Outpatient surgeries that can be done in the office or at the hospital are considered “minimally invasive” if a patient can be discharged or sent home after the procedure and do not typically stay for longer than 6 hours. These surgeries include dilatation and curettage, hysteroscopy, laparoscopy and endometrial ablation. Descriptions of each and what they entail are to follow.
Dilation and Curettage (D&C)
This is a procedure used to evaluate or remove the contents/lining of the uterus called the endometrium. It is performed for irregular or abnormal bleeding, incomplete miscarriage, to detect uterine cancer and for abnormal radiographic findings.
This procedure is performed with anesthesia but may involve local anesthesia consisting of a uterine block (paracervical block) or with a general anesthesia in which you are completely asleep. You must discuss your anesthesia options with your physician before the procedure. After anesthesia is placed, the patient is then placed in stirrups and a speculum is placed in the vagina and the cervix is opened or dilated to allow entry into the uterine cavity. This dilation may occur prior to surgery with placement of seaweed rods, “laminaria” in the cervix or by using softening agents like cytotec placed in the vagina. These agents take an extra visit but decrease the chance of cervical laceration that can occur with mechanical dilators. After dilation of the cervix, the lining of the uterus is removed with either a curette or by suction. The tissue is then sent to the lab for evaluation and will generally take 7 days for results.
Risks of this procedure are rare, but may include bleeding, infection, injury to the cervix causing weakness in the future, uterine scarring or perforation and incomplete removal of tissue. If heavy bleeding, fever, significant pain or changes in your menstrual cycles occurs, you should call and discuss with your physician. Return to normal activities and avoiding anything in the vagina for 1-2 weeks are typical post-op instructions.
This is a procedure used to look into the uterine cavity with a lighted camera/scope. It is placed into the uterine cavity through the cervix and anesthesia and dilation of the cervix is also done as above with a D&C. This is a direct look into the uterine cavity to evaluate an abnormal ultrasound for a polyp or fibroid or to evaluate abnormal uterine bleeding. A directed biopsy can be taken at the same time to evaluate abnormal bleeding. Hysteroscopy can also be used for removal of a uterine septum, polyp or fibroid, removal of an IUD, removal of adhesions or to accomplish sterilization with placement of coils or plugs in the fallopian tubes.
This procedure is performed similar to a D&C with the same positioning, possible cervical dilation, anesthesia and risks. Hysteroscopy differs in that it is a “direct look” into the uterine cavity and is not meant to remove as much of the uterine lining as a D&C.
Laparoscopy is a procedure done without making a large incision. Instead several small incisions (0.5-1 cm) are made on the abdomen to allow a lighted camera to view the pelvic organs and instruments are used to treat a woman’s symptoms of pain or infertility. This minimally invasive surgery can be used to address endometriosis, fibroids, ovarian cysts, adhesions, ectopic pregnancy and sterilization on an outpatient basis, but is performed at the hospital and not in an office setting.
A general anesthesia is generally used due to the need for ventilation given the dynamics of the surgery. During the procedure the abdomen is distended with gas (carbon dioxide) to allow better visualization and movement of pelvic organs. Through the other incisions, instruments may be used to address the type of procedure needed.
Laparoscopy is a safe procedure, but there are possible complications and risks tend to be directly related to the complexity of the procedure. Possible complications include bleeding, hernia (bulging at incision site), infection, damage to blood vessel or organ (stomach, bowel or bladder) or complications from anesthesia.
Recovery from laparoscopy is generally just a few days, but may be longer depending on the complexity of the surgery. The use of gas to distend the abdomen can cause right shoulder pain and bloating and may take a couple days to resolve. Anesthesia may also cause a sore throat, make you feel light-headed or dizzy and may cause nausea with vomiting. If you experience these symptoms over a couple days or fever with unusual drainage, you should call your physician for evaluation. You will need someone to take you home from the hospital and must avoid heavy lifting or exercise for several days to a couple weeks.
Sonohysterography is done to evaluate abnormal bleeding, infertility or repeated miscarriage. This is a procedure done in the office with transvaginal ultrasound and is generally performed without anesthesia. Minimal cramping maybe experienced during the procedure and it is generally recommended that 400-600mg of ibuprofen be taken one hour prior to the procedure. The procedure involves placement of a small catheter (1 mm) through the cervix and saline (2-3 cc) is injected into the uterine cavity. This uterine cavity distention is used to diagnose fibroids, polyps, scarring of the uterine cavity, abnormal uterine shape and thickening/irregularity of the lining of the uterus that may be causing abnormal bleeding. This procedure should not be done with heavy bleeding, pregnancy or active pelvic infection. Risks are minimal but a patient may drive home after the procedure and spotting for up to 10 days may occur.
HSG is a procedure done in the office or in a radiology facility to diagnose problems of infertility or pregnancy. It can be used to document uterine cavity abnormalities or patency of fallopian tubes. It can also be used to document closure of fallopian tubes after a sterilization procedure. No anesthesia is needed and is performed like a sonohysterogram with injection of a dye instead of saline with the same risks and contraindications. Transvaginal ultrasound is not used, but an X-ray of the dye filling the uterus and fallopian tubes is seen directly with a machine positioned above the abdomen when a patient is lying flat on a table. Minimal cramping with infusion of the dye can occur and ibuprofen should be taken one hour prior to the procedure. It is also contraindicated with pregnancy, pelvic infection and heavy bleeding and should be performed after menses has finished.