Caesarean Delivery
Birth by Caesarean Section is common, safe and efficient. It is a valid choice for delivery and although not without its risks and complications,
enjoys a number of advantages over natural birth. Everyone can be born by caesarean section whereas the same cannot be said about vaginal birth.
No one who professes any knowledge of childbirth and labour should malign a choice of caesarean section and this is the one surgical technique
responsible for saving more lives than all other surgery combined. Who then, could be so arrogant as to fail to revere this miracle of medicine?
Whether a caesarean section is appropriate or not, is an entirely different matter. In this practice, a request for a caesar, unless strongly motivated,
will be neatly deflected to the 37 week visit.
Abdominal Hysterectomy
This operation is indicated when the vaginal route is not deemed suitable. This may be due to previous surgery, suspected additional pathology or sheer size.
The cut is often made on a previous caesarean scar and is generally a bikini cut. In rare circumstances, a vertical incision is made below the belly button. Muscles are split and not cut, thus function is not affected & you will be able to do those sit-ups again 6 weeks after surgery!
Once inside, a little time is taken to restore anatomy, that is to ensure the womb and ovaries are correctly orientated and free of attachments to surrounding organs (called adhesions). The womb is then removed using sutures and/or electrocautery. The vaginal vault is sutured onto the supporting ligaments to guard against later prolapse or sagging. The ovaries are generally retained and are secured to the pelvic side wall.
Ovaries are generally only removed where compromised such as in suspected cancer or extensive benign disease.
The abdomen is closed in 3 layers, firstly the covering membrane or peritoneum, thereafter the muscle sheath and finally hidden sutures below the skin. I use a comfeel dressing which acts like a second skin, preventing movement at the scar and eliminating the risk of unsightly keloid. Please refer to ‘do’s & don’ts for abdominal surgery for post operative guidelines.
Vaginal Hysterectomy
The removal of the womb via the vagina. In most cases, this is the route of choice. Vaginal removal obviates the need for a skin incision significantly reducing post operative pain and immobility. I will offer this route in all cases where it is possible.
A spinal or general anaesthetic can be offered for this procedure. We use stirrups to gain vaginal access. The bladder is emptied and catheterised. The mouth of the womb, or cervix, is grasped and infiltrated with local anaesthetic. This helps to define the tissue layers, as well as improve pain control. A circular incision is made in the cervix. The bladder is moved from the upper surface and the rectum from the lower surface.
The membrane surrounding the abdominal cavity, or peritoneum, is punctured, exposing the connecting tissue, ligaments and blood vessels at the sides. These are then clamped and sutures in 3 or 4 steps at each side.The ovaries are inspected and biopsies may be taken. The fallopian tubes may also be removed. A vault repair is then performed using the remnants of the cardinal ligaments to ensure the vaginal vault remains secure and stable.
A corrugated drain and cloth vaginal plug are inserted which remain over night.A scope of the bladder (cystoscopy) may be conducted if you have had previous surgery (such as a C/section) Hospitalisation generally lasts 2 nights.
Laparoscopic ventrosuspension
Laparoscopic Ventrosuspension is the management of choice for symptomatic uterine retroversion. In this condition, the womb lies backwards with its body directly behind the vaginal vault. This can cause considerable discomfort during intercourse and back pain, particularly during menstruation. Other symptoms are prolonged bleeding with cramping. The condition is also associated with impaired fertility.
A retroverted womb is, however not an abnormality and may also resolve spontaneously. Up to 40% of woman may have retroversion at examination. Management only ever becomes relevant if symptoms are significant. The Ventrosuspension operation is also only relevant where fertility is still desired. If the family is complete, a hysterectomy is a better choice for symptomatic retroversion.
The operation is conducted through 3 incisions. One at the umbilicus (belly button) to introduce the camera, and two on the bikini line, on either side of the midline. The round ligaments are used to pull the womb forward where they are attached by suture to the anterior abdominal wall. This restores the antevert or forward facing position of the womb.
The round ligaments are extremely sensitive and this operation is associated with considerable discomfort. Recovery can take up to 3 weeks. Frequency (having to visit the loo often) and difficulty in standing upright is common. Patients are advised to sleep with a pillow under the knee initially. Nerve sensitivity may persist for up to three months.
Long term satisfaction with the procedure is high with excellent resolution of most symptoms.
A subsequent pregnancy is unaffected by the procedure, however, this may lead to a recurrence of the retroversion.
LLETZ Biopsy
Large Loop Excision of the Transformation Zone is the technique used to manage pre-cancerous lesions of the mouth of the womb (cervix) . The procedure can be conducted under local or general anaesthetic.
Stirrups are used and access to the cervix is obtained by means of a speculum. Iodene or acetic acid is used to demarcate the affected area.
Local anaesthetic is injected around the cervix. A semicircular electrode is chosen according to the size of the lesion and it is removed with a clear boundary in one or two sweeps. The biopsy is sent to the laboratory for confirmation of stage and clearance. It may be necessary for an additional biopsy or further surgery. In all cases regular review in the future is required.
Endoscopic Procedures
This is so-called key-hole surgery. It forms an integral part of all modern surgical disciplines and consists of diagnostic and therapeutic procedures conducted under guidance of a camera. The surgeon focuses on the image on the screen to conduct the procedure and does not come into direct contact with the target organ. There are three major types of gynaecological endoscopy: Laparoscopy, Hysteroscopy and Colposcopy.
This comprises the imaging of the abdominal and pelvic cavities through the umbilicus or belly button. A cavity is created by introducing Carbon Dioxide gas via a needle or directly through a laparoscopic port. In diagnostic procedures, the camera alone may suffice but for more complex operative procedures up to 3 additional ports may be sited. These ports vary in size from 5 to (rarely) 15mm. A wide variety of instruments can be used laparoscopically, from scissors, to cautery, to laser. Tissue can be removed via an endobag or by morcellation (where it is removed in strips). This is particularly useful for laparoscopic hysterectomy.
Recovery time from laparoscopy is extremely rapid, and therein lies the benefit of this approach. Most laparoscopies are day cases.
In this procedure, a camera is introduced through the cervix or mouth of the womb. It images the uterine cavity and the openings of the Fallopian tubes. Small benign growths such as polyps and fibroids as well as developmental defects such as septa can be removed. This procedure is important in abnormal bleeding to take directed biopsies to exclude cancer.
Generally an office procedure. A colposcopy is ordered where the routine PAP smear has found evidence of abnormality (see Routine Screening) The colposcope is essentially a microscope that is directed through the vaginal speculum. It magnifies the cervix and highlights areas of abnormal keratin deposition or other patterns associated with pre-cancer or cancer. It assists with directed biopsies or help to choose between an office procedure (such as cryotherapy or freezing the lesion) or surgical excision in theatre.
