of Infertility & Key hole surgerySun Medical Centre, Unit of
Trichur heart hospital, near Saktan market
Assisted Vaginal Hysterectomy
evaluation of Infertility:
Laparoscopic management of
Laparoscopy for Chronic
septal resection, adhesiolysis,etc
Reversal of Tubal
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 entirely through the
route, there is no incision on the abdomen.
As there is no incision on the abdomen, there is
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
injuries are fewer when hysterectomy is performed
The patients normally go home
on the 3rd
post-operative day and are even allowed
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
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
and she can go
home on the 3rd day
costs the same as Abdominal hysterectomy.
Medical centre, in normal course of events, the
rough cost may be just around Rs.35,000.totally. Laparoscopic
assistance may cost a bit more.
: In the
past 18years around 95% of all hysterectomies have been done
through the vaginal route by this surgepm successfully . Uterus upto the size of a 6 month pregnancy have also been removed
evaluation of Infertility:
Laparoscopy serves as an excellent
mode of diagnosis in the evaluation
blocks in the fallopian tube if they occur in the abdominal end of the tube
by releasing the adhesions in the tube
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
ovaries, one of the causes of infertility
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.
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
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
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
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 under the care of Dr.Shobhana
Mohandas.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
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.
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 many of
them have subsequently concieved and delivered a full term baby after
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 betweenRs.20000-25000 , all inclusive, depending on the type of procedure.
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
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
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
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
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
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.
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.
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.20,000.
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.2000/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.
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
of Tubal sterilisatiion
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.35,000, all inclusive.