Endoscopy (key hole surgery) for diagnosis and treatment in Gynaecology

Endoscopy also known as minimal invasive surgery, is one of the greatest achievements of medicine in the 21^st century. The magnification and clarity of the images, the small holes on the skin, the absence of post- operative pain and the immediate mobilization after surgery provide the best surgery outcome and safety for the patient. The complications are less, the need of painkillers after surgery is minimal and the majority of the gynaecological operations are performed in an out patients’ setup. The overall cost is much lower compared to the conservative way of laparotomy, the open type of surgery, which does large skin incisions for the same operations.  Transabdominal laparoscopy offers uninterrupted check to all points of the abdominal and pelvic cavity and general anaesthesia is usually necessary. Laparoscopy by local anaesthesia is also feasible but skills, experience, knowledge and selection of the patients are the factors determining this option. Detailed diagnosis and treatment at the highest level can be provided only by experts and trained laparoscopists.

The transvaginal laparoscopy (TVL) enables full investigation of the pelvis via the vagina. The posterior vaginal wall is only 5mm away from the pelvic cavity. The introduction of a small diameter telescope of 2.8mm is easy and the risk of complications almost zero. The major advantage of the TVL is the potential of diagnosis of subtle lesions, making this technique very important for the etiology of the unexplained infertility patients and early diagnosis of ovarian cancer. These pathologies cannot be identified by standard laparoscopy in 40% of the cases with unexplained infertility as published several times in the medical literature. TVL is performed under sedation and local anaesthesia and the patient returns home after 2-3 hours in excellent condition.

Hysteroscopy is the method used to examine the endometrial cavity of the uterus. A telescope of 1.5mm is progressed via the vagina and cervix into the cavity of a uterus. Normal saline solution or Ringer lactate solutions are usually used to distend the uterine walls in order to be able to observe and examine the endometrium quality, anatomical landmarks and also endometrial functionality. By combining hysteroscopy with ultrasound examination simultaneously in the operating room. Many infertility pathologies can be diagnosed concerning the junctional zone, myometrial and subendometrial layers. In older women and post-menopausal ladies, with menstrual abnormalities, heavy bleedings, polyps, myomas etc hysteroscopy is the best option for diagnosis and treatment at the same time. The cervical dilatation and uterine curettage (D&C) is considered unreliable since 18 % of the pathologies will be missed and its failure to excise a polyp completely can be as high as 40%.

Most of the hysteroscopic operations do not need anaesthesia since there is no inervation in the endometrial layer. In some cases painkillers and local anesthesia are used. Even in difficult hysteroscopic operations like myomectomy the anesthesia used is sedation with a laryngeal mask.  Hysteroscopy together with the TVL provide an integrated and reliable procedure for the diagnosis and treatment of women with infertility, repeated pregnancy loss, ectopic cervical pregnancies, heavy uterine bleedings and many more.