Minimally Invasive Surgery Approaches and Gynecology

#### **Chapter 2**

## Minimally Invasive Surgery in Gynecology

*Morena Antonilli, Vasileios Sevas, Maria Luisa Gasparri, Ammad Ahmad Farooqi and Andrea Papadia*

#### **Abstract**

The first laparoscopic procedure was performed by 1901 by Georg Kelling in dogs while the first laparoscopic procedure in humans was performed by Hans Chrisitan Jacobaeus in 1910. Minimally invasive surgery offers multiple advantages over conventional laparotomy and is associated with reduced estimated blood loss, a lower incidence of complications and a shorter hospital stay and recovery. Over a century later, the vast majority of surgical procedures in gynecology are performed via minimal invasive technique. These include laparoscopy, minilaparoscopy, robotic surgery, laparoendoscopic single site surgery (LESS) and natural orifices transluminal endoscopic surgery. In this chapter we review these surgical techniques, analyze the main differences among these techniques and comment on their advantages and disadvantages.

**Keywords:** Gynecology, Minimally invasive surgery, Laparoscopy, Robotic Surgery, Ergonomics, artificial intelligence

#### **1. Introduction**

Minimally invasive surgery (MIS) can be considered as the greatest surgical innovation over the past 30 years. The major change and innovation of this surgery was to entry inside the abdomen avoiding large incisions on the skin, without affecting the surgical result and safety. The first description of minimal invasive approach as part of an endoscopy is attributed to Phillip Bozzini in 1805, who has visualized the urethral mucosa with a simple tube and candle light. Pantaleoni in 1869 has performed the first gynecologic procedure identifying uterine polyps. In 1910, in Sweden Hans Christian Jacobaeus performed the first Laparoscopy using a Nitze cystoscope. Heinz Kal, a German physician was revolutionary when developing laparoscopy into a diagnostic and surgical procedure in the early 1930's. The use of gaseous distention with lithotomy Trendelenburg position was firstly conceived by a French gynecologist Raoul Albert Charles Palmer a pioneer of Gynecologic Laparoscopy. The use of "cold light" and fiberoptics were landmark innovations in the endoscopy development. These outriders of endoscopic surgery as well as several other scientists and physicians have led the crucial groundwork that has enabled modern gynecology surgeons to perform laparoscopy on a routine basis, with a variety of energy systems under increasingly ergonomic and efficient conditions. Over time variants of the conventional laparoscopic technique have been developed to improve post-operative pain, cosmetic results and minimized trauma to tissue. (Minilaparoscopy, LESS, NOTES). In addition, since the 1980s surgical

robots have been developed to address the limitation of laparoscopy in term of two dimensional visualization, incomplete articulation of instruments and ergonomic limitations. The Da Vinci System developed by the Stanford Research Institute along with the Defense department comprises of three components: a surgeon's console, a patient-side cart with four robotic arms manipulated by the surgeon (one to control the camera and three to manipulate instruments), and a highdefinition three-dimensional (3D) vision system. Articulating surgical instruments are mounted on the robotic arms, which are introduced into the body through cannula. The need for remote interventions led to create a project by the National Aeronautics and Space Administration (NASA) in 1970s and funded by the Defense Advanced Research Project Administration (DARPA), for astronauts and soldiers in battlefields. Surgical robotics were first used in 1985 in neurosurgery; applications soon followed in urology (1988), orthopedics (1992) and gynecology (1998). It is important to notice that both traditional laparoscopic and robotic surgery have been widely adopted prior to emergence of data supporting efficacy and safety, because of its clear advantages compared to conventional surgery.

The patient is placed in a supine lithotomy position. Trendelenburg position is typically used to properly visualize the pelvis by displacing the bowel loops in the superior abdominal quadrants. The correct positioning of the patient plays a crucial role in the laparoscopic technique in terms of neurologic injury, ergonomic surgeon positioning, and adequate access to the vagina, if necessary. The patient's legs are placed in booted stirrups and it is important to maintain moderate flexion at the knee and hip with minimal abduction or external rotation at the hip. The buttocks should be a few centimeters beyond the edge of the table to allow uterine manipulation. To prevent migration in Trendelenburg position there are different methods: egg-crate foam directly beneath the patient, a vacuum-beanbag mattress, or shoulder braces. A variety of uterine manipulators are available to displace the uterus to facilitate access to pelvic structures. To manipulate the vaginal cuff, for women without uterus, a sponge stick can be positioned in the vagina.

To date, numerous studies have shown the superiority of minimal invasive surgery over laparotomy in terms of perioperative complications, hospitalization and quicker return to normal activity. On the other hand it was initially evident that there was a longer operating time and steeper learning curve for the laparoscopic technique. Today a greater surgical experience of surgeons and innovation of instrumentation have enabled a time overlap of most surgical procedures. In addition, a careful assessment of the patients (comorbidities, BMI and body habitus, patient's surgical history, type of pathology: size, shape, and mobility) to allow an appropriate safe and efficient procedure is crucial.

#### **2. Minimally invasive techniques and approaches**

#### **2.1 Diagnostic and operative laparoscopic surgery**

The laparoscopic technique uses a laparoscope that is introduced into the abdomen by means of small incisions on the skin (into or near the umbilicus) and that projects the images on an external screen. The laparoscope consists of a camera and a light source. Thanks to the gas insufflation inside the abdominal cavity, the operating space is increased for better visualization of the operating field and instruments. To date we have a wide range of laparoscopic instruments that mimic the ones used in conventional laparotomy. Two or three additional accesses are required for most surgical procedures. In gynecological surgery, usually the ancillary trocars are placed 2 cm medial and cranial to the lateral iliac spines, lateral to the inferior hypogastric artery [1–5].

#### *Minimally Invasive Surgery in Gynecology DOI: http://dx.doi.org/10.5772/intechopen.98474*

Laparoscopes range from 1.8 mm to 12 mm in diameter having a distal end available in different angles. The 0-degree telescope is most commonly used and provides a straightforward view. While in contrast, a 30-degree fore-oblique lens allows for visualization in a large frontal view. Light is introduced through the laparoscope with a fiber optic cable powered by a light source. The camera unit consists of camera head, cable and camera control. The image resolution is dependent on the number of pixels on the chip. Most laparoscopic cameras have 250,00 to 380,000 pixels. Newer developments include the use of voice-activated, wireless systems designed to provide central control over operating room devices using either a microphone or a movable touch-pad screen.

Laparoscopy, as well as other endoscopic techniques, is based on two concepts that make it quite different from the open approach. These are triangulation and the fulcrum effect. Triangulation is a fundamental principle for endoscopic surgery as it allows to perceive the position of the instruments in three-dimensional space by sensing the position of our upper joints and arms across our chest together with visualization of the instrument tips (**Figure 1**). In fact, it is quite challenging to assess the distance or depth of the tip of a long instrument held in one hand. However, when a second instrument is used, the human brain can process the operative field visualized in the monitor with an impressive accuracy. Fulcrum effect is called the phenomenon where a handle movement of an instrument towards one direction is followed by a tip movement in the exact opposite direction. The tissue acts as a fulcrum or pivotal point. The tip movements ability and the right force needed to perform it, depends on the distance of the middle sign of the length of the instrument from the pivotal point according to the rules of physics (rule of moments). In other words, if more than 50% of the instrument length is beyond the fulcrum point, the tip movements are forceless and with a greater spectrum of movements (**Figure 2**) compared with the position when most of the instrument length is below the contact with the tissue.

#### **Figure 2.**

*Fulcrum effect: the abdominal wall, where the trocars are inserted, work as a fulcrum for the laparoscopic instruments. By moving the handle of the instrument to the left, through the fulcum effect, the tip of the same instrument will move to the right.*

Gynecologic laparoscopic entry is commonly at or through the umbilicus. The traditional technique is to blindly pass a sharp Veress needle, at the umbilicus, insufflate, and then to pass a sharp trocar. Other closed technique entry, such as direct trocar entry, the radially expanding access system and open techniques are widely used. The method by which incisions are made to introduce the laparoscope may influence the likelihood of complications of the first step (injury to surrounding blood vessels or the bowel). However, a recent systematic Cochrane review comparing groups of patients undergoing laparoscopy with different entry technique, concludes that evidence is insufficient to show whether there were differences between groups in the rate of failed entry, vascular injury, or visceral injury, or in other major complications with the use of an open-entry technique in comparison to a closed-entry technique [6].

In general, complications of laparoscopy include nerve injury, vascular injuries, gastrointestinal injuries, trocar site hernia and urinary tract injury. Successful laparoscopy, just as in laparotomy, requires adequate visualization of the operative field and safe retraction of non-target tissues. An inability to displace bowel out of the pelvis, such as in morbidly obese women, and indistinct events such as acute intra-abdominal hemorrhage, may prompt a conversion to laparotomy. Poor candidates for laparoscopy are those with ventilatory problems, severe cardiorespiratory problems or elevated intracranial pressure as well as patients who cannot tolerate steep Trendelenburg or peritoneal insufflation.

#### **2.2 Minilaparoscopy**

Minilaparoscopy uses smaller abdominal incisions than contemporary laparoscopy and refers to the use of instruments and port sites of 5 mm or less. The 5 mm

#### *Minimally Invasive Surgery in Gynecology DOI: http://dx.doi.org/10.5772/intechopen.98474*

laparoscopes show high resolution and transport enough energy to properly illuminate the surgical field. These smaller port sites may be used for camera and/or accessory instruments (**Figure 3**). Although minilaparoscopy has been studied more extensively in general surgery and urology applications in gynecology have been described since 1991. A 3-mm incision was made for visualization with a plastic sheath. Two additional 3-mm incisions were used for accessory instruments to aid in adhesiolysis, biopsy of endometriosis, and laser myomectomy. The use of smaller instruments enhances the chance of decreased incisional pain, less need for post-operative opioid pain medication, shortened recovery time, minimization of tissue trauma, and provides a more favorable cosmetic outcome. One of the advantages that arise from minilaparoscopy in comparison with other forms of MIS is that it uses the same operating techniques, patient positioning, and instrument configuration as conventional laparoscopy. Few studies have shown contradictory results concerning operation time. No difference was proven in postoperative complications such as infection, conversion to laparotomy, reoperation, hospital readmission, estimated blood loss, and venous thrombosis although the literature in that field is still scarce [7]. Minilaparoscopy is an intriguing alternative to traditional laparoscopy and may gradually prove to be even superior.

#### **2.3 Laparoendoscopic single site surgery**

Laparoendoscopic single-site surgery (LESS), which is also called single-port surgery or single-incision laparoscopy is a procedure in which all instruments are inserted through a single skin incision, normally at the umbilicus (**Figure 4**). The first reported case of LESS was a gynecological procedure (tubal sterilization) performed by Wheeless in 1969. Approximately 20 years later, Pelosi et al. reported the first case of hysterectomy through LESS [8]. Currently, LESS is used in different surgical fields (general surgery, gynecology, urology). Compared with conventional laparoscopy, LESS shows substantial technical differences in procedure which, however, continue to be improved. These include: loss of triangulation and depth perception because the camera and working instruments are parallel to each other, limited extra-abdominal working space and decreased field of view due to suboptimal instrument or camera position. For this reason a specialized training is needed

#### **Figure 3.**

*Standard laparoscopy/Minilaparoscopy illustration: 3–4 entry sites are used on the abdomen for insertion of the instruments. The instruments will converge from different angles and will neither collide nor cross.*

#### **Figure 4.**

*Laparoendoscopic single-site surgery (LESS): a single port access is used and through this port, laparoscope and instruments are inserted. The instruments will cross at the umbilicus and will collide inside the abdomen.*

to minimize these limits, but for surgeons experienced with standard laparoscopic techniques, adopting LESS seems to be feasible and safe. Essentially the advantage of this technique over the multiport laparoscopy would lie in the improvement of cosmesis, less pain, and decreased incisional morbidity. Recent data in gynecological surgery do not support the added of advantages of LESS over MLS. From an analysis of six randomized controlled trials (RCTs), conducted by Schmitt et al. in 2017 in patients undergoing LESS or MLS for adnexal pathology, there were no differences in length of hospital stay, blood loss, postoperative pain, and cosmetic outcomes [9]. In summary, the choice of LESS depends to a large extent on the skills and preferences of the surgeon after a thorough assessment of the morbidity of the patient and her pathology.

#### **2.4 Natural orifice transluminal endoscopic surgery**

Natural orifice transluminal endoscopic surgery (NOTES) has emerged as the newest concept of MIS (Minimally invasive Surgery) as an experimental alternative to conventional laparoscopy which provides an access to the peritoneum traversing a "natural" orifice (stomach, bladder, vagina, or rectum) with a multichannel endoscope [10]. When the procedure involves only transluminal access it is coined "pure" NOTES, compared with "hybrid" NOTES, which refers to a procedure performed through a natural body orifice with transabdominal assistance. The key technical elements in a NOTES procedure are access via a hollow viscus, performance of the desired maneuver once in the target cavity, and closure of the port upon exit. The choice of the entry site depends on the topography of the organ that must be subjected to surgery, considering a good visualization and proper manipulation of the instruments. For example, the trans-gastric pathway is appropriate for lower abdominal and pelvic procedures, while a trans-vaginal approach is preferable for upper abdomen organs. The conceptual bases that led to the development of NOTES have been the potential benefits of an incision of a viscus compared to the skin, the decrease in the risk of post-operative hernias and the obvious cosmetic result. On the other side, there are some limitations: many of the current instruments in use today are difficult to maneuver when the uterus is retroflexed.

#### *Minimally Invasive Surgery in Gynecology DOI: http://dx.doi.org/10.5772/intechopen.98474*

Furthermore, a thorough closure of the viscerotomy is crucial to avoid bacterial contamination of the peritoneal cavity and abscess formation.

Of all the approaches, presently the transvaginal access to NOTES is the most common and seems to be the safest and most feasible for clinical application (**Figure 5**). Transvaginal NOTES (vNOTES) has been used for several operations other than cholecystectomy and appendectomy in humans. Potential complications of this approach include: dyspareunia, infertility, rectal and urinary injury. In 2012, Ahn et al. demonstrated firstly the feasibility and safety of vNOTES in gynecologic surgeries, which represented the key milestone in the evolution of NOTES [11]. The innovative and positive aspects of natural orifice surgery in gynecology include the lack of abdominal incisions, less operative pain, shorter hospital stay, improved visibility, and the possibility to skip lysis of adhesion to reach the pelvic cavity. However, for patients with severe adhesion and obliteration in the pouch of Douglas, vNOTES may be a contraindication due to higher risk of rectal injury. To date, two studies compared the surgical outcomes of vNOTES with conventional laparoscopic technique in gynecologic surgery. Both studies demonstrated that vNOTES could be safely performed for benign and large ovarian tumors and vNOTES might offer superior operative outcomes including blood loss, operating time and length of stay, compared to conventional laparoscopic technique [12, 13]. It seems obvious that sexual dysfunction may be an essential reservation of the females. Surprisingly, a study about transvaginal surgery has showed no problems of sexual intercourse and almost no cases of dyspareunia in a long-term follow-up [14]. The transvaginal peritoneal access for a gynecologist might not cause stress because of being familiar with the pelvic anatomy. Although transvaginal NOTES represents one of the most important innovations in surgery since the advent of laparoscopy, there are still technical limitations that must be overcome before the widespread use of this approach.

#### **Figure 5.**

*Transvaginal natural orifice transluminal endoscopic surgery (vNOTES). An incision is made in the posterior vaginal fornix through which camera and instruments are inserted in the abdominal cavity.*

#### **2.5 Robotic surgery**

Similar to laparoscopy, robotic surgery uses abdominal ports to create pneumoperitoneum to expand the operative field and to introduce the endoscopic instruments. The most known and currently the only commercially available system is the Da Vinci System (**Figure 6**). The patient is placed in the standard low dorsal lithotomy position with the legs supported in stirrups. One or two surgeon consoles are used to control robot arm movement. A separate robot column is positioned by the bedside and serves as the base for the four robotic arms. One of these arms controls the laparoscope while the other arms hold the robotic instruments. If port sites in addition to the basic four are needed, an assistant surgeon can operate by the patient bedside through one or two additional laparoscopic accessory ports. Port placement for robotic surgery is unique in that ports must be placed with a minimum interval distance of 8 cm. This makes sure that robot arms do not collide with each other and with any accessory port. Importantly, the depth of the inserted trocar in the abdomen is marked by a black ring around the cannula in order to adjust the right fulcrum during the operation. Robotic surgery presents significant technical advantages and some disadvantages compared with conventional laparoscopy. Advantages include 3D visualization of the operative field, mechanical improvement (instrument with seven degrees of freedom of movement), stabilization of instruments within the surgical field, and improved ergonomics. Disadvantages are mainly lack of tactile perception, increased cost, increased operating room time, large size of the devices and risk of mechanical failure. However, the robotic procedure is very useful and decisive in complex surgical procedures where extensive demolition is necessary with consequent restoration of the anatomy. In particular, the Endo Wrist technology is able to overlap with open techniques facilitating the execution of complex maneuvers even for the less experienced. Certainly, surgical simulation, tele-mentoring and telepresence surgery are potential novel benefits of robotic technology. Through robotic surgery most gynecological surgical interventions can be safely performed with an increased comfort for the operator as compared with conventional laparoscopy. However, randomized studies have not demonstrated the superiority of this technique compared to conventional laparoscopy and a clear indication of its use. Moreover, in comparison to conventional laparoscopy the learning curve for becoming proficient in robotic surgery is less steep and has

#### **Figure 6.**

*Robotic surgery set up. It includes 3 components. A surgeon's console, a patient-side cart with four robotic arms manipulated by the surgeon (one to control the camera and three to manipulate instruments), and a highdefinition three-dimensional (3D) vision system. Articulating surgical instruments are mounted on the robotic arms, which are introduced into the body through cannulas.*

#### *Minimally Invasive Surgery in Gynecology DOI: http://dx.doi.org/10.5772/intechopen.98474*


### **Table 1.**

*Advantages and disadvantages of various types of MIS in Gynecology.*

allowed a smooth transition to minimally invasive surgery for many gynecologists [15–20]. Last but not least, a newer Single Port Robot is currently available although not yet FDA approved for gynecologic procedures.

As it comes clear, nowadays there are various available minimally invasive techniques in the field of gynecology, each of them presenting specific advantages and disadvantages as shown below in **Table 1**.

#### **3. Ergonomics in minimally invasive surgery**

The term ergonomics derives from 2 Greek words: "Ergon" that means work and "nomos" that means law. In simple words it describes the science that prepares the worker to best fit his job by developing his working environment and necessary tools by offering the maximum favorable conditions [21]. Usually, when we talk about safety in the OR, anyone might be automatically thinking of safety concerning the patient and not the safety of medical and paramedical staff. Despite the proven safety and efficiency for patients, the development of laparoscopy came with exclusive ergonomic risks such as instrument length and handle design, inappropriate monitor position, and excessively high operating tables. Work-related musculoskeletal injuries and disorders are extremely common in the surgical staff with specific risk situations present in open, laparoscopic, vaginal, and robotic surgery. Needless to point out, that surgeon's safety has received scarce consideration, throughout the passage from laparotomy to MIS. Studies have shown that, despite significant impact of surgeon injury on productivity and career longevity, surgeons seldom and almost never report work-related injuries to the hospitals, building up a tendency of silent suffering. Although surgical ergonomics guidelines do exist, most surgical staff is not aware of guidelines, while targeted surgical ergonomics training is rare.

Work-related musculoskeletal disorders (WMSDs) as being the official term of this emerging phenomenon contribute immensely to reduced productiveness and job absenteeism. According to the guidelines, behaviors such as repetitions, application of more than 30% of strength, excess body segment positioning, prolonged static posture, use of vibration equipment and exposure to cold shall be averted. Given all that, it comes clear that WMSDs have the highest prevalence in the group of surgeons [22]. These sometimes inevitable movements could have important consequences to the admittedly long career life of a surgeon. Therefore, evidence based ergonomics training protocols should be available and become a compulsory part of residency programs to all teaching hospital around the world as it is well known, in the medical life but as well as in other scenarios bad habits hardly dissolve.

#### **3.1 Ergonomics of conventional laparoscopy**

The importance of ergonomics in the field of laparoscopy cannot be overemphasized. Studies have shown that ergonomics awareness and structured training can reduce chronic pain among surgeons as well as suturing time. The commonest sites of injury include the neck, back, shoulder, elbow, and wrist. This is no surprise as in comparison to conventional open surgery, in laparoscopy the surgeon presents prolonged static posture with no dynamic movements of the body resulting in decreased blood supply in the muscles and consequently elevated lactic acid and toxins in the blood circulation due to anaerobic metabolism. Moreover, redundant internal rotation of shoulder and deviation of elbow and wrist are more common in laparoscopy and have a huge impact in the mechanism of strain of the described regions. Risk factors for WMSDs include physician's traits such as younger age, shorter stature, female sex, smaller glove size, and higher volume, as well

#### *Minimally Invasive Surgery in Gynecology DOI: http://dx.doi.org/10.5772/intechopen.98474*

as higher patient BMI. On the other hand, protective factors include ergonomics awareness and training, excessive practice and higher surgeon age. Monitor position is a key component in laparoscopic surgery. Ergonomically, the ideal monitor position for laparoscopy is with the monitor image at or within 25 optimal degrees below the horizontal plane of the eye at a distance of approximately 60 cm. The same height, at which the video monitor used to be set for surgeons of different heights, has been demonstrated to be the underlying cause of neck pain and spondylosis in high-volume laparoscopic centers in the first decade after the onset of MIS in routine clinical practice [22–24].

#### **3.2 Ergonomics of robotic surgery**

Robotic surgery offers certain improvements in ergonomics such as greater degrees of freedom, motion scaling, tremor reduction, and 3-D immersive optics. Robotic equipment permits performance of fine tasks without the 'arcing' motions characteristic of conventional laparoscopy. Overall pain with robotics is decreased in comparison to open surgery and laparoscopy. Nevertheless, recent studies have questioned this demonstrated ergonomic advantage of robotics as McDonald et al. in 2017 concluded that robotic procedures were associated with more discomfort, stiffness and fatigue in a survey study of 350 surgeons [25]. Another study by Franasiak et al. has shown that approximately 45% of robotic surgeons experienced WMSDs while an impressive percentage of 26% showed to have experienced permanent damage. As resulted by the same study none of the observed surgeons reported injury to institutions while less than 17% of the total number had formerly received appropriate ergonomics training [26]. Given the rapidly emerging field of robotics in gynecologic surgery it comes clear that more solid evidence is needed in order to make safe comparisons between the ergonomic limitations of robotics versus laparoscopy [27].

#### **4. Artificial intelligence and training the next generation of minimally invasive surgeons**

Artificial intelligence (AI) and augmented reality have been steadily permeating the healthcare field and are expanding into gynecology. Although virtual artificial intelligence systems are still lacking in gynecology, gynecologic surgery has already integrated augmented reality (AR) technology into the operating room. For instance, cervical cancer models using AI have been used to foresee survival after surgery [28]. Over the past decade, gynecologic surgery has incorporated augmented reality in the form of computer-assisted or robotic platforms to close the native gap between open and minimally invasive surgical skills [29]. A.I applications range from simple prognostic tools to more complex models that incorporate clinical data, imaging, and histopathology to contribute into the optimal therapy decision. Various researchers argue that artificial intelligence is superior to traditional regression models in predicting outcomes. Another example of augmented reality in surgery is projecting preoperatively obtained radiologic images to the operating field during surgery to allow surgeons to understand the anatomical relationship between pathologic and healthy organs. Real time detection of the ureter during surgery is currently experimentally tested for eventual future use [30]. 3D printing is already reality in many centers and it permits advanced preoperative surgical planning and as a result minimizes potential injury. The most applicable example is by understanding the variation in uterine myomas where parameters such as size, location, and depth vary a lot and as a result 3D printing could guide the gynecologist to achieve an outstanding level of pre-op planning [31]. A recently

published case report has had success in mapping endometriosis nodules with spatial organ involvement preoperatively with a 3DP model [32].

Virtual simulators have been recently utilized in training gynecologic surgeons for laparoscopic and robotic surgery. The simulator's efficacy has been assessed through published studies and has been shown to improve basic and advanced laparoscopic skills in all training levels. Novice residents improved their speed of execution, accuracy, and maintenance of horizontal view, while senior residents shortened their speed of execution. Virtual simulators could be incorporated into compulsory residency training as tools for practicing coordination and precision [33]. Hopefully we will reach to a point where as in aviation, it could become a requirement for novice trainees to practice and demonstrate adequate mastery of minimally invasive surgical skills before boarding on real surgery.

#### **5. Conclusions**

In conclusion, endoscopic approach remains the best choice in most of gynecological interventions. Despite the continuous groundbreaking advances in the medical technology concerning gynecologic procedures, the standard laparoscopic approach remains the universal king of the endoscopic gynecologic surgery. In everyday clinical practice, the final decision of the preferred technique depends on different variables: surgeon experience with the proposed technique, patient's characteristics and desire and finally costs. In particular, surgical costs can be divided into equipment costs and operating room time and surgical staff has to be more familiar with these costs as there is evidence that when surgeons are well informed and educated about operating room outlay, the cost of the procedure decreases. Moreover, the cost differential between robotic and laparoscopic hysterectomy decreases as surgeon and hospital volume increase [34]. For example, in selected cases such as hysterectomies for large uteri greater than 750 gr, robotic surgery has been shown to have cost-effective benefits compared to laparoscopic hysterectomy [35]. Minilaparoscopy, LESS and NOTES gave new perspectives to the minimal invasive conception, however despite of specific important flaws they are not frequently used into clinical practice up to date. Laparoscopic training as well as reduction of robotic-assisted technology costs by expanded use seem to be the constant for the future of minimal access surgery in the field of gynecology.

#### **Conflict of interest**

The authors declare no conflict of interest.

*Minimally Invasive Surgery in Gynecology DOI: http://dx.doi.org/10.5772/intechopen.98474*

### **Author details**

Morena Antonilli1,2, Vasileios Sevas1,2, Maria Luisa Gasparri1,2, Ammad Ahmad Farooqi3 and Andrea Papadia1,2\*

1 Service of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Regional Hospital of Lugano EOC, Lugano, Switzerland

2 Faculty of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland

3 Institute of Biomedical and Genetic Engineering (IBGE), Islamabad, Pakistan

\*Address all correspondence to: andrea.papadia@eoc.ch

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[24] Lee, Gyusung, et al. "Ergonomic risk associated with assisting in minimally invasive surgery." Surgical endoscopy 23.1 (2009): 182-188. DOI: 10.1007/ s00464-008-0141-4

[25] McDonald, Megan E., et al. "Physician pain and discomfort during minimally invasive gynecologic cancer

surgery." Gynecologic oncology 134.2 (2014): 243-247. DOI: 10.1016/j.ygyno. 2014.05.019

[26] Franasiak, Jason, et al. "Feasibility and acceptance of a robotic surgery ergonomic training program." JSLS: Journal of the Society of Laparoendoscopic Surgeons 18.4 (2014). DOI: 10.4293/JSLS.2014.00166

[27] Stylopoulos, Nicholas, and David Rattner. "Robotics and ergonomics." Surgical Clinics 83.6 (2003): 1321-1337. DOI: 10.1016/S0039-6109(03)00161-0.

[28] Obrzut, Bogdan, et al. "Prediction of 5–year overall survival in cervical cancer patients treated with radical hysterectomy using computational intelligence methods." BMC cancer 17.1 (2017): 1-9. DOI: 10.1186/s12885- 017-3806-3

[29] Sørensen, Stine Maya Dreier, et al. "Three-dimensional versus twodimensional vision in laparoscopy: a systematic review." *Surgical endoscopy* 30.1 (2016): 11-23. DOI: 10.1186/s12885- 017-3806-3

[30] Song, Enmin, et al. "A novel endoscope system for position detection and depth estimation of the ureter." Journal of medical systems 40.12 (2016): 1-11. DOI: 10.1007/s10916-016-0607-1

[31] Bourdel, Nicolas, et al. "Augmented reality in gynecologic surgery: evaluation of potential benefits for myomectomy in an experimental uterine model." Surgical endoscopy 31.1 (2017): 456-461. DOI: 10.1007/s00464-016-4932-8

[32] Ajao, Mobolaji O., et al. "Case report: three-dimensional printed model for deep infiltrating endometriosis." Journal of minimally invasive gynecology 24.7 (2017): 1239-1242. DOI: 10.1016/j.jmig. 2017.06.006

[33] Paquette, Joalee, et al. "Virtual laparoscopy simulation: a promising pedagogic tool in gynecology." JSLS: Journal of the Society of Laparoendoscopic Surgeons 21.3 (2017). DOI: 10.4293/JSLS.2017.00048

[34] Misal, Meenal, Ritchie Delara, and Megan N. Wasson. "Cost-effective minimally invasive gynecologic surgery: emphasizing surgical efficiency." Current Opinion in Obstetrics and Gynecology 32.4 (2020): 243-247. DOI: 10.1097/ GCO.0000000000000636

[35] Moawad, Gaby N., et al. "Comparison of cost and operative outcomes of robotic hysterectomy compared to laparoscopic hysterectomy across different uterine weights." *Journal of robotic surgery* 11.4 (2017): 433-439. DOI: 10.1097/GCO.0000000000000636

### **Chapter 3**

## Minimally Invasive Surgical Treatment of Pelvic Pain in Teenagers and Young Women

*Panagiotis Tsikouras, Christos Tsalikidis, Xanthoula Anthoulaki, Anna Chalkidou, Aggeliki Gerede, Stefanos Zervoudis, Anastasia Bothou, Spyridon Michalopoulos, Georgios Dragoutsos, Nikolaos Panagiotopoulos, Fotini Gaitatzi, Ionnis Tsirkas, Irini Babgeorgaka, Theopi Nalbanti, Natalia Sachnova, Alexios Alexiou, Constantinos Nikolettos, Sebaidin Perente, Panagiotis Peitsidis and Nikolaos Nikolettos*

#### **Abstract**

Pelvic pain could be acute or chronic but rarely could be life threatening with various reasons such as pathological, physiological or functional. Clinical evaluation and management should be performed simultaneously, especially in emergencies that carry a high risk of mortality. Clinical evaluation and management should be performed simultaneously, especially in emergencies that carry a high risk of mortality. Although a detailed history, physical and gynecological examination, supplemented with imaging modalities can itself be diagnostic, the role of laparoscopy for diagnosis should not be overlooked. The common causes of pelvic pain with focus on a minimally invasive approach in this age group are as following: endometriosis, rupture of ovarian cyst, infection, ovarian torsion, pelvic vein syndrome, adhesions pain due to previous surgery and unsatisfactory treated infections.

**Keywords:** acute and chronic pelvic pain, gynecologic, non-gynecologic, endometriosis, cyst accident, torsion, ectopic pregnancy

#### **1. Introduction**

Pelvic pain is categorized as chronic or acute. Moreover should be mentioned that the incidence of pathology is different by age and it is essential to distinguish the causes that could be gynecological or non-gynecological. In adolescents appendicitis, cyst eruption or intussusception consist the most common causes of pelvic pain and on the other hand ectopic pregnancy, uterine fibroids, torsion of ovarian cyst, and pain are Mittelschmerz the most common causes of pelvic pain in women of reproductive age. Additionally, in postmenopausal woman diverticulitis, tumors and renal stones are the most frequent pathology.

There are multiple causes **of** pelvic pain with a broad spectrum of possible pathologies, physiological **processes** and functional syndromes that can cause pain. The pain is usually noncyclic. Chronic pain is defined as lasting for 3 to 6 months or more) [1]. The condition can be combined with abdominal pain. Contrary to the impression that chronic pelvic pain is usually related to gynecologic conditions, the majority of cases is related to gastrointestinal and urologic conditions [2]. Pelvic pain, in its severe form, can cause functional disability requiring an etiological or symptomatic treatment. Considering that the range of etiologies is diverse, both symptomatic and etiological management is often necessary. Among others, endometriosis, leiomyomas, adenomyosis, pelvic inflammatory disease and pelvic adhesions are included in the gynecologic conditions; interstitial cystitis, recurrent cystitis and recurrent urolithiasis are included in the urologic conditions; and irritable bowel syndrome, inflammatory bowel disease and celiac disease are included in the gastroenterologic disorders causing pelvic pain. Minimally invasive techniques could be proposed in both investigating and managing some of the above conditions. As an example, laparo-endoscopic single-site surgery technique could be considered in the management of endometriosis [1, 3]. Similarly, although routine laparoscopic adhesiolysis is not advised for pelvic adhesions, in selected cases, such as in one or two scars around an ovary, this specific adhesiolysis could be proved beneficial.

The surgical treatment of gynecological diseases in adolescence differs from that of adults. The way of coping with is affected by the high life expectancy and the necessity to maintain reproductive capacity [3, 4].

The sensitive psychology of adolescents should not be overlooked. Finding a mass inside the pelvis is an unpleasant experience at any age, but, in adolescence, is considered traumatic for both of the patient herself and her family [5, 6].

From the data of the international literature, which involve a large number of adolescent patients, it appears that:


A variety of gynecologic and non- gynecologic conditions such as approximately in 20% of cases endometriosis, pelvic inflammatory, adhesive disease, irritable bowel diverticulitis can lead to pelvic pain.

In this review is presented pelvic pain resulting from several gynecologic conditions and referred according to our experience [8–12].

#### **2. Acute pelvic pain**

Acute pelvic pain in this age group is characterized with the following symptoms: sharp, sudden pelvic pain, exacerbating pain with great intensity, short duration

*Minimally Invasive Surgical Treatment of Pelvic Pain in Teenagers and Young Women DOI: http://dx.doi.org/10.5772/intechopen.97778*

(<24 hours) and usually occur in lower abdomen. In most cases, appeared also symptoms based on irritation of neural system like nausea, vomiting, sweating and tremor. Acute pelvic pain is the most often cause of visiting emergency department of gynecological clinic and it is a challenge for gynecologists for prompt diagnosis and treatment. The most often causes acute pelvic pain are as following [13–15]:


#### **3. Chronic pelvic pain (CPP)**

Chronic pelvic pain is referred in pain has duration more than 6 months, occur lower abdomen and is associated to pain intensity great influence in life quality and sometimes requires multiple doctors visits and hospital admissions. The most common causes which could be functional, pathological, physiological are as following:


Frequency is approximately 4–25%, however the minority of woman in this age group (33%) visit doctor.

Various studies have studied the incidence of chronic pelvic pain (CPP) in 5,000 women, aged 12 - -22 years, in the United States. In these studies, it was revealed that 15% suffer from CPP. Of these, only 10% visited a gynecologist, while 75% had no visits in any health care provider.

Despite the fact that such an increased number of women did not visit a doctor, CPP was the cause of 10% of gynecological visits, 10 - -40% of laparoscopic surgeries, and 10 - -16% of hysterectomies [18–23].

In the USA, every year are performed approximately 4000,000. If 10 - -16% of them done for CPP, then we could assume that 65000 to 104000 hysterectomies are performed due to CPP.

In addition, while the mortality of hysterectomies is about 0.1%, 65 - -104 of deaths can be attributed to surgeries for the treatment of CPP each year. About 35% had no visible abnormal CPP findings on laparoscopy. It is estimated that 58% of

women limit their physical activity to at least one day a month, 10% seek for a doctor other than a gynecologist, while 1% seek for treatment with a psychiatrist [18–23].

The majority of the patients with chronic pelvic pain and negative laparoscopic findings (41%) were taken contraceptives, while 25% GnRH analogues for 3 months [18–23]. The American College of Obstetricians & Gynecologists recently argued that it is appropriate to prescribe empirical treatment with GnRH analogues for 3 months to women with CPP, without an exact diagnosis, who have not had any other anti-inflammatory drugs [18–23].

This approach is considered relatively safe and effective. If there is no response to this treatment, a laparoscopy or other surgical approach should be performed [18–23].

An empirical protocol is proposed by Winkel, which, after excluding other pathologies such as pelvic inflammatory disease or ovarian cysts, administers GnRH in proportion to an improvement effort. According to the results of various women, there is an improvement of 80% in patients with, or without, endometriosis, r17-22egardless of whether they have undergone laparoscopy or not [13–21].

#### **4. Endometriosis**

#### **4.1 Definition and incidence**

Endometriosis is characterized by the presence of endometrium outside the uterus, the proliferation and differentiation of tissue similar to the endometrium outside the cavity of the uterus. It is the one of most common cause of pelvic pain in women of reproductive age and the second most common gynecological condition after fibroids. Any peritoneal surface including tube ovary (where it may form endometriomas, peritoneal, bowel, bladder etc.


The term '"deep endometriosis" includes the morphological classification of endometriosis, which has a penetration depth greater than 5 mm [22–26].

The clear differentiation of deep endometriosis from other forms of the disease was observed by Donnez [24–28]. The nodular form of these lesions is due to the proliferation of smooth muscle fibers, their localization is retroperitoneal and may extend laterally to the anterior part of the rectum.

Although this entity is a common gynecological disease, responsible for 10 - -15% of infertility cases, little is known about the pathogenesis of the disease. For its etiology, several pathophysiological mechanisms have been proposed -, anatomical, immunological, endocrinological, environmental and finally genetic factors with genetic predisposition [24–28].

The genetic processes that regulate endometrial cell proliferation have not been fully elucidated. The etiology of endometriosis is unknown, but there is evidence to suggest that the genetic factor is associated with the development of endometriosis. The notion that endometriosis is a genetic disease was initially relied on poorly controlled studies in which a familial impact of the disease was found [24–28]. A familial tendency for endometriosis was first reported in 1957, but the first representative study of endometriosis genetics was conducted in Europe by Simpson et al. *Minimally Invasive Surgical Treatment of Pelvic Pain in Teenagers and Young Women DOI: http://dx.doi.org/10.5772/intechopen.97778*

in 1980 in Europe. It should be noted that relatives of second-degree patients had a 1.8% risk of endometriosis. Women with a family history of endometriosis tended to develop allergic reactions (eczema, asthma, allergic rhinitis). In addition, women with congenital endometriosis developed the disease at a younger age (mean age 22.1 years).

Finally, women with congenital endometriosis usually had the most severe form of the disease, the third and fourth stages of endometriosis, according to a revised American Fertility Society ranking. Although, the above information is consistent with the view of the existence of a genetic basis in endometriosis, other factors could explain the endogenous impact of the disease. Symptomatic women, for example, may seek medical help sooner if they have a relative diagnosed with endometriosis.

According to a study conducted by the Australian National Commission on Health and Social Research on 3,096 twin sisters, endometriosis was observed in 2% of singletons and 0.6% of twins. The increasing incidence of endometriosis in monozygotic twin sisters makes genetic factors more important in the etiology of the disease [29, 30].

#### **5. Diagnosis**

When the vaginal bleeding and pelvic pain, which consist symptoms of endometriosis are mild to moderate, the first line treatment is hormonal therapy. Depending on the diagnostic method that will be used, the diagnosis of endometriosis is stated only in 19–20% of cases. The majority of specialists use laparoscopy to diagnose endometriosis. This technique, however, is not without disadvantages. Laparoscopy will diagnose endometriosis in 20% of patients. Another problem with laparoscopy is that even if there are visible lesions, histological confirmation of endometriosis is not always possible. Histological confirmation also depends on the biopsy. In addition, to this due to different forms of the disease, it can be overestimated in more than 2/3 of the patients. Although, is helpful as it allows the patient and clinician to refocus on alternative medical strategies for management, especially in early stages (deep endometriosis). When positive findings – then laparoscopic ablation/resection can be undertaken. The appropriate treatment of endometriosis is of great importance in this age group due to the fact that that fertility should be maintained, also in cases in which tubes are not affected by endometrial lesions because in these cases could be negative laparoscopy findings but could affect fertility(negative influence of occurred endometrial lesions in ovum and sperm). Symptoms of endometriosis are as following: dysmenorrhea 60–80%, pelvic pain 30–50%, subfertility 30–40%, dyspareunia 25–40%, menstrual abnormalities 10–20%, periodical dysuria and hematuria 1–2%, constipation 1–2% and < 1% rectal bleeding and fatigue.

Another big problem for the diagnosis of CPP is that 80% of the patients who have had a laparoscopy has negative findings. And what about these patients who have negative findings? Doyle reports that of the patients with the negative findings, 53% wanted analgesics, 50% were unsatisfied with the treatment and 43% did not have a good quality of life. The presence of endometrial implants in the peritoneum can cause local peritoneal inflammation [30–34].

The cystic form of ovarian endometriosis is usually followed by adhesions, which is known that play an important role in the progression of the disease, explaining why ovarian endometriosis is classified as Π AFS. The determination of Ca-125 is a useful and reliable diagnostic tool, as well as intrarectal ultrasound, while transvaginal ultrasound and magnetic resonance imaging (NMR) are not

diagnostic methods used in the diagnosis. Donnez et al. distinguish 3 forms of the disease, endometrial septal endometriosis (Type I), posterior atrial dome endometriosis (Type II) and deep endometrial edema (Type III endometriosis). **Table 1** Koninckx and Martin report another stage of the disease **Table 2**, **Figures 1**–**5**.

Additional data on the genetic basis of endometriosis, based on sibling studies, are provided by the finding that siblings, non-twins who develop the disease, usually develop the pain symptom at the same age. The incidence of all stages of endometriosis in the sisters of afflicted women in comparison to the general population is six to nine times.

The relationship between endometriosis and increased estrogen production is a popular and biologically plausible hypothesis. Endometriosis and fibroids develop in women of childbearing potential and regress after menopause or after ovulation, which is consistent with the view that the development of these diseases is estrogen dependent.

The estrogen receptor (ER) and the aromatase gene (CYP19) are potential candidate genes. Both could enhance estrogen accumulation and produce a more abundant [34–36].

Thus, it has been investigated whether the polymorphism of the estrogen receptor gene Pa (ER-α) is associated with the development of endometriosis. It is recognized that ectopic endometrial foci have estrogen receptors. Endometrial foci also express cytochrome P450 aromatase, an enzyme that catalyzes the conversion of androgens to estrogens, recommending that local estrogen production may be increased.


#### **Table 1.**

*Distinction of endometriosis according to Donnez et al.*


#### **Table 2.**

*Distinction of endometriosis according to Koninckx and Martin.*

*Minimally Invasive Surgical Treatment of Pelvic Pain in Teenagers and Young Women DOI: http://dx.doi.org/10.5772/intechopen.97778*

**Figure 1.** *Ultrasound image showing large endometriomas.*

**Figure 2.** *Doppler ultrasound in endometriomas with high PI (pulsatility index).*

**Figure 3.** *Ultrasound image of endometriomas (chocolate cyst).*

**Figure 4.** *Pelvic MRI scan showing large endometriomas in cross section.*

*Minimally Invasive Surgical Treatment of Pelvic Pain in Teenagers and Young Women DOI: http://dx.doi.org/10.5772/intechopen.97778*

#### **Figure 5.**

*Ovarian cyst during laparotomy due to ovarian torsion.*

Thus, topical estrogens, together with those originating from the bloodstream, stimulate the development of endometrial foci through the estrogen receptor [37–39].

The main support for the action of aromatase in endometriosis is adrenal and ovarian androstenedione. Aromatase converts androstenedione to estrone, a weak estrogen, which must be converted to estradiol to exert a strong eff. In contrast, the enzyme 17β-hydroxysteroid dehydrogenase type II (17β-HSDIII), encoded by a different gene, inactivates estradiol by catalyzing its conversion to conversion by conversion etc.). The enzyme 17β-hydroxysteroid in endometriosis. Progesterone induces the activity of the enzyme 17β-HSDIII in endometrial cell cultures. Expression of 17β-HSD type II is absent from endometrial glandular cells during the secretory phase [37–39].

Moreover, in healthy women PP genotype was less common than PP and Pp genotype, compared with control group women and women with endometriosis. The distribution of genotypes to women in the control group was intermediate between women with endometriosis and women without disease. The frequency of the heterozygous Pp genotype did not differ between the groups. The p allele was less common than the P allele in women without the disease, compared with women with endometriosis and women in the control group from the general population. Thus, PvuII polymorphism of the ER gene is associated with the risk of developing endometriosis. The mechanism by which anonymous intron polymorphism affects the function of the estrogen receptor has not been clarified.

In the future, the clarification of this mechanism will contribute to the understanding of the pathogenesis and pathophysiology of estrogen-dependent diseases of the uterus. Loss of genetic material or DNA refers to loss of heterozygosity. Loss of heterozygosity can be caused by exogenous factors, such as carcinogens which can cause genetic damage that leads to deletions and mutations in DNA [34–39].

Mutations and deletions are particularly important in the remaining tumor suppressor genes, because if one is deleted or inactivated due to a mutation, the gene does not work properly. Such deletions can cause genetic mutations, which lead

to inactivation of genes resulting in the loss of heterozygosity. That is, the loss of heterozygosity is the result of the deletion of an area of a putative tumor suppressor gene, leading to the inactivation of that gene. Tumor suppressor genes are altered in ovarian cancers, which is consistent with the view that inactivation of these genes may play a role in the development of endometriosis. LoH heterozygous allelic mutation has been shown to occur for several DNA repair genes MSH2, MSH6, MLH1, and PMS1. The finding of LOH in regions 2p22.3-p16.1 and 3p24.2-p22, where the hMSH2 and hMLH1 genes are located, leads to the hypothesis that in some of the cases of endometriosis there may be a predisposition to cancer. Other evidence suggests the involvement of PTEN, hMLH1, p16 and INK41 in the malignancy of endometriosis. Mutation in hMLH1 methylation has been observed in four of 46 (8.6%) cases of stage III/IV endometriosis. No detectable protein expression of hMLH1 was present in these four cases, the carcinoma coexisted in two, while abnormal methylation of p16 was observed in only one case and reduced protein expression of PTEN was detected in 21 cases (15%). Both of these cases also showed hypermethylation of hMLH.

#### **5.1 Tumor suppressor genes for endometriosis (TP53, PTEN)**

Cell monoclonal expression has already been identified in endometriosis by overexpression of certain oncogenic genes (c-myc, c-erg B1). Cytogenetic abnormalities are common in malignancies. Obata and Hoshiai studied: (a) the determination of the cloning of endometriosis foci, (b) the presence of mutations in the TP53 and RASK genes, (c) the lack of heterozygosity at the sites of ovarian cancer, and (d) in endometrial carcinoma. These authors showed a lack of heterozygosity on chromosomes 9p (18%), 11q (18%) and 22q (15%). Overall, 28% of endometriosis foci showed a lack of heterozygosity at one or more sites [33–39].

There is a view that two or more genes are sequentially needed to cause endometriosis. Unlike neoplasms, not all genes involved in endometriosis need to be oncogenes or tumor suppressor genes. We believe that the first "hit" involves a gene that manifests a growing predisposition to attach and implant retrograde menstrual tissue [33–39].

This gene includes the cytoskeleton (MMPs), the cell adhesion molecule (ICAM1)), or macrophage accumulation. The second gene (`hit ') may include genes that support endometrial growth, such as the estrogen receptor (ER) or steroid perturbations (CYP19). We also assume that the additional shocks involve a tumor suppressor gene, which leads to uncontrolled cell proliferation. If a tumor suppressor gene is involved in endometriosis, LoH heterozygosity could be lost at such a genetic locus. Iang et al. found the loss of LoH heterozygosity in endometriosis, by studying the chromosomal regions at 9p, 11q, and 22q in endometrial tissue. In a second study, chromosomal alterations were observed in nine of the 11 cases in which ovarian carcinoma had occurred within, or adjacent to, endometriosis [33–39].

Changes in chromosomal regions 5q, 6q, 9p, 11q, and 22q were observed in 25 - -30% of cancer-associated endometriosis cases. This is consistent with the view of some deletion in the areas where the supposed tumor suppressor genes are present, a condition seen in ovarian cancer that coexists with endometriosis. No lack of heterozygosity was found in the normal endometrium. The normal endometrium does not show molecular genetic damage. Tissue samples from endometriosis, adjacent to endometrial carcinoma, atypical endometriosis and endometrial carcinoma of the ovary were examined and common genetic changes were found with stability and joint [33–39].

These common changes did not exist in foci that were far apart. In endometrial cancers, an increased incidence of mutations in the PTEN/MMAC tumor suppressor genes were observed, while no corresponding mutations were found in serous carcinomas and clear cell carcinomas, which is evident for the tumor [33–39].

*Minimally Invasive Surgical Treatment of Pelvic Pain in Teenagers and Young Women DOI: http://dx.doi.org/10.5772/intechopen.97778*

A second tumor suppressor gene studied in endometriosis is PTEN, which is located on chromosome 10q23. The gene is perturbed in a variety of cancers, including autosomal dominant disorders (Cowden syndrome and Bannayan-Zonana syndrome). PTEN mutations have been reported in endometrial cancers and in an epithelial ovarian tumor, which show some association with endometriosis but not with the serous or mucous epithelial tumors of the ovaries. Mutations involving PTEN have been observed only in endometrial tumors, at 21%. %Sato et al. [33–39] found that LoH heterozygosity was lost for PTEN in eight of 19 endometrial carcinomas (42.1%), in six of 22 clear-cell carcinomas (27.3%), and in 13 of the 23 endometrial cysts. The relationship was even greater when endometrial carcinomas were synonymous with endometriosis [33–39]

Mutations of TP53, PTEN could be associated with the transformation of benign endometrial cells into malignant cells.

In conclusion, in endometriosis there is significant damage to the molecules and to somatic cells. Also, in a percentage of cases, the lesion can continue the progression of the disease. Moreover, regions with chromosomal losses may contain important tumor suppressor genes for the pathogenesis of the disease. Lastly, in a very small percentage of cases, the disease develops into endometrial carcinoma.

#### **6. Abdominal discomfort and pregnancy**

In particular, abdominal pain during pregnancy is a the most common phenomenon due to hyperemia of the pelvic vessels or dilation of the ligaments. Due to the frequent occurrence of abdominal pain during pregnancy, it is possible not to diagnose early or even possible pathological causes of abdominal pain.

Fortunately, it is not always associated with a potential risk to pregnancy or to a woman's health, due to pelvic vascular hyperemia or dilation of the round ligaments.

The purpose of this report is to describe some areas of abdominal pain that are less troubling, which of course should be appreciated, and others that dictate immediate medical attention.

Abdominal discomfort should be associated with either a pregnancy complication or a pregnancy-related acute condition. Sometimes after the second trimester, palpable uterine contractions occasionally are painful and frequent in pregnancy.

The diagnosis of childbirth presupposes the existence of rhythmic contractions of a completely eliminated cervix and dilation of the cervix.

Physiological causes of abdominal pain in pregnancy:

Delivery. Ectopic Pregnancy. Ovarian cysts. Uterine torsion. Preeclampsia. Placental abruption. Acid fatty liver in pregnancy. Musculoskeletal Pain 20–30% of women refer experience lumbar pain and sacroiliac pain. Natural gases and bloating.

It is very likely that you will have pain caused by gas during pregnancy, due to hormones that slow down the digestion and increasing pressure of the uterus on stomach and intestines.

#### **6.1 Constipation**

Sexual intercourse remains one of most common causes of abdominal pain during pregnancy. It is known that the sperm contains prostaglandins, which can "activate" the uterus in some way after ejaculation in the vagina and cause its gentle contractions, which become even more noticeable after orgasm [40–42].

Another point, which means that abdominal pain does not seem to be associated with a serious problem, is its change depending on whether the abdominal pain decreases as soon as gas is released. Rather it is associated with a common and annoying phenomenon, which occurs during pregnancy -: bloating and constipation.

However, there are signs, which, combined with abdominal pain, during pregnancy, are a kind of "alarm" and need immediate investigation:

First of all, if 5 or more uterine contractions occur within an hour, then there is a possibility that premature birth is imminent and it is necessary to administer tocolytic treatment [40–42].

The combination of abdominal pain and vaginal bleeding at any stage of pregnancy is a point of concern. Vaginal bleeding of intense red color, in combination with abdominal pain, depending on the stage of pregnancy during which is, is a point that can hide, miscarriage, premature birth, ectopic pregnancy or placental abruption.

Finally, any abdominal pain during pregnancy, which is very intense, needs to be investigated immediately, because it may be associated with pathology of each of these pregnancies or with pathology independent of pregnancy, which needs immediate treatment. In fact, if this pain is associated with severe nausea and vomiting or fever, it may hide conditions such as appendicitis, nephrolithiasis or cholecystitis [40–42].

#### **7. Treatment of endometriosis and pain**

The treatment can be: 1) surgical, 2) conservative.

#### **8. Conservative pharmaceutical treatment**

In traditional laparoscopic surgery the percentage of recurrences or nonimprovement of symptoms is about 40%. Regarding the corresponding rate of conservative drug treatment, in a study by Waller and Shaw in patients receiving GnRH for 6 months, 30% of patients reported no improvement.

Medical doctors in the field of CPP usually use analgesics or non-steroidal antiinflammatory drugs or oral contraceptives or progesterone, but have not diagnosed endometriosis from the beginning.

The treatment that has been introduced and is considered as the second line, is GnRH analogues, usually after laparoscopy.

According to the American College of Obstetricians and Gynecologists, the treatment with GnRH analogues is an appropriate approach to failed diagnosis of the cause of pelvic pain [33–39].

#### **9. Traditional surgery treatment**

The traditional surgical treatment consists of destruction of the removal of the lesions from the ectopic endometrial tissue, mainly laparoscopically.

*Minimally Invasive Surgical Treatment of Pelvic Pain in Teenagers and Young Women DOI: http://dx.doi.org/10.5772/intechopen.97778*

If the problem is more dysmenorrhea, there is a high probability of lesions related to the uterine ligaments. In this case, the destruction of the ectopic localized endometrial tissue in the uterosacral ligaments laser can be used.

Also, the cross-section of the uterosacral ligaments with bipolar diathermy has been used.

There are 3 different types of ovarian endometriosis [25].


Laparoscopic treatment of ovarian endometriosis includes the following options:

1.Drainage

The chocolate cyst is aspirated and the cyst cavity is flushed. Postoperatively, subcutaneous injection of GnRH analogues (e.g. goserelin, etc.) is recommended at 0, 4, 8, and 12 weeks [25].


Foci of endometriosis smaller than 1 cm in diameter can be ablated, while endometriomas of 1-3 cm in size are treated as follows: In the beginning, an area is removed from the top of the cyst, the chocolate fluid is aspirated, the ovarian cyst is flushed, and is performed ovarian cystoscopy. Subsequently the inner wall of the cyst is ablated with CO2 Laser at 40 W, until the epithelial layer is damaged (Donnez technique) [25]. However, cauterization of the inner wall of the bladder can be done with monopolar diathermy, endocoagulation or Ultracision as well.

#### **10. Laparoscopic surgery IN CASE the ovarian torsion**

Ovarian endometriomas larger than 3 cm in diameter. The protocol proposed by Donnez and applied is the following:

During the diagnostic laparoscopy, a biopsy of the endometrium is taken, the area is rinsed, and then a GnRH analog is administered for 3 months.

A second laparoscopy is performed, and, if the bladder is less than 3 cm, it is ablated as previously described. If the diameter is larger than 3 cm, a part of the cyst is removed (partial ovarian cystectomy) and the ablation of the residual endometroid ovarian cyst is followed.

#### **10.1 Ovarian cystectomy**

Described by Semm. The contents of the ovarian cyst are first aspirated, followed by an ovarian cystoscopy of its inner surface. Then, by the guidance/ assistance of 2 pairs of contraction forceps, the cyst wall is detached from the ovarian tissue by rotating movements of the forceps that have captured the ovarian cyst wall, and with a movement opposite to the other forceps that has the opposite forceps.

If the ovarian cyst is firmly attached to the area of the ovary, after the remaining part of the ovary has been removed in the manner described above, the part of the ovarian cyst that is firmly attached the ovary may be exposed to CO2.

#### **10.2 Fenestration and ablation**

Fayez and Vogel argued that the removal of only one part of the endometrium, in combination with the laser ablation of the remaining part of the ovarian cyst, is associated with the development of fewer adhesions compared to the total removal of the ovarian cyst.

Absence of a thickened capsule around the endometrium makes it difficult to exclude the ovarian cyst wall, resulting in the loss of healthy ovarian tissue during ovarian cystectomy.

Thus, the exclusion of the endometrium through a Fenestration removal of 2 cm of the bladder wall and destruction of the endometrium, appears as the best therapeutic method of surgery on the ovary and the best on the ovary.

Laser laparoscopic treatment, according to Sutton's work, relieved symptoms in 71% of patients after 6 months - while 29% had no improvement. In the same study, one year after laparoscopic treatment, 56% of patients were symptom-free, while 14% had not improved or had relapsed [25, 40–45].

#### **10.3 Additional surgical procedures to treat endometriosis**

It has been shown that medication does not cure endometriosis, but makes it temporarily inactive, and that's seems to be the reason of the recurrence after discontinuation of the treatment. Various surgical approaches have been described, such as the use of the CO2 laser in relation to tissue separation and the use of bipolar diathermy.

The use of high-power CO2 laser in superpulse mode has the advantage of accurate tissue cross-section and the simultaneous achievement of hemostasis. On the contrary, the large area of thermal damage after electrocautery makes this approach less accurate, while the clear separation between healthy and abnormal tissue is more difficult. The evolution of the endoscopic equipment, which has been achieved during the last decade, as well the acquired experience and knowledge, have as a result the expansion of the indications of the laparoscopic surgery. The laparoscopic approach is an alternative to laparotomy, which is accompanied by clear and undeniable advantages. However, given that the resection of deep endometriosis is technically extremely difficult and requires vast experience, it is addressed to very few endoscopists. In addition, there are no prospective randomized trials comparing the laparoscopic approach to laparotomy [46].

*Minimally Invasive Surgical Treatment of Pelvic Pain in Teenagers and Young Women DOI: http://dx.doi.org/10.5772/intechopen.97778*

Laparoscopic surgery is performed by the method of triple puncture, while, when a CO2 laser is used, the surgical laparoscope is angular 12 mm for the diode of the laser beam that is inserted through.

The surgical technique involves separating the anterior surface of the rectum from the posterior surface of the vagina and cutting or sublimating the endometriosis. First, a complete and thorough separation of the anterior surface of the rectum is performed throughout the incision, until the loose tissue of the rectal space appears.

During this surgical step the endometrial catheter is pushed downwards in order to anteriorly inflate the uterus, while some endoscopes use water for separate the fluid from the uterus. After complete preparation, it is cut from the point of adhesion to the rectum. In cases of large infiltration of the vaginal wall, it is necessary to remove part of this vagina, but also the en bloc laparoscopic removal of the entire area followed by closure of the posterior wall of the vagina. In cases of significant degree of infiltration, partial resection of the intestine and final peritoneal anastomosis laparoscopically have been described. The anterior surface of the rectosigmoid junction after surgery is not lubricated, while Interceed can be used to cover the area to be removed. Also, the excision of the intestinal part is restored laparoscopically [46].

Candiani et al. report a decrease in dyspareunia and dysmenorrhea to 60% and 40% after 3.5 years. Candiani et al. also report partial - complete remission of chronic pelvic pain in 70% of patients and a recurrence rate of 5% in 5 years [47].

The pharmaceutical approach to pelvic pain with GnRH analogues also seems to be very adequate. However, the effectiveness of laparoscopic treatment is consider as the first line therapy.

#### **11. Conclusion**

The treatment of patients with endometriosis and chronic pelvic pain (COPD) is one of the most challenging situations in every day clinical gynecology medical practice. Chronic pelvic pain is a "key point" for a woman's quality of life.

Nowadays, the diagnosis of the endometriosis still remains difficult despite the knowledge we have acquired after years of study and research. Based on the above there is strong evidence, which supports the position that the pathogenesis of endometriosis is multifactorial, and is influenced by the interaction of genetic and environmental factors. The notion that endometriosis occurs in women with reduced immune function, which is related to genetic predisposition or environmental factors, seems more acceptable in the last decade.

The analysis of the biochemical function of the gene products will lead to a better understanding of the pathophysiology and etiology of endometriosis. New genetic markers can be used to identify high-risk women.

However, the design of epidemiological studies for predisposing factors of endometriosis is insufficient in terms of sample size and phenotype.

Basic research has laid the groundwork for new treatment protocols, particularly useful in women of childbearing age, as understanding pathology is helpful in designing a new improved but permanent treatment.

#### **Acknowledgements**

I would like to acknowledge warmest Professor George Iatrakis for supporting this research.

*Advances in Minimally Invasive Surgery*

#### **Author details**

Panagiotis Tsikouras1 \*, Christos Tsalikidis2 , Xanthoula Anthoulaki1 , Anna Chalkidou1 , Aggeliki Gerede1 , Stefanos Zervoudis3,4, Anastasia Bothou1 , Spyridon Michalopoulos1 , Georgios Dragoutsos1 , Nikolaos Panagiotopoulos1 , Fotini Gaitatzi1 , Ionnis Tsirkas1 , Irini Babgeorgaka1 , Theopi Nalbanti1 , Natalia Sachnova1 , Alexios Alexiou1 , Constantinos Nikolettos1 , Sebaidin Perente2 , Panagiotis Peitsidis4 and Nikolaos Nikolettos1

1 Department of Obstetrics and Gynecology, Democritus University of Thrace Medical School, Alexandroupoli, Greece

2 Second Department of Surgery, Democritus University of Thrace Medical School, Alexandroupoli, Greece

3 Technological Educational Institute of Athens, Athens, Greece

4 Rea Maternity Hospital, Athens, Greece

\*Address all correspondence to: tsikouraspanagiotis@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Minimally Invasive Surgical Treatment of Pelvic Pain in Teenagers and Young Women DOI: http://dx.doi.org/10.5772/intechopen.97778*

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#### **Chapter 4**

## Hysteroscopy, the Window into the Uterine Cavity

*Shani Naor-Revel, Ruth Goldstone and Ariel Revel*

#### **Abstract**

Hysteroscopy, is a technique by which we can look into the uterine cavity entering through the cervix and is today the most applied minimally invasive technique in Gynecology. Indications for hysteroscopy include infertility investigation, abnormal uterine bleeding, and evaluation of suspicious sonographic findings. Nowadays we approach the uterus via vaginoscopy with no anesthetic. Once inside the uterus, we remove polyps or stringless IUD and take a biopsy. These procedures are often referred as "see and treat". Operative hysteroscopy under GA or sometimes cervical block, uses larger instruments to resect myomas, cut a septum (metroplasty) or separate intrauterine adhesions (Asherman's). As Glycine is no more used in hysteroscopy it has become quite a safe procedure. Use of disposable scopes will enable this tool to be part of every gynecologic clinic.

**Keywords:** hysteroscopy, infertility, uterine bleeding, menorrhagia, metrorrhagia, intrauterine device, septate uterus, asherman's uterine adhesion, fibroids, endometrium, polyps, see and treat

#### **1. Introduction**

In 1950, doctors could expect medical knowledge to double every 50 years. By 2020, it will take just 73 days. How's a doctor supposed to keep up? [1]. Writing a chapter to a textbook is thus a challenge. Even if we succeed in being up to date by the time this chapter is published it might already be obsolete. The reader should thus read the chapter as an introduction and follow up on the topics read. As carrying out hysteroscopies requires manual training, we hope that the gynecologist reading our chapter will gain theoretical understanding along with his or her training first on a simulator before performing this procedure on real patients. We think that a gynecology resident should perform 100 diagnostic hysteroscopy procedures before attempting an operative one.

#### **2. History of hysteroscopy**

"Hysteroscopy" comes from the Greek terms hysteros meaning uterus and scopy meaning to look. Hysteroscopy enabled visualization of a narrow and dark space, which was difficult until the mid-nineteenth century. Endoscopy was invented by Bozzini in 1805. The first successful hysteroscopy however was performed 65 years later by Pantaleoni when he investigated the uterus of a 60-year-old patient complaining of postmenopausal bleeding. Bozzini detected a polyp in the uterus which


#### **Table 1.**

*Milestones in the development of the hysteroscope.*

he cauterized with silver nitrate. Bozzini died at 35 years of age from typhoid fever, and his attempts to improve the light conductor ended. **Table 1** mentions some of the pioneers that have contributed to the hysteroscope.

For distending the uterine cavity for operative hysteroscopy normal saline is used nowadays as it is significantly less dangerous than glycine when fluid loss occurs. Hysteroscopy today represents 200 years of significant innovations in instrumentation, new clinical applications for existing instruments, and continual modification of techniques, all aiming at observing, diagnosing, and treating pathologic conditions of the uterine cavity.

#### **3. Indications**

Indications for diagnostic hysteroscopy include many conditions where knowledge about the endometrial cavity is relevant to patient care but the scope of this chapter has not been able to go into depth for every indication. In **Table 2** we list the most common indications for the procedure as well as which tools are required and how long we recommend for such a procedure. This may help the team communicate with each other and referring physicians and the patients, where should the procedure be scheduled and how long it should take and which equipment is required for the procedure.

#### **3.1 Menstrual cycle bleeding**

Bleeding at menstruation (menorrhagia) or in between them (metrorrhagia). Postmenopausal bleeding should include a blind biopsy. Patients with bleeding under hormonal replacement therapy should be examined. A frequent referral are patients on continuous Tamoxifen therapy [2]. Bleeding under medical therapy requires a pathological sampling to exclude malignancy. Pipelle ® sampling has 100% sensitivity and specificity to detect malignant cells [3].

Heavy menstrual bleeding is a significant health problem in pre and perimenopausal women. If no pathology is diagnosed using diagnostic hysteroscopy and biopsy, patients should be counseled about treatment which could be hormonal and non-hormonal. As medical therapy is not always successful, Endometrial ablation may be an alternative to hysterectomy that preserves the uterus. Many techniques have been developed to ablate the endometrium. First-generation techniques require visualization of the uterus with a hysteroscope during the procedure.


#### **Table 2.**

*Inpatient or outpatient indications for hysteroscopy, device and time needed to complete the procedure.*

Second- and third-generation techniques are quicker than previous approaches because they do not require hysteroscopic visualization during the procedure. Decision as to visual or blind procedure is based on the skills of the surgeon and on the size of the uterus. Results and patient satisfaction appear to be similar [4].

#### **3.2 Postpartum or post miscarriage/induced abortion bleeding**

Postpartum bleeding raises a suspicion of placental remains. There also may be bleeding due to retained products of conception following an abortion either spontaneous or induced for medical reasons.

#### **3.3 IUD related**

Common referral to hysteroscopy is to remove an IUD. In cases where the strings are not apparent referral to hysteroscopy is preferable to the patient than attempting blind instrument IUD extraction.

#### **3.4 Suspected malignancy by sonography**

Often the indication is sonographic findings such as suspicion of submucosal uterine fibroids, adenomyosis, endometrial cancer. It should be stressed that following removal of a polyp and diagnosis of malignancy it is obligatory to plan hysterectomy even if the rest of the cavity seemed normal in hysteroscopy. In an Israeli study, residual complex atypical hyperplasia (CAH) or endometrial cancer (EC) was present in 89% of the hysterectomy specimens, mostly (55.6%) as multifocal lesions [5].

#### **3.5 Asherman's**

Hysteroscopy is currently considered the gold standard diagnostic and therapeutic approach for patients with intrauterine adhesions [6]. An integrated approach,

including preoperative, intraoperative, and postoperative therapeutic measures, however, are warranted owing to the complexity of the syndrome.

#### **3.6 Fibroid, septate uterus**

Hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI and IVF may improve the clinical pregnancy rate compared to simple diagnostic hysteroscopy [6].

#### **3.7 Primary/secondary infertility; assessing tubal patency**

Hysteroscopy should be part of evaluation of primary and secondary infertility [6]. The performer should investigate and describe the uterine shape to exclude a septate uterus or other Mullerian abnormalities of the uterus, the endometrium to exclude intrauterine synechia (adhesions, Asherman's) and atrophy. Moreover an attempt to pass bubbles via the tubal ostia determines tubal patency [7].

#### **3.8 Habitual abortions/recurrent pregnancy loss (RPL)**

When a woman has 3 or more consecutive spontaneous abortions we recommend evaluation which includes a diagnostic procedure to evaluate the uterine cavity. Office hysteroscopy, is the easiest and most informative tool to investigate possible intrauterine abnormalities such as septate uterus or intrauterine adhesions or a polyp in patients with RPL or recurrent implantation failure (RIF).

#### **3.9 Niche**

Control examination of the uterine cavity after operations on the uterus such as cesarean to see the niche, curettage to evaluate whether there are remains, Asherman's to evaluate the reappearance of adhesions. Following metroplasty for septate uterus it is good practice to evaluate the cavity by hysteroscopy to confirm if postoperatively the uterine cavity is fit for pregnancy. In some cases, a reoperation is required to complete cutting an extensive septum. Also, following myomectomy it is recommended to repeat hysteroscopy to judge whether there are any remnants of the myoma and that no postoperative adhesions have formed.

#### **4. The hysteroscopy team**

The hysteroscopy clinic enables patients to undergo the procedure in the office setting. Patients can continue their day plans without need to cancel pleasure activities or work. The team involves administrative, nursing and the physician. It is quite important for the team to work in a concerted way so that the patient arrives at the correct time and the correct equipment is ready for the procedure.

#### **4.1 The administrative assistant**

An experienced secretary is an important player for a well-orchestrated team to work coherently. When a patient calls in for an appointment, you should transfer the call to a dedicated secretary and follow a planned call questionnaire. The most important question is asking about the date of the patient's last menstrual period. In premenopausal women, hysteroscopy should be performed between days 7–11 following the beginning of the menstrual period. This achieves a certainty about our patient not being pregnant and the lining of the uterus is thin, in order to see a good view of the uterus. The patient is advised to eat before coming to the clinic to reduce the complication of a low blood sugar or weakness after the procedure.

In case of doubt the patient is required to carry out βhCG in the blood before coming the clinic. if this was not performed, a urinary pregnancy test to ensure βhCG is negative. Moreover, it is easier to introduce the scope during menstruation as the cervix is slightly relaxed.

#### **4.2 Nursing**

Dedicated and professional nursing is an integral part of hysteroscopy. We find it quite efficient to have three nurses working with the physician hysteroscopist in the diagnostic and in the see and treat hysteroscopy clinic. One nurse sits with the patient and explains to her the procedure and prepares her for the signing of the informed consent with the physician and to offer the patient oral analgesia before the procedure.

The second nurse will be assisting the physician during the procedure making sure that the equipment is sterile, connecting the light cable and the normal saline to the scope as well as handing over surgical tools such as grasper or scissors to perform a 'see and treat' procedure and to ensure the wellbeing of the patient. The patient will be seated and covered by the nurse and at the end of the procedure the nurse will ensure that the patient safely descends from the gynecological chair and is able to go and get dressed on her own.

The third nurse oversees sterilization of the hysteroscope optics and sheaths.

It is recommended for a busy clinic to have quite a few both diagnostic and 'see and treat' scopes. We usually schedule a dozen patients per clinic morning, sterilization must thus be carried out in parallel to performing the procedures so that unprepared equipment is not the bottleneck of the clinic. It is recommended that the hysteroscopy clinic nurse attends courses given to physicians or to nurses about hysteroscopy, its indications, contraindications and how the procedures are performed. Teaching a new nurse should be done by an experienced nurse to ensure that safety and efficacy are carried out. Only after such training should a new nurse assist a hysteroscopy clinic. In the UK, a nurse hysteroscopist performs diagnostic procedures [8]. In Israel and to the best of our knowledge in mainland Europe and North America however, only physicians are licensed to carry out invasive procedures on live patients.

Before signing the informed consent, the nurse briefs the patient on the hysteroscopic procedure. Main points explained are the following:


#### **4.3 The Gynecologic surgeon**

A hysteroscopist is usually a certified gynecologic surgeon. There is mounting evidence in the surgical literature to support the use of skilled labs outside of the operating room for resident training and indeed simulation is the key point for an appropriate surgical learning [9]. It is necessary to improve the quality of the simulators by enhancing or introducing tactile feedback [10].

The physician must carry out three main duties prior to beginning hysteroscopy. Firstly, review the patient's medical, gynecological, and obstetrical history in general and the reason for referral to the procedure.

Secondly, explain the indication to the patient and thus discuss expectations. For example, if it is to evaluate the endometrial cavity prior to embryo transfer, or to remove an IUD. Another example is suspicion of postpartum residual placental tissue where it should be clear that we will need to schedule an operative procedure as the amount of tissue to be removed exceeds possibility by see and treat equipment.

Thirdly the physician is responsible to rule out an ongoing pregnancy. In case of any suspicion, the patient performs a urinary or blood hCG.

It is imperative that the doctor detail and explain the very rare complications of a procedure prior to starting surgery. The physician should make sure the patient understands that there are rare complications in less than 1% of cases. Anesthesia if used, has rare complications. Intrauterine infection is a contraindication for hysteroscopy. Perforation of the uterus can occur and should be diagnosed immediately by the gynecologist. In such complication the patient will be evaluated to rule out possible damage to her bowel, blood vessel or bladder. Intrauterine adhesions may occur following operative surgery, especially for large lesion such as a myomectomy. With the use of normal saline as distending medium there are no adverse reaction to the distention media as was seen sometimes with Glycine or Dextran. After reviewing such these rare complications, the physician and patient are now ready to sign an informed consent form.

#### **5. The equipment**

Equipment that is needed to perform diagnostic hysteroscopy includes the fibreoptic scope, a light cable, and the camera. The camera is connected to a screen. It is recommended to have a camera and a printer to capture and then insert pictures into your operative report. Through an operating channel mechanical tools can be inserted to carry out a 'see and treat' procedure in an outpatient setting [11]. Moreover, the advent of new technologies is further changing the approach of outpatient hysteroscopic surgery. Some procedures that in the past required cervical dilatation to introduce the resectoscope can currently be perfomed using a thin hysteroscope [12].

For all purposes we use a 1.9 (2.8 with sheath) millimeter rigid hysteroscope. For the see and treat the diameter is 4.2 millimeter with the scope of 2.9 millimeter. We find those scopes are well tolerated even by nulliparous or postmenopausal patients.

#### **5.1 Distension of the uterine cavity**

Currently we use normal saline for all our hysteroscopic procedures. The use of Glycine is dangerous as it may cause hyponatremia [13]. For the diagnostic procedure the one- or three-liter bag of normal saline flows using gravity is used. It is however easier to use a balloon handpump as sometimes the patient has blood clots in the uterine cavity that need to be flushed out so the gynecologist can see the endometrial cavity.

#### **5.2 Single use scopes**

Clinics commonly perform hysteroscopy with multiple use equipment. Recently single use hysteroscopes have been developed (Neoscope or Lina operascope). This may be a suitable option at a gynecologist office where few procedures are performed.

#### **5.3 Hysteroscopy tissue removal systems**

Hysteroscopic tissue removal systems (Truclear®, Myosure® or IBS®) may offer an advantage in successful removal of pathology and shorten total operation time.

#### **6. Hysteroscopic method**

For purpose of clarity, we will describe how to perform outpatient and inpatient procedures, separately.

#### **6.1 Outpatient hysteroscopy**

In order to overcome the sensation of pain caused by speculum and tennaculum among patients undergoing office hysteroscopy the vaginoscopy approach (no touch) was first proposed by Bettocchi [14]. The method uses no insertion of speculum nor any instruments to grasp the uterine cervix. The performer uses vocal analgesia. This means that you keep talking to your patient while performing the procedure and not necessarily showing her the instruments that you use. The patient is encouraged to look at the screen and be part of the procedure. In a randomized trial, oral analgesia was shown to reduce pain [15].

The patient is covered in lithotomy position with her legs comfortably in stirrups. There is no need for scrubbing nor washing. Following digital gentle separation of the major labia and gently inserting the tip of the hysteroscope, the performers eyes are then reverted to the screen while filling the vagina with normal saline.

At this point the cervix should be located. Usually, the uterine cervix will be found in the posterior part of the vagina, you then direct the scope to the opening of the cervix and gently land on it with your scope in order to enter. The rigid hysteroscope needs to gently enter into the cervical canal. The scope has a 30 degree angle and therefore while going through the cervical canal the opening of the canal should be seen at 6 o'clock and gently slide along the cervical canal until the inner os of the uterine cavity is observed. In a retroverted uterus this is the opposite, the hands should be reversed and therefore the opening of the cervix will be seen at 12 o'clock. When the uterus is very introverted you could use your hand to put a little suprapubic pressure on the uterus in order to straighten it. You can use one hand at this step in order to enter the uterus and if needed ask a nurse to apply the suprapubic pressure or even the patient herself. The entry to the uterine cavity should be performed very slowly and carefully watching in order to prevent pain and in order to avoid the possibility of entering forcefully and causing a perforation. Throughout the procedure the patient should be relaxed. The physician should perform all actions slowly using the left hand to hold the camera in a fixed position while the scope with a 30 degree angle is moved along the longitudinal axis, observing the right wall then the anterior wall, then the left wall and then the posterior wall. All these should be done by rotating the attachment of the light cable to the hysteroscope, Taking pictures is recommended.

The whole procedure is performed very slowly., retracting the scope looking on the exit at the lower anterior wall of the uterus. This is especially relevant in patients who had a previous cesarean section, in order to observe if there is a niche. Looking at the cervical canal can give some information about the possibility of a polyp. The instrument is then removed from the vagina. The whole procedure should take no longer than one minute.

#### **6.2 See and treat**

Performance of diagnostic and operative procedures for gynecological conditions in the consultation room setting is becoming increasingly commonplace to reduce risks of general anesthetic, decrease healthcare costs and increase convenience for both patient and gynecologist. Diagnostic hysteroscopy is performed using the required instrument (e.g. scissors or grasper) on standby inside the working canal. Intrauterine contraceptive device (IUD) removal or its fragments is a common referral. Use of small diameter hysteroscopes and resectoscopes allow these procedures to be performed as a single stage "see-and-treat" hysteroscopy in the comfort and safety of an office-based setting.

#### **6.3 Operative**

Hysteroscopic surgery has become the standard of care to treat benign intrauterine disease in pre-menopausal and even postmenopausal women. The various hysteroscopic procedures have been shown as safe and highly effective to treat lesions such as submucous myomas, endometrial polyps, uterine septa and intracavitary adhesions.

Operative hysteroscopy is performed in the OR and thus offers advantages and disadvantages. Advantages include the possibility to remove large pathologies from the uterine wall. The operative hysteroscope is inserted following dilatation of the uterine cervix to hegar dilator 10-10.5 under general anesthesia.

There are 3 parts to the operative procedure. First the dilatation of the cervix. This might turn out to be the risky part and indeed most complications occur at this step [6]. The second part deals with the pathology, whether it be using the loop to resect a polyp or type 0 submucosal fibroid [pedunculated fibroids without any intramural extension]. It is more difficult to remove a type 1 [submucosal with minor intramural] fibroid. Type 2 fibroids [mostly intramural, the angle with the endometrium is>90°] should not be removed by hysteroscopic surgery.

#### **7. Analgesia**

With new hysteroscopes, it is possible not only to examine the cervical canal and uterine cavity but also to perform biopsies or treat benign diseases in a relatively short time, without any premedication for anesthesia. This is because the sensory innervation of the uterus mainly regards the myometrium, while the endometrium and the fibrous tissue of septa and synechiae are almost insensative [16]. Preventing pain is very important.The pain is caused by distending the uterus and mostly in the cervical canal.

#### **7.1 Analgetics**

The use of rectal indomethacin, ropivacaine or levobupicavaine diluted in the saline distension medium, the use of multimodal local anesthesia as well as the use of premedication by means of diclofenac potassium or tramadol are all effective methods to reduce pain. There is a lack of consensus on the choice of analgesia for

outpatient hysteroscopy, with a recent meta-analysis and systematic review suggesting oral nonsteroidal anti-inflammatory drugs and transcutaneous electrical nerve stimulation (TENS) for pain relief [17].

#### **7.2 Preparation of the cervix with vaginal misoprostol**

Giving low-dose (25 mcg) Misoprostol before the procedure may soften the cervix sufficiently to allow an easier and more successful test. This medication has been tested before intrauterine procedures including hysteroscopy and, in some patients, it has been shown to be beneficial. Cervical priming facilitated hysteroscopy by dilating the cervix, allowing for easier entry and reducing procedural time. Administration of a cervical preparation, however, increased the risk of adverse effects, namely genital tract bleeding, abdominal pain/cramping and gastrointestinal disturbance [18].

#### **7.3 Distraction techniques**

Non-pharmacological options of pain relief at outpatient hysteroscopy include music, hypnosis, adjusting the temperature and pressure of distension medium, stretching of the uterus with a full bladder and electricity via TENS. What we usually do is to have a cheerful conversation with the patient, and we suggest controlled breathing in order to relax the body. It is helpful to suggest to the patient to watch the screen as we explain what we see. Since this chapter is written during the covid-19 pandemic we do not allow the partner to join the patient. Somewhat surprisingly we are under the impression that this has resulted in reducing patient stress.

#### **7.4 Virtual reality**

Virtual reality (VR) was suggested as a distraction technique for non-pharmacological pain relief. It is a computer-generated representation of an immersive environment viewed through a headset. VR is effective in reducing pain and anxiety during outpatient hysteroscopy [19].

#### **8. Contraindications**

Hysteroscopy is contraindicated in patients with Pelvic infection, Pregnancy, Cervical cancer or Heavy uterine bleeding. If the contraindications to hysteroscopy are observed, complications should be rare.

#### **9. The hysteroscopy reports**

The medical report represents one of the most critical steps not only from a legal, medical point of view but also for the patient and other health professionals. It should first include the description of the instruments used: hysteroscope, optics, distension medium, and any mechanical or energy tools. Subsequently, the technique used for access to the cervical canal should be reported, plus the morphology of the cervical canal and the uterine cavity should be carefully described. We report the visualization of both the tubal Ostia and whether they appear patent by passing bubbles. Findings such as polyps, fibroids, adhesions, or a septum should be described in detail. This includes location, size, vascularization, and severity. At the end of the report, your patient should receive

recommendations. If surgery is required it should be stated and a referral for surgery added. In patients undergoing infertility treatment it should be added when the exam is normal that the uterus appears to be compatible for pregnancy. This will indicate to the patient and the infertility team that it is recommended to proceed with IVF or other methods used.

Before discharge, all information written in the letter should be explained to the patient and questions should be answered in detail so that the patient has all the information required for further treatment.

#### **10. Complications**

Morbidity and even death have been reported after hysteroscopic interventions [20, 21].

#### **10.1 Adhesions resulting in defective endometrial receptivity**

Hysteroscopic resection of a polyp, fibroid or placental pregnancy products is frequently performed to increase IVF success rates. Moreover, a septate uterus may hinder pregnancy following embryo transfer. Hysteroscopic adhesiolysis is the gold standard intervention to treat intrauterine adhesions.

Nevertheless, intrauterine procedures by themselves may cause defective endometrial receptivity [22].

We thus carry out the procedure with paramount prudence so as not to harm normal endometrium nor cause adhesions. In patients who have children, it is crucial to know before surgery if the patient has completed her family plans. For example, if a patient in her 40's has perimenopausal menorrhagia is undergoing hysteroscopic polypectomy the operation would be carried out in different mode whether she wants to preserve her fertility potential or not. This should be described in her informed consent. Some have claimed that endometrial thickness is narrower following polypectomy. We have looked into this and have found that our pregnancy rates were higher despite a mild postoperative decrease in endometrial thickness [23].

#### **10.2 Perforation of the uterine wall**

The most common complication of hysteroscopy is uterine perforation (approximately 1%) which can occur with a blunt instrument (uterine sound, dilator, curette, hysteroscope) or during the use of an energy source such as electrosurgery (i.e., inappropriate use of electrodes), with a possible injury of the surrounding organs (bladder, bowel, vessel) resulting in catastrophic consequences. An alternative to the utilization of a thermal energy source during hysteroscopic surgery is the use of mechanical energy such as scissors or intrauterine morcellator (IUM) to treat benign pathologies such as polyps, myomas, and retained products of conception.

#### **10.3 Infection**

The prevalence of infections following in-office hysteroscopy is low (0.06%) [24]. routine antibiotic prophylaxis is thus unnecessary before hysteroscopy. Patients should be counseled that if they have fever following an hysteroscopic procedure they should contact your office or out of hours go to the gynecology emergency room.

*Hysteroscopy, the Window into the Uterine Cavity DOI: http://dx.doi.org/10.5772/intechopen.99069*

#### **10.4 Bleeding**

In most patients, we performed the procedure on the last days of the menstrual cycle therefore bleeding is still present before and after hysteroscopy. The patient should be informed that mild bleeding is normal after the procedure nevertheless if severe bleeding ensues or continues the patient should contact the clinic or out of hours go to the emergency room to exclude a serious complication from the hysteroscopic procedure. In diagnostic hysteroscopy we perform a procedure using the new vaginoscopic approach, therefore in most cases there is no bleeding at all from the procedure itself. In inpatient hysteroscopy. anesthesia we use the tenaculum and Hagars to dilate the cervix, therefore bleeding results mostly from the surgical intervention. Also following the removal of fibroids or polyps some bleeding is expected, although this should stop within a few hours following the procedure. In some cases removing a large fibroid leaves a large area of exposed blood vessels and attempts should be made during the procedure to obtain hemostasis using coagulation. If bleeding continues the physician may introduce an intrauterine Foley catheter and inflate it, which should be removed an hour later. In most cases, this stops the bleeding and patient is discharged home only after evaluation that there is no substantial bleeding after surgery.

#### **11. Cost**

In Israel, most procedures are performed in the HMO setting and therefore it is free for our patients. According to the Israeli ministry of health price list the reimbursement for a diagnostic hysteroscopy is 606 NIS whereas, for a surgical procedure the reimbursement is 1,104 NIS.

In USA, the cost of a hysteroscopy ranges from \$750-\$3,500. The cost depends on the extent of the procedure. For instance, a diagnostic-only procedure is much less than one involving surgery. The cost may be higher for a more extensive procedure which includes surgery in the hospital and general anaesthesia. Costs for these extensive procedures can be up to \$7,000. Some US health insurance carriers will cover a hysteroscopy, at least partially.

 In an Italian paper [25], total hospital costs for polypectomy with all systems were significantly less expensive in an office setting compared with same-day surgery in the hospital setting (p=.0001).

#### **12. Conclusions**

Hysteroscopy is an essential part of the gynecologist's toolbox. Nowadays, hysteroscopy is the gold standard for the diagnosis and treatment of intrauterine pathologies as it represents a safe and minimally invasive procedure that allows the visualization of the entire uterine cavity. It is an inexpensive however valuable method. Cervical preparation before examination with vaginal misoprostol reduces pain during outpatient hysteroscopy and can be offered particularly to nulliparous or postmenopausal patients. Hysteroscopy requires certain skills and experience and is not exempt from complications, especially in unexperienced hands. The report should describe the method used to perform the procedure and then the relevant findings. This includes the shape of uterine cavity, the endometrium, and the right and left ostia. In infertile patients, describe whether bubbles travel through the fallopian tube openings. Gynecologist should be familiar with this tool for better evaluation and treatment of their patients.

#### **Acknowledgements**

Rabbi Yitchok Melber for kindly reviewing the manuscript.

### **Conflict of interest**

The authors declare no conflict of interest.

#### **Notes/thanks/other declarations**

This paper is dedicated in memory of my friend Dr. Yaron Aaron Hamani, MD. A dear friend and a fine gynecologist who passed away at young age.

### **Author details**

Shani Naor-Revel1 \*, Ruth Goldstone2 and Ariel Revel3

1 Shamir Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

2 Misgave Ladakh Hospital, Meuhedet HMO, Jerusalem, Israel

3 Division of Reproductive Endocrinology and Infertility, Shamir Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

\*Address all correspondence to: shaninaor3@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Hysteroscopy, the Window into the Uterine Cavity DOI: http://dx.doi.org/10.5772/intechopen.99069*

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### Section 3
