Departmnt of Infertility & Key hole surgeryElite Mission Hospital ,Thrissur,Kerala, India. 

Painless Hysterectomy             

Laparascopic Assisted Vaginal Hysterectomy

Laparoscopic evaluation of Infertility:

Laparoscopic management of ectopic pregnancy

Laparoscopic Ovarian cystectomy/Ovariotomy

Laparoscopic Myomectomy

Laparoscopy for Chronic Pelvic Pain

Thermal/Electric Ablation

Hysteroscopic tubal cannulation

Hysteroscopic myomectomy

Hysteroscopic septal resection, adhesiolysis,etc

Intra uterine insemination.

Sperm Banking.

Reversal of Tubal sterilization

Painless Hysterectomy

Hysterectomy is traditionally performed through the abdominal route when the uterus is not prolapsed.

This involves pain at the incision site. The majority of patients find it painful to turn over,walk,etc on the

second post-operative day.The patient has to be hospitalised for 5-9 days and has to take rest from

heavy jobs for a period of 3 months at least. There is a small risk of wound infection,incisional hernia,etc.

When the procedure is done enntirely through the vaginal route, there is no incision on the abdomen.

As there is no incision on the abdomen, there is no chance of wound infection or incisional hernia.

The patient has no pain and is very comfortable while bending,turning over,walking,etc from the second day itself.

Internationally, various studies have shown that ureteric injuries are fewer when hysterectomy is performed this way.

The patients normally go home on the 3rd post-operative day and are even allowed to travel by bus .

They can resume normal duties within 7-10 days of surgery.

When there are adhesions in the abdomen due to previous surgery or some other conditions like infection or endometriosis,

or if there is an ovarian cyst in addition to the pathology in the uterus, a Laparascopic Assisted Vaginal Hysterectomy may be done . An instrument called the laparoscope is inserted through tiny holes in the abdomen and part of the hysterectomy is done using laparoscopic instruments. The rest of the job is completed vaginally.

This procedure also leaves the patient painfree and she can go home on the 3rd day itself.

Cost: Vaginal hysterectomy costs the same as Abdominal hysterectomy.

At Elite Mission Hopital in normal course of events, the rough cost may be just around Rs.15,000.totally. Laparoscopic assistance may cost a bit more.

Experience : In the past eight years around 95% of all hysterectomies have been done through the vaginal route in this unit successfully . Uterus upto the size of a 6 month pregnancy have also been removed vaginally.

Laparoscopy:

Laparoscopic evaluation of Infertility:

·         Laparoscopy serves as an excellent mode of diagnosis in the evaluation of infertility.

·         Laparoscopy can correct blocks in the fallopian tube if they occur in the abdominal end of the tube by releasing the adhesions in the tube

·         Endometriosis is a condition where endometrium, the lining of the uterus is abnormally found in the abdomen, on the uterus,ovaries, etc. Laparoscopic treatment of this condition offers excellent prospects of cure.

·         Laparoscopic puncture of ovaries can cure some cases of Polycystic ovaries, one of the causes of infertility

Laparoscopic management of ectopic pregnancy

Ectopic pregnancy is the development of a pregnancy outside the uterine cavity. Laparoscopy is sometimes the only way to clinch the diagnosis in some cases where an ultrasonography may give doubtful results.

The following procedures have been done successfully in this unit for ectopic pregnancy for a number of cases.

·         Salpingectomy,where the tube with pregnancy is cut off in patients who have completed their family.

·         Salpingostomy,where the tube is retained and the pregnancy is taken out through an incision in the tube in patients who want to retain the fertility potential of their tube.

·         Suction of products of conception from the abdomen in cases where the pregnancy has aborted through the abdominal end of the tube.

·         Salpingo-oophorectomy,where the tube and affected ovary is removed in cases of ovarian pregnancy.

Laparoscopic Ovarian cystectomy:

The ovaries may sometimes develop membraneous bags in them filled either with blood or sometimes, a colourless fluid which sometimes requires surgery for correction

·         These cysts can be removed laparoscopically . A number of unmarried girls who had cysts of this kind (some of them even extending above the umbilicus) have undergone ovarian cystectomy/salpingoophorectomy in this unit.For such patients it is a boon not to have a scar on the abdomen,besides avoiding the stigma of prolonged hospital stay in a gynaecology unit. The magnification offered by the video camera also allows for a more meticulous surgery.

·         When such cysts occur in an older woman,after meticulously ruling out cancer, using blood tests and colour doppler ultrasound, it is possible to remove them laparoscopically. These procedures have also been done in patients with history of multiple surgeries done in the past. When such patients under go open procedures many surgeons often remove the uterus also fearing that if it needs removal in future, it may lead to another traumatic surgery for the patient. Thus laparoscopic surgery in these cases also allows for a less morbid surgical procedure.

Laparoscopic Myomectomy

The uterus sometimes developes noncancerous tumours in them called fibroids.When single,they can be removed succesfully through the laparoscope allowing for early discharge.

Experience: A number of such laparoscopic myomecties with endosuturing have been done in this unit and one of them has subsequently concieved and delivered a full term baby after that.

Laparoscopy for Chronic Pelvic Pain

Continous low grade pain is a very common condition found in middleaged women. Quite often it is due to some low grade infection which can be cured when treated meticulously. Sometimes it leaves scars around the uterus and ovaries leading to pain. Sometimes it is due to dilated veins. In both these conditions a laparoscopy is very useful. When these patients undergo hysterectomy it is found that the pain recurs in 30% of cases, much to the patient's distress. Instead, if a videolaparoscopy is done it is possible to release adhesions if that is the cause of pain leading to a cure. Sometimes no abnormality is found and in these instances it is my practice to show them the videocassette of the procedure,and then the patients are ready to accept the pain or control it with simple analgesics as they have the happy knowledge that nothing serious is wrong with them.

Cost Laparoscopic procedures cost betweenRs.5000-15000 depending on the type of procedure.

Thermal/Electric Ablation

Sometimes women get heavy irregular bleeding around the age of forty. Clinical and ultrasound examination shows the uterus to be free from any structural abnormalities. This type of bleeding in medical language is called Dysfunctional uterine bleeding and is usually due to variations in the hormones like oestrogens and progesterones. Quite often it is controlled with medicines,but in cases where it is not, women used to resort to hysterectomy, a very morbid procedure.

Ablation of the endometrium is an alternative treatment for this procedure. Uterus has an innermost lining called the endometrium which is shed every time the woman menstruates. It is the shedding of this lining that leads to menstruation.

Removal of this lining will lead to a stoppage of menstruation. Ablation is an attempt at doing this.

Thermal ablation of the endometrium: Under sedation in the D&C room a rubber balloon (Part of a urinary catheter) is passed into the uterine cavity and hot water passed in it. The heat in the water passes through the balloon and sort of cooks the endometrium. (Cost AroundRs2000)

Electric ablation of the endometrium: The endometrium can be removed using electric current, but in this unit it is done only under anaesthesia. An instrument called the hysteroscope is used for this. (Cost- Around Rs7000)

After these procedures the patients get either reduced bleeding during periods or have normal periods. Some of the patients who have undergone these procedures 7 years back in this unit have been followed up recently and found to be doing well

Hysteroscopy

Hysteroscopic tubal cannulation

In some infertile patients the fallopian tubes necessary for the passage of the egg and the ovum is blocked near their

entry into the uterus. These types of blocks called cornual blocks can sometimes be removed by passing a tube through the uterus negotiating through the block and into the fallopian tube using the hysteroscope.

Hysteroscopic myomectomy:

Sometimes fibroids protrude into the cavity of the uterus causing heavy bleeding. In such cases if their size is less than 5cm, they can be removed through the hysteroscope using electric current. There is no scar on the abdomen and no incision need be made into the muscle of the uterus. The patient goes home the next day absolutely painfree.

Hysteroscopic septal resection, adhesiolysis,etc

Some patients abort repetitively and when an X-ray is taken they are found to have some structural abnormality like a fibrous wall in the centre(Septum) , some adhesions between the walls of the uterus or some abnormality in the shape of the uterus. These can be corrected through the hysteroscope after which the patient has excellent prospects of carrying the pregnancy to term.

Cost of all hysteroscopic procedures - Around Rs.8000.

INTRA UTERINE INSEMINATION

This is a procedure done for the treatment of intractable infertility. In this procedure, the husband's semen is collected, mixed with a little medical fluid and centrifuged. The good motile sperms are separated and deposited into the wife's uterus. This is done for patients with intact tubes. Cost in this unit-Rs.1000/cycle for the procedure. There is provision for the wife to sit in the room where the processing is being done,so that the couple is reassured that there is no mixing of samples.

Sperm Banking.

Sperms of Husbands who may be going out of station(for eg; to the gulf) can be stored in liquid nitrogen to be used in his absence.In our social context, this sample may be used only if the insemination is done within a few days of the husband leaving the station In this unit such samples can be used only for Intra uterine insemination and hence the huband should essentially have a good count as 30% is lost during cryopreservation and hence samples with very low counts may after cryopreservation be too bad to do IUI Cost- Around Rs.5000

Reversal of Tubal sterilisatiion

Sometimes a couple may lose a child after tubal sterilisation. If they desire a child ,the cut ends of the tube can be rejoined by microsurgery. This procedure offers an 80% success rate. Cost- around Rs.15,000.