Dilation (dilatation) and curettage

literally refers to the dilation (opening) of the cervix and surgical removal of the contents of the uterus. It is a therapeutic gynecological procedure as well as a rarely used method of first trimester abortion. It is commonly referred to as a D&C.

D&C normally refers to a procedure involving a curette, also called sharp curettage. However, some sources use the term D&C to refer more generally to any procedure that involves the processes of dilation and removal of uterine contents, which includes the more common suction curettage procedures of manual and electric vacuum aspiration.

Procedure

The first step in a D&C is to dilate the cervix, usually done a few hours before the surgery. The woman is usually put under general anesthesia before the procedure begins. A curette, a metal rod with a handle on one end and a sharp loop on the other, is inserted into the uterus through the dilated cervix. The curette is used to gently scrape the lining of the uterus and remove the tissue in the uterus. This tissue is examined for completeness (in the case of abortion or miscarriage treatment) or pathologically for abnormalities (in the case of treatment for abnormal bleeding).

Clinical uses

D&Cs are commonly performed to resolve abnormal uterine bleeding (too much, too often or too heavy a menstrual flow); to remove the excess uterine lining in women who have conditions such as PCOS (which cause a prolonged buildup of tissue with no natural period to remove it); to remove tissue in the uterus that may be causing abnormal vaginal bleeding; to remove retained tissue (also known as retained POC or retained products of conception) in the case of an incomplete miscarriage; and historically, as a method of abortion that is now uncommon

Because medical and non-invasive methods of abortion now exist, and because D&C requires heavy sedation or general anesthesia and has higher risks of complication, the procedure has been declining as a method of abortion. The World Health Organization recommends D&C as a method of abortion only when manual vacuum aspiration is unavailable. According to the Centers for Disease Control and Prevention, D&C only accounted for 2.4% of abortions in the United States in the year 2002, down from 23.4% in 1972.

Complications

If the procedure is performed too roughly, scar tissue may form and seal the uterus shut (Asherman's syndrome), resulting in infertility. Another consequence of excessively forceful technique is uterine perforation. Although normally no treatment is required for uterine perforation, a laparoscopy may be done to verify that bleeding has stopped on its own. Infection of the uterus or fallopian tubes is also a possible complication, especially if the woman has an untreated sexually transmitted infection.

Having two or more sharp curettage procedures may increase the risk of complications in future pregnancies, such as ectopic pregnancy, miscarriage, andplacenta previa

Hysterectomy

 A hysterectomy (from the Greek word histera, meaning "womb") is the surgical removal of the uterus, usually done by a gynecologist. Hysterectomy may be total (removing the body and cervix of the uterus; often called "complete") or partial (removal of the uterine body completely but leaving the cervix in place; also called supra-cervical). During a hysterectomy it is a common practice for surgeons to remove normal ovaries and fallopian tubes in surgery called bilateral salpingo-oophorectomy. The term "hysterectomy" is often used colloquially (but not correctly) to refer to any procedure involving the removal of any of the female reproductive organs. According to the National Center For Health Statistics, of the 617,000 hysterectomies performed in 2004, 73% also involved the surgical removal of the ovaries. In the United States, 1/3 of women can be expected to have a hysterectomy by age 60. There are currently an estimate of 22 million women in the United States who have undergone this procedure. An average of 622,000 hysterectomies have been performed a year for the past decade.

Opponents of overutilization of hysterectomy, such as the Hysterectomy Educational Resources and Services (HERS) Foundation, have noted that both the uterus and the ovaries have important life-long functions in the maintenance of a woman's health, and that there is never an age or a time when the uterus and ovaries are not essential to health and well-being. Additionally, some opponents view the removal of otherwise healthy ovaries during a hysterectomy as castration

Indications

The term "hysterectomy" is derived from the Greek word for "womb", histera (sometimes spelled "hystera "), and shares the same root word with the term "hysteria". Ancient medical texts from the Greek describe "hysteria" as being a condition peculiar to women and caused by disturbance of the uterus, a belief possibly attributable to the hormonal imbalances many uterine conditions either create or are amplified by. Though the term "hysteria" has fallen out of favor within the psychiatric community due to its origins incorrectly placing blame for a mental condition on a woman's reproductive system, the term "hysterectomy" has remained to describe any surgery that involves removal of the uterus and its associated structures.

Hysterectomy is usually performed for problems with the uterus itself or problems with the entire female reproductive complex. Some of the conditions treated by hysterectomy include uterine fibroids (myomas), endometriosis (overgrowth of the uterine lining), adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into the uterine wall), several forms of vaginal prolapse, heavy or abnormal menstrual bleeding, and at least three forms of cancer (uterine, advanced cervical, ovarian). Hysterectomy is also a surgical last resort in uncontrollable postpartum obstetrical hemorrhage.

Uterine fibroids, although a benign disease, may cause heavy menstrual flow and discomfort to some women. Many alternative treatments are available, such as pharmaceutical (the use of NSAIDs or opiates for the pain, or hormones to suppress the menstrual cycle) or myomectomy (removal of uterine fibroids while leaving the uterus intact); often, no treatment is necessary. If the fibroids are inside the lining of the uterus, submucosal, and are smaller than 4cm, hysteroscopic removal is an option. A submucosal fibroid larger than 4cm and fibroids located in other parts of the uterus can be removed with a laparotomic myomectomy, where a horizontal incision is made above the pubic bone for better access to the uterus.

Technique

Most hysterectomies in the United States and in most parts of the world are done via laparotomy, sometimes called the "open technique". The abdominal wall is sliced open, usually inside the hair line of a woman's lower pelvis, similar to the incision made for a caesarian section. This technique allows doctors the most access to the reproductive structures and is normally done for removal of the entire reproductive complex. The recovery time for an open hysterectomy is 4-6 weeks and sometimes longer due to the need to cut through the abdominal wall, and the open technique carries increased risk of hemorrhage due to the large blood supply in the pelvic region and abdominal infection from the need to move intestines and bladder in order to reach the organs.

An increasing number of uterine removals not involving removal of the ovaries are done through the cervix ("supra-cervical"), reducing the size of the incision and the recovery time as well. The main drawback with supra-cervical hysterectomy is the increased risk of cervical prolapse due to the removal of the support structures around the uterus through this technique.

The newest technique is robotic-assisted laparoscopic hysterectomy. Instead of a large incision, a few tiny incisions are made through which thin instruments are passed. This new technique significantly reduces scarring, pain, healing time, blood loss, and duration of hospital stay when compared to open technique.

Risks and side effects

The average onset age of menopause in women who underwent hysterectomy is 3.7 years earlier than normal. This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy. When the ovaries are also removed, blood estrogen levels fall, removing the protective effects of estrogen on the cardiovascular and skeletal system. Although sometimes referred to as surgical menopause, that is incorrect and misleading because it implies that it is the same as natural menopause. In fact, naturally menopausal women have the benefit of the function of their uterus and ovaries, women who undergo hysterectomy and/or removal of the ovaries have a permanent loss of their functions.

When only the uterus is removed there is a three times greater risk of cardiovascular disease. If the ovaries are removed the risk is seven times greater. Several studies have found that osteoporosis (decrease in bone density) and increased risk of bone fractures are associated with hysterectomies. This has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting.

Women who experience uterine orgasm will not experience it if the uterus is removed. The vagina is shortened and made into a closed pocket and there is a loss of support to the bladder and bowel.

Women who have undergone a hysterectomy with both ovaries conserved typically have reduced testosterone levels as compared to intact women. Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density, while conversely, increased testosterone levels in women are associated with a greater sense of sexual desire. Hysterectomy has also been found to be associated with increased bladder function problems, such as incontinence.

Alternatives

Many alternatives to hysterectomy exist. Women with dysfunctional uterine bleeding may be treated with endometrial ablation, which is an outpatient procedure in which the lining of the uterus is destroyed with heat. Endometrial ablation will greatly reduce or entirely eliminate monthly bleeding in ninety percent of patients with DUB. In addition, uterine fibroids may be removed without removing the uterus. This procedure is called a "myomectomy." A myomectomy may be performed through an open incision or, in appropriate cases, laparoscopically. Various other techniques (such as Fibroid Artery Embolization, Myolysis, HALT, and Focused Ultrasound Surgery) kill the fibroid, and then leave it in place to be (usually only partially) reabsorbed by the body. Prolapse may also be corrected surgically without removal of the uterus.

New treatment options have begun to decrease the number of hysterectomies performed in the United States, Canada, and Britain. Despite the availability of alternative treatments to hysterectomy, many women still have traditional hysterectomy, though some of these other techniques, such as myomectomy, uterine artery embolization and endometrial ablation might be equally as effective and less invasive or life-changing than hysterectomy. For some patients, these alternatives are not appropriate, or may have been previously tried and been found unsuccessful.

Menorrhagia (heavy or abnormal menstrual bleeding) may also be treated with the less invasive endometrial ablation.

Gender Transitioning and Hysterectomy

Hysterectomies with bilateral salpingo-oophorectomy are often performed either prior to or as a part of Transman (sometimes called "female-to-male" or "FTM") gender reassignment surgery. Some in the transman community prefer to have this operation along with testosterone therapy in the early stages of their gender transition to avoid complications from heavy testosterone use while still having female hormone producing organs in place (uterine cancer, hormonally-induced coronary artery disease) or to remove as many sources of female sex hormones as possible in order to better "pass" during the real life experience portion of their transition. Just as many, however, prefer to wait until they have full "bottom surgery" (removal of female sexual organs and construction of male-appearing external anatomy) to avoid undergoing multiple separate operations. Many FTM never complete "bottom surgery" for a number of reasons, and instead choose to have their breasts and reproductive organs removed to remove all outward appearances of their femininity

Oophorectomy

Oophorectomy(or ovariotomy) is the surgical removal of an ovary or ovaries. In the case of animals, it is also called spaying and is a form of sterilization. Removal of the ovaries in women is the biological equivalent of castration in males, and the term is occasionally used in the medical literature instead of oophorectomy. Another term that is used, but rarely, is "orchiectomy".

In the case of humans, oophorectomies are most often performed due to diseases such as ovarian cysts or cancer; prophylactially to reduce the chances of developing ovarian cancer or breast cancer; or in conjunction with removal of the uterus

Overview

The removal of an ovary together with a Fallopian tube is called salpingo-oophorectomy or bilateral salpingo-oophorectomy if both ovaries and tubes are removed. Oophorectomy and salpingo-oophorectomy are not common forms of birth control in humans; more usual is tubal ligation, in which the Fallopian tubes are blocked but the ovaries remain intact. In many cases, surgical removal of the ovaries is performed concurrent with a hysterectomy. The surgery is then called "total abdominal hysterectomy with bilateral salpingo-oophorectomy" (sometimes abbreviated TAH-BSO). However, the term "hysterectomy" is often used colloquially yet incorrectly to refer to removal of any parts of the female reproductive system, including just the ovaries.

Hormone Replacement

In general, hormone replacement therapy is somewhat controversial due to the known carcinogenic and coagulative properties of estrogen; however, many physicians and patients feel the benefits outweigh the risks in women who may face serious health and quality of life issues as a consequence of early surgical menopause. The ovarian hormones of estrogen, progesterone, and testosterone are involved in the regulation of hundreds of bodily functions; it is believed by some doctors that hormone therapy programs mitigate surgical menopause side effects such as increased risk of cardiovascular disease, and female sexual dysfunction. There are many options for hormone replacement currently available and a considerable controversy exists in regards to synthetic versus natural or bio-identical regimens.

Risks

Longevity Risk

Removal of ovaries causes hormonal changes and symptoms similar to, but generally more severe than, menopause. Women who have had an oophorectomy are usually encouraged to take hormone replacement drugs to prevent other conditions often associated with menopause. Women younger than 45 who have had their ovaries removed face a mortality risk 1.7 times greater than women who have retained their ovaries. Retaining the ovaries when a hysterectomy is performed is associated with greater longevity However, hormone therapy is commonly believed by many doctors to mitigate the mortality risks of oophorectomy.

Women who have had bilateral oophorectomy surgeries lose most of their ability to produce the hormones estrogen and progesterone, and lose about half of their ability to produce testosterone, and subsequently enter what is known as "surgical menopause" (as opposed to normal menopause, which occurs naturally in women as part of the aging process). "Surgical menopause" differs from naturally occurring menopause in several respects: Surgical menopause is an iatrogenic procedure, while menopause is a natural event. A menopausal woman has intact functional female organs, a woman with surgical menopause does not. In natural menopause the ovaries generally continue to produce low levels of hormones, while in surgical menopause the ovaries and their hormones are absent, which can explain why surgical menopause is generally accompanied by a more sudden and severe onset of symptoms than natural menopause, symptoms which may continue until natural age of menopause arrives. These symptoms are commonly addressed through hormone therapy, utilizing various forms of estrogen, testosterone, progesterone or a combination of them.

Cardiovascular Risk

When the ovaries are removed a woman is at a seven times great risk of cardiovascular disease,but the mechanisms are not precisely known. The hormones produced by the ovaries cannot be truly replaced. The ovaries produce hormones a woman needs throughout her entire life, in the quantity they are needed, at the time they are needed, and released directly into the blood stream in a continuous fashion, in response to and as part of the complex endocrine system.

Bone Density Risk

In women under the age of 50 who have undergone oophorectomy, hormone supplements (usually estrogen) are often prescribed as part of hormone replacement therapy (HRT) to offset the negative effects of sudden hormonal loss (most notably an increased risk for early-onset osteoporosis) as well as menopausal problems like hot flashes that are usually more severe than those experienced by women undergoing natural menopause.

Some studies have found that increased bone loss or fracture risk is associated with oophorectomy. Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density,

Sexuality Risk

Oophorectomy generally greatly impacts sexuality in women, reducing or eliminating the ability to have an orgasm, and lowering sexual desire. This reduction is greater than that seen in women undergoing natural menopause. Some of these problems can be addressed by taking hormone replacement. Increased testosterone levels in women are associated with a greater sense of sexual desire, and oophorectomy greatly reduces testosterone levels. Reduction in sexual well being was reported in women who had been given a hysterectomy with both ovaries removed.

Statistics

According to the Center for Disease Control, 454,000 women in the United States underwent this type of operation in 2004.

Technique

When performed alone (without hysterectomy), an oophorectomy is generally performed by abdominal laparotomy.

Tubal ligation

Tubal ligation(informally known as getting one's "tubes tied") is a permanent form of female sterilization, in which the fallopian tubes are severed and sealed or "pinched shut", in order to prevent fertilization. Hormone production, libido, and the menstrual cycle are not affected by a tubal ligation

Procedure

In women, a tubal ligation can be done in many forms; through a vaginal approach, through laparoscopy, a minilaparotomy ("minilap"), or through regular laparotomy. Also, a distinction is made between postpartum tubal ligation and interval tubal ligation, the latter not being done after a recent delivery. There are a variety of tubal ligation techniques; the most noteworthy are the Pomeroy type that was described by Ralph Pomeroy in 1930, the Falope ring that can easily be applied via laparoscopy, and tubal cauterization done usually via laparoscopy. In addition, a bilateral salpingectomy is effective as a tubal ligation procedure. A tubal ligation can be performed as a secondary procedure when a laparotomy is done; i.e. a cesarean section. Any of these procedures may be referred to as having one's "tubes tied."

Less commonly used is the Essure procedure, developed in 2002, of occluding the fallopian tubes by the scarring effects of deposited pellets inserted by a catheter passed through the cervix and uterus.

Reversal

Generally tubal ligation procedures are done with the intention to be permanent, and most patients are satisfied with their sterilizations. Tubal reversal is microsurgery to repair the fallopian tube after a tubal ligation procedure.

Usually there are two remaining fallopian tube segments - the proximal tubal segment that emerges from the uterus and the distal tubal segment that ends with the fimbria next to the ovary. The procedure that connects these separated parts of the fallopian tube is called tubal reversal or microsurgical tubotubal anastomosis.

In a small percentage of cases, a tubal ligation procedure leaves only the distal portion of the fallopian tube and no proximal tubal opening into the uterus. This may occur when monopolar tubal coagulation has been applied to the isthmic segment of the fallopian tube as it emerges from the uterus. In this situation, a new opening can be created through the uterine muscle and the remaining tubal segment inserted into the uterine cavity. This microsurgical procedure is called tubal implantation, tubouterine implantation, or uterotubal implantation.

Tubal reversal, if done by a specialist microsurgeon, has a high success rate and few complications. Successful repair of the fallopian tubes is now possible in 98% of women who have had a tubal ligation, regardless of the type of sterilization procedure. Dr. Berger of Chapel Hill Tubal Reversal Center reports two-thirds of patients become pregnant within a year of their reversal. As expected, younger women had higher pregnancy rates than older women; pregnancy rates after tubal reversal surgery ranged from 77% for women under 30 to 34% for women over 40 years of age and older. He also cautions that tubal reversal patients need to monitor their early pregnancies for slightly increased chances of ectopic pregnancy.

IVF in vitro fertilization may overcome fertility problems in patients not suited to a tubal reversal

Hysteroscopy

Hysteroscopy is the inspection of the uterine cavity by endoscopy. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy).

Method

The hysterocope has an optical system usually now connected to a video system, a light bearing system with fiber optics, and a channel for delivery of a distention medium. The uterine cavity is a potential cavity, for inspection it needs to be distended. Thus during hysteroscopy either fluid (saline, sorbitol, or a dextrane solution) or CO 2 gas is introduced to expand the cavity. After cervical dilation, the hysteroscope is guided into the uterine cavity and an inspection is performed. If abnormalities are found, an operative hysteroscope also has a channel to allow specialized instruments to enter the cavity and perform surgery. Typically hysteroscopic intervention is done under anesthesia, but a diagnostic procedure can be performed without anesthesia with instruments of smaller caliber.

Indications

Hysteroscopy is useful in a number of uterine conditions:

• Polyp (medicine)
• Leiomyomata
• Asherman syndrome
• Gynecologic bleeding
• Uterine malformations

Complications

The most common problem is a uterine perforation when the instrument breaches the wall of the uterus. This can lead to bleeding and to damage to other organs. Distention media also can lead to an embolus or water intoxication.

Laparoscopic surgery

Laparoscopic surgery, also called minimally invasive surgery (MIS), band aid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5 - 1.5 cm) as compared to larger incisions needed in traditional surgical procedures. Laparoscopic surgery includes operations within the abdominal or pelvic cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called thoracoscopic surgery. Laparoscopic and thoracoscopic surgery belong to the broader field of endoscopy.

The key element in laparoscopic surgery is the use of a laparoscope: a telescopic rod lens system, that is usually connected to a video camera (single chip or three chip). Also attached is a fiber optic cable system connected to a 'cold' light source (halogen or xenon), to illuminate the operative field, inserted through a 5 mm or 10 mm cannula to view the operative field. The abdomen is usually insufflated with carbon dioxide gas to create a working and viewing space. The abdomen is essentially blown up like a balloon (insufflated), elevating the abdominal wall above the internal organs like a dome. The gas used is CO2, as it is common to the human body and can be removed by the respiratory system if it absorbs through tissue. It is also non-flammable, which is important due to the fact that electrosurgical devices are commonly used in laparoscopic procedures.

It is difficult to credit one individual with the pioneering of laparoscopic approach. In 1902 George Keeling of Dresden performed the first laparoscopic procedure in dogs and in 1910 Hans Christian Jacobaeus of Sweden reported the first laparoscopic operation in humans. In the ensuing several decades, numerous individuals refined and popularized the approach further for laparoscopy. It was not until 1985 when, with the advent of a new and specialized computer chip television camera, the approach was broadened in scope to include surgical resection of organs such as gall bladder. The first successful laparoscopic removal of gall bladder in humans was reported in 1987 in France. The introduction of computer chip television camera was a seminal event in the field of laparoscopy. This innovation in technology provided the means to project a magnified view of the operative field onto a monitor, and at the same time freed both the operating surgeon's hands, thereby facilitating performance of complex laparoscopic procedures. Prior to its conception, laparoscopy was a surgical approach with very limited application and used mainly for purposes of diagnosis and performance of simple procedures in gynecologic applications.

The introduction in 1990 of a laparoscopic clip applier with twenty automatically advancing clips (rather than a single load clip applier that would have to be taken out, reloaded and reintroduced for each clip application) made surgeons more comfortable with making the leap to laparoscopic cholecystectomies (gall bladder removal). Dr. Eddie Joe Reddick was the surgical guru for this procedure in the U.S., and he played a huge role in training the first generation of laparoscopic general surgeons.

Laprascopic cholecystectomy is the most common laparoscopic procedure performed. In this procedure, 5mm-10mm thin instruments (graspers, scissors, clip applier) can be introduced by the surgeon into the abdomen through trocars (hollow tubes with a seal to keep the CO2 from leaking). Rather than a minimum 20 cm incision as in traditional cholecystectomy, four incisions of 0.5-1.0 cm will be sufficient to perform a laparoscopic removal of a gall bladder. Since the gall bladder is similar to a small balloon that stores and releases bile, it can usually be removed from the abdomen by suctioning out the bile and then removing the deflated gallbladder through the 1 cm incision at the patient's navel. The length of postoperative stay in the hospital is usually 2-3 days.

In certain advanced laparoscopic procedures where the size of the specimen being removed would be too large to pull out through a trocar site (as would be done with a gallbladder), an incision larger than 10mm must be made. The most common of these procedures are removal of all or part of the colon (colectomy), or removal of the kidney (nephrectomy). Some surgeons perform these procedures completely laparoscopically, making the larger incision toward the end of the procedure for specimen removal, or, in the case of a colectomy, to also prepare to reconnect the remaining bowel (create an anastomosis). Many other surgeons feel that since they will have to make a larger incision for specimen removal anyway, they might as well use this incision to have their hand in the operative field during the procedure to aid as a retractor, dissector, and to be able to feel differing tissue densities (palpate), as they would in open surgery. This technique is called hand-assist laparoscopy. Since they will still be working with scopes and other laparoscopic instruments, CO2 will have to be maintained in the patient's abdomen, so a device known as a hand access port (a sleeve with a seal that allows passage of the hand) must be used. Surgeons that choose this hand-assist technique feel it reduces operative time significantly vs. the straight laparoscopic approach, as well as providing them more options to deal with unexpected adverse events (i.e. uncontrolled bleeding) that may otherwise require conversion to a fully open surgical procedure.

Conceptually, the laparoscopic approach is intended to minimise post-operative pain and speed up recovery times, while maintaining an enhanced visual field for surgeons. Due to improved patient outcomes, in the last two decades, laparoscopic surgery has been adopted by various surgical sub-specialties including gastrointestinal surgery (including bariatric procedures for morbid obesity), gynecologic surgery and urology. Based on numerous prospective randomized controlled trials, the approach has proven to be beneficial in reducing post-operative morbidities such as wound infections and incisional hernias (especially in morbidly obese patients), and is now deemed safe when applied to surgery for cancers such as cancer of colon.

The restricted vision, the difficulty in handling of the instruments (hand-eye coordination), the lack of tactile perception and the limited working area are factors which add to the technical complexity of this surgical approach. For these reasons, minimally invasive surgery has emerged as a highly competitive new sub-specialty within various fields of surgery. Surgical residents who wish to focus on this area of surgery, gain additional training during one or two years of fellowship after completing their basic surgical residency.

The first transatlantic surgery (Lindbergh Operation) ever performed was a laparoscopic gall bladder removal.

Advantages

There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:

• reduced blood loss, which equals less risk of needing a blood transfusion.
• smaller incision, which equals less pain and shorter recovery time.
• less pain, which equals less pain medication needed.
• Although procedure times are usually slightly longer, hospital stay is less, and often with a same day discharge which equals a faster return to everyday living.
• reduced exposure of internal organs to possible external contaminants thereby reduced risk of acquiring infections.
• can be used in GIFT surgery to put the eggs back into the fallopian tubes

Possible benefits

• The expert advisers said that laparoscopic surgery may increase the chance of completely removing the cancer. They also said it offers an improved chance of the cancer not returning.
• The healthy tissue that is removed with the cancer is examined after surgery to check that all of the cancer has been removed. Eight studies of laparoscopic surgery and open surgery showed that the rate of not removing all of the cancer was similar. Two studies showed that this occurred more often with open surgery, and one study showed that it occurred more often with laparoscopic surgery.
• Out of just over 1400 men treated with laparoscopic surgery, the cancer was not fully removed in 1 in 5 patients. Out of just over 22,000 men treated with open surgery, nearly 1 on 4 had some cancer that was not removed  

Labia Reduction (Labiaplasty)

Before                     After

Introduction

Correction of Labia

This operation solves hypertrophy of labia. Very often, it is the case that each side of the labia is of different size, so operation also corrects such asymmetry too.

Most common reason for this operation is the uncomfortable feeling in tight clothes, sometimes uncomfortable or painful sensation during; sexual intercourse, biking etc.

Another reasons can be also aesthetic - women who are not happy with shape or size of labia and decide to correct it. As with other problem areas, any feelings of discomfort can have adverse effects on self-confidence and personal relationships. In such instances, labia reduction treatment may help, especially if the lips are asymmetrical or particularly long.

Purpose:

To reduce the size of the labia minora (inner lips) to achieve a more natural appearance.

The treatment:

This procedure should be carried out by a surgeon with relevant skills and experience.

Labia reduction is performed under normally takes place under general anaesthetic, or local anaesthetic plus sedation.

The shape of labia is corrected by cutting off excessive tissues and then stitched by sewing their edges with dissolvable stitches & high standard of hygiene is important.

After definitive healing – in about 2 months – is line of the cut almost unrecognizable.

Operation should not be performed at time of period.

The results:

After definitive healing – in about 2 months – is line of the cut almost unrecognizable.

The results should be permanent.

The risks:

After the surgery, the genital area will be swollen and painful and it is therefore likely that you will be unable to have sexual intercourse for six weeks. There is also the risk of infection, permanent colour change and loss of sensation.

Creation of Hymen(Reconstruction of Virgin Membrane)

Introduction

Creation of Hymen (reconstruction of virgin membrane)

Operation is carried out under general anaesthesia within the operation theatre, and can be performed soon after the rupture or much later.

The operation consists of reconstruction of hymen circle, with movements of tissues, therefore the entrance into vagina is reduced and thus it causes the illusion of original hymen.

Hymen restoration is used for reconstructing the hymen of women who need to have their virginity restored mostly for cultural or religious reasons.

Purpose:

To restore virginity after the hymen has been ruptured.

The treatment:

The surgeon will join again the hymeneal remnants with very small sutures.

It will be necessary to make two small incisions on the edges of each fragment before joining them so that they will heal and constitute a unit.

The stitches do not need to be removed, since an absorbable surgical thread is used.

The resulting scars are very small and, since the area heals very well, they become almost unnoticeable as time goes by.

It may happen that no hymeneal remnants are available; this may be because they are too small or because you were born without a hymen. In these cases, the surgeon will reduce the vaginal opening using a small portion of the vaginal mucous tissue in order to shape a new hymen.

Operation should not be performed at time of period.

The results:

To restores virginity after the hymen has been ruptured. It can be performed soon after the rupture or much later. The hymen may rupture during rape, agreed intercourse, insertion of tampons, sports, falls, etc.

Hymen reconstruction will allow you to have your next sexual intercourse as if you were a virgin, without worrying about failing to fulfill the cultural and religious expectations of your family or social group.

The risks:

After the surgery, the genital area maybe be swollen and some slight pain.

It is very unlikely for hymen reconstruction surgery to present any complications when performed by a qualified surgeon.

However, every surgical procedure, regardless of its triviality, has some risks and we should always think of them as a possibility.

• A too elastic hymen that will expand and not rupture.
• Adverse reactions to anesthesia.
• Infections, although they are very unusual if you take the right antibiotics.
• If bruises get too large, they may require drainage.
• Seromas, or fluid accumulation beneath the skin. In some cases, they may require to be drained with a syringe.
• Temporary alteration of the labia’s sensibility. During some time, the area may have less sensibility, more sensibility, or a different sensibility altogether. This is not serious and it tends to go back to normal by itself.

Antenatal care

In obstetric practice, an obstetrician or midwife will see a pregnant woman on a regular basis to check the progress of the pregnancy. An individual woman's schedule of antenatal appointment varies depending on local resources and her risk factors, such as diabetes.

The main rationale for these visits is surveillance for diseases of pregnancy which are detectable. Some examples are:

• pre-eclampsia. The blood-pressure and urine of a pregnant woman is checked at every opportunity to check for this.
• placenta praevia. On ultrasound, the placenta is visible obstructing the birth canal
• unusual presentation (late pregnancy only). The fetus may be feet-first or buttocks-first(breech), side-on (transverse), or at an angle (oblique presentation)
• IUGR (Intrauterine Growth Restriction), this is a general designation, where the fetus is too small for its gestational age. Causes can be intrinsic (in the fetus) or extrinsic (usually placental problems). IUGR refers to fetal growth that is less than 10% of what is expected at that gestational age.

Signs

Anatomical model of a human pregnancy

Trimesters

First trimester : elevated β-hCG (human chorionic gonadotrophin) of up to 100,000 mIU/mL by 10 weeks GA can cause morning sickness, fatigue, mood swings and food cravings. The symptoms can last through 12 to 16 weeks of gestation.

Second trimester : The abdomen shows an obvious swelling arising from the pelvis, starting the "obvious phase" of pregnancy. Hyperpigmentation, including linea nigra, may appear.

Third trimester : The mother may experience backaches due to increased strain. Typically, the curvature of the spine is changed as pregnancy evolves in order to counteract the change in weight distribution. The mother may also suffer mild urinary incontinence due to pressure on the bladder by the pregnant uterus, as well as heartburn(due to compression of the stomach).

Overall

• Bluish discoloration of vagina and cervix (Chadwick's sign)
• Softening and cyanosis of cervix after 4 weeks (Goodell's sign)
• Softening of uterus after 6 weeks (Ladin's sign)
• Breast swelling and tenderness
• Linea nigra from umbilicus to pubis
• Telangiectasias
• Palmar erythema
• Amenorrhea
• Nausea and vomiting
• Breast pain
• Fetal movement
• Sciatica (Pain caused by compression of the sciatic nerve)

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