The advance of information technology by the end of this century directly affected medical science, extending a doctor’s horizons to unimaginable lengths, enabling accurate diagnoses, and faster and less traumatic treatments.
Former open surgeries that required large incisions gradually gave way to the so-called microsurgery, with minimal orifices made with specific and adequate devices, providing safe treatment, shorter hospital stay, and faster recovery, enabling patients to go back to their daily activities much earlier than before.
Therefore, adequate technology improves quality of life, and reduces both direct and indirect costs to society.
An endoscopic procedure consisting of a small incision in the abdomen, with an optic system coupled to a video camera that fits into the surgeon’s hand. It provides a direct view of the female reproductive and other organs through an image projected on a monitor, with an immediate two-fold magnification. This amplified image, with advantages over the non-magnified view, enables accurate, fast and less traumatic diagnoses, eliminating the need for most exploratory laparotomies, reducing hospital stay to one day, and providing immediate recovery.
Whenever a pathological condition requiring surgery is detected, and provided that there is no technical contraindication to the method, the specialist – with the same instruments used for diagnostic purposes, plus delicate grasping pliers, different types of scissors, and cutting and coagulation material – can perform the operation and either solve the problem or refer the patient elsewhere. Video endoscopy, therefore, avoids numerous unnecessary abdominal surgeries, reducing trauma and scarring.
Any procedure requiring a diagnosis through direct view of the pelvis, analysis of the ovaries, fallopian tubes, uterus, bag fundus, peritoneum, intestine, and other abdominal cavity organs. Biopsy and pathological process staging. In video laparoscopic surgical procedures, the only limitations are the instruments used, the specialist’s technical skill (learning curve), and disease-specific contraindications, e. g., radical oncological surgical treatments.
Endometriosis, a disorder that affects about 4% of women at a fertile age, is best diagnosed and treated by video laparoscopy. According to the 1990 Census (carried out by the Brazilian Institute of Geography and Statistics, IBGE), at that time there were roughly thirty million women at fertile age, meaning that 1,200,000 women are at risk of being affected. The disorder (foci of endometrial tissue outside the uterus) may be located in the ovaries, fallopian tubes, peritoneum, intestine and bladder, and the later the diagnosis, the more extensive the damage. The process is not malignant, may be discreet in some patients, increasing dysmenorrhea. Other women may experience bleeding at the endometriosis foci, with excruciating pain, sometimes leading to an acute abdomen condition that requires surgery. During the process, the foci increase, inflammation sets in, and adhesions form impairing the patient’s sexual life and reproduction capacity, causing extreme damage to the “frozen pelvis”.
Video endoscopy is capable of detecting endometriosis 40% more frequently than 6 years ago, when it was not being used, and more important, it enables early diagnosis, in the initial stage of the disease, before the reproductive organs are functionally impaired. The foci are vaporized and cauterized, the content of endometric cysts is aspirated, and medical treatment may be associated. Thus, potential infertility may be prevented.
Different from what we used to believe, “open sky” conventional surgery in this specific case speeds up the pathological process stimulating adhesion formation, that is, worsening the prognosis.
Ectopic pregnancy is treated by aspiration of gestation site’s content, preserving the fallopian tubes.
In acute inflammatory processes such as those caused by Chlamydia trachomatis, which affect a significant portion of the population, the current procedure is to associate medical treatment with early intervention to remove any adhesion that may form, avoiding impairment of the fallopian tubes which could be irreversible and, in case the patient wished to get pregnant, lead to in vitro fertilization, a costly procedure for the majority of the population.
Expansive masses located in the ovaries, Douglas bag bottom, and other sites that would require accurate diagnosis, may be removed in the same surgical procedure. Likewise, with miomas of the uterus and ovary cysts impervious to clinical treatment.
Correction of urinary incontinence by strain via the abdomen.
Video laparoscopy assisted vaginal hysterectomy.
Destruction of nervous fibers of the uterus-sacro ligament in recalcitrant painful processes, Cotte’s surgery.
There are many other indications and new ones will come up as the technique improves.
An endoscopic procedure performed through the vagina, in which the optical system enters the cervical canal and uterus cavity, diagnosing any anomaly and enabling the treatment thereof through the same procedure.
Diagnostic video hysteroscopy enables the detection of polyps, synechia, uterine septa, fibroids, endometrial changes, and adenocarcinoma of the endometrium. It can be used to guide endometrial biopsy. With the spread of HRT (hormone replacement therapy) it became part of routine control, and prevention of hyperplasia and endometrial carcinoma.
Surgical video hysteroscopy enables quick polyp, foreign body, and fibroids removal; and sept resection.
In refractory metrorrhagia, besides helping the diagnosis, it enables endometrial ablation. Through this procedure nearly the whole endometrium may be removed, reducing excessive bleeding, a condition that weakens the patient. With the drop in estrogen receptors, that are removed along with the tissue, the uterus reduces in size. When properly indicated, endometrial ablation cures or improves the patient’s condition. This prevents total removal of the uterus, avoiding unnecessary hysterectomies that are then restricted to cases in which bleeding is associated with adenomyosis (endometrium within the uterine muscle). Currently, hysterectomy is the most performed surgery worldwide: 200,000 procedures every year in the US alone.
Surgical video hysteroscopy is done under general anesthesia, on an outpatient basis.
In summary, at present, the correct use of different imaging methods associated to video endoscopy clarifies most pathological processes in gynecology, enabling faster diagnosis and treatment. Hospitalization, when necessary, is kept to a minimum, enabling women to resume their activities and go back to their family with no delay.
- High resolution video-monitor
- S-VHS Video
- High resolution endocamera
- Electronic insufflator with automatic abdominal pressure control
- 400-watt xenon gas light
- Mono and bipolar radiofrequency cautery
- CO2 pressure aquapurator, for water instillation and dissection
- Low pressure surgical aspirator
- 90 degree, 10 mm optics
- 90 degree, 7 mm optics
- Microsurgery material including Manhes pliers, Semm forceps, single-pole needles, bipolar pliers, insulated scissors, Cambriagui knot applier, etc.
- Aspiration trocars (20, 10, 7 and 5 mm)
- Saline solution heating device
- Rack for the equipment
- Polypropylene trays
- Fiber optic
- Bipolar cabling
- Single-pole cabling
- Line filters
For video hysteroscopy, add:
- 30-degree, 4mm hysteroscopy
- Diagnostic shirt
- Operating shirt with operative bridge
- Semi-flexible micro-scissors
- Semi-flexible grasping and micro biopsy pliers
- Semi-flexible cutting and biopsy pliers
- Ceramic tip resect scope, for electricity isolation
- Regular loop
- Roller-ball loop
- Scalpel-shaped loop
- Single-pole cable
- Hysteroscopy probes with coupled liquid instillation and outlet devices
- CO2 insufflator - Hysteroflator – for distension of the cavity of the uterus.
As the technique evolves, new equipment is being used, older ones have been replaced, and the procedure has definitely become part of the medical armamentarium of our times.