Miguel A. Marrero, M.D., P.C.
REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY
GYNECOLOGIC SURGERY

FREQUENTLY ASKED QUESTIONS & ANSWERS

OPERATIVE LAPAROSCOPY


Dr. Miguel Marrero specializes in laparoscopic excisional treatment of endometriosis (including severe stage IV) for pelvic pain and/or infertility. This minimally invasive surgery allows for small incisions (usually 5 mm), faster patient recovery, and minimizes the risk of scar tissue formation.

During operative laparoscopy, many abdominal disorders can be safely treated throughout the laparoscope at the same time that the diagnosis is made. When performing operative laparoscopy, the physician inserts additional instruments such as probes, scissors, grasping instruments, biopsy forceps, electrosurgical or laser instruments, and suture materials through two or three incisions in the area above the public bone. Lasers, while a significant help in certain surgeries, are expensive and are not necessarily better or more effective than other surgical techniques used during operative laparoscopy. The choice of technique and instrumentation depends on many factors including the physician's training, location of the problem, and availability of equipment.


This approach allows for the surgical management of large ovarian endometriomas, ovarian cysts, removal of intestinal, ovarian, tubal, uterine and bladder adhesions, as well as the resection of deep nodules of endometriosis.

"There are four stages of endometriosis: Minimal (Stage I), Mild (Stage II), Moderate (Stage III) and Severe (Stage IV). symptoms of endometriosis include: menstrual cramps, pain during intercourse, abnormal uterine bleeding, infertility and diarrhea/nausea with the onset of menstrual cycle."

Mild Endometriosis: Implants are small, flat patches of endometrial cells growing outside their normal location lining the uterus. Endometrial cells are discharged into the pelvic cavity. This may result in implantation and growth of the residual endometrial tissue. Researchers have reported measurable differences in various cells and chemicals related to the immune system in some women with endometriosis.

Women who have sisters or a mother with endometriosis have a greater incidence of the disease. Therefore, genetic factors are probably involved. Whether these factors pertain to changes in the immune system, as previously discussed, is not known. In spite of decades of research, the reason why some women develop endometriosis while others do not is not completely understood.

Moderate Endometriosis: The "chocolate cysts" of endometriosis may be smaller than a pea or larger than a grapefruit.

What Does Endometriosis Look Like? Early implants look like small, flat patches or flecks of dark paint sprinkled on the pelvic surface. The small patches may remain unchanged, become scar tissue, or spontaneously disappear over a period of months. Endometriosis may invade the ovary, producing blood-filled cysts called endometriomas. With time, the blood darkens to a deep reddish-brown color. Once a cyst has developed to this point, it is often described as a "chocolate cyst." These cysts may be smaller than a pea or larger than a grapefruit. Sudden pain may occur when a large cyst bleeds into itself or bursts. The spilled fluid may cause further inflammation and the development of scar tissue.

Another area of Dr. Marrero’s surgical expertise is the laparoscopic removal of fibroids (subserosal and intramural leiomyomas) and the hysteroscopic excision of submucosal fibroids. Depending on the location and size of the fibroids, this treatment is beneficial in the management of pelvic pain, irregular or excess vaginal bleeding, treatment of infertility and recurrent miscarriage.

TYPES OF FIBROIDS

Fibroids are usually found in or around the uterus, but they sometimes occur in the cervix. Fibroids can be divided into three categories: subserous, intramural, or submucous. Subserous fibroids are located in the outer wall of the uterus, intramural fibroids are found in the muscular layers of the uterine wall, and submucous fibroids are found in the muscular layers of the uterine wall, and submucous fibroids are located on the inner wall of the uterus and may protrude into the uterine cavity.

DIAGNOSTIC HYSTEROSCOPY

The benefits of these surgical approaches are the minimal size of the incisions, faster patient recovery and the minimal amount of blood loss.

Gas or solution is used to expand the uterine cavity, clears blood and mucus away, and enables the physician to directly view the internal structure of the uterus.

Diagnostic hysteroscopy is usually conducted on an outpatient basis with either general or local anesthesia. Diagnostic hysteroscopy is usually performed soon after menstruation because the uterine cavity is more easily evaluated and there is no risk of interrupting a pregnancy.

OPERATIVE HYSTEROSCOPY

Operative hysteroscopy can treat many of the abnormalities found during diagnostic hysteroscopy. Treatment may be performed at the same time as diagnostic hysteroscopy or at a later date. Operative hysteroscopy is similar to diagnostic hysterscopy except that a wider hysterscope is used to allow operating instruments such as scissors, biopsy forceps, electrosurgical or laser instruments, and graspers to be placed into the uterine cavity through a channel in the operative hysteroscope. Fibroids, scar tissue, and polyps can be removed from inside the uterus. Congenital abnormalities, such as a uterine septum, may also be corrected through the hysteroscope. After surgical repair of the uterine cavity, a Foley catheter or intrauterine device (IUD) may be placed inside the uterus to prevent the uterine walls from fusing together and forming scar tissue. Antibiotic and/or hormonal medication may also be prescribed after uterine surgery to prevent infection and stimulate healing of the endometrium (uterine lining). Endometrial ablation, an operative hysteroscopy procedure in which the endometrium is destroyed, can be used to treat excessive uterine bleeding when a hysterectomy is not considered feasible.

*All images used with permission from the American Society for Reproductive Medicine