Definition:This is a blood test that measures the levels of alpha-fetoprotein (AFP), a protein released by the fetal liver and found in the mother’s blood. AFP is sometimes called MSAFP (maternal serum AFP ) This blood test for pregnant women, also called a “triple screen,” checks the levels of protein and hormones being produced by the fetus. The levels of three different substances together can enable doctors to identify pregnancies that are at a higher risk for birth defects such as Down syndrome or neural tube defects (brain and spinal cord problems). If the blood test suggests problems, your doctor might recommend additional tests, such as amniocentesis or fetal ultrasound, to confirm the findings. CLICK & SEE THE PICTURES
The alpha-fetoprotein (AFP) test is available to women between their 15th and 20th week of pregnancy to screen for fetal abnormalities. This simple blood test measures the level of a protein called alpha-fetoprotein which is secreted by the liver of the fetus and enters the mother’s blood stream. Elevated levels of AFP may indicate an increased risk of neural tube defects such as spina bifida or anencephaly, while low levels suggest Down Syndrome or other chromosomal defects.
The AFP test does not determine the existence of these genetic disorders; it only predicts their likelihood. And while the AFP test is most often used to screen for these defects, it can also be used to identify abdominal wall defects, some renal and urinary tract abnormalities, Turner syndrome, low birth weight, and placental complications. An incorrectly-calculated gestational age and multiple fetuses can also cause abnormal AFP levels.
How do you prepare for the test?
* Before having this test done, you need to think carefully about what you would do with the results once you have them. The results of this blood test cannot show for sure whether you have either a healthy fetus or one with a problem; it can only suggest which patients might want to go ahead with further testing. Because amniocentesis (the test that is usually recommended after an abnormal triple screen) has a small risk of miscarriage, and because most people with an abnormal triple screen decide to go ahead with amniocentesis, this is an important decision. You should have this test done only if you think the information it offers would help you to make decisions about your pregnancy.
What happens when the test is performed?
* Your blood is drawn for this test sometime between your 15th and 20th weeks of pregnancy. The blood is tested for three protein and hormone levels: maternal serum alpha fetoprotein (MSAFP), unconjugated estriol (uE3), and human chorionic gonadotropin (hCG). Your doctor needs to weigh you on the day you have your blood drawn and ask when your last period began or what your expected due date is. The analysis of the results will take into account your weight and stage of pregnancy to determine whether the levels are normal.
What risks are there from the test?
* There are no risks from this test itself, but there are some risks from tests that might be recommended if the test result comes back abnormal (see-> “Amniocentesis,” ). This test can be stressful for expectant parents. Several things can cause the test to come back as abnormal even when there are no real health problems. Confusing results can happen, for example, in twin pregnancies and when mistakes have been made in estimating the age of the pregnancy.
Definition Chorionic villi are small structures in the placenta that act like blood vessels. These structures contain cells from the developing fetus. A test that removes a sample of these cells through a needle is called chorionic villus sampling (CVS).Chorionic villus sampling (CVS) is the removal of a small piece of placenta tissue (chorionic villi) from the uterus during early pregnancy to screen the baby for genetic defects CLICK & SEE
CVS answers many of the same questions as amniocentesis about diseases that the baby might have. Diseases that can be diagnosed with CVS include Tay-Sachs, sickle cell anemia, cystic fibrosis, thalassemia, and Down syndrome. (Rh incompatibility and neural tube defects, however, can be diagnosed only through amniocentesis.) CVS can be done earlier in pregnancy than amniocentesis and can be done when there is not enough amniotic fluid to allow amniocentesis. However, it has some extra risks when compared with amniocentesis.
Why the Test is Performed
The test is a way of detecting genetic disorders. The sample is used to study the DNA, chromosomes, and enzymes of the fetus. It can be done sooner than amniocentesis, about 10 to 12 weeks after your last menstrual period. Test results take about 1 to 2 weeks, whereas amniocentesis results may take longer.
Chorionic villus sampling does not detect neural tube defects. If neural tube defects or Rh incompatibility are a concern, an amniocentesis will be performed.
This test can usually not diagnose problems in the way the body forms.
How the Test is Performed
CVS can be done through the cervix (transcervical) or through the abdomen (transabdominal). The techniques are equally safe when done by a provider with experience, although miscarriage rates are slightly higher when done through the cervix. The health care provider will use ultrasound to pick the safest approach and as a guide during sampling.
An abdominal ultrasound is performed to determine the position of the uterus, the size of the gestational sac, and the position of the placenta within the uterus. Your vulva, vagina, cervix, and abdomen are cleaned with an antiseptic such as Betadine.
The transcervical procedure is performed by inserting a thin plastic tube through the vagina and cervix to reach the placenta. The provider uses ultrasound images to help guide the tube into the appropriate area and then removes a small sample of chorionic villus tissue.
The transabdominal procedure is performed by inserting a needle through the abdomen and uterus and into the placenta. Ultrasound is used to help guide the needle, and a small amount of tissue is drawn into the syringe.
The sample is placed in a dish and evaluated in a laboratory.
What happens when the test is performed.
There are two ways that your doctor can perform CVS. Some patients have the sampling done through the vagina and cervix. Most patients have the sampling done through the abdominal wall. For both types of sampling, you lie on your back on an examination table and the doctor uses ultrasound to locate the fetus and the placenta.
If the sampling is to be done through the vagina and cervix, you place your feet in footrests and bend your knees up, as you would for a pelvic examination. A speculum (a device that looks like a duck-bill that can be opened and closed) is used to open the vagina so that your doctor can see inside. A long tube, much narrower than a straw, is inserted through the cervix and moved forward while your doctor watches on the ultrasound until it is next to the fetal side of the placenta. A small sample of the lining around the fetus is then pulled into the tube for testing.
If the sampling is to be done through the abdominal wall, your lower abdomen is cleaned with an antibacterial soap. In some cases, the doctor uses a small needle to inject a numbing medicine just under the skin, so that you do not feel the sampling needle. (Because the sampling needle does not cause much more stinging than the numbing medicine itself, not every doctor includes this step.) A hollow needle several inches long is inserted through the skin and muscle of the abdomen and through the wall of the uterus, to the edge of the placenta. This needle is held in place as a guide needle. A narrower needle is then inserted through the first needle and is rotated and moved inward and outward a number of times while a sample is collected into an attached syringe.
The fetal heart tones and the mother’s blood pressure and heart rate are checked at the beginning and end of the procedure. The whole procedure takes close to 30 minutes.
How to Prepare for the Test.
CVS can be done between the 10th and 13th weeks of pregnancy. Tell your doctor ahead of time if you have ever had an allergic reaction to lidocaine or the numbing medicine used at the dentist’s office.
Your health care provider will explain the procedure, its risks, and alternative procedures such as amniocentesis. Genetic counseling is recommended prior to the procedure. This will allow you to make an unhurried, informed decision regarding options for prenatal diagnosis.
You will be asked to sign a consent form before this procedure, and you may be asked to wear a hospital gown.
The morning of the procedure you may be asked to drink fluids and refrain from urinating to fill your bladder, which allows adequate visualization so the sample may be taken.
How the Test Will Feel
The ultrasound doesn’t hurt. A clear, water-based conducting gel is applied to the skin to help with the transmission of the sound waves. A handheld probe called a transducer is then moved over the area. In addition, your health care provider may apply pressure on your abdomen to find the position of your uterus.
The antiseptic cleansing solution will feel cold at first nd may irritate your skin if not washed off after the procedure. Some people are allergic to Betadine. Notify your health care provider if you are allergic to Betadine or if you have any other allergies.
Some women say the vaginal approach feels like a Pap smear with some discomfort and a feeling of pressure. There may be a small amount of vaginal bleeding following the procedure.
An obstetrician can perform this procedure in about 5 minutes, after the preparation
The risks of CVS are only slightly higher than those of an amniocentesis.
Possible complications include:
* Rh incompatibility in the mother
* Rupture of membranes
The risk of miscarriage and other complications from CVS is slightly higher than the risk from amniocentesis, although some parents feel that it is worth the extra risk to be able to makedecisions earlier in the pregnancy if the results show the baby has a health problem. There have also been some reports that suggest there is a very small risk of birth defects (abnormal limbs) in the fetus.
One particular difficulty with this test is that due to variability in the cells of the placenta (called mosaicism), occasionally you can have an abnormal test result even if the baby is normal and healthy. This might lead you to make decisions about pregnancy termination that you would not have made if you had better information.
Some women have vaginal bleeding after the procedure. Infection is uncommon.
Report any signs of complications to your health care provider.
CVS may also cause limb problems in the fetus. This risk appears to be very low (1 in 3,000) when CVS is performed after 10 weeks gestational ag
Time to know the result of the test
Chromosome analysis of the sample takes two weeks or more. The results of some tests may be available sooner.
RESULTS:- Normal Results
A normal result means there are no signs of any genetic defects. However the test could miss some genetic defects.
Note: Normal value ranges may vary slightly among different laboratories. Talk to your doctor about the meaning of your specific test results.
What Abnormal Results Mean
An abnormal result may be a sign of more than 200 disorders, including:
* Down syndrome
* Tay-Sachs disease
If your blood is Rh negative, you may receive RhoGAM to prevent Rh incompatibility.
You will receive a follow-up ultrasound 2 to 4 days after the procedure to make sure the pregnancy is proceeding normally.
Amniocentesis (also referred to as amniotic fluid test or AFT), is a medical procedure used in prenatal diagnosis of chromosomal abnormalities and fetal infections, in which a small amount of amniotic fluid, which contains fetal tissues, is extracted from the amnion or amniotic sac surrounding a developing fetus, and the fetal DNA is examined for genetic abnormalities
Tests of fetal cells found in this fluid can reveal the presence of Down syndrome or other chromosome problems in the baby. Amniocentesis can also show whether the lungs of the baby are mature enough to allow it to survive if it were elivered right away.
Amniocentesis is often recommended for pregnant women over age 35, women who have an abnormal “triple screen” blood test during pregnancy, or women who have (or whose husbands have) a family history of certain diseases or birth defects.
How do you prepare for the test?
You should have a serious discussion with your obstetrician regarding whether to have amniocentesis. Amniocentesis may be done anytime between the 14th and 20th weeks of pregnancy to test for fetal abnormalities. To check on fetal lung development, the test may be done late in the third trimester.
Tell your doctor ahead of time if you have ever had an allergic reaction to lidocaine or the numbing medicine used at the dentist’s office.
Just before the test, you should empty your bladder.
How the test is performed ?
Before the actual procedure, a local anesthetic is sometimes given to relieve the pain when inserting the needle used to withdraw the fluid. A needle is usually inserted through the mother’s abdominal wall through the wall of the uterus into the amniotic sac. With the aid of ultrasound-guidance, a physician aims towards an area of the sac that is away from the fetus and extracts approximately 20ml of amniotic fluid for testing. The puncture heals, and the amniotic sac replenishes the liquid over a day or so. After the amniotic fluid is extracted, the fetal cells are separated from it. The cells are grown in a culture medium, then fixed and stained. Under a microscope the chromosomes are examined for abnormalities. The most common abnormalities detected are Down syndrome, Edward syndrome [Trisomy 18] and Turner syndrome [Monosomy X]. Amniocentesis is most safely performed after the 14th-16th week of pregnancy, does not need to be done before then due to risk it can to to the babys limbs. Usually genetic counseling is offered prior to amniocentesis.
What happens when the test is performed?
You wear a hospital gown and lie on your back on a table. An ultrasound is done to show the location of the fetus and placenta. Your lower abdomen is cleaned with an antibacterial soap. In some cases, the doctor uses a small needle to inject a numbing medicine just under the skin, so you do not feel the amniocentesis sampling needle later. (Because the sampling needle does not cause much more stinging than the numbing medicine itself, not every doctor includes this step.)
The hollow sampling needle is several inches long and is inserted through the skin and abdominal muscle and then through the wall of the uterus. A syringe attached to the needle is used to collect a sample of fluid.
The baby’s heart tones and the mother’s blood pressure and heart rate are checked at the beginning and end of the procedure. The whole procedure takes close to 30 minutes.
Although the procedure is routine, possible complications include infection of the amniotic sac from the needle, and failure of the puncture to heal properly, which can result in leakage or infection. Serious complications can result in miscarriage. Other possible complications include preterm labor and delivery, respiratory distress, postural deformities, fetal trauma and alloimmunisation (rhesus disease). Studies from the 1970s originally estimated the risk of amniocentesis-related miscarriage at around 1 in 200 (0.5%). A more recent study (2006) has indicated this may actually be much lower, perhaps as low as 1 in 1,600 (0.06%). In contrast, the risk of miscarriage from chorionic villus sampling (CVS) is believed to be approximately 1 in 100, although CVS may be done up to four weeks earlier, and may be preferable if the possibility of genetic defects is thought to be higher
Most women experience a few hours of mild pelvic cramping, and a few will have slight vaginal bleeding. About 1 in 100 women will have a temporary leak of amniotic fluid through the vagina; this usually causes no problem.
There is a small risk of miscarriage associated with amniocentesis; this occurs in about 1 in every 200 to 400 cases, depending in part on the timing of the test and the experience level of the physician performing it. Other risks (such as infection or injury to the fetus that does not cause miscarriage) are extremely rare.
What must you do after the test is over?
If the test confirms that you are Rh incompatible with the fetus, you will need to receive an injection of a medicine called Rh immune globulin (Rhogam) to protect the baby from complications.
Let your doctor know immediately if you are having any vaginal bleeding, fluid leakage, or strong abdominal pain.
Time to know the result:
Chromosome analysis of the fluid sample takes two weeks or more. The results of some tests may be available sooner.
Amniocentesis and stem cells:
Recent studies discovered that in amniotic fluid there are a lot of multipotent stem cell, mesenchymal, hematopoietic, neural,epithelial and endothelial stem cell. Amniotic stem cells don’t have ethical problem. In fact, in harvesting embryonic stem cells, a human embryo is destroyed, and so it’s considered it immoral. Another potential benefit of using amniotic stem cells over those obtained from embryos is that they side-step ethical concerns among pro-life activists by obtaining pluripotent lines of undifferentiated cells without harm to a fetus or destruction of an embryo.
Artificial heart valves, working tracheas, as well as muscle, fat, bone, heart, neural and liver cells have all been engineered through use of amniotic stem cells . Tissues obtained from amniotic cell lines show enormous promise for patients suffering from congenital diseases/malformations of the heart, liver, lungs, kidneys, and cerebral tissue
Laparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery, keyhole surgery is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5-1.5cm) 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. There are two types: a telescopic rod lens system, that is usually connected to a video camera (single chip or three chip) or a digital laparoscope where the charge-coupled device is placed at the end of the laparoscope, eliminating the rod lens system. 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 or trocar 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, which is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures.
Laparoscopy is a surgery that allows your doctor to see and operate on the organs inside your pelvis and abdomen through very small incisions in the abdominal wall. Many types of abdominal surgery can be done with laparoscopy, including diagnosis and treatment of infertility or pelvic pain, gallbladder or appendix removal, and tubal ligation for preventing pregnancies.
How do you prepare for the test?
Discuss the specific procedures planned during your laparoscopy ahead of time with your doctor. Laparoscopy is done by either a surgeon or a gynecologist-obstetrician. You will need to sign a consent form giving your doctor permission to perform this test.
If you take aspirin, nonsteroidal anti-inflammatory drugs, or other medicines that affect blood clotting, talk with your doctor. It may be necessary to stop or adjust the dose of these medicines before your test.
You will be told not to eat anything for at least eight hours before the surgery. An empty stomach will help prevent the nausea that can be a side effect of anesthesia medicines. You should arrange for a ride home from the hospital if your doctor plans on sending you home on the same day.
Before the surgery (sometimes on the same day), you will meet with an anesthesiologist to go over your medical history (including medicines and allergies) and to discuss the anesthesia.
It is difficult to credit one individual with the pioneering of laparoscopic approach. In 1902 Georg Kelling, of Dresden, Saxony, 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. 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). On the other hand, some surgeons continue to use the single clip appliers as they save as much as $200 per case for the patient, detract nothing from the quality of the clip ligation, and add only seconds to case lengths.
Laparoscopic cholecystectomy is the most common laparoscopic procedure performed. In this procedure, 5-10mm diameter 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 20cm incision as in traditional cholecystectomy, four incisions of 0.5-1.0cm will be sufficient to perform a laparoscopic removal of a gallbladder. 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 1cm incision at the patient’s navel. The length of postoperative stay in the hospital is minimal, and same-day discharges are possible in cases of early morning procedures.
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 the remaining healthy bowel to be reconnected (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 in dealing with unexpected adverse events (i.e. uncontrolled bleeding) that may otherwise require creating a much larger incision and converting 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 (new hand-eye coordination skills are needed), 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 gallbladder removal.
Laparoscopic techniques have also been developed in the field of veterinary medicine. Due to the relative high cost of the equiment required, however, it has not become commonplace in most traditional practices today but rather limited to specialty-type practices. Many of the same surgeries performed in humans can be applied to animal cases – everything from an egg-bound tortoise to a German Shepherd can benefit from MIS. A paper published in JAVMA (Journal of the American Veterinary Medical Association) in 2005 showed that dogs spayed laparoscopically experienced significantly less pain (65%)than those that were spayed with traditional ‘open’ methods. Arthroscopy, thoracoscopy, cystoscopy are all performed in veterinary medicine today. The University of Georgia School of Veterinary Medicine and Colorado State University’s School of Veterinary Medicine are two of the main centers where veterinary laparoscopy got started and have excellent training programs for veterinarians interested in getting started in MIS.
What happens when the test is performed?
Laparoscopy is done in an operating room. You wear a hospital gown. You have an IV (intravenous) line placed in your arm so that you can receive medicines through it.
You have general anesthesia for this test, which puts you to sleep so you are unconscious during the procedure. For general anesthesia, you breathe a mixture of gases through a mask. After the anesthetic takes effect, a tube may be put down your throat to help you breathe.
During laparoscopy, a tiny camera is inserted through a very small incision (less than an inch long), usually in or just below your navel. A gas such as carbon dioxide or nitrous oxide is pumped into your abdomen to help lift your abdominal wall off of your pelvic and abdominal organs so that the camera can view them clearly. If you are having any procedure more complicated than inspection of the pelvis or abdomen, your doctor makes one or more additional incisions to allow other instruments to reach into your abdomen. For pelvic surgeries, it is common for the additional incision to be just below the pubic hair line. You should ask your surgeon where you might expect to have incisions as part of your laparoscopy.
A wide variety of instruments are useful in laparoscopy. These include instruments that can cut and place clips onto internal structures, burn away scar tissue or painful areas in the pelvis, or remove small biopsy samples or even whole internal organs (often in pieces so that larger incisions are not necessary). Your doctor can see the work he or she is doing by watching a television screen.
At the end of the surgery, the instruments are withdrawn, the gas is removed, and the incisions are stitched closed. Your anesthesia is stopped so that you can wake up within a few minutes after your laparoscopy is finished.
Advantages: There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:
*reduced haemorrhaging , which reduces the chance of needing a blood transfusion.
*smaller incision, which reduces pain and shortens recovery time.
*less pain, leading to less pain medication needed.
*Although procedure times are usually slightly longer, hospital stay is less, and often with a same day discharge which leads to 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 Gamete intrafallopian transfer (GIFT) surgery to put the eggs back into the fallopian tubes
Risk Factors: Some of the risks are briefly described below:
*The most significant risks are from trocar injuries to either blood vessels or small or large bowel. The risk of such injuries is increased in patients who are obese or have a history of prior abdominal surgery. The initial trocar is typically inserted blindly. While these injuries are rare, significant complications can occur. Vascular injuries can result in hemorrhage that may be life threatening. Injuries to the bowel can cause a delayed peritonitis. It is very important that these injuries be recognized as early as possible.
*Some patients have sustained electrical burns unseen by surgeons who are working with electrodes that leak current into surrounding tissue. The resulting injuries can result in perforated organs and can also lead to peritonitis.
*There may be an increased risk of hypothermia and peritoneal trauma due to increased exposure to cold, dry gases during insufflation. The use of heated and humidified CO2 may reduce this risk.
*Many patients with existing pulmonary disorders may not tolerate pneumoperitoneum (gas in the abdominal cavity), resulting in a need for conversion to open surgery after the initial attempt at laparoscopic approach.
*Not all of the CO2 introduced into the abdominal cavity is removed through the incisions during surgery. Gas tends to rise, and when a pocket of CO2 rises in the abdomen, it pushes against the diaphragm (the muscle that separates the abdominal from the thoracic cavities and facilitates breathing), and can exert pressure on the phrenic nerve. This produces a sensation of pain that may extend to the patient’s shoulders. For an appendectomy, the right shoulder can be particularly painful. In some cases this can also cause considerable pain when breathing. In all cases, however, the pain is transient, as the body tissues will absorb the CO2 and eliminate it through respiration. 
*Coagulation disorders and dense adhesions (scar tissue) from previous abdominal surgery may pose added risk for laparoscopic surgery and are considered relative contra-indications for this approach.
*Patients can often have trouble walking after surgery for a few days
It is easier for patients to recover from laparoscopy compared with regular abdominal surgery (often called “open” surgery) because the wounds from the incisions are so small. You will have a small straight scar (less than an inch long) wherever the instruments were inserted.
*Sometimes a small amount of the gas used to expand the abdomen will remain after the surgery for a day or two, before it dissolves away. This can cause some shoulder pain. Depending on the type of operation your laparoscopy involved, you might also have some cramping in the pelvis or abdomen. Some laparoscopy procedures in the pelvis normally cause a small amount of bleeding through the vagina. Some patients experience some nausea from the medicines used for anesthesia or anxiety.
*General anesthesia is safe for most patients, but it is estimated to result in major or minor complications in 3%-10% of people having surgery of all types. These complications are mostly heart and lung problems and infections. For laparoscopy, the risk of complications from anesthesia are smaller than average, because most surgeries done with laparoscopy are fairly simple and do not require you to have anesthesia for much longer than an hour.
Must you do anything special after the test is over?
You will be watched for a few hours after your surgery to make sure that you are recovering well. You may be asked to sit up and drink liquids. For many laparoscopic procedures, you can go home the same day. You should not drive or drink alcohol the day of your test.
You should contact your doctor if you develop a fever over 101° F, strong pain, or bleeding from the vagina that is heavier than expected.
You will have a follow-up visit with your doctor to remove stitches if needed and to make sure you are recovering well.
How long is it before the result of the test is known?
If your laparoscopy was done to look for a cause of pain or other diagnosis, your doctor can tell you right after the surgery what was seen during the test. If a biopsy sample is removed, you may have to wait several days for the report. Robotics and technology
The process of minimally invasive surgery has been augmented by specialized tools for decades. However, in recent years, electronic tools have been developed to aid surgeons. Some of the features include:
*Visual magnification – use of a large viewing screen improves visibility
*Stabilization – Electromechanical damping of vibrations, due to machinery or shaky human hands
*Simulators – use of specialized virtual reality training tools to improve physicians’ proficiency in surgery
*Reduced number of incisions
Robotic surgery has been touted as a solution to underdeveloped nations, whereby a single central hospital can operate several remote machines at distant locations. The potential for robotic surgery has had strong military interest as well, with the intention of providing mobile medical care while keeping trained doctors safe from battle. Click to enlarge->..
Non robotic hand guided assistance systems
There are also user-friendly non robotic assistance systems that are single hand guided devices with a high potential to save time and money. These assistance devices are not bound by the restrictions of common medical robotic systems. The systems enhance the manual possibilities of the surgeon and his team, regarding the need of replacing static holding force during the intervention.
Some of the features are:
*The Stabilisation of the camera picture because the whole static workload is conveyed by the assistance system.
*Some systems enable a fast repositioning and very short time for fixation of less than 0.02 seconds at the desired position. Some systems are lightweight constructions (18kg) and can withstand a force of 20 N in any position and direction.
*The benefit – a physically relaxed intervention team can work concentrated on the main goals during the intervention.
*The potentials of these systems enhance the possibilities of the mobile medical care with those lightweight assistance systems. These assistance systems meet the demands of true solo surgery assistance systems and are robust, versatile and easy to use. Resources:
Definition: 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).
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The hysteroscope is a long tube, about the size of a straw, which has a built-in viewing device. Hysteroscopy is useful for diagnosing and treating some problems that cause infertility, miscarriages, and abnormal menstrual bleeding. Sometimes other procedures, such as laparoscopy, are done at the same time as hysteroscopy.
The hysteroscope is an optical instrument connected to a video unit with a fiber optic light source, and to the channels for delivery and removal of a distention medium. The uterine cavity is a potential cavity and needs to be distended to allow for inspection. Thus during hysteroscopy either fluids or CO2 gas is introduced to expand the cavity. The choice is dependent on the procedure and the patient’s condition. Fluids can be used for both diagnostic and operative procedures. However, CO2 gas does not allow the clearing of blood and endometrial debris during the procedure, which could make the imaging visualization difficult. Gas embolism may also arise as a complication. Since the success of the procedure is totally depending on the quality of the high-resolution video images in front of surgeon’s eyes, CO2 gas is not commonly used as the distention medium. Electrolytic solutions include normal saline and lactated Ringer’s. Current recommendation is to use the electrolytic fluids in diagnostic cases, and in operative cases in which mechanical, laser, or bipolar energy is used. Since they are conducting electricity, these fluids should not be used with monopolar electrosurgical devices. Non-electrolytic fluids eliminate problems with electrical conductivity, but can increase the risk of hyponatremia. These solutions include glucose, glycine, dextran (Hyskon), mannitol, sorbitol and a mannitol/sorbital mixture (Purisol). Water was once used routinely, however, problems with water intoxication and hemolysis discontinued its use by 1990. Each of these distention fluids is associated with unique physiological changes that should be considered when selecting a distention fluid. Glucose is contraindicated in patients with glucose intolerance. Sorbitol metabolizes to fructose in the liver and is contraindicated if patients has fructose intolerance. High-viscous Dextran also has potential complications which can be physiological and mechanical. It may crystallize on instruments and obstruct the valves and channels. Coagulation abnormalities and adult respiratory distress syndrome (ARDS) have been reported. Glycine metabolizes into ammonia and can cross the blood brain barrier, causing agitation, vomiting and coma. Mannitol 5% should be used instead of glycine or sorbitol when using monopolar electrosurgical devices. Mannitol 5% has a diuretic effect and can also cause hypotension and circulatory collapse. The mannitol/sorbitol mixture (Purisol) should be avoided in fructose intolerant patients.
A hysteroscope is in fact a modification of the traditional resectoscope, which is used for transurethral resection of the prostate. It has a double-channeled sheath allowing for continuous flow of fluid or gas media into the uterus through the larger channel, while allowing for less outflow through the smaller channel. This results in the distention of the uterine cavity. With modern optical technologies, hysteroscopes are getting smaller in diameter yet able to provide larger and brighter images for surgeons’ convenience.
After cervical dilation, the hysteroscope is guided into the uterine cavity and an inspection is performed. If abnormalities are found, an operative hysteroscope with a channel to allow specialized instruments to enter the cavity is used to perform the surgery. Typical procedures include endometrial ablation, submucosal fibroid resection, and endometrial polypectomy. Typically hysteroscopic intervention is done under general endotracheal anesthesia or Monitored Anesthesia Care (MAC), but a short diagnostic procedure can be performed in a gynecologist‘s office with just a paracervical block using the Lidocaine injection in the upper part of the cervix.
Why it is Done: Hysteroscopy is useful in a number of uterine conditions:
Hysteroscopy has the benefit of allowing direct visualization of the uterus, thereby avoiding or reducing iatrogenic trauma to delicate reproductive tissue which may result in Asherman’s syndrome. How do you prepare for the test
The time that you schedule this test can be important. Your gynecologist is able to get the best view of the uterine lining during the week that follows your period. If you have regular cycles, it is helpful for you to anticipate the timing of your next period and plan to have the hysteroscopy done in the following week.
Tell your doctor ahead of time if you have ever had an allergic reaction to lidocaine or the numbing medicine used at the dentist’s office. Discuss different options for anesthesia with your doctor in advance.
If your doctor plans on giving you any anti-anxiety medicines before the procedure, or if you are going to have other tests done at the same time as hysteroscopy, you might be told not to eat or drink for eighthours or more before the test. Just before the test, you should empty your bladder.
After the procedure, you may have slight vaginal bleeding and cramps for one or two days. Sometimes a small amount of the gas used to expand the uterus can float up to the top of the abdomen and remain there for a day or two before it dissolves away. This can cause some shoulder pain. Some patients experience nausea from medicines used for anesthesia or anxiety.
Some of the procedures that are done along with hysteroscopy have risks of their own. You should ask your doctor about special risks that might come along with additional procedures planned for you.
A common problem is the uterine perforation when the instrument breaches the wall of the uterus. This can lead to bleeding and damage to other organs. A life-threatening condition is the bowel perforation by the instruments after the uterine perforation, resulting in acute peritonitis which can be fatal. Furthermore, cervical laceration, intrauterine infection (especially in prolonged procedures), electrical and laser injuries, and complications caused by the distention media described above are also not uncommon. The overall complication rate for diagnostic and operative hysteroscopy is 2% with serious complications occurring in less then 1% of cases.
How long is it before the result of the test is known
Your doctor can tell you what was seen through the hysteroscope right away. If a biopsy sample is removed, the analysis might take several days.