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Gynecology Center:
Endoscopy & Pelvic Reconstruction

Fermin Barrueto, M.D., Director of The Gynecology Center, as well as Chief of Endoscopy and Pelvic Reconstruction, and his associates, Kevin Audlin, M.D., Meghan Lynch, M.D., and Christine O'Connor, M.D., have specialized skill in the diagnosis and treatment of both common and rare gynecologic issues including abnormal uterine bleeding, chronic pelvic pain, fibroids, and infertility.

Diverse Surgical Skills

With a diverse and unique set of surgical skills, the physicians of The Gynecology Center are recognized experts in a number of gynecologic surgical techniques:

• Hysteroscopy - A thin scope, inserted in the vagina and cervix, used to both diagnose gynecologic conditions as well as perform minimally invasive operations.
• Laparoscopy - A minimally invasive surgical technique, including the innovative single-incision (SILS) technique, used as an alternative to traditional surgery. Involves a much smaller surgical incision and typically results in shortened recovery periods and less post-surgical pain.
• Microsurgery - A specialized, complex surgical technique in which very small blood vessels and nerves are reconnected.
• Robotic surgery - A robot-guided method of minimally invasive surgery in which robotic arms move over the patient according to the surgeon's command. Typically reduces blood loss, is less invasive and shortens hospital stays as compared with traditional open surgery.

Treating a Wide-Range of Gynecologic Conditions

Dr. Barrueto and his colleagues have extensive experience utilizing their broad range of surgical skills to treat a variety of gynecologic conditions including:

• Abnormal uterine bleeding
• Chronic pelvic pain
• Endometriosis
• Fibroids
• Infertility issues including:
  • Asherman's Syndrome
  • Tubal ligation reversal

Diagnosis and Treatment Techniques at The Gynecology Center

Hysteroscopy
Hysteroscopy can be performed diagnostically in the office, without anesthesia, or in an operating room as a way to remove lesions. Diagnostic hysteroscopy is used to examine the uterus and cervical canal. Hysteroscopy provides patients with a viable alternative to hysterectomy, thus preserving the genital tract. Using a thin telescope (hysteroscope) to look inside the uterus and cervical canal, hysteroscopy can be used to locate polyps, cysts, fibroids and other pathology (diagnostic hysteroscopy) or to treat and/or remove pathology (operative hysteroscopy).

In the United States, a tremendous number of hysterectomies are performed each year, of which some are due to abnormal uterine bleeding and may not be necessary. A less invasive, targeted treatment, hysteroscopy, which does not require hospitalization, is often a viable alternative.

Hysteroscopy has proven to be an essential investigation technique in the assessment of abnormal uterine bleeding, post-menopausal bleeding, uterine anomalies, menorrhagia related to fibroids and Asherman's syndrome.

Resectoscopic myomectomy is a type of operation that can be performed with a hysteroscope. Used to treat abnormal uterine bleeding or uncomfortable fibroid symptoms, resectoscopic myomectomy involves the use of a small telescope, called a resectoscope, which is placed through the vagina and cervix into the uterine cavity. Electricity is passed through a thin wire attachment of the telescope allowing the instrument to remove fibroids located within the cavity of the uterus and within the endometrial cavity itself. No abdominal incision is necessary and it is considered an outpatient procedure.

The physicians at Mercy have are able to use the most advanced technology for resectoscopic myomectomy, allowing for more precision, less risk and fewer complications in this complex surgery.

When resectoscopic myomectomy is performed for heavy bleeding, nearly 90 percent of patients return to normal menstrual flow. When fibroids are the cause of infertility, pregnancy rates following this procedure have been about 50 percent.

Laparoscopy
Laparoscopy is usually performed in the hospital under general anesthesia. A small incision, made in the abdominal area, is used as an entry point for a laparoscope (rod with a light source and small video camera). With the innovative single-incision laparoscopy surgery (SILS), a single incision is made in the belly button only and the entire surgical scar is then concealed by the belly button. (View video demonstration.)

After the incision is made, the abdominal region is filled with carbon dioxide gas, which helps move the abdominal wall and any organs out of the way, creating a larger space to work in and allowing the surgeon more visibility.

The laparoscope is then inserted through the incision. Used to see the inside of the pelvis and abdomen, it can help the surgeon diagnose a condition or it can be used to aid in surgery when additional instruments are inserted.

When the procedure is completed, the instruments are removed, the gas is released and the incision(s) is closed.

Laparoscopy may be used to detect and treat a wide range of gynecologic conditions including endometriosis, some cancers, uterine fibroids, pelvic inflammatory disease and ectopic pregnancy. Hysterectomies can be performed laparoscopically, typically resulting in less pain and shorter recovery periods.

Robotic Surgery
This state-of-the-art technology is performed with the aid of robotic arms, which react to a surgeon's command. Using a surgical platform that incorporates 3D technology, only a few small incisions are made.

The robotic arms move just like a surgeon's wrist, eliminating normal hand tremors and allowing for increased precision.

Gynecologic robotic surgery can be used for hysterectomy, myomectomy (treatment of uterine fibroids), endometriosis, sacrocolpopexy (treatment for vaginal vault prolapse) and the removal of endometrial and cervical malignancies.

Due to the minimally invasive approach, robotic surgery typically results in less pain, less blood loss, less scarring and a faster return to normal activities.

Common Conditions Treated at The Gynecology Center

Abnormal Uterine Bleeding
Abnormal bleeding is said to occur if you have a period more often than every 21 days, less often than every 35 days, or if you have bleeding or spotting in between periods. Very heavy bleeding, saturating a pad or tampon every hour or two for more than a few hours, is also abnormal. There are a number of causes of abnormal bleeding, and most causes are non-cancerous and treatable.

The physician team at Mercy seeks to provide patients with a thorough clinical diagnosis and the best treatment plan for abnormal uterine bleeding. According to Dr. Barrueto, "nearly all women, at some time in their life, experience heavy bleeding during a period. As many as 2 million women each year see their doctors about menorrhagia. It is the most common gynecologic complaint and the reason for two-thirds of all hysterectomies." The physicians of The Gynecology Center have particular expertise in a variety of treatment options available for this very common condition.

Endometrial ablation is the best alternative to hysterectomy in treating excessive menstrual bleeding. Endometrial ablation is a minimally invasive procedure and can be performed using several different methods, available to patients of The Gynecology Center at Mercy.

Chronic Pelvic Pain
Chronic pelvic pain, non-menstrual pain in the pelvic area lasting for over 3 months, is a common problem that presents a challenge to physicians, as the cause can be very wide-ranging. Potential causes can be reproductive, urologic, gastrointestinal, musculoskeletal, endocrine or neurologic disorders, which is why physician experience and multidisciplinary input are so important in diagnosing and treating this condition.

The physicians of The Gynecology Center take the time to extensively evaluate a patient's history in determining the cause of chronic pelvic pain. These experts have a diverse range of surgical skills to treat many of the gynecologic issues that cause pelvic pain including endometriosis, adhesions, fibroids, cysts and polyps. Additionally, they have access to other renowned and well-respected physicians in the gastrointestinal, neurologic, musculoskeletal and endocrine fields for multidisciplinary consults so that a patient's issue can be fully addressed.

Fibroids
Uterine fibroids are very common non-cancerous growths. Many women have fibroids, but do not require treatment because they are asymptomatic. Some women, however, experience uncomfortable symptoms due to fibroids including, abnormal bleeding, prolonged menstrual periods (more than 7 days), backaches, pelvic pressure, frequently urination, constipation, or pain with intercouse.

The presence of fibroids can be confirmed with hysteroscopy, and once confirmed, many treatment options exist. If there are no signs or symptoms, women can engage in "watchful waiting" or expectant management, pursuing a treatment option only if and when symptoms arise.

If uncomfortable symptoms are present, women can consider many options including myomectomy (fibroid removal which can be performed with hysteroscopic, laparoscopic or robotic techniques), endometrial ablation, or even hysterectomy.

The physicians of The Gynecology Center have acquired a unique and diverse set of surgical skills to treat fibroids through a variety of methods, depending on a patient's needs.

Infertility
Asherman's Syndrome is an acquired uterine disease, characterized by the formation of scar tissue or adhesions in the uterus. This occurs most often after uterine surgery, particularly a dilation and curettage done after a birth, miscarriage or abortion. The extent of the adhesions defines whether the case is mild, moderate or severe. The adhesions can be thin or thick, can be spotty in location, or can cause the walls of the uterus to adhere to one another.

When the condition is severe, a woman usually does not have a period and it can cause infertility or miscarriages. Some infections can also cause Asherman's Syndrome such as tuberculosis or schistosomiasis, but this problem is rare in the United States.

The treatment of Asherman's Syndrome requires a highly specialized team with experience in operative hysteroscopy (resectoscopic surgery) that is performed under laparoscopic control, which is necessary for a successful outcome. Dr. Barrueto and his team have extensive experience treating Asherman's Syndrome with good pregnancy rates for many women.

Microsurgical Tubal Anastomosis (or tubal ligation reversal) is the process of reconnecting the fallopian tube segments after a tubal ligation. The success of tubal ligation reversal depends on several factors, however, the skill and experience of the surgeon are of the utmost importance. Dr. Barrueto has many years of experience in repairing tubal ligations and uses the most meticulous skill and technique to perform the procedure. Using a surgical microscope, Dr. Barrueto carefully opens the blocked ends of the tubal segments and uses microscopic sutures to precisely realign and reconnect the tube segments. Dr. Barrueto is available for consultations to discuss the procedure and the individual likelihood of successfully rejoining the tubal segments.

See Dr. Barrueto on WBAL-TV's The Woman's Doctor discussing this procedure.

For more information on diagnosis or treatment, please call 410-321-8452.

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