Pelvic pain, endometriosis and minimal-access surgery

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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:

• What is the nature, site, type and onset of the pain? Is it constant or intermittent? Is it colic-like?

• What are the exacerbating and relieving factors?

• How does it relate to periods? A 3-month symptom diary is helpful in relating the pain to the hormonal cycle.

• How does the pain vary with defecation or micturition? Are there associated factors such as nausea, vomiting, bloating or malaise?

• A thorough urinary and bowel history is always necessary.

• Is there any significant previous surgical history?

• Is there dyspareunia?

• Is there a history of sexually transmitted infection?

• Is there a history of fertility problems?

• Have there been previous pregnancy complications, such as ectopic, evacuation of retained products of conception or termination of pregnancy?

• Is the woman currently in a relationship? Are there any relationship or sexual problems?

• Is there a history of sexual abuse in childhood or adult life?

Examination

Inspection of the abdomen will identify scars from previous surgery. Abdominal palpation may reveal tenderness, peritonism, masses, renal-angle tenderness or a loaded colon. Sims speculum may show abnormal bleeding or discharge. Bimanual examination features may include cervical motion tenderness (‘cervical excitation’), adnexal tenderness, pelvic masses, uterine immobility or uterosacral nodules.

Investigations

All women with acute pelvic pain must have a pregnancy test. Other investigations should be performed according to the history and examination findings and generally include:

• Endocervical swabs and high vaginal swabs for Chlamydia, gonorrhoea and Trichomonas

• Midstream urine

• Pelvic ultrasound to exclude ovarian cysts, tubal masses or uterine pathology

• Renal tract ultrasound and/or intravenous urogram if a renal cause cannot be excluded.

Laparoscopy is the gold-standard investigation for gynaecological pathology and may reveal adhesions, endometriosis or evidence of PID (dilated, oedematous, tortuous or scarred tubes, with fine filmy adhesions). Fitz-Hugh–Curtis syndrome is the association of perihepatic adhesions (seen at laparoscopy) with previous Chlamydia or gonorrhoeal infection and supports the diagnosis of PID as the cause of the pain, even in the absence of obvious tubal damage.

Management

Acute pelvic pain

Pelvic pain in early pregnancy

Women with a positive pregnancy test need urgent ultrasound and serial human chorionic gonadotrophin beta-subunit to exclude an ectopic pregnancy. If an intrauterine pregnancy is confirmed, then the commonest cause of pain is an enlarged or haemorrhagic corpus luteum. This should be identified on ultrasound scan and managed conservatively. Other ovarian cysts, urinary tract infection or appendicitis should also be considered and managed accordingly.

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.

Ovarian cyst accident

Ovarian cyst haemorrhage or rupture is managed conservatively with admission and analgesia. Laparoscopy is indicated if the pain does not settle within 24–48 hours.

Ovarian cyst torsion should not be missed, as failure to recognize the symptoms and signs may lead to irreversible ischaemia of the ovary. Urgent laparoscopy is indicated, after initial resuscitation, to confirm the diagnosis. Cystectomy may be possible, but signs of ischaemia or necrosis indicate oophorectomy by either laparoscopy or laparotomy.

Appendicitis

Women with appendicitis generally complain of anorexia, malaise, nausea and abdominal pain, which originates centrally and moves to the right iliac fossa. A low-grade pyrexia, tachycardia and localized tenderness and peritonism are clinical signs. The white blood count is usually raised.

Urgent referral to the general surgical team should be made, and the woman kept fasted, with intravenous fluids and analgesia given. Appendicectomy is performed laparoscopically or through an open procedure using a right iliac fossa incision. The appendix is normal in 10–20% of appendicectomy specimens.

Appendix mass and abscess

An appendix mass forms when an inflamed appendix becomes walled off by omentum and small bowel. This presents with a longer history of several days localized pain and pyrexia. A mass is palpable in the right iliac fossa and the diagnosis is confirmed with ultrasound or computed tomography (CT) scan. Management is conservative with fluids, analgesia and antibiotics, with consideration of appendicectomy after 6–8 weeks.

An appendix abscess is a collection of pus associated with appendicitis. Management depends on the clinical situation and may involve CT or ultrasound-guided drainage or an open procedure as well as fluids, analgesia and antibiotics.

Chronic pelvic pain

Pelvic inflammatory disease

PID can present with chronic pelvic pain. This may be associated with a history of previous sexually transmitted infection, a change of partner, an abnormal discharge or irregular bleeding. Reinfection may be occurring where a woman who has been treated for PID continues to have unprotected intercourse with an untreated partner. Even where the diagnosis is not certain, a trial of antibiotic treatment can be helpful, with appropriate treatment for the partner and avoidance of unprotected intercourse until treatment for both partners has been completed.

Adhesions

Adhesions may be present as a result of previous infection or surgery. The benefit of division of adhesions to relieve pelvic pain is not clear, but it is likely to be more helpful in women with severe adhesions and where division is performed laparoscopically. Adhesiolysis is associated with a high risk of visceral damage. The development of further adhesions is common after adhesiolysis, especially if an open (rather than laparoscopic) approach is used.

Ovarian cysts (see Chapter 7)

Ovarian cysts are managed according to the symptoms and investigation findings. Simple cysts should be managed conservatively and usually resolve spontaneously over 6–12 weeks. However, persistent pain is an indication for cystectomy. Endometriomas and dermoid cysts may be managed expectantly if small, but should be removed, preferably laparoscopically, if there is persistent pain or subfertility.

Suspicious ultrasound features of ovarian cysts or raised cancer antigen 125 (CA 125) are also indications for surgical removal.

Fibroids (see Chapter 7)

Fibroids do not normally cause pain. However, they may be painful where the size of the fibroid causes a pressure effect, where the fibroid is degenerating or where an intracavity fibroid is being expelled from the uterus. Myomectomy should be performed for intracavity fibroids causing pain or for large fibroids causing a pressure effect. Fibroid degeneration is managed conservatively initially, with analgesia, fluids and antibiotics, but persistent or recurrent pain is an indication for surgery.

Chronic pelvic pain syndrome

Chronic pelvic pain syndrome is long-term pelvic pain with no identifiable pathology at laparoscopy. The aetiology of chronic pelvic pain syndrome is poorly understood. Theories include undiagnosed IBS, congested dilated pelvic veins (pelvic congestion syndrome), disordered neurological signalling to the spinal cord (where normal sensation is perceived as painful) and functional pain.

Effective treatment options are laparoscopic uterosacral nerve ablation (effective in 30–90%), antidepressants and counselling.

Irritable bowel syndrome

IBS affects up to 20% of people in the UK, with three times as many women affected as men. Diagnosis is clinical (after excluding other pathology) and symptoms include constipation, diarrhoea, pelvic pain, passage of mucus with the stool and bloating. The symptoms are often worse with eating, defecation, stress and in the premenstrual period. Treatment is with antispasmodic agents (e.g. mebeverine hydrochloride) for pain; antimotility agents (e.g. loperamide) for diarrhoea; and bulk-forming laxatives (e.g. ispaghula husk) for constipation, and increased dietary fibre may be of benefit.

Constipation

Many women with pelvic pain are constipated and a detailed gastrointestinal history will elucidate this. On examination a palpable loaded colon may be present. Treatment is with laxatives and suppositories as well as dietary and fluid modification.

Urinary tract infection/interstitial cystitis/renal calculi

Recurrent infections and irritative bladder symptoms are often associated with bladder pain. Thorough questioning about urinary symptoms is essential in a woman presenting with pelvic pain. Investigations should include urine microscopy and culture, and if necessary, cystoscopy and biopsy to exclude interstitial cystitis. Calculi may be identified in the ureters or bladder by ultrasound or intravenous urogram. Referral to the urologist should be made accordingly for treatment.

Functional pain

All women undergoing investigation for pelvic pain should be informed that no specific cause might be found. This reassures most women and spontaneous resolution of symptoms is not uncommon. If pain persists, sensitive questioning around social and sexual circumstances may reveal an underlying problem, such as relationship difficulties, sexual abuse history or fears around sexuality or fertility.

Endometriosis

Definition

Endometriosis is the presence of functioning endometrial tissue outside the cavity of the uterus.

Incidence

Twenty-one per cent of women with infertility, 15% of women with chronic abdominal pain and 6% of women undergoing sterilization have endometriosis at laparoscopy.

Age

Endometriosis is most common in the 25–35-year age group, but can occur at any age from menarche until the menopause, or later if the woman is taking hormone replacement.

Aetiology

Various theories exist about the development of endometriosis:

• Retrograde menstruation

• Developmental (coelomic metaplasia)

• Immunological.

Retrograde menstruation is the passage of menstrual debris, containing endometrial cells, along the fallopian tubes to the peritoneal cavity. The cells are thought to adhere to the peritoneal surfaces and proliferate. This is the most likely aetiology. However, retrograde menstruation occurs in up to 90% of women and it is, therefore, likely that the development of endometriosis also depends on individual local peritoneal immunological factors.

Coelomic metaplasia is a more likely theory for endometriosis development at sites outside the pelvis.

There is also increasing evidence for a complex genetic predisposition to endometriosis.

Pathology

Endometriosis usually involves deposits of endometrial tissue anywhere in the pelvis, commonly the ovaries, uterosacral ligaments or ovarian fossae. Extrapelvic sites include operation scars, the vagina, the ureters, the bladder, the bowel, the umbilicus and, rarely, the lungs. Endometriomas (chocolate cysts) occur when the blood shed forms an encapsulated collection, usually on the ovary or in the pouch of Douglas. Adhesions are common from the monthly intraperitoneal bleeding.

History

The classic presentation is dyspareunia, dysmenorrhoea and subfertility. Non-menstrual pelvic pain may occur if adhesions or an endometrioma is present. Cyclical haematuria, rectal bleeding or haemoptysis can occur with endometriosis from other sites. The severity of disease at laparoscopy relates poorly to the symptoms reported and many women are asymptomatic.

Examination

Abdominal palpation

Tenderness is common. An endometrioma may be palpable as a mass if large. Vaginal endometriosis can be seen as blue nodules on speculum examination. Uterosacral nodules, endometriomas, adnexal tenderness or a fixed retroverted uterus may be palpated bimanually.

Investigations

Transvaginal ultrasound may suggest the presence of an endometrioma (ground-glass appearance) or a fixed retroverted uterus, and exclude other causes of a pelvic mass, but is not diagnostic for endometriosis.

Laparoscopy is needed to confirm the diagnosis, which is clinical, though biopsies may be indicated for unusual appearances.

Laparoscopic appearances include:

• Blue or black powder burn lesions

• Red, blue or white papular or flat lesions

• Peritoneal scarring and fenestrations (‘peritoneal windows’)

• Endometriomas

• Frozen pelvis (fixed, immobile uterus with dense adhesions to ovaries and tubes and obliterated pouch of Douglas).

The commonest sites of endometriosis are the ovaries, uterosacral ligaments and pouch of Douglas.

Endometriosis may be classified as stage I–IV by the revised American Fertility Society Score, according to the severity and extent of the disease at laparoscopy. More commonly, the laparoscopic findings are recorded diagrammatically and a judgement of mild, moderate or severe endometriosis assigned. Figure 6.1 illustrates some typical patterns of endometriosis found at laparoscopy.

Figure 6.1 Typical patterns of endometriosis found at laparoscopy.

Treatment

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

Medical

Analgesia

Non-steroidal anti-inflammatory drugs may be effective for mild symptoms.

Hormonal medical treatment

All hormonal treatments have an 80–90% rate of improvement of endometriosis symptoms. However, symptoms may recur within 12–24 months of stopping treatment. The recurrence rate after completion of medical treatment is up to 74% for severe disease.

Hormonal medical treatment inhibits cyclical hormonal stimulation and causes atrophy of endometriotic tissue. Most treatments have significant side effects and long-term treatment is contraindicated for gonadotrophin-releasing hormone (GnRH) analogues and danazol or gestrinone.

There is no difference in efficacy of treatments and a few women will not respond to any medical treatments. If an endometrioma is suspected, then medical treatment should not be first-line management.

Fertility is not improved by hormonal treatments, all of which delay conception further.

Combined oral contraceptive pill

The combined oral contraceptive pill suppresses ovulation and, therefore, inhibits cyclical stimulation of endometriosis, but is more effective if the monthly withdrawal bleed is omitted by taking three packs continuously (tri-cycling). It is reasonable to attempt a trial of therapy prior to laparoscopy for symptom control in a woman who is not attempting pregnancy and in whom a pelvic mass is not suspected.

Progestogens

Continuous progestogens, such as medroxyprogesterone acetate, dydrogesterone and norethisterone, either oral or as depot form, are as effective as GnRH analogues and danazol for short-term pain relief. In the oral form they may be given continuously or cyclically (3-week course followed by a 1-week break). Medroxyprogesterone acetate can be given in the depot form, though this may delay ovulation for up to 18 months after stopping treatment, thus delaying fertility. Progestogens may be suitable for long-term management in women who are not planning to become pregnant.

Gonadotrophin-releasing hormone analogues

GnRH analogues (leuprorelin, buserelin, nafarelin and goserelin) suppress gonadotrophin release from the anterior pituitary, thus interrupting the cyclical stimulation of endometriotic tissue. They are given subcutaneously or intranasally. Side effects include menopausal symptoms and loss of bone density (6% reduction over 6 months’ treatment, which is reversed within 9 months of stopping treatment). Add-back hormone replacement therapy can be given to treat the menopausal symptoms and prevent the loss of bone density, without reducing efficacy.

Endometriomas may shrink by 20% with GnRH analogues, but surgical treatment should be first-line management of endometriomas if symptomatic or if fertility treatment is anticipated.

Antiandrogens

Danazol and gestrinone are oral antiandrogens with antioestrogen and antiprogestogen properties. They inhibit endometriosis by inhibiting ovulation and directly suppressing the endometrial tissue. Side effects occur in 80% and include acne, hirsutism, weight gain and mood changes. Voice-lowering is a rare, but irreversible, side effect of treatment. They are not commonly used now as other treatments are equally effective, with better side effect profiles.

Surgical

Laparoscopic diathermy/laser ablation or excision

The aim is to excise or ablate all visible endometriotic deposits and restore normal anatomy as far as possible. Care must be taken to avoid damage to other pelvic structures, particularly the ureters and rectum. From 60% to 70% of women experience cure or improvement in symptoms, more so if the disease was severe at the time of laparoscopy. Postoperative medical therapy may further improve the outcome for some women after laparoscopic treatment.

Surgical excision

Endometrioma excision should be performed laparoscopically where possible. Cystectomy is the aim, but where this is not possible, the cyst is drained, fenestrated and the capsule ablated. Rarely, laparotomy is needed for cystectomy if adhesions are severe or the cyst is very large. Spillage of endometrioma contents is very irritable to the peritoneum and vigorous saline washout of the cavity should be performed if this occurs, with consideration of postoperative medical suppressive therapy.

Laparoscopic uterosacral nerve ablation

Division of the uterosacral nerves by diathermy or laser is effective for 70–90% of women with chronic pelvic pain from endometriosis.

Total abdominal hysterectomy

This is usually a last resort for patients with endometriosis. Bilateral salpingo-oophorectomy should also be performed to prevent the continued cyclical oestrogen and progestogen stimulation to any microscopic residual deposits of disease. Women under the age of 50 need hormone replacement therapy after bilateral salpingo-oophorectomy, and this should be a continuous combined preparation, as unopposed oestrogen may stimulate any residual endometriosis.

Support

Women with endometriosis should be given clear information about the disease and treatment options. Support groups are also helpful sources of information and psychological benefit.

Fertility

Endometriosis is associated with infertility, even where there is no demonstrable tubal blockage. Surgical treatment improves the fertility rate by 13% for mild to moderate disease, but not severe disease. Medical treatment does not improve the chance of pregnancy and prolongs the time to possible conception, as all medical hormonal treatments are contraceptive. In vitro fertilization is commonly indicated.

Prognosis

Endometriosis may recur after medical or surgical treatment and tends to regress spontaneously after the menopause.

Adenomyosis

Adenomyosis is defined as the presence of functional endometrial tissue within the myometrium of the uterus. It may be focal or diffuse and occurs more commonly in the posterior uterine wall. It is found in 15–25% of hysterectomy specimens, whether pelvic pain had been a feature in the history or not.

It tends to occur in women over 35 years and it may be found in association with fibroids. Risk factors are parity, previous termination of pregnancy and previous caesarean section. Clinical features are predominantly severe dysmenorrhoea with a slightly bulky soft uterus.

The diagnosis can only be confirmed histologically after hysterectomy; however, the condition may be suspected on ultrasound or magnetic resonance imaging scan.

If adenomyosis is suspected, analgesia or medical suppression may be tried as for endometriosis. The only definitive surgical treatment is hysterectomy, though endometrial resection and shelling-out of diffuse areas of suspected disease have been attempted.

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

Preoperative counselling

Preoperative counselling should cover the following points:

• Indication for the procedure – Is this the appropriate operation? Has the clinical situation changed since the outpatient consultation? If there was an ovarian cyst, has a repeat scan been performed to check it has not resolved?

• Last menstrual period: all premenopausal women should have a pregnancy test on the day of the procedure. If it is negative and they have had unprotected sex, they must be warned about the potential risk of instrumentation of the uterus to a very early pregnancy.

• Proposed procedure: women need an explanation of the proposed procedure, the reasons for it and the possible findings. It should be explained that images are printed out for the medical records and to help the patient understand the findings.

• Possible findings: it should be explained that laparoscopy is often normal in women with pelvic pain.

• Complications of the procedure and how they may be dealt with (laparotomy).

• Likely postoperative symptoms (e.g. pain, bleeding).

• Follow-up plans.

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.

Closure of the wounds

• Secondary ports should be removed under direct vision to check for bleeding from the sites and for any entrapment of bowel or fat in the port site.

• Expel as much gas as possible through the trocar.

• Close the rectus sheath where the incisions are greater than 5 mm (except at the umbilicus).

• Close skin wounds with skin glue, absorbable sutures or Steri-strips.

• Remove the manipulator from the vagina.

Postoperative management

• Intraoperative and postoperative analgesia should be given as required.

• In recovery the woman is encouraged to eat and drink as soon as she feels ready.

• When the woman has had something to eat and drink, passed urine and is not in severe pain, she can usually be discharged within 2–4 hours.

• A 5-day course of paracetamol and non-steroidal anti-inflammatories (or dihydrocodeine) is usually sufficient for pain management and the patient should be advised about shoulder-tip pain, from peritoneal irritation by gas.

Complications

The overall complication rate is 6 per 1000 procedures. These include anaesthetic risks, infection (wound or urinary tract) and visceral (bowel or bladder) or vascular injury (port entry sites or major vessels). The risk of visceral or vascular injury is 0.6–1% for diagnostic procedures and 0.9–1.8% for therapeutic procedures.

Safety in laparoscopy

Important safety factors include the following:

• Checking the instruments.

• Good visualization. There may be a problem with the lens, light source or monitor. Alternatively, blood within the abdominal cavity may be absorbing light and decreasing view. The operating doctor or assistant should ensure that the area of interest and all instruments are at the centre of the view at all times.

• Alternative entry techniques. Where adhesions are suspected an open entry can be used (Hasson technique). Alternatively, Palmer’s point can be used for entry, 2 cm below the left costal margin in the mid clavicular line, after excluding splenomegaly.

Contraindications

Absolute contraindications to laparoscopy are hypovolaemic shock, intestinal obstruction, a large abdominal mass and severe cardiac disease. Relative contraindications are peritonitis, obesity, previous major or multiple abdominal surgery, bleeding disorders and anaesthetic risks (e.g. heart disease or obstructive airways disease).

Electrosurgery in laparoscopy

Electrosurgery (diathermy, electrocautery) uses electrical energy to coagulate or cut tissues.

Risks from diathermy include capacitive coupling, direct coupling and thermal injury.

Risks are minimized by using equipment with an alarm system, ensuring correct positioning of the plate, using the lowest power setting needed for the surgery being performed, checking the insulation on the equipment before use and regular service checks.

Unipolar

The electrical current returns to the ground electrode through the body and via the plate, usually positioned on the patient’s thigh. A greater heat is produced around the operating area and the risk of visceral injury by thermal damage is, therefore, higher.

Bipolar

The electrical current passes between the jaws of the forceps only. The surrounding thermal damage, for example causing bowel injury, is lower and the technique is safer. Bipolar diathermy should be used where possible.

Lasers in laparoscopy

Laser (light amplification by stimulated emission of radiation) uses a concentrated beam of light to cut or coagulate tissue. The advantages are that the laser is very precise and peripheral tissue damage is minimal. It is used most commonly during laparoscopy for adhesiolysis, ablation of endometriosis and uterosacral nerve ablation in women with pelvic pain. However, it can also be effective for salpingotomy in infertility management.

Different types of laser have different tissue penetration depths.

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:

• All premenopausal women must have a pregnancy test on the day of the procedure. If it is negative and they have had unprotected sex since the last menstrual period, they must be warned about the potential risk of instrumentation of the uterus to a very early pregnancy.

• Last menstrual period: menstruation at the time of hysteroscopy interferes with the operative view and theoretically increases the chance of retrograde flow of menstrual blood through the fallopian tubes, causing endometriosis. However, in some cases of intractable bleeding, not responsive to progestogen treatment, hysteroscopy may still be performed.

• The woman should have an explanation of the nature of the proposed procedure, the indication for it and the possible or expected findings.

• Explain that images will be printed or stored for the medical records and for the woman to see.

• Advise that the procedure takes only a few minutes, but that she may expect pain or discomfort during an outpatient hysteroscopy, similar to period pain, from dilatation of the cervical canal and spill of fluid into the peritoneal cavity through the fallopian tubes.

• Inform the woman of the rare complications of hysteroscopy.

• Explain that the woman should expect bleeding for up to 1 week after the procedure and may pass debris after a resection procedure.

• Simple analgesia may need to be taken for up to 24 hours.

• Explain that antibiotic prophylaxis is needed for women under 40 years.

Technique

The essential steps in the basic hysteroscopy procedure are:

• Place the patient in the Lloyd Davis position (and clean the vagina in an anaesthetized patient). Catheterization is not indicated.

• Insert a Cusco’s speculum (and gently clean the vagina in a conscious patient).

• If indicated, inject the cervix with local anaesthetic with adrenaline (epinephrine) at the 12, 3, 6 and 9 o’clock positions.

• Grasp the anterior lip of the cervix using a vulsellum forceps or tenaculum.

• Depending on the diameter of the hysteroscope, dilate the cervix.

• Insert the hysteroscope with the gas or saline flowing and guide it along the cervical canal under direct vision.

• Inspect the uterine cavity, rotating the lens to visualize the tubal ostia (cornu) and anterior and posterior walls. Observe for polyps, submucous fibroids, adhesions or irregular lesions suggestive of malignancy.

• Visualize the cervical canal carefully as the hysteroscope is removed from the uterus.

Distension media

The uterine cavity is distended with saline or gas for diagnostic procedures and glycine for procedures where electrosurgery is anticipated.

Types of hysteroscope

Flexible hysteroscopes are generally of smaller diameter and more appropriate when dilatation of the cervix is difficult or if the cervix is atrophic or scarred. They are likely to cause less discomfort for the patient. However, the image may be less clear than with a rigid hysteroscope. Rigid hysteroscopes are always used for operative hysteroscopy.

Hysteroscopes vary from about 3 to 10 mm diameter. Smaller-diameter hysteroscopes are less painful to insert, but may give a more limited view and generally cannot be used in conjunction with instruments. The direction of view is usually 30° for diagnostic procedures and 12° for resection procedures.

All hysteroscopes have ports for fluid or gas input. Most also have outflow ports for effective irrigation of blood or debris from the field of view.

Operating hysteroscopes have channels for simple procedures such as inserting graspers for removal of a lost intrauterine contraceptive device. A resectoscope consists of a telescope, an attachment for electrosurgical instruments (e.g. resection loop, hook or rollerball) and inflow and outflow tracts for fluid distension and irrigation.

Antibiotic prophylaxis

All women of reproductive age should be screened for infections prior to a hysteroscopy. Any sexually transmitted infection should be treated prior to the procedure and consideration should be given to antibiotic prophylaxis for all premenopausal women.

A suggested prophylaxis regime is azithromycin (1 gram), given orally as a single dose.

Complications

Haemorrhage

Haemorrhage may occur with resection procedures, especially transcervical resection of fibroids. This is usually controlled with electrocautery. In cases of intractable bleeding, a Foley catheter is inserted and the balloon inflated in the uterine cavity to create a tamponade effect. This is then removed after 12 hours.

Infection

Endometritis and PID occur in less than 1% of women after hysteroscopy, but antibiotic prophylaxis should be used in all premenopausal women.

Cervical shock

Instrumentation and dilatation of the cervix can induce a vagal response. This is associated, in the conscious patient, with dizziness and nausea and may result in loss of consciousness. The patient is bradycardic and hypotensive, but recovers when the instrument is removed. Treatment with atropine is rarely required.

False passage

A false passage through the cervix may occur during difficult dilatation. It is diagnosed by visualization of a blind-ending canal when the hysteroscope is inserted. Occasionally, the false passage may go through to the peritoneal cavity and the features and management are as for perforation of the uterus.

Uterine perforation

The instrument (dilator or hysteroscope) may pass through the uterus, most commonly into the pouch of Douglas. It is usually noticed by an abnormal feel and sudden loss of view as the distension fluid floods out into the peritoneal space. In most cases damage will be minimal if perforation is mechanical. However, if electrocautery is in use, then there is a more significant chance of damage to other structures. Laparoscopy must always be performed to check for uterine bleeding and bladder, bowel or vessel injury.

Occasionally, perforation is not noted at the time of the procedure and the woman may present with abdominal pain, pyrexia and systemic disturbance in the next few days. Ultrasound or CT scan may confirm the presence of free blood in the pouch of Douglas or haematoma around the uterus. Any suggestion of bowel injury necessitates urgent surgical review.

Fluid overload

Operative hysteroscopy uses a non-electrolytic fluid (usually glycine) for distension and irrigation of the cavity. However, this fluid may be absorbed into the circulation through the open blood vessels within the myometrium, thus causing hyponatraemia. Prevention involves strict monitoring of fluid input and output with a continuous calculation of the presumed fluid absorbed. The procedure should be stopped once the fluid deficit exceeds 1000 ml. The management of fluid overload is mainly supportive with strict fluid balance recording, monitoring of electrolytes and treatment of any ensuing pulmonary oedema.

Contraindications

The absolute contraindications for hysteroscopy are acute endometritis, PID and pregnancy.

Summary

• Pelvic pain is a common symptom, with both gynaecological and non-gynaecological causes. Genitourinary, gastrointestinal and gynaecological features are all important in the history.

• Pregnancy (and ectopic) must be excluded in all women with acute pelvic pain.

• Laparoscopy is the main diagnostic tool for women with pelvic pain.

• Endometriosis is a major cause of pelvic pain and infertility.

• The severity of symptoms of endometriosis correlates poorly with the extent of disease found at laparoscopy.

• All medical treatments for endometriosis have similar efficacy.

• Surgical treatment for endometriosis is more effective than medical treatment, especially in women wishing to become pregnant.

• All women undergoing hysteroscopy or laparoscopy should have a pregnancy test on the day of the procedure.

Related

Essentials of Obstetrics and Gynaecology