Surgical Procedures Explained

Endometrial ablation is the removal or destruction of the lining of the womb. It is an alternative to hysterectomy for many women with heavy periods (menorrhagia) who wish to avoid major gynaecological surgery. It is generally performed as a day-case procedure and most women return to normal daily activities within a couple of days. Increased vaginal discharge for 2-4 weeks is normal as the lining of the womb is shedding. Intercourse and strenuous activities should be avoided for about 2 weeks. Patient selection and surgeon experience are essential elements to a successful outcome of endometrial ablation.

Endometrial ablation can be performed using a special hysteroscope (telescope) called a resectoscope. This instrument allows visualisation of the cavity of the womb and has a built-in wire loop or roller-ball that uses high-frequency electrical energy to cut or coagulate tissue. The procedure is carried out under anaesthesia. Approximately 85% of women experience relief of their symptoms within the first few months, with many having scant or absent periods after the procedure. Other methods of ablation have more recently been introduced. The Thermachoice™ balloon uses a balloon filled with hot water which is placed in the uterine cavity through the cervix. The Microwave Endometrial Ablation (MEA) involves inserting a microwave probe (long slender tube) into the cavity of the womb to heat the lining. With the temperature maintained at 75-80˚C, the probe is moved from side to side of the uterine cavity to destroy the tissue.

The risks of endometrial ablation procedures include perforation of the womb, infection, bleeding, excess fluid absorption, injury to pelvic and abdominal organs.

Since endometrial ablation will destroy the lining of the womb, which is essential for embryo implantation and establishment of pregnancy, ablation of the endometrium should not be offered to women who wish to maintain their fertility. It also should not be performed on women with pre-malignant or malignant conditions of the womb, and in women with active pelvic inflammatory disease (PID).

The tissue reaction to any injury is known as inflammation. Depending on the type of tissue involved and the amount of damage, the tissue may be restored to normal or scar tissue may form. Tissue injury is generally the result of surgery, infection, haemorrhage (heavy internal bleeding) or trauma.

An adhesion is a thin or thick band of scar tissue that joins two or more internal body surfaces together, hence covering adjacent organs and cavities. Most adhesions are only diagnosed at the time of surgery. Adhesions that involve the uterus, ovaries, fallopian tubes, bowel and/or bladder can form and can lead to chronic pelvic pain, infertility, pain during intercourse (deep dyspareunia) and increased the risk of ectopic pregnancy.

Adhesiolysis involves cutting and releasing the adhesions in order to restore the normal anatomy of the involved organs. Treatment of adhesions can be carried out either by laparoscopy (keyhole surgery) or laparotomy (making a cut in the abdomen). Laparoscopy with gentle tissue traction, the use of non traumatic instruments and hydrodissection (separation of the tissue using sterile water) is preferred as it appears to be associated with a lower rate of adhesions reformation. At the end of the operation, barriers can be inserted to prevent the healing tissue from sticking together with scar tissue. Barriers are like thin sheets of paper, which are gradually absorbed by the inside tissues.

This surgery consists of removing deposits of endometriosis in an attempt to ease symptoms such as persistent pelvic pain, painful intercourse and painful periods, and increase the chance of pregnancy if infertility is an issue. Surgery can either be conservative or radical (removal of the uterus and fallopian tubes with or without both ovaries).

Using various surgical techniques, endometriotic implants, cul-de-sac nodules, ovarian cysts (endometrioma) and/or adhesions may be carefully, precisely and completely removed. These implants will not recur, though new implants may grow in the same anatomic area in the future. Endometriotic deposits may be destroyed with a laser beam or electric current (electrocautery) passed down a fine probe. Incomplete removal may result in the endometriosis recurring and the symptoms persisting. In case of an endometrioma, the surgical approach associated with less recurrence is the drainage and excision of the cyst. Repeated surgery for endometriosis is likely to cause adhesions and scar tissue that ultimately affect fertility. Anti-adhesions barriers should always be used at the end of surgery to minimise this risk.

Laparoscopic (keyhole) treatment of pelvic endometriosis is generally the preferred approach as recovery is quicker, though laparotomy is still preferred by some surgeons. Often the management of advanced endometriosis requires a multidisciplinary approach including a colorectal surgeon and an urologist as endometriotic lesions can be found to affect the gastrointestinal and the genitourinary tracts.

Surgical treatment of endometriosis may sometimes be combined with medical therapy, especially in patients who are not currently seeking pregnancy. The combination of surgery and medical therapy is used in the hope that it may stop the growth of new endometriotic lesions before the patient begins to try conceiving. Surgery is preferred to medical therapy for women actively trying to conceive as the latter approach delays the time to conception. The exception to this management is for those women with endometriosis undergoing in-vitro fertilitzation (IVF). A three-month course of treatment with GnRH-analogue seems to improve the outcome of IVF.

What you need to know about Mr Nardo's expertise in endometriosis surgery

Mr Nardo has extensive clinical experience and an academic interest in the management of advanced endometriosis. He is an internationally renowned lecturer and opinion leader in the field. He works very closely with a multidisciplinary team made of a colorectal surgeon, a urological surgeon and a pain management specialist to ensure his patients receive the best available care. Furthermore, he leads a very active research group whose programmes focus on different aspects of endometriosis-associated infertility.

What is Hysterectomy?

A hysterectomy is an operation to remove the uterus (womb). Usually the cervix (neck of the womb) is removed at the same time. Depending on the reason why the procedure is performed, the woman's age, the presence of other diseases, hysterectomy is sometimes combined with the removal of one or both ovaries and fallopian tubes (uni- or bilateral salpingo-oophorectomy). Other types of hysterectomy are: subtotal hysterectomy (the body of the uterus is removed, leaving the cervix behind) and Wertheim's or radical hysterectomy (the body of the uterus, the cervix, part of the vagina, fallopian tubes, usually ovaries, parametria, lymph glands and fatty tissue in the pelvis are all removed).

Why is hysterectomy performed?

• Persistent heavy periods (menorrhagia)
• Pelvic pain
• Endometriosis
• Fibroids
• Ovarian cysts (in menopausal women)
• Cancer

What does the surgery involve?

Hysterectomy can be carried out by conventional open surgery which involves making a cut across the abdomen (laparotomy), or through the vagina which involves making a cut in the vagina, or by laparoscopy which involves making four tiny cuts (about 1 cm each) in the abdomen in order to insert a telescope and some other instruments to carry out the operation.
Where possible the laparoscopic (minimally invasive) approach should be preferred to the others. The advantages and disadvantages of laparoscopic hysterectomy are:

• It involves a much shorter hospital stay (1 or 2 days maximum)
• It takes less time to recover from the operation (resume all activities within 2-3 weeks)
• There is less pain after the operation as the abdomen is not cut open
• The scars are very tiny and often are not seen a few months after the operation
• There may be some discomfort in the abdomen and the shoulders after surgery because of the use of gas during the operation to expand the abdominal cavity
• As with any type of operation, laparoscopic hysterectomy has a small risk of complications, such as damage to the vessels causing haemorrhage (heavy bleeding), damage to the bowel, the bladder and the ureters (tubes between the kidneys and the bladder), deep venous thrombosis (clots in the blood stream).

Over 75% of the hysterectomies performed by Mr Nardo are laparoscopic. If you need a hysterectomy to treat any of the above-mentioned gynaecological problems, and if you wish to enquire whether you are a candidate for minimally invasive hysterectomy please make an appointment with Mr Nardo in his consulting rooms either in Manchester or London.

This is a technique to look directly inside the womb (uterus). It may be done because of abnormal uterine bleeding, postmenopausal bleeding, miscarriage or subfertility. A thin telescope called a hysteroscope is passed through the neck of the womb (cervix) into the cavity of the womb itself. Sterile water is put in via the hysteroscope to separate the walls of the womb and allow visualisation of the inside of the uterus. The hysteroscope is generally attached to a TV screen and photographs can be taken.

Hysteroscopy can be done either with or without general anaesthetic. If performed without anaesthetic the hysteroscopy is generally carried out in an environment very similar to the outpatient suite. Sometimes there can be mild discomfort like period pain, which should settle down within a couple of hours. A biopsy (a sample of tissue) of the lining of the womb may be taken and sent to the laboratory to be looked at under a microscope.

The whole procedure is likely to take about 10-15 minutes, although sometimes extra procedures such as the removal of a polyp may be necessary and could make it last a bit longer.

Hysteroscopic resection is a technique which is used as conservative treatment for women with menstrual symptoms. It is often performed instead of a hysterectomy (removal of the womb). Initially a narrow telescope (a hysteroscope) is introduced through the cervix to examine fully the cavity, then by passing electrical current through a small loop placed inside the hysteroscope the lining of the womb is removed (shaved-off).

Hysteroscopic resection also allows removal of fibroids that grow inside the uterus and that cause heavy menstrual bleeding, uterine septum (a thick band of tissue inside the womb) that may cause miscarriages, and intrauterine adhesions (cling film inside the womb) that cause infertility, absence or very light periods and pelvic pain.

Sometimes it is necessary to take a course of tablets or to have one or more injections before the procedure. This approach helps to reduce the thickness of the lining of the womb and the diameter of fibroids and make the operation more successful. Hysteroscopic resection of either the endometrium (lining of the womb) or of fibroids is usually performed under a light general anaesthetic. The complications of such procedure are rare. They include perforation of the uterus which may lead to injury to the bowel and/or to the bladder, infection, bleeding and excessive fluid absorption. The whole procedure may take between 20 and 45 minutes. No overnight hospital stay is generally required. Normal activities can be resumed after 5-7 days.

Laparoscopy is an operation carried out under general anaesthetic which enables examination of the pelvic cavity and pelvic organs (uterus, tubes and ovaries). A small cut is made just below the umbilicus (belly button) and a needle is inserted to inflate the abdomen with carbon dioxide gas. Next, a tube (known as a trocar) is passed through the incision in to the abdomen. A laparoscope, which is a thin telescope is inserted into the abdomen through the trocar. The telescope will transmit images of the inside of the pelvis and abdomen to a TV monitor in the operating theatre. Another small cut is made along the pubic hair line to allow another instrument to be put in which can move the pelvic organs around. Sometimes additional small cuts are made in the lower part of the abdomen in order to insert other surgical instruments. These small cuts will then be sewn or glued together once the operation is completed.

This procedure can be used to make a diagnosis, for example if there are painful periods or painful intercourse or to investigate tubal patency in women trying to conceive. Laparoscopy can also be used to carry out excision of endometriosis, tubal surgery and reversal of sterilization, division of adhesions, removal of fibroids (myomectomy), removal of the uterus (hysterectomy) and/or of the ovaries (oophorectomy).

As with any kind of surgery, there are some complications associated with laparoscopy such as infection, bleeding, injury to organs or blood vessels inside the abdomen. These complications are more common where there have been multiple previous surgeries.

Laparotomy is a surgical procedure done by making an incision in the abdomen to gain access into the abdominal cavity. This allows inspection of the pelvis for suspected pathologies and at the same time to operate safely. A laparotomy could be either diagnostic (exploratory laparotomy) or therapeutic. When a specific operation is already planned (for example, a hysterectomy), laparotomy is considered merely the first step of the surgery.

There are different incisions for laparotomy and the use of one or the other depends on the type of access necessary to perform the procedure safely and effectively. The most common incisions for laparotomy in gynaecology are the midline incision (a vertical incision between the umbilicus and the pubic symphysis or bikini line) and the Pfannenstiel incision (just above the pubic symphysis or bikini line).

Many of the procedures that required a laparotomy in the past can now be performed with laparoscopy (keyhole surgery). Compared to laparoscopy, laparotomy leaves much larger scars, it is associated with increased risk of infection and usually requires a longer recovery period.

Myomectomy is a procedure in which uterine fibroids (also known as myomas) are surgically removed from the uterus (womb). Fibroids can cause heavy and persistent uterine bleeding, pressure feeling, pain and in certain cases infertility. Women who wish to have children or simply do not want to lose their uterus (hysterectomy) look for conservative treatments. Myomectomy can be performed using different surgical approaches.

Abdominal myomectomy: removal of fibroids through an incision in the abdomen. The incision is usually horizontal (bikini line), although in cases of very large fibroids a midline incision may be required. There is no limit to the size or number of fibroids that can be removed. The disadvantage of abdominal myomectomy is that it requires an incision in the abdomen, so recovery is longer than required if an incision is avoided.

Laparoscopic myomectomy: removal of fibroids through keyhole surgery. Fibroids that are located on the outside of the uterus (subserous fibroids), those located in the muscular layer of the uterus (intramural fibroids) and those which are attached to the uterus by a stalk (peduncolated fibroids) are easy to remove laparoscopically. Fibroids located deep in the wall of the uterus in contact with the endometrium (submucous fibroids) are better removed by hysteroscopy. The advantage of a laparoscopic myomectomy over an abdominal myomectomy is that 3 or 4 small incisions (0.5-1 cm each) are used rather than one larger incision. If there is a large number of fibroids (generally more than 5) and if the larger fibroids measures more than 10cm, an abdominal myomectomy is a much better option in terms of repairing the uterus.

Hysteroscopic myomectomy (hysteroscopic resection of myomas): removal of fibroids through the cervix using a special hysteroscope called resectoscope. This instrument uses high-frequency electrical energy to cut or coagulate tissue. Only fibroids located in the inner part of the uterus (submucous fibroids) and intracavitary fibroids (bulging inside the uterine cavity) can be removed using this technique. No skin incision is necessary. The complications of myomectomy include bleeding, organs injury, blood vessels and nerve injuries, infection and blood clot formation. The risk of hysterectomy following myomectomy is of 1%.

Oophorectomy is an operation to remove one or both the ovaries. In pre-menopausal women this will cause hormonal changes resulting in surgical menopause. Oophorectomy can be carried out either by laparoscopy (keyhole surgery) or laparotomy (making a cut in the abdomen). The former approach carries several benefits over the latter, and should therefore be the preferred option if possible.

Oophorectomy can be performed at the same time of another procedure such as hysterectomy (removal of the womb using any of the available routes -- laparoscopy, laparotomy or vaginal) or alone as a planned operation because of an ovarian cyst or an ovarian accident (torsion).

Prophylactic oophorectomy is the removal of the ovaries for the potential benefit of preventing long-term morbidity and mortality. The term prophylactic means that the ovaries are normal at the time of surgery; however they are removed in an attempt to reduce the possibility to develop a future disease such as ovarian and breast cancer in certain high risk women.

Women who have had a bilateral oophorectomy (both ovaries removed) before reaching the menopause physiologically, usually have to take some sort of hormone replacement therapy (HRT) to prevent other health conditions associated with the onset of menopause.

Benign ovarian cysts can be removed safely and effectively either by laparoscopy (keyhole surgery) or laparotomy (making an incision in the abdomen) while leaving the healthy ovarian tissue in place and unharmed. Use of diathermy should be avoided during an ovarian cystectomy as this has been shown to damage the ovarian function and to impair future fertility. Sutures should be used instead to secure bleeding if this occurs. Women undergoing surgery for removal of an ovarian cyst should be made aware of the risk of loosing their ovary too. The laparoscopic approach is usually preferred because of its many advantages over the traditional open approach (laparotomy).

Using laparoscopy, the cysts, regardless of their size, can be removed intact as they are carefully dissected free of the ovary. The cysts are placed in laparoscopic retrieval bags, the contents are aspirated (drained) to reduce the volume and the cysts can be removed within the bag through a small incision.

In most cases laparoscopic ovarian cystectomies are performed as day case procedure. The recovery time with return to normal daily activities is around 1 or 2 weeks.

Vaginal surgery gives access to the pelvic organs (uterus, ovaries and fallopian tubes) through the vagina. The necessary cuts are made in the vagina without leaving any visible scar on the outside. Apart from vaginal hysterectomy (removal of the womb through the vagina), the vaginal route is used for repairing the prolapse of organs adjacent to the vagina such as bladder and rectum. The ovaries and tubes can also be removed at the time of hysterectomy. Generally, the vaginal approach has fewer complications compared to the abdominal one, requires a shorter hospital stay and has a more rapid recovery.

Vaginal repair (or pelvic floor repair) is an operation to correct the weakness of the vaginal walls (prolapse) that can be a cause of persistent discomfort and affect daily activities. Urine incontinence and other urinary symptoms may also be present.

A bulge of the front vaginal wall caused by the bladder prolapsing into the vagina (cystocoele) is corrected by an anterior repair, while a bulge of the back vaginal wall caused by the rectum prolapsing into the vagina (rectocoele) is corrected by a posterior repair. Often the womb (uterus) and the neck of the womb (cervix) are also prolapsed (uterine prolapse) and a hysterectomy may be needed at the same time.

The operation is done by making an incision in the prolapsed vaginal wall and dissolvable stitches are put in to give extra support to the weakened area. Complications of this procedure are infection in the bladder and/or vagina, bleeding from the vagina and although very rare damage to the bladder or bowel can happen. The average recovery time after vaginal surgery is approximately four weeks.