ENDOSCOPIC SURGERY

What is hysteroscopy?

As the name suggests, hysteroscopy (hystero = uterus; scope = seeing) is the application of an endoscope into the uterus to examine the lining on its inner surface. The method can be helpful in diagnosing various uterine problems that can cause infertility, such as:

- Submucosal (internal) fibroids

- Adhesions

- Endometrial polyps

- Uterine chambers and other congenital malformations

Before hysteroscopy; Hysterosalpingography (radiography showing the uterus and fallopian tubes) may be taken to obtain information about the uterus that may be useful during surgery. Many doctors also perform vaginal ultrasonography as an adjunct. Diagnostic hysteroscopy is an examination performed under general or local anesthesia and completed in approximately 30 minutes.

How is hysteroscopy done?

In the first step of hysteroscopy, the uterine neck (cervix) is stretched and opened using a series of dilators. When dilatation is complete, the hysteroscope, a narrow, lighted optical device, is passed through the cervix and delivered to the lower end of the uterus. A clear solution (Hsykon or glycine) or carbon dioxide gas is then injected into the uterus through the hysteroscope. Solution or gas introduced into the uterus; It expands the uterine cavity, clears blood and mucus, and allows the surgeon to directly visualize the uterine lining.



The doctor systematically; examines the lining of the cervical canal and the inner surface of the uterus, tries to see the ends (ostium) of the fallopian tubes, where they open into the uterine cavity.

Some doctors perform curettage (a surgical scraping of the lining of the uterus with a surgical instrument) after hysteroscopy and send pieces of endometrial tissue for pathological examination.

What is operative hysteroscopy?

The hysteroscopy technique has been expanded to include operative hysteroscopy. Operative hysteroscopy allows various uterine abnormalities found during diagnostic hysteroscopy to be treated at diagnosis.

Operative hysteroscopy technique is similar to diagnostic hysteroscopy; The difference is that surgical instruments such as scissors, biopsy forceps, electrocauteries and grippers are inserted into the uterine cavity through the channel in the operative hysteroscope, and fibroids, scar tissue (adhesions or synechiae) and polyps can be removed from the uterus using these instruments. Congenital abnormalities, such as the presence of a septum in the uterus, can also be corrected with the hysteroscope.

What are the complications of hysteroscopy?

Complications are rare during hysteroscopy. In a small number of cases, infection may develop in the uterus or fallopian tubes. Sometimes a hole can be made (perforation) in the posterior wall of the uterus. However, since the opened hole closes by itself, it does not cause a serious problem. When extensive operative hysteroscopy is planned, diagnostic laparoscopy is also performed to allow the surgeon to view the inside as well as the outside of the uterus in order to reduce the risk of accidental uterine perforation. Allergic reactions and bleeding are other possible complications that can be seen during hysteroscopy.

What is laparoscopy?

Laparoscopy, also called endoscopy or pelviscopy; It is the insertion of an optical instrument into the abdominal cavity through a small incision made under the umbilicus and allowing the doctor to see the pelvic organs of the infertile woman. laparoscopy; Damaged tubes can provide diagnosis for many problems that cause infertility, such as endometriosis, adhesions and tuberculosis.

When is laparoscopy done?

In previous years, diagnostic laparoscopy was a routine examination method used to complete the evaluation in women with infertility problems. Since it is a surgical (invasive) procedure, it was usually a method used after basic infertility tests were performed. However, the place of laparoscopy in the treatment of infertile women is extremely limited and we rarely use laparoscopy in our clinic.

Timing of laparoscopy

Some doctors perform laparoscopy in the pre-menstrual period (within the week before the next menstrual period starts). Since these doctors perform laparoscopy by combining dilatation and curettage (with scraping of the inner surface of the uterine cavity), they also have information about the ovulation status of the woman within the scope of the same procedure.

Some doctors prefer to combine diagnostic laparoscopy with hysteroscopy because it is in the post-menstrual phase when the endometrium is thin.

What precautions should be taken before the laparoscopy procedure?

The patient is advised not to eat or drink anything for a certain period of time before the procedure. Before laparoscopy, some tests can be done to find out whether the anesthesia is safe, but nowadays these tests are not needed in almost any healthy young women. Some doctors may request an HSG (hysterosalpingogram) be done before laparoscopy.

Laparoscopy is usually performed during the day. During the procedure, the patient is applied under general anesthesia in order to sleep so that he does not feel any discomfort.

How is laparoscopy done?

Laparoscopy attempt

First of all, the skin of the abdomen is cleaned and covered as necessary. An instrument can then be inserted into the uterus by entering through the vagina. Carbon dioxide, nitric oxide or air is introduced into the abdominal cavity, just below the navel. This given gas creates a space that separates the abdominal wall and intestines from the organs in the pelvis area, making it easier to see the reproductive organs.

Laparoscopy, a thin tube resembling a miniature sailor's binoculars, is inserted through an incision made just below the belly button. With a second probe inserted into the abdominal cavity through another incision, the pelvic organs are positioned for better visibility. A diagnostic laparoscopy performed without opening this “second hole” is not complete since it is not possible to see all formations completely when the said probe is not used.

During laparoscopy, the entire pelvis is scanned, organs - uterus; The ovaries and the covering that covers the inner surface of the abdomen (peritoneum) are systematically examined by direct visual inspection (inspection). In addition to the diseases that may be in these formations, the doctor also looks for the presence of adhesions (bands), endometriosis and tubercles. If there are abnormalities seen, the doctor; either tries to fix them (operative laparoscopy) or uses a biopsy forceps to take small pieces of tissue (biopsy) for examination in pathological examination. A blue dye (methylene blue) is then injected into the uterus and fallopian tubes to see if they are open. When the laparoscopy is complete, the introduced gas is evacuated and one or two stitches are placed to close the incisions. Because the incisions are so small, these sutures are usually not needed and it is sufficient to cover the holes with a plaster.

As mentioned earlier, some doctors also perform dilatation and curettage along with laposcopy and send pieces of the endometrium for histological examination to rule out the possibility of occult tuberculosis; It also investigates whether ovulation has occurred. Others perform diagnostic hysteroscopy at the same time as laparoscopy to make sure the uterine cavity is normal.

Most of today's doctors use the video laparoscopy technique, in which a video camera is attached to the laparoscope, allowing the surgeon to see what he sees on the TV monitor. This type of laparoscopy also greatly aids in patient education by allowing physicians to display video or CD recordings to the patient at a later time to explain the nature of the problem present.

Recent advances that have made devices smaller and smaller have allowed very small laparoscopes to be made. We call these laparoscopes, which are one needle thick, as microlaparoscope or needle scope. These miniature laparoscopes allow laparoscopy to be performed in the office without the use of anesthesia. However, the quality of images obtained with these small laparoscopes has not yet been improved.