Problems that occur with a woman’s reproductive organs sometimes cannot be found by a physical examination alone. Laboratory tests, Ultrasound, X- Rays may still leave some uncertainty. Frequently, problems that cannot be discovered by routine investigations can be discovered by laparoscopy or hysteroscopy, two procedures which provide a direct look at the pelvic organs. Laparoscopy and hysteroscopy can be used for both diagnostic (looking only) and operative (looking and treating) purposes.

Diagnostic laparoscopy may be recommended to look at the outside of the uterus, fallopian tubes, ovaries, and internal pelvic area. Diagnostic hysteroscopy is used to look inside the uterus. If an abnormal condition is detected during the diagnostic procedure, operative laparoscopy or hysteroscopy can often be performed to correct it at the same time, avoiding the need for second surgery.

DIAGNOSTIC LAPAROSCOPY
Laparoscopy can help gynecologists diagnose many problems including endometriosis, uterine fibroids and other structural abnormalities, ovarian cysts, adhesions, ectopic pregnancy, tubal disease, and genital tuberculosis. Many infertile patients require laparoscopy for a complete evaluation. Generally, the procedure is performed after the basic infertility tests, although the presence of pain, history of past infection or an abnormal ultrasound may signal a need to perform diagnostic laparoscopy sooner in the evaluation.

Laparoscopy is usually performed as an outpatient basis, under general anesthesia, and with minimal discomfort.

LAPAROSCOPIC PROCEDURE
After anesthesia, a needle is inserted through the navel, and the abdomen is filled with carbon dioxide gas. As the gas enters the abdomen, it creates a space inside by pushing the abdominal wall and the bowel away from the organs in the pelvic area allowing a view of the reproductive organs. Next, a long thin telescope (laparoscope) is inserted through the insertion in the navel. It is connected to a tiny camera which sends images to a television monitor. While looking at the monitor, the surgeon can see the uterus, fallopian tubes, ovaries, and nearby structures (figure 1). A small probe is inserted through another incision in order to move the pelvic organs into clear view Additionally, a blue solution is injected through the cervix to determine if the fallopian tubes are open. (fig 2). If no abnormalities are noted at this time, one or two stitches close the incisions. The incisions are closed using an adhesive dressing. If defects or abnormalities are discovered, one can proceed to operative laparoscopy.



OPERATIVE LAPAROSCOPY
Many infertility disorders can be safely treated through the laparoscope at the same sitting. Operating instruments like graspers, biopsy forceps, scissors, coagulators, electrosurgical or laser instruments, needle holders and suture materials are inserted through two or three incisions in the area above the pubis.

Operative procedures include adhesiolysis, treatment of blocked tubes, fulguration of endometriosis, removal of chocolate cysts, treatment of ovarian cysts, PCOD drilling, removal of diseased ovaries, removal of uterine fibroids, and treatment of ectopic pregnancy.

Operations for female sterilization, hysterectomy, urinary incontinence and genital prolapse can also be performed laparoscopically.

DIAGNOSTIC HYSTEROSCOPY
Hysteroscopy is an important tool in the study of infertility, recurrent miscarriage, or abnormal uterine bleeding. Diagnostic hysteroscopy is used to examine the inside of the uterus, also known as the uterine cavity (figure 3) and is helpful in diagnosing abnormal uterine conditions such as polyps, internal fibroids, scarring, and developmental abnormalities. A hysterosalpingogram (an x-ray of the uterus and fallopian tubes) may be performed before a diagnostic hysteroscopy. Diagnostic hysteroscopy is usually conducted on an outpatient basis with either general or local anesthesia.

For infertility evaluation the hysteroscopy and laparoscopy are combined together usually soon after menstruation because the uterine cavity is more easily evaluated and there is no risk of interrupting a pregnancy.

HYSTEROSCOPIC PROCEDURE
After dilating the cervix (mouth of the uterus) with a series of dilators, a narrow telescope (hysteroscope) is passed through the cervix into the uterine cavity. Special clear solutions are then injected into the uterus through the hysteroscope sheath. This distends the uterine cavity, clears blood and mucus, and allows the gynecologist to directly view the internal structure of the uterus.

OPERATIVE HYSTEROSCOPY
A wider hysteroscope allow operating instruments such as scissors, biopsy forceps, graspers, electrosurgical or laser instruments to be introduced into the uterine cavity through a channel in the operative hysteroscope. Fibroids, polyps, adhesions can be removed from inside the uterus. Congenital abnormalities, such as uterine septum, can also be corrected through the hysteroscope.

After surgical repair, a Foley catheter or intrauterine device may be placed inside the uterus to prevent the uterine walls from fusing together. Antibiotics and/or hormonal medication may also be prescribed after uterine surgery to prevent infection and stimulate healing of the endometrium (uterine lining).

RISKS OF LAPAROSCOPY / HYSTEROSCOPY
Serious complications of diagnostic and operative laparoscopy are rare. Allergic reactions and anesthesia complications rarely occur. The major risk is damage to the bowel, bladder, ureters, major blood vessels, or other organs, which would require immediate laparotomy to repair the injury. Injury can also occur during the insertion of various instruments through the abdominal wall or during operative treatment. Certain conditions may increase the risk of serious complications. These include previous abdominal surgery, presence of bowel or pelvic adhesions, severe endometriosis, obesity or excessive thinness. In experienced hands the risk of injury is 2-3 per 1000 procedures.
The risk of death during laparoscopy is 1-2 per 100000 procedures, is less than the risk of death during pregnancy.

Complications of hysteroscopy are rare and seldom serious. Perforation of the uterus (hole in the uterus) is the most common complication, but the hole usually heals on its own. Some complications related to the liquids used to distend the uterus include fluid overload, pulmonary edema (fluid in the lungs), blood clotting problems, and severe allergic reactions. Complications related to the surgical procedure include damage to intra-abdominal organs and hemorrhage. Severe or life threatening complications, however, are very uncommon.

RECOVERY
After Laparoscopy / Hysteroscopy, the patient is allowed to rest for 2 – 4 hours to recover from the anesthesia. She is allowed liquids after 4 hours and soft diet in the evening. After the operation, the patient may feel some discomfort :

Most of these minor complaints are gone in a day or two after surgery.

CONCLUSION
Previously, diagnosing and treating gynecological problems required major surgery and many days of hospitalization. However, laparoscopy and hysteroscopy allows correction of these problems on an outpatient basis. The procedures decrease patient discomfort, significantly reduce recovery time and has minimal risks.