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خارج كردن رحم با لاپاراسكوپي

Written by dr- zhila abedi asl. Posted in Uncategorised

جراحي خارج كردن رحم با لاپاراسكوپي  )هیسترکتومی به معنی خارج کردن رحم است)

در هیسترکتومی ممکن است علاوه بر برداشتن رحم، لوله های فالوپ و یا تخمدان ها نیز برداشته شوند.

انواع مختلفی از هیسترکتومی وجود دارد که بر مبنای بافت هایی که برداشته می شوند، تعریف می شوند. هیسترکتومی کامل که شایعترین نوع این عمل جراحی بوده و در آن رحم و دهانه رحم برداشته می شوند.

هیسترکتومی جزئی که در آن رحم برداشته می شود اما دهانه رحم برداشته نمی شود.

هیسترکتومی رادیکال که در آن رحم، دهانه رحم، بخش های کوچکی از قسمت بالایی مهبل و برخی از بافت های نرم درون لگن برداشته می شوند.

این نوع عمل تنها در موارد سرطان دهانه رحم انجام می شود و باید حتما توسط متخصص زنان آموزش دیده انجام شود.

زمان انجام هیسترکتومی:

بیش از یک پنجم تمام زنان در طول عمر خود عمل هیسترکتومی را انجام می دهند و می توان گفت که این عمل بسیار شایع است. هیسترکتومی تقریبا در تمام موارد سرطان رحم و یا سرطان دهانه رحم الزامی است و معمولا در سرطان تخمدان نیز توصیه می شود. با این حال بیشتر عمل های هیسترکتومی در زنانی انجام می شود که سرطان نداشته اما به علت خونریزی و درد شدید در رحم ترجیح می دهند رحم خود را بردارند و عمل هیسترکتومی را انجام می دهند.

این گونه عمل های جراحی برای زنانی مناسب است که تمایلی به بارداری در آینده نداشته باشند. هیسترکتومی معمولا یکی از گزینه های درمانی در زنان مبتلا به فیبروئید، اندومتریوز، بیماری التهابی لگن و یا دوره های سنگین قاعدگی می باشد. زنانی که به پرولاپس رحم نیز مبتلا هستند، ممکن است پزشک برای ترمیم پرولاپس از هیسترکتومی استفاده کند

نحوه انجام هیسترکتومی:

هیسترکتومی یک عمل ماژور بوده و تحت بیهوشی عمومی انجام می شود. علاوه بر انواع مختلف هیسترکتومی، روش های مختلفی نیز برای انجام این عمل وجود دارد. انتخاب روش انجام عمل هیسترکتومی به عواملی مانند اندازه رحم، تجربه و تخصص جراح بستگی دارد. هیسترکتومی شکمی رایجترین روش است که در آن یک برش تقریبا 6 اینچی ایجاد شده و از طریق این برش عمل انجام می شود.

هیسترکتومی واژینال که عمل جراحی از طریق واژن انجام می شود. در این نوع از هیسترکتومی هیچ اثری از انجام عمل جراحی بر روی بدن فرد باقی نمی ماند. هیسترکتومی واژینال به کمک لاپاروسکوپی که در آن پزشک از طریق یک برش بسیار کوچک و به کمک لاپاروسکوپی و همچنین از طریق واژن عمل را انجام می دهد.

برداشتن رحم با لاپاروسکوپی ( هیسترکتومی لاپاراسکوپیک) امروزه بسیاری از اعمال جراحی با روش لاپاراسکوپی (جراحی بسته) انجام می شود و علت ان مزایای بسیار زیاد لاپاروسکوپی است. در روش لاپاروسکوپی باایجاد چند برش کوچک روی شکم (معمولا ۴ برش ۰٫۵ و۱ سانتی) با دوربین ها و وسایل تخصصی و پیشرفته جراحی انجام می شود. به همین علت و بدلیل بزرگنمایی دوربین های تخصصی عمل جراحی با دقت بیشتری انجام می شود.

فواید هیسترکتومی از طریق لاپاراسکوپی:

به دلیل برش های کوچک میزان درد بعد از عمل خیلی کمتر از جراحی باز است. دوره ی نقاهت کوتاه تر است برگشت به فعالیت روزانه و کار سریع تر است برگشت سیستم ایمنی به وضعیت قبل از عمل سریع تر اتفاق می افتد برگشت به وضعیت فیزیولوژیک نرمال سریع تر است عفونت محل عمل بسیار کمتر است نکته ی بسار مهم در برداشتن رحم با لاپاروسکوپی چسبندگی بعد از جراحی است که در لاپاراسکوپی بسیار کمتر از جراحی باز است که این سبب کاهش درد های لگنی در داز مدت می شود.حتی در بیمارانی که به دلیل جراحی های قبلی چسبندگی دارند ازاد کردن چسبندگی ها با لاپاراسکوپی بسیار کمک کننده است. باوجود فواید بسیار زیاد لاپاروسکوپی که تعدادی از انها در بالا ذکر شد اما اگر لاپاراسکوپی توسط جراح ماهر ودوره دیده انجام نشود می تواند عوارض جدی داشته باشد.

بعد از عمل:

برای چند روز بعد از عمل جراحی مسکن های قوی تجویز می شود. اغلب زنان برای یک تا دو روز بعد از عمل جراحی در بیمارستان نگهداری می شوند. دوره نقاهت عمل هیسترکتومی تا رسیدن به بهبودی کامل معمولا 4 تا 6 هفته طول می کشد. هیسترکتومی واژینال و هیسترکتومی لاپاروسکوپی دوره نقاهت کوتاه تر و هیسترکتومی رادیکال دوره نقاهت طولانی تری دارد.

 

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Laparoscopy

Written by dr- zhila abedi asl. Posted in Uncategorised

Laparoscopy λαπάρα (lapara), meaning "flank, side", and σκοπέω (skopeo), meaning "to see") is an operation performed in the abdomen or pelvis through small incisions (usually 0.5–1.5 cm) with the aid of a camera. It can either be used to inspect and diagnose a condition or to perform surgery

Types

There are two types of laparoscope: (1) a telescopic rod lens system, that is usually connected to a video camera (single chip or three chip), or (2) a digital laparoscope where a miniature digital video camera is placed at the end of the laparoscope, eliminating the rod lens system. The mechanism mentioned in the second type is mainly used to improve the image quality of flexible endoscopes replacing traditional fiberscopes. Nevertheless, laparoscopes are rigid endoscopes. The rigidness is required in clinical practice. The rod lens based laparoscopes are highly dominant in practice, due to their fine optical resolution (50um typically, dependant on the aperture size used in the objective lens), and the image quality can be better than the digital cameras if necessary. The second type is very rare in the laparoscope market and hospitals

Surgery

Main article: Laparoscopic surgery

The laparoscope allows doctors to perform both minor and complex surgeries with a few small cuts in the abdomen

There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include reduced pain due to smaller incisions and hemorrhaging, and shorter recovery time

Gynecological diagnosis

In gynecology, diagnostic laparoscopy may be used to inspect the outside of the uterus, ovaries and fallopian tubes, for example in the diagnosis of female infertility. Usually, there is one incision near the navel and a second near to the pubic hairline. For gynecological diagnosis a special type of laparoscope can be used, called a fertiloscope. A fertiloscope is modified to make it suitable for trans-vaginal application

A dye test may be performed to detect any blockage in the reproductive tract, wherein a dark blue dye is passed up through the cervix and is followed with the laparoscope through its passage out into the fallopian tubes to the ovaries

Laparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations are performed far from their location through small incisions (usually 0.5–1.5 cm) elsewhere in the body

There are a number of advantages to the patient with laparoscopic surgery versus the more common, open procedure. Pain and hemorrhaging are reduced due to smaller incisions and recovery times are shorter. The key element in laparoscopic surgery is the use of a laparoscope, a long fiber optic cable system which allows viewing of the affected area by snaking the cable from a more distant, but more easily accessible location

There are two types of laparoscope: (1) a telescopic rod lens system, that is usually connected to a video camera (single chip or three chip), or (2) a digital laparoscope where the charge-coupled device is placed at the end of the laparoscope

 Also attached is a fiber optic cable system connected to a 'cold' light source (halogen or xenon), to illuminate the operative field, which is inserted through a 5 mm or 10 mm cannula or trocar. The abdomen is usually insufflated with carbon dioxide gas. This elevates the abdominal wall above the internal organs to create a working and viewing space. CO2 is used because it is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures

 

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Hysteroscopy

Written by dr- zhila abedi asl. Posted in Uncategorised

Hysteroscopy

(Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy

Hysteroscope

A hysteroscope is an endoscope that carries optical and light channels or fibers. It is introduced in a sheath that provides an inflow and outflow channel for insufflation of the uterine cavity. In addition, an operative channel may be present to introduce scissors, graspers or biopsy instruments. A hysteroscopic resectoscope is similar to a transurethral resectoscope and allows entry of an electric loop to shave off tissue, for instance to eliminate a fibroid A contact hysteroscope is a hysteroscope that does not use distention media

Procedure

Hysteroscopy has been done in the hospital, surgical centers and the office. It is best done when the endometrium is relatively thin, that is after a menstruation. Diagnostic can easily be done in an office or clinic setting. Local anesthesia can be used. Simple operative hysteroscopy can also be done in an office or clinic setting. Analgesics are not always necessary. A paracervical block may be used using a Lidocaine injection in the upper part of the cervix. The patient is in a lithotomy position during the procedure. Hysteroscopic intervention can also be done under general anesthesia (endotracheal or laryngeal mask) or Monitored Anesthesia Care (MAC). Prophylactic antibiotics are not necessary

Cervical dilation

The diameter of the hysteroscope is generally too large to conveniently pass the cervix directly, thereby necessitating cervical dilation to be performed prior to insertion. Cervical dilation can be performed by temporarily stretching the cervix with a series of dilators of increasing diameter Misoprostol prior to hysteroscopy for cervical dilation appears to facilitate an easier and uncomplicated procedure only in premenopausal women

Insertion and inspection

The hysteroscope with its sheath is inserted transvaginally guided into the uterine cavity, the cavity insufflated, and an inspection is performed

Insufflation media]

The uterine cavity is a potential cavity and needs to be distended to allow for inspection. Thus during hysteroscopy either fluids or CO2 gas is introduced to expand the cavity. The choice is dependent on the procedure, the patient’s condition, and the physician's preference. Fluids can be used for both diagnostic and operative procedures. However, CO2 gas does not allow the clearing of blood and endometrial debris during the procedure, which could make the imaging visualization difficult. Gas embolism may also arise as a complication. Since the success of the procedure is totally depending on the quality of the high-resolution video images in front of surgeon's eyes, CO2 gas is not commonly used as the distention medium

Electrolytic solutions include normal saline and lactated Ringer’s solution. Current recommendation is to use the electrolytic fluids in diagnostic cases, and in operative cases in which mechanical, laser, or bipolar energy is used. Since they conduct electricity, these fluids should not be used with monopolar electrosurgical devices. Non-electrolytic fluids eliminate problems with electrical conductivity, but can increase the risk of hyponatremia. These solutions include glucose, glycine, dextran (Hyskon), mannitol, sorbitol and a mannitol/sorbital mixture (Purisol). Water was once used routinely, however, problems with water intoxication and hemolysis discontinued its use by 1990. Each of these distention fluids is associated with unique physiological changes that should be considered when selecting a distention fluid. Glucose is contraindicated in patients with glucose intolerance. Sorbitol metabolizes to fructose in the liver and is contraindicated if a patient has fructose malabsorption.

High-viscous Dextran also has potential complications which can be physiological and mechanical. It may crystallize on instruments and obstruct the valves and channels. Coagulation abnormalities and adult respiratory distress syndrome (ARDS) have been reported. Glycine metabolizes into ammonia and can cross the blood brain barrier, causing agitation, vomiting and coma. Mannitol 5% should be used instead of glycine or sorbitol when using monopolar electrosurgical devices. Mannitol 5% has a diuretic effect and can also cause hypotension and circulatory collapse. The mannitol/sorbitol mixture (Purisol) should be avoided in patients with fructose malabsorption.

When fluids are used to distend the cavity, care should be taken to record its use (inflow and outflow) to prevent fluid overload and intoxication of the patient

Interventional procedures

If abnormalities are found, an operative hysteroscope with a channel to allow specialized instruments to enter the cavity is used to perform the surgery. Typical procedures include endometrial ablation, submucosal fibroid resection, and endometrial polypectomy. Hysteroscopy has also been used to apply the Nd:YAG laser treatment to the inside of the uterus

Indications

View of a submucous fibroid by hysteroscopy

Hysteroscopy is useful in a number of uterine conditions:

  • Asherman's syndrome (i.e. intrauterine adhesions). Hysteroscopic adhesiolysis is the technique of lysing adhesions in the uterus using either microscissors (recommended) or thermal energy modalities. Hysteroscopy can be used in conjunction with laparascopy or other methods to reduce the risk of perforation during the procedure
  • Endometrial polyp. Polypectomy
  • Gynecologic bleeding
  • Endometrial ablation (Some newer systems specifically developed for endometrial ablation such as the Novasure do not require hysteroscopy)
  • Myomectomy for uterine fibroids
  • Congenital uterine malformations (also known as Mullerian malformations)
  • Evacuation of retained products of conception in selected cases
  • Removal of embedded IUDs

The use of hysteroscopy in endometrial cancer is not established as there is concern that cancer cells could be spread into the peritoneal cavity. Hysteroscopy has the benefit of allowing direct visualization of the uterus, thereby avoiding or reducing iatrogenic trauma to delicate reproductive tissue which may result in Asherman's syndrome

Hysteroscopy allows access to the utero-tubal junction for entry into the Fallopian tube; this is useful for tubal occlusion procedures for sterilization and for falloposcopy

Complications

A possible problem is uterine perforation when either the hysteroscope itself or one of its operative instruments breaches the wall of the uterus. This can lead to bleeding and damage to other organs. If other organs such as bowel are injured during a perforation, the resulting peritonitis can be fatal. Furthermore, cervical laceration, intrauterine infection (especially in prolonged procedures), electrical and laser injuries, and complications caused by the distention media can be encountered

The use of insufflation (also called distending) media can lead to serious and even fatal complications due to embolism or fluid overload with electrolyte imbalances. Particularly the electrolyte-free insufflation media increase the risk of fluid overload with electrolyte imbalances, particularly hyponatremia, heart failure as well as pulmonary and cerebral edema. The main factors contributing to fluid overload in hysteroscopy are

 Hydrostatic pressure of the insufflation media

  • Amount of exposed blood vessels, such as being increased in endometrial ablation and myomectomy
  • Duration of the hysteroscopy procedure

Women in fertile age are at increased risk of resultant hyponatremic encephalopathy, likely because of increased level of estrogens

 The overall complication rate for diagnostic and operative hysteroscopy is 2% with serious complications occurring in less than 1% of cases

HysteroscopyHysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy)HysteroscopeA hysteroscope is an endoscope that carries optical and light channels or fibers. It is introduced in a sheath that provides an inflow and outflow channel for insufflation of the uterine cavity. In addition, an operative channel may be present to introduce scissors, graspers or biopsy instruments. A hysteroscopic resectoscope is similar to a transurethral resectoscope and allows entry of an electric loop to shave off tissue, for instance to eliminate a fibroid A contact hysteroscope is a hysteroscope that does not use distention mediaProcedureHysteroscopy has been done in the hospital, surgical centers and the office. It is best done when the endometrium is relatively thin, that is after a menstruation. Diagnostic can easily be done in an office or clinic setting. Local anesthesia can be used. Simple operative hysteroscopy can also be done in an office or clinic setting. Analgesics are not always necessary. A paracervical block may be used using a Lidocaine injection in the upper part of the cervix. The patient is in a lithotomy position during the procedure. Hysteroscopic intervention can also be done under general anesthesia (endotracheal or laryngeal mask) or Monitored Anesthesia Care (MAC). Prophylactic antibiotics are not necessaryCervical dilationThe diameter of the hysteroscope is generally too large to conveniently pass the cervix directly, thereby necessitating cervical dilation to be performed prior to insertion. Cervical dilation can be performed by temporarily stretching the cervix with a series of dilators of increasing diameter Misoprostol prior to hysteroscopy for cervical dilation appears to facilitate an easier and uncomplicated procedure only in premenopausal womenInsertion and inspectionThe hysteroscope with its sheath is inserted transvaginally guided into the uterine cavity, the cavity insufflated, and an inspection is performedInsufflation media]The uterine cavity is a potential cavity and needs to be distended to allow for inspection. Thus during hysteroscopy either fluids or CO2 gas is introduced to expand the cavity. The choice is dependent on the procedure, the patient’s condition, and the physician's preference. Fluids can be used for both diagnostic and operative procedures. However, CO2 gas does not allow the clearing of blood and endometrial debris during the procedure, which could make the imaging visualization difficult. Gas embolism may also arise as a complication. Since the success of the procedure is totally depending on the quality of the high-resolution video images in front of surgeon's eyes, CO2 gas is not commonly used as the distention mediumElectrolytic solutions include normal saline and lactated Ringer’s solution. Current recommendation is to use the electrolytic fluids in diagnostic cases, and in operative cases in which mechanical, laser, or bipolar energy is used. Since they conduct electricity, these fluids should not be used with monopolar electrosurgical devices. Non-electrolytic fluids eliminate problems with electrical conductivity, but can increase the risk of hyponatremia. These solutions include glucose, glycine, dextran (Hyskon), mannitol, sorbitol and a mannitol/sorbital mixture (Purisol). Water was once used routinely, however, problems with water intoxication and hemolysis discontinued its use by 1990. Each of these distention fluids is associated with unique physiological changes that should be considered when selecting a distention fluid. Glucose is contraindicated in patients with glucose intolerance. Sorbitol metabolizes to fructose in the liver and is contraindicated if a patient has fructose malabsorption.High-viscous Dextran also has potential complications which can be physiological and mechanical. It may crystallize on instruments and obstruct the valves and channels. Coagulation abnormalities and adult respiratory distress syndrome (ARDS) have been reported. Glycine metabolizes into ammonia and can cross the blood brain barrier, causing agitation, vomiting and coma. Mannitol 5% should be used instead of glycine or sorbitol when using monopolar electrosurgical devices. Mannitol 5% has a diuretic effect and can also cause hypotension and circulatory collapse. The mannitol/sorbitol mixture (Purisol) should be avoided in patients with fructose malabsorption.When fluids are used to distend the cavity, care should be taken to record its use (inflow and outflow) to prevent fluid overload and intoxication of the patientInterventional proceduresIf abnormalities are found, an operative hysteroscope with a channel to allow specialized instruments to enter the cavity is used to perform the surgery. Typical procedures include endometrial ablation, submucosal fibroid resection, and endometrial polypectomy. Hysteroscopy has also been used to apply the Nd:YAG laser treatment to the inside of the uterusIndicationsView of a submucous fibroid by hysteroscopyHysteroscopy is useful in a number of uterine conditions:Asherman's syndrome (i.e. intrauterine adhesions). Hysteroscopic adhesiolysis is the technique of lysing adhesions in the uterus using either microscissors (recommended) or thermal energy modalities. Hysteroscopy can be used in conjunction with laparascopy or other methods to reduce the risk of perforation during the procedureEndometrial polyp. PolypectomyGynecologic bleedingEndometrial ablation (Some newer systems specifically developed for endometrial ablation such as the Novasure do not require hysteroscopy)Myomectomy for uterine fibroidsCongenital uterine malformations (also known as Mullerian malformations)Evacuation of retained products of conception in selected casesRemoval of embedded IUDsThe use of hysteroscopy in endometrial cancer is not established as there is concern that cancer cells could be spread into the peritoneal cavity. Hysteroscopy has the benefit of allowing direct visualization of the uterus, thereby avoiding or reducing iatrogenic trauma to delicate reproductive tissue which may result in Asherman's syndromeHysteroscopy allows access to the utero-tubal junction for entry into the Fallopian tube; this is useful for tubal occlusion procedures for sterilization and for falloposcopyComplicationsA possible problem is uterine perforation when either the hysteroscope itself or one of its operative instruments breaches the wall of the uterus. This can lead to bleeding and damage to other organs. If other organs such as bowel are injured during a perforation, the resulting peritonitis can be fatal. Furthermore, cervical laceration, intrauterine infection (especially in prolonged procedures), electrical and laser injuries, and complications caused by the distention media can be encounteredThe use of insufflation (also called distending) media can lead to serious and even fatal complications due to embolism or fluid overload with electrolyte imbalances. Particularly the electrolyte-free insufflation media increase the risk of fluid overload with electrolyte imbalances, particularly hyponatremia, heart failure as well as pulmonary and cerebral edema. The main factors contributing to fluid overload in hysteroscopy are Hydrostatic pressure of the insufflation mediaAmount of exposed blood vessels, such as being increased in endometrial ablation and myomectomyDuration of the hysteroscopy procedureWomen in fertile age are at increased risk of resultant hyponatremic encephalopathy, likely because of increased level of estrogens The overall complication rate for diagnostic and operative hysteroscopy is 2% with serious complications occurring in less than 1% of cases 

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fibroid

Written by dr- zhila abedi asl. Posted in Uncategorised

uterine fibroid

A uterine fibroid is a leiomyoma (benign tumor from smooth muscle tissue) that originates from the smooth muscle layer (myometrium) of the uterus. Fibroids are often multiple and if the uterus contains too many leiomyomata to count, it is referred to as diffuse uterine leiomyomatosis. The malignant version of a fibroid is extremely uncommon and termed a leiomyosarcoma.

Other common names are uterine leiomyoma, myoma, fibromyoma, fibroleiomyoma.

Fibroids are the most common benign tumors in females and typically found during the middle and later reproductive years. While most fibroids are asymptomatic, they can grow and cause heavy and painful menstruation, painful sexual intercourse, and urinary frequency and urgency. Some fibroids may interfere with pregnancy although this appears to be very rare.

In the United States, symptoms caused by uterine fibroids are a very frequent indication for hysterectomy.

Signs and symptoms

Fibroids, particularly when small, may be entirely asymptomatic. Symptoms depend on the location of the lesion and its size. Important symptoms include abnormal gynecologic hemorrhage, heavy or painful periods, abdominal discomfort or bloating, painful defecation, back ache, urinary frequency or retention, and in some cases, infertility. There may also be pain during intercourse, depending on the location of the fibroid. During pregnancy they may also be the cause of miscarriage, bleeding, premature labor, or interference with the position of the fetus.

While fibroids are common, they are not a typical cause for infertility accounting for about 3% of reasons why a woman may not be able to have a child. The majority of women with uterine fibroids will have normal pregnancy outcomes. In cases of intercurrent uterine fibroids in infertility, a fibroid is typically located in a submucosal position and it is thought that this location may interfere with the function of the lining and the ability of the embryo to implant. Also larger fibroids may distort or block the fallopian tubes.

Location and classification

 

Schematic drawing of various types of uterine fibroids: a=subserosal fibroids, b=intramural fibroids, c=submucosal fibroid, d=pedunculated submucosal fibroid, e=fibroid in statu nascendi, f=fibroid of the broad ligament

Growth and location are the main factors that determine if a fibroid leads to symptoms and problems. A small lesion can be symptomatic if located within the uterine cavity while a large lesion on the outside of the uterus may go unnoticed. Different locations are classified as follows:

  • Intramural fibroids are located within the wall of the uterus and are the most common type; unless large, they may be asymptomatic. Intramural fibroids begin as small nodules in the muscular wall of the uterus. With time, intramural fibroids may expand inwards, causing distortion and elongation of the uterine cavity.
  • Subserosal fibroids are located underneath the mucosal (peritoneal) surface of the uterus and can become very large. They can also grow out in a papillary manner to become pedunculated fibroids. These pedunculated growths can actually detach from the uterus to become a parasitic leiomyoma.
  • Submucosal fibroids are located in the muscle beneath the endometrium of the uterus and distort the uterine cavity; even small lesions in this location may lead to bleeding and infertility. A pedunculated lesion within the cavity is termed an intracavitary fibroid and can be passed through the cervix.
  • Cervical fibroids are located in the wall of the cervix (neck of the uterus). Rarely fibroids are found in the supporting structures (round ligament, broad ligament, or uterosacral ligament) of the uterus that also contain smooth muscle tissue.

Fibroids may be single or multiple. Most fibroids start in an intramural location, that is the layer of the muscle of the uterus. With further growth, some lesions may develop towards the outside of the uterus or towards the internal cavity. Secondary changes that may develop within fibroids are hemorrhage, necrosis, calcification, and cystic changes.

Diagnosis

While a bimanual examination typically can identify the presence of larger fibroids, gynecologic ultrasonography (ultrasound) has evolved as the standard tool to evaluate the uterus for fibroids. Sonography will depict the fibroids as focal masses with a heterogeneous texture, which usually cause shadowing of the ultrasound beam. The location can be determined and dimensions of the lesion measured. Also magnetic resonance imaging (MRI) can be used to define the depiction of the size and location of the fibroids within the uterus.

Imaging modalities cannot clearly distinguish between the benign uterine leiomyoma and the malignant uterine leiomyosarcoma, however, the latter is quite rare. Fast growth or unexpected growth, such as enlargement of a lesion after menopause, raise the level of suspicion that the lesion might be a sarcoma. Also, with advanced malignant lesions there may be evidence of local invasion. A more recent study has suggested that diagnostic capabilities using MRI have improved the ability to detect sarcomatous lesions. Biopsy is rarely performed and if performed, is rarely diagnostic. Should there be an uncertain diagnosis after ultrasounds and MRI imaging, surgery is generally indicated.

Other imaging techniques that may be helpful specifically in the evaluation of lesions that affect the uterine cavity are hysterosalpingography or sonohysterography.

Treatment

Most fibroids do not require treatment unless they are causing symptoms. After menopause fibroids shrink and it is unusual for fibroids to cause problems.

Symptomatic uterine fibroids can be treated by:

  • medication to control symptoms
  • medication aimed at shrinking tumours
  • ultrasound fibroid destruction
  • myomectomy or radio frequency ablation
  • hysterectomy
  • uterine artery embolization

Women who undergo evaluation at a uterine fibroid center have more options and most undergo uterine-preserving minimally invasive therapies.

Myomectomy is a surgery to remove one or more fibroids. It is usually recommended when more conservative treatment options fail for women who want fertility preserving surgery or who want to retain the uterus. There are three types of myomectomy:

  • In a hysteroscopic myomectomy (also called transcervical resection), the fibroid can be removed by either the use of a resectoscope, an endoscopic instrument inserted through the vagina and cervix that can use high-frequency electrical energy to cut tissue, or a similar device.
  • A laparoscopic myomectomy is done through a small incision near the navel. The physician uses a laparoscope and surgical instruments to remove the fibroids. Studies have suggested that laparoscopic myomectomy leads to lower morbidity rates and faster recovery than does laparotomic myomectomy.
  •  A laparotomic myomectomy (also known as an open or abdominal myomectomy) is the most invasive surgical procedure to remove fibroids. The physician makes an incision in the abdominal wall and removes the fibroids from the uterus.

Laparoscopic myomectomy has less pain and shower time in hospital than open surgery.

Prognosis

About 1 out of 1000 lesions are or become malignant, typically as a leiomyosarcoma on histology. A sign that a lesion may be malignant is growth after menopause. There is no consensus among pathologists regarding the transformation of leiomyoma into a sarcoma. Most pathologists believe that a Leiomyosarcoma is a de novo disease

 

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hysterectomy

Written by dr- zhila abedi asl. Posted in Uncategorised

Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries, fallopian tubes and other surrounding structures

Usually performed by a gynecologist, hysterectomy may be total (removing the body, fundus, and cervix of the uterus; often called "complete") or partial (removal of the uterine body while leaving the cervix intact; also called "supracervical"). It is the most commonly performed gynecological surgical procedure. In 2003, over 600,000 hysterectomies were performed in the United States alone, of which over 90% were performed for benign conditions. Such rates being highest in the industrialized world has led to the major controversy that hysterectomies are being largely performed for unwarranted and unnecessary reasons

Removal of the uterus renders the patient unable to bear children (as does removal of ovaries and fallopian tubes) and has surgical risks as well as long-term effects, so the surgery is normally recommended when other treatment options are not available or have failed. It is expected that the frequency of hysterectomies for non-malignant indications will fall as there are good alternatives in many cases

 Oophorectomy (removal of ovaries) is frequently done together with hysterectomy to decrease the risk of ovarian cancer. However, recent studies have shown that prophylactic oophorectomy without an urgent medical indication decreases a woman's long-term survival rates substantially and has other serious adverse effects. This effect is not limited to pre-menopausal women; even women who have already entered menopause were shown to have experienced a decrease in long-term survivability post-oophorectomy

Indications

Hysterectomy is a major surgical procedure that has risks and benefits, and affects a woman's hormonal balance and overall health for the rest of her life. Because of this, hysterectomy is normally recommended as a last resort to remedy certain intractable uterine/reproductive system conditions. Such conditions include, but are not limited to

  • Certain types of reproductive system cancers (uterine, cervical, ovarian, endometrium) or tumors, including uterine fibroids that do not respond to more conservative treatment options
  • Severe and intractable endometriosis (growth of the uterine lining outside the uterine cavity) and/or adenomyosis (a form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall musculature), after pharmaceutical or other surgical options have been exhausted
  •  Chronic pelvic pain, after pharmaceutical or other surgical options have been exhausted
  • Postpartum to remove either a severe case of placenta praevia (a placenta that has either formed over or inside the birth canal) or placenta percreta (a placenta that has grown into and through the wall of the uterus to attach itself to other organs), as well as a last resort in case of excessive obstetrical haemorrhage
  • Several forms of vaginal prolapse

Occasionally, women express a desire to undergo an elective hysterectomy—that is, a hysterectomy for reasons other than the resolution of reproductive system conditions or illnesses. Some of the conditions under which a person may request to have a hysterectomy (or have one requested for her if the woman is incapable of making the request) for non-illness reasons include

  • Prophylaxis against certain reproductive system cancers, especially if there is a strong family history of reproductive system cancers (especially breast cancer in conjunction with BRCA1 or BRCA2 mutation), or as part of recovery from such cancers
  • Part of overall gender transition for trans men
  • Severe developmental disabilities, though this treatment is controversial at best, and specific cases of sterilization due to developmental disabilities have been found by state-level Supreme Courts to violate the patient's constitutional and common law rights. Types

Schematic drawing of types of hysterectomy

Hysterectomy, in the literal sense of the word, means merely removal of the uterus. However other organs such as ovaries, fallopian tubes and the cervix are very frequently removed as part of the surgery

  • Radical hysterectomy: complete removal of the uterus, cervix, upper vagina, and parametrium. Indicated for cancer. Lymph nodes, ovaries and fallopian tubes are also usually removed in this situationTotal hysterectomy: complete removal of the uterus and cervix, with or without oophorectomy
  • Subtotal hysterectomy: removal of the uterus, leaving the cervix in situ

Subtotal (supracervical) hysterectomy was originally proposed with the expectation that it may improve sexual functioning after hysterectomy, it has been postulated that removing the cervix causes excessive neurologic and anatomic disruption, thus leading to vaginal shortening, vaginal vault prolapse, and vaginal cuff granulations. These theoretical advantages were not confirmed in practice, but other advantages over total hysterectomy emerged. The principal disadvantage is that risk of cervical cancer is not eliminated and women may continue cyclical bleeding (although substantially less than before the surgery). These issues were addressed in a systematic review of total versus supracervical hysterectomy for benign gynecological conditions, which reported the following findings

  • There was no difference in the rates of incontinence, constipation, measures of sexual function or alleviation of pre-surgery symptoms
  • Length of surgery and amount of blood lost during surgery were significantly reduced during supracervical hysterectomy compared to total hysterectomy, but there was no difference in post-operative transfusion rates
  • Febrile morbidity was less likely and ongoing cyclic vaginal bleeding one year after surgery was more likely after supracervical hysterectomy
  • There was no difference in the rates of other complications, recovery from surgery, or readmission rates

In the short-term, randomized trials have shown that cervical preservation or removal does not affect the rate of subsequent pelvic organ prolapse.

Supracervical hysterectomy does not eliminate the possibility of having cervical cancer since the cervix itself  is left intact and may be contraindicated in women with increased risk of this cancer, regular pap smears to check for cervical dysplasia or cancer are still needed

Technique

Hysterectomy can be performed in different ways. The oldest known technique is abdominal incision. Subsequently the vaginal (performing the hysterectomy through the vaginal canal) and later laparoscopic vaginal (with additional instruments inserted through a small hole, frequently close to the navel) techniques were developed

Laparoscopic-assisted vaginal hysterectomy

With the development of the laparoscopic techniques in the 1970-1980s, the "laparoscopic-assisted vaginal hysterectomy" (LAVH) has gained great popularity among gynecologists because compared with the abdominal procedure it is less invasive and the post-operative recovery is much faster. It also allows better exploration and slightly more complicated surgeries than the vaginal procedure. LAVH begins with laparoscopy and is completed such that the final removal of the uterus (with or without removing the ovaries) is via the vaginal canal. Thus, LAVH is also a total hysterectomy, the cervix must be removed with the uterus

Laparoscopic-assisted supracervical hysterectomy

The "laparoscopic-assisted supracervical hysterectomy" (LASH) was later developed to remove the uterus without removing the cervix using a morcellator which cuts the uterus into small pieces that can be removed from the abdominal cavity via the laparoscopic ports

Total laparoscopic hysterectomy

Total laparoscopic hysterectomy (TLH) was developed in the early 90s by Prabhat K. Ahluwalia in Upstate New York. TLH is performed solely through the laparoscopes in the abdomen, starting at the top of the uterus, typically with a uterine manipulator. The entire uterus is disconnected from its attachments using long thin instruments through the "ports". Then all tissue to be removed is passed through the small abdominal incisions