SURGERY

Dr. Surya Krishnan is an Obstetrician, Gynaecologist, Gynaecology Endoscopic Surgeon and Robotic Surgeon.

What is robotic surgery?

Robotic surgery is the most advanced form of laparoscopic surgery, commonly known as ‘keyhole surgery’, where the operation is carried out through a series of small incisions with the use of a thin surgical telescope called a laparoscope and long thin instruments. Laparoscopic surgery avoids the need for the large abdominal incision required for traditional open surgery.

What are the benefits of robotic surgery?

Robotic surgery, like conventional laparoscopic surgery, has the following proven benefits:

  • Improved vision with 3D high definition technology
  • Smaller incisions with a better cosmetic result and less wound related complications compared to open surgery
  • Less blood loss
  • More precise control of instruments and therefore a more delicate surgery with less internal scar formation (adhesions)
  • Less post-operative pain
  • Shorter hospitalisation
  • Quicker recovery
  • Earlier return to work and normal activities
  • Robotic surgery facilitates difficult surgical tasks and can make difficult complex procedures easier 

Is robotic surgery safe?

The da Vinci Robotic System was approved in the USA in 2000 and introduced to Australia in 2003. Since then, thousands of units have been installed across the globe and over 6 million procedures have been performed, across multiple surgical disciplines. The system is now on its 4th generation with countless innovations and refinements.

Useful Links
Da Vinci Surgery | Gynecology Robotic Assisted Surgery

What is laparoscopy?

Laparoscopy is a minimally invasive technique of performing a surgery through smaller incisions. A thin fibre-optic instrument called a laparoscope is inserted into the abdomen through a small cut. It allows visualisation of pelvic organs and also treatment of problems if detected.

Why is it required?

Laparoscopy in gynaecology is used to check for any abnormalities in the uterus, ovaries, fallopian tubes, and other organs which are not evident by other diagnostic procedures such as X-rays and other scans. Laparoscopy is used to diagnose and treat the conditions of pelvic pain, infertility, fibroids, cysts, tumours, endometriosis, ectopic (tubal) pregnancies, pelvic inflammatory disease and other gynaecological problems.

How is laparoscopic surgery done?

The procedure is performed under general anaesthesia in the operating theatre. Your surgeon will make a small incision in your abdomen below the navel through which the laparoscope is inserted. The abdomen is filled with a gas, usually carbon dioxide, which gives a clear view of the pelvic organs. Other incisions will be made to insert surgical instruments if any abnormalities are detected that require treatment. Once the treatment is complete, the incisions are closed. In most of the gynaecological procedures, the procedure may take about 30 minutes.

What are the advantages of laparoscopic surgery?

Laparoscopic surgery has a number of proven advantages including:

  • Better vision due to magnified, high-definition digital images captured through a surgical telescope
  • More delicate surgery from the use of fine instruments
  • Less blood loss
  • Less internal scar formation (adhesions)
  • Smaller incisions compared to a large traditional incision
  • Less post-operative pain
  • Shorter recovery period with earlier return to work
  • Better cosmesis 

Useful Links
Laparoscopy

What is a hysteroscopy?

A hysteroscopy is a procedure that examines and treats conditions inside the uterine cavity. This is done through a thin telescope introduced from the vagina through the cervical opening, therefore avoiding any incisions on the abdomen. It is often performed to investigate and treat causes of abnormal uterine bleeding and conditions that impair fertility.

When do you need to have a hysteroscopy?

Hysteroscopy is performed for the following situations:

  • To investigate abnormal bleeding (heavy, prolonged, intermenstrual and postmenopausal bleeding)
  • To investigate causes of infertility
  • Exclude presence of uterine cancers
  • Removal of retained IUD or insertion of IUD or Mirena device
  • Removal of uterine polyps (soft outgrowth of uterine lining)
  • Removal of uterine lining as a treatment for heavy menstruation (Hysteroscopic resection of endometrium/ablation)
  • Removal of uterine septum (aberrant uterine partition)
  • Removal of uterine fibroid (firm rubbery muscular growth arising from uterine wall)
  • Removal of scarring inside the uterine cavity (Asherman’s syndrome)

How is a hysteroscopy carried out?

Hysteroscopic procedures are carried out as a day procedure in hospital under general anaesthesia. The simplest form of hysteroscopy is when the telescope is introduced to simply inspect the uterine cavity to ensure there is no pathology, this is called a diagnostic hysteroscopy. A gentle scrapping of the uterine lining, called curetting, is often carried out to obtain a tissue sample for pathologyanalysis. When dealing with a larger lesion that needs to be removed or when other interventions are required, a more elaborate instrument called an operative hysteroscope is necessary. An operative hysteroscope has a small channel along the side of the telescope called a working channel, that allows the introduction of thin instruments to perform delicate tasks inside the uterus.

Complex hysteroscopic procedures

Hysteroscopic resection of endometrium/ablation

  • Menstrual loss comes from the shedding of the uterine lining and ablation is a therapeutic procedure to remove this lining to treat heavy menstrual loss. Ablation aims to remove the full thickness of the uterine lining plus a superficial portion of underlying uterine muscle.
  • The goal is to reduce the menstrual loss to a manageable level, not to have no periods altogether. A large proportion of patients end up having minimal loss during their future periods.
  • In some instances, it can result in worsening of period pain, particular when adenomyosis is present.
  • Ablation should only be carried out when there is no further plan for pregnancy, however it is not contraceptive.
  • Following the procedure, there can be 3-4 weeks of bloodstained discharge.



Hysteroscopic resection of fibroid

  • To remove a submucosal fibroid, a hysteroscopic resectoscope is required. A resectoscope can have a wire loop attachment that can function as an electrical knife.
  • Submucosal fibroid of up to 5cm can be resected hysteroscopically.



Hysteroscopic resection of uterine septum

  • A uterine septum is a congenital uterine partition that has failed to resolve during embryological development and can increase the chance of miscarriage.
  • It is rarely symptomatic and usually diagnosed following a miscarriage or on a routine pelvic ultrasound.
  • Treatment by hysteroscopic resection of uterine septum aims to reduce the chance of miscarriage. The condition does not prevent a woman from falling pregnant and uncomplicated pregnancies can still occur without treatment.
  • Resection of uterine septum is usually reserved for those who have had miscarriages that may be attributed to uterine septum.
  • If a woman has no plan for pregnancy, no treatment is required.



Hysteroscopic division of uterine adhesions (Asherman’s syndrome)

  • Asherman’s syndrome is condition where scar tissue has formed inside the uterine cavity. This can lead to light or no menstrual flow, pain and impaired fertility.
  • Causes of Asherman’s syndrome include uterine procedures particularly around the time of pregnancies such as postpartum curetting for retained placenta or surgical termination. The risk of developing Asherman’s syndrome is particularly high if there is infection at the time.
  • Asherman’s syndrome is graded based on the proportion of the uterine cavity affected.
  • Asherman’s syndrome can be diagnosed on regular pelvic ultrasound but a specialised ultrasound procedure called sonohysterogram, where fluid is instilled into the uterine cavity, provides better visualisation and assessment.
  • Treatment of Asherman’s syndrome is indicted when there are fertility issues or pain. Treatment consists of hysteroscopic division of the uterine scar tissue to restore the uterine cavity. At the end of the procedure, anti-adhesion agent or a small balloon may be placed in the uterine cavity for a short period of time to minimise scar recurrence. A course of oestrogen is given to enhance endometrial healing, as the endometrial lining is sensitive to oestrogen. Following a withdrawal bleed with a short course of progesterone, the uterine cavity is re-checked with another sonohysterogram, at which time minor early scar formation is likely to be broken down by the distension of the cavity during this ultrasound procedure. In severe cases of Asherman’s syndrome, surgery may need to be repeated.


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