancy.

Chronic pelvic pain

Endometriosis

Treatment

Treatment should be based on age, fertility wishes, location of disease, severity of symptoms and patient choice.

Medical

Surgical

Minimal-access surgery

Minimal-access surgery (MAS) is the term used for surgical procedures where instruments are inserted through small access points and fibreoptic telescopes are used to facilitate diagnostic or therapeutic procedures without major incisions.

MAS aims to minimize the insult to the patient without compromising the safety or effectiveness of the treatment.

The advantages of MAS are reduced pain, reduced length of time in hospital, faster return to work, cost-effectiveness and a better cosmetic appearance.

The disadvantages are the specific surgical risks associated with minimal-access procedures, the training needed for the operator and the equipment investment needed.

Laparoscopy

Laparoscopy is the visualization of the abdominal viscera via a telescope inserted through a small incision in the anterior abdominal wall (usually just below the umbilicus), with carbon dioxide insufflation of the peritoneal cavity. The image is usually transmitted via a camera to a monitor. Other instruments may be inserted into the operative field through secondary entry sites in the abdominal wall. The procedure may be used for diagnostic purposes or for visualization during a therapeutic procedure. The procedure is performed under general anaesthetic, usually in a day-surgery unit.

The uses of laparoscopy in gynaecology are shown in Table 6.1.

Table 6.1 Uses of laparoscopy in gynaecology

Diagnostic uses of laparoscopy:
Pelvic pain (acute or chronic)
Subfertility (to assess for endometriosis and to look for spill of dye during a dye test)
Suspected ectopic pregnancy
Therapeutic uses of laparoscopy:
Sterilization
Adhesiolysis
Diathermy/laser/excision of endometriosis
Salpingectomy (ectopic pregnancy, hydrosalpinx)
Salpingotomy (ectopic pregnancy, hydrosalpinx)
Ovarian cystectomy
Oophorectomy
Myomectomy
Colposuspension
Laparoscopically assisted vaginal hysterectomy
Lymphadenectomy

Technique

The essential steps involved with the basic laparoscopy procedure are the following:

Ensure the woman has been fully counselled about the proposed procedure, reasons and risks for the operation, with informed consent given.

Place patient level on the operating table with the legs at 45°; clean and drape the abdomen.

Clean the external genitalia and vagina and catheterize.

Examine bimanually to assess for uterine position, mobility, size and any pelvic masses.

With a Sims speculum inserted along the posterior vaginal wall, insert an instrument (ideally, a Spackman-style) through the cervix into the uterine cavity for manipulation during the procedure and then remove the speculum.

Check the instruments (light source, Veress needle, gas supply, trocar, laparoscope, any electrocautery equipment).

Make a small vertical or horizontal infraumbilical incision (depending on the size of the trocar and laparoscope to be used, usually 5–10 mm) with a scalpel.

Insert the Veress needle at 45° (towards the sacral promontory) and check the position by hearing a ‘double click’ as it passes through the rectus sheath and the peritoneum, saline test and by checking the gas flow and pressure once connected.

Insufflate with carbon dioxide until the intra-abdominal pressure reaches 18 mmHg.

Remove the Veress needle and insert the trocar through the same incision (the anterior abdominal wall can be lifted or pressure exerted superiorly to enhance tension).

Remove the introducer from the trocar and insert the laparoscope. Once the correct position is confirmed then attach and switch on the gas, aiming for an operating pressure of 14–18 mmHg.

Place the patient in the Trendelenburg position (head down).

Under direct vision, insert secondary ports, commonly in the right or left iliac fossae, lateral to the inferior epigastric vessels or in the suprapubic region. These can be used for graspers, irrigation, scissors, diathermy or drains.

Hysteroscopy

Hysteroscopy is the use of a telescope through the cervix to visualize the uterine cavity. Diagnostic hysteroscopy is usually performed in the outpatient clinic, with or without local anaesthetic. Therapeutic procedures are generally performed under general anaesthetic in a day surgery unit.

Table 6.2 shows the diagnostic and therapeutic uses of hysteroscopy.

Table 6.2 Uses of hysteroscopy

Diagnostic uses of hysteroscopy:
Investigation of postmenopausal bleeding
Investigation of intermenstrual bleeding
Suspected polyp on ultrasound
Suspected uterine abnormality associated with infertility or miscarriage
Therapeutic uses of hysteroscopy:
Retrieval of an intrauterine contraceptive device
Resection of fibroid
Resection of a polyp
Resection of the endometrium
Resection of a septum (metroplasty)
Division of intrauterine adhesions (Asherman’s syndrome)

Preprocedure counselling

Preprocedure consultation should cover the following points:

Complications