Procedure Information

Procedure InformationPlease find below detailed explanatory notes regarding many of the operations I commonly perform. Note that the exact conduct of YOUR procedure may vary slightly to that in the notes, due to the demands of your particular circumstances. The same disease will affect different people in different ways! I hardly ever perform exactly the same operation twice and am constantly updating as new technologies and research becomes available.

Analgesic (pain relief) after surgery

It is well known that post procedural and post discharge pain is not well managed. This is because patients, once discharged from hospital, lack daily interaction with doctors and nurses who are able to help them with choice and administration of pain relieving medication. In addition, it is common to be confused about the various forms of analgesia available and how they may be used. The following is general advice regarding the principles by which you may manage your analgesics at home.

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Bartholin’s cyst / abscess (removal and marsupialisation)

The Bartholin’s glands are approximately 1.0 x 2.0 cm glands situated at the rear aspect of the vagina underneath the skin. Their normal function is to produce secretions which lubricate the vaginal mucosa. Rarely, the duct (canal) that leads to the surface can become blocked resulting in the gland accumulating mucous. Often this goes unnoticed until the gland becomes infected, forming an abscess, which results in acute pain and discomfort. The procedure employed is to either remove the gland in its entirety, drain the gland or marsupialise the abscess.

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Caesarean section

A Caesarean Section is an operation to remove the baby from the uterus via a sideways or vertical incision in the lower abdomen just above the hairline followed by an incision in the uterus. The baby and placenta are removed through the same incision. Occasionally obstetric forceps are used to ease the baby out through the wound. Reasons for caesarean sections may include maternal choice, elective repeat caesarean section, non-reassuring status of the baby during labour, difficulties with labour, an abnormal uterus or placenta or suspected difficulties in giving vaginal birth due to the baby or mother’s condition.

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Care of surgical wounds

The following is intended to be general advice regarding the care of surgical incisions. Your particular circumstances may vary. In general it is not possible to make wounds heal any faster than is naturally possible, however it is possible to remove potentially harmful factors that may slow healing.

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Colposcopy

If you have had an abnormal Pap smear or symptoms that may suggest an abnormality of the cervix you require a colposcopy to gain further information and to plan your further treatment, if any is needed. This is an examination of the cervix, or mouth of the uterus (womb) with a purpose-built microscope.

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Copper containing IUCDS: Multiload CU 375 or Copper-t 380A

IUD stands for intra-uterine device. Otherwise known as IUCD. An IUD does not guarantee absolute protection against pregnancy but it is very effective. Pregnancy rates are less than 1% per year. There is no “user error” component. It works as soon as it is inserted.

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Cystoscopy

Cystoscopy is a procedure to examine the inside of the bladder using a 5mm diameter rod lens telescope attached to a video camera. Cystoscopy is frequently carried out to investigate pain when passing water, pain with a full bladder, urgency, and incontinence or as an investigation for non-specific pelvic pain.

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Diagnostic hysteroscopy and curettage

Diagnostic hysteroscopy is a procedure to examine the inside of the uterus using a 5mm diameter rod lens telescope attached to a video camera. Curettage refers to passage of a narrow metal spoon-like instrument through the cervix or mouth of the womb to take a sample from the endometrium.

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Diathermy of condylomata (warts)

Genital condylomata (singular, condyloma) are very common, and caused typically by Human Papilloma Virus (HPV) types 6 and 11. The wart virus is found on up to 75% of people sometime in their lives. The virus is transmitted by physical contact involving the genital area.

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Endometrial ablation (roller ball)

The purpose of endometrial ablation is to lessen or stop menstrual flow. There must be no plans to conceive afterwards as this procedure is essentially sterilizing – but must not be regarded as contraceptive in itself. For this reason the procedure is often combined with tubal ligation. A 5 mm diameter rod-lens telescope with a channel for instruments, attached to a video camera is passed through the cervix (or mouth of the womb). Occasionally a laparoscopy is required at the same time. The roller ball device is attached to a diathermy current (electricity) which burns away the lining of the uterus (endometrium).

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Female sterilisation / tubal ligation

Female sterilization is performed to achieve permanent birth control, which is irreversible. You should not have the operation if you uncertain about whether or not you will want further children and it should be assumed that this operation cannot be reversed. Sometimes the clips can be removed and the fallopian tubes re-joined by microsurgical technique although this is successful in achieving a live pregnancy in less than 50% of cases. The procedure is usually performed laparoscopically.

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Labioplasty

Sometimes the inner labia (labia minora) are too large and this causes difficulty and discomfort whilst wearing certain clothes and during activities such as sex, cycling, horse-riding etc. The appearance itself may be distressing or embarrassing. The labia minora often then take on a “rugous” or hyperkeratotic appearance which means that the skin is reacting to the increase in physical trauma or friction. It is a straightforward procedure, in most cases, to achieve functional and cosmetic improvement.

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Laparoscopy

A surgical procedure in which a fibre-optic instrument is inserted through the abdominal wall to view the organs in the abdomen and pelvis or to perform an operation. Laparoscopic surgery has come to present the cutting edge of many surgical techniques and is now at a stage where there a very few abdominal and pelvic operations that cannot be performed advantageously carried out via laparoscope.

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Laparoscopic treatment of Fibroids – (Laparoscopic Myomectomy)

Laparoscopic Myomectomy is a surgical procedure in which a fibre optic instrument is inserted through the abdominal wall in order to remove uterine leiomyomata (fibroids). There are many reasons for removing fibroids, which will vary from person to person in their type, size and significance. In the vast majority of cases where removal of fibroids is required, a laparoscopic route is appropriate.

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LLETZ

Under general anaesthetic, you will have a colposcopy (microscope examination of the cervix) in order to carefully delineate the extent of the abnormal cells on your cervix. The aim of the procedure is to remove the abnormal cells in their entirety and to invoke an immune response which will tidy up any residual cells. The procedure is performed to prevent the possible progression of abnormal cells to frank cervical cancer. A small amount of tissue, around the size of the tip of your finger, is removed from the centre of the cervix then sent to pathology for examination.

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Long term sperm storage

Over the past 10 to 15 years technology has advanced so that now it is possible to store sperm at very low temperatures, in liquid nitrogen, almost indefinitely. The sperm are processed and stored in a special medium before freezing. There is some small loss of sperm quality on thawing but the sperm still remains functional and suitable for use.

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Insertion of progesterone releasing intra-uterine device (MIRENA)

While invented as a contraceptive device, the Mirena is more commonly used in order to control period pain or heavy periods. The Mirena device is a small T-shaped white plastic IUD containing progesterone hormone which has a beneficial effect on menstrual flow, period pain and provides contraception. The Mirena device comes from the manufacturer loaded in a 4 mm diameter plastic tube which is passed into the cervix or mouth of the womb either under anaesthetic or in the doctor’s office. The Mirena is deployed from the end of the plastic tube and remains in the uterus.

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Instructions after laparotomy (abdominal surgery)

Laparotomy comes from the Greek “lapara” (flank) and “tomy” (cutting). It is the general term given to a cut in the abdomen to look inside and achieve some kind of surgical end. This approach may be used to correct problems with uterine fibroids, very large ovarian cysts, or to deal with any other issue requiring direct access to the abdomen. It always requires a sleeping (general) anaesthetic. The cut may be sideways on your lower abdomen (commonest gynaecological approach) or elsewhere depending on how much room and what access is required.

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Minor vaginal procedures

The following notes cover minor vaginal procedures such as excision of skin tags/ lumps and bumps, hymen repair, excision of Gartner’s Duct cyst, hymenectomy and hymenotomy, and repair of labial tear.

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Monarc Sub-urethal Sling

The Monarc sling is a minimally invasive operation, often combined with a vaginal repair, to correct stress urinary incontinence (SUI). The sling supports the mid portion of the urethra in a “tension free” fashion, ie it only acts when lifting/ straining/ coughing. This technique has been shown to improve stress incontinence in over 90% of cases in short term follow up (5 years).

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Novasure Ablation

The purpose of the Novasure ablation is to lessen or stop menstrual flow. In contrast to a Roller ball endometrial ablation, pre operative endometrial “thinning” is not required. There must be no plans to conceive afterwards as this procedure is essentially sterilizing – but must not be regarded as contraceptive. For this reason the procedure is often combined with tubal ligation. Generally 90%+ “cure” rate, so in 30% periods stop, 30% very light, 30% back to normal flow. This procedure offers excellent control of periods in most cases with a lesser hospital stay and recovery than a hysterectomy, at less cost.

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Operative Hysteroscopy – for polyps/ fibroids/uterine septum

The purpose of an Operative Hysteroscopy may include to remove parts of fibroids within the cavity of the uterus, remove polyps or scar tissue, correct some abnormalities of the uterus which may inhibit fertility, and to remove IUD’s. A 9 mm diameter rod-lens telescope with a channel for instruments, attached to a video camera is passed through the cervix (or mouth of the womb). The operation may be carried out using a small wire loop, probe or scissors. Occasionally a laparoscopy is required at the same time.

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Post Surgery Analgesic (pain relief) Guidelines

It is well known that post procedural and post discharge pain is not well managed. This is often because patients, once discharged from hospital, lack daily interaction with doctors and nurses who are able to help them with choice and administration of pain relieving medication. In addition, it is common to be confused about the various forms of analgesia available and how they may be used. The following is general advice regarding the principles by which you may manage your analgesics at home. It is important to realize that due to an individual patient’s allergies, other medical conditions and the procedure performed, requirements for pain relief may vary vastly from person to person and you may need to seek specific advice.

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Sperm retrieval – Open Testicular Biopsy

As many as 10 – 15% of infertile men have no sperm in their ejaculate. This is called azoospermia. Around 40% of these cases are due to blockage somewhere in the reproductive tract. This means that although sperm are being produced, they cannot reach the outside. Defects in sperm production account for the rest.

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Suction curette

Suction curettage is generally indicated after diagnosis of a miscarriage (missed, incomplete) although is sometimes used after a term vaginal delivery. Under general anaesthetic, the cervix is dilated and a plastic sucker is inserted to evacuate blood clots and placental material from the cavity of the uterus. This is generally sent to pathology for microscopic examination which will exclude unusual conditions of placental overgrowth (molar pregnancy). However information regarding the cause of the miscarriage is not obtained.

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Total Laparoscopic Hysterectomy (TLH) and Bilateral Salpingectomy

TLH means removing the uterus (womb) using an operating telescope (laparoscope) inserted through the abdominal wall. This avoids having a large abdominal wound, so usually your recovery is much faster and cosmetic result superior. The vast majority of straightforward hysterectomies should be done in this fashion, and many more challenging ones too. The cervix (neck of the womb) is also removed so you usually will not need Pap smears any more. The ovaries may or may not be removed depending on your wishes and condition; i.e. the term TLH refers to removing the uterus and cervix only, entirely using the telescope.  There is no medical equivalent of the lay term “complete hysterectomy”, but some take this to mean removal of the ovaries as well. The ovaries are not part of the uterus, they simply lie close by and their removal at the time of hysterectomy is termed “hysterectomy and bilateral salpingo-oophorectomy”.

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Vaginal hysterectomy

A vaginal hysterectomy (VH) is a procedure in which the uterus is surgically removed through the vagina. Occasionally one or both ovaries and fallopian tubes may be removed during the procedure as well. The cervix is also removed, as it represents the bottom part of the uterus. Vaginal hysterectomy has fewer complications and a faster recovery time than abdominal hysterectomy (AH).

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Vaginal repair, +/- cystoscopy, sacrospinous colpopexy or sacrospinous hysteropexy

The purpose of the procedure is to restore the anatomy, increase patient comfort, increase confidence with sexual intercourse and to treat urinary incontinence in various combinations. There are many different techniques for performing vaginal repairs. The procedure is generally performed on women who have a prolapse (a soft lump protruding from the vagina). Sometimes the lump may protrude all the time. This may involve the bladder, the rectum or the upper part of the vagina.

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Vulvoscopy and excisional biopsy

The purpose of the procedure is to remove or sample abnormal areas of skin in the vagina, or outside, which may later develop into cancer. Some benign conditions are also managed in this way, in order to arrive at a diagnosis.

Under general anaesthetic, the skin outside the vagina is examined with a colposcope (binocular microscope). A dilute solution of acetic acid (vinegar) is applied to the skin which enables me to see areas of abnormal cells. Following this, antiseptic is applied to the skin, the areas of abnormal cells are removed or biopsied (sampled). The specimens are sent to pathology and the skin defects closed with dissolving sutures.

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