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Gynaecological Endoscopic Surgery


Endoscopic surgery refers to the use of optical instruments or lenses to visualize the pelvis or inside of the uterus and the use small instruments to perform the surgery. This is a highly advanced way of performing gynaecological surgery providing the best level of care for the patient. It allows operations that would usually require large incisions(laparotomy) to be performed through a few small incisions resulting in less pain, shorter hospital stay, quicker recovery and superior cosmetic results. At Aevitas we aim to provide all our surgery via an endoscopic route. Gynaecological Endoscopy can be divided into laparoscopy and hysteroscopy:


Hysteroscopy

Hysteroscopy refers to the visualization of the inside of the uterus with a lens inserted through the vagina and cervix. This allows for the inspection of the uterine cavity and the diagnosis of any intrauterine pathology. Major advances in hysteroscopic equipment allows for surgery to be performed through the hysteroscopy to address a range of condition. These procedures can be done in our day theatre with discharge on the same day. 


Laparoscopy

Laparoscopy refers to the visualization of the peritoneal cavity, including the pelvis, with a lens inserted through the umbilicus. This allows for the inspection of abdominal organs and in particular the pelvic organs as it relates to gynaecology. The addition of two to three smaller(5mm) incisions allows for the performance of even major pelvic surgery through this minimal access technique. 


Index


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Abdominal Adhesions
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Previous abdominal or pelvic surgery can cause adhesion formation between bowel and pelvic organs and the abdominal wall. This can cause abdominal pain and be a cause of infertility. These adhesions can be released with operative laparoscopy. The magnification and specialized instruments used during laparoscopy is especially useful during adhesiolysis, helping to identify tissue planes and vital structures. This can restore normal bowel function and improve fertility.
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Asherman's Syndrome
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Asherman’s syndrome is a condition characterized by extensive scarring and adhesions formation in the uterine cavity that can develop due to infection or after uterine procedures like evacuation or D&C. The surgical treatment of severe Asherman’s syndrome can be very challenging. Our approach involves systematic resection and development of the uterine cavity with a hysteroscopy and hysteroscopic scissors. This is done under ultrasound guidance to aid in the accuracy of the resection. Intrauterine adhesion barriers are placed to limit the reformation of scarring. Depending on the degree of fibrosis and the reformation of adhesions, complete restoration of the uterine cavity will often require multiple resection procedures. 
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Caesarean Section Scar Defect
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Previous lower segment cesarean section can result in a defect in the muscle of the uterus. This is termed an isthmocele or a uterine niche an can easily be diagnosed on ultrasound. Patients with an isthmocele typically struggle to fall pregnant after as cesarean section and often complain of spotting before and after their menstruation. The defect in the myometrium (uterine muscle) can be visualized with a hysteroscope at which time it can be resected. If the defect is large, or the remaining muscle thin, this can be repaired laparoscopically by excising the defect and re-suturing the uterus in layers. 
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Cervical Incompetence
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Cervical incompetence refers the inability if the cervix to maintain a normal pregnancy to term. This usually is a result of tissue weakness, or a result of previous surgery to the cervix. These patients typically present of the loss of more than one normal pregnancy during the second trimester. First line management in these cases usually involve the placement of a cervical cerclage vaginally. If such a cerclage (McDonald’s Suture or Shirodkhar Stich) fails, an abdominally placed vaginal cerclage is indicated. This cerclage can be placed with a laparoscopic approach. 
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Congenital Uterine Anomalies
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Abnormalities in the embryologic development of the uterus represents a spectrum of uterine malformations. This can be as simple as a partial uterine septum and a rudimentary horn or as complex as a complete duplication with a double uterus and two cervixes, or in rare cases the absence of a cervix, uterus or part of the vagina. These malformations are associated with premature delivery, recurrent miscarriages or occasionally infertility. The surgical treatment of these conditions is complex. It may be as simple as resection of a septum or a partial hysterectomy to remove a functional uterine horn. In more complicated malformations laparoscopic reconstruction with fusion of a double uterus might be indicated, a so-called Strassman Metroplasty. In cases of where there is malformation or the absence of the upper vagina, complex surgical techniques are used for vaginoplasty and the reconstruction of the genital tract.
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Endometriosis Surgery
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Laparoscopic surgery is the gold standard for the treatment of endometriosis . The latest high definition laparoscopy equipment in our theatre allows for excellent visualization of endometriosis and access to the pelvis for optimal treatment. We perform both ablative as well as excisional surgery for the treatment of endometriosis, depending on the depth of infiltration.

We are a Centre of Excellence for Endometriosis surgery and receive referrals for surgery for severe endometriosis from all over the country as well as from other African countries. We follow a multidisciplinary approach to the surgery of endometriosis. This starts with the pre-operative assessment and the rational use of advanced imaging like MRI to aid in surgical planning. The colorectal surgeons from Matley and Partners form part of our surgical team and take part in the surgery where infiltrative endometriosis requires resection of the bowel. We aim to provide the most complete resection of endometriosis to limit recurrence and avoid repeated surgery.

Our fertility background put us in a unique position to optimize the surgical strategy to the reproductive wishes of a patient. This could include hormonal downregulation or fertility preservation before surgery or performing surgery to improve spontaneous conception.

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Laparoscopic Hysterectomy
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Laparoscopic hysterectomy can be performed in almost all cases of benign disease. This is the gold standard for hysterectomy and results in less post-operative pain, shorter hospital stay and quicker return to normal daily activities. The hysterectomy can be done through 4 small skin incisions and allows for the evaluation of the pelvic organs and ovaries. In most cases a total hysterectomy would be performed with extraction of the uterus through the vagina and laparoscopic suturing of the vaginal vault. In cases where a sub-total hysterectomy is indicated, the cervix is not removed, and the uterus is morcellated through one of the small skin incisions. 
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Sterilisation Reversal
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The magnification afforded by laparoscopy and the small instruments available allows for the re-anastomosis of the Fallopian tubes by utilizing micro-surgery principles. The success of this procedure depends on the type of sterilization that was performed as well as the quality and length of tube that is available to reconnect. Factors such as age an male factor infertility needs to be taken into account when deciding on this form of treatment. 
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Sub-Mucosal Fibroids And Polyps
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Submucosal fibroids and polyps are both causes of abnormal uterine bleeding and can also contribute to infertility. Management of these two conditions have greatly improved with the advancement of endoscopic technology in the form of small caliber hysteroscopes, resectoscopes and intra-uterine morcellators. These advances allow us to perform resection of fibroids and polyps in an outpatient setting allowing the patient to go home within a few hours of the procedure. In our day theatre we utilize a combination of these techniques to offer the optimal solution to remove the fibroids and polyps. We routinely use latest evidence based intra-uterine adhesion barriers to ensure minimal scarring and adhesion formation after our hysteroscopic surgery. 
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Uterine Fibroids
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Uterine fibroids that are in the uterine cavity can be removed hysteroscopically. This is performed as a day procedure and involves resecting the fibroid with an advanced bipolar resectoscope or small intracavity morcellator. This is done through the cervix of the uterus and does not require any skin incisions.

Larger uterine fibroids can be removed by a laparoscopic approach, this involves small skin incisions and insertion of small instruments as described in the laparoscopy section. The uterus is then incised, and the fibroid carefully dissected to preserve the normal uterine tissue. The uterus is then closed in layers with laparoscopic suturing to allow it to heal adequately.
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Uterine Septum And Adhesions
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A uterine septum is usually a congenital malformation of the uterus but can also develop due to scarring and adhesion formation after previous uterine procedures like evacuations or myomectomy. These can then be resected hysteroscopically on an outpatient basis in our day theater. With the use of small (4Fr) caliber hysteroscopic scissors inserted through the working channel of a 5mm hysteroscopy, this surgery can be done without the use of thermal energy, protecting the normal endometrium and with minimal discomfort the patient. Placement of an intra-uterine adhesion barrier after the resection will prevent scarring and reformation of the adhesions. 
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