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This section details the other services that Dr. Leong provides in his practice. If the services you are looking for are not detailed here, please ring his rooms for more information.

Hysteroscopic resection of fibroids, septum and uterine synechiae

Pathology within the uterine cavity is quite common. The presence of fibroids and polyps can cause abnormal and heavy vaginal bleeding. These abnormalities can often be detected on a high quality ultrasound scan. Uterine septum is a congenital abnormality and consists of a midline wall defect of the uterine cavity of varying severity. In the most severe cases, the septum extends down all the way into the cervix. Uterine scarring also known as synechiae can be caused by previous infections of the uterine cavity from retained placental tissues or products of pregnancy. These pathological abnormalities can often interfere with one’s chance of conceiving naturally.

Because the problem exists within the uterine cavity, the best approach for treatment is to use a hysteroscope (smaller device much like the laparoscope) to gain access into the uterine cavity. A fluid medium e.g. normal saline or glycine solution is used as the distension medium to allow visualization of the uterine cavity by the hysteroscope. Normal saline is used if the operation is mostly diagnostic and for the minor treatment of polyps. If an electric current is required then an inert fluid medium such as glycine is used. Electrocautery instruments are passed through small channels within the housing of the hysteroscope to allow resection of synechiae, fibroids and septum. The aim of the resection is to return the shape of the uterine cavity back to normal.

Hysteroscopy is generally performed under general anaesthetic. Most hysteroscopic surgery takes about ten minutes. A much longer time is required if resection of fibroids or synechiae is performed. This can take up to an hour. Hysteroscopy is often performed together with laparoscopy. No cuts are made on the abdomen or vagina during hysteroscopy.

Most women are able to go home about four hours post surgery. It is recommended that a relative or friend drives you home afterwards. It is best to avoid going to work for 24 hours post operation so to allow the anaesthetics to wear off. You may need to take two days off work if you are required to make important decisions. You can shower as normal but it is best to avoid baths, spas and swimming for a week to minimize the risk of infection. Avoid tampons but wear a sanitary pad instead. Expect some draining of a small amount of blood-stained fluid from the vagina following the procedure for up to a week. Mild cramping similar to period cramps may be experienced for a few days afterwards. Panadol and anti-inflammatory drugs may help the pain if required. If the surgery takes an hour or longer then you may need to stay in hospital for 24 hours for observation.

Risks specific to hysteroscopy include post operative infections (uterine or bladder infection), trauma to cervix during dilatation, perforation of the uterus, potential damage to nearby organs such as bowels, blood vessels and bladder, significant postoperative bleeding and fluid imbalance. Please speak to Dr Leong about these risks.

Hysteroscopic resection of fibroids
Hysteroscopic resection of fibroids
Hysteroscopy - view of inside of a normal uterus
Hysteroscopy - view of inside of a normal uterus
Hysteroscopy and resection of fibroid. Note the large and round fibroid taking up the whole view at hysteroscopy
Hysteroscopy and resection of fibroid. Note the large and round fibroid taking up the whole view at hysteroscopy
Hysteroscopy with view of an endometrial polyp
Hysteroscopy with view of an endometrial polyp
Hysteroscopy with view showing the polyp is removed.
Hysteroscopy with view showing the polyp is removed.
Hyteroscopy and resection of fibroid. The loop diathermy tip of the resectoscope used to cut and scoop the fibroid
Hyteroscopy and resection of fibroid. The loop diathermy tip of the resectoscope used to cut and scoop the fibroid
Uterine septum
Uterine septum
Hysteroscopic resection of uterine septum

Open abdominal gynaecology surgery

Although this type of surgery is rarely required these days especially in the area of benign gynaecology, open surgery for gynaecology is still performed. Open surgery may be indicated if the patient has had numerous abdominal surgeries in the past or if one expect lots of adhesions or scarring from a previous medical condition, e.g. perforated bowels. Laparoscopy may not be safe because adhesions or scarring alter anatomical position of important organs such as bowels, ureters, bladders, blood vessels etc. making laparoscopy particularly unsafe. The initial insertion of the camera port and subsequent insertion of other operating ports may be difficult and expose various organs to injury. Various methods can be used to gain access into the abdomen as safely as possible at laparoscopy but the fact remains that on occasion this is just not possible and open surgery must be performed. Sometimes if a complication is encountered during laparoscopy, conversion to open surgery may be necessary.

With open surgery, a transverse skin incision of about 10 cm in length is made on the lower part of the abdomen, just above the pubic hairline. Various layers of tissue will need to be cut or parted before entering the abdominal cavity. With closure of the wound, the various layers are usually closed independently. The deepest layer called the peritoneum is closed first with a vicryl suture, follow on by the sheath layer closed by a tough and long lasting (though not permanent) PDS suture. It this layer is not closed adequately, a hernia may form where internal organs such as omental fat or bowels pass through a deficient gap in the sheath presenting as a visible lump on the abdomen. Next the subcutaneous or fat layer is closed and finally the skin is closed with a fine monocryl (dissolvable) or prolene (permanent) suture in a subcuticular stitch. This means no visible suture is exposed except when prolene suture is used where the ends are exposed. The exposed ends are left deliberately to allow for easy removal of the suture just before the patient is discharged from hospital.

Sometimes a vertical midline skin incision is made on the abdomen from the pubic hairline to the navel or higher. This type of incision is required if adequate access into the abdomen or pelvis is important say for a large uterus. If cancer is encountered, this incision is also required for optimal access for disease clearance.

Large abdominal incisions cause a considerable amount of pain afterwards, slower discharge from hospital and protracted recovery phase. Hospital stay tends to be 5-6 days. The key to recovery is good pain management. This can be achieved by taking your pain medication regularly and on time every three to four days post operation even if pain is not too severe. Once you are on top of the pain, you can start weaning off the stronger pain medications. Most patients will have a relatively pain free recovery if this is done correctly.

Open abdominal gynaecology surgery
Open abdominal gynaecology surgery
 

Vaginal surgery and sling procedures

Vaginal surgery is an important part of gynaecology surgery. It is performed for prolapse problems where the vagina or uterus may ‘drop’ and cause a bulge in the vagina. The prolapse can cause a significant amount of discomfort, pain or bleeding and may interfere with bowel or bladder functions.

Depending on the nature of the problem, the prolapsed vaginal wall may need to be repaired. Redundant skin may need to be trimmed and deep layers of stitches applied to strengthen the area. If the uterus is prolapsed then it should be removed (vaginal hysterectomy). The ovaries are usually left behind. In fact, good visualization of the ovaries is not always possible via the vaginal route. After surgery, a urinary catheter is inserted to help with voiding 24 to 48 hours afterwards. A long strip of gauze or pack is inserted into the vagina to stop any slow ooze of blood. The pack is normally removed the next morning. The length of stay in hospital is usually three to four days. Full recovery takes about six weeks. It is advisable that you do not undertake any heavy pushing, pulling, lifting, vigorous exercise or sexual intercourse for six weeks post surgery. If not sure, always check with Dr. Leong first. It is quite normal to feel tightness initially during sexual intercourse but sexual function should remain unchanged. Please beware that pain medication can cause a temporary change in bowel habits.

Please note that Dr. Leong only performs native tissue vaginal repair. This means no vaginal mesh is used in the repair. If you have a recurrent prolapse and also a past history of previous repair, vaginal mesh may be required. In this case, Dr Leong will refer you on to a urogynaecologist.

For the surgical management of urinary stress incontinence (leakage or seepage of urine with coughing, sneezing, exercise or intercourse), Dr Leong would use a sling or fine mesh inserted around the bladder neck.

There are specific risks of pelvic prolapse surgery you should be aware of:

  • The procedure fails in five to ten percent of patients.
  • 30% of women may require another operation for prolapse in five years.
  • Up to five percent of women may develop stress incontinence not previously present before surgery.
  • Some women may experience difficulty passing urine afterwards and require a urinary catheter for a week or longer.
  • A bladder infection may develop after surgery requiring antibiotic treatment.
  • The mesh may cause the wound not to heal around it. It may be infected or even rejected by the tissue. Sometimes it may erode into other organs such as bowel or bladder. Rarely when the problem does not resolve, the mesh may need to be removed.
  • Injury to urethra or bladder may occur during surgery and when detected and repaired in the same operation, complications would be rare. However a fistula may develop (connecting channel between bladder and vagina or rectum and vagina) if the injury is not detected in 2% of patients.
  • Intercourse may remain painful or uncomfortable for up to 5% of women afterwards.
  • A few women may continue to experience incomplete bowel emptying after repair.

Pap smear and cervical LLETZ procedure

Abnormal pap smears are often referred for further management. Normally a colposcopy is the required follow up. Dr Leong performs this in his Mitcham rooms. Colposcopy is a procedure performed using a magnifying binocular scope with a light to visualize any abnormal changes on the cervix, vagina or vulva. The patient is awake and seated in a special couch with the legs positioned with each to the side and fastened to a stirrup. A speculum is inserted in the vagina to display the cervix. A pap smear is performed at the start and then acetic acid (medical type acid – smells like vinegar) is applied to the cervix with a swab. Abnormal dysplastic cells normally appear as white plaques or patches on the cervix – known as acetowhite changes. A sample of tissue from the abnormal area is biopsied and sent to the laboratory for further analysis. If high grade dysplasia is confirmed, a cervical LLETZ procedure is normally warranted. This procedure is performed under general anaesthetic. A shallow biopsy of the cervix is obtained with a loop electrocautery instrument. The tissue obtained is larger than from the colposcopy biopsy specimen. Hence the result is more accurate. A shallow crater is left on the cervix which may bleed. The bleeding is stopped with either a continuous stitch or diathermy to the base.

Further management depends on the result of the LLETZ biopsy.

You might experience some light bleeding for a few days after the procedure. In the next few weeks, you will notice a mucousy discharge. This is part of the normal healing process. So please wear a sanitary pad.

Infections can occur after a LLETZ procedure. You may experience cramping pains, on-going bleeding which may be heavy, an offensive vaginal discharge and fever. If so, please contact Dr Leong. Usually if required a course of oral antibiotic is prescribed. Long-term complications include cervical scarring causing stenosis and cervical incompetence.

Colposcopy. Inspection of the cervix for abnormal cells.
Colposcopy. Inspection of the cervix for abnormal cells.
Conization of the Cervix
Conization of the Cervix
 

Endometriosis and fibroid follow-up services

It is advisable that moderate to severe cases of endometriosis and fibroids be followed up on a long term basis. Even after optimal surgical treatment endometriosis can recur. The oral contraceptive pill and other medications do not necessarily prevent endometriosis from returning. The time to recurrence varies but may take as early as six months but more like a few years. Early detection and treatment may help to prevent the disease from getting worse and causing more long term damage. Dr. Leong normally sees you about six weeks after surgery and then about three months after that. If all is well, you will then be reviewed on an annual basis. You may need to have an ultrasound scan prior to coming back for review. Please speak with Dr. Leong about it.

Fibroids need to be monitored regularly if not operated on and if sizeable because they do tend to grow albeit slowly. If multiple fibroids exist, each only needs to grow by a small margin before they have an overall effect. Sometimes small fibroids are left behind at surgery whereas the big ones are removed. The residual fibroids will need to be monitored for growth. It is advised that fibroids be monitored on an annual basis by ultrasound scan. Rapidly growing fibroids may signal quicker return of symptoms or be a sign of potential malignancy (though rare).

Heavy and painful periods

It is generally accepted that women have some measure of discomfort or pain during their periods. It is rare for women not to have any discomfort at all. Because period pains are common, many women are told their symptoms are normal. If period pains start early with the first onset of menses, try taking some simple painkillers such as paracetamol or anti-inflammatory medications with the periods. If the medications do not help, you should see your family doctor. Often other stronger pain medications may be suggested. Sometimes your doctor may prescribe the oral contraceptive pill and organize an ultrasound scan. If an abnormality is present on the ultrasound scan or the oral contraceptive pill did not help with the pain, it is advisable that you seek a referral to a gynaecologist. Your severe period pain is called primary dysmenorrhoea because the pain starts with your first few periods.

If you develop period pain later in life and previously do not have any issues with pain then you have secondary dysmenorrhoea. Secondary dysmenorrhoea is always abnormal and due to some underlying gynaecological disorder (e.g. fibroids, polyps, endometriosis, pelvic infections etc). Hence you should see your family doctor for a referral to a specialist.

Heavy menstrual flow is associated with increased period pains. Heavy flow with the passage of large blood clots and the need to change sanitary pads every hour or more is not normal. If you have heavy periods and often feel tired you may be anaemic from blood loss. If your blood loss exceeds 80 ml per period and lasts longer than seven days then you have heavy periods or menorrhagia by definition. Please see a specialist about this.

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