Gynecological Clinic
THE FOLLOWING ARE PERFORMED IN OUR HOSPITAL:
- Abdominal and vaginal hysterectomy
- Surgical procedures in treating incontinency and pelvic floor defects (SPARC, PERIGEE, APOGEE)
- Hysteroscopy
- Laparoscopy
- Cervical conisation
- LETZ (Loop Excision of Transformation Zone)
- Aspiration of the ovarian cyst
- Incision and extirpation of the Bartholin gland
- Removal of benign vulvar tumors
- Excision of the vaginal septum
- Curettage
- Electrocauterization of condyloma
- Corrective surgery
ABDOMINAL HYSTERECTOMY (REMOVAL OF THE UTERUS)
Abdominal hysterectomy is done under total anesthesia. The urinary bladder is emptied by inserting a catheter through the urethra. In most cases, the catheter stays in the urethra for 2 to 3 days. Once the operating area is washed and disinfected, the surgeon makes an incision right above the pubic area. The uterus is separated from the joining organs and the relevant blood vessels are tied. Once removed, the whole uterus or uterus with the ovaries is sent to the laboratory for pathological analysis.
MoreVAGINAL HYSTERECTOMY (REMOVAL OF THE UTERUS THROUGH THE VAGINA)
Vaginal hysterectomy is a surgical procedure by which the uterus is removed through the vagina. The indications for both types of hysterectomies overlap to a great extent, but vaginal hysterectomy is technically more demanding. On the other hand, patient recovery and hospital stay is significantly shorter than that of the abdominal hysterectomy. The surgical procedure begins with a circular incision with which the cervical fascia is prepared and separated from the urinary bladder. Intraperitonal entry is done by a back incision, the uterine bands are tied, and the uterus removed. The advantages of this procedure are that any additional malformations of the pelvis and issues related to incontinence can be remedied in a better way. Possible future defect like cistocele and enterocele are prevented by additionally securing the descensus vaginae.
Treatment of bladder disorders
Urinary dysfunction affects nearly 50% of women over 50 years of age
25% to 30% of women are affected by urinary incontinence (SIU). SIU treatments favor simple sling methods like SPARC*, while in treating defects of the pelvic floor, the preferred methods are APOGEE* and PERIGEE*. These methods significantly shorten hospital stay, the patients regain their daily functionality in a shorter period, and damages to the surrounding tissue and local interventions are minimal.
HYSTEROSCOPY
Minimally invasive gynecological surgery is used to diagnose and treat your gynecological problems with quick recovery.
Hysteroscopy is a minimally invasive endoscopic procedure that allows a detailed view of the inside of the uterus. Hysteroscopy is performed with an instrument that is connected to a video camera (a kind of narrow telescope) and is introduced through the cervix into the uterine cavity. Through hysteroscop in the uterine cavity during the entire procedure is introduced special solution which expands the walls of the uterus for better visualization. Hysteroscopy can be diagnostic or therapeutic.
Diagnostic hysteroscopy takes a few minutes and it is on outpatient basis, in the short-term anesthesia. The reasons for the procedure are problems of infertility, repeated miscarriages, irregular and heavy menstrual bleedings, irregular bleeding in the peri and postmenopausal period, control of endometrium in women taking some kind of drug for breast cancer. At the end of the process is sometimes necessary to take a sample of the tissue in order to conduct a histopathological analysis.
Therapeutic hysteroscopy is done for the purpose of treatment within the cavity of the uterus, usually done under general anesthesia but can in short-term depending on the duration of the planned project. After the procedure hospitalization is usually for several hours to one day. The reasons for carrying out is removal of polyps and fibroids that are found in the uterine cavity, exscision of the uterine septum or adhesions in the uterus and removal of the intrauterine device that cannot be removed by normal means.
Possible complications – Complications are possible as with any surgical procedure, but in the case of hysteroscopy are very rare, even more seldom than complications related to uterine curettage, because it is done under the control of the eye. Complications include bleeding, perforation of the uterine cavity and infection.
The postoperative period – Symptoms that sometimes occur after this procedure, refer to the menstrual like pain, discharge or light bleeding (7-14 days after the procedure).
Patient can take painkillers (Ibuprofen, Voltaren, Ketonal).
Laparoscopy
Minimally invasive gynecological surgery is used to diagnose and treat your gynecological problems with quick recovery
Diagnostic laparoscopy is done when you need to find the cause or explain the symptoms of discomfort in the pelvis that cannot be determined by gynecological examination, ultrasound or other tests. Indications for diagnostic laparoscopy may be acute and chronic pain, suspected ectopic pregnancy, and holds a special place in the processing and treatment of infertility.
Operative laparoscopy is usually done for removal of ovarian cyst (cystectomy), tubal ligation (sterilization), removal of fallopian tubes (salpingectomy), removal of fibroids (myomectomy), operation for ectopic pregnancy with (salpingectomy) or without removal (salipingotomy) of the altered fallopain tubes if the pregnancy is in the fallopian tube.
How is laparoscopy performed?
Laparoscopy is an endoscopic surgery that is performed through small openings in the skin of the abdomen the size of 5-10 mm. It is done under general anesthesia. Before the procedure, the anesthesiologist will inform you about the details and risks of anesthesia.
The bladder is emptied before the procedure by introducing a permanent catheter through the urethra. The catheter in the bladder usually remains for several hours after the procedure.
After cleaning and disinfection of the operating field doctor begins to engage with the section below the navel size 5-10 mm. First, through this incision brings the needle through which the abdomen is filled with carbon dioxide to provide a better overview of pelvic organs. Through the same incision introduces a special kind of telescope (laparoscope) with a video camera. Other instruments are introduced into the pelvic cavity through small incisions also on the skin just above the pubis. If operative laparoscopy is necessary, a cyst or else is removed from the belly through the same incision and sent in the solution of 10% formaldehyde for histopathology. At the end of the operation gas is discharged, and openings in the skin are closed with surgical sutures. In very complicated cases before closing the abdominal openings in the skin through the side cut sets plastic drain that allows runoff secretions and blood.
The postoperative period after laparoscopy
After the procedure you may feel pain in the shoulders and in the rib cage due to residual small amounts of gas below the diaphragm, pain in the muscles, pain in the surgical wound, discomfort or fatigue the next few days, a certain degree of nausea, and in some women may appear like menstrual pain with the occurrence of vaginal discharge in a few days. If necessary, you can take painkillers.
When the symptoms disappear and when you feel better, you can continue with your usual physical and sexual activities, not earlier than 2 weeks after the surgery.
Hospital discharge is usually second day after surgery. Sometimes it is necessary to stay in the hospital for several days depending on the complexity of the procedure and the postoperative course of which you will discuss and agree with your doctor.
Small Gynecologic procedures
he following are performed in our hospital:
- Cervical conisation
- LETZ (Loop Excision of Transformation Zone)
- Aspiration of the ovarian cyst
- Incision and extirpation of the Bartholin gland
- Removal of benign vulvar tumors
- Excision of the vaginal septum
- Curettage
- Electrocauterization of condyloma
- Corrective surgery
Small Gynecologic procedures
The following are performed in our hospital:
Cervical conisation
CERVICAL CONISATION (COLD-KNIFE CONISATION)
Cold-knife conisation is a surgical procedure where the deformed part of the cervix is removed with a scalpel. After the removal, usually a so called “plastic surgery of the cervix” is performed. It adjusts the rest of the cervix and decreases the possibility of post surgery bleeding.
Conisation is as a rule, conducted under total anesthesia and a 3 to 4 day stay in the hospital. Cold-knife conisation is primarily a diagnostic procedure but is also often a therapeutic surgical method. The final diagnosis is given by the pathologist after a series of microscopic analysis of the removed tissue. The pathologist also estimates the degree to which the cervix and the surrounding tissue have been affected – this will significantly influence the treatment of the patient. Although conisation is not in itself a complex surgical undertaking, the rate of complications is relatively high. The most frequent early complication is bleeding that occurs in 6 to 7% of the cases. Some patients may have difficulties conceiving (4%), and others may miscarry or have an early delivery (1%).
LETZ (Loop Excision of Transformation Zone)
LETZ (LOOP EXCISION OF TRANSFORMATION ZONE)
LETZ is a procedure with which the transformation zone of the cervix is removed with a “diathermic loop” – an electric loop where cutting and coagulation happen simultaneously along the incision. In everyday usage LETZ only denotes the technique – the use of the electric loop is not only used for the removal of the transformed zone but also for taking cervical samples from any of its areas, called biopsy.
The removed part of the cervix undergoes pathological evaluation.
The transformational zone is an area on the border between the multilayered squamous epithelium, which is the external cover of the cervix and the cylindrical epithelium, that covers the internal canal that leads into the uterus. That is the area of the metaplastic epithelium which is most susceptible to the influence of oncologic factors. In treating CIN, it is important to treat the abnormality in a manner that will allow its complete removal and avoid negative consequences to the reproductive system, since mostly women of reproductive age and adolescents are affected.
LETZ is actually a spare procedure since the incision does not go very deep into the cervix but removes the surface. The determination if the whole leason has been removed during the procedure can only be reached after a histological analysis of the removed tissue. Since a high frequency current coagulates the blood vessels, bleeding during the procedure is decreased and plastic modification of the cervix are unnecessary. This method is highly recommended for women who have not yet been pregnant.
Additional
POSSIBLE COMPLICATIONS DURING SURGERY
- In exceptionally rare cases there is a possibility of intense, uncontrolled bleeding that requires a blood or blood component transfusion
- In case of life threatening bleeding, in some cases, a hysterectomy is necessary
- Injuries of neighboring organs (blood vessels, intestines, urinary bladder, urethra) is higher if the patient has had previous surgeries because of growths and changes in anatomy
- Infections of the uterus, urinary tract, pneumonia, and peritonitis
- In exceptional cases there is the possibility of blood vessel obstruction and blood clotting
IT IS NECESSARY TO FOLLOW THE LISTED AFTER THE PROCEDURE:
- The gauze saturated with the medicine that stops bleeding that is inserted into the vagina after the surgery, needs to be taken out slowly 6 to 12 hours after the procedure
- In case of pain (which isn’t supposed to be stronger than menstrual pain) use some of these medications – Ketonal/Ketoprofen, Voltaren, Brufen/Ibuprofen
- After the LETZ procedure a 14 day bed rest is recommended as a preventive measure (bleeding)
- The discharge is initially watery; in the second week of recovery it may be slightly bloody to bloody, but lighter than a “regular” period
- Take a shower instead of a bath
- Avoid intercourse or use of tampons prior to the first checkup to avoid injury to the operated area
- Avoid alcohol since it expands blood vessels
- The first checkup is 8 to 12 weeks after the procedure; an examination of the operated area, colposcopy, and PAP- smear is conducted.
Attached are additional informational leaflets on the procedure
Incision and extirpation of the Bartholin gland
Attached are additional informational leaflets on the procedure
The Bartholin grand cyst is normally located in the bottom third of the opening of the vagina and is caused by previous infections or trauma scars which provoke blockage of the gland’s duct, which in turn causes the accumulation of the mucus.
Secondary bacterial infection of the mucus causes an acute inflammation (Bartholinithis) that is characterized by intense pain and redness. In that phase, treatment is possible with antibiotics. In case of an abscess it is necessary to make an incision of the gland with a scalpel and allow drainage. Since the inflammations tend to reoccur, a removal of the gland is recommended. The following procedures are available:
- Marsupialization is a surgical procedure by which the ends of the gland are everted (turned inside-out), to assure continuous drainage.
- Extirpation or removal of the Bartholin gland through an incision on the internal side of the vaginal opening.
The procedure may be done under total anesthesia and the patient is released the following day. The patient should avoid any kind of physical strain two to three weeks after the surgery because of possible bleeding in the operated area. The removed tissue is sent for pathological analysis.
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Excision of the vaginal septum
Excision of the vaginal septum
Septum is an inborn vaginal anomaly that may divide it into two parts or exist only in one of its segments. It may be positioned horizontally or vertically.
Due to the septum, anomalies in the development of the uterus are frequent. Difficulties that are caused by the septum usually start in adolescence as painful menstruations and pain during intercourse. A septum is usually discovered during a routine checkup.
The septum can usually be corrected by a surgical procedure under total anesthesia. A complete diagnostic analysis is necessary for additional anomalies of the gynecological organs and possibly simultaneous surgical corrections.
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Curettage
Curettage
There are several reasons for dilation and curettage:
- Removal of the fetus and other material in case of a failed pregnancy or miscarriage is performed by dilation, vacuum aspiration, and curettage (DVAC).
- Removal of tissue from the uterus that may be different, benign, malignant, hormonal or inflamed. Diagnostic curettage is performed most often because of irregular bleeding from the uterus in mature women, especially during menopause. Therapeutic curettage is performed in cases of various bleeding from the uterus that do not respond to medication. The tissue from the uterus is sent for pathologic analysis for a final diagnosis.
- Termination of pregnancy and abortion by dilation, vacuum aspiration, and curettage (DVAC).
POSSIBLE COMPLICATIONS
Patients must be aware that no medical procedure is risk free. Even though the utmost attention is given to every patient and procedure, in some cases there is a risk involved either during or after the procedure. In most cases the complication can be detected instantly and remedied. At the same time one must always keep in mind that the seriousness of some complications during surgery may even endanger the life of the patient.
COMPLICATIONS DURING THE PROCEDURE
Injuries of the uterine wall may be caused by instruments used during the surgical procedure. These are usually harmless and do not require further treatment. In very rare cases the organ or other abdominal structures may be perforated or an injury of the neighboring organs may occur, for example the intestines (which may lead to peritonitis), urethra or the uterine bladder (may lead to urosepsis), or injury of the blood vessels. These complications require a surgical intervention (laparotomy).
Excessive bleeding occurs very seldom. It is usually detected on time and stopped promptly. Abdominal surgery to stop the bleeding and remove the uterus is necessary in exceptionally rare cases. Some cases necessitate a blood transfusion. In very rare cases there is a risk of transmitting infections (hepatitis and HIV) during the transfusion.
Nerve and soft tissue pressure injuries occur in very rare cases despite following standard procedures in adequately positioning the patient for the procedure. These injuries disappear spontaneously within a week.
COMPLICATIONS AFTER THE PROCEDURE
Urine retention – urine flow may slow down or cease during the first few hours after the procedure. It can easily be remedied with a temporary insertion of a catheter into the urinary bladder for drainage.
Pain can occur in the abdominal area but usually stops very soon.
Slight bleeding is common after curettage and does not require any treatment. It may last up to a few days after the procedure (resembles menstrual bleeding). In rare cases there is heavy bleeding that requires treatment.
Cervical incompetence occurs in rare cases. It is the inability of the cervix to stay closed, which indicates a tendency to miscarriage and early delivery in late pregnancies. Cervical cerclage may help in late pregnancy.
Allergies to local anesthesia or other medications (vomiting, itching, difficulty breathing, rash) occur very seldom. These usually cease spontaneously. Serious allergic reactions include disorders in circulation, heart function, brain, or nerves (asthma, circulatory collapse or shock) occur very rarely and require hospitalization. Because of an insufficient blood flow they may lead to permanent organ damage (kidney failure, nerve paralysis).
Placenta leftovers – Curettage needs to be repeated in very rare cases where there are placenta leftovers or even residues of the whole fetus in the uterus.
Haematometra/Hydrometra – Curettage needs to be repeated in very rare cases when blood and fluid may accumulate in the uterus.
Infection of the uterus, oviduct, or urinary bladder occurs rarely, even after few days after surgery and is treated with antibiotics. Due to the infection, damage to the oviduct functions that lead to infertility and formation of adhesions is extremely rare.
Blood clots (thrombosis) may travel through and block the blood vessels (pulmonary embolism, CVI) especially in patients with decreased mobility. If blood thinners are administered, they may cause increased bleeding.
Irregular menstrual cycles are rare and do not require special treatment.
Fistulas (abnormal connections between the vagina and intestines and between the vagina and the uterine bladder) may develop in rare cases and necessitate a surgical intervention.
Skin and soft tissue injury (abscess due to injection, nerve and blood vessel irritation) is provoked by the piercing of the needle and may cause extended symptoms like pain and scaring.
HOW TO BEHAVE AFTER A SURGICAL PROCEDURE?
Curettage is an outpatient procedure. The patients are asked to have someone drive them home and stay for 24 hours after the procedure. Because of the effect of the medications used during the procedure the patients are not allowed to drive a car or ride a bicycle, handle machinery, make important decisions or drink alcohol for 24 hours after surgery.
It is necessary to:
- Avoid physical activity on the day the procedure was performed
Call a doctor immediately in case of abdominal pain, fever, excessive bleeding or other symptoms - Avoid using tampons or intimate wash soaps the first few days after the procedure
- A gynecological checkup is necessary two weeks later.
In case of a DC due to a miscarriage or failed pregnancy, the exam includes a check for extra uterine pregnancy. In case of diagnostic curettage, depending on the PHD results, further checkups and treatment may be necessary. The decision is made in consultation with the doctor
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Removal of benign vulvar tumors
Removal of benign vulvar tumors
Benign vulvar tumors usually manifest as painless swellings, well defined from the surrounding tissue.
The growths may also be sebaceous cysts, cysts of the Bartholin gland, and mucous or inclusion cyst. Beside cysts, they can also be benign tumors like fibroids, lipoma, hydrodenoma, and pigmented mole.
The surgery is conducted under local or total anesthesia and the tumor needs to be removed in its entirety. The patient is discharged the following day. The removed tumor is sent for pathological analysis.
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