Controversies In Operative Gynaecology

CONTROVERSIES IN OPERATIVE GYNAECOLOGY CONSENT AND COUNSELING CHALLENGES INCISION ENTERING THE ABDOMEN LAPAROSCOPIC PROCEEDURES ●PRE-SACRAL NEURECTOMY ●UTERINE NERVE ABLATION ● ABLATION OF ENDOMETRIAL DEPOSITS ● OVARIAN DRILLING ENDOMETRIAL DESTRUCTION

COLPOSUSPENSION

Consent and Counseling   

Medico-legal implication Removal of both ovaries Sexual Function

Challenges for the Present Day: 

 

Pelvic pain (Endometriosis, PID) Excessive Blood Loss Infertility – not so much a challenge

INCISION  

Transverse for most gynaecological surgeries Longitudinal _ Reserved for – – –

Large masses Suspected or proven malignancies ‘Exploratory’ – diagnosis uncertain.

ENTERING THE ABDOMEN  

Avoid Bleeders Use only as long an incision as necessary

LAPAROSCOPIC PROCEEDURES A. Pre-Sacral Neurectomy (LPSN) B. Uterine Nerve Ablation (LUNA).

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

Limited evidence suggesting that LUNA was more effective in pain relief than diagnostic laparoscopy. A second RCT compared LUNA and LPSN and found no significant different in pain relief in the short term. However, LPSN was significantly more effective in the long term.

LAPAROSCOPIC PROCEEDURES C. Ablation of Endometrial Deposits  Insufficient evidence on the effects of LUNA in pain attributed to endometriosis.  Insufficient evidence on the effects of Laparoscopic ablation of deposits on its own.  However, combined treatment with ablation of deposits and LUNA reduced pain more than diagnostic Lap. at six months.

LAPAROSCOPIC PROCEEDURES OVARIAN

DRILLING

No difference in pregnancy rates in ladies who were managed with FSH and HMG.

ENDOMETRIAL DESTRUCTION and HYSTERECTOMY  Hysterectomy

is the only CERTAIN way of stopping ALL menstrual loss.  Endometrial Ablation removes the basal layer of the endometrium, thereby preventing or reducing regeneration and menorrhagia is cured.

ENDOMETRIAL DESTRUCTION  Methods:

– Roller ball ablation – Electro-surgical Resection – Microwave ablation – Thermal balloon therapy – Laser ablation These are only successful in relieving The majority of symptoms in 80% of cases.

MYOMECTOMY  Insufficient

evidence on the effects of Myomectomy in women with menorrhagia.

Open Vs Laparoscopic and Hysteroscopic Myomectomy  Needs

training in Endoscopy  Expensive  Short hospital stay  The methods of the future

ENDOMETRIAL THINNING (PRE-OP)  Danazol

also effective but less so than GnRH analogues. Insufficient evidence on the use of progestogens  Review of RCTs found that use of GnRH analogues (e.g. Gaserelin) to thin endometrium before surgery facilitates and reduces the duration of surgery and increases the rate of post-operative amenorrhea.

COLPOSUSPENSION  

 

Burch Colposuspension Anterior repair and bladder buttress Tension-free vaginal tape Sub-urethral sling procedure

CONCLUSION ‘Key-hole’

holds the key to the future. Need to encourage institutions and young doctors to undergo training.