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Investigative & definitive surgery

The Australian Centre for Female Pelvic and Vaginal Rejuvenation
The Australian Centre for Female Pelvic and Vaginal Rejuvenation

What is surgery?

Surgery is the branch of medicine concerned with treating or investigating disease and injuries through operative or manual procedures

The aim of investigative surgery

Surgery carried out in order to:

  • Produce a diagnosis.
  • Confirm a diagnosis.
  • Exclude pathology (disease process).
  • Determine the approach to definitive surgery.

The aim of definitive surgery

Surgery carried out in order to:

  • Relieve, improve or cure a symptom.
  • Relieve, improve or cure a condition.
  • Relieve, improve or cure a disease.
  • Restore normal function &/or appearance.

Examples of investigative surgery

Laparoscopy
Laparoscopy

The laparoscope is a specialised telescope which is passed through the abdomen into the abdominal cavity allowing the surgeon to look inside as well as operate inside the abdomen and pelvis. Diagnostic laparoscopy is the term used when the laparoscope is used to make or aid in making a diagnosis.

Assessing prolapse
Assessing prolapse

When assessing the degree of prolapse it can be very informative and essential in planning definitive surgery to inspect the state of the pelvis as well as the degree of movement of the prolapsed structures and organs.

Identifying adhesions
Identifying adhesions

Adhesions can cause many symptoms and problems. They cannot be identified through imaging techniques such as ultrasound and X-Ray and must be visualised directly. This is usually done through laparoscopic assessment of the abdomen and pelvis.

Diagnosing interstitial cystitis
Diagnosing interstitial cystitis

Interstitial cystitis causes bladder pain, lower abdominal pain and urinary frequency. This condition is, however, diagnosed by direct inspection of the bladder via a cystoscope. Typically, back bleeding from vessels occurs after hydrodistension. Sometimes a Hunners ulcer will be seen.

Urethroscopy
Urethroscopy

Urethroscopy is a form of endoscopy {a method of looking inside an organ – in this case the urethra}. A special telescope is passed into the urethra. Fluid moving through the urethroscope distends the urethra, allowing it to be inspected.

Examination under anaesthetic
Examination under anaesthetic

Most women will be examined when they are awake. Examination under anaesthesia may be required if it is not possible to perform an examination when the patient is awake. When assessing prolapse, the degree of prolapse is often more pronounced and reflective of the true state.

Diagnosing cause of pelvic mass
Diagnosing cause of pelvic mass

A pelvic mass can be identified through examination &/or imaging such as ultrasound. When planning appropriate treatment, direct inspection of the mass is more likely to lead to a definitive diagnosis. This information will enable Dr Onuma doctor to discuss all the available options for treatment with the patient.

Hysteroscopy
Hysteroscopy

The hysteroscope is a specialised telescope which is passed through the cervix into the uterus allowing the surgeon to look inside as well as operate inside the endometrial cavity and the cervix. Diagnostic hysteroscopy is the term used when the hysteroscope is used to make or aid in making a diagnosis.

Diagnosing lichen sclerosus
Diagnosing lichen sclerosus

The cause of lichen sclerosus has not been determined. It causes irritation of the external genitalia. Visually, the skin becomes white and thick. A tissue biopsy will confirm the diagnosis. Treatment is usually with topical steroids and medical surveillance will be required for life.

Diagnosing endometriosis
Diagnosing endometriosis

Endometriosis is a condition that has a multitude of symptoms and appearances. Taking a history of menstrual function and pain can often lead to a suspicion of endometriosis. In severe endometriosis, imaging such as ultrasound may be highly suggestive of endometriosis. Direct visualisation through laparoscopy remains the gold standard for diagnosis (and treatment).

Identifying cause of pain
Identifying cause of pain

There are many different and diverse causes of lower abdominal and pelvic pain. Pain can be referred from one organ or area to another. A pelvic examination can provide a guide as to potential causes, but direct inspection is the gold standard and is often required to establish a diagnosis.

Bladder biopsy
Bladder biopsy

Visual inspection of the bladder, with or without hydrodistension is essential in identifying bladder pathology. A tissue specimen sent for histological analysis may be required to establish the exact nature of the lesion. This is called a bladder biopsy.

Examples of definitive surgery

Suburethral sling procedure
Suburethral sling procedure

The suburethral ‘sling’ procedure, also know as a TVT (tensionless vaginal tape), is currently viewed as the gold standard surgery for stress urinary incontinence. It is a minimally invasive procedure which is done as a day case or overnight stay. It can be combined with other types of pelvic reconstructive surgery.

Repair of rectocele
Repair of rectocele

A rectocele is a prolapse of the posterior wall of the vagina. Symptoms include feeling of a bulge, pressure, backache, pain/discomfort during intercourse and a visible lump coming out of the vagina. The defect is repair through the vagina with reconstruction of the vaginal epithelium, the fascial connective tissue and detached or ruptured muscle.

Laparoscopic myomectomy
Laparoscopic myomectomy

Myomas (fibroids) are smooth muscle tumours of the uterus. They are usually benign. They can be discovered incidentally but can cause a variety of pressure symptoms, heavy periods or problems with conception. Removal of the fibroid is called a myomectomy and can be done as an open procedure or laparoscopically.

Laparoscopic uterine suspension
Laparoscopic uterine suspension

The uterus occupies the space at the top of the vagina. It can become prolapsed and descend into the vagina, pulling the vaginal walls with it. Resuspension of the uterus can be achieved through a variety of techniques. Laparoscopic uterine/pelvic floor suspension involves re-attaching the utero-sacral ligaments to the back of the cervix and the transverse cervical ligaments.

Laparoscopic oophorectomy
Laparoscopic oophorectomy

Oophorectomy is the technical term for removal of an ovary. This can usually be done as a laparoscopic (keyhole surgery) procedure with the patient able to go home the day of surgery and, thus allowing a rapid return to normal activities. The fallopian tubes can be removed at the same time (salpingo-oophorectomy) or by themselves (salpingectomy).

Ovarian cystectomy
Ovarian cystectomy

The ovaries are physiologically active prior to the menopause but most cysts resolve spontaneously. When they become enlarged, complex and symptomatic they can often be ‘shelled’ out of the ovary using a laparoscopic technique during day surgery. Return to normal activities is usually rapid. Ovarian cysts can recur.

Labia majora reduction
Labia majora reduction

The labia majora are also known as the ‘outer lips.’ Reduction involves removal of some vulval skin and subcutaneous fat with reconstruction in 2-3 layers. Requests for labia majora reduction are made because of discomfort, pre-existing scar tissue, excess fat or sagging of the skin.

Resecting endometriosis
Resecting endometriosis

Indications for endometrial resection includes removal of large polyps, fibroid polyps and the endometrial layer of the uterus in women who have heavy menstrual bleeding (who have completed their family). It is done as a day surgery hysteroscopic technique which does not involve any external scars. Recovery is usually rapid.

Division of adhesions
Division of adhesions

Division of adhesions (adhesiolysis) is often done as a laparoscopic day case procedure. Symptoms of adhesions can include lower abdominal-pelvic pain, alteration of bowel function and reduced fertility. Adhesiolyis can restore quality of life and function, however, recurrence rates are high and currently available preventive measures are poor.

Labiaplasty
Labiaplasty

Labiaplasty typically refers to labia minora (inner lips’) reduction. Requests for labiaplasty have increased as women are less likely to tolerate being patronised and become aware that surgery is available. The most common reason for requests for labiaplasty are labial discomfort and aesthetic concerns. Surgery is done as a day case procedure with a rapid return to most normal activities.

Vaginal vault suspension
Vaginal vault suspension

Vaginal vault descent or prolapse occurs when the uterus had been removed in the past. The top of the vagina (vault) descends down into the vagina and in severe prolapse can appear at or just outside the entrance to the vagina (introitus). Suspension involves re attaching the utero-sacral ligaments to the vaginal vault or attaching mesh between the sacrum and the vaginal vault.

Laser vaginal surgery
Laser vaginal surgery

Use of the laser as a dissecting tool in vaginal reconstructive surgery can reduce scar formation, improve healing and may improve sensation during intercourse, particularly when the surgeon adopts a sexual function approach to pelvic reconstructive surgery. Terms used include ‘rejuvenation,’ ‘reconstruction’ and ‘repair.’ The importance is not the term used, it is that the surgery carried out attends to all layers of damaged tissue to restore normal anatomy as far as possible.

Investigative & definitive surgery are not mutually exclusive. Depending on the nature of pre-surgery counselling and consents, diagnosis can proceed immediately to definitive surgery if appropriate in the particular circumstances.

For example:

  • For most cases of symptomatic mild-moderate endometriosis, surgical treatment can be performed.
  • Adhesions thought to be the cause of pain can be divided.
  • Ovarian cysts that are symptomatic or large can be dealt with.
  • Endometrial polyps discovered at hysteroscopy should be removed if possible.

The most important factors in progressing from diagnosis to treatment during the same episode of anaesthesia include:

  • Thorough pre-surgery discussion about the parameters of surgery.
  • Appropriate consents for surgery.
  • The patient and surgeon being on the same ‘wave-length.’
  • The condition that may require treatment is not overtly complex.
  • An unexpected finding is made where the treatment options are very variable.
Laser Vaginal Rejuvenation Institute of Adelaide
Laser Vaginal Rejuvenation Institute of Adelaide