Procedures

Sometimes a procedure may be offered or recommended. This can involve day procedures that are done either while you are awake with local anaesthetic or some light sedation; or procedures that involve a general anaesthetic (being put to sleep).

We have a strong preference for minimally invasive surgery, which means large incisions on the abdomen are avoided as much as possible.

Laparoscopy (Keyhole surgery)

Laparoscopy involves making a small cut in the belly button and placing a thin camera (either 5mm or 10mm diameter) into the abdomen. The abdomen is then filled with gas (carbon dioxide) and 1-3 additional small incisions (usually 5mm) are made. Instruments are placed through these incisions to allow the surgery to be performed, while the surgeon uses a TV screen to visualise the surgery.

Most surgery on the ovaries or uterus can be done laparoscopically. Sometimes the incision at the belly button needs to be made slightly larger to remove larger tissue such as large ovarian cysts or fibroids.

After laparoscopy some patients can go home the same day, but most will stay in hospital for one night. The incisions will have dissolvable stitches covered in waterproof dressings. Generally we would recommend not driving for at least two weeks, and avoiding heavy lifting for at least four weeks but this will depend on the specific surgery.

We recommend reading the RANZCOG information sheet on laparoscopy


Endometriosis Surgery

Laparoscopy for endometriosis involves looking in all the places that endometriosis can occur, and then removing all of the disease. Endometriosis can be superficial, sitting on top of the lining of the abdominal cavity (peritoneum), or deep, involving structures like the bladder, the bowel, the uterosacral ligaments and the ureters. Deep disease can cause organs and structures to stick together, which can increase the risks of surgery. In severe cases, it may be impossible to remove all of the endometriosis. Surgery sometimes takes less than one hour, but can take more than 3 hours in severe cases. Pain after surgery can be significant; there are lots of options that we use in conjunction with the anaesthetic team to minimise this as much as possible. Most patients will be able to go home after one night in hospital, but sometimes a longer stay is needed.

There is some controversy around excision vs ablation of endometriosis. Excision involves making incisions around the abnormal area and removing it, while ablation means using electrical current (diathermy) to treat the abnormal area. Excision is generally the preferred option for several reasons. This allows the surgeon to better appreciate the depth of the abnormality and ensure that all the abnormal tissue is removed. It also allows the tissue to be sent to the laboratory to confirm the diagnosis. There are some specific situations where ablation may be preferred, such as areas where excision is considered higher risk of injuring surrounding structures. 


Hysterectomy (Removal of the uterus and fallopian tubes)

Almost all hysterectomies we perform are done with laparoscopy (keyhole surgery). This involves removing the uterus and fallopian tubes, and sometimes the ovaries depending on the age of the patient and why the surgery is being done. A device called a uterine manipulator is placed inside the uterus through the vagina (after the general anaesthetic is given). An incision is made around the cervix, which allows the uterus to be removed through the vagina. This means there is no big incision on the abdomen (usually a 1cm incision in the belly button and three 5mm incisions on the abdomen). After the uterus is removed, the top of the vagina is stitched closed laparoscopically with a dissolving stitch. The procedure usually takes around one hour. Most patients will stay one night in hospital and be able to go home the following day.


Myomectomy (Removal of Fibroids)

Fibroids that are on the outer part of the uterus (subserosal) or within the muscle/myometrium (intramural) can often be removed with keyhole surgery. Removing fibroids without removing the entire uterus is usually only done when the patient wants to have future pregnancies, as there is a risk of developing more fibroids in the future. As fibroids are extremely common, they are only removed when they are causing symptoms, like abnormal bleeding, pain or pressure, affecting bowel or bladder function, or affecting fertility.  To get the fibroid tissue out of the abdomen using keyhole surgery, the fibroid usually needs to be cut into smaller pieces (morcellated) within a surgical bag inside the abdomen. This becomes more complex for larger fibroids. 


Removal of Ovarian Cysts

Ovarian cysts can often be removed with keyhole surgery. Sometimes the entire ovary is removed, depending on the type of cyst, the age of the patient and their preferences. Cysts arise within the ovary, so the healthy ovarian tissue is often stretched around the outside of the cyst. After the cyst is removed, the ovary usually needs to be sutured to return it to its normal anatomy and minimise bleeding. The cyst is then usually placed in a surgical bag, the fluid is drained out of it and the deflated cyst is removed in the bag through the belly button. This can allow relatively large cysts to be removed through small incisions that may be 1-3cm. The procedure may take 1-2 hours and patients will usually stay in hospital for one night.


Sterilisation

There are two main options for women wanting to undergo sterilisation. Small metal clips (Filschie clips) can be placed on the Fallopian tubes, which blocks the path between the sperm and the egg. This involves an incision in the belly button and either one or two other incisions. The alternative is removal of both Fallopian tubes (salpingectomy). This has the increased advantage that it reduces the risk of ovarian cancer (as most ovarian cancers are thought to arise in the Fallopian tubes). This involves at least three 5mm incisions in total. 

Neither of these procedures involve any surgery to the ovaries. This means that the ovaries will still function normally, and this procedure will not affect cycles or periods.

Laparotomy (Open surgery)

A laparotomy involves a larger incision on the abdomen which may be 3-15cm (or occasionally larger) depending on the surgery being performed. This is usually a horizontal incision near the top of the pubic hair line, similar to a caesarean section. Occasionally the incision is along the midline extending up to the belly button or higher if needed.

We only perform open surgery where minimally invasive options are not appropriate. This can involve ovarian cysts where there is a suspicion of cancer. This is because ovarian cancer can be spread if the cyst is burst during the surgery; so laparoscopy is often not recommended. Occasionally a laparotomy is needed for a hysterectomy, again where certain types of cancer are suspected (particularly a rare type of cancer within a fibroid called leiomyosarcoma), or where large fibroids need to be removed.

Recovery from a laparotomy depends on the size and type of incision and what surgery was performed. Generally patients will stay 1-3 nights in hospital and need 4-6 weeks for full recovery. Heavy lifting and most sports/physical activity will need to be avoided for at least 4 weeks. Light activities like walking are encouraged. Driving should be avoided for 2-6 weeks, depending on the specific surgery. 

Hysteroscopy

Hysteroscopy is a small procedure that involves placing a long thin camera (3-6mm diameter) inside the uterus. This is done both to make a diagnosis and often also to provide treatment. Hysteroscopy can be performed as a day procedure (no overnight stay is needed), with pain relief and local anaesthetic, and the option of light sedation. It can also be performed with a general anaesthetic (being put to sleep). Usually this comes down to the patient's preference, however, some treatments, like endometrial ablation or removal of fibroids will always require a general anaesthetic. A general anaesthetic is safe, however, does carry some additional risk, and increases the amount of time needed in the hospital (usually 3-5 hours) compared with a day procedure (1-2 hours). People are often slightly groggy day after a general anaesthetic.

We recommend reading the RANZCOG information sheet


Diagnostic hysteroscopy

Hysteroscopy is used to find the cause for abnormal bleeding. This can involve heavy periods, bleeding between periods, bleeding after menopause and other causes. Other reasons can include part of a fertility workup, or to identify polyps or other findings seen on ultrasound.

This is usually done with a very thin camera (3mm) passed through the vagina into the cervix to visualise the inside of the uterus. Usually a biopsy will need to be taken to send to the laboratory for testing. Hysteroscopy is the definitive test used to diagnose endometrial polyps as well as endometrial cancer or hyperplasia. 

The procedure usually takes less than 15 minutes. If done without a general anaesthetic patients can experience discomfort and sometimes pain. Local anaesthetic to the cervix, pain relief options and light sedation can be used to help with this.


Removal of polyps

When polyps are identified at hysteroscopy they can be removed using hysteroscopic instruments. Some of these instruments require a slightly wider diameter hysteroscope (6-8mm) depending on the size of the polyps and the instruments used. Polyps can cause abnormal bleeding, and rarely can contain cancer, so it is always recommended that they are removed. Removing polyps may add 5-10 minutes to the procedure. This can usually be performed without a general anaesthetic, although some patients will prefer to be put to sleep.


Removal of fibroids

Fibroids that project into the inner part of the uterus (submucosal) can cause abnormal bleeding and affect fertility. These can be removed using hysteroscopic instruments. This is generally a procedure that requires a general anaesthetic, as it can be a longer procedure depending on the size of the fibroids and requires a larger hysteroscope (8mm).


Endometrial Ablation

Endometrial ablation is a procedure used to treat abnormal bleeding. Ablation uses electrical current (diathermy) to cauterise the lining of the uterus (endometrium). We typically use a Novasure device to perform this procedure. This involves performing a diagnostic hysteroscopy (as outlined above) and then placing the Novasure device inside the uterus. Some measurements are taken, and then the device applies bipolar current for up to two minutes. Around 80% of patients are happy with the results of endometrial ablation (the other 20% may need further treatment, such as a hysterectomy). The procedure requires a general anaesthetic. After the procedure there will be some crampy pain, and there may be a small amount of black or watery discharge for up to a week.

Colposcopy

Colposcopy is used to diagnose and treat abnormalities of the cervix, usually picked up with cervical screening tests, but sometimes due to symptoms like bleeding after sex. This involves sitting in a specially designed chair that raises slightly off the ground. The gynaecologist places a speculum (the instrument used during a smear test). The colposcope does not actually touch the patient, but sits around 20-30cm away from the speculum. It allows a magnified view of the cervix. Different types of fluid are placed on the cervix (acetic acid and iodine), which helps identify abnormal areas. If abnormalities are found, a biopsy will need to be taken. This can cause an uncomfortable pinching sensation for a few seconds and then leave a crampy feeling afterwards. Sex and tampons should be avoided for at least a week after a biopsy.

Biopsies from the cervix are generally classified as either normal, low grade abnormalities, high grade abnormalities or cancer. Low grade abnormalities often resolve without treatment, so usually a repeat colposcopy is recommended to ensure that they have resolved. High grade abnormalities carry a small risk of developing into cancer, so the recommendation is usually for removal of these cells with a LLETZ treatment (see below). Cancer of the cervix is uncommon, but when diagnosed will need referral to the gynaecology oncology service at Wellington Hospital for further tests and treatment.

All specialists providing colposcopy services are required to be credentialled and registered with RANZCOG, and participate in regular multidisciplinary colposcopy meetings. 

LLETZ

LLETZ stands for Large Loop Excision of the Transformation Zone (referred to as LEEP or Loop Electrosurgical Excision Procedure in some countries). This treatment involves removing the outer part of the cervix (the transformation zone) where the abnormal cells are. The cervix contains two types of cells - squamous cells which are like the skin on the inside of the vagina; and glandular cells which are like inner part of the uterus. The border between these two cells moves throughout the life cycle and the menstrual cycle. This means that there is a small area in the cervix where the cells are continuously changing between one cell type and the other, called the transformation zone. This area is where the majority of abnormalities in the cervix occur. LLETZ treatment uses a small wire loop with electrical current passing through it (diathermy) to remove the transformation zone. Usually 6-8mm of tissue is removed from the outer part of the cervix, but this depends on the shape of the cervix and the type of abnormality.

LLETZ is usually performed with local anaesthetic to the cervix. The actual LLETZ procedure takes less than a minute, but including the colposcopy and setting up the equipment takes around 15 minutes. After a LLETZ it is usual to expect some black or watery discharge for up to a week. Sex and tampons should be avoided for 6 weeks.


Pelvic Floor Botox

Many different factors can lead to the muscles in the pelvic floor becoming overactive (hypertonic). This can contribute to persistent pelvic pain, and can contribute to pain related to sex. The key treatment for this pelvic physiotherapy, which can be challenging but have life changing results. Sometimes physiotherapy is not able to be performed adequately and the physiotherapist might recommend Botox treatment. Botox injections to the pelvic floor can improve the chances of a good outcome. Botox is a substance that blocks the nerve signal triggering muscle contraction; the injections cause muscles to relax. In the pelvic floor this can treat hypertonic muscles. The procedure is performed either under sedation or general anaesthetic, using a nerve stimulator to identify the correct muscles. Local anaesthetic is usually used to block the surrounding nerves to minimise any pain after the procedure. Many patients experience a slight increase in pain for a few weeks after the procedure. The effects of Botox lasts for around six months, and many patients do not need repeat treatments. 

Vaginal Surgery / Prolapse Surgery

Prolapse can involve different organs in the pelvis, and prolapse surgery differs depending on where the prolapse is coming from. It is common that there is more than one area contributing the prolapse, and often several of these procedures are performed together. We do not use mesh for any procedures. The International Urogynaecological Association has fantastic patient information about these procedures and others.


Anterior Vaginal Repair

Prolapse from the front wall of the vagina is repaired by strengthening the tissues between the vagina and the bladder to stop the bladder from pressing down on the vagina. Anterior vaginal repair involves an incision in the midline of the front wall of the vagina. The tissue overlying the bladder is brought together and strengthened using dissolvable stitches to stop the bladder bulging into the vagina. The skin is then stitched back together. It is important to note that this is a procedure performed for a prolapse, not performed as an incontinence procedure, although this procedure can affect bladder function. We recommend reading the IUGA patient information sheet.


Posterior Vaginal Repair and Perineal Reconstruction

Prolapse from the back wall of the vagina can be caused by either the rectum (rectocoele), or part of the abdominal cavity (enterocoele), or sometimes both, pushing against the back wall of the vagina . Posterior vaginal repair involves a midline incision along the back wall of the vagina. The tissue overlying either the rectocoele and/or enterocoele is brought together and strengthened using dissolvable stitches. The vaginal skin is then stitched back together.

Prolapse in the back wall of the vagina is almost always also associated with loss of muscle tone in the space between the vagina and the anus (the perineum). These muscles are often stretched and torn during childbirth, especially where forceps were used for the delivery. Often to get the best results for treating the prolapse these muscles need to be brought together and strengthened, called a perineal reconstruction. We recommend reading the IUGA patient information sheet.


Sacrospinous Suspension and Hysterectomy

Prolapse can also come from the uterus pushing down on the vagina; or where a hysterectomy has been performed previously the top of the vagina can be pushing down. A suture can be placed at the upper part of the vagina to attach it to a strong ligament in the back of the pelvis called the sacrospinous ligament. We perform this using a dissolvable stitch. We recommend reading the IUGA patient information sheet.

Sometimes where the uterus is pushing down it is preferable to perform a hysterectomy and remove the uterus. This can be done entirely from the vagina, or with laparoscopy (keyhole surgery).